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Development Of Laparoscopic Single-Site Cholecystectomy Mandates Critical View Of Safety Dissection and Routine Intraoperative Cholangiography
422
Letters
J Am Coll Surg
Table 2. Factors Independently Associated with a Greater than Moderate Self-Reported Likelihood of Leaving Current Practice in the Next 2 Years Variable
Burned out Screen positive for depression Active military practice Age of youngest child ⬎22 y Age† Hours per week in operating room‡ Have children Specialty plastic surgery Specialty ophthalmology
Odds ratio*
2.5 2.1 2.1 2.0 1.03 0.99 0.6 0.7 0.6
Factors included in multivariate model: burnout, suicidal ideation, age, sex, relationship status, parental status, surgical specialty, years in practice, hours worked per week, hours per week in operating room, nights on call per week, practice setting, compensation type, time spent on nonpatient care activities, academic rank, age of youngest child, depression screen status. *All p values significant at the 0.006 level. † Odds ratio for each year older. ‡ Odds ratio for each additional hour in operating room per week.
workforce in the US,4 and they underscore the potential importance of burnout and satisfaction in surgeon turnover and exit from practice. More research on the factors that cause surgeons to consider leaving practice is needed. REFERENCES 1. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg 2009;250:463–471. 2. Shanafelt TD, Balch C, Dyrbye LN, et al. Suicidal ideation among American surgeons. Arch Surg 2010; in press. 3. Balch CM, Shanafelt TD, Dyrbye L, et al. Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg 2010;211:609–619. 4. Poley S, Belsky D, Gaul K, et al. Longitudinal Trends in the US Surgical Workforce 1981–2006. Chapel Hill, NC: American College of Surgeons Health Policy Research Institute, May 2009.
Disclosure information: Nothing to disclose.
Development Of Laparoscopic Single-Site Cholecystectomy Mandates Critical View Of Safety Dissection and Routine Intraoperative Cholangiography Pascal Bucher, MD Philippe Morel, MD Geneva, Switzerland
We read with interest the article by Rawlings and colleagues, “Single-Incision Laparoscopic Cholecystectomy with Critical View of Safety Recognition and Routine Intraoperative Cholangiography.”1 We would like to comment and emphasize the importance of these issues at the time of single-access cholecystectomy diffusion. We are now at the time of the possible introduction in routine clinical practice of a new, less invasive approach for cholecystectomy, but we cannot let history repeat!2,3 The uncontrolled introduction of laparoscopy was associated with a dramatic rise in the incidence of biliary injuries.2,4,5 This should not be repeated with the introduction of laparoendoscopic single-site surgery (LESS). We should not forget principles of safety elaborated during decades of minimally invasive cholecystectomy.2 Although the benefits of LESS cholecystectomy will rely mainly on cosmesis, we cannot accept a rise in biliary lesion incidence and its related morbidity.6 We should never hesitate to place an additional port in the case of poor exposition (a safe reduced-port laparoscopic cholecystectomy might be more beneficial for the patient than a morbid single-access surgery). Poor exposition can be defined differently according to surgeon, but inability to gain the critical view of safety might be a strong definition for this. It should be recommended that inability to obtain or prepare the critical view of safety implies placement of additional ports or exposition devices without concern for the cost. We have introduced in our practice of LESS cholecystectomy, mandatory photo documentation of the critical view of safety as recommended by others and some surgical societies (eg, the Dutch Society of Surgery) for conventional laparoscopy. For us, and according to Rawlings and colleagues, this recommendation should be supported, especially as newer methods such as LESS or natural orifice translumenal endoscopic cholecystectomy are introduced.1,4,7 Biliary tract injury during cholecystectomy can be associated with life-long morbidity and complications, especially if not recognized promptly.5 One of the most reliable methods to promptly detect a biliary tract lesion during cholecystectomy is intraoperative cholangiography.5 As noted by Rawlings and colleagues, few published series of single-access cholecystectomies have reported routine use of intraoperative cholangiography. In addition, among 41 series published since 2008, only 3 have reported its routine use, 1 by Rawlings and colleagues and 2 by our group.1,2,8 We agree that intraoperative cholangiography increases the cost of cholecystectomy by increasing requested disposable and operative time, but these costs can counterbalance the cost associated with unrecognized biliary tract lesion.5 It can be argued that use of intraoperative cholangiography might minimize the cosmetic benefit of single transumbilical access, as performed by
Vol. 212, No. 3, March 2011
Rawlings and colleagues, but cholangiography can be performed through the umbilical access without need for another access.2,8 We have completed 175 LESS cholecystectomies and the rate of success of intraoperative cholangiography is 87% (institutional database for LESS cases). We are not discussing the practice of intraoperative cholangiography for routine clinical practice, but for an innovative surgical approach for which the risks are not well-defined and instrumentation is still under evaluation.2 In summary, we would strongly recommend implementation of intraoperative cholangiography during single-access cholecystectomy until its safety has been demonstrated. In conclusion, following the critical view of safety principle and performing routine intraoperative cholangiography in a series approaching 200 LESS cholecystectomies has been associated with the absence of biliary tract lesion in our institution. Despite the risk of being viewed as “aficionados” of surgical innovation and LESS, we want to stress that in our experience this approach can be safe and beneficial to patients, but we recommend adhering to the principles elaborated to increase the safety of minimally invasive cholecystectomy.
