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Background: When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD)., Methods: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient., Results: The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy., Conclusions: Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise., (© 2024. The Author(s).)

Background: Weight recurrence (WR) affects nearly 20% of patients after bariatric surgery and may decrease its benefits, affecting patients' quality of life negatively. Patient perspectives on WR are not well known., Objectives: Assess patient needs, goals, and preferences regarding WR treatment., Setting: Single MBSAQIP-accredited academic center, and online recruitment., Methods: An 18-item, web-based survey was distributed to adults seeking treatment for WR after a primary bariatric surgery (PBS), in addition to online recruitment, between 2021 and 2023. Survey items included somatometric data, questions about the importance of factors for successful weight loss, procedure decision-making, and treatment expectations., Results: Fifty-six patients with > 10% increase from their nadir weight were included in the study. Patients had initially undergone Roux-en-Y gastric bypass (62.5%), sleeve gastrectomy (28.6%), adjustable gastric banding (3.6%), or other procedures (5.3%). When assessing their satisfaction with PBS, 57.1% were somewhat/extremely satisfied, 33.9% somewhat/extremely dissatisfied, while 8.9% were ambivalent. Patients considered the expected benefits (for example, weight loss) as the most important factor when choosing a treatment option for WR. Patient goals included "feeling good about myself" (96.4% very/extremely important), "being able to resume activities I could not do before" (91% very/extremely important), and "improved quality of life" and "-life expectancy" (> 90% very/extremely important). Finally, RBS, lifestyle modification with peer support, and anti-obesity medication were ranked as first treatment options for WR by 40%, 38.8%, and 29.8% of the respondents, respectively., Conclusions: Patients considered weight loss as the most important factor when choosing treatment modality for WR, with RBS and lifestyle changes being preferred over weight-loss medications. Large prospective randomized trials are needed to counsel this patient population better., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Minimally invasive surgery has been used for both de novo insertion and salvage of peritoneal dialysis (PD) catheters. Advanced laparoscopic, basic laparoscopic, open, and image-guided techniques have evolved as the most popular techniques. The aim of this guideline was to develop evidence-based guidelines that support surgeons, patients, and other physicians in decisions on minimally invasive peritoneal dialysis access and the salvage of malfunctioning catheters in both adults and children., Methods: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed the literature since the prior guideline was published in 2014 and developed seven key questions in adults and four in children. After a systematic review of the literature, by the panel, evidence-based recommendations were formulated using the Grading of Recommendations Assessment, Development and Evaluation approach. Recommendations for future research were also proposed., Results: After systematic review, data extraction, and evidence to decision meetings, the panel agreed on twelve recommendations for the peri-operative performance of laparoscopic peritoneal dialysis access surgery and management of catheter dysfunction., Conclusions: In the adult population, conditional recommendations were made in favor of: staged hernia repair followed by PD catheter insertion over simultaneous and traditional start over urgent start of PD when medically possible. Furthermore, the panel suggested advanced laparoscopic insertion techniques rather than basic laparoscopic techniques or open insertion. Conditional recommendations were made for either advanced laparoscopic or image-guided percutaneous insertion and for either nonoperative or operative salvage. A recommendation could not be made regarding concomitant clean-contaminated surgery in adults. In the pediatric population, conditional recommendations were made for either traditional or urgent start of PD, concomitant clean or clean-contaminated surgery and PD catheter placement rather than staged, and advanced laparoscopic placement rather than basic or open insertion., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Considerable weight recurrence (WR) after Roux-en-Y gastric bypass (RYGB) may occur in nearly 20% of patients. While several nonoperative, endoscopic, and surgical interventions exist for this population, the optimal approach is unknown. This study reports our initial experience with distal bypass revision (DGB) and provides a comparison with patients after primary