The role of remote and virtual surgical training in expanding cardiothoracic surgical capacity in low-resource regions

Abstract

Cardiothoracic surgery remains one of the most challenging specialties to train in, particularly in resource-limited settings where traditional apprenticeship-based models remain impracticable. This article addresses how emerging digital technologies - virtual reality (VR) simulators, augmented reality (AR) platforms, artificial intelligence (AI) surgical training platforms, and tele-mentoring platforms - are transforming cardiothoracic surgical training globally. We present convincing evidence from African implementation studies demonstrating that these innovative approaches can effectively address critical training gaps. For instance, a recent systematic review identified that tele-mentoring initiatives in Rwanda significantly improved outcomes in cardiac surgery procedures. These technologies offer numerous advantages over conventional training methods, including risk-free simulation environments, standardized skill assessment, remote expert advice, and the ability to repeatedly practice complex procedures. However, significant barriers to large-scale implementation persist, particularly in low-resource settings. Significant barriers include limited technological infrastructure, high cost of implementation, lack of reliable internet connectivity, and resistance to changing traditional training paradigms. The article proposes a multifaceted strategy to cover these gaps and suggests policy adjustments to incorporate virtual training into national surgical education courses, low-budget simulation solutions establishment, global cooperation in training, and curricula tailored to environments. We make available successful worldwide collaboration models, such as the Pan-African Association of Surgeons’ VR learning program and Operation Smile’s virtual mentorship efforts. The discussion pinpoints the promise for strategic use of these digital training solutions in revolutionizing cardiothoracic surgery training in low-resource settings, ultimately enhancing access to lifesaving surgical services while maintaining high standards of training quality and patient safety.

Introduction

The phrase “See one, do one, teach one” has long been a cornerstone of surgical training programs for over a century. However, this approach is less applicable to highly specialized fields like cardiothoracic surgery, particularly in resource-limited settings. These regions face a severe shortage of cardiothoracic surgeons due to challenges such as inadequate infrastructure, limited access to surgical training programs, and the migration of skilled professionals to high-income areas, which further widens the gap in the availability of care and postgraduate surgical training opportunities [1]. Also, cardiothoracic surgery involves intricate, high-risk procedures such as open-heart surgery, valve repairs, and lung resections. These require years of supervised training, advanced technical skills, and a deep understanding of surgical anatomy, physiology, and perioperative care. Simply observing a procedure once is not sufficient for safe and effective execution. In an attempt to alleviate the situation of surgical burden in Africa, the World Health Organization developed the Integrated Management for Essential and Emergency Surgical Care program [2]. The two essential strategies for developing a successful rural surgical training ground are: (i) supporting recruitment and retention of rural surgeons by preparing trainees across a range of surgical specialties for rural practice; and (ii) facilitating high-quality cost-effective surgical services to rural areas [3]. However, traditional training paradigms, such as on-site residencies or overseas fellowships, are often inaccessible due to financial, logistical, or institutional constraints. Consequently, innovative strategies are urgently needed to bridge this gap and equip healthcare professionals with the necessary skills.

Remote and virtual surgical training platforms have emerged as transformative tools in addressing these limitations, and have been shown to enhance learning experiences, improve technical proficiency, and elevate patient care [4]. Virtual education is the utilization of technology to provide teaching in situations where learners are distanced from their instructors by either space or time, and more recently accounts for the use of technologies to offer feedback in lieu of the instructor [5].

By leveraging advancements in virtual reality (VR), augmented reality (AR), and telecommunication technologies, these platforms provide scalable and accessible solutions for knowledge dissemination and skill development [6]. For instance, VR enables users to explore 360-degree videos, offering the ability to observe surgical procedures from multiple angles. This enables surgeons to engage in interactive, hands-on training regardless of location, reducing the need for physical proximity to specialized centers while maintaining high learning standards [7]. With this narrative review, we examined the role of remote and virtual surgical training in expanding cardiothoracic surgical capacity in low and middle-income countries.

Methods

This narrative review examines the impact of remote and virtual surgical training on expanding cardiothoracic surgical capacity in low-resource settings. The review explores the role of digital training modalities, including virtual reality (VR), augmented reality (AR), artificial intelligence (AI) training platforms, and tele-mentoring, in bridging critical gaps in traditional surgical education.

The review incorporated a literature search across PubMed, Scopus, Web of Science, and Google Scholar, and the data obtained from selected 66 literatures was organized around three thematic pillars: (1) the current landscape of remote and virtual surgical training in cardiothoracic surgery; (2) the potential of virtual platforms to transform training; and (3) strategies to overcome challenges and build sustainable training infrastructure. We have summarized the definitions of frequently used terms in our study in Table 1.

[IMAGE OMITTED: SEE PDF]

Current landscape of remote and virtual surgical training in cardiothoracic surgery

Traditionally surgical education was based on rigorous, hands-on endeavor where trainees learn by observing, assisting then performing. This teaching method has some drawbacks related to patient safety, limited exposure, and inconsistent training experiences due to the variability of trainers. Advanced surgical technologies consist, in part, of remote and virtual platforms that facilitate surgical care and surgical education (Fig. 1). It also includes the infrastructure necessary to utilize these platforms (e.g., internet access, robotic systems, and simulators [1]. Since COVID-19, the use of telemedicine has rapidly expanded. The impacts of VR have been appreciated as it increases the efficiency of care and patient satisfaction, decreases waiting time, and increases access to specialty care [2]. In the case of surgical training and education, VR has increased access to more advanced education in surgery and skill acquisition using multiple technologies [3].

[IMAGE OMITTED: SEE PDF]

The flowchart above was developed to illustrate the integration of virtual and traditional training modalities for cardiothoracic surgical skill acquisition in low-resource settings. It outlines a structured pathway starting with pre-training assessment, followed by theoretical learning via online modules, virtual simulation using VR/AR, and tele-mentoring for real-time guidance. Supervised clinical practice, continuous evaluation with tools like OSATS and GRS, and certification milestones ensure competency and safe transition to patient care safe.

