92
Ann. surg. . January 1992
LETTERS TO THE EDITOR
to apparently accrue large sums of money by charging inordinate fees for preceptorship should be discouraged. If one has experience with laparoscopic cholecystectomy, he should share this experience with the fledgling laparoscopic surgeon for free (or at the very most, have his incurred expenses covered). JOSEPH F. UDDO, JR., M.D. Metairie, Louisiana
April 29, 1991
surgeons
April 22, 1991 Dear Editor: We would like to thank Dr. Uddo for his kind comments regarding the paper "Safety and Efficacy of Laparoscopic Cholecystectomy." We think he has pointed out some very accurate issues with regard to training and credentialling of surgeons in this area and we wholeheartedly agree with much that he says. We might remind him that the manuscript was prepared very early in the history of laparoscopic cholecystectomy. As he points out, and as has become clear over the ensuing months, this is a procedure that can be performed safely by the average general surgeon and, thus, we agree with his assessment. Nevertheless, we might also add that we are becoming more convinced that it is a more dangerous procedure, however, than open cholecystectomy. We think the procedure is generally safe, given appropriate training, caution, and an accepting attitude toward conversion to open cholecystectomy, but it may represent an inherently increased risk over open cholecystectomy. Time will allow us the answer. The issue of whether this procedure was actually devised by "average" general surgeons is certainly open to debate. As he knows, it originated in French clinics, and Dr. Mouret, who pioneered the procedure in France, is a clinical laparoscopist with extensive experience. Describing his laparoscopic abilities as average would be inadequate to say the least. In addition, although it was indeed developed at many community hospitals within the United States, we would also question whether the surgeons involved in such innovative endeavors could be described as average. We have had the opportunity to participate in training courses for laparoscopic cholecystectomy involving several hundreds of surgeons, and it has been our observation that there are many that find it difficult. It is by no means a natural extension of our usual surgical abilities. Dr. Uddo seems offended by the assertion that we should question whether the average general surgeon is capable of performing new procedures. He also suggests that implied in our statement is an argument for limiting the procedure to a limited group of surgeons. The authors clearly did not intend any such meaning by posing the question. We think it would be inappropriate for us not to question whether any new procedure, especially one that is as technologically different as laparoscopic cholecystectomy, can be taken from the laboratory into the clinical realm with training that would be available and reasonable to the majority of surgeons and then could be applied safely. Thus, the intent of the question was exactly the opposite of Dr. Uddo's suggestions. We believe it would be highly inadequate to develop procedures that could not be easily expanded to the realm of the majority of surgeons quickly. We agree with his assessment that the emphasis should be placed on proper training, including a demonstration of competence. The entrepreneurism that has been associated with this procedure is an unfortunate consequence of the realities of the 1990s marketplace and should be discouraged. JEFFREY H. PETERS, M.D. Columbus, Ohio
Dear Editor: Dr. Simons' excellent letter describes the treatment of a young girl who presented with extrusion of a free fragment or "remnants" of spleen through a shrapnel wound in the left flank. Extrusion of a free fragment of liver or spleen devoid of blood supply is not unique, especially in patients with large wounds and significant intraperitoneal injury that leads to an elevated intraperitoneal pressure. The extrication of such exteriorized fragments from clothing, dressing, the cart, or from the wound edge bears no resemblance to the historical external splenectomies described by our forbears who identified ligation and division of the externalized splenic blood supply. The word laparotomy is derived from the Greek word "lapara," which means loin or flank. Had Dr. Simons explored this patient through her flank wound, this "laparotomy" approach would have permitted safe vascular division with extrication of the fragmented spleen and repair of the injured diaphragm. Indeed, extension of a flank wound into a formal "laparotomy" is my preferred approach in a few carefully selected patients with a close-range shotgun blast that is clearly confined to the flank area. The decision by Dr. Simons to obtain intraperitoneal vascular pedicle control though the traditional anterior celiotomy permitted a more thorough inspection of the pancreas, which was normal. The fine result achieved by Dr. Simons reflects his decision to perform the traditional open approach by one of the many different anatomic pathways to achieve complete safe splenectomy. Dr. Simons' description of this girl's presentation, her interoperative findings, and the subsequent photograph of her flank wound on postoperative day 4 reinforce my conclusion that the beginning ofthe modern era of splenic surgery for trauma should be the splenectomy performed by Riegner, who, in 1893, performed an anterior celiotomy to remove the fractured spleen of a young man who had fallen from a scaffold.' John Hunter, the renowned 18th century anatomist and surgeon, would have recognized the distinct differences from the presentation of Dr. Simons' patient and the formal flank exposures by myself as compared with the historical splenectomies with extraperitoneal division of the vascular pedicle reported by his predecessors. John Hunter also would have recognized that deviation from the traditional historical concept invites excited commentary. Reference 1. Riegner 0. Ueber einen Fall Von Exstirpation der Traumatisch Zerrissenen Milz. Berl Klin Wochnschr 1893; 30:177-181.
