Surgery on Conscious Patients: Ambulatory Surgery in the Bumese Naga Lands.
By Dr Naga Thein Hlaing, Gregory Kleiman, Heiko Rudolph (ed.).
Copyright Dr Naga Thein Hlaing
Published by Heiko Rudolph.
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PREFACE by Greg Kleiman,
I have met some pretty remarkable people in my visits to Myanmar over the last 28 years. One of my favourite finds is Dr Naga Thein Hlaing. He is a 76 year old practising surgeon who has developed his own surgical techniques to suit the remote, poor, and primitive area of Naga Hills that he was posted to in 1965-1971. He has continued to practise the same techniques since then so he has more than 40 years' experience now as a surgeon. He is always telling me that a surgeon needs to have: the heart of a lion, eyes of an eagle, the hands of a lady, and the mouth of an angel. You should be able to gauge a little of these qualities from the photos and documents attached.
There are only a few simple tricks he has used to perform his surgery. The most important is that he uses local anaesthesia to operate on his patients. This means that his patients are conscious while he operates on them. He is able to perform all types of surgery except chest surgery and brain, using local nerve block techniques. The advantage of this is that he can operate single handed and the patient is not in any danger from the side effects of general anaesthetics. He can constantly monitor the patients status by talking to them which makes it easier to do goitre operations and not cut the nerves associated with voice box function. The patient is able to get up and walk out of the operating theatre at the end of the operation and eat immediately.
They do not need to stay in a hospital, he can operate on people in their own homes or villages as long as the place is reasonably clean.
Where he worked in the Naga Hills there was no real hospital in our sense of the word and no supplies of blood. So he used a little lateral thought and developed a method where he sews before he cuts a blood vessel. A normal surgeon would cut a vessel first and then suture the ends of it. He sutures where the ends will be and then cuts. This means he doesn't have hardly any blood loss for the patient.
One of his last tricks is to give an antihistamine at the same time as he uses the local anaesthetic and this increases the time that the anaesthetic lasts by about 4 times.
He has used this type of surgery to become proficient in goitre operations which is his speciality. He has operated on thousands of goitres in both Naga Hills and also in other parts of Burma.
One of the things I like about him is his honesty and sincere regard for his patients. When he lived in Naga hills he developed a respect for them as people and even went around dressed as one of them sometimes. He travelled the area on foot from village to village for there were no roads there.
He has this wonderful collection of old photos from the region. Many of them are before and after shots of people he operated on and so are a bit gruesome, but they are a real and valid record of the area. Oh did I forget to mention the Nagas are head hunters!
I have edited and compiled this document of his work and photos. Hoping that some doctors out there may find the information contained to be useful and informative. Be warned some pictures show a real operation with a conscious patient! They are even sticking their tongues out in the few of them. Remember that although this is not what you are used to thinking about operations you go to the dentist and they do most of their work under local. Just imagine your doctor did the same it is not that hard if you have the heart of a lion...
Greg Kleiman, Pyin Oo Lwin, Myanmar 2009
---(O)---
Introduction to the 2011 edition: by Heiko Rudolph
Dr Naga's life story came to me via Greg's first edition of this book in 2009. C. Win U and I met Dr Naga in person on 4 January 2011, hoping to talk to him for an hour or so. We spent until late afternoon listening to his stories about life in in the Naga Land hills, visiting the surgery at his house, and leaving with bags of disks, books, 70Giga Bytes of data, and his written blessing to get his story out into the world, so that others may follow his practical low technology methods of easing suffering and pain.
I love the simple effective methods he developed. None of the components are in themselves radically new, but together they gave relief, saved lives, eased suffering. Dr Naga listened to the request of the Naga people: to be treated in their villages, to remain conscious, and to have relatives and friends close by. He let his patients be his teachers, and developed a solution which reached people in places nothing else could have.
Dr Naga's work appeals to me for these reasons:
1) He was able to find a solution to a problem that seemed unsolvable: thousands of people with goitres, tumours, growths, lumps and bumps. The people refused to come to a modern hospital. By combining current knowledge and applying it in novel ways Dr Naga found a way to help those people, in what he calls 'ambulatory surgery'.
2) Simple, low technology and affordable for all. Seeing firsthand the advantages of fairly major surgery performed on conscious patients. Dr Naga writes " Since consciousness is not lost, various protective body reflexes remain active." To this I would add, that the patients seem calmer and more reassured. Often their relatives are close by within earshot or even assisting. Watching video recordings in which the patient sings, counts or speaks with the surgeon while her neck is opened up in a big red patch is an unusual sight for a Westerner of my protected background. I would not have believed it possible.
