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In the past 30 years, laparoscopic liver resection has made dramatic progress with the establishment of its safety and superiority to open surgery. In recent years, the indications for laparoscopic approach have been gradually expanding in Japan, even for anatomical liver resection. The key surgical techniques in laparoscopic anatomical liver resection are the Glissonean approach and parenchymal transection. Glissonean branches and hepatic veins are confirmed from various anatomical landmarks. Exposure of the hepatic veins is the most important aspect of parenchymal transection and the craniocaudal approach allows for efficient parenchymal transection while avoiding unnecessary bleeding.

Although laparoscopic liver resection (LLR) has become recognized as the standard treatment worldwide, laparoscopic major hepatectomy (LMH) has yet to become widespread. LMH was first defined as resection of 3 or more segments or the difficult posterosuperior segments (4a, 7, 8) in 2008. Although the definition is still under debate and is not clearly defined, several studies reported that LMH was associated with less blood loss, shorter hospital stays and fewer complications compared with open surgery. According to a nationwide survey of Japanese National Clinical Database, advanced LLR increased from 3.3% of all resections in 2011 to 10.8% in 2017, with its mortality 3.6% in 2011, and 1.0% in 2017. The IWATE criteria can be used to predict the difficulty of LLR from preoperative variables and to appropriately select patients according to the surgeons’ skill level. The learning curve for LMH has been discussed, but conclusive number of cases for the mastery of LMH cannot be decided with variety of studies. Since laparoscopic parenchymal-sparing anatomical liver hepatectomy (Lap-PSAH = segmentectomies and sub-segmentectomies) shares some surgical techniques with LMH, it may help shorten the learning curve of LMH. In conclusion, LMH still remains technically demanding, but it has been gradually developed with the improvement of surgical techniques and the careful expansion of indications.

The first version of Tokyo Guidelines (TG07) for acute cholecystitis was published in 2007 after an international consensus meeting held in 2006. The guidelines have been revised twice in 2013 and 2018 to bridge the gap between the guidelines and real-world clinical practice since then. The updated version of Tokyo Guidelines (TG 18) reflected validation studies of the previous version of TG07 and TG13 and newly published clinical evidence. The guidelines consist of several chapters including: (1) diagnostic criteria and severity grading of acute cholecystitis, (2) flowcharts for management of acute cholecystitis, and (3) surgical management of acute cholecystitis. Although TG18 have been widely used not only in clinical practice but also in numerous research studies of acute cholecystitis, there is still room for discussion about the flowchart for management. Here, we describe the outlines of TG18 and room for its improvement in the future.