Surgical Care for Northeast India: Take Home Message from a ARSICON 2017 Session

By: Dr. J. Gnanaraj and William Bolton

Several current challenges in delivering rural surgery to underserved populations of the north-eastern states of India were discussed at the 2017 Association of Rural Surgeons of India Conferences (ARSICON) this November. Rural surgery needs to be attractive for both surgeons to train and practice in, and for patients to engage and seek affordable, timely care. At present surgeons all too often do not stay and work in the rural area long term. There are several reasons why this may be the case, and some we can’t directly impact, such as community/infrastructure issues like lack of schools and roads. However, there are some areas we can tackle to enhance healthcare in these regions, which over time will lead to greater investment in the area in the long term. In collaboration with ARSI, we can make rural surgery more attractive for surgeons through the following potential work areas:

  1. Collaborating with ARSI in the generation of rural surgical guidelines and protocols to outline what rural surgeons can do, when and where. This will improve the legal status of rural surgeons and make them more protected to function in these challenging environments.
  2. Enhancing rural surgery specific training. We can do this through local medical college enhancement with rural surgery curriculums but also showcasing that surgeons can still obtain their skills in laparoscopy (for example) through the use of novel technology such as the GLLS device.

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The Gas Less Lift Laparoscopic Surgery [GLLS] workshop session shortly after ARSICON was well attended and anecdotally, GLLS was well received and stimulated good discussion. The session was attended by several key stakeholders including surgeons and surgical nurses using GLLS in rural areas, surgeons familiar with open and conventional laparoscopic surgeries, GLLS research teams from India and abroad and Medtronic Labs members. Medtronic Labs distributed a survey for all delegates and collected quantitative and qualitative data on GLLS use and views surrounding it and they have offered to share this information with us when they have it written up. All key stakeholders were happy to discuss collaboration moving forward in terms of the GLLS device development and evaluation in rural areas of north east India.

In addition to the GLLS the other low cost surgical devices that could make impact in rural settings were explored throughout the ARSICON:

  1. Low cost Gastroscopy devices: Pietro Vadastri from University of Leeds has developed a low cost Endoscopy unit
  2. Low cost vacuum therapy unit that is produced at Karunya University
  3. The low cost Joshi External Stabilization System [JESS]

These projects will be explored further and developed over time. After the conference there was some time to host meetings between key stakeholders and surgical leaders from Arunachal Pradesh which is the initial key location for the University of Leeds projects.

THE PROPOSED MODEL FOR ARUNACHAL PRADESH

The Tomo Riba Institute of Health & Medical Sciences (TRIHMS), Medical College & Hospital, Government of Arunachal Pradesh, Itanagar (state capital) would act as the Hub for training and research for Global surgery and the 100,000 population between Bhalukpong and Bomdila would be one of the spokes for the pilot project. They could then be extended to Ziro, Aalo, Tezu and Khonsa.

The initial plans would be the following:

  1. SURGICAL CAMPS: These could start from early 2018 and for Arunachal Pradesh be at the TRIHMS hospital and at Bhalukpong every month. The surgical team from SEESHA would visit these places to train the local surgeons.
  2. DIAGNOSTIC CAMPS: These would cater to the initial target area of about 100,000 population between Bhalukpong and Bomdila. The purpose of these camps would be to diagnose surgical patients and empower the local doctors with diagnostic capabilities. Three places [Trizino, Singchong and Nafra] would be chosen and one of these would be combined with the surgical camps so that each place would have 4 diagnostic camps a year.
  3. SURVEY: Primarily the area between Bhalukpong and Bomdila.
  4. TRAINING PROGRAMS: These could be a joint efforts Lancet India, University of Leeds, Karunya University, ARSI and SEESHA. For the first year it could involve Task Specific Training and Competency based credentialing for:
    1. Spinal anaesthesia
    2. Level 1 Urology procedures
    3. GLLS
    4. Gastroscopies
    5. Ultrasound examinations
    6. Primary trauma care
    7. Diabetic and other non-healing wound care

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.
William Bolton, University of Leeds is a Surgeon in training from the United Kingdom and NIHR Clinical Research Fellow in the Global Health Research Group Surgical Technologies in Leeds, taking time out of training to complete a PhD on surgical technologies for application in low and middle-income countries. My research interests include the development and evaluation of novel surgical technology, its applications to low-resource settings and clinical trial design in Global Surgery.

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