Ambulatory laparoscopic fundoplication.
BACKGROUND
Increasingly larger series of laparoscopic fundoplications (LF) are being reported. A well-documented advantage of the laparoscopic approach is shortened hospital stay. Most centers report typical lengths of stay (LOS) for LF of 2-3 days. Our success with LF with a LOS of 1 day led to an attempt at performing LF on an ambulatory basis.


METHODS
Sixty-one consecutive patients with appropriate criteria for LF underwent surgery at our institution. Patients were counseled by the authors as to the usual postop course and progression of diet. All patients received preemptive analgesia (PEA) consisting of perioperative ketorolac and preincisional local infiltration with bupivicaine. Anesthetic management included induction with propofol, high-dose inhalational anesthetics, minimizing administration of parenteral narcotics, and avoidance of reversal of neuromuscular blockade. Immediate postop pain management included parenteral ketorolac and oral hydro- or oxycodone. All patients were given oral fluids and soft solids after transfer from the recovery room to the postoperative observation unit. Two patients were excluded from ambulatory consideration due to excessive driving distance from our hospital. Another two were hospitalized for observation after experiencing intraoperative technical problems.


RESULTS
Of 57 patients in whom same-day discharge was attempted, there were three failures requiring overnight hospitalization: All were due to pain and nausea; one patient also suffered transient urinary retention. There were no adverse outcomes related to early discharge, and there were no readmissions. One patient returned to the emergency room after delayed development of urinary retention. Median time from conclusion of operation to discharge was less than 5 h. No patients expressed dissatisfaction with early discharge on follow-up interview.


CONCLUSIONS
LF can be safely performed as an ambulatory procedure. Analgesic and anesthetic management should be tailored to minimize nausea and provide adequate pain control.
Milford
M A
MA
Department of Surgery, Kaiser Foundation Medical Center, 4647 Zion Avenue, San Diego, CA 92120, USA.
Paluch
T A
TA
D000328:Adult; D000368:Aged; D000556:Ambulatory Surgical Procedures; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000627:therapeutic use; D018685:Anesthetics, Inhalation / Q000008:administration & dosage; D018686:Anesthetics, Intravenous; D000779:Anesthetics, Local / Q000008:administration & dosage; D002045:Bupivacaine / Q000008:administration & dosage; D004032:Diet; D004750:Enteral Nutrition; D005260:Female; D018662:Fundoplication / Q000009:adverse effects / Q000379:methods*; D006760:Hospitalization; D006801:Humans; D006853:Hydrocodone / Q000627:therapeutic use; D007279:Injections, Subcutaneous; D020910:Ketorolac; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000209:etiology; D010098:Oxycodone / Q000627:therapeutic use; D010149:Postoperative Pain / Q000209:etiology / Q000517:prevention & control; D010353:Patient Education as Topic; D010359:Patient Readmission; D017060:Patient Satisfaction; D011182:Postoperative Care; D011292:Premedication; D015742:Propofol / Q000008:administration & dosage; D014046:Tolmetin / Q000031:analogs & derivatives / Q000627:therapeutic use; D016055:Urinary Retention / Q000209:etiology
D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D018685:Anesthetics, Inhalation; D018686:Anesthetics, Intravenous; D000779:Anesthetics, Local; D006853:Hydrocodone; D010098:Oxycodone; D014046:Tolmetin; D002045:Bupivacaine; D015742:Propofol; D020910:Ketorolac