Laparoscopic Gastric Bypass: A Training Model

by Susannah M. Wyles, MBBS, MSc, MRCS (Eng), and
Ahmed R. Ahmed, MBBS, BSc (Hons), FRCS

Dr. Wyles is Clinical Research Fellow, Imperial College, London, United Kingdom. Dr. Ahmed is Consultant Upper Gastrointestinal and Bariatric Surgeon, Department of Bariatric Surgery, Imperial College Healthcare, Charing Cross Hospital, London, United Kingdom.

Bariatric Times. 2009;6(12):12–13

Abstract
The demand for bariatric surgery is increasing on a daily basis due to the rapidly increasing number of patients with obesity worldwide. This is directly creating a requirement for more trained surgeons in these complex operative techniques. In the United Kingdom in particular, there are limited training opportunities for bariatric surgery. The aim was to create a bariatric training course with a hands-on training model. This article briefly reviews the basic hands-on training model and includes illustrative photos.

Introduction
Bariatric surgery is one of the most technically challenging branches of general surgery.[1] It involves complex operative techniques, which are even more difficult when performed laparoscopically.[2,3] It has been well proven that bariatric surgery is the most effective treatment for severe obesity, and with the increasing worldwide epidemic of obesity and super-obesity, more patients will be requiring this treatment.[4] Yet, particularly in the United Kingdom, there is a shortfall of surgeons competent to perform such surgery. This is in part because it takes time for surgeons to master the technique and ascend the “learning curve,” but it can also be attributed to the limited number of training posts and fellowships available for trainees. In the United Kingdom, there is also a notable lack of bariatric training courses, and more specifically those that allow for surgeons to get actual “hands-on” experience in addition to live-link surgery.[5]

Hands-on training model
Acknowledging this gap in training opportunities, we developed a bariatric surgery training course with the following objectives:
•     To cover laparoscopic surgical procedures in bariatric surgery requiring the use of gastrointestinal stapling devices
•     To provide indications for surgical treatment and discuss operative complications
•     To highlight technicalities of surgical interventions through the broadcasting of live procedures
•     To allow real-time discussion between the operators and the surgeon trainees
•     To provide hands-on sessions to improve skills in laparoscopic surgery through practice on ex-vivo tissue
•     To allow multidisciplinary team (MDT) training by describing the roles of the bariatric MDT, the postoperative clinical results, and practical applications of evidence-based clinical medicine, as well as giving tips to those setting up a bariatric surgery practice.

The course had two key foci: an emphasis on the multidisciplinary approach to providing a successful bariatric service and to provide trainees, as well as established upper gastrointestinal surgeons, the opportunity to practice some key steps in laparoscopic gastric bypass and sleeve gastrectomy using a laparoscopic box simulator.

We developed a training model that enabled each trainee to perform a model laparoscopic gastric bypass and a sleeve gastrectomy under the close supervision of an expert bariatric surgeon. First, we created a short training video demonstrating the proposed procedure in a stepwise fashion, interspersed with technical tips. This allowed the trainees to ask the experts questions before they got started, but also it meant they could recreate the training model back in their own hospital.

To start, the animal tissue model is laid out on a cork board and pinned (Figure 1 and Figure 2). It is placed within a standardized laparoscopic box trainer. The trainee can then use all the usual operative equipment including the harmonic scalpel, staplers, and staple-line reinforcing material (Figure 3 and Figure 4). This has the added advantage of allowing the trainees to familiarize themselves with these instruments without putting a patient at risk. The delegates then individually create a gastric pouch, a gastroenterostomy, and an enteroenterostomy using a combined stapled and handsewn technique, taking turns to hold the camera (Figure 5, Figure 6, and Figure 7).

This animal tissue training model with instructive video is a safe, cheap, feasible, and effective way to begin the learning curve of a complicated surgical procedure: laparoscopic gastric
bypass.

References
1.    Nguyen NT, Root J, Zainabadi K, Set al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg. 2005;140:1198–1202.
2.    Schauer P, Ikramuddin S, Hamad G, Gourash W. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc. 2003;17:212–215.
3.    Oliak D, Ballantyne GH, Weber P, et al. Laparoscopic Roux-en-Y gastric bypass: defining the learning curve. Surg Endosc. 2003;17:405-408.
4.    Nguyen NT, Rivers R, Wolfe BM. Factors associated with operative outcomes in laparoscopic gastric bypass. J Am Coll Surg. 2003;197:548–555.
5.    http://www.rcseng.ac.uk/education
/courses/advanced-skills-in-laparoscopic-surgery-bariatrics Accessed 11/13/2009.

Tags: bariatric, Laparoscopic, training course

Category: Past Articles, Review