KING FAISAL SPECIALIST HOSPITAL AND RESEARCH CENTRE (KFSH&RC)

NURSING AFFAIRS
OPERATING ROOM SKILLS CHECKLIST

Name of Applicant: __________________ Date: _________________

HOW TO COMPLETE THIS FORM:
A thorough evaluation of your skill level in various specialty areas will
enable us to locate assignments that are suitable to your skills and the
needs of our patients. Please place an "X" in the box that most accurately
describes your level of expertise for the skills listed.
LEVELS OF PROFICIENCY:
A = Perform Well (as least one year of current
experience, very comfortable performing without
supervision).
B = Limited Experience (six months to one year of
experience, would require some assistance).
C = Perform Infrequently (less than three months
of experience, need more experience and
practice, assistance required).
D = No Experience (have never performed this
task, willing to learn).

Scrub Circulating
Experience Experience

skills A B C D A B C D

GENERAL SURGERY:
Abdomen Debride Necrotizing Soft Tissue
Abdominal / Pelvic Tumour Resection
Abdominal Adhesions Release
Abdominal Perineal Resection
Abdominal Wash Out
Abdominalperineal Resect, Rectal Prolaps
Abdominoperineal Resect, Lap, Colostomy
Abdominoperineal Resect, Colostomy
Abdominoperineal Resect, Pull Thru, Colo
Adrenalectomy - Bilateral, Open
Adrenalectomy - Laparoscopic
Adrenalectomy - Unilateral, Open
Anal Dilatation
Anal Fissurectomy
Anal Fistula Laying Open
Anal Fistulotomy
Anal warts fulguration
Appendectomy Laparoscopic
Axillary Mass Excision
Axillary Node Dissection
Back\Flank Soft tissue Superficial Biops
Band Ligation

Page 1 of 25
Updated February 2016
 Biliary Dilation
Bowel Repair
Breast Biopsy
Breast Conserving Treatment
Breast Debridement
Breast Lumpectomy
Breast Lumpectomy With Axillary Dissecti
Bronchogram Bilateral
Cervical Biopsy
Chest Wall Tumor Excision
Cholecystectomy w/X-Ray Laparoscopic
Cholecystectomy With Cholangiograms
Closure Of Rectovesical Fistula
Colectomy Sigmoid Laparascopic
Colonic Lavage, Intraoperative
Colonoscopy through stoma
Colonoscopy With Polypectomy
Colonoscopy, control of bleeding
Colonoscopy, removal of foreign body
Colonoscopy, ultrasound examination
Colonoscopy, ultrasound examination with
Colostomy Creation
Colostomy Revision
Cut Down Intravenous or Intra Aterial
Cyst, Excision of
Debridement Wound
Decortication
Dehiscence / Abdominal Wound Resuture
Diverticulectomy
EGD + Achalasia Dilation
EGD + Biopsy + CLO
Endoscopic Ultrasound Rectal with biopsy
Endoscopic Ultrasound with biopsy, colon
Endoscopic Ultrasound, colonoscopy
Endoscopic Ultrasound, Rectal
Esophageal Bypass
Esophageal Dilatation Surg
Esophagectomy
Esophagogastrectomy
Esophagoscopy
Esophagoscopy Rigid Or Flexible With Rem
EUA General
Excision Of Cyst Or Adenoma Of Thyroid
EXTRALEVATOR ABDOMINOPERINEAL
EXCISION(ELAPE)

Page 2 of 25
Updated February 2016
 Fistulectomy-Rectal
Gastrectomy
Gastrectomy Distal
Gastric Band Adjustment
Gastric Band Removal, Laparascopic
Gastric Band Revision
Gastric Bypass
Gastric Bypass Laparoscopic
Gastric Bypass Open
Gastroduodenectomy Billroth I
Gastroenterostomy
Gastro-Jejunostomy
Gastroplasty
Gastrostomy Laparoscopic
Gastrostomy Open
Gastrostomy Percutaneous Endoscopic
Glossectomy Partial
Groin Dissection
Groin Lymph Node Biopsy
Groin Tumour Excision
Gynecomastia Excision
Hartmanns Procedure
Hartmanns Reversal
Hemorrhoid, banding
Hemorrhoid, infrared coagulation
Hemorrhoid, injection of sclerosing agen
Hemorrhoidectomy
Hernia Rep, Umbilical < 5 Y, Reducible

Hernia Rep,Inguinal,Recurrent Any Age,Re

Ileo Bypass
Ileo-Anal Pouch
Ileoplasty
Ileostomy Closure
Ileostomy Creation
Imperforate Anus Repair
Infusaport Change
Infusaport Insertion
Inguinal Exploration

Intramural/Submucosal Abscess Transanal

Jejunocolic Anastomosis
Jejunostomy
Lap Sur Rep Ventral Hernia Reducible
Lap, Sur, Rep, Incal Hernia; Incarc/Stra

