الفهرس 
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Abstract
Cholecystectomy is the only effective management of symptomatic gallstones, with 93% of gallbladder disease problems referred to surgeons. Open cholecystectomy (OC) has been widely replaced by laparoscopic cholecystectomy (LC). Cholecystectomy can be performed either laparoscopically, using a video camera, or via an open surgical technique. LC has proven to be a safe procedure with multiple benefits to the patients, including reduced postoperative pain, smaller scars, shorter hospital stay, shorter convalescence period, and decreased risk of selected complications compared with open cholecystectomy.
There are several patients who have had a postoperative hospital stay of more than 24 hours, due to conversion to open surgery or complications. Thus, the factors predicting this should be investigated to inform the at-risk patients. The complications encountered during laparoscopic cholecystectomy are numerous: some that are specific to this unique technique and some that are common to laparoscopic surgery in general.
Different risk factors have been described as decisive for conversion, such as male gender, patients older than 50 years, obesity, history of abdominal surgery, emergency surgery, increase in C-reactive protein, elevated leukocytes and alkaline phosphatase, ultrasound findings such as thickening of the gallbladder wall, dilatation of the common bile duct and a scleroatrophic gallbladder, history of cirrhosis and portal hypertension, acute biliary pancreatitis, Mirizzi’s syndrome, gallbladder cancer, the experience of the surgical team and a biliary duct injury.
Aim of the study:
This study aims to assess factors contributing long hospital stay in patient undergoing laparoscopic cholecystectomy, through:
1- Assess patients’ related factors including demographic data and medical health history:
2- Assess intra operative related factors.
3- Assess postoperative related factors.
Research Question:
The current study is based on answering the following question:
- What are the factors that contributing long hospital stay in patient under going on laparoscopic cholecystectomy?
Operational definition of Long hospital stay
- Can be defined as patient with long stay postoperative >24 hours (Rice et al., 2019).
Research Design
A descriptive exploratory design was used to conduct this study. Descriptive exploratory design defines the variables and determines they interact with each other and identifies cause and effect relationships (Rendle et al., 2019).
Study Settings
The study was conducted in The National Liver Institute in Menoufia University, Department of Surgery. In fifth flour which consists of
• 16 rooms double beds.
• 16 rooms single private.
• Intensive care unit with 12 peds.
• Intermediate care unit with 8 beds.
• The total capacity (68 beds) in department of surgery.
Subject:
The study subjects included 66 patients who attended previously mentioned-setting during 2022 and willing to participate in the study.
Tools of data collection:
Two tools were used in this study and classified as the following:
Tool I. Factors contributing long hospital stay assessment questionnaire:
This tool was developed by the researcher based on the related literatures, it consists of five parts.
Part I: Patients related factors: it was included two sections
Section I: demographic characteristics it was include 6 items it was used to assess patients’ age, gender, occupation, marital status, educational level and residence (Ko-Iam et al., 2017).
Section II: Medical health was include 6 items history it was used to assess present, past, medication, surgical, family medical history and patients lifestyle.
This part adopted from (López-Torres López et al., 2021).
Part II: Pre-operative Preparation Related Factors: it was used to assess three domains as physical domain included 18 items, psychological preparation included five items, health education included five items.
Part III: Anesthetic technique related Factors: It was include 3 sections. The first section used to assess physical status of patients according to the American society of anesthesiologists (ASA) risk classification, it included Class I (Healthy), Class II (Mild diseases only without substantive functional limitations) and Class III (Substantive functional limitations; One or more moderate to severe diseases). The second section was used to assess type of anesthesia (6 items). The third section was used to assess the anti emetic drugs (4 items). It was adopted from American Society of Anesthesiologists, (2020).
Part IV: Surgical technique related Factors: it was adopted from Rocha & Clanton (2016). It was used to assess of three items as type of procedure, use of preemptive analgesia, and operative time.
Part V: Post-operative treatment related Factors: It was used to assess three domains as 1st patient treatment related factors (5 items) as Intravenous antiemetic drug and Parenteral analgesia requirement > 2 doses post-operative. 2nd domain: Patients Postoperative care related factors (10 items) as Promote pain control and assessment of surgical site and drainage tubes. 3rd domain: post-operative complication (8 items) as shock, hemorrhage, wound infection it was adopted from (Lee & Vollmer, 2017).
