Ethiopia's first minimally invasive surgery program: A novel approach in global surgical education.

Objective: Complex lung diseases are among the leading causes of death in Ethiopia. Access to thoracic surgery is limited, and before 2016 no thoracic surgeons were trained in minimally invasive surgery. A global academic partnership was formed between the University of Toronto and Addis Ababa University. We describe implementation of the first minimally invasive surgery training program in sub-Sahara Africa and evaluate its safety. Methods: We performed a retrospective cohort analysis of open versus minimally invasive thoracic and upper gastrointestinal procedures performed at Addis Ababa University from January 2016 to June 2021. Baseline demographic, diagnostic, operative, and postoperative outcomes including length of stay and complications were compared. Results: In our bilateral model of surgical education, training is provided in Ethiopia and Canada over 2 years with a focus on capacity building through egalitarian forms of knowledge exchange. Program features included certification in Fundamentals of Laparoscopic Surgery, high-fidelity lobectomy simulation, and hands-on training. Overall, 41 open and 56 minimally invasive surgery cases were included in the final statistical analysis. The average length of stay in the minimally invasive surgery group was 5.2 days versus 11.0 days in the open group (P < .001). The overall complication rate was 18% in the minimally invasive surgery group versus 39% in the open group (P = .020). Conclusions: We demonstrated the successful initiation of sub-Sahara Africa's first minimally invasive surgery program in thoracic and upper gastrointestinal surgery and characterize its patient safety. We envision the minimally invasive surgery program as a template to continue expanding global partnerships and improving surgical care in other resource-limited settings.

Penetrating cardiac injury presentation and management in resource-limited settings: A case series from Ethiopia.

INTRODUCTION AND IMPORTANCE: Penetrating cardiac injury is rare (0.1 % of trauma admissions) but fatal. Presentation is with features of cardiac tamponade or hemorrhagic shock. Urgent clinical evaluation, ultrasound, temporizing pericardiocentesis or surgical repair with cardiopulmonary bypass as back up consist of standard management. In this paper, experience of management of penetrating cardiac injury from a resource limited country is presented. CASE PRESENTATIONS: There were seven patients, five had a stab injury and two had gunshot wound. All were men with mean age of 31.1 years. Patients arrived within 30 min (3), 2 h (2), 4 h (1) and 18 h (1) after injury. Mean initial blood pressure and pulse rates were 83/51 mm Hg and 121, respectively. One patient had pericardiocentesis before referral. Exploration was via left anterolateral thoracotomy. Four (57.1 %) had right ventricle perforation, one had both right and left ventricle, and two (28.5 %) had left ventricle perforation. Suture repair (6) and pericardial patch (1) were done without bypass machine as back up. Mean duration of stay in the intensive care unit and in the surgical wards were 4.4 days (range: 2-15) and 10.8 days (range: 1-48), respectively. All were discharged improved. CLINICAL DISCUSSION: Penetrating cardiac injury presents with low blood pressure and tachycardia after stab or gunshot wounds. Right ventricle is mostly affected. Pericardiocentesis can be done as temporary measure. While having bypass machine as back up is recommended, the absence of it should not preclude intervention. Suture repair can be done with left anterolateral thoracotomy. CONCLUSION: Penetrating cardiac injury can be managed in resource limited settings without back up of cardiopulmonary bypass. Early identification and surgical intervention results in favorable outcome.

Surgical Management of Acute Abdomen in Adult Patients: Experience from a Private Hospital in Addis Ababa, Ethiopia.

Background: Acute abdomen is a major surgical problem in Ethiopia with surgery for acute abdominal conditions accounting for roughly one-third of total emergency operations in many centers. This study was conducted with the aim of studying the pattern and outcome of surgically managed acute abdominal cases in a private general hospital in Addis Ababa, Ethiopia. Methods: This was a retrospective cross-sectional study of acute abdominal cases in adult patients operated at Teklehaimanot General Hospital between January 1, 2018 and August 1, 2019. Results: A total of 267 patients' medical records were reviewed. The male to female ratio was 1.5:1 and majority of patients were between the age range of 20 to 40 years with mean age of 36±16 years. The average duration of symptoms before arrival was 71.1±84.4 hours (range 3 to 504 hours) and only 85 (31.8%) of patients reached to the Hospital within 24 hours or less of onset of symptoms. Acute appendicitis was the most common cause of acute abdomen; observed in 193 (72.3%) of the cases. Overall post-operative complication rate was 14.8% and post-operative mortality rate was 1.9%. It was found that delayed presentation (OR 2.01, 95% CI 1.64-7.84), old age (OR 1.51, 95% CI 1.89-3.59), and tachycardia at presentation (OR 2.85, 95% CI 1.03-6.82) were major predictors of morbidity and mortality in operated patients. Conclusion: In this study acute appendicitis accounted for the majority of cases operated for acute abdomen. Length of post-operative hospital stay, early post-operative complication rate, and overall mortality rate were found to be significantly lower in our series than other reports.

