# Acute Cholecystitis — GCMD Library living collection

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

Updated: n/a · 4 episodes · 157 cited statements

## Episodes
### Surgical Management
- [Acute Cholecystitis](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442) — podcast · 32:28 · [machine version](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442.md)
- [Acute Cholecystitis](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373) — video · 32:30 · [machine version](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373.md)
- [Acute Cholecystitis](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747) — podcast · 32:28 · [machine version](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747.md)

### In-Depth Reviews
- [Gallstone Disease](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379) — podcast · 47:36 · [machine version](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=0) Introduction and Guest Presentation (Ep 1)
- [1:53](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=113) Diagnostic Workup and Management of Acute Cholecystitis (Ep 1)
- [7:11](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=431) Laparoscopic Cholecystectomy Technique and Port Placement (Ep 1)
- [11:37](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=697) Dissection Techniques for Difficult Gallbladders (Ep 1)
- [14:48](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=888) Intraoperative Cholangiography Indications and Technique (Ep 1)
- [19:32](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1172) Postoperative Care and Evaluation of Complications (Ep 1)
- [22:03](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1323) Management of Bile Leaks Post-Cholecystectomy (Ep 1)
- [27:27](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1647) Gallstone Pancreatitis: Initial Management Strategy (Ep 1)
- [33:27](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2007) Intraoperative Common Bile Duct Stone Management (Ep 1)
- [36:24](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2184) Laparoscopic Common Bile Duct Exploration with Choledocotomy (Ep 1)
- [40:28](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2428) Management of Severe Cholecystitis and Difficult Cases (Ep 1)
- [42:25](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2545) Common Bile Duct Injury: Prevention, Recognition, and Management (Ep 1)
- [46:00](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2760) Closing Remarks (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=0) Case presentation and initial assessment (Ep 2)
- [2:30](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=150) Surgical timing and preoperative management (Ep 2)
- [5:18](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=318) Management of high-risk patients with percutaneous cholecystostomy (Ep 2)
- [8:59](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=539) Preoperative cardiac optimization and operative approach (Ep 2)
- [12:00](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=720) Port placement and initial dissection technique (Ep 2)
- [17:26](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1046) Dissection to achieve critical view of safety (Ep 2)
- [20:39](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1239) Intraoperative cholangiography technique (Ep 2)
- [24:07](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1447) Management of common bile duct stones (Ep 2)
- [26:07](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1567) Bailout strategies for severe inflammation (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=0) Case presentation and initial management decision (Ep 3)
- [3:27](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=207) Preoperative preparation and antibiotic therapy (Ep 3)
- [6:37](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=397) Percutaneous cholecystostomy technique and management (Ep 3)
- [8:00](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=480) Cardiac risk assessment and operative timing (Ep 3)
- [11:36](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=696) Port placement strategy and initial laparoscopic access (Ep 3)
- [15:32](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=932) Management of omental adhesions and gallbladder decompression (Ep 3)
- [17:21](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1041) Dissection technique and the critical view of safety (Ep 3)
- [20:07](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1207) Intraoperative cholangiography and transcystic common bile duct exploration (Ep 3)
- [25:40](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1540) Bailout strategies for severe inflammation (Ep 3)
- [28:29](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1709) Subtotal cholecystectomy and complication avoidance (Ep 3)
- [0:07](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=7) Introduction and case presentation setup (Ep 4)
- [2:30](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=150) Initial management strategy and timing of surgery (Ep 4)
- [5:18](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=318) Management of high-risk patients with percutaneous cholecystostomy (Ep 4)
- [7:12](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=432) Timing of tube removal and preparation for delayed surgery (Ep 4)
- [11:36](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=696) Laparoscopic port placement technique (Ep 4)
- [15:04](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=904) Initial dissection and omental adhesiolysis (Ep 4)
