Introduction

The surgical workforce across Africa is critically under-resourced, with a workforce density approximately 20 times lower than the World Health Organization’s recommended threshold [1]. Despite the well-documented benefits of laparoscopic surgery—including improved postoperative outcomes and reduced risk of infection—its adoption in Africa remains limited, likely due to financial barriers [2, 3]. In fact, a recent study reported that, among 68,000 surgical cases performed by the College of Surgeons of East, Central, and Southern Africa (COSECSA) surgical trainees between 2015 and 2020, only 0.9% were laparoscopic [4]. This corresponds to just 616 laparoscopic procedures conducted across the region over a five-year period, underscoring the substantial disparity in access to laparoscopic surgery between low- and high-income settings. This profound shortage underscores an urgent need to expand and enhance surgical training throughout the continent.

Numerous barriers hinder the widespread implementation of laparoscopy in Africa, including economic constraints, limited institutional infrastructure, and insufficient technical support [5, 6]. However, a particularly significant challenge is the lack of comprehensive laparoscopic education, mentorship, and hands-on training opportunities for surgical trainees [7]. For instance, in Tanzania, although 68% of hospitals report access to laparoscopic equipment, these institutions perform an average of only five laparoscopic procedures per week, suggesting that resource availability alone is insufficient without a parallel educational infrastructure [8].

Simulation-based training has become a cornerstone of surgical education globally, and laparoscopic simulation has seen increasing integration into surgical training curricula [9, 10]. These tools have demonstrated effectiveness in improving surgical competence and bridging the gap between knowledge of procedures and operative performance. However, many commercially available simulators are expensive and technologically complex, rendering them impractical for use in low- and middle-income countries (LMICs). While some laparoscopic training programs do exist in Africa, their reach and impact remain limited [7]. Consequently, many surgical trainees complete residency without adequate exposure to or confidence in performing laparoscopic procedures [7]. Innovative solutions, including the use of low-cost box trainers in countries such as Tanzania and Ghana, have yielded encouraging outcomes [11, 12].

In response to this pressing need for laparoscopic education and low-cost simulation training in Africa, the ALL-SAFE initiative was established in 2021 through a collaboration between the Pan-African Academy of Christian Surgeons (PAACS) and several U.S.-based academic institutions. ALL-SAFE seeks to increase access to laparoscopic training via free, open-source virtual modules complemented by an innovative, user-assembled, low-cost simulation platform. Using readily available materials—including a cardboard box, smartphone, laptop, and basic laparoscopic instruments—participants can construct a functional box trainer that simulates a laparoscopic environment. This setup enables trainees to practice essential laparoscopic procedures aligned with the ALL-SAFE curriculum, which includes management of pathologies such as ectopic pregnancy, appendicitis, handling of the small intestine, penetrating thoraco-abdominal trauma, safe trocar placement, and gallbladder disease. All instructional materials and modules are accessible online, allowing learners to develop foundational laparoscopic skills in a cost-effective and scalable manner [13].

To enhance adoption of the ALL-SAFE program and demonstrate its utility, a two-day in-person course was conducted at the National Hospital in Abuja, Nigeria, using the ALL-SAFE curriculum. Our group conducted an initial study utilizing pre- and post-course surveys to assess participants’ self-reported confidence and competence in laparoscopic surgery. Findings from this study indicated a statistically significant improvement in both domains, particularly in performing and teaching laparoscopic appendectomies [14].

While the initial study demonstrated immediate gains following the intervention, little is known about the long-term impact of the ALL-SAFE training. The current study aims to evaluate participant retention of knowledge and technical skills, ongoing engagement with laparoscopic procedures, and integration of laparoscopy into their clinical practice 8 months post-training.

