Surgical Endoscopy

, Volume 31, Issue 11, pp 4697–4704 | Cite as

Accuracy and inter-operator variability of small bowel length measurement at laparoscopy

  • Benny Gazer
  • Danny Rosin
  • Barak Bar-Zakai
  • Udi Willenz
  • Ofer Doron
  • Mordechai Gutman
  • Avinoam Nevler



Measurement of bowel length is an essential surgical skill for laparoscopic and open gastrointestinal surgery in order to achieve favorable outcomes and avoid long-term complications. Variations in accuracy between the two surgical approaches may exist. However, only few studies have tried to assess these differences. Our aim was to assess reliability and inter-rater variability of small bowel length assessment during laparoscopy in an in vivo porcine model.


This is a single-institution, double-blinded, technical assessment study in a porcine in vivo model. Fourteen participants (ten senior surgeons with >1000 laparoscopic procedures and four junior surgeons) had to assess and mark lengths of small bowel in both laparoscopic and open surgical approaches. Each participant was assigned to measure and mark specific, randomized distances (range 25–197 cm) in both laparoscopic and open approaches using color-coded vessel loops. Actual participant-marked distances were compared to the assigned distances followed by Bland–Altman plots and linear regression analysis to determine accuracy and proportional error trends. Study data were further compared to available data sets from previously published studies.


Laparoscopy measurements were significantly shorter than required (difference 33.8 ± 28.7 cm, P < 0.001, 95% CI 17.8–49.7). The measuring error was proportional to the length of the measured segment (63% of the required distances, IQR 58.9–79.0%, P = 0.02). At laparotomy, mean difference and standard deviation were lower (1.5 cm ± SD 15 cm) and not statistically significant (P = 0.7). Re-analysis of previously published data sets validated the observed errors in laparoscopic bowel measurement (P < 0.01).


Small bowel length assessment during laparoscopy is inaccurate and associated with substantial variability. There is a need to develop a standardized laparoscopic technique for measuring small bowel length which is simple, reproducible, and easy to learn.


Laparoscopy Bariatric surgery Small bowel length Surgical education Surgical complications 



The authors acknowledge Drs. Jordan M. Winter M.D. and Talar Tatarian, M.D. (Thomas Jefferson University, Philadelphia, PA), for their critical review of the manuscript.


The laparoscopic equipment used in this study was provided in part by Covidien Inc. (Medtronic) as well as supporting the travel of Dr. Gazer to the SAGES Annual Meeting (Boston, MA, March 17–19, 2016). The company had no influence or editorial control over the content of the study.

Compliance with ethical standards


Dr. Nevler received honoraria from the Janssen Labs (San-Diego, CA) unrelated to the submitted work. Mr. Doron and Drs. Rosin, Bar-Zakai, Willenz, Gutman and Gazer have no conflicts of interest or financial ties to disclose.

Supplementary material

464_2017_5538_MOESM1_ESM.docx (14 kb)
Supplementary material 1 (DOCX 14 kb)


