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Background: Obesity is a chronic disease that is significantly linked to metabolic syndrome. Bariatric surgery is considered the most effective treatment for obesity resulting in long-term weight loss and comorbidity resolution. Prior studies have demonstrated the overall cost effectiveness of bariatric surgery; however, there is little data regarding direct pharmaceutical costs. The objective of this population-based study is to compare the cost of dispensed common prescription medications for metabolic syndrome before and after bariatric surgery. Methods: All patients that were enrolled in the Center for Metabolic and Bariatric Surgery who underwent gastric bypass or sleeve gastrectomy between 2013 and 2019 in Manitoba were included. Basic demographic information and outpatient prescription dispensation data were obtained from the Manitoba Population Research Data Repository, which is housed at the Manitoba Centre for Health Policy. Specific drug categories that were reviewed for costs 5 years before and after surgery included Antihypertensives, Lipid Lowering Agents, Insulin and Non-insulin Diabetic Drugs. Results: One thousand one hundred and eighty four patients were included in this review. Comparing the 5-year pre- and post-surgery, there was a decrease in the overall amount of drug dispensed and the overall cost for all drug categories in the 5 years following surgery. These categories included Antihypertensives ($506,268.8), Lipid Lowering Agents ($173,866.48), Insulin ($549,305.92), and Other Diabetes Drugs ($513,371.1). Additionally, older patients experienced a larger proportion of cost savings compared to younger patients, with the exception of non-insulin diabetic medications which trended to have more cost savings in the 30–49 year old grouping. Conclusion: This is the first Canadian study to use accurate dispensing data from a provincial administrative prescription database to capture long-term cost savings for metabolic prescriptions after bariatric surgery. The results are consistent with the existing literature for prescriptions post-bariatric surgery. Future study will include subgroup analysis by patient age, gender, income quintile, and geography.

Background: Obesity is a chronic and progressive disease associated with significant morbidity, mortality, and health-care costs. Bariatric surgery is the most effective intervention for sustainable weight loss and resolution of obesity-related comorbidities. Studies examining comorbidity resolution largely rely on individual self-reported outcomes and electronic record reviews. We present a population-based study looking at prescription medication utilization before and after bariatric surgery as a measure of comorbidity resolution. Methods: All patients enrolled in the Center for Metabolic and Bariatric Surgery who underwent either gastric bypass or sleeve gastrectomy between 2013 and 2019 in Manitoba were included. Demographic information, follow up, and outpatient prescription dispensation data were obtained from the Manitoba Population Research Data Repositoryhoused at the Manitoba Centre for Health Policy for 5 years pre- and post-surgery. Results: A total of 1184 patients were included. Antidepressants and selective serotonin reuptake inhibitors were the most commonly prescribed classes, and along with thyroid medication, utilization remained stable after bariatric surgery. Proton pump inhibitors and opioid class drugs increased at 1 year after surgery then returned to baseline. Glucose and lipid-lowering medications, including statins, biguanides, sulfonylureas, and insulin, were decreased. Antihypertensives, including ACE inhibitors, calcium channel blockers, angiotensin receptors blockers, thiazides, and beta blockers, similarly decreased. Conclusion: This is the first Canadian study employing a provincial-wide prescription database to measure long-term comorbidity resolution after bariatric surgery. The use of administrative data eliminates potential biases and inaccuracies in follow up and self-reported outcomes. Consistent with the literature, prescriptions for the treatment of metabolic syndrome all decreased and were sustained at long-term follow up. Further studies are needed to delineate the effects of altered pharmaceutical utilization on patient quality of life and health-care expenditures.

