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J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):73-86. doi: 10.1002/jhbp.517. Epub 2018 Jan 10.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos).

Author information

1
Department of Surgery, Ageo Central General Hospital, Saitama, Japan.
2
Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan.
3
Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
4
Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.
5
Section of Hepato-Pancreato-Biliary Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA.
6
Department of Surgery, Mayo Clinic College of Medicine, Jacksonville, FL, USA.
7
Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan.
8
Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan.
9
Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan.
10
Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan.
11
Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
12
Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan.
13
Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
14
Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea.
15
Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
16
Department of Surgery, Yonsei University Gangnam Severance Hospital, Seoul, Korea.
17
Department of Surgery, Konyang University Hospital, Daejeon, Korea.
18
Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan.
19
Chair of General Surgery and Minimal Invasive Surgery "Taquini" University of Buenos Aires, DAICIM Foundation, Buenos Aires, Argentina.
20
Clinical Surgery, University of Edinburgh, Edinburgh, UK.
21
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
22
Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy.
23
First Department of Surgery, Agia Olga Hospital, Athens, Greece.
24
Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India.
25
Department of Surgery, Surgery Centre, Hong Kong Sanatorium and Hospital, Hong Kong.
26
Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
27
Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan.
28
Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan.
29
Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Aichi, Japan.
30
Department of Surgery, Dokkyo Medical University Koshigaya Hospital, Saitma, Japan.
31
Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
32
Director, Mie Prefectural Ichishi Hospital, Mie, Japan.
33
Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan.
34
Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan.
35
Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France.
36
Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan.
37
Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan.
38
Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina.
39
Department of Surgical Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, India.
40
Department of Surgery, Tohoku Rosai Hospital, Miyagi, Japan.
41
Department of Hemodialysis and Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan.
42
Department of EBM and Guidelines, Japan Council for Quality Health Care, Tokyo, Japan.
43
Department of Emergency Medicine, School of Medicine University of Occupational and Environmental Health, Fukuoka, Japan.
44
President, Oita University, Oita, Japan.
45
Department of Surgery, JR Sapporo Hospital, Hokkaido, Japan.
46
Director, Toho University, Tokyo, Japan.
47
Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Aichi, Japan.

Abstract

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

KEYWORDS:

Acute cholecystitis; Critical view of safety; Difficult; Laparoscopic cholecystectomy; Safety

PMID:
29095575
DOI:
10.1002/jhbp.517
[Indexed for MEDLINE]
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