INTRODUCTION The Roux-en-Y gastric bypass (RYGB), the one-anastomosis gastric bypass (OAGB), and singleanastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) are effective and often performed metabolic bariatric procedures with comparable outcomes of weight loss and nutritional deficiencies.1–3 The optimal lengths of the alimentary limb and biliopancreatic limb (BPL) remain a topic of discussion. The aim of an optimal limb length is to achieve ideal results in terms of weight loss while minimizing the chance of nutritional deficiencies.4–6 In RYGB, a longer alimentary limb seems to have no influence on weight loss outcomes, whereas a longer BPL results in more weight loss overall.6–8 In the discussion about the optimal limb length, the accuracy and precision of limb length measurement is essential. Inadequate measurement results in over- or underestimation of a bowel segment. This may have clinical consequences in terms of weight loss, rates of malnutrition, and vitamin deficiencies. In gastric bypass surgery different techniques are performed to measure the small bowel length.9 Some surgeons use a rope or ruler to measure the segments of the small bowel.10 Others use graspers or other laparoscopic instruments as a reference tool to stepwise estimate the length of the small bowel.11 Regardless of the performed measurement method, laparoscopic small bowel measurement remains challenging due to the influence of limited range of motion, the high flexibility of the bowel structure, and the two-dimensional imaging of a three-dimensional bowel.12 There is limited literature investigating the accuracy of laparoscopic small bowel measurement performed in metabolic bariatric surgery (MBS). The aim of this study was to assess the intra- and the interindividual variability of laparoscopic small bowel length measurement using a hand-over-hand technique with marked graspers in an ex vivo experiment. METHOD Participants This is a single-centre ex vivo experiment including all four metabolic bariatric surgeons and four surgical residents of a non-academic teaching hospital in the Northern Netherlands. Baseline data were collected of all participants including, age, gender, laparoscopic experience, and metabolic bariatric experience. For cadaver studies no ethical approvement is required in the Netherlands. The intestine of the porcine cadavers was supplied by a 6 115 Laparoscopic small bowel length measurement using a hand-over-hand technique
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