(rectal cancer synoptic operative report template)
RECTAL cancer surgery checklist
INSTRUCTIONS
Summary Report
Consists of 19 essential data elements followed by your narrative report. Dictate all the items on the list. If an item is not applicable, please dictate not applicable. Specify the element number, name and response (eg. 5. Procedure: Total Proctocolectomy).
SAmple operative report
1) Clinical Preamble Patient is a 55 year old male who presented with rectal bleeding. He has a long tumour extending from 7.5-11cm from the anal verge. He received long course radiation and presents today for surgical management of his rectal cancer. 2) Summary Report 1. Preoperative Radiotherapy: Long Course (5 weeks) 2. Preoperative Imaging: ERUS, CT abdomen/pelvis and CXR 3. Preoperative Stage: T3 N1 MX 4. Operative Urgency: Elective 5. Intent of Surgery: Curative 6. Procedure: Total Mesorectal Excision (TME) with Colo-Anal anastomosis 7. Technique: Open 8. Diverting ostomy: Yes, ileostomy 9. Height of tumour: From anal verge on sigmoidoscope was 7.5 cm preoperatively 10. Height of anastomosis: From anal verge suspected to be 3-4 cm, not examined using sigmoidoscopy 11. Anastomosis: Stapled 12. Reconstruction: Side-to-end anastomosis 13. Splenic flexure mobilization: No 14. Air Leak Test: No leak 15. Multivisceral Resection: No 16. Intra-abdominal Adhesions: None 17. Surgical Specimen: Grade 3 18. Residual Cancer: None 19. Blood Transfusion: No 20. Unplanned Events: None 3) Narrative Report Dictate your narrative operative report with any additional details.
1) CLINICAL PREAMBLE Dictate as appropriate 2) SUMMARY REPORT Preoperative Details 1. Preoperative Radiotherapy a. None b. Short Course (5 days) c. Long Course (5 weeks) d. Other (specify) e. Unknown 2. Preoperative Imaging (include all that apply) a. None b. MRI c. ERUS d. CT Abdomen/Pelvis e. CXR f. Unknown 3. Preoperative Stage (TNM) Specify T (x, 0, 1-4) Specify N (x, 0, 1-3) Specify M (x, 0, 1) 4. Operative Urgency (include all that apply) a. Elective b. Emergent Obstruction c. Emergent Bleeding d. Emergent Perforation Operative Details 5. Intent of Surgery a. Curative b. Palliative 6. Procedure a. Subtotal Mesorectal Excision (sTME) with Colo-Rectal Anastomosis b. Total Mesorectal Excision (TME) with ColoAnal Anastomosis c. Hartman Procedure with TME and Stapled Anorectal Junction d. Hartman Procedure with (sTME) and Stapled Rectum e. Abdominoperineal Resection with Permanent Colostomy f. Total Proctocolectomy g. Diverting Loop Colostomy (no resection) h. Diverting Loop Ileostomy (no resection) 7. Technique a. Laparoscopic (no abdominal incision) b. Laparoscopic Assisted c. Laparoscopy Converted to Open d. Open 8. Diverting Ostomy a. Yes, ileostomy b. Yes, colostomy c. No 9. Height of Tumour Cm. from anal verge on rigid or flex sig 10. Height of Anastomosis Cm. from anal verge on rigid sig in OR 11. Anastomosis a. None b. Stapled c. Handsewn
12. Reconstruction a. None b. Straight Anastomosis c. Side-to-End Anastomosis d. Colonic J Pouch e. Transverse Coloplasty f. Ileal Pouch Anal Anastomosis g. Other (specify) 13. Splenic Flexure Mobilization a. Yes b. No 14. Air Leak Test a. No Leak b. Leak Repaired c. Leak Diverted d. Not done 15. Multivisceral Resection (include all that apply) a. No b. Bladder c. Ovary, specify (L, R, bilateral) d. Fallopian Tubes, specify (L, R, bilateral) e. Uterus f. Ureter, specify (L, R, bilat) g. Seminal Vesicles, specify (L, R, bilateral) h. Vagina i. Prostate j. Other (specify) 16. Intra-abdominal Adhesions a. None b. Few c. Many/Dense 17. Surgical Specimen a. Not Applicable b. Grade 1 (Poor, incomplete excision of mesorectum, deep clefts in mesorectal fascia that expose rectal muscularis) c. Grade 2 (Fair, complete excision of mesorectum, superficial defects in mesorectal fascia that do not expose rectal muscularis) d. Grade 3 (Good, complete excision of mesorectum, mesorectal fascia intact, no defects) 18. Residual Cancer (include all that apply) a. None b. Local/Regional (unable to clear rectal disease, grossly positive margin) c. Metastatic (obvious distant disease at time of surgery) 19. Blood Transfusion a. Yes, specify units of packed red blood cells (PRBC) b. No 20. Unplanned Events a. None b. Describe (if occurred) 3) NARRATIVE REPORT Dictate your narrative operative report with any additional details.