The GILLS or Gas Insufflation Less Laparoscopic Surgeries are slowly gaining popularity in remote and rural areas thanks to the involvement of researchers from NIHR - GHRG project of the University of Leeds. The first set of trainees were from Northeast India and it is being practiced in remote and rural areas of Northeast in places like Assam near the Bhutan border, in Nagaland, Manipur and Mizoram. The following is the excerpts from the lecture delivered through LapGuru.
The primary reason for us choosing this method was that there is no logistic nightmare of providing gases in rural and remote areas for both anaesthesia and surgery. Our rural surgeons have found it easier to learn especially when they can use traditional instruments and surgeries can continue with fluctuations in voltages etc.
NOT MUCH CHANGE WITH PNEUMOPERITONEUM. Over the years not much has changed about the pneumoperitoneum except that more people are using air now as the current insufflators can change to air when CO2 is not there. In 2002 when we started with ether, EMO machine and air probably no one was using these.
COMPLICATIONS & PROBLEMS
Most of those doing laparoscopic surgeries would not bother about the listed complications and they are primarily for publications and papers. Some might be just theoretical. As they are few and isolated no one worried unless they have had the complication talking to most laparoscopic surgeons they might not have had these complications.
THE SIGNIFICANT ONES
Probably the only significant disadvantage
with gas is when there is fogging of the lens and bleeding. The laparoscopic
suction is not all that effective and loss of pneumoperitoneum makes everything
difficult. I have talked to some of those who edited the videos for surgeons
who presented how they tackled their bleeding etc., and found only a small
portion of the actual footage was used for the presentations.
The reason for
the Western World working on Gas Less was the various physiological advantages
of gas less surgeries and to mitigate the problems with gas in high risk
patients and longer surgeries
SUMMARY OF THE
COMPLICATIONS
In our setting the only people who really appreciate the GILLS are the anaesthesiologists especially for those high risk patients.
ADVANTAGES
If there are 16 disadvantages then there have to be 16 advantages. Most of them are opposite of what was listed as disadvantage like if there shoulder pain with gas then there is no shoulder pain. If infection or spread is more than it is less with GILLS. If there are complications with port insertions they are not there with GILLS. Patients probably appreciate more the cosmetic value of single umbilical incisions.
The surgeons appreciate the use of open surgical instruments, the larger suctions, the gauze pieces inside the abdomen and open needle holders etc. Since the need for ports is not there the manoeuvrability is better especially for the single incision surgeries. Also single incision surgeries are much easier for GILLS unlike conventional laparoscopic surgeries.
THE RURAL SURGEONS like it because of the low cost, possibility of the laparoscopic surgeries under spinal anaesthesia and surgeries in remote areas.
The common surgeries carried out by the Rural surgeons were Cholecystectomies and pelvic surgeries and appendicectomies and diagnostic laparoscopic surgeries in emergency. The senor surgeons and faculty did hernia surgery.
THE NIHR –GHRG PROJECT of the University of Leeds helped us with TARGET TRAINING PROGRAM and now the Martin Luther Christian University is credentialing the course.
The video of the TARGET training program is
found in YouTube
Dr. 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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Introduction to Gas Insufflation Less Laparoscopic surgeries for Rural Areas
The GILLS or Gas Insufflation Less Laparoscopic Surgeries are slowly gaining popularity in remote and rural areas thanks to the involvement of researchers from NIHR - GHRG project of the University of Leeds. The first set of trainees were from Northeast India and it is being practiced in remote and rural areas of Northeast in places like Assam near the Bhutan border, in Nagaland, Manipur and Mizoram. The following is the excerpts from the lecture delivered through LapGuru.
https://www.lapguru.com/lapguru.php and https://www.lapguru.com/lecturePlayer/player.php?trans_id=1493882006
GILLS is very relevant during this time of COVID 19 pandemic because:
This is the reason why the Association of Rural Surgeons of India [ARSI] and the International Federation of Rural Surgeons (IFRS) recommended GILLS during and after the pandemic.
WHY GILLS?
The primary reason for us choosing this method was that there is no logistic nightmare of providing gases in rural and remote areas for both anaesthesia and surgery. Our rural surgeons have found it easier to learn especially when they can use traditional instruments and surgeries can continue with fluctuations in voltages etc.
NOT MUCH CHANGE WITH PNEUMOPERITONEUM. Over the years not much has changed about the pneumoperitoneum except that more people are using air now as the current insufflators can change to air when CO2 is not there. In 2002 when we started with ether, EMO machine and air probably no one was using these.
COMPLICATIONS & PROBLEMS
Most of those doing laparoscopic surgeries would not bother about the listed complications and they are primarily for publications and papers. Some might be just theoretical. As they are few and isolated no one worried unless they have had the complication talking to most laparoscopic surgeons they might not have had these complications.
THE SIGNIFICANT ONES
Probably the only significant disadvantage with gas is when there is fogging of the lens and bleeding. The laparoscopic suction is not all that effective and loss of pneumoperitoneum makes everything difficult. I have talked to some of those who edited the videos for surgeons who presented how they tackled their bleeding etc., and found only a small portion of the actual footage was used for the presentations.
The reason for the Western World working on Gas Less was the various physiological advantages of gas less surgeries and to mitigate the problems with gas in high risk patients and longer surgeries
SUMMARY OF THE COMPLICATIONS
In our setting the only people who really appreciate the GILLS are the anaesthesiologists especially for those high risk patients.
ADVANTAGES
If there are 16 disadvantages then there have to be 16 advantages. Most of them are opposite of what was listed as disadvantage like if there shoulder pain with gas then there is no shoulder pain. If infection or spread is more than it is less with GILLS. If there are complications with port insertions they are not there with GILLS. Patients probably appreciate more the cosmetic value of single umbilical incisions.
The surgeons appreciate the use of open surgical instruments, the larger suctions, the gauze pieces inside the abdomen and open needle holders etc. Since the need for ports is not there the manoeuvrability is better especially for the single incision surgeries. Also single incision surgeries are much easier for GILLS unlike conventional laparoscopic surgeries.
THE RURAL SURGEONS like it because of the low cost, possibility of the laparoscopic surgeries under spinal anaesthesia and surgeries in remote areas.
The common surgeries carried out by the Rural surgeons were Cholecystectomies and pelvic surgeries and appendicectomies and diagnostic laparoscopic surgeries in emergency. The senor surgeons and faculty did hernia surgery.
THE NIHR –GHRG PROJECT of the University of Leeds helped us with TARGET TRAINING PROGRAM and now the Martin Luther Christian University is credentialing the course.
The video of the TARGET training program is found in YouTube
More videos on GILLS could be found in YouTube
https://www.youtube.com/user/jgnanaraj/videos?view_as=subscriber
Dr. 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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