Indian Surgeons Research Articles

Bile duct injury during laparoscopic cholecystectomy: An Indian e-survey.

Backgrounds/AimsIn the absence of national registry of laparoscopic cholecystectomy (LC) or its complications, it is impossible to determine incidence of bile duct injury (BDI) in India. We conducted an e-survey among practicing surgeons to determine prevalence and management patterns of BDI in India. Our hypothesis was that majority of surgeons would have experienced a BDI during LC despite large experience and that most surgeons who have a BDI tend to manage it themselves.MethodsAn 18-question e-survey of practicing laparoscopic surgeons in India was done.Results278/727 (38%) surgeons responded. 240/278 (86%) respondents admitted to a BDI during LC and 179/230 (78%) affirmed to more than one BDI. A total of 728 BDIs were reported. 36/230 (15%) respondents experienced their first BDI even after >10 years of practice and 40% had their first BDI even after having performed >100 LCs. 161/201 (80%) of the respondents decided to manage the BDI themselves, including 56/99 (57%) non-biliary surgeons and 44/82 (54%) surgeons working in non-biliary center. 37/201 (18%) respondents admitted to having a mortality arising out of a BDI; the mortality rate of BDI was 37/728 (5%) in this survey. Only 13/201 (6%) respondents have experienced a medico-legal case related to a BDI during LC.ConclusionsPrevalence of BDI is high in India and occurs despite adequate experience and volume. Even inexperienced non-biliary surgeons working in non-biliary centers attempt to repair the BDI themselves. BDI is associated with significant mortality but litigation rates are fortunately low in India.

Enhanced Recovery After Gynecological/Oncological Surgeries: Current Status in India

With the day-to-day advances in science and technology, perioperative practices are also evolving and include high-quality evidence that improves surgical outcomes. We inspected the perioperative trends in major elective gynecological and oncological surgeries performed by various surgeons practicing in the field of gynecological and oncological surgery in India. A ‘39-questions’ questionnaire was developed on the basis of the recently published ERAS society recommendations for the major gynecological and oncological surgeries using Google Forms© and was sent to the various consultants practicing gynecology or surgical oncology across major cancer centers across India. The results of the first 100 responses were noted and analyzed. Response rate was 83.3%. 83 surgical and 17 gynecological oncologists participated from 59 different institutions. It was observed that many surgeons were adhering to the latest evidence-based practices like pre- and postoperative education, prehabilitation, DVT prophylaxis, use of MIS, multimodal analgesia, and regular audit. However, there were also some areas where traditional practices were still prevalent which included mechanical bowel preparation, keeping patients fasting overnight, no carbohydrate loading, unnecessarily keeping IP drains and NG tubes for longer times, and refraining from starting orally within 24 h of surgery. While most Indian oncological surgeons were adhering to the latest evidence-based practices, they were still lagging behind in certain aspects and traditional practices were being carried forward. With increasing awareness among surgeons, the latest guidelines should be followed for better surgical results.

Current Surgical Antibiotic Prophylaxis Practices: A Survey of Orthopaedic Surgeons in India.

Surgical antibiotic prophylaxis (SAP) has become the standard of care in orthopaedic surgery. Inappropriate usage of antibiotics (dosage, strength, and/or administration time and duration) can inadvertently result in superadded infections and antimicrobial resistance. The purpose of this study was to document and analyse the prescription patterns for SAP, and to investigate the factors associated with divergence from standard guidelines. We conducted an online cross-sectional questionnaire-based study to collect information about the SAP practices of the members of the Indian Orthopaedic Association (IOA) using Google forms. A link to the questionnaire was sent by e-mails. The overall response rate was 5.73%. While 97.3% respondents practised SAP routinely, the practice was not aligned with standard guidelines' recommendations. There was heterogeneity in the use of SAP in terms of choice of antibiotic(s), number of co-prescribed drugs, single- versus multiple-dose regimens, and the duration of therapy. The prescription practice patterns showed that orthopaedic surgeons almost always used broad-spectrum antibiotics for long durations, regardless of the type of surgery. While Orthopaedic surgeons in India are practicing SAP, the pattern of antibiotic usage is heterogeneous. Variations were noted in the choice of antibiotics for different types of surgeries, time of administration, duration of usage in the postoperative period as well as co-prescriptions. This study highlights the urgent need for a comprehensive, rational, and robust national SAP policy for orthopaedic surgeries.

