Episode 9

Laparoscopic Surgery Insights with Dr. Michael Sarap

Episode Transcript

Dr. Randy Lehman: [00:00:07] Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman. On this show, you'll receive powerful insights and resources for rural surgeons. I'm a general surgeon in northwest Indiana, and this show is tailored around the nuts and bolts of rural general surgery practice.

You'll find topics ranging from practical surgical tips to a host of others, including rural lifestyle, finance, training, practice models, and more. We'll have a segment called "Classic Rural Surgery Stories," where you'll get a feel for how practice in the country differs from the city. Whether you're a surgeon, other specialist, primary care provider, or simply someone interested in healthcare for rural America, I'm glad you're here. Now, let's get into the show.

Hello, listener. Welcome back to The Rural American Surgeon. We're here joined today by Mike Sarap, a rural surgeon from southern Wisconsin—or southern Ohio, I'm sorry. We are so privileged to have you here. You have such a rich and storied history.

First off, you went to the same medical school that I did, which is the University of Cincinnati. But the difference is you graduated before I was born! You've had a 35-year or more career. I was reading through some of the things that you've been able to do—the body of work you've published as a rural surgeon, your busy practice, your involvement with the American College of Surgeons, and your leadership opportunities there.

We'd love to talk about that a little bit more, but just want to say thank you so much for joining us. Welcome to the show, Mike. I appreciate you being here.

Dr. Michael D. Sarap: [00:01:42] Totally my pleasure. Thanks for having me.

Dr. Randy Lehman: [00:01:44] Absolutely. So why don't we dive right into the rewards and challenges of rural surgery practice? You've been a rural surgeon your entire career, correct?

Dr. Michael D. Sarap: [00:01:55] Yes.

Dr. Randy Lehman: [00:01:56] And this is by choice.

Dr. Michael D. Sarap: [00:01:58] Yeah, sure.

Dr. Randy Lehman: [00:02:00] So what have been some of those things that have kept you going for this long, and what excites you most about your job day-to-day?

Dr. Michael D. Sarap: [00:02:09] I think the reward, certainly when I started out, was that it allowed me to do everything in my practice that I was trained to do. We were trained in a day where everything was open. General surgeons did all the vascular work, a lot of thoracic, endocrine procedures, and those kinds of things.

When I was looking for a place to practice, I wanted to use those skills to help people. It was very rewarding to have a broad-based practice. I had a really nice training experience in endoscopy, and that's been a big focus of my practice as well—advanced endoscopy, as it is with most rural surgeons.

I think one of the rewards is that you can really make a difference. You're meaningful to people. It's not like you're in a major metropolitan area with 15 or 20 general surgeons where everyone does a good job. In a small community, you're filling a need. I got very excited about that.

Throughout my 37 years, whenever we felt there was a need or gap, we were able to fill it with extra training, new procedures, or more technology. That’s very exciting.

The long-term relationships are also rewarding. We've cared for patients with multiple cancers, and we've treated their kids and grandkids. Those connections are unique to small towns.

Dr. Randy Lehman: [00:03:41] How many of your patients do you know? You grew up in Ohio, and you're practicing about an hour and a half from your hometown, correct? Do you see people that you knew, like from your high school days?

Dr. Michael D. Sarap: [00:03:53] Actually, I do, yeah. I see some folks that I graduated with, including people who grew up on my street and later migrated to this little town. We had people who came here to teach or to coach. I’ve taken care of my high school football coaches, people who lived on my street, and certainly, over the years, I’ve taken care of my kids' teachers.

There are all these little ties and connections. In a small town, it’s never just about a patient-physician relationship. It’s always more personal. For instance, you might hear, “Yeah, you were in Cub Scouts with my kid” or “You went to school with my kid.” So, there are a lot of personal ties.

Dr. Randy Lehman: [00:04:36] Yeah, I basically start every conversation with, “Let’s find our one degree of separation.” It’s not seven degrees! For me, I wanted to come back to my hometown, too, so it’s very personal. I know everybody—it’s crazy! The next town over and the next county to the south is where my mom’s from and where my dad grew up. If I don’t know someone, they probably knew my parents.

You can’t hide either, and that’s the other thing. There are pros and cons to that. I’m four and a half years out now. I started at one critical access hospital with the goal of eventually going to my hometown, which is in the next county over. I was able to do that—it’s a long story, not for right now, but I’ve talked about it in other podcasts.

Now, I’m in both hospitals and actually cover two other critical access hospitals in adjacent counties. I do sort of an outreach thing two days a month right now. I’ve built a practice and know what it takes, but I’m still early in my career. Talk to me—or that chief resident considering going into rural surgery—about how to build a practice in rural surgery.

Dr. Michael D. Sarap: [00:05:49] Interestingly, I wrote a little piece about this. The American College of Surgeons has a primer workbook for employed and self-employed surgeons, and I contributed to that. I think the three big things are touching base with your community, your colleagues, and your coworkers.

There are several ways to do this. As the expert in your little town on medical and surgical problems, you can build a practice by getting out there—on the radio, the Internet, or through community presentations. Nationwide programs like Stop the Bleed are amazing. I don’t know if you’re familiar with it, but you can start with your local EMS and take it to the schools or churches. You can become a local champion. Once you train a few people, they become trainers, and it spreads like wildfire—with your name attached to it.