Page 3 of 25
Updated February 2016
 Lap, Sur, Rep, Incal Hernia; Reducible
Lap, Sur, Rep, Recurrent Inc Hernia; Inc
Lap, Sur, Rep, Recurrent Incal Hernia; R
Lap, Sur, Rep, Ventral; Incarc/Strang
Laparascopic Gastric Banding
Laparoscopic Bilio-Pancreatic Diversion
Laparoscopic Retroperitoneal Lymph Nodes
Laparotomy Exploratory
Laparotomy,Abdominal Washout,Liver Biops
Liver Biopsy Laparoscopic
Liver Biopsy Open Laparotomy
Liver Harvest - Cadaver
Liver Resect Trisegmentectomy
Liver Resect Ttl Leftlobectomy
Liver Resect Ttl Right Lobectomy
Liver Resect, Part Lobectomy
Liver Resection
Lobectomy - Lung
Lobectomy Lung Sngl Lobe
Lung Biopsy Percutaneous
Lung Cyst Resection
Lymph Node Biopsy
Lymph Node Biopsy - Axillary
Lymph Node Dissection - Laparoscopic
Mastectomy - Skin Sparing
Mastectomy Modified Radical
Mastectomy Simple
Mastectomy W/Axillary Disection
Mastectomy With Sentinal Lymph Node BiopSY
Mediastinal Tumor Resection
Mediastinoscopy
Mediastinoscopy With Biopsy
Metastatic Tumour Excision
Mole Removal
Multi Organ Harvest
Neck Dissection - Unillateral
Neck Exploration
Needle Biopsy
Omentectomy
Pancreatectomy Distal
Parathyroid Re-Implantation
Parathyroidectomy
PEG Replacement Only
PEG Tube Removal Only
Perm Cath Insertion

Page 4 of 25
Updated February 2016
 Perm Cath Removal
Pilonidal Sinus Excision
Pilonidal Sinus Lay Open
Polypectomy (Eu)
Procedure Cancelled
Proctocolectomy
Proctoplasty-Abdominal Approach
Proctoscopy
Proctotomy
Pyloromyotomy
Pyloroplasty
Pyloroplasty and Vagotomy
Rectal Biopsy
Rectal Polypectomy + Histopathology
Rectal Polyps Excision
Rectal Prolapse Excision
Rectal Reconstruction
Rectal sphincterotomy, Lateral internal
Rectal Stricture division
Rectal Stricture, Dilatation
Rectal, transrectal drainage
Rectal\Perirectal Abscess Inc And Drain
Red, Intussusception/Volvulus/Hernia, La
Removal Of Fecal Impaction
Retroperitoneal Tumour Resection
Revision Of Hepatico Jejunostomy
Roux-En-Y
Sentinal Lymph Node Biopsy
Sigmoidoscopy
Sigmoidoscopy Flexible W/ Bx
Sigmoidoscopy, decompression of volvulus
Skin Tag Excision
Sleeve Gastrectomy Laparascopic
Small Bowel Resection
Small Bowel Wash Out
Sphincteroplasty
Splenectomy
Splenectomy - Laparoscopic
Splenectomy, Ttl
Splenectomy, Ttl, En Bloc For Extensive
Supraclavicular Node Biopsy
Suture Lrg Intestine Colorrhaphy W/ Colo
Suture Lrg Intestine Colorrhaphy W/O Col
Suture of Laceration
Sympathectomy, Cervical

Page 5 of 25
Updated February 2016
 Thoracoscopic Lung Resection
Thoracoscopy

Thoracoscopy Lung/Pleural Space Diag W/O

Thoracotomy - Wedge Resection Of Upper O

Thyroglossal Duct Cyst Excision
Thyroidectomy
Thyroidectomy Completion
Thyroidectomy Subtotal
Thyroidectomy with Neck Dissection
Tracheal Dilatation
TRANS ANAL MINIMAL INVASIVE SURGERY (TAMIS)
Upper GI Endoscopy; Control Of Bleeding
Upper GI Endoscopy; Dilation Of Gastric
Upper GI Endoscopy; Removal Of Foreign B
Upper GI Endoscopy; Removal Of Tumors, P
Upper GI Endoscopy; Transendoscopic Sten
Vulva/Perineal Abscess Inc And Drain
Whipple Procedure
Wound Closure Secondary
Wound Postop Inc & Drain, Cmplx
Wound Re-Exploration
PEDIATRICS
Abdominal adhesion release - laparoscopi
Abdominal adhesion release - open
Abdominal tumor resection
Adrenalectomy-laparoscopic/open
Anal Fistulotomy
Appendectomy-laparoscopic/open
BONE MARROW BIOPSY
Bowel atresia repair
Branchial Fistula Resection
Broviac catheter insertion
Broviac catheter removal
Chest neuroblastoma - thoracotomy
Chest Neuroblastoma Thoracoscopy Resecti
Chest wall tumor excision - thoracoscopi
Cholecystectomy Laparoscopic
Cholecystectomy with operative cholangio
Cholecystectomy-laparoscopic/open
Choledochoduodenostomy - laparoscopic/op
Choledochoduodenostomy - open
Choledochojejunostomy - laparoscopic/ope
Choledochojejunostomy - open

