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

Task/step

1          2

  3         4

      5

  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

  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

  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

  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