The Need for A Global Change

Lack of  access to surgical care due to the too few sufficiently trained medical personnel and the overwhelming backlog of cases has proven unmanageable given the current resources. New resources and technology must be developed to address the need for more reliable and accessible surgical care in LMIC’s.

Surgically treated disorders represent a significant portion of the global health burden and are inadequately addressed in low- and middle-income countries (LMICs). (1). Obstetrical fistula is one such can disorder that can be remedied by access to surgical care. It is a common and demeaning affliction of an estimated 3.5 million young women, with approximately 150,000 new cases occurring annually (2). Without treatment these women are often homeless, unable to live normal lives and interact with their families, maintain employment or play an active role in their community.

Unfortunately, the majority of women in LMICs do not have access to surgical care due to the lack of sufficiently trained medical personnel and the existing capacity to treat these women at barely 14,000 cases per year. Given these numbers, it is clear that the backlog of cases is too overwhelming to be effectively managed given the current resources. (3)

Traditional hands-on surgical training at the global, regional, and local levels is both costly and time intensive. Even with proper training, many medical providers lose confidence and often stop repairing fistula upon returning to their home institution. Trainees need more efficient, higher quality, and access to follow-up and advanced training in order to provide safe, effective and sustained fistula surgical care within their communities.

Simulation and video training tools have dramatically changed the face of medical training in the developed world (4), but have yet to be effectively introduced in LMICs.

MSI’s mission to bring state-of-the-art surgical training in fistula repair to LMICs has culminated in the development of an interactive video simulation platform which can be executed on a standard personal computer. As most LMIC hospitals have at least one computer, our program by default is universally accessible.

The foundation of this program is a series of high definition video recordings of fistula repairs performed by a master surgeon. The curriculum is robust and blends live intra-operative video with expert lectures, anatomy reviews, decision making flowcharts, texts, animations, still images as well as quizzes and a test of knowledge into an interactive format, is designed for medical professionals to engage and optimally prepare them for hands-on fistula repair training at a certified center.

The video is broken down and organized into a series of logical steps. “Hot spots” are integrated within the video picture frame to highlight the anatomic structures in the surgical field. After watching the full procedure, the trainees engage in a video-based procedure by choosing an instrument from a virtual instrument stand using their computer’s mouse to maneuver and perform specific actions. Errors are logged to identify an area which requires more focused training and will require the trainee to repeat the step until the correct choice is made. Once correct, the video provides running commentary of the missed step, providing useful tips to supplement the trainee’s learning.

Step-by-step, the trainee completes all steps to simulate an entire fistula repair.

We expect this program to dramatically improve the efficiency and the quality of the hands-on training that takes place when these trainees present to a certified fistula training center. Additionally, upon returning to their home hospital, this video trainer will provide the trainee with a useful refresher and build confidence to deter trainees from abandoning their newly acquired skills. The measured outcomes include assessments of trainees’ cognitive knowledge acquisition, skill acquisition and number of cases performed.

Content has been developed in partnership with the International Federation of Obstetrics and Gynecology (FIGO) and a panel of expert fistula surgeons.

More than 30% of the global health burden is due to diseases requiring surgical treatment (5), a space which, unfortunately, global health initiatives have neglected for decades. In nations with the lowest performing health indicators, >95% of the population lacks access to basic surgical care, leaving as many as 4.8 million people worldwide unable to obtain a simple, life-saving procedure. A lack of appropriately trained personnel is a key contributor to this problem and there is an immediate need to increase the numbers of qualified health professionals.

In March 2015, the World Bank published results of a comprehensive financial analysis which found that investments in a small number of basic surgical procedures would be highly cost effective and save more than 1.5 million lives per year. A total of 44 procedures in a variety of disciplines were identified as “essential” to provide in LMICs (1). The Cesarean section is one such procedure.

In order to meet the need, high quality surgical instruction in routine procedures must be available to surgical clinicians from all disciplines. Within this group of 44 “essential” surgeries heralded by the World Bank report, the maternal reproductive health care segment demonstrates critical access deficiencies for communities in need of sexual and reproductive health (SRH) procedures. MSI’s 36 month plan is to develop, distribute and validate three additional video simulation trainers to teach medical providers of various disciplines to perform Ceserean section, tubal ligation and vasectomy.
Loking further, our 10 year aim is to upscale the production of video simulation trainers to build a digital library of video-based surgical simulators that will be provided free of charge to medical trainees and providers of all disciplines in LMIC. A hybrid of public, non-governmental and commercial investments will be the engine to drive this expansion. Engagement of national ministries of health as well as regional, national, and local medical societies will be essential in the distribution and uptake of these training tools.


  1. “Essential Surgery” Vol. 1, World Bank. Disease Control Priorities, 3rd edition. 2015.
  2. Wall, L.L., J.Wilkinson, S.S. Arrowsmith, O.Ojengbedee, and H. Mabeya. 2008. “A Code of Ethics for the Fistula Surgeon. International Journal of Gynecology and Obstetrics 101 (1):84-87.
  3. UNFPA data
  4. Ross E. Willis, Kent R. Van Sickle, “Current Status of Simulation-Based Training in Graduate Medical Education”, Surg Clin N Am 95 (2015) 767-779
  5. The Lancet Commission on Global Surgery. Volume 386, No. 9993, p569–624, 8 August 2015