Mobile gastrointestinal and endoscopic surgery in rural Ecuador: 20 years' experience of Cinterandes.

INTRODUCTION: Five billion people worldwide do not have timely access to surgical care. Cinterandes is one of the only mobile surgical units in low- and middle-income countries. This paper examines the methodology that Cinterandes uses to deliver mobile surgery. METHODS: Founding and core staff were interviewed, four missions were participated in, and internal documents and records were analysed between 1 May and 1 July 2014. RESULTS: Cinterandes performed 7641 operations over the last 20 years (60% gastrointestinal/laparoscopic), travelling 300,000 km to remote areas of Ecuador. The mobile surgery programme was initiated by a local Ecuadorian surgeon in 1980. Funding was acquired from businesses, private hospitals, and individuals, to fund a low-cost surgical truck, simple equipment, and running costs. The mobile surgical unit is a 24-foot modified Isuzu truck containing a preparation room with general equipment storage and running water, together with an operating room including the operating table, anaesthetic and surgical equipment. Mission structure includes: patient identification by a network of local medical personnel in remote regions; pre-operative assessment at 1 week by core team via teleconsultations; four-day surgical missions; post-operative recovery in tents or a local clinic; post-operative follow-up care by local personnel and remote teleconsultations. The permanent core team includes seven members; lead surgeon, lead anaesthetist, operating-room technician, medical coordinator, driver, general coordinator, and receptionist. Additional support members include seven regular surgeons, residents, medical students, and volunteers. CONCLUSION: Surgery is a very effective way to gain the trust of the community, due to immediate results. Trust opens doors to other programmes (e.g. family medicine). Surgery can be incorporated with all other aspects of health care, which can in turn be incorporated with all other aspects of human development, education, food production and nutrition, housing, work and productivity, communication, and recreation.

Laparoscopic repair of potentially contaminated abdominal ventral hernias using a xenograft: a case series.

BACKGROUND: The aim of this study was to describe the preliminary experience of definitive single stage laparoscopic reconstruction of the abdominal wall utilizing a tissue matrix in a potentially contaminated surgical field. METHOD: Retrospective review of potentially contaminated ventral hernias repaired with a minimally invasive technique utilizing biological mesh. Reconstruction required the laparoscopic restoration of the midline with or without a minimally invasive component separation technique and reinforcement with a xenograft (Strattice™ Reconstructive Tissue Matrix, LifeCell, Branchburg, NJ). RESULTS: We describe the first three cases of a xenograft placed laparoscopically in a potentially contaminated ventral hernia. There were no mesh-related complications or early recurrences during short-term 6 month follow-up. CONCLUSION: Strattice™ Reconstructive Tissue Matrix appears to be a promising new biological matrix for laparoscopic ventral hernia repair, especially in potentially contaminated fields. Further studies and long-term follow-up are still required.

Real-time Internet connections: implications for surgical decision making in laparoscopy.

OBJECTIVE: To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation. SUMMARY BACKGROUND DATA: Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will open the operating room environment to remote real-time surgical consultation. METHODS: Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account. The connection permitted video and audio teleconferencing to support real-time consultation as well as the transmission of real-time images and store-and-forward images for observation by the consultant panel. A total of six live consultations were analyzed. In addition, paired local and remote images were "grabbed" from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to evaluate the effect of transmission on image quality. RESULTS: The authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. The consultant panel of surgeons correctly remotely identified biliary and arterial anatomy during six laparoscopic cholecystectomies. Within the Web-based questionnaire, 15 surgeons could not blindly distinguish the quality of local and remote laparoscopic images. CONCLUSIONS: Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Use of these inexpensive, portable technologies will allow sharing of surgical procedures and decisions regardless of location. Internet telemedicine consistently supported real-time intraoperative consultation in laparoscopic surgery. The implications are broad with respect to quality improvement and diffusion of knowledge as well as for basic consultation.

Evaluation of the effectiveness of portable low-bandwidth telemedical applications for postoperative followup: initial results.

