Laparoscopic cholecystectomy seems to be the most promising new technique for the treatment of symptomatic gallstone disease. For different reasons, controlled clinical trials comparing comfort and trauma for the patient of conventional versus laparoscopic cholecystectomy are difficult to perform at our institution. We therefore report on the results of our first 400 laparoscopic cholecystectomies using a strict and detailed protocol on technical performance, safety and benefit for the patient. Data was obtained immediately after the operation and after a short-term follow-up. To analyze the technical performance and the safety of the procedure, we developed a new classification system (I-V) of adverse events, including both the patients' and the surgeons' viewpoints. Our results show that in nearly 80% of the cases an optimal result (no adverse events in any respect) was obtained. For different reasons, the surgical procedure had to be changed during the operation in 20 cases (5%). In 3 cases (0.8%), an injury of the common bile duct occurred; 2 patients died (mortality 0.5%). On the first post-operative day, vomiting occurred in only 8% and nausea in 19% of the patients. Pain intensity was always below the level where patients demand analgesic medication and declined near zero the day after the operation. Patients fatigue was measured on a scale from 0-10 and rose from 2.2 preoperatively to 3.3 postoperatively. Only a short hospital stay of 3 days median was required. At short-term follow-up 6 weeks after the operation, pain was only rarely reported, the patients were fit and only 20% avoided some kind of food. We conclude that laparoscopic cholecystectomy is the treatment of choice for this precisely defined patient population with symptomatic gallstone disease.

Between 1986 and 1992, 265 men of mean age 51 (range 16-75) years with a primary inguinal hernia were randomized to undergo surgery by staff surgeon or surgical resident and further randomized to receive a modified Bassini operation (transversalis fascia not divided but included in the repair) or Shouldice procedure. The follow-up rate was 92.1 per cent with a mean follow-up of 3.3 years. Recurrence developed in 12 of 125 patients with a Bassini procedure and two of 119 after a Shouldice repair (9.6 versus 1.7 per cent, P = 0.006). The recurrence rate was no different for staff surgeons and trainees (5.9 versus 5.6 per cent, P not significant). Multivariate analysis identified the presence of a direct hernia (P = 0.003) as the additional main factor for the development of recurrence.

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Bhopal RS, Tonks A. The role of letters in reviewing research. BMJ 1994; 308: 1582-3. Glassow F. Inguinal hernia repair using local anaesthesia. Ann R Coll Surg Engl 1984; 66: 382-7. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the open tension-free herniqhsty. Am J Suq 1993: 165: Finley RK, Jr, Miller SF, Jones LM. Elimination of urinary retention following inguinal herniorrhaphy. A m Surg 1991; 369-71. 57: 486-8. Authors' reply SirThere are now six trials in which junior trainee surgeons, as opposed to hernia experts, have reported their results with the Shouldice operation'-6. In Liverpool, at a mean follow-up of 30 months, recurrence rate in the Shouldice group was 4.3 per cent; at the Lackland Air Force Base, Texas, at average follow up of 36.4 months, the recurrence rate was 6.6 per cent; at the Krankenhaus der Augustinerinnen, Cologne, the two-year recurrence rate was 10 per cent; in the multicentre French Association for Surgical Research Trial, the five year recurrence rate was 3 per cent (stainless steel wire) and 6 per cent (polypropylene); in a trial carried out in Vienna, the recurrence rate at between 3-4 years was 3 per cent; and finally, in the Cologne Hernia Study Group recently reported in this Journal the 3.3 year recurrence rate for the Shouldice operation was 1.7 per cent in patients within the trial and 5 per cent in a group of patients excluded from the study during the same period. From these results, it would be fair to say that at five years follow-up, the recurrence rate of the Shouldice operation in the hands of trainees is expected to be between 5 per cent and 10 per cent. It is interesting that this is the percentage recurrence reported for the classic Bassini operation (of which the Shouldice is a revival) in the 1920s and 1930s. The attrition rate of trainees is such that their recurrence rate is between 5 and 10 times that of the Shouldice operation in the hands of hernia specialists.Our results of the Lichtenstein repair and those of Kux et aL7 suggest that trainees can more closely emulate the results of hernia specialists with the Lichtenstein operation.With regard to local anaesthesia, many factors are involved in utilizing this technique including patient choice, surgeon choice, availability of skilled general anaesthesia with rapid recovery and the confidence of trainees with this method. In our institution, we place priority on surgical technique and only those highly skilled in the Lichtenstein operation undertake it under local anaesthetic.A. N. Kingsnorth Randomized trial of modified Bassini versus Shouldice inguinal hernia repairLetter 1 SirWe read with interest the article by Dr Paul and colleagues (Br J Surg 1994; 81: 1531-4) comparing the results of the Shouldice technique of hernia repair with a modified Bassini repair. Although the authors are to be congratulated on obtaining a low recurrence rate using the Shouldice repair, it is clearly not a new