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REVIEW
Systematic review of laparoscopic surgery in low- and middle-
income countries: benefits, challenges, and strategies
Tiffany E. Chao
1,2
•Morgan Mandigo
2,3
•Jessica Opoku-Anane
4
•Rebecca Maine
2,5
Received: 3 January 2015 / Accepted: 31 March 2015
Springer Science+Business Media New York 2015
Abstract
Background Laparoscopy may prove feasible to address
surgical needs in limited-resource settings. However, no
aggregate data exist regarding the role of laparoscopy in
low- and middle-income countries (LMICs). This study
was designed to describe the issues facing laparoscopy in
LMICs and to aggregate reported solutions.
Methods A search was conducted using Medline, African
Index Medicus, the Directory of Open Access Journals, and
the LILACS/BIREME/SCIELO database. Included studies
were in English, published after 1992, and reported safety,
cost, or outcomes of laparoscopy in LMICs. Studies per-
taining to arthroscopy, ENT, flexible endoscopy, hys-
teroscopy, cystoscopy, computer-assisted surgery,
pediatrics, transplantation, and bariatrics were excluded.
Qualitative synthesis was performed by extracting results
that fell into three categories: advantages of, chal-
lenges to, and adaptations made to implement la-
paroscopy in LMICs. PRISMA guidelines for systematic
reviews were followed.
Results A total of 1101 abstracts were reviewed, and 58
articles were included describing laparoscopy in 25
LMICs. Laparoscopy is particularly advantageous in
LMICs, where there is often poor sanitation, limited di-
agnostic imaging, fewer hospital beds, higher rates of
hemorrhage, rising rates of trauma, and single income
households. Lack of trained personnel and equipment were
frequently cited challenges. Adaptive strategies included
mechanical insufflation with room air, syringe suction,
homemade endoloops, hand-assisted techniques, extracor-
poreal knot tying, innovative use of cheaper instruments,
and reuse of disposable instruments. Inexpensive labora-
tory-based trainers and telemedicine are effective for
training.
Conclusions LMICs face many surgical challenges that
require innovation. Laparoscopic surgery may be safe, ef-
fective, feasible, and cost-effective in LMICs, although it
often remains limited in its accessibility, acceptability, and
quality. This study may not capture articles written in
languages other than English or in journals not indexed by
the included databases. Surgeons, policymakers, and
manufacturers should focus on plans for sustainability,
training and retention of providers, and regulation of efforts
to develop laparoscopy in LMICs.
Keywords Global Surgery Laparoscopy LMIC
Low-resource settings Training/courses
Surgical conditions are an acknowledged and often ne-
glected global health problem disproportionately affecting
the world’s poorest people [1]. Perioperative mortality is as
high as 5–10 % in low-income countries (LICs) compared
to 0.4–0.8 % in high-income countries, with the majority
related to infections, anesthesia complications, and
&Tiffany E. Chao
tchao@mgh.harvard.edu
1
Department of Surgery, Massachusetts General Hospital, 55
Fruit Street, GRB 425, Boston, MA 02114, USA
2
Program in Global Surgery and Social Change, Harvard
Medical School, Boston, MA, USA
3
University of Miami Miller School of Medicine, Miami, FL,
USA
4
Department of Obstetrics and Gynecology, George
Washington University School of Medicine and Health
Sciences, Washington, DC, USA
5
Department of Surgery, University of California San
Francisco, San Francisco, CA, USA
123
Surg Endosc
DOI 10.1007/s00464-015-4201-2
and Other Interventional Techniques
hemorrhage. Inadequate infrastructure, equipment,
medications, organizational management, and infection
control contribute to these difficulties [2].
In developed countries, many surgical conditions are
preferentially treated with minimally invasive surgery
(MIS), including laparoscopy. MIS provides several ad-
vantages over open surgery, including decreased infection,
decreased blood loss, reduced postoperative pain, improved
bed utilization, and rapid return to work [3,4]. These
distinct advantages of laparoscopy over open operations
may be even more pronounced in developing countries,
where access to clean water and sanitary living conditions
can be limited [5] and blood banks are scarce. In addition,
modern diagnostic imaging is often not available in low-
and middle-income countries (LMICs), and diagnostic la-
paroscopy may be both clinically and economically ef-
fective [6,7]. For example, in a district hospital in Nigeria,
the unnecessary laparotomy rate was found to be 14 %
among patients with acute abdomen, resulting in 6 un-
necessary deaths as well as other significant morbidity [6].
Diagnostic laparoscopy may be more cost-effective as
well; the equipment cost ratio of laparoscopy/ultrasonog-
raphy/CT/MRI has been estimated at 1:500:2500:4500 [7].
Laparoscopy equipment may be accessible in some
LMICs as a result of laparoscopic tubal ligation campaigns
that occurred in the 1970s and 1980s [8] and subsequent
donations from charitable organizations. Surgeons in re-
source-limited settings have shown that the procedures can
be affordable and patient costs can be similar to laparotomy
[9,10]. Udwadia described doing his first 3200 diagnostic
laparoscopies using a single laparoscopic set and reusable
instruments from 1972 to 1990. Equipment costs per case
were $0.75. His next 1084 cases of laparoscopic chole-
cystectomies had a total cost per patient of $20 [9]. There is
an abundance of literature reporting adaptations that can
decrease costs and surmount other barriers to allow for
more widespread utilization of laparoscopy in LMICs [7,
11].
