Interview with Surgeon - Dr Chanchal Raj Chhallani
Hyperbaric Oxygen Therapy - Controversies Arosen!
Short Note on Surgical Training
Rare Experiences in Surgeon's Life
How Did They Die? !!!!
Laparotomy: Scoping Systematic Review
Classifieds | Trivia | Upcoming Events
Dr. Kalaivani.V President
Table of Contents
Dr. Sreekar Pai A Hon. Jt. Secretary
Dr. Manish Joshi Hon. Treasurer
June 2020
Dear Esteemed Member of SSB,
‘SUSHRUTA’ is a monthly newsletter, creating a platform where in
the members and surgical postgraduates can publish original
articles, case reports, surgical guidelines or any other material
of surgical relevance, This will be made available online for
all the members.
I request everyone to make use of this platform to disseminate,
share or acquire knowledge.
Dr Kalaivani V President SSB KSCASI CC
Editorial
Request all the SSB members to actively contribute, participate and
wholeheartedly appreciate this new initiative "Sushruta - official
newsletter of the Surgical society of Bangalore"
Regards, The Editorial team of Sushruta
Academic Articles Non-Academic
Please send articles, guidelines, humour, stories, trivia, quiz
questions and interesting
Case report or case series with Review of literature for academic
purposes.
Inviting articles - That may be appropriate and interesting to the
SSB members. Examples: life beyond surgery, my daily routine, how I
manage
stress, interesting place I traveled, books I recommend etc.
Opportunities / Classifieds Feedback / Suggestions
Relevant Jobs, Ad's and upcoming events can be included at a
nominal fee as per the
discretion of the Editorial team.
Any other suggestions for improvements, feedback, letters to the
editor, inputs are
welcome.
Send your article to :
[email protected] WhatsApp -
8197910166
Dear All,
Kindly encourage this new monthly initiative of the SSB.
Please mark all your contributions via emails, WhatsApp with the
heading for Sushruta and
mention your name, designation and institution.
June 2020
Dr.Kalaivani, Dr.Venkatesh & all the E.C. Members, I don’t need
any other Honours than
this , I am Touched & Moved . A Very Big Thnx to the Entire
Executive Com Members with
special Thnx to Dr. Manish Joshi our EDITORIAL Chief for the
interview.
- Dr Ashok Kumar K V
Letters to the Editor
Newsletter of Surgical Society of Bangalore
Great effort! Proud of SSB Nice write up of Ashok Kumar Sir
- Dr. M Ramesh
Very nicely done. Many Congratulations to you and your Editorial
team Kalaivani!!. -Dr Arvind Gubbi
June 2020
a very interesting & varied reading.
Congratulations to the whole team
- Dr. Srinath
I am expessing my sicere NAMASKARS to the Sushruta editorial board
for putting in the news letter. Regards -Dr S A Subramani
Great interview Sir. A good read for everyone and surgeons in
particular. Great effort Dr Kalaivani and team. Well
done. - Dr Rajshekar Nayak
Dr Rajiv Lochan’s article “Sunshine” makes us to reflect more on
our actions. Many times we face such dilemmas.
Surgical practice has many faces- medical, moral, ethical, social
etc.
Sad part is...by the time we understand all or some of this, we
would have crossed 60 ! or may not think about it at all !! Thanks
& congratulations Dr Rajiv & team. - Dr Shivaram HV
You are a great good example for every one in younger generation
sir. Great initative by dr Kalaivani and team
-Dr Nagesh NS
Thank-You Dr. B.R Ambedkar Medical College and Vydehi Institute of
Medical Sciences for organising this MCM
Thank Dr Ramesh from Vydehi institute and Dr Ramesh from AMC for a
very good scientific session.
Dr Kalaivani
Send your News, Articles, Event details, Classifieds, etc. to
"
[email protected]"
Feedback & Comments
Sushruta
Thank you Dr. Ramesh of AMC & Dr. Ramesh Reddy of Vydehi for
the excellent Scientific Meeting.. Congratulations
Dr Murali
Dear all Drs. of SSB. I am very happy to see the pictures of Surg.
Clinical Meeting of June 2020.I should thank & Congratulate for
good proceedings & pictures sent. For senior citizens there
will be some technical difficulty in viewing live programmes. I am
very happy you have sent pictures & I was able to see early
morning. Let this continue. My suggestion is even after Clinical
Meetings start with Dinner & Drinks also this typing of sending
pictures & Description on paper continue as it will help those
unable to attend the Clinical Meetings. Let this go on with other
meetings also. Thanks.
Dr. B. G. S. Murthy 9343207939.
Congratulations both Ramesh. Very good session
-Dr Srikanth KN
June 2020
A 30 year old male presented with complains of abdominal pain and
distension from 2 days, with Vomiting 2-3 episodes, immediately
after food, associated with H/o breathing difficulty since 2 day,
on examination patient was conscious and oriented, pulse 100bpm and
BP 150/100mmHg. Spo2-90% at RA, with RR of 24c/m, per abdomen was
diffusely distended with epigastric tenderness, guarding and
rigidity, bowel sounds sluggish. Lab investigation showed only
raised total leucocyte counts, remaining parameters were normal, x-
ray chest showed abdominal contents in left hemi-thorax, x-ray
erect abdomen showed double air fluid level. CECT was s/o
diaphragmatic hernia with deviation in stomach axis, patient was
taken up for exploratory laparotomy intraoperatively stomach was
grossly distended and mal-rotated (organo-axially)which couldn’t be
de-rotated, 1cm gastrotomy made on the stomach and 7.5 litres of
partially digested food aspirated, ligaments of stomach released
and stomach is de-rotated to its anatomical position. Colon and
omentum are reduced into the abdominal cavity from thorax.
Diaphragmatic defect noted and plication done, prolene mesh placed
15 x 15 cm. Anterior gastropexy was done with prolene sutures. And
FJ performed. ADK drain placed. ICD placed in the left hemithorax.
ICD removed on POD3. POD5 patient developed burst abdomen and
tension suturing done. Patient sent home with FJ in situ, later
removed after 4 weeks. Patient recovered well, with no recurrence
of symptoms till 6 months.
