John Rodriguez

330 statements · 3 topics

Featured statements

▶ Ep 7 · 22:23
I like to flush the duct with a good 20 ccs of saline, uh, cause a lot of times when there's sludge and there's stones, uh, I think clearing that before you should do your cholangiogram, uh, can be very helpful.
quote · Acute Cholecystitis
▶ Ep 6 · 19:31
I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well.
quote · Acute Cholecystitis
▶ Ep 7 · 7:00
I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients.
quote · Choledocholithiasis
▶ Ep 7 · 20:39
I almost use routine cholangiography.
quote · Choledocholithiasis
▶ Ep 7 · 2:46
In straightforward acute cholecystitis with symptoms less than two days in a reasonable surgical candidate, early laparoscopic cholecystectomy during the same admission is favored because attempts to cool down have high recurrence rates and patients often return on weekends making management more difficult.
opinion · Cholelithiasis
▶ Ep 7 · 24:52
The key for transcystic CBD exploration is to place a wire under fluoroscopic guidance distally into the duodenum; once the wire is down, the kit's basket (Dormia-type) can crush and retrieve stones, or the balloon dilator can push small stones through via antegrade sphincteroplasty.
clinical · Cholelithiasis

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John's statements about Acute Cholecystitis 165 statements

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Acute Cholecystitis

▶ Ep 2 · 2:30
clinical 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. ↗
▶ Ep 2 · 2:30
clinical 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. ↗
▶ Ep 2 · 2:30
quote I think the ones that we try to cool down and try to get them out of the hospital have a high recurrence rate, and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. ↗
▶ Ep 2 · 5:18
quote The last thing you want to do is, you know, take a patient with a very significant cardiac history to the operating room and end up giving her an acute cardiac event. ↗
▶ Ep 2 · 5:18
clinical Percutaneous cholecystostomy tubes can be placed by interventional radiology in patients who are not good operative candidates. ↗
▶ Ep 2 · 5:18
clinical Many high-risk patients with acute cholecystitis will cool down with antibiotics alone and require no additional intervention. ↗
▶ Ep 2 · 5:18
clinical 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. ↗
▶ Ep 2 · 6:37
clinical 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. ↗
▶ Ep 2 · 6:48
clinical Percutaneous cholecystostomy tubes are placed through the liver into the gallbladder. ↗
▶ Ep 2 · 6:58
clinical 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. ↗
▶ Ep 2 · 7:14
clinical 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. ↗
▶ Ep 2 · 7:28
clinical If the cystic duct is not patent when the cholecystostomy tube is removed, the patient will develop a recurrent episode of acute cholecystitis. ↗
▶ Ep 2 · 8:10
clinical Patients with cholecystostomy tubes will have remaining stones in the gallbladder that cannot be managed with percutaneous intervention. ↗
▶ Ep 2 · 8:10
clinical 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. ↗
▶ Ep 2 · 9:33
clinical 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. ↗
▶ Ep 2 · 9:33
clinical 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. ↗
▶ Ep 2 · 10:29
clinical 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. ↗
▶ Ep 2 · 10:29
clinical Some high-risk cardiac patients may require cardiac catheterization with stent placement before cholecystectomy to improve cardiac function. ↗
▶ Ep 2 · 11:17
clinical Laparoscopic approach is used 99% of the time for cholecystectomy, even in very difficult acute cholecystitis cases. ↗
▶ Ep 2 · 12:02
clinical 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. ↗
▶ Ep 2 · 12:17
clinical 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. ↗
▶ Ep 2 · 12:29
clinical 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. ↗
▶ Ep 2 · 12:29
quote I've never had to place another trochar because that one doesn't help me. ↗
▶ Ep 2 · 12:51
clinical Rodriguez uses the left upper quadrant Palmer's point 5mm port as his right-hand operating port during laparoscopic cholecystectomy. ↗
▶ Ep 2 · 13:00
clinical The second trocar is a 12mm periumbilical port placed under direct vision for the camera, with patient positioned in reverse Trendelenburg for exposure. ↗
▶ Ep 2 · 13:09
clinical 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. ↗
▶ Ep 2 · 14:27
clinical Placing trocars under direct laparoscopic vision (after the first port) provides better orientation toward the gallbladder based on liver and gallbladder position. ↗
▶ Ep 2 · 15:07
clinical 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. ↗
▶ Ep 2 · 15:30
