|MISSION HOSPITAL SECTION
|Year : 2015 | Volume
| Issue : 1 | Page : 87-90
Feasibility and issues related to performing laparoscopic surgeries in rural areas
Sungtiakum Jamir1, Gnanaraj Jesudian2
1 Executive Director, Surgical Services Initiative, Coimbatore, India
2 Director - Medical Services, SEESHA, Samiti for Education, Environment, Health and Social Action, Burrows Memorial Christian Hospital, Coimbatore, Tamil Nadu, India
|Date of Web Publication||14-Jan-2015|
Dr. Gnanaraj Jesudian
Director of Medical Services, Samiti for Education, Environment, Health and Social Action, Alpha 5, Karunya University Quarters, Karunyanagar, Coimbatore - 641 114, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Survey of mission hospitals in North and Northeast India revealed that even the hospitals that had donated laparoscopic surgical equipment were unable to offer laparoscopic surgeries because of the high cost of the disposables involved. Although there are several studies comparing the disposable versus re-usable instruments (especially the ports) especially with respect to the costs, there is hardly any study looking at the re-use of disposable instruments. Although many might not admit it officially, it is a common practice in India to re-use disposable instruments. We present our findings with re-use of disposable laparoscopic items at the various mission and rural hospitals where our team has operated, and other issues related to laparoscopic surgeries in rural hospitals.
Keywords: Disposables, laparoscopic surgeries, re-use
|How to cite this article:|
Jamir S, Jesudian G. Feasibility and issues related to performing laparoscopic surgeries in rural areas. CHRISMED J Health Res 2015;2:87-90
|How to cite this URL:|
Jamir S, Jesudian G. Feasibility and issues related to performing laparoscopic surgeries in rural areas. CHRISMED J Health Res [serial online] 2015 [cited 2020 Feb 24];2:87-90. Available from: http://www.cjhr.org/text.asp?2015/2/1/87/149360
| Introduction|| |
When Dr. Elias EngleKing conducted a survey of surgical facilities among the members of the Association of rural surgeons of India,  he found that almost all of them were interested in performing laparoscopic surgery but the high equipment cost prevented them. Survey of mission hospitals in North and Northeast India revealed that even the hospitals that had donated laparoscopic surgical equipment were unable to offer laparoscopic surgeries because of the high cost of the disposables involved.
Although there are several studies comparing disposable instruments versus re-usable instruments (especially the ports) especially with respect to the costs, there is hardly any study looking at the re-use of disposable instruments. Although many might not officially admit it, re-using disposable instruments is a common practice in India. We present our findings with re-use of disposable laparoscopic items at the various mission and rural hospitals where our team has operated.
The disposables used
A wide variety of them is used and some of them are as follows:
- Disposable ports and trocars (Apple)
- Disposable hand instruments such as Maryland, graspers, etc
- Disposable clip applicators
- Disposable hernia Tachs
- Disposable harmonic and vessel-sealing handles.
| Method of Sterilization and Cleaning|| |
Most operating rooms (ORs) have special technicians who have received special training to clean these instruments. However, ultrasonic cleaner is rarely available as these are rural hospitals. After thorough cleaning with special and regular brushes, these instruments are sterilized. Soaking the instruments in Gluteraldehye (Cidex plus) solution is the most popular form for disinfection. Some hospitals use formalin chambers. There are hardly any ORs where they are autoclaved. However, autoclaving does not seem to affect the quality of the instruments.
The reasons for re-use
Although the cost consideration is the primary reason for re-use of the disposables, we have found other reasons too. The following are the reasons given:
- Disposable instruments cost less than one-fourth that of the re-usable ones of similar kind. Often the good quality re-usable ones could cost more than 10 times. The cost of Apple trocars is about INR 3500 and if used 10 times, it works out to only INR 350 per patient. One such trocar was used more than 500 times. The patients need not be charged for disposables used, and this would make the surgeries affordable to many patients 
- The quality of the re-usable instruments is often such that they are difficult to use and break as quickly as the good quality disposable ones
- Disposable instruments are lighter and easy to handle
- Disposable instruments could be received as donation from abroad or other surgeons who use them frequently.
| Results|| |
[Table 1] lists the laparoscopic surgeries carried out during a decade (2000-2009) at Burrows Memorial Christian Hospital in Alipur, Assam. The data was taken from a computer software used at the hospital. There is a column for entering wound infection but the actual figures might be higher (if an infection was not entered in the software).
The infections were graded as minor ones requiring few days or dressing, intermediate, or severe sepsis. Except for the patient who had peritonitis, all others had only minor infections, which needed few days of dressings. None of them had cultures.
The infections were treated with oral cephalosporins and outpatient dressings in all patients at Burrows Memorial Christian hospital, while treatment was similar at the camps except for the patient with peritonitis. The additional costs due to treatment varied from Rs. 200 to Rs. 500 depending on the place and the outpatient dressing and antibiotic costs.
One of the serious problems encountered was that in one patient, probably due to the defect in insulation, there was damage to the small bowel and she presented with peritonitis few days following laparoscopy-assisted vaginal hysterectomy. The patient needed laparotomy to close the perforation and have peritoneal lavage, which was carried out in another hospital, and recovered.
