EPISODE 44

Nasty Gallbladders and Negotiating Contracts | Dr. Seung Gwon (Part 1)

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 The Rural American Surgeon podcast. I'm your host, Dr. Randy Lehman. I have with me today Dr. Sung Guan. Thank you so much for joining us. Dr. Guan, good morning.

Dr. Seung Gwon [00:00:56]: Nice to be here.

Dr. Randy Lehman [00:00:57]: And she is a surgeon with a very interesting story that I first heard on a presentation that you did to SAGES about the urban to rural experience. So let's start just right off with an introduction of you and how you ended up where you are. And we'll ask some questions from there.

Dr. Seung Gwon [00:01:15]: So I grew up in a small town. It wasn't a farming town, but it was a small town. And then I went to UCLA for undergrad and fell in love with the big city. From there, I went to medical school in Chicago, went to the Chicago School, and then I initially matched in general surgery at Loyola University. And then 18 months in, there was some family stuff that happened, so I ended up transferring into a community program in Santa Barbara, California.

And so I fell in love with everything that big city life offered: museums, symphony concerts, coffee shops open all night long. I just fell in love with all of that. So when I originally started looking for a job post-residency, I was looking at areas like San Diego and Los Angeles. A recruiter contacted me and told me there was this great opportunity just east of San Diego. I obviously didn't know my geography well enough, and there's a little town called El Centro, a little over two hours away from San Diego. It's two hours from San Diego, two hours from Palm Springs, about an hour and a half from Yuma.

When I first came out here for my interview, I was thinking, there's no way I can come out here. This is smaller than the town I grew up in. But I really loved the people, and that's what convinced me. Every person I met in this community was so kind, so generous, and so authentic that I was like, well, maybe this is a good place to start. I'll learn how to do surgery. I just came from general surgery. This way I'll keep all my skills up. I signed a contract with the hospital. It was an income guarantee for one year plus a three-year commitment. And, at the end of four years, I just fell in love with my patients. I loved the fact that I got to do surgery without a lot of additional bureaucracy. I like the fact that my OR director talked to me about the types of things that I wanted to bring into the OR. I just love the impact I had on my patients. So, it's been 20 years, and I'm still here, and now I'm the chief medical officer trying to pave the way for other surgeons to come down here and just grow our community.

Dr. Randy Lehman [00:03:16]: Yeah, that's awesome. I heard a Seinfeld clip recently, which I liked, that said, "What happened? That money became everything." He goes, "When I was in the '70s, it wasn't like that. I don't know if this is true." Okay, but he said in the '70s it was, "How cool is your job? And if your job's cooler than mine, then you win." But then somewhere along the way, nobody talked about money or whatever, and then that was how the clip went. But there's this concept I've talked about, the Japanese concept of ikigai. Have you heard of that?

One, it's like a four-circle Venn diagram. And one circle is what you love, like what you're passionate about; two is what the world needs; three is what you can get paid for; and four is what you're good at. If you look it up on Google or something like that, you'll see that in certain places there's overlapping of some circles but not all, and you'll get a certain amount of satisfaction or reward from that. For example, if it's something that you can't get paid for, but you love it and the world needs it, then that's like your passion. But yet, you know, you can't put food on the table. But the thing about surgery is, for me, it is all four of those things. And I think for a lot of surgeons, it can be that. But in terms of your purpose, one of the things when you practice in rural America, it's the impact. Because if you go to the city, you're kind of a number, and they're going to find somebody else to do it if you don't. But that's not always true in rural America. You make such a bigger impact, and you can have more of a personal connection with people, if that's what you desire. And that's sort of what you're describing. So, you're describing the cool factor or an element of the cool factor or an element of the mission factor. I guess the purpose, the impact, all that kind of like rolled up into one, which I really appreciate.

Dr. Seung Gwon [00:05:20]: Absolutely. I realize that the impact I have here and the education I can provide for my patients means so much to me, and I get so much more back from them.

Dr. Randy Lehman [00:05:31]: Yeah. And ironically, in 2025 in the United States, you can actually make more money in rural America too.

Dr. Seung Gwon [00:05:37]: At the same time, now that I'm on the other side and negotiating with the hospital to do contracts, absolutely. Because the need is so great. And so, yeah, there is a financial incentive now that there wasn't previously.

Dr. Randy Lehman [00:05:51]: So I had a couple of questions about the start and then where you're at now with the practice model. So, you talked about an income guarantee per year, then a three-year commitment after that. Were you billing your own, like an independent surgeon at that time? And second question, were there partners?

Dr. Seung Gwon [00:06:09]: Good question. So, by my fifth year of residency, I was really tired of other people telling me what to do. I really was. I sort of had my fill of that. I felt like I had cultivated my own style based on what all my different attendings had taught me. And the problem is you're working with 20 different attendings, and you do something that another attending does well, and then you get criticized for it, right? So, you have to run that careful balance and not offend the person you're working with; it's their surgery, their patient, but you're trying to develop your own style.

So, I was looking at practices where I would be allowed to do what I knew I could do, where I could continue to grow, and I could do the surgeries I wanted. And as I was interviewing, I realized that a lot of the larger practices I was looking at, I would basically be coming in like an intern again. So, low man on the totem pole, take a lot of call. They tell you what surgeries you get to do. The partners at the top don't take call, and they take all the big fun cases.

So, when the recruiter reached out to me and I came here, one of the things I really appreciated was the hospital told me, "We can set you up. You can come work for the hospital, or we can set you up as a solo independent practitioner." What an income guarantee is, is that first year, they guarantee whatever your income is going to be. So, we talked about it, we figured out what a fair amount would be, and then every month you give them your receipts. So, you're doing your own billing. I had to hire a biller. And then whatever number you didn't make up to, they give you the difference. And so it gives you freedom because you know that every month you're going to have a guaranteed amount coming in.

