Correspondence:
Dr. Wai Key YUEN FRCS FACS FRACS, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China.
Tel: (852) 28553024; Fax: (852) 28165284; E-mail: wkyuen@ha.org.hk

To cite this article:
Chok Siu Ho Kenneth, Lau Hung, Yuen Wai Key. Development of Outpatient Laparoscopic Surgery in Hong Kong. Day Surg J India 2006; 2:29-

Since the introduction of laparoscopic surgery in the late 1980s and early 1990s, it has soon become the standard treatment for a variety of diseases. In recent studies, some of the laparoscopic procedures have been evaluated as a safe and effective outpatient procedure (1, 2). In Hong Kong, we have been practising outpatient laparoscopic cholecystectomy (LC) and outpatient endoscopic totally extraperitoneal inguinal hernioplasty (TEP) since 2000 and 2001, respectively (2-4). Now they have become our standard treatments for selected patients with symptomatic gallstone diseases and groin hernias. Unlike other western countries, advocating outpatient procedures in Hong Kong is not cost-driven but patient-driven. Patients in Hong Kong have a drive to receive a high standard of surgical service and alternative treatments for surgical diseases.

Since 2000, we have been routinely performed outpatient LC in selected groups of patients with symptomatic gallstone diseases. Patients of

American Society of Anaesthesiologists (ASA) risk classification I or II, less than 70 years of full perioperative details were explained. They would be given the date of operation and written instructions concerning the preparation, admission and highlights of procedures. Patients were admitted at 7:30 am on the day of operation.

Outpatient LC was defined as operations performed on patients who could be discharged before 6:00 pm on the day of operation. We adopted the standard four-port technique using 12 mmHg of CO2 pneumoperitoneum, and intraoperative cholangiography was not routinely used. Gastric tube and Foley catheter were not used. More than 95% of the patients were operated by two experienced specialist surgeons (YWK, LH) and the remaining 5% of the cases was performed by higher surgical trainees under supervision. Patients were then transferred to Day Surgery Centre for close observation.

In 2000, the successful outpatient LC rate was only 72.7%, among which 8% was overnight stay and the was induced using intravenous propofol and fentanyl at the body-mass-dependent dose. Following an endotracheal intubation, all patients were put on mechanical ventilation and on inhalational anaesthetic agents (nitric oxide and isoflurane) for maintenance. Before reversal of the anaesthesia, all of them would be given intravenous metoclopramide as the anti-emetics. Another dose of metoclopramide or ondansetron would be given when necessary after the procedure if they developed repeated vomiting. Opiate- free anaesthetic protocol, involvement of an experienced anaesthesiologist and good communication between the anaesthesiologist and the operating surgeon (so as to reduce inhalational anaesthetic gas at the end of operation earlier) would be the keys to the avoidance of postoperative nausea and vomiting.
At the end of the operation, all port-sites would be infiltrated with 2-3 ml of 0.25% bupivacaine. After the operation, all patients were given adequate oral DologesicÒ (Llorens Pharmaceuticals, Miami, FL, USA) 1 tablet every 6 hours and diclofenac (Voltaren SRÒ; Novartis Pharmaceuticals, Basel, Switzerland) 100 mg tablet daily when necessary. Pain control based on the above regimen was excellent (3-4).

TEP was first performed in 1999 at our institution. With an experience of 200 in-patient TEPs, outpatient TEP has been performed since 2001. Between March 2001 and 2003, patients who underwent outpatient TEP by a single surgeon (HL) at our department were recruited. Inclusion criteria were reducibility of the inguinal hernia, ASA risk classification of I or II, as well as the presence of a competent adult to accompany the patient home and look after the patient for 24 hours. In addition, patients had to live within one hour’s travel to the hospital. Previous lower abdominal surgery was considered a contraindication for TEP.

All patients were admitted to DSC on the day of operation. Pre-emptive ketorolac 30 mg was administered intravenously upon induction of general anaesthesia. The standard anaesthetic protocol and the anaesthetic team were the same as described in outpatient LC. The operative details were described elsewhere (6). A three-port technique was employed. Balloon dissection and urinary catheter were not utilized. The extraperitoneal space was dissected and created using endoscissors with diathermy. A Prolene mesh of 10 x 14 cm2 (Ethicon, Inc., Somerville, NJ, USA) was placed to cover the deep inguinal ring, the posterior wall of the inguinal canal, and the femoral ring. Wounds were infiltrated with 0.5% bupivacaine as in outpatient LC.

A total of 417 patients underwent TEP during the study period. One hundred and two patients (24.5%) with 114 inguinal hernias, who underwent TEP as an outpatient procedure, were recruited. All TEPs were successfully performed. None of the patients required conversion. The successful rate was 97%. Three patients were admitted overnight because of ECG changes during surgery and dizziness. One patient required readmission to hospital on postoperative day one because of wound pain and vomiting. Overall, the rate of postoperative nausea and vomiting was very low. Only mild postoperative complications such as: seroma and bruising, were encountered, but they were all self-limiting. No recurrence was noted at a mean follow-up of 5 months (2).
The important roles of DSC, a standardized anaesthetic protocol and postoperative pain management as well as the PAC have been previously discussed. In addition, a randomized trial was conducted to compare the outcomes of outpatient TEP with outpatient open Lichtenstein hernioplasty.

Comparison with outpatient Lichtenstein hernioplasty in male patients:

From 2002 to 2004, a total of 200 male patients were randomized to undergo either outpatient unilateral TEP or open Lichtenstein hernioplasty under general anaesthesia. All TEPd were successfully performed without conversion. The mean operation time for TEP (50 ± 13.2 min) was significantly shorter than that for open repair (58 ± 17.6 min) (P < 0.001). The pain score at rest was significantly lower in the TEP group than in the open group. On average, the patients returned to work 8.6 days after TEP and 14 days after Lichtenstein hernioplasty (P = 0.006).
The incidence of chronic groin pain 1 year after TEP (9.9 %) was significantly lower than that after open surgery (21.7%) (P = 0.032).
In conclusion, outpatient TEP was superior to open Lichtenstein hernioplasty for repair of primary inguinal hernia in male patients. The benefits of outpatient TEP included less pain, a faster return to work, and a lower incidence of chronic groin pain (7).

Despite the early success in outpatient LC, striving for a higher standard of patient care is still the ultimate goal for surgeons. Recently, a randomized trial was conducted at our department to compare low-pressure (7 mmHg) versus standard-pressure pneumoperitoneum (12 mmHg) in outpatient LC. It was shown that for simple and uncomplicated gallstone diseases, low-pressure pneumoperitoneum was safe and effective with similar outcomes when compared with diseases treated under standard-pressure pneumoperitoneum (8).

Our results showed that most patients undergoing laparoscopic surgery had a high level of satisfaction (3). Less than 3% of the patients refused an outpatient LC if they were to be treated again, reflecting that patient acceptance was high (3). Opponents against outpatient laparoscopic surgery, probably is because of its potential complications, and more importantly, delayed diagnosis due to early discharge. Previous studies showed that most postoperative complications related to LC such as bile leakage, retained ductal stones and biliary pancreatitis were not apparent on the first 2 days of postoperation (11-13). After patients were discharged from the hospital, the nursing staff in DSC would perform telephone follow-up on postoperative days 1 and 3. Possible complications such as abnormal discharge from wound, unusual degree of wound or abdominal pain and fever would be noted. After initial assessment on the phone, patients would be arranged to have a follow-up by the operating surgeon at their earliest convenience. So far, no major complications have been encountered.