Introducing GILLS in Africa: First Impression

INTRODUCTION

The Gas Insufflation Less Laparoscopic Surgeries also called GILLS is ideal for Lower, Middle-Income Countries [LMIC] because it makes laparoscopic surgeries possible under the easily available Spinal anesthesia. The logistic nightmare of providing gases for surgery and anesthesia, the need for experienced anesthesiologists is not there with GILLS.

The Association of Rural Surgeons of India [ARSI] and the International Federation of Rural Surgeons [TFRS] promoted GILLS among the members by starting the Project GILLS and facilitated the randomized control trial at the Maulana Azad Medical College to prove that GILLS is not inferior to conventional laparoscopic surgeries.

GILLS brought together the International Collaboration on Innovation for Global Surgery and the first congress of the collaboration was held in Delhi in April 2022. The University of Leeds earlier produced the second-generation equipment for GILLS namely the RAIS device [Retractor for Abdominal Insufflation - less Surgeries] using frugal innovation and participatory design technique.

ARSI and IFRS formed Rural Surgery Innovations [RSI] to work on the low – cost innovations and organize training programs for them. RSI was invited to conduct GILLS workshop at PECA Hospital at Chogoria by the Operation Theater Practitioners of Kenya [OTPAK] and by Friends of St. Francis Hospital Foundation at St. Francis Hospital at Mutolere in Uganda.

The RSI is currently working on Laptop Cystoscope that connects the Cystoscope directly to the Laptop Computer and has an endo – cam attached to it replacing the telescope, camera, light source, etc., thus reducing the investment for doing diagnostic cystoscopies to less than one twentieth of the current full set of equipment necessary.

THE METHOD

The participants for the workshops were advised to register for the free online course at One. Surgery for rural urology practice and watch the lectures and videos in the IFRS health education YouTube channels. This was done to make sure that those who come for the workshop already are aware of what they want to do at the workshop.

The actual workshops were held during the following days

July 12, 2022= Rural Urology course at Methodist Medical College, Meru in Kenya

July 13 to 15, 2022 = GILLS workshop at PECA Hospital, Chogoria in Kenya

July 18 to 21, 2022= GILLS workshop at St. Francis Hospital, Mutolere in Uganda

The workshops had didactic lectures, training on the simulator boxes and hands on training in the Operating Rooms.

THE RESULTS

The Rural Urology course was well attended by both the students and the staff of the medical college who were surprised that low – cost cystometrogram can clearly explain the reasons behind the Lower Urinary tract symptoms and help with correct treatment for them. They were able to use the Laptop Cystoscope at the minor operating room in the Emergency department.

Those who attended the workshop in Chogoria were surgeons who are familiar with conventional laparoscopic surgeries. Although some were skeptical about the use of GILLS before coming for the workshop, they were convinced that the pictures that they saw through the telescope was no different from that of conventional laparoscopic surgeries. A trainee, a general surgeon and a gynecologist were able to perform the surgeries by themselves using GILLS.

In Uganda none of the surgeons and gynecologists had prior experience with conventional laparoscopic surgeries and needed more time to perform Diagnostic Laparoscopies for Infertility by themselves. They also tried conventional laparoscopic surgeries but found GILLS easier.

TAKE HOME MESSAGES

In Africa the Urologists felt that they did not have much time for Diagnostic Cystoscopies because they had to be performed in the Operating Rooms (that had the Laparoscopic Towers). It was expensive and it was difficult to find time for Diagnostic Cystoscopies. The Laptop Cystoscope could help them perform the Diagnostic Cystoscopies in the Outpatient department or minor operating rooms where anesthesiologists were not needed.

In Kenya the residents learnt conventional laparoscopic surgeries during the training period but felt it was not useful as they did not have laparoscopic surgical facilities in the places where they would go after training, and it would take several decades for those places to have such facilities. Hence, they were keen to try and use the Laptop Cystoscope for GILLS procedures and felt that they would be able to continue laparoscopic surgeries with GILLS and Laptop Cystoscope and the cost of these would be only $2000 which is easily affordable for the rural hospitals.

Those from places that had conventional laparoscopic surgical facilities felt that doing laparoscopic surgeries under spinal anesthesia was a big blessing as most of the anesthesiologists were clinical officers who were more comfortable with Spinal anesthesia. The surgeons felt that they were reluctant to give sufficient muscle relaxants during surgery and the leaks from old used ports and instruments made surgeries more difficult.

In Uganda in one of the conventional laparoscopic surgeries due to gas leak the entire large carbon di oxide cylinder was used up quickly. The second patients had conversion to GILLS as they ran out of carbon di oxide.

In Africa those places who have the latest and expensive conventional laparoscopic surgical donated to them still prefer GILLS because the advantages of Spinal Anesthesia and the difficulties of getting the carbon di oxide gas. In Uganda carbon di oxide cylinders came from a place that was 10-hour drive from the Hospital. Clinical officers are more comfortable with Spinal Anesthesia too.

If a low–cost Laptop Laparoscope is made available to them it would dramatically change the way surgeries are carried out in Africa.

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J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is an urologist and laparoscopic surgeon trained at CMC Vellore. He is the Past President and Project Lead for the Project GILLS of the Association of Rural Surgeons of India, the Secretary of the International Federation of Rural Surgeons and board member of the G 4 Alliance. He is also an Adjunct Professor at Karunya University. He has over 400 publications in national and international Journals related to rural surgery and has won many innovations award like the EHA innovation award, Antia Finseth award, the Lockheed Martin award, the Millennium Alliance award, etc., He has few patents and the low cost equipment is listed in the WHO compendium of medical equipment for resource poor setting. He has helped many hospitals start Minimally Invasive Surgeries. The popular innovations that have made MIS possible in rural areas are the Gas Insufflation Less Laparoscopic Surgeries and the Laptop cystoscope. 

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