2018 日本指南：急性胆囊炎手术治疗-急性胆囊炎腹腔镜胆囊切除术的安全步骤

Q1. What are the indicators of surgical difficulty in laparoscopic cholecystectomy for acute cholecystitis?

Besides preoperative factors and severity of AC, intraoperative findings are considered to be appropriate indicators of surgical difficulty in LC for AC. (Level D)

Severe inflammation of the GB and its surroundings increases both the difficulty of LC and the frequency of postoperative complications. The estimated incidence of serious complications such as BDI and VBI is 2–5 times higher for LC than for open cholecystectomy [12, 13]. As AC is a common disease, even if the frequency of complications is low, the absolute number of cases is high. To reduce these serious complications, it is essential to assess the surgical difficulty appropriately and to standardize treatment strategies. Many previous studies have used factors such as the open conversion rate, operating time, and the incidence of complications as indicators of surgical difficulty.

An investigation of preoperative data and diagnostic imaging using operating time or the open conversion rate as indicators of surgical difficulty in cases of symptomatic cholelithiasis (including AC) identified body mass index, non-visualized GB on preoperative cholangiography, cystic duct length, temperature, and abnormal findings on computed tomography as five factors that significantly affected the time required for cholecystectomy [14]. Another study found that the three factors of GB wall thickening, incarcerated stones in the GB neck, and duration of elevated C-reactive protein contributed to prolonged operating time [15], and many other studies have found that factors including male sex, elevated white blood cell count, low albumin, high bilirubin, fluid retention around the GB, and diabetes are predictive of open conversion [16–19]. A meta-analysis of the collected results of these observational studies identified GB wall thickening (>4 to 5 mm) on ultrasound, male sex, advanced age, and obesity as risk factors for open conversion [20]. A recent study has found that the rates of open conversion and complications were significantly higher in

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TG13 Grade II and III cases compared with Grade I cases [21] (Table 1).

From these results, the level of surgical difficulty might be predictable on the basis of factors including preoperative imaging and blood tests, and TG13 grade. Some studies investigating surgical timing and surgical difficulty also found that if surgery was performed within 72 h of the onset of AC, there were fewer complications, operating time was shorter, and surgical difficulty was lower [22, 23]. One issue is that almost all these studies were observational studies derived from single-center data, and no studies have provided a high level of evidence.

Questionnaire surveys of Japanese, Korean, and Taiwanese experts have found that operating time, which is frequently used as an indicator of surgical difficulty, is greatly dependent on the skill and experience of the operator and that the criteria for conversion to open cholecystectomy vary among surgeons [10, 24]. Operating time and conversion rate are useful indicators of surgical difficulty but must be interpreted in light of surgical training, skill and experience. Some studies have suggested that it may be possible to identity objective indicators of surgical difficulty on the basis of intraoperative findings, some of which are not based merely on expert opinion [25] but are also based on a Delphi consensus among a large number of surgeons of different nationalities [26]. The use and evaluation in future studies of intraoperative findings (Table 2) as objective, direct indicators capable of measuring of surgical difficulty is therefore desirable.

Q2. Which surgical procedures are alternatives to difficult laparoscopic cholecystectomy for acute cholecystitis?

Surgeons should choose bail-out procedures to prevent BDI according to the intraoperative findings. (Recommendation 1, level C)

In TG13, conversion to open cholecystectomy was the only recommendation in cases of AC for which LC was

difficult. In the current revisions, the specific bail-out procedures listed below are suggested, and it is strongly recommended that surgeons make appropriate judgments and choose a bail-out procedure based on intraoperative findings in order to avoid secondary damage (level C).

Subtotal cholecystectomy

The procedure involves making an incision in the GB, aspirating the contents, and then removing as much of the GB wall as possible and treating the stump instead of removing the entire GB has been in use since the days of open cholecystectomy [27]. Previous studies have not drawn a clear distinction between partial and subtotal removal, and the situation is confused. Strasberg et al. designated all procedures in which as much of the GB wall as possible is removed as subtotal (rather than partial) resection (Fig. 1a) and proposed that resection of the fundus alone should be referred to as “fundectomy” [28]. Subtotal cholecystectomy is deemed “reconstituting” when a closed GB remnant is left and “fenestrating” when the remnant is left open or the internal opening of the cystic duct is closed (Fig. 1) [28].

