Brief Summary of work by “Team Innovation”

‘Preventing’ the Peptic Ulcer

Every one of us, at some point or the other has suffered from symptoms of hyperacidity and 1-4% population goes on to develop Peptic Ulcer. While scientific research has focused on treating the peptic ulcer, we paid attention to ‘prevention of ulcer’. Taking a leaf out of Ayurveda (Indian traditional medicine), we studied the simple concept of “Dry Meals” (not drinking water with meals). Our study of 220 ulcer patients found that “Dry Meals” not only helps in alleviating the symptoms of hyperacidity but also prevents it’s recurrence after the discontinuation of conventional treatment.

Dealing with surgical complications of Peptic Ulcer

Peptic perforation is among the commonest surgical emergency in developing countries. We have published techniques to deal with difficult cases and how to manage their complications.

Developing simple economical disease-severity scoring systems for developing world

Seriously ill patients are classified with the help of disease severity scoring systems for the purpose of prognostication and triage. These scoring systems measure a large number of biochemical parameters, which makes them impractical and expansive for use on a daily basis in developing countries. We have shown, in a series of studies that prognostication is possible without expansive tests and we could develop many simple, objective, accurate, user-friendly and economical scoring systems which can be used even in smallest of hospitals. These modified scoring/ risk stratification systems work for day-to-day common diseases such as peptic/ typhoid perforation peritonitis and thermal burn patients.

Simple treatment for worm infestation in children

Worm infestation in children is a very common illness in developing world, and it can give rise to many dangerous surgical complications. We haveshown that freshly made hypertonic saline (made from kitchen/ table salt) enema can give relief in > 95% cases. This study is the largest published series on this safe and effective treatment modality; allowing it to be known and used on a wider scale.

‘New’ does not mean ‘better’ every time

It is only too easy to discard conventional effective surgical procedures in favor of newer more fashionable ones. We continue to logically question and argue against this profligacy in vogue. We have demonstrated that many old and dependable procedures (for peptic ulcer perforations, cancer of rectum and biliary system) can still be used, instead of being dumped in the dustbins of history.

Developed innovative original low-cost surgical techniques for developing countries: developing ‘appropriate’ techniques

Working in resource-poor circumstances without expansive technology has prompted us to visualize and devise many new low-cost surgical procedures in response to this need. These include operation for bleeding in cases of portal hypertension (avoids use of expansive staplers), new technique for excision of cancer of esophagus (avoids use of post-operative ventilatory support which is often not available), and new technique for excision of cancer rectum (avoids use of expansive staplers). These innovative techniques are of great relevance for developing countries, as they do not require expensive instrumentation and can be used even in small hospitals.

A paradigm shift in philosophy for treatment of Typhoid intestinal perforations

Infections like Typhoid are still prevalent in developing world, and operation for intestinal perforation due to Typhoid is a common surgical emergency. Typhoid intestinal perforations had ~ 30% mortality, but if the repair of typhoid perforation fails, resulting in leakage and fistula formation, then it leads to 100% mortality; as expansive antibiotics, ventilatory support, expansive total parental nutrition and ICU care are not available. We circumvented this catastrophe by by-passing the diseased segment and performing temporary ileostomy in ‘all’ cases. This simple change in philosophy brought the mortality down from 30% to <3%.

Saw difficulties as opportunities and developed original surgical techniques for dealing with difficult situations

Our philosophy of “seeing difficulties as opportunities” allowed us to develop and publish many novel surgical techniques; these techniques include a new bypass operation for cancer of esophagus, use of simple technique of using locally available muscle for re-operation on peptic perforation cases, and a new – first in the world - technique of removal of spleen in complicated cases of sickle cell anemia. These techniques have the advantage of being very easy to use and can be used as ‘surgical parachutes’ to bail out of difficult situations.

Need-based-tailoring done in trauma index and audit system for use in developing world

We recognized the fact that international indices and audit systems cannot be used without validation in Indian scenario as the patient populations are different. We have shown that internationally accepted abdominal trauma index needs modification before it can be used accurately in India. Similarly, the popular audit system Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) is not a good predictor of low-risk patients and needs risk adjustment with the help of correcting factor for accurately predicting the mortality and morbidity.

Devising simple solutions for complex problems

Our motto is “Modify-Simplify-Apply”. Our steadfast belief in Leonardo da Vinci’s Maxim “Simplicity is the ultimate sophistication”, led us to devising many simple solutions for complex problems.

Lack of availability of sophisticated investigations to diagnose and prognosticate the outcome in Congenital Diaphragmatic Hernia prompted us to publish simple means to overcome these resource-related problems.

Large number of patients present with inoperable visceral malignancies associated with severe unbearable pain. These patients require coeliac plexus block for palliation of their pain. We have a shown simple technique of applying this block when sophisticated imaging modalities are not available.

Choice of digestive tract reconstructive following total gastrectomy is crucial and determines the quality of life of patient after such a major surgery. We have published a critical reappraisal of this important topic and suggested guidelines.

We have also simplified the reporting of Colposcopic index for examination of cervix so as to make it easier to use.

Our successful use of Linseed oil in preventing peri-ileostomy skin excoriation was very economical for patients. This idea met with immediate social acceptance as patients from rural populations have time-honored faith in its medicinal properties.

We have shown that use of economical nylon mosquito net is an acceptable alternative to commercially available polypropylene mesh in tension-free hernia repair.

Controversies about preparation of bowel or use of proximal stoma persist regarding various emergency resections of left sided colon. We have shown that bowel preparation is not needed. Similarly we have shown that resection and anastomosis of gangrenous sigmoid volvulus is safe without a proximal stoma.

Complete surgical excision of vascular anomalies is technically difficult, we have shown that repeated intralesional injections of n-butyl cyanoacrylate and fibrin glue leads to complete disappearance of smaller lesions and significant reduction in size of bigger lesions; making them easier to surgically excise with minimal blood loss.

Electronic Data Collection is increasingly being used in Surgery, but most of these software and apps are expansive, cannot be customized according to individual need and are available only after paying a commercial fee. To circumvent these issues we have developed a mobile app Electronic Data Collection of techniques and outcome of abdominal wall closure which is simple and cost effective.

Surgery for Incisional hernia (IH) is among the commonest surgical operations performed. Important factors for outcome analysis are: location, number of IH, use of prosthetic material, technique of repair, fixation/placement of mesh, and occurrence of complications and recurrence of hernia. Collection and analysis of this data is cumbersome, if done by conventional methods. We developed a simple user friendly mobile app for this purpose of Electronic Data Collection and analysis. Another advantage of this app is that it is coded in such a way that its template and variables can be changed according to requirement of a new study; thus it can be used again and again in any study design with minor modifications.

Synthetic non-absorbable mesh are routinely used in hernia surgery for clean cases but are avoided in case of clean-contaminated or contaminated hernia or dirty cases to minimize the risk of infection. We have shown that use of polypropylene mesh is safe and effective for contaminated and dirty strangulated hernias; and there is no need to use expansive absorbable meshes..

Our idea of using ordinary drainage bags for auto-transfusion of blood is very economical, utterly simple, safe and logical.

Prophylactic mesh placement for routine midline laparotomy in high risk cases for development of incisional hernia is gaining increasing acceptance. However, data for use of prophylactic mesh placement in emergency midline laparotomy in perforation peritonitis is scarce – mainly for fear of infection. Our study has shown that prophylactic polypropylene mesh placement for emergency midline laparotomy in perforation peritonitis is safe and it is effective in preventing abdominal fascial dehiscence.

Doing research on what is ‘important’ rather than what is ‘interesting’

Patients with Chronic Liver disease can present with gastro-intestinal bleeding, if Endoscopes are not available then detecting the cause and site of bleeding can become a problem. We showed that a simple biochemical test for liver disease estimation of serum-ascitic albumin concentration gradient (SAAG) which is possible even in a small, modestly equipped laboratory; and can provide a new means for the identification of high-risk patients for gastro-intestinal bleeding in developing countries.

Iatrogenic trauma of Spleen is not uncommon; we have shown ways of preventing this avoidable complication in abdominal surgery.

It is often said that a pigment gall stone is a tomb erected in the memory of bacteria infecting the bile. We showed that all gall stones, including cholesterol stones, have bacterial DNA; suggesting that bacteria have a possible role in the formation of even cholesterol gallstones. At the same time we published the much needed epidemiological data from Central India; which is in variance with studies from the northern and southern parts of the country.

Perforation of intestine with spread of infection in abdomen is the commonest emergency in surgical wards of developing countries. We showed that when bacterial infection is associated with fungal infection, it leads to worse outcome. A simple test (fungal culture) can allow early recognition and effective treatment; thereby improving outcome.

