Specific Educational Goals and Education

Level: PGY-4

Service: Methodist General

Supervision: PGY-4 → Attending

All management decisions will be discussed with the faculty.

Duty Hours:

Hours are to be logged into GMEOne 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 30 consecutive hours. 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.

Educational Activities:

  1. Recommended Reading
    1. Schwartz's Principles of Surgery
    2. SCORE curriculum modules
  2. Conferences
    1. Wednesday Resident Educational Curriculum

Surgical Oncology

Competency Based Performance Objectives:

Patient Care:

Goal: Demonstrate the ability to formulate and implement a diagnostic and treatment plan for diseases of the abdomen and pelvis that are amenable to surgical intervention and use acquired skills and knowledge to demonstrate proficiency in diagnosis, preparation, operative treatment, and total management of the cancer patient, including long-term follow-up care.

Objectives: The resident will be able to:

  1. Perform, record, and report complete patient evaluation and assessment.
  2. Perform initial consultation for inpatients with problems of the GI tract; develop differential diagnosis and initiate treatment plan.
  3. Evaluate and diagnose the acute abdomen.
  4. Select and interpret appropriate pre- and post-operative diagnostic studies.
  5. Assist with hernia repairs in the groin or umbilicus, demonstrating a basic understanding of the anatomy and surgical repair.
  6. Evaluate and institute management of abdominal wound problems such as; infection, evisceration, fasciitis, and dehiscence.
  7. Coordinate pre- and post-operative care for the patient with the acute abdomen.
  8. Institute drainage for abdominal wall fistula and protection of surrounding structures, especially skin.
  9. Open and close abdominal incisions of all varieties.
  10. Perform laparotomy for acute abdomen, demonstrating a systematic approach for determination of the etiology of the process via a systematic abdominal exploration and appropriate measures for its management (, acute appendicitis, small bowel obstruction, perforated peptic ulcer [the 5th year resident should be able to guide the more junior resident through the case]).
  11. Perform more complex laparotomies involving diffuse peritonitis in the septic patient (, a gangrenous or severely inflamed gallbladder or perforated diverticulitis requiring resection).
  12. List equipment needed for complex procedures, select instruments needed, set up room (including patient position) and equipment, troubleshoot equipment when malfunction occurs.
  13. Demonstrate facility in endoscopic knot-tying, stapling, and suturing, either in a box-trainer, an animal model, or the operating room.
  14. Perform, under appropriate supervision, GI operations, including:
    1. Vagotomy
    2. Pyloroplasty
    3. Gastric resection and reconstructive techniques
    4. Small bowel resection with anastomosis
    5. Drainage of pancreatic cysts
    6. Drainage of abdominal and retroperitoneal abscesses
    7. Lysis of adhesions
    8. Repair of enterotomies
    9. Colon resection
    10. Creation of ostomies
  15. Participate in increasingly complex procedures under supervision, such as:
    1. Laparoscopic hiatal hernia repair
    2. Laparoscopic surgery for achalasia
    3. Laparoscopic splenectomy
    4. Laparoscopic inguinal hernia repair
  16. Perform appropriate reoperative laparotomy for a variety of gastrointestinal problems.
  17. Supervise post-operative care of GI and digestive tract surgical patients
  18. Independently evaluate a new breast patient through history and physical examination, ordering appropriate and cost-effective tests such as mammogram, ultrasound, or fine-needle aspiration (FNA).
  19. Formulate a diagnostic work-up and treatment plan for most common breast problems, including the common types of breast carcinomas.
  20. Consult and interact with other members of the professional cancer team in explaining options to the newly diagnosed breast cancer patient.
  21. Perform, under direct supervision, more advanced procedures on the breast such as:
    1. Radical mastectomy
    2. Modified mastectomy
    3. Lumpectomy and axillary dissection
    4. Sentinel lymph node biopsy
    5. Excision of lactiferous duct fistula
    6. Needle-localized breast biopsy
    7. Simple mastectomy for gynecomastia
  22. Acquire basic experience with breast reconstruction and cosmetic surgical techniques.
  23. Evaluate the physical status of patients who report for evaluation of augmentation and reduction mammoplasties.
  24. Prescribe various types of adjuvant therapy such as:
    1. Chemotherapy
    2. Hormonal therapy
    3. Radiation therapy
    4. Biologic response modifiers
  25. Manage unusual breast diseases such as:
    1. Inflammatory carcinoma
    2. Paget's Disease
    3. Lactiferous duct fistula
    4. Mondor's Disease
    5. Bilateral breast cancer
    6. Male breast cancer
    7. Cystosarcoma phyllodes
  26. Outline an appropriate follow-up schedule for patients who have undergone:
    1. Treatment of breast cancer with curative intent
    2. Treatment of DCIS
    3. Biopsy which revealed fribroadenoma, benign epithelial hyperplasia, or fibrocystic disease with atypia

General Surgery

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.

Objective: The resident will be able to:

  1. Perform initial consultation for inpatients with problems of the GI tract; develop differential diagnosis and initiate treatment plan.
  2. Select and interpret appropriate pre- and post-operative diagnostic studies.
  3. Assist junior residents in the diagnosis, surgical management, and follow-up care of patients with diseases of the alimentary tract and digestive system.
  4. Perform, under appropriate supervision, GI operations, including:
    1. Vagotomy
    2. Pyloroplasty
    3. Gastric resection and reconstructive techniques
    4. Small bowel resection with anastomosis
    5. Drainage of pancreatic cysts
    6. Drainage of abdominal and retroperitoneal abscesses
    7. Lysis of adhesions
    8. h. Repair of enterotomies
    9. i. Colon resection
    10. j. Creation of ostomies
  5. Develop diagnostic and therapeutic endoscopy skills such as:
    1. Diagnostic esophagogastroduodenoscopy
    2. Percutaneous endoscopic gastroscopy
    3. Dilation of intestinal strictures
    4. Diagnostic colonoscopy
  6. Coordinate intervention of multiple specialties that may be involved in management of complex GI problems such as:
    1. Variceal hemorrhage
    2. Biliary obstruction
    3. Inflammatory bowel disease
    4. Chronic abdominal pain
    5. Chronic constipation
    6. Localized and advanced malignancies
  7. Perform appropriate reoperative laparotomy for a variety of gastrointestinal problems.
  8. Supervise post-operative care of GI and digestive tract surgical patients.
  9. Open and close abdominal incisions of all varieties.
  10. Treat wound complications such as infections and evisceration. Use retention sutures appropriately.
  11. Assist with thoracoabdominal and retroperitoneal exposures for access to kidneys, pancreas, aorta, iliac arteries.
  12. Perform laparotomy for acute abdomen, demonstrating a systematic approach for determination of the etiology of the process via a systematic abdominal exploration and appropriate measures for its management (, acute appendicitis, small bowel obstruction, perforated peptic ulcer [the 5th year resident should be able to guide the more junior resident through the case]).
  13. Perform more complex laparotomies involving diffuse peritonitis in the septic patient (, a gangrenous or severely inflamed gallbladder or perforated diverticulitis requiring resection).
  14. Coach a junior resident through the repair of simple hernia (indirect inguinal or umbilical). (The chief resident should be able to perform repair of any of the hernias mentioned earlier in the text.)
  15. Provide appropriate surgical drainage for any intra-abdominal abscess.
  16. List equipment needed for complex procedures, select instruments needed, set up room (including patient position) and equipment, troubleshoot equipment when malfunction occurs.
  17. Demonstrate facility in endoscopic knot-tying, stapling, and suturing, either in a box-trainer, an animal model, or the operating room.
  18. Participate in increasingly complex procedures under supervision, such as:
    1. Laparoscopic hiatal hernia repair
    2. Laparoscopic surgery for achalasia
    3. Laparoscopic splenectomy
    4. Laparoscopic inguinal hernia repair
  19. Demonstrate understanding of uses of endoscopic ultrasound and other intraoperative adjuncts.
  20. Perform detailed evaluation of patients with liver and biliary disease and plan appropriate management and operative approach.
  21. Perform, under supervision, increasingly complex hepatobiliary surgery:
    1. Laparoscopic cholecystectomy with cholangiography
    2. Common bile duct exploration with choledochoscopy
    3. Biliary drainage procedures, such as:
      1. Choledochoduodenostomy
      2. Roux-en-Y and loop choledochojejunostomy
      3. Cholecystojejunostomy
      4. Sphincteroplasty
    4. Drainage of liver abscess
    5. Peritoneovenous shunts
    6. Complicated cholecystectomy--acute, gangrenous
    7. Simple liver resection
  22. Coordinate overall care of patients with hepatobiliary disease including:
    1. Initial evaluation
    2. Appropriate diagnostic studies
    3. Indicated consultations
    4. Operative management
  23. Perform detailed evaluation of patients with pancreatic disease and plan appropriate medical or surgical management.
  24. Perform increasingly complex pancreatic surgery such as:
    1. Internal drainage of pseudocysts with Roux-en-Y cystojejunostomy
    2. Longitudinal pancreaticojejunostomy (Puestow Procedure)
    3. Distal pancreatectomy
    4. Biliary bypass for carcinoma
  25. Coordinate overall care of patients with complex pancreatic disease, including initial evaluation, appropriate diagnostic studies, and operative management of:
    1. Pancreatic abscess and infected pancreatic necrosis
    2. Cystadenomas
    3. Periampullary carcinoma
    4. Endocrine tumors of the pancreas
  26. Perform complex pancreatic procedures such as:
    1. Whipple resection
    2. Total or subtotal pancreatectomy
    3. Operative debridement and drainage of pancreatic abscess or infected necrosis
    4. Surgical exploration for islet cell tumors of the pancreas
    5. Local resection for ampullary tumors
  27. Serve as an effective surgical team leader.

