Correspondence

Return to work after inguinal hernia repair La pa rosco pic c holecystectomy

Sir We read with interest the Review on laparoscopic cholecystectomy by MessrsMacintyre and Wilson (Br JSurg 1993; 80: 552-9). The authors state that one of the generally agreed contraindications to laparoscopic cholecystectomy is the presence of a cholecystoenteric fistula.

We have encountered five cholecystoduodenal fistulas in a series of 300 laparoscopic cholecystectomies, which we are reporting in Surgical Laparoscopy and Endoscopy. Of these, two were diagnosed before operation. One patient had a previous cholecystoduodenostomy and another had aerobilia on computed tomography. It was possible to deal with four fistulas laparoscopically. The fifth patient had to undergo conversion to laparotomy as the duodenum was inadvertently perforated during dissection. In the remainder it was possible to display the cholecystoduodenal fistula with a combination of careful blunt and sharp dissection. The fistula was divided and stapled at the same time by a single firing of an Endo-GIG30 stapler (US Surgical, Norwalk, Connecticut, USA) through an epigastric 12-mm cannula. Intra- operative cholangiography was performed in each patient to confirm biliary anatomy and detect bile duct stones.

We maintain that, with increasing expertise, better imaging and improved instrumentation, it is feasible to repair most cholecysto- duodenal fistulas laparoscopically.

A. Sharma R. J. E. Foley

Department of Surgery Bedford Hospital Bedford MK42 9DJ UK

New adjustable knot for securing su bcuticular running sutures

Sir We read with interest the Surgical Workshop by D r Di Saverio and colleagues on an adjustable knot for securing subcuticular sutures (Br J Surg 1993; 80: 873). Careful adjustment of tension and a small knot might well reduce the problems associated with anchoring subcuticular sutures to the skin surface. However, where an absorbable suture is used, the marked skin and potential route of infection from the skin surface can be avoided by other techniques.

Ranabaldo’ recently described a knotless technique involving several acutely angled passages through the subcutaneous tissue. Occasional immediate gaping was admitted, suggesting that the technique may be less suitable for low-friction monofilament sutures.

We believe that the problems of knot ulceration with absorbable subcuticular suturing can be avoided by using very light gauge material. Since 1992, one general surgeon (F.L.H.) has used S / O polydioxanone for all incisions except some on the face and scrotum. A three-throw conventional buried knot is used proximally and a three-throw Aberdeen knot distally. The cases include a large number of mastectomies and other breast procedures, laparotomy wounds and lower-limb amputations. The suture is also used by junior surgeons wfith no previous experience in subcuticular closure with such a small needle and fine material. Over 500 closures have been performed with no early wound dehiscence. Most major incisions have been reviewed in outpatients for other reasons, and no knot protrusion has been detected. The few wounds known to have dehisced were associated with infection among patients in whom a high incidence of wound problems might have been expected. Dehiscence occurred in a small part of a midline incision after proctectomy for Crohn’s disease in an octogenarian with a low albumin level and recent steroid medication.

This suture dictates a meticulous technique, distributing tension over multiple small bites, and this contributes to a good cosmetic result.

N. D. Downing F. L. Hinson

Depurtment of Surgery Derby City General Hospital Derby DE22 3NE UK

1 . Ranabaldo C. Simplified method of subcuticular skin closure. Br J Surg 1992; 79: 1288.

Sir I read with interest the Short Note by Dr Rider and colleagues (Br J Sury 1993; 80: 745-6). I was surprised at the decision to study this subject retrospectively over a 10-year period. Patient recall of subjective matters such as preoperative expectations of convalescence are strongly susceptible to bias a t the best of times and cannot safely be analysed in retrospect, especially when the events being recalled may have occurred many years before. More objective data such as the length of time off work would still be difficult to evaluate unless corroborated by means of an independent source such as employment records or general practitioner’s notes, and I can find no reference to this sort of information in the study. In the light of these methodological difficulties, which are to some extent inherent in retrospective analysis but accentuated in this study, I did not feel it is justifiable to draw the conclusion that the time off work following routine inguinal hernior- rhaphy is reducing.

In a prospective study I conducted 2 years ago, for 101 patients from the Northern health region, the median time off work following inguinal hernia repair was 45 (interquartile range 23-83) days. This was of similar length to the figures quoted from earlier studies. Although there was a greater proportion of patients performing heavy work (37 uersus 27 per cent), the same relationship between type of work and time off was not observed. Perhaps more significant was the observation that only 20 per cent of patients received advice concerning return to work before operation and 44 per cent after surgery. Some 63 per cent of patients made their own decision about when to return to work without consulting either their general practitioner (GP) or surgeon.

I agree with the authors that there is a great need for better preoperative education of patients (in particular) and GPs concerning the appropriate time of return to work, but I d o not feel that they have presented adequate evidence to suggest that the current position is improving.

S. E. Stock

Department of Surgery Newcastle General Hospital Newcastle upon Tyne NE4 6BE UK

Authors’ reply

Sir We feel the strength of our study lies in considering inguinal hernia operations performed by only one surgeon, but we accept the shortcomings of its retrospective nature. Considering procedures performed by only one surgeon removes the influences on return to work of both variable hospital doctor advice (which does occur’) and differences in operation technique.

In Nottingham, time off work following routine inguinal hernior- rhaphy appears to be reducing. In 1978 a mean of 78 (range 18-229) days convalescence was taken’. By 1991 this figure had fallen’ to 28 (range0-120)days. As previously suggested’, it is possible that patients in Nottingham return to work today earlier than elsewhere.

Mr Stock’s findings suggest that in the Northern health region, unlike e l ~ e w h e r e ’ ~ ~ , views on when to return to work are correctly independent of the physical content of the patient’s job.

M. A. Rider D. M. Baker

A. Locker A. N. Fawcett

University Hospital Queen’s Medicul Centre Nottinyham NG7 2UH U K

1 . Baker DM, Rider MA, Locker A, Fawcett AN. How long do patients convalesce after inguinal herniorrhaphy 7 Ann R CON Surg Engl 1993; 75: 216 (Comment). Bourke JB, Taylor M . The clinical and economic effects of early return to work after elective inguinal hernia repair. Br J Surg 1978;

Robertson GS, Haynes IG, Burton PG. How long do patients convalesce after inguinal herniorrhaphy ? Current principles and practices. Ann R Coll Sury Engl 1993; 75: 30-3.

2.

65: 728-31. 3.

Br. J. Surg., Vol. 80, No. 11, November 1993 1489