Minimally Invasive Surgery and Inequalities in Access to Care

Abstract

Minimally invasive surgery (MIS), including robotic and laparoscopic surgery, is a groundbreaking approach that has revolutionized surgical procedures. It confers an extensive list of benefits for patients, including but not limited to improved overall patient outcomes and reduced overall costs. Despite these and other well-documented advantages of MIS, there continues to be disparate access to these types of procedures locally and globally, and invariably, disparate health outcomes for distinct patient populations. This chapter thoroughly examines the advantages of minimally invasive surgery (MIS), the existing disparities in access, and proposes strategies to address and reduce these barriers, with a focus on the populations most affected by these disparities. It offers a comprehensive overview of the benefits of MIS, the challenges in accessing it, and provides solutions to promote equity in healthcare.

1. Introduction

The benefits of minimally invasive surgery have been documented for many years. It has profoundly changed the standard of care for a myriad of surgical pathologies while significantly reducing perioperative morbidity. These benefits include fewer complications, shorter hospital length of stays, less narcotic pain medication use, overall reduced costs, improved cosmesis, and faster recovery times. Robotic surgery, in particular, has become increasingly popular in the twenty-first century with the added benefits of improved range of motion, ease of intracorporeal suturing, enhanced surgical ambidexterity, improved safety, and decreased operator workload [1, 2]. Robotic-assisted surgery has infiltrated specialties spanning general surgery, colorectal, gynecology, thoracic, and urologic procedures.

Despite the steadily growing use and added benefits, significant disparities in access to these modalities remain [3]. The disparities in choice of surgical access exist based on several patient-related factors such as ethnicity or insurance status, among others as well as patient-independent factors, including but not limited to the treating hospital, surgeon experience, and geographical residential area. Understanding the factors contributing to inequitable access is paramount for the continued widespread implementation of MIS and open access to all patient populations.

In writing this chapter, we conducted an extensive literature review to examine the multifaceted challenges in accessing minimally invasive surgery (MIS). This methodical approach allowed for identifying and synthesizing key barriers—ranging from socioeconomic factors to geographic disparities—that hinder equitable access to minimally invasive surgery.

2. Health equity impact

2.1 Access to care

Access to healthcare significantly influences health equity, with disparities in the availability of minimally invasive procedures (MIS) leading to unequal health outcomes. As many minimally invasive surgical approaches have become the standard of care, the lack of equitable access to these techniques exacerbates health disparities. MIS is associated with benefits such as shorter healing times, reduced hospital stays, lower requirements for pain medication, and quicker recovery periods. These advantages hold particular importance for individuals in certain socioeconomic groups, especially those who face economic pressures to return to work quickly. The transition of minimally invasive procedures to the standard of care underlines their effectiveness and the demand for these treatments. However, when access is uneven across different populations, it directly contributes to health inequities. Individuals unable to access MIS may undergo more traditional and invasive surgeries, facing longer recovery times and higher risks of complications. This not only affects their immediate health outcomes but also has broader socioeconomic implications. For example, prolonged recovery can lead to extended work absences, financial instability, and increased stress, disproportionately impacting lower-income individuals who may already be more vulnerable due to preexisting disparities. The significance of MIS in ensuring a quicker return to daily activities and work underscores the need for policies and practices that promote equitable access to these procedures. Addressing the barriers to MIS can help bridge the gap in health outcomes, contributing to broader health equity. Efforts to enhance access include expanding insurance coverage for MIS, investing in healthcare infrastructure in underserved areas, and increasing awareness among healthcare providers and patients about the benefits of minimally invasive techniques.

