Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 1, 2003, pp. 73-76

Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 73-76

Innovation

Innovations in Rural Surgery

K. C. Sharma, Uma Sharma, Navneet Sharma

Sarv Sidhi Nursing Home, I Trikut Marg, Udhampur, Jammu and Kashmir
Address for correspondence: Dr. K. C. Sharma, Sarv Sidhi Nursing Home, I Trikut Marg, Udhampur, Jammu and Kashmir

Paper received: June 2002
Paper accepted: November 2002

Code Number: is03015

INTRODUCTION

Most of us, if asked to name some of the great advances in modern medicine and surgery, may probably list some. Nobel laureates and the discoveries or inventions closely linked with their names, for example, Roentgen with X-Ray, Koch with Tubercle bacilli, Fleming with Penicillin. Enders with Polio virus, Banting with insulin etc. Yet once in a while an event that is not eligible for a Nobel prize has had just as important an impact on medical advance, as one that has won an award. Many highly useful research works have been successfully conducted in small laboratories that did not have research facilities or finances at their disposal. Still their works were no less important than those, which were recognized in the world of science and technology. Many of us get different ideas now and then but very few follow them up seriously. Every idea is worth serious consideration, howsoever small and bizarre it may be. As Huxley puts it "method of scientific investigations is nothing more than the expression of the necessary mode of working of human mind:. "Every man ought to try to do some good bit of original work," said Paget.

Whenever a person faces a problem, if he observes and studies it closely he may be able to innovate his own methods and devices to solve it. If his innovation is good, others will support it and accept it otherwise it will get rejected. Necessity is the mother of invention, it is also the mother of innovation. When there was an urgent necessity of doctors in Bangladesh, the Magsassay award winner Dr. Zafrulla Chaudhari took the bold decision to train paramedics to perform surgical operations.¹ The US thoracic surgeon Dr. Collin Mcord supported this novel action of Dr Chaudhari. When the poorly staffed burns unit of Thane hospital could not cope up with the conventional dressings of the patients, Dr. Antia thought it fit to let patients themselves remove the dressings and wash the wounds with soap and water during a bath and an innovative new method of burns dressing was born. These wounds not only required less nursing care, they also required lesser antibiotics besides being ready for skin grafting much sonner! Maurice King writes in his book Primary Surgery (1991) that procedures like oesophageal surgery cannot be carried out in rural practice; but there are innovative rural surgeons in India like Dr. Sivasubramnian who perform oesophageal surgery under epidural anaesthesia in their rural nursing homes! Dr. G. D. Sharma has introduced a low-cost hook for the dissection of cystic duct in minimal access surgery. The unreasonably high cost of prolene mesh for hernia repair made Dr. Brahma Reddy try ordinary mosquito net (cost 0.50 Paise) for the same purpose and now we know it serves the purpose admirably.

Our surgeons are talented and intelligent the two important requirements for innovation. Encouragement and appreciation by the leaders of the profession and support from their colleagues may bring to the notice of all, many more such innovations in our country. Talents and intelligence are not seen in medical personnel only, they are God given gifts distributed in all classes of people. Anyone can author an innovation. We only need to be generous enough to recognize one when we see it. For example the conventional stretcher is impractical to transport a patient in hilly terrain, where stretcher-bearers have to move in a single file. The community there, have a stretcher on which four persons can carry a patient in a single file (Fig.1). There is one other variety (Fig.2) that can be used with only two bearers. These stretchers are made of locally available material and so are cheap. It is up to us to find such innovations and use them.

Some examples are given below.

NEW SURGICAL TECHNIQUES

1. Pre-pubic vasectomy : ^2,3 (Fig -3) After performing scrotal vasectomies for twelve years and closely observing its complications, particularly in the working class, a new and safer method was developed, the "pre-public vasectomy". Its chief advantages are :

i. The rugosity-free skin in the pubic area clean and heals better than the scrotal skin.
ii. The vas is relatively stable and fixed here, and so easily located and caught.
iii. The pampiniform plexus has fewer veins at this level, so chances of damaging it are small.
iv. Postoperatively there is no dragging sensation.
v. The patient can walk, run and even perform manual work immediately after this procedure.
vi. The process is easy in cold weather where contraction of dartos is inconvenient for scrotal procedure.
vii. The incisions being away from the testis, chances of funiculitis, epididymitis and scrotal oedema are fewer
viii. It is a preferred method in patients with hydrocele, varicocoele or filariasis of scrotum.
ix. It is a better method when spermatic cord is short.
x. The wound does not interfere with normal sexual activity.

2. Skin Episiotomy:⁴ Nature has provided physiologically active and anatomically perfect sphincters at all openings in the body. They work painlessly during all physiological functions. Delivery of a baby is a normal human physiological process. Therefore, the vaginal sphincter should relax and enlarge sufficiently well to allow the passage of a foetus.

Mechanism of a tear : All tears start from the muco-cutaneous junction of the vagina due to the stretching by the presenting part. The tear extends to the vaginal sphincter secondarily since it is adherent to the skin by sub-cutaneous tissue. The principle of skin episiotomy is that if we allow the sphincter muscle to draw away from the skin after incising only the skin and the mucosa, the sphincter muscle will then stretch wide enough for the passage of the baby without tearing itself.

