Assessment of resource capacity and barriers to effective practice of laparoscopic surgery in training hospitals affiliated with the College of Surgeons of East, Central and Southern Africa (COSECSA).

BACKGROUND: The adoption and accessibility of laparoscopy have been serious issues in countries with limited resources, and for varied reasons. This study assessed resource capacity and barriers to the effective practice of laparoscopic surgery in training hospitals affiliated with the College of Surgeons of East, Central and Southern Africa (COSECSA). METHODS: A multi-country survey was conducted from January 2021 to October 2021 using a questionnaire distributed to surgeons in COSECSA hospitals located in 16 different countries. Available resources and surgical volume were assessed, and the barriers to routinely performing laparoscopy were determined. RESULTS: Ninety-four surgeons working in 44 different hospitals from 16 countries participated in the survey. The majority of respondents were general surgeons (n = 75, 79.7%). Other specialties included urology (n = 12, 12.8%) and pediatric surgery (n = 7, 7.4%). Senior surgeons accounted for 60.6% of participants, more than 40% had a managerial position and approximately 20% were surgical trainees. Most respondents practiced in public hospitals (n = 66, 70.2%). A median of three surgeons per hospital performed laparoscopic surgery with, on average, two laparoscopic towers and two sets of laparoscopic instruments available. A median of 10 procedures was carried out per month. The cost of laparoscopic procedures and laparoscopic consumables were reported as being covered by some health insurance payments in 76.9% and 48.4% of cases, respectively. Cholecystectomy was the most commonly reported laparoscopic procedure performed. The five top barriers to performing laparoscopic surgery were: a lack of consumables, a limited quantity of equipment, a lack of skilled surgeons, the high cost of laparoscopic procedures and complicated cases. In addition, having access to skilled anesthesiologists and anesthesia equipment, carbon dioxide, a consistent electric power supply and equipment maintenance were cited as significant challenges. CONCLUSION: The practice of laparoscopy is currently limited in COSECSA countries due to a scarcity of skilled staff and the lack of a funding plan to make laparoscopic services accessible. Therefore, policymakers and stakeholders should take strategic measures to respond to this need.

Exploring Laparoscopic Surgery Training Opportunities in the College of Surgeons of East, Central, and Southern Africa region.

OBJECTIVE: The resource-limited environment in Sub-Saharan countries, with a lack of expert trainers, impedes the progress of laparoscopic training. This study aimed to identify the opportunities and limitations of laparoscopic surgery training in the College of Surgeons of East, Central, and Southern Africa (COSECSA) countries. DESIGN AND SETTING: A multicountry online survey was conducted from January 2021 to October 2021 in COSECSA-accredited training hospitals within 16 countries. Available resources and challenges faced in order to set up well-structured laparoscopic training programs were explored. RESULTS: Ninety-four surgeons answered the questionnaire. The average resources reported per hospital were 3 trained laparoscopic surgeons, 2 laparoscopic towers, and 2 sets of laparoscopic instruments. The training of the majority of these surgeons has been in local institutions (53%), a further 37% within African countries and only 10% outside Africa. Approximately 45% of them declared that laparoscopic modules were planned within the University Curricula, while only 18% of surgeons recognized that laparoscopic modules are only planned within the COSECSA program. About 57% of participants reported that at the end of residency training, graduating surgeons were not able to perform basic laparoscopic procedures. The quoted barriers included: limited laparoscopic equipment, absence of simulation lab, lack of qualified trainers, lack of training programs and time for teaching by skilled doctors, and lack of institutional support. CONCLUSIONS: The well-structured set up of laparoscopic training programs in the COSECSA region is hindered due to the lack of qualified personnel and insufficient resources for the acquisition of equipment and simulation laboratories. Ongoing efforts to set up laparoscopic programs through the development of adaptive curricula, innovative strategies for reduction of equipment cost and adequate training of surgeons are crucial for patient safety and the development of laparoscopy.

