what I tell the residents is called a controlled avulsion. So left hand, a lot of traction on the pulling the gallbladder away from the liver, right hand just barely touching that that junction of gallbladder with liver with low water's cautery and essentially carve it out of there
I'll put a, a suction, irrigation suction thing in my left hand. Um, I'll I'll, I'll do this before I can completely take the gallbladder off the bed so that the assistant can be holding up the right lobe of the liver with that remaining bit of gallbladder
instead of getting a whole bunch of Kittner dissectors, I'll just get my suction aspiration catheter and use that in my, in my right hand, my dissecting hand, to really push again right along the gallbladder wall as much as you can to get things separated
I would make sure I've dissected out the critical view of safety. So all of that fatty material, all of that peritoneal. Stuff, all of the scar tissue holding that neck, the infundibule of the gallbladder into the liver has been divided
quoteit sounds like she's going to probably have a very chronically inflamed gallbladder with a bunch of omentum stuck to it↗
▶Ep 1 · 2:08
quoteI'm going to put my initial one down at the umbilicus where it should be well away from anything that that's Going on in the right upper quadrant↗
▶Ep 1 · 2:22
clinicalIn patients with BMI under 32-35, Hasson technique is used for initial umbilical port placement↗
▶Ep 1 · 2:27
clinicalIn patients with BMI over 32-35, Veress needle technique is used for initial port placement to avoid large incision required for Hasson↗
▶Ep 1 · 2:43
quoteI've seen a couple of terrible complications when people have used that, and so I, I'm old school↗
▶Ep 1 · 3:00
clinicalStandard port configuration includes epigastric port (placed last for optimal angle), midclavicular line port, and anterior axillary line port in right upper quadrant↗
▶Ep 1 · 3:17
quoteI always put in the epigastric one last because that's the most important one in terms of your angle getting at the gallbladder↗
▶Ep 1 · 3:39
quotesome of the hardest cases are the ones where you can't even find the gallbladder for half an hour or something↗
▶Ep 1 · 3:54
clinicalOmental adhesions to chronically inflamed gallbladder can be taken down using low-wattage cautery or harmonic shears at the junction of omentum with underlying tissue↗
▶Ep 1 · 5:03
quotewhat I tell the, what I tell the residents is we're going to do a modified top down but only start about a third of the way up from the bottom↗
▶Ep 1 · 5:03
clinicalModified top-down dissection should start approximately one-third of the way up from the infundibulum, not at the fundus↗
▶Ep 1 · 5:13
clinicalBilateral dissection technique ("waving the flag") alternating between medial and lateral sides provides better three-dimensional view and more freedom for dissection↗
▶Ep 1 · 5:13
quoteI try and get right on the wall of the gallbladder and go back and forth from medial to lateral, what the French used to call waving the flag↗
▶Ep 1 · 5:32
opinionAngled laparoscope is superior to 0-degree laparoscope for laparoscopic cholecystectomy↗
▶Ep 1 · 5:32
quoteI can't understand how some people still use 0 degree laparoscopes↗
▶Ep 1 · 5:43
clinicalCritical view of safety must be achieved before any irreversible steps such as clipping or cutting structures↗
▶Ep 1 · 5:43
quotewhat we're going to try to achieve before doing, you know, anything irreversible with clips or cutting or anything else is to, is to see the critical view of safety↗
▶Ep 1 · 6:11
quoteI see a lot of the trainees who just stay on the, on the left side of the gallbladder, the ventral side of the gallbladder for 99% of the dissection. I think that really hurts you↗
▶Ep 1 · 6:11
clinicalDissecting only on the ventral (left) side of the gallbladder limits freedom of movement and makes dissection more difficult↗
▶Ep 1 · 6:22
