Adoption of laparoscopy after utilization of low-cost simulation-based laparoscopy training

Introduction: Lack of access to traditional educational methods continues to hamper surgeons from learning laparoscopy in many low- and middle-income countries (LMIC). To address this gap, low-cost simulation platforms and assessment tools have been developed to support learning, practice, and assessment of laparoscopic psychomotor skills. While these tools show promise in enhancing skills, their impact on clinical practice remains unknown. ALL-SAFE, an open-source, low-cost laparoscopic surgery training system was piloted at several LMIC sites, including Mbingo Baptist Hospital (MBH). Previous studies indicate cognitive and psychomotor skill acquisition with ALL-SAFE, but its broader clinical impact needs further exploration. To characterize the impact of a laparoscopic training system beyond the simulation lab, characteristics of the practice of laparoscopic surgery were studied at MBH before and after the implementation of the ALL-SAFE program. Methodology: A retrospective chart review was conducted of operating room and in-patient medical records from before (January - December 2020) and after (January 2021- December 2023) the use of ALL-SAFE at MBH (2021). Total laparoscopic case volumes were extracted with proportions of laparoscopic and open surgeries calculated for surgical management of appendicitis and ectopic pregnancy. Additionally, a voluntary one-question survey soliciting barriers to implementation of laparoscopy was administered via email to all surgical faculty and residents at MBH. Results: At MBH, laparoscopic appendectomy accounted for 14.3% (1/7) of total appendectomy cases in 2020, 100% (7/7) in 2021, 76.9% (10/13) in 2022, and 55.6% (5/9) in 2023. Laparoscopic salpingectomy for management of ectopic pregnancy accounted for 22.2% (2/7) of total ectopic pregnancy cases in 2020, 60% (3/5) in 2021, 33.3% (2/6) in 2022, and 55.6% (5/9) in 2023. The survey findings indicated that the most frequently reported barriers to laparoscopy uptake included lack of protected operating room time, lack of structured curricula, and surgeon preference. Access to experienced trainers, equipment availability, equipment maintenance, and funding ranked as less significant. Conclusion:Higher laparoscopic utilization in the management of appendicitis and ectopic pregnancy was found in the years following the use of ALL-SAFE. An open-source, low-cost laparoscopic training system may have a role in increasing the volume of laparoscopic surgery, thereby impacting clinical care.