Laparoscopic appendicectomy at the Aga Khan Hospital, Nairobi

First experience in laparoscopic surgery in low and middle income countries: A systematic review

BACKGROUND

Laparoscopic surgery has reduced morbidity and mortality rates, shorter postoperative recovery periods and lower complication rates than open surgery. It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources. However, introducing laparoscopic surgery in low-and-middle-income countries (LMIC) can be expensive and requires resources, equipment, and trainers.

AIM

To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC. Included studies were published between 1996 and 2022 with full text available in English. Exclusion criteria were studies considering only open surgery, ear, nose, and throat, endoscopy, arthroscopy, hysteroscopy, cystoscopy, transplant, or bariatric surgery.

RESULTS

Ten studies out of 3409 screened papers, from eight LMIC were eligible for inclusion in the final analysis, totaling 2497 patients. Most reported challenges were related to costs of equipment and training programmes, equipment problems such as faulty equipment, and access to surgical kits. Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff. The benefits of introducing laparoscopic surgery were economic and clinical, including a reduction in hospital stay, complications, and morbidity/mortality. The introduction of laparoscopic surgery also provided training opportunities for junior doctors.

CONCLUSION

Despite financial and technical challenges, many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients. While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported, more support is critically required, in particular regarding training.

Improving Access to Laparoscopy in Low-Resource Settings

Laparoscopy has numerous clinical benefits compared to laparotomy. However, a functional laparoscopy program requires significant investment and, as a result, remains unavailable for the majority of the world’s population in low- and middle-income countries. The effort to bring laparoscopy to low-resource settings has produced variable outcomes resulting from the challenges inherent to a complex surgical program. This paper highlights these shortcomings and identifies opportunities to improve future laparoscopy programs.

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

BACKGROUND

Laparoscopy may prove feasible to address surgical needs in limited-resource settings. However, no aggregate data exist regarding the role of laparoscopy in low- and middle-income countries (LMICs). This study was designed to describe the issues facing laparoscopy in LMICs and to aggregate reported solutions.

METHODS

A search was conducted using Medline, African Index Medicus, the Directory of Open Access Journals, and the LILACS/BIREME/SCIELO database. Included studies were in English, published after 1992, and reported safety, cost, or outcomes of laparoscopy in LMICs. Studies pertaining to arthroscopy, ENT, flexible endoscopy, hysteroscopy, cystoscopy, computer-assisted surgery, pediatrics, transplantation, and bariatrics were excluded. Qualitative synthesis was performed by extracting results that fell into three categories: advantages of, challenges to, and adaptations made to implement laparoscopy in LMICs. PRISMA guidelines for systematic reviews were followed.

RESULTS

A total of 1101 abstracts were reviewed, and 58 articles were included describing laparoscopy in 25 LMICs. Laparoscopy is particularly advantageous in LMICs, where there is often poor sanitation, limited diagnostic imaging, fewer hospital beds, higher rates of hemorrhage, rising rates of trauma, and single income households. Lack of trained personnel and equipment were frequently cited challenges. Adaptive strategies included mechanical insufflation with room air, syringe suction, homemade endoloops, hand-assisted techniques, extracorporeal knot tying, innovative use of cheaper instruments, and reuse of disposable instruments. Inexpensive laboratory-based trainers and telemedicine are effective for training.

CONCLUSIONS

LMICs face many surgical challenges that require innovation. Laparoscopic surgery may be safe, effective, feasible, and cost-effective in LMICs, although it often remains limited in its accessibility, acceptability, and quality. This study may not capture articles written in languages other than English or in journals not indexed by the included databases. Surgeons, policymakers, and manufacturers should focus on plans for sustainability, training and retention of providers, and regulation of efforts to develop laparoscopy in LMICs.

Variations in the position and length of the vermiform appendix in a black kenyan population

Background. Topography of the appendix influences its mobility, degree of mobilization of the cecum, and need for additional muscle splitting during appendectomy. Although appendectomy is a common surgical procedure, there is a paucity of data on its topography in black Africans. Methods. The position and length of the appendix and relation of the appendicular base with spinoumbilical line were determined in 48 cadavers obtained from the Department of Human Anatomy, University of Nairobi, Kenya. Results. The commonest appendicular types in males were retrocecal 10 (27%) while in females was subileal 4 (36.4%). The average length of the appendix was 76.5 ± 23.6 mm. The base of the appendix was located along, below, and above the spinoumbilical line in 25 (52.1%), 9 (18.8%), and 14 (29.2%) cases, respectively. Conclusion. The topography of appendix in Kenyans shows variations from other populations. Knowledge of these variations is important during appendicectomy.