|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 4 | Page : 158-162
Pediatric laparoscopic surgery in North-Central Nigeria: Achievements and challenges
Lukman Olajide Abdur-Rahman1, Kayode T Bamigbola2, Abdulrasheed A Nasir1, Adewale O Oyinloye1, Nurudeen T Abdulraheem1, Olanrewaju O Oyedepo3, James O Adeniran1
1 Department of Surgery, Division of Pediatric Surgery, University of Ilorin Teaching Hospital, University of Ilorin, Ilorin, Nigeria
2 Department of Surgery, Federal Medical Centre, Owo, Nigeria
3 Department of Anesthesia, University of Ilorin Teaching Hospital, University of Ilorin, Ilorin, Nigeria
|Date of Web Publication||14-Oct-2016|
Lukman Olajide Abdur-Rahman
Department of Surgery, Division of Pediatric Surgery, University of Ilorin Teaching Hospital, University of Ilorin, Ilorin
Source of Support: None, Conflict of Interest: None
Background and Objective: Advances in laparoscopy are making the service accessible even in resource-poor countries where adaptations are made to meet local challenges. We report our experience in the provision of laparoscopy service to children at a tertiary health center in North-central Nigeria. Methods: A team of pediatric surgeons, anesthetists, and nurses collaborated to provide service and train other personnel. A prospective collection of data on biodata, diagnoses, procedure, and outcome over an effective period of 36 months of laparoscopy intervention of the 54 months between September 2009 and February 2014 was done. Consent, which also included the possibility of conversion to open was obtained from the parents of the patients. Results: A total of 73 patients aged 2 weeks to 16 years with a male: female ratio of 3 to 1 had laparoscopy done during the period. Fifty-two (71.2%) procedures were therapeutic, and 21 (28.8%) cases were done as emergency. Laparoscopic appendectomy was the most commonly performed procedure 25 (34.3%), followed by laparoscopic orchidopexy 17 (23. 3%), and diagnostic laparoscopy for disorders of sexual differentiation in 13 (17.8%). The length of stay in hospital postoperative was 1-3 days with a mean of 1.34 0.45 days. The complications recorded included hemorrhage, in a case of infantile hypertrophic pyloric stenosis due to failed electrocautery, one port site burns injury from diathermy dissection, and two periport pain postoperation. There was no mortality recorded. Conclusion: Pediatric laparoscopic service is gaining recognition in our practice in spite of poor resources, incessant industrial actions, and apathy from support staff. The outcomes are encouraging as the patients had minimal morbidities. Skills are improved through practice and retraining and manpower, and instruments are being expanded through our collaboration and training.
Keywords: Achievements, challenges, pediatric laparoscopy, resource-poor setting
|How to cite this article:|
Abdur-Rahman LO, Bamigbola KT, Nasir AA, Oyinloye AO, Abdulraheem NT, Oyedepo OO, Adeniran JO. Pediatric laparoscopic surgery in North-Central Nigeria: Achievements and challenges. J Clin Sci 2016;13:158-62
|How to cite this URL:|
Abdur-Rahman LO, Bamigbola KT, Nasir AA, Oyinloye AO, Abdulraheem NT, Oyedepo OO, Adeniran JO. Pediatric laparoscopic surgery in North-Central Nigeria: Achievements and challenges. J Clin Sci [serial online] 2016 [cited 2020 Feb 16];13:158-62. Available from: http://www.jcsjournal.org/text.asp?2016/13/4/158/192271
| Introduction|| |
Minimally invasive surgery has become technologically advanced with laparoscopic surgery advocated for diverse procedures and pathologies in different age groups and miniature articulated instruments developed to cater for the small patients' needs. The outcomes have been very encouraging, and acceptance is global. ,,
In spite of the lean health budget in a developing country like Nigeria, there are several pioneering efforts from some parts of the country highlighting the feasibility of laparoscopy service with emphasis on local adaptations to mitigate against immense challenges. ,,,
Pioneering laparoscopy services, especially for children in a resource-poor setting like ours in Nigeria comes with added challenges as there is scepticism expressed by many general surgeons on the feasibility, safety, and relevance of laparoscopy in our environment. Many have argued that pathologies that require surgical interventions were rather presented late or at advanced stages and often times laparoscopic interventions are belated. Adisa et al. , have demonstrated the role of laparoscopy even in the very sick and those with undetermined diagnoses.
