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Uzun M, Zrara NS, Wodajo EK, Zahra NM, Wojtara M, Uwishema O. Challenges and Innovations in Minimally Invasive Surgery for Pediatric Patients in Africa: A Comprehensive Review. Health Sci Rep 2025; 8:e70437. [PMID: 39917594 PMCID: PMC11798743 DOI: 10.1002/hsr2.70437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 10/10/2024] [Accepted: 01/17/2025] [Indexed: 02/09/2025] Open
Abstract
Background Minimally invasive surgery (MIS) has proven to be a successful, developing improvement in surgical practice. Allowing surgeons to operate with minimal incisions, ensures the completion of such procedures with minimal damage to the patient and provides recovery in a shorter time. The use of MIS in the pediatric population has also been growing with the increased involvement of surgeons in the evaluation of training and expertise. In Africa, however, the growth of MIS in the pediatric population faces some obstacles which are in research and innovation, cost, and affordability. Additionally, to the scarcity of resources, the limited number of pediatric surgeons available leads to a substantial workload that affects the quality of care. This paper aims to evaluate the challenges facing MIS in Africa and assess its potential in the future. Methods Data were collected through online databases such as PubMed, Google Scholar, Ovid MEDLINE, and Embase. The research team reviewed all relevant articles regarding MIS in Africa and pediatrics. Results The utilization of MIS in the pediatric population in Africa faces some major challenges. In addition to the limited resources, there is a significantly disproportionate number of physicians per population, and the training received by pediatric surgeons rarely incorporates minimally invasive techniques. This leaves a lot of work to be done to allow better access to MIS on the African continent. The recent advances by Africans in minimally invasive and endoscopic surgical training programs, as well as the establishment of minimally invasive centers, show great promise in the attempt to increase the utilization of MIS in Africa. Conclusions The work done to grow the field of MIS application in Africa is commendable, but efforts need to be strengthened and focus needs to be given to ensure the sustainability of these programs. Furthermore, the work accomplished by countries like Egypt, Senegal, and Nigeria will serve as a huge teaching point to increase the technical expertise of surgeons in the region.
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Affiliation(s)
- Mert Uzun
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Department of General Medicine, Faculty of MedicineKaradeniz Technical UniversityTrabzonTurkey
| | - Nancy S. Zrara
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Department of General Medicine, Faculty of MedicineLebanese UniversityBeirutLebanon
| | - Essey K. Wodajo
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- College of Health Sciences, School of MedicineAddis Ababa UniversityAddis AbabaEthiopia
| | - Najwa M. Zahra
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Department of General Medicine, Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Magda Wojtara
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Department of Human GeneticsUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Olivier Uwishema
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
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Hamitoglu AE, Fawaz V, Elawad SOM, Assker MM, Nader TM, Wellington J, Uwishema O. Trends and Outcomes of Laparoscopic Surgery in Low-Resource Settings: Lessons From Two African Healthcare Systems-A Narrative Review. Health Sci Rep 2024; 7:e70304. [PMID: 39720243 PMCID: PMC11667220 DOI: 10.1002/hsr2.70304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 11/09/2024] [Accepted: 12/05/2024] [Indexed: 12/26/2024] Open
Abstract
Introduction Laparoscopic surgery (LS) has been a promising development in surgical practice globally ever since its introduction. LS has exhibited many an advantage, including bettering patient outcomes, lowering the risk of postoperative infection, and displaying economical affluence. However, its implementation in the African continent still faces various challenges. In this review, we investigated the status of laparoscopic surgery integration in Africa. Objectives In this review, we aimed to investigate the challenges posed by the implementation of LS in low resource countries as well as critically evaluating initiatives and their impact within said domiciles. We also provide recommendations that may assist in LS prosperity in these settings by focusing efforts on improving training and financial incentives. Methods A comprehensive literature review was conducted to garner up-to-date evidence concerning the fate of LS adoption in low- to middle-income countries. This comprised the analysis of different case studies from countries including Nigeria and Botswana, and investigated relevant recommendations and policies provided by other African countries. Results Various challenges face the implementation of LS in countries with low resources comprising poor infrastructure, scarce training programs, and expert training personnel alongside financial boundaries. The adoption of LS in Africa has proved its benefits in improving patient outcomes and reducing hospital admissions. From a perspective of policy, it is crucial to sustain strong ties amongst institutions, stressing the importance of dynamic collaboration and locally tailored policies. Conclusion It has been demonstrated that LS implementations in African nations lower infection rates and expedite recovery. A strong collaboration between governments, stakeholders, and healthcare providers is fundamental for successful integration of LS. Such extension in low-resource environments may be achieved by providing proper training programs, funding infrastructure and equipment, and fostering effective financial initiatives.
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Affiliation(s)
- Ali Emir Hamitoglu
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Department of General Medicine, Faculty of MedicineNamık Kemal UniversityTekirdagTurkey
| | - Violette Fawaz
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Faculty of PharmacyBeirut Arab UniversityBeirutLebanon
| | - Shaima Omer Mohamed Elawad
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Department of General Medicine, Faculty of MedicineUniversity of KhartoumKhartoumSudan
| | - Mohamad Monif Assker
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Department of EducationSheikh Khalifa Medical CityAbu DhabiUAE
| | - Thea Maria Nader
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Faculty of PharmacyLebanese American UniversityJbeilLebanon
| | - Jack Wellington
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
- Bradford Teaching Hospitals NHS Foundation TrustBradfordUK
| | - Olivier Uwishema
- Department of Research and EducationOli Health Magazine OrganizationKigaliRwanda
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Obayemi JE, Donkersloot J, Kim E, Thelander K, Byrnes M, Kim GJ. A needs assessment for simulation in African surgical education. Surg Endosc 2024; 38:1654-1661. [PMID: 38326586 DOI: 10.1007/s00464-023-10665-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/28/2023] [Indexed: 02/09/2024]
Abstract
INTRODUCTION There is a critical need for comprehensive surgical training in African countries given the unmet surgical burden of disease in this region. Collaborative and progressive initiatives in global surgical education will have the greatest impact on trainees. Little is known about surgical education needs from the perspective of practicing surgeons and trainees in low-middle-income countries (LMICs). Even less is known about the potential role for simulation to augment training. METHODS A modified Delphi methodology with 2 rounds of responses was employed to survey program directors (PD) and associate program directors (APD) of Pan-African Association of Christian Surgeons (PAACS) general surgery residency programs across eight low-middle-income countries in Africa. 3 PD/APDs and 2 surgical residents participated in semi-structured interviews centered around the role of simulation in training. Descriptive analysis was performed to elicit key themes and illustrative examples. RESULTS The survey of program directors revealed that teaching residents the psychomotor skills need to perform intracorporeal suturing was both high priority and desired in multiple training sites. Other high priority skills were laparoscopic camera driving and medial visceral rotation. The interviews revealed a specific desire to perform laparoscopic surgery and a need for a simulation curriculum to familiarize staff and trainees with laparoscopic techniques. Several barriers to laparoscopic surgery exist, such as lack of staff familiarity with the equipment, lack of public buy in, and lack of generalizable and adaptable educational modules. Trainees saw utility in the use of simulation to optimize time in the operating room and sought opportunities to improve their laparoscopic skills. CONCLUSION Faculty and surgical trainees in LMICs have interest in learning advanced surgical techniques, such as laparoscopy. Developing a simulation curriculum tailored to the trainees' local context has the potential to fill this need.
