Section 1: Summary Document

SECTION 1: SUMMARY DOCUMENT

Pelvic Floor Surgery Core Curriculum

This curriculum aims to promote understanding and safe delivery of pelvic floor services. Pelvic floor surgery has developed as a special interest of coloproctology, itself a subspecialty of General Surgery.

OBJECTIVES

Management of the patient presenting with common pelvic floor conditions to the surgical clinic.
Knowledge of the role of different investigations in the assessment of pelvic floor problems
Understanding of the range of treatments that can be offered to treat pelvic floor patients including the role of surgery and potential complications
Understanding of the roles of different members of the multi-disciplinary team (MDT) in the management of pelvic floor dysfunction

KNOWLEDGE

Pelvic floor conditions include incontinence, obstructive defecation, constipation, prolapse, solitary rectal ulcer and chronic anorectal pain. Knowledge of the conditions should include:

Definitions and potential overlap
Pathophysiology and associations
The investigations used and appropriate timing
Therapeutic options
Indications for pelvic floor surgery
Types of surgery performed
Complications of surgery and their management
Management of recurrent/ persistent problems
Components of a pelvic floor service and MDT

CLINICAL SKILLS

Take a directed history from a patient with pelvic floor dysfunction including bladder, bowel and sexual dysfunction
Perform a physical examination directed towards pelvic floor dysfunction
Request and interpret clinical investigations
Discuss non-operative treatment strategies and the involvement of different healthcare professionals
Select patients for appropriate operations
Management decisions for early and late complications of pelvic floor surgery

TECHNICAL SKILLS

Abdominal rectopexy
Perineal repair of prolapse
Anal sphincter repair
Neuromodulation in pelvic floor dysfunction
Endoanal ultrasound
Anorectal Physiology

SECTION 2: DETAILED CURRICULUM

ASSESSMENT OF PELVIC FLOOR FUNCTION

Objectives

Ability to take a directed history and examination for pelvic floor disorders
Competence in describing commonly used investigations in pelvic floor dysfunction.
Understanding of anatomical abnormalities and their likely functional effects.
Understanding of role of multi-disciplinary team meeting in treatment of pelvic floor dysfunction.(MDT)

Knowledge

Indications for investigations including sigmoidoscopy, colonoscopy, anorectal physiology, endoanal ultrasound, MRI, transit studies and defecating proctograms.
Range of normal values seen on anorectal physiology and transit studies.
Describe the basic equipment and performance of anal manometry.
Classification of anatomical abnormalities on defecating proctography and correlation to symptoms and clinical findings.

Clinical Skills

Take a detailed history for pelvic floor disorders including obstetric history, urinary and sexual dysfunction.
Perform a focused examination of the anorectum and perineum.
Performance and interpretation of anorectal physiology including manometry and rectal sensation.
Anatomical interpretation of endoanal ultrasound and endocoil MRI.
Describe the performance and interpretation of transit studies.
Describe how a defecating proctogram is performed.
Anatomical interpretation of fluoroscopic and MRI defecating proctography. In particular identification of prolapse, intussusception, rectocele, enterocele, sigmoidocele and anismus. Identify associated bladder and vaginal abnormalities.
Describe the clinical relevance of the abnormalities identified (see topics 1-4).
Diagnosis through response to treatment, eg botulinum toxin in anismus
Discuss the patient and their investigation findings in an MDT.

Technical Skills

Endoanal ultrasonography

Anorectal physiology- manometry and rectal sensation

2. CONSTIPATION AND OBSTRUCTIVE DEFECATION

OBJECTIVES

Investigation and treatment of patients with constipation
Competency in the management of outlet obstruction constipation
Motility Disorders: Competency in the management of colonic inertia and colonic pseudo-obstruction

KNOWLEDGE

Normal colonic physiology and the process of defecation
Definition of constipation and its epidemiology
Classification of types and causes of constipation including obstructive defecation and slow transit constipation
Differential diagnosis in a patient with constipation
Different types of laxatives and describe the indications, contraindications, modes of action, and complications of each: stimulant, osmotic, bulk-forming, lubricant
Definition, causes and diagnosis of anismus
Indications, techniques, complications and results of rectocele repair
Role of colectomy in colonic inertia including indications, complications and expected results
Common causative factors for colonic pseudo-obstruction, clinical and radiological findings and suggested treatments

