Current Implementation Outcomes of Digital Surgical Simulation in Low-Middle Income Countries: A Scoping Review (Preprint)
Authors: Mahajan Arnav , Hawkins Austin 
Published: August 2022

BACKGROUND

Digital surgical simulation and telecommunication provides an attractive option for improving surgical skills, widening access to training, and improving patient outcomes; however, it is unclear whether sufficient simulations and telecommunications are accessible, effective, or feasible in low-middle income countries (LMICs).

OBJECTIVE

Our objectives will be to determine which types of surgical simulation tools have been most widely used in LMICs, how surgical simulation technology is being implemented, and what the outcomes of these efforts have been. We also hope to offer recommendations for the future development of digital surgical simulation implementation in LMICs.

METHODS

We searched PubMed, MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, and the Central Register of Controlled Trials to look for qualitative studies in published literature discussing implementation and outcomes of surgical simulation training in LMICs. Eligible papers had characteristics that involved surgical trainees or practitioners that are based in LMICs. Excluded were allied healthcare professionals involved in task-sharing. We focused specifically on digital surgical innovations and excluded flipped classroom models and 3D models. Implementation outcome had to be reported according to Proctor’s taxonomy.

RESULTS

The scoping review examined the outcomes of digital surgical simulation implementation in LMICs. The majority of participants were medical students and residents who identify as male. Participants rated surgical simulators and telecommunications devices highly for acceptability and usefulness, and they believed the simulators increased their anatomical and procedural knowledge. However, limitations such as image distortion, excessive light exposure, and video stream latency were frequently reported. Depending on the product, the implementation cost varied between $25 and $6,990 USD. Penetration and sustainability are understudied implementation outcomes, as all papers lacked long-term monitoring of the digital surgical simulations. The majority of authors are from high income countries suggests that innovations are being proposed without a clear understanding of how they can be incorporated into surgeons' practical training. Overall, the study indicates that digital surgical simulation is a promising tool for medical education in LMICs; however, additional research is required to address some of the limitations in order to achieve successful implementation, lest scaling efforts prove futile.

CONCLUSIONS

The study indicates that digital surgical simulation is a promising tool for medical education in LMICs, but further research is necessary to address some of the limitations and ensure successful implementation. We urge more consistent reporting and understanding of implementation science approaches in the development of digital surgical tools, as this is the critical factor that will determine whether or not we are able to meet the 2030 goals for surgical training in LMICs. Sustainability of implemented digital surgical tools are a pain point that must be focused on if we are to deliver digital surgical simulation tools to the populations that demand them the most.

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