Background
Strategies are needed to increase the availability of surgical equipment in low‐ and middle‐income countries (LMICs). This study was undertaken to explore the current availability, procurement, training, usage, maintenance and complications encountered during use of electrosurgical units (ESUs) and laparoscopic equipment.

Methods
A survey was conducted among surgeons attending the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA) in December 2017 and the annual meeting of the Surgical Society of Kenya (SSK) in March 2018. Biomedical equipment technicians (BMETs) were surveyed and maintenance records collected in Kenya between February and March 2018.

Results
Among 80 participants, there were 59 surgeons from 12 African countries and 21 BMETs from Kenya. Thirty‐six maintenance records were collected. ESUs were available for all COSECSA and SSK surgeons, but only 49 per cent (29 of 59) had access to working laparoscopic equipment. Reuse of disposable ESU accessories and difficulties obtaining carbon dioxide were identified. More than three‐quarters of surgeons (79 per cent) indicated that maintenance of ESUs was available, but only 59 per cent (16 of 27) confirmed maintenance of laparoscopic equipment at their centre.

Conclusion
Despite the availability of surgical equipment, significant gaps in access to maintenance were apparent in these LMICs, limiting implementation of open and laparoscopic surgery.
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To comply with the large global need for surgery, surgical equipment that fits the challenging environment in low-and middle-income countries (LMICs) should be designed. The aim of this study is to present a context-specific design of an electrosurgical unit (ESU) and a monopolar handheld to improve global access to surgery. This paper presents both a detailed description of electrosurgery in clinical practice in LMICs and the design of an ESU generator and monopolar handheld for this specific setting. Extensive fieldwork (by means of surveys, interviews, observations, and collection of maintenance records) was done by authors RO, KO, and LH. Feedback from users working in Kenya on the first demonstrator designs was obtained, after which the designs were adapted into conceptual prototypes. These were further evaluated by surveying respondents who attended the annual meeting of the College of Surgeons of East, Central, and Southern Africa (COSECSA) in Kigali, Rwanda in December 2018. Conceptual prototypes were developed for (a) an affordable ESU that is compact and battery powered and (b) a robust reusable monopolar handheld that can be cleaned in the autoclave and by chemicals (e.g., glutaraldehyde solution). The conceptual prototypes were positively received by the 51 respondents of the survey. The findings from the field work and the feedback from users during the design phase have led to a clear understanding of the specific needs and potential solutions. The presented conceptual prototypes need to be further developed into functional prototypes, which could be implemented in Kenya and other settings for further evaluation.

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