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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_857_Библиотеки_им_академика_М_И_Перельмана
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H. M. Spotnitz and M. E. Spotnitz
require more hardware and expertise for implementation, maintenance, programming, and use
[1, 2]. RDBMSs are well suited for synthesis of
the surgical data across domains of the electronic
health record. RDBMS designs allow tracking
surgical patients across different services in a
healthcare system. This allows investigators to
study non-operative management, resource utilization, and long-term outcomes. Furthermore,
RDBMSs are better suited for high-volume
access, which allows for clinicians from different
specialties to access data concurrently. In summary, the decision for whether to implement a
at le or RDBMS depends on the size and complexity of the data as well as the number of users.
For simple data that are used by a small number
of users in resource-constrained settings, at les
are likely best. Alternatively, RDBMSs are best
for large, complicated data sets that are used by a
large number of users.
Data Entry
Creation of a database requires a computer and a
programmer who can enter data and modify the
database as needs develop. The simplest way to
start a surgical database is to purchase an inexpensive computer and software. These purchases
should be directed by the programmer who will
operate the system. These steps will be directed
by an overall strategic plan.
The primary purpose of a new database is to
maintain records of surgical procedures. These
records are necessary to provide follow-up care
for patients who return to the primary care center
at infrequent intervals.
The following are critical patient data
MRN This is a numerical index that is unique
to each patient and is used to track critical data.
Names (demographics) are critical for patient
identication and should not be duplicated
First Name
Last Name
Date of Birth
Sex
Once demographics are entered, they should
remain unique to the patient and should not be
changed.
In contrast, data specic to a surgical proce-
dure are highly variable and specic:
Date of Surgery (DOS)
Date of Admission for Surgery (DOA)
Date of Discharge (DODC)
Name of Operations performed: Op1,2,3…..
Surgical Complications: Comp1,2,3…
Surgical Diagnosis:Dx1,Dx2, Dx3
Surgical Team:
Surgeon
Assistants
Anesthesiologists
Surgical procedures can be uniquely identied
by a CONCATENATED INDEX consisting of
the MRN and DOS strung together as in
“MRN*DOS.”
Getting Started
A relatively simple approach to surgical data uses
a at le with the following entry form:
First Name
Last Name
SEX
DOA
DODC
These data would be entered into the computer system at the time of admission and would
be updated daily.
Indexes andMultiuser
Congurations
Multi-user databases provide the ultimate exibility and are based on multiple independent
tables of data linked by indexes. HELIX and SQL
are marketed examples.
Summary
Database structures are essential for surgical follow- up and quality improvement. In the simplest
form, these consist of punch cards, but current
developments are based heavily on multiuser
15 How ToSelect aDatabase Software forSurgical Data inLow- andMiddle-Income Countries
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151
databases and indexing. For a new surgical unit,
at les offer effective, simple data management
and effective patient follow-up.
References
1. Scheider MAE, Siebels J, Schmitt C.Data base management in interventional electrophysiology—the relational advantage. J Intervent Cardiac Electrophysiol.
1998;2:333–41.
2. Stein L. Creating databases for biological information: an introduction. Curr Protoc Bioinform.
2013;42:9.1.1–9.1.10.
Websites
https://www.techwalla.com/articles/difference- flat- file-
relational- database, https://otiskopp.com/at- lesvs- relational- databases/, http://carltonmatthews.com/
at- le- vs- rdbms/
Part II
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Education and Training
How toEstablish Surgical
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Teaching, Guidance,
andSimulation Practices inLowandMiddle-Income Countries
ShamirO.Cawich, PaulShridathRamphal,
MarlonMencia, ChrisDodgion, andAlazarBehre
A mentor must expect their mentees to supersede their own performance in order to
consider themselves successful.