Online Monthly Clinical Meeting - Presentations
Page 5
Gastric volvulus, Challenges & Solution in Management: Case
Report
Presenters : Dr.Tinnu George, Dr. Ravi Kumar.H, Dr. Sai Kalyan
Guptha A,
Department of General Surgery, Vydehi Institute of Medical Sciences
and Research Center - Bangalore
Gastric volvulus is a rare condition. Cardia and the pylorus are
the fixed points. The clinical presentation depends on the degree
of rotation and time of onset. Acute volvulus usually presents with
abdominal or chest pain, severe vomiting and epigastric distension.
Borchardt triad (pain, retching and inability to pass a nasogastric
tube) occurs in up to 70% of cases. Torsion occurs along the
stomach’s longitudinal axis (organo-axial) in 70% of cases,
vertical axis (mesentro-axial) in 30% cases and combined. Type 1
(primary) idiopathic is due to laxity of gastro-colic,
gastro-splenic, gastro-phrenic and gastro-hepatic ligaments. It’s
also associated with congenital asplenia and wandering spleen. Type
2 (secondary) is associated with congenital or acquired
abnormalities like diaphragmatic defects and post hepatic
transplant.
Discussion
Gastric Volvulus is an unusual entity, often not recognized at an
early stage, which can become a surgical emergency. Gastric
Volvulus presents more frequently with intermittent symptoms.
Timely diagnosis and treatment of acute gastric volvulus can
potentially decrease morbidity and mortality
Conclusion
Gastric Volvulus is twisting of all or part of the Stomach by more
than 180 degrees with obstruction of the flow. In 1886 Berti was
the first to describe a gastric volvulus after performing an
autopsy on female patient. Usually associated with diaphragmatic
defect. Incidence is equal in both genders. About 20% of cases
occur in children or after the 5th decade of life. Gastric volvulus
is an uncommon cause of gastric obstruction (closed loop
obstruction) but its intermittent nature and vague symptoms may
make diagnosis difficult.
Case Report
Dr Tinnu George
Page 6
FOURNIER’S GANGRENE: A RECONSTRUCTIVE CHALLENGE – OUR
EXPERIENCE
Presenter - Dr Sanyal Sumbul Rana (P.G.Student) Department of
General Surgery
Dr B R Ambedkar Medical College - Bangalore
Fournier’s gangrene is an acute, rapidly progressive and
potentially fatal, necrotizing fasciitis. Reconstruction of the
scrotal, penile and perineal defect after the initial debridement
is a challenge as these organs have unique texture, contour and
function. Extensive destruction of the surrounding skin, over the
abdominal wall, thigh and the gluteal region, limits the skin
available for the reconstruction. Proximity to anus and
contamination with urine, contributes to poor results. There is no
consensus on the best method of reconstruction. To avoid erroneous
reconstruction , in 2015 Karian et al proposed a simple algorithm
based reconstruction. We have improvised the algorithm to add anal
sphincteroplasty and vaginal reconstruction and we aim to study the
algorithm based various options in reconstruction and their
outcome.
Background
Sushruta
Methods Our Aim of the study was to study the algorithm based
choice of reconstruction options, their indications and outcome in
terms of hospital stay, functional outcome and the cosmesis of the
surgery with patient satisfaction. This was a retrospective study
of a duration of 2 years with a total number of 35 patients. All
patients admitted with a diagnosis of Fournier’s gangrene at Dr B R
Ambedkar Medical College and Hospital were evaluated.
In our study 32 patients were male and belonging to the age
category of 50+years. The most common organism isolated was
E.coli(34.28%) and majority of the patients had extension into the
perineum (57%). There were 3 patients ( 8.5%) with defects that
healed by primary closure, 5(14.3%) with secondary intention,
10(28.5%) with local flaps, 3 (8.5%) with distant cutaneous flaps,
9 (25.7%) patients underwent musculocutaneous flap placement and 5
(14.3%) with free flaps. 3 of our patients had anal
sphincteroplasty and 1 had vaginal reconstruction as per our
algorithm. The mean time from disease occurrence to defect
reconstruction was 18 days. The average hospital stay was 8.6 days.
The major complication that we encountered was poor cosmesis and
the most common minor complication was seroma formation.
Results
Conclusion Losses of up to 50% of skin can be repaired with local
flaps. This is the most cosmetic and functional reconstruction.
More than 50% of the skin loss patients benefitted from
musculocutaneous flaps. The ideal method differs for each patient.
As a lot of patients have associated co-morbidities, a single
stage surgery/anaesthesia is preferred and a vascularised flap
provides the best results. Gracilis myocutaneous flap is the
workhorse for post Fournier’s defect as it can cover the deeper,
larger and contaminated areas. It is robust, reliable, easy to
harvest, provide better testicular protection with low incidence of
contraction and low donor site morbidity. An algorithm-based
approach will definitely help the surgeons to decide.
June 2020
Page 7
Day Care Laparoscopic Cholecystectomy - Factors Influencing Same
Day Discharge : An Observational Study
Presenters : Dr Nischitha TJ, Dr Ramesh Reddy G, Dr Vinay HG, Dr
Kiran Kumar, Dr Swetha R Chandra
Department of General Surgery, Vydehi Institue of Medical Science
and Research Centre, Bangalore
Patient who met the criteria had a successful DCLC and day care
pathway was considered to be achieved. Our study concluded that
PONV, Pain, difficult Calots dissection, need of conversion to
open, need of subtotal cholecystectomy, drain and RT requirement
post operatively, anxiety, responsible care taker, reassurance by
the treating surgeon, dedicated surgical and anaesthesia team and
patient‘s education in understanding necessary post-operative
discharge instructions all played a vital role in achieving
DCLC.
Results
DCLC is safe, feasible, equally effective as elective LC, providing
early recovery, return to work, good hospital bed utilization, as
it has high same day discharge rate, and low complications which
can be easily managed at home by patient education and low
readmission rates. Provided patient are selected with caution,
skillful surgical techniques and safe anesthesia. PONV and
post-operative pain require high attention and management protocols
during immediate perioperative period.
Conclusion
Laparoscopic cholecystectomy (LC) has been routinely performed
since 1989 and it is now considered the gold standard treatment for
symptomatic gallstones and cholecystitis.
This is a prospective observational study performed in Vydehi
Institute of Medical Sciences and Research Centre from January 2018
to June 2019. 53 patients presenting with chronic calculous
cholecystitis were included in the study. Patients underwent
laparoscopic cholecystectomy. Six hours post operatively patients
were encouraged to mobilize and take oral fluids if
they were not nauseated. Six hours of observation was done in all
patients prior to discharge.