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Affiliation(s)
- Joy E Obayemi
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5331, USA.
| | - John Donkersloot
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5331, USA
| | - Erin Kim
- University of Michigan Medical School, University of Michigan, Ann Arbor, USA
| | - Keir Thelander
- Pan-African Academy of Christian Surgeons, Palatine, IL, USA
| | - Mary Byrnes
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5331, USA
| | - Grace J Kim
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5331, USA
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Troller R, Bawa J, Baker O, Ashcroft J. First experience in laparoscopic surgery in low and middle income countries: A systematic review. World J Gastrointest Surg 2024; 16:546-553. [PMID: 38463379 PMCID: PMC10921192 DOI: 10.4240/wjgs.v16.i2.546] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/02/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Laparoscopic surgery has reduced morbidity and mortality rates, shorter postoperative recovery periods and lower complication rates than open surgery. It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources. However, introducing laparoscopic surgery in low-and-middle-income countries (LMIC) can be expensive and requires resources, equipment, and trainers. AIM To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources. METHODS MEDLINE, EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC. Included studies were published between 1996 and 2022 with full text available in English. Exclusion criteria were studies considering only open surgery, ear, nose, and throat, endoscopy, arthroscopy, hysteroscopy, cystoscopy, transplant, or bariatric surgery. RESULTS Ten studies out of 3409 screened papers, from eight LMIC were eligible for inclusion in the final analysis, totaling 2497 patients. Most reported challenges were related to costs of equipment and training programmes, equipment problems such as faulty equipment, and access to surgical kits. Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff. The benefits of introducing laparoscopic surgery were economic and clinical, including a reduction in hospital stay, complications, and morbidity/mortality. The introduction of laparoscopic surgery also provided training opportunities for junior doctors. CONCLUSION Despite financial and technical challenges, many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients. While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported, more support is critically required, in particular regarding training.
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Affiliation(s)
- Rebekka Troller
- Department of Surgery, Medway Maritime Hospital, Gillingham ME7 5NY, Kent, United Kingdom
| | - Jasmine Bawa
- Department of Surgery, University Hospital Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - Olivia Baker
- Department of Surgery, University Hospital Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - James Ashcroft
- Department of Surgery, University Hospital Cambridge, Cambridge CB2 0QQ, United Kingdom
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Nyundo M, Umugwaneza N, Bekele A, Chikoya L, Detry O, Gashegu J. Exploring Laparoscopic Surgery Training Opportunities in the College of Surgeons of East, Central, and Southern Africa region. JOURNAL OF SURGICAL EDUCATION 2023; 80:1454-1461. [PMID: 37620181 DOI: 10.1016/j.jsurg.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/30/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE The resource-limited environment in Sub-Saharan countries, with a lack of expert trainers, impedes the progress of laparoscopic training. This study aimed to identify the opportunities and limitations of laparoscopic surgery training in the College of Surgeons of East, Central, and Southern Africa (COSECSA) countries. DESIGN AND SETTING A multicountry online survey was conducted from January 2021 to October 2021 in COSECSA-accredited training hospitals within 16 countries. Available resources and challenges faced in order to set up well-structured laparoscopic training programs were explored. RESULTS Ninety-four surgeons answered the questionnaire. The average resources reported per hospital were 3 trained laparoscopic surgeons, 2 laparoscopic towers, and 2 sets of laparoscopic instruments. The training of the majority of these surgeons has been in local institutions (53%), a further 37% within African countries and only 10% outside Africa. Approximately 45% of them declared that laparoscopic modules were planned within the University Curricula, while only 18% of surgeons recognized that laparoscopic modules are only planned within the COSECSA program. About 57% of participants reported that at the end of residency training, graduating surgeons were not able to perform basic laparoscopic procedures. The quoted barriers included: limited laparoscopic equipment, absence of simulation lab, lack of qualified trainers, lack of training programs and time for teaching by skilled doctors, and lack of institutional support. CONCLUSIONS The well-structured set up of laparoscopic training programs in the COSECSA region is hindered due to the lack of qualified personnel and insufficient resources for the acquisition of equipment and simulation laboratories. Ongoing efforts to set up laparoscopic programs through the development of adaptive curricula, innovative strategies for reduction of equipment cost and adequate training of surgeons are crucial for patient safety and the development of laparoscopy.
