World J Surg (2017) 41:1225–1233

DOI 10.1007/s00268-016-3851-0

ORIGINAL SCIENTIFIC REPORT

Laparoscopic Versus Open Cholecystectomy: A Cost–Effectiveness

Analysis at Rwanda Military Hospital
Allison Silverstein1,2 • Ainhoa Costas-Chavarri1,3 • Mussa R. Gakwaya3 •
Joseph Lule3 • Swagoto Mukhopadhyay1,4 • John G. Meara1,5 • Mark G. Shrime1,6

Published online: 30 November 2016

Ó Société Internationale de Chirurgie 2016

Abstract
Background Laparoscopic cholecystectomy is first-line treatment for uncomplicated gallstone disease in high-income
countries due to benefits such as shorter hospital stays, reduced morbidity, more rapid return to work, and lower mortality
as well-being considered cost-effective. However, there persists a lack of uptake in low- and middle-income countries.
Thus, there is a need to evaluate laparoscopic cholecystectomy in comparison with an open approach in these settings.
Methods A cost–effectiveness analysis was performed to evaluate laparoscopic and open cholecystectomies at
Rwanda Military Hospital (RMH), a tertiary care referral hospital in Rwanda. Sensitivity and threshold analyses were
performed to determine the robustness of the results.
Results The laparoscopic and open cholecystectomy costs and effectiveness values were $2664.47 with 0.87 quality-
adjusted life years (QALYs) and $2058.72 with 0.75 QALYs, respectively. The incremental cost–effectiveness ratio
for laparoscopic over open cholecystectomy was $4946.18. Results are sensitive to the initial laparoscopic equipment
investment and number of cases performed annually but robust to other parameters. The laparoscopic intervention is
more cost-effective with investment costs less than $91,979, greater than 65 cases annually, or at willingness-to-pay
(WTP) thresholds greater than $3975/QALY.
Conclusions At RMH, while laparoscopic cholecystectomy may be a more effective approach, it is also more
expensive given the low caseload and high investment costs. At commonly accepted WTP thresholds, it is not cost-
effective. However, as investment costs decrease and/or case volume increases, the laparoscopic approach may
become favorable. Countries and hospitals should aspire to develop innovative, low-cost options in high volume to
combat these barriers and provide laparoscopic surgery.

Introduction cholecystectomy is now the first-line treatment for uncom-

plicated gallstone disease in high-income countries and is
The 1980s welcomed the introduction of laparoscopic associated with shorter hospital stays, reduced morbidity,
cholecystectomy as an alternative to the traditionally open more rapid return to work, lower mortality, and significantly
approach to removing the gallbladder [1]. Laparoscopic

& Mark G. Shrime 3

Rwanda Military Hospital, Kigali, Rwanda
shrime@mail.harvard.edu 4
Department of Surgery, University of Connecticut,
1 Farmington, CT, USA
Program in Global Surgery and Social Change, Harvard
5
Medical School, 641 Huntington Ave #411, Boston, Department of Plastic and Oral Surgery, Boston Children’s
MA 02115, USA Hospital, Boston, MA, USA
2 6
University of Miami Miller School of Medicine, Miami, FL, Department of Otolaryngology and Office of Global Surgery,
USA Massachusetts Eye and Ear Infirmary, Boston, MA, USA

