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Teaching Advanced Laparoscopic Skills in Surgery for Morbid Obesity

  • Alice Yi-Chien TsaiEmail author
  • Alan Osborne
  • Richard Welbourn

Abstract

Obesity is a serious public health issue in the Western world and rapidly climbing in developing countries. The data overwhelmingly suggest that bariatric surgery is currently more effective than conventional medical therapy. As the volume of bariatric surgery is increasing worldwide, it is essential to safeguard the standard of bariatric training and facilities that provide bariatric services.

Bariatric operations were originally designed as a restrictive procedure, such as gastric band and sleeve gastrectomy, or mal-absorptive procedures, such as Roux-en-Y gastric bypass. Laparoscopic bariatric surgery requires mastery of a broad range of cognitive and technical skills, including the management of severely obese patients. In the UK, the bariatric training pathway cumulates in a fellowship of 6 months to 1 year. During a bariatric fellowship, trainees start by learning the skills required in laparoscopic gastric banding including access in obese patients, trocar placements, liver retraction, pars flacida approach and laparoscopic suturing. Once these competencies are achieved, trainees progress to learning more challenging procedures such as laparoscopic Roux-en-Y gastric by-pass (LRYGB).

Structured training programmes adapt the teaching methods to the learning styles of trainees and facilitate trainees to go through the learning cycle under close supervision to minimise the proficiency-gain curve effect. Video-enhanced feedback forms an integral part of continuing self-reflection and assessment. Bariatric fellowships should be based in bariatric centres that can provide sufficient exposure, adequate case volume and variety of operations, and meet the professional standards for delivering patient-centred multidisciplinary care.

