"Laparoscopic surgery for the poorest of the poor"
by Daniel Kruschinski, MD and Michaela Katzer
The Preamble of the W.H.O. constitution:
"The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human without distinction of race, religion, political belief, economic or social condition"
But…
In rural areas 20 % of surgeons are addressing the need of 80 % of the population without basic infrastructure power, water, sanitation, roads, and schools.
So …
With this dismal background of health care, can we hope to give quality surgical care to the poor?
Contradictory as it may sound, the answer is an emphatic YES.
I am confident that inspite of official apathy, or perhaps because of it, we are moving in the right direction.
The surgical care for the poor is an uphill and Herculean task, yet a task worthy of every ounce of our collective effort and energy. No one person, no one country can have the answers. It is vital all surgeons from all spheres of activity in the developing world from Professors to village doctors, as also those from all developed areas pool their concerns in this effort. If success is defined not by what one has attained but by the effort made in overcoming obstacles, just our sincere efforts in this cause would be by far the greatest triumph, the ultimate success story in the art and science of surgery - to ensure basic surgical care for all the poor.
For around 17 years lecturing about gasless Lift-Laparoscopy I have advocated, that for pragmatic progress in surgery in the developing world one must adhere to the concept of the 5 A's (acc. to Udwadia, 2003)
Available, Affordable, Accessible, Acceptable and Appropriate
If CO2 cylinders have to be transported 200 kilometres over rough terrain to refill, the use of gasless laparoscopy would be available, accessible, acceptable, affordable, and hence appropriate.
The situation of laparoscopic surgery in many underdeveloped countries is fatal. Dr. John Ojokwu (the only laparoscopic surgeon in Nigeria) for example, who uses carbon dioxide said at our course in Ibadan that gasless Lift-laparoscopy is “a god send tool”.
The future of (laparoscopic) surgery as also of the surgical care of the poor in those countries lies in the proliferation, education, acknowledgement, recognition of the emerging genre of surgeons who by dint of courage, capability, innovation, improvisation, sacrifice have given a new dimension and aura to rural surgery
An example from India:
“Surgeons in India have innovated laparolift equipment out of towel clips, coat hangers, water pipes to permit the penetration of gasless laparoscopy to rural India and quality M.A.S. has been taken into small town rural India.”
Nande AG, 1997
Deshpande SV, 1997
Ramakrishna HK, 2003
To try to help establish laparoscopic surgery in underdeveloped countries, we conduct courses for Lift-laparoscopy, like our last course in the University of Ibadan, Nigeria last November, where we spent 14 days at the course:
“1st Ibadan Laparoscopic Surgery Training Workshop (Standard / Gasless)” under Prof. A.O. Ilesamni (CMD of the UCH Ibadan) and organised locally by Dr. Chris Enakpene from UCH Ibadan.
The University College Hospital is the oldest and the most prestigious in West-Africa, as it is founded 1952 by the London University.
The course which we have organised together with EndoSurgery Ltd, as a gyneco-general surgical course, together with the ONLYONE endoscopic surgeon, Dr. John Ojokwu from Lagos, Nigeria, we had each 5 days gynecologic procedures (4 total hysterectomies, 5 myomectomies, 4 endometriosis cases, 3 adnexal masses cases) and in general surgery (11 cholecystectomies, 3 hernias, 2 diagnostic laparoscopies).
At the course we had 15 participants from all over the country, like from Abuja, Lagos, Ibadan.
We trained one gynecologic surgeon in Lift-Laparoscopy and are invited to come there again this December to train more of them. We have left two Abdo-Lift equipment in the UCH.
The CMD of the UCH Ibadan, Prof. Ilesanmi assured us that this workshop was an important step and that Workshops on laparoscopy via gasless Lift-Laparoscopy will provide the exhilaration of a wonderful metamorphosis in rural surgery and he believes that this is the key technology for under developed countries. He has connections to the WHO which is very much interested to support such missions to provide modern medicine to the poorest of the poor.
Our next project is a course in Mali, near to Timbuktu in the Koutiala Hospital, where some American doctors are helping in mission hospitals and doing a great work. The mission hospital has already received an Abdo-Lift equipment. The course will take place in February on the same basis as in Ibadan.
