Evidence-based surgery for laparoscopic cholecystectomy

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.


INTRODUCTION
Approximately 10%-15% of American adults have cholelithiasis. Although the majority of these patients remain asymptomatic, roughly 1 in 5 will develop complications from their gallstones [1]. Development of minimally invasive cholecystectomy by French [2] and American surgeons in the late 1980s decreased the potential morbidity associated with cholecystectomy, leading to a broadening of indications for the procedure [1]. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) identifies symptomatic cholelithiasis, biliary dyskinesia, acute cholecystitis, and complications of choledocholithiasis as indications for laparoscopic cholecystectomy in patients healthy enough to undergo the procedure [3]. Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgeries, with 1.3 million of these procedures performed in the United States in 2021 [4].
All 4 studies comparing 3-LC and 4-LC demonstrated less postoperative pain and quicker return to work/physiologic baseline among 3-LC patients [12][13][14][15]. For 2-LC versus 4-LC, Tavassoli and Sreenivas found decreased pain and quicker return to baseline after 2-LC [17,18], whereas Poon did not find improvements in pain [16]. Poon et al notably conducted careful patient blinding with application of surgical dressings at four sites for both groups and adequately powered the study to detect 30% reduction in pain score. Gurusamy et al did not investigate pain in their meta-analysis of 4-LC versus 2-LC and 3-LC but did report quicker return to baseline in the reduced-port LC group [19].
All RCTs investigating cosmesis saw improvement with reducedport LC. Liu et al found higher cosmetic satisfaction at 3 months among the 3-LC group with 90% reporting high satisfaction with their scars vs 57% of the 4-LC group, although they did not report a P value [12]. Tavassoli et al [17] and Sreenivas et al [18] detected significantly improved cosmesis for the 2-LC group (Table 2). However, one systematic review investigated cosmesis and determined that reduced-port LC did not produce significantly better cosmetic results than 4-LC [19].
Only Singal et al found increased operative time for reduced-port LC (93.16 min for 3-LC vs 50.66 min for 4-LC), although this study suffered from a lack of P values [13]. Poon et al even found significantly lower operative time for 2-LC (54.6 min vs 66.0 min, P = .04) [16]. However, it should be noted that for use of unique 2-LC equipment and techniques, operative time and safety depend heavily on surgeon familiarity.
No articles, including Hajibandeh's meta-analysis of 2,111 patients [14] and Gurusamy's meta-analysis of 855 patients, demonstrated increased complications for 2-LC or 3-LC when compared with 4-LC. Several studies had significant statistical issues: Singal et al did not report P values, and [13] Liu et al did not report power calculations [12]. All RCTs were underpowered to detect differences in complication rates. Gurusamy et al reported that most trials included in their systematic review were at high risk of bias, and authors did not feel that they could issue a recommendation given the current base of evidence [19]. Compared with 4-LC, 2-LC and 3-LC may result in quicker return to baseline without significant safety concerns, while evidence for pain reduction and improved cosmetic satisfaction remains conflicted.
None of the RCTs that were completed reported differences in complication rates between groups. Although there were some consistent benefits to MLC including less pain, the fact that 2/5 RCTs were unsuccessful because of instrument issues must be considered by any surgeon contemplating adding MLC to their repertoire. The 3 completed studies either were powered to detect differences in pain/cosmesis rather than complications [21,23] or did not have power calculations provided [22]. The technical difficulty of switching to MLC may outweigh the benefit of mild pain reduction.

1A
Three-port LC is associated with less short-term postoperative pain and quicker return to activity compared with 4-port LC without differences in complication rates or operative time.    [37]. However, postoperative pain differed substantially among studies comparing SILC and 3-LC (Table 5): one study saw increased postoperative pain for patients who underwent SILC [33], another saw decreased postoperative pain after SILC [34], and one observed no difference between groups [32]. Justo-Janeiro et al (SILC versus 2-LC versus 3-LC) noted less immediate postoperative pain in the SILC group but more pain at their final time point of 8 days [35]. Four of 6 RCTs comparing SILC and 4-LC and all 3 studies comparing SILC and 3-LC recorded improved cosmesis scores with SILC [27][28][29][30][32][33][34]. Umemura et al saw no difference in cosmetic satisfaction at 3 and 14 days postoperatively but failed to track cosmetic satisfaction as long as other studies [37]. Tamini et al performed the only systematic review to investigate cosmesis and found improvement after SILC compared with 3-or 4-LC [38].
