The Practice of Pediatric Laparoscopic Surgery in Rural Cameroon, A Retrospective Review.

Laparoscopy is an established practice in developed countries but is not widely utilized in sub-Saharan Africa.  Resource constraints and the absence of sustainable training models are among the main reasons hampering the uptake of laparoscopy in this region[1,2]. However, several pioneering attempts have been made to adapt this less morbid surgical technique to low-resource settings, with reports on its feasibility and safety in the region [3–6].  To highlight the feasibility of complex pediatric laparoscopic surgery in the region, we sought to report our experiences with pediatric laparoscopic surgery at Mbingo Baptist Hospital (MBH), a rural hospital in Northwest Cameroon.

Study design

This retrospective descriptive study involved reviewing operating room (OR) records of all pediatric operations performed at MBH from January 1, 2018, to December 31, 2024. All pediatric patients who had laparoscopy during the 7-year study period were identified, and their charts and electronic medical records (EMR) were reviewed. The variables extracted included age, sex, diagnosis, procedure, surgery time, intraoperative complications, conversion rates, postoperative complications, hospital stay days, procedure and hospital stay costs. Surgery time was considered as the time from incision to skin closure. Procedure cost was the cost of the surgery, including anesthesia consumables. The cost of healthcare was evaluated from the provider’s perspective, using a top-down approach that considers remuneration, consumables, equipment, maintenance, and other compulsory hospital operational costs for inpatient care. Details on the direct and indirect costs were extracted from the hospital’s billing records on EMR. However, donated equipment and infrastructure mitigate the indirect cost to the patients, hence underreporting the indirect cost to each patient. To ensure international comparability, the costs were adjusted from XAF to international dollars using purchasing power parity exchange rates for 2021.

We entered data into a database in Microsoft Excel 2016, de-identified, and coded it. The data was analyzed using Excel 2016 and SPSS v25. The Mann-Whitney U test was used to compare two medians. P ≤ 0.05 was considered statistically significant. The association between hospital length of stay and overall cost was compared using a Pearson correlation.

Ethical approval was obtained from the Cameroon Baptist Convention Health Board IRB.

Study setting and participants

Mbingo Baptist Hospital is a rural tertiary hospital in Northwest Cameroon. The pediatric surgery service performed 2,638 surgeries during the 7-year study period, averaging about 377 major cases yearly. There is a pediatric surgery team that includes one pediatric surgeon, two pediatric anesthetists, two anesthesiologists, scrub nurses, and a dedicated pediatric operating room, by kidsOR. Although the general surgery team operates on pediatric surgery patients in the absence of the pediatric surgeon, 99% of the laparoscopic cases were performed by the lone pediatric surgeon, assisted mostly by surgery residents.

One hundred and sixty-seven out of 2,638 (6.3%) pediatric surgeries were done via laparoscopy during the 7-year study period. This included 125 (74.9%) males and 42 (25.1%) females, with a male: female ratio of 3:1. Their ages ranged from 6 weeks to 20 years, with a mean age of 5.5 years ± 5.3 SD (Table 1).

A wide variety of pathologies were managed via laparoscopy, but the most common were cryptorchidism (non-palpable undescended testes) (28.1%), Hirschsprung (18.6%), appendicitis and its complications (7.8%), and pyloric stenosis (5.9%) (Table 2)

74.9% (125/167) of cases were therapeutic, while 25.1% 942/167) were diagnostic. 13.7% (22/167) of cases were converted to open, while 86.8% (145/167) were completed laparoscopically. The most common indications for conversion to open were technical difficulties and visceral injuries (Table 3).

4.8% (8/167) of patients sustained intraoperative complications. 62.5% (5/8) were converted to open, while 37.5% (3/8) were managed laparoscopically. 11.4% (19/167) of patients developed post-op complications. It is worth noting that some patients developed more than one post-op complication. 1.2% (2/167) of patients where hospitalised for >28days following surgery (Table 4).

Surgery time ranged from 10 to 380 minutes, with an average operative time of 97.2 minutes ± 62.6 SD (median=90 minutes).  Patients who developed postoperative complications were most likely to have been in surgery for more than 120 minutes, P = 0.001. Hospital stays ranged from 0 to 30 days post-op, with a median stay of 3 days (Table 5)

The cost of laparoscopic surgery ranged from 256.6 to 2,052.4 international dollars(I$PPP), with a median of 769.6 I$PPP. Without conversions to open surgeries, the average cost was 811.3I$PPP, and when converted to open surgery, the average cost was 897.9I$PPP. However, the cost of hospital stay ranged from 494.8 to 5,497.8I$PPP, with a median of 1,197.0I$PPP.

Despite the well-documented benefits of laparoscopic surgery, its adoption remains remarkably low and underreported in sub-Saharan Africa, particularly in the pediatric population. A recent multicentre study highlighted that pediatric laparoscopy is still a rarity, with significant disparities in its practice across the East, Central, and Southern African (COSECSA) region[7]. A major reported limitation of this research was the lack of data from several key institutions, underscoring the urgent need for comprehensive documentation. Our study aims to bridge this gap by sharing our valuable experience with pediatric laparoscopic surgery, emphasizing its feasibility and critical importance for enhancing pediatric surgical care in the region.