Background: Synoptic operative reporting has been used as a solution to the poor quality of narrative reports. The aim of this study was to develop operative report quality indicators for the laparoscopic sleeve gastrectomy and to generate parameters by which these reports can be evaluated and improved. Methods: A Delphi protocol was used to determine quality indicators for LSG. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Transferrable consensus items for LSG from previously developed Roux-en-Y gastric bypass operative indictors were put forward for consideration. Participants also initially submitted potential QIs. These were grouped by theme. Items were rated on 5-point Likert scales in subsequent rounds. Scores of 70% or higher were used for inclusion and 30% or less denoted exclusion. Elements scoring 30% to 70% agreement were recirculated by runoff in subsequent rounds to generate the final list of quality indicators. Results: Seven bariatric surgeons, representing all regions preforming LSG in Canada, were invited to participate in the Delphi group. Multidisciplinary invitees included one academic minimally invasive/acute care surgeon, one tertiary abdominal radiologist, and one academic gastroenterologist with bariatric expertise. Two rounds were required to achieve consensus. Both rounds achieved a 100% response (10/10). In round 1, forty items reached consensus. In Round 2, an additional 28 items reached consensus, with three items excluded, bringing the total number of quality indicators to 65. Conclusion: This study establishes consensus-derived multidisciplinary quality indicators for LSG operative reports. Application of these findings aims to advance the quality and completeness of operative reporting in LSG in order to improve communication of important surgical details and quality measures to the multidisciplinary team involved in bariatric surgery care.

Background: Despite limited endoscopy resources, repeat endoscopy prior to surgery is commonly practised. Our aim was to determine repeat preoperative endoscopy rates and factors influencing this practice at a high-volume Canadian tertiary centre. Method: A retrospective cohort study was conducted on all patients undergoing elective colorectal resections for benign and malignant neoplasms at a tertiary centre in Winnipeg, Canada between 2007 and 2017. Multivariable logistic regression analysis was used to identify predictors of repeat preoperative endoscopy. Results: Of 1062 patients identified, mean age was 68 years and 56% were male. Rate of repeat preoperative endoscopy was 29%. On multivariable analysis, male sex (OR 1.68, CI 1.19–2.34, p= 0.003) and lesions located in the left colon (OR 2.73, CI 1.79–4.14, p< 0.001), rectosigmoid (OR 9.11, CI 2.14–38.8, p= 0.003), and rectum (OR 4.06, CI 2.58–6.38, p< 0.001) were at increased odds of undergoing repeat preoperative endoscopy. Patients with a tattoo placed at index endoscopy were at markedly lower odds of undergoing repeat preoperative endoscopy (OR 0.48, CI 0.34–0.68, p< 0.001). Index endoscopist specialty was not a significant predictor of repeat endoscopy (OR 0.76, CI 0.54–1.06, p= 0.09). Conclusions: Repeat preoperative lower endoscopy is commonly practised and may be unnecessary if appropriate identification and documentation of lesions has been achieved. Tattooing of suspicious lesions is a key modifiable factor associated with reduced likelihood of repeat preoperative endoscopy. This study highlights the need for standardized guidelines and endoscopy reporting practices given the delays and costs associated with repeat preoperative endoscopy.

Background: Repeat preoperative endoscopy is common for patients with colorectal neoplasms. This can result in treatment delays, patient discomfort, and risks of colonoscopy-related complications. Repeat preoperative endoscopy has been attributed to poor communication between endoscopists and surgeons. In January 2019, mandatory electronic synoptic reporting for endoscopy was implemented to include elements consistent with quality indicators proposed in national guidelines. The aim of the present study is to assess whether the repeat preoperative endoscopy rate for colorectal lesions changed following synoptic report implementation. Methods: A retrospective review was performed of 1690 consecutive patients who underwent elective surgical resection for colorectal neoplasms from January 2007 to June 2020 at a tertiary hospital in Canada. Patients who had an index endoscopy documented via synoptic report were compared to those reported via narrative report. Primary outcomes were rates of repeat preoperative endoscopy and inclusion of colonoscopy quality indicators: photo-documentation, tattoo placement, and bowel preparation score. Results: In total, 1429 patients who underwent elective colorectal resection for colorectal cancers or polyps between January 2007 and June 2020 were included. 115 had index endoscopies recorded via synoptic report and 1314 by narrative report. The repeat preoperative endoscopy rate after endoscopies documented by narrative report was 29.07% (95% CI 26.63–31.61) and 25.22% (95% CI 17.58–34.17%) for synoptic report. Patients whose index endoscopies where performed by a practitioner other than their operating surgeon had a re-endoscopy rate of 36.03% (95% CI 32.82–39.33%) after narrative report and 38.81% (95% CI 27.14–51.50%) for synoptic report. Rates of tattoo placement, photo-documentation, and reporting of bowel preparation quality were all significantly increased with synoptic reports (p≤ 0.003). Conclusions: Endoscopy synoptic reports based on current guidelines were not associated with a decrease in rates of repeat pre-operative endoscopy at a high-volume colorectal cancer centre. Future study should examine guideline deficiencies for this purpose and make necessary modifications.

