|Year : 2012 | Volume
| Issue : 2 | Page : 75-78
Pioneering laparoscopic surgery in South-eastern Nigeria: A two-center general surgery experience
Christopher N Ekwunife1, Gabriel U Chianakwana2, Stanley N Anyanwu2, Chinemelum Emegoakor2
1 Department of Surgery, Federal Medical Centre Owerri, Nigeria
2 Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
|Date of Web Publication||12-Mar-2013|
Christopher N Ekwunife
Department of Surgery, Federal Medical Centre Owerri
Source of Support: None, Conflict of Interest: None
Background: Nigeria lags behind in the deployment of laparoscopic surgical services, even among the developing countries. In spite of the huge abundant human and materials resources at its disposal, public hospitals are still underfunded. However, some tertiary health institutions in our sub-region have been able to brave the odds to modernize their services. Aim: To review the early experiences of two general surgery units in laparoscopic surgery at two institutions in South-eastern Nigeria. Materials and Methods: A 3-year retrospective analysis of the laparoscopic general surgery operations carried out in Nnamdi Azikiwe University Teaching Hospital, Nnewi, and Federal Medical Centre Owerri, Nigeria, was done. Results: A total of 20 cases have been done in both hospitals: 9 laparoscopic cholecystectomies, 10 laparoscopic appendectomies, and 1 laparoscopic liver abscess drainage. There was no conversion to open surgery. The average duration of postoperative stay after cholecystectomy and appendectomy were 2.1 and 1.5 days, respectively. There was no major complication despite the challenging intraoperative adverse conditions. Conclusion: Laparoscopic surgery is safe in our region, but its evolution is still slow in our centers. Improved surgeon training and subsidization of the costs of the procedures may hold the key for accelerated development.
Keywords: General surgery, laparoscopy, Nigeria
|How to cite this article:|
Ekwunife CN, Chianakwana GU, Anyanwu SN, Emegoakor C. Pioneering laparoscopic surgery in South-eastern Nigeria: A two-center general surgery experience. Niger J Basic Clin Sci 2012;9:75-8
|How to cite this URL:|
Ekwunife CN, Chianakwana GU, Anyanwu SN, Emegoakor C. Pioneering laparoscopic surgery in South-eastern Nigeria: A two-center general surgery experience. Niger J Basic Clin Sci [serial online] 2012 [cited 2021 Dec 2];9:75-8. Available from: https://www.njbcs.net/text.asp?2012/9/2/75/108469
| Introduction|| |
Laparoscopy was born over 100 years ago when Kelling inspected the abdominal cavity of a dog with a cystoscope.  It was not until Mouret did the first laparoscopic cholecystectomy in 1987 that general surgeons became keenly interested in this innovative field.  The 1990s was a watershed period in the global laparoscopic surgery revolution, and there is a continuing evolution of newer techniques that suit the modern concept of treatment: "Maximum efficacy with minimum adverse effects."
Laparoscopic surgery is the logical progression of general surgery. It is a humanitarian imperative that the benefits of laparoscopic surgery be offered more widely in the developing world where over 75% of the global population resides. Surgeons in some of these countries have surmounted enormous difficulties while delivering cost-effective minimal access surgical service. , In this regard, Nigeria lags behind in the deployment of laparoscopic surgery services despite the relatively huge financial and human resources at its disposal. A significant part of the problem is underfunding of healthcare, but this has not deterred some public health institutions in seeking avenues to modernize their services.
| Materials and Methods|| |
We examined the case notes and operating room records of patients who underwent laparoscopic general surgery procedures at Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, and Federal Medical Centre Owerri (FMCO) between January 2006 and December 2009. Data extracted were on patient demographics, types of operation done, and postoperative outcomes. The analysis of the data was done with Microsoft Excel 2007.
| Results|| |
The first laparoscopic surgery (cholecystectomy) done at NAUTH was on 5 November 2006, whereas at FMCO, it was on 27 September 2007. These initial procedures were done by expatriate surgeons during the course of a 1-week hands-on training course. Local surgeons performed all the other procedures outside this training period. In the period under review, 9 laparoscopic cholecystectomies, 10 laparoscopic appendectomies, and 1 laparoscopic liver abscess drainage were done at the two centers. The indication for the cholecystectomies was chronic cholecystitis secondary to cholelithiasis, whereas for the appendectomy it was acute or recurrent appendicitis. The age range of patients operated on was from 10 to 68 years. Female patients predominated at 15 in number versus the 5 male patients operated upon (M:F = 1:3).
At the NAUTH, Nnewi, four cholecystectomies and one appendectomy were done within this period. On the other hand, at FMCO, five cholecystectomies, nine laparoscopic appendectomies, and one liver abscess drainage were done [Table 1].
The duration of the cholecystectomy done by the expatriates ranged from 1 h 50 min to 2 h 25 min, while those done by the local surgeons was from 105 to 283 min with an average time of 197 min. The appendectomy operating time for the local surgeons ranged from 65 to 105 min with the standard three-port technique. However, when the one-port transumbilical laparoscopy-assisted technique was utilized, the procedure duration dropped toward the 31-40 min range. The average time duration for appendectomy for the local surgeons was 68.1 min. The average postoperative stay after laparoscopic appendectomy was 1.5 days, whereas it was 2.1 days after laparoscopic cholecystectomy.