clinical 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. ↗
▶ Ep 2 · 15:30
quote I find it that when you don't control the bleeding early on, it tends to impede with your visualization later on. ↗
▶ Ep 2 · 15:57
clinical Hook electrocautery is a very fine dissecting tool that is hemostatic for lysing omental adhesions in acute cholecystitis. ↗
▶ Ep 2 · 16:29
clinical Rodriguez has a low threshold to decompress tense, hard, thick gallbladders before attempting to grasp them. ↗
▶ Ep 2 · 16:36
clinical 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. ↗
▶ Ep 2 · 17:26
clinical 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. ↗
▶ Ep 2 · 17:53
clinical 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. ↗
▶ Ep 2 · 17:53
quote As long as you're on the gallbladder, you know you're safe. ↗
▶ Ep 2 · 18:27
clinical The suction device is a great dissecting tool during laparoscopic cholecystectomy. ↗
▶ Ep 2 · 18:52
clinical 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. ↗
▶ Ep 2 · 18:52
quote That's where, that's how you get in trouble in, in some of these cases. ↗
▶ Ep 2 · 19:17
clinical 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. ↗
▶ Ep 2 · 19:17
clinical Maryland forceps are a great tool for gentle dissection at the cystic duct-gallbladder junction. ↗
▶ Ep 2 · 19:17
clinical 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. ↗
▶ Ep 2 · 20:19
clinical 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. ↗
▶ Ep 2 · 20:39
clinical Rodriguez uses routine intraoperative cholangiography, performing it almost always including in acute cholecystitis cases. ↗
▶ Ep 2 · 20:43
clinical For cholangiography, Rodriguez uses the Ponsky catheter (small ERCP-type catheter with wire that makes cystic duct cannulation easy) placed through an Olsen clamp. ↗
▶ Ep 2 · 21:03
clinical 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. ↗
▶ Ep 2 · 21:26
clinical 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. ↗
▶ Ep 2 · 21:57
clinical 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. ↗
▶ Ep 2 · 22:14
clinical 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. ↗
▶ Ep 2 · 22:56
clinical 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. ↗
▶ Ep 2 · 23:36
clinical For small retained common bile duct stones on cholangiogram, first attempt flushing the duct again with saline. ↗
▶ Ep 2 · 23:49
clinical Administer glucagon to relax the ampulla of Vater, which can help pass distal common bile duct stones, then repeat cholangiogram. ↗
▶ Ep 2 · 23:52
clinical 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. ↗
▶ Ep 2 · 24:20
clinical 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. ↗
▶ Ep 2 · 24:35
clinical 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. ↗
▶ Ep 2 · 24:39
clinical 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. ↗
▶ Ep 2 · 24:39
clinical Transcystic CBD exploration kits include a Dormia-type basket that can be placed through the cystic duct to crush and retrieve stones. ↗
▶ Ep 2 · 26:07
clinical 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. ↗
▶ Ep 2 · 26:36
clinical 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. ↗
▶ Ep 2 · 27:06
opinion There is nothing magical about a specific number of trocars; surgeons should place them where needed and not be afraid to add additional trocars. ↗
▶ Ep 2 · 27:06
quote There's nothing magical about, uh, one number or another. You just put them where you need them. ↗
▶ Ep 2 · 27:28
quote The reality of things is that a lot of times in some of these more severe cases, going open and trying to be heroic and going for that cystic duct is not that safe either. ↗
▶ Ep 2 · 27:28
clinical 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. ↗
▶ Ep 2 · 27:28
clinical 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. ↗
▶ Ep 2 · 28:21
clinical When performing open cholecystectomy in severely inflamed cases, Rodriguez would proceed with fundus-first (dome-down) dissection to carefully find the anatomy. ↗
▶ Ep 2 · 28:46
clinical 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. ↗
▶ Ep 2 · 29:08
clinical 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. ↗
▶ Ep 2 · 29:31
clinical 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. ↗
▶ Ep 2 · 30:03
clinical In difficult cholecystectomy cases requiring subtotal cholecystectomy or bailout procedures, always leave a surgical drain to control potential bile leak. ↗
▶ Ep 2 · 30:06
clinical 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. ↗
▶ Ep 2 · 30:06
quote I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster for. ↗
▶ Ep 2 · 30:38
clinical When leaving the posterior gallbladder wall adherent to liver in subtotal cholecystectomy, cauterize the residual mucosa with coagulation on high setting. ↗