However, some suggest that laparoscopic surgery may
not be appropriate for developing countries, arguing that it
is expensive, requires specialized training and technical
support, and distracts attention from urgent basic needs
[12]. Traditional open surgery is often considered to be
safer, and in limited-resource settings, mortality can be a
greater priority than both decreased morbidity and im-
proved cosmesis.
There are no validated models that can determine the
safety and feasibility of laparoscopic surgery in resource-
limited settings. The purpose of this paper is to aggregate
the literature, including feasibility, risks and benefits, and
required adjustments. Additionally, we suggest recom-
mendations to ensure patient safety and sustainability.
Materials and methods
This study follows the guidelines for Preferred Reporting
Items for Systematic Reviews and Meta-Analyses
(PRISMA) [13]. A database inquiry was initiated in Medline,
LILACS/BIREME/SCIELO, DOAJ, and African Index
Medicus for studies analyzing safety, cost, and outcome
aspects of minimal invasive surgery in LMICs after 1992.
Studies in English were included, but not studies pertaining
to arthroscopy, ENT, flexible endoscopy, hysteroscopy, cys-
toscopy, computer-assisted surgery, children under 18, organ
transplantation, stem cell transplantation, or bariatric surgery.
Complete search terms were as follows: (‘‘Laparoscopy’’ or
‘‘Thoracoscopy’’ or ‘‘Minimally invasive surgery or surgical
procedures’’) ?(LMIC code) ?(‘‘Safety’’ or ‘‘Costs and
cost analysis’’ or ‘‘Treatment outcome’’ or ‘‘Mortality’’ or
‘‘Length of stay’’) -(‘‘Endoscopy’’ or ‘‘Flexible endoscopy’’
or ‘‘Colonoscopy’’ or ‘‘Hysteroscopy’’ or ‘‘Cystoscopy’’ or
‘‘Computer assisted surgery’’ or ‘‘Eye*’’ or ‘‘Ocular*’’ or
‘‘Ophtal*’’ or ‘‘Nose’’ or ‘‘Nasal’’ or ‘‘Throat’’ or ‘‘Child*’’ or
‘‘Infan*’’ or ‘‘Adolesc*’’ or ‘‘Teen*’’ or ‘‘Pediatr*’’ or ‘‘Pae-
diatr*’’ or ‘‘Transplant*’’ or ‘‘Bariatric*’’).
Additional articles were discovered by manually re-
viewing references from pertinent studies. Studies not fo-
cusing on minimal invasive surgery, studies conducted in
developed countries, case reports, and editorials were ex-
cluded, as were studies for which online full-text was not
available through the authors’ institutions. Studies report-
ing advanced laparoscopic techniques were also excluded,
as they likely represented well-established laparoscopy
programs with abundant resources.
Results
The process of identification, abstract screening, full-text
eligibility assessment, and inclusion is presented in Fig. 1.
Fifty-eight articles were found describing laparoscopic
surgery experiences in 25 different LMICs (Table 1).
A number of studies highlighted advantages of la-
paroscopy, delineated in Table 2. These benefits could be
broadly classified as clinical, economic, or systemic. Many
advantages paralleled those found in developed countries,
while others were specific to limited-resource settings. For
instance, in settings where there is no clean water in the
patient’s home, open incisions carry significantly higher risk
of infection [5]. Because infectious diseases can cause di-
verse symptoms that can be challenging to diagnose with
basic laboratory and radiology facilities, laparoscopy is ideal
for the diagnosis of peritoneal tuberculosis [7,14–16], the
treatment of biliary ascariasis [17], and many gynecologic
conditions [18–20].
Surg Endosc
123
In terms of economic benefits, many studies found la-
paroscopy to be cost-effective [10,21–23], and one author
noted that investing in laparoscopy equipment is much
cheaper than investing in CT or MRI technology [7].
Others point out that early return to work can be important
in LMICs since families likely depend on day-to-day
earnings and have little savings [5,24,25]. Similarly, the
value of decreased bed utilization may be more important
in LMICs since unmet surgical need is greater and inpatient
capacity is smaller [26].
There were a number of challenges identified facing the
development of laparoscopic surgery, shown in Table 3.
Two authors cited the lack of safe clinical guidelines as a
challenge particularly relevant in LMICs [26,27]. The most
common challenge named was related to the cost of la-
paroscopy. Some argued that high purchase costs impose the
need for laparoscopic equipment to be donated [10,28], and
others posited that in the setting of widespread unemploy-
ment and low wages, early discharge was not as beneficial as
others had concluded [10,29,30]. In countries that had
health insurance, beneficiaries were likely to be provided
with coverage for open operations, but not laparoscopy, re-
sulting in high out-of-pocket costs [21]. Systemic challenges
included the limited availability of trained staff [23,31,32]
and training opportunities [15,19,21,27,28,30,32–36], as
well as a dearth of resources to maintain equipment [19,37]
and handle challenging complications [15].
