Katie M Wells, MD, Raymond R Price, MD, Orgoi Sergelen, MD, Byadran Lkhagvabayar, MD, Tsiiregzen Enkh-Amgalan, MD, Matthew D Price, Michael R Marohn, DO. Dept of Surg Health Sciences Univ of Mongolia; Nat’l Cancer Ctr of Mongolia; Songdo Hospital; Dept of Surg Ctr for Global Surg, Univ of Utah; Dept of Surg Intermountain Med Ctr; Dept of Surg, Johns Hopkins Medical Univ..
Introduction: Laparoscopy has been perceived to be too costly for developing countries. As economies improve, many patients in low-resource countries spend large amounts of money seeking modern surgical care elsewhere. In Mongolia, 30,000 people travel abroad each year seeking appropriate healthcare. The Mongolian Ministry of Health along with surgical leaders at the Health Sciences University of Mongolia (HSUM) identified laparoscopic surgery as a critical need to provide improved quality surgical care locally in Mongolia. The process for introducing advanced laparoscopic surgical procedures at the HSUM is described.
Methods: The procedure for advanced laparoscopic training in Mongolia included three two-week advanced laparoscopic courses (2006, 2012, 2013):
1. Didactic and practical hands-on patient training in basic laparoscopy
2. Laparoscopic skills development through practice on inanimate training boxes
3. Proctored advanced practical hands-on patient experience courses
4. Educating the public and other healthcare professionals about the benefits of laparoscopy
5. Promote business models to support equipment and supply needs for laparoscopy
Practical patient experiences included: 2013- 2 sigmoid colectomies , 1 low anterior resection, 1 right hemicolectomy, 2 paraesophageal hernias with Nissen fundoplication, 3 Nissen fundoplication, 3 incisional hernia repairs with mesh, 3 totally extraperitoneal hernia repairs, 1 right adrenalectomy, 1 left adrenalectomy, 1 thoracoscopy with resection of bleb, and 10 cholecystectomies; 2012- 4 Nissen fundoplication, 2 open Nissen fundoplication, and 19 cholecystectomies; 2006- 2 appendectomies, 1 abdominal perineal resection, 2 total colectomies/J pouch/ loop ileostomies, 1 sigmoid colectomy, 1 Nissen fundoplication, 1 left adrenalectomy, 34 cholecystectomies, 1 open right hemicolectomy, 1 open completion colectomy/ J pouch/ ileostomy, and 1 open parastomal hernia repair.
Results: Following the 2006 course, one surgeon participant has now completed 409 laparoscopic colectomies (Pathology: adenocarcinoma 399 (97.6%); diverticulitis 10 (2.4%)). Procedures for colon cancer: 23% right colectomy; 25% L colectomy; 19% sigmoid colectomy; 25% rectal/ low anterior resection; 6% abdominal perineal resection; 1% other colectomy. Staging size of colon cancer mostly more advanced tumors: 2% T1-2; 59% T3; 39% T4.
One surgeon participant seeing the adrenalectomy studied an additional 3 dedicated months of laparoscopy in Korea and returned to do the first primarily Mongolian surgeon adrenalectomy one year later.
Another surgeon participant has performed 39 laparoscopic left lateral segment and small right and left wide excisions using equipment (harmonic scalpel) loaned from a private non-governmental organization. Pathology: 72% hepatocellular carcinoma; 8% adenoma; 8% hemangioma a few other benign diseases. They now also perform laparoscopic splenectomy, distal pancreatectomy, as well as cholecystectomy.
One surgeon has become the director of laparoscopic training for HSUM having participated in all the advanced laparoscopic courses.
Conclusions
Short-term didactic and practical advanced laparoscopic courses have helped stimulate further development of advanced laparoscopic procedures in Mongolia despite limited resources. Local surgeon dedication, obtaining vital equipment, and public demand are providing Mongolia with modern surgical care that may help decrease the number of people seeking care abroad.
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