– V.Naraynsingh
16
Abbreviations
AHPBA Americas Hepato-Pancreato-
Biliary Association
ARRIVE Animal Research Reporting In Vivo
Experiment
CaSES Caribbean Society of Endoscopic
Surgeons
CCOS Caribbean College of Surgeons
GPD Gross domestic product
HICs High-income countries
ICU Intensive care unit
LMICs Low- and middle-income countries
MDT Multidisciplinary team
MIS Minimally invasive surgery
S. O. Cawich (*) · M. Mencia
University of the West Indies,
St Augustine Campus, Trinidad and Tobago
P. S. Ramphal
University of the West Indies, Princess Margaret
Hospital, Nassau, Bahamas
C. Dodgion
Surgery Medical College of Wisconsin,
Milwaukee, WI, USA
e-mail: cdodgion@mcw.edu
A. Behre
College of Medicine and Health Sciences, Hawassa
University, Awasa, Ethiopia
MISTELS McGill Inanimate System for
NASKHO Netherlands-Caribbean Foundation
SAGES Society of American
Background
There are many low- and middle-income countries (LMICs) scattered across the globe, each
with different healthcare systems and their individual challenges. This may range from landlocked nations on the African continent with
large land masses and scattered populations that
may be difcult to access to the small island
nations of the Caribbean geographically separated by the Caribbean Sea. Most are independent nations with their own languages, customs,
governments, healthcare systems, infrastructure,
and medical customs. Some of these nations are
small states, with populations as low as 5000 persons [1]. These characteristics present several
challenges to both surgical practice and to
surgical education, which make them quite dif-
Training and Evaluation of
Laparoscopy
for Clinical Higher Education
Gastrointestinal and Endoscopic
Surgeons
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_16
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S. O. Cawich et al.
ferent from that in developed, high-income countries (HICs).
Specic Challenges
The practice of surgery and therefore its teaching
in LMICs may be affected in the areas discussed
below.
1. Lack of Subspecialty Services
Nations with small populations cannot attract
subspecialty trained surgeons as the workload is
often too small. In these circumstances, most
operations that would normally be performed by
subspecialty surgical teams are now performed
by general surgeons at low volumes. Additionally,
in many countries of the world, there are limited
educational opportunities for surgical specialization, and therefore supply of subspecialty care is
inadequate. This means that general surgery
teams will perform a wide cadre of procedures,
but each at low volumes.
An immediate concern arises: Several authors
in the latter part of the twenty-rst century demonstrated signicantly reduced morbidity and
mortality when complex operations were performed in high-volume hospitals and by highvolume surgeons [2]. However, this would not be
possible in small nations, such as the Caribbean
Islands. Even in the more populous islands of the
Anglophone Caribbean, there were no hospitals
that qualied as high-volume facilities in the year
2021 [3].
This creates the situation where patients who
require complex operations have no choice but to
consent to surgery in the LMICs or to travel to
high-volume hospitals in developed nations. The
high-volume centers are often located in HICs,
and only a fraction of persons can afford healthcare in these centers. Even in 2014, Naraynsingh
etal. [1] documented that only 4 of 19 Caribbean
countries had the services of a urologist and in
2022 only 5 of 19 Caribbean countries had access
to hepatobiliary surgeons. Even when a specialist
center exists within the Anglophone Caribbean,
transporting patients between the nearby islands
proves impractical as there is no provision for
cost-sharing between the countries. Many other
cases such as replant surgery, vascularized free
tissue transfer, myocutaneous aps, and neonatal
surgery are performed by the general surgeons.
2. Limited Opportunity for Multidisciplinary
Cooperation
A multidisciplinary team (MDT) approach to
therapeutics has become standard of care in modern healthcare delivery systems [4–6]. There are
numerous advantages associated with the structured forum to exchange information and ideas,
including improved working relationships, expedited investigations, adherence to evidence-based
treatment, and ultimately improved clinical outcomes [7]. Unfortunately, the MDT approach to
disease management is not routinely practiced in
LMICs [4, 5]. Again, this may be partly due to
the small population size and small cadre of specialists and subspecialists. In healthcare systems
like these, it has become commonplace for a
small cadre of doctors to assume responsibility
for healthcare for the entire nation. Subspecialty
support is often unavailable, and general surgeons must be versatile, often performing operations that range from gynecology, obstetrics,
orthopedics, and neurosurgery, all in the same
week. These doctors often have no choice because
they may work in remote and isolated areas [5].
The phrase sole practitioner culture was coined
to describe this situation where medical decisions
are made autonomously by attending doctors in
an autocratic manner, with very little collaborative input and without routine application of
MDT principles [4, 5].
3. Limited Equipment (Hardware)
LMICs often have underfunded healthcare systems and provide only basic levels of healthcare
to the population. Policy makers prioritize their
spending, and often, only a small fraction of
their gross domestic product (GDP) is directed
for healthcare. Therefore, surgeons in these
nations are challenged to provide innovative
effective high-quality care in a setting where
resources are limited. This may occasionally be
difcult without regular access to basic drugs
(antibiotics, anesthetic agents, analgesics, etc.)
