Barriers to the uptake of laparoscopic surgery in a lower-middle-income country

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.

How Should Laparoscopic Surgery Training be Planned in a Resource-Limited Environment?

OBJECTIVE

Laparoscopic surgeries (LSs) are underperformed in low-income countries with inadequate health infrastructure due to many restrictive factors. In this study, we aimed to present the process and results of the first bilateral collaboration protocol (BCP) for LS in an African university hospital where laparoscopic surgery had not been performed before.

DESIGN

A 3-stage BCP was implemented between the University of Health Sciences (Turkey) and Jigjiga University Hospital (Somali State, Ethiopia) between January and June 2024. In the first stage, training was received in Turkey for 3-6 months. In the second stage, 2 general surgery, 2 gynecology and obstetrics, and one ear-nose-throat (ENT) clinic training officers from the University of Health Sciences went to Jigjiga University Hospital and provided the installation of laparoscopic devices, on-site training of surgeons and other operating room personnel, and the initiation of the first laparoscopic and minimally invasive surgeries for a week. In the third stage, LS performed in the first 30 days after the end of the program were connected via video call.

SETTING

This training was held at Jigjiga University Hospital, the only university hospital in the Somali state of Ethiopia.

PARTICIPANTS

The first stage of this training was attended by the teaching staff of the surgical clinics at Jigjiga University Hospital. The second stage of the program was attended by all surgeons, clinical assistants, operating room nurses and staff at Jigjiga University Hospital.

RESULTS

In the second stage of the program, a total of 25 patients underwent the first laparoscopic and minimally invasive surgeries in the state in 1 week. 13 (52%) were performed by general surgery, 7 (28%) by gynecology and 5 (20%) by ENT. In the third stage, 24 laparoscopic procedures were performed in the first 30 days.

CONCLUSIONS

In low-income countries with limited resources, laparoscopic surgeries can be introduced with the right training programs and appropriate bilateral collaboration programs.

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.

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.

Clinical Presentations and Surgical Features of Morgagni Hernia in Adults: A Retrospective Study

Background and Aims

Morgagni hernias are rare congenital diaphragmatic defects that can lead to bowel obstruction and incarceration if not repaired. While this disease typically manifests as respiratory distress, frequent respiratory infections, and infant growth failure, it can sometimes be accidentally discovered in adulthood through cross-sectional imaging. We aimed to report our experience managing this entity during 20 years at our referral center.

Methods

A retrospective chart review was performed of adult patients diagnosed with Morgagni diaphragmatic hernia who underwent surgery at Shiraz University of Medical Sciences in two main referral hospitals between 2002 and 2022. Patients' demographic and clinical data, including surgical features and hospitalization, course were extracted and subsequently analyzed.

Results

Seventeen patients, including three men and 14 women, with an age range of 26 to 92 years (average age 61.5 years), were diagnosed with Morgagni diaphragmatic hernia. Three patients had left-sided hernias, and 14 had right-sided hernias. The most common clinical manifestations were shortness of breath and abdominal pain. The most commonly herniated contents were the omentum and colon. All patients underwent laparotomy, and the hernia sac was removed in 11 patients.

Conclusions

Morgagni is a rare congenital diaphragmatic hernia usually diagnosed incidentally. Laparoscopic repair has high success rates and is a viable option for patients with this pathology.

Telesurgery: humanitarian and surgical benefits while navigating technologic and administrative challenges

Telesurgery, the remote execution of surgical procedures through telecommunication and robotic systems, has witnessed substantial growth in recent years, promising to address global healthcare disparities and enhance surgical expertise. This paper explores the humanitarian and surgical benefits of telesurgery, emphasizing its potential to provide expert surgical care to underserved regions. Despite its transformative potential, telesurgery faces significant technologic challenges, including issues of data transmission, latency, and the need for advanced robotic platforms. The advent of 5G networks and innovative robotic systems provides a promising technological landscape, yet global disparities in 5G coverage remain a concern. Ethical considerations, ranging from preserving the surgeon-patient relationship to addressing patient vulnerability and conflicts of interest, are pivotal aspects that demand attention. The paper underscores the importance of clear regulatory frameworks and international collaboration to navigate legal complexities and ensure ethical standards. As telesurgery progresses, integrating artificial intelligence, augmented reality, and haptic feedback technologies holds promise for further advancements. Despite these challenges, telesurgery has the potential to achieve equitable access to expert surgical care; however, it requires a collective effort to overcome its intricate technologic and administrative hurdles.

Laparoscopy experience in East, Central, and Southern Africa: insights from operative case volume analysis

BACKGROUND

With the primary objective of addressing the disparity in global surgical care access, the College of Surgeons of East, Central, and Southern Africa (COSECSA) trains surgeons. While sufficient operative experience is crucial for surgical training, the extent of utilization of minimally invasive techniques during COSECSA training remains understudied.

METHODS

We conducted an extensive review of COSECSA general surgery trainees' operative case logs from January 1, 2015, to December 31, 2020, focusing on the utilization of minimally invasive surgical procedures. Our primary objective was to determine the prevalence of laparoscopic procedures and compare this to open procedures. We analyzed the distribution of laparoscopic cases across common indications such as cholecystectomy, appendicitis, and hernia operations. Additionally, we examined the impact of trainee autonomy, country development index, and hospital type on laparoscopy utilization.

