4-0 kPa to 6 4 kPa. This presents a problem with some theatre ventilators, which are unable to cope with this degree of reduced chest wall compliance and fail to deliver the set tidal volume, resulting in an even greater rise in end tidal pressure. Prolonged abdominal distention can also lead to diaphragmatic elevation and basal lung atelectasis, which, if persisting into the postoperative period, increase the risk of hypoxaemia. Thirdly, this procedure takes longer than conventional cholecystectomy. In the first 20 cases that we studied the mean surgical operating time was 110 minutes, significantly longer than an operating time of 30 minutes for conventional cholecystectomy found in a recent British series.' This has implications both for the total amount of anaesthetic given and for the incidence of complications, such as deep venous thrombosis, which increases in frequency with prolonged preoperative immobility.45 Thus although laparoscopic cholecystectomy offers potential benefits to the patient and significant cost saving,' 2 it is too early to state that "this procedure will inevitably become the only method for routine cholecystectomy." The balance between potential preoperative complications and postoperative benefits needs to be considered carefully for each patient, particularly very obese
patients. J GARETH JONES C CARR
University Department of Anaesthesia, Leeds LS2 9LN 1 Wastell C. Laparoscopic cholecystectomy. BMJ 1991;302:303-4.
(9 February.) 2 Greville AC, Clements AF, Erwin DC, McMillan DL, Wellwood
JM. Pulmonary air embolism during laparoscopic laser cholecystectomy. Anaesthesia 1991;46:113-4. 3 Steger AC, Moore KM, Hira N. Contact laser or conventional cholecystectomy: a controlled trial. Br J Surg 1988;75: 223-5. 4 Merli GJ, Martinez J. Prophylaxis for deep vein thrombosis and pulmonary embolism in the surgical patient. Medical Clinics of North America 1987;71:377-97. 5 Clarke-Pearson DL, DeLong ER, Synan IS, Coleman RE, Creaseman WT. Variables associated with postoperative deep vein thrombosis: a prospective study of 411 gynecology patients and creation of a prognostic model. Obstet Gynecol 1987;69: 146-50.
for both procedures and no deaths. These data do not show any advantages of laparoscopic cholecystectomy over minicholecystectomy. Professor Wastell estimates that laparoscopic cholecystectomy would save the health service £21m a year because of the reduction in hospital stay for the 30000 cholecystectomies performed. He did not take into account the increased time spent in theatre not only performing the procedure but preparing the equipment. One hour of theatre time, at a premium of £250 an hour, is equivalent to the cost of keeping a patient in hospital for an extra day. Our laparoscopic cholecystectomies have taken one hour longer than the minicholecystectomies, and even the experienced are averaging about 90 minutes for the laparoscopic procedure, which is 30 minutes longer than for minicholecystectomy.2 3 Therefore, there does not seem to be any appreciable cost difference between the procedures. One of the main benefits of minimally invasive procedures to the patient is the short convalescent period. Patients are able to return to work within one to two weeks after laparoscopic cholecystectomy and within two to three weeks after minicholecystectomy. In practice, however, it is difficult to convince patients and their general practitioners that gall bladder surgery no longer requires a lengthy convalescent period. To determine that there is benefit from a laparoscopic cholecystectomy a trial comparing the laparoscopic technique with minicholecystectomy is required. There are, however, ethical constraints to such trials, and a German study has been abandoned.4 Perhaps it is preferable to assess the procedures in parallel with carefully controlled measures of outcome to make a valid comparison, or is this another subject in which the media with their emphasis on information before justification have usurped our ability to achieve fully informed consent for a trial? SARAH CHESLYN-CURTIS
Hammersmith Hospital, London W12 OHS R C G RUSSELL
Middlesex Hospital, London WIN 8AA 1 Wastell C. Laparoscopic cholecystectomy. BMJ 1991-302:303-4.
(9 February.)
