Nathaniel Soper
68 statements · 1 topic
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if I was deep into the bed in one of these intrahepatic gallbladders, I will, I will put an active drain in and leave it in, you know, at least for several hours if we're going to try and send them home, or usually keep the patient overnight and just make sure there's no bile in there
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Cholelithiasis
what I tell the residents is called a controlled avulsion. So left hand, a lot of traction on the pulling the gallbladder away from the liver, right hand just barely touching that that junction of gallbladder with liver with low water's cautery and essentially carve it out of there
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Cholelithiasis
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Nathaniel's statements about Cholelithiasis 68 statements
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StayCurrent Forums - Laparoscopic Cholecystectomy
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it sounds like she's going to probably have a very chronically inflamed gallbladder with a bunch of omentum stuck to it
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I'm going to put my initial one down at the umbilicus where it should be well away from anything that that's Going on in the right upper quadrant
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In patients with BMI under 32-35, Hasson technique is used for initial umbilical port placement
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In patients with BMI over 32-35, Veress needle technique is used for initial port placement to avoid large incision required for Hasson
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I've seen a couple of terrible complications when people have used that, and so I, I'm old school
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Standard port configuration includes epigastric port (placed last for optimal angle), midclavicular line port, and anterior axillary line port in right upper quadrant
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I always put in the epigastric one last because that's the most important one in terms of your angle getting at the gallbladder
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some of the hardest cases are the ones where you can't even find the gallbladder for half an hour or something
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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
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Modified top-down dissection should start approximately one-third of the way up from the infundibulum, not at the fundus
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what I tell the, what I tell the residents is we're going to do a modified top down but only start about a third of the way up from the bottom
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I try and get right on the wall of the gallbladder and go back and forth from medial to lateral, what the French used to call waving the flag
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Bilateral dissection technique ("waving the flag") alternating between medial and lateral sides provides better three-dimensional view and more freedom for dissection
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Angled laparoscope is superior to 0-degree laparoscope for laparoscopic cholecystectomy
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what we're going to try to achieve before doing, you know, anything irreversible with clips or cutting or anything else is to, is to see the critical view of safety
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Critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures
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Dissecting only on the ventral (left) side of the gallbladder limits freedom of movement and makes dissection more difficult
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I see a lot of the trainees who just stay on the, on the left side of the gallbladder, the ventral side of the gallbladder for 99% of the dissection. I think that really hurts you
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if you get it from the lateral side as well, you get lots more freedom on that gallbladder to be able to dissect underneath it and be able to move it around
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Intraoperative ultrasound can be performed multiple times during difficult cholecystectomy to identify gallbladder location and bile duct position relative to dissection
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in a tough case like this, I'll often actually do it multiple times. Once at the beginning of the operation to get an idea where the gallbladder is in this particular patient
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an ultrasound can show you where the gallbladder ends, where the bile duct is in relation to where you're dissecting
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I don't think that there are any real tricks to this, Jeff. I mean, it's a lot of traction, counter traction
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Irrigation-suction catheter can be used for blunt (Kittner) dissection in the right hand when there is blood and bile obscuring the field
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I actually use a lot of what I call irrigation suction, kittner dissecting. So blunt dissecting
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instead of getting a whole bunch of Kittner dissectors, I'll just get my suction aspiration catheter and use that in my, in my right hand, my dissecting hand, to really push again right along the gallbladder wall as much as you can to get things separated
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Indocyanine green (ICG) given too early results in everything appearing bright green, limiting its utility
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I've had trouble getting patients in early enough to give it early enough, so everything is just bright green usually when I get in there
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In cases with significant tissue inflammation, ICG may not adequately visualize ductal structures
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I have, I have not been really impressed with ICG, but I know a lot of people who have been and use it on a regular basis
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I would make sure I've dissected out the critical view of safety. So all of that fatty material, all of that peritoneal. Stuff, all of the scar tissue holding that neck, the infundibule of the gallbladder into the liver has been divided
