Date Archives August 2019

Dr Aparna Govil Bhasker MS,

Bariatric and Laparoscopic Surgeon, Mumbai, India

The business of saving lives begins in the company of death. For most of us something changed the moment we walked into the anatomy dissection hall on the first day of our medical training. It is a surreal experience, frightening and fascinating at the same time. We spend the best decade of our lives to learn how to repair wounds, how to heal a body, how to make it whole again. On day one of our medical career the cadaver teaches us that we can only try our best and eventually there may be some wounds that we may not be able to repair and some bodies that we cannot heal. As it lies on the dissection table surrounded by a bevy of zealous and fervent medical students, a cadaver teaches us the first and the most important lesson that “Doctors are not God”.

In the 3rd century BC, the city of Alexandria was home to two physicians- Herophilus and Erasistratus who defied the law and dissected human corpses to clear many misconceptions about the human body. They eventually fell into disrepute as reports of dissection by them on live prisoners started coming in. Although it was banned for centuries in many regions of the world, cadaver dissection has been integral to anatomical and surgical research. From Leonardo-da Vinci to Michael Angelo, many renowned artists attended dissections to understand nuances of the human body and went on to publish their drawings to add to the anatomical literature.

Surgical training is at a tipping point today. The advent of surgical simulators, computer modeling, animal and human dummies, free availability of surgical videos on platforms like you tube and other online libraries have provided training avenues like never before. Yet when a young surgeon wields the scalpel for the first time, his hands are shaky and that first cut invokes a combination of both dread and awe. No simulator or app can mimic the complexity of human anatomy and tissue fidelity.

Like most other branches of medicine, surgery is an ever evolving field. It is about learning the technique, practicing it and eventually mastering it. Every few years there is a paradigm shift and we as surgeons need to constantly update and upgrade ourselves with the newer technology. Most of us learn these techniques from the experts and eventually end up practicing on our unassuming patients. The process is not only unfair to our patients but is also painfully long and most of the times it takes years for a surgeon to be confident of her/his skillset. A surgeon has to be on her/his “A-Game” every time she/he walks into the operation theater and no other specialty in the medical profession demands as much precision and commitment as surgery. 

In the recent years cadaver labs have emerged as a useful and effective method for surgical training. Spatial perception of anatomy is one of the biggest advantages that a cadaver offers over any other training modality. It also helps surgeons to practice new techniques in a safe environment before performing on a live patient and cadaver training can benefit all surgeons from the trainee level to the more experienced consultants. In an ideal world, surgery training would probably include practicing surgical procedures on cadavers to become proficient before operating on live patients.

Unfortunately there is a perpetual shortage of cadavers in most parts of the world and body donation is a challenge almost everywhere. Most cadaver labs rely on unclaimed bodies and however gory it may sound, grave digging still thrives as a business in some places.

In a country like India, cultural and religious reasons prevent most people from donating their bodies for medical advancement. M S Ramaiah Institute in Bangalore was the first to start a cadaveric research and training unit in India. Recently Amrita institute of medical sciences in Kochi was the second Indian institute for initiating training courses on cadavers. Now we have a few more. However, the acceptance is very slow and these institutes constantly grapple with shortage of cadavers.

The east and the west have devised two very different approaches to tackle this issue of body donation. My first experience of a cadaver lab was at the Chula Surgical Training Center in Bangkok, Thailand set up in 2007 by Dr. Suthep Udomsawaengsup. Equipped with 48 state of the art working stations, multiple training workshops are conducted round the year at this lab.

Till 30 years ago, Thailand was struggling like any other country to acquire cadavers. Today most cadavers are acquired through voluntary un-remunerative donation. Body donation is considered as the highest form of donation. Not only is it approved by the King, donors are also bestowed with the highly regarded status of “ajarn yai” or the “great teacher”. Unlike the west which treats the cadaver as the “first patient” the east regards it as the “first teacher”. The other difference is that the west lays more focus on emotional coping and the east primarily focuses on forming a relationship with the new teacher. The west thrives on anonymity whereas in the eastern culture training starts with the introduction and life history of the cadaver that was once a person [1].

Medical University of Vienna is well known for its hands on courses on fascial aesthetic surgery and dental implant surgery on fresh cadavers. Unlike Asian countries, most European countries have an “opt out” program for organ and body donation.  Donation occurs automatically unless a specific request has been made prior to death. The “opt out” system works better 

for obvious reasons and the rate of organ and body donation is higher in countries that practice this system.  Hesitancy to discuss regarding their death, religious reasons and a gap between intent and action are the primary reasons for failure of the “opt in” system most of the times. 

Solo surgery time is a landmark day in the life of every surgical resident. We slog day and night, for that one moment when we would be allowed to operate on a patient independently. It’s a different high, to have another fellow being’s life in our hands, to be in total control. Great power comes with greater responsibility and what we cannot afford is………..to make a mistake. Errors in surgery can prove to be devastating for the patient as well as the surgeon. Training is the key to minimizing these errors and in future cadaver labs will play a significant role in surgical training. Surgery cannot be learnt from books alone and as the French anatomist Marie François Xavier Bichat once said- “Open up a few corpses: you will dissipate at once the darkness that observation alone could not dissipate”

References

1. Andreas Winkelmann, Fritz H Güldner. Cadavers as teachers: the dissecting room experience in Thailand. 2004 Dec 18; 329(7480): 1455–1457.

Acknowledgements

1. Dr Suthep Udomsawaengsup – King Chulalongkorn Memorial Hospital, Bangkok, Thailand
2. Dr Ajjana Techagumpuch- King Chulalongkorn Memorial Hospital, Bangkok, Thailand
3. Dr Debraj Shome – Breach candy and Saifee hospitals, Mumbai, India