So I bought ultrasounds, and I bought a lot of equipment that I would have otherwise had difficulty trying to finance right off the bat. But because I knew I had the money, I could. And then you don't have to pay any of the money back. So the income guarantee is your money, no payback. What I didn't know over the next three years, what they do is they take the money that they gave you, they divide it by three, and then they give you a 1099 for that for the next three years.

The one thing I didn't appreciate was that there's an increased tax liability because now I'm making my income, plus I've got an additional, you know, 30%. Despite all that, it was really nice because it gave me the confidence and the financial backing to basically start my own practice, get space decorated the way I want to, buy my exam tables, hire the people I needed, and then I've been a solo practitioner ever since.

Dr. Randy Lehman [00:08:37]: That was solo. But there were other surgeons at the hospital at the time or no?

Dr. Seung Gwon [00:08:40]: There were three other general surgeons at the hospital. So I was number four, and then one retired right after I got here. Then the second one left town and moved north, and it was just the two of us with lots of locums, and then it was all locums. And then now we actually have two others. So there's three of us providing full-time general surgery.

Dr. Randy Lehman [00:09:01]: Okay, but you're still solo in terms of your practice model?

Dr. Seung Gwon [00:09:04]: I am. There's a little bit of a difference. Now, the other two general surgeons didn't want income guarantees from the hospital. They were both mid-career, changing locations, and so we now share our office space and we share the staff, but we are independent. We sort of provide a loose cross coverage, but everyone bills out their own, does it their own way, has their own favorites. But we decrease our overhead by sharing office space and staff.

Dr. Randy Lehman [00:09:34]: Sure. So did you need to take out a loan to start your practice?

Dr. Seung Gwon [00:09:37]: I didn't, because of the hospital income guarantee, and that was...

Dr. Randy Lehman [00:09:40]: Did they give you a sign-on bonus too? I'm thinking that first month you have to have your biller, you know?

Dr. Seung Gwon [00:09:45]: Yeah, yeah. So I got a lot of people.

Dr. Randy Lehman [00:09:46]: Come out of residency, have no cash, but sometimes they do.

Dr. Seung Gwon [00:09:49]: So I had a sign-on bonus, I had a relocation bonus, and I got them to give me a loan forgiveness stipend for the first month.

Dr. Randy Lehman [00:09:59]: Got it. Okay. Is that what you would recommend to residents now, to do what you're doing? What would be the variables that would say whether it's a good idea or not?

Dr. Seung Gwon [00:10:10]: I guess the reason I wouldn't is because, number one, you're by yourself, and we already know that rural surgery can be a lonely profession. What I didn't anticipate was that you don't have an easy mentorship ability, someone you can call into regularly, someone you can lean on. Luckily, I had a lot of friends from my residencies, and so I was constantly on the phone with them. Hey, what do you think about this? What do you think about that? Discussing cases. It is a difficult model, I think, though. If you don't necessarily care about that, meaning you have a good network, it's a nice model in that it's so hard to start up a private practice. They're disappearing, all private practices. That's what happened to the two mid-career people. Their practices, their hospitals, their call panels all got eaten up by bigger groups, and they were getting squeezed out. Then I was like, hey, you can still do what you want down here. I don't know how many fresh grads want to do it the way we did. The option's still out there, but it's hard.

Dr. Randy Lehman [00:11:14]: Yeah. Did the hospital pay you to take call ever?

Dr. Seung Gwon [00:11:17]: Yes, 100%. I just found out yesterday for the first time in California that in LA, there's so many people wanting to take call that the hospitals make it a mandatory call requirement to have privileges, so they don't get paid. My jaw dropped. Not only is there a call stipend, but we've managed to successfully negotiate increases every, like, five years in order to help encourage doctors to want to come here.

Dr. Randy Lehman [00:11:42]: What's a reasonable stipend for general surgery call for a 24-hour block?

Dr. Seung Gwon [00:11:49]: It really depends on where you are. I've heard everything as low as 500, which I think is way too low, to a high of 2500 for a 24-hour period. We sit there right in the middle.

Dr. Randy Lehman [00:12:02]: And then that still includes when you're doing that call, then if you're doing a case, you're still billing for that case.

Dr. Seung Gwon [00:12:09]: We are, but probably 20% of my patients are uninsured, and so that's just free care. The other 80% have either Medicare, Medi-Cal, or some insurance, and then we get to bill out on top of it.

Dr. Randy Lehman [00:12:25]: I have a lot of listeners that are. First off, I like to talk to one listener at a time because that's how people listen. They have their earbuds in right now, or they're in their car or whatever, and it's one person. The podcast is a really cool, very intimate thing because it's literally that listener and us right now. But that said, if you look at the block of listeners in total, a lot of them are residents. So I try to speak to the practicing surgeon, which is myself, which is the true audience, and also to them. I could share a little bit about what I've done and get your feedback, solicit your feedback, a little bit on the practice model bit, and then we can just move on from this and talk about the other things we want to talk about. I now have done three models that are like the main three, and I've already done them in five years. The first thing I did is I took a W2 job. The reason I did that is I had student loans, and I knew that I could get student loan repayment. The reason I took the job I did at the place where I was was it's geographically close to where I wanted to be, though not exactly where I wanted to be. There were two other surgeons that I thought could provide mentorship. I thought that was very important. That ended up being a little different than I was prepared for. I guess I was pretty well prepared, and there were things that I just bringing that, you know, it wasn't. From day one, my first week, I did a laparoscopic intracorporeal anastomosis for bowel resection for small bowel obstruction. Then I find out later that's the first time that's ever happened, and I was able to complete it.

Dr. Randy Lehman [00:14:28]: So if you're a resident, just focus on your training. Just give up your time. That's the time to do it. Get all the cases under your belt with as much autonomy as you can. Build your book of numbers in your cell phone as much as you possibly can. That is what I didn't appreciate as much, but it's okay because I pretty much still did it. Then what happened is my goal was to go back to my hometown, which is the next county over, and start an independent practice. To me, it's like independent practice. What you just described, brick and mortar, you know, have my office decorated the way I wanted, hire the staff, the culture, the way that I wanted, build the way I wanted to all that. What I didn't realize was the cost of overhead and how much you would actually collect.