RESULTS

Among 68,659 total cases, only 616 (0.9%) were laparoscopic procedures. Notably, 34 cases were conducted during trainee external rotations in countries like the United Kingdom, Germany, and India. Gallbladder and appendix pathologies were most frequent among the 582 recorded laparoscopic cases performed in Africa. Laparoscopic cholecystectomy accounted for 29% (276 of 975 cases), laparoscopic appendectomy for 3% (76 of 2548 cases), and laparoscopic hernia repairs for 0.5% (26 of 5620 cases). Trainees self-reported lower autonomy for laparoscopic (22.5%) than open cases (61.5%). Laparoscopy usage was more prevalent in upper-middle-income (2.7%) and lower-middle-income countries (0.8%) compared with lower-income countries (0.5%) (p < 0.001). Private (1.6%) and faith-based hospitals (1.5%) showed greater laparoscopy utilization than public hospitals (0.5%) (p < 0.001).

CONCLUSIONS

The study highlights the relatively low utilization of minimally invasive techniques in surgical training within the ECSA region. Laparoscopic cases remain a minority, with variations observed based on specific diagnoses. The findings suggest a need to enhance exposure to minimally invasive procedures to ensure well-rounded training and proficiency in these techniques.

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.

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 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.

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.

Evolution of laparoscopic surgery in a sub-Saharan African country: a 30-year literature review in Senegal

INTRODUCTION

The advent of laparoscopy has significantly reduced the morbidity associated with the majority of abdominal surgeries. In Senegal, the first studies evaluating this technique were published in the 1980s. The objective of this systematic review is to assess the evolution of laparoscopy research in Senegal.

METHODS

A search of PubMed and Google Scholar was carried out without limit of publication date. The keywords used were "senegal" AND "laparoscop*". Duplicates were removed, and remaining articles were assessed for selection criteria. We included all articles about laparoscopy published in Senegal. The parameters studied in each included article were the place and year of study, average age, sex ratio, assessed indications and results.

RESULTS

41 Studies published between 1984 and 2021 met selection criteria. The average age of patients was 33 years (range 4.7-63). The sex ratio was 0.33. The main indications for laparoscopy according to the studies were: benign gastrointestinal disorders in 11 studies (26.8%), abdominal emergencies in 9 studies (22%), gallbladder surgery in 5 studies (12.2%), benign gynecological pathology in 6 studies (14.6%), malignant gynecological pathology in 2 studies (4.9%), diagnostic laparoscopy in 2 studies (4.9%), groin hernia repair in 2 studies (4.9%) and testicular pathology in 1 study (2.4%). Overall mortality was estimated at 0.9% (95% CI 0.6-1.3) and overall morbidity for all complications was estimated at 5% (95% CI 3.4-6.9).

CONCLUSIONS

This systematic review showed a predominance of the laparoscopy publications from the capital in Dakar with favorable outcomes. This technique should be popularized in the different regions of the country and its indications expanded.

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.

Access, Safety, and Barriers in Adoption of Emergency Laparoscopy Surgery for Trauma Patients in a Low-Resource Setting

Introduction  This study analyzes barriers to the adoption of emergency laparoscopy (EL), safety, and accessibility in a low-resource setting of a low- and middle-income country (LMIC). Methods  In this prospective observational study, patients with blunt trauma abdomen (BTA) who required exploration were included and divided into two groups-open exploration (open surgery [OSx]) and laparoscopic exploration (laparoscopic surgery [LSx]). Data were compiled and analyzed. Results  Out of 94 BTA patients, 66 required exploration, and the rest were managed conservatively. Out of 66 patients, 42 were in OSx and 24 were in LSx, reason for not selecting LSx was the surgeon's preference for OSx in 26 patients and the lack of availability of operation theater (OT) slots in 16 patients. LSx even after indication was less likely if patients had preoperative evidence of perforation peritonitis. Conclusion  Lack of resources (OT availability and trained personnel) are barriers to the adoption of emergency LSx in low-resource settings.

Simulation-based education in urology - an update

Over the past 30 years surgical training, including urology training, has changed from the Halstedian apprenticeship-based model to a competency-based one. Simulation-based education (SBE) is an effective, competency-based method for acquiring both technical and non-technical surgical skills and has rapidly become an essential component of urological education. This article introduces the key learning theory underpinning surgical education and SBE, discussing the educational concepts of mastery learning, deliberate practice, feedback, fidelity and assessment. These concepts are fundamental aspects of urological education, thus requiring clinical educators to have a detailed understanding of their impact on learning to assist trainees to acquire surgical skills. The article will then address in detail the current and emerging simulation modalities used in urological education, with specific urological examples provided. These modalities are part-task trainers and 3D-printed models for open surgery, laparoscopic bench and virtual reality trainers, robotic surgery simulation, simulated patients and roleplay, scenario-based simulation, hybrid simulation, distributed simulation and digital simulation. This article will particularly focus on recent advancements in several emerging simulation modalities that are being applied in urology training such as operable 3D-printed models, robotic surgery simulation and online simulation. The implementation of simulation into training programmes and our recommendations for the future direction of urological simulation will also be discussed.

Serbian National Training Programme for minimally invasive colorectal surgery (LapSerb): short-term clinical outcomes of over 1400 colorectal resections

INTRODUCTION

The Serbian National Training Programme for minimally invasive colorectal surgery (LapSerb) was introduced to implement laparoscopic colorectal surgery across Serbia. The programme aimed to accelerate training of established colorectal surgeons through a competency-based programme. This involved knowledge assessment, workshops, live operating, and competency-based assessment of unedited videos. The aim of this study is to report the outcomes of laparoscopic colorectal resection performed by LapSerb certified surgeons.

METHODS

LapSerb prospectively maintained multicentred database was analysed for laparoscopic colorectal resections from January 2015 to February 2021. Data collected included patient demographics, indications for surgery, perioperative data, and 30-day outcomes.

