Despite substantial challenges, laparoscopic surgery programs have been successfully implemented in many LRS through the use of creative and adaptive solutions. The literature highlights numerous innovative techniques that allow surgeons to perform laparoscopic procedures without relying on high-cost consumables such as energy devices or staplers [29,30,31]. Surgeons working in LRS have demonstrated remarkable ingenuity in overcoming barriers, often repurposing available technologies to meet their needs. Examples include rechargeable battery-powered LED light sources [32], mobile phones as improvised laparoscopic cameras [32, 33], and manual hand bellows to achieve air insufflation [34]. Particularly encouraging are the many descriptions of low-cost laparoscopic trainers [35, 36]. Below are some of the adaptations made by surgeons and institutions to incorporate laparoscopy into their LRS.

Adaptation in simulation equipment

Laparoscopic skills have a steep learning curve, and studies show that simulation significantly improves skill acquisition [37,38,39,40]. Simulators offer a safe, low-risk environment for practice. Beyond building technical skills, simulation also helps trainees develop familiarity with equipment handling, instrument maintenance, and troubleshooting, reducing misuse and prolonging the lifespan of essential laparoscopic tools [41]. However, many trainees in low-resource settings lack access due to the high cost of commercial simulators, which often range from $500 to $4,000 USD [16, 38, 42].

A basic laparoscopic trainer requires only a box, camera, light source, monitor, and instruments. In LRS, affordable self-made trainers using readily available materials and smartphone-assisted visualization offer a practical alternative to costly commercial systems, providing essential hands-on experience [43,44,45] (Fig. 1a, b). Obtaining laparoscopic instruments for simulation practice can be more challenging than acquiring simulation boxes, as there are few low-cost, homemade alternatives available. At minimum, trainers need a needle holder, Maryland grasper, and scissors. Instruments can be borrowed on nonsurgical days if resterilized, though this may reduce their lifespan. Expired equipment is also useful for training [46]. Donations, used instruments (often < $50 USD), and 3D printing, while of lower quality, offer cost-effective alternatives for simulation use [47]. In contrast, laparoscopic training models can be crafted from everyday materials like foam, rubber, and silicone, offering cost-effective, realistic simulations of human tissue [48, 49]. Examples include cutting shapes from foam or gauze, moving small objects between instruments, and suturing on foam or silicone pads (Fig. 2a, b) [50]. Use of animal tissue in trainers, with similar haptic feedback to human tissue, has also been described [51, 52].

Fig. 1

a The ALL-SAFE laparoscopic trainer. Source https://www.appropedia.org/w/index.php?curid=91761. Open Source Accessed 12 Sept 2024. b Hands-on optimum planner for surgical education (HOP Box). Photos courtesy of Dr. Maria Marcela Bailez. Source Bailez et al. [103]

Fig. 2

a Hands-on optimum planner for surgical education models of cholecystectomy, uterine teratoma, and low-cost FLS alternatives. Source (1) Falcioni et al. [104]. (2) www.glap.sages.org. b (i) Simulation box made from wood illuminated by natural light and visualization using phone or tablet. (ii) Suturing tasks made from dish sponge, velcro, and balloon or foam. (iii) Peg transfer task using styrofoam, cardboard, and plastic straw. (iv) Simulation box made from cardboard, supported by clips and wooden sticks, with visualization via phone or tablet. Courtesy of Dr. Maria Marcela Bailez

Much past literature confirms the effectiveness of low-cost laparoscopic trainers, showing they match commercial simulators while offering greater accessibility and more freedom in practice time, supporting equitable global surgical education [35, 39, 53,54,55]. An example of successful simulation-based education is the Center for Studies for the Prevention and Correction of Abdominal Diseases (CEPCEA) in Peru, which uses short, intensive training with low-cost, locally made models to build laparoscopic skills and instrument handling. Studies show it improves both cognitive and technical abilities, supporting its use as a model for LRS [56].

Adaptation in simulation-based training and telementoring

Beyond acquiring simulation materials, there is a growing push to implement simulation-based training and telementoring in low-resource settings. Telementoring and virtual simulation expand laparoscopic training access in LRS by overcoming distance barriers and conserving equipment. Trainees use improvised trainers and receive expert feedback via synchronous feedback or asynchronous video review, promoting consistent equipment use without constant access to costly labs. Real-time telementoring during surgeries enhances technical support and reduces equipment errors. Partnering with surgical societies can help strengthen training efforts and support the development of simulation training infrastructure [26, 57, 58]. Additionally, investigators can now leverage artificial intelligence for assessing performance on simulators [59].

