A Pilot for Surgical Education in Low-and Middle-Income Countries: Establishing a Basic Laparoscopic Training Program in Cambodia

A Pilot for Surgical Education in Low-and Middle-Income Countries: Establishing a Basic Laparoscopic Training Program in Cambodia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Pilot for Surgical Education in Low-and Middle-Income Countries: Establishing a Basic Laparoscopic Training Program in Cambodia Anna Melissa Darelli-Anderson, Vithiea Dara, Angel Flores Huidobro Martinez, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6298044/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose: Nine of 10 people in low- and middle-income countries (LMICs) such as Cambodia do not have access to safe, affordable surgical and anesthesia care. This disparity is exacerbated by a lack of proper training opportunities for surgeons to further specialize in areas like minimally invasive surgery. The principal objective of this study was to develop and establish a sustainable basic laparoscopic surgery training program starting at Calmette Hospital in Phnom Penh, Cambodia and expanding to two regional hospitals in more rural areas. This model may be employed for use in other LMICs. Methods: Between 2022 and 2023, a comprehensive basic laparoscopy training program was implemented across three Cambodian hospitals: Calmette, Kampong Cham, and Kampong Thom. The curriculum included didactic lectures, simulation-based exercises, and practical in-theatre experience. Local educators were trained to perpetuate the program. A total of 59 participants, including 36 attending physicians and 23 trainees, completed the training. Pre- and post-training surveys were deployed to assess skill improvement and confidence; paired t-tests were used to analyze performance across laparoscopic simulation tasks. Results Participants demonstrated significant improvements in laparoscopic skills, with reduced task completion times and improved accuracy (p < 0.05). Post-training surveys revealed that 85% of learners continued practicing their skills, and most reported increased confidence in performing laparoscopic procedures. Attending physicians and trainees benefited equally. Conclusions This model provides a standardized and replicable platform with theoretical, practical, and evaluation components for expanding access to self-sustained MIS training in LMICs such as Cambodia. Cambodia global surgery laparoscopy LMICs minimally invasive surgery surgical education Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Minimally invasive, or laparoscopic, surgery can be used to treat a broad range of surgical diseases, including those of the gallbladder, appendix, colon, and many obstetric procedures. Benefits of minimally invasive surgery (MIS) include fewer complications, reduced postoperative pain, quicker recovery time, and shorter hospital stays. In high-income countries (HICs), laparoscopy has been used to treat these conditions since the 1980s [ 1 ]; however, implementation of MIS in low- and middle-income countries (LMICs), while increasing in more recent years, has been difficult. Additionally, the global burden of surgical disease is multifaceted and affects a significant portion of the world’s population. Nine of 10 people in LMICs do not have access to safe, timely, and affordable surgical and anesthesia care; indeed, Southeast Asia alone has an unmet surgical need of nearly 12.5 million surgical procedures each year, or 2,045 per 100,000 population [ 2 ]. Reasons for this include direct and indirect costs to both patients and hospitals; a scarcity of formal medical education, leading to a general lack of healthcare personnel [ 3 ]; limited local resources; social and political matters; and issues of distance, poor roads, and insufficient suitable transport [ 4 ]. Moreover, LMICs not only struggle with a shortage of trained surgeons—with Cambodia boasting an estimated surgical workforce of 4 per 100,000 population [ 5 ] compared to the 20 per 100,000 population recommended by the Lancet Commission on Global Surgery [ 2 ]—but also proper training opportunities for further specialization in areas like laparoscopy. However, some methods for establishing laparoscopic surgery in LMICs have proven successful. For example, forming alliances with local academic centers offers the advantage of being able to educate a group of surgeons rather than single individuals. This also allows for the creation of locally designed, culturally sensitive education programs that can be implemented not only within surgical residency programs but extended to community and rural surgeons as well [ 6 ]. Previous ventures in Botswana and Mongolia have also shown the benefits of a combination of didactics, simulations, and practical training in establishing and improving laparoscopy in LMICs [ 7 , 8 ]. The first cholecystectomy performed in Cambodia occurred in 1987 [ 9 ], though there remains no standardized training for laparoscopic surgery within the country. The principal objective of this study was to develop and establish a sustainable basic laparoscopic surgery training program at Calmette that may be employed as a model to expand MIS in Cambodia, and for use in other LMICs. Methods A multidisciplinary team of experts in general surgery, obstetrics and gynecology (OBGYN), anesthesiology, and medical education conducted this project over a 3-year period. To guide the educational approach, the team employed a combination of the ADDIE (Analysis, Design, Development, Implementation, and Evaluation) model, Bloom’s taxonomy (in which cognitive learning is arranged into six levels: remembering, understanding, applying, analyzing, evaluating, and creating), and Kolb’s theory of experiential learning (premised on the transformation of experience for knowledge creation). The ADDIE model provided a structured framework, ensuring that each phase—from analyzing learning needs to designing materials, developing modules, implementing training, and evaluating outcomes—was methodically executed. Bloom’s taxonomy supported the learning progression, advancing from foundational knowledge of laparoscopic skills to more complex applications and analysis, with increasing levels of learner engagement at each stage. Finally, Kolb’s theory reinforced experiential learning, emphasizing hands-on practice, reflection, and skill refinement. First, an in-person two-week basic laparoscopic surgery training program was developed that included a didactic curriculum on principles of laparoscopic surgery and an educator workshop, a simulation skills course, and a hands-on in-theatre practical training component. Prior to implementation of training, sites’ infrastructure were evaluated and developed as needed. In-country team visits were planned for twice a year, with the objective of the initial trip being to establish both the program and a laparoscopic skills training center at the country’s flagship medical center, Calmette Hospital. Subsequent trips had two objectives: 1) to reinforce training at previously visited sites and 2) to establish the program at a new site. In this manner, each site longitudinally benefited from direct interactions and feedback from the team of experts on at least three separate occasions. Developing the Didactic Curriculum The first aspect of the basic training program consisted of didactic instruction. The Principles of Laparoscopic Surgery course (Table 1 ) was comprised of 10 modules, beginning with an introduction tailored for LMICs, emphasizing the accessibility and adaptation of laparoscopy in diverse settings. Subsequent modules guided participants through essential preparatory steps, such as setting up the room and troubleshooting during procedures. A strong focus was placed on sterile techniques, including scrubbing, gowning, and gloving, to ensure the highest standards of hygiene and safety. The course also taught the intricacies of electrosurgery and the critical physiological and anesthesia considerations specific to MIS. Preoperative concerns were covered in depth to prepare surgeons for the procedural workflow. Practical skills were stressed in modules on laparoscopic entry and port placement, followed by a thorough examination of potential complications and their management. The course concluded with an overview of diagnostic laparoscopy, encapsulating the key concepts and skills needed to perform surgery effectively. Table 1 Principles of Laparoscopic Surgery Core Didactic Curriculum Module Topic 1 Introduction to Laparoscopy for Low- and Middle-Income Countries 2 Setting Up the Room for Laparoscopy 3 Troubleshooting During Laparoscopy 4 Introduction to Sterile Techniques: Scrubbing, Gowning, and Gloving 5 Electrosurgery in Laparoscopy 6 Physiology and Anesthesia Considerations for Laparoscopy 7 Preoperative Considerations 8 Laparoscopic Entry and Port Placement 9 Complications in Laparoscopy 10 Overview of Diagnostic Laparoscopy Due to the mixed nature of learners’ backgrounds, additional content for both surgical and gynecological breakout sessions were created. Specifically, the Surgery Breakout Session included four modules on laparoscopic cholecystectomy about 1) preoperative considerations, 2) intraoperative considerations, 3) preparation, and 4) technique. The gynecology modules were: 1) MIS for gynecology, 2) preoperative, operating room (OR), and entry considerations for gynecologic laparoscopy, 3) laparoscopic tubal ligation, and 4) laparoscopic ovarian cystectomy (and postoperative considerations and troubleshooting). The comparison between the effectiveness of traditional didactics and computer-based training (CBT) methodologies in medical education is a vital question. Traditional didactics offer direct engagement and hands-on learning experiences. However, with the emergence of CBT, a new dimension to medical education has surfaced, offering flexible learning environments and adaptive learning pathways. In light of these advancements, the adaptability of traditional methods remains crucial, especially in contexts where resources are limited. As such, a strategic integration of both traditional didactics and CBT was utilized. That is, delivery of the didactic curriculum occurred in person and involved interactive elements such as a live exhibition and demonstration of surgical instruments. Furthermore, in consideration of the scarcity of resources, the curriculum was also adapted for use on an open-source online learning platform. Creating the Educator Workshop For those learners who were already attending surgeons or OBGYNs, and/or who had the potential or interest to go on to teach minimally invasive surgical skills—those located at teaching hospitals or willing to travel to more rural areas to teach—an additional educator workshop was created on Teaching Laparoscopic Surgery in LMICs . The course was comprised of five introductory modules on planning, developing, and teaching laparoscopic surgery, and culminated in a final two-hour hands-on module on program development to provide them with an understanding of the general concepts of curriculum development and the skills to design a basic program to expand their medical education capabilities and for the purposes of sustainability. Specifically, the two-day workshop focused on: 1) how to develop a laparoscopic skills training center, 2) teaching the differences between open and laparoscopic surgery, 3) simulation-based education, 4) communication skills to facilitate learning in surgical education, 5) understanding advanced laparoscopic skills, and 6) program development. Designing the Skills Simulation Course Since the turn of the century, Surgical Skills Laboratories (SSLs) have been used in HICs to enhance surgical training, with the American Council for Graduate Medical Education (ACGME) later making it a required element of general surgery residency programs in 2008 [ 10 ]. Certainly, simulation training has been proven to significantly improve surgeons’ skills, such as precision cutting and intracorporeal knot tying, useful in MIS [ 11 ]. Accordingly, we endeavored to create a blueprint for a small-scale SSL involving box simulators to be used in LMICs. Inspired by the Society of American Gastrointestinal and Endoscopic Surgeons’ (SAGES) Fundamentals of Laparoscopic Surgery (FLS) program, six training exercises (rubber band transfer, spandex, needle through loop, circle cut, extracorporeal knot tying, and intracorporeal knot tying) were developed to be used with items easily purchased from local suppliers in Asia (e.g., rubber bands, gauze, etc.) (Table 2 ). This approach ensured that learners could effectively practice surgical skills within the constraints of the provided resources and equipment, thereby maximizing the educational value of the training program. Table 2 Basic Laparoscopic Skills Simulation Training Curriculum Task Technical Objectives Rubber Band Transfer A basic coordination and dexterity exercise where one transfers rubber bands from posts on one side of the simulator to the other, switching hands with each transfer. • Achieve proficiency in bimanual object manipulation. • Develop hand dexterity to facilitate precise movements. • Master basic compression and release techniques, along with modulation of grip strength. Spandex A dexterity and precision exercise where rubber bands are stretched and placed around posts in a sequential pattern. • Expand abilities in bimanual manipulation techniques for handling tissue effectively. • Attain mastery in depth orientation. • Apply appropriate strength and traction techniques for optimal handling. Needle Through Loop A needle-handling exercise where one threads a needle through a series of loops, switching hands and maintaining precise control. • Develop proficiency in bimanual manipulation techniques for handling tissue and the needle during procedures. • Learn the skill of presenting a needily accurately for precise insertion. • Refine suture manipulation skills for smooth and effective suturing. • Enhance movement precision while maneuvering a needle through a designated path. • Achieve adept depth orientation to accurately gauge needle penetration during procedures. Circle Cut A precision-cutting exercise where a circular shape is cut from gauze. • Develop proficiency in executing precise incisions with surgical instruments. • Master the technique of controlling the depth and angle of the cut to achieve optimal tissue preservation. • Acquire the ability to maintain steady hand movements and a stable surgical field during precision-cutting procedures. • Ensure consistent