Establishing a contextually appropriate laparoscopic program in resource-restricted environments: Experience in Botswana

Objective: Differences in opinion exist as to the feasibility of establishing sustainable laparoscopic programs in resource-restricted environments. At the request of local surgeons and the Ministry of Health in Botswana, a training program was established to assist local colleagues with laparoscopic surgery. We reviewed our multifaceted and evolving international collaboration and highlighted those factors that have helped or hindered this program. Methods: From 2006 to 2012, a training program consisting of didactic teaching, telesimulation, Fundamentals of Laparoscopic Surgery certification, yearly workshops, and ongoing mentorship was established. We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing themwith patientswho underwent open cholecystectomy, and measured the indicators of technical independence and program sustainability. Results: Twelve surgeons participated in the training program and performed 270 of 288 laparoscopic cholecystectomies. Ninety-six open cases were performed by these and 5 additional surgeons. Fifteen laparoscopic cases were converted (5.2%). The median postoperative length of hospital stay was significantly shorter in the laparoscopic group than in the open group (1 day vs 7 days, P < 0.001). As the training program progressed, the proportion of laparoscopic cases completed without an expatriate surgeon present increased significantly (P = 0.001). Conclusions: A contextually appropriate long-term partnership may assist with laparoscopic upskilling of colleagues in low- and middle-income countries. This type of collaboration promotes local ownership and may translate into better patient outcomes associated with laparoscopic surgery. In resourcerestricted environments, the factors threatening sustainability may differ from those in high-income countries and should be identified and addressed.