Minimally Invasive Surgery

Goal: Demonstrate an understanding of the applications and risks of minimal access surgery (MAS). Demonstrate an understanding of the technical and physiologic principles of minimal access surgical techniques. Develop specific technical skills and demonstrate proficiency in performance of basic laparoscopy, laparoscopic cholecystectomy, and other minimal access procedures. Synthesize the principles of minimal access surgery into a practice philosophy conducive to the development and evaluation of future surgical techniques.

Objectives: The resident will be able to:

  1. List equipment needed for complex procedures, select instruments needed, set up room (including patient position) and equipment, troubleshoot equipment when malfunction occurs.
  2. Demonstrate facility in endoscopic knot-tying, stapling, and suturing, either in a box-trainer, an animal model, or the operating room.
  3. Participate in increasingly complex procedures under supervision, such as:
    1. Laparoscopic hiatal hernia repair
    2. Laparoscopic surgery for achalasia
    3. Laparoscopic splenectomy
    4. Laparoscopic inguinal hernia repair
  4. Demonstrate understanding of uses of endoscopic ultrasound and other intraoperative adjuncts.

Complete additional MAS training as necessary through specialized courses at the home or outside institution to certify one's proficiency in performing currently practiced and widely accepted procedures.

Surgical Oncology

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal: Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of diseases of the abdominal cavity and pelvis. Demonstrate understanding of the biology, pathology, diagnosis, treatment, and prognosis of neoplastic disease.  Understand surgical options of curative and palliative care for cancer patients. Understand the network of community resources and their functions, available to patients at end of life.

