|Year : 2015 | Volume
| Issue : 1 | Page : 2-7
The past, the present, and the future of pediatric surgery in India
President, Indian Association of Pediatric Surgeons, Consultant, Hinduja Hospital, Mumbai, India
|Date of Web Publication||27-Nov-2014|
President, Indian Association of Pediatric Surgeons, Consultant, Hinduja Hospital, Mumbai
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shah R. The past, the present, and the future of pediatric surgery in India
. J Indian Assoc Pediatr Surg 2015;20:2-7
Good evening friends,
Dr. Minu Bajpai President Elect, Dr. S. Ramesh Honorary Secretary, my good friend Dr. Ramkumar Raghupathy Organizing Chairman, Dr. V. Kumaran Organizing Secretary, Dr. V. Ravikumar Organizing patron, my colleagues, and their family members, if I have to address all of you in few words then it would be "MY PEDIATRIC SURGEON FAMILY."
It is indeed a proud privilege for me to stand before you today and address this august gathering of pediatric surgeons of India, and I am humbled by this honor. Before I begin my talk, I must congratulate Dr. Ramkumar, Dr. Kumaran, and entire organizing team for successfully organizing Indian Association of Pediatric Surgeons Conference (IAPSCON) 2014. Friends, I congratulate the entire Executive Council of Indian Association of Pediatric Surgeons (IAPS), especially Dr. S. Ramesh, who along with Dr. Robert Antony has sorted out some of the crippling problems of the IAPS.
It is important to know the past as it is the foundation of today and it will guide us to understand the future course of likely events. In addition, if our juniors know about the future, they can plan their career, which will help them to be successful and this in turn will help in the growth of IAPS.
I have been personally associated with pediatric surgery and IAPS since 1989 and I have seen its progress over past 25 years. About the past of pediatric surgery and IAPS, I have read from the books and learnt from my seniors.
History of pediatric surgery can be divided broadly in three phases. The first phase, which is prior to 1960; second phase, from 1960 to 1990; and third phase after 1990. These phases overlap with each other but each still has a distinct and different flavor of growth and its own momentum.
Even at the time of Sushruta, children were operated upon, but general surgeons who also performed surgery in adults undertook these procedures. The interest in the field of pediatric surgery remained limited - the main reason for this was the high mortality. The major breakthrough happened in 1941 when Dr. Cameron Haight from Michigan reported the first survival of esophageal atresia in a 12-day-old baby using a primary single-stage left-sided extrapleural approach. It galvanized the general surgeons and propelled them to learn more about pediatric surgery and some decided to devote their careers to this developing field.
In India, Dr. U. C. Chakravorty in Kolkata, Prof. Raman Nayar in Trivandrum, Dr. Subhash Dalal, Dr. V. C. Talwalkar and Dr. R. K. Gandhi in Mumbai, Dr. I. C. Pathak in Chandigarh, Col R. D. Ayyar in New Delhi, Dr. M. S. Ramkrishanan in Chennai, Dr. T. Dorairajan in Madurai, Dr. Dr. Anjanyela at Hyderabad, Dr. Purushottam Upadhyaya in New Delhi, Dr. Taliat and Dr. K. K. Verma at Calicut, Dr. Meerabai at Hyderabad, Dr. Singhal at Banaras, Dr. K. C. Sogani at Jaipur, etc. were among the first few general surgeons who restricted their career to pediatric surgery. Friends, all the progress in Indian pediatric surgery has been made possible because successive generations of pediatric surgeons have stood on the shoulders of these giants.
It has been said that all truth passes through three stages: first it is ridiculed, then it is violently opposed, and then it is accepted as self-evident. Thus, it was perhaps not surprising that the general surgical colleagues of these pioneers ridiculed them. Though their passion to take care of children with surgical diseases continued and they sowed the seed for the field of pediatric surgery in India and created a strong foundation on which the speciality stands tall today.