Acute Cholecystitis

▶ Ep 6 · 2:55
clinical 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. ↗
▶ Ep 6 · 2:55
quote I think the ones that we try to cool down and and try to get them out of the hospital have a high recurrence rate and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. ↗
▶ Ep 6 · 3:58
clinical Preoperative antibiotics should be started in acute cholecystitis cases presenting to the emergency room. ↗
▶ Ep 6 · 5:18
clinical In high-risk patients with significant cardiac history, medical subspecialty consultation is needed to determine realistic operative risk factors before proceeding with cholecystectomy. ↗
▶ Ep 6 · 5:40
quote The last thing you want to do is, you know, take a patient with a very significant, uh, cardiac history to the operating room and end up giving her an acute, uh, cardiac event. ↗
▶ Ep 6 · 6:58
clinical Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in high-risk surgical patients, with most patients having uneventful recovery. ↗
▶ Ep 6 · 7:00
quote I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients. ↗
▶ Ep 6 · 7:30
clinical 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. ↗
▶ Ep 6 · 7:51
quote if you don't do that, as soon as you take that tube out, they'll get a recurrent episode. ↗
▶ Ep 6 · 8:18
clinical 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. ↗
▶ Ep 6 · 9:33
clinical 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. ↗
▶ Ep 6 · 9:33
quote I think it's not the gallbladder you want to just add on at the end of the day with, you know, when you're tired from, from an all day, uh, surgical volume. ↗
▶ Ep 6 · 10:11
quote in my experience, those gallbladders tend to be pretty challenging, and they, they take up quite some time to do. ↗
▶ Ep 6 · 11:39
clinical The laparoscopic approach is used in 99% of cholecystectomy cases, even in very difficult acute cholecystitis. ↗
▶ Ep 6 · 11:44
quote I think we've all gotten pretty good at doing laparoscopic cholecystectomies even in, in, in, you know, very difficult cases. ↗
▶ Ep 6 · 12:15
clinical 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. ↗
▶ Ep 6 · 13:10
clinical Placing the lateral right-sided trocar under direct laparoscopic vision while visualizing the gallbladder allows optimal positioning for retraction based on individual patient anatomy. ↗
▶ Ep 6 · 15:41
clinical In acute cholecystitis, edematous tissue bleeds easily, and controlling bleeding from omentum early with cautery prevents impaired visualization later in the case. ↗
▶ Ep 6 · 15:54
quote I find it that when you don't control the bleeding early on, it tends to impede with your visualization later on ↗
▶ Ep 6 · 16:29
quote I have a very low threshold to decompress those gallbladders before you start trying to grab them. ↗
▶ Ep 6 · 16:29
clinical There is a low threshold to decompress tense, inflamed gallbladders before attempting to grasp them, to prevent tearing the gallbladder wall. ↗
▶ Ep 6 · 16:36
clinical Gallbladder decompression is performed at the fundus using a long reusable needle connected via luer-lock to a 60cc syringe, aspirating under direct vision. ↗
▶ Ep 6 · 18:04
clinical 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. ↗
▶ Ep 6 · 18:29
clinical The suction device is an effective dissection tool in laparoscopic cholecystectomy. ↗
▶ Ep 6 · 19:08
quote that's where, that's how you get in trouble in, in some of these cases. ↗
▶ Ep 6 · 19:31
quote I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well. ↗
▶ Ep 6 · 19:45
clinical 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. ↗
▶ Ep 6 · 20:39
clinical Routine intraoperative cholangiography is performed in nearly all cholecystectomy cases. ↗
▶ Ep 6 · 20:39
quote I almost use routine cholangiography. ↗
▶ Ep 6 · 21:08
clinical 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. ↗
▶ Ep 6 · 22:23
clinical Flushing the cystic duct with 20cc of saline before cholangiography clears sludge and stones and removes air bubbles from the system. ↗
▶ Ep 6 · 22:59
clinical 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. ↗
▶ Ep 6 · 23:41
clinical 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. ↗
▶ Ep 6 · 24:07
clinical 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. ↗
▶ Ep 6 · 24:41
clinical 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. ↗
▶ Ep 6 · 25:16
clinical For small CBD stones, balloon dilation (antegrade sphincteroplasty) to push stones through is often easier than basket extraction. ↗
▶ Ep 6 · 25:20
quote I think if it's a small stone, most of the time it's easier to do that than to try to ↗
▶ Ep 6 · 26:14
clinical 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. ↗
▶ Ep 6 · 26:20
quote I am very aggressive about in cases like that, going in a top-down fashion. ↗
▶ Ep 6 · 26:41
clinical 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. ↗
▶ Ep 6 · 27:28
clinical 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. ↗
▶ Ep 6 · 27:28
quote the reality of things is a lot of times in some of these more severe cases going open and trying to be heroic and going for that cystic duct is not that safe either. ↗
▶ Ep 6 · 27:52
clinical 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. ↗
▶ Ep 6 · 29:10
clinical 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. ↗
▶ Ep 6 · 29:24
quote the reality is a lot of those cases and, and they can be labeled as duct of Lushka leaks are not really duct of Luska leaks. I think it's just that the surgeon gets a little bit too deep into the liver and injures ↗
▶ Ep 6 · 29:58
clinical A drain should be left after subtotal cholecystectomy to control potential bile leak. ↗
▶ Ep 6 · 30:24
quote I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster ↗
▶ Ep 6 · 30:24
clinical 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. ↗
▶ Ep 6 · 30:38
clinical In subtotal cholecystectomy where posterior wall is left, the residual mucosa should be cauterized with coagulation on high setting. ↗

