Abstract
Objective
Complex lung diseases are among the leading causes of death in Ethiopia. Access to thoracic surgery is limited, and before 2016 no thoracic surgeons were trained in minimally invasive surgery. A global academic partnership was formed between the University of Toronto and Addis Ababa University. We describe implementation of the first minimally invasive surgery training program in sub-Sahara Africa and evaluate its safety.
Methods
We performed a retrospective cohort analysis of open versus minimally invasive thoracic and upper gastrointestinal procedures performed at Addis Ababa University from January 2016 to June 2021. Baseline demographic, diagnostic, operative, and postoperative outcomes including length of stay and complications were compared.
Results
In our bilateral model of surgical education, training is provided in Ethiopia and Canada over 2 years with a focus on capacity building through egalitarian forms of knowledge exchange. Program features included certification in Fundamentals of Laparoscopic Surgery, high-fidelity lobectomy simulation, and hands-on training. Overall, 41 open and 56 minimally invasive surgery cases were included in the final statistical analysis. The average length of stay in the minimally invasive surgery group was 5.2 days versus 11.0 days in the open group (P < .001). The overall complication rate was 18% in the minimally invasive surgery group versus 39% in the open group (P = .020).
Conclusions
We demonstrated the successful initiation of sub-Sahara Africa's first minimally invasive surgery program in thoracic and upper gastrointestinal surgery and characterize its patient safety. We envision the minimally invasive surgery program as a template to continue expanding global partnerships and improving surgical care in other resource-limited settings.
Key Words: global surgery, minimally invasive, surgical education, thoracic surgery
Video Abstract
Graphical abstract
Minimally invasive surgical training program in Ethiopia: educational framework and timeline.
Central Message.
The TAAAC initiated sub-Saharan Africa's first minimally invasive thoracic surgery training program, leading to reduction in hospital LOS and complications.
Perspective.
The academic partnership between Toronto and AAU led to the creation of the nation's first minimally invasive thoracic program. Through the analysis of the first 103 patients since its initiation, we demonstrate the program's successes in terms of patient safety. This program could serve as a template for future global surgical partnerships.
One of the leading causes of death in Ethiopia is infectious lung disease, such as tuberculosis, which results in more than 40,000 deaths annually.1,2 Other infectious processes such as pulmonary aspergilloma are highly prevalent in the region and harbor long-term sequalae, such as pulmonary fibrosis or massive hemoptysis for which surgical resection is a mainstay of therapy.3 Despite being the second most populous country in Sub-Saharan Africa, Ethiopia currently has 4 thoracic surgeons and before 2016, none were trained in thoracic minimally invasive surgery (MIS).4,5 MIS has been proven to reduce hospital length of stay (LOS), costs, and complications, and improve morbidity and mortality, and therefore would be of tremendous benefit in Ethiopia.6, 7, 8, 9, 10
One challenge Ethiopia faces when it comes to administration of subspeciality health care is due to the concept of brain drain.11 This phenomenon, described as the outward migration of highly specialized medical professionals, has significantly impacted Ethiopia's growth potential of its training programs.11 A 2008 report demonstrated that 73% of Ethiopian physicians left the public sector to work in private institutions or to live abroad.12 Most MIS fellowship training programs operate on a unilateral basis, where international trainees are invited to an overseas country for continual education. One observed effect of this a model is that international graduates from these programs are at higher risks for not returning to their home country upon graduation.11
The Toronto Addis Ababa Academic Collaboration (TAAAC) is a multidisciplinary educational initiative partnering University of Toronto with Addis Ababa University (AAU). The goal of the program is to ameliorate the concept of brain drain by prioritizing sustainability and capacity building in Ethiopia.13 The original partnership, started in 2003, led to Ethiopia's first psychiatry residency program and since then has expanded to numerous fields, including dentistry, critical care, and emergency medicine.14
In 2016, this partnership was expanded to minimally invasive thoracic surgery. As a part of this bilateral educational model, Ethiopian surgeons were invited to Toronto to complete their Fundamentals of Laparoscopic Surgery training, complete observerships, and undergo simulation training with high-fidelity lobectomy simulators. In turn, surgical faculty and nursing staff from Toronto visited Ethiopia in 2017 to conduct teaching and assist in infrastructure building for a MIS program in Ethiopia. During this time, the combined Ethiopian and Canadian team performed a number of MIS thoracic cases, including the first MIS pneumonectomy in Sub-Saharan Africa. The result of the program was a fellowship training certificate for the surgeon and a new MIS center in Ethiopia, which has continued to train fellows and residents in MIS techniques in a self-relying sustainable fashion.
