L. Michael Brunt¹, Jin Ye Yeo²

¹Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA; ²ALES Editorial Office, AME Publishing Company

Correspondence to: Jin Ye Yeo. ALES Editorial Office, AME Publishing Company. Email: ales@amegroups.com

This interview can be cited as: Brunt LM, Yeo JY. Readers’ Choice: Author Interview with Dr. L. Michael Brunt. Ann Laparosc Endosc Surg. 2025. Available from: https://ales.amegroups.org/post/view/readers-rsquo-choice-author-interview-with-dr-l-michael-brunt.

Expert introduction

Dr. L. Michael Brunt is a nationally recognized laparoscopic surgeon. He is the former chief of the Section of Minimally Invasive Surgery and is the Pruett Professor of Surgery at the Washington University School of Medicine in St. Louis. He has focused on laparoscopic abdominal, solid organ, and biliary surgery, including adrenal tumors.

Dr. Brunt’s article, “How do I do it: laparoscopic cholecystectomy”, published in our journal, has received an outstanding readership and entered the journal’s Most Read Article List.

Interview

ALES: You have had a distinguished career in laparoscopic surgery. What first drew you to this field, and how did you decide to specialize in minimally invasive techniques? 

Dr. Brunt: When I was in training in the 1980s, I did not do a single laparoscopic case as a resident. Shortly after, when I started to practice, the first laparoscopic cholecystectomy was done at our institution and the benefits were so obvious for the patients, such as less pain, faster recovery, return to activity, and fewer complications. It was apparent that this was the next step. None of us knew where it was headed, and it evolved a lot more quickly than we realized it could. I was fortunate to get involved pretty early on.

ALES: How have you seen the field of laparoscopic surgery evolve over the years? What do you believe are the most significant advances that have reshaped the specialty?

Dr. Brunt: There have been so many advances that have occurred. When we first started doing laparoscopic surgery, the equipment was fairly rudimentary. The imaging was okay, but it has gotten so much better, and the quality of the imaging and the surgical tools that we use, many of which did not exist in the early 1990s when we first started doing this. For example, advanced energy devices, ultrasound coagulators, advanced bipolar instruments, and laparoscopic stapling instruments. These advances have helped move the field forward tremendously.

More recently, robotics certainly had a positive impact and expanded the number and types of surgeries that can be done with a minimally invasive approach. Another thing that is often unappreciated is that laparoscopic surgery really changed the surgical training paradigm. As it is a totally different technique and technology, it made us start to learn things in the lab before we do the surgery, compared to before, when we learned everything on the job in the operating room. It was also the primary impetus for developing surgical and laboratory skills, which are now ubiquitous and an important part of every training program. I think oftentimes people do not appreciate that all our surgical skills labs arose out of the laparoscopic revolution.

I would also be remiss if I did not mention my dear friend and colleague, Dr. George Berci, who was the father of laparoscopy. Dr. Berci passed away this past August at the age of 103, and he spent his entire career from the late 1950s working on laparoscopic surgery. The imaging system that we have today, the Hopkins rod lens system, and so many surgical tools that we have today were direct results of Dr. Berci’s seminal work, which he continued, and the field would not be where it is today if it were not for his many contributions.

ALES: What do you consider to be the most common obstacles in laparoscopic surgery?

Dr. Brunt: One of the things that has happened over the last decade that I have witnessed in my career is the complexity of patients and cases. We are seeing more re-operative surgery, and re-operative surgery is more difficult for laparoscopic surgery.

The obesity epidemic has also raised challenges for doing both open and minimally invasive surgery. Fortunately, bariatric surgery is now done minimally invasively. One of the great advantages of using minimally invasive techniques is that for obese patients, there are even greater advantages because they have a much higher risk of complications and morbidity.

ALES: Your article, "How do I do it: laparoscopic cholecystectomy," has received widespread attention and recognition. What do you think it is about your approach or perspective that resonates most with the surgical community?

Dr. Brunt: First of all, laparoscopic cholecystectomy is the most common operation done by general surgeons, so the whole topic is of wide interest. It is an operation that typically has a short recovery and full return to activity with low complications. But if you have a bile duct injury, it can be devastating for the patient and the surgeon. So, I think surgeons recognize that and want to achieve better outcomes. It is a fundamental operation that every surgeon is trained to do, so I think it is for the aforementioned reasons that there has been a lot of interest in safety. It is an area where, if we embrace those principles, I really believe, and I am starting to see it, that it can have an impact in lowering the rate of bile duct injuries and serious complications that occur in these operations.

