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 |