John Rodriguez

251 statements · 2 topics

Featured statements

the reality of things is that a lot of times in some of these more severe cases, Going open and trying to be heroic and going for that cystic duct is not that safe either.
quote · Acute Cholecystitis
The reality of things is a lot of times in some of these more severe cases going open and trying to be heroic and going for that cystic duct is not that safe either.
quote · Acute Cholecystitis
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.
clinical · Choledocholithiasis
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.
clinical · Choledocholithiasis

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John's statements about Acute Cholecystitis 148 statements

Open the Acute Cholecystitis collection →

Acute Cholecystitis

Quotation I think the ones that we try to cool down and try to get them out of the hospital have a high recurrence rate, and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. Open
Statement Early cholecystectomy is favored for straightforward acute cholecystitis because patients managed conservatively have a high recurrence rate and often return on weekends Open
Statement 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 Open
Quotation The last thing you want to do is, you know, take a patient with a very significant cardiac history to the operating room and end up giving her an acute cardiac event. Open
Statement 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 Open
Quotation So most of these patients actually have an uneventful recovery and they're able to leave the hospital. Open
Statement Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in high-risk patients Open
Quotation I think it's very important that before taking these tubes, you have a good discussion about the patient of what is, you know, the potential of her developing a recurrent episode. Open
Statement 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 Open
Statement 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 Open
Statement Laparoscopic approach is used in 99% of cholecystectomy cases even in very difficult acute cases Open
Quotation I think we've all gotten pretty good at doing laparoscopic cholecystectomies even in, in, in, you know, very difficult cases. Open
Statement 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 Open
Statement In acute cholecystitis, edematous omental tissue bleeds easily, and controlling bleeding early with cautery prevents impaired visualization later in the operation Open
Quotation I find it that when you don't control the bleeding early on, it tends to impede with your visualization later on. Open
Statement There is a low threshold to decompress tense, hard gallbladders before attempting to grasp them to prevent tearing Open
Quotation I have a very low threshold to decompress those gallbladders before you start trying to grab them Open
Statement Gallbladder decompression is performed at the fundus using a long reusable needle connected to a 60cc syringe under direct vision Open
Statement 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 Open
Statement 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 Open
Quotation I, I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well. Open
Statement 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 Open
Statement Taking the back wall of the gallbladder off the liver bed just superior to the cystic duct junction provides increased length for safer dissection Open
Statement Routine cholangiography is used in nearly all cholecystectomy cases Open
Statement 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 Open
Statement Flushing the cystic duct with 20cc of saline before cholangiography clears sludge and stones and removes air bubbles from the system Open
Quotation I think clearing that before you should do your chalangiogram, uh, can be very helpful. It also gets some of those air bubbles out of the system. Open
Statement 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 Open
Statement For small distal common bile duct stones, flushing the duct again and giving glucagon to relax the ampulla should be attempted first Open
Statement Transcystic common bile duct exploration uses a commercial kit with a percutaneous introducer, step dilator, and wire placed under fluoroscopic guidance into the duodenum Open
Quotation I'm always worried about trauma to the duct and, and, and backwalling it. Open
Statement 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 Open
Statement Transcystic exploration kits include a Dormier-type basket for stone extraction and a balloon dilator for antegrade sphincteroplasty to push small stones through Open
Quotation I think if it's a small stone, most of the time it's easier to do that than to try to Open
Quotation I am very aggressive about, in cases like that, going in a top down fashion. Open
Statement When the infundibulum, cystic duct, artery, and Calot's triangle cannot be defined due to severe inflammation, a dome-down approach is used aggressively Open
Quotation the reality of things is that a lot of times in some of these more severe cases, Going open and trying to be heroic and going for that cystic duct is not that safe either. Open
Statement In severe acute cholecystitis cases, going open and attempting to reach the cystic duct is often not safe either Open
Statement Bailout options for severe inflammation include opening the gallbladder for partial cholecystectomy or leaving part of the back wall on the liver Open
Statement 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 Open
Statement Many postoperative bile leaks attributed to ducts of Luschka are actually from surgeons dissecting too deep into the liver and injuring the ductal system Open
Statement 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 Open
Statement The primary goal in severe acute cholecystitis is avoiding major bile duct injury, which would be a disaster for the patient Open
Quotation I think it's always the safest thing to do. I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster Open
Statement When leaving the back wall of a necrotic gallbladder, the mucosa is cauterized on a high coagulation setting and a drain is left Open