According to a systematic review and a meta-analysis, although postoperative bile leakage was more common following laparoscopic subtotal cholecystectomy compared with open conversion, rates of BDI, postoperative complications, reoperation, and mortality were all lower [29, 30]. More patients whose surgery concluded with drainage because the stump of the neck of the GB was not closed underwent postoperative endoscopic retrograde cholangiography compared with those in whom closure was successfully performed, but there was no change in the rate of complications. In long-term follow-up after subtotal resection, gallstones recurred in approximately 5% of patients and these patients have usually had subtotal reconstituting operations [30]. Although risk of concomitant GB cancer has also been reported, frequency of occurrence is low [29]. Laparoscopic subtotal cholecystectomy is an important procedure that should be considered in order to avoid serious damage to the bile duct or blood

Table 1 Risk factors associated with prolonged operative time and open conversion

|Prolonged operative time [8, 9]|Conversion [15, 16]| |---|---| |Gallbladder wall thickening|Gallbladder wall > 4–5 mm on preoperative ultrasound| |Incarcerated stones in the gallbladder neck|Age >60 or 65 years| |Duration of elevated C-reactive protein|Male gender| |Non-visualized gallbladder on preoperative chocolangiography|Acute cholecystitis (TG13 grade II/III)| |Body temperature|Contracted gallbladder on ultrasound| |Abscess formation|Previous abdominal surgery| |BMI|BMI ASA score|

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Table 2 Difficulty score for each intraoperative finding

|Intraoperative findings|Score| |---|---| |A. Factors related to inflammation of the gallbladder|| |(a) Appearance around the gallbladder|| |1. Fibrotic adhesions around the gallbladder due to inflammation|2| |2. Partial scarring adhesions around the gallbladder|2| |3. Diffuse scarring adhesions around the gallbladder|4| |(b) Appearance of the Calot's triangle area|| |4. Sparse fibrotic change in the Calot's triangle area|2| |5. Dense fibrotic change but no scarring in the Calot's triangle area|3| |6. Partial scarring in the Calot's triangle area|4| |7. Diffuse scarring in the Calot's triangle area|5| |(c) Appearance of the gallbladder bed|| |8. Sparse fibrotic change in the gallbladder bed|1| |9. Dense fibrotic change but no scarring in the gallbladder bed|2| |10. Partial scarring in the gallbladder bed|3| |11. Diffuse scarring in the gallbladder bed (includes atrophic gallbladder with no lumen due to severe contraction)|4| |(d) Additional findings of the gallbladder and its surroundings|| |12. Edematous change around the gallbladder/in the Calot's triangle area/in the gallbladder bed|1| |13. Easy bleeding at dissection around the gallbladder/in the Calot's triangle area/in the gallbladder bed|3| |14. Necrotic changes around the gallbladder/in the Calot's triangle area/in the gallbladder bed|4| |15. Non-iatrogenic, perforated gallbladder wall and/or abscess formation towards the abdominal cavity noted during adhesiolysis around the gallbladder|3| |16. Abscess formation towards the liver parenchyma|4| |17. Cholecysto-enteric fistula|5| |18. Cholecysto-choledochal fistula (included in the expanded classification of Mirizzi syndrome)|6| |19. Impacted gallstone in the confluence of the cystic, common hepatic, and common bile duct (included in the expanded classification of Mirizzi syndrome)|5| |19. Intra-abdominal factors unrelated to inflammation|| |20. Excessive visceral fat|2| |21. Inversion of the gallbladder in the gallbladder bed due to liver cirrhosis|4| |22. Collateral vein formation due to liver cirrhosis|4| |23. Non-inflammatory (physiological) adhesion around the gallbladder|1| |24. Anomalous bile duct|4| |25. Gallbladder neck mounting on the common bile duct|3|

Expert surgeons participated in a Delphi process and graded the 25 intraoperative findings using the seven-stage scale ranging from 0 to 6 (0: easiest, 6: most difficult). The median point for each item was set as the difficulty score. Cited from Yamashita et al. [5]

vessels. Video S1 shows a typical case of laparoscopic total cholecystectomy.

