Laparoscopic cholecystectomy: first, do no harm; second, take care of bile duct stones

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The introduction of laparoscopic cholecystectomy (LC) inthe USA in 1989 marked the beginning of what has becomeknow as the ‘‘laparoscopic revolution’’ [1–4]. It was quicklyadopted among surgeons in private practice. The Society ofAmerican Gastrointestinal Endoscopic Surgeons (SAGES)was the first organization to take the lead in ensuring patientsafety by insisting on quality training through certifiedtraining courses, establishing guidelines, and introducingcredentialing criteria for laparoscopic surgery. More thantwo decades later, it is time for SAGES to assume a lead-ership role in addressing two major and troublesome issuesthat remain in laparoscopic biliary surgery relating topatient safety and high-quality outcomes.Bile duct injuryA bile duct injury (BDI) rate of 0.2 % was reported in theera when open cholecystectomy (OC) was the standard [5].Currently, LC BDI rates ranging from 0.2 to 0.5 % aremore the norm in large population-based studies [6–9].Although the laparoscopic BDI rate may be lessening withthe passage of time, BDI is still more likely with LC thanwith OC, and remains a real danger in the learning curve ofevery surgeon [10]. After 25 years of LC, it appears thatthe risk of laparoscopic BDI is approximately twice what itwas in the OC era. Even in the hands of competent sur-geons, it is unlikely that BDI can ever be completelyeliminated because inflammation and anatomic variationdistort and obscure the anatomy. However, misidentifying