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Affiliation(s)
- Martin Nyundo
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda.
| | - Nathalie Umugwaneza
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - Abebe Bekele
- Department of Surgery, School of Medicine, University of Global Health Equity, Kigali, Rwanda
| | - Laston Chikoya
- Department of Neurosurgery, Levy Mwanawasa Medical University, Lusaka, Zambia
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium
| | - Julien Gashegu
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda; Clinical Anatomy Department, University of Rwanda, Kigali, Rwanda
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Nyundo M, Kayondo K, Gasakure M, Urimubabo JC, Houben JJ, Limgba A, Nifasha A, Gashegu J, Detry O. Patient-reported outcome, perception and satisfaction after laparoscopic cholecystectomy in Kigali, Rwanda. Surg Open Sci 2023; 15:67-72. [PMID: 37745196 PMCID: PMC10514211 DOI: 10.1016/j.sopen.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/16/2023] [Accepted: 09/08/2023] [Indexed: 09/26/2023] Open
Abstract
Background Laparoscopic surgery is the gold standard for many abdominal surgeries. Laparoscopic programs in low- and middle-income countries (LMICs) and in sub-Saharan Africa face many constraints, although its use is safe, feasible, and clinically beneficial. The authors assessed patient-reported outcomes and the experience of patients operated on at the University Teaching Hospital of Kigali (CHUK). Methods This is a retrospective cross-sectional study combining medical data from medical files and information collected from telephone calls to 288 patients who underwent laparoscopic cholecystectomy at CHUK from January 2015 to December 2020. Results Among 446 laparoscopic surgeries performed at CHUK over 6 years, cholecystectomies accounted for 64.6 % of cases (288/446). Postoperative complications and mortality after laparoscopic cholecystectomy were low, respectively 1.7 % and 0.7 %, while the median length of stay was 3 days. About 74 % of surveyed patients had never heard of laparoscopic surgery prior to their procedure. Knowledge of laparoscopic surgery was associated with patient education level (p < 0.001). Half of patients had not been involved in the choice of the surgical technique. Overall satisfaction was over 95 % and >90 % of patients consider laparoscopic surgery as the best surgical approach in Rwanda, and for this reason they declared to be ready to promote this new technology despite its higher cost. However, patients reported some weaknesses and made recommendations for improving public awareness of laparoscopy and its benefits, patient-provider relationships, training of surgical workforce, laparoscopic equipment, and infrastructure. Conclusion Laparoscopic cholecystectomy can be performed with a low rate of postoperative complications in a resource-limited setting like Rwanda. Patient satisfaction was high, but efforts should be made to improve public awareness of laparoscopic surgery, improve surgical capacity, laparoscopic equipment, and infrastructure.
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Affiliation(s)
- Martin Nyundo
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Rwanda
| | - King Kayondo
- Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda
| | - Miguel Gasakure
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Rwanda
| | | | - Jean Jacques Houben
- Department of Abdominal Surgery, ERASME Hospital, Université Libre de Bruxelles, Belgium
| | - Augustin Limgba
- Department of Abdominal Surgery, King Faisal Hospital, Kigali, Rwanda
| | - Antoine Nifasha
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Rwanda
| | - Julien Gashegu
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Rwanda
- Clinical Anatomy Department, University of Rwanda, Rwanda
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liège, University of Liège, Belgium
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Ndong A, Diallo AC, Rouhi AD, Diao ML, Yi W, Tendeng JN, Williams NN, Cissé M, Dumon KR, Konaté I. Evolution of laparoscopic surgery in a sub-Saharan African country: a 30-year literature review in Senegal. Surg Endosc 2023:10.1007/s00464-023-10192-w. [PMID: 37308759 DOI: 10.1007/s00464-023-10192-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/31/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION The advent of laparoscopy has significantly reduced the morbidity associated with the majority of abdominal surgeries. In Senegal, the first studies evaluating this technique were published in the 1980s. The objective of this systematic review is to assess the evolution of laparoscopy research in Senegal. METHODS A search of PubMed and Google Scholar was carried out without limit of publication date. The keywords used were "senegal" AND "laparoscop*". Duplicates were removed, and remaining articles were assessed for selection criteria. We included all articles about laparoscopy published in Senegal. The parameters studied in each included article were the place and year of study, average age, sex ratio, assessed indications and results. RESULTS 41 Studies published between 1984 and 2021 met selection criteria. The average age of patients was 33 years (range 4.7-63). The sex ratio was 0.33. The main indications for laparoscopy according to the studies were: benign gastrointestinal disorders in 11 studies (26.8%), abdominal emergencies in 9 studies (22%), gallbladder surgery in 5 studies (12.2%), benign gynecological pathology in 6 studies (14.6%), malignant gynecological pathology in 2 studies (4.9%), diagnostic laparoscopy in 2 studies (4.9%), groin hernia repair in 2 studies (4.9%) and testicular pathology in 1 study (2.4%). Overall mortality was estimated at 0.9% (95% CI 0.6-1.3) and overall morbidity for all complications was estimated at 5% (95% CI 3.4-6.9). CONCLUSIONS This systematic review showed a predominance of the laparoscopy publications from the capital in Dakar with favorable outcomes. This technique should be popularized in the different regions of the country and its indications expanded.
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Affiliation(s)
- Abdourahmane Ndong
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint Louis, Senegal.
| | - Adja C Diallo
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint Louis, Senegal
| | - Armaun D Rouhi
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed L Diao
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint Louis, Senegal
| | - William Yi
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jacques N Tendeng
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint Louis, Senegal
| | - Noel N Williams
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mamadou Cissé
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint Louis, Senegal
| | - Kristoffel R Dumon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ibrahima Konaté
- Department of Surgery, Saint-Louis Regional Hospital, Gaston Berger University, Road of Ngallelle, 234, Saint Louis, Senegal
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Nyundo M, Umugwaneza N, Bekele A, Chikoya L, Gashegu J, Detry O. Assessment of resource capacity and barriers to effective practice of laparoscopic surgery in training hospitals affiliated with the College of Surgeons of East, Central and Southern Africa (COSECSA). Surg Endosc 2023:10.1007/s00464-023-09985-w. [PMID: 36932190 DOI: 10.1007/s00464-023-09985-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/25/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND The adoption and accessibility of laparoscopy have been serious issues in countries with limited resources, and for varied reasons. This study assessed resource capacity and barriers to the effective practice of laparoscopic surgery in training hospitals affiliated with the College of Surgeons of East, Central and Southern Africa (COSECSA). METHODS A multi-country survey was conducted from January 2021 to October 2021 using a questionnaire distributed to surgeons in COSECSA hospitals located in 16 different countries. Available resources and surgical volume were assessed, and the barriers to routinely performing laparoscopy were determined. RESULTS Ninety-four surgeons working in 44 different hospitals from 16 countries participated in the survey. The majority of respondents were general surgeons (n = 75, 79.7%). Other specialties included urology (n = 12, 12.8%) and pediatric surgery (n = 7, 7.4%). Senior surgeons accounted for 60.6% of participants, more than 40% had a managerial position and approximately 20% were surgical trainees. Most respondents practiced in public hospitals (n = 66, 70.2%). A median of three surgeons per hospital performed laparoscopic surgery with, on average, two laparoscopic towers and two sets of laparoscopic instruments available. A median of 10 procedures was carried out per month. The cost of laparoscopic procedures and laparoscopic consumables were reported as being covered by some health insurance payments in 76.9% and 48.4% of cases, respectively. Cholecystectomy was the most commonly reported laparoscopic procedure performed. The five top barriers to performing laparoscopic surgery were: a lack of consumables, a limited quantity of equipment, a lack of skilled surgeons, the high cost of laparoscopic procedures and complicated cases. In addition, having access to skilled anesthesiologists and anesthesia equipment, carbon dioxide, a consistent electric power supply and equipment maintenance were cited as significant challenges. CONCLUSION The practice of laparoscopy is currently limited in COSECSA countries due to a scarcity of skilled staff and the lack of a funding plan to make laparoscopic services accessible. Therefore, policymakers and stakeholders should take strategic measures to respond to this need.
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Affiliation(s)
- Martin Nyundo
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda.
| | - Nathalie Umugwaneza
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - Abebe Bekele
- School of Medicine, University of Global Health Equity, Kigali, Rwanda
| | - Laston Chikoya
- Department of Neurosurgery, Levy Mwanawasa Medical University, Lusaka, Zambia
| | - Julien Gashegu
- Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda.,Clinical Anatomy Department, University of Rwanda, Kigali, Rwanda
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium
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9
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Esmer AC, Çolak T, Edizsoy A, Tazeoğlu D, Serdar Karaca A. Current status of laparoscopic surgery usage in Türkiye: A middle-income country. Turk J Surg 2022; 38:353-361. [PMID: 36875273 PMCID: PMC9979558 DOI: 10.47717/turkjsurg.2022.5713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 08/31/2022] [Indexed: 01/12/2023]
Abstract
Objectives This study aimed to determine the usage status of laparoscopic procedures in general surgical practice in Türkiye, which is a sample of middle-income countries. Material and Methods The questionnaire was sent to general surgeons, gastrointestinal surgeons, and surgical oncologists who have completed their residency training and are actively working in university, public or private hospitals. Demographic data, laparoscopy training and the period of education, the rate of laparoscopy use, the type and volume of laparoscopic surgical procedures, their views on the advantages and disadvantages of laparoscopic surgery, and the reasons for preferring laparoscopy were determined with a 30-item questionnaire. Results Two hundred and forty-four questionnaires from 55 different cities of Türkiye were evaluated. The responders were mainly males, younger surgeons (F/M= 11.1/88.9 % and 30-39 y/o), and graduated from the university hospital residence program (56.6%). Laparoscopic training was frequently taken during residency (77.5%) in the younger age group, while the elderly participants mostly received additional training after specialization (91.7%). Laparoscopic surgery was mostly not available in public hospitals for advanced procedures (p <0.0001) but was available for cholecystectomy and appendectomy operations (p= NS). However, participants working in university hospitals mostly stated that the laparoscopic approach was the first choice for advanced procedures. Conclusion The results of this study showed that the surgeons working in MICs spent strong effort to use laparoscopy in daily practice, especially in university and high-volume hospitals. However, inappropriate education, cost of laparoscopic equipment, healthcare policies, and some cultural and social barriers might have negatively impacted the widespread use of laparoscopic surgery and its usage in daily practice in MICs such as Türkiye.
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Affiliation(s)
- Ahmet Cem Esmer
- Department of Surgical Oncology, Mersin University Faculty of Medicine, Mersin, Türkiye
| | - Tahsin Çolak
- Department of Surgical Oncology, Mersin University Faculty of Medicine, Mersin, Türkiye
| | - Akay Edizsoy
- Department of Surgical Oncology, Mersin University Faculty of Medicine, Mersin, Türkiye
| | - Deniz Tazeoğlu
- Department of Surgical Oncology, Mersin University Faculty of Medicine, Mersin, Türkiye
| | - Ahmet Serdar Karaca
- Clinic of General Surgery, Başkent University Faculty of Medicine İstanbul Hospital, İstanbul, Türkiye
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Ndong A, Gaye NF, Tendeng JN, Diao ML, Diallo AC, Niang FG, Diop S, Dia DA, Diedhiou M, Dieng M, Fall ML, Ma Nyemb PM, Konaté I. Profile of Patients with Gallstone Disease in a Sub-Saharan African General Surgery Department: A Retrospective Cohort Study Protocol. Int J Surg Protoc 2021; 25:61-65. [PMID: 34013146 PMCID: PMC8114842 DOI: 10.29337/ijsp.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: Gallstone disease is a disorder characterised by the formation of stones in the biliary tract. It is the most common biliary condition accounting for more than 98% of all gallbladder and biliary tract disorders. In Africa, previous studies have shown a relative rarity of this condition with a prevalence less than 5%; since it is between 2 and 5 times higher in other continents. A good knowledge of the profile of patient with gallstone disease in a surgical setting could allow to reduce gallstone disease complications and to tailor better the treatment. To our knowledge, there was no previous study about gallstone disease in this region even if there is a high prevalence of metabolic factors of gallstone disease. Methods: This study objective is to describe the epidemiological, diagnostic and therapeutic profile of patients with gallstone disease at the Department of General Surgery of Saint-Louis Hospital (Senegal). It will be a single-centre retrospective cohort study in a period of 5 years (January 2015 – December 2020). The patients’ record of the department of general surgery will be consulted and the patient contacted if there are missing data. Patients with gallstone disease diagnosed with imaging (ultrasonography and/or CT scan) regardless the presentation (asymptomatic, biliary colic, cholecystitis, common bile duct lithiasis, angio-cholitis, pancreatitis) will be included. Adults and paediatric patients will be enrolled. Patient records lacking sufficient data will be excluded. Studied parameters will be epidemiological, clinical, paraclinical and therapeutic aspects. Ethics and dissemination: Anonymity and confidentiality of information collected in patients will be respected. This research protocol will be submitted to the Ethics Committee of our institution for approval. The knowledge of the profile of patients with gallstone disease in a surgical setting could allow to reduce gallstone disease complications and to tailor better the treatment. Finally, it will help to reduce the burden of gallstone disease. Highlights
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Affiliation(s)
- A Ndong
- Department of Surgery, Gaston Berger University of Saint-Louis, Senegal
| | - N F Gaye
- Department of Surgery, Gaston Berger University of Saint-Louis, Senegal
| | - J N Tendeng
- Department of Surgery, Gaston Berger University of Saint-Louis, Senegal
| | - M L Diao
- Department of Surgery, Gaston Berger University of Saint-Louis, Senegal
| | - A C Diallo
- Department of Surgery, Gaston Berger University of Saint-Louis, Senegal
| | - F G Niang
- Department of Imaging, Gaston Berger University of Saint-Louis, Senegal
| | - S Diop
- Department of Surgery, Gaston Berger University of Saint-Louis, Senegal
| | - D A Dia
- Department of Surgery, Gaston Berger University of Saint-Louis, Senegal
| | - M Diedhiou
- Department of Anaesthesiology, Gaston Berger University of Saint-Louis, Senegal
| | - M Dieng
- Department of Anaesthesiology, Gaston Berger University of Saint-Louis, Senegal
| | - M L Fall
- Department of Anaesthesiology, Gaston Berger University of Saint-Louis, Senegal
| | - P M Ma Nyemb
- Department of Surgery, Gaston Berger University of Saint-Louis, Senegal
| | - I Konaté
- Department of Surgery, Gaston Berger University of Saint-Louis, Senegal
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Abstract
Laparoscopy has numerous clinical benefits compared to laparotomy. However, a functional laparoscopy program requires significant investment and, as a result, remains unavailable for the majority of the world’s population in low- and middle-income countries. The effort to bring laparoscopy to low-resource settings has produced variable outcomes resulting from the challenges inherent to a complex surgical program. This paper highlights these shortcomings and identifies opportunities to improve future laparoscopy programs.
