Rural Surgical Innovation: Victories, Challenges, and Opportunities
Edited Article
Abstract:
Surgical innovation is the introduction or implementation of a novel idea, process, technology, or
device designed to meet a specific surgical need. Innovation is critical to care provision in low
resources settings, which may be characterized by inadequate infrastructure and supplies, limited
workforce, patients with very low affordability. In the high-income setting, innovation often
improves processes or increases efficiency; in low-resource settings, innovation makes care
possible. Here, we highlight several innovations borne from low-resource settings, devised by
clever clinicians in order make care provision possible for their patient populations.
Introduction:
Surgical innovation is the introduction or implementation of a novel idea, process,
technology, or device designed to meet a specific surgical need.1 Innovation is critical to care
provision in low resources settings, which may be characterized by inadequate infrastructure and
supplies, limited workforce, patients with very low affordability. 1 In the high-income setting,
innovation often improves processes or increases efficiency; in low-resource settings, innovation
makes care possible.
Here, we highlight several innovations borne from low-resource settings, devised by
clever clinicians in order make care provision possible for their patient populations. We collected
data through discussions with experts in low-resource care provision, particularly individuals
with extensive experience in Indian rural surgery through working group meetings and panel
discussions leading up to and including at the Association of Rural Surgeons of India Conference
(Karad, India, Nov 2015) and the WHO Lancet Commission on Global Surgery India Surgical
Forum (New Delhi, India, March 2016). We focus on three innovations which have or could
benefit from an academic partnership, and we postulate on three distinct stages in the
development of an innovation, with different needs from the clinical, academic, and industrial
communities.
Delayed Abdominal Closure
In 1984, Dr. Oswaldo Borraez was a surgical resident in Bogotá, Colombia at the
Hospital San Juan de Dios, struggling in the operating room with a patient with severe
peritonitis.2 Abdominal closure was unsafe due to the risks of abdominal compartment
syndrome, so the abdomen would have to be left open for delayed closure. Dr. Borraez suggested
that a three-liter polyethylene bladder irrigation bag be cut open to be attached temporarily to the
edges of the patient’s abdominal wound.3 Not only would the bag provide a barrier between
abdominal contents and the outside world, its transparency would allow continuous visualization
of the viscera.4 The previous method of packing the abdomen with surgical towels was known to
increase the rate of infection and entero-atmospheric fistulas.2
The Bogotá bag for delayed abdominal closure represents an innovation that has been
assessed and successfully scaled worldwide. It is now the standard of care for the management of
the open abdomen2 as well as modern surgical textbooks.5 In this example, partnerships aided in
the original expansion of the method as a visiting trauma surgeon from the United States noted
the ingenuity of the innovation and its potential to change standard of care worldwide. The
international academic community conducted several retrospective studies on the safety and
efficacy of the colloquially termed ‘Bogotá bag’ that showed equivalent outcomes to alternative
management for delayed abdominal closure.6-10
Mosquito Net Mesh for Hernia Repair
Hernia repair is one of the most frequently performed surgeries around the world and has
been shown to be cost-effective even in low-resource settings.11,12 The most common method for
hernia repair in HICs involves implantation of a synthetic mesh to reinforce the inguinal floor.
Unfortunately, these meshes cost hundreds of dollars which is unaffordable in many low- and
middle-income countries (LMICs).13
Fortunately, in the early 1990’s, Indian surgeons Dr. Ravindranath Tongaonkar and Dr.
Brahmma Reddy noted mosquito net had a similar consistency, thickness, and durability to
commercial mesh. Mosquito net is widely available and cheap: several economic studies have
discussed the savings associated with using the mosquito net mesh, with one study estimating
that it was 0.1% of the price of a commercial mesh.13 Drs. Tongaonkar and Reddy used sterilized
mosquito net to replace synthetic mesh in hernia repair and reported excellent outcomes. Their
wound complication rates were low and they found no significantly different risk of infection
when compared to commercially available mesh.14-17
Though there is evidence that mosquito net mesh was used in a few LMICs, only recently
have a number of studies built upon this work.18-20 Microscopically, the strength and structure
was proven to be equivalent to commercially available meshes (Figure 1).17 And most notably, a
well-designed, highly-powered randomized controlled trial published in The New England
Journal of Medicine showed no significant difference in rates of hernia recurrence and
postoperative complications between mosquito net mesh and commercial mesh.20
Gasless Laparoscopy
In the 1980s, the introduction of laparoscopic techniques to surgery significantly dropped
patient morbidity associated with traditional open procedures.21-23 It has been said to have
changed the field of general surgery more dramatically than any other single event.21 However, it
can be difficult to perform in low resource settings, as it requires video-laparoscopic equipment,
monitors, carbon dioxide, an insufflator, and a well-trained anesthesiologist who can manage the
increased pressures in the peritoneal cavity. Thus, gasless laparoscopy was developed in order to
allow laparoscopic surgery to be performed under spinal anesthesia rather than general
anesthesia, using a device that physically raises the anterior abdominal wall rather than inflating
it with gas (Figure 2).
