Service: Rural Surgery/Endoscopy
Supervision: PGY-3 → Attending
All management decisions will be discussed with the faculty.
Hours are to be logged into New Innovations on a weekly basis and will be reviewed weekly by the Program Director for ACGME violations and reviewed weekly for delinquencies by the Program Coordinator. Over a four week period; you will not average more than 80 hours a work week, you will have one day in seven free of clinical duty, in-house call will be no more frequent than one in three nights, you should receive 10 hours free between all duty periods and after in-house call and you will not be on duty for more than 24 consecutive hours with an additional 4 hours for transitional duties only. If you are assigned more hours than mentioned heretofore or have patient care duties that are extending you beyond these limits, it is your responsibility to notify your supervising resident or faculty so arrangements can be made to relieve you.
- Schwartz's Principles of Surgery
- Cameron’s Current Surgical Therapy
- •SCORE curriculum modules
•Wednesday Resident Educational Curriculum
Competency Based Performance Objectives:
Goal: Through the acquired skills and knowledge of general surgery principles the resident can demonstrate the ability to manage disease and injury of the general surgery patient amenable to surgical intervention. The resident will be also able to use acquired skills and knowledge to demonstrate the ability to use a variety of endoscopic instruments in the screening, diagnosis, and treatment of various diseases.
Objective: The resident will be able to:
1.Perform, record, and report complete patient evaluation and assessment.
2.Evaluate emergency department or clinic patients who present with problems referable to the GI tract.
3.Evaluate and diagnose the acute abdomen
4.Evaluate and manage nutritional needs (enteral and parenteral) of surgical patients until normal GI function returns.
5.Serve as assistant to the primary surgeon during operations of the esophagus, stomach, small intestine, colon, and anorectum
6.Perform surgical procedures such as:
- Meckel's diverticulectomy
- Anal fissurectomy and fistulectomy
- Incision and drainage of perirectal abscesses
- Colectomy of all types
7.Accept responsibility for the post-operative management of:
•Abdominal incisions (simple and complicated)
8.Provide follow-up care to the surgical patient in the outpatient clinic or surgical office
9.Assist with hernia repairs in the groin or umbilicus, demonstrating a basic understanding of the anatomy and surgical repair.
10.Interpret the following in coordination with attending radiologists and staff; upper GI series, barium enema, and abdominal ultrasound and CT scans.
11.Evaluate and institute management of abdominal wound problems, including; infection, evisceration, fasciitis, and dehiscence.
12.Coordinate pre- and post-operative care for the patient with the acute abdomen
13.Institute drainage for abdominal wall fistula and protection of surrounding structures, especially skin
14.Assist in closure of abdominal incisions; exhibit competency in suture technique
15.Perform history and physical examination specifically focused on liver and biliary system
16.Select and interpret appropriate laboratory and radiologic evaluations in the work-up of the jaundiced
17.Perform uncomplicated hepatobiliary surgery under supervision, such as cholecystectomy, both laparoscopic and open, with operative cholangiography.
18.Assist in more advanced hepatobiliary operations.
19.Perform history and physical examination focused on the pancreas.
20.Select and interpret appropriate laboratory and radiologic examinations in evaluation of pancreatic disease
21.Assist in management of patient with acute pancreatitis.
22.Assist in perioperative management of patients undergoing pancreatic surgery.
23.Perform minor pancreatic procedures under supervision such as external drainage of pseudocyst or internal drainage via cystgastrostomy.
In addition the resident will be able to:
1.Observe and monitor appropriate anesthetic techniques used to sedate the patient.
2.Prepare patients for various routine and elective endoscopic procedures.
3.Under supervision, demonstrate proper cleansing and sterilization of endoscopic instruments.
4.Distinguish between the indications for use and the preparation methods of biopsy, smears (cytologic), culture, and cytology.
