|Year : 2016 | Volume
| Issue : 1 | Page : 8-11
Short-stay surgery experience with laparoscopic appendicectomy in Ibadan
Oludolapo O Afuwape1, Omobolaji Ayandipo1, Tinuola Adigun2
1 Department of Surgery, College of Medicine, University College Hospital, Ibadan, Nigeria
2 Department of Anaesthesia, College of Medicine, University College Hospital, Ibadan, Nigeria
|Date of Acceptance||10-May-2016|
|Date of Web Publication||20-Dec-2016|
Oludolapo O Afuwape
Department of Surgery, University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
Introduction: Laparoscopic appendectomy is becoming accepted as the standard treatment for uncomplicated appendicitis. Appendicectomy consumes a significant portion of hospital resources and also disrupts routine life style of the patients' families; reduction in hospital stay will minimize hospital cost and disruption of the household life style. This study presents our initial experience with short-stay laparoscopic appendicectomy. Methods: This is an observational study from January 2012 to December 2012. The exclusion criteria included patients less than 16 years of age (pediatric patients), elderly patients (60 years and above), and obese patients. The patients were admitted on the evening of surgery and discharged as soon as they were fit for discharge based on the protocol. Results: Twenty patients fulfilled the selection criteria, but only 11 patients consented consisting of four females and seven males. Age range was 16-42 years with a mean of 22 ± 8.15 standard deviation (SD). There was one conversion to open surgery due to an ileocecal. The duration of surgery ranged from 45 to 110 min with a mean operation time of 50 ± 18.03 SD min. Five patients were discharged in the evening about 7-8 h after the surgery. Three patients were discharged home early the next day <24 h after the surgery. Two patients were discharged about 36 h after the surgery while one patient was discharged 4 days after the surgery. Conclusion: Short-stay surgery is safe and may become a standard protocol in future. Reduction in appropriate duration of hospital admission requires hospital organization.
Keywords: Appendicectomy, day case, laparoscopy
|How to cite this article:|
Afuwape OO, Ayandipo O, Adigun T. Short-stay surgery experience with laparoscopic appendicectomy in Ibadan. Niger J Surg Sci 2016;26:8-11
| Introduction|| |
Appendicitis is one of the most common general surgical emergencies.  It consumes a significant portion of hospital resources and also disrupts routine life style of the patients' families.  Reduction in hospital stay will minimize the use of hospital facilities and disruption of the household life style. Laparoscopic appendectomy is becoming accepted as the standard treatment for uncomplicated appendicitis because of the advantages of less postoperative pain, shorter hospital stay, and quicker return to normal daily activities. , Traditionally, patients are hospitalized for an average of 43-53 h after laparoscopic appendectomy.  In recent times, reduction in the duration of admission for laparoscopic surgery in particular to <24 h has been demonstrated to be safe.  In countries such as the USA or Canada, the concept of day-case laparoscopic appendectomy is already widely accepted. , The primary goal of day-case or short-stay surgery is for patients' convenience without compromising patients' safety.  The main advantages of patient satisfaction and cost-effectiveness are attractive to patients, surgeons, and hospital administrators.  The need to adopt cutting edge surgical treatment in developing countries while simultaneously adopting a strategy of cost reduction and prudent management of limited bed spaces makes this option attractive to health-care delivery systems.
The aim of this study is to present our initial experience with day-case laparoscopic appendicectomy.
| Methods|| |
This was an observational study carried out in a teaching hospital in Ibadan. This is a 1000-bed hospital with multiple subspecialties. Laparoscopic surgery has only recently been introduced. The general surgical units in the hospital have performed laparoscopic surgical procedures for about 3 years. The surgeons were of consultant grade, but were assisted by senior resident doctors. From January 2012 to December 2012, the surgeons encouraged selected patients to consider elective day-case appendicectomy. All the patients were elective cases with American Association of Anaesthesiologists Classification (American Society of Anaesthetists [ASA] 1). Selection criteria included consenting patients after a thorough explanation of the concept of day-case surgery. Patients between the ages of 16 and 59 years who lived with and were accompanied by an adult were included in the study. Exclusion criteria were overweight or obese patients, pediatric patients (below 16 years), elderly patients, (60 years and above), and patients of complicated appendicitis. This is because of the altered drug metabolism and excretion in the elderly and the obese patients. All the patients were admitted on the evening of the surgery. Preoperative investigations included full blood count, serum electrolytes, chest X-ray, and an anesthetic review on admission. The patients were encouraged to get up in bed 4-6 h after surgery and also to take liquid diet before discharge from the ward on the day of the surgery. All the patients had 4 mg of parenteral dexamethasone to prevent nausea intraoperatively and 75 mg of parenteral diclofenac at the end of the surgery. The patients were commenced on oral tramadol 50 mg 6 hourly and paracetamol 1 g 8 hourly until review at follow-up. Follow-up was scheduled for the 3 rd and 10 th postoperative days for all discharges.
