"*" indicates required fields Reviewer Name*Title*Copy and Paste the title of this activity. This field is hidden when viewing the formInventory ID NumberThis field is hidden when viewing the formtypeAccess Instructions To access this video, visit the site below and log in with the following credentials: username:sagesreview password:foregut Leave the Institution ID blank Access Instructions To access this video, visit the site below and log in with your sages.org account: Please review this content item based on the Foregut Pathway Goals and Objectives . This field is hidden when viewing the formIs this content relevant to the Foregut Masters Pathway* Relevant Somewhat Relevant Not Relevant This field is hidden when viewing the formIs this content relevant to any of the below Masters Pathways?*Select all that apply Acute Care Surgery Bariatric Biliary Colorectal Flexible Endoscopy Hernia Leadership & Professional Development Liver Pancreas Robotics Difficulty Level*Select the level to which this content applies. Select All that Apply. Competency Level: Equip the surgeon with the requisite knowledge of the anatomical and other patient considerations to perform MIS peripheral wedge resection and/or MIS left lateral sectionectomy Proficiency Level: Equip the surgeon with the requisite knowledge of the anatomical and other patient considerations to perform MIS radical cholecystectomy Mastery Level: Equip the surgeon with the requisite knowledge of the anatomical and other patient considerations to perform formal MIS right hepatectomy Select AllCompetency LevelCompetency Goals*Select whether the content relates to either Pre-operative or Intra-operative goals. Select All the Apply. Pre-Operative: Equip the surgeon with the requisite knowledge of the anatomical and other preoperative patient considerations to perform MIS left lateral sectionectomy or peripheral wedge resection. Specific emphasis will be placed on indications for operation here along with requisite surgeon experience and importance of appropriate hospital infrastructure. Discuss possibility of concurrent colon resection Intra Op: Assist the surgeon in acquiring the required knowledge and operative skills to perform MIS left lateral sectionectomy or peripheral wedge resection Post Op: Manage post-operative issues in MIS left lateral sectionectomy or peripheral wedge resection Select AllCompetency Level: Pre-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Presentation: Typical and atypical presenting signs & symptoms of a patient with colorectal liver metastases or early stage HCC DDx: Other clinical conditions to consider in the differential (ie: cholangiocarcinoma, metastasis from other source, benign etiology) Diagnostic work-up: Which tests? How are they performed? How to interpret them? If and when to do pretreatment biopsy (atypical imaging phenotype etc). Understand the global assessment of HCC patients (liver function, viral status, alcohol, comorbidities) and how it relates to staging and choice of therapy for HCC. Management considerations: Understand correct work-up of mass in context of patient oncologic status Understand importance of operative timing and interventions in relationship to other treatments (chemotherapy in case of CRLM, and transplant eval for HCC). Select AllCompetency Level: Pre-Operative SME Objectives*Select the Objectives covered by this content. Select All the Apply. Describe the typical presentation of patients with colorectal liver metastases or HCC. Describe LIRADS criteria and for HCC diagnosis, describe appropriate staging imaging for this and CRLM Recall the list of options available for HCC treatment and understand the data supporting each treatment path; Recall data supporting resection or MIS ablation of solitary synchronous or metachronous CRLM Recognize the utility of and indications for CT, MRI, PET, and biopsy. Independently interpret resectability and indications that would preclude resection on straightforward imaging Identify patients who will benefit from MIS left lateral sectionectomy or peripheral wedge resection and incorporate the patient’s comorbidities & workup into deciding the choice of procedure. Recall the appropriate pre-operative instructions for anesthesia (low CVP, IV access) Understand what equipment is needed to perform a SAFE MIS liver resection and Intraoperative Disaster (massive bleeding) management; incorporate idea of Emergency timeout (plan for disaster before it happens) Select AllCompetency Level: Intra-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Explain the critical steps of a left lateral sectionectomy and/or peripheral wedge resection; include comments on patient positioning based upon lesion location Demonstrate the key anatomic landmarks for left lateral sectionectomy and/or peripheral wedge and understand how to manage unexpected intraoperative events - hemorrhage control, CO2 embolism, evidence of bile lead after transection. Emphasize importance of intraoperative ultrasound, and importance of parenchymal preservation - use of ablation if needed. Discuss rare indications (or lack thereof) for drain placement; Understand the tools/options for parenchymal transection and hemostasis (electrosurgery, ultrasonic energy, CUSA, Aquamantys etc); Discuss how to handle if disease is unexpectedly advanced Select AllCompetency Level: Intra-Operative SME Objectives*Select the Objectives covered by this content. Select All the Apply. List several methods of mobilizing and retracting the left lateral section of the liver and techniques for exposing the posterior surface for wedge resection. Describe several techniques for verifying adequate parenchymal margin prior to transection Explain at least 4 methods of parenchymal transection. Describe the various factors that increase bile leak, hemorrhage, and conversion to open Describe the disadvantages of and rare indications for drain placement Select AllCompetency Level: Post-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Pathway: Typical immediate post-op