Resource Limitations and Surgical Safety Concerns

Recent events in India have again drawn the world’s attention to the importance of safe surgical practices.  A report from the state of Orissa in India revealed that surgical teams were using bicycle tire pumps to insufflate women’s abdomens for sterilization procedures, as well as reusing needles, gloves, and other surgical supplies in an unsafe manner during operations.  During certain surgical procedures, air is pumped into the abdominal space to “insufflate” (or inflate) the belly.  This allows the surgeon to navigate instruments within the abdominal space and to visualize different anatomical structures.  In most settings, however, this is accomplished with a device called an insufflator, which pumps carbon dioxide (CO2) under pressure-controlled settings.  A bicycle pump, on the other hand, does not adequately control air pressure and pumps atmospheric air, which contains a number of molecules other than carbon dioxide that may be hazardous.  Following this report, further investigations also revealed that a large number of patients were left partially blind after undergoing cataracts operations in a surgical camp led by a non-governmental organization in Punjab. 

Unsafe surgical techniques in resource-limited settings are unfortunately more common than one would hope.   A study in the Lancet by Funk et al showed that nearly 20% of operating rooms worldwide are not equipped with pulse oximeters, a basic monitoring device that allows anesthesia providers to measure blood-oxygen levels.   In most cases, these incidents are not matters of malfeasance or ill will, but a product of critical resource limitations.  Surgical care, although demonstrated to be highly cost-effective, is a resource-intense specialty and requires substantial investment, both in equipment and education.  Resource constraints in combination with immense need can lead to substandard conditions, poor judgment and unsafe, ad hoc “work-arounds” like seen in Orissa. 

Although the nature of these incidents and the patient complications resulting are unacceptable and extremely unfortunate, there are lessons to be learned from these events.  First, organizations and practitioners providing surgical care must be integrated into the local health system.  Not only is this essential to maximize overall health system efficiency, but to ensure that regulations and licensure requirements are continually met.  While organizations may often have internal practice guidelines, such as Operation Smile’s Global Standards of Care, government regulations have been established by ministries of health and local entities to ensure minimum safety standards and are a necessary constituent of safe surgical care.  Next, ad hoc “work-arounds” can be associated with major risks and must be rigorously evaluated before being implemented in patient care.  A number of low-cost devices have been developed for resource-poor settings, and although these may have great potential for decreasing costs and improving care delivery, they need to be tested and assessed to ensure that they first protect patient safety.  Lastly, these incidents highlight the need for further investment in surgical systems in low- and middle-income countries.  Access to surgery, limited as it may be, is not enough for those in need; and, while resources alone will not be sufficient, greater global investments in infrastructure, equipment, training, and supplies are essential for increasing access to safe surgery for the world’s poor.

Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC, Wilson IH, Dziekan G, Gawande AA. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet. 2010 Sep 25;376(9746):1055-61.

Sahu S. India's Orissa halts 'bicycle pump sterilisation surgery'. BBC News. Available from: Accessed: December 15, 2014.

India cataracts scandal: Arrest over 'botched' surgery. BBC News. Available from: Accessed: December 15, 2014.


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