Introduction: Past education literature has shown benefits for random practice schedules (termed contextual interference) for skills retention and transfer to novel tasks. The purpose of fundamentals of laparoscopic surgery (FLS) training is to develop skills in simulation and transfer to new in vivo intraoperative experiences. The study objective was to assess whether individuals trained over a fixed number of trials in the FLS tasks would outperform untrained controls on an unpracticed previously validated bile duct cannulation task and scoring system and to determine whether random training schedules conferred any relative advantage. Methods: 44 trainees with no laparoscopic experience were recruited to participate. 35 were randomized to practice the FLS tasks using either a blocked or random training schedule. Nine were randomized to no additional training (controls). Participant performance was measured throughout training to monitor skills acquisition and were then tested on an unpracticed bile duct cannulation simulation task 4 to 6 weeks later. Outcomes included previously validated FLS scores and hand–motion analyses. Results: All 44 participants completed the study. Trained individuals in both groups showed significant improvements in all FLS tasks after training. There were no differences between groups in performance on the cannulation task median scores (Blocked: 89.8 [IQR:37.6]; Random: 83.2 [32.3]; Control: 83.6 [19.1]; p= 0.955), number of hand motions (Blocked: 42.5 [IQR:130.3]; Random: 75.3 [111.3]; Control: 63.0 [71.8]; p= 0.912), or distance traveled by participants hands (Blocked: 2.0 m [IQR:5.8]; Random: 3.8 [8.9]; Control: 2.6 [2.5]; p= 0.816). Cannulation task performance had no correlation with total FLS performance, R2linear = 0.014, p= 0.445. Conclusions: Skills acquired from conventional FLS tasks did not effectively transfer to a laparoscopic bile duct cannulation task. Neither blocked nor random practice schedules conferred a relative advantage. These findings provide evidence that cannulation is a distinct skill from what is taught and assessed in FLS.

Background: The COVID-19 pandemic challenges our ability to provide surgical education, as our ability to gather and train together has been restricted due to safety concerns. However, the importance of quality surgical education has remained. High-fidelity simulation platforms have been developed that merge virtual reality video streams to allow for remote instruction and collaboration. This study sought to validate the use of a merged virtual reality (MVR) platform for the instruction and assessment of the fundamentals of laparoscopic surgery (FLS) skills. Methods: This was a prospective randomized controlled non-inferiority study. Thirty participants were randomized between three groups: The standard group received in-person instruction and expert feedback, the experimental group received identical training via the MVR platform, and the control group practiced on their own, but received no feedback. All participants were pre-tested for baseline performance at the beginning of the study. Change in performance was evaluated immediately after training and one month later for retention. Ordinary one-way analysis of variance was used to evaluate the effects of time, group, and time-on-group. Results: The pre-test confirmed baseline homogeneity between the groups. MVR was non-inferior to standard in-person training for total FLS times on either the post-test (p= 0.632) or the retention test (p= 0.829). Performance was also identical between MVR and standard training groups for each of the individual FLS tasks. Each group improved significantly in nearly all tasks after practice; however, the standard and MVR training groups both improved significantly more than controls for the ligating loop, extracorporeal suturing, intracorporeal suturing, and total FLS task training but did not reach statistical significance for peg transfer and pattern cut tasks. Conclusion: This randomized, controlled trial has demonstrated the use of an MVR platform as non-inferior to in-person instruction for the FLS program, forming the foundation for future work on remote instruction and collaboration.

