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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 1-5

Early experience with laparoscopic surgical operations in Aminu Kano Teaching Hospital, Kano, Northwestern Nigeria


1 Department of Surgery, General Surgical, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Urology Units, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication14-Jul-2014

Correspondence Address:
Abdurrahman A Sheshe
Department of Surgery, General Surgical Unit, Aminu Kano Teaching Hospital/Bayero University, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.136688

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  Abstract 

Background: New knowledge in health sciences, advances in technology, and a greater awareness of human rights add up to the need for higher standards in medical training and health services. Laparoscopic surgery is a major breakthrough in surgical practice that is now virtually integrated into all surgical fields. Its benefits have been recognized over many conventional open surgical procedures. However, its appropriateness and our readiness for the practice of laparoscopic surgery in Nigeria is yet to be determined. The objective of this study was to describe early experience, challenges, and prospect with laparoscopic surgical operations in Aminu Kano Teaching Hospital Kano, northwestern Nigeria.
Materials and Methods: The case notes of patients admitted into the Surgical Wards of Mallam Aminu Kano Teaching Hospital in Kano, northwestern Nigeria that had laparoscopic surgical operations from October 2005 to October 2013 were retrieved and studied. The data collected from these was entered into Minitab Statistical Software. Relevant statistical indices were calculated.
Results: A total of 42 patients were the subject of this review. Their mean age was 37 years, ranged 13-62 years. The male:female (M:F) was 1:1.2. The most common indication of laparoscopic operation was gallbladder disease in 38 (90.5%) patients. Laparoscopic cholecystectomy was the most common laparoscopic procedure performed. Two patients were converted to open surgery. The average duration of post-operative hospital stay was 4 days and the average operating time was 3 h.
Conclusion: Experience with laparoscopic surgery is still early in our center, nevertheless the prospect is enormous. There is need for further skills acquisition and effective organization in order to maintain these services. Involvement of the National Health Insurance Scheme should assuredly bring about technological developments and subsidize the services to meet the socioeconomic challenges and changing disease pattern in our environment.

Keywords: Cholecystectomy, common bile duct exploration, laparoscopic surgery


How to cite this article:
Sheshe AA, Yakubu AA, Alhassan SU, Tsauni I. Early experience with laparoscopic surgical operations in Aminu Kano Teaching Hospital, Kano, Northwestern Nigeria . Arch Int Surg 2014;4:1-5

How to cite this URL:
Sheshe AA, Yakubu AA, Alhassan SU, Tsauni I. Early experience with laparoscopic surgical operations in Aminu Kano Teaching Hospital, Kano, Northwestern Nigeria . Arch Int Surg [serial online] 2014 [cited 2024 Mar 28];4:1-5. Available from: https://www.archintsurg.org/text.asp?2014/4/1/1/136688


  Introduction Top


Aminu Kano Teaching Hospital is one of the federal tertiary health centers located in Kano northwestern part of Nigeria. It caters for a large population of Nigerians and that of neighboring countries of Chad, Cameron, and Niger Republic. New knowledge in health sciences, advances in technology, and a greater awareness of human rights in all communities of the world add up to the need for higher standards in training and services. [1] Laparoscopic surgical instruments were acquired by the hospital in 2005 in order to provide better service envisaged with the procedure, improve standard of training, and keep in touch with new developments and technologies.

Laparoscopic surgery is a major breakthrough and a historical milestone in surgical practice and is now virtually integrated into all surgical fields.

Modern therapeutic laparoscopy was first described in the early 1980s. [2],[3],[4],[5] The first laparoscopic appendectomy in 1983 was followed by laparoscopic cholecystectomy 4 years later. [2],[4],[5],[6],[7] Laparoscopic surgical techniques have presently been integrated into virtually all surgical fields. [2],[3] Its benefits have been recognized over many conventional open surgical procedures. [2],[3],[4],[5] However, surgery in Nigeria like other developing countries is still largely that of surgical infections, delayed presentations with advanced malignancies, and increasing incidence of trauma. [1],[8],[9] Is laparoscopic surgery therefore relevant and appropriate in a developing country like Nigeria? The objective of this study was to describe our experience, challenges and prospects of laparoscopic surgical operations in Aminu Kano Teaching Hospital, Kano, Nigeria.


  Materials and Methods Top


This was a retrospective study of patients admitted into the surgical wards of Aminu Kano Teaching Hospital in Kano, northwestern Nigeria and had laparoscopic surgery during the period of 8 years (October 2005-October 2013). Data was collected from records in theater, surgical wards, and hospital records department. The parameters studied were: Age, sex, previous operation, diagnosis, abdominal ultrasonogram reports, day of admission, American Society of Anesthesiologist (ASA) score, day of operation, postoperative outcome, day of discharge, and follow-up at 2 and 6 weeks. Technical problems encountered during the procedures were also noted. The data collected was entered into Minitab Statistical Software 12, © 2007 Minitab Incorporated. Basic statistical indices were calculated.


