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Ambulatory open cholecystectomy and multimodal analgesia as the critical step: An observational study

Aim: Cholecystectomy is the most frequent, nonurgent surgery in the surgical services around the world. The access to laparoscopic cholecystectomy is neither always available in health services nor indicated in every patient. For this reason, the open approach is still frequently utilized. The objective of this study is to confirm the safety and feasibility of an ambulatory open cholecystectomy. Methods: From August 2015 to December 2015, patients aged 18-60 years underwent open cholecystectomy in a rural hospital in Chiapas of Mexico were included in this operational study. A multimodal analgesia protocol was employed including presurgical nonsteroidal anti-inflammatories (NSAIs), interpleural blockade before surgery, skin infiltration with local anesthetic, and the use of NSAIs and avoidance of opioids in the postoperative period. The visual analog scale (VAS) was evaluated at 4 and 8 h after surgery. Feeding began 4 h after surgery and walking after feeding. Discharge criteria included feeding tolerance and VAS < 3 points at 8 h after surgery. Patients returned next day for evaluation. Pathologic background, surgical findings and outcomes, VAS score, and length of hospital stay were registered and analyzed. Results: A total of 90 patients with 78 females (86.7%) were included in the study. Moreover, 48 patients (53.3%) presented acutely (first episode of cholecystitis). Complicated cholecystitis was presented in 6 cases (6.7%). Surgical complications included hypovolemic shock in 2 patients (2.2%), and postsurgical complications were present in 10 patients (11.1%). At 4 h after surgery, a VAS < 2 was seen in 44 patients (48%), VAS = 3 in 42 patients (46.7%), and VAS > 6 in 4 patients (4.4%). A total of 62 patients (68.9%) were completely ambulatory in < 12 h after open cholecystectomy and were discharged at that time. A total of 81 (90%) patients were discharged by 48 h after surgery. Conclusion: Ambulatory cholecystectomy is a safe and feasible surgical approach in the era of enhanced recovery programs. Multimodal analgesia is the key factor to achieve early walking, intestinal movements, and early feeding, allowing discharge after an uncomplicated.