Current Implementation Outcomes of Digital Surgical Simulation in Low- and Middle-Income Countries: Scoping Review
Authors: Mahajan Arnav , Hawkins Austin 
Published: March 2023

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- and middle-income countries (LMICs).

Objective
This study aims 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 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 involved surgical trainees or practitioners who were based in LMICs. Papers that include allied health care professionals involved in task sharing were excluded. 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
This scoping review examined the outcomes of digital surgical simulation implementation in LMICs for 7 papers. The majority of participants were medical students and residents who were identified as male. Participants rated surgical simulators and telecommunications devices highly for acceptability and usefulness, and they believed that 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 US $25 and US $6990. Penetration and sustainability are understudied implementation outcomes, as all papers lacked long-term monitoring of the digital surgical simulations. Most authors are from high-income countries, suggesting 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, unless scaling efforts prove futile.

Conclusions
This 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 of science approaches in the development of digital surgical tools, as this is the critical factor that will determine whether we are able to meet the 2030 goals for surgical training in LMICs. Sustainability of implemented digital surgical tools is 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.