Welcome to the 12th Annual Update Course in Pediatric Surgery recap series, hosted by Dr. Em Gootee from Cincinnati Children’s Hospital. In this Green Circle (established practice) session, Drs. David Vitale, Luke Neff, and Jeff Ponsky explore the “surgery-first” approach to pediatric biliary stone disease, highlighting the growing prevalence of choledocholithiasis in children and the evolving strategies to manage it effectively.

Key Highlights:

• Surgery-First vs. ERCP-First: The panel compares the two main management strategies: ERCP followed by laparoscopic cholecystectomy versus laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) and stone removal.
• Practice-Based Decision Making: Experts emphasize that choice depends on surgeon skill, institutional resources, and the ability to perform IOC effectively.
• Clinical Evidence: Studies show an 86–90% success rate for ductal clearance using a surgery-first approach with IOC and flushing—offering a safe, resource-efficient option that minimizes ERCP-associated risks like pancreatitis.
• Learning Curve & Equipment: Surgeons are encouraged to become more comfortable with intraoperative stone removal techniques. Having a prepared kit and standardized workflow is key to success.
• ERCP Complications: While ERCP is effective, it carries a ~10% risk of complications including cholangitis and pancreatitis—making intraoperative solutions appealing when feasible.

This session underscores a shift toward empowering surgeons with tools and confidence to manage choledocholithiasis directly in the OR, improving outcomes and optimizing resource utilization across institutions.