Operative time was consistently longer for SILC. In 6 RCTs [26][27][28]32,33,35] and the 2 systematic reviews that investigated operative time [38,39], SILC took longer to complete than 3-LC, 4-LC, or MLC (Table 6). Although Subirana et al did not find a difference in operative time, they noted that surgeon-rated subjective difficulty was higher for SILC [29]. Sulu et al specifically sought to determine whether operative duration for SILC could be reduced by adding a sub-xiphoid port for gallbladder retraction and noticed that operative time was halved for 2-LC compared with regular SILC (35.0 ± 12.3 vs 79.1 ± 7.7 min, P < .05) [36] (Table 5).
None of the RCTs reported significantly increased rates of complications for SILC. Of the 3 systematic reviews, Tamini et al noted no increase in complications [38], whereas Tan et al and Allemann et al noticed slightly elevated though insignificant complications with SILC [31,39]. The systematic review of Allemann et al specifically evaluated bile duct injury (BDI) and other biliary complications (requiring readmission or intervention such as endoscopic retrograde cholangiopancreatography [ERCP] or drain placement) after SILC versus 4-LC, but even their study was underpowered [31]. Their power calculations revealed that with their combined BDI rate of 0.7%, 14,048 patients would be needed to detect a difference in BDI; thus, all included studies were underpowered to detect these relatively rare complications. The main benefit of SILC is improved cosmesis at the cost of longer operative time. Postoperative pain is not reliably reduced. Perhaps partially because of the rarity of biliary complications, no studies showed increased complication rate with SILC. Complications with SILC remain acceptably low, suggesting that SILC technique remains an option for LC.

PICO 1 Overall Recommendation
2-LC and 3-LC resulted in quicker postoperative return to baseline without increased operative time but infrequently yielded improvements in cosmesis. Similarly, MLC yielded reduced postoperative pain compared with 4-LC without differences in cosmesis or operative time. Although SILC was associated with longer operative times, this option demonstrated more consistent cosmetic benefit. There were no significant differences in complication rates, although even the metaanalyses may be underpowered to compare complication rates. Benefits of mildly reduced postoperative pain, quicker return to activity, and cosmesis may be weighed against surgeon skill/preference and accordingly longer operative times. All studied port configurations are comparable from a safety and perioperative morbidity standpoint and thus remain acceptable choices per surgeon preference, which the SAGES guideline noted as well [3], although EASL and Tokyo guidelines both advocated against reduced-port LC in the absence of affirmative evidence of benefit [40,41]. Reduced-port and SILC should be considered a safe option only by those with significant training in these techniques. Notably, no included studies evaluated the impact of port placement on achievement of the critical view of safety, which was emphasized in the recent SAGES consensus statement as the most important element of safe LC (see PICO 2) [5]. Future studies regarding optimal port placement should collect this information as proxy for relative safety of various techniques. PICO 2: In adult patients undergoing laparoscopic cholecystectomy for acute cholecystitis or symptomatic cholelithiasis, what method of identifying the cystic artery and duct is safest?
Background. Several methods exist for identifying the cystic duct and artery safely. Fundus-first dissection involves grasping the fundus and dissecting the gallbladder off of the cystic plate from fundus toward the cystic duct and artery [42]. Critical view of safety technique requires dissection of the hepatocystic triangle, bounded by the cystic duct, common hepatic duct, and inferior edge of the liver, and dissection of the lower third of the gallbladder from the cystic plate. Usually, this dissection is initiated at the triangle of Calot (between the cystic duct, common hepatic duct, and cystic artery). Once these steps are complete and only 2 structures are seen entering the gallbladder, the cystic duct and artery may be safely identified and divided [43]. The "infundibular technique" is not commonly used but is a pared down version of critical view of safety, whereby a surgeon merely has to confirm that the cystic duct is in continuity with the infundibulum of the gallbladder prior to dividing it [44]. Dissection techniques may be augmented with intraoperative cholangiography, fluorescent cholangiography, or laparoscopic ultrasonography (LUS), all of which may be used for either elucidation of biliary anatomy or detection of common bile duct (CBD) stones [45,46]. Four RCTs evaluated critical view of safety and dissection methods used to obtain it. Two RCTs and three systematic reviews investigated radiographic, fluorescent, and ultrasound intraoperative bile duct visualization (Table 7).
