Jugaad Innovations for Rural Surgery

INTRODUCTION

Jugaad Innovation is described as frugal and flexible innovations. It is very important for rural surgeons to learn the Jugaad techniques as they would help them to serve the rural surgical patients better. It is important for rural surgeons to multitask and they should also have sufficient engineering knowledge to be service engineers. It will not only prevent them from being cheated but would also help in preventive maintenance of various equipment. In this article, we describe the various Jugaad Innovations that we have used over the years for minimally invasive and rural surgeries.

THE INNOVATIONS ARE NOT NEW IN INDIA

This is true especially in rural India. In one of the mission hospitals in Assam Dr. Quentin D. Kenoyer worked in the fifties and sixties when there were no effective medicines for tuberculosis. There were so many tuberculosis patients that the hospital needed a TB sanatorium. Abdominal tuberculosis was common and so were GI malignancies. Hence, he used the proctoscope to take biopsies from the abdomen instead of using a regular laparotomy for biopsies because of the morbidity of laparotomy. When patients had severe haemoptysis Dr. Kenoyer used Table tennis balls to collapse the lung to stop the bleed.

BIOMEDICAL ENGINEERING JUGAAD

A variety of innovations are found in most of the rural hospitals. The following are some of them [1]

  1. Use of industrial oxygen instead of medical oxygen and this greatly reduces the cost and is easily available and there is only a marginal insignificant reduction in purity
  2. The car head lamps give very powerful light and the only drawback is the heat it generates and fans are used to drive it outside
  3. Local designs for water softening and heating with firewood for hot water are cost effective options for rural hospitals
  4. Manual suctions are necessary

Figure 1: Locally designed water softener

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THE NEWMON VENTILATOR

One of the innovations from the Association of Rural Surgeons of India that illustrates nicely the objective of Jugaad Innovation is the Newmon Ventilator. It is a low-cost ventilator costing a fraction of the standard ventilators and can run either on electricity or compressed air and could be operated mechanically if everything fails.

MINIMALLY INVASIVE SURGERIES BEFORE THE LAPAROSCOPE

We were fortunate that as an urologist we had the scopes and a camera before getting the laparoscopic surgical instruments. We started with the diagnostic laparoscopies using the cystoscope [2].

It was very convenient that there were channels for insufflation and for biopsies if necessary. We started the insufflations with BP cuff and air but realized that one of the nurses had to work almost all the time for the insufflation. We did try smaller fish tank pumps but could not get proper filters and finally settled for using nitrous oxide especially when we had to use the electrocautery for hemostasis. We started with guide wire and pusher initially but later could buy the bugbee electrode. From these diagnostic procedures, we then graduated to minor surgical procedures like appendicectomies, tubectomies and ovarian cystectomies. Here we used small incisions directly over the structures and used the scope to identify and pull the structure out [for example pull the appendix out of the small incision]

MINIMALLY INVASIVE OPEN SURGERIES

Only of the important lessons that we learnt watching laparoscopic surgeries was that position of the patient would help a lot in open surgeries too. For instance, a head up and clockwise tilt of the operating table helped the bowel move away from the gall bladder and made open surgeries possible with smaller incisions.

We could use the cord light that we had for cystoscope to provide light at the place it was needed and the quality of light was much better. The cystoscope could be used for close visualization even in open surgery.

Making the tissue wet using the laparoscopic suction cannula and syringe and using traditional cautery machine made it work like vessel sealing equipment if the correct colour change was observed.

We also devised incisions like the Chinchpada incision [modified Cherney’s incision] that involves detaching the rectus attachment to the pubic bones [and later suturing back to the periosteum] that greatly improved the exposure and decreased the need for retraction during pelvic surgery. Steep Trendelenburg position made the bowel go away from the area of surgery.