Methods

ALL-SAFE curriculum and study design

ALL-SAFE is a global surgical initiative dedicated to delivering accessible and affordable laparoscopic training to healthcare providers in LMICs, with a primary focus on Africa. The program offers free, online modules that address both cognitive and psychomotor skills required for essential laparoscopic procedures. These include: Laparoscopic salpingectomy for ectopic pregnancy (Module 1), Laparoscopic appendectomy for appendicitis (Module 2), Laparoscopic handling of small bowel through management of Meckel’s diverticulum (Module 3), Laparoscopic suturing through repair of traumatic diaphragmatic injury (Module 4), Placement of laparoscopic trocars (Module 5), and Gallbladder disease instrument handling (Module 6). Participants are guided in building a low-cost simulation platform using locally available materials such as cardboard, sand, plastic sheets, rubber, and tape, as shown in Fig. 1. With access to a smartphone, laptop, and internet or Bluetooth connection, trainees can upload practice videos for self-review and peer feedback [13].

Fig. 1
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Box trainer used by ALL-SAFE trainees

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Using this established curriculum, we implemented a two-day laparoscopic skills workshop at a national teaching hospital in Abuja, Nigeria. After the in-person training, participants were provided with resources to continue practicing independently using the ALL-SAFE modules [14].

Survey design and data collection

An 8-month post-course survey was initially created by an interdisciplinary ALL-SAFE team comprising practicing surgical faculty, surgical trainees, medical students from teaching hospitals in Africa and the United States, education scientists, and a researcher with expertise in simulation-based medical education and assessment. The survey was then reviewed by a Nigerian American surgeon, whose involvement helped ensure the clarity and contextual relevance of the survey questions for surgeons in Nigeria. Questions were framed based on the Consolidated Framework for Implementation Research (CFIR) and the Kirkpatrick Model, Levels 3 and 4, with a focus on how the ALL-SAFE training impacted changes in participant behavior and surgical performance 8 months after the in-person training course [15,16,17]. The survey was iteratively refined through multiple rounds until a final consensus survey was achieved.

The 23-item survey was divided into four categories. The first category (3 items) was demographics, where participants were de-identified. The second category (7 items) was designed to measure engagement with the ALL-SAFE modules after the in-person course by asking participants to quantify their usage of the ALL-SAFE modules and the probability of future usage. The third category (10 items) was designed to measure knowledge and skill acquisition, which was measured by using a 5-point scale to report increased confidence and competence. Participants were also given free-text questions to explain what improvements in skills they noticed after practicing with the ALL-SAFE modules. The fourth category (3 items) was designed to measure the impact on participants’ social networks following the course. Participants’ data were deidentified, with the only demographic characteristic collected being practice setting. The full survey is provided in Appendix 1.

Statistical analysis

Descriptive statistics were used to characterize participant demographics and summarize responses to all survey domains. Frequencies and proportions were calculated for categorical variables, while measures of central tendency and dispersion were summarized for continuous variables, where applicable. Survey items related to demographics, knowledge and skill acquisition, engagement with the curriculum, and anticipated future utilization were analyzed individually and reported in aggregate. All analyses were conducted using descriptive methods given the exploratory nature of the study.

Study site

The study was conducted at the National Hospital Abuja, a tertiary care center located in Gwagwalada, within the Federal Capital Territory (FCT) of Abuja, Nigeria. As a 520-bed referral hospital, it serves patients from across the country and offers specialized medical and surgical services [18]. The hospital is equipped with modern infrastructure to support both clinical care and medical education, including the resources necessary for performing laparoscopic surgery. It houses dedicated departments for multiple surgical specialties, such as general surgery, pediatric surgery, urology, neurosurgery, cardiothoracic surgery, and plastic/reconstructive surgery. The surgical team includes 18 consultant surgeons and 43 residents.

Recruitment and study cohort

The in-person course was broadly promoted via social media, word of mouth, and professional networks, including the West African College of Surgeons. It was designed for a diverse group of participants, including surgeons and surgical trainees new to laparoscopy, those looking to refresh foundational skills, and individuals with prior training aiming to begin performing laparoscopic procedures. The course was open to all general surgeons, urologists, and gynecologists-at the faculty and trainee level-across Nigeria and neighboring countries. This mix of learners was considered a realistic reflection of the broader surgical community seeking to expand their skill set and adopt new techniques. The course objectives, as advertised, were to develop both the cognitive and psychomotor skills essential for laparoscopic surgery. Through a combination of hands-on training at laparoscopic box trainer stations and live case observation, participants progressed from basic skills to simulated operative scenarios. Eight months following the course, all participants were invited to complete an online follow-up survey via email and WhatsApp.

