Global Surgery Research Articles

Unveiling the Lasting Impact: A 15-Year Follow-Up of Short-Term Surgical Mission Experiences

IntroductionResident interest in global surgery has increased over recent years. Incorporating short-term surgical missions (STSMs) into training improves Accreditation Council for Graduate Medical Education (ACGME) competencies and aids in understanding of global health infrastructure. We aim to investigate the impact of STSM participation during residency on the desire for participation after residency, and barriers in doing so. MethodsEighteen general surgery residents who participated in STSM with the International Surgical Health Initiative from 2009 to 2017 were surveyed. An 18-question survey encompassing demographics, mission-specific data, ACGME competencies, current perspectives, barriers, and areas for improvement was distributed. ResultsThe group averaged 5.4 y out of residency and 89% (n = 16) completed the survey. Mean age was 38.5 y with a female predominance (62.5%). During residency, 10 (62.5%) participated in ≥ two STSMs and six (37.5%) participated in one STSM. On average, each resident performed 24 cases per mission. All reported that after their resident STSM experience, they were more inclined to participate as an attending. Twenty-five percent (n = 4) participated in STSMs after residency. Vacation, scheduling, and family factors were ranked the highest barriers. All ACGME competencies were felt to be significantly improved by STSMs. ConclusionsThis is the first long-term follow-up study of general surgery residents who participated in STSMs confirming that resident involvement increases desire for continued participation. Although 100% of residents wanted to participate as attendings, only 25% were successful in doing so. While operative experience is salient in surgical residency, there are other valuable experiences to be gained. Further work should focus on enhancing experiences and mitigation of barriers to continued participation in global humanitarian initiatives.

Global Neurosurgery: A Path Forward Through Health System Strengthening.

The future of global neurosurgery should focus on addressing the unmet neurosurgical need from a health system approach should we hope to achieve sustainable and ethical change. In this article, we review the global building blocks, as defined by the World Health Organization, and use this framework to propose strategies to strengthen neurosurgical care on the global frontier. The targets for Universal Healthcare Coverage by 2030, as outlined by the United Nations Sustainable Development Goals, are reviewed, and the role of neurosurgeons in addressing the global targets is discussed. Surgical indicators according to the Lancet Commission on Global Surgery are also reviewed, and neurosurgical indicators are proposed according to the 6 surgical indicators of the commission. The execution of these global targets and indicators within the context of health system strengthening will be a persistent challenge, given the complexity of health system and its components. The neurosurgical community must continue to support, promote, and diversify collaborations, especially among deserts of neurosurgical care across the world. Innovative technology and education are essential to this global dilemma.

Achieving Equity Through Global Neurosurgery Research.

Since the release of the Lancet Commission on Global Surgery report in 2015, there has been an increase in the number of published papers on global neurosurgery, gaining widespread support from major neurosurgery journals. However, there remains no consensus on what may be considered part of global neurosurgery literature. Here, we propose that global neurosurgery research encompasses all scholarly work that measure, explore, or address inequity in the care of neurosurgical disease. We describe the growth of global neurosurgery research, cite landmark papers, and discuss barriers to participation, particularly among neurosurgeons in low- and middle-income countries. We introduce the 3Rs framework, advocating for global neurosurgery research that is rigorous, responsive, and responsible. This narrative review aims to guide young neurosurgeons and other researchers interested in the field, and to provide a framework through which global neurosurgery practitioners and advocates can evaluate previously accomplished work, paving the way toward neurosurgery that is timely, safe, and affordable to all.

