Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 2 Issue: 4

Adoption of Laparoscopy in a Rural Medical College Hospital: Minimal Access Surgery for Masses a Reality

Gillellamudi Sarath Babu1 and Vellanki Venkata Sujatha2*
1Department of General Surgery, Kamineni Institute of Medical Sciences (Sreepuram), Narketpally, Nalgonda, Andhra Pradesh, India
2Department of Obstetrics and Gynaecology, Kamineni Institute of Medical Sciences (Sreepuram), Narketpally, Nalgonda, Andhra Pradesh, India
Corresponding author : Venkata Sujatha Vellanki
Department of Obstetrics and Gynaecology, Kamineni Institute of Medical Sciences, Sreepuram, Narketpally, Nalgonda, Andhra Pradesh-508254, India
Tel: 08682 272118; Fax: 08682 272829; 919849047585
E-mail: [email protected]
Received: March 15, 2013 Accepted: June 15, 2013 Published: June 20, 2013
Citation: Sarath Babu G, Venkata Sujatha V (2013) Adoption of Laparoscopy in a Rural Medical College Hospital: Minimal Access Surgery for Masses a Reality. J Womens Health, Issues Care 2:4. doi:10.4172/2325-9795.1000112

Abstract

Adoption of Laparoscopy in a Rural Medical College Hospital: Minimal Access Surgery for Masses a Reality

Since the early 1970’s, pioneers in India have set mile stones in laparoscopy. Dr. F.P. Antia, then Physician at the KEM Hospital, Mumbai performed a diagnostic laparoscopy on a patient with cirrhosis using a Nitze-type telescope and a feeble filament light bulb and atmospheric air instilled with the help of a sigmoidoscope pump for induction of pneumoperitoneum. In time many of these hospitals became specialised high volume centers based in major cities.

Keywords: Laparoscopy; Laparoscopic appendectomy; Laparoscopic hysterectomy

Keywords

Laparoscopy; Laparoscopic appendectomy; Laparoscopic hysterectomy

Introduction

Since the early 1970’s, pioneers in India have set mile stones in laparoscopy. Dr. F.P. Antia, then Physician at the KEM Hospital, Mumbai performed a diagnostic laparoscopy on a patient with cirrhosis using a Nitze-type telescope and a feeble filament light bulb and atmospheric air instilled with the help of a sigmoidoscope pump for induction of pneumoperitoneum [1]. In time many of these hospitals became specialised high volume centers based in major cities.
The preamble of the World Health Organization charter reads: “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” [2].
Out of the total of 1210.2 million population in India, the size of Rural population is 833.1 million (or 68.84% of the Total Population) [3].
With two thirds of India’s population living in rural areas and one third of the population living below the poverty line, access to sophisticated surgery is limited. However these patients benefit most from the early return to work after minimal access surgery [4]. This need based study was conducted to assess the feasibility and outcome of laparoscopic surgery at a rural teaching hospital.

Materials and Methods

The laparoscopic system of surgery was made available for the poor and needy patients of this area who otherwise had to travel a long distance to city hospitals for this facility. This study was carried out at Kamineni Institute of Medical college hospital Narketpally, Andhra Pradesh from January 2011 to December 2013 and was completed in two years. This college is situated in a rural area which consists of rural and tribal people with no good medical facilities within 80 kilometres of the college. The present study elaborates the early experience of laparoscopy in both department of general surgery and gynecology in a rural set up in terms of morbidity and mortality and patient acceptability. In each case written informed consent was obtained including a statement that procedure may be converted to laparotomy if required. In diagnostic laparoscopy consent was taken to proceed for operative laparoscopy should the need arise. Our patient acceptance for this protocol was good. The study was conducted after approval from Institute review board. Laparoscopy instruments used were mostly reusable and are used after autoclaving. The endobags are prepared in the hospital using disposable gloves. This cut downs the costs of the surgery. This hospital is a teaching hospital that caters the rural population who cannot afford the costly medical expenses. The management of the institute does not charge the patients for any surgeries either open or laparoscopy.

Results

A total of 206 cases were done. Surgeries included from appendectomy, cholecystectomy, salpingectomy for ectopic pregnancy, laparoscopic ovarian drilling and chromopertubation, tubal ligation, ovarian cystectomy, sling operations for Prolapse and hysterectomy (Table 1). Previous surgeries and obesity were not considered as contraindications. Infact we noticed that the post operative recovery was faster and the patients were ambulated within 24 hours. Hysterectomy formed the major bulk of our operations. The mean duration of the operation was 80 minutes. There was a long time taken for setting up the trolley and cables initially around one hour but now it takes only 30 minutes from induction of anaesthesia to the skin incision. The mean duration of the operation was 80 minutes though the surgeries lasted from 20 minutes to three to four hours (Table 2). Initially we took around three hours for a hysterectomy, but now an uncomplicated case takes us only one hour though time was never criteria in our cases. The postoperative hospital stay was from 2 to 6 days. No intra operative complications occurred and the hospital course of all patients was uncomplicated (Table 3). In one case, laparoscopy was converted to laparotomy. One patient had minor wound infection at umbilical port site. The patients did not report any complaints during follow up and the clinical examination findings were normal in all, up to 2 months after discharge.
Table 1: Type of Laparoscopic surgeries performed.
Table 2: Operative time ranges/number of patients.
Table 3: Postoperative complications/Number of patients.

Discussion

Laparoscopic surgery is not a super specialty-it is merely the logical progress of general surgery brought about by advanced technology in instrumentation and imaging. To make this advance available to the entire Indian community irrespective of socio-economic status, it is imperative to spread this advance to every surgeon in India - a goal which can only be achieved if every teaching hospital imparts training in minimal access surgery to every resident and every University incorporates this advance as an essential element in its curriculum. This is the real challenge faced by surgeons in India, to realize that laparoscopic surgery can grow in India not with robots but with basic equipment, to go beyond merely following the developed world by devising technology compatible with our country [1].
A large number of the laparoscopic procedures are usually performed for ovarian masses [5-7] and this was 21% in our study. Hysterectomy with bilateral salpingo-oophorectomy is not necessarily essential for all postmenopausal women with a clinically palpable ovary. In our series there were 3 such patients above the age of 40 years in whom a laparoscopic ovarian cystectomy was considered to be an adequate procedure after careful evaluation of the ovarian mass. Therefore a thorough preoperative workup of the ovarian mass is essential to decide whether the patient should undergo conservative management, cyst aspiration, laparoscopic surgery or laparotomy.
Hysterectomy is one of the commonest inpatient surgical procedures in gynecology and approximately 70% have been done using the conventional abdominal route [8]. In our study Laparoscopic assisted vaginal hysterectomy was performed in 19 patients who would have otherwise needed laparotomy. Two cases required conversion and were during our initial phase as one had a cervical fibroid extending on to the pelvic side wall and the other had previous caesarean delivery and there were adhesions though later on we started doing cases of previous caesarean delivery by following lateral and sharp dissection for separation of the bladder. We have started doing total laparoscopic hysterectomy in 13 patients and suturing the vault from inside as it has the advantage of less blood loss and anchoring the uterosacral ligaments to vault was easier.
Laparoscopic abdominocervicopexy was done for Nulliparous Uterovaginal Prolapse with uterine conservation and also for vault suspension with good results and less intraopertive blood loss and reduced operative time.
Myomectomy was done in three cases for infertility. Endo suturing was done in two cases and transperitoneal suturing was done in one. Myoma were retrieved by extending the supra pubic port incision as we do not have a morcellator.
Ectopic gestations could be managed by operative laparoscopy in 8/9 patients. Both ruptured and unruptured cases could be treated and one patient had conversion due to haemodynamic instability.
Laparoscopic appendectomy was done in 47 cases. The base of the appendix was ligated with a pre tied Roeder knot made of chromic catgut prepared just before insertion. This helped us to reduce the cost of the surgery.
In one patient of intussusception a large laparotomy scar was avoided as the loop of bowel was identified laparoscopically and was brought out through a 3 cm mini incision and corrected and slipped back into the peritoneal cavity. All the complications were grade II as per the Dindo Clavien classification [9].
This is a very early experience of the authors and further studies would be done to assess the each surgery in comparision with open surgeries in view of hospital stay and operating time and complications.

Conclusion

It is possible to safely implement Laparoscopy in both department of general surgery and gynecology, in a rural set up.
The well known advantages of laparoscopy: replacing long and painful incisions with multiple small punctures results, less disfigurement, less post operative pain, shorter inpatient hospital stay and shorter convalescence can be achieved, also in this setting.
Laparoscopy is probably even more beneficial to the patients from rural area as most of them are daily wagers and they can resume their work early.

Competing Interests

The authors declare that they have no competing interests.

Acknowledgments

The cases were managed and operated by Gillellamudi Sarath Babu and Vellanki Venkata Sujatha. The authors have read and approved the final manuscript. Gillellamudi Sarath Babu underwent one year fellowship in laparoscopic surgery after three years of masters degree in general surgery in a recognized institute with facilities for laparoscopic surgery and training. Vellanki Venkata Sujatha took two weeks hands on training in basic laparoscopy after three years of masters degree in obstetrics and gynaecology in a recognized institute with facilities for laparoscopic surgery and training.

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