Nested EPA: Bowel Anastomosis

Nested EPA: Bowel Anastomosis

Bowel Anastomosis: Hand-sewn or stapled bowel anastomosis.
Hand- Sewn: Able to set up hand sewn anastomosis with stay sutures and positioning of the bowel. Able to correctly select suture type and perform 1-2 layer closure (Connell, Gambee, Lembert).
Stapled: Able to set up anastomosis with stay sutures and positioning of the bowel. Understands and selects appropriate stapler type and size. Closes enterotomies with stapler or sutures.

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Date of Assessment*

Rotation*

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Anatomy*

Describes different layers of bowel wall

Describes types of anastomosis (stapled, hand-sewn, side to side, end to side, end to end)

Describes potential benefits or challenges of different types of anastomosis but unable to adapt to complex anatomy

Describes potential benefits or challenges of different types of anastomosis and able to adapt plan based on operative findings

Surgical Technique*

Displays some coordination of instruments, but tissue handling is inconsistent with both hands. May result in bowel injury including serosal tear, hematoma, or devascularization

Handles instruments safely but tentatively. Displays inefficient and uncoordinated hand movements under direct instruction

Consistently demonstrates careful tissue handling, atraumatic suturing and tying on bowel. May require assistance during complex anastomosis

Careful tissue handling and suturing. Avoids injury in both straightforward and complex anastomosis

Steps of Procedure*

Requires prompting to articulate steps of bowel anastomosis

Articulates basic steps of bowel anastomosis and requires active direction to perform the anastomosis. Does not recognize the benefits/challenges of stapled vs hand-sewn anastomosis.

Demonstrates the ability to set up, orient, and perform bowel anastomosis (hand-sewn and stapled) in straightforward cases. For hand-sewn, articulates and performs different types of stitches. For stapled, knows different types of staplers and cartridges.

Performs bowel anastomosis in complex cases. Walks junior residents through straightforward cases.

Dealing with Potential Error / Complications*

Describes basic complications (bleeding staple line or bowel wall hematoma)

Independently manages basic complications. Does not recognize how to minimize the risk of anastomotic leak.

Independently manages basic complications. Understands factors that increase risk of anastomosis (tension, suture spacing, corners leaking, staple line integrity). Knows when to close the mesentery defect.

Understands and implements early management steps to minimize factors that increase risk of anastomosis. Interprets intraop factors that may prevent anastomosis (ischemia, bowel wall inflammation, hemodynamic instability)

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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