Practical Considerations for Sustainable Surgery in the Limited-Resource Region

Prof Hannah Krause
Prof Hannah KrauseMBBS FRANZCOG CU MPHIL PHD, Australia

Managing the increasing costs of healthcare provision is a significant burden for healthcare leaders and systems worldwide. There is much emerging debate and contributions to the literature on healthcare sustainability, including considerations of costs, quality of care, and environmental impacts. When providing urogynecology services in limited-resource regions, a detailed understanding of accessible funding, costs of service provision, and availability of medical and surgical resources are needed to determine available treatment and management options.

When considering surgical options for pelvic organ prolapse repairs, stress urinary incontinence procedures, and fistula surgery, well-resourced locations may offer laparoscopic or robotic approaches in addition to open abdominal or vaginal surgeries. However, where the supply of electricity in inconsistent, laparoscopic, and robotic options are not feasible. The high cost of purchasing laparoscopic and robotic systems and instruments and the unavailability of persons and materials to service and repair minimally invasive technology also prevent their use. Personal headlamps with rechargeable batteries are required when external lighting is not reliable. Spinal anesthesia offers a high degree of safety and affordability compared to general anesthesia, where resources are limited, and is very suitable for all open abdominal and vaginal urogynaecological procedures.

Repair of apical vaginal prolapse with sacrospinous fixation sutures is an effective technique and is widely utilized. The use of non-disposable instruments minimizes costs per procedure. A blunt aneurysm needle (left-handed to allow passage of the needle through the ligament from cephalad to caudal), retrieval hook, and Breisky retractor are affordable, easily re-sterilized, and unlikely to break or wear out despite multiple procedures.

Inconsistent availability of cystoscopy reduces the option of high uterosacral ligament suspension, as ureteric patency must be assessed.

I do not advocate the use of the currently available permanent synthetic surgical meshes for Urogynaecological procedures in locations where there is no expertise or experience in mesh removal, which is then necessary when mesh-related complications arise. In addition, the use of autologous tissue may be more sustainable and cost-effective compared to purchasing synthetic materials.

Other practical suggestions include minimizing the wastage of suture materials when performing hand ties and utilizing instrument ties where appropriate. Open each suture only when it is required. The avoidance of disposable surgical equipment may help stabilize costs and evade supply shortages. The purchase of good-quality surgical instruments is advisable to promote improved tissue handling, and by ensuring good care of the instruments, a longer instrument lifespan is enabled. I recommend the development of lists of instruments/ equipment needed for each surgical procedure as this allows only the necessary instruments to be opened for each case and minimizes the need for re-sterilization of instruments that are opened and not utilized.

Finally, another critical aspect of quality healthcare and safe surgical care is ensuring adequate sterile processing capabilities. This includes effective cleaning, decontamination, and sterilization of instruments. As included in the 2009 WHO Surgical Safety Checklist (1), confirmation of instrument sterility is required prior to starting surgery. More recently, in 2016, a manual for decontamination and reprocessing of medical devices in low-income and middle-income countries (LMICs) was developed (2). Adequate resources and capacity for sterile processing must be instilled into each surgical unit to enable quality healthcare.


1. WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Geneva: World Health Organization; 2009.

2. World Health Organisation and Pan American Health Organization. Decontamination and reprocessing of medical devices for health-care facilities. Secondary decontamination and reprocessing of medical devices for health-care facilities 2016.