Objectives: The resident will be able to:

  1. Describe the embryological development of the peritoneal cavity and the positioning of the abdominal viscera.
  2. Diagram the anatomy of the abdomen including its viscera and anatomic spaces:
    1. Musculoskeletal envelope
    2. Lesser sac
    3. Subphrenic spaces
    4. Morrison's pouch
    5. Foramen of Winslow
    6. Pouch of Douglas
    7. True pelvis
    8. Lateral gutters
    9. Contents of the retroperitoneum
    10. Major lymph node groups and their contents
  3. Surgical outcome is dependent on coexistent disease. Describe changes in the following organ systems that result from the aging process:
    1. Heart
    2. Lung
    3. Kidney
    4. Brain
    5. Hematopoietic system
    6. Gastrointestinal tract
  4. Explain absorption and secretory functions of the peritoneal surfaces and the diaphragm.
  5. Describe the anatomy of the omentum and its role in responding to inflammatory processes.
  6. Assess the following signs associated with the acute abdomen and describe their pathophysiology:
    1. Referred pain
    2. Rebound tenderness
    3. Guarding
    4. Rigidity
  7. Specify characteristics of the history, physical examination findings, and mechanism of visceral and somatic pain for the following processes:
    1. Acute appendicitis
    2. Bowel obstruction
    3. Perforated ulcer
    4. Ureteral colic
    5. Diffuse peritonitis
    6. Biliary colic
  8. List possible distinctions in the presentation and examination of the elderly patient with the following causes of acute abdomen:
    1. Perforated viscus
    2. Cholecystitis
  9. Discuss the differences in the physiologic response to stress in the geriatric patient.
  10. Explain the mechanism of referred pain in:
    1. Ruptured spleen
    2. Biliary colic
    3. Basilar pneumonia
    4. Renal colic
    5. Pancreatitis
    6. Inquinal hernia
  11. Discuss the following causes of paralytic ileus:
    1. Post-operative electrolyte imbalance
    2. Retroperitoneal pathology
    3. Trauma
    4. Extraperitoneal disease (central nervous system, lung)
  12. Illustrate use of the following diagnostic studies in the work-up of each process in #7 and #10 above:
    1. Laboratory evaluation
    2. Urinalysis
    3. Plain x-rays
    4. Contrast gastrointestinal (GI) studies
    5. Ultrasound
    6. Computed axial tomography (CAT)
    7. Biliary studies
    8. Renal studies
  13. When there is a possibility of wound complications consider; the contributing risk factors for abdominal wound infection, dehiscence and evisceration; the usual clinical presentations, timing, and incidence of wound infection; and wound complications that are more problematic in the elderly patient.
  14. Identify the anatomic locations for the following intra-abdominal abscesses; name disease process(es) associated with each:
    1. Left subphrenic space
    2. Right subphrenic space
    3. Subhepatic space
    4. Lesser sac
    5. Interloop
    6. Pelvis
    7. Left paracolic gutter
    8. Right paracolic gutter
    9. Psoas muscle
  15. Differentiate between the conditions favoring percutaneous drainage versus operative drainage for each of the abscesses in #.  Describe the safest and most effective approach using each technique.
  16. Differentiate between the following intestinal fistulas and the organs to which they most often communicate:
    1. Esophageal
    2. Gastric
    3. Enteric (including duodenal)
    4. Colonic
  17. Explain the formation of fistulas in each of the following disease processes or factors:
    1. Operative complications (bowel injury with abscess formation)
    2. Inflammatory bowel disease
    3. Acute pancreatitis
    4. Foreign body or prosthetic material
    5. Malignancy
  18. Explain the role of a fistulogram in the diagnosis of intra-abdominal fistulas and abscesses.
  19. List the factors that prevent healing of a fistula.
  20. Summarize the conditions favoring operative versus non-operative treatment for fistulas listed in #.
  21. Describe the anatomy, clinical presentation, and complications of non-operative management for these hernias:
    1. Direct and indirect inguinal, femoral, and obturator
    2. Sliding hiatal
    3. Paraesophageal
    4. Ventral
    5. Umbilical
    6. Spigelian
    7. Paraduodenal
    8. Richter's
    9. Lumbar and Petit
    10. Parastomal
    11. Diaphragmatic
      1. Posterolateral (Bochdalek)
      2. Anterior (Morgagni)
      3. Traumatic
    12. Internal
  22. Name the hernia types that are most common in elderly patients, and explain how they may become problematic.
  23. Define a Richter's hernia and describe its clinical presentation.
  24. Define a sliding hernia and describe its repair.
  25. Differentiate between incarceration and strangulation.
  26. Summarize the surgical procedures available for repair of the hernias listed in #23 above.
  27. Outline the uses of prosthetic material and management of infection for incisional or recurrent hernias involving prosthetic material.
  28. Explain the operative approaches for each of the following, including laparoscopic:
    1. Abdominal cavity: liver/biliary tract, spleen, small bowel, large bowel, and pelvis
    2. Retroperitoneal organs: kidneys, pancreas, adrenal glands, abdominal aorta
    3. Thoracoabdominal aorta
    4. Pericardial sac
  29. Outline the techniques for wound closure (including type of suture material) for each of the incisions named in #28 immediately above.
  30. Explain the rationale for and mechanics of techniques of peritoneal dialysis
  31. Assess the treatment of secondary peritoneal infections due to peritoneal dialysis catheters.
  32. Describe the pathophysiology and treatment of ascites in:
    1. Malignancy
    2. Hepatic disease: cirrhosis, Budd Chiari Syndrome
    3. Chylous leak
    4. Pancreatic leak
    5. Cardiac disease
    6. Renal disease
    7. Bile leak
  33. Explain the indications for use and complications of peritoneo-venous shunts.
  34. Describe the etiology, manifestations, and treatment of:
    1. Desmoid tumors
    2. Rectus sheath hematoma
    3. Retroperitoneal fibrosis
  35. Describe the more common retroperitoneal tumors, sarcomas, and liposarcomas. (What are their clinical presentations, treatments, and prognoses?)
  36. Specify the pathophysiology of multisystem problems of the alimentary tract and digestive system, including neurohumoral and hormonal interactions.
  37. Explain the physiologic rationale for the following gastrointestinal operations:
    1. Vagotomy
    2. Pyloroplasty
    3. Gastric resection for ulcer disease and reconstructive techniques
    4. Small bowel resection with anastomosis
    5. Ostomy formation
    6. Resection of GI tract segments with nodes for tumors
    7. Bypass of GI tract segments for resectable tumors
    8. Drainage of pancreatic cysts (internal vs. external)
    9. Drainage of abdominal and retroperitoneal abscesses (percutaneous vs. operative)
  38. Detail the standard intraoperative techniques and alternatives associated with each of the above operations.
  39. Explain the indications and contraindications for diagnostic and therapeutic endoscopy of the alimentary tract.
  40. Assess alternatives to surgical intervention in the management of complex diseases of the alimentary tract and digestive system such as:
    1. Short gut syndrome
    2. Achalasia
    3. Barrett's esophagus
    4. Intestinal polyposis
    5. Inflammatory bowel disease
    6. Seropositive status for H. pylori
    7. Multifocal atrophic gastritis in the elderly
  41. Discuss the surgical ramifications of the following statement: The expectation of more frequent vague gastrointestinal complaints by the elderly patient may delay presentation with significant illness and diagnosis.
  42. Summarize the pre-operative, intraoperative, and post-operative management of complex diseases of the alimentary tract and digestive system, including:
    1. Re-operative abdomen
    2. Failed peptic ulcer and reflux operation
    3. Management of post-gastrectomy syndromes
    4. High output GI fistulas
    5. Inflammatory bowel disease with strictures, pouches, ostomies, and perineal fistulas
    6. Recurrent colon malignancy
    7. Carcinomatosis
  43. Differentiate between conventional open and scope-assisted surgery, including:
    1. Anesthetic considerations
    2. Effects of pneumoperitoneum
    3. Cardiovascular stability
    4. Need for team participation
    5. Differences in patient outcome
  44. Discuss the physical limitations imposed on the user participating in minimally invasive surgery, including:
    1. Surgeon fatigue and diminished proficiency over time
    2. Two-dimensional perspective
    3. Visual limitations of scope and monitoring equipment
    4. Crucial importance of patient position and cannula position for optimum exposure
  45. Understand strategies to offset the difficulties suggested in #44 above, including:
    1. Proper alignment of eye-camera-instrument axes
    2. Efficient biomechanics
    3. Effective use of assistants
    4. Appropriate use of other advanced technologies such as endoscopic ultrasound
  46. Analyze the factors affecting the decision to select a minimally invasive approach (as opposed to an open surgical approach) for a particular clinical problem.
  47. Explain the concept of the learning curve, and discuss the need for quality control in the education and evaluation of surgical house staff in developing proficiency in minimally invasive surgery.
  48. Explain the mechanics and principles for safe and effective use of the following equipment/procedures
    1. Cautery (monopolar and bipolar)
    2. Ultrasonic shears
    3. Laser
    4. Telescopic direction (straight and angled laparoscope)
    5. Insulation technique and hazards
    6. Maintaining visualization of operative field
    7. Dissecting and knot tying
  49. Discuss appropriate anesthetic management for minimally invasive techniques for surgery involving the abdomen, thorax, and joints and soft tissue spaces.
  50. Summarize areas of current investigation in minimally invasive surgery, including:
    1. Virtual reality
    2. Use of robots/robotics
    3. Three-dimensional imaging systems