CHARLES E. LUCAS, M.D. Detroit, Michigan March 7, 1991 Dear Editor: It was with great interest that I read Dr. Lucas's article "Splenic Trauma, Choice of Management" (Ann Surg 1991; 213:98-112). His dismissal of the historical accounts of splenectomy, performed by detaching the spleen as it presented in the wound, is made on the basis of a lack of documented contemporary descriptions of spleens prolapsing from wounds. His conclusions, however, may be somewhat premature. One of the first patients I saw as a Red Cross surgeon in Thailand was a 12-year-old girl who presented with a through-andthrough shrapnel injury of the left flank in whom the remnants of her injured spleen were seen to be prolapsing from her wound.
Vol. 215.No. I
LETTERS TO THE EDITOR
93
She was managed in the now traditional approach of exploratory laparotomy with completion splenectomy but, had we been so
inclined, we could have accomplished amputation of the injured organ, where it presented in the primary wound. Laparotomy findings included a diaphragmatic tear and a severely damaged spleen that was separated from all its peritoneal attachments and freely mobile on its intact hilar pedicle. The pancreas was uninjured. The accompanying photograph (Fig. 1) was taken at the time of delayed primary wound closure, some 4 days after I -vlil j her laparotomy, and illustrates her through-and-through injury. The spleen was history by this time as, I suspect, may have been the case with her 17th and 18th century counterparts. Medical progress requires constant critical evaluation of accepted tenets. To fully justify discounting historical descriptions, if> _gt;' t however, requires more than a want of similar personal experiences. After all, the 18th century saw some of the keenest obi!U8>Bservers in the history of surgery. John Hunter's name comes to mind. FIG. 1. Twelve-year-old Cambodian girl with a through-and-through shrapnel injury to her left flank, through which her injured spleen was RICHARD SIMONS, M.B. protruding. Seattle, Washington
Ann. surg. . January 1992
LETTERS TO THE EDITOR
to apparently accrue large sums of money by charging inordinate fees for preceptorship should be discouraged. If one has experience with laparoscopic cholecystectomy, he should share this experience with the fledgling laparoscopic surgeon for free (or at the very most, have his incurred expenses covered). JOSEPH F. UDDO, JR., M.D. Metairie, Louisiana
April 29, 1991
surgeons
April 22, 1991 Dear Editor: We would like to thank Dr. Uddo for his kind comments regarding the paper "Safety and Efficacy of Laparoscopic Cholecystectomy." We think he has pointed out some very accurate issues with regard to training and credentialling of surgeons in this area and we wholeheartedly agree with much that he says. We might remind him that the manuscript was prepared very early in the history of laparoscopic cholecystectomy. As he points out, and as has become clear over the ensuing months, this is a procedure that can be performed safely by the average general surgeon and, thus, we agree with his assessment. Nevertheless, we might also add that we are becoming more convinced that it is a more dangerous procedure, however, than open cholecystectomy. We think the procedure is generally safe, given appropriate training, caution, and an accepting attitude toward conversion to open cholecystectomy, but it may represent an inherently increased risk over open cholecystectomy. Time will allow us the answer. The issue of whether this procedure was actually devised by "average" general surgeons is certainly open to debate. As he knows, it originated in French clinics, and Dr. Mouret, who pioneered the procedure in France, is a clinical laparoscopist with extensive experience. Describing his laparoscopic abilities as average would be inadequate to say the least. In addition, although it was indeed developed at many community hospitals within the United States, we would also question whether the surgeons involved in such innovative endeavors could be described as average. We have had the opportunity to participate in training courses for laparoscopic cholecystectomy involving several hundreds of surgeons, and it has been our observation that there are many that find it difficult. It is by no means a natural extension of our usual surgical abilities. Dr. Uddo seems offended by the assertion that we should question whether the average general surgeon is capable of performing new procedures. He also suggests that implied in our statement is an argument for limiting the procedure to a limited group of surgeons. The authors clearly did not intend any such meaning by posing the question. We think it would be inappropriate for us not to question whether any new procedure, especially one that is as technologically different as laparoscopic cholecystectomy, can be taken from the laboratory into the clinical realm with training that would be available and reasonable to the majority of surgeons and then could be applied safely. Thus, the intent of the question was exactly the opposite of Dr. Uddo's suggestions. We believe it would be highly inadequate to develop procedures that could not be easily expanded to the realm of the majority of surgeons quickly. We agree with his assessment that the emphasis should be placed on proper training, including a demonstration of competence. The entrepreneurism that has been associated with this procedure is an unfortunate consequence of the realities of the 1990s marketplace and should be discouraged. JEFFREY H. PETERS, M.D. Columbus, Ohio