Open conversion

No randomized controlled trial (RCT) has investigated the merits and demerits of open conversion, but a meta-analysis found that open conversion had no effect on the rate of local postoperative complications [31]. However, some studies have pointed out that as LC comes to account for the great majority of procedures and surgeons have less experience performing open cholecystectomy, open conversion may not necessarily be safe [32]. In a

questionnaire survey of experts in Japan, South Korea, and Taiwan, only 17.5% of the total responded that open conversion made surgery easier [24]. Although decision-making on open conversion may vary greatly between hospitals, appropriate judgment should be made in light of the surgeon's skill level. Subtotal cholecystectomy may also be done after conversion when it is found that complete cholecystectomy is dangerous.

Fundus first technique

The procedure in which the separation of the GB from the liver starts at the fundus, without initially visualizing a

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 cystic artery and cystic duct in the Calot's triangle (Fig. 1d), has not yet been adequately studied. Even the terminology has yet to be made consistent, with terms including "dome down," "fundus first," and "fundus down" all being used. A search of PubMed reveals that "fundus first" is the most commonly used. If a difficult case with severe inflammation of the Calot's triangle is encountered, fundus first LC with subtotal cholecystectomy may offer an option that enables the completion of LC while avoiding BDI as an alternative to immediate conversion to open cholecystectomy. The merits and demerits of the fundus first technique have been reported in previous studies [33, 34], and several case series have described successful use of the fundus first technique [35–37]. Other studies described a subtotal cholecystectomy combined with a fundus first technique starting with retrograde dissection of the GB [38, 39]. However, because of the low event rate of BDI, large numbers of patients are required to demonstrate safety of a technique in respect to this complication. Therefore, these studies cannot be used to draw a conclusion that the techniques are safe or better than other techniques in regard to BDI. Some studies indeed have warned that VBI may occur due to misidentification of the layer to be dissected when dissecting from the fundus of the GB toward its neck [40, 41]. Importantly, this technique has been shown to be associated with an "extreme" VBI when performed in patients with marked

chronic inflammation with biliary inflammatory fusion and contraction [40]. Therefore, the plane of dissection should always be kept close to the GB [42, 43].

Delphi consensus on bail-out procedures in difficult situations

Indications to perform a bail-out procedure have been identified by a recent Delphi consensus [11]. A bail-out procedure should be chosen if a CVS cannot be achieved because of scarring or severe fibrosis, as long as the Calot's triangle is appropriately retracted and is recognized as a landmark.

Q3. What are the important points to avoid biliary injury in laparoscopic cholecystectomy for acute cholecystitis?

Early LC before fibrosis: AC for LC should be performed at an early stage before florid inflammation and fibrosis develop in order to avoid BDI. Creation of the CVS: To perform LC safely, it is recommended that the three criteria of CVS be achieved and noted in a “time-out” before clipping or cutting structures.

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Dissection along the GB surface with the following landmarks: If the GB surface is difficult to identify in the Calot's triangle, an attempt should first be made to identify the GB surface from the dorsal side of the neck of the GB. If the GB surface is still difficult to identify, bail-out procedures (see Q2) should be considered. The base of Segment 4 and the roof of Rouvière's sulcus should be used as anatomical landmarks, and any surgical procedures during cholecystectomy should be performed above the imaginary line connecting these two landmarks.

Bail-out procedures: Subtotal laparoscopic or open cholecystectomy have been reported to reduce BDI (see Q2).

Perioperative imaging: Although there is no evidence for the value of intraoperative cholangiography, preoperative magnetic resonance cholangiopancreatography (MRCP), intraoperative fluorescence cholangiography, and intraoperative ultrasound may reduce BDI. (Level D)

In AC, surgery becomes more difficult as fibrosis progresses in the inflammatory process, so performing LC early is recommended [5, 44]. Early LC has been found to cause fewer total complications and to reduce operating time and total cost [44–48]. Because BDI occurs infrequently, some studies have found that early LC has no impact on BDI [44], whereas others have found that early LC reduces BDI [45–48]. A recent meta-analysis [47] and a propensity score matching study [48] found that early LC resulted in significantly fewer cases of BDI and a 50% reduction in cases of BDI [47].