The objective of this article is to describe the experience of the implementation of the TAAAC MIS program in Ethiopia and evaluate the successes of the program in terms of patient safety and outcomes, including LOS and rate of complications using a prospective database established at AAU.
Patients and Methods
Study Design and Population
This study was a retrospective cohort analysis of open versus minimally invasive thoracic and upper gastrointestinal procedures performed at AAU from January 2016 to June 2021. A prospective database was established at AAU since the TAAAC MIS programs inception in 2016. Health records of patients were retrospectively reviewed to abstract sex, age, presenting diagnosis, details of procedure, lead/assistant surgeon, postoperative complications, and LOS. Institutional Review Board approval was obtained at AAU and by the research ethics board at Toronto Academic Health Sciences Network for this study.
Indications for inclusion were those where MIS is being offered at AAU including, but not limited to, lung wedge resection, lobectomy, pneumonectomy, pleuroscopy, biopsy, decortication, mediastinal mass resection, hydatid cystectomy, esophagectomy, and Heller cardiomyotomy. MIS cases that were converted to an open procedure were excluded from statistical analysis but were described qualitatively. MIS and open cases were selected on the basis of surgeon preference. Preference was based on a combination of independent surgical expertise and patient clinical and physiologic status.
Surgical complications were defined according to the Ottawa Thoracic Morbidity & Mortality System.15 Minor complications were defined as grade I or II complications, and major complications were defined as grade III and V. For example, a grade II air leak was defined as one requiring medical therapy only or prolonged (>5 days) of pleural drainage. A grade IIIa air leak was defined as one requiring endoscopic, radiological, or additional bedside pleural interventions. Grade II air leaks and below were classified as “minor air leak,” and grade IIIa air leaks and above were classified as “major air leaks.”
Subgroup analysis categorized patients into major or minor procedures. Major procedures included anatomic lung resection, mediastinal mass resection, and esophagectomy. Minor procedures were all other cases including but not limited to nonanatomic lung resection, bullectomy, pleuroscopy, pleurodesis, lymph node mediastinal or pleural biopsy, and hydatid cyst removal.
Statistics
Baseline demographic, diagnostic, operative, and postoperative outcomes (including LOS and complications) were compared between MIS and open groups. For continuous variables, an F test for 2-sample variance was used to establish if significant differences existed between population variances, and a 2-tailed t test was used to establish difference in mean values. For categorical variables, a chi-square test was used. Differences between groups were reported as mean and standard error, mean for continuous variables, and percentages for categorical variables. All analysis was 2 sided. All analyses were performed in Microsoft Excel version 16.54 (Microsoft Corp).
Results
Our educational design for a global MIS fellowship training program was categorized into 3 phases (Figure 1). In phase I, the preprogram phase, our primary goal was to establish feasibility in setting up a MIS program in Ethiopia and consisted of conducting needs assessments in Ethiopia, initial observerships in Toronto, and infrastructure setup in Ethiopia.
Figure 1.
Educational model for a global surgery health alliance training program. TAAAC MIS program. AAU, Addis Ababa University; MIS, minimally invasive surgery; CPSO, College of Physicians and Surgeons of Ontario; FLS, fundamentals of laparoscopic surgery; OR, operating room.
