Bariatric Surgeon Training: Learning Curve and Surgical Skill Acquisition

**Bariatric Surgeon Training**

Stacy A.Brethauer,Philip R.Schauer

The number of bariatric surgeries performed worldwide has increased dramatically over the past decade. 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 adult and childhood obesity in the world, and the increase in 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. (Data from the American Academy of Bariatric Surgery)

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 Surgeons (SAGES) and the American Society of Bariatric Surgery (ASBS) have jointly published guidelines for the certification process for bariatric surgeons. In addition, ASBS has established guidelines for bariatric surgery specialty training programs to ensure 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 programs. 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 (25%) in the first 500 patients, but only in 28 cases (4.7%) in the latter 600 patients; erosion and perforation of the gastric wall at the banding site into the stomach occurred in 34 cases (3%), 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 intra-abdominal anatomy of morbidly obese patients (large amounts of visceral fat accumulation, hepatomegaly, and adhesions from previous surgeries) complicates the procedure. Regarding the learning curve of laparoscopic gastric bypass surgery, studies have found that traumatic infection, anastomotic leakage, operative time, and technique-related complications significantly decrease after completing 100 surgeries. Oliak et al. found significant reductions in operative time and complications after 75 surgeries, 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 (open and laparoscopic) performed during the chief residency was 5.8, higher than the 2.8 average in 2000, but still far from the minimum requirement (35) or the number needed to overcome the learning curve (75–100). 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 as mandated by ASBS. 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.