Cases of symptomatic cholecystolithiasis were evaluated on outpatient basis. Existing co-morbidity were brought to most stable condition. Emergency LC, conversion to open surgery, placement of drain, abandonment of the procedure was excluded. Elective LC was done under general anaesthesia using CO₂ pneumoperitoneum at 8mmHg pressure from 8:00 AM to 2:00 PM in most of the patients. Standard four ports were used for the surgery. A fifth port was placed at the left midclavicular line, when the Callot’s tringle was getting obscured to retract the fatty omentum for proper visualization and dissection of cystic artery and duct. As indicated second procedure were done as per the willingness of the patients. After a general laparoscopy to exclude any trocar injury, the gall bladder was identified, all adhesion was released. The cystic duct and the cystic artery were clipped in a standard way and the specimen was dissected out using harmonic scalpel and the specimen removed after haemostasis. A total of 72 patients underwent a second procedure under the same anaesthesia. Before closure the port sites were infiltrated each with 2-4ml of 0.25% Bupivacaine.

The discharges were decided considering the anesthesia, surgical, co-morbidity and psycho-social factors [Table/Fig-1] by 6:00 PM. None were sent against the wish of the patient or their relatives. The data were kept in an excel sheet with a comment added on each visit. Before leaving the ward they were given injectable analgesic (Diclophenac 75mg in patients < 50 years and Tramadol 50mg in patients > 50 years, to be continued SOS) and antiemetic (Ondesetron 4mg). The relatives were briefed about the possible re-admission procedure, place of reporting and the doctor to attend them on arrival with the mobile numbers of surgical team. All others received the same analgesics and medication for co-morbidity but observed in the wards overnight. All were advised sedative (Calmpose 5mg) at bed time for a day and SOS thereafter and ranitidine 150mg twice daily for 7 days. Any re-admission after leaving the hospital till 30 days was noted.

Data was collected prospectively. In the continuous data the mean with SD and percentages were calculated.

LC was attempted in 1042 patients during the study period of Jan 2005 to Jan 2015. Thirteen cases were excluded from the study (two ductal injury converted {0.191%} for hepatico-jejunostomy, one post- operative cystic artery bleeding at recovery room and required open surgery for haemostasis, one Mirrizzi’s syndrome, one LC was abandoned due to alcoholic cirrhosis with portal hypertension and 8 drain placement). A total of 1029 were included in this study. There were 634 females and 395 males. Age range was from 38 to 91years (mean 44.65, SD 14.15). A total of 121 patients (11.76%) had medical co-morbidity and few associations which can affect the surgical outcome [Table/Fig-2]. A total of 72 of the patient underwent a second surgery as their consented choice for their convenience of single hospitalization. (Laparoscopic tubectomy-37, vasectomy-1, liver biopsy-12, transcystic Common Bile Duct (CBD) stone removal-5, mesenteric lymph node biopsy-2 appendicectomy-6, small liver tumour -1, liver cyst deroofing-2, ovarian cyst -1 and open minor surgery-5. The surgery time ranged from 20-94minutes (mean14.32, SD 16.03) and anaesthesia time was 26-185minutes (mean 51.35, SD 17 .67). Only 8 (0.86%) could go home by 6:00 PM and most of them were hospital staff [Table/Fig-3]. Majority preferred overnight stay. None came for re-admission for the first 14 days. Two (0.21%) cases required re-admission in 30 days. One patient had pain (Possibly biliary colic due to missed small common duct stone) on15^th day and became asymptomatic after 2 days of conservative therapy. The second patient presented with diabetic hypoglycaemic coma on 29^th day with soft abdomen but re-laparoscopy reveled flecks of pus at the sub hepatic area and drained bile next day due to cystic ductal leak. This was because of a missed common bile duct stone or a slipped stone during LC [Table/Fig-4]. The hypoglycemia possibly due to inadequate intake of food in presence of antidiabetic therapy, just a day before possibly due impaction of the stone at the ampulla. This patient required another elective surgery for removal of common bile duct stone following failure of endotherapy. The stone was impacted at the ampulla and could only be removed via the trans-duodenal route [Table/Fig-4].