In phase II, the program action phase, the Ethiopian surgeon traveled back to Canada and participated in advanced MIS at 2 sites in Toronto (St Joseph's Health Sciences Centre and Trillium Health Partners) over the duration of 4 months. Following this, the Toronto and Ethiopian surgeons traveled back to Ethiopia to continue the training program at the local institution for 1 month. This cycle was repeated once more with the last visit in Ethiopia emphasizing operator independence and delivery of safe, high-quality MIS care. Figure 2 outlines the program timeline in further detail.
Figure 2.
Bilateral educational framework and timeline. MIS, Minimally invasive surgery.
In the final phase, the goal is for high-quality knowledge transfer at the local institution. During this time, the local institution disseminates teaching in MIS through their own training programs. A prospective database is established to track patient outcomes, which is important for future quality improvement initiatives and research. We describe our first 103 patients since the initiation of the MIS program at AAU.
Overall, 41 open cases and 62 MIS cases were performed during the study period. In the MIS group, 6 cases were converted to open and were not included in the final statistical analysis (n = 56). Groups were similar in terms of age and sex distribution. The average age was 33 years in the MIS group versus 32 years in the open group (P = .642). A total of 66% of patients in the MIS group were male versus 56% in the open group (P = .318). Additionally, the proportion of major procedures performed was similar between groups. A total of 23.2% of procedures in the MIS group constituted major procedures versus 39% in the open group (P = .093). Table 1 describes the demographic, diagnostic, and procedural details. Retained hemothorax, hydatid cysts, empyema, and esophageal/gastroesophageal junction cancer were the most common diagnoses in both groups. Decortication, hydatid cystectomy, and anatomic lung resection were common procedures in both groups (Table 1).
Table 1.
Patient, diagnostic, and procedural characteristics of study cohort
| MIS (n = 56) | Open (n = 41) | P value | |
|---|---|---|---|
| Age (±SEM) | 33.125 (±1.754) | 31.951 (±1.701) | .642 |
| Sex (% male [n]) | 66.0714 (23) | 56.098 (37) | .318 |
| Major procedures (%) | 13 (23.2%) | 16/41 (39.0) | .093 |
| Diagnosis (%, n) | |||
| Retained hemothorax | 16.071 (9) | 9.756 (4) | |
| Hydatid cyst | 12.5 (7) | 21.951 (9) | |
| Lung cancer | 3.571 (2) | 4.878 (2) | |
| Esophageal/GEJ cancer | 8.929 (5) | 7.317 (3) | |
| Empyema | 8.929 (5) | 9.756 (4) | |
| Primary spontaneous pneumothorax | 7.143 (4) | 4.878 (2) | |
| Lung mass NYD | 5.357 (3) | 2.439 (1) | |
| Mediastinal mass | 5.357 (3) | 2.439 (1) | |
| Persistent air leak | 1.786 (1) | 0 | |
| Pleural cancer | 3.571 (2) | 0 | |
| Pleural mass | 3.571 (2) | 0 | |
| Aspergilloma | 3.571 (2) | 7.317 (3) | |
| Achalasia | 3.571 (2) | 7.317 (3) | |
| Bronchiectasis | 0 | 9.756 (4) | |
| Bronchopleural fistula | 1.786 (1) | 0 | |
| Endobronchial mass | 1.786 (1) | 0 | |
| Malignant pleural effusion | 1.786 (1) | 0 | |
| Hilar mass | 1.786 (1) | 0 | |
| Giant bulla | 0 | 7.317 (3) | |
| Hydropneumothorax | 1.786 (1) | 0 | |
| Diaphragm injury | 1.786 (1) | 0 | |
| Carcinoid tumor | 1.786 (1) | 0 | |
| Foreign body | 1.786 (1) | 0 | |
| Pyogenic pericarditis | 1.786 (1) | 0 | |
| Trapped lung | 0 | 2.439 (1) | |
| Post-TB fibrosis | 0 | 2.439 (1) | |
| Procedure | |||
| Decortication | 33.929 (19) | 21.951 (9) | |
| Hydatid cystectomy | 10.714 (6) | 19.512 (8) | |
| Anatomic lung resection | 8.929 (5) | 14.634 (6) | |
| Nonanatomic lung resection | 8.929 (5) | 12.195 (5) | |
| Pleural/lymph node biopsy/pleurodesis | 10.714 (6) | 0 | |
| Esophagectomy | 7.143 (4) | 7.317 (3) | |
| Pneumonectomy | 3.571 (2) | 14.634 (6) | |
| Mediastinal mass resection/biopsy | 5.357 (3) | 2.439 (1) | |
| Diaphragm repair | 1.786 (1) | 0 | |
| Cardiomyotomy | 3.571 (2) | 7.317 (3) | |
| Air leak closure | 1.786 (1) | 0 | |
| Pericardial window | 1.786 (1) | 0 | |
| Feeding jejunostomy | 1.786 (1) | 0 | |
MIS, Minimally invasive surgery; SEM, standard error of the mean; GEJ, gastroesophageal junction; NYD, not yet diagnosed; TB, tuberculosis.
