Operative Gynecologic Laparoscopy in Ile-Ife,Nigeria: Preliminary Experience

Abstract

Background: Operative gynecologic laparoscopy (OGL) had remained in latency in Nigeria ostensibly because of widespread lack of equipment and skilled personnel. Following the tertiary health care intervention program of the Nigerian government, video-assisted laparoscopy equipment became available in the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria, in 2010. Methods: OGL was commenced in OAUTHC, Ile-Ife in 2011, and prospective data began to be collected using a specifically designed instrument. An analysis of the data collected over the 12-month period from November, 2011 to October, 2012 was performed. Results: There were 51 OGLs, making up 23.7% of the 215 gynecologic surgeries over the study period. The patients' ages ranged from 20 to 50 years (mean age=32.6±6.0 years). Ten (19.6%) of the OGLs were emergencies, whereas 41 (80.4%) were elective. Twenty-eight patients (54.9%) had tubal surgery for tubal-factor infertility, whereas 6 (11.8%) had endometriosis surgery. There were 6 salpingectomies for ectopic pregnancy (11.8%), including 1 heterotopic pregnancy. Two total laparoscopic hysterectomies (3.9%) and 2 ovarian cystectomies were also performed. The duration of surgery ranged from 33 minutes to 185 minutes (mean time=79.8±42.9 minutes). Various improvisations and local adaptations were necessary in the course of 14 procedures (27.5%). There were 5 conversions to laparotomy (9.8%), all following emergency laparoscopy. The duration of hospital stay postoperatively ranged from 4 hours to 5 days (median time=6 hours). There was no postoperative morbidity or mortality. Conclusions: With basic equipment and indigenous skilled personnel, routine OGL is possible even in resource-constrained settings such as Nigeria. Health care providers, therefore, need to consider and endorse this possibility for every patient requiring gynecologic surgery. (J GYNECOL SURG 29:186)

Introduction

Operative gynecologic laparoscopy first began with simple single-handed therapeutic interventions such as oophorectomy and appendectomy, which were first performed by the German gynecologist Kurt Semm, MD, by direct visualization through a laparoscope.¹ A major breakthrough, however, came in the 1980s, with the adaptation of video-camera technology for use with the laparoscope; thus, giving rise to the modern era of video-assisted laparoscopy.² This development led to a virtual explosion in the spectrum of interventions performed laparoscopically, such that today, almost all known gynecologic procedures have been performed laparoscopically in the developed world.³

In Nigeria, laparoscopy first became available in the 1970s and was used mainly for diagnostic purposes and a few tubal sterilizations. Unfortunately, over the next 3 decades, this rapidly evolving subspecialty in gynecology slowed and eventually came to a virtual halt as a result of infrastructural decay in most government hospitals in Nigeria. A handful of private hospitals in the country, however, managed to keep laparoscopy alive in their practices, and they are the ones credited with the <10 published reports of operative laparoscopy in Nigeria, until recently.^4,5

The Nigerian Federal Government under former President Olusegun Obasanjo (1999–2007) instituted a tertiary health care intervention program of which the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) in Ile-Ife was a beneficiary. The completion of this project in OAUTHC, Ile-Ife in 2010 witnessed the supplying of some modern video-assisted laparoscopy equipment to the hospital. This article presents the preliminary experience in operative gynecologic laparoscopy in OAUTHC, Ile-Ife, Southwestern Nigeria, since then.

Methods

An analysis of prospective data obtained from all women undergoing gynecologic laparoscopy at OAUTHC, Ile-Ife over the 1 year period from November, 2011 to October, 2012 was performed. It was not possible, however, to perform laparoscopic surgery for ∼3 months within the study period (December 15, 2011 to March 13, 2012) because of a fault in the camera unit. All data were collected prospectively, using a specifically designed study instrument. Patients were recruited based on eligibility for laparoscopic surgery from the gynecology clinic (elective cases) and the adult casualty department (emergency cases) after thorough evaluation. Adequate counseling was provided for all patients and written informed consent was obtained for laparoscopy and possible conversion to laparotomy.

All patients had clinical and radiologic evaluation (ultrasonography±hysterosalpingography, as appropriate) along with laboratory investigations for proper diagnosis and identification of any existing comorbidities. Every patient was reviewed preoperatively by the anesthetist, and all of the laparoscopies were performed with the patients under general anesthesia. Carbon dioxide (CO₂) pneumoperitoneum was used for all the cases via the Veress needle technique, and intra-abdominal pressure was maintained between 14 mm Hg and 18 mm Hg. The Palmer's point entry technique was used in patients who had had previous abdominal surgery.⁶ The total number of ports used in each case ranged between two and five, depending upon the operative procedure performed.

