Background

Laparoscopic surgery is the standard of care for many surgical diseases in high-income countries, but it is not available in most low- and middle-income countries (LMICs) due to prohibitive costs and poor access to training equipment and mentors. Laparoscopic surgery is needed in these settings to reduce recovery time, improve infection rates and allow patients to return to work, thereby decreasing catastrophic health expenditure. 

Since 2018, a Bass Connections team has been developing a low-cost, locally manufactured laparoscopic system (KeySuite) that will substantially increase access to laparoscopy in LMICs. For the KeySuite to be useful, however, there must be a corresponding training program to teach surgeons to utilize this newly available laparoscopic resource. 

Project Description

This project team will develop a low-cost laparoscopic simulator for surgeons in Uganda. In high-income settings, surgical trainees use simulation equipment called box trainers to practice psychomotor skills, which are then tested in a skills exam. This team will develop a low-cost box trainer that is manufactured locally, so that LMIC surgeons can develop the fundamental skills necessary to perform laparoscopy and improve surgical patient outcomes. 

Working with surgical and biomedical engineering colleagues from Makerere University in Uganda, team members will develop a box trainer prototype that is appropriate for a Ugandan setting. The prototype will be portable so that it can be used at home, eliminating the need for a university-based simulation center, and it will be compatible with the KeySuite technology. The materials to construct the trainers will be locally sourced and easily assembled in Uganda. Team members will also design and manufacture six laparoscopic “skills” to be practiced with the device, including peg transfer, circle cutting, stretch band, needle pass, extracorporeal knot tying and intracorporeal knot tying.

The team will validate the box trainer against the U.S. surgical training program standard. Thirty Duke medical students and general surgery residents will be recruited, and after a brief demonstration of the six laparoscopic tasks, they will be given 30 minutes to practice on both the team-generated prototype and the standard simulation stations in the Duke Surgery Education and Activities Lab. Participants will then be randomly assigned to start testing on the standard model or the prototype model. Their scores and experiences will be statistically compared.
 
After validation, the prototype will be tested with Ugandan medical students and residents using a similar process. The outcomes of these surveys will be used to make final modifications to the box training and task design.

Finally, the team will also develop manufacturing process instructions that enable the box trainer to be constructed locally in Uganda.

Anticipated Outputs

Low-cost, high-fidelity box trainer prototype; manufacturing process instructions; training course for surgeons in Uganda; peer-reviewed publications; abstracts for conference presentations; data for future grants to develop a laparoscopic training course for LMICs

Student Opportunities

Ideally, this project team will include 2 graduate students and 8 undergraduates with interests in global health, engineering, health education and training, biostatistics, surgery and medicine.

Team members will break into three subteams:

1. Engineering and design: This subteam will develop the box trainer and task prototypes, including the manufacturing process instructions. Team members will work closely with Ugandan biomedical engineering students to develop context-appropriate technology.
2. Education and testing: This subteam will coordinate the validation and testing process for the box trainer and tasks, and help analyze outcomes.
3. International/domestic team-building: This subteam will facilitate team-building and communication for domestic and international colleagues.

Team members will meet weekly to learn new research methods, present progress, ask questions, give and receive feedback, and collaborate with international partners. In Fall 2024, the team will meet on Tuesdays from 12:30-2:30 p.m.

All team members will participate in discussions on the surgical challenges in LMICs, human-centered design, surgical training and simulation across settings, and capacity-building partnerships. They will also review and evaluate the current literature on surgical training and biomedical engineering innovation and have the opportunity to develop leadership and communication skills in a dynamic setting.

Students will have the opportunity to travel to Uganda for two weeks in Summer 2024 to work with Ugandan students on the design and manufacturing process for the box trainer prototype. One or two students from the education and testing subteam will also have the option to travel to Uganda in Summer 2025 to test the box trainer with Ugandan medical students and residents.

Timing

Summer 2024 – Summer 2025

• Summer 2024 (optional): Begin prototype design and testing; travel to Uganda to work on design and manufacturing processes with international partners
• Fall 2024: Finalize box trainer design; develop manufacturing process instructions and share with partners; develop multiple prototypes; recruit Duke residents and students for prototype validation
• Spring 2025: Test box trainer and analyze results; apply modifications to prototypes across settings; prepare manuscripts for publication
• Summer 2025 (optional): Travel to Uganda to test box trainer with Ugandan medical students and residents

Crediting

Academic credit available for fall and spring semesters; summer funding available

See earlier related team Sustainable Implementation of Laparoscopy in Low-income Countries (2021-2022).