Materials & Methods
Abstract
To identify the surgical and clinical factors which could be the
determinants in decision to discharge patients‘ same day. Determine
the recovery of DCLC, thereby accessing the safety and feasibility
of DCLC.
Objective
Best Paper
Worked in Bengaluru in various hospitals since 1992 including
Mallya Hospital,
June 1983 to 1992 July - Worked in Benghazi - Libya
Feb 1989 – July 1992 – lecturer at Al Arab University Benghazi,
Libya.
Feb 1987 – Jan 1989 – assistant lecturer at Al Arab University
Benghazi, Libya.
June 1983 – Jan 1987 – senior registrar in ministry of health,
Benghazi, Libya.
April 1981 – May 1983 – civil assistant surgeon and i/c referral
primary health center
Teacher for undergraduate students from American board medical
college (2006-2009)
Teacher for undergraduate students from international medical
school (2009-till date)
Postgraduate teacher for DNB students from 2006
Faculty at Best Institute & Research Center for Laparoscopic
training at Bengaluru from (1998-2016)
Dr. Chanchal Raj Chhallani
Present Designation: Senior Surgeon and Head of Department, General
and Minimally invasive surgery – Bhagwan Mahaveer Jain Hospital and
Santosh Hospital – since 1992.
Past Service:
Nimaj- Rajasthan
Page 8
Sushruta June 2020
Internship (1974-75): Dr S.N. medical college and M.G.Hospital –
Jodhpur
Civil Assistant Surgeon Govt. of Rajasthan – 1976 to 1977
MS General Surgery (1977-80): Safdarjung Hospital – New Delhi and
Dr S.N.Medical
college Jodhpur (Rajasthan university)
Training in GI endoscopy and laparoscopic surgery from AIIMS – New
Delhi – 1994.
Interview with Surgeon - Dr. Chanchal Raj Chhallani
Page 9
Three children –
Son – Abhishek, MS- Mechanical Engineering (Germany) – working in
Bosch
Personal Life
Birth & Education
June 2020
Page 10
Your Mentors -
How and why did you choose Surgery?
1. Prof S.K. Pandey – HOD Surgery and Superintendent of
M.G.Hospital and
Dr.S.N. Medical College Jodhpur and My Guide.
2. Prof V.C.Bothra - Prof Surgery – Dr. S.N. Medical College –
Jodhpur
3. Prof A.K.Kripalani – Prof Surgery AIIMS – New Delhi
4. Prof Satyanand – Safdarjung Hospital – New Delhi
5. Prof Joe Devadatta – Former Prof Surgery CMC, Vellore.
Since my younger days, I always had the ambition to be a surgeon
someday. With
much dedication, hard work, perseverance and patience I was able to
join surgery
after waiting for 2 years even though I had the choice of
anesthesia, radiology
and ENT).
One of my professors Dr S.K.Pandey was my mentor and inspired and
guided me
always through this journey of becoming a surgeon.
There is a saying in our medical fraternity that goes (with due
respect)
“physicians are physicians, however surgeon plays the role of a
physician as well
as a surgeon”.
Sushruta
Interview with Surgeon - Dr. Chanchal Raj Chhallani What surgeries
are your favourite ?
My preference includes challenging surgeries like major abdominal,
neck and
chest trauma- blunt, penetrating, gun shot, including vessel
injuries.
Other abdominal surgeries like mesenteric vascular thrombosis,
peritonitis,
perforation of hollow viscus, appendicular perforations.
All types of obstructed and strangulated hernias.
Thyroidectomies.
for carcinoma breast, benign breast lumps.
All types of hernias – large and very large incisional hernias,
paraumbilical
hernia, inguinal and femoral hernias.
Gastric surgery for benign and malignant.
Small and large bowel surgery for benign and malignant
diseases.
Haemorrodectomy, fistulectomy, fistulectomy with seton tie and
fissurectomy.
Laparoscopic surgeries – lap cholecystectomy, lap appendicectomy,
abdominal
hernias, lap assisted bowel resection, sometimes gynecological
surgery.
What are your less liked surgeries ?
Surgeries involving recurrent complex fistulae
Intestinal fistulae
Release of dense adhesions
Mutilating surgeries in advance malignancy.
What would you do different if you get a chance to relive PG days
?
I am a general surgeon with experience in all types of
surgeries.
a.
b.
c.
d.
e.
We learned how to enjoy our lives along with lots of hard work,
responsibilities and
experiences. "WORKED LIKE A DONKEY AND ENJOYED THE LIFE LIKE A KING
".
And there was a lot of love and respect we earned in the hospital
as well as in our
families and society. I would love to relive those days.
However, we lacked such advanced technology and digitalization in
those days. That
would be something I would like to add, if I had to relive those PG
days.
Page 11
June 2020
Interview with Surgeon - Dr. Chanchal Raj Chhallani
Page 12
Interests beyond surgery :
Organizing social gatherings and picnics for associations.
Organizing free medical and surgical camps by hospitals and
NGO’s.
Balance my life with yoga and listening to soothing old Hindi
melodies.
I love spending time with my family.
Favourite food :
Favourite book
Favourite place of travel:
We are as a family love to visit places of historical places,
religious and
otherwise.
My bucket list includes travel to Eastern Europe, Russia and Parts
of Gujarat
and Rajasthan.
Favourite quote:
Karmay-Evdhikras te m Phalehu Kadchana – one must keep
performing
their duties, without worrying or expecting the fruits of
success.
One satisfied patient will bring ten more patients and an
unsatisfied patient
will take away hundred patients.
Any regrets: None.I am satisfied as I got whatever I have dreamt of
and achieved
even though sometimes with delay and struggle.
Key to your success: Hard work- No Shortcuts
a.
b.
c.
d.
I relish home cooked vegetarian food. My favorites include
authentic Rajasthan
cuisine and being in South India for so many years developed a
liking for fresh Idlis
with chutney and sambar, North Karnataka Jowar and Bajra meals
served on banana
leaf. And ofcourse main favorites are green salad and fruits.
Of course books related to surgical field, but I also love reading
the newspaper,
magazines like India today, readers digest, few books on culture
and religious
a.
b.
c.
a.
b.
c.
