EPA: Abdominal Wall Hernia-MIS

EPA: Abdominal Wall Hernia-MIS

Evaluatee Name (Last, First)*

Enter resident starting with last name. Once a form has been submitted, the resident will receive a copy of the evaluation.

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Evaluator Name (Last, First)*

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Date of Assessment*

Rotation*

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Phase of Care

UPDATE! You can only select one phase of care. Complete an assessment for each phase of case separately.

Intraoperative

Postoperative

Preoperative/Nonoperative

For each category, select the statement that best describes the resident behavior for this patient encounter.

Preoperative: Evalaution

OBTAINS H&P inclusive of hernia-specific symptoms with cultural humility but may NOTE ASK ABOUT MODIFIABLE RISK FACTORS.

Identifies modifiable risk factors: smoking, obesity; NEEDS GUIDANCE TO MANAGE COMORBITITIES: lung or liver disease/steroid use and to interpret imaging studies. Discerns incarcerated & reducible hernias. Understands nonop & op strategies.

Develops a plan for MANAGING HEALTHY PATIENT W/ PRIMARY HERNIA, considering all operative approaches and the use of mesh as indicated

MANAGES COMPLEX PATIENT: concomitant fistula, infected mesh, parastomal hernia. Identifies the need to coordinate another intra-abdominal operation. ADDRESSES MODIFIABLE RISK FACTORS BEFORE SURGERY; optimizes comorbid conditions before elective surgery.

Not applicable/not observed

Preoperative: Medical Knowledge

Displays LIMITED UNDERSTANDING of abdominal wall hernia REPAIR OPTIONS, including use of MIS and mesh

Understands BASIC APPROACHES TO REPAIR but does not consider hernia characteristics, comorbidities, or patient preferences to select an optimal repair strategy; LIMITED KNOWLEDGE of advanced hernia repair techniques such as component separation

Identifies an UNUSUAL HERNIA type such as a flank or Spigelian hernia and selects a repair strategy

Develops a TREATMENT PLAN that ACCOUNTS FOR HERNIA CHARACTERISTICS and a patient's COMORBID CONDITIONS.

Not applicable/not observed

Preoperative: Communication with patient

Respectfully communicates BASIC FACTS about the condition to a patient/caregiver(s) but INCONSISTENTLY uses applicable language services and audio/visual aids.

Respectfully communicates basic facts, OVERCOME BARRIERS & CULTURAL DIFFERENCES, uses applicable language services/audio & visual aids. Communicates INFORMED CONSENT FOR STRAIGHTFORWARD CASE but not discussion about risk factor modification.

AS ABOVE, DISCUSS RISK FACTOR MODIFICATION & COMORBITIES to elicit personalized care plan for straightforward presentation in shared decision-making process. Conducts informed consent with cultural humility and completely documents discussion.

Discusses nuances of repair (futility, mesh, management of modifiable risk factors & comorbidities); manages patient/caregiver & health care team conflict. CONDUCTS INFORMED CONSENT FOR COMPLEX REPAIR Documents risks & benefits individualized to patient.

Not applicable/not observed

Preoperative: Evidence Based Management

IDENTIFIES EVIDENCE regarding the best approach to abdominal wall hernia repair

APPLIES EVIDENCE when planning a hernia repair strategy

DEVELOPS EVIDENCE-BASED PLAN for a patient with a RECURRENT OR COMPLEX hernia, considering hernia characteristics, comorbid conditions, and patient preferences

CRITICALLY APPRAISES AND APPLIES EVIDENCE but can adjust for a more complex and nuanced hernia presentation and TAILOR THE PLAN TO A PATIENT'S SITUATION.

Not applicable/not observed

Case Difficulty*

Straightforward

Moderate

Complex

Intraoperative: Technical Skills (MIS)*

Assists w/ surg positioning/pt prep. Handles instruments/camera safely but tentatively & lacks 2-hand coordination. Displays coordinated but inefficient hand movements for simple maneuvers. Closes superficial wound.

