Operative and post-operative costs of hand-reconstructive surgery at Lalgadh Leprosy Services Centre, Dhanusha District, Nepal
A project of Nepal Leprosy Trust
For the past few years a life-changing event has taken place at Lalgadh Leprosy Services Centre (LLSC), usually in November. The distinguished British plastic and hand-reconstructive surgeon Dr. Donald Sammut (www.donaldsammut.com) has been coming to LLSC with a small surgical team (an anaesthetist and one or two other reconstructive/ orthopaedic surgeons), to run an intensive 10-day hand-reconstructive surgery session. The operations can literally change the lives and futures of the patients—both those affected by leprosy and others—and also provide a special opportunity for mentoring and training of our own staff in surgery techniques, particularly our surgeon at Lalgadh, Dr. Krishna Tamang.
Dr. Sammut runs plastic and reconstructive surgery clinics in Bath and Windsor, and regularly lectures and trains surgeons in London and elsewhere. But for several years, at his own expense, he has been giving two weeks of his time to come to our centre at Lalgadh in Nepal. Upon arrival, he reviews the many potential patients who have responded to our advertising, and then operates for long hours each day, repairing and reconstructing the deformed hands of the adults and children whose conditions are operable. Most of these patients have deformed hands that are beyond the repair-skills of most Nepalese surgeons, and way beyond the budget of those needing the surgery.
Lalgadh Leprosy Services Centre, located in Dhanusha District in south-eastern Nepal close to the border of Bihar state, India, is one of the world’s busiest leprosy referral centres, managing some 11,000 leprosy patient visits each year along with nearly 60,000 general outpatient visits (sometimes totalling more than 600 in a day). One of the many terrible consequences of leprosy is irreversible nerve damage, which often leads to ulceration and progressive mutilation of hands, eyes and feet. Ulcerated, twisted, curled and clawed fingers, and hands that have lost sensation and movement, are regularly seen in leprosy-affected patients, including children as young as 7 or 8 years old.
Although leprosy is the main mutilator leading to severe hand deformities in this region, there are other types of severe hand damage that many people can’t hope or even imagine to have restored, but which Dr. Donald tackles. These include congenital hand malformations, burns, crush or other injuries, tendon and joint injuries.
Radio and health post announcements inform people in surrounding towns and villages, that Dr. Donald is coming. Our health and community workers also call or visit leprosy patients we know with hand deformities, inviting them to come to the centre for assessment by Dr. Donald. People of all ages come from a wide area, including northern India, with hand injuries and deformities, in the hope that their hands might be repaired or reconstructed, and restored to functional usefulness and a more normal appearance. Much preparatory work is done at our Lalgadh centre, with some patients requiring a preliminary physiotherapy work-up, prior to any reconstructive surgery. Usually some 30 – 35 patients are selected, of whom about 70 % are affected by leprosy.
Further details of the proposed hand surgery in 2015
This year (2014) Dr. Donald and his team came to Lalgadh for 10 days of hand surgery, up to 23rd November. The dates for the 2015 visit have not yet been set, but are likely to be in November 2015.
Upon arrival, Dr. Donald and his team spend a day screening patients, determining which have the most severe conditions, but also which deformities are the most likely to be repaired successfully, resulting in maximum benefit. Special attention is given to children and young people so as to try to restore potential to their futures.
There follows up to 10 days of operating, usually from early morning to late evening. The order of patients on the list is partly determined by whether they need intensive physiotherapy or antibiotics or nutritional build-up (as some are malnourished) before reconstructive surgery.
The reconstructive and repair procedures typically include:
- claw-hand repair and tendon transplant reconstruction,
- metacarpal-phalangeal joint fusion, and other hand and wrist joint reconstruction,
- post-burn contractures repair,
- full-thickness skin grafts, and various web-plasties and z-plasties,
- syndactyly reconstruction (congenital fused finger separation),
- finger flexor muscles (FDP & FDS) repair/reconstruction,
- tendon repair/reconstruction (various).
The majority of patients have their hand and arm in a plaster of Paris (POP) cast for 4-6 weeks, following surgery. Most need a range of medications – analgesics and antibiotics. Once the plaster cast is removed and sutures removed, gentle progressive physiotherapy is then required for 2-4 weeks. Those who have had tendon transplants for leprosy claw have to learn to use their hand and fingers from scratch, as different nerves and tendons are now attached to the previously paralysed fingers. The average hospital stay is thus 8 weeks. For many, their new hand is an unimagined miracle, and their previously gloomy future now filled with hope and potential.
Whilst Dr. Donald and his team provide their services free of charge, and we have the necessary basic surgical facilities, there is a substantial cost associated with this surgical event that Lalgadh Leprosy Hospital needs to bear. It includes LLSC staff time, medications, x-rays, anaesthetic materials, sutures, bandages, POP-casts, and 8 weeks of inpatient hospital bed, food and care costs. The following table provides a summary of the costs, which total an estimated £ 7303.
We are thus seeking funding support of £ 7303 to cover the costs of the reconstructive surgical 10-day event in 2015, which will greatly improve the lives of around 30 patients, including children, with severe hand deformities.