TRAINING IN METABOLIC AND BARIATRIC SURGERY Metabolic bariatric surgery (MBS) is a major part of general and gastrointestinal surgical practice with 10,000 - 12,000 procedures each year in the Netherlands.1 With limited training hours in the surgical resident curriculum, a goal-directed MBS rotation can enhance the acquisition of surgical skills and prepare residents for a career in MBS. In this chapter the main conclusions of the research presented in this thesis will be discussed, to provide a basis for such an MBS curriculum. This curriculum may enhance training of residents and fellows and be part of the lifelong learning of attending surgeons. With a survey amongst Young-IFSO members (members of the International Federation for the Surgery of Obesity and Metabolic Disorders of 45 years and under) in 2022-2023, the MBS training of surgeons from 61 different countries, spread across five continents, was explored. The most performed MBS procedures during residency were the laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Of the respondents 66.1% and 45.2% respectively, performed at least one of these procedures, followed by the one-anastomosis gastric bypass (OAGB) (23%) and laparoscopic adjustable gastric band (LAGB) (20.1%).2 Therefore, it is reasonable to select the LSG and LRYGB as the primary focus of research in this thesis. In the final part of this international Young-IFSO training survey, support for a global metabolic bariatric curriculum is discussed. As international practice still differs significantly, this thesis has focused primarily on an MBS curriculum tailored to the surgical practice setting in the Netherlands. In this chapter the available training techniques in MBS will be discussed, including the role of simulation and the benefits of stepwise training. These were the topic of the first part of this thesis. In the second part of the thesis, the key steps of the LRYGB and LSG were determined. Based on these key steps a procedure-based assessment of the LRYGB was created. In this chapter the currently available assessments will be detailed, as well as their role in entrustment and certification. In the third part of this thesis specific consideration is given to the training and outcomes of a specific step of the LRYGB, determining small bowel limb length. In addition to the technical aspects, acquisition of non-technical skills for surgeons (NOTSS) such as situation awareness, decision making, teamwork and communication are an essential part of surgical training.3 Knowledge about the pathophysiology of obesity and metabolic 148 8
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