In resource-limited countries, several factors impede the provision of necessary and equitable surgical care, including a shortage of skilled healthcare workers, lack of equipment, infrastructural challenges, geographic constraints, and the high cost of accessing care. In this setting, virtual platforms have been shown to reduce the cost and increase access to surgical education while removing barriers related to time, space, and resources [3, 4].

The first significant step in the development of remote and virtual surgical training is the introduction of a simulation-based teaching system that mimics real-life surgery and enables trainees to practice skills without causing complications in the cases [8]. Over time, technologies incorporate Virtual Reality and Augmented Reality to further improve skill acquisition and enhance teaching experience. These surgical technologies share key features, which includes immersive, interactivity, presence of a feedback mechanism, and repeatability. Several studies have also shown their efficacy in surgical training [9,10,11].

One important clinical tool for surgeons that provides a great opportunity to alter surgical practice and to offer patients the best expertise in surgical treatment, despite variable geographic location, is video conferencing. It facilitates virtual lectures, discussions, and live demonstrations, enabling trainees to interact with the most experienced surgeons [6]. Telemedicine has become an essential platform in healthcare delivery. It enhances healthcare service by enabling remote monitoring of patients and virtual consultations with senior specialists [7, 12]. However, the surgical team needs to pay attention to one important ethical consideration: clarification of fiduciary responsibility. It must be clearly established who holds primary responsibility for the patient’s care – whether it is the remote consultant, the consulting physician, or a shared responsibility between both. Clear communication protocols and guidelines are essential to ensure patient safety and uphold professional standards.

Simulation-based training is the cornerstone of surgical education [13] and has variable features and technologies, including Virtual Reality, Augmented Reality, and Haptic devices. Virtual Reality is a tool that allows trainees to home diagnostic skills, pre-operative planning techniques, intraoperative decision-making, and surgical techniques outside of the operating room. It provides novice trainees with immediate constructive feedback and assistance with their performance [8]. Augmented Reality, unlike virtual reality, it integrates a real-world environment, such as a physical patient, anatomical model, or simulated operative field, by providing the surgeon with computer-processed imaging data in real-time via dedicated hardware and software [14]. AR is made possible by using displays, projectors, cameras, trackers, or other specialized equipment. It is proved to be an effective tool for training and skill assessment of surgery residents, medical staff, or students [15].

Integrating AI and machine learning with Virtual Reality can enhance performance analysis and personalized feedback to performed procedures. AI and machine learning also enhance patient safety and surgical quality outcomes [16]. For long, medical education, particularly surgical education, has relied on the “see one, do one, teach one” model, a method that, while widely practiced, often exposes learners to real procedures before they have gained sufficient hands-on experience [12, 13]. This traditional approach can inadvertently increase the risk of procedural errors, particularly among early trainees [12]. With patient safety a critical concern, simulation-based technologies such as virtual reality (VR) have emerged as effective tools for skill acquisition in a controlled, low-risk environment [8].

A prospective study from a major urban teaching hospital revealed that approximately 20% of patients experienced adverse events while under the care of first-year residents following conventional training schedules, and nearly half of those events were deemed preventable. The study also among every 1,000 patients, the overall incidence of adverse events reached 80.5, with 36.2 of those classified as preventable occurrences [14].

A randomized controlled trial compared VR-trained residents with their non-VR-trained peers and consistently demonstrated superior performance among the VR-trained residents. For instance, in laparoscopic procedures, non-VR-trained residents made three times more errors, required 58% longer surgical time, and demonstrated less consistent outcomes (P < 0.0037) [15]. A randomized double blinded study has also identified a six times less errors (P < 0.008) in VR-trained groups [16]. These findings underscore the value of integrating VR into surgical education, both as a means of enhancing competency, increasing patient safety and as a strategy to mitigate preventable harm in clinical settings.

Remote guidance and support from experienced surgeons will benefit trainees and novice surgeons learn new skills. It will also help as a consultation modality in case of complicated cases [1]. For instance, Touch Surgery, which is a smart application, aims to provide motor skill simulation and surgical step rehearsal by helping professionals familiarize and prepare for particular procedures [12, 17]. One study demonstrated that participants using the Touch Surgery app demonstrated better initial performance based on prior surgical experience and improved performance of a simulated surgical procedure with practice [18].

Another example, Proximie, is a telemedicine and surgical training platform that uses augmented reality to enable experienced and physically not present surgeons to virtually scrub into the OR from anywhere in the world. This allows trainees and novice surgeons to get hands-on mentorship and feedback from the experienced surgeons [19, 20]. More than 50 countries and 800 Hospitals have been adopting it, facilitating cross-border collaboration, knowledge sharing, and the sharing of surgical expertise [21]. Fundamental surgery is a virtual reality-based surgical training program that allows professionals to perform procedures in a simulated environment with tactile sensation. Fundamental surgery incorporates a haptic system that stimulates the sensation of bone texture, muscle, and soft tissue. The impact of this fundamental surgery (Haptic device) on surgical training was studied. The result showed 46% of the haptic-trained group exhibited outcomes suggestive of an achieved plateau phase beyond the initial learning curve compared with 6% of the non-haptic trained group [22].

Tele-mentoring is a form of remote training involving real-time guidance from experienced surgeons during procedures. This approach has been particularly effective in cardiothoracic surgery, where complex techniques such as coronary artery bypass grafting (CABG) and valve repair require expert oversight. In a study conducted in Rwanda, tele-mentoring was used to guide local surgeons through complex cardiac procedures, resulting in improved surgical outcomes and increased confidence among trainees [17, 23]. Similarly, a program in Ghana utilized tele-mentoring to train surgeons in minimally invasive cardiac surgeries, achieving a 30% reduction in procedural complications [18]. These models demonstrate the potential of remote training to enhance surgical capacity in underserved regions.

In cardiothoracic surgery, VR platforms such as Surgical Theater and Osso VR have been used to simulate complex operations, including minimally invasive cardiac surgeries and thoracic resections [19]. One notable example is the use of VR simulations to train surgeons in transcatheter aortic valve replacement (TAVR), a minimally invasive procedure for treating aortic stenosis. A study conducted at the University of California, San Francisco, found that surgeons who trained using VR simulations performed TAVR procedures more efficiently and with fewer complications compared to those who relied solely on traditional training methods [20, 21]. Another study in the UK demonstrated that VR-based training reduced the learning curve for thoracoscopic lobectomy by 50%, highlighting its potential to accelerate skill acquisition [22].

