Systematic review of laparoscopic surgery in low- and middle-income countries: benefits, challenges, and strategies

The role of clinical exchange programs in postgraduate obgyn training: A case-study of the FIGO-WATOG One World Exchange

OBJECTIVE

To evaluate the role of clinical exchange programs in postgraduate obgyn training using the International Federation of Gynecology and Obstetrics (FIGO)-World Association of Trainees in Obstetrics and Gynecology (WATOG) One World Exchange (OWE), a clinical exchange program held in France in October 2023, as a case-study.

METHODS

This was a cross-sectional study. A 31-item structured questionnaire designed with Google Forms was electronically distributed to the 51 obgyn postgraduate trainees (OWE fellows) who participated in the OWE, to collect information about the exchange. Collected data was analyzed using IBM Statistical Product and Service Solutions (SPSS) Statistics for Windows.

RESULTS

The survey response rate was 68.6%. The mean age of the respondents was 33.0 ± 4.0 years. Majority of the them were females (26, 74.3%), married (19, 54.3%), at least in their third year of training (30, 85.7%) and from Africa (11, 31.4%). During the period of the exchange program, fellows observed various obstetric and gynecologic procedures, including open and minimal access procedures, with more than one-fifth (8, 22.9%) of them reporting that they were allowed to assist in some of these procedures. The fellows noted salient differences in practice between their exchange hospitals and their home countries. An overwhelming majority (30, 85.7%) of the fellows believed the OWE was beneficial and would positively impact their clinical practices back in their home countries.

CONCLUSION

Clinical exchange programs like the OWE provide valuable benefits in improving the clinical knowledge and skills of postgraduate obgyn trainees.

Orienting global surgery initiatives toward advancing minimally invasive surgery in Africa: a commentary based on continent-wide reviews

Surgical care has advanced with the introduction of minimally invasive surgery (MIS) techniques, which have resulted in a reduced length of hospital stay and improved patient outcomes with regard to morbidity, mortality, and aesthetics. Implementation in Africa remains limited due to economic, infrastructural, and training-related issues. Our previous reviews show that adoption of MIS in Africa has been highly variable. Only Egypt and South Africa, for example, have significantly reported robotic surgery programs. Despite present challenges, recent developments show that progress is being made. Advantages of MIS in resource-limited settings include fewer postoperative complications and shorter hospital stays, crucial for African patients who cannot afford unexpectedly extensive postoperative care and are also reliant on daily earnings. In the future, tele-robotic surgery can improve access to surgical care in under-served regions of the continent. Implementation barriers include the high cost of equipment, inadequate healthcare infrastructure, and limited training opportunities. Investment in the development of low-cost innovations, such as MIS equipment suited for resource-limited settings, local manufacturing or assembly of MIS equipment, and the establishment of training programs within the continent, is necessary to overcome these challenges. Policies supporting the integration of MIS into national healthcare plans are also required. The development of more robust MIS programs in Africa will not only enhance surgical care but will also contribute to the improvement of healthcare and economic outcomes across the continent. We present this commentary on the current state, challenges, and opportunities for the wider adoption of MIS across Africa, based on recent continent-wide reviews.

Laparoscopic appendectomy improves outcomes and reduces costs in rural Kenya

BACKGROUND

Acute appendicitis is a common emergency in rural Kenya. While open appendectomy is widely used, minimally invasive approaches may improve postoperative recovery and superficial surgical site infection rates. However, adoption in resource-limited settings is hindered by cost and availability, with fewer than 1% of operations involving laparoscopy. This study evaluates the effectiveness and costs of laparoscopic versus open appendectomy to inform practices in similar settings.

METHODS

A retrospective study at Tenwek Hospital, Kenya (2015-2019), compared laparoscopic and open appendectomy using a bottom-up micro-costing method for true healthcare costs, adjusted for inflation and expressed in international dollars using purchasing power parity (I$PPP). Outcomes, including operating room turnaround time, hospital length of stay, superficial surgical site infections, and financial impact, were analyzed with Pearson's chi-squared, Wilcoxon rank-sum tests, and a multilevel generalized linear model to adjust for patient comorbidities and severity.

RESULTS

Among 168 patients, median age was 34 years (IQR: 26-44), with 71% men, and perforation in 45%. Laparoscopic surgery was performed on 31 patients, with one conversion, versus open surgery in 137. The laparoscopic group had longer operating room turnaround times (115 vs. 75 min, p < 0.001) but shorter hospital stays (2 vs. 4 days, p = 0.002). Total costs were lower for laparoscopy cases (1527 vs. 1816 I$PPP, p = 0.049), with surgical site infections (3.2% vs. 16.7%, p = 0.026).

CONCLUSIONS

Despite longer surgery times, laparoscopic appendectomy significantly reduces hospital stays, total costs, and surgical site infections compared to open surgery in rural Kenya.

Advancing laparoscopic skills training in Namibia: Implementation of the Global Laparoscopic Advancement Program (GLAP) of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

BACKGROUND

In low- and middle-income countries (LMICs), laparoscopic surgery is challenging to implement due to limited resources and lack of expert surgeons as teachers. The Global Laparoscopic Advancement Program (GLAP) was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to deliver sustainable and effective methods for teaching safe laparoscopic surgery. GLAP aims to train surgical leaders and trainees with the goal of eventual in-country replication of GLAP programming. After successful implementation in Mexico and Costa Rica, this study evaluates the feasibility of a pilot training course in Namibia, Southern Africa.

METHODS

In December 2022 and September 2023, GLAP partnered with the Namibian Surgical Society and the College of Surgeons of East, Central, and Southern Africa (COSECSA) to administer 2 GLAP courses, with hands-on simulation practice and lectures on surgical education, training, and curriculum development. Participants completed surveys assessing their surgical background and experiences, their experience with simulation, and interest in curriculum development at their home institutions. Participants were also evaluated on their time to completion for the five FLS tasks during the initial and final days of the program.

RESULTS

Over two GLAP courses, there were a total of 31 practicing general, gynecologic, and urologic surgeons from Namibia, Ethiopia, Malawi, Somali, and Zambia, taught by 5-7 GLAP faculty members. Overall, 35.5% had formal laparoscopic training during residency or fellowship, 16.13% had no experience with laparoscopy, and 77.42% learned laparoscopy through observation. Fifty-three percent of respondents had never practiced laparoscopy on a simulator before and 45% of respondents noted they did not have mentors to help them learn laparoscopic skills. Eighty percent of participants noted lack of equipment as the most important factor limiting the use of laparoscopy, followed by 76% noting lack of trained surgeons and 73% noting lack of formal training. The majority of respondents noted a very strong desire for formal training (61%), including additional short-term courses in laparoscopy (58%) and FLS skills testing opportunities (63%) in the future. For skills acquisition, there was a statistically significant reduction in the time to complete the circle cut task at the end of the course (359.2 s vs 206 s, p-value 0.016) across both years.

CONCLUSIONS

There is limited adoption of laparoscopy in Namibia, hindered by lack of training, expert trainers, and equipment. Implementation of GLAP is feasible and offers an additional training opportunity to the region.