Any deviation from the routine practice is met with resistance as quoted by Mahatma Gandhi. He said, "First they ignore you, then they ridicule you, then they fight you and then you win." This fits well with pediatric surgery and even with some of the other sub-specialities. The human mind accepts change relatively slowly and those who can adopt it rapidly and become a part of this change create history.
In the 1950s and 1960s, there were no teaching programs in India to obtain training in pediatric surgery. These enthusiastic surgeons had to go abroad to learn pediatric surgery; approximately 39 general surgeons went abroad and returned to India during this period. They brought the advance knowledge to take care of children suffering from surgical diseases. They settled down across the lengths and breadths of the country. Initially they worked in general surgical departments but slowly, steadily but surely and battling all odds ploughed their way to create separate departments of pediatric surgery.
In 1960s, there was an enormous challenge to operate upon children. To administer intravenous fluid a venous cut down was mandatory for insertion of a plastic cannula. It was difficult to get the right sizes of endotracheal tubes to anesthetize the child. It was even more challenging to find anesthetists who were confident and knowledgeable about pediatric anesthesia. The routine surgeries consisted of repair of hernia, orchiopexy, colostomy, etc. However, with the meagre resources as existed then, it was a challenge to perform complex operation upon children. The science progressed rapidly and the physicians learnt soon that children are anything but small adults. They learnt the need for correct fluid and electrolyte replacement and appropriate doses of drugs used in children. This understanding of physiology coupled with availability of antibiotics and better suture materials etc. improved the results of surgery. In late 1960s, the success rate of complex surgery carried out in newborns was a dismal 20-30%. Today, this has improved to more than 90 % in most of the standard operations.
Initially, these pediatric surgeons worked in the general surgery or pediatric wards taking care of children needing surgery. Soon their work was recognized and results of surgery on children started improving. This resulted in tremendous increase in the workload and there was need for more pediatric surgical beds and more hands. The first need was taken care by establishment of departments of pediatric surgery in many hospitals with adequate number of beds. The second challenge was to have enough hands to take care of the increasing workload. The only way out was to start teaching courses in the pediatric surgery department. The first M. Ch course was started in 1966 in Chennai under Dr. M. S. Ramkrishnan and Dr. T. K. Subramanian was the first to secure M. Ch (Pediatric Surgery) under him. By 1972, there were seven teaching departments, which had increased to 14 by 1987 and at present we have almost 50 teaching departments across India. By 1987, India had trained 270 pediatric surgeons and at present the number has increased to more than 1,300.
These indigenously trained pediatric surgeons either joined the existing teaching departments or started pediatric surgery department in other hospitals. As the science was progressing and many specialities had started organ-wise training. Taking the clue from this changes, some department decided to divide the work with the focus on organ or system. In India, 40-50% of surgical work of a pediatric surgeon is related to pediatric urology. Dr. Keshavan in Chennai and Dr. T. P. Joseph in Calicut were among the first few who concentrated on pediatric urology. In 1990s, Dr. Bajpai and Dr. Sujit Chowdhary in New Delhi, Dr. Sripathy and Dr. Ramesh Babu in Chennai focused to pediatric urology. At present, there are few more junior pediatric surgeons have focused their practice to pediatric urology. There is enormous scope for those young surgeons who obtain further training in the field of pediatric urology and restrict themselves to it when they start independent practice.
Dr. Sripathy and Dr. Namasivayam at Chennai have started a one-year fellowship in pediatric urology. There are three more fellowship courses in pediatric urology under trained urologists at NU Trust (Bangalore), Karnatak Lingayat Education Society (KLES; Belgaum), and Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGI; Lucknow). There is a need for many such courses and other teaching departments have to take the lead to start courses on similar lines.
