Original Article
Gynaecological laparoscopic surgery: eight years experience in the Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, Cameroon
Tropical Doctor 2014, Vol. 44(2) 71–76 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475513517116 tdo.sagepub.com
Emile Mboudou1, Frederick LI Morfaw2, Pascal Foumane3,4, Julius Dohbit Sama3, Bernard Armand Enama Mbatsogo5 and Jacqueline Ze Minkande6
Abstract This is a retrospective analysis of eight years of gynaecological laparoscopic surgery in a resource-limited setting. All gynaecological patients managed by laparoscopy at the Yaounde´ Gynaeco-Obstetric and Paediatric Hospital from 1 January 2004 to 30 November 2011 were included. Amongst the 9194 gynaecological surgeries performed during the study period, 6.9% (633) were done by laparoscopy. Most of the women underwent an operative laparoscopy (568/592; 95.9%). The most common indication was infertility (415/592; 70.1%). Diagnostic laparoscopies were mostly indicated for chronic pelvic pain (18/24; 75%). The most common surgical finding was tubo-peritoneal adhesions (412/592; 69.6%). A total of 35 patients (35/592; 5.9%) had at least one complication. The mean duration of hospitalization was 3.4 1.8 days. The general uptake of gynaecological laparoscopic surgery is low in our setting. The laparoscopic complication rate of 5.9% is encouraging.
Keywords Cameroon, gynaecological surgery, laparoscopy, low resource setting
Introduction Laparoscopy is a very common procedure in gynaecology and is being increasingly used in other specialties.1 Today, it is estimated that 70%–80% of gynaecological surgery can be performed by laparoscopy.2 There is evidence that laparoscopy provides significant benefits over laparotomy for patients.3 The major advantages of this minimal access approach have been documented in a large number of clinical trials.4 For the past 15 years, gynaecological laparoscopic surgery has been practiced in Cameroon.5 Cameroon, like many other African countries, faces crises in its economic and health care systems.6 The introduction of laparoscopic surgery in resource-limited settings such as ours has been controversial, with some regarding it as a luxury and others as a necessity.6 Yet, whether this surgical technique is a luxury or a necessity, it offers an interesting surgical alternative which needs assessment before a widespread implementation in our settings can be freely recommended.7 The aim of this study is to outline the experience of gynaecologic laparoscopic surgery in a resource-limited
setting and to determine its role in the surgical management of gynaecologic patients in these settings. We provide a descriptive analysis of all cases of gynaecological laparoscopic surgery managed in the Yaounde´ Gynaeco-Obstetric and Paediatric Hospital between 1
Associate Professor, Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, The University of Yaounde´ 1, Cameroon 2 Doctor, Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, The University of Yaounde´ 1, Cameroon 3 Senior Lecturer, Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, The University of Yaounde´ 1, Cameroon 4 Senior Lecturer, Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, Yaounde´, Cameroon 5 Doctor, Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, Yaounde´, Cameroon 6 Associate Professor, Department of Anaesthesiology & Reanimation, Faculty of Medicine and Biomedical Sciences, The University of Yaounde´ 1, Cameroon Corresponding author: Dr Pascal Foumane, Senior Lecturer, Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, PO Box 4362 Yaounde´, Cameroon. Email: [email protected]
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2004 and 2011. It shows the proportion and category of patients who are likely to benefit from this intervention in our setting, the gynaecological pathologies in need of this intervention and the complications that may be expected following its widespread implementation. We believe that this information will help inform clinicians and policy makers not only of the usefulness and potential benefits of gynaecological laparoscopy but also of some of the expected difficulties and challenges for its implementation.
Materials and methods This is a retrospective review of all gynaecological cases managed by laparoscopy between the 1 January 2004 to the 30 November 2011 at the Yaounde´ GynecoObstetric and Paediatric Hospital, which is one of the four referral hospitals situated in Yaounde´, the Capital of Cameroon. We excluded women with incomplete records and women whose records could not be identified. The equipment used for laparoscopy during the study period was made by Karl Storz (Tuttlingen, Germany). It consisted of a Sony 21 inch monitor, a camera, a Xenon 300 light source, an electronic insufflators, a 350 high frequency and a suction-irrigation unit. Ancillary equipment included a CO2 bottle, a voltage regulator and a minor surgical set comprising of a pair of Kocher forceps, Mayo scissors, a needle holder, dissecting forceps, retractors haemostatic forceps and a scalpel holder. The laparoscopic procedure generally included the closed entry technique and all of the surgeries were performed under general anaesthesia. Data collection was retrolective from the patients’ files and hospital registers. We used a standardized questionnaire developed based on the study objectives. We recorded information on the socio-demographic data of the patients, the past medical history of the patients, the indication for laparoscopy, the surgical procedures performed complications noted and the postoperative stay of the patient. Data analysis was done using SPSS version 14. Data sheets were confidentially filled with identification codes and authorizations obtained from the National Ethics Committee and from the General Directorate of the Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, Cameroon.