CLINICAL SKILLS

Take a directed history for a patient with constipation and perform a directed physical examination
Arrange a treatment plan based on endoscopic, radiological and physiology tests: defaecating proctogram, transit studies, anorectal manometry, EMG, balloon expulsion, endoscopy and CT colonogram
Plan a treatment programme for a patient with constipation that may include the following: dietary measures, fibre, laxatives, prokinetic medications, enemas, suppositories, per-anal irrigation and psychological support.
Describe the process and role of biofeedback and physiotherapy in obstructive defecation
Role of neuromodulation in constipation
Management of anismus: medical management, biofeedback, botulinum toxin, surgery
Manage short segment/adult Hirschsprung's disease
Recognise the clinical presentation of symptomatic rectocele and internal prolapse. Assessment of degree of internal prolapsed.
Diagnosis, relevance and both non-operative and operative management of enterocele and sigmoidocele
Discuss the indications for surgery, operative techniques and potential complications for these anatomical abnormalities including the relative merits and risks of ventral mesh rectopexy, suture rectopexy, resection rectopexy and STARR.
Describe associated urological and gynaecological symptoms and presentations of pelvic floor weakness.
Management of immediate, early and late complications following surgery for obstructive defecation.
Management of recurrent symptoms following surgery for obstructive defecation.
Evaluation and management of recurrent constipation after colectomy.
Evaluate a patient with suspected colonic pseudo-obstruction
Manage a patient with colonic pseudo-obstruction by medical or surgical means

TECHNICAL SKILLS

Rectopexy
STARR

3. PROLAPSE

OBJECTIVES

Competency in the management of all patients with rectal prolapse

KNOWLEDGE

The incidence, pathophysiology and epidemiology of rectal prolapse
Understanding of internal intussusception, with its radiological findings and treatment options
Understanding of clinical presentations of rectal prolapse and intussusception
Identification of intussusception and prolapse on a proctogram and associations such as enterocele and sigmoidocele
Understand the perineal and abdominal surgical options for prolapse with the indications for each approach, complications, recurrence rate and functional results

Clinical skills

Identify the associated anatomical findings of rectal prolapse and its clinical presentation including functional disturbances and physical findings
Differentiate between mucosal prolapse, prolapsing internal haemorrhoids and rectal prolapse
Appropriate management of incarcerated and strangulated rectal prolapse
Manage constipation and incontinence in the context of rectal prolapse
Describe factors that influence the type of operative repair including pre-operative investigations.
Consent a patient for rectal prolapse repair, including potential complications
Perform operation for rectal prolapse - perineal or abdominal; open or laparoscopic
Manage a patient with recurrent rectal prolapse
Management of intussusception including conservative and surgical approaches.

Technical Skills

Prolapse-abdominal rectopexy
Prolapse-rectopexy + sigmoid resection
Prolapse-perineal repair

3B. SOLITARY RECTAL ULCER SYNDROME

OBJECTIVES

Ability to diagnose and manage solitary ulcer syndrome

Knowledge

The clinical presentation of solitary rectal ulcer and the differential diagnosis

Understand the associated pelvic floor disorder, including prolapse and obstructive defecation.

Clinical skills

Recognise the clinical presentation, endoscopic and histological findings in a patient with solitary rectal ulcer.
Utilise appropriate medical/surgical treatment options

4. FAECAL INCONTINENCE

OBJECTIVES

Understanding of the epidemiology of faecal incontinence
Understanding of the causes, clinical findings and physiological findings in faecal incontinence.
Ability to manage faecal incontinence by non-operative means
Operative management: Competency in the operative treatment of faecal incontinence.

KNOWLEDGE

Epidemiology

Knowledge of mechanisms of continence and abnormalities that can lead to incontinence.

Classification of the various types of incontinence, their incidence and their pathophysiology
Specific knowledge about the nature of obstetric injuries

Evaluation

Anatomical, neurological, dermatological, and endoscopic findings that differentiate various types of incontinence
Normal and abnormal findings in imaging studies used in incontinence including endoanal ultrasound and MRI
Knowledge of scoring systems for assessing severity of faecal incontinence and affect on quality of life
Indications, uses and results of biofeedback and physiotherapy in incontinence
Indications for and techniques used in surgery for incontinence, including complications and functional results: anal sphincter repair, muscle transpositions, artificial bowel sphincter, sacral nerve stimulation. Complications and functional results.
Understand the concept of antegrade continent enema conduits

