Evidence-based surgery for laparoscopic cholecystectomy

Andrea T Fisher; Kovi E Bessoff; Rida I Khan; Gavin C Touponse; Maggie M K Yu; Advait A Patil; Jeff Choi; Christopher D Stave; Joseph D Forrester

doi:10.1016/j.sopen.2022.08.003

Evidence-based surgery for laparoscopic cholecystectomy

Surg Open Sci. 2022 Aug 18:10:116-134. doi: 10.1016/j.sopen.2022.08.003. eCollection 2022 Oct.

Authors

Andrea T Fisher¹, Kovi E Bessoff¹, Rida I Khan², Gavin C Touponse³, Maggie M K Yu⁴, Advait A Patil⁵, Jeff Choi¹, Christopher D Stave⁶, Joseph D Forrester¹

Affiliations

¹ Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA.
² University of California Berkeley, Berkeley, CA.
³ Stanford School of Medicine, Stanford University, Stanford, CA.
⁴ Department of Molecular, Cell, and Developmental Biology, University of California Los Angeles, Los Angeles, CA.
⁵ Department of Computer Science, Stanford University, Stanford, CA.
⁶ Lane Medical Library, Stanford School of Medicine, Stanford, CA.

Abstract

Background: Laparoscopic cholecystectomy is frequently performed for acute cholecystitis and symptomatic cholelithiasis. Considerable variation in the execution of key steps of the operation remains. We conducted a systematic review of evidence regarding best practices for critical intraoperative steps for laparoscopic cholecystectomy.

Methods: We identified 5 main intraoperative decision points in laparoscopic cholecystectomy: (1) number and position of laparoscopic ports; (2) identification of cystic artery and duct; (3) division of cystic artery and duct; (4) indications for subtotal cholecystectomy; and (5) retrieval of the gallbladder. PubMed, EMBASE, and Web of Science were queried for relevant studies. Randomized controlled trials and systematic reviews were included for analysis, and evidence quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation framework.

Results: Fifty-two articles were included. Although all port configurations were comparable from a safety standpoint, fewer ports sometimes resulted in improved cosmesis or decreased pain but longer operative times. The critical view of safety should be obtained for identification of the cystic duct and artery but may be obtained through fundus-first dissection and augmented with cholangiography or ultrasound. Insufficient evidence exists to compare harmonic-shear, clipless ligation against clip ligation of the cystic duct and artery. Stump closure during subtotal cholecystectomy may reduce rates of bile leak and reoperation. Use of retrieval bag for gallbladder extraction results in minimal benefit. Most studies were underpowered to detect differences in incidence of rare complications.

Conclusion: Key operative steps of laparoscopic cholecystectomy should be informed by both compiled data and surgeon preference/patient considerations.