Episode 26
Honduras Medical Missions & Gallbladder Cases with Dr. John Haeberlin
Episode Transcript
Dr. Randy Lehman [00:00:11]: Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more. We have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the chloraprep has dried, let's make our incision. Welcome back to another episode of The Rural American Surgeon. I'm your host, Dr. Randy Lehman, and I have with me today Dr. John Haberlin. A great storied history to Dr. Haberlin's practice. He started as a military surgeon and spent time in training programs as well as in rural America. We're down here in Honduras for the week. We just finished up, wrapped up our week of mission surgery essentially as a team. We did a total of 62 operations this week. I think 62 or 64 in rural Honduras. I am so glad that we have the opportunity to sit down together. Thank you for joining us.
Dr. John Haeberlin [00:01:30]: Thank you for having me. I appreciate it.
Dr. Randy Lehman [00:01:32]: So just a little bit more detailed introduction of you. You began your surgical career in what year?
Dr. John Haeberlin [00:01:41]: Med school ended in 1989. So, I started residency then in '89.
Dr. Randy Lehman [00:01:47]: Yep. And that was a military residency, correct?
Dr. John Haeberlin [00:01:49]: It was military residency, El Paso, Texas.
Dr. Randy Lehman [00:01:52]: And then you spent how many years in the military after residency?
Dr. John Haeberlin [00:01:55]: Another eight years after. So 13 years total up until 2002, with multiple deployments.
Dr. Randy Lehman [00:02:01]: And you were in over the 9/11 and everything, correct. And then you moved back to Wisconsin?
Dr. John Haeberlin [00:02:07]: Yes, my wife said I had one option that was Wisconsin. So that's where we moved to.
Dr. Randy Lehman [00:02:12]: The spouse drives the location very often. And then you've had a couple, we don't have to go into all the details, but some opportunities to be in training programs as well as now you're working in Tomah, Wisconsin, which is a place that I, you know, kind of half-heartedly have covered. That's how we got to meet each other.
Dr. John Haeberlin [00:02:31]: Yeah.
Dr. Randy Lehman [00:02:32]: And then you've also done quite a bit of mission work, not with the organization we've just been with, but with another, in the north part of...
Dr. John Haeberlin [00:02:42]: Honduras, Atlantic side, close to Guatemala. Been doing that for about 18 years. Yeah, it started off where I was just building churches and medical missions, and then it turned into a surgical mission over about the last 10, 12 years. Yeah.
Dr. Randy Lehman [00:02:56]: And so I don't know how this background music is going to come through, but we... we stopped that moving. Yeah, we stopped at Roatan on our way home for two days. That's kind of a touristy area of Honduras. Very beautiful. We've got the ocean right in front of us that we can see and the resort side behind us, and a little time to rest and reflect on what we're doing. So the first part of our show is why you love rural surgery so much.
Dr. John Haeberlin [00:03:26]: Yeah, I might be a good person to answer that question because I've had the whole gamut of surgery. I was in the military, as you noticed and said before, but then also I was in academia. I was in smaller hospitals, but still very vibrant. Then started in this rural setting. Now I've touched it in the past, but now I've kind of embraced it. And why, I guess would be because I think it's vital. I think it's vital to the success of surgery in our country. I don't know about surgery across the rest of the world. I can't really say. I've never practiced outside of the United States except on these missions. So I don't know how vital it is elsewhere. But I can say that in the United States, its vitality is important to maintain. It's where so much surgery is done. And I think it's one of those things that if neglected, it would go away. That would be sad to see that, and it would be one of those things where we wish we hadn't done it.
Dr. Randy Lehman [00:04:34]: It's almost the biggest underserved...
Dr. John Haeberlin [00:04:37]: Agreed. American, and yet a huge population that does need to be served. You.
Dr. Randy Lehman [00:04:44]: Yeah. So since we are down here in Honduras, we should probably talk a little bit more about the mission aspect of what we've been doing. So what do you find? You said what you love about rural surgery. What do you love about the mission surgery?
Dr. John Haeberlin [00:04:58]: Yeah, mission surgery is something that's very satisfying. And I would like to say different words, if I could, that I'm sure other people have spoken, including yourself, during this time where we got to know each other. Not just satisfying. I think it lets you reflect on the actual source of why you became a medical provider surgeon in the beginning. Because I think by and large, the majority of all people in healthcare are doing it because they like taking care of people. Unfortunately, in the United States, as government gets more involved in healthcare, sometimes it corrals our hands a little bit. It's like diabetics with their white blood cells. I always consider them, their hands are tied behind their backs. They don't work as well. Similarly in surgery, I think that's what happens in the United States. When you come down here, you're actually allowed to practice surgery the way you want, the way you think is right, and affect an incredible number of people in a very efficient way. Much more efficient than the United States.
Dr. Randy Lehman [00:06:10]: Yeah, I mean, if the charting, the computer wrestling, obviously when you're down here volunteering, billing and coding, and things like that are not right, you know, not important parts. You still have a lot of resource limitations. So I've been to a few different rural places. There's always resource limitations. Different places are set up differently. But you know, the place that we're at is more of like an outpatient surgery center type of a setup. I mean, it's got a clinic that runs 24/7. They have X-ray, they have labs, but they do not have a CT scanner, MRI scanner. They do have ultrasound. The patients show up with their packet, manila envelope filled with their ultrasound pictures and the report, all their labs, their pre-op chest X-ray. Yeah.
Dr. John Haeberlin [00:06:56]: From 12 years ago where they had, you know, maybe an infection of their left toe. It's pertinent to what you're needing to...
Dr. Randy Lehman [00:07:03]: See them for, so it's highly efficient in that aspect. But there's... I guess I have a story that I'd like to tell about a case while we were down here, but it will kind of tie into our how I do it anyway. So why don't we just do the how I do it and then we'll lead into that story.
Dr. John Haeberlin [00:07:22]: Perfect.
Dr. Randy Lehman [00:07:23]: We're going to talk about lab chole today. So how are you doing? I mean, one of the most basic general surgery operations. What we do on the how I do it is we talk in great detail about just the really minor aspects of the operation, as if you're, you know, talking to maybe a fourth-year med student just so that we can kind of see. And then the other thing, I happen to know that you have access to a robot and you're using that for certain things. Now, how many of your gallbladders in the United States and Tomah, Wisconsin are you doing on the robot versus laparoscopically right now?
