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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 10  |  Page : 1368-1374

Development and practice of laparoscopic surgery in a Nigerian tertiary hospital


Department of Surgery, College of Medicine University of Lagos/ Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria

Date of Submission14-Mar-2020
Date of Acceptance30-May-2020
Date of Web Publication12-Oct-2020

Correspondence Address:
Dr. O S Balogun
Department of Surgery, College of Medicine University of Lagos/Lagos University Teaching Hospital, Idi-Araba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_125_20

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   Abstract 


Background: For the benefits of less postoperative pain, early recovery and discharge, and better cosmesis, laparoscopic surgery is rapidly gaining acceptance amongst surgeons as a better alternative to traditional open procedures. In January 2015, bookings for laparoscopic surgery became a more regular feature on our operation list. Aims: We reported the indications, management outcome, and challenges in patients who had laparoscopic surgery in our institution. This is to document the trends in our surgical practice. Methodology: This is a descriptive study of 137 patients who had laparoscopic surgery for general surgical indications in our institution over a period of 5 years. Patients data as collected from the records department were evaluated for demographic characteristics, medical comorbidities, type of procedures done, and perioperative outcome. Data analysis was performed using Statistical Package for Social Sciences (SPSS). Results: A total of 137 Patients had laparoscopic general surgery between January 2015 and December 2019. There were 48 males and 89 females with a male-to-female ratio of 1:1.9. The mean age of the patients was 38.8 ± 3.4 years (range 16–87 years). Laparoscopic cholecystectomy (35%) and laparoscopic appendicectomy (29.9%) were the most common procedures performed. Five (3.7%) cases were converted to open surgery. Superficial surgical site infection (5.8%) following laparoscopic appendicectomy was the most common postoperative complication. There was no 30-day postoperative mortality. Conclusion: Laparoscopic surgery is safe and can be applied to wide variety of general surgical conditions in developing countries. Minimal postoperative morbidity of laparoscopy is a major benefit to the patients.

Keywords: Advanced, basic, laparoscopy, laparotomy , Nigeria, practice


How to cite this article:
Balogun O S, Osinowo A O, Olajide T O, Lawal A O, Adesanya A A, Atoyebi O A, Bode C O. Development and practice of laparoscopic surgery in a Nigerian tertiary hospital. Niger J Clin Pract 2020;23:1368-74

How to cite this URL:
Balogun O S, Osinowo A O, Olajide T O, Lawal A O, Adesanya A A, Atoyebi O A, Bode C O. Development and practice of laparoscopic surgery in a Nigerian tertiary hospital. Niger J Clin Pract [serial online] 2020 [cited 2022 Dec 10];23:1368-74. Available from: https://www.njcponline.com/text.asp?2020/23/10/1368/297915




   Introduction Top


Over the past few decades, laparoscopic surgery has gained very fast momentum. Indications for laparoscopy are rapidly evolving with diagnostic and therapeutic applications in wide varieties of surgical conditions.[1],[2],[3] A great leap in the use of laparoscopy has occurred since Eric Muhe reported the first case of laparoscopic cholecystectomy.[4] The drive to fast adoption of laparoscopy by surgeons stemmed from its well documented benefits to the patients. These include: Reduced postoperative pain, early recovery, early ambulation, and better.[5] On an economic scale, early discharge from the hospital reduces the loss of man-hour, which translates to huge economic gain to the patients.[6]

In developed countries, laparoscopy is a well-established procedure across most surgical specialities, but in many low and middle-income countries (LMIC), laparoscopic services are not widely available. Poor healthcare financing, infrastructural deficits, lack of training opportunities, hierarchical nature of local surgical culture, and reluctance for a change are some of the factors hindering the practice of laparoscopic surgery in many LMIC.[7],[8]

In recent times, sporadic reports emanating from some government-owned establishments in the country have affirmed the feasibility of sustainable laparoscopic surgical practice in a developing country like Nigeria.[9],[10] Local adaptations to the equipment set-up and laparoscopic instrumentation in some centers practicing laparoscopy in the country have helped to reduce operative cost and have also encouraged the practice in Nigeria.[9],[10]

After some preceding years of sporadic workshops, bookings for laparoscopic surgery became a more regular occurrence on our operation list. This paper provided an audit of the indications and outcome of laparoscopic procedures done at our institution in the last 5 years. We also discussed some challenges and constraints as we introduced laparoscopic surgery into our surgical armamentarium.