A number of adaptive measures have been undertaken to
work around limitations in developing countries, as shown in
Table 4. Equipment and technique alternatives include me-
chanical insufflation with room air [38,39], syringe suction,
homemade endoloops [9], hand-assisted techniques, extra-
corporeal knot tying [40], innovative uses of cheaper in-
struments [9,11], and the reuse of disposable trocars and
graspers [9,12,37,40–43]. Spinal and local anesthesia may
be safe and possibly advantageous alternatives to resource-
intensive general anesthesia [9,44–47]. Training systems
using lectures, workshops, laboratory-based trainers, animal
models, and telemedicine are integral in teaching skills
outside of the operating room [22,48–52].
Discussion
There are many benefits to laparoscopy that have been re-
alized in developed countries for several decades [3,4].
However, while laparoscopy has not yet become widely
available across LMICs, it offers a number of advantages for
these settings in particular. While laparoscopy is often cri-
ticized as being an expensive surgical technology, it may be
highly cost-effective considering its diagnostic applications.
It has been estimated that ultrasound equipment costs 500
times as much as laparoscopy equipment, while CT imaging
costs 2500 times more and MRI costs 4500 times more [7].
As cars and motorcycles become more prevalent in devel-
oping countries, trauma is rising concomitantly. Diagnostic
laparoscopy could reduce unnecessary laparotomies [25,
53]. Laparoscopy is also highly useful as a diagnostic tool
when there is suspicion for extra-pulmonary tuberculosis and
other infectious diseases [7].
In resource-poor settings, reduced postoperative hospi-
talization may be far more important than in high-income
countries. Inpatient beds are often in limited supply since
they may be required for pre-operative patients who are
often pre-admitted because they must travel great distances
to reach surgical care [26], patients who are unable to pay
the bill, or postoperative patients that have no other suit-
able place to recover. Furthermore, families often have
only one wage-earner, and a loss of income during a
lengthy hospitalization can be devastating to the entire
family [24,25]. For laborers and merchants, there is no
such concept as sick leave—i.e., no work means no pay—
and they often live hand-to-mouth with little in the way of
savings or investments. Additionally, in patriarchal soci-
eties, there may not be another family member who can
work in place of the sick individual [5]. Many hospitals
require family members to assist with nursing care, which
adds to family hardship by disrupting both childcare and
earning potential. However, shortened hospitalization can
be risky if homes are not equipped with basic necessities
such as clean water. Laparoscopic surgery is attractive
because it can decrease hospitalization without the addi-
tional infection risk borne by a larger incision [5].
Anesthesia-related mortality is often higher in LMICs
than high-income countries. One study reported a general
anesthesia mortality rate of 1 in 504 at a central hospital in
Fig. 1 Study selection
Surg Endosc
123
Table 1 Included articles Reference # First author Year Pub. Country Laparoscopy
[5] Basha 1995 Yemen LC
[7] Udwadia 2004 India DL
[9] Udwadia 2001 India DL
[10] Bendinelli 2002 Senegal Diverse
[11] Gnanaraj 2010 India DL
[12] Adisa 2013 Nigeria Diverse
[14] Krishnan 2008 India DL
[15] Manning 2009 Afghanistan LC
[16] Malik 2011 Pakistan DL
[17] Astudillo 2008 Ecuador Ascariasis Tx
[18] Darwish 2003 Egypt Gyn
[19] Raiga 1999 Cameroon Gyn
[20] Sewta 2011 India Gyn
[21] Teerawattananon 2005 Thailand LC
[22] Straub 2011 Mongolia LC
[23] Dobbyne 2011 Tanzania Diverse
[24] Vellani 2009 Pakistan LA
[25] Mir 2009 India LO
[26] Bal 2003 India DCLC
[27] Brekalo 2007 Bosnia DCLC
[28] Bekele 2012 Ethiopia LC
[29] Clegg-Lamptey 2010 Ghana LC
[30] Tintara 1995 Thailand Gyn
[31] Khan 2010 Pakistan LC
[32] Piukala 2006 Tonga LC
[33] Hussain 2008 Yemen LC
[34] Parkar 2003 Kenya Gyn
[35] Mehraj 2011 Pakistan LC
[36] Mufti 2007 Pakistan LC
[37] Asbun 1996 Nicaragua, Bolivia LC
[38] Nande 2002 India LC
[39] Tintara 1998 Thailand Gyn and DL
[40] Adisa 2012 Nigeria LA
[41] Mir 2008 India LC
[42] Price 2013 Mongolia Diverse
[43] Mir 2007 India LC
[44] Bessa 2010 Egypt LC
[45] Hamad 2003 Egypt LC
[46] Yuksek 2008 Turkey LC
[47] Singh 2010 Nepal DCLC
[48] Merrell 1999 Zimbabwe, Ecuador LC
[49] Beard 2014 Tanzania Diverse
[50] Mir 2008 India LC
[51] Okrainec 2009 Botswana Diverse
[52] Okrainec 2010 Botswana Diverse
[53] Yahya 2008 Libya DL
[56] Chauhan 2006 India DCLC
[57] Garg 2009 India LA
Surg Endosc
123
Malawi, and another reported 1 in 133 deaths at a teaching
hospital in Togo [54,55]. Laparoscopy can be performed
with spinal or local anesthesia instead of general by using
gasless abdominal tenting, balloon laparoscopy, or creating
a pneumoperitoneum with room air; all of these techniques
were described in the included studies.
