Podcast_BTK Open Chole Team Mizzou final

Welcome to Behind the Knife with the Emergency General Surgery Team at the University of Missouri School of Medicine. This is our inaugural episode at Mizzou, and we're excited to join the team at Behind the Knife to provide educational content in emergency general surgery. I'm Ru Dev, and today we're bringing back an essential skill that's fading from our collective memory open cholecystectomy.

This episode is about getting back to the basics and walking through the key steps of open cholecystectomy, including how and when to perform them safely. So let's meet our team. Hey y'all. My name's Jeff Kau. I'm one of the acute care surgeons and the trauma medical director at the Mitchell Trauma Center here at Mizzou.

I'm Dr. Chris Nelson. I'm another acute care surgeon here at Mizzou. I'm the medical director of emergency general Surgery also. And I'm Micah Anta. I'm currently finishing my second year of fellowship for the a CS Fellowship here at Mizzou. My name's Desire. I'm currently a third year in general surgery here at Mizzou, and I'm interested in pursuing acute care.

So guys, what do we all know other than I have

international and national hatred for all gall lags? Well, cholecystectomy is one of the most performed operations of the United States. We know that about 1.2 million cases are documented every year, and as far as we do know. Through most recent inpatient records, about six to 7% of complications still occur annually.

That's right. And don't forget the fear complication of bile duct injury that remains at three to four out of a thousand operations a year. Even for the most experienced surgeons. Yeah, for acute care surgeons, man, I sometimes feel like every severely inflamed gall bag is just a grenade with a pin waiting to be pulled.

Severe complications from bile duct injuries are life-threatening, but also kind of altering for a surgeon's career. I wanna take this point to remind everyone about episode 5 34 on the difficult gall bladder. It's an excellent resource when approaching the core fundamentals of the specific disease process.

Hey, Dr. Fletcher, can you give us a brief review of how we define or grade cholecystitis when considering surgical approaches?

Yeah, absolutely. So as I'm sure y'all are all aware, there's several grading systems out there to characterize the severity of cholecystitis, either pre-op or inter-op. So most side systems that are well known include the Tokyo guidelines, the Parkland Grading Scale, and the American Association of Surgery for Trauma.

All of these are validated with a good degree of accuracy. Notably, the Parkland scale has been shown to be most accurate in predicting conversion to open or the use of some other bailout bailout techniques such as subtotal cholecystectomy. Recently, the Journal of Trauma and Acute Care Surgery ref referenced independent studies selecting risk factors that are associated with the difficulty of each cholecystectomy.

Some of these include male sex, an elderly patient, a higher a SA score, Charleston comorbid index greater than six. Multiple abdominal surgeries, diabetes, prior shin, atomy, and a delayed cholecystectomy greater than two weeks from presentation. The more risk factors in each patient,

obviously increases the likelihood of conversion and then a difficult dissection.

Yeah. So, Dr. Anta, do you think you can tell us a little bit about what programs are out there? To help guide surgeons when potentially approaching a difficult gallbladder? Yeah, of course. So in 2018, the Society of American Gastrointestinal and Endoscopic Surgeons, AKA Sages published consensus recommendations, known as a safe COI cystectomy program.

They outlined six strategies to help minimize the incidence of bile duct injuries. One, use a critical view of safety, method of identification of the cystic duct and cystic artery during laparoscopic chole cystectomy. Number two. Understand the potential for apparent anatomy in all cases. And to that degree, I'd also add in, make sure you look at all pre-op imaging.

Know if you have apparent or variations in your vasculature as well. Number three, make liberal use of CHO angiography or other methods to image the biliary tree intraoperatively. Number four, consider an intraoperative, momentary pause during laparoscopic

cholecystectomy prior to clipping, cutting, transecting any ductal structures.

Number five. Recognize when the dissection is approaching the zone, a significant risk and halt the dissection before entering that zone. Finish the operation by a safe method other than cholecystectomy of conditions around the gallbladder are too dangerous. And number six, doctor does favor get help from another surgeon from the dissection, or conditions are difficult.

Great, great, great. I'm glad. I'm glad the humor's about to pick up. So let's unpack number one and two just a little bit more and provide some clarity on some of those key terms. So first, Desiree. Can you define the critical view of safety for us? Yeah, sure. So the critical view of safety is clearly defined by three important points.

This should be visualized both anterior and posterior. So first, the hepa cystic triangle is cleared of all fatty tissue. The triangle is defined by the anatomic boundaries of the cystic duct to the common hepatic duct and the inferior edge of the liver. That's where it interfaces with the neck of the bag.