In early 1990s, laparoscopic surgery was becoming popular among the general surgeons. However, till late 1990s, there was not much laparoscopic work carried out in children. Dr. Vinod Kapur from B. J. Wadia Children's Hospital, Mumbai was one of the first one to perform laparoscopy in children in 1980s. The actual laparoscopic pediatric surgical work in India began in late 1990s. I was one of the first pediatric surgeons fortunate enough to obtain training in the field of minimally invasive pediatric surgery when I worked for 3 years (1995-98) with Dr. Thom Lobe at University of Tennessee, Memphis, USA and returned to Mumbai, India in 1998. The other surgeons to start performing laparoscopic surgery in children were Dr. Selvarajan in Coimbatore, Dr. Srimurthy and Dr. S. Ramesh in Bangalore, and Dr. T. Dorairajan in Chennai.
At that time, the laparoscopic pediatric surgery was being performed with single chip cameras, halogen light sources, television sets, and generally with very limited resources. It was a time when most of the hospitals in India did not have and did not care to purchase laparoscopic equipment. The enthusiastic laparoscopic pediatric surgeons had no choice but to buy their own equipment, carry the entire set from place to place, and perform this form of surgery. The criteria for choosing one's car was whether it had a large enough dickey to hold the six to seven bags housing video camera, insufflator, light source, light cable, CO2 cylinders, TV set, video recorder, hand instruments, etc.
Dr. Sandesh Parelkar invited and assisted me to perform the first laparoscopic pull through for Hirschsprung's disease in India on December 22, 1998 at B. Y. L. Nair hospital. During the surgery, CO2 gas ran out and the rest of surgery was completed with air insufflation using hand pump used for sigmoidoscopy. This created a landmark event in the history of laparoscopic pediatric surgery in India. Many pediatric surgeons realized its potential and showed interest in learning and offering this modality of surgery to their patients.
In late 1990s and upto certain extent even today there are very few centers teaching the art of laparoscopic pediatric surgery during the postgraduate training. In addition, the laparoscopic pediatric surgery falls in advance category and it is difficult to master. To impart the knowledge of laparoscopy in pediatric surgery, many live operative workshops were organized 1998 onwards. Dr. T. Dorairajan (Chennai), Dr. Ravikumar (Coimbatore), Dr. C. Gopalan (Banaras), Dr. Anirudh Shah (Ahmedabad), Dr. Sanjay Oak and I (Mumbai), Dr. Srimurthy and Dr. S. Ramesh (Bangalore) organized laparoscopic pediatric surgery workshops.
It is difficult to learn the art of laparoscopy by attending the workshops and there was need of hands on training courses, which were organized by Dr. Selvarajan at Coimbatore, Dr. Srimurthy and Dr. S. Ramesh at Bangalore, and by our team in Mumbai. In Mumbai, laparoscopic pediatric surgery hands on training courses were started in Ethicon Institute of Surgical Training in 2001 and since last year these courses are being carried out at Center of Excellence for Minimal Access Surgical Training (CEMAST).
Dr. Sandesh Parelkar in King Edward Memorial (KEM) hospital, Mumbai and Dr. S. Ramesh in Indira Gandhi Institute of Child Health, Bangalore has started 1-year certificate course in Laparoscopic Pediatric Surgery. I sincerely hope that few more courses for training in Laparoscopic Pediatric Surgery are started in near future.
Among the pediatric surgeons, Dr. Ashley D'Cruz and Dr. Sanjay Rao can be credited with starting liver transplant at Narayana Hrudayalaya. The first liver transplant was performed in 2005 and they have completed more than 55 liver transplantation. The youngest being 7 months old and weighing 3 kg. More pediatric surgery department needs to focus on transplant surgery as it is the need of the hour and if pediatric surgeons do not get into this field then it will be taken over by other specialists.
The expected natural growth has to be the organ based specialization and pediatric surgery departments will have to offer focused training in pediatric thoracic surgery, pediatric hepatobiliary surgery, pediatric neurosurgery, pediatric oncosurgery, etc. Minimally invasive surgery will be part of the organ-based sub-speciality. The minimally invasive surgery will be part of training of all these specialities and it is unlikely to exist as separate speciality for very long.
