Operation Record Form for Cervical Cancer General information Patient ID Name Operation date Operator Assistant FIGO staging □ □ □ □ □ □ □ □ □ □ Ia1 Ia2 Ib1 Ib2 IIa1 IIa2 IIb IIIa IIIb IVa IVb Preoperative histologic diagnosis □ Neuroendocrine carcinoma Others ( ) Disease status □ Primary disease After neoadjuvant chemotherapy □ After chemoradiation Recurrent disease Others ( ) Preoperative marker □ □ □ SCC-Ag ( ) CA-125 ( ) CEA ( ) Anesthesia □ □ □ □ General Spinal Epidural Local Others Patient's position □ □ Supine Lithotomy Others Approach Laparotomy □ Lower midline incision Extended lower midline incision □ □ Pfannenstiel’s incision Maylard incision Others ( ) Minimally invasive surgery □ Laparoscopic Port numbers( ) □ Robotic Port numbers( ) □ Conversion No Yes from ( ) to ( ) □ □ □ Reason Bleeding Adhesion Organ injury □ Other organ invasion Others ( ) Operation type - Hysterectomy (KGOG classification) □ □ Conization (LEEP) Cold knife conization Trachelectomy (Cervicectomy) Type A(T) Minimum resection of paracervix (Simple trachelectomy;Simple cervicectomy) Type B(T) Transection of the paracervix at the ureter (Radical trachelectomy;Radical cervicectomy)
Operation Record Form for Cervical Cancer General information Patient ID Name Operation date Operator Assistant FIGO staging Ia1 □ Ia2 □ Ib1 □ Ib2 □ IIa1 □ IIa2 □ IIb □ IIIa □ IIIb □ IVa □ IVb Preoperative histologic diagnosis Neuroendocrine carcinoma □ Others ( ) Disease status Primary disease □ After neoadjuvant chemotherapy After chemoradiation □ Recurrent disease Others ( ) Preoperative marker □ SCC-Ag ( ) □ CA-125 ( ) □ CEA ( ) Anesthesia General □ Spinal □ Epidural □ Local □ Others Patient's position Supine □ Lithotomy □ Others Approach Laparotomy Lower midline incision □ Extended lower midline incision Pfannenstiel’s incision □ Maylard incision □ Others ( ) Minimally invasive surgery Laparoscopic □ Port numbers( ) Robotic □ Port numbers( ) Conversion □ No Yes from ( ) to ( ) Reason □ Bleeding □ Adhesion □ Organ injury Other organ invasion □ Others ( ) Operation type - Hysterectomy (KGOG classification) Conization □ (LEEP) □ Cold knife conization Trachelectomy (Cervicectomy) Type A(T) Minimum resection of paracervix (Simple trachelectomy;Simple cervicectomy) Type B(T) Transection of the paracervix at the ureter (Radical trachelectomy;Radical cervicectomy)
ORF_cervix.docx