Optimising Surgical Technique in Laparoscopic Cholecystectomy: a Review of Intraoperative Interventions.

BACKGROUND: Laparoscopic cholecystectomy (LC) is one of the most commonly performed procedures worldwide but there is considerable variance amongst surgeons regarding intraoperative technique. This review aims to provide a comprehensive summary, with evidence-based recommendations, of intraoperative interventions in LC.
METHODS: A literature search was performed using PubMed, EMBASE, Google Scholar and Cochrane Review databases. Articles were screened for eligibility with inclusion criteria based on study design, surgical approach, surgical timing, pathology and intervention type. The most contemporary, comprehensive or relevant articles were used as the primary evidence for the final analysis and discussion.
RESULTS: A total of 25 systematic reviews and/or meta-analyses and 19 individual trials were identified from the literature and grouped into ten clinical intervention topics. Three intraoperative interventions offer clinical benefit and are recommended: wound/intraperitoneal local anaesthetic, low-pressure pneumoperitoneum and manoeuvres to reduce residual pneumoperitoneum. No benefit was demonstrated for routine subhepatic drain placement and gallbladder aspiration. Techniques which appear to demonstrate improvements but do not translate into clinical efficacy are the use of warmed/humidified carbon dioxide, installation of intraperitoneal saline and the use of advanced imaging techniques. Techniques demonstrating equipoise, and for which no recommendations can be made, are type of energy source and cystic duct occlusion methods. DISCUSSION: This review highlights and suggests specific intraoperative techniques during uncomplicated LC that should be employed, avoided or considered by the individual surgeon. Optimising surgical technique in this way can lead to improved patient outcomes.