Dr. John Haeberlin [00:07:56]: Oh, I would say the majority of them are done laparoscopically, so, you know, well over 50%. I'd say it's probably more like 75% laparoscopically.
Dr. Randy Lehman [00:08:06]: Okay, maybe we touch on it just a little bit at the end, but let's talk about your lap chole?
Dr. John Haeberlin [00:08:10]: Absolutely.
Dr. Randy Lehman [00:08:12]: So first off, you have a. We don't, don't worry about the indications. We all kind of, I think, have that right. Patients, they're ready to go to sleep. They get general endotracheal anesthesia. They're supine. Do you tuck the arms for a lap chole?
Dr. John Haeberlin [00:08:26]: No.
Dr. Randy Lehman [00:08:26]: You leave both arms out?
Dr. John Haeberlin [00:08:28]: Yes. Anesthesia prefers that. And I'm looking up, so I don't need to tuck them.
Dr. Randy Lehman [00:08:32]: Okay, sounds good. I usually tuck the left foot. And then your full prep of the abdomen. Any special things about your prep or drape use?
Dr. John Haeberlin [00:08:41]: Floor prep, yes.
Dr. Randy Lehman [00:08:43]: And you use the big laparoscopic drape with the clear pockets on the side. All right. And any other special equipment that you use primarily?
Dr. John Haeberlin [00:08:56]: I'm thinking for the initial setup, no.
Dr. Randy Lehman [00:08:59]: Okay.
Dr. John Haeberlin [00:08:59]: And yeah, so that's a good question. What have I done in the past and that's led me to this? That's another discussion, maybe for another time, you know, who's gone through the harmonic scope and things like that. But right now I would say not really. I've tried to keep it as bare and easy because sometimes the people you work with in a rural setting may not have the same background as some other people. So you try to be kind to your helpers.
Dr. Randy Lehman [00:09:26]: Yeah. So five or ten scope, I use five, always 33.0°. Okay. 5:30 scope. You use a hook cautery or usually a hook cautery. That's all by itself. Is it foot pedal or is it pencil?
Dr. John Haeberlin [00:09:45]: Pencil.
Dr. Randy Lehman [00:09:45]: You prefer that you can roll your fingers a little bit better.
Dr. John Haeberlin [00:09:49]: Yes.
Dr. Randy Lehman [00:09:49]: And then use a clip applier, 5 millimeter clip applier.
Dr. John Haeberlin [00:10:13]: Yeah. And that's something that I'm kind of adamant on. I won't use the multi-fire metal flat clip. I had a bad occurrence where all three clips fell off, and I had a bile leak. So for the last 10 years, I've solely used the 5 millimeter clip applier with the Weck locking or Hem-o-lok locking clip.
Dr. Randy Lehman [00:10:13]: The little white one?
Dr. John Haeberlin [00:10:14]: Little white plastic clip? Yeah.
Dr. Randy Lehman [00:10:15]: Okay. Very similar to the ones used on the robot.
Dr. John Haeberlin [00:10:17]: Correct.
Dr. Randy Lehman [00:10:18]: So they're plastic, so they don't show up on an X-ray either.
Dr. John Haeberlin [00:10:28]: Correct. Any other special tools? Do you ever needle decompress the gallbladder?
Dr. Randy Lehman [00:10:31]: Sometimes, sure. If they're hard to grab, absolutely.
Dr. John Haeberlin [00:10:36]: Okay. And then you use some kind of mother-in-law to grasp and retract the gallbladder.
Dr. Randy Lehman [00:10:42]: I usually have that. I call it the wavy grasper.
Dr. John Haeberlin [00:10:42]: The teeth are wavy but not real sharp. They tend to perforate the gallbladder less, but they have good grabbing power.
Dr. Randy Lehman [00:10:46]: Okay, so that's your equipment setup. So what kind of ports do you use?
Dr. John Haeberlin [00:10:53]: I'm probably abnormal, and most people would agree. I'll start off by the periumbilical area almost in the high 90%, and I'll put a 10 or 11 for usually, and I'll vary entry unless they've had significant surgery or mesh in that area. Then I'll Hassan and use a Hassan trocar with the balloon. Once I've got that trocar in periumbilical, I'll place my other ones. I usually have my assistant completely on the left side of the patient. So hence, I'll put the camera trocar on the left side somewhere, right lateral, usually not right upper, but right lateral. This gives them space to back off and have the ability to put another 5 millimeter trocar in, if need be, to grab the fundus of the gallbladder up high. Because I'm just a three port technique.
Dr. Randy Lehman [00:11:54]: So more often than not, you just use three ports.
Dr. John Haeberlin [00:11:56]: Three ports.
Dr. Randy Lehman [00:11:57]: Back to the Veress needle placement. Assume this person has had no prior surgery.
Dr. John Haeberlin [00:12:02]: Right.
Dr. Randy Lehman [00:12:03]: How exactly do you put your Veress needle?
Dr. John Haeberlin [00:12:07]: I'll actually make the incision. I use local anesthesia, make the incision usually infraumbilical, but sometimes supraumbilical depending on the distance from the subcostal edge down to the umbilicus. Then I'll grab the edges of my incision with a penetrating towel clamp, lift up on the abdomen, and place the Veress needle.
Dr. Randy Lehman [00:12:33]: Okay, so how big is this incision?
Dr. John Haeberlin [00:12:38]: Usually enough. It depends on what my preoperative ultrasound has shown if there are big stones or small stones. Because then, you know, I hate fighting at the end of the surgery trying to get a big stone out. So usually just big enough to allow the gallbladder and the stones.
Dr. Randy Lehman [00:12:54]: So it's a transverse but slightly curved incision?
Dr. John Haeberlin [00:13:02]: Correct.
Dr. Randy Lehman [00:13:03]: And you're making it with an 11 blade?
Dr. John Haeberlin [00:13:14]: Yes. I make the incision two centimeters, using penetrating clamps to hold up. Veress needle in.
Dr. Randy Lehman [00:13:14]: Do you have some saline on the Veress?