Results Between January 2004 and November 2011, a total of 9194 gynaecological surgeries were performed in Yaounde´ Gynaeco-Obstetric and Paediatric Hospital for varying indications. Amongst these, 6.9%
(633/9194) were performed by laparoscopy, while the remainder were performed by laparotomy. Of the 633 women who underwent laparoscopy during the study period, 592 fulfilled our inclusion criteria and were included in the descriptive analysis. The ages of the women varied between 6 and 47 years, with a mean age of 31.7 5.4 years. The majority of the women were aged between 30 and 34 years (243/592; 41.0%). Most of the women undergoing laparoscopy were married (401/592; 67.7%) and were educated, with the majority having received at least a secondary education (496/592; 83.8%). Most were either housewives or without any formal employment (361/592; 61.0%) and most were urban dwellers (557/592; 94.1%). The gravidity of the women ranged from 0–9 with a mean gravidity of 1.63, with 27.2% (161/592) being nulligravids, 29.6% (175/592) being primigravids and the remaining 43.2% (256/592) being gravida 2 and above. The parity of the women ranged from 0–7 and most were either nulliparous or primiparous (509/592; 86.0%). Of the 592 women (Table 1), a relevant previous surgical history was reported by 109 (109/592; 18.4%). Most of the women with a relevant previous surgical history had undergone a myomectomy and were returning for a ‘second-look’ laparoscopy (66/109; 60.5%). Most of the women underwent an operative laparoscopy (568/592; 95.9%). The most common indication (Table 2) for laparoscopy was infertility (415/592; 70.1%), primary or secondary infertility. Diagnostic laparoscopies were mostly indicated for chronic pelvic pain (18/24; 75%). Most of the patients had more than one finding peroperatively (Table 3). These findings varied according to the indications of the surgery and, in some cases, did not correspond with the surgical indication. The most common surgical finding was tubo-peritoneal adhesions Table 1. Relevant previous surgical history of study participants (n ¼ 592). Relevant previous surgery
n
%
None Myomectomy Ectopic pregnancy Pelvic peritonitis Caesarean section Tuboplasty Total abdominal hysterectomy Appendectomy Unspecified pelvic surgery Total
483 66 35 2 1 1 1 1 2 592
81.6 11.1 5.9 0.3 0.2 0.2 0.2 0.2 0.3 100
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(412/592; 69.6%). A good proportion of the patients had evidence of Fritz Hugh Curtis syndrome (108/592; 18.2%). The youngest patient in the sample was a 6-year-old who underwent laparoscopy for a left adnexal mass. The per-operative finding was a benign ovarian cyst and was drained per laparoscopy without any events. The laparoscopic procedures (Table 4) undertaken during the study period varied according to the peroperative findings. The most common procedures were adhesiolysis, performed in 66.4% (393/592) of the patients, and tuboplasty (fimbryoplasty, neosalpingostomy) performed in 56.9% of the patients (337/592). A total of 35 patients had at least one complication, giving an overall complication rate of 5.9% (35/592). Twelve patients (12/592; 2.0%) had per-operative complications, the most common being vessel rupture with massive haemorrhage, reported in five (5/12; 41.7%) of the patients with per-operative complications (Table 5). Most of these occurred during operative laparoscopy (10 cases of infertility, one case of ectopic pregnancy). Most of these complications (10/12; 83.3%) were managed laparoscopically and, hence, there were minor complications. Of these, two (2/12; 16.7%) had major complications and a laparo-conversion was performed. Post-operative complications (Table 6) could be identified in 23 of the patients (23/592; 3.9%), the most commonly identified being post-operative pains (10/23; 43.5%). The mean duration of hospitalization was 3.4 1.8 days with a minimum hospitalization duration of 1 day and a maximum of 21 days.
