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A new paradigm in distance surgical education. A promising solution for a surgeon’s daily challenges

India is a country with a population of nearly 1.3 billion people. India has a very low doctor-to-patient ratio and it becomes more abysmal when we consider the surgeon-to-patient ratio.

We also have to remember that India has a huge disparity in terms of standards of living, the kind of facilities available in metro, towns, rural areas. The population in a rural area can be considered lucky if they have a local surgeon in a 50-100 km radius. The problem is this surgeon is in most cases a general surgeon and hence getting treatment for specific issues that require Ortho, Neuro, ENT or even Dental surgeons becomes a challenge. This skewed ratio has put tremendous pressure on healthcare service delivery in our country. Patients in smaller towns and rural areas can expect to get treatment only for limited diseases as could be managed by the local surgeon. When a patient with an advanced disease diagnosis approaches the local surgeon (if one is available), he is advised to go to the nearest city to a tertiary care hospital. This is true not only for patients from small towns or rural areas but also in the cities and metros approaching a surgeon in a small nursing home. This results in the tertiary care hospitals overflowing with patients which in turn means very minimal time that can be given to each patient.

This problem is being solved to an extent through surgical conferences and workshops and also through some courses offered by surgery training institutes. The statutory requirement of collecting credit points through CME’s approved by the state or the national council does help in a limited way by ensuring some knowledge dissemination to the medical professionals. But one can’t overlook the fact that surgery is a matter of skill and dexterity and just watching some videos will not improve the surgical skills. The ability of the surgeon to wield all the surgical instruments with consummate ease, having fine control, being able to maneuver the anatomy and the tissue in question, even in the most challenging cases will decide the outcomes of a surgical procedure.

India is in dire need of a large number of skilled surgeons and hence it becomes imperative to have in place a system of education that is convenienteffective, safe, scalable and progressive. Let’s look at why these are the necessary and sufficient properties and how each of these would shape the outcome of a surgery training course.


A training course at any surgery training institute requires a physical presence of the surgeon for a minimum of 3-5 days. For outstation candidates, it means an additional cost of travel and stay. An even bigger cost is losing out on a week of clinical practice and surgeries. The last one is not just a financial impact for the surgeon but it also impacts all patients who are dependent on the only surgeon available to them locally. A training course that can be arranged within a 50 km radius would mean that the surgeon can operate in the mornings, travel to the training center for hands-on skills practice and get back to the hospital for the OPD/rounds by evening. If a skills center is not available at a quickly accessible location, then the learner should have an option to practice the skills locally at the hospital or any place for that matter. Surgery training courses will be accepted by the surgeons only if it takes into account the real problems of the surgeon.

To ensure improvement in surgical training courses, the theory can be disseminated through online mediums but it is imperative that we need to consider the availability of hands-on training centers in every district. Online training coupled with local skill centers will be the most convenient and inspiring opportunity that we can offer the surgeons.


If a surgery training course does not guarantee a tangible change in the understanding and skill levels of the surgeon, it is a pure waste of time and money. Any course that is being conducted should be done with the objective of taking the surgeon to a higher level of knowledge and skill. The courses that last for less than a week just bombard and overwhelm the learner with information, offer very little chance to practice the hands-on exercises and result in a very small percentage of learners who have the confidence to handle cases using the newly taught concepts and techniques.

An effective surgery training course needs to have a structure and process that hand holds the surgeon till the time the surgeon reaches a higher level of skill. Confidence building in the learner can be achieved through regular mentoring and skill evaluation processes. With the use of technology this can be done remotely and at the convenience of the mentor and mentee.


There are 2 critical factors for ensuring safe outcomes from a surgery – deep understanding of the surgical anatomy and dexterity in handling the surgical instruments while doing surgical steps such as dissection, knotting and suturing. Understanding of surgical anatomy can be done by watching surgery videos, assisting senior surgeons in surgery and through many other ways. However, surgical dexterity can be achieved only by continuous practice. The problem is a surgeon cannot afford to develop this skill by practicing on live patients. Training on cadavers has been an approved and safe way to practice. Nowadays, non-cadaveric surgical models are available that give the surgeon a real-life experience of surgery.

A surgical training course should have exercises that can be done on tissues, cadavers or models. If the faculty can guide the learner on developing some models on their own, it can help the learner practice the surgical skills at will in a safe way and that too at a fraction of the cost.


There are only a handful good surgery training institutes in our country today. An effective training course requires good faculty to give time to observe the learners, handhold them and mentor them when they practice their skills. In a surgery training institute, there is a limitation on the number of learners that can be accommodated and hence the faculty requirement is also limited. In some other cases, the institute limits the number of learners due to unavailability of good faculty.

To ensure a course that is scalable, we need to ensure that a substantial number of good faculty is available all the time and the delivery mechanism should also be able to accommodate a large number of simultaneous learners. This is possible only in a distance learning course as the faculty can deliver the course from anywhere. Given an option and resources, the institute can onboard faculty from anywhere in the world. Since the course is being delivered online and not restricted by space constraints, a large number of learners can be enrolled for the course.

Scalability is an important factor as it will take the country’s healthcare service to the next level in a short period.


As is the case with any other profession, there is a certain growth path that a surgeon can follow. Let’s take an example of laparoscopic surgery. A novice practitioner of laparoscopic surgery will typically attempt to do a couple of surgical procedures like laparoscopic cholecystectomy and laparoscopic appendicectomy. The most common next milestone is to start doing laparoscopic hernia repair and then move further into onco surgeries. Generally, a surgeon after a few years of practice with a certain set of procedures wishes to move to the next level of skill and for this, needs to undergo some formal training at a surgical training institute. Medicine and surgery has reached such fine levels of super specialization that a surgeon will need to invest a lot of time attending courses to achieve the next milestone of surgical skill.