quoteif you get it from the lateral side as well, you get lots more freedom on that gallbladder to be able to dissect underneath it and be able to move it around↗
▶Ep 1 · 6:52
clinicalIntraoperative ultrasound can be performed multiple times during difficult cholecystectomy to identify gallbladder location and bile duct position relative to dissection↗
▶Ep 1 · 6:59
quotein a tough case like this, I'll often actually do it multiple times. Once at the beginning of the operation to get an idea where the gallbladder is in this particular patient↗
▶Ep 1 · 7:09
quotean ultrasound can show you where the gallbladder ends, where the bile duct is in relation to where you're dissecting↗
▶Ep 1 · 7:23
quoteI don't think that there are any real tricks to this, Jeff. I mean, it's a lot of traction, counter traction↗
▶Ep 1 · 7:33
clinicalIrrigation-suction catheter can be used for blunt (Kittner) dissection in the right hand when there is blood and bile obscuring the field↗
▶Ep 1 · 7:33
quoteI actually use a lot of what I call irrigation suction, kittner dissecting. So blunt dissecting↗
▶Ep 1 · 7:48
quoteinstead of getting a whole bunch of Kittner dissectors, I'll just get my suction aspiration catheter and use that in my, in my right hand, my dissecting hand, to really push again right along the gallbladder wall as much as you can to get things separated↗
▶Ep 1 · 8:12
quoteI've had trouble getting patients in early enough to give it early enough, so everything is just bright green usually when I get in there↗
▶Ep 1 · 8:12
clinicalIndocyanine green (ICG) given too early results in everything appearing bright green, limiting its utility↗
▶Ep 1 · 8:19
clinicalIn cases with significant tissue inflammation, ICG may not adequately visualize ductal structures↗
▶Ep 1 · 8:29
quoteI have, I have not been really impressed with ICG, but I know a lot of people who have been and use it on a regular basis↗
▶Ep 1 · 9:14
clinicalCritical view of safety requires complete dissection of fatty material, peritoneal tissue, and scar tissue so the gallbladder infundibulum is separated 1.5 inches from surrounding structures↗
▶Ep 1 · 9:14
quoteI would make sure I've dissected out the critical view of safety. So all of that fatty material, all of that peritoneal. Stuff, all of the scar tissue holding that neck, the infundibule of the gallbladder into the liver has been divided↗
▶Ep 1 · 9:31
quotethe gallbladder is, you know, now 1 inch and a half away from anything around it↗
▶Ep 1 · 9:43
quoteIf it's cystic duct with a hole in it, there's no big deal. I mean, I might put a catheter down, do a changiogram just to prove, you know what I was trying to get you to do↗
▶Ep 1 · 9:59
clinicalIf critical view of safety cannot be achieved, intraoperative cholangiography is mandatory to clarify ductal anatomy↗
▶Ep 1 · 9:59
quoteIf you have not dissected it all out, then you absolutely have to do a changiogram so you can get a better idea of what that ductal structure↗
▶Ep 1 · 10:25
quoteI actually, um, believe in a, in a couple of things in, in, in the Lapoli religion uh wars. Um, one of that is that everybody should know how to do cholangiography↗
▶Ep 1 · 10:33
opinionAll residents should learn intraoperative cholangiography technique regardless of selective use in practice↗
▶Ep 1 · 10:38
quotein a residency program, I think we ought to do them very frequently regardless of indications↗
▶Ep 1 · 10:44
opinionIntraoperative ultrasound should be taught to residents because it allows visualization beyond visible surfaces in the laparoscopic abdomen↗
▶Ep 1 · 10:44
quoteI love teaching residents how to use ultrasound in the, in the laparoscopic abdomen because you can only see the visible surfaces and the ultrasound lets you see beyond those visible surfaces↗
▶Ep 1 · 10:56
clinicalCholangiography adds time and cost, and is not absolutely necessary in the majority of cases↗
▶Ep 1 · 10:56
