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Hertz P, Rattenborg S, Haug TR, Houlind K, Konge L, Bjerrum F. Training and assessment for colorectal surgery and appendicectomy- a systematic review. Colorectal Dis 2024; 26:597-608. [PMID: 38396135 DOI: 10.1111/codi.16905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/07/2023] [Accepted: 12/28/2023] [Indexed: 02/25/2024]
Abstract
AIM There is currently an increased focus on competency-based training, in which training and assessment play a crucial role. The aim of this systematic review is to create an overview of hands-on training methods and assessment tools for appendicectomy and colon and rectal surgery procedures using either an open, laparoscopic or robot-assisted approach. METHOD A systematic review of Medline, Embase, Cochrane and Scopus databases was conducted following the PRISMA guidelines. We conducted the last search on 9 March 2023. All published papers describing hands-on training, evaluation of performance data and development of assessment tools were eligible. The quality of studies and the validity evidence of assessment tools are reported. RESULTS Fifty-one studies were identified. Laparoscopic assessment tools are abundant, but the literature still lacks good-quality assessment tools for open appendicectomy, robotic colectomy and open rectal surgery. Overall, there is a lack of discussion regarding the establishment of pass/fail standards and the consequences of assessment. Virtual reality simulation is used more for appendicectomy than colorectal procedures. Only a few of the studies investigating training were of acceptable quality. There is a need for high-quality studies in open and robotic-assisted colon surgery and all approaches to rectal surgery. CONCLUSION This review provides an overview of current training methods and assessment tools and identifies where more research is needed based on the quality of the studies and the current validity evidence.
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Affiliation(s)
- Peter Hertz
- Department of Surgery, Hospital Lillebaelt, University of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Kolding, Denmark
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR and Education, Copenhagen, Denmark
| | - Søren Rattenborg
- Department of Regional Health Research, University of Southern Denmark, Kolding, Denmark
- Department of Surgery, Hospital Lillebaelt Vejle, Colorectal Cancer Center South, University of Southern Denmark DK, Kolding, Denmark
| | - Tora R Haug
- Department of Surgery, Gødstrup Hospital, Herning, Denmark
- Aarhus University, Aarhus, Denmark
| | - Kim Houlind
- Department of Regional Health Research, University of Southern Denmark, Kolding, Denmark
- Department of Vascular Surgery, Hospital Lillebaelt, University of Southern Denmark, Kolding, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR and Education, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bjerrum
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR and Education, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Gastrounit, Surgical Section, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
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2
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Grüter AAJ, Van Lieshout AS, van Oostendorp SE, Henckens SPG, Ket JCF, Gisbertz SS, Toorenvliet BR, Tanis PJ, Bonjer HJ, Tuynman JB. Video-based tools for surgical quality assessment of technical skills in laparoscopic procedures: a systematic review. Surg Endosc 2023:10.1007/s00464-023-10076-z. [PMID: 37099157 DOI: 10.1007/s00464-023-10076-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/08/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND Quality of surgery has substantial impact on both short- and long-term clinical outcomes. This stresses the need for objective surgical quality assessment (SQA) for education, clinical practice and research purposes. The aim of this systematic review was to provide a comprehensive overview of all video-based objective SQA tools in laparoscopic procedures and their validity to objectively assess surgical performance. METHODS PubMed, Embase.com and Web of Science were systematically searched by two reviewers to identify all studies focusing on video-based SQA tools of technical skills in laparoscopic surgery performed in a clinical setting. Evidence on validity was evaluated using a modified validation scoring system. RESULTS Fifty-five studies with a total of 41 video-based SQA tools were identified. These tools were used in 9 different fields of laparoscopic surgery and were divided into 4 categories: the global assessment scale (GAS), the error-based assessment scale (EBAS), the procedure-specific assessment tool (PSAT) and artificial intelligence (AI). The number of studies focusing on these four categories were 21, 6, 31 and 3, respectively. Twelve studies validated the SQA tool with clinical outcomes. In 11 of those studies, a positive association between surgical quality and clinical outcomes was found. CONCLUSION This systematic review included a total of 41 unique video-based SQA tools to assess surgical technical skills in various domains of laparoscopic surgery. This study suggests that validated SQA tools enable objective assessment of surgical performance with relevance for clinical outcomes, which can be used for training, research and quality improvement programs.
