title: Systematic review of laparoscopic surgery in low- and middle-income countries: benefits, challenges, and strategies.
abstract: BACKGROUND
  Laparoscopy may prove feasible to address surgical needs in limited-resource settings. However, no aggregate data exist regarding the role of laparoscopy in low- and middle-income countries (LMICs). This study was designed to describe the issues facing laparoscopy in LMICs and to aggregate reported solutions.
  
  
  METHODS
  A search was conducted using Medline, African Index Medicus, the Directory of Open Access Journals, and the LILACS/BIREME/SCIELO database. Included studies were in English, published after 1992, and reported safety, cost, or outcomes of laparoscopy in LMICs. Studies pertaining to arthroscopy, ENT, flexible endoscopy, hysteroscopy, cystoscopy, computer-assisted surgery, pediatrics, transplantation, and bariatrics were excluded. Qualitative synthesis was performed by extracting results that fell into three categories: advantages of, challenges to, and adaptations made to implement laparoscopy in LMICs. PRISMA guidelines for systematic reviews were followed.
  
  
  RESULTS
  A total of 1101 abstracts were reviewed, and 58 articles were included describing laparoscopy in 25 LMICs. Laparoscopy is particularly advantageous in LMICs, where there is often poor sanitation, limited diagnostic imaging, fewer hospital beds, higher rates of hemorrhage, rising rates of trauma, and single income households. Lack of trained personnel and equipment were frequently cited challenges. Adaptive strategies included mechanical insufflation with room air, syringe suction, homemade endoloops, hand-assisted techniques, extracorporeal knot tying, innovative use of cheaper instruments, and reuse of disposable instruments. Inexpensive laboratory-based trainers and telemedicine are effective for training.
  
  
  CONCLUSIONS
  LMICs face many surgical challenges that require innovation. Laparoscopic surgery may be safe, effective, feasible, and cost-effective in LMICs, although it often remains limited in its accessibility, acceptability, and quality. This study may not capture articles written in languages other than English or in journals not indexed by the included databases. Surgeons, policymakers, and manufacturers should focus on plans for sustainability, training and retention of providers, and regulation of efforts to develop laparoscopy in LMICs.
authors: Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB 425, Boston, MA, 02114, USA. tchao@mgh.harvard.edu.|Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA. tchao@mgh.harvard.edu.
authors: Tiffany E
authors: TE
authors: Chao
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.|University of Miami Miller School of Medicine, Miami, FL, USA.
authors: Morgan
authors: M
authors: Mandigo
authors: Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
authors: Jessica
authors: J
authors: Opoku-Anane
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.|Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
authors: Rebecca
authors: R
authors: Maine
mesh_terms: D003906:Developing Countries; D006295:Health Resources; D006297:Health Services Accessibility; D006801:Humans; D010535:Laparoscopy
keywords: Global Surgery; LMIC; Laparoscopy; Low-resource settings; Training/courses