CLINICAL SKILLS

Take a directed history to differentiate types of incontinence
Perform a physical examination to differentiate types of incontinence
Identify and interpret anorectal physiology tests, including manometry, rectal sensation and nerve conduction studies, and the results of endoanal ultrasound.
Outline a non-operative bowel management plan incorporating: dietary measures, medications, biofeedback, enemas and irrigation, perineal skin care, anal plug
Make a treatment plan for a patient with incontinence, including knowledge of side-effects
Select patients for operation according to the physical and laboratory findings
Select type of operative repair
Role and procedure for both sacral nerve stimulation and percutaneous tibial nerve stimulation
Discuss options for recurrent problems following surgery
Select patients for temporary and permanent faecal diversion

TECHNICAL SKILLS

Anal sphincter repair (including postanal repair, anterior sphincter repair)
Anal sphincter- artificial sphincter
Neuromodulation- sacral nerve stimulation, percutaneous tibial nerve stimulation

5. CHRONIC ANORECTAL PAIN

Objective

Competency in the management of chronic rectal pain syndromes.

Knowledge

Differential diagnosis for rectal pain including ilevator ani syndrome, proctalgia fugax, chronic idiopathic pelvic pain, coccygodynia.
Associations with pelvic floor pathology including anismus, obstructive defecation, intussusception or enterocele.
Pudendal nerve entrapment and neuralgia

Clinical skills

Directed history and examination to differentiate cause
Appropriate investigation of chronic rectal pain.

Manage pelvic pain by means of: bowel management programmes, analgesics, antidepressants, levator massage, electrogalvanic stimulation, nerve blocks, steroid injections, trans gluteal nerve decompression, botulinum toxin injections, biofeedback, psychiatric or psychological treatment, surgery

6. IRRITABLE BOWEL SYNDROME

OBJECTIVE

Competency in the management of irritable bowel syndrome

Knowledge

The pathophysiology and spectrum of irritable bowel syndrome
The differential diagnosis of IBS

Clinical skills

Directed history, examination and investigation

Diagnose irritable bowel syndrome and outline a medical treatment programme that may include the following: diet, fibre, laxatives, prokinetic medications, enemas, suppositories, psychological support

SECTION 3: Procedure Based Assessments

PBAs for:

1. Abdominal rectopexy (laparoscopic ventral mesh rectopexy)

2. Perineal rectopexy (delorme’s procedure)

3. Sacral nerve stimulator placement

GENERAL SURGERY PBA LAPAROSCOPIC VENTRAL MESH RECTOPEXY

I. Consent Rating Comment
C1 / Demonstrates sound knowledge of indications and contraindications including alternatives to surgery
C2 / Demonstrates awareness of different surgical approaches and advantages and disadvantages
C3 / Demonstrates sound knowledge of complications of surgery and rates of recurrence
C4 / Explains the procedure to the patient/ relatives/ carers and checks understanding
C5 / Explains likely outcome and time to recovery and checks understanding
II. Pre-operative planning Rating Comment
PL1 / Demonstrates recognition of anatomical and pathological abnormalities, and their likely clinical relevance, and selects appropriate operative strategies/ techniques to deal with these
PL2 / Demonstrates ability to make reasoned choices of appropriate equipment, materials or devices (eg mesh) taking into account appropriate investigations e.g proctograms
PL3 / Checks materials, equipment and device requirements with operating staff
PL4 / Checks operative records, personally reviews investigations
III. Pre operative preparation Rating Comment
PR1 / Checks in theatre that consent has been obtained
PR2 / Gives effective briefing to theatre team
PR3 / Ensures proper and safe positioning of the patient on the operating table
PR4 / Demonstrates careful skin preparation
PR5 / Demonstrates careful draping of the patient’s operative field
PR6 / Ensures general equipment and materials are deployed safely (eg diathermy)
PR7 / Ensures appropriate drugs are administered
IV. Exposure and closure Rating Comment
E1 / Demonstrates knowledge of optimum skin incision/ portal/ access
E2 / Achieves an adequate exposure through purposeful dissection in correct tissue planes and identifies all structures correctly
E3 / Uses graspers, diathermy and other energy devices so as to minimise the risk of iatrogenic injury
E4 / Completes a sound wound repair
E5 / Protects the wound with dressings or glue
V. Intra-operative technique: global(G) and task Rating Comment
specific items(T)
IT1
(G) / Follows an agreed, logical sequence or protocol for the procedure
IT2
(G) / Consistently handles tissue well with minimal damage
IT3
(G) / Controls bleeding promptly by an appropriate method
IT4
(G) / Demonstrates a sound technique of knots and sutures
IT5
(G) / Uses instruments appropriately and safely
IT6
(G) / Proceeds at appropriate pace with economy of movement
IT7
(G) / Anticipates and responds appropriately to variation e.g anatomy
IT8
(G) / Deals calmly and effectively with unexpected events/complications
IT9
(G) / Uses assistant(s) to the best advantage at all times
IT10
(G) / Communicates clearly and consistently with scrub team
IT11
(G) / Communicates clearly and consistently with the anaesthetist
IT12
(T) / Safely obtains pneumoperitoneum and places ports in suitable positions
IT13
(T) / Small bowel is safely delivered out of the pelvis and the rectum is clearly exposed
IT14
(T) / Dissection of the lateral pelvic peritoneum and continues dissection anteriorly. Awareness of ureters, pelvic nerves and vagina in females, seminal vesicles in males.
IT15
(T) / Appropriate use of traction and maintaining field of view to facilitate dissection
IT16
(T) / Identification of the pelvic floor and insertion and suturing of mesh.
IT17
(T) / Safely secures mesh to sacral promontory
IT18
(T) / Peritoneal closure safely performed
IT19
(T) / Performs abdominal wall closure
VI. Post-operative management Rating Comment
PM1 / Ensures the patient is transferred safely from the operating table to the bed
PM2 / Constructs a clear operation note
PM3 / Records clear and appropriate post-operative instruction
PM4 / Deals with specimens (if appropriate). Labels and orientates specimens appropriately

