# Choledocholithiasis — GCMD Library living collection

Everything in the library about choledocholithiasis — built automatically from dossiers that name it.

Updated: n/a · 7 episodes · 141 cited statements

## Episodes
### Surgical Management
- [Choledocholithiasis: Diagnosis and management](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883) — podcast · 12:11 · [machine version](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883.md)
- [Acute Cholecystitis](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373) — video · 32:30 · [machine version](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373.md)

### Evidence & Research
- [Quick Literature Updates Episode 12](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976) — video · [machine version](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976.md)
- [Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558) — video · 1:04 · [machine version](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558.md)
- [Multi-Institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122) — video · 0:59 · [machine version](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122.md)

### Case-Based Learning
- [Acute Cholecystitis](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442) — podcast · 32:28 · [machine version](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442.md)

### In-Depth Reviews
- [Choledocholithiasis with Drs. David Vitale & Lucas Neff](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884) — podcast · 15:27 · [machine version](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884.md)

## Chapters
- [0:00](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=0) Case presentation and initial management strategy (Ep 1)
- [3:27](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=207) Preoperative preparation and management of high-risk patients (Ep 1)
- [6:37](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=397) Percutaneous cholecystostomy tube management (Ep 1)
- [8:59](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=539) Operative preparation for patients with cholecystostomy tubes (Ep 1)
- [11:16](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=676) Port placement technique and initial laparoscopic entry (Ep 1)
- [15:07](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=907) Initial dissection and gallbladder decompression (Ep 1)
- [17:26](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1046) Dissection technique and critical view of safety (Ep 1)
- [20:39](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1239) Intraoperative cholangiography technique (Ep 1)
- [22:46](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1366) Management of retained common bile duct stones (Ep 1)
- [26:07](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1567) Fundus-first approach for severe inflammation (Ep 1)
- [28:46](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1726) Bailout strategies and subtotal cholecystectomy (Ep 1)
- [0:00](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=0) Introduction and app promotion (Ep 2)
- [0:21](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=21) Initial workup and diagnosis of choledocholithiasis (Ep 2)
- [1:43](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=103) Indications for ERCP versus intraoperative management (Ep 2)
- [2:35](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=155) Surgical options for CBD stone clearance (Ep 2)
- [3:32](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=212) Intraoperative cholangiogram and transcystic approach (Ep 2)
- [4:49](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=289) Laparoscopic common bile duct exploration technique (Ep 2)
- [6:48](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=408) Open CBD exploration technique (Ep 2)
- [8:22](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=502) Management of impacted stones and drainage procedures (Ep 2)
- [9:37](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=577) Instrumentation and preparation (Ep 2)
- [10:41](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=641) Summary and closing (Ep 2)
- [0:00](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=0) Laparoscopic Common Bile Duct Exploration with Balloon Sphincteroplasty (Ep 3)
- [2:24](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=144) Cervical Collar Clearance in Obtunded Children Without Known Trauma (Ep 3)
- [3:44](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=224) Transanastomotic Feeding After Congenital Duodenal Obstruction Repair (Ep 3)
- [0:00](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558?t=0) Study Overview: Transcystic Laparoscopic CBD Exploration vs ERCP (Ep 4)
- [0:04](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=4) Introduction and Risk Factors for Choledocholithiasis (Ep 5)
- [1:15](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=75) Case Presentation and Risk Stratification (Ep 5)
- [3:34](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=214) Treatment Options: ERCP vs Laparoscopic Exploration (Ep 5)
- [5:07](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=307) Surgery-First Paradigm with Intraoperative Cholangiography (Ep 5)
- [7:41](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=461) Technical Details of Laparoscopic Common Bile Duct Exploration (Ep 5)
- [11:20](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=680) Safety Considerations and Learning Curve (Ep 5)
- [13:48](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=828) Summary and Key Takeaways (Ep 5)
- [0:00](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122?t=0) Surgery-First Approach for Pediatric Choledocholithiasis (Ep 6)
- [0:00](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=0) Introduction and Case Presentation (Ep 7)
- [3:53](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=233) Initial Management and Timing of Surgery (Ep 7)
- [8:00](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=480) Laparoscopic Technique and Port Placement (Ep 7)
- [15:17](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=917) Dissection Technique and Critical View of Safety (Ep 7)
- [20:06](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1206) Intraoperative Cholangiography and CBD Stone Management (Ep 7)
- [25:40](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1540) Difficult Cases and Bailout Strategies (Ep 7)
- [31:07](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1867) Summary and Closing (Ep 7)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Dantes et al. performed a multi-center retrospective review of pediatric and adult patients treated for choledocholithiasis between 2018 and 2024 — Alex Halpern (epidemiological) [Ep 6 · 0:11](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122?t=11)
- 724 patients were included in the study — Alex Halpern (epidemiological) [Ep 6 · 0:22](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122?t=22)
