Medicosnext
Dr Ashish Lal Shrestha, MBBS, MS, MCh, FACS, FAIS, FIAPS
Associate Professor and Chief, Department of Pediatric Surgery
Kathmandu Medical College and Teaching Hospital
Pediatric surgery is a unique and demanding specialty, dedicated to addressing surgical conditions in the most vulnerable members of society—the children. In Nepal, the journey to develop this specialized field has been challenging, with limited infrastructure, resources, and awareness among both the medical community and the public. However, significant strides have been made in recent years, largely thanks to the relentless efforts of pioneering professionals. In this article, we sit down with Nepal’s first registered MCh Pediatric Surgeon, who has been at the forefront of transforming pediatric surgical care since 2017. Join us as we explore the insights and expertise of a pioneering Pediatric Surgeon, shedding light on the challenges, advancements and future prospects of pediatric healthcare in Nepal.
How do you see Paediatric Surgery in the present scenario of Nepal?
Paediatric Surgery is a higher speciality of General Surgery that is entirely defined by age rather than a particular organ system. As Paediatric Surgeons we deal with most of the surgical conditions but only in children. My work translates into varied sub-specialities within Paediatric Surgery, mainly Paediatric Urology (kidneys, ureters, bladder and external genitalia), Paediatric Gastro-Intestinal Surgery, Paediatric Thoracic Surgery, Paediatric Surgical Oncology (Tumours and Cancer), Paediatric Plastic and Burns Surgery, Paediatric Trauma Surgery and Neonatal Surgery (Newborns).
When I completed my training and returned in 2017, I became the first registered MCh qualified Paediatric Surgeon in Nepal. Since then, I have seen a lot of development in the field but much is still needed in terms of creating awareness and I think Medicos provides us with a strong platform for that purpose.
Where did you get trained and what exactly is MCh training?
I trained at Christian Medical College, Vellore popularly known as CMC, Vellore. This is a hospital that was started in 1900 by a missionary and visionary Dr. Ida Sophia Scudder in Vellore, which used to be a small town then in Tamil Nadu state of South India. The legacy has continued over the years and starting from a single bed, it has now become 3500 bedded multi-speciality centre serving patients from all over India and neighbouring countries like Bangladesh, Bhutan, Sri Lanka, Nepal, etc. I spent 12 years of training there starting with MBBS, going on to pursue further training as a surgical specialist in General Surgery and finally opting for Paediatric Surgery as a higher speciality.
MCh is considered a PhD equivalent in terms of understanding the subject matter and effort and time that is invested by an individual in learning the finer details. Following post-graduation of 3 years into General Surgery, one is authorized to practice as a General Surgeon but to practice Paediatric Surgery a further 3 years of intensive training called Magister Chirurgiae (MCh) is required.
What are the most common conditions that you handle as a Paediatric Surgeon?
Well, the list is quite elaborate since the speciality encompasses a broad range of organ systems but for practical purpose, I would like to name the commonest elective and emergency conditions in children. The commonest elective condition is Groin Hernia and the commonest emergency is Acute Appendicitis.
Aren’t both these conditions that you named supposed to be rare in children?
Well, that is a common misconception. In contrary to the general belief, both these conditions are very common in children and a frequent reason to pay a hospital visit.
What are the symptoms of groin hernia in children? Can it affect girls too?
Groin hernia is more commonly observed in boys and infrequently in girls. Most children develop a swelling in the groin that appears with activity and reduces on lying down. Older children may be able to reduce their groin hernia themselves. Sometimes parents may note a gurgling feel while trying the reduction which could mean that the intestine is herniating out through the hernial defect.
Pain is usually a symptom of complication and may mean that the hernia is becoming irreducible that may progress on to becoming stuck and requiring immediate operation.
Can a Groin Hernia wait until a few years till the child grows?
Well, for most parents the idea of putting their children through general anaesthesia for an operation becomes unagreeable due to fear and anxiety but what is a necessary must is what I normally advise. A Groin Hernia has tendency to get stuck anytime and this cannot be predicted. Therefore, it is very important to explain to the parents that the it needs a repair at the earliest date possible to avoid complications.
What are the possible complications of a Groin Hernia?
By and large, its tendency to get stuck is quite unpredictable and the resulting event like intestine losing its blood supply may require a more complicated procedure like removal of a bowel segment. This may not be achievable without a more prolonged surgery with its associated complications. Besides, a jammed Groin Hernia can impinge upon the blood supply of the testicle towards the affected side and if unrectified may cause it to atrophy (becoming smaller and nonfunctional).
What are the modalities of treatment of Groin Hernia?
Traditionally an open procedure called open high ligation of hernia was being followed but with technological advancements and for obvious benefits, I prefer a minimal access technique for my patients which employs 3 incisions each 3mm long for a mini-laparoscopic high ligation of hernia. This requires special instruments and advanced laparoscopic skills.
When do we suspect a child to have acute appendicitis?
A child who develops symptoms acutely of pain around the umbilicus that later localizes towards the right lower abdomen often accompanied by vomiting and fever could be diagnosed with acute appendicitis. Frequently, there is poor appetite and tenderness on palpation over the right lower abdomen.
How is it confirmed and what is the treatment process?
When clinical findings are supported with high blood leukocytes count and ultrasound of the abdomen, the child is administered with intravenous fluid bolus, analgesics and antibiotics and an emergency appendectomy is undertaken preferably using laparoscopy or minimal access techniques.
What are the outcomes of treatment for Groin Hernia and Acute Appendicitis?
The outcomes are very good especially with laparoscopic techniques for both the conditions. We have operated more than 100 children with Groin Hernia and more than 200 with Acute Appendicitis over last few years all of them laparoscopically, the average hospital stays being 1 day for hernia and 2 days for Appendicitis respectively. With less pain, almost negligible wound infection, earlier return to normal activity and wonderful scar cosmesis, it has been our preferred method of treating both these conditions in children.
What advice would you give to parents who are hesitant about surgical procedures for their children?
Naturally, when we break the news to the parents regarding the imminent need for an operative treatment for their child, their first response is always a denial and to look for non-surgical options. This is when I take time to explain them about the risks and complications of the disease process itself before making them aware of the benefits and complications of surgery. Starting from the kind of anaesthesia that is pretty safely performed by a team of expert Paediatric Anaesthetists and the surgical techniques involved, I allow them to ask their queries until they are fully convinced about the need for such a treatment. It is very important to address their fears and concerns before we embark on a procedure.
How accessible are advanced surgical tools like those required for minimal access techniques in Nepal?
We at Kathmandu Medical College feel fortunate to say that we are well equipped with high end equipment and have necessary expertise to perform Paediatric Advanced Laparoscopy and Minimal Access Surgery along with supporting tests, investigations and sophisticated imaging that help us in managing most complex of cases in children.
Is there anything else you would like to share with our readers about your experience in this field?
My experience so far has been wonderful in this field because I feel that Paediatric Surgery is a highly rewarding field in terms of professional satisfaction. Being able to help so many children coming from all over the country with such diverse surgical conditions that I would not have been able to manage without a proper specialisation and training. The difference that I have been able to bring into their lives as their Surgeon is really gratifying. I feel the future of Paediatric Surgery in Nepal is bright as it continues to evolve and with increasing awareness among the people, I feel more and more children will be benefitted with our services.
