5 billion people worldwide lack access to safe, affordable surgical care despite up to 1/3rd of the global burden of disease arising from surgically treatable conditions. 90% of all such individuals unable to access surgical care reside in Low-and-Middle-Income-Countries (LMICs), and despite 80% of the global population residing in LMICs, only 6% of all surgical procedures performed occur in such regions. [1, 2]
Endoscopes and laparoscopes are medical instruments that can be credited with revolutionising diagnostic and interventional medicine, and reducing the requirement for traditionally complex surgical procedures, with high complication and mortality rates. Yet, the many benefits of endoscopies and laparoscopic procedures are not equitably distributed across the globe, often lacking where they are most required.
Endoscopic procedures use a device to look at the interior of the body, most commonly the gastrointestinal, urinary, and respiratory tract, as well as the female reproductive system, amongst others. Along with assisting in the visual detection of abnormalities, endoscopic developments have allowed the procedure to be used to take biopsies, massively aiding the diagnosis of otherwise undetectable pathologies, and have been shown to have a complication rate of less than 1 in 5000. [3] Endoscopies often allow the early detection and treatment of many diseases which would have an extremely poor prognosis if diagnosed at later stages, such as cancers, and have a much higher diagnostic yield than radiological studies.[3] Additionally, endoscopies can be used for in treatment of many common conditions, such as Acute Gastrointestinal Bleeding (AGIB), with a global incidence of 1/1000. Endoscopic management of AGIB is now the gold standard treatment and is 90% effective in stopping bleeding, massively reducing the mortality of such a frequent condition.
Laparoscopic surgery, also termed minimally invasive or key-hole surgery, provides surgeons with access to the body for surgical procedures without making large incisions to the skin. Currently over 13 million key-hole surgeries are performed globally per annum, with 79.2% of all appendectomies performed laparoscopically. [4] Laparoscopic surgery has numerous benefits, including reduced blood loss, a lower amount of required analgesic and fewer perioperative complications, and has been associated with a 50% reduction in post- operative wound infection rates. [5] [6]Minimally invasive procedures have also been found to have a decreased risk of all-cause mortality compared to open procedures, as well as being associated with lower hospital costs.[7] [8] The reduced recovery time following a laparoscopy allows patients to return to regular activities quicker and reduces the risk of bone loss, muscle atrophy, urinary retention, HCAIs and DVT which are associated with lengthy bed rest and hospital stays. [8]Additionally, the scar resulting from laparoscopies are much smaller than traditional open surgery wounds, reducing the psychological burden on patients post-operatively. [5]
The many benefits minimally invasive surgeries and endoscopies confer over traditional surgery and diagnostic practises would be the most advantageous in LMICs, where poor sanitation and crowded hospitals result in infection rates up to 25-fold greater than High Income Countries (HICs); access to anaesthesia is limited; and blood supplies are low, which results in LMICs having a 12-fold higher rate of perioperative mortality than developed countries. [1, 9] Additionally, the decreased recovery and hospital stay time after a laparoscopy would be highly beneficial in LMICs, where households often have few savings and only one earning member, and a limited number of inpatients beds with high demand. [9]In LMICs such as Mozambique, which has the highest global HIV prevalence with an incidence of 12.5% in the 15–29-year-old population, the low intra and post operative bleeding in laparoscopic procedures could massively reduce the risk of HIV transmission during surgical procedures for healthcare workers. [1]
A plethora of issues result in laparoscopic procedures not being regularly performed in LMICs, the most prominent of which is lack of sufficient funds and resources. The national healthcare system in most LMICs is either grossly underfunded; for example, Pakistan only spends 1.2% of its GDP on healthcare rather than 5% as recommend by the WHO, or else healthcare is highly privatised and only available to the affluent able to afford it. This results in endoscopic procedures not being available in most regions in LMICs. The high cost of laparoscopic equipment and the costs to build surgical facilities often means that healthcare providers adopt fee-for-service models to displace the additional cost to patients, resulting in laparoscopic procedures being more expensive than traditional open surgery and fewer patients opting for the more expensive, safer procedure. [2] Additionally, poor departmental organisations in rural hospitals, as was observed in a study conducted in rural Mongolia, results in a poor turnover of operating rooms, slow sterilisation of equipment and insufficient adherence to guidelines amongst other issues, resulting in laparoscopic procedures being poorly implemented even when the resources are available.
Sufficiently training staff in laparoscopic procedures is also essential for their safe and effective implementation; however, training programmes are mostly held in big cities with high costs for travel and attendance, resulting in surgeons from rural areas not attending and receiving the training. Hospital funding for such procedures is often reserved for senior doctors who are expected to pass on the skills to juniors; however, high rates of doctors emigrating and practising abroad – with 37% of all South African doctors working outside the country for more than 5 years during their career – means this often does not happen. More than one training session is also required to ensure surgeons are sufficiently competent to perform laparoscopies, however such repeated sessions are unfeasible due to the high cost of training equipment, most frequently donated by international sponsors, and a lack of trainers from HICs willing to spend long periods of time in LMICs to teach laparoscopies. Willing trainers are often confronted with language barriers while teaching native surgeons, as was noticed in a training programme between American and Mongolian surgeons during a laparoscopic cholecystectomy training programme. Laparoscopic procedures are also best suited to highly specialised surgeons due to the very specific, technical skills required for each procedure- rural and highly dense, under-staffed hospitals often do not have the capacity for this as surgeons must be proficient in a wide range of surgeries to meet high demand, making laparoscopic surgeries less preferable. The selection of hospitals in LMICs to receive funding for laparoscopic training is done based on pre-existing institutional relationships, rather than by an objective assessment of the recipient partner’s needs and ability to sustain a laparoscopic programme, resulting in areas with the greatest need and potential for laparoscopic procedures being insufficiently funded and trained. [6]Trained surgeons are often not provided with sufficient opportunity to practise the laparoscopic skills they have learned due to limited theatre times, a high volume of patients and inadequate training materials. Additionally, social, and cultural barriers often discourage senior surgeons from being open to learning and performing new procedures, as well as patients being hesitant to consent to unfamiliar surgeries. [1, 9]
Much of the same issues are the cause of low endoscopy rates in LMICs as for laparoscopic procedures. Additionally, even when endoscopic resources and equipment are available, a multitude of issues prevents their effective use. The commonest cause of endoscopic procedure failure in Nigeria is power supply failure, which is unsurprising in a nation with the world’s least efficient power supply system. [10]There is a dire lack of trained gastroenterologists to perform endoscopic procedures in LMICs – while the US has 3.9 trained gastroenterologists per 100,00 people, Gambia only has 3.8 medical doctors per 100,00 people and Nigeria has a concerning 60 registered gastroenterologists in their nation of 140 million residents. [11, 12] The nascent state of endoscopy in such personnel and resource limited settings leads to much higher mortality rates in common conditions diagnosed or treated using endoscopes than would be seen in HICs – AGIB emergencies have a 18.75% higher mortality rate in LMICs than HICs, and the overall mortality rate of oesophageal cancer across Africa is 97.2% compared to 88% in the UK. [11] Additionally, there is often one endoscope available for many patients who must be seen in a very short period, resulting in the recommend minimum period for which re-usable endoscopes used in such settings must be immersed in disinfecting solution not being met, with dire consequences for infection control. [10] A study by Kamran et al. in Karachi, Pakistan also showed that insufficient guidelines for indications for endoscopies result in the procedure being performed when not sufficiently indicated, resulting in endoscopic equipment in short supply being wasted where not required. [3]