Dr. John Haeberlin [00:13:14]: I'll insert the needle by feel, use my syringe with some saline, and inject, aspirate, then put a bit in to see if it falls.
Dr. Randy Lehman [00:13:26]: Hold up. And it falls. You don't take a Kocher through your incision, grab the umbilical stock, hold up?
Dr. John Haeberlin [00:13:40]: Correct. That's a great technique when starting, but for me, that's early in my career.
Dr. Randy Lehman [00:13:40]: Okay, gotcha. Then you hook that up to your insufflation?
Dr. John Haeberlin [00:13:40]: Correct. You let it go to 15 pressure before pulling out Veress or pull at 12?
Dr. Randy Lehman [00:13:40]: I keep the flow low, like 3. Pressure starts at 15 unless there's significant pulmonary disease, then peak pressure at 10-12.
Dr. Randy Lehman [00:14:18]: I never get the Veress to put more than three in anyway.
Dr. John Haeberlin [00:14:18]: That's correct. Feel better turning it up to 20 or 40.
Dr. Randy Lehman [00:14:18]: I just go 15 or 40.
Dr. John Haeberlin [00:14:18]: Yes.
Dr. Randy Lehman [00:14:18]: But I don't use the Veress. If I did, drop it in, check real flow rate at three, often three due to whatever.
Dr. John Haeberlin [00:14:30]: Pascal has that limited diameter.
Dr. Randy Lehman [00:14:30]: Once you're at 15, you take the Veress out.
Dr. John Haeberlin [00:14:51]: Right.
Dr. Randy Lehman [00:14:51]: Do you put a 10 or 11 non-ballooned disposable trocar in here?
Dr. John Haeberlin [00:14:58]: Yes.
Dr. Randy Lehman [00:14:59]: And are you looking as you go through, or you're just sliding it in, pulling the introducer out?
Dr. John Haeberlin [00:15:05]: Correct.
Dr. Randy Lehman [00:15:06]: And then you bring your 530 scope in, and you put your other two ports. I'm sorry, I kind of, with the three-port technique, I was a little confused. So where exactly are they going?
Dr. John Haeberlin [00:15:18]: So first of all, excuse me, I'll use the patient to help. So anesthesia will put the patient head up, feet down, airplane towards the patient's left. The first trocar that I'll put in is, I'll put in that camera port on the right lateral aspect of the abdomen. From that point, I will have the assistant put the camera in on that port. And usually, if the gallbladder is hidden, which seems to be my case too often, then with my periumbilical port, I'll put my grasper in to find the gallbladder and lift it up. That gives me the ability to now find where I'm going to work and how I need to get there. I'll put another 5-millimeter port, usually epigastrum, a lot of times to the left of the epigastrum. So I have a nice, comfortable feeling with my hands at the right level and at the right distance apart, where I can work where I'm most comfortable.
Dr. Randy Lehman [00:16:18]: Sure. But your camera is not between your hands.
Dr. John Haeberlin [00:16:20]: That is correct.
Dr. Randy Lehman [00:16:21]: So, yeah, because that's what I've always been. They beat that, you know, instructed well, sure.
Dr. John Haeberlin [00:16:26]: It was the way we started because.
Dr. Randy Lehman [00:16:27]: I'm working like this with my hands on either side of my eyes in the middle. So I always try to put my camera in between my hands. But that works for you, basically? Yeah. The way that you're talking about, okay.
Dr. John Haeberlin [00:16:38]: And the reason there's always a reasoning for putting the camera between the hands. Too often, you're operating and you're hitting the arm of your assistant who's holding the camera. This way, they have their whole side of the bed. Your hands are away from theirs. I've never hit them. They like it. They're more comfortable. They have the freedom to move the light board because it's a 30-degree. That's just my reason.
Dr. Randy Lehman [00:17:02]: Okay, fair enough. All right, so then you grasp and retract the gallbladder, and you start dissecting down from the surface of the gallbladder.
Dr. John Haeberlin [00:17:11]: Correct. With my left hand, I've used that technique where I'll grab the neck of the gallbladder and the fundus simultaneously, which I learned that technique, of course, you know, perfecting it with the robot, because a lot of times, you're going to grab the neck of the gallbladder, stick the knuckle of the robot up into the fundus. The key is all about dissecting that neck of the gallbladder. You have to start on the gallbladder and then you pull down from there towards the common duct. You should always be seeing that neck of the gallbladder. That's just how I've done it. If it means I've got to take the peritoneum on both sides, north and south, or cranial-caudal, whatever it takes to get to a point where there's no doubt in my mind that I'm working on the cystic duct. I'll continue that until I'm for sure about my critical view. The only other structure, of course, is the cystic artery, which in my experience, is usually quite diminutive and almost something you can just cauterize. There should be nothing else between that liver edge and in the cystica.
Dr. Randy Lehman [00:18:16]: Yeah. So you shoot for a critical view or a, yeah, critical view of safety.
Dr. John Haeberlin [00:18:21]: Correct.
Dr. Randy Lehman [00:18:22]: Every time. So do you document that in your OP note?
Dr. John Haeberlin [00:18:24]: I do.
Dr. Randy Lehman [00:18:25]: A specific way. How do you say it?
Dr. John Haeberlin [00:18:27]: I'll say the area was dissected and cleaned up to the point where there was absolutely no question that you had liver edge, cystic duct, neck of gallbladder, and there was nothing else between there.
Dr. Randy Lehman [00:18:38]: Yeah. You think that that's, if that's not documented in the OP note, and then the person has a common bile duct injury, that the surgeon has violated the standard of care.
Dr. John Haeberlin [00:18:57]: Wow. We're going to go down that can of worms right away. I like it, good for you. No, not necessarily. I think it makes it highly suggestive. And in a court of law, you're absolutely correct. They'll be persecuted because of documentation. But the other thing is, how does that surgeon normally do the surgery every single day of their life and how they've been doing it for the last 10, 20, 30 years? Because you can set precedent and say, I've always done it this way. Yeah, that's a really good question.
Dr. Randy Lehman [00:19:35]: The reason I bring that up, we have in the state of Indiana, our malpractice tort reform that we have is that every malpractice case has to go before three peers. Okay. And they can throw it out. Okay. They can just say, this is frivolous.
Dr. John Haeberlin [00:19:50]: Gotcha.