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Affiliation(s)
- Alexander A J Grüter
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - Annabel S Van Lieshout
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Stefan E van Oostendorp
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, Vondellaan 13, Beverwijk, The Netherlands
| | - Sofie P G Henckens
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Johannes C F Ket
- Medical Library, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | | | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - Hendrik J Bonjer
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
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van Zwieten T, Okkema S, van Det M, Pereboom I, Veeger N, Pierie JP. Assessment methods in laparoscopic colorectal surgery: a systematic review of available instruments. Int J Colorectal Dis 2023; 38:105. [PMID: 37074421 PMCID: PMC10115727 DOI: 10.1007/s00384-023-04395-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Laparoscopic surgery has become the golden standard for many procedures, requiring new skills and training methods. The aim of this review is to appraise literature on assessment methods for laparoscopic colorectal procedures and quantify these methods for implementation in surgical training. MATERIALS AND METHODS PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched in October 2022 for studies reporting learning and assessment methods for laparoscopic colorectal surgery. Quality was scored using the Downs and Black checklist. Included articles were categorized in procedure-based assessment methods and non-procedure-based assessment methods. A second distinction was made between capability for formative and/or summative assessment. RESULTS In this systematic review, nineteen studies were included. These studies showed large heterogeneity despite categorization. Median quality score was 15 (range 0-26). Fourteen studies were categorized as procedure-based assessment methods (PBA), and five as non-procedure-based assessment methods. Three studies were applicable for summative assessment. CONCLUSIONS The results show a considerable diversity in assessment methods with varying quality and suitability. To prevent a sprawl of assessment methods, we argue for selection and development of available high-quality assessment methods. A procedure-based structure combined with an objective assessment scale and possibility for summative assessment should be cornerstones.
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Affiliation(s)
- Tom van Zwieten
- Department of Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934AD, Leeuwarden, The Netherlands.
- Postgraduate School of Medicine, University Medical Centre Groningen (UMCG), Groningen, The Netherlands.
| | - Sietske Okkema
- Department of Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934AD, Leeuwarden, The Netherlands
| | - Marc van Det
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands
| | - Ilona Pereboom
- Department of Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934AD, Leeuwarden, The Netherlands
| | - Nic Veeger
- Department of Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934AD, Leeuwarden, The Netherlands
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jean-Pierre Pierie
- Department of Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934AD, Leeuwarden, The Netherlands
- Postgraduate School of Medicine, University Medical Centre Groningen (UMCG), Groningen, The Netherlands
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4
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Sirimanna P, Ravindran P, Smigielski M, Gladman MA, Naganathan V. Validation and reliability testing of a rating scale for objective assessment of performance in laparoscopic appendicectomy surgery. ANZ J Surg 2022; 92:1731-1736. [PMID: 35748500 PMCID: PMC9546355 DOI: 10.1111/ans.17862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/23/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022]
Abstract
Backgrounds To achieve a competency‐based training paradigm, the ability to obtain reliable and valid quantitative assessments of intraoperative performance is required. Through this, weaknesses can be identified and practiced, and competency assessed. This study aimed to determine the validity and reliability an objective evaluation tool for assessment of performance in laparoscopic appendicectomy (LA). Methods A prospective single‐blinded observational study design was used. Videos of inexperienced (performed <10 LAs) and experienced (performed >100 LAs) surgeons performing LA surgery were collected. Surgical performance during each recording was rated by two independent, blinded expert surgeons using the LA Rating Scale (LARS) and the modified Objective Structured Assessment of Technical Skill (OSATS) scale. Results The intraclass correlation coefficient (ICC) for LARS was 0.95 (95%CI 0.83–0.98). The ICC for each step ranged from 0.48 to 0.90, and the test–retest ICC for LARS was 0.91 (95%CI 0.69–0.98). Significant differences (P < 0.001) between median performance scores as rated by LARS were observed between the inexperienced and experienced surgeons. A Spearman's correlation coefficient of 0.87 (P < 0.001) was observed between LARS performance scores and modified OSATS scores. Conclusion LARS demonstrated excellent inter‐rater and test–retest reliability, and construct and concurrent validity and can be used to quantitatively evaluate performance during LA. This can potentially allow specific weaknesses to be identified and improved upon through deliberate practice. Progress can be tracked through re‐evaluation and scores of expert surgeons can be used as performance goals for credentialing in LA.
