Int Surg 2012;97:363–371

A Successful Model for Laparoscopic Training

in Mongolia

Gabriela Vargas1, Raymond R. Price1,2,3, Orgoi Sergelen3, Byadran Lkhagvabayar3,

Pandaan Batcholuun3, Tsiiregzen Enkhamagalan3

1Department of Surgery, University of Utah Hospitals and Clinics, Salt Lake City, Utah, USA

2Department of Surgery, Intermountain Medical Center, Intermountain Healthcare, Salt Lake City, Utah, USA

3Department of Surgery, Health Sciences, University of Mongolia, Ulaanbaatar, Mongolia

The benefits of laparoscopic surgery have not been available to the majority of

Mongolians. Mongolian surgical leaders requested assistance in expanding laparoscopy.

A capacity-building approach for teaching laparoscopic cholecystectomy throughout

Mongolia is reviewed. A laparoscopic cholecystectomy training program was developed.

The program included a didactic course and an intensive 2-week practical operating

experience. Courses were taught in Ulaanbataar and at 3 of the 4 regional diagnostic

referral and treatment centers from 2006 to 2010. During this training period, a total of 303

teaching laparoscopic cholecystectomies were performed. There was one common bile

duct injury and one duodenal injury. The conversion rate was 2.0%. This program has

been successful in creating a self-sustaining practice of training. The traditional surgical

approach to gallbladder disease in Mongolia has been challenged and has, in turn, been a

stimulus for improvement in the medical community.

Key words: Developing countries – Specialties surgical/education – Cholecystectomy –Laparoscopic – Mongolia – Cholecystectomy laparoscopic/education – Laparoscopy/economics – Laparoscopy/standards

Cholecystectomy is one of the most commonoperations performed worldwide.1 Laparoscop-

ic cholecystectomy has revolutionized the care ofgallbladder disease, allowing for faster recovery,

shorter hospitalizations, decreased wound infec-tions, and decreased use of narcotic medications.In developed countries, laparoscopic cholecystecto-my has now become the gold standard in the

Reprint requests: Raymond R. Price, MD, Intermountain Surgical Specialists, 5169 South Cottonwood Street, Suite 410, Salt Lake City,

Utah 84107.

Tel.: 801.507.1600; Fax: 801.507.1625; E-mail: raymond.price@imail.org

Int Surg 2012;97 363

treatment of gallstones. However, open cholecystec-tomy with its increased morbidity remains thestandard of care in developing nations owing tolimitations in training, funding, and availability ofequipment. The benefits of laparoscopic surgeryelude much of the developing world, where peopleoften accept several painful conditions as a fact of life.

In Mongolia, 49% of the 2.7 million people residein rural areas and live a nomadic lifestyle.2

Mongolia covers a large geographic area equal tothe combined areas of Great Britain, France, Ger-many, and Italy; it is the most sparsely populatedcountry in the world. The dry deserts and wetmountains coupled with the extremes of weather aresignificant obstacles to adequate road building andimpede transportation for patients in need. The vastrural areas of Mongolia are isolated and present aserious challenge to providing access to adequatemedical and surgical care.

In 2006, expenditures for health care reached 4.6%of the gross domestic product of Mongolia; thistranslated into US $23.2 per capita for health careper year.2 Weiser et al3 found that surgery is almostabsent in countries where less than US $100 is spenton health care per person per year. Laparoscopiccholecystectomy was first introduced into Mongoliain 1994, but by 2005 only 2% of the gallbladderswere being removed laparoscopically, and nolaparoscopy was performed outside of the capitalcity, Ulaanbataar.4,5

The epidemiology of diseases in Mongolia hasdramatically changed over the last 3 decades. Whereechinococcal disease was one of the leading surgicaldiagnoses in the early 1960s, it is now uncommon.Today, the second most common cause of hospitalmorbidity in Mongolia is gastrointestinal diseases,with liver diseases, appendicitis, and gallbladderdisease representing the majority of these illnesses.A cohort study in Mongolia in 2006, comparing thefew laparoscopic cholecystectomies to the manyopen cholecystectomies, found that the laparoscopicapproach afforded patients lower infection rates andshorter hospitalizations, and provided hospitals costsavings.6