Dear Editor: Dr. Simons' excellent letter describes the treatment of a young girl who presented with extrusion of a free fragment or "remnants" of spleen through a shrapnel wound in the left flank. Extrusion of a free fragment of liver or spleen devoid of blood supply is not unique, especially in patients with large wounds and significant intraperitoneal injury that leads to an elevated intraperitoneal pressure. The extrication of such exteriorized fragments from clothing, dressing, the cart, or from the wound edge bears no resemblance to the historical external splenectomies described by our forbears who identified ligation and division of the externalized splenic blood supply. The word laparotomy is derived from the Greek word "lapara," which means loin or flank. Had Dr. Simons explored this patient through her flank wound, this "laparotomy" approach would have permitted safe vascular division with extrication of the fragmented spleen and repair of the injured diaphragm. Indeed, extension of a flank wound into a formal "laparotomy" is my preferred approach in a few carefully selected patients with a close-range shotgun blast that is clearly confined to the flank area. The decision by Dr. Simons to obtain intraperitoneal vascular pedicle control though the traditional anterior celiotomy permitted a more thorough inspection of the pancreas, which was normal. The fine result achieved by Dr. Simons reflects his decision to perform the traditional open approach by one of the many different anatomic pathways to achieve complete safe splenectomy. Dr. Simons' description of this girl's presentation, her interoperative findings, and the subsequent photograph of her flank wound on postoperative day 4 reinforce my conclusion that the beginning ofthe modern era of splenic surgery for trauma should be the splenectomy performed by Riegner, who, in 1893, performed an anterior celiotomy to remove the fractured spleen of a young man who had fallen from a scaffold.' John Hunter, the renowned 18th century anatomist and surgeon, would have recognized the distinct differences from the presentation of Dr. Simons' patient and the formal flank exposures by myself as compared with the historical splenectomies with extraperitoneal division of the vascular pedicle reported by his predecessors. John Hunter also would have recognized that deviation from the traditional historical concept invites excited commentary. Reference 1. Riegner 0. Ueber einen Fall Von Exstirpation der Traumatisch Zerrissenen Milz. Berl Klin Wochnschr 1893; 30:177-181.
CHARLES E. LUCAS, M.D. Detroit, Michigan March 7, 1991 Dear Editor: It was with great interest that I read Dr. Lucas's article "Splenic Trauma, Choice of Management" (Ann Surg 1991; 213:98-112). His dismissal of the historical accounts of splenectomy, performed by detaching the spleen as it presented in the wound, is made on the basis of a lack of documented contemporary descriptions of spleens prolapsing from wounds. His conclusions, however, may be somewhat premature. One of the first patients I saw as a Red Cross surgeon in Thailand was a 12-year-old girl who presented with a through-andthrough shrapnel injury of the left flank in whom the remnants of her injured spleen were seen to be prolapsing from her wound.
Vol. 215.No. I
LETTERS TO THE EDITOR
93
She was managed in the now traditional approach of exploratory laparotomy with completion splenectomy but, had we been so
inclined, we could have accomplished amputation of the injured organ, where it presented in the primary wound. Laparotomy findings included a diaphragmatic tear and a severely damaged spleen that was separated from all its peritoneal attachments and freely mobile on its intact hilar pedicle. The pancreas was uninjured. The accompanying photograph (Fig. 1) was taken at the time of delayed primary wound closure, some 4 days after I -vlil j her laparotomy, and illustrates her through-and-through injury. The spleen was history by this time as, I suspect, may have been the case with her 17th and 18th century counterparts. Medical progress requires constant critical evaluation of accepted tenets. To fully justify discounting historical descriptions, if> _gt;' t however, requires more than a want of similar personal experiences. After all, the 18th century saw some of the keenest obi!U8>Bservers in the history of surgery. John Hunter's name comes to mind. FIG. 1. Twelve-year-old Cambodian girl with a through-and-through shrapnel injury to her left flank, through which her injured spleen was RICHARD SIMONS, M.B. protruding. Seattle, Washington