LOS in the MIS group was 5.2 days versus 11.0 days in the open group (P < .001). LOS subgroup analysis for major procedures was 6.4 days in the MIS group versus 10.8 days in the open group (P = .040). LOS subgroup analysis of minor procedures was 4.8 days in the MIS group versus 11.0 days in the open group (P < .001) (Table 2).
Table 2.
Minimally invasive surgery versus open length of stay and complication rates
| MIS (n = 56) | Open (n = 41) | P value | |
|---|---|---|---|
| Length of stay (mean ± SEM) | 5.196 (±0.517) | 10.976 (±1.32) | <.001 |
| Minor procedure | 4.837 (±0.638) | 11.08 (±1.874) | <.001 |
| Major procedure | 6.385 (±0.636) | 10.813 (±1.768) | .040 |
| Complications (total, % percentage) | 10/56 (17.857%) | 16/41 (39.024%) | .020 |
| Minor complications (total, percentage) | 6/56 (10.714%) | 11/41 (26.829%) | <.001 |
| Major complications | 4/56 (7.143%) | 5/41 (12.195%) | .397 |
Values that are bolded were statistically significant. MIS, Minimally invasive surgery; SEM, standard error of the mean.
The complication rate was significantly reduced in the MIS group versus the open group (10/56 [18%] vs 16/41 [39%], respectively, P = .020). Moreover, the rate of minor complications was significantly reduced in the MIS group when compared with the open group, 6/56 (10.7%) and 11/41 (26.8%), respectively (P < .001). Subgroup analysis was performed stratifying patients by major and minor procedures (Table 3). In patients who underwent major procedures, complication rates were similar between the MIS and open group (5/13 [38.5%] vs 4/16 [25%], respectively, P = .436). In the subgroup of patients who underwent minor procedures, complications were significantly reduced in the MIS group (5/43 patients [11.6%]) versus the open group (12/25 patients [48%]) (P < .001). Table 4 shows the qualitative descriptions of each complication in further detail.
Table 3.
Subgroup analysis of complications stratified by major and minor procedures
| MIS | Open | P value | |
|---|---|---|---|
| Major procedures (n = 29) | |||
| Complications (total, % percentage) | 5/13 (38.5%) | 4/16 (25%) | .436 |
| Minor procedures (n = 68) | |||
| Complications (total, % percentage) | 5/43 (11.6%) | 12/25 (48%) | <.001 |
Values that are bolded were statistically significant. MIS, Minimally invasive surgery.
Table 4.