Table 1 continued Reference # First author Year Pub. Country Laparoscopy
[58] Mohamed 2013 Egypt LA
[59] Utpal 2005 India LA
[60] Ali 2010 Pakistan LA
[61] Mucio 1994 Mexico LC
[62] Malla 2010 Nepal LC
[63] Patel 2003 Kenya LA
[64] Sharma 1998 India LC
[65] Vijayaraghavan 2006 India Diverse
[66] Agarwal 2007 India LC
[67] Sinha 2009 India LC
Diverse indicates many different basic laparoscopic procedures
Pub published, LC laparoscopic cholecystectomy, DL diagnostic laparoscopy, Tx treatment, Gyn gyneco-
logic laparoscopy, LA laparoscopic appendectomy, LO laparoscopic orchiectomy, DCLC day care la-
paroscopic cholecystectomy
Table 2 Advantages of laparoscopy
Clinical Shortened hospital stay; Decreased convalescence and pain; Faster return to work [9,15,17,19,22,28,30,35,40,41,51,57–60]
Improved clinical outcomes [9,17,19,23,24]; specifically:
1. Smaller wound [28,35] (particularly important in the setting of unclean water in the patient’s home)
a
[5]
2. Fewer infections [19,22,51,57,58]
3. Fewer long-term complications, including hernias and adhesions [19,25,35,40,57,61,62]
4. Less immunosuppression [51]
5. Less abdominal drainage [58]
Fewer unnecessary appendectomies [40]
When imaging is limited
a
[7], laparoscopy reduces unnecessary laparotomy [25] and can be diagnostic for:
1. Tuberculosis
a
[7,14–16]
2. Intra-abdominal malignancies [15]
3. Pelvic inflammatory disease [20]
4. Traumatic injuries [53]
And both diagnostic and therapeutic for:
1. Ascariasis in the biliary tree
a
[17]
2. Gynecologic conditions and procedures, such as: paratubal and paraovarian cysts, ectopic pregnancy, hysterectomy, and tubal
ligation [18–20]
Economic Equipment cost ratio for laparoscopy/ultrasound/CT/MRI is 1:500:2500:4500
a
[7]
More cost-effective for hospitals than open surgery [9,10,19,21–23] due to:
1. Minimal use of analgesics, antibiotics, medical supplies [9,30]
2. Early discharge [21,30]
Better for patients due to lower hospital bill [24] and quicker return to work [5,21,24,25,42] (particularly important given unequal
distribution of labor)
a
Systemic Beds in short-supply are made available due to quicker discharge
a
[12,26,56]; therefore, elective surgery wait times decrease
a
[47]
Laparoscopic training facilitates courses for basic and emergency surgical services [42]
Gives surgeons a sense of professional accomplishment and motivation [42]
Generates faith in the health system [42]
a
a
Issues that may be specific to low-resource settings
Surg Endosc
123
Certainly, there are major clinical, economic, and in-
frastructure-related limitations to utilizing laparoscopy in
LMICs. Hospitals must overcome these infrastructure
limitations and resource-allocation issues, and deal with
safety and ethical concerns as well, if they hope to begin
laparoscopic surgical care. In the absence of guidelines for
resource-poor settings, safety is of utmost concern [26].
Staff training requires a significant investment of time and
money, and there is often limited availability of individuals
to serve as trainers [31–33].
While some studies have cited the cost-effectiveness of
laparoscopy, others argue the opposite. It has been claimed
by some that the lower costs of inpatient care [29]and
surgery [26] in developing countries mean that prioritizing
early discharge does not yield significant cost-savings.
Others have argued that the costs of providing day surgeries
in developing countries are higher than in developed settings
[56]. High-cost equipment is often not available and hospi-
tals may require donations [10,31,32], which may not in-
clude all the necessary components. Furthermore, it can be
difficult to quickly secure repairs and replacements for high-
price donated items. In the absence of a robust insurance
system, these additional costs may be prohibitive to patients
[5,12]. The assertion that early discharge is an important
priority for patients has also been contended. Studies
conducted in Senegal have concluded that low salaries di-
minish the importance of an early return to work [10,29].
There are sociocultural barriers to advancing la-
paroscopy in LMICs as well. People often mistrust the new
technology [33] and may not perceive the benefits [56].
Lack of education, poor health literacy, and the presence of
nonscientific beliefs are all contributing factors [26,56]. As
is the case with any surgery, barriers to follow-up care are
abundant. Patients often have poor access to health fa-
cilities due to poverty, poor transportation infrastructure,
and large distances in rural settings [26,47,56]. In the case
of complications and emergencies, patients may not have
access to any mode of communication with a health pro-
fessional, much less an ability to reach a hospital [26,56].
Furthermore, local providers who are unfamiliar with la-
paroscopy may not be able to appropriately assess and
address complications.
