Light and shadow of laparoscopic cholecystectomy

Since the advent in 1987, laparoscopic cholecystectomy (LC) become standard procedure for its less-invasiveness. Cosmetic merits should not be underestimated and scar-less surgery is already available. The incidence of bile duct injury (BDI) during cholecystectomy, however, was reportedly 5-6 folds higher in laparoscopic approach. The cause of high incidence of BDI was initially attributed to the surgeon's inexperience but it turned out that is not the case and the incidence of BDI has been unchanged since that time. Many studies that investigate the cause, recognition, prevention, and treatment of BDI have been published. Many researchers agree that the cause of BDI during LC is miscomprehension of the surgical anatomy rather than insufficient techniques. Despite these reports, the number of BDI was not decreased and the serious outcome was repeatedly reported and many lawsuit cases were filed. The most important discussion is prevention of its occurrence. Among the many proposition, the critical view of safety (CVS) is the most accepted concept. We have been performing bi-annual survey for overwhelmingly all case of laparoscopic surgery since 1990. We also started ESSQS (Endoscopic Surgical Skill Qualification System) in 2004, demanding CVS for LC. Before introduction of ESSQS, the incidence of BDI was constantly about 0.7% and it became lower after 2004. The incidence of BDI in 2011-13 was as low as 0.53%. Continuous effort is warranted for safer LC.