retrospective design. The results of the Rovito series have to be interpreted with care, as the mean operative time of 213 minutes by the attending surgeon and 170 minutes by the trainees suggest a severe selection bias. The results of the surgeon were collected earlier in the learning curve and may be a reflection of more difficult operations by the attending, as they reported on a significant number of patients with a BMI > 50 kg/m2 in this group. Currently, no published expertise exists on the actual training method of these steps for bariatric procedures, such as the Intraoperative Video ENhanced Surgical Training (INVEST) as proposed by van Det et al. for laparoscopic cholecystectomies.30 Our results suggest that dividing the operations into smaller steps, however, may be one of many ways to enhance resident teaching. One of the fundamental steps in surgical training is knowledge gathering. Azer et al. successfully implemented an Internet-based knowledge module.18 As the largest effect was found in a subgroup analysis of residents who completed a bariatric rotation before their study, it can be hypothesized that participating in surgeries and acquiring knowledge could best be combined. Next to knowledge gaining, preoperative ex vivo training was studied in several studies. The use of a wet lab and box trainer at some point in the training appears to be a useful instrument.19-22 The presented systematic review did not show any specific animal model training. The importance of training of residents and fellows must be considered in respect to the possible side effects on patient outcomes such as surgical site infections (SSI) and venous thromboembolic events (VTE).31 Single studies as performed by Davis et al. did not show these effects.5 Owing to the heterogeneity of the reviewed studies, our data could not be pooled to provide additional evidence on this subject. A small study of Harrington et al. reported on the costs of intraoperative resident training.25 The reported operation times may not reflect current standard techniques; however, the calculation of the additional costs of training may still be valid, and these should also be considered. Further research could lead to the development of training programs leading to sufficient expertise in laparoscopic metabolic bariatric surgery after completion of surgical rotations or a specific fellowship, which may result in granting of bariatric privileges. The ideal curriculum focusing on technical skill training in metabolic bariatric surgery should include the components studied in this article. Assuming basic laparoscopic skills are 36 2
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