    4. Dissection techniques for soft tissues
  51. Discuss the potential economic impact of increased utilization of operating room time, advanced equipment, and disposable instruments on health care costs.
  52. Summarize protocols for appropriate cleaning, sterilization, maintenance, and handling of minimally invasive equipment.
  53. Basic Laparoscopic Skills
    1. Discuss techniques for gaining access to the abdomen, including
      1. Veress needle
      2. Open (Hassan cannula)
      3. Direct visualization trocars
    2. 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 ultrasound.
    3. Discuss recognition and management of complications, including major vascular injury, massive Carbon dioxide embolus, or visceral injury.
    4. List contraindications for laparoscopic surgery, and be able to explain why these conditions are considered relative or absolute contraindications.
  54. Laparoscopic Cholecystectomy (LC)
    1. Discuss the indications and contraindications for laparoscopic cholecystectomy.
    2. Describe the technical aspects of preparing for and operating on a patient undergoing L
    3. Identify major considerations for the decisions involved in converting from laparoscopic to open cholecystectomy, including:
      1. Difficulty identifying anatomy (i., common duct)
      2. Poor visibility
      3. Hemorrhage control
    4. Select management options for handling bile duct injuries, including immediate and delayed diagnosis and treatment.
    5. Specify the indications and technique for percutaneous cholangiography, endoscopic ultrasound, and common bile duct exploration (CBDE), including use of choledochoscopy.
    6. Discuss management of the patient with common duct stones, including:
      1. Choice of approach (open common duct exploration, versus laparoscopic CBDE, versus LC followed by/preceded by endoscopic stone extraction)
      2. Timing of surgery
      3. Safety and cost-effectiveness of each approach
  55. Additional Laparoscopic Procedures
    1. Describe current theories, including advantages and disadvantages, regarding the use of laparoscopic anti-reflux procedures and myotomies.
    2. Discuss advantages and limitations of thoracoscopic versus laparoscopic approach for esophagomyotomy.
    3. Discuss indications and contraindications for addition of partial fundoplication to esophagomyotomy.
    4. Describe management of paraesophageal hernia.
    5. Outline the potential benefits and limitations to:
      1. Laparoscopy-assisted colectomy
      2. Pre- and trans- peritoneal groin hernia repairs
      3. Laparoscopic ventral hernia repair
      4. Appendectomy
    6. Summarize other intra-abdominal laparoscopic procedures currently being performed, including:
      1. Adrenalectomy
      2. Gastrectomy
      3. Splenectomy
      4. Donor nephrectomy
  56. Describe the characteristics, diagnosis, and therapy of less common lesions of the breast such as:
    1. Inflammatory carcinoma
    2. Paget's Disease
    3. Lactiferous duct fistula
    4. Mondor's Disease
    5. Cystosarcoma phyllodes
    6. Bilateral breast carcinoma
    7. Male breast carcinoma
  57. Understand the methodologies and results of landmark breast cancer trials: B-04, B-06, B-17, B-24 (NSABP)
  58. Define appropriate breast conservation therapies, their benefits, and comparative outcomes, and compare them with modified radical mastectomy.
  59. Summarize the role of adjuvant chemotherapy and radiation therapy for the treatment of primary breast carcinom
  60. Outline the importance of estrogen and progesterone receptors in the prognosis and treatment of breast cancer.
  61. Describe the basic issues in the staging and treatment of metastatic breast cancer, including the role of:
    1. Chemotherapy
    2. Radiation therapy
    3. Hormonal therapy
  62. Summarize the physiologic changes associated with pregnancy, including breast problems peculiar to pregnancy. Theorize appropriate management of breast cancer diagnosed during pregnancy.
  63. Formulate plans for basic patient care, including pre-, intra-, and post-operative car
  64. Summarize the major considerations for post-mastectomy breast reconstruction.
  65. Identify and analyze the data addressing controversial areas of breast disease, such as:
    1. Current concepts in the management of cancer
    2. Cancer prevention techniques, such as tamoxifen and raloxifene
    3. Role of various adjuvant therapy programs.
    4. Biological behavior of lesions such as lobular carcinoma in situ
    5. Benefit and frequency of screening mammograms
    6. Relationship of mammographic parenchymal patterns to the risk of subsequent malignancy
  66. Review and evaluate the following areas of research in breast disease:
    1. Role of breast cancer susceptibility genes
    2. Monoclonal antibodies
    3. Other breast markers, including Her-2/neu, cathepsin D, and flow cytometry with chromosomal analysis
  67. Explain the role of sentinel lymph node biopsy for breast cancer
    1. Sensitivity and specificity
    2. Indication and contraindications
    3. Technique
    4. Treatment plan based on findings

