Laparoscopic cholecystectomy quickly emerged as an alternative to open cholecystectomy. However its safety, efficacy, and morbidity have yet to be fully evaluated. During the first 6 months of 1990, we performed 100 consecutive laparoscopic cholecystectomies with no deaths and a morbidity rate of 8% (8 of 100 patients; 4 major, 4 minor). There were 81 women and 19 men, with a mean age of 46.1 years (range, 17 to 84 years). All patients had a preoperative history consistent with symptomatic biliary tract disease, and most had proved gallstones by sonography. This included four patients with acute cholecystitis. Mean operating time improved significantly from month 1 to month 6 (122 +/- 45.4 minutes versus 78.5 +/- 30 minutes, respectively), indicating a rapid learning curve. Mean hospital stay was 27.6 hours, reflecting a policy of overnight stay. Postoperative narcotic requirements were limited to oral or no medications in more than 70% of patients. A regular diet was tolerated by 83% of the patients by the morning following the procedure. Median time of return to full activity was 12.8 +/- 6.8 days after operation. In addition analysis of the hospital costs of these 100 cases demonstrates a modest cost advantage over standard open cholecystectomy (n = 58) (mean, $3620.25 +/- $1005.00 versus $4251.76 +/- $988.00). There was one minor bile duct injury requiring laparotomy and t-tube insertion, two postoperative bile collections, and one clinical diagnosis of a retained stone that passed spontaneously. Four patients required conversion to open cholecystectomy because of technical difficulties with the dissection. Although there is a significant learning curve, laparoscopic cholecystectomy is a safe and effective procedure that can be performed with minimal risk. Laparoscopic cholecystectomy should be performed by surgeons who are trained in biliary surgery and knowledgeable in biliary anatomy, and, as with all operations, it should be performed with meticulous attention to technique.

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The need for axillary dissection for staging and treating early breast cancer has been questioned recently. Can a patient forego axillary dissection, with its associated costs, risks, and morbidity, if it does not affect survival? The study attempted to find a subset of patients with early breast cancer in whom disease-free survival was independent of axillary lymph node status. If survival does not depend on lymph node status, axillary dissection could be omitted in the care of these patients. This study included 378 women over age 70 with T1 breast cancer diagnosed and treated during January 1992 to December 1999 at both of our institutions: a large tertiary teaching hospital in Columbus, Ohio and a breast cancer treatment center in West Columbia, South Carolina. We compared the disease-free survival, using the Kaplan-Meier estimate, in 334 node-negative patients and 44 node-positive patients with T1 breast cancer. The 3- and 5-year survival rates of patients with T1N0 tumors were 86% and 77%, respectively; and the 3- and 5-year survival rates for T1 node-positive tumors were 81% and 69%, respectively (p = 0.0673). There was no statistical difference between the node-negative and node-positive groups. Axillary dissection in women over 70 years of age with early breast cancer may be unnecessary, as the presence of lymph node metastases does not appear to affect disease-free survival rates significantly in this patient group.