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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.

Awake focussed craniotomy for oedematous/large brain lesions: A pilot study for safety and feasibility

Awake craniotomy is helpful in allowing intraoperative neuromonitoring for cranial lesions. Traditionally this is done for only small or non-edematous tumors. We have now shown that it is safe and feasible in even large and non-edematous space-occupying lesions.

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.

Combining omental plug and patch: a simple adjunct to safer repair of Giant Prepyloric Perforations

Giant prepyloric perforation (i.e size > 2 cm) is a challenging surgical problem; options include repair with an omental patch or an omental plug. Alternative methods are more complicated and the leak rate and mortality is unacceptably high. This prompted us to combine the omental plug and patch for an effective repair. We present a case series of five patients repaired in this fashion, all of whom had an uneventful recovery, except for one who had a superficial abdominal wound dehiscence, but there was neither post-operative leak nor mortality.

Challenging the existent dogma - synthetic mesh placement in enterostomy closure

Enterostomy reversal and fascial defect cause weakness in the abdominal wall and may lead to formation of incisional hernia. Conventional thinking suggests that placement of synthetic mesh in dirty/contaminated wound causes high chances of surgical site infection (SSI) and mesh related complications. We challenged this dogma by conducting a prospective case-control study in 60 patients undergoing enterostomy reversal. In 30 (23 loop ileostomy, 5 double barrel ileostomy, and 2 colostomy) patients polypropylene mesh was placed (9 sublay and 21 onlay) and other 30 (28 loop ileostomy, 1 double barrel ileostomy, and 1 colostomy) were taken as control where mesh was not placed after stoma closure. SSI was significantly lower in mesh group than non-mesh group (16.6% vs. 40%; P=0.019). Use of mesh was associated with slightly better outcomes in terms of rate of wound dehiscence (3.3% vs. 6.7%; Z=0.59; P=0.554) and incisional hernia (0 vs. 6.7%; p= 0.492). Mesh removal for chronic infection was not required in any case. We showed that placement of permanent synthetic polypropylene mesh at the site of enterostomy closure for prevention of incisional hernia can be done safely without fear of having increased risk of SSI and need of mesh removal.

The science behind the learning curve

Measuring the surgical learning curve (LC) has potential benefits for patient safety and surgical education. Even though it is known that the learning of a practical skill becomes easier with time, the LC remained underutilized in medicine and surgery for decades. The understanding of the LC amongst surgeons needs to be enhanced in terms of its components, measurement, application, and reporting. We reviewed the science behind the learning curve and its application in surgical learning and research. Application of knowledge of learning curve can help the surgeons to more rapidly achieve/maintain a high expertise level, improvise outcomes for their patients, and facilitate the investigators to scientifically report, audit, or research the surgical learning/innovations.

Platelet to Lymphocyte Ratio (PLR) and Neutrophil to Lymphocyte Ratio (NLR): predictors of mortality in Peptic Ulcer Perforation Patients

We evaluated the prognostic role of Platelet to Lymphocyte Ratio (PLR) and Neutrophil to Lymphocyte Ratio (NLR) as predictors of mortality in Peptic Ulcer Perforation Patients. ROC curve analysis showed that the value of PLR ≥ 216.1 and NLR ≥ 10.68 has diagnostic value in predicting the mortality in Peptic Ulcer Perforation Patients and can be uses as prognostic markers.

Harmonic scalpel hemorrhoidectomy - Open versus closed: a comparative study

We compared open versus closed method of harmonic scalpel hemorrhoidectomy to determine the differences in terms of operative time, hospital stay, postoperative bleeding, pain, and other complications. A total of 40 patients, 20 each in open and closed method harmonic scalpel hemorrhoidectomy were followed up for 6 weeks postoperatively. Early and late outcomes were compared. Operative time in closed method was longer (30.25 ± 5.49 vs. 22.0 ± 4.70). However, postoperative pain was significantly more in open method group compared with closed on days 1, 3, 7, and 21. There was no significant difference between groups in terms of hospital stay, postoperative bleeding, and complications. Leaving mucosa open after hemorrhoidal tissue excision is comparable to closed in terms of safety, complication and is cost-effective in terms of operative times and utility of suture materials at the expense of need for analgesics.

Prophylactic Mesh Placement in Emergency Midline Laparotomy for Intestinal Perforation Peritonitis: An appeal for caution

Prophylactic mesh placement (PMP) is increasingly being used to reduce the incidence of incisional hernia after routine and emergency midline laparotomy (EML). However, such studies are not available for EMLs done solely for intestinal perforation. Patients who underwent non-absorbable PMP during EML for intestinal perforation (Group A, 15 patients) were compared with those who had a conventional abdominal wall closure (Group B, 20 patients). The incidence of wound dehiscence was significantly higher in Group A, while surgical site infection (SSI), and incisional hernia were similar in both groups. Mesh explantation was needed in half the cases. A prophylactically placed non-absorbable mesh in patients undergoing EML for intestinal perforation is associated with significantly higher rates of wound dehiscence and of mesh explantation and therefore, routine use of such a mesh appears not to be justified.

A call for greater public involvement in public health

Public health, by definition and default, involves everyone and should ideally be the intersection of society with health. With an increasing recognition of the roles of Global Health and Global Surgery, there is greater interest towards more pragmatic, community-inclusive methods in finding public health solutions. Thus people should not just be passive beneficiaries, but should actively contribute and collaborate in healthcare improvement initiatives with social innovations. The time has come to take social knowledge seriously in medicine and use the translational social science ‘from field/ community to bedside’. Rudolf Ludwig Carl Virchow, (the father of modern pathology, 1821-1902), reminds us that ‘medicine is a social science’. The onus is on the public for greater involvement in public health – thus creating it a win-win situation.

Epilepsy-Related Injuries in Children: An Institution-Based Study

Epilepsy carries a lifetime risk of seizure-related accidents. The pediatric age group has different risk and injury profiles compared to adults, and the data from this age group was lacking from Asia. In a prospective study of 135 children, we found a striking observation of more than 70% of pediatric epilepsy patients having injuries.

Occam’s razor and Surgeons

Occam’s razor is a historical heuristic principle that states that “if there are many explanations/hypotheses for any phenomenon, the simplest one with the fewest assumptions is generally better than more complex ones.” Occam’s razor has many examples in surgery: good technique is the simplest and the most efficient way of doing something. One of the secrets is finding the correct plane of dissection. Newer advances in technology are making the technically demanding surgical steps simpler and safer. The basic tenet of global surgery “modify-simplify-apply” exemplifies the Occam’s razor and is used to find low-cost solutions for diagnosis, prognostication, surgical treatment, instrument development, and surgical training. Surgeons are innovators by nature and continuously refine and simplify the surgical technique—which is the very principle of Occam’s razor applied to surgery.

Comparison of suction drain and corrugated drain after hydrocele surgery

Corrugated drain is conventionally used after Hydrocele surgery to prevent hematoma formation. However, it may not prevent hematoma, may result in retrograde infection and requires frequent change of dressings. Therefore we hypothesized that close system suction drain will avoid these problems. Fifty patients with 60 hydroceles (10 patients had bilateral hydroceles) were operated by Jaboulay procedure.  They were randomized in to study group (suction drain; n = 31) and control group (corrugated drain; n = 29 patients). Outcome measures included hematoma, seroma, surgical site infection, frequency of change of dressings and Visual Analogue Score for pain. Incidence of hematoma, seroma, surgical site infection and Visual Analogue Score was similar in both the groups. However; dressing change was not required in the study group. Suction and corrugated drains are equally effective following hydrocele surgery, but suction drain has the advantage of no dressing change.

An international consensus for mitigation of the detrimental effects of the COVID-19 pandemic on laparoscopic training

Surgical training was significantly disrupted during the COVID-19 pandemic. This mixed qualitative and quantitative study will be conducted to achieve an international consensus on how to recover lost training opportunities and the results will help inform future guidelines about the recovery of surgical training after the pandemic. We plan a Delphi-style survey, addressed to trainers, to establish a pragmatic step-by-step approach to improve training (with special focus on minimally invasive surgery training) during and after the pandemic.

Safety of contralateral sacral 1 root transection and transfer for lumbosacral plexus avulsion injuries: A Systematic review

Contralateral sacral roots (cS1) transfer to treat avulsion injuries of lumbosacral plexus (LSP) has been described, however; concerns about its safety remain. We performed a systematic review of a hypothesis regarding safety of cS1 transection and transfer for treatment of LSP avulsion injuries from available studies. A literature search on Pub Med, Cochrane database and Goggle scholar was performed using appropriate key words for choosing relevant articles. Methodological quality of selected articles was assessed using Brink’s criteria and results were analyzed using level of evidence. The literature search retrieved a total of 877 publications; out of which 9 articles met the inclusion criteria and were reviewed. 6 articles were investigated for both the reliability and validity and 3 articles evaluated qualitatively; all were of limited quality. Though all studies showed that cS1 nerve root transfer leads to improvement in motor power of muscles and sensory recovery neurotised by cS1 with transient donor site morbidity; however, evidence is of limited. cS1 nerve root Transection and transfer for the repair of LSP avulsion injury appears to be a safe option but the evidence is limited and further validation of this finding needs to be done.

Sensory nerve transfer to restore sole sensations in Hansen’s disease

Loss of sensation in the sole due to Hansen’s disease (HD) may lead to repeated trauma, chronic non-healing ulcers and even amputations. We hypothesised that Saphenous Nerve (SN) to Posterior Tibial Nerve (PTN) sensory nerve transfer can restore sensation in the sole. All patients who underwent sensory nerve transfer surgery were assessed by pre- and post-operative sensory tests performed on the sole, including tests for touch, pain, temperature, pressure, vibration and two-point discrimination. Results were classified as per British Medical Research Council (MRC) scoring system. Twenty-six patients (37 feet) diagnosed with loss of sensation of the sole due to HD were included in this study. 23 patients (26 feet) had associated ulcers on the sole. All sensory parameters improved in all patients at 6 months follow-up after sensory nerve transfer surgery. All ulcers healed completely in all feet. MRC scores improved from S0 in 27 feet and S1 in 10 feet (pre-operative) to S3+ in 29 feet, S3 in 6 feet and S2 in 2 feet. We concluded that SN to PTN transfer can restore protective sensation to the sole in HD.

