Harmeet Khaira & Julian Hull

(This article was originally published in the Journal of One-Day Surgery Vol. 23 No. 3, 2013. It was Number 6 in the 'How i Do It' series, updated in 2020)

Patient Selection

• Standard day case criteria

Anaesthetic Techniques

• General anaesthesia:
  TIVA (Total IntraVenous Anaesthesia) comprising propofol and remifentanil as target controlled infusions.
  Intubation or Laryngeal Mask and IPPV ventilation. Air/O₂ only.
  Short duration muscle relaxants as these operations can take less than 20 minutes.
  Routine iv fluids (minimum 1000ml Hartmann’s).
  Routine anti-emesis (iv ondansetron 4mg and iv dexamethasone 4mg) as lap. Cholecystectomy has a high incidence of post-operative nausea and vomiting (PONV).

Surgical Technique

• Standard positioning of patient with slight head-up tilt and table rotation towards surgeon. Use intermittent pneumatic compression for DVT prophylaxis.
• Local anaesthetic infiltration to all port sites before insertion of ports (20ml 0.25% chirocaine).
• Use of three 5mm ports and one 10mm port.
• Low pressure CO₂ insufflation (10mmHg)
• Meticulous washout at end of procedure.
• Instillation of 500ml warm saline containing 20ml 0.25% chirocaine around liver and gallbladder bed.
• No drains.

Peri-operative Analgesia

• Peri-operative analgesia utilising a multi-facetted approach with NSAID, paracetamol, iv fentanyl (250-300mcg), local anaesthetic to wound sites and local anaesthetic wash to gall bladder bed
• Post-operative analgesia:
  Analgesia requirements vary hugely between patients. Group directive allows recovery staff to titrate iv fentanyl or oral morphine for rapid relief of post-operative prior to return to DCU ward.
  Regular paracetamol and ibuprofen.

Take Home Medication

• Regular oral paracetamol 1g qds and ibuprofen 600mg qds.

Organisational issues

• Ensure admission to day-case ward only.
• Early introduction of fluids, diet and mobilization.
• Allow home even if not passed urine

Common Pitfalls

• Care should be taken not to inflate stomach prior to intubation.
  Pain and PONV need to be treated aggressively

Anticipated day case rates

• 90%