Quality Grading of Reports The quality grading of reports is displayed in Table 1. For a full overview, a risk of bias assessment is included in Appendix I. Most included studies were small and retrospective. Using the GRADE system, 2 randomized controlled trials (RCT) were graded as “high” with arguments to upgrade the grade for 1 RCT. Two studies provided moderate evidence. The remaining 12 publications provided low (n = 6) or very low (n = 4) graded evidence. Owing to the heterogeneity between the studies, reflected for instance in operating times and types of interventions, statistic comparison or pooling of data was not possible. Training Level and Assessment Most studies applied to senior surgical residents (postgraduate year 3-5). Trainees’ experience in minimal invasive surgery (MIS) was described in detail by Iordens et al. and Bonrath et al.23,26 The Global Ratings Scales, Objective Structured Assessment of Technical Skill (OSATS), Bariatric OSATS (BOSATS), and error counts were used for evaluation of the effects of various interventions.20,26,27 The resident and fellow education remarks are summarized in Table 2. Effects on Surgical Outcome Seven publications that included information on the effects of resident participation on surgical outcome are summarized in Table 3. The average difference in operation time is a decrease of 9.6 minutes (range: −93 to +40 minutes). After exclusion of studies that showed decreased operating room (OR) times due to simplification of the operative procedure, or severe inclusion bias, OR time was increased by 29.3 minutes (range: +13 to +40 minutes).24,28 Two studies described no difference in complication rates. Davis et al. described increased morbidity and return to operating room rates.5 Martin et al. found an overall decrease of early complications from 15% to 5% and a significant decrease in anastomotic strictures using a simplified technique.28 Fanous and Carlin reported increased rates of acute renal failure from 0% to 0.82% (p = 0.047).6 This study found a nonsignificant effect on excess weight loss (64% vs. 66%). Harrington et al., who reported on the effects of in vivo training of the jejunojejunostomy, found increased costs of $1457 per anastomosis (mean duration 93.5 minutes).25 30 2
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