Critical View of Safety Versus Infundibular Technique. In a singlecenter comparative study, Zarin et al randomized patients undergoing laparoscopic cholecystectomy to either "infundibular technique" involving only identification of the cystic duct prior to cystic duct division (n = 220) or critical view of safety technique (CVS) (n = 218) [44]. Major bile leaks were reduced for patients in the CVS group (0.5% vs 1.4%), and operative time was shorter. Rates of minor bile leaks were comparable between both groups (0.5% vs 0.9%). Although others may consider any CBD injury to be a significant surgical event, Zarin et al defined "minor" and "major" bile leaks as varying degrees of CBD injury. Minor bile leak was defined as a < 25% CBD diameter injury, and major leak was >25% CBD diameter injury or presence of CBD stricture per McMahon et al classification [47]. This study was weakened by the omission of adequate statistical analysis including P values or confidence intervals, but since CVS is so widely accepted, this paper was the only direct comparison found between CVS and an alternate criterion for cystic duct and artery division [44].
Dissection to Obtain the Critical View of Safety. Three RCTs compared fundus-first dissection against initiating dissection near the infundibulum. Cengiz et al and Saeed et al performed fundus-first dissection with ultrasonic shears and used electrocautery for dissection beginning near the infundibulum/triangle of Calot [48,49], whereas Gupta et al used electrocautery for both approaches [50]. Ultrasonic fundus-first dissection led to significantly shorter duration of operation and fewer overnight hospital stays in both studies [48,49], which may be related   to postoperative pain and nausea reductions investigated by one of the studies [48]. Neither study was powered to detect differences in BDI. For electrocautery fundus-first dissection, patients had shorter operative times on noninflamed gallbladders but longer operative times on inflamed gallbladders compared to electrocautery dissection beginning near the infundibulum [50]. However, 27 patients randomized to infundibulum-first dissection (23 of whom had inflamed gallbladders) required conversion to fundus-first technique, and 3 of these were converted to open, skewing the fundus-first group toward more difficult and less time-efficient dissections. Bile spillage occurred less frequently in the fundus-first group and mostly among patients with gallbladder inflammation. Although the high crossover rate suggests advantages in fundus-first dissection, it also limits utility of other comparisons drawn from this study. Taken all together, fundus-first approach may yield mild advantages over infundibulum-first approach for both ultrasonic and electrocautery dissection when seeking the critical view of safety.
Routine Intraoperative Cholangiography. Two systematic reviews and 1 RCT evaluated the role of intraoperative cholangiography (IOC) in preventing or detecting BDI and CBD stones during cholecystectomy. Slim et al, in a systematic review, excluded studies including fewer than 12,000 patients (because of low incidence of BDI) and found that half of included large-scale studies demonstrated a protective effect of routine IOC [51]. The two largest studies showed 34% (0.34% vs 0.48%) [52] and 33% (0.39% vs 0.58%) [53] overall risk reductions for BDI, and another showed 62% reduction in mortality risk (1.1% vs 3.9% 1-year mortality) [54]. In contrast, systematic review by Ford et al did not reveal reductions in BDI with routine or selective IOC but did elucidate longer operative times whenever IOC was performed [55]. In their evaluation, IOC  [57]. Although IOC provided improved visualization of the right and left hepatic ducts, no difference was observed between techniques for evaluation of the cystic duct, CBD, junction of biliary ducts, or common hepatic duct. Surgeons rated fluorescent cholangiography as significantly easier than IOC. Systematic review by Dili et al compared LUS and IOC for prevention of BDI; however, no included studies reported any incidences of BDI [45]. LUS provided complete visualization of extrapancreatic biliary anatomy in 92%-100% of patients and complete visualization of intrapancreatic biliary anatomy slightly less often (73%-100%). CBD stone sensitivity and specificity were noted to be superior to IOC in one included meta-analysis (0.90 and 0.99 for LUS and 0.87 and 0.98 for IOC, P < .05 for both) and comparable to IOC in the other included meta-analysis. The authors note that qualitative advantages of LUS include avoidance of radiation and ability to use LUS before dissection of Calot's triangle, which is not possible with traditional x-ray IOC. Fluorescent cholangiography and LUS yield some advantages over IOC (ease of use, reduction of radiation) and provide reliable information about extrahepatic biliary anatomy; however, these newer techniques have not yet been shown to reduce incidence of BDI.