Colombian surgical outcomes study insights on perioperative mortality rate, a main indicator of the lancet commission on global surgery – a prospective cohort study

Surgical care holds significant importance in healthcare, especially in low and middle-income countries, as at least 50% of the 4.2 million deaths within the initial 30 days following surgery take place in these countries. The Lancet Commission on Global Surgery proposed six indicators to enhance surgical care. In Colombia, studies have been made using secondary data. However, strategies to reduce perioperative mortality have not been implemented. This study aims to describe the fourth indicator, perioperative mortality rate (POMR), with primary data in Colombia. A multicentre prospective cohort study was conducted across 54 centres (hospitals) in Colombia. Each centre selected a 7-day recruitment period between 05/2022 and 01/2023. Inclusion criteria involved patients over 18 years of age undergoing surgical procedures in operating rooms. Data quality was ensured through a verification guideline and statistical analysis using mixed-effects multilevel modelling with a case mix analysis of mortality by procedure-related, patient-related, and hospital-related conditions. 3807 patients were included with a median age of 48 (IQR 32-64), 80.3% were classified as ASA I or II, and 27% of the procedures had a low-surgical complexity. Leading procedures were Orthopedics (19.2%) and Gynaecology/Obstetrics (17.7%). According to the Clavien-Dindo scale, postoperative complications were distributed in major complications (11.7%, 10.68-12.76) and any complication (31.6%, 30.09-33.07). POMR stood at 1.9% (1.48-2.37), with elective and emergency surgery mortalities at 0.7% (0.40-1.23) and 3% (2.3-3.89) respectively. The POMR was higher than the ratio reported in previous national studies, even when patients had a low-risk profile and low-complexity procedures. The present research represents significant public health progress with valuable insights for national decision-makers to improve the quality of surgical care. This work was supported by Universidad del Rosario and Fundación Cardioinfantil-Instituto de Cardiología grant number CTO-057-2021, project-ID IV-FGV017.

A Cognitive Load Theory Perspective of the Undergraduate Anesthesia Curricula in South Africa.

Safe anesthesia is indispensable to achieve global safe surgery and equitable health care access. The disease burden and lack of specialists in South Africa (SA) require junior, nonspecialist doctors to be fit-for-purpose from day 1 when they provide anesthetic services in peripheral hospitals with limited supervision. Graduating students report low self-perceived preparedness for administering anesthesia, but it is not known how their curricular experiences influence their learning. Cognitive load theory defines intrinsic, extraneous, and germane cognitive loads (subtypes). Intrinsic load relates to learning tasks, extraneous load to distractions, and germane load to students' learning processes. This study used a cognitive load theory lens to explore SA students' experiences of their undergraduate anesthesia training. In a constructivist cross-sectional descriptive study, we explored the qualitative factors that influenced students' curricular experience of undergraduate anesthesia training in SA. Two investigators analyzed the data independently in an initial coding round. An emerging theme of lack of time to achieve the expected outcomes, prompted the use of cognitive load theory as a conceptual framework for further analysis by the 3 authors. The subsequent analysis informed the development and refinement of a final cognitive load theory framework for anesthesia training, the COLOAD (COgnitive LOad in Anesthesia eDucation) framework. Data were collected between November 2017 and February 2019. The 1336 respondents (79% participation) reported a variety of determinants of learning pertaining to all 3 cognitive load subtypes. Participants were novices in an inherently complex environment and experienced a high cognitive load during anesthesia training. The number-, complexity-, and interactivity of tasks influenced intrinsic load, while extraneous load was affected by ineffective instructional methods, external- and internal distractors. Program design, metacognition, and learner motivation impacted germane load. Cognitive load theory provided a useful theoretical basis for understanding students' curricular experiences. The COLOAD framework suggests a microlevel interrelatedness of the constituting elements of the 3 cognitive load subtypes. This has implications for curriculum design, pedagogy, and student support. Learning outcomes development and curriculum mapping are important to ensure a lean curriculum, but measures to enhance germane cognitive load might be equally important to achieve competence. Attention to the hidden curriculum and active promotion of reflective practice might reduce cognitive load in complex learning environments such as anesthesia training.

Assessment of surgical, anesthesia, and obstetric workforce in Somalia.