Many patients need skin grafting for their skin defects. Traditional teaching was that wound healing is directly related to hemoglobin level in the blood; therefore blood transfusion was given in anemic patients before surgery could be performed. Our clinical study proved that skin graft uptake is possible even at hemoglobin level of 6g/dL and it is not mandatory to keep hemoglobin level at or >10 g/dL, as mild to moderate anemia per se does not adversely affect wound healing. This important study has prevented many un-necessary prophylactic blood transfusions.

Difficulties in learning and mastering the technique of Laparoscopic Inguinal Surgery are well known. We noticed this long and steep learning curve and devised a simple technique to help the novice surgeon which has the advantage of ease and simplicity and can be used as a “bridge” until the necessary dexterity with laparoscopic skills is achieved.

Cheattle’s forceps are commonly used in surgical wards and operation theaters to transfer sterilized instruments and materials to the doctors’ hands. But there was little information available on the bacteriological contamination of Cheattle's forceps during routine use and the effects of antiseptic solutions. Our study fulfilled this unmet need and found that Cheattle's forceps should be kept in a bottle containing glutaraldehyde or chloroxylenol and NOT in Cetrimide which is the commonest antiseptic used. This relevant first-of-its-type study resulted in much needed sea change in day-to-day practice.

Superficial abdominal reflex is an important part of the neurologic assessment, and it may be absent in various pathological conditions. The presence of an abdominal incision creates a dilemma in the mind of the clinician for it effect on this reflex. We studied the effect of abdominal incisions on superficial abdominal reflex and showed that subcostal transverse abdominal incisions were not found to affect this reflex.

Studies on Quality of life after Gastro-intestinal Surgery

We have measured and shown the importance of ‘Quality of life’ after emergency and oncological Gastro-intestinal Surgery.

Learning from everyone

Our desire to learn from every one led us to explore ideas generated from various disciplines. Laparoscopic surgery demands mastering technically demanding intra-corporeal suturing or use of expansive commercially available pre-knotted loops. We successfully borrowed the idea from the art of ‘tatting’ (lace-making) for a simple, inexpensive, easy to use and safe technique of extracorporeal knotting.

Abdominal wall closure is one of the most important parts of abdominal operation. Our insight generated from the art of knitting led us to use an idea for secure closure of abdominal wall. This contributed to a better technique of abdominal wall closure after abdominal operations. This simple technique has the advantage of stronger repair (proved by principles of physics) and decreases the incidence of post-operative incisional hernia.

Landmark surgical anatomical studies which led to change in thinking

We have conducted many landmark anatomical studies. These studies reveal differences in anatomy between different ethnic populations and have bearing on quality control of many surgical procedures for liver, cancers of esophagus, stomach and rectum.

Our studies have implications for surgical procedures in the cranium, abdomen, hand, feet, leg and surgical treatment of dry eyes.

Two of our landmark studies have proved to be milestones and resulted in change of nomenclature in anatomical texts.

Landmark surgical anatomical studies which have the potential to improve bladder bowel continence and lower limb power in Spinal Cord injury patients

Damage to pudendal nerve or sacral roots results in bladder and bowel incontinence, which leads to significantly decreased quality of life. Restoration of bladder/bowel function by nerve transfer has the potential to markedly improve quality of life, and help prevent long term complications. We have shown the feasibility of transfer of motor fascicles from sciatic nerve to pudendal nerve in order to improve bladder and bowel continence.

The transfer of peripheral nerves originating above the level of injured spinal cord into the nerves/roots below the injury is a promising approach; as it can facilitate the functional recovery in lower extremity, bladder/bowel and sexual function in paraplegics. We have shown, in this in human cadaver study, the anatomical feasibility of transfer of Subcostal nerve to ventral root of S2 in an attempt to restore bladder function while 10th and 11th ICN had enough length to neurotize lumbar plexus.

Injury to pudendal nerve leads to Bowel/bladder incontinence which compromises the quality of life in these patients. We assessed the anatomic feasibility, by ultrasound; of transfer of femoral nerve’s motor branch to vastus lateralis (MNVL) to the pudendal nerve for restoring continence in 30 randomly selected male volunteers. The origin of MNVL was traced in the distal thigh up to the level the nerve was visible using high frequency ultra sound probe. The length of the nerve was measured with help of measuring tape. Pudendal nerve was identified just medial to ischial tuberosity on the same side. We found that MNVL has enough length and calibre to neurotize pudendal nerve in majority of the subjects and could be traced/ imaged by USG. USG can be a handy tool to assess the feasibility of transfer of MNVL to the pudendal nerve.

Simple ideas which have made a difference in management of Burns and wounds

Diabetic and ischemic non-healing pedal ulcers have a tendency for chronicity and increased chances of infection, which may threaten the viability of the foot. Systemic administration of therapeutic agents may be insufficient in these cases. Our work showed the usefulness retrograde venous perfusion which improves ischemia and promotes healing.

Similarly, we showed the utility of venous flap; which is a good alternative for reconstruction of the small defects of hand and digits. It is easy to design/ harvest, is pliable, and does not need sacrifice of a major artery at the donor site.

Burnt raw areas need early coverage and it is well known that skin graft is the best dressing which promotes fast healing. We showed that it is possible and safe to use lyophilized cadaveric skin allograft. These have become the first step to starting a skin bank – a much needed support for burn patients.

We have shown that a simple economical hand held infrared thermometer can be used in conjunction with clinical examination to improve efficacy of burn wound depth assessment; which is very important because it determines the choice of treatment and prognosis. This can be especially useful at primary health care centers and smaller hospital where burn specialists are not available; and for remote consultation.

We conducted the first ever study using surgical removal of epidermis and using dermis-only allografts in humans. Our proof of concept study has shown that if epidermis is removed from skin allograft then it survives longer because epidermis contains immunogenic cells and its removal reduces antigenicity of allograft and delays its rejection. We evaluated biological response of cadaveric glycerol preserved dermis-only allograft in 50 patients and found that duration of dermal allograft adherence to the wound bed in our study was on average 24.8 days, which is 10-14 days more than other studies using full thickness skin allografts. Removing the epidermis from the allograft can result in this profitable trade-off.

Studies in Urological Surgery

Our work has simplified surgery of female urethral injury, evaluation of healing at the urethral anastomotic site and minimal invasive technique of treating Benign Prostatic Hyperplasia with Ozone.

We have also shown the importance of screening for malignancy when Buccal Mucosal Grafts are used for urethral reconstruction and damaging effects of vesico-ureteric reflex after total nephrectomy.

Simplifying Minimally Invasive Surgery in Children

Our Pediatric Surgical team has spearheaded a successful campaign for simplifying minimally invasive surgery in children. Our work resulted in Thoracoscopic treatment of collection of pus around the heart in a child.

External angular dermoid cysts are benign lesions in children that were conventionally excised through an incision over the eyebrow; which left a cosmetically unacceptable visible scar. We described a minimally invasive subcutaneo-scopic technique that involves placing incisions above the hairline to avoid scarring on the face.

Similarly, our team showed, successfully the feasibility of laparoscopy in the treatment of pediatric urolithiasis, using trans-peritoneal laparoscopic removal of stones. Another study by us showed safety and feasibility of early laparoscopic appendix removal in complicated appendicitis and appendicular lump – which were previously considered a contraindication. This study paved the way for avoiding complications and/or failure of non-operative treatment of a potentially lethal disease. We have also described a Single Incision Trocar-less Endoscopic technique for liver hydatid cyst in children which simplifies their treatment.

Our team has described a simple easy stepwise “steering wheel” technique for derotation of volvulus associated with malrotation in children; which is the most difficult and confusing part of the surgery. 

Intrahepatic stones are often associated with Choledochal cyst in children and need removal during excision of cyst. The endoscopic equipment needed for their clearance is pediatric flexible cholangioscope; but it is expansive and not often available in resource-poor setups. We described a modified technique of per-operative rigid cholangioscopy using rigid pediatric cystoscope (an easily available instrument) for stone removal during open choledochal cyst excision. 

Laparoscopic herniotomy for hydrocele in children is an accepted procedure and provides advantages of contralateral diagnosis and repair with the same incisions. The suturing of patent processus vaginalis is associated with various complications. We have described a simple, easy and suture-less technique which can reduce suture and suturing related complications for these children.

Laparoscopic pyloromyotomy (LP) for the treatment of infantile hypertrophic pyloric has advantage of smaller incisions, faster recovery, reduction in wound related complications and better cosmesis. Various laparoscopic knives and spreaders have been used for LP but they do not provide the depth and tissue perception as in open surgery. We describe the laparoscopic ‘hybrid’ pyloromyotomy which combines the 'manual touch' of Surgeon with advantages of Laparoscopic approach. It is simple, does not require any special instrument, it is easy to learn and teach, improves safety and accuracy of the procedure.

