EDUCATION AND TRAINING Pilot study outcomes from a resource-limited setting for a low-cost training program for laparoscopic surgical skills Pamela Andreatta a,b, ⁎, Joseph Perosky b , Jessica Klotz a , Charlotte Gamble b , Frank Ankobea c , Kwabena Danso c , Vanessa Dalton b a Department of Urologic Surgery, University of Minnesota Medical School, Minneapolis, USA b Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, USA c Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana article info Article history: Received 29 August 2013 Received in revised form 23 October 2013 Accepted 2 February 2014 Keywords: Laparoscopic surgery Laparoscopic training Low-cost training program Medical education Training initiatives for expanding the use of laparoscopic surgery in resource-limited regions could have significant benefits for the health outcomes and economies of the population [1]. The option to use laparoscopic surgical techniques depends on the availability of equipment, instruments, and trained providers. Even if a physical infrastructure supports laparoscopy, training surgeons to master the requisite techniques is resource intensive in terms of time, facilitation, and materials. Training challenges for the surgeon include learning to translate a 2D video display into a 3D mental model of the operative field, controlling the camera to optimize visualization, and manipulating the long-shafted instruments to account for fulcrum ef- fects while maintaining surgical precision and efficiency. Simulation-based training programs are frequently used to facilitate the acquisition of laparoscopic skills. These programs require substan- tial financial investment to establish and sustain—something few insti- tutions can afford in resource-limited environments. Although some low-technology simulation solutions such as the Fundamentals of Lapa- roscopic Surgery have demonstrated efficacy in selected performance domains, their costs remain beyond the feasibility of most programs in resource-limited regions [2]. The aim of the present study was to evalu- ate the feasibility and baseline impact of a low-cost, low technology, and locally sourced simulation-based program for high-fidelity laparoscopic surgical training in a resource-limited environment. The study received an exemption after review by the institutional re- view boards at the University of Michigan and the Kwame-Nkrumah University of Science and Technology (KNUST). All participants provid- ed informed consent prior to study participation. The sample comprised 18 faculty and house officers from KNUST and Komfo Anokye Teaching Hospital in Kumasi, Ghana. Four (22%) participants were women and all participants had observed laparoscopy fewer than 2 times, with no pro- cedural involvement. Laparoscopic towers, equipment, and instruments were donated by the University of Michigan Medical School to help facilitate the de- velopment of laparoscopic surgery capabilities in Ghana. A comprehen- sive instructional program was developed (by P.A.) to include training exercises, performance criteria, objective feedback, and proficiency tar- gets for learning novice-level laparoscopic surgical skills. The training exercises are outlined in Box 1. All training materials were selected based on cost sensitivity and local availability in order to encourage sus- tainability. Box trainers were built using wood, foam, heavy fabric, glue, and hardware hinges (Fig. 1). The course materials for the entire pro- gram cost less than US $30 per participant. All materials were purchased and assembled in Ghana, with the exception of small foam pieces brought from the USA (later also locally sourced). Each participant completed a 3-hour introductory session, which in- cluded hands-on familiarization with each of 7 exercises and training in laparoscopic surgical skills associated with tissue manipulation, not clinical or procedural knowledge. The exercises were designed with var- iable challenges, including the following: instrument control of escalat- ing difficulty with variable complexity templates and differing size and shape foam pieces; cutting exercises using a long balloon and rubber bands; camera navigation through increasing complexity models; translocation along predefined paths; and dissection to focus on preci- sion and tissue preservation. Tissue damage is the primary cause of iatrogenic injury for surgical patients; therefore, tissue handling and associated damage to tissue were selected as the primary variable of interest for all exercises. Al- though time is associated with surgical expertise, it is not the primary in- dicator of surgical skill. Practice exercises were not time limited, unlike the time limits for the assessments, in order to provide participants the freedom to focus on development of tissue-handling skills with minimal damage. Participants completed training exercises individually, although peer-to-peer teaching was encouraged during practice sessions held daily over 12 consecutive days, following the initial session. A final 3- International Journal of Gynecology and Obstetrics 125 (2014) 186–188 ⁎ Corresponding author at: 420 Delaware Street S.E., A590-1 Mayo Memorial Building – MMC 394, Minneapolis, MN 55455, USA. Tel.: +1 612 626 4791; fax: +1 612 626 3994. E-mail address: pandreat@umn.edu (P. Andreatta). 0020-7292/$ – see front matter © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.10.030 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo