Nathaniel Soper

250 statements · 3 topics

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▶ Ep 1 · 12:39
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
quote · Cholelithiasis
▶ Ep 1 · 13:13
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
quote · Cholelithiasis
▶ Ep 1 · 7:48
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
quote · Cholelithiasis
▶ Ep 1 · 9:14
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
quote · Cholelithiasis
▶ Ep 4 · 12:42
For intrahepatic gallbladders, use 'controlled avulsion' technique: strong traction on the gallbladder with the left hand pulling away from the liver, while the right hand barely touches the gallbladder-liver junction with low-wattage cautery to carve it out.
clinical · Hepatobiliary & Colorectal Surgery
▶ Ep 4 · 9:17
For the critical view of safety, all fatty material, peritoneal tissue, and scar tissue holding the gallbladder neck and infundibulum to the liver must be divided so the gallbladder is an inch and a half away from surrounding structures.
clinical · Hepatobiliary & Colorectal Surgery

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Nathaniel's statements about Cholelithiasis 68 statements

Open the Cholelithiasis collection →

StayCurrent Forums - Laparoscopic Cholecystectomy

▶ Ep 1 · 1:57
quote it sounds like she's going to probably have a very chronically inflamed gallbladder with a bunch of omentum stuck to it ↗
▶ Ep 1 · 2:08
quote 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 ↗
▶ Ep 1 · 2:22
clinical In patients with BMI under 32-35, Hasson technique is used for initial umbilical port placement ↗
▶ Ep 1 · 2:27
clinical In patients with BMI over 32-35, Veress needle technique is used for initial port placement to avoid large incision required for Hasson ↗
▶ Ep 1 · 2:43
quote I've seen a couple of terrible complications when people have used that, and so I, I'm old school ↗
▶ Ep 1 · 3:00
clinical Standard port configuration includes epigastric port (placed last for optimal angle), midclavicular line port, and anterior axillary line port in right upper quadrant ↗
▶ Ep 1 · 3:17
quote I always put in the epigastric one last because that's the most important one in terms of your angle getting at the gallbladder ↗
▶ Ep 1 · 3:39
quote some of the hardest cases are the ones where you can't even find the gallbladder for half an hour or something ↗
▶ Ep 1 · 3:54
clinical 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 ↗
▶ Ep 1 · 5:03
clinical Modified top-down dissection should start approximately one-third of the way up from the infundibulum, not at the fundus ↗
▶ Ep 1 · 5:03
quote 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 ↗
▶ Ep 1 · 5:13
quote 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 ↗
▶ Ep 1 · 5:13
clinical Bilateral dissection technique ("waving the flag") alternating between medial and lateral sides provides better three-dimensional view and more freedom for dissection ↗
▶ Ep 1 · 5:32
opinion Angled laparoscope is superior to 0-degree laparoscope for laparoscopic cholecystectomy ↗
▶ Ep 1 · 5:32
quote I can't understand how some people still use 0 degree laparoscopes ↗
▶ Ep 1 · 5:43
clinical Critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures ↗
▶ Ep 1 · 5:43
quote 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 ↗
▶ Ep 1 · 6:11
quote 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 ↗
▶ Ep 1 · 6:11
clinical Dissecting only on the ventral (left) side of the gallbladder limits freedom of movement and makes dissection more difficult ↗
▶ Ep 1 · 6:22
quote 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 ↗
▶ Ep 1 · 6:52
clinical Intraoperative ultrasound can be performed multiple times during difficult cholecystectomy to identify gallbladder location and bile duct position relative to dissection ↗
▶ Ep 1 · 6:59
quote 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 ↗
▶ Ep 1 · 7:09
quote an ultrasound can show you where the gallbladder ends, where the bile duct is in relation to where you're dissecting ↗
▶ Ep 1 · 7:23
quote I don't think that there are any real tricks to this, Jeff. I mean, it's a lot of traction, counter traction ↗
▶ Ep 1 · 7:33
quote I actually use a lot of what I call irrigation suction, kittner dissecting. So blunt dissecting ↗
▶ Ep 1 · 7:33
clinical Irrigation-suction catheter can be used for blunt (Kittner) dissection in the right hand when there is blood and bile obscuring the field ↗
▶ Ep 1 · 7:48
quote 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 ↗
▶ Ep 1 · 8:12
quote 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 ↗
▶ Ep 1 · 8:12
clinical Indocyanine green (ICG) given too early results in everything appearing bright green, limiting its utility ↗
▶ Ep 1 · 8:19
clinical In cases with significant tissue inflammation, ICG may not adequately visualize ductal structures ↗
▶ Ep 1 · 8:29
quote 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 ↗
▶ Ep 1 · 9:14
quote 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 ↗
▶ Ep 1 · 9:14
clinical 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 ↗
▶ Ep 1 · 9:31
quote the gallbladder is, you know, now 1 inch and a half away from anything around it ↗
▶ Ep 1 · 9:43
quote 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 ↗
▶ Ep 1 · 9:59
quote 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 ↗
▶ Ep 1 · 9:59
clinical If critical view of safety cannot be achieved, intraoperative cholangiography is mandatory to clarify ductal anatomy ↗
▶ Ep 1 · 10:25
quote 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 ↗
▶ Ep 1 · 10:33
opinion All residents should learn intraoperative cholangiography technique regardless of selective use in practice ↗
▶ Ep 1 · 10:38
quote in a residency program, I think we ought to do them very frequently regardless of indications ↗
▶ Ep 1 · 10:44
opinion Intraoperative ultrasound should be taught to residents because it allows visualization beyond visible surfaces in the laparoscopic abdomen ↗
▶ Ep 1 · 10:44
quote 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 ↗
▶ Ep 1 · 10:56
quote 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 ↗
▶ Ep 1 · 10:56
clinical Cholangiography adds time and cost, and is not absolutely necessary in the majority of cases ↗
▶ Ep 1 · 11:11
clinical Indications for selective intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound ↗
▶ Ep 1 · 11:18
quote 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 ↗
▶ Ep 1 · 11:18
clinical 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 ↗
▶ Ep 1 · 11:35
clinical Presence of cystic duct stones is a prime indicator that common bile duct stones are also likely present ↗
▶ Ep 1 · 11:35
quote 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 ↗
▶ Ep 1 · 12:19
quote I, I just use low, low watt cautery and again, a lot of, a lot of traction on the gallbladder ↗
▶ Ep 1 · 12:25
quote 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 ↗
▶ Ep 1 · 12:25
clinical Chronically inflamed gallbladders are usually intrahepatic with no plane between gallbladder and liver ↗
▶ Ep 1 · 12:39
quote 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 ↗
▶ Ep 1 · 12:39
clinical 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 ↗
▶ Ep 1 · 13:10
clinical Gallbladder bed hemostasis can be achieved in 99% of cases using cautery with irrigation-suction in left hand and cautery in right hand ↗
▶ Ep 1 · 13:13
quote 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 ↗
▶ Ep 1 · 13:31
quote 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 ↗
▶ Ep 1 · 14:06
clinical 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 ↗
▶ Ep 1 · 14:06
quote 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 ↗
▶ Ep 1 · 14:18
clinical Active drain should be placed for deep intrahepatic gallbladder dissection and left in for several hours or overnight to monitor for bile leak ↗
▶ Ep 1 · 14:18
quote 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 ↗
▶ Ep 1 · 14:40
clinical 95% of laparoscopic cholecystectomy patients are discharged home the same day ↗
▶ Ep 1 · 14:40
quote Absolutely, 95% go home ↗
▶ Ep 1 · 14:52
clinical Postoperative pain management includes intraoperative IV acetaminophen, prescription for only 5 hydrocodone tablets, and recommendation for ibuprofen or acetaminophen for first few days ↗
▶ Ep 1 · 14:52
quote the, the anesthesiologist will usually give them some, we, we usually use IV Tylenol, which I think works pretty well ↗
▶ Ep 1 · 15:00
clinical Pain requiring more than 5 hydrocodone tablets postoperatively suggests a problem and warrants patient contact ↗
▶ Ep 1 · 15:00
quote 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 ↗
▶ Ep 1 · 15:12
quote 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 ↗
Nathaniel's statements about Cholelithiasis 106 statements

Open the Cholelithiasis collection →

StayCurrent Forums - Laparoscopic Cholecystectomy

▶ Ep 1 · 1:57
quote it sounds like she's going to probably have a very chronically inflamed gallbladder with a bunch of omentum stuck to it ↗
▶ Ep 1 · 2:08
quote 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 ↗
▶ Ep 1 · 2:22
clinical In patients with BMI under 32-35, Hasson technique is used for initial umbilical port placement ↗
▶ Ep 1 · 2:27
clinical In patients with BMI over 32-35, Veress needle technique is used for initial port placement to avoid large incision required for Hasson ↗
▶ Ep 1 · 2:43
quote I've seen a couple of terrible complications when people have used that, and so I, I'm old school ↗
▶ Ep 1 · 3:00
clinical Standard port configuration includes epigastric port (placed last for optimal angle), midclavicular line port, and anterior axillary line port in right upper quadrant ↗
▶ Ep 1 · 3:17
quote I always put in the epigastric one last because that's the most important one in terms of your angle getting at the gallbladder ↗
▶ Ep 1 · 3:39
quote some of the hardest cases are the ones where you can't even find the gallbladder for half an hour or something ↗
▶ Ep 1 · 3:54
clinical 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 ↗
▶ Ep 1 · 5:03
quote 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 ↗
▶ Ep 1 · 5:03
clinical Modified top-down dissection should start approximately one-third of the way up from the infundibulum, not at the fundus ↗
▶ Ep 1 · 5:13
clinical Bilateral dissection technique ("waving the flag") alternating between medial and lateral sides provides better three-dimensional view and more freedom for dissection ↗
▶ Ep 1 · 5:13
quote 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 ↗
▶ Ep 1 · 5:32
quote I can't understand how some people still use 0 degree laparoscopes ↗
▶ Ep 1 · 5:32
opinion Angled laparoscope is superior to 0-degree laparoscope for laparoscopic cholecystectomy ↗
▶ Ep 1 · 5:43
clinical Critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures ↗
▶ Ep 1 · 5:43
quote 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 ↗
▶ Ep 1 · 6:11
clinical Dissecting only on the ventral (left) side of the gallbladder limits freedom of movement and makes dissection more difficult ↗
▶ Ep 1 · 6:11
quote 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 ↗
▶ Ep 1 · 6:22
quote 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 ↗
▶ Ep 1 · 6:52
clinical Intraoperative ultrasound can be performed multiple times during difficult cholecystectomy to identify gallbladder location and bile duct position relative to dissection ↗
▶ Ep 1 · 6:59
quote 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 ↗
▶ Ep 1 · 7:09
quote an ultrasound can show you where the gallbladder ends, where the bile duct is in relation to where you're dissecting ↗
▶ Ep 1 · 7:23
quote I don't think that there are any real tricks to this, Jeff. I mean, it's a lot of traction, counter traction ↗
▶ Ep 1 · 7:33
clinical Irrigation-suction catheter can be used for blunt (Kittner) dissection in the right hand when there is blood and bile obscuring the field ↗
▶ Ep 1 · 7:33
quote I actually use a lot of what I call irrigation suction, kittner dissecting. So blunt dissecting ↗
▶ Ep 1 · 7:48
quote 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 ↗
▶ Ep 1 · 8:12
quote 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 ↗
▶ Ep 1 · 8:12
clinical Indocyanine green (ICG) given too early results in everything appearing bright green, limiting its utility ↗
▶ Ep 1 · 8:19
clinical In cases with significant tissue inflammation, ICG may not adequately visualize ductal structures ↗
▶ Ep 1 · 8:29
quote 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 ↗
▶ Ep 1 · 9:14
clinical 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 ↗
▶ Ep 1 · 9:14
quote 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 ↗
▶ Ep 1 · 9:31
quote the gallbladder is, you know, now 1 inch and a half away from anything around it ↗
▶ Ep 1 · 9:43
quote 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 ↗
▶ Ep 1 · 9:59
quote 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 ↗
▶ Ep 1 · 9:59
clinical If critical view of safety cannot be achieved, intraoperative cholangiography is mandatory to clarify ductal anatomy ↗
▶ Ep 1 · 10:25
quote 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 ↗
▶ Ep 1 · 10:33
opinion All residents should learn intraoperative cholangiography technique regardless of selective use in practice ↗
▶ Ep 1 · 10:38
