First steps of laparoscopic surgery in Lubumbashi: encountered problems and preliminary results

First steps of laparoscopic surgery in Lubumbashi: encountered problems and preliminary results

 

Willy Arung^1,&, Nathalie Dinganga¹, Emmanuel Ngoie¹, Etienne Odimba¹, Olivier Detry²

 

¹Department of General Surgery, University of Lubumbashi Clinics, University of Lubumbashi, Lubumbashi, Katanga Province, Democratic Republic of Congo, ²Department of Abdominal Surgery and Transplantation, University Hospital of Liège, University of Liège, Liège, Belgium

 

 

^&Corresponding author
Willy Arung, Department of General Surgery, University of Lubumbashi Clinics, University of Lubumbashi, Lubumbashi, BP 1825, Katanga Province, Democratic Republic of Congo

 

 

 

 

For many decades now, laparoscopic surgery has been used for minimal invasive surgical procedures on the abdominal cavity, and its indications have been extended even further. Since 1988, laparoscopic cholecystectomy has become a standard procedure for gallbladder removal [1]. Since 1992, gynaecologic surgical treatment has been carried out laparoscopically, and from then, classical abdominal surgery has increasingly entered into a laparoscopy era [2]. While laparoscopic surgery is now routinely performed in all developed countries, its development has been difficult to initiate in many developing countries, as in the Lubumbashi School of Medicine. This is due to several constraints. The authors hereby acknowledge the contribution of the Lubumbashi Don Bosco Missionary Hospital, (LDBMH) in the establishment of this new approach to abdominal surgery. The missionary hospital has been providing university surgeons with training and practice in laparoscopic surgery, making the necessary equipment and consumables available, as well as providing cooperation from Belgian trainers. The aim of this study was to report on our first ten-month experience of laparoscopic surgery at the LDBMH.

 

 

Study settings and staff training

 

Lubumbashi is the second largest city in the Democratic Republic of Congo (DRC), important not only administratively but also for its infrastructure and population of about three million. With its copper, cobalt, uranium mines and other minerals, Lubumbashi was called the "DRC economic capital" or the "DRC lung". The world economic crisis has dramatically altered this situation but it is still being called the “Copper Capital". The LDBMH is located near the Lubumbashi University administrative building along Kasapa road, which leads to the main campus of Lubumbashi University. It is a multidisciplinary health centre directed by the Don Bosco congregation, which has been active in the DRC for many decades. The institution enjoys support from the congregation but also from the Belgian Government and many non-governmental organisations (NGOs). The LDBMH employs many general medical practitioners and several Lubumbashi medical specialists. Apart from the supervisor and the surgeon who were trained abroad (the first in the visceral and digestive surgery department of CHU Amiens-Nord (France), and the second (W.A.) in the digestive surgery and transplantation department of CHU of Liege, Belgium), the rest of the staff have had two training sessions in laparoscopic surgery in Lubumbashi given by the by European Union NGO: "Doctors Without Holidays". Nursing and paramedical staff also included four nurses: an assistant, a scrub, a runner and a technician nurse, in addition to two anaesthetists. All were trained during two months.

 

Study time frame

 

The study was undertaken from 1 April 2009 to 28 February 2010.

 

Study design, sampling and inclusion criteria

 

The study was a cross-sectional descriptive study with a significant sample size. During the time frame of the study, the laparoscopic procedures were only performed on patients with abdominal surgical conditions who consented to laparoscopy and when the logistical constraints of the procedure were overcome: trained staff, fitness and availability of equipment and consumables.
Independent variables were patients' demographic parameters, appropriate staff, equipment and consumables. Dependent parameters included surgical abdominal diseases, intra-operative circumstances and postoperative short-term outcomes (morbidity and mortality).

 

Data collection, data analysis

 

Pre-established forms were filled in with independent data (age, sex, disease, operating staff) and dependent variables (intra-operative events, postoperative mortality; morbidity, hospital stay and time for discharge). Our data were introduced and analysed using 2007 Excel and 2005 Epi info softwares. The mean (average) and its parameters of distribution were determined for Gaussian distributions; and the median and its parameters of distributions were measured for non-Gaussian distributions; as well as standard deviation.

 

 

Age and sex distribution

 

A total of 75 procedures were performed in the study period (7 cases per week, or 2 cases per working day on average). These 75 laparoscopic surgical procedures accounted for 1.5% of the total activity in abdominal surgery at the LDBMH. Mean patient age was 30.2±2 years. Females were predominant, with a sex ratio of 2F/1M, as shown in Table 1.

 

Causes and performed procedures

 

As it is shown in Table 2 and Figure 1, the most frequent procedure was appendectomy (64%), followed by exploratory laparoscopy (9.3%), adhesiolysis (9.3%), and cholecystectomy (5.3%). These procedures are the commonest general surgical procedures in the DRC environment.

