Innovations in Minimally Invasive Surgeries for Rural Areas

Presentation at Bethune Round Table 2015 of the Canadian Network for International Surgery

Background

Minimally invasive surgeries are relevant for the poor and marginalized in rural areas where the patients need to get back to work as soon as possible, because they are often the sole bread winners of the family. Unfortunately, the high costs make minimally invasive surgeries unaffordable for the poor. We describe the innovations that we made, to make minimally invasive surgeries possible in remote rural areas in India over the last two decades.

Methods

The data of patients who underwent operations in remote rural areas of North and Northeast India were analyzed from the computer software where they are recorded, and the papers published by the author regarding the various minimally invasive surgical techniques were reviewed and complied.

Results

The following are the significant minimally invasive surgical techniques that were used:

  1. Ureterorenoscopic removal of renal stones with no “C” arm fluoroscopy unit
  2. Transurethral vaporization of prostate
  3. Uterine endometrial vaporization for DUB
  4. Low-cost topical vacuum therapy for non-healing ulcers and diabetic foot
  5. Modifications for laparoscopic surgeries like using ether with an EMO machine for anesthesia, use of a dental compressor for insufflation, re-use of  laparoscopic disposables, etc., along with modification of techniques
  6. Lift laparoscopic or gasless laparoscopic surgeries that are carried out under spinal anesthesia with traditional open surgical instruments
  7. The diagnostic and surgical camp model

URS for Renal Stones

In this method, the rigid ureterorenoscope is used to visualize the stones in the kidney and break them with pneumatic lithoclast. Both of these pieces of equipment are portable and are used in small hospitals in rural areas. This is possible because prior DJ stenting dilates the ureter. The drawback of the procedure is that several sittings are required for stone clearance. The highlights and references are given below.

  • Prior DJ stenting
  • Lithoclast for breaking stones
  • 355 stones in 2 years @ $ 100 to $400 per patient, 37 still not stone free with > 7 mm stones and no follow-up for stones < 7 mm in the final X rays (202)
  1. J. Gnanaraj, Balaji Prasad Ellapan. Ureterorenoscopic removal renal stones: Cost effective patient friendly method in rural areas. Tropical Doctor April 2011, 41 page 102.
  2. J. Gnanaraj, S. Jamir, N Chongtham. Innovative and cost effective treatment for renal stones in remote areas by Surgical Services initiative. mdCurrent-India, June 2014.
  3. Dr. J. Gnanaraj, Dr. Sungtiakum Jamir, Dr. Nandamani. Tackling Renal Calyceal Stones: A challenge for Rural Surgeons. Rural Surgery Vo. 10, No. 2, p 13-15, October 2014.

Transurethral Vaporization of the Prostate (TVP)

Transurethral resection of the prostate is still considered as the gold standard for treatment of bladder outflow obstruction due to Benign Prostatic Hyperplasia, or BPH. The procedure has small but definite complications and significant morbidity, so that it is not possible to do them in rural hospitals and walk away. The transurethral vaporization procedure, especially the new one using normal saline, makes it possible to do the surgeries in rural hospitals. The highlights and references are given below.

  • Excellent vision, minimal blood loss, and no dilution hyponatremia – especially with use of normal saline
  • 57 patients with glycine and 38 with normal saline
  • Costs about $200 per patient
  1. Gnanaraj J, Lionel Gnanaraj. Transurethral electrovaporisation of prostate. A boon to the rural surgeon. Aust N Z J Surg 2007 Aug; 77 (8) 708.
  2. J. Gnanaraj. Transurethral vaporization of Prostate in patients with small urethra, a new technique. Rural Surgery Vol. 8 No. 2, June 2012 p 15.

Endometrial Vaporization for DUB

Removal of the uterus for Dysfunctional Uterine Bleeding (DUB) is a major procedure. Despite the availability of laparoscopic surgeries, and especially gasless Lift Laparoscopic surgeries, it is still a major procedure. The vaporization of the uterine endometrium using the urology resectoscope and VaporTrode gives excellent results and can be carried out as a day care procedure. The highlights and references are given below.