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reduced hospital costs [2–4]. The practice of laparoscopy in
low- and middle-income countries (LMICs) remains limited
[3]; economic and cost–effectiveness concerns are fre-
quently cited as major barriers to widespread acceptance of
laparoscopic surgery [5–10].
Despite such uncertainty regarding the value of laparo-
scopy in LMICs, studies have repeatedly demonstrated that
minimally invasive surgery is safe, feasible, and beneficial in
low-resource settings [4, 7, 11–14]. Successful implemen-
tation of laparoscopy in low-resource settings has been
demonstrated in Mongolia, where laparoscopic procedures
have been associated with decreases in surgical site infec-
tions, shorter hospital stays, and lower hospital expenditures
in comparison with an open approach [14, 15]. While the
laparoscopy expansion project in Mongolia did not assess the
economics of laparoscopy, it made cost-minimizing adap-
tations, such as utilization of reusable ports, sterilization
techniques for otherwise disposable materials, meticulous
care of instruments to extend life, and use of surgical gloves
as extraction bags [14]. Other countries such as Nigeria have
demonstrated use of similar cost-saving methods in con-
junction with their integration of laparoscopy [4].
In 2015, The Lancet Commission on Global Surgery esti-
mated that five billion people lack access to safe, affordable
surgical and anesthesia care when needed [16, 17]. Further,
essential surgical and anesthesia care was established as cost-
effective interventions in low-resource settings [18]. How-
ever, 81 million individuals face catastrophic health expen-
ditures due to payment for both surgery and anesthesia, and the
non-medical costs associated with accessing surgical care
[19]. Determining the most cost-effective option is key to
ensuring that limited resources are best used to combat the
unmet need of surgical care. Given robust evidence supporting
the safety and feasibility of laparoscopy in LMICs and the
continual lack of uptake of laparoscopic surgery, there is a
need to determine the value of laparoscopic cholecystectomy
in comparison with an open approach.
Methods
Study design
This study looks at a single institution, Rwanda Military
Hospital (RMH), a referral hospital that provides secondary
and tertiary level care as well as educational activities.
RMH is one of the four major referral hospitals in Rwanda.
It provides health care services to both civilian (80%) and
military (20%) patients and has a capacity of approxi-
mately 350 beds [20]. A cost–effectiveness analysis (CEA)
was performed following the recommendations published
on behalf of the Panel on Cost-Effectiveness in Health and
Medicine in JAMA 1996 [21–23].
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Fig. 1 Sequential decision tree. GB gallbladder, Lap chole laparo- c
scopic cholecystectomy, Open chole open cholecystectomy, CBD
common bile duct, USG ultrasonography, CBDE common bile duct
exploration, MRCP magnetic resonance cholangiopancreatography,
Square decision node, Circle probability node, Left pointed triangle
with square terminal node. Numerical values for all variables are
defined in Table 1
Design of decision trees
The study evaluated two treatment options for biliary dis-
ease at Rwanda Military Hospital—laparoscopic or open
cholecystectomy. In this setting, where endoscopic retro-
grade cholangiopancreatography (ERCP) is not available,
suspected cholelithiasis requires imaging for diagnostic
confirmation as well as assessing for the presence of
common bile duct (CBD) stones. For each of the radio-
logical studies—ultrasound, CT, and magnetic resonance
cholangiopancreatography (MRCP)—tree branches were
constructed for true-positive, true-negative, false-positive,
and false-negative possibilities. In cases where CBD stones
were suspected, a common bile duct exploration (CBDE)
was performed in addition to the general open approach.
Terminal nodes reflected common outcomes of cholecys-
tectomies—uncomplicated recovery, bile duct injury, sur-
gical site infection (SSI), incisional hernia, or death. The
tree is depicted in Fig. 1.
Event probability estimation
A literature review was conducted to determine the prob-
abilities of each event in the tree pathway. Due to the small
sample size of laparoscopic cholecystectomies at RMH,
other sources were consulted; outcomes at RMH are
compared to these estimates in Table 1. Sources were
evaluated and selected in the following order: (1) country
(Rwanda), (2) region (East Africa), (3) super-region (sub-
Saharan Africa), (4) development group (low-income
countries), (5) high-income country data (preferably older),
and (6) assumptions [24].
Effectiveness measure estimation
Quality-adjusted life years (QALYs) were used as the
measure of effectiveness. Sources were evaluated in the
same order as those for probability estimations. The anal-
yses include a study for patients undergoing ventral hernia
repair to define the utility weights for surgical site infection
and incisional hernia because no study was identified
which assessed these utility weights in patients undergoing
a cholecystectomy [25].
World J Surg (2017) 41:1225–1233 1227

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Table 1 Point estimates for probabilities of epidemiological variables and utility values, and distributions used for probabilistic sensitivity
analysis as well as parameterization
Variables RMH Point Standard error a (success b (failure n Distr Author
estimates estimates [sq (pq) – 0.05] or lower or upper
(mean) bound) bound)

