INTRODUCTION Metabolic bariatric surgery (MBS) is a still increasing part of the general and gastrointestinal surgeons’ workload. Metabolic bariatric operations, and especially laparoscopic Roux-en-Y gastric bypass (LRYGB), are among the most frequently performed laparoscopic procedures.1 As the master-apprentice system is still fostered in resident- and fellow training, a significant number of the metabolic bariatric procedures are performed with trainees, either as assistants or as first surgeons. A national questionnaire in 251 surgical residency programs and 48 minimally invasive fellowship programs in the United States by Buchwald and Williams showed that in 185 of the 251 programs, metabolic bariatric surgery was performed, and 100% of cases were taught to residents.2 Numerous reports on the effects of fellow and resident participation in LRYGB are available in literature.3-7 Kim et al. reported benefits of fellowship programs for fellows, metabolic bariatric centres, and patient outcome.8 Negative effects, such as increased operating time, have also been reported.3,4 Steps have been made to incorporate MBS in the resident programs in several countries, including the United States, the bariatric curriculum of the Spanish Society of Bariatric Surgery and Metabolic Diseases (SECO), and the postgraduate Surgery for Obesity Registrar Training and Educational Development (SORTED) program in the United Kingdom.9,10 In the limited time span of surgical residency, as a result of current working hour regulations, advanced laparoscopic skills have to be mastered efficiently, without compromising patient safety.2 An email questionnaire among 132 residents and 59 faculty members performed by Gardner et al. shows that gaps exist in the technical competency of the residents, especially in advanced and laparoscopic cases.11 Mattar et al., describing that 80% of residents are pursuing an additional fellowship to enhance their training level, observed the same problem.12 However, they also describe a gap between the level of the finishing resident and the required level of starting fellows, both on technical and nontechnical aspects. These studies show that a critical appraisal of current teaching techniques could enhance future curriculum development. Among advanced laparoscopic procedures, metabolic bariatric surgery takes a special place because past research has focused on the learning curve of surgeons accustomed with open 2 25 Current techniques of teaching and learning in bariatric surgical procedures
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