pathway (e.g., diet, activity, med changes, dvt prophylaxis, d/c home when appropriate etc) Outcomes: Typical expected outcomes (e.g., % of patients with curative surgery vs those who require ongoing surveillance; expectations for adjuvant treatment) Short-term post-op complications: (e.g., PE, DVT, hemorrage, bile leak, abscess) – incidence, workup, how to manage complications Long-term post-op complications: (e.g., liver failure, chronic abscess, bile leak) – incidence, diagnostics, how to manage them Select AllCompetency Level: Post-Operative SME Objectives*Select the Objectives covered by this content. Select All the Apply. Elaborate the typical immediate post-op pathway following a MIS left lateral sectionectomy or peripheral wedge resection (including: diet, activity, med changes, etc) List the typical expected outcomes % of patients in terms of recurrence risk and address concerns regarding adjuvant treatment Identify the most common short-term post-op complications, state their incidence, appropriate diagnostic work-up, and how to manage them. know median length of stay for similar cases Identify the most common long-term post-op complications, state their incidence, appropriate diagnostic work-up, and how to manage them Select AllProficiency LevelProficiency Goals*Select whether the content relates to either Pre-operative or Intra-operative goals. Select All the Apply. Pre Op: Equip the surgeon with the requisite knowledge of the anatomical and other preoperative patient considerations to perform MIS radical cholecystectomy Intra-Op: Assist the surgeon in acquiring the required knowledge and operative skills to perform MIS Radical Cholecystectomy Post Op: Manage post-operative issues for radical cholecystectomy Select AllProficiency Level: Pre-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Describe the proper clinical and radiological evaluation for a patient presenting with incidentally identified gall bladder cancer on path from cholecystectomy Describe the proper clinical and radiological evaluation for a patient presenting with a radiographic finding of gall bladder mass/abnormal or eccentric gallbladder wall thickening Evaluate the anatomical implications and planning of the operation based on integration of the clinical and radiological results. Understand and describe the clinical staging of gall bladder cancer, indications and contra-indications for operative intervention for gall bladder cancer Describe the role of neoadjuvant chemotherapy for gall bladder cancer. Describe the various management options and steps of the operation based on individual cases Select AllProficiency Level: Pre-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Identify and describe the proper radiographic and laboratory work up for a patient with gall bladder cancer. Identify and describe indications and contraindications of MIS radical cholecystectomy based on laboratory, radiographic work up, and clinical staging Name the appropriate preoperative steps to perform MIS Radical Cholecystectomy safely Propose and explain treatment strategies for a specific patient, to include indications for neoadjuvant chemotherapy vs surgery and appropriate adjuvant therapies. Describe the anticipated pre- and post-operative findings related to an oncological safe and effective procedure. Select AllProficiency Level: Intra-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Preparation: Appropriate identification and listing of pathways for operative clearance (E.g. antibiotics, clearance by anesthesia, preop labs, staging etc.) Positioning: How is the patient to be positioned and secured for the procedure? Instrument selection: Ports, staples, energy device, drains, sutures. Other intra-operative considerations: pneumoperitoneum, intraoperative fluid management +/- CVP monitoring, use of pringle. Operative steps: Describe and execute the proper steps and its sequence along with trouble shooting common pitfalls. Build on liver transection techniques from the previous module, describe portal lymphadenectomy in detail. Intraoperative complications: management of common intra-op complications including control hemorrhage, prevention and management of CO2 embolus, etc. Debrief: Analize, describe and sumarize events and results of the operation along with feedback discussion with a surgeon who is a master in MIS radical cholecystectomy Select AllProficiency Level: Intra-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Describe different options for conducting the appropriate intraoperative steps including intraoperative ultrasound, pringle maneuver, parenchymal transection, portal lymph node dissection. Describe how the patient is to be positioned and secured for the procedure. Describe how intra-operative fluids are managed, how pneumoperitoneum is used, how potential intraoperative issues such as hemorrhage, CO2 embolus are managed List the key operative steps to include: Access/Incisions: How many ports, what size, where to put them, energy devices and stapling choices List Key Operative Steps: Key anatomic landmarks for safe parenchymal transection (relationship to the right portal pedicle), portal LN dissection, adequacy of LN dissection List Key Operative Steps: Final Exploration: obtain/confirm hemostasis and closure (drain placement when applicable) Select AllProficiency Level: Post-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Typical immediate post-op pathway (e.g., diet, pain management, drain management etc) Short-term post-op complications: (e.g., PE, DVT, hemorrhage, abscess, bile leak, etc) – incidence, diagnostics, how to manage them timely and appropriately Outcomes: Typical expected outcomes (e.g., % of patients with curative surgery, indications for adjuvant therapies to include chemotherapy and radiation) Select AllProficiency Level: Post-Operative SME Objectives*Select the topics covered by this content. Select All the Apply. Describe the typical immediate post-op pathway (including: diet, activity, pain management, etc) Describe the