Abstract
Background
Significant disparities exist in laparoscopic training opportunities for surgeons in low- and middle-income countries (LMICs). ALL-SAFE is an innovative, low-cost training system for LMIC surgeons’ laparoscopic development. However, strategies to implement and scale ALL-SAFE are unstudied. We aimed to assess the impact of implementation science strategies on ALL-SAFE uptake in Liberia, a novel and low-resource context.
Methods
This study used implementation science approaches to evaluate ALL-SAFE uptake in three Liberian hospitals: John F. Kennedy Medical Center, Phebe, and ELWA. Five validated implementation strategies of program orientation, local champions, network weaving, feedback mechanisms, and practical supervision were piloted. All five strategies were implemented at two hospitals, while four strategies, excluding clinician supervision, were implemented at the final site as a pseudo-control, to evaluate the impact of resource-intensive supervision. Participants included surgical consultants, residents, and medical students. Engagement was assessed with mixed methods including participant number, practice hours, module completion rates, and strategy feasibility through end-user interviews.
Results
Across three hospitals, 33 participants used ALL-SAFE for 87.8 total training hours (5,268 min). Participant numbers varied across sites (NJFK = 20, 80%; NPhebe = 7, 88%; NELWA = 6, 86%), as did practice times (TotalJFK = 3,060 min, Median time/ParticipantJFK = 103 min; TotalPhebe = 1,434 min, Median time/ParticipantPhebe = 126 min; TotalELWA = 774 min, Median time/ParticipantELWA = 100 min). Sites with practical supervision demonstrated higher engagement than those without (P = 0.042). Interviews (n = 8) revealed positive perceptions toward program orientation, practical supervision, and network weaving. Participants recommended thirteen additional strategies for sustainability including translating ALL-SAFE skills to patient care.
Conclusion
Our study is one of the first to evaluate implementation science strategies for laparoscopic training in sub-Saharan Africa. The implementation bundles of five validated strategies were considered feasible by Liberian surgeons in both urban and rural hospitals. Mixed methods suggested a positive association between engagement and the resource-intensive practical supervision strategy. Future studies should focus on quantifying individual strategy contributions with rigorous implementation designs and assessing sustainability strategies.
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Acknowledgements
The authors would like to thank surgical departments at JFK Medical Center, Phebe and ELWA Hospital, including surgical consultants and residents for their support of this study. Datasets and analytic methods involved in this study are available from the corresponding author upon reasonable request.
Funding
This study was funded by the Global Surgical Training Challenge from the Intuitive Foundation and a SAGES Medical Student Summer Research Award.
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Christopher Reynolds, Ayun Cassell, Tresor Mabanza, Deborah Rooney, Ronald Kollie, Rachel O’Reggio, Yarvoh Moore-Wilson, Aaron Keita, Dieudonné Lemfuka, David Jeffcoach, and Grace Kim have no conflicts of interest, financial, or otherwise related to this study.
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Reynolds, C.W., Cassell, A., Mabanza, T. et al. Analysis of implementation science strategies to train laparoscopic surgical skills among Liberian surgeons using ALL-SAFE. Surg Endosc 39, 582–593 (2025). https://doi.org/10.1007/s00464-024-11340-6
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DOI: https://doi.org/10.1007/s00464-024-11340-6