RESULTS

A total of 1456 laparoscopic colectomies by 24 certified surgeons were included in the final analysis. Mean age was 67 (± 12) years old and male to female ratio was 1:1.5. 83.1% of the colectomies were malignant, mainly due to adenocarcinoma. Anterior resection was the most common procedure with 699 (48%) cases, followed by right and left colectomies with 357 (24.5%) and 303 (21%) procedure respectively. 4.8% of patients required conversion to open surgery. Thirty-day readmission and reoperation rates were 2.3% and 4.7%, respectively. Overall mortality in all cases was 1.1% and R0 resections were achieved in 97.8% of malignant colectomies.

CONCLUSION

The LapSerb programme successfully and safely established laparoscopic colorectal surgery across the country with comparable and acceptable short-term clinical outcomes.

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.

Attending guidance advised: educational quality of surgical videos on YouTube

INTRODUCTION

YouTube is the most used platform for case preparation by surgical trainees. Despite its popular use, studies have noted limitations in surgical technique, safety, and vetting of these videos. This study identified the most viewed laparoscopic cholecystectomy (LC) videos on YouTube and analyzed the ability of attendings, residents, and medical students to identify critical portions of the procedure, technique, and limitations of the videos.

METHODS

An incognito search was conducted on YouTube using the term "laparoscopic cholecystectomy." Results were screened for length, publication date, and language. The top ten most viewed videos were presented to general surgery attendings, residents, and medical students at a single academic institution. Established rubrics were used for evaluation, including the Critical View of Safety (CVS) for LC, a modified Global Operative Assessment of Laparoscopic Skills (GOALS) score, a task-specific checklist, and visual analog scales for case difficulty and operator competence. Educational quality and likelihood of video recommendation for case preparation were evaluated using a Likert scale. Attending assessments were considered the gold standard.

RESULTS

Six attending surgeons achieved excellent internal consistency on CVS, educational quality, and likelihood of recommendation scales, with Cronbach alpha (⍺) of 0.93, 0.92, and 0.92, respectively. ⍺ was ≥ 0.7 in all the other scales measured. Attending evaluations revealed that only one of the ten videos attained all three established CVS criteria. Four videos demonstrated none of the CVS criteria. The mean educational quality (mEQ) was 4.63 on a 10-point scale. The mean likelihood of recommendation (mLoR) for case preparation was 2.3 on a 5-point scale. Senior resident assessments (Postgraduate Year (PGY)4 + , n = 12) aligned with attending surgeons, with no statistically significant differences in CVS attainment, mEQ, and mLoR. Junior residents (PGY1-3, n = 17) and medical students (MS3-4, n = 20) exhibited significant difference with attendings in CVS attainment, mEQ, and mLoR for more than half the videos. Both groups tended to overrate videos compared to attendings.

CONCLUSION

YouTube is the most popular unvetted resource used for case presentation by surgical trainees. Attending evaluations revealed that the most viewed LC videos on YouTube did not attain the CVS, and were deemed as inappropriate for case preparation, with low educational value. Senior resident video assessments closely aligned with attendings, while junior trainees were more likely to overstate video quality and value. Attending guidance and direction of trainees to high-quality, vetted resources for surgical case preparation is needed. This may also suggest a need for surgical societies with platforms for video sharing to prioritize the creation and dissemination of high-quality videos on easily accessible public platforms.

Characterization of Near-Infrared Imaging and Indocyanine-Green Use Amongst General Surgeons: A Survey of 263 General Surgeons

BACKGROUND

Near-infrared fluorescence imaging (NIRFI) is an increasingly utilized imaging modality, however its use amongst general surgeons and its barriers to adoption have not yet been characterized.

METHODS

This survey was sent to Canadian Association of General Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons members. Survey development occurred through consensus of NIRFI experienced surgeons.

RESULTS

Survey completion rate for those opening the email was 16.0% (n = 263). Most respondents had used NIRFI (n = 161, 61.2%). Training, higher volumes, and bariatric, thoracic, or foregut subspecialty were associated with use (P < .001).Common reasons for NIRFI included anastomotic assessment (n = 117, 72.7%), cholangiography (n = 106, 65.8%), macroscopic angiography (n = 66, 41.0%), and bowel viability assessment (n = 101, 62.7%). Technical knowledge, training and poor evidence were cited as common barriers to NIRFI adoption.

CONCLUSIONS

NIRFI use is common with high case volume, bariatric, foregut, and thoracic surgery practices associated with adoption. Barriers to use appear to be lack of awareness, low confidence in current evidence, and inadequate training. High quality randomized studies evaluating NIRFI are needed to improve confidence in current evidence; if deemed beneficial, training will be imperative for NIRFI adoption.

The RAIS Device for Global Surgery: Using a Participatory Design Approach to Navigate the Translational Pathway to Clinical Use

Background: Over 5 billion people worldwide have no access to surgery worldwide, typically in low-resource settings, despite it being a primary life-saving treatment. Gas Insufflation-Less Laparoscopic Surgery (GILLS) can address this inequity, by improving current GILLS instrumentation to modern surgical standards. Objective: to develop and translate a new Retractor for Abdominal Insufflation-less Surgery (RAIS) into clinical use and thus provide a context-appropriate system to advance GILLS surgery. Methods: A collaborative multidisciplinary team from the UK and India was formed, embedding local clinical stakeholders and an industry partner in defining user and contextual needs. System development was based on a phased roadmap for ‘surgical device design in low resource settings’ and embedded participatory and frugal design principles in an iterative process supported by traditional medical device design methodologies. Each phase of development was evaluated by the stakeholder team through interactive workshops using cadaveric surgical simulations. A Commercialisation phase undertook Design to Manufacture and regulatory approval activities. Clinical validation was then conducted with rural surgeons performing GILLS procedures using the RAIS system. Semi-structured questionnaires and interviews were used to evaluate device performance. Results: A set of user needs and contextual requirements were defined and formalised. System development occurred across five iterations. Stakeholder participation was instrumental in converging on a design which met user requirements. A commercial RAIS system was then produced by an industry partner under Indian regulatory approval. This was successfully used in clinical validation to conduct 12 surgical procedures at two locations in rural India. Surgical feedback showed that the RAIS system provided a valuable and usable surgical instrument which was appropriate for use in low-resource contexts. Conclusions: Using a context-specific development approach with close engagement of stakeholders was crucial to develop the RAIS system for low-resource regions. The outcome is translation from global health need into a fully realized commercial instrument which can be used by surgeons in low-resource regions across India.