- Surgery first approach with upfront laparoscopic cholecystectomy with intraoperative cholangiogram was performed in 201 pediatric patients and 169 adult patients — Alex Halpern (clinical) [Ep 6 · 0:25](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122?t=25)
- Laparoscopic common bile duct exploration was attempted in 84 children and 140 adults in the surgery first group — Alex Halpern (clinical) [Ep 6 · 0:35](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122?t=35)
- Common bile duct exploration success was higher in pediatric than adult patients — Alex Halpern (clinical) [Ep 6 · 0:43](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122?t=43)
- Complication rates were similar between pediatric and adult patients in the surgery first approach — Alex Halpern (clinical) [Ep 6 · 0:43](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122?t=43)
- A surgery first approach can be a safe and effective tool for managing choledocholithiasis in pediatric patients — Alex Halpern (opinion) [Ep 6 · 0:49](https://origin-library.globalcastmd.com/watch/multi-institutional-analysis-of-choledocholithiasis-in-pediatric-vs-adult-patien-10122?t=49)
- Risk factors for choledocholithiasis include metabolic diseases, hemolysis such as sickle cell, and congenital biliary anomalies like choledochal cysts. — David Vitale (clinical) [Ep 5 · 0:55](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=55)
- Choledocholithiasis is more common in older children, children with higher BMI, and patients of Hispanic ethnicity. — David Vitale (epidemiological) [Ep 5 · 1:03](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=63)
- Retrospective data comparing ERCP versus laparoscopic common bile duct exploration is conflicted and the choice is institution-dependent and provider-dependent based on expertise. — David Vitale (opinion) [Ep 5 · 4:03](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=243)
- Stones above the cystic duct pose a problem because they can float up during attempted laparoscopic removal, making a straightforward procedure much more difficult. — David Vitale (clinical) [Ep 5 · 4:39](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=279)
- Local expertise and availability is the most important factor in the decision tree between ERCP and laparoscopic common bile duct exploration. — David Vitale (opinion) [Ep 5 · 5:00](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=300)
- Dr. Neff uses a 12-gauge angiocath for access, which may be hard to find in pediatric hospitals but can be ordered. — Luke Neff (clinical) [Ep 5 · 9:37](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=577)
- The angle of entry into the cystic ductotomy should be as flat as possible, which is why a new incision is made rather than using existing ports. — Luke Neff (clinical) [Ep 5 · 9:42](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=582)
- Dr. Neff uses a 6 French urethral stent cut down shorter for better flow, with a glide wire inside, using a coaxial technique to navigate the valves of Heister. — Luke Neff (clinical) [Ep 5 · 9:57](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=597)
- Dr. Neff typically uses either a 6 millimeter or 8 millimeter angioplasty balloon, but definitely not more than that. — Luke Neff (clinical) [Ep 5 · 10:37](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=637)
- The balloon dilation technique involves inflating the balloon in the duct, pulling back for tactile feedback to locate the sphincter, partially deflating, straddling the ampulla, then going to full profile under fluoroscopy and holding for about 5 minutes. — Luke Neff (clinical) [Ep 5 · 11:02](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=662)
- Never use a balloon larger than the dilated common bile duct, as adult literature shows higher rates of pancreatitis with ampullary dilation without sphincterotomy. — David Vitale (clinical) [Ep 5 · 11:23](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=683)
- After balloon dilation, Dr. Neff creates a seal on the distal common duct by partially inflating a balloon straddling the cystic duct-common duct junction so that flushing through the guide wire lumen gets pressurized downstream. — Luke Neff (clinical) [Ep 5 · 11:55](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=715)
- If laparoscopic common bile duct exploration is not successful, Dr. Neff places an endoloop on the cystic duct and refers to GI for ERCP. — Luke Neff (clinical) [Ep 5 · 12:16](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=736)
- The prevalence of stone disease is increasing. — Luke Neff (epidemiological) [Ep 5 · 12:34](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=754)
- The learning curve for laparoscopic common bile duct exploration is around 5 to 10 cases, though this is person-specific. — Luke Neff (clinical) [Ep 5 · 13:38](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=818)
- The position of the 12-gauge angiocath is critical, and the ability to manipulate the catheter and wire in the duct depends on the initial setup and how flat the angle of entry is into the cystic duct. — Luke Neff (clinical) [Ep 5 · 13:24](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=804)
- Patients with acute cholecystitis who are cooled down with conservative management and discharged have a high recurrence rate and typically return on weekends, making management more difficult. — John Rodriguez (clinical) [Ep 1 · 2:30](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=150)
- For a 45-year-old woman with straightforward acute cholecystitis (symptoms less than 2 days, normal LFTs, reasonable surgical candidate), early same-admission laparoscopic cholecystectomy is favored over conservative management. — John Rodriguez (clinical) [Ep 1 · 2:30](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=150)
- For high-risk patients (e.g., 75-year-old with ejection fraction 15% and history of previous MIs), medical subspecialty consultation is needed to determine realistic operative risk factors before proceeding with cholecystectomy. — John Rodriguez (clinical) [Ep 1 · 5:18](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=318)
- Many high-risk patients with acute cholecystitis will cool down with antibiotics alone and require no additional intervention. — John Rodriguez (clinical) [Ep 1 · 5:18](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=318)
- Percutaneous cholecystostomy tubes can be placed by interventional radiology in patients who are not good operative candidates. — John Rodriguez (clinical) [Ep 1 · 5:18](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=318)
- For high-risk cardiac patients with acute cholecystitis, admit to hospital, start broad-spectrum antibiotics, and if no improvement after one to two days, perform percutaneous cholecystostomy. — John Rodriguez (clinical) [Ep 1 · 6:37](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=397)
- Percutaneous cholecystostomy tubes are placed through the liver into the gallbladder. — John Rodriguez (clinical) [Ep 1 · 6:48](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=408)