Dr. Randy Lehman [00:19:52]: Then if. And they do often, because a lot of it is. But then if it's not frivolous, and it's almost like if the peers said there's something here, then there's a lot more settlements or whatever. Malpractice wins.
Dr. John Haeberlin [00:20:07]: You're doing this based on documentation only, or are you doing this with the surgeon in the room answering questions?
Dr. Randy Lehman [00:20:14]: Well, I've only been on the board one time, and as a, you know, as one of the peers. Yeah. So, like, by having a license in the state of Indiana, you're obligated to.
Dr. John Haeberlin [00:20:24]: Sure. Just like jury duty.
Dr. Randy Lehman [00:20:25]: Yeah, yeah. And you can. They, their attorney. The attorneys on both sides have a striking committee, and they can eliminate certain people, and one person ends up being on. And so anyway, I was on a case that's kind of like this. And for me, I did not feel like not doc. I mean, I document it that way. I say basically three things. There's a critical view of safety, that the cystic triangle is clear of all fibro fatty tissue. There are two and only two structures entering the gallbladder. And the inferior one-third of the cystic plate was freed, was dissected free from the liver. So, like, the inferior one-third of the gallbladder fossa is free. Now that's a critical view of safety. I'm with you. Not more often than not, but a sizable minority of patients, the cystic artery is so small, or I'm dividing it on its branches so close to the gallbladder, sometimes I don't clip an artery.
Dr. John Haeberlin [00:21:25]: I know.
Dr. Randy Lehman [00:21:26]: But that being said, it's clearly just the cystic duct, and you've dissected the whole cystic triangle.
Dr. John Haeberlin [00:21:31]: Correct.
Dr. Randy Lehman [00:21:32]: But just because, like I said, just because somebody didn't say that they did, it doesn't mean that they didn't do that.
Dr. John Haeberlin [00:21:37]: That is correct. That's the crux right there.
Dr. Randy Lehman [00:21:41]: And this particular case, they had so many claims that were wrong about. This is the problem. The surgeon did this, this, this, this, and all those claims were false, but they didn't say, well, they didn't dissect the critical view of safety. But that was the thing that another person in the committee kind of honed in on. And we all agreed that since that wasn't said, that was like, it was a. Raises your eyebrows a little bit. But that being said, this person's a seasoned surgeon and, you know, I don't know.
Dr. John Haeberlin [00:22:12]: So I may have a different point or a very interesting point of view in that once you've worked with junior surgeons—and I'm not talking residents, really, I've worked enough with residents that I know how they dissect and how they think—but once you work with junior surgeons when they are out of the program and they're doing this, and this has happened so many times, I can't even tell you how many times in my career where they'll call you in and say, "Hey, what do you think?" You see how they have dissected, and then you watch how they go and see. So often they come off of the gallbladder, and they continue to stay off of the gallbladder and they go farther away from the gallbladder. Your internal turmoil button or scope or degree just keeps going up. It's like, you know, I would stay up more on the gallbladder. Yeah. And I don't know what's the creation of that. I don't know if they just get comfortable or if it's easier. I think that might be it—they're easier to get farther off the gallbladder. Sometimes the dissection is easier. And if you think about it, one of the unfortunate things, as junior surgeons come out into their training, is they're almost castigated if they go too slow and are considered to be better surgeons if they go fast. Which is sad, because that couldn't be farther from the truth; careful has nothing to do with speed.
Dr. Randy Lehman [00:23:47]: Yeah. I mean, you don't want to waste.
Dr. John Haeberlin [00:23:48]: Time, but you know, but still, you certainly don't want to get a common bile duct injury.
Dr. Randy Lehman [00:23:53]: True.
Dr. John Haeberlin [00:23:54]: Yeah.
Dr. Randy Lehman [00:23:54]: Speaking of wasting time. So now that. Thank you. Nice. Thanks for diving.
Dr. John Haeberlin [00:23:59]: Very nice segue. We go down rabbit holes too easy, too well.
Dr. Randy Lehman [00:24:04]: So you've dissected your critical view of safety, and let's say you do have a duct and an artery, do you do a cholangiogram? No, not routinely.
Dr. John Haeberlin [00:24:15]: Not routinely.
Dr. Randy Lehman [00:24:16]: What causes you to do a cholangiogram?
Dr. John Haeberlin [00:24:19]: If preoperatively they had a bump in their LFTs, if they had gallstone pancreatitis, the usual indications. I don't need to go over those. Anatomically, if I have any question, my critical view is there, but I have a question. There's something I don't like. I will go up by the neck of the gallbladder, and I'll stick the catheter in there just to confirm that I'm okay.
Dr. Randy Lehman [00:24:44]: And you're using what kind of clamp for this?
Dr. John Haeberlin [00:24:46]: Oh, nice. Very nicely done. Good. Yeah. We're not gonna go over the name of the clamp right now, but you can clamp across the neck of the gallbladder and throw a needle down and then do your cholangiogram that way. Or you can make a little cut in your cystic duct neck with gallbladder and just put an Aero catheter, which is my preference.
Dr. Randy Lehman [00:25:11]: Yeah. Well, we stand on the shoulders of giants, you know, with some of these instruments that have been created before us. Yeah.
Dr. John Haeberlin [00:25:18]: Yes, we do. Okay.
Dr. Randy Lehman [00:25:19]: Yeah.
Dr. John Haeberlin [00:25:20]: Mr. DeBakey, let's go down there a different direction.
Dr. Randy Lehman [00:25:23]: Okay. So you don't do a cholangiogram. You clip, you cut with scissors.
Dr. John Haeberlin [00:25:28]: It depends. I've started to get to a point where I realize the more different changes I do—and this is caused more by the robot—the more changes I do for instruments, the more time it takes and the less efficiency now. So I try to get to a point: can I control the duct with just the cut mode on the quadrant? The answer is yes, you can. Yeah.
Dr. Randy Lehman [00:25:53]: Yeah, I do that sometimes.
Dr. John Haeberlin [00:25:55]: Yeah.
Dr. Randy Lehman [00:25:56]: All right. And if you did use scissors, is it reusable or is it an EndoSure?
Dr. John Haeberlin [00:25:59]: Reusable.