Acute Cholecystitis

▶ Ep 7 · 2:46
opinion In straightforward acute cholecystitis with symptoms less than two days in a reasonable surgical candidate, early laparoscopic cholecystectomy during the same admission is favored because attempts to cool down have high recurrence rates and patients often return on weekends making management more difficult. ↗
▶ Ep 7 · 2:55
quote I think the ones that we try to cool down and and try to get them out of the hospital have a high recurrence rate and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. ↗
▶ Ep 7 · 3:58
clinical Preoperative preparation for acute cholecystitis includes admission, antibiotics, NPO status, routine labs, coagulation studies, type and screen, and pregnancy test to avoid delays in operative intervention. ↗
▶ Ep 7 · 5:30
quote The last thing you want to do is, you know, take a patient with a very significant, uh, cardiac history to the operating room and end up giving her an acute cardiac event. ↗
▶ Ep 7 · 5:30
clinical For patients with significant cardiac history, the last thing you want is to take them to the operating room and cause an acute cardiac event, so cardiology consultation and realistic risk assessment are essential. ↗
▶ Ep 7 · 5:59
clinical In high-risk patients, antibiotics alone often cool down acute cholecystitis without additional intervention, but percutaneous cholecystostomy tubes can be very helpful for sicker patients who are not good operative candidates. ↗
▶ Ep 7 · 6:37
clinical For patients who are poor operative candidates, admit to hospital, start broad spectrum antibiotics, and if no improvement after one to two days, recommend percutaneous cholecystostomy. ↗
▶ Ep 7 · 6:58
quote I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients. ↗
▶ Ep 7 · 6:58
clinical Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in sicker patients, with most having uneventful recovery and hospital discharge. ↗
▶ Ep 7 · 7:30
clinical Before removing a cholecystostomy tube, wait 4-6 weeks and perform cholangiogram through the tube to ensure the cystic duct is patent; if the duct is not patent, removing the tube will cause recurrent episode. ↗
▶ Ep 7 · 7:36
quote I think it's very important that before taking these tubes, you have a good discussion about the patient of what is, you know, the potential of her developing a recurrent episode. ↗
▶ Ep 7 · 8:18
clinical Cholecystostomy tubes are useful for timing intervention in patients on antiplatelet therapy for stents who need to wait (e.g., one year) before they can safely come off Plavix or aspirin for definitive surgery. ↗
▶ Ep 7 · 9:33
opinion Cholecystectomy in patients with prior cholecystostomy tubes are more challenging cases that need to be planned well and should not be added on at the end of a long surgical day when the surgeon is tired. ↗
▶ Ep 7 · 12:17
clinical Palmer's point is located two finger breadths below the rib cage on the left side in the midclavicular line and is one of the safest locations for initial trocar entry. ↗
▶ Ep 7 · 13:16
clinical Placing the most lateral trocar while visualizing the gallbladder allows the assistant to grab and elevate it, providing better location for the left hand port. ↗
▶ Ep 7 · 15:32
clinical When lysing omental adhesions in acute cholecystitis, use cautery (especially when colon and duodenum are visible) because edematous tissue bleeds easily, and uncontrolled bleeding impedes visualization later in the case. ↗
▶ Ep 7 · 16:29
quote I have a very low threshold to decompress those gallbladders before you start trying to grab them. ↗
▶ Ep 7 · 16:29
clinical There is a very low threshold to decompress tense gallbladders before trying to grab them, using a long reusable needle connected via luer lock to a 60cc syringe, inserted under direct vision into the fundus to aspirate. ↗
▶ Ep 7 · 17:27
clinical Start dissection high up on the gallbladder where you are certain you are on the gallbladder, then gently and patiently tease tissues down toward the duodenum using hook electrocautery. ↗
▶ Ep 7 · 18:35
clinical As Calot's node is taken down, the cystic artery becomes visible; dissect it up toward the body of the gallbladder to get length, because as long as you are on the gallbladder you are safe. ↗
▶ Ep 7 · 18:45
quote As long as you're on the gallbladder, you know you're safe. ↗
▶ Ep 7 · 19:07
quote That's where, that's how you get in trouble in, in some of these cases. ↗
▶ Ep 7 · 19:17