and reliable performance in following predetermined cutting lines or patterns as required. • Demonstrate skill in achieving optimal tissue exposure and traction to facilitate precise cutting. Extracorporeal Knot Tying An exercise where one creates secure knots outside of the simulator and uses a knot pusher to guide and tighten the knots inside the simulator. • Learn to handle the needle and suture material outside the body cavity. • Master the technique of forming secure knots outside the surgical field. • Develop the ability to manipulate the knot and adjust its tension accurately. • Acquire precision in knot placement and configuration to ensure reliable closure and tissue approximation. • Demonstrate consistency and efficiency in completing extracorporeal knot tying tasks within a designated time frame. Intracorporeal Knot Tying An exercise where one ties a square knot entirely within the simulator. • Successfully grasp and manipulate the needle and suture material within the surgical field. • Master the technique of forming secure knots within the body cavity without the need for extracorporeal assistance. • Develop proficiency in adjusting knot tension to achieve optimal tissue approximation and hemostasis. • Attain precision in knot placement and configuration to ensure reliable surgical closure and tissue integrity. • Demonstrate consistency and efficiency in completing intracorporeal knot tying tasks within a designated time frame. The course was arranged according to level of difficulty, with the first exercise being the least difficult and the sixth the most difficult. One and a half hours were allotted to each of the first two tasks (rubber band transfer and spandex), and two hours apiece for the remaining tasks. Each session began with an explanation of objectives, video and photo demonstration of the exercise, and review of scoring guidelines. Throughout the sessions, instructors also exhibited the skills on the box simulators themselves for each group. Then, participants were asked to first complete the task without any hands-on practice to determine baseline levels. They were subsequently allowed to practice the task for 15 minutes before officially attempting the exercise again. All learners’ skills were assessed using a standardized 10-point rubric measuring time, precision, and adherence to technique. Scores from each repetition were recorded and documented, and trainees were provided with ongoing feedback. Regular practice combats the natural decay of learned skills by validating knowledge and motor memory, thereby slowing the rate of forgetting and promoting longer-term retention. To overcome Ebbinghaus’ forgetting curve [ 12 ], which illustrates how memory retention declines over time without reinforcement, participants were further encouraged to continue practicing and recording their results on an ongoing basis following the initial course. This ongoing documentation also allowed for tracking the progression of skills over time, enabling participants to not only retain but also refine and advance their laparoscopic skills. Organizing the Practical Training Component When possible, following didactic instruction and simulation training, learners were then provided supervised graduated hands-on in-theatre experience (Fig. 1 ). In preparation for the practical training component of the program, patients with cholecystitis were screened, selected, and scheduled for surgery based on urgency. Expert general surgeons first performed laparoscopic cholecystectomies while learners observed. The experts took time to: 1) explain each step and the reasoning behind their actions, 2) demonstrate key points of the procedure, 3) troubleshoot any complications that came up, and 4) answer learners’ questions in real time. The next phase of the training was much the same, with the addition of having the learners take turns assisting on the procedure. Once the surgical educators were confident that participants had the basic skills and understanding, attending surgeons took turns taking the position of Surgeon while our instructors served as Assistants. Training progressed until local surgeons filled the roles of both Surgeon and Assistant(s) under the supervision of the experts. Upon the experts’ departure, learners were able to complete laparoscopic cholecystectomies as a team entirely independently. Assessing Prospective Sites Prior to implementation of the program, leaders from Calmette and the Ministry of Health were consulted regarding local country guidance and thorough evaluations were conducted across various essential domains at each potential site. In February 2022, initial preprogram site visits were made to Calmette, Kampong Cham, and Phnom Penh Municipal Referral Hospitals. Additional visits were carried out at the Cambodian Japanese Friendship Mongkul Borei Referral Hospital (in Banteay Meanchey) and Battambang Provincial Hospital in December 2022, as well as Kampong Thom Provincial Hospital and the Cambodia-China Friendship Tboung Khmum Hospital in February 2023 (Fig. 2 ). Each hospital was rigorously evaluated using a comprehensive assessment tool encompassing several critical areas: First, hospital-specific details such as the name, address, and leadership structure were documented, including the Chief Hospital Administrator and primary points of contact. This provided insights into the administrative hierarchy and facilitated direct communication channels. Infrastructure assessment encompassed crucial factors such as the hospital’s level and type, annual admissions categorized by age and gender, and availability of essential utilities such as water, electricity, and sanitation. The presence of backup generators and waste disposal systems were also noted, highlighting the hospital’s preparedness for uninterrupted operations and adherence to hygiene standards. Demographic considerations included the size of the population served by each hospital, predominant patient languages, and primary modes of patient transportation. These elements were pivotal in understanding potential barriers to health care access and the hospital’s role within the local health care system. The evaluation also examined the documentation practices within each hospital, detailing whether patient charts were maintained electronically or in hard copy, and the methods employed for their storage. The availability of dedicated training facilities was appraised, including the presence of conference rooms equipped with necessary amenities like electricity, projectors, screens, and internet access. Technological support, both on-site and off-site, was also scrutinized to assess the hospital’s capacity for integrating advanced educational tools such as video conferencing into the training program. Examining the hospital’s educational framework, the assessment considered whether the facility operated as a teaching hospital, its affiliates with educational institutions, and the annual training capacities for surgical and OBGYN residents. This provided insights into the hospital’s role in medical education and its potential for sustaining a structured laparoscopic training initiative. Regarding personnel, the evaluation included specific inquiries into the number and specialization of trained general surgeons, OBGYNs, anesthesiologists, nurses, and OR staff. Further details on nursing staff included their highest level of education, average tenure, and roles in assisting surgeries, all of which contributed to understanding the hospital’s clinical support capacity and readiness to support surgical training. Additionally, operational aspects such as the number of designated ORs, their turnaround times, and the hospital’s ability to adhere to predefined start times for surgeries were assessed. These components were paramount in gauging the hospital’s efficiency in surgical scheduling and resource management. Equipment inquiries addressed whether the hospital possessed resources for repairing or replacing laparoscopic parts locally, its budget allocation for equipment maintenance, and methods for sterilizing surgical instruments, ensuring compliance with surgical safety standards. Collectively, the comprehensive program site assessment provided a holistic understanding of each facility’s readiness and capacity to support a basic laparoscopic surgery training program. With a focus on addressing local needs and ensuring the program’s alignment with the health care landscape of LMICs, this served as a foundational step in identifying key strengths and challenges across prospective hospitals in Cambodia. Thus, of the seven sites evaluated, three were selected for inclusion. Implementing the Program In partnership with the Association of the Church of Jesus Christ of Latter-day Saints’ Cambodia Health Improvement Effort (CHIE) for both funding and logistical support, the program was implemented at a new site during each of three visits occurring in December 2022, February 2023, and September 2023. The first iteration was administered at Calmette, and the second and third at Kampong Cham and Kampong Thom, both rural centers (Fig. 2 ). A team of experts comprised of general surgeons, OR staff, and medical educators and/or research assistants was assembled for each trip. Throughout the program, participants were surveyed to assess their perceived confidence, knowledge, and technical dexterity before and after the program. The survey aimed to evaluate the effectiveness of the curriculum, identify gaps in skills and experience, and assess participants’ perceptions of how the program influenced their readiness to both perform and teach others laparoscopic surgery. The pre-program survey collected demographic data, prior laparoscopic experience, and self-reported comfort with specific surgical skills, while the post-program survey focused on learners’ confidence levels, perceived skill improvement, and the impact of the program on their surgical practice. The post-program survey also included a section specifically for attending physicians supervising trainees to capture their observations on trainee performance and stress levels in the OR. December 2022 — Calmette Hospital Conducted in December 2022, the purpose of the first visit was to set up a center of excellence for laparoscopic training at Calmette and involved 16 lectures, six skills modules, and hands-on surgical proctoring. Originally established in 1958 before being destroyed during the Khmer Rouge Regime in the 1970s, Calmette was then rebuilt as a public hospital following the Cambodian Civil War. Providing much-needed free-of-charge care to impoverished Cambodians, one of Calmette’s principal missions is to “participate in education…and serving as field practical training for medical students and other health care professionals” [ 13 ]. Focusing on attending general surgeons and OBGYNs, the team began with the two-day educator workshop. A subsequent three-day training was held for trainees (i.e., surgical residents and medical students), to include the didactic curriculum and skills simulation course, with the trained Cambodian faculty serving as instructors. The following week was then spent acquiring in-theatre experience. A pre- and post-course survey was administered to evaluate confidence levels with laparoscopic surgery, as well as perceived improvements after completion of the training. February 2023 — Kampong Cham and Calmette Hospitals In February 2023, the team returned to Cambodia to carry out the training program at Kampong Cham. Because Kampong Cham is a small rural hospital with only the occasional trainee in attendance, the time was spent simply teaching MIS to the one general surgeon and the two OBGYNs that served as attending physicians there. This included the 10-module Principles of Laparoscopic Surgery course, the full skills simulation course, and practical training time in the OR. Additionally, an anesthesiologist was added to the team to assess anesthesia care currently available in-country. During the second week of this visit, while the majority of the team continued to provide training at Kampong Cham, a small crew consisting of a general surgeon, the anesthesiologist, and the medical educator returned to Phnom Penh to 1) aid the previously trained educators at Calmette with facilitating further replications of the basic course, 2) assist in and gauge capabilities for more advanced surgical cases, and 3) explore opportunities for improving available anesthesia care and training. September 2023 — Kampong Thom and Kampong Cham Hospitals The final visit occurred in September 2023, during which the team of attending surgeons at Kampong Thom received both didactic and simulation training on basic laparoscopic surgery. One of three referral hospitals in a province serving more than 850,000 people, Kampong Thom was recently renovated by CHIE throughout 2023 [ 14 ]. However, due to the ORs not having been completed by the time of the visit, and the need for further anesthesia development, the practical training component of the program was deferred to a future trip, allowing the surgeons additional time to practice and develop their laparoscopic skills until then. Part of the team returned to Kampong Cham for a follow-up in-theatre course to reinforce the newly developed laparoscopic skills and an in-depth debrief and further discussion on the results of the implementation of laparoscopic surgery over the previous seven months. While there, the team also reinforced the need for continuing quality assurance evaluation, including data collection efforts about their open and laparoscopic surgical cases and postoperative complications. Results Descriptive statistics were generated for all potential predictors of success and after stratification by participant status. A total of 59 learners participated in our program: 36 attending physicians (28 surgeons and eight OBGYNs; 61.02%) and 23 trainees (20 surgical residents and three medical students; 38.98%) (Fig. 3 ). The vast majority were men (91.53%), with only five women in the group (four OBGYNs and one medical student; 8.47%), and the average age was 33 years old. Nearly two-thirds (62.72%) stated they had prior experience with laparoscopic surgery, though the majority (58.06%) had less than one year; nevertheless, more than three-quarters (77.50%) had performed or assisted in MIS. Amongst the 28 surgeons who took part, 10 (35.71%) did not define their specialty, 12 (42.86%) specifically named general surgery, four (14.29%) stated they were urologists, and two (7.14%) described themselves as thoracic