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or materials such as vascular grafts or laparoscopic equipment.
Specialized surgical equipment is often
unavailable. A simple example is the practice of
minimally invasive surgery (MIS) that has been
well accepted across the globe. The advantages
of early mobilization, minimal scarring,
decreased pain, and early return to work are well
documented for a variety of operations. In the
English-speaking Caribbean, only few countries
are able to offer regular MIS services because
many do not have the requisite expertise and/or
equipment. For example, Naraynsingh etal. [1]
documented that as recently as 2014, laparoscopic stacks were only available in public hospi-
Fig. 16.1 Single-use laparoscopic consumables have
been sterilized and re-packaged for continued use in lowincome nations
tals in 25% of countries in the Caribbean.
Therefore, surgeons are simply unable to offer
laparoscopic operations, even if the expertise
exists. In addition to hardware acquisition, the
additional nancial burden of equipment maintenance and the high cost of disposable instruments
and consumables limit laparoscopic surgery seriously in LMICs [1].
rates in our practice. In addition, many of LMICs
also deal with the concomitant problem of interpersonal violence. The high burden of trauma
patients often consume what little blood products
are available.
It is not uncommon that surgeons have to pro-
ceed with complex operations, such as major
4. Operative Consumables
As the move away from open surgery to laparoscopic and robotic surgery continues, more consumables are being utilized, such as stapling
devices or ultrasonic dissectors. Frequently, the
cost of these consumables is beyond the limited
budgets of hospitals in LMICs, and consequently,
liver resections, pancreatico-duodenectomy, or
abdominal aortic aneurysm that usually would
require standby products, with only one unit of
packed cells available. Most surgeons will agree
that such a situation is less than desirable and
may be outright dangerous, unless a cell saver is
available and is usable.
surgeons would use sutures instead of staples or
cautery dissection instead of ultrasonic dissectors. West Indian surgeons have navigated around
this issue by sterilizing and re-purposing singleuse instruments (Fig.16.1).
6. Intensive Care Unit Support
Intensive care is costly to deliver and to outt.
Therefore, many LMICs may not be able to
afford the recommended number of intensive
care unit (ICU) beds per capita population. Often,
5. Blood Products
The stark reality is that in low-resource settings,
there is a relative lack of blood products. This
limits the type of care that can be delivered. For
example, complex procedures such as major liver
resections or aneurysm repairs that may require
large volumes of blood products often cannot be
even when nations may have physical ICU bed
space, the requisite consumables, stafng, and
pharmacologic support are not readily available,
effectively rendering the ICU unavailable. This
again limits the support trauma patients can
receive and limits the number of major cases that
can be done safely.
done. Surgeons in the LMICs of the Caribbean
have partially compensated for this by increasing
the use of tranexamic acid in surgery as it is relatively inexpensive and has reduced transfusion
7. Private Healthcare
The limitations outlined above in LMICs have
increased patient demand for improved standards
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of care. Many private facilities have been created
to ll this demand using the fee-for-service model
of healthcare delivery. Although this offers some
societal benets as it increases the cadre of services available in the nation, it also creates disparity and inequity in healthcare.
Solutions toSpecic Challenges
It is clear that there are many challenges to provision of surgical care and surgical teaching in
LMICs. These are the realities, and it is obvious
that many of these scenarios are imperfect. Many
LMICs have devised innovative solutions discussed below to overcome these challenges.
(1) Surgical Education
Surgical education in LMICs differs signicantly
from that in HICs. While it is benecial for surgeons practicing in resource-poor nations to be
exposed to surgical care in high-volume hospitals
located in developed countries, many of the practices cannot be readily transposed to their home
countries. In the Caribbean, we recognized this
difference and responded by forming professional bodies, which include 250 general surgeons practicing in the Caribbean nations. There
are also subspecialty professional associations
dedicated to the practice of liver and pancreatic
surgery, The Caribbean Chapter of the Americas
Hepatopancreatobiliary Association (AHPBA), a
professional association dedicated to MIS, and
the Caribbean Society of Endoscopic Surgeons
(CaSES). The important aspect of these professional associations is their mandate to foster continued professional development specic to
healthcare systems in LMICs. All societies host
regular educational activities to develop regional
surgical practice. A specic example relates to
the practice of liver and pancreatic surgery in the
Caribbean where in 2022, there were only seven
subspecialty trained hepatopancreatobiliary surgeons. There are few opportunities for properly
organized multidisciplinary care meetings as
these surgeons are scattered across the region.