clinical The critical view of safety requires visualization of the cystic duct-gallbladder junction, the cystic artery within Calot's triangle, and liver in the dissection window. ↗
▶ Ep 7 · 19:28
quote I've always, especially when I teach residents, I, I, I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well. ↗
▶ Ep 7 · 20:39
clinical Dr. Rodriguez uses routine cholangiography in almost all cases. ↗
▶ Ep 7 · 21:08
clinical For cholangiography, place a clip very close to the gallbladder, make a dicotomy, then milk the cystic duct proximally with scissors or Maryland to express any stones before cannulation. ↗
▶ Ep 7 · 21:57
clinical The Olsen clamp has a layout where the tip comes together but the middle does not, providing just enough occlusion of the cystic duct around the catheter without occluding the catheter itself. ↗
▶ Ep 7 · 22:18
clinical Flush the cystic duct with 20cc of saline before cholangiography because when there is sludge and stones, clearing that beforehand is very helpful and also removes air bubbles from the system. ↗
▶ Ep 7 · 22:23
quote I like to flush the duct with a good 20 ccs of saline, uh, cause a lot of times when there's sludge and there's stones, uh, I think clearing that before you should do your cholangiogram, uh, can be very helpful. ↗
▶ Ep 7 · 22:56
clinical To get contrast to flow into the intrahepatic ducts when it only goes down initially, place the patient in Trendelenburg position or use the camera to put pressure on the distal common bile duct. ↗
▶ Ep 7 · 23:41
clinical For a small stone in the distal duct, first try flushing again with good pressure, give glucagon to relax the ampulla, and repeat cholangiogram; if that does not work, use a commercial transcystic common bile duct exploration kit. ↗
▶ Ep 7 · 24:07
clinical The transcystic CBD exploration kit includes a percutaneous introduction catheter with step dilator; introduce it through a separate stab incision (not through existing trocar) from the right side at a parallel angle to the cystic duct to avoid trauma and backwalling the duct. ↗
▶ Ep 7 · 24:52
clinical The key for transcystic CBD exploration is to place a wire under fluoroscopic guidance distally into the duodenum; once the wire is down, the kit's basket (Dormia-type) can crush and retrieve stones, or the balloon dilator can push small stones through via antegrade sphincteroplasty. ↗
▶ Ep 7 · 26:14
clinical When the infundibulum, cystic duct, Calot's triangle and node cannot be defined and dissection is very difficult, be aggressive about going top-down (fundus-down) fashion laparoscopically. ↗
▶ Ep 7 · 27:41
quote The reality of things is that a lot of times in some of these more severe cases, going open and trying to be heroic and going for that cystic duct is not that safe either. ↗
▶ Ep 7 · 27:52
clinical In severe cases, the decision is between doing a partial cholecystectomy or leaving part of the back wall on the liver; sometimes opening the gallbladder, removing all stones, and placing a large cholecystostomy tube can bail you out. ↗
▶ Ep 7 · 28:21
clinical When going open for a difficult case, top-down (dome-down) dissection is still the preferred approach. ↗
▶ Ep 7 · 28:47
clinical Some patients have a very superficial right ductal system, and digging too deep into the liver during gallbladder dissection can injure it; many bile leaks labeled as duct of Luschka leaks are actually from the surgeon getting too deep into the liver and injuring the ductal system. ↗
▶ Ep 7 · 29:24
quote I think it's just that the surgeon gets a little bit too deep into the liver and injures the ductal system. ↗
▶ Ep 7 · 29:31
clinical In subtotal cholecystectomy, open the gallbladder, remove stones, get down to a safe point, close it up (the cystic duct can eventually open again), and leave a drain to control bile leak if it occurs. ↗
▶ Ep 7 · 30:06
clinical Back-wall preservation is indicated in horrible cases where the gallbladder is necrotic and falling apart and the cystic duct area looks equally bad; it is the safest approach to avoid major bile duct injury. ↗
▶ Ep 7 · 30:21
opinion The big goal in difficult cholecystectomy cases is avoiding a major bile duct injury that will end up being a disaster. ↗
▶ Ep 7 · 30:21
quote I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster. ↗
▶ Ep 7 · 30:36
clinical When leaving the back wall, cauterize the mucosa with coagulation on a high setting and leave a drain. ↗
John's statements about Choledocholithiasis 121 statements

