The three key elements for a successful bariatric surgeon: skill, knowledge, and fairness.

**Three key elements for a successful bariatric surgeon: skill, knowledge, and fairness**

James C. Rosser, Jr. and Liza Eden Giammaria

Modern American society faces a significant challenge from the high prevalence of overweight and obesity among adults (aged 20-74). The results of the Second National Health and Nutrition Examination Survey (NHANES II), conducted between 1976 and 1980, showed that 47% of adults were overweight (BMI ≥ 25), and 15% met the obesity criteria (BMI ≥ 30). The Third Survey (NHANES III), conducted between 1988 and 1994, showed that 56% of adults were overweight, and the obesity rate reached 23%. The Fourth Survey (NHANES IV, 1999-2000) further indicated that the overweight population reached 64%, and the obesity rate reached 31%. Recent statistics suggest that the prevalence of overweight and obesity will continue to rise in the future.

Obesity rates are generally higher among certain minority groups, particularly women of African descent, Mexican descent, Native American descent, Pacific Islander descent, Puerto Rican descent, and Cuban descent. The increasing numbers of these minority groups in the United States are one reason for the rising obesity rates. Therefore, the obesity problem should be addressed and resolved as soon as possible. Obesity is not just a problem in the United States; it is a problem faced by many countries around the world, a price paid for social progress and development. Long-term dietary control and exercise are important strategies for combating obesity, although their short-term effects may not be significant. For those already obese, dietary control and exercise are often ineffective, requiring them to seek other treatment methods.

Currently, the number of people eligible for bariatric surgery is enormous. In the United States, 14 million people have a BMI of 36-39, and only those with accompanying obesity-related complications meet the current surgical criteria. Despite this limitation, a considerable number still meet the current surgical treatment criteria. In addition, 8 million people have a BMI of 40 or higher. Clearly, the number of people in the United States who need bariatric surgery is now substantial. As some prominent celebrities publicly revealed that they had also chosen surgery to treat obesity, the public stigma associated with this treatment lessened. Subsequently, bariatric surgery rapidly gained popularity and generated a huge demand effect, with the number of surgeries increasing from 5,500 in 2000 to 77,000 in 2001. In 2002, a total of 116,000 surgeries were performed, including 15,000 laparoscopic adjustable gastric banding procedures. In 2004, the number of surgeries reached 140,000, with approximately 25,000 being laparoscopic adjustable gastric banding procedures. Recent statistics show that the number of surgeries continues to grow, with more than 200,000 surgeries performed in 2006.

The number of qualified surgeons capable of safely performing these procedures has not grown as rapidly as demand. In 2000, nearly 500 general surgeons performed bariatric surgery as their primary work. This number rose to 696 in 2001, 865 in 2002, 1143 in 2003, and over 1500 in 2004. Many believe that large medical centers can increase their surgical volume to meet demand; however, this is not the case, with these centers averaging only 33% annual case growth. Meanwhile, laparoscopic surgery has become increasingly common. Schauer et al. reported that the learning curve for bariatric surgery is the longest of all minimally invasive surgeries, and the high skill requirements make training excellent bariatric surgeons difficult. Increased surgical risks and reduced health insurance coverage have also contributed to a shortage of qualified surgeons who can safely perform this procedure. This situation is partly due to the fact that many insurance companies do not cover this treatment.

All these factors place immense pressure on medical schools and teaching hospitals in training such surgeons, as traditional educational models are inefficient in producing the necessary numbers. Surgeons must possess advanced surgical skills and a solid knowledge base to provide comprehensive care and perform these surgeries minimally invasively. Furthermore, aspiring bariatric surgeons cannot be motivated solely by gaining experience and earning money. They must also support patients who lack social acceptance, burdened not only by excess body fat but also by discrimination in society and at work. New approaches to help these patients must be continuously explored.