Dr. Randy Lehman [00:26:01]: Okay. Is it a parrot beak or is it a...
Dr. John Haeberlin [00:26:05]: Yes, the parrot beak.
Dr. Randy Lehman [00:26:06]: That's it. Okay. Whatever. I don't think those things really matter. I'm just kind of curious what people are doing, actually, to be quite honest with you.
Dr. John Haeberlin [00:26:13]: It's whatever they hand me.
Dr. Randy Lehman [00:26:15]: Yeah.
Dr. John Haeberlin [00:26:15]: Because once again, it just doesn't matter. Yeah.
Dr. Randy Lehman [00:26:17]: And then when you're clipping, one other question. You said something about three clips falling off.
Dr. John Haeberlin [00:26:22]: Yes.
Dr. Randy Lehman [00:26:22]: You use three clips on the stay side or two clips on...
Dr. John Haeberlin [00:26:25]: There's two clips on the stay side and then one on the gallbladder side.
Dr. Randy Lehman [00:26:29]: And then if you have the artery, you do the same thing.
Dr. John Haeberlin [00:26:32]: Or maybe I'll just put two on the stay side, and then I'll just cauterize by the gallbladder. Yeah.
Dr. Randy Lehman [00:26:39]: Do you document two clips proximal, one clip distal?
Dr. John Haeberlin [00:26:44]: I do.
Dr. Randy Lehman [00:26:45]: Do you think there's any potential for liability if one of those clips fell off and was now located somewhere down in the pelvis later, and you documented two clips there rather than just saying that it was clipped and divided?
Dr. John Haeberlin [00:27:02]: With metal clips, sure. Because I now have obviously come across it, they can pull off. I've not seen a Hem-o-lok clip fall off. I don't think they can.
Dr. Randy Lehman [00:27:15]: Okay. Well, I had somebody tell me that they think it's a bad idea to say how many clips you used on whatever place because what if they migrate or whatever. And I'm like, I'm sorry...
Dr. John Haeberlin [00:27:31]: I don't believe that. I would put exactly what I did.
Dr. Randy Lehman [00:27:34]: Or even, what if they only find three in there? And you said you clip two and two, and now there's only three clips, period, in the abdomen. I don't know. I'm just asking the question because it's kind of a stupid thing that I heard before.
Dr. John Haeberlin [00:27:46]: Right. I get that. I suppose if you're doing this, this doesn't happen to me anymore. It may have when I was early in my career. If you're doing multiple gallbladders in a day back to back to back, and if you somehow missed dictating one before the other because they had the patient in the room, then, okay, I can see how you might be able to make that mistake. But short of that, I now do not start my next case ever until I'm done dictating the case.
Dr. Randy Lehman [00:28:14]: Before you actually dictate the whole...
Dr. John Haeberlin [00:28:17]: I get out of the operating room, and I'm putting in orders and dictating that case.
Dr. Randy Lehman [00:28:20]: You don't use a template?
Dr. John Haeberlin [00:28:22]: I do use a template, but I still augment whatever is different.
Dr. Randy Lehman [00:28:26]: Okay. I don't... Yeah. Okay, that's fair enough. So then you take the gallbladder off the fossa using the hook cautery?
Dr. John Haeberlin [00:28:32]: Yes.
Dr. Randy Lehman [00:28:33]: And any tricks on how to not rupture it?
Dr. John Haeberlin [00:28:37]: Yeah, I tend to. Especially when I'm down low, I'll go in with my hook and kind of dissect, or I use the word, I kind of nooger in there and get in and dissect until I've got a good thing and then pull it away. That's a good word. That's great. You know, we can keep it.
Dr. Randy Lehman [00:28:54]: Yeah.
Dr. John Haeberlin [00:28:56]: I don't use the back of the hook at that point. I use the point, the neck, or the bend, the elbow. I'll get in there and take that tissue and pull it away. And by doing that, I think you have less chance of rupture.
Dr. Randy Lehman [00:29:10]: I just have a quick tip for the resident that's with us so that when you're doing this hook cautery move any of the dissection, there's going to be an element of give after you cauterize. If you're angling, you do not want to be pointing down. You want to be pulling out of your instrument or pushing somewhere—maybe towards the liver would be okay. You know, if you pass point and you buzz the liver, that's one thing. But if you're cauterizing down and you pass point and then you buzz either the common bile duct or the duodenum or the transverse colon, then that's a big issue. Having that angle allows you to kind of go quicker because, even if it gives way a little faster than you were expecting, you're...
Dr. John Haeberlin [00:29:54]: You're...
Dr. Randy Lehman [00:29:55]: You're either pulling out of your instrument or pushing up into space, like towards the abdominal wall or something like that. That's not going to be critical or leave you with a delayed balance or something of that nature. Right. So then you take the gallbladder down. You talked about that. And then do you put it in a bag?
Dr. John Haeberlin [00:30:11]: I usually do in the United States because they almost hand me one even before I have the option to say, "Don't hand me one." Yeah.
Dr. Randy Lehman [00:30:20]: So at that point, you have your right hand with cautery, and your left hand is holding where you're going to take the gallbladder out. So then you take another grasper in your right hand, grab it, then take that board out. Okay. And then you bring your bag in, dunk it, and then anything like, do you take it out or do you make everything. Taking it out as the last part? Make sure everything's...
Dr. John Haeberlin [00:30:43]: Yeah, I take it out as the last part. So I'll check the liver bed. And so now I use ICG dye almost ubiquitously in the United States and I use it as an assistant while I'm dissecting to make sure my common bile duct. But then at the end, I also make it so I can get it on ICG mode. Make sure there's no duct of Luschka or any sort of accessory duct in the liver bed. And then also the cystic duct is not leaky.
Dr. Randy Lehman [00:31:10]: What if you saw a little bit of ICG leaking out of the liver bed, but you don't actually see a duct?
Dr. John Haeberlin [00:31:15]: I have seen that, as a matter of fact, times. Once. You always have that one time. And I put a clip there.
Dr. Randy Lehman [00:31:21]: Okay. It's kind of in the bed.
Dr. John Haeberlin [00:31:22]: Yes.
Dr. Randy Lehman [00:31:23]: You didn't leave a drain.
