Innovating Indian Surgery: Integrating Ayurveda with Contemporary Surgical Science

Glimpses of Surgical Content in Sushruta Samhita

The Sushruta Samhita, widely considered the earliest documented surgical text [Figure 1], presents a highly systematic approach to surgery (Shalya Tantra).

OPEN IN VIEWER Figure 1.

Palm leaves of Sushruta Samhita (available in the public domain as an educational endowment from the Los Angeles County Museum of Art)

Sushruta Samhita addresses the surgical treatment of various conditions, including burns, ascites, splenomegaly, urinary stones, hernia, hydrocele, tumours, traumatic injuries (including soft tissue injuries, fractures, dislocations, and haemorrhages), corns, anal and urethral strictures, and rectal prolapse. Many of the management principles he outlined align closely with modern practices. Notably, he recommended keeping patients nil by mouth (NBM) prior to surgery in cases such as obstructed labour, ascites, piles, urinary calculi, fistula-in-ano, and oral cavity disorders. Sushruta advocated the use of anaesthesia in surgery through herbal agents such as wine, cannabis, opium, and henbane, administered orally, topically, or via inhalation to sedate and relieve pain. Though limited in efficacy by modern standards, his methods laid the groundwork for surgical pain management.^[8]

Ayurvedic surgical ethics strongly emphasised assessing the prognosis of a condition, openly discussing it with the patient and their family, and undertaking surgery only when a favourable outcome was anticipated.

A surgical protocol is structured into three phases: Purva Karma (pre-operative), Pradhana Karma (operative), and Paschat Karma (post-operative care). The text details 101 blunt (Yantras) and 20 sharp (Shastras) instruments [Figure 2], complete with specifications for design, measurement, and use, many of which closely resemble modern surgical tools [Table 1]. The text outlines eight types of surgical procedures, three forms of incisions and four suturing techniques, using various suture materials and needles in great detail. These comprehensive surgical principles underscore the enduring relevance of Sushruta’s contributions to operative care.^[9]

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Table 1.

List of Shastras and Yantras with their Corresponding Modern Surgical Instruments^[9]

Shastra and Yantra	Modern Surgical Instrument
Mandalagra Shastra	Circular knife
Karapatra Shastra	Bone saw
Vruddhipatra Shastra	Scalpel
Nakha Shastra	Nail parer
Utpala Shastra	Lancet
Suchi Shastra	Suturing needle
Kushapatra Shastra	Paget’s knife
Atimukha Shastra	Episiotomy scissor
Shararimukha Shastra	Mayo and Metzenbaum scissors
Kutharika Shastra	Chisel
Vrihimukha Shastra	Trocar
Ara Shastra	Awl
Vetasapatra Shastra	Tenotomy knife
Badisha Shastra	Sharp hook
Dantashanku Shastra	Tooth scaler
Eshani Shastra	Sharp probe
Swasthika Yantra	Cheatle’s forceps, Sponge holding forceps, Kocher’s forceps, Mayo’s towel clip, Artery forceps, Haemostat, Allis tissue forceps, Babcock forceps, Needle holder
Sandamsha Yantra	Toothed and non-toothed dissecting forceps
Tala Yantra	Ear scoop and Volkmann’s scoop
Naadi Yantra	Proctoscope, Rubber ball vaginal douche, Rubber catheter, Syringe irrigator, Cannula, Inhaler, Anal dilator, Cupping glass, Suction ball
Shalakha Yantra	Blunt probe, Tooth elevator, Retractor, Swab probe, Nasal curette, Urethral sound

OPEN IN VIEWER Figure 2.

A few examples of Shastras and Yantras mentioned in Sushruta Samhita

Sushruta emphasised the importance of hands-on training in surgical techniques, recommending the use of experimental models like animal parts, various plants, fruits, vegetables, and inanimate objects.^[8] Similarly, modern surgical education relies heavily on practice kits and simulation models as integral tools for skill development.

Sushruta’s anatomical knowledge was sophisticated for his era, though naturally constrained by the technological limitations of the time, and offered detailed descriptions of structures like bones, joints, muscles, ligaments, and blood vessels. He was the first to outline a method for preserving dead bodies and strongly advocated cadaver dissection, an act considered taboo at the time. This bold approach was instrumental in gaining anatomical knowledge and represented a major leap forward in surgical practice. His contributions laid the groundwork for modern anatomical studies and significantly influenced the evolution of surgical science.