Table 2. Frequency of different indications of laparoscopy among recruited patients (n ¼ 592). Indication Infertility Primary Secondary ‘Second-look’ post myomectomy Adnexeal mass/ovarian cyst Ectopic pregnancy Heterotopic pregnancy Tubal sterilization Upper genital tract infection Chronic pelvic mass Urogenital malformation Total
Diagnostic Operative Total aparoscopy laparoscopy n (%) 0 0 0 0
415 106 309 63
415 (70.1) 106 (17.9) 309 (52.2) 63 (10.6)
2
27
29 (4.9)
0 0 0 1
51 5 1 1
51 (8.6) 5 (0.8) 1 (0.2) 2 (0.2)
18 3 24 (4.1)
5 0 568 (95.9)
23 (3.9) 3 (0.5) 592 (100)
Discussion During the 8 year period of our study, laparoscopy represented 6.9% of the total gynaecological surgery performed. This proportion is lower than the 10% reported by Pither et al. in Gabon8 and is even smaller when we consider that over 70%–80% of gynaecologic surgery can be performed by laparoscopy.2 One potential reason for this situation could be the lack of the man-power available to perform the procedure. Another potential explanation for the low uptake of laparoscopy in our settings could be its cost. On average, this procedure costs about US$600. In a country where medical care is paid for directly by the patient, the cost of this procedure may be a prohibitive factor for its uptake. The lower rate of laparoscopic surgery may also be explained by the unavailability of spare parts and trained teams to care for equipment breakdown. For instance, in our study setting, the
Table 3. Common surgical findings described in the patients (n ¼ 592). Findings Tubal Tubo-peritoneal adhesions Unilateral hydrosalpinx Bilateral hydrosalpinx Unilateral pyosalpinx Bilateral pyosalpinx Unilateral proximal obstruction Bilateral proximal obstruction Paratubal cysts Erection of the tubal isthmic portion Tubar phimosis Non-ruptured ectopic pregnancy Ruptured ectopic pregnancy Ovarian Ovarian cyst Polycystic ovaries Tubo-ovarian abscess Uterine Myomatous uterus Urogenital malformation Pelvic Endometriosis Hemoperitoneum Normal pelvis Liver Fritz Hugh Curtis syndrome Other
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n
%
412 89 98 13 5 10 5 39 8 95 43 7
69.6 15.0 16.6 2.2 0.8 1.6 0.8 6.6 1.4 16.0 7.3 1.2
79 49 7
13.3 8.3 1.2
100 6
16.9 1.0
27 13 12
4.6 2.2 2.0
108 32
18.2 5.4
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Table 4. Surgical procedures performed in the patients (n ¼ 592). Surgical procedure Tubal Adhesiolysis Fimbryoplasty Neosalpingostomy Salpingectomy Tubal ligation Ectopic pregnancy Salpingostomy Salpingectomy Adnexectomy Tubal abortion Ovarian Intraperitoneal cystectomy Drainage of cyst Ovarian drilling Uterine Myomectomy/myolysis Pelvic/peritoneal Peritoneal washing/drainage Cautery of endometriosis Biopsies Other
Table 6. Post-operative complications observed (n ¼ 592).
n
%
393 119 218 4 1
66.4 20.1 36.8 0.7 0.2
20 25 2 3
2.8 4.4 0.3 0.5
38 49 47
6.4 8.3 7.9
30
5.1
27 20 14 6
4.6 3.4 2.5 1.0
Table 5. Per operative complications in our sample (n ¼ 592). Per-operative complications
n
%
None Minor complications Intestinal perforation Vessel rupture with haemorrhage Uterine perforation Major complications Rectal perforation Vessel rupture with massive haemorrhage Total
580 10 2 4 4 2 1 1 592
97.9 0.3 0.7 0.7 0.2 0.2 100
laparoscopic equipment has not been functional since November 2011 and is still non-functioning at the time of writing. In our study, 18.4% of the patients had a relevant previous surgical history. This is important as the risk of laparoscopic complications increase with pelvic surgery.8 Reports indicate that 13%–26% of women undergoing laparoscopy have undergone previous pelvic surgery which is directly relevant to the
Post-operative complication
n
%
None Pains Incisional herniation Fever Pelvic peritonitis Digestive problems Abdominal wall bleeding Total
569 10 1 6 1 3 2 592
96.1 1.7 0.2 1.0 0.2 0.5 0.3 100
laparoscopic procedure.7–9 However, our proportion was lower than the 39.1% reported by Tchente et al.10 in a neighbouring hospital but we did not evaluate the association between previous surgery and laparoscopic complications. Most of the laparoscopies performed at the Yaounde´ Genesco-Obstetric and Paediatric Hospital during the study period were for infertility (70.1%). This is probably because of the long held belief in Africa that infertility is a disaster.7 Our proportion was comparable to the 76.3% of laparoscopic surgery for infertility reported by Tchente et al.10 This proportion was, however, higher than the 32% reported by Pither et al.8 and the 12% reported by Ngou Mve Ngou et al.11 in Gabon. ‘Second-look’ laparoscopy following myomectomy was the second most common indication for laparoscopy after infertility (10.6%). Tchente et al. also found ‘second-look’ laparoscopy to be the second most frequent indication for laparoscopy, after infertility, performed in 15% of their patients.10 Given that myomectomy easily causes the development of adhesions, it is important to liberate them in order to improve the chances of fertility.10 In contrast to other authors,10,12 we did not find any cases of advanced laparoscopic surgery (hysterectomies, utero-suspension, etc.) among our patients. Our results imply that there is a need to expand the indications of laparoscopy, equip our hospitals and further train doctors and nurses in this technique on the management of different gynaecological problems in our setting. Our most common operative finding was tubo-peritoneal adhesions and, consequently, pelvic adhesiolysis was the most commonly performed procedure. This was not surprising as pelvic adhesions (usually related to pelvic infections) are a common finding in our setting and are found in the majority of women with compromised fertility.7 However, the extent of tubo-peritoneal adhesions was not routinely described in the patient files. Our findings of these peritoneal adhesions and