One of the core indicators recommended by the Lancet Commission is surgical workforce density, aiming to improve the number of surgery, anesthetists, and obstetric (SAO) providers to 20 per 100,000 population by 2030. We assessed SAO workforce capacity in Somalia and made recommendations for improvement. A cross-sectional study was conducted using a structured questionnaire from the WHO Program for Global Surgery and Social Change (PGSSC) Surgical Assessment Tool. All hospitals that offer surgical care services were included. A descriptive analysis was conducted using the statistical software SPSS. Of the 55 surveyed facilities providing surgical care services, 28 (50.9%) were public, mainly in urban areas. We found that there were 474 SAO specialists and non-specialists (SAO providers) and 446 other important personnel (e.g., midwives, radiologists, and pathologists). Out of 474 SAOs, Banadir had 288. Overall, surgery specialties were the most prevalent profession among SAO providers' workforce, accounting for 160 (33.7%) surgery specialists, with 1.2 per 100,000 population. The six states of Somalia have 54 OB/GYN specialists (0.4 per 100,000 population). There were a total of 22 anesthesia specialists, with a ratio of 0.2 anesthesia specialists per 100,000 population. We found a serious shortage of the SAO workforce in Somalia, and it is unlikely to meet the 2030 Lancet Commission on Global Surgery targets. There is a need for additional training of SAO providers who can offer effective leadership in surgical care services to combat the extremely avoidable surgical-related morbidities and mortalities.

The current landscape of global international surgical rotations for general surgery residents in the United States: a survey by the Association for Program Directors in Surgery’s (APDS) global surgery taskforce

As interest in global surgery increases among surgical trainees, more programs are incorporating global surgery rotations into residency training. The structure of such rotations varies widely and there are multiple barriers to establishing, maintaining, and expanding international global surgery rotations. This study assesses the existing opportunities for global surgery experiences at US general surgery residency programs and explores opportunities for sharing resources and expertise among the Association of Program Directors in Surgery’s membership.

Ethical Considerations and Equipoise in Cancer Surgery.

The changing landscape of cancer surgery requires ongoing consideration of ethical issues to ensure patient-centered care and fair access to treatments. With technological advancements and the global expansion of surgical interventions, healthcare professionals must navigate complex ethical dilemmas related to patient autonomy, informed consent, and the impact of new technologies on the physician-patient relationship. Additionally, ethical principles and decision-making in oncology, especially in the context of genetic predisposition to breast cancer, highlight the importance of integrating patient knowledge, preferences, and alignment between goals and treatments. As global surgery continues to grow, addressing ethical considerations becomes crucial to reduce disparities in access to surgical interventions and uphold ethical duties in patient care. Furthermore, the rise of digital applications in healthcare, such as digital surgery, requires heightened awareness of the unique ethical issues in this domain. The ethical implications of using artificial intelligence (AI) in robotic surgical training have drawn attention to the challenges of protecting patient and surgeon data, as well as the ethical boundaries that innovation may encounter. These discussions collectively emphasize the complex ethical issues associated with surgical innovation and underscore the importance of upholding ethical standards in the pursuit of progress in the field. In this study, we thoroughly analyzed previous scholarly works on ethical considerations and equipoise in the field of oncological surgery. Our main focus was on the use of AI in this specific context.

681 Application of Low-Cost Automated Progress Tracking System (APS) on Laparoscopic Appendicectomy Simulation Models (LaApSi) for the Laparoscopic Simulation Training in the Lower-Middle-Income-Countries (LMICs)