3) Above all I admire his courage and initiative. It was this very courage to stand up to an unfair status quo that put him into conflict with the authorities of his University and his Medical College. He was posted to the Naga Lands as punishment, and he turned it to positive to produce his greatest life's work. He chose to make the best of a situation where others might have succumbed to anger and bitterness or given up.
Each method has its rightful place. Dr Naga's ambulatory surgery was ideal for the Nagaland hills of Burma in the 1960's. We hope this book inspires others to find practical solutions that give aid in equally challenging places around the world.
Dr Naga was once asked to teach and train people in North-East Africa, the Sudan, Ethiopia, Eritrea, region. May this book reach those and other places of need.
This book is the voice of Dr Naga. It is based on Dr Naga's initial written work and was extensively extended, edited and finally published as a PDF document by Gregory Kleiman in 2009. Preparing the ebook format and minor editing in 2011 was my contribution in the chain. We have tried to keep the distinctive style and voice of Dr Naga.
Heiko "Hai-ko" Rudolph, Yangon (Rangoon), Myanmar, September 2011.
Contact: DrNagaSurgeon@gmail.com
DISCLAIMER, WARNING: This book is for illustration and telling a story only, it is not a textbook or instruction book. The techniques shown were carried out by a qualified surgeon, Dr Naga, and represent that surgeon's view. Surgical details are given by Dr Naga to provide evidence of and give confidence in the success of the methods used in Naga Land.
The authors take no responsibility or liability for the accuracy of any information in this book.
We hope other surgeons are inspired to follow Dr Naga's footsteps. Please feel free to circulate this book widely.
CONTENTS
PREFACE
INTRODUCTION
A BIOGRAPHY OF DR. (NAGA) THEIN HLAING
ENDEMIC GOITRE SURVEY FOR PREVENTION AND CONTROL
AMBULATORY
SURGERY
AMBULATORY SURGERY PHOTOS
PROCEDURE FOR THYROIDECTOMY
UNDER LOCAL ANAESTHESIA:
BEFORE AND AFTER PHOTOS
TOXIC GOITRE
TOXIC GOITRE IN MYANMAR (BURMA)
TREATMENT OF TOXIC GOITRES
(APPENDIX-A): Detailed list of Toxic Goitre Operations from
1965-2009
Chapter 1: INTRODUCTION
My name is Dr Thein Hlaing and I am also known as Dr Naga Thein Hlaing because of my work in the Naga hills area of Myanmar between 1965 to 1971. I have written the information contained in these pages for the following purpose:
1. In order to share my more than 40 years of learning, experience and service as a doctor and ambulatory surgeon with my fellow health professionals.
2. To explain the unique methods of surgery and treatment which I have developed through strenuous effort, and which I have put my heart and soul into developing, so that one or two people may become interested to learn from my experience and research and continue to practise these methods in the future.
3. To amend the wrong and find the truth in my own practice and to help the people who are in need. For as the old saying of Professor T. Levit goes, "Nothing is static, change is constant, not only in the sequence of life but also in the understanding there of." At the beginning of my 40 years of service I really had no special field of interest, but as a young doctor I was posted to the remote area of Naga Land, where I found that 60-70% of the population had goitres. This initiated in me a desire to learn something more about goitres and why and how they are so highly endemic in this remote hilly region. With learning from books I set out into the Naga hills to study the endemicity of goitres there and to perform a field survey of the area. In these pages I have therefore written a section on that goitre survey.
While carrying out the survey I also came across many other ailments amongst the Naga tribes, patients presenting with lump, bumps and minor ailments. Since the people of this region were uneducated, illiterate, head hunters and spirit worshippers I tried to attain their confidence and trust by removing their lumps and bumps. I operated on them wherever they lived and used local nerve block techniques during these operations. They remained conscious throughout the operation. I gradually developed my own methods, findings and experience in this field which I call 'ambulatory surgery'. Therefore here also I have written a section on ambulatory surgery.
While performing small and minor operations such as lipomas, dermoid cysts, hydrocoele, hernias, FA breast etc. in their presence the Nagas requested for me to perform goitre operations in their villages. Thus, it became unavoidable and I had to operate starting with a small adenoma solitary in nature and by and by thyroidectomy under local anaesthetic became my daily subject. Therefore here I have also written a section on thyroidectomy under local. So as the years went by I gradually become a local surgeon, an ambulatory surgeon and a thyroidectomist.
