steps. In the Netherlands the most common procedural sequence for a LRYGB is constructing the pouch first, GJ second and JJ last.21 Laparoscopic Sleeve Gastrectomy The technique of a laparoscopic sleeve gastrectomy (LSG) is relatively easy to explain and the HTA in Chapter 4 revealed fever substeps compared to the LRYGB. However, the results of the LSG are defined by precise execution. With the upcoming role of the LSG as the second, probably even first, most performed procedure worldwide, even more surgeons must master this procedure. Especially when adopting the LSG procedure, the learning curve should be considered. The 2022 Young-IFSO survey showed that the LSG is commonly the first MBS procedure that residents and fellows learn.2 The key steps of the LSG are subject of different research groups as well, again with different consensus techniques and different goals. Two PBAs, the Sleeve OSATS (SOSATS) and independence-scaled PBA were created based on the substeps of the LSG as well as an Objective Clinical Human Reliability Analysis (OCHRA).13,22–25 In addition to the LRYGB, research of Hashimoto provides an AI framework for automated fragment recognition in sleeve gastrectomy.26 A comparison of the results of these studies is shown in Appendix D. The expert consensus of Rutte et al., creating an OCHRA for the LSG, and the Delphi consensus presented in Chapter 4 shows fairly similar results, presumably because these are both executed in the Netherlands. The expert consensus of Hashimoto adds two steps: liver biopsy, which is not routinely used in the Netherlands, and bagging of the specimen. The Delphi Consensus by Blackham et al., which forms a basis for the SOSATS and sleeve gastrectomy curriculum, focused on the technical execution as well as non-technical aspects. All outcomes are in line with the consensus statement on sleeve gastrectomy by Mahawar et al..27 Stepwise Training The term stepwise training can be used in different ways. Some authors use it to describe the steps in a training program. An example is found in the research of Nishi et al. on a stepwise training program for laparoscopic (oncologic) gastrectomy.28 This program starts off with basic, supervised, dry box training, followed by advanced training including cadaveric models, clinical experience, and finally self-assessment and feedback. This resembles the SBME program described by Zevin.12 In this thesis stepwise training is used in terms of breaking 8 153 General discussion and future perspectives
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