Background
Methods/design
Objective
Study design
Settings and trainees
Inclusion and exclusion criteria
Training curriculum
Basic skills | Excercise |
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Camera manipulation | The 30° angle camera is used to locate 10 balls and take a photo |
Eye-hand coordination | Blue or red color objects have to be touched with the same color instrument tip |
Clip applying | Ducts have to be clipped in order to stop water leakage |
Clipping and grasping | Ducts have to be grasped and pulled to avoid water leakage |
Two-handed maneuvers | Balls have to be grasped from a jelly mass and placed into a jelly bowl with the use of both hands |
Cutting | A circular form has to be cut with scissors while retracting it |
Electrocautery | Highlighted bands have to be cut with the hook cautery |
Peg transfer | Pegs have to be transferred from non-dominant hand to the other hand mid-air and placed on that side of the board and then transferred to the other side the same way |
Task/step | 1 2 | 3 4 | 5 |
Dissection of the gastro-phrenic ligament (angle of His): | |||
Pull fundus of stomach down (exposure) | Insufficient retraction; traumatic; insufficient exposure | Satisfactory retraction after some repositioning; suboptimal exposure | Appropriate retraction; optimal exposure |
Dissect angle of His close to stomach while keeping tension on fundus | Dissection in incorrect plane; insufficient or too much tension; bleeding | Dissection in correct plane; appropriate tension majority of time; occasional tissue damage, bleeding | Dissection in correct plane; careful handling of tissue; appropriate tension at all times; minimal tissue damage, bleeding |
Creation of the gastric pouch: | |||
Dissect along lesser curvature of stomach approx. 7 cm from the gastro-esophageal junction and keep close to stomach | Incorrect plane; incorrect anatomic location; excessive tissue trauma; bleeding with need of suction | Correct plane developed with some difficulty; moderate tissue damage; bleeding not requiring suction | Correct plane in correct anatomic location developed without difficulty or excessive tissue trauma, bleeding |
Create a posterior tunnel | Dissection in incorrect plane; unnecessary force; bleeding requiring suction | Dissection in correct plane; occasional tissue damage; bleeding not requiring suction | Dissection in correct plane; careful handling of tissue, minimal tissue damage, bleeding |
Introduce and apply a linear cutting stapler transversely to the stomach | Stapler applied in incorrect orientation; serosal damage to stomach | Stapler applied transversely after multiple repositioning attempts | Stapler applied transversely; no requirement for multiple repositioning attempts; no trauma to stomach wall |
Remove all tubes from the stomach before firing the stapler | Not done | Done after delay; with prompting | Done without delay or making sure the tube is not stapled (by movement) |
Fire stapler | Uncontrolled fire with excessive pull on the stomach | Controlled fire; some slippage of stomach between jaws | Smooth, controlled fire |
Develop a posterior tunnel towards the angle of His | Dissection in incorrect plane; unnecessary force; bleeding requiring suction | Dissection in correct plane; occasional tissue damage; bleeding not requiring suction | Dissection in correct plane; careful handling of tissue, minimal tissue damage, bleeding |
Introduce and apply another linear cutting stapler to the stomach | Stapler applied in an incorrect orientation; serosal damage to stomach | Stapler applied correctly; multiple repositioning attempts | Stapler applied correctly; no repositioning required; no trauma to stomach wall |
Fire stapler | Uncontrolled fire with excessive pull on the stomach | Controlled fire; some slippage of stomach between jaws | Smooth, controlled fire |
Confirm complete transection of stomach | Not confirmed | Confirmed briefly without adequate visualization | Methodical confirmation of complete transection |
Time: | |||
Task/step | 1 2 | 3 4 | 5 |
Creation of gastro-jejunal anastomosis: | |||
Linear stapler technique | |||
Create a gastrotomy in the gastric pouch | No entry into gastric lumen; poor relation between grasper and energy source; excessively large or small; penetration of posterior bowel wall; bleeding | Entry into gastric lumen; appropriate size; more than 1 attempt required | Entry into gastric lumen; appropriate size; no extra movements required |
Location of ligament of Treitz | Not found | Rough movements; poor orientation | Smooth movements; correct orientation |
Measure approximately 40–60 cm of jejunum distal to the ligament of Treitz | Length not measured | Measured, however individual measurements not of the same size; poor orientation | Measured methodologically; each measurement of the same size; correct orientation |
Create an enterotomy in the Roux limb | No entry into bowel lumen; poor relation between grasper and energy source; excessively large or small; penetration of posterior bowel wall | Appropriate size and entry into bowel lumen; not placed in antimesenteric location | Appropriate size and placement of enterotomy; good relation of grasper and energy source; no extra movements required |
Introduce one limb of linear cutting stapler into gastric pouch and the other into Roux limb | Unclear of how to insert the staple device; drives staple jaws blindly into the enterotomies | Inserts the stapler, but lacks appreciation of the ideal angle for insertion | Inserts staple jaws with ease; controlled manner; correct angle |
