Dr Nada trains others in paediatric keyhole surgery

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He has been teaching keyhole surgery to paediatric surgeons around the region and locally. Dr Nadarajan Sudhakaran, Consultant Paediatric Surgeon of Pantai Hospital Kuala Lumpur, specialises in paediatric and neonatal minimally invasive surgery (keyhole).

He obtained his medical degree from the University of Wales in 1995. After acquiring the surgical membership from the Royal College of Physicians and Surgeons of Glasgow, he proceeded to do two years of research on stem cell at Oxford University. His higher specialist training in paediatric surgery was in London.

Dr Nada was a consultant paediatric surgeon at St Georges University Hospital in London for two years before returning to Malaysia in mid-2012, where he was a Professor of Paediatric Surgery at Universiti Malaya. He moved to the Gold Coast, Australia, in early 2016 to help set up the paediatric surgical service, only to later return to Malaysia.

He is a keen teacher and has published many chapters in text books, medical journals, newspapers and magazines on paediatric and neonatal keyhole surgery.

Here, he answers some questions from Thots n Tots:

Why did you come back to Malaysia after more than 15 years abroad?

Malaysia has always been home to me and seeing that there is a lack of paediatric surgeons and trainers in this country, I decided to return home. On a personal note, our parents are ageing and my wife and I thought it was best we spend more time with them. Besides these, there is nowhere else in the world that can beat the warmth of the people nor the amazing selection of food.

Why did you decide to become a paediatric surgeon? What or who influenced this decision?

I love working with kids. It is in my nature to be child-like too, where I can engage with kids of all ages and also with their parents. I made the choice of going into paediatric surgery instead of becoming a paediatrician as I am technically-minded and a skilled “hands-on” person. I felt that I was meticulous in my operative skills and that suited the delicate nature of children’s surgery. Early in my career as a doctor I was fortunate to work with an amazing paediatric surgeon who was a role model, he was my influence towards this speciality.

What does it take to become a paediatric surgeon?

As a paediatric surgeon one has to be a good listener and have excellent observational skills. We have to be child-like with the kids and be able to have adult discussions with their parents. We have to be empathic and honest in giving the most up-to-date information to parents while keeping it simple. With regard to the technical aspects of paediatric surgery, it is delicate and precise and a single corrective procedure should last the child’s lifetime.

What are some perks of being a paed surgeon?

The obvious perk is being able to play with the kids and returning them to their parents, especially when their nappies are full!

What is the hardest part about your job?

The hardest part of my job would be the stress of working with a very sick child or someone with a terminal illness. With my years of experience, I am well adept to deal with the most critical medical situations in children. The emotions through each of those situations, however, can be overwhelming.

What is your policy or belief when it comes to children’s health?

Like the lyrics of a Whitney Houston song, “I believe the children are our future”!

We need to make good investments in their health and education for the goodness of our family, society and country in years to come. After all, we are investing in people who will take over our roles and perhaps looking after us in our old age! Hence too is my interest in training young doctors. The investment in child health in Malaysia could be better, both in the public and private sectors. A simple example is how we lag in the advancement of keyhole surgery for kids.

What are the most common illnesses you see?

Most of my work involves congenital anomalies, i.e., the child is born with a medical condition. The commonest are those that are related to the boy’s genitalia. Some examples are undescended testicles or a condition called hypospadias where the penis is malformed. These conditions are increasing in numbers due to environmental factors, feminising our boys. These boys should have their problems sorted within the first year of life, to get the best outcomes and so they will not have any negative memory of it in the long term.

Other less common conditions are abnormalities or obstructions to the kidneys and urinary systems or abnormalities of the intestine, from the oesophagus at the top, right through to the bottom, at the anus. There could be issues with other organs in the abdomen such as the liver or in the chest such as the lung. Some of these conditions can be identified on the antenatal scans before the child is born. For these pregnancies, parents may see me at that stage to get the full picture of the condition and treatment options and to map out the journey for the child, once born.

Is keyhole surgery on children harder than keyhole surgery on adults?

Generally, adult conditions are different from that of the child and hence the types of operations also differ significantly. The anatomy, physiology and the psychology of a child is not as robust as an adult and so, as a paediatric surgeon, everything I do is to a minimal scale. One needs to have excellent spatial orientation to perform surgeries in very tight spaces. The space provided whilst doing keyhole surgery is extremely small compared to an adult, and my procedures are done with extremely precise movements. Even for a common procedure like an appendectomy, our approach varies from the adult surgeon. It is advisable that all children surgeries should be done by a child surgeon, especially keyhole surgery.

How many keyhole surgeries would you do in a month? Are there fewer risks?

Almost all procedures I do in the abdomen or chest are by the keyhole method. The limiting factor to operating is the availability of the small keyhole instruments that I use, as there are not many of the smaller 3mm instruments in Malaysia. I travel to Alor Setar on a monthly basis to operate in the public hospital there, whilst training the surgeons on keyhole surgery. This is where I perform the most complex surgeries. The hospital has invested on several sets of the smaller instruments as their surgeons are adequately trained. The inherent risks of performing surgery for a particular condition is the same via the keyhole or open technique if the operator is adequately trained.

Why should a parent opt for keyhole surgery for their child?

For keyhole surgeries, we place instruments through very small incisions on the skin and the muscle layer is just pushed apart to allow the instruments in. Open surgeries involve cutting through the many layers of the abdominal or chest wall, including the muscles. This causes a lot of pain and the recovery is prolonged. In addition, the tissues heal by scar formation. These muscles are never as good as new and can cause an imbalance in the way they function compared to if it were done via keyhole surgery. Most prominently, open operations on the chest can leave a spinal curvature in the long term. The small incisions on the skin cause minimal pain, heal quickly and are hardly noticeable once healed.

How many surgeons perform keyhole surgery on children in Malaysia?

There are not enough children surgeons doing keyhole surgery. Keyhole surgery is just another way of doing the operations we have been doing for years. What is required is training, so that all kids requiring surgery in any part of this country have the option of this service.

Tell us more about how you train surgeons.

I am passionate about skills training for surgeons and have been involved with training even when I was in the UK and Australia. Currently I have been invited to train surgeons in different states in Malaysia and in countries such as Myanmar and Indonesia.

On a formal basis, I am a trainer at the Centre of Excellence in Minimal Access Surgery Training (CEMAST) in Mumbai, India, and will be conducting training camps with the Society of Endoscopic and Laparoscopic Surgeons of Malaysia (SELSMA) around this country.

What is your best advice to parents for better health?

I would encourage all parents to be aware of what their kids eat and drink and to encourage them to exercise. “We are what we eat” is so true and taking efforts to have good nutrition is a great long-term investment for their child. Parents should also get involved in outdoor activities with their kids.

Do you have any kids yourself?

I have a girl who is nearly two years old.

Has being a parent helped you in your job?

Having a child gives me a better perspective of what my patient’s parents are going through emotionally. Often parents would want to know what choices I would make if it was for my own child – an opinion I can readily give now. For example, when my daughter was born with a tongue-tie, I snipped it immediately. This is an opinion I share with parents of babies with tongue-tie and that takes away the worry of their decision.

If you could invent something child-related, what would it be and why?

I would like to invent an “airbag” for kids. Something light to be worn that could recognise an impending fall or impact and the bag deployed to protect the child, especially from head injuries.