John Dunn, who has removed more gallbladders than anyone in New Zealand. His tally stands at 6000.
John Dunn, who has removed more gallbladders than anyone in New Zealand. His tally stands at 6000.
Steve Braunias reports on the controversies surrounding one of the most common surgical operations in New Zealand.
Very likely right now someone somewhere in New Zealand is submitting to an exquisitely precise surgical procedure to remove that curious, meddling organ, the gallbladder. I submitted to it in April. A surgeonfrom Belgium tore it out of my flesh in the manner of pulling, as another quack described it, “on a handkerchief”. It went well. No complications, no damage. There has only been one side-effect. I have become obsessed with the apparent uselessness of the gallbladder, an organ that goes about its business with huge self-importance, but is rarely missed when yanked out and later incinerated, exiting with a puff of bilious smoke.
About 10,000 gallbladder operations are performed each year in New Zealand. It’s one of the most common surgeries. “Welcome to the gallbladderless gang,” emailed Tracey Brake, after I wrote a column in Canvas that asked readers to share their experiences; I was swamped with replies, evidence of just how routine it is to lie back in the lovely sleeplessness of Propofol anaesthesia and yield to a laparoscopic cholecystectomy, the typically oversyllabic medical term for gallbladder surgery. It’s often abbreviated to lap chole, a friendlier nickname which sounds like a nice hot cup of tea, an appropriate image for a simple and straightforward operation that brings comfort to the patient’s stomach.
Lap chole is keyhole surgery, four points of entry, invasive but minimally so. The depth of incision ranges from 5mm to about 12mm. Rods and scopes enter the body. They surround the gallbladder, approach it with stealth and purpose. They film. They cauterise. They also employ – I love this term, which sounds weaponised – a grasper. The gallbladder is attached to the liver; lap chole unattaches it with fire, cauterising it, then holds it in a firm grasp, hooking it like a fish and bringing it to the surface through the umbilicus, ie belly button. Of course there is much more to it including the delicate complications of dividing the cystic duct but Auckland gallbladder surgeon Adam Bartlett provided an excellent precis of lap chole: “Look, cook, and hook.”
It remains the most revolutionary advance in gallbladder surgery in history. It was first performed by a German surgeon Erich Mühe in 1985. Previously, surgeons cut a dirty great 15cm (six inch) incision beneath the ribs on your right side. Mühe’s four little incisive keyholes changed the course of surgical practise and has became the routine procedure throughout the world. It was introduced to New Zealand in 1991 by Auckland surgeon John Dunn, who first saw it performed in South Africa. I spoke with the godfather of New Zealand lap chole, and he said: “It was an epiphany. I realised, ‘Oh. My. God. This is going to change everything.’ It was such an epiphany that I knew I had to go home immediately because here was a huge opportunity to be at the forefront of something quite revolutionary. I intended to stay away longer - I was going to go off to the UK and work there - but I knew I knew I had to get home and make some money.”
He duly made some money. Before we spoke, he sent an email which expressed the same kind of excitement and sense of wonder at his epiphany in South Africa. He wrote: “I was working in Cape Town training in liver surgery when an American surgeon Karl Shuker visited. He had done about 100 laparoscopic cholecystectomies by then. A real pioneer. I got him to show me how to do it in pigs. Eventually I took on a human with my Profs and became the first NZ surgeon to do the procedure at the tender age of 31. This was the first such case in the whole continent of Africa.
“I came home with the technique in 1991 (having ensured the release of Mandela and dismantling of the Berlin Wall) and started doing and teaching. Hugely. Since then I have personally removed more gallbladders than anyone in the history of NZ surgery.”
I asked for the number. He said six thousand. Six thousand! Behold one of the great plumbers of the New Zealand body, forever voyaging into our foul drains to cook and hook the gallbladder, and escort it off the premises. Dunn emailed, “I am a lover of the gallbladder. Not just because it’s paid my mortgage. But also because you can make a very crook patient very well quite quickly by taking it out and dropping it in a bucket. It’s great to get a positive result. Very self affirming.”