Probabilities
Common bile duct stones 0.805 60 685 B Ersumo [31]
USG detecting CBD stones if 0.82 0.33 B Pickuth [32]
they exist
USG detecting CBD stones if 0.02 0.09 B Pickuth [32]
they do not exist
CT detecting CBD stones if 0.86 0.30 B Pickuth [32]
they exist
CT detecting CBD stones if 0.02 0.09 B Pickuth [32]
they exist
MRCP detecting CBD stones 0.96 0.15 B Pickuth [32]
if they exist
MRCP detecting CBD stones 0.02 0.09 B Pickuth [32]
if they exist
Open chole cure 1.0 0.9291 694 D Ersumo [31]
Open chole BDI 0.0 0.0027 2 D Ersumo [31]
Open chole SSI 0.0 0.0562 42 D Ersumo [31]
Open chole incisional hernia 0.0 0.0080 6 D Ersumo [31]
Open chole mortality 0.0 0.0040 3 D Ersumo [31]
Open chole ? CBDE cure 0.7741 45,099 D Vellacott and Powell [33]
Open chole ? CBDE BDI 0.0128 747 D Vellacott and Powell [33]
Open chole ? CBDE SSI 0.1795 10,458 D Ersumo [31]
Open chole ? CBDE 0.0080 468 D Vellacott and Powell [33]
incisional hernia
Open chole ? CBDE 0.0256 1,494 D Vellacott and Powell [33]
mortality
Lap chole cure 0.9412 0.9386 2,668 D Mohamed et al. [34]
Lap chole BDI 0.0 0.0031 9 D Mohamed et al. [34]
Lap chole SSI 0.0 0.0021 6 D Mohamed et al. [34]
Lap chole incisional hernia 0.0 0.0028 8 D Mohamed et al. [34]
Lap chole mortality 0.0 0.0021 6 D Mohamed et al. [34]
Lap conversion to open chole 0.0588 0.0513 145 D Mohamed et al. [34]
Utilities
Open/CBDE chole (cure) 0.77 0.54 1.0 U Bass et al. [35]
Lap chole (cure) 0.91 0.82 1.0 U Bass et al. [35]
Bile duct injury 0.61 0.22 1.0 U Moore et al. [36]
Surgical site infection 0.69 0.38 1.0 U Chatterjee et al. [25]
Incisional hernia 0.60 0.20 1.0 U Chatterjee et al. [25]
Mortality 0
Open chole open cholecystectomy Lap chole laparoscopic cholecystectomy CBDE common bile duct exploration USG ultrasonography CBD
common bile duct MRCP magnetic resonance cholangiopancreatography BDI bile duct injury SSI surgical site infection Distr distribution B beta
D Dirichlet U uniform

Cost estimation of surgery including transportation, lost salary during

hospital admission for both the patient and accompanying
For costing data, a societal perspective was taken. Cost family members, as well as time until return to work were
parameters were gathered primarily via RMH’s electronic also considered [26]. Terminal node costs were calculated
medical records which details exact costs. Ancillary costs in consideration of the procedure received—laparoscopic

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Table 2 Costs per patient in 2014 USDs related to open and versus open. For example, those patients who developed an
laparoscopic cholecystectomy incisional hernia following an open procedure incurred
Variable Cost ($) greater costs than those who had laparoscopic surgery due
to increased cost of supplies. Contrastingly, patients
Open chole 596.63
incurred the same cost following a bile duct infection no
Open chole ? CBDE 691.88 matter which intervention they received. Using Rwanda’s
Lap chole 1305.55 purchasing power parity, costs were converted to 2014
Lap conversion to open chole 1612.17 USD for analysis [27]. The initial investment for laparo-
Abdominal USG 33.00 scopic equipment was amortized over a period of five years
Abdominal CT 682.07 to reflect yearly investment.
MRCP 838.36
Post-op: cure 7.31 Cost–effectiveness and sensitivity analysis
Post-op: BDI 1445.33
Post-op: SSI 409.19 Analysis was performed to test alternative data and
Post-op: incisional hernia (lap chole) 904.59 assumptions to elucidate the stability of the findings. A
Post-op: incisional hernia (open chole) 930.47 tornado diagram was run to identify those variables whose
Post-op: mortality 0.0 uncertainty most greatly drive the results; probabilities
were standardized to avoid sums greater than 1.0. Subse-
quently, for all parameters that crossed the willingness-to-
Table 3 Cost–effectiveness for open and laparoscopic cholecystec- pay (WTP) threshold on the tornado diagram, one-way
tomy approaches sensitivity analyses were performed to assess for thresholds
Strategy Cost Effectiveness Incremental C/E (ICER) at which laparoscopic cholecystectomy became cost-ef-
fective. The WTP threshold was set at three times Rwan-
Open chole 2058.72 0.75 da’s gross domestic product (GDP) per capita or $2088
Lap chole 2664.47 0.87 4946.18 USD [28, 29]. Of note, this threshold was originally

