Surgical conditions are an acknowledged and often neglected global health problem disproportionately affecting the world’s poorest people [1]. Perioperative mortality is as high as 5–10 % in low-income countries (LICs) compared to 0.4–0.8 % in high-income countries, with the majority related to infections, anesthesia complications, and hemorrhage. Inadequate infrastructure, equipment, medications, organizational management, and infection control contribute to these difficulties [2].

In developed countries, many surgical conditions are preferentially treated with minimally invasive surgery (MIS), including laparoscopy. MIS provides several advantages over open surgery, including decreased infection, decreased blood loss, reduced postoperative pain, improved bed utilization, and rapid return to work [3, 4]. These distinct advantages of laparoscopy over open operations may be even more pronounced in developing countries, where access to clean water and sanitary living conditions can be limited [5] and blood banks are scarce. In addition, modern diagnostic imaging is often not available in low- and middle-income countries (LMICs), and diagnostic laparoscopy may be both clinically and economically effective [6, 7]. For example, in a district hospital in Nigeria, the unnecessary laparotomy rate was found to be 14 % among patients with acute abdomen, resulting in 6 unnecessary deaths as well as other significant morbidity [6]. Diagnostic laparoscopy may be more cost-effective as well; the equipment cost ratio of laparoscopy/ultrasonography/CT/MRI has been estimated at 1:500:2500:4500 [7].

Laparoscopy equipment may be accessible in some LMICs as a result of laparoscopic tubal ligation campaigns that occurred in the 1970s and 1980s [8] and subsequent donations from charitable organizations. Surgeons in resource-limited settings have shown that the procedures can be affordable and patient costs can be similar to laparotomy [9, 10]. Udwadia described doing his first 3200 diagnostic laparoscopies using a single laparoscopic set and reusable instruments from 1972 to 1990. Equipment costs per case were $0.75. His next 1084 cases of laparoscopic cholecystectomies had a total cost per patient of $20 [9]. There is an abundance of literature reporting adaptations that can decrease costs and surmount other barriers to allow for more widespread utilization of laparoscopy in LMICs [7, 11].

However, some suggest that laparoscopic surgery may not be appropriate for developing countries, arguing that it is expensive, requires specialized training and technical support, and distracts attention from urgent basic needs [12]. Traditional open surgery is often considered to be safer, and in limited-resource settings, mortality can be a greater priority than both decreased morbidity and improved cosmesis.

There are no validated models that can determine the safety and feasibility of laparoscopic surgery in resource-limited settings. The purpose of this paper is to aggregate the literature, including feasibility, risks and benefits, and required adjustments. Additionally, we suggest recommendations to ensure patient safety and sustainability.

Materials and methods

This study follows the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [13]. A database inquiry was initiated in Medline, LILACS/BIREME/SCIELO, DOAJ, and African Index Medicus for studies analyzing safety, cost, and outcome aspects of minimal invasive surgery in LMICs after 1992. Studies in English were included, but not studies pertaining to arthroscopy, ENT, flexible endoscopy, hysteroscopy, cystoscopy, computer-assisted surgery, children under 18, organ transplantation, stem cell transplantation, or bariatric surgery. Complete search terms were as follows: (“Laparoscopy” or “Thoracoscopy” or “Minimally invasive surgery or surgical procedures”) + (LMIC code) + (“Safety” or “Costs and cost analysis” or “Treatment outcome” or “Mortality” or “Length of stay”) − (“Endoscopy” or “Flexible endoscopy” or “Colonoscopy” or “Hysteroscopy” or “Cystoscopy” or “Computer assisted surgery” or “Eye*” or “Ocular*” or “Ophtal*” or “Nose” or “Nasal” or “Throat” or “Child*” or “Infan*” or “Adolesc*” or “Teen*” or “Pediatr*” or “Paediatr*” or “Transplant*” or “Bariatric*”).

Additional articles were discovered by manually reviewing references from pertinent studies. Studies not focusing on minimal invasive surgery, studies conducted in developed countries, case reports, and editorials were excluded, as were studies for which online full-text was not available through the authors’ institutions. Studies reporting advanced laparoscopic techniques were also excluded, as they likely represented well-established laparoscopy programs with abundant resources.

Results

The process of identification, abstract screening, full-text eligibility assessment, and inclusion is presented in Fig. 1. Fifty-eight articles were found describing laparoscopic surgery experiences in 25 different LMICs (Table 1).