Surgical courses delivered through the distance learning mechanism can speed up this process as the surgeon can move from one level to the next at his own convenience. Also, as seen earlier since the distance learning mode of surgical training is much more cost-effective for the surgeon, there is a better chance that the surgeon will adopt continuous learning as a way of life and keep improving his surgical skills in length (types of procedures) and breadth (skill level to do complicated cases in each type of procedure).

DISSECT – Distance Surgical Education and Capability Training is an online surgical education platform that addresses the 5 requirements mentioned earlier. It is essentially structured as a 3-phase course with a Pre-course phase that builds awareness in the learner, a hand-on phase that focuses on building hands-on skills and dexterity and the most important Post-course phase that gives confidence to the learner through continuous hand-holding, live tele-mentoring and objective skill evaluation that precisely identifies the shortcomings in the learner and helps in focused learning and improvement.
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Performing laparoscopic surgeries in rural areas with LapGuru

Teaching and training methods for Laparoscopic surgeries have evolved considerably since it was first introduced in late 1980’s and early 1990’s. Most of the learning in those days was limited to short-term courses that were largely centred in big cities, followed by quick implementation in the operation theatre. This unstructured approach sometimes resulted in major threats to patient safety and undesired outcomes for the surgical process undertaken. There was a huge lacuna that existed in training laparoscopic surgeons, more so in tier 2 and tier 3 cities.

For example:  In rural areas, due to limited resources available, women usually come very late to health care facility and desire a permanent cure for their disease. Till sometime ago, the newer and lesser radical treatment options for gynecological conditions like laparoscopic hysterectomy was not available in remote areas. A number of minimally invasive surgical options for hysterectomy do exist now and are promising like endometrial ablation, thermal balloon therapy and uterine artery embolization. However, there exists a need to train more and more surgeons on these procedures so that they can be widely used.

When compared with open surgeries, laparoscopy is somewhat difficult to both, learn and train. For example, during open procedures the operating surgeon can teach a learner in a direct fashion whereas in a laparoscopic surgery the operating surgeon is simultaneously teaching while retracting a tissue or driving a camera. Surgeons need distinctive skills sets to perform laparoscopic surgery efficiently and accurately. It uses specialized equipment and the surgeons must be familiar with the workings of devices such as suction irrigators, clip appliers, staplers etc. While the cognitive skills can be accurately disseminated via traditional methods, learning the technical skills for laparoscopic surgeries requires a more structured approach.

In a first, LapGuru, an online surgical training platform for laparoscopic surgeons, has launched online live surgical videos to train rural doctors in small towns and far-flung areas to help augment their laparoscopic skills. The ideology behind the platform is that there are lakhs of doctors who may not have the time to attend physical conferences, continued medical education programs as they are busy working in rural or tier two cities. Distance, time and sometimes expenses become a major hindrance in pursuit of excellence for them. LapGuru can help save many precious lives and improve quality of life of many more by improving skills of the doctors attending to them.

Advanced medical care is often unavailable to patients in remote, rural areas. LapGuru has become an effective method of teaching the local doctors practical and cost-effective new methods in Laparoscopic surgeries. It broadcasts live surgeries for doctors in rural settings to learn from some of the world’s top laparoscopic experts.

“LapGuru is an excellent platform to view surgical videos in various disciplines. The high quality videos contain step-by-step procedures, checkpoints and are supplemented with the instrument list for each procedure. Watching the LapCole videos on LapGuru has helped me to come up with alternative approaches to complications encountered during surgery. I have also been able to save a lot of time as the videos have helped to cut down on unnecessary things during procedures. I am thoroughly impressed and fascinated by the value it provides to seasoned surgeons along with those who may be interested in pursuing a career in surgery.” Says Dr. Subhadeep Tripathy who is practicing laparoscopic surgeon in rural Maharashtra.

 Many medical facilities in rural areas are not equipped with the latest technologies to train staff on latest up to date advancements and medical information to run a more efficient healthcare practice. Having access to materials such as a library of live surgery videos that demonstrate the correct way to perform tasks and error avoidance strategies can be very helpful to bring world-class expertise into rural operating theatres.

 For example, in Satara one hundred eight patients have undergone laparoscopic cholecystectomy; there have been no deaths; 2 cases were converted to open procedures; no common bile duct injuries, postoperative complications, or long-term complications.

While there is a growing issue with a shortage of doctors, rural healthcare facilities can utilize programs and modern technologies to improve the care provided to patients. And leveraging LapGuru can help train the medical staff in real-time from leading experts across the globe. LapGuru has a library of over 2500+ live surgery broadcasts in which surgeons have performed various procedures like General, Bariatric, Colorectal, Urologic and Gynecologic surgery in real-time, and have taken questions over a video stream. Viewers only need a standard web browser on a computer, a laptop or mobile device to join in and watch. The surgeons can watch a re-run of the surgeries at their own convenience a number of times to master both the nuances of procedure as well as handling of the equipment used.

How a surgery that leaves no scars can still cause ugly damage!

Laparoscopic surgery is one the most noteworthy advancement in the field of surgery in recent years. This minimal access approach has been widely accepted and adopted for many types of surgeries. The benefits include decreased post-operative pain, shorter lengths of in-patient hospitalization, increased patient acceptance, and a more rapid return to normal routine. Though this procedure is considered to be highly reliable, it is unlikely that no errors can occur throughout this process, even in the simplest of cases. One can definitely say that lesser incision length, less incision pain, less hospital stay may not actually translate into less risk. 

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