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S. Kamarajah, Omar Kouli, W. Ng, R. Pius, Catherine Shaw, A. Ademuyiwa, A. Adisa, A. E. Agbeko, Maria Lorena Aguielera, M. Alves, R. Atun, A. Aregawi, A. Bhangu, M. Cameron, N. Clark, Richard Crawford, A. C. Dawson, M. Elhadi, G. Gallo, Junyi Gao, D. Ghosh, Eilidh G M Gunn, P. Haque, A. Isik, Afra Jiwa, Stephen R. Knight, I. Lawani, S. Lawani, Janet Martin, John G. Meara, Ana Minaya Bravo, Dion G Morton, Faustin Ntirengaya, F. Pata, M. Picciochi, Raymond S Price, John Primrose, Nobhojit Roy, S. Tabiri, Chris Varghese, E. Griffiths, A. Ramos-De la Medina, D. Badran, D. Chaudhry, Alex Dermanis, R. Evans, Laura Kehoe, H. Spiers, Thomas W. Thorne, N. To, I. Dajti, Z. Djama, Nicolás Avellaneda, M. Palacios, Konigsrainer Ingmar, N. Bayramov, Ehsan Rahat, Dmitry M. Adamovich, Hasan Eker, C. Bokossa, Samir Delibegović, Felipe Coimbra, D. Dardanov, Adama Sanou, A. Sanou, J. Mbonicura, C. Nwegbu, Baohong Yang, J. A. Calvache, J. Mihanovic, N. Gouvas, B. East, S. Batista, N. Campuzano, E. Lincango, S. Emile, E. Reitano, N. Boumas, Z. Demetrashvili, C. Kamphues, Jane Acquaye, I. Katsaros, Georgios Tsoulfas, K. Futaba, A. Zaránd, P. Møller, J. Dhiman, A. Suroy, Christopher Ryalino, Hamed Tahmasebi, H. Ali, I. Stephens, G. Marom, D. Hashimoto, F. Ayasra, I. Fakhradiyev, I. Hisham, M. Alherz, Igors Ivanovs, A. Dulskas, Edoardo Rosso, I. Chik, I. Duran, Melissa Fragosso, L. Martinez, S. Erdene, Amina Houmada, P. Nashidengo, T. Schok, Michael Jen Jie Chu, Deborah Wright, T. Risteski, Silje Holte, Zainab Al-balushi, A. Qureshi, H. Abu-Arish, M. Cukier, Hugo Gomez, G. Mendiola, M. Sacdalan, W. Krawczyk, I. Negoi, A. Butyrskii, Alshahrani Mushabab, D. Radenkovic, S. Wijerathne, J. Košir, Abdisamed Ahmed, C. Kloppers, D. Wickramasinghe, H. Fadlalmola, M. Nikberg, Eleftherios Gialamas, Sara Maa Albared, Bernard Mbwele, Suphakarn Techapongsatorn, A. Hasnaoui, Isaac Mubezzi, S. Chooklin, Amal Suhool, N. Horesh, Osama Bahsas Zaky, T. Nguyen, M. Al-Shehari, A. Abbasov, A. Abd Elrahman, M. Abd-erRazik, M. Abdelkabir, S. Abdelmohsen, A. Abdelrahman, Ahmed Abdelsamad, Ahmed Abdelwahab, Aidil Faizul Abdul Rahim, Eman Abdulwahed, Abdussemee Abdurrazzaaq, Jose Modesto Iii Abellera, Yitagesu Aberra, G. Abouelnagah, Anwaar Abozid, H. Abozied, E. E. Abuobaida Banaga Hag El Tayeb, Luis Enrique Acosta Cumberbatch, Emmanuel Acquah, A. A. Adam, S. Adegbola, I. Adel, Safia Adem, Olalekan Adepoju, Ademola Adeyeye, P. Aeschbacher, Effa Afif Zain, P. Agbonrofo, M. K. Agrawal, H. Aguado López, José Aguilar, Irving Hugo Aguilar Preciado, F. Aguilar-Espinosa, A. A. H. Ahmad Zaidi, E. A. Ahmed, Z. Ahmed, Salma Ahmed, H. Ahmed, I. Ahmed, Mohey Aldien Ahmed Elamin Elnour, Amiin Ahmed Rashid, A. Aiolfi, Ayoub Akwaisah, S. Al Riyami, A. A. Al Sakini, H. Al-Aamri, M. Al-Dhaheri, A. Al-Fandi, M. Al-Juaifari, Abdullah Al-Mallah, B. Al-Sarireh, Yousef Alalawi, Mohammed N. Alali, S. Alananzeh, M. Albendary, M. Aleem, P. Alexander, Julio Cesar Alfaro Varela, Ahmed Alhamss, F. Alharmoodi, M. Alharthi, A. Alhello, Irfan Ali, Haithm Ali Alwah, O. Aliosin, A. Aljorfi, A. Alkaseek, Ali Alkhayat, K. Almeida, M. B. Almoshantaf, Abdullah Almunifi, Mohammed Alnasser, Mohammad Alnees, Othman Alrashidi, B. Alrayes, Lana Alsabe, H. Alsaleem, B. Alshaikh, Ahmed Albagir Ali Altayyeb, Fatemah Altheyab, Y. Altinel, A. Alvarez, E. D. Alvarez Sores, Ahmad Fais Mukriz Alwi, N. Alzerwi, Lavinia Amato, Marijus Ambrazevicius, F. Amico, M. Amisano, N. Amjad, Ahmed Siddique Ammar, G. Ammerata, E. Andolfi, J. Andreuccetti, V. Andriola, Roberta