Nested EPA: Open Abdominal Closure

Nested EPA: Open Abdominal Closure

Primary fascial closure, either simple or running, with multi-layer superficial closure.
Able to select appropriate suture and needle size.
Re-approximates abdominal wall layers with appropriate sized bites on fascia and equal travel between sides.
Includes decision making, positioning, and placement of abdominal drains.

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Date of Assessment*

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Anatomy*

Demonstrates basic understanding of layers of abdominal wall

Understands layers of abdominal wall, including changes expected above/below arcuate line. Describes different types of closure (simple, running).

Understands all layers of abdominal wall. Performs fascial closure using evidence-based data. Requires some guidance with closure in patients with previously violated or weakened fascial planes.

Understands all layers of abdominal wall. Independently identifies abnormal anatomy and pivots operative plan as needed to accommodate for unexpected findings. Walks junior residents through abdominal wall closure in a straightforward case.

Surgical Technique

Handles instruments safely but tentatively. Displays coordinated hand movements for simple maneuvers under direct instruction, but is inefficient.

Performs straightforward closure (suturing, tissue exposure) skills w/ guidance. Actively retracts and assists w/ portions of operation. Needs guidance on appropriate fascial bite sizes. Closes superficial layers w/ occasional guidance on depth/quantity.

Performs straightforward closure w/o guidance and w/ efficiency. Independently ensures appropriate fascial bites, distance traveled, & closes superficial layers. Identifies fascia on re-operative field, but needs guidance on appropriate fascial bites.

Independently sets up for efficient closure. Identifies intraop challenges that require careful technique. Adapts tissue handling to avoid damage.

Steps of Procedure*

Requires prompting to articulate principles of fascial closure

Articulates basic steps and requires active direction to move case forward. Requires guidance for needle and suture selection.

Performs fascial and superficial layer closure w/out guidance in straightforward case. Has basic knowledge of mesh closure techniques, but cannot determine need w/o prompting. Appropriately chooses needle and suture type.

Independently performs fascial and superficial layer closure in straightforward and complicated cases. Implements plan when deviation from the initial plan is required. Determines need for adjuncts such as mesh.

Dealing with Potential Error / Complications*

Evaluates basic complications (pulled through suture, gaps between sutures, large empty subQ space) Requires assistance to recognize some signs of complex complications (hollow viscus injury, muscle perforator bleeding).

Independently manages basic complications. Requires assistance to manage complex complications. Articulates techniques to avoid hollow viscus injury during fascial closure.

Independently manages both basic complications and complex complications with some guidance. Demonstrates techniques to avoid hollow viscus injury during fascial closure.

Independently manages both straightforward and complex complications. Takes appropriate precautions to minimize common complications associated with fascial/superficial abdominal wall closure. Knows when to leave skin open or perform delayed closure.

Overall Performance*

Limited Participation - Demonstrates understanding of information and has very basic skills

Direct Supervision - Demonstrates understanding of the steps of the operation but requires direction through principles and does not know the nuances of a basic case

Indirect Supervision - Can do a basic operation but will not recognize abnormalities and does not understand the nuances of an advanced case

Practice Ready - Can manage more complex patient presentations and operations and take care of most cases

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