Impact of a medical university on laparoscopic surgery in a service-oriented public hospital in the Caribbean

Disparities in Access to Minimally Invasive Surgery in Low and Middle-Income Countries

BackgroundAlthough every human being has a basic right to access quality health care, the unfortunate reality is that inequities still exist in the year 2025. The inequities may be readily visible in low and middle-income countries (LMICs), and they are most apparent in the specialties that require significant allocations of human and institutional resources, such as the provision on minimally invasive surgery (MIS).PurposeThis discursive paper explores the reasons for the disparities, taking into account the fundamental differences between the health care environments in LMICs and high-income countries.Research DesignThis is a discursive paper that considers expert opinions on the inequities in healthcare in LMICsStudy SampleThis study discusses the availability of MIS in the health care environments in LMICs of the Anglophone Caribbean.Data Collection and/or AnalysisA literature review of all published data from LMICs in the Anglophone Caribbean.ResultsThis disursive paper explores the reasons for disparity in access to MIS and proposes strategies to restore equity in LMICs.ConclusionsIt is possible to overcome these challenges, but it requires strong leadership, development of creative solutions, and a concerted effort to change the health care environment.

Implementation of robotic and laparoscopic hepatopancreatobiliary surgery in low- and middle-income settings: a systematic review and meta-analysis

BACKGROUND

Despite numerous barriers, the application of minimally invasive surgery (MIS) for hepatopancreatobiliary (HPB) conditions has been increasing globally. This study aims to review the current status of HPB MIS in LMICs.

METHODS

Relevant databases were searched, identifying 3452 publications, 38 of which met the inclusion criteria. Meta-analysis of outcomes was carried out using "R" statistical software.

RESULTS

This study reviewed reports of application of MIS for HPB conditions in LMICs, analyzing a total of 3272 procedures. India (66.87 %) and Egypt (20.11 %) contributed majorly to the procedures reviewed. Others were from Indonesia (8.68 %), Colombia (3.06 %), Pakistan (0.67 %), Sri Lanka (0.34 %), Trinidad and Tobago (0.18 %), and Nigeria (0.09 %). India was the only LMIC with robotic HPB MIS. The majority of the procedures were biliary (74.88 %). Basic procedures accounted for 55.63 %, while 44.37 % were advanced. The overall conversion rate and prevalence of morbidity were 8 % [95 % CI: 5; 13], and 15 % [95 % CI: 9; 22], respectively. Robotics was associated with higher conversion (14 % vs 6 %, p < 0.01) but lower morbidity (10 % vs 16 %, p = 0.91), compared to laparoscopic surgery. There were 5 cases of mortality from laparoscopy.

CONCLUSION

The outcomes in this systematic review, compared to findings in other settings indicate successful implementation of HPB MIS in LMICs.

Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy

BACKGROUND

Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer, but we have experienced resistance to the introduction of the FreeHand® robotic camera holder to augment laparoscopic colorectal surgery.

AIM

To compare the initial results between conventional and FreeHand® robot-assisted laparoscopic colectomy in Trinidad and Tobago.

METHODS

This was a prospective study of outcomes from all laparoscopic colectomies performed for colorectal carcinoma from November 29, 2021 to May 30, 2022. The following data were recorded: Operating time, conversions, estimated blood loss, hospitalization, morbidity, surgical resection margins and number of nodes harvested. All data were entered into an excel database and the data were analyzed using SPSS ver 20.0.

RESULTS

There were 23 patients undergoing colectomies for malignant disease: 8 (35%) FreeHand®-assisted and 15 (65%) conventional laparoscopic colectomies. There were no conversions. Operating time was significantly lower in patients undergoing robot-assisted laparoscopic colectomy (95.13 ± 9.22 vs 105.67 ± 11.48 min; P = 0.045). Otherwise, there was no difference in estimated blood loss, nodal harvest, hospitalization, morbidity or mortality.

CONCLUSION

The FreeHand® robot for colectomies is safe, provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.

Surgical training in the Caribbean: The past, the present, and the future

The six million inhabitants of these diverse English-speaking Caribbean countries are grateful to the University of the West Indies, which has been central in the independent training of surgical specialists in all areas of surgery for the past 50 years. Similar to the per capita income, the quality of surgical care, albeit acceptable, is quite variable throughout the region. Globalization and access to information have revealed that the quality of training and surgical care being delivered can be further improved. Technological advances will perhaps never be on par with higher-income countries, but collaborative ventures with global health partners and institutions can ensure that the people of the region will have appropriately trained surgical doctors and, therefore, the provision of accessible quality care will remain a staple, with even the possibility of income generation. This study reviews the journey of our structured surgical training program delivered in the region and outlines our growth plans.