  • Low cost day care procedure
  • Costs about $200 to the patient
  • Urology instruments are used
  1. J. Gnanaraj, Jessie Lionel. Endometrial resection/vaporization: A patient friendly first option treatment for menorrhagia in rural area. Tropical Doctor 2008: 38: 103-104 (April 2008).

Low-Cost Vacuum Therapy

India is slowly becoming the diabetic capital of the world. Infected diabetic foot, often necessitating amputation, is a very common problem in rural areas. Vacuum therapy, which is effective in preventing amputations, is well out of reach of the poor, who are greatly incapacitated by amputations. The low-cost methods and machines are of great help to the poor in rural areas. The highlights and references are given below.

  • Low-cost and proven method
  • Successfully prevented amputations in 27 patients posted earlier for amputations
  1. J. Gnanaraj. Low-cost topical negative pressure wound dressing system Tropical Doctor 2010; 40: 208–209.
  2. Arun Prasad, Danita G, Ida Sheela, K Rajasekaran, J. Gnanaraj. Low cost topical wound suction system & 3 in 1 machine. Rural Surgery, Vol. 7, No. 1, January 2011 p 3.
  3. J. Gnanaraj, Danita Gnanaraj, Arun Prasad. Salvaging Diabetic foot: A new cost effective method. Tropical Doctor 42: 88-89, 2012.
  4. J. Gnanaraj. Topical Vacuum therapy for Fournier’s gangrene: A challenge. Rural Surgery Vol.9 No.1 April 2013 p 8, 9.
  5. J. Gnanaraj, Arun Prasad. Negative pressure wound therapy: Low cost machines and local adaptations. mdCurrent-India, January 2014. (http://mdcurrent.in/primary-care/negative-pressure-wound-therapy-low-cost-machines-local-adaptations/)
  6. J. Gnanaraj. Quick case: Diabetic foot treatment with topical vacuum therapy. mdCurrent–India, February 2014. (http://mdcurrent.in/case-studies/quick-case-diabetic-foot-treatment-topical-vacuum-therapy/)

Low-Cost Laparoscopic Surgeries

Laparoscopic surgeries are appropriate for rural patients, as the rural patients need to get back to work as soon as possible to prevent the family from going below the poverty line. Unfortunately, laparoscopic surgeries are expensive and not easily available in rural areas, and several modifications were carried out to make them available. The highlights and references are given below.

  • Under Ether anesthesia with an EMO machine
  • Dental compressor for insufflation
  • Over 5,000 such surgeries
  1. Gnanaraj J. Laparoscopic closure of duodenal ulcer perforation. An effective and patient friendly option for rural areas. ANZ J Surg. 2007; 77(9):800.
  2. Gnanaraj J. Laparoscopic surgeries in rural areas: challenges and adaptations: an experience of over 1300 laparoscopic surgeries. ANZ J Surg. 2007; 77(9):799-800.
  3. Gnanaraj J, Cherk-Yun. Minimally invasive appendicectomy using the cystoscope. Tropical Doctor, 2008 Jan 38 (1) 14-15.
  4. J. Gnanaraj. Laparoscopic surgeries in rural areas: Challenges and adaptations. Rural Surgery Vol. 4, No. 4, October 2008.

Lift Laparoscopic Surgeries

The need for general anesthesia and the cost of the delicate equipment are among the top reasons for laparoscopic surgeries not being available in rural areas. Learning opportunities are also difficult for rural surgeons. Lift laparoscopic surgery is an innovation that is easy to learn, and surgeries are carried out with sturdy instruments under regional anesthesia. The highlights and references are given below.

