Abstract
Background
Laparoscopy has proven to be feasible and effective at reducing surgical morbidity and mortality in low resource settings. In Rwanda, the demand for and perceived challenges to laparoscopy use remain unclear.
Methods
A mixed-methods study was performed at the four Rwandan national referral teaching hospitals. Retrospective logbook reviews (July 2014–June 2015) assessed procedure volume and staff involvement. Web-based surveys and semi-structured interviews investigated barriers to laparoscopy expansion.
Results
During the study period, 209 laparoscopic procedures were completed: 57 (27.3%) general surgery cases; 152 (72.7%) ob/gyn cases. The majority (58.9%, 125/209) occurred at the private hospital, which performed 82.6% of cholecystectomies laparoscopically (38/46). The three public hospitals, respectively, performed 25% (7/28), 15% (12/80), and 0% (denominator indeterminate) of cholecystectomies laparoscopically. Notably, the two hospitals with the highest laparoscopy volume relied on a single surgeon for more than 85% of cases. The four ob/gyn departments performed between 4 and 87 laparoscopic cases (mostly diagnostic). Survey respondents at all sites listed a dearth of trainers as the most significant barrier to performing laparoscopy (65.7%; 23/35). Other obstacles included limited access to training equipment and courses. Equipment and material costs, equipment functionality, and material supply were perceived as lesser barriers. Twenty-two interviews revealed widespread interest in laparoscopy, insufficient laparoscopy exposure, and a need for trainers.
Conclusion
While many studies identify cost as the most prohibitive barrier to laparoscopy utilization in low resource settings, logbook review and workforce perception indicate that a paucity of trainers is currently the greatest obstacle in Rwanda.
Similar content being viewed by others
References
Tiwari MM, Reynoso JF, High R et al (2011) Safety, efficacy, and cost-effectiveness of common laparoscopic procedures. Surg Endosc 25:1127–1135
Shankar P, Nandi A, Horton S, Levin C, Laxminarayan R (2015) Costs, effectiveness, and cost-effectiveness of selected surgical procedures and platforms. Dis Control Prior 1:325
Stylopoulos N, Gazelle GS, Rattner DW (2003) A cost–utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients. Surg Endosc 17:180–189
Bickler SN, Weiser TG, Kassebaum N et al (2015) Global burden of surgical conditions. In: Debas HT, Donkor P, Gawande A et al (eds) Essential surgery: disease control priorities, vol 1, 3rd edn. The International Bank for Reconstruction and Development/The World Bank, Washington
Basha YY, el-Muttarid NS, Sief M et al (1995) The first 100 laparoscopic cholecystectomies in the Republic of Yemen. J Laparoendosc Surg 5:163–167
Sergelen O (2006) Development of Laparoscopic Surgery in Mongolia. http://www.gfmerch/Medical_education_En/PGC_RH_2006/Reviews/pdf/Orgoi_laparoscopy_2006pdf
Bendinelli C, Leal T, Moncade F et al (2002) Endoscopic surgery in Senegal. Benefits, costs and limits. Surg Endosc 16:1488–1492
Brekalo Z, Innocenti P, Duzel G et al (2007) Ten years of laparoscopic cholecystectomy: a comparison between a developed and a less developed country. Wien Klin Wochenschr 119:722–728
Bal S, Reddy LG, Fau-Parshad R, Fau-Guleria R et al (2003) Feasibility and safety of day care laparoscopic cholecystectomy in a developing country. Postgrad Med J 79(931):284–288
Contini S, Fau-Taqdeer A, Fau-Gosselin RA (2010) Should laparoscopic cholecystectomy be practiced in the developing World? The experience of the first training program in Afghanistan. Ann Surg 251(3):574. https://doi.org/10.1097/SLA.0b013e3181d13ff8
Galukande MJJ (2011) Feasibility of laparoscopic surgery in a resource limited setting: cost containment, skills transfer and outcomes. East Cent Afr J Surg 16:112–117
Murphree S, Dakovic S Fau - Mauchaza B, Mauchaza B Fau - Raju V, et al (1994) Laparoscopic cholecystectomy in Zimbabwe: initial report
Price R, Sergelen O, Unursaikhan C (2013) Improving surgical care in Mongolia: a model for sustainable development. World J Surg 37:1492–1499. https://doi.org/10.1007/s00268-012-1763-1
Straub CM, Price RR, Matthews D et al (2011) Expanding laparoscopic cholecystectomy to rural Mongolia. World J Surg 35:751–759. https://doi.org/10.1007/s00268-011-0965-2
Chao TE, Mandigo M, Opoku-Anane J et al (2016) Systematic review of laparoscopic surgery in low- and middle-income countries: benefits, challenges, and strategies. Surg Endosc 30(1):1–10. https://doi.org/10.1007/s00464-015-4201-2