- [17:56](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1076) Dissection technique and critical view of safety (Ep 4)
- [20:06](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1206) Intraoperative cholangiography technique (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Biliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative. — Jeffrey Ponsky (clinical) [Ep 1 · 1:53](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=113)
- Modern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks. — Jeffrey Ponsky (clinical) [Ep 1 · 5:00](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=300)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 5:40](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=340)
- There is no evidence that prophylactic antibiotics help in acute cholecystitis management. — Jeffrey Ponsky (clinical) [Ep 1 · 6:10](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=370)
- In A-frame patients (narrow costal margin), port placement must be adjusted lower because ribs prevent standard subcostal port positioning. — Todd Ponsky (clinical) [Ep 1 · 9:44](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=584)
- The sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas. — Jeffrey Ponsky (clinical) [Ep 1 · 12:12](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=732)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 12:40](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=760)
- Easy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed. — Jeffrey Ponsky (opinion) [Ep 1 · 13:02](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=782)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 14:50](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=890)
- 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). — Jeffrey Ponsky (clinical) [Ep 1 · 18:33](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1113)
- Intraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy. — Jeffrey Ponsky (clinical) [Ep 1 · 19:00](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1140)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 20:30](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1230)
- For suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP. — Jeffrey Ponsky (clinical) [Ep 1 · 21:11](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1271)
- 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. — Jeffrey Ponsky (opinion) [Ep 1 · 21:32](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1292)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 22:37](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1357)
- Biliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative. — Jeffrey Ponsky (clinical) [Ep 1 · 23:41](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1421)
- Gallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla. — Jeffrey Ponsky (clinical) [Ep 1 · 24:11](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1451)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 24:40](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1480)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 25:10](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1510)
- 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. — Jeffrey Ponsky (opinion) [Ep 1 · 26:27](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1587)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 30:14](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1814)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 30:56](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1856)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 31:35](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1895)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 32:44](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1964)
- After transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties. — Jeffrey Ponsky (clinical) [Ep 1 · 33:27](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2007)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 34:56](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2096)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 35:30](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2130)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 37:40](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2260)
- T-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks. — Jeffrey Ponsky (clinical) [Ep 1 · 38:50](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2330)
- For severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve. — Jeffrey Ponsky (clinical) [Ep 1 · 39:27](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2367)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 40:00](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2400)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 41:04](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2464)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 41:47](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2507)
- Common bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance. — Jeffrey Ponsky (clinical) [Ep 1 · 42:29](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2549)
- 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.' — Jeffrey Ponsky (clinical) [Ep 1 · 43:00](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2580)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 43:29](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2609)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 44:00](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2640)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 44:37](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2677)