GENERAL SURGERY PBA: PERINEAL PROLAPSE REPAIR (DELORME’S)

I. Consent Rating Comment
C1 / Demonstrates sound knowledge of indications and contraindications including alternatives to surgery
C2 / Demonstrates awareness of different surgical approaches and advantages and disadvantages
C3 / Demonstrates sound knowledge of complications of surgery and rates of recurrence
C4 / Explains the procedure to the patient/ relatives/ carers and checks understanding
C5 / Explains likely outcome and time to recovery and checks understanding
II. Pre-operative planning Rating Comment
PL1 / Demonstrates recognition of anatomical and pathological abnormalities, and their likely clinical relevance, and selects appropriate operative strategies/ techniques to deal with these
PL2 / Demonstrates ability to make reasoned choices of appropriate equipment, materials or devices taking into account appropriate investigations e.g proctograms
PL3 / Checks materials, equipment and device requirements with operating staff
PL4 / Checks operative records, personally reviews investigations
III. Pre operative preparation Rating Comment
PR1 / Checks in theatre that consent has been obtained
PR2 / Gives effective briefing to theatre team
PR3 / Ensures proper and safe positioning of the patient on the operating table- lithotomy or prone
PR4 / Demonstrates careful skin preparation
PR5 / Demonstrates careful draping of the patient’s operative field
PR6 / Ensures general equipment and materials are deployed safely (eg diathermy)
PR7 / Ensures appropriate drugs are administered
IV. Exposure and closure Rating Comment
E1 / Achieves optimum access to the perineum and displays operative field, including use of anal retractors
E2 / Achieves an adequate exposure through purposeful dissection in correct tissue planes and identifies all structures correctly
E3 / Appropriate use of diathermy
E4 / Completes a sound wound repair
V. Intra-operative technique: global(G) and task Rating Comment
specific items(T)
IT1
(G) / Follows an agreed, logical sequence or protocol for the procedure
IT2
(G) / Consistently handles tissue well with minimal damage
IT3
(G) / Controls bleeding promptly by an appropriate method
IT4
(G) / Demonstrates a sound technique of knots and sutures
IT5
(G) / Uses instruments appropriately and safely
IT6
(G) / Proceeds at appropriate pace with economy of movement
IT7
(G) / Anticipates and responds appropriately to variation e.g anatomy
IT8
(G) / Deals calmly and effectively with unexpected events/complications
IT9
(G) / Uses assistant(s) to the best advantage at all times
IT10
(G) / Communicates clearly and consistently with scrub team
IT11
(G) / Communicates clearly and consistently with the anaesthetist
IT12
(T) / Logical examination under anaesthetic, identifying and displaying extent of the prolapse
IT13
(T) / Appropriately placed incision. Considers use of adrenaline solution to demonstrate submucosal layer.
IT14
(T) / Safe dissection in the correct plane with constant attention to haemostasis
IT15
(T) / Appropriate cessation of dissection in the inner aspect of the prolapse.
IT16
(T) / Placement of muscle plicating sutures. Mucosal defects closed.
VI. Post-operative management Rating Comment
PM1 / Ensures the patient is transferred safely from the operating table to the bed
PM2 / Constructs a clear operation note
PM3 / Records clear and appropriate post-operative instruction
PM4 / Deals with specimens (if appropriate). Labels and orientates specimens appropriately