One-stage laparoscopic anorectoplasty for division of recto-urinary fistula in high male anorectal malformation provides maximum potential for ‘‘normal’’ defecation reflexes right at birth and avoids complications/ problems of colostomy and two stage surgery. We introduced a simple 16G intracath in the perineum through the site of future neo-anus. The needle with the plastic sheath was directed upward along the curve of pelvis and inserted completely. The needle was withdrawn out of cannula and free aspiration of air with meconium stain confirmed the placement of cannula into the rectum. Proper placement of intracath was also confirmed by decompression of rectum on laparoscopic view. Meconiolysis and evacuation was done using warm saline and 2% N-acetyl cysteine. Creation of enough abdominal space was achieved after evacuation and two working instruments were placed in paraumbilical positions. The laparoscopic dissection and division of fistula was done as followed in standard laparoscopic anorectoplasty. Transperineal Intracath Meconiolysis and Evacuation (TIME) technique is a very simple and effective way to overcome the problem of associated colonic distension in neonatal one-stage laparoscopic anorectoplasty.

3-D laparoscopy is popular and well accepted in adults; however, its application in pediatric surgery is limited. We did a comparison of 2-D and 3-D Laparoscopic-assisted anorectal pull-through (LAARP) in male high anorectal malformations (ARM). There was a significant reduction of laparoscopy execution time, physical discomfort (for eye, hand and wrist strain), and overall mental strain in the 3-D group. Our study showed that 3-D LAARP is feasible and safe in the surgical treatment of ARM in children.

High-type anorectal malformations (ARM) are conventionally managed by an initial left iliac fossa sigmoid colostomy followed by laparoscopic anorectoplasty (LARP). Such a stoma occupies left half of infra-umbilical region and hinders the LARP ergonomics; leading to surgeon’s discomfort. We studied the impact of ‘lateralizing’ (shifting laterally in the abdominal wall) the colostomy on port ergonomics and found lateralization of high sigmoid colostomy (n = 40) showed many significant advantages over conventional group (n = 40); including less peri-stomal adhesions, better vision, shorter operative time, and better ergonomics (better manipulation, elevation and Azimuth angles). It also significantly reduced surgeon’s discomfort for 2nd stage LARP.

Simplifying treatment for Buerger’s disease: The commonest vascular problem for the poorest patients

In a global context, the Indian Buerger’s patients are from the lowest socio-economic strata which limit their treatment options. Our problem-solving approach resulted in simplifying surgical techniques for increasing blood supply in these poor patients – both for upper as well as lower limb ischemia.

The concept of using patient’s own blood containing various growth factors promoting improved blood supply and enhanced wound healing was used for the first time in these patients by us. This method of treatment fulfils the previously unmet need for treatment of these patients at grass root level. It is very easy, reliable and economical to prepare and can be made available in the OPD of smallest of the hospitals.

Improving quality of life of post-spinal injury patients by Simple Surgery leading to spontaneous bladder evacuation (First clinical report in the World)

Many post-spinal injury patients cannot pass urine as the denervation of urinary bladder results in its inability to contract and expel urine. These unfortunate patients are condemned to life-long clean intermittent catheterization or chronic indwelling catheter; both lead to multiple complications. Our team, for the first time in the world, showed the effectiveness of transposing an abdominal wall muscle (rectus abdominis) and wrapping it around urinary bladder which allows voluntary voiding in these patients. This simple surgery prevents complications associated with recurrent/ continuous catheterization and improves the quality of life of these ill-fated patients.

This paper led to the award of prestigeous 'Peet Prize' of Association of Plastic Surgeons of India in 2017 to its first author, Professor Pawan Agarwal. Read

Improving quality of life of Leprosy patients by Simple Surgery leading to Restoration of Sole sensation (First clinical report in the World)

Loss of sensation of sole is very disabling problem in patients of Leprosy and Diabetes; repetitive trauma in anesthetic area leads to chronic non healing ‘trophic’ ulcers, which may lead to amputation. Our team has shown, for the first time in the world, that a simple transfer of saphenous nerve to the sensory component of posterior tibial nerve at the level of ankle can restore sensation of the sole and promote healing of ulcers. This simple surgery prevents complications associated with loss of sensation of sole and improves the quality of life of these unfortunate patients.

This paper got the Dr. N. H. Antia Award (2019) of the Association of Plastic Surgeons of India for Best Article Published by Indian Authors in any journal during the previous year.

Improving quality of life of Diabetes patients by Simple Surgery leading to Restoration of Sole sensation

Diabetic sensorimotor polyneuropathy is the most common form of neuropathy. Loss of sensations in sole leads to diabetic foot ulcers and its complications including amputations. Our work has shown that, in selected patients, a simple surgery - Tarsal Tunnel Release - improves plantar sensitivity in diabetic neuropathy, prevents future complications and improves the quality of life of these patients.

Studying mindset of a surgeon just before operation (First clinical report in the World)

Surgeons are trained to make important decisions and perform high pressure tasks during surgery. The mindset of a surgeon just before operation may affect the outcome of surgery. We studied the thought process just before surgery, while scrubbing by using a Web-based questionnaire to obtain this information. We found that majority (>80%) of the Surgeons did mental revision of steps of surgery, were ready with alternative plans for unexpected findings, and thought of expected complications. Apprehensions about infrastructural deficiencies (54.4%), anesthesia (55.45%) and limitations of scrub team/ assistance (49.92%) also occurred. Mental preparation before actual surgical procedure has an important role to play and should be incorporated in preparation for surgery.

Studying retraction of rectus sheath after midline laparotomy (First in-vivo quantitative assessment report in the world)

The edge of rectus sheath retracts after the incision due to tissue elasticity. We conducted a prospective study to study the quantitative assessment of this change by this using electronic digital Vernier calliper. To our knowledge, this is the first time ‘in vivo’ assessment of rectus fascial changes has been done. Retraction of rectus was significantly more (p<0.05) in upper and lower part than in middle part of incision for both emergency and routine midline laparotomies. The retraction was significantly more (p<0.05) in emergency laparotomies than in routine midline laparotomies. Maximum retraction of rectus is about 40%; putting a question mark over the ‘actual’ distance of bites used for rectus closure. Practical utility of this observation on techniques of abdominal closure will require further study.

Ipsilateral fibular transposition (Huntington's procedure) for reconstruction of major tibial defects

Management of gap non-union of tibia is difficult for the surgeons, and time consuming for patients with unpredictable results. There are various methods to treat gap non-union, but each one has its own limitations. We reported the outcomes of ipsilateral fibular transposition (Huntington's procedure) for reconstruction of major tibial defects. It simple and technically easy for large tibial defects as it does not require microsurgical skill and/ or implants. The union of transferred fibula is faster than conventional graft as it is a vascularized graft. It is a rational choice for the treatment of large tibial defects in selected cases.

Priorities of desired functional recovery in Indian spinal cord injury patients (First report in Indian patients)

Spinal cord injuries affect various functions and therefore the Quality of life (QOL) of these patients. Regaining even partial function can lead to improved QOL; making it crucial to know which functions are most important for these patients. We conducted this survey by personal interview of patients in different spinal injury rehabilitation centres across India. A total of 112 patients completed the survey. Regaining arm and hand function was ranked as first priority by quadriplegics while bowel/bladder function and walking movements were ranked as 2nd and 3rd priority. Paraplegics ranked return of walking movements as their first priority, bladder/bowel recovery as second and trunk strength/sexual function as 3rd priority. This knowledge empowers us to focus our research on what is most important for their QOL.

Low-cost solutions in Neurosurgery

Neuroendoscopy is an upcoming branch of Neurosurgery with a steep learning curve; we have shown an easy technique of learning which is of use to develop hand-eye coordination skills required for this technique.

Pituitary macroadenoma surgery is a common procedure and requires diverse ways to reduce intraoperative blood loss. Clonidine tablet is a simple and inexpensive way to reduce the vascularity of the nasal and sphenoidal mucosa, thus reducing the blood loss and mucosal secretions. Our study showed its safety and efficacy in a randomized controlled trial.

The surgical models and simulators are important for young surgeons as there is a dearth of cadavers and ethical issues associated with animals to practice surgical skills. We have shown that various inexpensive models and simulators (of less than 1 US $ each) can be used to learn complex neuro-endoscopic skills.

Epilepsy is common in developing countries, and commoner is the stigma associated with it. Due to this stigma, patients may become outcast in society and face social, financial, and medical disparities. Our study has shown that surgery is helpful to decrease or eliminate the stigma associated with epilepsy.

Migraine is a common form of primary neurologic headache. These patients suffer from a significant disability and also from adverse effects of drugs. Our randomized controlled trial compared functional outcomes of migraine surgeries using peripheral neurectomies with medically treated patients. All patients of the operative group got free from prophylactic migraine treatment. We were able to show that Migraine surgery using peripheral neurectomies is more effective than chronic drug treatment in appropriately selected patients.