Patient-reported outcome, perception and satisfaction after laparoscopic cholecystectomy in Kigali, Rwanda.

Background: Laparoscopic surgery is the gold standard for many abdominal surgeries. Laparoscopic programs in low- and middle-income countries (LMICs) and in sub-Saharan Africa face many constraints, although its use is safe, feasible, and clinically beneficial. The authors assessed patient-reported outcomes and the experience of patients operated on at the University Teaching Hospital of Kigali (CHUK). Methods: This is a retrospective cross-sectional study combining medical data from medical files and information collected from telephone calls to 288 patients who underwent laparoscopic cholecystectomy at CHUK from January 2015 to December 2020. Results: Among 446 laparoscopic surgeries performed at CHUK over 6 years, cholecystectomies accounted for 64.6 % of cases (288/446). Postoperative complications and mortality after laparoscopic cholecystectomy were low, respectively 1.7 % and 0.7 %, while the median length of stay was 3 days. About 74 % of surveyed patients had never heard of laparoscopic surgery prior to their procedure. Knowledge of laparoscopic surgery was associated with patient education level (p < 0.001). Half of patients had not been involved in the choice of the surgical technique. Overall satisfaction was over 95 % and >90 % of patients consider laparoscopic surgery as the best surgical approach in Rwanda, and for this reason they declared to be ready to promote this new technology despite its higher cost. However, patients reported some weaknesses and made recommendations for improving public awareness of laparoscopy and its benefits, patient-provider relationships, training of surgical workforce, laparoscopic equipment, and infrastructure. Conclusion: Laparoscopic cholecystectomy can be performed with a low rate of postoperative complications in a resource-limited setting like Rwanda. Patient satisfaction was high, but efforts should be made to improve public awareness of laparoscopic surgery, improve surgical capacity, laparoscopic equipment, and infrastructure.

Unusual anatomical variations of the hepatic arteries and bile ducts: What are the surgical implications.

Introduction: The knowledge of anatomy is essential for surgical safety and impacts positively on patients' outcomes. Surgeons operating on the liver and bile ducts should keep in mind the normal anatomy and its variations as the latter are common. Case Presentation: We conducted a structured surgical dissection course of the supra-colic compartment of the abdominal cavity on 2nd and 3rd October 2020. While dissecting a 46years-old male cadaver, we encountered unusual anatomical variations of the hepatic arterial branching, the biliary tree, and arterial supply to the common bile duct. The common hepatic artery was dividing into two branches: a common short trunk for the left hepatic artery and the right gastric artery (hepato-gastric trunk) and a common trunk for the right hepatic artery and gastroduodenal artery (hepato-gastroduodenal trunk). The right hepatic duct was duplicated with a main right hepatic duct and an additional smaller duct. The bile duct was supplied by an artery coming from the abdominal aorta. Conclusion: We described three unusual anatomical variations: a variation of the hepatic arteries branching pattern, an aberrant right hepatic duct, and blood supply to the bile duct from the abdominal aorta. Surgeons should be aware of these rare variations.

Musculocutaneous and median nerve branching: anatomical variations. Case Series from UR clinical anatomy and literature review.

Introduction: The brachial plexus is highly variable, which is a well-known anatomical fact. Repeated observations on anatomical variations, however, constitute current trends in anatomical research. Case series: In an anatomical dissection course, three uncommon variations in the brachial plexus were identified in three young adults' cadavers. In one case, the musculocutaneous nerve gave a branch to the median nerve, while the median nerve gave or received musculocutaneous branches in the two remaining corpses. Conclusion: Anatomical variations of the brachial plexus do occur in our setting. The cases we presented are about anatomical variations of branching patterns of the median and musculocutaneous nerves. Knowledge of those variations is essential for surgery and regional anesthesia of the upper limbs.

Use of Student-Generated Multiple Choice Questions to Enhance Team-Based Learning of Anatomy at the University of Rwanda.