- The combination of percutaneous cholecystostomy tubes with antibiotics is very effective in managing acute cholecystitis in high-risk patients, with most having uneventful recovery and hospital discharge. — John Rodriguez (clinical) [Ep 1 · 6:58](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=418)
- Cholecystostomy tubes should be kept for 4 to 6 weeks before removal, with cholangiogram performed through the tube to confirm cystic duct patency before removal. — John Rodriguez (clinical) [Ep 1 · 7:14](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=434)
- If the cystic duct is not patent when the cholecystostomy tube is removed, the patient will develop a recurrent episode of acute cholecystitis. — John Rodriguez (clinical) [Ep 1 · 7:28](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=448)
- Patients with cholecystostomy tubes will have remaining stones in the gallbladder that cannot be managed with percutaneous intervention. — John Rodriguez (clinical) [Ep 1 · 8:10](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=490)
- For patients on antiplatelet therapy due to cardiac stents who need to wait a year before stopping medication, cholecystostomy tube placement is reasonable as definitive management becomes easier once they can discontinue Plavix or aspirin. — John Rodriguez (clinical) [Ep 1 · 8:10](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=490)
- Cholecystectomy cases in patients with prior cholecystostomy tubes are more challenging and should not be added at the end of the day when the surgeon is fatigued. — John Rodriguez (clinical) [Ep 1 · 9:33](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=573)
- In patients with cholecystostomy tubes, obtain cholangiogram through the tube preoperatively and do not remove the tube before surgery, as it can help with orientation in adhesive cases and allow intraoperative cholangiography if anatomy is unclear. — John Rodriguez (clinical) [Ep 1 · 9:33](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=573)
- For high-risk cardiac patients undergoing cholecystectomy, obtain cardiology consultation with stress testing if indicated, and coordinate timing of antiplatelet therapy cessation before surgery and resumption after surgery, particularly with newer generation blood thinners. — John Rodriguez (clinical) [Ep 1 · 10:29](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=629)
- Some high-risk cardiac patients may require cardiac catheterization with stent placement before cholecystectomy to improve cardiac function. — John Rodriguez (clinical) [Ep 1 · 10:29](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=629)
- Laparoscopic approach is used 99% of the time for cholecystectomy, even in very difficult acute cholecystitis cases. — John Rodriguez (clinical) [Ep 1 · 11:17](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=677)
- For laparoscopic cholecystectomy, Rodriguez uses optical entry at Palmer's point (two finger breadths below left costal margin in midclavicular line) for the first 5mm trocar in patients with higher BMI, influenced by bariatric surgery practice. — John Rodriguez (clinical) [Ep 1 · 12:02](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=722)
- Palmer's point (two finger breadths below rib cage on left side in midclavicular line) is one of the safest locations for initial laparoscopic entry. — John Rodriguez (clinical) [Ep 1 · 12:17](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=737)
- By placing the first trocar at Palmer's point and dropping the hand about another inch lower, Rodriguez has never needed to place another trocar that did not help, as this location provides adequate length with longer instruments. — John Rodriguez (clinical) [Ep 1 · 12:29](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=749)
- Rodriguez uses the left upper quadrant Palmer's point 5mm port as his right-hand operating port during laparoscopic cholecystectomy. — John Rodriguez (clinical) [Ep 1 · 12:51](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=771)
- The second trocar is a 12mm periumbilical port placed under direct vision for the camera, with patient positioned in reverse Trendelenburg for exposure. — John Rodriguez (clinical) [Ep 1 · 13:00](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=780)
- The third trocar (5mm, most lateral, right-sided) is placed under direct laparoscopic vision while visualizing the gallbladder, allowing the assistant to grab and elevate the gallbladder for better left-hand positioning, placed one to two finger breadths below the liver edge. — John Rodriguez (clinical) [Ep 1 · 13:09](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=789)
- Placing trocars under direct laparoscopic vision (after the first port) provides better orientation toward the gallbladder based on liver and gallbladder position. — John Rodriguez (clinical) [Ep 1 · 14:27](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=867)
- Rodriguez uses a four-port technique for laparoscopic cholecystectomy: left upper quadrant 5mm (right hand), periumbilical 12mm (camera), right lateral 5mm (assistant retraction), and a fourth port for left-hand dissection. — John Rodriguez (clinical) [Ep 1 · 15:07](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=907)
- When omentum is adherent to the gallbladder in acute cholecystitis, lyse adhesions gently using hook electrocautery, especially when colon or duodenum are visualized, because edematous tissue bleeds easily and uncontrolled bleeding impedes visualization. — John Rodriguez (clinical) [Ep 1 · 15:30](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=930)
- Hook electrocautery is a very fine dissecting tool that is hemostatic for lysing omental adhesions in acute cholecystitis. — John Rodriguez (clinical) [Ep 1 · 15:57](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=957)
- Rodriguez has a low threshold to decompress tense, hard, thick gallbladders before attempting to grasp them. — John Rodriguez (clinical) [Ep 1 · 16:29](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=989)
- Gallbladder decompression is performed using a long reusable needle connected via luer lock to a 60cc syringe, inserted under direct vision into the fundus of the gallbladder to aspirate contents and allow grasping without tearing. — John Rodriguez (clinical) [Ep 1 · 16:36](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=996)
- In severely inflamed gallbladders where infundibulum, cystic duct, artery, and Calot's triangle/node cannot be defined, Rodriguez is aggressive about using fundus-first (dome-down) dissection while remaining laparoscopic. — John Rodriguez (clinical) [Ep 1 · 26:07](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1567)
- For fundus-first dissection, the assistant uses the lateral left trocar for retraction; Rodriguez places this trocar under direct vision because he encounters difficult anatomy requiring dome-down approach more commonly than standard anatomy. — John Rodriguez (clinical) [Ep 1 · 26:36](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1596)
- There is nothing magical about a specific number of trocars; surgeons should place them where needed and not be afraid to add additional trocars. — John Rodriguez (opinion) [Ep 1 · 27:06](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1626)
