Low-cost laparoscopic surgeries: Taking modern surgery to the poor

The benefits of minimally invasive surgery are essential to the lives of those in poor rural areas, unlike for the urban rich. Seeing as the absence of any family member in these areas adversely affects their lifestyles, rural patients need to return to work as soon as possible.

Key Point: Single-incision laparoscopic surgery (SILS) is a relatively new technique that may reduce the trauma of surgery, leading to reduced port site complications and post-operative pain. This technique has benefits over traditional laparoscopic surgeries, including lower cost, which may make it a viable option even in rural areas.

Today, laparoscopic surgery is an integral part of the operative repertoire of any surgeon. It is a major technological innovation in surgery. Single-incision laparoscopic surgery (SILS) is a relatively new technique developed for performing operations without a visible scar and has become an area of active research and interest within the general surgeons’ community. SILS may further reduce the trauma of surgery leading to reduced port site complications and post-operative pain.

In recent times, however, the problems associated with laparoscopic surgeries involving the use of gas have been the subject of discussions, and this has lead to the development of gasless laparoscopic surgeries. Moreover, despite the many advantages of minimally invasive surgeries, like less pain, short hospital stay, less blood loss, etc., laparoscopic surgeries are not popular in rural areas because of their high cost.

We describe our experience with single-incision gasless lift laparoscopic surgery, which has the advantages of laparoscopic and open surgeries and does away with the drawbacks of traditional laparoscopic surgeries.
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From March 2012 until August 2013, 194 surgical procedures were carried out in seven mission hospitals in South and Northeast India and in one medical college. Table 1 gives the list of surgeries performed.

TABLE 1: Lift laparoscopic surgeries carried out by SEESHA (Samiti for Education Environment Social and Health Action) [March 2012 to August 2013]

SURGERY NUMBER
SILLS Infertility surgery

  • Adhesiolysis
  • Ovarian drilling
  • Tubal drilling
  • Endometriosis resection
  • Tubal patency testing
81
SILLS Appendectomy 58
SILLS Ovarian cystectomy 18
SILLS Diagnostic laparoscopy

  • Adhesiolysis
  • Drainage of abscess
  • Biopsies
8
SILLS Laparoscopy assisted vaginal hysterectomy 10
SILLS Myomectomy 5
SILLS Cholecystectomy 2
SILLS Tubal recanalization 2
SILLS Incisional hernia repair 2
SILLS Inguinal hernia repair 2
SILLS Burch colposuspension 1
SILLS Palomo operation 1
Lift laparoscopic cholecystectomy 2
Lift laparoscopic myomectomy 1
TOTAL 194

We used the lift apparatus designed by Dr. Daniel Kruschinski from Germany [1]. Shoulder braces are necessary for preventing the patient from slipping down, as the steep Trendlenburg position is necessary. The umbilical incision is at the lower end of the umbilicus, which is held up with two towel clips and cutting through the lower half of the umbilicus . The incision should be sufficiently wide to fit an index finger comfortably inside.

While inserting the abdominal portion of the lift apparatus, it is important to make sure that there is no bowel or omentum between the lift apparatus and the anterior abdominal wall. The lift apparatus is designed so that it lifts the abdominal wall, primarily lifting the umbilicus to about ten centimeters, lifting the recti muscles without extending beyond them , so that there is no injury. There is sufficient space to operate, and most surgeons who see only the television picture cannot believe that gas is not in use for the surgery, especially during the two live surgical workshops that we conducted.

Related Video: SILS

A combination of open and laparoscopic instruments is used for surgeries. Since there is no gas in use, larger instruments can be passed one at a time conveniently.

This technique was most useful for surgeries such as appendectomies and evaluations of infertility. Laparoscopy-assisted vaginal hysterectomies and ovarian cystectomies need a little more time for learning. Other surgeries require longer learning curves.

The exposure is not as good as that of regular laparoscopic surgeries, other than when performed on thin patients. However, it is sufficient for performing the surgeries.

