A group of doctors from Sweden and the US together with their Rwandan colleagues recently launched and effectively conducted a microsurgery visiting professor programme, the first of its kind, at the University Teaching Hospital of Kigali (CHUK), focusing on lower limb reconstruction. Three patients had a successful operation.
So far, microsurgery (a surgical discipline that combines magnification with advanced diploscopes, specialised precision tools, and various operating techniques) is still new in Rwanda, but training is underway to equip local doctors with the skills in the domain.
The New Times' Joan Mbabazi spoke to Prof. Faustin Ntirenganya, Head of the Plastic Surgery Unit at CHUK and Chair of the Department of Surgery at the University of Rwanda, to shed more light on the future of microsurgery in Rwanda.
Excerpts;
Microsurgery seems like a delicate procedure, what exactly does it entail?
Microsurgery is a branch of plastic surgery that deals with helping to reconstruct or treat different defects. We move tissues from far, to a place that is needed. In its practicality, we carry out surgery using microscopes. Some equipment is so small to see with our eyes, which is why the procedure requires a lot of patience and time.
What is your take on the development of such procedures in Rwanda?
We are advancing in a number of domains, including healthcare. In surgery, we started building capacity in different subspecialties, plastic surgery is one of those new specialties. In case of a tumour, nasty accident, and loss of tissues, the role of plastic surgery is to reconstruct both the function and the appearance.
Together with my colleague Dr Charles Furaha, we started training doctors locally in this specialty a few years ago in 2018. We created the programme though it wasn't easy as we didn't have some of the requirements in the country. Microsurgery was one of the missing components. We had to send students out of the country to attain that special skills and exposure. Before, there was no such plastic surgery training at the university. I trained in France and Charles in South Africa, which is why we decided to combine our skills and start a training programme.
Tell us more about the training.
We discovered that sending students to different countries to pursue the profession was costly, therefore, the only option was to come together to answer the needs of the population. That was the genesis of our programme in the country. We collaborated with different partners, the main one being Operation Smile, and the training kicked off. We started with three students who were either general surgeons or completed basic surgical training. They have graduated recently and passed excellently through the College of Surgeons of East, Central, and Southern Africa (COSECSA).
We have the second cohort of trainees, five in Year One, and four in Year Four. We now have an integrated programme where we start from zero to a five-year-long training. However, the students in the fourth year pursued other surgical domains but picked an interest in plastic surgery and joined in the third year.
Does Rwanda have what it takes to sustain microsurgery?
People have a perception that executing microsurgery procedures in countries like Rwanda is impossible, stressing that the technology can't survive. But we are making it happen. We are able to learn the needed skills and purchase the instruments necessary. We anticipate incorporating and providing students with maximum skills and knowledge in plastic surgery.
Four years back, we couldn't do microsurgery because of inadequate human resources, skills, and structural components. We needed a team of doctors to carry out the procedure, equipment, surgical microscope, and others.
You recently held week-long lectures and surgeries, how did that go?
We recently had a team of doctors from Sweden, and the US, performing microsurgery from high-volume centres. Together, we successfully operated on three patients. These were long procedures taking 8 to 10 hours each, making only one case per day. We focused on reconstructing the lower limbs. This included patients from accidents whose legs were at risk of amputation. We tried to find other tissues from either their backs or thighs to bring them down to reconstruct the leg.
We mostly used the muscle flap (a surgery that is versatile and a valuable tool in treating musculoskeletal damage and preserving limbs. It is an effective way to restore blood supply, muscle tissue, and function in areas severely damaged by an injury or illness.)
Why did you focus on the limbs?
We noticed that it is the first need. Limb trauma is complex. The surgical arena has few options to solve issues on lower limbs. When a person is involved in an accident and develops an open fracture (this exposes the bones, muscles, and nerves), they can't survive without this kind of reconstruction. If they don't die, there is a higher chance of losing a limb due to amputation. We still have higher rates of motorbike accidents, and many of these affect the limbs since nothing protects them.
Can we hope for more surgeries to lower the risk of amputation, and is the procedure affordable?
Operating them was one thing, making the reconstructed limb survive was another. That's where the team was needed. We had nurses, surgeons, anaesthesiologists, and others. Surgeries were a success and all the flaps survived.
In the past, the amputation rate has been high due to a lack of options, but it will be lowered because of microsurgery. This doesn't mean that there won't be any cases of amputation as the procedure is only at CHUK for now.
Sometimes what triggers amputation is when patients arrive at the hospital late from the time an accident occurred. You shouldn't go for first aid beyond six hours as there are few chances of surviving. However, the mechanism of injury matters a lot. A cut and a crushed wound won't be the same.
This procedure is a little bit expensive but Rwanda has made it possible for everyone to access it with health insurance, including Mutuelle de Santé.
How did you choose the people you operated on?
We had a number of patients waiting but very few were ready. It is important to have the right patient, the right flap, and the right vessel. Surgical decision-making is paramount here. We chose those who would be able to sustain the long procedures and who consented to the procedure. We also looked at the ones who would benefit more. For example, age may be an important factor to consider, we would prioritise younger patients compared to older ones. But the best option is to serve everyone if we can.
You have also been conducting training alongside surgery, tell us more about it.
Our residents performing plastic surgery were part of this process. We were shifting from theories to practicals. We had to discuss, look at the images, teach everything around us, and then perform surgeries in the presence of students. Some of the vessel preparations were done by trainees under our supervision. You know, surgery is like swimming, if you don't do it, you can't know your capability. That's why there have been a couple of training and lecturing sessions and multiple team discussions to learn together in order to apply the lessons mastered to the patients.
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What's the future of microsurgery in Rwanda?
The future is bright. We have already sent Dr Ian Shyaka, a recently graduated plastic surgeon from Rwanda Military Hospital, to go and learn microsurgery from Prof Fu-Chan Wei in Taiwan. It's a one-year long training. When he comes back, he will be the focal person of all this. However, if one person can't do microsurgery on his own, we will share the task with him and continue developing microsurgery skills in young plastic surgical trainees. Indeed, one case may require up to 12 doctors. We will, therefore, continue sending different colleagues to obtain such skills, but the training locally will continue going on. We look forward to extending these services to Rwandans in different hospitals such as Rwanda Military Hospital, and others.
How long will these services take to reach other hospitals?
This may not be soon as it requires a lot of logistics and equipment. For now, we can't pretend to be able to do microsurgery everywhere. However, as the health system will continue to mature, microsurgery will be expanded out of university hospitals to provincial and other referral hospitals. We may start small and expand as time allows. It is a journey that we have started, and we are optimistic.
I would like to thank the Ministry of Health and CHUK that enabled a good working environment, colleagues who spent their time and shared their expertise free of charge, trainees, nurses, and patients who trusted us. It's not easy to convince someone to carry out a procedure on them that you have never done before, and one that will take 10 hours or more under anaesthesia.
