Korea now has its own number for the worst thing that can go wrong in gallbladder surgery: 0.7 percent

Gallbladder removal is among the most common operations performed anywhere, and the question every patient asks before one is the question the surgical literature has been slowest to answer with a local number: how often does this go badly wrong here?

Korea now has an answer, produced prospectively across 18 academic hospitals. It is a reassuring number attached to a serious caveat.

What the Korean multicentre study found#

Researchers led from Ewha Womans University College of Medicine collected standardised prospective data on 2,514 patients who underwent laparoscopic cholecystectomy for benign gallbladder disease, and analysed 56 preoperative and intraoperative variables against outcomes. The study was published in Annals of Surgical Treatment and Research, the journal of the Korean Surgical Society.

The authors are direct about why the work was needed: analysis of risk factors for complications, including bile duct injury, has been largely overlooked. Factors that turned out to be associated with adverse outcomes included sex, age, smoking, emergency operation, hypertension, diabetes, chronic obstructive pulmonary disease, preoperative endoscopic removal of common bile duct stones, therapeutic antibiotic use, ASA physical status and acute cholecystitis.

A calculator built on seventeen events#

From those variables the team built a surgical risk calculator, reporting how well each model discriminated between patients who had the outcome and patients who did not.

• Bile duct injury: area under the curve 0.857.
• Delayed discharge: 0.833.
• Systemic complications: 0.775.
• Overall complications: 0.733.
• Surgery-related complications: 0.697.

What happens after the injury#

A rate of 0.7 percent is easy to hear as negligible. What that fraction buys is not.

A national cohort drawn from all three hepatobiliary centres in Ireland followed 34 patients who required surgery for an iatrogenic bile duct injury sustained during laparoscopic cholecystectomy between 2014 and 2024. Twenty-six of them (76.4 percent) needed a Roux-en-Y hepaticojejunostomy — the bile duct is reconstructed by joining it directly to a loop of small bowel. Three required a right hepatectomy alongside the reconstruction.

• Ten of 34 patients (29.4 percent) required reoperation.
• Four of the five patients whose first repair was a direct bile duct repair were among them.
• One patient ultimately required a liver transplant.
• Three patients died in the perioperative period.
• Median direct inpatient treatment cost was estimated at 85,961 euro.

The authors' conclusion is that these injuries carry a considerable risk of long-term complications and death, and that referral to a subspecialist hepatobiliary centre is central to managing them. This is Irish data and the Korean referral pattern may differ; what transfers is the shape of the consequence, not the numbers.

The technique meant to prevent it is not always achieved#

The standard defence against cutting the wrong duct is the critical view of safety: before dividing anything, the surgeon exposes the anatomy until only two structures can be seen entering the gallbladder, so that identification is demonstrated rather than assumed.

How reliably that standard is met has now been measured by blinded review of operative video. A Chilean nationwide study reviewed 548 recordings of operations performed by residents and could assess the critical view in 513 of them. It was achieved in 314 — 61.2 percent.

Achievement fell as operations got harder, and it remained independently associated with the surgeon's technical performance score after difficulty was accounted for — which the authors read as a skill component that exists on top of anatomical complexity.

The comparison worth holding alongside it comes from a Japanese high-volume centre, where 201 consecutive early cholecystectomies for acute cholecystitis produced a critical view in 76.1 percent of cases, a bailout procedure in 21.4 percent, and no bile duct injuries at all. Those are consultant-led operations at a specialist centre, so the gap is not a like-for-like comparison. It does indicate the range.

What none of this tells an individual patient#

1. The Korean figures come from 18 academic institutions. Operations at smaller hospitals are not represented, and there is no basis here for assuming the rate is the same there.
2. The risk calculator has been developed but not, on the published account, validated in an independent population, and its bile duct injury model rests on 17 events.
3. The consequences of injury are described with Irish data and the prevention technique with Chilean and Japanese data, because comparable Korean series were not available. Each is labelled here for that reason.
4. A population rate is not a personal risk. Emergency surgery, acute cholecystitis and comorbidity all moved the odds in the Korean analysis, which is the entire reason its authors built a calculator rather than quoting an average.