ALES: In the article, you emphasize the importance of adhering to the principles of safe cholecystectomy. Could you expand on these principles?

Dr. Brunt: One of the first things that we did when we started the Safe Cholecystectomy Program in SAGES in 2014 is we carried out a Delphi consensus among surgeons and SAGES community members on what were the most important principles for safety in this operation. Out of that work, we came up with a 6-step program for safe cholecystectomy. Number 1 on that list is understanding the critical view of safety and using it in every case. If there is only one thing that surgeons could adapt to and do, it is to ensure that they understand the critical view of safety (CVS) and use it on their patients. That is probably the single most important step one can embrace to reduce the risk of bile duct injury (BDI).

Secondly, having a more liberal approach to using intraoperative imaging, be it cholangiography or ultrasound, and now we have near-infrared cholangiography in which you can do biliary mapping throughout the case, and those technologies are something to embrace.

The third important principle would be to recognize when you are in the zone of danger, as the conditions can be really dangerous and increase the risk of injury, and alternating the approach to something else, such as a subtotal cholecystectomy. I would like to add that we also had a multi-society international consensus conference on the prevention of bile duct injury during cholecystectomy, which reiterated these important principles that surgeons can adopt to reduce the risk of BDI.

ALES:  Your article addresses the 6–8% complication rate for laparoscopic cholecystectomy. In your practice, what steps do you take to reduce the occurrence of these complications, and how do you ensure patient safety during the procedure?

Dr. Brunt: The complication rate should be less than that, and I think we made some progress in that aspect. First of all, recognizing patients who have higher risks, such as older patients and those who have had acute cholecystitis or obesity. Recognizing those risk factors in advance, being prepared to use different tools to make the operation safer, and using intraoperative imaging can result in a better patient outcome.

When you have a difficult case, there are a couple of important principles. One is to slow down when you are getting into a difficult area, step back to question yourself, and make sure you recognize the anatomy and be willing to shift gears if things are not going as expected. One final principle, which is one of the 6 steps, is to get help. Call for help if you are having difficulty.

ALES: In your opinion, where do you see the most room for improvement or innovation in the surgical techniques for laparoscopic cholecystectomy over the next few years?

Dr. Brunt: One area that we can do better is the management of common bile duct stones. Most patients with bile duct stones are managed by endoscopic retrograde cholangiopancreatography (ERCP), which is a very effective technique, but it has been clearly shown that it is better and less costly for patients if surgeons can manage it in a one-step operation. I think surgeons are becoming more comfortable with common bile duct exploration, and there have been some advances in that regard, such as intraoperative imaging with improved choledochoscopes, and education and training around bile duct exploration. But it remains an area for future work and improvement

Next is robotics. There is some controversy around robotic-assisted cholecystectomy. There have not been any studies that have shown that it improved outcomes or that robotic-assisted cholecystectomy has an advantage. In fact, there have been concerns that there may be an uptick in bile duct injuries during the learning curve, and it is more costly. The most important thing about robotics is that the surgical principles should not change. If you do an operation with a robot, the principles of safety do not differ from those of conventional laparoscopy. It is likely and inevitable that there will be more use of robotics, even for cholecystectomy, down the road. One really exciting area is the use of artificial intelligence in cholecystectomy and helping surgeons recognize danger zones. There is already some work being done in this area, and I foresee greater use of artificial intelligence in even common operations.

ALES: Finally, for surgeons looking to specialize in minimally invasive surgery, especially laparoscopic surgery, what advice would you offer them in terms of developing their skills and ensuring they are performing these procedures safely and effectively?

Dr. Brunt: For the residents, start early. The sooner you get to start doing minimally invasive operations, the more you can develop your skills. In fact, I would say to even start in the final year of medical school to prepare yourself for a surgical internship. Get involved in skills training labs and practice. Back in the early days of the laparoscopic revolution, we did not have any formal skills training, but we spent a lot of time in the lab working on procedures and gradually developing them over time. It is important to embrace programs like Fundamentals of Laparoscopic Surgery to ensure you have those important baseline skill sets. Advanced training in minimally invasive surgery and fellowship training has become critical for surgeons who want to do complex laparoscopic surgeries well.

Reference

1. Majumder A, Altieri MS, Brunt LM. How do I do it: laparoscopic cholecystectomy. Ann Laparosc Endosc Surg 2020;5:15.