RYGB., Methods: Single-institution, retrospective review was conducted for patients who underwent DGB from 2018 to 2020. A Roux and common channel of 150 cm each were constructed (total alimentary limb 300 cm). A group of primary RYGB patients with similar demographics were selected as controls. Demographics, comorbidity resolution, surgical technique, complications, excess weight loss (EWL), total weight loss (TWL), BMI, and weight change data were compared. Patient postoperative weight loss (WL) was also compared after their primary and DGB operations., Results: Sixteen DGB patients, all female, were compared with 29 controls. DGB was performed on average 12.3 years after primary RYGB. In the DGB group, mean BMI was 53.7 before primary RYGB, 31.9 at nadir, and 44.1 prior to DGB. Post-DGB, mean BMI was 40.5, 37.4, 34.8, and 34.4, at 3-, 6-, 12-, and 24-months, respectively. Five patients (31.3%) experienced complications and were readmitted within 30 days, with two of them (12.5%) requiring reintervention and one (6.3%) undergoing reoperation. Mean EWL and TWL up to 2 years after DGB were lower than that after the patient's original RYGB (52.3 ± 18.6 vs. 67.2 ± 33.2; p = 0.126 and 19.6 ± 13.3 vs. 29.6 ± 11.8; p = 0.027, respectively)., Conclusions: DGB resulted in excellent WL up to 2 years after surgery but was associated with considerable postoperative complication rates. The magnitude of TWL was lower compared with the primary operation. Only a few patients experienced nutritional complications. Results of this study can help counsel patients pursuing DGB for WR or nonresponse to primary RYGB. The comparative effectiveness of this approach to other available options remains to be determined., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Weight regain (WR) post bariatric surgery affects almost 20% of patients. It has been theorized that a complex interplay between physiologic adaptations and epigenetic mechanisms promotes WR in obesity, however, reliable predictors have not been identified. Our study examines the relationship between early postoperative weight loss (WL), nadir weight (NW), and WR following laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG)., Methods: A retrospective review of prospectively collected data was conducted for LRYGB or LSG patients from 2012 to 2016. Demographics, preoperative BMI, procedure type, and postoperative weight at 6, 12, 24, 36, and 48 months were recorded. WR was defined as > 20% increase from NW. Univariate and multivariate linear and logistic regression models were used to determine the association between early postoperative WL with NW and WR at 4 years., Results: Thousand twenty-six adults were included (76.8% female, mean age 44.9 ± 11.9 years, preoperative BMI 46.1 ± 8); 74.6% had LRYGB and 25.3% had LSG. Multivariable linear regression models showed that greater WL was associated with lower NW at 6 months (Coef - 2.16; 95% CI - 2.51, - 1.81), 1 year (Coef - 2.33; 95% CI - 2.58, - 2.08), 2 years (Coef - 2.04; 95% CI - 2.25, - 1.83), 3 years (Coef - 1.95; 95% CI - 2.14, - 1.76), and 4 years (Coef - 1.89; 95% CI - 2.10, - 1.68), p ≤ 0.001. WR was independently associated with increased WL between 6 months and 1 year (Coef 1.59; 95% CI 1.05,2.14; p ≤ 0.001) and at 1 year (Coef 1.24; 95% CI 0.84,1.63;p ≤ 0.001) postoperatively. The multivariable logistic regression model showed significantly increased risk of WR at 4 years for patients with greater WL at 6 months (OR 1.20, 95% CI 1.08,1.33; p = 0.001) and 1 year (OR 1.14; 95% CI 1.06,1.23; p ≤ 0.001)., Conclusion: Our findings demonstrate that higher WL at 6 and 12 months post bariatric surgery may be risk factors for WR at 4 years. Surgeons may need to follow patients with high early weight loss more closely and provide additional treatment options to maximize their long-term success., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Work related injuries in minimally invasive surgery (MIS) are common because of the strains placed on the surgeon's or assistant's body. The objective of this study was to compare specific ergonomic risks among surgeons and surgical trainees performing robotic and laparoscopic procedures., Materials and Methods: Ergonomic data and discomfort questionnaires were recorded from surgeons and trainees (fellows/residents) for both robotic and laparoscopic procedures. Perceived discomfort questionnaires were recorded pre/postoperatively. Intraoperatively, biomechanical loads were captured using motion tracking sensors and electromyography (EMG) sensors. Perceived discomfort, body position and muscle activity were compared between robotic and laparoscopic procedures using a linear regression model., Results: Twenty surgeons and surgical trainees performed 29 robotic and 48 laparoscopic procedures. Postoperatively, increases in right finger numbness and right shoulder stiffness and surgeon irritability were noted after laparoscopy