Gynaecological laparoscopic surgery: eight years experience in the Yaoundé Gynaeco-Obstetric and Paediatric Hospital,Cameroon

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 Yaoundé Gynaeco-Obstetric and Paediatric Hospital between 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 Yaoundé Gyneco-Obstetric and Paediatric Hospital, which is one of the four referral hospitals situated in Yaoundé, 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 Yaoundé Gynaeco-Obstetric and Paediatric Hospital, Cameroon.

Results

Between January 2004 and November 2011, a total of 9194 gynaecological surgeries were performed in Yaoundé 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%).

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Table 1.

Relevant previous surgical history of study participants (n = 592).

Relevant previous surgery	n	%
None	483	81.6
Myomectomy	66	11.1
Ectopic pregnancy	35	5.9
Pelvic peritonitis	2	0.3
Caesarean section	1	0.2
Tuboplasty	1	0.2
Total abdominal hysterectomy	1	0.2
Appendectomy	1	0.2
Unspecified pelvic surgery	2	0.3
Total	592	100

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%).

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Table 2.

Frequency of different indications of laparoscopy among recruited patients (n = 592).

Indication	Diagnostic aparoscopy	Operative laparoscopy	Total n (%)
Infertility	0	415	415 (70.1)
Primary	0	106	106 (17.9)
Secondary	0	309	309 (52.2)
‘Second-look’ post  myomectomy	0	63	63 (10.6)
Adnexeal mass/ovarian  cyst	2	27	29 (4.9)
Ectopic pregnancy	0	51	51 (8.6)
Heterotopic pregnancy	0	5	5 (0.8)
Tubal sterilization	0	1	1 (0.2)
Upper genital tract  infection	1	1	2 (0.2)
Chronic pelvic mass	18	5	23 (3.9)
Urogenital malformation	3	0	3 (0.5)
Total	24 (4.1)	568 (95.9)	592 (100)

Most of the patients had more than one finding per-operatively (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 (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.

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Table 3.

Common surgical findings described in the patients (n = 592).

Findings	n	%
Tubal
Tubo-peritoneal adhesions	412	69.6
Unilateral hydrosalpinx	89	15.0
Bilateral hydrosalpinx	98	16.6
Unilateral pyosalpinx	13	2.2
Bilateral pyosalpinx	5	0.8
Unilateral proximal obstruction	10	1.6
Bilateral proximal obstruction	5	0.8
Paratubal cysts	39	6.6
Erection of the tubal isthmic portion	8	1.4
Tubar phimosis	95	16.0
Non-ruptured ectopic pregnancy	43	7.3
Ruptured ectopic pregnancy	7	1.2
Ovarian
Ovarian cyst	79	13.3
Polycystic ovaries	49	8.3
Tubo-ovarian abscess	7	1.2
Uterine
Myomatous uterus	100	16.9
Urogenital malformation	6	1.0
Pelvic
Endometriosis	27	4.6
Hemoperitoneum	13	2.2
Normal pelvis	12	2.0
Liver
Fritz Hugh Curtis syndrome	108	18.2
Other	32	5.4

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).

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Table 4.

Surgical procedures performed in the patients (n = 592).

Surgical procedure	n	%
Tubal
Adhesiolysis	393	66.4
Fimbryoplasty	119	20.1
Neosalpingostomy	218	36.8
Salpingectomy	4	0.7
Tubal ligation	1	0.2
Ectopic pregnancy
Salpingostomy	20	2.8
Salpingectomy	25	4.4
Adnexectomy	2	0.3
Tubal abortion	3	0.5
Ovarian
Intraperitoneal cystectomy	38	6.4
Drainage of cyst	49	8.3
Ovarian drilling	47	7.9
Uterine
Myomectomy/myolysis	30	5.1
Pelvic/peritoneal
Peritoneal washing/drainage	27	4.6
Cautery of endometriosis	20	3.4
Biopsies	14	2.5
Other	6	1.0

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.

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Table 5.

Per operative complications in our sample (n = 592).

Per-operative complications	n	%
None	580	97.9
Minor complications	10
Intestinal perforation	2	0.3
Vessel rupture with haemorrhage	4	0.7
Uterine perforation	4	0.7
Major complications	2
Rectal perforation	1	0.2
Vessel rupture with massive haemorrhage	1	0.2
Total	592	100

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.

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Table 6.

Post-operative complications observed (n = 592).

Post-operative complication	n	%
None	569	96.1
Pains	10	1.7
Incisional herniation	1	0.2
Fever	6	1.0
Pelvic peritonitis	1	0.2
Digestive problems	3	0.5
Abdominal wall bleeding	2	0.3
Total	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 Gabon ⁸ 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 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 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 Yaoundé 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 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 Kenya ⁸ 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.