Minding the Ps and Qs in Global Surgery outreach programs

Global surgery (GS) 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. GS is a very appealing discipline and many outreach volunteer programs from Countries, Universities and Non-Government Organizations from the Global North provide help in some form to > 1/3rd of the World’s population which needs such assistance. Unfortunately, many instances of suboptimal conduct in these outreach efforts, amounting to a violation of the true spirit of GS, have led to calls for increased scrutiny and improvements in this field. These particularly perfidious transgressions are labeled as ‘neo-acts of colonization’. The guidelines and / checklists for how to plan, what to do, how to do it, what not to do, how to measure impact and even how to write in GS are comprehensively  documented. Best practices calls for leaving the ego behind and focusing on optimum patient care, academic partnership, outcome reporting and constant monitoring and/ evaluation (for efficiency, sustainability, preparedness, education and impact), reciprocity and mutual learning. Working in GS adds an extra layer of ethical complexity, which again has been documented in detail and principles and guidelines have been made available. To paraphrase Desmond Tutu (South African cleric, theologian and Nobel Peace Laureate 1984): ‘LMIC stakeholders in GS are no longer comfortable with picking up crumbs of compassion thrown from the table of someone who considers himself their master; as now they deserve a coequal respectable place at the table and the full menu of rights’. The problems are well known, the process of ‘red flagging’ these problems is established, the process of reform for their prevention and rectification has begun and the guidelines and roadmaps for a 50-50 partnership have already been constructed. All that is now needed is to ‘walk the talk’ with the volunteers to conduct themselves gracefully without being patronizing or condescending.

Seventh Cervical Nerve (C7) transection for Spastic Arm Paralysis following cerebral injury

Spastic limb paralysis due to cerebral injury can cause long-term disability. Patients with spastic arm paralysis who receive C7 nerve transection to their paralyzed side may have reduction in spasticity, pain and improvement in arm function. Four patients with spastic hemiparesis that had ceased to improve after 1 year of rehabilitation, having pain and poor function underwent C7 nerve transection plus rehabilitation. The outcome was assessed at 1, 3, and 6 months by Fugl-Meyer upper extremity scale for motor recovery, by Modified Ashworth Scale score for spasticity and Pain by VAS score. Functional use of the limb was also assessed by performance of activities such as dressing, tying shoe laces, wringing a towel, and operating a mobile phone. At the end of 6 months there was significant improvement in Mean Fugl-Meyer score, reduction in Modified Ashworth score and Visual Analogue scale for pain. At the beginning of study none of the patients could perform any day to day activities however at the end of 6 months 3/ 4 of the patients could perform at least one activity. We concluded that C7 neurectomy leads to improved motor function, reduction of spasticity and pain; and improvement in function in patients with spastic arm paralysis due to cerebral injury.

Frugal indigenous vessel loop made from surgical gloves

We report a simple, cost effective alternative to commercially available vessel loop made from sterilized surgical glove for retraction of vital structures during vascular trauma, micro-vascular/micro-neural surgeries and brachial plexus repair.

A systematic review and meta-analysis of touch imprint cytology and frozen section biopsy and their comparison for evaluation of sentinel lymph node in breast cancer

Evaluation of axillary lymph nodes after sentinel lymph node biopsy (SLNB) in breast cancer is mostly done by intraoperative frozen section biopsy (FSB) and/ or touch imprint cytology (TIC). In this systematic review and meta-analysis, we have compared the accuracy of these two modalities. PubMed, EMBASE, and Cochrane electronic databases were searched for articles comparing TIC with FSB. Articles were assessed for methodological and reporting quality. The main summary measures were pooled sensitivity, pooled specificity and diagnostic accuracy using bivariate generalized linear mixed models using random effects. Fourteen studies were included. The pooled sensitivity, specificity and diagnostic accuracy for FSB were 78%, 100% and 98.57%. For TIC, the pooled sensitivity, specificity and diagnostic accuracy were 74%, 98% and 98.37%. For both methods, visual inspection of summary ROC curves and of forest plots did not show significant heterogeneity. We concluded that TIC showed comparable sensitivity, specificity and accuracy to FSB and hence can be used as its substitute as a rapid and economical test for the detection of axillary lymph node metastasis during SLNB especially in low resource settings.

Performance Issues: supporting struggling trainees

Approximately 6 – 9% of trainees have performance issues of variable degrees with 3 - 5% of trainees struggling to complete their training and requiring additional targeted time or an extension of training. Some even leave the profession. The environment is complex, often chaotic and overstretched and now, made more difficult due to the impact of COVID – 19 on medical training. Addressing learning, and implementing new behaviours is a challenge; failure to address them can lead to bitterness and loss of the medical workforce, rarely suicide, huge remedial costs and legal challenges to educational institutions and employers. We provide an insight to understanding why trainees struggle and/or fail and how to analyse the causes of poor performance; how to pick up these issues early and raise them, and ultimately deal effectively with performance problems to get a good outcome for the trainees, patients, and institutions..

Delayed revascularization of extremities following vascular injuries: Challenges and outcome

In developing countries delayed presentation following major vascular injury is common due to limited vascular trauma units; delay in diagnosis and time lost in transit which pose a major challenge for limb salvage. We assessed limb survival and complications after delayed revascularization of extremity following major vascular injury in 20 patients, (19 males and 1 female, mean age 31.55 years) with major extremity vascular injury who presented > 8 hours after vascular trauma. Patients underwent primary vascular repairs, thrombectomy and/or interposition vein graft along with fixation of concomitant skeletal trauma. The commonest vessel injured was popliteal artery. The mean time of limb revascularization was 30.8 hours. Limb salvage rate was 95% and there was no perioperative mortality. 9 patients developed postoperative complications including sloughing of leg muscles (4), foot drop (3) pseudo aneurysm (1) and reperfusion injury (1). At 6 months follow-up all the patients were able to walk with full weight bearing and there was no chronic ischemia, pain or sinuses. We conclude that limb salvage can be achieved with good results in patients with delayed revascularization in selected cases. However; delayed revascularization leads to long and protracted postoperative course with high chances of vascular and neurological complications.

Effectiveness of adhesive taping to reduce pain, swelling and trismus after fracture mandible surgery

Swelling, pain and trismus constitute the major post-operative morbidity after surgery for mandibular fractures. We assessed the role of kinesio taping in mitigating these. Two groups of 15 patients were compared; those who had such applied to the side of the fracture and a control group of those who did not. Pain, swelling and trismus were assessed pre-operatively, and on the second, third and fifth post-operative days, and found to be significantly less in the study group. This simple frugal intervention is effective without any side effects.

Low-cost solutions incorporated in a standard surgical pathway for early breast cancer: A pilot study

We have shown the successful results of incorporation of low-cost solutions to provide a standard surgical care for early breast cancer (EBC) patients. This surgical pathway consists of a low-cost vacuum-assisted core needle biopsy, sentinel lymph node biopsy (SLNB) using low-cost methylene blue and fluorescin dyes under local anesthesia and oncoplastic breast surgery. Patients assessed as clinically node-negative axilla underwent such treatment. SLNB using low-cost dyes was performed without any complication. Oncoplastic surgical techniques were opted for in 32 patients, and the lumps were all excised with a ∼1-cm all-around margin on the final histopathological examination. We conclude that standard breast cancer surgery can be provided in low-resource settings to eligible EBC patients with low-cost solutions.

Role of endoscopic ultrasound ablative therapy in management of small pancreatic neuroendocrine tumors: A systematic review

Pancreatic neuroendocrine tumors (PNET) represent less than 3% of all primary pancreatic tumors. With the advent of advanced imaging techniques (Computed tomography/Magnetic Resonance Imaging/Endoscopic Ultra Sonography) the proportion of incidentally detected small PNET (less than 2cm) has increased. As surgery in small and/or non-functional PNET carries significant morbidity and mortality and is considered as overtreatment, newer methods viz. EUS guided radiofrequency ablation and ethanol / ethanol-lipoidal ablation have been reported with variable success. We systematically reviewed the current literature regarding EUS guided ablative therapy (EUSGAT) for PNETs. Seven prospective studies including 95 PNET patients were identified; there were no randomized controlled trials. Among 95 patients, 81% (n=77) had non-functional tumors and 19% (n=18) had functional tumors. Indication for selecting EUSGAT over surgery were poor functional status of patients. The overall effectiveness of EUSGAT was 90.5% (54%– 98 %) without differences between functional vs. non-functional PNETs (p = 0.3). Major complication in the form of pancreatitis was observed in 10.5% (n=10) patients and there was no mortality. We concluded that EUSGAT has acceptable effectiveness rate only for small PNETs. However, associated complication rate is also a cause for concern. As per current evidence we recommend that only those patients who have small functional (<2cm) PNET and are unfit or refuse surgery should be considered for EUSGAT after discussing goals of treatment and potential complications.

Assessment of prevalence and morphology of Plantaris Tendon in Indian population by ultrasound

There is wide racial difference in the prevalence of the absence of the plantaris tendon. We conducted this study to determine the prevalence of plantaris tendon in Indian population. The presence of the plantaris tendon was determined by ultrasound in 250 healthy volunteers using the standard technique. Out of 250 individuals 28 (11.2%) had absence of plantaris tendon either unilaterally or bilaterally. Unilateral absence of plantaris tendon was in 3.2%, bilateral absence in 4.8% and overall absence was in 8%. According to the hand and foot dominance the probability of finding right plantaris tendon in right dominant person was 92.3% and in left dominant is 89.7%. Height of the person also correlated significantly with tendon length. We conclude that plantaris tendon was absent in ∼11%, either unilaterally or bilaterally, in this cohort of Indian population.