2.2 Impact of education on diverse learners

Educating a diverse group of learners yields significant advantages not only for the individuals involved but also for the broader community. Research indicates that when there is a correlation between the cultural or ethnic backgrounds of patients and healthcare providers, there are improved health outcomes and higher rates of preventive care [4, 5]. This phenomenon may be attributed to better communication, increased trust, and a deeper understanding of the patient’s cultural and social context, which enhances the quality of care. Furthermore, educating diverse healthcare learners has profound implications for community impact. Studies have demonstrated that healthcare professionals from diverse backgrounds are more inclined to serve in communities with underrepresented minorities and individuals who are uninsured or insured by government programs [6, 7]. This trend is crucial for addressing healthcare disparities and ensuring vulnerable populations have access to quality medical care. The presence of diverse healthcare providers in these communities improves access to culturally competent care and helps build trust between healthcare systems and the communities they serve. This trust is essential for effective patient engagement and encouraging individuals to seek care and follow through with recommended treatments.

2.3 Community impact

The direct linkage between the improved health of the community and its downstream impacts, such as increased productivity and enhanced financial wealth, underscores the multifaceted benefits of advancements in healthcare. The introduction of minimally invasive surgery and improved access to care is a prime example of such advancements. These developments profoundly impact the overall viability of the communities they serve, further emphasizing the importance of health as a cornerstone for community development.

Minimally invasive surgery is characterized by smaller incisions, less pain, and quicker recovery times than traditional open surgery. This innovative approach not only enhances the patient’s overall experience and outcome but also substantially decreases the recovery time. As a result, individuals can return to their daily activities and work much sooner, thereby reducing the loss of productivity associated with prolonged illness or recovery periods. The quick return to work contributes positively to the community’s economy by ensuring a more consistent and efficient workforce.

Furthermore, improved access to surgical care, including minimally invasive procedures, plays a crucial role in addressing health disparities and ensuring that all community members can benefit from advanced medical treatments. By making such care more accessible, communities can effectively prevent the escalation of treatable conditions into chronic illnesses that require long-term management and substantial healthcare resources. This not only improves the quality of life for individuals but also reduces the overall healthcare costs borne by the community. Lower healthcare expenses mean more resources can be allocated to other essential services and investments, bolstering the community’s economic health and resilience.

The introduction of minimally invasive surgery and enhanced access to surgical care also illustrates how medical innovations contribute to public health and, by extension, to socioeconomic development. As communities become healthier, they experience a ripple effect of benefits, including higher productivity rates, increased financial wealth, and improved social well-being. This creates a more vibrant and sustainable community capable of attracting and retaining talent, encouraging investment, and fostering innovation.

Advancements in healthcare, exemplified by minimally invasive surgery and improved surgical care access, are crucial drivers of community viability. They not only enhance the health outcomes of individuals but also contribute significantly to the economic vitality and overall well-being of the communities they serve. This synergy between health and economic development highlights the importance of continued investment in healthcare innovations and accessibility as a strategy for community empowerment and prosperity.

3. Inequalities in access to minimally invasive surgical care

Multiple factors contribute to the challenges in accessing minimally invasive care. These barriers can include, but are not limited to, socioeconomic constraints, limited availability of specialized healthcare providers, geographical limitations, lack of awareness among patients about minimally invasive options, and potentially inadequate insurance coverage. Each of these elements plays a significant role in determining whether individuals can access the benefits of minimally invasive care. They also involve obstacles that necessitate tailored solutions and interventions for effective resolution and enhanced patient outcomes (Table 1).