Utilization of Staging Laparoscopy for Patients With Gastric Cancer in Ukraine

BACKGROUND

The use of advanced diagnostic methods, such as high-resolution CT or PET-CT scans, are limited in low and middle-income countries (LMICs). In gastric cancer, occult peritoneal disease may be present in up to 20% of cases, limiting the benefits of surgical resection. Accurate staging of gastric cancer is essential to ensure optimal patient management and prevent undue morbidity from unnecessary surgery. Our study evaluated the diagnostic accuracy and safety of staging laparoscopy (SL) versus computed tomography (CT) in detecting peritoneal metastases for gastric cancer in Ukraine.

METHODS

Patients who underwent SL between October 2017 and October 2022 were retrospectively reviewed. SL was performed for each newly diagnosed patient with gastric cancer without evidence of distant metastases, except when peritoneal carcinomatosis was in question. Pathological findings at SL were compared with initial CT reports, and analysis of the sensitivity and specificity for SL was performed.

RESULTS

Of 516 patients undergoing SL, 410 had no radiological considerations for distant metastases. Among them, radiographically occult peritoneal metastatic disease was found in 134 (32.7%). Overall SL sensitivity for peritoneal metastases was 90.6% (95% confidence interval [CI]: 85.8%-94.1%) and specificity 100.0% (95% CI: 98.8%-100.0%). Complications after SL occurred in 5 (1%) of patients. No mortality was associated with SL.

CONCLUSION

SL is a safe and effective method to evaluate the presence of peritoneal disease in patients with gastric cancer. This method may be appropriate for LMICs, where availability of advanced imaging technologies is limited.

Robotic Surgery from a Gynaecological Oncology Perspective: A Global Gynaecological Oncology Surgical Outcomes Collaborative Led Study (GO SOAR3)

BACKGROUND/OBJECTIVES

For healthcare institutions developing a robotic programme, delivering value for patients, clinicians, and payers is key. However, the impact on the surgeon, training pathways, and logistics are often overlooked. We conducted a study on the impact of robotic surgery on surgeons, access to robotic surgical training, and factors associated with developing a successful robotic programme.

METHOD

In our international mixed-methods study, a customised web-based survey was circulated to gynaecological oncologists. The Wilcoxon rank-sum test and Fisher's exact test, tested the hypothesis of the differences in continuous and categorical variables. Multiple linear regression was used to model the effect of variables on outcomes adjusting for gender, age, and postgraduate experience. Outcomes included situational awareness, surgeon fatigue/stress, and the surgical learning curve. Qualitative data were collected via in-depth semi-structured interviews using an inductive theoretical framework to explore access to surgical training and logistical considerations in the development of a successful robotic programme.

RESULTS

In total, 94%, 45%, and 48% of survey respondents (n = 152) stated that robotic surgery was less physically tiring/mentally tiring/stressful in comparison to laparoscopic surgery. Our data suggest gender differences in the robotics learning curve with men six times more likely to state robotic surgery had negatively impacted their situational awareness in the operating theatre (OR = 6.35, p ≤ 0.001) and 2.5 times more likely to state it had negatively impacted their surgical ability due to lack of haptic feedback in comparison to women (OR = 2.62, p = 0.046). Women were more risk-averse in case selection, but there were no self-reported differences in the intra-operative complication rates between male and female surgeons (OR = 1, p = 0.1). In total, 22/25 robotically trained surgeons interviewed did not follow a structured curriculum of learning. Low and middle income country centres had less access to robotic surgery. The success of robotic programmes was measured by the number of cases performed per annum, with 74% of survey respondents stating that introducing robotics increased the proportion of surgeries performed by minimal access surgery. There was a distinct lack of knowledge on the environmental impact of robotic surgery.

CONCLUSIONS

Whilst robotic surgery is considered a landmark innovation in surgery, it must be responsibly implemented through effective training and waste minimisation, which must be a key metric in measuring the success of robotic programmes.

Analysis of implementation science strategies to train laparoscopic surgical skills among Liberian surgeons using ALL-SAFE

BACKGROUND

Significant disparities exist in laparoscopic training opportunities for surgeons in low- and middle-income countries (LMICs). ALL-SAFE is an innovative, low-cost training system for LMIC surgeons' laparoscopic development. However, strategies to implement and scale ALL-SAFE are unstudied. We aimed to assess the impact of implementation science strategies on ALL-SAFE uptake in Liberia, a novel and low-resource context.

METHODS

This study used implementation science approaches to evaluate ALL-SAFE uptake in three Liberian hospitals: John F. Kennedy Medical Center, Phebe, and ELWA. Five validated implementation strategies of program orientation, local champions, network weaving, feedback mechanisms, and practical supervision were piloted. All five strategies were implemented at two hospitals, while four strategies, excluding clinician supervision, were implemented at the final site as a pseudo-control, to evaluate the impact of resource-intensive supervision. Participants included surgical consultants, residents, and medical students. Engagement was assessed with mixed methods including participant number, practice hours, module completion rates, and strategy feasibility through end-user interviews.

RESULTS

Across three hospitals, 33 participants used ALL-SAFE for 87.8 total training hours (5,268 min). Participant numbers varied across sites (NJFK = 20, 80%; NPhebe = 7, 88%; NELWA = 6, 86%), as did practice times (TotalJFK = 3,060 min, Median time/ParticipantJFK = 103 min; TotalPhebe = 1,434 min, Median time/ParticipantPhebe = 126 min; TotalELWA = 774 min, Median time/ParticipantELWA = 100 min). Sites with practical supervision demonstrated higher engagement than those without (P = 0.042). Interviews (n = 8) revealed positive perceptions toward program orientation, practical supervision, and network weaving. Participants recommended thirteen additional strategies for sustainability including translating ALL-SAFE skills to patient care.

CONCLUSION

Our study is one of the first to evaluate implementation science strategies for laparoscopic training in sub-Saharan Africa. The implementation bundles of five validated strategies were considered feasible by Liberian surgeons in both urban and rural hospitals. Mixed methods suggested a positive association between engagement and the resource-intensive practical supervision strategy. Future studies should focus on quantifying individual strategy contributions with rigorous implementation designs and assessing sustainability strategies.

Trends and Outcomes of Laparoscopic Surgery in Low-Resource Settings: Lessons From Two African Healthcare Systems-A Narrative Review

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.

LEFT-SIDED APPENDICITIS IN LATIN AMERICA AND THE CARIBBEAN: A SYSTEMATIC REVIEW OF CASE REPORTS

BACKGROUND

Worldwide, acute appendicitis (AA) is the most frequent cause of acute surgical abdomen. Although typically associated with pain migrating to the right iliac fossa, AA can also manifest with pain in the left lower quadrant, often linked to anatomical anomalies. Latin America and the Caribbean (LAC) have the highest incidence of AA compared to other regions of the world.

OBJECTIVE

To explore the sociodemographic characteristics; clinical characteristics, and postoperative outcomes in patients with left-sided AA in LAC.

