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.
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.
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.
Agarwal P, Adalti S, Agrawal V, Sharma D. A simple mortality prognostic scoring system for burns. Indian J Burns 2017;25:26-32. Read
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.
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.
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.
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%.
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.
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.
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.
Kothari R, Pandey N, Sharma D. A simple device for whole blood autotransfusion in cases of hemoperitoneum and hemothorax. Asian Journal of Surgery 2019; 42: 586-587. <https://doi.org/10.1016/j.asjsur.2019.01.018>. Read
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.
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.
We have measured and shown the importance of ‘Quality of life’ after emergency and oncological Gastro-intestinal Surgery.
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. Professor Sharma’s insight generated from the art of knitting led him 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.
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.
Agarwal P, Singh M, Sharma D. ‘Determination of types of foot in Indian population and its association with In-growing toe nail’. Journal of Foot and Ankle Surgery (Asia Pacific); January-June 2018, 5;1:1-3. Read
Two of our landmark studies have proved to be milestones and resulted in change of nomenclature in anatomical texts.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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 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.
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.
Agarwal P, Mukati P, Kukrele R, Sharma D. Indigenous Two-point discrimination testing device. Neurology India 2021;69:147-8. DOI: 10.4103/0028-3886.310095. Read
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.
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.
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.
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.
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.
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.
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 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.
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.
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’.
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.
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.
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
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.
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.
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.
Agrawal V, Yadav SK, Agarwal P, Sharma D. Rapid scoping review of laparoscopic surgery guidelines during COVID-19 pandemic and construction of a simple quality appraisal tool. Ind J Surg. 2020. Published online 17th Sept 2020; DOI: 10.1007/s12262-020-02596-y. Read
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.
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.
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.
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.
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.
Sandhu D, Sharma D. Mentoring surgical trainees. Ind J Surg 2021: Published online 8th January 2021. DOI: 10.1007/s12262-020-02665-2. Read
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.
Agarwal P, Yadav P, Sharma D, Agrawal V, Mishra A. Plastic Surgery in Camps in Rural India. Ind J Surg: Published online 6th January 2021. DOI: 10.1007/s12262-020-02681-2. Read
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.
Agarwal P, Sharma D, Agarwal V, Tiwari S, Kukrele R. Double rectangle fascia lata Frontalis sling: A rationale approach for ptosis. Indian Journal of Plastic Surgery 2021. DOI: 10.1055/s-0041-1723909. Read
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.
Agrawal V, Sharma D, Yadav SK. Artificial Intelligence, Machine Learning, Deep Learning and Big Data Analytics for Resource Optimization in Surgery. Ind J Surg. 2020; 82: 1317–1318. DOI 10.1007/s12262-020-02643-8. Read
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.
Agrawal V, Yadav SK, Agarwal P, Sharma D. Strategies for optimizing the use of PPE during surgery in COVID-19 pandemic: Rapid scoping review of guidelines. Indian Journal of Surgery. Published online 6th January 2021. DOI: 10.1007/s12262-020-02713-x. Read
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.
Agarwal P, Kukrele R, Sharma D. Simple modification in wiring for efficient application of arch bar to achieve Inter-maxillary fixation. Indian Journal of Plastic Surgery 2021.DOI: 10.1055/s-0041-1723905. Read
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.
Yadav P, Thakur S, Agarwal P, Sharma D, Kukrele R. Perforator based Propeller flap for coverage of lower leg: Single centre experience. Tropical Doctor: In Press.
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.
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.
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.
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.