# Cholelithiasis — GCMD Library living collection

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

Updated: n/a · 5 episodes · 75 cited statements

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

### Surgical Management
- [StayCurrent Forums - Laparoscopic Cholecystectomy](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324) — video · 16:04 · [machine version](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324.md)
- [Update Course 2021: THORACOTOMY VS VATS FOR OSTEO METS](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417) — video · [machine version](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417.md)
- [Update Course Rewind: Pediatric Biliary Stones - Surgery First Mindset 2024](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706) — video · 7:31 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706.md)

### Case-Based Learning
- [Case-Based Journal Review: Cholelithiasis 2024](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797) — podcast · 18:12 · [machine version](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797.md)

## Chapters
- [0:21](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=21) Introduction and Case Presentation (Ep 1)
- [1:56](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=116) Initial Access and Omental Adhesiolysis (Ep 1)
- [4:29](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=269) Modified Top-Down Dissection and Critical View of Safety (Ep 1)
- [7:21](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=441) Cholangiography Indications and Technique (Ep 1)
- [12:09](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=729) Gallbladder Removal and Hemostasis (Ep 1)
- [14:35](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=875) Postoperative Management and Closing Remarks (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=0) Introduction and ICG for Cholecystectomy (Ep 2)
- [3:34](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=214) ICG Cholecystectomy Technique and Timing (Ep 2)
- [9:34](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=574) ICG for Partial Nephrectomy and Varicocele Repair (Ep 2)
- [21:24](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1284) Pulmonary Metastasectomy Case Discussion (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=0) Introduction and case presentation (Ep 3)
- [1:32](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=92) Index admission versus delayed cholecystectomy (Ep 3)
- [4:49](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=289) Predicting common bile duct stones (Ep 3)
- [8:31](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=511) Approach to choledocholithiasis: ERCP versus laparoscopic exploration (Ep 3)
- [13:03](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=783) Indocyanine green fluorescent cholangiography (Ep 3)
- [16:25](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=985) Summary and closing (Ep 3)
- [0:04](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=4) Introduction and Risk Factors for Choledocholithiasis (Ep 4)
- [1:15](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=75) Case Presentation and Risk Stratification (Ep 4)
- [3:34](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=214) Treatment Options: ERCP vs Laparoscopic Exploration (Ep 4)
- [5:07](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=307) Surgery-First Paradigm with Intraoperative Cholangiography (Ep 4)
- [7:41](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=461) Technical Details of Laparoscopic Common Bile Duct Exploration (Ep 4)
- [11:20](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=680) Safety Considerations and Learning Curve (Ep 4)
- [13:48](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=828) Summary and Key Takeaways (Ep 4)
- [0:01](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=1) Introduction and Classification System (Ep 5)
- [1:06](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=66) First Clinical Scenario and Treatment Approaches (Ep 5)
- [2:22](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=142) Surgery-First Evidence and Technique (Ep 5)
- [5:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=300) Equipment and Case Selection (Ep 5)
- [5:43](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=343) Second Clinical Scenario: Sickle Cell Patient (Ep 5)
- [6:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=405) Summary and Key Takeaways (Ep 5)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "In adult centers, surgeons perform 100 to 300 cholecystectomies per year compared to 10 to 30 per year in pediatric centers" — Chiro Esposito (epidemiological) [Ep 2 · 3:34](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=214)
- "ICG is a soluble molecule that rapidly binds to albumin and is removed from circulation by the liver into bile juice" — Chiro Esposito (clinical) [Ep 2 · 0:23](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=23)
- "For cholecystectomy, ICG must be injected 12 to 15 hours preoperatively to allow secretion into bile juice for selective biliary tree visualization" — Chiro Esposito (clinical) [Ep 2 · 7:15](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=435)
- "If ICG is injected intraoperatively for cholecystectomy, the liver takes up the dye and appears green, making gallbladder identification difficult" — Chiro Esposito (clinical) [Ep 2 · 7:51](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=471)