Page 6 of 25
Updated February 2016
 Circumcision neonatal
Colectomy transverse - laparoscopic/open
Colostomy closure - laparoscopic/open
Colostomy closure-open
Colostomy Creation
Colostomy creation - laparoscopic assist
Colostomy creation-open
Colostomy revision - laparoscopic assist
Decortication
Decortication of lung
Decortication of lung - thoracoscopic/op
Diaphragm plication - thoracoscopic/open
Duodenal atresia repair
Endoscopy Upper GI (surgery)
Esophageal Atresia Repair
Esophageal atresia repair - laparoscopic
Esophageal Dilatation, Balloon
Esophageal duplication cyst excision
Esophagomyotomy (heller's)
Esophagomyotomy (heller's) - laparoscopi
Esophagoscopy w/Dilatation
Esophoageal Dilatation
Eua perineum with muscle stimulation
Excision Of Neck Mass Congenital
Gastro-Jejunostomy
Gastro-jejunostomy - laparoscopic/open
Gastroscopy
Gastrostomy Closure
Gastrostomy Percutaneous Endoscopic
Hemicolectomy Right
Hepaticojejunostomy - laparoscopic/open
Hepaticojejunostomy - open
Hernia Repair Diaphragmatic
Hernia repair diaphragmatic - thoracosco
Hernia repair diaphragmatic-open
Hernia Repair Incisional
Hernia repair incisional-laparoscopic/op
Ileostomy Creation
Ileostomy creation - laparoscopic/open
Ileostomy creation-open
Infusaport catheter change
Infusaport catheter insertion
Infusaport catheter removal
Infusaport Change
Infusaport Insertion <5yrs

Page 7 of 25
Updated February 2016
 Infusaport Removal
Kasai for Biliary Atresia
Ladd’s procedure-open
Ladd's procedure - laparoscopic/open
Ladds Procedure, Malrotation, Lysis Duod
Laparascopic Cardiomyotomy
Laparotomy Removal Hydatid Cyst
Liver Biopsy Laparoscopic
Liver biopsy laparoscopic/open
Liver Resection
Liver resection - thoracoscopic/open
Liver resection-open
Lobectomy - Lung
Lobectomy lung-thoracotomy
Lung Biopsy - Open
Lung Biopsy - Thorascopic
Lung biopsy-thoracoscopic/open
Lung biopsy-thoracotomy
Lung metastatectomy - open
Lung metastatectomy - thoracoscopic/open
Lung resection - thoracoscopic/open
Lung resection - thoracotomy
Lymph Node Biopsy
Lymph node biopsy-open
Nephrectomy - Laparoscopic
Nephrectomy-laparoscopic/open
Neuroblastoma Resection
Neuroblastoma resection - laparoscopic/o
Neuroblastoma resection-open
Nissen fundoplicatin with gt insertion-o
Nissen Fundoplication - Open
Nissen Fundoplication Laparascopic
Nissen fundoplication with gt insertion-
Operative cholangiogram possible kasai p
Orchidectomy - Radical
Orchiopexy Laparoscopic
Orchiopexy laparoscopic assisted
Osteotomy Pre-Bladder Repair Bil
Pancreatectomy - laparoscopic/open
Pelvic tumor resection
Pull through for anorectal malformation
Pull through procedure (hirschsprung's d
Pyloromyotomy
Pyloromyotomy - laparoscopic/open
Pyloroplasty

Page 8 of 25
Updated February 2016
 Pyloroplasty - laparoscopic/open
Rectal EUA with Muscle Stimulation
Sacro-coccygeal teratoma resection
Salter Pelvic Osteotomy for Bladder Extr
Sclerotherapy injection for cystic hygro
Splenectomy - Laparoscopic
Splenectomy-laparoscopic/open
Splenectomy-open
Tenchkoff catheter insertion - laparosco
Thoracoscopic/open for tumor resection
Thoracoscopy
Thoracoscopy diagnostic
Thoracotomy for tumor resection
Tracheal Esophageal Fistula Repair
Tracheo-Esophgeal Atresia Repair
Transanal pull through procedure
Transanal pull through procedure - lapar
Tumor mass biopsy - laparoscopic/open
Tumor mass biopsy - open
ONCOLOGY SURGERY
Bone Marrow Aspiration
Bone Marrow Biopsy
Bone Marrow Harvest-Donor
Brachytherapy Applicator Insertion, Vagi
IORT Intraoperative Radiation Therapy
IORT Intraoperative Radiation Treatment
Radiation Therapy
PLASTIC SURGERY
Alveolar Bone Graft
Arm Lesion Excision
Back Lesion Excision
Blepharoplasty
Brachioplasty
Breast Bilateral Reconstruction
Breast Implant Removal / Revision
Breast Implant Rev
Breast Implant Rmvl
Breast Recon Tissue Expande
Breast Reconstruct W/Tram Flap W/Microva
Breast Reconstruction
Breast Reconstruction with Flap - Single
Breast Single Recon W/ Flap
Breast Single Reconstruction
Breast Tissue Expander Insertion
Chalazion Excision

Page 9 of 25
Updated February 2016
 Cleft Lip Repair
Cleft Palate Repair w/Bone Graft
Commissuroplasty
Contracture Correction
Debridement Wound
Dermabrasion
Dressing Change
Ear Reconstruction
Face Lesion Excision
Facelife / Rhytidectomy
Facial Nerve Laceration
Facial Reconstruction
Fat Graft
fat graft harvest
Fat Injection
Flap Graft
Flap Release
Free Flap
Free Flap Microsurgery
Ganglion Excision
Gold Weight Insertion Eyelid
Gynecomastia Correction
Hand Reconstruction
Hemangioma Excision
Hematoma Evacuation
Incision and Drainage Minor
Keloid Excision
Keratoplasty
Lesion Excision
Lesion Excision - Arm
Lesion Excision - Back
Lip Bx
Lip Reconstruction
Lipoma Excision
Lipo-Suction
Liposuction - Tulip With Re-Injection Of
Liposuction Head And Neck
Liposuction,Lower Extremity
Liposuction,Trunk
Liposuction,Upper Extremity
Lymphocele, Laparascopic Drainage
Mammoplasty / Breast Augmentation
Mammoplasty / Breast Reduction
Mammoplasty Augmentation
Mammoplasty Reduction