Design, analysis, fabrication and testing of PC porous scaffolds using rapid prototyping in clinical applications

Introduction and Aim: Rapid prototyping is an advanced fabricating method, where three dimensional objects are built precisely from their three-dimensional computer aided design models in a very short duration. In contrast to traditional machining methods, most of the rapid prototyping techniques tend to fabricate parts based on additive manufacturing process. Fabrication of biomaterial into 3-D scaffold structures is the next vital step in the development of bone implants depending on bone injuries of individual patients, and it is highly demanding among the Indian orthopedic surgeons for treating those bone related defects. Therefore, the need for reliable and economically feasible design, better biomaterials, and efficient fabrication method for scaffold to treat musculoskeletal defects has increased in recent years.
 Materials and Methods: Investigation of scaffold for porous structured bone implant is a recently emerging field in medicine and is involved in developing artificial bones like structure using materials like Tri Calcium Phosphate (TCP), Polyether ether ketone (PEEK), Hydroxyapatite (HA), Polycaprolactone, polycarbonate (PC), poly (l-lactide) PLLA or Polyamide (PA) etc., by incorporating pores in the scaffold. In this research, the samples of the scaffold specimens were designed and fabricated using Stereo lithography technique with biocompatible PC resin and the strength of each sample were analyzed.
 Results: The porous scaffold models are structured with different designs utilizing the CAD software. The porous scaffold with various porosity and pore shape is analyzed through Finite Element Analysis (FEA). StereolithographyViperSi2 method was utilized to manufacture the polycarbonate scaffold. The manufactured rhombus pore model shows the stress value esteems around 200 MPa¸ which is nearest to the compressive strength of human bone. Subsequently the rhombus pore model gives better mechanical load bearing capacity when implanted for tissue recovery in bones.
 Conclusion: Bisphenol-A Polycarbonate material give better surface completion, 100% pore interconnectivity and new tissue arrangement of the fabricated porous scaffold. The SLA technique offers the more noteworthy load bearing quality and great exactness of the fabricated scaffold.

The dilemma faced by a budding cardiothoracic surgeon in India-a first hand account.

Cardiothoracic surgery is undoubtedly one of the most glamorous and exciting surgical fields on earth. The field requires passionate and hardworking youngsters who are always willing to learn. Bright young surgeons should know what is going to be on their platter once they have decided to take the plunge into cardiac surgery. This article is a fruit of my 3 years of residency experience and my ongoing stint as an assistant professor. In this article, I have tried to make young surgeons aware of what they will face during their residency tenure and also to attend to some of their worries prior to selecting cardiac surgery as a career option.

Need of the hour: Structural heart intervention training for trainee surgeons in India.

Cardiothoracic surgery is on the verge of undergoing a major metamorphosis from being a conventional surgical branch to a technologically powered specialty with plenty of emphasis on learning the minimally invasive techniques, and a step forward is the advent of interventional techniques to treat most of the major cardiac ailments. Though the world of interventions has been traditionally dominated by the physicians, it is time we surgeons get ourselves actively involved in learning and performing these interventional procedures to stay relevant. This is not an attempt to disrupt the physician-surgeon harmony but to nurture a symbiotic relationship between the two specialties for advancement in cardiac science and technological growth, ultimately to benefit the patient. In this article, we discuss the Indian and the global scenario of the role of surgeons in the interventional arena and various training modalities available for surgeons to learn the art of cardiac interventions. We tried to understand the impediments in implementing interventional training for surgeons and also propose certain amendments to the way the future cardiothoracic surgeons are trained.

Evolution of aesthetic surgery in India, current practice scenario, and anticipated post-COVID-19 changes: a survey-based analysis.

BackgroundThe declaration of COVID pandemic by the WHO can certainly be seen as a watershed era the world has witnessed in modern times. All non-essential industries and services have taken a back seat including aesthetic medicine. Over the last decade, India has witnessed a steady growth in medical tourism owing to global standards of care and services at a relatively modest cost. The following study was conducted to ascertain the sea change that this pandemic has brought into aesthetic surgeons’ practice, patient management, planning and consultation. This paper throws light on the journey of Indian aesthetic surgery from its infancy to its current presence in the global market as a context of the study. We have also discussed the impact of social media on aesthetic surgeons’ practice, lifestyle and its role as an emerging new method of medical education.MethodsA questionnaire consisting of 62 questions divided in 3 sections was rolled out to 150 Indian aesthetic surgeons who have been practising either independently in their clinics or are associated with hospitals. A: Pre-COVID practice management and lifestyle; B: life during the lockdown; C: anticipated changes in post-COVID era.ResultsIn the pre-COVID era, an average aesthetic surgeon was finely balancing his profession, personal lifestyle, learning, and recreation. The lockdown clamped their practices which lead into a financial drought; despite which, they were able to maintain their productivity by engaging in webinars, reading, and research. The post-COVID times demand an implementation of safety protocols along with changes in set-up, regulating patient traffic, engaging in distant learning through virtual conferences, and maintaining a healthy lifestyle acquired during the lockdown.ConclusionsIndia was rightly witnessing a surge in popularity of aesthetic surgery and medical tourism over the last decade. The corona pandemic has definitely hit this escalating growth curve hard, and it will take some time for the demand to recover. Our study revealed the following conclusions: The effect of COVID 19 demands a major change in aesthetic surgeons’ professional practice like limiting consultations, changing hospital floor plan, following COVID testing, and having new safety protocols. Social media is rightly poised to be a major tool for education and marketing as also for recreation and leisure. The role of teleconsultation needs to be reprised and legalised. Webinars and virtual conferences will find more takers in future.Level of evidence: not ratable.Electronic supplementary materialThe online version of this article (10.1007/s00238-020-01730-z) contains supplementary material, which is available to authorized users.

Developmental Dysplasia of the Hip: An Examination of Care Practices of Orthopaedic Surgeons in India.

We evaluated screening, referral and treatment practices for developmental dysplasia of the hip (DDH) in India by surveying Orthopaedic surgeons who treat patients with DDH. The survey assessed the timing of DDH presentation, resource availability, and current state of screening and diagnosis, which would help in the development of a DDH care pathway for India. An online survey was distributed to Orthopaedic surgeons practicing in India via email and administered onsite to those attending the annual conference of the Pediatric Orthopaedic Society of India in 2019. 173 completed surveys were received from surgeons practicing in a predominantly urban setting. 68.8% of respondents had performed initial evaluations on children with DDH aged over 1 year in the past 12months, and 49.1% had assessed children with DDH aged > 2years on initial presentation. There was no consistent use of established guidelines, with only 30% of respondents stating that a care pathway was in place at their institution. However, 91.9% would support the implementation of a care pathway developed in India, to decrease the incidence of delayed diagnosis and facilitate earlier intervention. 85% of respondents had ready access to ultrasound scans and 95.4% had access to X-rays. In India, there is still a large number of late-presenting cases of DDH, which could be improved with effective screening. The development of a care pathway for DDH in India is well-supported by Orthopaedic surgeons and may help decrease the incidence of late presenting cases; potentially improving outcomes, decreasing morbidity, and upskilling local practitioners.

How Much has COVID-19 Pandemic Affected Indian Orthopaedic Practice? Results of an Online Survey.

BackgroudCoronavirus Disease 2019 (COVID-19) has spread globally affecting all strata of people including the orthopaedic surgeons of India. We have witnessed a drastic fall in the number of patients. The aim of study was to assess the extent to which the Indian orthopaedic practice has been affected by the pandemic.MethodsWe conducted an online survey amongst currently practicing Indian orthopaedic surgeons. Those currently not in practice or under training or having left clinical practice before the onset of pandemic were excluded. A total of 533 orthopaedic surgeons took part in the study amongst which, complete responses were obtained from 407 individuals. Statistical analysis was done to see the association between demographic profile of study participants and various variables of orthopaedic practice.ResultsThere was drastic fall in all the parameters of orthopaedic practice. Over half of the practicing surgeons witnessed fall in out-patients over 90%. Most had stopped elective surgeries (64%) and even emergency ones (21%) altogether. More than 50% of doctors had their earnings reduced by > 75%. We found a statistically highly significant association of reduction in earnings with the sector, type of set-up and duration of practice. (p-value < 0.001).ConclusionThis study suggests that orthopaedic surgeons across all sectors in different kinds of set-ups have been affected in their out-patient and operative numbers. With regards to earnings, those working in private and running their own (individual) hospitals & clinics have been most severely affected while those in government sector and medical colleges have been affected the least.

An Audit of General Surgery Publications by Indian Authors

Indian surgeons have a substantial workload. But how much of it do we document and publish thus facilitating evidence-based practice? We undertook to document the contribution of Indian authors to the world literature in general surgery and to elicit the view of Indian surgeons regarding scientific publications. We carried out a search of articles in general surgical journals, published by Indian authors working in India. The journals chosen were those with an impact factor of more than 2. In addition, the Indian Journal of Surgery, with an impact factor of 0.55, was included as it is our flagship journal. The period of study was between January 2014 and April 2020. Additionally, a survey was carried out among the members of the Karnataka State Chapter of the Association of Surgeons of India. The survey was designed to elicit responses from surgeons regarding their attitude towards surgical publications. In American Journal of Surgery, British Journal of Surgery and Annals of Surgery only one original publication each was found. In Canadian Journal of Surgery and Journal of American Medical Association Surgery there were no publications in the study period. Surgeons put forth several reasons for this lack of publication culture—the main ones being lack of motivation, lack of data and lack of training to write. It is clear that Indian authors contributed to a minuscule number of papers in scientific surgical journals. The culture of publication must be inculcated from an early stage of surgical training.

Comparing Surgeon Adherence with World Health Organization Antiseptic Guidelines for Surgical Site Preparation in the United Kingdom and India.

Background: Skin preparation with an antiseptic solution aims to reduce surgical site infection rates. Surgical site infections (SSIs) create a high burden on healthcare systems with impacts on morbidity, mortality, and cost. In 2016, The World Health Organization (WHO) conducted an extensive systematic review and meta-analysis of the existing evidence. From this, they recommended the use of "alcohol based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures." This study aimed to assess surgeon compliance with this guidance in the United Kingdom and India. Methods: A multiple-choice questionnaire was developed to assess surgeon preferences for antiseptic use in their surgical site preparation. The end point of data collection was defined after 50 responses in each region. Results: The majority of respondents in each center was general surgeons (n = 24, 48% United Kingdom; n = 21, 45% India), and registrars (n = 22, 44% United Kingdom; n = 23, 49% India). No surgeon preferred the use of any aqueous preparation. Chlorhexidine gluconate (CHG) was the preparation used most commonly in both centers (n = 30, 64% India; n = 24, 48% United Kingdom). In India, this represented a statistically significant difference (p = 0.0008), however, this was not observed in the United Kingdom (p = 0.22). There were no statistically significant differences between surgeon's reasons between the United Kingdom and India, other than "easier to see" (p = 0.016). Conclusions: This data show a reduced compliance of U.K. surgeons with WHO guidance for antiseptic use compared with Indian surgeons. Although the WHO has attempted to summarize the existing data to minimize the previous uncertainty surrounding antiseptic choices, the use of CHG continues to not be adopted widely. To draw robust conclusions to provide the foundations of further guidelines, future research should focus on prospective randomized controlled trials with large numbers across multiple surgical specialties.

Impact of COVID 19 lockdown on orthopaedic surgeons in India: A survey

BackgroundIn the fight against COVID 19, the government of India announced a 3 weeks lockdown of the entire country of 1.3 billion people on 24th March 2020. MethodsOne week after the lockdown was announced, we conducted an anonymous online survey of the orthopaedic surgeons in India through social media platforms to assess the impact of the lockdown during COVID 19. The survey had a total of 13 questions with (3–5) options and was designed with an aim to understand the perception and the state of mind of the Orthopaedic surgeons in the lockdown situation. ResultsThe survey was completed by 611 orthopaedic surgeons from 140 cities in India. There were 22.5% orthopaedic surgeons who said that they were definitely stressed out, and 40.5% who said they were mildly stressed out. As the age decreased, the percentage of orthopaedic surgeons feeling “definitely stressed out” increased. Disruption of life-work balance and uncertainties regarding return to work were other strongly associated factors with the “definitely stressed out” group. ConclusionThe psychological impact of the lockdown during COVID 19 on orthopaedic surgeons may become a potential concern that will require addressal through open discussion. Level of evidencediagnostic level 4.

Are Surgeons in India prepared for COVID-19?

Are Surgeons in India prepared for COVID-19?

COVID-19 and orthopaedic surgeons: the Indian scenario.

The emergence of COVID-19 has impacted orthopaedic surgery worldwide. India, with its large population and limited health resources, will be overwrought over the coming days due to the number of cases of critically ill patients with COVID-19. It is important to understand the challenges for orthopaedic (and other) surgeons in India when dealing with patients during the COVID-19 pandemic. This article highlights the challenges in the triaging of patients, care in dealing with a patient with COVID-19 in orthopaedic surgery, and the effects on academics and research activities; it also suggests immediate measures and recommendations that also apply to other specialties.

Pioneers of congenital heart surgery in India: historical perspective: Mumbai - The Gateway of Congenital Heart Surgery to India.

Congenital heart surgery was born in the USA and then spread all over the world in the second half of the twentieth century. The speciality was brought to India by foreign-trained Indian surgeons as well as American and Canadian missionary surgeons. The first generation Indian surgeons were trained in the USA, Canada, Australia, and New Zealand. In this article, an attempt is made to explore how the pioneer surgeons established this speciality in India by reviewing the published literature, visiting institutions of historical significance, and also interviewing few surgeons who took the key role in both laying the foundation as well as training the next generation surgeons.

Impact of COVID 19 on orthopedic surgeons in India during the early phase of lockdown in South India: A survey-based report

Background/Purpose: The pandemic of COVID 19 has swept across the livelihood and economy throughout the world. We created an online survey during the 2nd week of the first phase of national lockdown and assessed the impact of COVID 19 pandemic on orthopedic surgeons in South India, who are almost forgotten in this fight. Methods: The simple survey which included questions divided into categories – demographic details, awareness of the situation, clinical practice, effects on research, training, and personal aspects. The survey was shared on social media and responses were recorded online using Google forms and analyzed. Results: A total of 132 surgeons from various states of India, mostly from South India answered the survey in 7 days. More than 50% responded that their institution had no specific guidelines nor had adequate personal protective equipment (PPEs). Sixty-percent of the surgeons used only standard precautions and not PPE for emergency surgeries. Sixty-seven percent used telecommunication for regular follow-ups and most preferred WhatsApp messenger over SMS or calls. Over 50% were not confident to handle medical emergencies. 53.6% felt postgraduate training was significantly affected due to the lockdown and 58.8% were most stressed about their personal and family health. Seventy-five percent surgeons used this leisure period to spend time with their family. Conclusion: The pandemic of COVID 19 has significantly affected different domains of work and personal life of orthopedic surgeons in India. The survey helped to identify the deficiency and necessary changes which were implemented further. The situation would lead to long lasting changes in clinical practice and view of surgeons in the field of medicine and personal life in general.

Economic impact of Coronavirus disease of 2019 pandemic on vascular surgeons in India

