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Case 36: Trouble getting a cholangiogram.

You have had difficulty dissecting laparoscopically a small contracted, chronically fibrosed gallbladder. You have now performed a cholangiogram and cannot get the contrast to flow proximally to show the intrahepatic ductal anatomy. Here is your cholangiogram.

1. What manoeuvres can you use to get the contrast to flow 'up-hill'?

2. You realise what the problem is at this stage. What does your cholangiogram show?

3. What structure is marked '1'?

4. What is happening at '2'?