Rambodoc at large

(Circa: some time in this century, in a hypothetical hospital in Kolkata)
Mohit Bansal was a businessman who normally made his bucks count by selling second hand mobile phones as new ones, in his multiple shops littered in the markets of Kolkata. Nothing made him as happy as when he could clinch a portion of his customer’s bank balance just by the sheer gift of being able to flex the metaphorical muscles of the frontal cortex. As it happened that day, when he was about to scam a couple of thousand rupees from an unsuspecting clerk out on the prowl for a bargain phone, he felt a discomfort that needed a bathroom call. To his shock, he bled blood from his rectum, quite like money from a bride’s tight-fisted father. An alarmed Bansal fled to his family GP, who tried things like Thank God, but to no avail. Bansal was somewhat educated, and did a Google search and came up with an article that seemed to answer his every cry for help. Piles, he read, could be operated without painful cuts, and clean up his health and wealth.
With great trepidation, like how Harry Potter’s creator must have viewed the launch of her first book, he set out to meet a surgeon, with the rather phoren sounding name of Dr. Urs Truly. The surgeon truly did not bat an eyelash, nor did his nasal vibrissae move (as the patient noted indignantly) when he pronounced a need for Bansal to undergo immediate surgery. In fact, it seemed to Bansal that Dr. Truly, the way his myopic eyeballs were popping out, seemed to relish the prospect of chopping up his posterior, and profit from it. In a strange way, Bansal pictured himself at his last sale, when he convinced a college student to part with ten big ones for a Nokia phone that would do a favor on its owner by not exploding by his ear-side, or worse, in his trouser pocket.
When the surgeon, using an irritating matter-of-fact tone, stated the total price tag for the new-fangled surgery, Bansal didn’t know which organ he needed to use to gulp the figure inwards. With the difficulty with which dentists extract an impacted molar tooth, or first time mothers deliver babies obstinate on coming out butt-first, he managed to arrange for the ransom quoted for his surgery.
When he came to the hospital for his admission, he was shown in with great gusto, as if he was the first-ever swindling shopkeeper to grace the linoleum floors of the institution.
As soon as he settled down in his room by 9 pm, a nurse came in and expertly poked in an IV line in several places till she found no fault in one. By this time, his wrists had swollen up enough to bear comparing with that of a pugilist who gets his ears habitually bitten off by Mike Tyson-types.
All night, Bansal fretted, unable to sleep because the darn IV cannula would get stuck in the sheet somewhere the moment his eyes closed. After all, tomorrow morning, 7 am, he was due for surgery.
In what seemed like five minutes after he drifted into sleep, he was woken up by the nurse in a way that is normally reserved for the more exceptional inmate of the Guantanomo Bay facility. When the nurse demanded that he get ready for surgery, he asked to be given a little time for freshening up. He brushed his paan-stained teeth, bled some more in the pan, and drank two glasses of water. The nurse, when she heard of this, behaved in a way as to suggest to Bansal that he actually deserved to be in the American facility north of Cuba. Normally, Bansal was as unflappable as an Indian Airlines hostess, if you could imagine Bansal dressed up in a sari and exposing a two-inch deep umbilicus to the scanning eyes of 456 bored passengers with nothing better to look at. No one told him not to drink water, though the nurse had said ‘No breakfast” tomorrow!
The patient was getting increasingly stressed out at the injustice of putting in an IV channel at 9pm in the evening when the first drug was to be given at 7 the next morning. When he asked the nurse why he had to suffer this through the night, when it could very well have been done just when it was needed, she looked elsewhere and said, “We are only two of us in the floor, and don’t have time for all this in the morning”. That got Bansal’s goat, though he never sanctioned identifying said animal for man’s selfish needs. A brief verbal skirmish ensued, not dissimilar to a tired Hamas-Israeli exchange long after the world had got used to the sound of sundry missiles and all-knowing bunker-busters monopolizing the otherwise silent night. You see, both sides know it is nothing serious, but just like dogs urinate by their favorite lampposts, they both declare their differing positions and sentiments. In Kolkata, Bansal then went one ahead. He questioned the ancestry of the nurse in question, and all nurses in general. By the time the aggrieved nurse went to call her supervisor (one of the blessed breed of women who can still sleep in spite of the milkman, the school-going child, and those unsocial crows who shout abuses at their ilk from across buildings in Kolkata), a Class IV staff came into Bansal’s room. In the classless society that is India, Class IV staffs are those who line up at the time of surgery or discharge for the largesse of satisfied customers. They are to be found outside maternity wards, when a baby is born every time the minute hand of the ancient clock strikes a Roman numeral. At the time of discharge, each ward boy who had served tea in the room even once would line up along the corridor, like a victory salute, looking pointedly at the exiting and excited parents. The parents also know the ‘sistam’ (a.k.a. the ‘shistame’) whereby the Class IV staffs are rewarded appropriately for having successfully helped with the delivery. At least, the parents’ looks suggest that, as do the self-congratulatory expressions on the visages of the ward boys. Digression complete.
Aforementioned ward boy to Bansal: “Saar, shaving karna hai” (“Sir, I’ve come to shave you”)
B: “Theek hai, karo!” (Ok, go ahead).
If you remember, the patient was due for a piles operation. While self-declared modernists like Dr. Urs Truly scoffed at the tradition of shaving patients’ body parts before surgery, the ‘system’ had its way, and the doc was ignored. Surgery meant shaving, doc be damned!
The ‘barber’ pulled up the patient’s shirt, as if to shorn B of his manly growth on his chest and abdomen.
With a dangerous glint in his eyes, he asked, “ You know which part of the body to shave?”
The boy shook his head casually, as if it was quite an absurd question for which he had no time.
A shudder of abuses followed the barber to the restless door. To prepare the patient finally for surgery, a boy from the Housekeeping department came in with a towel: “please sponge yourself”. When the patient asked for hot water for this, the boy came back with a beaker of hot water and poured it into the basin, filling it up. Throwing the towel into the steaming basin, he waited. Bansal looked at the basin, and said, “You expect me to wash myself in the same dirty basin where everyone spits and coughs? What do you think I am, an asshole?”
We don’t know if the boy was cheeky enough to answer in the affirmative, but all Hell , like an environmentalist’s movie on global warming, broke loose.
The patient, clearly, could not take the loss of advancing 50,000 Indian rupees (around $1300) for the operation, and be given such a raw deal in service. He almost empathised, at that moment, with a student who, two months ago, came back to him just weeks after buying a ‘new’ cell phone that now had no display. Bansal had shooed away the student, accusing him of dropping the gadget into his morning coffee or tea, with milk and one spoon of sugar.
Back to the present. Bansal refused to go into surgery, expressing great suspicion as to the behavior of the nurses and ward boys after surgery. He feared that they would take turns in kicking him (in his immediate drowsy post-anesthesia state) after covering him with blankets so that no marks would found of both the surgery and the post-surgical trauma.
Called to the scene of the battle, Dr. Urs Truly did the smart thing. Surrounded by a belligerence of relatives, he just laughed it off. He said they were right in every allegation they hurled, and said the Hospital’s deficiencies were incurable. He asked them to take the patient to his rival’s hospital, where (he assured them) the surgeon and the nurses were brilliant. He said sorry, and shook every hand in sight, till he realized one of them belonged to the bewildered self-professed barber. Smiling ingratiatingly at one and all, with the appearance of an American President waving at a crowd of prospective watch-stealers, he disappeared, leaving behind a feeling of awe in the crowdling. As he turned off the corner, Bansal thought, “Now if I had Him as a partner, I could make my own brand of mobile phone!”
He decided then and there that he would get operated only by Dr. Truly even if he chose to do so under the shade of a tree. He did not believe in being mobile with his requirements!