And so, when I was, so then what happened is I, I got privileges at my hometown hospital because it took so long to get privileges at the first place. I was like, maybe I should just start getting privileged. I didn't know anything, right? Then after that happened, this surgeon that was there had a stroke. And so, he was doing all this wound care in the hospital. I had a good relationship with him. I told him, eventually, I'm going to be here. This is my goal.

Then they asked, well, could you come and handle this wound care right now while the other surgeon's recovering or whatever. And so, I did. And then with the hospital's permission that I was employed at, I started an independent practice over there. Well, then a building fell in my lap. I bought a building, I hired a nurse practitioner, I hired some staff. All the things that you need, the electronic medical record, malpractice. And what I ended up with was a part-time practice with full-time overhead.

I wasn't very good at running the business, I don't think, but my overhead ended up being like 600 grand a year, and my income ended up being like 300 or 350. That's with my nurse practitioner and me both.

Speaker B: Sure.

Speaker A: And so, I was underwater like 20 to 30 thousand dollars a month, and I was subsidizing it out of my W2 job, plus some real estate deals that I had done. I blew a lot of money over about a period. I was full bore on that for about 18 months, and I probably blew like 300, 350 thousand dollars doing that. I lost more money doing that experience than my whole medical school cost. You know, it's just bonkers.

Basically, it wasn't going to work for me. And I did the numbers. Like, what if I quit my job and I came here? Then I said, okay, I'll probably make like 125 thousand dollars a year, probably, but not guaranteed because of my increased volume.

And then there were also limitations at that hospital too. Like we didn't have 24/7 calls, so I couldn't just walk out and do colons and some of the bigger cases, hiatal hernias, you know. And I did have, in that period of time, because they didn't have those services there. I did have some of my patients that were going over. So it was helping me on my BONUS at my W2 job, you know, so maybe not quite as bad as I say it is, but it was still pretty bad and totally not sustainable.

So I had to do something, and I was prepared to just shut all that down, go back and lick my wounds, and start again. But what I was able to do is contract the business to the hospital. And so then I became a 1099 contractor for them, and I turned it to a deal where I get paid daily, a daily guarantee, and then I get a productivity incentive that's calculated daily. So if I have a monster day, then I get paid more over a certain number of RVUs.

But I use their clinic that's in the hospital, their nurses, their computer system. At first, I billed still, but then eventually, they took over the billing, and so the only cost to me is my malpractice. And then they just pay me for the work that I did. It's all on a daily and RVU basis.

After I did that, I had two other doctors reach out to me from two other surrounding counties with little critical access hospitals. They both said, hey, we know you're passionate about rural surgery. Would you be willing, we have like nothing going in our hospital, would you be willing to come over here? So I said, yes, I will. But they had in mind that I was going to do it the initial way, you know, the old-school way. And I said, the only way I'm going to come is if I can work out some deal like this with the hospital.

I called both hospitals, and they were very interested and set it up immediately. And so, now I have this contracting deal. Actually, yesterday was my last day at my W2 job, and I converted that to the same contract because it didn't feel right anymore.

That's why, that's the main reason is because I was saying like technically my contract said I was a full-time employee. And I had backed it off a little bit, but I needed to back it off further and say like, because really I'm on, I am covering call there every third week for a week at a time still. But now I'm going to be paid just daily per diem for call. We have worked out the rate for weekends and holidays is a little higher, makes you feel a little better about that. Then you get, you know, basically, the days that I do come in scheduled surgery or scheduled clinic, and I'm also bringing my nurse practitioner over there, we get a daily rate and then productivity incentive. Then if I come in on call, then I'll just get paid for the work that I do on call as well.

So that's kind of my experience. And that's only in five years and one month that I've had all that experience.

Speaker B: You've literally done everything. That's the craziest story I've ever heard. It's interesting. There's a statistic that says that 50% of physicians change their first job within two to five years. I don't know what the statistics are for changing your job like that.

Speaker A: Well, I mean, technically, I'm still doing the job that I started, and I'm happy to do it. But I found something that. And people's brains are different, too, because when I was working at, when I was a resident at Mayo, you know, they're all on salary, and they. The thing is, they all know their numbers. They know their productivity numbers, and if they don't hit their numbers, then they're going to have problems.

But they all say, oh, we're not incentivized to do more surgery on somebody or unnecessary surgery on somebody or something like that, because we're not paid on a per, like, per widget basis. But I don't have any pressure to do unnecessary surgery. And I say no to surgery all the time. I just think that you can be in my model and think the other model's bad. You can be in that model and think the other model is bad.

For the most part, I don't think people are doing unnecessary surgery. I think most surgeons are very well trained, and they're making good decisions. They have good judgment, like the vast majority of us. But for me to be motivated to come to work, I think it motivates me more if I have, like, okay, I know I'm getting paid for this day, show up. I'm going to trade my time for money for this day. The salary thing, I would be motivated to try to do as little as possible, I think. I don't know.

Speaker B: It's interesting. We have all four models available in my community now. So when I first got here 20 years ago, it was all about the income guarantee. Now that you can get a W2 from the hospital, you can get a salary with a productivity bonus, and then you can get an RVU base with a productivity bonus. And everyone has a separate call contract.

It's sort of interesting now that you can. And they're literally all four models. So you're right. When you look at the mindset of the person who's on salary, it doesn't matter what they do, versus the person who's on RVU versus a person who's like me, I was like, this is my practice, and I take call, and I'll do one on call. But I think the residents need to know that, number one, you have a lot of flexibility, and you have a lot of negotiating power. You really do. You can design it the way you want to, to a certain extent, depending upon how much the hospital needs. And I always tell everyone, just ask for it because they can say no, but they can also say yes.

