Cover Page. The following handle holds various files of this Leiden University dissertation:

Transcription

1 Cover Page The following handle holds various files of this Leiden University dissertation: Author: Spruit, E.N. Title: Increasing the efficiency of laparoscopic surgical training: assessing the effectiveness of training interventions Issue Date:

2 CHAPTER 12 APPENDIX A SUB-TASKS, OPERATIVE STEPS AND DECISION POINTS DURING LAPAROSCOPIC SIGMOID COLON RESECTION

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4 Appendix A Chapter 12 Appendix A. Sub-tasks, operative steps and Decision points during Laparoscopic Sigmoid Colon Resection Sub-task Patient positioning & Trocar placement Investigation of the abdominal cavity Creating a submesentaric window & transecting the sigmoid veins Operative steps & Decision Points (N): Novice, (I): Intermediate, (A): Advanced (N) Time-out procedure (N) Place patient in Trendelenburg with a 1-2 degree vertical tilt and a -10 degree tilt to the right. Legs are spread with feet at the level of the hips. (N) Surgeon and assisting surgeon are positioned to the right of the patient (I) Place first trocar at the umbilicus (N) Place second trocar at the right flank (N) Place third trocar just above the pubic bone (I) Given the patients size, are more trocars needed? Yes -> Place fourth/fifth/sixth trocar No -> Proceed to next sub-task (I) Check for spread of infection to other organs (I) Move the omentum and the small intestines anteriorly to facilitate exposure of the sigmoid colon (I) Investigate the colic tumor locally (A) Is it an ingrown tumor? No -> proceed to next sub-task Yes -> grown into which structures? Left ureter -> Convert to open (laparotomy) Abdominal wall / bladder / appendix / coecum / small intestine -> Is adequate visualization possible? Yes -> Proceed to next task No -> Convert to open (I) Is there adequate visualization of the sigmoid mesocolon and the trunk of the sigmoid arteries? Yes -> Adopt Medial-to-Lateral approach No -> Mobilize lateral attachments first (I) Suspend the uterus to facilitate exposure (optional in the case of postmenopausal female patients) (I) Identify the sigmoid mesocolon (I) Where is the tumor located exactly? Sigmoid -> Dissect sigmoid arteries Colosigmoid -> Dissect sigmoid arteries and colica sinistra Rectosigmoid -> Dissect sigmoid arteries, rectus superior and the inferior mesentaric artery just above the branch of the Sigmoid Arteries (I) Establish rough margins for the to-be-extracted colon specimen at five centimeters distal and proximal to the tumor (while also taking into account blood supply) in order to guide the dissection of the sigmoid mesocolon and the dissection of the artery supply (I) Apply traction ventrally to facilitate identification of the trunk of sigmoid arteries (I) Blunt dissection of the avascular layers of the sigmoid mesocolon to create a submesentaric window 12 11

5 Chapter 12 Appendix A Sub-task Creating a submesentaric window & transecting the sigmoid veins Posterior and lateral mobilization of the Sigmoid Colon Mobilization of the descending colon towards the splenic flexure Division of the sigmoid colon Creating the anastomosis Operative steps & Decision Points (N): Novice, (I): Intermediate, (A): Advanced (A) Expose and identify the trunk of the sigmoid arteries (A) Expose and identify the left ureter (A) Expose and identify the hypo gastric nerve (A) Transect the sigmoid veins at a level that includes a minimum of twelve lymph nodes attached to the to-be-extracted colon specimen using a stapler, clips or Ligasure (A) Transect Rectus Superior, Inferior Mesentaric Artery or Colica Sinistra if necessary (I) Further dissect the peritoneum of the sigmoid mesocolon and lift it ventrally while preserving the lymph nodes (I) Dissect the posterior attachments of the sigmoid colon to the retroperitoneum (I) Dissect the lateral attachments of the sigmoid colon to the abdominal wall (A) Is there a tensionless fit of the upper and lower end of the colon? Yes -> Proceed to Division of the sigmoid colon No -> Proceed to Mobilization of the left colon towards the splenic flexure (A) Mobilize the descending colon (and splenic flexure) laterally to gain length on the proximal colon (A) Is there a tensionless fit of the upper and lower end of the colon? Yes -> Proceed to Division of the sigmoid colon No -> Mobilize the descending colon (and splenic flexure) medially to gain length on the proximal colon (A) Divide the distal sigmoid colon with a stapler at a minimum of five centimeters below the tumor (I) Create a 6-centimer incision above the pubic bone (I) Extract the sigmoid colon using a wound protector (I) Divide the proximal mesocolon with a stapler at the level of the division of the sigmoid arteries (I) Divide the proximal sigmoid colon with a stapler at a minimum of five centimeters above the tumor (A) What kind of anastomosis will be created? End-to-end, side-to-side or side-to-end (I) Place and suture the first anvil in the proximal end of the colon (I) Put the proximal colon back into the abdominal cavity (I) Re-establish the pneumoperitoneum (I) Place the circular stapler in the distal end of the colon/rectum via the anus (I) Connect the anvil to the stapler (I) Check that the proximal colon is not twisted (N) Fire the circular stapler (I) Optional: Create a stoma (A) Test the anastomosis for leakage (A) Given the current dissection, is there high risk for inguinal hernia? Yes -> Close the sigmoid mesocolon (I) Final inspection and cleaning of the operative field (I) Close the trocar wounds 12

6 CHAPTER 1 APPENDIX B SURGICAL SKILLS PROFILE

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8 Appendix B Chapter 1 Appendix B. Surgical Skills Profile Form of Proficiency Surgical Skill Relevance Surgical knowledge Perceptual skills Motor skills Clinical decision making Mental endurance Social skills Technology skills Anatomy (including anomalies) Procedural steps Pathology Identification of tissue types (anatomy) Depth perception Haptics Mental Imagery Instrument handling Blunt dissection Mobilizing tissue for exposure/dissection Sharp dissection Using cautery/ultrasonic shears/stapler/etc. Intra-corporeal suturing Switching operative techniques Changing pace of operation Situation awareness Meta cognition of skill acquisition Performance monitoring Response inhibition Emotional stability Mental focus (concentration) Team communication Instructing assisting staff Understanding the mechanics of hard-ware Trouble-shooting equipment 1 1

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