Remote-access thyroidectomy techniques aim to address patient concerns regarding visible cervical scars but are often limited by cost, equipment, and learning curves. We describe a novel open technique thyroidectomy via an infraclavicular open scar-concealing approach that re-locates the incision to a clothing-concealed infraclavicular site while preserving the principles of conventional open thyroidectomy.

A defunctioning loop ileostomy is widely used to protect distal bowel repair and anastomoses, but is associated with significant stoma-related morbidity and the obvious need for a second procedure for closure. We therefore evaluated the creation of an unopened exteriorized (covering) ileal loop without ostomy as a simple, feasible alternative. In our prospective interventional study, 26 patients undergoing emergency surgery for ileal perforation or distal intestinal obstruction underwent this procedure, with an option for bedside conversion to ileostomy if required. Stoma conversion was required in only four patients, while the remainder avoided ileostomy and underwent loop repositioning without complication. This technique appears simple and safe, avoids stoma-related morbidity, and eliminates the need for a second surgery in the majority of patients.

Diabetic foot ulcers (DFUs) are among the most debilitating complications of diabetes mellitus, substantially increasing morbidity, healthcare costs, and risk of amputation. We prospectively evaluated the efficacy of various tailored surgical offloading procedures in promoting biomechanical ulcer healing and preventing recurrence. No patient experienced ulcer recurrence or new ulcer formation during a mean follow-up of one year. Revision surgery was not required in any case. Individualised surgical offloading techniques are viable and effective for DFUs as they address the underlying biomechanical derangements that predispose to ulceration.

Introduction Diabetic foot is a major cause of morbidity and nontraumatic amputations in India. Despite national guidelines, care remains fragmented across specialties. This study aimed to examine the roles of various surgical specialists in diabetic foot care in India. Materials and Methods A web-based survey comprising 20 questions was distributed via WhatsApp to general, plastic, orthopaedic, and vascular surgeons across India. The survey assessed specialty involvement, interdisciplinary collaboration, procedural roles, availability of protocols, and awareness of newer techniques. Responses were analyzed using descriptive statistics. Results A total of 126 surgeons responded: 50% were plastic surgeons, followed by general (25%), orthopaedic (16%), and vascular surgeons (9%). While 94% favored dedicated diabetic foot clinics, only 16% reported the presence of written institutional protocols. Plastic surgeons were the most commonly identified team leaders (83%) and were predominantly involved in wound coverage (97%). Vascular surgeons led in revascularization (86%) and orthopaedic surgeons in deformity correction (62%). Collaboration was highest with physicians (79%). Awareness of nerve transfer techniques was high (86%), but practice was limited. Conclusion The survey highlights strong support for multidisciplinary diabetic foot care but reveals widespread gaps in structured protocols and coordinated team roles. A national call to action is needed to implement unified, context-sensitive, team-based diabetic foot care pathways across health care levels.

Cleft lip and/or palate (CLP) is among the most common congenital anomalies worldwide. While primary surgical repair is essential, comprehensive CLP care also depends on equally important secondary services such as speech therapy, audiologic support, orthodontic care, and revision surgeries. In many low- and middle-income countries (LMICs), these services remain limited or inaccessible, resulting in suboptimal long-term functional, aesthetic, and psychosocial outcomes. Our narrative review searched across PubMed and Embase databases to identify the availability, delivery models, and outcomes of secondary CLP services in LMICs. We found 17 relevant studies and mapped existing evidence, identified key gaps, and explored barriers related to workforce shortages, training, infrastructure, and financial constraints. Our findings highlight the urgent need to strengthen multidisciplinary CLP care pathways beyond primary surgery. Investments in sustainable local capacity, tele-health enabled service models, task-sharing, and community-based interventions are crucial to achieving equitable, high-quality CLP outcomes in resource-limited settings.

Negative pressure wound therapy (NPWT) has transformed the management of complex wounds across surgical disciplines. However, widespread adoption in low- and middle-income countries is constrained by the high cost and proprietary nature of commercial systems. This narrative review examines appropriate low-cost NPWT alternatives and discusses strategies to mitigate commonly cited limitations through protocol-driven care. Wider adoption supported by pragmatic evaluation and standardized protocols offers an opportunity to expand equitable access to advanced wound care in resource-constrained settings.

