PILOT EXPERIENCE WITH LAPAROSCOPIC CHOLECYSTECTOMY IN JOS, NIGERIA - CHALLENGES AND PROSPECTS

Misauno MA.
Department of Surgery, Jos University Teaching Hospital, PMB 2076, Jos, Nigeria.
E- mail:micoyedim@yahoo.co.uk
Telephone: +234 8035895880

*Correspondence
Grant support: None
Conflict of Interest: None

Abstract

Background: While laparoscopic cholecystectomy is the gold standard in developed countries for the removal of the diseased gallbladder, the procedure is just gaining popularity in Nigeria. This was a documentation of the authour’s initial experience with laparoscopic cholecystectomy in a private hospital setting.

Aims & Objectives: To highlight the challenges of laparoscopic cholecystectomy in our environment and recommend solutions.

Materials and Methods This was a prospective analysis of 35 consecutive patients presenting for laparoscopic cholecystectomy at a private hospital with special interest in endoscopy located in Jos, North Central Nigeria from June 2008 to May 2011. A Standard four-port laparoscopic cholecystectomy was performed in all the patients. The demographics, clinical features and management outcome were entered in a proforma and analyzed with Epi-info.

Results: A total of 35 laparoscopic cholecystectomies were performed during the study period. There were 5(14%) males and 30(86%) females giving a male: female ratio of 1:6. The mean age of the study population was 40.1± 11.4years and the mean operating time was 90 minutes with a range of 45-125 minutes. All the patients had chronic calculous cholecystitis and one (2.9%) of them also had empyema of the gall bladder. There were 2 conversions to open cholecystectomy in this study giving a conversion rate of 9.1%.

Conclusion: Laparoscopic cholecystectomy is a safe and acceptable way of performing cholecystectomy in our environment even in a private hospital with careful patient selection, attention to details and performed by experienced surgeons.

Key words: Laparoscopic cholecystectomy, Challenges, Good outcome, Jos, Nigeria.

INTRODUCTION

Laparoscopic cholecystectomy is now accepted worldwide as the gold standard procedure for the removal of diseased gall bladders1 because of its clear cut advantages of reduced surgical trauma, less post-operative pain and easy return to normal life when compared to conventional open cholecystectomy2. The practice of laparoscopic surgery is however new to some African countries due not only to the high cost of this technology but also to the inability of the patients to afford the cost of treatment and scarcity of experienced laparoscopic surgeons in our environment. However, a few reports from elsewhere in Africa showed that it was not only feasible but affordable3. In spite of the initial capital investment in procuring the equipment and training of personnel, laparoscopic surgery offers enormous advantages that cannot be ignored4. This study was aimed at evaluating our initial experience with laparoscopic cholecystectomy in a private hospital setting in Nigeria over a three-year period to highlight the challenges and the prospects.

Patients and methods

The 35 consecutive patients presenting for laparoscopic surgery at Adoose Specialist Hospital in Jos, Nigeria from June 2008 to May 20011 were prospectively analyzed and formed the subject of this study. Ultrasonography was the diagnostic investigation after detailed clinical history and physical examination. All the procedures were carried out under general anaesthesia with cuffed endotracheal tube and nasogastric tube. Initial access was gained by introducing the umbilical port into the peritoneal cavity through a sub umbilical incision without the need for the Verre’s needle, and pneumoperitoneum was achieved via the umbilical port using carbon dioxide (CO2) gas. Visibility was afforded by a 33cm long zero degree laparoscope mounted over a Stryker camera and light source. All the operations were performed by the author who had had laparoscopic cholecystectomy training. A standard four- port laparoscopic cholecystectomy was performed in all the patients and on two occasions, we improvised delivery bags from latex gloves – a procedure practiced in resource-scarce environments.

Results

A total of 35 laparoscopic cholecystectomies were performed during the study period. There were 5(14%) males and 30(86%) females giving a male: female ratio of 1:6. The mean age of the study population was 40.1± 11.4years and the mean operating time was 90 minutes with a range of 45-125 minutes. There were 2 conversions in this study giving a conversion rate of 9.1%. 0ne patient had port site wound infection post cholecystectomy for empyema of the gallbladder.

There was no mortality in this study. All the patients were discharged on the second post operative day except for the two conversions that were discharged on the 5th post operative day. The average cost of each procedure was two hundred thousand naira ($1250).

Discussion

The main finding was that majority (86%) of the patients that had laparoscopic cholecystectomy in this study were females. This is in agreement with reported works in literature on laparoscopic cholecystectomy5-8 . This is attributable to the fact that gall bladder diseases are more common in females than males coupled with their desire for the better cosmetic outcome conferred by laparoscopic Cholecystectomy5-7. Most of the patients were in their fourth and fifth decade which was in agreement with what was generally known about gallstones being common in fat, fertile, fair females in their forties. The same finding had also been reported by other researchers1,8,9. The mean operative time was ninety minutes and compared favourably with that reported by Clegg-Lamp10 from Ghana but longer than that reported by Sanogo and Michalowski11,12. The variability in the operation time for the different studies reflected the learning curve involved in laparoscopic surgery.

There was a 9% conversion rate in this study which was much higher than the 2% reported by Salam.(1) This may be explained by the small sample size and the relative inexperience of the surgeons which were indeed the limiting factors in this study. Wound infection which occurred in the only patient with empyema of the gall bladder was the only complication in this study.

All the patients were discharged on the 2nd post-operative day except for the two patients who had conversion to open cholecystectomy and were discharged on the 5th post-operative day; a finding in agreement with the findings of other workers2,13,14. There was no mortality in this study which attested to the safety of laparoscopic cholecystectomy15.

A lot of challenges hampered the development of laparoscopic surgery in resource poor settings especially the high cost of setting up and maintaining the tower, expensive training cost for personnel and shortage of consumable items4,16 which had made some surgeons to wonder whether developing countries were ripe for this practice17.

Conclusion: Laparoscopic cholecystectomy was a safe and acceptable way of performing cholecystectomy even in a private hospital with careful patient selection, attention to details and performed by experienced surgeons. The challenges were in the cost of installation of the laparoscopic tower, the maintenance of the equipment, provision of the accessories and training of general surgeons who would perform the procedure safely.

Acknowledgement

Our sincere gratitude goes to the management and staff of Adoose Specialist Hospital, Jos and to Dr Ron Cheney of Navigators African partners for providing hands-on workshops.

References

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