A surgeon friend of mine tells me a story.
A young 13-year-old girl is being evaluated for a disease no one is able to catch. The clinically astute doc ordered a special x-ray test (the name of which is immaterial) that ultimately clinched the diagnosis and spared her a major surgery. You can well imagine how relieved and grateful the parents would have been. One can imagine these people sending sweets to the doc’s house on Diwali, and expect him to attend the girl’s marriage in the future.
This story, unfortunately, did not quite go along these lines. The twist in the story came in the x-ray room. During the procedure, the x-ray technician fondled the breasts of the young, innocent girl. She asked him why he was doing so. ‘Just adjusting your clothes’ for the x-ray, said the technician. After the procedure, the kid cried out to her mother, who hushed her up (afraid of a scandal), and only much later told the surgeon what had happened. My friend was deeply, deeply offended. "How dare the swine?" he asked the CEO of the hospital. The CEO promised immediate action. The action was not dismissal, for that could cause problems with the Workers’ Union. No, a three-member committee was appointed to investigate the incident. In the meanwhile, the patient (and her parents) went back home, and soon became well with the medicines prescribed by the surgeon. As the days went by, they chose to forget the unpleasantness. They decided never to go to the hospital again. Courtesy their family doctor, they got another surgeon later. Embarrassment avoided.
Our surgeon got busy again with his patients, but still called up the CEO: “What happened to that technician? Why hasn’t he been sacked?”
Now, the technician had genuflexed to the Committee, saying he had a pregnant wife and a small baby, and that “I can’t afford to lose this job, as I am a poor man”. It was obvious to the Committee that sexually deprived as he was, he just succumbed to some "momentary weakness". The hospital was facing a shortage of trained hands capable of doing certain procedures, and the Committee members agreed within themselves that he wasn’t easy to replace. On top of that, bad press was inevitable should the thing get out. They therefore pronounced the whole thing as a mistake and a misunderstanding, and reassured the parents in writing that “strong action” was “being contemplated”.
Bullshitting over, the world carried on with its business. Only the victim of the pressure-cooked male lust, that little girl, remembered it all. She became a timid woman. She lacked normal responsiveness to men. We don’t know what became of her. Another lost nonentity, another collaterally injured victim of sub-human control, of mindless androgenic aggression. And so much more.

If you are interested in health, or if you or your near ones are potential surgical candidates, I strongly urge you to spend five minutes reading this article.
This article talks about avoiding surgery, when other, less invasive options, exist. I have previously mentioned how surgeries for weight loss, back pain and for suspected appendicitis are tilted in favor of the knife-wielder. Surgery has a great role to play in many of the cited instances, but the option should only be exercised as the best option, not the first option. As David Dent, a learned South African academic surgeon, once said, "The patient comes to the surgeon for an opinion, not for an operation".
Alas, most of us (surgeons) don't realise this!

They say a surgeon is remembered only for his complications. One bad day, one stroke of bad luck, and all his good work is forgotten. Years of dedicated and successful work comes to nought. So, me thinks, if you get some sunshine on your head for some good work, you better feel you are one lucky dog you aren't in the news for the wrong reasons, right!?
Times of India, Kolkata, page 5 (free registration may be required).
(And, of course, the photo is grossly unjust to both patient and surgeon!)

