Masters Laparoscopic Colectomy - Formative Assessment

Surgeon Name (Trainee)*

First Last

Faculty member name*

First Last

Hospital/Training Facility*

Date of surgery*

This is my laparoscopic colectomy number*

Please elaborate

CASE INFORMATION

BMI*

Prior abdominal surgery?*

Yes
No

Indication for surgery*

Benign
Malignant

Surgery

Type of resection*

Please specify

Specimen extraction site*

Operative time- minutes, skin to skin*

Converted to open?*

Yes
No

Reason for conversion*

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Complicated Surgery

No
Yes

If yes, please select:*

Multi-select by using the CTRL or COMMAND key

Please specify*

Anastomosis*

Intracorporeal
Extracorporeal

Extracorporeal*

Stapled
Hand-sewn

Stoma*

None
Ileostomy
Colostomy

Reason*

Intra-op event*

Bleeding
Enterotomy/Seromyotomy
Other Iatrogenic injury
Other

Please specify*

SELF-ASSESSMENT

1- Unable to Perform
2- Very Difficult
3- Experienced a few difficulties
4- Slight Difficulties
5- Competent
6- Proficient
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 and lateral dissection along white line of Toldt )

Safe identification and dissection of vascular pedicles*

Dissection of mesentery and mesocolon*

Identification of duodenum, ureter*

Mobilization 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*

How difficult was this operation?

Comments

Masters Laparoscopic Colectomy – Formative Assessment

To be completed by the Trainee after each procedure

CASE INFORMATION

Surgery

SELF-ASSESSMENT