A call for greater participation of academia in public health

Public health, by definition and default, involves everyone and should ideally be the intersection of society with health. Rudolf Ludwig Carl Virchow (the father of modern pathology, 1821-1902) historically defined ‘medicine as a social science’. In our editorial we argue that there is no reason why academia should be an exception to either of these two dictums. Academia has this continuous cycle of learning, un-learning and re-learning to move forward. Learning about and contributing towards public health is the logical extension of the same. Academic Surgeons are all natural leaders and adding this public health facet can only enhance their leadership qualities; a win-win situation for all.  

Validation Sentinel Lymph Node Biopsy Study in post NACT cN0 Axilla using low-cost dual dye technique: Potential Solution for Resource Poor Settings

High costs and limited availability of radio-pharmaceutical and/or gamma probe are major deterrents in performing Sentinel lymph node biopsy (SLNB) in developing countries. We have successfully shown in this prospective cross-sectional non-randomized validation study in patients with clinically node-negative axilla that SLN identification (SLN-IR) of fluorescein-guided (FG) SLNB in combination with methylene blue dye (MBD) is feasible. We concluded that SLNB using low-cost dual dyes in early breast cancer patients can be used in low resource settings. However, SLNB in post NACT axilla is associated with low identification rate and needs further evaluation.

Management of Complex Fistula in Ano by TROPIS

In this prospective study we validated the results of TROPIS (transanal opening of intersphincteric space) while avoiding damage to the anal sphincter, in 35 consecutive patients with complex fistula in ano. After a pre-operative MR fistulogram TROPIS procedure was conducted in all the patients; St. Mark’s Incontinence Score was assessed pre-operatively, and post-operatively at 3 months. 16 patient had intersphincteric, 10 trans-sphincteric, 2 extrasphincteric, and 3 had horseshoe tracts.  4 had recurrent tracts with 3 being trans-sphincteric and 1 intersphincteric. The fistula healed in 82.86% (29/35) patients following the TROPIS procedure. Curettage was done in remaining 6 patient allowing healing in 3 patients, translating to overall healing rate of 91.4%. The mean preoperative incontinence score was 0. One patient developed incontinence to gas post-operatively at 2nd week but there was no significant change in the scores post-operatively at 3 months. We conclude that TROPIS is an effective method for the treatment of complex fistula in ano, with minimal risk for incontinence.

Modifications of Glasgow Coma Scale – A Systematic Review

Glasgow coma scale is the mainstay of scoring traumatic brain injury patients for nearly five decades. It has seen several modifications based on various parameters; which include age, pupils, and brainstem reflexes. We systematically reviewed all the modifications of the Glasgow coma scale in the English literature by searching PubMed and Scopus. The search yielded 5718 articles of which 54 were eligible. The modifications were based on age, brainstem reflexes, motor score alone, serum factors, etc. The use of the majority of 54 eligible articles was limited to the index centres that have designed them; however, the paediatric Glasgow coma score and the Full Outline of Unresponsiveness score hold promise.

Primary sphincter repair after fistulectomy: A simple and safe option for complex Fistula in Ano.

Complete tract excision for complex Fistula in Ano, by dividing the sphincter followed by primary repair is increasingly being done. We assessed its feasibility and safety in this  prospective study on 60 consecutive patients (54 male and 06 female). Secondary outcome assessed was comparative study between PDS and Vicryl sutures by randomly allocating these patients into two groups of 30 each: end–end suture repair of sphincter after fistulectomy with either 2-0 Vicryl or 2-0 PDS. Patient was followed up for 3months and suture related morbidity, post-operative pain, healing time, continence score and recurrence in each group were evaluated. We showed feasibility and safety of Primary sphincter repair after fistulectomy. Hospital stay, infection, post-operative pain and continence scores between Primary sphincter repair after fistulectomy: A simple and safe option for complex Fistula in Anoboth Vicryl and PDS groups were comparable.

‘Flip-flap’ hernia sac sandwich mesh hernioplasty for Giant Incisional Hernia

The treatment of giant incisional hernia (IH) with domain loss is a challenge for surgeons. Our modified and simplified form of sandwich technique of flip-flap repair in 21 patients of giant ventral hernia ensures that hernia sac is tailored in the best possible way. Explantation of mesh was not needed and recurrence was not seen in any patient. We conclude that the flip-flap repair technique is safe and effective surgical technique that can be used for the treatment of giant IH regardless of the size, BMI or position of IH.

Time to stop the witch-hunt against Observational Studies

Surgical research has been often criticized for its over-dependence on observational studies instead of stronger evidence of more scientifically rigorous randomized control trials. Our editorial calls for a change in this attitude against observational studies and accord them their due respect in the hierarchy of evidence-based medicine.

LMIC patients’ perspectives after surgery related complications among breast cancer patients

Long term quality of life in breast cancer patients has been studied and published regularly. However, the lived experiences of patients who develop complications after surgery are not well understood. Determining this experience of patients is challenging in most low- and middle-income countries where majority of patients belong to poor strata of society and are uneducated. We aimed to explore the thoughts, feelings, and experiences of patients with surgery related complications after breast cancer surgery by semi structured interviews of 28/ 210 patients who developed any postoperative complication. Common patterns of patient experiences were identified and analysed using descriptive thematic analysis. Median age was 48 years (Range 32-65 years). Majority (n=26) were housewives, educated below primary level (n=11) and below poverty line (n=13). Complications included seroma (n=17), flap necrosis and infection, (n=5) and hematoma (n=1). Seven domains emerged from the interviews- Knowledge of complications, psychological impact, burden, disruptiveness, social impact, relationship with surgical team and suggestions to improve experience. The themes identified in the present study provide insights into the lived experiences and can inform the future development of a patient-reported outcome measures and quality improvement programs, including more effective pre-operative counselling and consent.

Low value surgical care: are we choosing wisely?

In the era of evidence-based medicine, surgical care which no longer shows benefit or provides harm or provides marginal benefits at a disproportionately high cost is termed as Low Value Care (LVC). The term can be applied to diagnosis (including unwarranted secondary tests for incidental findings), treatment (adverse events, poor patient outcomes and over-treatment) and system-level delivery of healthcare (inefficient use of resources threatening the sustainability of systems). Increasing awareness of health care economics and the need for value-based care has led to realization of this wastage, prompting initiatives such as the international ‘Choosing Wisely’ movement (starting from US in 2012) and the UK NICE ‘do not do’ guidelines which work at achieving clinician consensus on what constitutes LVC and how its use can be reduced from everyday practice. The systemic process of identifying and reducing the use of LVC is labeled as de-implementation; aka de-adoption, de-escalation, de-commission and scale-down etc. In this editorial we write about the importance of reducing low value surgical care in improving health equity; how to go about de-implementation; current status of de-implementation of low value surgical care; the barriers and facilitators for de-implementation and show the way forwards.

‘DISSEMINATE’: a roadmap for facilitating adoption of affordable surgical innovations in low-and middle-income countries

Affordable Surgical Innovations (ASIs) provide simple, safe and equitable solutions in resource-limited settings. Effective dissemination is needed for widespread adoption and uptake of ASIs in low- and middle-income countries (LMICs). However, surgical systems in these settings face challenges with adoption and uptake of ASIs, which remain unknown and/or unused even after supporting evidence is published. A surgery-specific, implementation-science-informed framework can provide a roadmap delineating the actions needed to achieve this goal; however, none exist currently. This prompted the development of a well-defined roadmap for this purpose. The proposed ‘DISSEMINATE’ roadmap presents 18 non-sequential domains to be considered in a comprehensive approach to equitable accessibility for surgical innovations: Design of the innovation; Innovate by combining the IDEAL surgical innovation framework with local multidisciplinary expertise; Substantiate available evidence; Scale-Up application of evidence in surgical practice; Share knowledge on multidisciplinary platforms; Sustainability; Endorsement of the innovation by local catalysts; Media promotion; Identify Early Adopters; Improve and refine the innovation; Improvise during setbacks; Implementation Science Methods; Navigate Through Barriers; Aspirational Affordability; Advocacy for the value of ASIs; Tools for scalability and adoption; Evaluate impact of dissemination; and Extend use of the innovation to resource-rich settings. This surgery-specific roadmap provides structure for effective dissemination to help in overcoming know-do gaps in the use of ASIs in LMICs.

Academic Surgery – the 3 perils: Sticky floor, Glass ceiling and the Slippery slope

Diversity, Equity and Inclusion (DEI) are the buzz words of 21st Century.  Academic Surgery also needs to be conscientious about it. Academic Surgery is a highly competitive field lacking the diversity and inclusiveness in various ethnic groups,   gender and those with lesser socio-economic-academic backgrounds. This has led to lack of equity, because certain groups establish their hegemony and paramountency over others due to their backgrounds especially the privileges they receive in education system. The impedance to this process of forging DEI can be seen in the 3 perils of academic surgery viz; sticky floor, glass ceiling and the slippery slope; which are a continuum which acts as barriers against minorities. The key to reducing such disparities is by making critical and clear judgment in the assessment of diversity amongst the student and surgeon workforce. Many initiatives are being undertaken in Indian Surgical system too. In the Indian context, policy of reservations and opening of large number of medical colleges in both public and private sectors has created several opportunities for all and will mitigate the issue of sticky floor to a large extent. Awareness of DEI has led to many changes but a lot more remains to be achieved in academic surgery to prove the thesis that all people are equal and deserve equal rights and opportunities.

