On 25-Dec-08, at 10:41 PM, Moshe Schein wrote:

Dear members,

This morning I found time to read your comments – accumulated over the last week. A few I find insightful, some very entertaining, and others are extremely confused – almost psychotic.

This is what I have to say – not in order of its importance…

1. I applaud all of you who can judge what happen and criticise it based on an isolated static image taken perhaps 5 minutes before the complication occurred.

2. Unlike others, in the image I provided I see very clearly the GB, cystic duct and CBD – the distance between the former and later not more than 1 cm.

3. I do not think that removing a few more «fibres of tissue» from the CD would made it longer or easier to clip. In fact, overzealous skeletonization of the CD can tear it – as we all experienced.

4. I agree with Ramana that laparoscopic surgeons should learn laparoscopic suture techniques. However some of you do not understand limitations of practice. Some surgeons, like me, have missed on the laparoscopic revolution – which developed after they had concluded their training. Thereafter they continued practising in centers not exposed to advance lap surgery – and not doing cases which require lap suturing. Take the average US rural surgeon: his laparoscopic practice is limited to LC and some gynecological procedures – no opportunity to get confident in lap suturing. And now – when an opportunity arrives – is this the time to experiment on the patient?

5. Ramana. I have never seen a patient dying BECAUSE he was converted. I have seen many (not mine) who died because they were NOT converted to open. Thus, while I enjoyed reading your aphorism I would not use it as a plague on my OR room. In fact, I would consider such a plaque dangerous and remove it.

6. I found the post by the Russian Émigré colorectal surgeon from Florida (I forgot his name) really hilarious (he calls me a "broken man"). However I am honored that I may be the reason (my poor performance after 2006…) for his potential resignation from this list. As if this List depends on what one members writes or thinks…

7. That Russian Émigré accuses me for not admitting mistakes. This is not true. Those who know me here over the years know that I was among the very few who had the «courage» to report my surgical disasters. But not all complications are caused by a clear error – there is lots of gray zone and many way to skin the cat. And in the case under discussion of course that there was a technical error which could have been avoided. But once the complication has occurred there were many ways to deal with it – as manifested by all your replies.