quoteThe reality is that cholangiograms do add time, um, they do add money. Um, and the majority of the time they're not absolutely necessary↗
▶Ep 1 · 11:11
clinicalIndications for selective intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound↗
▶Ep 1 · 11:18
quotethe other thing that I do routinely is before I clip and and divide the cystic duct, I'll put a clip on the, on the stay side up on the gallbladder and make a little incision in the cystic duct and milk it backwards to see if there are stones in the cystic duct↗
▶Ep 1 · 11:18
clinicalBefore clipping and dividing the cystic duct, place a clip on the gallbladder side, make a small incision, and milk backwards to check for cystic duct stones↗
▶Ep 1 · 11:35
clinicalPresence of cystic duct stones is a prime indicator that common bile duct stones are also likely present↗
▶Ep 1 · 11:35
quoteif there's stones in the cystic duct, in our experience, that's one of the prime. Uh, things that will show you that there probably are common bile duct stones too↗
▶Ep 1 · 12:19
quoteI, I just use low, low watt cautery and again, a lot of, a lot of traction on the gallbladder↗
▶Ep 1 · 12:25
clinicalChronically inflamed gallbladders are usually intrahepatic with no plane between gallbladder and liver↗
▶Ep 1 · 12:25
quotethe other thing that happens with these gallbladders that you've just mentioned in terms of the degree of chronic inflammation, they're usually intrahepatic. There's no plane between the gallbladder and the liver↗
▶Ep 1 · 12:39
quotewhat I tell the residents is called a controlled avulsion. So left hand, a lot of traction on the pulling the gallbladder away from the liver, right hand just barely touching that that junction of gallbladder with liver with low water's cautery and essentially carve it out of there↗
▶Ep 1 · 12:39
clinicalControlled avulsion technique for intrahepatic gallbladders involves maximal traction with left hand and minimal contact with low-wattage cautery in right hand at the gallbladder-liver junction↗
▶Ep 1 · 13:10
clinicalGallbladder bed hemostasis can be achieved in 99% of cases using cautery with irrigation-suction in left hand and cautery in right hand↗
▶Ep 1 · 13:13
quoteI'll put a, a suction, irrigation suction thing in my left hand. Um, I'll I'll, I'll do this before I can completely take the gallbladder off the bed so that the assistant can be holding up the right lobe of the liver with that remaining bit of gallbladder↗
▶Ep 1 · 13:31
quoteLeft hand then with an irrigating suction, suction, you can suck the smoke, you can suck blood or whatever. Right hand with a with a cautery and just touching the. The areas that are bleeding and 99% of the time you can get it stopped↗
▶Ep 1 · 14:06
quoteif it's a Lushka duct, I would probably try to put a stitch in it. Um, you know, a small stitch, but the likelihood is that's not going to hold anyway, so I'd put a drain in↗
▶Ep 1 · 14:06
clinicalFor suspected duct of Luschka injury in the gallbladder bed, attempt suture closure but drain placement is usually necessary as sutures are unlikely to hold↗
▶Ep 1 · 14:18
clinicalActive drain should be placed for deep intrahepatic gallbladder dissection and left in for several hours or overnight to monitor for bile leak↗
▶Ep 1 · 14:18
quoteif I was deep into the bed in one of these intrahepatic gallbladders, I will, I will put an active drain in and leave it in, you know, at least for several hours if we're going to try and send them home, or usually keep the patient overnight and just make sure there's no bile in there↗
clinical95% of laparoscopic cholecystectomy patients are discharged home the same day↗
▶Ep 1 · 14:52
clinicalPostoperative pain management includes intraoperative IV acetaminophen, prescription for only 5 hydrocodone tablets, and recommendation for ibuprofen or acetaminophen for first few days↗
▶Ep 1 · 14:52
quotethe, the anesthesiologist will usually give them some, we, we usually use IV Tylenol, which I think works pretty well↗
▶Ep 1 · 15:00