I get into schools a lot. I go to college days, and we have a program with the Scouts called Medical Explorers. The hospital hosts it over several weeks. One night, we’d set up a laparoscopic trainer with foam organs, and the kids would help each other perform tasks like removing a gallbladder or uterus laparoscopically. They couldn’t see what they were doing but could see the results on the screen.

At the same time, we’d have an intubation head available, and the anesthesiologist would let the kids perform an intubation with the GlideScope so they could see what it looks like. Another night, the orthopedists would come in. Programs like this spread the word that you care about the youth and are involved in the community.

Often, parents come to these events and want to participate, too. You can also organize free screenings in the community. For example, we do skin cancer screenings several times a year.

Dr. Michael D. Sarap: [00:08:46] People are walking around—I know you see the same thing—without insurance and with horrible lesions. We see them, and we can get them into the clinic to take care of these issues. We’ve done vascular screenings and pre-colonoscopy screenings if there’s a need.

There are so many things you can do in the community. You can use social media, local radio, or TV stations, which are always looking to fill time, and you are the local expert. That can really build something. Once you show commitment and meet people, you can join groups like Kiwanis or Rotary and connect with the community. If there’s a need in town, you can even be part of a cooperative effort to address it.

I think these are ways you can adhere yourself to the community, in addition to showing up and taking care of people when they come into the emergency room sick or injured.

Dr. Randy Lehman: [00:09:07] That’s obviously step one—meeting people at their point of need. So, who is your client, if you will? Let me back up a second. What is your practice model like? Are you employed, independent, and has it changed over time?

Dr. Michael D. Sarap: [00:09:26] Interesting time to bring it up. For 37 years, I was part of a three-person private practice. We’ve been our own bosses for that entire time. We had an office right across the street from the hospital, and we only took call at one hospital.

My two younger partners did some locums work on their days off in the next county, taking call and doing elective work. But we’re in one of the most socioeconomically disadvantaged counties in Ohio. In terms of payers, we’re talking 80–85% Medicare and Medicaid. It’s become very difficult to make a living that way.

We were in the process of hiring a new partner, which would bring us to four surgeons—something I was very happy about. This new hire is someone I’ve been mentoring for 18 years, a local woman and a gifted surgeon. I didn’t feel like we could offer her what she needed while also keeping my partners happy. So, as of August, we joined the largest group in Columbus, called OhioHealth.

Our hospital joined their group about a year and a half ago. Now, they own the hospital, and I’m working for “the man,” if you will, for the first time. I’ve never dealt with RVUs before. We used to just work hard and do our own office billing, but now things have changed. Running a private practice in an Appalachian county like ours, where reimbursements are so low and keep decreasing, became impossible.

I care deeply about my employees, but they were struggling with childcare costs and the rising expense of health insurance. Meanwhile, we faced annual reimbursement cuts of around 3%. It all came to a head when we lost a couple of key office staff, including a coder and biller. Several factors aligned, and we decided that becoming employed was the best opportunity for our team’s future.

As part of the deal, we got a brand-new office building and a state-of-the-art Epic EMR system. We were paper-based before—can you imagine? It’s been an interesting few months transitioning to EMR, but I think it’s the best move for my partners. I’m at the end of my career and can tolerate just about anything, but I’ve built a legacy I want to see continue. After 37 years, this is my hometown now.

Dr. Randy Lehman: [00:11:56] Yeah, I can imagine you’ve just put so much into it.

Dr. Randy Lehman: [00:13:19] I think your story is going to be very familiar to some listeners. The interesting part is that I just did the same thing within a four-year span. Are you aware of much about what I did here? I started an independent practice.

Okay. Yeah. So, I think you’re about 10–15 years behind most people in terms of selling to the hospital or someone else because it’s been pushing so hard. And you’re in a very difficult place. That shows, first off, the level of volume you’ve probably been cranking out this whole time just to hang on. And secondly, it shows your willingness and commitment.

What I did was, first off, I took an employee job where I had loan repayment. I was a W-2 employee and everything. My goal was to get my loans paid off, and then I wanted to go independent in my hometown. But the problem was I was about 25 years too late.

Do you know any of the numbers—like what you were being paid per RVU on average in your practice before you joined the hospital?

Dr. Michael D. Sarap: [00:13:19] Not a clue. I mean, I didn’t even know what an RVU was.

Dr. Randy Lehman: [00:13:22] Yeah. So, you tracked things in terms of dollars, I guess—collections and billing—and also volumes, like numbers of cases, how many patients you saw per day, and so on?

Dr. Michael D. Sarap: [00:13:34] Right.

Dr. Randy Lehman: [00:13:34] So, when you were setting up this new contract with the hospital, what pieces of information did you have to gather to ensure you were getting a fair deal for you and your partners?

Dr. Michael D. Sarap: [00:13:51] Well, I knew what we’d made over the last few years, and it’s continued to go down in terms of the salary we were paying ourselves. I also knew what our expenses were. So, number one, I could compare the base salary they offered to what we’d been making. They also offered a productivity bonus and some other incentives.

We run a wound clinic for the hospital, and like many rural surgeons, we have a huge endoscopy volume. I do about 1,200 endoscopies a year. I cover a five-county referral area and have been doing screening colonoscopies for 30 years. I know the volume of procedures I do, so when you start counting colonoscopies, gallbladder surgeries, and hernia repairs, you can estimate the RVUs you generate in a year.

We compared that to the base salary and productivity bonuses they were offering. We had a pretty good idea of what to expect going forward if they accurately captured all of our activity. We’ve done our own billing and coding in-house, so it worries me that someone in Columbus will now be handling my charts and determining the coding and billing.