I had no idea you could ask for a relocation bonus, a sign-on bonus, income forgiveness, or loan forgiveness. The first year, I knew about the public loan, the physician loan forgiveness program, but I didn't want a W2. So I was like, all right, even though I'm going to a rural community, I'm just going to let that part go. As I watch my colleagues after 10 years get their loans forgiven, I'm like, maybe I made the wrong call on that one.

Dr. Randy Lehman [00:22:59]: Yeah, and probably so. Ask people that are in your network, your circle. And I've thought about kicking around, maybe this is when I started, but having a little contract review business, you know. But the thing is, I'm not an attorney, but mostly it's like just a consult for, you know, what do you think about this type of thing? I can't do that for everybody, so it would have to be like, you know, a fee or something. But I don't know. Mainly, people that are your mentors, go to them and talk to them.

The other thing that I did that I’m glad I did is, I'm actually sitting in Campbellsville, Kentucky, right now at my mentor's cabin. He tried to recruit me to come down here. I thought very seriously about it. I came down, looked at the interview, saw the contract, and they gave me a contract to interview. Then I thought, well, maybe I just don't take the first job that I'm offered, you know.

So I called Merritt Hawkins, which is a physician rec company, and there's lots of other ones too. I got floated a job that was in Missouri, near my aunt, where she had moved down there. So I was like, well, maybe I should do this. Then we had our baby. I googled my hometown, zoomed out, and googled hospitals. I called the five closest hospitals, and what I found was the two that were independent offered me a job right on the spot. The three that were part of a chain said to call them back when I was done with residency. But then, at that point, I had two other contracts in hand, and then these two places gave me offers, so I could kind of see what is normal.

Basically, the place that I signed with put all of it together: the sign-on bonus, the loan repayment, the relocation, the salary, the incentives—all that. And gave me the best sort of package, which I signed four years in advance. So to some degree, it was fair when I signed it. By the time I got there, it was four years late. But that's okay. I mean, it's whatever. But I had a question for you: Who covers your patients when you're on vacation?

Dr. Seung Gwon [00:25:00]: Good question. So the way the community I live in has always set it up is that whoever is on call for the hospital in the emergency room will also do the favor of cross-covering your patients if you have to be out of town. Luckily, I have a good relationship with the other general surgeons, and we have a mutual understanding and partnership in that way. For example, for the next two weeks, I'm on call because both of the other surgeons are on vacation. If something comes in, they'll come to my office, my clinic, and I'll take care of it if it's an emergency. If their patients come to the emergency room, I'll take care of them and then let them know what happened.

We have a really good relationship with that, which is one of the important things. You have to get along with everybody else in your community that's covering call if you're going to be a solo practitioner.

Dr. Randy Lehman [00:25:52]: Do you ever scrub together?

Dr. Seung Gwon [00:25:54]: Absolutely. In the beginning, I didn't do it as much. Now, I do it much more often. At first, you're afraid to bring people into your OR because you don't want it to look like you don't know what you're doing, or you don't want someone to try to take the case away from you. That was my mentality. I think now all of us are seasoned enough where we'll just go in and out of our ORs. We're on the same day and say, hey, do you need help? What's going on? It's made it much less lonely. The first few years out here, I was very lonely. Then I was like, okay. I recruited one of my best friends to come out here, and now there's, you know, I was the first female general surgeon in my community. Now there are six of us, and it's cool.

Dr. Randy Lehman [00:26:35]: Six?

Dr. Seung Gwon [00:26:36]: Yeah. There are two hospitals. So there are three at one hospital and three at the other. And I'm the only one that goes to both.

Dr. Randy Lehman [00:26:42]: Okay, that's cool to me. I like to have, you know, some people say, well, we'd rather be at one place if there's benefits to that. But I'm in more than one hospital, too. There are just different reasons why that's a good thing. Basically, you have different options at different places, different resources, and things like that. And in your case, different surgeons to collaborate with and talk to.

I think we've talked about why rural surgery is special to you. Let's move on to the next segment of our show, which is "How I Do It." We are going to talk today about acute care surgery—acute care abdominal surgery—and we're going to start with the gallbladder and see where it takes us. What's your approach? I've got a crazy story about an acute gallbladder too, but what's your approach to the acute gallbladder? We'll start there.

Dr. Seung Gwon [00:27:31]: Okay. So where I trained, people were really thin and really healthy, so I really never saw a true acute gallbladder. You had acute cholecystitis, a little bit of edema, no big deal. Still got that Robin's blue egg. Then I came to a rural community where patients don't see their doctors. The diet is really high in fried food, tons of diabetes, tons of smokers, obesity. These are now the gallbladders I'm seeing. It was really a shock that first year. I thought maybe I wasn't as well-trained as I thought I was.

Dr. Seung Gwon [00:28:01]: These patients are presenting in a way I've never seen in training, based on where I lived. It definitely cultivated a lot. So when the patient comes in for gallbladders in general, a lot of people come in just for biliary colic. My rule of thumb is if the white count's normal, the liver function tests are normal, and there's nothing that looks out of place on imaging, they go home the first time.

But what I've learned, because now I know that the patients down here have actually pretty good pain tolerances, they don't come the first time they have it. They come the first time it's really bad. So they all get one time that they. I'll send them home the second time that they come in where it's documented, they came in, I'll pretty much take them to the operating room. Most of the time that by the second time, they've got a white count or something else going on.

Dr. Seung Gwon [00:28:32]: Every time I take them in, the second time you go in and it's just, it's a nightmare. You've got elemental matting, you've got this thickened gallbladder that looks like hydrops, you've got inflammation. You can't see that cystic triangle very well. Those are the types of gallbladders. I tell people all the time, if you want a fellowship on how to do a really tough gallbladder, come down here for like two months. We'll get you trained up and get you back home, and you can do them all.

