Gynaecologic endoscopy and experience with training in Africa
O. A. Lapido
Association for Reproductive and Family Health, Ibadan, Nigeria
Department of Obstetrics and Gynaecologist, University College Hospital, Ibadan, Nigeria
E. O. Akande
Word Health Organisation (HRP) Geneva, Switzerland
A few Gynaecologists receiving training in Europe during the late 1960's and early 1970's returned to Africa with accounts of their use of gynaecologic endoscopes. However, it was not until the mid 1970's that endoscopes were introduced into institutions with financial assistance from donor agencies, e.g. United States Agency for International Development (USAID), John's Hopkins Program for International Education in Reproductive Health (JHPIEGO) and Pathfinder Fund. Laparoscopy and hysteroscopy have gained popularity with the potential to provide new opportunities for research into the complex physiology of human reproduction. An earlier effort to introduce culdoscopic sterilisation was short lived because the procedure was only possible in about half of the cases. Failures were usually due to gross pelvic adhesions secondary to previous inflammatory disease.
Very few physicians in Africa have acquired skills in endoscopy. Resource constraints restrict widespread use of endoscopy both for diagnostic and therapeutic procedures. The indications for gynecologic endoscopy in Africa are the same as those in developed countries.
Laparoscopy is becoming widely used for fertility investigations though still the most common use is for female surgical sterilisation which is usually performed as an interval outpatient procedure.
HYSTEROSCOPY IN AFRICA
Although hysteroscopy is routinely practiced in the developed world very few institutions in Africa, both private and public, use this invaluable technology (12 - 13). This is largely because of resource constraint and limited trained personnel. Regrettably, the international organisations who popularised and encouraged widespread use of the laparoscope have not invested in the use of the Hysteroscope for diagnostic and therapeutic purposes.
LAPAROSCOPIC TRAINING IN AFRICA
In the early 1970's John Hopkins's Programme for International Education in Gynaecology and Obstetrics (J.H.P.I.E.G.O.) Baltimore U.S.A., pioneered the introduction of laparoscopy as a surgical method for voluntary female sterilisation. Although, the training in laparoscopy was initially U.S. based, it later shifted to international settings. For example, in Africa tertiary institutions in the following countries were designated as laparoscopy training centres for a variety of health workers - Nigeria, Kenya, Cameroon, Rwanda, Senegal and Zimbabwe. At one time group training was also conducted in Niger and Central African Republic.
The physicians trained in either U.S. based or African institutions in turn trained their colleagues and resident doctors thus ensuring a critical mass of skilled laparoscopists in most countries. These trainees provided diagnostic and therapeutic services in both the private and public sector though facilities in the private sector appear to adapt better to changes in instrumentation and advances in gynaecologic endoscopy.
The purpose of the JHPIEGO programme is to provide training and medical equipment to physicians in developing countries (14). This training, which has continued to the present, is designed to provide service providers and clinical trainers, primarily specialists in obstetrics and gynaecology, with the requisite knowledge and skills to initiate voluntary sterilisation (V.S.) services.
OBJECTIVES OF THE UCH IBADAN TRAINING PROGRAMMES
The objectives of the training programme at the University College Hospital, Ibadan, Nigeria, are as follows:
- To provide didactic and clinical training in laparoscopy to physicians from Government hospitals with emphasis on management of fertility and infertility and the use of the laparoscope for diagnostic and therapeutic procedures.
- To provide didactic and clinical training to operating room nurses in the skills necessary to assist the surgeons from their institutions.
- To provide didactic and clinical training in the use of local anaesthesia for endoscopic procedures to anaesthesiologists from key institutions in West Africa.
- To provide medical equipment, educational materials and consultant support to selected institutions.
Criteria for Selection of Trainees
The physicians are obstetricians/gynaecologists or general surgeons or experienced senior medical officers with prior experience or training in the performance of abdomino-pelvic surgery. They are usually recruited from University Teaching Hospitals, State or Missionary Hospitals that are able to provide sufficient support staff, operating space and time for the use of the laparoscope.
Designated laparoscopy training institutions also ensure that residents acquire skills in diagnostic laparoscopy before undertaking the specialist M.Med or Fellowship examinations in their respective countries.
These are operating room nurses who were selected from the same institutions as the physicians. At the University College Hospital, Ibadan, Nigeria trained nurses/midwives regularly rotate through the Obstetrics and Gynaecology theatre to acquire skills in endoscopic procedures in an informal training programme.
These are anesthetists or nurse-anaesthesiologists who provide complementary specialised services in the theatres.
Training Course Contents
The primary objective of the training programme is to provide participants with the skills needed to screen, refer clients and to perform safe effective sterilisation procedures. The trainees are also involved in a variety of service-delivery activities including counselling, pre-operative preparation, anaesthesia application, surgery, post-operative monitoring and follow up. The physicians course is a two week programme while that of theatre nurses lasts one week and that of anaesthetists is five days.
Phase I Didactic Course
This consists of a series of seminars designated to update and standardise trainees reproductive health knowledge including current techniques of fertility management.