5.Performance (under supervision) of diagnostic:
6.Observe, recognize, and interpret normal and abnormal findings by the use of the endoscopic procedures listed abov
7.Be familiar with uncomplicated therapeutic endoscopic maneuvers such as:
•Excision of pedunculated colonic polyps
•Performance of percutaneous endoscopic gastrostomy (PEG)
•Sclerotherapy and banding of esophageal varices
•Electrocoagulation of upper and lower bleeding lesions
•Removal of foreign bodies
Competency Based Knowledge Objectives:
Goal: Demonstrate an understanding of the anatomy, physiology, and pathophysiology of the alimentary tract and digestive system and be able to demonstrate the ability to manage those problems that are amenable to surgical intervention. Demonstrate knowledge of anatomy, physiology and pathophysiology of diseases identified by endoscopy
Objectives: The resident will be able to:
1.Define the basic scientific principles of the alimentary tract and digestive system diseases to include:
•Anatomy, embryology, and biochemistry of the gastrointestinal (GI) tract
•Embryologic development of primitive foregut and hindgut and its appendages, including normal rotation and fixation
•Histology of alimentary tract, including differentiation of cell types
•Anatomy of alimentary tract from esophagus to anus with emphasis on systemic blood supply, portal venous drainage, neural-endocrine axis, and lymphatic drainage
•Abdominal anatomy, explaining its relationship to lower thorax, retroperitoneum, and pelvic floor
•Mucosal transport, including mechanism of absorption of nutrients and water
•Sites of electrolyte and acid-base regulation
•Physiology of deglutition and phases of digestion
•Neuroendocrine control of GI secretion and motility
•Regional controls of mucosal secretion and absorption (neural and hormonal)
•Neuromuscular control of defecation
•Digestion of sugars, fats, proteins, vitamins, and cofactors
•Rates of mucosal turnover
•Nutritional needs of surgical patients
•Normal secretory rates for the stomach, small bowel, biliary tree, and pancreas
•Normal bacterial flora and their concentrations in the upper and lower GI tract
•Immunologic properties of the GI tract and how this barrier is affected by: trauma, sepsis, burns, malnutrition, and chronic disease
•Principles of intestinal healing
•Normal GI tissue integrity and strength and how this relates to healing of anastomoses
•Effects of suturing and stapling techniques of the gut
2.Explain and give examples for the following aspects of gastrointestinal diseases:
•Infections inside and outside the GI tract from esophagus to anus, including the peritoneum
•Embryologic abnormalities of the GI tract, including:
•Congenital and acquired abnormalities of gut motility
•Neoplasia of the GI tract
•Ulceration of the proximal and distal GI tract
•Causes of GI obstruction
•Causes of paralytic ileus
•Causes of GI hemorrhage
•Causes of GI perforation
•Causes of abdominal abscess formation or secondary peritonitis
•Short gut and malabsorptive conditions
•Acute and chronic mesenteric ischemia
•Portal hypertension and venous thrombosis
•Inflammatory bowel diseases
•o. Causes of an acute abdomen
•p. Management of intestinal ostomies
•q. Traumatic injury to abdominal viscera
•r. Ischemic bowel
3.Discuss some of the more common diseases of the esophagus in elderly patients, to include:
•Tumors (benign and malignant)
4.Outline the essential characteristics of routine and highly specialized diagnostic evaluation of the alimentary tract, including:
•Past surgical history
•Radiologic examinations, including:
•Upper GI Series with small bowel follow-through
•Magnetic Resonance Imaging
• Nuclear scans for bleeding or to evaluate for Meckle's diverticulum
•Rigid anoscopy and sigmoidoscopy
•Tests of GI function including:
•Gastric analysis (basal and stimulated)
•Radioisotope clearance studies
2.Technetium HIDA (hepatic 2,6-dimethyliminodiacetic acid) dynamic biliary imaging
•Gastric emptying studies
5.Summarize current medical management and its potential limitations; explain the role of surgical intervention when management fails in the following:
•Peptic ulcer disease
•Upper and lower GI bleeding
•Inflammatory bowel disease
6.Describe the embryological development of the peritoneal cavity and the positioning of the abdominal viscer
7.Familiarity with the anatomy of the abdomen including its viscera and anatomic spaces:
•Foramen of Winslow
•Pouch of Douglas
•Contents of the retroperitoneum
•Major lymph node groups and their contents
8.Surgical outcome is dependent on coexistent diseases. Describe changes in the following organ systems that result from the aging process:
9.Explain absorption and secretory functions of the peritoneal surfaces and the diaphragm
10.Describe the anatomy of the omentum and its role in responding to inflammatory processes.
11.Assess the following signs associated with the acute abdomen and describe their pathophysiology:
12.Specify characteristics of the history, physical examination findings, and mechanism of visceral and somatic pain for the following processes:
13.List possible distinctions in the presentation and examination of the elderly patient with the following causes of acute abdomen:
14.Discuss the differences in the physiologic response to stress in the geriatric patient.
