From
StayCurrentMD
Gallstone Disease
With Dr. Jeffrey Ponsky · hosted by Dr. Alexander Gibbons & Dr. Todd Ponsky
Chapter 1 of 13 · Fundamentals
Introduction
Introduction and Guest Presentation
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
Acute Cholecystitis
Todd Ponsky · 32 min · Published Jul 2026
Video
2025 Pediatric Surgery Update Course - Updates in Lap Chole and Cholecystitis Management
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Video
Index admission cholecystectomy for acute cholecystitis reduces 30-day readmission rates in pediatric patients
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La colecistectomía al ingreso por colecistitis aguda reduce las tasas de reingreso a 30 días en pacientes pediátricos
Published Feb 2024
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CCHMC Pediatric Surgery · 58 min · Published Nov 2020
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Overview of the Surgical Management of Acute and Chronic Pancreatitis in Children with Dr. Juan Gurria
66 min · Published Apr 2026
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Pancreatitis in pediatric patients with pancreatic solid pseudopapillary neoplasms- a single center experience
59 s · Published Apr 2026
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Update Course Rewind: Pediatric Biliary Stones - Surgery First Mindset 2024
Dr. Todd Ponsky · 7 min · Published Jul 2025
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Multi-Institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients
59 s · Published Mar 2025
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Total pancreatectomy with islet autotransplantation (TPIAT) - Cincinnati Children's Pancreas Care Center
CCHMC Pediatric Surgery · 10 min · Published Dec 2024
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Chronic Pancreatitis - Pancreatic Pathologies by Cincinnati Children's Pancreas Care Center
CCHMC Pediatric Surgery · 8 min · Published Nov 2024
Podcast
The invention of the PEG tube with Dr. Jeffrey Ponsky
Jeffrey Ponsky · 33 min · Published Jul 2026
Podcast
Update Course Rewind: Pediatric Biliary Stones - Preventing Gallstone Pancreatitis 2024
Jeffrey Ponsky · 3 min · Published Aug 2025
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ACS Icons in Surgery | Jeffrey L. Ponsky, MD, FACS
Jeffrey Ponsky · 20 min · Published Jul 2024
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SAGES Stories Episode 11 – Jeff Ponsky, MD
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From Idea to Ubiquity - the PEG Journey
Jeffrey Ponsky · Published Nov 2023
Podcast
Innovations in Surgery: PEG Tube
Jeffrey Ponsky · Published Aug 2023
Video
Intestinal Atresia Types Explained: Grossfeld Classification for Pediatric Surgery
1 min · Published Sep 2026
Video
Derivation and validation of the Pediatric Community-Acquired Pneumonia Severity (PedCAPS) score: A prospective cohort study
50 s · Published Sep 2026
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FETO for Late-Diagnosed Severe Congenital Diaphragmatic Hernia (CDH) at Cincinnati Children's with Dr. Beth Rymeski
4 min · Published Sep 2026
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Severe Congenital Diaphragmatic Hernia (CDH) Case: FETO Management & Unexpected Findings with Dr. Beth Rymeski
3 min · Published Sep 2026
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Fetoscopic Endoluminal Tracheal Occlusion (FETO) Procedure: Step-by-Step Guide with Dr. Beth Rymeski
4 min · Published Sep 2026
Video
Choledochal Cyst Types Explained: Pediatric Surgery Fundamentals
1 min · Published Sep 2026
What the experts said
Biliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative.
Modern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks.
For stable acute cholecystitis without peritonitis, it is reasonable to wait until the next operating day (e.g., Monday if presenting Saturday) rather than operating emergently.
There is no evidence that prophylactic antibiotics help in acute cholecystitis management.
In A-frame patients (narrow costal margin), port placement must be adjusted lower because ribs prevent standard subcostal port positioning.
The sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas.
After isolating the cystic duct-gallbladder junction, turning the hook cautery toward the gallbladder and lifting while cauterizing gains an additional half-centimeter of cystic duct length.
Easy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed.
Routine intraoperative cholangiography is debated; some institutions do it in every case for teaching and to improve transcystic exploration skills, while selective use based on risk factors (pancreatitis history, jaundice, dilated duct) is also acceptable.
