Siddhartha Phukan – My Surgical World

By Dr Siddhartha Phukan, Consultant Surgeon

21 July 2026

After twenty-two years as a hepatobiliary surgeon in Northeast India, I have learned that the common bile duct, whose surgery is often dismissed as routine, remains one of surgery’s greatest teachers of restraint. The anatomy here is adversarial—distorted by stones, strictures, inflammation, or the calcific scars of tropical pancreatitis that plague our region.

There comes a point in every biliary surgeon’s career when confidence quietly matures into something far more valuable—humility. It is rarely taught in textbooks, never demonstrated in operative videos, and cannot be acquired in any workshop. It is learned one difficult case at a time.  

And Calot’s triangle is where many of us learn this lesson. No structure in the human body has punished overconfidence so precisely, or so often.

The biliary tree has a remarkable way of reminding us that anatomy is only partly visible. What appears straightforward on imaging often becomes uncertain beneath the laparoscope. A cystic duct disappears into inflammation. A right hepatic artery appears where it was never expected. A stone refuses every attempt at extraction. The operation that seemed routine in the morning becomes an exercise in patience by noon. Biliary surgery is common enough to become invisible to the mind that performs it. And this familiarity is where humility erodes fastest — not in the difficult case, where every surgeon is already alert, but in the thousandth easy one, where the hands move faster than the judgment does. This is not simply an anecdote. It happens every year to surgeons of every level because the greatest danger is not technical difficulty—it is psychological ease.

Early in my career, I believed that technical excellence was enough. I thought every difficult gallbladder could be conquered with persistence and every duct explored if only one possessed sufficient skill. Experience has since taught me that persistence without judgment is merely another form of pride.

One particular case made that lesson unforgettable. I still remember a woman with repeated attacks of cholangitis. Her scan showed a large common bile duct stone. The ERCP began smoothly, but the stone would not come out. My first instinct was to keep trying. Experience told me otherwise. We changed our plan and performed a laparoscopic bile duct exploration. Even then, the duct became fragile and developed a small tear. We placed a stent, drained the area, and allowed healing. She recovered well. The case reminded me that humility protects patients far better than stubbornness.

Most bile duct injuries occur not because surgeons lack technical skill but because they become certain of an anatomy that is not truly understood. The Critical View of Safety exists precisely to challenge that certainty. It forces us to pause before clipping or cutting. If doubt remains, cholangiography, ultrasound, subtotal cholecystectomy, or simply stopping the dissection become acts of wisdom rather than failure. Every pause reminds us that certainty must be earned, not assumed.

Humility in biliary surgery manifests first as respect for the unseen. We must remember that a failed ERCP is not defeat; it is data. The decision to place a T-tube or internal stent, to call for gastroenterology or interventional radiology input, or simply to stage the procedure reflects maturity, not inadequacy. 

Converting a laparoscopic operation to an open one is not regression but wisdom, and perhaps, I would argue, the single most under-celebrated act of skill in our field. It requires no dexterity. It requires only the capacity to set ego beside the patient, rather than between them and the patient. And these are not signs of weakness. It is the wisdom to recognise the limits of certainty. They are signs of maturity.

Modern technology—Cholangiography, indocyanine green fluorescence, and emerging AI-assisted anatomical recognition- does not remove the need for doubt. They simply give doubt a second instrument. And it does not replace judgment. It simply gives humility another instrument.

After years of performing ERCP, laparoscopic bile duct exploration, and complex biliary reconstruction, I have realized that success is not measured by the number of difficult operations completed. It is measured by the complications we prevent. The cases that bring me the greatest satisfaction are often those in which I deliberately chose the safer, simpler path.

I have come to think of humility in biliary surgery not as a virtue to be summoned in difficult moments, but as a discipline to be maintained in easy ones. The surgeon who feels no uncertainty in a “simple” gallbladder is often the surgeon closest to error. Conversely, the one who still asks — is this truly the cystic duct, have I truly separated it from the porta hepatis, would another set of eyes see what I see — is practicing the only reliable safeguard we have.

Perhaps that is the enduring lesson of biliary surgery. The anatomy does not care about our reputation, our experience, or our confidence. It rewards only careful observation, disciplined judgment, and profound respect for anatomy, tissue planes, and the patient whose life depends on our judgment. Because ultimately, biliary surgery humbles us by revealing surgery’s true nature: a temporary alliance with the body’s resilience. We incise, clear, reconstruct, and step back—leaving the final healing to forces beyond our control. Pride belongs to the patient who walks out of hospital; the surgeon’s role is stewardship, not ownership. 

In the operating theatre, as in life, the greatest skill is knowing when to pause, when to seek help, and when to accept that, ‘Some stones, like some truths, resist immediate conquest’. True mastery lies not in flawless execution but in the quiet courage to remain teachable. The biliary tree continues to instruct those willing to listen.