Do probiotics aid in the recovery ofgastrointestinal motility after surgery for Gastroduodenal perforation peritonitis?

Probiotics are known to reduce the risk of infective complications and promote gastrointestinal motility after elective abdominal surgery. However, their role in postoperative recovery after peritonitis has not been studied; prompting us to conduct this prospective study in 88 operated patients of Gastro-duodenal perforation peritonitis which were randomized into control and study groups. Surgical procedure and post-operative recovery protocols were standardised in all patients, but the study group received probiotics (Lactobacillus casei strain Shirota). Time to first bowel sound, first flatus, serial White Blood Cells counts, morbidity, mortality and hospital stay were compared between the two groups. However, no significant differences were found between the two groups.  We concluded that the beneficial role of Probiotics seen in elective abdominal surgeries could not be demonstrated in cases of Gastro-duodenal perforation peritonitis.

Restoration of hand sensations in Hansen’s disease by Transfer of superficial branch of Radial Nerve to the Median Nerve: First report in the World

Loss of hand sensations in Hansen’s disease (HD) leads to major disability which compromises the patient’s quality of life. We report the first case of sensory restoration in the hand in Hansen’s disease by transfer of superficial branch of radial nerve to the median nerve.

'Flip-flap' hernia sac sandwich mesh hernioplasty 2.0

This is a further simplification of our recently published simple technique of hernia sac sandwich mesh hernioplasty. Our technique utilized the hernia sac itself, making two flaps encasing a polypropylene mesh in between, thereby separating it from intraperitoneal contents and subcutaneous tissue. This was shown to be a safe and effective surgical technique for the treatment of giant ventral hernia (GVH; > 10 cm size defect). One of the important steps of this technique is making multiple small incisions in the flap for the passage of multiple strips of the mesh which were later sutured together. Candid feedback received mentioned concerns of the vascularity and therefore viability of hernial sac flap owing to the multiple small incisions made within it. Although this concern appeared theoretical, as the mesh never required explantation in any of our 21 cases, we have simplified our flip-flap technique by making a single slit in the mesh (instead of the hernial sac) through which whole of hernial sac flap is passed to the opposite side. This technique avoids any possibility of devascularizing the hernial sac flap.

Overcoming the barriers between resource constraints and healthcare quality

The seven pillars of healthcare quality are: efficacy, efficiency, optimality, acceptability, legitimacy, equity, and cost. A strong health system comprises of essential elements which can be remembered with the help of 5 S mnemonic: staff, stuff, space, systems, and social support. To this another 5 S can be added to complete the list:  surgical capacity (for workload), skills, supply (chain), strong training for the health care workers and stewardship for coordinating complex management protocols. Healthcare quality and resource constraints are often mutually exclusive, and this is a significant challenge in the field of Global Surgery which needs to be addressed urgently so the patients get the high-quality care that need and deserve. In this editorial we discuss available solutions which can overcome the barriers between resource constraints and healthcare quality.

Total vs less than total thyroidectomy for benign non-toxic multinodular goitre: An updated systematic review and meta-analysis

We have performed an updated meta-analysis of randomized controlled trials (RCT) comparing total thyroidectomy (TT) with less than total thyroidectomy (LTT) for benign multinodular non-toxic goiter (BMNG) by searching PubMed, EMBASE, Cochrane library and online registers for articles comparing TT with LTT. Articles were assessed for risk of bias using the Cochrane’s revised tool to assess risk of bias in randomized trials (RoB 2 tool). The main summary measures were risk difference using random effects model. Five randomized controlled trials were included in the meta-analysis. All studies had unclear risk of bias for blinding of the participants and personnel and high risk of bias for certain selective reporting. This meta-analysis did not show any clear benefit or harm of either procedure (TT vs LTT) for goitre recurrence and re-operation rates (for both recurrence and incidental thyroid cancer). However, re-operation for goitre recurrence was significantly higher in LTT group based on a single RCT. Evidence suggests increased rates of temporary hypoparathyroidism with TT but there was no difference in the rate of RLN palsy and permanent hypoparathyroidism between the two methods. The overall quality of evidence was low to moderate.

Jabalpur Prognostic Scoring System: Revisited after 2 decades

Jabalpur Prognostic Scoring System (JPSS), a simple scoring system was developed to prognosticate the outcome for perforated peptic ulcer (PPU) in 2003 when there was no dedicated Surgical Intensive Care Unit (SICU) in the authors’ institution. It is based on six easily available parameters; namely patient’s age, perforation-operation interval, mean systolic blood pressure, heart rate, serum creatinine and the presence of co-morbid illness. Its accuracy has since been validated by many authors and has been found to be comparable with other prognostic scoring systems. Availability of SICU in the last one decade has prompted us to re-assess the utility and validity of the JPSS in the current age. Prospectively collected JPSS data of 214 consecutive patients (Prospective Group, PG), who underwent Graham’s patch omentopexy closure of a PPU, was compared with the JPSS cohort of 2003 (Original Group, OG). Sensitivity and specificity were calculated; and accuracy was measured using Receiver-Operating-Characteristic Curve analysis. The PG had 214 patients, while the OG had 140 patients. PG had significantly more women patients, and a shorter hospital stay, otherwise, both groups were comparable. Postoperative mortality and morbidity, both overall and in different JPSS classes were statistically similar. Overall accuracy of JPSS in PG was 77% with a cut-off of 11 as compared to the OG where these values were 92% and 9 respectively. JPSS continues to be effective and accurate in predicting the outcome of patients with PPU in the current age.

Frugal Surgical Innovations: the need of the hour

Innovation is defined by the dictionaries as “a new idea, device, or method; or the act or process of introducing new ideas, devices, or methods.” However, Surgical Innovation (SI) is more difficult to define. Common narratives include why-where-how-what-who as well as novelty, degree of change, safety, ethical standards, level of impact and peer acceptance. We have proposed a simpler, more egalitarian and ‘inclusive’ definition: “a SI is ‘any’ new surgical idea which improves patient welfare by solving an existing problem; and which like a three-legged stool is balanced by the three legs which represent surgical-precision, surgical-wisdom and patient-safety”. Frugal Surgical Innovations (FSIs) are low-cost surgical innovations which are designed for economic reasons. These are all about ‘doing more and better with less for more people’. FSIs make up for their lack in sophistication or complexity in affordability, without scrimping on safety or effectiveness. The three constructs of FSIs are: affordability, adaptability and accessibility. The philosophy of FSIs originates from grassroots, resource-constrained settings (RCS), where most abundant of all-natural resources — human ingenuity — is used to optimize limited resources to solve problems. Clinically meaningful inclusive research can be performed ‘only’ by surgeons working in RCS; as ‘only’ they understand the difficulties and nuances of various problems and can provide simple affordable solutions for their patients.

Novel technique of Vesico-vaginal fistula repair

Vesico-vaginal fistula (VVF) is a dreaded complication of gynaecologic and obstetric procedures with many approaches and techniques described for its repair. We present a novel technique of dual natural orifice transluminal endoscopic repair of VVF.

Husain S, Husain N, Sharma D. Dual natural orifice per luminal endoscopic repair of Vesico-vaginal fistula: A case report. Tropical Doctor: First published online June 12, 2023. DOI: 10.1177/00494755231181609. Read

Cutting of sphincter in fistulectomy with primary closure in complex fistula in ano: Is it feasible?

Treatment of complex fistulas like Inter/ Trans sphincteric, recurrent and high fistulae have high rate of recurrence or incontinence. Fistulectomy with primary sphincter reconstruction might represent an effective and safe alternative in order to reduce rate of recurrence and incontinence. The aim of this study is to assess incontinence and recurrence after fistulectomy with primary sphincter reconstruction for management of complex fistula. 60 patients with complex fistulae involving the sphincter, 56 male and 4 female, mean age 40.6 years were operated by fistulectomy and primary sphincter repair over a period of 7 years. Patients were followed up for 6months for any complications, recurrence and incontinence. Majority of the patients 50 (83.3%) had complete wound healing in 2 weeks. 4 (6.6%) patients had haematoma and superficial wound dehiscence which were managed conservatively and healed in 4 weeks. There was one recurrence. All patients had good continence postoperatively except mild faecal incontinence (FI score 3) was seen in 6 (10%) patients. However, all these patients regained continence within 6 weeks. Primary reconstruction of anal sphincter with fistulectomy is a safe, option for complex fistula in ano.

Impact of Topical Epinephrine with Xylocaine on drainage after axillary lymph node dissection: A randomized controlled trial.

We evaluated the impact of topical epinephrine with xylocaine on drainage after axillary lymph node dissection. Fifty-two women were randomized into two groups, epinephrine with xylocaine drainage (ED) and conventional drainage group (CD). The amount of drainage, duration of drainage catheter, incidence of seroma formation and wound infection were noted. The mean total drainage volume was less in ED group as compared to CD group (195 ml vs. 353 ml; p = .002). Drainage catheter was removed earlier in ED group as compared to CD group (5.07 + / - 0.99 days vs. 6.65 + / - 1.07 days; p = 0.0001). The incidence of seroma and wound infection was similar in two groups. Topical epinephrine with xylocaine after axillary lymph node dissection results in significantly decreased drainage volume and duration of drainage.

Pre-operative USG guided hydro-dissection and a low-cost indigenous muscle retractor facilitate Trans-oral Endoscopic Thyroid Surgery: A new simple technique

Hydrodissection of plane between thyroid and strap muscles and retraction of strap muscles using a low-cost indigenously made retractor are effective in overcoming technical difficulties in transoral endoscopic thyroid surgery.