SIR,-We disagree with Professor C Wastell's statement that "minilap cholecystectomy tends to combine the worst of all worlds and compares unfavourably with the endoscopic method."' By comparing our results of laparoscopic cholecystectomy and minicholecystectomy performed during the past year, we conclude that the advantages of the laparoscopic technique over other treatment methods are not as conclusive as has been claimed. Laparoscopic cholecystectomy was performed in 81 patients with a median age of 43 (male to female ratio 1:3). The procedure was completely successful in 74 patients but needed conversion to a minicholecystectomy in seven. The reasons for this were uncontrolled cystic artery bleeding, an unsuspected cholecystoduodenal fistula, adhesions from previous abdominal or gall bladder procedures, and difficulty in identifying the ductal anatomy. The 56 patients who underwent minicholecystectomy were older (median age 57; male to female ratio 1:2) and included those who had been turned down for the laparoscopic method because of predicted technical difficulties. Minicholecystectomy was successful in all cases. The median procedure time for laparoscopic cholecystectomy was about an hour longer than that for minicholecystectomy. The median postoperative hospital stay after laparoscopic cholecystectomy of two days (range one to five days) was, however, shorter than that after minicholecystectomy (four (range two to nine) days); the patients who had a minicholecystectomy after the failed laparoscopic procedure were discharged from hospital after three days. There was an 8% incidence of complications
594
2 Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Amj Surg 1990; 160:485-7. 3 Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy. A comparison with mini-lap cholecystectomy. SurgEndosc 1989; 3:131-3. 4 Neugebauer E, Troidl H, Spangenberger W, et al. Conventional versus laparoscopic cholecystectomy and the randomized controlled trial. BrJ Surg 1991;78:150-4.
Teaching junior doctors practical procedures SIR,-I agree with Dr Alison Walker that the casual approach to the learning of practical procedures will no longer do.' The haphazard system is dangerous for patients. My first solo pacing was an emergency; I had seen and assisted at one previous pacing. I was too scared of rebuttal to ring my (locum) registrar. By luck I succeeded. We wheeled the patient back past his worried family of school aged children. How much more worried would they have been had they known my inexperience? My situation was not unique: it is common for a senior house officer, possibly inexperienced, to be the senior resident doctor on call. I know that at times nobody on site at a district general hospital can pace. This hit and miss system may have been acceptable when such procedures were in their infancy. Now that they are standard practice it is not acceptable. We owe it to patients that a medical emergency in their lives is dealt with by doctors who know what they are doing. The present system is also dangerous for doctors. Firstly, increased scrutiny of our work will unmask
deficiencies in care and may lead to litigation. Secondly, I believe that lack of confidence in this area can lead to undermining of morale; many doctors find it difficult or inexpedient to express this. Doctors should know which procedures they are expected to perform and -no doctor should be required to do a dangerous procedure in which he or she is not competent. I conducted a confidential straw poll of two consultants, four senior registrars, and five senior house officers in our geriatric department at our morning review of the previous day's admissions. Only three of the 11 felt competent in all the techniques they thought their specialty and status demanded; only two of the 11 had received adequate instruction and supervision. All 11 thought more training and supervision were required, and 10 would take up an offer of further training. I accept that many procedures are not scheduled, but before a procedure is done it should be possible in all but extreme emergencies to contact doctors who have expressed an interest in learning the technique. This "on the job" learning should be targeted at preregistration doctors and senior house officers, but more senior doctors who wish to revise or fill in gaps in their knowledge should be encouraged to participate. It is time for a change. The will to learn is there, but the opportunity is not. HELEN NEWTON
University Department of Geriatric Medicine, General Hospital, Southampton S09 4XY 1 Walker A. Teaching junior doctors practical procedures. BMJ 1991;302:306. (9 February.)
SIR,-Dr Alison Walker correctly states that exposing house officers to more practical procedures during their undergraduate years would be one way of improving their preparation, especially for facing patients alone and at night.' Three years ago we took a small step towards correcting this deficiency by starting to teach practical skills on an introductory course for junior clinical students. The course included resuscitation skills taught on four different work stations on various manikins; initial assessment and management of multiple injuries on a "moulaged" casualty along the lines of the Royal College of Surgeons' advanced trauma life support course; suturing on oranges and pigs' trotters; venepuncture under supervision on each other; examination of eyes and fundus on each other; and systems examination on real patients in groups of three. The table shows the collated results of the past two years' assessment forms. The commonest reason given by students for the popularity of the practical sessions was that they were the kind of skills that fulfilled their expectation of a medical career, were most relevant to clinical medicine at their stage of training, and maintained the excitement of having switched from basic sciences to clinical medicine. The momentum to teach practical skills wanes during intermediate and senior training because students are distributed in smaller numbers to many firms in several hospitals. Herein lies the benefit of a skills centre. Students' assessment of quality of practical teaching sessions (76 students) Poor Fair
Examining patients Suturing
1
Venepuncture "Moulaged" casualties Eyes and fundus Resuscitation Average of six best lectures
8
BMJ VOLUME 302
5 3 6 10 19 2 32
Good Excellent 28 34 34 33 39 35 28
43 38 36 33 18 39 8
9 MARCH 1991
patients. J GARETH JONES C CARR
University Department of Anaesthesia, Leeds LS2 9LN 1 Wastell C. Laparoscopic cholecystectomy. BMJ 1991;302:303-4.
