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Fundamentals of Rectal Cancer SurgeryFundamentals of Rectal Cancer Surgery

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Standardized Operative Report

Standardized Operative Report is a topic covered in the Fundamentals of Rectal Cancer Surgery.

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The use of checklists for complicated processes is widely embraced and leads to reductions in morbidity as well as mortality rates of hospitalized patients.[1] Checklists help avoid omission of crucial steps, especially during uncommonly performed procedures or when information complexity negatively impacts situational awareness.[2]

The Quality Assessment and Safety Committee of the American Society of Colon and Rectal Surgeons (ASCRS) developed a rectal cancer surgery checklist as a guide to enhance safety and quality of care for patients with rectal cancer undergoing surgery, to incorporate best practices in treating these patients, to raise general awareness of the importance of each individual checklist item, and to serve as a potential foundation for building accredited centers in rectal cancer treatment.[3] The OSTRiCh (Optimizing the Surgical Treatment of Rectal Cancer) Standardized Synoptic Operative Report Committee subsequently utilized the ASCRS rectal cancer checklist as a guide in the development of its standardized synoptic operative report (Table 1). The National Accreditation Program for Rectal Cancer (NAPRC), developed through collaboration between The OSTRiCh Consortium and the American College of Surgeons Commission on Cancer (CoC), now includes synoptic operative reporting as a standard for Rectal Cancer Program NAPRC accreditation.[4]

The use of synoptic operative reporting in rectal cancer has been shown to increase the completeness and reliability of documentation of critical elements when compared to narrative reporting.[5],[6]

Table 1: Required elements and response options for Rectal Cancer Synoptic Operative Report.

Reprinted with the permission of the OSTRiCh Standardized Synoptic Operative Report Committee.

Elements

Response Options

1. ASA score

I; II; III; IV; V

2. Case status

Elective; urgent (obstructed; bleeding; perforated)

3. Operation

LAR; APR; TPC; local excision

4. Modality

Open; laparoscopic; hand-assisted laparoscopic; robotic; TES

5. Location of tumor within rectum

High; middle; low

6. Height of lower edge of tumor from anal verge

0–20 cm

7. Mobilization of splenic flexure

Yes; no

8. Level of ligation of inferior mesenteric artery

IMA; SRA; none

9. Level of ligation of inferior mesenteric vein

High; low; none

10. Level of rectal transection distal to distal edge of tumor (distal margin)

0–20 cm

11. Type of reconstruction

Stapled end-end; stapled end-side; handsewn end-end; handsewn end-side; colon J-pouch; ileal pouch-anal anastomosis; coloplasty; none

12. Anastomotic testing method(s)

Rectal air infusion under pelvic fluid; rectal instillation of betadine, indigo, or other fluid; palpation; observation of circular stapler rings only; none

13. Creation of stoma

Yes (ileostomy; colostomy); no

14. En bloc resection

Yes (bladder; vagina; prostate; ureter; small intestine; sacrum; other); no

15. Metastectomy

Yes (liver; peritoneum; other); no

16. Completeness of tumor resection

R0; R1; R2

17. Intraoperative complications

Yes (ureter injury; rectal perforation; enterotomy; vascular injury; other); no

18. Blood transfusion

Yes; no

19. TME photographed

Yes—in pathology report; yes—in operative report; no

20. Short narrative

***

-- To view the remaining sections of this topic, please log in or purchase a subscription --

The use of checklists for complicated processes is widely embraced and leads to reductions in morbidity as well as mortality rates of hospitalized patients.[1] Checklists help avoid omission of crucial steps, especially during uncommonly performed procedures or when information complexity negatively impacts situational awareness.[2]

The Quality Assessment and Safety Committee of the American Society of Colon and Rectal Surgeons (ASCRS) developed a rectal cancer surgery checklist as a guide to enhance safety and quality of care for patients with rectal cancer undergoing surgery, to incorporate best practices in treating these patients, to raise general awareness of the importance of each individual checklist item, and to serve as a potential foundation for building accredited centers in rectal cancer treatment.[3] The OSTRiCh (Optimizing the Surgical Treatment of Rectal Cancer) Standardized Synoptic Operative Report Committee subsequently utilized the ASCRS rectal cancer checklist as a guide in the development of its standardized synoptic operative report (Table 1). The National Accreditation Program for Rectal Cancer (NAPRC), developed through collaboration between The OSTRiCh Consortium and the American College of Surgeons Commission on Cancer (CoC), now includes synoptic operative reporting as a standard for Rectal Cancer Program NAPRC accreditation.[4]

The use of synoptic operative reporting in rectal cancer has been shown to increase the completeness and reliability of documentation of critical elements when compared to narrative reporting.[5],[6]

Table 1: Required elements and response options for Rectal Cancer Synoptic Operative Report.