Mongolia is divided into 21 geographic/admin-istrative areas called Aimags. In the early 2000s, theMinistry of Health of Mongolia, in an effort toincrease access to improved medical and surgicalcare to the rural areas throughout Mongolia,designated 4 of the Aimag hospitals as RegionalDiagnostic Referral and Treatment Centers(RDRTCs) and targeted them for improved infra-structure and human resource development.

Despite the obvious concerns of inadequatephysical and human resources, difficult travel, andrelatively limited financial investment in health care,the chief of surgery at the Health Sciences Universityof Mongolia, recognizing the need for improvedtreatment for gallbladder disease, requested assis-tance from the W.C. Swanson Family Foundation (anonprofit, nondenominational, non-governmentalorganization [NGO] that had been helping todevelop and improve the infrastructure of hospitalsin Mongolia since 1999) to help expand laparoscopiccholecystectomy to these 4 RDRTCs. This articlereviews the teaching methods and important con-cepts learned over the last 5 years in expandinglaparoscopy in a sustainable manner throughoutMongolia.5

Methods

In collaboration with the Health Science Universityof Mongolia (HSUM), the Ministry of Health (MOH)of Mongolia, and the W.C. Swanson Family Foun-dation (SFF), a comprehensive multidisciplinary2-week laparoscopic cholecystectomy–trainingcourse was developed. The organizational compo-nents included (1) maneuvering the local politicaland medical system, including importation laws andagreements, and licensing the surgeons on theteaching team; (2) developing and translating anappropriate didactic curriculum; (3) organizing afunctional practical component of the course thattrains all important team members and provides acontinuum of training including pre-, intra-, andpostoperative management; and (4) implementingmethods for sustainable infrastructure develop-ment that supports laparoscopy in a resource-poorenvironment.

Maneuvering the political and medical regulatoryenvironment in Mongolia

To facilitate the constant changing laws and regu-lations, a local Mongolian expert was hired as an in-country facilitator and representative for the SFF.Agreements through the MOH and support fromlocal political representatives led to critical long-term alliances that facilitated the import of thenecessary laparoscopic and medical supplies. Also,appropriate medical licenses were obtained throughthe MOH and the National Mongolian SurgicalSociety for the foreign surgeons. The chief of surgeryat HSUM was instrumental in obtaining the licensesas well as organizing the Mongolian doctors, nurses,

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and administrators for the courses at the variousfacilities each year.

Developing the didactic curriculum

The course combined both didactic and practicalsessions. The laparoscopic didactic lectures weregiven either the first day, or over several days in themorning. The initial topics for the laparoscopicdidactic course were developed through discussionsbetween the chief of surgery at HSUM and themedical director for the SFF. The topics includedbasic and advanced laparoscopic training as the firstcourse and was scheduled for Hospital No. 1 wherelaparoscopy had begun in 1994 (Fig. 1). Later, withpermission from the Society of American Gastroin-testinal and Endoscopic Surgeons (SAGES), thedidactic lectures from the Fundamentals of Laparo-scopic Surgery course replaced some of the initial

lectures. These lectures, combined with those onbasic laparoscopy skills, sterile technique, andsurgical safety as outlined by the World HealthOrganization (WHO) surgical safety checklist, pro-vided a total of 8 hours of didactic lectures (Fig. 2).All lectures and presentations were translated intoMongolian. Medical translation for the PowerPoint(Microsoft, Redmond, WA) slides and during theactual course proved to be a significant hurdle solvedby collaborating with native surgeons and otherphysicians from the tertiary care centers in the capitalcity, who were bilingual in Mongolian and English.Following the direction of the chief of surgery atHSUM, an Emergency Surgery didactic lecture serieswas also develop and included during the complete2-week training course at the RDRTCs (Fig. 3).Surgeons and nurses from different surgical special-ties (orthopedics, obstetrics and gynecology, andothers) attended the didactic portions of the course.