Improved teaching of assessment of Glasgow Coma Scale among Surgical Residents by Videos

Glasgow coma scale (GCS) assessment is vital for the management of various neurological, neurosurgical, and critical care disorders. Learning GCS scoring needs good training and practice. Our prospective study has shown that a significant improvement in GCS scoring by residents is possible after watching the videos with maximum benefit to the junior-most ones.

Contraction of skin flaps: re-examining the scientific basis

Contraction in a skin flap is unavoidable after it is raised because of its elastic content and despite the best of planning a flap may fall short which may lead to some necrosis. Surprisingly, scientific literature on this subject is rather scarce. We analysed the extent of contraction of flaps and the factors that might influence this contraction. We found that mean flap contraction was 20.01% in skin flaps and 20.38% in fascio-cutaneous flaps. Flaps retracted more when constructed parallel to relaxed skin tension lines as compared to perpendicular, in females and in patients with high BMI. Age did not affect the contraction. Adequate allowance should be provided to avoid stretching, and subsequent necrosis and dehiscence. The most practical way of providing this allowance is by planning in reverse in which flap size is always bigger than the defect therefore providing margin for flap contraction.

Indigenous Two-point discrimination testing device

Measurement of Two-point discrimination (2-PD) is used in clinical practice to evaluate the severity of nerve injuries, neuropathy and recovery of patients following nerve repair. Commercially available 2-PD testing devices are costly and therefore not available everywhere. We made an economical indigenous 2-PD testing device from off-the-shelf components and confirmed its efficacy in volunteers. This device is simple to make, very economical and obtains accurate 2-PD measurements.

Assessment of collateral hand circulation by modified Allen’s test in normal Indian subjects

Allen’s test (AT) and Modified Allen’s Test (MAT) are used as screening methods for assessment of the hand circulation. Few people lack the dual blood supply of hand and are at risk of hand ischemia after any intervention on radial artery. We assessed the collateral circulation of hand using MAT in 900 normal Indian subjects (1800 hands). They were divided in two groups. Group I had participants with age < 50 years and group II had participants with age > 50 years. MAT was performed in all participants and results were compared between the two groups. A positive/ abnormal test was significantly more common (5.66% vs. 1.66%, P < 0.00001) in older group. MAT is simple, time tested and non-invasive test to assess arterial flow through the palmar arches of the hand. A negative MAT safely selects patients for radial artery harvest; however, if the test is positive and in older patients then a second objective test may be needed.

Microskin grafting

Split-thickness skin autografts offer the best form of wound coverage, but limited donor sites and donor site related morbidity have resulted in the search for alternatives in the form of microskin graft. 25 consecutive patients with post burn, post traumatic and post cellulitis raw area were included in this study. After appropriate preparation of recipient bed, microskin graft was applied using standard skin grafting technique. Assessment of microskin graft was done clinically on 5th, 7th, 10th and 14th day and till the wound healed. Late assessment was done at 3 and 6 months postoperative to assess the scar. All wounds healed in ~17.28 days without the need of secondary skin grafting. There was no clinically evident infection in the grafted wounds. Over all graft survival rate was ~94.76%. After 2 months homogenous scar was present but there was hypo pigmentation in 4 cases. There was no hypertrophy or scar contracture at 6 months. We concluded that Micrografting is a feasible alternative for wound coverage and a useful tool for surgeons.

Use of PVC feeding tube, a frugal innovation for Staged flexor tendon reconstruction

Staged flexor tendon reconstruction is most suitable treatment method for delayed zone II flexor tendon injuries of hand. Hunter’s silicon rod used in this procedure is costly and not easily available. We have shown that use of ordinary PVC feeding tube, as a frugal innovation, is a cost effective, easily available and effective alternative for staged flexor tendon reconstruction.

Fast and frugal innovations in response to the COVID-19 pandemic

Necessity has been the mother of invention in the response to the COVID-19 pandemic, triggering many fast and frugal innovations. Frugal innovation in healthcare does not mean low quality but instead means the ability to provide safe healthcare in the best way possible under given circumstances and constraints. While there is a predominant emphasis on affordability and low cost in frugal innovation, three approaches help us to relate the examples we have encountered thus far in responding to the COVID-19 threat: repurposing, reuse and rapid deployment. Our study describes several such frugal innovations in some detail.

Roadmap for restarting elective surgery during/ after COVID-19 pandemic

The worldwide COVID-19 pandemic has resulted in complete stoppage of elective surgery in most countries; which has created a huge backlog of waiting patients. We have assessed and summarized the current challenges of restarting elective surgery during/ after COVID-19 pandemic.

Frugal solutions for operating room during COVID-19 pandemic

Ongoing COVID-19 pandemic has forced many changes in how surgery is and will be conducted in near future. Crucial suggestions have been made by an international Delphi consensus on COVID-19 related safe operating room practice. Some of these are quite expensive and out of financial reach of smaller stand-alone hospitals in LMICs. We have suggested some simple frugal innovative alternatives which can work under given constraints.

Questioning earlier practices followed during COVID-19 pandemic

The on-going COVID-19 pandemic has created havoc and has disrupted the health economics of all countries – barring none. As the knowledge about it is evolving, many earlier practices are being questioned. We have shown that rigorous evidence is needed before such practices are incorporated into guidelines and scientific judicious use of preoperative RT-PCR testing, CT Scan Chest and PPE kits can result in conservation of resources.

Initial advice to avoid Laparoscopic Surgery due to fear of COVID-19 virus transmission: Where was the evidence? 

Initial advice to label Laparoscopic Surgery (LS) as a high risk procedure was based on theoretical potential of virus transmission during LS as guidelines from academic associations erred on the ‘side of safety’. However, there no substantial evidence of transmission risk to Health Care Professionals. Safe management of surgical smoke is possible and frugal low‐cost smoke filters are now easily available to assuage the unproven fears of LS.

COVID19: an opportunity to rethink global cooperation in higher education and research

This on-going pandemic presents significant challenges for higher education and clinical training. It also comes as an opportunity to improve global cooperation in higher education and research by moving to online, digital learning; enhanced networks between institutions from the Global North and South; and a reformed funding and reward structure.

Surgical training: before and after COVID-19

COVID-19 pandemic has caused universal disruption of surgical training. ‘Live’ surgical learning opportunities have been significantly affected due to reduced number of operations, reduced elective surgery exposure, reduced resident staff in operating rooms; and necessitated focus on service rather than learning. Teaching safe surgical skills in these difficult times is a challenge and requires innovative ideas. We propose a needs-driven module of surgical training involving readily available low-cost simulation-based training and more ‘hands-on mentoring’.

‘EMERGE’: Construction of a simple quality appraisal tool for rapid review of laparoscopic surgery guidelines during COVID-19 pandemic

Conventional appraisal tools which assess the quality of evidence and methodological rigor in the development of guidelines have very rigorous exhaustive checklists; making them impractical for the evaluation of rapidly emerging guidelines in a pandemic scenario. Additionally, recommendations from these guidelines have not been evaluated in terms of their consequences on already resource‐constrained surgical services in low and middle‐income countries. This prompted us to develop a simple quality appraisal tool to address these research gaps. A simple objective framework to assess the quality of rapidly emerging guidelines – EMERGE (Evidence, Methodology, Ease, Resource, Geography & Economy) ‐ was constructed. In addition to evidence and methodology, it included four other domains: ease of understanding, optimization with available resources, the inclusion of input for different geographical areas, and economic implications.

Needs-driven skill training for surgical residents

We studied the impact of a needs-driven surgical training course. The course was taken by 17 first-year residents of surgery, and included a pre-course knowledge assessment test, pre-test skills assessment, as well as post-test assessment and feedback impressions. Mean post-test scores improved significantly (P < 0.05) in all theoretical and clinical skills areas. Our short and intensive needs-driven skills video training course for surgical residents fills the gap in skills development for general surgery residents.

