surgical procedures into operative steps and teach and train these steps separately, a step-bystep approach. The survey amongst Dutch metabolic bariatric centres described in Chapter 3 shows that most centres adopted some sort of stepwise training.21 The benefits of stepwise training are multiple. By training one step at a time the additional operative times are reduced. Stepwise training can be supported by educational tools such as intraoperative video-enhanced surgical procedure training (INVEST).29 Next, procedures like the LRYGB include key components of advanced laparoscopic training such as stapling, suturing and mobilization of the stomach and small intestine. Training these steps separately can support skill acquisition for other laparoscopic procedures, even without completing a LRYGB or LSG learning curve. In the third part of this thesis, one specific step of the laparoscopic Roux-en-Y gastric bypass was highlighted: running the small bowel and determining its length. To determine how we should train and assess trainees in this technique, Chapter 6 studies the performance of the metabolic bariatric surgical staff and general surgery residents on their accuracy in determining length.30 The step was transferred to an ex vivo situation in a laparoscopic box with an animal small bowel model. The study showed that surgeons are more proficient in determining limb length, and thus have learned this along the way of gaining expertise, without explicit training. Assessing this skill in surgeons provides feedback on their accuracy, which may benefit both surgical outcome and the process of lifelong learning. In Chapter 7 a laparoscopic training box exercise on a rope was used to allow residents to train this step in a simple box.31 Using the animal small bowel model as a gold standard, the accuracy and speed of the residents improved by training on such a simple model. More sophisticated models of artificial small bowel exist, including automated limb length measurement.32 These models might prove feasible to be both the training exercise and assessment. However, animal, and cadaveric models are both expensive and labour-intensive to create. In previous studies another step, the jejunojejunal anastomosis, was also simulated in an exvivo model.10,11 This research shows that ex vivo training shortens the time needed in intheatre training. As in the rope-exercise model, assessment was done with a more realistic, in this case cadaveric, model. For suturing and especially stapling more sophisticated models are needed to create realistic exercises and assessments. 154 8
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