The metabolic bariatric surgeon who structurally underestimated the lengths, has adapted his measurement steps when performing the hand-over-hand measurement technique. As optimal limb length in MBS is a subject of many studies, differences between goal and actual limb length and differences among surgeons have possible consequences for studies investigating limb lengths. The results of this study emphasizes that studies investigating limb lengths should incorporate results on the intra- and inter-individual variability of bowel length measurement in their centre. It highlights the need for research to optimize this laparoscopic measurement technique and to evaluate different bowel length measurement techniques in metabolic bariatric surgery. Furthermore, the inaccurate estimation of the limb lengths by the surgical residents and the inter-individual differences between the metabolic bariatric surgeons both emphasizes the need for a standardized learning method. Limitations of this study were the use of an ex vivo model with devascularized porcine intestine, which caused a different sensation of the tissue and excluded the relevant factor of peristaltic bowel movements. The quality of the porcine intestine decreased during the day, which may have affected the measurements at the end of the day. An in vivo model would be preferable, but with the ex vivo model it was possible to compare the estimated bowel lengths with the actual goal lengths, without having to perform animal experiments. Porcine intestine has several similarities with the human bowel, making it an appropriate model for this experiment.17 The flexibility and sticky characteristics of the devascularized porcine intestine may have affected the tape measures determining the actual limb lengths, therefore these measurements can also deviate from the actual limb lengths. Tape measures were performed twice to minimize this deviation. This study has a limited sample size with only four metabolic bariatric surgeons. However, this might be an adequate reflection of several metabolic bariatric centres, employing approximately four metabolic bariatric surgeons. In conclusion, metabolic bariatric surgeons performed laparoscopic small bowel length measurements with on average less than 10% deviation from the goal lengths. However, this still resulted in 30% of the estimated lengths with more than 15% deviation. There were considerable inter-individual differences between the metabolic bariatric surgeons. Surgical residents structurally underestimated the limb lengths. Ascertainment of measurement accuracy and sufficient training of metabolic bariatric surgeons is essential for metabolic bariatric surgeries in which limb length is of importance. 6 125 Laparoscopic small bowel length measurement using a hand-over-hand technique
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