Inequalities in access to minimally invasive surgical care	Impacted patient population(s)	Barriers	Solutions
Geographic inequities	Rural communities Low- or Middle-income countries	Difficulty attracting subspecialists; Decreased access to advanced training; Socioeconomic limitations/Inability to allocate sufficient healthcare budget; Capital costs and equipment maintenance; Unconscious bias; Limited access to resources and advanced technology; Patient volume to maintain surgical skill level; Willingness of healthcare leadership to implement	Training and expertise acquisition; Attracting specialists; Unconscious bias training; Cultural competency training; Resource acquisition; Advocacy/Policy Effective Leadership; Surgical mentoring Research Innovation to overcome training limitations Common interest groups
Socioeconomic disparities	Lower socioeconomic status patients	Difficulty attracting subspecialists; Socioeconomic limitations/Inability to allocate sufficient healthcare budget; Unconscious Bias Limited access to resources and advanced technology; Capital costs and equipment maintenance	Training and expertise acquisition; Attracting specialists; Unconscious bias training Resource acquisition; Advocacy/Policy Effective leadership Research Common interest groups
Insurance access	Lower socioeconomic status population Under/uninsured patients	Difficulty attracting subspecialists; Unconscious bias	Attracting specialists; Resource acquisition; Advocacy/Policy Effective leadership Research
Racial/Ethnic disparities	Underrepresented ethnic communities/patients	Difficulty attracting subspecialists; Decreased access to advanced training; Unconscious bias; Limited access to resources and advanced technology	Training and expertise acquisition; Attracting specialists; Unconscious bias training; Cultural competency training; Resource acquisition; Advocacy/Policy Effective leadership Surgical mentoring; Research Common interest groups
Age Disparities	Elderly	Unconscious bias	Training and expertise acquisition; Attracting specialists; Unconscious bias training; Cultural competency training; Advocacy/Policy; Effective Leadership Research Common Interest Groups

Table 1.

Inequalities, barriers, and solutions in minimally invasive surgical care.

3.1 Geographic inequities

Geographic inequities in access to minimally invasive surgery (MIS) have significant implications for patient care. These include disparities in global access to MIS and rural vs. urban access inequities. A national analysis over 20 years in Switzerland found that rural residents were statistically noted to have decreased access to MIS. Rural geographical residence also correlated with lower socioeconomic status, which was also associated with reduced access to MIS [8]. These results have also been demonstrated in US studies, which show that rural residence is associated with a decreased likelihood of robotic surgery [9].

3.2 Socioeconomic disparities

Lower-income and minority communities face significant barriers in accessing advanced medical technology, which may lead to a higher risk of complications, including poorer clinical outcomes, more frequent readmissions, and an increased likelihood of needing reoperations. A study of the New York Statewide Planning and Research Cooperative System database, focusing on adult patients who underwent primary open, laparoscopic, and robotic hernia repairs between 2010 and 2016, shed light on these disparities. The findings revealed that factors, such as male gender, older age, non-Hispanic ethnicity, commercial insurance, and the ability to access academic medical facilities, were significantly linked to the likelihood of undergoing robotic surgery for hernia repair [6]. Furthermore, financial status played a crucial role, with every $10,000 increase in income increasing the chances of receiving robotic hernia repair by 6% [10].

3.3 Insurance access disparities

Multiple studies have demonstrated a decreased likelihood of robotic surgery for publicly insured or uninsured patients. Price et al. demonstrated that Medicaid enrollment was associated with decreased odds of robotic hysterectomy [11]. Additional studies have shown that private insurance status is associated with an increased positive predictor of robotic use [9, 12].

3.4 Racial/ethnic disparities

Systemic and structural racism significantly impacts access to healthcare, including access to minimally invasive procedures. Bodurtha Smith et al. demonstrate in their cross-sectional study of more than 725,000 women who underwent hysterectomies that the African-American race was associated with a decreased likelihood of robotic surgery [10]. Additionally, further research has demonstrated that African-American women have nearly half the odds of receiving a robotic hysterectomy and have decreased odds of robotic colorectal surgery [11, 13].

3.5 Age disparities

Although some studies have shown enhanced access to minimally invasive surgery (MIS) for elderly patients, numerous others indicate a reduction in access [9, 12, 13]. This discrepancy is of particular concern, given that the inherent frailty associated with aging can lead to poorer health outcomes. Consequently, the benefits of MIS, including better health outcomes and quicker recovery times, are especially crucial for this demographic. Addressing access disparities is essential in this patient population to ensure that elderly patients can fully benefit from the advantages of MIS.