As an iodization program was introduced into Myanmar some people came to the false idea that iodine or iodized salt cures goitre. These poor fellows, without consulting a physician, monkey with iodine and turn from a peaceful lamb into a galloping horse and then toxicity sets in which is a rare and self inflicted disease. They would then come to me to operate on them and so I have operated on many patients with toxic goitres. Therefore I have also written a section on toxic goitres and how to achieve a permanent cure.
Since the second year of study for my M.B.B.S I developed a keen interest in human anatomy, and this lead me in my clinical years, after third year, to wish to become a surgeon and I really put my heart and soul towards this aim. At that time I also became the Secretary General of the All Young Doctors Association and I led a strike as an intern in 1960 which led to the House Surgeons getting an increase in pay. Although I won the demands from the Government but I was removed from internship and my hopes to become a surgeon were dashed.
Anyhow, I still tried my level best to become a surgeon and have become a surgeon recognized by my patients even if not by my fellow professionals. Thus, for my fellow professionals I would like to educate them what a surgeon is and to reveal how and why I become one anyway. This is also a topic you will find covered here in these writings.
Chapter 2: A BIOGRAPHY OF DR. (NAGA) THEIN HLAING
I was born on the 3rd of November 1933, in Thaton, Moulmein Division, Myanmar. My father's name was Tan Hoke Won and my mother's name was Nang Kyin Thone and they had nine children all boys. I am the second eldest of these sons. As you may notice from the names of my parents I am Sino Burmese. My name is Thein Hlaing also known as Edward Thomson Hoke Won and at present also known as Dr. Naga Thein Hlaing.
Before the Second World War I went to school as a boarder at St Joseph's Convent in Moulmein (present day spelling is Maylamyine). After the end of the war I attended St. Patrick's Roman Catholic School of Moulmein and was there from third grade until my matriculation in 1952.
After summer vacation in 1952 I enrolled myself for intermediate (A) at Rangoon University studying Physics, Chemistry and Biology. In 1954 I passed the intermediate science examination and became eligible to proceed to attend the Medical College Institute of Rangoon.
While I was a medical college student I become the founder of Thee Thant (Non-aligned) Association in 1957 and took the duty of Secretary General of Medical College Students' Union.
While holding the post of General Secretary of Medical College Student Union, I reinstated as emeritus professor Prof Ba Than, surgeon of Rangoon General Hospital who was about to retire by requesting permission from Rector Dr.Htin Aung of Rangoon University and the Educational Minister U Than Aung (Mr. Rivers). I also fought for to make the 3 Fail system to 6 Fail system for the first year medical students.
As the secretary general of the Medical College Student Union I was sent by the then Prime Minister U Nu to the Republic of China in 1958 to study the way of life in that Communist country. I had never failed any subjects in my life before, but in 1958 I failed my pathology exam. I was given a warning by the Professor of Pathology Dept., Prof U Khin Maung Win that if I did not give up my student political activities he would fail me again. So I was forced to set my political work aside and passed my exams and became an M.B.B.S in Rangoon in March of 1960.
In 1960, among the 85 house surgeons of our group 58 enjoyed a 205 kyats bonus given by the government; for one year of house surgeon ship. The 27 house surgeons who failed to get the 205 kyats requested me to help them to make a claim to receive the same as the others. So I approached the Prime Minister and put up the case for my fellow house surgeons in order to get the 205 kyats bonus for all. Prime Minister U Nu rejected our demand and so I formed an association by the name of Young Doctors Association of Burma.
As the Secretary General of the Y.D.A. I called a press conference and declared that if our demand was not met within 7 days the house surgeons would go on strike. Thus on the 7th night after that the strike began and lasted 4 days before the government gave in to our demand. But after this initial success and with only 3 months of my internship remaining I was removed from working as a house surgeon and my 3 months of internship for surgical ward was not awarded and withdrawn as a punishment. Thus, I only completed 9 months of my internship.
I had been very keen to become a surgeon and tried my best as a student to learn and know the human anatomy, keeping Grey's anatomy as my bible. Unfortunately, because I had become a strike leader of house surgeons my hopes to become a surgeon were dashed.