and increased back stiffness after robotic surgery. Further, the laparoscopic group saw increases in right hand/shoulder pain (OR 0.8; p = 0.032) and left hand/shoulder pain (0.22; p < 0.001) compared to robotic. Right deltoid and trapezius excessive muscle activity were significantly higher in laparoscopic operations compared to robotic. Demanding and static positioning was similar between the two groups except there was significantly more static neck position required for robotic operations., Conclusion: Robotic assisted surgeries led to lower postoperative discomfort and muscle strain in both upper extremities, particularly dominant side of the surgeon, but increased static neck positioning with subjective back stiffness compared with laparoscopy. These recognized ergonomic differences between the two platforms can be used to raise surgeon awareness of their intraoperative posture and to develop targeted physical and occupational therapy interventions to decrease surgeon WMSDs and increase surgeon longevity., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Standards for preoperative bariatric patient selection include a thorough psychological evaluation. Using patients "red-flagged" during preoperative evaluations, this study aims to identify trends in long-term follow-up and complications to further optimize bariatric patient selection., Methods: A multidisciplinary team held a case review conference (CRC) to discuss red-flagged patients. A retrospective chart review compared CRC patients to control patients who underwent bariatric surgery in the same interval. Patients under 18 years old, undergoing revisional bariatric surgery, or getting band placement were excluded. High-risk characteristics causing CRC inclusion, preoperative demographics, percent follow-up and other postoperative outcomes were collected up to 5 years postoperatively. If univariate analysis revealed a significant difference between cohorts, multivariable analysis was performed., Results: Two hundred and fifty three patients were red-flagged from 2012 to 2013, of which 79 underwent surgery. After excluding 21 revisions, 3 non-adult patients, and 6 band patients, 55 red-flagged patients were analyzed in addition to 273 control patients. Patient age, sex, initial BMI, ASA, and co-morbidities were similar between groups, though flagged patients underwent RYGB more frequently than control patients. Notably, percent excess BMI loss and percent follow-up (6 months-5 years) were similar. In multivariable analysis, minor complications were more common in flagged patients; and marginal ulcers, endoscopy, and dilation for stenosis were more common in flagged versus control patients who underwent RYGB. Perforation, reoperation, revision, incisional hernia, and internal hernia were statistically similar in both groups, though reoperation was significantly more common in patients with multiple reasons to be flagged compared to controls., Conclusion: Bariatric patients deemed high risk for various psychosocial issues have similar follow-up, BMI loss, and major complications compared to controls. High-risk RYGB patients have greater minor complications, warranting additional counseling of high-risk patients., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Chylous ascites is often reported in cases with lymphatic obstruction or after lymphatic injuries such as intraabdominal malignancies or lymphadenectomies. However, chylous ascites is also frequently encountered in operations for internal hernias. We sought to characterize the frequency and conditions when chylous ascites is encountered in general surgery patients., Methods: Data from patients who underwent operations for CPT codes related to open and laparoscopic abdominal and gastrointestinal surgery in our tertiary hospital from 2010 to 2019 were reviewed. Patients with the postoperative diagnosis of internal hernia were identified and categorized into three groups: Internal Hernia with chylous ascites, non-chylous ascites, and no ascites. Demographics, prior surgical history, CT findings, source of internal hernia, open or laparoscopic surgery, and preoperative labs were recorded and compared., Results: Fifty-six patients were found to have internal hernias and were included in our study. 