Health Lifestyle

Dr. R Padmakumar: The Extraordinary Laparoscopic Surgeon with Excellence

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Apart from being an extra-ordinary keyhole surgeon, Dr. Padmakumar, who is one of the unique surgeons in the world performing all forms of minimally invasive surgeries, is well known for his caring and compassionate attitude. He, who has dedicated his entire life for hospitality, is not only an asset to our state of Kerala, but also a gem to the entire world. He is at a time a student, who is always eager to learn new techniques in laparoscopy; as well as a teacher who finds happiness in sharing what he has learned, to others who are eager to know about the topic.
After securing an MBBS degree from Alappuzha Medical College, his destiny was to be a part and a leader of a medical revolution. As a surgeon with around 23 years of experience, he stands with a magical method which offers a permanent solution to painful surgeries. It is important to remember that the doctor has contributed immensely in developing this surgical method and in passing what he has learned to the next generation for the benefit of the society.

It is the knowledge and experience he has gained from New Delhi AIIMS, Chennai Apollo and Mumbai Tata Memorial, and his hard work, accuracy and self-learning capability is what that makes Dr. Padmakumar one of the finest Keyhole surgeons in the world. He is a source of comfort not only to patients in Kerala, but also to patients in the GCC countries. He is the fifth person in the world and the first person in the Gulf countries and Kerala to conduct a surgery to surgically resolve the condition of diabetes under the non-obesity category. He is one of the rare doctors who has expertise in endoscopic thyroidectomy, and is the first doctor to successfully perform intestinal surgery with just two grams of haemoglobin. He is the inventor of Ileal Hybrid technology. It is a commendable achievement that he was ranked twenty-eight when the 100 most powerful Indians were selected in Gulf countries in the year 2012. The doctor has a lot of golden feathers in the crown of excellence such as Global Achievers Award 2014, Voice of Gulf Returnees Excellence Award 2016 and Icon of Laparoscopy 2018. In the year 2016, he was the National President of the Indian Hernia Society. Currently, he is the Chairman of the Association of Surgeons of India (Kerala Chapter) and National Vice President of SELSI (Society of Endoscopic and Laparoscopic Surgeons of India). Let’s hear what the apostle of simplicity and service has to say about the importance of keyhole surgery and many things related to that.


The Importance of Endoscopic Neck Surgery
Endoscopic neck surgery is one of the rare surgeries in the world. This is mostly done in thyroid cases. Nonetheless, this can be done in cases of para-thyroid, thyro-glossal cyst surgery and lymph node operation. Specifically speaking, a three-year-old Omani child with branchial cyst condition was treated with the help of keyhole surgery. Usually, this surgery is not done in children. This case is a world record. Generally, patients show disinterest to thyroid surgeries as it may leave a mark on the neck of patients. Today, using the potential of keyhole surgery, this condition can be cured without the fear of any permanent mark. The publication about Endoscopic Neck Surgery has appeared in the International Journal. A special invitation was made by the government of Dubai to perform these surgeries on their natives. What makes this method attractive is it does not make permanent mark and does not consume too much time for recovery. This surgery is of great importance in the treatment of cancer.

Small Wound, Excellent Results
Minimally invasive surgery training needs lot of dedication and hard work. Many complex surgeries which required large cuts (20 to 30 cm) in abdomen or chest can now be performed using one or two centimetre cuts. This will bring down pain very significantly and reduce hospital stay. Patient will be in a position to resume normal activities in few days. In cases of cancer, as the cuts are very smaller in laparoscopy, patient can proceed with additional treatments like chemotherapy or radiation without much delay. The need for blood transfusion is reduced to one-hundredth as we have precision, magnification by HD camera and vessel sealing by use of ultrasonic devices.

Obesity Treatment
Obesity in children is managed by Intragastric balloon placement with the help of endoscope. Women suffering from infertility due to polycystic ovarian disease also benefits very well by this procedure, if they have high levels of body fat. People with morbid obesity will require Bariatric surgery. This keyhole procedure helps them not only in fat loss or weight loss but also helps to resolve their medical conditions like Diabetes, high BP, high cholesterol, sleep disorders. The joint disease & fatty liver also improves a lot once the person loses weight. Risk of cancer especially of colon, breast, ovary – are reduced remarkably with weight loss.