Total scoring system:
Part I, IV, V (No. + %)
Part III: scoring system was correct answer (yes) scored one and incorrect answer (no) were scored zero. The total scoring system for preoperative preparation was 28 degree and it was categorized in two levels adequate preparation ≥ 60% and inadequate preparation <60% of the total score.
Tool 2: Numerical rating scale (NRS) it was adopted from Iohom (2006). It was used to assess postoperative pain and it was included 0 to 10, with 0 being”no pain” and 10 being” the worst pain imaginable.” The patient picks (verbal version) or draws a circle around the number that best describes the pain dimension, usually intensity. The score of patients categorized as no pain (0 score), mild pain (1-3), moderate pain (4- 6), severe pain (7- 10).
It was used to assess postoperative pain and it was included 0 to 10, with 0 being”no pain” and 10 being” the worst pain imaginable.” The patient picks (verbal version) or draws a circle around the number that best describes the pain dimension, usually intensity. The score of patients categorized as no pain (0 score), mild pain (1-3), moderate pain (4- 6), severe pain (7- 10).
Results:
The duration of the stay in the hospital post operative labroscobic cholecystectomy medical history of the studied patients. It shows that 69.7% of them had two days, 13.6% had 3 days, 10.6% 4days and 6.1% > 4 days regarding the time difference between surgery and discharge.
Summary of our results:
• 50.0% of the patients were 55 years old and above, with mean 52.89±12.53 years. In addition, 56.1%, 57.6% of them were females and weren’t employee respectively. As well, 89.4% of them were married. Additionally, 28.8%, 25.8% of them weren’t educated respectively. Moreover, 60.6% of them live in rural area.
• 47.0% of patients have chronic disease. Besides, 93.9%, 92.4% of them don’t sleep adequate time and take unhealthy food respectively.
• 69.7% of them have two days regarding the time difference between surgery and discharge. Regarding indication for surgery, 50.0% of them suffer from acute cholecystitis. As well, 68.2% of them admitted to postoperative intermediate care. Moreover, 86.4% of them suffer from upper right quadrant pain. Concerning BMI, 53.7% of them are overweight (25:29.9 Kg/m2) with mean and SD=30.09±5.49 Kg/m2.
• Past medical history of the studied patients represented that 45.5% of them entered hospital before. In addition, 56.7% of them admitted once. As regard reasons of the admission, 26.7%, 26.7% of them had E.R.C.P, COVID and COPD respectively. also, 51.5% had comorbidities, 52.9%, 55.8% of them, suffered from it 5-10 years ago and had hypertension respectively.
• 53.0%, take medications and 54.3% of the patients take hypertension medication. Additionally, 37.9%, 36% of them have previous surgery and have Appendectomy respectively. Regard type of anesthesia used in the previous operation, 64% of them toke general anesthesia.
• Pre-operative physical preparation of the studied patients showed that 100% of them were identified by the nurse, signed the consent form, confirmed the operation schedule, completed the referral sheets, pre-anesthesia assessment done by a Anesthetist, history, admission, physical exam done, laboratory and diagnostic reports were available and attached to the file, Blood request and confirmation done, pre-op vital signs taken, removed jewelries, dentures, and maintained NPO. Furthermore, 69.7% of them didn’t take pre-operative medications.
• 43.9% of the patients cope with surgery, while 100% of them don’t think positively. As well, 25.8% of them learned about managing pain after surgery, but visualization and imaging technique didn’t used among 100% of them.
• 100% of the studied patients have inadequate health education, while 98.5% of them have adequate physical preoperative preparation. Concerning total preoperative preparation, 90.9% of them have inadequate preparation.
• 46.9% of studied patients were obese (30<BMI<40). In addition, 100% of them have COPD. Also, 38.5% of them are smokers and 56.3% of them have uncontrolled DM/HTN.
• 48.5% of the studied patients have mild systemic disease, 39.4% of them are normal healthy patients, whilst 12.1%of them have sever systemic disease.