Fig. 1 Initial lectures for didactic laparoscopy course.

Fig. 2 Revised lectures for didactic laparoscopy course.

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Organizing the practical training component

The first laparoscopic course in 2006 included 1 weekof laparoscopic cholecystectomy experience and1 week of advanced laparoscopic surgical proce-dures (colectomies, an adrenalectomy, a Nissenfundoplication). From 2007 to 2010, all of thepractical laparoscopic training components focusedon laparoscopic cholecystectomy, with a few appen-dectomies. The laparoscopic cholecystectomy prac-tical portion of the course provided general sur-geons with 5 days of hands-on experienceperforming laparoscopic cholecystectomies in 2different operating rooms. The experience wasinitially designed to provide 2 to 3 Mongoliansurgeons per operating room the opportunity togradually learn the laparoscopic skills—progressingfrom camera holder, then advancing to first assis-tant, and finally to lead surgeon. It was politicallyvery difficult to limit the number of surgeonsparticipating in this first practical session. ManyMongolian surgeons assisted, but few gainedenough experience to allow them to act as the leadsurgeon. Future courses were able to select the fewsurgeons who would receive the operative practicalexperience before the teams arrived, allowing forvery intensive, focused training with the graduatedapproach. The numbers of teaching laparoscopiccholecystectomies were also decreased to 3 (or rarely4) cases, from 6, per day for each operating room; as6 cases overwhelmed local resources and staff.Relatively few course participants had receivedprior training in laparoscopy.

Each course included a multidisciplinary educa-tion team consisting of 2 surgeons, an anesthesiol-ogist, an operating room nurse, an operating roomscrub technician, and a bio-technician. A surgical

resident frequently joined the team to facilitateresearch and patient improvement projects. Eachteam member was tasked with training his/herMongolian counterpart about the specifics of lapa-roscopic surgery from their perspective. This in-cluded not only the intra-operative training, but alsothe pre- and postoperative management of thepatients and the care and cleaning of the equipment.Bio-technicians trained their counterparts on main-tenance and repair of the equipment and helpedidentify sustainable ways to replace and upgradeequipment. Inanimate laparoscopic skill simulatorboxes were added to the practical component of thecourse during the last 2 years (2009–2010).

Due to the infrastructure of the health care systemin Mongolia, training began first in the capitol city ofUlaanbaatar (UB), where tertiary care is provided.Training was subsequently expanded to the regionalcenters in 3 of the 4 regional diagnostic referralcenters (Erdenet, Khovd, and Choibalsan), and thefourth (Uvukhanghai) was scheduled for training inJune 2011. Each education site received an initialtraining course and a follow-up course the next year.(The initial course in Choibalsan was completed in2010.) Participants were issued a certificate ofcompletion signed by the President of the NationalMongolian Surgical Society and the Medical Direc-tor of the SFF at the conclusion of the course. Thisdid not imply any competency but supported theMongolian national standards for required continu-ing medical education.

During the 2 weeks of laparoscopic training, anyemergency and trauma cases at that facility weremanaged together with the local Mongolian surgicalteam and the visiting surgical education team.This included the pre-, intra-, and postoperative

Fig. 3 Emergency surgery didactic lecture series.

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management, with daily combined-team roundsmorning and night. Some patients with appendicitiswere offered the laparoscopic approach to beginexpanding the students’ laparoscopic skills. Tradi-tional open surgical procedures were done for allother emergency cases.