Open the Choledocholithiasis collection →

Acute Cholecystitis

▶ Ep 1 · 2:30
clinical 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. ↗
▶ Ep 1 · 2:30
clinical 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. ↗
▶ Ep 1 · 2:30
quote I think the ones that we try to cool down and try to get them out of the hospital have a high recurrence rate, and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. ↗
▶ Ep 1 · 5:18
quote The last thing you want to do is, you know, take a patient with a very significant cardiac history to the operating room and end up giving her an acute cardiac event. ↗
▶ Ep 1 · 5:18
clinical 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. ↗
▶ Ep 1 · 5:18
clinical Percutaneous cholecystostomy tubes can be placed by interventional radiology in patients who are not good operative candidates. ↗
▶ Ep 1 · 5:18
clinical Many high-risk patients with acute cholecystitis will cool down with antibiotics alone and require no additional intervention. ↗
▶ Ep 1 · 6:37
clinical 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. ↗
▶ Ep 1 · 6:48
clinical Percutaneous cholecystostomy tubes are placed through the liver into the gallbladder. ↗
▶ Ep 1 · 6:58
clinical 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. ↗
▶ Ep 1 · 7:14
clinical 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. ↗
▶ Ep 1 · 7:28
clinical If the cystic duct is not patent when the cholecystostomy tube is removed, the patient will develop a recurrent episode of acute cholecystitis. ↗
▶ Ep 1 · 8:10
clinical Patients with cholecystostomy tubes will have remaining stones in the gallbladder that cannot be managed with percutaneous intervention. ↗
▶ Ep 1 · 8:10
clinical 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. ↗
▶ Ep 1 · 9:33
clinical 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. ↗
▶ Ep 1 · 9:33
clinical 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. ↗
▶ Ep 1 · 10:29
clinical 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. ↗
▶ Ep 1 · 10:29
clinical Some high-risk cardiac patients may require cardiac catheterization with stent placement before cholecystectomy to improve cardiac function. ↗
▶ Ep 1 · 11:17
clinical Laparoscopic approach is used 99% of the time for cholecystectomy, even in very difficult acute cholecystitis cases. ↗
▶ Ep 1 · 12:02
clinical 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. ↗
▶ Ep 1 · 12:17
clinical 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. ↗
▶ Ep 1 · 12:29
clinical 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. ↗
▶ Ep 1 · 12:29
quote I've never had to place another trochar because that one doesn't help me. ↗
▶ Ep 1 · 12:51
clinical Rodriguez uses the left upper quadrant Palmer's point 5mm port as his right-hand operating port during laparoscopic cholecystectomy. ↗
▶ Ep 1 · 13:00
clinical The second trocar is a 12mm periumbilical port placed under direct vision for the camera, with patient positioned in reverse Trendelenburg for exposure. ↗
▶ Ep 1 · 13:09
clinical 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. ↗
▶ Ep 1 · 14:27
clinical Placing trocars under direct laparoscopic vision (after the first port) provides better orientation toward the gallbladder based on liver and gallbladder position. ↗
▶ Ep 1 · 15:07
clinical 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. ↗
▶ Ep 1 · 15:30
quote I find it that when you don't control the bleeding early on, it tends to impede with your visualization later on. ↗
▶ Ep 1 · 15:30
clinical 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. ↗
▶ Ep 1 · 15:57
clinical Hook electrocautery is a very fine dissecting tool that is hemostatic for lysing omental adhesions in acute cholecystitis. ↗
▶ Ep 1 · 16:29
clinical Rodriguez has a low threshold to decompress tense, hard, thick gallbladders before attempting to grasp them. ↗
▶ Ep 1 · 16:36
clinical 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. ↗
▶ Ep 1 · 17:26
clinical 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. ↗
▶ Ep 1 · 17:53
clinical 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. ↗
▶ Ep 1 · 17:53
quote As long as you're on the gallbladder, you know you're safe. ↗
▶ Ep 1 · 18:27
clinical The suction device is a great dissecting tool during laparoscopic cholecystectomy. ↗
▶ Ep 1 · 18:52
quote That's where, that's how you get in trouble in, in some of these cases. ↗
▶ Ep 1 · 18:52
clinical 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. ↗
▶ Ep 1 · 19:17
clinical 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. ↗
▶ Ep 1 · 19:17
clinical 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. ↗
▶ Ep 1 · 19:17
clinical Maryland forceps are a great tool for gentle dissection at the cystic duct-gallbladder junction. ↗
▶ Ep 1 · 20:19
clinical 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. ↗
▶ Ep 1 · 20:39
clinical Rodriguez uses routine intraoperative cholangiography, performing it almost always including in acute cholecystitis cases. ↗
▶ Ep 1 · 20:43
clinical For cholangiography, Rodriguez uses the Ponsky catheter (small ERCP-type catheter with wire that makes cystic duct cannulation easy) placed through an Olsen clamp. ↗
▶ Ep 1 · 21:03
clinical 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. ↗
▶ Ep 1 · 21:26
clinical 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. ↗
▶ Ep 1 · 21:57
clinical 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. ↗
▶ Ep 1 · 22:14
clinical 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. ↗
▶ Ep 1 · 22:56
clinical 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. ↗
▶ Ep 1 · 23:36
clinical For small retained common bile duct stones on cholangiogram, first attempt flushing the duct again with saline. ↗
▶ Ep 1 · 23:49
clinical Administer glucagon to relax the ampulla of Vater, which can help pass distal common bile duct stones, then repeat cholangiogram. ↗
▶ Ep 1 · 23:52
clinical 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. ↗
▶ Ep 1 · 24:20
clinical 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. ↗
▶ Ep 1 · 24:35
clinical 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. ↗
▶ Ep 1 · 24:39
clinical Transcystic CBD exploration kits include a Dormia-type basket that can be placed through the cystic duct to crush and retrieve stones. ↗
▶ Ep 1 · 24:39
clinical 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. ↗
▶ Ep 1 · 26:07
clinical 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. ↗
▶ Ep 1 · 26:36
clinical 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. ↗
▶ Ep 1 · 27:06
opinion There is nothing magical about a specific number of trocars; surgeons should place them where needed and not be afraid to add additional trocars. ↗
▶ Ep 1 · 27:06
quote There's nothing magical about, uh, one number or another. You just put them where you need them. ↗
▶ Ep 1 · 27:28
clinical 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. ↗
▶ Ep 1 · 27:28
quote The reality of things is that a lot of times in some of these more severe cases, going open and trying to be heroic and going for that cystic duct is not that safe either. ↗
▶ Ep 1 · 27:28
clinical 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. ↗
▶ Ep 1 · 28:21
clinical When performing open cholecystectomy in severely inflamed cases, Rodriguez would proceed with fundus-first (dome-down) dissection to carefully find the anatomy. ↗
▶ Ep 1 · 28:46
clinical 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. ↗
▶ Ep 1 · 29:08
clinical 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. ↗
▶ Ep 1 · 29:31
clinical 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. ↗
▶ Ep 1 · 30:03
clinical In difficult cholecystectomy cases requiring subtotal cholecystectomy or bailout procedures, always leave a surgical drain to control potential bile leak. ↗
▶ Ep 1 · 30:06
quote I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster for. ↗
▶ Ep 1 · 30:06
clinical 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. ↗
▶ Ep 1 · 30:38
clinical When leaving the posterior gallbladder wall adherent to liver in subtotal cholecystectomy, cauterize the residual mucosa with coagulation on high setting. ↗

