degree feedback as an alternative, but the training of non-technical skills could probably benefit from specific feedback and assessment. Although some studies have focused on knowledge acquisition about the pathophysiology of obesity and metabolic complications further research is needed to structure this important non-technical part of surgical training. An online training-module with predefined goals as proposed by Azer et al. is a valuable addition to an MBS curriculum, as it emphasizes the importance of knowledge acquisition.58 In the specific case of severe obesity, this chronic disease is surrounded, and possibly aggravated, by a social stigma. Treating patients with obesity requires at least awareness of this stigma as well as awareness of the provider’s own attitude towards obesity. In a study of Acosta et al. training on the treatment of obesity in internal medicine residency programs was increased. After this training a shift in attitudes of these internal medicine residents was observed toward patients with obesity, improving knowledge, treatment behaviour and positive attitudes.59 This type of training could also be added to MBS or general surgical residency programs. The Role of Metabolic Bariatric Surgery in the General Curriculum In training of new surgeons, the safety of the patient comes first. Therefore, the effect of incorporating MBS training in the operating theatre on patient safety and outcomes should be monitored. Participation of general surgical residents or fellows in minimally invasive fellowships in metabolic bariatric procedures may lead to a higher complication rate, mainly due to prolonged operation times.60–62 A recent review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database by Hoagland et al. has shown the same pattern for the LSG; prolonged operation times when trainees are involved.63 However, in most studies the role of the trainee is not described specifically. Involvement of the resident as first assistant or performing specific (key)steps of the procedure may have different impact on outcomes.63 Efforts made to further incorporate MBS in the training curriculum should include efficient and goal directed training, to keep the additional operative times and learning curve related complications to a minimum. MBS procedures and especially the LRYGB include key components of laparoscopic surgery such as stapling, suturing, gastrojejunal anastomosis and gastric dissection and therefore provide a framework for training of advanced laparoscopic skills.64 The large case volume adds 8 161 General discussion and future perspectives
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