quote in a residency program, I think we ought to do them very frequently regardless of indications ↗
▶ Ep 1 · 10:44
quote 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 ↗
▶ Ep 1 · 10:44
opinion Intraoperative ultrasound should be taught to residents because it allows visualization beyond visible surfaces in the laparoscopic abdomen ↗
▶ Ep 1 · 10:56
clinical Cholangiography adds time and cost, and is not absolutely necessary in the majority of cases ↗
▶ Ep 1 · 10:56
quote 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 ↗
▶ Ep 1 · 11:11
clinical Indications for selective intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound ↗
▶ Ep 1 · 11:18
clinical 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 ↗
▶ Ep 1 · 11:18
quote 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 ↗
▶ Ep 1 · 11:35
quote 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 ↗
▶ Ep 1 · 11:35
clinical Presence of cystic duct stones is a prime indicator that common bile duct stones are also likely present ↗
▶ Ep 1 · 12:19
quote I, I just use low, low watt cautery and again, a lot of, a lot of traction on the gallbladder ↗
▶ Ep 1 · 12:25
clinical Chronically inflamed gallbladders are usually intrahepatic with no plane between gallbladder and liver ↗
▶ Ep 1 · 12:25
quote 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 ↗
▶ Ep 1 · 12:39
clinical 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 ↗
▶ Ep 1 · 12:39
quote 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 ↗
▶ Ep 1 · 13:10
clinical Gallbladder bed hemostasis can be achieved in 99% of cases using cautery with irrigation-suction in left hand and cautery in right hand ↗
▶ Ep 1 · 13:13
quote 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 ↗
▶ Ep 1 · 13:31
quote 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 ↗
▶ Ep 1 · 14:06
quote 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 ↗
▶ Ep 1 · 14:06
clinical 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 ↗
▶ Ep 1 · 14:18
clinical Active drain should be placed for deep intrahepatic gallbladder dissection and left in for several hours or overnight to monitor for bile leak ↗
▶ Ep 1 · 14:18
quote 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 ↗
▶ Ep 1 · 14:40
quote Absolutely, 95% go home ↗
▶ Ep 1 · 14:40
clinical 95% of laparoscopic cholecystectomy patients are discharged home the same day ↗
▶ Ep 1 · 14:52
quote the, the anesthesiologist will usually give them some, we, we usually use IV Tylenol, which I think works pretty well ↗
▶ Ep 1 · 14:52
clinical Postoperative pain management includes intraoperative IV acetaminophen, prescription for only 5 hydrocodone tablets, and recommendation for ibuprofen or acetaminophen for first few days ↗
▶ Ep 1 · 15:00
quote 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 ↗
▶ Ep 1 · 15:00
clinical Pain requiring more than 5 hydrocodone tablets postoperatively suggests a problem and warrants patient contact ↗
▶ Ep 1 · 15:12
quote 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 ↗

StayCurrent Forums - Laparoscopic Cholecystectomy

▶ Ep 8 · 2:22
clinical For non-obese patients, Hassan technique is used for initial umbilical port placement; for patients with BMI over 32-35, Veress technique is preferred to avoid a large incision. ↗
▶ Ep 8 · 2:43
quote I've seen a couple of terrible complications when people have used that, and so I, um, I'm old school. ↗
▶ Ep 8 · 3:17
clinical The epigastric port is placed last because it is the most important port in terms of angle for reaching the gallbladder and serves as the surgeon's right hand. ↗
▶ Ep 8 · 3:38
quote some of the hardest cases are the ones where you can't even find the gallbladder for half an hour or something ↗
▶ Ep 8 · 3:50
clinical Dense omental adhesions to the gallbladder should be taken down using traction and low-wattage cautery at the junction of omentum with other structures, sometimes requiring harmonic shears if bleeding occurs. ↗
▶ Ep 8 · 4:35
clinical Omental adhesions must be taken down completely off the gallbladder and away from the cystic duct and artery area, otherwise they will tether the right lobe of the liver and make exposure difficult. ↗
▶ Ep 8 · 5:03
clinical Modified top-down dissection should start about one-third of the way up from the bottom of the gallbladder, staying right on the gallbladder wall. ↗
▶ Ep 8 · 5:03
quote 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 ↗
▶ Ep 8 · 5:13
quote what the French used to call waving the flag ↗