15.Explain the mechanism of referred pain in:
16.Discuss the following causes of paralytic ileus:
•Post-operative electrolyte imbalance
•Extraperitoneal disease (central nervous system, lung)
17.Illustrate use of the following diagnostic studies in the work-up of each process in #12 and #15 above:
•Contrast gastrointestinal (GI) studies
•Computed axial tomography (CAT)
18.When considering the possibility of wound complications:
•What are the risk factors for abdominal wound infection?
•What are the contributing factors for abdominal wound dehiscence and evisceration?
•What are the usual clinical presentations and timing?
•What is the incidence of wound infection in surgeries involving the biliary tree, upper GI tract, and colon?
•List wound complications that are more problematic in the elderly patient.
19.Identify the anatomic locations for the following intra-abdominal abscesses; name disease process(es) associated with each:
•Left subphrenic space
•Right subphrenic space
•Left paracolic gutter
•Right paracolic gutter
20.Differentiate between the conditions favoring percutaneous drainage versus operative drainage for each of the abscesses in #1Describe the safest and most effective approach using each technique
21.Differentiate between the following intestinal fistulas and the organs to which they most often communicate:
•Enteric (including duodenal)
22.Explain the formation of fistulas in each of the following disease processes or factors:
•Operative complications (bowel injury with abscess formation)
•Inflammatory bowel disease
•Foreign body or prosthetic material
23.Explain the role of a fistulogram in the diagnosis of intra-abdominal fistulas and abscesses.
24.List the factors that prevent healing of a fistula
25.Summarize the conditions favoring operative versus non-operative treatment for fistulas listed in #1
26.Describe the anatomy, clinical presentation, and complications of non-operative management for these hernias:
•Direct and indirect inguinal, femoral, and obturator
•Lumbar and Petit
27.Name the hernia types that are most common in elderly patients, and explain how they may become problemati
28.Define a Richter's hernia and describe its clinical presentation.
29.Define a sliding hernia and describe its repair.
30.Differentiate between incarceration and strangulation
31.Differentiate between conventional open and scope-assisted surgery, including:
•Effects of pneumoperitoneum
•Need for team participation
•Differences in patient outcome
32.Discuss the physical limitations imposed on the user participating in minimally invasive surgery, including:
•Surgeon fatigue and diminished proficiency over time
•Visual limitations of scope and monitoring equipment
•Crucial importance of patient position and cannula position for optimum exposure
33.Understand strategies to offset the difficulties suggested in #32 above, including:
•Proper alignment of eye-camera-instrument axes
•Effective use of assistants
•Appropriate use of other advanced technologies such as endoscopic ultrasound
34.Analyze the factors affecting the decision to select a minimally invasive approach (as opposed to an open surgical approach) for a particular clinical problem
35.Explain the concept of the learning curve, and discuss the need for quality control in the education and evaluation of surgical housestaff in developing proficiency in minimally invasive surgery.
36.Explain the mechanics and principles for safe and effective use of the following equipment/procedures
•Cautery (monopolar and bipolar)
•Telescopic direction (straight and angled laparoscope)
•Insulation technique and hazards
•Maintaining visualization of operative field
•Dissecting and knot tying
37.Discuss appropriate anesthetic management for minimally invasive techniques for surgery involving the abdomen, thorax, and joints and soft tissue spaces.
38.Discuss the potential economic impact of increased utilization of operating room time, advanced equipment, and disposable instruments on health care costs.
39.Summarize protocols for appropriate cleaning, sterilization, maintenance, and handling of minimally invasive equipment.
40.Basic Laparoscopic Skills
•Discuss techniques for gaining access to the abdomen, including:
•Open (Hassan cannula)
•Direct visualization trocars
•Discuss indications for and limitations of diagnostic laparoscopy, as well as pros and cons of this diagnostic technique compared with other diagnostic modalities such as CT scan or ultrasoun
•Discuss recognition and management of complications, including major vascular injury, massive Carbon dioxide embolus, or visceral injury.
•List contraindications for laparoscopic surgery, and be able to explain why these conditions are considered relative or absolute contraindications.
41.Laparoscopic Cholecystectomy (LC)
•Discuss the indications and contraindications for laparoscopic cholecystectomy.
•Describe the technical aspects of preparing for and operating on a patient undergoing L
•Identify major considerations for the decisions involved in converting from laparoscopic to open cholecystectomy, including:
•Difficulty identifying anatomy (, common duct)
•Select management options for handling bile duct injuries, including immediate and delayed diagnosis and treatment.
