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Saiura. Mini-invasive Surg 2023;7:2 https://dx.doi.org/10.20517/2574-1225.2022.119 Page 3 of 6

HPB surgery is one of the most difficult and risky gastrointestinal surgeries. In Japan, there is a system to
evaluate and certify surgeons and institutions involved in HPB surgery, including minimally invasive
surgery. There are two systems for evaluating individual surgeons. One is the highly skilled specialist system
offered by the Japanese Society for Hepatobiliary and Pancreatic Surgery, and the other is the Endoscopic
Surgical Skill Qualification System (ESSQS), a system for highly skilled specialists performing endoscopic
abdominal surgery. The former is mainly for open, highly difficult hepatobiliary and pancreatic surgeries,
and evaluates not only surgical skills but also comprehensive and instructive qualities as a hepatobiliary and
pancreatic surgeon, including patient selection, while the latter is mainly for the evaluation of safety specific
to laparoscopic surgery. However, both certifications make use of unedited videos of surgeries, which are
reviewed to determine whether they are performed safely, appropriately and independently. This innovative
method involving the evaluation of surgical videos contributes to the improvement of hepatobiliary and
pancreatic surgery in Japan. The passing rate lies between 20% and 50%.

The Japanese Society for Hepatobiliary and Pancreatic Surgery has also established a system to certify
institutions that perform more than 30 cases of highly advanced HPB surgery per year. The Japanese
national data show that advanced HPB surgeries performed at these institutions have significantly lower
mortality rates . These individual and institutional certification systems have made it possible to safely
[5]
deploy minimally invasive surgery in HBP surgery.

A SERIES OF SERIOUS MEDICAL ACCIDENTS IN LAPAROSCOPIC HBP SURGERY IN
JAPAN
Around 2010, a series of fatal accidents in laparoscopic HPB surgery at two leading hospitals in Japan were
reported in newspapers and other media. This led to a pause in the deployment of minimally invasive HPB
surgery in Japan. A third-party committee investigated the cause of the medical accidents. They concluded
that inexperienced surgeons prioritized the introduction of new medical technology, and that the hospital
failed to properly manage the department. These accidents illustrated the grave consequences that can be
caused by an inexperienced surgeon in high-risk surgery such as HPB surgery. It resulted in a pause and set
back the introduction of minimally invasive surgery, as it became widely known to the public that
minimally invasive HPB surgery may be fatal if not properly introduced. New efforts were thereafter
initiated by academic societies and research groups. Subsequently, to prevent the recurrence of such
accidents, the national government and academic societies worked together to establish a system for the safe
introduction of minimally invasive HPB surgeries. The centerpiece of this improvement program is the
prospective registration of all advanced laparoscopic HBP surgeries.

To perform these procedures safely, the government stipulated the criteria for institutions in which
laparoscopic HBP surgeries can be performed, and for the correct management of patient selection and
surgery in cooperation with related academic societies. Specific criteria are listed in Table 2, but there are
very strict criteria regarding surgeon and institution. Patient selection and proper management of surgery
are supported by registering cases in the National Clinical Database (NCD), a database of the Japanese
Surgical Association; a case registration system of the Japanese Society of Hepatobiliary and Pancreatic
Surgery; as well as treatment policies such as indications for surgery and postoperative management. For
high-risk procedures such as laparoscopic pancreatoduodenectomy, we implemented prospective
registration of clinical information and required preoperative information to be registered with the NCD at
least one day before the surgery and postoperative information 90 days after the surgery date.

The results of a prospective registry showed that complication and mortality rates were comparable to those
of open surgery [Table 3].