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Affiliation(s)
- Pramudith Sirimanna
- Department of Surgery, Sydney Medical School—Concord University of Sydney Sydney New South Wales Australia
| | - Praveen Ravindran
- Australian National University and Australian Robotic Colorectal Surgery Canberra Australian Capital Territory Australia
| | | | - Marc A Gladman
- Adelaide Medical School University of Adelaide Adelaide South Australia Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing Concord Hospital and University of Sydney Sydney New South Wales Australia
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5
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Tica VI, Tica AA, De Wilde RL. The Future in Standards of Care for Gynecologic Laparoscopic Surgery to Improve Training and Education. J Clin Med 2022; 11:jcm11082192. [PMID: 35456285 PMCID: PMC9028106 DOI: 10.3390/jcm11082192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/16/2022] Open
Abstract
Standards of care offer doctors and patients the confidence that an established quality, evidence-based, care is provided, and represent a tool for optimal responding to the population’s needs. It is expected that they will increasingly express a multimodal relationship with gynecologic laparoscopy. Laparoscopy is, now, a standard procedure in operative gynecology, standards are embedded in many laparoscopic procedures, standardization of the skills/competency assessment has been progressively developed, and the proof of competency in laparoscopy may become a standard of care. A continuous development of surgical education includes standard equipment (that may bring value for future advance), standardized training, testing (and performance) assessment, educational process and outcome monitoring/evaluation, patients’ care, and protection, etc. Standards of care and training have a reciprocally sustaining relationship, as training is an essential component of standards of care while care is provided at higher standards after a structured training and as credentialing/certification reunites the two. It is envisaged that through development and implementation, the European wide standards of care in laparoscopic surgery (in close harmonization with personalized medicine) would lead to effective delivery of better clinical services and provide excellent training and education.
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Affiliation(s)
- Vlad I. Tica
- Department of Obstetrics and Gynecology, Doctoral School, University “Ovidius”—Constanta, University Emergency County Hospital of Constanta—Bul. Tomis, 140, Academy of Romanian Scientists, 900591 Constanta, Romania;
| | - Andrei A. Tica
- Department of Pharmacology, University of Medicine and Pharmacy of Craiova, Emergency County Hospital of Craiova, Str. Tabaci, nb. 1, 200534 Craiova, Romania
- Correspondence:
| | - Rudy L. De Wilde
- Pius Hospital, Carl von Ossietzky University, 26121 Oldenburg, Germany;
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Ryan JF, Mador B, Lai K, Campbell S, Hyakutake M, Turner SR. Validity Evidence for Procedure-specific Competence Assessment Tools in General Surgery: A Scoping Review. Ann Surg 2022; 275:482-487. [PMID: 34520421 DOI: 10.1097/sla.0000000000005207] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to provide a focused and detailed assessment of the validity evidence supporting procedure-specific operative assessment tools in general surgery. SUMMARY OF BACKGROUND DATA Competency-based assessment tools should be supported by robust validity evidence to be used reliably for evaluation of operative skills. The contemporary framework of validity relies on five sources of evidence: content, response process, internal structure, relation to other variables, and consequences. METHODS A systematic search of 8 databases was conducted for studies containing procedure-specific operative assessment tools in general surgery. The validity evidence supporting each tool was assessed and scored in alignment with the contemporary framework of validity. Methodological rigour of studies was assessed with the Medical Education Research Study Quality Instrument. The educational utility of each tool was assessed with the Accreditation Council for Graduate Medical Education framework. RESULTS There were 28 studies meeting inclusion criteria and 23 unique tools were assessed. Scores for validity evidence varied widely between tools, ranging from 3 - 14 (maximum 15). Medical Education Research Study Quality Instrument scores assessing the quality of study methodology were also variable (8.5-15.5, maximum 16.5). Direct reporting of educational utility criteria was limited. CONCLUSIONS This study has identified a small group of procedure-specific operative assessment tools in general surgery. Many of these tools have limited validity evidence and have not been studied sufficiently to be used reliably in high-stakes summative assessments. As general surgery transitions to competency-based training, a more robust library of operative assessment tools will be required to support resident education and evaluation.
