# Hepatobiliary & Colorectal Surgery — GCMD Library living collection

Updated: n/a · 11 episodes · 96 cited statements

## Episodes
### Biliary Disease
- [Cholecystitis- Drs Jeffrey Ponsky and Rae Hanke](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721) — video · 24:33 · [machine version](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721.md)
- [StayCurrent Forums](https://qa.library.globalcastmd.com/watch/staycurrent-forums-13733) — video · [machine version](https://qa.library.globalcastmd.com/watch/staycurrent-forums-13733.md)
- [StayCurrent Forums - Laparoscopic Cholecystectomy](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-13739) — podcast · [machine version](https://qa.library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-13739.md)
- [Update Course Rewind: Pediatric Biliary Stones - Preventing Gallstone Pancreatitis 2024](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735) — video · 3:53 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735.md)
- [Update Course Rewind: Pediatric Biliary Stones - Preventing Gallstone Pancreatitis 2024](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736) — podcast · 3:53 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736.md)
- [Intra-operative Bile Leak During Cholecystectomy](https://qa.library.globalcastmd.com/watch/intra-operative-bile-leak-during-cholecystectomy-13732) — video · [machine version](https://qa.library.globalcastmd.com/watch/intra-operative-bile-leak-during-cholecystectomy-13732.md)

### Hernia Surgery
- [Inguinal Hernia With M. Rosen](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756) — podcast · 31:05 · [machine version](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756.md)

### Colorectal Cancer
- [Colorectal Cancer](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749) — podcast · 26:42 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749.md)

### Pediatric Obesity
- [Staycurrent Forums](https://qa.library.globalcastmd.com/watch/staycurrent-forums-13740) — podcast · [machine version](https://qa.library.globalcastmd.com/watch/staycurrent-forums-13740.md)

### General Digestive Health
- [StayCurrent Forums Trailer](https://qa.library.globalcastmd.com/watch/staycurrent-forums-trailer-13734) — video · [machine version](https://qa.library.globalcastmd.com/watch/staycurrent-forums-trailer-13734.md)
- [Commercial Audio Only (1080p)](https://qa.library.globalcastmd.com/watch/commercial-audio-only-13743) — podcast · 0:37 · [machine version](https://qa.library.globalcastmd.com/watch/commercial-audio-only-13743.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=0) Introduction and Course Framework (Ep 4)
- [0:53](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=53) Case Presentation: Neutropenic Patient with Cholecystitis (Ep 4)
- [1:40](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=100) Management of Gallstone Pancreatitis (Ep 4)
- [3:11](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=191) Summary and Key Takeaways (Ep 4)
- [0:19](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=19) Pathophysiology and Risk Factors of Cholecystitis (Ep 1)
- [3:37](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=217) Clinical Presentation and Diagnostic Evaluation (Ep 1)
- [8:08](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=488) Advanced Imaging and Biliary Dyskinesia (Ep 1)
- [12:31](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=751) Medical Management and Antibiotic Selection (Ep 1)
- [14:14](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=854) Surgical Technique and Anatomical Considerations (Ep 1)
- [19:22](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1162) Conversion to Open Surgery (Ep 1)
- [20:08](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1208) Post-operative Complications and Management (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=0) Introduction and Update Course Classification System (Ep 5)
- [0:53](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=53) Case Presentation: Neutropenic Patient with Cholecystitis (Ep 5)
- [1:39](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=99) Gallstone Pancreatitis Management Discussion (Ep 5)
- [3:11](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=191) Summary and Closing (Ep 5)
- [0:00](https://qa.library.globalcastmd.com/watch/commercial-audio-only-13743?t=0) New Interview Series Announcement (Ep 11)
- [0:00](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=0) Introduction and colonoscopy screening (Ep 8)
- [2:03](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=123) Serrated adenomas: recognition and management (Ep 8)
- [4:16](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=256) Rectal cancer: location and surgical margins (Ep 8)
- [9:03](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=543) Rectal cancer staging: MRI versus ultrasound (Ep 8)
- [14:07](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=847) Transanal resection: indications and limitations (Ep 8)
- [16:58](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1018) Neoadjuvant therapy for rectal cancer (Ep 8)
- [19:22](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1162) Sigmoid and left colon cancer surgery (Ep 8)
- [22:29](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1349) Right colon and cecal cancer surgery (Ep 8)
- [24:13](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1453) Genetic assessment and hereditary syndromes (Ep 8)
- [0:00](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=0) Asymptomatic Hernias and Watchful Waiting (Ep 7)