  Results Top


A total of 42 patients had laparoscopic operations. Consent was obtained from each patient with adequate explanation of the possibility of conversion to open surgery and documented in the consent form. The mean age of the patients was 37 years, with a range of 13-62 years. Thirteen (30.9%) patients were aged 50 years and above. The male:female (M:F) was 1:1.2. All the patients had abdominal ultrasound, and other preoperative checkups. Additionally, one patient with right pelvic urethral junction obstruction had intravenous urogram prior to admission.

The duration of admission before operation was 3 days or less in 68.0%, up to 7 days in 28.7%, and more than a week in 3.3%. Laparoscopic operation was rescheduled in five patients. Seven (16.7%) patients were classified ASA III and the rest were ASA II. Comorbidities recorded includes two patients with controlled hypertension, one with gross obesity (body mass index (BMI) 40), and another with controlled diabetes and hypertension. Records showed a previous laparotomy for an inflammatory condition in another patient carried out about 10 years ago.

The commonest indication for laparoscopic operation was gallstone disease in 26 (61.9 %) patients followed by chronic acalculus cholecystitis in 12 (28.6%). Others were recurrent appendicitis in three (7.1%) patients and pelvic ureteric junction obstruction in one (2.4%) patient.

The laparoscopic procedures carried out were cholecystectomy in 38 (90.5%) however eight patients had open cholecystectomy within the same period. This was followed by appendectomy in two (4.8%) and pyeloplasty in one [Table 1]. Two patients were converted to open surgery, one with recurrent appendicitis, and the other with impacted stones in the common bile duct. These two had open appendectomy, and choledocholithotomy respectively. Bilateral tubal ligation that was consented was done in one patient following laparoscopic cholecystectomy. The duration of the laparoscopic operation ranged from 2 h 30 min to 4 h with an average of 3 h. The mean duration of laparoscopic cholecystectomy was 2 h 55 min. The duration of postoperative hospital stay ranged from 2 to 10 days with a mean of 4 days. Most patients 18 (42.8%) were discharged on the 2 nd day after operation.
Table 1: Laparoscopic procedures and complications in 42 patients

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The postoperative complications recorded in three patients during admission were prolonged ileus in a diabetic patient, postoperative pyrexia, and bile peritonitis. The patients responded to the treatments given. These were soluble insulin, intravenous fluid, and nasogastric tube suction over 4 days to the diabetes patient, antimalaria drugs for the pyrexia, and exploratory laparotomy and ligation of cystic duct was carried out for the patient with bile peritonitis. No mortality was recorded.

Follow-up was for 6 weeks in 40 (95%) patients with no record of untoward problems. In the remaining two patients, one died on her way to the hospital for the first follow-up appointment and was certified in the emergency unit. No postmortem examination was done and the cause could therefore not be ascertained. She otherwise had an uncomplicated laparoscopic cholecystectomy. The other could not meet up because of distance, but was communicated with over the phone.


  Discussion Top


In Nigeria and indeed many parts of west Africa, very little attention is given to therapeutic laparoscopy despite the recognition of its advantages. This situation may not be unconnected to dwindling socioeconomic factors, lack of clinical impetus, and public awareness among others. [1],[2] The decision to commence laparoscopic surgery in Aminu Kano Teaching Hospital is a giant leap to provide the needed services and keep trend with development that has evolved in the surgical field. The low number of patients that had laparoscopic operations was due, among other factors, to lack of regular supply of consumables, inadequate operating theatre time, space, and absence of a dedicated laparoscopy unit to enable the operation of more patients demanding the service.

Cholecystectomy was the commonest laparoscopic procedure performed in our center similar to other reports. [5],[7],[10],[11] Laparoscopic cholecystectomy is now the gold standard treatment for patients with chronic and acute cholecystitis. [10],[11] During the same period under review, eight patients had open cholecystectomy for gallbladder stones. This was either due to time constraints, lack of some consumables, or unaffordable cost.

The changing pattern of surgical conditions in Nigeria as well as other developing countries towards that of more industrialized nations is noted by many authors [1],[12],[13],[14] with rising incidence of gallbladder diseases, diabetes, and hypertensive heart disease. Domestic, vehicular, industrial injuries, and malignancies are similarly on the increase. It is necessary to meet up and adapt to these changes to provide optimal services to our community. The ready availability of abdominal ultrasonography for the investigation of a wide range of abdominal symptoms has resulted in the increased diagnosis of asymptomatic gallstones. [15] Management of such incidentally discovered gallstones poses a dilemma as conclusive evidence of the benefits of cholecystectomy is lacking. [15] However the benefit of laparoscopic versus open cholecystectomy is well-established as is the finding of the average duration of hospital stay of 3 and 8 days in this study.