   Methodology Top


We gained our initial impetus for starting laparoscopic surgery from a series of short-term training workshops held in our institution. These training workshops were facilitated by some Nigerians practicing as surgeons abroad and local experts in the country. Our learning curve was reduced by a basic laparoscopic simulation training program developed by the author. With modifications, basic laparoscopic skills were practiced on trainer boxes on a periodic basis. We also had some animal laboratory sessions to practice procedural steps of laparoscopic cholecystectomy on donated Karl Storz laparoscopic towers. Special training sessions were held for enthusiastic nurses on perioperative handling and sterilization of laparoscopic hand instruments.

This paper provides a review of data of 137 consecutive patients who had laparoscopic surgery at our institution between January 2015 and December 2019. Consent for surgery and the possibility of conversion to open surgery in difficult intraoperative situations were taken from the patients. Approval for this study was obtained from the Ethical Review Committee of our institution.

Relevant data on case management and followup were retrieved from the medical records department of the hospital. We included adult patients 16 years and above who had laparoscopic surgery for general surgical procedures during the period under review.

Information on demographic characteristics of the patients, indications for laparoscopic surgery, laparoscopic procedure performed, and postoperative complications were retrieved for analysis. Laparoscopic procedures were classified into basic and advanced according to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) model.[11] Basic laparoscopy comprised laparoscopic cholecystectomy, appendicectomy, and diagnostic laparoscopy. All other laparoscopic procedures were classified as advanced.[11]1 Our primary outcome measure was the success rate of laparoscopic surgery and secondary outcome measures were postoperative morbidity and 30-day postoperative mortality.

Data analysis was carried out using the Statistical Package for Social Sciences (SPSS) software. Results of data analysis were expressed in proportions for categorical variables and mean ± standard deviation for quantitative variables.


   Results Top


A total of 137 patients had laparoscopic surgery in general surgery for various indications over a period of 5 years. Of these, there were 48 males and 89 females giving a male-to-female ratio of 1 to 1.9. The age range of patients was 16–87 years with a mean of 38.8 ± 3.4 years.

Thirty-five (25.5%) patients were between 31 and 40 years and this constituted the majority of the patients [Table 1]. Essential hypertension (5.8%) and sickle cell anemia (4.4%) were the most common comorbidities in the study. Previous cesarean (3.6%) section and appendicectomy (3.6%) were the most common previous abdominal surgeries in the patients.
Table 1: Age distribution, comorbid medical conditions, and previous abdominal surgical history of the patients (n=137)

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Laparoscopic surgery was completed in 132 (96.4%) out of 137 patients. Leading indications for laparoscopic surgery were cholecystitis in 48 (35.5%) patients and acute appendicitis in 41 (29.9%) patients [Table 2]. One hundred and eight basic laparoscopic procedures comprising 47 cholecystectomies, 40 appendicectomies, and 21 diagnostic laparoscopies constituted 78.7% of all cases performed [Table 3]. Twenty-four (17.5%) patients had advanced laparoscopic procedures. Of these, laparoscopic adhesiolysis was performed in 8 (5.8%) patients and was the most common advanced laparoscopic surgery done. Five (3.7%) cases were converted to open surgery due to intraoperative adverse events, which were hemorrhage, dense adhesions, cardiac arrhythmias, appendix mass, and bladder injury [Table 3].
Table 2: Indications for laparoscopic surgery (n=137)

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Table 3: Laparoscopic procedures completed and conversions to open procedure (n=137)