▶ Ep 8 · 5:13
clinical Dissection should alternate between medial and lateral aspects of the gallbladder ('waving the flag') to achieve good three-dimensional visualization from both sides. ↗
▶ Ep 8 · 5:32
quote I can't understand how some people still use zero-degree laparoscopes ↗
▶ Ep 8 · 5:32
opinion An angled laparoscope is essential for adequate visualization during laparoscopic cholecystectomy; zero-degree laparoscopes are inadequate. ↗
▶ Ep 8 · 5:43
clinical The critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures. ↗
▶ Ep 8 · 6:09
clinical Keeping dissection symmetrical on both ventral and lateral sides of the gallbladder provides much more freedom to dissect underneath and move the gallbladder around, compared to staying on the ventral side for 99% of dissection. ↗
▶ Ep 8 · 6:11
quote 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. ↗
▶ Ep 8 · 6:52
clinical Intraoperative ultrasound can be performed multiple times during a difficult case to identify where the gallbladder ends and where the bile duct is in relation to the dissection when the critical view of safety is difficult to achieve. ↗
▶ Ep 8 · 7:30
quote I don't think that there are any real tricks to this, Jeff. I mean, it's a lot of traction, counter traction. ↗
▶ Ep 8 · 7:36
clinical Irrigation-suction can be used as a blunt dissecting instrument (kittner dissection) in the surgeon's right hand to push along the gallbladder wall when there is significant blood or bile obscuring the field. ↗
▶ Ep 8 · 8:13
opinion Indocyanine green fluorescence has limited utility in severely inflamed gallbladder cases because tissue characteristics prevent adequate visualization of the duct, and if given too early, everything appears uniformly bright green. ↗
▶ Ep 8 · 8:33
quote 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. ↗
▶ Ep 8 · 9:17
clinical For the critical view of safety, all fatty material, peritoneal tissue, and scar tissue holding the gallbladder neck and infundibulum to the liver must be divided so the gallbladder is an inch and a half away from surrounding structures. ↗
▶ Ep 8 · 10:02
clinical If the critical view of safety cannot be achieved, cholangiography must be performed to better understand the ductal anatomy. ↗
▶ Ep 8 · 10:37
opinion All residents should learn how to perform intraoperative cholangiography and laparoscopic ultrasound, even though these techniques add time and cost and are not always necessary. ↗
▶ Ep 8 · 10:37
quote everybody should know how to do cholangiography ↗
▶ Ep 8 · 10:47
clinical Laparoscopic ultrasound allows visualization beyond the visible surfaces of the abdomen, which is particularly valuable given that laparoscopy only shows visible surfaces. ↗
▶ Ep 8 · 10:47
quote the ultrasound lets you see beyond those visible surfaces ↗
▶ Ep 8 · 11:15
clinical Indications for intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound. ↗
▶ Ep 8 · 11:18
clinical Before clipping and dividing the cystic duct, place a clip on the gallbladder side, make a small incision in the cystic duct, and milk it backwards to check for stones in the cystic duct. ↗
▶ Ep 8 · 11:38
epidemiological Cystic duct stones are one of the prime indicators that common bile duct stones are also likely present. ↗
▶ Ep 8 · 12:29
clinical Chronically inflamed gallbladders are usually intrahepatic with no plane between the gallbladder and liver. ↗
▶ Ep 8 · 12:42
clinical For intrahepatic gallbladders, use 'controlled avulsion' technique: strong traction on the gallbladder with the left hand pulling away from the liver, while the right hand barely touches the gallbladder-liver junction with low-wattage cautery to carve it out. ↗
▶ Ep 8 · 12:42
quote what I tell the residents is called a controlled evulsion ↗
▶ Ep 8 · 13:17
clinical For gallbladder bed bleeding, use irrigation-suction in the left hand to clear smoke and blood while applying cautery with the right hand to bleeding areas; this controls bleeding 99% of the time. ↗
▶ Ep 8 · 13:55
clinical A small bile leak from the middle of the gallbladder bed, when ductal anatomy is otherwise clear, is likely a duct of Luschka and should be managed with attempted suture repair, though the stitch is unlikely to hold. ↗
▶ Ep 8 · 14:15
clinical A drain should be placed for suspected ducts of Luschka or when dissection is deep into the bed of an intrahepatic gallbladder, and the patient should be kept overnight to ensure no bile accumulation. ↗