Translation, transcultural adaptation and validation of the caregiver Quality of Life Index-Cancer (CQOLC) scale in Hindi language for Caregivers of Breast Cancer patients

The aim of this study was to translate the Caregiver Quality of Life Index-Cancer (C-QOLC) into Hindi and test its reliability and validity. The translation process started after taking permission from original authors—forward translation done by four persons, including a general surgeon, endocrine surgeon, psychologist and a Hindi lecturer, then reconciliation of the gathered data followed by backward translation by an English lecturer. A pre-survey assessment was done, and lastly validation study among the caregivers was conducted. The translated version was validated on a total of 110 caregivers of Breast cancer patients. The Cronbach’s alpha score of the total scale was 0.72. Exploratory factor analysis resulted in four factor structure: burden, disruptiveness, patient’s health concerns and social support concerns. Hindi version of the Caregiver Quality of Life Index-Cancer was found to be a reliable and valid measure of the quality of life in this cohort of Hindi speaking caregivers.

The disappearing art of clinical examination

In this editorial we lament about the disappearing art of clinical examination and how it is likely to affect the practice of medicine, and the well-being of patients; especially those in poor resource environments who will suffer most. 

PRESS Survey: PREvention of Surgical Site Infection -A Global Pan-Specialty Survey of Practice Protocol

Surgical site infections (SSI) complicate up to 40% of surgical procedures, leading to increased patient morbidity and mortality. Previous research identified disparities in SSI prevention guidelines and clinical practices across different institutions. The study aims to identify variations in SSI prevention practices within and between specialities and financial systems and provide a representation of existing SSI preventative measures to help improve the standardisation of SSI prevention practices. This collaborative cross-sectional survey will be aimed at pan-surgical specialties internationally. The study has been designed and will be reported in line with the CROSS and CHERRIES standards. An international study steering committee will design and internally validate the survey in multiple consensus-based rounds. This will be based on SSI prevention measures outlined in the CDC (2017), WHO (2018), NICE (2019), Wounds UK (2020) and the International Surgical Wound Complications Advisory Panel (ISWCAP) guidelines. The questionnaire will include demographics, SSI surveillance, preoperative, peri-operative and postoperative SSI prevention. Data will be collected on participants’ surgical speciality, operative grade, country of practice and financial healthcare system of practice. The online survey will be designed and disseminated using QualtricsXM PlatformTM through national and international surgical colleges and societies, in addition to social media and snowballing. Data collection will be open for three months with reminders, and raking will be used to ascertain the sample. Responses will be analysed, and the chi-square test used to evaluate impact of SSI prevention variables on responses. Given the inconsistency in guidelines on how to prevent SSIs, there is a need for standardisation. This survey will investigate the disparity in SSI preventative measures between different surgical fields and countries.

Uro-Vaginal Fistula repair – Critical appraisal of our failures

Uniform guidelines for the management of uro-vaginal fistula are not well established due to variable presentation. We present the results of surgical audit of our failures.  

Decolonizing global health in the Global South by the Global South: turning the lens inward

The “decolonize global health” agenda aims to dismantle power asymmetries and knowledge production approaches established through colonial and neocolonial ideologies and practices. Calls, actions, and guidance for decolonizing global health have dominated the field in the past few years; however most of these initiatives are focused on changes at the Global North-South interface. One of the key spaces at which decolonization should occur is at the “local Global South” level: the internal settings of formerly colonized countries and their institutions. In this editorial, we call on the Global South to turn the lens inward and do some introspection on its role in perpetuating coloniality in global health and on its responsibility to dismantle both internal and external coloniality.

My learning curve with the Indian Journal of Surgery

Indian Journal of Surgery has published 53 of my papers (1/6th). This is an account of this journey which includes the whole gamut of output by an academic surgeon working in a General Surgery Department: Case reports (n = 4); Images in Surgery (n = 2); Viewpoints/ Letters to Editor (n = 9); Technical Notes (n = 2); Review articles (n = 12); Original Articles (n = 16) and Editorials (n = 8).

Outcomes in Paediatric Laparoscopic Anorectoplasty for Ano-rectal malformations using Enhanced Recovery After Surgery protocols: a study from Central India

The revolutionary concept of using the body's innate stress response to surgery to access the advantage of early recovery in the postoperative period has changed the overall outcome of health systems of LMICs in terms of cost-effectiveness and increased patient turnover. Hence, is now the standard of care in many adult surgical specialities, but with very little evidence in paediatric surgical fields. This lacuna in the knowledge was identified and addressed which yielded positively comparable results. This is a retrospective and prospective validation study conducted in the Department of General Surgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India between 1st March 2020 - 30th May 2022. The peri-operative parameters affecting convalescence after surgery were reviewed and the results of the conventional peri-operative protocols were compared with the ERAS group. 50 patients with Ano-rectal malformations underwent laparoscopic anorectoplasty, of which 25 patients were treated with conventional peri-operative protocol and 25 were treated with ERAS protocol. The results obtained were comparable and effective with the existing results in adult surgical specialities and also were statistically significant in most of the parameters. Shorter hospital stay reduces the financial burden alleviating both the physical and psychological stress of the patients and their parents. Also, judicious use of the available resources can increase the patient turnover of the existing health systems with the same financial assistance.

A comparison of Swallowing Related Quality of Life in Patients Undergoing Transoral Endoscopic versus Open Thyroid Surgery: 1st report in the World

This is the first report comparing swallowing related quality of life (SWAL-QoL) between endoscopic trans-oral and open approaches after Hemithyroidectomy. Our findings suggest that trans-oral endoscopic thyroidectomy results in significant superior swallowing related quality of life.

Correlation of post thermal burn hepatic dysfunction with outcome

Alteration of liver morphology and function is common following major burns; however, it has not received much attention. In this study we have assessed the impact of thermal burn on liver in relation with mortality in 55 patients (33 female and 22 males) with TBSA 10-90% and age ranged from 18 to 75 years. A bed side serial ultrasonography to assess the volume of liver and liver function tests was done on the 2nd, 9th and 16th day following burn. 8 patients died during 2nd week following burn and 47 survived. The mean TBSA for survivors was 37% and for non survivors 80%. Mean liver volume in survivors steadily decreased from 1693.70 cm3 to 1631.31 cm3 over 3 weeks. Mean liver volume in non- survivors steadily increased from 1855.88 cm3 to 2028.50 cm3 over 2 weeks. Liver function test in survivors steadily improved while in non survivors it deteriorated over 2 weeks. We concluded that there is a correlation between altered liver morphology and function with mortality among severely burnt patients; however, liver volume did not show statistical significance. A decreasing trend of liver dysfunction parameters and hepatomegaly following burn is associated with good prognosis.

Clinical and Academic Impact of first Endocrine Surgery Unit on a General Surgery Department

Endocrine surgery is one of the newest subspecialties of general surgery. We have analyzed the impact of first endocrine surgery unit on a general surgery department. A retrospective study of all endocrine surgical procedures and research output of a teaching surgical department in India was performed. Data was compared between two 3-year periods: before (Jan 2017–Dec 2019) and after (Jan 2020–Dec 2022) the start of a dedicated endocrine surgery unit. The number of surgeries (thyroid, parathyroid, and adrenal), conference presentations, and publications on endocrine surgery went up significantly (<0.05). In addition, newer minimally invasive techniques like endoscopic thyroid and adrenal surgeries were started and became a regular feature. Advent of a new endocrine surgery unit substantially increased the endocrine surgical volume and academic output in the field of endocrine surgery.

Low-cost Radio-Opaque Tumor Marking Techniques for Breast Cancer Patients Undergoing Neo-Adjuvant Chemotherapy: A systematic review

Current standard of care localization techniques used in breast conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) are expensive and may not be available in LMICs (lower-middle income countries). This review evaluated the efficacy of radio-opaque low-cost tumor markers. A systematic search was conducted as per PRISMA guidelines through November 30, 2022, for all studies using non-commercial radio-opaque tumor markers for patients undergoing BCS post NACT. Rate of unsatisfactory margin on final histology was the primary outcome. Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to assess internal validity. After screening, 7 studies were included for data synthesis. For marking, four studies used LIGA clips, two used 5-mm cut pieces of K-wire, and one used cut pieces of 25-G needle. Incidence of unsatisfactory margins (positive/close) ranged from 0 to 11%. All studies found these low-cost markers to be feasible, with 100% pre-surgery visibility and 100% retrieval rate. Low-cost radio-opaque tumor markers (LIGA clips, 5-mm cut pieces of K-wire and 25-G needle) are effective methods of tumor localization especially for LMICs.

An ode to Sisyphean challenges of a Global Surgeon

This is an ode to many Sisyphean challenges faced by a Global Surgeon working in the global south – based on my lived-in experience for the last three and half decades.

Global Surgery: Quo Vadis?

Global surgery is a rapidly developing multidisciplinary field. This editorial chronicles the beginnings of GS, highlighting its evolution, milestones, challenges, and gazes in to the future as it becomes evident that global surgery has the potential to play a transformative role in achieving global health equity.

Substitution urethroplasty in Female urethral stricture

We compared the results of different substitutional urethroplasty for the stricture urethra in females. Urethral calibration (unable to pass 8 Fr catheter) and urinary flow rate of less than 12 ml per second were taken as inclusion criteria. Substitution urethroplasty was performed using vaginal ventral onlay flap vaginal dorsal graft (n = 8), dorsal buccal mucosa (n = 8), and labial skin grafts (n = 4) over 3 years. Twenty patients with urethral stricture were identified (mean age of 49.9 years). Uroflowmetry at six months showed normal flow in all vaginal flap/ graft patients and buccal mucosa grafts, while only 50% of labia minora grafts showed mild improvement. Urethroplasty using dorsal onlay buccal mucosa and vaginal graft gives the best results in women. The vaginal wall can be used safely in nonavailability of buccal mucosa.