A number of promising strategies have been described
to overcome these barriers. When infrastructure, equip-
ment, and training supplies remain cost-prohibitive, tactics
such as using a cystoscope as a laparoscope, foregoing
insufflation, or using sunlight instead of a fiberoptic light
source have been described, although the safety of these
techniques has not been robustly studied. A number of
alternative low-cost solutions can be made as replacement
Table 3 Challenges facing laparoscopy
Clinical High rate of conversion to open [14,31]
Higher incidence of major complications [15]
Absence of safe guidelines
a
[26,27]
Increased time to perform laparoscopic operations [30,57,58,60] (though decreases with experience) [40]
No clear clinical advantage of laparoscopic appendectomy over open [60]
Trained laparoscopic surgeon not always available [63]
a
Economic Cost-prohibitive given hospital billing procedures
a
[5], absence of health insurance
a
[12], or insurance that only pays for open
surgery
a
[21]
Early return to work is not a priority when salaries are low
a
[10,29,30]
High start-up costs [19,21,30,32,34,41,43,64] often necessitate donated equipment
a
[10,28]
Laparoscopy costs at least the same [24] and often more than open operations [21,28,29,33], although standardized discharge
protocols could reduce the cost [60]
Early discharge is not significantly cost-saving to hospitals
a
[26,29]
Higher costs for anesthesia due to increased OR time [30]
Economic benefit may only apply to high-income patients [30]
Systemic Limited availability of trained staff
a
[23,31,32] and high-quality training opportunities
a
[15,19,21,27,28,30,32–36] leads to
inability to handle complications [15]
Limited resources
a
, equipment
a
[15,31,32,35–37], and maintenance availability
a
[19,37]
After discharge, patients have poor access to telephones
a
[26,56] and medical resources
a
[26,47,56]
People mistrust the ‘‘new’’ [38] and may not perceive benefits due to lack of education, poor health literacy, and presence of
nonscientific beliefs
a
[26,28,56]
Chemical sterilization of laparoscopic equipment can lead to atypical mycobacteria infections [65]
a
May be country- or hospital-specific issues
Surg Endosc
123
for endopouches for appendectomies or cholecystectomies,
and a number of instruments can be reused.
Limitations
The techniques and modifications described here are only
the tip of the iceberg. Surgeons in LMICs face significant
barriers to publication in general, and to publishing reports
about technical adaptations, in particular. Though we uti-
lized African Index Medicus and LILACS-BIREME to
maximize the probability of including LMIC publications,
there are likely many journals that were not identified—
especially those published in languages other than English.
Furthermore, there may be a publication bias toward ad-
vancing laparoscopy in LMICs rather than challenging its
utility. Nonetheless, we did identify several articles that
presented significant obstacles, and in fact, contradicted
advantages reported elsewhere. These contradictions
represent differences in the costing methodology, as well as
the economic circumstances of individual hospitals and
countries. The LMIC category encompasses a wide range
of economies with a wide spectrum of resource availability
and infrastructure, even within a given country.
Recommendations
Laparoscopy should be considered an important component
of surgical care that can be developed in low-resource
settings.
1. Long-term planning for sustainability
•Involvement of all stakeholders, including patients,
local surgeons, anesthetists, and nurses, Ministries
of Health, donors, academic institutions, and
Table 4 Adaptive strategies
Infrastructure Discharged patients asked to telephone the hospital rather than vice versa [26]
Local soft drink manufacturers may supply affordable CO2 [42]
Equipment Use reusable ports and instruments (though trocars need to be sharpened and disposable rubber replaced) [9,12,37,40–43],
using glutaraldehyde sterilization [10] or tube drapes that can be washed and autoclaved [11]
1. Instruments can be reused for up to 18 years [9,42]
2. Reusable instruments save USD$300 per case [25]
To reduce the cost of clips:
1. Replace clips with: intracorporeal ligatures [42,43], vicryl sutures [41], or polyglactin sutures [25]
2. Sterilize clip applicators and reload clips [12,42]
3. Use low-cost laparoscopic ligatures manufactured in India [22]
Make alternative Endopouches from low-cost condoms [42,43], nasogastric tube covers [25,41], 10-mm port itself [12,40], or
gloves [42]
Make endoloops using catgut [9]
Make cholangiography catheters with infant feeding tubes [9]
Substitute expensive equipment:
1. Use sunlight as a light source [7,66]
2. Use a sigmoidoscope air pump [9], or a locally manufactured air pump [38,66] to create a pneumoperitoneum
3. Use a simple hook dissector to skeletonize tubular structures [9]
4. Use ovum forceps to make a lithotripter and stone evacuator [9]
5. Use a cystoscope as a laparoscope [11]
6. Replace a Harmonic scalpel with clips and diathermy [12]
7. Make tripolar forceps with a blade in between bipolar cautery [40]
Technique Perform gasless laparoscopy: using towel clips or wire loops to tent the abdominal skin [38,39]; or using a laparolift, laparofan,
or electric power actuator and abdominal wall retractor [39]
Use a Gazayerli endoscopic retractor with insufflation [39]
Perform extracorporeal ligation instead of endoloops [40]
Perform solo laparoscopic female sterilization using 1 port and a laparocator with a camera [20]
Use local anesthesia [9,39]
Use of spinal anesthesia is safe [39,44–46], feasible with adaptations [9,44–46,67], and advantageous [44–46]
Training Cheap skills labs can be created with inexpensive box trainers and laptops [41–43,49,50]
Short training courses can be cheap, easy, and effective [22,37] but may require more than 3 days [51]
If reliable internet is accessible, FLS can be taught via telesimulation [23,48,52], even intra-operatively [48]
Surg Endosc
123
industry is needed to assess pertinent risks and
benefits within a given socioeconomic context.
