 This boy, Harshal Kadam suffers from a condition called as epidermolysis bullosa. It is a very, very rare condition wherein the skin blisters at the smallest of injuries. Basically, it is a genetic condition and it is very difficult to handle these children. A lot of these children die at birth. Some of them live up to the teenagers and very few of them survive to full adulthood. The main problem here is the epidermis that is the outermost layer of the skin is not formed properly. So, what happens is with the smallest of injuries, the act of either lifting the child or forcefully or pinching or rubbing the skin, the skin peels off. It is extremely painful for the children and they have to undergo prolonged dressings. As a result of this very many injuries in the hand, slowly the injuries merge together and all the fingers get stuck together. So, that is why as you can see in this boy, both the hands and the feet, the toes, all of them are stuck together in the form of a cocoon. So, these are known as cocoon hands or the cocoon feet. Also, in addition, these children also have problems with the intestinal lining, the esophageal lining. That is why the mouth is a little small. They are unable to open the mouth fully. The esophagus is involved and they are unable to eat properly and therefore their intake is less and they are always, always small for their weight. He had come to us a few years back when we had seen him when he was about 4 years old. We had suggested surgery. Unfortunately, for very many social reasons they were not able to undergo surgery at that time and they came up towards about a month ago when we planned a treatment plan for him. It is a very challenging case to perform because it requires multidisciplinary approach. We need to involve the dermatologist, we need to involve anesthetist, we need to involve a periodic surgeon, our nursing staff, our ward staff, the OT staff. Everybody needs to be sensitized to the special needs of these children. And as a team we made a plan for him and we planned two surgeries at one shot that is all under one anesthesia. And this was accomplished at Manipal Hospital. We did a reconstructive leg surgery and also gastroostomy for his feeding because he was hardly putting on weight and he could barely stand although he was about 8 or 10 years of age. However, having done a few of these cases, we are quite comfortable handling these children. This child had only one desire when he came to me. He wanted to walk. He said he is quite comfortable with his hands, he is using a mobile, he is able to draw, he is able to color but because of the knee contracture, he is unable to walk. And the only request of the family was if we can help him walk, they would be very grateful. Now, in a normal course of events where there is a contracture around the knee or the elbow we would release, take skin from the thigh and then apply it on the wound. But in his case, we didn't have any much skin and the only area I could take any skin was from the scalp. So we had to shave his head under anesthesia very carefully making sure that we didn't cause any blisters. This baby was lubricated very well with liquid paraffin in the pre-op room. The entire anesthesia and OT team were sensitized to these type of cases and the baby was moving himself from the table to onto the OT table so there was no friction of the skin. Generally anesthesia was induced by inhalation method. A scalp pain was secured with 24 gauge cannula. Fortunately for us the incubation was not very difficult. We had used a video larigoscope and a five-member endotracheal tube was inserted and we were secured with a Vaseline cost tape. Having done that, then we harvested skin from the scalp and we were fortunate enough for us to get enough skin to cover both the knee contractures which were released to be covered. The other thing with these children is that they are extremely difficult to anesthetize. Even getting a simple thing like an IV line to give a glucose drip is very difficult. And therefore we had a lot of challenges with him trying to get an IV line. We cannot stick any blisters on the skin. Everything has to be a soft compressible bandage. And fortunately everything went on well. Right now both his knees are released because he has been bedridden for so long. He needs to undergo some amount of physiotherapy and walking help before he is able to walk freely on his own. We hope to see him soon so that we can release his hands and make him use all the fingers instead of the hand as a single unit. Each of the fingers will be able to move separately and he should be able to use his hand fully. I am very grateful to the Manipal Hospital and all the doctors and their assistants. I am grateful to them.