795
collaboratively by the Government Organisation.
of Zambia and the World Health
REFERENCES Cholera situation in the Americas. 1-24. 2. Stock RF. Cholera in Africa: diffusion of the disease 1970-1975 with particular emphasis on West Africa. African Environmental Special Report 3. London: International African Institute, 1976. 3. World Health Organisation. Cholera. Wkly Epidemiol Rep 1991: 55-70. 4. Goodgame RW, Grenough III WB. Cholera in Africa: a message for the West. Ann Intern Med 1975; 82: 101-06. 5. Feachem RG, Miller CJ, Drasar BS. Environmental aspects of cholera epidemiology. II. Occurrence and survival of Vibrio cholerae in the environment. Trop Dis Bull 1981; 78: 865-80. 6. Woodward WE, Moseley WH. The spectrum of cholera in rural Bangladesh. II. Comparison of El Tor Ogawa and classical Inaba infection. Am J Epidemiol 1971; 96: 342-51. 7. Pollitzer R. Epidemiology. In: Cholera. World Health Organisation Monograph Series 43. Geneva: World Health Organization, 1959: 820-92. 8. Baine WB, Zampieri A, Mazzotti M, et al. Epidemiology of cholera in Italy in 1973. Lancet 1974; ii: 1370-74. 9. Salamaso S, Greco D, Bonfiglio B, et al. Recurrence of pelecypodassociated cholera in Sardinia. Lancet 1980; ii: 1124-27. 10. Lowry PW, Pavia AT, McFarland LM, et al. Cholera in Louisiana: widening spectrum of seafood vehicles. Arch Intern Med 1989; 149: 2079-84. 11. Blake PA, Allegra DT, Snyder JD, et al. Cholera—a possible endemic focus in the United States. N Engl J Med 1980; 302: 305-09. 12. Tauxe RV, Homberg SD, Dodin A, Wells JV, Blake PA. Epidemic cholera in Mali: high mortality and multiple routes of transmission in a famine area. Epidemiol Infect 1988; 100: 279-89. 13. Johnston JM, Martin DL, Perdue J, et al. Cholera on a Gulf Coast oil rig. N Engl J Med 1983; 309: 523-26. 14. St Louis ME, Porter JD, Helal A, et al. Epidemic cholera in West Africa: the role of food handling and high-risk foods. Am J Epidemiol 1990; 131: 719-27. 1. Pan American Health
Organization.
Epidemiol Bull 1991; 12:
15. Makukutu CA, Guthrie RK. Behavior of Vibrio cholerae in hot foods. Appl Environ Microbiol 1986; 52: 824-31. 16. Feachem RG. Environmental aspects of cholera epidemiology. III. Transmission and control. Trop Dis Bull 1982; 79: 1-47. 17. Kolvin JL, Roberts D. Studies on the growth of Vibrio cholerae biotype el tor and biotype classical in foods. J Hyg 1982; 89: 243-52. 18. Levine MM, Kaper JB, Black RE, Clements ML. New knowledge on pathogenesis of bacterial enteric infections as applied to vaccine development. Microbiol Rev 1983; 47: 510-50. 19. Mhalu FS, Mtango FDE, Msengi AE. Hospital outbreaks of cholera transmitted through close person-to-person contact. Lancet 1984; ii: 82-84. 20. Cliff JL, Zinkin P, Martelli A. A hospital outbreak of cholera in Maputo, Mozambique. Trans R Soc Trop Med Hyg 1986; 80: 473-76. 21. Lindenbaum J, Greenough WB, Islam MR. Antibiotic therapy of cholera in children. Bull World Health Organ 1967; 37: 529-38. 22. World Health Organisation. The rational use of drugs in the management of acute diarrhoea in children. Geneva: World Health Organisation, 1990. 23. Glass RI, Khan MR, Greenough WB, Holmgren J. The use of family studies for prospective epidemiologic investigations of cholera. In: Kuwahara S, Pierce N, eds. Advances in research on cholera and related diarrheas. Tokyo: KTR Publishers, 1986: 25-33. 24. Glass RI, Holmgren J, Haley CE, et al. Predisposition for cholera of individuals with O blood group: possible evolutionary significance. Am J Epidemiol 1985; 121: 791-96. 25. Mhalu FS, Mmari PW, Ijuba J. Rapid emergence of El Tor Vibrio cholerae resistant to antimicrobial agents during first six months of fourth cholera epidemic in Tanzania. Lancet 1979; i: 345-47. 26. Glass RI, Huq MI, Lee JV, et al. Plasmid-borne multiple drug resistance in Vibrio cholerae serogroup 01, biotype El Tor: evidence for a point-source outbreak in Bangladesh. J Infect Dis 1983; 147: 204-09. 27. Clemens JD, Sack DA, Harris JR, et al. Field trial of oral cholera vaccines in Bangladesh: results from three-year follow-up. Lancet 1990; 335: 270-73. 28. World Health Organisation. Guidelines for cholera control. WHO/ CDD/SER/80.4, REV 2. Geneva: World Health Organisation, 1991. 29. Mahalanabis D, Choudhuri AB, Bagchi NG, et al. Oral fluid therapy of cholera among Bangladesh refugees. Johns Hopkins Med J 1973; 132: 197-205.