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Robertson F, Mutabazi Z, Kyamanywa P, Ntakiyiruta G, Musafiri S, Walker T, Kayibanda E, Mukabatsinda C, Scott J, Costas-Chavarri A. Laparoscopy in Rwanda: A National Assessment of Utilization, Demands, and Perceived Challenges. World J Surg 2019; 43:339-345. [PMID: 30232568 DOI: 10.1007/s00268-018-4797-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Laparoscopy has proven to be feasible and effective at reducing surgical morbidity and mortality in low resource settings. In Rwanda, the demand for and perceived challenges to laparoscopy use remain unclear. METHODS A mixed-methods study was performed at the four Rwandan national referral teaching hospitals. Retrospective logbook reviews (July 2014-June 2015) assessed procedure volume and staff involvement. Web-based surveys and semi-structured interviews investigated barriers to laparoscopy expansion. RESULTS During the study period, 209 laparoscopic procedures were completed: 57 (27.3%) general surgery cases; 152 (72.7%) ob/gyn cases. The majority (58.9%, 125/209) occurred at the private hospital, which performed 82.6% of cholecystectomies laparoscopically (38/46). The three public hospitals, respectively, performed 25% (7/28), 15% (12/80), and 0% (denominator indeterminate) of cholecystectomies laparoscopically. Notably, the two hospitals with the highest laparoscopy volume relied on a single surgeon for more than 85% of cases. The four ob/gyn departments performed between 4 and 87 laparoscopic cases (mostly diagnostic). Survey respondents at all sites listed a dearth of trainers as the most significant barrier to performing laparoscopy (65.7%; 23/35). Other obstacles included limited access to training equipment and courses. Equipment and material costs, equipment functionality, and material supply were perceived as lesser barriers. Twenty-two interviews revealed widespread interest in laparoscopy, insufficient laparoscopy exposure, and a need for trainers. CONCLUSION While many studies identify cost as the most prohibitive barrier to laparoscopy utilization in low resource settings, logbook review and workforce perception indicate that a paucity of trainers is currently the greatest obstacle in Rwanda.
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Affiliation(s)
- Faith Robertson
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.
| | - Zeta Mutabazi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Patrick Kyamanywa
- Department of Surgery, Faculty of Clinical Medicine and Dentistry, Kampala International University Western Campus, Kampala, Uganda
| | | | - Sanctus Musafiri
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,Centre Hospitalier Universitaire de Butare, Butare, Rwanda
| | - Tim Walker
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
| | | | | | - John Scott
- Brigham and Women's Hospital, Boston, MA, USA
| | - Ainhoa Costas-Chavarri
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Rwanda Military Hospital, Kigali, Rwanda.,Boston Children's Hospital, Boston, MA, USA
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Ghesquière L, Garabedian C, Boukerrou M, Dennis T, Garbin O, Hery R, Rubod C, Cosson M. Implementation of laparoscopy surgery training via simulation in a low-income country. J Gynecol Obstet Hum Reprod 2018; 47:187-190. [PMID: 29510268 DOI: 10.1016/j.jogoh.2018.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/23/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate laparoscopy training using pelvitrainers for gynaecological surgeons in a low-income country. METHODS The study was carried out in Madagascar from April 2016 to January 2017. The participants were gynaecological surgeons who had not previously performed laparoscopy. Each surgeon was timed to evaluate the execution times of four proposed exercises, based on the fundamentals of laparoscopic surgery (FLS) programme's skills manual, as follows: exercise 1, involving a simple object transfer; exercises 2 and 3, comprising complex object transfers; and exercise 4, a precision cutting exercise. The 8-month training and evaluation programme was divided into different stages, and the four following evaluations were compared: a pretest (T0), assessment at the end of the first training (T1) and auto-evaluation at 2 months (T2) and 8 months (T3). RESULTS Eight participants were included. The median time was significantly reduced (P<0.05) at each evaluation for exercises 1, 2 and 4 compared to the pretest. For exercise 3, there was no difference between T0 and T1 (P=0.07). After 8 months of training, all participants progressed in all exercises. CONCLUSION Our study showed that it is possible and beneficial to develop a programme for teaching laparoscopic surgery in low-income countries before providing the necessary equipment.
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Affiliation(s)
- L Ghesquière
- CHU Lille, Department of Gynaecology, 59000, Lille, France; University of Lille North of France, EA4489 - Perinatal Environment and Infant Growth, 59000 Lille, France.
| | - C Garabedian
- CHU Lille, Department of Gynaecology, 59000, Lille, France; University of Lille North of France, EA4489 - Perinatal Environment and Infant Growth, 59000 Lille, France
| | - M Boukerrou
- University Hospital of Reunion Island, Gynaecology and Obstetrics Unit, BP 350, 97448 Saint Pierre Cedex, Réunion, France; Perinatal Studies Center of the Indian Ocean, University Hospital of Reunion Island, BP 350, 97448 Saint Pierre Cedex, Réunion, France; Faculty of Medicine, University of Reunion, 97490 Saint Denis, Réunion, France
| | - T Dennis
- University Hospital of Reunion Island, Gynaecology and Obstetrics Unit, BP 350, 97448 Saint Pierre Cedex, Réunion, France
| | - O Garbin
- CHU Strasbourg, CMCO, Gynecology Unit, 67000 Strasbourg, France
| | - R Hery
- CHU Befelatanana, Maternity of Befelatanana, Antananarivo University, Madagascar
| | - C Rubod
- CHU Lille, Department of Gynaecology, 59000, Lille, France; University of Lille North of France, 59000 Lille, France
| | - M Cosson
- CHU Lille, Department of Gynaecology, 59000, Lille, France; University of Lille North of France, 59000 Lille, France
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Adisa AO, Lawal OO, Adejuyigbe O. Trend Over Time for Cholecystectomy following the Introduction of Laparoscopy in a Nigerian Tertiary Hospital. Niger J Surg 2017; 23:102-105. [PMID: 29089733 PMCID: PMC5649423 DOI: 10.4103/njs.njs_56_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: There still exist some concerns about the desirability of laparoscopic surgery in lower-middle income countries. We recently adopted laparoscopy for common general surgical procedures and observed many benefits. This study aims to describe the changing rate of cholecystectomy before and after the introduction of laparoscopy in our hospital. Methods: We reviewed the records of cholecystectomies performed before and after the introduction of laparoscopic cholecystectomy (LC) in 2009 in a single general surgery unit of the Ife Hospital Unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. Cholecystectomy was reviewed as a percentage of general procedures performed, and postoperative length of stay was calculated. Results: A total of 173 cholecystectomies were performed in the hospital between January 2005 and December 2015. The yearly number rose from 7 in 2005 to 31 in 2015 corresponding to 2.7% of total elective major general surgery procedures in 2005 and 9.1% in 2015. A marked progressive increase was observed in the number and rate of cholecystectomies from 2009 following introduction of LC. From 0% in 2005, LC rose to 90% of all cholecystectomies in 2015. The mean postoperative length of stay of patients undergoing cholecystectomy declined from 5.2 days in 2005 to 3 days in 2009 and 1.8 days in 2015. Conclusion: This study demonstrates an increased rate of cholecystectomy following the introduction of LC in our setting. We recommend increased adoption of laparoscopy and other forms of minimally invasive surgery across the country.
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Affiliation(s)
- Adewale Oluseye Adisa
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Obafemi Awolowo University, Ile-Ife 220005, Osun State, Nigeria
| | - Oladejo Olukayode Lawal
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Obafemi Awolowo University, Ile-Ife 220005, Osun State, Nigeria
| | - Olusanya Adejuyigbe
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Obafemi Awolowo University, Ile-Ife 220005, Osun State, Nigeria
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Laparoscopic Versus Open Cholecystectomy: A Cost-Effectiveness Analysis at Rwanda Military Hospital. World J Surg 2017; 41:1225-1233. [PMID: 27905020 DOI: 10.1007/s00268-016-3851-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy is first-line treatment for uncomplicated gallstone disease in high-income countries due to benefits such as shorter hospital stays, reduced morbidity, more rapid return to work, and lower mortality as well-being considered cost-effective. However, there persists a lack of uptake in low- and middle-income countries. Thus, there is a need to evaluate laparoscopic cholecystectomy in comparison with an open approach in these settings. METHODS A cost-effectiveness analysis was performed to evaluate laparoscopic and open cholecystectomies at Rwanda Military Hospital (RMH), a tertiary care referral hospital in Rwanda. Sensitivity and threshold analyses were performed to determine the robustness of the results. RESULTS The laparoscopic and open cholecystectomy costs and effectiveness values were $2664.47 with 0.87 quality-adjusted life years (QALYs) and $2058.72 with 0.75 QALYs, respectively. The incremental cost-effectiveness ratio for laparoscopic over open cholecystectomy was $4946.18. Results are sensitive to the initial laparoscopic equipment investment and number of cases performed annually but robust to other parameters. The laparoscopic intervention is more cost-effective with investment costs less than $91,979, greater than 65 cases annually, or at willingness-to-pay (WTP) thresholds greater than $3975/QALY. CONCLUSIONS At RMH, while laparoscopic cholecystectomy may be a more effective approach, it is also more expensive given the low caseload and high investment costs. At commonly accepted WTP thresholds, it is not cost-effective. However, as investment costs decrease and/or case volume increases, the laparoscopic approach may become favorable. Countries and hospitals should aspire to develop innovative, low-cost options in high volume to combat these barriers and provide laparoscopic surgery.
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Alfa-Wali M, Osaghae S. Practice, training and safety of laparoscopic surgery in low and middle-income countries. World J Gastrointest Surg 2017; 9:13-18. [PMID: 28138364 PMCID: PMC5237818 DOI: 10.4240/wjgs.v9.i1.13] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/03/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
Surgical management of diseases is recognised as a major unmet need in low and middle-income countries (LMICs). Laparoscopic surgery has been present since the 1980s and offers the benefit of minimising the morbidity and potential mortality associated with laparotomies. Laparotomies are often carried out in LMICs for diagnosis and management, due to lack of radiological investigative and intervention options. The use of laparoscopy for diagnosis and treatment is globally variable, with high-income countries using laparoscopy routinely compared with LMICs. The specific advantages of minimally invasive surgery such as lower surgical site infections and earlier return to work are of great benefit for patients in LMICs, as time lost not working could result in a family not being able to sustain themselves. Laparoscopic surgery and training is not cheap. Cost is a major barrier to healthcare access for a significant population in LMICs. Therefore, cost is usually seen as a major barrier for laparoscopic surgery to be integrated into routine practice in LMICs. The aim of this review is to focus on the practice, training and safety of laparoscopic surgery in LMICs. In addition it highlights the barriers to progress in adopting laparoscopic surgery in LMICs and how to address them.
