Acute cholecystitis: When to operate and how to do it safely.

I like to thank the AAST and President Cioffi for the great honor to present this Master Surgeon Lecture. On this date, I must acknowledge that it is September 11, and we need to take a moment of silence for our fallen colleagues and countrymen on that day. My topic today is, ‘‘Acute Cholecystitis: When to Operate and How to Do It Safely.’’ The obvious question is why did I select such a mundane topic? It is estimated that 30% to 49% of surgeons will produce a bile duct injury during their careers. This event is difficult both for the patient and the surgeon. The premise of my talk is that nearly all bile duct injuries during cholecystectomy are avoidable. Approximately 700,000 cholecystectomies are performed per year in the United States, with an estimated incidence of bile duct injury in 0.5% (3,500 patients). When laparoscopic cholecystectomy was initially introduced, bile duct injury was four times more frequent than for open cholecystectomy. Current estimate is that the incidence of bile duct injury remains twice as frequent with laparoscopic versus open cholecystectomy. A population-based study from Sweden, reviewing 153,000 cholecystectomies from 1987 through 2002, showed a slight increase in the incidence of bile duct injury despite decades of experience with laparoscopic cholecystectomy (0.32Y0.47%). Similarly, the incidence of bile duct injury in Japan is unchanged from 1990 to 2009 (0.66Y0.62%). Thus, laparoscopic cholecystectomy is clearly an operation that we have not perfected, despite how often it is performed. The goals in today’s talk are as follows: