clip was started from the opening of the first limb, again ending with cutting the last stitch. Each fragment was edited to enhance visibility with a standardized stepwise manner: [1] cut out all instrument changes and instruction moments, [2] speed up specific fragments (firing stapling 15 seconds, running small bowel) [3] add text information about these changes, as well as supervisor take overs. [4] add an instruction screen of 20 seconds. Expert Assessor Panel Twelve experienced metabolic bariatric surgeons were included in a new Expert Panel of Dutch and Belgian Bariatric Surgeons. Of each Dutch Hospital performing over 700 LRYGB a year one metabolic bariatric surgeon was invited to participate. The other half of selected experts were invited based on their specific interest in (metabolic bariatric) surgical training. In a randomized order each assessor viewed a fragment of the pouch, creation of BPL and GJ and creation of AL and JJ, each on a different operative experience level. Randomization was done with a Graeco-Latin Square design (PASS -11).26 Comparable Assessments Two different assessments were selected to evaluate the potential of this new PBA. First, the Dutch golden standard for assessment and feedback in resident training, the OSATS, was included. Second, the BOSATS created by Zevin et al., was used as a comparison.23 The BOSATS is an example of a PBA with specified scoring criteria for each observed item. As the BOSATS and PBA both use a 5-point Likert scale a version of the OSATS with a 5-point scale was used. An overview of the OSATS and the relevant items of the BOSATS are shown in Appendix II and III. 14,27 The presented PBA has 30 items in total, divided over 6 steps, of which 16 items (3 steps) were used in this study. Assuming a direct trocar introduction and above-mentioned technique the BOSATS has 64 items in total of which 34 were relevant to the specific steps in this study. The OSATS has 7 items, as it is a global rating scale, we used the full OSATS on all steps. This is summarized in Table 1. A full list of the observed items is found in Appendices I, II and III. 86 5
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