This document discusses a review of 11 pediatric patients who underwent day case laparoscopic cholecystectomy (DCLC). Key findings include: - All 11 procedures were successfully completed without complications on an outpatient basis. - Rigorous patient selection criteria and a clinical care pathway that emphasized adequate pain management using a transversus abdominis plane block, early mobilization, and strict dietary guidelines helped ensure successful outcomes. - A multidisciplinary team approach involving surgeons, anesthesiologists, nurses, and families was essential to explain the procedure and discharge expectations to safely perform this major surgery in an ambulatory setting.

1. DAY CASE LAPAROSCOPIC
CHOLECYSTECTOMY (DCLC) IN
PEDIATRICS: A REVIEW OF 11 CASES
Dr Prakash Agarwal
Dr R.K.Bagdi
Apollo Children’s
Hospital, Chennai.

2. INTRODUCTION:
 Laparoscopic cholecystectomy (LC) as first
line treatment for symptomatic cholelithiasis
is well established.
 Introduction of day-case LC (DCLC) in adults
since 1990s in Pediatrics since 2003.
 DCLC is now listed on the British Association
of Day Surgery
 India: Day case surgical association.

3. AIM
 Clinical outcomes of Paediatric
laparoscopic Cholecystectomy in day care
 Cost-effectiveness
 The primary consideration however should
remain patient safety

4. DCLC IN ADULTS
“A recent meta-analysis of five randomized
controlled trials in adults demonstrated that
compared with overnight stay, DCLC is safe
and effective in selected patients and is likely to
save costs”

5. DCLC IN PEDIATRICS
• INCLUSION CRITERIA
- ASA Gr I & II
- Staying close to Hosp
- Willing to return to hosp in
case of problem
- Parents able to understand
the instructions well
• EXCLUSION CRITERIA
- Co-morbid conditions
- Raised LFT
- Staying far from the
hospital
- Insurance company not
agreeing for Day care
surgery
- If a second surgery is
planned
•The role of DCLC in pediatric practice is yet to be
established.
•There has been only two reports on DCLC in children

6. CLINICAL CARE PATHWAY
Referral of children with symptomatic cholelithiasis to outpatients clinic
History and examination & Informed consent for laparoscopic cholecystectomy
Outpatient CBC, U&Es, LFTs and abdominal ultrasound scan
Inclusion criteria for DCLC met-DCLC
scheduled
Inclusion criteria for DCLC not met-
DCLC not appropriate
Admission on morning of procedure and
LC on morning list
Anaesthetic/Analgesia
protocol
PONV prophylaxis and
management
Nursing Protocol

7. PATIENTS AND METHODS
• Data relating to the cases were collected
prospectively and clinical outcomes were
audited
• All patients were seen in the outpatient clinic
before DCLC
• Informed consent was obtained.
• Blood tests and an abdominal ultrasound scan
were requested.
• Patients were admitted electively on the
morning of the procedure and
• Underwent a LC on the morning list.

8. OPERATIVE CONSIDERATIONS
ANESTHESIA SURGERY
 Induction of anesthesia was
with propofol. All patients
were ventilated via an
endotracheal tube with air,
oxygen, and isoflurane.
 Prophylactic antiemesis –
ondansetron
 Analegsia – Tap Block
 A standard four-port technique
was used
 10mm at the umbilicus, 10mm
epigastric and 2 X 5mm at the
right iliac
fossa/hypochondrium
 CO2 insufflation below
12mmHg and rate from 1-3
L/min.
 At the end of procedure, an
attempt was made to
evacuate all CO2

9. TRANSVERSUS ABDOMINIS PLANE (TAP)
BLOCK

10. LAP CHOLE - OPERATIVE

11. POST OPERATIVE CONSIDERATIONS
 Early mobilization was encouraged
 Postoperative feeding regime from liquids to
light diet for 72 hours
 Pain was assessed by the Nurse and scored
using the Wong and Baker FACES pain rating
scale.
 Patients were reviewed in the afternoon by the
anesthetic team and jointly by the surgical and
the nursing team and a decision was made
regarding discharge
 Final decision regarding discharge made jointly

12. CRITERIA FOR DISCHARGE
• Normal temperature,
pulse and blood
pressure,
• Tolerance of fluid and
light diet,
• Adequate pain control,
comfortable
mobilization, and
patient/carer
satisfaction with
discharge.

13. RESULTS:
 Jan 2013-July 2013 = 11 patients
 M:F = 4:7
 Age = 15-10 years (11.8 years)
 Indications for surgery – Persisting pain
abdomen
 Co-morbid conditions – Obesity in 2 children
 Ultrasound: Done preoperatively to diagnose
cholelithiasis in all patients

14. RESULTS
• Duration of Surgery- 45-70 min (Avg 57 min)
• Intra operative problems - Nil
• Post operative problems - Nil
• Conversion to open - Nil
• Pain score at Discharge – 3/10
• PONV - Tolerable
• Pain score on follow up – 2/10 (R shoulder
tip pain =4)

15. CONCLUSION
• Admission on the day before the procedure was
unnecessary
• Explanation of the procedure and discharge
policy to the families in the outpatient setting
was extremely important in acceptance of
having a major procedure performed in an
ambulatory setting,
• The use of Transversus abdominis plane (TAP)
block is the cornerstone if success behind
DCLC.

16. ROLE OF THE NURSING TEAM
 Should not be underestimated.
 Requires a major shift away from a traditional
conservative approach with regard to
introduction of enteral feeds, mobilization,
and pain management.
 Introduce an element of balance to the
decision regarding patient discharge

17. SUCCESSFUL OUTCOME
• Rigorous patient selection is a prerequisite for
the success of DCLC.
• A cornerstone of successful DCLC practice is
adequate pain management. The use of
transversus abdominis plane block
demonstrated huge benefits.
• No PONV due to routine combination
intraoperative antiemetics, minimization of the
use of long acting intravenous opioids, and a
strict dietary regime

18. TAKE HOME MESSAGE
• DCLC in children is feasible in the majority of
patients requiring cholecystectomy as a sole
procedure
• Performed with excellent results without
compromising patient safety.
• A multidisciplinary team approach
• Adoption of a clinical care pathway
• Adequate pain management and avoidance of
PONV are a prerequisite for success.

19. LITERATURE