We present our experience in pediatric laparoscopic surgical service at a tertiary health care facility in Nigeria, relating the coping measures in the face of challenges.
| Methods|| |
A team of pediatric surgeons, anesthetists, and nurses collaborated to provide service and train other personnel that included surgical trainees on rotation, general surgeons, nurses, and technician. Data were collected prospectively from September 2009 to February 2014 in a pediatric surgical laparoendoscopy structured Microsoft Excel® 2013 (v15.0) sheet as our database and analysis done with SPSS 17.0 for Windows (SPSS Inc., Chicago, Illinois, USA). All parents of the patients were duly informed about the type of procedure, likely duration, and complications, and consent was obtained (which also included a possibility of conversion to open surgery) before each procedure. The information extracted included: Age, diagnosis, procedures performed (including whether diagnostic or therapeutic), and length of hospital stay as well as the occurrence of perioperative complications. We commenced oral feeds between 6 and 12 h postoperatively, and the patient had one short of intravenous fentanyl 2 μg/kg intraoperative, 1-2 doses of intravenous acetaminophen 15 mg/kg postoperative, and later continued with Ibuprofen 10 mg/kg or acetaminophen 15 mg/kg orally for 72 h.
| Results|| |
During the period under review, 73 patients underwent laparoscopic surgery within the effective duration of 36 months out of the 54 months [Table 1].
The patients' ages ranged from 2 weeks to 16 years with a male:female ratio of 3:1. Fifty-two (71.2%) procedures were therapeutic while 21 (28.8%) were diagnostic, and 21 (28.8%) cases were done as emergency. The most commonly performed procedures were laparoscopic appendectomy, 25 (34.3%), laparoscopic orchidopexy, 17 (23.3%), and diagnostic laparoscopy for disorders of sexual differentiation (DSD), 13 (17.8%) patients [Table 2].
In the diagnostic cases, we were able to confirm the types of DSD, severe hypospadias with intra-abdominal testes, biliary atresia, and late presenting congenital diaphragmatic hernia, which was repaired, [Table 3].
The length of the hospital stay after surgery was 1-3 days with a mean of 1.34 ± 0.45 days. The complications recorded included hemorrhage, in a case of infantile hypertrophic pyloric stenosis (IHPS) due to failed electrocautery, one case of port site burn injury from diathermy dissection, and two patients had periport pain postoperation. There was neither wound infection nor mortality recorded.
| Discussion|| |
In our center, the pediatric surgeons started therapeutic laparoscopy before the adult surgeons unlike what happened in other centers in our country. ,,,, Our center pioneered pediatric laparo-endoscopy services in the whole of Nigeria.  We started by postresidency fellowship training abroad and attendance of workshops and seminars because before this; laparoscopy services were only available at a diagnostic level among the gynecologists in our center whose practice had collapsed for the lack of incentives and dilapidated equipment. We also encouraged and trained residents (who also had access to laparoscopic training boxes for practice in the skills room) and nurses in the preparation (operative set up), care, and handling of instruments so that a team was built. We collaborated with adult surgeons who showed interest in laparoscopy so that we could provide support for adult service. These efforts were meant to develop a sustainable, comprehensive laparoendoscopy center of excellence for our region as alluded to in other studies. ,
At the inception of the service, equipment used were mostly privately sourced to complement the few available hospital owned equipment before the purchase of 3 mm laparoscopy ports and working instruments for the pediatric laparoscopy service as was the case with Ray-offor et al.  in Port Harcourt. These were predominantly adapted equipment to meet the immediate needs of providing laparoscopy service in our region. In fact, local adaptation of equipment appears to be a common theme among laparoscopic surgeons in our part of the world ,, without which the disruption in laparoscopy services would be significantly more than what was reported in our series because procurement or upgrade of laparoscopy equipment is challenged by numerous competing interests and laparoscopy is considered very low priority in the face of meagre funds. Smaller babies (2 weeks to 3 years) benefitted following the procurement of pediatric sets (3 mm ports and hand instruments). Proportionately, laparoscopic intervention increased progressively at our center if not for the incessant national industrial action.
There have been suggestions 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  The benefits of laparoscopic surgery, which includes faster recovery, shorter hospitalizations, decreased wound infections and decreased use of narcotic medications, and shortened waiting list are all confirmed in this study. Some developing countries such as Mongolia demanded that this benefits should be extended to her rural community through special training.  In doing this, the benefits that have eluded much of the developing world, where people often accept several painful conditions as a fact of life were reduced or eliminated.
A general consensus is that laparoscopy is a gateway to improve the infrastructure of tertiary and regional care centers as presumed during a Ministry of Health personnel visit for need assessment for upgrading of tertiary health institutions in 2008, in Nigeria. This led to the procurement of a complete laparoscopy (KARL STORZ, German) tower for the General Surgeons that we incidentally found in the central store in 2010 because there was no surgeon to use it. This buttressed the noncommittal and conservative attitude of some surgeons to laparoscopy service.  We had several consultation with the management to support this initiative and to train more staff (surgeons, perioperative nurses, and technicians) who have shown interest in laparoendoscopy service. We also contacted industries and agencies that market laparoscopy consumables and those that maintain equipment. This assisted us with cost containment and enticement of clients.