Acute Cholecystitis

Statement Patients with acute cholecystitis who are cooled down and discharged have a high recurrence rate and typically return on weekends, making management more difficult. Open
Quotation I think the ones that we try to cool down and and try to get them out of the hospital have a high recurrence rate and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. Open
Statement 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. Open
Quotation The last thing you want to do is, you know, take a patient with a very significant, uh, cardiac history to the operating room and end up giving her an acute, uh, cardiac event. Open
Statement 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. Open
Statement Many patients with acute cholecystitis will cool down with antibiotics alone and no additional intervention is needed. Open
Statement Percutaneous cholecystostomy tubes can be very helpful for patients who are not good candidates for operative intervention. Open
Statement 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. Open
Quotation I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients. Open
Statement The combination of percutaneous cholecystostomy tubes with antibiotics is very effective in managing acute cholecystitis in sicker patients, with most having an uneventful recovery. Open
Statement 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. Open
Quotation I think it's very important that before taking these tubes, you have a good discussion about the patient and what is, you know, the potential of her developing a recurrent episode. Open
Statement 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. Open
Quotation As soon as you take that tube out, they'll get a recurrent episode. Open
Statement 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. Open
Statement 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. Open
Quotation I think it's, it, there are cases that need to be planned well. Open
Statement 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. Open
Quotation In my experience, those gallbladders tend to be pretty challenging, and they, they take up quite some time to do. Open
Statement Gallbladders in patients with prior cholecystostomy tubes tend to be pretty challenging and take quite some time to remove. Open
Statement 99% of the time the approach for cholecystectomy is laparoscopic, even in very difficult cases. Open
Quotation I think we've all gotten pretty good at doing laparoscopic cholecystectomies even in, in, in, you know, very difficult cases. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement Hook electrocautery is a very fine dissecting tool that tends to be hemostatic for taking down omental adhesions. Open
Statement 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. Open
Statement Decompressing the gallbladder allows grasping without tearing the wall. Open
Statement 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. Open
Statement The suction device is a great dissection tool during laparoscopic cholecystectomy. Open
Statement 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. Open
Quotation As long as you're on the gallbladder, you know you're safe. Open
Statement 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. Open
Quotation That's where, that's how you get in trouble in, in some of these cases. Open
Statement The Maryland dissector is a great tool for gentle dissection at the junction between the cystic duct and gallbladder. Open
Statement Moving the gallbladder back and forth with the left hand allows dissection on the lateral side, which is always a safe spot. Open
Quotation I, I, I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well. Open
Statement 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. Open
Statement Routine cholangiography is used in almost all cholecystectomy cases. Open
Statement 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. Open
Statement Giving the cholangiogram catheter a 45-degree angle before placing it into the body helps with cannulation. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement There is no hesitation to add another trochar when needed during laparoscopic cholecystectomy. Open
Statement 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. Open
Quotation The reality of things is a lot of times in some of these more severe cases going open and trying to be heroic and going for that cystic duct is not that safe either. Open
Statement 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. Open
Statement When converting to open cholecystectomy for severe inflammation, the approach is still top-down dissection. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement In subtotal cholecystectomy cases, a drain is left most of the time to control a bile leak if it occurs. Open
Quotation That would be one of those horrible cases that you start wishing you were never there from the start. Open
Quotation I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster for the patient. Open
Statement 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. Open
Statement When leaving the back wall of the gallbladder, cauterize the mucosa with coagulation on a high setting. Open

Acute Cholecystitis

Statement Patients with acute cholecystitis who are cooled down and discharged have a high recurrence rate and often return on weekends, making management more difficult. Open
Quotation I think the ones that we try to cool down and and try to get them out of the hospital have a high recurrence rate and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. Open
Statement 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. Open
Quotation The last thing you want to do is, you know, take a patient with a very significant, uh, cardiac history to the operating room and end up giving her an acute cardiac event. Open
Statement In patients with significant cardiac history, the risk of taking them to the operating room includes precipitating an acute cardiac event. Open
Statement Percutaneous cholecystostomy tubes placed by interventional radiology can be very helpful for patients who are not good candidates for operative intervention. Open
Statement 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. Open
Quotation I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients. Open
Statement 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. Open
Quotation I think it's very important that before taking these tubes, you have a good discussion about the patient of what is, you know, the potential of her developing a recurrent episode. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Quotation And that's where, that's how you get in trouble in, in some of these cases. Open
Statement 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. Open
Quotation I've always, especially when I teach residents, I, I, I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well. Open
Statement 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. Open
Statement Flushing the cystic duct with 20cc of saline before cholangiography helps clear sludge and stones and removes air bubbles from the system. Open
Quotation I think clearing that before you should do your cholangiogram, uh, can be very helpful. It also gets some of those air bubbles out of the system. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Quotation And, and the reality of things is that a lot of times in some of these more severe cases, going open and trying to be heroic and going for that cystic duct is not that safe either. Open
Statement 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. Open
Quotation I think it's just that the surgeon gets a little bit too deep into the liver and injures, um, what do you horrible gallbladder. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Quotation I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster. Open
John's statements about Choledocholithiasis 103 statements

