Dr Pradeep Chowbey, joint managing director, chief – surgery and allied surgical specialities and director – Max Institute of Minimal Access, Metabolic and Bariatric Surgery (MAMBS) at Max Healthcare Institute, New Delhi, is a pioneer of laparoscopic surgery in India.
As a surgeon of great excellence, he has to his credit treating some of the most important personalities like former presidents K R Narayanan and Pratibha Patil and spiritual head Dalai Lama besides others who seek his assistance and medical intervention.
Dr Chowbey established the minimal access, metabolic and bariatric surgery centre at Sir Ganga Ram Hospital, New Delhi in 1996, which became the first of its kind in the Asian subcontinent under his chairmanship. Under his leadership, the Max Institute of MAMBS was accredited as an International Centre of Excellence for Bariatric Surgery by the Surgical Review Corporation (SRC), US and Centre of Excellence in Endo Hernia Surgery by the Asia Pacific Hernia Society, first in India to receive these accreditations.
He was awarded the Padma Shri in 2002 for his dedication and service in the field of Minimal Access Surgery by the President of India. He was also awarded Honorary Membership of Indonesian Hernia Society in 2009 and Gulf Cooperation Council Hernia Society (National Chapter of Asia Pacific Hernia Society) in 2010 and German Hernia Society in 2011. He was one of the founder members of Indian Association of Gastrointestinal Endo Surgeons (IAGES) and later served as president of the association.
In a candid interview with India Medical Times, Dr Pradeep Chowbey talks about his journey from scratch and his future plans:
How did you decide to choose medicine as a profession?
I think it was more because of my father, Dr Ramdulari Chowbey. He himself was a doctor and that time he was probably one of the very qualified doctors. We used to live in a small district (Raipur). He did his MBBS from Madras Medical College in 1928. When we grew up we saw a lot of things happening because he was a so-called surgeon, gynaecologist performing caesareans, then he also used to operate cataracts, so he used to get a lot of recognition and respect because there was hardly any doctor in the whole district who could do multiple things.
He was a civil surgeon. In those days a surgeon was expected to do almost everything – Medicine, Surgery, Gynae etc. A whole lot of crowd, which used to throng our place for treatment used to intrigue me a lot. The happiness on the faces of patients and families who were treated by him gave a lot of courage and incentives. So that and his hard work inspired me a lot.
When I joined medical college in 1967, super-specialisations were already there in colleges. During dissection in college, I realized I am good at dissection. So whatever the structures which were described in anatomy book, I used to dissect them delicately and take them out. Students from other tables used to call me for dissection. So, this made me confident to choose surgery as my area of specialty later.
Then I became a surgeon and cardiac surgery was a very in thing at that time. So, I took up some competitive examinations and then I got into cardiothoracic surgery. But because of limited vision, you can say, everybody used to discourage me by saying that if you will go back to your native place i.e. Raipur to practice, you wouldn’t be able to do cardiac surgery because of poor infrastructure. I got a little discouraged and thought of doing cancer surgery. So, I went to Tata Cancer Hospital, Bombay and from there I went to Memorial Sloan Kettering Cancer Hospital in New York. Then I super-specialised in surgical oncology and my special area of interest was liver cancer, gall bladder cancer and breast cancer.
How you became interested in Laparoscopic Surgery?
Laparoscopy came much later in around 90’s. In 1989 when I was attending one of the Surgical Congress meetings, they started talking about endoscopic gall bladder surgery. They presented about four to five cases of one surgeon and they showed the video of a patient walking out in the evening after having operated upon in the morning. So, it sort of fascinated and interested me that after such a major surgery the patient is walking and is healthy. So, this interested me a lot.
I started exploring it around that time. In 1990, I went to Singapore because there Dr Mohan Chellappa did the first gallbladder surgery in laparoscopy in Asia Pacific in Singapore General Hospital and because of him being an Indian I had a feeling he will help and he definitely did. He trained me in laparoscopic gall bladder surgery and he did a lot of experimental work on pigs. At that time equipments were very expensive and unavailable in India. When I came back from Singapore I hardly had any money to buy the equipment. We secured loan and sold some ornaments and bought the equipments. Today we, at Max, have reached a point where we have crossed about 60,000 operations of laparoscopy. Then, over the years, we moved on from gall bladder to hernia surgery, endoscopic surgery, thyroid, cancer endoscopic surgery, solid organs tumours, liver and spleen and about 13 years back we moved on to obesity surgery for diabetes.
