Video-based assessment for laparoscopic fundoplication: initial development of a robust tool for operative performance assessment

  • E. Matthew RitterEmail author
  • Aimee K. Gardner
  • Brian J. Dunkin
  • Linda Schultz
  • Aurora D. Pryor
  • Liane Feldman
2019 SAGES Oral



While better technical performance correlates with improved outcomes, there is a lack of procedure-specific tools to perform video-based assessment (VBA). SAGES is developing a series of VBA tools with enough validity evidence to allow reliable measurement of surgeon competence. A task force was established to develop a VBA tool for laparoscopic fundoplication using an evidence-based process that can be replicated for additional procedures. The first step in this process was to seek content validity evidence.


Forty-two subject matter experts (SME) in laparoscopic fundoplication were interviewed to obtain consensus on procedural steps, identify potential variations in technique, and to generate an inventory of required skills and common errors. The results of these interviews were used to inform creation of a task inventory questionnaire (TIQ) that was delivered to a larger SME group (n = 188) to quantify the criticality and difficulty of the procedural steps, the impact of potential errors associated with each step, the technical skills required to complete the procedure, and the likelihood that future techniques or technologies may change the presence or importance of any of these factors. Results of the TIQ were used to generate a list of steps, skills, and errors with strong validity evidence.


Initial SMEs interviewed included fellowship program directors (45%), recent fellows (24%), international surgeons (19%), and highly experienced super SMEs with quality outcomes data (12%). Qualitative analysis of interview data identified 6 main procedural steps (visualization, hiatal dissection, fundus mobilization, esophageal mobilization, hiatal repair, and wrap creation) each with 2–5 sub steps. Additionally, the TIQ identified 5–10 potential errors for each step and 11 key technical skills required to perform the procedure. Based on the TIQ, the mean criticality and difficulty scores for the 11/21 sub steps included in the final scoring rubric is 4.66/5 (5 = absolutely essential for patient outcomes) and 3.53/5 (5 = difficulty level requires significant experience and use of alternative strategies to accomplish consistently), respectively. The mean criticality and frequency scores for the 9/11 technical skills included is 4.51/5 and 4.51/5 (5 = constantly used ≥ 80% of the time), respectively. The mean impact score of the 42/47 errors incorporated into the final rubric is 3.85/5 (5 = significant error that is unrecoverable, or even if recovered, likely to have a negative impact on patient outcome).


A rigorous, multi-method process has documented the content validity evidence for the SAGES video-based assessment tool for laparoscopic fundoplication. Work is ongoing to pilot the assessment tool on recorded fundoplication procedures to establish reliability and further validity evidence.


Video-based assessment Assessment Fundoplication Content validity Test development 


Compliance with ethical standards


Dr. Ritter reports royalties from the Henry M. Jackson Foundation for the Advancement of Military Medicine outside the submitted work. Dr. Gardner reports fees for contracted consultant work from the SAGES Foundation during the conduct of the study. Dr. Dunkin reports fees for contracted consultant work from the SAGES Foundation during the conduct of the study and is currently employed by Boston Scientific. His employment with Boston Scientific occurred outside of the submitted work. Ms. Shultz has nothing to disclose. Dr. Pryor reports speaking fees from Ethicon, Gore Medical, Medtronic, and Stryker, all outside the submitted work. Dr. Feldman reports research Grants from Medtronic and Merck, both outside the submitted work.


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Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2019

Authors and Affiliations

  1. 1.Department of SurgeryUniformed Services University of the Health Sciences and Walter Reed National Military Medical CenterBethesdaUSA
  2. 2.Baylor College of MedicineHoustonUSA
  3. 3.Houston MethodistWeill Cornell Medical CollegeHoustonUSA
  4. 4.Society of American Gastrointestinal and Endoscopic SurgeonsLos AngelesUSA
  5. 5.Department of SurgeryStony Brook University Renaissance School of MedicineStony BrookUSA
  6. 6.Department of SurgeryMcGill UniversityMontrealCanada

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