Affordable Laparoscopic Camera System (ALCS) Designed for Low- and Middle-Income Countries: A Feasibility Study

Low-cost otolaryngology simulation models for early-stage trainees: a scoping review

BACKGROUND

Medical simulation is essential for surgical training yet is often too expensive and inaccessible in low- and middle-income countries (LMICs). Furthermore, in otolaryngology-head and neck surgery (OHNS), while simulation training is often focused on senior residents and specialists, there is a critical need to target general practitioners who carry a significant load of OHNS care in countries with limited OHNS providers. This scoping review aims to describe affordable, effective OHNS simulation models for early-stage trainees and non-OHNS specialists in resource-limited settings and discuss gaps in the literature.

METHODS

This scoping review followed the five stages of Arksey and O'Malley's Scoping Review Methodology. Seven databases were used to search for articles. Included articles discussed physical models of the ear, nose, or throat described as "low-cost," "cost-effective," or defined as <$150 if explicitly stated; related to the management of common and emergent OHNS conditions; and geared towards undergraduate students, medical, dental, or nursing students, and/or early-level residents.

RESULTS

Of the 1706 studies screened, 17 met inclusion criteria. Most studies were conducted in HICs. Most models were low-fidelity (less anatomically realistic) models. The most common simulated skills were peritonsillar abscess aspiration and cricothyrotomy. Information on cost was limited, and locally sourced materials were infrequently mentioned. Simulations were evaluated using questionnaires and direct observation.

CONCLUSION

Low-cost simulation models can be beneficial for early medical trainees and students in LMICs, addressing resource constraints and improving skill acquisition. However, there is a notable lack of contextually relevant, locally developed, and cost-effective models. This study summarizes existing low-cost OHNS simulation models for early-stage trainees and highlights the need for additional locally sourced models. Further research is needed to assess the effectiveness and sustainability of these models.

Low-Cost Otolaryngology Simulation Models for Early-Stage Trainees: A Scoping Review

Importance

There is a notable lack of low-cost OHNS simulation models that are relevant for early medical trainees and students. By conducting this study, we will understand the current landscape of low-cost otolaryngology-head and neck surgery simulation for early medical trainees and students.

Objectives

Medical simulation is essential for surgical training yet is often too expensive and inaccessible in low- and middle-income countries (LMICs). Furthermore, in otolaryngology-head and neck surgery (OHNS), while simulation training is often focused on senior residents and specialists, there is a critical need to target general practitioners who carry a significant load of OHNS care in countries with limited OHNS providers. This scoping review aims to describe affordable, effective OHNS simulation models for early-stage trainees and non-OHNS specialists in resource-limited settings and discuss gaps in the literature.

Evidence Review

This scoping review followed the five stages of Arksey and O'Malley's Scoping Review Methodology. Seven databases were used to search for articles. Included articles discussed physical models of the ear, nose, or throat described as "low-cost," "cost-effective," or defined as <$150 if explicitly stated; related to the management of common and emergent OHNS conditions; and geared towards undergraduate students, medical, dental, or nursing students, and/or early-level residents.

Findings

Of the 1706 studies screened, 17 met the inclusion criteria. Most studies were conducted in HICs. Most models were low fidelity (less anatomically realistic) models. The most common simulated skills were peritonsillar abscess aspiration and cricothyrotomy. Information on cost was limited, and locally sourced materials were infrequently mentioned. Simulations were evaluated using questionnaires and direct observation.

Conclusion and Relevance

Low-cost simulation models can be beneficial for early medical trainees and students in LMICs, addressing resource constraints and improving skill acquisition. However, there is a notable lack of contextually relevant, locally developed, and cost-effective models. This study summarizes existing low-cost OHNS simulation models for early-stage trainees and highlights the need for additional locally sourced models. Further research is needed to assess the effectiveness and sustainability of these models.

Endoscopic versus microscopic discectomy for pathologies of lumbar spine: A nationwide cross-sectional study from a lower-middle-income country

Objective

We conducted a cross-sectional study to assess the preference of spine surgeons between MD for microdiscectomy and endoscopic discectomy (ED) surgery for the management of lumbar pathologies in a lower-middle-income country (LMIC).