The complications included infection in one patient and prolonged ileus in four patients with appendicitis , which was probably caused by peritonitis, rather than the method used for removing the appendix. Difficulties included the omentum or bowel getting between the anterior abdominal wall and the lift in obese patients.

Compared to the traditional procedure with a CO2 pneumoperitoneum, the results of the first gasless procedures demonstrate potential advantages [2]. In addition to very rare risks, like air embolism, which could lead to death and other complications, there are several physiological changes that occur during the gas laparoscopic surgeries [3]. These prolong the recovery period and can cause post-operative adhesions, shoulder pain, etc. Hence, gasless or lift laparoscopic surgeries were promoted. However, they did not become very popular because of the limitations in exposure as opposed to the regular laparoscopic surgeries using gas.

Despite the lack of evidence demonstrating any superiority of SILS, it is being increasingly performed. Byron F. et al [4], reported a study which had compared the performance of standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS) program using either the LAP or the SILS technique. His study demonstrated that performing tasks using SILS techniques is more technically challenging even for surgeons with previous SILS experience.
lift apparatus setup

Figure 1: The Lift apparatus setup.

However, the use of familiar open surgical instruments [Figure 1], the lack of cross-over of instruments, and the ability for instruments to be passed one at a time [Figure 2] make it easier to learn. For rural areas, the advantages of short stay, less pain, faster recovery, ability to perform under regional anesthesia, less expense and an easier learning process for doctors makes SILS an ideal procedure for taking modern surgery to the poor and the marginalized. open surgical instruments

Figure 2: Use of open surgical instruments and passing them one at a time.

References (click to show/hide)

  1. Lift-Laparoscopy: The new concept of gasless laparoscopy with the Abdo-Lift™ http://www.lift-laparoscopy.com/InstrumentSet.pdf [accessed on June 18, 2013]
  2. Paolucci V, GuttCN, Schaeff B, Enckle A. Gasless laparoscopy in abdominal surgery. Surg Endosc 1995 May 9 (5) 497 -500
  3. Laparoscopic surgery History. http://www.news-medical.net/health/Laparoscopic-Surgery-History.aspx [accessed on March 8, 2013]
  4. Byron F. Santos, Daniel Enter, Nathaniel J. Soper Eric S. Hungness .Single-incision laparoscopic surgery (SILSTM) versus standard laparoscopic surgery: a comparison of performance using a surgical simulator: SurgEndosc 2007: 10; 1197-5

Gnanaraj-64 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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3 Comments

  1. vinod vijan
    Posted Oct 2013 at 12:31 am | Permalink

    Excellent Article. Keeping low cost surgeries in mind, what would be the cost in setting up a Laparoscopic unit?
    Please send the list and details by Email.
    Do we have Indigenous Laparoscopes of High quality and resolution?. Please mention.
    Thanks,
    Dr.Vijan. vmvijan@hotmail.com

  2. Dr.Pramod Kumar Sharma
    Posted Oct 2013 at 1:34 pm | Permalink

    Good step ahead of conventional Laparoscopic surgery especially in rural and remote areas of our country so the benefit reaches poor and needy.Your work is remarkable and commendable though it needs more work and data by other surgeons also.Keep it on,all the best.

  3. Dr. J. Gnanaraj
    Posted Oct 2013 at 5:10 am | Permalink

    Thanks for the comments and responses. We are very interested in taking laparoscopic surgery to the poor. The Lift laparoscopy solves the problem of needing special instruments for operating. Conventional open surgical instruments could be used. We are also working on adapting the ordinary cameras [like the cell phone camera] and laptop computers to get the pictures for operating. We have not yet come out with the prototype but have friends who are working on it.

    Meanwhile you could have a look at the following link

    http://www.imedicalapps.com/2013/10/study-iphones-mobile-endoscopic/

    to see how a cell phone could be connected to an endoscopic camera. We also have a similar camera to have the processing and light source from laptop computer. We are also working on the possibility of working without the need for a telescope too which is possible because of the Lift system.

    With the Karunya University we are planning to have training program in Lift laparoscopic surgery for rural surgeons.

    Please write to jgnanaraj@gmail.com for further details

    Thank you once again for your interest in rural surgery

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