Letters
423
We thank Drs Bucher and Morel for their comments about our article on single-incision laparoscopic cholecystectomy and congratulate them on their large series of 175 laparoendoscopic single-site surgery cholecystectomies with a high rate of success using intraoperative cholangiography. Drs Bucher and Morel reinforced the principles that we have elucidated in our article and we agree with their recommendation for “implementation of intraoperative cholangiography during single-access cholecystectomy until its safety has been demonstrated.” The authors note that cholangiography can be performed through the umbilical access route without the need for percutaneous puncture. We have also used that technique by inserting a cholangioclamp through an umbilical port and accessing the cystic duct from that viewpoint, although in some cases the angle for insertion into the cystic duct is less optimal than that achieved through percutaneous subcostal puncture with a needle stick. Surgeons should have both options available to them to enhance the success rate of cholangiography in this setting. Disclosure information: Nothing to disclose.
REFERENCES 1. Rawlings A, Hodgett S, Matthews B, et al. Single-incision laparoscopic cholecystectomy: initial expereince with critical view of safety dissection and routine intraoperative cholangiography. J Am Coll Surg 2010;211:1–7. 2. Bucher P, Pugin F, Morel P. From single-port access to laparoendoscopic single-site cholecystectomy. Surg Endosc 2010;24:234–235. 3. Connor S. Single-port-access cholecystectomy: history should not be allowed to repeat. World J Surg 2009;33:1020–1021. 4. Strasberg S, Brunt L. Rational and use of critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 2010;211:132–138. 5. Gigot J. Bile duct injury during laparoscopic cholecystectomy. J Chir 2007;144:383–384. 6. Bucher P, Pugin F, Ostermann S, et al. Population perception of surgical safety and body image trauma: a plea for scarless surgery? Surg Endosc 2010; Epub ahead of print. 7. Podolsky ER, Curcillo PG 2nd. Reduced-port surgery: preservation of the critical view in single-port-access cholecystectomy. Surg Endosc 2010;24:3038–3043. 8. Bucher P, Pugin F, Buchs N, et al. Single port access laparoscopic cholecystectomy (with video). World J Surg 2009;33:1015–1018.
Disclosure Information: Nothing to disclose.
Pioneers in Laparoscopic Colon Surgery Louise P King, MD, JD, Babak Hajhosseini, MD, Mona M Gomaa, MD Palo Alto, CA We read the recent article, “A fast-track recovery protocol improves outcomes in elective laparoscopic colectomy for diverticulitis,” by Larson and colleagues1 with great interest. We would like to provide a point of clarification. The authors report the first description of laparoscopic colon surgery as occurring in 1991. However, the first laparoscopic colon surgery was described in 1988 by our mentor, Dr Camran Nezhat, at the 44th Annual Meeting of the American Fertility Society. Dr Nezhat thereafter published his study results in 1989 and June of 1991, both of which predate the articles cited by the authors.2-4
Reply L Michael Brunt, MD, FACS Steven M Strasberg, MD, FACS St Louis, MO
REFERENCES 1. Larson DW, Batdorf NJ, Touzios JG, et al. A fast-track recovery protocol improves outcomes in elective laparoscopic colectomy for diverticulitis. J Am Coll Surg 2010;211:485–489.
