in the procedure. Training of fellows and residents during gastric bypass procedures may affect the quality and costs of the operations.16-18 A sufficient ex vivo training method could result in a reduction of the learning curve in the operating room. This emphasizes that research is necessary to investigate how accurate laparoscopic measurement of the small bowel can be practiced and learned. This study aimed to investigate if the accurate laparoscopic measurement of the small bowel length can be learned to surgical residents through an ex vivo training experiment. METHOD A laparoscopic training exercise was designed to train the skill of laparoscopic bowel length measurement. Laparoscopic small bowel measurement was simulated using a laparoscopic box trainer with the intestine of a porcine cadaver. The use of animal by-products was approved by the Netherlands Food and Consumer Product Safety Authority. In the Netherlands, no ethical approval is required for animal cadaver studies. Participants Ten surgical residents were asked to participate and provided informed consent. Baseline data of all participants including age, gender, and laparoscopic and metabolic bariatric experience were collected. None of the participants performed a complete laparoscopic gastric bypass before entering the study, neither supervised nor unsupervised. To ensure adequate knowledge of the techniques used, the participants were sent an instruction video including a fragment of the bowel length measurement during laparoscopic gastric bypass surgery. Study Design This is a single-centre ex vivo training experiment in a large peripheral teaching hospital, including all surgical residents working at the hospital during the study period from 2021 to 2022. For this type of study, no ethical approval is required in the Netherlands. Laparoscopic Training Exercise A laparoscopic box training system (Lapstar model 2, Camtronics B.V. Son, the Netherlands) with a fixed camera and two graspers was used to simulate the measurement of the small bowel. With a stepwise hand-over-hand technique using one marked grasper, the 134 7
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