Angelico, Luca Ansaloni, Amato Antonio, S. Anwar, L. Anyanwu, Jeyakumar R. Apollos, C. Apostolou, Fabrizio Aquilino, Juan Carlos Arana Reyes, Ramesh Ardhanari, Muyiwa Aremu, I. Aremu, G. Argenio, R. Armah, L. Arnalsteen, A. P. Arnaud, Carlos Arroyo Basto, R. Arshad, P. Arya, Offei Asare, F. Ascari, Yavor Asenov Nikolov, Fariha Ashraf, Alan Askari, A. Asla, Theodoros Aslanidis, Sivananthan Asokumar, E. Asumanu, Deniz Atasoy, T. Athwal, A. Attri, Pasquale Avella, Octavio Avila Mercado, Selmy S Awad, P. Azevedo, Suleiman Baba, N. Bacalbasa, Roselyn Baculi, S. Badiani, G. Baiocchi, Emad Bajubair, E. Baker, Bahadir Emre Baki, A. Bakri, Sankar Balakrishnan, Z. Balciscueta, E. Baldini, A. Balduzzi, M. Ballabio, O. Balogun, P. Bangeas, O. Baraket, Manuel Baravalle, A. Barberis, M. D. Barcelona, G. Baronio, G. Bashir, S. Basso, Fizza Batool, A. Bawa, M. Bayrak, Iva Bačak Kocman, A. Bedzhanyan, H. Beji, A. Bekele, Philimon Bekele, Raluca Belchita, A. Belgaumkar, R. Belouz, Pablo Beltran Miranda, Anis Ben Dhaou, N. Ben Hasan, Mohamed Ben Khalifa, A. ben Safta, S. Bennett, A. Bensaad, N. Berevoescu, Alessandro Bergna, J. Beristain-Hernández, Judith Del Rosario Bermudez Ruiz, Aguilar Ayala Bernabé Esteban, Daniele Bernardi, Rania Berrami, C. Bertoglio, J. Betalleluz Pallardel, Binod Bhandari, Kaushik Bhattacharya, K. Bhatti, H. Bhatti, K. Bhutia, A. Bianco, M. Bickford, K. Bielka, Radosław Bilat, H. Bileid Bakeer, A. Biloslavo, Kristina Bitunjac, A. Bocchino, G. Bogani, M. Bogdan, B. Bogdanic, M. H. T. Bokhari, Dinimo Bolivar Saenz, R. Bollino, G. Bond-Smith, G. Borda-Luque, David W Borowski, L. Bortolasi, A. Bottari, K. Bouchagier, Sidi Mohammed Bouchentouf, M. Bouziane, A. Braat, Luke Bradshaw, Swagata Brahmachari, A. Brolese, F. Brucchi, M. Bubenova, A. Bufalari, V. Bui, J. Buitendag, Guney Cem Bulbuloglu, D. Bulian, M. Buna-Arvinte, Gissel Alejandra Burbano Andrade, K. Bwala, N. Börner, I. Cakcak, R. Callcut, Pablo Calvo Espino, Francesco Cammarata, Yanet Andrea Campero, G. Canonico, Alp Ömer Cantürk, E. Çapkınoğlu, G. Capolupo, Patrizia Capozzi, L. Carbone, Silvia Carbonell-Morote, Diana Catalina Cardona Gómez, F. Catena, M. Cazador Labat, C. Cecconi, G. Cestaro, S. Chakravartty, P. Chandrasinghe, Munish Chauhan, Lizeth Norka Chavez Quispe, P. Chavkin, T. Chawla, Elaine Y. Cheng, V. Cherchi, Y. Cheung, Theresa Chin, M. Chiozza, A. Choudhry, C. Chouliaras, T. Chow, Sharfuddin Chowdhury, Gregorios Christodoulidis, Prokopis Christodoulou, N. Christou, I. Chukwu, J. Chávez Pacheco, P. Cianci, N. Cillara, Matteo Cinquepalmi, B. Çitgez, G. Clarizia, M. Clementi, G. Cocorullo, Elif Colak, D. Coletta, Emily Colonna, J. Contreras, F. Cordera, Jose Costa-Maia, A. Costas-Chavarri, M. Creanga, Andy Cresswell, B. Cribb, C. Crétolle, Ciprian Cucoreanu, Marta Cueva, S. Cunningham, G. Curletti, Andrew Currie, F. D’acapito, S. D’ugo, K. Dajani, Jan Danko, Laith Daraghmeh, R S Date, Brian Davidson, S. Davison, S. Dbouk, B. De Andrés-Asenjo, Michele De Capua, R. De Carlis, Sofía de la Serna Esteban, P. De Nardi, B. de Simone, R. De Vincenti, Kristof Dede, Georgia Dedemadi, Giacomo Deiro, Celeste Del Basso, Daniele Del Fabbro, Spiros Delis, Semra Demirli Atıcı, Muhammed Taha Demirpolat, Busomoke Denys Fabrice, Kibruyisfa Desalegn, Parikshit Deshmukh, John Devar, Satish Dharap, Isidoro Di Carlo, Francesco Di Maggio, F. Di Marco, D. Di Mauro, Salomone Di Saverio, R. Diab, A. Diamantis, Aida Diaz, Josefina Dib Hasan, T. Dilevska, N. Dimitriou, Ana Dimova, S. Dindyal, Burak Dinçer, R. Donchev, Natalia Dowgiałło-gornowicz, M. Drogouti, D. Dugar, A. Duro, D. Duttaroy, E. Dyer, S. Däster, R. Díaz Pedrero, Joel Kumar Earjala, S. Efetov, S. Egreara, O. Ekwunife, Christopher Ekwunife, M. El Boghdady, Mohamed Amine El Ghali, E. El Helou, Hamida El Magrahi, Moahmed El-Kassas, Ahmed El-Sharkawy, P. Elbe, Peter Elemile, M. Elfiky, Hamed Elgendy, F. Elhajdawe, Saifaleslam Elsahli, A. Elsayed, M. Elsayed, R. Elsheikh, I. Eltilib, A. Emran