Acute Cholecystitis

▶ Ep 7 · 2:55
quote I think the ones that we try to cool down and and try to get them out of the hospital have a high recurrence rate and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. ↗
▶ Ep 7 · 2:55
clinical 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. ↗
▶ Ep 7 · 3:58
clinical Preoperative antibiotics should be started in acute cholecystitis cases presenting to the emergency room. ↗
▶ Ep 7 · 5:18
clinical In high-risk patients with significant cardiac history, medical subspecialty consultation is needed to determine realistic operative risk factors before proceeding with cholecystectomy. ↗
▶ Ep 7 · 5:40
quote The last thing you want to do is, you know, take a patient with a very significant, uh, cardiac history to the operating room and end up giving her an acute, uh, cardiac event. ↗
▶ Ep 7 · 6:58
clinical Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in high-risk surgical patients, with most patients having uneventful recovery. ↗
▶ Ep 7 · 7:00
quote I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients. ↗
▶ Ep 7 · 7:30
clinical 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. ↗
▶ Ep 7 · 7:51
quote if you don't do that, as soon as you take that tube out, they'll get a recurrent episode. ↗
▶ Ep 7 · 8:18
clinical 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. ↗
▶ Ep 7 · 9:33
quote I think it's not the gallbladder you want to just add on at the end of the day with, you know, when you're tired from, from an all day, uh, surgical volume. ↗
▶ Ep 7 · 9:33
clinical 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. ↗
▶ Ep 7 · 10:11
quote in my experience, those gallbladders tend to be pretty challenging, and they, they take up quite some time to do. ↗
▶ Ep 7 · 11:39
clinical The laparoscopic approach is used in 99% of cholecystectomy cases, even in very difficult acute cholecystitis. ↗
▶ Ep 7 · 11:44
quote I think we've all gotten pretty good at doing laparoscopic cholecystectomies even in, in, in, you know, very difficult cases. ↗
▶ Ep 7 · 12:15
clinical 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. ↗
▶ Ep 7 · 13:10
clinical Placing the lateral right-sided trocar under direct laparoscopic vision while visualizing the gallbladder allows optimal positioning for retraction based on individual patient anatomy. ↗
▶ Ep 7 · 15:41
clinical In acute cholecystitis, edematous tissue bleeds easily, and controlling bleeding from omentum early with cautery prevents impaired visualization later in the case. ↗
▶ Ep 7 · 15:54
quote I find it that when you don't control the bleeding early on, it tends to impede with your visualization later on ↗
▶ Ep 7 · 16:29
clinical There is a low threshold to decompress tense, inflamed gallbladders before attempting to grasp them, to prevent tearing the gallbladder wall. ↗
▶ Ep 7 · 16:29
quote I have a very low threshold to decompress those gallbladders before you start trying to grab them. ↗
▶ Ep 7 · 16:36
clinical Gallbladder decompression is performed at the fundus using a long reusable needle connected via luer-lock to a 60cc syringe, aspirating under direct vision. ↗
▶ Ep 7 · 18:04
clinical 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. ↗
▶ Ep 7 · 18:29
clinical The suction device is an effective dissection tool in laparoscopic cholecystectomy. ↗
▶ Ep 7 · 19:08
quote that's where, that's how you get in trouble in, in some of these cases. ↗
▶ Ep 7 · 19:31
quote I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well. ↗
▶ Ep 7 · 19:45
clinical 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. ↗
▶ Ep 7 · 20:39
quote I almost use routine cholangiography. ↗
▶ Ep 7 · 20:39
clinical Routine intraoperative cholangiography is performed in nearly all cholecystectomy cases. ↗
▶ Ep 7 · 21:08
clinical 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. ↗
▶ Ep 7 · 22:23
clinical Flushing the cystic duct with 20cc of saline before cholangiography clears sludge and stones and removes air bubbles from the system. ↗
▶ Ep 7 · 22:59
clinical 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. ↗
▶ Ep 7 · 23:41
clinical 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. ↗
▶ Ep 7 · 24:07
clinical 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. ↗
▶ Ep 7 · 24:41
clinical 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. ↗
▶ Ep 7 · 25:16
clinical For small CBD stones, balloon dilation (antegrade sphincteroplasty) to push stones through is often easier than basket extraction. ↗
▶ Ep 7 · 25:20
quote I think if it's a small stone, most of the time it's easier to do that than to try to ↗
▶ Ep 7 · 26:14
clinical 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. ↗
▶ Ep 7 · 26:20
quote I am very aggressive about in cases like that, going in a top-down fashion. ↗
▶ Ep 7 · 26:41
clinical 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. ↗
▶ Ep 7 · 27:28
clinical 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. ↗
▶ Ep 7 · 27:28
quote the reality of things is a lot of times in some of these more severe cases going open and trying to be heroic and going for that cystic duct is not that safe either. ↗
▶ Ep 7 · 27:52
clinical 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. ↗
▶ Ep 7 · 29:10
clinical 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. ↗
▶ Ep 7 · 29:24
quote the reality is a lot of those cases and, and they can be labeled as duct of Lushka leaks are not really duct of Luska leaks. I think it's just that the surgeon gets a little bit too deep into the liver and injures ↗
▶ Ep 7 · 29:58
clinical A drain should be left after subtotal cholecystectomy to control potential bile leak. ↗
▶ Ep 7 · 30:24
clinical 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. ↗
▶ Ep 7 · 30:24
quote I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster ↗
▶ Ep 7 · 30:38
clinical In subtotal cholecystectomy where posterior wall is left, the residual mucosa should be cauterized with coagulation on high setting. ↗
John's statements about Cholelithiasis 44 statements