Intervention and follow-up: two-day skills course in October 2023

The laparoscopic skills course incorporated a combination of didactic lectures, hands-on training, and live surgical demonstrations to maximize participant engagement. The curriculum was intentionally structured to alternate between theoretical instruction and practical application.

Day 1 began with a series of lectures covering the physiology, mechanics, and clinical applications of laparoscopic surgery. These sessions were largely adapted from publicly available materials from the Fundamentals of Laparoscopic Surgery® (SAGES, Los Angeles, CA) and were designed to establish a foundational knowledge base for all participants [19,20,21]. Following the lectures, attendees rotated through skills stations focused on core technical exercises—such as bead transfer, pattern cutting, and intracorporeal knot tying—to build familiarity with laparoscopic instruments and enhance hand–eye coordination, depth perception, and bimanual dexterity. Participants then attended a session on constructing low-cost ALL-SAFE laparoscopic simulators using locally available materials, followed by a hands-on session in which they applied their skills in a simulated laparoscopic salpingectomy using the ALL-SAFE training module.

Day 2 featured live-streamed demonstrations of two laparoscopic cholecystectomies performed in the operating room. Afterward, a Nigerian surgeon led a lecture offering practical strategies for establishing laparoscopic programs within the financial and material constraints of local hospitals. Participants then returned to hands-on training to refine their basic laparoscopic skills—such as suturing and intracorporeal knot tying—before applying them in the ALL-SAFE laparoscopic appendectomy module.

The course concluded with a group debrief where participants and the ALL-SAFE team exchanged practical tips for integrating laparoscopy into their respective practice environments. At the end of the course, each participant received a box trainer and laparoscopic instruments to continue practicing with the ALL-SAFE modules independently.

Ethics

This research was granted exemption status by the University of Michigan Institutional Review Board (HUM00188880). Participants were provided with detailed information about the study objectives, procedures, potential risks, and benefits. They were given the opportunity to ask questions before participating in the course, with an option to opt out of the course without consequences or penalty. Before beginning the survey, participants were informed of the study objectives and notified that their anonymous responses would be used for research purposes. Participation was voluntary, and consent was implied through completion of the survey.

Results

Study participants and demographics table

Thirty-two surgeons participated in the two-day in-person course, as shown in Table 1.

Table 1 Overall course participant demographics, n = 32
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Among the course participants, 17/32 (53%) completed the 8-month post-course survey. The majority of participants (n = 10, 59%) practiced at a government hospital, while 29% (n = 5) practiced at a University hospital, and 11% (n = 2) practiced at a private hospital, as illustrated in Table 2. Numbers of respondents for various survey questions are reported. To preserve participant anonymity and encourage honest and uninhibited responses, demographic information (besides practice setting) was intentionally not collected (Table 3).

Table 2 Practice setting of survey respondents, n = 17
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Table 3 Summary of engagement data
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Knowledge and skill acquisition

Overall, 76% of participants reported being “very” or “extremely” satisfied with the ALL-SAFE course (n = 13). Regarding knowledge gains, 65% of participants expressed that they were “very” or “extremely” confident that their understanding of laparoscopic surgery had improved (n = 11). Additionally, 56% of participants felt “very” or “extremely” confident that their surgical competence increased since completing the ALL-SAFE course (n = 9/16).

Regarding translation of laparoscopic skill to clinical practice, 94% of participants reported observable changes in their surgical skills following the course (n = 16). The most frequently cited areas of improvement included intracorporeal knot tying, hand–eye coordination, and proficiency in handling laparoscopic instruments. Although the majority (76%, n = 13) had not served as the primary surgeon in laparoscopic procedures after the course, 88% reported assisting in at least one laparoscopic surgery thereafter (n = 15).

Importantly, the dissemination of learned skills was also evident: 47% of participants reported having taught laparoscopic techniques to others on at least four occasions since completing the course (n = 8), and 35% of participants reported teaching laparoscopic techniques 3 times or less after the course (n = 6).

Engagement

Following completion of the in-person course, 88% of participants (n = 15) either constructed their own box trainer or continued utilizing the trainer provided during the session. Additionally, 71% (n = 12) of participants reported continued engagement with the ALL-SAFE online modules after the in-person component.

Among those who persisted in using the online platform, all participants (100%, n = 12) engaged with the surgical skills training modules, with a median of 5 uses per participant (n = 6, IQR 13). In contrast, 50% (n = 6) accessed the cognitive modules, which were used a median of 7 times per participant (n = 4, IQR 2.5). More interactive features, such as submission of surgical skills videos and peer review of other videos, were less frequently utilized; only 25% (n = 3) engaged with these components, with median individual usage rates of 2 (n = 3, IQR 5) and 8 (n = 3, IQR 9.5) times, respectively.

Analysis of module-specific engagement revealed that the Appendicitis module was the most frequently accessed, with 75% of participants (n = 9/12) reporting its use. This was followed by the Trocar placement module (50%, n = 6), Ectopic pregnancy module (25%, n = 3), and both the Cholecystectomy and Meckel’s diverticulum modules (16%, n = 2) (Fig. 2).

Fig. 2
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The majority of participants felt that the in-person course was “extremely” or “very important” in maintaining engagement with ALL-SAFE online modules

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Regarding the perceived impact of the in-person course in October 2023, 47% of participants (n = 8) reported that it was “extremely important” in motivating their continued use of the online modules, while 35% (n = 6) rated it as “very important.” A minority (15%, n = 3) indicated it was “moderately,” “slightly,” or “not at all” important. Furthermore, 47% of the participants (n = 8) indicated it was “extremely likely” that a second in-person course would enhance their use of the online platform, while the remaining 53% (n = 9) considered it “very likely.”

Future utilization and professional networking

Regarding future engagement, 18% of participants (n = 3) anticipated using the ALL-SAFE modules more than once per week, while 53% (n = 9) planned to access them weekly. An additional 24% (n = 4) expected to engage with the modules on a monthly basis, and 12% (n = 2) indicated anticipated use was approximately 3–6 times per year.

Post-course collaboration also persisted beyond the training period, with 63% (n = 10/16) of participants maintaining communication with at least one individual they met through the ALL-SAFE course. The most frequently cited purpose for continued contact was the exchange of ideas and techniques related to laparoscopic surgery (Fig. 3). A summary of the overall survey findings is presented in Table 4.

Fig. 3
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The majority of participants anticipate continuing to use ALL-SAFE weekly for practice

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Table 4 Summary of survey responses
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Discussion

While numerous studies have demonstrated the positive impact on learners directly after a surgical simulation course, our study is the first to measure the long-term impact of a laparoscopic training course in LMICs [22, 23]. Our results demonstrate maintained participant satisfaction, engagement, and knowledge/skill acquisition after the ALL-SAFE course, thus highlighting the long-term value of the course. These findings are consistent with prior literature emphasizing the importance of low-cost simulation-based education in LMICs for surgical training [24,25,26,27].

Notably, our data reveals continued surgical skill and knowledge acquisition among participants at the 8-month post-training mark. While our previous study captured immediate improvements in laparoscopic confidence and technical competence after the in-person course, our current findings highlight the durable impact of the Abuja-based ALL-SAFE training program on long-term knowledge acquisition and technical proficiency [14]. Participants reported ongoing refinement of laparoscopic techniques and knowledge, underscoring the utility of sustained practice—even with low-cost models—in promoting skill retention, skill development, and procedural comprehension.

