Acute Cholecystitis

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current in General Surgery is edited by Jeffrey Ponsky, Mina Bolas, and Harveen Lamba in partnership with Global Cat MD and is recorded and produced at Cleveland Clinic in Cleveland, Ohio. We hope Good morning. Uh, I'm Doctor Jeffrey Ponsky. I'm a professor of surgery here at the Cleveland Clinic Learner College of Medicine in Cleveland, Ohio, and we're going to talk to Doctor John Rodriguez, who's on the staff of the Cleveland Clinic here in Cleveland, Ohio. And today's subject will be acute cholecystitis. I think you've seen one case, right, John? I think so. So you tell us about it today. That's great. OK. So let me ask you some questions about this. Let's assume that you have a patient who comes in and let's think that she's a 45 year old woman. Who comes into the hospital, you're called down to see her in the emergency room and they tell you that this lady's had a day and a half of severe right upper quadrant pain. Uh, this is not her first attack. She's had several. Attacks, which she hasn't told anybody about, but, uh, she's had these attacks of right upper quadrant pain and they came after eating, and now she's really having a lot of discomfort. Um, and you go to examine her and you see that, uh, indeed she's got, uh, uh, a little bit of a fever. Uh, she looks like she's in some, Acute distress as you look at her from the entrance to the room. You go to examine her. She's clearly not jaundiced. She looks OK. Her vital signs are normal, but when you examine her abdomen, she's got, uh, fullness in her right upper quadrant. It's very tender when you touch her up there. Uh, there's a suggestion of a mass right there in the right upper quadrant, but you can't examine her well. There's clearly some localized peritoneal signs, and the rest of her physical examination is entirely normal, and her laboratory work just shows, a white count of 12,000. And, uh, she's otherwise, uh, fine. Uh, so this lady, uh, has an ultrasound of her gallbladder, um, and they tell you this before you get down there, and it shows a thickened wall with percholecystic fluid and stones in the gallbladder. So that's what you're, uh, asked to look at and what do you think about this situation. So I wish all my cases were this straightforward, uh here at the clinic. OK. So, you know, this sounds like a, a, a, a fairly straightforward case of acute cholecystitis in a patient who seems to be a reasonable surgical candidate in terms of her past medical history and past surgical history. It doesn't sound like she has any, any significant risk factors for an operation. Sounds like the, uh, her symptoms have been there for a little bit less than 2 days. So, so in case like this, I'm, I'm fairly aggressive about, uh, offering them surgery as a first option and, and just doing an elective cholecystectomy because, 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. So a 45 year old lady with pretty straightforward cholecystitis, um, LFT seemed to be normal. I would, I would favor doing. A cholecystectomy, uh, basically this admission from the emergency room. OK, so you would look at this case as a case of acute cholecystitis. Uh, it's, uh, confirmed by your ultrasound. The laboratory, uh, values are not particularly abnormal, and you would plan to take her to surgery within a day. Hopefully as soon as possible, yes. OK. And you, you discussed why that is. Um, let's, uh, talk about what you might do to prepare her for surgery. Is there anything, do you need? Do you start antibiotics in a case like this? Uh, what are your thoughts? I usually do. Um, I, you know, this is obviously a patient, she's in the emergency room. I would admit her to my service, put her on antibiotics, uh, keep her NPO, get all the routine lab work that we would need for, for surgery. Uh, make sure she's, uh, that her coags are OK. Make sure that she's got a typing screen and. And a pregnancy test and, and make sure that those things are not going to delay our operative intervention. OK, so as we talk about this, uh, I always like to think and I'm expressing for the students the concept that acute cholecystitis is one of a number of what we like to call obstructive diverticulopathies. Here we have this diverticulum off the biliary tree, the, uh, gallbladder, uh, it becomes, uh, uh, the cystic duct becomes obstructed usually by a stone. And, uh, there's a backup of pressure in the gallbladder with, uh, a decreased blood flow in the wall, and, uh, uh, eventually it can rupture. Obviously, the wall becomes thickened, and this is why you want to go in quickly. Um, if this patient, uh, had, uh, other factors going on, if this were a 75 year old patient with an ejection fraction of 15% and a history of, of, of previous MIs, are there any other mitigating. factors here that might change your course of action. Well, obviously I think when we see these patients with a little bit of a more complex medical history and, you know, especially here with the acuity of our patients, I think that's probably the most common scenario. And I think we always have to get a little bit of help from some of our colleagues from the medical subspecialties in terms of really determining uh realistic risk factors for a lot of these patients. 