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  • New Subspecialty Symposia: A Twist on the PC

    Authors: Rimal H. Dossani, MD
    Gene Bolles, MD
    Bharat Guthikonda, MD

    Kurdistan is located amid the mountains of Ararat, a biblical location in ancient Mesopotamia where Noah’s Ark rested after the great flood. Kurdistan is not a sovereign nation but is composed of a large area overlapping four countries: Turkey, Iran, Iraq and Syria. Dr. Gazi Zibari, an American-trained transplant surgeon who hails from Duhok, a city in Iraqi Kurdistan, has led medical mission trips to Duhok for over two decades. In May 2012, Zibari introduced neurosurgeons to a multidisciplinary team of medical professionals. Over the years, our neurosurgical team has evaluated and operated on patients at Duhok Emergency Hospital, the local trauma center where most of the region’s emergent and elective neurosurgical procedures are performed. As volunteer neurosurgeons, we have delivered lectures on key neurosurgical topics and mentored local neurosurgeons in performing complex neurosurgical procedures.

    Existing neurosurgical facilities and challenges to neurosurgical practice in Duhok

    As part of Iraqi Kurdistan, Duhok has a bustling economy owing largely to the export of crude oil. Duhok’s infrastructure appears modern with well-developed roads, buildings and bridges. The basic amenities of shelter, water and electricity are available and affordable. However, unlike the industrial infrastructure, the medical facilities are underdeveloped. The hospitals are often in disrepair, medical equipment is sparse, and training programs are meager. Duhok Emergency Hospital is a 122- bed facility with 7 operating rooms and 8 ICU beds. It lacks a formal neurosurgical training programs but provides neurosurgical training in a year-long rotation to two senior residents from other Iraqi training programs. The Emergency Hospital is prone to electrical outages and the hospital generator often powers the surgical wards and operating rooms. The neurosurgical operating microscope is an outdated model but is surprisingly functional. Basic neurosurgical equipment such as stereotactic navigation and high-speed drills are lacking. Neurosurgical instruments such as the Hudson brace and the Gigli saw, which have long become antiquated in the developed world, are still used to perform cranial surgery (Figure 1).

    The local culture does not tolerate surgical complications, which are misperceived as surgical inexperience and incompetence, and patients often travel to Iran, Turkey, India or Jordan to undergo surgical procedures. As a result, Duhok neurosurgeons suffer from a lack of surgical volume to develop technical mastery because patients go to neighboring countries to seek neurosurgical care.

    Case examples and future directions

    A necessary goal of international medical missions should be to work with the local surgeons and health administrators to expand available and sustainable care. Over the last 8 years, we have seen hundreds of patients in consultation and performed more than 100 complex cranial and spinal operations jointly with local neurosurgeons (Figure 2).

    We have noticed a marked improvement in the local neurosurgeons’ surgical abilities. For example, Duhok neurosurgeons are now proficient in performing transsphenoidal approaches and in stabilizing the spine following trauma. However, they still need more technical training to handle the surgical management of large craniopharyngiomas and acoustic neuromas. We have formed an alliance with the Ministry of Health in Duhok and are in close contact with local neurosurgeons who update us on upcoming cases and ask for advice on challenging cases. Since 2012, the neurosurgical service in Kurdistan of Iraq has steadily grown as indicated by the increasing neurosurgical volume and the reduction in cases outsourced to Turkey, Iran, and India. The local neurosurgeons’ greatest accomplishment is in earning the trust of their patients, and we hope that in the coming years, they will sustain an independent neurosurgical service with little help from us.

    1. Dossani RH, Carr S, Bolles G, Balata R, Guthikonda B. Neurosurgery in Iraqi Kurdistan: An Example of International Neurosurgery Capacity Building. World Neurosurg. 2016 Aug;92:108-112. doi: 10.1016/j.wneu.2016. 04.088. Epub 2016 May 2. PubMed PMID: 27150657

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