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Viewpoint

Surgical Systems Are Built through Partnership: My Reflections from Mongolia and Cambodia

Leif M. Sorensen, BS

June 10, 2025

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Leif Sorensen

When I was 19 years old, I moved to Ulaanbaatar, Mongolia.

Surrounded by vast grasslands, roaming herds of livestock, and the white yurts of nomadic herders, I quickly became immersed in this unique culture. But as I moved outside the capital, I began to see a different reality—one where healthcare wasn’t just limited, it was almost entirely out of reach. Many Mongolians live without running water, proper sanitation, or reliable transportation.

As I continued to live in rural communities and became fluent in Mongolian, I gained a deeper understanding of the complex barriers Mongolians faced daily, including limited access to medications, a shortage of trained physicians, and limited access to surgical care, which is typically located hundreds of kilometers away, and even then, hospitals are often severely underequipped to provide care.

In many regions, capable doctors worked in professional isolation, without resources, specialists, or a structured referral system, and yet the dedication of these providers to their patients is unwavering. They help as much as they can with the resources that are available. It was after observing these challenges that I realized I wanted to find solutions to help.

This interest led me to Raymond Price, MD, FACS, cofounder of the Center for Global Surgery at The University of Utah in Salt Lake City, who has spent the past 2 decades expanding access to surgical care and strengthening health systems in Mongolia and around the world.

Inspired by the impact of his research, I joined Dr. Price’s efforts and quickly came to understand the vital role that surgery plays in a community, and that by focusing on strengthening surgical systems, we can drive broader improvements across entire healthcare systems.

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Dr. Raymond Price operates alongside newly trained laparoscopic surgeons at Battambang Provincial Hospital in Cambodia.

From Pilot Project to National Initiative

The introduction of the laparoscopic surgery training program in Mongolia in 2006 marked a turning point in the country’s surgical development.1 What began as a small pilot project to teach laparoscopic cholecystectomy evolved into a nationwide initiative. Through a long-standing partnership between The University of Utah and the Mongolian National University of Medical Sciences in Ulaanbaatar, laparoscopy transformed from a rare service offered only in the capital into the national standard of care.

Built on simulation-based training, graduated surgical mentorship, and a “train-the-trainers” model, this initiative empowered Mongolian surgeons to lead and teach within their own institutions. It was more than a technical milestone—it was a demonstration of what sustained, trust-based collaboration could achieve.

That success set a larger movement in motion. Like a flywheel gaining momentum, one well-executed program began empowering others. The credibility earned through laparoscopy opened the door for national efforts in trauma training, liver transplantation, and oncology, with each building on the infrastructure and partnerships developed in the years prior.

In collaboration with the ACS Committee on Trauma, The University of Utah then launched Advanced Trauma Life Support® (ATLS®) training in 2015, with the aim of addressing Mongolia’s significant trauma burden, specifically within the context of a rural landscape.2

Focused on the unique challenges of rural trauma care in Mongolia, ATLS training was quickly adopted nationwide. In fact, this initiative provided a strong foundation for trauma system development—one that the country is now actively building upon.

As I worked on these initiatives through contributions in the areas of translation, logistics, and data collection, I began to understand that successful global surgery work demands more than clinical expertise. I learned that lasting progress depends on aligning with national priorities, pacing interventions to match local readiness, and designing systems that respond to real-world constraints.

These lessons took on new urgency as Mongolia—facing some of the highest rates of liver and gastric cancer in the world—turned to international partners for support in strengthening its liver transplant capacity.

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The entire hospital staff at Battambang Provincial Hospital in Cambodia gathered to observe the hospital's first-ever laparoscopic surgery.

Mongolia’s liver transplant program has been active since 2011, but its recent growth was limited by resource constraints and a lack of technical training. Working with hepatobiliary surgeons and international experts, our team collaborated with Mongolian surgeons to update clinical pathways, refine donor and recipient protocols, and guide surgical planning.3

Between 2020 and 2023, Mongolia’s transplant team doubled the total number of living donor transplants performed in the entire previous decade—rising from 100 transplants between 2011 and 2020 to 200 by early 2023, and reaching 300 by early 2025. The rapid growth reflects the power of focused investment and shared learning.