Dr. John Haeberlin [00:31:24]: I thought about it, but I then sat there and watched it for a long enough time and felt that I had clipped it, that I did not.
Dr. Randy Lehman [00:31:31]: And the cautery would not...
Dr. John Haeberlin [00:31:33]: Would not cauterize it. No.
Dr. Randy Lehman [00:31:35]: And you sent the patient home the same day?
Dr. John Haeberlin [00:31:37]: Yes.
Dr. Randy Lehman [00:31:39]: Just don't get any routine labs afterwards unless they're getting jaundice or having pain. Okay, sounds good. Well, that's great. Then when you were coming out, how do you close that 10 at the belly button?
Dr. John Haeberlin [00:31:55]: If the patient... So this is another really good question because, you know, the patients that I do robotically, that 25% and I—it might even be 30. Am I allowed to go up or a 5% jump like that? Amy, let's say population-based. What is our population base where the BMI is over 35 or pick a number, 35 to 40. Yeah. For those patients, it's all BMI-driven. If their BMI is high, then I will close it with a Carter Thompson or some other thing where I don't have to go down the fascia. But then that also depends. Is their fat more intra-abdominal or is it from the fascia up towards the skin?
Dr. Randy Lehman [00:32:37]: Okay.
Dr. John Haeberlin [00:32:37]: And you can usually see that by ultrasound and you'll get an idea when you put in your veress needle.
Dr. Randy Lehman [00:32:41]: Okay, so if the patient's really fat, use a Carter Thompson.
Dr. John Haeberlin [00:32:44]: Yes.
Dr. Randy Lehman [00:32:45]: And if they're skinny, then you just use a couple s hooks and you...
Dr. John Haeberlin [00:32:48]: Go down close with anterior.
Dr. Randy Lehman [00:32:50]: And you just use pickups in your hand.
Dr. John Haeberlin [00:32:53]: Tissue forceps with teeth.
Dr. Randy Lehman [00:32:55]: All right. And you don't use a Coker in like grasp with fascia.
Dr. John Haeberlin [00:32:59]: I do not.
Dr. Randy Lehman [00:32:59]: And then you're using...
Dr. John Haeberlin [00:33:01]: What's it just an old bicycle suture, UR6.
Dr. Randy Lehman [00:33:03]: UR6. And stitching it up. And are you doing interrupted or figure of eight or...
Dr. John Haeberlin [00:33:09]: I do a figure of eight and then I'll... If the hole did have to get modified because there was a big stone or something, I'll use that one to hold up that stitch to see if I need to adjust one way or the other.
Dr. Randy Lehman [00:33:20]: Yeah. And you just put extra figures until they're closed. Okay. And if you're doing the Carter Thompson, then you're also doing a figure of eight.
Dr. John Haeberlin [00:33:27]: Yes.
Dr. Randy Lehman [00:33:27]: With an O Vicryl.
Dr. John Haeberlin [00:33:28]: Yeah.
Dr. Randy Lehman [00:33:28]: You just cut the stitch off and you're... And then on the Carter Thompson, you're standing opposite of your camera guy to do that and you find that to be easy.
Dr. John Haeberlin [00:33:37]: It is. It's not bad because they're... The only thing is they're looking towards you. But it's not as bad as you've... Everyone's experienced if you're having someone look up this way but you're not, you're operating in the completely opposite. 180 will confuse you every day. But 90 degrees is usually your brain can handle it.
Dr. Randy Lehman [00:33:57]: So you have a screen on both sides of the patient, one for them, one for you, and you're still looking across the patient when you're doing your... Okay, I would maybe turn my body and look at the other because there's...
Dr. John Haeberlin [00:34:07]: Not much time involved. But like I said, 90°. I usually don't. Yeah.
Dr. Randy Lehman [00:34:13]: And then on the Carter Thompson. Any other tricks? No. So my trick for the resident would be to start away from the camera.
Dr. John Haeberlin [00:34:23]: Yes. And then come...
Dr. Randy Lehman [00:34:25]: And then go to the other side and then come to the tail because it's much easier. And then, you know, cross across. Very good. And then you just close the skin after that.
Dr. John Haeberlin [00:34:37]: Correct.
Dr. Randy Lehman [00:34:37]: With the 4O monocryl subcuticular.
Dr. John Haeberlin [00:34:41]: What...
Dr. Randy Lehman [00:34:41]: What kind of needle?
Dr. John Haeberlin [00:34:43]: It's usually a very small needle, like PS2 or something like that.
Dr. Randy Lehman [00:34:47]: I like the PS2, but the real small ones, like the FS. I hate those.
Dr. John Haeberlin [00:34:51]: Yeah, those are a little too small. Those are great for plastic surgery. Closure on the face.
Dr. Randy Lehman [00:34:55]: Yeah, exactly. Exactly. And then what do you put?
Dr. John Haeberlin [00:34:59]: Whatever someone else wants to do, because it doesn't matter to me.
Dr. Randy Lehman [00:35:05]: All right. Well, that is, in a nutshell, very good. I'd like just to add one more thing that I do, which is the instrument that I love, which I probably would most demand if I went to a place and I use a suction. Oh, do you ever use suction cautery?
Dr. John Haeberlin [00:35:21]: Absolutely. So I'm glad you asked that. For any gallbladder that's hot, infected, whatever I do, I will universally use suction irrigation to actually dissect the gallbladder away from the liver bed. The only time being is when it's more of a chronic phase instead of acute. Then not so much.
Dr. Randy Lehman [00:35:42]: So I have a suction irrigator that has a hook cautery that comes out the middle of it.
Dr. John Haeberlin [00:35:46]: Yeah.
Dr. Randy Lehman [00:35:47]: And then you can pull the sleeve for the suction in and out, over and out, and then I don't have to trade. That's almost exclusively the instrument that I have in my right hand at all times.
Dr. John Haeberlin [00:35:58]: Great instrument.
Dr. Randy Lehman [00:35:59]: And then I can just switch. That's how I blunt, dissect, and suck. You know, the other thing is I often hit the suction as I'm buzzing, which cleans the smoke out as I'm going.
Dr. John Haeberlin [00:36:09]: Now that's a disposable article, though, right? Disposable tool. No, that's non-disposable.
Dr. Randy Lehman [00:36:17]: Right. Okay.
