Single incision laparoscopic cholecystectomy (SILC) is the most common SILS procedure that has gained momentum in general surgery. The goals of SILC/LESS cholecystectomy are similar to those behind the development of NOTES: decreased pain, decreased length of hospital stay and better aesthetic results that lead to increased patient satisfaction [1].

One of the latest advancements in the field of laparoscopic surgery is the introduction of Day Care Surgery. Day Care Surgery is described as the admission of selected patients for a planned surgical procedure, returning home on the very same day after the operative procedure [2]. Ability to provide high quality and cost-effective care has made ambulatory surgery one of the fastest growing areas in the health care system all over the world. Primary aim of the Day Care Surgery is to avoid special hospitalization but the patient safety is the ultimate goal of the concept [3]. Many studies have been performed in India to see the feasibility and safety of day care laparoscopic cholecystectomy and have reported it to be safe, feasible, and acceptable to patients and with social and economic benefits [4]. Currently, very few data is available on Day Care Single Incision Laparoscopic Cholecystectomy (SILC). Hence, in this study we aimed to compliance and satisfaction of in a hilly terrain like Shimla.

Set Up

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

Study Period

One-year w.e.f.1^st July 2018 to 30^th 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 and 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). Before the surgery, all patients had basic investigations such as routine haematological and biochemical investigations, electrocardiogram, ultrasonography of the abdomen and radiologic imaging such as chest radiograph done. All operations were performed by same group of surgeons.

Observation and Result

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:

Table 1: Look of Scar

Patient satisfaction in terms of recommending it to relatives

Table 2: recommending the procedure to relatives

Sex Distribution

Out of 30 patients 29 were female and 1 was male.

Age

• 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 

Patient Satisfaction Based on Look of the Scar 

Patients were asked to rate the look of their scar on a scale of 0-4 after one month of surgery. None of the patients were totally dissatisfied with the look of their scar. Maximum number of patients (90%) were completely satisfied with the look of their scar (Table 1).

On asking about their satisfaction of the procedure and whether they will recommend it to their relatives 90 % patients said that they will definitely do so (Table 2).

The aim of the present study was to assess the feasibility of SILC as Day Care Surgery in a tertiary care center with hilly terrain and to assess the compliance and satisfaction of patients for Day Care Surgery. 

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. 

Modes of assessing cosmesis varied between various studies [9]. We analyzed cosmetic outcome in our patients based on 3 parameters; healing of the wound, look of their scar and whether they will recommend it to relatives. Mean heal score was 3.733±0.827. 100% were satisfied with the look of their scar. 90% of patients felt that they would definitely recommend the procedure to their relatives.

Singh et al. used body image score for cosmetic analysis. They observed none of the patient felt a poor score at 1 week or 3 weeks. Excellent score was recorded in 73.3 % patients in SILC while none of the patient in FPLC (four port laparoscopic cholecystectomy) group had an excellent score at one week. At three weeks, 100 % were fully satisfied by their scar in SILC while 63.3 % had excellent score in FPLC [10].

Cosmetic score was evaluated after 4 weeks and was based on patient satisfaction. Three parameters taken were scar heal score, look of the scar and whether patient will recommend this surgery to family and friends. 

1. Gollan, J.L. et al. “Foreword: Gallstones and laparoscopic cholecystectomy.” The American Journal of Surgery, vol. 165, no. 4, January 1993, pp. 388–389.

2. Keulmans, Y. et al. “Laparoscopic cholecystectomy: Day care versus clinical observation.” Annals of Surgery, vol. 228, 1998, pp. 734–740.

3. Reynolds, J.W. “The first laparoscopic cholecystectomy.” JSLS: Journal of the Society of Laparoendoscopic Surgeons, vol. 5, no. 1, January 2001, pp. 89.

4. Kaman, L. et al. “Relevance of day care laparoscopic cholecystectomy in a developing nation.” Tropical Gastroenterology, vol. 26, no. 2, 2005, pp. 95–97.

5. Garg, P. et al. “Single-incision laparoscopic cholecystectomy vs. conventional laparoscopic cholecystectomy: A meta-analysis of randomized controlled trials.” Journal of Gastrointestinal Surgery, vol. 16, 2012, pp. 1618–1628.

6. Singh, M. et al. “Single-incision laparoscopic cholecystectomy using conventional laparoscopic instruments and comparison with three-port cholecystectomy.” Indian Journal of Surgery, vol. 77, 2015, pp. 546–550.