Consequently on the 5th of January 1961 I joined the Union of Burma Shipping Agent as a ship's surgeon. While on board there was nothing much for me to do, I become lonely and came to know that I will be nothing without a patient to cure. I passed the time by reading books.
One day when I arrived at Akyab (aka: 'Sittwe') I requested the Civil Surgeon Dr Hla Saw Khine to allow me to operate on a case of hydrocoele, thinking that it is an easy operation. However, while performing this hydrocoele operation I came to realise that I would never become proficient or successful by simply knowing the procedures only.
So I tried to search for ways and means to become a proficient surgeon and an able one. As I read books I came to learn many things about a surgeon's life. One famous surgeon wrote: 'There are many surgeons in the world. If you want to see a surgeon, go to a bazaar.' I followed the advice of this surgeon, but could not see his point. After many visits I came to learn that there are really many cutting, chopping, peeling surgeons selling beef, meat, pork, and chicken using their sharp edged knives.
A famous surgeon wrote: 'The surgeon is the one who professionally holds his knife in order to reveal what is not seen or known. Removing tissue for biopsy or to amend what is wrong, or to repair what is disfigured, or to remove a part or whole of the internal organs of a patient that is pathologically damaged, to prolong his or her life, to remove a part or whole of the extremities in order to prolong his or her own life.' Oh! what a great job I thought.
Then in another book I found: 'It should be remembered that beneath your knife lies life.'
Again in another book it is stated that: 'The surgeon must have the four essences of a surgeon, the heart of a lion, the hands of a lady, the eyes of an eagle, and the mouth of an angel.'
Yet another famous surgeon wrote that 'Surgery is the art of the hand using specially made instruments, where the hand cannot be used.'
Another
famous surgeon reminds us by saying .
1.
The one who know how to operate is a surgeon.
2. The one who
knows when to operate is an even better one, and
3. The one who
knows when not to operate is the best and second to none.
Thus, from the difficulty of one hydroceole operated by me in Akyab I come to know it is not the books that make one a surgeon. Then finally I come across another statement which initiated my desire to practice surgery. One learned surgeon wrote, 'If you are going with the books only, you will be a lonely sailor, sailing in a small canoe, in an enchanted sea.'
Thus, on Feb 8 1962, I left the ship and joined the service as Civil Assistant surgeon. But again I was very badly treated by the then director of hospital Dr. Po Saw, who did not accept me into service because I had gone on strike in 1960. Eventually the commissioner of public service accepted my application and posted me as Assistant Surgeon of Mergui hospital.
Since then the door was opened for me to become a surgeon and to fulfill my wish to know what a surgeon is. In 1963, I was transferred back to Yangon (Rangoon) General Hospital (Y.G.H ) and was taken to anaesthetic department by chief anaesthetist Dr. Charry. In a few months time I was promoted to become 'Ward in Charge' of the new emergency ward 3+4 of Y.G.H.
There I was allowed to practise surgery on all the emergency cases of Yangon which were admitted as emergency cases. Thus, with the help of my 7 house surgeons I become the emergency surgeon for 9 months. During that period of 9 months I become an able emergency surgeon without any consultation and help from the other surgeons. This is proof that the patients are the ones that made me an able surgeon. Without patients you will be nothing.
Since then I come to realize that it is important to be with the patient to learn, to know how and to be talented. Thus I always stayed in the hospital spending all my time with the patients throughout my career.
In 1964 April 11th, I was again promoted as chief assistant surgeon to Professor Dr. Ba Than of Mandalay General Hospital and Rector of the medical college Mandalay. There with 7 house surgeons under me I had to take care of the East surgical unit. There all the elective surgical cases were performed by me. Thus I become proficient and experienced for elective and emergency surgical cases of upper Myanmar. During that time as a surgeon in Mandalay I had the chance of operating on 10 goitre cases.
In 1964, I was improperly punished and sent to Naga land as my punishment with 2 years service cancelled and one increment stopped. Being innocent I never bothered to fight the accusation and just continued with my intention to become a surgeon.
At that time the Nagas never used modern medicines for their ailments, but instead they depended on their spirit worshiping treatment, i.e. spiritual healing.
My hospital was empty and not doing very much for anyone. I was in that remote area with one trained nurse, one ward servant, a clerk and a night watch man. Thus I become helpless and lonely without any patients in the hospital even for minor ailments.