NEWER INSTRUMENTS

1. Sharma's Cystostomy set : Not infrequently one fails to negotiate a urethral catheter in a man with retention of urine. After observing many such failure a safe and simple instrument has been designed (Fig. 4). The canula has a side hole, a side slot and a guard. A cystostomy is performed and a sterile baby feeding tube or even a sterilized drip set tube with multiple holes on its side near the tip is passed through the canula into the bladder. Once the urine starts flowing out, the tube is held in place while removing the canula out. This instrument is cheaper, handy and can be carried like a pen in the pocket. It can also be used to drain the abdomen, chest or any cavity containing fluid.

2. Vein Stripper : Commonly available scooter clutch wire or gear wire is cut to the length of about 4ft. 4 in. A steel head is welded to one of its ends (Fig.5). The wire, duly cleaned and sterilized can be used as a vein stripper for varicose veins of the leg. The advantage is tht such wires are easily available all over the country.

3. Newmon Ventilator : ⁵ Dr. D. M. Ghaisas from Ahmednagar, an anaesthetist, has designed and produced a simple but efficient ventilator (fig.5) that can be operated with electricity, dry cell power or even by hand. Almost all the available ventilators are operated with oxygen. Oxygen is not only costly but also not easy to supply continuously. One patient in a village in Maharashtra is on continuous ventilation with this equipment for over 26 months in spite of intermittent power cuts. This equipment is simple, affordable, reliable, durable and portable as well. Since it does not use oxygen, the operational cost is very little.

NEW CONCEPTS

1. Strangulation of groin hernias: ⁶ (Fig. 6) Whether a groin hernia will strangulate or not is difficult to predict with our present knowledge. However, now a prediction can be made, if one knows whether there is or not a Sharma's ring at the neck of the sac. It is a thickened peritoneal fold in the form of a ring, probably created by the reaction of the body to hold back the contents of the hernia. There may be one to three such rings in one sac. The ring is placed just distal to the internal inguinal ring. Sometimes it takes the form of a diaphragm with a little opening in the centre. It is known that neither the external nor the internal ring is responsible for strangulation. It is the presence of this ring that strangulates the hernia and the other rings play a secondary role.

2. Low Temperature Low Humidity Treatment of Burns : Though nursing a patient with burns at low temperature has proved to have had good results, neither the optimum temperature for the patients' room nor its humidity has been described. We have found that optimum temperature is 20°C and a humidity of 15-20% is ideal. When a patient with burns of not less than 15% body surface, irrespective of age, site, depth is nursed under such conditions, he is very comfortable, does not need ointment and dressings. His recovery is complete with hardly any late complications. (Burns are very common in Kargil, Ladakh areas for many months in a year).

3. New Skin Cleaning Solution, 20% Turmeric in water ⁷: 20% turmeric solution in sterile water can be safely used for skin cleaning before the surgical procedures. A comparative study of soap and water , povidone iodine and turmeric 20% in water was done in collaboration with the department of Micro-biology, Medical College, Jammu and it was found that turmeric 20% in water was as effective as the costly povidone iodine solution. Turmeric is very cheap and easily available and the solution can be prepared easily. The prepared solution has a shelf-life of 30 days. The solution does not stain the sheets.

Some Observations

Easy antenatal sex determination-the rural way.⁸

Five to ten days after a missed period, confirm the pregnancy by available pregnancy test. Sow 8-10 seeds each of barley and wheat in two separate wide-mouth pots filled with clay-free sand. Mark a pot B for barley and another W for wheat. Sprinkle 20% fresh urine of the pregnant women over the sand daily in addition to the water. Keep both pots at 20°-30° C room temperature. It will be noticed that if wheat germinates first it is a female foetus sand if it is barley first, the foetus will be male. The results can be confirmed by ultrasonography in due course (14-16 weeks).

CONCLUSION

Innovations are coming up all over the world in the face of constraints. Since research and innovation are continuing processes, often an inter-disciplinary approach and intrinsic desire are required to solve the problem. Innovations may play an important role in the development of appropriate technologies for our country.

REFERENCES

1. Chaudhari Z. Organisation, supervision and evaluation of primary health workers. Paper presented at IX International conference on health education, Ottawa, 1976.
2. Sharma KC. Prepubic suprascrotal vasectomy. Indian J Med Assoc 1980; 75: 69 -71.
3. Sharma KC. Prepubic suprascrotal vasectomy. Indian J Surg 1984; 46.
4. Sharma KC. Skin episiotomy. Rural Surg 2001; 8.
5. Ghaisas DM. Newman ventilatora-a modification. Paper presented at Annual conference of the Association of Rural Surgeons of India, 2001.
6. Sharma KC. Strangulation of exteral hernia: A new concept. Indian J Surg 1984; 46:11.
7. Sharma KC. Twenty percent turmeric . A new and cheaper skin cleaning solution before surgery. Paper presented at Annual conference of the Association of Rural Surgeons of India.
8. Sharma KC. Antenatal sex determination-the rural way. Rural Surg 2001; 8: 69.

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