Locally led simulation training sharply improves laparoscopic skills in Ethiopia

A short, intensive surgical training course designed and delivered entirely within Ethiopia produced large and measurable gains in the laparoscopic skills of practicing surgeons and surgical residents, according to a new study published in Global Surgical Education. The program required no visiting foreign faculty, a dependency that has long constrained surgical education across much of sub-Saharan Africa, where formal laparoscopic training infrastructure remains scarce and access to minimally invasive surgery is severely limited.

The curriculum enrolled thirty participants, fourteen surgeons and sixteen surgical residents, all of whom had no prior formal laparoscopic instruction. It followed a blended format: six weeks of asynchronous online modules built on the Fundamentals of Laparoscopic Surgery (FLS) framework, followed by a five-day intensive hands-on workshop. Crucially, every element was delivered by in-country faculty using both locally fabricated box trainers and commercially available models, demonstrating that a low-resource setting could mount a rigorous skills program without imported expertise.

To measure progress objectively, the researchers timed participants on three standardized FLS-based tasks before and after training: peg transfer, precision cutting, and intracorporeal suturing. They also administered a nine-domain Global Rating Scale with a maximum score of 45 and a twenty-item multiple-choice knowledge test. Statistical analysis relied on paired-samples t-tests, McNemar tests, Pearson correlation, and linear regression, with effect sizes estimated using Cohen’s d or Hedges’ g.

The results were striking. Twenty-eight of the thirty participants completed both assessments and were included in the analysis. Completion times fell dramatically across all three tasks: peg transfer dropped from 5.51 to 2.47 minutes, precision cutting from 5.74 to 3.17 minutes, and intracorporeal suturing from 10.95 to 3.71 minutes. All three improvements were statistically significant at p < 0.001, with effect sizes ranging from 0.94 to 1.26, indicating large, practically meaningful gains rather than marginal refinements.

Global Rating Scale scores told a similar story. The mean score rose from 17.8 to 30.1, an increase of 12.3 points that was highly significant (p < 0.001) and carried an effect size of 1.49. Improvement was not confined to a talented few: twenty-seven of the twenty-eight analyzed participants, or 96 percent, improved on the rating scale. Knowledge scores also rose, though more modestly, climbing from 13.5 to 15.5 out of 20, a mean gain of 2.0 points across all thirty participants, significant at p = 0.003.

Both professional groups benefited. Surgeons improved significantly in technical skill (p = 0.001), as did surgical residents (p < 0.001), and the magnitude of improvement did not differ significantly between the two groups. That finding matters for curriculum design, because it suggests the program’s value was not limited to trainees at one career stage but extended across the surgical workforce that would ultimately deliver minimally invasive care.

One of the study’s most intriguing results emerged from exploratory analyses of the relationship between knowledge and skill. Baseline theoretical knowledge was associated with baseline technical skill (r = 0.49; R² = 0.24; p < 0.01), consistent with the intuitive idea that surgeons who know more tend to perform better before any structured training. After the course, however, that association vanished: baseline knowledge showed no relationship with post-training skill (r = −0.03; p = 0.87). The authors interpret this as a suggestion that structured hands-on practice may reduce the influence of prior theoretical preparation, effectively leveling the field once deliberate, repeated practice takes over. As an exploratory observation, it invites confirmation in larger cohorts rather than settling the question outright.

The researchers are careful about what the curriculum does and does not achieve. Post-training task times remained above published FLS proficiency benchmarks, meaning graduates of the program should be regarded as having established foundational laparoscopic skills rather than certification-level proficiency. The authors frame the intervention accordingly: a brief, intensive, locally led blended curriculum produced large and consistent improvements in a low-resource setting, but it is a starting point on the competency pathway, not a substitute for the full FLS certification standard.

Why does this matter beyond Ethiopia? A curriculum that can be run by local educators with locally fabricated trainers offers something more durable: ownership. The study’s authors argue that their findings support locally owned, replicable models of surgical capacity building as a sustainable strategy for expanding minimally invasive surgery in the Global South, where the burden of surgical disease is high but access to laparoscopic techniques has lagged far behind high-income settings.

The study’s scope and limitations are worth keeping in view. It involved a single cohort of thirty trainees in one country, with twenty-eight completing both assessments, and the knowledge-test gain was reported for all thirty participants while the technical-skill analysis covered the twenty-eight completers. The knowledge-skill dissociation is explicitly labeled exploratory. Even so, the combination of large effect sizes, near-universal improvement, and a delivery model that required no external faculty makes a compelling case that simulation-based surgical education can be built, led, and sustained locally, turning a persistent dependency into a replicable template for other low-resource settings.

Subject of Research: A locally led simulation-based laparoscopic skills curriculum for surgeons and residents in Ethiopia

Article Title: Locally led, globally impactful: a simulation-based laparoscopic skills curriculum in Ethiopia

Article References: Woldehana, N. A., Suga, H., Suga, J., Kassa, N. I., Enumah, Z., Mikru, F. B., Fanta, E., Bekele, P. G., Suga, N., Adrales, G., Malore, E. T., & Rhee, D. (2026). Locally led, globally impactful: a simulation-based laparoscopic skills curriculum in Ethiopia. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 206. https://doi.org/10.1007/s44186-026-00615-2

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00615-2

Keywords: laparoscopic surgery, surgical education, simulation training, Ethiopia, Fundamentals of Laparoscopic Surgery, box trainers, surgical residents, low-resource settings, global surgery, minimally invasive surgery, capacity building, sub-Saharan Africa