EPA: Inguinal Hernia

EPA: Inguinal Hernia

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

Check the statement for each question that best describes the resident behavior for this patient encounter.

Preoperative: Evaluation*

Obtains an H&P with cultural humility and develops a differential for a patient presenting with signs and symptoms of an inguinal hernia

Evaluates a patient with an inguinal hernia, discerns incarcerated and reducible hernias, and makes recommendations for management. Determines when imaging is indicated for an inguinal hernia and interprets results. Reduces a straightforward hernia.

Develops a nonop or operative management plan. Forms a complete differential for a patient presenting with signs and symptoms of an inguinal hernia, without errors of omission or commission. Reduces a hernia requiring multiple different approaches

Manages a patient with a complex presentation or with significant comorbidities (eg, strangulated hernia, infected mesh, sepsis, anticoagulation, cardiopulmonary issues); anticipates logistical problems when optimizing a patient for surgery

Not applicable/not observed

Preoperative: Communication with patient*

Respectfully communicates BASIC FACTS ABOUT THE CONDITION and/or the elements of an informed consent discussion but inconsistently uses applicable language services and audio/visual aids or omits some elements of discussion in documentation.

Respectfully communicates basic facts of a plan and informed consent discussion for a STRAIGHTFORWARD ELECTIVE INGUINAL HERNIA; uses applicable language services. Answers questions related to hernia management, and completely documents the discussion

Performs the above tasks for patient with COMPLICATED presentation. Elicit a PERSONALIZED CARE PLAN in a shared decision-making process. Conducts discussion with cultural humility, individualizing risks, benefits, and alternatives to the patient.

Performs the above tasks in a CRITICAL OR LIFE THREATENING SITUATION and for COMPLEX AND EMERGENT REPAIR.

Not applicable/not observed

Preoperative: Evidence Based Management*

Requires oversight to initiate a cost-effective workup. Accesses evidence and considers patient preference regarding the management of inguinal hernia with respect to open and MIS approaches

Initiates a cost-effective workup for a straightforward presentation independently, requiring oversight for an advanced or unusual presentation. Considers patient preference for straightforward open versus MIS inguinal hernia repair

Applies evidence to manage complex situations (eg, infected mesh, hernia with large scrotal component)

Determines the best therapy for a patient by applying best available evidence, reconciling conflicting evidence, and integrating patient preferences

Not applicable/not observed

Case Difficulty*

Straightforward

Moderate

Complex

Intraoperative: Anatomy*

Describes the anatomic structures and relationships of the inguinal canal (inguinal ring, vas deferens, ilioinguinal nerve, inguinal floor, femoral vein).

Identifies the anatomic boundaries of the inguinal canal and direct and indirect inguinal and femoral hernias

Identifies all pertinent inguinal anatomy (eg, cord structures, nerves, musculofascial layers) in a patient with a straightforward (eg, elective) inguinal or femoral hernia with minimal supervision

Identifies all pertinent inguinal structures in a complex operative situation (eg, large hernia, recurrent hernia, strangulation with perforation) and adapts the operative plan as needed

Intraoperative: Steps of Operation*

Describes major steps of inguinal hernia repair. Requires active instruction to move the operation forward.

Provides a basic description of the operative plan but omits some steps. Usually proceeds to the next step of the procedure, though sometimes requires direction.

Identifies the need to modify operative technique for femoral or incarc/strangulated hernia and explains steps needed to address these variants. Performs straightforward inguinal hernia repair (elective repair of a small or moderately sized hernia)

Performs inguinal hernia repair in a patient with a recurrent, strangulated, or large and complex hernia with minimal or no guidance.

Intraoperative: Technical skills*

Demonstrates inefficient suturing and knot tying. Requires prompting to identify correct tissue planes. Demonstrates understanding of sharps safety, safe surgical energy use, and surgical field sterility.

Performs incision and exposure of the inguinal canal and layered closure. Requires guidance to place mesh in straightforward repair. Demonstrates awkward instrument handling in small spaces, with inefficient suturing technique during mesh placement.

Recognizes tissue planes that have not been previously dissected but may need assistance in identifying/managing variable anatomy or tissue planes in a reoperative field to prevent iatrogenic injuries.

Identifies tissue planes in an inflamed condition and adapts the dissection technique in a patient with a large, incarcerated, or recurrent inguinal hernia

Intraoperative: Complications*

Describe some critical structures at risk.

Identifies common positioning options but cannot name factors to select one over another; recognizes the importance of protecting against nerve and pressure injuries but cannot describe the resulting morbidity . Controls bleeding only with direction

Identifies and protects critical structures during dissection, including nerves and the vas deferens, and adjusts tissue handling based on tissue quality

Adapts planned repair based on unexpected findings (eg, incarcerated bowel, enterotomy, iatrogenic injury)

Postoperative: Communication with Patient*

Communicates basic aspects of the operative procedure and standard postop instructions to a patient/caregiver(s) but needs prompting to clarify expected outcomes and the anticipated treatment course

Communicates details of the operative procedure and postop instructions to a patient/caregiver(s) but misses some elements when discussing expected outcomes and the overall anticipated treatment course

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

Postoperative: Complications*

Recognizes and informs supervisor of general variances in the standard immediate postop course (eg, hematoma, hypotension, urinary retention)

Recognizes and manages a common immediate or delayed postop complication (eg, hematoma, hypotension, urinary retention, hernia recurrence, pain syndromes, wound infection).

Recognizes but requires assistance to synthesize a complete management plan for a complication specific to inguinal hernia or severe postop complications (eg, severe scrotal hematoma, chronic groin pain, mesh infection, sepsis)

Anticipates and develops a plan to mitigate potential postop complications. Manages a severe immediate or delayed postop complication (eg, hemorrhage; large, severe scrotal hematoma/seroma; chronic pain; mesh infection)

Not applicable/not observed

Postoperative: Management of Postoperative Pain*

Uses multimodal pain management strategies. Identifies literature regarding pain management strategies for postop inguinal hernia patients

Uses multimodal pain management with a focus on opioid-sparing strategies and adjusts the regimen for symptoms such as postop neuropathy. Partners with the patient on selection of a postop pain regimen

Manages a complex patient with chronic pain syndrome using best evidence for postop pain management

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*

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