4. Barriers to access

Multiple factors contribute to the challenges faced in accessing minimally invasive care. These include difficulty attracting trained specialists, lack of a diverse trained workforce, socioeconomic factors, high capital and start-up costs, and lack of supportive health system leadership.

4.1 Difficulty attracting subspecialists

Rural institutions and those in LMICs may find it challenging to attract MIS surgeons due to combinations of their small population size or limited healthcare budgets [14]. This is compounded by the reality that subspecialty-trained surgeons may not wish to work in settings where they may de-skill due to low case volumes and those in which remuneration is not commensurate with that in high-income institutions and nations [15]. The reality, then, is that there will be fewer resident laparoscopic surgeons in these institutions and similarly in LMICs.

4.2 Access to advanced training

Access to surgical training is essential to maintaining an appropriate cadre of surgical specialists. However, particularly in LMICs, there are disproportionate numbers of training opportunities at the undergraduate level [16]. In these cases, many doctors with a primary medical degree and an interest in surgery would seek licensure as International Medical Graduates (IMGs) to pursue surgical training in HICs [16, 17]. This creates two immediate problems. First, many of the skills learned, and tools used are not transferrable to the healthcare environment in LMICs. Secondly, many IMGs are lured to high-income countries by greater remuneration and quality of life [14]. The result is that only a fraction of IMGs repatriate to the LMICs of their origin [18]. This outward migration from LMICs to HICs is so well-documented that it has been named the “brain drain” [14, 15, 16, 17, 18, 19]. Reports show that 70–90% of medical graduates migrate to North America from regions, such as the Caribbean [18, 19]. This phenomenon makes it difficult to retain quality staff with MIS expertise in LMICs.

To curb this practice, many LMICs have started their own tertiary training programs in surgery. While this is commendable, many of these programs cannot attract the necessary funding, quality instructors, and modern equipment to provide an immersive MIS experience [15].

Therefore, most LMIC postgraduate universities provide general surgery training, focusing on open surgical experience [19, 20].

4.3 Socioeconomic factors

Many rural areas and LMICs have accrued sufficient debt that they can only allocate a small fraction of their GDP toward healthcare budgets [19, 21]. As recently as 2023, the Pan American Health Organization (PAHO) reported that public health expenditure for the Latin America and Caribbean region amounted to only 4% of the average GDP for the region [21]. This is also true for larger countries where most of the healthcare budget is disproportionately allocated to the larger hospital institutions, typically in metropolitan areas. Rural and smaller hospitals are often forced to contend with smaller budgets.

When one understands that this limited budget has to be further divided to satisfy other healthcare needs (consumables, pharmaceuticals, salaries—only to name a few), then it is clear that there will be limited funding for laparoscopic or robotic equipment and consumables. This paucity of funding for MIS has been well-documented by several authors in the literature [15, 22, 23, 24, 25, 26]. In one publication, it was stated that many patients in these healthcare systems “underwent open operations” [because their surgeons were] “under pressure to conserve resources” [15].

4.4 Access to resources and advanced technology

With limited healthcare budgets, smaller rural institutions locally and institutions in LMICs would find it difficult to procure advanced technology. Consider that in larger institutions, particularly in high-income nations, surgical circles no longer entertain the “laparoscopy versus open surgery” debate but have now moved toward debating conventional MIS vs. robotics [27]. However, with the exorbitant cost of surgical robots, smaller rural institutions locally and LMICs would not be able to procure surgical robots. Up to the year 2024, there were no surgical robots in any LMIC in the Caribbean region [15], and this is similar in other LMIC regions. Some authors commented that surgeons in LMICs still seem to be discussing the value of MIS over open surgery despite the rest of the world having moved on to robotics [28].

Conventional MIS would be more affordable for small rural institutions locally and LMICs with limited healthcare budgets. However, even conventional MIS has high start-up costs [20]. Consequently, many institutions still do not have the hardware to support conventional MIS.

