JOGS

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

A Comparative Study of Ripasa Scoring System and Ultrasonography in the Clinical diagnosis of the Acute Appendicitis in Resource Limited Settings

Warad Nikhil , Devani Kavin
Lokmanya Tilak Municipal Medical College, Mumbai, India

Background: Acute appendicitis is the commonest cause of acute abdominal pain in the surgical practice. Correct clinical diagnosis prevents unnecessary surgeries and complications. Various scoring systems are there to aid clinical diagnosis of the acute appendicitis.

Methods: A prospective observational study was carries out at the Department of Surgery, Lokmanya Tilak Municipal Medical College, Mumbai from February 2018 to December 2018. Demographic, clinical and laboratory investigations’ data was collected from consenting patients. The gold standard for the diagnosis was histopathological examination. The data was analyzed by IBM SPSS Statistics (2015). Sensitivity, specificity, accuracy and negative predictive value and positive predictive value (= precision) were compared.

Results: Majority of the patients with right iliac fossa pain were operated. RIPASA scores better than USG on all the 4 attributes viz. sensitivity (0.90 against 0.84), specificity (0.30 against 0.20), accuracy (0.80 against 0.73) and positive predictive value (= precision) (0.87 against 0.84). Conclusion: RIPASA is not only less reliant on the technology and skill but also better in guiding the prognosis. Thus, a useful tool in resource limited settings.

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

A New Innovation in Yogasan (A new Yogasan for quick relief of tension and sleeplessness)

K C Sharma , Uma Sharma
Serv Sidhi Nursing Home, Udhampur, India

For relaxation of body & mind “SHAV ASAN” & “BALASAN” (Vishram Asan) have been well described & practiced. In today’s fast moving life, people want to put themselves to sleep quickly so that they relax fully & awake fresh for next work. Therefore to meet this requirement a modified Valasan has been introduced which quickly puts the body into complete relaxation followed by deep sleep in just 8 – 10 minutes at normal body & surrounding atmospheric temp depending upon weather. With deep sleep tension is obviously relieved.

Method: With appropriate routine pillow under the head, person lies down in Rt. Or left lateral position, flex the upper leg partially, and keep lower leg almost straight. Perineum is directed towards the bed. Weight of the Chest, abdomen & pelvis must fall anteriorly towards the bed. Keep neck on same side & face touching the bed, lower arm flexed at elbow & keep near the face resting on the bed, the upper hand be kept straight but relaxed just behind the greater trochanter of the femur i.e. highest point of hip in this position. Coordinate this position with mind and take one or two deep breath to go to sleep see photo I, II, III.

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Expressed breast milk: Awareness and opinion on storage and utilization among mothers in tertiary health care center, Belagavi

Reewen George D Silva
Belagavi Institute of Medical Sciences, Belagavi, India

Introduction: For newborns and infants, breast milk is the best source of nutrition. To achieve optimal growth & development and health, the infants should be exclusively breastfed for the first six months of life [1, 2]. Various pieces of research show that the first time mothers and working mothers become a prey for formula feeds due to structural functional limitations.

Methodology: Cross sectional study was conducted by recruiting 200 subjects through Nonprobability purposive sampling from a tertiary health care center in Belagavi. A Gravid women between age group of 18-45 yrs attending IPD, OPD & follow up care and able to read & write were recruited. The data was collected post Institutional Ethical committee clearance and individual subject consent using a questionnaire. It constituted sections such as Knowledge, Attitude, Practice and Opinion regarding EBM.

Results: The mean age of subjects 28.79 (± 7.02) years. About 119 (59.5%) have not heard about EBM. About 162 (81%) had no idea of storage. 50.2% expressed requirement of professional help. 117(57.9%) said that Expressing will increase the milk production. Opinion on acceptance and need, 126 (63%) were willing to donate EBM, 160 (80%) expressed a need for EBM Bank, 166 (83%) expressed need for availability at every hospital. However 159 (79.5%) said creating awareness and making it a reality is a need of the hour. A χ2 computed shows that there was a significant association with age p <0.032, religion p <0.001, educational level p<0.001, learned on usage of EBM p <0.001 and idea on how to store and utilize EBM p<0.001.

Discussion: A similar study which was conducted by Rai S. concluded that 36% of participants had adequate knowledge[3]. The study by Prabhu P et al also reported that the knowledge about methods of breast milk expression and storage was not satisfactory[4]. An educated woman had higher scores, which was also reported by Ekambaram M et al., [5] there was a significant difference among religion, age, educational level which was statistically significant, which might be attributed to social and multifactorial constraints.

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Reverse Innovation in Healthcare from India

Muthu Singaram
HTIC, IIT Chennai, Chennai, India

Introduction: This review paper explores the innovations in healthcare arising from India and how many of these can be applied to the theory of reverse innovation This study demonstrates how Indian researchers can play a major role in reverse innovation application in healthcare. What is reverse innovation also as Trickle-up Innovation? This was first coined by two Dartmouth University Professors Vijay Govindarajan and Chris Trimble and GE’s Jeffrey R. Immelt. Later Vijay Govindarajan and Chris Trimble published the book Reverse Innovation (2012), these are innovations first arising in the developing countries which are later introduced in the western or developed markets.

Methodology: This study is based on scholarly publication in major journals we have studies over 100 articles and selected 50 for the purpose of our study. We have built nine case studies based on these articles and reliable publicly available data. These case studies shows us that if these success stories are applied lot more of the innovation coming out of India can fall into the reverses innovation from frugal innovation by apply the three box framework which would lead to a larger usage of these innovations and further hence Indian innovations and economic.

Results: The review paper would describe 14 Indian reserve innovations and their benefits to the world at large. Discussion This review paper looks at reverse innovation targeted at providing goods and services to the poorest people in the world and this would fall in the area of strategy-based innovation. This review paper makes a case for the fastest-growing new markets and entrepreneurial opportunities being found among the billions of people `at the bottom of the income pyramid’. BOP proposes that there are tremendous benefits for multi-national companies who prefer to serve these markets in ways aware of their needs.

Keywords: Reverses Innovation, Healthcare, Frugal Innovations, Three-box Framework, Rural health, Process Innovation, Product Innovation, Strategy Innovation, Service Innovation

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

System Innovation in Laparoscopic Simulation Training for intra-corporeal tissue re-approximation, knot tying and suturing technologies

Murugankutty Gopalan
Amrita Institute of Medical Sciences, Kerala, India

Minimally invasive procedures rule the domain of surgery worldwide. The simulator-based training in psychomotor skills necessary for doing ‘Intra-corporeal tissue re-approximation’ remains, the hardest obstacle, the greatest challenge and barrier for all the budding laparoscopic surgeons across the globe; especially in the areas of knot tying and suture placement techniques. As a solution to this issue, we offer our newly developed- hustle free, “trainee end- tool kit- with direct 3D vision as well as the 2D camera vision, with which one can have their psychomotor skills up- gradation within the comforts of their own home.

“Learn from Home” is the proposed system innovation here: As a practical solution to address the above issues, we have developed ‘Learn from Home Gear’ consisting of a Box Simulator + 24 x7 hours of web-based mentorship in combination. The new simulator box is foldable, lightweight, with no cables attached. And a web-based self-monitoring system, consisting of easy to-follow instructions, and well-defined checkpoints for easy self mentoring. These teaching contents shall be circulated to the registered trainees as short video clips.

We have started this training program since the last 6 years, on “one to one basis”- in our Amrita Clinical Skill simulation center and found to be very effective. We would like to diffuse and scale up to the maximum by opening an avenue for sharing this knowledge to the surgical fraternity all over the world taking advantage of the advancement in information- technology, which in turn will result in enhancing the healing power for the patients even at the remotest corner of the globe. With this we could achieve our aim to establish the easiest , simplest, remote skill learning with checkpoint aided self mentoring – the proposed system innovation –“Learn from Home Gear in Laparoscopic Simulation ”

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Music as an adjunct cost-effective therapeutic innovation for Management of Pain in Trauma Patients: A Systematic Review and Meta-analysis

Pratyush Kumar , Oshin Puri, Yogesh Bahurupi
Dr Baba Saheb Ambedkar Medical College and Hospital, New Delhi, India; AIl India Institute of Medical Sciences, Rishikesh, India

Introduction: Music therapy reduces pain perceived, alleviates mood and promotes relaxation, regular breathing and rest. Being a readily available and inexpensive therapy, its efficacy for Management of Chronic Pain, such as that experienced by Trauma patients needs further exploration in low resource settings.

Objective: To determine the effectiveness of Music Therapy as an adjuvant therapeutic intervention in trauma patients of adult and pediatric age group in the pre and post procedural period.

Method: PubMed (n=175), Trip Medical Database (n=278) and ClinicalTrials.Gov (n=28) were searched for ‘Trauma’, ‘Music’ & ‘Pain’. Studies identified from inception were imported to EndNote X9 Library and duplicates removed. Only completed RCTs (Pubmed; n-16, TMD; n=2, CT.Gov; n=6) were screened using Title, Abstract and full text (n=41). Data extracted from 12 studies, was analyzed in Review Manager 5.4.

Result: Due to significant heterogeneity (Chi² = 365.17, P < 0.00001; I² = 97%), inverse variance random effect meta-analysis was done. Scores of the various pain measurement scales from a total of 852 patients from 12 studies revealed a pooled Standard Mean Difference of 0.31 [-0.61, 1.22]. Test for overall effect Z = 0.66 (P = 0.51) indicates that there is no significant difference in pain outcomes between Music Adjuvant therapy (MAT) Vs. Conventional Analgesic care. Subgroup analysis reveals a significant favor [Z = 1.18 (P = 0.24)] to MAT in patients of non-malignant pain of traumatic origin while in burn trauma patients it has no significant benefit [Z = 2.23 (P = 0.03)]. Similarly, as per pooled evidence, MAT is highly effective in the pediatric age group [Z = 1.00 (P = 0.32)] while no significant benefit in the adult age group [Z = 1.11 (P = 0.27)].

Conclusion: The pooled evidence suggests that both interventions significantly improve pain outcomes but Music therapy does not have any significant benefit over conventional therapy when compared as a whole. Although, in patients of non-malignant pain of traumatic origin, MAT has significantly high benefit while for Burn trauma patients, MAT has no proven significant benefit over conventional therapy. Evidence from the meta analysis indicates high efficacy of MAT in children while non such benefit can be proven in adult age group. Therefore, MAT could be a potential inexpensive therapeutic adjuvant in non-malignant pain of traumatic origin (for example post fracture reduction, post operative pain, etc.) and for pain management in children.

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Designing Global Surgical Technology: Benefits of a Participatory Design Approach for the Surgeon

Tim Ho , Millie Marriot-Webb, William Bolton, Noel Aruparayil, Peter Culmer
University of Leeds, Leeds, United Kingdom

Introduction: Participatory Design (PD) is an approach to technology development that aims to improve outcomes through close and equal involvement of stakeholders in the development process. This approach is increasingly prevalent in medical technology development – particularly in Global Surgery and low-resource healthcare interventions, where understanding of the clinical context is vital to design. It has been argued that PD projects should prioritize participant outcomes alongside project objectives to ensure project longevity and success, yet there is a paucity of research regarding the impacts on clinical stakeholders, and how to optimise their collaboration. Better understanding of the benefits for clinical stakeholders will help facilitate these aims and promote better collaborations.

Methodology: Clinical stakeholders, involved in the development of the “RAIS” (Retractor for Abdominal Insufflation-less Surgery) device, were identified for interview. Semi-structured interviews were conducted with each participant to ascertain their personal motivations, experiences of multidisciplinary and international collaboration, and to explore any opportunities or skills that were developed. Personal frustrations and barriers to collaboration were identified and solutions to these concerns explored.

Results: Stakeholders unanimously prioritised clinical results over personal enrichment as the primary motivation for participation, though academic and career opportunities were recognised as key benefits. A non-hierarchical relationship between clinical and design teams allowed the clinicians to contribute and influence the design process to meet their specific needs as the device’s intended users. The geographical distance between teams and the lengthy design process were major sources of frustration. However, effective communication channels, and integration into design considerations, reduced miscommunication and enhanced contributions from the surgical team who were able to provide more detailed and valuable feedback.

Discussion: This study aims to catalyse further research to determine the ideal participant and project outcomes and the optimal approach to facilitate these. Key considerations for innovators considering using a PD approach include:
Project Conception:
1. Prioritize input from a variety of stakeholders based in LMIC’s in the initial design phase
2. Collaborate with local stakeholders throughout the design process to ensure continuity
3. Establish stakeholder-specific goals as part of the project’s objectives
Communication:
4. Communicate interactively to understand the context and form collaborative relationships with stakeholders
5. Espouse an ethos of equal stakeholdership to facilitate bi-directional information flow, encourage feedback and ensure participant motivations
6. Validate interventions with stakeholders in the contextual environment
Sustainability:
7. Support the development of innovation networks and capacities within LMIC’s
8. Empower stakeholders to innovate, collaborate and disseminate their knowledge
9. Employ formal PD frameworks to guide long-term and sustainable stakeholdership

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Lumbar Disc Degeneration, A Transdifferentiation Process-An Electron Microscopic Observation

Prashant B Lakhe
GIPMER, New Delhi, India

Introduction: Lumbar disc degeneration (LDD)is a common condition which affects quality of life. Repeated trauma, ageing and stress predispose to LDD. However exact mechanism is not fully understood. Transdifferentiation refers to a process where a one mature cell switches its phenotype and function to that of another mature differentiated cell type. Such mechanisms have been described in repair following fracture of bones. In order to understand it better, we conducted an electron microscopic study to analyze if LDD is a transdifferentiation process.

Methodology: After institutional ethics committee approval, patients who presented with LDD were subjected to preoperative MRI. Failure of medical management, and occurrence of neurological deficits formed the indication for surgery. Discoidectomy was done by standard microscopic techniques and the disc material was examined under electron microscopy. The disc material was collected and labelled according to proximity to adjoining osteophyte formation. The electron microscopic findings were correlated with clinical and radiological observations.

Results: Study was conducted from Jan 2020 – Dec 2021. A total of 50 patients with 28 males ,22 females with a mean age of 47 years were studied. Majority of the patients(26) had a prolapse at L4- 5 level with the mean duration of symptoms being 12 months. 80 % of patients had a VAS score of 7 and 8. Maximum (72 %) patients showed a Pfirrmann grade 4 of degeneration on MRI and type 2 Modic changes (64 %). Ten patients(20%) showed presence of posterior osteophytes. Electron microscopy showed chondrocyte clustering in 92 % patients, collagen abnormalities in 66% and intracellular inclusions in 60%. Chondrone formation was seen in 12 patients. Patients with higher pain severity and longer duration of symptoms showed increased chondrocyte clustering. Osteophyte formation was seen in patients with longer duration of symptoms. All the patients with osteophytes showed presence of chondrones.

Discussion: LDD is a process which can be explained on electron microscopy. Higher VAS score and longer duration of symptoms results in more chondrocyte clustering. In addition, formation of osteophytes was always associated with chondrone formation. These findings support our hypothesis that lumbar disc degeneration is a transdifferentiation process.

Keywords: lumbar disc degeneration, transdifferentiation, chondrocyte clustering, chondrone

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

External Fixation in Polytrauma Patients from Low and Middle Income Countries – A Case Report

Gopalkrishnan Murugesan , Vivek Udayachandran
Saveetha Medical College and Research Institute, Chennai, India

Road traffic accidents is the largest cause of death in the age group of 15-29(1). It has been reported that India has one of the highest mortality rate from RTA in the world and polytrauma cases comprised 13.3% of all adult trauma cases. Time, cost, infrastructure, availability of implants, surgical expertise and complications are important factors when it comes to selection of the limited treatment choices available in low and middle income countries (LMIC)(5). The case report below explores the feasibility of external fixation in patients with pelvic and long bone fractures from LMIC.

The report comprises of the clinical, radiological findings and the management of a polytrauma patient from LMIC. This study implies the efficacy and wide use of external fixators in developing countries. It has been shown that, if used properly, external fixators can treat bone and with low risk and reasonably high success rates. The early management of fractures reduces significant mortality which has been possible for the above patient. However the study limits to a case report. The high cost of commercially available devices sent a dilemma to our health care which puts emphasis to the need for locally manufacture external fixators to avoid burden of imported devices in our health care systems. Different studies have demonstrated the superiority of surgical fixation over conservative methods but several factors impose a roadblock to adoption of these methods. Also, the mortality and morbidity of polytrauma patients depends on other extraneous factors and a multidisciplinary approach with rehabilitation is needed.