Page 13
Key to your success:
Join surgery if that’s your ambition and dream.
Always follow ethical practices with honesty, sincerity and hard
work.
Set goals and work hard, success will come to you.
Come prepared when you come to assist or perform surgery
Always read before and after case presentations, seminars and
surgery.
Be informed and updated about recent advances in surgery, attend
workshops,
Do your work with a service motive and bring respect and pride to
your family,
Be faithful, truthful to your patient and institution
Always respect your seniors and show affection to your
juniors
Be soft spoken and a good listener
DOCUMENTATION, DOCUMENTATION, DOCUMENTATION is mandatory.
Right
from history, clinical examination, OT notes, ward rounds and each
procedure
done in the ward. It was important in the past but in the present
scenario, it is
important to save yourself.
Take care of your patients with affection and compassion.
For surgeons whenever you have time eat and take rest during PG
time.
In future balance your life between work and family.
There is no replacement for honesty, sincerity and hard work for me
in whatever I do.
Since my childhood, one important learning that has kept me
progressing is “what
could be more worse than a no”
I Hence kept trying and look at everything as an opportunity and
not to give up.
My message to younger surgeons would be
conferences and keep presenting scientific papers and attending
journal clubs.
institution and guide.
June 2020
We all surgeons are aware of hyperbaric oxygen therapy and
indications for which it was developed. As years passed, many
researchers claimed this therapy to be beneficial in variety of
condition ranging from diabetic foot to Alzheimer’s disease,
stroke, etc. However, various controversies also arouse as many
felt that experts were misleading people on usage of hyperbaric
oxygen therapy.
From past 2 decades, it was also seen that most expert were showing
excellent outcomes in diabetic foot with hyperbaric oxygen therapy
by claiming that this machine reduces amputation. However, the
recent few studies have put a huge question mark on it. It’s
believed that this machine was cleared by FDA only for
decompression sickness and most of the people have wrongly
propagated usage of this machine for other conditions and many
doctors started believing this to be a “wonder machine” as it was
shown by many doctors to have excellent results. This has resulted
in a tremendous increase in diabetic foot patients being subjected
to undergo weeks to months of therapy spending lakhs of rupees
because the healthcare professional scares the already scared
patient that he will lose his limb if he doesn’t undergo this
therapy and the vicious cycle of unethical practices begins.
In one of the largest cohort studies done by Margolis et al, it was
shown that hyperbaric oxygen therapy neither improved wound healing
nor decreased the amputation in diabetic foot. In a recent
systematic review by Thrane et al, it was shown that HBO was not
effective even in necrotizing fasciitis and the previous studies
done on it were poor and highly biased questioning the efficacy of
this machine. It is often seen that many have invested huge sum of
money costing millions on this machine and often they are the one
who claim it to be excellent machine.
As one of the diabetic foot practitioner over a decade, the sad
part noticed over past few years is that many healthcare
professional are subjecting patients to this machine to
reverse gangrene, or for diabetic foot abscess and even for a
trophic ulcer which are and were never a indication for hyperbaric
therapy but I guess it’s a market driven industry.
One should be extremely cautious in using this expensive machine
and should subject the patient only if needed/indicated and no
other option left as we know that time is tissue and delay can lead
to amputation. Most of our patients are of middle class and lower
class and adding a burden of lakhs of rupees on an adjuvant therapy
with controversial role will not only dent the backbone of the
patient but also will lead the entire family towards economic loss
from which they may not recover. There need to be regulations on
usage of this machine in India as currently there is not control
body to oversee this issue of rampant and blind usage of this
machine and over last 3-4 years, one has seen that most hospitals
are increasingly purchasing this machine and enforcing the
healthcare professional to achieve the target.
Newsletter of Surgical Society of Bangalore
HYPERBARIC OXYGEN THERAPY – CONTROVERSIES AROSEN!
Prof. Amit Jain, Dept of surgery, RRMCH
Sushruta June 2020
Short Note on Surgical Training
Dr. U Vasudeva Rao
The surgical training has three main components – The trainee, the
trainer and the subject
The subject has two components – Knowledge and skill
Knowledge is assimilated from many sources – text books internet
lectures etc
Skill can be related to procedure or it can be soft skill like
communication, audit, ethics etc
The primary objective of a trainer is to make sure that the trainee
acquires good amount of knowledge and becomes proficient in skills
which are needed to become a fully competent specialist. The
primary objective of trainee is the learn the art and science of
surgery within the given period of time with reasonable effort and
complete the course and the assessment.
Most of the trainees develop the interest in the specialty soon
after their induction and enhance their goal further during the
course. There are of course instances where a candidate has joined
the course for reason other than academic in which case, he may not
have any career related goal.
The art and science of surgery has undergone a sea change over the
years with advances in technology new disease entities more complex
procedures and increasing competitiveness. Added to these changes
are the requirement of effective communication, ethics, patient
safety etc. Research also has become an integral part of the
training but exactly how much role research has played and in what
manner it is incorporated in surgical training is subject of
debate.
In the past the bedrock of postgraduate training is mentorship
which means the trainee acquires the bulk of the knowledge and the
surgical skill from the professor or consultant under whom he
works. Additional knowledge used to come from attending clinics
journal club lecture etc. The only requirement other than
abovementioned learning tools is submission of thesis. This was the
only research component during the training and there was wide
variation in the manner in which the thesis was carried out. The
so-called eminence-based practice was in vogue for a long time and
the practicing surgeons never bothered to audit their work or the
outcomes under the false impression that whatever has been done was
done by their masters which gave good results.
Though the training methods have evolved to some extent the
trainee’s perspective has remained more or less the same. He wants
to complete the course and obtain a degree! (with minimum effort
and withing the given period of time) but the goals of all trainees
are not the same.
June 2020
Page 16
Short Note on Surgical Training
Dr. U Vasudeva Rao
Some may just want to get in to practice either independently or
join his elder relative or friend. Some others may decide to enter
into higher surgical training and become super specialist and
nowadays there are many sub specialities to choose from.
Some of the others may want take up the academic career either
teaching or research or both.
However, it is difficult from the trainer’s point of view to
categorise the training tools based on the individual needs and the
components of surgical training and the requirements need to be
uniform.
The surgical curriculum all over the world and the method of
assessment has undergone significant reforms but not much has
happened in our country except for additional requirements of a
trainee to publish an article and present papers in conferences in
addition to his thesis.