But I think they’ve offered a very good deal. I believe they negotiated in good faith. We’re the only game in town, and they want to maintain a successful rural hospital in their system. They now have eight rural hospitals, and their strategy seems to be expanding into rural areas as metropolitan covered lives become harder to access. They want to ensure small hospitals like ours succeed, knowing that general surgery is a crucial part of that.

Dr. Randy Lehman: [00:15:46] Yeah, well, it sounds good.

Dr. Michael D. Sarap: [00:15:47] Yeah, I think it’s a good deal. My partners agree, and we can worry less about human resources, hiring and firing staff, and making sure our employees can afford their childcare. Now, we just show up and do our work.

Dr. Randy Lehman: [00:16:06] It’s so hard.

Dr. Randy Lehman: [00:17:18] So basically, what I did was start an independent practice while I was employed—with the permission of my employer. This was in the next county over. I’m like, it’s not a competition here. These are two separate markets. People leaving town aren’t leaving to go to the other small town; they’re heading to the city up and down the interstate.

Anyway, it all worked out. I said, “If anything, it’s going to increase your volumes.” And it did because I took my larger cases there since I was more comfortable. Essentially, I built a $600,000 overhead for a part-time surgeon. I did have a nurse practitioner working for me, but they weren’t part of that overhead. I didn’t pay myself anything for about two years, losing $20,000–$30,000 a month for 18 months to two years. That’s not sustainable.

What I didn’t know is that I was getting paid $57 per RVU on average from insurance. Meanwhile, my employer was paying me more than that with benefits and no cost to produce those numbers.

Dr. Michael D. Sarap: [00:17:18] Right.

Dr. Randy Lehman: [00:17:19] So, no overhead, and I was getting paid through a tiered structure at the time: $75, $85, $90 based on productivity. But I also had a base salary guarantee underneath that. If you calculate it out to reach the bonus, the base guarantee worked out to something like $108. That’s not a lot, but factoring in call pay and the base salary, it was guaranteed income.

The problem was I didn’t even think to call the insurance companies to ask, “How much would I actually get paid for the things I was doing?” I didn’t know where to start. I had an app on my phone that showed me what Medicare would pay, and I almost couldn’t believe it. I thought, “That can’t be true. How could anyone run a practice like this?” But stupid me—I still started the practice.

It was just part of the journey I had to go through. Long story short, I ended up contracting my business to the hospital. Now I’m a 1099 contractor, but I still own the business—that’s the Liberty Clinic you see behind me.

Dr. Michael D. Sarap: [00:18:35] Gotcha.

Dr. Randy Lehman: [00:18:35] In terms of growing the practice, where I was initially going with this is: Who’s your actual client? Who are you really working for? Now, I have this 1099 practice, and I was able to set up a similar model successfully with two other adjacent critical access hospitals.

The way it’s set up, I know I’m only getting paid for showing up. The hospital and I share an interest in being busy. We set it up with a daily rate, so I’m protected for just showing up. But I also have an RVU-calculated daily bonus. If I have a big day, I’m happy, the patients get care, and the hospital is happy. If I have a slow day, I’m still protected.

I don’t like having slow days, though, so I make sure to stay busy. The hospital is incentivized to keep things moving. It’s been working pretty well so far. I added two hospitals this year, so I need more time to see how it works out long term. But I’ve been reflecting on it, and I realized: Who am I really working for?

I tell all my patients that I’m working for them. They are my clients. I have a professional relationship with them. But, realistically, 80% of my patients come from primary care providers.

Dr. Randy Lehman: [00:20:31] And so really, I’m kind of working for them too, because if I’m not taking care of my referring source, then I’ve got no business. I have no practice, basically. Now I’m contracted with the hospitals, and they’re my employer. In a way, they’re my client too.

It’s sort of like you need to think that all three of those things are true and maintain and develop each one of those relationships in different ways. Have you ever thought of it like that?

Dr. Michael D. Sarap: [00:20:31] Well, you wear a lot of hats—we all do. But when we’re in the room with a patient, they’re our focus.

Dr. Randy Lehman: [00:20:37] Right.

Dr. Michael D. Sarap: [00:20:38] That’s the bottom line—we’re there to care for them. And yeah, I joke now that I’m “working for the man.” I never did before, but it comes with a whole lot less worry.

Dr. Randy Lehman: [00:20:51] But even before, it’s like, am I working for Anthem, though? Yeah, I have a contract with Anthem, and I’ll take care of their patients and stuff. But Anthem never really sent many patients my way.

Dr. Michael D. Sarap: [00:21:02] For us, it’s 85% Medicare and Medicaid.

Dr. Randy Lehman: [00:21:04] So, you’re working for the government, basically.

Dr. Michael D. Sarap: [00:21:06] Exactly. You really can’t negotiate with Medicare or Medicaid. What you’re getting paid is fixed. You just get on a treadmill and keep going and going. At some point, the treadmill has to break down.

Dr. Randy Lehman: [00:21:18] Right. Your new partner— is she bringing anything to the practice that you guys are not currently doing?

Dr. Michael D. Sarap: [00:21:24] Absolutely. She’s bringing robotics. My most recent partner before her has been with us for 11 years and was beginning to dabble in robotics but is fully laparoscopically trained. She’s going to fully implement robotic surgery.