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The Role of Minimally Invasive Gynecologic Surgery in Sub Saharan Africa. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0184-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Morrow E, Bekele A, Tegegne A, Kotisso B, Warner E, Kaufman J, Amies Oelschlager AM, Oelschlager B. Laparoscopic simulation for surgical residents in Ethiopia: course development and results. Am J Surg 2016; 212:645-648. [PMID: 27649975 DOI: 10.1016/j.amjsurg.2016.06.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/15/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND We aimed to develop and implement a laparoscopic skills curriculum in an Ethiopian surgical residency program. We hypothesized that residents would improve with practice. METHODS We developed a laparoscopic curriculum by adapting existing training models. Six courses were conducted during 2012 and 2013 in a teaching hospital in Ethiopia. Eighty-eight surgical residents participated. Main outcome measures were laboratory task completion times and student survey responses. RESULTS Students showed improvement in time needed to complete skills tasks with practice. Mean times improved for all 5 tasks (P ≤ .01). Students uniformly reported that the course was valuable. The curriculum is now taught and sustained by local faculty. CONCLUSIONS The development and implementation of a collaborative and sustainable laparoscopic curriculum is possible in a low-resource environment. Such a curriculum can result in improved laparoscopic expertise, surgical trainee satisfaction, and may increase utilization of laparoscopy.
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Affiliation(s)
- Ellen Morrow
- Departments of Surgery and Obstetrics and Gynecology, School of Medicine, University of Washington, Seattle, Washington, USA.
| | - Abebe Bekele
- Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ayalew Tegegne
- Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Berhanu Kotisso
- Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Elizabeth Warner
- Departments of Surgery and Obstetrics and Gynecology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Jedediah Kaufman
- Departments of Surgery and Obstetrics and Gynecology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Anne-Marie Amies Oelschlager
- Departments of Surgery and Obstetrics and Gynecology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Brant Oelschlager
- Departments of Surgery and Obstetrics and Gynecology, School of Medicine, University of Washington, Seattle, Washington, USA
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Ekwunife CN, Nwobe O. First 100 laparoscopic surgeries in a predominantly rural Nigerian population: a template for future growth. World J Surg 2015; 38:2813-7. [PMID: 24898936 DOI: 10.1007/s00268-014-2656-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Minimal access surgery has revolutionized surgery practice. Its proven advantages, such as reduced postoperative pain, early return to unrestricted activities, and better cosmesis, have become important drivers for its rapid development. In sub-Saharan Africa this development has been slow. The aim of the current study was to describe the challenges and outcomes of laparoscopic procedures in a public hospital that caters to a predominantly rural population. MATERIAL AND METHODS The first 100 patients who underwent laparoscopic procedure in the Department of Surgery at Federal Medical Centre, Owerri, Nigeria were retrospectively analyzed. Data were retrieved from the medical records department as well as the surgical theater procedure register. The focus of the study was on patient demographics, indication for surgery, procedure performed, length of hospital stay, and morbidity and mortality data. Staff training was done locally and abroad. RESULTS Altogether, 100 patients had laparoscopic surgery in our general surgery unit from September 2007 through July 2013. The ages of the patients was 5-75 years (median 36.5 years). The three main procedures were cholecystectomy (36 %), diagnostic laparoscopy (29 %), and appendectomy (21 %). The other operations performed included liver abscess drainage (7 %), adhesiolysis (3 %), hernia repair (1 %), and Heller's myotomy (1 %). Four cases were converted to open surgery. There were no deaths. There were 14 grades I and II postoperative complications in nine patients. CONCLUSIONS Our study suggests that basic laparoscopic procedures could be offered safely to our resource-poor rural population. It is a platform on which we can hopefully introduce advanced laparoscopic surgical operations.
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Chao TE, Mandigo M, Opoku-Anane J, Maine R. Systematic review of laparoscopic surgery in low- and middle-income countries: benefits, challenges, and strategies. Surg Endosc 2015; 30:1-10. [PMID: 25875087 DOI: 10.1007/s00464-015-4201-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 03/31/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laparoscopy may prove feasible to address surgical needs in limited-resource settings. However, no aggregate data exist regarding the role of laparoscopy in low- and middle-income countries (LMICs). This study was designed to describe the issues facing laparoscopy in LMICs and to aggregate reported solutions. METHODS A search was conducted using Medline, African Index Medicus, the Directory of Open Access Journals, and the LILACS/BIREME/SCIELO database. Included studies were in English, published after 1992, and reported safety, cost, or outcomes of laparoscopy in LMICs. Studies pertaining to arthroscopy, ENT, flexible endoscopy, hysteroscopy, cystoscopy, computer-assisted surgery, pediatrics, transplantation, and bariatrics were excluded. Qualitative synthesis was performed by extracting results that fell into three categories: advantages of, challenges to, and adaptations made to implement laparoscopy in LMICs. PRISMA guidelines for systematic reviews were followed. RESULTS A total of 1101 abstracts were reviewed, and 58 articles were included describing laparoscopy in 25 LMICs. Laparoscopy is particularly advantageous in LMICs, where there is often poor sanitation, limited diagnostic imaging, fewer hospital beds, higher rates of hemorrhage, rising rates of trauma, and single income households. Lack of trained personnel and equipment were frequently cited challenges. Adaptive strategies included mechanical insufflation with room air, syringe suction, homemade endoloops, hand-assisted techniques, extracorporeal knot tying, innovative use of cheaper instruments, and reuse of disposable instruments. Inexpensive laboratory-based trainers and telemedicine are effective for training. CONCLUSIONS LMICs face many surgical challenges that require innovation. Laparoscopic surgery may be safe, effective, feasible, and cost-effective in LMICs, although it often remains limited in its accessibility, acceptability, and quality. This study may not capture articles written in languages other than English or in journals not indexed by the included databases. Surgeons, policymakers, and manufacturers should focus on plans for sustainability, training and retention of providers, and regulation of efforts to develop laparoscopy in LMICs.