Page 10 of 25
Updated February 2016
 Mastectomy W/T.R.A.M.Flap(Trans Rectus A
Mastopexy
Mole Removal
Mouth Reconstruction
Myo/Fasciocutanous Flap, Lower Extremity
Myo/Fasciocutanous Flap, Trunk
Myo/Fasciocutanous Flap, Upper Extremity
Nasal Tip Reconstruction
Neck Lift
Neck Reconstruction
Nevus Giant Excision
Nipple Reconstruction
Otoplasty (Ear Pinning)
Palatoplasty
Polydactyly Excision -Foot
Polydactyly Excision -Hand
Polysyndactyly
Removal Foreign Body
Rhinoplasty
Rhytidectomy; Forehead
Scar Revision
Skin Graft Full Thickness
Skin Graft Split Thickness
Suture Removal Surg
Syndactyly Release
Syndactyly Repair - Fingers
Syndactyly Repair - Toes
Tendon Graft
Thighplasty
Thumb Pollicization
Tissue Expander Insertion
Tissue Expander Removal
Tissue Expander Removal with Reconstruct
Tissue Expanders Revision
Tongue Tie Release
Tulip Liposuction (Fat Injection)
Z Plasty
ENT SURGERY
Adenoidectomy Primary =/> 12 Yrs
Adenoidectomy Secondary < 12 Yrs
Adenoidectomy Secondary =/> 12 Yrs
Adenotonsillectomy And Myringotomies Wit
Antrostomy
Branchial Cleft Cyst Excision
Bronchoscopy Fiber Optic

Page 11 of 25
Updated February 2016
 Bronchoscopy With Biopsy
Bronchoscopy, Diag
Caldwell Luc
Choanal Atresia Repair
Dermoid Cyst Excision
Ear Lesion Excision
Ears Examination Under Anesthesia
Emergency Tracheostomy
Endoscopy & Biopsy Nasopharynx/Larynx
Endoscopy ENT with Laser
Ethmoidectomy
Frontal Ethmoidectomy
Functional Endoscopic Sinus Surgery

Glomus Tumour Excision + Glomus Juglare

Glossectomy Total
Hard Palate Lesion Excision
Hemi Mandibulectomy with AO Plate

Hemimandibulectomy,Neck Dissection,Myocu
Hemimaxillectomy
Intra-Oral Flap EUA Debridement
Laryngeal Biopsy
Laryngeal Lesion Excision
Laryngectomy
Laryngectomy with Radical Neck Dissectio
Laryngo/Bronchoscopy
Laryngo/Bronchoscopy with Video
Laryngoscopy
Laryngoscopy & Biopsy
Laryngoscopy Foreign Body Removal
Laryngoscopy with Stent Removal
Laryngoscopy with Vocal Cord Injection
Laryngoscopy with Vocal Cord Stripping
Laser Cordectomy
Laser Laryngoscopy
Laser To Oral Cavity
Mandibulectomy
Mastoidectomy
Maxillary Sinus Biopsy
Microlaryngoscopy
Middle Ear Exploration
Myringoplasty
Myringotomy with Bilateral Tubes
Myringotomy with Insertion of Tube

Page 12 of 25
Updated February 2016
 Nasal Bone Reduction
Nasal Fracture Closed Reduction
Nasal Fracture Open Reduction
Nasal Packing Removal
Nasal Packing Surg
Nasal Polypectomy
Nasal Reconstruction
Nasopharyngeal Angiofibroma Excision
Nasopharyngeal Biopsy
Nasopharynx EUA
Neck Dissection - Radical
Neck Dissection - Unillateral
Neck Dissection Bilateral
Nose EUA & Biopsy
Nose Lesion Excision
Oral Cavity Biopsy
Oral Cavity EUA
Ossiculoplasty
Parotidectomy
Parotidectomy, Superficial
Parotidectomy, Total
Pharyngeal Flap
Pre-Auricular Cyst Excision
Radical Neck Dissection Bilateral
Radical Neck Dissection Unilateral
Septoplasty
Septorhinoplasty
SMD - Turbinate Cautery
Stapedectomy
Stapes Revision
Submandibular Gland Excision
Submucosal Resection
Submucous Diathermy
Tongue Exc, Bx, Ant Two-Thirds
Tongue Exc, Bx, Post One-Third
Tongue Exc, Bx, W/ Local Tongue Flap
Tongue Lesion Excision
Tonsillectomy
Tonsillectomy & Adenoidectomy
Tonsillectomy Primary Or Secondary =/> 1
Tonsillectomy, Primary Or Secondary < 12
Tracheal Fistula Closure
Tracheal Stenosis Resection with Primary
Tracheal Stoma Reconstruction
Tracheocutaneous Fistula Closure

