๐ Table of Contents
Background & Introduction
Minimally invasive thoracic surgery (MITS) has transformed the management of thoracic conditions worldwide, offering patients reduced postoperative pain, shorter hospital stays, and faster return to daily activities compared to traditional open thoracotomy. Video-assisted thoracoscopic surgery (VATS) represents the gold standard for a growing number of indications including lung resection, pleural disease management, mediastinal mass excision, and thoracic sympathectomy.
Despite the well-established benefits of VATS in high-income settings, uptake in sub-Saharan Africa has remained limited due to infrastructure constraints, equipment costs, and training gaps. Rwanda, however, has made substantial investments in its health system over the past two decades, positioning the country as a regional leader in surgical capacity-building.
"The expansion of minimally invasive thoracic surgery in Rwanda represents not just a technical achievement, but a paradigm shift in how we conceptualize surgical capability in East African health systems." โ Prof. Jean-Pierre Habimana, RSS President
This review examines five years of VATS implementation at Rwanda's two main referral centers โ the Centre Hospitalier Universitaire de Kigali (CHUK) and King Faisal Hospital โ analyzing procedural outcomes, complication rates, and the training ecosystem supporting adoption.
Methods & Study Population
We conducted a retrospective cohort analysis of all VATS procedures performed at CHUK and King Faisal Hospital between January 2020 and December 2024. Data was extracted from surgical registries and supplemented by medical record review. Primary outcomes included conversion to open thoracotomy, 30-day morbidity, 30-day mortality, length of hospital stay, and time to return to activity.
A total of 347 VATS procedures were identified across the study period. Patients ranged from 18 to 78 years of age (mean 46.3 ยฑ 14.2 years), with a near-equal gender distribution (54% male). The most common indications were:
- Spontaneous pneumothorax (31.4%)
- Pleural effusion and empyema (26.8%)
- Pulmonary nodule resection (21.3%)
- Mediastinal mass (12.1%)
- Other thoracic pathology (8.4%)
Key Results & Outcomes
Overall outcomes compared favorably with published benchmarks from comparable middle-income countries. The conversion rate to open thoracotomy was 7.2% in the first two years, declining significantly to 3.1% in years four and five โ reflecting growing surgical team experience and improved patient selection protocols.
Thirty-day morbidity occurred in 14.4% of cases, with the most common complications being prolonged air leak (6.1%), wound infection (3.5%), and atrial fibrillation (2.3%). The 30-day mortality was 1.7% overall, consistent with global benchmarks for this procedure type and patient population.
Mean hospital stay following VATS was 3.8 days โ significantly shorter than the 7.2-day average for equivalent open thoracotomy cases at the same institutions, demonstrating tangible patient benefit.
Challenges & Barriers
Despite positive clinical outcomes, multiple systemic barriers were identified that limit wider uptake across Rwanda and the region:
Equipment & Consumables
The capital cost of a full VATS setup โ including a high-definition camera system, COโ insufflator, specialized trocars, and reusable instruments โ represents a significant investment for public hospitals operating under constrained budgets. Supply chain disruptions for single-use components were cited as a recurring operational challenge by both centers.
Human Resource Constraints
As of 2024, only four surgeons in Rwanda are proficient in advanced VATS techniques. The dual burden of clinical service provision and training leaves limited time for skills transfer. Theatre scheduling and dedicated simulation time remain bottlenecks for trainee development.
Anaesthesiology Capacity
One-lung ventilation, required for most VATS lung resections, demands specialized anaesthesiology expertise. Limited availability of trained anaesthesiologists with thoracic experience was cited as a rate-limiting factor in procedural expansion beyond the two main referral centers.
Training & Capacity Building
The RSS established a structured thoracic surgery training pathway in 2022 in collaboration with COSECSA and international partners. The pathway includes a two-day simulation workshop using box trainers, mentored cases under direct proctorship, and a competency-based assessment before independent practice.
Eight surgical trainees completed the Level 1 certificate in VATS skills between 2022 and 2024, with two trainees proceeding to advanced fellowship training in Kenya and South Africa. A train-the-trainer model is being piloted to accelerate domestic capacity building.
Conclusions & Recommendations
This five-year review demonstrates that VATS is both feasible and effective in Rwanda's referral hospital setting. Outcomes are comparable to international standards, and the learning curve for local surgeons is surmountable with structured support. However, scale-up requires coordinated investment in equipment sustainability, anaesthesiology training, and a deliberate expansion of the surgical training pipeline.
We recommend that the Ministry of Health and RSS jointly develop a National Minimally Invasive Surgery Strategy that prioritizes simulation infrastructure, regional training hubs, and procurement frameworks for sustainable equipment access. Expansion to provincial hospitals should be considered a medium-term goal, contingent on human resource development milestones.