A simple Image-Based Staging and stage-directed decision-making algorithm for Pediatric Empyema Thoracis

Pneumonia in the pediatric age group is common and it can commonly progress to pediatric empyema thoracis (PET). We describe a new Jabalpur image-based staging system and stage-directed decision-making algorithm for empyema thoracis in children which sharply defines the stages and allows the selection of appropriate surgical modality in cases of PET and leads to improved outcomes. There was a significant improvement in the success of drainage and VATS procedures, significant reduction in mean preoperative stay, mean Intercostal tube drainage days, the number of chest X-rays, mean hospital stay, and the number of open procedures. Accuracy of a new staging system to identify exudative, fibrinopurulent and organized stages of PET was found to be 94.65%, 94.65%, and 97.86% respectively. The long-term successful outcome was observed in 95.72% children

Simplified extra-pleural technique for open decortication in late stages of pediatric empyema thoracis

The menace of pleural infections has been well recognized since the time of Hippocrates. Open decortication (OD) is indicated in stage III (Organized stage) of Pediatric empyema thoracis (PET). Conventional Open Decortication (COD) has a sketchy description in the literature and variable results. We adopted extrapleural approach, previously described for radical pleurectomy in mesothelioma, and describe Simplified Thoracic Extra- Pleural (STEP) approach as a step-wise technique for OD and compared with the COD in this retrospective study. The operative duration, blood loss, need for postoperative blood transfusion, prolonged air leak >7 days, ICTD days, and hospital stay were significantly (p<0.05) lower in the STEP group. The STEP approach is a simple, useful, safe, and effective procedure as compared to OD. The step-wise description of the STEP approach can act as a surgical guide for surgical novice and trainees.

Low-cost simulation systems for surgical training

Our narrative review appraises low-cost simulation systems for surgical training. These simulators are needed for minimally invasive and other advanced surgeries because opportunities for practicing these surgical skills using high-fidelity simulation in the workplace are limited due to cost, time and accessibility to junior trainees. A low-cost box simulator can be easily made by self-assembly of locally available/ bought from online shopping portals components and even utilising used/ discarded/ expired disposable instruments. Skills acquired through low-cost simulations translate into improvements in operating room performance and their efficacy is at par with expensive systems. These low-cost systems can result in significant saving in costs of resident’s training as well as in annual running costs of skills labs. Every speciality has developed its own versions of low-cost training systems and has shown their benefits. Low-cost laparoscopic training in 3D is also possible by using the visual feedback via transparent/ open top of the box trainer. Low cost system is the more easily and widely available cost-effective workhorse which can lay the foundation of basic generic surgical skills for younger trainees; over which the edifice of advanced skills can be then easily constructed with high cost high-fidelity systems.

Rapid scoping review of Laparoscopic Surgery guidelines during the COVID-19 pandemic

Our rapid scoping review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews protocol. It found two major research gaps: lack of systematic review of evidence during the development of Laparoscopic Surgery guidelines and insufficient weightage of their impact on surgical services from the global south. These significant issues were addressed by constructing a simple and more representative tool ‘EMERGE’ for evaluating rapidly emerging guidelines which also gives the rightful importance of their impact on surgical services from the global south.

‘GRASP’ module of self-assessment with virtual mentoring for uninterrupted surgical training during COVID-19 pandemic

Disruption in surgical training during the COVID-19 pandemic has prompted many innovative ‘virtual’ modules to address the loss of learning exposure during these difficult times. We suggest ‘GRASP’ (Gain, Recognise, Analyse, Simulate, and Perform) module of self-assessment with virtual mentoring for uninterrupted surgical training. This idea merges the advantages of self-assessment and mentoring for the benefit of surgical trainees. Its embedded continuous close individualized mentoring can change the surgical training culture by initiating an assessment of surgical learning and skills right from the beginning of surgical training. 

Aetiology-based decision-based protocol for pediatric cholelithiasis

Pediatric cholelithiasis is increasingly being diagnosed nowadays because of the use of abdominal ultrasonography screening. However, guidelines are lacking for its management; this prompted us to develop a simple aetiology-based decision-making protocol. Haemolytic and symptomatic stones warrant an early cholecystectomy. Asymptomatic idiopathic stones, ceftriaxone stones, and TPN-induced stones are candidates for medical therapy under close observation. Aetiology-based treatment protocol allows a judicious selection of PC patients for surgery.

Low-cost surgery for deformity correction in Rheumatoid Arthritis hands

Surgical correction of ulnar drift of metacarpo-phalangeal joint (MPJ) due to Rheumatoid arthritis (RA) is conventionally done by silicon joint arthroplasty which is expensive and may be associated with many complications. We report good outcome with low-cost autologous interpositional arthroplasty using dorsal capsule of the joint. This low-cost option improves the hand function and cosmesis. Additionally, it avoids all the costs and complications related with the use of silicon joints.

What Makes A Surgical Teacher Great?

A great surgical teacher is revered but ‘what makes a surgical teacher great?’ is not so easy to define. Teaching is a soft skill and there are not many objective scales to assess teaching abilities. We have tried to define the qualities of a great surgical teacher; these include their global teaching skills, clinical teaching vignettes, pearls of wisdom shared during peri-operative teaching, how surgeons learn and improve their teaching skills including mastering new emerging technologies, their emphasis on evidence based practice and research, importance of feedback and other objective methods to assess quality of imparted surgical training.  

Roadmap for clinical research in resource-constrained settings

It is well known that in resource-constrained settings, clinical research is significantly hindered. Constraints are various combinations of sub-optimal human resources, poor technological backing (especially online), limited research or library facilities, limited and unequipped secretarial assistance and lack of reserved time for research work. It is not uncommon therefore for clinicians to become despondent, cynical and negatively disposed towards clinical research as a whole. This is despite the fact that such a huge amount of pathology awaits dissection and analysis in these very zones. It is, however, possible to conduct clinically meaningful research in resource-constrained settings and we describe a roadmap which may assist a multitude of clinicians facing hitherto insuperable hurdles.

Mentoring surgical trainees

The safety and treatment of patients with surgical disease is dependent on the quality of education delivered to trainees. The role of education and clinical supervisors as ‘mentors’ is essential to enhance learning not only in terms of knowledge and skills gained, but also the attitudes and behaviours required to manage patients. A mentor is more than a combination of teacher, coach, preceptor, counsellor and supervisor; many such qualities contribute and allow trainees to achieve self-actualization.

Lessons learned from plastic surgery camps in rural Central India

Shortage of plastic surgeons is well known in the developing countries and this leads to denial of plastic surgery facilities to a very large population especially in the rural area. We report a retrospective review of our experience with 60 rural plastic surgery camps in Central India over 16 years. A total of 4317 patients were operated, majority (~ 65%) of patients had cleft lip/ palate and post-burn contractures. Results were satisfactory; and there were no major complications. Usefulness of such camps is obvious and we share lessons learnt during these camps.

A rationale approach to correction of ptosis

We evaluated the functional outcomes of a modified technique of double rectangle pattern for correction of severe ptosis. 26 eyelids were operated in 20 patients; at a mean follow-up of 12 months, adequate correction was achieved in 24 eyelids and 2 eyelids had under correction. Frontalis sling with a double rectangle is simple, more efficient, as it provides a straight line of pull to the eyelid for correction of severe ptosis. 

AI algorithm for resource-optimization during COVID pandemic

Deep learning (DL) is a subset of machine learning (ML) in artificial intelligence (AI) that is capable of learning unsupervised from data that is unstructured or unlabelled. Its ability to map out patterns from large amounts of data (‘big’ data), to self-improve as and when new data becomes available and its high speed (as compared to traditional mathematical and statistical tools) in accomplishing these tasks makes it invaluable in the war against COVID-19. We hypothesised that big data analysis, machine learning and deep learning) can be used for resource allocation and resource triage and optimization and constructed an iterative algorithm for this purpose.

A simple decision-making algorithm for optimizing the use of PPE during surgery in COVID-19 pandemic

Personal protective equipment (PPE) plays a fundamental role in the prevention of spread to Health Care Professionals; especially in a surgical setting. We performed this scoping review of surgery guidelines to appraise the quality of appropriate PPE recommendations and propose a strategy to optimize the PPE usage. Quality of evidence was graded according to GRADE guidelines and by EMERGE (Evidence, Methodology, Ease, Resource, Geography & Economy) tool. The searches yielded a total of 1725 studies, out of these 41 guidelines on surgery during COVID-19 matching with pre-defined criteria were evaluated. The level of evidence was uniformly rated ‘low’, as assessed by GRADE guidelines and recommendations provided by them were mostly non-specific covering a narrow range of items. Most of the guidelines had poor EMERGE score (<40%) in terms of evidence support, resource optimization and economic implication. The crucial issue of optimization of PPE was not addressed at al. Economic implications demand optimization of PPE and conservation of resources. A simple decision-making algorithm addressing all the limitations of guidelines was constructed, which allows HCWs to safeguard themselves and at the same time optimize/ conserving resources.

Simple modification in wiring for efficient application of arch bar to achieve Inter-maxillary fixation

Inter-maxillary fixation (IMF) is one of the most commonly performed procedures to achieve occlusion in maxillofacial fractures. Many times it becomes difficult to identify the correct ends of wires because multiple wire ends look same and lie close to each other in a confined area. We describe a simple modification to identify the correct end of the wire to avoid confusion and make arch bar application smooth. At the time of wire insertion one end of the first wire was circled, than the second wire was passed and its end was bent. Therefore alternatively wire ends were circled and bent; making it easy to identify correct ends for tightening. Such a simple modification of existing technique reduces the time and application of arch bar easy.