The lectures include:
- Family Planning in African culture
- Overview of Population Management of gynaecological infections and health
- Sexually transmitted diseases
- Maternal and child health problems
- Endoscopy in infertility management
- Advances in fertility management and contraceptive techniques
- Indications, contra-indications and complications of laparoscopy
- Preparation of operating room and basic techniques and methods of instrument sterilisation
- Minilaparotomy versus laparoscopy sterilisation
- Techniques for local and general anaesthesia
- Post operative care
Phase II Practical Training
This consists of clinical demonstrations and instruction in laparoscopic tubal occlusion using electro-coagulation, Yoon Fallope ® Ring or Filshie ® clip. This is generally supplemented by supervised clinical practice using the fibre-optic teaching aide. The clinical instructor is responsible for assessment of the trainees’ competency using an Evaluation Form and the trainees’ operative record form. A physician must satisfactorily complete ten solo procedures in order to be certified as competent to perform laparoscopic sterilisation. Similarly a nurse trainee must satisfactorily provide pre and post operative care, demonstrate appropriate skill in preparing and maintaining operating theatre equipment and assist the surgeon in laparoscopic procedure in order to be certified competent. Furthermore, depending on the performance of the physicians, the clinical instructor is mandated to make recommendations regarding the donation of laparoscopic equipment to their institutions.
Anaesthesia for laparoscopy
Selection of the anaesthesia/analgesia method depends on the desires and the needs of the patient. It also depends upon the availability of trained anaesthetists and equipment in the centre. Other factors involved are the experience and skill of the operator, the cost to the patient and the presence of any contra-indications in the patient to any particular method (15).
Conscious sedation (local anaesthesia) using intravenous Pethidine 100mg and Diazepam 10 mg with local sub-umbilical infiltration with 10-15cc of 1% plain Lignocaine is the most popular and frequently used analgesia method during training programmes (16). In addition it is well accepted by the surgeons and the patients. The cost is less and it reduces the post-operative recovery time and pain.
The limitations of local anesthesia include pain and discomfort from the pneumoperitoneum and visceral movement that are not completely abolished.
General anaesthesia is reserved for patients who are nervous, apprehensive, have a low pain threshold or in whom laparotomy may be contemplated. Neuroleptic and dissociative anaesthesia are generally not used during laparoscopy training programmes.
Resuscitation equipment such as Ambu bag, laryngoscope, endotracheal tubes and oxygen supply, cardiac drugs and narcotic antagonist should be available at the training centre and personnel involved in patient care are taught the basic knowledge and skills required for resuscitation
Although room air was recommended by J.H.P.I.E.G.O., most surgeons preferred carbon dioxide. Air was recommended because of unreliable supply and expense of carbon dioxide.
Phase III Follow up site visits
Follow up field visits were conducted at each trainees’ institution by a physician and an equipment technician essentially to provide on-site technical assistance, ensure competence, ascertain the institutions capacity to provide voluntary sterilisation services and install laparoscopic equipment.
Equipment Maintenance and Repair(RAM)
From an early stage J.H.P.I.E.G.O. recognised that to ensure that the laparoscopes remain operational it was important to establish maintenance and repair centres and could provide repair and maintenance services(RAM). RAM centres were established in: Ghana, Kenya, Nigeria and Sudan.
Additionally the RAM centres train the technicians who maintain the equipment. They also provide a maintenance /repair service to minimise the length of time equipment in nonoperational. The service is also designed to accommodate increasing numbers of instruments and new developments.
The Number of Trainees under JHPIEGO
Since 1972, more than 6000 health workers from developing countries have received laparoscopy training. Many of the trainees have become outstanding trainers in their own institutions further contributing to the spread of the technology in the region.
Current Status of Research on Gynaecologic Endoscopy in Africa
Research activities in gynaecological endoscopy are limited in Africa. The following areas are suggested for research:
- Assessment of local versus general anaesthesia
- Cost benefit of laparoscopic therapeutic procedures
- Assessment of laparoscopy for minimally invasive surgery in Africa
- Complication rates and the professional experience of the cadre of staff performing laparoscopy
- Evaluation of room air for pneumoperitoneum
- Hysteroscopy in the investigation and management of abnormal uterine bleeding.
- Hysteroscopy in the diagnosis and treatment of Asherman’s syndrome
- Hysteroscopy and endometrial ablation
- Patient discomfort during diagnostic or operative hysteroscopy
- Para-cervical anaesthetic block versus neuroleptic and dissociative anaesthesia
Endoscopic evaluation of gynaecological patients is gaining in popularity in Africa and has contributed to an improvement in reproductive health. Despite the simplicity and diverse indications enthusiasm for its use must be restricted to the trained physicians because of the potential risks. Equipment and training are only a means to an end not an end in themselves (17). The training of trainers model introduced to Africa in 1974 proved to be an effective approach to disseminating skills and information to widely dispersed members of a professional group. These training programs operated without the benefit of modern video-endoscopy. The use of video monitor is now considered essential for the training of all staff. Gynaecologic endoscopy requires the concerted efforts and skills of a team who must be taught and have a technical understanding of the instruments.
To ensure sustainability of an endoscopic programme it is essential to establish a maintenance culture with indigenous technicians. With more trained physicians in Africa there is a need for articulating a research agenda and also to establish a forum for sharing experience and resolving technical problems.
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Table 1. TOTAL NUMBER OF HEALTH WORKERS TRAINED IN LAPAROSCOPY BY CADRE AND TRAINING PROGRAMME
|Training Programme||CADRE||TOTAL TRAINED|
|Physician||Nurse Midwife||Anaesthetist||Equipment Technician|
|National and International||2,772||1,765||576||21||5,134|
|Number of trainees from AFRICA||908||452||353||18||1731|
|% of total||22.2%||25.4%||61.6%||24.3%||26.5%|
Country of JHPIEGO Organization, Baltimore, U.S.A.