BACKGROUND: The idea of using telemedical applications to evaluate patients remotely is several decades old. It has already been established that x-ray images (and magnetic resonance images) can be transferred using a personal computer and a modem, and many other such applications have been implemented. Over the past 50 years the expense and technical demands of the equipment involved in telemedicine have hindered its widespread deployment. The purpose of this study is to evaluate the ability of a mobile, low-bandwidth telemedicine platform to achieve real-time postoperative visits in the home. STUDY DESIGN: This evaluation was designed to evaluate the feasibility of performing a real-time clinical visit with computer and telecommunications hardware and software. A nurse and medical student (for information gathering only) made postoperative visits at patients' homes while the physician stayed at the office. Clinical evaluations were performed by using low-resolution and frame-rate video, high-resolution still images, and simultaneous telephony over a standard telephone line. These remote visits were followed by a standard visit in the office. Eleven patients were included, all of whom had undergone various laparoscopic procedures. They lived 5 to 240 miles from their surgeon. Efficiency was measured by recording the time required to capture and send data required by the physician to make a clinical decision. The time expense was measured at both the patients' and physician's locations. Technical issues were evaluated and patient satisfaction was assessed by standardized objective questionnaires. The accuracy of the evaluation at the remote visit was determined with a standard office visit. RESULTS: No technical problems were observed. The mean total time of the housecall at the remote site was 86 minutes (range 60 to 160 minutes) and at the base station site was 41 minutes (range 21 to 71 minutes). After personnel became familiar with the system, the last three visits averaged 61 and 25 minutes at the two sites, respectively. This corresponds favorablywith current time requirements for visiting nurses and office visits. The patients were highly satisfied with the home visit and, on average, rated the experience as 4.8 out of a maximum of 5. CONCLUSIONS: Followup visits in patients' homes after laparoscopic procedures can be accomplished by transmitting simultaneous voice, low-resolution video, and high-resolution still images to accurately perform postoperative evaluations over standard telephone lines, with time requirements and clinical accuracy similar to those of standard visits.

A simplified technique for laparoscopic jejunostomy and gastrostomy tube placement.

BACKGROUND: Percutaneous endoscopic gastrostomy and jejunostomy tube placement have long been considered the standard for supplying enteral nutrition when oral intake is not possible. Both have well-documented roles and limitations and are associated with a higher than generally appreciated incidence of aspiration. A distally placed tube in the jejunum decreases the chance of this morbid complication. Additionally, when percutaneous endoscopic gastrostomy is indicated but cannot be done for technical reasons, a minimally invasive alternative is desirable. METHODS: In prior series, the techniques suggested for laparoscopic enteral access have characteristics that are either difficult for the average surgeon to duplicate, or use nonstandard anchoring techniques of the bowel to the abdominal wall. A simple, laparoscopically directed, percutaneous technique utilizing cost-effective appliances is described, and suggested indications are outlined. RESULTS: This technique has been successfully applied in 46 patients with minimal complications. CONCLUSIONS: A simplified technique for laparoscopic jejunostomy and gastrostomy tube placement is described. This has been successfully deployed in 46 patients with minimal morbidity. The procedure lessens the need for sophisticated suturing skills and duplicates standard small bowel to abdominal wall fixation methods.

Minilaparoscopy without general anesthesia for the diagnosis of acute appendicitis.

The timely diagnosis of intra-abdominal pathology continues to be an elusive problem. Delays in diagnosis and therapeutic decision making are continuing dilemmas in patients who are females of childbearing age, elderly, obese or immunosuppressed. Minilaparoscopy without general anesthesia potentially can provide an accurate, cost-effective method to assist in the evaluation of patients with acute abdominal pain. Laparoscopy without general anesthesia is not a new technique, but with the combination of two emerging factors--1) the introduction of new technology with the development of improved, smaller laparoscopes and instruments, and 2) the shifting of emphasis on healthcare to a more cost-effective managed care environment--its value and widespread utilization is being reconsidered. We report the case of a 22 year old female with an acute onset of increasing abdominal and pelvic pain. Despite evaluation by general surgery, gynecology, emergency room staff, as well as, non-invasive testing, a clear diagnosis could not be made. In view of this, minilaparoscopy without general anesthesia was performed and revealed an acute, retrocecal appendicitis. The diagnosis was made with the assistance from the conscious patient. The utilization of this technique greatly expedited the treatment of this patient. Full-sized laparoscopic equipment was then used to minimally invasively remove the diseased appendix under general anesthesia. Both procedures were well tolerated by the patient.

Surgical Complications: Mobile Surgery vs. Hospital Surgery.

Mobile Surgery (MS) is an innovative method of delivering high quality surgical expertise and technology to underprivileged and remote areas. This is done by means of transporting a custom-built operating room in a truck and performing the operations on-site. Patients are referred to our program by rural doctors and family physicians. A screening process is completed by our surgical team, and those patients who meet our selection criteria are offered surgical treatment. Operations are meticulously performed and patients recover under our close observation in rural health centers, school rooms, or tents with our Mobile Surgical Unit (MSU) stationed adjacent to them.

Mobile surgery: a new frontier.

At the end of the 20th Century, the world lives in the midst of a tremendous contradiction. On one side we have great scientific and technological progress, designed for the well-being of mankind, and on the other, the everyday widening gap between a few who have more than what they need and the vast majority of people who do not have enough.