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Does rating with a checklist improve the effect of E-learning for cognitive and practical skills in bariatric surgery? A rater-blinded, randomized-controlled trial

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Mental training of laparoscopic procedures with E-learning has been shown to translate to the operating room. The present study aims to explore whether the use of checklists during E-learning improves transfer of skills to the simulated OR on a Virtual Reality (VR) trainer for Roux-en-Y gastric bypass (RYGB).


Laparoscopy naive medical students (n = 80) were randomized in two groups. After an E-learning introduction to RYGB, checklist group rated RYGB videos using the validated Bariatric Objective Structured Assessment of Technical Skills (BOSATS) checklist while group without checklist only observed the videos. Participants then performed RYGB on a VR-trainer twice and were evaluated by a blinded expert rater using BOSATS. A multiple choice (MC) knowledge test on RYGB was performed. Suturing on a cadaveric porcine small bowel was evaluated using objective structured assessment of technical skill (OSATS).


Checklist group was better in the knowledge test (A 8.3 ± 1.1 vs. B 7.1 ± 1.3; p ≤ 0.001) and there was a trend towards better VR RYGB performance (BOSATS) on the first try (85.9 ± 10.2 vs. 81.1 ± 11.5; p = 0.058), but not on the second try (92.0 ± 9.7 vs. 89.3 ± 10.5; p = 0.251). Suturing as measured by OSATS was not different (29.5 ± 3.0 vs. 29.0 ± 3.5; p = 0.472).


This study presents evidence that the use of a BOSATS checklist during E-learning helps trainees to improve their knowledge acquisition with E-learning. The transfer from mental training to the simulated OR environment seems to be partially enhanced by use of the BOSATS checklist. However, more research is required to investigate potential benefits.

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Bariatric objective structured assessment of technical skill


Multiple choice


Minimally invasive surgery


Operating room


Objective structured assessment of technical skills


Roux-en-Y gastric bypass


Virtual reality


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The authors would like to thank Carly Rae Garrow for proofreading of the manuscript. This study has been presented at the annual congress of the German Society of Surgery 2017 in Munich.

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Correspondence to Felix Nickel.

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Javier R. De La Gaza M.D., Mona W Schmidt, Karl-Friedrich Kowalewski, M.D., Laura Benner, Philip C. Müller M.D., Hannes Kenngott M.D., Lars Fischer M.D., Beat P. Müller-Stich M.D., Felix Nickel M.D. have no conflict of interest or financial ties to disclose.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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De La Garza, J.R., Schmidt, M.W., Kowalewski, KF. et al. Does rating with a checklist improve the effect of E-learning for cognitive and practical skills in bariatric surgery? A rater-blinded, randomized-controlled trial. Surg Endosc 33, 1532–1543 (2019).

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