- When fundus-first dissection fails to safely reach the cystic duct, the decision is between opening the gallbladder for partial cholecystectomy or leaving part of the back wall on the liver. — John Rodriguez (clinical) [Ep 1 · 27:28](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1648)
- In severe cases, the surgeon can assess laparoscopically how difficult it will be to proceed with open surgery, and going open to heroically pursue the cystic duct is often not safe either. — John Rodriguez (clinical) [Ep 1 · 27:28](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1648)
- Ponsky's bailout technique for horrible cases: open the gallbladder, remove all stones, place a large cholecystostomy tube, leaving an empty gallbladder with drainage. — Jeffrey Ponsky (clinical) [Ep 1 · 27:51](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1671)
- When performing open cholecystectomy in severely inflamed cases, Rodriguez would proceed with fundus-first (dome-down) dissection to carefully find the anatomy. — John Rodriguez (clinical) [Ep 1 · 28:21](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1701)
- When the gallbladder is severely inflamed and difficult to separate from liver, the concern is not primarily bleeding from liver but injury to a superficial right hepatic ductal system, which can cause bile leaks. — John Rodriguez (clinical) [Ep 1 · 28:46](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1726)
- Many postoperative bile leaks labeled as duct of Luschka leaks are not true ducts of Luschka but rather result from the surgeon dissecting too deep into the liver and injuring the ductal system. — John Rodriguez (clinical) [Ep 1 · 29:08](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1748)
- For necrotic, falling-apart gallbladders with poor anatomy near the cystic duct, perform subtotal cholecystectomy: open gallbladder, remove stones, reach a safe point, leave posterior wall adherent to liver, close the gallbladder, and leave a drain. — John Rodriguez (clinical) [Ep 1 · 29:31](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1771)
- When leaving the posterior gallbladder wall adherent to liver in subtotal cholecystectomy, cauterize the residual mucosa with coagulation on high setting. — John Rodriguez (clinical) [Ep 1 · 30:38](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1838)
- In difficult cholecystectomy cases requiring subtotal cholecystectomy or bailout procedures, always leave a surgical drain to control potential bile leak. — John Rodriguez (clinical) [Ep 1 · 30:03](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1803)
- The primary goal in difficult cholecystectomy cases is avoiding major bile duct injury, which would be a disaster for the patient, rather than achieving complete cholecystectomy. — John Rodriguez (clinical) [Ep 1 · 30:06](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1806)
- Rodriguez dissects high on the gallbladder where he is certain of being on gallbladder wall, then gently teases peritoneum down toward duodenum; acute cholecystitis cases have a thicker rind. — John Rodriguez (clinical) [Ep 1 · 17:26](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1046)
- The suction device is a great dissecting tool during laparoscopic cholecystectomy. — John Rodriguez (clinical) [Ep 1 · 18:27](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1107)
- Dissect toward Calot's node to visualize the cystic artery, and dissect up toward the gallbladder body to gain length on the cystic artery, because as long as you are on the gallbladder, you are safe. — John Rodriguez (clinical) [Ep 1 · 17:53](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1073)
- Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible, which is how surgeons get into trouble. — John Rodriguez (clinical) [Ep 1 · 18:52](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1132)
- The critical view of safety requires visualizing the cystic duct, the gallbladder wall, liver in the dissection window, and the cystic artery within Calot's triangle. — John Rodriguez (clinical) [Ep 1 · 19:17](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1157)
- Maryland forceps are a great tool for gentle dissection at the cystic duct-gallbladder junction. — John Rodriguez (clinical) [Ep 1 · 19:17](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1157)
- Residents should be reminded to use their left hand to move the gallbladder back and forth during dissection, allowing dissection on the lateral side which is always a safe spot. — John Rodriguez (clinical) [Ep 1 · 19:17](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1157)
- Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall from the liver bed provides increased length on the cystic duct. — John Rodriguez (clinical) [Ep 1 · 20:19](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1219)
- Rodriguez uses routine intraoperative cholangiography, performing it almost always including in acute cholecystitis cases. — John Rodriguez (clinical) [Ep 1 · 20:39](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1239)
- For cholangiography, Rodriguez uses the Ponsky catheter (small ERCP-type catheter with wire that makes cystic duct cannulation easy) placed through an Olsen clamp. — John Rodriguez (clinical) [Ep 1 · 20:43](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1243)
- Before cannulating the cystic duct for cholangiography, place a clip very close to the gallbladder, make a dicotomy, then milk the cystic duct proximally with the back of scissors or Maryland forceps to express any stones. — John Rodriguez (clinical) [Ep 1 · 21:03](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1263)
- Rodriguez introduces the Olsen clamp with Ponsky catheter through the left upper quadrant trocar and gives the catheter a 45-degree angle before inserting into the body, which helps with cannulation. — John Rodriguez (clinical) [Ep 1 · 21:26](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1286)
- The Olsen clamp tip comes together to occlude the cystic duct around the catheter, but the middle does not close, so it does not occlude the catheter lumen. — John Rodriguez (clinical) [Ep 1 · 21:57](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1317)
- Before injecting contrast for cholangiography, flush the catheter with saline to ensure no backflow, then flush the duct with 20cc saline to clear sludge, stones, and air bubbles. — John Rodriguez (clinical) [Ep 1 · 22:14](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1334)
- When cholangiogram contrast flows only distally and not proximally into the liver, place the patient in reverse Trendelenburg position or use the laparoscopic camera to compress the distal common bile duct, which redirects contrast flow proximally. — John Rodriguez (clinical) [Ep 1 · 22:56](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1376)
- For small retained common bile duct stones on cholangiogram, first attempt flushing the duct again with saline. — John Rodriguez (clinical) [Ep 1 · 23:36](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1416)
