A minority of patients show sub-optimal outcomes after weight loss surgery. Research has identified predictors of poor outcomes focusing on the patients’ perspective. No research has explored surgeons’ accounts.

Ten bariatric surgeons were interviewed using a critical incident approach to explore their explanations for sub-optimal outcomes in the context of a real-life case. Data were analysed using thematic analysis.

Three main themes were developed: ‘Challenges to success’ highlighting the role of psychosocial issues, poor adherence and patient non-disclosure; ‘Ideal world solutions’ describing who should identify and address psychosocial issues and ‘Real world compromise’ reflecting the impact of limited resources and weighing up risk between carrying out versus not carrying out surgery. Transcending these themes was the notion of ‘responsibility’ with surgeons balancing the role of the patient, themselves and the health care system.

Some surgeons concluded that if they had known before surgery what they know now, they may not have operated. All emphasised that they could only know what was disclosed by the patient, that they were not convinced that not operating would have resulted in better outcomes in the longer term and many felt that they were ‘damned one way or the other’.