METHODS

We performed a systematic review including PubMed, Scopus, Web of Science, Embase, LILACS, Dialnet, Redalyc, Scielo, and Google Scholar databases. We considered as inclusion criteria case reports of left-sided appendicitis involving specific anatomical anomalies, and studies conducted in LAC. Morevoer, we assessed methodologic quality using Joanna Briggs Institute tool for case reports.

RESULTS

A total of 23 patients were included in 23 case reports. Colombia accounted for the majority of left-sided AA cases. The median age was 37 years (8-65). Initial pain location was diffuse abdominal pain (39.1%), pain was refered (n=5; 55.6%) and migrated (n=11; 78.6%) mainly to left iliac fossa. Situs inversus totalis (SIT) was the most prevalent anatomical anomaly (69.6%), while laparotomy emerged as the predominant surgical approach (65.2%).

CONCLUSION

Considering left-sided AA in the diagnosis of adults with diffuse abdominal pain towards the left lower quadrant is crucial. SIT is the primary associated anatomical variation. These emphasize the significance of understanding atypical presentations for effective management in the LAC population.

Feeling of pulsations in artificial arteries with a real time haptic feedback laparoscopic grasper: a validation study

INTRODUCTION

Despite the advancements in technology and organized training for surgeons in laparoscopic surgery, the persistent challenge of not being able to feel the resistance and characteristics of the tissue, including pulsations, remains unmet. A recently developed grasper (Optigrip®) with real time haptic feedback, based on photonic technology, aims to address this issue by restoring the tactile sensation for surgeons. The key question is whether pulsations can be detected and at what minimal size level they become clinical significant.

METHODS

To simulate arterial conditions during laparoscopic procedures, four different silicone tubes were created, representing the most prevalent arteries. These tubes were connected to a validated pressure system, generating a natural pulse ranging between 80 and 120 mm Hg. One control tube without pressure was added. The surgeons had to grasp these tubes blindly with the conventional grasper or the haptic feedback grasper in a randomized order. They then indicated whether they felt the pressure or not and the percentage of correct answers was calculated.

RESULTS

The haptic grasper successfully detected 96% of all pulsations, while the conventional grasper could only detect 6%. When considering the size of the arteries, the Optigrip® identified pulsations in 100% the 4 and 5 mm arteries and 92% of the smallest arteries. The conventional grasper was only able to feel the smallest arteries in 8%. These differences were highly significant (p < 0.0001).

CONCLUSION

This study demonstrated that the newly developed haptic feedback grasper enables detection of arterial pulsations during laparoscopy, filling an important absence in tactile perception within laparoscopic surgery.

Beyond the Expected: Evaluating Preoperative Predictors of a Difficult Cholecystectomy Aboard the USNS Comfort

Mini abstract Typical preoperative markers of a difficult laparoscopic cholecystectomy did not apply during the US Naval ShipComfort Deployment in 2019. This prospective study reveals the importance of preparedness for short-term surgical missions, the impact of health care disparities on the severity of disease, and the need for deliberate and thoughtful engagement with host-nation partners.

Implementation of Laparoscopic Nissen Fundoplications in a Developing South African Pediatric Surgical Service

Introduction

Pediatric laparoscopic Nissen fundoplication (LNF) has become the standard approach at many centers. We developed a minimal access surgery (MAS) training curriculum to enhance the delivery of MAS for pediatric patients in a resource-limited setting. We reviewed our 10-year experience in implementing and performing LNF at our institution.

Methods

We described the challenges of implementing MAS training for LNF and how we addressed them. Beneficial technical considerations were described. A retrospective review was performed on all pediatric LNFs performed.

Results

We performed 268 LNFs. Specialists or trainees under supervision performed all LNFs. The trainee group performed 43 LNFs (16%). The median operative time for the specialists was 94 min (interquartile range [IQR] 50), and the trainee group was 140 min (IQR 62.5). The median number of cases performed until we improved operative time amongst the trainees was nine (IQR 3). There were seven repeat LNFs, and 11 cases were converted to open. The overall complication rate was 8.9%. A reduction in complications among specialists occurred over the years. The 30-day mortality post-LNF was 0.7%.

Conclusion

LNF can be successfully introduced at a tertiary training centre in South Africa with good outcomes. A comprehensive quality improvement program, including MAS training, supported this.

Safety and effectiveness of laparoscopic adult groin hernia repair in Africa: a systematic review and meta-analysis

BACKGROUND

Surgery is the recommended treatment of groin hernia, and laparoscopic approach is increasingly accepted due to lower risk of chronic pain. This systematic review aims to evaluate results of laparoscopic groin hernia repair (LGHR) in Africa.

METHODS

We performed a literature search of published studies using electronic databases. Included African articles reported at least one of outcomes after LGHR in adult population. Newcastle-Ottawa Scale was used for quality assessment. A quantitative meta-analysis was performed to estimate the pooled prevalence of the post-operative outcomes.

RESULTS

We included 19 studies from 6 countries which totalized 2329 hernia cases. Mean age was 44.5 years and male patients were predominant (sex-ratio 19.8). The mean operative time was 69.1 min. The pooled prevalence of conversion to open procedure was 2.578% (95% IC: 1.209-4.443). The pooled prevalence of surgical site infection and Hematoma/Seroma was respectively 0.626% (95%IC: 0.332-1.071) and 4.617% (95% IC: 2.990-6.577). The pooled prevalence of recurrence and chronic pain was respectively 2.410% (95% IC: 1.334-3.792) and 3.180% (95% IC: 1.435-5.580). We found that total morbidity for TAPP procedure was higher than TEP procedure (p = 0.0006; OR 1.8443).

CONCLUSION

These results confirm that LGHR is safe and feasible and would be recommended in our African context.

Advancing laparoscopy in resource-limited settings

BACKGROUND

Although laparoscopic surgery has made remarkable progress and become the standard approach for various surgical procedures worldwide over the past 30 years, its establishment in low-resource settings, particularly in public hospitals, has been challenging. The lack of equipment and trained expertise has hindered its widespread adoption in these settings. Cholecystectomy is one of the most commonly performed procedures using laparoscopy world wide AIM: The aim of the study is to determine whether laparoscopic cholecystectomy is feasible in a resource challenged setting METHODS: The research focused on individuals who underwent laparoscopic or open cholecystectomies at Yekatit 12 Hospital in Addis Ababa, Ethiopia, over a one-year period. Comprehensive data collection was conducted prospectively, encompassing both intraoperative and postoperative parameters. Follow-up was carried out via phone calls. The surgical procedures employed innovative techniques, including the reuse of sterilized single-use equipment and the utilization of local resources. The evaluation involved a comparison of demographic information, intraoperative details (such as critical view determination and operative duration), and postoperative complications, including assessments of pain and wound infections RESULTS: From August 2021 to September 2022, 119 patients were assessed. Among these patients, 65 (54.6%) underwent open cholecystectomies, while the remaining 54 (45.4%) underwent laparoscopic cholecystectomies. The average duration of the laparoscopic cholecystectomies was 90.7 min, which is 17.7 min behind the open. Patients in the laparoscopy group had significantly shorter hospital stays than the open group, and 94% were discharged by post operative day 2. The conversion rate from laparoscopic to open surgery was determined to be 3.3% CONCLUSION: To sum up, the safe execution of laparoscopic cholecystectomies is feasible in public hospitals and settings with limited resources, given adequate training and resource distribution. The study findings showcased superior outcomes, including reduced hospitalization duration and fewer complications, while maintaining comparable levels of operative duration and patient satisfaction in both groups.