Abstract Aim To assess the effectiveness of the Low-Cost Automated Progress Tracking System on Laparoscopic Appendicectomy (LA) Simulation Models (LaApSi) for Laparoscopic Training in Lower-Middle-Income-Countries (LMICs). To assess and record the progression of trainees’ performance during simulation training. Method After the successful application and validation of the LaApSi model during laparoscopic courses at LMICs, the APS system has been prototyped to assess the trainee’s progression of LA. This system helps to assess surgical steps during simulated LA with the help of the LaApSi model integrated with wires at various anatomical positions giving real-time computer feedback and allowing users to assess the timing of operation, blood vessel excision and injury to the base of the appendix/caecum. Results The prototype version tested in LMIC showed excellent results in the detection of the above-mentioned parameters (shown in photos). This cost-effective model (LaApSi< £5 and docking system <£15) showed huge potential as a laparoscopic training model in LMICs. There will be additional validation of 16 APS models during the Laparoscopic Surgery Course in Nepal in Jan 2024 in collaboration with Nepalese Doctors Association-UK which we believe will further solidify its application in the LMICs Conclusions There is a need for the transition to high-fidelity low-cost laparoscopic simulation models from the traditional training methods in the LMICs which in the long-term address global surgery values. These systems have the potential for remote proctorship in the rural parts adapting the Hub & Spoke model and integrating AI and Machine Learning which eliminates the use of wires and sensors in the models.

Global Surgery: The Challenges and Strategies to Win a War That Must Be Won.

Modern science has conquered seas, land, and space. Although great strides have been made in technology and infectious diseases, global surgery, which was reborn in 2015, has not made much progress. The burden of surgical disease in low- and middle-income countries remains seemingly unconquerable, and its growth unstoppable. The myriad challenges in meeting the surgical needs of 5 billion people has intrigued the author. The author collected the views of plastic surgeons on sources and impediments to the scale-up of plastic surgery in low- and middle-income countries, as well as potential strategies for overcoming these obstacles. The author then performed a literature search reviewing the topics that arose from those discussions. The author proposes a strategy using plastic surgery as a model surgical discipline. A root-cause analysis suggests that the Alma Ata Declaration, with its focus on primary healthcare, is the probable genesis of global surgery (GS) woes. The absence of a clear GS community leader and the fragmented nature of GS advocates who operate in multiple silos, without a clear unified goal, are the primary reasons GS advocates have achieved so little on the ground. Global surgery requires a business model to sustainably meet the surgical needs of the 5 billion people globally. The proposed and implemented strategies must meet rigorous criteria to ensure sustainability, as quick-fix solutions are counterproductive. The development of centers of excellence offers a viable solution to problems that must be addressed successfully.

708 Innovating Low-Cost Automated Progress Tracking System (APS) for Laparoscopic Cholecystectomy Simulation (LaChSi) Models in the Lower Middle-Income Countries (LMICs) and Its Application for the Global HPB Surgery in Resource-Limited Settings

708 Innovating Low-Cost Automated Progress Tracking System (APS) for Laparoscopic Cholecystectomy Simulation (LaChSi) Models in the Lower Middle-Income Countries (LMICs) and Its Application for the Global HPB Surgery in Resource-Limited Settings

Beyond borders: an appraisal of the global congenital cardiac surgery workforce.

Congenital heart disease (CHD) is the most common congenital abnormality worldwide. Patients in resource-constrained environments experience higher levels of mortality and morbidity from CHD. Many studies have quantified the incidence of CHD in resource-constrained environments and compared these to availability of surgeons per population. However, no study to date has compiled and created a repository of the global paediatric cardiac surgical workforce. We aimed to quantify the number and details of the congenital cardiac surgeons globally, compare the population of under 15's in each respective countries, and address the workforce gaps that currently exist within paediatric cardiac surgery. Cardiothoracic Surgery Network (CTSNet) was searched in 2021 to extrapolate the current paediatric cardiac surgical workforce. The data was evaluated with the current literature to address current gaps in workforce planning and sustainability to produce this appraisal. A total of 4,027 congenital cardiac surgeons were identified from CTSNet with 75% residing in high-income countries (HICs) or upper-middle-income countries (UMICs) despite these income groups only accounting for 16% of the world population. Despite similar incidence and prevalence of CHD globally, we found an unequal distribution in the availability of congenital cardiac surgeons worldwide. The disparity in the availability of surgeons between HICs and low-middle-income countries (LMICs) is a global health issue that will require serous thought and planning to resolve. The high proportion of preventable deaths from CHD cases is a regrettable figure that governments and medical organisations should further strive to decrease. Education and proactive investments in training up local teams in LMICs will allow for sustainability in global congenital cardiac surgery.

