title: Identification of essential steps in laser procedure for twin-twin transfusion syndrome using the Delphi methodology: SILICONE study.
abstract: OBJECTIVE
  To determine, by expert consensus, the essential substeps of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) that could be used to create an authority-based curriculum for training in this procedure among fetal medicine specialists.
  
  
  METHODS
  A Delphi survey was conducted among an international panel of experts (n = 98) in FLS. Experts rated the substeps of FLS on a five-point Likert-type scale to indicate whether they considered them to be essential, and were able to comment on each substep, using a dedicated online platform accessed by the invited tertiary care facilities that specialize in fetal therapy. Responses were returned to the panel until consensus was reached (Cronbach's α ≥ 0.80). All substeps that were rated  ≥ 4 by 80% of the experts were included in the evaluation instrument.
  
  
  RESULTS
  After the first iteration of the Delphi procedure, a response rate of 74% (73/98) was reached, and in the second and third iterations response rates of 90% (66/73) and 81% (59/73) were reached, respectively. Among a total of 81 substeps rated in the first round, 21 substeps had to be re-rated in the second round. Finally, from the initial list of substeps, 55 were agreed by experts to be essential. In the third round, the 18 categorized substeps were ranked in order of importance, with 'coagulation of all anastomoses that cross the equator' and 'determination of fetoscope insertion site' as the most important.
  
  
  CONCLUSIONS
  A total of 55 substeps of FLS for TTTS were defined by a panel of experts to be essential in the procedure. This list is the first authority-based evidence to be used in the development of a final training model for future fetal surgeons.
authors.affiliation: Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: S H P
authors.initials: SH
authors.lastname: Peeters
authors.forename: J
authors.initials: J
authors.lastname: Akkermans
authors.forename: M
authors.initials: M
authors.lastname: Westra
authors.forename: E
authors.initials: E
authors.lastname: Lopriore
authors.forename: J M
authors.initials: JM
authors.lastname: Middeldorp
authors.forename: F J
authors.initials: FJ
authors.lastname: Klumper
authors.forename: L
authors.initials: L
authors.lastname: Lewi
authors.forename: R
authors.initials: R
authors.lastname: Devlieger
authors.forename: J
authors.initials: J
authors.lastname: Deprest
authors.forename: E V
authors.initials: EV
authors.lastname: Kontopoulos
authors.forename: R
authors.initials: R
authors.lastname: Quintero
authors.forename: R H
authors.initials: RH
authors.lastname: Chmait
authors.forename: J S
authors.initials: JS
authors.lastname: Smoleniec
authors.forename: L
authors.initials: L
authors.lastname: Otaño
authors.forename: D
authors.initials: D
authors.lastname: Oepkes
mesh_terms: D003198:Computer Simulation; D032921:Consensus; D003697:Delphi Technique; D005260:Female; D005330:Fetofetal Transfusion / Q000601:surgery*; D005332:Fetoscopy / Q000193:education / Q000379:methods*; D006801:Humans; D053685:Laser Therapy / Q000379:methods*; D011247:Pregnancy; D011795:Surveys and Questionnaires; D062606:Tertiary Care Centers
keywords: Delphi methodology; evaluation; fetoscopic laser therapy; training; twin-twin transfusion syndrome