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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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Low-Cost Box Trainer Guides Learners in LMICs and Students Closer to Home

Serena S. Bidwell, MPH, Ahmad Hider, MPhil, Chioma Anidi, and Grace J. Kim, MD, FACS

Serena S. Bidwell, MPH, Ahmad Hider, MPhil, Chioma Anidi, and Grace J. Kim, MD, FACS

March 6, 2024


The ALL-SAFE box trainer was available at a laparoscopic training course for surgeons in Nigeria.

In an effort to increase educational opportunities for surgeons to learn laparoscopic techniques in low- and middle-income countries (LMICs), ALL-SAFE (African Laparoscopic Learners—Safe Advancement for Ectopic Pregnancy) was created by a global collaboration of surgeons, researchers, and technical developers.1,2

ALL-SAFE is an educational platform that includes both cognitive and psychomotor components to guide learners through surgical case scenarios and develop laparoscopic skills on a low-cost box trainer.

The box trainer—as well as anatomic simulations for trocar placement, appendectomy, salpingostomy, small bowel manipulation, and intracorporeal suturing—are created from materials readily available in LMICs. While use of laparoscopic surgery currently is limited in several LMICs due to lack of training and simulation opportunities, ALL-SAFE provides an educational tool that can be built and used at the point of care.3,4

Notably, ALL-SAFE is an innovative tool in laparoscopic training throughout teaching hospitals in Africa, with 320 users in more than 65 countries.

The program has established partnerships with the Pan-African Academy of Christian Surgeons, West African College of Surgeons, and College of Surgeons of East, Central, and Southern Africa. Additionally, the ALL-SAFE team received the 2023 Global Surgical Training Challenge grand prize, an initiative that supports the creation of low-cost training modules for surgeons in LMICs.5


The ALL-SAFE box trainer was available at a laparoscopic training course for surgeons in Nigeria.

Learning Opportunities for US Students

Not only has the tool increased in popularity throughout Africa, ALL-SAFE also was unexpectedly used by eager learners in a setting closer to home.

During the annual Youth Summit at the Big House in Ann Arbor, middle school students from underserved communities in Southeast Michigan learned about health sciences and medical careers through hands-on medical activities on the campus of the University of Michigan.6,7 Each year, the Youth Summit brings hundreds of students to rotate through activities sponsored by several Michigan Medicine departments. For example, a radiology booth may feature ultrasound machines; an emergency medicine table may teach CPR; and a physical therapy activity may involve a series of exercises and stretches. For many students, the Youth Summit is their first exposure to the medical field.

ALL-SAFE partnered with the HOPE Collaborative, an initiative within the Department of Surgery of the University of Michigan that works to increase health equity and opportunities for children.8 In 2023, ALL-SAFE created a simulation booth for the Youth Summit where young learners could use the ALL-SAFE box trainer and models. HOPE scholars—older students from Detroit who have graduated from college and are preparing for medical school—were instructors at the ALL-SAFE simulation booth to teach the middle schoolers how to use the simulation platform.


Students at the Michigan Medicine Youth Summit practiced performing a laparoscopic salpingostomy on an anatomic model made of a Play-Doh, cotton, felt, and a penrose drain.

Because the ALL-SAFE box trainer and models easily can be constructed from inexpensive, readily available materials—cardboard, tape, plastic wrap, gloves, socks, cotton, etc.—learners as well as instructors discovered that they could build the platform in their own homes and practice laparoscopic surgery.

The ALL-SAFE booth proved to be one of the most popular stations at the Youth Summit. Students had an opportunity to learn about appendicitis and ectopic pregnancy and try their hand at performing a laparoscopic salpingostomy on a simple anatomic model made of a Play-Doh, cotton, felt, and a penrose drain.9

When students were asked to rotate to different stations, several were hesitant to walk away from the ALL-SAFE box trainers, determined to complete the procedure. Some students even returned to the station later in the day or brought their chaperones over to proudly show off their successes. By giving these students an opportunity to access this low-cost technology and discover how they could build the tool themselves, they were able to learn about surgery while hopefully developing an interest in pursuing a career in medicine.