PICO 2 Overall Recommendation
Critical view of safety is the standard method of cystic duct and artery identification supported by surgical society guidelines [3,5,41,43,58], which may explain the paucity of studies comparing CVS to other techniques. In SAGES's recent consensus Delphi study on factors contributing to safe LC, obtaining the critical view was rated as the most important element [5]. Only one RCT compared the CVS with the infundibular technique (less comprehensive dissection prior to cystic duct division), finding that CVS is superior [44]. To obtain this critical view of safety and correctly identify the cystic duct and artery, fundusfirst dissection may provide advantages over beginning dissection lateral and medial to the triangle of Calot. Fundus-first dissection is also sometimes useful as a bailout maneuver when dissection in the triangle of Calot is difficult provided the CVS can be conserved, although SC may also be an option in this situation (see PICO 4). SAGES guideline provides both fundus-first and infundibulum-first dissection as first-line options, per surgeon preference [3], whereas WSES [58] and Tokyo [41] guidelines consider fundus-first dissection to be an acceptable bailout maneuver.
Traditional x-ray IOC is sometimes used as an adjunct to elucidate biliary anatomy or identify CBD stones, but because BDI is already quite rare, routine IOC for possible small reductions in BDI may not be worth the increased operative time it takes to perform. SAGES guideline agrees on this point, maintaining that routine IOC reduces BDI, but a selective approach may be more efficient once guidelines for selective IOC are established [3]. EASL and WSES guidelines both contend that for patients at low risk of CBD stones, IOC is not warranted [40,58].
Intraoperative ultrasound and intraoperative fluorescent cholangiography are gaining favor [ 58], providing valuable adjunctive information on biliary structure anatomy [59] without the need to predissect the triangle of Calot or expose the patient to radiation. SAGES supports use of intraoperative ultrasound in certain scenarios [3], and WSES advocates for use of fluorescent cholangiography [ 58]. However, these newer modalities have not yet been shown to reduce incidence of BDI. PICO 3: In adult patients undergoing laparoscopic cholecystectomy for acute cholecystitis or symptomatic cholelithiasis, what method of dividing the cystic artery and duct is safest?
Background. Once the cystic duct and artery have been identified and dissected, several options exist for division. Laparoscopic application of titanium or nonabsorbable polymer clips is common because of reliability of method and ease of use. However, occasional cases of clip migration have resulted in complications [60], prompting some to advocate for clipless ligation of the cystic artery and duct. Two RCTs and 1 systematic review were found investigating various methods of cystic artery and duct division (Table 8). Our search returned no prospective studies or systematic reviews evaluating stapled transection of the cystic duct or artery, although retrospective evidence supports use of a laparoscopic stapler for dilated or difficult cystic ducts [61].