surgeons. While three-quarters of the attending physicians indicated that they had prior experience with MIS (23 surgeons and four OBGYNs; 85.19% and 14.81%, respectively) (Fig. 4 ), primarily via box simulators and/or animal or cadaver labs, 78.57% of respondents had less than one year of training, with over a quarter (29.17%) not having had completed any training for at least two years prior. Seventy percent received their training abroad, with the majority having gone to France (42.86%) or Thailand (35.71%). Ten of those who had obtained training (nine surgeons and one OBGYN) reported that they had later taught others what they had learned. Of the 20 surgical residents included, 10 (50%) identified their specialty as general surgery, three (15%) as urology, and seven (35%) did not further elaborate. Half of the residents had prior experience with laparoscopic surgery (two did not indicate their level of training, two were PGY1s, one was a PGY2, two were PGY3s, two were PGY4s, and one was a PGY6), and none of the medical students did (Fig. 4 ). Of the residents who responded, 87.50% had less than one year of training, all within the previous two years. Only two residents indicated that they had gone on to teach what they had learned. Overall, after excluding incomplete data entries, 62.81% of participants repeated each simulation training exercise at least twice. Paired t-tests were conducted to determine whether there was a statistically significant mean difference between the time it took to complete each exercise, as well as scores, before and after training. As expected, participants completed all exercises faster after having been trained and allowed to practice as compared to their first attempt, though there was only a statistically significant decrease in time with the rubber band transfer, spandex, needle through loop, and circle cut exercises (Table 3 ). Similarly, scores also significantly increased by 2.1024 (95% CI, 1.5268 to 2.6780) points, t (124) = 7.2288, p < 0.05 across all exercises, though the spandex exercise was the only one in which the change was not statistically significant (Table 4 ). Interestingly, there was no significant difference between the improvement (in either time or score) of attending physicians as compared to trainees. Table 3 Basic Laparoscopic Skills Simulation Training Results (Time) Exercise First Attempt Mean (sec) Final Attempt Mean (sec) Difference (sec) 95% CI t -value p -value Rubber Band Transfer 175.2424 ± 97.3409 110.1212 ± 49.4386 -65.1212 37.9595–92.2829 4.8836 0.0000 Spandex 171.1875 ± 53.4867 148.5625 ± 40.0010 -22.625 -2.4583-47.7083 1.9226 0.0369 Needle Through Loop 322.7727 ± 168.5266 214.3182 ± 96.3013 -108.4545 40.4335-176.4756 3.3158 0.0016 Circle Cut 312 ± 110.9401 219.069 ± 89.2680 -92.9310 57.0216-128.8404 5.3011 0.0000 Extracorporeal Knot Tying 173.6923 ± 69.7930 145.8462 ± 47.2191 -27.8462 -16.3306-72.0229 1.3734 0.0974 Intracorporeal Knot Tying 268.9167 ± 101.5225 243.9167 ± 88.2903 -25 -21.3840-71.3840 1.1863 0.1303 Table 4 Basic Laparoscopic Skills Simulation Training Results (Score) Exercise First Attempt Mean (pts) Final Attempt Mean (pts) Difference (pts) 95% CI t -value p -value Rubber Band Transfer 7.1173 ± 3.3251 9.2676 ± 1.3154 2.1503 1.1367–3.1639 4.3212 0.0001 Spandex 8.7363 ± 1.5922 9.3075 ± 0.8410 0.5713 -0.3782-1.5207 1.2824 0.1096 Needle Through Loop 6.4409 ± 4.8819 9.03 ± 1.7057 2.5891 0.4586–4.7196 2.5273 0.0098 Circle Cut 1.8055 ± 3.9872 5.0183 ± 3.3205 3.2128 1.9745–4.4510 5.3148 0.0000 Extracorporeal Knot Tying 7.4285 ± 2.8039 8.9915 ± 1.3847 1.5631 -0.0628-3.1890 2.0947 0.0290 Intracorporeal Knot Tying 7.17 ± 2.8815 8.1608 ± 2.5742 1.0208 -0.1465-2.1882 1.9247 0.0403 Amongst the attending physicians, even though 86.36% of those with training had also previously performed or assisted in laparoscopic surgery (chiefly, laparoscopic appendectomies and cholecystectomies), at least half of them were “neutral,” “uncomfortable,” or “very uncomfortable” with their skills relating to precision cutting (54.17%), running bowel (91.30%), band transfer (83.33%), intracorporeal suturing (95.83%), extracorporeal suturing (78.26%), and endoloop (62.50%). Similarly, three-quarters of the trainees had previously performed or assisted in MIS, though at least three-quarters were “neutral,” “uncomfortable,” or “very uncomfortable” with their skills relating to precision cutting (87.50%), running bowel (100%), band transfer (87.50%), intracorporeal suturing (100%), extracorporeal suturing (75.00%), and endoloop (75.00%) (Fig. 5 ). With an 80.95% response rate (47.05% attending physicians, 38.24% residents, 14.71% unclassified), the results of the post-training survey showed that respondents found the didactic curriculum (81.37% “agreed” or “strongly agreed”) and skills simulation (73.04%) useful, and that 85.29% had continued practicing their skills after the program. When asked about comfortability with laparoscopic skills, the majority were “comfortable” or “very comfortable” with precision cutting (64.71%), running bowel (73.53%), band transfer (76.47%), intracorporeal suturing (52.94%), extracorporeal suturing (67.65%), and endoloop (82.35%), a marked increase from their preprogram numbers (Fig. 5 ). Respondents further reported increased confidence (72.41%), knowledge (93.10%), and dexterity and precision (89.66%); 65.52% likewise indicated that they felt less stressed during surgery following the program. Physician attendings who supervised trainees were also separately asked about their perceptions of trainees’ performance in the OR and similarly described increased confidence (86.67%), knowledge (93.33%), and dexterity and precision (86.67%), and decreased stress during surgery (86.67%) amongst their residents after the program. Finally, the impact of the initial training program extended significantly through the ensuing efforts of the educators trained in December 2022. After their initial instruction and supervised trial run at Calmette, these individuals took on the role of trainers themselves, essentially multiplying the reach of the program. This group of six surgeon educators has since gone to lead a dozen courses for over 320 students during the period of approximately one and a half years. All statistical analyses were performed using a standard software package (StataNow18, version 18.5, StataCorp). Discussion This study demonstrates the successful implementation and impact of a laparoscopic skills training program designed to address the shortage of MIS expertise in Cambodia. By focusing on sustainability, accessibility, and collaborative engagement, the program provides a model for advancing surgical education in LMICs. The program design, grounded in educational theory, provides a comprehensive framework that allows the needs and resource constraints of the local health care environment to be addressed. Indeed, the implementation of the program in both urban and rural settings, such as Calmette in Phnom Penh and more remote centers like Kampong Cham and Kampong Thom, showcases this adaptability. The outcomes of the program not only underline the immediate benefits of the training but also shed light on broader systemic needs within surgical education and health care infrastructure. Below, we discuss the implications of these results, organized around key themes. Effectiveness of the Program The training yielded significant improvements in laparoscopic skills and overall confidence among participants. Statistical analyses revealed substantial enhancements in performance across several simulation exercises, with significant reductions in completion times and increases in accuracy following training. The paired t-tests also showed that participants, regardless of their status as either attending physicians or trainees, benefited equally from the program. The post-training survey further highlighted the program’s impact, with a majority of respondents reporting increased comfort and confidence in performing laparoscopic procedures. These results align with prior research demonstrating that structured simulation-based training can effectively improve surgical skills, even in resource-limited settings [ 15 , 16 ]. Baseline Experience, Skill Gaps, and the Value of In-Country Training Programs Although nearly two-thirds of participants reported some prior laparoscopic experience, the majority had less than one year of training, and many had not practiced these skills for at least two years. The absence of significant differences in improvement between attending physicians and trainees suggests that both groups started with comparable baseline skills, reflecting the lack of specialty training in laparoscopy. Pre-training surveys further revealed widespread discomfort with core laparoscopic tasks, even among those with prior MIS exposure. Over half of attending physicians, and three-quarters of trainees, reported feeling “neutral,” “uncomfortable,” or “very uncomfortable” with skills such as precision cutting, intracorporeal suturing, and running bowel. These results emphasize the need to address foundational skill gaps to build confidence and competence in laparoscopic procedures. Interestingly, a striking finding was that 70% of attending physicians who had prior laparoscopic training obtained it abroad, predominantly in France and Thailand. This highlights the global interconnectedness of surgical education but also reveals the financial and logistical challenges associated with seeking training opportunities overseas. Establishing in-country programs like the one detailed here provides a more equitable and sustainable solution, ensuring broader access for learners who cannot afford to train abroad. Such initiatives are essential in resource-limited settings, where international travel remains infeasible for most practitioners. Sustainability Through Teaching and Local Integration A central aspect of this program’s success was its emphasis on sustainability. The program combines structured didactic content with hands-on simulation and live surgery, emphasizing sustainability through the training of in-country, native surgeon educators, who disseminated knowledge and skills beyond the initial cohort of learners. By equipping attending physicians and other health care professionals with both the clinical and pedagogical tools necessary to teach others, the program creates a multiplier effect, significantly broadening its impact. The collaboration between Cambodian surgeons and the expert team as co-trainers was equally critical in fostering a culture of continuous learning and mentorship. This partnership helped build trust and ensure that the curriculum was culturally relevant and contextually appropriate. Involving local trainers also facilitated better communication and learner engagement, while promoting expertise that will support long-term program sustainability. Broader Implications for Surgical Education and Future Directions Post-training surveys demonstrated that most participants continued practicing their skills and reported significant improvements in confidence, knowledge, and stress management during surgery. These findings underscore the effectiveness of a combination of didactic, hands-on, and simulation-based training in building both technical and non-technical competencies. Feedback from supervising physicians highlighted increased trainee confidence, dexterity, and knowledge. This reinforces the value of mentorship and structured training programs in elevating surgical performance and reducing stress in the OR. As the program continues to expand to additional hospitals in Cambodia, it will further strengthen its impact by incorporating education and training on more advanced laparoscopic skills. As a result, the team is in the program-planning stage for three new courses on colectomy, foregut surgery, and anesthesia. These offerings will not only enhance the clinical skill set of local surgeons but also expand the scope of laparoscopic procedures available in Cambodia. By advancing beyond basic skills, the program aims to address more complex surgical needs, continuing to contribute to the overall growth of surgical services in the region. Furthermore, the program offers valuable insights that can inform similar global surgical training initiatives. In contrast to larger, well-funded programs in HICs, this model is specifically tailored to LMICs, focusing on sustainability and long-term capacity building. The integration of local trainers and alignment with the existing health care structure ensures that the program remains relevant to local needs. By avoiding a “one-size-fits-all” approach, this initiative serves as a blueprint for how surgical training can be adapted and expanded in other LMICs, where infrastructure and resources vary widely. In addition to expanding the program content, the team is also addressing the accessibility of training resources. Currently, the Principles of Laparoscopic Surgery course is freely available on Thinkific. However, recognizing a need to develop the existing and future global surgical care workforce through training and education, the United Nations—in partnership with the Global Surgery Foundation and the Royal College of Surgeons in Ireland—launched SURGhub in June 2023. The online training platform was developed to provide “high-quality global surgery learning materials to frontline providers,” [ 17 ] harmonizing with this program’s goals. Plans to submit this basic laparoscopy training course for inclusion on SURGhub will bolster the program’s global scalability, extending its reach to areas with comparable health care difficulties. Leveraging global platforms like SURGhub allows for standardization and collaboration across different countries, building a more cohesive global surgical training network. Challenges, Limitations, and Implications Despite its successes, the program faces some challenges. A major limitation is the inconsistent availability of infrastructure in some of the hospitals, as seen in Kampong Thom, where the practical component had to be deferred due to unfinished ORs and a lack of anesthesia training and supplies. Additionally, while the program has had a positive impact on participants’ skills, the adaptation of training materials and techniques to fit the local context and available resources can be difficult. The reliance on box simulators and easily sourced materials for simulation exercises was necessary but may not fully replicate the conditions of more advanced simulators, resources, or training settings found in HICs. This adaptation, while pragmatic, could influence the depth of skills development achievable through the program. Another challenge is maintaining consistent post-training follow-up and data collection, particularly in resource-constrained settings. Monitoring long-term outcomes and ensuring the proper use of laparoscopic techniques can be taxing when hospital systems are still developing electronic medical records and tracking processes for surgical cases. Addressing these logistical issues will be crucial in ensuring the continued success and scalability of the program. Nonetheless, the overall positive outcome of this training initiative shows potential for parallel programs to enhance surgical education in LMICs, with several factors (e.g., customization to local contexts, sustained training and support, and evaluation and adaptation) to be considered to maximize effectiveness. Conclusion This model provides a standardized and replicable platform with theoretical, practical, and evaluation components for increasing access to self-sustained MIS training in LMICs such as Cambodia, aligning with broader efforts to enhance surgical capacity globally. The laparoscopy training program in Cambodia effectively increased surgical skills and confidence among a diverse group of participants. The integration of structured educational frameworks and hands-on practice proved successful, though challenges related to resource limitations need to be addressed in future iterations. By continuing to refine and adapt such programs, the potential to improve laparoscopic surgical education and patient outcomes in LMICs remains substantial. Declarations Conflict of Interest: On behalf of all authors, the corresponding author states that there is no conflict of interest. Data Availability: The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access storage at the University of Utah. References Alkatout I, Mechler U, Mettler L. The Development of Laparoscopy – A Historical Overview. Front Surg . 