Burnout and resilience at work among health professionals serving in tertiary hospitals, in Ethiopia

Background

The quality of healthcare service is strongly affected by the health professionals' levels of burnout and resilience at work (RaW). Developing resilience is a key component of medical professionalism. Although burnout and resilience are indicators used to assess the level of workplace hardship, there is a dearth of information in most developing countries, including Ethiopia.

Objective

To assess the levels of burnout and 'resilience at work' among health professionals who work in the surgical care departments in teaching Ethiopian hospitals.

Methods

A cross-sectional study design was applied among health professionals employed in surgical, gynecologic, and obstetric (Gyn/Obs) departments of two acute-care hospitals (n = 388). A structured self-administered English version questionnaire, consisting of validated scales to measure RaW and burnout, was used to collect the data;22 items of Maslach's burnout inventory human service survey tool and 20 items of Win wood's resilience at work' measuring tool" was employed to assess the health professionals' burnout level and Resilience at work, respectively. Linear logistics regression was employed for inferential statistical analysis to identify factors that predict RaW and burnout.

Results

Burnout syndrome was shown among 101 (26.0%) study participants. Furthermore, 205 (52.8%), 150 (38.7%), and 125 (32.2%) participants presented high emotional exhaustion, high depersonalization, and low personal accomplishment, respectively. Emotional exhaustion was predicted by the participants' profession, the hope of promotion, professional recognition, and workload. Depersonalization was predicted by age, profession, and perceived workload of the participants. The predictors for personal accomplishment were profession, relationship at work, professional recognition, and having a managerial position in addition to clinical duty. The participants' mean RaW score was 78.36 (Standard deviation ±17.78). A negative association was found between RaW and emotional exhaustion and depersonalization. In contrast, a positive association was identified between RaW and personal accomplishment. The type of profession and marital status were positive predictors of RaW.

Conclusion

A substantial amount of health professionals experience high burnout in one or more burnout dimensions. Level of RaW is more affected by burnout syndrome. Therefore, promoting activities that increase the level of professional RaW and recognition in their professional practice is needed to reduce job burnout. These findings are especially important concerning low socio-economic countries, as resilience is a vital component of the development of healthcare systems.

Robot-Assisted Common Bile Duct Exploration in Trinidad & Tobago

Although laparoscopic common bile duct exploration is a feasible and safe option for the operative management of choledocholithiasis, there has been a general reluctance to perform this procedure in Caribbean practice. This is largely because duct exploration is perceived to be difficult with laparoscopic instruments, and endoscopic retrograde cholangiopancreatography (ERCP) has become increasingly available. We report a case in which stones were extracted laparoscopically from the common bile duct, aided by the FreeHand® (Freehand 2010 Ltd., Guildford, Surrey, UK) robot, to show that the procedure is feasible and safe in the Caribbean environment.

Freehand-robot-assisted laparoscopic colorectal surgery: Initial experience in the Trinidad and Tobago

BACKGROUND

Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean, having been first performed in the region in the year 2011. We report the initial outcomes using a robot camera holder to assist in laparoscopic colorectal operations.

AIM

To report our initial experience using the FreeHand^® robotic camera holder (Freehand 2010 Ltd., Guildford, Surrey, United Kingdom) for laparoscopic colorectal surgery in Trinidad & Tobago.

METHODS

We retrospectively collected data from all patients who underwent laparoscopic colorectal resections using the Freehand^® (Freehand 2010 Ltd., Guildford, Surrey, United Kingdom) robotic camera holder between September 30, 2021 and April 30, 2022. The following data were recorded: patient demographics, robotic arm setup time, operating time, conversions to open surgery, conversions to a human camera operator, number and duration of intra-operative lens cleaning. At the termination of the operation, before operating notes were completed, the surgeons were administered a questionnaire recording information on ergonomics, user-difficulty, requirement to convert to a human camera operator and their ability to carry out effective movements to control the robot while operating.