LOW COST LAPAROSCOPIC SURGERIES

Once we got the equipment and started laparoscopic surgeries we found that getting gases was a logistic nightmare in rural areas. We had to travel more than 700 kilometers to get carbon dioxide and 50 kilometers to get nitrous oxide. Moreover, the nurse anesthetist we had was more comfortable with ether and EMO machine. Hence, we made the following changes for laparoscopic surgeries in rural areas [3]

  • More than 5,000 laparoscopic surgeries were carried out using ether and EMO machine for anesthesia
  • We modified the dental compressor to connect to the insufflator and used air instead of carbon dioxide
  • Instead of SILS port we used the locally made glove port for single incision surgeries using the thumb for the camera and the other fingers for 5 mm ports
  • With pyocele of the gall bladder instead of struggling to complete the removal of gall bladder we used the SPC trocar and cannula for cholecystostomy drainage

LAPAROSCOPY ASSISTED SURGERIES

We found that the laparoscopy assisted surgeries had all the advantages of MIS while they do away with the disadvantages of open surgeries and the high costs of full laparoscopic surgeries. For instance, for GJ Vagotomy doing vagotomy laparoscopically avoided the need for the large incision and doing the anastomosis using a small muscle splitting incision saved the cost of staplers that could cost three to four times the entire cost the patients paid for surgery.

We found that many patients with inoperable malignancies had downhill course following open diagnostic laparoscopies and anterior GJ. However, those who had diagnostic laparoscopies and GJ with small muscle splitting incision did better and many had chemotherapy and survived longer. Laparoscopic dissections and small incisions were similarly helpful in renal surgeries and surgeries like hemicolectomies.

CYSTOSCOPY ASSISTED SURGERIES

The concept of laparoscopy assisted surgeries was then extended to cystoscopy assisted surgeries for renal surgeries. The use of cystoscope or ureterorenoscope to break the stones with lithoclast in addition to making the incisions smaller made surgeries safer. This was because only the renal pelvis was opened and there was no need for renal incisions.

THE GAS LESS LAPAROSCOPIC SURGERIES

The gas less laparoscopic surgeries are an exciting innovation that has many advantages for rural areas. The most important one is that surgeries are possible under spinal anesthesia and neither carbon dioxide nor nitrous oxide is necessary [5]. There are more doctors or trained nursing staff to give spinal anesthesia compared to general anesthesia [even with use of ether and EMO machine] as the skill level required for anesthesia is less and the costs are low.

 

The following table lists the advantages.

VIDEO ASSISTED SURGERIES

The video assisted surgeries are more for experience [or fun] rather than any necessity. However, some like the video assisted inguinal block dissection using vessel sealing equipment had the advantage of healing without lymphocele and prolonged lymph drainage that is usually observed [6]. However thyroid surgeries, breast surgeries and surgeries for carpel tunnel had no significant advantage.

For carpel tunnel, we used the regular cold knife that we use for cutting urethral strictures [7].

RENAL STONES WITH URS

Renal surgeries in rural areas pose lots of challenges. To start with they require general anesthesia and experienced anesthesiologists. Better operating tables are required and incisions in the kidney can bleed significantly and blood transfusions might be required. We found that prior Double “J” [DJ] stenting makes the ureter dilate to 2.5 to 3 times the original diameter and this facilitates passage of the ureterorenoscope into the kidney [8]. Our innovative Easy Position Easy Fix Stirrups further helps in reaching the upper and middle calyces.

To tackle the lower calyceal calculus we used methods like ultrasound guided flushing, alternating suction and irrigation and use of guide wire to push the stone if possible.


However, the drawback of the procedure was that several sittings were required especially for larger stones.

VAPORIZATION SURGERIES

Arranging blood transfusions in rural areas is very difficult. The traditional resection of prostate sometimes gave us sleepless nights and we had to arrange blood as a safety measure and many times they were not required. When we started vaporization of prostate the surgeries were almost bloodless and we stopped arranging for blood which was a great relief. We then extended the method to vaporization of endometrium for dysfunctional uterine bleeding and for resection of intramural polyps and fibroids. Vaporization made removal of bladder tumor easier.

THE USE OF BUGBEE ELECTRODE

The bugbee electrode is a versatile equipment that could be passed either through the cystoscope or ureterorenoscope and we have used it for a variety of procedures like the following:

  • Vaporization of small bladder tumors
  • For vaporization of prostate when the size of the urethra does not allow the resectoscope
  • For treating TCC of the upper urinary tract through the URS
  • For minimally invasive treatment of fistula in ano
  • For treating urethral strictures when cold knife and urethrotome are not available
  • For treating uterine septum

MIS FOR FISTULA IN ANO

The fistula in ano treatment uses the modern principles of closure of the internal opening, division of the tract at the inter–sphincteric space and burning of the epithelial lining of the tract using bugbee and URS. [9]

The burning of the epithelial lining of the tract is possible with guide wire and pusher when ureterorenoscope is not available.

