Obesity Surgery

, Volume 29, Issue 2, pp 414–419 | Cite as

A Stepwise Approach in Learning Surgical Residents a Roux-en-Y Gastric Bypass

  • A. B. WalingaEmail author
  • S. R. van Mil
  • L. U. Biter
  • M. Dunkelgrün
  • G. H. E. J. Vijgen
Original Contributions



This study describes a stepwise training program to teach a laparoscopic Roux-en-Y gastric bypass (LRYGB). Results of a resident are compared to experienced bariatric surgeons (EBS).


The resident performed a varying amount of surgical steps and the duration of every step was measured using video analysis. In order to compare the resident’s results to EBS, the average time per step was calculated for 30 procedures.


The total procedure time of LRYGB was 61.15 (± 8.74) min for a novice resident. In comparison, the average of three EBS was 36.22 (± 9.06) min. Creation of the gastric pouch had an average of 12.82 (± 4.08) versus 6.93 (± 2.58) min. Duration of creating the stapled gastrojejunostomy was 7.43 (± 2.11) versus 4.48 (± 2.02) min. Suturing of the gastrojejunostomy was 12.60 (± 3.31) compared to 6.31 (± 2.53) min. Creating the jejunojejunal anastomosis had a duration of 7.12 ( ±2.31) versus 4.22 (± 1.60) min and suturing this anastomosis was 13.93 (± 3.81) compared to 8.51 (± 3.37) min. At the end of the traineeship, the observed progression approximated the skills level of the EBS.


The stepwise LRYGB-training program, analysed in this study, can result in an efficient and safe way to approach the learning curve to the level of the EBS. Within this training program, the total time of the operation is kept low in order to prevent adverse events for the patient and loss of efficiency in the bariatric program. The results of this study could act as a guideline for the development of such training programs.


Bariatric surgery Roux-en-Y gastric bypass Morbid obesity Surgical residents Training program Learning curve 



We would like to thank the help of Rien van den Oever, Functional Application Manager OK/Anaesthesia.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741–52. Available from: Google Scholar
  2. 2.
    Jl C, Picot J, Loveman E, Aj C. Surgery for obesity.Cochrane Database Syst Rev. 2009;2009(2):CD003641.Google Scholar
  3. 3.
    Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, Bantle JP, Sledge I. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. Elsevier Inc.; 2009;122(3):248–256.e5. Available from:
  4. 4.
    Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822–32.Google Scholar
  5. 5.
    Alqahtani A, Alamri H, Elahmedi M, et al. Laparoscopic sleeve gastrectomy in adult and pediatric obese patients: a comparative study. Surg Endosc. 2012;26(11):3094–100.Google Scholar
  6. 6.
    Gadiot RPM, Biter LU, Zengerink HJF. De Vos Tot Nederveen Cappel RJ, Elte JWF, Castro Cabezas M, Mannaerts GHH. Laparoscopic sleeve gastrectomy with an extensive posterior mobilization: technique and preliminary results. Obes Surg. 2012;22(2):320–9.Google Scholar
  7. 7.
    Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234(3):279–89. discussion 289–91. Available from: Google Scholar
  8. 8.
    Bach C, Miernik A, Schönthaler M. Training in robotics: the learning curve and contemporary concepts in training. Arab J Urol. 2014;58–61.Google Scholar
  9. 9.
    Rovito PF, Kreitz K, Harrison TD, et al. Laparoscopic Roux-en-Y gastric bypass and the role of the surgical resident. Am J Surg. 2005;189(1):33–7.Google Scholar
  10. 10.
    Ali MR, Tichansky DS, Kothari SN, et al. Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass. Surg Endosc. 2010;24(1):138–44.Google Scholar
  11. 11.
    Higa KD, Boone KB, Ho T, et al. Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients. Arch Surg (Chicago, Ill 1960). 2000;135(9):1029–33. discussion 1033-1034Google Scholar
  12. 12.
    DeMaria EJ, Sugerman HJ, Kellum JM, et al. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg. 2002;235(5):640–7.Google Scholar
  13. 13.
    Kligman MD, Thomas C, Saxe J. Effect of the learning curve on the early outcomes of laparoscopic Roux-en-Y gastric bypass. Am Surg. 2003;69(4):304–10. Available from: Google Scholar
  14. 14.
    Oliak D, Ballantyne GH, Weber P, et al. Laparoscopic Roux-en-Y gastric bypass: defining the learning curve. Surg Endosc. 2003;17(3):405–8. Available from: Google Scholar
  15. 15.
    Schauer P, Ikramuddin S, Hamad G, et al. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc. 2003;17(2):212–5.Google Scholar
  16. 16.
    Pournaras DJ, Jafferbhoy S, Titcomb DR, et al. Three hundred laparoscopic roux-en-y gastric bypasses: managing the learning curve in higher risk patients. Obes Surg. 2010;20(3):290–4.Google Scholar
  17. 17.
    Sánchez-Santos R, Estévez S, Tomé C, et al. Training programs influence in the learning curve of laparoscopic gastric bypass for morbid obesity: a systematic review. Obes Surg. 2012;22(1):34–41.Google Scholar
  18. 18.
    Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434–42. Available from: Google Scholar
  19. 19.
    Martin JA, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997;84(2):273–8.Google Scholar
  20. 20.
    Fried M, Hainer V, Basdevant A, et al. Inter-disciplinary European guidelines on surgery of severe obesity. Int J Obes. 2007;31(4):569–77. Available from: Google Scholar
  21. 21.
    Mannaerts GHH, van Mil SR, Stepaniak PS, et al. Results of implementing an enhanced recovery after bariatric surgery (ERABS) protocol. Obes Surg. 2016;26(2):303–12.Google Scholar
  22. 22.
    Clavien PA, Barkun J, De Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187–96.Google Scholar
  23. 23.
    >Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.Google Scholar
  24. 24.
    Aghajani E, Jacobsen HJ, Nergaard BJ, et al. Internal hernia after gastric bypass: a new and simplified technique for laparoscopic primary closure of the mesenteric defects. J Gastrointest Surg. 2012;16(3):641–5.Google Scholar
  25. 25.
    Reames BN, Bacal D, Krell RW, et al. Influence of median surgeon operative duration on adverse outcomes in bariatric surgery. Surg Obes Relat Dis. 2015;11(1):207–13.Google Scholar
  26. 26.
    Major P, Wysocki M, Dworak J, et al. Are bariatric operations performed by residents safe and efficient? Surg Obes Relat Dis. 2017;13(4):614–21.Google Scholar
  27. 27.
    Iordens GIT, Klaassen RA, Van Lieshout EMM, et al. How to train surgical residents to perform laparoscopic Roux-en-Y gastric bypass safely. World J Surg. 2012;36(9):2003–10.Google Scholar
  28. 28.
    Gonzalez R, Nelson LG, Murr MM. Does establishing a bariatric surgery fellowship training program influence operative outcomes? Surg Endosc. 2007;21(1):109–14.Google Scholar
  29. 29.
    Korndorffer JR, Dunne JB, Sierra R, et al. Simulator training for laparoscopic suturing using performance goals translates to the operating room. J Am Coll Surg. 2005;201(1):23–9.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • A. B. Walinga
    • 1
    Email author
  • S. R. van Mil
    • 1
  • L. U. Biter
    • 1
  • M. Dunkelgrün
    • 1
  • G. H. E. J. Vijgen
    • 1
  1. 1.Department of SurgeryFranciscusRotterdamthe Netherlands

Personalised recommendations