TASK / STEP 1 2 3 4 5 N/A Create a gastrotomy in the gastric pouch No entry into gastric lumen; poor relation between grasper and energy source; excessively large or small; penetration of posterior bowel wall; skiving; bleeding Entry into gastric lumen; appropriate size; more than 1 attempt required Entry into gastric lumen; appropriate size; no extra movements required Create an enterotomy in the Roux limb No entry into bowel lumen; poor relation between grasper and energy source; excessively large or small; penetration of posterior bowel wall Appropriate size and entry into bowel lumen; not placed in antimesenteric location Appropriate size and placement of enterotomy; good relation of grasper and energy source; no extra movements required Introduce one limb of linear cutting stapler into gastric pouch and the other into Roux limb Unclear of how to insert the staple device; drives staple jaws blindly into the enterotomies Inserts the stapler, but lacks appreciation of the ideal angle for insertion Inserts staple jaws with ease; controlled manner; correct angle Ensure both limbs are symmetrical before firing the stapler Does not ensure symmetry, antimesenteric location of stapler before closing of jaws Limbs either nonsymmetrical or not on antimesenteric border before closure of jaws Correct symmetry and antimesenteric position before closure of jaws Fire stapler Uncontrolled fire with excessive pull on the bowel and widening of enterotomies Controlled fire; some slippage of bowel from jaws Smooth, controlled fire; no widening of enterotomies Suture closed the enterotomy Poorly positioned stitch; blindly placed sutures; traumatic use of needle drivers; skiving and poor control of needle; too much or too little tension; poor quality knot Adequate stitch position; adequate closure of enterotomy. Sutures placed at varying distances apart; gathering of bowel edges; additional reinforcement sutures required; stitch pulled out clumsily. Correct stitch position; adequate size bites placed uniform distance apart; perpendicular to seromuscular layer; appropriate tension; adequate surgical knot; needle retrieved safely Ensure cinching of suture between bites Not done Done inconsistently Done at all times 104 5
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