Our patient population was predominantly male, with a male-to-female ratio of 3:1. Even though they had a younger patient population, Lukman Olajide et al reported a similar gender distribution [6]. The most common indications for laparoscopic surgery were cryptorchidism, Hirschsprung’s disease, acute appendicitis, Pyloric stenosis, and anorectal malformations (ARM). Cryptorchidism is a diagnosis of the male gender[8], and ARM, Hirschsprung, and pyloric stenosis are more common in males[9–11], which could explain the gender distribution in our patients.

All laparoscopic cases were performed with an intent-to-treat approach, although 25.1% ended at diagnostic procedures. Of this subset, the most common indications were disorders of sexual differentiation (DSD), Malrotation, and cryptorchidism. Other minor indications included malfunctioning VP shunt, adhesions, abdominal pain of unclear aetiology, intrabdominal abscesses, tuberculosis, trauma, intra-abdominal tumours, etc.  Laparoscopy is useful in the evaluation of patients with DSD as it allows for the identification of mullerian structures and inspection of gonadal morphology[12] as well as biopsies and possible excision of germ cell tumours[13,14]. Though Huntington et al report shorter hospital stays and fewer post-op complications with laparoscopic Ladd’s procedure[15], the superiority of laparoscopic over open Ladd’s is still controversial[16]. Isani et al report a 46.6% conversion to open in the cohort who had laparoscopic Ladd’s, alongside longer operating time[17], and more conversions to open Ladd’s have also been reported at the initial phase of the surgical experience[16]. This highlights the long learning curve required in performing laparoscopic Ladd’s procedure and the importance of surgical expertise and experience. Furthermore, laparoscopy is considered the gold standard for assessing the presence and location of non-palpable testes with 100% accuracy[18].

Of the subset who got therapeutic procedures, 13.2% were converted to open, mostly due to technical reasons that precluded the continuation of safe laparoscopic surgery. Technical reasons included complex pathologies like malrotation that require more expertise, abscesses with friable bowel or phlegmons, severely dilated small bowel, and dense intrabdominal adhesions. Three patients had enterotomies, 2 patients had pyloric perforation during the pyloromyotomy, and 1 patient had ischaemic bowel on laparoscopy. The pyloric perforations resulted from malfunctioning instruments and the unavailability of a proper myotome. The common causes of conversion to open described in the literature include dense adhesions[19], intraoperative complications[20,21], technical difficulties, and equipment malfunction (22), complex pathologies(19,22), and surgeons’ expertise(23). Consistent with our study, Saleh et al. reported technical difficulties as their most common reason for conversion[22].

We observed both intraoperative and postoperative complications. Eight patients had intraoperative complications, including bowel injury, vas injury, and one bladder injury that was only realized in the postoperative period when the patient developed a pelvic collection. This was subsequently drained via open surgery, and the bladder injury was repaired. One patient developed malignant hyperthermia intra-op, which was discovered late. Cases like this led to the purchase and mandatory use of ETCO2 monitors in the pediatric operating room. Regarding postoperative complications, 19 patients developed postoperative complications, including superficial, deep, and organ space infections and coloanal anastomosis breakdown. Only 2 (1.2%) postoperative complications were directly linked to laparoscopy. The first was a severely malnourished patient who developed a port site hernia post-Heller myotomy and fundoplication for achalasia, and the other developed a port site infection and anal wound breakdown post-laparoscopic-assisted anorectoplasty for a high malformation. Also, we observed a mortality of 2.4%. The first death was from malignant hyperthermia, and another was from sepsis following an infected VPS that migrated into the bowel. One had a diagnostic laparoscopy with a diagnosis of malrotation and chronic volvulus, had an open Ladd’s procedure, and died from severe acute malnutrition. Meanwhile, the last patient died from sepsis following a concealed coloanal anastomotic leak post-laparoscopic-assisted emergency colostomy pull-through for a gangrenous stoma prolapse in Hirschsprung disease. Increased postoperative morbidity and mortality are experienced in emergency procedures when compared to elective ones[24]. Longer procedures, greater than 120 minutes, were more likely to be associated with a postoperative complication. This is consistent with literature, where prolonged operative time has been associated with increased postoperative complications[25,26]. Longer operative times were more likely to be linked to the case complexities than to surgical inefficiency or equipment malfunction.

Furthermore, the median cost of hospitalization was 1,197.0I$PPP, which is similar to other reports from the region [27–29]. Patients who developed complications and stayed longer in the hospital incurred higher hospital bills. This is consistent with the higher financial burden incurred in patients who developed complications, as reported by Parker et al[30].

This study has several limitations that must be acknowledged. First, the lack of comprehensive documentation to accurately classify surgical complications according to a standardized classification system, along with insufficient data on operative duration, introduces potential bias in the reported outcomes. Additionally, the artificially lowered cost resulting from donated equipment further limits the generalizability of the cost reported in this study

Pediatric laparoscopic surgery at MBH encompassed a comprehensive spectrum of both fundamental and complex procedures, demonstrating comparable challenges, costs, and outcomes to those documented in the existing scientific literature.