Background: Appropriate tattooing of suspicious lesions during colonoscopy is critical for surgical planning. However, variability exists in tattoo placement, technique, and reporting. Our aim is to determine the rates and predictors of tattoo placement, tattoo location in relation to the lesion, and localization accuracy during lower endoscopy for individuals undergoing elective colorectal resections. Methods: We performed a retrospective chart review on all patients undergoing elective colorectal resections for benign and malignant neoplasms between 2007 and 2017 at a high volume Canadian tertiary centre. Patient demographics, endoscopic, and tumour-related characteristics were collected. Multivariable logistic regression analysis was used to identify predictors of tattoo localization. Results: Of the 1062 patients identified, laparoscopic resection occurred in 59% of patients. 57% of patients underwent tattooing for tumour localization at index endoscopy. Tattoos were placed distal (27%), both proximal and distal (4%), and just proximal (2%) to the lesion. However, in the majority of cases the tattoo location was not documented (67%). On multivariate analysis, patients who had lesions located in the transverse colon (OR: 1.93, 95% CI 1.04–3.59), had surgery performed after 2010 (2011–2014: OR: 1.88, 95% CI 1.31–2.68; 2015–2017: OR: 2.87, 95% CI 1.93–4.26), underwent laparoscopic resections (OR: 1.69, 95% CI 1.22–2.33), and had their index endoscopy performed in an urban setting (OR: 5.92, 95% CI 3.23–10.87), were at higher odds of having a tattoo placed at index endoscopy. Conclusion: Endoscopic tattoo placement and location in relation to the lesion varies widely, with reports containing suboptimal documentation. Lesion location and laparoscopic procedures were significant predictors of tattoo placement. This study highlights the need for standardized tattooing practices and reporting amongst endoscopists. One of the focus of quality improvement efforts should be educational initiatives for rural endoscopists.

Setting: The physiological and anatomical changes that occur as a consequence of bariatric surgery result in macro- and micro-nutritional deficiencies, especially iron deficiency. The reported incidence of iron deficiency and associated anemia after bariatric surgery varies widely across studies. Objectives: The aim of this systematic review is to quantify the impact of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on the incidence of iron deficiency. Methods: Databases including Ovid Medline, Ovid Embase, Helthstar, Scopus, Cochrane (CDSR), LILACS, and ClinicalKey were searched for original articles with additional snowballing search. Search terms included Obesity, nutrient deficiency, iron deficiency, iron deficiency anemia, bariatric surgery, Roux-en-Y gastric bypass, and sleeve gastrectomy. Original articles reporting the incidence of iron deficiency and anemia pre- and post-RYGB and SG from January 2000 to January 2015 with minimum 1-year follow-up were selected. Data extraction from selected studies was based on protocol-defined criteria. Results: There were 1133 articles screened and 20 studies were included in the final analysis. The overall incidence of iron deficiency was 15.2% pre-operatively and 16.6% post-operatively. When analyzed by procedure, the incidence of iron deficiency was 12.9% pre-RYGB versus 24.5% post-RYGB and 36.6% pre-SG versus 12.4% post-SG. The incidence of iron deficiency-related anemia was 16.7% post-RYGB and 1.6% post-SG. Risk factors for iron deficiency were premenopausal females, duration of follow-up, and pre-operative iron deficiency. Prophylactic iron supplementation was reported in 16 studies and 2 studies provided therapeutic iron supplementation only for iron-deficient patients. Iron dosage varied from 7 to 80 mg daily across studies. Conclusion: Iron deficiency is frequent in people with obesity and may be exacerbated by bariatric surgery, especially RYGB. Further investigation is warranted to determine appropriate iron supplementation dosages following bariatric surgery. Careful nutritional surveillance is important, especially for premenopausal females and those with pre-existing iron deficiency.

Operative reports can be used to evaluate quality of care indicators in surgical patients. This study evaluated documentation of preoperative and intraoperative quality of care indicators for rectal cancer surgery in synoptic reports and traditional dictated reports. Two surgeons independently reviewed 40 prospectively collected synoptic operative reports from rectal cancer cases and a case-matched historical cohort of 40 dictated reports. Rectal cancer–specific quality measures were scored in both report groups using two separate, previously validated checklists. Synoptic reports had significantly higher overall scores on both checklists 1 (mean adjusted score ± SD 76 ± 4 vs41 ± 19, P< 0.01) and 2 (54 ± 3 vs24 ± 11, P< 0.01; maximum score of 100 for both checklists). Synoptic reports scored significantly higher in reporting preoperative and intraoperative care indicators. Data were extracted quickly from synoptic reports (mean 3:46 vs6:21, minutes:seconds to complete checklists, P< 0.05). Synoptic reports are associated with accurate documentation of quality of care data for rectal cancer surgery. Refining the synoptic templates used will further enhance the collection of quality indicators and reporting in complex oncologic procedures.