A few reports on gasless laparoscopy have supported its use in low-resource settings. A
randomized comparison of gasless versus traditional laparoscopic appendectomy in China
reported no change in the duration of the procedure, complications or length of hospital stay.24
Additionally, they reported a decrease in pain medicine requirements by the patient and
decreased total hospital costs.24 In multiple randomized controlled trials in gynecologic surgery,
no significant differences in outcomes were noted, but there was decreased surgical exposure and
increased technical difficulty associated with gasless laparoscopy when compared to traditional
laparoscopy.25,26 However, recent publications have shown that problems with exposure have
been addressed and single-incision surgeries are much easier with gasless laparoscopic
techniques.27-29
Discussion:
Each of these three innovations reveals notable roles for academic partnerships. With the
Bogotá bag, the need to temporarily close an abdomen safely was universal: it existed similarly
in the high- and low-resource setting. With mosquito net for hernia repair, the need is not
necessarily universal: high-resource settings are not looking for a cheaper mesh in order to make
care provision possible. However, it represents a surgical innovation that is inexpensive,
effective, and context appropriate. With gasless laparoscopy, the innovation has not been
properly evaluated and is thus not yet in a position to scale.
The Bogotá bag was rapidly scaled worldwide due to successful academic partnerships
and sharing of this methodology. In a large systematic review of all techniques for temporary
abdominal closure, the Bogotá bag technique maintained a lower incidence of fistulae and
abscesses with a similar mortality rate when compared to the other techniques.30 Thus, in the
low-resource setting, this method can be performed safely with widely available materials. This
same review also clearly elucidated the influence of the Bogotá bag: many modern techniques
incorporate the same principals as the original solution from Colombia.30
The use of mosquito net mesh for tension-free hernia repair takes modern techniques and
uses a cheaper, but similar, material as an innovation. It also represents an academic feat-of-
excellence that can be strived for and achieved in low-resource settings through bidirectional
research partnerships. The current evidence supporting mosquito net mesh for hernia repair is
incredibly strong, and academic and industrial partnerships should advocate for the appropriate
scaling of mosquito net for hernia repair in LMICs worldwide.
Similarly, gasless laparoscopy brings laparoscopic techniques to the low-resource setting
without the requirement for an anesthesiologist, resulting in a lower morbidity operation when
compared to an open surgery. However, further critical assessment is necessary to elucidate the
costs and benefits. This innovation represents an excellent opportunity for academic partnership
in research, as no adequately powered or methodologically-meticulous randomized controlled
study has been performed to date.
These three innovations each fit into one of three distinct stages for surgical innovations
that we are proposing: (1) Innovations that have been critically assessed and widely scaled, (2)
Innovations that have been critically assessed but not yet scaled, and (3) Innovations that require
critical assessment. Classifying innovations using this framework can assist in the prioritization
of partnerships and the investment in scaling surgical innovations in the low-resource setting. In
the first group, the existing partnerships are successful, and can modeled in similar settings. In
the second group, industry, non-governmental organizations (NGOs), and media should be
encouraged to widely disperse the strong clinical evidence supporting various innovations
globally. In the final group, academic and research partnerships can develop and implement
research to strengthen the evidence for or against any given innovation.
In the development of the academic partnerships, bi-directional benefits are essential.
Local innovators should be included as co-authors on publications and there should be ample
opportunity for further professional development. Unfortunately, this is not always the case. A
survey of clinicians in Uganda reported that visiting foreign physicians improved their medical
education, but despite cooperative research being conducted in Uganda, none of the Ugandan
doctors were published as coauthors.31 This represents a remaining gap in true, equal
partnerships.
On the other hand, there have been significant achievements in many LMICs, and the
global community should learn from these victories in order to succeed in similar contexts
worldwide. Academic partnerships for funding and increased research capacity between high-
and low-resource settings have been shown to be extremely effective and bi-directionally
beneficial.32-34 For example, professional surgical societies in Ireland and Australasia have
partnered with similar organizations in sub-Saharan Africa and the Pacific Islands, respectively,
to enhance the training of medical professionals.33
Additionally, innovators in LMICs aren’t well equipped to publicize or compete for
grants,33 medico-legal protections cause clinicians to hide their innovations,35 and innovations
take time, energy, and money to develop and scale effectively, especially when originating from
a low-resource setting.36-38
Innovations originating from the rural or low-resource setting have the potential to drive
and improve surgery today. Academic partnerships at the local-regional level as well as at the
international level between high-resource partners can result in a bi-directional beneficial
relationship. Critically assessing these rural innovations will not only save the lives of one
surgeon’s patients, but may more broadly apply to the lives of patients in similar circumstances
worldwide. Rigorously proven rural surgical innovations, such as mosquito net for hernia repair,
should be academically duplicated and scaled rapidly to increase access to surgical care around
the world.
As the global community seeks to scale up surgical care, it must take advantage of the
clever workarounds that reduce cost while improving or maintaining efficacy that clinicians have
devised to make care provision possible with minimal resources. Academia and industry must
also take note, and actively partner with clinician-inventors to rigorously evaluate for safety
while providing avenues for scale.