- For small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak. — Jeffrey Ponsky (clinical) [Ep 1 · 44:56](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2696)
- 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. — Jeffrey Ponsky (clinical) [Ep 1 · 45:37](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2737)
- In most bile duct injury cases, the primary injury is compounded by the attempted repair. — Jeffrey Ponsky (clinical) [Ep 1 · 44:20](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=2660)
- Patients with acute cholecystitis who are cooled down and discharged have a high recurrence rate and typically return on weekends, making management more difficult. — John Rodriguez (clinical) [Ep 3 · 2:55](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=175)
- For a 45-year-old patient with straightforward acute cholecystitis and normal liver function tests, early cholecystectomy during the same admission from the emergency room is favored. — John Rodriguez (clinical) [Ep 3 · 3:15](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=195)
- Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed by a stone, causing backup of pressure in the gallbladder with decreased blood flow in the wall that can eventually lead to rupture. — Jeffrey Ponsky (clinical) [Ep 3 · 4:21](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=261)
- In patients with significant cardiac history, the last thing you want to do is take them to the operating room and cause an acute cardiac event. — John Rodriguez (clinical) [Ep 3 · 5:40](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=340)
- Many patients with acute cholecystitis will cool down with antibiotics alone and no additional intervention is needed. — John Rodriguez (clinical) [Ep 3 · 5:59](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=359)
- Percutaneous cholecystostomy tubes can be very helpful for patients who are not good candidates for operative intervention. — John Rodriguez (clinical) [Ep 3 · 6:06](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=366)
- For high-risk patients with acute cholecystitis, give antibiotics for about one to two days, and if there's no improvement, then recommend percutaneous cholecystostomy. — John Rodriguez (clinical) [Ep 3 · 6:37](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=397)
- The combination of percutaneous cholecystostomy tubes with antibiotics is very effective in managing acute cholecystitis in sicker patients, with most having an uneventful recovery. — John Rodriguez (clinical) [Ep 3 · 6:58](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=418)
- Before removing a cholecystostomy tube, wait about 4 to 6 weeks and perform a cholangiogram through the tube to ensure the cystic duct is patent. — John Rodriguez (clinical) [Ep 3 · 7:30](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=450)
- If the cystic duct is not patent when removing a cholecystostomy tube, the patient will get a recurrent episode as soon as the tube is removed. — John Rodriguez (clinical) [Ep 3 · 7:51](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=471)
- For patients on antiplatelet therapy due to stents who need to wait a year, keeping a cholecystostomy tube is reasonable because once they can come off Plavix or aspirin it's easier to manage a recurrent episode definitively. — John Rodriguez (clinical) [Ep 3 · 8:18](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=498)
- Cholecystectomy in patients with prior cholecystostomy tubes tends to be more challenging cases that need to be planned well and should not be added on at the end of the day when the surgeon is tired. — John Rodriguez (clinical) [Ep 3 · 9:33](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=573)
- In patients with cholecystostomy tubes, the tube should not be removed before surgery if possible because it's useful for finding anatomy when there are adhesions and can be used to shoot a cholangiogram intraoperatively if the surgeon is lost. — John Rodriguez (clinical) [Ep 3 · 9:49](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=589)
- Gallbladders in patients with prior cholecystostomy tubes tend to be pretty challenging and take quite some time to remove. — John Rodriguez (clinical) [Ep 3 · 10:11](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=611)
- 99% of the time the approach for cholecystectomy is laparoscopic, even in very difficult cases. — John Rodriguez (clinical) [Ep 3 · 11:39](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=699)
- Palmer's point is about two finger breadths below the rib cage on the left side in the midclavicular line and is one of the safest locations for initial laparoscopic entry. — John Rodriguez (clinical) [Ep 3 · 12:15](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=735)
- By placing the initial port at Palmer's point and dropping the hand about another inch lower, that port can serve as an operating port without needing an additional trochar. — John Rodriguez (clinical) [Ep 3 · 12:30](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=750)
- Placing the most lateral trochar under direct vision while being able to see the gallbladder allows the assistant to grab and elevate the gallbladder, giving better location for the left hand port. — John Rodriguez (clinical) [Ep 3 · 13:10](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=790)