typical expected outcomes (e.g., margin status, % of conversion, % of patients with bile leak, wound infection or other described complications) and expected post-op signs and symptoms List the short-term post-op complications following a MIS radical cholecystectomy (such as % of patients with bile leak, liver failure, wound infection or other described complications, etc), how often they occur/incidence, their diagnosis, and how to manage them timely and appropriately List the long-term oncologic outcomes after MIS radical cholecystectomy (indications for adjuvant therapies, surveillance routines, chance of recurrence (metastatic or local), management of recurrent disease Select AllMastery LevelMastery Goals*Select whether the content relates to either Pre-operative or Intra-operative goals. Select All the Apply. Pre-Operative: Equip the surgeon with the requisite knowledge of the anatomical and other preoperative patient considerations to perform formal MIS right hepatectomy Intra-Operative: Assist the surgeon in acquiring the required knowledge and operative skills to perform formal MIS right hepatectomy Post-Operative: Manage post-operative issues in formal MIS right hepatectomy Select AllMastery Level: Pre-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Presentation: Discuss the typical and atypical presenting signs & symptoms of a patient with right sided hepatocellular carcinoma and metastatic colorectal carcinoma. Indications: Discuss which hepatic neoplasms require a formal right hepatectomy. Diagnostic work-up: Discuss the Radiographic Studies needed to establish the diagnosis? What anatomic features (vascular, local invasion into adjacent organs) must be assessed on Cross-Sectional Imaging? Assess remnant liver volume, MELD score and patient co-morbidities. Assess hepatic function consider cirrhosis, steatohepatitis, neoadjuvant chemo/rad, fibrosis, etc. Management considerations: Discuss the tumor characteristics in the Cross-Sectional Imaging that will be important in operative planning. Discuss importance of establishing anatomical anomilies preoperatively. DIscuss determination of remnant liver volume and its significance to the proposed procedure.Discuss methods for augmentation of an inadequate liver remnant prior to surgery (PVE, ALPPS, APEAL, hepatic vein embolization etc). Locoregional Therapy: Discuss the role of preoperative portal vein embolization, RFA and TACE. Select AllMastery Level: Pre-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Describe the typical presentation of patients with colorectal liver metastases or HCC. Describe LIRADS criteria and appropriate staging, including nodal status Recognize the utility of and indications for CT, MRI, and biopsy. Independently interpret resectability for vascular (Portal Vein, SMV, SMA, Celial Axis) and adjacent organ involvement (Colon) and indications that would preclude resection on straightforward imaging Identify patients who will benefit from MIS right hepatectomy and incorporate the patient’s comorbidities & workup into deciding the choice of procedure (cirrhosis, diabetes, obesity, etc) Select AllMastery Level: Intra-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Preparation: Central line, A line, Foley, keep CVP low Positioning: What are the choices for patient positioning (eg supine with/without split legs) Explain the critical steps of a MIS Right Hepatectomy- Intraoperative US Explain the critical steps of a MIS Right Hepatectomy-Hepatocaval Dissection: Techniques for mobilizing right liver and dissection along IVC Hilum Dissection: hilum dissection and control of RHA, RPV and intra/extrahepatic RHD, Parenchymal Transection: Discuss options for transection of liver (eg stapler, energy devices) and control of the RHV. Discuss approaches to control of hemorrhage/bile leak. Recognize when it is necessary to convert to open (laparotomy). Discuss the indication for Multivisceral Resection (Colon) Discuss the indications for drain placement Select AllMastery Level: Intra-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Describe the typical presentation of patients with right sided HCC and right liver metastasis of colorectal carcinoma. Describe the anatomical rational for formal MIS right hepatectomy List several approaches of mobilizing and retracting the right liver, dissecting the hepatic veins and techniques for exposing the porta. Describe different methods of parenchymal transection and each of their advantages and disadvantages. Recognize when the need arises to convert to open and describe how. Describe the indications for drain placement Select AllMastery Level: Post-Operative Objective Topics*Select the topics covered by this content. Select All the Apply. Pathway: Typical immediate post-op pathway (e.g., diet, activity, med changes, drain management, etc) Outcomes: Typical expected oncologic outcomes (indications for Adjuvant Chemotherapy and/or Adjuvant Radiation). Short-term post-op complications: (e.g., PE, DVT, hemorrage, abscess, bile leak, acute liver failure) – incidence, diagnostics, how to manage them Long-term post-op complications: (e.g., hepatic insufficiency/liver failure, volume-outcome mismatch) – incidence, diagnostics, how to manage them Select AllMastery Level: Post-Operative SME Objectives*Select the objectives covered by this content. Select All the Apply. Elaborate the typical immediate post-op pathway following a right hepatectomy (including: diet, activity, med changes, drain management, etc) List the typical expected oncologic outcomes, describe the indications for Adjuvant Chemotherapy and Radiaton Identify the most common short-term post-op complications, state their incidence, appropriate diagnostic work-up, and how to manage them Identify the most common long-term post-op complications, state their incidence, appropriate diagnostic work-up, and how to manage them Select AllGeneral CommentsPlease list any general comments regarding this content. CommentsThis field is for validation purposes and should be left unchanged.