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the corresponding proportions of adhesiolysis (69.6% and 66.4%) are much higher than the 34.5% reported by Parkar et al. in Kenya.13 We identified perihepatitis in 18.2% of our patients. This frequency was much lower than the 40% reported by Nzintcheu et al. in the same hospital during a shorter study period.14 This difference may be due to the fact that our data was collected in the patient files whilst Nzintcheu et al. did a prolective data collection. The management of ectopic pregnancy by laparoscopy has undergone marked changes in the past decade.8 Laparoscopic management of ectopic pregnancy is today regarded as the gold standard.12 Therefore, it was not surprising that 9.4% of the laparoscopies among our patients were indicated for ectopic pregnancies. This proportion was similar to the 8.1% of laparoscopies for ectopic pregnancies reported by Pither et al. in Kenya8 and in contrast to the 1.5% found by Tchente et al.8 However it should be noted that in the developed world, over 95% of ectopic pregnancies are managed by laparoscopy,15 despite reports that laparoscopic management of ectopic pregnancy is increasingly common in our settings.6,16 The low use of laparoscopy for the management of ectopic pregnancy in our study could be explained by the fact that most patients with ectopic pregnancy usually present in a state of shock following ectopic rupture.17 The known rate of laparoscopic complication in adequately trained hands ranges from 1%–5%, and the mortality ranges between 4–8 deaths/100.000 cases.18 We had an overall complication rate of 5.9% and no laparoscopy related deaths were identified. Tchente et al. reported a complication of rate of 1.48% during laparoscopic surgery. This was similar to our results (2.0%) but our proportion of post-operative complications (3.9%) was much lower than the 8.3% described by Tchente et al.10 The laparoscopic complication rate of 5.9% in our study is encouraging, indicating that the procedure is associated with an acceptable rate of morbidity in our setting. This finding however, must be interpreted with caution as we could not completely rule out the under-reporting of potential complications. Despite our large sample size, our results must take into consideration the limitations inherent to retrospective studies as missing data may distort our figures. As a result of missing data, 41 files were excluded from the analysis which may give some bias to our results.
Conclusion Our study shows that despite the fact that laparoscopy has existed in our setting since 1992, its acceptability and use is still very low. Infertility represents the most common indication for laparoscopy in our setting and pelvic adhesions remain the main laparoscopic finding
in our study. The complication rate associated with laparoscopy is acceptable in our setting. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Ahmad G, O’Flynn H, Duffy JM, Phillips K and Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev 2012; 2: CD006583. 2. Bruhat MA, Glawaczower E, Raiga J, et al. Laparoscopic surgery [French]. Encycl Med Chir (Paris-France) 1995; 71-A-10: 16. 3. Garry R. Towards evidence-based laparoscopic entry techniques: clinical problems and dilemmas. Gynaecol Endosc 1999; 8: 315–326. 4. Murphy AA, Nager CW, Wujek JJ, Kettel LM, Torp VA and Chin HG. Operative laparoscopy versus laparotomy for the management of ectopic pregnancy: a prospective trial. Fertil Steril 1992; 57: 1180–1185. 5. Raiga J, Kasia JM and Bruhat MA. Laparoscopic surgery in the Cameroon. Int J Gynaecol Obstet 1999; 65: 65–66. 6. Raiga J, Kasia JM, Canis M, Glowaczower E, Doh A and Bruhat MA. Introduction of gynaecologic endoscopic surgery in an African setting. Int J Gynaecol Obstet 1994; 46: 261–264. 7. Kasia JM, Raiga J, Doh AS, et al. Laparoscopic fimbrioplasty and neosalpingostomy. Experience of the Yaounde´ General Hospital, Cameroon (report of 194 cases). Eur J Obstet Gynecol Reprod Biol 1997; 73: 71–77. 8. Pither S, Mayi Tsonga S, et al. Gynaecological laparoscopic surgery at Libreville: experience in 341 cases [French]. Med Afr Noire 2007; 54: 91–97. 9. Jansen FW, Kapiteyn K, Trimbos-Kemper T, Hermans J and Trimbos JB. Complications of laparoscopy: a prospective multicentre observational study. Br J Obstet Gynaecol 1997; 104: 595–600. 10. Tchente NC, Mboudou E, Tejiokem MC and Doh A. Complications of laparoscopic surgery in gynaecology unit A of Yaounde´ General Hospital, Cameroon [French]. Gynecol Obstet Biol Reprod (Paris) 2009; 38: 545–551. 11. Ngou Mve Ngou JP, Meye JF, Ndong P, Lassegue D and Mounanga M. Five year review of laparoscopy and laparoscopic surgery at Jeanne Ebori Foundation [French]. Bull Med Owendo 2002; 7: 22–25. 12. Parkar RB, Thagana NG, Baraza R and Otieno D. Experience with laparoscopic surgery at the Aga Khan Hospital, Nairobi. East Afr Med J 2003; 80: 44–50. 13. Parkar RB and Kamau WJ. Images in endoscopy. Laparoscopic excision of bilateral functioning noncommunicating and rudimentary uterine horns in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome and
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pelvic endometriosis. J Minim Invasive Gynecol 2009; 16: 522–524. 14. Nzintcheu Youssa JM, Foumane P, Mboudou ET, Nana PN, Fomulu JN and Doh AS. Perihepatitis finding during laparoscopy for infertility at the Yaounde´ Gynaeco-Obstetric and Paediatric Hospital: prevalence and correlation with tubopelvic lesions [French]. Clin Mother Child Health 2012; 9: 1–5. 15. Lansac J and Lecomte P. Gynaecology for the Practitioner [French], 5th edn. Paris: Masson, 1999.
