Bethune Round Table 2017

Many global surgery leaders from around the world joined in Ottawa from June 1-3rd for the Annual Bethune Round Table global surgery conference. Researchers came from Rwanda, Uganda, India, Zambia, Nigeria, South Africa, Bangladesh, Zimbabwe, Ethiopia, Canada, and the U.S. This year’s theme was “Evidence-Based Global Surgery.” The focus was to raise the standard of research being done in global surgery and to improve the way results are implemented in LMICs. 

<Parisa Fallah>

The conference began with a presentation from Dr. Ed Fitzgerald, a general surgery registrar in England. Dr. Fitzgerald runs GlobalSurg, an exciting research collaborative comprised of thousands of students and clinicians from 60 countries around the world. Rather than doing multiple smaller studies, GlobalSurg involves simultaneously collecting professionally crowd-sourced data from various sites worldwide, leading to large-scale studies that capture important trends in surgical care. Their most recent work includes developing a surgical instrument set for the bellwether procedures in global surgery.

One of the highlights of the conference was the Ab Guha Lecture given by Dr. Nobhojit Roy, who gave a talk titled, “Global Surgery 2030: What is Missing in the Discourse?” Dr. Roy filled in many of the gaps that exist between global surgery research and the way global surgery efforts are being implemented. He talked about topics that some have been more hesitant to discuss and left the audience with a lot of salient points to consider.

Other keynote speakers included Dr. Stephen Ttendo, who is working to build anesthesia capacity in Uganda, and Dr. Rachel Spitzer, who talked about equipping OB/Gyn trainees with the skills to participate in global surgery. The final keynote was given by Dr. Nadine Caron, who gave an incredible talk on the challenges to evidence-based indigenous health care in Canada and the importance of remembering that global can mean local as well.

Beyond the research presentations and keynotes, there were several workshops including: Innovation Development, Developing a Curriculum, Research in LMICs, Working with the World Bank, Advocacy for Political Change, Preparation for Successful Partnerships, and Getting Published in Global Surgery. There was also a banquet, where screenings of “The Checklist Effect” were shared and where director Lauren Brown talked about the value of media in enacting change. The conference ended on the final evening with multiple locally-hosted dinners that facilitated more conversations on global surgery.

From left to right: Dr. Laurence Bernard (Ob/Gyn resident), Dr. Adriana Ramirez (general surgery resident), Stacey Giles (nurse), Parisa Fallah (medical student), Dr. Andrew Giles (general surgery resident)

Several members of the Global Surgery Student Alliance (GSSA) leadership team were present, including Parisa Fallah, Dr. Andrew Giles, and Dr. Adriana Ramirez. Dr. Giles, one of the VPs for Residents/Trainees, presented his research on “Predictors of Obstetric Fistula Repair Outcomes in Lubango, Angola.”

As the InciSioN’s National Working Group (NWG) for the U.S., GSSA was able to have many conversations with key global surgery players at the conference and is now working towards partnering with Canadian medical students to help them develop their NWG in the coming year.

Look ahead to May 2018, when the Bethune Round Table will be held in Toronto. The theme is “The Role of Trainees,” so many will be listening closely to learn how they can support students and trainees in their localities who want to join the field of global surgery.

Access to Surgical Care in Pakistan

Najwa Nadeem (Final Year M.B.B.S.)

It was a different world when she woke up. Blinking and coughing, the woman looked around only to find herself surrounded by anxious, inquisitive faces, staring at her in disbelief. Not her exactly, but a part of her. Her feet. Words seemed gibberish and the whole crowd a blur when the pain hit her. She shrieked, catching everyone’s attention. The surgeon bandaging her fractured tibia, her lacerated foot hanging on to her leg, asked her to calm down, all the while telling the medical students around him that she’ll definitely lose her right foot due to the extent of the damage in the accident. She kept screaming in pain, lying on the stretcher she came in, all covered in blood. The nurse waited as soon as the other surgeon filled her chart to maintain her IV line and give her the necessary pain-killers. The rest of the treatment would have to wait until all necessary investigations were done and she was moved to Bay-1 of the ER, still on the stretcher. She screamed one last time as the analgesics kicked in, looking at the room she was in, surrounded by strangers, old and young alike and then finally falling unconscious. Her husband was asked to take her samples to the lab for tests and also to arrange blood so that surgery can be started. He wanted to ask so many questions but the ER is a busy place, with everyone yelling around and he was pushed away, still confused about the whole procedure.

This is not an unusual scenario at a tertiary hospital in Pakistan. If the woman and her husband lived in a village, she would have been taken to a Basic Health Unit (BHU) first where the doctor would suggest her to be taken to the city for surgery and in the meantime during transport (if available), she could lose not just her foot but her life as well. Barriers to optimal surgical care in Pakistan affect surgical access to the patients, which we will discuss here in more detail.

In 2011, the World Health Organization (WHO) Alliance for Health Policy and Systems Research brought out their report “Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries.” [1] The barriers which the paper mentioned included:

Pakistan being a low- and middle- income country (LMIC), faces similar barriers to optimal healthcare conditions for its population, majority of which belongs to rural areas. With the ever increasing population, Pakistan is yet to address these problems. The specialist surgical workforce density is 5.53 per 100,000 population. Risk of impoverishing expenditure for surgical care is 62.8% and that of catastrophic expenditure for surgical care is 75.2%. [2]

A study conducted in 2011 addressed many such variables [3]:

“Patient-related variables included age (elderly), gender (female), preferential use of alternative health providers (Hakeem, traditional healers, others), personal perceptions regarding disease and potential for treatment, poverty, personal expenses for healthcare, lack of social support, geographic constraints to accessing a health facility, and compromised general health status as it relates to the development of surgical disease. Environmental barriers include deficiencies in governance, the burden of displaced or refugee populations, and aspects of the medicolegal system, which impact treatment and referral. Barriers relating to the health system include deficiencies in capacity (infrastructure, physical resources, human resources) and organization, and inadequate monitoring. Provider-related barriers include deficiencies in knowledge and skills (and ongoing educational opportunities), delays in referral, deficient communication, and deficient numbers of female health providers for female patients.”

Surgery is described as an “indivisible, indispensable part of healthcare.” Unfortunately, in Pakistan, where the country is in a usual political turmoil, with only 2.6% of the GDP spent on healthcare, the situation is far worse. The government does provide some support to hospitals in urban areas but rural areas suffer from a lack of trained doctors and health facilities to treat major surgical ailments.

Patients in urban areas have access to emergency care and ambulances provide transport to the nearest care center. However those in rural areas reach a Basic Health Unit (BHU) first where only first aid and minor care can be provided (according to the competency of the duty doctor and the meager facilities available). They then have to travel miles away to a tertiary care center in urban areas to treat their ailment. Many lose their lives in the transit. Others can’t afford the treatment. Then there’s the issue of bed availability.

Emergency surgical procedures are done in a less than ideal setting where the patient is prone to all kinds of hospital-acquired infections. Even after the procedure the risk of surgical site infection is high. Patients’ families have to arrange blood on their own and are mostly seen running through the hospital looking for a referral or a familiar to doctor to help them out. Blood screening is another problem. Public hospitals don’t always provide a clean environment for the patients in general wards as those in private hospitals. Surgical waste once removed from the bedside is often heaped up outside, leading to environmental pollution.

A majority of the Pakistani population resides in rural areas and is illiterate which is another factor that affects treatment. Patients often have the wrong ideas about their illness (reinforced by the elders in the household) and avoid a visit to a medical practitioner. Instead, they seek help from hakims and quacks to heal. This worsens their condition. By the time they reach the doctor, it is already too late. The security threats pertaining to a BHU discourages female doctors to practice in distant rural areas and hence the female patients in the area suffer indirectly as the social setup discourages them to visit a male doctor.

The specialist surgical workforce density faces an imbalance as most specialists are concentrated in the urban areas and so people from villages have to travel a long way. Most avoid the transit and “wait it out”, unless it is absolutely necessary to go. Travel expenses, residence and arranging an appointment all add up to the patient and his family’s worries. Patients often refuse surgery and resort to medicines as they’re either afraid of the outcome or simply cannot afford it.

Government funding, proper planning and improvement in health facilities can help alleviate the situation. There’s a need for proper research into all these factors, development of policies and ensuring their implementation so to improve surgical access and its safety in Pakistan.


  1. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Jacobs B. et al. Health Policy and Planning 2011;1–13. Available online at
  2. World Development Indicators, The World Bank. Available online at

  3. Barriers to Accessing Surgical Care in Pakistan: Healthcare Barrier Model and Quantitative Systematic Review. Irfan, Furqan B. et al. Journal of Surgical Research , Volume 176 , Issue 1 , 84 – 94

A surgical skills workshop in Pakistan

<Aamna Aziz Jaspal>

Access to safe and affordable surgical care is the right of every individual in the world. But how can we -as students- make it a reality?

IFMSA Pakistan Global Surgery National Working Group -InciSioN chapter in Pakistan- believes surgical education is key, especially in developing countries where the burden of disease is high and the density of surgeons is low. Not only will it motivate medical students towards a surgical career but it will also improve their skills so they can contribute more effectively in their respective surgical teams. Therefore, we came up with the idea of basic surgical skills workshop for medical students. The aim was to spread the message of Global Surgery through a productive activity. 

Recently, we conducted our third basic surgical skills workshop. The past two workshops held in 2016 in different medical institutions of Pakistan achieved great success in terms of advocacy and education regarding Global Surgery. Punjab Medical College, a medical institution in the city of Faisalabad Pakistan, conducted the workshop on Saturday, 29th April 2017 in collaboration with IFMSA Pakistan Global Surgery National Working Group. However, in addition to basic surgical skills, this time we took the workshop to another level, by including the training for prehospital management of emergency circumstances like fractures or dislocation of the hand, forearm, arm, shoulder, collar bone, skull, jaw, ankle, and knees. The students were taught how to apply slings and bandages as well as how to control hemorrhagic bleeding in the limbs and head region using bandage.

Due to the limitation of trainers and to ensure the quality of the workshop, only 16 spots were available, all of which filled within one day. Even though it was a Saturday, students arrived at 9 a.m. sharp for the workshop which ran for 5 hours! The workshop began with a lecture aided with visual demonstrations to teach the different techniques including administration of injections in relation to surface landmarks, management of fractures followed by reef and surgical knot tying exercises which were then advanced to knot tying with instruments.

The biggest achievement of this workshop was that each of the 16 participants got a chance to practice each technique individually. The facilitator for the event Dr. Abdullah Saeed, a surgeon at Allied hospital, Faisalabad would demonstrate each skill and ensure that everyone had learnt it by watching them practicing in front of him. This hands-on approach of the workshop was the highlight among students who were even eager for more. The positive feedback received from the students assured us to continue organizing such workshops in the future, to spread the message of Global Surgery further and to empower the students to help their patients in need,  even before they reach a medical facility.

The Checklist Effect Screenings – #GlobalSurgeryDay

Screening in Grenada, May 5th 2017

A few months ago, a documentary painting a tour d’horizon of surgical care was released and the success was immediate. The Checklist Effect, a documentary directed by Lauren Anders Brown, of Collaborate: images and ideas and produced with the help of Lifebox, follows surgical teams in Haiti, USA, Uganda, United Kingdom, Moldova, Mongolia and Guatemala. A movie with such a global vision deserved to be seen by a large audience around the world, which is where InciSioN loved to help with! 

We had the honor of having members of our network voluntarily translate the subtitles to their respective native languages, which is why the documentary is now available with Dutch, French, Spanish, Portuguese, Arabic and Hindi subtitles.

The premiere of the translated versions happened in Geneva on May 24th, during the World Health Assembly side event : “What next for surgery and anaesthesia?” hosted by WFSA and Lifebox with the participation of InciSioN, G4 alliance and Operation Smile. You can watch the recorded video of the event here.