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Affiliation(s)
- Joanna F Ryan
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Brett Mador
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Krista Lai
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Sandra Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Momoe Hyakutake
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
| | - Simon R Turner
- Department of Surgery, University of Alberta, Edmonton, Canada
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7
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How can surgical skills in laparoscopic colon surgery be objectively assessed?-a scoping review. Surg Endosc 2021; 36:1761-1774. [PMID: 34873653 PMCID: PMC8847271 DOI: 10.1007/s00464-021-08914-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 11/21/2021] [Indexed: 11/08/2022]
Abstract
Background In laparoscopic colorectal surgery, higher technical skills have been associated with improved patient outcome. With the growing interest in laparoscopic techniques, pressure on surgeons and certifying bodies is mounting to ensure that operative procedures are performed safely and efficiently. The aim of the present review was to comprehensively identify tools for skill assessment in laparoscopic colon surgery and to assess their validity as reported in the literature. Methods A systematic search was conducted in EMBASE and PubMed/MEDLINE in May 2021 to identify studies examining technical skills assessment tools in laparoscopic colon surgery. Available information on validity evidence (content, response process, internal structure, relation to other variables, and consequences) was evaluated for all included tools. Results Fourteen assessment tools were identified, of which most were procedure-specific and video-based. Most tools reported moderate validity evidence. Commonly not reported were rater training, assessment correlation with variables other than training level, and validity reproducibility and reliability in external educational settings. Conclusion The results of this review show that several tools are available for evaluation of laparoscopic colon cancer surgery, but few authors present substantial validity for tool development and use. As we move towards the implementation of new techniques in laparoscopic colon surgery, it is imperative to establish validity before surgical skill assessment tools can be applied to new procedures and settings. Therefore, future studies ought to examine different aspects of tool validity, especially correlation with other variables, such as patient morbidity and pathological reports, which impact patient survival. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08914-z.
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8
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Cheng K, You J, Wu S, Chen Z, Zhou Z, Guan J, Peng B, Wang X. Artificial intelligence-based automated laparoscopic cholecystectomy surgical phase recognition and analysis. Surg Endosc 2021; 36:3160-3168. [PMID: 34231066 DOI: 10.1007/s00464-021-08619-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Artificial intelligence and computer vision have revolutionized laparoscopic surgical video analysis. However, there is no multi-center study focused on deep learning-based laparoscopic cholecystectomy phases recognizing. This work aims to apply artificial intelligence in recognizing and analyzing phases in laparoscopic cholecystectomy videos from multiple centers. METHODS This observational cohort-study included 163 laparoscopic cholecystectomy videos collected from four medical centers. Videos were labeled by surgeons and a deep-learning model was developed based on 90 videos. Thereafter, the performance of the model was tested in additional ten videos by comparing it with the annotated ground truth of the surgeon. Deep-learning models were trained to identify laparoscopic cholecystectomy phases. The performance of models was measured using precision, recall, F1 score, and overall accuracy. With a high overall accuracy of the model, additional 63 videos as an analysis set were analyzed by the model to identify different phases. RESULTS Mean concordance correlation coefficient for annotations of the surgeons across all operative phases was 92.38%. Also, the overall phase recognition accuracy of laparoscopic cholecystectomy by the model was 91.05%. In the analysis set, there was an average surgery time of 2195 ± 896 s, with a huge individual variance of different surgical phases. Notably, laparoscopic cholecystectomy in acute cholecystitis cases had prolonged overall durations, and the surgeon would spend more time in mobilizing the hepatocystic triangle phase. CONCLUSION A deep-learning model based on multiple centers data can identify phases of laparoscopic cholecystectomy with a high degree of accuracy. With continued refinements, artificial intelligence could be utilized in huge data surgery analysis to achieve clinically relevant future applications.