16. Mboudou ET, Ze Minkande J, Eyenga VC, Foumane P and Tchente NC. The complications of laparoscopic surgery in the Yaounde´ General Hospital (Cameroon) [French]. Rev Afr Anesth Med Urg 2007; 12: 3–7. 17. Foumane P, Mboudou ET, Dohbit JS, et al. Conservative treatment of ectopic pregnancy in a sub-Saharan African setting. Trop Doct 2011; 41: 79–81. 18. Bongard F, Dubecz S and Klein S. Complications of therapeutic laparoscopy. Curr Prob Surg 1994; 31: 862–924.
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Gynaecological laparoscopic surgery: eight years experience in the Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, Cameroon
Tropical Doctor 2014, Vol. 44(2) 71–76 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475513517116 tdo.sagepub.com
Emile Mboudou1, Frederick LI Morfaw2, Pascal Foumane3,4, Julius Dohbit Sama3, Bernard Armand Enama Mbatsogo5 and Jacqueline Ze Minkande6
Abstract This is a retrospective analysis of eight years of gynaecological laparoscopic surgery in a resource-limited setting. All gynaecological patients managed by laparoscopy at the Yaounde´ Gynaeco-Obstetric and Paediatric Hospital from 1 January 2004 to 30 November 2011 were included. Amongst the 9194 gynaecological surgeries performed during the study period, 6.9% (633) were done by laparoscopy. Most of the women underwent an operative laparoscopy (568/592; 95.9%). The most common indication was infertility (415/592; 70.1%). Diagnostic laparoscopies were mostly indicated for chronic pelvic pain (18/24; 75%). The most common surgical finding was tubo-peritoneal adhesions (412/592; 69.6%). A total of 35 patients (35/592; 5.9%) had at least one complication. The mean duration of hospitalization was 3.4 1.8 days. The general uptake of gynaecological laparoscopic surgery is low in our setting. The laparoscopic complication rate of 5.9% is encouraging.
Keywords Cameroon, gynaecological surgery, laparoscopy, low resource setting
Introduction Laparoscopy is a very common procedure in gynaecology and is being increasingly used in other specialties.1 Today, it is estimated that 70%–80% of gynaecological surgery can be performed by laparoscopy.2 There is evidence that laparoscopy provides significant benefits over laparotomy for patients.3 The major advantages of this minimal access approach have been documented in a large number of clinical trials.4 For the past 15 years, gynaecological laparoscopic surgery has been practiced in Cameroon.5 Cameroon, like many other African countries, faces crises in its economic and health care systems.6 The introduction of laparoscopic surgery in resource-limited settings such as ours has been controversial, with some regarding it as a luxury and others as a necessity.6 Yet, whether this surgical technique is a luxury or a necessity, it offers an interesting surgical alternative which needs assessment before a widespread implementation in our settings can be freely recommended.7 The aim of this study is to outline the experience of gynaecologic laparoscopic surgery in a resource-limited
setting and to determine its role in the surgical management of gynaecologic patients in these settings. We provide a descriptive analysis of all cases of gynaecological laparoscopic surgery managed in the Yaounde´ Gynaeco-Obstetric and Paediatric Hospital between 1
Associate Professor, Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, The University of Yaounde´ 1, Cameroon 2 Doctor, Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, The University of Yaounde´ 1, Cameroon 3 Senior Lecturer, Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, The University of Yaounde´ 1, Cameroon 4 Senior Lecturer, Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, Yaounde´, Cameroon 5 Doctor, Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, Yaounde´, Cameroon 6 Associate Professor, Department of Anaesthesiology & Reanimation, Faculty of Medicine and Biomedical Sciences, The University of Yaounde´ 1, Cameroon Corresponding author: Dr Pascal Foumane, Senior Lecturer, Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, PO Box 4362 Yaounde´, Cameroon. Email: [email protected]
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2004 and 2011. It shows the proportion and category of patients who are likely to benefit from this intervention in our setting, the gynaecological pathologies in need of this intervention and the complications that may be expected following its widespread implementation. We believe that this information will help inform clinicians and policy makers not only of the usefulness and potential benefits of gynaecological laparoscopy but also of some of the expected difficulties and challenges for its implementation.
