Introduction

Traditionally, the field of Public Health has been centred around the prevention of communicable diseases such as human immunodeficiency virus (HIV) and tuberculosis and that of behaviour such as obesity and diabetes mellitus [10]. Despite the excellent progress we have made with regards to the outlook of such diseases up to 32% of the world’s disease burden remains amenable to surgical intervention with 5 billion people still lacking access to safe surgery and anaesthesia [11]. Following the trend of the inverse care law those typically affected are patients are of poorer groups in society often residing in rural districts [2]. Recognising the need for change and coinciding with the shift towards sustainable development goals the Lancet commission has set a target of 80% coverage of safe surgery and anaesthesia access by 2030 [11].

The field of Surgery, described by [5] as the ‘neglected stepchild of global health’ has a pivotal role to play in helping both individuals and society fulfil their potential [5]. In fact, it has been highlighted that loss of individual productivity due to surgical morbidity may reduce gross domestic product growth by 2% [2]. The magnitude of the challenge ahead is well recognised with an estimated 143 million additional surgical procedures required to be performed annually to reach the 80% coverage [11].

A well-constructed cost-effective plan, utilising Jugaad principles [8] is thus required in order to create an environment whereby lesser economically developed countries grow under expert supervision. In order to maximise the chances of success as well as ensuring sustainability the aim must be multi-faceted, addressing not only the surgical intervention itself but also the pre-operative arrangements and post-operative follow.

With an aim of re-establishing both form and function Plastic Surgery has the potential to play a key role in enhancing access to safe and effective surgical care. Amongst the 44 surgical procedures recognised as imperative for a population’s health [2] the field of plastic surgery contributes in the management of trauma, burns and congenital deformities [17, 11] all of which can have physical, emotional, social and psychological sequelae. Building on the principles of successful well-established plastic surgery programs such as ‘Facing the World’ [7] we would like to introduce ‘Give Me 5 Foundation’, a no-profit organisation aiming to improve the surgical management of limb deformities in countries with limited resources. Both the upper and lower limbs play an integral role in our ability to successfully perform our activities of daily living; aiding our ability to work, communicate, mobilize and maintain adequate nutrition. Until now few organizations have focused on both surgical and microsurgical management of patients with limb defects secondary to congenital deformities, trauma and infection and thus we aim to bridge this gap and ensure efficient and effective surgical access to such patients [14].

Our Mission

In this paper we report the successful surgical treatment of a variety of conditions affecting extremities during a humanitarian mission to India organized by the charitable association “Give Me 5” (www.giveme5.foundation), in collaboration with Indian Society of Plastic Surgery. Our aim is to raise the awareness of the presenting pathology, highlight the associated impact on both individual and society as well as offer cost effective surgical solutions. Furthermore, we want to emphasize the importance of establishing effective collaboration between surgical teams, especially plastic, general and orthopaedic surgeons and to cooperate with local government physicians and staff to ensure consistent and sustainable practice.

This is the third international mission performed under the auspices of “Give Me 5 Foundation” a charitable organization set up in 2012 with headquarters in India, Italy and UK. The mission was held in Shri Sainath Hospital, Shirdi, a town situated within the state of Maharashtra, Western India between 19th and 25th March 2018. A holy town famous for its religious leader Sai Baba and production of Sugar Cane it houses a population of nearly 40,000. Strict alcohol and smoking laws within the region have helped to maintain a relatively healthy population however like most states within the country trauma, congenital deformities and filariasis infection with associated lymphoedema cause significant limb morbidity. In addition, due to many women not being able to meet the Dowry requirements, domestic assaults, usually incorporating burns unfortunately remains commonplace. With no formal plastic surgery department within the hospital the majority of the cases are conducted by the general surgery residents.

A worldwide team of plastic surgeons were involved in the mission representing countries of Italy, United Kingdom, Taiwan, Thailand, Singapore and Greece (Figure 1). The team worked in tandem with plastic, orthopaedic and general surgeons from India with an aim to leave a sustainable improvement in the surgical management of plastic surgery pathology. A Public Awareness Campaign was started 6 months in advance, with banners and posters positioned in nearby temples highlighting pictures of extremity deformities and injuries amenable to surgical treatment (Figure 2). A total of 238 patients with pathologies impairing function and cosmesis reported at the outpatients’ clinic before being examined by a local plastic surgeon. The final screening and planning of operations was done on the first day of the mission involving the whole international team and patients found suitable were scheduled for surgery in the coming week. Surgeries commenced at 8:00 am and continued till 20:00 pm for 5 days. Every morning and at the end of all surgeries, 1 surgeon and 1 anaesthetist carried out the round to ensure patients were stable both pre and post-operatively respectively.