RESULTS

Nine patients at a mean age of 58.9 ± 7.1 years underwent colorectal operations using the FreeHand robot: Right hemicolectomies (5), left hemicolectomy (1), sigmoid colectomies (2) and anterior resection (1). The mean robot docking time was 6.33 minutes (Median 6; Range 4-10; SD ± 1.8). The mean duration of operation was 122.33 ± 78.5 min and estimated blood loss was 113.33 ± 151.08 mL. There were no conversions to a human camera holder. The laparoscope was detached from the robot for lens cleaning/defogging an average of 2.6 ± 0.88 times per case, with cumulative mean interruption time of 4.2 ± 2.15 minutes per case. The mean duration of hospitalization was 3.2 ± 1.30 days and there were no complications recorded. When the surgeons were interviewed after operation, the surgeons reported that there were good ergonomics (100%), with no limitation on instrument movement (100%), stable image (100%) and better control of surgical field (100%).

CONCLUSION

Robot-assisted laparoscopic colorectal surgery is feasible and safe in the resource-poor Caribbean setting, once there is appropriate training.

Robot-Assisted Minimally Invasive Surgery: First Report from the Caribbean

Although advanced minimally invasive surgery and robotic surgery were well accepted in developed countries by the turn of the 21st century, they did not enjoy the same popularity in the Anglophone Caribbean. Advanced minimally invasive surgery only became available in select Caribbean countries from the year 2010. And up to the year 2021, robotic surgery was completely non-existent in the Anglophone Caribbean.

Surgical leaders in the Anglophone Caribbean recognized a need to encourage the introduction of advanced surgical techniques in the region and engaged local and international stakeholders in an attempt to stimulate this development. In the year 2021, through a collaborative effort by a local medical university, a government-funded hospital, and industry partners in the United Kingdom, robot-assisted minimally invasive surgery was successfully introduced to the Caribbean.

We report our experience of introducing robot-assisted minimally invasive surgery in the Eastern Caribbean. By discussing the pitfalls and successes from our experience, we hope that the lessons can be used to guide the introduction of robot-assisted minimally invasive surgery in other resource-poor countries in the Caribbean.​

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.

Trauma surgery via distance mentoring: A model inspired by the 2020 pandemic

When the COVID-19 pandemic unfolded in March 2020, surgical care was impacted globally. The developing nations in the Caribbean were unprepared with fragile, resource poor healthcare systems. A series of rapid policy changes in response to the pandemic radically changed surgical care and prevented the usual oversight in the operating theatre. Attending surgeons responded utilising readily available technology for distance mentoring. Using this model, postgraduate surgical residents were able to complete 96% of trauma laparotomies safely without major complications.

Time to abandon the old dictum of delayed laparoscopic cholecystectomy after acute cholecystitis has settled in Caribbean practice

Although laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis, many Caribbean surgeons are reluctant to operate during the acute attack. We collected data for all consecutive patients who underwent laparoscopic cholecystectomy for acute cholecystitis from January 1 to 31 December 2018. Delayed cholecystectomy was done >6 weeks after acute cholecystitis settled. We compared data between early and delayed groups. Delayed laparoscopic cholecystectomy was performed in 54 patients, and 42 had early laparoscopic cholecystectomy. Delayed surgery resulted in significantly more complications requiring readmission (39% vs 0), longer operations (2.27 vs 0.94 h) and lengthier post-operative hospitalisation (1.84 vs 1.1 days). Caribbean hospitals should abandon the practice of delayed surgery after cholecystitis has settled. Early laparoscopic cholecystectomy would be financially advantageous for our institutions, and it would save patients recurrent attacks of gallstone disease.

Single-Incision Laparoscopic Cholecystectomy: Initial Report From the Turks and Caicos Islands

There has been no prior report of single-incision laparoscopic surgery (SILS) from the Caribbean island of Turks and Caicos. We report our initial experience with SILS cholecystectomy to show that SILS in this environment is feasible with minimal change to the existing hardware. It is a safe alternative to conventional multi-trocar laparoscopic cholecystectomy in this setting.

Totally Laparoscopic Whipple's Operation: Initial Report from the Caribbean

Oncologic surgery in the Caribbean has evolved over the past decade, with increasing reports of advanced minimally invasive operations being performed. However, the minimally invasive approach has not been used for peri-ampullary lesions. This is because a laparoscopic Whipple's operation is a technically demanding and time-consuming operation. We report the first case of a totally laparoscopic Whipple's operation to be performed in the Caribbean.