Infrastructure development

As laparoscopy requires a totally different set ofequipment and instruments, and none of theRDRTCs had any of this equipment, each of thecourses included on-site evaluations well in advanceof the training sessions. Hospital infrastructure wasassessed, including suitability of the power source,status of basic surgical equipment (instruments,cautery, suction, anesthesia machines, operatingroom lights and beds, autoclaves, and other sterili-zation methods), and supplies (suture, bandages,medicines). The SFF supplied the necessary infra-structure, initially using equipment obtained from UShospitals that had been refurbished to meet USstandards. Working with industry, new equipmentand supplies were donated. Containers were shippedmonths in advance of the education teams, and theninstalled in the hospitals working with the localMongolian counterparts. Laparoscopic towers andequipment were installed in each facility (HospitalNo. 1, Erdenet; Hospital No. 2, Khovd) prior to thetraining through the SFF; except in Choibalsan,where a Belgium project had installed some equip-ment the previous year and had begun laparoscopictraining there. Additional laparoscopic equipmentwas installed in Choibalsan by the SFF. Operatingroom tables, anesthesia machines, autoclaves, elec-trocautery machines, open surgical instruments, andopen retractors were also donated. Partnerships withindustry have begun establishing local vendors inUlaanbataar to help maintain and provide sources forcontinued training, supplies, and equipment.

Evaluation

Data were prospectively collected on the numbers ofstudents attending the courses. Patient demograph-ics were collected prospectively on all patientsduring the training course. Complications wereidentified prospectively and confirmed with aretrospective follow-up after the courses.

Patient demographics (age and sex), ultrasoundfindings, procedure type (open versus laparoscopicversus conversion), surgeon (trainee versus trainer),intraoperative complications, and postoperative

complications were collected. Hospital records fromJanuary 2005 to September 2010 were reviewed in 2of the 3 regional centers (Khovd and Choibalsan) forall cholecystectomies, and the following data werecollected: patient age, sex, preoperative diagnosis,type of procedure, and surgeon. Data collected fromErdenet have recently been published.5

Results

All foreign surgeons and anesthesiologists were able toobtain a medical license while in Mongolia. The studywas approved by the chief of surgery at the HSUM, thechief of surgery at each hospital, the hospital admin-istration, and the review board of the SFF.

Training courses were organized and taught inUlaanbataar at Hospitals Nos. 1 and 2, and at 3 ofthe 4 RDRTCs in Erdenet, Khovd, and Choibalsanfrom 2006 to 2010. Erdenet, Khovd, and Choibalsaneach only had 4 active general surgeons, all of whomcompleted the practical training. Courses taught atHospitals Nos. 1 and 2 included students frommultiple hospitals throughout Mongolia.

Mongolian surgeons conducted evaluations ofpatients with symptoms consistent with gallbladderpathology prior to the arrival of the teaching team.All patients underwent laboratory studies consistingof complete blood count (CBC) and comprehensivemetabolic panel (CMP). Nearly all patients under-went right upper quadrant ultrasound to verify thepresence of cholelithiasis. The patients selected forlaparoscopic cholecystectomy had the presence ofstones confirmed and symptoms consistent withsymptomatic cholelithiasis. The patients were reex-amined the day before the planned surgery with acombined training team of Mongolian and interna-tional surgeons. Laboratory and radiographic stud-ies were reviewed together during these preopera-tive teaching rounds. Patients suspected of havingcholedocholithiasis or acute cholecystitis were treat-ed by traditional open surgery.

A total of 303 laparoscopic cholecystectomieswere performed during the practical componentsof the courses from 2006 to 2010. The female to maleratio was 3.7:1. All patients with gallstones wereidentified preoperatively with ultrasound. Therewas one common bile duct injury (0.33%) and oneduodenal injury (0.33%). The conversion rate was2.0% (Table 1). Intra-operative cholangiogram tech-nique was taught during 3 cases in Choibalsan, as itwas the first facility that had the capability for intra-operative x-ray during our training courses.