4.5 Capital costs and equipment maintenance

Capital costs and equipment maintenance fees are significant obstacles to MIS, particularly because of the associated high costs associated with hardware acquisition, equipment maintenance, and procurement of consumables [14, 28, 29]. However, with fewer hospitals having MIS equipment in lower-resourced areas, there is a paucity of distributors to offer support and maintenance services. It is simply not a service that is prioritized. Perry et al. [28] reported that 40–60% of hospital medical equipment in developing countries “was out of service.”

4.6 Patient volume

Another limitation is geographical areas that have small populations [14]. This means there will be small annual case volumes to maintain subspecialists’ skill sets. While a possible compromise would be to set up centralized centers of excellence in these regions, this is rarely achieved [30]. In some regions, inter-regional and intergovernmental cooperation is required, which has proven difficult to realize.

4.7 Surgical leadership

It is well-documented that Prof Eric Muhe was victimized by the German Surgical Society when he first described laparoscopic surgery [31]. Although that was a clear failure of leadership, in the long run, MIS did progress. Unfortunately, similar lapses in leadership have been repeatedly documented, thereby limiting MIS development even in the twenty-first century [15, 24, 32, 33].

Consider the fact that MIS is a relatively new approach. This means that leaders chosen based on “seniority” would most likely have no MIS training but would still be required to encourage surgeons to perform MIS to advance the healthcare system. It takes little imagination to see the conflict of interest. Two authors wrote insightful pieces: “Instead of uniting those they lead, they may use administrative powers to erect barriers and marginalize younger surgeons, fueling their outward migration from the healthcare systems” [34, 35].

5. Strategies to mitigate inequalities in access

It is critical to adopt a multifaceted strategy to effectively address the issue of limited access to minimally invasive surgery (MIS). This approach will streamline processes and ensure sustainable, impactful solutions through efficient implementation.

5.1 Training and expertise acquisition

A significant obstacle to retaining experts after training is the “brain drain” phenomenon. One way to retain MIS surgeons is to improve the existing specialist training programs within LMICs. We previously pointed out that many existing medical universities had limited exposure to MIS because (1) it was not included in the curriculum, (2) they did not have knowledgeable trainers, (3) appropriate hardware/equipment was unavailable, and (4) there was a paucity of funding [15]. Each of these limitations could be individually addressed.

Once surgical leaders recognize that it is essential to facilitate training in MIS; they can advocate for its inclusion into teaching curricula. Many existing professional societies have existing training models. They may also be willing to collaborate with universities in LMICs, including the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in North America, Caribbean Society of Endoscopic Surgeons (CaSES) in the Caribbean, Indian Association of Gastrointestinal Endosurgeons (IAGES) in India, Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) in Britain and Ireland, among others.

5.2 Attracting specialists

Researchers within LMIC healthcare systems have reported that operating room medical staff cite workplace dissatisfaction and insufficient work-related rewards as the main reasons for outward migration [15]. Surgical staff also noted that a source of workplace dissatisfaction was working in systems with outdated equipment, lack of collegial support, financial challenges, and unavailability of hardware and consumables [19, 20, 23].

To achieve workplace satisfaction, we must strive to eliminate hostile environments, poor communication, and interpersonal conflict [15, 32, 36, 37, 38]. Instead, we should nurture a culture of freedom of expression and avoid discrimination [15, 32, 33, 34].

Herzberg et al. [38] suggested that motivation in the workplace required reward recognition and achievement/self-actualization. While small rural institutions locally and institutions in LMICs may not be able to compete financially with high-income employers, similar results may be achieved with managerial praise or award ceremonies as nonmonetary staff motivators. Of course, MIS surgeons must be given the means to work, and employers should facilitate this as much as possible.

5.3 Resources

It is accepted that MIS brings significant cost benefits to the healthcare system in the long term despite high up-front costs [24, 39]. Despite this, there may simply be insufficient funding in some institutions to allow the acquisition of hardware and consumables. Therefore, surgeons in these institutions may need to take innovative approaches.