Developing Laparoscopic Surgery on the Caribbean Island of St. Lucia: A Model for Public-Private Partnership

The first recorded laparoscopic operation in the Caribbean was a cholecystectomy performed in 1991. After a temporary peak in basic laparoscopic operations in subsequent years, the initial interest waned. While laparoscopic surgery was being popularized in the developed world, there was a stagnation in the Caribbean. There were many reasons for this stagnation, including a lack of surgical expertise, the negative attitudes of health-care workers, active opposition from surgical leaders, and equipment deficiencies, all exacerbated by the global financial recession in the early twenty-first century. A similar situation existed on the Caribbean island of St. Lucia, where laparoscopic surgery remained relatively dormant. After a strong desire by community surgeons to incorporate advanced laparoscopy into surgical practice, surgical leaders in St. Lucia engineered a public-private partnership to achieve this. This review article evaluates the available data, documents the obstacles encountered, and explains the mechanisms to overcome these obstacles to incorporate advanced laparoscopy in St. Lucia. This information is important because it can serve as a template for other developing Caribbean countries.

Laparoscopic Liver Resection by Distance Mentoring - Trinidad to Barbados: A Report

Laparoscopic liver resections require advanced laparoscopic skill sets. In the Caribbean, a unique situation exists where centers of excellence for liver resections exist, but surgeons who are trained in advanced laparoscopic surgery are not available throughout the region. Therefore, many patients who are candidates for liver resection in the Caribbean do not have the opportunity to receive laparoscopic operations. 

We report a case of distance mentoring using readily available, inexpensive equipment to complete a laparoscopic liver resection, mentored by an expert hepatobiliary surgeon. It may be considered, in special cases, as a way to increase the availability of laparoscopic operations. We acknowledge that there are many limitations to the use of this technology and we discuss the pros and cons of distance mentoring for this purpose.

Cancer control in the Caribbean island countries and territories: some progress but the journey continues

Cancer causes a fifth of deaths in the Caribbean region and its incidence is increasing. Incidence and mortality patterns of cancer in the Caribbean reflect globally widespread epidemiological transitions, and show cancer profiles that are unique to the region. Providing comprehensive and locally responsive cancer care is particularly challenging in the Caribbean because of the geographical spread of the islands, the frequently under-resourced health-care systems, and the absence of a cohesive approach to cancer control. In many Caribbean countries and territories, cancer surveillance systems are poorly developed, advanced disease presentations are commonplace, and access to cancer screening, diagnostics, and treatment is often suboptimal, with many patients with cancer seeking treatment abroad. Capacity building across the cancer-control continuum in the region is urgently needed and can be accomplished through collaborative efforts and increased investment in health care and cancer control.

Single incision laparoscopic surgery from a caribbean perspective

Conventional laparoscopy with multiple ports has recently gained a strong foothold in the Caribbean, but single incision laparoscopic surgery (SILS) has lagged behind. In this paper, we compare the data on SILS and conventional multi-port laparoscopy in the English-speaking Caribbean.

A historical perspective on the introduction of laparoscopic basic surgical training in the Caribbean and factors that contribute to sustainability of such training

OBJECTIVE

To report the development of minimally invasive training courses and workshops in the Caribbean and specifically the establishment of the Basic Surgical Skills Course of the Royal College of Surgeons of England (RCSEng) in Trinidad with respect to their value toward Surgical laparoscopic or minimally invasive training in the Caribbean.

DESIGN

& Methods: The literature written on laparoscopy in the region was reviewed and in particular that related to the minimally invasive training courses provided over the period 2004 to 2019 and the development of laparoscopic surgical training described from a historic perspective. The factors that contribute to sustainability of courses were identified.

RESULTS

Laparoscopic surgical training courses were sporadically introduced into the Caribbean over the period 2004 to 2019 in countries including Barbados, Curacao, Guyana, St. Lucia, Jamaica and Trinidad & Tobago. These were timed and closely related to the establishment of the Caribbean College of Surgeons (CCOS) with the help of the Royal College of Surgeons of England. However, the only certified course introduced was the Basic Surgical Skills (BSS) course of the RCSEng into Trinidad in 2012. This has now been established as a recognised overseas centre by the RCSEng and provides the Intercollegiate BSS course annually forming a solid basis for trainees to learn safe surgical and laparoscopic skills prior to commencing formal surgical training. This has resulted in the sustainable development of minimally invasive training in Trinidad in particular.

CONCLUSION

Laparoscopic skills courses and workshops have been established in the Caribbean for 15 years beginning circa. 2004 to 2019 and have grown in number and locations throughout the Caribbean. The RCSEng and the CCOS have been instrumental in the development process. Of note, the only recognised overseas training centre for Basic Surgical Skills Course was established in Trinidad & Tobago with the support of the RCSEng and seems to be the main contributor to the successful, regular maintenance of these and other minimally invasive courses in General Surgery, ENT, Gynaecology and other fields on an annual, sustainable basis.