Reprinted with the permission of the OSTRiCh Standardized Synoptic Operative Report Committee.

Elements

Response Options

1. ASA score

I; II; III; IV; V

2. Case status

Elective; urgent (obstructed; bleeding; perforated)

3. Operation

LAR; APR; TPC; local excision

4. Modality

Open; laparoscopic; hand-assisted laparoscopic; robotic; TES

5. Location of tumor within rectum

High; middle; low

6. Height of lower edge of tumor from anal verge

0–20 cm

7. Mobilization of splenic flexure

Yes; no

8. Level of ligation of inferior mesenteric artery

IMA; SRA; none

9. Level of ligation of inferior mesenteric vein

High; low; none

10. Level of rectal transection distal to distal edge of tumor (distal margin)

0–20 cm

11. Type of reconstruction

Stapled end-end; stapled end-side; handsewn end-end; handsewn end-side; colon J-pouch; ileal pouch-anal anastomosis; coloplasty; none

12. Anastomotic testing method(s)

Rectal air infusion under pelvic fluid; rectal instillation of betadine, indigo, or other fluid; palpation; observation of circular stapler rings only; none

13. Creation of stoma

Yes (ileostomy; colostomy); no

14. En bloc resection

Yes (bladder; vagina; prostate; ureter; small intestine; sacrum; other); no

15. Metastectomy

Yes (liver; peritoneum; other); no

16. Completeness of tumor resection

R0; R1; R2

17. Intraoperative complications

Yes (ureter injury; rectal perforation; enterotomy; vascular injury; other); no

18. Blood transfusion

Yes; no

19. TME photographed

Yes—in pathology report; yes—in operative report; no

20. Short narrative

***

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Last updated: September 20, 2021

Citation

"Standardized Operative Report." Fundamentals of Rectal Cancer Surgery, 2021. ASCRS U, www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831021/all/Standardized Operative Report.
Standardized Operative Report. Fundamentals of Rectal Cancer Surgery. 2021. https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831021/all/Standardized Operative Report. Accessed March 21, 2023.
Standardized Operative Report. (2021). In Fundamentals of Rectal Cancer Surgery https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831021/all/Standardized Operative Report
Standardized Operative Report [Internet]. In: Fundamentals of Rectal Cancer Surgery. ; 2021. [cited 2023 March 21]. Available from: https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831021/all/Standardized Operative Report.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Standardized Operative Report ID - 2831021 Y1 - 2021/09/20/ BT - Fundamentals of Rectal Cancer Surgery UR - https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831021/all/Standardized Operative Report DB - ASCRS U DP - Unbound Medicine ER -
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Grapherence® [↑4]
    • Fundamentals of Rectal Cancer Surgery
    • Background
    • Rectal Anatomy
    • Rectal Cancer Biology and Hereditary Cancer Syndromes
    • Rationale for Multi-Modality Therapy
    • Preoperative Issues
    • Preoperative Staging
    • Role of Tumor Board
    • Indications for Preoperative Neoadjuvant Therapy
    • Local Excision
    • Indications for LAR Versus Intersphincteric Resection Versus APR
    • Indications for Extended Resection
    • Preoperative Preparation
    • Interoperative
    • Patient Positioning and Equipment for Rectal Cancer Surgery
    • Inferior Mesenteric Artery
    • Inferior Mesenteric Vein (IMV)
    • Splenic Flexure Mobilization
    • Surgical Techniques for Length
    • Technique of Total Mesorectal Excision (TME)
    • Tailored Mesorectal Excision (TME)
    • Bowel Transection and Anastomosis
    • Indications for Fecal Diversion
    • Abdominoperineal Resection
    • Standardized Operative Report
    • Management of Intraoperative Vascular and Urinary Complications
    • Postoperative Issues
    • Rectal Cancer Pathology Assessment
    • Adjuvant Therapy for Rectal Adenocarcinoma
    • Surveillance After Rectal Cancer Treatment
    • Management of Local Recurrences
    • Short-Term Complications - Anastomotic
    • Short-Term Complications - Urinary
    • Ostomy Complications and Management
    • Long-Term Complications – Bowel Dysfunction
    • Long-Term Complications - Sexual Dysfunction and Its Management
    • Parastomal and Perineal Hernias
    • Impact of Postoperative Complications On Oncologic Outcomes
    • Course Complete
    • Final Assessment
Grapherence® [↑4]
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