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

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 Rouvi ere'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:

Acute cholecystitis or simple biliary colic after an emergency presentation: why it matters

“…Depending on the duration of symptoms, this can be undertaken safely in most patients and with a low rate of conversion to an open operation. Subspecialty surgical expertise is sometimes required if gross inflammatory changes or obliteration of the peri‐ductal anatomy is encountered …”

Segment IV approach for difficult laparoscopic cholecystectomy

“…Achievement of CVS requires dissection of the proximal one‐third of the cystic plate and skeletonization of the cystic structure; however, these tasks are not easy in the scenario of difficult gallbladder because of severe scarring around the neck of the gallbladder . Recently, the 2018 Tokyo Guidelines (TG‐18) proposed imaging of a connecting line between the base of segment IV of the liver and the roof of Rouviére's sulcus as the appropriate first step for achieving CVS during LC . However, when managing a difficult gallbladder, a more anatomically specific landmark should be designated to achieve LC, as the “base” of segment IV provides obscure and anatomically non‐specific positional information.…”

“…5,6 Recently, the 2018 Tokyo Guidelines (TG-18) proposed imaging of a connecting line between the base of segment IV of the liver and the roof of Rouviére's sulcus as the appropriate first step for achieving CVS during LC. 7 However, when managing a difficult gallbladder, a more anatomically specific landmark should be designated to achieve LC, as the "base" of segment IV provides obscure and anatomically non-specific positional information. Rouviére's sulcus is also widely accepted as a landmark, at least in the posterior view, as it indicates the bifurcation point of hepatic inflow structures to the right hepatic lobe.…”

Hybrid procedure combining endoscopic gallbladder lavage and internal drainage with elective cholecystectomy for acute cholecystitis: A prospective pilot study (The BLADE study)

“…Urgent or early cholecystectomy is the current standard treatment for acute cholecystitis . However, carrying out the procedure may be unfavorable in patients in generally poor health or with high surgical risk.…”

“…U RGENT OR EARLY cholecystectomy is the current standard treatment for acute cholecystitis. [1][2][3] However, carrying out the procedure may be unfavorable in patients in generally poor health or with high surgical risk. In such cases, delayed elective cholecystectomy is considered after decompression of the swollen gallbladder by percutaneous or endoscopic transpapillary drainage.…”