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Laparoscopic Surgery, Telemedecine and the Third World

Practical problems facing in abdominal surgery performed

in the third world are : 

1. difficult management of hospital structures
2. insufficient paramedical training
3. insufficient hygiene, lack of appropriate medication and overcrowding of the wards by patients relatives who are in charge of the food supply to the patient.

These problems are the direct cause of a high would infection rate, hence longer hospital stay and unnecessary drainage of the already depleted means of care.

The advantages of laparoscopic surgery are :

1. a reduced infection risk thanks to the absence of large incisions
2. reduced patient immobilization, hence shorter hospital stay for the patient and his relatives, which is of the utmost importance in a system where social coverage does not exist
3. it constitutes a readily available diagnostic tool, advantageously replacing more expensive equipment as CT scan and NMR.

In a third world environment, theoretical disadvantages of laparoscopy are :

1. relative technical sophistication of the technique (maintenance problems) in a developing country where technical means may be absent.
2. cost of the equipment.
   Equipment cost however can be contained by the use of reusable cannulas and trocars as well as by avoiding the use of stapling instruments which can be omitted provided advanced surgical manual techniques are used.
   Finding a video monitor is hardly a problem in today's third world. The only weak link in the chain are the relatively sophisticated insufflator and video camera, which constitute the only and absolute priority in the laparoscopic surgeons armamentarium. Taking care of these instruments however is less time consuming for a surgeon than the alternatives (supervising administration, nursing care and long stays).

Practical application areas of laparoscopy in third world countries are :

1. Abdominal emergencies (cf. diagnostic complications already mentioned) In case of traumatic acute abdomen, laparoscopy permits a quick diagnosis of visceral damage; a second look can also easily be performed in a patient with a rapidly degrading condition.
   In the case of peritonitis, laparoscopy can determine or confirm the source of the infection as well as its localization. Treatment can then be undertaken either laparoscopically (e.g. in appendicitis, ectopic pregnancy, perforated ulcer) or conventionally, but via a well defined incision, right across from the target organ as diagnosed laparoscopically.
2. Functional gastric surgery : ulcer disease and gastrooesophageal reflux can thus be cured at low cost (as compared with a lifelong drug treatment in a poorly complying population). Also, the surgical procedure (plication of the fundus, vagotomy) is relatively benign since no organectomy or organotomy is performed. The morbidity of the open procedure lies in the way of access (long laparotomy incision, long retraction), which is much more advantageous in the laparoscopic procedure.
3. Surgical treatment of infectious and parasitic disease (echinococcal cyst, deeply located abscesses).

Two problems remain however. First : who will provide the money necessary to start laparoscopy ? Second : who will teach the technique ?

Besides the "classical" cooperative aid mechanisms, one can hope for commercial companies to invest in these countries which for them are potential large markets in a near future.

Permanent improvement of the present laparoscopic equipment in the industrial world has outdated lots of "first generation" instruments which still work fine and have the advantage of being relatively simple. Some companies involved in endoscopic imaging have already taken the option to donate such instruments to projects in the third world or to sponsor punctuate medical missions (Algeria, Vietnam, Rumania).

One of the most efficient teaching forms is the partnership between well experienced European laparoscopic departments and third world university departments with a clear hierarchic structure and a well defined teaching mission. This partnership should be based on a man to man contact and implemented by cooperative aid structures providing financing and helping in obtaining the necessary permits from the involved embassy as well as non-governmental organizations and commercial firms.

As for now, teaching implies frequent travels for teacher and student. Financing for travels and fellowships up to 1 year can be granted by organizations in the third world country as well as in the western countries.

For the past six years, our hospital has run an educational program specifically targeted at medical professionals in developing countries. The program sends instructors to educational centers in six locations:

• A. Le Dantec Hospital in Dakar, Sénégal;
• Kamenge Hospital Center (King Khaled Hospital) in Bujumbura, Burundi;
• Ngaliema Clinic in Kinshasa, Democratic Republic of Congo;
• Treichville CHU in Abidjan, Côte d’Ivoire;
• Point G National Hospital in Bamako, Mali; and
• King Fayçal Hospital in CITY, Rwanda.

