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.
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.
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.
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; https://doi.org/10.1016/j.asjsur.2019.01.018. Read
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.
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.
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.
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.