Open and video-assisted thoracoscopic surgery complication descriptions
| Patient No. | Patient demographics, Age (y) | Diagnosis | Procedure | Complication | Grade | LOS |
|---|---|---|---|---|---|---|
| Open | ||||||
| 1 | 40M | RLL hydatid cyst | Hydatid cystectomy | Minor air leak | II | 10 |
| 4 | 15F | Right complicated hydatid cyst | Hydatid cystectomy | Minor air leak | II | 16 |
| 6 | 29M | RUL giant bulla | Right upper lobectomy | Superficial SSI | II | 16 |
| 9 | 23M | Retained hemothorax | Decortication | Minor air leak | II | 12 |
| 10 | 34M | LUL hydatid cyst | Hydatid cystectomy | Postoperative atelectasis | I | 12 |
| 12 | 52M | Left primary spontaneous pneumothorax | Apical bullectomy, mechanical pleurodesis | Wound site seroma | II | 9 |
| 15 | 28M | Right empyema | Decortication | Persistent air leak | IIIa | 26 |
| 20 | 40M | Retained hemothorax | Decortication | Hospital-acquired pneumonia | II | 8 |
| 22 | 57F | LLL complicated hydatid cyst | Left lower lobectomy | Bronchopleural fistula | III | 32 |
| 24 | 21F | Left trapped lung | Decortication | Minor air leak | II | 10 |
| 29 | 31M | Right loculated empyema | Decortication | Pneumothorax | II | 15 |
| 30 | 34M | Post-TB lung fibrosis (right) | Right upper lobe wedge resection | Bronchopleural fistula | III | 49 |
| 33 | 58F | Esophageal cancer | 3-hole esophagectomy | Anastomotic Leak, complete wound dehiscence | III | 14 |
| 37 | 27F | Mediastinal mass | Mediastinal mass resection | Pneumothorax | II | 19 |
| 38 | 32M | Right empyema | Decortication | Empyema | II | 11 |
| 39 | 41F | LUL aspergilloma | Left upper lobe wedge resection | Persistent air leak | IIIa | 17 |
| MIS | ||||||
| 47 | 30M | Left empyema | VATS Decortication | Minor air leak | II | 5 |
| 66 | 30F | LUL aspergilloma | VATS left upper lobectomy | Minor air leak | II | 5 |
| 71 | 40F | Esophageal cancer | MIS esophagectomy | Anastomotic leak | III | 11 |
| 74 | 35M | LUL aspergilloma | VATS left upper lobectomy | Minor air leak | II | 10 |
| 76 | 62F | Esophageal cancer | MIS esophagectomy | Anastomotic Leak, Mediastinitis, Death | V | 8 |
| 78 | 25F | RLL, RML complicated hydatid cyst | VATS right lower lobectomy, right middle wedge resection | Minor air leak | II | 6 |
| 85 | 25M | Right hydropneumothorax | VATS decortication and biopsy | Persistent pneumothorax and recurrent empyema managed with window (open?) | IIIb | 21 |
| 89 | 30M | Tuberculous empyema (right) | VATS decortication | Postoperative atelectasis, persistent air leak | IIIa | 21 |
| 101 | 25M | Left lung mass NYD | VATS wedge biopsy | Minor air leak | II | 8 |
| 103 | 48F | Right hydatid cyst | VATS cystectomy, handsewn obliteration of cyst cavity | Minor air leak | II | 6 |
LOS, Length of stay; M, male; RLL, right lower lobe; F, female; RUL, right upper lobe; SSI, surgical site infection; LUL, left upper lobe; LLL, left lower lobe; TB, tuberculosis; VATS, video-assisted thoracoscopic surgery; MIS, minimally invasive surgery; RML, right middle lobe; NYD, not yet diagnosed.
In the open group, the most common complication was minor air leak (4/16, 25% of all complications). Minor complications included superficial surgical site infection, minor air leak, postoperative atelectasis, wound seroma, hospital acquired pneumonia, pneumothorax, and empyema. Five major complications occurred in the open group. Two patients had persistent air leak requiring prolonged hospitalizations and further pleural interventions. Two patients developed a bronchopleural fistula. One patient developed an anastomotic leak with complete wound dehiscence post–3-hole esophagectomy (Table 4).
The only minor complication in the MIS group was minor air leak (6/10, 60% of all complications). Four major complications occurred in the MIS group. One patient developed postoperative atelectasis with persistent air leak. One patient developed persistent pneumothorax and recurrent empyema. Two patients had anastomotic leaks after MIS esophagectomy, and 1 of these patients died (Table 4).