10 lessons for Global Surgery researchers form LMICs

Global surgery is an area of study, research; practice and advocacy that seeks to improve health outcomes and achieve health equity for all people who require surgical care, with a special emphasis on underserved populations. Researchers and institutions in LMICs are the major stakeholders in this and have to provide the academic leadership in this emerging field. I am a lifelong activist and campaigner for appropriate technology and affordable low-cost surgical solutions to achieve equitable surgical care for underserved populations. It gives me great pleasure to share our successful ideas which made a difference and which become our vade mecum over the years, as lessons for global surgery researchers from LMICs.

Achieving surgical, obstetric, trauma, and anesthesia care for all in South Asia

South Asia is a demographically crucial, economically aspiring, and socioculturally diverse region in the world. The region contributes to a large burden of surgically-treatable disease conditions. A large number of people in South Asia cannot access safe and affordable surgical, obstetric, trauma, and anesthesia (SOTA) care when in need. Yet, attention to the region in Global Surgery and Global Health is limited. Here, we assess the status of SOTA care in South Asia. We summarize the evidence on SOTA care indicators and planning. Region- wide, as well as country-specific challenges are highlighted. We also discuss potential directions—initiatives and innovations—toward addressing these challenges. Local partnerships, sustained research and advocacy efforts, and politics can be aligned with evidence-based policymaking and health planning to achieve equitable SOTA care access in the South Asian region under the South Asian Association for Regional Cooperation (SAARC).

Assessment of symptomatic response to intravesical alkalinized Lidocaine, Bupivacaine, Heparin and Steroids in patients with Bladder Pain Syndrome

Bladder Pain Syndrome (BPS) is commonly treated with a variety of holistic to invasive therapies but none of them provide long-term effective relief. Intra-vesical instillation of heparin alone or in combination with alkalinized lidocaine has shown promise but the effects were transient. This prompted us to add bupivacaine (a potent and long acting local anaesthetic) and steroids (for their non-specific anti-inflammatory action) to the instillation solution. Evaluating the beneficial effects of 6 weekly Intra-vesical instillation of this admixture we noted early and long-term relief of BPS.

Advocacy for Surgeons: Ensuring Excellence in Patient Care

Surgery plays a pivotal role in modern healthcare, with surgeons at the forefront of medical interventions that can significantly impact patients' lives. Beyond their technical expertise, surgeons and allied professionals must navigate complex healthcare systems, policy landscapes, and societal expectations. In this context, advocacy for surgeons emerges as a critical component. A significant mission of advocacy for Global Surgery has been to make decision makers and funders realize that the resources allotted by them do not follow the data. Surgical conditions are recognized to cause a higher number of annual fatalities compared to the combined death toll of HIV/AIDS, malaria, and tuberculosis. Despite this fact, the allocation of resources for non-communicable diseases remains considerably lower when compared with funding for infectious diseases.

Double Blind Randomized Controlled Trial of Efficacy of Ormeloxifene in Treatment of Fibroadenoma (The FIBROCENT Study)

We evaluated the effectiveness of Ormeloxifene (Centchroman) on regression of Fibroadenoma in a double-blind placebo-controlled trial. Patients aged above 18 years with Fibroadenoma were recruited between March 2023 and October 2023. Patients were divided in two arms- Ormeloxifene group and Placebo group. Response was evaluated using USG and no residual mass was defined as complete regression and more than 30% decrease in size was considered as partial regression. A total of 130 consecutive patients with Fibroadenoma were randomized to Ormeloxifene group (n=65) and Placebo Group (n= 65). Complete regression was observed in 9% (6/65) patients in Ormeloxifene group and 6% in Placebo Group at the end of 12 weeks (p=0.49). Adverse events were reported by twelve patients taking Ormeloxifene as compared to none in other group. In our study Ormeloxifene was not found to be effective in treatment of fibroadenoma and had concerning side effects.

Defunctioning Ileostomy for Typhoid Ileal Perforations: out of the frying pan into the fire?

Typhoid ileal perforation (TIP) is a common surgical emergency in low-middle income countries. Its high surgical morbidity and mortality is due to its often late presentation or diagnosis, the patient's mal-nutrition, severe peritoneal contamination and unavailability of intensive care in most peripheral hospitals. This had prompted the philosophy of minimizing the crisis by avoiding any repair or anastomosis, limiting the surgery in these physiologically compromised patients and performing only a temporary defunctioning ileostomy (DI) which could then be closed 10-12 weeks later. The dogma of minimal intervention and in particular a defunctioning ileostomy is challenged in this analysis, arguing that ileostomy adds insult to existing pathology which is not helpful and often deleterious.

DuraGen a dermal substitute for management of suboptimal wounds

Using a flap in large wound with a very small area of exposed vital structures may be an excessive intrusion and cause unnecessary donor site morbidity. Dermal matrix (DuraGen) was applied onto critical areas where bone or tendons were exposed and a split skin graft placed thereon. All patients had satisfactory wound closure without the need for flap. DuraGen appears to be a safe, single stage alternative, to a flap for the healing of complex wounds.

Flap blood glucose measurement for flap monitoring and early detection of circulatory problems

Post-operative monitoring of skin flaps is subjective and cannot detect early circulatory problems in the flap. Early detection and rapid remedial re-exploration are important for flap salvage. We evaluated flap glucose measurement to monitor the flaps for early detection of circulatory problems. 30 patients underwent cutaneous flap reconstruction. This is an easy, economic, objective and reliable method for flap monitoring and can detect early venous congestion requiring remedial measures.

A Systematic Review and Meta-analysis of Diagnostic Performance of Fluorescein Guided Sentinel Lymph Node Biopsy in Early Breast Cancer

Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or alternative to isotope like Indocyanine green (ICG). Both are very resource-intensive; which has prompted development of low-cost technique of Fluorescein Sodium (FS) guided SLNB. This systematic review and meta-analysis evaluates the diagnostic performance of FS guided SLNB in early breast cancer. Articles were retrieved from PubMed, EMBASE, Cochrane library and online clinical trial registers and assessed for risk of bias using the QUADAS-2 tool. The main summary measures were pooled Sentinel Lymph Node Identification Rate (SLN-IR) and pooled False Negative Rate (FNR) using random effects model. A total of 45 articles were retrieved by the initial systematic search. Out of which, seven studies with a total of 332 patients were included in the meta-analysis. The pooled SLN-IR was 93.2% (95% confidence interval [CI], 0.87–0.97; 87% to 97%). Five validation studies were included for pooling the false negative rate and included a total of 211 patients. The pooled FNR was 5.6% (95% confidence interval [CI], 2.9–9.07).  Fluorescein-guided SLNB is a viable option for detection of lymph node metastases in clinically node negative patients with early breast cancer. It achieves a high pooled Sentinel Lymph Node Identification Rate (SLN-IR) of 93% with a false negative rate of 5.6% for the detection of axillary lymph node metastasis. 

Bibliometric analysis of surgical publications from Asian countries

Asia is having rapid economic growth, advancements in healthcare infrastructure and a burgeoning cadre of skilled researchers. Our bibliometric analysis is aimed at discovering the evolving trends in surgical publications across Asian nations. We accessed the SCOPUS data from the SCImago Journal & Country Rank website for analysis of quantitative (number of publications) and qualitative (citations, self-citations, citations per publications and h-index) publication metrics. The bibliometric profile of surgical publications from the Top 10 Global Nations in 2022 shows the primacy of the United States of America, followed by China, Japan, the United Kingdom and India. China and India have made large strides recently and improved their rankings. Among 31 Asian countries, China stands at the top of the ranking with the highest publications in 2022, followed by Japan and India; however, Singapore leads in citations per document and Japan in h-index. Our bibliometric study provides an analysis of the current state and trajectory of surgical research in Asian countries.

Low cost smart phone based laryngoscopy for the assessment of vocal cords in patients undergoing thyroid surgery: A pilot study

Can a smart phone application be reliably used for laryngoscopy? This thesis was tested for peri-operative evaluation of vocal cords in patients undergoing thyroid and parathyroid surgery. Our study showed that low cost app based vocal cord assessment technique is feasible, universally applicable, reliable, cheapest and easiest to perform.

Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients with Positive Nodes using low-cost dual dye technique: Identifying factors associated with adequate FNR threshold

In this prospective cross-sectional non-randomized validation study in patients with post NACT with clinically node negative axilla who were node positive prior to start of NACT were studied. Patients underwent validation SLNB using fluorescein (and blue LED light) and MBD. Axillary dissection was performed irrespective of SLNB histology. SLIN-IR and False Negative Rate (FNR) were assessed and compared with various molecular subtypes. The SLNs were identified in 102 out of 120 (85%) post Neoadjuvant Chemotherapy (NACT) patients. The median number of sentinel lymph nodes identified was 2 (range 1-3). The SLN-IR using MBD was 85%, FD was 82.5%, and combined MBD FD was 85%. Two or more SLNs were removed in 72 patients and 11 patients had tumor in rest of axilla, resulting in an FNR of 17.4%. FNR was 25% in case only one SLN was found, and it was 11.42% if two or more than two SLNs were excised. This cohort study found that use of low-cost dual dyes in patients with positive axillary disease, rendered cN0 with NACT, with 2 or more negative SLNs with SLNB alone, results in FNR  of 11.4%. Her 2 positive and TNBC with 2 or more negative SLNs is associated with FNR of <10%. However, number of such patients was small and further studies with larger sample size are warranted to confirm these findings.

Prevalence and risk factors of diabetic peripheral neuropathy in central India

Aim of this study was to estimate prevalence and associated risk factors for diabetic peripheral neuropathy (DPN) in Diabetic patients in central India. 150 consecutive patients, age ranged from 30-80 years, 85 male 65 female with Type 2 diabetes mellitus were screened for DPN and associated risk factors. DPN was assessed using the Neuropathy Disability Score and Neuropathy Symptom Score and correlated with risk factors. The overall prevalence of DPN was 68%. Age, duration of diabetes, HbA1c, and Hypertension were found to be significantly associated with DPN. Gender, family history, BMI, diet, alcohol, smoking and dyslipidemia were not found as risk factors. Majority of patients had axonal, sensory-motor polyneuropathy in lower limb. DPN was common in diabetic patients, with its prevalence seen at 68%. Common risk factors associated with it were age, duration of diabetes, HbA1c, and Hypertension.