The laparoscopic approach to the appendix gave the opportunity to confirm the diagnosis and exclude other differentials. Open appendectomy is a well-established and safe procedure for the treatment of acute appendicitis, moreover, a critical review and a meta-analysis of randomized controlled trials did not establish any conclusive benefit in terms of cost, morbidity, or early return to work, to warrant routine use of the laparoscopic approach. [16],[17]

Many other studies however, have shown convincing advantage of laparoscopic appendectomy, [19],[20] especially in uncertain diagnosis; thereby, avoiding unnecessary exploratory laparotomy. [5] This is probably much so important in the young female where diagnosis of appendicitis is often shrouded by a lot of uncertainties. [21],[22],[23] Our study recorded conversion to open appendectomy that was deemed necessary in one patient, due to obscure anatomy resulting from multiple adhesions. This is acceptable when anatomy could not be demonstrated clearly. The second conversion to laparotomy involved a patient with impacted stones in the common bile duct. It was deemed more expedient and safer to convert to open operation rather then remove the stones by endoscopic means.

The mean operation time of 3 h led to delay in the remaining elective surgical list and congestion of subsequent lists in the weeks that followed. The average operating time for open cholecystectomy was 1 h 30 min, this made some members of the team to agitate for the open procedure. This experience is similar to reports on early laparoscopic operation in other centers. This depicts the steep learning curve required to establish a new hand-eye coordination when teaching learning surgeons. [2],[24] Subsequently, it becomes difficult to put in laparoscopic operation in the regular operation list and arrangement has to be made on light work days to carry out the operations. Provision of simulators for training may improve the learning curve and time utilization, thereby, allowing more experienced surgeons to provide the needed services.

Careful selection of patients in the process of setting a new procedure is important to avoid any untoward problems in order to attract and encourage patients to consent and similarly improve the confidence of the operating team. The laparoscopic complication recorded was minimal and comparable to other reports. [10],[25],[26] Bile leak is a common complication following laparoscopic cholecystectomy either due to missed accessory bile duct, cystic duct or injury to the common bile duct. [25],[26] Open exploration is often required as was done in one of our patients that had bile peritonitis following missed accessory duct. Burst abdomen was recorded in a sickle cell patient that had open cholecystectomy for multiple bile stones and later died. There was no mortality in the laparoscopic operations.

Two technical problems encountered during the operations were lack of regular supply of Laparoscopic clips necessitating the use of ligatures, thereby, prolonging the operation time. This continued to be a challenge until recently. The tubing connecting the carbon dioxide cylinder to the insufflator was found to be missing in the supplied package; this was improvised with another one of lower quality in the early operations, which lead to gas wastage due to leak. The proper one was later acquired and utilized.

The user-fee charges in the hospital have been frequently reviewed to tally with changing economic situation being a public health service. Presently, laparoscopic operations in our center costs $400.00, though very cheap by world standard is about thrice that of an open operation, this is necessary in order to recover the cost of consumables. The local procurement of these consumables and inclusion of laparoscopic operations in the National Health Insurance Services program would be valuable in reducing the cost implication and making it affordable to many.

A full laparoscopy unit is justifiable in order to regularize the service in the hospital. A lot of enthusiasm is shown by both surgeons and patients in the innovative laparoscopic technique. As expected, provision of such a new technology is bound to change the outlook of surgery in our environment.


  Conclusion Top


Surgeons in Nigeria and indeed west Africa must progress beyond the traditional open operations to the future in which minimal access approaches are utilized. The experience with laparoscopic surgery in our center is limited, but comparable to other centers in our subregion. However, a meticulous appraisal to look at time, space, user-fee, outcome, and feasibility of training may be needed in order to effectively plan and maintain a functional laparoscopic surgical unit. Cost of laparoscopic operations could be subsidized further through participation of the National Health Insurance Scheme to address issues of logistics and supplies.

 
  References Top

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13.Archampong EO, Owusu PA, Amankwa JA. The pattern of acute intestinal obstruction at the Korle Bu teaching hospital. West Afr J Med 1984;3:253-70.  Back to cited text no. 13
    
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25.Duca S, Bala O, Al-Hajjar N, Iancu C, Puia IC, Munteanu D, et al. Laparoscopic cholecystectomy: Incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations. HPB (Oxford) 2003;5:152-8.  Back to cited text no. 25
    
26.Russell JC, Walsh SJ, Mattie AS, Lynch JT. Bile duct injuries, 1989-1993. A statewide experience. Connecticut Laparoscopic Cholecystectomy Registry. Arch Surg 1996;131:382-8.  Back to cited text no. 26
    



 
 
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