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Overall, superficial surgical site infection was the most common postoperative complications, in 8 (5.8%) and 4 (3%) patients after laparoscopic appendicectomy and cholecystectomy, respectively [Table 4]. There were postoperative complications in 2 patients that required laparotomy. The first patient had a missed duodenal injury diagnosed 24 h after laparoscopic cholecystectomy. The second patient presented with a pelvic abscess one week after laparoscopic appendicitis [Table 4]. The overall range of hospital stay of the patients was between 1 to 15 days with a mean of 3.4 ± 2.1 days.
Table 4: Procedure-related postoperative complications and management (n=137)

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   Discussion Top


Several studies have confirmed the feasibility, safety, and advantages of laparoscopic surgery in low and middle-income countries (LMIC). Laparoscopy once regarded as an esoteric high-tech procedure of little relevance to present day Nigeria.[12] has been successfully established in some private and government-owned institutions in the country over the last decade.[13],[14],[15]

The gender distribution of patients in this study revealed a preponderance of female patients. A similar finding has been reported by other laparoscopic surgeons in Nigeria.[13],[14],[16] Interestingly, more than half of the patients in this review were young (<40 years). A quarter of the study population was in the 31–40-year age group and they constituted the majority of the age group in the study. This may explain the relatively low comorbid medical conditions in our study. Essential hypertension, the most common medical comorbidity was found in 8 (5.8%) patients.

Gallbladder disease accounted for the majority (35%) of indications for laparoscopy. Consequently, laparoscopy for calculous cholecystitis (34.3%) was the greatest number of completed procedures in this study. Next in frequency was laparoscopy for acute/recurrent appendicitis, which accounted for 29.1% of all the cases. Even though acute appendicitis is more common than acute cholecystitis in our local practice, most of the patients with acute appendicitis are still being managed by open procedures.

The spectrum of cases in our initial experience was akin to those documented in the pilot experience of other health institutions in Nigeria in laparoscopy.[10],[14] However, to the best of our knowledge, this series is one of the highest to be reported in Nigeria and the first to show a transition from the widely reported basic laparoscopy surgeries to advanced therapeutic procedures. This paper provided an insight into our initial experience in advanced laparoscopic surgery, especially in trauma and oncology settings.

Diagnostic laparoscopy was mainly performed for biopsy of abdominal masses in our institution. In the last few years, laparoscopic surgery has been applied in the diagnosis and therapeutic management of hemodynamically stable patients with abdominal injuries.[17] Laparoscopic interventions in abdominal trauma have helped to reduce the negative laparotomy rate.[18],[19],[20] Mohammed et al.[21] reported that laparoscopy was useful in avoiding laparotomy in 53 (81.5%) patients with abdominal trauma. We performed diagnostic laparoscopy on 4 patients with abdominal trauma during the period under review. There were two cases of penetrating abdominal injuries due to stab and gunshot wounds. The remaining two patients had blunt abdominal injuries with liver lacerations. The 4 patients were successfully managed laparoscopically.

In selected patients, the safety of laparoscopy for the treatment of patients with chronic abdominal pain and or recurrent bowel obstruction has been established[18] Laparoscopic adhesiolysis for symptomatic (pain and partial intestinal obstruction) intestinal adhesions was performed in 8 (5.8%) patients in this study. The principal symptoms in these patients were recurrent abdominal pain and abdominal fullness after a history of previous abdominal surgery.

In recent times, there have been recommendations that laparoscopy can be used for surgical treatment of gastrointestinal stromal tumors. Localized tumors with less aggressive biological behavior have been safely resected with laparoscopy.[22],[23],[24] We completed wedge resection of a large (10 cm diameter) gastric gastrointestinal stromal tumor (GIST) in one of two patients in the series. This patient has been followed up with an abdominal computed tomography scan to date without recurrence. The second patient was a case of jejunal GIST, which was converted to an open procedure due to uncontrolled hemorrhage.

