EPISODE 59

Why Rural Surgeons Maintain the Broadest Scope of Practice with Dr. Bob Sticca

Episode Transcript

Dr. Randy Lehman (00:00:00):

I have a great episode for you today with Dr. Bob Sticca, past president of the North American Rural Surgical Society and second vice president currently of the American College of Surgeons with a wealth of knowledge and we talk in depth detail about disastrous that he's seen from gallbladder has gone wrong from how to deal with the difficult gallbladder during his time in Fargo as an HPB and surgical oncologist. Also, a quick reminder that Liberty Clinic is expanding in northwest Indiana in a rural northwest Indiana and we have some opportunities and I would say a timeframe of about two years we're going to be looking to hire another general surgeon or two, and if you are interested in that type of position, please visit the rural american surgeon.com and just submit something there. Or if you know of somebody that may be interested or may be a good fit, we're basically looking for a general surgeon that can perform the type of practice that I've sort of described on this show, which is general surgery. Plus there will be an opportunity for a mid range hospital where there will be ICU capabilities and some call responsibilities and things helping develop some things from the ground up and then also the rural practices sort of geographically. And for more information, just please go ahead and reach out and we will get back to you.

(00:01:38):

Welcome back, listener to the Rural American Surgeon Podcast and I'm honored to have Dr. Bob Sticca on with me today. Thanks Dr. Sticca for joining us.

Dr. Bob Sticca (00:01:47):

You're welcome. I'm glad to be here.

Dr. Randy Lehman (00:01:50):

I really appreciate it. We have connected through the North American Rural Surgical Society where you've been a leader and an example, an inspiration I would say to all of us and also training residents. And I guess if you would like to just go ahead and tell us a little bit about your practice and your background and why you're passionate about rural surgery. I'll open the floor to you.

Dr. Bob Sticca (00:02:13):

Sure, Randy. Thanks. Well, I'll give you some background and especially pertinent things with regard to my involvement in rural surgery. So I, going way back, I was raised in a military family and lived in different parts of the country. I went to school mostly on the east coast, the University of New Hampshire for my undergraduate University of Connecticut for medical school. And then I did a fellowship in surgical oncology at Roswell Park Cancer Institute in Buffalo, New York. After that, I practiced in sort of a quasi rural environment in Greenville, South Carolina for 10 years. And then I made the decision to go to a little bit more of an academic program and was recruited at the University of North Dakota as the vice chair and program director. I've been here for 23 years and it's, when I came to North Dakota, they really got much more involved with rural surgery and really began to understand the rural surgeons issues and the fact that they were more of a unique entity, still part of general surgery, but sort of a separate entity. I will tell you that back in the two thousands when I first started getting involved in the rural surgery issues and we started doing some research, there were people in the country in some of the more prominent societies that disputed that even rural surgery was even anything different than a general surgery. As a matter of fact, I remember distinctly at a national meeting where one of the leaders got up and said, there's really no such thing as rural surgery. All general surgeons are the same and they should be trained the same and so forth.

(00:04:36):

Again, I think the history since then has shown that that's actually not true and rural surgery is certainly a distinct entity. Now in regards to my rural surgery involvement, when I came to North Dakota as the program director, we started training residents and even then before we had a defined rural surgery tract, the majority of our residents went into rural surgeon, rural surgical positions and that even that persists. Today we have one of the highest rates in the country, but we started looking at the differences between a rural surgeon and an urban or metropolitan general surgeon, and it was pretty clear that the rural surgeons had a much broader scope of practice. We did some research studies that were published looking at the different kinds of cases that rural surgeons did and saw that they did a lot of endoscopy. They did a lot of subspecialty procedures and so forth.

(00:05:41):

So we eventually developed the first A-C-G-M-E recognized rural surgery track at University of North Dakota, and that has been in place since 2012 and we've produced a number of residents that have gone into rural surgery tracts in regards to the North American Rural Surgery Society. That's also another bit of a story, but we can talk about that a little bit later. But I was one of the founding members of the transition from that from a vascular to a rural surgery society and it's really grown and I hope to be able to talk a little bit about that in the future. And then finally, my current practice, I practiced as a surgical oncologist for most of my career, but worked with rural surgeons all over the state of North Dakota, Minnesota, parts of South Dakota and worked with them and took referrals from them and so forth. So technically I was not a rural surgeon, but training rural surgery residents and working with rural surgeons was my main connection with the rural surgery community. And finally the last thing, recently, I've just gotten elected as the second vice president of the American College of Surgeons, and I was nominated by the Rural Surgery community, which I certainly was honored and very much appreciate.

(00:07:39):

I hope my term has just begun, but I hope to be able to do some things and help and continue the emphasis on rural surgery and maybe we could talk a little bit about that later.

Dr. Randy Lehman (00:07:57):

And maybe just to highlight, I mean the importance of that. That's so fantastic. What a feather in your gap and obviously comes from your servant leadership, which I've personally directly witnessed for the time that I've been involved, so I just really appreciate you. Is that kind of the pinnacle of professional achievement at this point for you with the second vice president election, or what other things are you most proud of with your career?

Dr. Bob Sticca (00:08:29):

Well, I think that's an interesting question. I have a couple of things I'm very proud of, but one, certainly the election as the second vice president and nomination by the rural surgery community was a very important step and my contributions and the things that we've done to recognize rural surgery would be another one. And the other one I would say it had to do with more my clinical practice. We brought a surgical oncology practice here to North Dakota, which was non-existent before I came here and been able to keep a lot of people having major oncologic operations in their own communities.