In order to fully address the gross inequalities between the availability of laparoscopic and endoscopic services in LMICs and developed countries, government ministries of health, national and international regulatory bodies and public sectors institutions must be fully committed to developing effective training programmes, funding equipment and infrastructural changes and monitoring the implementation of such procedures routinely to ensure guidelines are being strictly adhered to and the many advantages of laparoscopic and endoscopic procedures are being conferred to patients. This can only be done by the in-depth study and analysis of local conditions and needs, and the co-ordination of large, complex, international efforts. Many organisations and groups have attempted to address these issues through means such as teleproctering, as was carried out between Canadian and Botswanan surgeons; the development of low cost box trainers; and low cost curricula to train surgeons in Africa – however, these initiatives often did not achieve their aims due to the lack of inclusion of the cost of computers, laparoscopic instruments for further practise or insufficient connectivity and electricity for powering the procedures. [1] A team at Duke University is currently working to increase access to laparoscopic surgery by developing low-cost, reusable laparoscopes suitable for use in LMICs. The kit, called KeySuite, contains a low maintenance laparoscope; software allowing surgeons in different countries to interact visually and audibly during surgery and exchange information; a laparoscopic retractor eliminating the need for CO2 monitoring; a pressure regulator; and continues electricity – all of which were developed by collecting information from Uganda, Singapore, US, Papua New Guinea, and Myanmar. Such initiatives have great potential but requiring trialling.
Laparoscopic and endoscopic procedures have great potential to reduce mortality and morbidity in LMICs through earlier diagnosis, fewer intra-operative complications, less infection and better outcomes; however, overcoming the many barriers preventing their routine use and implementation, as has been achieved in most developed countries, requires a co-ordinated approach between governments, local and international healthcare systems, donors and healthcare professionals in order to reap the greatest benefits for patients.
1. Pizzol, D., et al., Laparoscopy in Low-Income Countries: 10-Year Experience and Systematic Literature Review. International Journal of Environmental Research and Public Health, 2021. 18(11): p. 5796.
2. Schwartz, M., C.-J. Jeng, and L.T. Chuang, Laparoscopic surgery for gynecologic cancer in low- and middle-income countries (LMICs): An area of need. Gynecologic Oncology Reports, 2017. 20: p. 100-102.
3. Kamran, M., et al., Upper gastrointestinal endoscopy; A study from a rural population of Sindh, Pakistan. Pak J Med Sci, 2021. 37(1): p. 9-14.
4. Nguyen, N.T., et al., Use of laparoscopy in general surgical operations at academic centers. Surg Obes Relat Dis, 2013. 9(1): p. 15-20.
5. Agha, R. and G. Muir, Does laparoscopic surgery spell the end of the open surgeon? J R Soc Med, 2003. 96(11): p. 544-6.
6. Rosenbaum, A.J. and R.G. Maine, Improving Access to Laparoscopy in Low-Resource Settings. Ann Glob Health, 2019. 85(1).
7. Laudicella, M., et al., Impact of laparoscopic versus open surgery on hospital costs for colon cancer: a population-based retrospective cohort study. BMJ Open, 2016. 6(11): p. e012977.
8. Donohue, S.J., et al., Laparoscopy is associated with decreased all-cause mortality in patients undergoing emergency general surgery procedures in a regional health system. Surgical Endoscopy, 2022. 36(6): p. 3822-3832.
9. Chao, T.E., et al., Systematic review of laparoscopic surgery in low- and middle-income countries: benefits, challenges, and strategies. Surgical Endoscopy, 2016. 30(1): p. 1-10.
10. Pascu, O., Gastrointestinal Endoscopy. 2011: InTech.
11. Chudy-Onwugaje, K. and E.C. von Rosenvinge, Improving global digestive health: the gastroenterologists’ role. The Lancet Gastroenterology & Hepatology, 2020. 5(10): p. 882-883.
12. Perl, D., et al., Endoscopic capacity in West Africa. Afr Health Sci, 2016. 16(1): p. 329-38.
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