We pushed hard for the hospital to bring on the robot. That will help us recruit for OB-GYN in the future and more general surgeons when I need to be replaced, which will be pretty soon. She’s also going to do complex abdominal hernia component separation repair.

I’ve really not embraced that. We do laparoscopic hernias, but we haven’t ventured into component separation. I don’t feel comfortable doing that for my patients after just watching a YouTube video. I’ve embraced lots of new technologies, like ERCPs and other things we’ll talk about today, but only when I feel confident. I want to do the right thing for my patients.

So yes, she’s bringing robotics, complex hernia repair, and other skills she’s picked up along the way. We’re going to teach her a lot of things, too, as we do with every new partner.

Dr. Randy Lehman: [00:22:39] What sorts of things? Are there subspecialty areas outside of general surgery that you’ll teach her?

Dr. Michael D. Sarap: [00:22:45] Well, we have a pretty advanced endoscopic practice. We do ERCP, place esophageal stents, and have a capsule endoscopy system. We perform pH and manometry studies and a lot of foregut surgery.

The other day, I showed her how to read a pill cam. We’re breaking her in on ERCPs—taking baby steps. Mentoring and progressive learning is a good way to learn something. You don’t need to do a year-long fellowship to learn one procedure, especially when you’re already very familiar with flexible endoscopy in other contexts.

She didn’t do much foregut work in training, so we’ll be doing fundoplications and hiatal hernia repairs with her. We also do a little bit of everything, like carpal tunnels and hydroceles. I still do some open inguinal hernias, which she didn’t get much exposure to.

Dr. Michael D. Sarap: [00:23:59] So it’s just kind of day-to-day stuff that they pick up. One of my previous partners had never placed a suprapubic catheter. His first colon resection came up when they couldn’t get a Foley in, and he was just dumbfounded. I showed him how to do it, and it became a learn-on-the-job experience.

Dr. Randy Lehman: [00:23:59] Yeah, I haven’t done a suprapubic catheter either, but it’s good to know. So, how big is the town that you’re in?

Dr. Michael D. Sarap: [00:24:07] The town has 14,040 people in the county. There are eight counties in southeastern Ohio without a healthcare facility. Not all of them come to us, but we’re right in the middle of where I-70 and Route 77 crisscross. It’s actually the largest interstate connector in the country geographically.

People come from a fairly long distance. Some neighboring counties have critical access hospitals but lack surgical coverage on many weekends. Our catchment area probably includes over 120,000 to 150,000 people.

Dr. Randy Lehman: [00:24:47] Do you have OB-GYN services there, then?

Dr. Michael D. Sarap: [00:24:52] Yes, we have two excellent OB-GYNs, and they have locums who cover for them every third weekend. When I first came to town, one of my partners had a busy OB practice, performing C-sections and vaginal deliveries as a general surgeon. They were also doing trauma orthopedic procedures, like hip fractures.

After I joined, we recruited two well-trained OB-GYNs and are now recruiting a third. We’re very blessed in that regard. I don’t have to perform C-sections anymore, but I’ll scrub in to help if something urgent arises. When I arrived, we were doing a ton of hysterectomies, and I still have full privileges for that.

Certainly, I don’t mind handling adnexal issues in the middle of the night. We’ve been with and without urology services over the years. Currently, we have one very busy urologist, but in the past, we’ve handled many of those cases ourselves, including carpal tunnels and hand procedures.

Dr. Randy Lehman: [00:25:52] Yeah, it’s similar here. The beautiful part of what I have going on is that there are four critical access hospitals nearby. Each has its own specialties. For example, one might have three urologists, while another has none.

So, I’ve dealt with phimosis cases and vasectomies, but most of the more complex cases don’t fall to me. I thought I’d manage testicular masses when I was in residency, but I don’t see the volume here. It really depends on the location.

I do have access to urologists within an hour, so for most things, I refer out. However, if I found myself needing to manage a torsion, I probably would. Other than that, my urology work is limited to placing ureteral stents when anticipating a difficult colon resection.

So, I can see why rural surgery is so important to you—you’ve lived it. Why did you choose it in the first place? Was there something special about rural surgery that drew you to it?

Dr. Michael D. Sarap: [00:27:20] I think it was always in me. I came from a small town called Steubenville, down on the river. It’s a middle town. I didn’t want to go to a big city. I wanted to work in a small community. I didn’t know it would end up being a rural farming community like Cambridge.

When I was looking for a place, my parents were still in Steubenville, and I had a brother and sister in Columbus. Cambridge was equidistant, right in the middle of the state. There was also a real need here when I arrived—nobody was doing vascular surgery.

Dr. Michael D. Sarap: [00:29:27] Up until Covid, I performed carotid surgeries, open aortas, and distal bypasses. There was a real need for those services. There was also a need for endoscopy, which filled another significant gap in care.

Many of my patients came from rural areas. I trained in Huntington, West Virginia, at Marshall for my residency, and I found that rural people genuinely appreciate what you do for them. I’ve always had a love for the common person—mechanics, farmers, and others who keep our country running. These are hardworking individuals with real problems who need to get back on their feet and back to work.

There are 60 million people in rural America, and only about 10% of general surgeons are taking care of them. I’ve been in the same rural community for 37 years, so I must have found something I truly enjoy. One of the great things about rural surgery is that you can have a real family life. In a small town, the soccer field, football field, or gym is often just a few blocks from the hospital.