Dr. Randy Lehman (00:09:12):

Yep. Great. I was just curious how you answer that. So I appreciate it. And then the rural surgery, there's the proximity effect. So you land in North Dakota, you need to train rural surgeons as rural America all around you. So there's an element of that, but the next question usually on the show is why rural surgery? And so whatever draws you to it and why you think it's still relevant and it still matters today maybe more than ever.

Dr. Bob Sticca (00:09:41):

Yeah, so again, that's a very good question. And during my time in North Dakota, obviously North Dakota's a rural state. I mean, we only have 750,000 people in the whole state, and there's a lot of small communities, a lot of small hospitals, and I have interacted with a lot of them. I mean, I used to go out and visit these hospitals on a regular basis and so forth, although I wouldn't say that I was completely convinced when I first got here, the more that I interacted with and the more that I got to know the rural surgeons, it became clear to me that a rural surgery practice was different and that some of the things that you do in a rural surgery practice without a lot of specialists around is significantly different than any urban or metropolitan general surgeon. And so that that allowed us to develop our goals, which were to train rural surgeons and keep the rural hospitals going, which as most of us know, is really in many cases dependent on a surgeon in the community.

Dr. Randy Lehman (00:11:06):

Yeah, perfect. And how is it different? I understand it's different, you understand it's different. What did you find in your research that's actually different because I'm thinking to myself having trained in a rural surgery track, self-branding, trying to be the poster boy for rural surgery. I did rotations in ortho urology, ENT plastics, OB GYN when I was a resident. I do carpal tunnel trigger, finger release ganglion, vasectomy, hysterectomy, tubal ligation, skin flaps for skin cancer on the ear, on nose throughout the body, as well as a spectrum of general surgery. But of course you're giving up because choosing to practice in a place that doesn't have all of those resources. You're giving up esophagectomy, whipple, liver resection, large amount of vascular, I do veins and ports and things like that. But am I describing it well, the endoscopy might be the other thing that I'm leaving out and potentially C-sections, but what else am I missing?

Dr. Bob Sticca (00:12:03):

No, I think you categorized it pretty well. I mean, to me the biggest difference is the scope of practice at my presidential address for the North American Rural Surgery Society. The one thing I said was I personally think the only true general surgeons left anymore are rural surgeons. I mean, if you're in a big city, almost everything, I guess I would say the majority of the things that you do could be done a lot of times are done by a specialist. I mean breast surgery, colorectal surgery, vascular surgery and all those kinds of things. The rural surgeon is the one person that still has a, although not a complete practice in all those different general surgery subspecialties, but is the one surgeon that has elements of all of that. The second thing, as you alluded to was the independence, the isolation from the major medical centers, from the specialists and so forth.

(00:13:21):

So in many cases, you're called on to do some basic things in subspecialties that most general surgeons don't even get training in anymore. I mean, when I trained, which was many, many years ago, we used to do rotations in urology and plastics and OB GYN and all those things. Many of those got cut out over the years because of the emphasis that the general surgery trainees needed a certain amount of months in general surgery and so forth. And so now really the only ones that get those are programs that have an emphasis in rural surgery like ours and some of the other ones around the country.

Dr. Randy Lehman (00:14:07):

Yeah, great. Before we go to the how I do it, could you just tell me about your program and maybe for a medical student that's interested in coming, what would be the ideal candidate for somebody in your program?

Dr. Bob Sticca (00:14:20):

So our program which was developed based on our research and what a rural surgeon needs to go into practice basically involves the rural track residents, which we actually have three now and three what we call traditional track residents. The rural track residents have about nine to 12 months of their rotations out of 60, which are different than the traditional or the regular general surgery track. And those rotations are in things that we identified the need for,

(00:15:07):

Such as ob, GYN. They do two months of OB GYN. They usually do two to four months with one of our rural partners and they go out and practice in a rural community. They do ENT, they do urology. Again, our rotations sometimes are dependent on the willingness of the subspecialists to work with our residents, but for the most part we have pretty good cooperation and we do plastics and some of the things. And then we have also done a number of follow-up studies where we look at, we've sent out surveys and communicated with our graduates in rural practices as to what they actually are using and of those rotations, and we found out that there are certain things that we made some changes. I mean, we're looking at getting a little more concentration in hand injuries and like you say, carpal tunnels and those kinds of things and so forth for a medical student.

(00:16:15):

And we do get a lot of students that apply to us primarily because of our reputation in rural surgery. For a medical student, the optimal, this has been documented time and time again, the optimal student or the optimal person to go into a rural practice is somebody who has a little bit of a rural background. And if you take somebody that was born and raised in New York City, the chances that they're going to be able to go to a rural community and be happy are unlikely, even though sometimes they say that, but most of the time their spouse and children or it just doesn't work out. If you take somebody that was born and raised in a rural community and knows what a rural community's like, knows the small town atmosphere, that knowing everybody in town and so forth, those people tend to go into rural practices and have some longevity and stay there. So,

Dr. Randy Lehman (00:17:14):

Yep. Very good. Well, I relate to that obviously very much having moved back to the farm that I grew up on and probably never leave. So here I am. But there are Dorothy, Dorothy Hughes presented about the rural surgery stayers and I can't remember what the other word was, ones that went to the city and came. And certainly I know some of those folks too for a number of different reasons, but then a lot of times their practice is maybe not that broad thing. It's then parsing back in general surgery and they're not going to learn how to do a hysterectomy, for example. But just interesting things to consider. I love talking about technical things, and so how I do it is the next section of the show, which for you, a lot of things that you do are not maybe the standard thing that we're going to be doing. So surgical oncology wise, is there anything specific that you would want to dive into or do you want to talk about? You mentioned the difficult gallbladder.

