Dr. J. Gnanaraj’s Contribution for The Karad Global Surgery Consensus Statement on Surgical Needs and Innovation in Rural Surgery

Presentation at the International Federation of Rural Surgeons [IFRS] and Association of Rural Surgeons of India [ARSI] Conference at Karad

Problem statement:
The Indian surgeon has adapted his skills to the low-resource environment, to be able to deliver high-quality surgery. There is much they can teach the rest of the world, in controlling the cost of surgery and improving surgical access...

Solutions proposed:

  1. single incision laparoscopic surgeries - dr gProblem = Laparoscopic surgeries are better but difficult in rural areas: Dental compressor was used for insufflation, BP cuff and assistant was used for insufflation for short procedures, EMO machine and ether was used for anaesthesia, cystoscope was used for diagnostic laparoscopy.
  2. Problem = General anaesthesia is not available in many rural places and when available much more expensive: Gasless lift laparoscopic surgeries were carried out under spinal anaesthesia. Learning curve was easier because traditional open instruments could be used because there is no gas leak
  3. Problem = Modern minimally invasive surgeries not available in rural areas: Over 500 single incision gas less laparoscopic surgeries were carried out in rural areas using specially designed hand instruments and regular laparoscopic surgical instruments
  4. Problem = 75% of those with surgically treatable conditions were not aware of the problem: Diagnostic camps took the diagnostic facilities at the hospital [like the U/S. Gastroscopy, etc.,] to the remote rural areas.
  5. Problem = Modern surgical facilities not accessible to the rural areas: The sur-gical camps took the modern surgeries to remote rural hospitals. They were also used for training rural surgeons (combined with free online courses: http://mdcurrent.in/camps-and-rural-healthcare/ )
  6. Problem = Minimally invasive stone surgery like PCNL / ESWL not available in the rural areas: The method of Ureterorenoscopic removal of renal stones was de-veloped and more than 1000 such procedures performed in rural areas
  7. use of cystoscope and lithoclast - dr gProblem = X rays not available in Operating room: Cystoscope and Urete-rorenoscope were used for checking stone clearance and for lithotripsy during pyeloli-thotomy
  8. Problem = Flexible bronchoscope not available: The Ureterorenoscope was used for FB removal in esophagus and bronchial tree
  9. Problem = Laparoscopic instruments not available in rural areas: The cysto-scope was used for appendicectomies and diagnostic laparoscopies [diagnosis, staging and biopsies]
  10. Problem = Pyocele of the GB: Emergency lap. Cholecystoscopy [using SPC trocar and Foley’s catheter] followed by cholecystoscopy stone clearance and wash out fol-lowed by lap. Cholecystectomy
  11. Problem = No culturally acceptable Minimally invasive treatment for DUB in rural areas: Endometrial vaporization / resection for DUB as day care procedure
  12. fasciotomy - dr gProblem = Evaluation of infertility difficult in rural areas: Use of single incision gasless laparoscopic surgery, Ureterorenoscopic hydrosufflation of Fallopian tubes, re-section of Fibroids with resectoscope, etc. made minimally invasive evaluation affordable in rural areas
  13. Problem = Advanced minimally invasive surgery not available: Minimally inva-sive fasciotomy, surgery for carpel tunnel syndrome, for thyroid surgery, for inguinal block dissection, etc. with Urology instruments made it available in rural areas
  14. vacuum foot 2 - dr gProblem = Non – healing diabetic foot requiring amputations because lack of adequate treatment for prevention of amputation: Low cost topical vacuum therapy developed at Karunya University
  15. Problem = TURP difficult to perform and teach in rural areas: Vaporization of prostate easier to do and teach, and now is possible with normal saline too
  16. Problem = Mesh used for hernia surgery expensive: Mosquito net that is similar to Prolene mesh is used for hernia surgery including laparoscopic hernia repair
  17. Problem = Suction drains are expensive: Glass IV bottles with air sucked out could be used as suction drain
  18. Problem = Rural patients find it difficult to afford surgery: Health insurance programs, pig for elective surgery program, differed payment options, productive work for relatives during hospital stay of patients, etc.
  19. Problem = Urodynamic evaluation not available in rural areas: Low cost Uro-dynamic study designed and used extensively during diagnostic and surgical camps
  20. Problem = Lack of training programs for rural surgeons: Online training pro-grams with contact program during surgical camps
  21. Problem = Mesh for laparoscopic incisional hernia repair expensive: Use of combined technique with peritoneal covering makes it possible to use the regular Pro-lene mesh or mosquito net
  22. Problem = Surprised in the operating room with increased workload: Use of WHO surgical safety check list helps avoid lot of embarrassing problems