- In acute cholecystitis cases, tissue can be very edematous and bleed easily, and when bleeding is not controlled early on it tends to impede visualization later. — John Rodriguez (clinical) [Ep 3 · 15:41](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=941)
- Hook electrocautery is a very fine dissecting tool that tends to be hemostatic for taking down omental adhesions. — John Rodriguez (clinical) [Ep 3 · 16:04](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=964)
- There is a very low threshold to decompress tense gallbladders before trying to grab them, using a long reusable needle connected to a 60cc syringe inserted at the fundus under direct vision. — John Rodriguez (clinical) [Ep 3 · 16:29](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=989)
- Decompressing the gallbladder allows grasping without tearing the wall. — John Rodriguez (clinical) [Ep 3 · 17:04](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1024)
- In acute cholecystitis, gallbladders tend to have a thicker rind, so once you get down on the gallbladder wall you can start gently teasing tissues down towards the duodenum. — John Rodriguez (clinical) [Ep 3 · 18:12](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1092)
- The suction device is a great dissection tool during laparoscopic cholecystectomy. — John Rodriguez (clinical) [Ep 3 · 18:29](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1109)
- As you take Calot's node down you can visualize the cystic artery, and dissecting up towards the body of the gallbladder gets length on the artery because as long as you're on the gallbladder you know you're safe. — John Rodriguez (clinical) [Ep 3 · 18:35](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1115)
- 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, because that's how you get in trouble. — John Rodriguez (clinical) [Ep 3 · 18:53](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1133)
- The Maryland dissector is a great tool for gentle dissection at the junction between the cystic duct and gallbladder. — John Rodriguez (clinical) [Ep 3 · 19:17](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1157)
- Moving the gallbladder back and forth with the left hand allows dissection on the lateral side, which is always a safe spot. — John Rodriguez (clinical) [Ep 3 · 19:31](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1171)
- The critical view of safety requires visualizing the cystic duct, the gallbladder wall, liver in the window, and the cystic artery within Calot's triangle. — John Rodriguez (clinical) [Ep 3 · 19:45](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1185)
- A useful trick is to take some gallbladder just superior to the junction of the cystic duct with the gallbladder and take the back wall off the liver bed to give increased length. — Jeffrey Ponsky (clinical) [Ep 3 · 20:19](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1219)
- Routine cholangiography is used in almost all cholecystectomy cases. — John Rodriguez (clinical) [Ep 3 · 20:39](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1239)
- Before attempting to cannulate the cystic duct for cholangiography, place a clip very close to the gallbladder, make a dichotomy, and milk the cystic duct proximally with scissors or a Maryland to see if there are any stones and try to get them out. — John Rodriguez (clinical) [Ep 3 · 21:08](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1268)
- Giving the cholangiogram catheter a 45-degree angle before placing it into the body helps with cannulation. — John Rodriguez (clinical) [Ep 3 · 21:31](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1291)
- The Olsen clamp has a layout where the tip comes together but the middle doesn't, allowing occlusion of the cystic duct around the catheter without occluding the catheter itself. — John Rodriguez (clinical) [Ep 3 · 21:57](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1317)
- Flushing the cystic duct with a good 20cc of saline before cholangiography can be very helpful when there's sludge and stones, and also gets air bubbles out of the system. — John Rodriguez (clinical) [Ep 3 · 22:18](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1338)
- To get contrast to flow proximally into the liver during cholangiography, tricks include laying the patient in slight Trendelenburg position or using the camera to put pressure on the distal common bile duct. — John Rodriguez (clinical) [Ep 3 · 22:59](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1379)
- For a small stone in the distal common bile duct, first try flushing again with good pressure and give glucagon to relax the ampulla, which can sometimes help get distal stones out. — John Rodriguez (clinical) [Ep 3 · 23:41](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1421)
- Commercial transcystic common bile duct exploration kits include a percutaneous introduction catheter with a step dilator that should be placed at a parallel angle to the cystic duct through a separate stab incision from the right side to avoid trauma to the duct. — John Rodriguez (clinical) [Ep 3 · 23:57](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1437)
- The key for transcystic common bile duct exploration is to place a wire under fluoroscopic guidance distally into the duodenum, after which instruments including a Dormier basket and balloon dilator can be used for stone extraction. — John Rodriguez (clinical) [Ep 3 · 24:51](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1491)