Dr. Bob Sticca (00:18:22):

When I saw that was on the agenda, I thought about it a little bit. And again, obviously most of my career I did pancreatic surgery, liver surgery, esophagectomy, upper GI surgery, some colon and rectal stuff and so forth. But the thing that where I had a lot of more interactions with the rural surgeons was the difficult gallbladder. And every general surgeon experiences this. You go in, especially somebody comes in with acute cholecystitis, you go in and everything is just socked in and so forth and so on. And you want to try to, you're nervous about dissecting out the base of the gallbladder because you don't know where the common bile duct is, and it's all scarred. It's all fibrotic and socked in and so forth, and you just can't see it well and so forth. So I'm sure you're aware, and many of the viewers are aware that one of the options that is now proposed is the subtotal cholecystectomy.

(00:19:43):

And again, as a surgical oncologist and an HPB surgeon, we would tend to get either the very difficult gallbladders that people were not comfortable doing. I've had people put a scope in, say, I just can't do this, and then send the patient or the post attempt or fixing the injuries after a common bile duct transection. And as I'm sure you're aware, there's a number of options when you get in there, but the subtotal cholecystectomy where you do either a fenestrated, which is to leave the gallbladder, just take off inflamed portion of the gallbladder, usually get down to the fundus and then leave that open versus the reconstituted where you try to staple off the gallbladder are the two main options. So we actually are presenting a paper on this where we've called it completion cholecystectomy, where we've had to go back on a number of these people anywhere from three to six months up to five or 10 years later and take out the remnant gallbladder.

(00:21:09):

And part of that is dependent on what was done at the first operation and how that was treated. But my recommendation to people would be if you get in a situation like that, you're not comfortable and you, you're not comfortable around the porta hepatis, which was in some situations could be almost impossible to identify because of the inflammation and so forth, is to do a subtotal cholecystectomy and use the fenestrated option. The ones where you leave the gallbladder open, you get a certain number of those that will have to leak bile for a while, but most of the time they will close. But when you reconstitute it, when you staple off the gallbladder, a good percentage of those patients come back later and need a completion cholecystectomy. So that was the one area where, I mean, obviously when I would interact with rural surgeons when they would have diagnosis of pancreatic or esophageal cancer or whatever, but the ones where we actually had the most interaction was around these difficult gallbladders and where either they had to bail out or they had to do a subtotal cholecystectomy.

Dr. Randy Lehman (00:22:37):

Yeah, I like that. Thank you.

Dr. Bob Sticca (00:22:39):

You must have seen some difficult gallbladders in your time, right, Randy?

Dr. Randy Lehman (00:22:44):

Yeah. So I'm six years out. You've got the open option. So when do you think that a surgeon should open?

Dr. Bob Sticca (00:22:53):

Well, that's an interesting question. In my day, I trained right around the time we were switching from open to laparoscopic surgery, which is something that people in your generation don't really identify with anymore. But in my day, if we couldn't do it laparoscopic, we just opened, it wasn't even a big deal for some reason. And that's another point that I would make to people if you're comfortable doing that, which not everybody is, but if you're comfortable doing that, there's no reason and is not a sign of incompetence or anything just to open and try to do an open procedure. Then again, even sometimes even then, sometimes the inflammation and the fibrosis and chronic inflammation is so bad that sometimes people will still even not be able to get the complete gallbladder out. And again, the same options are present, which are a subtotal, cholecystectomy and so forth. But if you can't dissect down and see to the base of the gallbladder and see the cystic duct and comfortably see it, then that is an option, both as an open or a laparoscopic procedure. I personally believe that if you're comfortable with it, that if you get in there laparoscopically, you can't see, well, you're not a hundred percent sure. You can't get the critical view that in that situation you should open. But if you're not comfortable with it, then you can just stop and send it to a HPB surgeon

Dr. Randy Lehman (00:24:52):

Versus finished training. I mean, if it was you and you're in the middle of this very rural state and you got acute severe acute cholecystitis, you're the patient and your surgeon starts a lap chole, and it's really hard, do you want them to open you fenestrated cholecystectomy or close and transfer? So

Dr. Bob Sticca (00:25:23):

If it's a surgeon that has good open experience in gallbladder surgery, I would want them to open me. If they couldn't get the base of the gallbladder dissected free, I would want them to 'em do a fenestrated cholecystectomy, put a big drain in, and then hopefully it'll heal without requiring any other procedures or anything.

Dr. Randy Lehman (00:25:52):

So even if they open, you wake up and you have an open incision and a 19 French round jp, single 19 French round JP sitting in the gallbladder fossa. Is that what you're expecting? And you had a fenestrated cholecystectomy, you're happy with that outcome?

Dr. Bob Sticca (00:26:08):

Yeah, yeah, because in general, those things, the majority, not all of 'em. Okay. I've done some where the fenestrated gallbladder hasn't closed for months or even years. I had one that was like five years, but

Dr. Randy Lehman (00:26:27):

Had a dream for five years.

