Title : Minimally invasive, maximally efficient: Barriers to implementation of laparoscopic appendicectomy practice and evaluation of the introduction of a laparoscopic simulation training programe in a developing country

Background: Laparoscopic surgery is widely adopted for emergency operations in high-income countries due to its association with reduced postoperative pain, shorter hospital stay, and faster recovery. However, uptake in low- and middle-income countries remains limited despite these benefits. Bangladesh continues to rely predominantly on open techniques for many emergency procedures. This study aimed to identify key barriers to the adoption of laparoscopic surgery in Bangladesh and evaluate whether targeted simulation training could improve trainee confidence and skills. 
Methods: A mixed-methods cross-sectional study was conducted from November 2022 to March 2023. Surgical residents across Bangladesh were invited to complete a structured questionnaire assessing barriers to laparoscopic practice. Eighty-one responses were collected. Based on these responses, residents were randomly selected to participate in a two-day laparoscopic simulation training course designed to address the identified training gaps. In addition, a focus group with consultant surgeons using semi-structured interviews explored institutional and cultural barriers to laparoscopic adoption. 
Results: The most reported barrier to laparoscopic practice was lack of operative training opportunities, followed by limited access to simulation facilities and insufficient senior leadership in adopting laparoscopic techniques. Following the simulation course, participants reported improved confidence in handling laparoscopic instruments and performing basic laparoscopic tasks. Trainees with prior experience in open surgery demonstrated rapid acquisition of laparoscopic skills during the short training programme. 
Conclusion: Targeted simulation training informed by trainee needs can be delivered through low-cost, short-duration courses and may represent a practical strategy to accelerate laparoscopic adoption in resource-limited healthcare systems. This model provides a scalable framework for improving minimally invasive surgical training in developing countries.

Dr Emiko Sultana is a PhD student and Clinical Research Fellow in colorectal surgery at Imperial College London and Imperial College Healthcare NHS Trust. She completed an MSc in Surgical Science and Practice at the University of Oxford, where her research focused on improving access to minimally invasive surgery in low- and middle-income countries. Her academic interests include surgical outcomes research, health inequalities in surgery, and global surgical training. She has led multiple collaborative research projects and is currently investigating inequalities in access to pelvic floor surgery across the United Kingdom.