Page 47 - World Journal of Laparoscopic Surgery

ORIGINAL ARTICLE Laparoscopic Instruments Marking Improve Length Measurement Precision

Laparoscopic Instruments Marking Improve

Length Measurement Precision

Isreb S, Hildreth AJ, Mahawar K, Balupuri S, Small P
Surgical Department, City Hospital Sunderland NHS Foundation Trust, UK

Correspondence: Isreb S, Surgical Department, City Hospital Sunderland NHS Foundation Trust, 26D, Bowsden Court
Southgosforth, Newcastle Upon Tyne, NE3 1RR, UK, Phone: 00447973297007, e-mail: drisreb@yahoo.com

Abstract
Introduction: Bariatric surgery has increased the demand for accurate laparoscopic bowel length measurement. Measures to achieve
such precision are scarce in the medical literature. Our study investigates the effect of instruments marking on measurement precision.
Methods: Eight consultants and fourteen senior trainees with laparoscopic experience were asked to estimate 150 cm on a piece of
string fixed within a standard laparoscopic training stack. Each candidate carried out three pairs of measurement using standard
laparoscopic instruments without marking, with 10 cm and with 5 cm mark. Each measurement was timed separately. Candidates were
result blinded to prevent any self-correction. Data were analyzed using Bland-Altman plots along with ANOVA tests.
Results: Greater accuracy was achieved via marked instrumentation, the differences being statistically significant (P < 0.01). The
improvement was significant regardless of candidates' level or initial length judgment. Time was almost doubled for the marked
measurement. No statistically significance differences were found between the 5 or 10 cm instrument markings for measurement or
time.
Conclusions: Marked laparoscopic instrument is a simple and effective way of enhancing length measurement precision regardless of
surgeons' experience.
Keywords: Laparoscopy, instrument length measurement, bariatric surgery, laparoscopic instrument design.

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INTRODUCTION followed in 1994, and hence the demand for accurate
laparoscopic bowel length measurement started. Currently the
Bowel length measurement has always been a part of surgical
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practice, whether it is performed for Michel's diverticulum or recommendation for roux limb varies according to the body
to avoid short bowel syndrome during bowel resection. The mass index, namely 75, 150, 200 and 250 cm for patients with
introduction and evolution of barbaric surgery has increased body mass indices of less than 40, 40 to 50, greater than 60 and
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the demand for measurement precision. Early bariatric surgical 70 to 80 respectively. Despite the demand for length precision,
attempts in 1950s adopted the malabsorption approach by there is as yet no consensus regarding a standard approach for
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creating short bowel syndrome. Following the same principle, laparoscopic measurement. The majority of laparoscopic
the Jejunocolic bypass was introduced followed by, the instruments are not length marked; therefore unguided
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jejunoileal bypass. Along with its side effects of mineral and estimation of length is common practice. One study suggested
vitamins loss, purely malabsorption procedures failed to that a 5 cm groove mark be introduced to the Babcock shaft to
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maintain weight loss due to bowel adaptation. The gastric help standardize bowel length measurements. Two text books
restriction approach followed in the 1960s with gastric pouch hinted at the possibility of using a special bowel grasper with
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and Billroth II gastrectomy. Following the popularity of Roux- 10 cm marking, premeasured umbilical tap or a ruler for length
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en-Y anastomosis in 1970s, Mason started to perform gastric measurement without ruling out the established length
pouches with various lengths of jejunal Roux-en-Y anastomosis. estimation practice. 13,14
Various gastroplasty and gastric banding approaches were Multiple factors affect the laparoscopic vision including
developed under the same gastric restriction umbrella that lacked lens magnification, distance from the object, resolution, depth
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the malabsorption concept. The current approach in bariatric of the field and optical light transmission. Magnification is
surgery combines the two principles of malabsorption and well known to change length perception as there is an inverse
gastric restriction. The two dominant operations under this association between magnification and length perception. This
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approach are biliopancreatic diversion and the duodenal effect is well-established even when background landmarks are
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switch. Both operations use the jejunal Roux-en-Y anastomosis given. All these effects will impair length estimation under
approach. laparoscopic vision.
Joining the laparoscopic era in the 1990s the first This study was designed to investigate the difference
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laparoscopic procedure was gastric banding. Gastric bypass between estimation and length measurement using marked and
World Journal of Laparoscopic Surgery, September-December 2009;2(3):57-60 57