•Collaborative research should help identify and
propagate solutions to common challenges.
•Regional equipment production and maintenance
facilities must be established to ensure cost-effec-
tiveness. Collaborations between industry, donors,
and governments can facilitate the generation of
local employment opportunities.
2. Training and retention of providers
•Basic laparoscopic training should be incorporated
in major teaching hospitals. Promoting training in
advanced procedures may help to retain health care
providers or and attract others who have left.
•Training should also be offered to operative nurses,
anesthesia providers, and biomedical professionals
as well as surgeons.
•Training programs can include surgical simulation
using low cost, locally made trainers, internet-
based surgical videos, exchange programs, tele-
medicine, and intraoperative practice.
3. Regulation
•Perioperative outcome data are needed to develop
quality and safety measures.
•Ministries of Health and donors can collaborate to
develop national programs to monitor and improve
surgical quality.
•Existing surgical societies (e.g., COSECSA,
WACS, PAACS) can provide mentorship and
advice regarding guidelines and essential equip-
ment and instrumentation.
Summary and future directions
Developing countries face challenges that require greater
efforts in innovation. Laparoscopic surgery may be safe,
effective, feasible, and cost-effective in LMICs, although it
often remains limited in its accessibility, acceptability, and
quality. Surgeons, policy makers, and manufacturers must
work together to overcome limitations and optimize im-
plementation where appropriate.
Acknowledgments The authors thank Dr. John Meara, Dr. Lars
Hagander, and Martha Stone for their support in the implementation
of this study.
Disclosures Drs. Chao, Opoku-Anane, Maine, and Ms. Mandigo
have no conflicts of interest or financial ties to disclose.
References
1. Ozgediz D, Riviello R (2008) The ‘other’ neglected diseases in
global public health: surgical conditions in sub-Saharan Africa.
PLoS Med. doi:10.1371/journal.pmed.0050121
2. Gawande AA (2009) WHO guidelines for safe surgery: safe
surgery saves lives. World Health Organization, Geneva
3. Nguyen NT, Goldman C, Rosenquist CJ, Arango A, Cole CJ, Lee
SJ, Wolfe BM (2001) Laparoscopic versus open gastric bypass: a
randomized study of outcomes, quality of life, and costs. Ann
Surg 234:279–289 (discussion 289–291)
4. Murphy AA, Nager CW, Wujek JJ, Kettel LM, Torp VA, Chin
HG (1992) Operative laparoscopy versus laparotomy for the
management of ectopic pregnancy: a prospective trial. Fertil
Steril 57:1180–1185
5. Basha YY, El-Muttarid NS, Sief M, Shamoun SE, Rypins EB
(1995) The first 100 laparoscopic cholecystectomies in the
Republic of Yemen. J Laparoendosc Surg 5:163–167
6. Ogbonna BC, Obekpa PO, Momoh JT, Obafunwa JO, Nwana EJ
(1992) Laparoscopy in developing countries in the management
of patients with an acute abdomen. Br J Surg 79:964–966
7. Udwadia TE (2004) Diagnostic laparoscopy. Surg Endosc 18:
6–10
8. Ryder RM, Vaughan MC (1999) Laparoscopic tubal sterilization.
Methods, effectiveness, and sequelae. Obstet Gynecol Clin North
Am 26:83–97
9. Udwadia TE (2001) One world, one people, one surgery. Surg
Endosc 15:337–343
10. Bendinelli C, Leal T, Moncade F, Dieng M, Toure CT, Miccoli P
(2002) Endoscopic surgery in Senegal. Benefits, costs and limits.