Dr. Bob Sticca (00:26:29):

Yeah, it's a long story. I had ERCPs every three to six months, and it was just kind of crazy in any event. But the vast majority of those will close, and most of those will not require any further surgery. Occasionally somebody will come back with symptoms or a retained stone in the neck of the gallbladder and they'll require a completion cholecystectomy. But the difference is a completion cholecystectomy done six or 12 months later when all the inflammation's gone and everything is a much easier procedure. And the risk of injury, the risk of common bile duct injury is much less.

Dr. Randy Lehman (00:27:19):

So I have several questions. First off, that patient with the five year thing, so then did you have to re-operate on the patient and then tie off the cystic duct?

Dr. Bob Sticca (00:27:27):

Yeah, basically the patient had, he kept getting ERCPs and they'd shoot dye up there and it would come out the drain. And they said he had a fistula, which was really just an open gallbladder. It was probably about 25, 30% of the gallbladder that was still present and it just never closed. And why they kept, I mean, this is before I saw the patient, why they kept doing, why kept doing the ERCPs. It was beyond me, but in any event, I just took the patient back. I think I did it robotically, and we just dissected out the cystic duct, which at that time was much more visible and easier to dissect out and clipped it and removed the remnant of the gallbladder and the patient did fine.

Dr. Randy Lehman (00:28:24):

And were you prepared, so if you could not have done that, or if there was very little cystic duct remaining, then you would've done an HJ or what was your bailout plan?

Dr. Bob Sticca (00:28:37):

Yeah, I mean, that's something that I'm always prepared to do in a situation like that, but based on the multiple ERCPs, I could see that this patient had a two centimeter cystic duct that was present and a remnant of the gallbladder. And so really going into that, I didn't think I would have to do that, but if that was necessary, I certainly would've been able to. And it certainly was discussed with the patient beforehand, there's a possibility you'll have a bigger incision, you'll have anastomosis here, small bowel and as the definitive procedure.

Dr. Randy Lehman (00:29:21):

Yeah. So what is a reasonable timeframe for clarity? You recommend if you have to do a subtotal, do not close it and just finish straight and leave a jp?

Dr. Bob Sticca (00:29:35):

That's correct.

Dr. Randy Lehman (00:29:35):

Right. Okay. So then say I do that in my practice and then the patient comes back and they're draining ous fluid at two weeks and I see 'em back again maybe two weeks after that. How frequently should I be seeing the patient back? Are there any labs that I should be drawing, any other studies that I should be doing? And then at what point if the drain is still ous, do I need to get the ERCP?

Dr. Bob Sticca (00:30:04):

So I would give it about two at most four weeks to give it chance to scar in and close. And if it doesn't, by the end of that time, and especially if you're, you're monitoring the amount of drainage, if the drainage is going down and down and down, then likely that the duct, the remnant cystic duct or remnant gallbladder is closing and just needs enough time to heal. But if it's not, it's still you're getting a hundred, 200 ccs a bile every day, which isn't a big problem. I mean, you got the drain in and do, the patient has a little bit of a bag, but if it's not doing that, then I think that's when you have to start thinking of referring them for an ERCP. And if there's nothing that can be done endoscopically, then they need to see somebody who's going to remove the remnant of that gallbladder.

Dr. Randy Lehman (00:31:06):

And then what about, you're saying six to 12 months later or whatever, it's very easy to go back and take out a remnant gallbladder. What about the same surgeon doing that operation themselves, or would you recommend against that because again, it's a different operation at that point. It is much easier. I can imagine the same skillset person still might be able to get it done the second time.

Dr. Bob Sticca (00:31:26):

Yeah, so again, that depends entirely on the patient, on the surgeon's skillset, and I certainly would not object to it. And again, we do most of our completion cholecystectomies robotically, just because we put the ICG in, we can see the common bile duct and we see the anatomy a little bit better. And again, I would say when I say it's easier, I don't mean it's the easiest thing in the world. I mean, there's still some inflammation and so forth, but in general, when it's not acute in inflammation and fibrosis, you can dissect it out a little bit better. In most cases, you can see the common duct cystic duct junction, and based on your ICG and so forth, you can then put the clips on the cystic duct and remove the remnant gallbladder. So again, if the rural surgeon is comfortable doing that,

(00:32:32):

I mean more and more rural surgeons are getting robots these days. I think that technology is great for those kind of things because the visualization and the robotic manipulation is so much better than laparoscopic, but it certainly can be done laparoscopically. I mean it all depends on your comfort level and so forth. Now, the one thing I kind of left out a little bit is the paper that we're going to be presenting in a couple months at the Southwestern Surgical Congress on completion cholecystectomy. Our recommendation for people that have a subtotal cholecystectomy, whether it's a fenestrated or a reconstituted, is that they be followed up in six to 12 months to see if they have symptoms because almost every one of the patients that we have done a completion cholecystectomy on has come back at a certain time point. It's not always that soon, but they will come back and they have typical biliary colic symptoms with right upper quadrant pain after eating and so forth. And so those people, then if you see somebody nine months later and they say, I'm having pain in my right upper quadrant after I have a Hamburg or something, then you need to do a little more investigation, repeat an ultrasound, maybe get a CAT scan, and if they have a significant remnant of the gallbladder, either you take it out or send them to somebody else to take it out.