In Africa, where access to advanced surgical training is limited, VR simulations could play an important role in changing surgical education. For example, the Pan-African Association of Surgeons (PAAS) has initiated a program to introduce VR-based training modules for cardiothoracic surgery in several African countries. Early results indicate that trainees who used VR simulations showed significant improvement in their technical skills and decision-making abilities [24]. Additionally, a study in South Africa found that VR training improved the accuracy of mitral valve repair procedures by 25% among trainees [25].

Online modules and e-learning platforms complement VR simulations by providing theoretical knowledge and step-by-step guidance on surgical procedures. These platforms are particularly valuable in regions where access to formal surgical education is limited. For instance, the European Association for Cardio-Thoracic Surgery (EACTS) offers an online learning portal that includes video lectures, interactive quizzes, and virtual case studies tailored to cardiothoracic surgery trainees [26]. Initiatives like the African Cardio-Thoracic Surgery Network (ACTS-Net) have developed online modules to train surgeons in basic and advanced cardiothoracic procedures. These modules are designed to be accessible on low-bandwidth internet connections, making them suitable for remote and rural areas. A case study from Kenya demonstrated that surgeons who completed ACTS-Net’s online training program were able to perform complex procedures such as mitral valve repair with greater confidence and precision [27]. Similarly, a program in Tanzania reported a 40% increase in surgical competency among trainees who completed online modules on CABG procedures [28, 29].

Several case studies illustrate the transformative impact of remote and virtual training in cardiothoracic surgery. In Nigeria, a tele-mentoring program was implemented to train local surgeons in CABG procedures. Over two years, the program successfully trained 15 surgeons, who went on to perform over 100 CABG surgeries with a success rate comparable to international standards [30]. This initiative not only improved surgical outcomes but also reduced the need for patients to travel abroad for treatment.

Another example comes from South Africa, where VR simulations were used to train surgeons in minimally invasive thoracic surgery. A study conducted at Groote Schuur Hospital in Cape Town found that trainees who used VR simulations achieved proficiency in video-assisted thoracoscopic surgery (VATS) 40% faster than those who relied on traditional training methods [31, 32]. Similarly, a program in Uganda utilized VR-based training to improve the accuracy of pediatric cardiac surgeries, resulting in a 20% reduction in postoperative complications [33].

Virtual reality and remote training technologies are reshaping cardiothoracic surgery education by providing accessible, scalable, and effective solutions for skill acquisition. In low-resource countries, where the demand for specialized surgical care far exceeds the availability of trained professionals, these technologies offer a promising pathway to address the shortage of cardiothoracic surgeons. By leveraging VR simulations, tele-mentoring, and online modules, surgical trainees can gain the expertise needed to perform complex procedures with confidence and precision. As these technologies continue to evolve, their integration into surgical education will play a critical role in improving healthcare outcomes across the continent [34].

The potential of virtual platforms to transform cardiothoracic surgical training

The integration of these technologies has not only improved surgical care but also improved patient outcomes and overall health outcomes for the general population. The most important benefit of remote and virtual surgical training is the ability to overcome geographical barriers [35]. In many LMICs, aspiring surgeons mostly reside in rural areas where access to advanced surgical education is restricted. Traditional training programs often require a physical presence in urban centers, which can be prohibitively expensive and logistically challenging. Virtual training platforms, however, enable surgeons to participate in high-quality educational programs from their local settings [36]. This accessibility ensures that more healthcare professionals can receive specialized training in cardiothoracic procedures, ultimately leading to a more skilled workforce capable of addressing the surgical needs of their communities.

Additionally, remote training facilitates continuous education and skill development for the healthcare team [35] as well as the patient, as it is vital in preoperative education for them [37]. Ongoing education is essential in cardiothoracic surgery, where techniques and technologies constantly evolve. Virtual platforms provide opportunities for surgeons to engage in webinars, online courses, and virtual simulations that keep them updated on the latest advancements in the field [38]. This continuous learning environment fosters a culture of knowledge sharing and collaboration among surgeons worldwide, allowing practitioners in LMICs to gain insights from experts and peers in more developed regions. The result is a more competent surgical workforce that can implement contemporary techniques and improve patient care.

Moreover, virtual surgical training can significantly reduce costs associated with traditional training methods such as using cadavers [39]. In-person training often involves substantial expenses, including travel, accommodation, and course fees. For surgeons in LMICs, these costs can be a significant barrier to accessing high-quality education. Remote training eliminates many of these financial burdens, making it more feasible for healthcare professionals to pursue advanced training. This cost-effectiveness not only benefits individual surgeons but also allows healthcare institutions in LMICs to allocate resources more efficiently, ultimately improving the overall quality of care provided to patients.

A multicenter randomized controlled pilot study found that virtual reality (VR)–based simulation training is emerging as a cost-effective alternative to traditional methods such as cadaver-based and mannequin-based simulations [40]. Medical school simulation examinations can cost over £355 per student, with cadaver-based simulations being particularly expensive due to the limited supply and high storage demands [41, 42]. One study reported that a single cadaver lab session costs $1,268.20 per resident and acquiring just four cadavers could instead fund an entire year of VR training. In comparison, the average cost for VR hardware and a one-year software license is $4,900, enabling repeated use across multiple trainees with minimal additional cost [43].

Moreover, a cost-utility analysis demonstrated that virtual simulation had a more favorable cost-utility ratio of $1.08, compared to $3.62 for mannequin-based simulation, reinforcing the financial advantages of VR-based education [44]. Recent advancements have also driven down the cost of consumer-grade VR headsets, further increasing accessibility. VR platforms are easier to scale and distribute across institutions, demanding fewer operational resources and enabling broader reach. Studies comparing different modalities have consistently highlighted VR’s superior cost-efficiency: where traditional models like cadavers and mannequins require ongoing investment per session, VR’s upfront costs can be amortized over time and across large numbers of users [45,46,47].