For instance, the Global Laparoscopic Advancement Program (GLAP) of SAGES has utilized virtual simulation and telesimulation in its educational program in various LRS, including Costa Rica, Mexico, El Salvador, Namibia, Uganda, and Ethiopia, with significant improvement in participants’ Fundamentals of Laparoscopic Surgery (FLS) skills [58]. To support sustainable training networks, GLAP is integrated into national surgical societies and works closely with local stakeholders to embed its programs into existing health education systems, ensuring long-term adoption and scalability.

The Simnovate Global Health Domain found that brief, low-fidelity simulations can improve knowledge, skills, and protocol adherence, especially when tailored to local needs like obstetric or infectious emergencies, supporting efforts to scale virtual and telesimulation and integrate them into local health systems for lasting impact [41]. Similarly, the LAPP curriculum from Universidad Catolica de Chile offers structured, performance-based laparoscopic training with scalable simulations, remote asynchronous feedback, enabling repetitive practice outside the operating room [60]. This reduces strain on surgical equipment and has been successfully adapted in several LRS countries, including El Salvador, Mexico, Brazil, and Tanzania [61, 62].

Adaptations in procurement of laparoscopic equipment and instruments

Institutional support is key to successfully implementing laparoscopy, ensuring funding, space, and infrastructure. It enables equipment procurement, staff training, and maintenance, while aligning the program with clinical goals and long-term sustainability.

Many hospitals in LRS rely on donations due to the high cost of laparoscopic equipment [42, 63]. A carefully planned and implemented donation initiative remains a necessary part of the solution, as uncoordinated donations can result in incompatible or unusable tools. A well-planned strategy that follows ethical guidelines and fosters equitable partnerships is essential to ensure donated equipment meets local needs, functions properly, and adheres to both local and international medical donation guidelines and best practices [63, 64].

When donations are not feasible, innovative strategies are essential to maintain a reliable supply chain. Procurement should prioritize safe, low-cost alternatives and durable, reusable instruments to prevent service disruptions [8, 42]. Scheduling laparoscopic cases on designated days and partnering with local vendors on a fee-for-service basis can reduce costs and strengthen local supply chains [63]. Sharing resources across surgical subspecialties avoids redundant investments, while local innovations can replace costly devices without sacrificing quality [65, 66]. At the policy level, fostering collaboration between international and local stakeholders can promote affordable technologies, reduce dependency, and empower communities to build innovative, long-term solutions to support sustainable laparoscopic surgery programs [8, 67,68,69].

Increase sustainability of laparoscopic equipment

Sustainable laparoscopic programs require durable equipment, reliable supply chains, and environmental responsibility. Relying on donated or imported supplies risks service disruption. Regional procurement and local maintenance capacity ensure continuity, while reusable tools and efficient sterilization reduce costs and waste. Long-term planning must account for maintenance and consumables, supported by collaboration among industry, donors, investors, and governments to highlight laparoscopy’s lasting value [6, 8, 64].

Endoscopes

Rod-lens laparoscopes are commonly used in all settings and typically last 5–10 years, though donated scopes in low-resource settings often have shorter lifespans, especially 5 mm ones. Proper handling, regular inspection, and maintenance are key to extending their use. Assigning one or two trained scrub technicians to manage and sterilize equipment, rather than having all staff handle it, can significantly protect these delicate tools and is a critical step before launching a laparoscopy program.

Trocars and cannulas

In LRS, laparoscopic trocars and cannulas, often reused beyond their intended lifespan, are cleaned until they leak or break [42, 70]. To ensure proper cleaning and extend the longevity of trocars, many hospitals in LRS have established routine cleaning protocols [71]. Soft plastic or latex seals can be disinfected with solutions like Cidex (0.55% ortho-phthalaldehyde) and stored in climate-controlled areas to prolong use. Disposable plastic cannulas cannot be disassembled, so extra care is needed to clean internal valves gently. Cidex is effective for disinfecting various materials, including metal and plastic trocars and instruments [72].