Surg Endosc 16:1488–1492
11. Gnanaraj J (2010) Diagnostic laparoscopies in rural areas: a
different use for the cystoscope. Trop Doct 40:156
12. Adisa AO, Lawal OO, Arowolo OA, Alatise OI (2013) Local
adaptations aid establishment of laparoscopic surgery in a semi-
urban Nigerian hospital. Surg Endosc 27:390–393
13. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group
(2010) Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. Int J Surg Lond Engl 8:
336–341
14. Krishnan P, Vayoth SO, Dhar P, Surendran S, Ponnambathayil S
(2008) Laparoscopy in suspected abdominal tuberculosis is useful
as an early diagnostic method. ANZ J Surg 78:987–989
15. Manning RG, Aziz AQ (2009) Should laparoscopic cholecys-
tectomy be practiced in the developing world? the experience
of the first training program in Afghanistan. Ann Surg 249:
794–798
16. Malik AM, Talpur KAH, Soomro AG, Qureshi JN (2011) Yield
of diagnostic laparoscopy in abdominal tuberculosis: is it worth
attempting? Surg Laparosc Endosc Percutan Tech 21:191–193
17. Astudillo JA, Sporn E, Serrano B, Astudillo R (2008) Ascariasis
in the hepatobiliary system: laparoscopic management. J Am Coll
Surg 207:527–532
18. Darwish AM, Amin AF, Mohammad SA (2003) Laparoscopic
management of paratubal and paraovarian cysts. J Soc La-
paroendosc Surg 7:101–106
19. Raiga J, Kasia JM, Bruhat MA (1999) Laparoscopic surgery in
the Cameroon. Int J Gynaecol Obstet 65:65–66
20. Sewta RS (2011) Laparoscopic female sterilisation by a single
port through monitor–a better alternative. J Indian Med Assoc
109:262, 263, 266
21. Teerawattananon Y, Mugford M (2005) Is it worth offering a
routine laparoscopic cholecystectomy in developing countries? a
Thailand case study. Cost Eff Resour Alloc 3:10
Surg Endosc
123
22. Straub CM, Price RR, Matthews D, Handrahan DL, Sergelen D
(2011) Expanding laparoscopic cholecystectomy to rural Mon-
golia. World J Surg 35:751–759
23. Dobbyne C, Horgan LF (2011) Through the keyhole. J Vis
Commun Med 34:98–100
24. Vellani Y, Bhatti S, Shamsi G, Parpio Y, Ali TS (2009)
Evaluation of laparoscopic appendectomy vs. open appendecto-
my: a retrospective study at Aga Khan University Hospital,
Karachi, Pakistan. J Pak Med Assoc 59:605–608
25. Mir IS, Mohsin M, Kirmani O, Cheachek BA, Alam I, Wani M
(2009) Is laparoscospic orchidectomy the treatment of choice in
adults with impalpable testis in rural hospitals in the developing
world? Trop Doct 39:12–15
26. Bal S, Reddy LGS, Parshad R, Guleria R, Kashyap L (2003)
Feasibility and safety of day care laparoscopic cholecystectomy
in a developing country. Postgrad Med J 79:284–288
27. Brekalo Z, Innocenti P, Duzel G, Liddo G, Ballone E, Simunovic
VJ (2006) Ten years of laparoscopic cholecystectomy: a com-
parison between a developed and a less developed country. Wien
Klin Wochenschr 119:722–728
28. Bekele S, Biluts H (2012) Laparascopic cholecstectomy at
Myungsung Christian Medical Center, Ethiopia: a five-years ex-
perience. Ethiop Med J 50:251–257
29. Clegg-Lamptey JN, Amponsah G (2010) Laparoscopic chole-
cystectomy at the Korle Bu Teaching Hospital, Accra, Ghana: an
initial report. West Afr J Med 29:113–116
30. Tintara H, Leetanaporn R (1995) Cost-benefit analysis of la-
paroscopic adnexectomy. Int J Gynaecol Obstet 50:21–25
31. Khan N, Naeem M, Bangash A, Sadiq M, Hamid H (2010) La-
paroscopic cholecystectomy: an experience at Lady Reading
Hospital, Peshawar. J Ayub Med Coll Abbottabad 22:46–51
32. Piukala S (2006) Laparoscopic cholecystectomy: complications
and experiences in Tonga. Pac Health Dialog 13:107–110
33. Hussain A, Mahmood HK, Dulku K (2008) Laparoscopic
cholecystectomy can be safely performed in a resource-limited
setting: the first 49 laparoscopic cholecystectomies in Yemen.
J Soc Laparoendosc Surg 12:71–76
34. Parkar RB, Thagana NG, Baraza R, Otieno D (2003) Experience
with laparoscopic surgery at the Aga Khan Hospital, Nairobi.
East Afr Med J 80:44–50
35. Mehraj A, Naqvi MA, Feroz SH, Ur Rasheed H (2011) Laparo-
scopic cholecystectomy: an audit of 500 patients. J Ayub Med
Coll Abbottabad 23:88–90
36. Mufti TS, Ahmad S, Naveed D, Akbar M, Zafar A (2007) La-
paroscopic cholecystectomy: an early experience at Ayub Teach-
ing Hospital Abbottabad. J Ayub Med Coll Abbottabad 19:42–44
37. Asbun HJ, Berguer R, Altamirano R, Castellanos H (1996)
Successfully establishing laparoscopic surgery programs in de-
veloping countries. Clinical results and lessons learned. Surg
Endosc 10:1000–1003
38. Nande AG, Shrikhande SV, Rathod V, Adyanthaya K,
Shrikhande VN (2002) Modified technique of gasless laparo-
scopic cholecystectomy in a developing country: a 5-year expe-
rience. Dig Surg 19:366–371 (discussion 372)
39. Tintara H, Leetanaporn R, Getpook C, Suntharasaj T (1998)
Simplified abdominal wall-lifting device for gasless laparoscopy.
Int J Gynaecol Obstet 61:165–170
40. Adisa AO, Alatise OI, Arowolo OA, Lawal OO (2012) Laparo-
scopic appendectomy in a Nigerian teaching hospital. J Soc La-
paroendosc Surg 16:576–580
41. Mir IS, Mohsin M, Majid T, Wani K, Hasan M, Kirmani O,
Naqshbandi J, Maqbool M (2008) Laparoscopic cholecystectomy
in a small rural hospital in Kashmir Valley, India. Trop Doct
38:213–216
42. Price R, Sergelen O, Unursaikhan C (2013) Improving surgical
care in Mongolia: a model for sustainable development. World J
Surg 37:1492–1499
43. Mir IS, Mohsin M, Kirmani O, Majid T, Wani K, Hassan M,
Naqshbandi J, Maqbool M (2007) Is intra-operative cholangiog-
raphy necessary during laparoscopic cholecystectomy? a multi-
centre rural experience from a developing world country. World J
Gastroenterol 13:4493–4497
44. Bessa SS, El-Sayes IA, El-Saiedi MK, Abdel-Baki NA, Abdel-
Maksoud MM (2010) Laparoscopic cholecystectomy under spinal
versus general anesthesia: a prospective, randomized study.