(9 February.) 2 Greville AC, Clements AF, Erwin DC, McMillan DL, Wellwood
JM. Pulmonary air embolism during laparoscopic laser cholecystectomy. Anaesthesia 1991;46:113-4. 3 Steger AC, Moore KM, Hira N. Contact laser or conventional cholecystectomy: a controlled trial. Br J Surg 1988;75: 223-5. 4 Merli GJ, Martinez J. Prophylaxis for deep vein thrombosis and pulmonary embolism in the surgical patient. Medical Clinics of North America 1987;71:377-97. 5 Clarke-Pearson DL, DeLong ER, Synan IS, Coleman RE, Creaseman WT. Variables associated with postoperative deep vein thrombosis: a prospective study of 411 gynecology patients and creation of a prognostic model. Obstet Gynecol 1987;69: 146-50.
for both procedures and no deaths. These data do not show any advantages of laparoscopic cholecystectomy over minicholecystectomy. Professor Wastell estimates that laparoscopic cholecystectomy would save the health service £21m a year because of the reduction in hospital stay for the 30000 cholecystectomies performed. He did not take into account the increased time spent in theatre not only performing the procedure but preparing the equipment. One hour of theatre time, at a premium of £250 an hour, is equivalent to the cost of keeping a patient in hospital for an extra day. Our laparoscopic cholecystectomies have taken one hour longer than the minicholecystectomies, and even the experienced are averaging about 90 minutes for the laparoscopic procedure, which is 30 minutes longer than for minicholecystectomy.2 3 Therefore, there does not seem to be any appreciable cost difference between the procedures. One of the main benefits of minimally invasive procedures to the patient is the short convalescent period. Patients are able to return to work within one to two weeks after laparoscopic cholecystectomy and within two to three weeks after minicholecystectomy. In practice, however, it is difficult to convince patients and their general practitioners that gall bladder surgery no longer requires a lengthy convalescent period. To determine that there is benefit from a laparoscopic cholecystectomy a trial comparing the laparoscopic technique with minicholecystectomy is required. There are, however, ethical constraints to such trials, and a German study has been abandoned.4 Perhaps it is preferable to assess the procedures in parallel with carefully controlled measures of outcome to make a valid comparison, or is this another subject in which the media with their emphasis on information before justification have usurped our ability to achieve fully informed consent for a trial? SARAH CHESLYN-CURTIS
Hammersmith Hospital, London W12 OHS R C G RUSSELL
Middlesex Hospital, London WIN 8AA 1 Wastell C. Laparoscopic cholecystectomy. BMJ 1991-302:303-4.
(9 February.)
SIR,-We disagree with Professor C Wastell's statement that "minilap cholecystectomy tends to combine the worst of all worlds and compares unfavourably with the endoscopic method."' By comparing our results of laparoscopic cholecystectomy and minicholecystectomy performed during the past year, we conclude that the advantages of the laparoscopic technique over other treatment methods are not as conclusive as has been claimed. Laparoscopic cholecystectomy was performed in 81 patients with a median age of 43 (male to female ratio 1:3). The procedure was completely successful in 74 patients but needed conversion to a minicholecystectomy in seven. The reasons for this were uncontrolled cystic artery bleeding, an unsuspected cholecystoduodenal fistula, adhesions from previous abdominal or gall bladder procedures, and difficulty in identifying the ductal anatomy. The 56 patients who underwent minicholecystectomy were older (median age 57; male to female ratio 1:2) and included those who had been turned down for the laparoscopic method because of predicted technical difficulties. Minicholecystectomy was successful in all cases. The median procedure time for laparoscopic cholecystectomy was about an hour longer than that for minicholecystectomy. The median postoperative hospital stay after laparoscopic cholecystectomy of two days (range one to five days) was, however, shorter than that after minicholecystectomy (four (range two to nine) days); the patients who had a minicholecystectomy after the failed laparoscopic procedure were discharged from hospital after three days. There was an 8% incidence of complications
594
2 Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Amj Surg 1990; 160:485-7. 3 Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy. A comparison with mini-lap cholecystectomy. SurgEndosc 1989; 3:131-3. 4 Neugebauer E, Troidl H, Spangenberger W, et al. Conventional versus laparoscopic cholecystectomy and the randomized controlled trial. BrJ Surg 1991;78:150-4.