Clinical effectiveness of gasless laparoscopic surgery for abdominal conditions: systematic review and meta-analysis

BACKGROUND

In high-income countries, laparoscopic surgery is the preferred approach for many abdominal conditions. Conventional laparoscopy is a complex intervention that is challenging to adopt and implement in low resource settings. This systematic review and meta-analysis evaluate the clinical effectiveness of gasless laparoscopy compared to conventional laparoscopy with CO2 pneumoperitoneum and open surgery for general surgery and gynaecological procedures.

METHODS

A search of the MEDLINE, EMBASE, Global Health, AJOL databases and Cochrane Library was performed from inception to January 2021. All randomised (RCTs) and comparative cohort (non-RCTs) studies comparing gasless laparoscopy with open surgery or conventional laparoscopy were included. The primary outcomes were mortality, conversion rates and intraoperative complications.

SECONDARY OUTCOMES

operative times and length of stay. The inverse variance random-effects model was used to synthesise data.

RESULTS

63 studies were included: 41 RCTs and 22 non-RCTs (3,620 patients). No procedure-related deaths were reported in the studies. For gasless vs conventional laparoscopy there was no difference in intraoperative complications for general RR 1.04 [CI 0.45-2.40] or gynaecological surgery RR 0.66 [0.14-3.13]. In the gasless laparoscopy group, the conversion rates for gynaecological surgery were high RR 11.72 [CI 2.26-60.87] when compared to conventional laparoscopy. For gasless vs open surgery, the operative times were longer for gasless surgery in general surgery RCT group MD (mean difference) 10 [CI 0.64, 19.36], but significantly shorter in the gynaecology RCT group MD - 18.74 [CI - 29.23, - 8.26]. For gasless laparoscopy vs open surgery non-RCT, the length of stay was shorter for gasless laparoscopy in general surgery MD - 3.94 [CI - 5.93, - 1.95] and gynaecology MD - 1.75 [CI - 2.64, - 0.86]. Overall GRADE assessment for RCTs and Non-RCTs was very low.

CONCLUSION

Gasless laparoscopy has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings.

Laparoscopic cholecystectomy: review of 1430 cases in Cure International Hospital, Kabul, Afghanistan

Background

Laparoscopic cholecystectomy (LC) is the gold standard for the treatment of cholelithiasis in most countries of the world. The objective of this study was to evaluate the outcomes of LC in the surgery department of Cure International Hospital, Kabul, Afghanistan.

Methods

A retrospective study was conducted on 1430 LC cases performed by the general surgery department of Cure International Hospital. Data was collected from patient files and the operation theatre registry for whom LC was performed during January 2008 through December, 2019.

Results

Mean age was 45.77 ± 13.45 years (14–90 years), with male/female ratio of 1:4.7. One third (33%) had comorbidities. Most of patients (~ 97%) were classified as ASA grade I and II. Of all patients, 26.8% of males and 13.2% of females had gallbladder inflammation (OR = 2.203, 95% CI 1.56–2.61, P = 0.000). Overall mean duration of anesthesia was 75 ± 25.6 min. The conversion rate to OC was 4.6% (N = 66), most commonly dense adhesions at Callot’s triangle (3.8%). The intraoperative complication rate was 17.5% (N = 249), where bile/stone spillage was the most common indication (N = 235, 16.4%). Immediate postoperative complication rate was 2.4% (N = 35). Average length of stay (ALOS) after LC was 2.23 ± 1.43 days (1–19 days).

Conclusion

This study shows that elective LC can be performed safely in Afghanistan with comparable outcomes in terms of complications, conversion rates, and ALOS to other countries of the region and the world. Proper case selection and careful preoperative evaluation and management can decrease further conversion, intra- and postoperative complications.

Recent advances in benign gynecological laparoscopic surgery

Minimally invasive surgery continues to transform the field of gynecological surgery and is now the standard of care for the surgical treatment of many diseases in gynecology. Owing to minimally invasive surgery's clear advantages, new advances in technology are being employed rapidly and enabling even the most complicated procedures to be performed less invasively. We examine recent literature on minimally invasive surgical innovations, advances, and common practices in benign gynecology that, from our point of view, made an impact on the way laparoscopic surgery is performed and managed in the last decade.

Assessment of laparoscopic instrument reprocessing in rural India: a mixed methods study

Background

Laparoscopy is a minimally-invasive surgical procedure that uses long slender instruments that require much smaller incisions than conventional surgery. This leads to faster recovery times, fewer post-surgical wound infections and shorter hospital stays. For these reasons, laparoscopy could be particularly advantageous to patients in low to middle income countries (LMICs). Unfortunately, sterile processing departments in LMIC hospitals are faced with limited access to equipment and trained staff which poses an obstacle to safe surgical care. The reprocessing of laparoscopic devices requires specialised equipment and training. Therefore, when LMIC hospitals invest in laparoscopy, an update of the standard operating procedure in sterile processing is required. Currently, it is unclear whether LMIC hospitals, that already perform laparoscopy, have managed to introduce updated reprocessing methods that minimally invasive equipment requires. The aim of this study was to identify the laparoscopic sterile reprocessing procedures in rural India and to test the effectiveness of the sterilisation equipment.

