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Training paper

Dutch Delphi consensus training paper for RYGB and LSG

The paper identifies 29 steps for laparoscopic gastric bypass and 26 for laparoscopic sleeve gastrectomy that are crucial to correctly perform these procedures to the standards of their expert panel

Authors in the Netherlands have published a Delphi consensus paper that will be used to develop a laparoscopic bariatric surgery-training model or curriculum in the country. The paper identifies 29 steps for laparoscopic gastric bypass and 26 for laparoscopic sleeve gastrectomy that are crucial to correctly perform these procedures to the standards of their expert panel.

The paper, ‘A Delphi Consensus of the Crucial Steps in Gastric Bypass and Sleeve Gastrectomy Procedures in the Netherlands’, published in Obesity Surgery, aimed to establish consensus among expert on the performance of the two procedures and included the participation of 68 bariatric surgeons from 20 centres in the Netherlands.

The investigators divided the two procedures into surgical steps and then into a broad range of sub-steps (in total 73 steps for RYGB and 51 steps for LSG) and contacted their bariatric colleagues via email to the web-based questionnaire. In the first round of questions, experts were asked to rate the different sub-steps on a 5-point scale (not important, sometimes important, important, very important, essential). The investigators received replies from 38 surgeons (response rate 56%) from 18 centres (90%).

Outcomes

The authors revealed that the LRYGB procedure was divided into nine surgical steps: operative setup, starting laparoscopy, creating the pouch, creating the biliopancreatic limb, performing gastro-jejunostomy, creating the alimentary limb, performing entero-enterostomy, check of the bypass, and finishing the procedure. The surgical steps were then divided into 73 sub-steps and 19 sub-steps were included as key steps, with 12 of 73 sub-steps deemed unnecessary.

For LSG, the procedure was assessed in six surgical steps: operative setup, starting laparoscopy, mobilization of the greater curvature, stapling the sleeve, check of the sleeve and finishing the procedure. The identified surgical steps were divided into 51 sub-steps: 14 steps (17%) were seen as key steps, 5 steps (10%) were excluded and 32 steps (63%) were re-evaluated in a second round where 12 of the remaining items were accepted as key steps. For both procedures, this Delphi consensus resulted in a list of key steps and advised steps (please click here to view the steps).

The authors note that the design of the study was done so not include most controversial sub-steps such as limb length. In addition, the replies from experts also highlighted current controversies in bariatric surgery such as the closure of mesenteric defects. Interestingly, leak tests with methylene blue or air were not considered a key step by this expert panel.

“Now that a comprehensive framework for the execution of these procedures has been established, these lists could be used for evaluation of skill acquisition and to perform further research on training of these procedures,” the researchers conclude. “The results of this study will be used for the development of a bariatric surgery-training model or curriculum and can also be implemented as part of a tele-mentoring programme, as a guideline for privilege granting and as the basis of a structured skill assessment.”

To access this paper, please click here

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