Page 13 of 25
Updated February 2016
 Tracheostomy
Tracheostomy Tube Change
Tracheostomy, Emergency, Transtracheal
Tracheostomy, Planned, Younger Than Two
Turbinectomy
Tympanomastoidectomy
Tympanoplasty
Tympanotomy / Myringotomy
Uvulectomy
Uvulo-Pharyngo-Palatoplasty
Vocal Cord Nodule Excision
Vocal Cords Excision
OPHTHALMOLOGY
Blepharoplasty Lower Eyelid
Blepharoplasty Upper Eyelid
Browplasty
Exenteration W/ Medial Forehead Flap
Exenteration W/ Split Skin Graft
Exenteration W/ Temporalis Forehead Flap
Exenteration, Orbital Content
Eyelid large swelling, excision of
Eyelid small swelling, excision of
Eyelids Reconstruction W/ Skin Graft fro
Glaucoma Surgery
Lid Canalicular Repair W/ Silastic Intub
Lid laceration repair(complex case)
Lid laceration repair(simple case)
Medial Canthal Reconstruction with Skin
Orbital swelling removal combined w/ ENT
Pterygium Excision & Conjunctival Transp
Secondary IOL implant
Vitrectomy
UROLOGY
Bladder Irrigation With Clot Evacuation
Bladder Neck Contracture Incision
Cloacal Exstrophy Repair - One Stage Rec
Cystectomy
Cystectomy - Radical
Cystectomy Complete
Cystectomy; Partial
Cystolithotomy
Cystolithotripsy
Cystoplasty
Cystoplasty Augmentation
Cysto-Prostatectomy - Radical

Page 14 of 25
Updated February 2016
 Cystoscopy
Cystoscopy and Biopsy
Cystoscopy and JJ Stent Removal
Cystoscopy Fulguration
Cystoscopy Laser Stone Fragmentation
Cystoscopy Optical Urethrotomy
Cystoscopy Stent Exchange
Cystoscopy Stent Insertion
Cystoscopy Suprapubic Catheter Insertion
Cystoscopy with Botox Injection
Cystoscopy with Deflux Injection
Cystoscopy with Laser Urethrotomy
Cystoscopy-Foreign Body Removal
Cystoscopy-Hydro distension
Cystoscopy-Memocath Exhange
Cystoscopy-Memocath Removal
Cystoscopy-Urethral Dilatation
Hydrocelectomy
Hypospadias Repair
Ileo Conduit
Kidney Biopsy Open
Kidney Biopsy Percutaneous
LAPAROSCOPIC ADRENALECTOMY
Meatoplasty
Meatotomy-Ureter
Meatotomy-Urethra
Micro-TESE
Nephrectomy
Nephrectomy - Laparoscopic
Nephrectomy - Partial Laparascopic
Nephrectomy - Partial Open
Nephrectomy - Radical
Nephrostomy Percutaneous
Orchiectomy Bilaterial
Orchiectomy Unilateral
Orchiopexy - Single
Orchiopexy Bilateral
Orchiopexy Laparoscopic
Pelvic Lymphadenectomy Laparoscopic
Penile Biopsy
Penile Implant Removal
Penile Prosthesis Change
Penile Prosthesis Insertion, Inflat,Pmp,
Percutaneous Nephro-Lithotripsy (PCNL)
Prostate Biopsy

Page 15 of 25
Updated February 2016
 Prostatectomy
Prostatectomy - Laser
Prostatectomy - Radical
Pyelolithotomy
Pyeloplasty
Radical Orchidectomy
Renal Exploration
Resection And Anastomosis Of Ureter
Scrotal Exploration
Spermatocelectomy
Sphincterotomy Transurethal
Stone Manipulation Ureteric
Suprapubic Catheterization
Suprapubic Prostatectomy
TESA-Testicular Sperm Aspiration
Testicle Reduction Of Torsion
Testicular Biopsy Surg
Testicular Prosthesis Implant
Transplant Nephrectomy
TRANSURETHRAL RESECTION OF BLADDER
Transurethral Resection Of Prostate
Transurethral Vaporization
Ureteric Catheterization
Ureteric Exploration
Ureteric Reimplantation
Ureteric Stone Removal
Ureterolithotomy
Ureteroscopy
Ureteroscopy with Biopsy
Ureteroscopy-Laser Stone Fragmentation
Urethral Biopsy
Urethral Fistula Repair
Urethral Valve Fulguration
Urethroplasty - Perineal
Urostomy
Varicocelectomy-Bilateral
Varicocelectomy-Single
Vasectomy
Vesicolithotomy Open
Vesicostomy
Vesico-Vaginal Fistula Repair
OBGYNE SURGERY
Anorectal EUA
Anterior & Posterior Repair
Anterior Repair

