Designing devices for global surgery: evaluation of participatory and frugal design methods

Introduction: Most people living in low- and middle-income countries have no access to surgical care. Equipping under-resourced health care contexts with appropriate surgical equipment is thus critical. “Global” technologies must be designed specifically for these contexts. But while models, approaches and methods have been developed for the design of equipment for global surgery, few studies describe their implementation or evaluate their adequacy for this purpose. Methods: A multidisciplinary team applied participatory and frugal design methods to design a surgical device for gasless laparoscopy. The team employed a formal roadmap, devised to guide the development of global surgical equipment, to structure the design process into phases. Phases 0–1 comprised primary research with surgeons working in low-resource settings and forming collaborative partnerships with key stakeholders. These participated in phases 2–3 through design workshops and video events. To conclude, surgical stakeholders (n=13) evaluated a high-fidelity prototype in a cadaveric study. Results: The resulting design, “RAIS” (Retractor for Abdominal Insufflation-less Surgery), received positive feedback from rural surgeons keen to embrace and champion innovation as a result of the close collaboration and participatory design methods employed. The roadmap provided a valuable means to structure the design process but this evaluation highlighted the need for further development to detail specific methodology. The project outcomes were used to develop recommendations for innovators designing global surgical equipment. To inform early phases in the design roadmap, engaging a variety of stakeholders to provide regular input is crucial. Effective communication is vital to elucidate clear functional design requirements and hence reveal opportunities for frugal innovation. Finally, responsible innovation must be embedded within the process of designing devices for global surgery. Conclusion: A community-wide effort is required to formally evaluate and optimize processes for designing global surgical devices and hence accelerate adoption of frugal surgical technologies in low-resource settings

Gasless laparoscopy in rural India-registry outcomes and evaluation of the learning curve

Background A program of gasless laparoscopy (GL) has been implemented in rural North-East India. To facilitate safe adoption, participating rural surgeons underwent rigorous training prior to independent clinical practice. An online registry was established to capture clinical data on safety and efficacy and to evaluate initial learning curves for gasless laparoscopy. Methods Surgeons who had completed the GL training program participated in the online RedCap Registry. Patients included in the registry provided informed consent for the use of their data. Data on operative times, conversion rates, perioperative complications, length of stay, and hospital costs were collected. Fixed reference cumulative sum (CUSUM) model was used to evaluate the learning curve based on operative times and conversion rates published in the literature. Results Four surgeons from three rural hospitals in North-East India participated in the registry. The data were collected over 12 months, from September 2019 to August 2020. One hundred and twenty-three participants underwent GL procedures, including 109 females (88.6%) and 14 males. GL procedures included cholecystectomy, appendicectomy, tubal ligation, ovarian cystectomy, diagnostic laparoscopy, and adhesiolysis. The mean operative time was 75.3 (42.05) minutes for all the surgeries. Conversion from GL to open surgery occurred in 11.4% of participants, with 8.9% converted to conventional laparoscopy. The main reasons for conversion were the inability to secure an operative view, lack of operating space, and adhesions. The mean length of stay was 3 (2.1) days. The complication rate was 5.7%, with one postoperative death. The CUSUM analysis for GL cholecystectomy showed a longer learning curve for operative time and few conversions. The learning curve for GL tubal ligation was relatively shorter. Conclusion Gasless laparoscopy can be safely implemented in the rural settings of Northeast India with appropriate training programs. Careful case selection is essential during the early stages of the surgical learning curve

Clinical effectiveness of gasless laparoscopic surgery for abdominal conditions: systematic review and meta-analysis

Background In high-income countries, laparoscopic surgery is the preferred approach for many abdominal conditions. Conventional laparoscopy is a complex intervention that is challenging to adopt and implement in low resource settings. This systematic review and meta-analysis evaluate the clinical effectiveness of gasless laparoscopy compared to conventional laparoscopy with CO2 pneumoperitoneum and open surgery for general surgery and gynaecological procedures. Methods A search of the MEDLINE, EMBASE, Global Health, AJOL databases and Cochrane Library was performed from inception to January 2021. All randomised (RCTs) and comparative cohort (non-RCTs) studies comparing gasless laparoscopy with open surgery or conventional laparoscopy were included. The primary outcomes were mortality, conversion rates and intraoperative complications. Secondary outcomes: operative times and length of stay. The inverse variance random-effects model was used to synthesise data. Results 63 studies were included: 41 RCTs and 22 non-RCTs (3,620 patients). No procedure-related deaths were reported in the studies. For gasless vs conventional laparoscopy there was no difference in intraoperative complications for general RR 1.04 [CI 0.45–2.40] or gynaecological surgery RR 0.66 [0.14–3.13]. In the gasless laparoscopy group, the conversion rates for gynaecological surgery were high RR 11.72 [CI 2.26–60.87] when compared to conventional laparoscopy. For gasless vs open surgery, the operative times were longer for gasless surgery in general surgery RCT group MD (mean difference) 10 [CI 0.64, 19.36], but significantly shorter in the gynaecology RCT group MD − 18.74 [CI − 29.23, − 8.26]. For gasless laparoscopy vs open surgery non-RCT, the length of stay was shorter for gasless laparoscopy in general surgery MD − 3.94 [CI − 5.93, − 1.95] and gynaecology MD − 1.75 [CI − 2.64, − 0.86]. Overall GRADE assessment for RCTs and Non-RCTs was very low. Conclusion Gasless laparoscopy has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings

Training programme in gasless laparoscopy for rural surgeons of India (TARGET study) - Observational feasibility study

Background: Benefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India. Methods: A 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated. Results: Seven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers. Conclusion: Structured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context

Effect of Resisted Sprint versus Plyometric Training on Leg Strength of Male Sprinters

The purpose of the study was to find out the effect of resisted sprint (RS) versus plyometric training (PT) on the leg strength of male sprinters. To achieve the purpose of the study the researcher selected thirty intercollegiate level male sprinters as subjects. They were divided into three equal groups of ten sprinters. Group-I performed RS training (n = 10), Group-II performed PT (n = 10), and Group-III acted as control (n = 10). The age of the selected subjects was ranged from 18 to 22 years. The statistical procedure was “t-test” and percentage changes were used Further, analysis of covariance (ANCOVA) was used to determine the significant difference existing between pretest and posttest on stride frequency. When the obtained “F ratio” value in the ANCOVA test was significant the Scheffe’s test was applied as a post hoc test to determine the paired mean differences if any. The results showed that twelve weeks of RS and PT considerably improved the leg strength of the male sprinters, whereas PT was significantly better than RS training. The result produced a 3.71% percentage of changes in leg strength due to RS training and 7.44% of changes due to PT

High voltage (∼5V) olivine-type LiCoPO4/C nano-particle cathode material synthesized from modified solid state reaction

Nano particle sized LiCoPO4 cathode material was synthesized through modified solid state reaction and other methods. Carbon coating on the surface of the cathode material particles was carried out using an in situ carbon coating procedure. The calcination temperatures between 550°C and 750°C were used to synthesize cathode materials. The synthesized cathode materials were characterized by X-ray powder diffraction (XRD) for structure determination, scanning electron microscopy (SEM) for morphology studies, particle size analyses. Coin/pouch cells were built and cycled in standard carbonate based lithium hexafluoride phosphate (LiPF6) electrolyte solutions. The cathode film forming additives include 2,3-dihydrofuran (2,3-DHF) and 2,5-dihydrofuran (2,5-DHF), LiFOB, and vinylene carbonate (VC) were also investigated in cells. ©The Electrochemical Society