They also proposed a 5-step, mostly ex vivo, metabolic bariatric surgery training curriculum, consisting of knowledge-based learning, a procedural task analysis, training in a laboratory environment before the last 2 steps, transfer of skills to the operating room, and granting privileges. The studies of Leandros et al., Varas et al., and Zimmerman et al. described advanced laparoscopic training courses focused on bariatric procedures.19,20,22 These wet lab and box trainer studies concluded the LRYGB and LSG, or steps of the procedures, can be trained ex vivo before transferring skills to the operating theatre even for PGY1 residents. In 2007, Harrington et al. performed a time-cost analysis on the LRYGB procedural step of the laparoscopic jejunojejunostomy.25 Their results showed that it would cost around $45,000 to give 15 senior residents the opportunity to perform 2 anastomoses. Part of their calculation was the educational time, and the extra 43 minutes of operation time residents needed compared to surgeons. Martin et al. reduced the learning curve by simplification and standardization of the operative technique, introducing a linear stapled anastomosis. In this study, PGY 2 to 5 residents performed 140 LRYGB surgeries. The average operating time was 116 minutes. A survey between the surgeons and residents showed the new technique to be faster and simpler, and easier to teach.28 DISCUSSION This systematic review is the first to focus on education of bariatric surgical procedures. Fourteen studies describing training aspects of the LRYGB and LSG were included. With the use of the educational database ERIC, attempted was made to include studies from an educational point of view; however, none of the search hits were suitable for inclusion. We will next asses the systematic review process, summarize the data on training and effect on patient outcomes, and propose how to implement these outcomes. A variety of methods to perform a systematic review are available. In this study, the GRADE technique was used because this system is suitable for both studies with a high and low level of evidence, and both RCTs and local initiatives were expected.17 This system not only assigns grades to the type of evidence but also offers clear guidelines for altering this grade with a downgrade or upgrade for the quality of this study. For health care education literature, 34 2
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