▶ Ep 8 · 14:44
epidemiological 95% of laparoscopic cholecystectomy patients are discharged the same day. ↗
▶ Ep 8 · 14:55
clinical Postoperative pain management includes intraoperative IV acetaminophen, 5 hydrocodone tablets for home use (patients should call if they need more), and ibuprofen or acetaminophen for the first few days. ↗
▶ Ep 8 · 15:15
clinical Pain requiring more than 5 hydrocodone tablets after laparoscopic cholecystectomy indicates a problem and warrants evaluation. ↗
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▶ Ep 4 · 2:22
clinical For non-obese patients, Hassan technique is used for initial umbilical port placement; for patients with BMI over 32-35, Veress technique is preferred to avoid a large incision. ↗
▶ Ep 4 · 2:22
clinical For non-obese patients, Hassan technique is used for initial umbilical port placement; for patients with BMI over 32-35, Veress technique is preferred to avoid a large incision. ↗
▶ Ep 4 · 2:43
quote I've seen a couple of terrible complications when people have used that, and so I, um, I'm old school. ↗
▶ Ep 4 · 2:43
quote I've seen a couple of terrible complications when people have used that, and so I, um, I'm old school. ↗
▶ Ep 4 · 3:17
clinical The epigastric port is placed last because it is the most important port in terms of angle for reaching the gallbladder and serves as the surgeon's right hand. ↗
▶ Ep 4 · 3:17
clinical The epigastric port is placed last because it is the most important port in terms of angle for reaching the gallbladder and serves as the surgeon's right hand. ↗
▶ Ep 4 · 3:38
quote some of the hardest cases are the ones where you can't even find the gallbladder for half an hour or something ↗
▶ Ep 4 · 3:38
quote some of the hardest cases are the ones where you can't even find the gallbladder for half an hour or something ↗
▶ Ep 4 · 3:50
clinical Dense omental adhesions to the gallbladder should be taken down using traction and low-wattage cautery at the junction of omentum with other structures, sometimes requiring harmonic shears if bleeding occurs. ↗
▶ Ep 4 · 3:50
clinical Dense omental adhesions to the gallbladder should be taken down using traction and low-wattage cautery at the junction of omentum with other structures, sometimes requiring harmonic shears if bleeding occurs. ↗
▶ Ep 4 · 4:35
clinical Omental adhesions must be taken down completely off the gallbladder and away from the cystic duct and artery area, otherwise they will tether the right lobe of the liver and make exposure difficult. ↗
▶ Ep 4 · 4:35
clinical Omental adhesions must be taken down completely off the gallbladder and away from the cystic duct and artery area, otherwise they will tether the right lobe of the liver and make exposure difficult. ↗
▶ Ep 4 · 5:03
quote 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 ↗
▶ Ep 4 · 5:03
clinical Modified top-down dissection should start about one-third of the way up from the bottom of the gallbladder, staying right on the gallbladder wall. ↗
▶ Ep 4 · 5:03
quote 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 ↗
▶ Ep 4 · 5:03
clinical Modified top-down dissection should start about one-third of the way up from the bottom of the gallbladder, staying right on the gallbladder wall. ↗
▶ Ep 4 · 5:13
quote what the French used to call waving the flag ↗
▶ Ep 4 · 5:13
clinical Dissection should alternate between medial and lateral aspects of the gallbladder ('waving the flag') to achieve good three-dimensional visualization from both sides. ↗
▶ Ep 4 · 5:13
quote what the French used to call waving the flag ↗
▶ Ep 4 · 5:13
clinical Dissection should alternate between medial and lateral aspects of the gallbladder ('waving the flag') to achieve good three-dimensional visualization from both sides. ↗
▶ Ep 4 · 5:32
quote I can't understand how some people still use zero-degree laparoscopes ↗
▶ Ep 4 · 5:32
opinion An angled laparoscope is essential for adequate visualization during laparoscopic cholecystectomy; zero-degree laparoscopes are inadequate. ↗
▶ Ep 4 · 5:32
quote I can't understand how some people still use zero-degree laparoscopes ↗
▶ Ep 4 · 5:32
opinion An angled laparoscope is essential for adequate visualization during laparoscopic cholecystectomy; zero-degree laparoscopes are inadequate. ↗
▶ Ep 4 · 5:43
clinical The critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures. ↗
▶ Ep 4 · 5:43