In the pediatric surgery departments, the consultants will have to choose subspecialty and gain adequate expertise. Once adequate expertise is achieved, then they will have to offer training to postgraduates in the subspecialty.
| ChIldren's Hospital|| |
The B. J. Hospital for children started in 1927 was the first children's hospital in India and it is the part of Sir J J Group of Hospitals and Grant Medical College. The pediatric surgery department was added in 1967. After that some other children's hospitals have been started, but even today their number across the country is very small. Requirements of a sick child are completely different from those of an adult and they don't get the necessary attention in multispeciality hospitals. As a pediatric surgeon, it is always better to work in children's hospital and my plea to all the younger surgeons is that if you get such an opportunity then grab it with both hands. Future of pediatric surgery lies in children's hospitals and pediatric surgeons should join hands with pediatricians and gynecologists to start mother and child hospitals. We hope that in the next decade many more children's hospital will come up in India.
| Indian association of pediatric surgeons|| |
The group of pediatric surgeons requested office bearer of Association of Surgeons of India to start a section devoted to pediatric surgery in the Silver Jubilee Conference of Association of Surgeons of India in 1964 held at Mumbai. At that time, the ASI President Dr. R. N. Cooper and Secretary Dr. A. Venugopal agreed to put the proposal in its general body meeting. And fortunately, after a lengthy debate, the proposal was approved. Dr. Arthur de Sa was the first president and Dr. R. K. Gandhi was first Secretary cum Treasurer. The section made rapid progress by learning, inspiring and competing with each other in creating history, which turned out to be good for the growth of pediatric surgery in India. It is always good to have healthy competition for growth of an individual as well as of any society. In 1979, the IAPS was converted as full-fledged separate speciality. The first constitution of IAPS was adopted in 1967 and the present constitution was adopted in 2008.
The IAPS continued to have their annual conference along with the annual conference of ASI. In addition to these, a mid-term conference of pediatric surgeons was started from 1967, which was held every second year and since 1984 it is held every year. Due to the popularity of mid-term conferences, in 1990 it was decided to change the terminology to annual conference and only sectional meetings were continued along with the annual conferences of Association of Surgeons of India.
In the laparoscopic workshop organized at B. Y. L. Nair Hospital, Mumbai in 2004, it was decided to launch an organization of pediatric surgeons interested in the field of endoscopic pediatric surgery. The formal "Pediatric Endoscopic Surgeons- India" (PESI) was launched in the meeting at Coimbatore in 2005 and later on the section was converted officially as the section of IAPS (2007). PESI-IAPS is one of the most active sections and has its annual conference with workshop since the last 10 years.
Subsequently "Pediatric Urology Section of IAPS" and "Research Section of IAPS" were started and they are active since last five years and have their annual conference with workshop. These subsections have been very popular among the pediatric surgeons and their annual conference and workshops are well-attended. It has given a platform to showcase the talent among the pediatric surgeons of India. It has given opportunity to pediatric surgeons to learn from each others. There were few other sections started but are inactive and need to be handed over to enthusiastic, popular, and dynamic leaders in the respective fields.
West Bengal Chapter is the oldest state chapter in India. More than 9 state chapters' are active at present. The annual conferences of state chapters are lively and it gives an opportunity to have excellent discussion, fellowship among the pediatric surgeons and thus creating bonding among them.