Letters
J Am Coll Surg
Table 2. Factors Independently Associated with a Greater than Moderate Self-Reported Likelihood of Leaving Current Practice in the Next 2 Years Variable
Burned out Screen positive for depression Active military practice Age of youngest child ⬎22 y Age† Hours per week in operating room‡ Have children Specialty plastic surgery Specialty ophthalmology
Odds ratio*
2.5 2.1 2.1 2.0 1.03 0.99 0.6 0.7 0.6
Factors included in multivariate model: burnout, suicidal ideation, age, sex, relationship status, parental status, surgical specialty, years in practice, hours worked per week, hours per week in operating room, nights on call per week, practice setting, compensation type, time spent on nonpatient care activities, academic rank, age of youngest child, depression screen status. *All p values significant at the 0.006 level. † Odds ratio for each year older. ‡ Odds ratio for each additional hour in operating room per week.
workforce in the US,4 and they underscore the potential importance of burnout and satisfaction in surgeon turnover and exit from practice. More research on the factors that cause surgeons to consider leaving practice is needed. REFERENCES 1. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg 2009;250:463–471. 2. Shanafelt TD, Balch C, Dyrbye LN, et al. Suicidal ideation among American surgeons. Arch Surg 2010; in press. 3. Balch CM, Shanafelt TD, Dyrbye L, et al. Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg 2010;211:609–619. 4. Poley S, Belsky D, Gaul K, et al. Longitudinal Trends in the US Surgical Workforce 1981–2006. Chapel Hill, NC: American College of Surgeons Health Policy Research Institute, May 2009.
Disclosure information: Nothing to disclose.
Development Of Laparoscopic Single-Site Cholecystectomy Mandates Critical View Of Safety Dissection and Routine Intraoperative Cholangiography Pascal Bucher, MD Philippe Morel, MD Geneva, Switzerland
We read with interest the article by Rawlings and colleagues, “Single-Incision Laparoscopic Cholecystectomy with Critical View of Safety Recognition and Routine Intraoperative Cholangiography.”1 We would like to comment and emphasize the importance of these issues at the time of single-access cholecystectomy diffusion. We are now at the time of the possible introduction in routine clinical practice of a new, less invasive approach for cholecystectomy, but we cannot let history repeat!2,3 The uncontrolled introduction of laparoscopy was associated with a dramatic rise in the incidence of biliary injuries.2,4,5 This should not be repeated with the introduction of laparoendoscopic single-site surgery (LESS). We should not forget principles of safety elaborated during decades of minimally invasive cholecystectomy.2 Although the benefits of LESS cholecystectomy will rely mainly on cosmesis, we cannot accept a rise in biliary lesion incidence and its related morbidity.6 We should never hesitate to place an additional port in the case of poor exposition (a safe reduced-port laparoscopic cholecystectomy might be more beneficial for the patient than a morbid single-access surgery). Poor exposition can be defined differently according to surgeon, but inability to gain the critical view of safety might be a strong definition for this. It should be recommended that inability to obtain or prepare the critical view of safety implies placement of additional ports or exposition devices without concern for the cost. We have introduced in our practice of LESS cholecystectomy, mandatory photo documentation of the critical view of safety as recommended by others and some surgical societies (eg, the Dutch Society of Surgery) for conventional laparoscopy. For us, and according to Rawlings and colleagues, this recommendation should be supported, especially as newer methods such as LESS or natural orifice translumenal endoscopic cholecystectomy are introduced.1,4,7 Biliary tract injury during cholecystectomy can be associated with life-long morbidity and complications, especially if not recognized promptly.5 One of the most reliable methods to promptly detect a biliary tract lesion during cholecystectomy is intraoperative cholangiography.5 As noted by Rawlings and colleagues, few published series of single-access cholecystectomies have reported routine use of intraoperative cholangiography. In addition, among 41 series published since 2008, only 3 have reported its routine use, 1 by Rawlings and colleagues and 2 by our group.1,2,8 We agree that intraoperative cholangiography increases the cost of cholecystectomy by increasing requested disposable and operative time, but these costs can counterbalance the cost associated with unrecognized biliary tract lesion.5 It can be argued that use of intraoperative cholangiography might minimize the cosmetic benefit of single transumbilical access, as performed by
Vol. 212, No. 3, March 2011
Rawlings and colleagues, but cholangiography can be performed through the umbilical access without need for another access.2,8 We have completed 175 LESS cholecystectomies and the rate of success of intraoperative cholangiography is 87% (institutional database for LESS cases). We are not discussing the practice of intraoperative cholangiography for routine clinical practice, but for an innovative surgical approach for which the risks are not well-defined and instrumentation is still under evaluation.2 In summary, we would strongly recommend implementation of intraoperative cholangiography during single-access cholecystectomy until its safety has been demonstrated. In conclusion, following the critical view of safety principle and performing routine intraoperative cholangiography in a series approaching 200 LESS cholecystectomies has been associated with the absence of biliary tract lesion in our institution. Despite the risk of being viewed as “aficionados” of surgical innovation and LESS, we want to stress that in our experience this approach can be safe and beneficial to patients, but we recommend adhering to the principles elaborated to increase the safety of minimally invasive cholecystectomy.