Keywords

Bariatric Obesity Roux-en-Y Gastric Bypass Weight Loss Proficiency-gain curve 

References

  1. 1.
    Misra A, Khurana L. Obesity and the metabolic syndrome in developing countries. J Clin Endocrinol Metab. 2008;93:S9–30.CrossRefPubMedGoogle Scholar
  2. 2.
    Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants. Lancet. 2011;377:557–67.PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Health Survey for England – 2010: Respiratory Health. The NHS Information Centre. 2011. Available from: www.ic.nhs.uk/pubs/hse10report.
  4. 4.
    Butland B, Jebb S, Kopelman P, McPherson K, Thomas S, Mardell J, et al. Foresight tackling obesities: future choices – project report. Foresight; 2007. Available from: www.foresight.gov.uk.
  5. 5.
    Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, et al. JAMA. 2003;289:76–9.CrossRefPubMedGoogle Scholar
  6. 6.
    National Audit Office. Tackling Obesity in England. London: the stationery office; 2001. Available from: https://www.nao.org.uk/report/tackling-obesity-in-england/.
  7. 7.
    Sjöström L, Lindroos A, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683–93.CrossRefPubMedGoogle Scholar
  8. 8.
    Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366:1567–76.PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E, Baxter L, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009;13(41):1–190.CrossRefGoogle Scholar
  10. 10.
    Shedding the pounds. Obesity management, NICE guidance and bariatric surgery in England. Office of Health Economics; 2010. Available from: http://www.rcseng.ac.uk/news/docs/BariatricReport.pdf.
  11. 11.
    Obesity. Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE clinical guideline 43; 2006. Available from: http://www.nice.org.uk/guidance/index.jsp?action=download&o=30365.
  12. 12.
    Hutchison RL, Hutchison AL. Cesar Roux and his original 1893 Paper. Obes Surg. 2010;20:953–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Mason EE, Printen KJ, Blommers TJ, Lewis JW, Scott DH. Gastric bypass in morbid obesity. Am J Clin Nutr. 1980;33:395–405.PubMedGoogle Scholar
  14. 14.
    Story of Obesity Surgery [Internet]. American Society for Metabolic & Bariatric Surgery. [updated 2005 May 25, cited 2014 Jan 20]. Available from: http://asmbs.org/story-of-obesity-surgery/.
  15. 15.
    Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4:353–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Luján JA, Frutos MD, Hernández Q, et al. Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study. Ann Surg. 2004;239(4):433–7.PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    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.PubMedCentralCrossRefPubMedGoogle Scholar
  18. 18.
    MacLean LD, Rhode BM, Nohr CW. Late outcome of isolated gastric bypass. Ann Surg. 2000;231:524–8.PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    MacLean LD, Rhode BM, Sampalis J, Forse RA. Results of the surgical treatment of obesity. Am J Surg. 1993;165:155–62.CrossRefPubMedGoogle Scholar
  20. 20.
    Welbourn R, Fiennes A, Kinsman R, Walton P. The United Kingdom national bariatric surgery registry. First registry report to March 2010. Dendrite Clinical Systems; 2011.Google Scholar
  21. 21.
    De la Torre RA, Scott JS. Laparoscopic Roux-en-Y divided gastric bypass with transgastric anvil placement. In: Inabnet WB, Demaria EJ, Ikramuddin S, editors. Laparoscopic bariatric surgery. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 116–22.Google Scholar
  22. 22.
    Kurian M, Roslin M. Laparoscopic Roux-en-Y gastric bypass: transoral technique. In: Inabnet WB, Demaria EJ, Ikramuddin S, editors. Laparoscopic bariatric surgery. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 95–101.Google Scholar
  23. 23.
    Brolin RE, Kenler HA, Gorman JH, Cody RP. Long-limb gastric bypass in the superobese. A prospective randomized study. Ann Surg. 1992;215:387–95.PubMedCentralCrossRefPubMedGoogle Scholar
  24. 24.
    Bruder SJ, Freeman JB, Brazeau-Gravelle P. Lengthening of Roux-en-Y limb increases weight loss after gastric bypass: a prelimary report. Obes Surg. 1991;1:73–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Brolin RE. Long limb Roux en Y gastric bypass revisited. Surg Clin North Am. 2005;85:807–17.CrossRefPubMedGoogle Scholar
  26. 26.
    Christou NV, Look D, MacLean LD. Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 Years. Ann Surg. 2006;244:734–40.PubMedCentralCrossRefPubMedGoogle Scholar