I can take call and still attend my kids’ activities, and now my grandkids’ too. The soccer field is only a mile away, which has been great for my family life. It’s a good balance, not being stuck in the hospital all the time. I love that aspect of it.

Dr. Randy Lehman: [00:29:27] I would echo that. Not to mention, rural hospitals let you land your helicopter on-site, which is a big plus. They don’t let you do that in the city!

Let’s move on to the next section of the show, called "How I Do It." This is my favorite part because I love talking about surgery and could do it all day. You’re going to talk about something I’m equally passionate about—this very niche thing.

I’m a big supporter of laparoscopic common bile duct exploration in the hands of rural surgeons. It’s a great skill in urban settings too, but with ubiquitous ERCP availability in cities, it’s often overlooked. When I trained at Mayo, the question wasn’t, “Can we get the ERCP?” It was, “Can we do the ERCP and keep the patient asleep as we transport them from endoscopy to perform the laparoscopic cholecystectomy at the same time?”

I just wanted to add something about family life. Jack, come here, buddy. Now that I’m in my own private office, things are a little different than when I worked in the hospital. When I was at Mayo Clinic, it wasn’t the same.

In the hospital, I kept books and toys for my kids in my office, which made it easier to spend time with them. At Mayo, that wasn’t possible, and it was more challenging. Jack, you want to say hi? No? Okay, he’s fine.

Dr. Michael D. Sarap: [00:31:05] That’s great.

Dr. Randy Lehman: [00:31:07] One more thing before we dive into laparoscopic common bile duct exploration. When I first started my practice, I mailed out these flyers. This was a big project and probably part of why I lost so much money early on, but it was totally worth it. Let me show you.

Here’s one. It says, “If you need lipoma surgery, varicose surgery, or debridement surgery for wounds…” And here’s the good stuff: hernia surgery.

Dr. Michael D. Sarap: [00:31:37] Yeah, that’s cool.

Dr. Randy Lehman: [00:31:39] If you need surgery, we’ve got you covered. Those flyers were a great way to introduce myself to the community and let people know what I offered.

Dr. Randy Lehman: [00:32:13] If you need hernia surgery in 30 years, call us. But if you have an abdominal bulge today, call my dad. He’s the best.

Dr. Michael D. Sarap: [00:32:13] That’s fantastic.

Dr. Randy Lehman: [00:32:14] For more information, like details about the process, maybe I’ll put a link in the show notes about where I ordered it and everything. If anyone in private practice is interested in doing something like this, I think we produced these for about $1.50 each and mailed out 40,000 of them.

Dr. Michael D. Sarap: [00:32:35] Wow.

Dr. Randy Lehman: [00:32:36] Yeah, I got a lot of initial responses to the mailer, but more importantly, two years later, when primary care doctors send patients over, people often say, “Yeah, I remember getting your mailer.” I only had to do it once, which was nice.

Dr. Michael D. Sarap: [00:32:55] Yeah.

Dr. Randy Lehman: [00:32:55] I haven’t done much with print ads since then. I do have a Facebook page, and I use it to host Facebook Lives, interact, and provide as much free content as possible. I feel like it really helps.

The point of this podcast isn’t about my hometown. It’s about connecting with the national body of rural surgeons. But the live video and interaction model works well in any context. It’s just wonderful. Thanks, guys, for listening. My kids are heading home, so that’s terrific. Love you all.

Dr. Michael D. Sarap: [00:33:28] Thanks for sharing.

Dr. Randy Lehman: [00:33:31] Yeah. Brittany, want to say hi? Come on in. No? Okay, fine. She doesn’t want to. Alright, buddy, you can have it.

Okay, back to laparoscopic common bile duct exploration. First off, what kind of patient would you consider for this procedure?

Dr. Michael D. Sarap: [00:33:57] Well, potentially anyone I’m performing a gallbladder surgery on, especially if they have elevated liver enzymes or if an MRCP has detected defects or sludge in the common bile duct. There are several scenarios where this might be planned.

It only takes two minutes to set up the equipment. My staff is already trained, and we have fluoroscopy in the room since we perform cholangiograms on everyone. I’ve been doing these procedures for 12 years now.

When I trained, we only did open cholecystectomies. I learned laparoscopic cholecystectomy on the job after being hired. During training, we frequently performed open common bile duct surgeries, so it felt second nature. But when laparoscopic cholecystectomy became common, I wondered how we’d handle common duct stones without opening the patient.

At first, I thought we needed to learn ERCP. I was hiring someone from my program and told them they needed to learn ERCP before joining me because I wanted them to teach me. There was a course in Baltimore’s Inner Harbor where they used live animal models, like pigs or dogs, for training.

The course taught ERCP techniques, and I learned to identify the ampulla. After that, I was mentored by my colleague. We began performing ERCPs, but then I realized we might be able to access the common duct laparoscopically. About 12 years ago, I started doing these procedures myself.

We’ve since refined the technique and now have over 150 cases between myself and one of my younger partners who was interested in learning it.

Dr. Michael D. Sarap: [00:37:16] And so we’ve refined it into a pretty straightforward skill. If you don’t do it, you end up shipping people out. Most small towns don’t have ERCP capabilities. This means an extra procedure, higher costs, and longer hospital stays.

I think the most important point for a rural surgeon is that when you send someone out, it feels like you’ve performed an incomplete operation. The community wonders, “This is a simple gallbladder surgery—why do I have to go to the big city?” It’s subtle but significant. If a patient comes to you with a problem, you should be able to address it definitively rather than sending them out for every little issue.

