INTRODUCTION Laparoscopic gastric bypass procedures such as Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) are common surgical procedures for patients with severe obesity and metabolic disorders.1,2 Although these procedures are widely studied, still no consensus exists on the optimal lengths of the alimentary and biliopancreatic limbs in the RYGB and OAGB. Both too-long and too-short limb lengths may have clinical consequences and reduce the effect of the bypass or induce side effects, such as nutritional deficiencies and steatorrhea.3-5 Only a few studies investigated the accuracy of laparoscopic measurement of the small bowel, showing wide variability in the estimated lengths both in the hands of surgeons and residents. While the clinical implications of inaccurate bowel length measurements have not been investigated, studies have indicated that the magnitude of the discrepancies is noteworthy, with deviation ranging from 34 to 50 cm when the intended length is 150 cm.6,7 Research regarding limb length may produce inadequate or irreproducible results if bowel length measurements are not precise, emphasizing the relevance of this issue. In many metabolic bariatric centres, a stepwise hand-over-hand technique is used to estimate limb lengths. With this technique, marked graspers are used as reference points to estimate the length of the bypassed bowel.8 Recently, our metabolic bariatric centre performed an ex vivo experiment to analyse the accuracy and variability of small bowel measurements in our metabolic bariatric surgeons and surgical residents.9 Our study showed that metabolic bariatric surgeons measured bowel length with on average less than 10% deviation from the goal lengths, but surgical residents structurally underestimated limb lengths, with a much wider spread. These results support the study of Jackson et al, who also found residents underestimated laparoscopic measured limb lengths.7 Several studies have been published on ex vivo training of laparoscopic metabolic bariatric skills, including augmented reality simulation, human cadaver and animal models, and box trainers.10-15 However, to our knowledge, no literature is available about how to practice or train these methods of laparoscopic small bowel measurement. As running the small bowel is a basic skill, used in other procedures as well, it is important for residents to acquire the skill of accurate estimation of bowel length. Handling the small bowel to make a measurement or estimate the length requires tissue handling skills, accuracy, and a certain speed to avoid delay 7 133 Measuring small bowel length in metabolic bariatric surgery: a training experiment
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