The Times of India, I was told in hushed whispers, has run a story on some deaths that have occured in Indian patients who had undergone bariatric surgery. As I said in my last post, WTF? I mean "Why The Fuss?"
Bariatric surgery is a science that causes massive weight loss in severely obese patients. There are a few types of these, which work by reducing the amount of food that the person can eat, and by preventing full digestion and absorption of ingested food. The commonest operations are the Gastric Bypass and the Lap Band.
Now, these operations, done by the popular keyhole (laparoscopic) method, are rather painless and allow rapid return to home and the workplace. Plus there IS weight loss: big time (70% of excess body weight)!
Now this boring medical, technical-kinda blogpost takes an interesting twist: bariatric surgery does cause fatality. There is a known complication rate. But why should it hit the papers? I have known of this happening in virtually every city in the world where bariatric surgeries are done, and there is always a big ruckus, and then things go back to normal again. Why?
Bariatric Surgery has been hyped up by the surgical industry. It's the truth, and there's no trying to escape that. The media is always fed stories on the positive aspects of the story, but since there is little point in dampening the enthusiasm of prospective patients, the complications are rarely dealt with. And WE, the surgeons, are guilty of this. I, too, have written about this, and not just once.There has been brand-selling in the name of awareness-building. And, of course, the surgical products industry is solidly behind the initiative. These are truths. You may argue over the ethics of it, but good work does get done because of the awareness building, patients do lose weight and get cured of their diabetes and high blood pressure, and surgeons do get their next big car or mistress, and their children do go to elite schools that wipe your bank accounts clean like Coke does to toilets. But, among the positives, there is a stain of the ugly, and the faint stench of death. Surgeons may underplay the issue of complications of bariatric surgery, resulting in a high level of expectations on the side of the patients. So, whenever a death occurs, there is a jolt, a jhatka. The ensuing agitation reaches the media, and there is hullah. After a while, things become normal when the positive spin starts the next cycle. After all, obesity is always a hot topic.
And, you know what, I do bariatric surgery. I make it a point to balance the hype of the positive endpoints (weight loss, improved outlook in life, etc.) with the possible complications and the mortality risks. Because I speak candidly ("Of course, one can die after this surgery, being in a special high risk group"), I don't get too many of these onto the operating table. But then, my fat is not on the fire, neither! That is, at least, one good thing to say about being a poor surgeon!

If you remember, I have posted my satirical piece 'New Surgical Species' with hyperlinks, in this blog before.
Well, the General Surgery News article is now available online here. I am not sure if you can get direct access to the article, and you may be asked to fill in the free registration form.

We have all read of the Indian teen surgeon who did a Caesarian Section under the doting eyes of his parents, one a surgeon and the (m)other a gynecologist. The father thought he could post a claim for the 'youngest surgeon of the world' tag with a beer manufacturing company that recognises the oddballs in the world, and out of it! The only thing is he forgot his son had no degree, and that for the patient, it would be a medical third-degree.
Now, after putting the parents behind bars, the cops are out looking for the young boy.
I have some brilliant points lined up as commentary about this event. In case I forget these and end up with just a typically chaotic circum-Presidential mish-mash (a.k.a. 'beating about the bush'), blame it on the hot air. Global warming is finally here!



First, the act of experimenting on a patient is tough enough to defend. Next, the father has to defend doing that without taking due consent from the patient and her unborn child. Another problem: he has to explain away his enormous stupidity to his in-laws on one side of the prison bars! How could he, as a practising doctor, not know that he was publicising an act that would make him not only a criminal in law, but a criminal-in-law!?
To top it all, he didn't have the brains to marry a woman who would have the senses about her to tie him down to his chair and ask him to behave. What sort of woman allows her husband to make such a global ass of himself, unless he is the President of the United States? I mean, is her name Hillary or what?
Dr. Murugesan (let us all reverentially call him by that prefix before it gets struck off the rolls) was not much more than stupid and unlucky. He just had the typical Indian laissez faire (to give the term a bad name it doesn't deserve) chalta hai attitude that embellishes a blatant disrespect for the law, and a conviction that in this country, do what you can before you get caught, if at all, and then buy and beg your way out.
In much of the country, health care is about making a black buck and hunting a case like the animal of the same name.
So a surgeon trains his son to be an expert surgeon, a money making cottage industry, without remembering that civilised Third world countries also profess (practice is a different thing altogether) the need for certain recognisable standards like degrees (what degrees?), credentialling and privileges. Those are Western standards. Do they have any relevance in a country where quacks treat a majority of people, where politicians and actors sniff the pungent feet of inebriated sadhus and babas, where neurosurgeons cut hydroceles, and cardiac surgeons do hernia operations? Yes, I am not talking of the big city hospitals, but of the real India, from which we are blissfully protected by our LCD screens and power-windows.
In a country where the health infrastructure rests dominantly on quacks, why target an errant surgeon to this extent? Let us give him his place under the Indian sun, and make him a Health Minister or something. That will show the world that, bullshitters though we may be, we are consistent and honest, unlike Zimbabwe, Gabon or Bangladesh. But, as we say: "What to do, we are like this only!"

This article I wrote is the front page editorial of this June issue of General Surgery News, though the online version is not yet available.

Scientists, poor sods, say that a new species of animal or insect is discovered only once in every ten years or so. With scientific research booming, along with the explosion of the information technology industry, there is very little that is new. Somewhere in the chaotic interaction of gigabytes and Google, of genetic engineering and gamete storage, new species of human beings have evolved right under our very noses, and yet remained undiscovered. Amazingly, the mutation (for this is a sudden, unplanned change rather than the other, slowish sort of genetic change for which there surely is a name) has happened in a classa humanis that stubbornly resists change, almost like the Indian socialist: I refer to Homo surgicalis, the erstwhile, slowly extinctifying class of barber-ic surgeons.