- Administer glucagon to relax the ampulla of Vater, which can help pass distal common bile duct stones, then repeat cholangiogram. — John Rodriguez (clinical) [Ep 1 · 23:49](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1429)
- If flushing and glucagon do not clear retained CBD stones, use a commercial transcystic common bile duct exploration kit with percutaneous introducer catheter and step dilator. — John Rodriguez (clinical) [Ep 1 · 23:52](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1432)
- For transcystic CBD exploration, introduce the catheter from the right side through a separate stab incision (not through an existing trocar) at a parallel angle to the cystic duct to avoid trauma and backwalling the duct. — John Rodriguez (clinical) [Ep 1 · 24:20](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1460)
- The key to transcystic CBD exploration is placing a guidewire under fluoroscopic guidance into the duodenum; once the wire is down, various instruments from the kit can extract stones. — John Rodriguez (clinical) [Ep 1 · 24:35](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1475)
- Transcystic CBD exploration kits include a Dormia-type basket that can be placed through the cystic duct to crush and retrieve stones. — John Rodriguez (clinical) [Ep 1 · 24:39](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1479)
- Transcystic CBD exploration kits include a balloon dilator; passing the balloon can push small stones through (transcystic antegrade sphincteroplasty), which is often easier than attempting basket retrieval. — John Rodriguez (clinical) [Ep 1 · 24:39](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1479)
- Patients with deep jaundice or cholangitis (jaundice, fever, right upper quadrant pain, sometimes sepsis) are potential candidates for emergency ERCP to relieve common bile duct obstruction. — Jeff Ponsky (clinical) [Ep 2 · 1:43](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=103)
- Patients with gallstone pancreatitis (jaundice, abdominal pain, and elevated pancreatic enzymes) are potential candidates for emergency ERCP. — Jeff Ponsky (clinical) [Ep 2 · 1:43](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=103)
- If a patient's pancreatitis improves the next day, there is no rush to do the ERCP. — Jeff Ponsky (clinical) [Ep 2 · 2:07](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=127)
- The first thing to do in the management of a patient with suspected common bile duct stones is to get an intraoperative cholangiogram. — Jeff Ponsky (clinical) [Ep 2 · 2:35](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=155)
- Transcystic exploration is amenable to small stones, usually in the distal duct. — Jeff Ponsky (clinical) [Ep 2 · 4:27](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=267)
- You can dilate the cystic duct with a balloon or ureteral dilator and then pass a choledochoscope or basket for transcystic stone removal. — Jeff Ponsky (clinical) [Ep 2 · 4:27](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=267)
- You can flush or push tiny stones through the papilla of Vater using glucagon to relax the papilla. — Jeff Ponsky (clinical) [Ep 2 · 4:27](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=267)
- For laparoscopic common bile duct exploration, you make a small incision (perhaps 1 centimeter) in the anterior surface of the common bile duct. — Jeff Ponsky (clinical) [Ep 2 · 5:08](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=308)
- You can use Fogarty balloons or baskets and eventually choledochoscope, both upward and downward, to clear stones from the common bile duct. — Jeff Ponsky (clinical) [Ep 2 · 5:08](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=308)
- For T-tube placement, you use a 12 or 14 T tube, cut the back wall off, slice it longitudinally, put it into the abdomen and place its arms into the duct both proximally and distally. — Jeff Ponsky (clinical) [Ep 2 · 5:58](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=358)
- Use a dissolvable suture such as Vicryl or chromic to put a stitch one distal to the tube and one proximal to the tube. — Jeff Ponsky (clinical) [Ep 2 · 5:58](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=358)
- After CBD exploration, take out the gallbladder and put a drain in the foramen of Winslow. — Jeff Ponsky (clinical) [Ep 2 · 5:58](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=358)
- A surgeon should consider converting to open CBD exploration when the inflammation is great, when unfamiliar with laparoscopic suturing techniques, or when exposure is not good. — Jeff Ponsky (clinical) [Ep 2 · 6:55](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=415)
- In open technique, you do a Kocher maneuver where you take down the lateral peritoneum lateral to the duodenum so you can put traction on the common duct by holding the duodenum and pancreatic head. — Jeff Ponsky (clinical) [Ep 2 · 7:25](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=445)
- For transduodenal sphincteroplasty when stones are impacted at the papilla, you make a duodenotomy over the papilla, take small clamps and go into the 11 o'clock position and open the papilla a few millimeters at a time, similar to endoscopic sphincterotomy. — Jeff Ponsky (clinical) [Ep 2 · 8:22](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=502)
- Transduodenal sphincteroplasty is not very common anymore. — Jeff Ponsky (epidemiological) [Ep 2 · 8:22](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=502)
- Essential instruments for CBD exploration include cholangiogram catheters, contrast material, dilating balloons for the cystic duct, balloons and baskets for the common duct, and a choledochoscope. — Jeff Ponsky (clinical) [Ep 2 · 9:37](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=577)
- Many instruments for CBD exploration can be obtained from the urology cart because they use similar items for the ureter and ureteral stones. — Jeff Ponsky (clinical) [Ep 2 · 9:37](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=577)
- The choledochoscope is an inexpensive tool which makes laparoscopic or open common bile duct exploration very easy. — Jeff Ponsky (opinion) [Ep 2 · 9:37](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=577)
- Choledocholithiasis is a disease that belongs to the surgeons, and to use ERCP as an adjunct is appropriate, but the surgeon should be comfortable doing exploration and management of common bile duct stones. — Jeff Ponsky (opinion) [Ep 2 · 10:49](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=649)
- In acute cholecystitis cases presenting within 48 hours with straightforward presentation, early cholecystectomy during the same admission is favored over conservative management because cases managed conservatively have high recurrence rates and often return on weekends making management more difficult. — John Rodriguez (clinical) [Ep 7 · 2:55](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=175)