Discussion
We describe the first successful implementation of a MIS program in Ethiopia. After the initiation of our program, we were able to demonstrate its effectiveness in terms of hospital LOS and complication rate for patients undergoing thoracic and upper gastrointestinal surgery (Figure 3, Video Abstract). Through this bilateral educational model, emphasis was placed on strengthening capacity and sustainability for the graduate programs in Ethiopia, allowing for future initiatives such as the use of this prospective database to collect patient information, assess outcomes, develop research programs, and initiate efforts in local quality improvement.
Figure 3.
Graphical Abstract. Ethiopia's first MIS program: a novel approach in global surgical education. MIS, Minimally invasive surgery.
In 2015, the Lancet Commission on Global Surgery estimated that approximately 5 billion people lack access to safe, affordable, and timely surgical care.16 Global surgery is an integral component of global health, and since 2015, efforts have been made to address disparities in access to surgical services on the global stage. A critical component of this endeavor is the initiation of global surgical education initiatives emphasizing patient safety and egalitarian forms of knowledge exchange.
Several models for educational partnerships exist, ranging from a short-term volunteer of surgical service or “surgical missions” to more sustainable health system–strengthening approaches that include skills transfer and education or “academic partnership.” These academic partnerships focus on developing collaborations around patient care, clinical research, workforce education, and surgical capacity building in the “twinning model.”17,18 Our global academic partnership represents an adaptation of the twinning model where a substantial portion of the training is done in a low-middle income country (LMIC). In this fashion, training is provided in LMICs for the entire healthcare team, including anesthesia, nursing, and allied health, and not just for the individual surgeon. This form of interdisciplinary partnership allows the program to adapt techniques for training depending on the unique challenges faced within the home country using their equipment, staff, and resources.
Despite the shift of global surgical education toward more longitudinal designs, a recent review of the landscape of academic global surgery demonstrated that only 12.5% of programs adopted a bilateral model where there was an exchange of residents and faculty between high-income countries and LMICs.19 We argue that not only is there added benefit for a bilateral model of education for harboring egalitarian knowledge transfer but also this model is more sensitive to understanding how power imbalances due to colonialism, racism, and epistemic injustice shape global health partnerships.20 We believe our education model emphasizes capacity building, sustainability, and self-reliance in the LMIC. This is most apparent in phase 3 of our program, where the high-income country withdraws from hands-on training and emphasizes building the LMIC training program in a self-reliant fashion. During this period, the LMIC is responsible for knowledge dissemination within their local institution and teaching MIS techniques through residency education with support of the partnering institution when requested. Other described advantages of bilateral models include resource sharing, mutual education, community engagement, and bilateral authorship.21
We demonstrated safety in the initiation of a global MIS program that led to reductions in hospital LOS and complication rate. Several MIS operations were performed throughout the study period, from minor procedures such as biopsy and pleurodesis to major procedures such as anatomic lung resection, esophagectomy, mediastinal mass resection, and the first video-assisted thoracoscopic pneumonectomy in sub-Sahara Africa. Successful implementation of the MIS program in Ethiopia holds promise for expansion of other global academic partnerships to implement MIS programs in other LMICs to improve local surgical safety and patient outcomes, a critical component of the Lancet Commission on Global Surgery.22
Analysis of our data demonstrates an expanded role for MIS for therapeutic purposes and diagnosis. For example, 6 patients (6/52, 10.714%) in the MIS group underwent pleural/lymph node biopsy/pleurodesis versus zero patients in the open group. Until other departments such as interventional radiology become more developed in LMICs, surgery plays a dominant role in obtaining pathological diagnosis to facilitate future treatment regimens. Therefore, our data demonstrate that the MIS techniques may be a safe alternative to traditional open surgery in Ethiopia, arguing for an important role for its use in developing countries for therapeutic and diagnostic purposes.