Another vital aspect of remote surgical training is the ability to provide mentorship and support through virtual platforms. Experienced surgeons from around the world can offer guidance and share their expertise with trainees in LMICs, fostering a mentor-mentee relationship that transcends geographical limitations. This mentorship can be instrumental in enhancing the confidence and skills of trainees, as they receive personalized feedback and support tailored to their specific needs. Such relationships can also lead to collaborative research opportunities, further advancing the field of cardiothoracic surgery in LMICs.

Furthermore, virtual training can enhance the quality of surgical education by incorporating advanced technologies such as virtual reality (VR) and augmented reality (AR) [48]. These immersive technologies allow trainees to practice surgical techniques in a risk-free environment, simulating real-life scenarios without the ethical concerns associated with practicing on patients. By using VR and AR, surgeons can refine their skills, develop critical thinking abilities, and gain hands-on experience in a controlled setting. This experiential learning approach is particularly beneficial in cardiothoracic surgery, where precision and technical skill are paramount. The COVID-19 pandemic has underscored the importance of remote and virtual training in healthcare. With restrictions on travel and in-person gatherings, many surgical training programs were forced to adapt quickly to virtual formats. This shift not only maintained the continuity of education during a challenging time but also demonstrated the effectiveness of remote training methods. As the world gradually recovers from the pandemic, the lessons learned from this experience can be leveraged to create more robust and flexible training programs that can withstand future disruptions.

The benefits of remote and virtual surgical training in expanding cardiothoracic surgery in low and middle-income countries are profound. By overcoming geographical barriers, reducing costs, and facilitating continuous education, virtual training enhances the skills of healthcare professionals and improves patient outcomes. The incorporation of advanced technologies and mentorship further enriches the training experience, fostering a culture of collaboration and innovation. As the field of cardiothoracic surgery continues to evolve, embracing remote training methods will be essential in ensuring that surgeons in LMICs are equipped with the knowledge and skills necessary to provide high-quality care to their patients. By investing in these innovative training approaches, we can help build a more equitable healthcare system that benefits all, regardless of their geographical location.

Advancements in technology-driven learning have made remote and virtual cardiothoracic surgery training a viable solution to improve access to high-quality training in low- and middle-income countries (LMICs). AI is transforming cardiothoracic surgical training by providing personalized learning, simulation-based training, predictive modeling, augmented reality (AR), and remote education. AI-driven adaptive learning tailors training to individual needs, improving efficiency [49]. Simulation-based training through virtual reality (VR) allows surgeons to practice complex procedures in a risk-free environment, reducing patient risk and training costs. Predictive AI models help anticipate surgical complications, improving patient outcomes, while AR enhances real-time decision-making during operations [49, 50]. AI-powered remote training expands access to education, particularly in low-resource regions.

Despite these benefits, several challenges remain. Lack of standardization in surgical techniques makes it difficult to train AI effectively. High costs limit accessibility, especially in developing regions. Ethical and legal concerns, including data privacy and liability, must be addressed. Additionally, resistance to AI adoption persists among traditionally trained surgeons. To maximize AI’s potential, global collaboration is essential to standardize training protocols, reduce costs, and integrate AI responsibly [51]. AI should complement, rather than replace, traditional mentorship, ensuring safer, more efficient, and widely accessible surgical education. With strategic investment and innovation, AI has the power to revolutionize cardiothoracic surgery training and improve global healthcare outcomes.

Overcoming challenges and building a sustainable virtual training infrastructure

Virtual surgical training has emerged as a promising solution to address the gaps in surgical capacity in low-resource regions. However, its implementation comes with a lot of challenges that must be overcome to ensure its success. These challenges include technological limitations, financial constraints, infrastructural deficits, and cultural barriers [9].

Virtual surgical training relies on advanced technologies such as high-speed internet, virtual reality (VR) systems, and simulation software. In many low-resource settings where access to cadavers is limited, it is imperative that surgical trainees are not confined to theoretical knowledge alone, and access to these technologies is limited. For instance, VR surgical simulators often fail to replicate the dynamic characteristics of human tissues accurately, reducing their utility for skill acquisition [9]. Additionally, poor internet connectivity hinders the implementation and regular use of e-learning platforms essential for surgical training [10]. Hardware and software unavailability in these areas is a major concern as many low-resource healthcare institutions cannot afford the necessary devices, such as VR headsets and high-performance computers [11]. Furthermore, even when such technology is available, the lack of experienced trainers in more remote LMIC regions is a major barrier to these trainings and the utilization of this equipment [11].

The financial barriers to implementing virtual training programs are substantial. Many low-resource regions operate under constrained budgets that prioritize immediate healthcare needs over long-term investments in training infrastructure. Purchasing VR hardware, maintaining software licenses, and funding technical support require significant financial resources, which are often unavailable [52, 53]. Healthcare professionals in these regions also have heavy workloads with insufficient remuneration, leaving little time or incentive to participate in virtual training programs [54]. Moreover, the high cost of developing and deploying training content addressed to local needs exacerbates financial challenges [55].

Infrastructural limitations are widespread in low-resource settings, significantly impeding the adoption of virtual training. Reliable electricity, stable internet, and suitable physical spaces for simulation labs are often lacking [56]. Without these basic prerequisites, the implementation of virtual training programs becomes very difficult. Another critical issue is the shortage of experienced surgical mentors who can oversee and facilitate virtual training programs. Mentorship is crucial for translating theoretical knowledge from virtual platforms into practical skills. The lack of standardized training curricula and regulatory oversight further complicates the situation, leading to inconsistent outcomes [57, 58].

Cultural factors and educational gaps also hinder the adoption of virtual surgical training. In some regions, traditional training methods are mostly practiced and believed, leading to skepticism about the efficacy of virtual platforms [59]. Resistance to adopting new technologies is often exacerbated by a lack of understanding of how virtual training can complement traditional approaches [60]. Additionally, training programs that are not tailored to the specific needs and cultural contexts of low-resource regions may fail to resonate with local healthcare providers. The stigma associated with certain surgical procedures in some cultures further complicates efforts to establish comprehensive training programs [61].