Open the Cholelithiasis collection →

Acute Cholecystitis

▶ Ep 7 · 2:46
opinion In straightforward acute cholecystitis with symptoms less than two days in a reasonable surgical candidate, early laparoscopic cholecystectomy during the same admission is favored because attempts to cool down have high recurrence rates and patients often return on weekends making management more difficult. ↗
▶ Ep 7 · 2:55
quote I think the ones that we try to cool down and and try to get them out of the hospital have a high recurrence rate and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. ↗
▶ Ep 7 · 3:58
clinical Preoperative preparation for acute cholecystitis includes admission, antibiotics, NPO status, routine labs, coagulation studies, type and screen, and pregnancy test to avoid delays in operative intervention. ↗
▶ Ep 7 · 5:30
clinical For patients with significant cardiac history, the last thing you want is to take them to the operating room and cause an acute cardiac event, so cardiology consultation and realistic risk assessment are essential. ↗
▶ Ep 7 · 5:30
quote The last thing you want to do is, you know, take a patient with a very significant, uh, cardiac history to the operating room and end up giving her an acute cardiac event. ↗
▶ Ep 7 · 5:59
clinical In high-risk patients, antibiotics alone often cool down acute cholecystitis without additional intervention, but percutaneous cholecystostomy tubes can be very helpful for sicker patients who are not good operative candidates. ↗
▶ Ep 7 · 6:37
clinical For patients who are poor operative candidates, admit to hospital, start broad spectrum antibiotics, and if no improvement after one to two days, recommend percutaneous cholecystostomy. ↗
▶ Ep 7 · 6:58
clinical Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in sicker patients, with most having uneventful recovery and hospital discharge. ↗
▶ Ep 7 · 6:58
quote I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients. ↗
▶ Ep 7 · 7:30
clinical Before removing a cholecystostomy tube, wait 4-6 weeks and perform cholangiogram through the tube to ensure the cystic duct is patent; if the duct is not patent, removing the tube will cause recurrent episode. ↗
▶ Ep 7 · 7:36
quote I think it's very important that before taking these tubes, you have a good discussion about the patient of what is, you know, the potential of her developing a recurrent episode. ↗
▶ Ep 7 · 8:18
clinical Cholecystostomy tubes are useful for timing intervention in patients on antiplatelet therapy for stents who need to wait (e.g., one year) before they can safely come off Plavix or aspirin for definitive surgery. ↗
▶ Ep 7 · 9:33
opinion Cholecystectomy in patients with prior cholecystostomy tubes are more challenging cases that need to be planned well and should not be added on at the end of a long surgical day when the surgeon is tired. ↗
▶ Ep 7 · 12:17
clinical Palmer's point is located two finger breadths below the rib cage on the left side in the midclavicular line and is one of the safest locations for initial trocar entry. ↗
▶ Ep 7 · 13:16
clinical Placing the most lateral trocar while visualizing the gallbladder allows the assistant to grab and elevate it, providing better location for the left hand port. ↗
▶ Ep 7 · 15:32
clinical When lysing omental adhesions in acute cholecystitis, use cautery (especially when colon and duodenum are visible) because edematous tissue bleeds easily, and uncontrolled bleeding impedes visualization later in the case. ↗
▶ Ep 7 · 16:29
clinical There is a very low threshold to decompress tense gallbladders before trying to grab them, using a long reusable needle connected via luer lock to a 60cc syringe, inserted under direct vision into the fundus to aspirate. ↗
▶ Ep 7 · 16:29
quote I have a very low threshold to decompress those gallbladders before you start trying to grab them. ↗
▶ Ep 7 · 17:27
clinical Start dissection high up on the gallbladder where you are certain you are on the gallbladder, then gently and patiently tease tissues down toward the duodenum using hook electrocautery. ↗
▶ Ep 7 · 18:35
clinical As Calot's node is taken down, the cystic artery becomes visible; dissect it up toward the body of the gallbladder to get length, because as long as you are on the gallbladder you are safe. ↗
▶ Ep 7 · 18:45
quote As long as you're on the gallbladder, you know you're safe. ↗
▶ Ep 7 · 19:07
quote That's where, that's how you get in trouble in, in some of these cases. ↗
▶ Ep 7 · 19:17
clinical The critical view of safety requires visualization of the cystic duct-gallbladder junction, the cystic artery within Calot's triangle, and liver in the dissection window. ↗
▶ Ep 7 · 19:28
quote I've always, especially when I teach residents, I, I, I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well. ↗
▶ Ep 7 · 20:39
clinical Dr. Rodriguez uses routine cholangiography in almost all cases. ↗
▶ Ep 7 · 21:08
clinical For cholangiography, place a clip very close to the gallbladder, make a dicotomy, then milk the cystic duct proximally with scissors or Maryland to express any stones before cannulation. ↗
▶ Ep 7 · 21:57
clinical The Olsen clamp has a layout where the tip comes together but the middle does not, providing just enough occlusion of the cystic duct around the catheter without occluding the catheter itself. ↗
▶ Ep 7 · 22:18
clinical Flush the cystic duct with 20cc of saline before cholangiography because when there is sludge and stones, clearing that beforehand is very helpful and also removes air bubbles from the system. ↗
▶ Ep 7 · 22:23
quote I like to flush the duct with a good 20 ccs of saline, uh, cause a lot of times when there's sludge and there's stones, uh, I think clearing that before you should do your cholangiogram, uh, can be very helpful. ↗
▶ Ep 7 · 22:56
clinical To get contrast to flow into the intrahepatic ducts when it only goes down initially, place the patient in Trendelenburg position or use the camera to put pressure on the distal common bile duct. ↗
▶ Ep 7 · 23:41
clinical For a small stone in the distal duct, first try flushing again with good pressure, give glucagon to relax the ampulla, and repeat cholangiogram; if that does not work, use a commercial transcystic common bile duct exploration kit. ↗
▶ Ep 7 · 24:07
clinical The transcystic CBD exploration kit includes a percutaneous introduction catheter with step dilator; introduce it through a separate stab incision (not through existing trocar) from the right side at a parallel angle to the cystic duct to avoid trauma and backwalling the duct. ↗
▶ Ep 7 · 24:52
clinical The key for transcystic CBD exploration is to place a wire under fluoroscopic guidance distally into the duodenum; once the wire is down, the kit's basket (Dormia-type) can crush and retrieve stones, or the balloon dilator can push small stones through via antegrade sphincteroplasty. ↗
▶ Ep 7 · 26:14
clinical When the infundibulum, cystic duct, Calot's triangle and node cannot be defined and dissection is very difficult, be aggressive about going top-down (fundus-down) fashion laparoscopically. ↗
▶ Ep 7 · 27:41
quote The reality of things is that a lot of times in some of these more severe cases, going open and trying to be heroic and going for that cystic duct is not that safe either. ↗
▶ Ep 7 · 27:52
clinical In severe cases, the decision is between doing a partial cholecystectomy or leaving part of the back wall on the liver; sometimes opening the gallbladder, removing all stones, and placing a large cholecystostomy tube can bail you out. ↗
▶ Ep 7 · 28:21
clinical When going open for a difficult case, top-down (dome-down) dissection is still the preferred approach. ↗
▶ Ep 7 · 28:47
clinical Some patients have a very superficial right ductal system, and digging too deep into the liver during gallbladder dissection can injure it; many bile leaks labeled as duct of Luschka leaks are actually from the surgeon getting too deep into the liver and injuring the ductal system. ↗
▶ Ep 7 · 29:24
quote I think it's just that the surgeon gets a little bit too deep into the liver and injures the ductal system. ↗
▶ Ep 7 · 29:31
clinical In subtotal cholecystectomy, open the gallbladder, remove stones, get down to a safe point, close it up (the cystic duct can eventually open again), and leave a drain to control bile leak if it occurs. ↗
▶ Ep 7 · 30:06
clinical Back-wall preservation is indicated in horrible cases where the gallbladder is necrotic and falling apart and the cystic duct area looks equally bad; it is the safest approach to avoid major bile duct injury. ↗
▶ Ep 7 · 30:21
quote I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster. ↗
▶ Ep 7 · 30:21
opinion The big goal in difficult cholecystectomy cases is avoiding a major bile duct injury that will end up being a disaster. ↗
▶ Ep 7 · 30:36
clinical When leaving the back wall, cauterize the mucosa with coagulation on a high setting and leave a drain. ↗