An interesting approach was reported from Jamaica [24]. The surgeons in a small community hospital collaborated with supply companies that funded trainers, donated consumables, provided equipment on consignment, and provided loaner hardware to allow their MIS service to start in a public government-funded facility. Once their program was demonstrated to be feasible, it was heavily advertised in the community. With the support of potential voters, it was easier to get funding and continued support from health administrators [24].

In another model, a government-funded public hospital possessed donated MIS hardware but had insufficient funding to maintain a supply of consumables. In this model, the surgeons offered MIS operations as long as patients independently procured any necessary consumables [23, 33].

In other models from Trinidad and Tobago, surgeons created active partnerships with colleagues in high-income countries through interpersonal relationships. These partnerships commenced to seek advice, graduating to collaboration through research and culminating in links to receive retired or decommissioned equipment [15, 35, 40].

Another model in many LMICs with government-funded public hospitals is the evolution of parallel systems with private facilities using the fee-for-service healthcare delivery model. There are societal benefits in this approach as it increases the range of available services in the nation, but it may also create disparities and inequities in healthcare access and services [41].

Finally, as surgical consumables become more commonly utilized, there is an increased demand for items such as surgical staplers, and ultrasonic dissectors. The cost of these consumables may exceed the facility’s budget. Therefore, MIS surgeons may have to adapt by suturing instead of stapling, using cautery instead of ultrasonic dissectors, or reusing single-use instruments after re-sterilization [29].

5.4 Advocacy/policy

We must recognize that hospital administrators answer to governments, who, in turn, answer to the population. In one model published by Wilson et al. [24], they empowered the general population through free educational campaigns on the benefits of MIS. The educated general population then began to demand this service from their local government representatives, who then acquired hardware to answer the demands. This can be a very powerful tool when harnessed skillfully.

5.5 Effective leadership

Healthcare managers have the task of using institutional resources to promote population health. It requires training in healthcare leadership and management. These managers should be chosen based on managerial training, not seniority, political bias, or age.

It should be mandatory for the next generation of surgical leaders to have formal managerial training, and perhaps, regional universities should integrate management courses for future generations. Not only should leaders be trained, but they also should be required to undergo continued training, regular performance evaluations, and enforcement of accountability for persons in formal leadership roles.

An essential quality of a good leader is that they must be able to influence their staff through force of character (charisma power) [15, 42]. Leaders can only achieve this with maturity and mastery of interpersonal interaction skills. When leaders attempt to use punitive power (influencing actions through threat of punishment), it does not create the desired effect [43].

A surgical leader must accept that they will become outdated far more rapidly than their predecessors or contemporaries in other fields [32]. The MIS surgeons who trained in the early twenty-first century, for example, would have already lost ground unless they continued to learn advanced techniques such as SILS, NOTES, and robotics. On top of that, they may be required to support their juniors who, in a short time, may be able to do things that even the young leader cannot do [32]. This is a serious challenge to the psyche of even the most mature surgical leader. Therefore, humility and maturity are indispensable qualities of modern surgical leaders [34, 35], very different from the philosophies of earlier generations.

5.6 Surgical mentoring

Mentoring refers to the professional relationship in which one experienced surgical mentor facilitates a surgeon at an earlier stage in their career or skillset development in the operating room. In a recent survey from LMICs, a lack of effective mentorship was shown to be a significant source of workplace dissatisfaction [44]. This is also important in the development of MIS in LMICs.

Administrators should ensure that formal mentorship programs are created in their institutions. Informal mentorship, where one seeks out mentors [45], should also be encouraged. Effective mentorship programs have been shown to facilitate the transfer of knowledge, honing of skills, and improvement in workplace satisfaction [46, 47, 48].