Methods

We assessed laparoscopic instrument sterilisation capacity in four rural hospitals in different states in India using a mixed-methods approach. As the main form of data collection, we developed a standardised observational checklist based on reprocessing guidelines from several sources. Steam autoclave performance was measured by monitoring the autoclave cycles in two hospitals. Finally, the findings from the checklist data was supported by an interview survey with surgeons and nurses.

Results

The checklist data revealed the reprocessing methods the hospitals used in the reprocessing of laparoscopic instruments. It showed that the standard operating procedures had not been updated since the introduction of laparoscopy and the same reprocessing methods for regular surgical instruments were still applied. The interviews confirmed that staff had not received additional training and that they were unaware of the hazardous effects of reprocessing detergents and disinfectants.

Conclusion

As laparoscopy is becoming more prevalent in LMICs, updated policy is needed to incorporate minimally invasive instrument reprocessing in medical practitioner and staff training programmes. While reprocessing standards improve, it is essential to develop instruments and reprocessing equipment that is more suitable for resource-constrained rural surgical environments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00976-x.

KeyLoop: Mechanical Retraction of the Abdominal Wall for Gasless Laparoscopy

Background. Despite favorable outcomes of laparoscopic surgery in high-income countries, its implementation in low- and middle-income countries (LMICs) is challenging given a shortage of consumable supplies, high cost, and risk of power outages. To overcome these barriers, we designed a mechanical retractor that provides vertical tension on the anterior abdominal wall. Methods. The retractor design is anatomically and mathematically optimized to provide exposure similar to traditional gas-based insufflation methods. Anatomical data from computed tomography scans were used to define retractor size. The retractor is constructed of biocompatible stainless steel rods and paired with a table-mounted lifting system to provide 5 degrees of freedom. Structural integrity was assessed through finite element analysis (FEA) and load testing. Functional testing was performed in a laparotomy model. Results. A user guide based on patient height and weight was created to customize retractor size, and 4 retractor sizes were constructed. FEA data using a 13.6 kg mass (15 mm Hg pneumoperitoneum) show a maximum of 30 mm displacement with no permanent deformation. Physical load testing with applied weight from 0 to 13.6 kg shows a maximum of 60 mm displacement, again without permanent deformation. Retraction achieved a 57% larger field of view compared to an unretracted state in a laparotomy model. Conclusions. The KeyLoop retractor maintains structural integrity, is easily sterilized, and can be readily manufactured, making it a viable alternative to traditional insufflation methods. For surgeons and patients in LMICs, the KeyLoop provides a means to increase access to laparoscopic surgery.

Cost-effectiveness analysis of nonoperative management versus open and laparoscopic surgery for uncomplicated acute appendicitis in Colombia

BACKGROUND

Traditionally, uncomplicated acute appendicitis (AA) has been treated with appendectomy. However, the surgical alternatives might carry out significant complications, impaired quality of life, and higher costs than nonoperative treatment. Consequently, it is necessary to evaluate the different therapeutic alternatives' cost-effectiveness in patients diagnosed with uncomplicated appendicitis.

METHODS

We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer´s perspective at the secondary and tertiary health care level. The time horizon was 5 years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed.

METHODS

We performed a model-based cost-effectiveness analysis comparing nonoperative management (NOM) with open appendectomy (OA) and laparoscopic appendectomy (LA) in patients otherwise healthy adults aged 18-60 years with a diagnosis of uncomplicated AA from the payer's perspective at the secondary and tertiary health care level. The time horizon was five years. A discount rate of 5% was applied to both costs and outcomes. The health outcomes were quality-adjusted life years (QALYs). Costs were identified, quantified, and valorized from a payer perspective; therefore, only direct health costs were included. An incremental analysis was estimated to determine the incremental cost-effectiveness ratio (ICER). In addition, the net monetary benefit (NMB) was calculated for each alternative using a willingness to pay lower than one gross domestic product. A deterministic and probabilistic sensitivity analysis was performed.

RESULTS

LA presents a lower cost ($363 ± 35) than OA ($384 ± 41) and NOM ($392 ± 44). NOM exhibited higher QALYs (3.3332 ± 0.0276) in contrast with LA (3.3310 ± 0.057) and OA (3.3261 ± 0.0707). LA dominated the OA. The ICER between LA and NOM was $24,000/QALY. LA has a 52% probability of generating the highest NMB versus its counterparts, followed by NOM (30%) and OA (18%). There is a probability of 0.69 that laparoscopy generates more significant benefit than medical management. The mean value of that incremental NMB would be $93.7 per patient.

CONCLUSIONS

LA is a cost-effectiveness alternative in the management of patients with uncomplicated AA. Besides, LA has a high probability of producing more significant monetary benefits than NOM and OA from the payer's perspective in the Colombian health system.

Barriers to training in laparoscopic surgery in low- and middle-income countries: A systematic review

Laparoscopic surgery has the potential to improve care in resource-deprived low- and-middle-income countries (LMICs). This study aims to analyse the barriers to training in laparoscopic surgery in LMICs. Medline, Embase, Global Health and Web of Science were searched using ‘LMIC’, ‘Laparoscopy’ and ‘Training’. Two researchers screened results with mutual agreement. Included papers were in English, focused on abdominal laparoscopy and training in LMICs. PRISMA guidelines were followed; 2992 records were screened, and 86 full-text articles reviewed to give 26 key papers. Thematic grouping identified seven key barriers: funding; availability and maintenance of equipment; local access to experienced laparoscopic trainers; stakeholder dynamics; lack of knowledge on effective training curricula; surgical departmental structure and practical opportunities for trainees. In low-resource settings, technological advances may offer low-cost solutions in the successful implementation of laparoscopic training and improve access to surgical care.

