Anesthesia for laparoscopic surgery is particular because of the hemodynamic, ventilatory and neurological repercussions induced by the pneumoperitoneum and by the positioning of the patient [1] - [4] . Increased intra-abdominal pressure and hypercapnia after insufflation of carbon dioxide through the pneumoperitoneum during laparoscopic surgery are the mechanisms of hemodynamic, respiratory, etc. changes. The risks are linked to pneumoperitoneum and positioning (atelectasis, hypercapnia, gas embolism, renal attack, cardiovascular changes). Intra-abdominal pressure greater than 20 mmHg increases the risk of respiratory complications (atelectasis, gas embolism), renal attack, high and low blood pressure, rhythm disturbances. The main objectives of anesthetic management are understanding the primary pathophysiology, optimizing functional status and hemodynamics, and managing comorbidities to minimize the effects and impacts of pneumoperitoneum in patients undergoing this type of surgery [5] [6] .

This is why this surgery is conventionally done under general anesthesia with tracheal intubation [7] . Volume-controlled ventilation with positive end expiratory pressure (PEEP) of approximately 5 cmH₂O is the most commonly used mode. Pressure-controlled ventilation is used if there is a significant rise in airway pressure with risk of barotrauma and in this case tidal volume must be monitored [6] . The laryngeal mask presents the risks of inhalation and displacement but is proposed and used by certain teams [8] [9] . However, publications on the advantages of locoregional anesthesia, particularly spinal anesthesia, exist in the literature [10] - [12] .

Laparoscopic surgery is preferable over conventional laparotomy due to its advantages, such as less trauma, early mobilization, minimal blood loss, more aesthetic and small scars, reduced postoperative pain, postoperative recovery time and shorter hospital stay, as well as lower mortality and morbidity [5] .

These advantages mean that it is now practiced in patients of all ages, including infants and even newborns [13] . It is performed almost for all surgeries and has become the gold standard for cholecystectomy, appendectomy, splenectomy, gastroesophageal reflux surgery, colectomy, abdominal wall hernias, etc. [14] [15] .

Postoperative pain is short-lived and almost 80% of patients may require the use of opioids. Locoregional anesthesia techniques (peri-medullary and peripheral) as well as the infiltration of local anesthetics are effective in this type of surgery [6] .

Patient limitations to laparoscopic surgery can be: difficult access to the abdomen, obliteration of the peritoneal space, organomegaly, intestinal distension, and the potential for dissemination or recurrence of cancer, pregnancy, increased intracranial pressure, abnormalities of cardiac output and gas exchange in the lung, and chronic liver disease and coagulopathy. While many of these conditions were formerly considered absolute contraindications to laparoscopy, they are now considered, by many surgeons, to be only relative contraindications [16] .

Although laparoscopic surgery has become the gold standard for many thoracic and abdominal visceral procedures in high-income countries [14] [15] , it has been slow to develop in low-income countries. Thus, in the Democratic Republic of Congo, its practice dates back more than thirty years but its development is more recent and publications in anesthesia on this subject are rare. The study recently published in December 2023 by Muamba only concerned digestive endoscopy [17] . At the Monkole Hospital Center, the technique began around the year 2016 and this study reports the experience of anesthesia in laparoscopic surgery in this hospital since it has been practiced there.

During this period, 84 patients were anesthetized for laparoscopy for nearly 2000 eligible, or 4.5%. All 84 patients were analyzed.

This study was carried out to report the experience of laparoscopic anesthesia at the secondary level hospital locate in suburban environment which only concerned 84 patients or 4.2% of eligible cases. The median age was 31 years with a predominance of the group between 15 and 30 years (p = 0.034) and of the female gender. Patients cared for by their companies were the majority. Indeed, the cost of laparoscopic surgery remains higher than open surgery, so patients whose costs (medical expenses, instead of costs) are covered by the company have access to it more easily than those who have to provide by themselves. Note that health coverage is not yet effective for surgery in the DRC. Comorbidities were: sickle cell disease (25.3%), alcohol consumption (25%), cardiovascular pathology (17.6%) and obesity (14.3%). Paraclinical examinations were not systematically requested. The ASA class was: I (35.2%), II (36.3%) and III (28.6%). Anesthesia was general with intubation for all patients maintained with halogens. The indications for operation were mainly vesicular and appendicular. Anesthesia often lasted more than two hours and postoperative analgesia used morphine in 27.5%. All patients were treated in hospital. Intraoperative complications were present in 18.7% and mainly represented by arterial hypotension (9.8%). Postoperative complications were present in 9.9% and consisted mainly of anemia requiring transfusion (5.4%) and three deaths (metastatic cancer, multiple organ failure and stroke) were recorded postoperatively. Alcohol consumption and ASA class 3 were associated with intraoperative complications. Anesthesia duration greater than two hours, ASA3 class, alcohol consumption and cholecystectomy were associated with postoperative complications.

Anesthesia was general with intubation for all patients although the literature abounds for locoregional anesthesia, particularly perimedullary anesthesia [11] [18] . The debate on the choice between general anesthesia and locoregional anesthesia remains open, the patient’s opinion should sometimes be preponderant and certain intraoperative positions are uncomfortable for the patient under locoregional anesthesia. A recent meta-analysis [19] in laparoscopic gynecological surgery did not show the advantages of spinal anesthesia compared to general anesthesia. The laryngeal mask although recommended by certain authors [8] [9] was not used due to the risk of inhalation as the duration of surgery often exceeded one hour. The little team experience does not yet allow this risk to be taken. No cholecystectomy or appendectomy was performed under regional anesthesia. However, cases of cholecystectomy and appendectomy by laparoscopic surgery under locoregional anesthesia peri-medullary are published in the literature [20] [21] .