Screening in Rwanda, May 25th 2017

Translating the subtitles wasn’t enough for our dedicated students and many of them wanted to screen the movie in their home towns. We are happy to announce that we already had screenings held in Brazil, Grenada, Ecuador and Rwanda. The feedback from those countries was the same as ours: students loved the movie! Have a look at those pictures and we hope that you will like them just as much as we do!

Screening in Brazil, May 25th 2017

There are more screenings planned around the globe, in countries as diverse as the USA, Belgium, Morocco, Australia and India. Please stay tuned through our social media pages to find out more!

If you are interested in hosting your own screening of The Checklist Effect, feel free to email us at

Screening in Ecuador, May 25th 2017






Surgery – Beyond the Noble Profession

“Surgery has been the neglected stepchild of global health.” A very well-known saying across the world of surgery first introduced by Dr. Paul Farmer. Has it ever crossed your mind why surgery is viewed that way? Allow us to take you on a journey of hope where motivation is formed by the touch of a scalpel!

<Muna Rommaneh>

On a sunday night, while looking for something to watch, a quick look at TV news is enough to help you notice the amount of crisis, disaster and conflict across the world. Has it ever occurred to you how these people get access to surgical care? These three major problems are usually linked to displacement. The case only gets worse when the population is underserved. Healthcare has been one of the most important topics discussed globally. Improving healthcare is the current ultimate goal. As human beings, it is our right to have access to health care including safe surgery. Unfortunately, global surgery has been neglected during the majority of these discussions though it is a key factor in improving healthcare.

Surgery is a noble profession.[1] When referring to something with the word “noble”, it must  possess outstanding qualities such as eminence and dignity, have power of transmitting by inheritance, or indicate superiority or commanding excellence of mind, character, or high ideals or morals. Without a doubt, these three attributes befit the profession of surgery. Though many surgeons have tried to set standards of ethical and humane practice and have made magnificent contributions in education, clinical care and science; we still have a long way to go!

Looking at surgery today, we notice that profound changes are taking place at all levels. These changes have caused surgeons and those involved in the surgical profession to come across both new challenges and opportunities. These changes are occurring on a global level, on the national level, in science and technology, in healthcare, and in surgical education and practice. Surgical care has been revolutionized throughout the years. As a result, we have seen significantly improved longevity and the quality of human life. Needless to say, surgery must keep evolving with time.

Why should anyone lose a loved one because they did not have access to safe surgical care? A condition that needs a few tens of minutes to be treated may have to wait up to months in some areas leading to fatal results. Who is responsible for improving surgical care globally? WE ARE! Join us today on #GlobalSurgeryDay to say loud and clear: “Safe surgery is our right!”. Your voice matters and it is indeed very valuable!


  1.   Debas HT. Surgery: A Noble Profession in a Changing World. Ann Surg. 2002 Sep;236(3):263–9.

Global Paediatric Surgery

Recent estimates revealed that approximately 5 billion people lack access to safe and quality surgical care globally (1); the need for pediatric surgical care is similarly significant. (2) Given that pediatric conditions can occur during development, many have an added risk of mortality or disability. (3)

<Varshini Cherukupalli>

Although approximately 85% of children in low- and middle-income countries (LMICs) will have a condition that can be treated by surgery by the age of 15 years, the global burden of pediatric surgical care remains to be determined. (2) To address this gap in research, the Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument has been utilized in Rwanda, Uganda, Sierra Leone, and Nepal as a household survey-based approach to determining surgical need.  An analysis of these results demonstrated that an estimated 3.7 million children are living with a surgical need in these four LMICs. (4)

Image source: Northwestern University, Division of Paediatric Surgery

Addressing pediatric surgical conditions can reduce costs and create opportunities for investment.  An economic analysis of pediatric surgical care in LMICs suggests that surgical services such as inguinal hernia repair, trichiasis surgery, cleft lip/palate repair, congenital heart surgery, and orthopedic surgeries should be considered essential pediatric procedures. (5)  Thus, by raising awareness for the need for pediatric surgery, we can provide societal economic benefits and most importantly, save the lives of future generations.