Fig. 2 Net monetary benefit

one-way cost–effectiveness
sensitivity analysis.
Willingness-to-pay measured in
2014 USD

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Fig. 3 Cost–effectiveness
acceptability cure. Willingness-
to-pay measured in 2014 USD
defined by the WHO as per DALY averted, not per QALY
gained.
A probabilistic sensitivity analysis (PSA) was also per-
formed. For this analysis, costs were defined as gamma
distributions, probabilities as beta or Dirichlet distribu-
tions, and utilities as uniform distributions. Lastly, a Monte
Carlo simulation with 1,000 total runs was conducted as
well as a two-way sensitivity analysis looking at the rela-
tionship between investment cost and number of cases
performed annually in determining cost–effectiveness
recommendations.
Results
Parameter estimation
There were 17 total laparoscopic cholecystectomies con-
ducted at RMH prior to the study; during a time-matched
period, there were 12 documented open cholecystectomies.
Based on these numbers, terminal node event probabilities
are included in Table 1 for comparison with the outside
sources utilized in calculations due to greater sample sizes.
Due to the small sample sizes, they were not included in
calculations.
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Other point estimates for probabilities of epidemiolog-
ical variables and utility values are found in Table 1. Cost
estimates are summarized in Table 2.
Cost–effectiveness analysis
Laparoscopic and open cholecystectomy cost and effec-
tiveness values were $2664.47 with 0.87 QALYs and
$2058.72 with 0.75 QALYs, respectively (Table 3). The
incremental cost–effectiveness ratio (ICER) for laparo-
scopic cholecystectomy, compared to open cholecystec-
tomy, was $4946.18/QALY.
Sensitivity analyses
If the initial investment cost of the laparoscopic equipment
was not included in the total cost for the relevant pathways,
the new laparoscopic approach cost and effectiveness val-
ues were $1851.30 with 0.88 QALYs. The cost and
effectiveness values for the open approach remained the
same. In this case, the laparoscopic approach strictly
dominated the open cholecystectomy approach.
The one-way sensitivity analysis evaluating for the
threshold number of cases performed at RMH in order for
the laparoscopic cholecystectomy route to become more
World J Surg (2017) 41:1225–1233
Fig. 4 Two-way sensitivity
analysis on investment cost and
number of cases. cInvestment
measured in 2014 USD; nCases
reflects annual volume
cost–effective at the WTP threshold was 65 laparoscopic
cholecystectomy cases annually (Fig. 2). Additionally, a
one-way sensitivity analysis looking at investment cost
found that laparoscopic cholecystectomies were cost-ef-
fective at the WTP threshold for investment costs less than
$91,979. Results were robust to other sensitivity analyses.
The Monte Carlo simulation demonstrated that at WTP
thresholds greater than $3975/QALY, a laparoscopic
cholecystectomy becomes more likely to be cost-effective.
For all WTP values below this value, the open cholecys-
tectomy was more likely to be cost-effective (Fig. 3).
A graph generated from the two-way sensitivity analysis
on investment cost and number of cases performed annu-
ally depicts the threshold considerations for both parame-
ters in combination; it models the values above or below
which laparoscopic surgery becomes more cost-effective
than an open approach for cholecystectomy (Fig. 4).
Discussion
The results from RMH demonstrate that while a laparo-
scopic cholecystectomy may be a more effective approach,
it is also more expensive. At a WTP threshold of 39 GDP
per capita in Rwanda ($2088), the open approach is
1231
recommended. Sensitivity analyses showed that above a
WTP threshold of $3975, the laparoscopic approach is
more likely to be cost-effective. This suggests that
laparoscopic surgery may become more affordable in
LMICs as GDP per capita grows.
In sensitivity analyses performed without consideration
of initial investment costs, the laparoscopic approach is
both less expensive and more effective, strictly dominating
the open approach. This suggests that in settings where
machinery can be donated, where machinery has already