  27. 27.
    Orci L, Chillcott M, Huber O. Short versus long Roux-limb length in Roux-en-Y gastric bypass surgery for the treatment of morbid and super obesity: a systematic review of the literature. Obes Surg. 2011;21:797–804.CrossRefPubMedGoogle Scholar
  28. 28.
    Le Roux CW, Aylwin SJ, Batterham RL, Borg CM, Coyle F, Prasad V, et al. Gut hormone profiles following bariatric surgery favor an anorectic state, facilitate weight loss and improve metabolic parameters. Ann Surg. 2006;243:108–14.PubMedCentralCrossRefPubMedGoogle Scholar
  29. 29.
    Scholtz S, Miras AD, Chhina N, Prechtl CG, Sleeth ML, Daud NM, et al. Obese patients after gastric bypass surgery have lower brain-hedonic responses to food than after gastric banding. Gut. 2014;63(6):891–902. doi:  10.1136/gutjnl-2013-305008.
  30. 30.
    Belachew M, Legrand M, Vincenti VV, Deffechereux T, Jourdan JL, Monami B, et al. Laparoscopic placement of adjustable silicon gastric band in the treatment of morbid obesity: how to do it. Obes Surg. 1995;5:66–70.CrossRefPubMedGoogle Scholar
  31. 31.
    O’Brien PE, Dixon JB, Laurie C, Anderson M. A prospective randomized trial of placement of the laparoscopic adjustable gastric band: comparison of the perigastric and pars flaccida pathways. Obes Surg. 2005;15:820–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Di Lorenzo N, Furbetta F, Favretti F, Segato G, De Luca M, Micheletto G, et al. Laparoscopic adjustable gastric banding via pars flaccida versus perigastric positioning: technique, complications and results in 2459 patients. Surg Endosc. 2010;24:1519–23.CrossRefPubMedGoogle Scholar
  33. 33.
    Kini S, Rao R, editors. Review of obesity and bariatric surgery. Essential notes and multiple choice questions. New York: Informa Healthcare; 2012.Google Scholar
  34. 34.
    Shen R, Dugay G, Rajaram K, Cabrera L, Siegel N, Ren CJ. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg. 2004;14:514–9.CrossRefPubMedGoogle Scholar
  35. 35.
    O’Brien P, Dixon JB. Laparoscopic adjustable gastric banding. In: Inabnet WB, Demaria EJ, Ikramuddin S, editors. Laparoscopic bariatric surgery. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 75–84.Google Scholar
  36. 36.
    Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8(3):267–82. doi: 10.1381/096089298765554476.CrossRefPubMedGoogle Scholar
  37. 37.
    De Csepel J, Burpee S, Jossart G, Andrei V, Murakami Y, Benavides S, et al. Laparoscopic biliopancreatic diversion with a duodenal switch for morbid obesity: a feasibility study in pigs. J Laparoendosc Adv Surg Tech A. 2001;11:79–83.CrossRefPubMedGoogle Scholar
  38. 38.
    Milone L, Strong V, Gagner M. Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI > or =50). Obes Surg. 2005;15:612–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Trelles N, Gagner M. Updated review of sleeve gastrectomy. Open Gastroenterol J. 2008;2:41–9.CrossRefGoogle Scholar
  40. 40.
    Basso N, Casella G, Rizzello M, Abbatini F, Soricelli E, Alessandri G, et al. Laparoscopic sleeve gastrectomy as first stage or definitive intent in 300 consecutive cases. Surg Endosc. 2011;25:444–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Eisenberg D, Bellatorre A, Bellatorre N. Sleeve gastrectomy as a stand-alone bariatric operation for severe, morbid and super obesity. JSLS. 2013;17:63–7.PubMedCentralCrossRefPubMedGoogle Scholar
  42. 42.
    Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V. Biliopancreatic by-pass for obesity. II. Initial experience in man. Br J Surg. 1979;66(9):618–20.CrossRefPubMedGoogle Scholar
  43. 43.
    Kelly J, Shikora S, Jones D, Hutter M, Robinson MK, Romanelli J, et al. Best practice updates for surgical care in weight loss surgery. Obesity. 2009;17:863–70.CrossRefPubMedGoogle Scholar
  44. 44.
    Dorman RB, Rasmus NF, al-Haddad BJ, Serrot FJ, Slusarek BM, Sampson BK, et al. Benefits and complications of the duodenal switch/biliopancreatic diversion compared to the Roux-en-Y gastric bypass. Surgery. 2012;152:758–65.CrossRefPubMedGoogle Scholar
  45. 45.
    Livingston ED. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg. 2010;200:378–85.PubMedCentralCrossRefPubMedGoogle Scholar
  46. 46.
    Statistics on obesity, physical activity and diet: England, 2012. The NHS Information Centre; 2012. Available from: http://www.hscic.gov.uk/catalogue/PUB05131/obes-phys-acti-diet-eng-2012-rep.pdfGoogle Scholar