Methods of developing and determining General Surgery (GS) residents’ competency in gastrointestinal endoscopy in Canada are not currently standardized. This study aimed to assess the status of gastrointestinal endoscopy training in Royal College of Physicians and Surgeons of Canada (RCPSC) GS residency programs. A 35-question survey was developed using GS gastrointestinal endoscopy curricula guidelines. All 17 RCPSC GS program directors were contacted to complete the questionnaire via the web-based SurveyMonkey.ca® platform. All 17 program directors completed the survey (100% response rate). Program demographicsSixteen programs reported having dedicated endoscopy rotations with a mean duration of 2.8 months (range 0–4, SD 1.1). Upon completion of dedicated endoscopy rotations, four programs (25%) reported having formal skills assessments and three (18.8%) reported formal knowledge examinations. All programs required endoscopy procedures be logged throughout residency, but only three (21.4%) included quality indicators. Only one program required residents to obtain Fundamentals of Endoscopic Surgery certification. Program outcomesThe reported estimated mean number of procedures during residents’ endoscopy rotations was 82 (range 10–150, standard deviation 33.6) gastroscopies and 156 (40–350, 76.3) colonoscopies. The mean number of procedures during residents’ entire residencies was 150 (20–400, 98.6) gastroscopies and 241 (50–500, 76.3) colonoscopies. The number of months of dedicated endoscopy training significantly correlated with the total estimated number of endoscopic procedures performed (ρ= 0.67, p= 0.02). Eleven program directors (73.3%) believed residents were prepared for independent endoscopy practice, while four disagreed (26.7%). Program directors’ perceptions of residents’ preparedness were significantly correlated with the number of endoscopic procedures performed by residents (p< 0.01) but not the robustness of the endoscopy curriculum (p= 0.72). Endoscopy training in RCPSC GS residency programs is highly variable. Program directors’ perceptions of residents’ competency appear to be significantly correlated with procedure numbers and few have adopted formal curricula and performance assessments.

Research in healthcare leadership has focused on leaders. In contrast, organizational success may be more influenced by followers. Kelley described five followership styles based on two characteristics: active engagement and independent critical thinking. We examined the literature on the association between followership style and workplace outcomes.

Synoptic reporting (SR) is one solution to improve the quality of operative reports. However, SR has not been investigated in bariatric surgery despite an identified need by bariatric surgeons. SR for RYGB was developed using quality indicators (QIs) established by a national Delphi process. The objective of this study is to assess the completeness, accuracy, reliability, and efficiency of synoptic versus narrative operative reports (NR) in Roux-en-Y gastric bypass (RYGB). A NR and SR were completed on 104 consecutive RYGBs. Two evaluators independently compared the reports to QIs. Completeness and accuracy measures were determined. Reliability was calculated using Bland–Altman plots and 95% limits of agreement (LOA). Time to complete SR and NR was also compared. The mean completion rate of SR was 99.8% (±SD 0.98%) compared to 64.0% (±SD 6.15%) for NR (t= 57.9, p< 0.001). All subsections of SR were >99% complete. This was significantly higher than for NR (p< 0.001) except for small bowel division details (p= 0.530). Accuracy was significantly higher for SR than NR (94.2% ± SD 4.31% vs. 53.6% ± SD 9.82%, respectively, p< 0.001). Rater agreement was excellent for both SR (0.11, 95% LOA −0.53 to 0.75) and NR (−0.26, 95% LOA −4.85 to 4.33) (p= 0.242), where 0 denotes perfect agreement. SR completion times were significantly shorter than NR (3:55 min ± SD 1:26 min and 4:50 min ± SD 0:50 min, respectively, p= 0.007). The RYGB SR is superior to NR for completeness and accuracy. This platform is also both reliable and efficient. This SR should be incorporated into clinical practice.

