OUTREACH OF MIRCOSURGERY IN SMALL TOWNS
The compiler of these “Short Notes” (Ravin Thatte) was aware of the unusual and intrepid exploits of Dr. Mangesh Tandale, a plastic reconstructive and microsurgeon from the city of Chhatrapati Sambhajinagar (formerly Aurangabad), in the state of Maharashtra, in India. This year he won two awards at the Asia Pacific Microsurgery Conference at New Delhi in 2024 for his paper on Reconstruction of the Abdominal Wall and a poster on Palliative Surgery for Cancer of the Head and Neck. His work on reconstruction on cases of mucor-mycosis is also well known in this part of the world. Photographs from his award-winning paper and the poster are reproduced below.
A reproduction of the poster which too won an award
Here is the story of this plastic surgeon in the first-person singular who took microsurgery to patients in small towns and cities albeit helped along by this compiler. This story is reproduced here because medical science indeed is majestic, but its real worth is when it reaches the patient.
Ravin Thatte
Dr. Mangesh Tandale’s narration
Looking back, what happened to my career resembles a miracle. I came from a humble rural background in what is the least developed and poverty-stricken part of the state of Maharashtra (India) called Marathwada and what is more, my school education was imparted to me in Marathi, my mother tongue and the ‘state language’ while English was only a subject but not the medium of instruction. When I entered graduate college and later the medical college in Nanded a district headquarters the medium of instruction was English and this was a daunting challenge which I overcame with some effort. The seeds of trying to give back my expertise to the needy and the impoverished citizens of my area were probably present in my mind but the story how these seeds sprouted and ultimately grew into a microsurgical reconstructive enterprise on wheels in my land of Marathwada follows.
After graduating from the medical college in Nanded and while I was doing my Masters in general surgery at the B.J. Medical college at the Sassoon hospital in Pune, a metropolitan city in Maharashtra (India) I happened to rotate through the plastic surgery department in that hospital and was utterly fascinated by the specialty. The department was headed by the calm kind and skillful Dr. Madhuri Kulkarni and the dynamic Dr. Parag Sahasrabudhe an expert reconstructive micro surgeon was her assistant. Dr. Nikhil Panse who is well known now as a lateral thinking plastic surgeon was one year senior to me during this period. I was thrilled by their technique and expertise and in this environment my mind came to be made up that I not only wanted to be a plastic surgeon but a micro surgeon at that. I remember vividly that I did my first microsurgical repair on my own during that rotation. I soon got selected to pursue Mch in plastic surgery under Dr. Yogesh Bhatt in the Government medical college Baroda in the state of Gujrat (India). Under the mentorship of Dr. Bhatt a redoubtable but understated and soft spoken plastic surgeon I slowly but surely became a plastic surgeon as well as a micro surgeon. The lesson Dr Bhatt imparted was very simple but extremely valuable namely “every cut and every stitch is of great consequence”. Luckily Dr. Nikhil Panse of my Sassoon hospital days was a predecessor in this department as well and he together with my other two seniors Dr. Girish Ambat and Dr. Hitesh Laad created an excellent environment to nurture my surgical skills. In due course I qualified as a plastic surgeon and started thinking of my future.
The places where Dr. Mangesh Tandale received his education
In the beginning the city of Pune did figure in my mind to make my career and in fact I did apply for an academic appointment at the Sassoon hospital but for some reason the interviews for that appointment got delayed and this delay was providential indeed ! An old thought rejuvenated in my mind that perhaps my skills were most suitable and needed for the large population of Marathwada because I knew and had experienced the travails of this population when it came to getting treatments that I could offer and for which they had to travel to big cities like Pune and Mumbai and suffer delays and inevitably wreak economic havoc on their limited earnings. I therefore moved back to Aurangabad (now Chhatrapati Sambhajinagar) the city near which I had grown and realized that I will have to reach out to patients in smaller towns and two and three tier cities/towns to offer my services at their doorsteps if I was succeed in the aim of serving people in the area in which I had grown up.