CLINICAL PRACTICE Elective
laparoscopic cholecystectomy for "all-comers"
Laparoscopic cholecystectomy is a safe and effective procedure in specialist centres, but its wider application will depend on the ability of general surgeons to become skilled in this technique. 180 underwent elective patients laparoscopic cholecystectomy during a nine-month period at a single district general hospital. All patients who would have been eligible for elective open cholecystectomy were offered the laparoscopic alternative. Laparoscopic cholecystectomy was abandoned in favour of an open procedure in 10 (6%) patients. Median operating time was 55 min. 2 patients had serious morbidity (right hepatic duct injury and a duodenal fistula) and there were no deaths. 3 patients required subsequent treatment for retained common duct stones. 90% of patients were discharged within 48 h of the operation and the median time to resume full activity after discharge
12 days. Laparoscopic cholecystectomy is a safe and cost-effective technique in a district general was
hospital. Introduction
Laparoscopic cholecystectomy is an effective and safe procedure that is now offered in many centres, usually by a few enthusiastic general surgeons. The technique is likely to eclipse other recent advances in this field. However, if laparoscopic cholecystectomy is to replace conventional gallbladder removal, it must be proved to be effective in ADDRESS: Department of Surgery, Royal Lancaster Infirmary, Ashton Road, Lancaster LA1 4RP, UK (P. Wilson, FRCS, T. Leese, MD, W P Morgan, ChM, J. F. Kelly, FRCS, J K. Brigg, FRCS). Correspondence to Mr P. Wilson, Department of Surgery, Creighton University School of Medicine, 601 North 30th Street, Omaha, Nebraska 68131, USA.
796
district general hospitals where most cholecystectomies take place. Cholecystectomy workload is so great that one or two surgeons would be unlikely to be able to cope with all cases in a district general hospital. We describe our initial experience of laparoscopic cholecystectomy in such a hospital where all four consultant general surgeons were skilled in this technique, and where all patients requiring elective cholecystectomy were offered the laparoscopic alternative.
TABLE I-REASONS FOR CONVERSION TO OPEN
Patients and methods
normal biliary anatomy, and no bileduct stones were detected. Complications developed in 9% (16) of patients (table III). There were no deaths. The patient who had a right hepatic duct injury had abnormal anatomy (cystic duct entering right hepatic duct) and required conversion to laparotomy to repair the damaged duct. No stricture was seen at cholangiography six months postoperatively. In 1 patient, an injury occurred to the small bowel after insertion of the subumbilical 10 mm trocar and sheath. This injury was recognised and repaired by delivering the small bowel through the subumbilical incision. The laparoscope was then reintroduced and cholecystectomy proceeded uneventfully. Surgical emphysema over the anterior abdominal and chest walls developed in 1 patient after a port slipped during the procedure. This complication resolved within 24 h. A further patient had a retained tip from a broken pair of gallbladder grasping forceps. The patient was told of this retained foreign body, and no further action was taken. A low-volume duodenal fistula, probably secondary to disruption of a small cholecystoduodenal fistula during dissection, was associated with a marked cellulitis in the drain wound. Escherichia coli that was resistant to the prophylactic antibiotic used was cultured from both the gallbladder and wound. The fistula resolved after 6 days of antibiotic cover. 5 patients were readmitted after laparoscopic cholecystectomy with non-specific abdominal pain. Abdominal ultrasound scans were normal in all patients. These patients were managed conservatively and pain
All
symptomatic patients who
have
gallstones confirmed by
ultrasound and who require elective cholecystectomy have been offered laparoscopic cholecystectomy in the Lancaster district since the technique was introduced in September, 1990. All four consultant general surgeons adopted the technique at the same time and assisted each other during the early cases. The first forty procedures were videotaped to allow retrospective analysis. Patients did not undergo laparoscopic cholecystectomy if they were unfit for general anaesthesia, were pregnant, had a second intra-abdominal lesion that required treatment by open surgery, or needed emergency cholecystectomy for acute cholecystitis. Preliminary
endoscopic retrograde cholangiopancreatography (ERCP) was completed in patients with a history of jaundice, previous pancreatitis, abnormal liver enzymes, or dilated bileducts on ultrasound scanning. All patients received single-dose antibiotic prophylaxis at the time of anaesthetic induction and subcutaneous heparin during the perioperative period. Laparoscopic cholecystectomy was done under general anaesthesia by a standard technique.1 A detailed audit sheet was completed for each patient at the end of the procedure, at discharge, and at the sixth week of follow-up.
