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:

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High rate of SLN detection was achieved using the ICG fluorescence method. The first SLN identified by fluorescence imaging provides an exact indication of the axillary status. Therefore, the ICG fluorescence method provides precise information required to avoid unnecessary ALND.

Although we need to evaluate the long-term outcomes, our procedure is considered technically feasible, safe, and useful for the resection of gastric submucosal tumors located near the esophagogastric junction.

Although laparoscopic pancreatic resection of selected patients is a feasible and safe procedure in the hands of experienced laparoscopic surgeons, patients must be carefully observed after surgery to avoid serious conditions by pancreatic fistula.

We evaluated the safety and efficacy of primary systemic chemotherapy (PSC) with docetaxel (DOC), epirubicin (EPI) and capecitabine (Xeloda:XLD) in 10 patients with advanced breast cancer. Their mean age was 54.7 years,and preoperative stages were IIB, seven cases; IIIA, two; and IV, one,respectively. The regimen consisted of XLD (2,400 or 3,000 mg/day) orally for 14 consecutive days, and DOC (60 or 70 mg/m2) and EPI (50 or 60 mg/m2) intravenously on day 8. This was repeated 4 times every 3 weeks. One patient discontinued this regimen after one course at her own request. Although the results revealed leucopenia and neutropenia of more than grade 3 in 8 and 10 patients,they could be treated on an outpatient basis with the use of G-CSF to maintain this regimen. Alopecia of grade 2 was found in all patients,neutropenic fever of more than 38.5 degrees C in 5,and hand-foot syndrome in 3. Downstaging after PSC was demonstrated in 7 cases (Stage IIB to I, three cases; IIB to IIA, three; and III A to I, one), with a response rate of 77.8%. Breast conserving therapy was performed in 8/10 patients. Pathological findings on cytological degeneration showed grade 0, one; grade 1a,seven; grade 2, one; and grade 3, one, respectively. Axillary lymph node metastasis was revealed in 7 cases. This regimen would be an alternative to PSC on an outpatient basis while taking great care of myelosuppression and hand-foot syndrome.

Background/purpose We evaluated the usefulness of intraoperative exploration of the biliary anatomy using fluorescence imaging with indocyanine green (ICG) in experimental and clinical cholecystectomies. Methods The experimental study was done using two 40-kg pigs and the clinical study was done in 12 patients for whom cholecystectomy was planned from January 2009 to June 2009. Initially we used a laparoscopic approach for the evaluation of fluorescence imaging of the biliary system in the two pigs. Then the clinical study was started on the basis of these experimental results. ICG (1.0 ml/body of 2.5 mg/ml ICG) was infused 1-2 h before surgery. With the subjects under general anesthesia we observed in real time the condition of the biliary tract under the guidance of fluorescence imaging employing an infrared camera or a prototype laparoscope. ICG was added intravenously to observe the location or flow condition of the cystic artery. Results We obtained a clear view of the biliary tract and the location of the cystic duct in the two pigs. Local compression with a transparent hemispherical plastic device was effective for offering a clearer view. The biliary tract, except for the gallbladder, was clearly recognized in all clinical subjects. Local compression with a transparent hemispherical plastic device for open cholecystectomy and a flat plastic device for laparoscopy provided clearer visualization of the confluence between the cystic duct and common bile duct or common hepatic duct. The location of the cystic artery was revealed after division of the connective tissues, and the flow condition of the cystic artery was confirmed 7-10 s after intravenous re-infusion of ICG. There were no adverse events related to the intraoperative procedure or the ICG itself. Conclusions This method is safe and easy for the identification of the biliary anatomy, without requiring cannulation into the cystic duct, X-ray equipment, or the use of radioactive materials. Although fluorescence imaging is still at an early stage of application in comparison with ordinary intraoperative cholangiography, we expect that this method will become routine, offering a lower degree of invasiveness that will help avoid bile duct injury.

Schwannomas are rarely located in the pelvis. A 54-year-old woman was found incidentally to have a tumor in the abdomen. Abdominal computed tomography and magnetic resonance imaging revealed a well-defined, heterogeneous tumor, 5 cm in diameter, in the pelvic cavity. With a diagnosis of a mesenteric tumor, a laparoscopic procedure was performed. Intra-operatively, an elastic tumor was identified in the pelvis adjacent to the right internal iliac vein and ureter. The tumor was dissected free from adjacent structures using Liga-Sure and blunt maneuvers. A complete laparoscopic excision was performed. Histopathological examination revealed a benign schwannoma. The patient had an uneventful post-operative course, and was discharged on the fourth post-operative day. Laparoscopic treatment is useful and feasible for retroperitoneal pelvic schwannoma, with minimal invasiveness and an early post-operative recovery. Thus, this procedure may be the first-choice surgical procedure for retroperitoneal pelvic schwannomas.