Reconstructive Surgery

One of the crucial procedures in the medical world is reconstructive surgery. All about repairing bodily structures and restoring their functions, these surgeries are conducted to better the body parts usually affected by birth defects, developmental abnormalities, trauma/injuries, infections, tumors, and others. As a complex practice, it is imperative that the patients get proper procedures and care in time through a surgeon who specializes in reconstructive surgeries. These surgeons not only seek to restore function and alleviate pain, but also try to improve the appearance of the operated parts.

Dr. Shilu Shrestha from Blue Cross Hospital, Tripureshwor, began practicing the art of reconstructive surgery as a junior resident, when her seniors used to leave her with hand injuries after they were done with big hip and pelvis fractures. “I used to do it with much consideration and interest. It used to look beautiful when completed. But, when they came for follow up, the most common complication was related to hand injuries.” She adds, “The patients were not able to perform their daily activities and they even had to lose their jobs. The outcome of hand injuries was not rewarding, therefore, my seniors were also not very keen to do it like other injuries.” Amidst the expert specialists on hip, spine, arthroscopy, pediatric, and arthroplasty, the lack of specialist for hand surgery and the passion to give these injuries a better outcome drove Dr. Shrestha to pursue a career in reconstructive surgery.
She received her specialty training, combined with reconstructive surgery and microsurgery, in Singapore and USA, and recalls them as a much-needed look into this massive subject. The skill and knowledge it provides on all kinds of tissues in the body is indeed remarkable. Likewise, the outcome given to the patient after the injury through reconstructive surgery can be life-changing.

“I feel fortunate to have great mentors and leaders during each stage of my career. Dr. Ashok Banskota has been key on nurturing me as an orthopedic surgeon and seeding my interest in hand surgery. Likewise, Dr. David and Dr. Sebastian from Singapore have been instrumental in making me a hand surgeon, while Dr. James Chang from Stanford University has been the one to refine and give direction to my career,” she says.
Interacting with patients closely is another responsibility that comes along with being a surgeon. The conventional idea of doctor-patient relationship is one where doctors need to decide everything for the patient, and the patient would just follow without understanding. “However, in the present days, the concept has changed drastically, with patients being more educated and well informed. And, there are various treatment modalities for any problem with their own pros and cons, of course. I explain everything to the patient and try to involve them in the decision making process. That way, it gives me a lot of understanding about the patient’s need and desire. And, they also tend to take on their responsibility,” she adds. “For me, the final outcome of the surgery does not depend on how it looks on X-ray or appearance; it depends on how comfortable and happy the patient is.”
One such case that she particularly remembers is that of a patient named Sunil Kumar Bista from Dhangadi. On January 2021, Bista was driving his motorcycle, when he got hit by a truck. The accident not only broke his left leg, but he also sustained near leg amputation. After hearing from the local center that the patient should be referred to a hospital in Kathmandu, and that his leg might have to be severed, his father got in touch with one of the doctors at Blue Cross Hospital. And, after about six hours of injury, he fortunately was at the hospital under the supervision of Dr. Shilu and her team.

Dr. Shilu recalls, “We found out that he was in a very critical condition, with near amputation condition of the left leg, along with vascular injury, nerve injury, comminuted FX, and soft tissue loss. There was no time to stall, so we immediately started off the surgery with vascular and never repair with provisional fixation of the FX.” With the first surgery, the team was able to salvage the limb successfully. Then, the patient also required a serial clean out of the wound and its coverage. In the second major surgery, Dr. Shilu changed the temporary fixation of the FX to permanent fixation, and the patient was soon able to walk around with the help of splint and crutches. After 105 days of treatment and care at the Blue Cross Hospital, Bista returned home with a smile on his face.
With the stellar experience of conducting over 5,000 different surgeries so far, she spends most of her time working on various studies when not performing a surgery. Around three years ago, she began exploring the subject of Volkmann’s ischemic contracture. She explains, “It is a serious and irreversible complication of compartment syndrome that mainly happens because of tight plasters and vascular injuries after trauma or surgery.” The permanent shortening (contracture) of the forearm muscle gives rise to a claw-like deformity of the hand, fingers, and wrist, and causes significant functional impairment, particularly in the upper extremity. Grip becomes impossible, and passive extension of fingers is restricted and painful.

The most basic teaching in orthopedics, applying a cast, is all it needs to heal correctly or prevent this problem. But, if it has happened, Dr. Shrestha mentions that there are various surgical modalities, ranging from simple lengthening procedure to micro-surgical reconstruction (which is complex and needs expertise). “This study highlights the importance of simple procedure and prevents ischemic contracture, which is very difficult to treat, needs expertise, is expensive, includes a long rehabilitation period, and which will have some residual problem, after all.”
When asked about the impact this study can make in the Nepalese medical programs, she says, “We are at the stage where orthopedics is developing multiple subspecialties, which is great news. This study on Volkmann’s ischemic contracture will raise the red flag that we also need to look back on our basic training, teaching, and the foundation on which these sub specialties are to grow.”