Masters Laparoscopic Colectomy Course - Cadaver Lab Trainee Evaluation

To be completed by Faculty at Course

* Denotes required field

Surgeon Name (Trainee)*
First Last
Faculty member name*
First Last
Date of program*
MM slash DD slash YYYY
Hospital/Training Facility*
EVALUATION OF TRAINEE BY FACULTY ON CADAVER
1- NOT PERFORMED: Step had to be done by faculty
2- PARTLY PERFORMED: Step had to be partly done by faculty
3- PERFORMED: With substantial guidance
4- PERFORMED: With minor guidance
5- COMPETENT PERFORMANCE: Safe without guidance
6- PROFICIENT PERFORMANCE: Couldn't be better
0- NOT APPLICABLE
Correct OR setup*
(Positioning of monitors, energy platform, foot pedal, etc.)
Appropriate patient positioning*
(Tucking arms correctly, securing patient with bean bag, avoiding pressure points, ensuring access to anus for transanal stapling)
Safe access of peritoneal cavity & establishment of pneumoperitoneum*
Exposure of surgical planes*
(e.g. deflection of small bowel for medial to lateral approach, adequate retraction to identify vascular pedicles, plane between omentum and transverse colon, lateral dissection along white line of Toldt)
Safe identification and dissection of vascular pedicles*
Dissection of mesentery and mesocolon*
Identification of duodenum, ureter*
Dissection of hepatic/splenic flexure*
Mesorectal dissection (where applicable)*
(Correct identification of mesorectal plane, hypogastric nerves)
Safe extraction of specimen*
(use of wound protector, avoiding overaggressive traction on specimen)
Anastomosis*
Overall Performance*
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