the increasing need for cost savings and the safety of the procedure has led to this procedure being carried out on a day case basis . this has been shown to be quite effective in the developed countries where there are well established day surgery facilities . developing countries have also shown the feasibility and safety of conducting day case laparoscopic cholecystectomy . laparoscopic cholecystectomy has been the default operation for symptomatic gall stones in our health facility since 2007 . we therefore initiated this prospective study to determine the feasibility of conducting day case laparoscopic cholecystectomy , even in the absence of an autonomous day case surgery unit . it is also one of the few hospitals that carry out minimal access general surgery in eastern nigeria . all patients who had symptomatic ultrasound - confirmed cholelithiasis from may 2010 to april 2012 were evaluated for possible inclusion in this study . the eligibility criteria set out in conjunction with the anaesthetic department were : 
 age < 65 yearsbody mass index < 35 kg / mamerican society of anaesthesiology ( asa ) physical status classification : class i and iipatient s place of temporary or permanent residence within 20-kilometre drive from the hospitalpatient acceptance of the procedurepresence of a responsible adult to accompany the patient to his / her residence 
 patients who had acute cholecystitis or previous history of complicated upper abdominal surgery were excluded from the study . also excluded , were patients with a previous history of jaundice , pancreatitis or cases where there was a suspicion of stone in the common bile duct . the operating surgeon counselled the patients on the experimental nature of the study and also obtained consent from the patient . body mass index < 35 kg / m american society of anaesthesiology ( asa ) physical status classification : class i and ii patient s place of temporary or permanent residence within 20-kilometre drive from the hospital patient acceptance of the procedure presence of a responsible adult to accompany the patient to his / her residence the patient attended anaesthesiology consultation prior to surgery , where the asa score was assigned . patients were prescribed 10 mg diazepam to be taken on the night before surgery . on the day of surgery patients were told to present themselves for admission before 7.00 a.m. eligible patients were listed first on the day s operation list . general anaesthesia was induced with propofol 2.5 mg / kg . for maintenance , propofol and halothane intravenous ceftriazone , 1 g , and metoclopramide , 10 mg , were given at induction of anaesthesia . intramuscular diclofenac , 75 mg or intravenous pethidine 1 mg / kg was given intra - operatively . the nasogastric tube and urethral catheter inserted after induction of anaesthesia was removed at the end of the surgical procedure . standard four - port technique was utilized : 10 mm infraumbilical port for the 0 laparoscope , 10 mm sub - xiphoid port , and 5 mm subcostal ports at the right mid - clavicular and anterior axillary lines . electrosurgical current attached to maryland forceps was used for initial dissection to create a critical view of the calot s triangle . the cystic duct and artery the gallbladder was retrieved from the sub - xiphoid port . at the end of the procedure , the objective was for the patient to ambulate and take oral fluids within 4 hours of the operation . patients were evaluated by the surgical team in the ward and discharged if established criteria are met : awake and oriented , adequate pain control , ability to tolerate fluids , ability to ambulate and pass urine as well the patients desire to go home . on discharge patients were reviewed at surgery outpatient clinic on the ninth postoperative day where an assessment of port sites was made . all patients who had symptomatic ultrasound - confirmed cholelithiasis from may 2010 to april 2012 were evaluated for possible inclusion in this study . the eligibility criteria set out in conjunction with the anaesthetic department were : 
 age < 65 yearsbody mass index < 35 kg / mamerican society of anaesthesiology ( asa ) physical status classification : class i and iipatient s place of temporary or permanent residence within 20-kilometre drive from the hospitalpatient acceptance of the procedurepresence of a responsible adult to accompany the patient to his / her residence 
 patients who had acute cholecystitis or previous history of complicated upper abdominal surgery were excluded from the study . also excluded , were patients with a previous history of jaundice , pancreatitis or cases where there was a suspicion of stone in the common bile duct . the operating surgeon counselled the patients on the experimental nature of the study and also obtained consent from the patient . body mass index < 35 kg / m american society of anaesthesiology ( asa ) physical status classification : class i and ii patient s place of temporary or permanent residence within 20-kilometre drive from the hospital patient acceptance of the procedure presence of a responsible adult to accompany the patient to his / her residence the patient attended anaesthesiology consultation prior to surgery , where the asa score was assigned . patients were prescribed 10 mg diazepam to be taken on the night before surgery . on the day of surgery patients were told to present themselves for admission before 7.00 a.m. eligible patients were listed first on the day s operation list . general anaesthesia was induced with propofol 2.5 mg / kg . for maintenance , propofol and halothane intravenous ceftriazone , 1 g , and metoclopramide , 10 mg , were given at induction of anaesthesia . intramuscular diclofenac , 75 mg or intravenous pethidine 1 mg / kg was given intra - operatively . the nasogastric tube and urethral catheter inserted after induction of anaesthesia was removed at the end of the surgical procedure . standard four - port technique was utilized : 10 mm infraumbilical port for the 0 laparoscope , 10 mm sub - xiphoid port , and 5 mm subcostal ports at the right mid - clavicular and anterior axillary lines . electrosurgical current attached to maryland forceps was used for initial dissection to create a critical view of the calot s triangle . the cystic duct and artery the gallbladder was retrieved from the sub - xiphoid port . at the end of the procedure , the objective was for the patient