There are two different training programs with few commonalities –
One which is undertaken by the colleges and universities and the
other conducted by National Board which is somewhat similar to the
speciality boards overseas
I will not go in to the details of the differences in two systems
but there is an element of research in both
That brings us to the question of research in surgical
training.
Surgical research is an essential component of modern
evidence-based practice and is the cornerstone of profession
(1)
R&D is the cornerstone of advances made in any field of human
endeavour and the same is true for art & science of medicine.
Research in healthcare is necessary to adopt evidence-based
medicine. (1)
Many believed that teaching institutions focus mainly on
acquisition of surgical skills and leave research training to
universities.
But the trend of opinion and practice in many parts of the world
seem to favour integration of training in to residency training.
(1)
Present day surgical training is a multifaceted process. They need
to be good clinicians & technicians, good communicator, scholar
health advocate and a professional.
June 2020
Short Note on Surgical Training
Dr. U Vasudeva Rao
Critical analysis – literature review Scientific writing
Presentation skills Research methods – trial design statistics etc
Knowledge & Exposure to national & international meetings
Competitiveness Time away from clinical work What are the drawbacks
if any? It may prolong the training period Navigating bureaucracy –
Obtaining data sample collection etc Perception – If you get
involved too much in to research you may get side lined Those who
cannot operate teach who can’t teach do research – True to some
extent but not an excuse to neglect research There are critics of
including research in surgical training but not many (3) Some feel
that compulsory research does not necessarily produce good science
or encourage self-education in later life- ref It is waste of
resources and contribute to significant and avoidable problems. It
is felt that the goal could be better accomplished by offering a
choice of two distinct career paths
The benefits of training in research are (2)
From the foregoing discussion it is evident that there has
to be an element of research in the existing training
programs.
What then is the role of full-time research during surgical
training – Should all trainees undertake an extended period of
research or should this be limited to those who are academically
inclined (2)
In some universities and specialty boards the trainee need devote a
full year exclusively to research as part of the training but the
feasibility of this approach is controversial. In UK it is not
uncommon for a trainee to take break from clinical work once he
completes the clinical training to involve in some research
activities so that when he re-joins the clinical activity it will
be easy for not only to get better placement but also engage
further in research. In conclusion integration of research into
surgical training should be in such a way that it doesn’t side line
the basic need of a trainee that is professional knowledge and
skill. It also mandates commitment not just by the trainee but also
from the faculty and administration. The trainee should not be
burdened too much with research work in the middle of carrying his
clinical and operative work especially when he is not given time
off to carry out such activity.
June 2020
Page 18
Short Note on Surgical Training
Dr. U Vasudeva Rao
Having associated with surgical training on and off for the last
three decades and having been actively associated with reforms in
training under ASI many years ago and also having spent a short
period as head of the university postgraduate teaching program, I
have following suggestions to make. I must confess, I am no expert
in this field and there are many others who are veterans with vast
knowledge and who are up to date with current scenario 1)
All trainees should be trained in conducting research during their
postgraduate course. This can be in house with involvement of
experienced faculty or with the help of external experts.
2) The training should be structured like any other subject –
It should not be just one or two lectures just for completion
sake
While all trainees should attend these lectures, the assignment can
be graded as per the year of training
First year – Audit & case reports, Poster presentation, topic
or subject review presentation (this will help in improving the
quality of presentation slide preparation etc)
Second year – Retrospective analysis Data collection Literature
review Statistics.
Final year – Prospective and or randomised studies (He would have
by now collected the data and analysed for final presentation)
Publications / Presentations
3) The trainee would engage in all aspects of research right
from the beginning once he chooses the topic for this thesis. But
it will be unfair to expect him to give a presentation to an
audience straightaway without having any knowledge of what is
required. He should just present a case which may be relevant to
his thesis or even a short review of the topic.
In fact, in many departments including our won (when I was the HOD)
the exercise begins with a trainee giving an overview of the topic
for which he is going to do research with review of literature.
Even other trainees are expected to have some knowledge of the
subject which is being discussed.
A reputed professor of a leading teaching institution would not
allow his trainees to attend a conference and present paper unless
he is fully satisfied which means the trainee has to present at
least ten times and modifies the presentation each time I used to
insist on this for every postgraduate so that the mistakes are
minimised during the final presentation and he is well prepared to
face the crowd.
June 2020
Short Note on Surgical Training
Dr. U Vasudeva Rao
Finally, the proposal by SSB to help trainees acquire necessary
skills in scientific presentations and clinical research is
laudable and I am sure the HOD’s of teaching institutions will
welcome this move. Of course this will no way infringe upon the
responsibility of the faculty who are the ultimate mentors for the
trainee but it will lessen their burden so that they can focus more
on other aspects of training. The society just provides a platform
for the trainees to get the experience of facing the audience and
opportunity to correct mistakes if any. The senior mentors while
pointing out the lapses should not be too critical as the trainee
may be facing the situation for the first time and he is bound to
commit mistakes Even these mistakes can be minimised by prior
exposure to the basic elements of research and this is exactly what
Surgical Society intends to do with cooperation from the HOD’s of
respective teaching institutions.
References:
1 The intersection of research & Surgical Training: Akinyinka O
Omigbodun Journal of West African College of Surgeons Vol 2 No Mar
2012
2 Tark Sammour, Andrew G Hill : Fulltime research during Surgical
Training: Career killer or stepping stone?
3 Is there a place for research in Surgical Training? Frank Arnold
Postgrad Med J (1992) 68 978-980
June 2020
I am Dr. B.G.Srinivasa Murthy, Born on 20th August 1945. Did
M.B.B.S. from Bangalore Medical College –1968, M.S. Gen. Surgery
from Mysore Medical College in the year 1976. F.I.C.A. USA in
1983
My KMC registration No. is 6772. My Phone No. is 9343207939
I became a Surgical Society Bangalore member in the year 1989. On
my transfer in State Government service from Mysore to
Bangalore.
I was an active member in the Surgical Society of Bangalore. Then
served as E.C. member for about 10 years. Then became Treasurer for
two years in the years 2007 and 2009.
I used to attend all Clinical meetings and E.C.meetings. I used to
attend the office of S.S.B. off and on to enquire
difficulties, welfare and do official Treasurer work.
