Simple and low-tech is good enough: Emergency craniotomies through 13 years at a local hospital in Cambodia

Abstract

Abstract
Where the epidemic of trauma hits hardest - like in Cambodia - trauma centers are few if at all existing, and skilled treatment too expensive for most trauma victims. In 2013 the authors decided to build capacity for emergency craniotomies at a referral hospital in Northwestern Cambodia. Two local general surgeons and one trauma nurse underwent hands-on training in craniotomy and post-operative monitoring, first on live anesthetized animal models, then during brief study periods at a referral trauma hospital in Norway. At the Cambodian study hospital, the craniotomies were done by hand-drills and Gigli-wire saws, and the ICU did not have ventilators. During the first four years all head trauma cases admitted was managed under on-line guidance from Norwegian neurosurgeons. In this period 246 patients with traumatic brain injury underwent craniotomy, the mortality rate was 7% and long-term outcome satisfactory with Glasgow Come Outcome ratings at 4 or 5 in 93% of the patients. From 2017 to 2025 the Cambodian head trauma center operated independently without distance monitoring by neurosurgeons. During this period a total of 484 post-traumatic emergency craniotomies were performed with recovery rates like the initial study period, mortality rates remaining low, at 8.3%. Successful decompressive craniectomies done in this period indicate capable surgery. The main lesson learned in the Cambodian intervention is that proper head trauma surgery does not depend on high-tech instruments, subarachnoid monitors, or advanced ventilators. Critical alterations in cerebral perfusion can be read by clinical signs, and the patient managed accordingly - provided you are dedicated, well trained, and stay close to the patient at all times.