Hamamci EO, Besim H, Bostanoglu S et al (2002) Use of laparoscopic splenectomy in developing countries: analysis of cost and strategies for reducing cost. J Laparoendosc Adv Surg Tech Part A 12:253–258
Naude AM, Heyns CF, Matin SF (2005) Laparoscopic urology training in South Africa. J Endourol 19:1180–1184
Raiga J, Kasia JM, Canis M et al (1994) Introduction of gynecologic endoscopic surgery in an African setting. Int J Gynaecol Obstet 46:261–264
Nande AG, Shrikhande SV, Rathod V et al (2002) Modified technique of gasless laparoscopic cholecystectomy in a developing country: a 5-year experience. Digest Surg 19:366–372
Rwanda Human Resources for Health Consortium; Rwanda Ministry of Health., February 2015
Wengraf T (2001) Qualitative research interviewing: biographic narrative and semi-structured methods. Sage Publications, Thousand Oaks
Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 19:349–357
Glaser BS, Anselm LS (1967) The discovery of grounded theory: strategies for qualitative research. Weidenfeld and Nicolson, London
Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3:77–101
COSECSA Global Surgery Map In: Surgeon Workforce editor (2015)
Silverstein A, Costas-Chavarri A, Gakwaya MR et al (2017) Laparoscopic versus open cholecystectomy: a cost-effectiveness analysis at Rwanda Military Hospital. World J Surg 41:1225–1233. https://doi.org/10.1007/s00268-016-3851-0
Udwadia TE (2004) Diagnostic laparoscopy. Surg Endosc 18:6–10
Rasheed S, Zinicola R, Watson D et al (2007) Intra-abdominal and gastrointestinal tuberculosis. Colorectal Dis 9:773–783
Lofters AK (2012) The “brain drain” of health care workers: causes, solutions and the example of Jamaica. Can J Public Health 103:e376–e378
Szekanecz Z, Toth Z, Hamar A et al (2017) Why would doctors from Debrecen go abroad? Results of a questionnaire. Orv Hetil 158:1458–1468
Ricketts TC (2010) The migration of surgeons. Ann Surg 251:363–367
Wells KM, Lee YJ, Erdene S et al (2015) Expansion of laparoscopic cholecystectomy in a resource limited setting, Mongolia: a 9-year cross-sectional retrospective review. Lancet (London, England) 385(2):S38
Wells KM, Shalabi H, Sergelen O et al (2016) Patient and physician perceptions of changes in surgical care in Mongolia 9 years after roll-out of a national training program for laparoscopy. World J Surg 40:1859–1864. https://doi.org/10.1007/s00268-016-3498-x
Beard JH, Akoko L, Mwanga A et al (2014) Manual laparoscopic skills development using a low-cost trainer box in Tanzania. J Surg Educ 71:85–90
Merrell R, Rosser J (1999) Integration of quality programs by telemedicine in surgical services. Stud Health Technol Inf 64:108–114
Mir IS, Mohsin M, Malik A et al (2008) A structured training module using an inexpensive endotrainer for improving the performance of trainee surgeons. Trop Doct 38:217–218
Okrainec A, Henao O, Azzie G (2010) Telesimulation: an effective method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries. Surg Endosc 24:417–422
Okrainec A, Smith L, Azzie G (2009) Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course. Surg Endosc 23:2493–2498
Meara JG, Leather AJM, Hagander L et al (2015) Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386(9993):569–624. https://doi.org/10.1016/S0140-6736(15)60160-X
Shrime MG, Bickler SW, Alkire BC et al (2015) Global burden of surgical disease: an estimation from the provider perspective. Lancet Global Health 3(Suppl 2):S8–S9
Acknowledgements
The authors would like to acknowledge the Scholars in Medicine Office at Harvard Medical School for their financial support of medical student Faith Robertson on this project.
Funding
Faith Robertson received medical student funding from the Harvard Medical School, Scholars in Medicine Office. This was in the form of financial reimbursement for a round trip flight to Rwanda.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
Faith Robertson BS, Zeta Mutabazi MD, Patrick Kyamanywa MD, Georges Ntakiyiruta MD, Sanctus Musafiri, MD, PhD, Tim Walker MD, Emmanuel Kayibanda MD, Constance Mukabatsinda MD John Scott MD, MPH, and Ainhoa Costas-Chavarri MD, MPH have no conflicts of interest or financial ties to disclose.
Rights and permissions
About this article
Cite this article
Robertson, F., Mutabazi, Z., Kyamanywa, P. et al. Laparoscopy in Rwanda: A National Assessment of Utilization, Demands, and Perceived Challenges. World J Surg 43, 339–345 (2019). https://doi.org/10.1007/s00268-018-4797-1
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-018-4797-1