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)
- Standard day case criteria
- 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).
- 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 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.
- Ensure admission to day-case ward only.
- Early introduction of fluids, diet and mobilization.
- Allow home even if not passed urine
- Care should be taken not to inflate stomach prior to intubation.
Pain and PONV need to be treated aggressively
Anticipated day case rates