Int Health 2016; 8: 367–368 doi:10.1093/inthealth/ihw046 Advance Access publication 4 November 2016 Collaboration and innovation in rural surgery Benjamin B. Massenburg a,b,c, *, Nakul P. Raykar b,c,d , Amul Pawaskar e , Jesudian Gnanaraj f and Nobhojit Roy g,h a Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, USA; b Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA; c Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, USA; d Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; e Department of Surgery, Swaroop Hospital, Sindhudurg, India; f Department of Electronics and Instrumentation, Karunya University, Karunya Rural Community Hospital, Karunyanagar, India; g Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India; h Tata Institute of Social Sciences, School of Habitat, Mumbai, India *Corresponding author: E-mail: ben.massenburg@mssm.edu Received 29 September 2016; revised 6 October 2016; accepted 7 October 2016 Keywords: Global surgery, Innovation, Partnership, Surgical innovation Surgical innovation is the introduction or implementation of a novel idea, process, technology or device designed to meet a specific surgical need. 1 Innovation is critical to care provision in low resources settings, which may be characterized by inad- equate infrastructure and supplies, limited workforce and patients with very low affordability. 1 In the high-income setting, innovation often improves processes or increases efficiency; in low-resource settings, innovation makes care possible. Several innovations have been developed in low-resource set- tings and enhanced by academic partnerships, and may fit into one of three distinct stages for surgical innovations: (1) innova- tions that have been critically assessed and widely scaled, (2) innovations that have been critically assessed but not yet scaled, and (3) innovations that require critical assessment. Classifying rural surgical innovations using this framework can assist in the prioritization of partnerships and the investment in scaling innovations in the low-resource setting. In the first group, the existing partnerships are successful and should be modeled in similar settings. In the second group, industry, non- governmental organizations (NGOs) and media should be encouraged to widely disperse the strong clinical evidence to support the innovation globally. In the final group, academic and research partnerships can develop and implement research methodologies to strengthen the evidence for or against any given innovation. In 1984, Dr Oswaldo Borraez, a surgical resident in Bogotá, Colombia, at the Hospital San Juan de Dios, was struggling in the operating room with a patient with severe peritonitis. 2 Abdominal closure was unsafe due to the risks of abdominal compartment syndrome, so the abdomen would have to be left open for delayed closure. Dr Borraez suggested that a three-liter polyethylene bladder irrigation bag be cut open to be attached temporarily to the edges of the patient’s abdominal wound. 3 Not only would the bag provide a barrier between abdominal contents and the outside world, its transparency would allow continuous visualization of the viscera 3 and decrease the rate of infection and entero-atmospheric fistulas associated with the previous method of packing the abdomen with surgical towels. 2 In this example, partnerships aided in the original expansion of the colloquially termed ‘Bogotá bag’ as a visiting trauma sur- geon from the United States noted the ingenuity of the innov- ation and its potential to change standard of care worldwide. The international academic community conducted several retro- spective studies on technique, and a large systematic review reported that the Bogotá bag technique maintained a lower incidence of fistulae and abscesses with a similar mortality rate when compared to the other techniques for delayed abdominal closure. 4 Thus, in the low-resource setting, this method can be performed safely with widely available materials. This same review also clearly elucidated the influence of the Bogotá bag: many modern techniques incorporate the same principals as the original solution from Colombia. 2,4,5 There are numerous examples of other rural surgical innova- tions in the other stages of development. Mosquito net for her- nia repair is an innovation that has been critically assessed 6 but is not yet used consistently around the world; thus, it would benefit from industry, NGOs and media dispersal of the support- ing clinical evidence. Gasless laparoscopy is an innovation that EDITORIAL © The Author 2016. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 367 Downloaded from https://academic.oup.com/inthealth/article-abstract/8/6/367/2433262 by guest on 22 May 2020