Methodology

An online survey assessing the preference of spine surgeons for various lumbar pathologies was developed and disseminated in "Neurosurgery Cocktail" a social media platform. Statistical analyses were performed using SPSS software with a level of significance <0.05.

Results

We received responses from 160 spine surgeons having a median experience of 6.75 years (range 0-42 years) after residency. Most of the spine surgeons preferred MD over ED, preference being homogeneous across all lumbar pathologies. In ED, the interlaminar approach was preferred more frequently than the transforaminal approach. The most commonly chosen contraindication for the interlaminar approach and transforaminal approach was ≥ 3 levels lumbar disc herniation (LDH) (n = 117, 73.1%) and calcified LDH (n = 102, 63.8%), respectively. There was no significant association between the type of approach preferred (MD vs. ED; and interlaminar vs. translaminar endoscopic approach) with the type of workplace and the level of experience.

Conclusion

Spine surgeons were inclined toward MD over ED, due to various reasons, such as a steep learning curve, lack of training opportunities, and upfront expenses. There is a pressing need for the upliftment of ED in LMICs which requires global action.

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.

Healthcare Simulation: A Key to the Future of Medical Education - A Review

AIM

Simulation originates from its application in the military and aviation. It is implemented at various levels of healthcare education and certification today. However, its use remains unevenly distributed across the globe due to misconception regarding its cost and complexity and to lack of evidence for its consistency and validity. Implementation may also be hindered by an array of factors unique to the locale and its norms. Resource-poor settings may benefit from diverting external funds for short-term simulation projects towards collaboration with local experts and local material sourcing to reduce the overall cost and achieve long-term benefits. The recent shift of focus towards patient safety and calls for reduction in training duration have burdened educators with providing adequate quantity and quality of clinical exposure to students and residents in a short time. Furthermore, the COVID-19 pandemic has severely hindered clinical education to curb the spread of illness. Simulation may be beneficial in these circumstances and improve learner confidence. We undertook a literature search on MEDLINE using MeSH terms to obtain relevant information on simulation-based medical education and how to best apply it. Integration of simulation into curricula is an essential step of its implementation. With allocations for deliberate practice and mastery learning under supervision of qualified facilitators, this technology is becoming essential in medical education.

PURPOSE

To review the adaptation, spectrum of use, importance, and resource challenges of simulation in medical education and how best to implement it according to learning theories and best practice guides.

CONCLUSION

Simulation offers students and residents with adequate opportunities to practice their clinical skills in a risk-free environment. Unprecedented global catastrophes provide opportunities to explore simulation as a viable training tool. Future research should focus on sustainability of simulation-based medical education in LMICs.

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.

An Accessible Laparoscope for Surgery in Low- and Middle- Income Countries

Laparoscopic surgery is the standard of care in high-income countries for many procedures in the chest and abdomen. It avoids large incisions by using a tiny camera and fine instruments manipulated through keyhole incisions, but it is generally unavailable in low- and middle-income countries (LMICs) due to the high cost of installment, lack of qualified maintenance personnel, unreliable electricity, and shortage of consumable items. Patients in LMICs would benefit from laparoscopic surgery, as advantages include decreased pain, improved recovery time, fewer wound infections, and shorter hospital stays. To address this need, we developed an accessible laparoscopic system, called the ReadyView laparoscope for use in LMICs. The device includes an integrated camera and LED light source that can be displayed on any monitor. The ReadyView laparoscope was evaluated with standard optical imaging targets to determine its performance against a state-of-the-art commercial laparoscope. The ReadyView laparoscope has a comparable resolving power, lens distortion, field of view, depth of field, and color reproduction accuracy to a commercially available endoscope, particularly at shorter, commonly-used working distances (3-5 cm). Additionally, the ReadyView has a cooler temperature profile, decreasing the risk for tissue injury and operating room fires. The ReadyView features a waterproof design, enabling sterilization by submersion, as commonly performed in LMICs. A custom desktop software was developed to view the video on a laptop computer with a frame rate greater than 30 frames per second and to white balance the image, which is critical for clinical use. The ReadyView laparoscope is capable of providing the image quality and overall performance needed for laparoscopic surgery. This portable low-cost system is well suited to increase access to laparoscopic surgery in LMICs.

