an alternative, the porcine small bowel model used in this experiment as well as other studies could be used to assess the residents’ skills.22 The presented study focuses on the accuracy of the trainee’s measurement. However, handling the small bowel to estimate limb length requires multiple subskills, accuracy, tissue handling, and speed. Obtaining some speed may be a side-effect of this exercise, but it was not the goal. A reduction of the time needed to estimate 150 cm bowel length was observed, from circa 2.5 to 2 minutes, however, this was not statistically significant. Tissue handling was not trained or measured, this part of the skill should still be trained in vivo or obtained otherwise. To our knowledge, this is the first study creating a training experiment to train surgical residents in laparoscopic small bowel measurement. The learning curve of a gastric bypass procedure comprises 30 - 200 cases, depending on the definition of the endpoint of the learning curve.23 During this learning curve operative times are longer, and complication rates are higher.24 However, the learning curve can be shorter if the different skills needed are already mastered. As Buchwald and Scopinaro have stated: all techniques needed in the substeps of the procedures can and have to be mastered in the surgical training program.25 This ex vivo training method with box trainers is a simple, easy to implement, and low in costs method to train residents in laparoscopic small bowel measurements. It can be implemented in teaching hospitals to train surgical residents. With high demands on operative quality and costs, ex vivo training is a relevant alternative and addition to on-site training. Further research is necessary to optimize training methods to be able to train more of the gastric bypass sub-steps using an ex vivo model. A limitation in the design is that the box trainer does not use a laparoscopic camera, but the graspers and cord are manipulated under direct sight. This excludes the magnification of the camera and gives 3D instead of 2D sight. However, the use of marked cords was designed to train the motoric memory in a hand-over-hand technique with 5 cm step intervals. These 5 cm difference in spatial position between the two graspers stays the same, regardless of the viewpoint of the trainee, in 2D, 3D, and different magnifications. Using a plexiglass assembly box makes it possible to be used multiple times, at low cost, and can be used to practice at home next to a laparoscopic box with a camera system. Another limitation was the small sample size of the study including only 10 surgical residents in the study. Nevertheless, due to the high percentage of improvement in the residents who adhered to the training this sample 7 141 Measuring small bowel length in metabolic bariatric surgery: a training experiment
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