Is neocolonialism existing in global surgery practice? An analysis of a web-based survey amongst global surgery practitioners

Background There is an ongoing discussion for decolonization of global health and a resetting of global health partnerships and practices. However, a lack of understanding and agreement on the issues involved remain a major limitation. The aim of this study was to understand and identify the manifestations of neocolonialism in global surgery practice. Methods This was a qualitative web-based survey of 445 low-and middle-income countries (LMICs) and high-income countries (HICs) global surgery practitioners. We also captured through focussed interviews their perceptions and reported manifestations of neocolonialism in global surgery. Results The majority (73.9%) came from LMICs, while 26.1% were from HICs. Surgeons formed the largest group (57.6%), with many having extensive experience (38.7% with over 10 years in global surgery). Neocolonialism was defined as an unequal power dynamic favoring HIC agendas. Uncompensated work by LMICs staff and funding disparities were identified as neocolonial practices by HICs participants. Limited research capacity and frustrated LMICs providers were seen as consequences. Factors enabling neocolonialism included limited local funding and training priorities set by funders, not local needs. More than 75% of participants agreed that fear of losing HIC support was a major barrier to open communication about neocolonialism in global surgery. Conclusions This study among global surgery players unbderscores existence and experiences of neocolonialism in global surgery. The impact of this practice and the enablers need to be urgently addressed by implementing mitigating solutions.

Persistent unmet need for surgical care in Western Uganda.

Treatable surgical diseases account for a significant proportion of the global burden of disease, particularly in low- and middle-income communities. The number of deaths owing to poor surgical care or its non-availability has been reported to exceed those from HIV/AIDS, tuberculosis and malaria combined. The Ugandan government and its development partners aim to put in place measures to achieve universal health coverage for all communities. These include construction and equipping health facilities, training of health workers, opening up road networks, and poverty alleviation programmes. However, these efforts have, as yet, fallen short as evidenced by external hernias remaining the leading cause of intestinal obstruction for more than 40 years. We recommend establishment of global surgery collaborations with rural-based medical training schools and other health facilities, essential surgical skills training for medical students, task shifting in surgical care and integration of regular surgical camps in the Uganda's healthcare delivery model.

The State of Surgical Research in Sub-Saharan Africa: An Urgent Call for Surgical Research Trainers.

Surgery in low- and middle-income countries (LMICs) is poorly developed because of years of neglect. Sustained research on global surgery led to its recognition as an indivisible and indispensable part of primary healthcare in 2015. However, this has had little visible effect on surgical ecosystems within LMICs, especially in sub-Saharan Africa (SSA). SSA surgical research systems strengthening, which includes skills transfer, with local priority setting driving the research agenda, is needed to propel global surgery into the future. The authors performed a literature review of the state of surgical research within SSA and also report the initial efforts of two research training nonprofits to empower young African surgeons with research skills. Surgical research in SSA is disadvantaged even before it is birthed, facing monumental challenges at every stage of development, from research agenda determination to funding, study execution, and publication. Compared with a global output of 17.49 publications per 100,000 population, SSA produces 0.9 (P < 0.0001). The Surgeons in Humanitarian Alliance for Reconstructive, Research, and Education and Enabling Africa Clinical Health Research programs are involved in the longitudinal research mentorship of surgical residents within SSA; the improved quality of research and successful publications by participants suggest nascent steps in growing young surgical scientists. In the absence of an existing surgical research infrastructure within LMICs, global surgery research trainers should link up and collaborate to help develop a surgical research community that will provide the local data required to help transform the SSA surgical ecosystem.

No frugal innovation without frugal evaluation: the Global IDEAL Sub-Framework

ObjectiveThe Global IDEAL Sub-Framework Study aimed to combine the intended effects of the 2009/2019 IDEAL (Idea, Development, Exploration, Assessment, Long-term study) Framework recommendations on evaluating surgical innovation with the vision...

