WASHINGTON, DC—A University of Michigan surgeon has found a way to successfully perform laparoscopic gallbladder removal in Nicaragua, despite limited clinical resources and poor operating room conditions. This development has kept patients who need the operation from traveling for hours to a faraway location for an open procedure that also requires a much longer recovery period. Sabina Siddiqui, MD, reported on her successful cases in this low- resource country during a global surgery session at the 2013 Clinical Congress of the American College of Surgeons.
During a seven-day trip in November 2012, Dr. Siddiqui performed cholecystectomies—gallbladder removal procedures—on 17 adults in Chinandega, Nicaragua, the country’s third most populous city. “I’ve been practicing surgery for 13 years. These cases were some of the hardest cholecystectomies I’ve done,” Dr. Siddiqui said. One of her patients had a six-centimeter gallstone, which is nearly 2.5 inches in diameter. “I’ve performed hundreds of these procedures, but I’d never seen a stone that large. The disease state of these patients was quite advanced.”
The trip was part of a volunteer service with Amigos for Christ, a nonprofit organization in Nicaragua that organizes medical missions. The trip was Dr. Siddiqui’s third journey to Nicaragua in the past four years.
For many of these patients, an open operation is their only surgical treatment option, even though laparoscopic techniques have been proven to reduce the risk of complications, hospitals stays, and recovery. These patients, who are suffering from the ill effects of gallbladder disease, typically have to travel several hours from rural towns—sometimes trudging along muddy, unpaved roads or descending mountainous terrain—to the acute care hospital in the departmental seat of Chinandega or to the capital city of Managua.
“Usually, the patients bring along a family member, which means they have to pay for a place to stay,” according to Zachary J. Ernstberger, a first-year medical student at Indiana University and a volunteer with Amigos for Christ who accompanied Dr. Siddiqui as a translator. The travel alone could cost patients their entire savings, said Dr. Siddiqui, especially considering that their annual per capita income is about $3,730 according to the World Health Organization.*
Sterilization presented another barrier for surgeons and patients. All surgical equipment is sterilized at a nearby hospital once a day. If a tool didn’t make it in that day’s wash, it would have to be sterilized using a less effective solution onsite, which could increase the risk of infection. Another issue faced was the presence of insects. Mr. Ernstberger was one of the operating room’s official human fly swatters during Dr. Siddiqui’s procedures. In fact, he won an award for killing the most flies in a day. “The only rule was he couldn’t swat the patient,” Dr. Siddiqui said.
Fortunately, only one of the two 30-minute power outages during Dr. Siddiqui’s stay actually held up an operation, Mr. Ernstberger said. And Chinandega’s main city is developed enough to feature running water. Because of the resource limitations and conditions, Dr. Siddiqui said the seven other surgeons at the Chinandega hospital doubted she could successfully perform the gallbladder removal procedures laparoscopically.
“Some things were pieced together to perform the operations,” Dr. Siddiqui said. For example, instead of high definition flat-screen monitors, Dr. Siddiqui and her team relied on a functional but well-worn Sony TV as a monitor. Another equipment substitution was made for a specimen retrieval bag. In a U.S. operating room, laparoscopic gallbladder removal normally uses a special bag to retrieve the gallbladder and prevent bile from spilling into the abdomen. The retrieval bag can cost up to $150. But Dr. Siddiqui successfully improvised with a surgical glove and a suture to develop an effective retrieval bag. The cost was about two dollars.
Another critical step in a gallbladder removal procedure is peeling the gallbladder off its neighboring organ, the liver. The gallbladder is joined to the liver by an artery and a duct that could spill bile into the abdomen if it’s cut. In the U.S., surgeons use a $200 pair of disposable clip appliers to separate the gall bladder from the duct. Dr. Siddiqui used a $1.25 silk suture.
More importantly, Nicaraguan surgeons at the hospital also were able to learn the techniques as Dr. Siddiqui performed the operations, and adapt to using her makeshift resources. Five months later, postoperative follow-up of the patients by the Nicaraguan surgeons showed no complications. Only one of the 17 patients had to have her procedure converted to an open procedure. This was the patient with the 6-centimeter gallstone. “The only reason I had to convert to open was so I could remove the 6-centimeter stone, as it wouldn’t fit through a 1-centimeter port site,” Dr. Siddiqui explained. The other 16 patients were all successfully treated laparoscopically and reported no complications and recovered well from their procedures.
“Laparoscopy can be successfully and safely introduced into resource-limited environ-ments with the use of ‘less-costly’ surgical equipment and materials,” concluded Dr. Siddiqui and Mr. Ernstberger in their presentation abstract.
Dr. Siddiqui plans to return to Chinandega in January 2014 to perform additional laparoscopic cholecystectomies and focus on training Nicaraguan surgeons. However, she considers the trip an exchange of skills, rather than a unilateral transfer of service. “We go abroad into other countries with this mentality that our way is the right way and impose our resource utilization and skills on communities that may be strapped for resources,” Dr. Siddiqui said. “During these trips, I learn just as much as I teach. I can’t depend on someone to show up with the latest and greatest equipment. I have to really know my craft.”
Dr. Siddiqui said her research also has implications for health care costs in the United States, which by far are the highest in the world. Her study begs the question: If less expensive methods achieve the same results, why are tools like $200 clip appliers and specimen retrieval bags—which are both disposed after each procedure—standard practice?
“In other countries, it’s more sustainable to focus on the tools that are available and find economical alternatives that provide the same quality of care,” she said. “That premise should be true for the United States as well.”