 

Progression of laparoscopic surgery

 

As shown on Figure 2, the laparoscopic surgery procedures increased at the beginning of the study, but decreased at the end of the year 2009, a period where only emergency surgery was performed. There was some increase again around February 2010. Meanwhile there was an improvement in performance shown by a reduction in the average duration of the procedures (Figure 3) following the acquisition of skills and mastering of events. It was also been noted from the low rate of conversion from laparoscopy to laparotomy and the reduction in operation duration as shown in Figure 3 (appendectomy).

 

Origin of patients and costs

 

As shown in Figure 4, private patients were rare. Patients mainly originated from subscribed companies that had financial agreements with the missionary hospital, or from LDBMH staff. The laparoscopic surgery was and is still the surgery for the few people who could pay LDBMH directly or indirectly.

 

Outcomes

 

There was a conversion rate of 4% to laparotomy and there was no mortality in this series. All patients were discharged after a hospital stay relatively shorter than that after laparotomy for the same procedure. For appendectomy, postoperative pain was less severe and lasted for a shorter period than after laparoscopic surgery. The mean hospital stay after laparoscopic appendectomy was three days while this average was six days after open appendectomy.

 

 

The expansion of laparoscopy in developing countries has been sporadic and minimal, despite being widely accepted in developed countries. Many authors have described some barriers to the development of laparoscopy in these countries [1-4]. Ian Choy [4] reported three overarching barriers: the organizational structure for funding laparoscopic procedures, the hierarchical nature of the local surgical culture, and the expertise and skills associated with a change in practice. The first barrier showed how the number of laparoscopic cases was limited by the on-going funding structure, rather than upfront costs, of the laparoscopic program. The description of the second barrier showed the importance of understanding the local surgical culture in attempts to adopt a new technology. The third barrier emphasized the fact that, due to the generalist nature of surgical practice, surgeons might be reluctant to learn and practice more technically complex procedures [4]. Due to logistical constraints, the first steps of laparoscopic surgery use took place in Lubumbashi only in 2008, at the LDBMH, an institution that provides university surgeons with training and practice in this minimal invasive abdominal approach. In fact, in our environment, laparoscopic surgery is still seen as a very costly technique, the surgery for a minority, either very rich citizen or privileged patients from the LDBMH staff and companies subscribed to the hospital. Indeed, it requires specific costly equipment and consumables, as well as high skilled staff. This situation is similar in most of Africa countries: the number of surgeons per capita in many African countries is low [5]. The brain drain and migration of health care providers - whether to the private sector, to NGOs, or overseas - places a strain on the ability of a country to provide essential surgical services [6]. Adequate facilities are crucial to the provision of basic surgical care. Even the best-trained and motivated surgical team cannot function without appropriate infrastructure. In Malawi, a study of district hospital theatres showed that most did not have dedicated theatre staff, and half did not have adequate instruments to perform common operations. More than half did not have basic skin and soft tissue sutures available on the day of inspection [7].

 

In the international literature [3] as in Lubumbashi [8], appendectomy is the most frequent procedure in abdominal surgery, but cholecystectomy is the most frequently performed laparoscopic surgery [1]. However, the advantage of laparoscopic appendectomy over the classical open appendectomy is still controversial despite several randomized studies. The duration of laparoscopic appendectomy is longer than of open appendectomy. Surgical site infection is more frequent after open appendectomy but there is more deep sepsis after laparoscopy than after open appendectomy mainly in more complicated appendicitis. Postoperative pain is less severe and activity resumption is faster after laparoscopic appendectomy. Moreover in the latter, the hospital stay is shorter. It has been reported that laparoscopic appendectomy avoids unnecessary appendectomy especially in sexually active women and that it has more secondary advantages than open appendectomy in young women, in patients with professional activity and in the obese. However other authors [9] have reported negative opinions and mentioned that the clinical advantages of laparoscopic appendectomy are not substantial and that the risk of deep abscesses has to be taken in account, especially in perforated or gangrenous appendicitis. However laparoscopic advantages on postoperative comfort, wound healing, early discharge from hospital, fast duty resumption, lesser intra-abdominal adhesions that may cause intestinal obstruction, chronic pain and infertility [10-12] pledge for its wider use also in our environment. For example, in USA [13], it has been illustrated that post-laparotomy adhesions had been drastically increasing operative time table lists as about 3,000 adhesiolysis procedures had to be carried out annually, costing about $1.3 billion [14].