Page 16 of 25
Updated February 2016
 Bipartite Leforte III
Cervical Biopsy
Cervical Cerclage
Cervical Polypectomy
Cervical Stump, Abdominal, Removal
Cervical Stump,Vaginal, Removal
Cesarean Section
Colposcopy Of Cervix And Vagina, Bx Cerv
Dilatation and Curettage
Ectopic Pregnancy Removal Laparoscopic
Hysterectomy after Cesarean Section
Hysterectomy Radical Node Dissection
Hysterectomy Subtotal
Hysterectomy Total Abdominal
Hysterectomy Total Abdominal & Bilateral
Hysterectomy Vaginal
Hysterectomy Vaginal and A & P Repair
Hysteroscopy Diagnostic
Insertion of Intrauterine Device
Laparoscopic Myomectomy
Laparoscopy
Laparoscopy Diagnostic
Laparoscopy Dye Test
Laparotomy for Ectopic Pregnancy
Laparotomy Staging
Laparotomy with Multiple Biopsies
Laser Conization Cervix
Laser Tissue Excision
Laser Vaporization
Lymphadenectomy Pelvic&Para-Aortic Ltd F
Mini- Laparoctomy Tubal Ligation
Myomectomy Fibroid Tum Abdominal Approac
Myomectomy, Laparascopic - 1-4 Myomas
Myomectomy, Laparascopic - 5 Or More Myo
Oopherectomy - Laparoscopic
Oophorectomy - Open
Ovarian Biopsy
Ovarian Biopsy Laparoscopic
Ovarian Cystectomy
Ovarian Cystectomy - Laparoscopic
Ovarian Tumor Resection
Pelvic Exenteration
Pelvic Floor Repair
Posterior Repair
Recto-Vaginal Fistula Repair

Page 17 of 25
Updated February 2016
 Removal Of Intrauterine Device
Removal Of Intrauterine Device
Salpingectomy
Salpingo-Oopherectomy
Sigmoidoscopy with Biopsy
Suction Currettage Of Uterus
Trachelorrhaphy/Trachelectomy, Plastic R
Tubal Ligation After A Cesarean Section
Tubal Ligation Laparoscopic
Tubal Ligation-Open
Urethro-Vaginal Fistula Repair
Uterine Endometrial Thermal Balloon Abla
Uterine Endometrial Thermal Balloon Abla
Uterine Suspension
Vaginal Biopsy
Vaginal Cyst Excision
Vaginal Hysterectomy with BSO Laparoscop
Vaginoscopy
Vulval Biopsy
Vulvectomy
Vulvectomy Radical
ORTHO SURGERY
Ankle Fusion
Arthroscopy Diagnostic
Arthroscopy Operative

Cementless, Total Hip Replacment (Unilat)

Elbow Arthroscopy Diagnostic
Elbow Arthrotomy
Elbow Contracture Release
Elbow Open Reduction Internal Fixation
Femur I/M Nailing
Femur I/M Nailing Adjustment
Femur Osteotomy
Foot Open Reduction Internal Fixation
Foot Reconstruction
Hip Arthroplasty Bilateral Total
Hip Arthroplasty Total
Hip Arthroplasty Total Revision
Hip ArthroplastyTtl Rev Femur
Hip ArthroplastyTtl Rev Femur Acetabulum
Hip Open Reduction & Pelvic Osteotomy
Hip Open Reduction Internal Fixation
Humerus Intramedullary Nailing

Page 18 of 25
Updated February 2016
 Humerus Open Reduction Internal Fixation
Knee Arthroplasty Bilateral Total
Knee Arthroplasty Total
Knee Arthroplasty Total Revision
Knee Arthroscopy Diagnostic
Knee Arthroscopy with Meniscal Repair
Knee Arthroscopy with Meniscal Shaving
Osteotomy
Osteotomy and Bone Graft
Pelvic Osteotomy Steel Triple
Pelvis Open Reduction W/Internal Fixatio
Pelvis Osteotomy
Shoulder Acromioplasty
Shoulder Arthroplasty Total
Shoulder Arthroscopy Diagnostic
Shoulder Arthroscopy with Bankart Repair
Shoulder Arthroscopy with Rotator Cuff Repair
Shoulder Capsulotomy
Shoulder Contracture Release
Shoulder Open Reduction Internal Fixatio
Shoulder, Dislocation, Orif
Soft Tissue Release Limbs, Bil, Hips, Kn
Spinal Exploration and Biopsy
Spinal Fixation Internal
Spinal Fusion Ant W/W0 Cast 4 To 7 Segme
Spinal Fusion In Situ
Spinal Fusion Post, Thoracic 1 Level
Spinal Instrumentation, Ant, 4-7 Segment
Spinal Instrumentation, Post, 7-12 Segme
Spinal Release - Anterior
Spine Post Segmental Instrumentation Rem
TAL (Tendo-Achilles Lengthening)
Tendon Repair
Tibia Intra Medullary Nailing
Tibia Open Reduction Internal Fixation
Tibial Osteotomy
Total Elbow Replacement/Arthroplasty
MAXFAX
Dental Restorations & Extractions
Extra-Oral Osteotomies
Incision&Drainage Abscess Complicated/Multiple
Leforte 3 - Orbital Osteotomies
Mandible A/O Plating
Mandible Open Reduction