Open the Choledocholithiasis collection →

Acute Cholecystitis

Quotation I think the ones that we try to cool down and and try to get them out of the hospital have a high recurrence rate and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. Open
Statement Patients with acute cholecystitis who are cooled down and discharged have a high recurrence rate and typically return on weekends, making management more difficult. Open
Statement 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. Open
Statement 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. Open
Quotation The last thing you want to do is, you know, take a patient with a very significant, uh, cardiac history to the operating room and end up giving her an acute, uh, cardiac event. Open
Statement Many patients with acute cholecystitis will cool down with antibiotics alone and no additional intervention is needed. Open
Statement Percutaneous cholecystostomy tubes can be very helpful for patients who are not good candidates for operative intervention. Open
Statement 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. Open
Statement The combination of percutaneous cholecystostomy tubes with antibiotics is very effective in managing acute cholecystitis in sicker patients, with most having an uneventful recovery. Open
Quotation I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients. Open
Statement 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. Open
Quotation I think it's very important that before taking these tubes, you have a good discussion about the patient and what is, you know, the potential of her developing a recurrent episode. Open
Quotation As soon as you take that tube out, they'll get a recurrent episode. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Quotation I think it's, it, there are cases that need to be planned well. Open
Statement 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. Open
Statement Gallbladders in patients with prior cholecystostomy tubes tend to be pretty challenging and take quite some time to remove. Open
Quotation In my experience, those gallbladders tend to be pretty challenging, and they, they take up quite some time to do. Open
Statement 99% of the time the approach for cholecystectomy is laparoscopic, even in very difficult cases. Open
Quotation I think we've all gotten pretty good at doing laparoscopic cholecystectomies even in, in, in, you know, very difficult cases. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement Hook electrocautery is a very fine dissecting tool that tends to be hemostatic for taking down omental adhesions. Open
Statement 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. Open
Statement Decompressing the gallbladder allows grasping without tearing the wall. Open
Statement 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. Open
Statement The suction device is a great dissection tool during laparoscopic cholecystectomy. Open
Statement 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. Open
Quotation As long as you're on the gallbladder, you know you're safe. Open
Statement 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. Open
Quotation That's where, that's how you get in trouble in, in some of these cases. Open
Statement The Maryland dissector is a great tool for gentle dissection at the junction between the cystic duct and gallbladder. Open
Quotation I, I, I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well. Open
Statement Moving the gallbladder back and forth with the left hand allows dissection on the lateral side, which is always a safe spot. Open
Statement 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. Open
Statement Routine cholangiography is used in almost all cholecystectomy cases. Open
Statement 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. Open
Statement Giving the cholangiogram catheter a 45-degree angle before placing it into the body helps with cannulation. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement There is no hesitation to add another trochar when needed during laparoscopic cholecystectomy. Open
Statement 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. Open
Quotation The reality of things is a lot of times in some of these more severe cases going open and trying to be heroic and going for that cystic duct is not that safe either. Open
Statement 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. Open
Statement When converting to open cholecystectomy for severe inflammation, the approach is still top-down dissection. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement In subtotal cholecystectomy cases, a drain is left most of the time to control a bile leak if it occurs. Open
Quotation That would be one of those horrible cases that you start wishing you were never there from the start. Open
Statement 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. Open
Quotation I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster for the patient. Open
Statement When leaving the back wall of the gallbladder, cauterize the mucosa with coagulation on a high setting. Open

Acute Cholecystitis

Quotation I think the ones that we try to cool down and and try to get them out of the hospital have a high recurrence rate and they end up, you know, coming back usually on the weekends, which makes their management a little bit more difficult. Open
Statement Patients with acute cholecystitis who are cooled down and discharged have a high recurrence rate and often return on weekends, making management more difficult. Open
Statement 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. Open
Quotation The last thing you want to do is, you know, take a patient with a very significant, uh, cardiac history to the operating room and end up giving her an acute cardiac event. Open
Statement In patients with significant cardiac history, the risk of taking them to the operating room includes precipitating an acute cardiac event. Open
Statement Percutaneous cholecystostomy tubes placed by interventional radiology can be very helpful for patients who are not good candidates for operative intervention. Open
Statement 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. Open
Quotation I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients. Open
Statement 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. Open
Quotation I think it's very important that before taking these tubes, you have a good discussion about the patient of what is, you know, the potential of her developing a recurrent episode. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Quotation And that's where, that's how you get in trouble in, in some of these cases. Open
Statement 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. Open
Quotation I've always, especially when I teach residents, I, I, I remind them of the use of their left hand in terms of, you know, moving the gallbladder back and forth, so you can always dissect on the lateral side, which is always a safe spot as well. Open
Statement 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. Open
Quotation I think clearing that before you should do your cholangiogram, uh, can be very helpful. It also gets some of those air bubbles out of the system. Open
Statement Flushing the cystic duct with 20cc of saline before cholangiography helps clear sludge and stones and removes air bubbles from the system. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Quotation And, and the reality of things is that a lot of times in some of these more severe cases, going open and trying to be heroic and going for that cystic duct is not that safe either. Open
Statement 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. Open
Quotation I think it's just that the surgeon gets a little bit too deep into the liver and injures, um, what do you horrible gallbladder. Open
Statement 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. Open
Statement 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. Open
Statement 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. Open
Quotation I think the, the big goal that any surgeon has in a case like this is avoiding, uh, a major bile duct injury that will end up being a disaster. Open