The Globalization of Laparoscopic Surgery: Translating Laparoscopic Surgical Practice Into Resource-restricted Contexts

Ian Choy, BEng, MEd, MD, Simon Kitto, DipEd, PhD, Adu-Aryee Nii, MD, MHPE, Allan Okrainec, MD, MHPE

Div. General Surgery, The Wilson Centre, Temerity/Chang Telesimulation Centre, Toronto Western Hospital, University Health Network; University of Toronto; Korle-Bu Teaching Hospital, University of Ghana;

INTRODUCTION
The adoption of laparoscopic surgery in Africa has been sporadic and minimal. While the most commonly cited explanation for this has been an apparent lack of resources and training, recent studies and numerous training courses have demonstrated that these constraints may not be as significant as previously denoted in the literature. Moreover, there has been a growing interest amongst the surgical community, and more specifically surgical societies and academic institutions, to develop laparoscopic programs in resource restricted contexts. The overall objective of this study was to explore and analyze the potential barriers to the adoption of laparoscopic surgery in a resource restricted hospital, with a view to inform future development of laparoscopic surgical training programs in these contexts. More specifically, this study aimed to: 1) Identify the key actors and institutional processes in the hospital environment that affect the adoption of laparoscopic surgery, 2) identify surgical and institutional attitudes towards laparoscopic surgical practice, and 3) explore how these actors and processes affect the adoption of laparoscopic surgery.

METHODS AND PROCEDURES
This qualitative study employed a case study design to frame the investigation of facilitators and barriers to the adoption of laparoscopic surgery in a tertiary hospital in Sub-Saharan Africa. The hospital had purchased laparoscopic equipment 4 years prior to this study, and a number of surgeons at this hospital had undergone FLS training 2 years afterwards. The exploratory case study employed a combination of over 600 hours of participant observation, 13 semi-structured interviews and a discourse analysis of relevant documents over three months. During this time, a remote telesimulation FLS course was conducted on campus and this was also observed. A thematic analysis was conducted iteratively throughout the data collection period. In addition, data triangulation enhanced the rigour and depth of the analysis. The study findings were further explored and connected to current literature about knowledge translation and laparoscopic surgical training programs.

RESULTS
The study findings indicated that aside from resource constraints and training limitations, there were several other significant contextual barriers to the adoption of laparoscopic surgery. More specifically, cultural, social and institutional barriers directly influenced the partial uptake of laparoscopic surgery. Additionally, the opinions, attitudes and incentives of local surgeons towards laparoscopic surgery often varied significantly from those of their Western colleagues. Consequently, this led to constant negotiation concerning global pressures and local needs, which influenced training sessions and clinical practice.

CONCLUSIONS
This exploratory case-study approach to examining the barriers to the adoption of laparoscopic surgery in a resource restricted context exemplifies a novel approach to addressing issues that have plagued surgeons across low to middle income countries for many years. An understanding of such barriers is an essential step in translating new knowledge into tangible practice changes and clinical outcomes. This study can inform the development of future laparoscopic training curricula and the implementation of training programs in resource-restricted countries.


Session: Podium Presentation

Program Number: S113

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