quotewe'll send them home with that like 5, hydrocodone tablets or something like that, but only 5, and tell them if they need more than that, they need to call↗
▶Ep 1 · 15:00
clinicalPain requiring more than 5 hydrocodone tablets postoperatively suggests a problem and warrants patient contact↗
▶Ep 1 · 15:12
quoteI, I, I just tell them to go ahead and take either ibuprofen or Tylenol in addition to that for the first few days. If they have more pain than that, there's a problem↗
Nathaniel's statements about Cholelithiasis68 statements
quoteit sounds like she's going to probably have a very chronically inflamed gallbladder with a bunch of omentum stuck to it↗
▶Ep 1 · 2:08
quoteI'm going to put my initial one down at the umbilicus where it should be well away from anything that that's Going on in the right upper quadrant↗
▶Ep 1 · 2:22
clinicalIn patients with BMI under 32-35, Hasson technique is used for initial umbilical port placement↗
▶Ep 1 · 2:27
clinicalIn patients with BMI over 32-35, Veress needle technique is used for initial port placement to avoid large incision required for Hasson↗
▶Ep 1 · 2:43
quoteI've seen a couple of terrible complications when people have used that, and so I, I'm old school↗
▶Ep 1 · 3:00
clinicalStandard port configuration includes epigastric port (placed last for optimal angle), midclavicular line port, and anterior axillary line port in right upper quadrant↗
▶Ep 1 · 3:17
quoteI always put in the epigastric one last because that's the most important one in terms of your angle getting at the gallbladder↗
▶Ep 1 · 3:39
quotesome of the hardest cases are the ones where you can't even find the gallbladder for half an hour or something↗
▶Ep 1 · 3:54
clinicalOmental adhesions to chronically inflamed gallbladder can be taken down using low-wattage cautery or harmonic shears at the junction of omentum with underlying tissue↗
▶Ep 1 · 5:03
quotewhat I tell the, what I tell the residents is we're going to do a modified top down but only start about a third of the way up from the bottom↗
▶Ep 1 · 5:03
clinicalModified top-down dissection should start approximately one-third of the way up from the infundibulum, not at the fundus↗
▶Ep 1 · 5:13
quoteI try and get right on the wall of the gallbladder and go back and forth from medial to lateral, what the French used to call waving the flag↗
▶Ep 1 · 5:13
clinicalBilateral dissection technique ("waving the flag") alternating between medial and lateral sides provides better three-dimensional view and more freedom for dissection↗
▶Ep 1 · 5:32
quoteI can't understand how some people still use 0 degree laparoscopes↗
▶Ep 1 · 5:32
opinionAngled laparoscope is superior to 0-degree laparoscope for laparoscopic cholecystectomy↗
▶Ep 1 · 5:43
clinicalCritical view of safety must be achieved before any irreversible steps such as clipping or cutting structures↗
▶Ep 1 · 5:43
quotewhat we're going to try to achieve before doing, you know, anything irreversible with clips or cutting or anything else is to, is to see the critical view of safety↗
▶Ep 1 · 6:11
quoteI see a lot of the trainees who just stay on the, on the left side of the gallbladder, the ventral side of the gallbladder for 99% of the dissection. I think that really hurts you↗
▶Ep 1 · 6:11
clinicalDissecting only on the ventral (left) side of the gallbladder limits freedom of movement and makes dissection more difficult↗
▶Ep 1 · 6:22
quoteif you get it from the lateral side as well, you get lots more freedom on that gallbladder to be able to dissect underneath it and be able to move it around↗
▶Ep 1 · 6:52
clinicalIntraoperative ultrasound can be performed multiple times during difficult cholecystectomy to identify gallbladder location and bile duct position relative to dissection↗
▶Ep 1 · 6:59
quotein a tough case like this, I'll often actually do it multiple times. Once at the beginning of the operation to get an idea where the gallbladder is in this particular patient↗