This approach became reproducibly true when, during the height of the COVID-19 pandemic, leadership at the National Cancer Center of Mongolia (NCCM) reached out to stakeholders at The University of Utah and University of Minnesota in Minneapolis for help to address the 88% mortality rate among late-stage breast cancer patients in Mongolia.4

Together, through the pandemic, we launched a multidisciplinary virtual tumor board, connecting Mongolian oncologists with US-based breast surgeons, radiologists, pathologists, and medical oncologists. Meeting monthly, the virtual tumor board served as both a clinical consultation space and a platform for continuing education during a time when international travel was severely limited.

By 2023, through this collaboration, the mastectomy rate at NCCM dropped from 94% to 32%, signaling a significant shift toward breast-conserving surgery and more individualized care. Supporting this effort, my global surgery cofellow and I coordinated case discussions, translated between teams, and prepared educational materials. Through this work, I gained a clearer view of how cancer systems could take shape in resource-limited settings, where distance, limited diagnostics, and workforce shortages demand creative, collaborative solutions.

After years of virtual collaboration, our teams returned to Mongolia in 2024, to continue working on the ground. In the absence of widespread mammography and formal referral systems, we turned to ultrasound as a practical, portable tool for breast cancer screening in rural areas. I helped lead efforts in a remote mining town in the Gobi Desert, working alongside Mongolian clinicians to launch the region’s first screening initiative and train rural physicians in ultrasound techniques.

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Sorensen (right front) guides residents as they practice their laparoscopic skills on a box trainer at Calmette Hospital in Phnom Penh, Cambodia.

Working in rural Mongolia taught me that addressing cancer care is not just about introducing new technology; it’s about rethinking how we deliver care in places that have historically been underserved. We’re now building on those lessons by conducting a nationwide breast cancer needs assessment in partnership with the Mongolian Ministry of Health.

Adapted from a model first developed in Ghana and tailored to Mongolia’s unique geography and health system, the assessment evaluates access to screening, surgery, imaging, and oncology services across all provinces. More than a survey, it represents a shift in how the country is approaching cancer care—mapping existing gaps and creating the foundation for more coordinated, equitable, and sustainable solutions.

This work has shown me what is possible when local leadership and long-term collaboration align. The challenges of rural surgical care in Mongolia are complex, but the lessons we have learned continue to inform efforts in other countries. They serve as a reminder that solutions must be context-driven, sustainable, and rooted in partnership.

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Dr. Raymond Price assists laparoscopic surgeons at Battambang Provincial Hospital, following a graduated responsibility model.

From Mongolia to Cambodia

In 2022, Dr. Price and The University of Utah Center for Global Surgery were invited to help establish a national laparoscopic training program in Cambodia. Inspired by Mongolia’s focus on strengthening surgical systems, this government request gave our team the chance to apply 2 decades of experience in partnership, mentorship, and sustainable system-building to a new setting. This highlights a broader shift in how countries are approaching surgical development—not through short-term workshops, but through long-term partnerships.

By the end of 2022, our collaboration was underway. Partnering with surgeons from Calmette Hospital with the University Hospital in Cambodia and funded through the Cambodia Health Improvement Effort by the Church of Jesus Christ of Latter-Day Saints, the initiative focused on expanding training beyond the Cambodian capital, Phnom Penh, into high-volume, strategically located provincial hospitals.

Drawing directly from lessons learned in Mongolia, our team began developing a skills-based curriculum tailored to Cambodia’s needs. We collaboratively designed a laparoscopic box-trainer curriculum, created task-specific rubrics to evaluate technical performance, and developed digital tools to track simulation scores. Working closely with my global surgery cofellow, I saw how even simple tools, when thoughtfully implemented, could shift the entire dynamic of training. I came to understand that building trust, confidence, and clinical competence begins long before the operating room.

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The Mongolian breast cancer team joins Sorensen (second from the left) during the first-ever breast cancer screening in the rural mining village of Khanbogd, Mongolia.

