Knowledge and Perception of Laparoscopic Surgery among Surgical Outpatients in a Nigerian Teaching Hospital

Design of the study: This was a prospective study carried out on consenting new patients at the surgical out-patient clinic of the surgical out-patient clinic of a Nigerian Teaching Hospital. The questionnaire was administered to consenting patients through a face-to-face interview by nonmedical personnel who had been instructed by the investigators. Data collection was on clinic days within the period.


INTRODUCTION
Minimal access surgery (Laparoscopic surgery) is prospected as the future of surgery.It offers the benefits of reduced morbidity, earlier return to work, better pain control, cosmesis and reduced duration of hospitalization among other benefits.The advantage of early return to work is of paramount importance in developing or low income countries where lost days at work translate into lack of income for some families.Consequently minimal access surgery seems to be of immense benefit even in low income countries.
The consequence of the increased patient demand was a competition in the surgical instrument manufacturing sector to produce better, cheaper and more user and patient friendly surgical instruments.Furthermore there is enough volume of procedures for training and to drive the reduction in overall cost of surgery.The patients' demands for minimal access surgery is a function of both knowledge and perception of this innovative technique of surgery.
In developing and many low income countries apart from numerous challenges such as cost of instrumentation and technology the knowledge of the procedure and perception may be some of the reasons why patients' acceptance and willingness to have laparoscopic approach for relatively simple procedures despite government subsidy on the cost of laparoscopic surgery.
The aim of this study is to determine the knowledge level and perception of laparoscopic surgery in patients attending the surgical outpatient for the first time in a teaching hospital in Nigeria.We also determined probable factors which affect this.

Study Design
This was prospective study carried out at the surgical outpatient (SOP) clinic of the gastrointestinal surgery division of the surgery department of the University College Hospital Ibadan.

Study Area
The hospital is a tertiary level facility which serves state (Oyo) primarily but is also a national referral center.The average patient attendance in the gastrointestinal surgery division outpatient clinic is about sixty to seventy patients on the clinic days with about fifteen percent of this population being new referrals without any previous with the gastrointestinal surgery division.

Study Population
The study population included all new referrals (patients) attending surgical gastrointestinal outpatient clinic over a six month period (January to June 2016).

Sampling Techniques and data collection procedures
The patients were approached and after explaining the study and seeking consent, the questionnaire was administered through a face-to-face interview by a non-medical personnel who had been instructed by the investigators.The data were collected on every clinic day which was once a week within the period.

Inclusion criteria
Patient selection included every consenting patient.

Exclusion criteria
Critically ill patients were excluded from the study Data analysis and Demographics such as age, education level and employment status were obtained.The proportions of patients with variable levels of knowledge of laparoscopy and perception were calculated.Secondary analysis compared proportions across demographics.Odds ratios (OR) and 95% confidence intervals were calculated.

RESULTS
A total of 370 persons were recruited in this study with a male: female ratio of 1:1.79.The age distribution was between 14years and 81 years with a mean age of 44.19.The marital distribution of these patients were 83 and, 257 as single and married respectively while the rest were separated or widowed (Table1).

Variables Frequency Percent
An evaluation of the knowledge base component of the questionnaire revealed that 62.6% had no knowledge of laparoscopic surgery (figure 1).While the analysis of perception and knowledge is in Table 2.A further analysis of the 145 respondents who had any knowledge of the concept of laparoscopic surgery revealed that 108 (38 males; 70 females) had positive or appropriate perception of laparoscopic surgery.The duration of knowledge prior to the administration of the questionnaire is as in figure 2.
There is an inverse relationship between the duration of the perceived knowledge and the appropriate perception of laparoscopic surgery as demonstrated in figure 3.There is a statistically significant relationship between academic qualification, occupation and knowledge about the perception of laparoscopic surgery as shown in table 3. Predictors of acceptance of laparoscopic surgery

DISCUSSION
Following the successful introduction of laparoscopic surgery in America and Europe many patients requested for this surgical approach for their various surgical conditions from their doctors.Consequently many innovations and advances in laparoscopic surgery made were "patient demand" driven.Patient demand is one of the major factors responsible for the development and success of minimal access surgery.Sally Wilde and others demonstrated that patients and their relations play significant roles in the decision making process in surgery.Results of economic evaluation also suggest when a critical volume of surgery is attained the cost of operative procedures become further reduced as the surgical capacity increases.As patients' demands increase so do innovation techniques of surgery.The volume of demands also reduces cost of instrumentation.Philippe Mouret and François Dubois performed their first laparoscopic cholecystectomies in the late 1980s in France.By 1990 Dubois had performed 220 procedures with minimal complications.Consequently laparoscopic cholecystectomy spread from Europe to North America and the United States.The demand for laparoscopic surgery was a major factor in the advances made in minimal access surgery.
There have been several studies on the feasibility of implementing laparoscopic procedures in resourcepoor countries and how to overcome the challenges involved .There is a strong association between patients' knowledge, perception and demand for laparoscopic surgery.A fundamental understanding of the concept of knowledge would be in terms of concepts like truth, belief, justification and reliability.Thus perception is a derivative of knowledge.The major limitations to laparoscopic surgery in our setting in the reference hospital are patients' awareness, acceptance and the cost of the procedure.Where there is a low level of or negative perception of the procedure the demand for surgery is low, the overall cost of surgery is high because of the prolonged 'down' time of equipment and facilities.
The results in this study demonstrate that the level of knowledge of laparoscopic surgery in the index population is low.61.1% had no knowledge of laparoscopic surgery while 9% and 30% had low and above knowledge levels respectively.Unlike a study in Korlebu hospital in Ghana where the older population i.e.50 years and above are more likely not to have appropriate knowledge there is no significant association with the ages of the respondents and the appropriate perception of laparoscopic surgery.47.5% of respondents with tertiary education had "average and above" levels of knowledge of laparoscopy while 0% and 25% with no formal education or secondary education respectively had any knowledge.There was a significant association between knowledge level and appropriate perception of laparoscopic surgery.
The main economic activities engaged in by the Ibadan population include agriculture, trade, public/civil service employment, factory work, service sectors and artisans.These jobs were subsequently reclassified into four broad groups (Trading/Self-employed/Employed /Others) with the distribution as (13.8%/ 15.1%/45.6%/5.5%)respectively.In view of this job distribution, analysis of knowledge revealed that the population with the highest proportion of acceptable levels of knowledge are those in paid employment which may be related to their educational status as corporate or government employees (Table 3).Contrary to expectation patients with less than a year's awareness of the laparoscopic surgery had a more positive concept of this surgical technique (Figure 3).

CONCLUSION
The low demand for laparoscopic surgery despite the availability of the facility may be due to the low level of knowledge of the procedure.Secondly there is a significant level of negative perception due to misinterpreted information among patients.There is a need for public health education in the region to drive this relatively new frontier of surgery to improve our practice and encourage indigenous innovations.Consequently if the patient volume increases the cost of surgery reduces.
in the developing countries.