In our study, 6 cases were converted to open (6/62, 8%). Indications were post-trauma hematoma with persistent air leak (1/6), advanced lung cancer with massive effusion (3/5), giant bulla (1/6), and post-tuberculosis bronchiectasis (1/6). Literature suggests the conversion rate ranges between 10% and 20% for video-assisted thoracoscopic lobectomy.23, 24, 25 Therefore, our conversion rate is on par with other institutions, suggesting adequate surgeon technical competency after the MIS training program.
Study Limitations
A few limitations exist within our study that have implications for selection bias. First, patients were not randomized or matched by diagnosis or procedure. Second, our study did not assess patients' operative risk or physiologic status before the operation. Third, from an educational and patient safety perspective, MIS cases were more likely selected for optimal chance of success. When teaching the MIS technique, a learning curve is expected and careful patient selection is part of what makes a successful learning experience. Taken together, these observations likely reflect more than just chance selection bias because the selection of MIS cases was likely based on the assessment of more favorable patient factors, surgical technical factors, and educational factors.
Previous studies have established the benefits of MIS versus open.6, 7, 8, 9, 10 However, these patient populations are significantly different than the one presented here and are typically of older age, with the primary indication for surgery being oncological, and surgeries are performed at high-volume centers. We have demonstrated the MIS approach is a safe alternative, feasible approach that is in keeping with standard-of-care treatment in resource-abundant settings. Future work is needed in this specific patient population to further elucidate examine outcomes-based research for patients undergoing MIS in Ethiopia.
The goal of this article was to demonstrate the feasibility and safety of a new model for global surgical education, which we have accomplished. Given that a prospective database has been established at AAU, future studies are under way examining surgical outcomes of MIS procedures specific to the Ethiopian thoracic surgery population. Moreover, future studies should examine the implementation of MIS programs in other surgical specialties, including expansion to general, urological, gynecological, cardiac, and vascular surgery and allied specialties such as interventional radiology.
Conclusions
We demonstrated the successful initiation of sub-Sahara Africa's first MIS program in thoracic and upper gastrointestinal surgery (Video Abstract). In addition to documenting the safety of this program, MIS techniques allowed for an expanded role in the treatment and diagnosis of various thoracic and abdominal disease processes not offered by traditional open techniques, justifying the utility of this program for diagnostic and therapeutic purposes. Through a bilateral educational framework, emphasis was placed on building capacity, sustainability, and self-reliance in Ethiopia by creating an academic partnership based on egalitarian forms of knowledge exchange. We envision the thoracic unit at AAU to be a minimally invasive center of excellence that will continue to expand the MIS program into other surgical specialties and serve as a template for other institutions in the region. In the future, global academic partnerships may be established in other countries to develop MIS programs to improve patient outcomes in resource-limited settings.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Acknowledgments
This work and TAAAC in minimally invasive thoracic surgery were supported in part through an educational grant by Covidien. The authors thank Dr Brian Hodges, Vice President, Education at the University Health Network (UHN) for support of the program; Dr Kazuhiro Yasufuku, Division Head of Thoracic Surgery at UHN, for providing the video-assisted lobectomy simulation models; Dr Allan Okrainec Division Head of General Surgery at UHN, for support and providing the Fundamentals of Laparoscopic Surgery for the program; Dr Vaibhav Gupta, for input and support in formatting the article; and all the nurses from Black Lions Hospital, Addis Ababa, and St Joseph's Health Centre, Toronto, who participated in this project. Without your efforts this would not be possible.
Footnotes
Funding: This work was sponsored in part through an educational grant provided by Covidien.
Unity Health Research Ethics Office REB #022-006. Approval date: February 22, 2022.
Supplementary Data
Video abstract outlining the initiation of Ethiopia’s first minimally invasive surgery program. Video available at: https://www.jtcvs.org/article/S2666-2736(22)00411-9/fulltext.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Video abstract outlining the initiation of Ethiopia’s first minimally invasive surgery program. Video available at: https://www.jtcvs.org/article/S2666-2736(22)00411-9/fulltext.