Figure 1 

International team arrived in Shirdi welcome by local authorities.

Figure 2 

Public Awareness Campaign using banners and posters highlighting pictures of extremity deformities and injuries amenable to surgical intervention.

Results

Eighty-eight (88) patients were treated over four days with the majority jointly managed by both local and travelling surgeons ensuring education provided throughout to trainees (Table 1). The operative procedures are greater than the number of cases, as more than 1 procedure was sometimes performed during a single case. The majority (55) were male and the avearage age of participants was 24 years (range 5–76 years), highlighting the impact made on the most functional members of society. Of the procedures performed 36% (32) involved release of burn contractures of the neck and extremities. Eleven cases of syndactyly of the hand and foot (5 cases bilateral) were performed using standard approach (Brunner incision) and full thickness skin graft from the anterior thigh. Microsurgical procedures were performed on two patients. The first a 21-year-old gentleman with a brachial plexus injury (C5-C6-C7) secondary to a fractured clavicle treated with nerve transfer from spinal Accessory nerve to supra scapular nerve, median nerve fascicle to musculocutaneous nerve and ulnar nerve fascicle to nerve to lateral head of triceps. The other, a 35-year-old female with left leg lymphedema treated with vascularized lymph node flap from the supraclavicular region. The majority of cases were either done using brachial plexus block (27) with or without the addition of spinal anaesthesia or under general anaesthesia (26) with all cases managed by a local anaesthetist. At 6 months follow up we have had no complications to date and all patients were discharged from hospital within a week (average time stay in hospital 2 days).

Table 1

Procedure Defined Category (Some patients had more than 1 or bilateral procedure and is counted as a single operation).

Body Region Case type Surgical procedure* Anaesthesia** Total

Head & Neck Post Burn Contracture (12)
Ectropion (3)
Vascular malformation (3)
Scar (3)
Ear malformation (2)
Trauma (2)
Dermatochalasis (1)
Release & STSG (7)
Release & local flap (6)
Release & Z plasty (4)
Surgical correction (4)
Excision & direct closure (3)
Release & FTSG (2)
General (14)
Local (11)
Local + SA (1)
26

Upper Limb Post Burn Contracture (12)
Skin Lesion (2)
Lymphedema (2)
Brachial Plexus Injury (1)
Release & STSG (6)
Release & FTSG (4)
Release & Z plasty (3)
Release & local flap (2)
Microsurgery (1)
Liposuction (1)
General (6)
BB (6)
BB + SA (3)
Local (1)
Wrist Block (1)
17

Hand Syndactyly (10)
Post Burn Contracture (5)
Neurofibromatosis (2)
Skin lesion (2)
Dupuytren (2)
Trauma (1)
Scar (1)
Release & FTSG (7)
Excision & direct closure (4)
Release & Z plasty (3)
Release + FTSG + K Wire (3)
Release & STSG (2)
Release & local flap (2)
Release & pedicled flap (1)
Tendon transfer (1)
BB + SA (10)
BB (8)
Local (2)
General (1)
Wrist Block (1)
Digital Block (1)
23

Genito Urinary Hypospadias (4)
Lymphedema (2)
Vaginal atresia + stenosis(1)
Surgical correction (4)
Excision & STSG (2)
Release & local flap (1)
Local + SA (4)
General (3)
7

Soft tissue Gynecomastia (2)
Keloid (2)
Liposuction and excision (2)
Excision & direct closure (2)
General (2)
Local (2)
4

Lower Limb Post Burn Contracture (3)
Lymphedema (3)
Post Burn Ulceration (2)
Release & Z plasty (2)
Excision & STSG (2)
Release & STSG (2)
Release & FTSG (1)
Microsurgery (1)
SA (4)
RB + SA (2)
Local (1)
Lumbar Epidural (1)
8

Foot Post Burn Ulceration (1)
Syndactyly (1)
Skin lesion (1)
Debridement & local flap (1)
Release & FTSG (1)
Excision & direct closure (1)
SA (2)
Digital Block (1)
3

*STSG: Split Thickness Skin Graft, FTSG: Full Thickness Skin Graft.