Dr. Seung Gwon [00:29:02]: Part of it is understanding that because the patients down here don't go to the doctors and because they actually deal with their pain at home a lot, by the time they present, they pretty much all have acute on chronic cholecystitis with these really bad, nasty gallbladders. Once we get them in the emergency room, we get them consented, bring them to the operating room.

So the things that I do, probably a lot of other people do. I've sort of modeled it after things that other doctors do and also things that work for me. So, for example, when we first come to the operating room, the first thing I do is tell the staff, after prep and drape, to throw the CO2 tubing off. The reason why is after I gain access and put in my Veress needle, they now have five minutes that it's going to take for the pneumoperitoneum to get everything else done so they don't have to feel rushed. Because a lot of times when you come in at nighttime, everyone's rushing. They're trying to get things done.

And I'm like, everyone, pause, throw off the tubing. Now you've got all this time to set up your back table. And they do. It just sort of takes down the panic. So the way I start is I always start with either an infraumbilical or a supraumbilical incision based on how much torso I have. I put a Kocher clamp on the umbilical stalk, and then I go in with the Veress needle. I always listen for the two pops. The first pop when you go through the fascia, the second pop when you go through the peritoneum. I don't do a drop test. I put the CO2 tubing on, and I look to see where the level started and whether it dropped right away. Then I know that I'm in the space that I need to be.

If something doesn't feel right, I'll redirect. And if I really feel like there's something that doesn't feel right, I'll go up to Palmer's Point, because I feel like that's the safest place to go into the belly. Once I'm in, I always go in with an OptiView, so I have my camera and my trocar, so I can see the layers dissecting through. It's always blunt for me. I don't like using the bladed trocars. Then you see the tissue layers from the fat to the fascia to the muscle to the pre-peritoneal fat and the peritoneum, and you can see all the layers go through so that even if you have adhesions underneath, you know what the layers are before you go in.

And so that's how I typically enter. I know some people do the Hasson. I know some people just do the OptiView without the insufflation, the Veress needle. I think I tell everyone to do what you're trained to do and what you're comfortable doing because the literature shows it doesn't matter how you enter. Our incidence of injury from putting in that first camera is pretty equal across all boards.

Speaker A: I have a couple of questions about your entry. So, number one, tell me about the numbers that you expect to see when you first place your Veress. And then when do you take the Veress out? Like, do you reach a certain pressure or a certain volume or what?

Speaker B: So normally when I enter, I expect the pressure to be anywhere between like 8 and 10, because there's no gas, and you're right up against, you know, the other omentum, et cetera. Within, like, seconds, I expect that pressure to drop to two or three and then come back up again. And so if I go in and the pressure is at 12, I'm like, oh, there's something. I'm too close to something, or maybe it's too deep. If I go in and I don't see that pressure drop as I'm getting my pneumo, then I know I'm probably underneath the omentum or someplace where I don't want to put in a lot of gas. I insufflate up to 15 before I take out the Veress needle just because I like their belly nice and big to ensure that when I'm putting in the camera, even though it's a blunt trocar, I'm not going to be unduly pushing into something or twisting into something that I don't want to be twisting into.

Speaker A: And then when you come in with your optical entry, is it a zero camera?

Speaker B: Yes.

Speaker A: Do you switch to a 30 after that?

Speaker B: Only if it's a tough case. And the reason why is I trained using a 30 in residency. But what I realized is, when it's just me and a scrub tech in the middle of the night, having them try to handle the degree and me constantly having to stop and push the camera to the angle I want, it got to be frustrating. So unless it's like all matted up and I really need the additional angulation, I've actually trained myself now to use a zero. I probably pull the 30 scope maybe like a couple of times a year.

Speaker A: Okay, and do you have gas plugged in on that OptiView trocar as you're pushing it in?

Speaker B: No, no. Once I insufflate to 15, I shut off the gas and then I go in and then I hook it up once I've seen and I know I'm inside.

Speaker A: Okay, and what if they've had prior surgery at the umbilicus?

Speaker B: Then I'll go up into Palmer's Point and left of the quadrant. And it depends.

Speaker A: What if the prior surgery was just a tubal?

Speaker B: Oh, so if they have previous laparoscopic surgery, even knowing that there could be some adhesions, I might go supraumbilical versus infraumbilical, depending upon where it is. So I might go around the umbilicus for the initial entry. If they've had like an exploratory laparotomy or something with a big incision in the midline, and I have no idea what their syndrome will look like, then I'm going to go up at Palmer's Point. If they've had a laparoscopic surgery, I still feel pretty safe going in through the umbilicus because I know that if there's a wall of omentum.

What sometimes I might do, what I try to do anyway, is I try not to put holes in the midline when I'm doing laparoscopic surgery because I don't want them to develop a hernia. And we know that that's the weakest point. So normally when I'm going in, I go off to the left or go superior anyway, so I'm actually going through the muscle, and I find then if there's any adhesions to that trocar site or whatever, the umbilicus, I'm normally up in front of it or to the side of it.

Speaker A: Okay, and I'm sure we'll talk about this, but where's the gallbladder come out for you?

Speaker B: For me, when I'm doing it straight lap, I have an epigastric trocar, and that's my large 1.2 cm one. If they're really morbidly obese with a BMI greater than 40 with a chronic bad gallbladder, then I'll actually do it robotically. And then again, I take the gallbladder out off of midline. I try really hard not to make the midline my big incision that I have to close.

Speaker A: So your epigastric port, is that in the midline or just off?

Speaker B: Midline is slightly to the right of midline.

Speaker A: To the right midline. Okay. Okay, that sounds good. Let's. I think I'm out of questions. Let's carry on a little bit.

Speaker B: So then I put in the rest of my trocars. If I'm doing a straight lap, then I have my epigastric port to the right of midline. That way I also miss the falciform ligament. So it's a little bit on top of the liver. Then I have two on the right lateral aspect, right mid and right lateral. Then I put the patient in position. They're going to be in reverse Trendelenburg position with the right side rotated up. And then learning how to put all my instruments in when I'm operating by myself and not relying on a scrub tech who may or may not have ever seen the surgery before in the middle of the night.