Dr. Randy Lehman (00:34:17):

Got it. One more question on timeframe. So you said two to four weeks give 'em to chance to close in your clinic after fenestrated, cholecystectomy and then maybe ERCP. But if the ER CP and stent, how long would you give it after the ER CP and stenting until you say, this is failing to close, somebody needs to go back in and

Dr. Bob Sticca (00:34:42):

Yeah, I would give it again, another two to three weeks. I mean, if you put a stent in, you should probably see a significant drop off in the drainage immediately within a week or so. And if that happens, then most of the time that's going to close and you don't have to worry. Obviously, the patient will probably have to have another ERCP to have the stent removed at some point. But

Dr. Randy Lehman (00:35:09):

What percentages could I tell a patient that the chance that it's going to close on its own versus needing an ERCP and then if you get an ERCP chances that it'll close with and without?

Dr. Bob Sticca (00:35:20):

Yeah, I don't know any data on that. I wish I did. I would, based

Dr. Randy Lehman (00:35:26):

On my clinical opinion. Yeah,

Dr. Bob Sticca (00:35:28):

Yeah, I would estimate probably somewhere between 50 and 75% of them, maybe even a little higher with an ERCP will close, and it's certainly not the most common thing for a patient to require another surgical procedure to remove the remnant of the gallbladder, the majority of them will close.

Dr. Randy Lehman (00:35:55):

Okay. Where does cholangiogram fit into this?

Dr. Bob Sticca (00:35:59):

Again, depending on the technique and the technology that you have available, if you are doing a laparoscopic completion cholecystectomy, in most cases, I would recommend doing a cholangiogram. If you can identify the cystic duct. If you are doing a robotic and you're using ICG, in most cases you can see the common bile duct and you usually don't need to do a cholangiogram. What was I going to say? The other thing is that it's a little harder to do a cholangiogram robotically, and in most of those patients you've got some preoperative imaging. I mean, it is rare that I see one of those patients that hasn't had either a CT scan or MRCP before they send them to us. And so if the MRCP shows no stones in the duct and you've got a remnant gallbladder with a big stone in it, then you just have to, in those cases, it's unlikely that you're going to have any kind of a choledocholithiasis

Dr. Randy Lehman (00:37:34):

So last thing, and then maybe we move on to the next section, but like I said, this is really me wanting to talk about this stuff with you and I have this captive audience, the master of all champions at gallbladder and all things advanced abdominal surgery. So I'm thinking of four different cases that I've had. These are the cases, three cases that I opened, and then one that I thought I might have to, but it didn't in my six years since residency. So one was a multiple gunshot wound to the abdomen. Patient in the past was paralyzed and was living in the nursing home attached to our facility and had gallstones and classic biliary, well, not classic biliary symptoms because it was more like vomiting, postprandial and vague symptoms because he had limited sensation to his abdominal region. I thought it was going to be terrible, but I agreed. He had of course, a big vertical midline laparotomy. I agreed to try it, and this was after a few years out, I wanted to stay away from that vertical midline. I considered doing a off midline Hassan port to the right. I ended up deciding to go more Palmer's point just to see what I could see. So I started with a Hassan left upper quadrant, midclavicular line, Palmer's point. I went in there, it was straight, everything was just white and scar. There was nothing. You couldn't really see bowel loops.

(00:39:16):

I made just a little pocket of domain there and inflated, but there's no way I was going to get to the other side. So I don't know if I want to ask what I should have done or just tell you what I did did. I'll tell you what I did. So I just pulled up the CT scan and I measured from the belly button how far over the gallbladder. I'm like the gallbladder's going to be exactly where it is on the CT scan because everything in the AB is fixed. And I measured over how many centimeters from the midline and how many centimeters above the umbilicus. And I just made a mark and I made an incision directly over, it was probably about 10 centimeter incision directly over where I knew the gallbladder had to be. I dissected straight down through the layers, found myself right at the edge of the liver, gallbladder was right there, just dissected it out and took it out open. And that worked out. I tell that story so that people can think about it, but also to get your opinion on that one

Dr. Bob Sticca (00:40:19):

In that situation. And I've seen abdomens like that before. You put a trocar in there and you of sometimes the adhesions aren't terrible and you start taking 'em down and you can work your way further and further and so forth and get across to the right side and see the liver and the gallbladder. Other times, like you say, where it's completely socked in, you just can't do it, then your next step would've been, I would fully agree that next step is just to do an open procedure. I would've just done a standard right subcostal incision and that incision was designed for the gallbladder and just go in there and dissect down and find the gallbladder and take it out as an open procedure. So yeah, I think that's exactly what I would've done.

Dr. Randy Lehman (00:41:13):

Do you have any technical tips on open gallbladder surgery? So for me, for the listener, my big tip would be the two laps behind the do of the liver elevating it, that's probably number one. And then probably two clamps on theus and to be able to manipulate simultaneously. I'm sure you have other technical things. What could you tell me?

Dr. Bob Sticca (00:41:37):

Yeah, so I mean really when I was in training, we used to put actually four different laparotomy packs in. We had put one on the in midline on the right and pull. We used to use a book wall retractor, which is not used. I mean one of those, it's a ring retractor, and we would put one on towards the midline and pull the tissue over that way. We put one inferiorly and one on the liver, and then actually kind of two over towards the hepatic flexure of the colon. And that way there you can usually get very good exposure of the gallbladder fossa and the inferior aspect of the liver. Again, in your situation that you just described, you're going to have to work a little to get that exposure because you got all adhesions there. But once you do it, and then once you get that exposure, I do the same thing that you do. I put a P on at the fundus of the gallbladder and the infundibulum just retract the gallbladder similar to what you do laparoscopically and then carefully dissect out the base, find the base, try to get the critical view, and then put your clips on the artery and the duct and then remove the gallbladder.