- [5:00](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=300) High-Risk Patients and Non-Operative Management (Ep 7)
- [7:55](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=475) Selecting Operative Approach: Open versus Laparoscopic (Ep 7)
- [13:52](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=832) Contraindications and Patient Selection for Laparoscopy (Ep 7)
- [17:06](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1026) Laparoscopic Technique and Mesh Placement (Ep 7)
- [23:43](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1423) Mesh Selection and Fixation (Ep 7)
- [25:18](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1518) Open Repair Techniques and Femoral Hernias (Ep 7)
- [28:04](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1684) Special Scenarios: Recurrent, Bilateral, and Incarcerated Hernias (Ep 7)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The patient spontaneously passed the stone, LFTs came back down, counts recovered, and he proceeded to elective cholecystectomy. — Luke Neff (clinical) [Ep 4 · 1:31](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=91)
- From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, ERCP is not performed right away in gallstone pancreatitis. — Jeff Ponsky (clinical) [Ep 4 · 2:13](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=133)
- When symptoms are improving in gallstone pancreatitis (biochemical normalization is not required), the approach is to proceed to cholecystectomy with intraoperative cholangiogram and coordinate with ERCP availability in case it might be needed. (clinical) [Ep 4 · 2:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=145)
- Studies show that if you wait one day when a patient comes in with acute biliary pancreatitis and the amylase/lipase go up, then you do ERCP because the stone is impacted; but most of the time the levels will go right down as the stone passes spontaneously, and you can proceed to cholecystectomy. — David Vitale (clinical) [Ep 4 · 2:38](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=158)
- Most stones can be cleared, some stones pass spontaneously, and good clinical judgment with local resources must be factored into management decisions. — Luke Neff (opinion) [Ep 4 · 2:59](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=179)
- A 16-year-old male with acute lymphoblastic leukemia (ALL), neutropenic and thrombocytopenic, presented with right upper quadrant pain, markedly elevated liver function tests, and ultrasound findings consistent with acute cholecystitis and choledocholithiasis. — David Vitale (clinical) [Ep 5 · 0:53](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=53)
- Over 50% of the live and virtual audience poll opted to start antibiotics and address the elevated liver function tests in the neutropenic thrombocytopenic patient. — David Vitale (opinion) [Ep 5 · 1:18](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=78)
- Dr. Neff's patient spontaneously passed the stone, LFTs came back down, counts recovered, and the patient proceeded to elective cholecystectomy. — David Vitale (clinical) [Ep 5 · 1:27](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=87)
- Gallstone pancreatitis is inflammation of the pancreas triggered by a gallstone obstructing the bile duct, which can also impede pancreatic drainage, preventing pancreatic enzymes from reaching the small intestine and leading them to accumulate and damage the pancreas. — Luke Neff (clinical) [Ep 5 · 1:39](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=99)
- Some surgeons will do cholecystectomy within a few days for gallstone pancreatitis, while others will wait for a week. — Luke Neff (opinion) [Ep 5 · 2:07](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=127)
- From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, ERCP is not performed right away for gallstone pancreatitis. — Luke Neff (clinical) [Ep 5 · 2:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=135)
- When symptoms are improving in gallstone pancreatitis, cholecystectomy with intraoperative cholangiogram can proceed without waiting for biochemical normalization, coordinating with ERCP availability if needed. — David Vitale (clinical) [Ep 5 · 2:24](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=144)
- Studies have shown that if amylase and lipase levels go up when a patient comes in with acute biliary pancreatitis and then start going down, the stone has likely passed and the patient can proceed to cholecystectomy. — Luke Neff (clinical) [Ep 5 · 2:38](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=158)
- If amylase and lipase continue to rise one day after presentation with acute biliary pancreatitis, ERCP should be performed because the stone is likely impacted. — Luke Neff (clinical) [Ep 5 · 2:38](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=158)
- Most biliary stones can be cleared, and some stones pass spontaneously, requiring good clinical judgment. — David Vitale (clinical) [Ep 5 · 2:59](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=179)
- Local resources and what is available must be factored into management decisions for biliary stones. — David Vitale (opinion) [Ep 5 · 3:07](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=187)
- Colonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect. — Conor Delaney (clinical) [Ep 8 · 1:15](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=75)
- Serrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes. — Conor Delaney (clinical) [Ep 8 · 2:03](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=123)
- Serrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome. — Conor Delaney (clinical) [Ep 8 · 2:03](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=123)
- Serrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds. — Conor Delaney (clinical) [Ep 8 · 3:26](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=206)
- Six centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds). — Conor Delaney (clinical) [Ep 8 · 4:59](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=299)
- Distal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated. — Conor Delaney (guideline) [Ep 8 · 4:59](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=299)
- MRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer. — Conor Delaney (clinical) [Ep 8 · 13:18](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=798)
- Endoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer. — Conor Delaney (clinical) [Ep 8 · 13:18](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=798)
- Historical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent. — Conor Delaney (epidemiological) [Ep 8 · 9:03](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=543)
- With optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent. — Conor Delaney (epidemiological) [Ep 8 · 9:03](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=543)
- For total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection. — Conor Delaney (guideline) [Ep 8 · 9:03](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=543)
- A total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane. — Conor Delaney (clinical) [Ep 8 · 9:03](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=543)
- Most accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive. — Conor Delaney (guideline) [Ep 8 · 9:03](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=543)
- For node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted. — Conor Delaney (guideline) [Ep 8 · 13:11](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=791)
- Historical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers. — Conor Delaney (epidemiological) [Ep 8 · 14:07](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=847)
- Transanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1. — Conor Delaney (guideline) [Ep 8 · 14:07](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=847)
- For young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required. — Conor Delaney (opinion) [Ep 8 · 14:07](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=847)
- For rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps. — Conor Delaney (clinical) [Ep 8 · 16:23](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=983)
- In Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later. — Conor Delaney (guideline) [Ep 8 · 17:25](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1045)
- In the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period. — Conor Delaney (guideline) [Ep 8 · 17:25](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1045)
- Twenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging. — Conor Delaney (clinical) [Ep 8 · 17:25](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1045)
- For colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16. — Conor Delaney (guideline) [Ep 8 · 19:22](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1162)
- Total mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete. — Conor Delaney (clinical) [Ep 8 · 19:22](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1162)
- Scandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery. — Conor Delaney (epidemiological) [Ep 8 · 19:22](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1162)
- For a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken. — Conor Delaney (guideline) [Ep 8 · 22:44](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1364)
- Extracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic. — Conor Delaney (epidemiological) [Ep 8 · 23:59](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1439)
- Genetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family. — Conor Delaney (guideline) [Ep 8 · 24:32](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1472)
- Genetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection. — Conor Delaney (clinical) [Ep 8 · 24:32](https://qa.library.globalcastmd.com/watch/colorectal-cancer-13749?t=1472)
- In Fitzgibbons' VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%). — Michael Rosen (epidemiological) [Ep 7 · 3:22](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=202)
- In Fitzgibbons' original two-year VA study, almost one-third of patients in the observation group went on to develop symptoms and need an operation. — Michael Rosen (epidemiological) [Ep 7 · 4:00](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=240)
- In long-term follow-up of Fitzgibbons' VA study patients (approximately five years), almost three-quarters of patients developed symptoms requiring repair. — Michael Rosen (epidemiological) [Ep 7 · 4:20](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=260)
- The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200 to 250 cases required. — Michael Rosen (clinical) [Ep 7 · 8:40](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=520)
- In laparoscopic inguinal hernia repair, mesh is placed away from the nerves, and the risk of chronic pain when done correctly is lower than in open inguinal hernias. — Michael Rosen (clinical) [Ep 7 · 9:20](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=560)
- Laparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair, not a month or three to four months. — Michael Rosen (clinical) [Ep 7 · 12:10](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=730)