- For small common bile duct stones, it's easier to push them through with a balloon dilator (performing transcystic antegrade sphincteroplasty) than to try to extract them with a basket. — John Rodriguez (clinical) [Ep 3 · 25:20](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1520)
- When the infundibulum, cystic duct, artery, and Calot's triangle cannot be defined due to severe inflammation and duodenal adherence, the approach is aggressive top-down dissection while remaining laparoscopic. — John Rodriguez (clinical) [Ep 3 · 26:14](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1574)
- Placing the lateral left trochar under direct vision is helpful because it positions the port to be useful in difficult situations beyond just standard cholecystectomy technique. — John Rodriguez (clinical) [Ep 3 · 26:41](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1601)
- There is no hesitation to add another trochar when needed during laparoscopic cholecystectomy. — John Rodriguez (clinical) [Ep 3 · 27:09](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1629)
- You can tell laparoscopically how difficult it's going to be if you convert to open, and the reality is that in severe cases going open and trying to be heroic going for the cystic duct is not safe either. — John Rodriguez (clinical) [Ep 3 · 27:29](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1649)
- In severe cases where anatomy cannot be defined, the decision is between opening the gallbladder and doing a partial cholecystectomy, or leaving part of the back wall on the liver. — John Rodriguez (clinical) [Ep 3 · 27:52](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1672)
- In horrible cases, opening the gallbladder, taking out all the stones, and placing a large cholecystostomy tube creates an empty gallbladder with a tube and can bail you out. — Jeffrey Ponsky (clinical) [Ep 3 · 28:14](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1694)
- When converting to open cholecystectomy for severe inflammation, the approach is still top-down dissection. — John Rodriguez (clinical) [Ep 3 · 28:21](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1701)
- Some patients have a very superficial right hepatic ductal system, and as you start digging into the liver you can injure it, leading to bile leaks. — John Rodriguez (clinical) [Ep 3 · 29:02](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1742)
- Many patients who come back with bile leaks labeled as duct of Luschka leaks are not really duct of Luschka leaks but rather the surgeon getting too deep into the liver and injuring the ductal system. — John Rodriguez (clinical) [Ep 3 · 29:10](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1750)
- In cases where you cannot safely dissect to the cystic duct, open the gallbladder, get the stones out, get down to a point where you know you're safe and not injuring anything, then close it up rather than leaving it open. — John Rodriguez (clinical) [Ep 3 · 29:31](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1771)
- In subtotal cholecystectomy cases, a drain is left most of the time to control a bile leak if it occurs. — John Rodriguez (clinical) [Ep 3 · 29:46](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1786)
- When leaving the back wall of the gallbladder, cauterize the mucosa with coagulation on a high setting. — John Rodriguez (clinical) [Ep 3 · 30:38](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1838)
- The big goal any surgeon has in a difficult cholecystectomy case is avoiding a major bile duct injury that will end up being a disaster for the patient. — John Rodriguez (clinical) [Ep 3 · 30:21](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13373?t=1821)
- Early cholecystectomy is favored for straightforward acute cholecystitis because patients managed conservatively have a high recurrence rate and often return on weekends — John Rodriguez (clinical) [Ep 2 · 2:30](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=150)
- Patients with acute cholecystitis should be admitted, started on antibiotics, kept NPO, and have coagulation studies, type and screen, and pregnancy test completed before surgery — John Rodriguez (clinical) [Ep 2 · 3:58](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=238)
- For patients with prohibitive cardiac risk and acute cholecystitis, broad-spectrum antibiotics are given for 1-2 days, and if no improvement occurs, percutaneous cholecystostomy is recommended — John Rodriguez (clinical) [Ep 2 · 6:37](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=397)
- Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in high-risk patients — John Rodriguez (clinical) [Ep 2 · 6:58](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=418)
- Cholecystostomy tubes should remain in place 4-6 weeks, and a cholangiogram through the tube should confirm cystic duct patency before removal to prevent recurrent episodes — John Rodriguez (clinical) [Ep 2 · 7:28](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=448)
- Patients on antiplatelet therapy for cardiac stents who need cholecystectomy require cardiology consultation to determine safe timing for stopping medications before surgery and restarting them after — John Rodriguez (clinical) [Ep 2 · 10:29](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=629)
- Laparoscopic approach is used in 99% of cholecystectomy cases even in very difficult acute cases — John Rodriguez (clinical) [Ep 2 · 11:17](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=677)