Perforator based Propeller flap for coverage of lower leg: Single centre experience

We evaluated clinical outcomes of perforator based propeller flaps as a surgical alternative in reconstruction of small-medium size soft-tissue defects in the distal third of the leg and ankle in 53 patients. Primary aetiology was trauma (n= 41), electric burn (n=8), pressure ulcers (n=2), and post cellulitis defect and squamous cell carcinoma in one each. Co-morbidities were present in 12 patients (9 diabetes mellitus, 5 with hypertension). 3 patients were smokers. Flaps were based either on single perforator of peroneal artery (n=35) or posterior tibial artery (n=18). The range of rotation varied from 90-180̊. Mean size of flap was 90.41cm2. 43/ 53 flaps survived without any complications. There were minor complications like distal necrosis (n=5), epidermolysis (n= 2) and venous congestion (n= 3) but none of the flap was lost completely. Conclusion - Propeller flap is a versatile, reliable, quick to perform flap and gives aesthetic results for small to medium sized defects of the lower leg. Size of flap was not related to survival and co-morbidities were not associated with higher flap failure.

Standalone Flow Sensor with Alarm for Tracheostomy Tube: a Hypothesis

Tracheostomy tubes are commonly needed airway devices. Not infrequently, these tubes may get blocked, which may be life-threatening. We hypothesized to build a Standalone flow sensor that can sense and raise an alarm when the tracheostomy tube gets blocked or flow changes. This flow sensor for tracheostomy tube will sense and raise an alarm when the tube gets blocked or flow changes. This automated alarm system will enable less-trained staff and relatives to easily sense the blockage and take timely corrective measures.

Sensory neurotization of diabetic insensate feet can prevent complications of Diabetic sensorimotor polyneuropathy, improve the quality of life of patient and change its natural history (First clinical report in the World) 

Diabetic sensorimotor polyneuropathy (DSPN) is the commonest form of neuropathy which leads to insensate sole, diabetic foot ulcers (DFU) and its complications. We have shown that recovery of sensation in the sole is possible after nerve decompression (ND) or sensory neurotization surgery (sensory reinnervation of sole by transfer of saphenous nerve to sensory fascicles of posterior tibial nerve). 32 patients (46 feet) were selected for either nerve decompression or sensory neurotization depending upon presence or absence of Tinel’s sign at tarsal tunnel. At 6 month post-operatively perception of touch and pain recovered in all feet; temperature and pressure perception recovered in ∼95% feet; average vibration perception threshold returned to normal range and 2-Point Discrimination came down significantly. There were no ulcers or amputation in operated limbs during follow up period of 6 months. Prophylactic surgery in the form of ND and NT can be offered with minimal complications which significantly improve sensations in the sole in selected cases of DSPN. These have the potential to prevent complications of Diabetic sensorimotor polyneuropathy, improve the quality of life of patient and change the natural course of disease.

‘Second victim’ syndrome among the Surgeons from South Asia

Awareness of ‘second victim' syndrome and available support systems in South Asia is quite limited. We conducted this web based cross sectional Google forms questionnaire survey to assess its prevalence, impact, available coping mechanisms, gap in support systems, and future suggestions for dealing with it among the surgeons from South Asia. A total of 658 surgeons responded to the survey, 91.03 % (n=599) reported having experienced the ‘second victim’ syndrome. Prevalence of ‘second victim’ syndrome was found similar among the two genders, different experience groups, different specialties. A varied set of physical, psychological and professional impacts were noted; however any structured institute based support system was lacking and victims sought help from colleagues. Development of a structured ‘crisis plans’ providing emotional, psychological and legal support, minimizing the trauma, and guiding the second victim through the recovery process; is the need of the hour.

A study of personal financial literacy among Indian postgraduate residents

Postgraduate residents’ ability to understand and effectively manage their finances is variable. We conducted this web-based cross-sectional Google forms multiple choices questionnaire survey to assess the awareness of personal financial literacy among Indian residents. A total of 215 Indian residents responded to the survey (males-80.9%, unmarried-74.4%, pursuing broad specialties-83.3%). The majority were unaware of stocks, special student/ doctor loans, tax planning, life insurance, professional indemnity, and tax/financial planning. The majority opined that personal finance and investing should be taught at medical school/residency. This study highlights this gap in the medical curriculum and the need for formal structured financial education during training. A financial pyramid based on the hierarchy of needs is proposed.

Ghost ileostomy in typhoid ileal perforations to avoid actual loop ileostomy

Loop Ileostomy is commonly performed for Typhoid Ileal Perforations as temporary fecal diversion. This is associated with several stoma-related complications and also requires further surgery for its closure. Our prospective observational study showed the safety, feasibility and efficacy of Ghost Ileostomy in selected patients with Typhoid Ileal Perforations, thus avoiding Loop Ileostomy in one third of patients.

A call for reforms in global health publications

Global Health is all about “including the excluded”; and Lower and Middle Income Countries researchers are its major stakeholders. However, they find themselves marginalized as authors in Global Health publications. Major reforms are needed for correction of such disproportionate imbalance of power and decolonization of Global Health.

Workplace violence towards resident doctors in Indian teaching hospitals

Violence at work is becoming an alarming phenomenon worldwide affecting the millions of health care workers. We conducted this study to assess the violence towards Resident doctors in Indian teaching hospitals. Google forms questionnaire was developed and circulated electronically to resident doctors working in India. Vast majority (86%) of respondents reported having experienced violence with no difference among two genders. Verbal threat and abuse was the commonest (~94%) form of violence. Over 94% residents accepted that they had never received any training to deal with work place violence. Majority (80%) of the respondents favoured better communication, strict Laws and strengthening of security measures in hospital to prevent WPV. A workplace violence prevention program should be a required component of the patient safety system of all health care organizations.

A simple technique of immobilization of digits following soft tissue surgery

After release of post burn flexion contracture of fingers it is desirable to maintain the fingers in full extension, which is conventionally done by insertion of Kirschner wires through phalanges and metacarpal. We showed the safety and efficacy of a simpler idea of dorsally and supraperiosteally inserting spinal or intracath needle for finger immobilization in 73 fingers of 31 patients. All patients achieved stable immobilization of fingers. Our idea is minimally invasive, simple to perform and provides stable immobilization.

A novel approach to improve reliability of the distally based sural flap

Complex soft-tissue defects of the distal third of the leg, foot and ankle with exposed bones/joints, tendons and implants need a flap for their closure. Distally based sural flap is commonly used but it has a high partial necrosis rate due to venous insufficiency. We have shown that Arteriovenous supercharging by Dorsalis pedis artery with lesser saphenous vein improves the distal arterial perfusion in the flap and prevents distal flap necrosis.

A simple modification of Laparoscopic-assisted modified posterior sagittal anorectoplasty for recto-bulbar urethral fistula

Laparoscopic Anorectoplasty is useful for management of recto-prostatic urethral fistula due to easier rectal mobilization, avoidance of posterior sagittal muscular incision, and shorter hospital stay. However, its role in rectobulbar urethral fistula is still debated as there is a chance of urethral diverticulum due to incomplete dissection.  Laparoscopy-assisted modified posterior sagittal anorectoplasty utilizes advantages of Laparoscopic Anorectoplasty combined with fistula dissection using small sagittal incision preserving puborectalis. We have shown that Laparoscopy-assisted modified posterior sagittal approach is better and offers better surgical outcome.

A clarion call for more qualitative studies in surgery

Qualitative studies in Surgery are important because they contextualize the previously missing social facets of the surgical narrative and inquire in to the crucial issues of quality of life/ well-being, gender and other discriminations and biases faced by surgeons and patients, surgical education/training, mental issues and burnout etc. This has resulted in an increasing trend of qualitative studies in surgery. Authors, editors and journals have to insure that the principles of scientific rigour in qualitative research are followed; otherwise the answers will not be valid; thus rendering the whole exercise futile. More studies, addressing these fascinating ‘social’ facets of surgery, are needed.

A call for GLOCAL guidelines for global health

Current medical literature is teeming with Clinical Practice Guidelines for most disease processes. These translate best available evidence into recommendations by expert consensus for optimizing clinical management of a particular disease. However, these face sub-optimal implementation in resource-poor environments owing to practical and logistic constraints. Use of ‘glocal’ philosophy, i.e. global wisdom tailored to local resources, can ensure incorporating experience of both worlds, and thus literally gets the best of both worlds. If grass-root stakeholders are involved as Clinical Practice Guidelines co-creators, they can offer local expertise regarding strengths and weaknesses of a particular guideline and improve it.

