B. Abebe1, B. Woisha1, M. Lee3, T. Jaraczewski5, R. Price4, S. Hirbo1, S. Zafar2 1Hawassa University Comprehensive Specialized Hospital, Surgery, Hawassa, SIDAMA, Ethiopia 2University Of Wisconsin, Surgery, Madison, WI, USA 3Virginia Commonwealth University, Surgery, Richmond, VA, USA 4University Of Utah, Surgery, Salt Lake City, UT, USA 5Medical College Of Wisconsin, Surgery, Milwaukee, WI, USA
Introduction: Laparoscopic surgery has reduced surgical morbidity and mortality through faster recovery, shorter hospitalizations and decreased wound infections. However, this technology is not available in many low- and middle-income countries (LMICs). We utilized a train-the-trainer model to introduce laparoscopy at Hawassa University Comprehensive Specialized Hospital (HUCSH). In this study we review our approach to training and implementation of laparoscopy and assess the metrics since implementation.
Methods: From 2020-2022, a surgical team from the US hosted remote laparoscopic surgery didactic courses via Zoom teleconferencing to HUCSH general surgery faculty and residents. From February-April 2023, an in-country Global Surgery Fellow jointly developed a structured laparoscopic skills curriculum that was then taught to nine HUCSH general surgery attendings. From this group, two surgeons were selected based on their initial involvement in the laparoscopy didactic sessions and aptitude in the skills lab, to receive supervised, intraoperative training. A team of US surgeons provided supervised in person training to the two local surgeons. Only patients presenting for elective cholecystectomy for biliary colic were included. At the completion of the supervised training the Hawassa surgeons began operating independently with plans to send images of the critical view of safety after every case to the trainers. Cholecystectomy specific quality metrics were tracked to assess each surgery. Data from every patient was collected using REDcap software and compared between supervised and unsupervised cases using chi-square or Students T test when appropriate.
Results: A total of 39 cases were performed between April 2023 – June 2024. Of these, 10 were supervised and 29 unsupervised. The average age was 38.8 (±9.9) and 88% were female. There was a non-statistical difference in average operative time between the supervised cases (88.2 +/- 6.1 mins) and the unsupervised cases (70.9 +/- 5.7 mins). There was no difference in postoperative length of stay (LOS) between supervised and unsupervised case (1.2 vs 1.3 days, P = 0.791). Laparoscopic cases had a shorter LOS compared to open cholecystectomies (1.3 vs 4.4 days, P < 0.001). All of the supervised and unsupervised cases had appropriate critical view of safety and dual clipping of the cystic duct and artery. There were two reported surgical site infection in the unsupervised group compared to none in the supervised group. No common bile duct injury and no deaths have been reported.
Conclusion: This study presents our experience with implementation of a laparoscopic training program in Hawassa, Ethiopia using a flipped classroom technique. This novel teaching and implementation method enabled rapid uptake of safe and independent operations.