Team building started in earnest by imploring like minds for collaboration in lending support for forming of the pediatric laparoendoscopy team. Hence, we started with two consultant pediatric surgeons, a consultant pediatric anesthetist, three perioperative nurses, and three senior registrars. We started using the adult equipment (10 mm telescope, 6 mm ports, and 5 mm forceps) in children older than 6 years initially for diagnostic procedures (DSD, nonpalpable undescended testis, 6 Fr cystoscopy for posterior urethral valves, bladder stones and strictures) and later, we moved on to therapeutic procedures (hernia repair, appendectomy, gonadectomy, and pyloromyotomy). ,, In this study, laparoscopic appendectomy was the most often performed surgery as reported in other studies. ,
Our study reinforced the advantages of laparoscopy in the management of DSD, nonpalpable undescended testes, and severe hypospadias. ,,,,,,
Challenges experienced in the use of basic laboratory investigations (liver function tests, urinalysis) and confusion caused by ultrasonography in the diagnosis of biliary atresia were overcome by the laparoscopic inspection of atretic gallbladder, appearance of the liver and its biopsy, and laparoscopic-assisted cannulation of the biliary tree for intraoperative cholangiography in three patients. This use is supported by report in a study. 
The learning curve was steep due to early building of team members (surgeons, residents, nurses) who had regular brief and debrief about procedures. The stop-start nature of the service due to strikes, unavailability of consumables at some point, as well as challenges with equipment in the early days of the service, also affected the learning curve. There was so much enthusiasm among team members who were ready to make things happen in spite of our challenges. The challenges of time for equipment set up (technical issues) and unfaithful equipment that often times required adjustment by the lead surgeons and need to train camera operators on the job slowed down the pace of work. We were able to address this by educating team members on their roles, completing set up of trays before the commencement of anesthesia to reduce anesthesia time, and use of a checklist to ensure nothing was missed out. There was also the challenge with staff and residents' apathy because they were intolerant of the long procedure time in our early phase of laparoscopy practice. We were also confronted by management's aggressive drive for internally generated revenue because laparoscopy service is thought to be and should be a "money-spinning service" for the institution. We practice in an environment where we need to train the workforce (medical students, residents doctors, and nurses), and health care is predominantly financed out of pocket by our clients who are mainly public servants, laborers (artisans), and peasant traders who live from hand to mouth (and absence from work means no income); they can hardly afford open surgery from out of pocket payment. Increasing the cost of laparoscopy would mean that we would not get patients and invariably we would not be able to train manpower. The majority of our patients in this study were children of parents who are National Health Insurance Scheme (NHIS) enrollee and elites, who had sponsors from outside Ilorin. The coverage provided by NHIS for laparoscopy is an advantage as against what is obtainable in many countries that had health insurance scheme, which covers for open operations only, resulting in high out-of-pocket costs. ,
On the average, our patients commenced oral intake early and spent <2 days on admission postlaparoscopic intervention. This in a way supported our drive for high turnover of in-patients service, reduced waiting time, made bed space available for many more patients, early return to home environment where pediatric patients recuperate better, and saving the parents cost of absence from their duty posts and the children from missing classes in the school. 
| Conclusion|| |
Pediatric laparoscopic service is gaining recognition in spite of poor resources, incessant industrial action, and apathy from support staff. We were able to build a team and trained more resident doctors and nurses. The outcomes are encouraging as this has proved that diagnostic laparoscopy saved the patients and relations unnecessary interventions and stress. It also saves the surgeons professional embarrassment that might follow a negative open laparotomy.  We hope to consolidate on collaboration with adult surgeons to increase laparoscopy service within the hospital and by extension other centers when our residents become fellows.
Financial support and sponsorship
The cost for this project is borne by the authors.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zitsman JL. Pediatric minimal-access surgery: Update 2006. Pediatrics 2006;118:304-8.
Karakus OZ, Hakgüder G, Ates O, Olguner M, Akgür FM. Cholecystectomy conducted with single-port incisionless-intracorporeal conventional equipment-endoscopic surgery. J Laparoendosc Adv Surg Tech A 2013;23:728-32.
Blanco FC, Kane TD. Single-port laparoscopic surgery in children: Concept and controversies of the new technique. Minim Invasive Surg 2012;2012:232347.
Talabi AO, Adisa AO, Adefehinti O, Sowande OA, Etonyeaku AC, Adejuyigbe O. Early experience with laparoscopic surgery in children in Ile-Ife, Nigeria. Afr J Paediatr Surg 2015;12:29-32.