GENERAL SURGERY PBA: SACRAL NERVE STIMULATOR INSERTION (SNS)- TEMPORARY (T) AND PERMANENT (P)

I. Consent Rating Comment
C1 / Demonstrates sound knowledge of indications and contraindications including alternatives to surgery. Discusses role of initial trial of temporary SNS.
C2 / Demonstrates awareness of role of SNS in managing functional bowel disorders with advantages and disadvantages
C3 / Demonstrates sound knowledge of complications of surgery and success/failure rates.
C4 / Explains the procedure to the patient/ relatives/ carers and checks understanding
C5 / Recognises advantages and disadvantages of procedure under local or general anaesthetic
C6 / Explains likely outcome and time to recovery and checks understanding. Discusses future procedures (T) and awareness of life span of battery (P)
II. Pre-operative planning Rating Comment
PL1 / Demonstrates recognition of anatomical and pathological abnormalities, and their likely clinical relevance, and selects appropriate operative strategies/ techniques to deal with these
PL2 / Demonstrates ability to make reasoned choices of appropriate equipment, materials or devices taking into account appropriate investigations
PL3 / Checks materials, equipment and device requirements with operating staff
PL4 / Checks operative records, personally reviews investigations
III. Pre operative preparation Rating Comment
PR1 / Checks in theatre that consent has been obtained
PR2 / Gives effective briefing to theatre team
PR3 / Ensures proper and safe positioning of the patient on the operating table- prone
PR4 / Demonstrates careful skin preparation
PR5 / Demonstrates careful draping of the patient’s operative field and exposure of perineum and lower limb to observe for contractions
PR6 / Ensures general equipment and materials are deployed safely (eg diathermy and X-ray)
PR7 / Ensures appropriate drugs are administered
IV. Exposure and closure Rating Comment
E1 / Displays operative field to allow access to necessary structures.
E2 / Appropriate administration of local anaesthetic
E3 / Makes an appropriate skin incision for the battery (P)
E4 / Appropriate use of diathermy
E5 / Completes a sound wound repair
V. Intra-operative technique: global(G) and task Rating Comment
specific items(T)
IT1
(G) / Follows an agreed, logical sequence or protocol for the procedure
IT2
(G) / Consistently handles tissue well with minimal damage
IT3
(G) / Controls bleeding promptly by an appropriate method
IT4
(G) / Demonstrates a sound technique of knots and sutures
IT5
(G) / Uses instruments appropriately and safely
IT6
(G) / Proceeds at appropriate pace with economy of movement
IT7
(G) / Anticipates and responds appropriately to variation e.g anatomy
IT8
(G) / Deals calmly and effectively with unexpected events/complications
IT9
(G) / Uses assistant(s) to the best advantage at all times
IT10
(G) / Communicates clearly and consistently with scrub team
IT11
(G) / Communicates clearly and consistently with the anaesthetist
IT12
(T) / Clearly identifies (and marks if appropriate) surface markings to allow identification of sacral foramina.
IT13
(T) / Trial of needle locations to obtain most effective response. Observe for pelvic floor contraction and hallux/ plantar flexion. Checks sensation (LA only)
IT14
(T) / Placement of lead. Fluroscopic confirmation of lead. placement (P)
IT15
(T) / Safe dressing of lead (T). Creation of subcutaneous tunnel for lead (P)
IT16
(T) / Connection to external battery pack (T). Creation of buttock or abdominal wall ‘pocket’ for battery and correct connection and orientation of IPG (P).
VI. Post-operative management Rating Comment
PM1 / Ensures the patient is transferred safely from the operating table to the bed
PM2 / Constructs a clear operation note
PM3 / Records clear and appropriate post-operative instruction.
Explains use of external battery (T)
Organises switch on of IPG and programming
PM4 / Organises a clear follow up plan

This document has been drafted for presentation to the training committee of the pelvic floor society by J.Randall. It uses some of the original ISCP curriculum and uses the same structure. It also takes influence from the Bariatric and Metabolic Fellowship Core Curriculum.