•Specify the indications and technique for percutaneous cholangiography, endoscopic ultrasound, and common bile duct exploration (CBDE), including use of choledochoscopy.
•Discuss management of the patient with common duct stones, including:
•Choice of approach (open common duct exploration, versus laparoscopic CBDE, versus LC followed by/preceded by endoscopic stone extraction)
•Timing of surgery
•Safety and cost-effectiveness of each approach
42.Additional Laparoscopic Procedures
•Describe current theories, including advantages and disadvantages, regarding the use of laparoscopic anti-reflux procedures and myotomies.
•Discuss advantages and limitations of thoracoscopic versus laparoscopic approach for esophagomyotomy.
•Discuss indications and contraindications for addition of partial fundoplication to esophagomyotomy.
•Describe management of paraesophageal hernia.
•Outline the potential benefits and limitations to:
•Pre- and trans- peritoneal groin hernia repairs
•Laparoscopic ventral hernia repair
•Summarize other intra-abdominal laparoscopic procedures currently being performed, including:
43.Describe the anatomy of the liver and biliary system, including commonly found variations.
44.Describe the physiology and function of liver and biliary system to include:
•Function of bile in fat metabolism
45.Explain the formation of bile, its composition, and its function in digestion. Describe the pathophysiology of gallstone formation
46.Correlate bile formation and composition with disease states affecting the biliary system such as gallstone formation and biliary obstruction
47.Discuss the enterohepatic circulation of bile
48.Outline the work-up and differential diagnosis of the jaundiced patient.
49.Identify the most significant determinants of mortality in elderly patients following cholecystectomy.
50.Discuss various types of liver cysts (echinococcal or hydatid, nonparasitic) and the appropriate management of eac
512.Discuss the principal characteristics of and the treatment for the following:
•Metastatic lesions to the liver
•Primary malignancies of liver and biliary tree
•Benign tumors of the liver
52.Summarize the etiologies and management of pyogenic and amebic hepatic abscesses.
53.Explain types of infectious hepatitis (A, B, C) with:
•Modes of transmission
•Time course for serologic conversion
54.Outline the pathophysiology, evaluation, and management of the following:
•Primary biliary cirrhosis
•Secondary biliary cirrhosis
•Benign biliary stricture
•Congenital biliary atresia
55.Describe the anatomy of the pancreas, including regional vascular anatomy.
56.Summarize changes that occur in the anatomy of the pancreas with aging by considering:
•Duodenal C loop
•Head of the pancreas
•Atrophy of pancreas
•Pancreatic ductal anatomy
57.Discuss the physiology of the pancreas, including endocrine and exocrine function and hormonal regulation.
•Non-Beta (pancreatic polypeptide)
58.Explain the pathophysiology of pancreatitis to include:
•Common etiologies such as:
•Post endoscopic retrograde cholangiopancreatography (ERCP)
•Diagnosis, evaluation, and medical management
•Role of peritoneal lavage
•Complications of pancreatitis, such as:
•Adult respiratory distress syndrome (ARDS; Acute lung injury-ALI also used)
•Sterile pancreatic necrosis
•Infected pancreatic necrosis
•Indications for operative management of pancreatitis
•Management of gallstone pancreatitis with timing of surgery
•Methods of prognostic assessment
59.Describe the incidence of these diseases in the elderly patient:
•Acute gallstone pancreatitis
60.Explain the pathophysiology of carcinoma of the pancreas to include:
•Typical history and presentation
•Diagnostic evaluation using:
•Computed axial tomography
•Percutaneous transhepatic cholangiography (PTC)
•Operative versus nonoperative biliary drainage
•Percutaneous versus endoscopic stenting
•Concomitant gastrojejunostomy with operative biliary bypass
61.Discuss presentation, evaluation, and management of pancreatic pseudocysts with attention to:
•Complications of pseudocysts (hemorrhage, infection, rupture)
•Timing of drainage
•Percutaneous versus surgical drainage
•Indications for external versus internal drainage
•Choice of internal drainage procedure
62.Explain the diagnosis and management of pancreatic ascites.
In addition the resident will be able to:
1.Review normal anatomy and physiology of the gastrointestinal tract, airway, mediastinum, and thorax.