Titanium Clips Versus Locking Clips/Ligature Versus Harmonic Shears. Two RCTs and 1 systematic review evaluated ligation of the cystic duct and artery using various methods [62][63][64]. Dijk et al (systematic review and meta-analysis) included 47,491 patients in total and compared titanium clips (nonlocking), locking clips or ligature, and harmonic shears for division of the cystic duct. Their analysis revealed that harmonic energy resulted in slightly lower, though insignificant, postoperative cystic duct leak (CDL) rates than clip closure (odds ratio [OR] 0.4, 95% confidence interval [CI] 0.06-2.48). Locking clips or ligature had lower CDL than nonlocking clips (OR 0.17, 95% CI 0.03-0.93) [64]. In the RCTs comparing titanium clips against harmonic shears, less operative time was required for the harmonic shear groups. Baloch et al demonstrated no differences in complication rates, with 1 bleeding complication in the titanium clip group and 1 minor bile leak (bile observed in surgical drain at 24 hours, which quickly resolved) in each of the groups [62]. Sanawan et al noted that the harmonic shear group sustained fewer gallbladder perforations (5 patients, 7% vs 16 patients, 21%; P = .01) and fewer instances of liver bed bleeding (1 patient, 1% vs 23 patients, 31%; P < .0001), although the authors did not define what constituted liver bed bleeding. At 2-and 4-week follow-up ultrasound, there were no bile leaks or subhepatic fluid collection in either group [63]. Neither study distinguished whether benefits of harmonic shear use are due specifically to lack of clip use or harmonic versus electrocautery dissection of the cystic plate. With so few instances of bile leaks at follow-up, these studies could not conclusively distinguish whether clipless ligation is as durable as clip ligation in keeping critical structures closed.

PICO 3 Overall Recommendation
Division of cystic duct with a locking clip or ligature may result in lower rates of CDL than nonlocking clip, supporting the preference of locking clips when feasible from a cost perspective. Clipless cystic artery and duct ligation with harmonic shears seems to result in quicker operative time compared to traditional clip ligation without a rise in intraoperative complications or increased risk of CDL. However, none of the included studies adequately evaluated long-term risk of clip migration because it is a rare complication. Additionally, no included study controlled for gallbladder dissection technique: when harmonic scalpel was used to divide the cystic duct/artery, it may have also been employed for dissection, confounding findings. Although clipless ligation has not been demonstrated to be inferior to clip ligation, it cannot yet be recommended over clip ligation. No commonly used society guideline commented on technique for division of cystic duct and artery. Background. Subtotal cholecystectomy, which constitutes removal of portions of the gallbladder, is performed in difficult cholecystectomies where inflammation or adhesions in Calot's triangle preclude safe dissection to facilitate obtaining the critical view of safety and usual ligation of the cystic duct and artery [65]. Alternative approaches to SC include open cholecystectomy, fundus-first dissection, and cholecystostomy tube placement to allow the gallbladder to decompress, facilitating cholecystectomy at a later time [42,66,67]. SC can be fenestrated, with gallbladder stump left open and drain placed with or without internal closure of the cystic duct, or reconstituted, with staples placed across the infundibulum. Fenestrated SC may put patients at risk for postoperative fistula, whereas reconstituted SC may put patients at risk of recurrent symptomatic cholelithiasis from stone reformation in the remnant pouch [68]. Three systematic reviews investigate predictors, indications, and outcomes of SC (Table 9).
Indications and Predictors of Difficult Cholecystectomy. The systematic review of Hussain et al of 91 studies on difficult cholecystectomy included 324,553 patients [69]. Male sex, older age, obesity, cirrhosis, adhesions, emergency cholecystectomy, acute cholecystitis, cystic duct stones, and large liver and gallbladder were associated with a more difficult operation. Elshaer et al (a systematic review including 1,231 patients) noted that indications for SC were severe inflammation at Calot's triangle (72%), cirrhosis and portal hypertension (18%), perforation and empyema (6%), and Mirizzi syndrome (3%) [70].
Outcomes of SC. Hussain et al also evaluated conversion to open for SC and determined that the use of laparoscopic SC kept the conversion rate to 0.5%. The authors report low complication rates in all 12 studies evaluating SC, concluding that it is a safe option, although they do not report a comparator group.
For more granular analysis, both Henneman et al and Elshaer et al assessed complications of laparoscopic SC by operative technique [65]. Each review assessed bile leaks, retained stones, and reoperation across several operative choices: resection of the posterior gallbladder wall versus leaving it on the cystic plate, and closing the gallbladder stump versus leaving it open (fenestrated). In both studies, fenestrated SC was associated with significantly higher rates of bile leaks, recurrent/ retained stones, and reoperation. Elshaer et al also calculated mortality for all included patients undergoing SC and noted an overall 30-day mortality of 0.4%. They noted that this is more common than the rate of reoperation and mortality for total cholecystectomy (0.2% and 0.08%, respectively).