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. So. So I think in, in patients like that, um, it's helpful to take a step back, make sure you get a good understanding of what her overall medical problems are, and make a decision. A lot of times with antibiotics, they will cool down and, uh, no additional intervention is needed. But our colleagues from radiology can be very helpful by placing percutaneous cholecystostomy tubes in some of our sicker patients, uh, that are not, you know, good candidates for operative intervention. Um, so tell me about that. So, let's assume that you have a patient who's had a recent cardiac event or has a very poor cardiac, uh, function, and you look at this patient and say this is a prohibitive operative risk, at least at this time, and they have acute cholecystitis. Tell us how you would then manage that patient. So, definitely a patient I would admit to the hospital and, and put him on broad spectrum antibiotics. I usually like to give them about a day or two, and if there's no improvement, then I would recommend doing a percutaneous cholecystostomy. All right, so the, you call radiology for that and they put the tube in through the liver into the gallbladder? Yes. OK. And what then do you do with that tube? So those tubes seem to be very effective. I think the combination of those tubes with antibiotics are very effective in managing acute cholecystitis in some of our sicker patients. So most of these patients actually have an uneventful recovery and they're able to leave the hospital. OK. When do you take that tube out? So the, the, the key about taking these tubes out is kind of determining what is the risk of recurrence of, of what. The underlying problem is. So, are we going? So tell me, when would you take these tubes out? So I usually like to wait about 4 to 6 weeks, and I like to do a cholangiogram through the tube and make sure that the cystic duct is open. You were talking earlier about the diverticulum, the diverticulum behavior, and I, 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. And obviously, make sure that the cystic duct is patent, because if, if you don't do that, as soon as you take that tube out, they'll get a recurrent episode. OK. So, you try to make sure the cystic duct is patent when you take out the tube. OK. If they have remaining stones, though, what do you do with that patient? Well, I think they, they all are going to have remaining stones cause, you know, usually they, you, you don't, you can't really manage those with, with any percutaneous intervention. I, I think the, the key is, You know, if it's a temporary situation, for example, we see a lot of patients who are on, on antiplatelet therapy uh because of stents and, and they have to wait a year and you're getting closer to that date, then I think it's a reasonable thing to do because, you know, once they can come off their Plavix or their aspirin, and it's much easier to, to manage a recurrent episode in a more definitive way. But some of our patients are, are sick and they have conditions that are not going to improve. And I think with those patients, um, it's always important to have a good discussion about what the true risk of a recurrent episode is and, and, you know, obviously, the, the role of the tube. OK. So, this allows you to time your intervention more carefully. Um, What do you do to prepare a patient like this for surgery if you deem that they're, let's say, relatively uh young and you want to go in and do something, what do you do to prepare them for surgery? You mean a patient with a tube? Yes. This is a patient who has a. Yeah. Poor ejection fraction, uh, who's had a previous cardiac stent, for example, and has stones, uh, and, uh, remaining in the gallbladder. Yeah. So, so they, they, in my experience, they tend to be more challenging cases and, and I think it's not the gallbladder you want to just add on at the end of the day with, you know, when you're