Following a “train-the-trainers” model, the program emphasized foundational laparoscopic cholecystectomy skills at provincial hospitals. Cambodian instructors led simulation sessions and hands-on instruction, while our team stood nearby ready to support when needed. From the outset, the structure was designed to prioritize local surgical champions and long-term sustainability.

Since its launch, more than 20 laparoscopic training courses have been conducted across Cambodia, training more than 400 surgeons and residents. The results have been striking. At Kampong Cham Referral Hospital, from 2023 to 2025, the average number of monthly cholecystectomy cases increased by 188% after the training began. Of those cases, more than 94% were performed laparoscopically, with a complication rate under 3%.5 For patients, this shift has meant shorter hospital stays, faster recoveries, and reduced risks of infection.

Perhaps most significantly, our Cambodian colleagues are now independently organizing and running their own training courses without direct intervention from our team. Additionally, the collaboration is expanding beyond basic laparoscopic general surgery into surgical oncology, colorectal surgery, obstetrics, gynecology, critical care medicine, and other specialties, marking a promising step toward a fully self-sustaining national training system.

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A patient shows her laparoscopic surgery bandages.

What has emerged is more than a skills course. It is a coordinated, multisite effort to build national surgical capacity grounded in local ownership, guided by long-term partnerships, and driven by the belief that education, mentorship, and data can produce meaningful change. As in Mongolia, the goal is not simply to introduce techniques but to equip local surgical teams with the tools, confidence, and leadership to transform their health systems from within.

Through interpreting in operating rooms in Mongolia, navigating late-night Zoom calls across time zones, and working alongside surgeons on two continents, I have learned that surgical systems are not simply delivered. They are built slowly, collaboratively, and through mutual respect and long-term partnership.

Looking ahead, our partnerships in Mongolia and Cambodia continue to grow, shaped by the lessons of the past and a shared vision for the future. In both countries, we are deepening our collaboration with local leaders to strengthen surgical systems, expand equitable access to care, and develop the next generation of clinician-educators. Each step forward reflects the same guiding principle: empower local providers, support national priorities, and invest in systems that are built to last.

The greatest lesson I’ve learned is that surgery, when grounded in shared purpose, becomes one of the most powerful tools for equity. It has the potential to strengthen systems, uplift communities, and create trust across borders. That belief continues to guide me. As I build on the work of those who came before me, I look to the future of global surgery with hope—committed to becoming someone who carries this mission forward, one partnership at a time.


Acknowledgment

Sincere thanks to Nathan Richards, MD, MBA, FACS, Jade Nunez, MD, MSc, FACS, and Raymond R. Price, MD, FACS, for their contributions to the development of this article.


Disclaimer

The thoughts and opinions expressed in this article are solely those of the author and do not necessarily reflect those of the ACS.


Leif Sorensen is a research scholar and master of science in clinical investigation student at The University of Utah in Salt Lake City, where he focuses on global surgery and health systems strengthening. He has spent several years supporting surgical training and capacity-building initiatives in Cambodia and Mongolia. Sorensen is applying to medical school this upcoming cycle.


References
  1. Vargas G, Price RR, Sergelen O, Lkhagvabayar B, et al. A successful model for laparoscopic training in Mongolia. Int Surg. 2012;97(4):363-371.
  2. Kornfeld JE, Katz MG, Cardinal JR, Bat-Erdene B, Jet al. Cost analysis of the Mongolian ATLS program: A framework for low- and middle-income countries. World J Surg. 2019;43(2):353-359.
  3. Banzragch G, Ganzorig B, Batsaikhan B, Sainbuyan T, et al. Building a self-sufficient liver transplant program in Mongolia. Transplantation. 104(S3):S532.
  4. Brownson KE, Flores-Huidobro Martinez A, Ganbayar J, Sorensen LM, Det al. Development of an international virtual multidisciplinary tumor board for breast cancer in Mongolia. J Surg Res. 2024;295:776-782
  5. Sorensen L, Darelli-Anderson, AM, Sin P, Flores A, et al. Refining global surgical education: Successful implementation of laparoscopic cholecystectomy training in Cambodia. J Am Coll. Surg. 2024;239(5):S206-S233.