Disposable plastic trocars have valves that accommodate various instrument sizes without air leakage. In contrast, metal cannulas use size-specific valves and require a trocar reducer (Fig. 3) to pass smaller (e.g., 5 mm) instruments through larger (e.g., 10 mm) cannulas, an essential tool when using metal trocar sets. The latex/plastic seals of 10 mm metal trocars often degrade with repeated needle passage during suturing. To prevent damage, the seal is temporarily removed before inserting the needle, then replaced prior to reinsert the instrument or camera.

Fig. 3

A trocar reducer (black arrow) allows insertion of a 5 mm instrument through a single-valved 10 mm port (red arrow) (Color figure online)

Laparoscopic instruments

Laparoscopic instruments are more delicate than those used in open surgery and require careful handling to avoid bending or damaging insulation on electrosurgical tools. Details are covered in the “Sterilization Processes” section. To keep instruments organized and prevent drops, sterilized cloth “pockets” can be attached to surgical drapes (Fig. 4), using materials like Mayo tray covers or sewn-together drape cloth. These pockets keep tools within reach, improving efficiency and protecting instrument integrity.

Fig. 4

A reusable cloth pocket, held in place by towel clamps, holding a diathermy pencil. Photo courtesy of Dr. Joseph Okello Damoi

Light source and cables

In LRS, halogen and xenon bulbs (globes) remain common due to donations, while LED systems are standard in high-resource environments. Halogen bulbs last around 2000 h, so having a backup is essential [73]. If using an internal spare bulb, order a replacement immediately after the first bulb expires. Additionally, thick window curtains may be needed to avoid unwanted light entering the operating room, making visualization more difficult overall.

Light sources generate significant heat, even with filters [73, 74]. To prevent burns, never place the fiber-optic cable tip on drapes or skin, especially at the end of surgery when the cable is hottest (Fig. 5). In high-resource settings, liquid gel cables have replaced fiber-optic ones due to their durability. In LRS, where fiber-optic cables are still common, careful handling is critical to avoid damage and preserve illumination. Twisting, kinking, especially near the scope, stretching, or squeezing the cable are avoided. Do not wind it tighter than 18 cm in diameter. The cable is always disconnected immediately after the procedure and allowed to cool before storing. The connector is handled only when attaching or removing it to prevent strain. Never pull the cable directly,  pull on the connector ends instead. Avoid using towel clips to secure it, as they can puncture the insulation. The outer surface is cleaned gently with a mild disinfectant and checked for dark spots at the illuminated end to detect internal damage [73]. Careful handling and maintenance can significantly extend the cable’s lifespan and performance.

Fig. 5

This patient sustained a burn on her lower abdomen during laparoscopy, most likely from the hot metallic end of the light cable

Cameras, control units, and video monitors

Regardless of the type of camera available, it must be introduced into the sterile field to be used in laparoscopic surgery. A disposable resterilizable cloth cover may be fashioned, (Fig. 6) or disposable plastic covers may be used [42]. An inadvisable approach is wiping the camera with alcohol or another cleaning solution; this is unsafe as it both jeopardizes the integrity of the nonwatertight camera and fails to provide sufficient sterilization.

Fig. 6

A piece of cloth sewn into a tube, with drawstrings at each end, can be sterilized and used as a camera cover as shown here. This same approach can be used for corded electric drills for orthopedic applications

The control unit processes the camera’s video signal and transmits it to the monitor via a rear cable. While some systems combine the light source and image processor, these are typically separate units [49]. The monitor usually sits on top of the laparoscopic trolley and is the most vulnerable component to damage when in transit. In LRS, the monitor can be replaced with alternatives like computer or television screens, but ensure the camera output (S-Video, VGA, HDMI) matches the monitor input [70].

Adaptations in insufflator options

Laparoscopic surgery traditionally relies on CO₂-induced pneumoperitoneum to create a clear operative field [75]. In LRS, limited biomedical support requires surgeons to be adept at troubleshooting and repairing donated insufflators to avoid patient harm. Although CO₂ tanks are designed with unique valves, international standards are inconsistent. For example, Kenya uses a CO₂ valve that is identical to U.S. oxygen tanks, posing safety risks (Fig. 7). When using imported equipment, hospital staff must remain vigilant and adopt systematic protocols for handling medical gases. This underscores the critical need for reliable biomedical technical support [76].

Fig. 7

A CO2 tank in Kenya: the adapter is of the type that would be used for oxygen in the United States of America

Unreliable gas access can cause service disruptions and higher conversion to open rates. Furthermore, CO₂ ins