tired from, from an all day, uh, surgical volume. I think it's, it, there are cases that need to be planned well. Um, I still get a cholangiogram before, uh, ahead of time. Through the, uh, through the, through the, through the tube, and I don't, if I can't, I don't take it out because it's useful sometimes, especially if there's a lot of adhesions, you know, uh, finding the tubes and, and, and sometimes even using them to shoot a chalangiogram in the operating room, um, if you're a little bit lost can be very helpful. So, but in my experience, those gallbladders tend to be pretty challenging and they, they take up quite some time to do. OK. So, let's talk about the operative preparation again. You would get a cardiology consult on this patient and get, uh, Yeah. What kind of tests? Absolutely. So, so depending on what the underlying cardiac risk, I usually, you know, obviously get some, some degree of, uh, of, of at least, uh, uh, a stress test if it's indicated, um, if they're on antiplatelet therapy, especially some of the newer generation, um, medications. Make sure I, I, I have them see their, Cardiologist and and discuss with the cardiologist what the uh what the safe time frame is for both uh stopping them before surgery and and you know and some of the, the, the newer generation blood thinners when to start them safely after surgeries to make sure that we at least try to, you know, keep the operation as safe as possible from a cardiac standpoint. And sometimes they need to even have a cardiac cath with stents before surgery to improve their cardiac function. Absolutely, absolutely. All right, well, let's talk about the conduct of the operation in a patient who has acute cholecystitis. And let's go back to our 45 year old woman with this acute, uh, gallbladder that you told me you were going to take her to surgery. You know, I'm not going to let you get away with an easy case. So, let's just talk about how you'd go in and conduct the operation. So, I'm, I, I, I think, uh, 99% of the time my, my approach is, uh, laparoscopic. Um, I think we've all gotten pretty good at doing laparoscopic cholecystectomies even in, in, in, you know, very difficult cases. So, for these patients, I think, um, if you get lucky and you catch them in that window and there's just some edema, uh. Tell me how you'd enter the abdomen. Let's get specific. So, I, I have a, a selection in terms of, uh, patient's BMI, and I think it's a little bit of a bias from my practice because I do some bariatric surgery as well. So, in patients, With a higher BMI, I have a tendency to do optical entries. Where do you put that first trochar? So, I usually, I like to go in the left upper quadrant, uh, close to Palmer's point, because it's one of the safest. Tell me what that is. So, it's about two finger breadths below the, uh, rib cage on the left side. In what? Um, in the midclavicular line. In the midclavicular line. OK. Um, and what I find is by doing that and just dropping your hand a little bit further, about another inch or so, Um, I've never had to place another trochar because that one doesn't help me. It's usually, if you go in that location, uh, you have a little bit of, of more length, but you can make that up with longer instruments. So, you use that as your, one of your operating ports? Yes. OK. So, I use it for my right hand. I stent or is that a 5? A 5 millimeter. 5. Yes. OK. And so you put in a 5 millimeter scope through that port once you, Get in. Yes. OK. So, after I do that port, then I do a, a perambilical 12 millimeter port, which I use for my camera. Under direct vision, you. Under direct vision, yes. OK. Um, and then I place the patient in, in, uh, in reverse Trend Dellenberg, um, and that helps me with exposure. And if I can see the gallbladder, one of the tricks that I've learned is that if you put your most lateral trochar, Uh, which is also a 5 millimeter trocher while being able to see the gallbladder. You can have your assistant grab the gallbladder and elevate it and it gives you a better location for your left hand, which usually goes, um, about midclavicular line, um, anywhere between two finger breadths and, and a little bit lower depending on the patient. All right. So, I want to make this clear again. So, you've got your left upper quadrant, uh, or left, yes, your left upper quadrant, uh, trochar, which is a 5, and you're using that for, uh, operating, You've got your camera port, which is now in the perambilical region, which you put in second, and now your third trochar is in the right side, lateral, and you're using that one for retraction of the gallbladder or