Laparoscopic experience and attitudes toward a low-cost laparoscopic system among surgeons in East, Central, and Southern Africa: a survey study

BACKGROUND

Laparoscopic surgery has become standard of care in high-income countries but is rarely accessible in low- and middle-income countries (LMICs). This study assessed experience with laparoscopy and attitudes toward a low-cost laparoscopic system among surgeons in sub-Saharan Africa.

METHODS

A survey assessing current laparoscopic practice and feedback on a low-cost laparoscopic system was administered to attendees of the College of Surgeons of East, Central, and Southern Africa (COSECSA) Scientific Conference between December 4 and December 6, 2019 in Kampala, Uganda.

RESULTS

Fifty-six surgeons from 14 countries participated. A majority were male (n = 46, 82%) general surgeons (n = 37, 66%) from tertiary/teaching hospitals (n = 36, 64%). For those with training in laparoscopy (n = 33, 59%), 22 (67%) reported less than 1 year of training and over half (n = 17, 52%) reported 1 month or less. Overall, a minority (n = 21, 38%) used laparoscopy in current practice, with 57% (n = 12) of those performing laparoscopy less than once per week. The most common laparoscopic surgeries performed were cholecystectomy (n = 15), diagnostic laparoscopy (n = 14), and appendectomy (n = 12). Few surgeons were performing more complex cases (n = 5). Barriers to laparoscopy included poor access to training equipment (n = 34, 61%), mentors (n = 33, 59%), laparoscopic equipment (n = 31, 55%), equipment maintenance (n = 25, 45%), access to consumable supplies (n = 21, 38%), and cost (n = 31, 55%). Fifty-two participants (93%) were interested in increasing their use of laparoscopy; the majority felt that a low-cost laparoscope (n = 52, 93%) and lift retractor for gasless laparoscopy (n = 46, 82%) would serve an unmet need in their practice.

CONCLUSIONS

While the use of laparoscopy is currently limited in COSECSA countries, there is a significant interest among surgeons to increase implementation. A low-cost, durable laparoscopic system was viewed as a potential solution to the current barriers and could improve implementation in LMICs.

Laparoscopic Appendectomy Performed by Surgical Interns: Is it Too Early?

BACKGROUND

Laparoscopic appendectomy (LA) is a common procedure among surgical trainees. However, first-year residents' involvement in this procedure is scarcely studied. We aimed to determine the safety and outcomes of LA performed by surgical interns early in their first year of surgical training.

MATERIALS AND METHODS

A retrospective review of all patients who underwent LA for acute appendicitis from 2006 to 2019 was performed. All patients operated by surgical interns were included. The sample was divided into 2 groups: LA performed during the first (G1) and last 3 months (G2) of their first year of residency. Demographics, operative variables, and postoperative outcomes were compared between groups.

RESULTS

A total of 2009 LA were performed during the study period; 1647 (82%) were done by surgical interns. A total of 934 LA were performed at both ends of the year; 505 belonged to G1 and 429 to G2. Each surgical intern performed a mean of 40 LA. Demographics, complicated appendicitis rates, and presence of peritonitis were comparable between groups. Operative time was longer in G1 (G1: 61 vs. G2: 52 min, P<0.0001). Major morbidity (G1: 2.1% vs. G2: 3.4%, P=0.2), postoperative intra-abdominal abscess rates (G1: 2.8% vs. G2: 2.8%, P=0.66), median length of hospital stay (G1: 1.9 vs. G2: 1.8 d, P=0.59), and readmission rates (G1: 1.6% vs. G2: 2%, P=0.73) were similar between groups. There was no mortality in the series.

CONCLUSIONS

LA can be safely performed by supervised surgical interns early in their training. Despite a longer operative time, postoperative outcomes were favorable and similar as those achieved at the end of surgical internship.