PLACES SUBSEQUENT LAPAROSCOPIC TROCARS after initial entry and CLOSES SKIN INDEPENDENTLY. Handles instruments safely but TENTATIVELY; STRUGGLES with 2-handed operating and operating against the camera. Uses surgical energy safely throughout the case.

Gains abd access/places ports EFFECTIVELY. Handles instruments SMOOTHLY & begins to work effectively against camera.

Obtains abdominal wall access for repair. Independently identifies and dissects the hernia sac/performs lap LOA. Independently positions and fixates the mesh.

Intraoperative: Steps of Operation (MIS)*

REQUIRES ACTIVE INSTRUCTION to move the operation forward. Not able to reduce hernia or lyse adhesions. Identifies tissue planes WITH ACTIVE GUIDANCE AND RETRACTION.

Performs some steps of SIMPLE ABD WALL HERNIA REPAIR W/ MINIMAL ASSISTANCE but cannot perform whole operation. Reduces simple hernia w/o help; NEEDS ASSISTANCE FOR SIGNIFICANT ADHESIONS & TO EXCISE SAC.

ANTICIPATES SOME NEXT STEPS in operation & necessary instruments. MINIMAL ASSIST: LAP LOA/SAFE REDUCTION OF HERNIA/EXCISE SAC. Closes small defect & sizes mesh for IPOM repair; NEEDS HELP W/ LARGE MESH. Needs prompting to use surgical drains.

Selects mesh & size (evidence-based recommendations). IDENTIFIES NEED TO CONVERT TO OPEN REPAIR W/O ASSISTANCE. Uses surgical drains when indicated.

Postoperative: Complications

EVALUATES SIMPLE POSTOP PROBLEMS, such as fever, wound erythema hypotension, PONV, or wound hematoma, BUT REQUIRES DIRECTION TO MANAGE them.

EVALUATES COMPLEX POSTOP PROBLEM (eg, sepsis, anastomotic leak) but needs help to develop a management plan. MANAGES SIMPLE POSTOP PROBLEMS (eg, fever, pain, oliguria).

EVALUATES AND MANAGES COMPLEX POSTOP PROBLEM after hernia repair (eg, sepsis, anastomotic leak). Formulates a postop plan for a patient with a ventral hernia, including drain management and activity limitations.

ANTICIPATES & MANAGES COMPLICATIONS INDEPENDENTLY (eg, superficial & deep wound SSI, early mesh infection, hematoma/seroma, prolonged postop ileus, unrecog visceral injury, early hernia recurrence [within 7 d], early fascial dehiscence w/wo SBO).

Not applicable/not observed

Postoperative: Communication

Communicates BASIC ASPECTS of the operative procedure and ongoing management plan to a patient/caregiver(s) but NEEDS PROMPTING TO CLARIFY EXPECTED OUTCOMES and the overall anticipated treatment course.

Communicates details of the operative procedure and ongoing management plan to a patient/caregiver(s) but OMITS SOME ELEMENTS WHEN DISCUSSING EXPECTED OUTCOMES and the overall anticipated treatment course.

Proactively explains CUSTOMIZED POSTOP INSTRUCTIONS AND UPDATES to a patient/caregiver(s) using a variety of methods to ensure understanding; DISCUSSES UNEXPECTED FINDINGS OR CHANGES to the intended plan with cultural humility.

CUSTOMIZES EMOTIONALLY DIFFICULT NEWS (eg, changes to the operative plan, adverse outcome, end-of-life discussion) to a patient/caregiver(s) in a culturally dexterous and caring manner

Not applicable/not observed

Overall Performance*

Based on your observation, what level of autonomy would you trust the resident to perform this task at the NEXT encounter?

Limited Participation: Learner has basic knowledge and skills, attending does show and tell

Direct Supervision: Attending provides active help

Indirect Supervision: Attending provides passive help

Practice Ready: Attending is available but is not needed for routine cases/presentations, but input may be needed for complex cases

Comment*

Please add comment on why you selected the answer above. Specifically note what steps the resident can take to achieve the next level of autonomy.

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