If you are unaware of the evolution, and yet are part of the revolution, you are probably a laparoscopic surgeon. And if, God save you and your patients, you are unaware of both, you are likely a true-blue general surgeon, whose ancestors were knee-deep in blood and other unspeakably foul-smelling and distasteful body fluids, chopping gangrenous small bowel that looked like mutant, imported (from Italy, of course) tagliatelle, and expertly removing gall bladders that looked like last year’s aubergines bought at the Giants’ special offer!
Anyways, back to the point: what is my point, you ask?
If you consider the nature of the surgeon in the last decade and the coming one, you will understand.
The Laparoscopic Surgeon (LS) is stereotypically a very dynamic, ambitious animal possessed of more skills than wisdom, much like a New York senator wanting to be President. In the midst of a busy, lucrative practice, he has to use his frequent flier points and travel to Honduras or Nicaragua and show the natives how to do a TEP or a fundoplication. He also has to appear annually, sage-like, at the world’s premier endoscopic surgical conference and present his ‘innovation’ in laparoscopy that he noticed in a third world workshop last year. It is a different matter that the audience is more interested in seeing his impressive list of ‘conflicting interests’ than in his video, but men will be men: ‘yours is bigger than mine’ is a syndrome of comparative truth, from childhood to andropause.
An amazing thing about this new class of Homo surgicalis: the lap surgeon uses tiny incisions of around six or eight inches, sometimes, that are only a few nanometers smaller than the huge ones made by his evolutionarily challenged brother, called ‘HALS’ or ‘extraction ports’, that dramatically reduce operating time, hospital stay, and wound infections. The world has woken up to this New Reality: that an incision heals faster and easier if made in laparoscopic surgery, especially ‘mine’, and the old buzzards better, well, buzz off! The chapter of open surgery is now closed!
The LS is like a hypothetical animal that uses its long horns to snare fruits from the top of a tree because it is aware of its long horns. It forgets its jaws, its strong limbs, and its quick jump, just because its long horns are its pride, its quintessential hubris. The LS, likewise, uses his scope-vision to treat all his patients. The results are likely to be, for want of a better word, fruitful.
Homo laparoscopus (HL) has another peculiar feature: the species is taller and more dynamic than the Gandhian ‘internist’ class of physicians, known in informed circles as Homo prescriptus. A sub sect of HL is a sub-specialist working in Hernia Institutes or as a consultant to Ethical and un-Ethical mesh manufacturing companies. This is an example of Homo inguinus, a groinocological surgeon.
A new disease affecting the calcaneum and the plantar ligaments awaits existence, but the treatment is already, um, ready: laparoscopic fasciectomies, tenotomies and other incomprehensible ablations, in the new department prosaically named the Laparoscopically Accessed Sole Surgery (LASS) and to be socked to the customers as ‘Hole-in-the-Sole’. As a new procedure class, it is a shoe-in, experts say. A niche in this would be endoscopically guided surgery for paronychia and hangnail removal that has been estimated to reduce global loss of millions of man-days every year. This class of surgeon should be anointed Homo subunguous. Research on stapling these stubborn hangnails and microvascular sealing systems to control bleeding from incisions should be available once the disease is recognized as a silent killer, much like the obesity pandemic that affects the poorest of countries. In fact, new research states that the poorer you are, the more likely you are to get fat. Says how badly the US economy has been doing for so long, isn’t it?
To come back to the laparoscopic surgeon, he is too self-possessed now to notice that his existence in the near future is jeopardized, much like an MP3 player walloped in the south pole by the iPod. He is focused on refining newer ways of image-guided gymnastics to such an extent that he fails to notice the change in the world around him. The new world is, forget small-incision surgery, all about no-incision (no scar) surgery.
This new class of specialist puts in scopes through all natural body orifices and takes out organs like a magician takes rabbits out of a hat. Only that the magician gets paid a lot less and is a lot more fun to watch. The invader of the hole on either pole of the body belongs to a new class called Pokus neodigestivus. Enter the new digestive surgeon, a hybrid of endoscopist and hard-boiled laparoscopic surgeon. Rarely, if ever, has a chimera extinguished a parent species, but this could well be the case here.
The interested audience to the new, enchanting, global, industry-sponsored circus-dance of the robots, the neo-endoscopists and the increasingly archaical laparoscopic surgeon is, as always, the general surgeon (sub-species skepticus) and the internist (sub-species studious). Seated in the ringside, so to speak, is the friendly media, Slurpus sensationalis.

Do you know how it is to be on the frontlines in an active war? Just like getting married to the wrong person!
After my internship I was drafted into the military service during the Iraq-Iran war and reported to my infantry Battalion as ordered. My commander, a Colonel, had some peri-anal issues. Based on what he told me, I did not think he had piles, but he insisted he did and would not take “no” for an answer.

One early morning, I was summoned to his post, where he demanded an examination. But I had no proctoscope (a metal tube half as wide as an ice cream cone). He dispatched me with his guards some 30 miles away to the nearest MASH unit. There I was greeted with unusual respect and was indulged with all the tools of my liking. Back at the frontline, I performed the proctoscopy on my commander, a 5 feet-nothing, chubby male with a face the color of sun-dried Italian tomatoes. As I advanced the scope, the enemy could have heard his groans! His face turned the color of sun-dried Italian olives. Luckily for me, it went through fairly quickly. As he pulled his pants up he said, "Thank God I am not gay!” Dismissed!!

One early morning, our group of twelve senior medical students reported to an outpatient clinic run by a consultant general surgeon. We started the day with a young chap complaining of pruritus ani (itchy butt-hole). What a way to start a day! Needless to say the patient was embarrassed to share his secret, and so were we, as we did not know what to expect.

The consultant surgeon interviewed the chap and asked him to the hot couch in knee-elbow position! While doing his digital exam, he gave us his blessings out of the corner of his eyes. Like soldiers in command, we all put our gloves on, each raising his or her index finger up in the air. With the patient looking on in awe, covering his face with his hands, each one of us got to greet his prostate! A total of thirteen of us! In sarcasm, the patient turned around while pulling his pants up and made a statement that is still ringing in my ears every time I take a medical student through such an exam: "Hey doc, for Heaven's sakes, is this a butt or a medical university?"

You have, like me, all seen at some time or the other, some movie or heard some joke about a surgeon's watch left in a patient's tummy during surgery. I don't know of too many doctors who can afford to leave their Breitlings and Rolexes in such secure vaults as the bellies of patients, but I do know of a few who have left pieces of cotton, called gauzes and mops (the latter being bigger and bulkier) inside, blissfully unaware that the patient was really not dying for the unwelcome implant!