- Preoperative antibiotics should be started in acute cholecystitis cases presenting to the emergency room. — John Rodriguez (clinical) [Ep 7 · 3:58](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=238)
- In high-risk patients with significant cardiac history, medical subspecialty consultation is needed to determine realistic operative risk factors before proceeding with cholecystectomy. — John Rodriguez (clinical) [Ep 7 · 5:18](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=318)
- Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in high-risk surgical patients, with most patients having uneventful recovery. — John Rodriguez (clinical) [Ep 7 · 6:58](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=418)
- Before removing a percutaneous cholecystostomy tube, wait 4-6 weeks and perform a cholangiogram through the tube to confirm cystic duct patency, because if the cystic duct is not patent, recurrent cholecystitis will occur immediately after tube removal. — John Rodriguez (clinical) [Ep 7 · 7:30](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=450)
- Percutaneous cholecystostomy is a reasonable temporizing measure for patients on antiplatelet therapy who need to wait (e.g., one year after cardiac stent) before it is safe to discontinue medications for definitive surgery. — John Rodriguez (clinical) [Ep 7 · 8:18](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=498)
- Cholecystectomy cases in patients with prior percutaneous cholecystostomy tubes tend to be more challenging and should be planned as dedicated cases, not added on at the end of a long operative day. — John Rodriguez (clinical) [Ep 7 · 9:33](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=573)
- The laparoscopic approach is used in 99% of cholecystectomy cases, even in very difficult acute cholecystitis. — John Rodriguez (clinical) [Ep 7 · 11:39](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=699)
- Palmer's point (two finger breadths below the left costal margin in the midclavicular line) is one of the safest locations for initial laparoscopic entry, particularly in higher BMI patients. — John Rodriguez (clinical) [Ep 7 · 12:15](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=735)
- Placing the lateral right-sided trocar under direct laparoscopic vision while visualizing the gallbladder allows optimal positioning for retraction based on individual patient anatomy. — John Rodriguez (clinical) [Ep 7 · 13:10](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=790)
- In acute cholecystitis, edematous tissue bleeds easily, and controlling bleeding from omentum early with cautery prevents impaired visualization later in the case. — John Rodriguez (clinical) [Ep 7 · 15:41](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=941)
- There is a low threshold to decompress tense, inflamed gallbladders before attempting to grasp them, to prevent tearing the gallbladder wall. — John Rodriguez (clinical) [Ep 7 · 16:29](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=989)
- Gallbladder decompression is performed at the fundus using a long reusable needle connected via luer-lock to a 60cc syringe, aspirating under direct vision. — John Rodriguez (clinical) [Ep 7 · 16:36](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=996)
- In acute cholecystitis, dissection should start high on the gallbladder where anatomy is certain, then work down toward Calot's node and triangle, staying on the thickened gallbladder wall. — John Rodriguez (clinical) [Ep 7 · 18:04](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1084)
- The suction device is an effective dissection tool in laparoscopic cholecystectomy. — John Rodriguez (clinical) [Ep 7 · 18:29](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1109)
- The critical view of safety requires visualization of the cystic duct, gallbladder wall, liver in the window, and the cystic artery within Calot's triangle. — John Rodriguez (clinical) [Ep 7 · 19:45](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1185)
- Taking the posterior gallbladder wall off the liver bed just superior to the cystic duct-gallbladder junction provides increased length for safer dissection. — Jeffrey Ponsky (clinical) [Ep 7 · 20:19](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1219)
- Routine intraoperative cholangiography is performed in nearly all cholecystectomy cases. — John Rodriguez (clinical) [Ep 7 · 20:39](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1239)
- Before cannulating the cystic duct for cholangiography, place a clip close to the gallbladder, make a dichotomy, and milk the cystic duct proximally to express any stones. — John Rodriguez (clinical) [Ep 7 · 21:08](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1268)
- Flushing the cystic duct with 20cc of saline before cholangiography clears sludge and stones and removes air bubbles from the system. — John Rodriguez (clinical) [Ep 7 · 22:23](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1343)
- If contrast flows only distally on cholangiogram, placing the patient in slight reverse Trendelenburg or using the laparoscope to compress the distal common bile duct can redirect flow proximally to visualize the hepatic ducts. — John Rodriguez (clinical) [Ep 7 · 22:59](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1379)
- For small common bile duct stones identified on cholangiogram, initial management includes flushing the duct and administering glucagon to relax the ampulla, which may allow spontaneous stone passage. — John Rodriguez (clinical) [Ep 7 · 23:41](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1421)
- Transcystic common bile duct exploration uses a commercial kit with a percutaneous introducer catheter and step dilator, inserted through a separate stab incision (not through an existing trocar) at a parallel angle to the cystic duct to avoid ductal trauma. — John Rodriguez (clinical) [Ep 7 · 24:07](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1447)
- The key to transcystic CBD exploration is placing a wire under fluoroscopic guidance distally into the duodenum, which then allows passage of basket or balloon instruments. — John Rodriguez (clinical) [Ep 7 · 24:41](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1481)
- For small CBD stones, balloon dilation (antegrade sphincteroplasty) to push stones through is often easier than basket extraction. — John Rodriguez (clinical) [Ep 7 · 25:16](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1516)
- When the infundibulum, cystic duct, cystic artery, and Calot's triangle cannot be defined due to severe inflammation, a top-down approach (starting at the fundus) should be used. — John Rodriguez (clinical) [Ep 7 · 26:14](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1574)
- Placing the lateral trocar under direct vision is particularly important because it positions the port to be helpful in difficult cases requiring top-down dissection, not just standard cholecystectomy. — John Rodriguez (clinical) [Ep 7 · 26:41](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1601)
