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Outpatient cholecystectomy is safe for the higher-risk patient. Patients who recover uneventfully from surgery can be discharged without harmful effects. "Precautionary" hospitalization may be harmful.

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This study was done to determine the factors contributing to laparoscopic failure (conversion to open surgery or early reoperation) during the learning curve for laparoscopic Nissen fundoplication in a 228-bed nonteaching community hospital. Data were gathered prospectively for the first 100 consecutive patients booked for elective laparoscopic Nissen fundoplication by the four general surgeons at the hospital. All complications were recorded contemporaneously, and particular note was taken of the factors surrounding conversion to open surgery and reoperation within 100 days of surgery. There were no deaths. The conversion rate was 20% and the early reoperation rate 6%. There were two late recurrences. The average operative time was 117 minutes and the average length of stay 1.8 days; 37 operations were performed on outpatients. The laparoscopic failure rate was 26% (18/68) during a surgeon's first 20 operations and 11% (3/28) thereafter (P < 0.09); the corresponding conversion rates were 22% and 4% (P < 0.05). During a surgeon's first 20 operations, the laparoscopic failure rate rose from 21% (12/57) to 55% (6/11) (P < 0.04) if a second surgeon did not assist. After 20 operations, this difference lost its significance. Intrathoracic herniation of the stomach was found preoperatively in 11 (44%) of 25 operations followed by laparoscopic failure and (8%) 6 of 75 without (P < 0.0002). Laparoscopic failure had no correlation with patient age, sex, ASA classification, duration of symptoms, or referring physician's specialty. The individual learning curve for laparoscopic Nissen fundoplication requires about 20 operations to surmount. Factors leading to laparoscopic failure during the learning curve are the surgeon's inexperience, absence of experienced help, and the presence of intrathoracic herniation.

This seems to be an effective, simple, and minimally invasive technique for repairing a difficult problem. Although the number of cases is small and the follow-up has been short, the technique mimics that used in massive ventral hernia repair with good results.

Wound infection at the umbilicus is similar to that at other sites, except after cholecystectomy. Postoperative ventral hernia at the umbilicus is similar to that at other sites and not related to preexisting fascial defects.