Results
patients underwent elective laparoscopic cholecystectomy between September, 1990, and May, 1991. 3 patients who required elective open cholecystectomy were not offered the laparoscopic technique because of the high probability of adhesions in the upper abdomen. These patients had had previous extensive upper abdominal surgery (gastrectomy, 2; aortic aneurysm repair, 1). Median patient age was 56 years (range 20-85) and the median patient weight was 72 kg (range 50-121). 132 (73%) patients were female. 68 (32%) had had at least one previous abdominal operation: appendicectomy, 24; lower abdominal surgery, 28; laparoscopic sterilisation, 14; and upper abdominal surgery, 2. 20 patients had a preliminary ERCP for suspected common bileduct stones. 9 of these patients required endoscopic clearance of stones before undergoing laparoscopic cholecystectomy. Drains were placed in occasional patients where dissection was difficult and where leakage from the gallbladder bed was anticipated. Peroperative cholangiograms were completed in selected patients only. Laparoscopic cholecystectomy was successful in 170 patients (94%) in whom it was attempted. 10 patients required conversion to open cholecystectomy. Details of these patients are given in table I. 6 of the 10 conversions to open operation occurred in the first 50 consecutive procedures. The median operating time for successful cases was 55 min (mean [SD] 58 [17], range 25-150). Two-thirds of cases were completed in 60 min or less. Anaesthetic time added a mean of 18 min to the procedure. Table II gives details of operating times for each consultant and for junior staff and (senior registrar registrars) Peroperative cholangiograms were completed in 12 patients (7%). All 180
CHOLECYSTECTOMY
cholangiograms showed
TABLE II-OPERATING TIMES
TABLE III-COMPLICATIONS
I
*Haemoglobin fell by 2 g/dl but no transfusion
was
required patient,
a further tWound infection was associated with duodenal fistula in one patient had a subumbilical wound infection that resolved after antibiotic treatment
797
firm
made. 3 patients for retained common bilerequired subsequent duct stones. This complication had not been suspected preoperatively, and patients had not undergone peroperative cholangiography. 2 patients were treated endoscopically, but 1 required an open operation to remove the stones. There has been no morbidity among the 20 patients who underwent a preoperative ERCP and the 2 who required postoperative ERCP (11 of whom had endoscopic sphincterotomy and removal of stones). The median postoperative stay after successful laparoscopic cholecystectomy was 2 days (range 1-7). 90% of patients were discharged within 48 h of surgery. Median time to resume full activities after discharge was 12 days
resolved without
a
diagnosis being
treatment
conventional cholecystectomy.3 We attribute our results to the cooperation of all surgeons during initial operations. Such shared experience programmes should be effective elsewhere and will allow a service to develop rapidly and safely in all district general hospitals. The economic benefits of reduced postoperative stay and low morbidity, especially that attributable to wound infection, are clearly evident from our series. The minimum postoperative morbidity and the rapidity of return to work make this procedure beneficial and cost-effective for patients and their employers. Our initial experience confirms the benefits of laparoscopic cholecystectomy for patients and the hospital service alike, and indicates that this technique should replace elective open cholecystectomy for most patients in all district
general hospitals.