General Surgery

Medical Knowledge:

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.

Objectives: The resident will be able to:

  1. Specify the pathophysiology of multisystem problems of the alimentary tract and digestive system, including neurohumoral and hormonal interactions.
  2. Explain the physiologic rationale for the following gastrointestinal operations:
    1. Vagotomy
    2. Pyloroplasty
    3. Gastric resection for ulcer disease and reconstructive techniques
    4. Small bowel resection with anastomosis
    5. Ostomy formation
    6. Resection of GI tract segments with nodes for tumors
    7. Bypass of GI tract segments for resectable tumors
    8. Drainage of pancreatic cysts (internal vs. external)
    9. Drainage of abdominal and retroperitoneal abscesses (percutaneous vs. operative)
  3. Detail the standard intraoperative techniques and alternatives associated with each of the above operations.
  4. Explain the indications and contraindications for diagnostic and therapeutic endoscopy of the alimentary tract.
  5. Assess alternatives to surgical intervention in the management of complex diseases of the alimentary tract and digestive system such as:
    1. Short gut syndrome
    2. Achalasia
    3. Barrett's esophagus
    4. Intestinal polyposis
    5. Inflammatory bowel disease
    6. Seropositive status for H. pylori
    7. Multifocal atrophic gastritis in the elderly
  6. Discuss the surgical ramifications of the following statement: The expectation of more frequent vague gastrointestinal complaints by the elderly patient may delay presentation with significant illness and diagnosis.
  7. Summarize the pre-operative, intraoperative, and post-operative management of complex diseases of the alimentary tract and digestive system, including:
    1. Re-operative abdomen
    2. Failed peptic ulcer and reflux operation
    3. Management of post-gastrectomy syndromes
    4. High output GI fistulas
    5. Inflammatory bowel disease with strictures, pouches, ostomies, and perineal fistulas
    6. Recurrent colon malignancy
    7. Carcinomatosis
  8. Summarize the surgical procedures available for repair of the hernias
  9. Outline the uses of prosthetic material and management of infection for incisional or recurrent hernias involving prosthetic material.
  10. Explain the operative approaches for each of the following, including laparoscopic:
    1. Abdominal cavity: liver/biliary tract, spleen, small bowel, large bowel, and pelvis
    2. Retroperitoneal organs: kidneys, pancreas, adrenal glands, abdominal aorta
    3. Thoracoabdominal aorta
    4. Pericardial sac
  11. Outline the techniques for wound closure (including type of suture material) for each of the incisions named in #10 immediately above.
  12. Explain the rationale for and mechanics of techniques of peritoneal dialysis in:
    1. Renal failure
    2. Management of peritoneal infections or pancreatitis
  13. Assess the treatment of secondary peritoneal infections due to peritoneal dialysis catheters.
  14. Describe the pathophysiology and treatment of ascites in:
    1. Malignancy
    2. Hepatic disease: cirrhosis, Budd Chiari Syndrome
    3. Chylous leak
    4. Pancreatic leak
    5. Cardiac disease
    6. Renal disease
    7. Bile leak
  15. Explain the indications for use and complications of peritoneo-venous shunts.
  16. Describe the etiology, manifestations, and treatment of:
    1. Desmoid tumors
    2. Rectus sheath hematoma
    3. Retroperitoneal fibrosis