What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice

OBJECTIVE

The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations.

BACKGROUND

In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework.

METHODS

A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model.

RESULTS

Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement).

CONCLUSIONS

Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.

A decision analysis comparing three strategies for peritoneal lavage cytology testing in staging of gastric cancer in China

BACKGROUND

Positive peritoneal cytology (PCY) indicates metastasis (M1) in gastric cancer (GC) patients; both the American and Chinese guidelines recommend laparoscopic peritoneal lavage (LPL) for cytology. However, relatively high costs impair the widespread use of LPL in some resource-limited regions in China, and the cost-effectiveness of PCY testing remains unclear. Therefore, we performed a decision analysis to evaluate the cost-effectiveness of PCY testing by comparing the guideline-recommended intraoperative LPL, a newly proposed preoperative percutaneous peritoneal lavage (PPL), and a third strategy of exploratory laparotomy with no cytology testing (ELNC) among GC patients.

METHODS

We developed a decision-analytic Markov model of the aforementioned three strategies for a hypothetical cohort of GC patients with curative intent after initial imaging, from the perspective of Chinese society. We estimated costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) as primary outcomes; we also conducted one-way and probabilistic sensitivity analyses to investigate the model's robustness.

RESULTS

We found that ELNC was dominated (i.e., more expensive and less effective) by PPL and LPL. LPL was the most cost-effective method with an ICER of US$17,200/QALY compared to PPL, which was below the Chinese willingness-to-pay (WTP) threshold of US$29,313 per QALY gained. In sensitivity analyses, PPL was more likely to be cost-effective with a lower WTP threshold.

CONCLUSIONS

Cytology testing through either LPL or PPL was less expensive and more effective than ELNC among GC patients. Moreover, LPL was the most cost-effective modality at the current WTP threshold, while PPL could potentially be cost-effective in lower-income areas.

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.

Barriers and facilitators to implementing evidence-based health innovations in low- and middle-income countries: A systematic literature review

The unsuccessful implementation of health innovations occurs frequently, leading to missed opportunities where improvements could have been made on various aspects of a health system. The purpose of this study is to identify, assess and synthesise the facilitators and barriers to sustainably implementing evidence-based health innovations in a low- and middle-income country (LMIC) context. To identify the LMIC specific facilitators and barriers, a systematic literature review was conducted. 79 studies were analysed, and the implementation barriers and facilitators identified in each study were extracted. The extracted barriers and facilitators were categorised and synthesized into one of seven concepts: context, innovation, relations and networks, institutions, knowledge, actors or resources. There were no substantial variations between the frequency that each concept was identified as a facilitator or barrier to implementation. However, resources, which includes time, human, financial and physical resources, was the most frequently mentioned concept; emphasising the need to focus on the resource situation in LMICs. This study contributes to the growing literature that aims to inform health system planners and evaluators in LMICs on effectively and sustainably implementing evidence-based health innovations.

North American pediatric surgery fellows' preparedness for humanitarian surgery

INTRODUCTION

The overwhelming burden of pediatric surgical need in humanitarian settings has prompted mutual interest between humanitarian organizations and pediatric surgeons. To assess adequate fit, we correlated pediatric surgery fellowship case mix and load with acute pediatric surgical relief efforts in conflict and disaster zones.

METHODS

We reviewed pediatric (age < 18) cases logged by the Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) from a previously validated and published database spanning 2008-2014 and cases performed by American College of Graduate Medical Education (ACGME) pediatric surgery graduates from 2008 to 2018. Non-operative management for trauma, endoscopic procedures, and basic wound care were excluded as they were not tracked in either dataset. ACGME procedures were classified under 1 of 32 MSF pediatric surgery procedure categories and compared using chi-squared tests.

RESULTS

ACGME fellows performed procedures in 44% of tracked MSF-OCB categories. Major MSF-OCB pediatric cases were comprised of 62% general surgery, 23% orthopedic surgery, 9% obstetrical surgery, 3% plastic/reconstructive surgery, 2% urogynecologic surgery, and 1% specialty surgery. In comparison, fellows' cases were 95% general surgery, 0% orthopedic surgery, 0% obstetrical surgery, 5% urogynecologic surgery, and 1% specialty surgery. Fellows more frequently performed abdominal, thoracic, other general surgical, urology/gynecologic, and specialty procedures, but performed fewer wound and burn procedures (all p < 0.05). Fellows received no experience in Cesarean section or open fracture repair. Fellows performed a greater proportion of surgeries for congenital conditions (p < 0.05).

CONCLUSION

While ACGME pediatric surgical trainees receive significant training in general and urogynecologic surgical techniques, they lack sufficient case load for orthopedic and obstetrical care - a common need among children in humanitarian settings. Trainees and program directors should evaluate the fellow's role and scope in a global surgery rotation or provide advanced preparation to fill these gaps. Upon graduation, pediatric surgeons interested in humanitarian missions should seek out additional orthopedic and obstetrical training, or select missions that do not require such skillsets.

LEVEL OF EVIDENCE

III.

Sustaining a laparoscopic program in resource-limited environments: results and lessons learned over 13 years in Botswana

BACKGROUND

Metrics of sustainability and frank descriptions of the unique challenges, successes, failures, and lessons learned from a longitudinal laparoscopic program in resource-limited environments are lacking. We set out to evaluate the safety and sustainability of the laparoscopic cholecystectomy program at Princess Marina Hospital, the largest tertiary and teaching hospital in Botswana.