All the patients had a standard three port laparoscopic appendicectomy consisting of a 10 mm umbilical port for the telescope and two working 5 mm ports in the left iliac fossa and the suprapubic region. The mobilization was with the use of blunt and sharp dissection. The mesoappendix was divided after coagulation using the bipolar diathermy. The appendix base was ligated using the extracorporeal knots. The specimen was retrieved through the 10 mm umbilical port under direct vision. The umbilical port was closed with a prolene "1" fascia suture whereas the three skin wounds were closed with vicryl "3/O."
All the patients were admitted on the evening of the surgery and were fasted overnight. Oral premedication diazepam 5 mg was given. All the patients were operated on the morning list under general anesthesia with endotracheal intubation. Intravenous metoclopramide 10 mg and dexamethasone 4 mg were given at induction as anti-emetic. Induction was with intravenous propofol 2 mg/kg. Intravenous fentanyl 1 μg/kg was administered at induction, intraoperative analgesia was maintained with boluses of fentanyl 0.5 μg/kg, and muscle relaxation for endotracheal intubation was with atracurium (0.5 mg/kg). Anesthesia was maintained with isoflurane 1.2% and oxygen. Heart rate, blood pressure, and oxygen saturation were recorded for every 5 min until the end of the surgery. The port sites were infiltrated with plain bupivacaine 0.5% before incision and placement of ports to minimize postoperative wound pain.
Intravenous paracetamol 1 g was administered 10 min to the completion of the surgery to all patients. Residual neuromuscular block was reversed with atropine 1.2 mg and neostigmine 2.5 mg. The patients were admitted to the recovery room and discharged to the ward when cardiopulmonary parameters and vital signs were stable.
In the ward, the patients were encouraged to get up 4-6 h after surgery to take liquid diet and were discharged from the ward in the evening once they fulfilled the discharge criteria.
The criteria for discharge included: (i) Stable vital signs for >90 min. (ii) No new signs or symptoms after the operation. (iii) Minimal nausea with oral fluids. (iv) Orientation to person, time, and place. (v) Adequate pain control with oral analgesics. (vi) No intraoperative surgical or anesthetic complication. (vii) Minimal dizziness after sitting for <30 min. (viii) A responsible escort.
| Results|| |
Twenty-five procedures were performed within this period, of which 20 fulfilled the inclusion criteria. However, 11 patients consented to the study. This consisted of four females and seven males. Age range was 16-42 years with a mean of 22 ± 8.15 standard deviation (SD). There was one conversion to open appendicectomy due to an ileocecal mass at the surgery. The duration of anesthesia from induction to the removal of the endotracheal tube ranged from 60 to 120 min with a mean duration of 82.1 ± 15.1 SD min. The duration of surgery measured from incision time to the time of closure of the umbilical port incision ranged from 45 to 110 min with a mean operation time of 50 ± 18.03 SD min. Anesthesia duration was 65.9 ± 6.35 min. All completed ten patients were ambulated 6 h after surgery and commenced oral sips shortly after. Five patients were discharged in the evening about 7-8 h after the surgery. Three patients were discharged home early the next day <24 h after the surgery. Two patients were discharged about 36 h after the surgery while the patient whose procedure was converted to an open procedure was discharged 4 days after the surgery [Figure 1]. Three patients were back to normal to daily activities in 3 days while the rest achieved normal activity levels in <7 days. There was one re-admission for vomiting which was attributed to tramadol medication.
| Discussion|| |
Day-case and short-stay laparoscopic surgeries are increasingly popular in developed countries.  The economic implications of day-case or short-stay surgery are substantial with a potential reduction in the cost of the operation by 11-25% per patient reported in some series.  The major problem associated with the acceptance of laparoscopy in developing countries, especially in our region, is the acceptance of laparoscopic surgery.  Second, the concept of day-case or short-stay surgery is alien to our culture where relatives think that all surgical procedures no matter how minor require prolonged admission. This is demonstrated in this study where 11 patients out of 20 consented to be included in the study. Short-stay surgery reduces the duration and cost of hospitalization. Similarly, it causes minimal disruption of family life style. Studies have revealed that 6 h is sufficient to detect most early postoperative complications. 