Frugal surgical innovations (FSIs) are increasingly recognized as practical solutions for improving access to safe, affordable surgical care, particularly in resource-constrained settings. However, the absence of a standardized taxonomy limits their description, comparison and evaluation. We developed the SHARMA-30 Framework to provide a common language for characterizing FSIs. Based on published examples and the authors' experience in resource-constrained surgical settings, the framework comprises six domains - Scale of innovation, Health-system integration, Affordability gain, Regulatory readiness, Maturity of evidence and Adaptability - each scored from 0 to 5, yielding a cumulative score (0-30) and a standardized profile. The framework enables consistent classification across surgical specialties, settings and innovation types, facilitating communication, comparison, prioritization and identification of strengths and evidence gaps. Although prospective validation and international consensus are required, SHARMA-30 Framework offers a practical foundation for standardizing the evaluation and reporting of frugal surgical innovations.

The necessity of drains after thyroidectomy remains debated, especially for large goitres. Our random controlled trial, conducted in a high-volume endocrine surgery unit and specifically evaluating drainage after thyroidectomy for large (>6 cm) goitres, demonstrated that routine drain placement does not significantly reduce post-operative haematoma nor seroma formation in our setting.Trial RegistrationCTRI/2021/03/031992.

Objecitve:Postoperative ileus (POI) is a significant complication after ileostomy closure, which results in recurrent vomiting, dehydration, delay in starting enteral feeding, and even anastomotic breakdown. We aimed to develop a prediction model for POI occurrence after ileostomy closure. Material and Methods:One hundred consecutive patients undergoing ileostomy closure were studied prospectively and data of various demographic and clinical variables were recorded in a predesigned proforma. The final prediction model was developed using logistic regression and internally validated in the next 50 patients. Results:Factors associated with POI were age, body mass index, tobacco or alcohol addiction, comorbidity, anemia, thrombocytopenia, renal dysfunction, as shown by creatinine level, hypoproteinemia, hypernatremia, and hypokalemia. The mean score of those who developed POI was higher (p=0.002) than those who did not. A cut-off at score 8 had a sensitivity of 85.71%, specificity of 73.12%, and area under the curve was 0.8241 (SE 0.1123). The predictive model was validated in the next 50 consecutive patients and showed good sensitivity (80%) and specificity (93.3%). Conclusion:Our predictive model can determine the occurrence of POI with accuracy.

Objective:Transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) offers a scarless alternative to conventional thyroidectomy. Most studies incorporate intraoperative neuromonitoring (IONM), which may be unavailable in resource-limited settings. We evaluated the learning curve, feasibility, and safety of TOETVA without IONM. Study Design:Retrospective. Setting:A retrospective analysis of 103 patients undergoing hemithyroidectomy by TOETVA between February 2020 and January 2025 was conducted at a tertiary care center in central India. Method:Learning curve assessment was performed using Cumulative Sum (CUSUM) analysis, and outcomes were compared between phase 1 (cases 1-50) and phase 2 (Cases 51-103). Statistical analyses included independent t tests for continuous variables and chi-square tests for categorical variables (P < .05). Results:Mean operative time significantly decreased from 185 ± 24 minutes in phase 1 to 105 ± 12.95 minutes in phase 2 (P < .001), with proficiency achieved after 50 cases. Nodule size was larger in phase 2 (4.5 ± 2.3 cm vs 3.0 ± 1.0 cm, P = .003). The conversion rate was 4.9%, with no permanent recurrent laryngeal nerve palsy. Hoarseness of voice and seroma rates remained unchanged (P = 1.00), whereas hospital stay significantly decreased (P < .001). Conclusion:TOETVA without IONM is feasible and safe, demonstrating a well-defined learning curve with low complication rates. These findings support its adoption in low-resource settings.

Sentinel lymph node biopsy (SLNB) has become the standard of care for patients with clinically negative axillary lymph node in patients with breast cancer. Low-cost dual dye technique using Fluorescein sodium and Methylene Blue Dye (FS + MBD) is particularly suitable for low-resource settings and surgeons using this must progress up a learning curve in order to ensure quality and safety equivalent to conventional SLNB. Learning curve of conventional SLNB has been evaluated; however, it has not been studied for FS + MBD. This prompted us to prospectively evaluate the learning curve for SLNB using FS + MBD. Identification rate of Sentinel lymph nodes, false negative rates, post operative morbidity were calculated for initial 100 consecutive cases for a single surgeon in a Tertiary teaching center in central India. The identification rate improved to 92