The figures for the surgeries during the surgical camps carried out at various mission and rural hospitals in North and Northeast India are given in [Table 2].
|Table 2: Laparoscopic surgeries at the surgical services initiative and SEESHA camps|
Click here to view
The problems encountered
The following are the problems that were associated with the re-use of disposable instruments and the magnitude of the problems are remarks are given in [Table 3].
The reason for us to keep the costs down both at the hospital and at the surgical camps is that our charges for surgical procedures are designed to meet the capabilities of the local community. In rural India, 40% of surgical patients have to borrow money or sell their assets to have treatment, and three-fourth of them are impoverished by it  and most of them could not comfortably afford over INR 10000 for surgeries. Hence, all the surgeries were carried out either as insurance program  where patients pay INR 1050 for enrollment and then only for medicines and investigations or for INR 10000 for major surgeries as a prepaid amount.
| Discussion|| |
In all mission and rural hospitals where these surgeries were performed, almost all patients received one dose of preoperative antibiotics. Although it would have been possible to go through individual surgery details and get the duration of surgeries to correlate with the infection, it was not done because apparently the infection rate for laparoscopic surgeries for infertility is similar to the other longer duration surgeries.
Romy et al. found significantly less surgical site and skin infections in laparoscopic surgeries, which varied from 1.7% in cholecystectomy to 11% in colorectal surgery and which were significantly less compared to open surgeries. Another study analyzed the re-use of disposable instruments processed with carefully monitored strict guidelines , found that the overall rate of infection was 1.8%, and the cost saving was significant. They also found that the instruments were used 1.7-68 times.
Our infection rates were much higher probably related to the conditions in rural Indian operating rooms and none of the institutions had any written guidelines or monitoring with regard to the re-use of disposable instruments. One of the 10-mm Apple disposable ports was used over 500 times.
Indian studies show about 3-3.6% port site infection. , The infections seem to be more common in lateral ports (64%), especially when there is bleeding.
The infection rate with open procedures are much higher compared to laparoscopic surgeries (4.41% vs. 1.08%).  Our infection rate with re-use of laparoscopic disposables was less than that with the open surgeries. 
The following rule of the thumb could be followed at mission hospitals:
- The ports could be reused if the quality of the insufflators is good. Otherwise, because of leak, it would be difficult to perform laparoscopic surgeries
- It is good to have very good quality Maryland forceps and hook, and the surgeon himself should clean and check these instruments after each use
- Although it looks sturdy, the clip applicator malfunctions if carried around
- The re-use of other disposable hand instruments is far superior and more comfortable compared to the low cost re-usable instruments are available at the market.
- Ultrasonic cleaner is a great boon if available.
| Other Modifications|| |
To reduce the costs of laparoscopic surgeries we have made other modifications. , These include,
- Using EMO machine and ether for anesthesia
- Using air and dental compressor for insufflation
- Using cell phone and torch light when there is no power supply.
However, a major innovation is the use of Gasless or Lift laparoscopic surgeries in rural areas, , which has the advantages of easier learning curve as traditional open instruments are used,  surgery under spinal anesthesia and much lower costs in addition to less physiological changes.
| Summary|| |
Despite a higher incidence of infection, re-use of laparoscopic disposables is acceptable as the infection rates are less than that of open surgical procedures and the saving in costs make the laparoscopic surgeries affordable to many who otherwise might not have had the benefit of laparoscopic surgeries. Strict monitoring and guidelines for use would make the procedures much safer and acceptable.
| References|| |
Elias EngleKing, Gnanaraj J. Survey of Rural Surgical Facilities. Rural Surg 2012;8:17-8.
Gnanaraj J, Jason LY, Khiangte H. High quality surgical care at low cost: The diagnostic camp model of Burrows Memorial Christian Hospital. Indian J Surg 2007;69:243-7.
Romy S, Eisenring MC, Bettschart V, Petignat C, Francioli P, Troillet N. Laparoscope use and surgical site infections in digestive surgery. Ann Surg 2008;247:627-32.
DesCôteaux JG, Poulin EC, Lortie M, Murray G, Gingras S. Reuse of disposable laparoscopic instruments: A study of related surgical complications. Can J Surg 1995;38:497-500.
DesCôteaux JG, Tye L, Poulin EC. Reuse of disposable laparoscopic instruments: Cost analysis. Can J Surg 1996;39:133-9.
Sharma AK, Sharma R, Sharma S. Port site infections in laparoscopic surgeries. Indian Med Gazette 2013;224-9.
Karthik S, Augustine AJ, Shibumon MM, Pai MV. Analysis of laparoscopic port site complications: A descriptive study. J Minim Access Surg 2013;9:59-64.
Jawien M, Wojkowska-Mach J, Rozanska A, Bulanda M, Heczko PB. Surgical site infection following cholecystectomy: Comparison of procedures performed with and without a laparoscope. Int J Infect Contr 2008;4:1.
Gnanaraj J. Laparoscopic surgeries in rural areas: Challenges and adaptations: An experience of over 1300 laparoscopic surgeries. ANZ J Surg 2007;77:799-800.
Gnanaraj J, Linda S. Single Incision gasless Laparoscopic surgeries and other low cost minimally invasive Techniques for evaluation of infertility in rural areas. Int J Infertil Fetal Med 2014;5:413-4.
[Table 1], [Table 2], [Table 3]