- "For all ICG indications except cholecystectomy (kidney, varicocele, lymphoma, tumors), the injection is given intraoperatively" — Chiro Esposito (clinical) [Ep 2 · 7:51](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=471)
- "ICG vial contains 25 mg in 4 ml, diluted with 10 ml sterile water, with 6 ml injected intravenously for cholecystectomy" — Chiro Esposito (clinical) [Ep 2 · 4:40](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=280)
- "For partial nephrectomy in duplex kidney, ICG is injected three times: via ureteral catheter to identify normal ureter, intravenously to visualize kidney vasculature, and intravenously again after vessel clipping to show devascularization line" — Chiro Esposito (clinical) [Ep 2 · 9:34](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=574)
- "In duplex kidney with reflux, the two ureters are attached to each other, making identification of the normal ureter difficult without ICG" — Chiro Esposito (clinical) [Ep 2 · 9:34](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=574)
- "For varicocele repair, intratesticular injection of 2 ml ICG solution allows intraoperative fluorescence lymphography to identify and spare lymphatic vessels" — Chiro Esposito (clinical) [Ep 2 · 17:30](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1050)
- "Palomo varicocele repair has success rate of more than 97-98% but ligating lymphatics in the spermatic bundle causes postoperative hydrocele in about 20% of cases" — Chiro Esposito (clinical) [Ep 2 · 17:30](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1050)
- "In a series of more than 150 varicocele patients using ICG lymphatic sparing technique, there were zero postoperative hydroceles" — Chiro Esposito (clinical) [Ep 2 · 19:10](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1150)
- "The spermatic bundle contains three to four lymphatic vessels" — Chiro Esposito (clinical) [Ep 2 · 17:30](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1050)
- "There is no maximum dose limit for ICG based on adult surgery studies" — Chiro Esposito (clinical) [Ep 2 · 21:53](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1313)
- "ICG vial remains usable for six hours after preparation" — Chiro Esposito (clinical) [Ep 2 · 21:24](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1284)
- "No adverse effects of ICG were observed in the presenter's experience" — Chiro Esposito (clinical) [Ep 2 · 21:24](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1284)
- "ICG technology can be used in both laparoscopy (requiring special camera and optic) and robotic surgery with Da Vinci XI Firefly system" — Chiro Esposito (clinical) [Ep 2 · 1:20](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=80)
- "The newer Rubin ICG system allows visualization in color with biliary tree appearing green, compared to older systems showing black and white images" — Chiro Esposito (clinical) [Ep 2 · 5:40](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=340)
- "For elective cholecystectomy cases, patients are hospitalized the day before surgery for ICG injection in the late afternoon if surgery is scheduled early morning" — Chiro Esposito (clinical) [Ep 2 · 8:42](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=522)
- "ICG technology helps reduce complications in laparoscopic cholecystectomy, particularly beneficial for trainees and in centers with longer learning curves due to lower case volumes" — Chiro Esposito (opinion) [Ep 2 · 3:34](https://qa.library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=214)
- "Chile has the highest rate of cholelithiasis globally" — Jose Campos (epidemiological) [Ep 3 · 1:07](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=67)
- "In a multi-center study of 167 early cholecystectomy patients versus 79 delayed, early cholecystectomy had 2% recurrence of pancreatitis compared to 22% in delayed surgery" — Cecilia Gigena (host_summary) [Ep 3 · 3:11](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=191)
- "When cholecystectomy was delayed more than 6 weeks after gallstone pancreatitis, recurrence rate increased to 60%" — Cecilia Gigena (host_summary) [Ep 3 · 3:36](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=216)
- "Even in patients with no stones remaining, 2% will get recurrent pancreatitis from the initial insult" — Todd Ponsky (clinical) [Ep 3 · 3:44](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=224)
- "Patients who underwent early cholecystectomy did not have more biliary complications than delayed surgery patients" — Cecilia Gigena (host_summary) [Ep 3 · 4:27](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=267)
- "When patients present with gallstone pancreatitis, most pain and elevated enzymes occur as the stone is passing, and symptoms often resolve overnight as the stone passes" — Todd Ponsky (clinical) [Ep 3 · 5:01](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=301)
- "If laboratory values normalize after gallstone pancreatitis, ERCP is not indicated, but intraoperative cholangiogram should be performed to check for additional stones" — Todd Ponsky (clinical) [Ep 3 · 5:36](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=336)
- "A Western Pediatric Surgery Research Consortium machine learning algorithm based on 1600 patients from 10 centers (2016-2019) can predict common bile duct stones using nine clinical factors, with 20% of patients having CBD stones" — Em Gootee (host_summary) [Ep 3 · 6:26](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=386)