been donated, or where local/regional equipment can be
purchased, the implementation of a laparoscopic approach
may be feasible and beneficial. At investments costs less
than $91,979, the laparoscopic approach is also more
favorable. Currently, opportunities exist to obtain laparo-
scopic equipment for investment costs less than $7500
from some sources such as Indian suppliers [30]. Thus, as
innovation leads to the availability of equipment at lower
investment costs, recommendations will shift to more
completely favor the laparoscopic approach.
Additionally, at an annual volume of 65 cases or more,
the laparoscopic cholecystectomy approach is more cost-
effective at the WTP threshold even with the high initial
capital cost paid in this specific case. RMH currently
operates at a volume of 37 cholecystectomies annually. Not
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only would increasing the number of laparoscopic chole-
cystectomies performed directly offset the investment cost
and consequently shift recommendations, but also would
increasing the number of laparoscopic procedures in gen-
eral. Utilization of laparoscopic equipment for additional
general surgery pathologies as well as other subspecialty or
OBGYN procedures would reduce the portion of initial
investment costs each patient is responsible for with each
laparoscopic procedure.
Such case threshold information can help guide recom-
mendations regarding whether and when a program would
benefit from starting to offer laparoscopic cholecystec-
tomies. The investment cost would actually need to decrease
approximately $70,000 (43% of initial investment) to a total
of $91,979 in order to be cost effective. Further, these
parameters must be considered in combination instead of in
exclusivity. Both the investment cost and case volume del-
icately impact recommendations, and a decrease in invest-
ment cost in parallel to an increase in case volume can most
effectively support introduction of laparoscopy in low-re-
source settings. As shown in Fig. 4, at each investment cost,
there is a specific case volume above which cost–effective-
ness shifts toward laparoscopic cholecystectomy. Similarly,
at each case volume, there is a specific investment cost
threshold. Such a model can enable healthcare leaders to
predict whether at X cases per week or per year, they can
afford instruments at Y cost in a cost-effective manner.
Healthcare leaders must consider this dichotomy when
developing new laparoscopy programs. Furthermore,
beyond the measures directly considered in this cost–effec-
tiveness analysis lie the economies of scope—this includes
these different specialties that may conduct different pro-
cedures using the same equipment. Hospital administrators
and policymakers must not only utilize information from
cost–effectiveness analyses, but also equally consider other
critical players in the system to inform their decisions.
Ultimately, given the widely accepted benefits of laparo-
scopic surgery, efforts must be made toward developing
programs and environments that can cost-effectively offer
laparoscopic care given the widely accepted benefits of such
minimally invasive surgery.
Previous studies indicate mixed results regarding whe-
ther or not implementation of laparoscopy is cost-effective
in low-resource settings [6, 7, 10]. Some support laparo-
scopic approaches at WTP thresholds of 39 GDP per
capita [10], while others suggest that economic benefit may
only be for higher-income patients until future cost
reduction strategies can be employed [9].
Of note, non-financial barriers to the integration of
laparoscopic surgery exist. Such barriers include lack of
training, lack of functioning equipment, and an unavail-
ability of qualified surgeons [12, 14]. Countries such as
Mongolia have demonstrated the successful development
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World J Surg (2017) 41:1225–1233
of basic laparoscopic courses and have implemented them
at multiple referral centers [14]. Other countries such as
Yemen have relied on the support of high-income coun-
tries [12]. However, even if finances shift and an LMIC
can afford to purchase the necessary equipment in a cost-
effective manner, lack of biomedical technicians in