**Skill**

The skills required for successful and safe laparoscopic bariatric surgery include accurate positioning, dexterity in two-dimensional space, and precise hand-eye coordination. These skills should not be merely mastered, but rather performed at a high level. Furthermore, surgeons should not rely solely on technology to achieve surgical efficiency and patient safety. They must possess the skills to protect patients and successfully complete surgeries even in the event of equipment malfunction. They must be able to perform internal sutures skillfully under endoscopic guidance, although this is the most challenging aspect of laparoscopic surgery. However, this skill is absolutely essential if the same level of safety as open surgery is desired.

In the past, it was believed that learning and mastering suturing techniques required long-term, high-intensity training. However, for the increasingly demanding bariatric surgery, suturing is an essential skill, not an auxiliary one. Numerous training courses and facilities have now been established to train in minimally invasive techniques. Gerald Fried et al. at McGill University in Canada developed the McGill Simulation Training and Evaluation System (MISTE), which has become the foundation of the Basic Laparoscopic Surgery (FLS) curriculum of the Society of Gastrointestinal Endoscopy (SAGES) and is now adopted by the American College of Surgeons and the American Society of Laparoscopic Surgery. These outstanding surgical training programs emphasize the training of fundamental surgical skills, not just internal suturing.

The Rosser Laparoscopic and Suturing Elite Training Program is a highly competitive, interactive training course proven to be effective and rapid in training laparoscopic techniques and suturing skills. Detailed information about this program is available in several publications. The program is well-structured, with a recommended student-to-faculty ratio of 4:1. Level I can be achieved in 1.5 days. Through effective preparatory exercises, participants acquire the fundamental skills required for in-vivo suturing. A CD-ROM containing all course materials and detailed instructions on suturing procedures is included with the course. A significant feature of the program is its large database, which indicates how well learners compare to their peers. Its distance learning platform and online continuing education capabilities facilitate further skill development. The program offers a progressively challenging series of courses, from Level I (basic skills and suturing), to Level II (advanced), and finally Level III (anastomosis).

Early minimally invasive training programs used the length of training time as a quantitative evaluation standard. Later training practices showed that time is not the sole criterion for judging training effectiveness, as the length of training time does not necessarily represent operational accuracy. Furthermore, elite training programs, as mentioned earlier, require a high teacher-to-student ratio to achieve good, error-free training results, a limitation that prevents the training of a large number of students. Traditional computer training programs, lacking a quantitative evaluation system for operational precision, cannot reflect the cost of training. To receive complete training, students need to attend multiple programs, thus increasing training costs. Additionally, busy work schedules significantly reduce students' motivation for self-learning.

The shortcomings of computer-based training programs include low reliability and reliance on virtual field systems, making the development of an integrated training system combining laparoscopic instruments and video displays essential. This system incorporates both visual information and haptic feedback, thereby improving computer-based training programs for surgeons. The integrated training system also incorporates methods that address key shortcomings of computer-based training programs, namely the inability to evaluate the precision and effectiveness of surgical procedures.

The Rosser Intelligent Training System (RIP) provides trainees with complex instrument handling training, as well as syllabus-based learning of endoscopic surgical skills and suturing techniques. Since 2001, it has been a component of the Rosser Elite Training Program. The system's assessment of trainees' skills has proven to reflect their surgical experience and skill level. It not only tests trainees' anatomical knowledge but also evaluates their judgment and intention during procedures. The system allows for detailed training in each skill, forcing trainees to recognize errors during procedures, as each error is automatically recorded. The system also includes an audio-visual system to alert trainees when errors occur. This system represents a standalone training system that significantly reduces human resource costs in the training process. Furthermore, it includes a database similar to that of the Elite Training Program; clearly, this system represents an upgrade to the Elite Training Program and a direction that other training systems should strive towards.

In summary, it must be emphasized that learning, maintaining, and mastering minimally invasive surgical skills are fundamental to advancing one's abilities in laparoscopic bariatric surgery and other advanced laparoscopic procedures. Mastering these skills is especially crucial for a surgeon to reduce surgical complications in the initial stages, particularly for bariatric surgeons, whose learning curve is generally considered to be around 100 surgeries-the longest of all minimally invasive surgical procedures. Regardless of the training method used, both novice and experienced bariatric surgeons should be prepared to invest significant effort in continuously improving their surgical skills.