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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
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If it's cystic duct with a hole in it, there's no big deal. I mean, I might put a catheter down, do a changiogram just to prove, you know what I was trying to get you to do
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If you have not dissected it all out, then you absolutely have to do a changiogram so you can get a better idea of what that ductal structure
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If critical view of safety cannot be achieved, intraoperative cholangiography is mandatory to clarify ductal anatomy
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I actually, um, believe in a, in a couple of things in, in, in the Lapoli religion uh wars. Um, one of that is that everybody should know how to do cholangiography
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All residents should learn intraoperative cholangiography technique regardless of selective use in practice
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in a residency program, I think we ought to do them very frequently regardless of indications
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Intraoperative ultrasound should be taught to residents because it allows visualization beyond visible surfaces in the laparoscopic abdomen
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I love teaching residents how to use ultrasound in the, in the laparoscopic abdomen because you can only see the visible surfaces and the ultrasound lets you see beyond those visible surfaces
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The reality is that cholangiograms do add time, um, they do add money. Um, and the majority of the time they're not absolutely necessary
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Cholangiography adds time and cost, and is not absolutely necessary in the majority of cases
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Indications for selective intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound
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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
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the other thing that I do routinely is before I clip and and divide the cystic duct, I'll put a clip on the, on the stay side up on the gallbladder and make a little incision in the cystic duct and milk it backwards to see if there are stones in the cystic duct
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Presence of cystic duct stones is a prime indicator that common bile duct stones are also likely present
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if there's stones in the cystic duct, in our experience, that's one of the prime. Uh, things that will show you that there probably are common bile duct stones too
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I, I just use low, low watt cautery and again, a lot of, a lot of traction on the gallbladder
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the other thing that happens with these gallbladders that you've just mentioned in terms of the degree of chronic inflammation, they're usually intrahepatic. There's no plane between the gallbladder and the liver
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Chronically inflamed gallbladders are usually intrahepatic with no plane between gallbladder and liver
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what I tell the residents is called a controlled avulsion. So left hand, a lot of traction on the pulling the gallbladder away from the liver, right hand just barely touching that that junction of gallbladder with liver with low water's cautery and essentially carve it out of there
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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
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Gallbladder bed hemostasis can be achieved in 99% of cases using cautery with irrigation-suction in left hand and cautery in right hand
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I'll put a, a suction, irrigation suction thing in my left hand. Um, I'll I'll, I'll do this before I can completely take the gallbladder off the bed so that the assistant can be holding up the right lobe of the liver with that remaining bit of gallbladder
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Left hand then with an irrigating suction, suction, you can suck the smoke, you can suck blood or whatever. Right hand with a with a cautery and just touching the. The areas that are bleeding and 99% of the time you can get it stopped
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if it's a Lushka duct, I would probably try to put a stitch in it. Um, you know, a small stitch, but the likelihood is that's not going to hold anyway, so I'd put a drain in
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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
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if I was deep into the bed in one of these intrahepatic gallbladders, I will, I will put an active drain in and leave it in, you know, at least for several hours if we're going to try and send them home, or usually keep the patient overnight and just make sure there's no bile in there
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Active drain should be placed for deep intrahepatic gallbladder dissection and left in for several hours or overnight to monitor for bile leak
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Postoperative pain management includes intraoperative IV acetaminophen, prescription for only 5 hydrocodone tablets, and recommendation for ibuprofen or acetaminophen for first few days
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the, the anesthesiologist will usually give them some, we, we usually use IV Tylenol, which I think works pretty well
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Pain requiring more than 5 hydrocodone tablets postoperatively suggests a problem and warrants patient contact
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we'll send them home with that like 5, hydrocodone tablets or something like that, but only 5, and tell them if they need more than that, they need to call
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I, I, I just tell them to go ahead and take either ibuprofen or Tylenol in addition to that for the first few days. If they have more pain than that, there's a problem
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