- The most important part of any laparoscopic repair is parietalization of the cord (stripping the peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs. — Michael Rosen (clinical) [Ep 7 · 18:20](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1100)
- The risk of recurrence in laparoscopic repair is the peritoneum coming under the mesh and then going back out to the defect inferiorly. — Michael Rosen (clinical) [Ep 7 · 18:40](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1120)
- According to Stoppa's original descriptions, for a unilateral inguinal hernia repair, one should never use less than a 15 by 15 centimeter piece of mesh (or 6 by 6 inch), which is much bigger than the vast majority of laparoscopic preformed meshes being placed. — Michael Rosen (clinical) [Ep 7 · 20:00](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1200)
- Heavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene mesh), midweight mesh is 40-50 grams per meter squared, and lightweight mesh (Ultrapro) is less than 30 grams per meter squared. — Michael Rosen (clinical) [Ep 7 · 21:20](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1280)
- The advantage of lighter weight mesh is less foreign body and potentially less contraction due to better ingrowth; the disadvantage is half the material, which in direct hernias where muscles never come back together puts the mesh at risk for fracturing. — Michael Rosen (clinical) [Ep 7 · 22:00](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1320)
- There is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation. — Michael Rosen (clinical) [Ep 7 · 24:09](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1449)
- If absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself. — Michael Rosen (clinical) [Ep 7 · 24:20](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1460)
- There is mounting evidence that medium-weight polypropylene mesh can be placed in a contaminated field, with several series demonstrating this in ventral hernias. — Michael Rosen (clinical) [Ep 7 · 24:56](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1496)
- For incarcerated femoral hernias, the lacunar ligament can be released medially to gain an extra centimeter of space for reduction without destroying the inguinal floor or inguinal ligament. — Michael Rosen (clinical) [Ep 7 · 27:00](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1620)
- For recurrent hernias, the surgeon should go where nobody has been before; if somebody has been in both places, go where you are best. — Michael Rosen (opinion) [Ep 7 · 28:12](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1692)
- For bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach. — Michael Rosen (opinion) [Ep 7 · 28:30](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1710)
- Surgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, although these patients might benefit most, they have the highest risk. — Michael Rosen (opinion) [Ep 7 · 28:40](https://qa.library.globalcastmd.com/watch/inguinal-hernia-with-m-rosen-13756?t=1720)
- Cholecystitis is an obstructive diverticulopathy, similar to appendicitis or diverticulitis of the colon, involving blind pouches with narrow outlets that can become obstructed. — Jeff Ponsky (clinical) [Ep 1 · 0:36](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=36)
- When the cystic duct becomes obstructed by a stone or mucus plug, gallbladder contents increase due to secretion while arterial inflow at 120 mmHg continues but venous outflow at 7-8 mmHg is overcome, trapping blood within the gallbladder wall. — Jeff Ponsky (clinical) [Ep 1 · 0:50](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=50)
- Biliary colic occurs when the obstructing stone falls away early in the process, allowing the patient to become asymptomatic, and this can recur with multiple episodes of intense pain. — Jeff Ponsky (clinical) [Ep 1 · 1:17](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=77)
- Without relief of obstruction, the gallbladder may undergo ischemia, leading to pericholecystic fluid, empyema, and subhepatic abscess. — Jeff Ponsky (clinical) [Ep 1 · 1:47](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=107)
- Acalculous cholecystitis occurs when the gallbladder becomes atonic in patients who haven't been eating for a long time or are critically ill, with continued fluid secretion and poor emptying despite absence of stones. — Jeff Ponsky (clinical) [Ep 1 · 2:22](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=142)
- Southwestern Indians and patients in South America have a high incidence of gallstones due to genetic predispositions. — Jeff Ponsky (epidemiological) [Ep 1 · 3:07](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=187)
- Patients with hemolytic diseases such as sickle cell anemia or spherocytosis can develop bile salt stones. — Jeff Ponsky (clinical) [Ep 1 · 3:19](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=199)
- Patients with rapid weight loss from diets or weight loss surgery develop gallstones with increased frequency. — Jeff Ponsky (clinical) [Ep 1 · 3:27](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=207)
- Biliary colic typically presents with right upper quadrant pain and nausea, often with vomiting, 20 minutes to 2 hours after eating due to cholecystokinin secretion from duodenal mucosa in response to fat. — Jeff Ponsky (clinical) [Ep 1 · 3:47](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=227)
- Murphy's sign—tenderness with a deep breath in the right upper quadrant that stops the patient's breath—suggests cholecystitis but can be present in other conditions including pancreatitis. — Jeff Ponsky (clinical) [Ep 1 · 5:42](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=342)