Diabetes cure through surgery
It is a big deal that diabetes can be cured using laparoscopic surgery. It is an undisputed reality that there is no clear understanding about this among people. This surgery is normally prescribed to type-2 diabetes patients, and is very effective. This is called Hybrid Ileal Interposition. It has been featured in an International Journal as a surgical innovation. This treatment is now very popular around the world. I was an invitee in the first IFSO conference held in Canada in 2014. Hybrid Ileal Interposition has gained greater recognition than Robotic Surgery when it has been identified that the former consumes less time and costs less compared to the latter. If this surgery is done in a patient with diabetes type-2, he/she can taste cure within a timeframe of 24 hours itself. If one is obese or overweight and under treatment for type-2 diabetes for long time, he/she can be treated with this method – which helps to adjust the intestine position and resume insulin production. But, this type of surgery is not effective in type-1 diabetes mellitus patients in which insulin production is completely defective.

Laparoscopic Hernia Surgery
All kinds of hernias can be effectively managed by minimally invasive technique. It avoids large cuts especially on the area of hernia which is already weak. Using a one centimetre cut, the lap surgeon can place large mesh – five times the size, possible in open surgery. Mesh will be placed in the beginning portion of hernia so as to get best strength and least reaction with skin and fat. It gives excellent results as recurrence chance is only 0.1 percent and infection chance is very negligible. Patient can be active in few days’ time compared to months of rest in cases done by open techniques.

How did you get interested in Laparoscopy
The Laparoscopy was introduced in India while I was doing my post-graduation in New Delhi. It was only few years since its inception in the world. My training period gave me the opportunity to observe and compare the laparoscopy with open methods. The remarkable advantage and comfort of laparoscopy experienced by patients, generated interest in me to pursue this speciality. I have trained and developed a team of experts who are now capable of performing these procedures and surgeons from all across globe continue to benefit from our training programmes.

Keyhole surgery: Further studies are underway
Right now, there are several surgical associations across the world. Special live operative sessions and conferences are arranged for – the members of these associations – who are interested in this specialty. In some cases, only a week long session is required to get an idea of this method. Sessions about this procedure also improve the knowledge of both teachers as well as students. I was a person who learned this technique with my own effort. Earlier, it needed at least one year to learn this method. But, now, it requires only weeks. What attracts doctors is the fact that laparoscopy require less time to perform.


This surgical procedure is taught through several steps and methods. Large pigs in animal labs at Yenopoya Medical College are used for training purpose. To get an opportunity to try this method on human, a surgeon has to get acquainted with this technique by observing several cases on a regular basis. International Conference is organised every year to discuss the latest developments of this specialty, and to promote this method. The main objectives of Verwandeln Institute in Kochi are to promote Laparoscopic training and conference. The institute activity benefits learners, and helps patients to be aware of this surgical innovation. Only when patients are aware, they seek such procedures and give consent to laparoscopic surgeries. There is an outpatient section, named Keyhole clinic in Kochi to educate patients about this method. For those who need the surgical service, it is done at VPS Lakeshore hospital.
There is a general confusion about whether there is any difference between keyhole surgery and laparoscopy. Actually, laparo means abdomen and scope means watch. That means when done in the abdomen – it is laparoscopy; when done in the chest -thoracoscopy; when at the joints- arthroscopy; and when in the neck- endoscopic neck surgery. Laparoscopic method is helpful to treat cancer – especially in cases connected to intestine. It avoids bringing out intestine – stoma.


Some experience
Jehovah’s Witness belief group will not accept blood transfusion. Once such a patient, with an intestine bleeding condition, consulted me. For him, his belief was much higher than his life. To save him and his belief, for the first time in the modern medical history, surgery was performed on him with just 2 gmHb; without the support of any blood administration. He was given oxygen assistance for at least four weeks. An injection to improve haemoglobin level –was administered. He successfully recovered from his disease. That story was featured in several global journals.
For a doctor, what is important is the health and satisfaction of his patients. He should be willing to go to any extend to help his patients. Had I not taken that risk, the aforesaid patient would not have survived his disease condition.
Likewise, a surgery performed on a cancer patient who was turned away by almost all major hospitals across India is also noteworthy. She was struggling with the pain caused by the disease condition. The tumour that had developed in her pelvis had spread to almost all nearby organs. Through surgery, the size of the tumour was reduced to around 1/20. It is very satisfying to see her moving around happily.
A surgery done on a woman who suffered a stab injury from a guest worker is similar to those mentioned above. She was bleeding to death. In that case also, the patient was successfully saved by an emergency chest surgery within minutes of her arrival to hospital.

