laparoscopic procedures.14–16 A protocol for deconstructing procedures is necessary, as experts tend to omit 70% of steps when describing a procedure due to their automated knowledge, which is not consciously accessible, and the tendency to blend steps into larger steps. Cognitive task analysis (CTA) protocols may be used to dissect a surgical procedure into these steps and tasks before consensus on the key components is started.17 Figure 2: Hierarchical Task Analysis of Making a Cup of Coffee by Thorvald et al.18 Laparoscopic Roux-en-Y Gastric Bypass In Chapter 4 a hierarchical task analysis was used to dissect the LRYGB into key steps, to form a base for a procedure-based assessment (PBA). After this task analysis an expert panel of Dutch metabolic bariatric surgeons reached consensus on the crucial steps of the LRYGB with a Delphi consensus technique. The same regimen was used by Zevin et al. in constructing the BOSATS.19 Ramesh et al. divided the LRYGB into steps for another purpose: automatic segmentation of video recorded procedures. In this Bypass40 project, artificial intelligence in the form of neural networks was used to dissect LRYGB procedures into phases and steps, which were defined using a CTA.20 The key steps of the LRYGB that resulted from the task analysis by these different research groups are shown in Appendix C of this thesis. Compared to the steps of Zevin et al., the Delphi consensus on key steps resulted in a more condensed version with fewer but identical steps, except for closure of mesenteric defects. This LRYGB step was not common practice in the Netherlands at that moment. The 11-step-analysis of Ramesh et al. also specified the division of the greater omentum and cleaning coagulation as a key step. The most striking difference between these three task analyses is the order of 152 8
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