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EDITORIAL
Year : 2016  |  Volume : 2  |  Issue : 3  |  Page : 113-115

The history of minimal access surgery in MAMC - Lessons to learn


Director Professor, Department of Surgery, Maulana Azad Medical College (University of Delhi) and Associated Lok Nayak Hospital, New Delhi - 110 002, India

Date of Web Publication7-Oct-2016

Correspondence Address:
Pawanindra Lal
Director Professor, Department of Surgery, Maulana Azad Medical College (University of Delhi) and Associated Lok Nayak Hospital, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-7438.191661

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How to cite this article:
Lal P. The history of minimal access surgery in MAMC - Lessons to learn. MAMC J Med Sci 2016;2:113-5

How to cite this URL:
Lal P. The history of minimal access surgery in MAMC - Lessons to learn. MAMC J Med Sci [serial online] 2016 [cited 2019 Nov 14];2:113-5. Available from: http://www.mamcjms.in/text.asp?2016/2/3/113/191661

Institutions and departments are known and made by individuals and not by buildings and equipment! MAMC had the privilege of having the best of the pioneer surgeons as its founders in the Department of Surgery. The great ideologies and legacy set in by the founder head of the department, Dr. Ramesh Nigam were carried forward by many other over the years.

More often than not, when you embark upon a new journey, you have no idea as to where would one reach and what would that path be like! More so, if that path is unknown and hitherto untraveled. One such journey was that of starting laparoscopic cholecystectomy in the year 1994 at MAMC by Prof. V J Anand, 7 years after first such successful procedure was performed in the world. This happened on a borrowed laparoscopic set as MAMC and Lok Nayak Jai Prakash Narayan (LNJPN as it was renamed from Irwin during the 1980s) hospital did not have it. This paved the way for the procurement of the hospital's own set, and the gall bladder surgery was soon being performed in this new way by few trained surgeons in the hospital. Learning curve for this procedure was steep for all, as none had any prior training and most were self-trained in learning hand-eye coordination between the screen in the front and the patient being operated through tiny holes admitting instruments. As this procedure became more popular with an increasing demand, more laparoscopic sets were procured under the dynamism of Prof. V K Ramteke, the then Head of the Department of Surgery who headed the department for the longest period from 1994 to 2005 and again from 2010 to 2012. The difference between the ordinary and the leader is a "visionary." Prof. Ramteke exhibited this quality in more ways than one in advancing the department in this niche area, by ensuring the best of the equipment and its supplies for the benefit of the needy, and making it readily available for use by its faculty and residents.

It was in 1999 when I (Pawanindra Lal [PL]) joined this prestigious department as a young Assistant Professor after having been initiated in laparoscopic surgery at Government Medical College, Chandigarh, as Senior Lecturer in Surgery, and after having received training from Sir Alfred Cuschieri, the doyen of minimal access surgery (MAS) from the United Kingdom. I joined the unit of the head of the department and soon found myself working alongside Prof. Jagdish Chander (JC), who was till then doing a lot of major cancer and reconstructive surgeries. Soon, JC was also keenly attracted toward MAS. Together we started performing many new procedures in MAS. While JC pioneered retroperitoneal surgery and common bile duct exploration, PL led the way in inguinal hernia repair, gastroesophageal reflux disease, and bariatric surgery.[1] Two is better than one and two masters together in a team make it 11! That is what our unit was. JC pioneered and innovated techniques in every MAS procedure and continued to challenge and inspire PL to keep up the spirit of innovation and learning.

It was in 2008, after my return from the UK from the commonwealth scholarship on hands-on training in laparoscopic colorectal surgery that we together (JC and PL) conceptualized postdoctoral training in MAS to senior resident level trainees who had a postgraduate MS/DNB qualification. There was till then no structured training in MAS in any government department in the country. After much persuasion, Dr. Ramteke, the then head of the department of surgery was convinced to create a dedicated unit of MAS which happened in February 2010. Prof. Amit Bannerjee, the then medical superintendent (Med S) accorded approval for the same in consultation with Prof. Arun K Agarwal, Dean of MAMC, and the metabolic and bariatric clinic was started in April of the same year. The application for the fellowship program in MAS under the National Board of Examinations (NBE) was made through the Med S.

