ACS HOPE and the Surgical Training Collaborative in Lusaka, Zambia—Part 1

The American College of Surgeons has committed to creating a global learning space through the launch of the ACS Health Outreach Program for Equity (HOPE). By providing surgeons with opportunities to teach and learn from one another to better serve all patients and communities, the program harnesses the humanitarian ethos of the surgical community to improve surgical access and provide optimal surgical care to medically underserved communities through surgical service and education.​​

In 2018, ACS HOPE joined forces with leading US hospital centers and the College of Surgeons of East, Central, and Southern Africa (COSECSA) to create a surgical training hub in Lusaka, Zambia, at the University Teaching Hospital (UTH). Due to the COVID-19 pandemic, the hub started working in a purely virtual format, developing programs through Zoom meetings and eventually conducting a thorough needs assessment which identified research support, quality improvement education, minimally invasive surgery platforms, and patient data collection and analysis as top priorities.

University Teaching Hospital UTH at Lusaka, Zambia

Lusaka is the capital city of Zambia with a population just under two million people. It’s the largest and busiest city in Zambia.

UTH is the biggest hospital in Zambia and the principal medical training institution in the country; it also trains nurses and clinical officers. It serves as the referral center for complicated medical conditions and has 1800 beds spread across four clinical departments: internal medicine (438 beds), surgery (460 beds), obstetrics and gynecology (343 beds), and neonatal and pediatrics (151 and 408 beds, respectively).

Recent visit by Stanford surgeons

Dr. Sherry Wren led the coordination of efforts with ACS and UTH to involve Stanford Surgery in this program. Global Engagement at Stanford Surgery sponsored the participation of three faculty who volunteered to participate in ACS HOPE and recently completed work on site in Lusaka, Zambia in June of 2024. Drs. Robin Cisco (general and endocrine surgery), Tom Pham (abdominal transplant) and Anita Mohan (plastic, reconstructive, and microsurgery) participated in knowledge and skills expertise transfer with counterparts at UTH over one to two weeks while on site.

Dr. Robin Cisco shared her experiences following her return from Zambia:

Tell us what motivated you to travel to Lusaka with ACS-HOPE, and how you prepared for the trip.

I have been interested in global surgery since medical school, when I did an international rotation in Ob-Gyn at a teaching hospital in Tanzania. This exposed me to surgical care in a relatively low-resource setting. In my clinical work as an endocrine surgeon at Stanford, I work in such a resource-rich setting where our focus is often on tiny incremental improvements in procedures that are already highly safe and effective. While this type of improvement is worthwhile, it seems even more important to work to ensure that good surgical care is available everywhere, especially for essential procedures. 

The opportunity to travel to UTH through the ACS HOPE program appealed to me, as the program is focused on transfer of knowledge and skills to help improve surgical capability at the host institution in a way that will hopefully last beyond the current collaboration. From a practical standpoint, the ability to travel to Lusaka for two weeks was a great opportunity which was feasible with my work schedule and my family obligations.

In preparation, I attended a Zoom meeting with faculty from other US institutions that have participated in the ACS collaboration at UTH. I spoke with Dr Sherry Wren, and she gave me advice about planning for my time at UTH. I also had the chance to speak with Dr. Kristin Long who was invited by Global Engagement to give Department of Surgery Grand Rounds, and who shared her experience with the ASC HOPE program in Hawassa, Ethiopia. Finally, I communicated with one of the general surgeons and one of the endocrinologists at UTH prior to traveling to Lusaka to make plans for the visit.

What goals did you identify as part of this participation and what were your days like?

I arrived in Lusaka on June 16th and returned to the US on June 28^th. It’s about a 30-hour trip to get to Zambia from California. With regard to goals of the collaboration, the UTH Department of Surgery requested that I focus on surgery for patients with functional adrenal tumors. UTH has a wide scope of general surgery services currently available, so they were interested in focusing on procedures that are less commonly performed there. 

In terms of didactics, I gave two lectures while at UTH. One was on preoperative evaluation of adrenal tumors, and the other was on operative and perioperative management of patients undergoing adrenalectomy. The lectures were attended by faculty, residents and medical students.

We evaluated a number of patients in the clinic who had been selected prior to my arrival by one of the UTH endocrinologists. Ultimately, we performed open adrenalectomy on four of these patients. We worked on developing a multidisciplinary collaboration including an endocrinologist, an anesthesiologist, a general surgeon and a urologist.

Tell us about the strengths as well as the gaps you experienced in terms of personnel, equipment and resources.

UTH is the major referral center for smaller hospitals across Zambia. There is currently no designated surgeon or team to receive referrals of patients with adrenal tumors. Patients may have a delay in care or may be maintained on pharmacologic management when surgical resection would be the preferred/curative approach.

There are a number of existing resources at UTH that are favorable for adrenal surgery. These include anesthesia capability for complex cases and ICU capability including invasive monitoring. Vasoactive medications are not always available but can be obtained. There is a blood bank, and blood is consistently available. There is an engaged endocrinologist, who is interested in the diagnosis and perioperative management of patients with adrenal tumors. CT imaging and laboratory studies are available in the local area if not at UTH itself.

There were several limitations. The lack of OR equipment was probably the most notable. We are discussing options for acquiring some of the equipment such as a retractor system that would be helpful in adrenal and other major abdominal surgery. Many patients travel a long distance for surgery. They may face significant out-of-pocket costs to acquire needed imaging studies and labs. There are no centralized medical records and records such as lab results or imaging studies must be hand-carried to clinic. If the reports or CDs are lost, the tests need to be repeated. We complain a lot about our EMR, but this experience was a reminder of its benefits.

What do you see as a next step for you in this collaboration?

This was a great experience, and I plan to return to UTH next year. I hope to continue communication with the UTH surgeons in between my visits.  I have offered that if patients with adrenal tumors are being evaluated at UTH, we can review the cases in our adrenal tumor board at Stanford and give input remotely.

With regard to future goals, I think that a major long-term goal would be to expand the availability of laparoscopic equipment and training at UTH.