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Acute Cholecystitis
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Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
For a 45-year-old patient with straightforward acute cholecystitis and normal liver function tests, early cholecystectomy during the index admission is favored over medical management. — John Rodriguez, Acute Cholecystitis · 3:14
Acute Cholecystitis
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John Rodriguez, MD and Jeffrey Ponsky, MD discuss Acute CholecystitisEdited by: Harveen Lamba, MD MS Mena Boules, and MD Todd PonskyDr. John Rodriguez, MD Professor of Surgery at Cleveland Clinic Lerner College of Medicine discusses acute c
podcast32:28 · Dec 2020
Acute Cholecystitis
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Dr. John Rodriguez, MD Professor of Surgery at Cleveland Clinic Lerner College of Medicine discusses acute cholecystitis with Dr Jeffrey Ponsky, MD Edited by: Harveen Lamba, MD MS Mena Boules, and MD Todd Ponsky
video32:30 · Jun 2026
Acute Cholecystitis
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An interactive discussion about acute cholecystitis disease between Jeffrey Ponsky, MD and John Rodriguez, MD. Dr. Rodriguez is a general surgery staff surgeon
podcast32:28 · Jul 2026
HIDA scans are useful to confirm normal biliary drainage when postoperative pain occurs without fluid collection, but are less useful than CT for detecting bile leaks. — Jeffrey Ponsky, Gallstone Disease · 21:32
Gallstone Disease
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This podcast is an interactive discussion about gallstone disease between Dr. Todd Ponsky and his father, Dr. Jeffrey Ponsky. Dr. Jeffrey Ponsky is a professor of surgery at Cleveland Clinic Lerner College of Medicine, and is an expert in a
podcast47:36 · Dec 2020
Expert statements from the recordings in this collection.
Gallstone Disease
Biliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative.
Jeffrey Ponsky1:53
Modern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks.
Jeffrey Ponsky5:00
For stable acute cholecystitis without peritonitis, it is reasonable to wait until the next operating day (e.g., Monday if presenting Saturday) rather than operating emergently.
Jeffrey Ponsky5:40
There is no evidence that prophylactic antibiotics help in acute cholecystitis management.
Jeffrey Ponsky6:10
In A-frame patients (narrow costal margin), port placement must be adjusted lower because ribs prevent standard subcostal port positioning.
Todd Ponsky9:44
The sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas.
Jeffrey Ponsky12:12
After isolating the cystic duct-gallbladder junction, turning the hook cautery toward the gallbladder and lifting while cauterizing gains an additional half-centimeter of cystic duct length.
Jeffrey Ponsky12:40
Easy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed.
Routine intraoperative cholangiography is debated; some institutions do it in every case for teaching and to improve transcystic exploration skills, while selective use based on risk factors (pancreatitis history, jaundice, dilated duct) is also acceptable.
Jeffrey Ponsky14:50
When contrast on cholangiogram flows only distally into the duodenum, pressing on the papilla with the laparoscope under fluoroscopy forces contrast proximally, avoiding the need for morphine to induce sphincter spasm (technique taught by Michelle Gagné).
Jeffrey Ponsky18:33
Intraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy.
Jeffrey Ponsky19:00
Any patient with pain 3-5 days after laparoscopic cholecystectomy should be assumed to have a bile leak or bile duct injury until proven otherwise; laparoscopic cholecystectomies do not cause pain if everything went well.
Jeffrey Ponsky20:30
For suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP.
Jeffrey Ponsky21:11
HIDA scans are useful to confirm normal biliary drainage when postoperative pain occurs without fluid collection, but are less useful than CT for detecting bile leaks.
For bile leaks (typically cystic duct), ERCP with sphincterotomy and short stent (10 French, 5cm) decompresses the biliary system and stops drainage; stent is removed at 3-6 weeks.
Jeffrey Ponsky22:37
Biliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative.
Jeffrey Ponsky23:41
Gallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla.
Jeffrey Ponsky24:11
In the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed.
Jeffrey Ponsky24:40
Current management of gallstone pancreatitis: admit, hydrate, NPO, observe overnight and check amylase/lipase trend. If improving, proceed to cholecystectomy during that admission. If worsening or jaundice persists, perform ERCP with sphincterotomy.
Jeffrey Ponsky25:10
Some experts (George Bursey, Joe Peatland) advocate taking patients with persistent common duct stones directly to the operating room for intraoperative cholangiogram and transcystic or laparoscopic common duct exploration, with postoperative ERCP only if unsuccessful.
The choice between preoperative ERCP versus intraoperative common duct exploration depends on local resources, surgeon comfort with laparoscopic ductal techniques, and availability of fluoroscopy and choledocoscopy.
For intraoperative common duct stone clearance, after cholangiogram shows a stone (meniscus sign), give 1 amp (1mg) glucagon IV, wait 1-2 minutes, flush with saline, and repeat cholangiogram.
Jeffrey Ponsky30:14
If glucagon fails to clear the stone, pass a soft-tip wire through the cystic duct under fluoroscopy into the duodenum to attempt to dislodge it; never push against resistance.
Jeffrey Ponsky30:56
A Dormia basket can be passed closed into the duodenum under fluoroscopy, opened slightly, and pulled back with jiggling to catch stones; alternatively, a #5 Fogarty catheter (vascular Fogarty works) can be inflated in the duodenum, pulled to the papilla, deflated slightly, re-inflated and pulled back.
Jeffrey Ponsky31:35
Modern choledocoscopes are less than 3mm diameter and can be passed through the cystic duct (sometimes requiring balloon dilation) for direct stone visualization and extraction with Dormia basket or balloon.
Jeffrey Ponsky32:44
After transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties.
Jeffrey Ponsky33:27
Laparoscopic common bile duct exploration via choledocotomy should only be performed in dilated ducts (>1-1.5cm, ideally 2cm) to avoid stricture risk; small-caliber ducts with stones should be managed with ERCP.
Jeffrey Ponsky34:56
For laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface.
Jeffrey Ponsky35:30
T-tube preparation for choledocotomy closure: cut to 1 inch on each side of the T, bevel the edges, remove half the back wall to facilitate insertion and later removal.
Jeffrey Ponsky37:40
T-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks.
Jeffrey Ponsky38:50