dissection? For retraction of the gallbladder. So that's my assistant's, uh, hand. All right. And is that, uh, is that, uh, lower near the, uh, anterior superior spine or is that up near the right costal margin? So, I do it based on, on how I visualize the edge of the, Liver. So, I usually try to get it, like about a finger breadth or two below the edge of the liver. Um-hum. And that's why I, I find it very helpful to do it on the direct, uh, laparoscopic vision cause it gives you a, uh, kind of a, a better orientation towards the gallbladder. So, you put your ports in after the first port based on the position of the liver and the gallbladder? Absolutely. OK. So, an alternative way, which I used to do, which is probably old fashioned, is I would do a direct cut down at the umbilicus, the Hassan technique. And then based again on the vision, I would put in an epigastric port and uh a, a right lower quadrant retracting port and then finally a right upper quadrant port to dissect with, but we end up with how many ports in your case, 3 or 4? 44. Of course. 4, and I would have 4, but you use all 5s, is that correct? No, the, usually the peri umbilical is a 12. Right. And that's the one you were going to extract the gallbladder with. Yes. In the end. OK. Yes. Um, so, as we proceed, let me just tell you that when you get in there, you see a ton of omentum up in the right upper quadrant, and, and, uh, uh, and you know the gallbladder's under, it's a hard mass under there. How do you proceed at that point? So I would usually start by lying adhesions, um, you know, gently. I, I like to use cautery, especially if I can visualize the colon, the duodenum. I, I try to use cautery because especially in some of these acute cholecyst, uh, acute cholecystitis cases, the tissue can be very edematous and it can bleed easily, and I find it that when you don't control the bleeding. Early on, it tends to impede with your visualization later on. So you're talking about the control of bleeding from the omentum. From the Omentum. Take it down. Yes. Do you ever use the harmonic in this situation? Sometimes I do, but, uh, most of the time with just some good hook electric cautery, you can, you can get, uh, it's a very fine dissecting tool and, and, uh OK. It tends to be hemostatic. So, your goal here is to take the omentum off the gallbladder. Yes. Is that, so, you do that and you take the omentum off the gallbladder. Now you can see the gallbladder is tense and hard and thick. What do you do? So, I have a very low threshold to decompress those gallbladders before you start trying to grab them and. Tell us what you mean by that. So, we have a, a, a long, uh, needle that, um, is actually a, a reusable, uh, needle that's in, in most of our laparoscopic sets. I'm sure you were the one that brought it here. No, I don't know. And, uh, I usually, it, it, it connects with a lure log to a 60 cc syringe and I usually under direct vision, uh, put it into the lumen of the gallbladder and aspirate. You do that at the fundus of the gallbladder? I do that at the fundus of the gallbladder. Right. OK. You aspirate to the purpose of, so that you can grab it. Right, without tearing it. Without tearing it. OK. So, let's assume that you're able to get some of that out and this, Get a lot of dark mucoid material out of that and now it's a little bit decompressed, although you can see the stones outlined by the gallbladder wall at this point. So, go ahead and tell me the conduct of your operation, cause I'm not going to make it easy for you. Let's go ahead. Right. So, I, I, I still, um, you know, if I'm able to do that and grasp the gallbladder and elevate it and, uh, I have a clear view, Um, you know, down by the infundibuum, I usually try to dissect, I try, I'd like to start high up and, and take the perineum off the, the gallbladder again, using the hook electrocautery, um, and try to visualize that, that, uh, Cloud's node, which is a good guide to, to cloud's triangle. All right. So, you're looking for Callo's node and Callo's triangle? Yes. OK. And, uh, you're, how do you get down, what are you doing? Describe how you see that point. So I, like I mentioned, I, I take the pernium high up on the gallbladder where I'm sure that I'm on the, uh, you know, on the gallbladder. And, uh, I try to, once, usually when these acute cholecystitis, they have to, they tend to have a, a thicker OK. Uh, rind. So, so once you get down on the gallbladder wall, you can start gently and very patiently teasing those tissues down towards the duodenum. Do you ever use the sucker as a dissector? I do. I do that a lot. It's a great tool. That's