A needs assessment for simulation in African surgical education

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.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

A Prospective, Observational Cost Comparison of Laparoscopic and Open Appendicectomy in Three Tertiary Hospitals in Nigeria

BACKGROUND

The clinical benefits of laparoscopic appendicectomy are well recognized over open appendicectomy. However, laparoscopic procedures are not frequently conducted in many low-and middle-income countries (LMICs) for several reasons, including perceived higher costs. The aim of this study was to assess the feasibility and cost of laparoscopic appendicectomy compared to open appendicectomy in Nigeria.

METHODS

A multicenter, prospective, cohort study among patients undergoing appendicectomy was conducted at three tertiary hospitals in Nigeria. Data were collected from October 2020 to February 2022 and analyses compared the average healthcare costs at 30 days after surgery. Quantile regression was conducted to identify variables that had an impact on the costs, reported in Nigerian Naira (Naira) and US dollars ($), with standard deviations (SD).

FINDINGS

This study included 105 patients, of which 39 had laparoscopic appendicectomy and 66 had open appendicectomy. The average healthcare cost of laparoscopic appendicectomy (147,562 Naira (SD: 97,130) or $355 (SD: 234)) was higher than open appendicectomy (113,556 Naira (SD: 88,559) or $273 (SD: 213)). The average time for return to work was shorter with laparoscopic than open appendicectomy (mean: 8 days vs. 14 days). At the average daily income of $5.06, laparoscopic appendicectomy was associated with 9778 Naira or $24 cost savings in return to work. Further, 5.1% of laparoscopic appendicectomy patients had surgical site infections compared to 22.7% for open appendicectomy. Regression analysis results showed that laparoscopic appendicectomy was associated with $14 higher costs than open appendicectomy, albeit non-significant (p = 0.53).

INTERPRETATION

Despite selection bias in this real-world study, laparoscopic appendicectomy was associated with a slightly higher overall cost, a lower societal cost, a lower infection rate, and a faster return to work, compared to open appendicectomy. It is technically and financially feasible, and its provision in Nigeria should be expanded.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Gasless laparoscopy in rural India-registry outcomes and evaluation of the learning curve

BACKGROUND

A program of gasless laparoscopy (GL) has been implemented in rural North-East India. To facilitate safe adoption, participating rural surgeons underwent rigorous training prior to independent clinical practice. An online registry was established to capture clinical data on safety and efficacy and to evaluate initial learning curves for gasless laparoscopy.

METHODS

Surgeons who had completed the GL training program participated in the online RedCap Registry. Patients included in the registry provided informed consent for the use of their data. Data on operative times, conversion rates, perioperative complications, length of stay, and hospital costs were collected. Fixed reference cumulative sum (CUSUM) model was used to evaluate the learning curve based on operative times and conversion rates published in the literature.

RESULTS

Four surgeons from three rural hospitals in North-East India participated in the registry. The data were collected over 12 months, from September 2019 to August 2020. One hundred and twenty-three participants underwent GL procedures, including 109 females (88.6%) and 14 males. GL procedures included cholecystectomy, appendicectomy, tubal ligation, ovarian cystectomy, diagnostic laparoscopy, and adhesiolysis. The mean operative time was 75.3 (42.05) minutes for all the surgeries. Conversion from GL to open surgery occurred in 11.4% of participants, with 8.9% converted to conventional laparoscopy. The main reasons for conversion were the inability to secure an operative view, lack of operating space, and adhesions. The mean length of stay was 3 (2.1) days. The complication rate was 5.7%, with one postoperative death. The CUSUM analysis for GL cholecystectomy showed a longer learning curve for operative time and few conversions. The learning curve for GL tubal ligation was relatively shorter.

CONCLUSION

Gasless laparoscopy can be safely implemented in the rural settings of Northeast India with appropriate training programs. Careful case selection is essential during the early stages of the surgical learning curve.

International Variations in Surgical Morbidity and Mortality Post Gynaecological Oncology Surgery: A Global Gynaecological Oncology Surgical Outcomes Collaborative Led Study (GO SOAR1)

Gynaecological malignancies affect women in low and middle income countries (LMICs) at disproportionately higher rates compared with high income countries (HICs) with little known about variations in access, quality, and outcomes in global cancer care. Our study aims to evaluate international variation in post-operative morbidity and mortality following gynaecological oncology surgery between HIC and LMIC settings. Study design consisted of a multicentre, international prospective cohort study of women undergoing surgery for gynaecological malignancies (NCT04579861). Multilevel logistic regression determined relationships within three-level nested-models of patients within hospitals/countries. We enrolled 1820 patients from 73 hospitals in 27 countries. Minor morbidity (Clavien-Dindo I-II) was 26.5% (178/672) and 26.5% (267/1009), whilst major morbidity (Clavien-Dindo III-V) was 8.2% (55/672) and 7% (71/1009) for LMICs/HICs, respectively. Higher minor morbidity was associated with pre-operative mechanical bowel preparation (OR = 1.474, 95%CI = 1.054-2.061, p = 0.023), longer surgeries (OR = 1.253, 95%CI = 1.066-1.472, p = 0.006), greater blood loss (OR = 1.274, 95%CI = 1.081-1.502, p = 0.004). Higher major morbidity was associated with longer surgeries (OR = 1.37, 95%CI = 1.128-1.664, p = 0.002), greater blood loss (OR = 1.398, 95%CI = 1.175-1.664, p ≤ 0.001), and seniority of lead surgeon, with junior surgeons three times more likely to have a major complication (OR = 2.982, 95%CI = 1.509-5.894, p = 0.002). Of all surgeries, 50% versus 25% were performed by junior surgeons in LMICs/HICs, respectively. We conclude that LMICs and HICs were associated with similar post-operative major morbidity. Capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention.

Exploring Laparoscopic Surgery Training Opportunities in the College of Surgeons of East, Central, and Southern Africa region

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.

Patient-reported outcome, perception and satisfaction after laparoscopic cholecystectomy in Kigali, Rwanda

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.

Evidence for a case-based module in the low-resource setting to teach ectopic pregnancy management

Introduction

Case-based learning (CBL) utilizes authentic clinical cases that connect theory to practice. CBL has been shown to result in deeper learning and high engagement of adult learners. An open-source, web-based CBL module was created to help learners develop the cognitive foundation of ectopic pregnancy management in the low-resource setting. We present psychometric evidence that supports the use of this web-based CBL in the low-resource setting.