Fig. 1
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Study selection

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Table 1 Included articles
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A number of studies highlighted advantages of laparoscopy, delineated in Table 2. These benefits could be broadly classified as clinical, economic, or systemic. Many advantages paralleled those found in developed countries, while others were specific to limited-resource settings. For instance, in settings where there is no clean water in the patient’s home, open incisions carry significantly higher risk of infection [5]. Because infectious diseases can cause diverse symptoms that can be challenging to diagnose with basic laboratory and radiology facilities, laparoscopy is ideal for the diagnosis of peritoneal tuberculosis [7, 14–16], the treatment of biliary ascariasis [17], and many gynecologic conditions [18–20].

Table 2 Advantages of laparoscopy
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In terms of economic benefits, many studies found laparoscopy to be cost-effective [10, 21–23], and one author noted that investing in laparoscopy equipment is much cheaper than investing in CT or MRI technology [7]. Others point out that early return to work can be important in LMICs since families likely depend on day-to-day earnings and have little savings [5, 24, 25]. Similarly, the value of decreased bed utilization may be more important in LMICs since unmet surgical need is greater and inpatient capacity is smaller [26].

There were a number of challenges identified facing the development of laparoscopic surgery, shown in Table 3. Two authors cited the lack of safe clinical guidelines as a challenge particularly relevant in LMICs [26, 27]. The most common challenge named was related to the cost of laparoscopy. Some argued that high purchase costs impose the need for laparoscopic equipment to be donated [10, 28], and others posited that in the setting of widespread unemployment and low wages, early discharge was not as beneficial as others had concluded [10, 29, 30]. In countries that had health insurance, beneficiaries were likely to be provided with coverage for open operations, but not laparoscopy, resulting in high out-of-pocket costs [21]. Systemic challenges included the limited availability of trained staff [23, 31, 32] and training opportunities [15, 19, 21, 27, 28, 30, 32–36], as well as a dearth of resources to maintain equipment [19, 37] and handle challenging complications [15].

Table 3 Challenges facing laparoscopy
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A number of adaptive measures have been undertaken to work around limitations in developing countries, as shown in Table 4. Equipment and technique alternatives include mechanical insufflation with room air [38, 39], syringe suction, homemade endoloops [9], hand-assisted techniques, extracorporeal knot tying [40], innovative uses of cheaper instruments [9, 11], and the reuse of disposable trocars and graspers [9, 12, 37, 40–43]. Spinal and local anesthesia may be safe and possibly advantageous alternatives to resource-intensive general anesthesia [9, 44–47]. Training systems using lectures, workshops, laboratory-based trainers, animal models, and telemedicine are integral in teaching skills outside of the operating room [22, 48–52].

Table 4 Adaptive strategies
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Discussion

There are many benefits to laparoscopy that have been realized in developed countries for several decades [3, 4]. However, while laparoscopy has not yet become widely available across LMICs, it offers a number of advantages for these settings in particular. While laparoscopy is often criticized as being an expensive surgical technology, it may be highly cost-effective considering its diagnostic applications. It has been estimated that ultrasound equipment costs 500 times as much as laparoscopy equipment, while CT imaging costs 2500 times more and MRI costs 4500 times more [7]. As cars and motorcycles become more prevalent in developing countries, trauma is rising concomitantly. Diagnostic laparoscopy could reduce unnecessary laparotomies [25, 53]. Laparoscopy is also highly useful as a diagnostic tool when there is suspicion for extra-pulmonary tuberculosis and other infectious diseases [7].

In resource-poor settings, reduced postoperative hospitalization may be far more important than in high-income countries. Inpatient beds are often in limited supply since they may be required for pre-operative patients who are often pre-admitted because they must travel great distances to reach surgical care [26], patients who are unable to pay the bill, or postoperative patients that have no other suitable place to recover. Furthermore, families often have only one wage-earner, and a loss of income during a lengthy hospitalization can be devastating to the entire family [24, 25]. For laborers and merchants, there is no such concept as sick leave—i.e., no work means no pay—and they often live hand-to-mouth with little in the way of savings or investments. Additionally, in patriarchal societies, there may not be another family member who can work in place of the sick individual [5]. Many hospitals require family members to assist with nursing care, which adds to family hardship by disrupting both childcare and earning potential. However, shortened hospitalization can be risky if homes are not equipped with basic necessities such as clean water. Laparoscopic surgery is attractive because it can decrease hospitalization without the additional infection risk borne by a larger incision [5].

Anesthesia-related mortality is often higher in LMICs than high-income countries. One study reported a general anesthesia mortality rate of 1 in 504 at a central hospital in Malawi, and another reported 1 in 133 deaths at a teaching hospital in Togo [54, 55]. Laparoscopy can be performed with spinal or local anesthesia instead of general by using gasless abdominal tenting, balloon laparoscopy, or creating a pneumoperitoneum with room air; all of these techniques were described in the included studies.