Teaching junior doctors practical procedures SIR,-I agree with Dr Alison Walker that the casual approach to the learning of practical procedures will no longer do.' The haphazard system is dangerous for patients. My first solo pacing was an emergency; I had seen and assisted at one previous pacing. I was too scared of rebuttal to ring my (locum) registrar. By luck I succeeded. We wheeled the patient back past his worried family of school aged children. How much more worried would they have been had they known my inexperience? My situation was not unique: it is common for a senior house officer, possibly inexperienced, to be the senior resident doctor on call. I know that at times nobody on site at a district general hospital can pace. This hit and miss system may have been acceptable when such procedures were in their infancy. Now that they are standard practice it is not acceptable. We owe it to patients that a medical emergency in their lives is dealt with by doctors who know what they are doing. The present system is also dangerous for doctors. Firstly, increased scrutiny of our work will unmask
deficiencies in care and may lead to litigation. Secondly, I believe that lack of confidence in this area can lead to undermining of morale; many doctors find it difficult or inexpedient to express this. Doctors should know which procedures they are expected to perform and -no doctor should be required to do a dangerous procedure in which he or she is not competent. I conducted a confidential straw poll of two consultants, four senior registrars, and five senior house officers in our geriatric department at our morning review of the previous day's admissions. Only three of the 11 felt competent in all the techniques they thought their specialty and status demanded; only two of the 11 had received adequate instruction and supervision. All 11 thought more training and supervision were required, and 10 would take up an offer of further training. I accept that many procedures are not scheduled, but before a procedure is done it should be possible in all but extreme emergencies to contact doctors who have expressed an interest in learning the technique. This "on the job" learning should be targeted at preregistration doctors and senior house officers, but more senior doctors who wish to revise or fill in gaps in their knowledge should be encouraged to participate. It is time for a change. The will to learn is there, but the opportunity is not. HELEN NEWTON
University Department of Geriatric Medicine, General Hospital, Southampton S09 4XY 1 Walker A. Teaching junior doctors practical procedures. BMJ 1991;302:306. (9 February.)
SIR,-Dr Alison Walker correctly states that exposing house officers to more practical procedures during their undergraduate years would be one way of improving their preparation, especially for facing patients alone and at night.' Three years ago we took a small step towards correcting this deficiency by starting to teach practical skills on an introductory course for junior clinical students. The course included resuscitation skills taught on four different work stations on various manikins; initial assessment and management of multiple injuries on a "moulaged" casualty along the lines of the Royal College of Surgeons' advanced trauma life support course; suturing on oranges and pigs' trotters; venepuncture under supervision on each other; examination of eyes and fundus on each other; and systems examination on real patients in groups of three. The table shows the collated results of the past two years' assessment forms. The commonest reason given by students for the popularity of the practical sessions was that they were the kind of skills that fulfilled their expectation of a medical career, were most relevant to clinical medicine at their stage of training, and maintained the excitement of having switched from basic sciences to clinical medicine. The momentum to teach practical skills wanes during intermediate and senior training because students are distributed in smaller numbers to many firms in several hospitals. Herein lies the benefit of a skills centre. Students' assessment of quality of practical teaching sessions (76 students) Poor Fair
Examining patients Suturing
1
Venepuncture "Moulaged" casualties Eyes and fundus Resuscitation Average of six best lectures
8
BMJ VOLUME 302
5 3 6 10 19 2 32
Good Excellent 28 34 34 33 39 35 28
43 38 36 33 18 39 8
9 MARCH 1991