2021; 8: 799442. https://doi.org/10.3389/fsurg.2021.799442 Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet . 2015; 386: 569-624. https://doi.org/10.1016/S0140-6736(15)60160-X Dawson AZ, Walker RJ, Campbell JA, Egede LE. Effective Strategies for Global Health Training Programs: A Systematic Review of Training Outcomes in Low and Middle Income Countries. Glob. J. Health Sci . 2016; 8(11): 278-292. https://doi.org/10.5539/gjhs.v8n11p278 Grimes CE, Bowman KG, Dodgion CM, Lavy CBD. Systematic Review of Barriers to Surgical Care in Low-Income and Middle-Income Countries. World J Surg . 2011; 35: 941-950. https://doi.org/10.1007/s00268-011-1010-1 Specialist surgical workforce (per 100,000 population). The World Bank. Updated 2018. Accessed February 14, 2024. https://data.worldbank.org/indicator/SH.MED.SAOP.P5 Vargas GM, Price RR. Laparoscopy. In: Meara JG, McClain CD, Mooney DP, Rogers SO Jr, eds. Global Surgery and Anesthesia Manual: Providing Care in Resource-Limited Settings . 1 st ed. CRC Press; 2015: 195-209. https://doi.org/10.1201/b17974 Okrainec A, Henao O, Azzie G. Telesimulation: an effective method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries. Surg Endosc . 2010; 24(2): 417-422. https://doi.org/10.1007/s00464-009-0572-6 Straub CM, Price RR, Matthews D, et al. Expanding Laparoscopic Cholecystectomy to Rural Mongolia. World J Surg . 2011; 35(4): 751-759. https://doi.org/10.1007/s00268-011-0965-2 Vithea D. MIS in Cambodia: History, Activity, & Challenges. PowerPoint slideshow. March 2022; Phnom Penh, Cambodia. Berg DA, Milner RE, Fisher CA, Goldberg AJ, Dempsey DT, Grewal H. A cost-effective approach to establishing a surgical skills laboratory. Surgery . 2007; 142(5): 712-721. https://doi.org/10.1016/j.surg.2007.05.011 Fisher R, Onuh OC, Vásquez Checo R, et al. The Successful Implementation of a Laparoscopic Simulation Training Program in the Dominican Republic. J Surg Res . 2022; 278: 337-341. https://doi.org/10.1016/j.jss.2022.04.020 Murre JMJ, Dros J. Replication and Analysis of Ebbinghaus’ Forgetting Curve. PLOS ONE . 2015; 10(7): e0120644. https://doi.org/10.1371/journal.pone.0120644 Vision, Mission, and Values. Calmette Hospital. Accessed June 18, 2024. https://calmette.gov.kh/ Asia’s Largest Humanitarian Project Commences in Cambodia: Kampong Thom Provincial Hospital renovation opened with a ceremony celebrating the commencement of the project. Official Newsroom of the Church of Jesus Christ of Latter-day Saints . January 18, 2023. Accessed June 8, 2024. https://news-kh.churchofjesuschrist.org/article/asia-rsquo-s-largest-humanitarian-project-commences-in-cambodia Tansley G, Bailey JG, Gu Y, et al. Efficacy of Surgical Simulation Training in a Low-Income Country. World J Surg . 2016; 40: 2643-2649. https://doi.org/10.1007/s00268-016-3573-3 Irfanullah EA, Chandra A, Solaiman RH, et al. Simulation Training in a Lower Middle-Income Country: Supporting a New Center and Developing Low-Cost Models for Critical Skill Acquisition. Cureus . 2023; 15(6): e40950. https://doi.org/10.7759/cureus.40950 SURGHUB – THE UNITED NATIONS GLOBAL SURGERY LEARNING HUB. United Nations Institute for Training and Research. Accessed June 5, 2024. https://unitar.org/sustainable-development-goals/people/our-portfolio/surghub-united-nations-global-surgery-learning-hub Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 28 Apr, 2025 Reviewers invited by journal 27 Apr, 2025 Editor invited by journal 13 Apr, 2025 Editor assigned by journal 26 Mar, 2025 First submitted to journal 25 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6298044","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":448734167,"identity":"0fb94443-a228-44b1-a0c8-65fde3363e86","order_by":0,"name":"Anna Melissa Darelli-Anderson","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-9468-8699","institution":"University of Utah","correspondingAuthor":true,"prefix":"","firstName":"Anna","middleName":"Melissa","lastName":"Darelli-Anderson","suffix":""},{"id":448734168,"identity":"9a773c16-1be9-4226-8def-6de820abd98a","order_by":1,"name":"Vithiea Dara","email":"","orcid":"","institution":"Calmette Hospital: Hopital Calmette","correspondingAuthor":false,"prefix":"","firstName":"Vithiea","middleName":"","lastName":"Dara","suffix":""},{"id":448734169,"identity":"eba8da59-4a28-4cfa-97df-10bf675991fc","order_by":2,"name":"Angel Flores Huidobro Martinez","email":"","orcid":"","institution":"University of Utah","correspondingAuthor":false,"prefix":"","firstName":"Angel","middleName":"Flores Huidobro","lastName":"Martinez","suffix":""},{"id":448734170,"identity":"ccc04646-aa2d-4789-a8a0-4ba789290c07","order_by":3,"name":"Leif Sorensen","email":"","orcid":"","institution":"University of Utah","correspondingAuthor":false,"prefix":"","firstName":"Leif","middleName":"","lastName":"Sorensen","suffix":""},{"id":448734171,"identity":"58f68133-ca21-4c03-99e7-af8217146d86","order_by":4,"name":"Liz Elvira","email":"","orcid":"","institution":"University of Utah","correspondingAuthor":false,"prefix":"","firstName":"Liz","middleName":"","lastName":"Elvira","suffix":""},{"id":448734172,"identity":"d1f64764-7d7d-4bd8-9c70-188d0fe51e09","order_by":5,"name":"Kossadyn Kirtchhoof","email":"","orcid":"","institution":"Calmette Hospital: Hopital Calmette","correspondingAuthor":false,"prefix":"","firstName":"Kossadyn","middleName":"","lastName":"Kirtchhoof","suffix":""},{"id":448734173,"identity":"ed74b135-a05c-43cc-b20e-e3ea37138cf9","order_by":6,"name":"Nathan G. Richards","email":"","orcid":"","institution":"University of Utah","correspondingAuthor":false,"prefix":"","firstName":"Nathan","middleName":"G.","lastName":"Richards","suffix":""},{"id":448734174,"identity":"14073283-e3e1-446a-9e1e-ee44bde3d2fb","order_by":7,"name":"Vutha Meas","email":"","orcid":"","institution":"Calmette Hospital: Hopital Calmette","correspondingAuthor":false,"prefix":"","firstName":"Vutha","middleName":"","lastName":"Meas","suffix":""},{"id":448734175,"identity":"301d57f7-683c-4ca8-b101-fbcf650e622c","order_by":8,"name":"Raymond R. Price","email":"","orcid":"","institution":"University of Utah","correspondingAuthor":false,"prefix":"","firstName":"Raymond","middleName":"R.","lastName":"Price","suffix":""}],"badges":[],"createdAt":"2025-03-24 19:46:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6298044/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6298044/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82203554,"identity":"0c66ab4f-f564-41a8-bc5e-46ab9479dc9f","added_by":"auto","created_at":"2025-05-07 16:47:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":610647,"visible":true,"origin":"","legend":"\u003cp\u003eLevels of OR Independence\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6298044/v1/4d51cb0a466e7370bd64fe92.png"},{"id":82204861,"identity":"c8ae96e0-348e-4c37-a74a-7b0ba6227ccc","added_by":"auto","created_at":"2025-05-07 17:03:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":93166,"visible":true,"origin":"","legend":"\u003cp\u003eHospital Site Locations in Cambodia\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6298044/v1/2d73358cb289052f46238c0a.png"},{"id":82204606,"identity":"0946b126-4d0a-4852-bb08-b6753bcd26e7","added_by":"auto","created_at":"2025-05-07 16:55:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":88371,"visible":true,"origin":"","legend":"\u003cp\u003eBreakdown of Program Participants\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6298044/v1/3afe52e8698d9b4499606fab.png"},{"id":82204605,"identity":"91597cf7-4c29-483a-9843-8f01b8e74051","added_by":"auto","created_at":"2025-05-07 16:55:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":62728,"visible":true,"origin":"","legend":"\u003cp\u003eBreakdown of Participants' Prior Experience (or Lack of)\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6298044/v1/a5bd525854f3d6419d7a3cdb.png"},{"id":82203551,"identity":"af02e70d-fea5-44bd-bdcb-699a66367d06","added_by":"auto","created_at":"2025-05-07 16:47:42","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":64659,"visible":true,"origin":"","legend":"\u003cp\u003eBreakdown of Participants' Comfortability with Laparoscopic Skills\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-6298044/v1/7284934f33c00f3d1babe31e.png"},{"id":82205288,"identity":"ba244087-63b5-44d1-96cd-6297bbf2fd2e","added_by":"auto","created_at":"2025-05-07 17:11:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1871334,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6298044/v1/b0a57515-2909-4b92-8b64-9a8fa07aaea7.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eA Pilot for Surgical Education in Low-and Middle-Income Countries: Establishing a Basic Laparoscopic Training Program in Cambodia\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMinimally invasive, or laparoscopic, surgery can be used to treat a broad range of surgical diseases, including those of the gallbladder, appendix, colon, and many obstetric procedures. Benefits of minimally invasive surgery (MIS) include fewer complications, reduced postoperative pain, quicker recovery time, and shorter hospital stays. In high-income countries (HICs), laparoscopy has been used to treat these conditions since the 1980s [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]; however, implementation of MIS in low- and middle-income countries (LMICs), while increasing in more recent years, has been difficult.\u003c/p\u003e \u003cp\u003eAdditionally, the global burden of surgical disease is multifaceted and affects a significant portion of the world\u0026rsquo;s population. Nine of 10 people in LMICs do not have access to safe, timely, and affordable surgical and anesthesia care; indeed, Southeast Asia alone has an unmet surgical need of nearly 12.5\u0026nbsp;million surgical procedures each year, or 2,045 per 100,000 population [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Reasons for this include direct and indirect costs to both patients and hospitals; a scarcity of formal medical education, leading to a general lack of healthcare personnel [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; limited local resources; social and political matters; and issues of distance, poor roads, and insufficient suitable transport [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, LMICs not only struggle with a shortage of trained surgeons\u0026mdash;with Cambodia boasting an estimated surgical workforce of 4 per 100,000 population [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] compared to the 20 per 100,000 population recommended by the Lancet Commission on Global Surgery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u0026mdash;but also proper training opportunities for further specialization in areas like laparoscopy.\u003c/p\u003e \u003cp\u003eHowever, some methods for establishing laparoscopic surgery in LMICs have proven successful. For example, forming alliances with local academic centers offers the advantage of being able to educate a group of surgeons rather than single individuals. This also allows for the creation of locally designed, culturally sensitive education programs that can be implemented not only within surgical residency programs but extended to community and rural surgeons as well [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Previous ventures in Botswana and Mongolia have also shown the benefits of a combination of didactics, simulations, and practical training in establishing and improving laparoscopy in LMICs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe first cholecystectomy performed in Cambodia occurred in 1987 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], though there remains no standardized training for laparoscopic surgery within the country. The principal objective of this study was to develop and establish a sustainable basic laparoscopic surgery training program at Calmette that may be employed as a model to expand MIS in Cambodia, and for use in other LMICs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA multidisciplinary team of experts in general surgery, obstetrics and gynecology (OBGYN), anesthesiology, and medical education conducted this project over a 3-year period. To guide the educational approach, the team employed a combination of the ADDIE (Analysis, Design, Development, Implementation, and Evaluation) model, Bloom\u0026rsquo;s taxonomy (in which cognitive learning is arranged into six levels: remembering, understanding, applying, analyzing, evaluating, and creating), and Kolb\u0026rsquo;s theory of experiential learning (premised on the transformation of experience for knowledge creation). The ADDIE model provided a structured framework, ensuring that each phase\u0026mdash;from analyzing learning needs to designing materials, developing modules, implementing training, and evaluating outcomes\u0026mdash;was methodically executed. Bloom\u0026rsquo;s taxonomy supported the learning progression, advancing from foundational knowledge of laparoscopic skills to more complex applications and analysis, with increasing levels of learner engagement at each stage. Finally, Kolb\u0026rsquo;s theory reinforced experiential learning, emphasizing hands-on practice, reflection, and skill refinement.