The CVS concept proposed by Strasberg et al. [49] has been popularized worldwide, and in a questionnaire survey of members of the UK Association of Upper Gas-trointestinal Surgeons, exposing a CVS was the most commonly recommended option for preventing intraoperative BDI [50]. Although the CVS is valuable for preventing BDI, greater awareness of this concept among surgeons is still required; the CVS score is increased [51] and actual operating time is decreased by resident training [52].

Fibrosis and adhesions surrounding the GB and in the Calot's triangle may be severe in AC, causing difficulty to identify local anatomy and achieve a CVS [41]. If the GB surface and/or the anatomy of the Calot's triangle is unclear, then bail-out procedures should be considered (see Q2 and the following paragraph). A safe procedure is to identify Rouvière's sulcus and the base of Segment 4 and perform all surgical procedures above the imaginary line connecting these two landmarks. To maintain the

plane of dissection on the GB surface throughout cholecystectomy is paramount to avoid injury to hilar structures and liver parenchyma [41, 53, 54].

If severe fibrosis in the Calot's triangle prevents safe completion of LC with/without using the fundus first technique, BDI can be avoided by subtotal LC or open conversion [55]. In a retrospective study of patients who underwent subtotal LC or open conversion, BDI occurred in 3.3% who underwent open conversion but in none of the patients who underwent subtotal LC [56]. Subtotal LC should be considered as an option when straightforward LC cannot be completed safely. At the moment, the decision to switch procedures depends on the subjective judgment of the operator. Intraoperative findings may serve as objective indicators of surgical difficulty; accordingly, there is a need to establish criteria for switching procedures based on intraoperative findings [10].

Whether intraoperative cholangiography reduces BDI has been reported with mixed results [13, 57–60], and its performance is optional [50, 61]. However, it is important to note that there is evidence that intraoperative cholangiography might reduce the extent of the injury. Perioperative cholangiography, including preoperative MRCP, decreases complications and open conversion [55], and laparoscopic ultrasound [62, 63] and fluorescence cholangiography may prevent BDI. Although these procedures may become standard during LC, further studies are required [64].

Q4. What are the safe steps in laparoscopic cholecystectomy for acute cholecystitis?

Standardized safe steps are recommended in difficult LC according to the intraoperative findings. (Level D)

Based on the recent Delphi consensus [11], we propose the following safe steps in LC for AC.

Step 1: If a distended GB interferes with the field of view, it should be decompressed by needle aspiration (Fig. 2a).

Step 2: Effective retraction of the GB to develop a plane in the Calot's triangle area and identify its boundaries (countertraction) (Fig. 2b).

Step 3: Starting direction from the posterior leaf of the peritoneum covering the neck of the GB and exposing the GB surface above Rouvière's sulcus (Fig. 2c).

Step 4: Maintaining the plane of dissection on the GB surface throughout LC (Fig. 2d).

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 Fig. 2 Standardized safe steps in laparoscopic cholecystectomy. (a) Decompression of a distended GB with needle aspiration (arrow). (b) Effective retraction of the GB to develop a plane in the Calot's triangle area and identify its boundaries (countertraction). (c) Starting dissection from the posterior leaf of the peritoneum covering the neck of the GB and exposing the GB surface above Rouvière's sulcus (arrow). (d) Maintaining the plane of dissection on the GB surface throughout laparoscopic cholecystectomy. (e) Dissecting the lower part of the GB bed (at least one-third) to obtain the critical view of safety (broken line). (f) Always obtaining the critical view of safety

Step 5: Dissecting the lower part of the GB bed (at least one-third) to obtain the critical view of safety (CVS) (Fig. 2e).

Step 6: Creating the critical view of safety (Fig. 2f).

*: For persistent hemorrhage, achieving hemostasis primarily by compression and avoiding excessive use of electrocautery or clipping.

Video S2 shows a typical procedure following these safe steps.

If there is a risk of BDI, intraoperative cholangiography, intraoperative ultrasound, intraoperative indocyanine green fluorescence imaging, or another imaging modality to confirm the courses of the bile duct and blood vessels may be useful, but there is no unified consensus on this.

If there is severe fibrosis and scarring in the Calot's triangle due to inflammation and impacted gallstones in the confluence with the cystic duct or if a CVS showing anatomically important landmarks cannot be achieved, a bail-out procedure should be considered (see Q2).