So far, IAPS has focused to pediatric surgeons and in recently there is a move to have trust with focus to children suffering from pediatric surgical conditions. General Body Meeting held on August 01, 2014 has approved to form such a trust and final blue print is under preparation. The suggested name of the trust is "CHILD HEALTH INITIATIVE BY PEDIATRIC SURGEONS" (CHIPS). If GBM approves then we can make it as the "Golden Jubilee Project of IAPS".
| Training in pediatric surgery|| |
In the last 50 years, there has been a steady growth in the number of pediatric surgery teaching departments. The goal of teaching departments should be to ensure that when the postgraduates complete their training and start independent practice, they are competent to compete with their senior colleagues. Some of the departments are imparting excellent teaching to the postgraduates and they are always in demand. The departments, where the seats are not filled up needs to introspect and to take corrective steps in their teaching program so that postgraduates are more inclined to joins these courses. Following quote explains what is expected from the postgraduate teachers; "True teachers are those who use themselves as bridges over which they invite their students to cross; then, having facilitated their crossing, joyfully collapse, encouraging them to create their own bridge." - Nikos Kazantzakis.
Post graduate CME
It is intensive coaching of postgraduates for 3-4 days to prepare them for the examination and they are very popular among the postgraduates. Dr. Pradnya Bendre and Dr. Tejasvini Kamat started it in Wadia Children's hospital in 2003 and subsequently even Maulana Azad Medical College New Delhi started similar activity.
| Journal of iaps|| |
Journal of Indian Association of Pediatric Surgeons (JIAPS) is the official organ of Indian Association of Pediatric Surgeons has completed 19 years. The journal publishes review articles, original articles, case reports, technical innovations, research papers and letter to the editors. Journal is published quarterly and articles can be submitted online at https://www.journalonweb.com/jiaps. JIAPS is an open access journal. Dr. Subir Chatterjee, pioneer pediatric surgeon took lead to start the "Journal of Indian Association of Paediatric Surgeon". He served as an Editor for 10 years, and was followed by Dr. D. K. Gupta, Dr. K. L. N. Rao and at present Dr. Biswanath Mukhopadhyay is the Chief Editor of JIAPS. There has been a steady improvement in the quality and consistency with resultant indexing with the various authorities. The editorial board has been expanded with many international reviewers and it is a matter of great pride that today the journal receives articles from across the world. The impact factor is improving steadily. The readership of JIAPS is not limited to the India and it has become in a true sense an International Journal.
We expect that with improvement in the impact factor there will be an increase in the subscription of the journal and increase in the number of advertisements and the journal will become self-sufficient and may even become profitable. Many of our members have expressed that they would prefer to receive only an electronic copy, which will further reduce the cost of printing and mailing the journal. Let us thrive to make it one of the leading journals of the world. IAPS is proud of JIAPS.
| Iaps yahoo groups|| |
Dr. V. Ravikumar visionary pediatric surgeon from Coimbatore is instrumental in starting IAPS YAHOO GROUP in 2003. In the initial period, I helped him as the moderator of the group. In 2006, the administration of the group was handed over to IAPS officials. This group has done wonders with a lot of interaction taking place among its members. As of September 2014, the IAPS YAHOO Group has 720 members and 14,600 messages have been uploaded. This group is very popular among the pediatric surgeon and has been an excellent mode of interaction as well as continuing medical education.
| Iaps website|| |
Dr. V. Ravikumar launched IAPS website www.iapsonline.org in 2005 and later on it was handed over to IAPS officials. The website has all-important information pertaining to IAPS. Dr. Sanjay Rao is the webmaster at present and he has been doing excellent work. His pediatric quiz was very popular. I am sure the best of website is yet to come, with addition of many important talks and video's, etc.
| The future ahead|| |
0Popularity of pediatric surgery
It is a well-known fact that by saving life of one child, we are adding at least 50 to 70 years of life. The smile on the face of these children is the biggest gift to the pediatric surgeon. Over the last decade the remuneration of pediatric surgeons has improved significantly due to the increase in the number of children who are covered with insurance. In addition, some of the insurance companies have started covering even internal congenital anomalies, which will further boost remuneration. Even many pediatric surgical conditions are covered by government's health for all schemes. These changes will increase the remuneration to pediatric surgeon and pediatric surgeons will be able to offer quality care to these patients. We need to educate prospective parents to have health insurance during pregnancy to cover the treatment of the child with congenital anomaly and that of mother's illness arising out of pregnancy. Dr. Sanjay Kulshrestha has filed PIL for inclusion of congenital anomalies by insurance companies and IAPS admire him for his efforts and hope that his efforts will end with positive result and will help thousands of children suffering from congenital anomalies.