\u003c/p\u003e \u003cp\u003eFirst, an in-person two-week basic laparoscopic surgery training program was developed that included a didactic curriculum on principles of laparoscopic surgery and an educator workshop, a simulation skills course, and a hands-on in-theatre practical training component. Prior to implementation of training, sites\u0026rsquo; infrastructure were evaluated and developed as needed. In-country team visits were planned for twice a year, with the objective of the initial trip being to establish both the program and a laparoscopic skills training center at the country\u0026rsquo;s flagship medical center, Calmette Hospital. Subsequent trips had two objectives: 1) to reinforce training at previously visited sites and 2) to establish the program at a new site. In this manner, each site longitudinally benefited from direct interactions and feedback from the team of experts on at least three separate occasions.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDeveloping the Didactic Curriculum\u003c/h2\u003e \u003cp\u003eThe first aspect of the basic training program consisted of didactic instruction. The \u003cem\u003ePrinciples of Laparoscopic Surgery\u003c/em\u003e course (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) was comprised of 10 modules, beginning with an introduction tailored for LMICs, emphasizing the accessibility and adaptation of laparoscopy in diverse settings. Subsequent modules guided participants through essential preparatory steps, such as setting up the room and troubleshooting during procedures. A strong focus was placed on sterile techniques, including scrubbing, gowning, and gloving, to ensure the highest standards of hygiene and safety. The course also taught the intricacies of electrosurgery and the critical physiological and anesthesia considerations specific to MIS. Preoperative concerns were covered in depth to prepare surgeons for the procedural workflow. Practical skills were stressed in modules on laparoscopic entry and port placement, followed by a thorough examination of potential complications and their management. The course concluded with an overview of diagnostic laparoscopy, encapsulating the key concepts and skills needed to perform surgery effectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrinciples of Laparoscopic Surgery Core Didactic Curriculum\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eModule\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTopic\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntroduction to Laparoscopy for Low- and Middle-Income Countries\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSetting Up the Room for Laparoscopy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTroubleshooting During Laparoscopy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntroduction to Sterile Techniques: Scrubbing, Gowning, and Gloving\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElectrosurgery in Laparoscopy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysiology and Anesthesia Considerations for Laparoscopy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative Considerations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaparoscopic Entry and Port Placement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplications in Laparoscopy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverview of Diagnostic Laparoscopy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDue to the mixed nature of learners\u0026rsquo; backgrounds, additional content for both surgical and gynecological breakout sessions were created. Specifically, the Surgery Breakout Session included four modules on laparoscopic cholecystectomy about 1) preoperative considerations, 2) intraoperative considerations, 3) preparation, and 4) technique. The gynecology modules were: 1) MIS for gynecology, 2) preoperative, operating room (OR), and entry considerations for gynecologic laparoscopy, 3) laparoscopic tubal ligation, and 4) laparoscopic ovarian cystectomy (and postoperative considerations and troubleshooting).\u003c/p\u003e \u003cp\u003eThe comparison between the effectiveness of traditional didactics and computer-based training (CBT) methodologies in medical education is a vital question. Traditional didactics offer direct engagement and hands-on learning experiences. However, with the emergence of CBT, a new dimension to medical education has surfaced, offering flexible learning environments and adaptive learning pathways. In light of these advancements, the adaptability of traditional methods remains crucial, especially in contexts where resources are limited. As such, a strategic integration of both traditional didactics and CBT was utilized. That is, delivery of the didactic curriculum occurred in person and involved interactive elements such as a live exhibition and demonstration of surgical instruments. Furthermore, in consideration of the scarcity of resources, the curriculum was also adapted for use on an open-source online learning platform.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCreating the Educator Workshop\u003c/h3\u003e\n\u003cp\u003eFor those learners who were already attending surgeons or OBGYNs, and/or who had the potential or interest to go on to teach minimally invasive surgical skills\u0026mdash;those located at teaching hospitals or willing to travel to more rural areas to teach\u0026mdash;an additional educator workshop was created on \u003cem\u003eTeaching Laparoscopic Surgery in LMICs\u003c/em\u003e. The course was comprised of five introductory modules on planning, developing, and teaching laparoscopic surgery, and culminated in a final two-hour hands-on module on program development to provide them with an understanding of the general concepts of curriculum development and the skills to design a basic program to expand their medical education capabilities and for the purposes of sustainability. Specifically, the two-day workshop focused on: 1) how to develop a laparoscopic skills training center, 2) teaching the differences between open and laparoscopic surgery, 3) simulation-based education, 4) communication skills to facilitate learning in surgical education, 5) understanding advanced laparoscopic skills, and 6) program development.\u003c/p\u003e\n\u003ch3\u003eDesigning the Skills Simulation Course\u003c/h3\u003e\n\u003cp\u003eSince the turn of the century, Surgical Skills Laboratories (SSLs) have been used in HICs to enhance surgical training, with the American Council for Graduate Medical Education (ACGME) later making it a required element of general surgery residency programs in 2008 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Certainly, simulation training has been proven to significantly improve surgeons\u0026rsquo; skills, such as precision cutting and intracorporeal knot tying, useful in MIS [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Accordingly, we endeavored to create a blueprint for a small-scale SSL involving box simulators to be used in LMICs.\u003c/p\u003e \u003cp\u003eInspired by the Society of American Gastrointestinal and Endoscopic Surgeons\u0026rsquo; (SAGES) Fundamentals of Laparoscopic Surgery (FLS) program, six training exercises (rubber band transfer, spandex, needle through loop, circle cut, extracorporeal knot tying, and intracorporeal knot tying) were developed to be used with items easily purchased from local suppliers in Asia (e.g., rubber bands, gauze, etc.) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This approach ensured that learners could effectively practice surgical skills within the constraints of the provided resources and equipment, thereby maximizing the educational value of the training program.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic Laparoscopic Skills Simulation Training Curriculum\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTask\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTechnical Objectives\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRubber Band Transfer\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA basic coordination and dexterity exercise where one transfers rubber bands from posts on one side of the simulator to the other, switching hands with each transfer.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Achieve proficiency in bimanual object manipulation.\u003c/p\u003e \u003cp\u003e\u0026bull; Develop hand dexterity to facilitate precise movements.\u003c/p\u003e \u003cp\u003e\u0026bull; Master basic compression and release techniques, along with modulation of grip strength.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpandex\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA dexterity and precision exercise where rubber bands are stretched and placed around posts in a sequential pattern.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Expand abilities in bimanual manipulation techniques for handling tissue effectively.\u003c/p\u003e \u003cp\u003e\u0026bull; Attain mastery in depth orientation.\u003c/p\u003e \u003cp\u003e\u0026bull; Apply appropriate strength and traction techniques for optimal handling.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeedle Through Loop\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA needle-handling exercise where one threads a needle through a series of loops, switching hands and maintaining precise control.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Develop proficiency in bimanual manipulation techniques for handling tissue and the needle during procedures.\u003c/p\u003e \u003cp\u003e\u0026bull; Learn the skill of presenting a needily accurately for precise insertion.\u003c/p\u003e \u003cp\u003e\u0026bull; Refine suture manipulation skills for smooth and effective suturing.\u003c/p\u003e \u003cp\u003e\u0026bull; Enhance movement precision while maneuvering a needle through a designated path.\u003c/p\u003e \u003cp\u003e\u0026bull; Achieve adept depth orientation to accurately gauge needle penetration during procedures.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCircle Cut\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA precision-cutting exercise where a circular shape is cut from gauze.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Develop proficiency in executing precise incisions with surgical instruments.\u003c/p\u003e \u003cp\u003e\u0026bull; Master the technique of controlling the depth and angle of the cut to achieve optimal tissue preservation.\u003c/p\u003e \u003cp\u003e\u0026bull; Acquire the ability to maintain steady hand movements and a stable surgical field during precision-cutting procedures.\u003c/p\u003e \u003cp\u003e\u0026bull; Ensure consistent and reliable performance in following predetermined cutting lines or patterns as required.\u003c/p\u003e \u003cp\u003e\u0026bull; Demonstrate skill in achieving optimal tissue exposure and traction to facilitate precise cutting.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExtracorporeal Knot Tying\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAn exercise where one creates secure knots outside of the simulator and uses a knot pusher to guide and tighten the knots inside the simulator.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Learn to handle the needle and suture material outside the body cavity.\u003c/p\u003e \u003cp\u003e\u0026bull; Master the technique of forming secure knots outside the surgical field.\u003c/p\u003e \u003cp\u003e\u0026bull; Develop the ability to manipulate the knot and adjust its tension accurately.\u003c/p\u003e \u003cp\u003e\u0026bull; Acquire precision in knot placement and configuration to ensure reliable closure and tissue approximation.\u003c/p\u003e \u003cp\u003e\u0026bull; Demonstrate consistency and efficiency in completing extracorporeal knot tying tasks within a designated time frame.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntracorporeal Knot Tying\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAn exercise where one ties a square knot entirely within the simulator.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Successfully grasp and manipulate the needle and suture material within the surgical field.\u003c/p\u003e \u003cp\u003e\u0026bull; Master the technique of forming secure knots within the body cavity without the need for extracorporeal assistance.\u003c/p\u003e \u003cp\u003e\u0026bull; Develop proficiency in adjusting knot tension to achieve optimal tissue approximation and hemostasis.\u003c/p\u003e \u003cp\u003e\u0026bull; Attain precision in knot placement and configuration to ensure reliable surgical closure and tissue integrity.\u003c/p\u003e \u003cp\u003e\u0026bull; Demonstrate consistency and efficiency in completing intracorporeal knot tying tasks within a designated time frame.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe course was arranged according to level of difficulty, with the first exercise being the least difficult and the sixth the most difficult. One and a half hours were allotted to each of the first two tasks (rubber band transfer and spandex), and two hours apiece for the remaining tasks. Each session began with an explanation of objectives, video and photo demonstration of the exercise, and review of scoring guidelines. Throughout the sessions, instructors also exhibited the skills on the box simulators themselves for each group. Then, participants were asked to first complete the task without any hands-on practice to determine baseline levels. They were subsequently allowed to practice the task for 15 minutes before officially attempting the exercise again. All learners\u0026rsquo; skills were assessed using a standardized 10-point rubric measuring time, precision, and adherence to technique. Scores from each repetition were recorded and documented, and trainees were provided with ongoing feedback.