  47. 47.
    Melissas J. IFSO guideline for safety, quality and excellence in bariatric surgery. Obes Surg. 2008;18:497–500.CrossRefPubMedGoogle Scholar
  48. 48.
    BOMSS Professional Standards Document March 2013. Available from: http://www.bomss.org.uk/pdf/clinical_services_standards/BOMSS-Professional-Standards-March-2013.pdf.Google Scholar
  49. 49.
    Resources for Optimal Care of Metabolic and Bariatric Surgery Patient 2014. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Available from: http://www.mbsaqip.info/?page_id=54.
  50. 50.
    Zevin B, Aggarwal R, Grantcharov TP. Volume-outcome association in bariatric surgery: a systemic review. Ann Surg. 2012;256:60–71.CrossRefPubMedGoogle Scholar
  51. 51.
    Osborne A, Hammond J, Allum W. Manpower planning in upper GI surgery: right or wrong? J ASGBI. 2011;35:3–7.Google Scholar
  52. 52.
    Oliak D, Ballantyne GH, Weber P, Wasielewski A, Davies RJ, Schmidt HJ. Laparoscopic Roux-en-Y gastric bypass: defining the proficiency-gain curve. Surg Endosc. 2003;17:405–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Pournaras DJ, Jafferbhoy S, Titcomb DR, Humadi S, Edmond JR, Mahon D, et al. Three hundred laparoscopic Roux-en-Y gastric bypasses: managing the proficiency-gain curve in higher risk patients. Obes Surg. 2010;20:290–4.CrossRefPubMedGoogle Scholar
  54. 54.
    Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004;199:543–51.CrossRefPubMedGoogle Scholar
  55. 55.
    Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357:753–61.CrossRefPubMedGoogle Scholar
  56. 56.
    Kothari SN, Boyd WC, Larson CA, Gustafson HL, Lambert PJ, Mathiason MA. Training of a minimally invasive bariatric surgeon: are laparoscopic fellowships the answer? Obes Surg. 2005;15:323–9.CrossRefPubMedGoogle Scholar
  57. 57.
    Kolb DA. Experimental learning experience as a source of learning and development. London: Prentice Hall; 1984.Google Scholar
  58. 58.
    British Obesity & Metabolic Surgery Society. Bariatric and metabolic fellowship core curriculum for the RCS national surgical fellowship scheme. 2013. Available from: http://www.bomss.org.uk/pdf/Bariatric%20and%20Metabolic%20Fellowship%20Core%20Curriculum%20for%20Post-CCT%20Fellows.pdf.
  59. 59.
    Osborne AJ, Hawkins SC, James A, Pournaras D, Pullyblank A. Training in current medical education: surgeons are different from their medical colleagues. B Roy Coll Surg Engl. 2012;94:242–5.CrossRefGoogle Scholar
  60. 60.
    Groat A, Musson T. Learning styles: individualising computer based learning environments. Assoc Learn Technol J. 1996;3:53–62.CrossRefGoogle Scholar
  61. 61.
    Cresswell B, Marron C, Hawkins W, Harrison E, Fitzgerald, von Roon A. Optimising working hours to provide quality in training and patient safety. A position statement by the Association of Surgeons in Training. 2009.Google Scholar
  62. 62.
    Dean B, Pereira E. Surgeons and training time. BMJ Careers. 2011. Available from: http://careers.bmj.com/careers/advice/view-article.html?id=20005162.
  63. 63.
    Herron DM. Establishing and organizing a bariatric surgery programme. In: Inabnet WB, Demaria EJ, Ikramuddin S, editors. Laparoscopic bariatric surgery. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 23–31.Google Scholar
  64. 64.
    Birkmeyer NJ, Dimick JB, Share D, Hawasli A, English WJ, Genaw J, et al. Hospital complication rates with bariatric surgery in Michigan. JAMA. 2010;304:435–42.CrossRefPubMedGoogle Scholar
  65. 65.
    DeSmidt B. Medicare drops centre of excellence program in bariatric surgery. The Pipeline. 2013. Available from: http://www.advisory.com/research/technology-insights/the-pipeline/2013/10/medicare-drops-center-of-excellence-program-in-bariatric-surgery.
  66. 66.
    Micheal Griffin S, Raimes SA, Jon S. Oesophagogastric surgery. Edinburgh/New York: Elsevier; 2014. p. 358–80. 978-0-7020-4962-0.Google Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  • Alice Yi-Chien Tsai
    • 1
    Email author
  • Alan Osborne
    • 2
  • Richard Welbourn
    • 3
  1. 1.Upper Gastrointestinal SurgeryMusgrove Park HospitalTaunton, SomersetUK
  2. 2.Department of Bariatric SurgeryNorth Bristol NHS Trust, Southmead HospitalBristolUK
  3. 3.Dept Upper GI and Bariatric SurgeryMusgrove Park HospitalTaunton, SomersetUK

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