2.Demonstrate a working knowledge of the anatomical landmarks in the following organs. Describe and contrast the normal and pathological appearance of the:
•Stomach and duodenum
3.Identify the indications for endoscopy and common pathological conditions outlined below:
•Classes of esophagitis
•Gastric polyps: benign/malignant
•Gastric outlet obstruction
•The post-operative stomach
•Inflammatory conditions (Duodenal Crohns)
•Tumors of the duodenum and ampulla of Vater
•Polyps: benign and malignant; sessile and polypoid
•Tumors: benign and malignant
4.Identify the various anatomical landmarks during endoscopy:
•Papilla of Vater
•Cecum, confluence of tinea coli, and appendiceal orifice
5.Describe the fundamental mechanics and physics of endoscopic equipment and accessories (e., rigid and flexible scopes, multichannel scopes, types of snares, and biopsy forceps).
6.Be familiar with the routine operation of endoscopes and their support systems, including:
•Ability to troubleshoot minor malfunctions
•Knowledge of established procedures for cleaning, sterilization, and routine handling
7.Summarize methodological issues in endoscopy to include:
8.Summarize the use of sedatives (conscious sedation) and analgesics during endoscopic procedures, including:
•Mode of onset
•Principles of monitoring
9.Differentiate between the following therapeutic maneuvers utilizing the endoscope:
•Electrocautery (bipolar, monopolar, heater probe)
10.Analyze the use of endoscopes in the diagnosis and treatment of upper and lower gastrointestinal hemorrhag
11.Assess the complications that may result from flexible endoscopic procedures, including:
•Perforation and the various causes
12.Determine and categorize the essential features of a wide variety of diseases as seen through the endoscopes listed in #8 abov
Interpersonal and Communication Skills:
Goal: Counsel patients and obtain informed consent for general surgery procedures
Objectives: The resident will demonstrate the ability to obtain informed consent, outlining the risks and benefits
Goal: Communicate effectively to discharge patients after surgery.
Objectives: The resident will demonstrate the ability to instruct patients regarding monitoring for general surgery complications.
Goal: Communicate effectively as a member of the healthcare team.
Objectives: The resident will demonstrate the ability to communicate effectively by:
1.Providing appropriate check out when handing patients to another team member
2.Requesting consults from other services with appropriate information
3.Dictating operative reports in a timely fashion
Goal: Maintain patient confidentiality
Objectives: The resident will demonstrate
1.The ability to protect health-related patient information per HIPAA compliance
2.List and be aware of sites in the hospital and clinic where loss of privacy for the patient may occur
Goal: Maintain appropriate professional relationships
Objectives: The resident will demonstrate professional interactions with:
2.Nursing and support staff
6.Patients and their families
Practice-Based Learning and Improvement
Goal: Identify personal and practice improvement strategies
Objective: The resident will demonstrate:
1.Receptiveness to faculty instruction and feedback
2.Ability to use medical information with the ability to access information through traditional and online sources to support their educational experience
Goal: Use medical evidence to evaluate general surgery practices and endoscopic practices
Objective: The resident will demonstrate the ability to:
1.Discuss studies regarding the general surgery procedures and endoscopic procedures
Goal: Provide safe patient care
Objective: The resident will:
1.Attend Crew Resource Management courses as required by the hospital
2.Follow recommended protocols in the OR for patient safety
3.Demonstrate compliance with Medical Center policy for surgical site identification
4.Demonstrate compliance with Medical Center policy for patient identification
1.Serve as PGY-3 on the Rural general surgery/Endoscopy service
2.Appropriate, professional supervision of student teaching in light of educational goals
3.Attend general surgery clinic as assigned
4.Manage OR patients with supervision
5.Assist with consultations to the general surgical service as assigned by the Faculty
6.Round on post surgical service patient's as instructed.
7.Attend educational conferences
8.Complete surgical case logs
9.Dictate in a timely fashion
10.Take night call as assigned
1.Performance feedback will be given to the resident as appropriate for educational events and mid-term progress will be discussed.
2.Global evaluation will be performed by the general surgery attending physicians at the completion of each rotation. Surgical case logs will be evaluated for the appropriate number and breadth of procedures and will be present in the resident's portfolio to be reviewed at the Program Evaluation meeting held twice yearly.
3.At the completion of this rotation, the resident is required to complete a rotation evaluation form assessing the quality of the rotation. The resident should also address the teaching undertaken by the attending physicians on the rotation at the conclusion of this rotation.