[Table/Fig-4]:

Common bile duct stone during re-laparoscopy.

All the patients were followed up well beyond the end point of the study of 30 days. The follow-up protocol was 7-10 days for stitch removal with biopsy report, 6 weeks an USG abdomen and liver function test for any biliary compromise, and any collection and final follow up 6-12 months any symptoms related to biliary pathology.

Feasibility, safety and success of day care LC has been well established in advanced countries for symptomatic gallstones [4,8]. The same was found to be safe and effective on meta-analysis [8]. The success depends on appropriate patient selection and on well-trained staff and skillful operative technique together with safe anaesthesia. Most of the studies have taken only ASA grade I and II, two of these have taken age above 60 and 70 years respectively and one study with over 1132 cases included ASA grade I, II and III [9–12].

Seleem et al., had included only controlled diabetics and hypertensives without any complication [13]. The present study is the first one to include all the co-morbidity and re-admission details up to 30 days. Going home after LC under day care, traveling back to hospital in case of emergencies and getting a readmission for a second surgical intervention is troublesome for the patients and relatives. Though unacceptable, it might be unavoidable [5,6]. In the present study there were no re-admissions for the first two weeks.

No study has included the comprehensive psycho-social factors, which are incorporated in the present study. Most of the patient and relative had apprehension for any untoward happening during the night and no administrative or psychological force what so ever was applied at any time for the discharge. Hence our actual day care is so low. This is based on the choice of the patient, which we considered as supreme. The re-admission rates in different studies varied from 1.9-10% [4–6,10–12,14]. Two of our patient came during the day time on the 15^th and 29^th day. During day time, it was easier for the patient and the relatives to come back to the hospital and locate the treating doctors. Arranging an emergency surgery becomes smoother. Going home during evening time in an Indian city is difficult and accident prone due to heavy traffic and going home early morning is better, safer and less costly. Besides this, overnight stay, oral medication and feed make the patients and the relatives much more convinced. The day care success varies from 33-98.5% in various studies and it is directly related to the infrastructure of the country [Table/Fig-5]. If we include the discharge fit patient, who stayed back over night, the success rate will be higher rate than that of a developed country. Overnight stay not only makes the patients happy but also build up the confidence and avoid inconvenient. Authors have given distance of 205 to 10013 Kilometers from the hospital as one of the factor for day care LC. The travel time and the distance are equated to the road infrastructure. It is considered better to stay overnight in the hospital then to travel in term of economy and comfort more so on the initial post- operative day in the developing countries. Few authors have excluded obesity [12,15] as it is known to make the surgery difficult and takes longer time when the Body Mass Index (BMI) is more than 27.5Kg/sq. Meter [16]. But the obese patients were not excluded in the present study to make it a true homogenized group. However, one more 5mm port was added in these patients, where there was difficulty in dissecting the Callot’s triangle. The 5^th port was used a left sub-costal area to retract the duodenum/omentum for safe dissection of the cystic duct and artery with the same 8mmHg pressure, which is not describe so far. The safety of low pressure pneumoperitoneum has to be established [17]. Low intra-peritoneal pressure maintained better haemodynamics from the anaesthesia monitoring. Even though, the exact pressure to label it as a low pressure for LC is not yet established, possibly 8mmHg pressure LC has given good result with minimal pain due to limited stretching of peritoneum in spite of various co-morbidity and virtually no shoulder pain. In few diabetic patients, the blood sugar was the lower side with the pre-operative dose of anti-diabetic therapy. One of the diabetic patients, who reported the hospital, was in fact due to hypoglycaemic state. After this lesson we started using lower dose of anti-diabetic therapy for initial 2-3 days and advised them to monitor the blood glucose till the patients start taking their usual diet.

Day care LC is safe even with co-morbidity and an indicated second surgery. In spite of fit for day care most of the patient choose to stay back due to psycho-social cause and went next day morning. Overnight stay makes them happy, psycho-socially confident in developing nation and best suited for all patients including co-morbidity. LC at 8mmHg pressure possibly reduced peritoneal stretch pain, shoulder pain and helped early recovery even in presence of cardio- respiratory co-morbidity.