Methods

The case scenario comprising 20 topics in ectopic pregnancy management was created by an Ethiopian team member and hosted on an interactive web-based platform. The module was reviewed by Ethiopian, Cameroonian, and US surgeons and OB/GYN team members for content, relevance, and clarity, followed by a psychometrician for clarity, bias, relevance, and alignment. Twenty participants (3-Mbingo Baptist Hospital-Cameroon, 6-Soddo Christian Hospital-Ethiopia, 3-Southern Illinois University (SIU), and 8-University of Michigan (UM)) then completed the module. Four attending surgeons (2 OB/GYN, 2 general surgery) were designated experts while 10 medical students and 6 residents were designated novices. The module included a 10-item dichotomously scored pre-test, the CBL content, and the same, but shuffled, post-test. Pre- and post-test summed scores were compared using paired Student's t-tests, while differences in scores across participants' experience levels and sites were analyzed using a many-facet Rasch model.

Results

Findings indicated a statistically significant improvement in participants' mean summed scores from pre-test (M = 6.7, SD = 2.2) to post-test (M = 9.0, SD = 1.5), t(20) = - 4.76, P < 0.0001 and confirmed by Rasch analysis, P < 0.001. An adequate distribution of difficulty was demonstrated and 80% of questions had high discrimination value between experts and novices, d = | 0.87, 1.40 |. There was no difference in scores across specialties. Following the module, expert scores (M = 9.7) were higher than novice scores (M = 9.0), but the difference was not statistically significant.

Conclusion

Our findings suggest that using a web-based CBL module could be used to effectively improve understanding of the management of ectopic pregnancy in the low-resource setting, especially for nascent surgeons. The concept of a web-based CBL module has special attraction in the low-resource setting as it may target the adult surgical learner in remote regions where established technologies and existing experts are unavailable.

Evidence supporting performance measures of laparoscopic appendectomy through a novel surgical proficiency assessment tool and low-cost laparoscopic training system

BACKGROUND

Laparoscopic training remains inaccessible for surgeons in low- and middle-income countries, limiting its widespread adoption. We developed a novel tool for assessment of laparoscopic appendectomy skills through ALL-SAFE, a low-cost laparoscopy training system.

METHODS

This pilot study in Ethiopia, Cameroon, and the USA assessed appendectomy skills using the ALL-SAFE training system. Performance measures were captured using the ALL-SAFE verification of proficiency tool (APPY-VOP), consisting of a checklist, modified Objective Structured Assessment of Technical Skills (m-OSATS), and final rating. Twenty participants, including novice (n = 11), intermediate (n = 8), and expert (n = 1), completed an online module covering appendicitis management and psychomotor skills in laparoscopic appendectomy. After viewing an expert skills demonstration video, participants recorded their performance within ALL-SAFE. Using the APPY-VOP, participants rated their own and three peer videos. We used the Kruskal-Wallis test and a Many-Facet Rasch Model to evaluate (i) capacity of APPY-VOP to differentiate performance levels, (ii) correlation among three APPY-VOP components, and (iii) rating differences across groups.

RESULTS

Checklist scores increased from novice (M = 21.02) to intermediate (M = 23.64) and expert (M = 28.25), with differentiation between experts and novices, P = 0.005. All five m-OSATS domains and global summed, total summed, and final rating discriminated across all performance levels (P < 0.001). APPY-VOP final ratings adequately discriminated Competent (M = 2.0), Borderline (N = 1.8), and Not Competent (M = 1.4) performances, Χ2 (2,85) = 32.3, P = 0.001. There was a positive correlation between ALL-SAFE checklist and m-OSATS summed scores, r(83) = 0.63, P < 0.001. Comparison of ratings suggested no differences across expertise levels (P = 0.69) or location (P = 0.66).

CONCLUSION

APPY-VOP effectively discriminated between novice and expert performance in laparoscopic appendectomy skills in a simulated setting. Scoring alignment across raters suggests consistent evaluation, independent of expertise. These results support the use of APPY-VOP among all skill levels inside a peer rating system. Future studies will focus on correlating proficiency to clinical practice and scaling ALL-SAFE to other settings.

The place of presumptive diagnosis in the management of peritoneal tuberculosis: A case report from rural Togo

INTRODUCTION AND IMPORTANCE

Tuberculosis is a major public health problem in developing countries. Its main abdominal form is peritoneal. The diagnosis of this peritoneal form is complex and difficult. We describe the role of presumptive diagnosis in the management of this condition in Togo, based on a case study.

CASE PRESENTATION

A security guard with no previous pathological history was seen in consultation with febrile ascites. Investigations revealed the exudative and lymphocytic nature of the ascites. The other investigations did not reveal any other organic lesion, particularly hepatic, or the germ. This typical ascites picture had for us a strong diagnostic value in favour of a tubercular origin. The patient was treated with antituberculosis drugs for 6 months. The evolution was satisfactory.

CLINICAL DISCUSSION

The diagnosis of peritoneal tuberculosis is difficult. Biological explorations are rather disappointing in this approach. Laparoscopy coupled with histological examination represents the best means of diagnosing peritoneal tuberculosis to date. However, in developing countries, the absence of these resources poses a real problem. Clinical and biological arguments are always at the forefront of the diagnosis in endemic countries. The latter is based on the demonstration of febrile, exudative and lymphocytic ascites.

CONCLUSION

The difficult diagnosis of peritoneal tuberculosis coupled with the lack of technical facilities gives the presumptive diagnosis an important place in the management of this condition in endemic countries.

Remote Robotic Surgery and Virtual Education Platforms: How Advanced Surgical Technologies Can Increase Access to Surgical Care in Resource-Limited Settings

Advanced surgical technologies consist of remote and virtual platforms that facilitate surgical care and education. It also includes the infrastructure necessary to utilize these platforms (e.g., internet access, robotic systems, and simulators). Given that 5 billion people lack access to safe and timely surgical care, the appeal of these technologies to the field of global surgery lies primarily in its ability to eliminate geographical barriers and address surgeon shortages. This article discusses the use of virtual and remote technologies in resource-limited settings, the potential applications of these technologies, the possible barriers to their integration, and the impact these technologies may have on access to surgical care and education. Specifically, it will explore how robotic surgery, telesurgery, virtual education platforms, and simulations have the potential to be instrumental in enhancing worldwide access to safe surgical care.

Availability of laparoscopic surgery in Mexico's public health system: a nationwide retrospective analysis

Background

Laparoscopic surgery remains limited in low-resource settings. We aimed to examine its use in Mexico and determine associated factors.

Methods

By querying open-source databases, we conducted a nationwide retrospective analysis of three common surgical procedures (i.e., cholecystectomies, appendectomies, and inguinal hernia repairs) performed in Mexican public hospitals in 2021. Procedures were classified as laparoscopic based on ICD-9 codes. We extracted patient (e.g., insurance status), clinical (e.g., anaesthesia technique), and geographic data (e.g., region) from procedures performed in hospitals and ambulatories. Multivariable analysis with random forest modelling was performed to identify associated factors and their importance in adopting laparoscopic approach.

Findings

We included 97,234 surgical procedures across 676 public hospitals. In total, 16,061 (16.5%) were performed using laparoscopic approaches, which were less common across all procedure categories. The proportion of laparoscopic procedures per 100,000 inhabitants was highest in the northwest (22.2%, 16/72) while the southeast had the lowest (8.3%, 13/155). Significant factors associated with a laparoscopic approach were female sex, number of municipality inhabitants, region, anaesthesia technique, and type of procedure. The number of municipality inhabitants had the highest contribution to the multivariable model.