Page 19 of 25
Updated February 2016
 Mandibular Biopsy
Mandibular Bone Graft
Mandibular Tumor Removal
Mandibulotomy
Maxilla Open Reduction
Maxilla-Cleft Palate Bone Graft
Maxillectomy W/Orbital Exenteration
Orbital Repositioning W/Bone Grafts Icra&Xtrc
Rcnstj Mandible/Maxl Endosteal Implant Complete
Reconstruction Orbit W/Osteotomies&Bone Grafts
Sinusotomy Maxillary Antrotomy Intranasal
Temporal-Mandibular Arthroscopy
NEUROSURGERY
A-V Malformation Resection
Burr Hole - Drainage Of Brain Abcess
CARPAL TUNNEL RELEASE
Cerv Laminectomy Cord Decomp, 1-2 Segmen
Cervical Anterior Discectomy And Fusion
Cervical Anterior Discectomy And Fusion
Cervical Laminoplasty
Cranial-Cervical Decompression & Fusion
Craniotomy - Aneurysm Clipping, Vertebro
Craniotomy - Arterio-Venous Malformation
Craniotomy - Cerebellum Tumour Removal
Craniotomy - Cerebro Spinal Fluid Leak W
Craniotomy - Clivus Tumour Removal
Craniotomy - Cortical Resection for Epil
Craniotomy - CP Angle Tumor Removal
Craniotomy - CSF Leak Repair
Craniotomy - CSF Leak Repair With Facial
Craniotomy - Depressed Skull Fracture El
Craniotomy - Ethmoid Sinus Tumour Remova
Craniotomy - Evacuation Hematoma Parench
Craniotomy Evacuation Hematoma Subdural
Craniotomy - Evacuation Hematoma, Epidur
Craniotomy - Frontal Tumor
Craniotomy - Hemispherectomy For Epileps
Craniotomy - Lateral Ventricle Tumour Re
Craniotomy - Lobectomy
Craniotomy - Lobectomy Temporal for Epil
Craniotomy - Occipital Tumour Excision
Craniotomy - Orbital Tumour Removal
Craniotomy - Parietal Tumour
Craniotomy - Petroclival Tumour Removal
Craniotomy - Pineal Region Tumour Remova
Craniotomy - Posterior Fossa Tumour Remo

Page 20 of 25
Updated February 2016
 Craniotomy - Redo Hematoma Evacuation/Re
Craniotomy - Suboccipital
Craniotomy - Suprasellar Tumour Removal
Craniotomy - Supratentorial Extra-Axial
Craniotomy - Supratentorial Intra-Axial
Craniotomy - Temporal Tumour Removal
Craniotomy - Tumor Excision
Endoscopic Exploration and Biopsy
EVD Insertion and VP Shunt Removal
External Ventricular Drain Removal
Laminectomy Excision Spinal Tumour
Laminectomy for Spinal Cord Compression
Laminectomy Redo
Lumbar Drain Insertion
Lumbar Fusion with Instrumentation
Lumbar Laminectomy for Bony Decompressio
Lumbar Laminectomy for Tumour Removal
MUSCLE BIOPSY
Myelomeningocele Repair
Myelomeningocele Repair and Shunt Insert
Occipital-Cervical Fusion
Omaya Reservoir Insertion
Omaya Reservoir Removal
Posterior Cervical Fusion with Instrumen
Scalp Debridement
Skull Tumour Excision and Cranioplasty
Subdural Shunt Insertion
Sub-Occipital Decompression C1-C2
Thoracic Discectomy - Thoracotomy Approa
Thoracic Discectomy and Fusion - Thoraco
Thoracic Laminectomy Exc Tum Extradural
Thoracic Laminectomy Exc Tum Intradural
Thoracic-Lumbar Fusion with Instrumentat
Transphenoidal Repair Of Sinus for C.S.F
Transphenoidal Resection Of Pituitary Tu
Vagal Nerve Stimulation
Vector Vision Navigation
Ventriculo-Peritoneal Shunt Insertion an
Ventriculo-Peritoneal Shunt Insertion wi
Ventriculo-Peritoneal Shunt Removal
CARDIAC SURGERY
ALCAPA REPAIR By Ligation
Aneurysmectomy
Aortic Coarctation Repair
Aortic Root Replacement

Page 21 of 25
Updated February 2016
 Aortic Valve Repair-Replacement
Aortic Valve Replacement
Aortic Valve Replacement With Prosthetic
Ascending Aorta Graft, Bentall
Atrial Septal Defect Repair
Atrial Septectomy
A-V Canal Repair
Banding Of Pulmonary Artery
Bidirectional Glenn Procedure
Blalock-Taussig Shunt
CABG (Coronary Artery Bypass Graft)
Complete Atrioventricular Canal Repair W
Coronary Artery Bypass, Vein Only; 2 Cor
Coronary Artery Bypass, Vein Only; 3 Cor
Coronary Artery Bypass, Vein Only; 4 Cor
Coronary Artery Bypass, Vein Only; 5 Cor
Coronary Artery Bypass, Vein Only; Singl
Coronary Endarterectomy
Damus Kaye Procedure
Descending Aortic Aneurysm Repair
Diaphragmatic Plication
Double Aortic Arch Repair
Drainage Pericardial Effusion
Drainage Pleural Effusion
ECMO - Weaning
ECMO Insertion
Excision Of Coarctation Of Aorta
Fenestration Fontan Circulation
Fontan Procedure
Glenn Shunt
Hypoplastic/Interrupted Aortic Arch Repa
Incomplete Or Partial AVC Repair
Infundibular Muscle Resection
Intra Aortic Balloon Pump Insertion
Kawashima Procedure
Konno Procedure
Left Ventricular Outflow Tract Obstructi
Median Sternotomy
Mitral Valve Annuloplasty
Mitral Valve Commissurotomy, Open
Mitral Valve Repair
Mitral Valve Repair/Replacement
Mitral Valve Replacement
Modified Fontan Procedure
Modified Maze Procedure