Dr. Randy Lehman (00:43:11):

Yep, love it. The other thing I'll just say how I put that packing over the top of the liver is really to get my hand all, and I agree, I did not do this at all in that case, I couldn't do anything. But to get all the way behind the liver where you're feeling the back edge of the liver and put the packs as low and as far back as you can, and it's pushing the liver up at you, pushing the gallbladder up at you, that's sort of like the big tip. And then the other question I had follow up is if you had to do that now, do you use a bookie or do you use some other retractor now?

Dr. Bob Sticca (00:43:48):

No, we, geez, our younger guys have got this Thompson retractor, which is, it is pretty expensive. I mean it like $50,000 or something and

Dr. Randy Lehman (00:44:03):

That

Dr. Bob Sticca (00:44:04):

Has that. And then we have an Omni, the one that I use is the Omni, which are similar. The book Walter has kind of got out of vogue just because it's a ring and it kind limits you a little bit more than just the bars that you can move and so forth. So I typically use an Omni, but my younger partners are using a Thompson, which in my opinion takes a little longer to set up, but it does have a lot more flexibility as far as putting different types of retractors in and moving 'em in different directions and so forth.

Dr. Randy Lehman (00:44:41):

Yeah, next real world case for my practice, patient with acute cholecystitis through the er, supposedly build, I go for lap coli. I'm dissecting, it's kind of stuck to the duo. And as I'm dissecting, long story short, I find myself inside the duo and the patient ends up having gallbladder cancer that was invading into the duo in retrospect. So her, I just opened immediately and got the gallbladder out, and then it became sort of more obvious that there was a mass, and then I closed the duodenum transversely. I think I patched some momentum over the top of it too. Paranoia, what should I have done differently there? I mean, I know he is try to know that ahead of time, but sometimes that's how straight up read from the radiology says acute cholecystitis.

Dr. Bob Sticca (00:45:37):

Yeah. So that actually was, is one of our more common referrals for gallbladder cancer. And we could spend another hour talking about gallbladder cancer, but in that situation, when you're not aware of it being a cancer when you get in there. And did you find out while you were in there or was it only at the final pathology?

Dr. Randy Lehman (00:46:03):

I had a pretty much, I knew it, but I didn't have frozen or anything, but pretty much knew that

Dr. Bob Sticca (00:46:09):

It was,

(00:46:11):

I mean, ideally if you know it's a gallbladder cancer and you're not prepared to do a radical cholecystectomy, you would stop and refer to a surgical oncologist or HPB surgeon. Again, that doesn't happen a lot of the time just because people aren't aware of it. And typically the referral that we would get would be somebody that had a difficult cholecystectomy and the final path came back and showed adenocarcinoma, the gallbladder, and they would send 'em to us and then we would do a partial segment, five resection and a full lymph node dissection. In your situation, what you did I think was very reasonable for the situation that you were in. I mean, obviously you obviously had to close the duodenum and you said you opened, right?

Dr. Randy Lehman (00:47:06):

Yeah, I opened. I didn't really know that it was cancer until after I was open and I was feeling it with my hands and I was like, oh, there's a gallbladder mass makes sense now. So then at that point I didn't feel like closing. I felt like taking the gallbladder out was still right. Somebody can come back and do the four B five portal lymphadenectomy resection, but maybe I made it a lot harder for them. I'm not sure. I ended up admitting her and she didn't transfer anywhere. I got her out of that hospitalization and then she went elsewhere afterwards.

Dr. Bob Sticca (00:47:38):

And I'll be honest with you, sometimes it's very hard to tell. I mean, you have acute severe inflammation of the gallbladder and it's rock hard and firm and so forth. It can be very hard to tell whether there's a cancer there or not. And it's only on the final path that you actually know about it. So I think in your situation that was, I mean, I've seen a number of those where people said, oh, it might be a gallbladder cancer, and we take it out and it's nothing. It's just severe inflammation. So I don't think what you did was unreasonable. The key is to get her to the, depending on certainly the age and the circumstances, but get her to a surgical oncologist and then they do the definitive operation within a couple of weeks after.

Dr. Randy Lehman (00:48:28):

Yep. Alright. And lastly, have you ever operated on anybody that has had Y 90 radiation before?

Dr. Bob Sticca (00:48:38):

You mean peritoneal Y 90,

Dr. Randy Lehman (00:48:42):

Like having a portal vein Y 90 and then had to do a gallbladder? That's what I had to do. Oh,

Dr. Bob Sticca (00:48:49):

Well, no, no. I've done some liver resections in those patients and I assume that they were treating either a liver cancer or a metastatic lesion in the liver. Yeah, they're

Dr. Randy Lehman (00:49:04):

Treating liver cancer and they felt that they were successful and now the patient has gallstones and they're symptomatic

Dr. Bob Sticca (00:49:13):

Well, so again, part of it depends on the cancer is in relation where the cancer was in relation to the gallbladder. If it was on the right side, you're going to have a difficult time because that whole side of the liver where they injected the Y 90 is going to be hard firm and fibrotic. If it was on the left side and the right side is the side that they salvaged, then it shouldn't be that much different than a standard gallbladder. What was your situation?