The Focused Assessment with Sonography for Trauma (FAST) examination has become a valuable tool in trauma resuscitation. Despite the widespread use of FAST training among traumatologists, no evidence-based guidelines exist to support optimal training requirements or to provide quantitative objective assessments of imaging capabilities. Both Task-Specific Checklist (TSC) and Global Rating Scale (GRS) have been validated as objective skill assessment tools; we developed both types of scoring checklist and assessed them for construct validity with the FAST examination.

Computer-based surgical simulators capture a multitude of metrics based on different aspects of performance, such as speed, accuracy, and movement efficiency. However, without rigorous assessment, it may be unclear whether all, some, or none of these metrics actually reflect technical skill, which can compromise educational efforts on these simulators. We assessed the construct validity of individual performance metrics on the LapVR simulator (Immersion Medical, San Jose, CA, USA) and used these data to create task-specific summary metrics. Medical students with no prior laparoscopic experience (novices, N= 12), junior surgical residents with some laparoscopic experience (intermediates, N= 12), and experienced surgeons (experts, N= 11) all completed three repetitions of four LapVR simulator tasks. The tasks included three basic skills (peg transfer, cutting, clipping) and one procedural skill (adhesiolysis). We selected 36 individual metrics on the four tasks that assessed six different aspects of performance, including speed, motion path length, respect for tissue, accuracy, task-specific errors, and successful task completion. Four of seven individual metrics assessed for peg transfer, six of ten metrics for cutting, four of nine metrics for clipping, and three of ten metrics for adhesiolysis discriminated between experience levels. Time and motion path length were significant on all four tasks. We used the validated individual metrics to create summary equations for each task, which successfully distinguished between the different experience levels. Educators should maintain some skepticism when reviewing the plethora of metrics captured by computer-based simulators, as some but not all are valid. We showed the construct validity of a limited number of individual metrics and developed summary metrics for the LapVR. The summary metrics provide a succinct way of assessing skill with a single metric for each task, but require further validation.

The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution. Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann–Whitney Utest. Linear regression was used to analyze the relationship between length of stay and total hospital cost. There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p= 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p= 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p= 0.900), reoperations (5.8/6.5 % lap/open; p= 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p= 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p= 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p= 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p= 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p= 0.000), and this correlated directly with hospital cost. Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.

Abstract: Background: General surgery trainees’ perceptions regarding their own laparoscopic training remain poorly defined. The objective of this survey was to identify and evaluate learner experiences with laparoscopic procedures in general surgery programs on a national level. Methods: Two hundred eighty-four residents were identified and contacted at English-speaking general surgery programs across Canada. Each was asked to complete a web- or paper-based survey regarding their demographics, experiences with basic and advanced minimally invasive surgery (MIS) procedures, and perceived barriers to training. Results: Two hundred fifty-two of 284 (89%) surveyed residents responded. Eighty-seven percent of the residents had access to a skills lab that taught MIS techniques; however, standardized MIS curricula were implemented 53% of the time. Eighty percent of residents felt that skills lab training translated to improved performance in the OR. Although 90% of residents felt that they would be comfortable performing basic laparoscopic procedures, only 8% stated they would be comfortable performing advanced procedures at the end of their training. Moreover, 90% of general surgery residents felt that it was the academic surgical department’s responsibility to teach both basic and advanced procedures, and 35% of respondents felt their surgical program was meeting this requirement. Half of the residents felt they had limited opportunity to be a primary surgeon because an MIS fellow was present. Conclusions: There exists a wide disparity between the expectations of residents and their actual experience. The majority of residents are concerned that they will not acquire sufficient laparoscopic skills during their training to perform advanced cases in practice. Additionally, the balance between resident and fellow-level cases needs to be more clearly defined as the majority of respondents identified the presence of a MIS fellow as a negative learning influence. Finally, although most centers had a surgical skills lab, 47% of respondents felt that the curriculum was not standardized and this also needs to be addressed.