This aspect is almost as important as the financial and cost-saving benefits. I’ve been a strong advocate for this, even as academics push back. Residents are eager for me to convince their faculty to teach them this skill. But their faculty often think it’s too time-consuming or complex, which it isn’t. It’s a straightforward and manageable procedure.

Dr. Randy Lehman: [00:37:16] I remember being in residency in Rochester. We almost never performed cholangiograms, and when we did, it felt like a huge ordeal. Now, I do them routinely. I did one this morning—it added less than 60 seconds to the procedure.

A normal cholangiogram doesn’t take long. The entire gallbladder surgery was probably 25 minutes, with maybe one minute spent doing the cholangiogram. That’s hard to believe for someone who hasn’t lived it, but it’s true.

Dr. Michael D. Sarap: [00:37:53] Agreed. Another issue is when patients develop common duct stones, pancreatitis, or jaundice weeks after their gallbladder surgery. They’ll ask, “Why didn’t you find this during the operation?” It’s embarrassing and can harm your reputation in the community.

It’s not uncommon—about one in nine cases involve common duct stones. If you look for them, you’ll find them, and you’ll be able to address them during the initial procedure.

Dr. Randy Lehman: [00:38:25] That’s why I asked earlier about planning. Who do you go in expecting to do this on, versus cases where it’s unknown? For me, the only thing you didn’t mention was a dilated common bile duct. You mentioned stones or sludge in the bile duct, but sometimes it’s just a finding on an ultrasound or CT scan without an MRCP. A dilated bile duct would be another reason.

Also, how do you approach direct versus indirect bilirubin? Could you explain that at a med student or resident level?

Dr. Michael D. Sarap: [00:39:00] I typically focus on the total bilirubin level. More importantly, I pay attention to the alkaline phosphatase (alk phos). Many patients have fatty liver—common in middle America with obesity rates being what they are—and elevated parenchymal enzymes like AST or ALT are frequently seen.

However, an elevated alk phos is more indicative of an obstructive process. If the alk phos is high, even with an elevated total bilirubin, I discuss the possibility of common duct stones with the patient.

Dr. Randy Lehman: [00:39:30] For any med students or residents listening, here’s what I was taught about direct and indirect bilirubin. Direct bilirubin is conjugated, meaning it’s already been processed by the liver. Indirect bilirubin is unconjugated and represents what hasn’t yet been processed by the liver.

Dr. Randy Lehman: [00:39:00] So if the indirect bilirubin is elevated, it suggests a liver problem, like cirrhosis. If the direct bilirubin is elevated, it usually indicates a post-hepatic issue, such as bile duct obstruction.

I’ve noticed that many people around me don’t request the direct fraction, and I often wonder, “Am I the crazy one, or is everyone else?” But I always request it. An elevated indirect bilirubin, especially if mild, is often indicative of Gilbert syndrome. However, an elevated direct bilirubin is more suggestive of a post-hepatic issue like a bile duct problem.

A typical patient I would plan a laparoscopic common bile duct exploration for would have a dilated bile duct. Normal is less than 6 mm, but this patient might have a bile duct measuring 1.2 cm. Ideally, they’d have a filling defect in the distal bile duct seen on CT, ultrasound, or MRCP. Even if they don’t, if their alk phos is slightly elevated, their direct bilirubin is elevated, or both, I’d consider it. Ideally, they wouldn’t have an elevated lipase, but sometimes these patients present with biliary pancreatitis.

Dr. Randy Lehman: [00:39:30] The presence of gallstones is another suggestive factor, but the type of stones matters. For instance, one large gallstone filling the entire gallbladder won’t lead to choledocholithiasis. However, it might cause issues like Mirizzi syndrome if it compresses the common hepatic duct. On the other hand, small, shot-like stones are more likely to pass into the bile duct.

The cystic duct anatomy is probably the most important factor in determining whether I proceed with laparoscopic common bile duct exploration. If the patient has a short, wide cystic duct, the procedure will likely be straightforward. However, a long, narrow cystic duct reduces the likelihood of choledocholithiasis because it naturally prevents stone passage. In those cases, I may opt for ERCP instead, depending on the situation.

During my training, surgeons emphasized tracking outcomes and choosing cases wisely. They used an 80% success rate as a benchmark for clearing the duct, which they felt indicated sound judgment and good technique. However, at an M&M conference, one of our HPB surgeons pushed back, saying even a 20% success rate would still be valuable. After all, those patients avoided a second procedure, transport, and additional costs.

Since completing training, I’ve performed this procedure about two to three times per year. Over four and a half years, I’ve only had one case where I couldn’t clear the duct, so I feel confident in my approach. The key, I think, is persistence and proper case selection.

Dr. Randy Lehman: [00:44:20] I didn't think I was going to clear it, but I just kept slowly working on it and then eventually did clear it. So, tell me, you're set up for a lap chole. Let’s paint another scenario. Let’s say you did a routine cholangiogram and found an unexpected stone. Walk me through the next step. When you're doing your lap chole, you use three ports, correct?

Dr. Michael D. Sarap: [00:44:20] Yeah.

Dr. Randy Lehman: [00:44:20] Okay, so you've got three ports. Where do you take the gallbladder out? Do you take it out periumbilically?

Dr. Michael D. Sarap: [00:44:27] I do a 10 mm incision at the umbilical area.

Dr. Randy Lehman: [00:44:29] Okay, that’s my setup too. So say you’re set up like that, you find a stone. Then what are your next steps?