- "The machine learning algorithm for predicting CBD stones has a negative predictive value of 98%, meaning only 2% chance of missing stones when algorithm predicts low risk" — Jose Campos (host_summary) [Ep 3 · 7:11](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=431)
- "The previous algorithm for predicting CBD stones was based on 300-400 patients, compared to 1600 in the new algorithm" — Em Gootee (host_summary) [Ep 3 · 7:33](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=453)
- "For patients with impacted stone, rising lipase, and worsening jaundice, ERCP is preferred because surgeon confidence in retrieving impacted stones intraoperatively is lower" — Todd Ponsky (opinion) [Ep 3 · 8:58](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=538)
- "In a multi-center study of 252 patients with choledocholithiasis, 156 underwent OR-first approach (laparoscopic cholecystectomy with intraoperative cholangiogram) and 96 underwent ERCP-first approach" — Cecilia Gigena (host_summary) [Ep 3 · 11:27](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=687)
- "Patients who underwent intraoperative cholangiogram first had fewer complications and shorter length of stay than ERCP-first patients, and 86% needed only the surgery without subsequent ERCP" — Cecilia Gigena (host_summary) [Ep 3 · 11:41](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=701)
- "The laparoscopic common bile duct exploration study included 4 centers with a broad range of surgeons, demonstrating feasibility beyond single expert centers" — Jose Campos (host_summary) [Ep 3 · 11:56](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=716)
- "Of patients who had ERCP after failed laparoscopic CBD exploration (14% of OR-first group), outcomes were good without increased bile duct leak or complications" — Jose Campos (host_summary) [Ep 3 · 12:15](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=735)
- "In the stepwise laparoscopic CBD exploration approach, 84% of patients had stones cleared with saline flush through a ureteral catheter alone" — Jose Campos (host_summary) [Ep 3 · 12:30](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=750)
- "In a study of 173 laparoscopic cholecystectomies over 10 years (2013-2023), 83 used standard technique and 90 used ICG fluorescence" — Em Gootee (host_summary) [Ep 3 · 13:34](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=814)
- "The ICG study showed perioperative complication rate of 12% in standard technique versus 0% with ICG, with significantly shorter operative times and better biliary visualization in the ICG group" — Em Gootee (host_summary) [Ep 3 · 13:54](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=834)
- "The ICG study compared different time periods rather than contemporaneous groups, confounding the comparison with improvements in surgical skill and instruments over time" — Jose Campos (opinion) [Ep 3 · 14:25](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=865)
- "The ICG study combined all complications without separately reporting common bile duct injuries, and bleeding complications are unlikely attributable to presence or absence of ICG" — Jose Campos (opinion) [Ep 3 · 14:43](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=883)
- "A complication rate of zero in any surgical series raises methodological concerns" — Jose Campos (opinion) [Ep 3 · 14:57](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=897)
- "ICG can be administered intravenously, eliminating the need for instrumentation required by traditional intraoperative cholangiogram" — Todd Ponsky (clinical) [Ep 3 · 15:21](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=921)
- "The ICG study compared ICG to simple visualization without any imaging technique, not to intraoperative cholangiogram, making improved visualization an expected rather than surprising finding" — Jose Campos (opinion) [Ep 3 · 15:38](https://qa.library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=938)
- "Choledocholithiasis stones may be made up of bile pigments or calcium and cholesterol salts." — Cecilia Gigena (host_summary) [Ep 4 · 0:43](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=43)
- "Risk factors for choledocholithiasis include metabolic diseases, hemolysis such as sickle cell, and congenital biliary anomalies like choledochal cysts." — David Vitale (clinical) [Ep 4 · 0:55](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=55)
- "Choledocholithiasis is more common in older children, children with higher BMI, and patients of Hispanic ethnicity." — David Vitale (epidemiological) [Ep 4 · 1:03](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=63)
- "According to ASGE guidelines, patients with high probability of common bile duct stones (common bile duct stones seen on ultrasound, ascending cholangitis, or quite high bilirubin) should go straight to ERCP." — David Vitale (host_summary) [Ep 4 · 1:52](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=112)
- "Patients with intermediate risk (abnormal liver biochemical tests or dilated common bile ducts) can undergo endoscopic ultrasound, MRCP, laparoscopic cholangiogram, or intraoperative ultrasound." — Cecilia Gigena (host_summary) [Ep 4 · 2:11](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=131)
- "In pediatric literature, direct (conjugated) bilirubin more than 2 mg/dL was the most predictive factor for common bile duct stones." — David Vitale (host_summary) [Ep 4 · 2:40](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=160)