When contrast on cholangiogram flows only distally into the duodenum, pressing on the papilla with the laparoscope under fluoroscopy forces contrast proximally, avoiding the need for morphine to induce sphincter spasm (technique taught by Michelle Gagné).
Intraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy.
Any patient with pain 3-5 days after laparoscopic cholecystectomy should be assumed to have a bile leak or bile duct injury until proven otherwise; laparoscopic cholecystectomies do not cause pain if everything went well.
For suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP.
HIDA scans are useful to confirm normal biliary drainage when postoperative pain occurs without fluid collection, but are less useful than CT for detecting bile leaks.
For bile leaks (typically cystic duct), ERCP with sphincterotomy and short stent (10 French, 5cm) decompresses the biliary system and stops drainage; stent is removed at 3-6 weeks.
Biliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative.
Gallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla.
In the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed.
Current management of gallstone pancreatitis: admit, hydrate, NPO, observe overnight and check amylase/lipase trend. If improving, proceed to cholecystectomy during that admission. If worsening or jaundice persists, perform ERCP with sphincterotomy.
The choice between preoperative ERCP versus intraoperative common duct exploration depends on local resources, surgeon comfort with laparoscopic ductal techniques, and availability of fluoroscopy and choledocoscopy.
For intraoperative common duct stone clearance, after cholangiogram shows a stone (meniscus sign), give 1 amp (1mg) glucagon IV, wait 1-2 minutes, flush with saline, and repeat cholangiogram.
If glucagon fails to clear the stone, pass a soft-tip wire through the cystic duct under fluoroscopy into the duodenum to attempt to dislodge it; never push against resistance.
A Dormia basket can be passed closed into the duodenum under fluoroscopy, opened slightly, and pulled back with jiggling to catch stones; alternatively, a #5 Fogarty catheter (vascular Fogarty works) can be inflated in the duodenum, pulled to the papilla, deflated slightly, re-inflated and pulled back.
Modern choledocoscopes are less than 3mm diameter and can be passed through the cystic duct (sometimes requiring balloon dilation) for direct stone visualization and extraction with Dormia basket or balloon.
After transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties.
Laparoscopic common bile duct exploration via choledocotomy should only be performed in dilated ducts (>1-1.5cm, ideally 2cm) to avoid stricture risk; small-caliber ducts with stones should be managed with ERCP.
For laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface.
T-tube preparation for choledocotomy closure: cut to 1 inch on each side of the T, bevel the edges, remove half the back wall to facilitate insertion and later removal.
T-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks.
For severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve.
For patients with multiple stones extending up both hepatic ducts in a very dilated common duct, or stone-formers like sickle cell patients, consider choledochoduodenostomy (2cm anastomosis) as a drainage procedure to allow future stones to pass.
Percutaneous cholecystostomy can temporize severe acute cholecystitis in high-risk patients or those with large phlegmon, allowing interval cholecystectomy at 6 weeks, but requires normal clotting studies.
In cases where anatomy is unrecognizable intraoperatively, subtotal cholecystectomy is acceptable: remove the anterior wall or fundus, cauterize the remaining mucosa on the back wall with bovie to prevent mucocele, place drains, and accept a controlled leak.
Common bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance.
The common duct can come up to the gallbladder and take a bend like a knee, appearing identical to the cystic duct; only continued dissection reveals the true 2-3mm cystic duct coming off the 'knee.'
Being able to pass an instrument around a structure does not prove it is the cystic duct—the common bile duct can be encircled and mistakenly used for retraction.
If common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair.
In most bile duct injury cases, the primary injury is compounded by the attempted repair.
Primary end-to-end repair of transected common bile duct is almost always fraught with failure; most common duct injuries (except small lateral injuries) are best treated with hepaticojejunostomy.
For small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak.
For complete common duct transection, leave everything alone, place multiple drains, do not place ties or tubes that will compromise remaining duct length for the hepatobiliary surgeon, and transfer the patient.
Some experts (George Bursey, Joe Peatland) advocate taking patients with persistent common duct stones directly to the operating room for intraoperative cholangiogram and transcystic or laparoscopic common duct exploration, with postoperative ERCP only if unsuccessful.