My Experience with Gas Insufflation Less Laparoscopy in India, June 10th, 2018 – June 29th, 2018

By: Dr. Mugisha Jerome and Dr. J. Gnanaraj

THE IDEA IS BORN

Two years back I had discussions with Dr. Peter Reemst and Katinka. The gist of the discussions was the future of Mutolere Hospital. The discussions centered on how to operationalize the vision of the hospital strategic plan currently in force: to be a leading model health care facility in the Western region in the context of Christian values. With government health centers taking up the role of primary health care, the church-based hospitals needed to invest in more sophisticated care to improve the quality of curative services since government paradigm shift emphasized preventive health care. Further it had already been observed that the communicable disease burden was slowly coming down and the private sector needed to invest in curative services where the government was not willing to invest heavily. It was observed that hospital considers introducing minimal access surgical procedures.
A year after the discussion, the hospital received a laparoscopy set from Storz, Germany. This was a kind donation because the hospital was working closely with Prof. Winfried who had been seconded by Humedica, a charity organization from Germany. After the installation of the equipment, practical issues emerged: we needed carbon dioxide for insufflation. This is bought from suppliers in Kampala the capital city of Uganda, 500 kilometers away. When we had filled some bottles, some other challenges like need for general anesthesia, need for sophisticated monitoring equipment, gas leakage among others emerged as we conducted some trainings and surgeries with Dutch and German visiting doctors. It is because of these challenges that Dr. Peter Reeemst informed us that Dr. Gnanaraj was performing minimal access surgeries without gas. I was informed that gas less laparoscopy was especially possible under spinal anesthesia for simple procedures like tubectomy, surgery for ovarian cysts, diagnostic laparoscopy for infertility and chronic pelvic pain among others.

GETTING READY

I had a couple of e-mail communications with Dr. Gnanaraj who informed me about surgical camps he normally conducts. He invited me to join the camps. He gave a link to do some online courses as I prepare to join the surgical camps. He also gave me a realistic budget that would be used as a basis for planning. After obtaining the visa, I was off to India.

THE EXPERIENCES

Upon arrival in India I was joined by Dr. Gnanaraj and his team the following day. We were also joined by Dr. Anurag Mishra, Associate Professor of Surgery at Maulana Azad Medical College (MAMC). After exchanging pleasantries, it was decided that a conference on gas less laparoscopy surgery (GLLS) would be held at the hospital the following day. The conference took place at the hospital and it was attended by surgeons and graduate students of surgery.

  • From the conference: we were told about the historical perspectives of minimally invasive surgery (MIS), how GLLS was adopted, the different devices that have been tried over time and their limitations, culminating in to the current abdominal lift apparatus. The advantages of GLLS were elaborately presented but it was emphasized that it is not appropriate for the very fat persons (BMI above 25). It was also emphasized that GLLS was not there to replace conventional laparoscopy with gas but rather to provide an opportunity for MIS to be performed even in rural and resource constrained settings where it may be hard to get gas. Graduate students at MAMC were encouraged to pick interest and research about GLLS and possibly join surgical camps organized by Dr. Gnanaraj in possibly in preparation for rural surgery. Videos were used for illustration
  • FIELD WORK: After the conference we were set to go to the field. We had been scheduled to have practical’s in Aarohi, Aizwal, Kolkata, Crofts Memorial Hospital in Bongaigon and Bhallukpong.

We first visited Aarohi, a small unit located in the mountainous Himalayas. I assisted in surgeries like ovarian cystectomy, laparoscopic assisted vaginal hysterectomy for uterine Myomata, vaginal hysterectomy among gynecological operations. We also had urological procedures. All patients were discharged in good condition. The next unit visited was Bethseda Hospital in Aizwal, the capital of Mizoram. In this city, buildings perilously hang on steep slopes of the very steep hills. We were able to perform different surgeries in gynecology and urology (stenting, lithotripsy for renal stones, laparoscopic puncture for polycystic ovarian cysts, tubal patency testing with methylene blue, and hysterectomy). At Kolkata Medical College, we met eminent staff and academicians of this hospital, which was started more than 150 years ago. We were ushered into the gynecology operating theatre where surgeries were ongoing. Dr. Gnanaraj was given opportunity to demonstrate how GLLS works with lift apparatus by performing a tubectomy in presence of other doctors and some graduate students. At the end of the operation it was generally accepted that it is possible, cheap and should be promoted. In the afternoon, we visited Sujit Mukherjee, the CEO of Endox. He manufactures/deals in laparoscopy equipment plus accessories. Given the fact that GLLS is performed largely through single incision, instruments used need to be modified to allow handling by the surgeon and assistant. He informed us that it is pretty possible to make the specified modifications. He was asked make prototypes and if the specifications are met he would provide the instruments possibly in large quantities. The next place visited was Crofts Memorial Hospital in Bongaigom. Remotely located near the border with Bhutan, surgical camps organized by Dr. Gnanaraj are a great relief to the residents who otherwise would travel long distances to access laparoscopy services. It is against this backdrop that the camp was well attended, forcing us to start work at 6pm, shortly after arrival after a grueling long journey from Guwahati airport. The day’s program ended shortly after 11pm and the following day we started at 8.30am ending shortly after 8pm. Finally, we were at Bhallukpong. Here we had consultations. Whereas I had difficulties entering Anuchal Pradesh state, the experience in Bhallukpong was very fascinating as I had an opportunity to perform gasless laparoscopy assisted by Dr. Gnanaraj. We were able to diagnose uterine fibroids that needed no further action. The operation, done under spinal anesthesia enabled us to explain the diagnosis in real time as the conscious patient was shown the images on the screen. This improves patient satisfaction and may improve the bond between the doctors and patients. As expected, the patient was discharged the next day.

CONCLUSIONS

The camps have offered me an opportunity to see GLLS first hand and perform the first one under close supervision. They have also offered me opportunity to appreciate that GLLS is possible and cheaper than conventional laparoscopy given the fact that the expenses on gas and general anesthesia are avoided. GLLS allows MIS to be extended to rural populations that do not have easy access to urban centers where conventional laparoscopy can be done. It was noted that the ordinary television set can be used as a monitor without necessarily compromising picture quality. As mentioned, most of the hospitals visited were remote rural centers and accessing MIS would have been a herculean task were it not for the GLLS innovation where even the team moves with a kit containing surgical instruments. Such patients would travel long distances and most probably would incur exorbitant costs to access quality gynecology and urology services. It would be gratifying to understand what motivates Dr. Gnanaraj to bring these much-needed services to the rural and vulnerable population in India.

Personally, I hope to find the means and resources to start GLLS. I would support and be part of efforts to introduce post graduate training in GLLS for rural doctors in Uganda in collaboration with Dr. Gnanaraj.

Acknowledgements:

  1. Dr. Gnanaraj and his team for extending the invitation to India and allowing me to have hands on experience in GLLS.
  2. The Friends of Mutolere in Holland for financial support. Special thanks go to Dr. Peter Reemst and his wife Katinka for the encouragement.
  3. Dr. Anurag Mishra for allowing us to hold the conference at his hospital.
  4. Staff at Mutolere Hospital for keeping up the work in my absence.
  5. The respective staff of the different hospitals for allowing us to practice from there.
  6. Bravin for ensuring I easily settle in, in the different places where we went.
Dr. Mugisha Jerome, MBChB, MMED (OBS/GYN), Fellow (Continuous Quality Improvement). He is a Gynaecologist and Medical Director at St. Francis Hospital Mutolere (a 200-bed private not for profit hospital belonging to Kabale Diocese) in South Western Uganda.
gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
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