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Operative time, expressed in minutes, was de-fined as the time of the operation from skin to skin.In Erdenet, the mean operative time for teachingcases was 78 minutes. The average operative timesfor teaching cases in UB, Khovd, and Choibalsanwere 64.3, 82.2, and 92.9 minutes, respectively.

Trainees progressed from camera holders to firstassistant once they were able to demonstrate theability to orient and move the camera appropriately.They did not progress to primary surgeon until theywere able to consistently place the instrumentssafely into the abdomen, handle tissue, retractappropriately, and dissect the gallbladder from thegallbladder fossa. Once these skills were obtained,they were allowed to perform the dissection of thetriangle of Calot. Acquisition of all of these skillswas the benchmark for successful training.

From 2005 to 2008 in Khovd and Choibalsan, allgallbladders were removed by the open technique.The overall frequency of cholecystectomy as well asthe number performed laparoscopically has in-creased in these facilities since training began in2009 (Figs. 4 and 5).

Two of the surgeons who received training duringthe advanced laparoscopic portion of the 2006 coursebecame part of the SFF education team in Erdenet.Two other surgeons from the 2006 laparoscopiccholecystectomy course also joined the SFF teams toteach in Khovd and Choibalsan. These surgeons havefacilitated follow-up on-site proctoring and providedshort-term fellowships at their facilities to continue thetraining of the surgeons from these regional hospitals.

In addition, one of these surgeons has become themedical director of Songdo Hospital, a new privateKorean hospital in Ulaanbataar, where he per-formed nearly 100 laparoscopic colectomies in 2010.

Discussion

The introduction of laparoscopy in resource-poorareas has been a topic of some debate. Some haveargued that the introduction of laparoscopy indeveloping countries does not contribute to theimprovement of quality and effectiveness of surgicalcare unless basic and essential surgical and anes-thetic services are strengthened in parallel and thatperhaps the drive for laparoscopy is driven byindustry or academia and not public demand.7

Others suggest that the benefits of laparoscopy—faster return to work, less pain, and fewer infec-tions—may actually be more important in thedeveloping world, leading to improved productivityin an already fragile economic environment.8

Laparoscopy had previously been introducedinto Mongolia in 1994, but 10 years later, very fewlaparoscopic cholecystectomies were being per-formed. Barriers to the expansion of laparoscopyincluded the lack of adequate training and signifi-cantly limited resources, especially in the ruralregions. In Mongolia, the impetus for the expansionof a laparoscopic program resulted from a concertedcampaign from the local surgical community toaddress a critical need for their country. Thepartnership created between the Health Sciences

Table 1 Complications and conversion rates in laparoscopic teaching courses (2006–2010)

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University of Mongolia and the W.C. SwansonFamily Foundation as well as the continued supportof the entire surgical community has been anextremely important concept for the successful andsustainable introduction of laparoscopy in Mongolia.

Many lessons were learned from the initial coursetaught in 2006, as the teams had to carefullynavigate the cultural and political nuances. InMongolia, physicians are trained in a system wherethey learn by watching and only sometimes assist-ing. Despite the predesigned curriculum, this led tomany surgeons each assisting during the practicalcomponent of the laparoscopic cholecystectomytraining without providing anyone with enoughexperience to competently perform a laparoscopiccholecystectomy independently. In order for thetraining to be effective, local leaders had to beconvinced that a different method of teaching wasrequired; training 2 surgeons in one operating roomover several days as they progressed through agraduated experience would allow the surgeons tobecome somewhat proficient in the technique. Thechief of surgery, Dr Sergelen, commented in 2009that one of the most important aspects of thetraining program had been the introduction of anew way to teach surgery in Mongolia—a ‘‘hands-on’’ approach that allows the surgeons to ‘‘do’’rather than just ‘‘watch’’—leading to a more rapidacquisition of new surgical skills. It was much easierto consolidate the practical training in Erdenet,Khovd, and Choibalsan, as each facility had only 4general surgeons and had selected 2 for the majorityof the operative experience. One of the mostimportant aspects of this training course is the

training of surgeons in their native operativeenvironment. They are able to learn on their ownequipment and are involved in troubleshooting andproblem solving when issues with the existinginfrastructure arise. All trainees continue to practiceat the RDRTC where they received their training.