Dr. Randy Lehman (00:49:45):

It was hard.

Dr. Bob Sticca (00:49:46):

Yeah, I can

Dr. Randy Lehman (00:49:47):

Imagine. Put your spidey senses up if you have Y 90 radiation. It was just a disaster. Yeah,

Dr. Bob Sticca (00:49:52):

I think a lot of people would not feel real comfortable doing that just because, but they usually don't do Y 90 to the whole liver. Usually that's a very targeted injection to one of the, either a lot of times, not even to the major right or left flow arteries, but it's more to submental arteries to treat the tumor.

Dr. Randy Lehman (00:50:20):

Got it. I, one more thing for the listener. I had a patient one time who had a prior attempted lab and the surgeon closed. The patient told me, see patients lie. So usually I got to be aware of that, but the patient told me, the other surgeon said that she didn't have a gallbladder and that he wasn't going to do it if she wanted to do anything, find somebody else or whatever. Well, of course, I'm getting sent this patient several years later, same symptoms the whole time through from the primary care who did a new updated ultrasound shows, gallstones shows the gallbladders there. I do every study under on CT scan, MRCP, the gallbladders there. I mean, I can see it. So I figured it was probably just covered with fatty adhesions. And I talked to my partner about it. I made sure I did it on a day that he was there. I was prepared to go open, but I told her I'd explore laparoscopically and take from there. And long story short, it was pretty easy. So that one was just had fatty adhesions covering it, and I just dissected it out. So if you can be thoughtful,

Dr. Bob Sticca (00:51:29):

You never know when gallbladder disease, I mean, even when the imaging is there and it looks very straightforward, I've seen some real difficult ones and then other times where you're lying awake the night before and you're worried about what's going to happen, and it turns out to be pretty straightforward. So you just never know. With gallbladder disease, you always ask,

Dr. Randy Lehman (00:51:52):

And there's no glory in a lap coli. So if it goes great, it's supposed to go great, but if it doesn't, then you're not going to win,

Dr. Bob Sticca (00:52:04):

As you know, can get into some trouble. And that's hopefully

Dr. Randy Lehman (00:52:08):

What

Dr. Bob Sticca (00:52:08):

We try to avoid with the subtotals and different options.

Dr. Randy Lehman (00:52:14):

Right. Well, I'm so glad that we dove into that, and that's exactly how I love how I do to go. So thank you so much for doing that. But let's move on to the financial corner. This is one practical money tip that you may have for our listener that you've learned over time.

Dr. Bob Sticca (00:52:29):

So what I would tell you, and it was an interesting topic because as you know, I'm close to retirement and so forth, but the one bit of financial advice I would have for all the young people out there is don't buy stuff you can't pay for. Okay. I mean, I can't tell you how many times I've seen people in financial trouble because they have a lake house, they have two boats, they have three cars and so forth. My wife and I have never been like that. We've always been able to pay for everything, and now we're very comfortable in our retirement coming close to retirement. So that would be the one bit of advice. I would say, you don't need three houses and five cars and all this other stuff if you can't pay for. And then the other one, and this was a bit of advice that was given to our program by Jay David Richardson, who unfortunately passed away a few years ago. But the other thing is, his statement was, one of the worst investments you can make is if you get divorced, there's

Dr. Randy Lehman (00:53:50):

Very

Dr. Bob Sticca (00:53:50):

Few investments that you make that you lose 50% of your net worth. And so that's another thing that you have to be certainly try to avoid. So

Dr. Randy Lehman (00:54:06):

Pick the right one and invest in it because that investment pays not just financially, but it's the quality of your whole life. Right?

Dr. Bob Sticca (00:54:15):

Absolutely.

Dr. Randy Lehman (00:54:15):

I just celebrated my 10 year anniversary one week ago, so

Dr. Bob Sticca (00:54:20):

Congratulations.

Dr. Randy Lehman (00:54:22):

We're loving it. But how do you know you're saying don't get things can't pay for, but that means that you're taking out a loan to buy the thing, like the vacation, the house, the second home or whatnot. I assume that's what you mean when you say you can't pay for it,

Dr. Bob Sticca (00:54:38):

Or you're living on credit cards or taking a lot of loans and so forth and have multiple mortgages or your cars are all financed and all that other stuff. I mean, after you've been in practice for 10, 15 years, most people should have their student loans paid off. They should be able to have some starting to build a nest egg for retirement. And then when you're at that point where you want to start having some other capabilities for maybe a place on the lake or a beach house or something like that, but as long as you can afford it, that's certainly a very reasonable thing to do.

Dr. Randy Lehman (00:55:29):

That's what my question is, how do you know you can afford it? Does it mean that you're paying cash for it? And if that's the case, what is okay for you to take out a loan for?

Dr. Bob Sticca (00:55:43):

So again, I think that for the most part, most people can't afford to put up the money, the cash for a house at least. Certainly not in their first 10 years of practice, but eventually with time, they can certainly do that. But obviously your payments can't be close to or more than you, you're making, I mean, you look at your income. I mean, if your income is $20,000 a month and your payments are 25,000, you're going to get into trouble. Obviously, most people have enough sense not to do that. But I will tell you, it's not unusual. I've had many partners that have to work in there until very late in life because either they've been divorced and have multiple alimony and child support payments, or they're paying off things that they bought. And a lot of times they maybe don't even get a chance to use working so hard to try to pay for everything.