▶Ep 1 · 7:09
quotean ultrasound can show you where the gallbladder ends, where the bile duct is in relation to where you're dissecting↗
▶Ep 1 · 7:23
quoteI don't think that there are any real tricks to this, Jeff. I mean, it's a lot of traction, counter traction↗
▶Ep 1 · 7:33
clinicalIrrigation-suction catheter can be used for blunt (Kittner) dissection in the right hand when there is blood and bile obscuring the field↗
▶Ep 1 · 7:33
quoteI actually use a lot of what I call irrigation suction, kittner dissecting. So blunt dissecting↗
▶Ep 1 · 7:48
quoteinstead of getting a whole bunch of Kittner dissectors, I'll just get my suction aspiration catheter and use that in my, in my right hand, my dissecting hand, to really push again right along the gallbladder wall as much as you can to get things separated↗
▶Ep 1 · 8:12
clinicalIndocyanine green (ICG) given too early results in everything appearing bright green, limiting its utility↗
▶Ep 1 · 8:12
quoteI've had trouble getting patients in early enough to give it early enough, so everything is just bright green usually when I get in there↗
▶Ep 1 · 8:19
clinicalIn cases with significant tissue inflammation, ICG may not adequately visualize ductal structures↗
▶Ep 1 · 8:29
quoteI have, I have not been really impressed with ICG, but I know a lot of people who have been and use it on a regular basis↗
▶Ep 1 · 9:14
clinicalCritical view of safety requires complete dissection of fatty material, peritoneal tissue, and scar tissue so the gallbladder infundibulum is separated 1.5 inches from surrounding structures↗
▶Ep 1 · 9:14
quoteI would make sure I've dissected out the critical view of safety. So all of that fatty material, all of that peritoneal. Stuff, all of the scar tissue holding that neck, the infundibule of the gallbladder into the liver has been divided↗
▶Ep 1 · 9:31
quotethe gallbladder is, you know, now 1 inch and a half away from anything around it↗
▶Ep 1 · 9:43
quoteIf it's cystic duct with a hole in it, there's no big deal. I mean, I might put a catheter down, do a changiogram just to prove, you know what I was trying to get you to do↗
▶Ep 1 · 9:59
quoteIf you have not dissected it all out, then you absolutely have to do a changiogram so you can get a better idea of what that ductal structure↗
▶Ep 1 · 9:59
clinicalIf critical view of safety cannot be achieved, intraoperative cholangiography is mandatory to clarify ductal anatomy↗
▶Ep 1 · 10:25
quoteI actually, um, believe in a, in a couple of things in, in, in the Lapoli religion uh wars. Um, one of that is that everybody should know how to do cholangiography↗
▶Ep 1 · 10:33
opinionAll residents should learn intraoperative cholangiography technique regardless of selective use in practice↗
▶Ep 1 · 10:38
quotein a residency program, I think we ought to do them very frequently regardless of indications↗
▶Ep 1 · 10:44
quoteI love teaching residents how to use ultrasound in the, in the laparoscopic abdomen because you can only see the visible surfaces and the ultrasound lets you see beyond those visible surfaces↗
▶Ep 1 · 10:44
opinionIntraoperative ultrasound should be taught to residents because it allows visualization beyond visible surfaces in the laparoscopic abdomen↗
▶Ep 1 · 10:56
quoteThe reality is that cholangiograms do add time, um, they do add money. Um, and the majority of the time they're not absolutely necessary↗
▶Ep 1 · 10:56
clinicalCholangiography adds time and cost, and is not absolutely necessary in the majority of cases↗
▶Ep 1 · 11:11
clinicalIndications for selective intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound↗
▶Ep 1 · 11:18
clinicalBefore clipping and dividing the cystic duct, place a clip on the gallbladder side, make a small incision, and milk backwards to check for cystic duct stones↗
▶Ep 1 · 11:18