Editorial: Challenges faced by Frugal Surgical Innovations

Surgical Innovations (SIs) are central to the development of surgical science. However, advanced SIs, usually with their cutting-edge technology, have high price tags which make them inaccessible to the majority of the population in LMICs. Frugal Surgical Innovations (FSIs) or Low-Cost Surgical Innovations (LCSIs) are developed in response to such economic challenges. This frugality is much more than a cost-effective alternative; it is rooted in heuristic-based decisions guided by the experience, learning, judgement and ingenuity of people working at the grassroots to optimize limited resources. The resultant FSIs are simple, safe, affordable, effective, ethical and evidence-based customized local solutions in LMICs. By making surgical procedures more affordable and therefore cost-effective, FSIs have the potential to revolutionize Surgery globally and improve surgical care for millions, and not just in LMICs. These solutions, however, face challenges at every step of the way. Scaling up the impact is the biggest challenge. In this editorial we reconsider the role of industry and the healthcare community in advancing and scaling FSIs.

Effect of Chewing Gum in reducing Postoperative Ileus after Gastro-duodenal perforation peritonitis surgery: a prospective randomized controlled trial.

Chewing gum reduces the duration of postoperative ileus and early recovery of bowel function following elective abdominal surgery. However, its role has not been studied in cases of gastroduodenal perforation peritonitis, prompting us to conduct this study. Patients were randomised into two groups, 39 patients received chewing gum (study group) and 43 patients were in the control group. Sensation of hunger, appearance of first bowel sound, and passages of flatus and faeces were significantly early in the study group; their hospital stay was also shorter. Chewing gum reduces the duration of postoperative ileus in cases of gastroduodenal perforation peritonitis.

Top tips for publishing your Global Surgery research

Global surgery research needs dissemination as it seeks to improve health outcomes and achieve health equity for all people who require surgical care, with a special emphasis on underserved populations. It gives me great pleasure to share my thoughts on "how to publish your global surgery research".

Evaluation of high-frequency ultrasonography for diagnosis of carpel tunnel syndrome

We assessed the sensitivity and specificity of ultrasonography in the diagnosis of carpal tunnel syndrome. The cross-sectional area of the median nerve at the carpal tunnel and at the level of pronator quadratus along with signs of nerve flattening, palmar bowing and increased nerve vascularity were valuable in confirming the diagnosis. A positive predictive value of ultrasonography was found to be > 95% and a negative predictive value was ∼ 66% for a diagnosis of carpal tunnel syndrome. Ultrasonography is, therefore, an effective diagnostic tool in this regard.

Pediatric Idiopathic Chylopericardium: A Case managed with thoracoscopic window pericardiotomy

Idiopathic chylopericardium (CP) in the pediatric population is a rare entity with very few reported cases and is characterized by the accumulation of chyle in the pericardial cavity. There are no guidelines for the management of this rare entity. We report a case of idiopathic CP in an infant and our experience of managing it by pericardial window creation using VATS and a multidisciplinary approach providing the optimum care for the child.

Normative data of Ulna length in Pediatric Indian population

We aimed to create clinical normative data for ulna length in pediatric population and to demonstrate the usefulness of such data by a nationally representative sample of healthy children of 1 day- 18 years of age from 5 centers across India. The percutaneous length of ulnar was measured by using certified calibrated measuring tape across all centers in 1300 children (883 male, 417 female) with age ranged from 1 day to 18 years. Our metacentric study provides normative data on percutaneous length of ulna in Indian pediatric population. Gradual lengthening of ulna was seen in all children with increasing age. The length of ulna was significantly more in males, obese and in South Indians. However, except for age other factors become insignificant at maturity.

Ten Commandments of Endoscopic Thyroid Surgery

In this review, based on our own experience and review of literature, we have described the “Ten Commandments” for safe endoscopic thyroid surgery. Patients and techniques should be selected wisely while performing endoscopic thyroid surgery. Crucial steps are the creation of sufficient working space, and the identification of superior laryngeal nerve, parathyroids, and recurrent laryngeal nerve (RLN). As the surgical field keeps advancing, many more commandments will keep on adding to the armamentarium of surgeons and hence our 11th commandment is that thou shalt keep learning, unlearning, and re-learning. The bottom line; however, is to master the surgical anatomy and the correct way of doing endoscopic thyroid surgery.

Normative values for thumb length in Indian adult population

We aimed to establish the relative thumb length in comparison to the index finger in central Indian adults. Five hundred normal adult hands (1,000 thumbs), 316 men and 184 women, mean age 30 years, were included in the study. The relative length of the thumb was measured using the length of the proximal phalanx of the index finger (thumb–proximal phalanx index) and the distance between the proximal digital crease and proximal interphalangeal crease of the index finger (thumb–digital crease index). We found that the tip of a normal adducted thumb extends to 69% of the length of the proximal phalanx of the index finger and 38% of the distance between the two proximal creases of the index finger. Relative normal thumb length is independent of gender, laterality, or hand dominance.

Using the Stanford Biodesign framework to develop Frugal Surgical Innovations

Needs-driven frugal surgical innovations (FSIs) have the potential to address the surgical care gap in accessing safe and affordable surgical and anaesthesia, especially in LMICs. Many FSIs have been published recently. However, many of these fail to diffuse to the hoped-for level as authors often struggle to translate a clinical innovation into a widely adopted one. Thus, many significant FSIs are only used locally/ regionally and never spread. Using the Stanford Biodesign framework can help not only in developing these FSIs but also escalating their wider use.

Navigating the disappointment of manuscript rejection: An Author’s dialogue with Reviewer and Editor of Tropical Doctor

With majority of the medical journals having a rejection rate of more than 80% of submitted manuscripts, it does come as a shock and grief to the author who had a lot of expectations before submission. Though most of the literature available does mention how to overcome the lacunae in the manuscript before considering resubmission in another journal, none addresses the mental agony and setback the author faces and the way to overcome this setback. A question-answer session between an eager enthusiastic author, a highly experienced reviewer, and the final authority Editor is presented for guidance.

Unveiling barriers of post mastectomy breast reconstruction: a questionnaire based survey of patients from central India

Post mastectomy breast reconstruction uptake remains low in the developing countries. We examined patient perspectives about it in a cohort of Indian breast cancer patients via a survey questionnaire to assess their perspective regarding post mastectomy breast reconstruction. None of the 192 patients underwent immediate or delayed reconstruction by the end of 24 months follow-up. Age, education level, occupation and marital status did not affect the uptake of post mastectomy breast reconstruction. The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery and the belief that it was not important (80% for each). System related factors such as additional cost of surgery and additional length of stay were reported to be important by 55% and 65% patients respectively. Understanding and addressing these barriers are crucial to ensuring comprehensive care for these breast cancer patients.

Frugal Surgical Innovations: A Step Closer to Improved Surgical Care in LMICs

Occam’s razor is a historical heuristic principle stating if a phenomenon has several explanations/hypotheses, the simplest one with the fewest assumptions is generally better than more complex ones. Occam’s razor can be applied to global health in low and middle-income countries (LMICs). The simplest ideas are likely the best and most economical solutions. There is a felt need for simple, safe, effective, user-friendly, ethical, local evidence-based, customized, and affordable solutions that can equitably serve people. A grassroots approach in which LMIC researchers and surgeons innovate under constraints specifically for their contexts is a promising alternative. Highlighting examples of such bootstrapped “for the LMICs, of the LMICs, by the LMICs” can be instrumental in decolonizing global surgery.

Cyst with Midgut Volvulus and Malrotation in Paediatric Population: A Rare Triad and Comprehensive Scoping Review

Occurrence of Chylolymphatic cyst with malrotation and midgut volvulus is a rare clinical entity and occurs as a result of lymphatic proliferation due to lymphatic obstruction caused by volvulus. We did a scoping review to identify the existence of the said condition in literature. Scoping review revealed that only 13 cases are reported in literature so far. The cyst predominantly occurred in the jejunum (61%) and, to a lesser extent, in the ileum (30%) among the cases investigated. Most postoperative recoveries proceeded without complications, barring two cases identified during postmortem examinations. Intraoperative findings included the presence of a Ladd's band in 5 out of the 13 cases; however, the referenced studies did not note significant additional anomalies, except for congenital atresia of the transverse colon. As this is a rare combination of two congenital anomalies, preoperative clinical diagnosis is difficult and requires careful evaluation and surgical management.

Comparison of clinical and patient reported outcomes in patients with benign euthyroid solitary nodules after ultrasound-guided percutaneous microwave ablation and endoscopic thyroidectomy: First report in the World

Percutaneous ultrasound-guided microwave ablation (MWA) for benign solid thyroid nodules is the newest modality for treatment. However, the differences in treatment outcomes between MWA and endoscopic thyroidectomy vestibular approach (TOETVA) for patients with benign euthyroid solitary nodules remain unknown. We are sharing initial results from our prospective study. Prospective study between January 2022 and December 2023 was conducted and data were noted at 3 time points in patients planned for treatment (Preoperative, 1 week, and 12 months). Main outcome measures were clinical outcome and comparison of thyroid-related quality of life using the ThyPRO-39hin and swallowing-related quality of life using the SWAL-QoL. Of the 36 included patients, 20 patients underwent TOETVA and 16 underwent MWA. Both the groups were comparable in terms of demographic and clinicopathological profiles. The nodule volume reduction rate of patients at 12 months after MWA was 75.10% and 100% for TOETVA. The mean preoperative ThyPRO-39hin and SWAL-QoL scores were comparable in all domains between the two groups. Mean ThyPRO-39hin and SWAL-QoL scores on postoperative day 7 were significantly better in the MWA group in domains impaired social life (p < 0.0001) and impaired daily life (p = 0.0002). However, at the end of 12 months, mean ThyPRO-39hin and SWAL-QoL scores became significantly better in the TOETVA group as compared to the MWA group. Our findings suggest that transoral endoscopic thyroidectomy results in significant superior clinical outcome, thyroid-related quality of life, and swallowing-related quality of life in the long term.