METHODS

We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy from January 2013 to December 2018. Technical independence and sustainability factors were measured and discussed.

RESULTS

Two hundred and twenty-six laparoscopic cholecystectomies (LC) and 39 open cholecystectomies (OC) were performed. Four surgeons who trained as part of the inaugural laparoscopic program performed 48.2% of LC. Eleven surgeons who trained elsewhere performed the remainder. Overall, 94.2% of LC were performed without expatriate surgeons. The conversion rate was 25/226 (11.1%). There were 3 bile duct injuries in the LC group (3/226, 1.3%) and none in the OC group. There was one mortality in the OC group (1/39, 2.6%) and none in the LC group. Fostering a trusting relationship among all stakeholder was identified as the major key to success, while the development of a system-based strategy was identified as the most significant ongoing challenge.

CONCLUSION

The laparoscopic cholecystectomy program in Botswana initially established between 2006 and 2012 has moved into its sustainability phase, characterized by increased usage of laparoscopy and greater independent operating by local surgeons, all while maintaining patient safety. Sustaining a laparoscopic program in resource-limited environments has particular challenges which may differ from country to country.

Evaluation of a novel low-cost laparoscopic training model for core laparoscopic skills

The study involves the testing of a novel laparoscopic training model by surgeons of various levels of experience.

BACKGROUND

There has been an increasing requirement for low-cost simulation. Our aim was to evaluate the construct validity of a low-cost model for teaching core laparoscopic skills.

METHODS

The Double-Glove model was made from 2 latex gloves, one placed in the other. The inner glove was filled with water and 3 ovals were drawn on the outer glove. Participants were required to dissect the middle oval out without perforating the inner glove or leaving the line border of the middle oval. The task was assessed using a previously validated scoring system (minimum -120; maximum 80).

RESULTS

Ninety-five participants completed the task: 40 novices, 45 intermediates, and 10 experts. The model revealed statistical significance between the three groups. Experts scored higher than novices (58/80 vs 11.7/80; p < 0.0001) and intermediates (58/80 vs 29.1/80; p = 0.0004), and intermediates scored higher than novices (29.1/80 vs 11.7/80; p = 0.014). Novices took more time to complete the task compared to intermediates (10 min vs 7.87 min; p < 0.0001) and experts (10 min vs 6.98 min; p < 0.0001). No correlation between time taken and score obtained was seen (r = -0.06, r = 0.01, r = -0.2 for novice, intermediate, and expert groups).

CONCLUSION

By differentiating between groups of variable experience, the model demonstrated construct validity. It offers an inexpensive model that can be utilized in low-cost laparoscopic simulation.

TYPE OF STUDY

Study of a diagnostic test.

LEVEL OF EVIDENCE

II.

Establishing a Sustainable Training Program for Laparoscopy in Resource-Limited Settings: Experience in Ghana

Background

Healthcare equipment funded by international partners is often not properly utilized in many developing countries due to low levels of awareness and a lack of expertise. A long-term on-site training program for laparoscopic surgery was established at a regional hospital in Ghana upon request of the Ghana Health Service and local surgeons.

Objective

The authors report the initial 32-month experience of implementing laparoscopic surgery focusing on the trainees' response, technical independence, and factors associated with the successful implementation of a "new" surgical practice.

Methods

Curricular structure and feedback results of the trainings for doctors and nurses, and characteristics of laparoscopic procedures performed at the Greater Accra Regional Hospital between January 2017 and September 2019 were retrospectively reviewed.

Findings

Comprehensive training including two weeks of simulation workshops followed by animal labs were regularly provided for the doctors. Among the 97 trainees, 27.9% had prior exposure in laparoscopic surgery, 95% were satisfied with the program. Eleven nurses attained professional competency over 15 training sessions where none had prior exposure to laparoscopic surgery. Since the first laparoscopic cholecystectomy in February 2017, 82 laparoscopic procedures were performed. The scope of the surgery was expanded from general surgery (n = 46) to gynecology (n = 33), pediatric surgery (n = 2), and urology (n = 1). The volume of local doctors as primary operators increased from 0% (0/17, February to December 2017) to 41.9% (13/31, January to October 2018) and 79.4% (27/34, November 2018 to September 2019), with 72.5% of the cases being assisted by the expatriate surgeon. There were no open conversions, technical complications, or mortalities. Local doctors independently commenced endoscopic surgical procedures including cystoscopies, hysteroscopies, endoscopic neurosurgeries and arthroscopies.

Conclusion

Sensitization and motivation of the surgical workforce through long-term continuous on-site training resulted in the successful implementation of laparoscopic surgery with a high level of technical independence.

Experience with a novel laparoscopic gynecologic curriculum in Haiti: lessons in implementation

BACKGROUND

An estimated one-third of the world's burden of disease requires surgical treatment. In many high-income nations, a large proportion of critical surgical procedures are performed laparoscopically due to a number of advantages the technique offers. There is forward progress in the global surgery field to increase access to laparoscopic techniques in low and middle-income settings (LMIC), with potential benefits to both patients and surgeons.

METHODS

A week long laparoscopic surgery curriculum for surgeons and hospital staff was designed and implemented in a low-resource setting. An iterative design was used to adapt the curriculum on the ground.

RESULTS

The local laparoscopic team was able to independently perform two laparoscopic procedures since the course was administered.

CONCLUSIONS

Implementing laparoscopic surgery programs may be feasible in many LMIC settings. Access to this care may benefit patients. Lessons learned for the global laparoscopist are described.

