LAUSR

B ile duct injury is the most common serious complication of cholecystectomy. Bile duct injuries, especially major bile duct injuries, are often very morbid and may lead to death. Bile duct injuries frequently result in additional procedures, long recovery, loss of time from work, and long-term diminution of quality of life, especially the psychological aspects. As such, these injuries are often the subject of litigation. This is not a new development. In 1992, writing about litigation after open cholecystectomy, Kern pointed out that complications of gallbladder surgery were listed as the most meritorious cases for negligence actions in a legal textbook devoted to medical malpractice. Litigation in this area has only become more frequent in the laparoscopic era partly due to the substantial increase in bile duct injury. Until now, our understanding of the nature and outcome of malpractice claims associated with laparoscopic gallbladder surgery in the USA has been based on small studies most published more than 20 years ago when learning curve issues were a dominant cause of injury. Our understanding has been greatly improved by the highly informative article in this issue entitled ‘‘What Have We Learned from Malpractice Claims Involving The Surgical Management of Benign Biliary Disease? A 128 Million Dollar Question.’’ The basis of the study is a database of over 350,000 malpractice claims involving >20 insurers, >165,000 physicians, and >400 hospitals. Importantly, this represents approximately 30% of closed US malpractice claims for general surgery from 1995 to 2015. Thus, although the geographic distribution of cases is not available, one may feel fairly confident that the data are representative of malpractice claims regarding gallbladder surgery in the USA. Also important is the fact that the authors studied over 750 cases, which provided the statistical power to examine subgroups. The cases were stratified according to severity based on the National Association of Insurance Commissioners Injury Severity Scale, which takes into account degree of disability produced and permanence of injury. The title of the article asks a question: What have we learned from malpractice claims involving the surgical management of benign biliary disease? Quite a lot it seems. We have learned that 18% of all general surgery malpractice claims in this database were related to the single operation of cholecystectomy—almost all laparoscopic cholecystectomy. The cost of dealing with these claims was 128 million dollars, but as the claims examined are about 30% of all USA claims, the total cost of claims in the 20-year period of study would probably be well over 500 million dollars. We have also learned about the causes for claim. The leading claim for negligence, present in 77% of cases, is technical error such as ductal misidentification, followed by errors in clinical judgment in 60% of claims, among which delays in diagnosis and referral were most important. Communication at 24% of claims was the third most important factor. The first cause for claim takes place in the operating room and the other 2 relate to actions before and after the procedure. Avoidance of technical errors, particularly avoidance of misidentification, has been the subject of much effort in the field over the years of this study, not only how to identify the ducts but also how to proceed when ductal identification cannot be achieved. Both are the subject of much attention in the soon to be reported Safe Cholecystectomy Consensus Conference initiated through SAGES and sponsored by multiple surgical societies. Does examination of litigation claims allow determination of whether technical errors are diminishing? Unfortunately, deriving this information was not possible through the database because the number of claims over time could not be trended. In discussing the clinical judgment, delay, and communication claims, the authors use 2 words of key importance to the avoidance of litigation—EXPECTATION and RAPPORT. Surgeons who consent patients carefully, letting them know what can be expected in terms of the risk of bile duct injury, while also establishing a caring relationship with them and their families have the patient on their side when complications occur. Giving the impression of not caring as when there are long