Interpretation

Laparoscopic procedures were more commonly performed in highly populated, urban, and wealthy northern areas. Access to laparoscopic techniques was mostly influenced by the conditions of the settings where procedures are performed, rather than patients' non-modifiable characteristics. These findings call for tailored interventions to sustainably address equitable access to minimally invasive surgery in Mexico.

Funding

None.

Management of abdominal gas leakage from surgical trocars in laparoscopic surgery: a preclinical study

Introduction: There is an ongoing concern about the potential infectious risk due to pneumoperitoneal gas leakage from surgical trocars in laparoscopic surgery. We aimed to visually confirm the presence of leakage from trocars and investigate the changes in the leakage scale according to intra-abdominal pressures and trocar types. Material and methods: We established a porcine pneumoperitoneum model and performed experimental forceps manipulation using 5-mm grasping forceps with 12-mm trocars. The gas leakage, if any, was imaged using a Schlieren optical system, which can visualize minute gas flow invisible to the naked eye. For measuring the scale, we calculated the gas leakage velocity and area using image analysis software. Four types of unused and exhausted disposable trocars were compared. Results: Gas leakage was observed from trocars during forceps insertion and removal. Both the gas leakage velocity and area increased as the intra-abdominal pressure increased. Every type of trocar we handled was associated with gas leakage, and exhausted disposable trocars had the largest scale gas leakage. Conclusions: We confirmed gas leakage from trocars during device traffic. The scale of leakage increased with high intra-abdominal pressure and with the use of exhausted trocars. Current protection against gas leakage may not be sufficient and new surgical safety measures and device development may be needed in the future.

Laparoscopy in Low- and Middle-Income Countries: A Survey Study

INTRODUCTION

An increasing shift towards non-communicable diseases and an existing high surgical burden of disease in low-middle-income countries (LMICs) has impelled the need for implementing laparoscopic surgery, a safe and cost-effective surgical service. However, despite countless benefits, laparoscopic surgery programs remain limited throughout LMICs, and limited understanding is known of healthcare professionals' views regarding the implementation of laparoscopic surgery in their local healthcare environments. Therefore, the purpose of this study is to better understand the perceived challenges and barriers to implementing long-term laparoscopic surgery programs from the perspective of healthcare professionals.

METHODS

Upon receiving ethical approval from the McGill University Health Center (MUHC), a nine-question survey (concerning attributes required to establish a successful laparoscopic program in LMICs and to gain insight into what surgeons from LMICs believed were the necessary next steps) was pilot tested amongst faculty members, and subsequently disseminated to healthcare professionals practicing in LMICs. Explicit consent was obtained from the participants before answering the survey.  Results: Thirty-four participants representing a total of 35 countries participated in the survey with the majority having received laparoscopic surgery training. Overall, participant responses were characterized by two major themes. Highlighted in the first theme, Laparoscopic Experience and Training Curriculum, were responses concerning current laparoscopic training and education, improved career opportunities provided by laparoscopic training, and a particular existing potential to incorporate laparoscopic surgery into the current surgical curriculum at various levels of training. Emphasized in the second theme, Challenges and Next Steps, were responses concerning barriers to the implementation of laparoscopic surgery, current institutional capabilities, and the need for improving mentorship through existing surgical societies such as the College of Surgeons of East, Central, and Southern Africa (COSECSA), West African College of Surgeons (WACS), and The Pan-African Academy of Christian Surgeons (PAACS).

CONCLUSIONS

A buy-in from the government, hospitals, staff, and industry is crucial for the long-term implementation of laparoscopic surgery in LMICs, which can only be accomplished through increased advocacy and the dissemination of the benefits of minimally invasive surgery both economically and socially.

Laparoscopic Versus Open Pre-Treatment Loop Colostomy for Fecal Diversion in Rectal Cancer Patients: Is Laparoscopic Colostomy Better?

Diversion colostomy plays a crucial role in the management of carcinoma rectum in low- and middle-income countries as significant number of patients present with partial intestinal obstruction. The aim of this study was to compare laparoscopic and open approaches for fecal diversion done in patients with adenocarcinoma of the rectum as a pretreatment procedure. The primary end point of our study was time to initiation of neoadjuvant chemo radiation. It was a retrospective study that included all patients diagnosed to have carcinoma rectum and underwent a pretreatment fecal diversion between 2012 and 2014. A total of 55 patients underwent pretreatment diversion colostomy of which 33 were performed via the laparoscopic approach while 22 had open diversion. The time for initiation of neoadjuvant therapy was shorter in the laparoscopic group compared to the open approach (16 days vs. 20.5 days, P = 0.31). The study concluded that pretreatment diversion colostomy using the laparoscopic approach was a safe option in low- and middle-income countries as it was associated with faster recovery and early initiation of neoadjuvant therapy in patients with partially obstructed locally advanced carcinoma rectum.

Challenges to implement laparoscopic appendectomy as the first-line treatment for acute appendicitis: a fifteen-year experience in a tertiary hospital in Brazil

BACKGROUND

the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil.

MATERIALS AND METHODS

retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes.

RESULTS

we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team's adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period.

CONCLUSION

the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries.

Technical Perspective for Video Based Assessment of Surgeries in Low-Resource Settings

OBJECTIVE

Scalable digital learning environments are essential to sustain surgical training programs worldwide. Detailed images of surgeries enriched with educational annotations are vital to train the eyes of the learners. Here, we report a low-cost method, deployed in a low-resource setting in West Africa, which may contribute to the growth of use in open-sourced digital surgical resources world-wide.

DESIGN

This paper is based on the authors participatory and observational experiences creating surgical video content by way of recording surgical procedures and reflecting on field notes and video content. All surgeries were recorded between January and December 2018.

SETTING

Masanga Hospital, a rural district hospital in Sierra Leone, West Africa.

PARTICIPANTS

Thirty-five patients undergoing inguinal hernia repair, elective caesarian section, salpingectomy, bowel resection, hydrocele repair, or below-knee amputation consented for recording their surgical procedure and using the anonymized material for educational purposes.

RESULTS

This manual for non-professional cinematographers provides chronological steps for shooting a surgical procedure in a low-resource setting. Recording a surgical procedure to explain surgical techniques, and perform quality assessment through error analysis and coaching requires more than just point-and-shoot. While taking into account local customs and possibilities, practical tips were provided to prepare for the set-up, and recording of a surgical procedure in a low-resourced setting.

CONCLUSION

Commercially available digital video technology allows for filming high-quality surgical procedures for educational purposes at rural district hospitals in a low-resource setting.

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)

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.

