This retrospective cohort study evaluated the characteristics and outcomes of patients undergoing elective LC for benign gallbladder disease before the Covid-19 pandemic and during the pandemic recover phase, in a single secondary care hospital in the UK. Overall, patient demographics in our study were comparable to those reported in other literature (3, 6, 7). However, the proportion of patients who were ASA-3 in our sample was higher at 17% compared to 7.9% reported by previous studies (7), the majority (54.7%) of our patients were operated for biliary colic. However, the proportions were different between the two groups. Before the pandemic (PP-2019 group), 68 (64.2%) of patients were operated for biliary colic compared to only 19 (35.8%) in the pandemic recovery cohort (PPR-2021) (p < 0.001). Previous studies conducted before the pandemic have also reported that the most common indication for elective laparoscopic cholecystectomy is biliary colic (4). The low rates of biliary colic observed during the pandemic recovery phase could be attributed to long waiting times and patients developing more complications from their gallstone disease. In fact, our data confirmed that the waiting time to surgery were significantly higher for patients in the 2021 cohort compared to the 2019 one (Figure 1). The waiting times were calculated from the time the patient was added on the waiting list for surgery which might underestimate the true duration of symptoms. However our data could not capture the waiting time to surgery from the onset of symptoms accurately as many patients were already seen in other hospitals in the region, GP practice or private sector.

A significantly lower proportion of patients underwent a complete cholecystectomy in the pandemic recovery phase (n = 49; 92.5%) compared to the those operated before the pandemic (n = 106; 99.1%; p = 0.04). From those five (3.1%) who haven't had a complete cholecystectomy, three underwent a subtotal cholecystectomy and two had their operation abandoned. The overall rate of subtotal cholecystectomy was 1.8%. This is lower than previously reported rates of 4.5%–16.2% in the literature (8, 9). The subtotal cholecystectomy rate in the recovery phase (4.1%) was higher compared to before the pandemic (0.9%). Whilst no procedures were abandoned in patients operated before the pandemic two were abandoned in patients operated during the pandemic recovery phase. In both patients, concerns of a choledocoduodenal fistula led to surgery being abandoned; one was referred to a tertiary hepatobiliary unit and the other for further imaging.

The overall rate of conversion to open surgery was 0.6% and was lower compared to previously published rates (1.6%–8.9%) (3, 7). Furthermore, there was no significant difference between the rates of open conversion rates or median operating times between the two groups. The threshold for drain placement varied between individual surgeons. Whilst the latter might not necessarily reflect an adverse event, drain insertions during LC can lead to increased length of stay and is associated with higher rates of wound infection (10). More patients received a drain at surgery following the pandemic (11.3% vs. 8.5%, p = 0.573). One study reported a drain insertion rate of 30.8% during laparoscopic cholecystectomy for patients with cholecystitis during the peak of the Covid-19 pandemic as 30.8% (3). Our findings may be attributable to the higher incidence of acute cholecystitis (35.8% vs. 18.9%) and more inflammatory intraoperative findings (thickened gallbladder, abscesses, empyema, adhesions) in the PRP-2021 group. However, it may also reflect the higher degree of caution and wariness amongst surgeons operating in patients within pandemic recovery phase group.

The rate of day case surgery in this sample was 60%. Whilst this was higher before the pandemic it was not statistically significant (64.2% vs. 50.9%; p > 0.05). The British Association of Day Surgery standards recommends at least 60% of all elective LC be done as day cases (11). Whilst this target was met for patients in before the pandemic it was however, not met for patients operated during the pandemic recovery phase. However, the proportion of patients undergoing day case surgery in either group was lower than previously reported in the literature (7, 12). Several studies identified predictors for failed discharge in day case surgery for LC. A “Cholecystectomy as a Day Case score” was developed in a study to predict the likelihood of successful day-case cholecystectomy. Factors associated with failed day-case cholecystectomy included older age, male sex, complicated choledocholithiasis, higher ASA Scores and previous admission with gallstone disease (13). Several patients during the pandemic recovery phase had one or more of these factors which could have contributed to the lower day-case surgery rate in this group.

There was no significant difference between postoperative complication rates between the two groups. However, there was a trend for worse outcomes during the pandemic recovery phase. For example, the proportion of patients that required return to theatre (Grade IIIb complication) was higher 3.8% compared to 1.9% before the pandemic. Due to the small number of patients in each cohort the complication rate might appear to be higher than the actual number. The 30-day re-admission rates overall in this study was 8.8% and this was compliant with UK standards (<10%) (5). It was higher in the recovery phase group at 11.3% compared to 7.5% in the pre-pandemic group. Previously published reports from the UK and USA reported the 30-day readmission rates between 5.4%–7% (8, 14, 15) and the most commonest complain was non-specific abdominal pain. This was the same reason for most readmissions in our cohort too.

The main limitation of this retrospective study was the relatively small sample size. Other limitations included the lack of inclusion of emergency cholecystectomies. However, our aim was to report the impact of COVID-19, on elective services during the recovery phase. Due to the retrospective nature of this study, we were unable to grade the intraoperative difficulty using an objective tool such as the Nassar operative difficulty scale (4). Greater intraoperative difficulty has been associated with worse outcomes following LC (10) and may therefore, be a confounder for observed outcomes across the two groups. Despite these limitations our study was one of the first to report the impact on the Covid-19 pandemic on elective laparoscopic cholecystectomy and variations in patient pathology, surgical practices and similarities between outcomes between pre-pandemic and recovery phase patients.

As the UK NHS emerges from the pandemic, there is increased pressure to maintain the high-quality standards of clinical practice and to reduce the waiting times for definitive treatment across all specialties. However, additional resources must be allocated to ensure more theatre capacity, staffing and elective beds including high dependency care are available to cater to more complex cases arising because of delayed surgery. Patient numbers allocated to elective lists may also need adjusting to compensate for the higher complexity of surgery. In addition, regular auditing is vital to ensure the practice meets the local pre-pandemic standards and national standards. The immediate and long-term impact on patients with benign conditions such as gallstone disease who had their definitive treatments delayed due to the pandemic warrants further attention and research.