how the tending steals the case from the, uh, resident here with the sucker. Right. So, go ahead. So, I, I, Gently start teasing things down and, and, you know, most of the time you can visualize as you're taking clots, note down, you can visualize the cystic artery there and I also dissect it up towards the body of the gallbladder to try to get some length on it, because as long as you're on the gallbladder, you know you're safe. All right. So this I want to emphasize that the dissection occurs at the junction of the cystic duct and the gallbladder, the cystic artery. And the gallbladder. You're not looking to go as close to the common duct as you can, is that correct? Absolutely not. And that's where, that's how you get in trouble in, in some of these cases. So, you strive to, uh, achieve this, uh, critical view of safety? Do you want to describe that a little bit? Sure. So, once, once you get down and usually as you take Clotte's note down, you can visualize the, the junction between the cystic duct and the gallbladder. And uh I, I like the Maryland, it's a great tool. I, I, I like to do some gentle dissection there. Um, 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. And uh I try to create a window there and, and the classic description of the critical view that I'm looking for is to try to visualize the cystic duct, the, uh, gallbladder wall, and, uh, I want to see liver in that window. And you want to see the cystic. Artery. And I want to see the cystic artery within Clot's note as well. Right. Within clots triangle, sorry. All right. Yes. Well, OK. So, that, that's the goal. And then if you were going to dissect this, you see those, let's assume that you have them all dissected. You do a combination of sharp and blunt dissection. Uh, I think a nice little trick is to, uh, to take some of the gallbladder, uh, just superior to the junction of the cystic duct with the gallbladder and take the back wall of the gallbladder off the liver bed to give you some increased length. Uh, but, uh, once you do that, uh, are you considering a cholangiogram in this case, or do you, don't you do it in acute cholecystitis? I do. I, I, I almost use routine cholangiography. You want to talk to me about how you do a cholangiogram here? Sure. So, um, I, I like to use the, uh, the, the catheter you invented, the Ponzi catheter. Um, it's, it's like a little ERCP catheter, right? So it's a little ERCP catheter that has a wire in it, so it makes cannulating the, uh, the cystic duct, uh, very easily, and then you put that catheter, uh, through a, um, uh, a clamp, uh an Olsen clamp. So what I do is I take a clip and I place it very close to the gallbladder and I make a dicotomy before I even try to cannulate, usually with the same, uh, kind of back of my scissors or a marrow, I try to kind of milk that cystic duct proximately and see if there's any stones, um, to try to get them out. Great idea. And then through my left upper quadrant, uh, trochar. I place the, uh, the, the clamp with the catheter and I, before I put it into the body, I like to kind of give it this little 45 degree angle cause it helps cannulate, uh, quite a bit. That's interesting. So, you use the left upper quadrant and shoot backwards. Yes. OK. I I use the right upper quadrant, uh, uh, one, and I go forwards, it's just a matter of, uh, of preference. OK. Yeah. But you put that in there and then you clamp the clamp, right? Right. So, the ultra clamp has this, uh, very nice, uh, kind of layout where, The, the tip of the clamp comes together, but the middle doesn't. So, just enough that you can occlude the cystic duct around the, around the catheter, but it does not occlude the catheter at all. OK. So, I get, I get my, um, I get my, my catheter down. Um, I usually flush with saline, make sure I don't have a lot of back, uh, flow. Um, and I like to flush the duct with a good 20 ccs of saline, uh, cause a lot of times when there's sludge and there's stones, uh, 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. OK. Um, a little bit better. And, um, following that, I bring my CR in and, uh, and I shoot a, a cholangiogram. And I, well, let me just, I'm not going to let you get away with this. So, let's assume that you shoot a cholangiogram and all the contrast goes down. Nothing goes up into the liver. What are you going to do? So, there's a couple of tricks to, to try to get things to go up. One is just kind of laying the patient, uh, a little bit of, of, uh, render position. That can be helpful. But a lot of times what I end up doing is I use the camera. Once I get that good view of the distal, uh, CBD and