More Surgical Clinical Trials are needed in India

Clinical trials in Surgery are central to research; however, very few surgical clinical trials are conducted in India. Such paucity of surgical trials is a cause for concern, and prompted us to explore the recent landscape of surgical trials in India. Common barriers to research are well known; if the State Government Medical Colleges can mentor a culture of research from an early stage of surgical training it can improve research productivity. Multicentre trials, involving smaller hospitals from tier 2 and tier 3 cities, are a potential solution to one of the major obstacles of surgical trials i.e. small number of patients; especially in this pandemic induced draught of elective surgical operations. A positive change in attitude of surgeons and provision of necessary funding can encourage more surgical clinical trials in India.

A low-cost model with feedback mechanism for learning hand-eye coordination in endoscopic surgery

Common Simulation models for learning neuroendoscopic skills are very expansive and lack a feedback mechanism. We have constructed an indigenous and inexpensive model which gives excellent feedback to the trainee and examiner for basic hand-eye coordination skills.

A 10-year study of the outcome of Wilms' tumor in Central India and identifying the practice gaps

Wilms’ tumor (WT) survival has shown remarkable improvement in western world, but sub-optimal outcome continues to be seen in resource-constrained settings. This 10-year retrospective observational study of 122 children revealed late presentation, sub-optimal survival and higher relapse in our setting due to practice gaps which can address preoperative staging/biopsy, preoperative chemotherapy, stage redistribution, and sub-optimal survival.

Closed suction drain can prevent postoperative seroma after Lichtenstein’s hernioplasty in complete inguinal hernia

Lichtenstein hernioplasty in complete inguino-scrotal hernia is associated with a 5-12% chance of postoperative scrotal hematoma and seroma formation; which is attributed to complete hernia sacs, extensive dissection, and the foreign body reaction due to polypropylene mesh. We have a shown that a simple idea of using a closed suction drain in the distal sac is safe and prevents formation of seroma/hematoma after repair of complete inguino-scrotal hernia.

Frugal indigenous elastic bands for Maxillo-mandibular fixation

Our simple indigenous elastic bands provide adequate traction which is maintained during Maxillo-mandibular fixation leading to complete immobilization and stabilization of the fracture segments for adequate bone healing. They are not only cheaper and readily available, but have real advantages over other conventional methods.

Total eyelid complex sparing orbital exenteration for Mucormycosis

Orbital exenteration is a radical surgery which conventionally involves complete removal of the orbital contents along with all or parts of the eyelid. However, eyelid complex can be totally spared in cases of benign disease like Mucormycosis without compromising on exposure and fear of devascularisation of the lids. We describe total eyelid complex preserving Orbital exenteration for Mucormycosis; it has the potential to speed up the healing process and provide dynamic functional and cosmetic rehabilitation.

A plea for standardised reporting of Frugal Innovations

Low-cost healthcare innovations which are designed for economic reasons, popularly called Frugal Innovations’ (FI), are all about ‘doing more and better with less for more people’. We perceived a need for scientifically unambiguous, unequivocal and transparent ‘structured’ reporting guidelines for standardised reporting of FIs because reporting of an innovation differs materially to the reporting of research. FI per se is both a solution and a process, and its many aspects are not commonly considered in normal research reporting. We propose guidelines for standardised reporting of FIs called STRONG-FI: STandardised Reporting Of Novel Grassroots Frugal Innovation which includes a 30 point checklist (Table 1). ‘STRONG-FI’ encompasses the whole process of FI from ideation, to development, to its possible usage and diffusion. The framework incorporates all three constructs of FI: affordability, adaptability and accessibility; and how it can integrate with IMRAD structure when reporting any FI.

A plea for 'Physician, heal thyself'

‘Equity in health’ is the raison d'être of Global Health, and must be the most commonly used phrase in this field. However, when the lens is turned inwards and the practice of health care on one’s own patch is examined for equity, everything is not so rosy. Despite much talk, discussion and writing, gender and ethnic discrimination, sexual harassment, aggression, misogyny, racism abound; the thesis that all people are equal and deserve equal rights and opportunities remains a theory, and not a practice. This is a call to all of us to put our own house in order first.

Bibliometric indices and Global Health publications

Several bibliometric indices are traditionally used to assess the relative importance or impact of an author, publication or a journal. However, recent rigorous scientific scrutiny has placed the actual value of these indices under a spotlight. The research quality of a publication is a multi-dimensional concept; conventional bibliometric indices, long considered a boon and basis of research evaluation reflect only one of its dimensions. Misinterpretation by using failed indices is even more obvious for Global Health publications; hence there is an immediate and obvious need for novel bibliometric indices to be developed in this field.

Low-cost model of breast biopsy for the trainees

Core needle biopsy of breast lesion is an essential skill for surgery trainees as it is required for tissue diagnosis. A very low-cost phantom breast model was created using foam as breast and beet root as core. Adequacy of core biopsy improved after demonstration with adequacy achieved in 85.7 % after demonstration versus 68.5 % before. Number of correct core sampling (beet root in biopsy gun) after demonstration was 91.4% compared to 75.7% before demonstration. All residents rated this experience as good to excellent. We conclude that for teaching core needle biopsy use of a foam-based breast model improves accuracy and adequacy of core needle biopsy in Surgery Trainees.

Systematic analysis of authorship demographics in global surgery

We investigated authorship demographics (systematic analysis of author characteristics, including gender, seniority and institutional affiliation) within recently (between 2016 and 2020) published global surgery literature. 1240 articles were included for analysis. Most authors were male (60%), affiliated only with HICs (51%) and of high seniority (55% were fully qualified specialist or generalist clinicians, Principal Investigators, or in senior leadership or management roles). Studies related to Obstetrics and Gynaecology had similar numbers of male and female authors, whereas there were more male authors in studies related to surgery (69% male) and Anaesthesia and Critical care (65% male). Compared with HIC authors, LMIC authors had a lower proportion of female authors at every seniority grade. Authorship disparities are evident within global surgery academia and remedial actions to address the lack of authorship opportunities for LMIC authors and female authors are required.

Bolus or Continuous Regimen of Jejunostomy Feed?

Enteral alimentation can be administered continuously, cyclically, intermittently, or by a bolus technique. Current literature does not suggest superiority of any one regimen. This prospective randomised control study compares the efficiency and safety of bolus and continuous jejunostomy feeding. 46 adults undergoing a feeding jejunostomy for nutritional support or as an adjunct to a major upper GI surgery, were randomised to bolus feeding (BF group, n=24) and continuous feeding (CF group, n=22). Demographic, anthropometric, and laboratory parameters were measured preoperatively and on post-operative days (POD) 3, 7, 15, and 30. These parameters; as well as nutritional and functional outcomes, and complications at POD 30; were comparable in both groups. Both groups tolerated jejunal feeds well. Bolus feeding is simple, inexpensive, and permits daily physical activities. Hence it may be preferred over continuous jejunostomy feeding for enteral alimentation.

Applied anatomy for Sphincter Saving Resection for Low Carcinoma Rectum

Abdomino-perineal Resection (APR) has been conventionally performed for Low and Ultra-low rectal carcinoma; but now the oncological long-term successful outcome of Sphincter Saving Resection (SSR) in these cases have been demonstrated. Despite the possibility of a significantly better quality of life and equivalent, if not better oncological outcome, APRs continue to be performed at a varied rate instead of SSR. Limited understanding of sphincter anatomy and the fear of incontinence among the surgeons are the main reasons for suboptimal uptake of SSR. Knowledge of sphincter preservation during surgery for anorectal malformation in children provides understanding of applied anatomy and can be used for SSR, is being presented as point of view.

Management of Giant cell tumour of hand and feet with special reference to reconstruction

Giant cell tumour (GCT) of hand/feet is a rare tumor with locally aggressive biological behaviour. After excision of GCT of small bones, reconstruction is a major challenge. This retrospective study includes 10 patients of GCT (3 recurrent and 7 primary) of hand and feet. There were 6 female and 4 male with mean age of 26.4 years. At mean follow up of 12.8 months all patients were pain free with good union and stability; there was no stress fracture of the graft, non-union or recurrence. Campanacci’s classification is helpful in planning the surgical treatment. Curettage or amputations do not require major reconstruction; formal reconstruction is needed after wide excision to preserve function and aesthetics. An algorithm for type of reconstruction needed after excision of GCT of small bones is provided.

