and feedback program for MBS. For the purpose of creating a technical framework, this study identified the surgical steps and sub-steps as described by Coa et al..10 METHODS Participant Selection Metabolic bariatric clinics’ websites were searched for names and contact details of all metabolic bariatric surgeons in the Netherlands. Moreover, an invitational email was sent through the Dutch Society of Metabolic and Bariatric Surgery to lead surgeons from all metabolic bariatric centres and forwarded to their fellow metabolic bariatric surgeons. All 68 identified metabolic bariatric surgeons in the Netherlands were invited to participate in this consensus analysis. Step Identification Through a literature search and operative protocols, the LRYGB and LSG procedures were divided into surgical steps. Next, these steps were broken down into a broad range of substeps. This study refrained from the task level, which would include, for example, introduction and extraction of separate instruments. As in previous research, the linear stapled technique with suture closing of the remnant defect was most commonly used in the Netherlands.13 Delphi Processes All metabolic bariatric surgeons received emails linked to a web-based questionnaire on SurveyMonkey®, asking to comment on the full list of steps in both LRYGB and LSG. In this first round, participants were asked to rate the different sub-steps on a 5-point Likert-scale (not important, sometimes important, important, very important, essential). They were instructed to comment on a step if needed, regarding order, content, or even missing steps. Reminders were sent after 7 and 10 days. The two-week response period was extended to 3 weeks to ensure the pre-set 50% participant response rate in the first round. After statistical analysis, sub-steps with a 95% confidence interval (CI) entirely < 3 were excluded as not relevant. Substeps with a direct CI > 4 were marked as key steps. All others were re-evaluated in a second round, again with a 3-week response time. The same 5-point Likert-scale was used, but respondents were allowed to comment on all sub-step responses and urged to comment on scores 1 and 2 (i.e. ‘not important’ or ‘sometimes important’). Sub-steps with a complete 95% 64 4
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