Health Lifestyle

COVID-19: THE CROWNED DOOM

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Article by,

Dr. Binoy John, MD DM (CARDIOLOGY) FCSI FACC FESC FSCAI FAPSIC Senior consultant interventional cardiologist & specialist in heart failure & advanced cardiac diseases

A virus is not even a living thing, but yet has managed to get a technologically and militarily advanced human-world in its entirety into a stupefying and unimagined lock-down, while every other animal moves gracefully free! It is enigmatic to realize that this virus which is just 0.06 – 0.14 Microns in size and a mere structure of a single strand of nucleic acid, some lipids, proteins and carbohydrates and that which actually needs a host to propagate has humbled the scepter wielding powers of the world.

About the virus:
The Corona virus has spikes on it which gives it the appearance of a crown or corona, from which it derives its name. It is with these spikes that the virus gains entry into the host cells and multiplies and then causes all the ensuing destruction. It was initially named the novel corona virus and subsequently as the Severe Acute Respiratory Syndrome Corona Virus – 2 (SARS-CoV-2). The virus is presumed to have originated in bats and then moved to probably the pangolin before it infected the humans for the first time in Wuhan, Hubei province in China. The Corona Virus disease 2019 or the COVID-19, is now a global pandemic affecting over 3.2 million people and counting, in 210 countries and territories of the world.

How does the virus spread?
The virus is spread mainly via droplets but can be aerosolized when someone coughs or sneezes and can remain stable in the atmosphere for up to 3 hours in the aerosol, depending on factors such as atmospheric temperature, humidity and ventilation. It can remain on hard surfaces from 24 hours on cardboards and to as many as 3 days on steel and plastics. There are reports that the virus is excreted via the stools also. The virus has a high reproduction number and therefore spreads easily. So the common mode of infection is when a person with the virus contaminated hand touches the nose, mouth or eye or inhales the virus containing aerosol, with the virus thus gaining entry into the lungs.

The incubation time or the time between the entry of the virus into the body and appearance of symptoms is an average of 4 to 5 days, but can range from 1 to 14 days. An infected person can spread the virus even when he has no symptoms and thus be an asymptomatic carrier of the virus. It is the combination of the high infectivity along with the ability of a person to infect even when he is asymptomatic, that has been responsible for the rapid spread and the pandemic proportions of the disease.

How does it damage the lungs and other organs?
The primary target of the virus is the respiratory system and the virus uses its spike proteins to enter the lung cells by binding to a receptor called angiotensin converting enzyme 2 (ACE-2). This enzyme is expressed in the heart also, in addition to the lungs and also plays a key role in the functioning of the heart and development of high blood pressure in humans.
Once the virus enters the lungs it begins to multiply and the symptoms during these early stages are mostly mild or can be none at all. The protective mechanisms in the body tries to fight and suppress the virus by producing immune cells and also chemicals called cytokines. In some patients however, the release of these chemicals can be sudden and severely out of proportion, a phenomenon called, the ‘cytokine storm’ which ultimately turns out to be damaging to the patient himself. The chemical release damages the lungs causing breathing difficulty and the failure of lungs to oxygenate the blood results in decreased oxygen supply to all organs affecting their normal functioning too. When the kidneys start failing, the waste products start accumulating in the body, further depressing the function of the organs and also causes additional bacterial infection in the blood and organs causing septic organ failure.

What are the symptoms and signs of COVID-19?
The usual symptoms are fever and dry cough but conspicuously a runny nose and gastrointestinal symptoms like diarrhea and vomiting are uncommon, though they can occur. 80% of the infected patients have no pneumonia (lung-infection) or may have only a mild pneumonia and only 15% develop more serious respiratory symptoms needing hospitalization and assisted breathing support and only 5% become critical with respiratory failure, shock and or multi organ failure.

Who are the people at high risk?
It is to be remembered that the virus is highly infective and all are equally susceptible to the infection. It is the severity of the disease and the complications that varies amongst subsets. The ones who are at risk for more severe disease, complications and a poorer outcome are people with poor immunity, the malnourished, elderly and frail, patients on long-term steroids and other immuno-suppressive drugs as liver, kidney and heart transplant patients.