Dr. Randy Lehman (00:56:56):

That's a great point too. Well, thanks for those great tips. Alright. Was there any classic case or a moment or just sort of like a surgeon lounge case that you wanted to bring to the show?

Dr. Bob Sticca (00:57:14):

I would say that the stuff that I talked about, that we talked about with the difficult gallbladders were the

Dr. Randy Lehman (00:57:22):

Ones

Dr. Bob Sticca (00:57:23):

That I think are the most pertinent to rural surgeons. And again, I could think back over the years of many different cases. So I don't have one that stands out in particular. It's just the management of gallbladder's disease is still in the realm of the general surgeon and how they manage those difficult gallbladders. So

Dr. Randy Lehman (00:57:50):

Yeah, that sounds good. Let's go ahead to the last segment of show then the resources for the busy rural surgeon. Do you have any one genuine resource that you think every rural surgeon should use?

Dr. Bob Sticca (00:58:02):

So again, it sounds to me like you're asking about a clinical resource, which I

Dr. Randy Lehman (00:58:10):

Can take it wherever you want. That's fine.

Dr. Bob Sticca (00:58:12):

Yeah. I personally think that right now in the current atmosphere and the current climate for rural surgeons, that some of the resources that are the most important ones are the North American Rural Surgery Society, which as we touched upon before, is a society that has evolved from the North Plains Vascular Surgery Society, which was around for about 25 years. And then when vascular became its own specialty, and it became really out of the reach of most rural surgeons just because of all of the endovascular procedures and so forth, we had to make a decision. And us in North Dakota we're really one of the primary sponsors of that society. And that's when we decided to go and make it the North Plains Rural Surgery Society. And then a couple of years ago to have a broader appeal, we made it the North American Rural Surgery Society.

(00:59:30):

But as you know, you went to the meeting here just this past year. It's a great meeting. We had our biggest meeting ever with a hundred, over a hundred people there. And it's a lot of very pertinent presentations and good discussion for rural surgeons. So I think that's a resource that I wish a lot more rural surgeons were aware of and used. It is designed with a rural surgeon's practice in mind in that we only do, it's only a two day meeting. And so you can get away and go to the full meeting, get some CME credits and return pretty much over a long weekend. And so that's the other one. And then the other thing that I would mention, and again, in my role as the newly elected second vice president of the college is that there is a very strong and renewed interest in rural surgery in the college.

(01:00:36):

And the college is looking at a number of different ways and is actually sponsoring collaborative efforts between the major players in rural surgery, which are the North American Rural Surgery Society, the Advisory Council for Rural Surgery, and the College of Surgeons is sponsoring that. And I think you're going to see, especially at next year's clinical Congress, there's going to be a separate half day dedicated to rural surgery topics. And it's be, they're a separate track at the College for Rural Surgery. So all of those things I think are going to be very good and valuable resources for rural surgeons as the subspecialty of rural surgery continues to be identified.

Dr. Randy Lehman (01:01:36):

Yeah, this is happening at the 2026 Clinical Congress, and that's in Washington DC this year. Is that right?

Dr. Bob Sticca (01:01:42):

Yeah. Yeah.

Dr. Randy Lehman (01:01:44):

September 26th through 29th. So I know some many rural surgeons that are not members in the college. And what if they're mid to late career and they want to join the college, what would you say to 'em? But they have nobody around that's in the college to be a reference or whatever.

Dr. Bob Sticca (01:02:04):

So I would say the advantages of being a member of the college, especially for a rural surgeon, are significant because most other general surgeons or certainly people that have done fellowships, they have a specialty society and so forth, whereas rural surgeons are true general surgeons and they need to have some for keeping up with state-of-the-art changes in general surgery and applying those to their practice. All of the stuff about robotic surgery and everything, I would say it's very, very beneficial to rural surgeons to be part of it. I mean, I've heard people complain about the cost and so forth, but if you look what you get for what you're paying, it's really fairly reasonable, especially if your hospital has any CME funds for you and so forth. And then the other point I think you alluded to was as a rural surgeon, are you able to join the American College of Surgeons? As long as you're board certified in general surgery, you should have no trouble whatsoever. I mean, you need a couple of references, but those applications go through your state chapter and each state chapter should have a committee to review the applications. But that's a number of steps. But you can join it and become a member and then get all the benefits of the College of Surgeons.

Dr. Randy Lehman (01:03:58):

Yep. I love it. Agree, complete with what you said. And I just thank you so much for taking this time to give me this interview and to give our listener to the interview. It's been just a joy having you, and thanks for everything you're doing for us on a national scale too, Dr. Sticca.

Dr. Bob Sticca (01:04:11):

You're welcome. I'm happy to do it. And now that I'm not doing as much clinically, I have a little more time and it's been a lot easier to do, but although I am still doing a lot of mission work, I'm actually going on a trip on the Mercy ship. I leave next Saturday and I'll be there doing surgery in Africa for three weeks. So I'm looking forward to that.

Dr. Randy Lehman (01:04:44):

Nice. That's awesome. Very good. Well, thank you very much for being here again, and thank you to our listener. This has been another episode with the Rural American Surgeon. We appreciate you being here, and we'll see you on the next episode of the show.