- "Common bile duct diameter greater than 6 millimeters was most sensitive for predicting common bile duct stones in children, although without statistical significance." — Cecilia Gigena (host_summary) [Ep 4 · 2:50](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=170)
- "The pediatric duct score (published in Journal of American College of Surgeons with 10 centers) identified three most predictive risk factors: ducts greater than 6 mm, common bile duct stones on ultrasound, or total bilirubin greater than 1.8 mg/dL." — David Vitale (host_summary) [Ep 4 · 3:03](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=183)
- "Pediatric literature with small sample size shows that same-anesthesia laparoscopic cholecystectomy with ERCP in stone disease led to less anesthesia time and lower length of stay." — David Vitale (host_summary) [Ep 4 · 3:41](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=221)
- "Retrospective data comparing ERCP versus laparoscopic common bile duct exploration is conflicted and the choice is institution-dependent and provider-dependent based on expertise." — David Vitale (opinion) [Ep 4 · 4:03](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=243)
- "Randomized trials from 2013 show no significant difference in morbidity, mortality, retained stones, or failure rates between ERCP and laparoscopic common bile duct exploration." — Cecilia Gigena (host_summary) [Ep 4 · 4:18](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=258)
- "Stones above the cystic duct pose a problem because they can float up during attempted laparoscopic removal, making a straightforward procedure much more difficult." — David Vitale (clinical) [Ep 4 · 4:39](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=279)
- "Local expertise and availability is the most important factor in the decision tree between ERCP and laparoscopic common bile duct exploration." — David Vitale (opinion) [Ep 4 · 5:00](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=300)
- "Most free-standing children's hospitals do not have ERCP capabilities." — Cecilia Gigena (host_summary) [Ep 4 · 8:59](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=539)
- "Dr. Neff uses a 12-gauge angiocath for access, which may be hard to find in pediatric hospitals but can be ordered." — Luke Neff (clinical) [Ep 4 · 9:37](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=577)
- "The angle of entry into the cystic ductotomy should be as flat as possible, which is why a new incision is made rather than using existing ports." — Luke Neff (clinical) [Ep 4 · 9:42](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=582)
- "Dr. Neff uses a 6 French urethral stent cut down shorter for better flow, with a glide wire inside, using a coaxial technique to navigate the valves of Heister." — Luke Neff (clinical) [Ep 4 · 9:57](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=597)
- "Dr. Neff typically uses either a 6 millimeter or 8 millimeter angioplasty balloon, but definitely not more than that." — Luke Neff (clinical) [Ep 4 · 10:37](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=637)
- "The balloon dilation technique involves inflating the balloon in the duct, pulling back for tactile feedback to locate the sphincter, partially deflating, straddling the ampulla, then going to full profile under fluoroscopy and holding for about 5 minutes." — Luke Neff (clinical) [Ep 4 · 11:02](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=662)
- "Never use a balloon larger than the dilated common bile duct, as adult literature shows higher rates of pancreatitis with ampullary dilation without sphincterotomy." — David Vitale (clinical) [Ep 4 · 11:23](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=683)
- "After balloon dilation, Dr. Neff creates a seal on the distal common duct by partially inflating a balloon straddling the cystic duct-common duct junction so that flushing through the guide wire lumen gets pressurized downstream." — Luke Neff (clinical) [Ep 4 · 11:55](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=715)
- "If laparoscopic common bile duct exploration is not successful, Dr. Neff places an endoloop on the cystic duct and refers to GI for ERCP." — Luke Neff (clinical) [Ep 4 · 12:16](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=736)
- "If the pancreatic duct is visualized during fluoroscopy, the procedure should be stopped due to higher risk for pancreatitis." — Cecilia Gigena (host_summary) [Ep 4 · 12:24](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=744)
- "The prevalence of stone disease is increasing." — Luke Neff (epidemiological) [Ep 4 · 12:34](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=754)
- "The learning curve for laparoscopic common bile duct exploration is around 5 to 10 cases, though this is person-specific." — Luke Neff (clinical) [Ep 4 · 13:38](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=818)
- "The position of the 12-gauge angiocath is critical, and the ability to manipulate the catheter and wire in the duct depends on the initial setup and how flat the angle of entry is into the cystic duct." — Luke Neff (clinical) [Ep 4 · 13:24](https://qa.library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=804)
- "Stone disease is increasing along with obesity in pediatric patients around the world, not just in the United States." — Em Gootee (host_summary) [Ep 5 · 0:52](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=52)
