Where’s the Lesion
A 72-year-old undergoing RFA for colorectal liver metastases has a superficial lesion that is difficult to visualize intraoperatively. The maneuver that improves surface resolution of the liver lesion is?
Submerge the probe in saline to improve acoustic coupling and surface visualization.
A patient with symptomatic gallstones has no fever, no leukocytosis, and normal labs. What is the appropriate management?
Elective outpatient laparoscopic cholecystectomy.
A stone is seen on intraoperative cholangiogram but cannot be flushed with saline. What pharmacologic option may help?
Glucagon administration to relax the sphincter of Oddi.
A patient has elevated lipase and RUQ pain with gallstones but no alcohol use. Diagnosis?
Gallstone pancreatitis.
A sickle cell patient with acute cholecystitis and vaso-occlusive pain—best initial management?
Stabilization and percutaneous cholecystostomy with interval cholecystectomy.
During intraoperative ultrasound of the liver, a lesion is poorly visualized using your current probe. What is the best adjustment?
Switch to a higher-frequency probe for improved resolution of superficial lesions.
A patient with biliary colic has resolution of pain in the ED and no signs of cholecystitis. What is next step?
Discharge with plan for elective cholecystectomy.
A distal CBD stone is confirmed intraoperatively and cannot be cleared. What is next step if minimally invasive options fail?
Laparoscopic or open common bile duct exploration.
A patient with gallstone pancreatitis improves clinically after 48 hours. What is next step?
Laparoscopic cholecystectomy.
A septic, unstable patient with acute cholecystitis and severe COPD—preferred initial intervention?
Percutaneous cholecystostomy tube.
A hepatic lesion cannot be found on IOUS despite correct preoperative imaging. What is a useful technique to improve visualization of posterior segments VI–VII?
Mobilize the right lobe and scan from the bare posterior surface of the liver.
A patient with acute pancreatitis undergoes ERCP with sphincterotomy and is scheduled for cholecystectomy. On day of surgery, she has RUQ pain. What is next step?
Proceed with laparoscopic cholecystectomy with intraoperative cholangiogram.
During open CBD exploration, what maneuver improves exposure of the distal bile duct?
Kocher maneuver (mobilization of the duodenum).
A patient has pancreatitis with normal CBD imaging and resolution of labs. What is definitive prevention of recurrence?
Cholecystectomy during index admission.
In a high-risk surgical patient with cholecystostomy planned, what finding pushes toward definitive surgery instead?
Gallbladder necrosis.
You suspect a lesion is present but IOUS is equivocal. What adjunct imaging feature is least helpful for detecting small metastases?
Color Doppler (tumor flow is often absent or nonspecific in small lesions).
What is the strongest indication to proceed urgently with cholecystectomy in symptomatic gallbladder disease?
Persistent or recurrent symptoms with confirmed biliary pathology without contraindications.
A patient has a known 1.5 cm distal CBD stone and requires open exploration. What is key step in operative planning?
Plan choledochotomy with ductal access and stone extraction ± T-tube.
A patient with gallstone pancreatitis improves after supportive care. Why is early cholecystectomy important?
Prevents recurrent pancreatitis and biliary events.
What is the role of cholecystostomy in critically ill patients?
Temporizing drainage until patient is stable for definitive cholecystectomy.
A lesion is very superficial and nearly missed on IOUS. Which principle explains why saline improves detection?
It eliminates air interface and improves acoustic coupling for near-field resolution.
A stable patient with gallstones and prior biliary pancreatitis has normalized labs after hospitalization. What definitive treatment is indicated?
Laparoscopic cholecystectomy during same admission.
What is the purpose of intraoperative cholangiography in gallstone disease?
To identify bile duct stones and define biliary anatomy.
What finding suggests pancreatitis is biliary in origin?
Elevated LFTs (especially bilirubin/AST/ALT) with gallstones on ultrasound.
A diabetic COPD patient with cholecystitis is initially managed nonoperatively. What finding mandates reconsideration of operative management?
Evidence of gallbladder necrosis or failure to improve clinically.