  1. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet (London, England). 2015;386(9993):569–624.
  2. Bickler SW, Rode H. Surgical services for children in developing countries. Bulletin of the World Health Organization. 2002;80(10):829–35. Pmid:12471405
  3. Ozgediz D, Poenaru D. The burden of pediatric surgical conditions in low and middle income countries: a call to action. Journal of pediatric surgery. 2012;47(12):2305–11. Pmid:23217895
  4. Butler K, Tran TM, Nagarajan N, Canner J, Fuller AT, Kushner A, et al. Epidemiology of pediatric surgical needs in low-income countries. PLOS One. 2017.
  5. Saxton AT, Poenaru D, Ozgediz D, Ameh EA, Farmer D, Smith ER, RIck HE. Economic Analysis of children’s surgical care in low- and middle-income countries: A systematic review and analysis. PLOS One. 2017.

Congenital Heart Defects


<Dominique Vervoort>

Congenital heart defects (CHD), defined as clinically significant structural heart disease, are the most common birth defect worldwide, and the most common cause of birth defect related deaths worldwide. As a result, every year, 100,000 babies (children under one) will not live to celebrate their first birthday.

Globally, an estimated 8-12 babies per 1,000 live births suffer from some form of CHD that needs treatment or is present at a year of age, although incidence does not vary much between countries and regions.1 These do not include other more benign cases, such as small muscular ventricular (VSD) and atrial septal defects (ASD), which generally close spontaneously before a year of age.

In the past decades, advances in pediatric cardiac surgery have made it possible to repair or palliate most CHDs, which makes that over 85% of operated cases are expected to survive to adult life. However, because of the lack of (human) resources in most developing countries, less than 1.5% of children with CHD are able to undergo the surgery they need.2

Although some babies are diagnosed during pregnancy or at birth, the diagnosis is often not made until later in life. Sometimes, especially in developing countries, CHD is not detected until adolescence or adulthood, during which the condition is often already associated with complications such as heart failure, pulmonary hypertension and severe polycythaemia. Moreover, children with CHD often suffer from associated defects and up to 50% of these patients present with some neurodevelopmental problems.3
Nevertheless, the earlier CHD is detected and treated, the higher the chances of survival and the less long-term health complications. One important preventable complication is the risk of infective endocarditis, which has a 20-year mortality of over 50% in patients with CHD.

The burden of supporting CHD patients falls heavier on countries with higher fertility rates, which tend to have the lowest incomes per capita, which only accentuates the disparity. Costs for open heart surgery are high and are accompanied by additional medical (treatment and follow-up) and non-medical (e.g., transport, which is especially difficult in rural areas or developing countries) costs. Moreover, there is a loss of parental working time when taking children to a medical center, which further puts a financial burden on these families.5

With the epidemiological transition from communicable to non-communicable diseases globally, there is an increasing interest in conditions such as CHD. Nevertheless, because of absolute and relative (maldistribution) shortages of the health workforce and diagnostic and therapeutic equipment, urgent measures need to be taken. After all, children should have the right to live, to live in full health, and be able to play with other children of their age without being harmed by such misfortune.


  1. Hoffman JI. The global burden of congenital heart disease. Cardiovascular Journal of Africa. 2013;24(4):141-145. doi:10.5830/CVJA-2013-028.
  2. Young JN, Everett J, Simsic JM, et al. A stepwise model for delivering medical humanitarian aid requiring complex interventions. J Thorac Cardiovasc Surg 2014;148:2480–9.e1.
  3. Marino BS, Lipkin PH, Newburger JW, et al. Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association. Circulation 2012; 126: 1143–1172.
  4. Delahaye F, Ecochard R, de Gevigney G, et al. The long term prognosis of infective endocarditis. Eur Heart J 1995; 16(Suppl B): 48–53.
  5. Hewitson J, Zilia P. Children’s heart disease in sub-Saharan Africa: Challenging the burden of disease. S Afr Heart J 2010; 7: 18–29.