80.3% were female and 86% had a previous Roux-en-Y gastric bypass procedure (RYGBP). Laparoscopy was the main approach for all groups. Ascites was present in 46% of the cases. Specifically, chylous ascites was observed in 27% of the total operations and was exclusively (100%) found in patients with gastric-bypass history. Furthermore, it was more commonly associated with Petersen's defect (p < 0.001), while the non-chylous fluid group was associated with herniation through the mesenteric defect (p < 0.001)., Conclusions: Chylous ascites is a common finding during internal hernia operations. Unlike other more morbid conditions, identification of chylous ascites during an internal hernia operation appears innocuous. However, in the context of a patient with a history of RYGBP, the presence of chylous fluid signifies the associated small bowel obstruction is likely related to an internal hernia through a patent Petersen's defect., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Postoperative dysphagia after anti-reflux surgery typically resolves in a few weeks. However, even after the initial swelling has resolved at 6 weeks, dysphagia can persist in 30% of patients necessitating esophageal dilation. The purpose of this study was to investigate the effect of esophageal dilation on postoperative dysphagia, the recurrence of reflux symptoms, and the efficacy of pneumatic dilations on postoperative dysphagia., Methods: A prospectively collected database was reviewed for patients who underwent partial/complete fundoplication with/without paraesophageal hernia repair between 2006 and 2014. Patient age, sex, BMI, DeMeester score, procedure type, procedure duration, length of stay, postoperative dysphagia, time to first pneumatic dilation, number of dilations, and the need for reoperations were collected., Results: The study included 902 consecutive patients, 71.3% females, with a mean age of 57.8 ± 14.7 years. Postoperative dysphagia was noted in 26.3% of patients, of whom 89% had complete fundoplication (p < 0.01). Endoscopic dilation was performed in 93 patients (10.3%) with 59 (63.4%) demonstrating persistent dysphagia. Recurrent reflux symptoms occurred in 35 (37.6%) patients who underwent endoscopic dilation. Patients who underwent a dilation for symptoms of dysphagia were less likely to require a revisional surgery later than patients who had dysphagia but did not undergo a dilation before revisional surgery (17.2% vs 41.7%, respectively, p < 0.001) in the 4-year follow-up period. The duration of initial dilation from surgery was inversely related to the need for revisional surgery (p = 0.047), while more than one dilation was not associated with additive benefit., Conclusion: One attempt at endoscopic dilation of the esophagogastric fundoplication may provide relief in patients with postoperative dysphagia and can be used as a predictive factor for the need of revision. However, there is an increased risk for recurrent reflux symptoms and revisional surgery may ultimately be indicated for control of symptoms., (© 2021. The Society for Surgery of the Alimentary Tract.)

Background: Laparoscopic suturing is associated with a steep learning curve. Hence, many general surgery graduate residents entering fellowship have reportedly not been able to proficiently suture laparoscopically despite achieving Fundamentals of Laparoscopic Surgery certification. To address this deficiency, the Advanced Training in Laparoscopic Suturing curriculum was developed. This study aimed to compare the effectiveness of the Advanced Training in Laparoscopic Suturing curriculum in improving laparoscopic suturing skills compared with Fundamentals of Laparoscopic Surgery training., Methods: Novices were enrolled in a prospective randomized controlled study. All novices followed proficiency-based training on Fundamentals of Laparoscopic Surgery peg-transfer and intracorporeal suturing. Students were then stratified based on their peg-transfer performance and randomized into an Advanced Training in Laparoscopic Suturing or Fundamentals of Laparoscopic Surgery group. The Advanced Training in Laparoscopic Suturing group trained on 3 of the 6 Advanced Training in Laparoscopic Suturing tasks (needle handling, offset forehand suturing, confined space suturing), while the Fundamentals of Laparoscopic Surgery group was assigned more stringent suturing performance goals. Each group trained for an additional 6 hours, after which the laparoscopic suturing performance of the 2 groups was compared on a Nissen fundoplication porcine model., Results: Thirty-nine medical students were enrolled in the study; 17 (11 males and 6 females) completed the study protocol (44%). Controlling for confounders including the student suturing performance at the end of stage-1 training, the Advanced Training in Laparoscopic Suturing group at the porcine model was significantly faster/safer (coefficient = 102.7, P = .037), and more skilled (coefficient = 19.1, P = .048) compared with the Fundamentals of Laparoscopic Surgery group., Conclusion: Compared with Fundamentals of Laparoscopic Surgery training alone the Advanced Training in Laparoscopic Suturing curriculum further enhances the laparoscopic suturing skill of novices. These findings support incorporating Advanced Training in Laparoscopic Suturing into existing skills curricula., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Following the publication of reports from landmark international consensuses (Louisville 2008 and Morioka 2014), minimally invasive hepatectomy became widely accepted as a legitimate