Page 36 - World Journal of Laparoscopic Surgery

Rafique B Parkar et al
Table 3: Laparoscopic surgery growth lower, which may be attributable to the years of expertise
Year (n) 0–5 6–10 11–15 16–20 21–23 Total and the number of surgical cases performed.
Total surgeries 875 997 1,789 2,013 1,874 7,548 The costs associated with laparoscopy are a rel-
performed (n) evant concern in the discussions of laparoscopy in
Laparoscopic 29 98 684 1,296 1,012 3,119 LMIC settings. We note that patients paid a nominal
procedures
performed (n) fee equivalent to USD 200 to 600 per procedure to the
Laparoscopy 3.3 9.8 38.2 64.4 54.0 41.3 hosting hospital; however, this fee was waived when it
percentage was considered unaffordable. The cost of each surgical
case (logistics, expendable supplies) to the organizers
did rise from USD 35 per patient in 1992 to USD 386 per
Table 4: Complications
patient in 2015; however, all surgeons volunteered their
n % time and expertise at no cost. All of the support for the
Sepsis 9 0.31 laparoscopic equipment was provided by local industry
Ureteral injury 1 0.03 partners, while the host hospital provided all additional
Secondary hemorrhage 22 0.75
Vesicovaginal fistula 3 0.10 equipment and supplies and managed postoperative
Port site herniation 4 0.14 care and follow-up.
Intestinal obstruction 2 0.07 The above illustration suggests that lack of equipment
Conversion to laparotomy* 211 7.27 and costs should no longer be accepted as limitation to
*Not considered as a complication patients having access to minimally invasive surgery.
Various adaptations can decrease costs and surmount
barriers allowing for more widespread acceptance of
procedures increased from 3.3% of total procedures
performed at these facilities in 1992 to 41.3% in 2015 laparoscopic surgery in low-income settings including
(Table 3). team work, sourcing of donated equipment, training of
The mean length of hospital stay for laparoscopic theater and support staff, encouraging local universities to
surgery patients was 1.9 days. There were 41 known incorporate laparoscopic surgery in their postgraduate
complications out of the 2,901 procedures performed teaching curriculums, developing safe clinical guidelines,
11,12
(1.41%). Complications included sepsis, wound dehi- and the use of reusable instruments. The argument
scence, secondary hemorrhage, port site herniation, that laparoscopic surgery is expensive is no longer
intestinal obstruction, ureteric injuries, and vesicov- acceptable since the cost-effectiveness of laparoscopic
aginal fistulas (Table 4). Secondary hemorrhage was the surgery has been reported to be superior in numerous
8,9,11,13
commonest complication occurring in 22 (0.75%) cases. publications.
One mortality was reported, resulting from uncontrol- Laparoscopic surgery has unlimited advantages in
14,15
lable hemorrhage during a converted laparotomy for an resource-limited settings; therefore, surgeons have to
ovarian tumor. Conversion to laparotomy occurred in be encouraged to undergo the required sustained train-
211 (7.2%) cases. ing for safe laparoscopic surgery, which is now available.
Concomitant incorporation of skills training in laparo-
scopic surgery at our existing universities will motivate
DISCUSSION
the younger surgeons to develop a sense of professional
The value of laparoscopic surgery in low-income and accomplishment and confidence to provide this essential
resource-limited settings has been debated for some time; service to the community. Additionally, laparoscopic
however, large-scale studies are limited. In an 8-year outreach programs can act as a tool for skills training,
retrospective analysis of gynecological laparoscopic giving new surgeons an opportunity to refine their skills.
10
surgery in a resource-limited setting, Mboudou et al This retrospective assessment provides unique insight
reviewed 9,194 surgeries where only 633 (6.9%) were per- into the use of laparoscopy in rural LMIC settings;
formed laparoscopically at the University of Yaounde’s however, the assessment has some limitations. An attempt
Teaching Hospital in Cameroon. The mean duration of was made to see all patients postoperatively during the
hospitalization was 3.4 ± 1.8 days and a complication week of the surgical camps, and continued follow-up was
10
rate of 5.9% was reported. In our review of data from left to the host hospital; nonetheless, we made every
17 rural hospitals in Kenya, a total of 7,548 surgical pro- effort to be informed of subsequent complications. This
cedures have been performed since 1992. Of these, 2,901 analysis is retrospective; albeit, given the volume of cases
gynecologic cases were completed laparoscopically with completed each year, a prospective study with defined
a complication rate of only 1.41% and a mean hospital stay characteristics will provide improved insight into the
of 1.9 days. In our series, the complication rate was much successes and challenges of laparoscopy in this setting.
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