Mr. Sundaran was a gentleman in his early 40s who was treated at a rural surgical care center for appendicitis. He had undergone an appendicectomy but had developed some serious complications soon after the operation.

Appendicectomy is the most common general surgical emergency, but it can sometimes have dreaded complications. During Sundaran's operation, another part of the intestine was injured while removing the appendix, which was unrecognised during the operation.

Soon after the operation, the intestinal contents started leaking into the abdominal cavity, which eventually resulted in a severe infection and sepsis. This was recognised early by the treating team, and rightly, a second operation was performed to repair the injured intestine. 

Unfortunately, he did not recover even after the second operation, and his condition progressively deteriorated. He was then referred to our tertiary care center in CMC Vellore for ‘expert’ management.

I was in my general surgical residency at the time.

The patient could have been sent with just a referral letter, like in most cases. At our centre, we mostly never read the referral letters, preferring to work up the patient from the start instead. However, in Mr Sundaran’s case,  the rural surgeon who had operated accompanied the patient all the way from the initial hospital and explained the series of events to us in great detail. 

At that point, we failed to see the genuine care that the surgeon had for the patient and instead thought he was only trying to cover up his errors.

We admitted Mr. Sundaran, performed another operation which consisted of bringing out his intestine through his abdomen, where the stools could be collected in a bag. This was done so that there was an adequate amount of time for the rest of the intestine to heal, along with the resolution of infection, a procedure known as making a stoma. 

This Stoma, although one of the most feared aspects of abdominal operations, is commonly performed in emergency and planned operations involving extensive infection and cancers of the intestine.  He was managed in the ICU for a few days and then in the ward for a couple of weeks, after which we discharged him in a stable condition. 

As he left, we thought, “Why do these rural surgeons take on challenging cases and mess up?” 

Little did we know or care that it was probably this surgeon’s first complication after an appendicectomy, who would have easily performed over a hundred appendicectomies in his center. What my colleagues and I believed at the time was that rural surgical care was subpar and not evidence-based based and hence these patients were being referred with complications to tertiary centres.

We disregarded the fact that we have had more and worse complications after a similar operation (injury to the intestine, urinary bladder, blood vessels, etc), only to be saved by the intense support system that we have.