good flow to the, to the duodenum, I use the, uh, the camera to put some pressure on the distal CBD, um, and that typically does the trick. Right. That allows you to compress the distal duct and then inject and get the stuff to go up. Right. OK. So, let's assume, and this is probably not going to happen in acute cholecystitis, but let's assume we see a small stone in the distal duct. What would you do now? So, there's a couple of, of different, uh, tips and tricks that, that you can do. I, I, I'm, you see, the first thing I do, I try to flush it again. Um, I give it a good, good flush and see if that'll do. Do you give a glucagon? I give glucagon to relax the ampula. OK. Uh, which can sometimes help get those distal stones out. Um, and I should repeat cholangiogram. And if the glucagon and flushing the duct doesn't do the trick, then, I like to use one of these, uh, the preset, uh, commercial transcystic common bile duct exploration kits. OK, which would include. So, it has a couple of different components. The one that I use has, uh, uh, a percutaneous introduction catheter that comes in, Um, with a, uh, uh, a step dilator. OK. So, you can get that in a, in a, I like to get it in a very, uh, kind of parallel angle to the cystic duct through a different stab incision. So, I don't use my trocher. OK. Um, it just gives you a, a, a little bit of a, of a more straight shot. And, and the key is to. This is from the right side. From the right side. Finally, we got. Yes. To the right side. Right. OK. Right. Go ahead. So, I'm on the right side. Um, and I try to get in a very parallel angle because it's, it's a little bit, uh, of a stiff introducer, and, and I, I'm always worried about trauma to the duct and, and, and backwalling it. But the key for this, uh, for this kit is to place a wire under fluoroscopic guidance this into the duodenum, and if you can get that wire to go down. Then the kit has a couple of different instruments that can be helpful for, for, uh, extracting stones. So it has a, a basket, um, dormer, a dormier type basket, yes, that you can place through the cystic duct and, and try to crush and retrieve some of these stones. Um, it also comes with a balloon, uh, dilator. Um, so, sometimes, you know, just place, passing those can help push the stones through, which I think if it's a small stone, most of the time it's easier to do that than to try to. So you're actually doing a transcystic anti-grade sphincteroplasty by dilating that and then flushing. Exactly. Very cool. Exactly. OK, very good. All right. So, let's assume that you do a transcystic extraction. Um-hum. And then you take out the gallbladder. But I'm not going to, again, make this so easy. Let's assume and go back to this dissection. And you find that this is really very difficult. You see the very top of the gallbladder, but it's very inflamed. The duodenum is adherent to it. Uh, you cannot define the infundibuum of the gallbladder, the cystic duct or artery or callow's triangular node. And you're halfway down the gallbladder and it's a rock and very bloody. What do you do now? So, that sounds like one or more, more of my typical cases. Yeah, in my life, right? Right. So, what are you going to do now? So, I, um, you know, uh, again, I would decompress the gallbladder. I think that's always a helpful thing, you've done that to do already. OK. Um, but I am very aggressive about, in cases like that, going in a top down fashion. So. You're still staying laparoscopic? Here? I, I still do. OK, I'm going to get you open eventually. I know you will, but. So, you're, you're, you're going to do it, tone down. Tone down, yeah. So OK. So. How do you retract the, the upper part of the liver while you're working on the gallbladder bringing it down. So, I, I usually get my, my assistant from that lateral left, uh, uh, kind of left lateral trochar, which is the other reason why I, I usually try to do it on direct vision because, Uh, I, I find myself more commonly in these situations than not. So, so, placing that trochar in a position that it will be helpful for other things than just a standard technique for cholecystectomy, you know, tends to be, uh. So I want to just make a point. You're not afraid to add another trochar? No, not at all. Far free. There's nothing magical about, uh, one number or another. You just put them where you need them. Right. OK. So, you're operating as you need it, and now you're trying to domed down. Yes. OK. And let's assume that that does not go well, that you get to that same point and you cannot get any further. What are you going to do now? So I always think of two options. One, it's