INTRODUCTION Metabolic bariatric surgery (MBS) is the standard for the treatment of severe obesity because of its superior long-term results.1 As these procedures aim not only to induce weight loss, but also to reduce associated diseases and increase life expectancy, high quality standards are demanded by medical society, the public, and health authorities.2 Multiple countries have adapted nationwide registries to ensure adequate auditing of surgical outcomes. Examples of these are the National Bariatric Surgery Registry (NBSR) in the United Kingdom, the Scandinavian Obesity Surgery Registry (SOReg) and the Dutch Audit for Treatment of Obesity (DATO) databases. These databases also provide opportunities to enhance these outcomes. Other improvement initiatives include peer review of technical skill and telementoring.3,4 However, a wide variation of techniques exists in literature, ranging from fully stapled to handsewn anastomosis techniques. This complicates comparing outcomes of scientific studies in terms of operating times, adverse events, and weight loss effects. Improvement of surgical quality may be achieved by offering detailed guidelines for the technical execution of surgical procedures. Standardization can also enhance training opportunities, facilitate feedback, and reduce error, resulting in shortening of the learning curve of these advanced laparoscopic procedures. Khamis et al. defined the deconstruction of procedures into key steps as a part of the educational strategy and curriculum development.5 The Delphi Method is a well-described technique for obtaining consensus between groups of experts, which can easily be used by email questionnaires.6,7 Previous research has used the Delphi method to reach consensus on the key steps for appendicectomy, cholecystectomy, sigmoid resection and right-sided colectomy.8,9 Coa et al. demonstrated hierarchical task analysis of surgical procedures such as cholecystectomy, inguinal hernia repair and fundoplication. These procedures can be broken into surgical steps and sub-steps, tasks, and subtasks, and these could even be divided into level of motions.10,11 The presented study aimed to reach expert consensus on the performance of the laparoscopic Roux-en-Y gastric bypass (LRGYB) and laparoscopic sleeve gastrectomy (LSG). These are the predominant metabolic bariatric procedures in the Netherlands, accounting for 89% of all primary procedures.12 This consensus will be used in the development of a training 4 63 The crucial steps in gastric bypass and sleeve gastrectomy procedures
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