Adisa AO, Lawal OO, Alatise OI, Adesunkanmi AR. An audit of laparoscopic surgeries in Ile-Ife, Nigeria. West Afr J Med 2011;30:273-6.
Misauno MA, Ismaila BO. Pioneering laparoscopic general surgery in Nigeria. Niger Med J 2011;52:104-6.
Ekwunife CN, Chianakwana GN, Anyanwu SN, Emegoakor C. Pioneering laparoscopic surgery in South-Eastern Nigeria: A two-center general surgery experience. Niger J Basic Clin Sci 2012;9:75-9.
Adisa AO, Mishra RK. Changing role of laparoscopy in the management of patients with Cirrhosis. J Minim Access Surg 2008;4:65-72.
Adisa AO, Lawal OO, Adesunkanmi AR, Adejuyigbe O. Impact of introduction of laparoscopic surgery on management of unresolved intra-abdominal malignancies in a West African hospital. World J Surg 2014;38:2519-24.
Ray-Offor E, Okoro P, Gbobo I, Allison A. Pilot study on laparoscopic surgery in port-harcourt, Nigeria. Niger J Surg 2014;20:23-5.
Abdur-Rahman LO, Nasir AA, Adeniran JO. Paediatric laparoscopic surgery in Ilorin: The needs and the advantages. Trop J Laparoendosc 2010;1:45-6.
Singh Y. Training and credentialing in laparoscopic surgery-the need of the day. Med J Armed Forces India 2005;61:7-8.
Galukand M, Jombwe J. Laparoscopic surgery in a resource limited setting: Cost containment, skills transfer and outcomes. East Afr J Surg 2012;16:112-7.
Straub CM, Price RR, Matthews D, Handrahan DL, Sergelen D. Expanding laparoscopic cholecystectomy to rural Mongolia. World J Surg 2011;35:751-9.
Abdur-Rahman L, Patel S, Desai A, Kraus R, Davenport M, Ade-Ajayi N. Development of a Paediatric Minimal Access Surgery Service: A Comparison between Two Tertiary Centres in UK and Africa. Abstracts of Papers Presented During the 9 th
Scientific and Annual General Conference of the Association of Paediatric Surgeons of Nigeria (APSON), Ilorin, September 2010. Afr J Paediatr Surg 2011;8:121-37.
Abdur-Rahman LO, Adeniran JO, Nasir AA, Bamigbola K. The Incredible Circumcisionist Abstracts of Papers Presented During the 9 th
Scientific and Annual General Conference of the Association of Paediatric Surgeons of Nigeria (APSON), Ilorin, August 2010. Afr J Paediatr Surg 2011;8:121-37.
Abdur-Rahman LO, Nasir AA, Bamigbola KT, Oyinloye O, Abdulraheem NT, Adeniran JO. Laparoscopic Surgery in Ilorin: Achievement and Challenges. Abstracts of Papers Presented During the 13 th
Scientific and Annual General Conference of the Association of Paediatric Surgeons of Nigeria (APSON), Nnewi APSON; 2014.
Yau KK, Siu WT, Tang CN, Yang GP, Li MK. Laparoscopic versus open appendectomy for complicated appendicitis. J Am Coll Surg 2007;205:60-5.
Satar N, Bayazit Y, Doran S. Laparoscopy in the management of impalpable testicle. Acta Chir Belg 2005;105:662-6.
Park JH, Park YH, Park K, Choi H. Diagnostic laparoscopy for the management of impalpable testes. Korean J Urol 2011;52:355-8.
Tsujihata M, Miyake O, Yoshimura K, Kakimoto K, Matsumiya K, Takahara S, et al.
Laparoscopic diagnosis and treatment of nonpalpable testis. Int J Urol 2001;8:692-6.
Osifo OD, Amusan TI. Female children with ambiguous genitalia in awareness-poor subregion. Afr J Reprod Health 2009;13:129-36.
Yu TJ, Shu K, Kung FT, Eng HL, Chen HY. Use of laparoscopy in intersex patients. J Urol 1995;154:1193-6.
Udwadia TE. Diagnostic laparoscopy. Surg Endosc 2004;18:6-10.
Teerawattananon Y, Mugford M. Is it worth offering a routine laparoscopic cholecystectomy in developing countries? A Thailand case study. Cost Eff Resour Alloc 2005;3:10.
Abdur-Rahman LO, Kolawole IK, Adeniran JO, Nasir AA, Taiwo JO, Odi T. Pediatric day case surgery: Experience from a tertiary health institution in Nigeria. Ann Afr Med 2009;8:163-7.
Chao TE, Mandigo M, Opoku-Anane J, Maine R. Systematic review of laparoscopic surgery in low- and middle-income countries: Benefits, challenges, and strategies. Surg Endosc 2016;30:1-10.
[Table 1], [Table 2], [Table 3]