Z6051 Rectal Surgery Form (RS) Laparoscopic-Assisted Resection or Open Resection in Treating Patients With Stage IIA, Stage IIIA, or Stage IIIB Rectal Cancer Source Form: NCI FormBuilder:

  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on:

January 9, 2015

To request one please log in.
License :
Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Colorectal Cancer NCT00726622 Treatment - Z6051 Rectal Surgery Form (RS) - 2718972v1.0

No Instruction available.

  1. StudyEvent: Z6051 Rectal Surgery Form (RS)
    1. No Instruction available.
Header Module
Did the patient have surgery as part of protocol treatment?
Reason surgery not performed
Surgical Approach
Was an ostomy created at the time of resection?
Sphincter preservation planned prior to surgery
Margins examined by frozen section
Rectum intact
Video documentation
Was attempted surgery complete
For Patients Randomized To Laproscopic Surgery Only
Surgical approach
Port Pattern
Hand Port
Ligation Method
TME Dissection Instrument
Low Rectal Transection Stapler Type
Scope Used
Was a change in ports required
Were retractors needed
Type of retractor
Was there organ displacement
Retractor used
Was a smoke evacuator used
Method used
Was laparoscopic resection converted to open
Reason laparoscopic resection was converted to open
Intra-operative Complications
Intra-operative Complications
Intra-operative Complications
Complication due to
Footer Module

Similar models

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial