Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 1, 2003, pp. 20-21

Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 20-21

Editorial

Hence this Special issue

Dr. Tehemton E. Udwadia

Chairman / Editor, Indian Journal of Surgery

Code Number: is03002

Why this Special Issue on Surgery in Rural India? After special issues on Endoscopic Surgery, Reoperative Surgery, Vascular Surgery, articles on stem cells in the past and on angiogenesis in the pipeline why has the Journal deliberately chosen to step-down gear this issue? This choice is indeed deliberate and in keeping with the editorial priorities enumerated in the first issue of the I.J.S. after this Editorial Board took office.¹

For far too long our thrust has been to publish thoughts, articles and surgical culture from our premier institutions, our foremost professionals in a conscious and at times contrived and exhausting effort to try and achieve, if not maintain, a level on par with Western literature. As stressed in the past, one of our foremost priorities is to be indexed. On the other hand, this is the Indian Journal of Surgery, and to be truly Indian it should factually reflect the full spectrum of surgery in India. And we all know the spectrum is breathtaking in its width and variety, from state of the art private hospitals, to teaching hospitals, nursing homes, mission hospitals, district hospitals, from the fabulously opulent to the shockingly deprived. If the Indian Journal of Surgery speaks for Indian surgery it must be the voice of the full spectrum-hence this special issue. I do hope and expect that our members will study this issue, which airs the tribulations and triumphs of the rural Indian surgeon. Personally I found this issue an eye-opener, an educative and humbling experience.

Many surgeons in large towns and cities will bemoan such a down gear of "academics", claiming they and their surgery have nothing to do with that done in rural India. This sense of disassociation is factually untenable and is the tragedy of Indian surgery. Both ends of the spectrum must work with respect, understanding and harmony like the left and right hands of a surgeon at laparoscopic surgery. A technology which has survived for over 2000 years teaches us that "whatever befalls the least of my children concerns me for what avails a man if he gains the whole world, but loses his soul?" India lives in her villages. Working against all odds, in the backwaters of the country, the rural surgeon is the backbone of surgery in India.

I am aware of all that is laid down in "guidelines" and accepting how important it is to follow these guidelines, I try doing so. I know that these "guidelines" would shudder and shrivel at the mere thought of instruments being sterilized in boiling water on a kerosene stove, surgeons operating with only one untrained unqualified assistant, anaesthesia conducted by unqualified anaesthetists with open ether anaesthesia, the same surgeon doing a trephine for an extradural, thoracotomy for an empyema, hysterectomy for a ruptured uterus, nephrolithotomy, reduction and plating for a fracture, transfusing a polytrauma patient with blood not drawn from an approved blood bank. The guidelines proclaim all of the above is forbidden, if not illegal. But I also know that it is not guidelines that save the life of a patient with a strangulated hernia or in obstructed labour in the rural setting. What saves these lives is the courage, capability, enterprise of the surgeon struggling with scanty resources yet amply compensated by wealth of feeling and determination. They live and work on the realization that when guidelines are logistically unattainable, they can yet achieve the basic purpose of all surgical endeavor-compassion, care and cure.

These rural surgeons are further burdened by peer pressure. Senior rural surgeons and "rural activists", set in their ways, pressurize their colleagues that any form of "modern" surgical innovation like endoscopic surgery is to be shunned as not in the interest of their patients and an abject surrender to the "West". At the other extreme, Professors in their ivory towers dictate that surgery can only be done as per their rigid guidelines. Recently at a laparoscopy workshop near Jammu I frowned on the use of atmospheric air for pneumoperitoneum. The retort was strong and logical-"if we need to send our CO₂ cylinders over 200 kms. of hostile terrain, we have no other option. Atmospheric air is accessible, available, affordable, hence appropriate and acceptable", and reminded me I had done laparoscopy with monopolar diathermy using atmospheric air for over 18 years! There is no risk of explosion with diathermy in the presence of atmospheric air, (we all use it in our operation theatres with atmospheric air!). CO₂ is safer to avoid gas embolism as it is absorbed in the blood stream at the rate of one litre per minute, not at higher flow rates. Perhaps abdominal lift without pneumoperitoneum would be the ideal answer for rural India.^2,3

It is a privilege to present two articles related to surgery in Africa. These are specially published to emphasize that we must build bridges with out neighbours in South East Asia and our colleagues in Africa, who share our problems, to learn from each other's experiences and innovations. I have endeavoured to keep the editorial process of every article to a bare minimum, turning a blind eye to errors of syntax or punctuation so that the voice and flavour of the rural surgeon comes through. I drove my pen in disgust through what I felt was an absurd paragraph for determining foetal sex with wheat and barley plants! And then I desisted. Did not milkmaids with cowpox help rid the world of its greatest scourge, smallpox? Were not villagers who used foxglove, Rauwolfia serpentina, and moulds ridiculed by "science" till digitalis, serpina, and penicillin were discovered? The motto of my Alma Mater, the G.S. Medical College, Mumbai, is "you are here not to worship what is taught but to question it". As Hunter wrote to Jenner "why think-try the experiment"! The Guest Editor Dr. R.D. Prabhu has written in his Editorial many others could have contributed to this issue. It is our hope that this issue will stimulate other rural surgeons to send their contributions to the I.J.S.

This issue may be misconstrued as tacit approval of this "surgery of necessity". That would not be true-this issue is an acknowledgement of harsh if unpalatable reality, a tribute to those nameless, selfless surgeons who devote their life and science to those of their countrymen who have no other succour. Above all, it is an expression of hope and faith that those of us who have the capacity to follow the guidelines will learn to share their resources, inculcate a sense of fellow feeling and oneness with their rural colleagues, so that we can not only hope but actively strive for the time when all Indian surgery will follow the guidelines.

REFERENCES

1. Udwadia TE. The ball is in your court. Indian J Surg 2001; 63: 17-18.
2. Deshpande SV. Abdominal wall lift technique. In: Udwadia TE, editor. Laparoscopic surgery in developing countries. 1st ed. New Delhi: Jaypee Medical Publishers: 1997. p 326-328.
3. Nande AG. A technique of abdominal wall lift. In: Udwadia TE, editor. Laparoscopic surgery in developing countries. 1st ed. New Delhi: Jaypee Medical Publishers: 1997. p 329-331.

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