In the days when I (as a resident) used to pick up patients from Government hospital OPDs and push them into surgeries because I wanted to do them (as opposed to their needing them at that moment), I once operated on a patient for a recurrent thyroid tumor. He had been operated a few years back and soon felt the same tumor, for which he came to me. No scans, those days. 'See and cut, cut and see' was the mantra. In the OR, the tumor turned out to be a piece of leftover gauze surrounded by a dense capsule of tissue reaction. Patient cured. Much later, I learnt that this was an example of a Gossypiboma. Doctors always try to mask this disaster as a 'Foreign Body', though not all foregn bodies are our creations (like thorns, fish-bones, etc).
It is every surgeon's nightmare when a mop goes missing during surgery. The theater nurse has to reconcile the count of mops she came in with before surgery, and she has to leave with the same numbers seen and counted outside the patient's abdomen. Else, an xray has to be got, though it is not a sure shot answer in the third world, and the patient may need to be re-opened, and...it is best avoided like an airplane co-passenger with XDR-TB!
Now, technology is here to make such silly things as obsolete as writing letters. SmartSponge System is a product that seems so simple you wonder why no one thought of it. It has a small Radio-frequency Identification Device (RFID) chip implanted in each sponge (an American name for a mop) with its own serial number. A device just detects the sponges at the end of surgery and counts them, with each number being listed. The FDA has just approved the device, and hopefully, it will become a standard gadget in our ORs.
As a laparoscopic surgeon, I have less worries with sponges, as it hard to imagine pushing in a six inch sponge through a 10 mm cannula. But I can push in small gauze pieces to soak up stuff, and this technology would be one way to prevent becoming too (in)famous!

Old people keep falling for a variety of reasons. They see things as if through a windshield on a rainy day when the wipers have lost their rubbers. They have creaky joints, powdery bones, and thin muscles to support them, as a result of age-related misuse and disuse. The resultant lack of balance makes them vulnerable to slipping on a bathroom floor or dog poo. It is also important to realise that these often lovable (and sometimes unlovable) ancient relics can lose consciousness for a variety of reasons: cerebral ischemia (called a TIA), heart block, low blood glucose, etc). Once the patient is discovered lying on the floor, they are often unable to say clearly whether they slipped and fell, or flipped and fell! Sometimes, they are picked up from the floor, and carried to bed, where they are kept 'in rest' for a week or more. It is when the patient becomes sick that an alert doc picks up the fracture in the neck of the femur by noting the laterally rotated foot on the bed. This means that when a patient lies flat in bed, normally her great toes would point to the GoogleEarth satellites far overhead. If they point towards the TV or the fridge, the hip is liable to be broken (real medical Holmes stuff, eh?). By the time the fracture is detected, the patient is already having urinary and lung infections, and taking blood-thinners and a dozen different drugs. In short, not the kind of patient an orthopedic surgeon will knife his competitor to take up!
There is evidence that surgery for fixing the broken bones leads to good results, as this excellent summary shows. However, it is important to postpone the surgery for a while to prepare the patient for surgery. Mortality is more if patients are wheeled straight to the operation theater from the Emergency Room. Should we, as our beautiful Nurse asked in her comment, operate on these 'fossils' only to make see them lie in bed, vegetatively incontinent and incoherent? Studies show that while conservative treatment is successful, it leads to longer convalescence and hospitalisation. No surprise, that! The bottomline, in my semi-literate mind, would be that if the patient is demented, incapable of independent activities even at the basic level (eating, cleaning, etc.), or if the medical problems are very severe, they should be spared the rod. I am talking, of course, of the steel that orthopods insert into broken limbs. Only, these days, they are more likely to 'screw' the patients!

Here is a very pedestrian article I have written for a senior-specific magazine called Harmony. The article deals with some points that should be known before a geriatric patient proceeds for surgery. There is published literature to support laparoscopic surgery in the elderly, and I believe these old birds don't take big incisions as well as the nicks of minimal access. However, more than the size of the cuts, it is what takes place inside the body (infections, leaks, blood clots, bleeding, etc.) that determines if the elderly patient lives after the surgery. While in most cases of mediocre surgeries, the patient survives in spite of the surgery rather than because of it (because Nature gives us a long rope), the elderly population is a clear exception. Their system is like a house of cards that comes crashing down if the balance is upset.
One thing I have realised in practice is: if you are successful initially operating on a few really sick old folks, you are going to sleep less for the rest of your life. Because the invisible social network of these patients drives more and more geriatric patients to you, crowding out the younger, fitter, easier cases, at least in the third world. If you come to my hospital OPD, you will see barely conscious, silvery hags carried horizontally over half-torn stretchers from hundreds of miles away for really advanced, Middle-Ages-level disease. For example, if you do a lap chole surgery on them, you would have to dissect out almost every upper abdominal organ that is irreversibly stuck on to a tiny, hard, fibrosed nodule that calls itself a gall bladder. If you do a hernia, the patient would look like he had, at some point in his youth, decided to transfer all his bowels from his tummy to a secret place beneath his trousers, and then suddenly, in the twilight of his life, decided that that was ALL that needed fixing in his otherwise perfect life! "Hey, commere, doc, just fix this hernia, will ya? And don't cut me up, d'ya hear? Only the best, latest, painless, bloodless keyhole surgery that you guys are doing these days! I am still getting my pension, so my kids don't want me to die!" Most of the grave 'bearers' of the bad news are very clear that they expect the surgery to take place this afternoon, and the patient should be up and about like a lustful monkey in a couple of days! And, of course, they couldn't possibly spend money on old, dying grandmothers and grandfathers, could they? "Be reasonable, doc! Okay, my maximum budget is ten thousand rupees (around $250)". Anything more than that, they say with their eyes and facial muscles, you will have to pay for, especially if she dies! At least, in my life, this has been my bane, and the reason for the premature greying of what hairs my head still proudly bears! And, of course, a reason for my still being so poor!!