Materials and methods This is a retrospective review of all gynaecological cases managed by laparoscopy between the 1 January 2004 to the 30 November 2011 at the Yaounde´ GynecoObstetric and Paediatric Hospital, which is one of the four referral hospitals situated in Yaounde´, the Capital of Cameroon. We excluded women with incomplete records and women whose records could not be identified. The equipment used for laparoscopy during the study period was made by Karl Storz (Tuttlingen, Germany). It consisted of a Sony 21 inch monitor, a camera, a Xenon 300 light source, an electronic insufflators, a 350 high frequency and a suction-irrigation unit. Ancillary equipment included a CO2 bottle, a voltage regulator and a minor surgical set comprising of a pair of Kocher forceps, Mayo scissors, a needle holder, dissecting forceps, retractors haemostatic forceps and a scalpel holder. The laparoscopic procedure generally included the closed entry technique and all of the surgeries were performed under general anaesthesia. Data collection was retrolective from the patients’ files and hospital registers. We used a standardized questionnaire developed based on the study objectives. We recorded information on the socio-demographic data of the patients, the past medical history of the patients, the indication for laparoscopy, the surgical procedures performed complications noted and the postoperative stay of the patient. Data analysis was done using SPSS version 14. Data sheets were confidentially filled with identification codes and authorizations obtained from the National Ethics Committee and from the General Directorate of the Yaounde´ Gynaeco-Obstetric and Paediatric Hospital, Cameroon.
Results Between January 2004 and November 2011, a total of 9194 gynaecological surgeries were performed in Yaounde´ Gynaeco-Obstetric and Paediatric Hospital for varying indications. Amongst these, 6.9%
(633/9194) were performed by laparoscopy, while the remainder were performed by laparotomy. Of the 633 women who underwent laparoscopy during the study period, 592 fulfilled our inclusion criteria and were included in the descriptive analysis. The ages of the women varied between 6 and 47 years, with a mean age of 31.7 5.4 years. The majority of the women were aged between 30 and 34 years (243/592; 41.0%). Most of the women undergoing laparoscopy were married (401/592; 67.7%) and were educated, with the majority having received at least a secondary education (496/592; 83.8%). Most were either housewives or without any formal employment (361/592; 61.0%) and most were urban dwellers (557/592; 94.1%). The gravidity of the women ranged from 0–9 with a mean gravidity of 1.63, with 27.2% (161/592) being nulligravids, 29.6% (175/592) being primigravids and the remaining 43.2% (256/592) being gravida 2 and above. The parity of the women ranged from 0–7 and most were either nulliparous or primiparous (509/592; 86.0%). Of the 592 women (Table 1), a relevant previous surgical history was reported by 109 (109/592; 18.4%). Most of the women with a relevant previous surgical history had undergone a myomectomy and were returning for a ‘second-look’ laparoscopy (66/109; 60.5%). Most of the women underwent an operative laparoscopy (568/592; 95.9%). The most common indication (Table 2) for laparoscopy was infertility (415/592; 70.1%), primary or secondary infertility. Diagnostic laparoscopies were mostly indicated for chronic pelvic pain (18/24; 75%). Most of the patients had more than one finding peroperatively (Table 3). These findings varied according to the indications of the surgery and, in some cases, did not correspond with the surgical indication. The most common surgical finding was tubo-peritoneal adhesions Table 1. Relevant previous surgical history of study participants (n ¼ 592). Relevant previous surgery
n
%
None Myomectomy Ectopic pregnancy Pelvic peritonitis Caesarean section Tuboplasty Total abdominal hysterectomy Appendectomy Unspecified pelvic surgery Total
483 66 35 2 1 1 1 1 2 592
81.6 11.1 5.9 0.3 0.2 0.2 0.2 0.2 0.3 100
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(412/592; 69.6%). A good proportion of the patients had evidence of Fritz Hugh Curtis syndrome (108/592; 18.2%). The youngest patient in the sample was a 6-year-old who underwent laparoscopy for a left adnexal mass. The per-operative finding was a benign ovarian cyst and was drained per laparoscopy without any events. The laparoscopic procedures (Table 4) undertaken during the study period varied according to the peroperative findings. The most common procedures were adhesiolysis, performed in 66.4% (393/592) of the patients, and tuboplasty (fimbryoplasty, neosalpingostomy) performed in 56.9% of the patients (337/592). A total of 35 patients had at least one complication, giving an overall complication rate of 5.9% (35/592). Twelve patients (12/592; 2.0%) had per-operative complications, the most common being vessel rupture with massive haemorrhage, reported in five (5/12; 41.7%) of the patients with per-operative complications (Table 5). Most of these occurred during operative laparoscopy (10 cases of infertility, one case of ectopic pregnancy). Most of these complications (10/12; 83.3%) were managed laparoscopically and, hence, there were minor complications. Of these, two (2/12; 16.7%) had major complications and a laparo-conversion was performed. Post-operative complications (Table 6) could be identified in 23 of the patients (23/592; 3.9%), the most commonly identified being post-operative pains (10/23; 43.5%). The mean duration of hospitalization was 3.4 1.8 days with a minimum hospitalization duration of 1 day and a maximum of 21 days.
