The effects of resident and fellow involvement in metabolic bariatric surgery on operation times and, most importantly, patient safety outcomes, have been discussed in several publications.7-11 In a retrospective study on 17,057 LRYGB patients from Michigan, resident involvement was an independent risk factor for wound infection, but not for venous thromboembolism.7 Several analyses of patients included in the American College of Surgeons NSQIP database have been published. Davis et al. reported a series of 12,390 LRYGB patients, showing that resident involvement was associated with increased morbidity rates (4.0% vs. 5.2%, p < 0.01).8 In another cohort of 10,838 LRYGB and sleeve gastrectomy patients, fellow involvement was found to be an independent risk factor for complications (overall, serious, and surgical) and reoperation rates in the LRYGB group, but not for sleeve gastrectomy.9 During the first six months of fellowship, Bhayani et al. specifically noted increased rates of surgical site infection, urinary tract infection, deep veinous thrombosis and sepsis.10 After six months, outcomes were similar to patients operated by attending. On the other hand, a multivariate analysis of a database of 47,342 patients from New York State showed that bariatric fellowship-accreditation was significantly associated with improved perioperative patient outcomes compared to non-fellowship-accredited hospitals.11 Mortality was not associated with fellow participation in any of the aforementioned studies. These data support the continued need for training programmes for both residents and fellows to improve technical skills. The previously described teaching model incorporated partially supervised laparoscopic box training with an efficient program to teach residents using an in vivo step-by-step method.6 The surgeons from this centre chose to teach the steps in order of increasing difficulty, which is consistent with contemporary teaching principles.12 The division of the procedures into several steps is thought to be a result of time pressure of the operating schedule. Several studies have supported breaking up procedures into sub-steps to facilitate training in vivo or in a training laboratory.13-15 Description of procedural key steps, which has been performed for laparoscopic colorectal surgery, cholecystectomy, and appendectomy, can help to establish structured teaching programs.16,17 We intend to describe these key steps for LRYGB and LSG in the future. It is noteworthy that the involvement of residents in the out-patient clinic for follow-up of patients and complications proved limited. As future surgeons, residents need to be able to actively inform patients on the risks and benefits of bariatric surgery, but should also be 52 3
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