Page 22 of 25
Updated February 2016
 Multiple Valve Replacement
Multiple VSD Closure & Pulmonary Artery
Norwood Procedure
Pacemaker Generator Change
Pacemaker Lead Revision
Pacemaker Revision
Partial Anomalous Pulmonary Drainage Rep
Patent Ductus Arteriosis Ligation
Pericardial Window
Pericardiectomy
Permanent Pacemaker Insertion
Permanent Pacemaker Insertion - Pediatri
Pneumonectomy
Pulmonary Artery Banding
Pulmonary Artery To Left Ventricle Condu
Pulmonary HomoGraft
Pulmonary Stenosis Repair
Pulmonary Valvuloplasty
Radio Frequency Ablation
Rastelli Procedure
Redo Sternotomy
Release Of Tamponade
Relief Right Ventricular Outflow Tract O
Repair of ALCAPA By Translocation to Aor
Repair Of Anomalous Pulmonary Venous Ret
Repair Of Atrial Septal Defect And Ventr
Repair of d TGA jatene type
Repair Of d TGA Jatene Type With Closure
Repair Of d TGA Jatene Type With Removal
Repair Of LVOT By Patch Enlargement Of T
Repair Of Thoracoabdominal Aortic Aneury
Replacement, Mitral Valve, With Cardiopu
Right Ventricular Outflow Tract Reconstr
Ross Procedure
RV To PA Connection
Secundum Atrial Septal Defect Repair
Shunt; Central, With Prosthetic Graft
Sternal Debridement
Sternal Exploration
Sternal Exploration and Hemostasis
Sternal Rewiring
Sternal Wire Removal
Sternotomy
Subaortic Membrane Resection
Tetralogy Of Fallot Repair With Transann

Page 23 of 25
Updated February 2016
 Tetralogy Of Fallot Total Correction
Thoraco Abdominal Aortic Aneurysm Repair
Total Anomalous Pulmonary Drainage Repai
Trans Annular Patch With Pericardium
Transesophageal Echo Cardiogram
Tricuspid Valve Annuloplasty
Tricuspid Valve Repair
Truncus Arteriosus Repair
Unifocalization Pulmonary Artery
Ventricular Septal Defect Closure
VSD Repair Adult
VASCULAR
Abdominal Aorti Aneurysmectomy
Aneurysmectomy
Aortic Dissection Repair
Aorto Hepatic Bypass
Aorto Iliac Bypass Graft
Artery Reconstruction
A-V Fistula Creation
A-V Fistula Creation With Gortex Graft
A-V Fistula Declotting
Axillary Femoral Bypass Other Than Vein
Axillary Femoral Bypass Vein Graft
Axillo Femoral Bypass Graft
Axillo-Axillo Bypass
Balloon Angioplasty Femoral
Brachial Vein Resection
Closure Of Enterovesical Fistula
Closure Of Rectourethral Fistula
Closure Of Rectovesical Fistula
Embol Or Thrombec Fempop Aortoiliac, Leg
Embol/Thrombec Ax Brachial Innom Subclav
Embol/Thrombec Carot/Subclav/Innom Art,
Embol/Thrombec Popliteal Tibio Peroneal,
Embol/Thrombec Radial Ulnar, Arm Inc
Embolectomy / Thrombectomy
Endarterectomy (w/Patch Graft)
Endarterectomy Carotid
EndoVascular Stenting of Aortic Aneurysm
Excision of Infected Vascular Graft
Fem Fem Bypass Graft
Fem Pop Bypass Graft
Fem Tib Bypass Graft
Femoral Aneurysm Repair
Femoral Artery Endarterectomy

Page 24 of 25
Updated February 2016
 Femoral Artery Exploration
Formation, Shunt, Peritoneovascular
Iliac Aneurysm Repair
Mesenteric Aneurysm Repair/Resection
Mid Tarsal Amputation
Popliteal Tibial Bypass
Profundaplasty
Pseudoaneurysm Repair
Renal Artery Endarterectomy
Repair - Blood Vessel
Saphenous Vein Graft-Resection
Shunt Schribner
Spleno-Renal Shunt, Distal
Spleno-Renal Shunt, Proximal
Subclavian Carotid Bypass Or Excision Ca
Subclavian-Axillary Bypass
Thrombec Subclavian Vein Neck Inc
Thrombec, Vena Cava/Iliac Vein, Abd Inc
Thrombec,Axillary/Subclavian, Arm Inc
Thrombec,Vena Cava/Iliac Vein/Fem-Pop, L
Thrombec,Vena Cava/Iliac/Fempop Vein, Ab
Varicose Vein Ligation And Stripping
Vena Cava Plication
TRANSPLANT SURGERY
Kidney Harvest - Cadaver
Kidney Transplant Cadaveric
Kidney Transplant Recipient (From Living
Nephrectomy
Nephrectomy - Living Donor Laparoscopic
Nephrectomy - Open
Nephrectomy-Living Related Donor
Quinton Catheter Insertion
Quinton Catheter Removal
Liver Harvest - Cadaver
Liver Transplant Cadaveric
Liver Transplant Recipient (From Living)

Signature of the Applicant: Date:

Page 25 of 25
Updated February 2016