probably not the most desired thing, but it depends on, on how really, I think I, I can tell laparoscopically how difficult it's gonna be to go open, 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. What would you do in that case? So, I would, I would, my decision would be between either do, you know, opening the gallbladder and doing a partial, uh, cholecystectomy, uh, or even sometimes, you know, I've, I've done cases where you leave part of the back wall on the liver and just kind of get down as, as much as you some of the things that I've done. In those horrible cases, open the gallbladder, take out all the stones, put it in a big tube. Uh, uh, it's a bigger cholecystostomy, and now you have an empty gallbladder with a big tube in it, and that can bail you out of a horrible case. But now. Right. Let's assume you go open and, uh, you can see the anatomy and you're taking it, would you go dome down if you did it open? I would. OK. I would go dome down. Dome down, going very carefully to find the anatomy, Let's assume that it's just as you describe a mess. You can sort of see the infundibuum, but it, you, it's like a rock beyond there. Uh, how do you proceed? You talked about leaving the back wall. Would you describe what that entails? Sure. So, sometimes when the gallbladder's very inflamed and, and, and it's difficult to get a plane between the liver and, and, and the gallbladder, and, you know, the one thing I, I'm always kind of careful with is, Not so much the bleeding from the liver, but there's usually, uh, some patients have a very superficial right system, and as you start digging into the, the system. The ductal system. Yeah. Um, so I've seen a lot of patients that come back with, with bio leaks and, and, You know, we, we attribute them to different things, but the reality is a lot of those cases, and, and they can be labeled as duct of Lushka leaks are not really duct of Luska leaks. I think it's just that the surgeon gets a little bit too deep into the liver and injures, um, what do you do with this horrible gallbladder? So I would, I, I, I, I, I like your idea. It's, it's something I've done quite some time of opening the gallbladder, getting the stones out, get down to a point where I, I know I'm safe. I'm not injuring anything. I usually don't leave it open. I close it up, you know, it would, these uh cystic ducts eventually can open up again, um, leave a drain, most, most of the time, I, in case like this, I do leave a drain. Uh, mostly to control a bio leak if it occurs. So, when you talk about leaving the back wall. How does that occur? Tell me what kind of case you do that in. So, that would be one of those horrible cases that you start wishing you were never there from the start. Um gallbladder's necrotic and falling apart. Gallbladder's necrotic, falling apart, the cystic, the, the, you know, as you get closer to the cystic duct, things don't look much better than that. Um, Then 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 for. When you leave this back wall and you've gone all the way down there. Do you do anything to the mucosa on the back wall? I cauterize it, uh, most of the time. Just a coag? Just a coag, uh, on, on a high setting. I, I cauterize it, um. Do you leave drains? I do leave a drain, yes. OK. Yes. Very good. Well, this is, these are tough cases and, Uh, you know, everyone's going to encounter them in, in their life, and I think you've made the point that first do no harm, uh, if you, uh, persist in going too far to the, uh, to the common duct, you're likely to get an injury, and that's what we want to avoid. So, I think that, uh, you've made the point that we want, To operate early in acute cholecystitis, particularly if it's uncomplicated. And in in patients who have other mitigating factors like cardiac disease, pulmonary disease or other things, we might want to, uh, put in a percutaneous cholecystostomy and come back in an elective time. And, uh, when we operate, it's not a crime to put in an extra port and to, uh, go dome down if you have to, and to even open, Uh, when you're not making progress, uh, complete cholecystectomy is not always possible or always necessary, and I think, uh, you've made all those points very well. So I wanna thank you, Doctor Rodriguez, for joining us today and, uh, hope we'll see you back in the future. Thank you, Doctor Ponsky. Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current in General Surgery is edited by Jeffrey Ponsky, Mina Bolez, and Harveen Lamba in partnership with Globalcast MD and is recorded and produced at Cleveland Clinic in Cleveland, Ohio. We hope