- In severe acute cholecystitis cases, the difficulty of open dissection can be assessed laparoscopically, and attempting heroic open dissection to reach the cystic duct is often not safe. — John Rodriguez (clinical) [Ep 7 · 27:28](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1648)
- In cases where complete cholecystectomy is unsafe, options include opening the gallbladder to perform partial cholecystectomy or leaving part of the posterior wall on the liver. — John Rodriguez (clinical) [Ep 7 · 27:52](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1672)
- A bailout technique for severe cases is to open the gallbladder, remove all stones, place a large cholecystostomy tube, creating an empty gallbladder with drainage. — Jeffrey Ponsky (clinical) [Ep 7 · 28:14](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1694)
- When dissecting the gallbladder off the liver bed in severe inflammation, caution is needed to avoid injury to superficial right hepatic ducts, as overly deep dissection can cause bile leaks often mislabeled as ducts of Luschka but actually representing injury to the ductal system. — John Rodriguez (clinical) [Ep 7 · 29:10](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1750)
- In subtotal cholecystectomy where posterior wall is left, the residual mucosa should be cauterized with coagulation on high setting. — John Rodriguez (clinical) [Ep 7 · 30:38](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1838)
- A drain should be left after subtotal cholecystectomy to control potential bile leak. — John Rodriguez (clinical) [Ep 7 · 29:58](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1798)
- The primary goal in difficult cholecystitis cases is avoiding major bile duct injury, which would be a disaster for the patient—this takes priority over achieving complete cholecystectomy. — John Rodriguez (clinical) [Ep 7 · 30:24](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1824)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The study was a multi-center retrospective study conducted in the US from 2018 to 2022 — Cecilia Gigena summarizing a resource [Ep 4 · 0:09](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558?t=9)
- The study aim was to compare patients with suspected choledocholithiasis who underwent transcystic laparoscopic common bile duct exploration versus those who underwent ERCP first — Cecilia Gigena summarizing a resource [Ep 4 · 0:09](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558?t=9)
- The study included 252 patients total — Cecilia Gigena summarizing a resource [Ep 4 · 0:28](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558?t=28)
- 156 patients were in group one (transcystic laparoscopic common bile duct exploration) — Cecilia Gigena summarizing a resource [Ep 4 · 0:28](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558?t=28)
- 96 patients were in group two (ERCP first) — Cecilia Gigena summarizing a resource [Ep 4 · 0:38](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558?t=38)
- Patients in group one (transcystic laparoscopic approach) had significantly less complication rates compared to group two — Cecilia Gigena summarizing a resource [Ep 4 · 0:38](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558?t=38)
- Patients in group one (transcystic laparoscopic approach) had lower length of stay compared to group two — Cecilia Gigena summarizing a resource [Ep 4 · 0:38](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558?t=38)
- Attempting a transcystic laparoscopic common bile duct exploration may benefit pediatric patients with choledocholithiasis — Cecilia Gigena summarizing a resource [Ep 4 · 0:52](https://origin-library.globalcastmd.com/watch/transcystic-laparoscopic-common-bile-duct-exploration-for-pediatric-patients-wit-8558?t=52)
- Choledocholithiasis stones may be made up of bile pigments or calcium and cholesterol salts. — Cecilia Gigena summarizing the discussion [Ep 5 · 0:43](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=43)
- According to ASGE guidelines, patients with high probability of common bile duct stones (common bile duct stones seen on ultrasound, ascending cholangitis, or quite high bilirubin) should go straight to ERCP. — David Vitale summarizes what Dr. Luke Neff said [Ep 5 · 1:52](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=112)
- Patients with intermediate risk (abnormal liver biochemical tests or dilated common bile ducts) can undergo endoscopic ultrasound, MRCP, laparoscopic cholangiogram, or intraoperative ultrasound. — Cecilia Gigena summarizing the discussion [Ep 5 · 2:11](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=131)
- In pediatric literature, direct (conjugated) bilirubin more than 2 mg/dL was the most predictive factor for common bile duct stones. — David Vitale summarizes what Dr. Luke Neff said [Ep 5 · 2:40](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=160)
- Common bile duct diameter greater than 6 millimeters was most sensitive for predicting common bile duct stones in children, although without statistical significance. — Cecilia Gigena summarizing the discussion [Ep 5 · 2:50](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=170)
- The pediatric duct score (published in Journal of American College of Surgeons with 10 centers) identified three most predictive risk factors: ducts greater than 6 mm, common bile duct stones on ultrasound, or total bilirubin greater than 1.8 mg/dL. — David Vitale summarizes what Dr. Luke Neff said [Ep 5 · 3:03](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=183)
- Pediatric literature with small sample size shows that same-anesthesia laparoscopic cholecystectomy with ERCP in stone disease led to less anesthesia time and lower length of stay. — David Vitale summarizes what Dr. Luke Neff said [Ep 5 · 3:41](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=221)
- Randomized trials from 2013 show no significant difference in morbidity, mortality, retained stones, or failure rates between ERCP and laparoscopic common bile duct exploration. — Cecilia Gigena summarizing the discussion [Ep 5 · 4:18](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=258)
- Most free-standing children's hospitals do not have ERCP capabilities. — Cecilia Gigena summarizing the discussion [Ep 5 · 8:59](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=539)
- If the pancreatic duct is visualized during fluoroscopy, the procedure should be stopped due to higher risk for pancreatitis. — Cecilia Gigena summarizing the discussion [Ep 5 · 12:24](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=744)
- Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture. — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 1 · 4:21](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-3442?t=261)
- If GGT and alk phos are elevated, you should think obstruction of the common bile duct. — The host summarizes what Dr. Jeff Ponsky said [Ep 2 · 1:13](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=73)
