Comment rigidity which aids duct cannulations without increased risk of perforation. The Olson clamp allows a high degree of catheter manoeuvrability with relatively precise placement and anchorage by a single operator. The capital cost of purchasing the clamp (£2OO) may be justified by reduced catheter manipulation leading to overall shorter operating times. A MASTERS FRCS FRCSEd Surgical Registrar W CHAPMAN MD
Consultant Surgeon I S BENJAMIN BSc MD FRCS
Honorary Senior Registrar
Professor of Surgery
J A RENNIE MS FRCS
H A BRADPIECE FRCS Senior Registrar King's College Hospital London
An unusual complication of laparoscopic cholecystectomy I read this case report with interest (Annals, July 1992, vol 74, p254). Study of this and a previous case report (1) of exactly this complication, suggests a likely explanation for its occurrence. In both of these cases, a small intestinal herniation occurred through the subumbilical 10 mm trocar entry point, leading to small bowel obstruction. Both patients were symptomatic by the 3rd postoperative day and the diagnosis was confirmed by imaging techniques (ultrasound and CT scanning, respectively) before repair. Many, if not most, trocars are inserted through the rectus sheath without incision of any structure other than skin. Thus the tract through the fascia is the product of forced dilation and it readily contracts on removal of the port. In addition, many laparoscopists do not attempt to close the rectus sheath at all and those that do, know that it is often difficult to be sure of a sound repair with such limited access. In spite of this, I have not yet seen a case report of a similar herniation to those described above, at a later stage after laparoscopy. Thus the initial herniation of the intestine is likely to have occurred perioperatively in these two cases. Surgeons regularly performing laparoscopic surgery will have had, on occasion, the experience of pulling small bowel or omentum out of the peritoneal cavity, while removing the last trocar. This usually occurs at the end of the procedure when the carbon dioxide is allowed to escape through the trocar, to empty the abdomen. The viscus becomes attached to the end of the trocar, presumably due to the pressure differential between the remaining gas in the peritoneal cavity and atmospheric pressure without. Obviously, there will be cases where the viscus is only partially extruded and therefore may not be seen easily. I would suggest that both of these cases were due to small intestine being displaced in this fashion, by the removal of the 10 mm trocar at the end of the operation. Therefore, rather than "meticulous repair of the rectus sheath", this complication should easily be avoidable by careful digital examination of all the trocar sites at the end of each laparoscopic procedure. MARK WHITELEY FRCS
Registrar Queen Alexandra Hospital Cosham, Portsmouth Reference I Maio A, Ruchman RB. CT diagnosis of postlaparoscopic hernia. J Comput Assist Tomogr 1991;15: 1054-5.
We disagree with the assertion by Boyce et al. that meticulous repair of the rectus sheath is required after laparoscopic cholecystectomy (Annals, July 1992, vol 74, p254). Incisional herniation through the 10 mm midline port is rare; in the symposium published in the same issue, 565 laparoscopic cholecystectomies without herniation were reported (1-3). These surgeons are divided among those who do close the fascial sheath (1,2) and those who only close the skin (2). Boyce et al. do not indicate the number of procedures performed before this complication arose. At our hospital, we have performed 61 laparoscopic procedures (38 laparoscopic cholecystectomies, 15 laparoscopic appendicectomies and 8 diagnostic laparoscopies) and we do not close the fascial defect after removing the 10 mm trocar unless the fascial defect has been enlarged deliberately. On theoretical grounds alone, we cannot see the virtue of closing a 1 cm defect (4). Indeed, we have found attempts to close the fascial defect extremely difficult and we remain concerned about the possibility of inadvertently 'picking up' the underlying bowel. We abandoned attempts to close the defect after our third procedure. Surely this case report demonstrates that their attempt to close the defect was unsuccessful. The authors do not comment on the relation of the small bowel loops to their Vicryl® stitches. Did the stitches actually close the fascial defect or did the stitches pick up the small bowel loops? C MCGUINNESS FRCS Senior House Officer A CHOY FRCS Senior House Officer H GAJRAJ MS FRCS Senior Registrar St Helier Hospital
Carshalton, Surrey References I Rees BI, Williams HR. Laparoscopic cholecystectomy: the first 155 patients. Ann R Coll Surg Engl 1992;74:233-6. 2 Scott ADN, McMillan L, Greville AC, Wellwood JMCK. Laparoscopic laser cholecystectomy: results of the technique in 210 patients. Ann R Coll Surg Engl 1992;74:237-41. 3 Hershman MJ, Rosin RD. Laparoscopic laser cholecystectomy: our first 200 patients. Ann R Coll Surg Engl 1992;74: 242-7. 4 Jenkins TPN. The burst wound: a mechanical approach. Br J Surg 1976;63:873-6.
The ORMA retractor holder I write in response to the letter of Mr Vickers (Annals, July 1992, vol 74, p300) commenting on the article by Messrs Woods and Croft (Annals, March 1992, Vol. 74, p95) which described usage of the ORMA retractor holder and expressed disquiet that such retraction might cause tissue and visceral damage. May I assure Mr Vickers that this is not the case. I base this assertion on the experience of using such retraction in my surgical practice for many years. Over 20 years ago I designed a piece of equipment in all respects virtually identical with the ORMA retractor holder, to achieve the same objectives, which I designated A Mechanical Assistant marketed by Downs Surgical (1-4). My mechanical assistant has subsequently been used by surgeons in this country and overseas with no detrimental reports and with much benefit in providing wound access avoiding imposing on assistants the mind-numbing duty to hold retractors steadily without attention wandering. We have all experienced that sort