to the arguments to consider MBS programs as a platform for skills acquisition to all general surgical trainees. A second MBS module aimed at aspiring MBS surgeons can include procedure specific training in LRYGB and LSG. In 2008 Maddaus et al. proposed to use each surgical ‘rotation’ as a specific course with specific goals. In this model a metabolic bariatric rotation early in surgical training may incorporate knowledge about the disease and the consequences of MBS on the patient’s anatomy. The rotation also includes technical skills as laparoscopic suturing and small bowel handling as specific goals, obtained by a combination of ex vivo training and participation in MBS cases.65 The high numbers of MBS procedures call for broadly distributed knowledge of these procedures amongst all general surgical practitioners, to ensure adequate handling of postoperative complications for example. In a questionnaire amongst general surgeons in Ontario Canada 25.9% of respondents replied not to be confident in managing MBS complications, although two-thirds felt this should be within the skill set of a general surgeon.66 The need for advanced laparoscopic skill acquisition, safe and goal-directed MBS training and the management of complications calls for a more prominent place of MBS in the general surgical curriculum. Where and When to Start? In the SCHERP curriculum the EPA MBS surgery is defined, including knowledge about the pathophysiology, anatomy, and complications. A description of the competencies is shown in Appendix D. With these end-goals in mind, what should be practiced first? In which phase of surgical training can MBS be instructed or be a component of skills acquisition? The survey amongst Dutch metabolic bariatric centres in Chapter 3 shows that training of the key parts of the LRYGB and LSG were started around PGY 4.21 The Young-IFSO survey concludes that LSG was usually the first procedure residents performed as a first surgeon and specifically the step of preparing the stomach during LSG.2 However, in a study of Bonrath et al. in 2020 in Germany, MBS was still primarily trained after completing general surgery training.67 By emphasizing on stepwise training, basic and advanced laparoscopic skills can be trained when the resident has mastered previous skills, not depending on the PGY. 162 8
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