be explained by the broad spectrum of surgical variations in LRYGB. Earlier studies have shown that a linear stapling technique of both the jejunojejunostomy and the antecolic antegastric gastrojejunal anastomosis is the standard method of operation in the Netherlands.24 This new PBA LRYGB follows this technique. Based on a previous Delphi consensus, the LRYGB was divided in 9 steps and 44 advised or crucial substeps. Following Kramp et al. in research on a PBA in LC these 9 steps were combined into 6 steps and 30 substeps to improve usability.21 Another difference with the BOSATS is the use of a 5-point Likert scale based on independence. Most procedural assessments specify the requirements for a specific score for a specific item. This may lengthen the time needed to complete the assessment. A remarkable result is that the surgeon with intermediate experience had a higher PBA score than the expert on the biliopancreatic limb and gastrojejunal anastomosis. Looking at the free text feedback of the assessor panel, although the steps were based on a Delphi consensus, they commented to execute this step with a slightly different technique than performed by the expert surgeon, which might have influenced their judgement.24 In clinical practice this would be less relevant assuming the trainee would, in general, follow their supervising attendings technique. A key difference between the current and previous PBA studies is that a third proficiency level was included.21,29 With the learning curve of the LRYGB still not fully defined the choice of the intermediate level between 10 and 100 procedures might be too broad a range. A limitation of this study is that it only addressed a part of the PBA LRYGB. In this study only the full laparoscopic steps were used as only video recordings of the laparoscopic camera were available. Future research with this PBA LRYGB should include all steps. The use of video recordings in an assessment was validated in previous research.30,31 The recordings were shortened in a step wise manner to ensure raters would not be influenced by the duration of the video, either biased after guessing the proficiency level or reviewer fatigue. The fragments did not include sounds, when relevant a supervisor take-over was displayed in text. Another limitation is that all video recordings showed a standard LRYGB case of females with a BMI < 45 kg/m2 and no previous abdominal surgery to make the video recordings comparable. Although other studies in assessment and training have used similar patients, further research is needed to conclude the assessments is also feasible in more complex cases.32 As next to the LRYGB the most widely used metabolic bariatric procedure in the Netherlands is the sleeve gastrectomy, both procedures are a part of the Entrustable Professional Activities (EPA’s) in 94 5
RkJQdWJsaXNoZXIy MTk4NDMw