the intervention group, P = 0.003). The intervention group also showed significant improvement of the standard Objective Structured Assessment of Technical Skill (OSATS), BOSATS, and technical errors from their baseline to post training measurements (all P = 0.008). The coaching sessions (33 of 40 sessions recorded) took a median time of 25 (23-28) minutes, and 53 minutes of assessment of the procedures, video editing, and defining learning curves. All the participants in the intervention group found the coaching very useful. Moran-Atkin et al. also performed an RCT studying the effect of a preoperative warm-up on performance of residents and fellows on laparoscopic procedures including LSG and LRYGB expressed in global rating scales (GRS) scores. Significant enhanced performance was noted on depth perception (P = 0.02), bimanual dexterity (P = 0.01), and efficiency of movements (P = 0.03).27 In a Dutch study, Iordens et al. described their technique to teach residents the LRYGB.23 Over a 4-year period, a resident performed the last operation of a day dedicated to bypass surgery; in the other procedures, the resident was first assistant. Noted is that all 5 were postgraduate year (PGY) 5 to 6 residents with specific interest in advanced laparoscopic procedures. The residents learned the procedure step-by-step. In this way, residents operated on a total number of 83 patients. This resulted in a slight but significant increase in operating times from 116 minutes to 129 minutes (p ≤ 0.001). Complication rates of 18% in the control group vs. 22% in the group operated by residents did not differ significantly (P = 0.455). The study of Rovito et al. showed a similar design.24 The five PGY 5 students in this group performed at least 12 procedures each. The attending surgeons’ surgical time was 213 minutes, the residents’ mean 170 minutes. In both groups, 2 leaks occurred. Preoperative Intervention Five studies focused on intervention in the training before the operation theatre, 1 group changed the operative procedure to facilitate training and shorten the learning curve. Azer et al. implemented an Internet-based knowledge module on metabolic bariatric surgery to their general surgery curriculum.18 The largest effect was found in a subgroup analysis of residents who completed a bariatric rotation before the study period. Zevin et al. identified the available simulation-based training programs in addition to re-examining the learning curve of Roux-en-Y gastric bypass.21 2 33 Current techniques of teaching and learning in bariatric surgical procedures
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