Although many participants were not yet serving as primary surgeons for laparoscopic operations following the course, most reported assisting in such procedures. This suggests that the ALL-SAFE platform effectively prepares participants for meaningful roles in the operating room, serving as a stepping stone toward surgical autonomy. At the same time, these findings indicate that ALL-SAFE is not a comprehensive laparoscopic training pathway; rather, it provides an initial foundation on which participants can build further skills. The high proportion of respondents who were not primary surgeons (76%) may also reflect the trainee status of much of the cohort, as many may not yet have attained the proficiency required to independently perform laparoscopic procedures. Importantly, the ripple effect of the program extended beyond direct participants, as many reported teaching laparoscopic skills to colleagues. This peer-to-peer knowledge transfer amplifies the reach and impact of the program across surgical networks in low-resource settings.

With regard to engagement with the ALL-SAFE online modules, participants who continued to engage with the online modules frequently utilized the surgical skills sections for ongoing practice, with a majority indicating intent to use the modules on a weekly basis. This sustained usage suggests that the ALL-SAFE platform has evolved into a long-term resource for continuous surgical education and practice, which is particularly valuable in resource-limited settings where formal training opportunities may be scarce. Moreover, these outcomes support the need for continued investment in surgical skill training across LMICs, a need which programs such as ALL-SAFE are actively addressing through the distribution of physical and virtual training materials [28].

Interestingly, the ALL-SAFE platform’s effectiveness appears to be enhanced when coupled with in-person training. Participants also expressed a strong desire for a second in-person session, suggesting that periodic, hands-on training can provide valuable opportunities for benchmarking personal progress, peer learning, and renewed motivation. The inclusion of such periodic reinforcement may significantly enhance the efficacy of this hybrid training model and encourage the broader adoption of laparoscopic techniques in LMICs, as evidenced by current literature in surgical education supporting distributed training [29, 30].

In parallel, innovative tools such as virtual reality applications and smartphone-based simulators have emerged to supplement surgical training globally [24, 25]. While digital platforms increase accessibility and flexibility, our findings highlight the critical role of in-person training in promoting sustained engagement. This aligns with existing studies that support the efficacy of hybrid education over completely virtual education and aligns with a recent study in plastic surgery education that supports hybrid learning models for skill development, particularly due to their flexibility in time management [31, 32].

Participants who maintained post-course engagement with the modules reported more pronounced improvements in technical skills such as instrument handling, knot tying, and hand–eye coordination—core elements of any laparoscopic procedure. The in-person component also fostered enduring professional relationships among participants. This suggests that ALL-SAFE functions not only as an educational resource but also as a platform for community-building and long-term professional development.

Despite these promising results, our study is not without limitations. The small sample size (n = 17, 53%) limits the generalizability of these findings to other contexts. Additionally, our reliance on self-reported measures of knowledge and skill improvement may introduce bias when measuring improvements in knowledge and skill, which may have been compounded by the positively leaning rating scales. The survey questions also did not capture other adjunctive measures with which the participants have been engaging to further their education in and practice of laparoscopy. Moreover, while the course and survey were administered in Nigeria, all participants spoke English fluently, limiting any impact of language barriers on their responses. Finally, because participant data were de-identified, we were unable to determine the specific training levels or trends in the responses of respondents. Future investigations should incorporate objective educational assessment tools and larger, more diverse samples to rigorously evaluate the longitudinal impact of ALL-SAFE participation on surgical performance, professional advancement, and patient outcomes. This may include the use of established instruments such as the Objective Structured Assessment of Technical Skills (OSATS) and the Verification of Proficiency (VOP) tool, which the ALL-SAFE team is currently implementing in forthcoming and current evaluations [33]. Insights from this survey are directly informing these future investigations, in which the ALL-SAFE team will assess long-term skill retention using objective, rather than self-reported, measures of laparoscopic performance.

In conclusion, the ALL-SAFE platform has demonstrated sustained utility as a cost-effective educational tool for laparoscopic training in LMICs. Eight months after the initial intervention, participants continued to engage with the platform, improve their surgical skills and knowledge, and maintain professional connections. These findings underscore the long-term potential of low-cost, hybrid surgical education models to address gaps in laparoscopic training, offering an initial solution towards expanding the surgical workforce and laparoscopic capacity in Africa.