The second point is that the lower

third of the gallbladder is free from the liver to expose the cystic plate. And then finally, two and only two structures are seen entering the gallbladder. Sweet. So, hey Micah, recognizing the zone of increased risk where further dissection could potentially lead to more injury as paramount, right?

So why can't you, or why don't you define for us some of the options available when this point of the operation is reached? Yeah. I also think this is a great segue into the meat of our discussion and how conversion to an open procedure can be part of that safe pathway. It's important to understand that approximately 10 to 15% of cases with severe inflammation will prohibit dissection of the critical view of safety that firstly described.

Yeah, man. Did you know that inflammatory wall of tissue over the HEPA cystic plate is called mc Elmo Shield? It's kind of stupid, but I kind of moved to call it barrier to happiness. Piggybacking off of that statement, safe Co Ectomy program highlights a brief pause, in fact, in a what you Need to Know series.

In the Journal of

Trauma this past year, they highlighted a straightforward algorithm to follow. So one, take a timeout. This is like a halftime timeout in the middle of your operation. Number two, employ the monic B safe, SAFE, and reorient yourself as 95% of bile duct injuries are due to spatial disorientation.

That breaks down. B, visualize the bile duct at the duodenum or the hylum. Either way that you can find it. S, visualize the sulcus of er A. Make sure the hepatic arteries to the left of the port of heus. F the umbilical fissures to the left. And then E and tear stomach or duodenum to orientate yourself vertically or correct your medical student or intern who's holding the camera.

Three. Ensure proper retraction. Four, call for a second opinion. Get a senior surgeon in the room to kind of help you identify what you need to see. And then five, consider intraoperative imaging. If you can't safely achieve a critical view at this point, you need to start considering what your bailout options and strategies are or convert

to an open procedure.

Yeah, yeah. Un Unpack that for us a little bit. So what are those bailout strategies? So, the most, two most common procedures described are called a fess and a reconstituting subtotal cholecystectomy. Dr. Strasberg defined both procedures as excising the free peritoneal portions of the gallbladder. The difference is the technique at the lowest portion of the gallbladder for which part for us is called infundibulum and the fenestrated procedure, a lip is created at the lowest part, and the posterior wall of the gallbladder is left inside you.

Some surgeons attempt to suture the cystic duct close from the inside. However, this manure can be difficult, especially laparoscopically. The reconstituting technique involves closing the gallbladder remnant at the lip. With a suture or stapler, reconstituting, quote unquote, an intact lumen. Yeah, so much like a lot of things in medicine, old becomes new and new becomes old.

This procedure has gained a lot of popularity in recent years. But we forget that it was originally ascribed in 1955. Like every decision we make even if it's safe, it's

not without risk. Most of the literature studying these procedures are retrospective and small, and we do know that the fenestrated technique is associated with a 35% bile leak rate and the need for ERCP in about 44% of all cases.

Additionally, REVE rates approach 5% versus 3% for subtotal versus open cholecystectomy respectively. Not to mention that the reconstituting technique creates a neo gallbladder increasing the risk of recurrent gallstone disease. Almost 3% of patients receiving a subtotal cholecystectomy require completion Cholecystectomies.

Yeah. But in those system systematic reviews wasn't bile duct injuries. Less in the subtotal group as compared to the open cholecystectomy. Yes. By numbers it was, but only by 0.9%. And when compared to bio leaks need for ERCP re-operations and overall need for percutaneous drainage, open cholecystectomy outperformed subtotal procedures.

Yeah. So with that, why don't we get into the details of approaching an open gallbladder.

Hey, Dr. So why don't you kick us off? Yeah. Let's pretend it's next week, which it is gonna be next week. On a typical day in EGS with Dev in the, or taking a 65-year-old male with a one week history of abdominal pain, A BMI of 40, and a past surgical history of a laparotomy for a sigmoid colectomy who has what looks like clinical and radiographic evidence of a A ST grade three cholecystitis.

So about an hour into the case as you expected. A call from the, OR comes out to you in routine fashion and unbeknownst to me, you had already cleared your day and you're knowing then, you know, you're about to be be called into the OR to help out. I'm available too. Yeah, whatever. You suck. At some point I'm gonna have a PSA about bullies in academic medicine.

But anyway, so coconut, you walk into the OR and you find Deb yelling some choice, but professional words while the OR lights are being turned on. And he's making an incision in the right upper abdomen. So what's the first thing to keep in mind when planning an open

cholecystectomy? So, I think I'll start with before, before we dig into the technique.

I think a lot of people will eventually realize that they're in trouble. They'll call for help and, and we kind of go down the pathway we're getting ready to describe. I think I'll make the point that the other important factor is even if you're not in trouble. Somebody has got to recognize when you're not making progress.

So if the case is not moving along, there's a lot of time-wasting maneuvers trying to, you know, Bovie through Rhine, just going up one side or the other, but there's really no focus on identifying the cystic duct or the cystic artery. And you've been at it for a while, then maybe it is time to consider.

Conversion to an open procedure. And I'm going to jump on board with what Dr. Nelson had said earlier that the description of subtotal or reconstituting certainly exists and there's been a lot of people discussing or writing about that and drainage, but I, I

think we would agree that it's just not a great option.

You really have to consider. A, what you're doing to the patient and the risk that they're gonna have additional problems. And B, who are you actually kicking the can down the road for? And I think often it's one of your own partners or somebody else in your institution who's gonna have to come and, and mop up this issue down the road.

'cause the cholecystitis ain't just magically gonna go away and the procedure becomes easy in a few weeks. I think those are important points. Yeah, those are salient. I always forget about that. You know, like one of my first cases here is remembering late in the afternoon, having one of you guys come up after about two and a half hours into a bad gallbladder.

And I got that face through the window and I think the statement was, so are you gonna make a decision to go open or not? We wanna go home. So I think you also have to think about too, you know, the patients that we're operating on that are to the point where they have a difficult gallbladder. When we do

these bailout procedures, how do they fail and what complications are we reintroducing into that system and are they gonna be able to tolerate that From a physiologic standpoint is also another consideration you need to have.

Yeah. Okay. So if we're gonna start the open procedure I think we all agree that we're gonna do the right subcostal incision. The first element that I would touch on is probably one of the things that might be least appreciated. In residency you know, it's not until you're out on your own that you recognize how a simple retractor application and getting good visualization of what you need to do was was maybe something done by the faculty.

And now when you're charged with doing it on your own it's a whole new ballgame whether or not you use the oval which probably a lot of us would do. You pull out the circle for a book, Walter. Somebody out there might be fans of an Omni. I don't think it matters. I think what matters for me is probably a medium length

right angle under the ribs so that you're able to pull the right costal margin up.

Usually some combination of a wider malleable inferiorly to pull the colon and some of that associated momentum down outta your way. And then often something medially to kind of pull the stomach and to put some medial retraction on the duodenum so that you have a pretty good exposure and ideally the gallbladder's in the middle of your field, I think you're gonna elevate the head of the or bed to some degree to kind of help that stuff drop down.

And then my only caution is there's, there's too much of a good thing. There's, there's too many retractor blades that then create. You know, this field like you're operating down at the bottom of a mason jar, right? And I don't think that's obviously no good. So there's a, there's just a fine line between good exposure and then too much stuff that gets in your way.

I'm gonna back up one step before putting your retractor in and just ask desire where that

proper incision should be for your subtotal or your subcostal incision. Two finger breaths below the right costal margin. Right? And I want to I really want emphasize the importance of taking your time, making this initial incision.

Number one, identifying both the anterior and posterior fascia. And number two, taking your time dividing the abdominal wall musculature. Take your time with cautery number one so it doesn't bleed throughout the case, and you come back and remove the retractors at the at closing time and find a bunch of blood behind them and a bunch of bleeding you have to deal with later.

But number two the more time you take making good clean incisions in those fascia the, it's gonna pay dividends for you when it comes time to closing that fascia in two layers and being able to re approximate that nicely. So, let's see. We've got incision we've got retractors in. If we're gonna now move towards taking everything

down I think most of the time you can separate the surrounding inflammatory rind, whether that's with your finger, whether that's with maybe one of the more firm plastic yank suction devices.

I think whatever you choose to use. You can start to sort of peel things off. There's almost always a very nice plane around the inflammatory rind of the gallbladder. And I think then the next question sort of becomes how do you optimize retraction? Can chop a hole in the dome of the gallbladder?

You can suck it out. We're, we're gonna almost always start with a dome down fashion but how do you best get either an Alice or a coker? On the dome so that you can begin to manipulate the top of the gallbladder left and right. And then once you get that figured out cautery, not just 30 30 but set up to stun so that you can really start to burn the gallbladder away from the liver edge and start working your way down towards the in fibula.