Table 2. Frequency of different indications of laparoscopy among recruited patients (n ¼ 592). Indication Infertility Primary Secondary ‘Second-look’ post myomectomy Adnexeal mass/ovarian cyst Ectopic pregnancy Heterotopic pregnancy Tubal sterilization Upper genital tract infection Chronic pelvic mass Urogenital malformation Total
Diagnostic Operative Total aparoscopy laparoscopy n (%) 0 0 0 0
415 106 309 63
415 (70.1) 106 (17.9) 309 (52.2) 63 (10.6)
2
27
29 (4.9)
0 0 0 1
51 5 1 1
51 (8.6) 5 (0.8) 1 (0.2) 2 (0.2)
18 3 24 (4.1)
5 0 568 (95.9)
23 (3.9) 3 (0.5) 592 (100)
Discussion During the 8 year period of our study, laparoscopy represented 6.9% of the total gynaecological surgery performed. This proportion is lower than the 10% reported by Pither et al. in Gabon8 and is even smaller when we consider that over 70%–80% of gynaecologic surgery can be performed by laparoscopy.2 One potential reason for this situation could be the lack of the man-power available to perform the procedure. Another potential explanation for the low uptake of laparoscopy in our settings could be its cost. On average, this procedure costs about US$600. In a country where medical care is paid for directly by the patient, the cost of this procedure may be a prohibitive factor for its uptake. The lower rate of laparoscopic surgery may also be explained by the unavailability of spare parts and trained teams to care for equipment breakdown. For instance, in our study setting, the
Table 3. Common surgical findings described in the patients (n ¼ 592). Findings Tubal Tubo-peritoneal adhesions Unilateral hydrosalpinx Bilateral hydrosalpinx Unilateral pyosalpinx Bilateral pyosalpinx Unilateral proximal obstruction Bilateral proximal obstruction Paratubal cysts Erection of the tubal isthmic portion Tubar phimosis Non-ruptured ectopic pregnancy Ruptured ectopic pregnancy Ovarian Ovarian cyst Polycystic ovaries Tubo-ovarian abscess Uterine Myomatous uterus Urogenital malformation Pelvic Endometriosis Hemoperitoneum Normal pelvis Liver Fritz Hugh Curtis syndrome Other
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n
%
412 89 98 13 5 10 5 39 8 95 43 7
69.6 15.0 16.6 2.2 0.8 1.6 0.8 6.6 1.4 16.0 7.3 1.2
79 49 7
13.3 8.3 1.2
100 6
16.9 1.0
27 13 12
4.6 2.2 2.0
108 32
18.2 5.4
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Table 4. Surgical procedures performed in the patients (n ¼ 592). Surgical procedure Tubal Adhesiolysis Fimbryoplasty Neosalpingostomy Salpingectomy Tubal ligation Ectopic pregnancy Salpingostomy Salpingectomy Adnexectomy Tubal abortion Ovarian Intraperitoneal cystectomy Drainage of cyst Ovarian drilling Uterine Myomectomy/myolysis Pelvic/peritoneal Peritoneal washing/drainage Cautery of endometriosis Biopsies Other
Table 6. Post-operative complications observed (n ¼ 592).
