Auckland general and laparoscopic surgeon John Dunn.
OPINION
On Tuesday afternoon I stood around in an operating theatre in Epsom and gazed for about 40 minutes inside the abdominal cavity of a patient having her gall bladder removed. It was an unusual experience.
I have seen worse – I once spent a week in the frozen wastes of Antarctica – but it looked like Hell in there, an inferno, smoke rising in misty vapours caused by pedal-operated jolts of heat at the end of a thin titanium rod that burned away the outer layer of the gall bladder and released it from the liver.
This is what happened to me recently, when I had my gall bladder removed, at Auckland Hospital; my curiosity about the procedure led to John Dunn, New Zealand’s number one gall bladderist, issuing an invitation to witness his practised hand go at it in the flesh.
“So you see the edge of the ribs is about there,” he said. He led a team of six, who watched the operation on a screen above the patient.
Endoscopy Auckland is in Gillies Ave. Silvia Cartwright opened it in 2001. It’s a private hospital that hernias and gall bladders built: Dunn is the pioneer of laparoscopic surgery in New Zealand, bringing the new and radical technique here after first witnessing it performed on a pig in Cape Town in 1991.
Laparascopics is keyhole surgery. There are four points of invasive entry. Startlingly long titanium rods enter the body. Little trickles of blood formed a thin red river over the patient’s stomach. Inside her were cameras, hooked up to a screen. There were other things inside her and to watch them at work was to wonder how anyone could survive. Laparoscopic cholecystectomy – or lap chole, the term for gall bladder surgery – is precise, efficient, and incredibly savage.
“So this is tiger country,” said Dunn. He meant the lower, most vulnerable section of the gall bladder. “So we’re going to stay away from that.”
It’s estimated that about 10,000 gall bladder operations are performed each year in New Zealand. Dunn has personally removed more than 6000. He founded Endoscopy Auckland and is its senior director. There were books on Colin McCahon in the waiting room, and paintings by Nigel Brown and John Pule on the walls.
He is a patron of the Auckland Art Gallery; his hobbies include flying helicopters; his shopping list includes St John’s church in Ponsonby, which he bought and is having restored into something he wants to look exquisite.
A portrait of the abdominal cavity filled the screen above the patient. It was a canvas in blacks and reds, of blood and guts, a brutal arrangement of looming amorphous shapes (the liver) and long straight lines (the titanium rods).
“So I do pretty much the whole operation with this little hook,” he said. The little hook caught the surface of the gall bladder, and sizzled it with a burst of cauterising heat. Smoke filled the screen. “So I’m just putting a current through it.”
His team of six included anaesthetist Ian Campbell, who Dunn has worked with since 1991. The patient was in the beautiful suspended state of Propofol anaesthesia when I was escorted into the operating theatre. Campbell asked me to lean very close over her face, and look inside her mouth. He pointed to an opening in the larynx where he was inserting a tube that breathed for her. “Can you see it?” he said. “I can see it,” I said, looking at a small black hole at the bottom of her throat that gave life.
“So with my left hand, I’m really dragging up quite hard and that makes the tissue easier to divide,” Dunn said. He was burning it off, peeling it off, tearing it off, hacking it off; there were titanium clamps that held down on the gall bladder, and caught it in its teeth; the little red river of blood on the patient’s stomach seemed so small compared to the epic invasiveness that the patient was being subjected to.
I spoke with scrub nurse and team leader Marie Fuller before the operation. She has worked with Dunn since 1995. She gave a basic rundown of what the team of six were about to perform (“Basically we’re shelling the gallbladder,” she said, meaning stripping its skin), and demanded that I drink a glass of water.
That would help, she said, if I suddenly started feeling faint at what I would be seeing. The symptoms, she said, were that my eyes would start seeing stars, I would have hearing loss, and my arms would feel hot and cold. I drank the water, I had a cup of tea and an Arnott’s biscuit. I was fine. So, too, was Grace Binks, the patient.
“Oh, I’m just ticketyboo,” said Grace, 68, when I called her on Wednesday, the day after her operation. I had met her and her husband Len before surgery. She had stayed the night at the Endoscopy hospital and Len drove her back in the morning to their home in Waipu. She was lying on the couch with a hottie on her feet. My phone call had woken her up. She thought she would have a go at the Herald crossword in the afternoon, and rest up.