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Affiliation(s)
- Ke Cheng
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China.,Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Jiaying You
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China.,Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Shangdi Wu
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China.,Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Zixin Chen
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China.,Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Zijian Zhou
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China.,Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Jingye Guan
- ChengDu Withai Innovations Technology Company, Chengdu, China
| | - Bing Peng
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China. .,Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
| | - Xin Wang
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China. .,Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
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Guilbaud T, Fuks D, Berdah S, Birnbaum DJ, Beyer Berjot L. Development of a novel educational tool to assess skills in laparoscopic liver surgery using the Delphi methodology: the laparoscopic liver skills scale (LLSS). Surg Endosc 2021; 36:2321-2333. [PMID: 33871719 DOI: 10.1007/s00464-021-08507-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS). METHODS A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach's alpha > 0.80. RESULTS A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert's comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach's alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19). CONCLUSIONS The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.
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Affiliation(s)
- Théophile Guilbaud
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France. .,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France.
| | - David Fuks
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Stéphane Berdah
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
| | - Laura Beyer Berjot
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
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10
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Elmunzer BJ, Walsh CM, Guiton G, Serrano J, Chak A, Edmundowicz S, Kwon RS, Mullady D, Papachristou GI, Elta G, Baron TH, Yachimski P, Fogel E, Draganov PV, Taylor J, Scheiman J, Singh V, Varadarajulu S, Willingham FF, Cote G, Cotton PB, Simon V, Spitzer R, Keswani R, Wani S. Development and initial validation of an instrument for video-based assessment of technical skill in ERCP. Gastrointest Endosc 2021; 93:914-923. [PMID: 32739484 PMCID: PMC8961206 DOI: 10.1016/j.gie.2020.07.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The accurate measurement of technical skill in ERCP is essential for endoscopic training, quality assurance, and coaching of this procedure. Hypothesizing that technical skill can be measured by analysis of ERCP videos, we aimed to develop and validate a video-based ERCP skill assessment tool. METHODS Based on review of procedural videos, the task of ERCP was deconstructed into its basic components by an expert panel that developed an initial version of the Bethesda ERCP Skill Assessment Tool (BESAT). Subsequently, 2 modified Delphi panels and 3 validation exercises were conducted with the goal of iteratively refining the tool. Fully crossed generalizability studies investigated the contributions of assessors, ERCP performance, and technical elements to reliability. RESULTS Twenty-nine technical elements were initially generated from task deconstruction. Ultimately, after iterative refinement, the tool comprised 6 technical elements and 11 subelements. The developmental process achieved consistent improvements in the performance characteristics of the tool with every iteration. For the most recent version of the tool, BESAT-v4, the generalizability coefficient (a reliability index) was .67. Most variance in BESAT scores (43.55%) was attributed to differences in endoscopists' skill, indicating that the tool can reliably differentiate between endoscopists based on video analysis. CONCLUSIONS Video-based assessment of ERCP skill appears to be feasible with a novel instrument that demonstrates favorable validity evidence. Future steps include determining whether the tool can discriminate between endoscopists of varying experience levels and predict important outcomes in clinical practice.