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Spontaneous common bile duct perforation presenting as extrahepatic bilioma: a rare clinical presentation of gall stone disease

Princy Gupta
Maulana Azad Medical College, New Delhi, India

A 45 years old female presented to surgery emergency with 5 days history of pain right upper abdomen with high grade fever, chills and rigors associated with yellowish discoloration of eyes and skin with generalized itching all over body. On examination, patient was febrile (101°F), tachypneic with tachycardia of 108/min, dehydrated and icteric. Abdomen was soft with tenderness present at right hypochondrium and right lumbar region. Murphy’s sign negative. Laboratory investigation revealed TLC of 9700 cells/mm3 with total bilirubin of 5.68, direct bilirubin of 3.49, and normal liver enzymes with elevated alkaline phosphatase (219). Ultrasound revealed dilated CBD, 12 mm at porta, distal CBD obscured with bilobar IHBRD and a contracted gall bladder. A diagnosis of acute cholangitis was made and patient was managed conservatively and was improving clinically as well as biochemically. On 3rd day of admission, patient developed abdominal distention, examination revealed a swelling of around 15×15 cm involving whole of the right abdomen, which was non tender. Her laboratory studies also demonstrated a marked increase in alkaline phosphatase level to 3529 from 219. Ultrasound revealed reduced distention of CBD to 7 mm with large thick walled collection with multiple internal echoes and dependent echogenic debri within in right lumbar region. Magnetic resonance cholangiopancreaticography revealed cholelithiasis with choledocholithiasis with resultant upstream bilobar IHBRD and a large thick walled hyperintense collection measuring 7.8x19x10 cm in subhepatic region, reaching upto right iliac fossa. The collection is reaching upto proximal CBD proximal to calculus, likely extra hepatic bilioma. Ultrasound guided pigtail catheter drainage was done which revealed stat output of 2000 mL of bilious fluid. Patient was taken up for exploratory laparotomy, which revealed a 2×2 cm perforation present over lateral edge of CBD with single large stone present just beneath the perforation site. Intrahepatic, normal, distended gall bladder with calculi, dense adhesions between liver, gall bladder, omentum and bowel and 10×10 cm well localized collection present in right lumbar region surrounded by omentum with pigtail in situ. Peritoneal lavage was done using warm normal saline. Cholecystectomy was done and CBD explored. CBD calculi removed and CBD closed over T tube, inserted through the perforation site. Patient improved symptomatically and biochemically. T Tube cholangiogram done on POD5 revealed a filling defect. T tube was clamped and repeat T tube cholangiogram revealed no abnormality. T tube was removed on POD15, and patient discharged on POD17. She was doing well on her first and subsequent visits for next 3 months.

Non traumatic perforation of extrahepatic bile ducts is a clinically rare entity seen more commonly in infants than adults. In infants, it is secondary to congenital anomalies like choledochal cyst, anomalous union of pancreatico-biliary ductal system, bile duct stenosis or atresia that weakens the common bile duct wall. Although the pathogenesis of spontaneous biliary perforation is poorly understood, the commonest cause for perforation was a stone in adults with the mechanism being impaction of stone followed by erosion. Other causes reported are tumor obstructing the lumen and increasing canalicular pressure, spasm of sphincter, intramural infection, mural necrosis secondary to mural vessel infarction, connective tissue defect, ischemic compromise or previous biliary tract surgeries. Kang et al. reviewed 70 cases of spontaneous bile duct perforations in adults. Among these, 42 patients had perforation in common bile duct, followed by hepatic duct in 28 cases. In our case, we attribute the perforation to the impacted stone within the CBD leading to ischemic compromise and eventually erosion of the duct. The presentation of CBD perforation may be acute or insidious, with the latter type being more common and characterized by progressive jaundice, painless abdominal distension and clay colored stools. The acute form is less common and presents with fever, vomiting and signs of fulminant peritonitis. Ultrasound findings in a case of extrahepatic biliary duct perforation reveals free fluid in peritoneal cavity with normal extra and intrahepatic biliary radicles. Failure to see distended gall bladder points towards the decompression of biliary system secondary to perforation. MRCP reveals the same finding with a collection communicating with the extra hepatic biliary ductal system, as in our case. In doubtful cases, radio isotope scanning can be done. Recommended standard of care in a case of spontaneous perforation of CBD is exploration of CBD with retrieval of stone and closure of CBD over T tube placed from the perforation site. If distal obstruction is anticipated, biliary enteric bypass can be done. Primary repair of CBD over CBD stent is hazardous in acute presentation due to local inflammation, especially if distal patency is not known.

Keywords: Non-traumatic perforation, extrahepatic bile ducts