INTRODUCTION: Teaching of human anatomy has undergone significant changes in the past three decades. At the University of Rwanda, anatomy is being taught using team-based learning (TBL). While student-generated multiple choice questions (MCQs) stimulate deeper thinking on a given topic, their impact on anatomy learning is not known. This study aimed to find out the impact of student-generated MCQs on the current anatomy teaching method at the University of Rwanda. METHODS: In this comparative interventional study, two similar chapters on anatomy were selected; one was taught using TBL while for the other one, in addition to TBL, students were encouraged to set MCQs while studying. Pre- and post-test scores were analyzed using SPSS 23 and the Student's t-test was used to compare the mean scores obtained. RESULTS: Thirty-one medical students were recruited. Pre-test mean scores were 25.10 and 25.19 out of 50 for chapters 1 and 2, respectively. Although the students' post-test scores improved after teaching for each chapter, the improvement was much greater for chapter 2 than for chapter 1, with mean scores of 39.97 and 32.45 out of 50, respectively (P<0.05). Despite such improvement, almost half of the students found that setting MCQs was not easy. CONCLUSION: This study found that student-generated MCQs can be used as a simple and cost-effective tool to enhance TBL of anatomy.

Development of multimedia learning modules for teaching human anatomy: application to osteology and functional anatomy.

Computer-assisted learning (CAL) is growing quickly within academic programs. Although the anatomical commercial packages that are available for this learning have attractive advantages, they also have drawbacks: they are frequently not in the local language of the students, they do not perfectly answer the needs of the local academic program, and their cost is frequently more than students can afford. This study describes a relatively inexpensive method to create CAL tutorials, whose content can be fully customized to local academic needs in terms of both program and language. The study describes its use in creating multimedia learning modules (MLMs) about Osteology and joint kinematics. The pedagogical content in these modules was collected from objective experiments to give students the opportunity to access new scientific knowledge during their education. It can be replaced, as desired, by almost any content due to the flexibility of the production method. Each MLM consists of two complementary subelements: a multimedia theoretical lecture and a three-dimensional interactive laboratory. Such MLMs are in use at both the University of Brussels (ULB) and the National University of Rwanda (NUR). The development of this work was part of the VAKHUM project, and the pedagogical validation is currently being performed as part of the MULTIMOD project.

HSP110, caspase-3 and -9 expression in physiological apoptosis and apoptosis induced by in vivo embryonic exposition to all-trans retinoic acid or irradiation during early mouse eye development.

Apoptosis is an essential physiological process in embryonic development. In the developing eye of vertebrates, three periods of developmental apoptosis can be distinguished: early, intermediate and later. Within the apoptosis pathway, caspases play a crucial role. It has also been shown that HSP110 may have a potential role in apoptosis. The aim of this research was to study the expression of HSP110, caspase-3 and -9 in physiological, retinoic- or irradiation-induced apoptosis during early eye development. Seven pregnant C57Bl/6J mice received 80 mg kg(-1) of all-trans retinoic acid mixed with sesame oil. Seven pregnant NMRI mice received 2 Gy irradiation at the same gestational day. Control mice of both strains (seven mice of each) were not submitted to any treatment. Embryos were harvested at 3, 6, 12 and 24 h after exposition, fixed, dehydrated and embedded. Coronal sections (5 microm) were made. Slide staining occurred alternatively using anti-caspase-3, anti-caspase-9 and anti-HSP110 immunohistochemistry. HSP110 and caspase-3 expression presented similar topographic and chronological patterns, whereas expression of HSP110 was more precocious in retinoic acid-treated embryos. After retinoic exposure, caspase-3- and HSP110-positive cells were increased in the region of the optic vesicle. By contrast, after irradiation, caspase-3- and HSP110-positive cells were noticeably increased in the optic vesicle, peri-optical mesoderm but less in lens placode. HSP110 was expressed before caspase-3. By contrast, caspase-9 was expressed by a very small number of cells in the optic vesicle either under physiological or under teratogenic conditions. Thus, it seems that activation of caspase-9 is dispensable in early eye developmental apoptosis.