Surgery

It's been a while since my last post.  My apologies. I've been rotating through neurosurgery, cardiac surgery, and ICU and staying later to maximize exposure to each one. I've also been trying to maximize tourism in Kathmandu :)

This post is primarily on the surgeries here (Operating Theatres or OTs as they are called here). I've split it by specialty because each was very different experience.

GI
The GI surgery team is made up of a Professor, Jr. Attending, 1x MCh (PGY4-6 Canada), 2x 3rd year MS (PGY3), and 1x 1st year MS (PGY1). Rounds with the team usually consisted of all the above, but sometimes the Professor or Jr. attending would not be present. English was only used by the Professor and the Junior attending, the residents were not comfortable enough in English and defaulted to Nepali during rounds.

Elective surgeries are typically done with the Jr. Attending or MCh as the principal surgeon, with the MS3s assisting. I never saw the MS1 scrub.

Emergency surgeries for GI are entirely different: the MS3 is the senior surgeon and the senior resident is called in only exceptional cases. Furthermore  common presentations such as appendectomies will be left to the MS2. This graded responsibility matches a Canadian surgical training. What astounds me is that unlike in Canada, the residents operate completely unsupervised - the Jr. attending will be home, and the MCh (senior resident) will only come for the very challenging cases. While I didn't stay to observe GI emergency surgeries, quality of the incisions (not midline etc.) makes me think that overall quality of care is sacrificed by using this system.

With respect to the surgeries themselves, surgeries are far more often done with an open approach. This reflect a combination of limited expertise for minimally invasive techniques as well as later presentation of cases such as cancers. Access to interventional radiology is also limited, necessitating more surgical approaches.

Open surgeries are generally similar to Canada with the same equipment. Drapes, gowns, and wraps for sterile equipment are all reusable. Curiously the OR lights use one large overhead fixture that is adjusted by unsterile assistants. Sponges are rinsed many times over and reused during the procedure.

Cases I saw included open splenectomy with splenic vein hepatic shunt, laparoscopic cholecystectomy, and elective appendectomy. Hernia repairs are actually done done under local anaesthesia in the minor OT, the same area that sebaceous cysts, lipomas, etc are done.

Equipment storage

Scrub sinks - the water is specially filtered

Equipment setup. The bowl with red is the basin for rinsing and reusing the sponges.

Empty OT. Giant light is visible in upper left.

Anaesthesia equipment

Sterile prep area. Individual  instruments that become required would be carried with a half sterile grasper.

 Formaldehyde. Doctors add it to pathology specimens before handing to patients' family for delivery to pathology.

Minor OT for hernia repairs under local anaesthesia.

Neuro Surgery
I spent 2.5 days with neurosurgery at the suggestion of Dr. Subhash Acharya, my contact here. I'm glad I did! The neurosurgeons are excellent teachers and their English is much better. I participated in 2 clinics plus a day of surgery. The clinics were much like te GI clinic (see other post), and was a great environment for practising neuro exams. There was one lady who presented with Pott's disease (TB of the spine) after 7months of being unable to walk. She had impressive upper motor neuron lesions!

Neurosurgery OTs were much as with the GI ones for equipment. Significant limitations were using a scalpel blade to shave the head (only tool available), using manual drill and saw to open the skull (they have a power saw but it's broken), and closing with sutures instead of plates (unable to access a plate distributor in Nepal). I can't really comment much more on the surgery itself because I haven't seen neurosurgery in Canada.

Neurosurgery was much more organized for emergency and the MCh (PGY4-6) was the principal surgeon.

Neurosurgery OT. Note the windows up high making it truly a theatre.

Hand saws

Saline warmer. In GI hot sterile saline would be poured from kettles into the field. In Canada the bottles are stored in a warm environment and so come hot.

Cardio, Thoracic, and Vascular
Cardiac, thoracic, and vascular surgery all takes place in a different building, the Monmahon Centre for Cardiothoracic Surgery and Transplantation. Apparently it is a separate hospital with different management from the TUTH but is still affiliated with Tribhuvan University. The building is newer than TUTH and feels much more organized.

OTs rooms in Monmahon are new (last. 10 years) and cardiac cases were almost identical experiences to home including disposable drapes. Largest equipment change was creating disposable pieces such as aortic and venous cannulas are sterilized and reused. Apparently the head and founder of CTVS completed fellowship at Sick Kids and Boston Children's so that would explain many of the similarities.

By far the largest different were the cases: mitral valve replacements were common, as were congenital repairs, including ASDs or Tetralogy of Fallots presenting at 20+years of age. Rheumatic fever is very common and I saw at least three cases of mitral stenosis on my clinic day.

With respect to responsibility, the professor was present for all the cardiac cases, but would only scrub in for theoat complex procedures (e.g. Tetralogy of Fallot, triscuspid repair). The junior faculty and senior staff did most of each case. There would also be 2-3 rooms going at one time, allowing up to 5 cases per day to be done (as supposed to a max of 2 at home). The senior resident (~PGY5) would operate autonomously with the junior resident (~PGY4) on common cases such as ASD closure and mitral valve replacement. In Canada mitral valve pathology is rare (thanks to antibiotics and low rheumatic fever incidence), and it wouldn't be until the final year of residency (PGY6) that a resident would attempt this under staff guidance.

Cardiac OT room. The bypass pump (heart lung machine) is under the red drape.

CVICU. The beds "look" empty but each actually has an infant on it. Monmahon does paediatric surgeries but does not have cribs.

I also did spend a day with thoracic and vascular. Vascular was a day of AV fistulas for dialysis and was much as in Canada. Thoracics seemed similar but having not done Canadian thoracics it's hard to say. There was one interesting case of a foreign body swallowed by a 1 month old. I'm not sure how and there is no child protection services here for further investigation. It was treated with scope to pick into the stomach and then surgery to remove from the stomach.