Understanding the limitations imposed by themedical system’s infrastructure was another lessonlearned during the 2006 course. Sterilization ofinstruments to allow rapid turnover of the operatingroom was a limiting factor. Lack of adequate humanresources and time, as well as the concern ofinadequate sterilization and transmission of infec-tious diseases if the system was strained, forced usto reevaluate the feasibility of performing a largevolume of cases. To overcome this problem, thenumber of procedures being done per day wasdecreased by nearly half, and enough scopes andinstruments are now taken to each site to allowadequate sterilization to safely facilitate 3 to 4laparoscopic cases per day.

Combining emergency and essential surgicaltraining in parallel with the laparoscopic trainingfor the RDRTCs indeed has allowed for culturallyacceptable methods to improve surgical care ingeneral. Teaching laparoscopic surgery not only ledto the expansion of more modern surgical tech-niques to rural Mongolia, but it also enabledimproved reception for basic surgical training. Inaddition to improved decision making and technicalabilities of the surgical team, teaching laparoscopyhas facilitated the acceptance of sterile techniquecourses and the implementation of surgical safety

Fig. 4 Incidence of cholecystectomy in Khovd.

Fig. 5 Incidence of cholecystectomy in Choibalsan.

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measures, such as incorporating the surgical safetychecklist and implementing a ‘‘time out’’ at thebeginning of the cases. By providing the surgeons inMongolia with the training they requested, trust hasbeen gained, allowing for the introduction oftraining in trauma surgery, emergency surgery,and pediatric surgery and anesthesia, in additionto laparoscopy.

Several studies in developing nations havedocumented both the feasibility and safety ofperforming laparoscopic cholecystectomies.9–11

With careful patient selection, the safety of same-day laparoscopic cholecystectomy has also beenestablished.1,12,13 The majority of this experience hasbeen carried out in tertiary care centers and has notbeen well studied in rural centers. As with theexperience in developed countries, there is alearning curve for the mastery of laparoscopic skills.Complication and conversion rates in Mongolia areconsistent with those seen at the inception oflaparoscopy in the 1990s.5

One might expect the complication rate to beelevated during the practical portion of the trainingperiod where surgeons learning laparoscopy havenot had previous experience. However, the commonbile duct injury rate and bowel injury rate thus farhas been extremely low during the 303 laparoscopiccholecystectomy cases performed. Although convert-ing to an open procedure is taught as good clinicaljudgment and not a complication, the conversion rateas well has been extremely low during the trainingcourses. An initial report of complication andconversion rates in Ulaanbataar and Erdenet indicat-ed acceptable rates following the trainings.5

The multidisciplinary team approach, teachingcomprehensive surgical care (pre-, intra-, andpostoperative care), and introducing twice dailyteam rounds with surgery, anesthesia, and nursingwas one of the features most appreciated by ourhosts. A significant amount of time was spentdiscussing and reviewing the appropriate work-upand selection of patients for surgery. Teachingappropriate patient selection and criteria for thesafe administration of anesthesia provided excellentopportunities to improve perioperative care. Thenotion that a patient scheduled for surgery shouldbe cancelled if not medically optimized has been animportant concept taught during all of the courses.The postoperative management training has beenfacilitated by improving monitoring capabilities ofeach facility. An important aspect of this courseincludes training for each person involved inlaparoscopy, including the central processing staff

sterilizing the equipment, operating room personnelcleaning the instruments, administrators who pro-vide financial and leadership support to replace andrepair the equipment, and the bio-technical supportpersonnel who maintain and troubleshoot theequipment in the operating room.