I was instrumental in making new members of S.S.B. One example I
made Dr. K. S. Hanumanthaiah a new member of S.S.B. in the year
2009. Then he served in different capacities and became a President
in 2017.
I served in Karnataka State Government service from 1970 to 2003.
(Age of retirement – 58 yrs then)
In the beginning of my service I was working in District Hospital –
Sri Jayachamarajendra Hospital, HASSAN, in various departments from
1970 to 1973.
At HASSAN in the year 1971 on a Sunday afternoon I was asked to do
Post Mortem on a lady on the spot. A 28 year old lady was murdered
by a male who attempted to Rape on her, in a remote isolated land
near Belur- a historical place. He had pressed his foot powerfully
on the Right 2nd and 3rd Ribs area anteriorly, resulting in sudden
death of the lady. And the murderer had removed her golden ear
rings and made a theft also.
In the Post Mortem report I had written fracture of Right 2nd and
3rd Ribs Anteriorly with slight Haematoma as the cause of death of
the lady.
In the Hassan District Court murder by that person was not proved
for want of eye witnesses. Theft of the ear golden ornaments was
proved. He was sentenced to 5 years Rigorous imprisonment in the
Judgement.
Page 20
Dr. B.G. Srinivasa Murthy
Rare Experiences in Surgeon’s Life
Dr. B.G. Srinivasa Murthy
I felt very unhappy that the difficult Post Mortem done in a remote
place far away from Hassan was not proved as murder done by him.
But I felt happy that the theft was proved and he was sentenced to
be in Jail for 5 years.
June 2020
After my M.S. I have served in the District Civil Hospital, Belgaum
from 1976 to 1981. I was also attached to J.N.M.C. Medical College
Belgaum.
At Belgaum in 1979 I had admitted a patient with all signs and
symptoms of Chronic Peptic Ulcer. There was no doubt in the
diagnosis. He was posted for surgery with no further
investigations. Those days there was a quota for taking
X-rays. Only when there is a doubt we used to take X-ray. As there
was no doubt in the diagnosis no X-ray taken.
On the Major O.T. table Operation was very difficult. While opening
the abdomen by Upper Midline Incision there was trouble at the
place of Peritoneum touching the Liver. With difficulty Peritoneum
was incised and abdomen opened. Patient had SITUS INVERSUS TOTALIS
with Chronic Duodenal Ulcer. Trunkal Vagotomy and Anterior G.J. was
done successfully. As Posterior G.J. was difficult in this case,
which we used to do regularly for Peptic Ulcer. Usually in
those days Trunkal Vagotomy and Posterior G.J. used to be
done.
Because of drugs for Peptic Ulcer, Surgery on Peptic Ulcer is less
performed these days since about 20 to 30 years.
Statistics of the Hospital showed that this was the only case of
SITUS INVERSUS TOTALIS in the past 10 years. But there was one case
every year of DEXTRO CARDIA in the past 10 years.
This case was presented in the Surgical Clinical Meeting at Belgaum
in that month. It was very well appreciated, as a very rare
case.
At Belgaum in 1979 I have conducted Post Mortem examination on the
body of a famous film Actress. She had died in a faraway place from
BELGAUM. The body was brought to District Hospital, Belgaum.The
District Surgeon called and ordered me to dothe Post Mortem. There
was a rumour that She had died because of swallowing Diamond. I
immediately went home to study Medico Legal text book regarding
Diamond swallowing. Text Book mentions that Diamond can only injure
Oesophagus, but it will not produce death. On Post Mortem I did not
find any Diamond or any injury to Oesophagus or any other Gut
areas. The cause of death was due to poisoning by swallowing lot of
Sleeping Tablets as per Bio Chemical reports. There was no trouble
by the General Public.
Page 22
Dr. B.G. Srinivasa Murthy
From 1981 to 1983 I was deputed to serve in Government of Iran
Hospitals by orders of Govt. of India and Karnataka State Govt.
offices, as Iranian Govt. was not having enough Doctors to serve
their people and there was Iran-Iraq war during that time. During
Iran-Iraq war time some Iranian doctors used to be posted to war
areas and Indian doctors to serve in peaceful areas.
June 2020
In the city of QOM, Iran Country, in the year 1981 a foreign field
worker had a STAB INJURY in the Epigastric region. He was almost
pulseless in the Casualty dept. Myself and an Iranian Surgeon
rushed him to major O.T. for IMMEDIATE SURGERY with an
Anaesthetist. Immediate blood transfusion arranged. In Iran near
Major O.T. blood bottles are stored for immediate usage. Under
sedation and G.A. Epigastric Stab injury area abdomen opened. There
was Diaphragmatic injury also and the stab had gone to the
Pericardium and Right Ventricle of the Heart. Chest was also
opened by Intercostal incision. Injured Pericardium and Right
Ventricle of the Heart were identified with heavy bleeding. The
wounds were closed with a drain kept in the Pericardium. He
progressed well and was discharged.
In QOM, Iran in the year 1981 a case of strangulated Inguinal
Hernia in critical condition was found in the ward in the evening
hours on my evening duty. Because of strangulation I wanted to
operate on him as an emergency operation immediately under local
anaesthesia. Even painting the part with Povidone Iodine and
draping the part the patient was not co-operating. I asked the
anaesthetist to give mild sedation. He was given a small dose of
sedation IV slowly. Patient suddenly died. We tried all
resuscitative measures. But it failed. Patient died on the O.T.
Table.
In QOM, Iran in the year 1981 I was called to go to a village to
see a dead child about 2 years old of burns. In the village there
was no electricity. Only kerosene lamps used at home. That child
was a First wife’s child. The First wife had died of natural cause.
There was a Second Wife with her mother. The 2nd wife had a small
baby of 5 months old. The 2nd wife had pressed on the neck of the
First wife’s child and had caused death. But she wanted to prove
that the cause of death was due to burns. So she had burnt the
lower limbs with Kerosene cloth bed sheet making people to imagine
that the cause of death is due to burns. At the place of death
myself and another Madras MBBS doctor with 5 years Iran
experience could not find any cause of death apart from burns. In
Iran if the cause of death is certified by the attending doctor no
Post Mortem is necessary in any Medico Legal case. In the child’s
death as we were not sure of cause of death we ordered for Post
Mortem. The body was sent to Tehran (Capital of Iran) which was
close to QOM for Post Mortem examination. In one week’s time the
Post Mortem report came mentioning Throttling – pressing the airway
in the neck as the cause of death. In India for all Medico Legal
cases Post Mortem must be done. But in Iran if the cause of death
is certified by a qualified Doctor no Post Mortem examination is
required.
