Worked cases

1. Differential. A retained duct stone, a bile leak with a collection, or a bile duct injury (a clip on, or division of, the common duct). A “straightforward” note does not exclude an injury: most injuries are not recognised at the operation.
2. Check for sepsis: observations, white count, CRP, cultures if febrile. Fever and jaundice together is cholangitis until proved otherwise.
3. Image: ultrasound for dilated ducts and a collection, then magnetic resonance cholangiopancreatography (MRCP) to map the ducts. CT if there is a collection or peritonism.
4. Look back at the operation note, the photographs and any cholangiogram. Was the doublet view recorded?
5. Act on the result. A stone: endoscopic retrograde cholangiopancreatography (ERCP) and clearance. A leak: drain the collection and ERCP stent. An abrupt cut-off, a clip across the duct or a transection: bile duct injury pathway, same-day referral to a hepatobiliary unit, no re-operation by the index team.
6. Tell the patient what you suspect and what you are doing.

Read more: retained stones, recognising an injury after the operation, the referral pathway.

1. Apply the stop rule. If the critical view cannot be achieved safely, stop dissecting in the triangle. Time spent is not a reason to keep going.
2. Call for help: a second consultant, ideally one experienced in hepatobiliary surgery. Re-orient on Rouvière’s sulcus and the base of segment IV.
3. Clarify the anatomy with biliary imaging, particularly IOC, if access is safe. ICG can assist as an adjunct but is not an equivalent substitute when injury is suspected; do not dissect unsafely to obtain an image.
4. Bail out. When CVS cannot be achieved and anatomy remains unclear despite other methods, favour subtotal over fundus-first total cholecystectomy: open the gallbladder, remove the stones, and leave a fenestrated or reconstituted remnant without entering the triangle. Fundus-first only if a clear plane on the gallbladder wall leads down; stop at the infundibulum.
5. If the patient is unstable or nothing is safe: a cholecystostomy tube or a drain, close, and refer.
6. Conversion is not a bail-out by itself; convert only for a problem that open surgery solves.
7. Document the reason, the photographs and what was left behind; warn the patient about a possible bile leak and later ERCP.

Read more: the stop rule, subtotal cholecystectomy, the difficult gallbladder.

1. Plan early laparoscopic cholecystectomy during this admission after initial treatment and obstetric/anaesthetic assessment. She has recurrent acute cholecystitis at 22 weeks; pregnancy alone is not a reason to defer necessary surgery. The SAGES 2024 recommendation supports this approach.
2. Individualise by disease and gestation. The option of observation for third-trimester biliary colic does not describe this patient’s recurrent acute cholecystitis. The evidence and trimester comparisons are on the linked pregnancy page.
3. Plan with obstetrics: fetal heart checked before and after, and the obstetric team involved throughout.
4. Technique: left lateral tilt, open entry or an entry point adjusted to the fundal height, pressure 10 to 15 mmHg, end-tidal CO₂ monitoring, mechanical thromboprophylaxis.
5. Cholangiography only if needed, with shielding. ICG is not licensed in pregnancy.

Read more: pregnancy.

1. Tell her, with a nurse specialist, and refer to the hepatobiliary multidisciplinary meeting.
2. Stage with CT of the chest, abdomen and pelvis (MRI as needed) to look for residual disease and spread.
3. Assess for re-resection if she is fit and staging confirms resectable disease without metastases: liver-bed resection and portal lymphadenectomy, with the extent planned by the hepatobiliary team. The bile duct is removed only if needed for a clear margin. Port-site excision is no longer recommended. (T1a needs nothing more if the cystic margin is clear.)
4. Timing: arrange staging and specialist review promptly. The team chooses the operative date; the reported survival advantage at 4 to 8 weeks is an observational association, not a mandatory waiting period.
5. Review the first operation: was there bile spillage or a perforation? Document it for oncological planning; operative spillage alone does not automatically change TNM stage.

Read more: incidental gallbladder cancer.