Even though Detroit-area middle schools and hospitals in sub-Saharan Africa are vastly different environments, there are some notable similarities. In both settings, learners are hampered by a lack of accessibility, exposure, and learning opportunities in medicine. These factors have acute downstream ramifications that impact healthcare disparities, such as reduced access to laparoscopic surgical care and worse outcomes following surgery.10,11

The ALL-SAFE box trainer serves the same purpose in both local and global environments—to increase access to surgical education. Whether the ALL-SAFE box trainer is being used at a laparoscopic training course for surgeons in Abuja, Nigeria, or at a medical exposure event in Ann Arbor, Michigan, the responses from learners were strikingly similar. They could not walk away from the simulators; they were excited and determined to finish the task at hand; and they desired more time interacting with the simple box trainer.


During the 2023 Youth Summit at Michigan Medicine, students were lined up to try the ALL-SAFE box trainer.

While global surgery training programs continue to gain interest, it is important to consider how we may advance the goal of tackling healthcare disparities locally. The ALL-SAFE box trainer and educational platform is one approach to bring global surgery tools to more communities, and developing similar hands-on training tools specific to various cultural contexts can further engage and empower communities.

Promoting mentorship programs and fostering long-term partnerships with local educational institutions to integrate healthcare awareness into school curricula can instill health-conscious behaviors from an early age. Lastly, using data analytics and community-driven research initiatives can identify specific healthcare disparities and tailor interventions. These approaches, when combined, can form a comprehensive strategy to promote equitable healthcare access and outcomes for all.

Although the ALL-SAFE box trainer was designed for use in LMICs, it may have a dual purpose of sparking interest and excitement for surgical careers among a wider audience. We were struck by the simplicity of this approach, as well as the ability to multipurpose low-cost technology to develop this learning tool. As our emphasis on global surgery expands within the academic surgery context, we should consider how strategies for combating healthcare inequities internationally may inform, support, and uphold our efforts to tackle disparities domestically.

Serena Bidwell is a fourth-year medical student at the University of Michigan in Ann Arbor and is a member of the ALL-SAFE global surgery collaborative. She also is pursuing her master of business administration degree with a focus on nonprofit management and hospital administration.

  1. ALL-SAFE. Training Courses in Laparoscopic Surgery. Available at: https://www.allsafe.education/. Accessed January 24, 2024.
  2. ALL-SAFE. Overview of our platform. Available at: https://www.appropedia.org/ALL-SAFE. Accessed January 24, 2024.
  3. Nyundo M, Umugwaneza N, Bekele A, Chikoya L, et al. Assessment of resource capacity and barriers to effective practice of laparoscopic surgery in training hospitals affiliated with the College of Surgeons of East, Central and Southern Africa (COSECSA). Surg Endosc. 2023;37(3):5121-5128.
  4. Farrow NE, Commander SJ, Reed CR, et al. Laparoscopic experience and attitudes toward a low-cost laparoscopic system among surgeons in East, Central, and Southern Africa: A survey study. Surg Endosc. 2021;35(12):6539-6548.
  5. Global Surgical Training Challenge: Congratulations to the Winners. Available at: https://globalsurgicaltraining.challenges.org/. Accessed January 24, 2024.
  6. OHEI Youth Summit at the Big House. Available at: https://medicine.umich.edu/dept/obstetrics-gynecology/events/202205/ohei-youth-summit-big-house. Accessed January 24, 2024.
  7. Youth Summit at the Big House 2023. Available at: https://www.youtube.com/watch?v=2yb81vNeNYs. Accessed January 24, 2024.
  8. Impacting HOPE Collaborative. Available at: https://medicine.umich.edu/medschool/about/key-initiatives/health-equity-inclusion/impacting-hope-collaborative. Accessed January 24, 2024.
  9. Rooney DM, Mott NM, Ryder CY, Snell MJ, et al. Evidence supporting performance measures of laparoscopic salpingostomy using novel low-cost ectopic pregnancy simulator. Global Surgical Education–Journal of the Association of Surgical Education. 2020;1(41):1-7.
  10. Pizzol D, Trott M, Grabovac I, Antunes M, et al. Laparoscopy in low-income countries: 10-year experience and systematic literature review. Int J Environ Res Public Health. 2021;18(11):5796.
  11. Meara JG, Leather AJ, Hagander L, Alkire BC, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth. 2016;25:75-78.