My main concern is not the possible increase in intragastric pressure or gastric insufflation during laparoscopic cholecystectomy. What concerns me most is the increase in gastric contents during surgery, due to duodenogastric reflux of bile and contrast medium. Professor Maltby and colleagues state that ‘regurgitation (active vomiting) of bile-stained gastric fluid is common during emergence from anaesthesia’ and claim that vomiting would not occur when anaesthesia is deep enough. I fully agree with this. I argue that this common occurrence of regurgitation during emergence from anaesthesia is the very reason why I believe that the trachea should be intubated to prevent pulmonary aspiration in patients undergoing laparoscopic cholecystectomy. My next major concern is regurgitation of bile. As Professor Maltby states, the patient undergoing laparoscopic cholecystectomy may often regurgitate bile-stained fluid, particularly during emergence from anaesthesia [1]. In addition, patients with gallstones may have frequent regurgitation even when they are awake [2]. When aspirated, bile damages the lungs much more seriously than gastric acid does [3, 4]. Therefore, a greater precaution is required to prevent aspiration of bile than that of acid. The estimated incidence of pulmonary aspiration for which intensive care is required after the use of the laryngeal mask in the general population is between 1 : 9000 and 1 : 250 000 [5]. To show that the incidence is no greater than this in patients undergoing laparoscopic cholecystectomy, between 30 000 and 750 000 patients would be required [6]. The number of patients (53 patients) that Professor Maltby and colleagues studied [7] is far less than these figures. In fact, when 95% confidence limits are calculated from their results, the incidence of pulmonary aspiration during the use of the laryngeal mask can be as high as 7% [6]. Therefore, there have been no convincing studies to support their claim. If there are no studies, one should judge indications and contraindications of each technique based on anecdotal reports and theoretical risks. Professor Maltby and colleagues claim that I only cited one case report [8] from 10 years ago to justify my concern. In fact, I cited two [8, 9], and several anaesthetists stated through their experiences that the patient undergoing laparoscopic cholecystectomy is at increased risk of pulmonary aspiration [10–12]. In contrast, I do not find any major advantages (that improve clinical outcome) of the use of the laryngeal mask over tracheal intubation in this group of patients. Therefore, it is reasonable to conclude that theoretical risks of the use of the laryngeal mask outweigh the advantages of its use in the circumstances, and I maintain my claim that the laryngeal mask is contraindicated in patients undergoing laparoscopic cholecystectomy.