Laparoscopic cholecystectomy has been performed since 1985 and throughout the next two decades this procedure became the standard of care for gallbladder disease [1]. Laparoscopic cholecystectomy has traditionally been performed using multiple small incisions/port sites. Single-incision or single-site, laparoscopic surgery has emerged as an alternative technique to improve cosmesis and minimize complications associated with multiple incisions. The first published report of a single skin incision laparoscopic cholecystectomy was by Navarra in 1997 [2]. Since that time, the idea of “scarless” surgery has gained increasing popularity among patients as well as surgeons.

Set Up

A tertiary care hospital-based study in the department of General Surgery, IGMC, Shimla

Study Period

One-year w.e.f.1st July 2018 to 30th June 2019

Setting

This study was done in a single unit of the Department of General Surgery at Indira Gandhi Medical College and Hospital, Shimla w.e.f. July 2018 to June 2019 on patients admitted for surgery

Study Design

Observational study

Selection of Cases

Inclusion Criteria 

• Age less than 70 years 

• ASA 1 & 2 

• Patient should be staying within 1hour of travelling distance from the hospital with adequate motivational level

• Has telephone access 

• Living with a responsible adult

• Able to reach the hospital on their own with or without depending on Emergency Medical Services (EMS)

• Able to understand discharge instructions

• Agrees to do the procedure as an outpatient, (informed consent)

• Has symptomatic uncomplicated gall bladder disease (gall bladder stones or polyps)

Exclusion Criteria

Patients with the following criteria were excluded:

• Patients with extreme obesity and co-morbid conditions like poorly controlled diabetes, hypertension and coronary artery disease or ischaemic heart disease

• Attacks of acute pancreatitis

• Choledocholithiasis with cholelithiasis

• Acute cholecystitis

• BMI > 40 kg/m2

• ASA grade more than II

• Lack of written informed consent

• Patients on warfarin

• Bleeding disorder

• Previous upper abdominal surgery

Self-reported data related to demographic characteristics and history was recorded as per structured data recording format. This was followed by anthropometric measurement using validated tools. BMI was calculated as ratio of weight in kilograms divided by height in square metres (kg/m2).

The present study was aimed to evaluate the feasibility and safety of SILC as a day care procedure. A total of 30 patients were included in the study over the period of one year at Department of General Surgery, Indira Gandhi Medical College, Shimla. Results of the study have been described below:

Sex Distribution

Out of 30 patients 29 were female and 1 was male (Table 1), while;

• Mean age of the study participants was 33.83 years. 

• 47% of the patients aged between 31 and 40 years while 40% of the patients aged below 30 years. 

• Only 3% of the patients aged more than 50 years

BMI

• Mean BMI of the study participants was 24.03 Kg/m2. 

• 54% of the patients were overweight to obese while 30% were normal (Table 2).

Table 1: Age-Based distribution of patients

Table 2: BMI-Based distribution of patients

As data is lacking in literature for day care SILC, so for our discussion we have compared our parameters with different SILC studies and studies from day care four port laparoscopic cholecystectomies.

The majority of our patients were of 20 km radius. This is obviously a variable that depends on economic resources, existing transport services and the geography of the terrain and our criterion is merely illustrative and intended to serve only as a guideline and/or methodological tool. Though the onus of reaching the hospital for perioperative problems was on the patient, our results suggest a satisfactory outcome if patients and relatives understand the issues related to Day Care Surgery and the response expected from them. It also appears that domiciliary perioperative care, even in our set-up, is feasible and reliable. Provided the pathways of care are clearly defined and understood, similar results can probably be achieved in most situations. 

In our study, the age of the patients ranged between 20 and 76 years with mean age 33.83 years. Park et al. had the mean patient age of 42.5 years [3]. Most of the studies had mean age between 40-50 years. This is because this is the commonest age group in which gall stone disease manifests [4,5].

There was no age limit in the present study. 86% of the patients in our study aged <40 years. There were no adverse peri-operative outcomes in the study depending on age factors and age has nothing to do with the acceptability for Day Care Surgery. 

Females outnumbered males in our study. There were 96.6% females and only 3.3 % males. In a study by Rivas et al. 85 % were females [5]. Saad et al. had a greater number of male patients [6].

BMI ranged between 18 and 30 kg/m2. Mean BMI of 24.03 kg/m2. Rivas et al. operated-on patients with mean BMI were 29.8 kg/m3.6 BMI in a study by Jorgensen was 26.6.4 In this present study, mean BMI of the study participants was 24.03 Kg/m2. 54% of the patients were overweight to obese while 30% were normal. Literature suggest that high BMI is a well-established risk factor for the formation of gallstones and, as a result, a large proportion of patients who require surgery for gallstone disease fall into the overweight (BMI 25–29 kg/m2), obese (BMI 30–39 kg/m2) or morbidly obese (BMI ≥40 kg/m2) categories. While these patients have long been assumed to present additional anesthetic risk, recent increases in the practice of bariatric surgery and the widening of the criteria for fitness for surgery has suggest that this risk may have been overestimated.

We conclude that most of patients were young female

1. Reynolds, W. Jr. "The first laparoscopic cholecystectomy." JSLS: Journal of the Society of Laparoendoscopic Surgeons, vol. 5, no. 1, 2001, pp. 89–94.

2. Navarra, G. et al. "One-Wound Laparoscopic Cholecystectomy." Journal of British Surgery, vol. 84, no. 5, 1997, p. 695.

3. Jørgensen, L.N. et al. "Randomized clinical trial of single-versus multi-incision laparoscopic cholecystectomy." Journal of British Surgery, vol. 101, no. 4, 2014, pp. 347–355.

4. Lurje, G. et al. "Cosmesis and body image in patients undergoing single-port versus conventional laparoscopic cholecystectomy: a multicenter double-blinded randomized controlled trial (SPOCC-Trial)." Annals of Surgery, vol. 262, no. 5, 2015, pp. 728–735.

5. Rivas, H. et al. "Single-Incision laparoscopic cholecystectomy: initial evaluation of a large series of patients." Surgical Endoscopy, vol. 24, no. 6, 2010, pp. 1403–1412.

6. Saad, S. et al. "Randomized clinical trial of single-port, minilaparoscopic and conventional laparoscopic cholecystectomy." Journal of British Surgery, vol. 100, no. 3, 2013, pp. 339–349.