PICO 4 Overall Recommendation
Subtotal cholecystectomy is indicated in LC where Calot's triangle cannot be safely dissected and the critical view of safety cannot be obtained per Tokyo 2018 guidelines [41], avoiding injury to the bile duct and nearby vascular structures. In addition, it may also reduce conversions to open cholecystectomy. Although SC is associated with more reinterventions and higher mortality than total cholecystectomy, patients requiring SC are usually more ill, confounding results. Somewhat intuitively, SC is thought to prevent BDI in patients with inflamed, complicated gallbladders [41]. Failure to ligate the cystic duct and/or close the gallbladder stump may result in higher rates of postoperative bile leaks [70] and reoperation [65]. Authors noted that drains were left more frequently in fenestrated SC, but no study provided guidance on the decision to leave a drain, and guidelines support a role for drains in complicated LC [3]. Background. The ideal method of specimen removal to minimize postoperative pain, port site hernia, and surgical site infection remains unclear [71]. Specimens may be removed from the umbilical or epigastric port sites using either an endocatch bag or a surgical glove, or directly from the body without a container [71,72]. Current SAGES guidelines for biliary surgery do not make recommendations for specimen extraction because of insufficient data [3]. Our literature review revealed 6 studies addressing specimen extraction techniques (Table 10).
Port Site-Umbilical Versus Epigastric. Four systematic reviews compared patient outcomes after gallbladder extraction from the epigastric or umbilical port [71,[73][74][75]. Only 1 study, Kulkarni et al observed differences in port site hernia, with more frequent occurrence in the umbilical port gallbladder extraction group over a follow-up of 30 days to 6 months [71]. No studies noted a difference in surgical site infection after extraction from epigastric or umbilical incision.
Mongelli et al and Sood et al both observed that patients undergoing umbilical port site removal had less immediate postoperative pain in the day following surgery [73,74], whereas Kulkarni and Hajibandeh found no difference in postoperative pain [71,75]. Furthermore, Hajibandeh and Sood noted significantly quicker gallbladder retrieval time from the umbilical site, with the latter describing fewer instances of gallbladder perforation during the extraction [74,75]. Umbilical retrieval seems to be associated with easier, less traumatic gallbladder extraction.
Both Sood and Hajibandeh's systematic reviews may be subject to selection bias due to the relatively high number of patients (n = 1800) included from the same nonrandomized study, contributing >50% of the patients in each [76].
Direct Specimen Removal Versus Specimen Retrieval Bag. One systematic review (La Regina et al) and 1 RCT (Rehman et al) compared surgical site infections with and without use of a gallbladder retrieval bag [72,77]. La Regina observed no difference in incidence of wound

PICO 5 Overall Recommendations
Only 1 out of 4 systematic reviews comparing hernia risk by gallbladder extraction site found an association between umbilical extraction and hernia, whereas the remaining 3 reviews found evidence that umbilical extraction resulted in less pain and/or easier and quicker extraction with less risk of gallbladder perforation. It must be noted that regardless of extraction location, the incision must be made large enough relative to the largest gallstone to facilitate successful extraction. No studies demonstrated a difference in surgical site infections. Benefit of the use of a gallbladder retrieval bag was equivocal, with one lower-quality RCT showing possible surgical site infection reduction and the other systematic review showing no difference. Similarly, SAGES guideline ruled that there are no data to guide choice of extraction technique [3]. In the absence of strong, consistent evidence supporting umbilical or epigastric extraction either with or without a retrieval bag, surgeon and patient preference should guide choice of gallbladder retrieval method.

CONCLUSION
Laparoscopic cholecystectomy is a widely performed procedure for which there exists ambiguity in a number of operative choices. By reviewing the evidence evaluating each operative step, we sought to determine whether recommendations could be issued to optimize providers' surgical decision-making and improve patient outcomes. Aside from recommendations on division of the cystic duct and artery, our findings are generally in line with SAGES guideline recommendations from 12 years prior, highlighting the durability of their suggestions in modern practice. Table 11 summarizes our recommendations for each question.