J Laparoendosc Adv Surg Tech A 20:515–520
45. Hamad MA, El-Khattary OAI (2003) Laparoscopic cholecystec-
tomy under spinal anesthesia with nitrous oxide pneumoperi-
toneum: a feasibility study. Surg Endosc 17:1426–1428
46. Yuksek YN, Akat AZ, Gozalan U, Daglar G, Pala Y, Canturk M,
Tutuncu T, Kama NA (2008) Laparoscopic cholecystectomy
under spinal anesthesia. Am J Surg 195:533–536
47. Singh DR, Joshi MR, Koirala U, Shrestha BR, Shrestha S,
Gautam B (2010) Early experience of day care surgery in Nepal.
J Nepal Med Assoc 49:191–194
48. Merrell R, Rosser J (1999) Integration of quality programs by
telemedicine in surgical services. Stud Health Technol Inform
64:108–114
49. Beard JH, Akoko L, Mwanga A, Mkony C, O’Sullivan P (2014)
Manual laparoscopic skills development using a low-cost trainer
box in Tanzania. J Surg Educ 71:85–90
50. Mir IS, Mohsin M, Malik A, Shah AQ, Majid T (2008) A
structured training module using an inexpensive endotrainer for
improving the performance of trainee surgeons. Trop Doct
38:217–218
51. 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
52. Okrainec A, Henao O, Azzie G (2010) Telesimulation: an ef-
fective method for teaching the fundamentals of laparoscopic
surgery in resource-restricted countries. Surg Endosc 24:417–422
53. Yahya A, Shuweiref H, Thoboot A, Ekheil M, Ali AA (2008)
Laparoscopic repair of penetrating injury of the diaphragm: an
experience from a district hospital. Libyan J Med 3:138–139
54. Hansen D, Gausi SC, Merikebu M (2000) Anaesthesia in Malawi:
complications and deaths. Trop Doct 30:146–149
55. Ouro-Bang’na Maman AF, Tomta K, Ahouangbe
´vi S, Chobli M
(2005) Deaths associated with anaesthesia in Togo, West Africa.
Trop Doct 35:220–222
56. Chauhan A, Mehrotra M, Bhatia PK, Baj B, Gupta AK (2006)
Day care laparoscopic cholecystectomy: a feasibility study in a
public health service hospital in a developing country. World J
Surg 30:1690–1695 (discussion 1696–1697)
57. Garg CP, Vaidya BB, Chengalath MM (2009) Efficacy of la-
paroscopy in complicated appendicitis. Int J Surg Lond Engl
7:250–252
58. Mohamed AA, Mahran KM (2013) Laparoscopic appendectomy
in complicated appendicitis: is it safe? J Minimal Access Surg
9:55–58
59. Utpal D (2005) Laparoscopic versus open appendectomy in West
Bengal, India. Chin J Dig Dis 6:165–169
60. Ali R, Khan MR, Pishori T, Tayeb M (2010) Laparoscopic ap-
pendectomy for acute appendicitis: is this a feasible option for
developing countries? Saudi J Gastroenterol 16:25–29
61. Mucio M, Felemovicius J, De la Concha F, Cabello R, Zamora A
(1994) The Mexican experience with laparoscopic cholecystec-
tomy and common bile duct exploration. A multicentric trial.
Surg Endosc 8:306–309
Surg Endosc
123
62. Malla BR, Shrestha RKM (2010) Laparoscopic cholecystectomy
complication and conversion rate. Kathmandu Univ Med J 8:
367–3369
63. Patel SC, Jumba GF, Akmal S (2003) Laparoscopic appen-
dicectomy at the Aga Khan Hospital, Nairobi. East Afr Med J
80:447–451
64. Sharma AK, Rangan HK, Choubey RP (1998) Mini-lap chole-
cystectomy: a viable alternative to laparoscopic cholecystectomy
for the Third World? ANZ J Surg 68:774–777
65. Vijayaraghavan R, Chandrashekhar R, Sujatha Y, Belagavi CS
(2006) Hospital outbreak of atypical mycobacterial infection of
port sites after laparoscopic surgery. J Hosp Infect 64:344–347
66. Agarwal BB, Agarwal B, Gupta M, Agarwal S, Mahajan K
(2007) Anatomical footprint for safe laparoscopic cholecystec-
tomy without using any energy source: a modified technique.
Surg Endosc 21:2154–2158
67. Sinha R, Gurwara AK, Gupta SC (2009) Laparoscopic chole-
cystectomy under spinal anesthesia: a study of 3492 patients.
J Laparoendosc Adv Surg Tech A 19:323–327
Surg Endosc
123