Anesthesia challenges can be managed with drug modifications. First-stage recovery in anesthesia lasts until the patient is awake, protective reflexes have returned, and pain is controlled. Modern anesthetic drugs and techniques allow complete early recovery at the time the patient leaves the operating theater.  This allows some patients to bypass the first-stage recovery area. Second-stage recovery ends when the patient is ready for discharge from the hospital. This is a nurse-led discharge using established unit protocols. The patients should be given verbal and written instructions on discharge. These instructions should be given in the presence of the escort who will care for the patient at home.
The success rate of short-stay surgery has been demonstrated in countries where it is routinely practiced. Proper patient selection improves the outcome.  Recurrent episodes of inflammation which are frequent in our patients cause adhesions around the appendix, consequently prolonging the operation time. This is demonstrated in one of our patients who had a conversion to open surgery because of a cecal mass. The patient had a right hemi-colectomy and was discharged home on the 4 th postoperative day. The histology report revealed inflammatory changes with no evidence of malignancy. Other factors associated with prolonged admission are the duration of surgery and the ASA. Adequate postoperative pain control and nausea are pertinent to short-stay surgery. These are issues taken into consideration both at the preanesthetic induction phase and intraoperatively. Two of our selected patients were discharged after 36 h as a result of inadequate pain control and nausea. A major factor which prolonged the duration of admission in some of our patients was the logistics of patient transfer to the operating room and a prolonged changeover period between surgical cases in the operating room. Despite these limitations, our pilot study demonstrates that short-stay surgery is safe and may become a standard protocol in future. Reduction in appropriate duration of hospital admission requires hospital organization. The short-stay unit (SSU) is a type of admission that can provide targeted care for patients requiring brief hospitalization ≤5 days. The SSU provides the same level of medical care as an ordinary ward. The SSU can be considered an alternative to conventional hospitalization.
However, there are some limitations in this study, which is the volume of patients despite recruiting patients for 12 months.
| Conclusion|| |
For selected patients, short-stay laparoscopic appendicectomy is feasible and safe. It provides a reduction in hospital costs and minimal disruption of the household. The duration of admission can be shortened further if the patients' preoperative reviews are done as outpatients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Al-Mulhim AA. Emergency general surgical admissions. Prospective institutional experience in non-traumatic acute abdomen: Implications for education, training and service. Saudi Med J 2006;27:1674-9.
Davies GM, Dasbach EJ, Teutsch S. The burden of appendicitis-related hospitalizations in the United States in 1997. Surg Infect (Larchmt) 2004;5:160-5.
Msika S, Iannelli A, Deroide G, Jouët P, Soulé JC, Kianmanesh R, et al.
Can laparoscopy reduce hospital stay in the treatment of Crohn's disease? Dis Colon Rectum 2001;44:1661-6.
Cash CL, Frazee RC, Smith RW, Davis ML, Hendricks JC, Childs EW, et al.
Outpatient laparoscopic appendectomy for acute appendicitis. Am Surg 2012;78:213-5.
Gurusamy K, Junnarkar S, Farouk M, Davidson B. Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy. Br J Surg 2008;95:161-8.
Ciardo LF, Agresta F, Bedin N. Day-case laparoscopic surgery for appendicitis and non-specific abdominal pain. Chir Ital 2007;59:299-304.
Kumar C, Page R, Smith I, Stocker M, Tickner C, Williams S, et al
. Day case and short stay surgery: Anaesthesia 2011;66:417-34.
Thomas WE, Senninger N. Short Stay Surgery. Springer-Verlag, Berlin, Heidelberg: New York; Science & Business Media; 2008.
Rosen MJ, Malm JA, Tarnoff M, Zuccala K, Ponsky JL. Cost-effectiveness of ambulatory laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2001;11:182-4.
Afuwape OO, Akute OO. The challenges and solutions of laparoscopic surgical practice in the developing countries. Niger Postgrad Med J 2011;18:197-9.
Sözen S, Ozdemir Cª. Day-case laparoscopic cholecystectomy: Is it a safe and feasible procedure? Eur J Gen Med 2010;7:372-6.
Erk G, Erdogan G, Sahin F, Taspinar V, Dikmen B. Which One Is Better Anesthetic For Laparoscopic Cholecystectomy: Desflurane, Sevoflurane or Propofol? Internet J Anesthesiol 2005;10:8.
Sato A, Terashita Y, Mori Y, Okubo T. Ambulatory laparoscopic cholecystectomy: An audit of day case vs overnight surgery at a community hospital in Japan. World J Gastrointest Surg 2012;4:296-300.