Distal shunt placement in pediatric ventriculoperitoneal shunt surgery: an international survey of practice

OBJECTIVE

Ventriculoperitoneal shunt (VPS) surgery is a common treatment for hydrocephalus in children and adults, making it one of the most common procedures in neurosurgery. Children being treated with a VPS often require several revisions during their lifetime with a lifetime revision rate of up to 80%. Several different techniques exist for inserting the distal catheter, while mini-laparotomy, trocar, or laparoscopy is traditionally used. As opposed to adults, only few studies exist, comparing the outcome of the different distal catheter placement techniques in children. This international survey aims to investigate the current daily practice concerning distal shunt placement techniques in children.

MATERIAL AND METHODS

An online questionnaire investigating the different techniques used to place the distal catheter in pediatric VPS surgery was distributed internationally. All results were analyzed using descriptive and comparative statistics.

RESULTS

A total of 139 responses were obtained. Mini-laparotomy was reported to be the most frequently used technique (n = 104, 74.8%) for distal shunt placement in children, while laparoscopic or trocar-assisted placements were only used by 3.6% (n = 5) and 21.6% (n = 30) of all respondents, respectively. Over half (n = 75, 54.0%) of all respondents do not believe that laparoscopic placement improves the outcome.

CONCLUSION

This international survey shows that mini-laparotomy is the most frequently used technique for distal VPS placement in children all over the world. Further randomized trials are needed to elucidate this matter.

Use of virtual platform for delivery of simulation-based laparoscopic training curriculum in LMICs

BACKGROUND

Laparoscopic surgery is rapidly expanding in low-and middle-income countries (LMICs), yet many surgeons in LMICs have limited formal training in laparoscopy. In 2017, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) implemented Global Laparoscopic Advancement Program (GLAP), an in-person simulation-based laparoscopic training curriculum for surgeons in LMICs. In light of COVID-19, SAGES adapted GLAP to a virtual format with telesimulation. This study explores the feasibility and efficacy of virtual laparoscopic simulation training in resource-limited settings.

METHODS

Participants from San Jose, Costa Rica, Leon, México, and Guadalajara, México enrolled in the virtual GLAP curriculum, meeting biweekly for 2-h didactic classes and 2-h hands-on live simulation practice. Surgical residents' laparoscopic skills were evaluated using the five Fundamentals of Laparoscopic Surgery (FLS) tasks during the initial and final weeks of the program. Participants also completed pre-and post-program surveys assessing their perception of simulation-based training.

RESULTS

The study cohort consisted of 16 surgical attendings and 20 general surgery residents. A minimum 70% response rate was recorded across all surveys in the study. By the end of GLAP, residents completed all five tasks of the FLS exam within less time relative to their performance at the beginning of the training program (p < 0.05). Respondents (100%) reported that the program was a good use of their time and that education via telesimulation was easily reproduced. Participants indicated that the practice sessions, guidance, and feedback offered by mentors were their favorite elements of the training.

CONCLUSION

A virtual simulation-based curriculum can be an effective strategy for laparoscopic skills training. Participants demonstrated an improvement in laparoscopic skills, and they appreciated the mentorship and opportunity to practice laparoscopic skills. Future programs can expand on using a virtual platform as a low-cost, effective strategy for providing laparoscopic skills training to surgeons in LMICs.

Lessons learned during the COVID-19 pandemic using virtual basic laparoscopic training in Santa Cruz de la Sierra, Bolivia: effects on confidence, knowledge, and skill

BACKGROUND

An international surgical team implemented a virtual basic laparoscopic surgery course for Bolivian general and pediatric surgeons and residents during the COVID-19 pandemic. This simulation course aimed to enhance training in a lower-resource environment despite the challenges of decreased operative volume and lack of in-person instruction.

METHODS

The course was developed by surgeons from Bolivian and U.S.-based institutions and offered twice between July-December 2020. Didactic content and skill techniques were taught via weekly live videoconferences. Additional mentorship was provided through small group sessions. Participants were evaluated by pre- and post-course tests of didactic content as well as by video task review.

RESULTS

Of the 24 enrolled participants, 13 were practicing surgeons and 10 were surgery residents (one unspecified). Fifty percent (n = 12) indicated "almost never" performing laparoscopic surgeries pre-course. Confidence significantly increased for five laparoscopic tasks. Test scores also increased significantly (68.2% ± 12.5%, n = 21; vs 76.6% ± 12.6%, n = 19; p = 0.040). While challenges impeded objective evaluation for the first course iteration, adjustments permitted video scoring in the second iteration. This group demonstrated significant improvements in precision cutting (11.6% ± 16.7%, n = 9; vs 62.5% ± 18.6%, n = 6; p < 0.001), intracorporeal knot tying (36.4% ± 38.1%, n = 9; vs 79.2% ± 17.2%, n = 7; p = 0.012), and combined skill (40.3% ± 17.7%; n = 8 vs 77.2% ± 13.6%, n = 4; p = 0.042). Collectively, combined skill scores improved by 66.3% ± 10.4%.

CONCLUSION

Virtual international collaboration can improve confidence, knowledge, and basic laparoscopic skills, even in resource-limited settings during a global pandemic. Future efforts should focus on standardizing resources for participants and enhancing access to live feedback resources between classes.

Global Health Challenges: Why the Four S's Are Not Enough

A well-known tenant of global health is the need for the four-S's to be successful in providing care in any context; Staff, Stuff, Space and Systems. Advanced thoracoscopy is slow to gain traction in low- and middle-income countries (LMICs). To our knowledge, no pediatric advanced thoracoscopy had been attempted previously in either LMIC. Therefore, we report the challenges associated with the adoption of the first advanced thoracoscopic procedures in two LMIC hospitals by a visiting surgeon. To further identify aspects of care in promoting the introduction of advanced thoracoscopy, we added a fifth S as an additional category-Socialization. A key to accomplishing goals for the patients as a visiting surgeon, particularly when introducing an advanced procedure, is acceptance into the culture of a hospital. Despite facing significant obstacles in caring for complex thoracic pathology with heavy reliance on disposable and reusable instrumentation provided through donation and limitations in staff such as access to neonatologists and pediatric surgeons, many obstacles have been overcome. In this perspective article, we show that a "fifth S" is also integral-having local surgeons and anesthesiologists eager to learn with acceptance of the visiting surgeon's expertise opens a path towards attempting advanced procedures in limited-resource settings.

Cost-effectiveness of gasless laparoscopy as a means to increase provision of minimally invasive surgery for abdominal conditions in rural North-East India

Laparoscopic surgery, a minimally invasive technique to treat abdominal conditions, has been shown to produce equivalent safety and efficacy with quicker return to normal function compared to open surgery. As such, it is widely accepted as a cost-effective alternative to open surgery for many abdominal conditions. However, access to laparoscopic surgery in rural North-East India is limited, in part due to limited equipment, unreliable supplies of CO₂ gas, lack of surgical expertise and a shortage of anaesthetists. We evaluate the cost-effectiveness of gasless laparoscopy as a means to increase provision of minimally invasive surgery (MIS) for abdominal conditions in rural North-East India. A decision tree model was developed to compare costs, evaluated from a patient perspective, and health outcomes, disability adjusted life years (DALYs), associated with gasless laparoscopy, conventional laparoscopy or open abdominal surgery in rural North-East India. Results indicate that MIS (performed by conventional or gasless laparoscopy) is less costly and produces better outcomes, fewer DALYs, than open surgery. These results were consistent even when gasless laparoscopy was analysed using least favourable data from the literature. Scaling up provision of MIS through increased access to gasless laparoscopy would reduce the cost burden to patients and increase DALYs averted. Based on a sample of 12 facilities in the North-East region, if scale up was achieved so that all essential surgeries amenable to laparoscopic surgery were performed as such (using conventional or gasless laparoscopy), 64% of DALYS related to these surgeries could be averted, equating to an additional 454.8 DALYs averted in these facilities alone. The results indicate that gasless laparoscopy is likely to be a cost-effective alternative to open surgery for abdominal conditions in rural North-East India and provides a possible bridge to the adoption of full laparoscopic services.

Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low-Middle-Income Countries (LMIC's): Enhanced Recovery After Surgery (ERAS) Society Recommendation

BACKGROUND

This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low-middle-income countries (LMIC's) for elective abdominal and gynecologic care.

METHODS

The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC's. The group consisted of seven members from the ERAS® Society and eight members from LMIC's. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592-695, Nelson et al in Int J Gynecol Cancer 29(4):651-668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC's and LMIC's were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC's. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC's and determined through discussions and consensus.

RESULTS

In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline.

CONCLUSIONS

These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC's.

The Successful Implementation of a Laparoscopic Simulation Training Program in the Dominican Republic

INTRODUCTION

Mount Sinai Hospital in New York introduced a laparoscopic surgery simulation center to a public hospital in Santiago, Dominican Republic to determine the feasibility of training programs in low-and-middle income countries (LMICs).

METHODS

In August 2018, recruitment and preliminary data were collected at the Hospital Jose Maria Cabral y Báez in Santiago, Dominican Republic. The simulation room consists of three simulation stations. Residents were required to practice 1 h/wk guided by a general surgery postgraduate year 3 (PGY3) Mount Sinai resident. Number of hours practiced was self-reported and follow-up data was collected in June 2019. The study endpoints include times on three simulated laparoscopic tasks including peg-transfer, precision cutting, and intracorporeal knot tying. Wilcoxon-signed rank tests were used for statistical analysis.

RESULTS

The partnership between hospitals allowed for successful integration into the Dominican general surgery training. Over 10 mo, residents averaged 25 h of practice (range: 8-35 h; SD 9.95 h). In total, 85% of the residents participated in the study (5 postgraduate year 1 [PGY1], 2 postgraduate year 2 [PGY2], and 4 postgraduate year 3 [PGY3]). Resident median simulation times significantly improved for precision cutting (3:49 min versus 2:09 min, P = 0.002) and intracorporeal knot tying (5:20 min versus 2:47 min, P = 0.037). There was neither significant difference in peg-transfer times nor performance between resident years (P = 0.12).

CONCLUSIONS

This study demonstrates the successful integration of a laparoscopic simulation program into an LMIC surgical resident training program. With commitment from local institutions and external resources, establishing laparoscopic simulation centers are feasible and expandable, thereby allowing general surgery residents in other LMICs, the opportunity to improve their laparoscopic skills.

The Cost of Setting Up an ENT Endoscopic Practice in Lower Middle-Income Countries of Sub-Saharan Africa

Ear, nose, and throat (ENT) surgeons in developing countries are constrained to practicing with lower technology, lower cost surgery, and reliance on outdated surgical techniques carried out with improvised instruments when compared with their counterparts in the developed world. In this review, we planned to lay open the bottle necks militating against setting up an ENT endoscopy practice in our setting with possible outcomes. The literature search was carried out to retrieve relevant published articles, books, and guidelines. Unpublished literatures were excluded. The search was limited to articles in English. ENT clinical practice in lower middle-income countries (LMICs) where there are limited or no ENT endoscopic setup due to high cost of procurement and maintenance, human resources, lack of subspecialty training, and inadequate funding by policy makers poses major challenges that can militate against the provision of adequate and effective surgical management. A continually improved management practices will positively affect the organisational structure, efficiency, and safety of a system. That is, an affordable and standard ENT endoscopic setup will go a long way to improve the access to training and practice for both ENT clinical and surgical purposes. The expansion of ENT endoscopic specialist training will improve both the diagnostic and therapeutic acumen in ENT practice in LMICs. The budget for health and the health-funding systems of our institutions must receive special and specific attentions tailored towards putting our health facilities in better shapes, subspecialty training, and procurement of state-of-the-art endoscopic equipment with proper plans on maintenance culture.

Setting up minimal invasive surgery services in gynecology in a resource-limited setting: an experience from Bhutan

OBJECTIVE

To describe the clinical profile of minimal invasive procedures performed in gynecology at the national referral hospital in Bhutan. A review of such procedures performed in gynecology was needed to assess the baseline information and generate our own experience. We conducted a descriptive study with a review of hospital records of minimal invasive procedures performed from 1st January to 31st December 2020 at the Department of Gynecology. Data were extracted into a structured pro forma. Descriptive statistics were used to express the results.

RESULTS

The mean age of the patients was 33.9 ± 8.6 years of which the maximum was in the age group 25-34 years. 28 (17.5%) and 132 (82.5%) patients underwent emergency and elective procedures respectively. 142 (88.8%) and 18 (11.2%) patients underwent laparoscopic and hysteroscopic procedures respectively. Ovarian cystectomy was the most commonly performed procedure. The median operating time was 100 min (IQR 62.5-157.5). The overall complication rate was 2.5%. The median postoperative length of hospital stay was 24 h (IQR 3-24). Using our data and experience, we recommend a new health policy to recognize MIS in gynecology as a subspecialty and strengthen the existing service in gynecological MIS.

The cost-effectiveness analysis of laparoscopic hepatectomy compared with open liver resection in the early stage of hepatocellular carcinoma: a decision-analysis model in Thailand

BACKGROUND

Laparoscopic liver resection is increasing operate. In the early stage of hepatocellular carcinoma (HCC), many studies supported that laparoscopic liver resection was a safe procedure and showed some clinical benefits. However, the full economic evaluation has not been fully investigated.

METHODS

A hybrid model of decision tree and Markov state transition model was constructed. Health outcomes were life-year gained (LYs), and quality-adjusted life years (QALYs). A deterministic sensitivity analysis was performed and a probabilistic sensitivity analysis was conducted by 1,000 micro-simulation. The incremental cost-effectiveness ratio (ICER) was reported and the willingness to pay (WTP) was defined at 160,000 THB per QALY gained.

RESULTS

Laparoscopic liver resection in the early stage of HCC was not cost-effective. In the base-case analysis, the total lifetime cost of laparoscopic approach was an average of 413,377 THB (US$13,214) higher than open approach by 55,474 THB (US$1,773) with a small QALY gained. The resulting ICER was 1,356,521 THB (US$43,362) per QALY gained.

CONCLUSION

Laparoscopic liver resection is not considered as a cost-effective alternative to open liver surgery in the early stage of HCC. In the Thai healthcare perspective, the results from this study may inform policymakers for the future policy implementation and healthcare resource allocation.