The opportunity for that venture was not long in coming when I was asked by a surgeon in Jalgaon a city north of Chhatrapati Sambhajinagar if I could help him with microsurgical reconstruction for a tumour around the mandible which he was to excise. I travelled to Jalgaon by a bus carrying all my instruments including a magnifying loupe my micro motor drill the required fine suture material a tourniquet and several other paraphernalia in my bag. My mind was filled alternately with doubt hope and confidence but all ended well. It took me six hours to perform the procedure but I was successful in transferring a free fibular flap for the excised mandible with the attached skin to cover the skin defect. History had been made in that city because a one stage reconstruction had been performed for the first time as compared to the time consuming multistage reconstructions that were in use till then. Tired though I was I then went on a hunt for a suitable lodging for near midnight and luckily found one. I checked the flap the next day and when I found that all was well returned again by bus to Chhatrapati Sambhajinagar. This was in the year 2010.
This photograph of the bus stand is very recent. In the year 2010 it was not as modern as is shown in this photograph.
Though the first case was a success there were difficulties in expanding my work. Modern setups with microscopes were not available in surrounding areas, which I overcame by using magnifying loupes.
Dr. Tandale continues to use the magnifying loupe in a majority of cases because a proper microscope is not available in several facilities in which he performs his surgeries.
There was a resistance to the new technology and there was the problem of monitoring flaps post operatively and I did not have a team who would travel with me. Anaesthesiologists were reluctant to accept cases of long duration because several shorter cases during that period were more attractive in monetary terms.
It was during this early period that I was helped greatly by my own old classmates from my undergraduate and postgraduate years namely Drs. Nilesh Chandak from north Maharashtra and Dr. Navin Kasliwal from Chhatrapati Sambhajinagar who were expert onco- surgeons. They offered their cases for one stage microvascular reconstructions, helped in monitoring flaps in the post-operative period and even more importantly spread the word that one stage microvascular reconstruction had arrived in our country and was the way to go forward for both oncological and orthopaedic reconstructions and spread the word that in Dr. Mangesh Tandale we have a dedicated professional who is willing to usher in this required change.
Since that first case in the year 2010 I have also evolved in organising my work, I have compartmentalized the instruments in various sets according to their use at different stages of surgery, travel overnight to the destination and spend the whole of the next day in that town and sometimes do other minor procedures after finishing the main case.
I have trained the local surgeons to monitor flaps and in addition I spend the night in that town to be extra careful because in my experience trouble with free flaps occurs in the first 24 hours. In order to keep my success rate high I do simple robust flaps, spend extra time on anastomosis and haemostasis because a post-operative haemorrhage is something that is dangerous to both the flap as well as the patient. I am particularly careful about any post-operative air way compromise and do not hesitate to do a tracheostomy particularly in smaller units in distant locations. Decasualizing a tracheostomy at an appropriate time is a simple matter as against losing a patient for want of expertise in reintubation at a critical time.
Though I have not kept detailed records here are some approximate figures of the reconstructive procedures that I have undertaken in the last fourteen years.
Reconstruction by free flaps in the area of the head and neck approximately 2500.
Of these free fibula 1038, Anterolateral thigh flaps 723, Radial artery forearm flaps 654, Free jejunum 6, Latissimus flaps 12, and free Gracilis muscle flaps 2.
In addition a total of 230 free flaps have been performed for traumatic and other defects.
The various towns and cities in which Dr. Tandale performed his micro-surgical reconstruction.
The government of India has started a “skilling project” for some years now which trains individuals with basic education. A course for surgical assistants is available under this scheme. Ilaj Yousuf Khan passed this examination in the year 2017 and he has been a great help since then in improving my speed and efficiency.
Dr. Mangesh Tandale
A postscript by the compiler of these short notes
As this chapter was being finalized I happened to hear a talk by Dr. Abhay Bang, a well known social worker in the forefront of eliminating the use of alcohol and tobacco from society. His carefully researched figures of the financial burden of care for treating the ill effects of those two substances were staggering. Assuming at least half if not more of the cases treated by Dr. Tandale were of oral cancer caused by the use of chewing tobacco it becomes obvious that in the end education on the ill effects of tobacco needs to be in the forefront to eliminate this scourge from the society.
Ravin Thatte
Short Notes in Plastic Surgery 