- Palmer's point is located two finger breadths below the rib cage in the left midclavicular line and is one of the safest sites for initial trocar entry — John Rodriguez (clinical) [Ep 2 · 12:17](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=737)
- In acute cholecystitis, edematous omental tissue bleeds easily, and controlling bleeding early with cautery prevents impaired visualization later in the operation — John Rodriguez (clinical) [Ep 2 · 15:32](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=932)
- There is a low threshold to decompress tense, hard gallbladders before attempting to grasp them to prevent tearing — John Rodriguez (clinical) [Ep 2 · 16:29](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=989)
- Gallbladder decompression is performed at the fundus using a long reusable needle connected to a 60cc syringe under direct vision — John Rodriguez (clinical) [Ep 2 · 16:36](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=996)
- Dissection should start high on the gallbladder where the surgeon is certain to be on the gallbladder wall, taking peritoneum off using hook electrocautery to visualize Calot's node — John Rodriguez (clinical) [Ep 2 · 17:26](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1046)
- In acute cholecystitis, the gallbladder tends to have a thicker rind, and once on the gallbladder wall, tissues can be gently teased down toward the duodenum — John Rodriguez (clinical) [Ep 2 · 17:53](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1073)
- 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 — John Rodriguez (clinical) [Ep 2 · 19:17](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1157)
- Taking the back wall of the gallbladder off the liver bed just superior to the cystic duct junction provides increased length for safer dissection — John Rodriguez (clinical) [Ep 2 · 20:19](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1219)
- Routine cholangiography is used in nearly all cholecystectomy cases — John Rodriguez (clinical) [Ep 2 · 20:39](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1239)
- Before cannulating the cystic duct for cholangiogram, a clip is placed close to the gallbladder, a dichotomy is made, and the duct is milked proximally to express any stones — John Rodriguez (clinical) [Ep 2 · 20:43](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1243)
- Flushing the cystic duct with 20cc of saline before cholangiography clears sludge and stones and removes air bubbles from the system — John Rodriguez (clinical) [Ep 2 · 22:14](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1334)
- When contrast flows only down and not up into the liver on cholangiogram, placing the patient in reverse Trendelenburg or using the camera to compress the distal common bile duct can redirect flow proximally — John Rodriguez (clinical) [Ep 2 · 22:56](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1376)
- For small distal common bile duct stones, flushing the duct again and giving glucagon to relax the ampulla should be attempted first — John Rodriguez (clinical) [Ep 2 · 23:36](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1416)
- Transcystic common bile duct exploration uses a commercial kit with a percutaneous introducer, step dilator, and wire placed under fluoroscopic guidance into the duodenum — John Rodriguez (clinical) [Ep 2 · 24:07](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1447)
- The introducer for transcystic exploration is placed from the right side in a parallel angle to the cystic duct through a separate stab incision to avoid trauma and backwalling the duct — John Rodriguez (clinical) [Ep 2 · 24:20](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1460)
- Transcystic exploration kits include a Dormier-type basket for stone extraction and a balloon dilator for antegrade sphincteroplasty to push small stones through — John Rodriguez (clinical) [Ep 2 · 24:39](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1479)
- When the infundibulum, cystic duct, artery, and Calot's triangle cannot be defined due to severe inflammation, a dome-down approach is used aggressively — John Rodriguez (clinical) [Ep 2 · 26:07](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1567)
- In severe acute cholecystitis cases, going open and attempting to reach the cystic duct is often not safe either — John Rodriguez (clinical) [Ep 2 · 27:28](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1648)
- Bailout options for severe inflammation include opening the gallbladder for partial cholecystectomy or leaving part of the back wall on the liver — John Rodriguez (clinical) [Ep 2 · 27:51](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1671)
- When the gallbladder is very inflamed and difficult to separate from the liver, there is risk of injuring a superficial right ductal system, which can cause bile leaks — John Rodriguez (clinical) [Ep 2 · 28:46](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1726)
- Many postoperative bile leaks attributed to ducts of Luschka are actually from surgeons dissecting too deep into the liver and injuring the ductal system — John Rodriguez (opinion) [Ep 2 · 29:08](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1748)
- In partial cholecystectomy, the gallbladder is opened, stones removed, and the gallbladder closed rather than left open, with a drain placed to control potential bile leak — John Rodriguez (clinical) [Ep 2 · 29:31](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1771)
- When leaving the back wall of a necrotic gallbladder, the mucosa is cauterized on a high coagulation setting and a drain is left — John Rodriguez (clinical) [Ep 2 · 30:33](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1833)
