SAGES white paper: strategic principles, operational considerations, and practical recommendations for building...

Minimally invasive surgery provides clear benefits to patient outcomes and is now standard practice in high-income countries. However, it remains underutilized in low- and middle-income countries (LMICs) due to limited training opportunities, infrastructure, mentorship, and long-term program sustainability. Recognizing these challenges, the Global Affairs Committee of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) launched the Global Laparoscopic Advancement Program (GLAP) to build sustainable laparoscopic training capacity. Over the past decade, GLAP has trained over 400 surgeons across Latin America and Africa, including programs in Costa Rica, Mexico, El Salvador, Ethiopia, Namibia, Uganda, Zimbabwe, and Kenya. The objective of this White Paper is to define strategic principles, operational considerations, and best practices necessary to build sustainable simulation-based laparoscopic training programs in low-resource regions, drawing on ten years of GLAP implementation experience and distilled into a structured 10-step guideline.

This White Paper was developed through expert consensus among members of the Global Affairs Committee and collaborators involved in the design and delivery of the global laparoscopic advancement program (GLAP). Contributors with direct programmatic experience identified key operational considerations across program planning, implementation, and sustainability. Draft recommendations were iteratively reviewed and refined among authors until consensus was achieved.

Consensus was reached on a 10-step implementation framework organized across three phases. Pre-program preparation includes: (1) establish strategic alignment, (2) assemble the team, (3) go to site, (4) establish operational structure, and (5) shape the curriculum. Program execution includes: (6) gather the right faculty, (7) lead delivery of a high-quality program, and (8) appreciate the moment. Post-program sustainability includes: (9) perform a structured debrief and (10) transition to local ownership. This can be summarised in the cognitive aid "SAGES GLAP!".

GLAP demonstrates that structured, simulation-based laparoscopic training can be successfully implemented in LMICs when programs are carefully planned, contextually adapted, and supported by committed local leadership. These insights provide a practical framework for expanding minimally invasive surgery globally, highlighting the importance of combining international expertise with local ownership to build lasting surgical capacity.