Sushruta
Rare Experiences in Surgeon’s Life
Dr. B.G. Srinivasa Murthy
The 2nd wife who committed murder was taken to the Police Station
with her child. She was looked after till the child became about 10
months old and then she was hanged in Public vision in the noon
hours near the Prayer hall on a Friday. So all the people attending
prayer can see the hanging of a murderer.
In India hanging is done in the jail compound only at about 4 a.m.
to avoid public cry. I have witnessed one such hanging in Belgaum
jail.
In Mysore Medical College where I was a PG between 1974-76 under
Dr. Y.B. HEGDE as unit chief and Dr. R.H.N.SHENOY as HOD of
Surgery. My thesis subject was Tumours and other space occupying
lesions in Liver.
June 2020
There was one case of Carcinoma of Liver Right lobe admitted to the
ward. I read many journals in MMC library. There was one
publication mentioning Hepatic Artery Ligation of the branch which
supplies the tumour will supress the tumour. Normal Liver is
supplied by Hepatic Artery and Splenic vein. But the Primary
Carcinoma is supplied by only Hepatic Artery branch. In the Right
sided Primary Liver Tumour, if Right Hepatic Artery branch is
ligated only the Tumour will not get blood supply. But the normal
Liver gets blood from Left branch of Hepatic Artery and by Splenic
Vein also. So the normal Liver should survive, but the Tumour will
lose blood supply and Tumour size can reduce. With this idea back
ground as found in Journals studied by me and unit chief, Surgery
was done on the patient. His Right Hepatic Artery branch was
ligated. But unfortunately Patient expired on the 3rd day. We could
not find out the exact cause of death.
We never tried this surgery again on any other patient.
I am herewith narrating a few of rare experiences of a Serving
Surgeon.
Just to share a few interesting facts on how some of our Surgical
Fore-fathers moved on…! 1. HAMILTON BAILEY
Intestinal Obstruction, d/o Carcinoma
Left
Colon, post operative Faecal Fistula, & Sepsis
2. CHARLES McBURNEY
Heart Attack (Ac MI) while on an
Hunting Trip! 3. FRIEDRICH TRENDLENBERG
Carcinoma Mandible 4.
JOHANN FRIEDRICH MECKEL Pulmonary
Tuberculosis 5. CARL LANGEBUCH
Peritonitis caused by Ruptured Appendix..! 6. JOHN
HUNTER
Acute Angina – MI –
Syphilitic Heart Disease..! 7. WILHELM RONTGEN
Carcinoma Rectum 8. RUDOLP VIRCHOW
Fracture Femur, while jumping of a moving train, death due
to septic complications of prolonged immobilisation!
9. HARVEY CUSHING
Of Acute MI, but Autopsy
showed ‘Colloid Cyst’
of 3rd Ventricle of his brain 10. WILLIAM
HALSTEAD
From bronchopneumonia as a complication
of
surgery for
gallstones and cholangitis 11. PERCEVIAL POTT Of
Pneumonia, after riding 20 miles in the rain, to see a patient. His
famous last words are “My life is almost extinguished. I hope it
has burned well for the benefit of others." 12. JOHANN
GEORG WIRSUNG Murdered in
1643 by Giacomo Cambier, reportedly the result of an argument, as
to who was the discoverer of the pancreatic duct. 13.
ARAMAND TROUSSEAU
Found himself to have the sign of internal
malignancy that he had described, was diagnosed as Carcinoma
Stomach, and died shortly thereafter. 14. KURT
SEMM
Complications of
Parkinson’s Disease 15. FREDRIC EUGENE BASIL
FOLEY Lung Cancer
Page 24
HOW DID THEY DIE…?……. !!!! Compiled By - Dr C.S.Rajan
Sushruta June 2020
Authors Ahmed W H Barazanchi 1, Weisi Xia 1, Wiremu MacFater 1,
Sameer Bhat 1, Hoani MacFater 1, Ashish Taneja 2, Andrew G Hill 1 3
(PMID: 32580245 DOI: 10.1111/ans.16082)
Affiliations 1. Department of Surgery, South Auckland Clinical
School, Faculty of Medical and Health Sciences, The University of
Auckland, Auckland, New Zealand. 2. Dept of General Surgery,
Auckland City Hospital, Auckland District Health Board, Auckland,
New Zealand. 3. Dept of General Surgery, Middlemore Hospital,
Counties Manukau District Health Board, Auckland, New
Zealand.
Risk Factors for Mortality After Emergency Laparotomy: Scoping
Systematic Review
Page 25
Newsletter of Surgical Society of Bangalore
Emergency laparotomy (EL) is a common procedure with high mortality
leading to several efforts to record and reduce mortality. Risk
scores currently used by quality improvement programmes either
require intraoperative data or are not specific to EL. To be of
utility to clinicians/patients, estimation of preoperative risk of
mortality is important. We aimed to explore individual preoperative
risk factors that might be of use in developing a preoperative
mortality risk score.
Background
Two independent reviewers identified relevant articles from
searches of MEDLINE, EMBASE and Cochrane databases from January
1980 to January 2018. We selected studies that evaluated only
preoperative predictive factors for mortality in EL patients.
Method
Result The search yielded 6648 articles screened, with 22 studies
included examining 157 728 patients. The combined post-operative
30-day mortality was 13%. All, but one small study, were at low
risk of bias. A meta-analysis of results was not possible due to
the heterogeneity of populations and outcomes. Age, American
Society of Anesthesiologists, preoperative sepsis, dependency
status, current cancer and comorbidities were associated with
increased mortality. Acute physiological derangements seen in
renal, albumin and complete blood count assays were strongly
associated with mortality. Delay to surgery and diabetes did not
influence mortality. Higher body mass index was protective.
Preoperatively, risk factors identified can be used to develop and
update risk scores specific for EL mortality. This scoping review
focused on the preoperative setting which helps tailor treatment
decisions. It highlights the need for further research to test the
relevance of newer risk factors such as frailty and
nutrition.