Laparoscopy has been a gateway to improve theinfrastructure of tertiary and regional care centers.In a recent update from Erdenet, the improvedinfrastructure has allowed the hospital there toincrease the volume of surgeries performed and todo a larger variety of cases. Subsequently, theyreport that wait lists for surgery have droppeddramatically, and infection rates have improved. InKhovd and Choibalsan, the overall number ofcholecystectomies has been increasing as well asthe number performed laparoscopically. It is hard toimagine that the incidence of gallbladder disease isincreasing this dramatically. The increase in chole-cystectomy may reflect the improved infrastructurethat lends itself to increased capability. It may alsorepresent the increased skills of the surgeons andtheir willingness to perform the surgery.

Prior to our training courses in 2006, many of theMongolian people, especially those in the ruralareas, were very skeptical about laparoscopic sur-gery. Just as the support of the medical communityis necessary for a program of this type to thrive, thepublic must also be educated about the newtechnology and its benefits. A task of this magnitudewould not succeed in an environment where thecommunity was distrustful of the technology orapprehensive of its benefits. Therefore, a componentof this project included public education utilizingthe local media to dispel myths and to clarify thepurpose and intent of the mission. The rise ingallbladder surgery may also reflect the generalpopulation’s increasing acceptance of laparoscopy.The training has led to many patients commentingthat their trust in their surgeons has increaseddramatically, leading to their willingness to undergosurgery in these facilities. The surgeons in Erdenetexpressed that by educating the general populationon the benefits of laparoscopy, the public will beginto demand increased access to laparoscopy andinitiate lobbying efforts to increase funding from thegovernment to support and sustain this technology.

The ultimate goal of this program has been toprovide Mongolian surgeons with the tools and skillsnecessary to advance the medical and surgical care oftheir country. Professors from the university wererecruited to translate and assist in the training of theirrural colleagues. This was a vital component of the

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program as it helped foster a mentoring relationshipbetween academic and rural surgeons. The programwas designed to accommodate two visits to eachtraining site in consecutive years. Some of the courseparticipants had received laparoscopic training fromother visiting foreign medical teams prior to partici-pating in one of our courses. Moreover, manysurgeons sought additional training opportunitiesabroad after participation in this course. Laparoscopictraining in Mongolia has been an enabling process thathas provided the local surgeons with an improvedconfidence and self-satisfaction; they can now providemodern surgical care for their people similar to thecare available in other parts of the world.

A multidisciplinary team approach, includingrepresentatives from industry, is essential in creatinga sustainable and practical program. While equipmentcan be donated, it is critical to supply these nationswith technological back-up and training in mainte-nance of the equipment, so that they may evolve theirmedical centers at their own pace.14 In order to avoidthe so-called ‘‘brain drain,’’ it is important to trainsurgeons in their own environment, and the trainingmust be adapted to meet the needs of the population.15

While the medical infrastructure of most developingcountries is in need of improvement in several areas,this should not be viewed as a contraindication to theintroduction of new techniques. Laparoscopy shouldbe viewed as an extension of general surgery and not adifferent type of surgery.16

With the ubiquitous access to information avail-able on the Internet and other media sources, theglobal community is beginning to understandpossibilities for improving their access to qualitysurgical care and is demanding the benefits fromminimally invasive surgery. Overcoming barriers oflimited resources and human capital to developlaparoscopy can be achieved in communities wherethey feel the benefits are significant and they havethe motivation to maintain it. This education modelhas provided direct training to surgical teams in thecapital and the Regional Diagnostic Referral andTreatment Centers in Mongolia as requested by theMongolian surgical leaders; subsequently, this hasprovided improved access to modern surgical carein rural Mongolia. The focused training on laparo-scopic cholecystectomy in a country that has a highprevalence of the disease has allowed for adequatepractical experience during short-term trainingexpeditions. Team training, infrastructure develop-ment, integration of laparoscopic training withessential and emergency surgical care, and partner-ing with local laparoscopic leaders have been key to

the successful and sustained laparoscopic develop-ment in Mongolia.

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