Robotic Surgery: An Overview and Reflection

<Ankit Raj>

What is robotic surgery?
Robotic surgery, or robot-assisted surgery is a type of minimally invasive surgery where miniaturized surgical instruments are fitted through a series of quarter-inch incisions. When performing surgery, these miniaturized instruments are mounted on three separate robotic arms, allowing the surgeon maximum range of motion and precision. A fourth arm that contains a magnified high definition 3-D camera provides stereoscopic view to the operating surgeon.[i]

Robotic surgery has evolved from its first use in a robot-assisted neurosurgical biopsy in 1985 to the approval of ground-breaking da Vinci Surgical System by FDA for general laparoscopic surgery in 2000.[ii]

Robots are currently used for procedures such as prostate surgery, hysterectomies, the removal of fibroids, joint replacements, open-heart surgery and kidney surgeries. They can also be used along with MRIs to provide organ biopsies. Coupled with telesurgery (surgery from a distance), it can be used by institutions and surgeons to perform operations in far and remote areas with otherwise limited human resources and infrastructure. Imagine a neurosurgeon sitting in Boston performing a decompressive craniectomy on a patient lying on an operating table in sub-Saharan Africa. This not only solves the concern of performing highly complex procedures in hospitals with under-staffing or inadequate infrastructure, but also cuts on hospital expenditures This principle can also be used for performing surgeries in war-torn and crisis-affected territories where surgeons are often not so keen to go.[iii]

Robotic surgery is at the cutting edge of precision and miniaturization in the realm of surgery. It provides improved diagnostic abilities, a less invasive and more comfortable experience for the patient, and the ability to do smaller and more precise interventions. Like any other minimally invasive surgery, it offers advantages of fewer post-operative complications, such as surgical site infection, less pain and blood loss, quicker recovery and smaller, less noticeable scars. It can also provide a better work environment for the physician by reducing strain and fatigue.

Along with improved patient care and surgical efficacy, another aim of robotic surgery is to significantly reduce medical and surgical costs. This is not possible when most of the robotic surgical systems cost more than $1 million to purchase and $100,000 a year or more to maintain. This means that hospitals and institutions must evaluate the benefits of robotic surgery against benefit of traditional surgeries. Reduced post-operative stay and quicker recovery following a robotic surgery cuts down on hospital expenses. There is also a reduction in the number of resource personnel needed during a robotic surgery, thus cutting down on hospital expenditure. Yet, it is still disproportionate to the expenses of installing and maintaining robotic surgical systems and training human resources for operating and programming these systems.

With very little competition in robotic surgery market, the few manufacturers have the freedom to set their own price, making robotic surgery highly unaffordable and prohibitive for huge proportions of hospitals, healthcare institutions and governments across the world. This becomes especially problematic in Low- and Middle-Income Countries (LMICs) where human resources are limited and healthcare expenditure is minuscule. Take India, for example, where per capita healthcare expenditure is a meagre $267 and where there is one of the highest out-of-pocket expenditure.[iv] A robotic radical prostatectomy at All India Institute of Medical Sciences, the premier-most government funded health institute of India, costs around INR 1.3 lakhs per case (USD 2025), which is way above than per capita healthcare expenditure.[v] This does not include robotic surgeries at private hospitals which are neither funded by government nor get instruments at a subsidized rate.

The main strength of robotic surgery is that it significantly improves surgical accuracy, particularly among the less-skilled. It was expected that rapid technological developments will make these systems cheaper, smaller, smarter and portable. Imagine the lives saved by a portable robot surgeon rushed to a motorway accident, or to a nuclear accident, a battlefield or to any disaster where one surgeon could carry out several procedures at the same time with help from medical assistants at the scene. But have we actually followed up on this technological advancement and exploited this opportunity in places where it matters? Have the benefits of robot-assisted surgery actually been employed in war-torn Syria or in Fukushima after its nuclear disaster? Sadly, more than 30 years after the first use of robot in a surgery, its use still remains confined within the exorbitant walls of sophisticated operating theatres in first-world.[vi]