A fundamental aspect of Ayurvedic surgical training is the concept of Marma—vital points where muscles, veins, ligaments, bones, and joints converge, and where Prana (life force) is believed to reside. The Sushruta Samhita identifies 107 such points, with injuries to these areas potentially resulting in serious deformity or even death. Therefore, careful avoidance of Marma points is critical during surgery.^[10] Emerging research also explores the contemporary therapeutic potential of Marma points in clinical practice.^[11,12]

Sushruta made significant contributions to orthopaedics by classifying six types of dislocations and 12 types of fractures. He also detailed their management using methods such as traction, manipulation, apposition, and immobilisation, followed by appropriate muscular and physiological rehabilitation.^[13] In recent times, fractures and their complications have been effectively managed through Ayurvedic interventions.^[14,15]

He also offers precise classifications of various wound types, including fresh wounds (Vrana), healing wounds, fully healed wounds, non-healing wounds, and gangrenous wounds. He also outlines the early signs of healthy granulation tissue during the healing process. A notable feature of his approach is the Shashti Upakrama, a comprehensive framework of 60 therapeutic strategies encompassing both medicinal and surgical interventions for ulcer and wound care. His texts provide detailed, stage-wise protocols for managing both simple and complicated wounds, often using single or multi-herbal formulations, extending even to the restoration of naturally hued hair without scarring.^[16]

Evolution of Modern Surgery from Shalya Tantra

Sushruta is widely regarded as a pioneer of plastic surgery, particularly for his innovative techniques in nasal reconstruction. He described various flap methods, including sliding, rotation, and pedicled flaps, tailored to the extent of nasal damage. These techniques influenced early European surgeons such as Branca de Branca in Sicily and his son Antonius, who developed the ‘Italian method’. The Indian approach gained prominence in Europe through Joseph Carpue’s successful revival of the forehead flap technique. Sushruta also documented reconstructive methods for earlobes, lips, skin grafting, and burn care, laying a foundational framework for modern plastic surgery with his emphasis on pattern design, suturing precision, and functional outcomes like airway patency.^[17]

In ophthalmology, Sushruta’s description of cataract couching remains one of the earliest systematic surgical accounts [Figure 3]. He recommended the procedure only for mature cataracts in middle-aged patients, emphasising careful patient preparation, proper instrument design, and meticulous surgical technique via pars plana entry. His detailed post-operative care, including immediate vision assessment, patient positioning, and protective measures, reflects a sophisticated understanding of both anatomy and recovery. These contributions highlight Sushruta’s advanced surgical understanding and his lasting influence on the foundational principles of both reconstructive and ophthalmic surgery.^[18]

OPEN IN VIEWER Figure 3.

AI-generated image of Sushruta performing an ophthalmic surgery

However, the central message of this article is not to glorify the past. It is a call for action for policymakers and medical professionals to act in the public interest: to systematically integrate modern surgical advances into Ayurvedic surgical education and practice, and to dismantle the longstanding silos that isolate Ayurveda surgery from mainstream surgery.

Clinical Strengths of Contemporary Ayurvedic Surgery

It is essential to acknowledge that indigenous surgical practices in Ayurveda have not vanished; rather, they continue to present valuable concepts, principles, and techniques that may hold potential value for modern global surgical practice. These aspects should be systematically identified in collaboration with experienced clinicians, rigorously validated through scientific methods, and thoughtfully incorporated into mainstream surgical frameworks.

For instance, the management of anorectal diseases in Ayurveda, using Kshara Karma (the application of a caustic alkaline paste), is unparalleled.^[19] The simple but elegant Ayurvedic technique of Kshara Sutra (use of medicated linen seton) for treating anal fistulas has already been clinically evaluated by institutions like PGI Chandigarh and AIIMS New Delhi.^[20] It is proven to be a minimally invasive, easy, inexpensive and safe procedure with higher success rates, lower recurrence rates and fewer post-operative complications compared to contemporary surgical treatments.^[21] The herbs used in preparing Kshara Sutra are known for their better pain management and wound-healing properties. Complex cases of anal fistula extending to the lower abdominal wall, foot, and prostate gland have been successfully treated using Kshara Sutra.^[22–24]

Sushruta’s insights into complex wound management have stood the test of time and continue to influence Ayurvedic clinical practice. For instance, wound dressing by a combination of ghee & honey has been demonstrated to work in difficult-to-heal infected wounds, namely (a) fungating malignant lesions, (b) chronic venous ulcers, (c) diabetic foot ulcers, (d) infected ventral hernia mesh in hernioplasty, (e) post-caesarean wound dehiscence.^[25] An integrated approach to treating chronic venous and diabetic ulcers has been successfully reported.^[26–28]

Para-surgical procedures like Jalouka (leech therapy) have been proven successful in managing various conditions such as varicose veins, epicondylitis, diabetic neuropathy, osteoarthritis, and chronic low back pain.^[29,30] Another important facet of Ayurvedic surgery is Viddha Karma, the use of a needle (no. 26 1/2) to pierce specific sites on the body. This was revived and practised by the late Vaidya R. B. Gogate of Pune, a renowned Ayurvedic physician known for his surgical expertise. He primarily applied this technique for managing pain in various patients. In recent years, Viddha Chikitsa has gained attention, primarily for its effectiveness in managing pain, especially joint, muscular, and neurological pain, as well as in conditions like PCOS, etc.^[31,32]

These are not merely historical curiosities but immediate opportunities for challenging research, innovation, and cross-disciplinary dialogue. With open-minded collaboration between biomedical researchers and Ayurvedic practitioners, novel surgical insights and practices can emerge that could enrich global surgical practices.