In Naga land, endemicity of goitre is high but since there is no complication of goitre very very few of them wished to undergo operation. But for cosmetic reasons and to relieve pressure on the chest a few wished to undergo operational removal. However for removal, they requested to remove under local, they wanted to be conscious and be able to walk back to their village immediately afterwards. They also wanted me to come to their uphill villages and operate on them there.
I actually did not know how to give local for such major operation, but unless I fulfilled their requests I would not have the chance to operate on them. At last I wrote and requested Dr. D.N.Biswas and Dr. Aung Tun, anaesthetists of Mandalay General Hospital to give me directions or share with me knowledge of how to give local anaesthesia. It was with their briefing and directives that I started to practice local nerve block for thyroid operation. And so I become a local surgeon or ambulatory surgeon in that region by using local nerve block.
From then on I tried to make friends with the people and visit the villages in order to meet with the patients and to teach, preach (on health), and to heal. I would go and give a lot of health talks about the dangers of lumps and bumps, hernias, hydrocoele, tumors of breast, and abnormal growths both within their body and superficial.
Thus by consultation by frequent contact and endless preaching and teaching on how to be healthy, they obtained confidence in me and came freely to show their concealed lumps and bumps tumors etc. Then, when once they become friendly and had confidence in me I tried to persuade them to undergo surgical removal.
All of these operations were performed for free and so cases started to come from near and far wherever I would go. Day in and day out without postponement I would fulfill their requirements and thus I became an experienced surgeon. I very quickly became a successful general surgeon operating in all fields including eye, obstetric and gynecology, neck, abdomen, traumatology, urology, etc. Everything except brain, lung, and heart surgery which cannot be done by local and require blood and artificial ventilation and other equipment not available to me. At the same time I was very lucky and with Gods help I become a very successful surgeon.
Not only in hospital but I also visited their villages whenever there was free time and acted as a mobile ambulatory surgeon. I had no specific operation day and never postponed unless preliminary treatment is necessary. And this is the way I become a competent surgeon, a general surgeon for all specialties except brain, lungs and heart surgery.
I operated on many cases of tumors, goitres, and hernias under local from 1965 - 1971 in Naga Land and I was promoted as Senior Township Medical Officer (TMO)
In April of 1971 I was transferred to Phyu, Pegu Division where endemicity of goitre was also high. Ambulatory surgery was continued and many cases of goitres were operated on.
In 1978 I was again transferred and promoted as Deputy Administrative Director (DYAD) Hospital of Bassein Division. Being a surgeon I went round to Pyin Kha Yaing, Nga Pu Daw, Ah Phauk, Ye Kyi, Ah Thoke, Kyaung Gone, Nga Thang Kyaung, Kyone Pyaw, Hin Thada and operated on many cases of goitres and other tumors as a mobile surgeon.
In December of 1978, I was transferred again to the Namkham Hospital in Northern Shan State where there are many goitres and the region is highly endemic. Thus again many cases of goitres and other tumors came for surgery.
In 1984, I was again transferred to Myanmar Railway as Divisional Medical Officer upper Myanmar. I practiced ambulatory surgery again in Mandalay.
In 1988, I was transferred to Tharrawady hospital as TMO. Here again I practiced ambulatory surgery.
In April of 1988 I resigned from government service and opened a private clinic at Pyin Oo Lwin until the present day. During that time I have been invited to Kanbawza private clinic in Thaung Gyi as a surgeon. After 4 months at Thaung Gyi I was invited to Aung Yadana clinic of Yangon as a surgeon. Having completed 6 months in Yangon I was invited to Seikthathukha clinic for 1 year as a surgeon and thereafter I resumed by duty in my own clinic.
Thus from 1965 to 2009, I have acted as an ambulatory surgeon.
To
conclude, I would like to give you one piece of good advice:
It
is the patient that teaches you and makes you an able surgeon, they
are the ones who make you to be a popular guy. Therefore treat
patients as patient and never turn your back upon them.
Thank you.
Chapter 3: ENDEMIC GOITRE SURVEY FOR PREVENTION AND CONTROL
In the year 1964, while I was in Mandalay General Hospital as a civil assistant surgeon and as chief assistant to Professor Dr. Ba Than, surgeon and rector of Mandalay General Hospital and Mandalay Medical College. I had the opportunity to operate on about 10 cases of goitres.
Nine months after that I was posted to Khamti in the so called Naga land as a punishment with the reward of two years service cancelled and an increment stopped for one year. Having taken up my new post on 15th January 1965, I became lonely and idle for there were only 6 in-patients in the hospital with malaria fever.