Ethical standpoint
The main argument to robotic surgery is whether the costs are ethically justifiable. It is, in fact, unethical to approve new technologies that will add to the cost of medicine, given the number of people, especially in LMICs, with no or minimal access to essential health services, safe surgery, women and child health, health insurance and disproportionate out-of-pocket expenditure.iii A WHO and World Bank report shows that 400 million people do not have access to essential health services and 6% of people in LMICs are tipped into or pushed further into extreme poverty because of out-of-pocket expenditure.[vii] Should not then our concern be focused first on providing universal health coverage, identifying gaps and raising the standard of healthcare in marginal and impoverished community? Should not this excessive expenditure be focused on developing basic health infrastructure in these regions rather than spending it on ethically irrational and doubtful practice? This unfair allocation of health resources and expenditure is surely a deadlock for possible development and further acceptance of robotic surgery across several nations.

Another fundamental disagreement against robotic surgery by large swathes of professionals and societies is its dubious and vacillating ethical ramifications. Where favorable media reporting and hospital advertisements have been partly responsible for unchallenged popularity of robotic surgery, data is still incomplete on its actual effectiveness and advantages. Where this data is present, it shows no outstanding advantage of robotic surgery over conservative surgery.iii A surgeon may also be influenced unconsciously by career benefits and elevated social status that follows after including robotic surgery in his protocol.

There are also issues with latency. This refers to the time lapse between the moments when the physician moves the controls and when the robot responds. Also, there is still a chance for human error if the physician incorrectly programs the robot prior to surgery. Computer programs cannot change course during surgery, whereas a human surgeon can make needed adjustments.ii

It is clear that robotic surgery brings with it the risk of patient harm from insufficiently trained surgeons. There are individual differences among surgeons too on inadequate training on robotic surgery. Some find it easy and feel comfortable with the device, while others have individual differences.[viii]

Lastly, there is also the dissension among bioethicists and philosophers that the sick and vulnerable need human contact. The touch and sound of a doctor gives comfort and sense of security to a person on an operating table. A robot, either controlled or automated, fails to do any of that.

Towards an ethically judicious future
Although robotically-assisted surgery has been steadily increasing in popularity among surgeons and patients, that could end quite suddenly if public perceptions change. Grumbling of complaints and medical malpractice lawsuits are snowballing. Priority should be to reduce the costs of robotic surgery and develop an ethical framework and guidelines on its practice.

Francis Daniels Moore, a pioneer in numerous experimental surgical treatments, offers three criteria to make “surgical innovation acceptable”: (i) sufficient laboratory experience before conducting innovative procedures, (ii) sufficient intellectual and technical expertise available in the institution, (iii) good “institutional stability” based on its resources, support systems and staff.[ix]

A regulatory body should be established to certify that a surgeon is qualified. This should be based not on the number of procedures performed, but on a criterion level of skill. Anything else is ethically indefensible. Institutions should have the right level of in-house technical expertise by ensuring that they have well-trained and knowledgeable support staff with an understanding of the robot. We also need more surgical robotics companies to create a competitive environment that drives innovation and reduces costs.iii

An ethical framework is needed that is grounded in notions of patient autonomy, dignity, wellbeing, privacy and fair allocation of resources, and it needs to accommodate the ethics of care practice. Patients must be told of negatives and offered cheaper equivalent procedures if available. Hospitals must constrain their marketing to the facts and be wary of conflicts of interest so that informed consent is not compromised.ii

To quote Alexander Pope, “Be not the first by whom the new are tried, nor yet the last to lay the old aside”. Robotic surgery is still an evolving technology with no great data on its cost-benefit analysis yet. We need to reconsider our priorities and focus on offering equitable distribution of healthcare at places where it is much needed rather than indulging ourselves in fancy toys.





[iii] Robotic Surgery: On the Cutting Edge of Ethics. Sharkey N, Sharkey AJ. Computer 46(1):56-64. 2013. DOI: 10.1109/MC.2012.424


[v] Current Status of Robotic Surgery in India. Dogra P.N. JIMSA. 25 (3). 145. 2012.