COVID-19 and the heart:
The primary damage to the heart results from the lack of oxygen supply to the heart which causes a progressive failure in the pumping function of the heart. Added to this insult, the sudden chemical storm can cause a fall in the blood pressure which further reduces the blood and oxygen supply to the heart, thus creating a vicious cycle of increasing damage. The brain when it senses this poor pumping efficiency of the heart, in order to maintain adequate oxygen supply to the organs causes an increase in the heart-rate. This helps initially, but then the heart starts failing like a repeatedly flogged horse does, to a point when it cannot cope up further and a cardiac arrest ensues.

People with heart ailments are not especially prone for COVID-19 and their risk to get the infection is the same as any healthy person. However, patients with heart diseases can have more severe complications when they get COVID, especially those with previous heart-attacks, heart failure, children with certain cardiac birth defects (blue-baby defects) to mention a few. Pregnant women who have heart ailments may be at a higher risk too. However there is no evidence that the virus can infect implanted heart-devices like pacemakers or defibrillators or that it can directly infect the valves, muscle or the covering of the heart. However it is important to note that the stress on the heart produced by the chemical storm may cause rupture of fatty plaques or blocks inside the arteries of the heart and can cause a heart-attack.

Another point of controversy and debate is regarding two medications used commonly to treat high blood-pressure (Angiotensin converting enzyme inhibitors and Angiotensin II receptor blockers) which block ACE-2 and its system through which the virus enters the body. It was of concern that people taking these medications could develop more lung complications with COVID-19. However these observations have no confirmatory scientific evidence and major guideline forming cardiology societies and associations like the American Heart Association, European Society of Cardiology, and British Cardiac Society have recommended that these drugs should not be stopped, because these are drugs with proven benefits. Stopping cardiac medications without advice from the cardiologist can only lead to complications.

How deadly is COVID-19?
Thankfully, majority of the patients recover. The death rate from COVID 19 is estimated to be 1.4% (which for flu is only 0.1%). The fatality increases with increasing age being less than 1% for people less than 50 years 1.3% for 50 to 60 years, 3.6% for 60 – 70 years, 8% for 70 – 80 years and 15% for those above 80 years of age. Also death occurred only in 0.9% of the patients when there was no associated illnesses but it was 6 – 10% when the patients had associated high blood pressure, diabetes and other cardiac conditions. The reason or mechanism as to why patients with high blood pressure have higher death rates is unclear but could mostly be only an apparent association because of the higher prevalence of high blood pressure in elderly age group (> 70 years of age) which had maximum deaths.

Diagnosis of COVID-19:
Testing for COVID specifically relies mainly on three tests, the real time reverse transcription-polymerase chain reaction (RT-PCR) which is the gold-standard for SARS-CoV -2 viral genetic material, the antigen test which detects viral surface proteins (eg: spike protein) and the third being antibody (immunoglobulin) testing. RT-PCR and antigen tests use specimens collected from the respiratory tract secretions of the patient. All the tests are useful in different stages of the infection as their titres are variable with the duration of infection, viral load and severity of symptoms. False positive results can occur with antigen testing and false negative tests can occur if the specimen collection is improper. Therefore a negative test should be repeated in a patient in whom the clinical index of suspicion for COVID is high.

Antibodies are produced by blood cells called lymphocytes, specifically against the virus and the antibodies bind tightly to the virus to inactivate it. Antibody levels start rising with time as the body tries to fight the infection and blood samples are used for detection of these. The immunoglobulin (Ig) M antibodies are the first to be produced in response to the infection and Ig G starts rising a week to 10 days after onset of infection and remains in the blood even after the patient has recovered and is the one that indicates possible immunity from subsequent infections. But it is too early to say how much immunity would be conferred by Ig G antibodies against COVID-19.

