Laparoscopic Appendectomy Rating Form
Evaluator:
Subject:
Status:
Program:
Please rate this resident's performance during this operative procedure. The
caption above each item provides descriptive anchors for 3 of the 5 points on the
rating scale. "N/A" (Not applicable) should only be selected when the resident did
not perform that part of the procedure.
Patient Location
MMC Inpatient
O
St. John’s Inpatient
MMC Outpatient
(23 hour )
O
O
St John’s Outpatient
(23 hour )
O
Hospital Medical Record Number
Date of Procedure
MM/DD/YY
OPRS Case Difficulty
Indicate the difficulty of the case:
1
Straightforward anatomy, no
related prior surgeries or
treatment
O
2
Intermediate difficulty
O
3
Abnormal anatomy, extensive
pathology, related prior
surgeries or treatment (for
example radiation), or obesity
O
1
Degree of Prompting or Direction
1
2
Substantial direction
by attending. Resident
performs all steps but
the attending provides
constant direction to
the resident and
surgical team.
3
Some direction by
attending. Resident
performs all steps but
the attending provides
occasional direction to
the resident and /or to
the surgical team.
O
Minimal direction by
attending. Resident
performs all steps and
directs the surgical
team independently
with minimum or no
direction from the
attending, to either the
resident or to the
surgical team.
O
O
Procedure Specific Criteria
Incision / Port Placement
5
Excellent
4
Very Good
Safe, efficient
and optimal
positioning of
ports for
procedure, &
anatomy
O
O
3
Good
2
Fair
Functional
but awkward
port
positioning,
generally
safe
technique,
some
difficulty
inserting
ports.
O
1
Poor
NA
Poor
choice of
port
position,
unsafe
technique
insertion
/removal.
O
O
O
Exposure
5
Excellent
Optimizes
exposure ,
efficiently directs
retraction and
camera to maintain
4
Very
Good
3
Good
Adequate
establishment and
maintenance of
pneumoperitoneum,
camera angle and
2
Fair
1
Poor
NA
Poor / Inadequate
pneumoperitoneum,
camera angle and
retraction with
frequent loss of
2
exposure and
pneumoperitoneum
O
O
retraction but with
occasional loss of
exposure.
O
exposure
O
O
O
Appendix Dissection
5
Excellent
Expedient and
efficient
location of
appendix and
creation of
mesoappendix
window close
to cecum
O
4
Very Good
3
Good
2
Fair
1
Poor
O
Adequate but
inefficient
dissection,
some bleeding
during
creation of
mesoappendix
window
O
O
O
O
3
Good
2
Fair
1
Poor
NA
O
O
Dissection of
appendix
inadequate to
place staples
and divide
safely.
Multiple
attempts to
place staples
O
O
3
Good
2
Fair
1
Poor
NA
NA
Dissection of
appendix
inadequate for
safe staple
placement
Appendix Division
5
Excellent
Safe and
secure staple
placement
across base of
appendix and
mesoappendix
with clean
division of
appendix
O
4
Very Good
Adequate but
inefficient
dissection,
stapled
securely but
spacing not
idea
O
Appendix Removal
5
Excellent
Efficient
placement of
appendix
within bag and
removal from
field, without
spillage or
contamination.
4
Very Good
Inefficient
placement of
appendix
within bag,
some
contamination,
Inadequate
division of
appendix or
mesoappendix
(multiple
attempts) did
not cleanly
remove
appendix, or
caused
spillage or
contamination.
3
O
O
O
O
O
O
1
Poor
NA
General Criteria
Instrument Handling
5
Excellent
4
Very Good
Fluid
movements
with
instruments
consistently
using
appropriate
force, keeping
tips in view,
and placing
clips placed
securely.
3
Good
2
Fair
Competent
use of
instruments,
occasionally
appeared
awkward, or
did not
visualize
instrument
tips
O
O
Tentative or
awkward
movements
often did not
visualize tips
of instrument,
or clips poorly
placed.
O
O
O
O
3
Good
2
Fair
1
Poor
NA
Respect for Tissue
5
Excellent
4
Very Good
Consistently
handled tissue
carefully
(appropriately),
minimal tissue
damage
Frequent
unnecessary
tissue force or
damage by
inappropriate
instrument
use.
Careful tissue
handling,
occasional
inadvertent
damage
O
O
O
O
O
O
4
Very Good
3
Good
2
Fair
1
Poor
NA
Time and Motion
5
Excellent
Clear
economy of
motion, and
maximum
efficiency
O
Efficient time
& motion,
some
unnecessary
moves
O
O
Many
unnecessary
moves
O
O
O
4
Operation Flow
5
Excellent
4
Very Good
Obviously
planned
course of
operation and
anticipation of
next steps.
3
Good
2
Fair
1
Poor
□
Some
forward
planning,
reasonable
procedure
progression
NA
Frequent
lack of
forward
progression;
frequently
stopped
operating
and seemed
unsure of
next move
.
O
O
O
O
O
O
Overall Performance
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
NA
O
O
O
O
O
O
Please indicate the weaknesses in this resident’s performance:
Please indicate the strengths in this resident’s performance:
5
References
Faiz, Omar; Clark, Jeremy; Brown, Tim; et al. Traditional and Laparoscopic
Appendectomy in Adults: Outcomes in English NHS Hospitals Between 1996 and
2006. Annals of Surgery. 248(5):800-806, November 2008.
Roumen, R. M. H.; Groenendijk, R. P. R.; Bruyninckx, C. M. A.; et al.
Randomized clinical trial evaluating elective laparoscopic appendicectomy for
chronic right lower-quadrant pain (Br J Surg 2008; 95: 169-174). British Journal
of Surgery. 95(6):800-801, June 2008.
Ng, Wai-Tat; Lee, Yiu-Kee ; Hui, Sheung-Kit ;et al. An Optimal, Cost-effective
Laparoscopic Appendectomy Technique for Our Surgical Residents. Surgical
Laparoscopy, Endoscopy & Percutaneous Techniques. 14(3):125-129, June
2004.
Motson, Roger W; Kelly, Michael D Simplified technique for laparoscopic
appendectomy. ANZ Journal of Surgery. 72(4):294-295, April 2002.
6