BACKGROUND:Management of axillary lymph nodes (ALNs) in breast cancer patients remains pivotal for staging and planning therapeutic strategies. However, In low-resource settings, achieving accurate axillary staging while avoiding overtreatment remains a challenge as the majority of patients present with advanced stage. In this prospective validation study, we assessed the efficacy of axillary ultrasound (AUS) combined with touch imprint cytology (TIC) for predicting negative axillary status in cT2-3 breast cancer patients. METHODS:This study was a prospective, single-centre validation study conducted in the Breast and Endocrine Unit of the Department of Surgery and the Department of Pathology in a tertiary teaching hospital in central India from September 2022 to April 2024. Eligible participants included adult female patients (aged ≥ 18 years) with core needle biopsy-proven invasive breast cancer classified as cT2-3, cN0, and scheduled for primary surgical treatment. The primary outcomes were the Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of the AUS + TIC approach in predicting pathologically negative axillary status. RESULTS:AUS + TIC had a sensitivity of 100% (95% CI: 47.82%-100%), a specificity of 100% (95% CI: 91.19%-100%) and an overall accuracy of 100% (95% CI: 92.13%-100%). There were no false negatives. CONCLUSION:Our findings suggest that the combination of AUS + TIC provides a reliable technique with high diagnostic accuracy, sensitivity, and specificity for assessing ALN in low resource settings.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a distant second choice as compared to conventional open thyroid surgery (OTSx) in India. The aim of this study was to understand the perspectives and decision-making of patients and healthcare workers (HCWs) about OTSx and TOETVA. Patients from a single centre were enrolled. Patients’ survey was done by using an interviewer-administered questionnaire, focusing on patients’ reasons for choosing the type of surgery. HCWs, who have assisted in TOETVA, were administered a questionnaire on their perspectives on TOETVA and OTSx. Patients Perspectives: A total of 70 patients underwent TOETVA and 95 patients underwent OTSx. Survey response rate was 90

Background: The management of early breast cancer patients with metastatic sentinel lymph nodes (SLNs) remains a critical decision point in balancing survival outcomes with surgical morbidities. This study addresses whether sentinel lymph node biopsy (SLNB) with or without regional node irradiation (RNI) can offer comparable survival outcomes to axillary lymph node dissection (ALND). Objectives: To evaluate overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and mortality outcomes of SLNB (with or without RNI) compared with ALND in patients with metastasis-positive SLNs. Design: We have performed an updated meta-analysis of randomized controlled trials (RCTs) comparing SLNB alone or with RNI vs. ALND for early breast cancer patients with metastatic SLNs. Data Sources and Methods: Eligibility criteria included RCTs comparing SLNB ± RNI vs ALND for metastasis-positive SLN. PubMed, EMBASE, the Cochrane library, and online registers were searched for articles comparing SLNB alone vs. ALND for metastasis-positive SLN. Articles were evaluated for risk of bias using Cochrane’s revised tool (RoB). The main summary measures using the random effects model were hazard ratio and risk ratio. Results: Seven RCTs were included in the meta-analysis. Overall survival and DFS were superior in the SLNB group compared to the ALND group. Locoregional recurrence and mortality were comparable between both the groups. After stratifying RCTs with regards to adjuvant RNI, these parameters were still comparable to ALND. Conclusion: This meta-analysis suggests that SLNB, with or without RNI, offers comparable OS and DFS to ALND for early breast cancer patients with metastasis-positive SLNs. However, the inclusion of studies that did not differentiate between micrometastases and macrometastases may introduce bias, particularly when assessing the impact of RNI. The role of RNI remains debated specially in those with macrometastases, and future research should focus on stratified analyses to clarify this. While SLNB represents a viable alternative to ALND, further trials are needed to define the optimal role in subgroups with high-risk tumor biology.

In this study, we propose a critical view of safety to promote standard visual identification and preservation of RLN during TOETVA. Laryngoscope, 135:1227-1228, 2025.

Surgeons in LMICs need to navigate resource constraints and require affordable, evidence-based solutions. ChatGPT, a generative AI, offers the potential for real-time, context-specific clinical support. Our study represents the first stage in constructing a ChatGPT-powered surgical assistant tailored for LMICs, focusing on validating an organized database of relevant affordable surgical solutions. A cross-sectional survey via Google Forms was sent to surgeons devoted to resource-limited surgical care. Some 25 previously published surgical solutions were assessed using a Likert scale for: (1) alignment with clinical practice, (2) recommendation for inclusion in guidelines, and (3) clarity of language. A total of 51 surgeons from 22 countries participated; most endorsed the solutions with 2/3 agreeing that they aligned with clinical practice and supported guideline inclusion, and >80% found their language clear. This endorsement supports the relevance and comprehensibility of the selected solutions and provides critical input for developing a ChatGPT-based surgical assistant, enabling tailored practical recommendations for LMIC surgeons.