• General anesthesia was used among 100% of studied patients. Additionally, 89.4% of them didn’t take fentanyl 2mic/kg during operation, while 56.1% of them toke Propofol 1.5–2mg/kg. As regard intraoperative antiemetic drug, 92.4%, 93.9% of them didn’t take Ondansetron and Metoclopramide respectively, but 66.7% of them toke a Combination of dexamethasone and metoclopramide.
• Low-pressure pneumo peritoneum (7 mmHg) was used among 77.3% of them. In addition, 72.7% of them didn’t take preemptive analgesia. Concerning operative time, 62.1% of them take 1 – 2 hours.
• Postoperative parenteral analgesia > 2 doses and intravenous fluid and antibiotic were used among 100% of the patients, while 18.2% of them haven’t postoperative nausea or vomiting. Regarding assessment of postoperative complications, 33.3% of them were assessed for bleeding, whilst 100% of them aren’t assessed for bowel injury. In addition, postoperative monitoring of rate and patency of IV fluids and IV access was done among 100% of them, but assessment of surgical site and drainage tubes isn’t done among 39.4% of them. Moreover, 33.3% of them have postoperative hemorrhage.
• There was a significant negative correlation between the studied patients’ gender, marital status and duration of stay after surgery with (r=-.256, p=0. 038) and (r=-.305, p=0. 013) respectively, but there was no significant correlation with other demographic characteristics registered.
• There was a highly significant positive correlation between the studied patients’ preoperative preparation and duration of stay after surgery (r=.329, p=0.007). Also, a highly significant positive correlation exists with pain scale (r=.290, p=0.018), whilst there is no significant correlation with other domains listed.
• There was a significant positive correlation between the studied patients’ duration of stay after surgery and gallstones with previous cholangitis or pancreatitis (r=.293, p=0. 017). As well, a highly significant positive correlation were found with postoperative admission (r=.698, p=0. 000), but there wasn’t significant correlation with other features registered.
• There was a significant positive correlation between the studied patients’ duration of stay after surgery and postoperative hemorrhage, wound infection and fever with (r=.295, p=0. 016), (r=.292, p=0. 018) and (r=.266, p=0. 031) respectively. There wasn’t significant correlation with other domains listed.
• Marital status of the studied patients have high frequency positive effect on duration of stay in the hospital after surgery at p value= 0. 002, while postoperative admission complications have slight frequency negative effect on duration of stay in the hospital after surgery at p value= 0. 017.
• Based on findings of the current study title it can be conduct that:
• The duatrion of hospital stay among the patients post-operative LC were, more than two third of them had 2days, and the minority of them had 3days and 4days. It were showed that the most common factors contributing long hospital stay among patients undergoing laparoscopic cholecystectomy were: Patients related factor as: Pre-operative Preparation Related Factors, anesthetic technique related factors, surgical technique related Factors, post-operative treatment related factors and pain.
Recommendations:
Based on the findings of the present study, the following recommendations are made:
Recommendations for patient related factors
• Developing a simplified and comprehensive booklet or brochure including basic information about laparoscopic cholecystectomy procedure as definition, indications, risk factors for laparoscopic cholecystectomy complications and prevention.
• Patients should be encouraged for contacting health care team regarding post operative relieving and aggravating measures of post laparoscopic cholecystectomy, pain therapeutic regimen and for follow up especially with one-day surgery or highly risk patients or frequently performed laparoscopic cholecystectomy procedure.
Recommendations for practitioner and laparoscopic cholecystectomy procedure related factors:
• Continuous assessment of patient’s before, during and after laparoscopic cholecystectomy by health care providers to identify risk factors of post laparoscopic cholecystectomy complications.
• Providing continuous training courses and evaluation about risk and protective factors of post laparoscopic cholecystectomy headache and updated laparoscopic cholecystectomy procedure technique and guidelines.
Recommendations for further studies:
• Further studies on constructing and testing the effect of applying check list about protective factors of post laparoscopic cholecystectomy for undergoing laparoscopic cholecystectomy procedure patients.
• Further studies should be conducted on assessing health care team level of knowledge regarding laparoscopic cholecystectomy procedure, risk factors of post laparoscopic cholecystectomy compolications and its management.
• Further studies should be conducted about the obstacles that interfere with health care team to provide pre- procedural instructions to patients.
• The study should be replicated on large sample size and in different hospitals setting in order to generalize the results and figure out more factors if present.