alternative to open surgery. We aimed to compare the operative, hospitalization, and total economic costs of open (OLR) vs. laparoscopic (LLR) vs. robotic liver resection (RLR)., Methods: We performed a systematic literature review (end-of-search date: July 3, 2020) according to the PRISMA statement. Random-effects meta-analyses were conducted. Quality assessment was performed with the Cochrane Risk of Bias tool for randomized controlled trials, and the Newcastle-Ottawa Scale for non-randomized studies., Results: Thirty-eight studies reporting on 3847 patients (1783 OLR; 1674 LLR; 390 RLR) were included. The operative costs of LLR were significantly higher than those of OLR, while subgroup analysis also showed higher operative costs in the LLR group for major hepatectomy, but no statistically significant difference for minor hepatectomy. Hospitalization costs were significantly lower in the LLR group, with subgroup analyses indicating lower costs for LLR in both major and minor hepatectomy series. No statistically significant difference was observed regarding total costs between LLR and OLR both overall and on subgroup analyses in either major or minor hepatectomy series. Meta-analyses showed higher operative, hospitalization, and total costs for RLR vs. LLR, but no statistically significant difference regarding total costs for RLR vs. OLR., Conclusion: LLR's higher operative costs are offset by lower hospitalization costs compared to OLR leading to no statistically significant difference in total costs, while RLR appears to be a more expensive alternative approach.

Background: Work-related musculoskeletal injuries have been increasingly recognized to affect surgeons. It is unknown whether such injuries also affect surgical trainees. The purpose of this study was to assess the ergonomic risk of surgical trainees as compared with that of experienced surgeons., Methods: Ergonomic data were recorded from 9 surgeons and 11 trainees. Biomechanical loads during surgery were assessed using motion tracking sensors and electromyography sensors. Demanding and static positions of the trunk, neck, right/left shoulder, as well as activity from the deltoid and trapezius muscles bilaterally were recorded. In addition, participants reported their perceived discomfort on validated questionnaires., Results: A total of 87 laparoscopic general surgery cases (48 attendings and 39 trainees) were observed. Both trainees and attendings spent a similarly high percentage of each case in static (>60%) and demanding positions (>5%). Even though residents reported overall more discomfort, all participants shared similar ergonomic risk with the exception of trainees' trunk being more static (odds ratio: -11.42, P = .006)., Conclusion: Surgeons are prone to ergonomic risk. Trainees are exposed to similar postural ergonomic risk as surgeons but report more discomfort and, given that musculoskeletal injuries are cumulative over time, the focus should be on interventions to reduce ergonomic risk in the operating room., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Given that smoking is known to contribute to gastrojejunal anastomotic (GJA) ulcers, cessation is recommended prior to laparoscopic Roux-en-Y gastric bypass (LRYGB). However, smoking relapse rates and the exact ulcer risk remain unknown. This study aimed to define smoking relapse, risk of GJA ulceration, and complications after LRYGB., Materials and Methods: We performed a retrospective cohort study of patients who underwent primary LRYGB during 2011-2015. Initially, three patient categories were identified: lifetime non-smokers, patients who were smoking during the initial visit at the bariatric clinic or within the prior year (recent smokers), and patients who had ceased smoking more than a year prior to their initial clinic visit (former smokers). Smoking relapse, GJA ulcer occurrences, reinterventions, and reoperations were recorded and compared., Results: A total of 766 patients were included in the analysis. After surgery, 53 (64.6%) recent smokers had resumed smoking. Out of these relapsed smokers, 51% developed GJA ulcers compared with 14.8% in non-relapsed recent smokers, 16.1% in former smokers, and 6% in lifetime nonsmokers (p < 0.001). Furthermore, relapsed smokers required more frequently endoscopic reinterventions (60.4%) compared with non-relapsed smokers (20.8%, p < 0.001), former smokers (20.7%, p < 0.001), and lifetime non-smokers (15.4%, p < 0.001). Additionally, relapsed smokers required a reoperation (18.9%) more often than non-relapsed recent smokers (5.7%, p < 0.001) and lifetime non-smokers (1.3%, p < 0.001)., Conclusion: Smokers relapse frequently after LRYGB, and the majority experience GJA complications. They should be counseled about this risk preoperatively and directed towards less ulcerogenic procedures when possible. Alternatively, longer periods of preoperative smoking abstinence might be needed.