Dr. Michael D. Sarap: [00:44:36] I tell them to open the kit. The kit includes an introducer that’s stiff, with a 4 mm external diameter. We use what’s called a T-tube introducer, which has a little trocar on it. We make a poke hole for that and put it in separately. Then I tap it out and look at the angle of the introducer. I want that introducer to come right down to my cystic duct. It needs to be stiff and long enough to reach the cystic duct.

So, that’s step one. We also have a guidewire and a biliary catheter. When I first started doing these, T-tube made an entire kit with an introducer, guidewire, and biliary catheter, but then they discontinued it. Cook makes a nice biliary balloon catheter, but it was back-ordered during COVID. In a pinch, we used angioplasty catheters. They’re 8 mm in diameter and 20 mm long. You can use those, but you’ll need a longer guidewire to pair with them.

Dr. Randy Lehman: [00:45:56] Question about that. So when you say "just go get," do you mean ordering from a supplier, or do you guys actually have angioplasty catheters on hand?

Dr. Michael D. Sarap: [00:46:04] Yeah, we had angioplasty catheters from when we were doing vascular procedures.

Dr. Randy Lehman: [00:46:07] We don’t have those, you know, in our setup.

Dr. Michael D. Sarap: [00:46:11] You can order two or three to have on hand. However, the biliary catheter is better because it’s shorter, and you’re not dealing with an overly long guidewire. It’s just long enough to get across the ampulla. It’s all part of a convenient, single kit—introducer, guidewire, and biliary catheter.

We clip the cystic duct-common duct junction and perform a cystotomy. For cholangiograms, I use a two-mark clamp. I don’t usually open the cystic duct; instead, I clamp the gallbladder-cystic duct junction and poke it with a needle. It’s very quick and easy—no need to thread something into the cystic duct. When we find a stone, we remove the clamp, place a clip above, and open the cystic duct.

The key is having a stiff introducer. You don’t need to grab the guidewire or biliary catheter with a manipulator. Instead, place the introducer right next to the cystotomy site, and you can thread your catheter directly into the cystic duct. Once the catheter tip is in, you can thread your guidewire. With fluoroscopy already in the room—because I do a cholangiogram on every patient—the guidewire is advanced under visualization.

You situate the two marks on the biliary catheter balloon across the ampulla. Then, I inflate the balloon manually with air—no fancy insufflators or saline—just hand-inflation for about 30 seconds.

Dr. Michael D. Sarap: [00:50:12] I pull the balloon back to the cystic duct-common duct junction and remove the guidewire. I then inflate the balloon again and inject dye. This allows me to beautifully fill the distal common duct. If there’s any residual sludge, the inflated balloon helps apply pressure to flush it out.

If the common duct distally is clear, I deflate the balloon and inject more contrast to ensure no stones were flushed proximally. Once confirmed, I remove everything, clip the cystic duct securely, and ensure the closure is adequate. If the clip is good, there’s usually no need for a Jackson-Pratt drain. Early on, we used to place a drain in everyone due to concerns about bile duct leaks, but now we rarely do so, provided the cystic duct closure is secure.

We reviewed 150 cases and found that the median surgery time for a gallbladder with a cholangiogram was 40 minutes. When adding common duct exploration, the median time was 55 to 60 minutes, adding only 10 to 25 minutes. We used the choledochoscope in just one out of every 10 cases. Most of the time, we rely solely on the balloon and guidewire. For large stones or those that resist flushing, we use the choledochoscope to grab and push the stones into the duodenum rather than pulling them back, as the cystic duct can be quite small.

Occasionally, we’ve used lithotripsy for particularly stubborn stones. This involves threading a metal lithotripsy device down the cystic duct to crush the stone from above. Once fragmented, the stone can be flushed out with the balloon. Over time, as you gain experience, you can incorporate advanced techniques and instruments. However, the vast majority of cases are straightforward.

We’ve achieved a 97% cannulation rate of the duct and an 82% success rate in clearing the duct over the first five years. For cases we couldn’t clear, we performed ERCP either immediately or the next day if the endoscopy team was unavailable. Just yesterday, we had a patient with the entire duct filled with sludge and stones well above the cystic duct junction. This wasn’t a good candidate for laparoscopic exploration. We completed the gallbladder removal, brought in the endoscopy team, and performed ERCP with a sphincterotomy to clear the duct.

Overall, we’ve had no cases of pancreatitis. The 8 mm balloon we use minimizes the risk of bleeding or complications, unlike the larger Bakes dilators used in open common duct surgeries. Additionally, since we’re not manipulating the pancreatic duct like in ERCP, the risk of pancreatitis is significantly reduced.

Dr. Randy Lehman: [00:51:18] Sure. When you first started this, though, you didn’t train in laparoscopic common bile duct exploration during residency. Did you take any courses, or do you have any recommendations for someone looking to add this to their practice?

Dr. Michael D. Sarap: [00:51:35] No, there were no courses when I began in 2012. I read about it in some early reports where people were starting to explore this technique. Nowadays, the American College of Surgeons’ Rural Surgery Council offers a skills course annually. It includes sessions on ultrasound and laparoscopic common bile duct exploration with a solid trainer setup.

Dr. Michael D. Sarap: [00:52:00] The folks from Northwestern now have a pretty good trainer that you can use to learn these techniques. They approach it a bit differently than I do, but there are options available. If you attend the Clinical Congress each year, you can take a course on this. There are also countless videos and resources online.