Even if inflammation is absent or mild, BDI may occur due to misidentification. Particular care is required not to misidentify the common bile duct as the cystic duct.

Table 3 shows a summary of the content of the recent Delphi consensus [11].

Q5. Is one-stage management for acute cholecystitis associated with common bile duct stone more effective than two-stage management?

Either approach is acceptable. (Level B)

For concomitant common bile duct stone and gallstone, multiple RCTs [65-67] and meta-analyses [68, 69] have shown that one- (laparoscopic common bile duct exploration plus LC or intraoperative laparoendoscopic rendezvous technique) and two-stage (endoscopic retrograde cholangiopancreatography followed by sequential LC)

Table 3 Proposal for avoiding vasculo-biliary injury based on the Delphi Consensus (2017)

How to prevent?

Effective retraction of the gallbladder to develop a plane in the Calot's triangle area and identify its boundaries (countertraction)

Creating the critical view of safety

For persistent hemorrhage, achieving hemostasis primarily by compression and avoiding excessive use of electrocautery or clipping

When to stop?

Severe fibrosis and scarring in Calot's triangle due to inflammation

Impacted gallstone in the confluence of the cystic, common hepatic, and common bile duct (included in the expanded classification of Mirizzi syndrome)

Where to stop?

Critical view of safety

Calot's triangle area

What are the alternative (bailout procedure)?

Open conversion

Subtotal (partial) cholecystectomy

Fundus first (dome down)

Cholecystostomy (drainage only)

Cited from Iwashita et al. [11] with summarization

approaches are equally safe and feasible. One randomized study [70] and one meta-analysis [71] concluded that a single-stage management has less morbidity and higher success rate. However, the aforementioned studies have combined patients having acute biliary colic with those accompanying AC, which are two different entities. The incidence and severity of AC are not reported in any of these series; therefore, it is difficult to recommend one way or the other at the moment for patients with AC. The frequency of common bile duct stone complicating AC range between 7.7% and 14.3% [72–74] and whether patients with AC are at higher risk of common bile duct stone remains debatable. There is no significant predictor for the

diagnosis of common bile duct stone to date and preoperative magnetic resonance cholangiography, endoscopic ultrasound, and intraoperative cholangiography are equally reliable [75].

Based on the RCTs since 2010 [65–67, 70], we conducted a meta-analysis and found no significant difference in the success rate of common bile duct stone removal (Fig. 3), complication rate (Fig. 4), and in-hospital mortality (Fig. 5). From a patient's point of view, it is clear that one-stage management is preferable because only a single procedure is required, which in turn results in a shorter hospital stay and lesser cost [65–69]. At this time, the feasibility of one-stage management is determined at the sole discretion of each institution depending on the skill and preference of endoscopists and surgeons (i.e. whether an endoscopist is willing to perform endoscopic retrograde cholangiography concurrently with the operation and whether a surgeon is capable of performing laparoscopic common bile duct exploration). Moreover, the adoption rate of one-stage strategy in each region and country remains unclear. There is also a wide variety of healthcare delivery systems and health economics/policies around the globe. Well-designed, large-scale multicenter RCT in patients exclusively with confirmed diagnosis of AC (in accordance with Tokyo Guidelines) associated with common bile duct stone are warranted.

Q6. What is the role of reduced port surgery for acute cholecystitis?

Because the superiority of reduced port surgery for AC is unclear, it is weakly recommended for use only in a limited number of appropriately selected patients. (Level D)

Reduced port surgery was not mentioned in TG13. In the current revisions, LC is designated as the first-choice

![|Study or Subgroup|Single-stage Events|Single-stage Total|Two-stage Events|Two-stage Total|Odds Ratio M-H, Random, 95% CI|Odds Ratio M-H, Random, 95% CI|\n|:---:|:---:|:---:|:---:|:---:|:---:|:---:|\n|ElGeidie 2011|89|91|90|93|1.48 [0.24, 9.09]||\n|Koc 2013|55|57|51|54|1.62 [0.26, 10.08]||\n|Rogers 2010|15|17|30|31|0.25 [0.02, 2.98]||\n|Tzovaras 2012|47|50|44|49|1.78 [0.40, 7.89]||\n|Total (95% CI)|215||227|100.0%|1.28 [0.52, 3.16]||\n|Total events|206||215|||\n](1/parseimages/figure2d21942ffd4c45899500f8b3b0041dd0_0_23.png) Fig. 3 Forest plot of the success rate of common bile duct stone removal