- Transaminases are elevated out of proportion in hepatocellular disease, while alkaline phosphatase and GGT are elevated out of proportion in biliary duct obstruction. — Jeff Ponsky (clinical) [Ep 1 · 6:13](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=373)
- Right upper quadrant ultrasound is superior to CT scan for initial diagnosis of cholecystitis and biliary colic because it shows gallbladder anatomy, wall thickness, pericholecystic fluid, stones in the gallbladder, and common bile duct diameter. — Jeff Ponsky (opinion) [Ep 1 · 6:52](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=412)
- CT scan is better than ultrasound when pancreatitis is suspected or there is any question about the pancreas. — Jeff Ponsky (opinion) [Ep 1 · 7:33](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=453)
- ERCP should not be performed for minimal bilirubin elevation (less than 2) or acute pancreatitis that improves in the first day, as studies show two-thirds of these patients have a normal duct because they passed the stone. — Jeff Ponsky (guideline) [Ep 1 · 8:21](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=501)
- ERCP should be performed when bilirubin is 4 or higher and not improving, as other conditions like ampullary tumors and ductal problems could cause elevated bilirubin. — Jeff Ponsky (guideline) [Ep 1 · 8:52](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=532)
- Patients should not be taken to the operating room for gallbladder operation with deep jaundice without advanced biliary imaging like ERCP or MRCP. — Jeff Ponsky (guideline) [Ep 1 · 9:02](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=542)
- Intraoperative cholangiogram should be performed if there is elevated bilirubin, abnormal liver functions, dilated duct on ultrasound, or recent pancreatitis—this is called selective cholangiography. — Jeff Ponsky (guideline) [Ep 1 · 9:46](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=586)
- HIDA scan evaluates gallbladder function rather than anatomy; if the gallbladder does not fill, this indicates cystic duct obstruction and acalculous cholecystitis. — Jeff Ponsky (clinical) [Ep 1 · 11:17](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=677)
- CCK cholecystography with IV cholecystokinin or fatty meal evaluates gallbladder motility; a normal gallbladder has an ejection fraction over 35%, while ejection fraction less than 35% indicates biliary dyskinesia. — Jeff Ponsky (clinical) [Ep 1 · 11:56](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=716)
- Current practice is to perform surgery during the index hospitalization after patient stabilization, rather than the old approach of bed rest, NPO, IV antibiotics, discharge, and delayed surgery in six weeks. — Jeff Ponsky (guideline) [Ep 1 · 12:43](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=763)
- Percutaneous transhepatic cholecystostomy to vent the gallbladder can be used in unstable patients (such as recent MI) with acute cholecystitis, allowing delayed surgery when the patient is lower risk. — Jeff Ponsky (clinical) [Ep 1 · 13:15](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=795)
- Antibiotic coverage for cholecystitis should target E. coli, Enterococcus, Klebsiella, and Enterobacter, with cephalosporins and fluoroquinolones being appropriate choices. — Jeff Ponsky (guideline) [Ep 1 · 13:53](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=833)
- The cystic duct can have aberrant entries including into the right hepatic duct, an accessory right hepatic duct, or can run parallel with the common duct in a common sheath all the way to the papilla of Vater. — Jeff Ponsky (clinical) [Ep 1 · 15:00](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=900)
- Anatomical variations include double gallbladder, totally intrahepatic gallbladder, and cystic artery that can flip over the cystic duct. — Jeff Ponsky (clinical) [Ep 1 · 15:41](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=941)
- Calot's triangle is bordered by the cystic duct below and the cystic artery above. — Jeff Ponsky (clinical) [Ep 1 · 16:45](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1005)
- The critical view of safety requires visualization of the cystic duct, cystic artery, and location of the common duct before dividing any structures. — Jeff Ponsky (guideline) [Ep 1 · 17:29](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1049)
- The gallbladder bed should be inspected with the abdomen deflated after removing the gallbladder, as pneumoperitoneum pressure can mask bleeding. — Jeff Ponsky (clinical) [Ep 1 · 18:59](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1139)
- Conversion to open surgery is indicated for dense adhesions, unclear anatomy, unplanned bleeding, or lack of progress, and is a management decision rather than a failure. — Jeff Ponsky (opinion) [Ep 1 · 19:25](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1165)
- Post-operative tachycardia, hypotension, or requirement for fluid pushes in the recovery room is not normal and may indicate acute bleeding from the cystic artery, requiring immediate return to the operating room. — Jeff Ponsky (clinical) [Ep 1 · 20:21](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1221)
- A patient presenting to the emergency department 2-3 days post-operatively with right upper quadrant pain should be assumed to have a complication, most often a bile leak. — Jeff Ponsky (clinical) [Ep 1 · 20:45](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1245)