When it comes to the future of surgery, there are three kinds of surgeons: those who watch it happen, those who make it happen, and those who wondered what happened.
While most of the world’s surgical community would easily fall in the last category, Jacques Marescaux is one of the movers and shakers of surgical development. Marescaux wears too many laurels to enlist. An iconic surgical pioneer, he made history with ‘Operation Lindbergh’, an epochal event in 2001 when he, from New York, performed a laparoscopic gall bladder surgery on a patient 4000 miles away in Strasbourg, France. As an example of robotic telesurgery, this event opened up to the world a bewilderingly fast evolution of surgery. Surgery, as we know it today, is going to be archaic and laughable in the future. Or is it?

NO SCARS AFTER SURGERY?
Marescaux is now working on a surgical project on ‘no-scar surgery’ at the European Institute of Tele Surgery (EITS). Called NOTES (Natural Orifice Transluminal Endoscopic Surgery), this project involves research on removal of organs inside the abdomen, like gall bladder, appendix, adrenal, spleen and pancreas using endoscopes passed through the mouth, anus or vagina. In a typical procedure, a specially designed flexible endoscope is passed through the mouth and a small hole created in the stomach wall. Through this hole, the surgeon passes instruments to dissect out the target organ, eventually to extract it out through the stomach and then out the mouth. End result: no scars on the belly, no pain of cuts and wound infections! Is that really possible?
Nageshwar Reddy and GV Rao of the Asian Institute of Gastroenterology, Hyderabad, conducted the first human cases of removal of appendix through the stomach. Presenting his experience at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Conference at Dallas in June 2006, Rao said, “We put in a laparoscope in addition to doing the transgastric appendectomy just to be safe”. So, what is the safety issue here? Says Marescaux, “This approach is very difficult to use in humans because of the difficulty in closing the stomach hole. We are developing a method to close the hole that will be easier than stitches and clips, though we cannot reveal the method right now”. Why not? Companies like Karl Storz and Ethicon Endo-Surgery are pouring in millions of dollars to develop the first commercially available endoscopic NOTES device. Naturally, confidentiality is the keyword for researchers. With a spreading feeling that NOTES could change the face of surgery, work is on to be the first off the block to market the devices. Ethicon recently gave a one million dollar grant to SAGES for research on the new science.
At present frenetic work is on to develop and refine newer endoscopes that can accommodate multiple sturdy instruments through them as well as make stomach wall closure safer.

So, to repeat our question, is no-scar natural orifice surgery realistic?
Moshe Schein, author of multiple surgical books and Associate Editor of the World Journal of Surgery, is critical: “The idea is superficially appealing. But, to me, violating the integrity of the stomach wall to take out the gallbladder is against the basic rules of surgery, including the KISS principle (Keep It Simple, Stupid). Do you really want to produce a hole in the stomach, and then having to fix it—risking leaks—in order to take out an appendix or gallbladder? Not on me!” Marescaux, ever the visionary, is clearly optimistic, “ I believe NOTES is more minimally invasive than the laparoscopic approach, though I don’t know if this will replace laparoscopy in the future”. When will we see it in action, in the real world beyond animal labs? “One to two years ” is his stunning assertion.
Richard Satava, Professor of Surgery, University of Washington Medical Center, Seattle sums up: “The most important feature of this new approach will be if there is significant improvement for the patient over current laparoscopic procedures – success must be determined by patient outcomes.”


ROBOT: MASTER OR SLAVE?

Contrary to popular notion, robotic surgery does not mean the surgeon being replaced by a robot. The four- armed robot, wielding cameras and multiple instruments, is merely the slave by the patient’s side, obeying commands from its master, the surgeon, who sits outside on his console, moving his hands on joystick equivalents while looking at his own monitors. The interposition of machine between surgeon and patient eliminates the surgeon’s hand tremors. In addition, the three-dimensional ‘In-Site’ ten-fold magnified vision makes surgery easier and safer. The robot can maneuver its instruments like a human wrist, something that is impossible in laparoscopic surgery, making complex operative steps easier.
Ashok Hemal, Professor of Urology at the AIIMS in New Delhi and formerly at Vatikutti Urology Institute, Henry Ford Hospital, says, “Mani Menon and his team there have done around 2700 robotic radical prostatectomies, with excellent results”. Menon has standardized this traditionally bloody and complex operation for prostate cancer by using the da Vinci robot. The artist Leonardo, who conceived the world’s first robot, is now the flag bearer in name not only of a best selling book by Dan Brown but also of the fast evolving field of surgical robotics. This robot is a virtual monopoly product of Intuitive Surgical, a $260 million US company, with 509 installations around the globe. India has four of these, with AIIMS holding two, Escorts Heart Institute at New Delhi and The Cardiac Research and Education Foundation at Hyderabad accounting for the rest. So why are heart hospitals going in for the da Vinci?
Operations like coronary artery bypass and mitral valve reconstruction can now be done by the key-hole approach and are being touted as two of the most marketable robotic procedures, apart from radical prostatectomy, hysterectomy and weight loss (bariatric) surgery.
Thought by many to be the future of surgery, robotics does not come cheap. The da Vinci is priced at $1.7 million (nearly seven crore rupees), with an additional annual service contract of more than $100,000. Each procedure needs instruments that cost between $1000 and $1500, provoking people like Schein and Danny Rosin to scoff at the benefits. Rosin, Senior Surgeon at Sheba Medical Center, Tel Aviv University questions whether “it is a solution waiting for a problem”. Hemal is cautious, “This expensive technology needs a good surgeon. By itself, it cannot make for good results. Robotics only expands the horizons of laparoscopic surgery, it cannot replace it”. In the US and Europe, robotic procedures are increasing, with more than 8000 prostatic cancers coming under the da Vinci’s arms every year. In India, though, hospitals are doing very little work to justify the huge investment. At AIIMS, Hemal has done 50 robotic radical prostatectomies.
While rare and difficult to implement, robotic telesurgery is evolving. Like Operation Lindbergh, the surgeon operates from a distance, using a sophisticated telecommunications system using high output fiber optics that results in little transmission delay. Mehran Anvari of McMaster University in Hamilton, Ontario, Canada performs advanced robotic surgery in North Bay, 300 km away from where he sits at his hospital.
Mobile robots are also being used for simpler jobs, like seeing patients from home or office. The RP-6 mobile telemedicine robot made by a Californian company called In-Touch is a robotic platform with a flat-panel monitor supported by a telemedicine connection. The nurse can go with the robot on rounds, and the patient can see and converse with the doctor over the telemedicine link. Satava remarks, “There has been surprisingly good acceptance of this technology, especially where physicians do not have much time for rounds. Patients quickly become accustomed to seeing their doctor on the video monitor, and frequently prefer this method of communication because the surgeon takes more time and has better eye contact with the patient – rather surprising!”