Yeah, I think that was actually a really good point,

watching you come in and help me out on almost every gallbladder that I've done open, but. Going up on the golf on the cautery to, you know, 60 60 and something with a little bit more thermal kick really helps as you're getting through that Rhine and also getting hemostasis.

So your field is essentially staying relatively dry so you can stay in a good plane and not get off. So I think that was a really good saline point at. Learned early on. I think a lot of us don't burn you. You don't burn in a straight line. I mean, you, you recognize that you're gonna kind of use that cautery to both divide the tissue and, and all those small vessels that are back there in that inflammation.

But you're also gonna use it to push the tissue apart. As you start to go and assuming you can find a good plane between the gallbladder or the rind and the liver bed, that's what you're gonna use. But if you can't. Then maybe that's when we talk about leaving some of the back wall in place as you start to work your way down.

Yeah, that was a big learning point for me. I think it's tempting to go in the wrong plane because, you know, you think you're making

progress. But any injury to those superficial hepatic branches off, whether that's the middle hepatic vein or those intra hepatic ductules, it not only risks significant blood loss, but it also risks postoperative myeloma.

Right. And you have to reenter a more superficial plane halfway down anyways, especially as you approach the infundibulum. Just like laparoscopic surgery. Maintaining constant tension and counter tension is paramount. Keeping in line with the principles of general surgery. But I've also found though, if you can develop that plane between the rind and the gallbladder wall proper, get an ALICE clamp on that or ring forceps, that will allow you to get that tension between those two planes that you're trying to separate that might allow for an easier blunt dissection.

I think in a global picture, what it, it's important to remember what you're trying to accomplish. Just like in traumas, we're trying to alize every organ system to try to remove it. We're, we're basically trying to do the same thing with the gallbladder. We're trying to remove the adhesions and bring it out into our incision to make it easier for us to manipulate.

So as we dissect

down through the planes, we're trying to elevate that. Out of the, the out of the liver bed into our incision and isolate that down to a single structure. As we've already talked about various methods of getting into that appropriate plane. I think finding that gallbladder wall, much like just reversing it when you're doing a laparoscopic procedure, when you get through that rind and you're doing it from a critical view of safety up.

Technique. Now you're doing a dome down technique. Getting through that rind and just finding the gallbladder wall and finding that plane. Never forget your finger's, the best dissector you have, right? And you may cause some bleeding back towards the liver, but that's usually superficial bleeding.

You're not lacerating in hepatic artery. It's really hard to hurt things with your finger. Not impossible, but it's difficult. I think you gotta be, you have to be very willing to, to be mobile. You know, you don't, you don't just, if something's not really very forgiving on one particular place,

you know, be, be willing to move around.

But don't forget, probably the typical aspects that you would employ when you're laparoscopic, that things don't live laterally, right? So you can have a little bit more a little bit more latitude or a little bit more freedom to, to find that plane that Dr. Nelson's talking about laterally first.

Okay. And then keep working your way more medial, more lower, lower, more medial. And eventually you should come to the, to more of a, you know, the funnel of the infundibulum. And I think it's almost a toss up too when a lot of these cases, the lower you go, the easier it'll get. You know, the dome is the part that's really nasty.

But, you know, cer certainly that's not a rule all the time. Sometimes that, that bottom part's tough or the toughest. So I wanna ask you guys, 'cause I've seen this a couple times since I've been here, we've developed that plane, we've gotten most of the do of the gallbladder down. What are the tools or the instruments or the techniques that you're using down there at the infundibulum to help you identify those structures?

Yeah,

like more importantly, you know, when you get to that inflammation that gets you to stop in a laparoscopic case where you're over a col collapsed triangle or the shield of Roy or whatever. You know, the, the shield of happiness. When, when you get to that point in an open procedure, what do you guys use instrument wise and kind of your, your retractor, your retraction and counter tension to help provide that dissection or to help you continue that dissection safely.

So as we talked about earlier, I think tension and counter tension's, your best friend especially as you get down there pulling it off. Pulling off the Port of Patti I'll many times have either you know, up to three Alices or three Babcocks in my hand on different portions of the gallbladder itself providing different areas of traction.

And I, it's really gonna depend on the type of inflammation you have, right? Is it that acute, inflammatory tissue from acute infection or is it that acute on chronic stuff? That's stuff that's been there for years. You're gonna

handle each of them different. The, the acute stuff is gonna be more friendly to you.