1 1. 2. 2026.

Safety and equity in scaling minimally invasive surgery worldwide in 109 countries using cholecystectomy as a tracer procedure: a prospective cohort study.

BACKGROUND Minimally invasive surgery is rapidly expanding globally, yet there is insufficient knowledge of how to scale this technology safely and equitably across diverse health systems. We aimed to identify health-system factors associated with safe implementation of minimally invasive surgery globally, using minimally invasive cholecystectomy as a tracer procedure. METHODS We conducted a multicentre, prospective cohort study of consecutive adults undergoing cholecystectomy between July 31 and Nov 19, 2023, in 1218 hospitals across 109 countries. Data were collected by more than 10 000 health-care workers using a core measurement set mapped to the WHO Health System Building Blocks and the Global Patient Safety Action Plan. The primary outcome was 30-day procedure-specific complications, with multilevel logistic regression used to examine associations between health-system features and patient outcomes. This study is registered on ClinicalTrials.gov (NCT06223061). FINDINGS Among 52 187 included patients, the adjusted procedure-specific complication rate varied 40-fold between hospitals, from 0·3% in the lowest risk quintile to 12·1% in the highest risk quintile. Despite large structural differences across income groups in access to minimally invasive surgery, diagnostics, and emergency services, country income level was not independently associated with complication rates (adjusted odds ratio [OR] 0·81 [95% CI 0·59-1·10] for upper-middle income vs high income and 0·99 [0·70-1·39] for lower-middle income or low income vs high income). Three modifiable hospital-level factors were strongly associated with safer outcomes: establishment of local simulation-based training facilities (adjusted OR 0·78 [0·71-0·86]; p<0·0001), adoption of intraoperative safety and communication strategies (0·87 [0·79-0·96]; p=0·0046), and on-site CT diagnostics (0·79 [0·65-0·97]; p=0·0220). Training facilities showed the greatest benefit in hospitals with limited infrastructure and an inexperienced workforce: the number needed to treat to prevent a procedure-specific complication was 21 (95% CI 14-35; p<0·0001). INTERPRETATION Safe implementation of minimally invasive surgery varies widely worldwide but is not defined by national income level; differences in outcomes reflect the ability of health systems to adopt and safely deploy new surgical techniques. We identified for the first time that the presence of local simulation-based training facilities is independently associated with improved patient outcomes. Simulation appears to be fundamental to the safe delivery of minimally invasive surgery, particularly in resource-constrained settings. Together with safety systems and diagnostic capacity, these findings offer actionable targets for health systems seeking to equitably scale up essential surgical technologies. FUNDING NIHR Global Health Research Unit and Wellcome Leap SAVE Programme.


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