I represented the MAS unit in the office of the NBE. The board constituted by some very senior doctors of the country, posed some really uncomfortable and tricky questions about the relationship between the department, hospital administration and government officials and if these cosy and amicable relations could change with time. These concerns were addressed to their satisfaction. The fellowship programme was given a "go-ahead" by the panel subject to the fulfilment of the requirements of the physical inspection of facility and documentation in the hospital. It was realized much later that cooperation amongst all the stake holders in any project or a new venture, is crucial to its continuation and successful running!

Inspection of the division (units of Prof. V K Ramteke where JC was working and Prof. N S Hadke where PL was working) took place and our number of cases in MAS in 1 year were more than modest to get us approval for two candidates per year. JC was designated Chairman and PL as Co-chairman of the MAS division (internal arrangement for the unit to work smoothly). After JC taking voluntary retirement in 2014, the MAS training was restricted to one unit of PL along with Dr. Anubhav Vindal as the junior faculty, the only two faculty recognized as senior and junior consultants for this sub-speciality training. With increasing workload, it was planned to convert this fellowship programme into an MCh training in MAS under the University of Delhi with a separate department.

The department has been lucky to get the top rankers of the entrance examination to join the department every year from 2011 onwards, in keeping with the reputation of the institution in the country towards range of MAS work and scope of hands-on training. The salaries for the first batch of fellows got delayed due to administrative procedures and with everyones support and cooperation, this issue was finally sorted out. Fellows in a post doctoral course work in government institutions as senior residents and get the salary equivalent to them. The government of Delhi thus created four new posts of fellows in MAS with independent salary, separate from the senior residents of the surgery department. For those who wish to start new programmes, it is important to ensure that posts are separate and not dependent on the general surgery pool. We ensured this from the very beginning to keep it independent and free of controversies. Everyone involved was extremely supportive and cooperative for the success of the programme in its initial years. It is important for people to realize that salaries and workload for the candidates need to be calculated for the maximum number of candidates at any given time. So for 2 candidates, one needs to assure a salary for 4 candidates over 2 years of their course and adequate hands on workload. It is a pleasure to note that all the fellows who have passed out from this department till date are successfully employed in the government or the private sector and doing great service to the nation in delivering quality MAS.

Controversies do not augur well for the health of departments and institutions.[2] It is important for visionaries and leaders to not only identify the strengths but more importantly to work on the deficiencies. All the advanced procedures pertaining to upper and lower gastrointestinal system, hepato-biliary system, genito-urinary system and hernia repairs are carried out in the unit in high numbers to ensure quality training. The department of MAS ensured that all the trainees get adequate balance of basic and advanced laparoscopic surgeries to assist and do independently or supervised. Publications and paper presentations were made mandatory requirement for the fellows and they were encouraged to spend a certain number of hours in the skills centre performing suturing skills in the simulation environment. In 2010, the Clinical Skills Centre of MAMC introduced laparoscopic human cadaveric skills workshops for the first time anywhere in any medical college in the country and our fellows gained a lot from this new source of training.

The division of MAS organized three national level academic conferences in the years 2010, 2012, and 2014 (held in February 2015) which were attended by more than 200 delegates and more than 100 faculty members in each conference. Each of these conferences had a 1-day live operative workshop where 12-16 procedures in MAS of the abdomen including gynecology, were telecast to a packed auditorium. The presence of national and international faculty demonstrated the latest procedures to delegates followed by a daylong CME. Hands-on pre-conference workshop was also a popular activity, including laparoscopic cadaveric surgery in 2015.[3] A mention here of the very supportive bureaucracy under the dynamic and energetic leadership of Mr. S C L Das, IAS, needs to be singularly applauded who allowed the pre-announced conference on 7th February 2015 to be held as it was the election day in New Delhi! DVDs were released containing entire presentations along-with live operative workshop with audience and faculty interaction.[4] The division of MAS received academic grants from MAMC and other academic bodies such as UGC, DST, CSIR, and MCI for these events. While the first conference was held under the Directorship of Prof. V K Ramteke, Prof. P N Agarwal continued to support MAS in the subsequent years when he headed the department from 2012 to 2015 overseeing the last two conferences. The progress of MAS has been well documented in scientific research with more than 15 publications in the highest ranking international journals in MAS till date over the past 15 years. These publications have established the division of MAS of MAMC not only in the country but also on the international stage.