clinical The critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures. ↗
▶ Ep 4 · 6:09
clinical Keeping dissection symmetrical on both ventral and lateral sides of the gallbladder provides much more freedom to dissect underneath and move the gallbladder around, compared to staying on the ventral side for 99% of dissection. ↗
▶ Ep 4 · 6:09
clinical Keeping dissection symmetrical on both ventral and lateral sides of the gallbladder provides much more freedom to dissect underneath and move the gallbladder around, compared to staying on the ventral side for 99% of dissection. ↗
▶ Ep 4 · 6:11
quote 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. ↗
▶ Ep 4 · 6:11
quote 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. ↗
▶ Ep 4 · 6:52
clinical Intraoperative ultrasound can be performed multiple times during a difficult case to identify where the gallbladder ends and where the bile duct is in relation to the dissection when the critical view of safety is difficult to achieve. ↗
▶ Ep 4 · 6:52
clinical Intraoperative ultrasound can be performed multiple times during a difficult case to identify where the gallbladder ends and where the bile duct is in relation to the dissection when the critical view of safety is difficult to achieve. ↗
▶ Ep 4 · 7:30
quote I don't think that there are any real tricks to this, Jeff. I mean, it's a lot of traction, counter traction. ↗
▶ Ep 4 · 7:30
quote I don't think that there are any real tricks to this, Jeff. I mean, it's a lot of traction, counter traction. ↗
▶ Ep 4 · 7:36
clinical Irrigation-suction can be used as a blunt dissecting instrument (kittner dissection) in the surgeon's right hand to push along the gallbladder wall when there is significant blood or bile obscuring the field. ↗
▶ Ep 4 · 7:36
clinical Irrigation-suction can be used as a blunt dissecting instrument (kittner dissection) in the surgeon's right hand to push along the gallbladder wall when there is significant blood or bile obscuring the field. ↗
▶ Ep 4 · 8:13
opinion Indocyanine green fluorescence has limited utility in severely inflamed gallbladder cases because tissue characteristics prevent adequate visualization of the duct, and if given too early, everything appears uniformly bright green. ↗
▶ Ep 4 · 8:13
opinion Indocyanine green fluorescence has limited utility in severely inflamed gallbladder cases because tissue characteristics prevent adequate visualization of the duct, and if given too early, everything appears uniformly bright green. ↗
▶ Ep 4 · 8:33
quote 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. ↗
▶ Ep 4 · 8:33
quote 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. ↗
▶ Ep 4 · 9:17
clinical For the critical view of safety, all fatty material, peritoneal tissue, and scar tissue holding the gallbladder neck and infundibulum to the liver must be divided so the gallbladder is an inch and a half away from surrounding structures. ↗
▶ Ep 4 · 9:17
clinical For the critical view of safety, all fatty material, peritoneal tissue, and scar tissue holding the gallbladder neck and infundibulum to the liver must be divided so the gallbladder is an inch and a half away from surrounding structures. ↗
▶ Ep 4 · 10:02
clinical If the critical view of safety cannot be achieved, cholangiography must be performed to better understand the ductal anatomy. ↗
▶ Ep 4 · 10:02
clinical If the critical view of safety cannot be achieved, cholangiography must be performed to better understand the ductal anatomy. ↗
▶ Ep 4 · 10:37
quote everybody should know how to do cholangiography ↗
▶ Ep 4 · 10:37
opinion All residents should learn how to perform intraoperative cholangiography and laparoscopic ultrasound, even though these techniques add time and cost and are not always necessary. ↗
▶ Ep 4 · 10:37
quote everybody should know how to do cholangiography ↗
▶ Ep 4 · 10:37
opinion All residents should learn how to perform intraoperative cholangiography and laparoscopic ultrasound, even though these techniques add time and cost and are not always necessary. ↗
▶ Ep 4 · 10:47
clinical Laparoscopic ultrasound allows visualization beyond the visible surfaces of the abdomen, which is particularly valuable given that laparoscopy only shows visible surfaces. ↗
▶ Ep 4 · 10:47
quote the ultrasound lets you see beyond those visible surfaces ↗
▶ Ep 4 · 10:47
quote the ultrasound lets you see beyond those visible surfaces ↗
▶ Ep 4 · 10:47
