4. Discussion In the present study the day-case rate following laparoscopic cholecystectomy increased fivefold following the introduction of a new streamlined gallbladder patient pathway, with no associated increase in either conversion rate or readmission rate. Expanding the criteria for day-case surgery and further information ensuring that patients were scheduled on morning operating lists increased this day-case rate further to 60 per cent. Day-case laparoscopic cholecystectomy can save costs and has been shown to be a safe and effective treatment for symptomatic gallstones [3�C6]. These cost savings primarily arise as a result of reducing unnecessary in-hospital patient stay, which is estimated at ��249 per day [7]. The day-case rate of 60 per cent achieved in the present study could therefore equate to annual savings of at least ��74,700 based on a hospital performing 500 cases per year.

Higher day-case rates are therefore desirable, although in the context of randomised controlled trials, with patients selected on the basis of operative fitness and proximity to hospital, a day-case rate of only 80 per cent is reported [3, 4, 8�C10]. This relates predominantly to uncontrolled pain, nausea, and vomiting, which are known to affect both hospital stay and patient discharge [3, 4]. The use of intraoperative local anaesthetic, postoperative paracetamol, and nonsteroidal anti-inflammatories, with an avoidance of opiates, have all been suggested as techniques to minimise these problems [1].

Since October 2009 our own institution has therefore introduced a standardised anaesthetic and postoperative analgesia protocol for day-case laparoscopic cholecystectomy, which it is hoped will further increase day-case rates. Additional cost savings are also achievable by using an integrated patient pathway, such as that shown in Figure 2, which can minimise the need for repeat ultrasound studies (��49), blood tests (��10), and outpatient appointments (��88) [7]. The use of nondisposable surgical instruments and limiting the use of intraoperative antibiotics is also important. The gallbladder pathway used in this study adheres to the principles outlined in the ��Focus on Cholecystectomy�� document [1]. Reducing the number of patient visits by providing preassessment at the initial clinic visit and preventing routine outpatient followup resulted in less disruption to patients.

This is particularly important due to the wide geographical distribution of our patients, although these limitations in access to transport may have also led to some patients not being suitable for day-case surgery. Providing patients with a choice of dates for surgery led to fewer cancellations on the day of surgery. Batimastat Staggered admission times, whilst preventing long periods of waiting or starvation, were not used during this study.