courses or other type of instruction prepared residents before performing MBS and the level of supervision reached by the residents at the end of formal training (A = assisting, B = strict supervision, C = limited supervision, D = without supervision, E = supervising). Surgeons were also interviewed on relevant technical details, such as the number of trocars used in LRYGB (excluding the liver retractor). Finally, the postgraduate year in which residents were allowed to perform specific steps of LRYGB and LSG was recorded. At least two residents or fellows were surveyed for each centre. Questionnaires were sent by email and regular mail. Residents and fellows were asked the following data: age, gender, postgraduate year (PGY); track specialization and hospital setting. The survey also consisted of questions on how many metabolic bariatric operations they had performed, the level of supervision, and in which order and pace different steps were instructed. Dutch residents are required to collect at least twenty electronic Objective Standard Assessment of Technical Skill (OSATS) observations per year, which include the level of supervision needed for specific procedures. The full list of translated questions is stated in Appendix I. Reminders were sent after two and six weeks. In February 2015, the survey was closed. For analyses, data from residency-accredited hospitals were included. Data from centres with unaccredited fellowships without residency accreditation were excluded. RESULTS Surgeons’ Responses Surgeons from all 19 centres participated in the study (100%). Baseline data of the 19 lead surgeons and residency accreditation are summarized in Table 1. The answers from twelve respondents working in resident teaching centres (12/19= 63%) were analysed in more detail. In these twelve hospitals, the average number of trained residents or fellows was 14 (range 3-33). LRYGB was the preferred training procedure in 10 centres, laparoscopic sleeve resection in 1 centre, and in 1 centre both procedures were taught equally. A mean number of 4 trocars were used (range 3-5). Lead surgeons, fellows and residents reported the PGY in which residents started performing various steps of the procedures (Table 2). The majority of lead surgeons stated that residents should be experienced with basic laparoscopic procedures (appendectomy, cholecystectomy, inguinal hernia repair) before embarking on bariatric procedures. All surgeons mandated completion of a basic laparoscopic 46 3
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