What were the initial hiccups in introducing the minimal access surgery in India?
Initially, with the introduction of minimally invasive surgery, newspapers, especially in UK, were filled with complications because everybody was learning, because endoscopy is a two-dimensional surgery and open surgery is a three-dimensional surgery. So, people took time to convert their three-dimensional ideas into two-dimensional ideas. This probably led to more mishaps in the early part. People were sceptic about the efficiency of minimally invasive treatments and the scepticism continued for almost ten years. When I operated former president Dr K R Narayanan at the age of 83 and within 24 hours he just walked of the hospital on his own, the press took notice of the success of such a treatment. That was a landmark in the country’s minimally invasive treatment success. Then a lot of people stopped asking questions because everybody thought if a president can opt for this particular surgery it should be a good option. So, I could visibly see the perception changing for such a surgery.
Who all had the biggest influence in your career?
Of course, Dr Mohan Chellappa. As far as the laparoscopy is concerned I think Dr S K Sama, who was the chairman of Ganga Ram Hospital, mentored me a lot. Though he was a gastroenterologist, still he realized the potential laparoscopy holds and he always encouraged for this and that is how he kept inspiring.
How was your stint with Ganga Ram Hospital?
I joined Ganga Ram in 1984 and we started laparoscopy in 1990. But then we realized we have to spread it and dedicate a department because then only the commitment level will come. So, in 1996 we established first exclusive department of minimally invasive surgery in the whole Asia Pacific. With this we moved on from gall bladder to hernia and lot many other. The journey has been pleasant. There was a lot of hard work. I used to work almost for about 18-20 hours. I used to travel a lot all over the country, demonstrating live surgeries to doctors so that they could learn and also created media awareness so that people could know that for gall bladder and hernia this is the best way of getting treatment. Of course, I am more than satisfied.
What are the latest advancements that are going on in the field of Minimally Invasive Surgery?
I think the major advancements, I would say, is the miniaturization of the instruments. So, instead of 12mm or 15mm, we have got 2mm instruments now, so that the puncture size is small, the pain is less. Other advancement is in the gadgetry. For Example: with a single chip camera, we are moving on to HD (high definition) cameras which have got a resolution of more than 1300-1400 lines. And this technology is advancing; we can do more and more complex surgical methods by this. This is another advancement.
Has the advent of Robotic Surgery and its growing popularity put any limitations to the growth and future prospects of Laparoscopic Surgery and its practitioners?
Robotic surgery has got a limited application. It is very expensive. It costs about almost Rs 10-12 crore. It is very useful for the surgeries, which are done in the pelvis. For example: uterine cancer, cancer of urinary blood, cancer of prostate. In this area robotic surgery is helpful, because that area is surrounded by the bone all around. So, with your wrist and with your instrument manipulating possibilities are less. Our wrist moves about only 190 degrees on one side but the robotic wrist can move almost up to 330 degrees. So, these are the areas where robots can help. But unfortunately many a times, robots are advertised and purchased to have a commercial gain. But I am very clear in my mind that robot has great advancements but has its use only in the pelvis. It is not at all a threat for laparoscopic surgeons and also we should consider that a lot of it is driven by the industry. So, many times patients pay a lot of extra money just for the robot, which may or may not be providing great advantage except in few procedures where it is proven to be advantageous.
What are the other areas where laparoscopic surgery could be performed but has yet not been explored?
