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𝗦𝘁𝗼𝗻𝗲 𝗥𝗲𝘁𝗿𝗶𝗲𝘃𝗮𝗹 𝗳𝗿𝗼𝗺 𝗡𝗮𝗿𝗿𝗼𝘄 𝗖𝗵𝗼𝗹𝗲𝗱𝗼𝗰𝗵𝗼𝘁𝗼𝗺𝘆 🔴Bring CBD stone trapped in basket to choledochotomy site 🔴Remove scope over wire 🔴Keep tension on basket wire with trapped CBD stone 🔴Introduce choledochotome (or laparoscopic scissors) and minimally extend choledochotomy over large CBD stone ➡️Prevents large choledochotomy #FOAMed #GITwitter #MedEd #SoMe4Surgery #Surgery

Derby Pancreaticobiliary & Robotic AWR Unit

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Anya Rossi• Live Now

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Tips for Retrieval of CBD Stone during Transcholedochal LCBDE 🔴CBD >8mm 🔴Atraumatic graspers useful 🔴"Milking" CBDS 🔴5mm choledochoscope with 0-Tip basket ➡️Gentle "to-and-fro" motion ➡️Irrigation 🔴Withdraw choledochoscope over basket wire with trapped CBDS 🔴Extend choledochotomy #FOAMed #GITwitter #Surgery #SoMe4Surgery #HPB

Tips for Retrieval of CBD Stone during Transcholedochal LCBDE 🔴CBD >8mm 🔴Atraumatic graspers useful 🔴"Milking" CBDS 🔴5mm choledochoscope with 0-Tip basket ➡️Gentle "to-and-fro" motion ➡️Irrigation 🔴Withdraw choledochoscope over basket wire with trapped CBDS 🔴Extend choledochotomy #FOAMed #GITwitter #Surgery #SoMe4Surgery #HPB

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Tips for Transcystic Laparoscopic CBD Exploration 🔴3mm choledochoscope ➡️Direct visualisation of duct 🔴Cephalad retraction 🔴Incise cystic duct parallel to CBD stone 🔴If large CBD stone ➡️withdraw scope over wire and provide gentle traction 🔴Milk backwards 🔴Keep CBD in view 🔴Reduce speed of irrigation to trap CBDS What are your tips and tricks for transcystic LCBDE? #FOAMed #GITwitter #surgery #hpb #MedEd #SoMe4Surgery

Tips for Transcystic Laparoscopic CBD Exploration 🔴3mm choledochoscope ➡️Direct visualisation of duct 🔴Cephalad retraction 🔴Incise cystic duct parallel to CBD stone 🔴If large CBD stone ➡️withdraw scope over wire and provide gentle traction 🔴Milk backwards 🔴Keep CBD in view 🔴Reduce speed of irrigation to trap CBDS What are your tips and tricks for transcystic LCBDE? #FOAMed #GITwitter #surgery #hpb #MedEd #SoMe4Surgery

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𝗟𝗮𝗽𝗮𝗿𝗼𝘀𝗰𝗼𝗽𝗶𝗰 𝗙𝗲𝗻𝗲𝘀𝘁𝗿𝗮𝘁𝗲𝗱 𝗦𝘂𝗯𝘁𝗼𝘁𝗮𝗹 𝗖𝗵𝗼𝗹𝗲𝗰𝘆𝘀𝘁𝗲𝗰𝘁𝗼𝗺𝘆 Patient Presentation: 🔵History of severe cholecystitis 🔵CT on index admission showed: ➡️Cholecysto-colic fistula ➡️Air locules on GB ➡️Figure 1 below 🔵Follow up CT (~4 months later): ➡️Good improvement with apparent resolution of fistula as absence of air in GB ➡️Figure 2 below 🔵Symptomatic gallstones 🔵Listed for planned biliary surgery Operative Approach: 🔴Colonic adhesion to GB fundus 🔴Fused hepatocystic triangle ➡️Decision to perform subtotal cholecystectomy 🔴Dissection plane (window) identified between GB and colon 🔴Presumed area of fistula tract detached with cuff of GB wall 🔴Stone retrieved and GB opened to identify cystic duct ostium on opening GB ➡️Closed with 2/0 Vicryl 🔴Gallbladder dissected off as far as safe to do so 🔴Detached colonic attachment with GB cuff ➡️No obvious fistula tract ➡️The area was under run to achieve haemostasis 🔴Cystic artery transfixed with figure of 8 suture 🔴Drain x 1 ➡️Removed after 24 hours 🔴Uneventful postop course #FOAMed #MedTwitter #GITwitter #SoMe4Surgery #HPB

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