quotethe other thing that I do routinely is before I clip and and divide the cystic duct, I'll put a clip on the, on the stay side up on the gallbladder and make a little incision in the cystic duct and milk it backwards to see if there are stones in the cystic duct↗
▶Ep 1 · 11:35
quoteif there's stones in the cystic duct, in our experience, that's one of the prime. Uh, things that will show you that there probably are common bile duct stones too↗
▶Ep 1 · 11:35
clinicalPresence of cystic duct stones is a prime indicator that common bile duct stones are also likely present↗
▶Ep 1 · 12:19
quoteI, I just use low, low watt cautery and again, a lot of, a lot of traction on the gallbladder↗
▶Ep 1 · 12:25
clinicalChronically inflamed gallbladders are usually intrahepatic with no plane between gallbladder and liver↗
▶Ep 1 · 12:25
quotethe other thing that happens with these gallbladders that you've just mentioned in terms of the degree of chronic inflammation, they're usually intrahepatic. There's no plane between the gallbladder and the liver↗
▶Ep 1 · 12:39
clinicalControlled avulsion technique for intrahepatic gallbladders involves maximal traction with left hand and minimal contact with low-wattage cautery in right hand at the gallbladder-liver junction↗
▶Ep 1 · 12:39
quotewhat I tell the residents is called a controlled avulsion. So left hand, a lot of traction on the pulling the gallbladder away from the liver, right hand just barely touching that that junction of gallbladder with liver with low water's cautery and essentially carve it out of there↗
▶Ep 1 · 13:10
clinicalGallbladder bed hemostasis can be achieved in 99% of cases using cautery with irrigation-suction in left hand and cautery in right hand↗
▶Ep 1 · 13:13
quoteI'll put a, a suction, irrigation suction thing in my left hand. Um, I'll I'll, I'll do this before I can completely take the gallbladder off the bed so that the assistant can be holding up the right lobe of the liver with that remaining bit of gallbladder↗
▶Ep 1 · 13:31
quoteLeft hand then with an irrigating suction, suction, you can suck the smoke, you can suck blood or whatever. Right hand with a with a cautery and just touching the. The areas that are bleeding and 99% of the time you can get it stopped↗
▶Ep 1 · 14:06
clinicalFor suspected duct of Luschka injury in the gallbladder bed, attempt suture closure but drain placement is usually necessary as sutures are unlikely to hold↗
▶Ep 1 · 14:06
quoteif it's a Lushka duct, I would probably try to put a stitch in it. Um, you know, a small stitch, but the likelihood is that's not going to hold anyway, so I'd put a drain in↗
▶Ep 1 · 14:18
clinicalActive drain should be placed for deep intrahepatic gallbladder dissection and left in for several hours or overnight to monitor for bile leak↗
▶Ep 1 · 14:18
quoteif I was deep into the bed in one of these intrahepatic gallbladders, I will, I will put an active drain in and leave it in, you know, at least for several hours if we're going to try and send them home, or usually keep the patient overnight and just make sure there's no bile in there↗
▶Ep 1 · 14:40
clinical95% of laparoscopic cholecystectomy patients are discharged home the same day↗
clinicalPostoperative pain management includes intraoperative IV acetaminophen, prescription for only 5 hydrocodone tablets, and recommendation for ibuprofen or acetaminophen for first few days↗
▶Ep 1 · 14:52
quotethe, the anesthesiologist will usually give them some, we, we usually use IV Tylenol, which I think works pretty well↗
▶Ep 1 · 15:00
quotewe'll send them home with that like 5, hydrocodone tablets or something like that, but only 5, and tell them if they need more than that, they need to call↗
▶Ep 1 · 15:00
clinicalPain requiring more than 5 hydrocodone tablets postoperatively suggests a problem and warrants patient contact↗
▶Ep 1 · 15:12
quoteI, I, I just tell them to go ahead and take either ibuprofen or Tylenol in addition to that for the first few days. If they have more pain than that, there's a problem↗