NO SMALL MATTER:
The world’s first medical micro robot, invented by Dmitry Oleynikov, Associate Professor, Department of Surgery, University of Nebraska Medical Center looks like a lipstick case and can navigate inside the abdominal cavity on wheels and tracks, capturing pictures with its own inbuilt camera and lights, all the while being controlled by an external remote control. Though the device today can do little beyond biopsies and recording pH, temperature and pressure, it is of sufficient potential for NASA to be interested in exploring its possibilities in space.

An Israeli company, GI View Ltd., is developing a new technique for screening colonoscopy called ‘Aer-O-Scope’. This device propels and navigates itself up the colon when placed in the rectum. Moshe Schein, in spite of being known as a conservative surgeon, is enthusiastic about the tech: “Recent studies show that GI physicians miss polyps during screening colonoscopy. I think it is because they are doing too many of these procedures per day (often up to 30) to do a complete check. Now imagine a small robot with a video camera, traveling on minute tracks, like a Merkava Tank, inserted in the rectum, walking up through the colon, and photographing everything. The video is loaded into a computer and interpreted.”

John Mellinger, Chief of Gastrointestinal Surgery, Medical College of Georgia, who recently wrote an article on Endoluminal surgery in Surgical Endoscopy says, “The entire colonic status is seamlessly reconstructed from the images we get from this painless procedure”.

AN EYE FOR PERFECTION:

Every surgeon makes mistakes. Often human anatomy and disease create illusions in appearance that fool even the most expert eyes and hands. During a gall bladder surgery, the bile duct can be injured, as can the urinary tube (ureter) during removal of the uterus, each with devastating consequences. If the surgeon could see each structure clearly separate from the other, it could reduce or eliminate injury. Augmented Reality, initially a neurosurgeon’s guide map, is now a high priority at Marescaux’s European Institute of Tele Surgery (EITS). EITS have developed software to reconstruct laparoscopic images in 3D system. The patient first undergoes a CT scan that a computer reconstructs in 3D and in color. Therefore, veins are colored blue, arteries red, and so on. When the patient is on the table for surgery, the CT reconstructed images are superimposed on the monitor that is showing the actual operation in real time. Marescaux demonstrates this in the laparoscopic removal of an adrenal gland tumor, where he uses the technology at will to show the perfect location of the major veins that lurk beneath the fat. Injury to these veins could lead to massive bleeding and death. Now, here is a method for reducing surgical errors and improving patient safety! Danny Rosin thinks this concept is “a promising technology that is not that far from more widespread use. The success of stereotactic neurosurgery with navigation systems is a proof that this can be useful.”
Marescaux is convinced that the future of abdominal surgery lies in Augmented Reality combined with Robotics, in both laparoscopic surgery and NOTES ‘no-scar’ surgery. As the rest of the world looks on, Marescaux uses a Persian phrase: "The madman forces doors, the wise follow”. As one preparing for it today, tomorrow seems destined to be his.

We have all heard and read of the world's first transvaginal gall bladder operation (cholecystectomy), done at a premiere institute in Strasbourg, France. While the public may react with delight at the thought of surgeries of the future occurring without scars at all, there are troubling thoughts.
The most important question that surgeons are asking is: "after a transvaginal cholecystectomy, can the patient have sex before six weeks?"
Just jokin'!!
On a serious note, the issue here is simple: is the abdominal wall so sacrosanct an organ that we are risking injuries to internal organs? After a transgastric appendectomy, where the operation is done through the mouth, there is a risk of the stomach hole leaking fatally. Is the risk worth it? As always, the response of the surgical community to this new Natural Orifice Surgery (called NOTES or NOS) is predominantly negative. I will just quote John Cage, who said, “I can't understand why people are frightened of new ideas. I'm frightened of the old ones.” Well, here is another quote on this, by Pearl Buck: “You can judge your age by the amount of pain you feel when you come in contact with a new idea.” Since the majority of the surgical community must be old farts and getting-there-old- farts, it is clear that the quote strikes the truth.
Though the surgical community as a whole watches in a mixture of revulsion, fascination and admiration, many patients must be planning to postpone surgeries for a few years till the new no-scar surgery becomes established. Homeopaths are going to have more patients, I am sure!
If you ask me, I think NOS is the surgery of the future, as long as surgery HAS a future. I seriously doubt that it has one, once the nanobots are let loose inside the body. Maybe another 20 years? I have written on the natural orifice surgeries and other futuristic surgical developments in KnowHow, the Telegraph. You can get the original full article in the 'future' label when you check the 'labels' list on the right of this blog-page.
However, on a personal level, it has become important for me to learn this soon. The problem is that the equipment is still not available in the market, being under development, and I am sure will be only slightly cheaper than a nuclear bomb! This is why practising surgery in this age is so difficult: you spend your best years learning something, only to see it becoming obsolete or proven useless just when you have reached some level of competence in it! Is laparoscopic surgery doomed? Will the neo-endoscopist rule? My answer is YES.
And, by the way, we still don't know enough to answer the 'most important question' above, unless we can do a retrospective study on all the pigs who had previously undergone the operation in the last couple of years, and ask them how soon did it feel good and safe to have sex!!