The hospital in Khamti was a double storey wooden building built in the year 1954 in remembrance of a joint meeting made by Prime Minister U Nu and Prime Minister of India Mr. Pandita Neru (Myanmar Indian border conference).
On my way to the hospital I had seen a lot of goitre cases especially in young Shan girls. I also saw goitres in the Nagas who came down from the hills. In order to keep myself busy and to make them have faith and confidence in me I requested the (Khamti Shan Prince) Sawbwa U Saw Mya Sein to give me a helping hand by sending someone for goitre operation.
A day or two later he brought his niece with a huge adenoma for operation ( Daw Aye Shin ). But at first she would not consent to the operation and was afraid to undergo operation saying that it was not effecting her except by its presence (weight). This is true, non toxic or endemic goitre usually presents no dramatic symptoms and are frequently ignored by the goitrous persons except when they are disfigured or produce complications.
After a time, Daw Aye Shin agreed to my surgical removal of her adenoma under local anaesthesia. There was no operating theatre in that hospital. So I used one room 20x10 foot as a theatre and I successfully removed her adenoma thyroid under local infiltration block. Seeing the adenoma in a kidney tray and the patient's well-being, almost all the people of that area wished to remove their huge goitres also.
So with a team of four: myself, one nurse Naw Mu Kyi, one ward servant, Ma Nyunt and a sweeper, Aung Thar. With God's help I successfully operated day after day on goitres and other tumors under local anaesthesia. Cases from around that area ( Khamti ) and also from outside areas such as Homalin, Mawlike, Chin Hill, Falam Thidin, Hakar, Myitkyina and Monywa etc. came to me for removal of various tumors. The reasons for this popularity was free surgery, under local anaesthesia and with zero mortality.
Within 6 months I was surprised to see all sorts of tumours in the people and thus come to know that not a single doctor who had been posted to upper Chindwin had acted as a surgeon for such ailments. This aroused curiosity and interest in my mind to go alongside the Chindwin river and make a survey of health problems and to go up into the hills for the same purpose.
This became the beginning or turning point of my life and career. I visited almost all villages uphill on foot with one helper, U Tha Lu, a vaccinator. I made goitre surveys, and performed ambulatory surgery for lumps and bumps. Thus I operated single handedly on mixed parotid tumours under local without other doctors, or even a nurse to help. I would just request anybody near me to help me only to hold things for me. This turned into a seemingly endless journey throughout the years without considering the so called open season and closed season.
By visiting almost all the villages uphill and making a clinical survey I came to realize that the endemicity for goitre was very high, at about 65-70 %. Therefore, I produced a report for the government with documentary photos and figures that the Naga hill are a highly endemic area for goitre and made recommendation that it was necessary to take action for its prevention.
The Minister of Health Col: U Hla Han agreed and sent a group of medical specialists as a research team, led by Dr. Kywe Thein, Dr. Dull Mya In, Dr. May May Yee etc. The Field survey did an earth soil and water analysis and also an analysis of iodine excretion in urine output. Their final report agreed with my initial report's findings that goitre is highly endemic and iodine seems to be necessary to prevent it. Thus a request made in my report for free iodized salt distribution was granted.
The iodized salt distribution was carried out for only 3 years from 1967-1971 and was so effective that the prevalence of endemicity dropped down from 68 % to 40 % within that time. However, after my transfer in 1971 the program failed to continue.
When I was in Phyu from April of 1971 to 1975, I also came to see a lot of goitres in that area. Many cases of different types of goitre from Laiway, Pyinmana, Thaungoo, Thandaung, Mone, Kyauk Kyi, Nyaung Lay Bin and Yoma areas and villages near the Sittaung river came for goitre operation in Phyu.
Thus I wrote a report that Yoma area is highly endemic for goitre and requested that a survey be done for its prevalence. Action was taken by the higher authorities, but the then A.D of Pegu division Dr. Hla Myint who without any investigation or research simply told the higher authorities that Dr. Thein Hlaing ( Naga ) Phyu TMO is famous and well known as a thyroidectomist therefore goitre cases from all areas follow him for removal and thus Yoma is not endemic. Thus, no survey was done though I believe it is highly endemic for goitres.