- If you see dilation of the common bile duct greater than 7 millimeters on ultrasound, you should think obstruction potentially with stones. — The host summarizes what Dr. Jeff Ponsky said [Ep 2 · 1:13](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=73)
- ERCP is definitely overused. — The host summarizes what Dr. Jeff Ponsky said [Ep 2 · 2:21](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=141)
- If a patient can go to the operating room and have an intraoperative cholangiogram and management of the common bile duct stones in one episode, they may be better off than having a preoperative ERCP. — The host summarizes what Dr. Jeff Ponsky said [Ep 2 · 2:21](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=141)
- If there is any question that there may be remaining stones in the bile duct or distal high pressure at the papilla, a T tube should be used as this will decompress the duct, allow it to heal, and allow access to the duct should there be a retained stone later. — The host summarizes what Dr. Jeff Ponsky said [Ep 2 · 7:57](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=477)
- The T tube is removed 10 days to 2 weeks later, even in the office. — The host summarizes what Dr. Jeff Ponsky said [Ep 2 · 7:57](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=477)
- If the duct is very dilated, very filled with stones, or if you cannot remove distal stones, consider a drainage procedure (choledochojejunostomy or choledochoduodenostomy) which provides permanent drainage. — The host summarizes what Dr. Jeff Ponsky said [Ep 2 · 9:13](https://origin-library.globalcastmd.com/watch/choledocholithiasis-diagnosis-and-management-3883?t=553)
- Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible—to avoid bile duct injury. — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 7 · 18:53](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1133)
- There is no magic number of trocars—additional ports should be placed wherever needed for adequate exposure and dissection. — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 7 · 27:09](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1629)
- Acute cholecystitis is one of several obstructive diverticulopathies where a diverticulum (the gallbladder) off the biliary tree becomes obstructed (usually by a stone), causing pressure backup, decreased wall blood flow, wall thickening, and potential rupture. — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 7 · 4:21](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13373?t=261)
- The Raugh et al. study reviewed laparoscopic common bile duct exploration with balloon sphincteroplasty for pediatric choledocholithiasis at their institution between 2018 and 2021. — The host summarizing a resource [Ep 3 · 0:42](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=42)
- Balloon sphincteroplasty was associated with increased operative time. — The host summarizing a resource [Ep 3 · 0:42](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=42)
- Balloon sphincteroplasty was associated with 100% success rate, meaning those patients didn't need an ERCP after the procedure. — The host summarizing a resource [Ep 3 · 0:42](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=42)
- Some patients who had laparoscopic common bile duct exploration with standard techniques (no balloon sphincteroplasty) did need an ERCP after the procedure. — The host summarizing a resource [Ep 3 · 0:42](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=42)
- Laparoscopic cholecystectomy with ERCP was associated with increased length of hospital stay and more complications like stent placements and stent migration. — The host summarizing a resource [Ep 3 · 0:42](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=42)
- For pediatric patients with choledocholithiasis, laparoscopic common bile duct exploration combined with balloon sphincteroplasty can be associated with decreased hospital length of stay and decreased complications. — The host summarizing a resource [Ep 3 · 0:42](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=42)
- There are no clear guidelines as to whether obtunded pediatric patients found down without a known traumatic mechanism of injury should be placed in a cervical collar. — Alex Halpern summarizing a resource [Ep 3 · 2:44](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=164)
- C-collars don't come without risks. — Alex Halpern summarizing a resource [Ep 3 · 2:44](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=164)
- The incidence of C-spine injury in obtunded pediatric patients without known traumatic mechanism is very low. — Alex Halpern summarizing a resource [Ep 3 · 2:44](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=164)
- Dr. Grant and her team from Penn State performed a 10-year retrospective chart review of 464 obtunded pediatric patients without a known traumatic mechanism of injury who presented to their pediatric ICU. — Alex Halpern summarizing a resource [Ep 3 · 2:44](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=164)
- 8.4% of the 464 obtunded pediatric patients were placed in C-collars. — Alex Halpern summarizing a resource [Ep 3 · 2:44](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=164)
- Kids placed in C-collars received significantly more imaging. — Alex Halpern summarizing a resource [Ep 3 · 2:44](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=164)
- There was zero C-spine injuries in the entire patient cohort of 464 obtunded pediatric patients without known traumatic mechanism. — Alex Halpern summarizing a resource [Ep 3 · 2:44](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=164)
- The Treider et al. study is a retrospective study done in Norway between 2003 and 2020 that analyzed 100 patients with congenital duodenal obstruction. — Cecilia Gigena summarizing a resource [Ep 3 · 4:07](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=247)
- 37% of the 100 patients received a transanastomotic feeding tube after congenital duodenal obstruction repair. — Cecilia Gigena summarizing a resource [Ep 3 · 4:07](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=247)
- Patients with a transanastomotic feeding tube had two days less of TPN. — Em Tombash summarizing a resource [Ep 3 · 4:28](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=268)
- Patients with a transanastomotic feeding tube started oral feeding 1.5 days earlier. — Em Tombash summarizing a resource [Ep 3 · 4:28](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=268)
- Patients with a transanastomotic feeding tube got fewer central venous catheters. — Em Tombash summarizing a resource [Ep 3 · 4:28](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=268)
- Transanastomotic feeding tubes are beneficial in patients with congenital duodenal obstruction. — Em Tombash summarizing a resource [Ep 3 · 4:28](https://origin-library.globalcastmd.com/watch/quick-literature-updates-episode-12-6976?t=268)

## Changelog
- Sep 24: 2 items added automatically
- Sep 17: 2 items added automatically
- Sep 12: 1 item no longer name choledocholithiasis
- Sep 7: 1 item added automatically
- Sep 7: 3 items added automatically

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