Dr. John Haeberlin [00:36:18]: The only ones I'd ever seen and used in the past were disposable. That's why the black sleeve is.
Dr. Randy Lehman [00:36:25]: I think the whole thing is non-disposable. I know the black sleeve is non-disposable because the other thing that I use, there's a plastic pink sheet that looks like an arrow quiver. Yep. And I use that too, and tuck it over, even though I have the big drape, because then I can just keep my own instruments and they're really organized. But I kind of put it in there too hard and dropped it in there. After repeated uses, I cracked one of the ends of it. So that's how I know it's reusable.
Dr. John Haeberlin [00:36:54]: Okay.
Dr. Randy Lehman [00:36:56]: I think that the stick on the inside is also part of it, and then it comes apart to clean and everything. It's a reusable instrument. But yeah, it's a very low-cost thing. But it makes my cases a lot faster because they're not changing. Absolutely, almost never do I use the Maryland. I saw the Maryland used a lot in residency. But because I can, little paddle, little buzz, that was a Dave Farleyism, which basically I'm doing the paddle with the suction and then the buzzing and the hooking. I can clean out the cystic triangle just fine without having to switch for that minute.
Dr. John Haeberlin [00:37:29]: No, that's great too. I might actually take that. That's the other thing I would like to say, if I can, is in no way do I figure that at the age of 63 that I have found my one and only best lap coli method. Yeah. I always continue to listen to other surgeons. I watch other surgeons, and I still adapt. Yeah, I think you should. I think that's one of the key components of growth and becoming a better surgeon. You should never think you're the best.
Dr. Randy Lehman [00:37:59]: Yeah, obviously, I share that opinion because I'm sitting here every week asking another surgeon how they do things. Of course, taking pieces that I like and whatever. So that's wonderful. We really dove into this. This “how I do it” is my favorite part of the show.
Dr. John Haeberlin [00:38:15]: Sure.
Dr. Randy Lehman [00:38:16]: I would like to talk about this one case that I had. So down here in Honduras, we'll probably have another, like maybe solo cast or something, where I talk about medical missions. You know, I'm highly concerned about not doing harm and also not hurting the country. You can come in and try to do good things. It's like your kid, you know, you give them too much. You give things for free; they don't appreciate it. You ruin them. Maybe you undermine the existing system. In Honduras in 2025, there are a lot of very poor people that are living with multiple people in a shanty dirt floor, with no running water, subsistence farming type of living. They have a social program for these people, theoretically to be able to get care. But we see dozens of people every time we come down here that have been put off. They go periodically and they never get the operation. It's been three, four, five years, and they've had gallstones that whole time.
Dr. John Haeberlin [00:39:24]: Absolutely concur 100% with that.
Dr. Randy Lehman [00:39:26]: So I really don't feel like I'm undermining anybody by seeing these people that are literally not getting care. They have no way to pay for the private stuff, so they're just stuck. And this one patient that I did a goal, we have a laparoscopic setup down here, which is sort of unheard of. Our setup down here is way better than it is in most developing countries.
Dr. John Haeberlin [00:39:44]: It's fantastic.
Dr. Randy Lehman [00:39:45]: And it's based on the people that set it up, which was a husband and wife search tech team. So, you know, we have air conditioning, four operating rooms. Just like being at home, pretty much. I had a patient who I, she, same deal. You don't really know how many years, but it's been many years of pain. I'm laparoscopically dissecting this intrahepatic gallbladder. But the first thing I saw when I got in was stones outside of the gallbladder, scarred in a little pocket near the.
Dr. John Haeberlin [00:40:19]: That's satisfying.
Dr. Randy Lehman [00:40:21]: Which means she had necrotic cholecystitis. Perforated her gallbladder in the past, lived through it; maybe she got antibiotics. I don't know all the details, but.
Dr. John Haeberlin [00:40:32]: Just walled off and controlled itself.
Dr. Randy Lehman [00:40:33]: Walled it off on its own. Clearly, there were still stones in the gallbladder and then there was another, like, adjacent pocket with these stones. So I kind of dissected that area, pulled the stones out, and then I'm following the gallbladder down. Now the other issue that, you know, I don't have a CT or anything, I have an ultrasound. The patient's got around a, almost a 2 centimeter common bile duct.
Dr. John Haeberlin [00:40:59]: Yeah. And in this area where the stones were, was down more towards the neck of the gallbladder.
Dr. Randy Lehman [00:41:05]: Right. So I cleaned that out. I'm chasing it down. The cystic duct is extremely short. She's like a setup, I feel like, for choledocholithiasis. She's got what I would say, she didn't have pre-operative elevated LFTs, but she's got a dilated bile duct and a short, fat cystic duct. So I'm thinking to myself, man, she could be; she could have stones in her bile duct. What am I going to do? We don't have the setup to do a cholangiogram. I don't have the setup that I have back home to do laparoscopic common bile duct exploration. At the same time, I think there's probably somebody in the country that does ERCP, but it's going to be extremely difficult to get them in. So what do I do? The other problem is the anatomy was not the clearest, and because of the intrahepatic nature of the gallbladder, you were there. I made the decision to go ahead and open. That's the third gallbladder I've opened since residency. The other two patients that I've opened were back in the States. One of them was actually gallbladder cancer that was invading the duodenum, but presented as an ER acute cholecystitis patient.
Dr. John Haeberlin [00:42:08]: Sure.
Dr. Randy Lehman [00:42:09]: So that one, I was repairing the duodenum, of course, open. The other patient was somebody that was a paraplegic in the nursing home attached to the hospital that had been shot in the abdomen nine times. And I was.
Dr. John Haeberlin [00:42:24]: Compare that one.