to ambulate and take oral fluids within 4 hours of the operation . patients were evaluated by the surgical team in the ward and discharged if established criteria are met : awake and oriented , adequate pain control , ability to tolerate fluids , ability to ambulate and pass urine as well the patients desire to go home . on discharge patients were reviewed at surgery outpatient clinic on the ninth postoperative day where an assessment of port sites was made . a total of 17 patients underwent laparoscopic cholecystectomy within the study period , out of which 12 patients ( 10 females and 2 males ) were worked up with the intent of achieving same - day discharge of the patient . summary of data of 12 patients intended for day case laparoscopic cholecystectomy there was no case of conversion to open cholecystectomy . five of the patients were discharged home on the day of the surgery while six were discharged after overnight stay . one patient , who had a drain , was discharged on the 2 postoperative day . one of the patients was an obese patient , who had spillage of intra - peritoneal bile and stones ; the others were attributable to improper closure of the port site with braided polyglactin 910 suture . the average age of patients discharged on the day of operation was 46.4 years compared to 50.6 years for those who were admitted . the duration of operation was longer in the patients that were eventually admitted ( 91.9 vs. 67.8 minutes ) , as shown in table 3 . reasons for failure of same - day discharge comparison of patients discharged same day vs. patients admitted day surgery procedures ideally should be carried out within the framework of a day surgery unit . this is more convenient for the patient and more cost - effective for the hospital in the face of competing demands for available bed spaces . this is not the case in nigeria where most day surgery cases are managed in general surgical wards . the clinical and nursing staff are not attuned to the demands of carrying out day - care surgery . these can be detected during surgery , and their incidences have been decreasing as proficiency increases . avoiding these major complications will reduce the chance of conversion to open operations , prolonged admission and readmission rates . this could be attributed to our painstaking approach to the surgery , especially in the early cases . the flip side is that prolonged surgery makes it difficult to achieve the aim of day case surgery . outpatient laparoscopic cholecystectomy is safe and cost - effective in a select group of patients . in fact , up to 70% of patients with symptomatic cholelithiasis undergoing laparoscopic cholecystectomy may be good candidates for same - day discharge . there is some difficulty , particularly , working against the mindset of patients who consider laparoscopic cholecystectomy a major surgical operation that must be followed by postoperative admission for observation . we did not have ready access to plain bupivacaine for infiltration at the trocar sites , neither did we instil any intraperitoneal local anaesthetic . incisional and intraperitoneal instillation of long acting local anaesthetics have been found useful in the multimodality management of postoperative pain especially in the setting of ambulatory care . the duration of surgery is an important factor in determining unplanned admissions after laparoscopic cholecystectomy . this is not only a reflection on the experience of the surgeon , but also the difficulty encountered in cases with thickened gallbladder and adhesions . the average duration of operation in our series was 82 minutes and this would have adversely affected early discharge . we did anticipate that delay in starting operations may defeat the aim of achieving successful same - day discharge . and we defined late operations as those commencing after 10.00 a.m. this was done so that the patient can have 4 - 6 hour postoperative recovery time before discharge . the timing was quite conservative when compared to findings in more experienced centres with day surgery units , where late operations are defined as operations starting after 1.00 p.m. a potential drawback of this study is the relative paucity of patients , which presents difficulties in drawing conclusions . however , there is a relative rarity of gallstone disease in our region , in comparison to asian and western populations . the admission rate of 58.3% is quite high when juxtaposed with current literature.[414 ] since this is a preliminary report , we believe that lessons learnt in this early phase will improve the outcome in future patients . these patients will also benefit from ondansetron , which has been shown to be highly beneficial against postoperative emesis . the demonstrable safety of laparoscopic cholecystectomy in our setting is a spur that will continue to make the case for outpatient operation . this will be boosted by establishment of day surgery unit in our hospital as well as increased proficiency of the clinical staff .
background and objective : laparoscopic cholecystectomy has been the default operation for cholelithiasis at federal medical centre , owerri for the past 2 years and the outcomes have been good . 
 the duration of post operative stay has been decreasing . 
 we therefore initiated a preliminary 2-year prospective study in may 2010 to determine the feasibility of carrying out day case laparoscopic cholecystectomy in our hospital.materials and methods : patients undergoing laparoscopic cholecystectomy were included in the study if they satisfied the following criteria : age < 65 years , body mass index < 35 kg / m2 , american society of anaesthesiology physical status class i and ii , patient residence within 20 km radius of the hospital , patient acceptance of the procedure and absence of previous complicated upper abdominal surgery.results:twelve patients ( 10 females , 2 males ) were worked up with the intent of achieving same - day discharge of the patients . 
 five of the patients ( 41.7% ) were discharged on the day of operation . 
 the reasons for overnight stay included inadequate pain control , insertion of drain and patient wishes . 
 there was no conversion to open surgery , no major complications and no case of readmission to the hospital.conclusions:day case laparoscopic cholecystectomy in our environment could be safely promoted but will depend on improved facilities and patient enlightenment .