T. D. Madni1, A. Ochoa2, C. Ortiz2, B. Mijangos2, J. B. Imran1, J. Herrejon1, S. Huerta1 1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2Hospital Nacional De San Benito,Peten, , Guatemala
Background: Over the past 20 years laparoscopic cholecystectomy (LC) has become the standard of care for acute cholecystitis and symptomatic cholelithiasis in the United States. However, in third world countries open cholecystectomies (OC) are still often performed given the relative lack of resources, expertise, and/or training. We have previously shown that over 50% of elective cholecystectomies in rural Guatemala are performed via an open approach. We hypothesize that the reasons for the scarcity of laparoscopic cholecystectomies is the result of the following factors: (1) deficiency of surgical training in laparoscopy; (2) lack of funding (government); (3) lack of equipment, maintenance, and replacement parts (i.e. trocars, verses needles, general anesthesia). This study was undertaken to outline factors that lead to the limitations of LC at the major referral hospital in Peten, Guatemala.
Methods: We reviewed 9402 cholecystectomies performed over 14 years by seven surgeons at the main referral county hospital in Peten, Guatemala (Hospital Nacional de San Benito: HNSB). We conducted personal interview with all the surgeons who perform cholecystectomies at HNSB to determine why OC were more often performed.. All data is expressed at means +/- standard deviation. Differences between LC vs OC were analyzed by Fisher’s exact test or X2. Statistical significance was established at a p<0.05 (two-sided).
Results: The average age of the surgeon involved was 43±12.1 yo with an average years in practice 14.1±9.9. Total number of cholecystectomies performed were 9402 [8440 (90%) OC, 962 (10%) LC]. The average number of cholecystectomies performed per surgeon were 1341.1±1244.9, OC 1205.7±1194.9, LC 137.4±188.0. The average number of LC performed during training were 262.8±263.9. Lack of formal training in laparoscopy was identified by 57% of surgeons. 71% of surgeons stated there was a lack of government funds to implement a laparoscopic program (29% felt there were insufficient ancillary staff, and 29% noted poor allocation of hospital funding to purchase laparoscopic equipment/training). Insufficient laparoscopic equipment was identified by 71% of surgeons. Of note, 57% preferred to perform LC if possible, 29% preferred OC, 14% did not have a preference. With regards to patient predilection: 14% of surgeons felt patients preferred LC, another 14% felt patients preferred OC, 43% felt that patients were split, and 29% did not feel their patients were educated enough to make this decision. 43% did not think the anesthesia providers were appropriately trained for general anesthesia required for LC.
Conclusion: Ninety-percent of cholecystectomies performed by these surgeons continue to be OC. The major limitation is the lack of funding to provide sufficient equipment or ancillary staff. The majority of surgeons preferred to perform LC if these problems could be addressed.