- "There are two main approaches for patients with stones in the common bile duct who need gallbladder removal: ERCP first to remove ductal stones followed by laparoscopic cholecystectomy, or laparoscopic cholecystectomy with intraoperative cholangiogram to identify and potentially remove stones during the same surgery." — Em Gootee (host_summary) [Ep 5 · 1:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=85)
- "The choice between surgery-first and ERCP-first depends on the setting in which you reside and your own technical capabilities." (opinion) [Ep 5 · 1:50](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=110)
- "A surgery-first pathway reduces resource utilization, including MRCP, according to recently published work." — Em Gootee (host_summary) [Ep 5 · 2:11](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=131)
- "A paper from the Journal of American College of Surgeons defined a very specific and predictive score for cholelithiasis." — Em Gootee (host_summary) [Ep 5 · 2:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=145)
- "ERCP adds potential morbidity to a procedure, and even with good technique, pancreatitis occurs 10% of the time." — Em Gootee (host_summary) [Ep 5 · 3:02](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=182)
- "If the surgeon cannot do a cholangiogram, then ERCP is needed if someone can do it." — Em Gootee (host_summary) [Ep 5 · 3:16](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=196)
- "If you know how to put in a central line and understand the principles of Seldinger technique, then you can do intraoperative stone removal." — Em Gootee (host_summary) [Ep 5 · 3:44](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=224)
- "In a paper published in JPS, stone clearance rate reflected by a negative intraoperative cholangiogram was 86% with a surgery-first mindset." — Em Gootee (host_summary) [Ep 5 · 3:50](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=230)
- "With minor additional techniques like advancing the catheter into the common bile duct or reaming the sphincter, the success rate was in the 90s." — Em Gootee (host_summary) [Ep 5 · 4:01](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=241)
- "At Cincinnati Children's, when surgeons cannot clear the duct, they call from the OR and an ERCP can be performed quickly in most cases." — Em Gootee (host_summary) [Ep 5 · 4:38](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=278)
- "At institutions without access to immediate ERCP, surgeons can place a clip or endo loop, close up, and perform ERCP within the next day or two." — Em Gootee (host_summary) [Ep 5 · 4:47](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=287)
- "According to Doctor Huntington, the biggest key to success is having all the necessary equipment in one place, because no one in the OR is going to know what to get on the fly." — Em Gootee (host_summary) [Ep 5 · 5:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=315)
- "A common bile duct with 3 or 4 impacted stones is typically not suitable for surgery-first approach." — Em Gootee (host_summary) [Ep 5 · 5:26](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=326)
- "Doctor Vitale cautions that when flushing, if a stone is impacted, there is a risk of inadvertently injecting contrast into the pancreatic duct, which can increase the risk of pancreatitis." — Em Gootee (host_summary) [Ep 5 · 6:03](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=363)
- "When the pancreatic duct lights up during flushing, that is a signal to slow down because you can cause pancreatitis by flushing contrast into the pancreatic duct with a stone present." — Em Gootee (host_summary) [Ep 5 · 6:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=375)
- "A study demonstrated an 86% success rate for surgery-first, but the ERCP group had a 10% complication rate, including cholangitis, bleeding, pancreatitis, and hemophilia." — Em Gootee (host_summary) [Ep 5 · 6:33](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=393)
- "Dr. Nathaniel Soper is professor and chairman of the Department of Surgery at the University of Arizona College of Medicine at Phoenix" — Jeff (host_summary) [Ep 1 · 0:21](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=21)
- "In patients with BMI under 32-35, Hasson technique is used for initial umbilical port placement" — Nathaniel Soper (clinical) [Ep 1 · 2:22](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=142)
- "In patients with BMI over 32-35, Veress needle technique is used for initial port placement to avoid large incision required for Hasson" — Nathaniel Soper (clinical) [Ep 1 · 2:27](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=147)
- "Standard port configuration includes epigastric port (placed last for optimal angle), midclavicular line port, and anterior axillary line port in right upper quadrant" — Nathaniel Soper (clinical) [Ep 1 · 3:00](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=180)
- "Omental adhesions to chronically inflamed gallbladder can be taken down using low-wattage cautery or harmonic shears at the junction of omentum with underlying tissue" — Nathaniel Soper (clinical) [Ep 1 · 3:54](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=234)
- "Modified top-down dissection should start approximately one-third of the way up from the infundibulum, not at the fundus" — Nathaniel Soper (clinical) [Ep 1 · 5:03](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=303)