This stock photo has nothing to do with gallbladder surgery - but it was previously published in the Herald to illustrate an alarming story about a Waikato surgeon who cut out tissue he thought was a woman's gallbladder before realising he had removed it 13 years earlier. Photo / Thinkstock
I was a very crook patient. One of my correspondents, retired doctor Peter Charlesworth, was right on the money when he emailed, “Attacks of gallbladder pain are triggered, in the classical case, by a preceding fatty or greasy meal.” I had scoffed three steaks in two days. The body threw a fit. Gallbladder disease is essentially the presence of gallstones, little crystals of fat and cholesterol, sometimes quite beautiful and really very wide-ranging in their shape and pattern – a 1769 copperplate illustration of gallstones, held at an anatomical museum in Berlin, is a gorgeous work of art. Gallstones put a cork in the flow of bile from the gallbladder to the liver. The pressure is dreadful, and can present itself as many hours of vomiting, of fever, of intense chest pain. I experienced those many hours as a sign I was about to die of a massive heart attack. I called an ambulance, was taken to Auckland hospital, and promptly diagnosed as suffering from nothing more than acute cholecystitis, ie gallstones. The day of national mourning was averted.
It’s estimated that about 15 per cent of the population will form gallstones; 15 per cent of the afflicted will need keyhole surgery to remove the gallbladder. Patients can choose to take the gallstones home. Corinne Young emailed, “I had to go to the morgue to pick it up which I thought was a bit macabre.” Carol Webb emailed to report that when she woke up from surgery, she was told of her gallbladder’s whereabouts: “That dirty rotten piece of meat is where it belongs.” Her surgeon made a tossing motion towards the waste paper bin in the recovery room.
Good riddance to it. Two surgeons doing the rounds after my operation called in at my ward. They said I would live my life just fine without a gallbladder. I asked them how useless it was, and they replied, “Pretty useless.”
Auckland gallbladder surgeon Adam Bartlett, who lives by the surgical motto: "Look, cook and hook."
The comment inspired a growing dislike for the organ I had carried in my body like a leech for 63 years. The gallbladder puts on an act. It plays the part of a butler, attending to the mansion of the body, poised at a moment’s notice to keep the household running smoothly as it produces bile to help with digestion. The whole thing is a scam. Our mansion - our blood-stained walls and aortal passageways and unspeakable basements - can function perfectly well without this faux Jeeves and its genteel application of bile. The gallbladder is a middle-man. It functions as a warehouse used to store bile. Nothing much happens in its warehouse. The bile sits there, an inert substance, active only when food arrives. The liver can produce bile just as easily. And so the gallbladder is a hanger-on, literally: it hangs onto the liver, sticks to it like a parasite. Junior doctors begin their lap chole training by being taught the simple technique of how to separate the gallbladder from “the liver bed”. It’s another telling image, with its implication that the gallbladder lies around in bed all day, a fat pear-shaped lump asleep on the job. Lap chole provides a rude awakening.
Better out than in; but there was something about the charade and redundancy of the gallbladder that I found worrying.
My concerns were purely existential. Readers shared gallbladder stories that were purely and agonisingly physical. Most emails were from women, which tallies with worldwide studies indicating that that the ratio of gallstones in women to men is nearly 2:1. Pain produced by stones lodged in the cystic duct is thought of as among the most severe a person can experience; when I suffered the attack, known as biliary colic, the only place I could find to lay still without pain was on the grass verge outside my house at 5am while waiting for the ambulance. The healing powers of morning dew.
Miranda Young wrote in her email that she suffered attacks for years, always in the middle of the night. Her gallbladder was eventually removed when she was 21. “My recovery pivoted as quickly as my attacks did: one moment I was almost comatose with pain / fatigue, and the next I was 100%. It was like a switch had been flicked.” She was bedridden for a week.
Amelia Woods wrote, “My laparoscopic surgery went wrong and I was left with a scar from rib to almost hip.” She is describing the dirty great cut from open surgery. Anne Martin stayed in hospital for 10 days after her lap chole: “Apparently there had been a slight mishap during the op resulting in someone being sent to find a pint or so of blood for a refill.”
Surgery “gone wrong”, a “slight mishap”…Lap chole is the gold standard, but there are three other, newer methods, even less invasive, which may or may not be safer, with possibly better outcomes. The emerging field of natural orifice transluminal endoscopic surgery, or Notes, incorporates gallbladder removal. It was first performed on a 24-year-old woman at Columbia University Medical Center. The New York Times reported on it without a flinch. “Doctors in New York have removed a woman’s gallbladder with instruments passed through her vagina.” The Journal of the Society of Laparoscopic and Robotic Surgeons actually has photographs of it.