Equipment used comprised a 10-mm and a 5-mm 0° laparoscope, a standard definition camera and monitor, a light source and fiberoptic light cable, and a quadromanometric insufflator. Added to these were a suction unit, a simple electrosurgical generator, and some reusable 10-mm and 5-mm trocars, in addition to a few hand instruments. Advanced energy sources such as Harmonic,^® LigAssure,^® and laser were not available in this center.

After each procedure, all the port sites were closed by suturing with 2/0 Vicryl. Patients were usually allowed oral intake once they were fully conscious, and were later discharged home on oral analgesics (usually nonsteroidal anti-inflammatory drugs [NSAIDs]) for 3 days, and oral antibiotics for 5 days. Each patient's wound dressings were removed on the third postoperative day, and the wounds were painted with Gentian violet. Patients were subsequently seen in the gynecology clinic 1 week postoperatively.

All the data obtained were analyzed for age, diagnosis, previous abdominal surgery, duration of surgery, type of surgery performed, need for improvisation, intraoperative complications, conversion to laparotomy, postoperative complications, and duration of hospital stay, using SPSS version 16.0. The results are presented as simple means and percentages.

Results

A total of 51 gynecologic laparoscopies were performed during the study period. This constituted 23.7% of all the 215 gynecologic surgeries, excluding uterine evacuations performed during the same period at OAUTHC, Ile-Ife. The ages of the patients ranged between 20 and 50 years, with a mean of 32.6±6.0 years. Eight (15.7%) of the patients had had previous abdominal surgery. Ten of the 51 laparoscopic surgeries (19.6%) were emergencies, whereas the remaining 41 (80.4%) were elective procedures. The patients' diagnoses and the surgeries performed are as shown in Table 1.

Table 1.

Diagnoses and Types of Gynecologic Laparoscopic Surgeries Performed in OAUTHC, Ile-Ife, Nigeria

	Diagnosis	Surgery performed	Frequency (%) N=51
Elective	Tubal-factor infertility	Tubal adhesiolysis	18 (35.3%)
		Salpingoneostomy	5 (9.8%)
		Salpingectomy	3 (5.9%)
		Fimbrioplasty	2 (3.9%)
	Endometriosis	Adhesiolysis, biopsy and ablation	6 (11.8%)
	Uterine fibroids	Myomectomy	3 (5.9%)
		Total laparoscopic hysterectomy	1 (2.0%)
	PCOS	Laparoscopic ovarian drilling	1 (2.0%)
	CIN	Total laparoscopic hysterectomy	1 (2.0%)
	Completed family size	Electrosurgical BTL	1 (2.0%)
Emergency	Ectopic pregnancy	Salpingectomy	5 (9.8%)
	Heterotopic pregnancy	Salpingectomy	1 (2.0%)
	Ovarian cyst accident	Ovarian cystectomy	2 (3.9%)
		De-torsion and aspiration	1 (2.0%)
		Oophorectomy	1 (2.0%)

OAUTHC, Obafemi Awolowo University Teaching Hospitals Complex; PCOS, polycystic ovarian syndrome; CIN, cervical intraepithelial neoplasia; BTL, bilateral tubal ligation.

The duration of surgery ranged from 33 minutes to 185 minutes, with a mean of 79.8±42.9 minutes. Various improvisations and local adaptations were necessary in the course of 14 (27.5%) of the procedures. These included the use of the wrist portion of a surgical glove tied at one end with a suture as a laparoscopic retrieval bag⁷ and the application of the plastic case of a 50-mL syringe as a colpotomizer. Others included the use of a laparoscopic myoma screw for optimal uterine manipulation and the exclusive use of monopolar electrosurgical energy during total laparoscopic hysterectomy.

There was no major intraoperative complications in any of the patients in this series. One woman (2.0%) had injury to her right inferior epigastric vessels, which was managed successfully by a balloon tamponade with a Foley's catheter for ∼24 hours. There was also a case of superficial thermal burns to the abdominal skin caused by a bipolar lead mistakenly placed on the patient's abdomen. This was managed by regular dressing with antibiotic-impregnated gauze, and the lesion healed satisfactorily within 2 weeks.

Five patients (9.8%) had their procedures converted to open laparotomy for various reasons. One laparoscopic ovarian cystectomy was converted to laparotomy when the camera unit broke down during the procedure. A salpingectomy for ectopic pregnancy was also converted because of a fault with the light source. The remaining 3 conversions were done because of rapid hemorrhage from a cornual ectopic gestation, a secondary abdominal pregnancy, and bilateral pyosalpinges, respectively. All of the conversions followed emergency laparoscopy.