You're gonna be able to break away with your finger or right angle, go through or use a bridge and cauterize through that chronic stuff. I find peeling is a great technique whether you're using kitner, whether you're using the back end of a right angle and just not. Not trying to burn through it, but just peeling, peeling it away by opening the, using, using the elbow of the right angle, just opening it up and peeling it down as you continue to try to make progress.

I think the other, the point I would make too, at this point in the case is that it's gonna bleed, right? And, and maybe this only comes with timing or experience, but, but expect there to be a bit of a bloody field. I know we're not talking about significant pulsitile surgical bleeding, but there's gonna be clot, there's gonna, it's gonna be messy.

You just have to have some confidence that as you get down to the bottom, you know, you're getting close as you get down and as you get

the cystic duct controlled and divided maybe or maybe not, you find a cystic artery more medially. Sometimes it's obliterated in these chronic conditions. But, but as you get down there and the thing comes out.

Gosh, it dries up, right? So just don't, don't let that scare you off that you're in the wrong, wrong place necessarily. So yeah, that kind of reminds me of the last couple of cases I did open where I was dealing with that acute kind of chronic inflammation and got down to the infundibulum, it couldn't progress, and you came in and you helped me kind of decide to open up the gallbladder there and essentially proceed from inside out.

Can you help unpack that a little bit or what, what kind of pearls. Wisdom you have on that maneuver? Yeah, I mean, I think a, a few options if it, if the if the rind is forgiving enough and you can finger fracture your way, then sometimes the very last part of that you can, you can palpate where the in fibula will transition into the cystic duct.

If you're lucky

enough to have a big stone impacted in the bottom of the gallbladder, that makes it very obvious where the bottom is. If you can't really feel very well, then just open the thing some more, right? And either visualize where theum is from the inside, or you know, you just put your finger down in there and you, and you'll feel where that bottom of that funnel is.

And now the only question is how do you finish the last bit of dissection medially, knowing that you're keeping an eye out for per a possible cystic artery, but you're almost there. What? Whether you control it with a right angle whether you. Get a tie around there, whether you just, you know that you're down to that level, do you just lop it off?

And then over, so if you can't clearly dissect your cystic duct, I think those are sort of game time options. The only caution here though, is you're at some point in time and was the case in my, common duct injuries, you will sometimes have that common duct stuck up to that chronic

inflammation and you think you're coming down along the bottom part of the, in fibular in the bag.

And every once in a while, that's the more anterior wall of the common bile duct. So there is, although we're talking about it like, hey, you're almost home free. You do still have to always maintain this high index of suspicion when the inflammation is all the way down on the portal. I remember your goal is to get down to one or two structures, and I emphasize one more than two.

'cause a lot of times you're going through the cystic artery or you obliterate the cystic artery, your dissection, you've never even seen it. A lot of times it's already been you know, clotted off the secondary to the inflammation, which is why your gallbladder's already dead and you're taking it out.

So a lot of times you never even see it. So you're really only going down to one structure. And, you know, don't forget your use of adjuncts. Especially down in this area, right? Can you shoot a cholangiogram? Right? Do you have that ability? Do you have ICG available to you to use, to help you delineate the anatomy?

It's better to try to attempt to delineate the anatomy before you start chopping across the structures you're

not sure of or keep you outta trouble later. Those are, those are pretty good, salient points I always forget about, you know, even considering just putting a cholangio catheter through that.

Cystic duct to see if there's any concern or question. And if it's obliterated, it's obliterated your job's done. Right. Do you guys leave drains at all at the end of your procedures when there's any concern? I think if, if I know that we've secured the cystic duct, no. 'Cause we're gonna, the bleeding's gonna stop.

We're gonna irrigate the field. Yeah. And there's no need for a drain. I think if you've just come across it and it's wide open or you just can't even find it 'cause it's so obliterated, then probably so. Yeah, so if I've got good purchase of purchase of tissue, I've got a good ligation around it, I've got a good clip across it.

Depending on what I'm able to do in the field, then I, I agree, no drain needed. Now if the patient had a big abscess cavity that I've also drained, I may leave one just for infectious drainage for a day or two. But if I'm confident in my ligation technique and I've identified the cystic duct that I'm sure of, I won't leave it for a b lead.

Okay.

Alright guys, so as we're getting through the critical, critical aspect of the case and the dissection, and we're close to the finish line Micah, you know, you, you're about to graduate and go out and be an attending on your own, start your career. Is there anything salient or is there anything important that you think you'd want to know specifically as a pearl from.