(range 2-40). REFERENCES
Discussion
Laparoscopic cholecystectomy has emerged as a costeffective treatment for symptomatic gallstone disease and has minimum morbidity. This technique is now offered in many centres,l-3but its place as the routine method of cholecystectomy has not yet been established in district general hospitals where most cholecystectomies take place. Since the technique demands new surgical skills, there has been debate4-6 about the necessity of training all surgeons in laparoscopic methods. Although we initially excluded patients with previous upper abdominal surgery and those who needed other combined procedures, our experience now persuades us that many are suitable for laparoscopic cholecystectomy. In 180 consecutive procedures there were no deaths and little morbidity. Only 2 patients had major complications that might have been avoided with open operation (right hepatic
duct injury and duodenal fistula associated with cellulitis), and one of these required conversion to an open operation. Wound infection has been reported as a major cause of morbidity in up to 7% of cases of open cholecystectomy.7,8 However, in our series of laparoscopic cholecystectomies, wound infection was a negligible cause of morbidity. We confirmed the reports of others2 that emergency laparoscopic cholecystectomy was associated with high morbidity. The procedure was attempted in 6 patients with either acute cholecystitis or empyema of the gall bladder. After ultrasound confirmation of the diagnosis, patients underwent surgery within 5 days of admission. Subsequent complications of unidentifiable anatomy that required open cholecystectomy, postoperative haemorrhage, and a cystic duct bile leak gave a 50% frequency of serious morbidity. In common with other centres we now exclude these patients.2 In our series, conversion to open operation and complication rates were more common in the first fifty operations (6 out of 10 conversions, 8 out of 16 complications). Both major complications occurred in the early cases. By contrast, in the last 100 procedures, there was no major morbidity and only 3 patients required conversion to open
operation.
We have screened all patients preoperatively for stones and have not completed routine peroperative cholangiography. This policy requires a readily accessible ERCP and therapeutic endoscopy service. If such facilities are not available, peroperative cholangiography should probably be mandatory. The mean operating time for laparoscopic cholecystectomy in our series is similar to that for
1. Reddick EJ, Olsen DO.
2. 3.
Laparoscopic laser cholecystectomy. Surg Endosc 1989; 3: 131-33. Cuschieri A, Dubois F, Mouiel J, et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;; 161: 385-87. Grace PA, Quereshi A, Coleman J, et al. Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg 1991; 78: 160-62.
4. Dent TL. Training, credentialling, and granting of clinical privileges for laparoscopic general surgery. Am J Surg 1991; 161: 399-403. 5. Society of American Gastrointestinal Endoscopic Surgeons. Granting of privileges for laparoscopic general surgery. Am J Surg 1991; 161: 324-25. 6. Paterson-Brown S, Garden OJ, Carter DC. Laparoscopic cholecystectomy. Br J Surg 1991; 78: 131-32. 7. Todd GJ, Reemtsa K. Cholecystectomy without drainage: factors influencing wound infection in 1000 elective cases. Am J Surg 1978; 135: 622-23. 8. Sullivan DM, Ruftin Hood T, Griffen WO Jr. Biliary tract surgery in the elderly. Am J Surg 1982; 143: 218-20.
From The Lancet Copper-bottomed? Freshly precipitated and moist
copper hydrate seems likely to place in agricultural science next in importance to that of manure. A mixture of lime and copper sulphate has been employed for some time now with success as an insecticide or germicide in the treatment of disease of the vine, potato, and tomato; and quite recently M Aime-Girard applied the same mixture to sugar beet plants threatened with the attacks of a specific fungus.... Under this treatment the disease is said to be effectually stayed, the leaves to become more luxuriant and the stalks to be so preserved that those occupy
a
attacked grew richer in saccharine constituent, while the proportion of sugar in the root was found to have increased 1-58 per cent.... As every student of elementary chemistry knows, lime-water (hydrate) and copper sulphate give calcium sulphate and copper hydrate; but it is to the latter body of course that the fungus-destroying action is due. Copper hydrate would appear to act on fungi as a weak solution of perchloride of mercury, without, however, affecting the growth or life of the plant, and its action may possibly be akin to that which takes place when it is added to solution of peptone-albumose. With this body it combines to form an insoluble compound-a reaction which has been taken advantage of in the separation and estimation of this variety of peptone. The effect, however, of using copper compounds for purposes of the kind above mentioned must be watched with due care, as plants are known to assimilate the metallic salts with readiness. Cereals, for instance, have been found to derive an important quantity of copper from the soil, and in view of the enormous consumption of sugar by infants as well as by invalids, the question may possibly become one of no little moment, upon the merits of which chemical analysis will, in course of time, decide.