  1. 1.
    Stefanidis D, Kuwada TS, Gersin KS (2011) The importance of the length of the limbs for gastric bypass patients—an evidence-based review. Obes Surg 21(1):119–124CrossRefPubMedGoogle Scholar
  2. 2.
    Birck MM, Vegge A, Stockel M, Gogenur I, Thymann T, Hammelev KP et al (2013) Laparoscopic Roux-en-Y gastric bypass in super obese Gottingen minipigs. Am J Transl Res 5(6):643–653PubMedPubMedCentralGoogle Scholar
  3. 3.
    Tacchino RM (2015) Bowel length: measurement, predictors, and impact on bariatric and metabolic surgery. Surg Obes Relat Dis 11(2):328–334CrossRefPubMedGoogle Scholar
  4. 4.
    Ciovica R, Takata M, Vittinghoff E, Lin F, Posselt AM, Rabl C et al (2008) The impact of Roux limb length on weight loss after gastric bypass. Obes Surg 18(1):5–10CrossRefPubMedGoogle Scholar
  5. 5.
    Gleysteen JJ (2009) Five-year outcome with gastric bypass: Roux limb length makes a difference. Surg Obes Relat Dis 5(2):242–247 (discussion 7–9) CrossRefPubMedGoogle Scholar
  6. 6.
    Spivak H (2015) A simple technique for jejunojejunal revision in laparoscopic Roux-en-Y gastric bypass. Obes Surg 25(12):2461CrossRefPubMedGoogle Scholar
  7. 7.
    Nightingale JM, Lennard-Jones JE (1993) The short bowel syndrome: what’s new and old? Dig Dis 11(1):12–31CrossRefPubMedGoogle Scholar
  8. 8.
    Brown NM, Helmer SD, Yates CL, Osland JS (2012) The revised ACGME laparoscopic operative requirements: how have they impacted resident education? Surg Endosc 26(6):1737–1743CrossRefPubMedGoogle Scholar
  9. 9.
    Lussenden R, Brams D, Sillin L, Nepomnayshy D (2012) Laparoscopic measurement of intestinal length: how accurate are we? (2012 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) San Diego, California, USA, 7–10 March 2012 Poster Presentations). Surg Endosc 26(S1):248Google Scholar
  10. 10.
    Jackson HT, Zettervall SL, Teitelbaum EN, Holzner M, Weissler J, Amdur RL et al (2015) Effects of experience and reference tools on laparoscopic length measurements. Surg Endosc 29(6):1297–1302CrossRefPubMedGoogle Scholar
  11. 11.
    Isreb S, Hildreth A, Mahawar K, Balupuri S, Small P (2009) Laparoscopic instruments marking improve length measuring precision. World J Laparosc Surg 2(3):57–60CrossRefGoogle Scholar
  12. 12.
    Teitelbaum EN, Vaziri K, Zettervall S, Amdur RL, Orkin BA (2013) Intraoperative small bowel length measurements and analysis of demographic predictors of increased length. Clin Anat 26(7):827–832PubMedGoogle Scholar
  13. 13.
    Scott DJ, Provost DA, Tesfay ST, Jones DB (2001) Laparoscopic Roux-en-Y gastric bypass using the porcine model. Obes Surg 11(1):46–53CrossRefPubMedGoogle Scholar
  14. 14.
    Schwenk W, Haase O, Neudecker J, Muller JM (2005) Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev 3:CD003145Google Scholar
  15. 15.
    Breukink S, Pierie J, Wiggers T (2006) Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev 4:CD005200Google Scholar
  16. 16.
    Sauerland S, Jaschinski T, Neugebauer EA (2010) Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 10:CD001546Google Scholar
  17. 17.
    Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M (2011) Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev 3:CD007781Google Scholar
  18. 18.
    Wilson CH, Sanni A, Rix DA, Soomro NA (2011) Laparoscopic versus open nephrectomy for live kidney donors. Cochrane Database Syst Rev 11:CD006124Google Scholar
  19. 19.
    Vennix S, Pelzers L, Bouvy N, Beets GL, Pierie JP, Wiggers T et al (2014) Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev 4:CD005200Google Scholar
  20. 20.
    Gurusamy KS, Pallari E, Midya S, Mughal M (2016) Laparoscopic versus open transhiatal oesophagectomy for oesophageal cancer. Cochrane Database Syst Rev 3:CD011390PubMedGoogle Scholar
  21. 21.
    Riviere D, Gurusamy KS, Kooby DA, Vollmer CM, Besselink MG, Davidson BR et al (2016) Laparoscopic versus open distal pancreatectomy for pancreatic cancer. Cochrane Database Syst Rev 4:CD011391PubMedGoogle Scholar
  22. 22.
    Trejos AL, Patel RV, Malthaner RA, Schlachta CM (2014) Development of force-based metrics for skills assessment in minimally invasive surgery. Surg Endosc 28(7):2106–2119CrossRefPubMedGoogle Scholar
  23. 23.
    Mashiach R, Mezhybovsky V, Nevler A, Gutman M, Ziv A, Khaikin M (2014) Three-dimensional imaging improves surgical skill performance in a laparoscopic test model for both experienced and novice laparoscopic surgeons. Surg Endosc 28(12):3489–3493CrossRefPubMedGoogle Scholar
  24. 24.
    Sorensen SM, Savran MM, Konge L, Bjerrum F (2016) Three-dimensional versus two-dimensional vision in laparoscopy: a systematic review. Surg Endosc 30(1):11–23CrossRefPubMedGoogle Scholar
  25. 25.
    Pinzon D, Byrns S, Zheng B (2016) Prevailing trends in haptic feedback simulation for minimally invasive surgery. Surg Innov 23(4):415–421. doi: 10.1177/1553350616628680 CrossRefPubMedGoogle Scholar
  26. 26.
    Mahawar KK, Kumar P, Parmar C, Graham Y, Carr WR, Jennings N et al (2016) Small bowel limb lengths and Roux-en-Y gastric bypass: a systematic review. Obes Surg 26(3):660–671CrossRefPubMedGoogle Scholar
  27. 27.
    Kalfarentzos F, Skroubis G, Karamanakos S, Argentou M, Mead N, Kehagias I et al (2011) Biliopancreatic diversion with Roux-en-Y gastric bypass and long limbs: advances in surgical treatment for super-obesity. Obes Surg 21(12):1849–1858CrossRefPubMedGoogle Scholar
  28. 28.
    Suarez Llanos JP, Fuentes Ferrer M, Alvarez-Sala-Walther L, Garcia Bray B, Medina Gonzalez L, Breton Lesmes I et al (2015) Protein malnutrition incidence comparison after gastric bypass versus biliopancreatic diversion. Nutr Hosp 32(1):80–86PubMedGoogle Scholar
  29. 29.
    Obeid NR, Malick W, Concors SJ, Fielding GA, Kurian MS, Ren-Fielding CJ (2016) Long-term outcomes after Roux-en-Y gastric bypass: 10- to 13-year data. Surg Obes Relat Dis 12(1):11–20CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of General Surgery and TransplantationChaim Sheba Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv)Ramat-GanIsrael
  2. 2.Department of SurgeryKaplan Medical CenterRehovotIsrael
  3. 3.Lahav C.R.OKibbutz LahavIsrael
  4. 4.The Dr. Pinchas Borenstein Talpiot Medical Leadership Program 2012Chaim Sheba Medical CenterRamat-GanIsrael
  5. 5.Department of SurgeryThomas Jefferson UniversityPhiladelphiaUSA

Personalised recommendations