Dr. Randy Lehman: [00:52:15] Right.

Dr. Michael D. Sarap: [00:52:15] We just started on our own. I got a biliary catheter and decided to give it a shot.

Dr. Randy Lehman: [00:52:24] What choledochoscope do you use?

Dr. Michael D. Sarap: [00:52:26] We use the Boston Scientific SpyGlass. We used to have a reusable flexible choledochoscope, but the optics were terrible. It would crack fibers with every use and didn’t work well. The disposable SpyGlass scopes are expensive, so we use them only when needed. However, the optics are phenomenal. You can see the entire duct, including the duodenum. It’s a game-changer.

Dr. Randy Lehman: [00:53:09] When you place the scope, does it go through your introducer?

Dr. Michael D. Sarap: [00:53:13] It doesn’t fit through the Taut introducer. Instead, we use a Cook introducer from their biliary kit, which fits snugly without air leaks. The Cook introducer is slightly larger but works perfectly. If the guidewire is in place, the scope follows it easily.

Dr. Randy Lehman: [00:54:12] How far down do you dissect? When I do a cholangiogram, I use a Taut catheter. I clip, cut, and insert the catheter. How far do you dissect the cystic duct?

Dr. Michael D. Sarap: [00:54:29] Not very far—just enough to identify the cystic duct-common duct junction. The further I stay from the common duct, the better. I only dissect enough to confirm it’s the cystic duct and access it.

Dr. Randy Lehman: [00:54:46] I sometimes have trouble with the valves in the cystic duct. To address that, I dissect further down to straighten it out. Do you ever do that?

Dr. Michael D. Sarap: [00:55:06] Not often. If I encounter issues, I use an open Maryland clamp to stretch the cystic duct at the valve area. This usually resolves the issue. Most of the time, the guidewire works if you’re persistent.

Dr. Randy Lehman: [00:55:29] What else should someone know if they’re looking to add this to their practice?

Dr. Michael D. Sarap: [00:55:35] If they’re a rural surgeon, they’re likely already doing flexible endoscopy. That’s a good foundation to build on.

Dr. Michael D. Sarap: [00:56:00] And so the choledochoscope is no different. It's got the wheels on it, and you have to inflate. It's more like cystoscopy because you use water instead of air. But no, I think there are a lot of good videos out there. You need to know the anatomy, obviously. But if you're already doing cholangiograms—especially if you're opening the cystic duct and inserting a catheter—it’s not a big jump to put a guidewire down there and use the biliary catheter. It’s certainly worth trying. You're not going to hurt anyone by doing it, right?

Dr. Randy Lehman: [00:56:16] Yeah. I think, you know, the bronchoscope and cystoscope, like you said, function the same way. You're basically turning your wrist, using your thumbs to manipulate the scope, and controlling insufflation. I use a 3-liter irrigation bag with pressure.

Dr. Randy Lehman: [00:56:40] Also, with your choledochoscope, you’ll have a second camera setup. Maybe I can share some pictures of my setup, showing how I scope a stone in the duct. The visuals might help. Your team has to be comfortable managing and hooking everything up. But the nice thing about a rural hospital is you have a small team. You don’t have to teach 100 different people—just your core group of techs. Once they know the process, everyone’s on the same page. That continuity is one of the best parts of my practice.

Dr. Michael D. Sarap: [00:57:28] Just to mention, if there’s a significant amount of material above the cystic duct junction in the proximal common duct, that’s not a good candidate to start on. If there’s only one small stone, you can elevate the patient’s head and let gravity help. You can suction with the cholangiogram catheter to try pulling it into the distal duct. But going backward with the choledochoscope to retrieve stones higher up is challenging. Most of the issues are in the distal duct.

Dr. Randy Lehman: [00:58:02] That makes sense. I have two more questions. First, glucagon?

Dr. Michael D. Sarap: [00:58:05] I give glucagon to everyone—one amp before starting a common duct exploration.

Dr. Randy Lehman: [00:58:09] You give it before every gallbladder case?

Dr. Michael D. Sarap: [00:58:12] No, just before the common duct exploration. You can give it while the cholangiogram catheter is in place. Wait three minutes and push to see if you get lucky and flush it out without doing the exploration. When you inflate the balloon and push, glucagon can help facilitate clearance.

Dr. Randy Lehman: [00:58:41] Interesting. I don’t have a huge volume in my small-town practice, but I’ve never had success flushing with glucagon. I’ve had success without glucagon, just using the cholangiogram, but never the other way around. I still try, though. Maybe one of these days it’ll work. Last question—how do you tell the difference between a bubble and a stone?

Dr. Michael D. Sarap: [00:59:16] We’re very particular about who sets up the cholangiogram catheter and syringes. It’s crucial to eliminate air in the system to avoid mistaking bubbles for stones.

Dr. Michael D. Sarap: [00:59:30] You know, it drives us crazy when you do that. But bubbles act differently—they move around. If you suck back on the cholangiogram catheter, they elongate sometimes, or they go away. Alternatively, you can flush with saline to clear the duct and perform another cholangiogram if you're worried it's a bubble.

Dr. Randy Lehman: [00:59:41] Yeah. Bubble maintenance is the most important thing there.

Dr. Michael D. Sarap: [00:59:44] Yeah.

Dr. Randy Lehman: [00:59:45] Great. Well, thank you. This was a wonderful "How I Do It."