Video Based Assessment Collection ToolCase Related QuestionsSubmitter Last Name*Submitter First Name*Procedure Type*FundoplicationInguinal HerniaCholecystectomyProcedure performed by*AttendingFellowResidentProgram Director First NameProgram Director Last NameFellow/Resident First NameFellow/Resident Last NameInstitution*Contact Email*For troubleshooting and follow up purposes only. Procedure Date* Date Format: YYYY dash MM dash DD What approach was used?* TEP TAPP eTEP OtherInguinal HerniaIs this a reoccurrence of a previous repair?*YesNoInguinal HerniaIf yes, how many previous repairs?*123 or moreInguinal HerniaWere any procedures performed in addition to unilateral inguinal hernia repair? (select all that apply)* Contralateral exploration Contralateral repair No additional procedures were performedInguinal HerniaDo you know of any post-operative issues? (Select all that apply)* Chronic Pain (≥ 3 months) Reoccurrence Hematoma Persistent Seroma ≥3Inguinal HerniaWere any procedures performed in addition to a fundoplication? (select all that apply)* Hiatal hernia repair <4cm Hiatal hernia repair >4cm Paraesophageal hernia repair Esophageal myotomy Esophageal lengthening procedure (e.g. Collis gastroplasty) Takedown of prior fundoplication (i.e. redo or revisional antireflux surgery) No additional procedures were performedFundoplicationDo you know of any post-operative issues? (Select all that apply)* Dysphagia > 3 months Persistent/Unresolved reflux Need for endoscopic intervention Need for surgical re-intervention Readmission related to the surgery No issues UnknownFundoplicationWere any procedures performed in addition to a cholecystectomy?* Intraoperative cholangiogram Common bile duct exploration EGD ERCP Other No additional procedures were performedCholecystectomyDo you know of any post-operative issues? (Select all that apply)* Need for endoscopic intervention Need for surgical re-intervention Readmission related to surgery No issues Unknown OtherCholecystectomyPlease provide more details on "Need for endoscopic intervention"*Please provide more details on "Need for surgical re-intervention"*Please provide more details on "Readmission related to surgery"*Please provide more details on "Other"*What is the patient's BMI*<2525-29.930-34.935-39.9≥40Please rate your opinion of the performance of each of the following steps.*Below AverageAverageAbove AverageVisualization of operative fieldHiatal dissectionFundus mobilizationEsophageal mobilizationHiatus repairWrap creationFundoplicationPlease rate your opinion of the performance of each of the following steps.*Below AverageAverageAbove AverageVisualization of operative fieldMPO dissectionMesh placementInguinal HerniaPlease rate your opinion of the performance of each of the following steps.*Below AverageAverageAbove AverageHepatocysticTriangle dissectionCritical view of safetyLibation of cystic duct & arteryDissection of gallbladder from liver bedCholecystectomyPlease note anything in this video that we should pay attention to. Portions that are particularly educational? Notable challenges? Etc.Trainee Involvement QuestionsThis section can be completed by both Program Directors and Fellows, as long as a trainee was involved.Was a trainee involved?*YesNoWhat level of supervision did the trainee have for the following steps of the procedureShow and TellActive HelpPassive HelpSupervision OnlyVisualization of operative fieldHiatal dissectionFundus mobilizationEsophageal mobilizationHiatus repairWrap creationSee definitions of the Zwisch scale supervision levels.Please rate your opinion of the performance of each of the following steps.Show and TellActive HelpPassive HelpSupervision OnlyVisualization of operative fieldMPO dissectionMesh placementSee definitions of the Zwisch scale supervision levels.Please rate your opinion of the performance of each of the following steps.Show and TellActive HelpPassive HelpSupervision OnlyHepatocysticTriangle dissectionCritical view of safetyLibation of cystic duct & arteryDissection of gallbladder from liver bedSee definitions of the Zwisch scale supervision levels. By checking this box, you acknowledge and agree that you own or have secured the necessary permission to grant SAGES use of de-identified data and images from the submitted video for research and education purposes.EmailThis field is for validation purposes and should be left unchanged.