LMICs hinders repair and maintenance of the equipment
[16].
This study has limitations. Due to the limited numbers
of laparoscopic cases performed at RMH and lack of
studies about laparoscopy in Rwanda, event probabilities
used in calculations were obtained from other LMICs.
While a methodical approach was utilized to ensure the
most representative results possible, and while RMH
probabilities were similar, the small sample size pre-
cludes direct applicability at RMH. Additionally, QALYs
are derived from studies in HICs and sometimes involved
other procedures. In order to combat these limitations, a
sensitivity analysis was conducted and demonstrated that
the results were not sensitive to any changes. Moreover,
the decision tree reflects current resources at RMH but
would be subject to change given the advent of new
resources. Such modifications to the decision pathway
could alter which choice is most cost-effective. Lastly,
the cost attributed to each case as a portion of the initial
equipment investment cost reflected only the number of
annual laparoscopic cholecystectomy cases; it did not
consider gynecologic or urologic laparoscopic cases
already currently performed at RMH.
Despite these limitations, our results are robust to
uncertainty in all parameters except for the initial invest-
ment in laparoscopic equipment and the annual number of
cases performed. This study contributes to the existing
debate as it illustrates situations in which implementation
of laparoscopic surgery may or may not be cost-effective.
It may serve as a model for future costing studies and also
provides an evidence-based insight on the opportunities for
laparoscopic surgery in LMICs.
Conclusion
Though a laparoscopic cholecystectomy approach is a
more effective option for patients with biliary disease, it
may be too expensive to replace open cholecystectomy at
current implementation costs and annual volume of cases.
At willingness-to-pay thresholds of 39 GDP per capita in
Rwanda’s current setting, open cholecystectomy is more
cost-effective than laparoscopic cholecystectomy. How-
ever, as investment costs decrease and/or case volume
increases, the laparoscopic approach may become cost-ef-
fective. Healthcare leaders must be aware of the complex
variables involved in implementation of laparoscopic
World J Surg (2017) 41:1225–1233
surgery and use cost–effectiveness analyses, in addition to
other considerations, in order to best inform and guide their
decisions. Ultimately, advocacy efforts should focus on
developing innovative, low-cost alternatives in order to
provide laparoscopic surgical care to those who need it
most.
Acknowledgements MGS receives support from the GE Safe Sur-
gery 2020 project and from the Steven and Carmella Kletjian
Foundation.
Compliance with ethical standards
Conflict of interest The authors have no conflicts of interest to
declare.
References
1. Moore D, Feurer I, Holzman M et al (2004) Long-term detri-
mental effect of bile duct injury on health-related quality of life.
Arch Surg 139:476–482
2. Tiwari MM, Reynoso JF, High R et al (2011) Safety, efficacy,
and cost-effectiveness of common laparoscopic procedures. Surg
Endosc 25(4):1127–1135
3. Topcu O, Karakayali F, Kuzu MA et al (2002) Comparison of
long-term quality of life after laparoscopic and open cholecys-
tectomy. Surg Endosc 17:291–295
4. Ray-Offor E, Okoro PE, Gbobo I et al (2014) Pilot study on
laparoscopic surgery in Port-Harvourt, Nigeria. Niger J Surg
20(1):23–25
5. Ali R, Khan MR, Pishori T et al (2010) Laparoscopic appen-
dectomy for acute appendicitis: is this a feasible option for
developing countries? Saudi J Gastroenterol 16(1):25–29
6. Bailey HH, Dan DV (2005) An economic evaluation of laparo-
scopic cholecystectomy for public hospitals in Trinidad and
Tobago. West Indian Med J 54(2):110
7. Bendinelli C, Leal T, Moncade F et al (2002) Endoscopic surgery in
Senegal. Benefits, costs and limits. Surg Endosc 16(10):1488–1492
8. Chao TE, Mandigo M, Opoku-Anane J et al (2016) Systematic
review of laparoscopic surgery in low- and middle-income
countries: benefits, challenges, and strategies. Surg Endosc
30(1):1–10
9. Tintara H, Leetanaporn R (1995) Cost-benefit analysis of
