Cleft lip and palate repair across two rural hospitals in a resource-challenged setting: immediate perioperative outcomes and lessons learned

Abstract

Cleft lip and palate (CLP) is a common congenital anomaly associated with significant functional and psychosocial consequences. In low-resource settings, limited infrastructure and surgical expertise may delay corrective surgery. This program audit aimed to describe the spectrum, frequency, and management of perioperative complications following CLP repair in two rural Indonesian hospitals and to derive context-specific perioperative recommendations. We conducted a retrospective program audit of consecutive patients aged < 18 years who underwent CLP-related surgery as part of social-service programs at two rural hospitals in East Nusa Tenggara, Indonesia, between 2023 and 2024. The primary outcome was a composite of in-hospital immediate postoperative outcomes, including bleeding requiring intervention, airway obstruction or laryngospasm, emergence agitation requiring pharmacological treatment, unplanned intensive care unit (ICU) admission, reoperation, or death. Complications were categorized as major or minor. Categorical variables were compared using Fisher’s exact test. A total of 173 patients were included (primary surgery, n = 138; secondary surgery, n = 35). The composite complication rate was 10.9% in the primary group and 8.6% in the secondary group (relative risk, 1.30; 95% confidence interval, 0.35–4.77; p = 1.000). Emergence agitation (4.3%) and perioperative hypothermia (3.6%) were observed only in the primary group, whereas post-extubation laryngospasm occurred in both groups (1.4% vs. 5.7%). No mortality, reoperation, or unplanned ICU admissions occurred 24 h postoperative. CLP repair performed through a social-service model in rural Indonesian hospitals was feasible and demonstrated a favorable immediate perioperative safety profile, with no mortality or unplanned ICU admissions. However, these findings are limited to in-hospital outcomes, as post-discharge complications were not systematically assessed. Furthermore, the study was not powered to detect clinically meaningful differences between surgical groups. Larger prospective studies with longer follow-up are needed to comprehensively evaluate perioperative and postoperative safety in resource-limited settings.