The application of simulation-based medical education in low- and middle-income countries; the Myanmar experience

Simulation-based medical education (SBME) has become a routine part of practice in many disciplines including paediatric surgery. There is an evolving evidence base of its benefits both for surgical education, training and also patient education in high-income countries (HICs) but not in the low- and middle-income country (LMIC) setting. The advantages are hypothesised to be the same in both of these settings, although our experience is that they may be increased. In this article we describe the various modalities of SBME that maybe utilised in a LMIC in South East Asia. The various tips for the establishment of a successful simulation-based paediatric surgical programme and the potential pitfall that should be avoided are discussed.

Pharmacists ascribing value of technician certification using an organizational behavior framework

PURPOSE

To gather rich details about the value of technician certification from diverse groups of pharmacists of various practice settings and levels of experience.

METHODS

Focus groups of pharmacists were conducted using a semistructured interview guide in 4 states (California, Idaho, Tennessee, and Washington) varying in pharmacy technician scope of practice, regulation, and education and/or training environment. Participant pharmacists came from health-system, clinic, and community pharmacy environments. The focus groups took the unique approach of an organizational behavior perspective to contextualize technician readiness for practice change and employer fit. The sessions were audio-recorded and transcribed verbatim. Rapid-based qualitative analysis was used to code the data, with summary templates completed by 2 of the researchers for each of the 4 sessions.

RESULTS

There were a total of 33 focus group participants, including 13 male and 20 female pharmacists ranging in age from 27 to 68 years. The 4 major themes yielded by the data were (1) impact of certification, (2) context of certification, (3) organizational culture considerations, and (4) future credentialing. Certification was deemed to have a greater impact on technician maturation, professional socialization, and career commitment than on actual job skills, even while job knowledge was also deemed to be enhanced. In fact, the certification process was also deemed beneficial in that it meshes with on-the-job training. Participants indicated preferences for technician certification examinations to incorporate more content in "soft skills" and also for development of more specialty and/or differentiated certification products.

CONCLUSION

Pharmacists from 4 states saw value in certification but agreed that certification is but one component of readying technicians for future practice. Suggestions for furthering the value of certification were shared.

Minimizing the impact of colorectal surgery in the older patient: The role of minimally invasive surgery in the geriatric population

With an aging population comes a greater incidence of colorectal cancer and a corresponding need for surgical resection in the geriatric population. This heterogeneous group of patients may benefit from multidisciplinary pre-operative evaluation and optimization, prehabilitation, enhanced recovery protocols, and a minimally invasive approach to resection. Concerns regarding the ability of the older patient to tolerate the physiologic demands of pneumoperitoneum have not been validated. Conversely, these vulnerable patients may experience a greater reduction in morbidity than their younger counterparts through the use of minimally invasive techniques.

Exploring employer perceptions of pharmacy technician certification in the community pharmacy setting

BACKGROUND

With the evolving roles of pharmacy technicians in the United States, the profession has attempted to define a national standard. Community pharmacy employers to-date have preferred on-the-job training to formal, accredited training programs or credentialing, however, limited evidence exists on the perceived needs of pharmacy technicians in the United States compared to those of community pharmacy employers.

OBJECTIVES

The aims of this study were to explore: 1) community pharmacy employer perceptions of associated benefits and perceived value of pharmacy technician certification and 2) needs of employers related to pharmacy technician attitudes and knowledge, skills and abilities (KSAs).

METHODS

Using a semi-structured interview guide, researchers interviewed 7 community pharmacy employers within top management teams in a variety of community pharmacy settings. The data were analyzed for themes using the human capital vs. signal theory.

RESULTS

Employers and managers generally saw both attitude and KSAs as vital to success. However, given a choice between experience and attitude, attitude was preferred. There was general agreement that certified technicians offered more value to their organization, however gaps in certified technician KSAs were noted (i.e., lack of day-to-day practical skills, vaccination screening, motivating patients to change behaviors, patient communication and workflow management).

CONCLUSIONS

New emerging directions for certification now exist due to the rapidly shifting pharmacy landscape, which is revolves around new and expanded clinical patient care services. This shifting landscape has exposed gaps, reinforced strengths, and uncovered potential new opportunities and needs related to technician certification.

Laparoscopy Assisted Distal Gastrectomy Versus Open Distal Gastrectomy for Patients with Gastric Cancer in A Middle Resources Country

Background:Laparoscopic surgery with a small laparotomy has several advantages over conventional open surgery, including less invasiveness, less pain, earlier recovery, and better cosmoses. The aim of this study was to compare technical feasibility and early clinical outcomes of laparoscopy-assisted distal gastrectomy in comparison with open distal gastrectomy for gastric cancer in a developing country. Patients and methods :In this retrospective study, patients with distal gastric cancer were divided into two groups (a) patients underwent laparoscopy assisted distal gastrectomy (LADG) (21 patients) and (b) open distal gastrectomy (ODG) (21 patients). For the postoperative pathologic results, the tumor-nodal-metastasis (TNM) stage, grade of tumor differentiation, distal and proximal margins, the number of harvested lymph nodes were evaluated. Staging was done according to the 7th edition of the UICC tumor, node, and metastasis (TNM) classification. D1/D2 lymphadenectomy with curative R0 intention was attempted in all cases. Perioperative mortality and morbidity were assessed. Results:The time to initiate oral intake, and postoperative hospital stay were significantly shorter in the LADG group than in the ODG group (P < 0.001). The operative time in the LADG group was significantly less than that of the ODG group (P = 0.05). Blood loss and blood transfusion frequency were significantly lower (P < 0.0001) in the LADG group in comparison to ODG group. Conclusion:Laparoscopic-assisted distal gastrectomy for distal gastric cancer could be safe and feasible technique alternative to open gastrectomy in a middle income country, with at least similar short term surgical and oncological results. However, laparoscopic gastric surgery is in need to adequate training and technical support especially in D2 lymphadenectomy.