One of the hallmark progresses was the setting up of the Metabolic and Bariatric Surgery Clinic in the hospital which has been running on alternate weeks ever since its inception in April 2010.[5] More than 400 patients have been enrolled in this clinic, of whom 100 have successfully undergone a bariatric procedure. This clinic is unique that it encompasses a team of surgeons working up for the patients along with a dedicated dietician and a team of physicians providing endocrinology and medical support. Two teams of anesthetists were largely instrumental in all the cases operated till date in extremely challenging working conditions, who improvised equipment and standardized techniques with the support of several colleagues. Patients experienced personalized care and cherished this experience of being handheld across their journey from pre-operative to their post-operative period and until discharge from the hospital. Without this individualized care, it would have been impossible to see this program through.[6] A true example of a TEAM approach!

Shortsightedness by senior officers can be detrimental to the progress of an institution. Departments, states, and countries have been brought down by negative people at the helm of affairs. Those who had the wisdom and courage to fight this mindset could save their nations. Despite odds, perseverance and diligence have ensured the continuity of MAS care and training. Let it be known to all that setting up anything new is never going to be easy, and the ride after the initial birth pangs could be a roller coaster one! Hold on and keep working with your head down!

Looking back, I see the footprints on the sand and the footprints on the sand, blown away by the winds! The journey thus far has laid the foundation to set up the first department of MAS in the country in a government teaching hospital. It has been full of challenges but at the same time thrilling. It is the thrill to provide our people with the type of advanced care they deserve to reduce their pain, suffering, and loss of working hours away from work. It is the thrill to provide high-quality training with enough hands-on cases to make the trainees confident and as skillful MAS surgeons. And finally, the thrill to see MAMC excel and be noted on the global scene! Looking back, it seems that the pain has really been all worth it every little bit.

 
  References Top

1.
Laparoscopic Sleeve Gastrectomy Produces Significant Excess Weight Loss in Both Morbidly Obese and Super Obese Patients - Initial Experience from a Tertiary Care University Teaching Hospital. Available from: http://www.sages.org/meetings/annual-meeting/abstracts-archive/laparoscopic-sleeve-gastrectomy-produces-significant-excess-weight-loss-in-both-morbidly-obese-and-super-obese-patients-initial-experience-from-a-tertiary-care-university-teaching-hospital/. [Last accessed on 2016 Aug 25].  Back to cited text no. 1
    
2.
Delhi Hospitals Refuse to Perform Surgeries on Overweight Patients - Neetu Chandra Sharma; 08 October, 2015. Available from: http://www.indiatoday.intoday.in/story/hospitals-refuse-to-do-surgeries-on-overweight-patients/1/493247.html. [Last accessed on 2016 Sep 10].  Back to cited text no. 2
    
3.
International Surgeons Meet - MAMC; 11 February, 2015. Available from: http://www.countryandpolitics.in/2015/02/11/international-surgeons-meet-mamc/. [Last accessed on 2016 Sep 10].  Back to cited text no. 3
    
4.
Nadda JP. Need for Innovation in Systems for Effective Healthcare Delivery: 7 th February, 2015. Available from: http://www.pib.nic.in/newsite/PrintRelease.aspx?relid=115244. [Last accessed on 2016 Aug 25].  Back to cited text no. 4
    
5.
First Obesity Clinic in Govt. Hospital Vidya Krishnan, Vidya Krishnan: New Delhi; Monday 22 February, 2010. Available from: http://www.archive.indianexpress.com/news/first-obesity-clinic-in-govt-hospital/582628/. [Last accessed on 2016 Aug 25].  Back to cited text no. 5
    
6.
LNJP Hospital Offers Help to Poor for Metabolic Surgery. New Delhi; 28 July, 2012. Available from: http://www.thehindu.com/todays-paper/tp-national/tp-newdelhi/lnjp-hospital-offers-help-to-poor-for-metabolic-surgery/article3695117.ece. [Last accessed on 2016 Aug 25].  Back to cited text no. 6
    




 

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