Though the challenges to implement virtual surgical training in low-resource regions are significant, they are not impossible to solve. Addressing technological, financial, infrastructural, and cultural barriers through targeted interventions and innovative solutions can pave the way for the successful integration of virtual training programs. With collaborative efforts and a focus on context-specific solutions, virtual surgical training can play a transformative role in expanding surgical capacity in low-resource settings.

The growing burden of cardiovascular diseases (CVDs) in low-resource regions highlights the urgent need for innovative training solutions to address workforce shortages [1]. Studies have demonstrated that virtual learning platforms, including simulation-based training and tele-mentoring, have proven to be effective methods for surgical education, offering innovative solutions to enhance surgical capacity, particularly in underserved and remote regions [2, 3]. Among these innovative solutions, digital health has proven to be a highly effective intervention in preventing and managing CVDs. It includes telemedicine, mobile health applications, remote monitoring systems, and wearable devices used to deliver personalized guidance and continuous monitoring. Additionally, digital health enhances access to care by enabling timely interventions, particularly in underserved or remote areas [1, 4].

Digital interventions can also be used as skill augmentation to expand cardiothoracic surgical care. For instance, the Global Surgical Training Challenge has fostered the development of a network of low-cost, open-access, and easily reproducible simulation training modules designed for low-resource settings [5]. These modules often combine advanced technologies with accessible materials, such as socks and cigarettes, to create realistic and effective training tools and are getting accepted and adopted by initiatives like the Surgical Education Learners Forum and the Wellcome Leap SAVE program [6, 7, 12, 13]. Recent advances in 3D printing have also enabled the rapid production of accurate anatomical models at a low cost. These include exact replicas of patient anatomy that can be used to prepare trainees and surgeons for complex procedures, facilitating the design of more precise surgical plans [8]. These examples highlight how technology-driven solutions are transforming surgical education and practice in healthcare, particularly in settings with limited resources.

In addition, telemedicine has redefined mentorship in healthcare by bridging geographical gaps and enabling real-time support during surgical procedures [14, 15]. Studies have emphasized how telemedicine fosters a dynamic learning environment by replicating the presence of mentors in operating rooms through remote observation and guidance. This technology is particularly valuable in remote or underserved areas, where it allows surgeons to consult with seasoned experts, leading to enhanced patient outcomes [16]. Moreover, when combined with other technology-driven mentoring tools, telemedicine creates an extensive repository of educational resources, promoting interactive and enriched learning opportunities for mentees [23]. These advancements exemplify how digital health technologies are addressing critical challenges in the surgical field that can translate to cardiothoracic surgery education and service delivery.

To make the most out of digital health in addressing cardiothoracic surgical expansion, policymakers, governments, international organizations, and academic institutions of LMICs should collaborate to prioritize integrating virtual and remote surgical training into existing training programs and health systems to enhance surgical capacity in settings where access to hands-on training and mentorship is limited [17, 18]. National health policies should integrate virtual training into broader health system-strengthening strategies to ensure sustainable and scalable surgical workforce development [19]. Governments should also prioritize building robust digital frameworks, including reliable internet connectivity and telemedicine platforms, essential for remote learning and virtual surgical training. Investments such as broadband expansion in Rwanda and Ethiopia, telemedicine networks in Kenya, and South Africa’s digital infrastructure initiatives demonstrate how digital advancements enhance healthcare access and training opportunities [20, 21]. Furthermore, subsidizing digital tools and internet connectivity for training centers and incentives to adopt virtual platforms can promote equitable access to resources and support sustainable solutions to workforce shortages.

International organizations such as the World Health Organization (WHO) and the Global Surgery Foundation are uniquely positioned to foster global collaboration and resource sharing [22, 24]. These entities can facilitate partnerships between high-resource and low-resource countries, enabling the exchange of expertise, training materials, and technology. For example, the Global Initiative for Children’s Surgery has effectively used virtual platforms to connect surgeons in high-income countries with their counterparts in low-resource settings, improving surgical outcomes [25]. Similarly, Operation Smile’s remote training initiatives in Southeast Asia demonstrate the impact of global partnerships in enhancing surgical skills and patient care [26]. International organizations should also establish universally recognized standards for virtual surgical training to ensure consistency and quality across programs. Moreover, advocating for increased funding, resource mobilization, and the inclusion of virtual training in international aid packages can accelerate progress by ensuring sustainability, scalability, and equity in low-resource settings.

Academic institutions are well-positioned to lead the development of competency-based curricula that integrate both theoretical knowledge and practical simulations for cardiothoracic surgery. Virtual reality (VR)-based training programs, such as those implemented by the Royal College of Surgeons of England, have demonstrated improvements in trainees’ surgical skills and confidence [27]. Similarly, simulation-based modules using VR and augmented reality (AR), as seen in programs at Stanford University, have proven effective in enhancing technical expertise [28]. Research from Harvard Medical School further highlights how VR-enhanced training increases competency in complex surgical procedures, making it invaluable for cardiothoracic surgery education [29]. Collaborative efforts with private sector innovators can drive technological advancements, such as AI-driven platforms for personalized learning, while formal certification programs lend credibility to these initiatives and promote global acceptance.

To guide institutions in adopting virtual training, we propose the following checklist:

Checklist for virtual training adoption in low-resource settings

☐ Assess Infrastructure: Evaluate internet connectivity, electricity reliability, and hardware availability (e.g., VR headsets, computers).

☐ Identify Training Needs: Survey local surgeons to determine specific cardiothoracic skills gaps (e.g., CABG, TAVR).

☐ Select Cost-Effective Tools: Prioritize affordable platforms like Touch Surgery or 3D-printed models.

☐ Engage Stakeholders: Partner with NGOs (e.g., Operation Smile) and academic institutions for funding and expertise.

☐ Develop Curriculum: Integrate VR simulations, tele-mentoring, and online modules into existing surgical training programs.

☐ Train Faculty: Provide workshops to equip local trainers with virtual platform expertise.

☐ Implement Assessment: Use validated tools (e.g., OSATS, GRS) to evaluate trainee competency.

☐ Monitor Outcomes: Track surgical outcomes (e.g., complication rates) to assess training impact.

☐ Secure Funding

☐ Evaluate and Scale: Conduct pilot programs, assess outcomes, and scale successful initiatives regionally.