However, through the Caribbean Chapter
AHPBA, regional MDT meetings are held, and a
trans-Caribbean support service using social
media is maintained for real-time second opin-
ions and technical support. The Caribbean
Chapter AHPBA also hosts biannual educational
events for tailored surgical education. These sur-
geons are all operating in similar conditions and
are poised to give relevant support/advice to their
colleagues.
(2) Multidisciplinary Cooperation
The benets of a MDT approach to disease man-
agement have already been discussed. It is not
routinely practiced in all LMICs because of the
previously described sole practitioner culture
[4]. With the well-documented benets of this
approach, inclusive of its educational value, it is
important to introduce and establish MDT prin-
ciples in LMICs with concern of the potential for
opposition to change [4, 5].
We recommend that this should be done in a
phased approach: Firstly, common interest
clinician- led groups should be established. They
can then provide a strong, unied voice to lobby
for change. This would be more effective than the
lobbying of only one or two isolated individuals.
As a second phase, all stakeholders should be
approached and given a chance to participate in
the process as to eliminate any individuals who
may be overlooked and who had the potential to
erect barriers [6]—this includes established clinicians. Institutional recognition is also important
to facilitate technical support and dedicated staffing. In a facility at the Port of Spain General
Hospital in Trinidad and Tobago, MDT principles
were implemented as a self-driven venture, with
interested individuals taking up roles for governance, documentation, audiovisual service, and
meeting coordination. The established clinicians
and institutional support followed, although they
were not excluded in the early stages.
Many nations will have budgetary limitations,
but these can be overcome by use of free software
such as WhatsApp® (WhatsApp Inc., California,
USA) and Google Mail® (Google Inc., Mountain
View, CA 94043, USA) to disseminate information, Dropbox® (Dropbox Inc., San Francisco,
California) to share clinical material/les, and
OsiriX® DICOM imaging software (Pixmeo,
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Geneva, Switzerland) to view radiologic images
[7]. In the initial stages of our MDT, personal
property was used such as personal computers,
software, and audiovisual equipment [4]. The
development of public–private partnerships is
encouraged as there are many interested foundations and businesses as well as individuals who
are willing to support healthcare development, by
contributing nancially and by providing their
expertise [4].
Critical to success of MDT is for all core
members to meet in advance and agree to protocols and to governance. For example, all participants agreed to document the information
exchanged and to abide by any collective decisions made by the MDT.This reduced the potential for interpersonal conicts during meetings
[4]. It is important to maintain regular audits of
outcomes of practices since this is the only way
to demonstrate meaningful benet of MDT to the
healthcare system. Following introduction of
MDT practice at a facility, there was a signicant
increase in participation and a major change in
treatment plans in 48% of cases after a MDT discussion [4]. The other benets included regular
interactions between various disciplines, which
led to a better understanding of the challenges
each member faced in a system with limited
resources [7] and allowed to effectively streamline patient pathways.
(3) Surgical Teaching Events
Healthcare systems in LMICs may not be able
to care effectively for complex cases for a variety of reasons. Routine transfer of such patients
to high- volume facilities is not only expensive
and difcult to execute but also important in
that the local surgeons are denied the opportunity to manage challenging cases, leaving them
exposed only to minor cases. To overcome this,
regular surgical teaching events have been held
across the Caribbean region. Surgical workshops are planned, and regional experts are
invited to the target country as speakers and as
surgical proctors. The advantage of this exercise is that a large audience can be reached in
target hospitals. The entire cadre of healthcare
workers, including operating room nurses, sur-
gical scrub technicians, surgeons, and support
staff, are exposed to surgical teaching at the
same time. This also improves the standard of
care for the nation, which hosts the workshop
[8]. Because regional experts are chosen as
proctors/tutors, they are able to teach tailored
surgical techniques, tips, and tricks that are relevant to LMIC healthcare systems since they
also work in similar resource- poor environments [8].
