Muscle-splitting mini-incision cholecystectomy under spinal anesthesia: cost-effective equitable minimally invasive surgery in laparoscopy era

Abstract

Introduction: Conventional open cholecystectomy has been increasingly replaced by laparoscopy which requires resources for expensive equipment, training, and maintenance. Muscle-splitting mini-incision cholecystectomy under spinal anesthesia has comparable outcomes to laparoscopy and requires fewer resources. This study analyzes the feasibility and outcome of muscle-splitting mini-incision cholecystectomy under spinal anesthesia. Methods: All consecutive cases of muscle-splitting mini-incision cholecystectomy (MC) performed for symptomatic cholelithiasis during three years ending in December 2019, at a periphery hospital in Janakpur, province-2, Nepal, were included. Complicated cholelithiasis (biliary pancreatitis, jaundice, cholangitis, dilated common bile duct) was excluded. Written informed consents were obtained. The need for general anesthesia, complications during and after surgery, and patient satisfaction were analyzed descriptively. Ethical approval was obtained. Results: Out of 148 MC completed under spinal anesthesia, six (4.1%) required fentanyl for shoulder discomfort. Mild post-operative pain was reported by 124 (83.8%) at six hours and 146 (98.6%) at 12 hours. The intravenous drip was stopped after surgery and oral liquid with analgesics started in two hours in 143 patients (96.6%). Post-operative antibiotic was given in nine, for 2(1.4%) cholecysto-duodenal fistulas, 4(2.7%) diabetics, and 3(2%) mucoceles. The mean hospital stay was one night. Wound complications occurred in 6(2.8%). Overall, 144 (97.3%) were satisfied and would recommend the procedure to others. Histopathology revealed adenocarcinoma in one case. There was no bile-duct injury, re-surgery, or mortality. Conclusion: Muscle-splitting mini-incision open cholecystectomy (MC) under spinal anesthesia is safe and effective with early feeding, short hospital stays, less demand for resources, and good patient satisfaction.

Global surgery and global health: One size does not fit all

“…Blindly pursuing the world's best technology is futile, which must be seen in the context of local resources, accessibility, sustainability, and the need of the community. 13 The COVID-19 pandemic has exposed the unethical practices and inequity prevalent in the healthcare services that came out in open; for example, in terms of equitable healthcare, vaccine rollout and its Journal of Patan Academy of Health Sciences. 2022Aug;9(2):1-7.…”

“…Healthy collaboration among surgeons and academics in the global surgery initiative has many roles in capacity built for quality surgery services that are accessible and affordable. 13,22,26 Most technology and devices used in LMICs are designed by and used in high-income countries. They result in a majority (3/4 th ) of them being out of context and non-functional, which continues to fuel the 10/90, for example, South Africa with its colonial and apartheid history is the most unequal country in the world with dual economy highlighting the 'frugal innovation' and health service delivery.…”