Presentation - University of Utah - School of Medicine

Revolutionizing Global Surgery
Raymond R. Price MD, FACS
Intermountain Surgical Specialists, Intermountain Healthcare
Associate Director, Center for Global Surgery, University of Utah

Emergency and Essential Surgery: Integral
Component of Primary Care

Highest Priority Interventions
• Large public health burden
• Treatment is highly successful
• Treatment is cost-effective
Hernia
SAGES.org
Cataract
Mock CN, et al, World J Surg 2010;34:381-385.
http://www.cureblindness.org/

Financial Feasibility
Dirk Noyes, MD
CBA = SFTP
Cost Benefit Analysis
=
No Surgery for the Poor
Dr. Paul Farmer

Distribution of the Burden of
• 10% of the world’s
population receives
90% of its surgical
resources.
Can J Surg. Vol. 48 No. 6 December 2005
Surgical Disease
12000
10000
8000
6000
4000
2000
0
234.2 million surgical
procedures worldwide
>1000
401-1000
101-400
100
Surgical
Procedures/
100,000
$ (US) / person/
healthcare/year
Weiser TG, et al, Lancet, July 2008

Revolutions in the Delivery of Surgical Care
• Aseptic technique
• Anesthesia
• Endoscopic and
laparoscopic surgery
3 Patient Friendly Innovations
Udwadia, T.E., Navigating laparoscopic surgery into the next decade in developing countries
- a personal perspective. Langenbecks Arch Surg, 2007. 392(1): p. 99-104.

Treatment of Gallbladder Disease
Developed Countries
Low/Middle Income
Countries
Gold Standard
Laparoscopic Cholecystectomy Open Cholecystectomy
The benefits of laparoscopic surgery elude much of the
developing world

Contini, Taqdeer, Gosselin (2010)
• We have serious doubts that many Afghan
people may really benefit from the
advantages of laparoscopic surgery…
– Earlier discharge
– Quicker recovery and return to work
– Less post-operative pain
– Less scarring……
Should laparoscopic cholecystectomy be practiced in the developing world? The
experience from the first training program in Afghanistan

Global Surgery and Public Health: a New Paradigm
Catherine deVries, Raymond Price

Laparoscopy as a Technological Enabler
for Improved Healthcare
Erdenet Khovd
Arvikheer

Mongolia
• The most sparsely populated
country in the world
• 49% of the population reside
in rural areas and live a
nomadic lifestyle
• The vast rural areas are
isolated and present serious
challenges to providing access
to health care

“Buck” Rusher Ganbold
Otgondaiai
Laparoscopy in Mongolia
Introduced in 1994
Nyamkhuu
• By 2005
– Only 2% of
gallbladder surgeries
were performed
laparoscopically
– Only in the capital city,
Ulaanbaatar

Morbidity: Inpatient
Diseases of the Digestive System (2 nd most common cause)
% of Total/
10,000
population
Health Indicators, 2006, Ministry of Health, Mongolia, p 34.

Multidisciplinary Education Team
– Two surgeons
– One anesthesiologist
– One operating room
nurse
– One operating room
scrub technician
– One biotechnician
– One surgical resident

Four-step Hospital Referral System
Primary Medical Care
Soum Hospitals
Primary and Secondary Medical Care
Inter-Soum Hospitals
Secondary Medical Care
Aimag Hospitals
Regional Diagnosis and Treatment Center
Tertiary Medical Care Hospitals
Maternity and Infants, Cancer, Traumatology and
Orthopedics, Cardiac Surgery, Neurosurgery, Colorectal,
Mongolia
Urology
Surgery in Mongolia, Gunsentsoodol B, Nachin B, Dashzeveg T, Arch Surg, v 141, Dec 2006

A network of facilities that have increasing resources and
capabilities provide a continuum of care that utilizes limited
resources that can be accessed by the entire community.

Improves Community Trust
Mongolia
Number
of Cases
5000
4000
3000
2000
1000
0
2000
2002
2004
2006
2008
Year
Total
Cholecys
tectomy
Laparosc
opic
Cholecys
tectomy

Developing Surgery Improves Capabilities
and Support for General Medical Care
Dr. Ganbat
Infrastructure
Lighting
Radiology
Bloodbank

Cholecystectomy Choibalsan, Mongolia 2005-2011
160
140
120
100
80
60
40
20
0
2005 2006 2007 2008 2009 2010 2011
Total
Laparoscopic
Open

Laparoscopic Colectomy
176 laparoscopic colectomies;
- 35 R colon
- 39 L colon
- 37 Sigmoid
- 44 LAR
- 12 Total colon
- 10 Hartman/colostomy
- 2 other
“…cost is one of the difficulties for us. But if somebody
will not use advanced technology in our countries, the
patients have to go to another country. Then the cost
will be much higher.” Byadran Lkhagvabayar MD

Laparoscopic Adrenalectomy?
“It is not only the
level of income of a
society that gives
quality to the lives of
its inhabitants,
rather it is people’s
capabilities to lead
the lives they value
that matters.”
Economist Amartya Sen, UNDP 1996, 49

Tanzania :
P. L. Kibatala MD
(Ministry of Health/
Surgeon),
Mchembe MD,
(Chief of Surgery,
Muhimbili National
Referral Hospital)

Nigeria
LASUTH
Hospital
2011

Patras, Greece
Laparoscopic vs Open Cholecystectomy 1992-2005
Vagenas, K., Karamanakos, S. N., Spyropoulos, C., Panagiotopoulos, S., Karanikolas, M., & Stavropoulos, M. (2006).
Laparoscopic cholecystectomy: a report from a single center. World J Gastroenterol, 12(24), 3887-3890.

“Warm Welcome American SAGES Experts
to Give Laparoscopic Training in our
Hospital”

Oyunbayer

Ubiquitous
Information Access
Increased participation of the global
community in understanding new
possibilities for improving their
access to quality surgical care

Laparoscopic surgery for gallbladder and
gynecologic disease is
likely to enter the realm of essential surgical
services as the developing
world innovatively develops cost-effective
delivery methods.
Mobile Laparoscopic Telepack
Reusable Instruments

Equity Revolution
“As we now live in a global society, it would be
unconscionable for Nigerians to be denied the
medical advantages of new technology.”
- Dr Leslie Akporiye, Medical Director of Shawsand Medical Center

Advantages of Laparoscopy in the
Global Surgical Ecosystem
• Enabling procedure
– Surgeon and community self
respect
– Maintain expertise incountry
(decrease disparity
in human resource
allocation)
– Source for improved
economy, poverty reduction
– Promotes overall health care
improvements
– Impetus for technological
advances

Swanson Family Foundation Medical Mission Mongolia
May 2008