Courses are one week long. Our experts and instructors arrive on the first day with two STORZ laparoscopy towers and a set of instruments. The towers are installed by a STORZ technician, who is responsible for the maintenance of the imaging equipment in Africa. The technician also ensures compatibility with local instruments and infrastructure. After the opening ceremony, conceptual classes begin, which also cover the specific needs of African countries. In the afternoon, live demonstrations commence. Two pelvic trainers constructed on-site in wood boxes are placed at the disposal of the students. As from the third day, the instructors assist local surgeons. The week culminates in the awarding of certificates.

Education

1. Conceptual Program
This part of the course takes place in the hospital’s auditorium. Essential support materials include pre-recorded VHS videocassettes and a PowerPoint presentation. The conceptual class covers the following subjects:
General Rules of Laparoscopy - Emergency Laparoscopy- Perforated Ulcer - Appendectomy - Ectopic Pregnancy - Traumatic Perforation - Diagnostics - Laparoscopy for Children - Elective Laparoscopy - VATS (Video Assisted Thoracic Surgery) - Cholecystectomy - Colonic Resection - Splenectomy - Hernia - Vagotomy - Nissen - Hydatic Cyst - Sterilization & Maintenance of Laparoscopic Equipment

 

 

2. Operative Demonstrations by the Instructors Appendectomy - Splenectomy - Truncal Vagotomy - Secondary Sterility - Exploratory Laparoscopy for Abdominal Trauma - Cholecystectomy

3. Operative Simulations Using the Pelvic Trainer The local surgeons use the pelvic trainer to practice their skills, assisted by direct viewing and endoscopy.

4. First Laparoscopic Interventions Performed by Local Surgeons, Assisted by Instructors and Experts Cholecystectomy - Exploratory Laparoscopy - Secondary Sterility - Truncal Vagotomy

More likely, however, the future of teaching relies in the adoption of the electronic highways - information will travel, obviating the need for the surgeons to do so. After completion of their fellowships, third world surgeons can perform their laparoscopic procedures at home in much safer conditions, thanks to the telematic connection with the expert who can guide him from a distance (proctoring). In case of mishaps, open correction can still be performed by the local surgeon who is obviously fully trained in conventional surgery.

This will permit surgeons to maintain their level of knowledge, even if they are physically located in a hospital in a rural area. During our trips to the developing countries, we will bring videoconferencing equipment (Vycon), which will be installed by two technicians from Eshango International.

An other aspect in this matter is : how to structure this new concept in cooperation with the third world. The following should be considered :

• to register foreign missions in order to facilitate coordination between the missions; to document contact persons and useful local information.
• to register training centers where surgeons can be taught laparoscopic surgery.
• to establish formal links with medical supply and drug companies in order to obtain sponsorship for travel and /or material.
• to collect grants from different institutions.
• to teach local nursing personnel particularly in the matter of instrumental maintenance.
• to develop teaching from a distance by satellite or telematics means; the virtuel reality.

References

1. G.B. Cadière, H. Fernandez. Points de vue sur la Chirurgie Coelioscopique dans le Tiers-monde. Annales de chirurgie, 1995 ; 10 : 875-877.
2. G.B. Cadière. Chirurgie coelioscopique et tiers-monde . In : actualités Digestives Médico-Chirurgicales, eds Masson, Paris. Jean Mouiel. Paris 1996 ; 183-185.
3. G.B. Cadière, J. Himpens, J. Bruyns. Laparoscopic surgery and the third world. Surg Endosc 1996 ; 10 : 957-958
4. J.M. ANDREU, G.B. CADIERE, O. GERMAY. CHIRURGIE LAPAROSCOPIQUE EN AFRIQUE NOIR : L’APPEL DE DAKAR
   Le journal de Coelio-Chirurgie 1999 ; 31

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