1. Likely source: the cystic duct stump (a slipped clip or a necrotic duct) or a duct of Luschka in the liver bed. A major duct injury must still be excluded.
2. Check that drainage is adequate. Keep the drain, monitor output and clinical progress, and assess for a collection with ultrasound or CT. Short observation is reasonable only while she remains well and improves; lack of improvement or deterioration requires prompt escalation.
3. Arrange ERCP for persistent or high-output leakage, or earlier if she fails to improve. Biliary stenting, with or without sphincterotomy as appropriate, lowers duct pressure so a leak with preserved continuity can seal. The cholangiogram also shows where the leak is and whether the common duct is intact.
4. MRCP first if the history or the operation raises the question of an injury.
5. If she becomes septic or peritonitic: laparoscopic washout and drainage, then ERCP. Refer to a hepatobiliary unit if a main duct is involved.

Read more: bile leak, bile duct injury.

1. Grade him on two axes: the Tokyo grade (severity of the cholecystitis) and his fitness (ASA, Charlson index, frailty, organ function). The Tokyo 2018 flowchart uses both.
2. High risk does not automatically mean drainage. Assess whether he can tolerate surgery; do not extrapolate trial results to patients too unstable or unfit for its criteria. In the CHOCOLATE trial (high-risk patients, APACHE II 7 to 14), laparoscopic cholecystectomy caused far fewer major complications than percutaneous drainage (12 versus 65 percent).
3. Use drainage when early surgery is unsuitable, including persistent organ dysfunction or unacceptable operative risk after multidisciplinary assessment. Apply the TG18 selection criteria and available expertise. Plan what happens to the tube and the gallbladder afterwards.
4. If you operate: a senior surgeon, early in the course, with a low threshold for subtotal cholecystectomy.
5. Talk to him and his family about his goals and what recovery will mean for him.

Read more: who should have a cholecystostomy, the elderly and frail patient.

1. Make sure it is a stone: a fixed defect, not a bubble (round, mobile, rises). Flush with saline; glucagon or hyoscine may let a small stone pass.
2. Clear it now if you have the skill and the kit: transcystic exploration first (basket under X-ray or a thin choledochoscope). Choledochotomy for a large stone, many stones or a stone above the junction, with primary closure and no routine T-tube.
3. Or finish the cholecystectomy and arrange ERCP after surgery, if transcystic access fails or the expertise is not there.
4. Tell the patient after the operation and record the plan.

Read more: laparoscopic bile duct exploration, reading the cholangiogram.

1. Stop. No more clipping, cutting or diathermy near the porta. Take over the camera and the decisions.
2. Call a senior surgeon, and a hepatobiliary surgeon if one is available.
3. Define the anatomy with a cholangiogram if it can be done safely; photograph everything.
4. Do not try to repair unless an experienced hepatobiliary surgeon is in theatre. Primary repairs by the injuring surgeon fail often and can turn a simple injury into a high one.
5. Control bile and bleeding without blind clips; place wide drains to the subhepatic space.
6. Refer the same day to a hepatobiliary unit, with the images. Tell the patient and family honestly after the operation.

Read more: what to do and not do immediately, recognising the injury on the table.

1. This is mild pancreatitis (revised Atlanta: no organ failure, no local complications).
2. Remove the gallbladder in this admission. In the PONCHO trial, same-admission cholecystectomy cut readmission for a gallstone complication or death from 17 to 5 percent. UK guidance accepts a firm plan within two weeks if the same admission is impossible.
3. No ERCP: there is no cholangitis and the bilirubin has settled. Check the duct at operation (cholangiogram) or before it (MRCP) if the liver tests do not normalise.
4. If he is not fit for surgery, an ERCP sphincterotomy lowers the risk of another attack.

Read more: when the gallbladder comes out.

1. Definite acute cholangitis by Tokyo 2018: inflammation (fever, white count), cholestasis (bilirubin) and imaging (dilated duct, gallstones).
2. Grade II: two grade II criteria (white count above 12,000/mm³ and fever of 39 °C or more; her bilirubin of 5.3 mg/dL, above 5, is a third). No organ dysfunction, so not grade III.
3. Treat: fluids, blood cultures, antibiotics by local protocol, and early ERCP drainage. Escalate to urgent drainage if she becomes hypotensive or confused.
4. Stop antibiotics 4 to 7 days after drainage (Tokyo 2018); a 2026 trial suggests one day may be enough after good drainage.
5. Then the gallbladder: cholecystectomy once she has recovered, ideally in the same admission.

Read more: acute cholangitis.