- "Bilateral dissection technique ("waving the flag") alternating between medial and lateral sides provides better three-dimensional view and more freedom for dissection" — Nathaniel Soper (clinical) [Ep 1 · 5:13](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=313)
- "Angled laparoscope is superior to 0-degree laparoscope for laparoscopic cholecystectomy" — Nathaniel Soper (opinion) [Ep 1 · 5:32](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=332)
- "Critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures" — Nathaniel Soper (clinical) [Ep 1 · 5:43](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=343)
- "Dissecting only on the ventral (left) side of the gallbladder limits freedom of movement and makes dissection more difficult" — Nathaniel Soper (clinical) [Ep 1 · 6:11](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=371)
- "Intraoperative ultrasound can be performed multiple times during difficult cholecystectomy to identify gallbladder location and bile duct position relative to dissection" — Nathaniel Soper (clinical) [Ep 1 · 6:52](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=412)
- "Irrigation-suction catheter can be used for blunt (Kittner) dissection in the right hand when there is blood and bile obscuring the field" — Nathaniel Soper (clinical) [Ep 1 · 7:33](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=453)
- "Indocyanine green (ICG) given too early results in everything appearing bright green, limiting its utility" — Nathaniel Soper (clinical) [Ep 1 · 8:12](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=492)
- "In cases with significant tissue inflammation, ICG may not adequately visualize ductal structures" — Nathaniel Soper (clinical) [Ep 1 · 8:19](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=499)
- "Critical 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" — Nathaniel Soper (clinical) [Ep 1 · 9:14](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=554)
- "If critical view of safety cannot be achieved, intraoperative cholangiography is mandatory to clarify ductal anatomy" — Nathaniel Soper (clinical) [Ep 1 · 9:59](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=599)
- "All residents should learn intraoperative cholangiography technique regardless of selective use in practice" — Nathaniel Soper (opinion) [Ep 1 · 10:33](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=633)
- "Intraoperative ultrasound should be taught to residents because it allows visualization beyond visible surfaces in the laparoscopic abdomen" — Nathaniel Soper (opinion) [Ep 1 · 10:44](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=644)
- "Cholangiography adds time and cost, and is not absolutely necessary in the majority of cases" — Nathaniel Soper (clinical) [Ep 1 · 10:56](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=656)
- "Indications for selective intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound" — Nathaniel Soper (clinical) [Ep 1 · 11:11](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=671)
- "Before 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" — Nathaniel Soper (clinical) [Ep 1 · 11:18](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=678)
- "Presence of cystic duct stones is a prime indicator that common bile duct stones are also likely present" — Nathaniel Soper (clinical) [Ep 1 · 11:35](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=695)
- "Chronically inflamed gallbladders are usually intrahepatic with no plane between gallbladder and liver" — Nathaniel Soper (clinical) [Ep 1 · 12:25](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=745)
- "Controlled 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" — Nathaniel Soper (clinical) [Ep 1 · 12:39](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=759)
- "Gallbladder bed hemostasis can be achieved in 99% of cases using cautery with irrigation-suction in left hand and cautery in right hand" — Nathaniel Soper (clinical) [Ep 1 · 13:10](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=790)
- "For suspected duct of Luschka injury in the gallbladder bed, attempt suture closure but drain placement is usually necessary as sutures are unlikely to hold" — Nathaniel Soper (clinical) [Ep 1 · 14:06](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=846)
- "Active drain should be placed for deep intrahepatic gallbladder dissection and left in for several hours or overnight to monitor for bile leak" — Nathaniel Soper (clinical) [Ep 1 · 14:18](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=858)
- "95% of laparoscopic cholecystectomy patients are discharged home the same day" — Nathaniel Soper (clinical) [Ep 1 · 14:40](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=880)
- "Postoperative pain management includes intraoperative IV acetaminophen, prescription for only 5 hydrocodone tablets, and recommendation for ibuprofen or acetaminophen for first few days" — Nathaniel Soper (clinical) [Ep 1 · 14:52](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=892)
- "Pain requiring more than 5 hydrocodone tablets postoperatively suggests a problem and warrants patient contact" — Nathaniel Soper (clinical) [Ep 1 · 15:00](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=900)

## Changelog
- Sep 15: 1 item added automatically
- Sep 7: 4 items added automatically

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