So there's an instrument called the Iron Intern. And so we have that. And that's really, really helpful because it's a single bar that you hook up to your table, and then it's just an arm that clamps. And so if I put my trocar, excuse me, my instrument in to grab the dome of the gallbladder, I can then clamp it with this and it doesn't move. If I want to move it, I've got to release it. So that's really helpful.

If for some reason I've got back-to-back gallbladders in the middle of the night, which happens, we only have one of those, then what I'll do is I'll take two towel clamps and I'll clamp the first, the clamp that I have on the gallbladder to the drape, and then I'll clamp the second one so that it doesn't pull back. And so then that will hold it.

Then that also frees up my scrub tech to do teching versus having to hold this gallbladder with one hand and trying to hold the camera and then not be able to pass off an instrument. The other thing that I do is we have these drapes that have pockets in them, and I put them near the head of the bed and then I put all my instruments, my laparoscopic instruments, in this drape so that no one has to pass them off. I can just grab it from them.

When we run out of drapes because someone forgot to reorder them, I take the mayo stand and I put it directly across from me just to free up my scrub tech. This way, for things like changing out from cautery to scissors to clip applier, etc., I don't have to have them do that part. They're holding the camera and doing the other things, and I can just grab it for myself.

So I try to make it where they don't have to get so caught up in doing something for me that if I ask them to do something else now, I've got to stop, hold, grab, and change. It really makes it an efficient operation for me.

Dr. Randy Lehman [00:37:07]: So one of the first things, since we're in that stage of the operation, when, if ever, do you decompress the gallbladder and how?

Dr. Seung Gwon [00:37:17]: So if they have hydrops, if they have an intrahepatic gallbladder with hydrops, and I just, I can't grab the gallbladder. The wall's too thick; it's too distended. I'll take a long laparoscopic needle, it's like 13 inches, 14 inches long. I hook it up to a 50cc syringe and then I will put it through one of my trocars. I will put it into the dome. That way I can grab it right afterwards, and then I'll aspirate enough so I can grab the gallbladder at that point.

Dr. Randy Lehman [00:37:45]: Perfect. And if you didn't have to do that, or even if you did, then I assume the next instrument you bring in is through that lateral trocar. And it's a fundus grasper.

Dr. Seung Gwon [00:37:53]: Yes.

Dr. Randy Lehman [00:37:54]: And it locks.

Dr. Seung Gwon [00:37:55]: Yes.

Dr. Randy Lehman [00:37:56]: Tell me more about that instrument.

Dr. Seung Gwon [00:38:01]: So I have my favorite instrument I actually use to grab the fundus. I don't know what it's actually called, but the label on the handles says Prestige. So I've called it a Prestige grasper since residency. I actually probably, and I think surgeons in general, sometimes we don't always know the name of something, we just know how to use it. It's a locking grasper, and it doesn't have teeth. I only use teeth if I've already made the hole, then I'll use teeth. But I don't want to create a hole using teeth.

So typically, I try to use non-toothed graspers. I put that on, and then I try to get the gallbladder above the liver and retract it superiorly so I can see my cystic structures. I feel like adequate retraction saves us a lot of not seeing the anatomy clearly. When I've got someone new that's starting and they're coming in and watching my cases, I tell them, you want to put enough retraction so you can see it, but you don't want to put so much that you thin it out and can't see it.

So I tend not to put it in one spot and leave it. But I retract it, do my dissection, retract it more, do my dissection, make sure that I know exactly where I am. Because sometimes with these nasty middle-of-the-night gallbladders, it's really easy to lose your anatomy because it's all stuck together and swollen.

Dr. Randy Lehman [00:39:21]: Yeah. All right. And there's an instrument where you push the end and three prongs come out. They can grab onto something. Have you ever used it?

Dr. Seung Gwon [00:39:29]: I haven't used it, but I've seen it.

Dr. Randy Lehman [00:39:32]: Okay. I mention that just to say there's more than one way to skin a gallbladder. Yes. But anyway, I do know people...

Dr. Seung Gwon [00:39:40]: Who use that, especially people who do robotic surgery and only want to use three arms. They have their assistant put that part in, and I've seen it. But then you spill bile, right? So, yeah, I've seen it. I just haven't used it before.

Dr. Randy Lehman [00:39:57]: There's also a device called the needlescopic, and then you can just poke it through for retraction. It makes your incision and fold just a little bit smaller. We have that in my hospital, but I've never used it. I just put the extra 5 mm...

Dr. Seung Gwon [00:40:12]: One of the surgeons in town, there's something called the alligator mini alligator grasper. It's a disposable instrument. It's not even a 3 millimeter, and you don't have to even put it through a trocar. He uses that, so he makes a little tiny, like, I want to say 2 to 3 millimeter incision and then just pokes it through the tissue and then pulls it up. The reason I don't like it is my patients that come in at nighttime typically tend to be overweight. It bends because it's disposable.

Dr. Randy Lehman [00:40:39]: Yeah. So then what do you do with your other... You've got your camera at your belly button and your other two arms you're doing what with?

Dr. Seung Gwon [00:40:46]: So you've got the person holding the camera underneath your armpit, and that's the one at the belly button. I have a grasper in my left hand, and that's normally what I'm going to use to bluntly dissect as well as provide my counter retraction to get my critical view. Then in my right hand, it depends. I always throw a Raytec down at the beginning of the case. I use a Raytec to either, if something looks like it's bleeding, I should use blunt dissection just like you would with a sponge stick. So I always have a Raytec down, and also if there's a little bit of spillage, then it's going to grab it right there, and I don't have to go looking for it.

Dr. Seung Gwon [00:41:20]: I like to do a lot of blunt dissection with my suction irrigator catheter. What I'll do is use that, especially down near the cystic neck. A lot of that fatty substance, I can bluntly dissect it away, and it's not going to cut through any of my structures, but it'll really nicely dissect through it. That's probably my favorite blunt dissection.

