Bariatric Surgeon Training: Learning Curve and Surgical Skill Acquisition

Bariatric Surgeon Training

Stacy A.Brethauer,Philip R.Schauer

Over the past decade or so, the number of bariatric surgeries performed worldwide has increased dramatically. Factors contributing to this increase include: ① the prevalence of obesity in industrialized societies; ② increased attention to the social burden of this epidemic; ③ the development of minimally invasive bariatric surgery techniques; and ④ a growing body of literature and research supporting the safety, effectiveness, and longevity of bariatric surgery. The United States has the highest prevalence of obesity among adults and children in the world, and the increase in the number of bariatric surgeries over the past decade reflects this trend. Estimated numbers of bariatric surgeries in the United States are as follows: 1992-1996: 15,000–20,000; 1997-1999: 20,000–30,000; 2000: 38,000; 2001: 48,000; 2002: 63,000; 2003: 104,000; 2004: 140,000.

Laparoscopic bariatric surgery, which began in the late 1990s, has made significant contributions to the treatment of obesity. This minimally invasive surgical approach has attracted many surgeons interested in advanced laparoscopic techniques and patients seeking less surgical trauma. With the rapid increase in bariatric surgeries, professional training and certification for bariatric surgeons have become essential. The American Academy of Gastrointestinal and Endoscopic Surgery and the American Society of Bariatric Surgery have jointly released guidelines for the certification process for bariatric surgeons. In addition, the American Society of Bariatric Surgery has established guidelines for bariatric surgery specialty training programs to ensure that trainees receive critical and diverse clinical training. Previously, surgeons could perform bariatric surgery through self-practice or short-term training; this method has now been largely replaced by formal training during residency or specialty training. This chapter will introduce the various existing bariatric surgery training methods, certification procedures, specialty training, and future development directions.

Learning curve

Surgical training follows various learning curves, primarily in the acquisition of surgical skills and patient management experience. These learning curves also apply to bariatric surgery training. To be competent in bariatric surgery, both surgical skills and patient management abilities must be up to par. The concept of a learning curve for a specific surgery originated in the late 1980s, when surgeons performing open cholecystectomy experienced higher complication rates in the early stages of laparoscopic surgery. Since then, numerous studies and publications have described the specific learning curve for each new laparoscopic surgery. A learning curve typically represents the number of cases required to achieve a complication rate equivalent to that of open surgery.

Laparoscopic adjustable gastric banding is less technically demanding than gastric bypass surgery, but some complications can still occur in cases performed early in a surgeon's career. In a study of 1120 cases of laparoscopic gastric banding using Lap-Band at O'Brien and Dixon's, the complication rate was higher in some early cases. For example, gastric mucosal prolapse at the banding site occurred in 125 cases in the first 500 patients, but only 28 cases in the latter 600; erosion and perforation of the gastric wall at the banding site into the stomach occurred in 34 cases, all in the first 500 patients. The Italian Lap-Band collaborative research group found that 5% of 1863 patients developed gastric sac enlargement, with two-thirds of these cases occurring in the first 50 cases at their center. The incidence of gastric sac enlargement decreased with increasing surgical experience.

Laparoscopic gastric bypass surgery is an advanced laparoscopic procedure with a longer learning curve. This surgery requires surgeons to possess excellent laparoscopic skills, including internal suturing, anastomosis at different locations in the abdomen, complex exposure techniques, gastrointestinal tract cutting and closure, and bimanual dissection techniques. The abdominal anatomy of morbidly obese patients adds to the difficulty of this procedure. Regarding the learning curve of laparoscopic gastric bypass surgery, studies have found that the incidence of traumatic infection, anastomotic leakage, operative time, and technique-related complications significantly decreases after completing 100 surgeries. Oliak et al. found that after 75 surgeries, both operative time and complications significantly decreased, and other studies have also found that the more surgical experience, the lower the probability of complications.

Acquisition of surgical skills

During surgical residency training, few surgeons complete the required number of laparoscopic bariatric surgeries. In 2004, the average number of bariatric surgeries performed during the chief residency was 5.8, higher than the 2.8 average in 2000, but still far below the minimum requirement or the number needed to overcome the learning curve. Besides operating room training, practicing laparoscopic techniques using animal models can significantly increase the surgical experience of surgeons at all levels. Laparoscopic training equipment can also objectively assess surgical skills, address deficiencies, and monitor progress in surgical technique.

Physicians can receive specific surgical training through short courses or weekend workshops, including classroom-style training and animal surgical practice. These courses are typically aimed at surgeons with advanced laparoscopic skills who also want to learn bariatric surgery. Simultaneously, surgeons who perform open bariatric surgery can also begin to explore laparoscopic bariatric methods through these short training programs. However, the training provided in these short courses is insufficient to enable trainees to perform surgery independently.

Short-term clinical training (SCT) refers to targeted, short-term clinical training in bariatric surgery and is the best option for surgeons beginning their bariatric practice. SCT is a 6-12 week program designed for surgeons with advanced laparoscopic skills who wish to gain experience in bariatric surgery. Its goal is to acquire the necessary experience required for bariatric surgery licensing by the American College of Bariatric Surgeons. Trainees must obtain a medical license in the state where their training facility is located. SCT trainees learn all aspects of bariatric surgery, including preoperative assessment, open and laparoscopic surgical procedures, postoperative routines and complication management, and long-term postoperative care. Theoretical learning in SCT is conducted through textbook review, participation in paper discussions, and clinical conferences. Trainees are also exposed to the organizational structure of bariatric surgery programs, personnel requirements, specific equipment and hospital facility requirements, and unique management issues associated with bariatric surgery.