Maintenance of anesthesia was done with halogens (sevoflurane or isoflurane) for all patients although the literature suggests total intravenous anesthesia with propofol because of the postoperative nausea and vomiting common in this type of surgery [22] . However, prevention with dexamethasone and ondasetron was often used and vomiting occurred in 1.2%. The duration of anesthesia was less than two hours in 46.2% and two hours or more in 53.8%. It must be recognized that the durations of the acts were quite long due to learning. In fact, most often it was a single laparoscopist who worked with the learners and also trained them in the technique, which extended the duration of the procedures.

Postoperative analgesia used morphine in 27.5% without the use of peripheral blocks, particularly the transversus abdominis block, and rarely local infiltration of xylocaine, contrary to certain literature which reports nearly 80% use of opioids [6] .

The operating indications were dominated by appendicitis (16.5%) and lithiasis with or without cholecystitis (48.4%). This corroborates literature data [14] [15] . Pyloromyotomy for hypertrophic pyloric stenosis is currently performed under laparoscopic surgery [13] . No cases of newborns were recorded in this series due to lack of equipment adapted to this type of patient; the youngest in this series was two years old. The management of ruptured ectopic pregnancy, already possible even in less developed countries [23] , was not possible due to the availability of the surgeon.

Eleven patients, or 11.9%, including 7 who underwent diagnostic laparoscopy, were not hospitalized; however, all patients treated for interventional laparoscopy were hospitalized, although laparoscopic surgery has the advantage of being performed on an outpatient basis [24] [25] . The reason is the level of understanding of patients, the journeys made from home to hospital, the duration of which varies greatly due to transport difficulties (traffic jams on the road) in the city of Kinshasa. However, a meta-analysis of randomized controlled trials did not show the advantages of ambulatory cholecystectomy compared to hospitalization in terms of mortality and morbidity except patient satisfaction which was in favor of ambulatory surgery [26] . It should be noted that apart from the blood count, all other examinations were not systematically requested in all patients in accordance with the recommendations of the French Society of Anesthesia and Intensive Care [27] .

Intraoperative complications were present in 18.7% and dominated by arterial hypotension (9.8%) in accordance with literature data [1] - [6] . Indeed, from the insufflation of carbon dioxide, after a brief increase in blood pressure linked to the increase in vascular resistance, especially splanchnic resistance, the drop in venous return following the increase in intra-abdominal pressure is accompanied by a reduction in venous return and stroke volume and therefore a reduction in blood pressure [1] - [6] . A significant increase in airway pressures was not observed, nor a significant decrease in tidal volume, probably because the increase in intra-abdominal pressure was limited to less than 16 mmHg. Indeed, intra-abdominal pressure greater than 20 mmHg is associated with an increase in respiratory and hemodynamic complications [6] . An accidental injury to the common bile duct had occurred and required conversion to laparotomy for repair without any consequences. On the other hand, the accidental perforation of the vesicle before its extraction was managed under laparoscopic surgery without problem. It must be recognized that the allergic reactions suspected in 3.6% were not the subject of an allergological investigation due to lack of resources. Postoperative complications present in 9.9% mainly consisted of anemia requiring transfusion (5.4%). This is explained by the fact that 25% of patients had sickle cell disease, 20% had hemoglobin <7 g/dl preoperatively. Note that for all these sickle cell patients, no transfusion exchange or measurement of hemoglobin levels was carried out. A case of biliary fistula occurred postoperatively and was always treated laparoscopically without any vital or functional consequences. On the other hand, the case of digestive fistula (2.1%), on the ground of metastasized cancer in an 80-year-old patient died in a picture of septic shock. ASA class 3 multiplies by 4 the risk of complications in accordance with data from the general literature [28] . While age below 60 was protective. Without an obvious explanation, alcohol consumption was associated with the occurrence of intra- and postoperative complications (risk multiplied by 2 and 3). Indeed, none of the patients in this series had cirrhosis, only one had metastatic liver cancer and none were in liver failure. In Kamaran’s study [29] , male sex was an independent risk factor for conversion to open surgery (aOR 2.65 (1.03 - 6.94)). In this series, during cholecystectomy, only one case of conversion was recorded following damage to the common bile duct without the necessary equipment for its repair under laparoscopy. Cholecystectomy appears to be a factor associated with the occurrence of postoperative complications, but this is a bias probably due to the small size of the sample. Cholecystectomy is one of the oldest and easiest procedures to perform in laparoscopic surgery [14] [15] . The absence of surgeons trained in laparoscopy seems to be an important factor limiting the development of laparoscopic surgery in low-income countries such as the DRC, in accordance with the results of the of the systematic review carried out by Wilkinson in 2021 [30] .

This study has the limitations of being single-center and retrospective but has the merit of being the first published and allows us to note that laparoscopic surgery is beginning to be practiced in the city of Kinshasa and in the DRC.

Laparoscopic surgery is not yet established at the MHC due to the absence of permanent surgeon(s) and its cost which is higher than open surgery and perhaps also the under-information of patients on the advantages of the technique. Subsequent studies investigating the determinants of the non-development of laparoscopic surgery prove useful in verifying these hypotheses in DRC.

We thank the entire operating room team at the Monkole Hospital Center in particular: Olga Milo, Jacquies Byengangu, Cathy Nziavake, Bénoît Rwabahizi and Maguy Tshiabu for their spirit of service and collaboration. Also Milka Mbombo for proofreading and correcting this English version.

Alphonse Mosolo: study design, data collection and writing of the manuscript.

Wilfrid Mbombo: study design, data collection and writing of the manuscript.

Freddy Mbuyi: data collection and correction of the manuscript.

Marc Tshilanda: statistical analyses.

All other authors: correction of the manuscript.