(July 18, 1891)>
collaboratively by the Government Organisation.
of Zambia and the World Health
REFERENCES Cholera situation in the Americas. 1-24. 2. Stock RF. Cholera in Africa: diffusion of the disease 1970-1975 with particular emphasis on West Africa. African Environmental Special Report 3. London: International African Institute, 1976. 3. World Health Organisation. Cholera. Wkly Epidemiol Rep 1991: 55-70. 4. Goodgame RW, Grenough III WB. Cholera in Africa: a message for the West. Ann Intern Med 1975; 82: 101-06. 5. Feachem RG, Miller CJ, Drasar BS. Environmental aspects of cholera epidemiology. II. Occurrence and survival of Vibrio cholerae in the environment. Trop Dis Bull 1981; 78: 865-80. 6. Woodward WE, Moseley WH. The spectrum of cholera in rural Bangladesh. II. Comparison of El Tor Ogawa and classical Inaba infection. Am J Epidemiol 1971; 96: 342-51. 7. Pollitzer R. Epidemiology. In: Cholera. World Health Organisation Monograph Series 43. Geneva: World Health Organization, 1959: 820-92. 8. Baine WB, Zampieri A, Mazzotti M, et al. Epidemiology of cholera in Italy in 1973. Lancet 1974; ii: 1370-74. 9. Salamaso S, Greco D, Bonfiglio B, et al. Recurrence of pelecypodassociated cholera in Sardinia. Lancet 1980; ii: 1124-27. 10. Lowry PW, Pavia AT, McFarland LM, et al. Cholera in Louisiana: widening spectrum of seafood vehicles. Arch Intern Med 1989; 149: 2079-84. 11. Blake PA, Allegra DT, Snyder JD, et al. Cholera—a possible endemic focus in the United States. N Engl J Med 1980; 302: 305-09. 12. Tauxe RV, Homberg SD, Dodin A, Wells JV, Blake PA. Epidemic cholera in Mali: high mortality and multiple routes of transmission in a famine area. Epidemiol Infect 1988; 100: 279-89. 13. Johnston JM, Martin DL, Perdue J, et al. Cholera on a Gulf Coast oil rig. N Engl J Med 1983; 309: 523-26. 14. St Louis ME, Porter JD, Helal A, et al. Epidemic cholera in West Africa: the role of food handling and high-risk foods. Am J Epidemiol 1990; 131: 719-27. 1. Pan American Health
Organization.
Epidemiol Bull 1991; 12:
15. Makukutu CA, Guthrie RK. Behavior of Vibrio cholerae in hot foods. Appl Environ Microbiol 1986; 52: 824-31. 16. Feachem RG. Environmental aspects of cholera epidemiology. III. Transmission and control. Trop Dis Bull 1982; 79: 1-47. 17. Kolvin JL, Roberts D. Studies on the growth of Vibrio cholerae biotype el tor and biotype classical in foods. J Hyg 1982; 89: 243-52. 18. Levine MM, Kaper JB, Black RE, Clements ML. New knowledge on pathogenesis of bacterial enteric infections as applied to vaccine development. Microbiol Rev 1983; 47: 510-50. 19. Mhalu FS, Mtango FDE, Msengi AE. Hospital outbreaks of cholera transmitted through close person-to-person contact. Lancet 1984; ii: 82-84. 20. Cliff JL, Zinkin P, Martelli A. A hospital outbreak of cholera in Maputo, Mozambique. Trans R Soc Trop Med Hyg 1986; 80: 473-76. 21. Lindenbaum J, Greenough WB, Islam MR. Antibiotic therapy of cholera in children. Bull World Health Organ 1967; 37: 529-38. 22. World Health Organisation. The rational use of drugs in the management of acute diarrhoea in children. Geneva: World Health Organisation, 1990. 23. Glass RI, Khan MR, Greenough WB, Holmgren J. The use of family studies for prospective epidemiologic investigations of cholera. In: Kuwahara S, Pierce N, eds. Advances in research on cholera and related diarrheas. Tokyo: KTR Publishers, 1986: 25-33. 