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Complication rate of complete extraction of common bile duct stone.

|Study or Subgroup|Single-stage|Single-stage|Two-stage|Two-stage|Odds Ratio|Odds Ratio|Odds Ratio| |---|---|---|---|---|---|---|---| |Study or Subgroup|Events|Total|Events|Total|Weight|M-H, Random, 95% CI|M-H, Random, 95% CI| |ElGeidie 2011|4|89|3|100|24.8%|1.52 [0.33, 6.99]|Odds Ratio| |Koc 2013|4|57|6|54|32.9%|0.60 [0.16, 2.27]|M-H, Random, 95% CI| |Rogers 2010|0|57|0|55||Not estimable|| |Tzovaras 2012|7|50|6|49|42.2%|1.17 [0.36, 3.76]|| |Total (95% CI)||253||258|100.0%|1.00 [0.47, 2.14]|| |Total events|15||15||||| |Heterogeneity: $τ^{2}$ = 0.00; $χ^{2}$ = 0.92, df = 2 (P = 0.63); $l^{2}$ = 0% Test for overall effect: Z = 0.01 (P = 0.99)||||||||

In-hospital mortality of complete extraction of common bile duct stone.

|Study or Subgroup|Single-stage Events|Total|Two-stage Events|Weight|Odds Ratio M-H, Random, 95% CI|Odds Ratio M-H, Random, 95% CI| |---|---|---|---|---|---|---| |ElGeidie 2011|0|98|0|100|Not estimable|| |Koc 2013|0|57|0|54|Not estimable|| |Rogers 2010|0|57|0|55|Not estimable|| |Tzovaras 2012|1|50|0|49|100.0%|3.00 [0.12, 75.44]| |Total (95% CI)||262||258|100.0%|3.00 [0.12, 75.44]| |Total events|1||0|||| |Heterogeneity: Not applicable||||||| |Test for overall effect: Z = 0.67 (P = 0.50)|||||||

treatment by surgical removal. LC seeks to be as minimally invasive as possible provided that safety is assured. Reduced port surgery is even less invasive than LC with better cosmetic results. The role of reduced port surgery as a laparoscopic procedure for AC is therefore mentioned in TG18.

Here, the term “reduced port surgery” is used as a general term for surgical procedures in which the size or number of trochars or the number of skin incisions is reduced compared to standard laparoscopic surgery for the purpose of reducing invasiveness or for cosmetic reasons.

In terms of reducing the number of trochars and skin incisions, the ultimate laparoscopic surgery is one-wound LC, described by Navarra et al. [76]. Although this technique is currently known by various names [77], here we use the term “single incision laparoscopic cholecystectomy” (SILC).

The RCTs comparing SILC with conventional laparoscopic cholecystectomy (CLC) have either excluded AC or included fewer than 40% of patients with AC [78, 79]. We can thus say that the role of SILC for AC has yet to

be investigated. According to a meta-analysis, pain assessed on a visual analog scale was lower in SILC [80]. However, the alleviation of pain was only significant at a very early stage after surgery, with no difference being evident after Day 1 [80]. Although many studies have not found significantly higher rates of complications associated with SILC [81, 82], the pooled risk ratio for serious complications (including BDI, reoperation, abdominal fluid retention, bile leakage, and abdominal infection) and the rate of moderate complications (wound infection and bile leakage or abdominal fluid retention that improved without treatment) have been found to be higher for SILC [80]. Furthermore, operating time was longer [81–86] and the number of trochars added intraoperatively were higher for SILC than for CLC [80, 82].