[vi] Don’t dismiss robot surgeons. Noel Sharkey.


[viii] Ethical Reflections on Health Care Robotics. Senthilkumar S., Shanmugapriya T. IJIRCCE. 2 (2). 2014.

[ix] Moore F.D. Ethical problems special to surgery: surgical teaching, surgical innovation, and the surgeon in managed care. Arch of Surg 135:14-6, 2000



Global Orthopaedics

As Global Surgery Day 2017 (May, 25th 2017) approaches, InciSioN’s Advocacy team will be publishing a series of blogs in an effort to emphasize the global need for timely access to safe, and affordable surgical care.

Global Orthopaedics

<Varshini Cherukupalli>

Globally, musculoskeletal disease is a major cause of mortality, morbidity, and increasing health care costs. (1) In 2013, 973 million individuals sustained injuries and 4.8 million people died from injuries. (2) In particular, the burden of injuries is rapidly growing in low- and middle-income countries (LMICs). Reasons for this phenomenon include more road traffic crashes, fewer orthopedic surgeons in developing countries, and higher prevalence of obesity and sedentary lifestyles. (2)

Historically, orthopedic conditions were not included in public health agendas, as the focus was on communicable and nutritional illnesses. In order to address this paucity of data and insufficient infrastructure to treat orthopedic conditions, during the Bone and Joint Decade (2000-2010), the World Health Organization, World Bank, and United Nations emphasized that more research on musculoskeletal conditions in LMICs must be performed. (3)  Treatment of open fracture is also included as one of three Bellwether procedures, or essential procedures that any first-level hospital must be able to provide. (4)

A recent study revealed that, as compared to a Level I trauma center (highest level of care) in an industrialized country, a referral hospital in an LMIC handles a disproportionate amount of trauma cases, severe fractures, and infections. (1)  As such, the burden of orthopedic conditions continues to significantly affect the developing world.  Increased awareness and further research of the burden of musculoskeletal disease are necessary in order to effectively target injuries in LMICs.  

  1. Brouillette MA, Kaiser SP, Konadu P, et al. Orthopedic surgery in the developing world: workforce and operative volumes in Ghana compared to those in the United STates. World J Surg. 2014;38(4):849-857.  
  2. Haagsma JA, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2014. Inj Prev. 2016;22(1):3-18.
  3. Lidgren L. The bone and joint decade 2000–2010. Bull World Health Organ 2003;81:629
  4. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.

InciSioN Rwanda – Global Surgery Workshop – University of Rwanda

Saturday (May, 6th 2017), the National Working Group (NWG) in Rwanda -InciSioN Rwanda- organized their first global surgery workshop at the University of Rwanda, with the aim of introducing local students and doctors to the actual surgical needs in developing countries, such as Rwanda.
<Dominique Vervoort, Isaac Ndayishimiye>
The event was built around means of coping with the lack of access to surgical care in low- and middle-income countries (LMICs). The event was an interactive competition with three teams (participants) and judges (local surgeons), starting off with a brainstorming session on surgical care needs in Rwanda, wound management and surgical infections. This was followed by a session on capacity building by Dr. Christian Ngarambe -Head of Department of Surgery at the University Teaching Hospital of Butare (Centre Hospitalier Universitaire de Butare – CHUB)- and ended with a practical surgical skills session by Dr. Ahmed Kiswezi (CHUB).
From left to right: Dr. Philemon (CHUB – Dep. of Surgery), Dr. Christian Ngarambe (CHUB – Head of Dep. of Surgery), Dr. Ahmed Kiswezi (CHUB – Dep. of Surgery)
With the initial interest of participants already being high, the event only strengthened their interest, shown by the large amount of attendees willing to contribute to InciSioN Rwanda (over 60 people signed up for active membership in the NWG). We would like to congratulate InciSioN Rwanda for their great work and start, and are excited to see the promising future they have ahead!