Dr. Randy Lehman [00:41:42]: As you pull with it.

Dr. Seung Gwon [00:41:44]: As I'm pulling it down and pushing away, I'm sucking at it, and you're getting these really nice, nice planes that don't bleed, rather than trying to cut through something and potentially cutting something you don't want to. I use that a lot, and I think between that and the Raytec, I get a lot of the blunt dissection, and normally it gives me a lot of what I need to see. I also then alternate the hook. I know some people use a spatula. I like the hook. Some people I know use scissors. I do a lot of dissection with the suction catheter and the hook so I can make sure I get my critical view before putting clips across.

Dr. Randy Lehman [00:42:19]: This would be my number one thing. Okay. For this case, if you haven't tried it, I would encourage someone to check it out. I use the suction hook cautery. Have you seen that?

Dr. Seung Gwon [00:42:33]: We have that, and one of the other physicians in town loves that. The reason why I don't love it is I tried it a couple of times. Well, not only does it clog, but you have to retract that hook back and forth.

And for me, it's easier for me just to pull the whole thing out and replace it than to move it with my finger. And with training, because the other surgeon who brought it to the Valley had used that in the same program. I was in Chicago before I went to Santa Barbara. I just never saw it there. And so I've seen it. I think it's interesting because then it's like a multi-use tool. I just haven't figured out how to do it.

Dr. Randy Lehman [00:43:05]: If I had to pick one instrument that if I was going to a new place, that I would add, it would be that. Because I use it on pretty much every laparoscopic case. And there’s... It’s like anything. You can make it look really hard, or you can make it look really easy. Once you learn how to not clog it and not buzz so much so that it chars up on the end and then my hands are big enough to... I mean, I'm only a seven and a half. It's not like I have huge hands, but to get down there and pull it back and forth with my two fingers, you know, it just works better for some people than others, but it works extremely well for me. So I do with that in my right hand.

Dr. Seung Gwon [00:43:42]: We do have that. Maybe I'll give it another chance. There is one surgeon who uses that for every single surgery. And that's why I tried the first time. The first time I was trying to pull it and I was like, oh, that it's just not the way my fingers are trained.

Dr. Randy Lehman [00:43:54]: Yeah. And I also bought a hard plastic sleeve. I don't know what it's called, but it's pink, and it’s like a... It looks like an arrow quiver. And I put that into the pouch on my laparoscopic drapes. And I do the same. I don't put all my instruments in there, but it's like step by step the things that I need. Like, you know, I put them in there, and then it doesn't poke holes through the drapes.

Dr. Seung Gwon [00:44:17]: Exactly. I do the same.

Dr. Randy Lehman [00:44:18]: You ever use a Kittner?

Dr. Seung Gwon [00:44:22]: I haven't in gallbladder because I find that between my suction catheter and the fact that I've got that ray-tec in there, I get... And a lot of times sometimes I'll have my ray-tec on the edge of my suction catheter tip, and I'm using that to push down. Which is basically very similar. But so concept-wise, 100%. But not specifically the Kittner.

Dr. Randy Lehman [00:44:39]: Yep. Okay, carry on.

Dr. Seung Gwon [00:44:42]: So then... So this is the one thing where I'm sure academic surgeons will get very upset for me saying that I 100% believe you need to get the critical view. I think you need to make sure that, especially because there are so many ways that the cystic duct can be looking like a cystic duct and actually very short cystic duct and a common bile duct or they're heat together that area. You know, if you don't have firefly, and I tell people that you can have ICG without the robot. Both Olympus and Stryker, and I think more and more are offering it. You just have to convince your hospital to buy the camera that allows that. But I do think immunofluorescence has done a lot in helping us identify it without getting into it. But if you don't have that, you want to make sure that you get your critical view.

But in some of the cases that I do, I feel it would be more potentially harmful to try to over-skeletonize these structures, and I get into trouble. So I always make sure I know as well as I can what I'm coming across, but I may not always see that perfect critical view. And the place where I find I learned about this the most is I do medical missions in Guatemala, and we bring surgeons out there, and there's two of us that are from this community that go. And then we have academic surgeons that will come join us. And sometimes they're just beside themselves. They're trying to get that critical view on these... Really, the gallbladders in Guatemala look just like the gallbladders...

Dr. Randy Lehman [00:46:04]: I do the same thing in Honduras. And it's just like you say, five years they've been having pain and...

Dr. Seung Gwon [00:46:09]: Yeah, totally. And so, you know, these people have... So sometimes when you're overly trying to dissect in this area, and it's not the robin's egg blue gallbladder, we can really open it up and see it beautifully. I do think sometimes you can get in trouble. So I do tell people if you know your landmarks, if you're by Rouviere's sulcus, if you're right at the neck of the gallbladder and dissecting down versus going down where you think it should be and dissecting up. If you get into a lot of trouble in that area, and it's just stuck or it's stuck down, I tell people, before you convert to open, just start from the dome of the gallbladder, do an open surgery laparoscopically. Use your retractors to push the liver up like you would, and then dissect off that bed and then bring it all down that way. Sometimes I'll put endo-loops in if I think if I'm down to the neck, knowing I'm going to leave a little bit of a cuff of the cystic duct, but doing that rather than getting into the common bile duct.

And the main reason is early on in my career, I brought in one of the more seasoned surgeons for a really tough gallbladder. And I was just trying to get that critical view. And his response was like, why don't we just do a cholangiogram, and then you know where you are. I was like, okay. So we did the cholangiogram, and we were in the common bile duct. So I was like, okay, now we have to do a common bile duct repair. And I wasn't comfortable enough at that point to do one laparoscopically. So we had now this patient got an open repair, right? And so after that, I was like, so the cholangiogram is great, lets us know if there's stones if we had to do a combination. But in that case, it told me I was in the wrong spot, so I didn't cut it. That was great. But I was like, I wish there was something else I could have done to avoid that because that was now an unnecessary 13 if you were...

