It does not matter if, thinking to laparoscopy, we speak of “revolution” or “evolution”: laparoscopic cholecystectomy (LC) is nowadays considered the gold standard therapy for gallstone diseases, both in scheduled as in emergency cases, and it is done in every hospital setting. The literature about LC might be considered overabundant, and it may be argued that most reports might reflect mainly the results of larger and dedicated centers. At the same time, it is important to find out what is the “true” practice of LC around the world, besides what is “perceived” or “reported.”

As editors of a book concerning laparoscopic cholecystectomy, along with the evidence, we wanted to examine the available data from national surveys, audits, and registry.

We have done a research on PubMed – search details: [((“laparoscopy”[MeSH Terms] or “laparoscopic”[All Fields]) and (“cholecystectomy”[MeSH Terms] or “cholecystectomy”[All Fields])) and (“register”[MeSH Terms] or databse[ptyp] or national survey[ptyp] OR audit[ptyp]) and English[lang] and “adult”[MeSH Terms] and “1995/1/1”[PDat]: “2014/01/01”[PDat])]. And these are the “practice evidences” we have found.

In the last decades, the number of cholecystectomies increased worldwide. This rising trend is mainly attributable to the diffusion of LC (about 90 % of all the cholecystectomies) even in population where patients are covered by a national health system. The question arises if this low threshold for the laparoscopic approach to gallstone disease is always justified by evidence-based medical indications (such as more symptomatic gallstone diseases) [1–3].

The demographics of the Western world is changing: in the last century the general population increased of almost 10 %, but the number of inhabitants older than 65 years increased more than 50 %. Surely, age is an independent negative predictor for outcome after cholecystectomy, especially in an acute setting, where the probability to be operated on during the same admission period ranges from 20 to 57 % [4–6].

However, as reported in a recent study from Denmark, more than 60 % of otherwise healthy octuagenarian patients had a fast and uncomplicated course if undergoing surgery before acute inflammatory complications occurred. Thus, elective laparoscopic cholecystectomy has been recommended also for the elderly when repeated gallstone symptoms have occurred, particularly before the patient experiences acute cholecystitis [7].

It is surprising to find in some national reports that acute cholecystitis (AC) is treated expectantly in almost 50 % of the cases, although several guidelines suggest the surgical therapy as standard. The probability of a subsequent gallstone-related event might reach 30 % in the first year, in those discharged without cholecystectomy. Of these events, 30 % might be for biliary tract obstruction or pancreatitis. When controlling for sex, income, and comorbidity level, the risk of a gallstone-related event is highest for young patients (18–34 years old) [5–8].

The long-term effectiveness of cholecystectomy and endoscopic sphincterotomy (ES) in the management of gallstone pancreatitis has been confirmed by data from the NHS hospitals in England on 5,079 patients. Recurrent pancreatitis after definitive treatment was more common among patients treated only with ES (6.7 %) than among those treated with cholecystectomy (4.4 %) or ES followed by cholecystectomy (1.2 %) (p ≤ 0.05). Admissions with other complications attributable to gallstones in patients treated with ES alone were similar to those seen in patients who had received no definitive treatment (12.2 vs. 9.4 %) [9].

When surgery is performed, LC is surely the treatment of choice for the acute setting, with more than 80 % of the procedures done with a laparoscopic approach. Primary open cholecystectomy is often chosen by surgeons when the patient is older and has a history of previous abdominal surgery or gangrenous cholecystitis is suspected. The conversion rate ranges from 3 to 30 % [10, 11].

About this last point, a recent population-based analysis of 4,113 patients with acute cholecystitis from the Swiss Association for Laparoscopic and Thoracoscopic Surgery [12] clearly demonstrates that delaying LC resulted in significantly higher conversion rates (from 11.9 % at day of admission surgery to 27.9 % at more than 6 days after admission, p < 0.001), surgical postoperative complications (5.7–13 %, p < 0.001), and reoperation rates (0.9–3 %, p = 0.007), with a significantly longer postoperative hospital stay (p < 0.001). These data are confirmed by two other population studies from the United States [13, 14].

On the other hand, if the delayed surgery is prevailing, it has been shown that LC in treating AC cannot show its superiority over the open approach in terms of postoperative complication rate and medical resource utilization [15, 16].

