Assessment: Open Manual of Surgery in Resource-Limited Settings1

"We will build a community that uses its own experience, knowledge, and resources to create a high quality, open-source, online, low bandwidth Manual for surgeons practicing in resource-limited environments, including a surgical atlas."

1. Problem identification and general needs assessment

  • Surgeons practicing in the developing world often care for patients with advanced disease, outside of their scope of training and with few referral options. 
  • There is some written material on surgical conditions available to these surgeons on the internet, from websites such as Medscape, UpToDate, and others. However, accessible surgical atlases are rare.2
  • Most surgical atlases or manuals, even ones intended for use in austere environments, are generally not accessible to surgeons who reside in these environments.3
  • A surgical atlas is an important step beyond head knowledge about surgical conditions, providing step by step instruction on performing surgery.


2. Needs assessment of targeted learners

  • Practicing surgeons in resource-limited settings who need to perform a surgery they have not done before
  • Residents in general or specialized surgical training in developing countries
  • Non-surgeons caring for surgical patients without the availability of a surgeon


3. Goals and Objectives

  • We plan to create an open access, online surgical manual consisting of guidelines and procedures that would be useful to a General Surgeon in a resource-limited setting, such as (but not limited to) the developing world. 


4. Educational Strategies

  • We will use the following media in making the atlas: 
    • Anatomical drawings and photographs, that are Open Source taken from the internet, primarily Gray’s Anatomy.4 Other potential sources include,Wikimedia Commons6 and open-source journal articles that allow such use. 
    • Intraoperative photos from the collections of our authors and contributors
    • Cadaver dissection photos from the collections of our authors and contributors, including animal dissections when appropriate.
  • We will use authors with experience performing surgery in developing countries, including our colleagues in resource-limited settings as much as possible. 
  • Our Atlas will intentionally be high quality but “low tech,” for three reasons: 
    • To allow easy access for those with poor internet access
    • To make contribution easier by authors who reside in similar settings
    • To inspire other authors in low-resource settings to create online learning material as well. 


5. Implementation

  • The Manual will be hosted online by the Vanderbilt University Medical Center.
  • Access to the atlas will never require a password, login, or the provision of any identifying material. 
  • We will publish chapters as they are written, which will allow us to seek feedback and update them as needed. 
  • Each chapter will be a PDF file, with intentionally low bandwidth to be easily accessible to our target audience. We will avoid animations or complex graphics that would increase download time. 
  • We will perform the typesetting and formatting ourselves using simple software such as Microsoft Word. 
  • The Manual will use Creative Commons licensing7


6. Evaluation and Feedback

  • Prior to publication, each chapter will be reviewed as much as possible by surgeons who practice full-time in a developing country, including senior and junior residents / registrars. Changes will be made based on their input. 
  • We will consider an Editorial Board to formalize and augment the peer-review process depending on interest and availability.
  • We will create an optional feedback mechanism on the website for each chapter as well as for the atlas as a whole, allowing the user to provide input on the usefulness of the atlas, including narrative feedback. 
  • We will use software to track the countries of origin of our users. 



  1.  Modeled after Kern’s 6 Step Approach: Kern, DE et al. Curriculum Development for Medical Education- A Six Step Approach 1998 Johns Hopkins University Press
  2.  One notable counter-example is the outstanding Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery…. We intend to use a similar model for our atlas. 
  3. A full list of the counter-examples we are aware of can be found at…;
  4. Accessible at 
  5. Accessible at
  6. Accessible at
  7. Explained further at and license will be  per License Finder at