‘completing the pouch in a cephaled direction’ was excluded, although the procedure cannot be done without this step. This suggested that either the inclusion criteria should be expanded, or participants may have found the sub-step too obvious. Zevin et al. also performed a hierarchical task analysis to define the key steps of LRYGB.22 Their analysis started with a total of 214 discrete steps and their results returned 99 sub-steps for review, with optional steps depending on the type of anastomosis. This difference can be explained by continuation of the hierarchical task into task level. Also, air or methylene blue leak testing and closure of the mesenteric defects were not considered common practice by members of the expert team, and were omitted in the current analysis, resulting into fewer sub-steps. For the purpose of training and coaching in vivo, the sub-step level of the analysis may prove sufficient. A recent study of Rutte et al. on the pitfalls of LSG identified only thirteen key steps, half of the 26 key steps in this study.23 This difference can be explained by the use of a hierarchical decomposition technique. As the six surgical steps in our study were broken into sub-steps, this may result into a more detailed list, not only regarding to the laparoscopic phase, but also including the start and end of the operation. Our expert panel excluded the twelfth step described by Rutte et al., ‘closure of the left lateral port’. However, their first step ‘bupivacaine injection before trocar insertion’ was not in our initial list of this study, but as more evidence has become available, this might be added as a key step.23–25 For LRYGB, a high variety exists for the anastomosis techniques. Linear stapled, circular stapled, fully stapled and hand sewn techniques are described.14 The tested list has the start of an antecolic omega loop bypass, with a linear stapled technique for both the gastrojejunal and jejunojejunal anastomosis, resembling the simplified LRYGB as proposed by Ramos et al..16 Three respondents commented on this, reporting performance of a fully stapled technique or a circular stapled method in which the sub-step ‘transecting small bowel between gastrojejunal and jejunojenunal anastomosis’ occurred in an earlier stage of the procedure.26 The Delphi technique was not used to provide consensus on the order of the performed steps, as these may be executed in a different sequence. These technical differences also explain why ‘completing gastrojejunal anastomosis with sutures’ in the LRYGB was accepted as a key step only in the second Delphi round, as some of the respondents used a stapler for this sub-step. Irrespective of the order and exact description of sub-steps, a high level of consensus was reached for both procedures, ranging from a Cronbach’s alpha 4 75 The crucial steps in gastric bypass and sleeve gastrectomy procedures
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