n
%
393 119 218 4 1
66.4 20.1 36.8 0.7 0.2
20 25 2 3
2.8 4.4 0.3 0.5
38 49 47
6.4 8.3 7.9
30
5.1
27 20 14 6
4.6 3.4 2.5 1.0
Table 5. Per operative complications in our sample (n ¼ 592). Per-operative complications
n
%
None Minor complications Intestinal perforation Vessel rupture with haemorrhage Uterine perforation Major complications Rectal perforation Vessel rupture with massive haemorrhage Total
580 10 2 4 4 2 1 1 592
97.9 0.3 0.7 0.7 0.2 0.2 100
laparoscopic equipment has not been functional since November 2011 and is still non-functioning at the time of writing. In our study, 18.4% of the patients had a relevant previous surgical history. This is important as the risk of laparoscopic complications increase with pelvic surgery.8 Reports indicate that 13%–26% of women undergoing laparoscopy have undergone previous pelvic surgery which is directly relevant to the
Post-operative complication
n
%
None Pains Incisional herniation Fever Pelvic peritonitis Digestive problems Abdominal wall bleeding Total
569 10 1 6 1 3 2 592
96.1 1.7 0.2 1.0 0.2 0.5 0.3 100
laparoscopic procedure.7–9 However, our proportion was lower than the 39.1% reported by Tchente et al.10 in a neighbouring hospital but we did not evaluate the association between previous surgery and laparoscopic complications. Most of the laparoscopies performed at the Yaounde´ Genesco-Obstetric and Paediatric Hospital during the study period were for infertility (70.1%). This is probably because of the long held belief in Africa that infertility is a disaster.7 Our proportion was comparable to the 76.3% of laparoscopic surgery for infertility reported by Tchente et al.10 This proportion was, however, higher than the 32% reported by Pither et al.8 and the 12% reported by Ngou Mve Ngou et al.11 in Gabon. ‘Second-look’ laparoscopy following myomectomy was the second most common indication for laparoscopy after infertility (10.6%). Tchente et al. also found ‘second-look’ laparoscopy to be the second most frequent indication for laparoscopy, after infertility, performed in 15% of their patients.10 Given that myomectomy easily causes the development of adhesions, it is important to liberate them in order to improve the chances of fertility.10 In contrast to other authors,10,12 we did not find any cases of advanced laparoscopic surgery (hysterectomies, utero-suspension, etc.) among our patients. Our results imply that there is a need to expand the indications of laparoscopy, equip our hospitals and further train doctors and nurses in this technique on the management of different gynaecological problems in our setting. Our most common operative finding was tubo-peritoneal adhesions and, consequently, pelvic adhesiolysis was the most commonly performed procedure. This was not surprising as pelvic adhesions (usually related to pelvic infections) are a common finding in our setting and are found in the majority of women with compromised fertility.7 However, the extent of tubo-peritoneal adhesions was not routinely described in the patient files. Our findings of these peritoneal adhesions and
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the corresponding proportions of adhesiolysis (69.6% and 66.4%) are much higher than the 34.5% reported by Parkar et al. in Kenya.13 We identified perihepatitis in 18.2% of our patients. This frequency was much lower than the 40% reported by Nzintcheu et al. in the same hospital during a shorter study period.14 This difference may be due to the fact that our data was collected in the patient files whilst Nzintcheu et al. did a prolective data collection. The management of ectopic pregnancy by laparoscopy has undergone marked changes in the past decade.8 Laparoscopic management of ectopic pregnancy is today regarded as the gold standard.12 Therefore, it was not surprising that 9.4% of the laparoscopies among our patients were indicated for ectopic pregnancies. This proportion was similar to the 8.1% of laparoscopies for ectopic pregnancies reported by Pither et al. in Kenya8 and in contrast to the 1.5% found by Tchente et al.8 However it should be noted that in the developed world, over 95% of ectopic pregnancies are managed by laparoscopy,15 despite reports that laparoscopic management of ectopic pregnancy is increasingly common in our settings.6,16 The low use of laparoscopy for the management of ectopic pregnancy in our study could be explained by the fact that most patients with ectopic pregnancy usually present in a state of shock following ectopic rupture.17 The known rate of laparoscopic complication in adequately trained hands ranges from 1%–5%, and the mortality ranges between 4–8 deaths/100.000 cases.18 We had an overall complication rate of 5.9% and no laparoscopy related deaths were identified. Tchente et al. reported a complication of rate of 1.48% during laparoscopic surgery. This was similar to our results (2.0%) but our proportion of post-operative complications (3.9%) was much lower than the 8.3% described by Tchente et al.10 The laparoscopic complication rate of 5.9% in our study is encouraging, indicating that the procedure is associated with an acceptable rate of morbidity in our setting. This finding however, must be interpreted with caution as we could not completely rule out the under-reporting of potential complications. Despite our large sample size, our results must take into consideration the limitations inherent to retrospective studies as missing data may distort our figures. As a result of missing data, 41 files were excluded from the analysis which may give some bias to our results.
Conclusion Our study shows that despite the fact that laparoscopy has existed in our setting since 1992, its acceptability and use is still very low. Infertility represents the most common indication for laparoscopy in our setting and pelvic adhesions remain the main laparoscopic finding
in our study. The complication rate associated with laparoscopy is acceptable in our setting. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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