In 1978, I was promoted to Deputy Administrative Director (DYAD), hospital administration in Bassein Division. On my arrival, I was stationed at Kyone Gone hospital and performed ambulatory surgery under local anaesthesia for various diseases. Operating goitres, GI and lumps and bumps, hernias, hydrocaele, gynecological cases all under local and became highly popular for my free service. At that time I moved from one town to another as a local ambulatory surgeon, operating on goitres and all tumours and different diseases in Pyin Kha Yang, Nga Pu Daw, Kyaung Gone, Ah Toke, Ye Kyi, Nga Thaing Kyaung, Kyone Pyaw, and Hinthada.
I came to notice that even in Irrawaddy division though it is low lying land there were also a lot of goitres. In other words, it is also highly endemic instead of being sporadic. Its endemicity may be due to frequent flooding of that region or intense glaciation of low areas.
On the 22nd of December 1978 I moved up to Northern Shan State as TMO – in the so called Namkham Hospital or Dr. Seagrave Hospital. I was again forced to operate on goitres with complications, cosmetic, pressure abnormally large goitres.
Chapter 4: AMBULATORY SURGERY
The surgery of ambulatory patients is totally neglected by doctors in Myanmar. Surgeons who are posted to district and divisional hospitals, often as a matter of convenience, admit patients to their hospitals even for minor surgical procedures.
When once in hospital, the patients with minor lesions tends to be lost in the background to more important and dramatic fields of major surgery. So also, general practitioners and younger surgeons who see many of the surgical conditions for which ambulatory care should be given are frequently ill prepared to deal with them because of a lack of experience, equipment or assistants.
As medical science advances doctors try to become specialist and specialists become highly specialized specialist and if that were so who would be left behind to care for all the minor ailments of the 95% rural people. Thus ordinary doctors should take responsibility to perform minor surgery for ailments which is meet on a daily basis.
Ambulatory surgery can be carried out easily and safely with limited equipment and assistance if the surgeon has the guts and mind to perform it. It is probably the cheapest form of surgery for minor lesions at any time, or any place.
It should therefore be considered as the work of both general practitioners and of surgeons. It must be remembered that ambulatory surgery has virtually no mortality, requires few assistants and usually can be performed in any place. Eg. in an office, out patient department or in any village.
ADVANTAGES OF AMBULATORY SURGERY
1) The patient is able to pursue his regular occupation with little or no disruption.
2) He can go back immediately and stay in his own home, saving the costs for staying in hospitals.
3) The patient does well because of less stress, and has no complications.
EQUIPMENT FOR AMBULATORY SURGERY
OPERATING ROOM
The operating room is a room completely or almost completely free of bacteria (aseptic room) where surgical procedure is performed. It could be anywhere so long as it is aseptic in nature and need not necessarily be in a so called hospital.
A small room 20 x 20 feet will do.
You need sufficient light and ventilation.
Wooden operation table and one or two wooden small tables is more than enough.
One or two, 5 cell battery torches will substitute for electrical lamp. (for visual surgery – operate against the light ).
The boiling method of sterilization is useful where no electricity is present for electrical sterilizers.
If no sterilizer drum is available, new cooking pots will do for sterilization of drapers and instruments.
Bucket, plastic or ithemineou for disposal of used water etc.
Basins: one or two for hot water, cleaning of instruments, gauze 6x6 etc. during operation.
Instruments only essential instruments are need for all surgery, with the exception of a few small special instruments such as badcork, allis, and lanes forceps.
Surgery is an art of the hand using specially made instruments where the hand cannot be used. Since you can't cut the skin or incise the skin with your hand medical engineers have invented a knife or surgical blades for us. Also we cannot hold the small artery or vein with our fingers thus artery forceps or dissecting forceps are made for us.
EQUIPMENT
Bard
parker blade holder
Dissecting forceps with teeth and without
teeth
Scissors -pointed and sharp
Scissors - curved on flat,
Mayo
Needle holder – large size, middle size, small size
Haemostat: Straight and pointed
Straight and curved tip
Mosquito curve
Lane's tissue forcep
Suture needles
Straight pointed
Curve rounded 1/2 circle
Curve
triangular
Mayo's round pointed ½ circle
Intestinal of
different sizes
Cotton thread No. 20 size and 40 size.
Cat
gut 0, 1/0, 2/0, 3/0
Syringes for local ( 20cc, 10cc, 5cc all
glass )
Needle for local anesthesia No.18,21,22,23,25
Bowl
for local solution
Draper for different surgical procedure and
dis gowns for surgeon
Swabs, gauze rolls, threes etc.