Introduction: Coronavirus disease of 2019 (COVID-19) pandemic has affected virtually everyone in every walk of life globally including all health-care services. The economic impact of such disruptions in vascular surgery services on vascular surgeons in India is unclear. This study aims to understand the economic impact of COVID-19 pandemic on vascular surgeons practicing in India. Materials and Methods: A questionnaire consisting of 15 questions was created using Google Forms and circulated through E-mail and WhatsApp groups dedicated to vascular surgeons in practice and/or training in India and was available for 2 weeks. Only vascular surgeons who are currently practicing in India were eligible to participate in the study. Results: One hundred and eighty-four out of 400 (46%) members that are thought to be currently practicing or in training in India participated in the study. 98.91% completed all the questions. 90.2% (n = 166) of the respondents were aged below the retirement age of 60. Thirty-four worked in government job, 89 in private sector on salary basis, and 58 in private sector as fee for service. Seventy-one percent of the respondents (including trainees) reported a negative impact on their monthly income due to COVID-19 pandemic ranging from 10% to 90%. Seventy-six percent of the respondents believed that there will be a further negative impact in the coming few months. Sixty-nine percent claimed that they did not have alternative sources of income. 82.6% were not aware of measures to overcome such adverse economic impact and have not taken any preventive steps or measures. Conclusion: The results of the study show that COVID-19 pandemic had a significant negative economic impact on majority of the vascular surgeons practicing in India resulting in a 50% or more reduction in their income. Skills and knowledge about financial resources, financial resilience, and risk management are needed to prevent or overcome future crisis.

Should colorectal surgery be a separate superspecialty in India?

Colorectal surgery is demanding and requires a certain degree of operative skill. The literature also suggests that the outcome of patients after colorectal surgery depends on the surgical expertise as well as the volume of colorectal cases in a hospital. Most parts of the world have already designated colorectal surgery to be a separate superspecialty, but in India, there is still little enthusiasm for this idea. However, considering the increasing incidence of colorectal cancer in India, especially in our younger population, we should consider whether it has become necessary to train doctors in such complex procedures from the beginning of their careers. However, whether colorectal surgery should be designated to be a separate superspecialty in this country is still debatable, but the initiative taken by the Association of Colon and Rectal Surgeons of India with their fellowship and instructional courses should be examined carefully.

Daily versus weekly evidence reports for orthopaedic surgeons in India: A mixed-methods study.

Background:There is a dearth of research regarding the impact of evidence-based medicine (EBM) tools, such as evidence summaries, in developing countries. The goals of this study were to: investigate accessibility, use, and impact of an online EBM knowledge dissemination portal in orthopaedic surgery in India; explore whether receiving daily targeted evidence summaries results in more frequent use of an EBM tool compared with receiving general weekly reports; and identify and explain the barriers and benefits of an online EBM resource in the Indian context.Methods:Forty-four orthopaedic surgeons in Pune, India, were provided free access to OrthoEvidence (OE), a for-profit, online EBM knowledge dissemination portal. Participants were subsequently randomized into 2 groups—1 group received daily targeted evidence summaries while the other received general weekly summaries. This study employed an explanatory sequential mixed methods design that incorporated 2 questionnaires, OE usage data, and semi-structured interviews to gain insight into the surgeons’ usage, perceptions, and impact of OE.Results:There were no observable differences in OE usage between groups. OE was deemed to be comprehensive, practical, useful, and applicable to clinical practice by the majority of surgeons. The exit survey data revealed no differences between groups’ perceptions of the OE tool. semi-structured interviews revealed barriers to keeping up with evidence that included limited access to relevant medical literature and limited incentive to keep up with current evidence.Conclusions:Neither frequency of delivery (daily versus weekly) nor targeted versus general content affected the use of evidence summaries. Facilitating uptake of current evidence into clinical practice among Indian orthopedic surgeons may require additional components beyond dissemination of evidence summaries.

Indian Surgeons’ Perspective Regarding Breast-Conserving Surgery: A Cohort Study

Objective: Breast-conserving surgery (BCS) has constantly evolved and recently involves many new facets in the form of SLNB, breast oncoplastic surgery, and brachytherapy. Breast surgeons are required to constantly unlearn and learn to keep abreast with the new guidelines. We aimed to study the Indian surgeons’ perspective about BCS. Participants: We mailed a questionnaire containing 20 questions regarding various aspects of BCS to 1200 surgeons. of these, 112 surgeons (40 endocrine surgeons, 40 surgical oncologists, and 32 general surgeons) responded. Results: We found that surgeons in the 31 to 40-year age group, surgeons with superspecialty training, surgeons working in private setup, and high-volume surgeons (&gt;100 cases/year) were performing more BCS. Conclusion: Indian surgeons should have more robust training in BCS to increase the rates of BCS in India.