The prime advantage and appeal of Notes is that it offers no-scar surgery. Nothing pierces the skin. Gynaecologists at Dunedin Hospital achieved a New Zealand first in 2021 when they performed a Notes hysterectomy, describing it operating “from the bottom up”. No one in New Zealand, however, has followed the Columbia University example of employing the vaginal technique to remove a gallbladder. “It’s a bit extreme,” as Auckland surgeon Adam Bartlett put it. He can offer the next best thing at his practice in Epsom: single incision surgery, just one cut, through the umbilicus.
I asked him why patients preferred it to four keyhole incisions. He said: “Well, young females come, and they don’t want any scars.” It’s entirely cosmetic. “You’re not doing it for any gain it takes. The operation takes longer. And so it involves a prolonged anaesthesia, and that’s probably not a great thing to go through. It’s technically more difficult, and it’s awkward. It’s awkward because you’re clashing with the instruments all the time, like chopsticks.”
Chopsticks! He wasn’t exactly selling it. “It’s not ergonomic, that’s for sure,” he said, describing the clash of laparoscope and three instruments (including the fierce grasper) voyaging towards the gallbladder through a single incision.
Gallbladder surgeon Richard Babor at Counties Manukau DHB was downright dismissive of it. “It’s a bit of a gimmick,” he said. “Like, people go, ‘Oh, yeah, it’s cosmetically better,’ but that’s really the only advantage. And it’s actually debatable whether it is cosmetically better, because you end up with a bigger incision in your umbilicus than with laparoscopic cholecystectomy. And there’s more scope for risk. It’s actually not safe. That’s why I’ve stayed away from it.”
I asked him whether single incision lap chole could be considered revolutionary. “It’s not an improvement,” he stated. “Laparoscopic cholecystectomy is kind of hard to improve on, you know what I mean? Single incision is just a different way of doing it. And it sort of sounds sexy and cool, but it’s not really a huge leap forward in terms of gallbladder surgery.”
There is a third new method of gallbladder removal. It kind of sounds “sexy and cool”. More so it sounds terrifying and efficient. Bring on the robots.
The robots are coming for your gallbladder: the da Vinci surgical robotic system hard at work.
There are an estimated six absolutely incredible robots in Auckland medical centres performing minimally invasive laparoscopic surgery. They are all da Vinci Xi robotic surgical systems, priced close to $5m, including the only model in public health, at North Shore Hospital. The da Vinci has four arms. It is remote controlled. It is also, in some ways definitely and in some ways only maybe, the future.
John Dunn remembers the future. He personified it, when he brought lap chole to New Zealand in 1991; it was as revolutionary and frightening here as when Erich Mühe first performed it in 1985, and was ridiculed by his peers in Germany as a “futureless technique,” and “circus surgery”. Dunn, too, faced resistance. “I was under the spotlight,” he said. “Everyone was waiting for me to fuck up.” He didn’t. He changed the way gallbladders are removed. “It’s a very visual technique rather than tactile technique, and you’ve got to adapt your brain for it. And some surgeons just couldn’t do it and it was actually quite traumatic because they were really good surgeons. You know, some of these guys, they were my teachers, my friends, they were mature surgeons in their 50s and 60s. And they just couldn’t do it. They were just all at sea. It was actually terrible to watch.”
That was over 30 years ago. Dunn is now 65. His sentiments towards the brave new world of robotic surgery were a mix of fear and loathing, mostly loathing. His comments may well echo the mature surgeons in their 50s and 60s who failed at lap chole surgery. He said of the da Vinci, “I think it’s absolute bullshit. You can sort of sit in the corner of a room at a console and do this operation with fancy robot arms going onto the abdomen, but it’s just unnecessary.” He had no doubt lap chole is faster, less expensive (“The expense is unconscionable with these robotics”), more efficient. The da Vinci is routinely used to perform urology and prostate cancer surgery. “But to use it for a standard gallbladder operation is absolute bollocks.”
He continued, “It’s one of those things a bit like Big Pharma. You know, these medical supply companies are amoral, and they just want to make money, which I get. But they’re pushing this robotics thing hard and they kind of create a culture whereby if you’re not doing robotics, then you’re going to get left behind.”
His colleague Adam Bartlett wonders whether he’s about to get left behind. He talked about how surgeons are training themselves on the da Vinci by performing gallbladder operations. “It’s caused a lot of heated argument around the country among surgeons. They’re saying, ‘This is not ethical. This should not be happening here. We shouldn’t be practising on people. It’s not right in any way or form.’”