Impact of COVID-19 on Surgical Volume: Single-Center Experience from Addis Ababa, Ethiopia.

BACKGROUND: The COVID-19 pandemic has caused substantial disruptions to surgical-care delivery mainly due to diversion of available resources from surgical to COVID-19 care, reduced flow of patients, supply-chain interruptions and social distancing and restriction measures. The purpose of this study was to understand the impact of the pandemic on surgical volume in our hospital. METHODS: A descriptive cross-sectional study was done at Tikur Anbessa Specialized Hospital. A 2- year data was collected from March 2019 up to March 2021 from the operation theatre registration books. The data registry at the admission records office was also reviewed to extract the number pf patients on the elective surgery waiting list. Data were recorded, analyzed and reported using SPSS software package 26. RESULTS: The findings showed that there was a significant drop in surgical volume during the COVID-19 era. Surgical volume has dropped by 19% for emergency and by 32% for elective surgeries. COVID-19 test positivity of patients was identified as the single most important reason for elective operation cancellation during the first wave of the pandemic, contributing to as high as 85% of the reasons. CONCLUSION: The outcome of our study showed that COVID-19 has adversely affected elective and emergency surgical volume in our institution. This has also led to a dramatic increase in the surgical waiting list load. We recommend immediate surgical systems strengthening measures to re-build the surgical care ecosystem significantly affected by COVID-19. Surgical and anesthesia systems strengthening should be an integral part of pandemic preparedness and management.

Malpractice Awareness among Surgeons and Surgical Trainees in Ethiopia.

BACKGROUND: In Ethiopia, a country where seeing medical errors is not rare, there is a lack of data concerning the overall awareness of medical malpractice issues among physicians. A recent study showed that 80% of malpractice claims in Ethiopia are related to some form of surgery or operation room activities. METHODS: A cross-sectional survey was conducted among surgeons and surgical trainees. Data were collected anonymously by an online survey using Google forms through a 56-items structured questionnaire. Subsequently, the data were analyzed and reported employing nonparametric statistical methods with SPSS software package 26. RESULTS: In our sample, the overall awareness regarding medical malpractice was relatively low. Surgery on a wrong patient (71.1%) was the most commonly reported form of malpractice, whereas unintended damage to adjacent organs (10.8%) was the most frequently disagreed up on form. In the event of a medical error, the majority (59.6%) reported readiness to disclose their error to the patient. The most common mentioned reason for not revealing a mistake was a threat of physical or verbal assault (68%). A significant number of respondents, i.e., 120(59.1%), reported being physically/verbally assaulted by a patient or their attendants at some point in their practice. CONCLUSION: The findings of our study provided a general picture of surgeons' and surgical trainees' knowledge, attitude, and practice regarding medical malpractice. This study recommends more robust ethics and law training modules to surgical trainees, refresher courses to surgeons, and advanced training programs in ethics and law.

Bronchiectasis: Experience of Surgical Management at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Bronchiectasis is one of the major health problems in Ethiopia. We analyzed the outcome of surgery done for bronchiectasis in a resource-limited setup. METHODS: A retrospective cross-sectional analysis of 22 patients who underwent surgery for bronchiectasis in Tikur Anbessa specialized hospital (TASH) during the period 2012 - 2017 were done. RESULTS: There were 13(59%) female and 9(41%) male patients with a mean age of 34.1 +/-16.9 years. The mean duration of symptoms was 2.2 years. Blood streak sputum, 13(59%), dyspnea, 9(49.9%), fetid sputum, 8(36.4%), dry cough, 6(27.3%), chest pain, 6(27.3%) and massive hemoptysis 3(13.6%) were the main presenting symptoms. In 20(91%) of the patients, previous history of TB treatment was identified. Recurrent childhood infection, 1(4.5%), and tumor obstruction, 1(4.5%), were also seen. Bronchiectasis was left sided in 12(54.5%), right-sided in 7(31.8%) and bilateral in 3(13.6%) patients. The disease affected multiple lung lobes in 9(40.9%), left lower lobe in 6(27.3%) and left upper lobe in 3(13.6%) cases. Indications for surgery were the failure of medical management in 10(45.5%), destroyed lung in 9(40.9%), and massive hemoptysis in 3(13.6%) cases. The procedures performed were lobectomy in 14(63.6%) and pneumonectomy in 8(36.4%) cases. Postoperative complications occurred in 5(22.7%) patients with one (4.5%) death. On the other hand, 77.3% of operated patients had significant improvement compared to their preoperative symptoms. CONCLUSIONS: In a resource-limited setup like TASH, localized bronchiectasis can be treated surgically with an acceptable result. Proper selection and preparation with complete resection of the involved segments are needed for maximum control of symptoms and better outcomes.