Teaching surgery: Out of Africa, into the future

Ad Gandhe

Ad Gandhe is a Trauma & Orthopaedic Surgeon at Portsmouth Hospitals University Trust, UK, where he is also an Honorary Senior Lecturer. He is the faculty of various national and international educational groups, including the AO Foundation and AO UK&I. He is also an ambassador for The Primary Trauma Care Foundation. He invented Touch Surgery which is an award-winning app and hence founded the company, Digital Surgery Ltd. This pioneering technology led the way to remote surgical training. He is the CEO and founder of Amodisc Ltd, which develops innovating technologies to help individuals and institutions deliver accessible, high quality surgical and medical education across the world.

“If there is one thing COVID-19 has proven, it is the interconnectedness of different actors of society, the underlying resilience to disruption, the ability to transform challenge into opportunity, and agility to respond to crises adaptively.”

Kenichi Yokoyama, Director General, South Asia Department, Asian Development Bank

On the 26th April 2022, I found myself sitting on a hotel balcony in Kigali, Rwanda, contemplating the road ahead. All my passion and love for combining education with technology had led me to this moment. My goal to democratise medical education was within reach. Here was my opportunity to take it further and what a place to start: Africa, the continent where we all originated from.

So, what led to this point? The short answer is that my experience in building technological solutions for surgical education led me to founding a new company, Amodisc, with exactly that vision. My contacts with Operation Smile, notably Wg Cdr Ankur Pandya of Operation Smile UK, introduced me to the international Operation Smile Team in late 2019. They were keen to enter the Global Surgical Training Challenge competition with a multimodal and cost-effective solution that remotely teaches specialist skills to surgeons around the globe. The listed benefits of remote surgical teaching are long. They include, greater reach, reduced carbon-footprint and cost-effective training. This was made more acute by the COVID-19 pandemic. Our visions were aligned and so the Amodisc - Operation Smile collaboration began. An international team of clinical and technological experts from South Africa, Rwanda, USA, Bolivia, Malta and the UK, led by a US plastic surgical resident, Zach Collier, met every Thursday on Zoom.

Together we designed and developed a low cost simulation model made from local materials and an accompanying app which interactively teaches the skills required to perform surgical procedures. We deliberately chose procedures that are not widely available in subSaharan Africa owing to the paucity of available specialist training programmes.

Working with this team has been one of the most challenging and enjoyable experiences I have ever had. Every member brought solutions to the ‘virtual table’ with a strong desire to succeed at our project. The competition host, NESTA threw curve-balls at us left, right and centre, but nothing was too big a challenge. In fact it gave us an opportunity to make our product better. The remarkable thing is that, despite never meeting one another in person for 18 months, we still completed our prototype and made it to the competition final round. The next phase had begun.

Operating theatre in Kigali University Hospital (with some equipment donated by Operation Smile).

Making a prototype app and low-cost simulator is one thing, but designing it to work in an unfamiliar environment is a different matter. I had never been to sub-Saharan Africa before and had no idea what to expect. Would the trainees want to adopt it? Do they have the same technology and infrastructure as us? Will they feel patronised by us? These were all questions racing through my mind… as I sat there on the hotel balcony in Kigali.

Sourcing raw materials for the low-cost physical simulator in Kigali marketplace.

Zach soon joined me along with our team’s Rwandan plastic surgery representative, Arsen Muhumuza. Arsen dedicated a week towards hosting us along with his two compatriots: Benjamin Ngarambe (Operation Smile Country Coordinator) and Andrew Karima (Operation Smile Country Manager). We visited three main institutions and their chiefs: Professor Ntirenganya Faustin, Plastic Surgeon at University Teaching Hospital of Kigali, Professor Julien Gashegu, Professor of Anatomy, at University of Rwanda, Butare and Dr Gahima John, Director General of Kibungo Provincial Hospital. This was a good mix of city hospital, district general hospital, and university. Our intention was primarily to meet our collaborators in Rwanda, build trust and discover the differences between our countries so that we can design our platform more effectively. However, what struck me were the similarities we share despite the resource restrictions they have. The poverty is evident, but how they overcome these limitations was impressive.

Computers in theatre

There are no short cuts to providing healthcare. The WHO checklists, team briefs and preoperative meetings are conducted as per usual. The theatres have computers in them and everyone has a smartphone: essential components of today’s data-driven healthcare. No arm table attachments for the operating table? No problem. They just use the patient bedside tables as they are height-adjustable. Theatre discipline is paramount (something we could all learn from) and of course, the residents have a jolly good knees-up at their end of year presentations.

WHO checklist in theatre.

Where there are challenges, there are opportunities. As I walked into the Kibungo Hospital, I heard a ‘thud’ behind me. Somewhat startled, I asked what this package was that had dropped out of the sky. In Rwanda, not all the hospitals have blood banks. The solution is a centrally run system whereby the path-lab calls an operator, who promptly dispatches the type-matched blood to the requesting hospital by drone. Blood is delivered within five minutes of the request. I felt this was a good example of where the resources are tight, innovations overcome. In the West, we have traditionally invested in cumbersome and antiquated systems, making the change to new technologies difficult to justify financially. Conversely, in Rwanda, they are not bound by these investments. They can use new disruptive technologies to bypass such systems, providing more cost-effective and efficient solutions.

Zach, myself and the trainees outside the newly constructed Plastic Surgery Department at Kigali University Hospital.

There was a refreshing willingness to solve many of the issues caused by the restricted resources. Professor Faustin had a vision of expanding the reach of plastic surgical education between the Rwandan institutions, giving all residents access to learning specialist procedures and thus providing better quality surgery. He viewed our platform as a potential solution for this. Professor Gashegu explained to me that cadaver supplies are limited in Rwanda for social and cultural reasons.

Trainees constructing their low-cost simulator.

We explored building augmented reality and smart technologies to deliver detailed anatomical teaching to his students remotely. Dr Gahima John demonstrated how the resilience and flexibility they used to pivot resources in order to overcome the issues caused by the pandemic, can be used in the same way to rebuild better data connectivity between their institutions. Remote access could therefore still be achieved where the infrastructure is lacking. I have the deepest respect for these individuals who understand the future is best mapped out through collaborative working.

Blood products that have just been air-dropped by drone outside Kibungo Hospital.

AMOSMILE accompanying simulator app.

Having met such positive people, I left Rwanda, feeling more energised than ever. There is clearly a need to deliver surgical teaching more effectively. Access to this training is far from universal, but the need persists. Technology can break down financial and geographical barriers so that we can deliver it remotely. As surgeons, we are best suited to find the most innovative ways to deliver this training, albeit through videos, interactive animations, augmented reality or whatever technology delivers us. Through collaboration, we have the greatest chance of achieving this goal. The road ahead will have its challenges in delivering the training remotely, but with this genuine solidarity and willingness to succeed, I feel we are moving into a future of the greatest possibilities.