24. Glass RI, Holmgren J, Haley CE, et al. Predisposition for cholera of individuals with O blood group: possible evolutionary significance. Am J Epidemiol 1985; 121: 791-96. 25. Mhalu FS, Mmari PW, Ijuba J. Rapid emergence of El Tor Vibrio cholerae resistant to antimicrobial agents during first six months of fourth cholera epidemic in Tanzania. Lancet 1979; i: 345-47. 26. Glass RI, Huq MI, Lee JV, et al. Plasmid-borne multiple drug resistance in Vibrio cholerae serogroup 01, biotype El Tor: evidence for a point-source outbreak in Bangladesh. J Infect Dis 1983; 147: 204-09. 27. Clemens JD, Sack DA, Harris JR, et al. Field trial of oral cholera vaccines in Bangladesh: results from three-year follow-up. Lancet 1990; 335: 270-73. 28. World Health Organisation. Guidelines for cholera control. WHO/ CDD/SER/80.4, REV 2. Geneva: World Health Organisation, 1991. 29. Mahalanabis D, Choudhuri AB, Bagchi NG, et al. Oral fluid therapy of cholera among Bangladesh refugees. Johns Hopkins Med J 1973; 132: 197-205.
CLINICAL PRACTICE Elective
laparoscopic cholecystectomy for "all-comers"
Laparoscopic cholecystectomy is a safe and effective procedure in specialist centres, but its wider application will depend on the ability of general surgeons to become skilled in this technique. 180 underwent elective patients laparoscopic cholecystectomy during a nine-month period at a single district general hospital. All patients who would have been eligible for elective open cholecystectomy were offered the laparoscopic alternative. Laparoscopic cholecystectomy was abandoned in favour of an open procedure in 10 (6%) patients. Median operating time was 55 min. 2 patients had serious morbidity (right hepatic duct injury and a duodenal fistula) and there were no deaths. 3 patients required subsequent treatment for retained common duct stones. 90% of patients were discharged within 48 h of the operation and the median time to resume full activity after discharge
12 days. Laparoscopic cholecystectomy is a safe and cost-effective technique in a district general was
hospital. Introduction
Laparoscopic cholecystectomy is an effective and safe procedure that is now offered in many centres, usually by a few enthusiastic general surgeons. The technique is likely to eclipse other recent advances in this field. However, if laparoscopic cholecystectomy is to replace conventional gallbladder removal, it must be proved to be effective in ADDRESS: Department of Surgery, Royal Lancaster Infirmary, Ashton Road, Lancaster LA1 4RP, UK (P. Wilson, FRCS, T. Leese, MD, W P Morgan, ChM, J. F. Kelly, FRCS, J K. Brigg, FRCS). Correspondence to Mr P. Wilson, Department of Surgery, Creighton University School of Medicine, 601 North 30th Street, Omaha, Nebraska 68131, USA.
796
district general hospitals where most cholecystectomies take place. Cholecystectomy workload is so great that one or two surgeons would be unlikely to be able to cope with all cases in a district general hospital. We describe our initial experience of laparoscopic cholecystectomy in such a hospital where all four consultant general surgeons were skilled in this technique, and where all patients requiring elective cholecystectomy were offered the laparoscopic alternative.