clinical Laparoscopic ultrasound allows visualization beyond the visible surfaces of the abdomen, which is particularly valuable given that laparoscopy only shows visible surfaces. ↗
▶ Ep 4 · 11:15
clinical Indications for intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound. ↗
▶ Ep 4 · 11:15
clinical Indications for intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound. ↗
▶ Ep 4 · 11:18
clinical Before clipping and dividing the cystic duct, place a clip on the gallbladder side, make a small incision in the cystic duct, and milk it backwards to check for stones in the cystic duct. ↗
▶ Ep 4 · 11:18
clinical Before clipping and dividing the cystic duct, place a clip on the gallbladder side, make a small incision in the cystic duct, and milk it backwards to check for stones in the cystic duct. ↗
▶ Ep 4 · 11:38
epidemiological Cystic duct stones are one of the prime indicators that common bile duct stones are also likely present. ↗
▶ Ep 4 · 11:38
epidemiological Cystic duct stones are one of the prime indicators that common bile duct stones are also likely present. ↗
▶ Ep 4 · 12:29
clinical Chronically inflamed gallbladders are usually intrahepatic with no plane between the gallbladder and liver. ↗
▶ Ep 4 · 12:29
clinical Chronically inflamed gallbladders are usually intrahepatic with no plane between the gallbladder and liver. ↗
▶ Ep 4 · 12:42
quote what I tell the residents is called a controlled evulsion ↗
▶ Ep 4 · 12:42
clinical For intrahepatic gallbladders, use 'controlled avulsion' technique: strong traction on the gallbladder with the left hand pulling away from the liver, while the right hand barely touches the gallbladder-liver junction with low-wattage cautery to carve it out. ↗
▶ Ep 4 · 12:42
clinical For intrahepatic gallbladders, use 'controlled avulsion' technique: strong traction on the gallbladder with the left hand pulling away from the liver, while the right hand barely touches the gallbladder-liver junction with low-wattage cautery to carve it out. ↗
▶ Ep 4 · 12:42
quote what I tell the residents is called a controlled evulsion ↗
▶ Ep 4 · 13:17
clinical For gallbladder bed bleeding, use irrigation-suction in the left hand to clear smoke and blood while applying cautery with the right hand to bleeding areas; this controls bleeding 99% of the time. ↗
▶ Ep 4 · 13:17
clinical For gallbladder bed bleeding, use irrigation-suction in the left hand to clear smoke and blood while applying cautery with the right hand to bleeding areas; this controls bleeding 99% of the time. ↗
▶ Ep 4 · 13:55
clinical A small bile leak from the middle of the gallbladder bed, when ductal anatomy is otherwise clear, is likely a duct of Luschka and should be managed with attempted suture repair, though the stitch is unlikely to hold. ↗
▶ Ep 4 · 13:55
clinical A small bile leak from the middle of the gallbladder bed, when ductal anatomy is otherwise clear, is likely a duct of Luschka and should be managed with attempted suture repair, though the stitch is unlikely to hold. ↗
▶ Ep 4 · 14:15
clinical A drain should be placed for suspected ducts of Luschka or when dissection is deep into the bed of an intrahepatic gallbladder, and the patient should be kept overnight to ensure no bile accumulation. ↗
▶ Ep 4 · 14:15
clinical A drain should be placed for suspected ducts of Luschka or when dissection is deep into the bed of an intrahepatic gallbladder, and the patient should be kept overnight to ensure no bile accumulation. ↗
▶ Ep 4 · 14:44
epidemiological 95% of laparoscopic cholecystectomy patients are discharged the same day. ↗
▶ Ep 4 · 14:44
epidemiological 95% of laparoscopic cholecystectomy patients are discharged the same day. ↗
▶ Ep 4 · 14:55
clinical Postoperative pain management includes intraoperative IV acetaminophen, 5 hydrocodone tablets for home use (patients should call if they need more), and ibuprofen or acetaminophen for the first few days. ↗
▶ Ep 4 · 14:55
clinical Postoperative pain management includes intraoperative IV acetaminophen, 5 hydrocodone tablets for home use (patients should call if they need more), and ibuprofen or acetaminophen for the first few days. ↗
▶ Ep 4 · 15:15
clinical Pain requiring more than 5 hydrocodone tablets after laparoscopic cholecystectomy indicates a problem and warrants evaluation. ↗
▶ Ep 4 · 15:15
clinical Pain requiring more than 5 hydrocodone tablets after laparoscopic cholecystectomy indicates a problem and warrants evaluation. ↗