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Table 2 Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale

From: Does rating the operation videos with a checklist score improve the effect of E-learning for bariatric surgical training? Study protocol for a randomized controlled trial

Task/step 1          2   3         4       5
 Dissection of the gastro-phrenic ligament (angle of His):
  Pull fundus of stomach down (exposure) Insufficient retraction; traumatic; insufficient exposure Satisfactory retraction after some repositioning; suboptimal exposure Appropriate retraction; optimal exposure
  Dissect angle of His close to stomach while keeping tension on fundus Dissection in incorrect plane; insufficient or too much tension; bleeding Dissection in correct plane; appropriate tension majority of time; occasional tissue damage, bleeding Dissection in correct plane; careful handling of tissue; appropriate tension at all times; minimal tissue damage, bleeding
 Creation of the gastric pouch:
  Dissect along lesser curvature of stomach approx. 7 cm from the gastro-esophageal junction and keep close to stomach Incorrect plane; incorrect anatomic location; excessive tissue trauma; bleeding with need of suction Correct plane developed with some difficulty; moderate tissue damage; bleeding not requiring suction Correct plane in correct anatomic location developed without difficulty or excessive tissue trauma, bleeding
  Create a posterior tunnel Dissection in incorrect plane; unnecessary force; bleeding requiring suction Dissection in correct plane; occasional tissue damage; bleeding not requiring suction Dissection in correct plane; careful handling of tissue, minimal tissue damage, bleeding
  Introduce and apply a linear cutting stapler transversely to the stomach Stapler applied in incorrect orientation; serosal damage to stomach Stapler applied transversely after multiple repositioning attempts Stapler applied transversely; no requirement for multiple repositioning attempts; no trauma to stomach wall
  Remove all tubes from the stomach before firing the stapler Not done Done after delay; with prompting Done without delay or making sure the tube is not stapled (by movement)
  Fire stapler Uncontrolled fire with excessive pull on the stomach Controlled fire; some slippage of stomach between jaws Smooth, controlled fire
  Develop a posterior tunnel towards the angle of His Dissection in incorrect plane; unnecessary force; bleeding requiring suction Dissection in correct plane; occasional tissue damage; bleeding not requiring suction Dissection in correct plane; careful handling of tissue, minimal tissue damage, bleeding
  Introduce and apply another linear cutting stapler to the stomach Stapler applied in an incorrect orientation; serosal damage to stomach Stapler applied correctly; multiple repositioning attempts Stapler applied correctly; no repositioning required; no trauma to stomach wall
  Fire stapler Uncontrolled fire with excessive pull on the stomach Controlled fire; some slippage of stomach between jaws Smooth, controlled fire
  Confirm complete transection of stomach Not confirmed Confirmed briefly without adequate visualization Methodical confirmation of complete transection
    Time:
Task/step 1          2   3         4       5
 Creation of gastro-jejunal anastomosis:
Linear stapler technique
  Create a gastrotomy in the gastric pouch No entry into gastric lumen; poor relation between grasper and energy source; excessively large or small; penetration of posterior bowel wall; bleeding Entry into gastric lumen; appropriate size; more than 1 attempt required Entry into gastric lumen; appropriate size; no extra movements required
  Location of ligament of Treitz Not found Rough movements; poor orientation Smooth movements; correct orientation
  Measure approximately 40–60 cm of jejunum distal to the ligament of Treitz Length not measured Measured, however individual measurements not of the same size; poor orientation Measured methodologically; each measurement of the same size; correct orientation
  Create an enterotomy in the Roux limb No entry into bowel lumen; poor relation between grasper and energy source; excessively large or small; penetration of posterior bowel wall Appropriate size and entry into bowel lumen; not placed in antimesenteric location Appropriate size and placement of enterotomy; good relation of grasper and energy source; no extra movements required
  Introduce one limb of linear cutting stapler into gastric pouch and the other into Roux limb Unclear of how to insert the staple device; drives staple jaws blindly into the enterotomies Inserts the stapler, but lacks appreciation of the ideal angle for insertion Inserts staple jaws with ease; controlled manner; correct angle
  Ensure both limbs are symmetrical before firing the stapler Does not ensure symmetry, antimesenteric location of stapler before closing of jaws Limbs either nonsymmetrical or not in antimesenteric border before closure of jaws Correct symmetry and antimesenteric position before closure of jaws
  Fire stapler Uncontrolled fire with excessive pull on the bowel and widening of enterotomies Controlled fire; some slippage of bowel from jaws Smooth, controlled fire; no widening of enterotomies
    Time:
Task/step 1          2   3         4       5
 Creation of jejuno-jejunal anastomosis:
Linear stapler technique
  Create enterotomies in biliopancreatic and Roux limbs Poor relation between grasper and energy source; excessively large or small; penetration of posterior bowel wall Appropriate size enterotomy; not placed in antimesenteric location Appropriate sized and placed enterotomies; no extra movements. Good relation of grasper and energy source
  Insert the limbs of linear cutting stapler into the enterotomies in Roux and biliopancreatic limbs Unclear of how to insert the staple device. Drives staple jaws blindly into biliopancreatic and Roux limbs Inserts the stapler with hesitation and lacks appreciation of the ideal angle for insertion Inserts staple jaws with ease; controlled manner; correct angle
  Ensure both limbs are symmetrical and stapler in antimesenteric border Does not ensure limb symmetry and antimesenteric position before enclose of jaws Limbs either non-symmetrical or not on antimesenteric border before closure of jaws Correctly ensures symmetry and antimesenteric position before closure of the jaws
  Fire stapler Uncontrolled fire with excessive pull on the bowel and widening of enterotomies Controlled fire; some slippage of bowel from jaws Smooth, controlled fire; no widening of enterotomies
    Time:
  Help needed during performance Asks a lot of questions and needed assistance Few questions and almost no assistance Few questions but no assistance