She felt perfectly fine that I had taken a good long look around one of the cellars of her body – the abdominal cavity – the day before. The action on the screen was magnified. The gall bladder looked a bit like one of the baby aliens in Ridley Scott’s Alien – small, red, slimy and also, kind of thrillingly, alive. It looked like a separate life form unto itself. It clung onto the liver. John Dunn unclung it. “It’s mainly steam from the tissue fluid,” he said, when I asked him about the smoke that climbed out of the gall bladder.
“I knew I had a whopper of a gallstone in there and I wanted to take it out,” said Grace. In part, it was a precaution for the trip she and Len are about to take in September, when they’ll trot around England on a fantastic three-week walking tour. They will hoof around Cornwell, the Cotswolds, and island-hop the Channel Islands. Such are the joys, she said, of retirement. She had worked as a primary school teacher, and Ian ran their dairy farm in Waipu. The last thing they wanted was to be held back by some potential gallstone crisis.
John Dunn continued to scorch and part the visceral peritoneum which covers, or sheathes, the entire gall bladder. Access was partly made possible by extending the stomach. “We are continuously inflating the abdomen with CO2.” It lifted the abdominal wall; it left space, and that space was as black as outer space, a chasm, a void, a dark galaxy. The gall bladder, that clinging alien, was all set to be escorted out of it.
“I was nervous the day we left home, which was last Saturday, to come to Auckland,” said Grace. “But apart from that, I was fairly calm, I think.” It’s a routine, minimally invasive procedure but lap chole is still a full-on assault on the tender furniture of the body.
The hooks, the clamps, the smoke; we are all just flesh and blood, we are all defenceless. Dunn: “This is the artery just slowly coming into view. I’m slowly picking away the tissues around it. Just tidying it up a little bit. And just behind here is the cystic artery, right there, and that’s a branch of the right hepatic artery, and as I’ve told you we’re staying away from what’s down there.” Tiger country.
“One of my sisters had had her gallbladder taken out by John, so we decided to come to him,” said Grace. Grace’s sister later had what she suspected was a side-effect – an allergy to opioids in painkillers, which sent her blood pressure through the roof and her heart racing. “My sister’s been to hospital a couple of times and they thought that she was having a heart attack.”
But one of the beauties of lap chole, which replaced open surgery to remove the gall bladder, is that recovery time is quick, usually without complications. “And now,” said Dr Dunn, “I’m going to take it out through the belly button.”
He started pulling on the rod that was inserted into her umbilicus. “So at this stage, Steve, I will typically make the hole a little bit bigger. This makes it easier to get the thing out. So I’ll just put my finger in there and just stretch it up a bit with my finger inside the abdominal cavity. Just stretching the hole a wee bit. Now we can get it out. Here it is,” said, pulling it out of her body and into the world, a small, red, sticky thing that still looked alive, although only just, “here.”
“Well,” I said to Grace, “it was very nice to meet you, even though it was in strange circumstances.” Grace said, “Super to meet you too.” John Dunn placed the gall bladder in a dish, stabbed it open, and took out the gallstone. Grace was not exaggerating when she described it as a whopper. It was 1.5cm of trouble. It lay in the dish next to a pool of yellow and dark brown bile, which smeared the dish like paint.
Emptied, skinned, a section of it popped into a little jar, the gall bladder looked like an old wet rag, something well and truly expired. “That was quite something,” I said to Dr Dunn, when we relaxed afterwards. I thanked him for the opportunity to watch his disturbing art. And then he asked, “Have you had a colonoscopy?” He had such a flair for small talk. No, I said.
“So,” he replied, “come in, you can have it for free, and you can write about that, too, if you like. Raise awareness.” This was a very generous offer. I felt like I was being asked to donate my body to scientific journalism.
I wondered: what else could I get for free that I might need? Plastic surgery? Dentistry? A lobotomy? I am open to offers. It could mark the start of a whole new adventure. I would never have started the journey, though, without the removal of that small, fragile assistant in the offices of the body, the poor old gall bladder.
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