Treatment of COVID-19:
Currently, the treatment is mainly supportive like ensuring control of fever, maintaining good hydration and nutrition and it is only when the oxygen content of the blood drops, the blood-pressure drops or the patient gets worse that hospitalization is advocated. Several drugs currently used against the virus are those targeted against the different mechanisms of virus multiplication and the chemical storm. An effective treatment or cure in the form of medications can only be obtained by a detailed understanding of the pathology of the disease obtained from post-mortem studies and a deep understanding of the microbiology of this novel virus, the pathogenesis and immunology of the disease and use of medications directed at every possible step. Until the recent evidence with the drug Remdesivir, there was no definitive success with the use of any specific drugs against the virus. All medications being used were merely on an experimental basis. However, Remdesivir an anti-viral drug which prevents multiplication of the virus in the body has been shown in a multi-centre randomized controlled trial to have clear-cut evidence in hastening the recovery of patients being treated with it. The use of Remdesivir has now been made ‘standard of care’ in the treatment of patients hospitalized with COVID-19.

Some of the other drugs being used in COVID-19 patients with variable results are those which would prevent virus entry into the cell (chloroquine) or to treat cytokine storm (Tocilizumab). Drugs like chloroquine and hydroxychloroquine have only been tested outside the human body to show some efficacy and there are no randomized controlled trials to prove its efficacy in humans with certainty. It is important however to remember that some of the drugs have cardiac side effects and can cause electrical abnormalities called ‘torsades de pointes’ which can cause sudden cardiac death and therefore needs electrocardiogram (ECG) monitoring and should not be taken without consulting a specialist.

Treatment with convalescent plasma is another option being investigated and attempted. It involves the transfusion of plasma obtained from recovered patients, containing high titres of antibodies against SARS Co V- 2, into other patients who have less severe infection or patients who are in early stages of the infection or people who are at high risk of getting COVID, as health-care professionals. The antibodies present will prevent multiplication of the virus in the body and thus prevent lung and other organ damage. However this procedure is not totally risk free to the person receiving the treatment and have a risk of transmitting other infections and causing other immune reactions.

Prevention is better than cure:
As of now with no cure in hand, prevention is the key and the steps to prevention are simple and involves avoiding touching the mouth, nose and eyes with unclean hands, washing hands thoroughly with soap and water for at least twenty seconds or the use of hand-sanitizers containing at least 60% alcohol. It is also important to keep frequently touched objects clean with disinfectants. Practicing social distancing or maintaining a safe distance of at least two metres from other people whenever possible and keeping away from sick people even if their symptoms are mild and also staying away from crowded areas is vital. Also covering one’s nose and mouth with a cloth or with the inside of the elbow when one sneezes or coughs and using the non-dominant hand to touch objects so that you would not unknowingly use it to touch your mouth nose or eyes are good practices. Wearing the right protective masks in public places is crucial and only masks which are recommended for COVID-19 protection will be protective and have to be used in the right manner and will be useful in public places where the chances of getting infected are high.

If one experiences fever, cough or chest infection it is important to consult a doctor on the phone and follow his instructions and get tested only after taking professional advice as testing centres can be potential areas of high infectivity.

Vaccines and immunity:
Vaccines are being researched on fervently but would take a while to be available for human use, after they are tested in animals and proven to be effective and safe. After the first infection, it is speculated that COVID 19 would confer immunity but if mutations and fresh strains occur, they could re-infect, and would need fresh vaccines, information about which is currently unavailable. Herd immunity is a concept where, when a large percentage of the population are infected and recover and get immunity, thereby providing protection in a community, where the chances of non-immune people getting infected are less because the percentage of infected carriers in that community steadily becomes fewer.

Thus, the COVID-19 has taken an erstwhile head-strong and free world unawares, with a chilling shock, sending them into hiding, when an invisible nothing has humbled seemingly invincible powers and the powerful of the world, putting medical researchers and organizations on their toes desperately trying to find a quick resolve, while the front-liners strive tirelessly risking their own lives to save humanity from a rapidly decimating disease. Adding to the cost of life, the economic repercussions would be severe too.

This infliction of unimaginable proportions has also given humanity an opportunity to introspect on the wrongs we have committed, when we abused nature with all our power and glory; has given us a time to introspect on what we did wrong as a world and as individuals when we divided ourselves with borders, languages, colour, religions, caste and what not; when now, standing together singularly as humanity with humaneness seems to be the only way to tide over this catastrophe of unfathomable proportions. Let us change for the better, but then will we be given that chance? Hope and faith is what has always kept the world going and so may God bless us all!

Pic Courtesy: google/ images are subject to copyright