  23. Problem = Increased work load making rural surgeons tired: Delegation of work like normal Gastroscopy, ultrasound examination, etc. to well trained nurses and monitoring them using monitor in front of OPD and going to take over if there is a need.
  24. laparoscopic-trainer-GProblem = Expensive monitoring devices and ICU set up: Using low cost wire-less monitors and non invasive haemoglobin and sugar monitor with computers analys-ing the data and trends and informing the concerned persons [being developed at Karunya University]
  25. Problem = Lack of sufficient training facilities: Low cost training equipment for practising surgery
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. Gnanaraj J. Minimally invasive surgery for rural surgeons; Low cost modifications for laparoscopic surgery in rural areas. mdCurrent India September 2015. [http://mdcurrent.in/courses/mis-for-rural-surgeons-lesson-4/ ]
  2. Gnanaraj J. Laparoscopic surgeries in rural areas: Challenges and adaptations Lessons learnt from 1300 laparoscopic surgeries in rural areas. Australia New Zealand Journal of surgery 2007, 77 (8) p 708
  3. Gnanaraj J. Gasless Laparoscopic surgeries: Instruments and maintenance mdCurrent India September 2015 [http://mdcurrent.in/courses/lift-laparoscopy-lesson-7/ ]
  4. J. Gnanaraj. Diagnostic and surgical camps: Cost effective way to address surgical needs of the poor and the marginalized. mdCurrent India January 2014. : [http://mdcurrent.in/primary-care/diagnostic-surgical-camps-cost-effective-way-address-surgical-needs-poor-marginalized/ ]
  5. Gnanaraj J, Lau Xe Xiang Jason, Hannah Kianhgte. 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
  6. Gnanaraj J, Balaji Prasad Ellapan. Ureterorenoscopic removal of Renal stones: Cost effective patient friendly method in rural areas. Tropical Doctor April 2011, 41 p102
  7. Gnanaraj J. Minimally Invasive Surgery for rural surgeons: Stone disease and DJ stenting. mdCurrent India September 2015 [http://mdcurrent.in/courses/mis-for-rural-surgeons-lesson-5/ ]
  8. Gnanaraj J, Allan A.Cystoscopic removal of coin in mid- esophagus: A descriptive case report. Rural Surgery Volume 4 No. 1 January 2008 p 6 -8
  9. Gnanaraj J. Video: Diagnostic Laparoscopy the low cost method. mdCurrent India April 2015 [http://mdcurrent.in/surgery/video-diagnostic-laparoscopy-the-low-cost-method/]
  10. Gnanaraj J. Video: Gall stones part 1 – 3. mdCurrent India April 2015 [http://mdcurrent.in/surgery/video-gall-stones-bmch-part-1/] [http://mdcurrent.in/surgery/video-gall-stones-bmch-part-2/] [http://mdcurrent.in/surgery/video-gall-stones-bmch-part-3/]
  11. Gnanaraj J, Jessie Lionel. Endometiral resection/Vaporization: A patient friendly first option treatment for menorrhagia in rural areas. Tropical Doctor 2008: 38 p103-104
  12. Gnanaraj J. Management of Infertility in rural areas: The available options. mdCurrent India 2015. [http://mdcurrent.in/patients/management-of-infertility-in-rural-areas-the-available-options/]
  13. Gnanaraj J. Minimally Invasive Fasciotomy with Urology instruments. mdCurrent India September 2015. [http://mdcurrent.in/primary-care/minimally-invasive-fasciotomy-with-urology-instruments/ ]
  14. Gnanaraj J, Danita G, Arun Prsad. Salvaging diabetic foot: A new cost effective method. Tropical Doctor 42 p88 -89 2012.
  15. Gnanaraj J, Lionel Gnanaraj. Transurethral electrovaporization of prostate: A boon to the rural surgeon. Australia New Zealand Journal of Surgery. August 2007 Vol 77 (8) p 708
  16. Ravindranath Tongaonkar Brahma Reddy et. Al. Preliminary multicentric trial of cheap indigenous mosquito net cloth for tension free hernia repair. Indian Journal of Surgery Vol. 65, No. 1 Feb 2003,p 89-95
  17. Gnanaraj J. A simple sterile low cost closed suction drainage system. Tropical Doctor April 1997 27 (2) p104
  18. Gnanaraj J. For presentation at Bethune Round Table Halifax Canada June 2016
  19. J. Gnanaraj. Low cost Urodynamic studies: A valuable Diagnostic tool for Rural Practitioners. mdCurrent India March 2015 [http://mdcurrent.in/primary-care/low-cost-urodynamic-studies-a-valuable-diagnostic-tool-for-rural-practitioners/ ]
  20. http://mdcurrent.in/courses/mis-for-rural-surgeons/
  21. Gnanaraj J, Joshua WJ. Small Incisional Hernia Repair: Low – Cost Minimally Invasive Technique for rural areas. mdCurrent India August 2015 [http://mdcurrent.in/primary-care/small-incisional-hernia-repair-low-cost-minimally-invasive-technique-for-rural-areas/ ]
  22. http://www.who.int/patientsafety/safesurgery/ss_checklist/en/
  23. Gnanaraj J. 17/3 Pipalya Kalan: Reaching the unreached. Rural Surgery Vol. 6 No. 1, January 2010 p 4-6
  24. Ida Sheela, K. Rajasekaran, J. Gnanaraj. Wearable vital signs monitoring system. Rural Surgery, Vol. 7, No. 3, June 2011, p 22 – 23
  25. Ayodele Awojobi, Gnanaraj J. Single incision Lift Laparoscopic Appendicectomy: The procedure, training and advantages to the rural surgeons. Rural Surgery Vol 11 (1) p 17-18 May 2015

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