 

 

Laparoscopic surgery had its first steps of use at the LDBMH. A substantial number of patients with various intra-abdominal conditions have undergone this minimal invasive procedure with very fair outcomes: minimal wound infection, minimal postoperative pain, short hospital stay and without postoperative early manifestations of intra-abdominal adhesions. Two main problems were encountered. Only LDBMH staff, employees from subscribed companies and a few private patients could be operated on because of the cost of the equipment and consumables. The second was the duration of the procedure related to staff skills and adaptability and this led to erratic recruitment with a low rate of the procedure with regard to all hospital abdominal surgical activities. Over time, and as the staff gained more experience, the duration of procedures was gradually reduced.
Recommendations: laparoscopic surgery has led to better outcomes at the Lubumbashi Don Bosco Missionary Hospital in all postoperative aspects. It is still restricted to a few citizens due to its logistical and cost requirements. Due to encouraging results we recommend the following: the continuous medical education on this surgical speciality, and the setting-up of well-equipped and functional laparoscopic surgery units at our Lubumbashi university hospitals and in the main surgical departments of the DRC.

 

 

Authors declare no competing interests.

 

 

All authors participated in the study and have read and approved the final manuscript.

 

 

This experience was part of a cooperation project entitled “Appui à l’organisation de l’école de chirurgie laparoscopique des cliniques universitaires de Kinshasa et à la formation des praticiens des hôpitaux de la RD Congo aux procédures laparoscopiques » financed by Wallonie Bruxelles International (WBI). This project links the University of Liege, Belgium, the University of Kinshasa, DR Congo (DRC), and the University of Lubumbashi (DRC) and aims to the development of laparoscopic and abdominal surgery in the DRC. The authors thank the CHU Liege, Belgium, the University of Liege, Belgium, and the CHR and the CHC Liege hospitals for their support and for the donation of varied equipments. Pr Willy Arung was supported by the CTB (Cooperation Technique Belge, the Belgian Development Agency) that financed his PhD thesis.

 

 

Table 1: laparoscopic surgery at ldnmh, patients’ sex distribution

Table 2: procedures, indications/findings and frequency of laparoscopic surgery at ldbmh

Figure 1: laparoscopy surgery at ldbmh

Figure 2: laparoscopic surgery at ldbmh progress overview

Figure 3: laparoscopic surgery timing (minutes) overview on appendicectomy

Figure 4: origin of patients

 

 

1. Berrebi W. Hépatologie Gastro-entérologie. Paris, Estem. 2006; 4th edition. PubMed | Google Scholar


2. Dargent D. [Laparoscopic surgery in gynecologic oncology]. J Gynecol Obstet Biol Reprod (Paris). 2000;29(3):282-4. PubMed | Google Scholar


3. Fagniez P, Housin D. Pathologie chirurgicale. Chirurgie digestive et thoracique. Paris, Masson, 1991. PubMed | Google Scholar


4. Choy I, Kitto S, Adu-Aryee N, Okrainec A. Barriers to the uptake of laparoscopic surgery in a lower-middle-income country. Surg Endosc. 2013;27(11):4009-15. PubMed | Google Scholar


5. COSECSA. College of Surgeons of East, Central and Southern Africa. http://www.cosecsa.org. PubMed | Google Scholar


6. Eastwood J, Conroy R, Naicker S and al. Loss of health professionals from sub-Saharan Africa: the pivotal role of the UK. Lancet. 2005;365:1893-900. PubMed | Google Scholar


7. Tindall A, Lavy C, Steinlechner C and al. Surgical facilities available at district hospitals in Malawi. Malawi Med J. 2007;19:28-9. PubMed | Google Scholar


8. Arung W, Tshilombo F, Mukeng C, Odimba K. Intestinal obstructions complicating peritoneal adhesions at the Lubumbashi University Clinics. Acta Chir Belg. 2012;112(3):195-9. PubMed | Google Scholar


9. Pirro N, Berdah SV. Appendicitis: yes or no to laparoscopic approach? J Chir. 2006 May-Jun;143(3):155-. PubMed | Google Scholar


10. Guo H, Leung JC, Cheung JS, Chan LY, Wu EX, Lai KN. Non-viral Smad7 gene delivery and attenuation of postoperative peritoneal adhesion in an experimental model. Br J Surg. 2009 Nov;96(11):1323-35. PubMed | Google Scholar


11. Cohen PA, Gower AC, Stucchi AF, Leeman SE, Becker JM, Reed KL. A neurokinin-1 receptor antagonist that reduces intraabdominal adhesion formation increases peritoneal matrix metalloproteinase activity. Wound Repair Regen. 2007;15(6):800-8. PubMed | Google Scholar


12. Arung W, Drion P, Cheramy Jp, Honore P, Meurisse M, Defraigne Jo, Detry O. Intraperitoneal adhesions after open and laparoscopic abdominal procedure: an experimental study in the rat. J Laparoendosc Adv Surg Tech. 2012 ; 22 (7) : 651-7. PubMed | Google Scholar


13. Miller G, Boman J, Shrier I, Gordon PH. Natural history of patients with adhesive small bowel obstruction. Br J Surg. 2000 Sep;87(9):1240-7. PubMed | Google Scholar


14. Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol 2011; 17: 4545-53. Google Scholar