But he seemed more sanguine about it, or resigned. The robotic arms are flexible, and can be used to mimic human hands; lap chole uses instruments as unbending as…chopsticks. He said, “Robotics is the next generation on. We’ve gone from using rigid long sticks to having sticks [the da Vinci hands] which now have greater dexterity. And I think the next generation of surgeons coming through, they’ll laugh at us and say, ‘What? Are you kidding me? Why would you be using this rigid thing?’ I think that’s what’s going to happen. I’m sure of it.”
Listening to his gloomy response conjured up an image of John Dunn’s amazing catch of 6000 gallbladders as relics from another age, fished up with stiff, rudimentary hooks. Perhaps they belong in a museum. I interviewed Sunny Srinivasa, New Zealand’s only gallbladder surgeon (he specialises in the severely oversyllabic field of hepatopancreaticobiliary surgery, or HPB) with formal robotic training. He spoke on the phone at Christchurch airport, about to fly home to Auckland after giving a masterclass at the annual conference of the Scientific Congress of Australasian College of Surgeons. His presentation was niftily titled, “I want a HPB robot.”
His sentences tramped like a T2 terminator over the bones of dear old lap chole. “Robot technology is undoubtedly superior to conventional keyhole surgery.” And: “Technologically, it’s like moving from a Nokia to a smartphone.” He was calling from the future.
The happy face of Sunny Srinivasa, New Zealand's only gallbladder surgeon with robotic training, which qualifies him as a kind of robodoc.
But he somewhat actually underplayed the importance and threat of the robot. He said, “At present, and at least for now, I don’t foresee a role for the robot to be used routinely for gallbladder surgery, which is to say that conventional keyhole surgery offers an excellent result. In all the evidence to date, the robot doesn’t necessarily make anything better.”
He expanded on that point, saying that its real use is for more complex surgery. “So that’s a very important distinction. The best application of robotic technology would not be to ubiquitously use it for the gallbladder, because conventional keyhole surgery is absolutely fine.”
Surgeons with two hands, robots with four hands – either way, they share the same purpose, the same intent to reach out and grab the gallbladder, and consign it to the dustbin of useless organs. “It’s amazing how many bits and pieces you can nip out of someone’s abdomen and they wouldn’t notice,” said Richard Babor at Counties Manukau DHB. “You know, you can take out metres of bowel, you can take out parts of the stomach, you can take out the uterus. There’s all sorts of things that people don’t notice.”
There was a certain kind of ruthlessness in his remarks. It was the same when I spoke with the other three surgeons. They all viewed the gallbladder with derision. They all wanted to cook it and hook it, make it redundant. But was it really so pathetic? Had I got it wrong about the gallbladder operating as a scam? I began to worry that its apparent charade - a hard-working member of staff in the downstairs rooms of the body – was in fact for real. Doubt gave way to forming existential ideas about the gallbladder. We all go about our business as best we can; we all slog away, and like to think of ourselves as performing a useful function, either as employees or as partners, as New Zealanders, as people. But we are constantly told no one is indispensable. The axe can fall at any moment. We live in fear that we serve no purpose, and, worse, that we won’t be missed when we’re gone. The gallbladder is us!
I searched medical literature for something that departed from the standard narrative which regarded the gallbladder as a piece of trash (“That dirty rotten piece of meat”, etc), and treated it with something at least resembling respect. It took a while. Finally, though, I found one ringing endorsement: “It is now recognised that the gallbladder has an indispensable function in regulating bile flow and storing bile that is disrupted by cholecystectomy.”
Indispensable! That was more like it. It was from a peer-reviewed article published in the US National Library of Medicine. It recommended that the gallbladder remain intact. Better, it claimed, to remove the source of acute biliary colic: gallstones. Best of all, it added, to perform a no-scar operation. The technique it favoured was natural orifice transluminal endoscopic surgery, aka our old friend Notes. You really don’t want to know the orifice they have in mind.
I was asked at Auckland Hospital before my operation if I wanted to keep the gallstones. I didn’t care one way or another. What I wish I’d been able to take home was that defamed and maligned organ, that faithful, humble butler, the poor old gallbladder. It worked hard in my body these past 63 years. It was always on hand to shovel bile. Like most patients, I don’t register its absence. But I like to think its ghost returns to visit its old haunts, in the manner that amputees talk of experiencing a phantom limb; right now someone somewhere in New Zealand is possibly experiencing the labours of a phantom gallbladder. The butler has checked out, but never, ever leaves.