TABLE I-REASONS FOR CONVERSION TO OPEN
Patients and methods
normal biliary anatomy, and no bileduct stones were detected. Complications developed in 9% (16) of patients (table III). There were no deaths. The patient who had a right hepatic duct injury had abnormal anatomy (cystic duct entering right hepatic duct) and required conversion to laparotomy to repair the damaged duct. No stricture was seen at cholangiography six months postoperatively. In 1 patient, an injury occurred to the small bowel after insertion of the subumbilical 10 mm trocar and sheath. This injury was recognised and repaired by delivering the small bowel through the subumbilical incision. The laparoscope was then reintroduced and cholecystectomy proceeded uneventfully. Surgical emphysema over the anterior abdominal and chest walls developed in 1 patient after a port slipped during the procedure. This complication resolved within 24 h. A further patient had a retained tip from a broken pair of gallbladder grasping forceps. The patient was told of this retained foreign body, and no further action was taken. A low-volume duodenal fistula, probably secondary to disruption of a small cholecystoduodenal fistula during dissection, was associated with a marked cellulitis in the drain wound. Escherichia coli that was resistant to the prophylactic antibiotic used was cultured from both the gallbladder and wound. The fistula resolved after 6 days of antibiotic cover. 5 patients were readmitted after laparoscopic cholecystectomy with non-specific abdominal pain. Abdominal ultrasound scans were normal in all patients. These patients were managed conservatively and pain
All
symptomatic patients who
have
gallstones confirmed by
ultrasound and who require elective cholecystectomy have been offered laparoscopic cholecystectomy in the Lancaster district since the technique was introduced in September, 1990. All four consultant general surgeons adopted the technique at the same time and assisted each other during the early cases. The first forty procedures were videotaped to allow retrospective analysis. Patients did not undergo laparoscopic cholecystectomy if they were unfit for general anaesthesia, were pregnant, had a second intra-abdominal lesion that required treatment by open surgery, or needed emergency cholecystectomy for acute cholecystitis. Preliminary
endoscopic retrograde cholangiopancreatography (ERCP) was completed in patients with a history of jaundice, previous pancreatitis, abnormal liver enzymes, or dilated bileducts on ultrasound scanning. All patients received single-dose antibiotic prophylaxis at the time of anaesthetic induction and subcutaneous heparin during the perioperative period. Laparoscopic cholecystectomy was done under general anaesthesia by a standard technique.1 A detailed audit sheet was completed for each patient at the end of the procedure, at discharge, and at the sixth week of follow-up.
Results
patients underwent elective laparoscopic cholecystectomy between September, 1990, and May, 1991. 3 patients who required elective open cholecystectomy were not offered the laparoscopic technique because of the high probability of adhesions in the upper abdomen. These patients had had previous extensive upper abdominal surgery (gastrectomy, 2; aortic aneurysm repair, 1). Median patient age was 56 years (range 20-85) and the median patient weight was 72 kg (range 50-121). 132 (73%) patients were female. 68 (32%) had had at least one previous abdominal operation: appendicectomy, 24; lower abdominal surgery, 28; laparoscopic sterilisation, 14; and upper abdominal surgery, 2. 20 patients had a preliminary ERCP for suspected common bileduct stones. 9 of these patients required endoscopic clearance of stones before undergoing laparoscopic cholecystectomy. Drains were placed in occasional patients where dissection was difficult and where leakage from the gallbladder bed was anticipated. Peroperative cholangiograms were completed in selected patients only. Laparoscopic cholecystectomy was successful in 170 patients (94%) in whom it was attempted. 10 patients required conversion to open cholecystectomy. Details of these patients are given in table I. 6 of the 10 conversions to open operation occurred in the first 50 consecutive procedures. The median operating time for successful cases was 55 min (mean [SD] 58 [17], range 25-150). Two-thirds of cases were completed in 60 min or less. Anaesthetic time added a mean of 18 min to the procedure. Table II gives details of operating times for each consultant and for junior staff and (senior registrar registrars) Peroperative cholangiograms were completed in 12 patients (7%). All 180
CHOLECYSTECTOMY
cholangiograms showed
TABLE II-OPERATING TIMES
TABLE III-COMPLICATIONS
I
*Haemoglobin fell by 2 g/dl but no transfusion
was
required patient,
a further tWound infection was associated with duodenal fistula in one patient had a subumbilical wound infection that resolved after antibiotic treatment
797
firm
made. 3 patients for retained common bilerequired subsequent duct stones. This complication had not been suspected preoperatively, and patients had not undergone peroperative cholangiography. 2 patients were treated endoscopically, but 1 required an open operation to remove the stones. There has been no morbidity among the 20 patients who underwent a preoperative ERCP and the 2 who required postoperative ERCP (11 of whom had endoscopic sphincterotomy and removal of stones). The median postoperative stay after successful laparoscopic cholecystectomy was 2 days (range 1-7). 90% of patients were discharged within 48 h of surgery. Median time to resume full activities after discharge was 12 days
resolved without
a
diagnosis being
treatment
conventional cholecystectomy.3 We attribute our results to the cooperation of all surgeons during initial operations. Such shared experience programmes should be effective elsewhere and will allow a service to develop rapidly and safely in all district general hospitals. The economic benefits of reduced postoperative stay and low morbidity, especially that attributable to wound infection, are clearly evident from our series. The minimum postoperative morbidity and the rapidity of return to work make this procedure beneficial and cost-effective for patients and their employers. Our initial experience confirms the benefits of laparoscopic cholecystectomy for patients and the hospital service alike, and indicates that this technique should replace elective open cholecystectomy for most patients in all district
general hospitals.