Abstract Introduction  Risk assessment by various methods for HR +/HER2– early-stage breast cancer (EBC) patients help clinicians stratify risk and tailor individual treatment. Multiple prognostic tests are available, both free and expensive. Free prognostic tools, the Nottingham Prognostic Index (NPI), and modified Adjuvant Online (mAOL) rely on clinical parameters. CanAssist Breast (CAB) considers both clinical parameters and tumor biology for assessing the risk of recurrence. Objectives  The objective is to assess risk by CAB, NPI, and mAOL and discern the differences in the risk stratification in the EBC cohort of Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India. Methods  Study cohort comprises 100 patients. Risk concordance was assessed by the kappa correlation coefficient and restratification analysis between risk groups of CAB, NPI, and mAOL was assessed using a two-sided p -value. Results  Cohort was predominated by patients aged above 50, with T2/N0/G2 tumors. Low-risk (LR) and high-risk (HR) proportions by CAB, NPI, and mAOL were 67:33, 19:81, and 14:86, respectively. Across both age groups, CAB stratified more patients as LR compared with NPI and mAOL. In subgroups of patients with N0, G2, and T2 tumors, CAB identified significantly ( p  < 0.0001) higher (3–8 times) patients as LR than NPI and mAOL. In patients with T1/G1 tumors, risk proportions were similar by all three tools. Interestingly, CAB LR (57%) was four times that of NPI (14%) in the N1 subgroup. In G3 tumors CAB LR was 13%. mAOL failed to identify LR in the N1 and G3 subgroups and NPI in the G3 subgroup. There was poor agreement between CAB and NPI/mAOL (k 0.14 [95% confidence interval: 0.03–0.24]/0.11 [0.02–0.20]). Up to 11% of mAOL/NPI LR were detected as HR by CAB and up to 63% of mAOL and NPI HR as LR by CAB. Conclusion  Prognostication by tools that use clinical parameters alone might be inadequate. Prognostication using CAB that integrates critical biomarkers indicative of tumor biology along with clinical parameters could be significant. The earlier published data on CAB across various ethnic cohorts and its comparable performance with Oncotype DX makes CAB a relevant prognostic test in HR +/HER2– EBC to make decisions on chemotherapy use.

We have performed a meta-analysis of studies reporting on Health-related quality of life (QoL) after endoscopic thyroidectomy (ETx) vs. open thyroidectomy (OTx). The objective was to evaluate the QoL outcomes of ETx compared to OTx. Eligibility criteria: Studies comparing ETx vs OTx PubMed, EMBASE, the Cochrane library, and online registers were searched for articles comparing QoL in ETx vs OTx. Articles were assessed for risk of bias using Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. The main summary measures using the random effects model were mean difference (MD). Three studies were included in the meta-analysis. Two studies compared QoL between Transoral Endoscopic Thyroidectomy vs OTx and one compared Transaxillary Endoscopic Thyroidectomy vs OTx. There were no significant differences in the QoL outcomes using SF-36 scale. Pain scores assessed using the visual analogue scale (VAS) and overall satisfaction were also comparable between ETx and OTx. Our systematic review and meta-analysis indicate that QoL outcomes for ETx and OTx may be comparable based on the currently available evidence. The substantial heterogeneity across studies and the lack of adequately powered trials limit the generalizability of these findings. Future large-scale randomized controlled trials with robust QoL measures, such as ThyPRO-39, are needed to provide higher-quality evidence on the comparative effectiveness of ETx versus OTx.

Surgical innovations bring about a transformation in surgical care. Low-cost surgical innovations (LCSIs) are increasingly being recognized for their cost-effective attributes, especially in low-income settings. This chapter explores the nature of LCSIs, how they differ from conventional SIs, and the reasons behind their growing prominence. Additionally, it delves into the evolution and evaluation of SIs, highlighting the unique challenges faced when assessing LCSIs. Through examples of our own LCSIs, this chapter discusses the specific difficulties encountered in evaluating them and suggests potential solutions. Without proper evaluation, along with a robust and impartial assessment of how LCSIs stack up against more expensive and sophisticated SIs, they risk remaining obscure or limited to use in low-income countries, missing the opportunity to expand into broader healthcare settings.