title: Expansion of laparoscopic cholecystectomy in a resource limited setting, Mongolia: a 9-year cross-sectional retrospective review.
abstract: BACKGROUND
  The benefits of laparoscopic cholecystectomy have been largely unavailable to most people in developing countries. Mongolia has an extremely high incidence of gallbladder disease. In 2005, only 2% of cholecystectomies were being done laparoscopically. Open cholecystectomies were associated with high rates of wound infections, complications, and increased recovery time. Because of the unacceptable complications associated with open cholecystectomies, and nearly 50% of the nomadic population needing faster post-operative recovery times, a national project for the development of laparoscopic surgery was organised. Multi-institutional collaboration between the Mongolia Health Sciences University, the Dr W C Swanson Family Foundation (SFF), the University of Utah, Intermountain Healthcare, and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) led to the promulgation of a formalised countrywide laparoscopic training programme during the past 9 years. This is a retrospective review of the transition from open to laparoscopic cholecystectomy throughout Mongolia.
  
  
  METHODS
  Demographic patient data, diagnosis, and operation preformed-laparoscopic versus open cholecystectomy, between January, 2005, and September, 2013, were collected and trends were analysed from seven regional diagnostic referral and treatment centres, and two tertiary academic medical centres from six of the 21 provinces (Aimags) throughout Mongolia. Data were analysed by individual training centre, by year, and then compared between rural and urban centres.
  
  
  RESULTS
  Nearly 16 000 cholecystectomies were analysed and compared (4417 [28·2%] men; 11 244 [71·8%] women). Men and women underwent laparoscopic cholecystectomy with the same frequency (41·2% men, 43·2% women) and had similar age (men, mean 52·2 years [SD 14·8]; women, mean 49·4 years [SD 15·7]). By 2013, 62% of gallbladders were removed laparoscopically countrywide as opposed to only 2% in 2005. More than 315 Mongolian practitioners have received laparoscopic training in 19 of 21 Aimags. On average 60% of cholecystectomies are done laparoscopically in urban surgical centres, up from 2%, versus 55% in rural surgical centres, up from 0%, in 2005. Laparoscopic cholecystectomy surpassed open cholecystectomy as the primary method for gallbladder removal countrywide in 2011.
  
  
  CONCLUSIONS
  By 2013, 62% of cholecystectomies countrywide were done laparoscopically, a great increase from 9 years ago. Despite being a resource limited country, the expansion of laparoscopic cholecystectomy has transformed the care of biliary tract disease in Mongolia.
  
  
  BACKGROUND
  The University of Utah Center for Global Surgery.
authors: The University of Utah Center for Global Surgery, Salt Lake City, UT, USA; The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Electronic address: katie.m.wells@gmail.com.
authors: Katie M
authors: KM
authors: Wells
authors: Stanford University School of Medicine, Palo Alto, CA, USA.
authors: Yu-Jin
authors: YJ
authors: Lee
authors: Mongolian National University of Medical Sciences (MNUMS), Ulaanbaatar, Mongolia.
authors: Sarnai
authors: S
authors: Erdene
authors: Mongolian National University of Medical Sciences (MNUMS), Ulaanbaatar, Mongolia.
authors: Sandag
authors: S
authors: Erdene
authors: Second General Hospital Mongolia, Ulaanbaatar, Mongolia.
authors: Urjin
authors: U
authors: Sanchin
authors: Mongolian National University of Medical Sciences (MNUMS), Ulaanbaatar, Mongolia.
authors: Orgoi
authors: O
authors: Sergelen
authors: Department of Epidemiology and Internal Medicine, University of Utah, Salt Lake City, UT, USA.
authors: Angela
authors: A
authors: Presson
authors: Department of Epidemiology and Internal Medicine, University of Utah, Salt Lake City, UT, USA.
authors: Chong
authors: C
authors: Zhang
authors: The University of Utah Center for Global Surgery, Salt Lake City, UT, USA.
authors: Brandon
authors: B
authors: Rodriguez
authors: The University of Utah Center for Global Surgery, Salt Lake City, UT, USA.
authors: Catherine
authors: C
authors: deVries
authors: Intermountain Healthcare and The University of Utah Center for Global Surgery, Salt Lake City, UT, USA.
authors: Raymond
authors: R
authors: Price