Certainly, there are major clinical, economic, and infrastructure-related limitations to utilizing laparoscopy in LMICs. Hospitals must overcome these infrastructure limitations and resource-allocation issues, and deal with safety and ethical concerns as well, if they hope to begin laparoscopic surgical care. In the absence of guidelines for resource-poor settings, safety is of utmost concern [26]. Staff training requires a significant investment of time and money, and there is often limited availability of individuals to serve as trainers [31–33].

While some studies have cited the cost-effectiveness of laparoscopy, others argue the opposite. It has been claimed by some that the lower costs of inpatient care [29] and surgery [26] in developing countries mean that prioritizing early discharge does not yield significant cost-savings. Others have argued that the costs of providing day surgeries in developing countries are higher than in developed settings [56]. High-cost equipment is often not available and hospitals may require donations [10, 31, 32], which may not include all the necessary components. Furthermore, it can be difficult to quickly secure repairs and replacements for high-price donated items. In the absence of a robust insurance system, these additional costs may be prohibitive to patients [5, 12]. The assertion that early discharge is an important priority for patients has also been contended. Studies conducted in Senegal have concluded that low salaries diminish the importance of an early return to work [10, 29].

There are sociocultural barriers to advancing laparoscopy in LMICs as well. People often mistrust the new technology [33] and may not perceive the benefits [56]. Lack of education, poor health literacy, and the presence of nonscientific beliefs are all contributing factors [26, 56]. As is the case with any surgery, barriers to follow-up care are abundant. Patients often have poor access to health facilities due to poverty, poor transportation infrastructure, and large distances in rural settings [26, 47, 56]. In the case of complications and emergencies, patients may not have access to any mode of communication with a health professional, much less an ability to reach a hospital [26, 56]. Furthermore, local providers who are unfamiliar with laparoscopy may not be able to appropriately assess and address complications.

A number of promising strategies have been described to overcome these barriers. When infrastructure, equipment, and training supplies remain cost-prohibitive, tactics such as using a cystoscope as a laparoscope, foregoing insufflation, or using sunlight instead of a fiberoptic light source have been described, although the safety of these techniques has not been robustly studied. A number of alternative low-cost solutions can be made as replacement for endopouches for appendectomies or cholecystectomies, and a number of instruments can be reused.

Limitations

The techniques and modifications described here are only the tip of the iceberg. Surgeons in LMICs face significant barriers to publication in general, and to publishing reports about technical adaptations, in particular. Though we utilized African Index Medicus and LILACS-BIREME to maximize the probability of including LMIC publications, there are likely many journals that were not identified—especially those published in languages other than English. Furthermore, there may be a publication bias toward advancing laparoscopy in LMICs rather than challenging its utility. Nonetheless, we did identify several articles that presented significant obstacles, and in fact, contradicted advantages reported elsewhere. These contradictions represent differences in the costing methodology, as well as the economic circumstances of individual hospitals and countries. The LMIC category encompasses a wide range of economies with a wide spectrum of resource availability and infrastructure, even within a given country.

Recommendations

Laparoscopy should be considered an important component of surgical care that can be developed in low-resource settings.

  1. 1.

    Long-term planning for sustainability

    • Involvement of all stakeholders, including patients, local surgeons, anesthetists, and nurses, Ministries of Health, donors, academic institutions, and industry is needed to assess pertinent risks and benefits within a given socioeconomic context.

    • Collaborative research should help identify and propagate solutions to common challenges.

    • Regional equipment production and maintenance facilities must be established to ensure cost-effectiveness. Collaborations between industry, donors, and governments can facilitate the generation of local employment opportunities.

  2. 2.

    Training and retention of providers

    • Basic laparoscopic training should be incorporated in major teaching hospitals. Promoting training in advanced procedures may help to retain health care providers or and attract others who have left.

    • Training should also be offered to operative nurses, anesthesia providers, and biomedical professionals as well as surgeons.

    • Training programs can include surgical simulation using low cost, locally made trainers, internet-based surgical videos, exchange programs, telemedicine, and intraoperative practice.

  3. 3.

    Regulation

    • Perioperative outcome data are needed to develop quality and safety measures.

    • Ministries of Health and donors can collaborate to develop national programs to monitor and improve surgical quality.

    • Existing surgical societies (e.g., COSECSA, WACS, PAACS) can provide mentorship and advice regarding guidelines and essential equipment and instrumentation.

Summary and future directions

Developing countries face challenges that require greater efforts in innovation. Laparoscopic surgery may be safe, effective, feasible, and cost-effective in LMICs, although it often remains limited in its accessibility, acceptability, and quality. Surgeons, policy makers, and manufacturers must work together to overcome limitations and optimize implementation where appropriate.