Credentialing and certification pathways are evolving to incorporate virtual simulation as a credible and standardized tool for surgical training and assessment [53]. Virtual training platforms now play a critical role in evaluating core competencies, offering objective and consistent assessments that help ensure trainees meet the minimum skill thresholds required for independent practice [53, 62]. Organizations such as the American Board of Surgery (ABS) have begun integrating simulation-based evaluations into their board certification processes, acknowledging their value in reliably measuring surgical proficiency [63]. Beyond initial certification, simulation technologies are also utilized in Continuing Medical Education (CME) programs, enabling surgeons to maintain and update their skills in alignment with current clinical standards and innovations. These modules provide an accessible and flexible means for ongoing professional development [64, 65]. Furthermore, leading accreditation bodies are increasingly endorsing simulation-based education—including virtual platforms—as a benchmark for high-quality surgical training programs [66]. This growing institutional recognition strengthens the legitimacy of virtual training not only as a preparatory tool but also as a formal component of certification and lifelong learning in surgical practice.

To enhance the clinical actionability of our policy recommendations and ensure a smooth transition from simulation-based training to patient care, we propose a structured five-phase implementation framework (Fig. 2). This framework offers step-by-step, practical guidance that practicing surgeons and institutional leaders can use to translate policy into action. It begins with a readiness and needs assessment to identify local training gaps, infrastructure capacity, and faculty engagement. This is followed by resource and technology planning, with an emphasis on selecting cost-effective, context-appropriate tools and platforms. The design and integration phase align virtual training with existing curricula and incorporates validated assessment methods, such as the Objective Structured Assessment of Technical Skill (OSATS) and the Global Rating Scale. It also includes continuous assessment and supervised practice to ensure a smooth transition to patient care. Implementation is supported through pilot programs, routine monitoring, and iterative feedback mechanisms that promote responsiveness to local needs. Finally, the framework provides guidance on credentialing and scale-up, facilitating alignment with national certification bodies and ensuring long-term sustainability. This structured approach aims to bridge the gap between strategic planning and real-world execution, making virtual surgical training both feasible and effective in low-resource settings.

[IMAGE OMITTED: SEE PDF]

By addressing policy gaps and leveraging evidence-based approaches, stakeholders can promote the adoption of virtual and remote surgical training to expand cardiothoracic surgical capacity in low-resource regions. These coordinated efforts can potentially transform the global surgical workforce and improve access to life-saving interventions in underserved communities.

Conclusion

Virtual and Remote surgical training is a promising area in surgery, especially among low and medium-resource countries. However, challenges are prominent, which hinder the implantation and effective utilization of this form of surgical training. Despite these challenges, various innovative solutions have been proposed. Offline-capable tools like the Smile Train Virtual Surgery Simulator allow trainees to access educational content without reliable internet connectivity. Mobile applications like Touch Surgery enable users to practice surgical procedures on their smartphones, making training accessible even in remote areas. Collaborative efforts between governments, non-governmental organizations, and private-sector stakeholders can provide the financial and technical support needed to establish and sustain virtual training programs.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

AI:

Artificial intelligence

AR:

Augmented reality

CABG:

Coronary artery bypass grafting

CVDs:

Cardiovascular diseases

GRS:

Global rating scale

LMICs:

Low and middle–income countries

OSATS:

Objective structured assessment of technical skill

VATS:

Video–assisted thoracoscopic surgery

WHO:

World health organization

TAVR:

Transcatheter aortic valve replacement

PAAS:

Pan–African association of surgeons

EACTS:

European association for cardio–thoracic surgery

ACTS:

Net–African cardio–thoracic surgery network

References

A van, Sebastian AB, Bhuiyan MMZU. Challenges and opportunities in training surgeons in rural areas. SAMJ South Afr Med J. 2022;112(11):886–7.

Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624.

Preparing surgeons for rural Australia. the RACS Rural Surgical Training Program - Chong – 2015 - ANZ Journal of Surgery - Wiley Online Library. Available from: https://onlinelibrary.wiley.com/doi/10.1111/ans.12880. Cited 2025 Feb 8.

Viewpoint. Virtual and augmented reality in basic and advanced life support training - PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/35319477/. Cited 2025 Feb 8.

The silver lining. of the pandemic in surgical education: virtual surgical education and recommendations for best practices | Global Surgical Education - Journal of the Association for Surgical Education. Available from: https://link.springer.com/article/10.1007/s44186-023-00137-1#ref-CR10 Cited 2025 Feb 8.

The impact of surgical simulation and training technologies on general surgery education - PMC. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11558898/#CR4. Cited 2025 Feb 8.

Virtual reality technology for. surgical learning: qualitative outcomes of the first virtual reality training course for emergency and essential surgery delivered by a UK–Uganda partnership - PMC. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10826552/. Cited 2025 Feb 8.

Mazur LM, Khasawneh A, Fenison C, Buchanan S, Kratzke IM, Adapa K, et al. A novel theory-based virtual reality training to improve patient safety culture in the department of surgery of a large academic medical center: protocol for a mixed methods study. JMIR Res Protoc. 2022;11(8):e40445.

Sibomana O. Could virtual reality be a solution in surgical trainings in resource-restricted settings? A perspective. Surg Open Sci. 2024;21:14–6.

Fariyike OA, Yao J, Baqri M, Liao P, Mohr C, Korir G, et al. See one, teach yourself one, do one: barriers and opportunities in self-administered training and assessment for global surgical education. Surg Open Sci. 2024;22:74–8.

Wilkinson E, Aruparayil N, Gnanaraj J, Brown J, Jayne D. Barriers to training in laparoscopic surgery in low- and middle-income countries: a systematic review. Trop Doct. 2021;51(3):408–14.

Ahlberg G, Enochsson L, Gallagher AG, Hedman L, Hogman C, McClusky DA, et al. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg. 2007;193(6):797–804.

Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK, Andersen DK, et al. Virtual reality training improves operating room performance: results of a randomized, Double-Blinded study. Ann Surg. 2002;236(4):458–64.

Francis J, George J, Peng E, Corno AF. The role of teamwork and mentorship in pediatric and congenital heart surgery. Transl Pediatr. 2024;13(10):1870–8.