It is essential to choose well-trained mentors with patience, professional integrity, and emotional intelligence [43, 44, 45]. It is also important to recognize that there may be local talent to harness as mentors. Surgeons already working in under-resourced settings may be good mentors because they understand the local culture and challenges and would have already found ways to overcome existing barriers to MIS in the healthcare systems [15].

5.7 Research

We have already established that the healthcare environment in small rural institutions and LMICs differs from that in larger institutions and high-income countries. Therefore, the MIS surgeon must understand the pitfalls in their environment to devise solutions to maintain quality service in the local healthcare environment [49]. Continuous monitoring of outcome parameters is essential to substantiated quality control [50].

5.8 Innovative methods to overcome training limitations

Simulation training is an attractive training tool because it immerses trainees in an environment to replicate real-life scenarios and does not expose patients to potential harm [51]. Because simulators are always available for use and can be used repeatedly, MIS surgeons in training can perform tasks repeatedly, mitigating the problem of low case volumes [52].

Although virtual reality and robotic simulators provide realistic experiences, they are expensive and impractical for resource-poor nations. Low-fidelity box trainers are more practical for LMICs. Although they are partial task trainers that only allow simple repetitive tasks, they are portable, cheap, and easily available. Some authors have even reported on homemade box trainers from inexpensive materials [53, 54]. There is published data proving that simulation trainers improve performance metrics when trainees transition to the operating room [55, 56, 57].

Simulators have been criticized because tissue handling is unrealistic, and anatomic relationships are not typical. Canine or porcine live models overcome these limitations, but many countries have existing laws against their use as surgical training models [58, 59]. In countries that allow live animal models, their use is effective and brings high trainee satisfaction levels [60, 61]. Cadaver training models have also been shown to be effective [62, 63, 64, 65], but cadavers can be difficult to procure and store.

Distance mentoring is an innovative teaching technique that has been described to encourage MIS in LMICs [66]. In this model, a surgical mentor coaches a colleague in MIS procedures without physically being present in the operating room using readily available equipment. In summary, the mentor views the operating surgeon performing an operation using two devices to view the operative field and laparoscopic feed by live stream. They have shown that the technique could be used with 96% success and good outcomes in emergencies [67], hepatectomies [68, 69], and colectomies [70].

5.9 Common interest groups

We believe it is important to identify common interest groups who share an interest in MIS and the unified desire to promote it in underserved areas [15]. By facilitating regional and international partnerships, these groups can assist with mentorship, support, and engaging members in the region who also operate in challenging environments.

Another benefit of collaboration is to organize workshops [14, 15, 71, 72, 73]. In a model from Guyana, experts were invited to perform local workshops rather than exporting patients in need. This way, the entire healthcare system improved their skill sets as a long-term investment. We have found that the industry is keen to support this, and they have actively organized and funded training workshops [71, 72, 73]. These workshops are invaluable to mentor entire surgical teams to develop MIS in their environments.

The advantage of this exercise is that a large audience can be reached in target hospitals. Therefore, the entire cadre of healthcare workers, including operating room nurses, surgical scrub technicians, surgeons, and support staff, are exposed to surgical teaching, which results in improving the standard of care for workshop-hosting nations.

6. Conclusion

The introduction and temporal implementation of minimally invasive surgery have shown tremendous benefits. Most importantly, increased access to minimally invasive surgery is associated with significant perioperative and outcome benefits. Lack of access to advanced care is associated with significant detriments in patient outcomes and also community impact. Additional implications regarding the education of a diverse workforce include that the education of a diverse workforce is crucial in achieving optimal patient outcomes. Therefore, this workforce must be afforded the opportunities to be educated in advanced surgical techniques, such as minimally invasive surgery. Access to these benefits by marginalized patient populations locally and in LMICs is imperative to reduce inequities and provide the highest quality of care.

Disclosures

Dr. Shaneeta Johnson is a consultant and proctor for Intuitive Surgical. Dr. Larry Hobson is a proctor for Intuitive Surgical.