The future of pediatric surgery in private practice is in group practice. We need to adopt the system from the west and like-minded pediatric surgeons will have to join hands and form teams. Additional advantage of group practice and operating as a team is that it decreases the stress, improves the quality of care and results of surgery.
Expectation from pediatric surgeons
The expectation from pediatric surgeons in metro cities and smaller towns are different. In a smaller city or and town, their number is low and they are expected to take care of all pediatric surgical conditions. In metro cities there are many pediatric surgeons and it is important for them to focus and develop their own niche area.
Change in the pediatric surgical diseases
Some of the common pediatric surgical conditions of the 1960s-1970s have been almost eradicated, e. g. roundworm obstruction, small bowel stricture due to tuberculosis. There is an increase in the life style related conditions like, appendicitis and morbid obesity. With advent of routine antenatal ultrasound examination, many congenital abnormalities are being detected and pregnancies are terminated. Pediatric surgeons will have to take initiative in starting fetal clinic and be the part of decision-making process for the well being of fetus.
| Meticulous data keeping|| |
In the last 50 years, pediatric surgeons have done a lot and a lot more than what needs to be done. We have enormous resources as far as the clinical material is concerned, which is decreasing in many other countries. The first and foremost importance for us is data keeping, analyzing it, correcting the shortcomings (if there are any), and publishing. This is the only way pediatric surgeons from India can lead the world.
Registry of pediatric surgical conditions
At national level, we have to insist on a registry of various surgical conditions in children with birth defects, solid organ tumors, etc.
Reach out to rural area
Many pediatric surgeons are reluctant to set up practice in district cities or larger towns and hence more than 50% of districts of India don't have pediatric surgical facility. It is our duty to reach out to these districts and make this facility available by either doing camps, liasoning with the district hospitals by negotiating with government, or educating general surgeons to right way of performing basic surgeries and taking care of emergencies in pediatric surgical conditions. Dr. Ravindra Vora has been in negotiation with government of Maharashtra to implement the pilot project, wherein pediatric surgeons visit government hospitals in districts where pediatric surgical facilities are not available. We hope that this project sees light of the day and pediatric surgical facilities are available at all India level.
| Innovation and research|| |
The results of biliary atresia, severe varieties of posterior urethral valve are very poor. The detailed research is needed in these and many other conditions to understand the etiology and to prevent these conditions. Pediatric surgeons need to get into research projects to help the children's of world.
Our colleagues have been engaged in creating innovative ideas, e. g., Raina's romodrain, Irani's Clamp for Duhamel's pull through, Mohan Abraham's Valvotome, etc. We need to come out with the ideas and Indian Institute of Technology, Powai with grant from government is establishing special department for liasoning between doctors and engineers. The entire infrastructure will be provided free of cost to develop the idea. At personal note, I have been engaged in developing laparoscopic devices and will be able to guide you in this process of "Convincing an Idea to taking it development to commercial production".
| Qualities of a pediatric surgeon|| |
The Pediatric Surgeon possesses the following qualities: They are enthusiastic, sincere, hard working, caring, passionate, loving person, who cares for their patients' more than personal luxury. He believes in "Start where you are, Use what you have and Do what you can" and hence pediatric surgeons do a lot of innovations across the world. Lucky people get opportunities, Brave people create opportunities, but real winners are those who convert their problems in opportunities. Pediatric surgeons are real winners as they are born to create opportunities from problems. Long live IAPS.
Thank you very much for a patient listening.