\u003c/p\u003e \u003cp\u003eRegular practice combats the natural decay of learned skills by validating knowledge and motor memory, thereby slowing the rate of forgetting and promoting longer-term retention. To overcome Ebbinghaus\u0026rsquo; forgetting curve [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], which illustrates how memory retention declines over time without reinforcement, participants were further encouraged to continue practicing and recording their results on an ongoing basis following the initial course. This ongoing documentation also allowed for tracking the progression of skills over time, enabling participants to not only retain but also refine and advance their laparoscopic skills.\u003c/p\u003e\n\u003ch3\u003eOrganizing the Practical Training Component\u003c/h3\u003e\n\u003cp\u003eWhen possible, following didactic instruction and simulation training, learners were then provided supervised graduated hands-on in-theatre experience (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In preparation for the practical training component of the program, patients with cholecystitis were screened, selected, and scheduled for surgery based on urgency. Expert general surgeons first performed laparoscopic cholecystectomies while learners observed. The experts took time to: 1) explain each step and the reasoning behind their actions, 2) demonstrate key points of the procedure, 3) troubleshoot any complications that came up, and 4) answer learners\u0026rsquo; questions in real time. The next phase of the training was much the same, with the addition of having the learners take turns assisting on the procedure. Once the surgical educators were confident that participants had the basic skills and understanding, attending surgeons took turns taking the position of Surgeon while our instructors served as Assistants. Training progressed until local surgeons filled the roles of both Surgeon and Assistant(s) under the supervision of the experts. Upon the experts\u0026rsquo; departure, learners were able to complete laparoscopic cholecystectomies as a team entirely independently.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eAssessing Prospective Sites\u003c/h3\u003e\n\u003cp\u003ePrior to implementation of the program, leaders from Calmette and the Ministry of Health were consulted regarding local country guidance and thorough evaluations were conducted across various essential domains at each potential site. In February 2022, initial preprogram site visits were made to Calmette, Kampong Cham, and Phnom Penh Municipal Referral Hospitals. Additional visits were carried out at the Cambodian Japanese Friendship Mongkul Borei Referral Hospital (in Banteay Meanchey) and Battambang Provincial Hospital in December 2022, as well as Kampong Thom Provincial Hospital and the Cambodia-China Friendship Tboung Khmum Hospital in February 2023 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Each hospital was rigorously evaluated using a comprehensive assessment tool encompassing several critical areas:\u003c/p\u003e \u003cp\u003eFirst, hospital-specific details such as the name, address, and leadership structure were documented, including the Chief Hospital Administrator and primary points of contact. This provided insights into the administrative hierarchy and facilitated direct communication channels. Infrastructure assessment encompassed crucial factors such as the hospital\u0026rsquo;s level and type, annual admissions categorized by age and gender, and availability of essential utilities such as water, electricity, and sanitation. The presence of backup generators and waste disposal systems were also noted, highlighting the hospital\u0026rsquo;s preparedness for uninterrupted operations and adherence to hygiene standards.\u003c/p\u003e \u003cp\u003eDemographic considerations included the size of the population served by each hospital, predominant patient languages, and primary modes of patient transportation. These elements were pivotal in understanding potential barriers to health care access and the hospital\u0026rsquo;s role within the local health care system. The evaluation also examined the documentation practices within each hospital, detailing whether patient charts were maintained electronically or in hard copy, and the methods employed for their storage.\u003c/p\u003e \u003cp\u003eThe availability of dedicated training facilities was appraised, including the presence of conference rooms equipped with necessary amenities like electricity, projectors, screens, and internet access. Technological support, both on-site and off-site, was also scrutinized to assess the hospital\u0026rsquo;s capacity for integrating advanced educational tools such as video conferencing into the training program. Examining the hospital\u0026rsquo;s educational framework, the assessment considered whether the facility operated as a teaching hospital, its affiliates with educational institutions, and the annual training capacities for surgical and OBGYN residents. This provided insights into the hospital\u0026rsquo;s role in medical education and its potential for sustaining a structured laparoscopic training initiative.\u003c/p\u003e \u003cp\u003eRegarding personnel, the evaluation included specific inquiries into the number and specialization of trained general surgeons, OBGYNs, anesthesiologists, nurses, and OR staff. Further details on nursing staff included their highest level of education, average tenure, and roles in assisting surgeries, all of which contributed to understanding the hospital\u0026rsquo;s clinical support capacity and readiness to support surgical training. Additionally, operational aspects such as the number of designated ORs, their turnaround times, and the hospital\u0026rsquo;s ability to adhere to predefined start times for surgeries were assessed. These components were paramount in gauging the hospital\u0026rsquo;s efficiency in surgical scheduling and resource management. Equipment inquiries addressed whether the hospital possessed resources for repairing or replacing laparoscopic parts locally, its budget allocation for equipment maintenance, and methods for sterilizing surgical instruments, ensuring compliance with surgical safety standards.\u003c/p\u003e \u003cp\u003eCollectively, the comprehensive program site assessment provided a holistic understanding of each facility\u0026rsquo;s readiness and capacity to support a basic laparoscopic surgery training program. With a focus on addressing local needs and ensuring the program\u0026rsquo;s alignment with the health care landscape of LMICs, this served as a foundational step in identifying key strengths and challenges across prospective hospitals in Cambodia. Thus, of the seven sites evaluated, three were selected for inclusion.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eImplementing the Program\u003c/h2\u003e \u003cp\u003eIn partnership with the Association of the Church of Jesus Christ of Latter-day Saints\u0026rsquo; Cambodia Health Improvement Effort (CHIE) for both funding and logistical support, the program was implemented at a new site during each of three visits occurring in December 2022, February 2023, and September 2023. The first iteration was administered at Calmette, and the second and third at Kampong Cham and Kampong Thom, both rural centers (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A team of experts comprised of general surgeons, OR staff, and medical educators and/or research assistants was assembled for each trip.\u003c/p\u003e \u003cp\u003eThroughout the program, participants were surveyed to assess their perceived confidence, knowledge, and technical dexterity before and after the program. The survey aimed to evaluate the effectiveness of the curriculum, identify gaps in skills and experience, and assess participants\u0026rsquo; perceptions of how the program influenced their readiness to both perform and teach others laparoscopic surgery. The pre-program survey collected demographic data, prior laparoscopic experience, and self-reported comfort with specific surgical skills, while the post-program survey focused on learners\u0026rsquo; confidence levels, perceived skill improvement, and the impact of the program on their surgical practice. The post-program survey also included a section specifically for attending physicians supervising trainees to capture their observations on trainee performance and stress levels in the OR.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDecember 2022 — Calmette Hospital\u003c/h3\u003e\n\u003cp\u003eConducted in December 2022, the purpose of the first visit was to set up a center of excellence for laparoscopic training at Calmette and involved 16 lectures, six skills modules, and hands-on surgical proctoring. Originally established in 1958 before being destroyed during the Khmer Rouge Regime in the 1970s, Calmette was then rebuilt as a public hospital following the Cambodian Civil War. Providing much-needed free-of-charge care to impoverished Cambodians, one of Calmette\u0026rsquo;s principal missions is to \u0026ldquo;participate in education\u0026hellip;and serving as field practical training for medical students and other health care professionals\u0026rdquo; [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Focusing on attending general surgeons and OBGYNs, the team began with the two-day educator workshop. A subsequent three-day training was held for trainees (i.e., surgical residents and medical students), to include the didactic curriculum and skills simulation course, with the trained Cambodian faculty serving as instructors. The following week was then spent acquiring in-theatre experience. A pre- and post-course survey was administered to evaluate confidence levels with laparoscopic surgery, as well as perceived improvements after completion of the training.\u003c/p\u003e\n\u003ch3\u003eFebruary 2023 — Kampong Cham and Calmette Hospitals\u003c/h3\u003e\n\u003cp\u003eIn February 2023, the team returned to Cambodia to carry out the training program at Kampong Cham. Because Kampong Cham is a small rural hospital with only the occasional trainee in attendance, the time was spent simply teaching MIS to the one general surgeon and the two OBGYNs that served as attending physicians there. This included the 10-module \u003cem\u003ePrinciples of Laparoscopic Surgery\u003c/em\u003e course, the full skills simulation course, and practical training time in the OR. Additionally, an anesthesiologist was added to the team to assess anesthesia care currently available in-country. During the second week of this visit, while the majority of the team continued to provide training at Kampong Cham, a small crew consisting of a general surgeon, the anesthesiologist, and the medical educator returned to Phnom Penh to 1) aid the previously trained educators at Calmette with facilitating further replications of the basic course, 2) assist in and gauge capabilities for more advanced surgical cases, and 3) explore opportunities for improving available anesthesia care and training.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSeptember 2023 \u0026mdash; Kampong Thom and Kampong Cham Hospitals\u003c/h2\u003e \u003cp\u003eThe final visit occurred in September 2023, during which the team of attending surgeons at Kampong Thom received both didactic and simulation training on basic laparoscopic surgery. One of three referral hospitals in a province serving more than 850,000 people, Kampong Thom was recently renovated by CHIE throughout 2023 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, due to the ORs not having been completed by the time of the visit, and the need for further anesthesia development, the practical training component of the program was deferred to a future trip, allowing the surgeons additional time to practice and develop their laparoscopic skills until then. Part of the team returned to Kampong Cham for a follow-up in-theatre course to reinforce the newly developed laparoscopic skills and an in-depth debrief and further discussion on the results of the implementation of laparoscopic surgery over the previous seven months. While there, the team also reinforced the need for continuing quality assurance evaluation, including data collection efforts about their open and laparoscopic surgical cases and postoperative complications.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDescriptive statistics were generated for all potential predictors of success and after stratification by participant status. A total of 59 learners participated in our program: 36 attending physicians (28 surgeons and eight OBGYNs; 61.02%) and 23 trainees (20 surgical residents and three medical students; 38.98%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The vast majority were men (91.53%), with only five women in the group (four OBGYNs and one medical student; 8.47%), and the average age was 33 years old. Nearly two-thirds (62.72%) stated they had prior experience with laparoscopic surgery, though the majority (58.06%) had less than one year; nevertheless, more than three-quarters (77.50%) had performed or assisted in MIS.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAmongst the 28 surgeons who took part, 10 (35.71%) did not define their specialty, 12 (42.86%) specifically named general surgery, four (14.29%) stated they were urologists, and two (7.14%) described themselves as thoracic surgeons. While three-quarters of the attending physicians indicated that they had prior experience with MIS (23 surgeons and four OBGYNs; 85.19% and 14.81%, respectively) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), primarily via box simulators and/or animal or cadaver labs, 78.57% of respondents had less than one year of training, with over a quarter (29.17%) not having had completed any training for at least two years prior. Seventy percent received their training abroad, with the majority having gone to France (42.86%) or Thailand (35.71%). Ten of those who had obtained training (nine surgeons and one OBGYN) reported that they had later taught others what they had learned.\u003c/p\u003e \u003cp\u003eOf the 20 surgical residents included, 10 (50%) identified their specialty as general surgery, three (15%) as urology, and seven (35%) did not further elaborate. Half of the residents had prior experience with laparoscopic surgery (two did not indicate their level of training, two were PGY1s, one was a PGY2, two were PGY3s, two were PGY4s, and one was a PGY6), and none of the medical students did (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Of the residents who responded, 87.50% had less than one year of training, all within the previous two years. Only two residents indicated that they had gone on to teach what they had learned.