- The primary goal in severe acute cholecystitis is avoiding major bile duct injury, which would be a disaster for the patient — John Rodriguez (clinical) [Ep 2 · 30:06](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1806)
- Patients with acute cholecystitis who are cooled down and discharged have a high recurrence rate and often return on weekends, making management more difficult. — John Rodriguez (clinical) [Ep 4 · 2:55](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=175)
- For a 45-year-old patient with straightforward acute cholecystitis and normal liver function tests, early cholecystectomy during the index admission is favored over medical management. — John Rodriguez (opinion) [Ep 4 · 3:14](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=194)
- Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed by a stone, causing backup of pressure, decreased blood flow in the wall, wall thickening, and potential rupture. — Jeffrey Ponsky (clinical) [Ep 4 · 4:28](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=268)
- In patients with significant cardiac history, the risk of taking them to the operating room includes precipitating an acute cardiac event. — John Rodriguez (clinical) [Ep 4 · 5:40](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=340)
- Percutaneous cholecystostomy tubes placed by interventional radiology can be very helpful for patients who are not good candidates for operative intervention. — John Rodriguez (clinical) [Ep 4 · 6:06](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=366)
- The combination of percutaneous cholecystostomy tubes with antibiotics is very effective in managing acute cholecystitis in sicker patients, with most having an uneventful recovery and being able to leave the hospital. — John Rodriguez (clinical) [Ep 4 · 6:58](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=418)
- Before removing a cholecystostomy tube, it is important to wait 4-6 weeks and perform a cholangiogram through the tube to ensure the cystic duct is patent, otherwise recurrent episodes will occur immediately after tube removal. — John Rodriguez (clinical) [Ep 4 · 7:30](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=450)
- For patients on antiplatelet therapy due to cardiac stents who need to wait a year, leaving a cholecystostomy tube is reasonable because once they can come off Plavix or aspirin, it is easier to manage a recurrent episode definitively. — John Rodriguez (opinion) [Ep 4 · 8:18](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=498)
- Patients with cholecystostomy tubes who later undergo surgery tend to be more challenging cases that need to be planned well and should not be added on at the end of a long surgical day. — John Rodriguez (opinion) [Ep 4 · 9:33](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=573)
- The cholecystostomy tube can be useful during surgery for finding anatomy when there are adhesions and for shooting an intraoperative cholangiogram if the surgeon is lost. — John Rodriguez (clinical) [Ep 4 · 9:54](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=594)
- Palmer's point is located about 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 placement. — John Rodriguez (clinical) [Ep 4 · 12:22](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=742)
- Placing the most lateral trocar while being able to see the gallbladder allows the assistant to grab and elevate it, providing better positioning for the surgeon's left hand. — John Rodriguez (clinical) [Ep 4 · 13:16](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=796)
- In acute cholecystitis cases, tissue can be very edematous and bleed easily; controlling bleeding early with cautery is important because uncontrolled bleeding impedes visualization later. — John Rodriguez (clinical) [Ep 4 · 15:41](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=941)
- There is a low threshold to decompress tense, hard, thick gallbladders before attempting to grasp them, using a long reusable needle connected to a 60cc syringe inserted at the fundus under direct vision. — John Rodriguez (clinical) [Ep 4 · 16:29](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=989)
- In acute cholecystitis, gallbladders tend to have a thicker rind, and once on the gallbladder wall, tissues can be gently and patiently teased down towards the duodenum. — John Rodriguez (clinical) [Ep 4 · 18:04](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1084)
- The cystic artery can be visualized as Calot's node is taken down, and dissection should extend up towards the body of the gallbladder to get length, because staying on the gallbladder ensures safety. — John Rodriguez (clinical) [Ep 4 · 18:35](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1115)
- 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, because that is how bile duct injuries occur. — John Rodriguez (clinical) [Ep 4 · 18:53](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1133)
- The critical view of safety requires visualizing the cystic duct, the gallbladder wall, liver in the dissection window, and the cystic artery within Calot's triangle. — John Rodriguez (clinical) [Ep 4 · 19:25](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1165)
- Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall from the liver bed provides increased length for dissection. — Jeffrey Ponsky (clinical) [Ep 4 · 20:18](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1218)