- For suspected bile leak, CT scan showing fluid in the gallbladder fossa should be tapped by radiology to confirm bile, followed by pigtail catheter placement and immediate ERCP. — Jeff Ponsky (guideline) [Ep 1 · 21:11](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1271)
- A biliary stent lowers pressure in the normal direction to zero, allowing bile leak from cystic duct or duct of Luschka to heal within days, with stent removal at six weeks. — Jeff Ponsky (clinical) [Ep 1 · 21:48](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1308)
- Retained common bile duct stones can be removed with ERCP with a 95% success rate. — Jeff Ponsky (clinical) [Ep 1 · 22:30](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1350)
- A patient with cholecystitis should not leave the hospital until they have their operation performed. — Jeff Ponsky (guideline) [Ep 1 · 24:04](https://qa.library.globalcastmd.com/watch/cholecystitis-drs-jeffrey-ponsky-and-rae-hanke-13721?t=1444)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The speaker is Rod Gerardo from Cincinnati Children's — Rod Gerardo summarizing a resource [Ep 11 · 0:00](https://qa.library.globalcastmd.com/watch/commercial-audio-only-13743?t=0)
- The new content format differs from existing YouTube videos and podcasts that go deep in the weeds with pediatric surgery — Rod Gerardo summarizing a resource [Ep 11 · 0:10](https://qa.library.globalcastmd.com/watch/commercial-audio-only-13743?t=10)
- Dr. Jeff Ponsky will co-conduct interviews with Rod Gerardo — Rod Gerardo summarizing a resource [Ep 11 · 0:20](https://qa.library.globalcastmd.com/watch/commercial-audio-only-13743?t=20)
- Interview subjects will include residents, fellows, and attendings from around the globe — Rod Gerardo summarizing a resource [Ep 11 · 0:24](https://qa.library.globalcastmd.com/watch/commercial-audio-only-13743?t=24)
- Topics will cover resident wellness, general surgery concepts, and new technologies — Rod Gerardo summarizing a resource [Ep 11 · 0:28](https://qa.library.globalcastmd.com/watch/commercial-audio-only-13743?t=28)
- Episodes will be available on the Stay Current Pediatric Surgery app and social media channels — Rod Gerardo summarizing a resource [Ep 11 · 0:32](https://qa.library.globalcastmd.com/watch/commercial-audio-only-13743?t=32)
- The patient is a 16-year-old currently undergoing treatment for acute lymphoblastic leukemia (ALL) who presents with right upper quadrant pain, neutropenia, markedly elevated liver function tests, and ultrasound findings consistent with acute cholecystitis and choledocholithiasis. — Em Gootee summarizing the discussion [Ep 4 · 0:56](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=56)
- In this neutropenic and thrombocytopenic patient, the approach taken was to start antibiotics and address the elevated liver function tests. — Em Gootee summarizing the discussion [Ep 4 · 1:20](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=80)
- Gallstone pancreatitis is inflammation of the pancreas triggered by a gallstone obstructing the bile duct, which can also impede pancreatic drainage, preventing pancreatic enzymes from reaching the small intestine and leading them to accumulate and damage the pancreas. — Em Gootee summarizing the discussion [Ep 4 · 1:49](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=109)
- In neutropenic and thrombocytopenic patients with cholecystitis and choledocholithiasis, initial conservative management with antibiotics can be effective, particularly when spontaneous stone passage occurs. — Em Gootee summarizing the discussion [Ep 4 · 3:11](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=191)
- For gallstone pancreatitis, early ERCP is typically reserved for cases with persistent biliary obstruction or cholangitis, as many patients improve without intervention. — Em Gootee summarizing the discussion [Ep 4 · 3:22](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=202)
- The timing of cholecystectomy in gallstone pancreatitis should be based on clinical improvement rather than complete biochemical normalization, with intraoperative cholangiogram and ERCP coordinated as needed. — Em Gootee summarizing the discussion [Ep 4 · 3:33](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-10735?t=213)
- The 12th annual update course in pediatric surgery introduced a new classification system with three categories: Green Circle for established practice, Blue Square for promising newer practice, and Black Diamond for early adopter practice only. — Em Gootee summarizing the discussion [Ep 5 · 0:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=8)
- In neutropenic and thrombocytopenic patients with cholecystitis and choledocholithiasis, initial conservative management with antibiotics can be effective, particularly when spontaneous stone passage occurs. — Em Gootee summarizing the discussion [Ep 5 · 3:11](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=191)
- For gallstone pancreatitis, early ERCP is typically reserved for cases with persistent biliary obstruction or cholangitis, as many patients improve without intervention. — Em Gootee summarizing the discussion [Ep 5 · 3:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=205)
- The timing of cholecystectomy in gallstone pancreatitis should be based on clinical improvement rather than complete biochemical normalization, with intraoperative cholangiogram and ERCP coordinated as needed. — Em Gootee summarizing the discussion [Ep 5 · 3:35](https://qa.library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-preventing-gallstone-pancreatitis-13736?t=215)

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