Strangely enough endoscopic surgery is of tremendous value in the chest, especially for lungs and for some other procedures of the heart. But somehow it has not caught on, as I would have expected. Because of very simple reason like cardiac surgeons mostly perform open surgeries so they have less experience of laparoscopic surgery, whereas a general surgeon is doing a lot of surgeries, so he has a great hand eye coordination. So, if a general surgeon does any new laparoscopic surgery he does it well. For example, we have now moved on to obesity surgery and surgery for diabetes and we do it very well. Because we have got a hand eye coordination whereas a cardiac surgeon may not have that expertise, that is why it has become less popular. And not many would like to go into the learning curve. It’s a long learning curve. Something like moving on from driving to flying, it’s a quantum jump in technology and a long learning curve simulations etc. Now a lot of things in laparoscopic are coming for the brain surgery, for the foetus surgery where laparoscopy holds lots of potential.
How is the medical training scenario in laparoscopy in India?
It used to be bad ten years back. But in the last decade we have seen a tremendous improvement in training and teaching, thanks to the industry, which is giving training at least in metros. Some computer-generated programmes, which have come, can train, and of course, via video conferencing it can be taught and trained. Internet also helps a surgeon sitting in a remote place; internet gives the images to the mentor in real time. Sitting here in Delhi, I can train so many surgeons and by receiving their images I can guide them what to do. This area is getting popular among professionals because of technological improvements in modalities of training.
What are you currently researching upon?
At the moment my very important research is surgery for diabetes, what you call a metabolic surgery. There are surgical procedures, which we have established now and it is beyond the clinical trials that we can treat obesity and diabetes by gastric bypass or some other modalities and this way we are able to treat diabetes. This is a breakthrough, I would say. I will compare it with the breakthrough of coronary artery bypass. Now there is a very bright future for obese persons and obese diabetic persons where they will not have to suffer.
Which was the most memorable case of your career?
Operating His Holiness The Dalai Lama was one of the landmark surgeries in my career. Because it not only gave me a lot of credentials as a surgeon but also gave a different feeling. There were lots of inspirations coming from him, lots of peace, quietness, calmness. He brought a lot of good things in our life, our team and family.
What improvements does Indian healthcare system demand?
As far as the medical talent is concerned and technology is concerned we are at par or even better than any other hospitals in the world. What I think we have to look into is the excellence in the clinical outcome, more researches and more outcomes. Of course, we need more talented people to provide services to the patients, better food and cleanliness.
Lower staff in hospitals lack in effective communication with the patient because of improper training. So, we have to make sure everything is done by a protocol. There should be laid down protocols, streamlined training for everyone, including lower staff. At the moment we have got great medical professionals, but avenues are lacking. Medical excellence should be matched by service excellence. So, if we have medical excellence synergized by service excellence, I am very sure soon India will be one of the leaders in the subcontinent and also in the world because we can already see foreigners pouring in for treatment here in great numbers. That itself is a symbol of our medical expertise.
Where do you see yourself ten years down the line?
Gracefully I would like to withdraw from the very active clinical practice over a period of time. Training and teaching has always been close to me. So, I will continue this. I am writing a lot of textbooks. As you grow, operating itself becomes a very small part of your contributions. What is more important is to make sure every surgery every surgeon does is a safe surgery and the patient is not harmed. And certainly because of the experience of more than 60,000 surgeries that we have to our credit at Max, probably we are in a very unique situation in the world to let people know what we have gone through, where we went wrong and where they should not go wrong. And that is the reason we organize workshops and congresses, with the single theme congresses and also with the theme like ‘mechanism of mishaps’ and ‘risk reduction strategies’ in surgery. So, we pick up various subjects and show them the videos how complications take place and warn them what things should not happen.
Max is also coming out with a medical college soon so I would probably like to contribute into that and also in other national and international areas of importance. This way you can bring a lot of glory to the country. Then you lose your individuality and you bring India on the map. I would be happier in leading the institutions rather than opening one and going into managing it. I would prefer to lead hospitals and medical colleges and not the financial and other similar management. So, I would like to concentrate on research, training and teaching, academics rather than handling the corporate side.
Your message for the readers?
My message is our colleagues should always make sure they should not harm their patients and their enthusiasm, justified or unjustified, should not be converted into ego trips and intentions should be good. Goals should be achieved by fair means. Everybody should create a win-win situation where the patient is a winner. Enthusiasm should not be mixed with ego, there has to be a balance between the two.
by Vidhi Rathee