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Affiliation(s)
- B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, Learning Institute and Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Gretchen Guiton
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, Case Western Reserve University, Cleveland, OH, USA
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Richard S. Kwon
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Georgios I. Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Grace Elta
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Vanderbilt University, Nashville, TN, USA
| | - Evan Fogel
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Peter V. Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
| | - Jason Taylor
- Division of Gastroenterology and Hepatology, Saint Louis University, Saint Louis, MO, USA
| | - James Scheiman
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Vikesh Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | | | - Gregory Cote
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Peter B. Cotton
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Violette Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rebecca Spitzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Rajesh Keswani
- Division of Gastroenterology, Northwestern University, Chicago, IL, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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ERCP and video assessment: Can video judge the endoscopy star? Gastrointest Endosc 2021; 93:924-926. [PMID: 33741092 DOI: 10.1016/j.gie.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/07/2020] [Indexed: 02/08/2023]
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Development of a novel tool to assess skills in laparoscopic gastrectomy using the Delphi method: the Japanese operative rating scale for laparoscopic distal gastrectomy (JORS-LDG). Surg Endosc 2019; 33:3945-3952. [PMID: 30756172 DOI: 10.1007/s00464-019-06681-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 01/23/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Assessment of the performance of laparoscopic gastrectomy is yet unreported, likely because of the complexity of the procedure. We aimed to develop a tool to assess the skills required for laparoscopic distal gastrectomy (LDG) through cognitive task analysis (CTA) and expert consensus using the Delphi method. METHODS CTA involved the listing of the knowledge and criteria required for completing each step of LDG as subtasks based on interviews by experts and novices and text book, instructional video, and procedural review. The Delphi evaluation method involved anonymous online surveys, conducted to merge the opinions of experts in laparoscopic gastrectomy. The experts were asked to rate (from 1 to 5) the importance of subtasks for skill evaluation and training for LDG using a Likert scale. Consensus among expert viewpoints was determined by the internal consistency of each item using Cronbach's approach. RESULTS Essential subtasks drafted for the assessment of LDG performance were determined based on the CTA. Thirty-one LDG experts participated in the online-survey with a response rate over 90%. A consensus was achieved after 2 rounds of surveys with a Cronbach alpha of 0.86, and 34 subtasks of LDG were selected. We finally created the Japanese Operative Rating Scale for Laparoscopic Distal Gastrectomy (JORS-LDG) based on the 34 subtasks. CONCLUSIONS We developed the JORS-LDG using CTA and the Delphi method.
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Gaitanidis A, Simopoulos C, Pitiakoudis M. What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature. Tech Coloproctol 2018; 22:151-160. [PMID: 29512045 DOI: 10.1007/s10151-018-1760-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 12/03/2017] [Indexed: 12/27/2022]
Abstract
Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.
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Affiliation(s)
- A Gaitanidis
- Second Department of Surgery, University General Hospital of Alexandroupoli, Democritus University of Thrace Medical School, 68100, Alexandroupoli, Greece.
| | - C Simopoulos
- Second Department of Surgery, University General Hospital of Alexandroupoli, Democritus University of Thrace Medical School, 68100, Alexandroupoli, Greece
| | - M Pitiakoudis
- Second Department of Surgery, University General Hospital of Alexandroupoli, Democritus University of Thrace Medical School, 68100, Alexandroupoli, Greece
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Peeters SHP, Akkermans J, Bustraan J, Middeldorp JM, Lopriore E, Devlieger R, Lewi L, Deprest J, Oepkes D. Operator competence in fetoscopic laser surgery for twin-twin transfusion syndrome: validation of a procedure-specific evaluation tool. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:350-355. [PMID: 26307171 DOI: 10.1002/uog.15734] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 07/29/2015] [Accepted: 08/14/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Fetoscopic laser surgery for twin-twin transfusion syndrome is a procedure for which no objective tools exist to assess technical skills. To ensure that future fetal surgeons reach competence prior to performing the procedure unsupervised, we developed a performance assessment tool. The aim of this study was to validate this assessment tool for reliability and construct validity. METHODS We made use of a procedure-specific evaluation instrument containing all essential steps of the fetoscopic laser procedure, which was previously created using Delphi methodology. Eleven experts and 13 novices from three fetal medicine centers performed the procedure on the same simulator. Two independent observers assessed each surgery using the instrument (maximum score: 52). Interobserver reliability was assessed using Spearman correlation. We compared the performance of novices and experts