**SA: Sedation, BB: Brachial Block, RB: Regional Block.

Discussion

Surgery is essential for addressing basic health needs and has a significant role to play in the management of both acute and chronic conditions. The increasing demand is consistent across all surgical specialties within the developing world with a projected 5000 more surgical procedures required per 100,000 people in order to try and alleviate the burden of surgical pathology [15].

There are several models recognised to enhance the development of global surgery with [4] highlighting ‘vertical (1 way)’, ‘vertical (2 way)’, ‘horizontal’ and ‘diagonal’ as potential methods. Vertical routes tend to be an efficient way of managing a specific problem however have the potential to lead to dependence on the expertise of the missionary group [4]. Horizontal methods have the primary target of enhancing the system and ensuring continuity however can be time and cost consuming and highly dependent on local staff to ensure progress. As a result, we tried to utilize a diagonal approach to ensure the benefits of the two described linear methods are obtained while minimizing their potential flaws.

The surgical mission was conducted by a team of international and Indian surgeons working and learning in tandem, with experts in the field providing valuable techniques into microsurgical management of brachial plexus injuries and lymph node transfer for the management of lymphedema. In addition, medical students and junior surgical residents were invited to attend and assist helping to enhance surgical skills and confidence in managing basic plastic surgery procedures such as scar revision and suturing (Figure 3).

Figure 3 

Junior doctors were invited to assist helping to enhance surgical skills and confidence in managing basic plastic surgery procedures.

Partnerships were built with local nurses teaching wound dressing principles while physiotherapists were involved to incorporate patients back into society post operatively. Such cooperation of host hospitals and locally active non-governmental organizations provides a sustainable model to provide treatments for extremities reconstruction and infective diseases such as lymphedema.

Filariasis is an infection of the lymphatic tissue spread by mosquitos. Affecting 120 million people worldwide [12], compared to the 38 million suffering from HIV [18], there is now a large paradigm shift into the prevention and cure of this potentially debilitating disease [13]. Although distribution of mosquito nets and anti-helminth medication can prevent and clear infection respectively, the 40 million suffering from incurable lymphedema often require surgical intervention to improve both form and function (Figure 4). The surgical management of lymphedema has excelled exponentially in recent years [16] and offers an alternative to patients not responding the de-congestive therapy. During this mission as well as ensuring the de-congestive therapy clinics are optimized we have been able to educate local clinicians into the art of microsurgery performing lymph node transfers to help treat lower limb lymphedema (Figure 5A, B). We have built links and provided opportunities for the Indian plastic surgeons to undertake prestigious fellowships within lymphedema centers in Taiwan ensuring continued professional development.

Figure 4 

A case of filarial lymphedema in advanced stage that is routinely seen in our clinic during humanitarian missions.

Figure 5 

Lymph node transfer procedure for the treatment of filarial lymphedema. A) Harvesting of the lymph node flap from the supraclavicular area and B) inset to the lower limb.

Reconstruction of extremities represent an important niche with high demand [19]. We have described an efficient model to provide such surgical procedures for patients with limb deformities and are keen to build on current success by collaborating with other organizations to cover the increased demand of global surgery. Furthermore, there are many humanitarian missions in the world where junior or trainee surgeons are encouraged to operate [3]. Recognizing that the participation of junior trainees can result in an increased number of complications [9] we have mentored our junior and local surgeons both from India and the western world strictly under supervision of an experienced surgeon. This ensured training was provided throughout the mission, maintaining trainee enthusiasm, enhancing interest and knowledge surrounding global surgery [1, 6] whilst also maintaining minimal complication rates.

Conclusion

Impairment of the limb secondary to trauma, infection or congenital deformity can have a major impact on a patient’s physical and psychological health thus impacting daily function. Give Me 5 Foundation is a charity with an aim of improving the surgical burden of disease to the limb in developing countries in a sustainable manner.