May 15, 1995 - Pontiac, Michigan. May 17,1995. Dear Editor: Dr. Sarr strongly criticizes in his reply' our comments about appendicular adenocarcinoma,' in ...
Letters to the Editor
Vol. 222 * No. 6
May 15,1995 Dear Editor: The authors wish to acknowledge Dr. Miguel A. Flores for his review of the microceliotomy cholecystectomy technique and for directing our attention to the paper of F. Dubois and B.
Berthelot.' The procedure described by Dubois and Berthelot is a minilaparotomy technique performed through a small transverse incision varying from 3 cm to 6 cm in length. This is not a microlaparotomy (microceliotomy) technique, but may be classified as a "modem minilaparotomy,"2 in which the peritoneal cavity is entered through an incision in the parietal peritoneum. Such a procedure is performed in similar fashion to an open conventional cholecystectomy albeit through a smaller incision. Dubois and Berthelot have confirmed that cholecystectomy can be safely performed through a minilaparotomy incision. Microceliotomy is a minimally invasive technique that minimizes tissue damage and allows safe dissection through a very small incision. The location of the incision in the minimal stress triangle allows for entry through the falciform ligament into the peritoneal cavity. It is an ideal location for a cholecystectomy incision. Anatomic advantages ofthis incision include minimal damage to the parietal peritoneum and restricted movements of the abdominal wall in this area, which are responsible for reduced postoperative pain. This location offers a direct vertical stereoscopic view of the structures in the porta hepatis and Calot's triangle, providing identification of all structures for safe dissection including anatomical variations. Furthermore, distance of structures in the porta hepatis during dissection usually is only 2 to 4 cm away from the skin surface, except in obese patients. The authors appreciate the suggestion of Dr. Flores to move the incision to a more lateral location by incising the rectus sheath midway between the fundus and Calot's triangle. In our experience, however, the location of the incision directly anterior to the common bile duct is most desirable because of added safety related to visualization and identification of the structures in Calot's triangle. Once the cystic duct and the cystic artery are transected and structures in the porta hepatis are safely isolated, retrograde dissection of the gallbladder from the liver bed is performed safely and easily. Splitting of the rectus muscle may be associated with some bleeding from muscular tissue. Additionally, there may be lack of availability of aponeurotic tissue of the posterior rectus sheath for closure of the wound. Use of the Nd:YAG laser tip near bile ducts and Calot's triangle is safe and effective, especially in patients with dense adhesions. Use of the laser, however, is not essential when blunt dissection with endoscopic instruments alone is sufficient. We continue to be reluctant about the use of electrocautery near Calot's triangle because of the potential for electrical damage of structures in the porta hepatis. We have used head mounted lamps and agree that the use of this modality enhances visibility for a safe dissection. However, when retractors with attached fiberoptic light carriers are available, an additional source of light is not required. A self-retaining microceliotomy retractor with attached light and suction
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carrier will optimize the level of lighting in the operative field for safe dissection. We have developed such a self-retaining microceliotomy retractor with its own attached light and suction source. Use ofthis self-retaining retractor allows the surgeon to perform cholecystectomy with one operating room assistant. Newer nondisposable microceliotomy instruments will further reduce the cost of cholecystectomy while enhancing the safety of the procedure and acceptance of the technique by other surgeons.
References 1. Dubois F, Berthelot B, Cholecystectomie par mini-laparotomie, LaNouvelle Presse Medicale 1982; 11, 15:1139-114 1. 2. Rozsos II, Jako GJ: Letter to the editor, Ann Surg 1995; 222:762763.
NARENDRA TYAGI, M.D. ALLEN SILBERGLEIT, M.D., PH.D. Pontiac, Michigan
May 17,1995 Dear Editor: Dr. Sarr strongly criticizes in his reply' our comments about appendicular adenocarcinoma,' in which we described an appendicular cystadenocarcinoma first manifested by an abscess in the Scarpa triangle. Dr. Sarr shows some concern about the possibility of a femoral hernia filled with "jelly" from the peritoneal cavity instead of an authentic abscess. First, we must make it clear to him that there was no femoral hernia because there were peritoneal layers present but there was no peritoneal communication between the Scarpa triangle and peritoneal cavity. The abscess was in communication with an extraperitoneal pelvic collection of pus, which was extra-
peritoneally drained. Second, we also must point out that the fluid present in the Scarpa triangle collection was pus and not "jelly." We are sure because we can differentiate between the two but, most importantly, gram-negative and anaerobic organisms grew in the cultures.
References 1. Sarr MG. Reply to letter to the editor. Ann Surg 1995; 221:202. 2. Rodriguez-Sanjuan JC, Castillo J, Casado F, Naranjo A. Letter to the editor. Ann Surg 1995; 221:202.
JUAN C. RODRIGUEZ-SANJUAN, PH.D.
Santander, Spain June 22, 1995 Dear Editor: My colleagues and I appreciate the response from Dr. Rodriguez-Sanjuan about our previous response to his first letter to