The Task‐Sharing Path to Safe and Accessible Anaesthesia Care in India: The Role of Professional Associations in Health Policy Reform

ABSTRACTThe worldwide anaesthesia workforce shortage is a concern and ‘shared responsibility’ for all the national or state anaesthetic societies and Ministries of Health. The Lancet Commission on Global Surgery estimated the need for 143 million additional surgeries each year globally. These would be included in the World Health Organization's (WHO) 44 essential surgeries to be performed at district hospitals. However, insufficient availability of safe anaesthesia is a key barrier. The World Federation of Societies of Anaesthesiologists (WFSA) recommends at least five specialist physician‐anaesthesia providers per 100,000 population. India requires at least 60,000 additional physician‐anaesthesiologists over the next 10 years. This paper discusses the two‐decade journey of a policy initiative by the Ministry of Health and Family Welfare (MoHFW) in India to create a new category of a physician with Life Saving Anaesthetic Skills (LSAS). This addressed the shortage of anaesthetists specifically for the dire emergency obstetric situations at the First Referral hospitals. The annual training capacity for physicians for LSAS training was 40–100 in 5 of the poorest states of India, with the maximum shortages of anaesthetists. On following up a sample of 838 LSAS physicians, only about two‐thirds were able to practice their life‐saving skills. The MoHFW innovated further by pairing a physician trained in Emergency Obstetric Care with an LSAS‐physician (buddy‐pairing) as a functioning team. For comparison, we discuss the midwife model supported by the professional association of obstetricians in India. The flexible, ‘team‐based’ task‐sharing approach optimizes anaesthesia care within available resources. Leadership and vision from the professional societies of anaesthesiology are key to policy reform in India. National engagement can be facilitated through support for district‐level non‐specialist physician provider with life‐saving anaesthesia skills training, engagement in research and formulation of the national surgical and anaesthesia plans to achieve universal healthcare in India.

A novel global safe surgery mentorship program using a multidisciplinary team approach.

The global surgery movement aims to provide equitable surgical care in low- and middle-income countries (LMICs) and attempts to address a wide range of issues around the lack of access and poor-quality. In response, the Lifebox McCaskey Safe Surgery Fellowship was established in Ethiopia to train a multidisciplinary team of healthcare professionals. We conducted this study to evaluate the outcome of this training program. A qualitative study was conducted to evaluate the implementations and outcomes of the first three cohorts of the McCaskey Fellowship. Interviews with fellows, mentors, and program staff reveal valuable insights into the program's strengths and challenges. Key findings include positive feedback on the program's curriculum highlighting its multidisciplinary nature. Challenges were noted in maintaining schedules, communication with healthcare facilities, and budget constraints, suggesting the need for improved program management. The fellowship's impact was evident in altering participants' perceptions of teamwork and enhancing their research and leadership skills. Fellows initiated quality improvement projects impacting surgical practices positively. However, challenges, such as hospital resistance and the COVID-19 pandemic, affected program implementation. Despite various challenges, the program's unique approach combining multidisciplinary training and local mentorship proves promising. It fosters a culture of teamwork, equips participants with essential skills, and encourages fellows to become advocates for safe surgery. As surgical quality champions emerge from this fellowship, there is optimism for lasting positive impacts on surgical care in LMICs.

Giving a voice to under-represented groups in Global Surgery

This issue of Impact Surgery has been timed for release alongside a Lancet and NIHR Unit on Global Surgery (University of Birmingham, UK) Side Event at the 7th World Health Assembly in Geneva (May 28th, 2024). The event aims to re-frame the relationship between surgeons and policymakers ahead of the 10 year anniversary of the Lancet Commission on Global Surgery (2015). The objectives are to prioritise research that can embed surgery into whole systems, rather than leave it as a standalone speciality that is seen as expensive.

Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries

Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition. This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model. 18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72-2·46) and bowel resection (1·85, 1·31-2·63), and less common after day-case surgery (0·39, 0·34-0·44). This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services. NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).