explain the different outcomes, as general surgeons perform laparoscopic small bowel measurements to a much lesser extent than metabolic bariatric surgeons. Furthermore, they used non-marked laparoscopic graspers as reference tool. A study of Isreb et al. investigated the effect of marking the graspers on measurement precision using a piece of string and a laparoscopic box trainer.11 Greater accuracy was found for the measurements performed with marked instruments. Furthermore, a study of Lusseden et al. evaluated the accuracy of stepwise laparoscopic small bowel measurement in residents and attendings using 500 cm porcine intestine in a laparoscopic box trainer.14 Both residents and attendings measured averaged 24 cm away from the 100 cm goal, concluding there is a wide variability in both residents and attendings. They concluded that both groups should be educated to measure small bowel length more accurately. However, the study included no metabolic bariatric surgeons, and the participants performed several different step sizes to measure the bowel length. Another study compared the accuracy and precision of laparoscopic measurement with and without the aid of a measuring tool, using a laparoscopic box trainer and a rope.15 The surgical residents underestimated with a mean of 128 ± 42 cm on the 150 cm goal length, comparable with the results of the residents in our experiment. Nevertheless, it is unknown if estimation with a rope is adequate with small bowel measurement, as it excludes relevant factors like the sensation and flexible structure of the intestinal tissue and the limited stretch of the mesentery. Considering the inter-individual differences between the metabolic bariatric surgeons, all four surgeons had learned the hand-over-hand measurement technique in vivo from more experienced metabolic bariatric surgeons. Those experienced metabolic bariatric surgeons provided the surgeons feedback and decided whether they accurately estimated the limb lengths. Possible different learning methods, effects, and subjective assessments may have contributed to differences in results between the metabolic bariatric surgeons. To our knowledge, this is the first study investigating the intra- and the inter-individual variability of stepwise hand-over-hand laparoscopic bowel measurement in metabolic bariatric surgeons using a representative ex vivo model. As this stepwise measurement technique with marked graspers is used in a wide number of metabolic bariatric centres over the world, this is an important first step in evaluating this method in gastric bypass surgery.16 In our metabolic bariatric centre this technique is performed in daily practice. Based on the results of the study we continue using this measurement technique in gastric bypass surgery. 124 6
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