Although analyses have found that SILC provides better cosmetic results [81, 83, 85, 86], its superiority has not been demonstrated in terms of postoperative quality of life score [80]. On the other hand, SILC requires a longer operating time and increases the risk of complications. The multi-channel ports used in SILC are

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Operative time and postoperative pain between needlescopic and conventional laparoscopic cholecystectomy.

operative time

|Study or Subgroup|Needlescopic C|Needlescopic C|Needlescopic C|Conventional lap-C|Conventional lap-C|Conventional lap-C|Conventional lap-C|Mean Difference IV, Random, 95% CI|||| |---|---|---|---|---|---|---|---|---|---|---|---| |Study or Subgroup|Mean|SD|Total|Mean|SD|Total|Weight|IV, Random, 95% CI|IV, Random, 95% CI|IV, Random, 95% CI|| |Alponat 2002|80.9|18.4|22|72.05|24.3|22|25.3%|8.85 [-3.89, 21.59]|8.85 [-3.89, 21.59]|8.85 [-3.89, 21.59]|| |Hsieh 2003|113.8|30.8|38|98.2|33.2|31|21.1%|15.60 [0.35, 30.85]|15.60 [0.35, 30.85]|15.60 [0.35, 30.85]|| |Look 2001|72.1|21.6|28|75.1|39.8|36|21.0%|-3.00 [-18.27, 12.27]|||| |Novitsky 2005|50.5|15.4|34|54.9|22.4|33|32.5%|-4.40 [-13.63, 4.83]|-4.40 [-13.63, 4.83]|-4.40 [-13.63, 4.83]|-4.40 [-13.63, 4.83]| |Total (95% CI)|||||||100.0%|3.47 [-5.92, 12.85]|3.47 [-5.92, 12.85]|3.47 [-5.92, 12.85]|3.47 [-5.92, 12.85]| |Heterogeneity: τ² = 48.26; χ² = 6.42, df = 3 (P = 0.09); t² = 53%|||||||||-50 - 25 0 25 50||| |Test for overall effect: Z = 0.72 (P = 0.47)|||||||||-Needlescopic Conventional|||

postoperative pain

|Study or Subgroup|Needlescopic C|Needlescopic C|Conventional lap-C|Conventional lap-C|Conventional lap-C|Conventional lap-C|Mean Difference IV, Random, 95% CI||| |---|---|---|---|---|---|---|---|---|---| |Study or Subgroup|Mean|SD|Total|Mean|SD|Total|Weight|IV, Random, 95% CI|| |Alponat 2002|1.6|1.2|22|1.4|1.7|22|32.1%|0.20 [-0.67, 1.07]|| |Cheah 1998|2.2|1.5|37|3.6|1.9|38|34.2%|-1.40 [-2.17, -0.63]|| |Novitsky 2005|3.9|1.5|34|4.9|1.8|33|33.7%|-1.00 [-1.79, -0.21]|| |Total (95% CI)|||93|||93|100.0%|-0.75 [-1.67, 0.16]|| |Heterogeneity: τ² = 0.48; χ² = 7.63, df = 2 (P = 0.02); t² = 74% Test for overall effect: Z = 1.61 (P = 0.11)||||||||||

Fig. 6 Forest plot of the operative time and postoperative pain between needlescopic and conventional laparoscopic cholecystectomy

expensive, and the procedure also requires special instruments. SILC is still at the stage of instrument development and improving the techniques involved in the procedure.

Reduced port surgery with trochar diameters <3 mm is known as “needlescopic surgery” [87]. Few RCTs have compared needlescopic cholecystectomy (NLC) and CLC for AC, but one study has found that although NLC requires a longer operating time, the rate of complications is within tolerable limits [88]. Figure 6 shows the results of a meta-analysis comparing NLC and CLC. This meta-analysis found that there was no difference in operating time and that pain tended to be less after NLC. Albeit for RCTs that either excluded AC or included very few patients with the condition, the ability to deal with inflammatory changes was found to be limited by technical difficulties related to the characteristics of the instruments [89], and high rates of conversion from NLC to CLC have been reported [90, 91]. Although NLC provides better cosmetic results, there is no difference with CLC in terms of patient satisfaction [92, 93].

These studies indicate that reduced port surgery for AC has no advantages other than cosmetic results and reduced pain. The extent to which these factors contribute to patient satisfaction should be investigated. Although it is hoped that the indications for reduced port surgery are extended in the future by instrument development and

improved techniques, at this point, it should only be performed in a limited number of selected patients.