Is it time to make Innovation learning part of UG and PG Surgical Education?

The field of surgery, with its complex procedures and critical outcomes, needs fresh innovations for its advancement. Despite this, structured innovation learning is not part of current Indian undergraduate (UG) and postgraduate (PG) surgical education. This editorial argues that incorporation of Innovation training in to the UG and PG surgical education will result in future surgeons who are not only competent but also pioneers in their field. This is even more important in India and other low- and middle-income countries where the need for innovative solutions in healthcare is even more pressing due to chronic resource constraints.

Bridging the Digital Divide: Data Science for Indian Surgeons

The advent of data science is revolutionizing surgical care worldwide, yet a significant digital divide exists that hampers the adoption of these advances by Indian surgeons.  This editorial underscores the transformative potential of data science in enhancing surgical outcomes and fostering evidence-based practice. The time has come for Indian surgeons to embrace data science to deliver cutting-edge surgical care.

Enhancing Global Biomedical Research: Educational Strategies for Bridging the Gap between HICs and LMICs

There is a pressing need to address the noticeable disparity in biomedical research output between High-Income Countries (HICs) and Low-Middle Income Countries (LMICs). This imbalance raises urgent concerns about equity and the impact on global health. Despite being home to most of the global population, LMICs face numerous challenges that hinder their ability to contribute significantly to research. This review explores the factors contributing to the disparities and proposes potential solutions to address this global imbalance. A comprehensive strategy is needed to tackle the differences in biomedical research productivity between high-income and low-middle-income nations. Enhancing global partnerships, ensuring fair allocation of resources, and prioritizing the development of research capabilities are crucial measures in nurturing a more diverse and influential worldwide biomedical research landscape. Closing this divide is essential for advancing scientific inclusivity and tackling the health issues economically disadvantaged countries face.

Is it time to say goodbye to drainage after axillary lymph node dissection in breast cancer? A randomized clinical trial of systemic Tranexamic Acid combined with topical Epinephrine+Xylocaine versus conventional drainage

Drainage after Axillary lymph node dissection (ALND) is a major cause of morbidity. The aim of this study was to evaluate the clinical outcomes of patients who received systemic Tranexamic Acid combined with topical Epinephrine+Xylocaine after ALND. This prospective study evaluated the outcomes of topical epinephrine with xylocaine + Systemic Tranexamic Acid (EXT) after ALND. The primary endpoint was the rate of seroma development. A total of 33 patients in each group were recruited. The rates of symptomatic seroma requiring aspiration was 14.4% in the EXT group and 4.8% in the CD group (P=0.3). Hospital stay was significantly less in EXT group as compared to CD group (3 + 1 vs 5 + 2.5 days, p=0.002). Use of systemic Tranexamic Acid combined with topical Epinephrine+Xylocaine resulted in reduced hospital stay with similar rates of seroma as drainage after ALND; thereby making it possible to avoid drainage.

Prospective closed loop audit on adherence of operative notes in tertiary care surgical unit in central India

Despite the guidelines, poor operative record keeping is common all over the World. We evaluated the role of audit for maintenance of quality of operative record. In the first loop of prospective audit, 150 consecutive operative notes were assessed for missing data and entries. After educational intervention second loop of audit was performed. In first cycle of audit overall 55.93% of parameters were documented in operative notes while it was improved to 74.39%. Legibility of operative notes was improved by 16%. 5 missing parameters in first cycle were added in second cycle of audit. Documentation of operative notes does not always comply with the set guidelines but by employing a clinical audit it is possible to identify the existing deficiencies and thereby improving the standards of practice.

Normative data of Liver volume in Indian adult population

Aim of this study was to establish normative data for the liver volume in healthy Indian adult population. 517 healthy adults age ranging from 20- 75 years, 267 males and 250 females underwent ultrasonographic assessment of liver volume. Liver volume was correlated with age, gender, Body Surface Area (BSA) and Body Mass Index (BMI) of the participants. The overall mean liver volume was 913 cc. The liver volume increases with increasing age up to 50 years and decreases after that. Mean liver volume in male was slightly more than in female (936.84 cc Vs. 882.70cc).  Mean Liver volume increases with increasing BMI and was found to be statistically significant below 40 years of age. BSA has positive correlation with liver volume up to 50 years of age. We concluded that normative data on the liver volume in Indian adult population is correlates with age, weight, height, and BMI except BSA.

Color Contrast Matters: Unraveling the impact of text-background combinations on PowerPoint presentations

The purpose of this study was to examine the effect of text/background colour combination on readability, visibility, and aesthetics of PowerPoint slides. 212 participants 100 male 112 female, ages ranged from 18-25 years were enrolled for study. Total 12 slides with 9 rows and two different foreground/background colors were used. These slides were projected in undergraduate class room and visibility was assessed by asking the audience to score the number of line clearly visible, readability was assessed by asking the participant to score one particular word in the slide appear how many times? The aesthetics professional quality was assessed by 3 point Likert’s scale with 1 is poor and 3 are excellent aesthetic. The most pleasing and professional looking color combination was Black text on white and least pleasing and professional combination was Red on green. Readability was best for Green on red and least readable combination was Purple on yellow. Colours with greater contrast ratio generally lead to greater readability; warm colour on cool background colours led to higher ratings of aesthetic quality.

Neonatal Pain management practices in central India: A Cross-sectional Survey

This descriptive survey assessed knowledge, attitude and practice regarding analgesic prescription practices in neonates. A web-based questionnaire was developed and circulated to 150 physicians working in public and private neonatal intensive care units, of whom 87% were aware of neonatal pain perception; however, only 57.3% had any definite pain management policy. Some 66% were aware of a pain assessment tool in neonates, yet none had used it, though 80% used analgesics in their neonatal intensive care unit but only 44.3% were satisfied with the subsequent pain management. The most commonly used agents were midazolam and fentanyl. A total of 55% thought that opioid analgesia should not be used in neonates and morphine was used by only 5%; however, there seemed a general acceptance of opioid use since 86% used fentanyl as an analgesic. Non-pharmacological methods were used by 81%. Pain treatment in neonatal intensive care units is thus suboptimal and requires more attention.

Academic Surgery: A Road Less Travelled

The term ‘Academic Surgeon’ broadly refers to a member of a medical school department of surgery, but this term does not do justice to the key role played by these surgeon-scientists. Their dual role involves, on one hand, the joys of teaching, disseminating knowledge and mentorship of the next generation, and on the other, advancing surgical science through innovations and translational research from bench to bedside. However, despite its importance, the steady decline in the number of surgeons opting for academic surgery is a matter of grave concern. In this editorial we discuss the he micro-, meso- and macro-level barriers and their solutions. It is, indeed, a road travelled by few, but it is also a road leading to a legacy of excellence, fame and enduring contributions.

Insights into Academic Surgery: A Survey of Trainees and Practicing Surgeons

Landscape of academic surgery is full of challenges and opportunities that vary greatly across different institutions and professional stages. Studies addressing these issues are scarce in Indian academic surgery. We conducted this survey among the surgical trainees and practicing surgeons in India to gather their perspectives. A multiple choices pattern web based cross sectional Google forms quantitative questionnaire was developed which focused on demographics of respondent, and their thoughts about barriers and facilitators in academic surgery. A total of 801 surgeons responded to the survey. Majority of responders considered academic surgery as fraught with several barriers which include the difficult funding environment, excessive clinical demands, and a lack of mentorship in academics. The suggested solutions included dedicated research period within the resident training engaging more closely with appropriate mentors, inculcating ‘team’ research and easier funding support. Our survey reveals critical insights into the current landscape, challenges, and opportunities in academic surgery. We also suggest targeted interventions which can enhance the academic environment for surgical trainees and practicing surgeons.

Preoperative Ultrasound Mapping of Suprascapular and Spinal Accessory Nerves: A Surgeon's Guide to Precision

We evaluated the feasibility of localization of spinal accessory nerve (SAN) and the suprascapular nerves (SSN) in suprascapular region in 100 healthy volunteers by ultrasonography and showed that both these nerves can be consistently and reliably mapped by ultrasound. This data can help in surface markings of both the nerves which increased operative precision, reduce the operating time and risk of iatrogenic injury.

Faeco-vaginal Fistulae: An algorithm for management

Faeco-vaginal fistulae are a challenging problem. We suggest a simple management algorithm to provide tailored approach for every patient.

Editorial: Shaping Global Health: The Indispensable Role of Biomedical Engineers

Modern medical science is the intersection of technology, precision and innovation. Health-care professionals have traditionally been the visible face of this technological revolution, but beneath the success of these complex procedures lies the expertise of bio-medical engineers. It is the bio-medical engineers who design, refine, and maintain the tools that enable such precision and patient safety and this synergistic partnership between HCPs and BMEs is indispensable to the evolution of medical science. Partly due to its technical character, the bio-medical engineers’ contribution remains under-acknowledged, particularly in Low- and middle-income countries, where challenges pertaining to resources and innovation ecosystem add unique dimensions to their role in healthcare. Bio-medical engineers rise to these challenges in Global Health by devising special solutions which are tailored to the realities of resource-constrained settings and are cost-effective, accessible, sustainable, and frugally innovative. This editorial highlights their vital role and impact on Global Health outcomes.

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Department of Surgery, Netaji Subhash Chandra Bose Government Medical College, Jabalpur, Madhya Pradesh, INDIA
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