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOverall, after excluding incomplete data entries, 62.81% of participants repeated each simulation training exercise at least twice. Paired t-tests were conducted to determine whether there was a statistically significant mean difference between the time it took to complete each exercise, as well as scores, before and after training. As expected, participants completed all exercises faster after having been trained and allowed to practice as compared to their first attempt, though there was only a statistically significant decrease in time with the rubber band transfer, spandex, needle through loop, and circle cut exercises (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Similarly, scores also significantly increased by 2.1024 (95% CI, 1.5268 to 2.6780) points, \u003cem\u003et\u003c/em\u003e(124)\u0026thinsp;=\u0026thinsp;7.2288, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 across \u003cem\u003eall\u003c/em\u003e exercises, though the spandex exercise was the only one in which the change was not statistically significant (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Interestingly, there was no significant difference between the improvement (in either time or score) of attending physicians as compared to trainees.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic Laparoscopic Skills Simulation Training Results (Time)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst Attempt Mean (sec)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinal Attempt Mean (sec)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDifference (sec)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRubber Band Transfer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e175.2424\u0026thinsp;\u0026plusmn;\u0026thinsp;97.3409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e110.1212\u0026thinsp;\u0026plusmn;\u0026thinsp;49.4386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-65.1212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37.9595\u0026ndash;92.2829\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.8836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpandex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e171.1875\u0026thinsp;\u0026plusmn;\u0026thinsp;53.4867\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e148.5625\u0026thinsp;\u0026plusmn;\u0026thinsp;40.0010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-22.625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.4583-47.7083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.9226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0369\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeedle Through Loop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e322.7727\u0026thinsp;\u0026plusmn;\u0026thinsp;168.5266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e214.3182\u0026thinsp;\u0026plusmn;\u0026thinsp;96.3013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-108.4545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40.4335-176.4756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.3158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircle Cut\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e312\u0026thinsp;\u0026plusmn;\u0026thinsp;110.9401\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e219.069\u0026thinsp;\u0026plusmn;\u0026thinsp;89.2680\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-92.9310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e57.0216-128.8404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.3011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtracorporeal Knot Tying\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e173.6923\u0026thinsp;\u0026plusmn;\u0026thinsp;69.7930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e145.8462\u0026thinsp;\u0026plusmn;\u0026thinsp;47.2191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-27.8462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-16.3306-72.0229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.3734\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0974\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracorporeal Knot Tying\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e268.9167\u0026thinsp;\u0026plusmn;\u0026thinsp;101.5225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e243.9167\u0026thinsp;\u0026plusmn;\u0026thinsp;88.2903\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-21.3840-71.3840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.1863\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.1303\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic Laparoscopic Skills Simulation Training Results (Score)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst Attempt Mean (pts)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinal Attempt Mean (pts)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDifference (pts)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRubber Band Transfer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.1173\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.2676\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.1503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.1367\u0026ndash;3.1639\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.3212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpandex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.7363\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5922\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.3075\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.5713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.3782-1.5207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.2824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.1096\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeedle Through Loop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.4409\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8819\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.5891\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.4586\u0026ndash;4.7196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.5273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircle Cut\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.8055\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.0183\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.2128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.9745\u0026ndash;4.4510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.3148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtracorporeal Knot Tying\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.4285\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.9915\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3847\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.5631\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.0628-3.1890\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.0947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0290\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracorporeal Knot Tying\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.17\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8815\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.1608\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5742\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.1465-2.1882\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.9247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0403\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmongst the attending physicians, even though 86.36% of those with training had also previously performed or assisted in laparoscopic surgery (chiefly, laparoscopic appendectomies and cholecystectomies), at least half of them were \u0026ldquo;neutral,\u0026rdquo; \u0026ldquo;uncomfortable,\u0026rdquo; or \u0026ldquo;very uncomfortable\u0026rdquo; with their skills relating to precision cutting (54.17%), running bowel (91.30%), band transfer (83.33%), intracorporeal suturing (95.83%), extracorporeal suturing (78.26%), and endoloop (62.50%). Similarly, three-quarters of the trainees had previously performed or assisted in MIS, though at least three-quarters were \u0026ldquo;neutral,\u0026rdquo; \u0026ldquo;uncomfortable,\u0026rdquo; or \u0026ldquo;very uncomfortable\u0026rdquo; with their skills relating to precision cutting (87.50%), running bowel (100%), band transfer (87.50%), intracorporeal suturing (100%), extracorporeal suturing (75.00%), and endoloop (75.00%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith an 80.95% response rate (47.05% attending physicians, 38.24% residents, 14.71% unclassified), the results of the post-training survey showed that respondents found the didactic curriculum (81.37% \u0026ldquo;agreed\u0026rdquo; or \u0026ldquo;strongly agreed\u0026rdquo;) and skills simulation (73.04%) useful, and that 85.29% had continued practicing their skills after the program. When asked about comfortability with laparoscopic skills, the majority were \u0026ldquo;comfortable\u0026rdquo; or \u0026ldquo;very comfortable\u0026rdquo; with precision cutting (64.71%), running bowel (73.53%), band transfer (76.47%), intracorporeal suturing (52.94%), extracorporeal suturing (67.65%), and endoloop (82.35%), a marked increase from their preprogram numbers (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Respondents further reported increased confidence (72.41%), knowledge (93.10%), and dexterity and precision (89.66%); 65.52% likewise indicated that they felt less stressed during surgery following the program. Physician attendings who supervised trainees were also separately asked about their perceptions of trainees\u0026rsquo; performance in the OR and similarly described increased confidence (86.67%), knowledge (93.33%), and dexterity and precision (86.67%), and decreased stress during surgery (86.67%) amongst their residents after the program.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFinally, the impact of the initial training program extended significantly through the ensuing efforts of the educators trained in December 2022. After their initial instruction and supervised trial run at Calmette, these individuals took on the role of trainers themselves, essentially multiplying the reach of the program. This group of six surgeon educators has since gone to lead a dozen courses for over 320 students during the period of approximately one and a half years.\u003c/p\u003e \u003cp\u003eAll statistical analyses were performed using a standard software package (StataNow18, version 18.5, StataCorp).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates the successful implementation and impact of a laparoscopic skills training program designed to address the shortage of MIS expertise in Cambodia. By focusing on sustainability, accessibility, and collaborative engagement, the program provides a model for advancing surgical education in LMICs. The program design, grounded in educational theory, provides a comprehensive framework that allows the needs and resource constraints of the local health care environment to be addressed. Indeed, the implementation of the program in both urban and rural settings, such as Calmette in Phnom Penh and more remote centers like Kampong Cham and Kampong Thom, showcases this adaptability.\u003c/p\u003e \u003cp\u003eThe outcomes of the program not only underline the immediate benefits of the training but also shed light on broader systemic needs within surgical education and health care infrastructure. Below, we discuss the implications of these results, organized around key themes.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness of the Program\u003c/h2\u003e \u003cp\u003eThe training yielded significant improvements in laparoscopic skills and overall confidence among participants. Statistical analyses revealed substantial enhancements in performance across several simulation exercises, with significant reductions in completion times and increases in accuracy following training. The paired t-tests also showed that participants, regardless of their status as either attending physicians or trainees, benefited equally from the program. The post-training survey further highlighted the program\u0026rsquo;s impact, with a majority of respondents reporting increased comfort and confidence in performing laparoscopic procedures. These results align with prior research demonstrating that structured simulation-based training can effectively improve surgical skills, even in resource-limited settings [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Experience, Skill Gaps, and the Value of In-Country Training Programs\u003c/h2\u003e \u003cp\u003eAlthough nearly two-thirds of participants reported some prior laparoscopic experience, the majority had less than one year of training, and many had not practiced these skills for at least two years. The absence of significant differences in improvement between attending physicians and trainees suggests that both groups started with comparable baseline skills, reflecting the lack of specialty training in laparoscopy.\u003c/p\u003e \u003cp\u003ePre-training surveys further revealed widespread discomfort with core laparoscopic tasks, even among those with prior MIS exposure. Over half of attending physicians, and three-quarters of trainees, reported feeling \u0026ldquo;neutral,\u0026rdquo; \u0026ldquo;uncomfortable,\u0026rdquo; or \u0026ldquo;very uncomfortable\u0026rdquo; with skills such as precision cutting, intracorporeal suturing, and running bowel. These results emphasize the need to address foundational skill gaps to build confidence and competence in laparoscopic procedures.\u003c/p\u003e \u003cp\u003eInterestingly, a striking finding was that 70% of attending physicians who had prior laparoscopic training obtained it abroad, predominantly in France and Thailand. This highlights the global interconnectedness of surgical education but also reveals the financial and logistical challenges associated with seeking training opportunities overseas. Establishing in-country programs like the one detailed here provides a more equitable and sustainable solution, ensuring broader access for learners who cannot afford to train abroad. Such initiatives are essential in resource-limited settings, where international travel remains infeasible for most practitioners.