Acknowledgments We express our deep gratitude to the Japanese Society of Hepato-Biliary-Pancreatic Surgery, the Japanese Society of Abdominal Emergency Medicine, the Japanese Society of Surgical Infection, the Japan Biliary Association, for their substantial support and guidance in the preparation of the article. We also would like to express our deep gratitude to the Japanese Society of Hepato-Biliary-Pancreatic Surgery for the article processing managing office of Tokyo Guidelines 2018 to prepare the publication. We appreciate all secretariats of the Japanese Society of Hepato-Biliary-Pancreatic Surgery for their technical support.

Conflict of interest Goro Honda has received honoraria from Johnson and Johnson and Medtronic.

Appendix: author's affiliations

Go Wakabayashi, Department of Surgery, Ageo Central General Hospital, Saitama, Japan; Yukio Iwashita and Masafumi Inomata, Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan; Taizo Hibi, Department of Surgery, Keio University School of Medicine, Tokyo, Japan; Tada-hiro Takada, Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan; Steven M. Strasberg,

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Section of Hepato-Pancreato-Biliary Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Horacio J. Asbun, Department of Surgery, Mayo Clinic College of Medicine, Jacksonville, FL, USA; Itaru Endo, Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan; Koji Asai, Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan; Akiko Umezawa, Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan; Kenji Suzuki and Taizo Kimura, Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan; Yasuhisa Mori and Masafumi Nakamura, Department of Surgery and Oncol-ogy, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Kohji Okamoto, Department of Surgery, Center for Gastroenterology and Liver Dis-ease, Kitakyushu City Yahata Hospital, Fukuoka, Japan; Henry A. Pitt, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA; Ho-Seong Han and Yoo-Seok Yoon, Department of Surgery, Seoul National University Bandang Hospital, Seoul, Korea; Tsann-Long Hwang and Keng-Hao Liu, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Dong-Sup Yoon, Department of Surgery, Yonsei University Gangnam Severance Hospital, Seoul, Korea; In-Seok Choi, Department of Surgery, Konyang University Hospital, Daejeon, Korea; Wayne Shih-Wei Huang, Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan; Mariano Eduardo Giménez, Chair of General Surgery and Minimal Invasive Surgery "Taquini", University of Buenos Aires, DAICIM Foundation, Buenos Aires, Argentina; O James Garden, Clinical Surgery, University of Edinburgh, Edinburgh, UK; Dirk J. Gouma, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; Giulio Belli, Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy; Christos Dervenis, First Department of Surgery, Agia Olga Hospital, Athens, Greece; Palepu Jagannath, Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India; Angus C. W. Chan, Department of Surgery, Surgery Centre, Hong Kong Sanat-torium and Hospital, Hong Kong; Wan Yee Lau, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Cheng-Hsi Su, Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan; Takeyuki Misawa, Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan; Akihiko Horiguchi, Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Aichi, Japan; Nobumi Tagaya, Department of Surgery, Dokkyo Medical University Koshigaya Hospital, Saitma, Japan; Shuichi Fujioka, Department of Surgery, The Jikei University Kashiwa

Hospital, Chiba, Japan; Ryota Higuchi and Masakazu Yamamoto, Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan; Satoru Shikata, Director, Mie Prefectural Ichishi Hospital, Mie, Japan; Yoshinori Noguchi and Masamichi Yokoe, Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan; Tomohiko Ukai, Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan; Daniel Cherqui, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France; Goro Honda, Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan; Atsushi Sugioka, Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan; Eduardo de Santibaëns, Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina; Avinash Nivritti Supe, Department of Surgical Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, India; Hiromi Tokumura, Department of Surgery, Tohoku Rosai Hospital, Miyagi, Japan; Masahiro Yoshida, Department of Hemodialysis and Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan; Department of EBM and Guidelines, Japan Council for Quality Health Care, Tokyo, Japan; Toshihiko Mayumi, Department of Emergency Medicine, School of Medicine University of Occupational and Environmental Health, Fukuoka, Japan; Seigo Kitano, President, Oita University, Oita, Japan; Koichi Hirata, Department of Surgery, JR Sapporo Hospital, Hokkaido, Japan; Yoshinobu Sumiyama, Director, Toho University, Tokyo, Japan; Kazuo Inui, Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Aichi, Japan.

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Supporting information

Additional Supporting Information may be found in the online version of this article at the publisher's web-site:

Video S1. Laparoscopic subtotal cholecystectomy. Video S2. Safe steps of laparoscopic cholecystectomy.