TASK / STEP 1 2 3 4 5 N/A Pull fundus of stomach down (exposure) Insufficient retraction; traumatic; insufficient exposure Satisfactory retraction after some repositioning; suboptimal exposure Appropriate retraction; optimal exposure Create a tunnel between the left crus of diaphragm and fundus of the stomach Incorrect location; associated trauma, bleeding Correct location after multiple attempts; minimal tissue trauma, bleeding Correct location; no difficulty or excessive tissue trauma Dissect angle of His close; keeping tension on fundus Dissection in incorrect plane insufficient or too much tension; bleeding Dissection in correct plane;appropriate tension majority of the time; occasional tissue damage, bleeding Dissection in correct plane; careful tension at all times; minimal tissue damage, bleeding Creation of the gastric pouch Dissect along lesser curvature of stomach 3-8 cm from the gastroesophageal junction and keep close to stomach Incorrect plane; incorrect anatomic location; excessive tissue trauma; bleeding with need for suction Correct plane developed with some difficulty; moderate tissue trauma; bleeding not requiring suction Correct plane in correct anatomic location developed without difficulty or excessive tissue trauma, bleeding Create a posterior tunnel Dissection in incorrect plane; unnecessary force; bleeding requiring suction Dissection in correct plane; occasional tissue damage; bleeding not requiring suction Dissection in correct plane; careful handling of tissues, minimal tissue damage, bleeding Introduce and apply a linear cutting stapler transversely to the stomach Stapler applied in incorrect orientation; serosal damage to stomach Stapler applied transversely after multiple repositioning attempts Stapler applied transversely; no requirement for multiple repositioning attempts; no trauma to stomach wall Remove all tubes from the stomach before firing the stapler Not done Done after delay; with prompting Done without delay Fire stapler Uncontrolled fire with excessive pull on the stomach Controlled fire; some slippage of stomach between jaws Smooth, controlled fire 102 5
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