  • Low cost surgeries under regional anesthesia
  • No physiological changes during anesthesia due to carbon dioxide
  • Easier learning, especially for single-incision surgeries
  1. J. Gnanaraj. Gasless Lift Laparoscopy. Rural surgery Vol. 8 No. 4, January 2013, p17 -19.
  2. J. Gnanaraj. Low cost laparoscopic surgeries: Taking modern surgery to the poor. mdCurrent-India, October 2013.
  3. Gnanaraj Jesudian. Single Incision Lift Laparoscopic Surgeries [SILLS]: Taking modern surgery to the poor. J Miss 2(3):e11465 Published online 2013 October 8.
  4. J. Gnanaraj. SILS appendicectomy with gasless lift laparoscopic surgery. mdCurrent-India, December 2013.
  5. J. Gnanaraj, Linda Sailo, Sharon Rebecca. Low-cost minimally invasive evaluation and treatment for infertility in rural areas. mdCurrent-India, January 2014.
  6. J. Gnanaraj, Sungtiakum Jamir. Lift Laparoscopic Cholecystectomy: Ideal for new converts to Laparoscopic surgery. mdCurrent-India, April 2014.
  7. J. Gnanaraj. Single Incision Lift laparoscopic Trans-abdominal Pre-peritoneal Herniorrraphy: A low cost technique for Rural Surgeons. mdCurrent-India, May 2014.
  8. Linda Sailo, Gnanaraj Jesudian. Single Incision gasless Laparoscopic surgeries and other low cost minimally invasive Techniques for evaluation of infertility in rural areas. International Journal of Infertility and Fetal Medicine. January – April 2014: 5(1) p413-4.
  9. J. Gnanaraj. Single Incision Lift Laparoscopic Appendicectomy. Initial experience. Rural Surgery Vo. 9, No. 4, Jan 2014 p 15-17.
  10. Gnanaraj J, Kevin Gnanaraj, Sungtiakum Jamir, Stanley Maria, Michel Rhodes. Instruments for Gasless Single-Incision Lift Laparoscopic surgery: Making laparoscopic surgery available to the poor. mdCurrent-India, July 2014.
  11. J. Gnanaraj, Michael Rhodes. Single incision lift–laparoscopic appendicectomy: a less expensive technique easy to learn. Trop Doct, OnlineFirst, published on October 7, 2014 as doi:10.1177/0049475514550236.

Diagnostic and Surgical Model

The diagnostic camps take most of the diagnostic facilities, like the laboratory, ultrasound examination, the various scopies, etc., to the remote and rural areas where the patients needing surgery are diagnosed. Surgeries are carried out in a nearby mission or rural hospital by a visiting team that includes those who come to help and those who come to learn. It is a win-win for all involved. The highlights and references are given below.

  • Cost-effective method of surgical care
  • Successfully carried out for over 2 decades
  • Win-win for all concerned (surgeons, trainees, donors, patients, local hospitals)
  1. J. Gnanaraj, Lau Xe Xiang Jason, Hanah Khiangte. High quality surgical care at low cost: The Diagnostic camp model of Burrows Memorial Christian Hospital. Indian Journal of Surgery Vol. 69, No.6, December 2007 p 243-247.
  2. J. Gnanaraj. Diagnostic and surgical camps: Cost effective way to address surgical needs of the poor and the marginalized. mdCurrent-India, January 2014.

Conclusions

The three major problems with respect to accessibility, availability and affordability have been addressed by the diagnostic and surgical camp model and the various low cost modifications described here.

Figure 1 One sitting of URS and lithotripsy

Figure 1: One sitting of URS and lithotripsy

figure 2 lift laparoscopic knotting

Figure 2: Lift laparoscopic knotting

figure 3 lift laparoscopic suturing

Figure 3: Lift Laparoscopic suturing

figure 4 gastroscopy during a diagnostic camp

Figure 4: Gastroscopy during a diagnostic camp

figure 5 low-cost vacuum therapy

Figure 5: Low-cost vacuum therapy

figure 6 the special vaporization electrode

Figure 6: The special vaporization electrode

figure 7 the opening of the fallopian tube into the uterus

Figure 7: The opening of the Fallopian tube into the Uterus
Gnanaraj-64 Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
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