Dr. Randy Lehman [00:42:25]: I was expecting it to be difficult. I did a cut down at Palmer's Point. I got in, it was a pure sheet of plastic everywhere, like white. So I just went to the CT scan, counted how many cuts above the belly button, how far over. I made an incision right over the top of the gallbladder, dissected right down, and there it was. Dissected it out and closed up. So you have to be able to do those open coleys. This was probably the easiest of my three open coleys, but I basically found that there was a dilated cystic duct and dilated common bile duct, almost non-existent cystic duct. Speaker A: I ended up suturing the cystic duct stump and kind of got the anatomy cleared, clarified, but I didn't have a way to go down and look in the distal bowel. I felt with my hands; you know, you can feel the head of the pancreas. I didn't feel a specific stone or mass, but there was a kind of fullness in that area. I don't know. Anyway, we really kicked around how to do it and ended up admitting the patient. We kept them for a couple of days and got LFTs, which bumped the next day, including my direct bilirubin, but then fell the following day. The patient was completely asymptomatic and had essentially no pain. So we discharged her with outpatient follow-up. I don't think she has an obstruction, but, you know, you're appropriately paranoid, of course. I just wanted to kind of say, you know, everything's real easy and straightforward. Surgeons I've heard say there's no glory in a lap chole, right? Because only badness can happen to you. But obviously it's one of the most common things that's needed, so we're going to continue to do a lot of them. You just have to have tips and tricks in your back pocket for when things look different. The other thing I do differently than what you do is I always do a calendar gram. The main reason I do that is because I'm in multiple small hospitals where our volumes are a little bit lower for the staff. I'm still doing a lot because I'm going to multiple places, but if I do that, I found that I can get a cholangiogram done on a routine one in like, literally less than two minutes. Speaker B: Yeah. Speaker A: And that's only because I've done so many. Now if we actually have a problem, it's very easy rather than being fussy for me to take care of it. Speaker B: I would never, ever, ever condemn another surgeon for doing a cholangiogram, routinely or otherwise. It makes no sense for any surgeon to persecute another surgeon for doing routine cholangiograms. That's just ludicrous. Speaker A: Yeah. So those are just my perspectives on how I do it. That's a bit of a rural surgery story. So maybe we can just call that our classic rural surgery story. Speaker B: That's a good one. Speaker A: I'd like to ask you just two more questions for the other segments of our show. Number one is our financial corner. Do you have a tip for basically your former self or junior surgeon financially? Speaker B: Yeah. As soon as you can, try to control your debt increase more than anything. Don't get excited because you're getting a paycheck and it's time to buy all those things you've been putting off your whole life and get into credit card debt. Credit card debt is not your friend, so don't do that. And then as early as you can—and I'm not talking to make this painful for your family—put a little money away, because the earlier you do that, the more growth potential it has. And then for sure, do not put all your eggs in the same basket. There's nothing wrong with having routine stocks and, or mutual funds, IRA, you know, contribute to that—it's, of course, wise. But there's nothing wrong with getting into the real estate market, possibly dabbling in that, and having fixed assets that can appreciate over time. Just be careful. Make sure you go and use the same brain you used to learn how to do surgery, to learn how to invest. Speaker A: Gotcha. So sell everything you have, borrow as much money as you can, and buy as much Bitcoin as you can. Got it? Speaker B: Yeah, something like that, but opposite. This is opposite day. Speaker A: Just kidding. Don't do that. Speaker B: Yeah. Speaker A: All right. Lastly, resources for the busy rural surgeon. What's something that you just can't do without? Speaker B: Wow. Well, I'm old. As you can see by the podcast, it probably makes me look taller or less fat. But I'm old. I'm 63 years old. And for the last 10 years, I have fully embraced the robot. I do believe that the robot as a platform offers some significant advantages over laparoscopic surgery. I'm not going to say the data shows that overwhelmingly for patients, because we've all read the literature. That's not true while that may pan out with more data points over time, that might happen. However, there's not a single surgeon, in my opinion, who's done robotic surgery, embraced robotic surgery, who would not say that it's an easier platform for the surgeon. And if it's easier for the surgeon, more than likely that's going to reflect on the patient. So a tool that I wouldn't do without in a rural setting because it might allow me to do some cases in that rural hospital where otherwise they'd have to get shipped out would be the robot. For instance, many perforated duodenal ulcers—if it's a sizable ulcer and the patient is stable, which most of them are if it's early on in their story, so to speak, or their presentation. I think I get a much, much better repair using the robot, suturing it than I would if I'm doing laparoscopic. I use the endostitch laparoscopically. I've done pretty well with the endostitch. And you know why I've done pretty well? I didn't have a robot. I didn't have another option. So I know for a fact I'm a horrible stitcher when it comes to laparoscopically trying to do it the regular technique. I never excelled at that, and I've had my whole career to try and get better. Speaker A: When's the last time you did a perforated duodenal ulcer in a rural hospital? Speaker B: Probably about four or five years ago. Speaker A: I just, I don't know. In my settings, right, they're all critical access, not just rural hospital access hospitals. I don't think I would do it. Speaker B: Stable early in their presentation, less than 12 hours. Maybe I would, maybe I would. But not that I want to push you out of your comfort zone, but... Speaker A: I don't know, maybe I just have to. It would depend on a lot of things. Comorbidities, the situation. I mean, I'm thinking of one case in residency. She was a Russian immigrant who was a cleaner and started having belly pain. To treat her own belly pain, she started taking ibuprofen by the fistful and drank a fifth of vodka. We're talking like she probably took, like, 10,000 milligrams of ibuprofen in a day and drank it. Speaker B: So besides killing her kidneys... Speaker A: She just perforated a teeny little anterior—it was actually an anterior antral ulcer. Speaker B: Sure. Speaker A: And so, we did that laparoscopically, not with the robot. We did a laparoscopic Graham patch. She was otherwise skinny, healthy, like, you know, 30 or something like that. But what's the chance in my small community that that patient is going to walk through the door? I guess if they did, I probably would do it, but there are so many ways it can go. Speaker B: Realize it's going to happen when you get back next week. You're out on call tomorrow, as a matter of fact. You know, it's going to be there. Just plan for it. Speaker A: Yeah, we'll see. Call me up. Speaker B: I'll come down. I'm not credentialed. I'll just sit in the back and tell you what to do. Speaker A: Yeah. Okay. Well, that... Thank you very much for joining us on this episode from the beach in Roatan, Honduras. This has been a very unique episode. I hope that the quality of the AV comes through and my AV guy doesn't kill me. If you enjoyed this episode or any other episodes of The Rural American Surgeon, please share it with friends that you think are also interested in and could benefit from it. We really appreciate the fact that you're here, and I've enjoyed this episode. I hope you have, too. I'll see you on the next episode of The Rural American Surgeon.
