Laparoscopic surgery

Abstract

I would make some comments on two randomised clinical trials to which Johnson1Johnson A Laparoscopic surgery.Lancet. 1997; 349: 631-635Summary Full Text Full Text PDF PubMed Scopus (106) Google Scholar refers, for which I am the principal investigator.The first study2McMahon AJ Russell IT Baxter JN Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial.Lancet. 1994; 343: 135-138Summary PubMed Scopus (362) Google Scholar compared laparoscopic with minichole-cystectomy and showed that the former was much more expensive than the latter. When reusable instruments were used this difference was £93 (95% CI £25–162), based on an increase in theatre costs caused by the extra time required for laparoscopic cholecystectomy (14 min). I would point out that this difference is academic, since undertaking a laparoscopic cholecystectomy, or indeed several procedures, did not result in any change in the number of patients placed on our operating list or an over-run in operating time during the study period. In my experience, operating time for laparoscopic cholecystectomy has dropped substantially since that time, from a median of 65 (46–70) to 50 (40–66) min (p=0·004).3Wallace DH, O'Dwyer PJ. Effect of a no-conversion policy on patient outcome following laparoscopic cholecystectomy. Br J Surg (in press).Google Scholar This fall is principally due to the fact that the learning curve for laparoscopic cholecystectomy is much longer than had been anticipated when the randomised trial was set up.2McMahon AJ Russell IT Baxter JN Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial.Lancet. 1994; 343: 135-138Summary PubMed Scopus (362) Google ScholarThe second study is the Medical Research Council trial funded to evaluate laparoscopic hernia repair. This trial does not compare laparoscopic hernia repair with many diffuse open methods, as Johnson suggests. The laparoscopic group is almost exclusively the totally extraperitoneal approach to hernia repair, which is not different from its open preperitoneal equivalent. Over 90% of patients in the open group have had a tension-free repair hernioplasty and a few have had other open procedures when use of mesh was considered unnecessary, eg, in a Nyhus type 1 hernia in a young adult. I would make some comments on two randomised clinical trials to which Johnson1Johnson A Laparoscopic surgery.Lancet. 1997; 349: 631-635Summary Full Text Full Text PDF PubMed Scopus (106) Google Scholar refers, for which I am the principal investigator. The first study2McMahon AJ Russell IT Baxter JN Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial.Lancet. 1994; 343: 135-138Summary PubMed Scopus (362) Google Scholar compared laparoscopic with minichole-cystectomy and showed that the former was much more expensive than the latter. When reusable instruments were used this difference was £93 (95% CI £25–162), based on an increase in theatre costs caused by the extra time required for laparoscopic cholecystectomy (14 min). I would point out that this difference is academic, since undertaking a laparoscopic cholecystectomy, or indeed several procedures, did not result in any change in the number of patients placed on our operating list or an over-run in operating time during the study period. In my experience, operating time for laparoscopic cholecystectomy has dropped substantially since that time, from a median of 65 (46–70) to 50 (40–66) min (p=0·004).3Wallace DH, O'Dwyer PJ. Effect of a no-conversion policy on patient outcome following laparoscopic cholecystectomy. Br J Surg (in press).Google Scholar This fall is principally due to the fact that the learning curve for laparoscopic cholecystectomy is much longer than had been anticipated when the randomised trial was set up.2McMahon AJ Russell IT Baxter JN Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial.Lancet. 1994; 343: 135-138Summary PubMed Scopus (362) Google Scholar The second study is the Medical Research Council trial funded to evaluate laparoscopic hernia repair. This trial does not compare laparoscopic hernia repair with many diffuse open methods, as Johnson suggests. The laparoscopic group is almost exclusively the totally extraperitoneal approach to hernia repair, which is not different from its open preperitoneal equivalent. Over 90% of patients in the open group have had a tension-free repair hernioplasty and a few have had other open procedures when use of mesh was considered unnecessary, eg, in a Nyhus type 1 hernia in a young adult.