Not so much the elder population, but maybe the wiser surgeons in the room that have done this procedure. Yeah, I think thinking if we're at this point in the case, you know, we've gotten the structures safely dissected free. 'cause that's the whole point of this is not to get through it quickly, but to get through it safely.

What is your decision making? What is your thought process when ligating these structures? Do you use silk? Do you use PDS? Do you use OOP to use clips to use staples? What is your thought process and what do you use and why? Most straightforward right angle and then a two or three oh silk around the end of the right angle.

Just a good old

fashioned ligation. So I was taught in su in residency to suture ligate. With a PDS, we always use a PDS. In my training, however, I've gone to what Dr. Kau does too, just a suture around a right angle if your anatomy. Agrees with that. As Desiree remembers last week you know, we did the 250 kilogram open gallbladder.

And kinda like Dr. Nar talked about his mason jar, we were working in a silo and we attempted to do a suture around the right angle, but it was so deep and so, thin that we were working. The glass dome or glass silo we were working was too thin to get a hand down there. So we chose an automatic clip applier and got good clips around the tissue deep in this hole that we were working in.

So, I think what the anatomy and what the patient's tissue quality plays a role in it. But yeah, I think just a suture a suture around a, a good clamp is, is for the go-to option. Okay. And ideally, you know, we, we've talked about these couple ways to secure that, but

there's gonna be the times where you've done a safe dissection, but there's still no good tissue, no good quality tissue left down there.

I would argue always better to just lay a drain behind may or be, or maybe not gonna have to engage your GI colleagues for stenting at some point. The last thing you want to do. Is try to push a suture ligation, especially when you're, you're just not sure where things are living deeper down.

Right. That's when you're gonna inadvertently injure something. Just, just let it, let it get drained and let it get dealt with another day. You've done the operation. Don't make things worse. Yeah. Stay outta tiger country and that's when Sure, yeah. That's when you leave that drain and from. My understanding, a lot of these, you know, post-op b leaks when the cystic duct may or may or may not be actually partially open from inflammation or not.

They tend to resolve on their own, even without a common bile duct stent. So it's just something to watch and

it's better to, you know, to have that than to get into any more trouble. Always choose the operation that will fail well. So if it's just leaving a drain and potentially having to do something, but I agree most of the time they're gonna do fine.

Yeah. And I think you know, as we get to the end of the operation just to reiterate, one of Dr. Nelson's biggest points is when we're done and we're on our way out, remember be safe and finish the case and do everything appropriately. And remember, when you're closing the fascia, there's two layers, right?

There's an anterior fascia and a posterior fascia. Two components that you should always close in two separate stitches that are running. Typically with a slow slowly absorbing slowly absorbing stitch, right? So, don't get too, don't get too hasten just to get outta the or do it right. So the patient has a good outcome.

So let's go ahead and just wrap things up now, right? So, Dera why don't you give us a couple of quick hits now that we've finished up such a big topic. Yeah, absolutely. So, keeping in mind Sage is six steps in the safe cholecystectomy

program. Number one, use the critical view of safety. This meth method identifies both the cystic duct and the cystic artery during a lap coli.

Number two is understanding the potential for aberrant anatomy and every case that you do. Number three, make liberal use of cholangiography or any other methods to image the biliary tree intraoperatively. Fourth, consider an intraoperative, momentary pause that we mentioned earlier in the podcast during a lap coley just prior to clipping, cutting, or transecting any ductal structures.

Number five, recognize when the dissection is approaching a zone of significant risk and stop before entering the zone. You want to finish the operation by a safe method other than a cholecystectomy. If any conditions around the gallbladder are too dangerous. And then finally, and probably most importantly, get help from another surgeon when the dissection or conditions are difficult.

That's my favorite. It your most often used? Yeah. Shadow. Finish this up. No. Also know your landmarks and anatomy, including vascular variance.

Remember, spatial disorientation leads to high rates of B duct injury. Remember them non be safe. So take your time. A good well-fed subcostal incision. That then has a retractor system of your choice that either has or very soon will have the gallbladder right in the middle of your operative field.

Converting to open is not failure. Okay? It may take some more time. As long as you're making progress, you can still perform the right operation for the patient and remove their disease process even though they have a longer incision. Maximally invasive surgery. Amen. All right, well, thanks everyone. Open Cholecystectomy isn't just an option.

It's a vital skill, so don't let it become a lost start from all of us here at Mizzou. Until next time, keep learning and stay sharp. Dominate the dominate the day.