DISCUSSION The results of this study show that after completing the training experiment, in total the surgical residents were able to improve their laparoscopic small bowel measurements by 13%, however, this difference was not statistically significant. Residents who practiced sufficiently improved significantly and were able to measure small bowel length with only 5% deviation from the goal length. The lack of statistical significance of the 13% reduction is probably due to the small sample size. In a subgroup analysis of residents who did practice sufficiently, the reduction was significant, which strengthens the relevance of practice. In a previous study, a ten percent or less deviation of the goal length was defined as acceptable, as these differences may not have clinical implications 9. With only 5% deviation, surgical residents measured small bowel length with an acceptable deviation from the goal length. An earlier review by Thingaard et al. showed that a take-home trainer box facilitated off-site training by making it accessible to residents.19 Moreover, other research has shown that in obtaining procedural, including surgical, skills distributed practice leads to more and more durable training effects compared to massed practice.19-21 Participants in our experiment were therefore instructed to practice at least every week of the experiment. Even with these low demands on training time, not all participants managed to find time for adequate practice. Clinical duties, on-call hours, and additional tasks during the COVID-19 outbreak interfered. However, even with these limited amounts of training a significant effect was found on the accuracy of limb length measurement. This may encourage residents to find a little time to practice their skills as even a small amount of practice shows to be beneficial. This is supported by the results of our questionnaire, in which over 70% of residents responded they feel their skills have improved during the study period. A remarkable result of our study is that although the small bowel measurements on the porcine bowel specimen significantly improved, the measurements of the rope did not improve over time. This observation could be explained by the specific characteristics of the cord, its stiffness, length, and thickness. The pros of this small cord are its accessibility, low costs, and haptic feedback when grasping it compared to a lint for example. The use of a different exercise tool, such as the cotton bowel used by Wagner et al. may be subject of further research to not only exercise the task but also assess the trainee’s skills ex vivo.14 As 140 7
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