(range 2-40). REFERENCES
Discussion
Laparoscopic cholecystectomy has emerged as a costeffective treatment for symptomatic gallstone disease and has minimum morbidity. This technique is now offered in many centres,l-3but its place as the routine method of cholecystectomy has not yet been established in district general hospitals where most cholecystectomies take place. Since the technique demands new surgical skills, there has been debate4-6 about the necessity of training all surgeons in laparoscopic methods. Although we initially excluded patients with previous upper abdominal surgery and those who needed other combined procedures, our experience now persuades us that many are suitable for laparoscopic cholecystectomy. In 180 consecutive procedures there were no deaths and little morbidity. Only 2 patients had major complications that might have been avoided with open operation (right hepatic
duct injury and duodenal fistula associated with cellulitis), and one of these required conversion to an open operation. Wound infection has been reported as a major cause of morbidity in up to 7% of cases of open cholecystectomy.7,8 However, in our series of laparoscopic cholecystectomies, wound infection was a negligible cause of morbidity. We confirmed the reports of others2 that emergency laparoscopic cholecystectomy was associated with high morbidity. The procedure was attempted in 6 patients with either acute cholecystitis or empyema of the gall bladder. After ultrasound confirmation of the diagnosis, patients underwent surgery within 5 days of admission. Subsequent complications of unidentifiable anatomy that required open cholecystectomy, postoperative haemorrhage, and a cystic duct bile leak gave a 50% frequency of serious morbidity. In common with other centres we now exclude these patients.2 In our series, conversion to open operation and complication rates were more common in the first fifty operations (6 out of 10 conversions, 8 out of 16 complications). Both major complications occurred in the early cases. By contrast, in the last 100 procedures, there was no major morbidity and only 3 patients required conversion to open
operation.
We have screened all patients preoperatively for stones and have not completed routine peroperative cholangiography. This policy requires a readily accessible ERCP and therapeutic endoscopy service. If such facilities are not available, peroperative cholangiography should probably be mandatory. The mean operating time for laparoscopic cholecystectomy in our series is similar to that for
1. Reddick EJ, Olsen DO.
2. 3.
Laparoscopic laser cholecystectomy. Surg Endosc 1989; 3: 131-33. Cuschieri A, Dubois F, Mouiel J, et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;; 161: 385-87. Grace PA, Quereshi A, Coleman J, et al. Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg 1991; 78: 160-62.
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From The Lancet Copper-bottomed? Freshly precipitated and moist
copper hydrate seems likely to place in agricultural science next in importance to that of manure. A mixture of lime and copper sulphate has been employed for some time now with success as an insecticide or germicide in the treatment of disease of the vine, potato, and tomato; and quite recently M Aime-Girard applied the same mixture to sugar beet plants threatened with the attacks of a specific fungus.... Under this treatment the disease is said to be effectually stayed, the leaves to become more luxuriant and the stalks to be so preserved that those occupy
a
attacked grew richer in saccharine constituent, while the proportion of sugar in the root was found to have increased 1-58 per cent.... As every student of elementary chemistry knows, lime-water (hydrate) and copper sulphate give calcium sulphate and copper hydrate; but it is to the latter body of course that the fungus-destroying action is due. Copper hydrate would appear to act on fungi as a weak solution of perchloride of mercury, without, however, affecting the growth or life of the plant, and its action may possibly be akin to that which takes place when it is added to solution of peptone-albumose. With this body it combines to form an insoluble compound-a reaction which has been taken advantage of in the separation and estimation of this variety of peptone. The effect, however, of using copper compounds for purposes of the kind above mentioned must be watched with due care, as plants are known to assimilate the metallic salts with readiness. Cereals, for instance, have been found to derive an important quantity of copper from the soil, and in view of the enormous consumption of sugar by infants as well as by invalids, the question may possibly become one of no little moment, upon the merits of which chemical analysis will, in course of time, decide.
(July 18, 1891)>