Apart from adenocarcinomas, pancreatic lesions are relatively uncommon in our practice. Laparoscopic cystogastrostomy was performed in a patient with pancreatic pseudocyst caused by penetrating abdominal gunshot injury.[25] Another young female patient with long-standing (19 years) left hypohondrial pain due to a calcific pancreatic tail mass had laparoscopic-assisted resection of the mass. Histology of the resected mass revealed a pseudo-papillary tumor. No evidence of recurrence after 1 year of followup with computed tomographic scan.

Most available local series on laparoscopy reported a conversion rate of less than 5%.[10],[13],[14] Conversion rate of 3.7% in this study approximates that reported by Ekwunife and Misauno in Nigeria and a similar study from Congo.[10],[13],[26] Conversions from laparoscopic to open surgery in this study occurred in 5 patients due to uncontrollable hemorrhage, dense adhesions, cardiac arrhythmias, appendiceal mass, and bladder injury.

The most common procedure-related complication in this review was superficial surgical site infections in 8 (5.8%) patients following laparoscopic appendicectomy. This is slightly less than 6.4% reported by Adisa et al.[27] The incidence of surgical site infection after laparoscopic appendicectomy was estimated to be between 2.8% and 12.8% in a larger volume series.[28]

Inadvertent intraoperative electrocautery injuries manifesting as complications in the postoperative period may occur during laparoscopic surgery. Electrocautery injuries to hollow viscus such as the duodenum may not be recognized at surgery.[29],[30] We performed an exploratory laparotomy in 2 of our patients in the postoperative period. The first patient developed duodenal fistula 24 h after surgery due to missed electrocautery injury. The second patient presented with a pelvic abscess one week after discharge following laparoscopic appendicectomy. These two patients had an uneventful recovery postlaparotomy.

As we progressed through the cases, we experienced some constraints and limitations that are probably not peculiar to our setting. Similar challenges have been documented by other local researchers.[9],[31],[32] Finding a readily available replacement part in case of equipment failure was a major challenge to the running of our laparoscopic services. We relied on local representatives of industries to import the needed equipment and spare parts as they were not available locally.

In the early stage of our procedures, the relative unfamiliarity with theatre instruments by other health care workers affected the preparation and delivery of surgical instruments at the surgery. The participation of theatre staff in a series of training workshops held in our center was of immense benefit in overcoming this learning curve. Similar to the experience of Ismaila et al.[31] in Jos, a power outage during laparoscopy did occur on rare occasions, but this was surmountable. Our caseloads were also limited by service interruptions due to intermittent industrial strikes of health workers. Even though the theatre fee for performing laparoscopic surgery in our institution was placed at an equivalence of the open surgical procedure, the cost of consumables needed for the procedures was on the high side for the majority of our patients who had to make out-of-pocket payments. For instance, the average cost of single-use trocars and disposable clips and extraction bags for laparoscopic cholecystectomy is about two hundred thousand seven hundred and fifty nairas, which is equivalent to about 550 Dollars. To make laparoscopic surgery more affordable, we made several cost-cutting measures. Hand-made Roeder's knot was used for ligating the appendix in place of commercial end loops, fabricated endo bags from surgical gloves were used for extracting tissue specimen in some cases. We also carried out intracorporeal and extracorporeal suturing when laparoscopic surgical clips and endo staplers were unaffordable or not available. Reusable instruments were used in the place of disposable instruments. A study on cost analysis in laparoscopy has shown that the cost of running laparoscopic services with disposable instruments could be up to 9 times that of reusable instruments.[33]

The range of hospital stay of this study was very wide hence the mean hospital stay was slightly higher than that reported by other surgical laparoscopists in the country.[14],[34] The difference can be attributed to the heterogeneity of cases in this study and the need to observe patients for a longer period in our early experience. Moreover, patients who had advanced laparoscopic procedures and those who had open surgery for postoperative complications had prolonged hospital stay.


   Conclusion Top


Laparoscopic surgery is safe and can be applied to wide variety of general surgical conditions in developing countries. Indications for laparoscopy are evolving in our practice. Our early experience in basic and some advanced laparoscopic procedures has yielded a satisfactory outcome. Minimal postoperative morbidity of laparoscopy is a major benefit to the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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