{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T17:38:30Z","timestamp":1791999510602,"version":"4.4.0"},"reference-count":93,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2018,1,10]],"date-time":"2018-01-10T00:00:00Z","timestamp":1515542400000},"content-version":"vor","delay-in-days":9,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Hepato Biliary Pancreat"],"published-print":{"date-parts":[[2018,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>\n                    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\u2010biliary 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\u2010out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail\u2010out 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\u00e8re'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:\n                    <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"http:\/\/www.jshbps.jp\/modules\/en\/index.php?content_id=47\">http:\/\/www.jshbps.jp\/modules\/en\/index.php?content_id=47<\/jats:ext-link>\n                    . Related clinical questions and references are also included.\n                  <\/jats:p>","DOI":"10.1002\/jhbp.517","type":"journal-article","created":{"date-parts":[[2017,11,2]],"date-time":"2017-11-02T11:20:36Z","timestamp":1509621636000},"page":"73-86","source":"Crossref","is-referenced-by-count":440,"title":["Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)"],"prefix":"10.1002","volume":"25","author":[{"given":"Go","family":"Wakabayashi","sequence":"first","affiliation":[{"name":"Department of Surgery Ageo Central General Hospital Saitama Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yukio","family":"Iwashita","sequence":"additional","affiliation":[{"name":"Department of Gastroenterological and Pediatric Surgery Oita University Faculty of Medicine Oita 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