to assess construct validity. RESULTS The interobserver reliability was high (Rs = 0.974, P < 0.001). Checklist scores for experts and novices were significantly different; the median score for novices was 28/52 (54%), whereas that for experts was 47.5/52 (91%) (P < 0.001). The procedure time and fetoscopy time were significantly shorter (P < 0.001) for experts. Residual anastomoses were found in 1/11 (9%) procedures performed by experts and in 9/13 (69%) procedures performed by novices (P = 0.005). Multivariable analysis showed that the checklist score, independent of age and gender, predicted competence. CONCLUSIONS The procedure-specific assessment tool for fetoscopic laser surgery shows good interobserver reliability and discriminates experts from novices. This instrument may therefore be a useful tool in the training curriculum for fetal surgeons. Further intervention studies with reassessment before and after training may increase the construct validity of the tool. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
| | - J Akkermans
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
| | - J Bustraan
- PLATO, Center for Research and Development in Education and Training, Faculty of Social Sciences, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, The Netherlands
| | - R Devlieger
- Department of Obstetrics, Division of Fetal Medicine, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Belgium
| | - L Lewi
- Department of Obstetrics, Division of Fetal Medicine, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Belgium
| | - J Deprest
- Department of Obstetrics, Division of Fetal Medicine, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Belgium
| | - D Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
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A Flexible Postoperative Debriefing Process Can Effectively Provide Formative Resident Feedback. J Am Coll Surg 2015; 220:959-67. [DOI: 10.1016/j.jamcollsurg.2014.12.048] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/26/2014] [Accepted: 12/29/2014] [Indexed: 11/23/2022]
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Abstract
OBJECTIVE The purpose of this study was to create a technical skills assessment toolbox for 35 basic and advanced skills/procedures that comprise the American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) surgical skills curriculum and to provide a critical appraisal of the included tools, using contemporary framework of validity. BACKGROUND Competency-based training has become the predominant model in surgical education and assessment of performance is an essential component. Assessment methods must produce valid results to accurately determine the level of competency. METHODS A search was performed, using PubMed and Google Scholar, to identify tools that have been developed for assessment of the targeted technical skills. RESULTS A total of 23 assessment tools for the 35 ACS/APDS skills modules were identified. Some tools, such as Operative Performance Rating System (OSATS) and Objective Structured Assessment of Technical Skill (OPRS), have been tested for more than 1 procedure. Therefore, 30 modules had at least 1 assessment tool, with some common surgical procedures being addressed by several tools. Five modules had none. Only 3 studies used Messick's framework to design their validity studies. The remaining studies used an outdated framework on the basis of "types of validity." When analyzed using the contemporary framework, few of these studies demonstrated validity for content, internal structure, and relationship to other variables. CONCLUSIONS This study provides an assessment toolbox for common surgical skills/procedures. Our review shows that few authors have used the contemporary unitary concept of validity for development of their assessment tools. As we progress toward competency-based training, future studies should provide evidence for various sources of validity using the contemporary framework.
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Tremblay C, Grantcharov T, Urquia ML, Satkunaratnam A. Assessment tool for total laparoscopic hysterectomy: a Delphi consensus survey among international experts. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 36:1014-1023. [PMID: 25574680 DOI: 10.1016/s1701-2163(15)30416-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To achieve consensus among experts on the essentials steps to include in an assessment tool for total laparoscopic hysterectomy. METHODS Using a Delphi consensus process, an initial survey was created based on the current literature and local expertise in laparoscopic surgery and sent to international experts in laparoscopic gynaecology. Experts were selected according to specific criteria. A second survey was formulated based on the answers and comments from the first round and sent to all experts who participated in the first round. Consensus was defined as a Cronbach alpha ≥ 0.80. A rate of agreement ≥ 0.70 was used to define which substeps to keep in the final tool. RESULTS From the 85 experts invited to participate, 53 (62%) agreed to participate, and 51 of these participated in both rounds. The final instrument to assess total laparoscopic hysterectomy was created using the items with a high level of agreement after two rounds. This final tool showed good internal consistency among the experts, with a Cronbach alpha of 0.90. CONCLUSION Using a Delphi methodology, we achieved international consensus among experts in laparoscopic gynaecology within a short time frame and with minimal costs. The resulting evaluation tool for total laparoscopic hysterectomy may serve in the assessment of surgical skills in the future, and would be a valuable adjunct to postgraduate training and continuing medical education programs. This tool will now undergo a validation process, comparing the rating scores of novices and experts surgeons.