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Affiliation(s)
- Tiffany E Chao
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB 425, Boston, MA, 02114, USA. .,Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
| | - Morgan Mandigo
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jessica Opoku-Anane
- Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Rebecca Maine
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Andreatta P, Perosky J, Klotz J, Gamble C, Ankobea F, Danso K, Dalton V. Pilot study outcomes from a resource-limited setting for a low-cost training program for laparoscopic surgical skills. Int J Gynaecol Obstet 2014; 125:186-8. [PMID: 24602775 DOI: 10.1016/j.ijgo.2013.10.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 10/23/2013] [Accepted: 02/02/2014] [Indexed: 12/11/2022]
Affiliation(s)
- Pamela Andreatta
- Department of Urologic Surgery, University of Minnesota Medical School, Minneapolis, USA; Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, USA.
| | - Joseph Perosky
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, USA
| | - Jessica Klotz
- Department of Urologic Surgery, University of Minnesota Medical School, Minneapolis, USA
| | - Charlotte Gamble
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, USA
| | - Frank Ankobea
- Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Kwabena Danso
- Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Vanessa Dalton
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, USA
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Beard JH, Akoko L, Mwanga A, Mkony C, O'Sullivan P. Manual laparoscopic skills development using a low-cost trainer box in Tanzania. JOURNAL OF SURGICAL EDUCATION 2014; 71:85-90. [PMID: 24411429 DOI: 10.1016/j.jsurg.2013.06.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/27/2013] [Accepted: 06/05/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To explore the feasibility and effectiveness of guided practice using a low-cost laparoscopic trainer on the development of laparoscopic skills by surgeons in a resource-poor setting. DESIGN This was a prospective trial involving a pretest/posttest single-sample design. Study participants completed a background survey and pretest on the 5 McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) tasks using a simulator developed and validated by researchers from the University of California, San Francisco. On completion of a 3-month guided practice course, participants were again tested on the MISTELS tasks and completed an exit survey. SETTING The Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania. PARTICIPANTS Fourteen Tanzanian surgery residents and specialists completed the study. RESULTS Most of the subjects were surgical residents (64.3%). Only 2 participants (14.2%) had previous laparoscopic training, and baseline laparoscopic surgical experience was limited to intraoperative observation only. Study subjects practiced the MISTELS tasks for an average of 8.67 hours (range: 4.75-15.25) over the 3-month course. On the posttest, participants improved significantly in performance of each of the MISTELS tasks (p < 0.001). Total scores on the tasks increased from 24 ± 44 on the pretest to 384 ± 49 on the posttest (p < 0.001). All study participants were satisfied with the course, found the training personally valuable, and felt that their laparoscopic skills had improved on completion of the training. CONCLUSIONS We have demonstrated the feasibility and effectiveness of training with a low-cost laparoscopic trainer box in Tanzania. Study participants achieved impressive posttest scores on the 5 MISTELS tasks with minimal baseline laparoscopic exposure. We feel that guided training by an expert was key in ensuring correct technique during practice sessions.
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Affiliation(s)
- Jessica H Beard
- Department of Surgery, University of California, San Francisco, California.
| | - Larry Akoko
- Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ally Mwanga
- Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Charles Mkony
- Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Loveland J, Numanoglu A, Hay SA. Pediatric minimally invasive surgery in Africa: limitations and current situation. Semin Pediatr Surg 2012; 21:160-3. [PMID: 22475122 DOI: 10.1053/j.sempedsurg.2012.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The second largest and most populous continent, with an exploding pediatric population, Africa has an overwhelming burden on its very limited pediatric surgical services. In an international environment of progressively advancing endoscopic and robotic surgical techniques, the authors focus on the current role of endoscopic surgery on the continent and explore the potential reasons for its delayed acceptance and implementation. They proceed to document the spectrum of what is available and, using their "African experience," expand on financially viable models of further rolling out these techniques, including discussion around suitable training models for surgeons and their teams.
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Affiliation(s)
- Jerome Loveland
- Department of Paediatric Surgery, Baragwanath Hospital, University of the Witwatersrand, Johannesburg, Gauteng, South Africa.
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Okrainec A, Henao O, Azzie G. Telesimulation: an effective method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries. Surg Endosc 2009; 24:417-22. [DOI: 10.1007/s00464-009-0572-6] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 05/04/2009] [Accepted: 05/14/2009] [Indexed: 11/29/2022]
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Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course. Surg Endosc 2009; 23:2493-8. [PMID: 19343438 DOI: 10.1007/s00464-009-0424-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Revised: 12/19/2008] [Accepted: 01/12/2009] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The use of laparoscopy in resource-restricted countries has increased in recent years. Although simulation is now considered an important adjunct to operating-room-based training for learning laparoscopic skills, there is very little literature assessing the use of simulation in resource-restricted countries. The purpose of this study was to determine the feasibility and impact of a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in Botswana, Africa. METHODS A total of 20 surgeons and trainees participated in a 3-day FLS course. A pretest FLS score was obtained for each subject, followed by 2 days of practice with feedback. A final FLS posttest score was then obtained. Participants also watched the FLS instructional CD-ROM and took the written test on day 3. RESULTS Mean posttest scores were significantly higher than pretest scores for each FLS task and for the total normalized FLS simulator score (285 +/- 94 versus 132 +/- 92, p < 0.001). The mean score on the written test was 242 (116). In total, only two surgeons achieved a passing score on both the cognitive and skills assessment required to obtain FLS certification. CONCLUSION To our knowledge, this is the first time the FLS program has been taught in Africa. We have shown that giving the FLS course in a resource-restricted country is feasible and resulted in a significant improvement in FLS technical skills after 3 days. Most surgeons, however, still did not reach FLS passing scores, indicating that more than 3 days will be required in future courses to help surgeons obtain FLS certification.
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Abstract
Ulcer surgery today concentrates on the complications of chronic ulcer disease, especially ulcer perforation and endoscopically uncontrollable ulcer bleeding. In this case the laparoscopic or open closure of the gastroduodenal defect or local hemostasis of the bleeding ulcer by laparotomy are the main aims of surgery. Elective operations due to recurrent gastric or duodenal ulcers have become rare. An indication for gastric ulcer resistant to conservative therapy could be persisting suspicion of malignancy whereas in duodenal ulcer gastric outlet obstruction represents a reason for surgery. If these indications are confirmed the classic procedures of gastric resection like Billroth I and Billroth II are performed whereas vagotomy is no longer used. Altogether ulcer surgery has become very safe although it is practiced quite rarely.
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Affiliation(s)
- A H Hölscher
- Klinik und Poliklinik für Visceral- und Gefässchirurgie der Universität, Köln, Kerpener Strasse 62, 50937 Köln.
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