Intraoperative problems encountered during the surgical procedures included electric power interruptions, equipment failures, and excessive bleeding [Table 2].
Postoperatively, there were two minor complications in the cholecystectomy cases: Fever and bleeding. The appendectomies were also complicated by vomiting and wound infection in two patients, respectively.
The solitary case of liver abscess drainage was done at FMCO on a 34-year-old male who did not respond to the conservative management. He made a dramatic recovery after laparoscopy-assisted drainage and was discharged on the 3 rd postoperative day.
General anesthesia was used in all our patients. There was no conversion to open surgery in any of the cases.
| Discussion|| |
The public hospitals in Nigeria are slowly rising up to the challenge of minimal access surgery in Nigeria. Just as was the trend worldwide in the development of laparoscopy, it is the gynecologists who realized early its value as a tool for the diagnosis of abdominal conditions.  Surgeons, in some cases, had to borrow equipment from the gynecologists to perform laparoscopic procedures.  The initial reports on the use of laparoscopy in general surgery units in Nigeria were also for diagnostic purposes. However, as increasing number of hospitals modernize their facilities, the increasing competencies in laparoscopic surgeries are becoming apparent at various centers across the country. , These seemingly exciting developments pale into insignificance when compared to experiences in other developing countries like India with laparoscopic surgery experience of over four decades.  Even some sub-Saharan African countries like Kenya had a comparatively early head start; Patel et al. reported a 106 case series of laparoscopic appendectomy over a 6-year period from 1996 to 2002.  While there may have been initial reservations about the appropriateness of complex minimal access surgery procedures to the 'third world' environment, largely due to the required huge capital outlay in the face of other health challenges, it has been shown that some of these procedures can be performed safely with results comparable to international standards. ,
The two centers under study are the leading tertiary hospitals in South-eastern Nigeria to have embarked on minimal access surgery. In both hospitals, there had been a practice of diagnostic laparoscopy by the gynecology department. However, a new set of laparoscopic equipment had to be purchased at the onset of the program. This new equipment was from a different manufacturer to the older equipment. This raised the problem of adaptability of the parts of the older equipment functioning as back-up when there is malfunction of any component. The fact that there was no significant input from end-users prior to equipment purchase implied that the manufacturer's representative was at liberty to supply to the hospital what they deemed fit for the procedures. This was compounded by the fact that training of surgeons only took place after equipment purchase.
There have been questions about the suitability of short-course training for laparoscopic surgery in building enough competencies to carry out safe operations. Indeed, the inadequacies of this model temporarily stalled the program at NAUTH. The modest achievement at FMCO was after the surgeon underwent a longer duration of training. However, institutions may not readily permit surgeons in our environment to undertake long training positions abroad; therefore, onsite training and mentorship by external experienced practitioners is still an option. 
Our review shows a relatively small number of patients who benefited from these procedures. Open appendectomy is commonly done in our hospitals. Our patients and even physicians are yet to fully appreciate the advantages of laparoscopy in appendicitis. Moreover, cost issues may be a deterring factor. Laparoscopic cholecystectomy is the gold standard for operation for gall bladder removal, but there is a relative rarity of indications for cholecystectomy in our region; Asuquo et al. reported 18 open cholecystectomies over a 10-year period at University of Calabar Teaching Hospital. 
The duration of our cholecystectomy is unduly long. This can be accounted for by the learning curve in this early stage of our development and the various intraoperative technical hitches we experienced. Shorter operating times (65-105 min) have been recorded by other surgeons in the country.  Subsequent procedures done by us outside this study period have shown marked reduced operating times. However, our average operating time for appendectomy for the procedures done by local surgeons was well within the 32-102 min average reported in systematic reviews.  The one-port transumbilical laparoscopy-assisted appendectomy may be a more acceptable technique than the standard three-port laparoscopic appendectomy: Operating time is shorter and cosmetic outcome is better. The enviable shortened postoperative hospital stay after minimal access surgery was noticeable in our patients (2.1 days after cholecystectomy and 1.5 days after appendectomy).
Safety of the patients was a primary concern for us to ensure sustainability of the program. No major complications occurred in our series unlike experiences in similar developing countries; although the basis for comparison may be unfair on account of our low numbers.  However, it should be commendable that we have had no conversion to open surgery in our practice. This could be attributed partly to a careful patient selection, excluding patients with acute cholecystitis, and also a conscious effort at meticulous operation by the surgeon.
| Conclusion|| |
This early effort at conducting laparoscopic surgery in a resource-limited region, in the face of institutional handicaps, has shown that safe outcomes consistent with the advantages of minimal access surgery can be achieved. It is hoped that further investments in human and material resources can expand this service to the greater patient population. Governments should also subsidize the costs of these operations.
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[Table 1], [Table 2]