Purpose: Up to 50% of patients with vertical banded gastroplasty (VBG) experience failure or complications in the mid- and long-term and present for revisional bariatric surgery. This study aimed to review our experience for patient outcomes after VBG revisions and compare their benefits to those of primary laparoscopic Roux-en-Y gastric bypass (LRYGB) operations., Materials and Methods: Data from patients who underwent VBG revision between 2009 and 2015 at a center of excellence were reviewed. Patient demographics, symptoms, comorbidities, weight loss, reinterventions, reoperations, and hospital stay were analyzed and compared with those of primary LRYGB patients (control group)., Results: Fifty-two patients (88.5% female, 55 ± 9.6 years old) underwent revisional surgery during the study period (86.5% LRYGB, 11.5% VBG reversal, and 2% sleeve gastrectomy). Patients presented 17.3 ± 7.2 years after their VBG for weight regain (55.8%), dysphagia (19.2%), or both (25%). Patients who underwent conversion to LRYGB for weight regain and for mix-symptoms had similar weight loss to the control group (38.2 ± 11.8 vs 35.6 ± 7.7, p = 0.108), along with similar comorbidity resolution. However, even though the early (< 30 days) complication rate was similar between the two groups, the conversion group had higher 4-year reoperation rate (29% vs 9.5%, p < 0.001) and length of stay (5.4 ± 5.3 vs 2.6 ± 3.1, p < 0.001). Additionally, dysphagia resolved in all the patients of our cohort., Conclusions: VBG conversion to LRYGB leads to significant weight loss, resolution of dysphagia, and comorbidities similarly to the primary LRYGB operations. However, higher mid-term complication rates should be expected.

Background: Improving operating room (OR) inefficiencies has financial and operational ramifications. However, their incidence has not been systematically studied, especially in bariatric surgery., Objectives: The study aimed to identify the operational inefficiencies of the laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure, specify the steps of the procedure, and investigate whether the inefficiencies are related to case-by-case variability, using a surgical application., Setting: University Hospital, United States METHODS: From July 2018 to January 2019, we observed consecutive nonrevisional LRYGB cases. We used a surgical application to capture in real-time all the inefficiencies/incidents that occurred inside the operating room. The duration and time variability, along with the number of incidents of each step, were recorded. Additionally, a multivariable analysis was conducted to investigate whether patient factors (age, race, body mass index, and American Society of Anesthesiologists physical status classification), surgeon and surgical-technician experience, resident-assist, and case difficulty affect the number of incidents., Results: Forty LRYGB procedures were observed. The duration of the procedural steps was linearly correlated with the number of incidents but case-to-case step duration variability was not. The steps that were linked with more inefficiencies included jejunojejunostomy creation that included more unrelated to the case conversations, and gastric pouch creation that had more anesthesia-related delays. Inefficiencies such as equipment malfunctions and missing supplies were equally distributed among all the steps. Multivariable analysis did not indicate that any of the tested factors were associated with the number of incidents., Conclusion: The use of the surgical app allowed us to accurately record the duration, variability, and the undesired incidents of each LRYGB procedural step. Future studies should target interventions to minimize the inefficient procedural steps we have identified to optimize operating room efficiency., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)