measurement was run in estimated steps of 5 cm. This method of bowel length measurement was described before by Slagter et al..99 For the baseline measurement, the entire small bowel of a porcine cadaver including its mesentery was placed in the laparoscopic box (Figure 1a). All participants were asked to measure a small bowel segment of 150 cm on the porcine intestine three times in a row. Each endpoint of a measurement was used as a starting point for the next measurement, to blind participants from their previous results. Next, the participants repeated these three 150 cm measurements on an unmarked rope in the laparoscopic box trainer. For all measurements on the small bowel, the time spent on the task was recorded. After the measurements on both porcine intestine and rope, the actual length of the marked segments was determined by the observer, using a tape measure outside the laparoscopic box, avoiding any traction on the porcine bowel during this tape measurement. The length of the porcine intestine was measured twice, and the mean of the two tape measure lengths was used as the actual measured length. The participants received feedback about the estimated lengths they performed on the small bowel and rope. Next, the participants were given a mini box trainer rope model with two training exercises to train their skills for two weeks. They received both verbal instruction and an instruction video to train at least once, but preferably three times, for at least 15 minutes during each week of the training experiment. A second measurement evaluation was made after one week of practice. The participants were now asked to perform three repeated measurements of 150 cm on a rope in the laparoscopic box trainer. The participants again received feedback about their estimated lengths. After another week of practice at home, again three times a week, the final measurements were done on both porcine small bowel and rope in the laparoscopic box. This training model is summarized in Figure 2. After completion of the training experiment, the participants were invited to give their opinion of the training method via a short questionnaire. The questionnaire comprised five statements that had to be rated on a 5-point Likert scale. 7 135 Measuring small bowel length in metabolic bariatric surgery: a training experiment
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