**2.4 Obstacles to the adoption of minimally invasive surgery**

The implementation and development of endoscopic surgery in LMICs is in fact confronted with multifactorial obstacles, the most important of which are insufficient investment in equipment and difficulties in accessing specific training [16]. Indeed, the lack of resources is the main obstacle. The low economic status in these countries makes it challenging to acquire and maintain endoscopic equipment, train surgeons and technicians and reinforce their capacity to perform endoscopic surgery. This explains the tendency to use endoscopy mainly as a diagnostic tool in developing countries [17].

There is a proportional relationship between a country's gross domestic product and the percentage and complexity of minimally invasive procedures performed [17].

The severe shortage of surgeons in low-income countries coupled with their heavy workload does not allow them to sub specialize; as a result, minimally invasive procedures are time-consuming and have the potential to lead to more significant complications [18].

This creates a self-inhibition that will make the learning curve much longer.

It has therefore become of paramount importance to facilitate and accelerate surgical training. The use of Smartphone seems to us to be an adequate solution [19, 20].

Surgery has traditionally been considered too expensive, complex and unprofitable. Indeed, surgery has never been included in primary health care, although surgical interventions are economically profitable in terms of saved lives and prevention of disabilities [21, 22].

The other hurdle is the socio-cultural barrier related to older surgeons' resistance to change and their reluctance to use new surgical technologies [16].