Shabir D, Abdurahiman N, Padhan J, Trinh M, Balakrishnan S, Kurer M, et al. Towards development of a tele-mentoring framework for minimally invasive surgeries. Int J Med Robot Comput Assist Surg. 2021;17(5):e2305.

Establishing National Telehealth Service in a Lower Middle-Income. Country—the Ghana Model. Available from: https://www.researchgate.net/publication/356472523_Establishing_National_Telehealth_Service_in_a_Lower_Middle-Income_Country-the_Ghana_Model. Cited 2025 Feb 15.

Virtual Reality (VR). Surgery Training & Simulators - PrecisionOS. Available from: https://www.precisionostech.com/. Cited 2025 Feb 15.

TAVR Surgery -. Virtual Reality Surgery Training Solution. Available from: https://smarttek.solutions/portfolio/tavr-surgery/. Cited 2025 Feb 15.

Virtual Reality Training for the Operating Room. and Cardiac Catheterisation Laboratory. Available from: https://www.researchgate.net/publication/8215958_Virtual_Reality_Training_for_the_Operating_Room_and_Cardiac_Catheterisation_Laboratory. Cited 2025 Feb 15.

Simulation-based training for. thoracoscopic lobectomy: a randomized controlled trial: virtual-reality versus black-box simulation - PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/24442678/. Cited 2025 Feb 15.

160 local surgeons access pan-African. training programme for children’s surgeons in first three years - Royal College of Surgeons in Ireland. Available from: https://www.rcsi.com/dublin/news-and-events/news/news-article/2024/05/160-local-surgeons-access-pan-african-training-programme-for-childrens-surgeons-in-first-three-years. Cited 2025 Feb 15.

The use of virtual reality in surgical training. implications for education, patient safety, and global health equity. Available from: https://www.researchgate.net/publication/376056265_The_Use_of_Virtual_Reality_in_Surgical_Training_Implications_for_Education_Patient_Safety_and_Global_Health_Equity. Cited 2025 Feb 15.

ESTS 2025–. 33rd Annual Meeting of the ESTS. Available from: https://estsmeeting.com/. Cited 2025 Feb 15.

Cardiothoracic surgery training in Sub-Saharan Africa. My Experience at the national cardiothoracic center, Korle-Blu teaching hospital | CTSNet. Available from: https://www.ctsnet.org/article/cardiothoracic-surgery-training-sub-saharan-africa-my-experience-national-cardiothoracic. Cited 2025 Feb 15.

Henson J, CardioStart I. Adult Cardiac Surgery & Congenital Mission in Tanzania. 2023. Available from: https://cardiostart.org/adult-cardiac-surgery-congenital-mission-in-tanzania/. Cited 2025 Feb 15.

Coronary artery bypass graft surgery in Tanzania. 5 years of experience at Jakaya Kikwete Cardiac Institute. Available from: https://www.researchgate.net/publication/346044094_Coronary_Artery_Bypass_Graft_Surgery_in_Tanzania_5_Years_of_Experience_at_Jakaya_Kikwete_Cardiac_Institute. Cited 2025 Feb 15.

Open heart surgery. in Nigeria; a work in progress | springermedizin.de. Available from: https://www.springermedicine.com/link?doi=10.1186/1749-8090-8-6. Cited 2025 Feb 15.

Arjomandi Rad A, Vardanyan R, Thavarajasingam SG, Zubarevich A, Van den Eynde J, Sá MPBO, et al. Extended, virtual and augmented reality in thoracic surgery: a systematic review. Interact Cardiovasc Thorac Surg. 2021;34(2):201–11.

Bedetti B, Bertolaccini L, Patrini D, Schmidt J, Scarci M. Virtual simulation and learning new skills in video-assisted thoracic surgery. Video-Assist Thorac Surg. 2018;3(0). Available from: https://vats.amegroups.org/article/view/4601. Cited 2025 Feb 15.

Virtual reality technology for surgical learning. qualitative outcomes of the first virtual reality training course for emergency and essential surgery delivered by a UK–Uganda partnership. Available from: https://www.researchgate.net/publication/377802708_Virtual_reality_technology_for_surgical_learning_qualitative_outcomes_of_the_first_virtual_reality_training_course_for_emergency_and_essential_surgery_delivered_by_a_UK-Uganda_partnership. Cited 2025 Feb 15.

Simulation-based medical education. an ethical imperative - PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/12915366/. Cited 2025 Feb 15.

Shrestha AB, Taha AM, Siddiq A, Shrestha S, Thakur P, Chapagain S, et al. Virtual and augmented reality in cardiovascular care in low and middle income country. Curr Probl Cardiol. 2024;49(3):102380. Available from: https://www.sciencedirect.com/science/article/pii/S0146280624000197. Cited 2025 Feb 9.

Khabir Y, Khan M, Iqbal U. The application of extended reality in cardiac surgery: potential implications for low- and middle-income countries. Int J Surg Lond Engl. 2023;109(1):41–2. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10389573/. Cited 2025 Feb 9.

van Rijn MM, de Heer LM, Nieuwenhuis-Wendt J, van der Kaaij NP, Moolenaar EGE, van der Ham DH, et al. Use of virtual reality in preoperative education of cardiac surgery patients – A feasibility study. Patient Educ Couns. 2024;129:108394. Available from: https://www.sciencedirect.com/science/article/pii/S0738399124002611. Cited 2025 Feb 9.

Vervoort D, Fiedler AG. Virtual reality, e-learning, and global cardiac surgical capacity-building. J Card Surg. 2021;36(6):1835–7.

Arjomandi Rad A, Hajzamani D, Sardari Nia P. Simulation-based training in cardiac surgery: a systematic review. Interdiscip Cardiovasc Thorac Surg. 2023;37(2):ivad07. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10435415/. Cited 2025 Feb 9.

Tran M, Ahmad M, Patel K, Argyriou O, Davies A, Shalhoub J. Comparing virtual reality and simulation to teach the assessment and management of acute surgical scenarios: a pilot study. Health Sci Rep. 2024;7(7):e2245.