Letters
423
We thank Drs Bucher and Morel for their comments about our article on single-incision laparoscopic cholecystectomy and congratulate them on their large series of 175 laparoendoscopic single-site surgery cholecystectomies with a high rate of success using intraoperative cholangiography. Drs Bucher and Morel reinforced the principles that we have elucidated in our article and we agree with their recommendation for “implementation of intraoperative cholangiography during single-access cholecystectomy until its safety has been demonstrated.” The authors note that cholangiography can be performed through the umbilical access route without the need for percutaneous puncture. We have also used that technique by inserting a cholangioclamp through an umbilical port and accessing the cystic duct from that viewpoint, although in some cases the angle for insertion into the cystic duct is less optimal than that achieved through percutaneous subcostal puncture with a needle stick. Surgeons should have both options available to them to enhance the success rate of cholangiography in this setting. Disclosure information: Nothing to disclose.
REFERENCES 1. Rawlings A, Hodgett S, Matthews B, et al. Single-incision laparoscopic cholecystectomy: initial expereince with critical view of safety dissection and routine intraoperative cholangiography. J Am Coll Surg 2010;211:1–7. 2. Bucher P, Pugin F, Morel P. From single-port access to laparoendoscopic single-site cholecystectomy. Surg Endosc 2010;24:234–235. 3. Connor S. Single-port-access cholecystectomy: history should not be allowed to repeat. World J Surg 2009;33:1020–1021. 4. Strasberg S, Brunt L. Rational and use of critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 2010;211:132–138. 5. Gigot J. Bile duct injury during laparoscopic cholecystectomy. J Chir 2007;144:383–384. 6. Bucher P, Pugin F, Ostermann S, et al. Population perception of surgical safety and body image trauma: a plea for scarless surgery? Surg Endosc 2010; Epub ahead of print. 7. Podolsky ER, Curcillo PG 2nd. Reduced-port surgery: preservation of the critical view in single-port-access cholecystectomy. Surg Endosc 2010;24:3038–3043. 8. Bucher P, Pugin F, Buchs N, et al. Single port access laparoscopic cholecystectomy (with video). World J Surg 2009;33:1015–1018.
Disclosure Information: Nothing to disclose.
Pioneers in Laparoscopic Colon Surgery Louise P King, MD, JD, Babak Hajhosseini, MD, Mona M Gomaa, MD Palo Alto, CA We read the recent article, “A fast-track recovery protocol improves outcomes in elective laparoscopic colectomy for diverticulitis,” by Larson and colleagues1 with great interest. We would like to provide a point of clarification. The authors report the first description of laparoscopic colon surgery as occurring in 1991. However, the first laparoscopic colon surgery was described in 1988 by our mentor, Dr Camran Nezhat, at the 44th Annual Meeting of the American Fertility Society. Dr Nezhat thereafter published his study results in 1989 and June of 1991, both of which predate the articles cited by the authors.2-4
Reply L Michael Brunt, MD, FACS Steven M Strasberg, MD, FACS St Louis, MO
REFERENCES 1. Larson DW, Batdorf NJ, Touzios JG, et al. A fast-track recovery protocol improves outcomes in elective laparoscopic colectomy for diverticulitis. J Am Coll Surg 2010;211:485–489.