The disadvantage is that this is a costly exercise. The limitation of high cost of this exercise
can be overcome by developing public–private
partnerships. As an example, there are two main
suppliers of surgical consumables in the
Caribbean, and under the public–private partnership arrangements, these suppliers fund the
regional workshops. The benet to these companies is that surgeons learn to use their consumables/equipment, and they are more likely to
generate additional sales. We have found that the
suppliers in the Caribbean have been supportive
of this initiative [9, 10]. Surgeons, however, must
be cognizant that close relationships with industry may create conicts of interest.
(4) Simulation Practices
Although surgery was traditionally taught using
the apprenticeship model, there has been a shift
toward surgical education by simulation. Here,
surgical trainees are interactively immersed into
environments that replicate real-world scenarios
[11]. Although surgical education via simulation
is still emerging, this concept has been well
accepted in other industries such as the aviation
industry [12]. Simulated surgical education
brings several advantages:
1. Patients are not exposed to the potential harm
when residents learn procedures in the operating room.
2. Trainee surgeons acquire technical skills in a
simulated environment so that they have
amassed signicant experience by the time
they are called upon to operate on patients
[10].
3. Simulators are always available for use and so
provide extended practice opportunities that
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are signicantly more exible than the operating room/clinical patient exposure [11].
4. There are reductions in operating time and
associated costs when resident teaching is
removed from the operating room.
Simulation can also be used to teach nontechnical skills, such as communication, crisis
management, teamwork, and professionalism,
but this chapter focuses predominantly on teaching technical skills. Surgical skill sets can be
taught through several simulation types, including benchtop models, cadaver models, live animal models, virtual reality simulators,
laparoscopic simulators, and robotic simulators.
Benchtop Simulators for Open Surgery
Benchtop models use inanimate/synthetic
material to teach and/or assess technical skills.
These benchtop models may range from simple,
crude models (Fig. 16.2) to interactive models
(Fig.16.3).
At the University of the West Indies, animal
part models have been used, such as pig intestines to teach residents to perform bowel anastomoses (Fig.16.4), pig aorta to teach creation of
vascular anastomoses (Fig.16.5), pig trotters to
teach tendon repair (Fig. 16.6), and chicken
breast to teach microwave ablation, use of energy
devices, and staple ring (Fig.16.7). There have
also been reports of obstetric sphincter injury
repair using pig tongue [13], endometrial resection, and ablation on pumpkin models [14]. Many
other simple and inexpensive examples of benchtop models have been described.
Benchtop models are attractive for LMICs
because they are inexpensive, safe, and made of
locally available materials, require little maintenance, and provide unlimited opportunities for
task repetition. They are probably the most likely
modalities used in LMICs. Benchtop models allow
residents to focus on other learning tasks when
Fig. 16.2 Crude benchtop model used to teach suture
closure of wounds
Fig. 16.3 A benchtop
model to simulate fascial
closure. A balloon is
inated within a box,
and the trainee sutures
overlying tissue to
mimic the task of fascial
closure without injuring
underlying bowel
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Fig. 16.4 Porcine intestine used to create a bowel anastomosis. The bowel was then injected with saline under
pressure to assess for leakage/spillage
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Fig. 16.5 A section of porcine aorta is used to teach principles of vascular anastomoses by creating a vein patch
Fig. 16.6 Piglet trotters with tendon repair using a
Kessler stitch
they go to the operating room [15] and result in
demonstrable improvement in metrics for task performance [16, 17] and transfer of competency to
the real operating room environment [16, 18].
Fig. 16.7 Chicken breast used to practice operating
energy devices and staple ring
There are also commercially developed inanimate models to teach skill sets such as cardiopulmonary resuscitation, endotracheal intubation,
and/or thoracostomy placement on a mannequin.
These are costly and are not always practical in
LMICs. A potential advantage from partnerships
for surgical education is that some equipment,
such as mannequins or laparoscopic simulators,
may be donated to the host institution.
Unfortunately, they also come with the cost of
maintenance and repair.
Full-task simulators are also available as
benchtop models. For example, Lauscher etal.
[15] designed the Berlin Operation Trainer
where the surgeon stands in a simulated operating eld in order to practice open GI anastomotic techniques. In Jamaica, animal
tissue-based surgical simulation training models were being explored and utilized. The culmination of these efforts was the development
of the world’s rst computer- controlled tissuebased simulator for teaching various aspects of
cardiac surgery [19].
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