WHEN THE POWER FAILS

Power supply is a constant problem in rural areas and despite having back-up generators and invertors sometimes all of them fail. We have had circumstances when we had to use torch light through the fibrotic cord and thanks to gas less surgeries the ordinary cell phones to complete surgical procedures. [10]

OTHER LOW-COST INNOVATIONS FROM RURAL SURGEONS

Some rural surgeons found that the good quality mosquito net looked very similar to the Prolene mesh and investigations showed that the similarity is much more than what was expected. Hence the rural surgeons have started using the mosquito net mesh and even Operation Hernia an international Organization helping with hernia surgery primarily in African countries have started using it. We have used it for laparoscopic hernia repair at a fraction of the cost of Prolene mesh.

INNOVATIONS IN DELIVERY SYSTEM

The innovations are not confined to equipment alone. The Diagnostic camps take most of the common diagnostic facilities at the hospital like the ultrasound, gastroscope, cystoscope, etc., to the remote and rural areas and the regular surgical team visits to rural health care facilities train and empower the rural doctors to provide surgical care. [11]

The innovative financial plans include deferred payments for surgeries, Churches donating piglets for elective surgeries that the family sell and bring the money for elective surgeries, accounts in local village grocery shops to pay the hospital dues and the family physician paying upfront and collecting the money from the patients later.

THE LANCET CENTER OF EXCELLENCE IN INNOVATION

The Lancet Commission on Global Surgery India has made SEESHA and Karunya University as the Center of Excellence in Innovation for Rural Surgery and several low cost surgical equipment design and trials are going on [12]. These include things like live smoke and specular reflection removal during laparoscopic and endoscopic surgeries, non-invasive hemoglobin and blood sugar monitoring, intelligent wireless low cost vital signs monitoring system and low-cost vacuum therapy.

SUMMARY

The following table lists some of the problems and their solutions.

FUTURE PLANS

The Lancet Commission on Global Surgery estimates the surgical need at 5,000 surgical procedures for every 100,000 populations. The vision is to form groups of 4 rural health care facilities, standardize them and empower them by Task Specific training and competency based credentialing and help them share human resources and equipment. This would help meet the surgical needs in rural areas and having a center for innovation in rural surgery if the first step that Lancet Commission on Global Surgery has taken in providing solutions.

gnanaraj 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.

References (click to show/hide)

  1. R R Tongaonkar, Gnanaraj J. How to reduce costs in rural areas. Presented at the IFRS conference. mdCurrent-India December 2015
  2. Gnanaraj J. Diagnostic laparoscopies in rural areas. A different use for cystoscope. Tropical Doctor 2010 40: 3 p 156 July 2010
  3. 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
  4. Gnanaraj. MIS for rural surgeons. Cystolithotomy. mdCurrent-India October 2015
  5. Gnanaraj J. M Rhodes. Laparoscopic surgery in low and middle income countries: gasless lift laparoscopic surgery. Surgical Endoscopy August 2015
  6. Gnanaraj J. MIS for rural surgeons. Video inguinal block dissection. mdCurrent-India December 2015
  7. Gnanaraj J. Minimally invasive surgery for Carpel Tunnel syndrome: A new cost effective method. mdCurrent-India August 2015
  8. Gnanaraj J. Blaji Prasad Ellapan. Ureterorenoscopic removal of renal stones: Cost effective patient friendly method for rural areas. Tropical Doctor 41 p 102, April 2011
  9. Gnanaraj J. Fistula in ano for rural patients. mdCurrent-India September 2016
  10. Gnanaraj J. MIS in rural areas. Solutions to problems of MIS in remote areas. mdCurrent-India, November 2013
  11. Gnanaraj J. Comprehensive surgical care in rural areas: A proposal for a pilot project in Northeast India. mdCurrent-India March 2016
  12. Gnanaraj J. Take home messages from WHO-Lancet commission on Global Surgery National Surgical Forum Delhi March 2016. mdCurrent-India March 2016

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