18 metabolic centres in the Netherlands participated, 29 and 26 key steps were identified in the LRYGB and in the LSG, respectively. These key steps resemble the work of other authors and reflect the current Dutch procedural standards. Based on this consensus, PBAs can be constructed for the LSG and LRYGB, as shown in Appendix E (LRYGB) and Appendix F (LSG). In these PBAs the key steps of the procedures are evaluated with an independence scale. Chapter 5 demonstrates the feasibility of this new independence-scaled PBA (IS-PBA) for LRYGB by testing it on video-recordings of the three main steps of the LRYGB. Twelve Belgian and Dutch metabolic bariatric surgeons assessed video-recordings of three steps of the LRYGB: creation of the pouch, alimentary limb and jejunostomy, and biliopancreatic limb and gastrojejunostomy. The IS-PBA, OSATS and Bariatric OSATS (BOSATS) were used for evaluation. This study demonstrates that the concept of IS-PBA is feasible, with comparable results to the OSATS and BOSATS in discriminating novice, intermediate and expert surgeons. Procedure-specific assessment tools (PSAT) as the IS-PBA, can be an important part of summative assessments, as global assessment scales are best known for their use in formative assessment or feedback. PART 3 – Technical Training One of the key steps of the LRYGB discussed in Chapter 4 is determining the length of the biliopancreatic and alimentary limb. Determining the length of the limb is arguably important to patient outcomes as the limb length balances the effects of gastric bypass surgery between effect and side-effects. Chapter 6 describes a single centre study in which the metabolic bariatric surgeons and residents are tested on their ability to determine 150-, 180- and 210centimetres bowel length on a porcine model. Inter-individual differences between surgeons exist, with one outlier underestimating the bowel length in a significant part of the measurements. Feedback to the individual provider creates the opportunity for changing bowel length determination, which may have positive effects on surgical outcomes. In the same study, residents also underestimated the length of small bowel, and more than half of their measurements were outside acceptable 15% margins. As incorrect assessment of limb length may be complex to assess correctly during LRYGB procedures, it is an important skill to train ex-vivo. Chapter 7 describes a training experiment in which residents practised the skill of determining limb length in a 2D training box. This study showed that training this 176 9
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