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSustainability Through Teaching and Local Integration\u003c/h2\u003e \u003cp\u003eA central aspect of this program\u0026rsquo;s success was its emphasis on sustainability. The program combines structured didactic content with hands-on simulation and live surgery, emphasizing sustainability through the training of in-country, native surgeon educators, who disseminated knowledge and skills beyond the initial cohort of learners. By equipping attending physicians and other health care professionals with both the clinical and pedagogical tools necessary to teach others, the program creates a multiplier effect, significantly broadening its impact.\u003c/p\u003e \u003cp\u003eThe collaboration between Cambodian surgeons and the expert team as co-trainers was equally critical in fostering a culture of continuous learning and mentorship. This partnership helped build trust and ensure that the curriculum was culturally relevant and contextually appropriate. Involving local trainers also facilitated better communication and learner engagement, while promoting expertise that will support long-term program sustainability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eBroader Implications for Surgical Education and Future Directions\u003c/h2\u003e \u003cp\u003ePost-training surveys demonstrated that most participants continued practicing their skills and reported significant improvements in confidence, knowledge, and stress management during surgery. These findings underscore the effectiveness of a combination of didactic, hands-on, and simulation-based training in building both technical and non-technical competencies. Feedback from supervising physicians highlighted increased trainee confidence, dexterity, and knowledge. This reinforces the value of mentorship and structured training programs in elevating surgical performance and reducing stress in the OR.\u003c/p\u003e \u003cp\u003eAs the program continues to expand to additional hospitals in Cambodia, it will further strengthen its impact by incorporating education and training on more advanced laparoscopic skills. As a result, the team is in the program-planning stage for three new courses on colectomy, foregut surgery, and anesthesia. These offerings will not only enhance the clinical skill set of local surgeons but also expand the scope of laparoscopic procedures available in Cambodia. By advancing beyond basic skills, the program aims to address more complex surgical needs, continuing to contribute to the overall growth of surgical services in the region.\u003c/p\u003e \u003cp\u003eFurthermore, the program offers valuable insights that can inform similar global surgical training initiatives. In contrast to larger, well-funded programs in HICs, this model is specifically tailored to LMICs, focusing on sustainability and long-term capacity building. The integration of local trainers and alignment with the existing health care structure ensures that the program remains relevant to local needs. By avoiding a \u0026ldquo;one-size-fits-all\u0026rdquo; approach, this initiative serves as a blueprint for how surgical training can be adapted and expanded in other LMICs, where infrastructure and resources vary widely.\u003c/p\u003e \u003cp\u003eIn addition to expanding the program content, the team is also addressing the accessibility of training resources. Currently, the \u003cem\u003ePrinciples of Laparoscopic Surgery\u003c/em\u003e course is freely available on Thinkific. However, recognizing a need to develop the existing and future global surgical care workforce through training and education, the United Nations\u0026mdash;in partnership with the Global Surgery Foundation and the Royal College of Surgeons in Ireland\u0026mdash;launched SURGhub in June 2023. The online training platform was developed to provide \u0026ldquo;high-quality global surgery learning materials to frontline providers,\u0026rdquo; [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] harmonizing with this program\u0026rsquo;s goals. Plans to submit this basic laparoscopy training course for inclusion on SURGhub will bolster the program\u0026rsquo;s global scalability, extending its reach to areas with comparable health care difficulties. Leveraging global platforms like SURGhub allows for standardization and collaboration across different countries, building a more cohesive global surgical training network.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eChallenges, Limitations, and Implications\u003c/h2\u003e \u003cp\u003eDespite its successes, the program faces some challenges. A major limitation is the inconsistent availability of infrastructure in some of the hospitals, as seen in Kampong Thom, where the practical component had to be deferred due to unfinished ORs and a lack of anesthesia training and supplies. Additionally, while the program has had a positive impact on participants\u0026rsquo; skills, the adaptation of training materials and techniques to fit the local context and available resources can be difficult. The reliance on box simulators and easily sourced materials for simulation exercises was necessary but may not fully replicate the conditions of more advanced simulators, resources, or training settings found in HICs. This adaptation, while pragmatic, could influence the depth of skills development achievable through the program.\u003c/p\u003e \u003cp\u003eAnother challenge is maintaining consistent post-training follow-up and data collection, particularly in resource-constrained settings. Monitoring long-term outcomes and ensuring the proper use of laparoscopic techniques can be taxing when hospital systems are still developing electronic medical records and tracking processes for surgical cases. Addressing these logistical issues will be crucial in ensuring the continued success and scalability of the program. Nonetheless, the overall positive outcome of this training initiative shows potential for parallel programs to enhance surgical education in LMICs, with several factors (e.g., customization to local contexts, sustained training and support, and evaluation and adaptation) to be considered to maximize effectiveness.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis model provides a standardized and replicable platform with theoretical, practical, and evaluation components for increasing access to self-sustained MIS training in LMICs such as Cambodia, aligning with broader efforts to enhance surgical capacity globally. The laparoscopy training program in Cambodia effectively increased surgical skills and confidence among a diverse group of participants. The integration of structured educational frameworks and hands-on practice proved successful, though challenges related to resource limitations need to be addressed in future iterations. By continuing to refine and adapt such programs, the potential to improve laparoscopic surgical education and patient outcomes in LMICs remains substantial.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eOn behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access storage at the University of Utah.\u003c/li\u003e\n\u003c/ul\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlkatout I, Mechler U, Mettler L. The Development of Laparoscopy \u0026ndash; A Historical Overview. \u003cem\u003eFront Surg\u003c/em\u003e. 2021; 8: 799442. https://doi.org/10.3389/fsurg.2021.799442\u003c/li\u003e\n\u003cli\u003eMeara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. \u003cem\u003eLancet\u003c/em\u003e. 2015; 386: 569-624. https://doi.org/10.1016/S0140-6736(15)60160-X\u003c/li\u003e\n\u003cli\u003eDawson AZ, Walker RJ, Campbell JA, Egede LE. Effective Strategies for Global Health Training Programs: A Systematic Review of Training Outcomes in Low and Middle Income Countries. \u003cem\u003eGlob. J. Health Sci\u003c/em\u003e. 2016; 8(11): 278-292. https://doi.org/10.5539/gjhs.v8n11p278\u003c/li\u003e\n\u003cli\u003eGrimes CE, Bowman KG, Dodgion CM, Lavy CBD. Systematic Review of Barriers to Surgical Care in Low-Income and Middle-Income Countries. \u003cem\u003eWorld J Surg\u003c/em\u003e. 2011; 35: 941-950. https://doi.org/10.1007/s00268-011-1010-1\u003c/li\u003e\n\u003cli\u003eSpecialist surgical workforce (per 100,000 population). The World Bank. Updated 2018. Accessed February 14, 2024. https://data.worldbank.org/indicator/SH.MED.SAOP.P5\u003c/li\u003e\n\u003cli\u003eVargas GM, Price RR. Laparoscopy. In: Meara JG, McClain CD, Mooney DP, Rogers SO Jr, eds. \u003cem\u003eGlobal Surgery and Anesthesia Manual: Providing Care in Resource-Limited Settings\u003c/em\u003e. 1\u003csup\u003est\u003c/sup\u003e ed. CRC Press; 2015: 195-209. https://doi.org/10.1201/b17974\u003c/li\u003e\n\u003cli\u003eOkrainec A, Henao O, Azzie G. Telesimulation: an effective method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries. \u003cem\u003eSurg Endosc\u003c/em\u003e. 2010; 24(2): 417-422. https://doi.org/10.1007/s00464-009-0572-6\u003c/li\u003e\n\u003cli\u003eStraub CM, Price RR, Matthews D, et al. Expanding Laparoscopic Cholecystectomy to Rural Mongolia. \u003cem\u003eWorld J Surg\u003c/em\u003e. 2011; 35(4): 751-759. https://doi.org/10.1007/s00268-011-0965-2\u003c/li\u003e\n\u003cli\u003eVithea D. MIS in Cambodia: History, Activity, \u0026amp; Challenges. PowerPoint slideshow. March 2022; Phnom Penh, Cambodia.\u003c/li\u003e\n\u003cli\u003eBerg DA, Milner RE, Fisher CA, Goldberg AJ, Dempsey DT, Grewal H. A cost-effective approach to establishing a surgical skills laboratory. \u003cem\u003eSurgery\u003c/em\u003e. 2007; 142(5): 712-721. https://doi.org/10.1016/j.surg.2007.05.011\u003c/li\u003e\n\u003cli\u003eFisher R, Onuh OC, V\u0026aacute;squez Checo R, et al. The Successful Implementation of a Laparoscopic Simulation Training Program in the Dominican Republic. \u003cem\u003eJ Surg Res\u003c/em\u003e. 2022; 278: 337-341. https://doi.org/10.1016/j.jss.2022.04.020\u003c/li\u003e\n\u003cli\u003eMurre JMJ, Dros J. Replication and Analysis of Ebbinghaus\u0026rsquo; Forgetting Curve. \u003cem\u003ePLOS ONE\u003c/em\u003e. 2015; 10(7): e0120644. https://doi.org/10.1371/journal.pone.0120644\u003c/li\u003e\n\u003cli\u003eVision, Mission, and Values. Calmette Hospital. Accessed June 18, 2024. https://calmette.gov.kh/\u003c/li\u003e\n\u003cli\u003eAsia\u0026rsquo;s Largest Humanitarian Project Commences in Cambodia: Kampong Thom Provincial Hospital renovation opened with a ceremony celebrating the commencement of the project. \u003cem\u003eOfficial Newsroom of the Church of Jesus Christ of Latter-day Saints\u003c/em\u003e. January 18, 2023. Accessed June 8, 2024. https://news-kh.churchofjesuschrist.org/article/asia-rsquo-s-largest-humanitarian-project-commences-in-cambodia\u003c/li\u003e\n\u003cli\u003eTansley G, Bailey JG, Gu Y, et al. Efficacy of Surgical Simulation Training in a Low-Income Country. \u003cem\u003eWorld J Surg\u003c/em\u003e. 2016; 40: 2643-2649. https://doi.org/10.1007/s00268-016-3573-3\u003c/li\u003e\n\u003cli\u003eIrfanullah EA, Chandra A, Solaiman RH, et al. Simulation Training in a Lower Middle-Income Country: Supporting a New Center and Developing Low-Cost Models for Critical Skill Acquisition. \u003cem\u003eCureus\u003c/em\u003e. 2023; 15(6): e40950. https://doi.org/10.7759/cureus.40950\u003c/li\u003e\n\u003cli\u003eSURGHUB \u0026ndash; THE UNITED NATIONS GLOBAL SURGERY LEARNING HUB. United Nations Institute for Training and Research. Accessed June 5, 2024. https://unitar.org/sustainable-development-goals/people/our-portfolio/surghub-united-nations-global-surgery-learning-hub\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cambodia, global surgery, laparoscopy, LMICs, minimally invasive surgery, surgical education","lastPublishedDoi":"10.21203/rs.3.rs-6298044/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6298044/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e \u003cp\u003eNine of 10 people in low- and middle-income countries (LMICs) such as Cambodia do not have access to safe, affordable surgical and anesthesia care. This disparity is exacerbated by a lack of proper training opportunities for surgeons to further specialize in areas like minimally invasive surgery. The principal objective of this study was to develop and establish a sustainable basic laparoscopic surgery training program starting at Calmette Hospital in Phnom Penh, Cambodia and expanding to two regional hospitals in more rural areas. This model may be employed for use in other LMICs.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eBetween 2022 and 2023, a comprehensive basic laparoscopy training program was implemented across three Cambodian hospitals: Calmette, Kampong Cham, and Kampong Thom. The curriculum included didactic lectures, simulation-based exercises, and practical in-theatre experience. Local educators were trained to perpetuate the program. A total of 59 participants, including 36 attending physicians and 23 trainees, completed the training. Pre- and post-training surveys were deployed to assess skill improvement and confidence; paired t-tests were used to analyze performance across laparoscopic simulation tasks.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants demonstrated significant improvements in laparoscopic skills, with reduced task completion times and improved accuracy (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Post-training surveys revealed that 85% of learners continued practicing their skills, and most reported increased confidence in performing laparoscopic procedures. Attending physicians and trainees benefited equally.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis model provides a standardized and replicable platform with theoretical, practical, and evaluation components for expanding access to self-sustained MIS training in LMICs such as Cambodia.\u003c/p\u003e","manuscriptTitle":"A Pilot for Surgical Education in Low-and Middle-Income Countries: Establishing a Basic Laparoscopic Training Program in Cambodia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 16:47:37","doi":"10.21203/rs.3.rs-6298044/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-04-28T20:40:43+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-27T23:51:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-04-13T16:35:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-26T14:02:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-03-25T12:16:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7e0d2ac8-59d5-4382-8ee3-01e75a6d0272","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T09:49:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 16:47:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6298044","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6298044","identity":"rs-6298044","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}