The risk of bile duct injury (BDI) in LC has drawn wide attention from the beginning of the laparoscopic era, after reports of an increase in the incidence of BDI (twice as open cholecystectomy) [17, 18].

The earlier reports, however, are not homogeneous, ranging from 0.1 to 0.45 %, and, what is surprising, with a lower rate reported in national registries than in retrospective multicenter surveys [19–22].

In addition, more recent data from registries are available. In Germany, the Institute for Applied Quality Improvement and Research in Health Care GmbH (AQUA) (commissioned by the Federal Joint Committee to collect and analyze data for quality assurance) has recently published its data: about 90 % of 172,368 cholecystectomies performed for benign disease were performed laparoscopically. Overall (laparoscopic and open approach) an “occlusion or transection of the CBD” was registered in 177 operations (0.1 %); the reintervention rate for all reasons (including BDI) was 0.9 %. The rate of intervention-specific complications requiring treatment after laparoscopically initiated surgery in 2010 was 2.4 % [23].

In Denmark (data from the Danish Cholecystectomy Database), 28,379 patients underwent a cholecystectomy between 2006 and 2009, with complete registration of data in 24,240 patients. A laparoscopic procedure was started in 97.7 % and completed in 92.6 %. A reconstructive bile duct surgery, within 30 days, had to be conducted in 0.1 % (2007) to 0.25 % (2008); another bile duct surgery within 30 days had to be conducted in 0.11 % (2009) to 0.19 % (2007) [24, 25].

In a large retrospectively analyzed Finnish cohort of 8,349 cholecystectomies, 75 BDIs were encountered (0.9 %). The incidence was 1.24 % (20/1,616) for the open and 0.82 % (55/6,733) for the laparoscopic approach. In open surgery, most reported injuries were minor (15/20), while in the laparoscopic cholecystectomies mostly were severe (29 of 55, 14 of them with complete transection or excision of common bile duct) [26]. This data is confirmed by another recent retrospective review of medical record from Kaiser Permanente Northern California (KPNC): 83,449 patients who underwent laparoscopic cholecystectomy (LC) between 1995 and 2008 were included in the study. A cumulative BDI rate of 0.04 % was found, less than a half of what is reported in the Nationwide Inpatient Sample (NIS) (0.11 %). The authors, analyzing the type of injuries, found a trend toward more severe injuries approaching the hilum and fewer distal or minor injuries without significant differences [27].

In conclusion, OC seems to be associated with a higher number of BDI but mostly classified as minor, while LC seems to be associated with less but more severe lesions.

The “critical view of safety” advocated by Strasberg is generally accepted as a safe method to obtain an overview of the key anatomical structures that should be clearly identified before clipping and transecting the cystic duct (we will analyze it in the following chapter). Recent studies report that most surgeons (up to 85 %) stated that they routinely dissect Calot’s triangle to provide a critical view of safety, to minimize the risk of bile duct injury during cholecystectomy [28]. Conversely, a recent Dutch survey reported that although it has been included in the Best Practice for Laparoscopic Cholecystectomy published by the Dutch Society of Surgery, the concept of a critical view of safety failed to gain wide acceptance in the Netherlands [29].

Several published papers suggest that desirable outcome could be related to the caseload of a hospital or a surgeon. Therefore, volume is often taken as a proxy measure for quality, particularly that for prevalent or possible high-risk procedures, including LC. The reports about this topic in the literature are scanty and have to be taken into consideration very cautiously for the wide variation among hospitals of the same area/region/nation in the management of gallstone disease. A Scottish study reports a lower risk of morbidity and mortality in high-volume centers, significant only for elderly patients and patients with comorbidity. On the other hand, its clinical value seems to be negligible for those at average risk [2, 30].

Nevertheless, patient and hospital demographics do affect the outcomes of patients undergoing cholecystectomy. Although male gender, African American race, Medicare-insured status, and large, urban hospitals are associated with less favorable cholecystectomy outcomes, only increased age predicts increased morbidity, whereas female gender, laparoscopy, and cholangiogram are protective. Increased age, complications, and emergency surgery are predicting factors for mortality, while laparoscopy and intraoperative cholangiogram have a protective effect [31].