Dr. Randy Lehman [00:47:42]: Doing that one again, you would have at that moment gone up to the dome and gone domed down. And you think that probably would have clarified for you.

Dr. Seung Gwon [00:47:49]: I think I would have clarified it because then you go from the dome down, you can clearly see where the gallbladder neck starts to narrow. And then you see that window. You try to dissect down so you can see the actual duct coming out. But if you can't, you can actually take it right there. You have a little bit longer of a cystic duct. And so that's... Some people are like, well, what if they have an additional issue later on? But as long as I feel like as long as I don't leave any gallbladder behind, you're not going to have somebody going back there to do a remnant cholecystectomy. So I just make sure I have the entire gallbladder itself, and I might leave a little bit more of the cystic duct than I would typically if I can really skeletonize the structure of the hip. My typical care review.

Dr. Randy Lehman [00:48:24]: Yeah. Well, you could even shoot a gram then.

Dr. Seung Gwon [00:48:27]: You could.

Dr. Randy Lehman [00:48:29]: And you could... You could. If you're worried about not knowing where you are, you could put your Maryland or something to mark where it's at when you shoot your gram.

Dr. Seung Gwon [00:48:36]: Oh, that's true.

Dr. Randy Lehman [00:48:38]: So, okay, great. And you brought up the word "open" at some point. I want to... Maybe now's the time. So how often do you open...

Dr. Seung Gwon [00:48:48]: My first year down here, more than I ever thought you were supposed to do. I remember the statistics. They're saying 3% for a, you know, a normal gallbladder. Maybe like, you know, 5 to 6% for a chronic gallbladder is what I was trained in residency, and my first year, I opened two. And I definitely did not do, like, you know, hundreds and hundreds my first year. And so I remember the end of my first year thinking I was an absolute failure.

Dr. Randy Lehman [00:49:16]: It's like, how can I possibly open two as I started? I think you did 50 in your first year. One a week?

Dr. Seung Gwon [00:49:19]: I probably did, like, yeah, one a week. Yeah, in the first year.

Dr. Randy Lehman [00:49:25]: How many do you do now?

Dr. Seung Gwon [00:49:26]: Probably like two to three a week. I do a lot of gallbladders. Yeah, probably like 150 a year. The last time I've opened a gallbladder was about eight years ago. So, I haven't opened one since. We have one surgeon down here who hasn't opened one in 10 years. I told you, our gallbladders down here are hard. If anyone wants to do a gallbladder fellowship, the first year is a little bit daunting. But we really learned how to not convert and yet keep it safe. Luckily, I haven't had to open. Right now, because we have the robot, I always do the gallbladders in the robot room. If it's a real mess, the first thing I'll do is put the robot on. It just gives you additional views, a better camera, and a little bit more capability. I find that there's probably one or two times where I've been like, oh, my God, I'm gonna either convert to open or I'm gonna hook up the robot. Then I was able to complete it robotically.

Dr. Randy Lehman [00:50:17]: Okay, that's good. I don't have a robot anywhere, so there's a problem with that. But I've opened three times in five years. I had one case that I thought I was going to open going into it, but then I didn't have to. That case was someone else at another place had tried to take the gallbladder out, I guess, laparoscopically, and couldn't. Couldn't find it.

Dr. Seung Gwon [00:50:39]: Oh, that's horrible.

Dr. Randy Lehman [00:50:40]: Then they told the patient, you don't have a gallbladder, and if you need it done, don't come back to me. I guess that's the way it was presented to me. So, I end up taking her. I mean, I did all the scans. I did every single scan — HIDA, MRCP, ultrasound, CT scan. Everyone sees it right there. I can see on the CT where it's at. So, I just went. I figured it was covered with fatty tissue, and it was. I just went on the liver, took the fat down, found the gallbladder, and took it out. I stayed laparoscopic. It was actually not that hard. She was very happy. But the three that I opened, one was a guy who was a paraplegic in the nursing home attached to the hospital, who had been shot in the abdomen like nine times.

Dr. Seung Gwon [00:51:18]: Times.

Dr. Randy Lehman [00:51:19]: I went in laparoscopically and I actually did a cut down at Palmer's Point. It was just like a sheet of plastic in there; there was no domain at all anywhere. The bowel was almost unrecognizable. I measured on the CT the number of cuts, you know, 5 millimeter cuts, how far above the belly button it was, and how far lateral to the midline it was. I made an incision, about probably 7 or 8 centimeters, and went straight down through the layers. The gallbladder was right where the CT said it should be because it's not moving around since everything's fixed in his belly and got it out. So that one, I just kind of tried the Palmer's Point and then went straight. The other one was a patient who was an ER patient with acute cholecystitis, but it wasn't. It was actually gallbladder cancer, and it was invading into the duo. As I'm kind of dissecting, I end up getting into the duo. I opened, fixed the duo, took the gallbladder out and went from there. The third one was a patient who had Y90 radiation to the liver and then had gallstones. I explained to her it was a very high-risk scenario, but it was a total mess. Everything was terrible. Be very suspicious when you see the Y90. You're gonna have a lot of scar tissue. I ended up deciding to go open on that one and got it out. She did all right in the short term, not long term. But, you know, that was her own other diagnosis. That's the issue there. So, just things to be suspicious of, when everything's normal until it isn't. My first two cases were an appendix and a gallbladder, but one turned out to be a second different patient with gallbladder cancer. The appendix was a 9 centimeter mucous seal.

Dr. Seung Gwon [00:53:12]: Oh, my gosh.

Dr. Randy Lehman [00:53:12]: It's normal until it isn't.

Dr. Seung Gwon [00:53:14]: I thought we had crazy pathology down here. That's crazy.

Dr. Randy Lehman [00:53:18]: I don't know if it's, you know, the agriculture, pesticides, or what's going on. But, yeah.