- Before attempting to cannulate the cystic duct for cholangiography, placing a clip close to the gallbladder and making a dicotomy, then milking the cystic duct proximally with scissors or a Maryland dissector can help extract stones. — John Rodriguez (clinical) [Ep 4 · 21:08](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1268)
- Flushing the cystic duct with 20cc of saline before cholangiography helps clear sludge and stones and removes air bubbles from the system. — John Rodriguez (clinical) [Ep 4 · 22:23](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1343)
- To get contrast to flow proximally into the liver during cholangiography, techniques include placing the patient in reverse Trendelenburg position or using the camera to compress the distal common bile duct. — John Rodriguez (clinical) [Ep 4 · 22:59](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1379)
- For small stones in the distal common bile duct, initial management includes flushing the duct and administering glucagon to relax the ampulla, which can sometimes help pass distal stones. — John Rodriguez (clinical) [Ep 4 · 23:41](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1421)
- Commercial transcystic common bile duct exploration kits include a percutaneous introduction catheter with a step dilator, and the key is to place a wire under fluoroscopic guidance distally into the duodenum. — John Rodriguez (clinical) [Ep 4 · 23:57](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1437)
- Transcystic exploration kits include a Dormia-type basket for crushing and retrieving stones and a balloon dilator that can push small stones through by performing an antegrade sphincteroplasty. — John Rodriguez (clinical) [Ep 4 · 25:01](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1501)
- In difficult acute cholecystitis cases where the infundibulum, cystic duct, artery, and Calot's triangle cannot be defined, a fundus-down approach is used aggressively. — John Rodriguez (clinical) [Ep 4 · 26:14](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1574)
- When fundus-down dissection fails to progress, the decision is between opening the gallbladder for partial cholecystectomy or leaving part of the back wall on the liver, rather than risking injury by pursuing the cystic duct in severe inflammation. — John Rodriguez (opinion) [Ep 4 · 27:28](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1648)
- Opening the gallbladder, removing all stones, and placing a large tube creates a cholecystostomy that can bail out a horrible case. — Jeffrey Ponsky (clinical) [Ep 4 · 28:14](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1694)
- Some patients have a very superficial right hepatic ductal system, and digging too deep into the liver during dissection can injure it, causing bile leaks that are often mislabeled as duct of Luschka leaks. — John Rodriguez (clinical) [Ep 4 · 28:47](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1727)
- In subtotal cholecystectomy, after opening the gallbladder and removing stones, the remnant is typically closed rather than left open, and a drain is placed to control potential bile leaks. — John Rodriguez (clinical) [Ep 4 · 29:34](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1774)
- When leaving the back wall of the gallbladder on the liver in necrotic, falling-apart cases where anatomy near the cystic duct is unclear, the mucosa is cauterized with high coagulation setting and a drain is placed. — John Rodriguez (clinical) [Ep 4 · 30:06](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1806)
- The primary goal in difficult cholecystitis cases is avoiding a major bile duct injury, which would be a disaster, even if it means not achieving complete cholecystectomy. — John Rodriguez (opinion) [Ep 4 · 30:21](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1821)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- 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. — Jeffrey Ponsky summarizing a resource [Ep 1 · 28:33](https://qa.library.globalcastmd.com/watch/gallstone-disease-1379?t=1713)
- Acute cholecystitis is an obstructive diverticulopathy where cystic duct obstruction by a stone causes pressure backup, decreased wall blood flow, and potential rupture with wall thickening — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 2 · 4:21](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=261)
- Dissection should occur at the junction of the cystic duct and gallbladder, not as close to the common duct as possible, to avoid injury — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 2 · 18:52](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1132)
- There is nothing magical about a specific number of trocars; additional ports should be placed where needed for adequate exposure — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 2 · 27:06](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1626)
- Operating early in uncomplicated acute cholecystitis is recommended, while patients with cardiac or pulmonary disease may benefit from percutaneous cholecystostomy with delayed elective surgery — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 2 · 30:48](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-3442?t=1848)
- There is no hesitation to add additional trocars as needed during difficult cases, as port number is not magical and they should be placed where needed. — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 4 · 27:07](https://qa.library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1627)

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