laparoscopic adnexectomy. Int J Gynecol Obstet 50:21–25
10. Teerawattananon Y, Mugford M (2005) Is it worth offering a
routine laparoscopic cholecystectomy in developing countries?
A Thailand case study. Cost Eff Resour Alloc 3:10
11. Brekalo Z, Innocenti P, Duzel G et al (2007) Ten years of
laparoscopic cholecystectomy: a comparison between a devel-
oped and a less developed country. Wien Klin Wochenschr
119(23–24):722–728
12. Hussain A, Mahmood HK, Dulku K (2008) Laparoscopic
cholecystectomy can be safely performed in a resource-limited
setting: the first 49 laparoscopic cholecystectomies in Yemen.
J Soc Laparoendosc Surg 12:71–76
13. Murphree S, Dakovic S, Mauchaza B et al (1993) Laparoscopic
cholecystectomy in Zimbabwe: initial report. Cent Afr J Med
39(5):85–88
14. Price R, Sergelen O, Unursaikhan C (2013) Improving surgical
care in Mongolia: a model for sustainable development. World J
Surg 37:1492–1499. doi:10.1007/s00268-012-1763-
1233
15. Straub CM, Price RP, Matthews D (2011) Expanding Laparo-
scopic Cholecystectomy to Rural Mongolia. World J Surg
35:751–759. doi:10.1007/s00268-011-0965-2
16. Meara JG, Leather AJM, Hagander L et al (2015) Global Surgery
2030: evidence and solutions for achieving health, welfare, and
economic development. Lancet 386(9993):569–624
17. Alkire BC, Raykar NP, Shrime MG et al (2015) Global access to
surgical care: a modelling study. Lancet Glob Health
3(6):316–323
18. Chao TE, Sharma K, Mandigo M et al (2014) Cost-effectiveness
of surgery and its policy implications for global health: a sys-
tematic review and analysis. Lancet Glob Health 2:e334–e345
19. Shrime MG, Dare A, Alkire B et al (2015) Catastrophic expen-
diture to pay for surgery: a modelling study. Lancet Glob Health
3:38–44
20. Rwanda Military Hospital; Ministry of Defence. (2015). http://
mod.gov.rw/about-the-mod/agencies-units/rwanda-military-hospi
tal/#.VdysN2ZXenM. Accessed 10 Jan 2015
21. Russell LB, Gold M, Siegel JE et al (1996) The role of cost-
effectiveness analysis in health and medicine. JAMA
276:1172–1177
22. Siegel JE, Weinstein MC, Russell LB et al (1996) Recommen-
dations for reporting cost-effectiveness analyses. JAMA
276(16):1339–1341
23. Weinstein MC, Siegel JE, Gold MR et al (1996) Recommenda-
tions of the panel on cost-effectiveness in health and medicine.
JAMA 276(15):1253–1258
24. Shrime MG, Verguet S, Johansson KA et al (2016) Task-sharing
or public finance for the expansion of surgical access in rural
Ethiopia: an extended cost-effectiveness analysis. Health Policy
Plan 31(6):706–716
25. Chatterjee A, Krishnan NM, Rosen JM (2014) Complex ventral
hernia repair using components separation with or without syn-
thetic mesh: a cost-utility analysis. Plast Reconstr Surg 133:137
26. Hussain Talpur KA, Mahmood Malik A, Khan Sangrasi A et al
(2011) Comparative study of conventional open versus laparo-
scopic cholecystectomy for symptomatic cholelithiasis. Pak J
Med Sci 27(1):33–37
27. World Bank Purchasing Power Parity (2015) http://data.world
bank.org/indicator/PA.NUS.PRVT.PP. Accessed 17 Sep 2015
28. Choosing interventions that are cost-effective [Internet]. Geneva:
World Health Organization (2016). http://www.who.int/choice/
en/. Accessed 30 Jan 2016
29. The World Bank: Rwanda Data (2015) http://data.worldbank.org/
country/rwanda#cp_wdi. Accessed Oct 9 2015
30. Indiamart: Laparoscopy Equipment from India (2016) http://dir.
indiamart.com/impcat/laparoscopy-equipment.html. Accessed 1
Aug 2016
31. Ersumo T (2006) Gallstone disease in a teaching hospital, Addis
Ababa: a 5-year review. Ethiop Med J 44(1):49–59
32. Pikuth D (2000) Radiologic diagnosis of common bile duct
stones. Abdom Imaging 25:618–621
33. Vellacott KD, Powell PH (1979) Exploration of the common bile
duct: a comparative study. Br J Surg 66:389–391
34. Mohamed MI, Abdalla AA, Alshaikh AA (2014) Laparoscopic
cholecystectomy: a 15-years experience at a single centre: Wad
Medani, Sudan. East Cent Afr J Surg 19(2):12–16
35. Bass EB, Pitt HA, Lillemoe KD (1993) Cost-effectiveness of
laparoscopic cholecystectomy versus open cholecystectomy. Am
J Surg 165:466–471
36. Moore DE, Feurer ID, Holzman MD et al (2004) Long-term
detrimental effect of bile duct injury on health-related quality of
life. Arch Surg 139:476–482
123