Surgery: The Presidential Cholecystectomy

Lurking half-hidden behind the lower edge of the liver, the pear-shaped gall bladder serves as a storehouse for an essential substance—the thick, greenish bile (or gall) that the liver manufactures to aid in the long and complex process of digestion. In the young, the gall bladder usually stays healthy and does its job quietly and uncomplainingly. By the time a man reaches his middle forties, his gall bladder becomes increasingly subject to infection (cholecystitis) or filling up with gallstones (cholelithiasis), or both.

The “stones” range in size from a grain of sand to a marble. They are made up of cholesterol, bile acids and other digestive substances, and when they interfere with the flow of fat-digesting bile to the duodenum (see diagram), they may cause sharp and colicky pain, especially after a heavy, fatty meal. This is what happened to President Lyndon Johnson at his Texas ranch early last month.

Live Without It. X rays ordered by the White House physician, Vice Admiral George G. Burkley, confirmed his suspicion of a poorly functioning gall bladder. A second set of X rays, forwarded to the President’s longtime friend and personal physician, the Mayo Clinic’s Dr. James C. Cain, gave added evidence that the gall bladder contained stones. Since some bile always passes directly through the common duct from the liver to the duodenum, and the duct seems able to develop some storage capacity of its own, man can live without his gall bladder. Thus surgery to remove the offending organ (cholecystectomy), far from being a desperate last resort was the doctors’ first choice.

With the development of antibiotics and safer anesthesia, removal of a gall bladder is now a safe though still a major operation. Only about one-half of 1% of patients die as a result of the operation, and most of these are in poor health as the result of other diseases. The President was in good health. Physicians saw no reason to suspect any connection between his gall-bladder trouble and his bouts of kidney stones in 1948 and early 1955; he had made a full recovery from his heart attack, which came later in 1955. The danger to his life from last week’s operation was negligible.

Dr. Cain understandably called in a Mayo Clinic surgical team whose members he knows well and with whom he has learned to work smoothly. Chief Surgeon George A. Hallenbeck, 50, son of a former Mayo physician, is a man of whom his wife says: “His outstanding quality is that he is always composed under stress”—a quality that was highly useful when he slit open the belly of the President of the United States at the Naval Medical Center in Bethesda. To assist him in the operation, Dr. Hallenbeck brought his Mayo colleague, Dr. Donald C. McIlrath, 36. Behind his distinguished patient’s head, in the vital role of senior anesthesiologist, controlling the unconscious patient’s breathing and monitoring his heartbeat and blood-oxygen level, he stationed Dr. Edward P. Didier, 40, assisted by the Navy’s anesthesiologist, Dr. Robert J. Van Houten.

Didier and Van Houten checked their instruments, which recorded the patient’s heartbeat, breathing rate and blood pressure. Not until they looked thoroughly satisfied did Surgeon Hallenbeck raise an interrogative eyebrow and ask, “Scalpel?” At Didier’s permissive nod, without which he would not have proceeded, Hallenbeck began a right subcostal (below the ribs) diagonal incision. (It was well away from the scars that had been left by the President’s 1937 appendectomy and his 1955 kidney-stone operation, which was on the left side.) The surgeons cut on down through 1½ in. of abdominal wall until they exposed the lower edge of the President’s liver, and the gall bladder beneath it. They severed the narrow, inch-long tube leading from the common duct to the gall bladder, and tied the stump closed. Then they delicately cut around the gall bladder, freeing it from its fibrous attachments to the liver’s casing and the peritoneal sac. In it they found a ½-in. stone.

A Second Stone. At this point, the surgeons faced the difficult and delicate task of ascertaining whether there were other stones in the common bile duct, where they can do the most damage, causing severe illness ending in liver failure. The common duct is only ¼-in. thick and is extraordinarily delicate and susceptible to surgical injury.* Dr. Hallenbeck’s team examined the duct by palpation (running their gloved fingers along it) and satisfied themselves that it was clear of stones.

The surgery was not yet over. X rays had indicated that there was a “kidney stone” (so called because that is where it had formed) which had begun to migrate down the right ureter toward the bladder. What the X rays had not shown clearly was whether the surgeons would be able to get at it easily. Fortunately the stone was readily accessible, about one-third of the way down the ureter, which it was partially obstructing. Mayo Clinic Urologist Ormond Gulp made a small cut into the side of the ureter, removed a ragged stone ¼-in. across, and sewed up the small incision in the ureter. It seemed probable that the ureter stone had caused some of the President’s recent discomfort.

“From skin to skin,” as surgeons speak of the time from the first incision to the placing of the last suture to close the wound, the operation took 21 hours. Only the last 15 minutes had been added by the ureteral-stone removal. The President will have some discomfort from the healing of the wound for several days. He may well be forced to take it easy for a few weeks, because his prodigious energy will not be quite up to par. And even after he is back on the job, he will have to stick to a moderately low-fat diet—which is what he is supposed to have been doing anyway, ever since his heart attack.

Hospital corridors and even some medical journals are full of chatter about difficulties said to be experienced by patients after gall-bladder removal. Usually the problem is dressed up under the name, “post-cholecystectomy syndrome.” Harvard’s Dr. William V. McDermott Jr. has looked into the situation, and reports in the authoritative textbook Surgery (Saunders; 1963): “In all probability there is no such syndrome.” Even without a gall bladder, President Johnson’s duodenum should continue to get as much bile as it needs. And the presence of yet another stone, discovered in Johnson’s kidney in 1955 but unmoved since then, seemed to pose no immediate problem.

* It was such an accidental injury that marred an otherwise successful operation on the Earl of Avon (Anthony Eden) in England in 1953, sent him to Boston two months later for repair of the duct.