Conclusion
June 2020
Very sad to hear the news . He was senior to me during MB
and MS. Then my colleague in MSR. A dear friend. I will
miss him. RIP -Dr MG Bhat
Obituary
Newsletter of Surgical Society of Bangalore
Dr Belani was my good friend and a colleague at St. John's
heartfelt condolences to the family.......Om Shanthi
- Dr. Ramdev
I pray: May his soul be blessed by the Almighty. We will miss a
very vocal member during MCM.
-Dr Shivaram HV
R.I.P om shanthi. Since 1981 first time meet in surgical
society and we were good surgical friends.
- Dr.Gopinath
RIP Dr SBB...! In 1977, he joined SJMC, after his MS from KMC
Manipal, and work at SMH. I was one of the 1st medical interns to
go thro his instructions then. In Nov 1981, I got the vacancy he
left at SMH, when he left SJMC for MSRMC..! Om Shanthi, kind
Sir..!
- Dr.C.S.Rajan
Very sad to know about the sad demise of Dr Srichand Belani Prof of
Surgery. A brilliant surgeon & teacher. We
were classmates for 4 Years at St Joseph’s college & close
friends those days and after.Even as a student he was
good & excellent at Zoology dissctions & Student science
circle meetings. Later after graduating from Manipal
he had great carrier & his presence was always felt at SSB
meetings. I am going to miss him very much. My
condolences to the family & prayers for his soul to Rest In
Peace
- Dr Srinath
Really a very sad news. Sir used to be in the first row always. We
are grateful to him for his contribution and active participation
in all meetings. My heartfelt condolences to the bereaved family.
Ohm Shanti
-Dr Kalaivani
Very sad to learn about Dr Belani. A very vocal live wire of our
society. He introduced the concept of video of patients during
clinical discussions in large audiences CMEs. We will miss his
presence
-Dr Raghuram
So sad to hear the news RIP Dr Balani, We really miss him regularly
attending SSB and exchange knowledge with junior surgeons. Om
Shanthi,
-Dr Lakanna
I worked alongside Dr. Belani at MSRMC for several years. A simple
and good human being. He was always supportive. It's indeed very
sad that he is no more. Our prayers are with him and his family.
May his soul rest in peace.
-Dr Ravi
I was the secretary when he was the president
of SSB ASIC. It was the 1st time in the history
of surgical society all monthly clinical
meetings were held centrally at St.Josephs
Auditorium. Great Person. Rest in Peace. Pray
God to give courage to his family members.
-Dr Prakash B R
Sushruta
Very sad to note the same. He was my teacher in UG and
very good person at heart. May his soul rest in peace
-Dr Satyakrishna
Newsletter of Surgical Society of Bangalore
Kind hearted person .Your absence will be felt in the SSB
meets. Om Shanthi
- Dr. Seshagiri Rao
His constant presence in all SSB meetings will be missed. He always
had questions for the students.
-Dr Venkatachala
Heartfelt condolences and fond remembrance expressed by
Dr Vasudev Rao and Dr Ashok Nayak prior to the online
MCM.
Sad to know the demise of our beloved Surgeon Prof. Belani. I
remember most one thing - I used to pick him up along with Ashok
Nayak and Srikant, and come to attend our monthly meet. While going
back we all used to have Pan near Shivananda Circle and always it
was Belani's treat for that day. He will only pay for that. He will
never allow us to pay. Then the routine of dropping him to his
house and then Srikant and Nayak.
It will be in my memory always. Very much saddened by his absence.
Om Shanti...
- Dr. Murali
Fond memories of him right from my post graduate days (when I used
to present cases during CSEP and he was a chair). To Me being the
President of SSBAICC when there was no monthly clinical meeting
without his presence and questions. Always a charm to see him
occupy the front seat. Rest in peace Sir.
You will forever be remebered. Om Shanthi
- Dr Arvind Gubbi
Very sorry to hear about Dr.Belani. Knew him well all through our
college days and as an active member of our KMC alumni
association.
-Dr Giridhar & Nalini Shenoy
Page 28
Sushruta
mandatory.
Roads are empty but it is impossible to go on long drive.
People have clean hands but there is a
ban on shaking hands.
Friends have time to sit together but they cannot get
together.
The cook inside you is crazy, but you cannot
call anyone to lunch or dinner.
On every Monday..the heart longs for the office but the weekend
does not seem to end.
Those who have money have no way to spend it. Those who don't
have
money have no way to earn it.
There is enough time on hand but you can't
fulfill your dreams.
The culprit is all around but cannot be seen. A world full of
irony!
So be positive and Stay negative...
Courtesy - Dr Venkatesh Kesarla
An Humble Appeal !!
Whenever u find a Person Infected with Covid 19 in your
neighbourhood and going for Quarantine or Hospital or isolation Pls
do not take Video or Photography and make him feel shameful or
guilty, Instead stand in your Balcony or Window or Terrace and Wish
him good luck and a Speedy Recovery.
1. Respect Him. 2. Pray for Him 3. Make him feel you are a good
friend / Neighbour / Relative. 4. Wish him to get well Soon.
This Disease can be cured by each others help and not by
humiliation. Feel the Pain he and his Family may go thru, Lets Pray
for Each other in these Hard times.
Feeling Others Pain is also a Sign of Humanity
Trivia
Humble Appeal Courtesy - Dr Murali L
June 2020
Courtesy - Dr Dr Rajshekar Halkud
June 2020
June 2020
Dear Doctor,
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Ethically Enhances Your Brand,
Generates Leads & Wins Patients?
Advertise your events, workshop or courses in this space at a
nominal charge.
Contact:
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Sushruta June 2020
June 2020
Page 34
Sushruta - Editorial Team 2020
Advisors
Dr C S Rajan Dr K Lakshman Dr Ramesh S Dr H V Shivaram
Members
Dr Sai Shruthi Rai Dr Monika Pansari Dr Nagbhushan J S Dr Wassim
Darr Dr Nayar Sajeet G Dr Santosh K
Chief Editors
Editorial Board
Dr Venkatesh KL Dr Sreekar Pai Dr Niranjan P Dr Mallikarjun M N Dr
Sunil Kumar V Dr Venkatesh S Dr K S Hanumnthaiah Dr Manohar T M Dr
Rajashekhar C Jaka Dr Hosni Mubarak Khan Dr Manjunath B D
Thank-You