First steps of laparoscopic surgery in Lubumbashi: problems encountered and preliminary results

For many reasons, laparoscopic surgery has been performed worldwide. Due to logistical constraints its first steps occurred in Lubumbashi only in 2008. The aim of this presentation was to report authors’ ten-month experience of laparoscopic surgery at Lubumbashi Don Bosco Missionary Hospital (LDBMH): problems encountered and preliminary results. The study was a transsectional descriptive work with a convenient sampling. It only took in account patients with abdominal surgical condition who consented to undergo laparoscopic surgery and when logistical constraints of the procedure were found. Independent variables were patients’ demographic parameters, staff, equipments and consumable. Dependent parameters included surgical abdominal diseases, intra-operative circumstances and postoperative short term mortality and morbidity. Between 1stApril 2009 and 28th February 2010, 75 patients underwent laparoscopic surgery at the LDBMH making 1.5% of all abdominal surgical activities performed at this institution. The most performed procedure was appendicectomy for acute appendicitis (64%) followed by exploratory laparoscopy for various abdominal chronic pain (9.3%), adhesiolysis for repeated periods of subacute intestinal obstruction in previously laparotomised patients (9.3%), laparoscopic cholecystectomy for post acute cholecystitis on gall stone (5.3%) and partial colectomy for symptomatic redundant sigmoid colon (2.7%). There were 4% of conversion to laparotomy. Laparoscopic surgery consumed more time than laparotomy, mostly when dealing with appendicitis. However, postoperatively, patients did quite well. There was no death in this series. Nursing care was minimal with early discharge. These results are encouraging to pursue laparoscopic surgery with DRC Government and NGO's supports.


Introduction
For many decades now, laparoscopy surgery stands for minimal invasive surgical approach of the abdominal cavity. Its indications have been more and more extended. Since 1988, coelioscopic cholecystectomy has become a standard procedure of removal of gall bladder [1]. From 1992, gynaecologic surgical treatment has been carried out laparoscopically. Since this date, classical abdominal surgeries enter more and more in new laparoscopy registry [2]. While laparoscopic surgery is now performed routinely in all developed worlds, its first steps have hardly occurred in many developing countries like at our Lubumbashi school of Medicine, due to several constraints. We hereby acknowledge the contribution of the Don Bosco missionary hospital, (LDBMH) to the establishment of this new surgical abdomen approach. The missionary hospital has been providing university surgeons with training and practice of laparoscopic surgery, disposing of necessary equipment and consumable as well as Belgian cooperation trainers. The aim of this study was to report our ten-month experience of laparoscopic surgery at the LDBMH: problems encountered and preliminary results.

Study settings and staff training
Lubumbshi is the second big town of the Democratic Republic of Congo (DRC) administratively but also by its infrastructure and population of about three millions. With its copper, cobalt, uranium mines and other minerals, Lubumbashi was used to be called the "DRC economic capital" or the "DRC lung". The world economic crisis has dramatically altered this situation but it is still being called Copper Capital". The LDBMH is located near the Lubumbashi University administrative building along Kasapa road that leads to Lubumbashi University main campus. It is a multidisciplinary health center directed by the Don Bosco congregation established in the DRC for many decades. The institution enjoys support by the congregation but also the Belgian Government and many ONGs. The LDBMH utilises many general medical practitioners and several Lubumbashi medical specialists. A part from the supervisor and the surgeon trained abroad (the first in the department of visceral and digestive surgery, CHU Amiens-Nord (France) and the second in the department of digestive, endocrine surgery and transplantation, CHU of Liege, Belgium) the staff had two sessions of training in laparoscopic surgery in Lubumbashi by European Union ONG: "Doctors Without Holidays". Nursing and paramedical staff included also four nurses : assistant, scrub, runner and technician nurses and two anesthetists. All were trained fort two months.

Study time frame
The study was undertaken from 1 st April 2009 to 28 th February 2010.

Study design, sampling and inclusion criteria
The study was a transsectional descriptive work with a convenient sampling. During the study time frame, the procedure was performed only to the patients with abdominal surgical conditions who consented and when logistical constraints of the procedure were sound: trained staff, fitness and availability of equipments and consumable. Independent variables were patients' demographic parameters, appropriate staff, equipments and consumable.
Dependent parameters included surgical abdominal diseases, intraoperative circumstances and postoperative short term outcomes (morbidity and mortality.)

Data collection, data analysis
Pre-established forms were filled in with independent data (age, sex, disease, operating staff) and dependent variables (intraoperative events, postoperative mortality; morbidity, hospital stay and delay for discharge). Our data were introduced and analyzed using 2007 Excel and 2005 Epi info logiciels. Mean (average) and its parameters' distribution were determined for Gauss distributions and median and its parameters' distributions were measured for non-Gauss distributions; as well as standard deviations.

Age and sex distribution
A total of 75 procedures were performed making an average of 7 cases per week, 2 cases per working day. During the study period the 75 laparoscopic surgeries accounted for 1.5% of the total abdomen activities at the LDBMH. Mean age was 30.25+2.02 years Page number not for citation purposes 3 and median at 34,5years. Females were predominant with a sex ratio of 2F/1M, as it is shown on Table 1.

Progression of laparoscopic surgery
As shown on diagram 2, the laparoscopic surgery activities increased at the beginning of the study time frame but decreased at the end of year 2009, period where only emergency surgeries were performed. There was again some increase around February 2010.
Meanwhile there was improvement of the performance noted by the reduction of average duration of operations (diagram 3) following the acquisition of skills and mastering of events. It was also been noted by the low rate of conversion from laparoscopy to laparotomy and the reduction operation duration as it is shown on diagram 3 (appendicetomy), (Figure 2, Figure 3).

Origin of patients and costs
As shown on Diagram 4, (Legend: Subscribed companies: Susc. Camp) private patients were rare. Patients mainly originated from subscribed companies that had schemes with the missionary hospital or from LDBMH staff. The laparoscopic surgery was and is still the surgery for few people who could pay directly or indirectly at LDBMH (Figure 4).

Outcomes
There were 4% of conversion to laparotomy and there was no mortality in this series and all patients got discharged after a hospital stay relatively shorter than that after surgical laparotomy for each disease. For appendicectomy, postoperative pain was less severe lasted shorter after coelioscopy surgery. The average hospital stay after laparoscopic appendicectomy was three days while this average was of six days after open appendicectomy.

Discussion
The adoption of laparoscopy in developing countries has been sporadic and minimal, despite the significant improvements in surgical care in developed countries. To uptake laparoscopic surgery in these countries, many authors have discribed some barriers [1][2][3][4]. Migration of health care providers -whether to the private sector, to nongovernmental organizations (NGOs), or overseas -places a strain on the ability of a country to provide essential surgical services [6]. Adequate facilities are crucial to the provision of basic surgical care. Even the best trained and motivated surgical team cannot function without appropriate infrastructure. In Malawi, a study of district hospital theaters showed that most did not have dedicated theater staff, and half did not have adequate instruments to perform common operations. More than half did not have basic skin and soft tissue sutures available on the day of inspection [7].
In the international literature [3] and in Lubumbashi [8], appendicectomy has been the most performed procedures but cholecystectomy is the most laparoscopic surgery frequently performed [1]. However, the advantage of laparoscopic

Competing interests
Authors declare no competing interests.

Authors' contributions
All authors participated in the study and have read and approved the final manuscript.

Acknowledgements
This experience was part of a cooperation project entitled "Appui à l'organisation de l'école de chirurgie laparoscopique des cliniques  Tables and figures   Table 1: Laparoscopic surgery at ldnmh, patients' sex distribution