Appendix 2. Evaluation tool to assess technical skill in laparoscopic right colectomy
ACCESS AND PORT INSERTION
Specific Skill
Creating access and placing 3 or 4
additional ports under direct vision
1
2
Created clumsily &
with difficulty
3
4
Created adequately
5
Created quickly
and skilfully
DIAGNOSTIC LAPAROSCOPY
Specific Skill
Inspecting the intra-abdominal contents
with the laparoscopic camera
1
2
Cursory inspection,
or not done
3
4
Moderately
detailed inspection,
areas not visualized
5
Careful and
thorough
inspection
INITIAL EXPOSURE
Specific Skill: Medial to
Lateral Approach
Identifying the ileocolic vascular pedicle
by applying traction to the cecum
Specific Skill: Lateral to
Medial Approach
Exposing and identifying the “valley” at
the base of the cecum and the terminal
ileal mesentery – this marks the junction
of the mesentery with the retroperitoneum
1
2
Insufficient or
traction in a
incorrect direction.
Poor identification
of pedicle
1
3
4
Satisfactory
traction and
identification
2
Incorrect plane
identified
3
5
Traction in correct
direction and clear
identification of
the vascular
pedicle
4
Identified
5
Clear identification
with excellent
exposure
DIVISION OF ILEOCOLIC VASCULAR PEDICLE
Specific Skill
Scoring the peritoneum under the
ileocolic vessels
Skeletonizing the ileocolic vessels
Dividing the ileocolic vessels
1
2
Scoring of
peritoneum in
incorrect location,
excessive tissue
traction, bleeding
Vessels poorly
isolated, excessive
tissue damage and
bleeding
Divided with
trauma or bleeding.
Not adequate
length from the
bowel
3
4
Peritoneum scored
satisfactorily, with
some tissue
damage and
bleeding
Vessels isolated
appropriately with
some tissue
damage
Divided adequately
5
Peritoneum scored
correctly and
accurately
Vessels
skeletonized in an
expert manner
Divided expertly
with no trauma
INITIAL DISSECTION
Specific Skill: Medial to
Lateral Approach
1
Developing a plane between the
mesocolon and the retroperitoneum in a
medial to lateral direction
Difficulty
developing correct
plane, bleeding
Identifying the duodenum
Duodenum not
identified
Dissection in
incorrect plane and
Continuing the medial to lateral
dissection until above the duodenum and
2
3
Plane developed
with some
difficulty, adequate
hemostasis
Satisfactory
identification
Dissection to
correct location
4
5
Plane developed
correctly with
excellent
hemostasis
Clear identification
Dissection
continued expertly,
the head of the pancreas and under the
transverse mesocolon
Identifying the right branch of the middle
colic artery
Dividing the right branch of the middle
colic artery
Specific Skill: Lateral to
Medial Approach
Scoring the peritoneum around the cecum
and the terminal ileum (TI) along this
valley and entering the retroperitoneal
plane
Opening the right lateral peritoneal
reflection (lateral to the cecum and the
ascending colon) and dissecting towards
the midline
Exposing the duodenum
Mobilizing the ascending colon to the
midline
with inadequate
exposure, tissue
trauma and
bleeding
Poor identification,
inadequate
dissection
Divided with poor
hemostasis
1
with minimal
trauma
in correct plane
and to correct
location. No
bleeding
Clear identification
Satisfactory
identification
Divided adequately
2
3
Difficulty entering
retroperitoneal
plane
Entered correct
retroperitoneal
plane
Difficulty
remaining in
correct plane
Correct plane
developed with
some difficulty
Poor exposure
Difficulty with
mobilization or
excessive bleeding
Adequate exposure
Mobilization with
moderate
hemostasis
Divided safely
with good
hemostasis
4
5
Entered into
correct plane
smoothly and
accurately
Correct plane
developed
Good exposure
Mobilization with
excellent
hemostasis
MOBILIZATION OF THE HEPATIC FLEXURE
Specific Skill
Positioning the patient in reverse
Trendelenburg with their right side up
Dividing the omental attachments at the
transverse colon
Entering the lesser sac and dividing the
omentum proximally
Medial-caudal retraction of the flexure
Dividing the flexure with an appropriate
energy source
1
2
3
Patient not
positioned
correctly
Patient positioned
correctly after
some delay
Attachments
divided with poor
technique, correct
plane not
identified, bleeding
Trouble entering
lesser sac.
Omentum divided
with associated
trauma
Flexure not
retracted in correct
direction
Flexure divided
with excessive
tissue trauma,
bleeding
Attachments
divided with some
bleeding
4
5
Patient
repositioned at
correct point in the
operation
Attachments
divided with good
hemostasis
Lesser sac entered
in the correct plane
with some
difficulty, minimal
bleeding
Flexure retracted
adequately after
some repositioning
Flexure divided
adequately
Lesser sac entered
and omentum
divided in an
expert manner
Flexure retracted
appropriately and
in correct direction
Flexure divided in
an expert manner
with no tissue
trauma or bleeding
EXTERIORIZATION BOWEL RESECTION AND ANASTAMOSIS
Specific Skill
Dividing the proximal and distal bowel
intra- or extra-corporeally
Using a wound protector if the bowel is
exteriorized
Anastomosis performed according to the
surgeon’s preference
1
Bowel divided
with tissue trauma
and gross
contamination
Wound protector
not used
Anastomosis made
clumsily with
spillage of bowel
contents, bleeding,
or under tension
2
3
Bowel divided
with minimal
spillage
Anastomosis made
adequately with
some assistance
4
5
Bowel divided
cleanly and
expertly
Wound protector
used
Anastomosis made
with no spillage,
good hemostasis
and no tension