Hernias that occur in front of the belly, commonly seen in obese or multiparous ladies, are called ventral hernias. They may variously be called 'umbilical', 'paraumbilical', 'epigastric', or 'incisional' hernias.
Open operation is the commonest way of tackling this problem, and I hate the damn operation. It is quite an extensive and traumatic procedure, and wound problems are very common.
The lap approach is so much better, though it is still not the perfect solution yet (pain, recurrence, etc. still being issues). In my own personal experience, I have seen four recurrences after around 200 of these cases. All of these patients had a Goretex DualMesh placed, though this was because I used this product most when I started doing lap hernioplasties. Nowadays, I am using the Proceed or Parietex tissue-separating meshes, and so far, so good!
A recent article talks of the results of lap ventral hernia repair, and I recommend that you read it here.
One thing I find funny no one has seemed to notice, is: when I went in laparoscopically to repair my own recurrences, I saw that there were multiple small defects at the site of the full-thickness sutures that I had placed to anchor the mesh previously. It is as if the muscle just shrank between the sutures, and created a hole again. The article does not deal with this at all. Rather, the authors advise us to "stretch the mesh taut", which seems to be overkill. If you over-stretch the mesh, you create tension, which, as all surgeons know, is not very good for long term integrity of the repair.
Anyways, the article will be good news for those of us who see ventral hernias on a daily basis, as the results keep getting better and better.

Don't be surprised if you hear who makes a better surgeon today.
Young surgeons who spend hours playing on their playstations beat their sedate and (possibly) more studious counterparts hollow as surgeons, as you can read here.
You can also read the abstract of the original article here.

The New England Journal of Medicine has published articles clarifying the issue of who needs surgery for back pain.
The original article is available here
Below is the extract of the article.

Back Surgery — Who Needs It?
Richard A. Deyo, M.D., M.P.H.

Back surgery is not the final common pathway for everyone with persistent back pain. It offers specific therapy for specific anatomical derangements associated with specific complexes of symptoms. When surgery ranges beyond carefully defined situations, we can expect disappointed patients.

Two articles in this issue of the Journal (text deleted) — bolsters the case that surgery is effective for patients with sciatica owing to herniated disks. Investigators studied patients with sciatica who had not had sufficient improvement after 6 to 12 weeks of nonsurgical treatment. Excluding patients with briefer episodes was important, because even without surgery, sciatica improves within 3 months in 75% of patients.
Even among patients with persistent sciatica, recovery was likely whether or not surgery was performed. Studies involving repeated imaging show that most herniated disks shrink over time. But surgery accelerates the pace of recovery, and for some patients, faster recovery may be worth the risks.

After a year, recovery was about the same with surgery as with nonsurgical care, though almost 40% of patients who were initially assigned to the nonsurgical group later underwent surgery. A similar convergence of results after 2 to 4 years was apparent in earlier randomized, controlled trials. Thus, for patients with persistent sciatica, there seems to be a reasonable choice between surgical and nonsurgical treatment, which may be influenced by aversion to surgical risks, the severity of symptoms, and willingness to wait for spontaneous healing.

Patients in this spondylolisthesis trial tended to have improvement with nonsurgical therapy but to a smaller degree than the authors observed in their previous trial of surgery for herniated disks. Previous studies of nonsurgical treatment for spinal stenosis similarly suggest a low rate of improvement, in contrast to studies in patients with herniated disks. The less favorable prognosis of spinal stenosis may be an important factor for patients considering surgery.

In the two trials presented here, both back pain and leg pain were ameliorated by surgery, but leg pain resolved more quickly and fully than back pain. Thus, benefits are likely to be greatest for nerve-root–associated symptoms.

Degenerative spondylolisthesis with stenosis is primarily a condition of older adults rather than of younger patients, who typically have herniated disks with sciatica. In addition, fusion surgery is more invasive than diskectomy, with a higher complication rate. Surgical complication rates increase substantially after 80 years of age, which changes the risk–benefit equation — a problem that has yet to be addressed directly by researchers.


So who needs back surgery? The consensus seems to be that patients who were excluded from these trials because of major motor deficits need surgery, as do some with major spine trauma. For these patients, surgery may preserve life or function. Absent major neurologic deficits, patients with herniated disks, degenerative spondylolisthesis, or spinal stenosis do not need surgery, but the appropriate surgical procedures may provide valuable pain relief. In such situations, decisions should be made jointly by well-informed patients and their physicians.

there was this interesting case of heterotopic pancreas in the small intestine of a young boy who used to bleed a lot. Surgery cured him.

The following was an assessment that I do not share completely today: I agree with the sceptics that there is every reason to avoid over-enthusiastic surgery for chronic pancreatitis. I am very conservative with these patients and advise surgery when pain-killing celiac ganglion blocks, enzyme supplements, etc. fail abjectly.
Anyways, here is what I had to claim in 2004-2005:

Laparoscopic pancreatic surgery has usually been restricted to

staging for malignancy,internal drainage of pseudocysts and

left-sided resections.

However, the more complex procedures for chronic pancreatitis

and cancer of the head of pancreas are also worth considering.

Laparoscopic Whipple’s operation, while affording spectacular

views and being a great exercise in laparoscopic skills, is

unlikely to become popular in the near future, owing to its

complexity and the lack of evidence regarding its benefits.

Laparoscopic palliation for cancer of the head of pancreas is

technically less difficult. 16 bypass procedures have been done

without any major complications.

Laparoscopic surgery for chronic pancreatitis is another niche

area where there is very little world literature.

Of the drainage procedures for chronic pancreatitis, laparoscopic

pancreaticojejunostomy is more classical but more tedious.

The newer procedure of lap pancreaticogastrostomy is

superior because of its near-zero leak rate, ease and simplicity of

the technique, and efficacy. In our developing series of cases, we

have not had any leak or complication with the procedure.

It is likely that in the near future, lap pancreaticogastrostomy will

be the procedure of choice for the disease.



DR.B.RAMANA
DR.T.SEN
DR.P.P.GUPTA

Department of Minimally Invasive Surgery
Anandalok Hospital
Kolkata