Jonathan Haqq.

Robotic TAPP (rTAPP) Repair of Left Inguinal Hernia with Imbrication of Transversalis Fascia Why imbricate: 🔵Direct defect/large hernia risk factors for postoperative seroma 🔵In open hernia repair, direct defect often closed ➡️Helps create a flat posterior wall and expedite mesh placement 🔵However it is not a routine practice during MIS Robotic Imbrication of Transversalis fascia: 🔴Possible advantages include: ➡️Reduce seroma risk formation ➡️Reduce risk of recurrence (mesh migration) 🔴Avoid deep bite ➡️Cord structures can be easily caught in sutures

Master the surgical anatomy of laproscopic inguinal hernia. Key concepts: Direct vs Indirect hernia, Femoral hernia, Triangle of Doom, Triangle of Pain, Iliopubic tract, Inferior epigastric vessels, and ASIS landmarks. A quick visual guide on this high-yield topic.

𝗙𝗲𝗹𝗹𝗼𝘄𝘀𝗵𝗶𝗽 𝗔𝗱𝘃𝗲𝗿𝘁 Our Post CCT/Senior Complex Benign PB & Robotic Fellowship at @UHDBTrust is now open for applicants to start from Aug 2026. Gain experience in advanced laparoscopic and robotic benign PB surgery. In addition, fellows will develop skills in laparoscopic and robotic hernia surgery including complex abdominal wall hernias as well as training in ERCP. Advert below or DM for more details: nhsjobs.com/job/UK/Derbysh…

Kehr's sign- It is the golden sign of splenic rupture, characterized by referred left shoulder pain due to diaphragmatic irritation from blood in the peritoneal cavity, elicited in supine position with leg elevation. ∆ Clinical Significance- Kehr's sign occurs via phrenic nerve referral (C3-C4) when free intraperitoneal blood from splenic laceration contacts the diaphragm undersurface. • It is highly specific (though less sensitive) for splenic injury in blunt abdominal trauma. #MedTwitter #FOAMed #MedX

70-year-old man from China underwent cholangioscopy to investigate blockage of bile duct. During the procedure, five live Clonorchis sinensis flatworms (liver flukes) were discovered and removed from his biliary tract. NEJM-DOI: 10.1056/NEJMicm2304237

Continuing on with medical Valentine’s, this is a heart of stone in the bile duct, also known as choledocholithiasis, seen during ERCP 💖

Laparoscopic Infracolic Necrosectomy and Drainage of RIF Abscess 🔴Septic patient but no organ failure 🔴Narrow window of access for EUS or IR drainage 🔴Single stage clearance of WON and drainage of RIF abscess ➡️Prevents hits of sepsis between multiple procedures ➡️Address both collections at once ➡️Select cases ➡️Benign PB MDT ➡️"One size does not fit all" Our paper on infracolic approach in @JournalofGISurg: sciencedirect.com/science/articl… #Surgery #HPB #Pancreatitis

This is a bile leak. What is the source of the leak? Dont blink! This is one of the reasons I like to do ERCP after cholecystectomy when suspect for stones — if there is a bile leak I do not want to do 2 ERCPs!

🔴Nice teaching case for the advanced therapeutic fellow ERCP Teaching Pearl 🧠 | Hock-Pull Technique in Supine Position 🛌 Supine patient = altered orientation → technique matters 🔹 Papilla orientation: In supine ERCP, the papilla often appears more inferior/posterior and less en face, with a tendency for the catheter to fall into the pancreatic duct due to gravity and scope torque. 🔹 Why Hock-Pull helps: • Hockey bow redirects the tip upward toward the biliary axis despite gravity. • Gentle pull-back everts and opens the papillary orifice, counteracting the “downward fall” seen in supine cases. • Improves coaxial alignment (~11 o’clock) without pushing. 🔹 Manoeuvrability advantage: • Pulling back stabilizes the papilla against respiratory motion. • Small rotations become effective—micro-adjustments instead of force. • Reduces repeated pancreatic duct entry and papillary trauma. 💡 Pearl: > “In supine ERCP, gravity favors the pancreas—hock-pull brings you back to bile.” #ERCP #SupineERCP #Endoscopy #GI #TeachingPearls #PatientSafety

Violin string adhesions in a patient with right upper quadrant pain - which condition is this? 🎻

ACUTE CHOLECYSTITIS - Timing of Surgery Changes Everything DIAGNOSIS: Gallstone obstruction causes 90-95% of cases. Ultrasound shows 81% sensitivity, 83% specificity. Early vs late laparoscopic cholecystectomy EARLY SURGERY (1-3 days): - 11.8% complications - 5.4 day hospital stay - Lower costs LATE SURGERY (>3 days): - 34.4% complications - 10.0 day hospital stay - Higher costs BOTTOM LINE: Early lap chole cuts complications by two-thirds and halves length of stay. SOURCE: J. Gallaher and A. Charles. JAMA. 2022;327(10):965-975 Read the full review: newsletter.endocollab.com/p/acute-cholec…

✅ Biliary tract anatomy ➡️ Know the variants 👍🏻

ERCP: Essential Tips for Bile Duct Stone Extraction Using Basket - Part I Quick Tip Video on EndoCollab

The Arteria Pancreatica Magna—the pancreas’ guardian vessel—is a tiny branch with mighty impact. Often a hidden arterial trap causing torrential bleeding if injured, it usually arises from the splenic artery but can surprise with variants. In celiac stenosis, it hypertrophies into a natural lifeline, preserving pancreatic & hepatic flow. #SurgicalAnatomy #HPBSurgery #Pancreas #VascularAnatomy #OncoSurgery @IHPBA @AHPBA @EAHPBA @SyedAAhmad5 @SanjayGovil8

Imaging of the bile duct during ERCP. What’s the name of this phenomenon?

Pancreatic exocrine replacement therapy (PERT) for pancreatic exocrine insufficiency (PEI) 💊 1️⃣ When to test and when to treat 🤔 2️⃣ Workup and treatment 🔍 3️⃣ What to tell patients 💬 4️⃣ Long term follow-up in PEI 🏥

Cholangitis and its syndromes 💡

Completed Beger Procedure. @TomVargheseJr @juliomayol @IHPBA

Gallstone removal during an ERCP procedure

Bile Ducts Strictures May Be Associated With Stones - Know the Potential Locations of Stones