Ensure both limbs are symmetrical before firing the stapler | Does not ensure symmetry, antimesenteric location of stapler before closing of jaws | Limbs either nonsymmetrical or not in antimesenteric border before closure of jaws | Correct symmetry and antimesenteric position before closure of jaws |
Fire stapler | Uncontrolled fire with excessive pull on the bowel and widening of enterotomies | Controlled fire; some slippage of bowel from jaws | Smooth, controlled fire; no widening of enterotomies |
Time: | |||
Task/step | 1 2 | 3 4 | 5 |
Creation of jejuno-jejunal anastomosis: | |||
Linear stapler technique | |||
Create enterotomies in biliopancreatic and Roux limbs | Poor relation between grasper and energy source; excessively large or small; penetration of posterior bowel wall | Appropriate size enterotomy; not placed in antimesenteric location | Appropriate sized and placed enterotomies; no extra movements. Good relation of grasper and energy source |
Insert the limbs of linear cutting stapler into the enterotomies in Roux and biliopancreatic limbs | Unclear of how to insert the staple device. Drives staple jaws blindly into biliopancreatic and Roux limbs | Inserts the stapler with hesitation and lacks appreciation of the ideal angle for insertion | Inserts staple jaws with ease; controlled manner; correct angle |
Ensure both limbs are symmetrical and stapler in antimesenteric border | Does not ensure limb symmetry and antimesenteric position before enclose of jaws | Limbs either non-symmetrical or not on antimesenteric border before closure of jaws | Correctly ensures symmetry and antimesenteric position before closure of the jaws |
Fire stapler | Uncontrolled fire with excessive pull on the bowel and widening of enterotomies | Controlled fire; some slippage of bowel from jaws | Smooth, controlled fire; no widening of enterotomies |
Time: | |||
Help needed during performance | Asks a lot of questions and needed assistance | Few questions and almost no assistance | Few questions but no assistance |
Procedure assessment and OSATS | Yes/no | ||
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Needle position 1 | 1 | Held at one half to two thirds distance from the tip | |
2 | Angle 90° ± 20° | ||
3 | Uses tissue or other instrument for stability | ||
4 | Attempts at positioning (≤3) | ||
Needle driving 1 (entry to incision) | 5 | Entry at 60° to 90° to tissue plane | |
6 | Driving with one movement | ||
7 | Driving needle with wrist suppination | ||
8 | Single point of entry through tissue | ||
9 | Removes needle along its curve | ||
10 | Pull suture through to establish short free end | ||
11 | Suture placed accurately, on target | ||
Needle position 2 | 12 | Held at one half to two thirds distance from the tip | |
13 | Angle 90° ± 20° | ||
14 | Uses tissue or other instrument for stability | ||
15 | Attempts at positioning (≤3) | ||
Needle driving 2 (entry in incision) | 16 | Driving with one movement | |
17 | Removes needle along its curve | ||
Techniques of knots | 18 | Correct C-loop | |
19 | Smoothly executed throw, no fumbles | ||
20 | Knot laid flat without air knots | ||
21 | Short free end maintained | ||
22 | Correct inverse C-loop | ||
23 | Smoothly executed throw, no fumbles | ||
24 | Knot laid flat without air knots | ||
25 | Correct third C-loop | ||
26 | Smoothly executed throw, no fumbles | ||
27 | Knot laid flat without air knots | ||
Pulling the suture | 28 | Needle on needle holder in view at all times | |
29 | Uses the pully concept | ||
30 | Knot squared | ||
31 | Appropriate tissue reapproximation without strangulation | ||
32 | Good use of both hands to facilitate knot tying | ||
General | 33 | Kept needle in view at all times when grasping | |
34 | Non-dominant hand helps dominant hand in suturing |
Knot quality assessment | Available points |
---|---|
No visible gaps between stacked throws | 1 |
Knot tight at base | 1 |
Only edges are opposed (no extra tissue in knot) | 1 |
Knot holds under tension | 2 |
Maximum | 5 |
1. Which ligament should be dissected as a first step of a laparoscopic Roux-en-Y gastric bypass (RYGB)? | |
A) Gastro-colic | C) Gastro-phrenic |
B) Spleno-renal | D) Gastro-splenic |
2. For the gastric pouch, dissection should begin at the lesser curvature of the stomach _____ cm from the gastro-esophageal junction. | |
A) 7 cm | C) 4 cm |
B) 10 cm | D) 12 cm |
3. For the gastric pouch, a posterior tunnel has to be dissected towards the _________. | |
A) Incisura angularis | C) Angle of His |
B) Pylorus | D) Spleen |
4. For the Roux limb creation, which ligament should be found? | |
A) Round ligament | C) Hepato-duodenal |
B) Treitz | D) Gastro-colic |
5. For the Roux limb creation, what gastrointestinal segment needs to be measured? | |
A) Duodenum | C) Jejunum |
B) Ileum | D) Colon |
6. What is the approximate length of the Roux limb? | |
A) 25–35 cm | C) 100 cm |
B) 70–90 cm | D) 40–60 cm |
7. For the gastro-jejunal anastomosis, what is the location for the jejunum’s enterotomy? | |
A) Anterior location | C) Mesenteric location |
B) Antimesenteric location | D) Posterior location |
8. Which instrument is mainly used for the creation of enterotomies? | |
A) Dissector/Maryland | C) Scissors |
B) Harmonic scalpel | D) Grasper |
9. For the creation of the biliopancreatic limb, does the surgeon measure the alimentary limb? | |
A) Yes | B) No |
10. How many staple fires are usually required for a jejuno-jejunal anastomosis? | |
A) 1 staple | C) 2 staples |
B) 3 staples | D) 4 staples |