Laparoscopic surgery has shown to improve outcomes in terms of early recovery and better patient satisfaction. However increased cost of equipment and lack of training has led to a reduced availability of laparoscopic surgery in lower middle income countries13. We have shown through our study that laparoscopic surgery is not just feasible in lower income countries but also has similar outcomes to those seen in high income countries.
This is not the first description of advanced laparoscopic procedures being performed in lower income countries. There are short case series reported from Pakistan. But most studies have few number of patients and very few have their settings as a public sector hospital9–12. We have shown in our study that advanced laparoscopic procedures are possible with comparable outcomes in terms of complications as compared to high income countries.
Laparoscopic surgery is costly and various adaptations are needed to ensure its availability in low income setups14. We focused on two aspects, reducing costs and improving the training. We trained our residents on basic laparoscopic skills using regular workshops on simulators and arranging hands on workshops by master trainers from all over the country. This is in concordance with studies showing that training on basic simulators improves laparoscopic skills15,16. We have a dedicated simulation lab with simple box simulators available round the clock for residents to practice and train.
For cost reduction various techniques have been used by surgeons in lower middle income countries17–19. We also adapted different methods to reduce costs. Hemolocks, pre tied endoloops were all avoided and intracorporeal and extracorporeal knotting were regularly used. This saved on cost but added extra time to the surgery. However public sector hospitals are not time bound and a few extra minutes during surgery can save the patient a few extra days in the hospital. We also started using metal trocars instead of disposable plastic trocars. Where possible instruments and energy devices were reused by resterilizing them using ETOH. This practice although criticized by some has been successfully done by a lot of surgeons in developing countries20. Alexandra et al. have be gone to the extent to show that you can resterilize a ligasure device a minimum of 10 times to ensure that no effect comes on the sealing capacity of the device. Some studies have quoted reusing upto 20 times21.
For inguinal hernias TEP and TAPP both were performed and mesh fixation was done with sutures. A metaanalysis done has shown no difference in recurrence between mesh fixation with tackers or sutures22. For TEP we have even tried not fixing the mesh at all. There is no difference in recurrence whether you fix or don’t fix the mesh23. For ventral hernias composite meshes are expensive and not readily available. We use prolene meshes for our patients and fix them with transfacial sutures. Omentum is then placed underneath the mesh to form a biological layer between mesh and the small bowel11. Various surgeons have shown acceptable long term outcomes with this technique in ventral hernia. Although there has been a few reports of mesh eroding into the bowel a few years after surgery.
Extracorporeal anastomosis for colorectal surgery is practiced widely and brings about a lot of cost reduction as expensive staplers are avoided and hand sewn anastomosis can be safely done outside. There is no addition to the size of the wound as the same size incision would still be needed to remove the specimen even if an intracorporeal anastomosis was done. It is however associated with longer hospital stay24.
We had a conversion rate of 8.6%. Most common reasons for conversion are bleeding, injury to vital organs, difficult anatomy and equipment failure. This is also similar to what has been reported in literature by other surgeons. We had our share of complications. Most common being wound infections. Our incidence of SSI is high as compared to other centers. Probably because we have included cases performed in emergency as well. We have even isolated mycobacterium tuberculosis from 8 patients. 4 patients had to undergo a delayed surgery for removal of an infected mesh. Other complications included bleeding and anastamotic leaks. One patients developed peritonitis after a leak and was re-explored and stayed in ICU. He eventually recovered and was discharged. Fortunately we had no deaths in our patients.
There are a few limitations to our study. This is only a short term measure of outcomes and doesn’t measure the long term outcomes such as hernia recurrences or oncological outcomes for cancers. Secondly there is no uniformity in the surgeons performing the operations. Senior registrars to Professors everyone was involved in these cases.