Examiner:

• "Ms. Mary Johnson, a 55-year-old female with a history of hypertension, hyperlipidemia, and Roux-en-Y gastric bypass surgery 5 years ago, presents to the emergency department with severe right upper quadrant abdominal pain and jaundice. She has had these symptoms for three days. Her vital signs are blood pressure 130/80 mmHg, heart rate 90 bpm, temperature 37.0°C, and respiratory rate 18 breaths per minute. What would be your initial assessment and management steps?"

Examinee:

• "Based on her presentation, I am concerned about acute cholecystitis, gallstone pancreatitis, or choledocholithiasis. As I have her history and examine, I would next order laboratory tests including a complete blood count, liver function tests, amylase, and lipase, and imaging studies including an ultrasound of the abdomen."

Examiner:

• "The laboratory results show a total bilirubin of 6.2 mg/dL, alkaline phosphatase of 320 U/L, AST of 85 U/L, ALT of 90 U/L, and a white blood cell count of 9,000 /µL. The ultrasound shows a thickened gallbladder wall with stones, pericholecystic fluid, and a dilated common bile duct measuring 10 mm with a possible stone."

Examinee:

• "Given the ultrasound findings and the elevated bilirubin and alkaline phosphatase levels, I would suspect acute cholecystitis with concurrent choledocholithiasis. To confirm this, I would order an MRCP to visualize the bile ducts and identify the location and number of stones."

Examiner:

• "The MRI is down at your facility at this time."

Examinee:

• "Given her history of Roux-en-Y gastric bypass surgery, ERCP is less feasible, and I don't have access to GI or IR at this time. Therefore, I would recommend laparoscopic cholecystectomy with intraoperative cholangiogram and possible laparoscopic common bile duct exploration (LCBDE) to provide definitive treatment in a single procedure. I would start the patient on intravenous fluids, antibiotics to cover the acute cholecystitis, and pain management and obtain informed consent for the surgery."

Examiner:

• "Describe the steps you would take to perform the laparoscopic cholecystectomy with LCBDE."

Examinee:

• "I would begin by positioning the patient in the supine position and ensuring all necessary equipment, including a C-arm for fluoroscopy, is available. After achieving pneumoperitoneum and placing trocars, I would identify the critical view of safety during the cholecystectomy. I would then perform a ductotomy in the cystic duct and secure a cholangiogram catheter. Using the C-arm, I would perform an intraoperative cholangiogram (IOC) to confirm the presence and location of the CBD stone."

Examiner:

• "The intraoperative cholangiogram demonstrates a filling defect in the distal common bile duct."

Examinee:

• "Once the stone is confirmed on the IOC, I would proceed with an algorithmic approach to clear the stone. I would advance the cholangiogram catheter into the common bile duct and use saline power flushing with intravenous glucagon to relax the Sphincter of Oddi. If the stone is not cleared, I would perform a fluoroscopic-guided balloon sphincteroplasty by advancing a balloon catheter over the guidewire and dilating the sphincter to facilitate stone passage with additional flushing. If these methods are unsuccessful, I would perform choledochoscopy for direct visualization and stone basket retrieval versus crushing and flushing into the duodenum."

Examiner:

• "What would you do if you were unable to successfully clear the duct transcystically?"

Examinee:

• "I would carefully dissect out the cystic duct to the common bile duct. I would dissect out the anterior common bile duct down to the duodenum with care to preserve the blood supply on the 3 and 9 o'clock lateral positions. I would make a 1.5 cm longitudinal incision on the anterior common bile duct, place stay sutures, and then perform choledochoscopy-guided wire basket removal. After confirming clearance of the duct with a final cholangiogram, I would close the choledochotomy with 5-0 PDS sutures and place a surgical drain nearby. If this was unsuccessful as well, I would close the choledochotomy over a T-tube."

Examiner:

• "After successfully removing the stone and completing the cholecystectomy, what are the key postoperative considerations?"

Examinee:

• "Postoperatively, I would monitor the patient for complications such as bile leaks, infection, or pancreatitis. I would ensure adequate pain control and provide instructions for early mobilization and respiratory exercises. Liver function tests and an abdominal ultrasound may be repeated to confirm the absence of retained stones and assess for bile duct patency. The patient would be educated on signs of complications to watch for at home and scheduled for a follow-up visit to assess recovery."