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Affiliation(s)
- Catherine Tremblay
- Département d'obstétrique-gynécologie, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal QC
| | - Teodor Grantcharov
- Department of Surgery, University of Toronto, Toronto ON; Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto ON
| | - Marcelo L Urquia
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto ON
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Foster JD, Francis NK. Objective assessment of technique in laparoscopic colorectal surgery: what are the existing tools? Tech Coloproctol 2014; 19:1-4. [PMID: 25428697 DOI: 10.1007/s10151-014-1242-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 07/28/2014] [Indexed: 12/18/2022]
Abstract
Assessment can improve the effectiveness of surgical training and enable valid judgments of competence. Laparoscopic colon resection surgery is now taught within surgical residency programs, and assessment tools are increasingly used to stimulate formative feedback and enhance learning. Formal assessment of technical performance in laparoscopic colon resection has been successfully applied at the specialist level in the English "LAPCO" National Training Program. Objective assessment tools need to be developed for training and assessment in laparoscopic rectal cancer resection surgery. Simulation may have a future role in assessment and accreditation in laparoscopic colorectal surgery; however, existing virtual reality models are not ready to be used for assessment of this advanced surgery.
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Affiliation(s)
- J D Foster
- Department of Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 2RH, UK
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Abstract
Despite its short history, surgical simulation has been successfully introduced into surgical residency programs in an effort to augment training. A wide range of simulator types and levels of complexity have proven an effective teaching method for surgical trainees. They have been used for training in areas such as general surgery, urology, gynecology, and ophthalmology among others. Coincident with the introduction of simulators is the need for objective evaluation of skills learned on them, which has led to the development and validation of multiple evaluation tools. This article evaluates the drivers for simulation, types of simulators, training, and evaluation of them especially as it pertains to laparoscopic colorectal surgery.
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Affiliation(s)
- Hoda Samia
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Sadaf Khan
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Justin Lawrence
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Conor P Delaney
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
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Zevin B, Bonrath EM, Aggarwal R, Dedy NJ, Ahmed N, Grantcharov TP. Development, feasibility, validity, and reliability of a scale for objective assessment of operative performance in laparoscopic gastric bypass surgery. J Am Coll Surg 2013; 216:955-965.e8; quiz 1029-31, 1033. [PMID: 23490542 DOI: 10.1016/j.jamcollsurg.2013.01.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 01/08/2013] [Accepted: 01/08/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is no objective scale for assessment of operative skill in laparoscopic gastric bypass (LGBP). The objective of this study was to develop and demonstrate feasibility of use, validity, and reliability of a Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale. STUDY DESIGN The BOSATS scale was developed using a hierarchical task analysis (HTA), a Delphi questionnaire, and a panel of international experts in bariatric surgery. The feasibility of use, reliability, and validity of the developed scale were demonstrated by reviewing 52 prospectively collected video recordings of LGBP performed by novice and experienced surgeons. RESULTS A total of 214 discrete steps were identified in HTA. A total of 12 and 17 panel members completed the first and second round of the Delphi questionnaire, respectively. Consensus among the panel was achieved after the second round (Cronbach's alpha = 0.85). The BOSATS scale demonstrated high inter-rater (intraclass correlation coefficient [ICC] = 0.954; p < 0.001) and test-retest reliability (ICC = 0.99; p < 0.001). Significant differences between BOSATS scores of experienced and novice surgeon groups were noted for the creation of jejunojejunostomy (JJ), gastric pouch, linear stapled gastrojejunostomy (GJ), circular stapled GJ, and hand-sewn GJ. Moderate to high correlations between BOSATS scale and Objective Structured Assessment of Technical Skills Global Rating Scale (OSATS GRS) were seen for JJ (rho = 0.59; p = 0.001), gastric pouch (rho = 0.48; p = 0.0004), linear stapled GJ (rho = 0.70; p = 0.0001), and hand-sewn GJ (rho = 0.96; p < 0.0001). CONCLUSIONS The BOSATS scale is a feasible to use, reliable, and valid instrument for objective assessment of operative performance in LGBP. Implementation of this scale is expected to facilitate deliberate practice and provide a means for future certification in bariatric surgery.
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