Expanding an Institutional Base for Surgical Education

Surgically treatable conditions today account for a substantial proportion of the global disease burden, particularly in low- and middle-income countries (LMICs) such as India.^[33] A key metric for measuring surgical capacity is the SAO density, the number of Surgeons, Anaesthetists, and Obstetricians available per 100,000 population. The Lancet Commission on Global Surgery (LCoGS) recommends a minimum SAO density of 20 per 100,000 by 2030 for LMICs. In contrast, India’s current SAO density ranges between 1.5 and 6.8 per 100,000, far below the global benchmark.^[34]

To address this significant and widening gap, India must adopt a comprehensive and inclusive strategy to expand its surgical workforce. This includes not only enhancing conventional surgical training in allopathic colleges but also the recruitment of additional modern surgical faculty in Ayurvedic educational institutions to complement the existing faculty. This will help to significantly improve and update the training of surgeons in Ayurveda institutions in order to train future surgeons on par with surgeons trained in mainstream medical institutions. Their inclusion must be scaled in proportion to the number of Ayurveda postgraduate colleges nationwide, ensuring they contribute meaningfully to the national surgical capacity.

It is important to note that the Bachelor of Ayurvedic Medicine and Surgery (BAMS) is a 5.5-year course, with basic instruction in Shalya Tantra (Ayurvedic surgery) introduced in the final year.^[35] The curriculum of the 3-year postgraduate degree, Master of Surgery (MS) (Ayu) in Shalya Tantra, is reported to be 90% similar to the conventional MS in General Surgery.^[36–38] Complementing modern surgery with Ayurvedic practices enhances the strengths of both medical systems, facilitating interdisciplinary collaboration. Integrating Ayurveda can foster the exchange of knowledge and best practices, thus creating a more holistic, patient-centred, and sustainable healthcare model.

Even Sushruta, the ‘Father of Surgery’, as far back as 1500 BCE, advocated the study of diverse, prevalent medical practices across cultures. He wisely advised that any knowledge system in isolation cannot progress; there should be a continuous crosstalk and incorporation of beneficial thoughts for the healthy growth of a knowledge community.

Future Directions and Challenges

It is heartening to see that in enlightened scientific institutions like the Indian Institute of Science (IISc) and the Tata Institute of Fundamental Research (TIFR), the traditional divide between Eastern and Western knowledge is breaking down. Emerging fields like Ayurveda-Biology and integrative clinical healthcare are beginning to be appreciated.

A meaningful integration of Ayurvedic surgical principles with mainstream surgical practices is a complex task that may require strategic roadmaps. First, there is a need to identify the strengths in Ayurvedic and contemporary modern surgery for clinical service, education and research embodied into an integrative surgery curriculum. Second, but very importantly, it needs policy and regulatory bodies to acknowledge the limitations in surgical education in Ayurvedic institutions. A phased implementation plan should introduce advances that are harnessed by contemporary surgery. Developments in anaesthetics, multi-organ surgical specialisations, minimally invasive surgery aided by imaging and robotic-assisted techniques, and interventional radiology need to be introduced in a phased manner. In addition, education tools for virtual anatomical and other forms of virtual training need to be urgently introduced.

Surgical training in Ayurveda establishments needs to adopt new benchmarks for precision and patient safety. Any integrative framework must therefore engage with these reforms and advances that align Ayurvedic approaches with established guidelines across diverse specialities, ranging from ophthalmology and oncological surgeries to simpler procedures like oesophageal surgical procedures, colonic resections, and neurosurgical interventions. In addition, the question of opening up superspeciality domains such as MCh programmes in Ayurveda medical institutions needs to be carefully considered. Addressing these challenges in a phased manner is essential to ensure that integration is competency-based and patient-centred, capable of contributing meaningfully to the evolving landscape of surgical sciences and surgical security of the Indian people.

Midcourse correction in India’s surgical training institutions, to bring them up to global standards of surgery in both Ayurveda and mainstream medical institutions, is a complex nation-building task. It requires direction from the highest levels of government to create a ‘strategy group’ with members drawn from advanced centres of surgery in both academic and clinical institutions of excellence, in the government, private sectors and international institutions, to design an operational roadmap.

There is an urgent need for both mainstream (NMC) and AYUSH medical councils (NCISM) to jointly constitute a non-partisan, open-minded expert clinical committee tasked with reimagining surgical training in India. The remit of the committee should aim to integrate and unify surgical education and multi-speciality surgical training in the country. India. This will involve drawing upon principles, proven pre-, post- and para-surgical practices from Ayurveda, while modernising infrastructure, content and pedagogy in surgical training, across all surgical establishments in the country, to generate the next generation of globally acknowledged skilled Indian surgeons.