The duration of hospital stay postoperatively ranged from 4 hours to 5 days, with a median of 6 hours. Two patients (3.9%) were discharged on the second postoperative day, both of them having had operative laparoscopy, with viable intrauterine pregnancies. Eight patients (15.7%) were discharged on the first postoperative day, including the 2 patients who had had total laparoscopic hysterectomy. All the others (76.5%) had same-day discharge, except for the 5 patients (9.8%) who had conversion to laparotomy, who were discharged between the fourth and fifth postoperative days. None of the patients in this series experienced postoperative complications, and no mortality was recorded.

Discussion

The entire body of literature on operative gynecologic laparoscopy in Nigeria consists of a handful of case reports.^4,5 This is probably evidence that the subspecialty has remained in latency in the country, with procedures being few and far between. Furthermore, most of the earlier published procedures were performed in private hospitals, and some of these procedures were performed by nonindigenous personnel. The present effort, therefore, represents a pilot attempt at entrenching operative gynecologic laparoscopy as a routine practice in a government hospital in Nigeria.

Although laparoscopy constituted <25% of gynecologic surgeries at the center, this still represented a giant leap forward, considering the fact that none had been performed for years previously in the center. This rate of laparoscopies is also much higher than the 2.87% laparoscopy rate reported from the National Hospital Abuja, Nigeria, where all the laparoscopies performed were diagnostic.⁸ Recurrent logistical problems with equipment were highlighted as a contributory factor to the low rate of laparoscopies in Abuja. Similarly, in the Ile-Ife center, several patients who might have benefited from laparoscopic surgery underwent open surgery instead, for reasons ranging from faulty laparoscopic equipment to lack of adequate awareness and an unexplained reluctance on the part of some personnel. These limitations are, however, being overcome gradually.

Tubal pathology has long been identified as a major problem among Nigerian women.⁹ This was corroborated in the current series, as tubal surgery for tubal-factor infertility was by far the most common elective gynecologic laparoscopic surgery performed. Moreover, ectopic pregnancy, which was the leading indication for emergency laparoscopy in this series, is also a consequence of tubal pathology. It is, therefore, evident that a great need exists for operative gynecologic laparoscopy among Nigerian women, at least as a more-affordable solution to the problem of tubal-factor infertility, considering the prohibitive cost of in vitro fertilization and embryo transfer (IVF+ET). Moreover, as was the case in some of these patients, laparoscopic tubal surgery is often required prior to IVF+ET in patients with hydrosalpinges. Currently, a long-term follow-up of the patients in this series is underway to determine the pregnancy and live birth rates following laparoscopic tubal surgery with or without IVF+ET.

It used to be thought that endometriosis was a very rare condition among Nigerian women. The finding of histologically confirmed endometriosis in 11.8% of the patients in this series is, however, evidence to the contrary. This lends support to the suggestion that endometriosis is grossly underdiagnosed in Nigerian women, ostensibly because of the widespread lack of facilities for laparoscopy. The rate obtained in this current study is comparable to the up to 10% prevalence reported in studies from developed countries.¹⁰

Spontaneous heterotopic pregnancy is a very rare phenomenon, with an incidence of 1:30,000 pregnancies.¹¹ Its incidence might be expected to be higher in Nigeria because of the country's high incidence of twinning and ectopic pregnancy.¹² One case of heterotopic pregnancy during the period of this study was recorded, and a laparoscopic salpingectomy with continuation of the intrauterine gestation was performed. Prior to this, there had been no published report of laparoscopic management of heterotopic pregnancy in Nigeria. Similarly, during this study, two total laparoscopic hysterectomies, which it is believed had never been reported from Nigeria previously, were performed.

The mean duration of the procedures (79.8 minutes) was comparable to the 76.9 minutes reported in a large series.¹³ The conversion rate of 9.8% was, however, higher than the 2.46% reported in neighboring Cameroon;¹⁴ however, it must be remembered that all conversions reported here occurred in emergency cases, a situation in which scrupulous case selection was not usually practicable, and some of these conversions occurred because of equipment malfunction. Nonetheless, this study's conversion rate still compares favorably with the two-digit figures that have been reported from some other African countries.¹⁵ The median duration of postoperative hospital stay in this series was 6 hours, which compared favorably with other reports.¹⁶ Having recorded no mortality or major complication thus far, it can be believed that operative gynecologic laparoscopy can be accomplished safely for both elective and emergency procedures in Nigeria.

Conclusions

It is hoped that this preliminary report has illustrated the practical feasibility of performing operative gynecologic laparoscopy in a resource-poor setting, such as the one described in this article. Laparoscopy is almost always an option in gynecologic surgery, be it elective or emergency, and the determination of the gynecologist to consider and endorse this technique even in the face of the numerous prevailing challenges will be pivotal to any progress that will ultimately be recorded in gynecologic laparoscopy in a developing country such as Nigeria.

Disclosure Statement

No competing financial conflicts exist.

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