Surgical Innovation in LMICs - the perspective from India

Surgical Innovations are central to surgical progress, and have led to exponential growth in various fields of Surgery. Surgical Innovations in Lower and Middle Income Countries are the result of creativity of frontline health workers in search of simple, safe and ethical solutions for their unique challenges. The key lies in: ‘simplifying the idea/ technique/ device’ to find patients’ needs-driven low-cost innovative surgical solutions; which can be used on a wider scale to achieve health equity for underserved populations. Local surgeons understand the difficulties and nuances of various problems and can provide local-evidence-based customized solutions for their patients’ health problems. We developed a Surgical Innovation Ecosystem allowing us to see difficulties as opportunities, learn from everyone and conduct research on what is ‘important’ rather than what is ‘interesting’. Barriers to Surgical Innovations in Lower and Middle Income Countries are well known; however, a roadmap to overcome these barriers is now available. The right balance has to be found between encouraging creativity and innovation while maintaining ethical awareness and responsibility to patients. Introduction and adoption of Surgical Innovations are governed by evidence-based principles and have to undergo a rigorous and scientific evaluation. Science of Surgical Innovations has finally come of age and is getting its due recognition and the pioneering innovators are receiving the much needed appreciation and support.

Is it time to prefer Never Frozen Plasma over Fresh Frozen Plasma?

Plasma is one of the mainstays of traumatic haemorrhage treatment. Fresh frozen plasma (FFP) is the commonest plasma formulation used. A recent in-vitro study showing significantly less growth factors (that play a role in angiogenesis, cell growth, and cell proliferation) and more pro-inflammatory chemokines in FFP, as compared to Never Frozen Plasma (NFP), has prompted a debate about preferred plasma formulation for transfusion in trauma patients. Hence, infusion of large amount of FFP may exacerbate an already activated inflammatory cascade. FFP has been shown to be associated with increased short-term mortality and enhanced risk of systemic inflammatory response syndrome, infection and sepsis. In light of these studies, a call can be made for increasing the use of NFP, which is safer, has immediate availability, a longer storage life, preserves potentially advantageous growth factors and avoids previously unrecognized possible harmful cytokines.

Molecular profile and clinico-pathological characteristics of breast cancer in Central India

This is the first study on molecular breast cancer subtypes from Central India. We prospectively reviewed 260 consecutive breast cancer patients diagnosed at the Department of Surgery, Government NSCB Medical College, Jabalpur (MP) between January 2017 and December 2020 and analysed their clinico-pathological and molecular profiles. In Central India breast cancer occurs at an earlier age and is diagnosed at a more advanced stage. In this region, pre-menopausal breast cancer is more common than post-menopausal and Triple-negative breast cancer tumors have similar incidence in pre-menopausal and postmenopausal women.

Low-cost vacuum assisted core needle biopsy technique for breast lumps

Core biopsy is now standard of care in the assessment of breast lumps to diagnose malignancy. Unfortunately, cost of core biopsy system is a major limitation in low-and middle-income countries (LMICs). This prompted us to devise and appraise a low-cost simple model of core biopsy (vacuum assisted core needle biopsy-VACNB) using a 50 ml syringe, a 10 ml syringe and a 14G needle. 57 consecutive women (median age 42.66 years) with breast lumps (median diameter 5.2 cm) underwent VACNB. The sensitivity for diagnosing malignancy was 92%, specificity was 100%, and diagnostic accuracy was 92.98%. The positive predictive value of this technique was 100%, and negative predictive value was 63.64%. The cost (~ 5.5 USD) of the system was significantly less than the cost of core biopsy needle (~ 41.00 USD) and vacuum assisted breast biopsy needle (~ 341.00 USD) in India. Our low-cost VACNB technique is easy to use and accurate. Frugal innovations are needed to overcome cost constraints in LMICs.

Post-Decolonisation: Global Health and Global Surgery’s coming of age

Our editorial ‘Post-Decolonisation: Global Health and Global Surgery’s coming of age’ highlights ongoing barriers to decolonization in Global Health and Global Surgery and how the HCWs from both Global North and Global South can lose their colonial and post-colonial mind-sets respectively, fully embrace the change so that they truly become the two sides of the same coin and ‘walk the talk’ – together, hand in hand.

Low cost dual dye technique for Sentinel Lymph Node Biopsy in Carcinoma Breast: Potential Solution for Resource Poor Settings

Sentinel lymph node biopsy using radio-pharmaceutical and a blue dye is gold standard for axillary staging in clinically node-negative breast cancer. High costs and limited availability of radio-pharmaceutical and/or gamma probe are major deterrents in performing Sentinel lymph node biopsy in developing countries. This prompted us to prospectively evaluate feasibility of Sentinel lymph node identification of fluorescein-guided Sentinel lymph node biopsy in combination with methylene blue dye. We found adequate Sentinel lymph node identification and False Negative Rate using low cost dual dyes in early breast cancer patients and this technique can be used in low resource settings.

Surgical Education and Academic Surgery: Quo Vadis?

For the last three and half decades, I have been passionately teaching the art and science of surgery. Over this long period, the disciplines of Surgical Education and Academic Surgery, as well as my approach to both, have undergone lot of changes. This editorial recounts some of them including cultivating my style of teaching, UG/ PG training and mentorship. It also highlights how small and mid-sized institutions can offer good academic innovative research atmosphere and invaluable experiences for their trainees. Other issues addressed include the age-old debates about evidence based teaching vs. eminence based teaching; knowledge vs. wisdom and the ‘Town vs. Gown’ conflict between the private and teaching hospitals. And finally it introduces this special issue of Indian Journal of Surgery and its eclectic range of articles.

Catch them young

Global surgery has become a force majeure recently but few medical schools include it in their curricula. Virchow’s teaching ‘medicine is a social science’, if practiced today can be a win-win situation for the individual student as well as for the discipline of global surgery.

Global Surgery: Advent of a new discipline

Global surgery is a rapidly developing multidisciplinary field, aiming to provide equitable and improved surgical care across international health systems often with a focus on underserved populations of low- and middle-income countries. Lancet Commission on Global Surgery report prompted the World Health Assembly, World Bank, and other stakeholders like World Health Organization, Surgical academic associations and institutions, the biomedical devices industry, and news media and advocacy organisations to a roadmap for building sustainable, resilient Global surgical systems. A recent attention on ‘decolonising’ it can only strengthen it, like a rite of passage, a coming of age. Future research must focus on gathering stronger data on quantifying its need, access and quality. 

Open-label three arm trial comparing Ormeloxifene, Gamma Linolenic Acid with methylcobalamine + vitamin C and placebo in mastalgia

We evaluated the beneficial effect of Ormeloxifene and combination of Gamma Linolenic acid with methylcobalamine and vitamin C on 113 consecutive women with mastalgia in a three-arm open-label placebo-controlled trial. Ormeloxifene was not found superior to GLA or placebo and had concerning side effects. Role of Ormeloxifene in mastalgia needs further evaluation before recommending it as preferred therapy.

Barriers and Challenges in providing standard breast cancer care in low resource settings

In this study, we investigated the barriers to the delivery of internationally accepted breast cancer care in low resource settings (LRS) as compared to well-endowed resource settings (WRS) via an online survey. The survey was completed by 199 surgeons from eleven countries: 51 from WRS and 148 from LRS, based on our definition. The two most common facilities lacking in LRS were sentinel lymph node biopsy and immune-histochemistry (67% and 60% respectively). Only 22% respondents from LRS confirmed that all their eligible patients received hormonal therapy and only 8% radiotherapy as compared to 98% and 75% from WRS.  Widespread limitations exist in most LRS, making internationally accepted breast cancer treatment guidelines impossible to follow, and thus resulting in suboptimal cancer care.

Global South Clinician: A juggler par excellence

This editorial is a panegyric for clinicians working in the global south. It is well known that these doctors have workloads hugely greater than their counterparts in the rich world, and also work against all types of odds; moreover, they have to wear many hats, juggle many responsibilities and can seem to be veritably a one person orchestra.

Anatomical feasibility of S1 neurectomy and contralateral S1 transfer for spastic hemiparesis

Acquired brain injury causing spasticity, pain and loss of function is a major cause of disability and lower quality of life. Sacral 1 (S1) neurectomy claims to reduce spasticity in lower limb without any permanent deficit thus promising outcomes in spastic hemiparesis. We conducted this cadaveric study to study the surgical anatomy, surgical approach and feasibility of S1 neurectomy and contralateral S1 (cS1) transfer. This study was conducted in 10 cadavers, 2 cadavers underwent endoscopic S1 neurectomy and 8 cadavers underwent open S1 neurectomy. Mean S1 root length and diameter were recorded using Schirmer tear strips and Vernier calliper. Feasibility of transfer was also assessed by measuring the distance between distal ends of donor nerve to proximal end of recipient nerve. Mean thickness of right S1 root was 4.02 ± 1.5 mm and left S1 was 3.89± 1.18 mm. Mean length of right S1 root was 24.9± 4.56 mm and left S1 was 23.6 ± 2.86 mm. Endoscopically dissected length of S1 was much less as compared to open technique. S1 neurectomy can be done by open as well as with endoscopic approach while for contralateral S1 transfer open approach needs to be used.


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