Nested EPA: Open Entry to Abdomen

Nested EPA: Open Entry to Abdomen

Entrance into the abdomen for open operation.

Resident is able to mark incision and perform skin incision, followed by dissection of subcutaneous tissue to fascia. Resident identifies and continues incision through linea alba without deviating from midline. Resident sharply incises peritoneum without injury to underlying structures.

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Date of Assessment*

Rotation*

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Anatomy*

Describes the layers of the abdominal wall

Identifies safe location for initial entry in straightforward cases (ex: Palmar's point, periumbilical)

Interprets pre-op imaging to determine safe entry points. Recognizes scenarios that increase risk of entry (ex: prior surgical hx/scars, likelihood of adhesions, pathology, pregnancy, prior mesh placement) but requires guidance to develop plan.

Independently develops plan for open entry in both straightforward and complex anatomy

Surgical Technique*

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

Performs incision and dissection to the level of the fascia. Displays some coordination of instruments, but tissue handling is inconsistent with both hands. Safely uses electrocautery.

Identifies and enters abdomen through the linea alba in midline laparotomy. Consistently demonstrates careful tissue handling.

Enters abdomen in patients with abnormal abdominal wall anatomy (scar tissue at previous laparotomy site) and avoids injury to underlying structures. Careful tissue handling.

Steps of Procedure*

Correctly marks the incision. Provides assistance during open abdominal entry.

Articulates basic steps and requires active direction to move case forward

Performs safe entry into the abdomen in straightforward cases

Performs entry into the abdomen in complex cases. Walks junior residents through safe entry into the abdomen in straightforward cases.

Dealing with Potential Errors / Complications*

Unable to recognize when to deviate from initial entry plan

Recognizes when deviation from the initial entry plan is required but requires coaching to implement plan

Devises and implements a plan when deviation from initial entry plan is required

Implements early management steps when an intraop complication (ex: hollow viscus or solid organ injury or vascular injury during entry) is identified

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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