I would also like to stress that going to Nigeria or Timbuktu doesn’t mean only fun, but also shows how poor the countries are. Even if it was the most prestige university of Western Africa one can see where it lacks:
Here you can see that they even don’t have high operating tables to ensure a good assistance of the nurse for laparoscopic surgery. But with a little improvisation we could build one.
John Awojobi, a rural surgeon who write many article about rural surgery and whom we met in Nigeria states: Similar improvisations are seen in almost every developing country. For example in rural Nigeria rain water is harvested in nursing homes for year around water supply, a charcoal furnace powers the autoclave, large windows which catch sunlight compensate for interrupted electric supply, all hospital equipment is fabricated by the village blacksmith, the rear wheel of a bicycle doubles as a haemotocrit centrifuge.
So just imagine the hygienic standard, the hospitals can’t afford special washing machines for laparoscopic instruments, so why to show them laparoscopic surgery with laparoscopic instruments that can not be washed and sterilised. Using unwashed instruments could make the problem of infections even more evident.
But…
As you can see, they are willing to learn laparoscopic surgery and they are extremely interested to try anything to be able to perform laparoscopic surgery, but off course they need a very cheap and simple start-up set.
They have outstanding surgeons and if we teach them, they will very soon become teachers for their regions and I can tell you that countries like Nigeria, Mali, Sudan, Ghabun and others are really those ones that will benefit from laparoscopic surgery, as the morbidity and even mortality associated with laparotomies is relatively high. And on the other site, the hospitals don’t have enough places to keep people inpatient so they have to discharge patients with laparotomies soon after the surgery back to their family homes.
Just imagine how much we could help, by supporting them with very simple equipment and ideas for starting laparoscopy and how many lives and complications they can avoid starting laparoscopy with the help of gasless Lift-Laparoscopy.
Above all, our teaching refocus on principles. The principles of surgery are universal, are few and are magnificently simple. The art of surgery consists of judgment and of the beauty of an operation well done, done gently, with respect for living tissue, for every cell, with reverence for form and function, carried out with compassion, always remembering that the only justification for invading the body of another individual is the intent to restore homeostasis. Whilst western technology might be the destiny of surgeons in rural areas they embrace it with consideration for appropriateness, equity, affordability - otherwise their practice will lack its ethical purpose: beneficence.
John Awojobi, a rural surgeon in Nigeria states:
In an age where Professors in teaching institutions inculcate and urban surgeons stress the importance of sub and super specialization, the rural surgeons will improve his surgical care by sterilizing his instruments in water boiling over a kerosene stove, with an untrained anaesthetist using ether anaesthesia, with an unqualified nurse as his sole assistant, quite often with torn or even no surgical gloves. These rural surgeons are prepared to do this because they know they are the last bastion of the poor - beyond them there is no other succour. Their gains may be meager but their joys and rewards are bountiful and they may well ask their urban colleagues, a question asked 2000 years ago - what avails a man if he gains the world, but loses his soul?
Anyway, on the other hand, for us it is quite dangerous to move around in some countries, like Nigeria. Even the local people don’t go out after sunset. For example in Lagos on the way to the airport, we were robbed; even we had a driver from one of our friends. Robbers and police work together, the policemen are all corrupted and don’t help. A dozen of machine gun armed guys in a uniform played military and we had to pay a royalty to pass the road. They wanted 30.000 Nigerian Naira, (like 200 Euros) and we bargained to 3000 Naira = 20 Euros. We were lucky to escape after paying 20 Euros as later some people in the waiting lounge at the airport told us that the robbers usually shoot in the knee, if you don’t give money.
Even this kind of danger does not make me afraid going into countries like this and help. The satisfaction one gets from the poor people you help is greater than the danger out of robbers and thieves. I feel, the little I do is very important for the regions of poor people all over the world and I for myself as a physician I have found for the first time in my life a deep satisfaction to teach and train laparoscopic surgery and am happy to be able to do that on a low cost basis together with a small company to ensure low cost, but effective systems for starting laparoscopy.
And we did
The first laparoscopic cholecystectomy at Ibadan and Nigeria
The first lift-laparoscopic total hysterectomy at Ibadan and Nigeria
The first lift-laparoscopic myomectomy at Ibadan and Nigeria
The first Adnexectomy at Ibadan and Nigeria and
The first Ovarian cyst enucleation at Ibadan and Nigeria
Best wishes.
Daniel Kruschinski, MD and Michaela Katzer (endoscopic nurse and owner of EndoSurgery Ltd.)