Brown C, Ross S, Cleland J, Walsh K. Money makes the (medical assessment) world go round: the cost of components of a summative final year objective structured clinical examination (OSCE). Med Teach. 2015;37(7):653–9.

Gilbody J, Prasthofer A, Ho K, Costa M. The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review. Ann R Coll Surg Engl. 2011;93(5):347–52.

Crockatt WK, Confino JE, Kopydlowski NJ, Jobin CM, Levine WN. Comparing skill acquisition and validity of immersive virtual reality with cadaver laboratory sessions in training for reverse total shoulder arthroplasty. JBJS Open Access. 2023;8(3). Available from: https://journals.lww.com/10.2106/JBJS.OA.22.00141. Cited 2025 Jul 27.

Haerling KA. Cost-utility analysis of virtual and mannequin-based simulation. Simul Healthc J Soc Simul Healthc. 2018;13(1):33–40.

Chang TP, Weiner D. Screen-based simulation and virtual reality for pediatric emergency medicine. Clin Pediatr Emerg Med. 2016;17(3):224–30.

Abulfaraj MM, Jeffers JM, Tackett S, Chang T. Virtual reality vs. high-fidelity mannequin-based simulation: a pilot randomized trial evaluating learner performance. Cureus. 2021. Available from: https://www.cureus.com/articles/64747-virtual-reality-vs-high-fidelity-mannequin-based-simulation-a-pilot-randomized-trial-evaluating-learner-performance. Cited 2025 Jul 27.

McGrath JL, Taekman JM, Dev P, Danforth DR, Mohan D, Kman N et al. R Fernandez editor. 2018 Using virtual reality simulation environments to assess competence for emergency medicine learners. Acad Emerg Med 25 2 186–95.

Silva JNA, Southworth M, Raptis C, Silva J. Emerging applications of virtual reality in cardiovascular medicine. JACC Basic Transl Sci. 2018;3(3):420–30 https://www.jacc.org/doi/10.1016/j.jacbts.2017.11.009.

Satapathy P, Hermis AH, Rustagi S, Pradhan KB, Padhi BK, Sah R. Artificial intelligence in surgical education and training: opportunities, challenges, and ethical considerations – correspondence. Int J Surg. 2023;109(5):1543–4.

Vedula SS, Ghazi A, Collins JW, Pugh C, Stefanidis D, Meireles O, et al. Artificial intelligence methods and artificial intelligence-enabled metrics for surgical education: a multidisciplinary consensus. J Am Coll Surg. 2022;234(6):1181.

AI-Powered Surgical Training Program Provides Real-. Time Feedback and Instruction. Available from: https://news.njit.edu/ai-powered-surgical-training-program-provides-real-time-feedback-and-instruction?utm_source=chatgpt.com. Cited 2025 Feb 11.

Laspro M, Groysman L, Verzella AN, Kimberly LL, Flores RL. The use of virtual reality in surgical training: implications for education, patient safety, and global health equity. Surgeries. 2023;4(4):635–46.

Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694–700.

Speirs C, Brazil V. See one, do one, teach one: is it enough? No. Emerg Med Australas. 2018;30(1):109–10.

Farra SL, Gneuhs M, Hodgson E, Kawosa B, Miller ET, Simon A, et al. Comparative cost of virtual reality training and live exercises for training hospital workers for evacuation. CIN: Computers, Informatics, Nursing. 2019;37(9):446–54.

Shahrezaei A, Sohani M, Taherkhani S, Zarghami SY. The impact of surgical simulation and training technologies on general surgery education. BMC Med Educ. 2024;24:1297.

Gosselin RA, Gyamfi YA, Contini S. Challenges of meeting surgical needs in the developing world. World J Surg. 2011;35(2):258–61.

Hosny SG, Johnston MJ, Pucher PH, Erridge S, Darzi A. Barriers to the implementation and uptake of simulation-based training programs in general surgery: a multinational qualitative study. J Surg Res. 2017;220:419-e4262.

ResearchGate. Infrastructural Barriers to e-Health Implementation in Developing Countries. Available from: https://www.researchgate.net/publication/235968797_Infrastructural_Barriers_to_e-Health_Implementation_in_Developing_Countries. Cited 2024 Dec 27.

Carolina P, Silvana P, Roberto V, Julio B, Pablo L, Juan M, et al. The role of mentorship in minimally invasive surgery simulation training. J Pediatr Surg Open. 2024;5:100069.

Surgical mentorship in low-resource environments. Opportunities and challenges, a perspective - Awuah – 2024 - Health Science Reports - Wiley Online Library. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/hsr2.2258. Cited 2024 Dec 27.

Choy I, Kitto S, Adu-Aryee N, Okrainec A. Barriers to the uptake of laparoscopic surgery in a lower-middle-income country. Surg Endosc. 2013;27(11):4009–15.

Mishra DRK. Laparoscopic Surgery in Developing Countries: Progress and Challenges. Available from: https://www.laparoscopyhospital.com/news/preview.php?id=455&p=9&search. Cited 2024 Dec 27.

Hodgson S, Abdelrahman M, Jemec B, Lam W, Muchemwa F, Ahmed T, et al. Cultural challenges facing UK surgeons providing education in low and middle income countries. Bull R Coll Surg Engl. 2022;104(4):196–200.

Olasky J, Sankaranarayanan G, Seymour NE, Magee JH, Enquobahrie A, Lin MC, et al. Identifying opportunities for virtual reality simulation in surgical education: a review of the proceedings from the Innovation, Design, and Emerging Alliances in Surgery (IDEAS) Conference: VR surgery. Surg Innov. 2015;22(5):514–21.

Weiss KB. Introductory remarks by the president of the American board of medical specialties. Acad Emerg Med. 2008;15(11):982–3.

Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: A best evidence practical guide. AMEE Guide 82 Med Teach. 2013;35(10):e1511–30.

Vanderbilt A, Baugh R, Muscaro M, Papadimos T. The importance of laparoscopic simulation in the continuing medical education of community surgeons. Int J Acad Med. 2017;3(1):84.

Pietersen PI, Bjerrum F, Tolsgaard MG, Konge L, Andersen SAW. Standard setting in simulation-based training of surgical procedures: a systematic review. Ann Surg. 2022;275(5):872–82.