  17. Describe the more common retroperitoneal tumors, sarcomas, and liposarcomas. (What are their clinical presentations, treatments, and prognoses?)
  18. Differentiate between conventional open and scope-assisted surgery, including:
    1. Anesthetic considerations
    2. Effects of pneumoperitoneum
    3. Cardiovascular stability
    4. Need for team participation
    5. Differences in patient outcome
  19. Discuss the physical limitations imposed on the user participating in minimally invasive surgery, including:
    1. Surgeon fatigue and diminished proficiency over time
    2. Two-dimensional perspective
    3. Visual limitations of scope and monitoring equipment
    4. Crucial importance of patient position and cannula position for optimum exposure
  20. Understand strategies to offset the difficulties suggested in #19 above, including:
    1. Proper alignment of eye-camera-instrument axes
    2. Efficient biomechanics
    3. Effective use of assistants
    4. Appropriate use of other advanced technologies such as endoscopic ultrasound
  21. Analyze the factors affecting the decision to select a minimally invasive approach (as opposed to an open surgical approach) for a particular clinical problem.
  22. Explain the concept of the learning curve, and discuss the need for quality control in the education and evaluation of surgical house staff in developing proficiency in minimally invasive surgery.
  23. Explain the mechanics and principles for safe and effective use of the following equipment/procedures
    1. Cautery (monopolar and bipolar)
    2. Ultrasonic shears
    3. Laser
    4. Telescopic direction (straight and angled laparoscope)
    5. Insulation technique and hazards
    6. Maintaining visualization of operative field
    7. Dissecting and knot tying
  24. Discuss appropriate anesthetic management for minimally invasive techniques for surgery involving the abdomen, thorax, and joints and soft tissue spaces.
  25. Summarize areas of current investigation in minimally invasive surgery, including:
    1. Virtual reality
    2. Use of robots/robotics
    3. Three-dimensional imaging systems
    4. Dissection techniques for soft tissues
  26. Discuss the potential economic impact of increased utilization of operating room time, advanced equipment, and disposable instruments on health care costs.
  27. Summarize protocols for appropriate cleaning, sterilization, maintenance, and handling of minimally invasive equipment.
  28. Basic Laparoscopic Skills
    1. Discuss techniques for gaining access to the abdomen, including:
      1. Veress needle
      2. Open (Hassan cannula)
      3. Direct visualization trocars
    2. 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 ultrasound.
    3. Discuss recognition and management of complications, including major vascular injury, massive Carbon dioxide embolus, or visceral injury.
    4. List contraindications for laparoscopic surgery, and be able to explain why these conditions are considered relative or absolute contraindications.
  29. Laparoscopic Cholecystectomy (LC)
    1. Discuss the indications and contraindications for laparoscopic cholecystectomy.
    2. Describe the technical aspects of preparing for and operating on a patient undergoing L
    3. Identify major considerations for the decisions involved in converting from laparoscopic to open cholecystectomy, including:
      1. Difficulty identifying anatomy (i., common duct)
      2. Poor visibility
      3. Hemorrhage control
    4. Select management options for handling bile duct injuries, including immediate and delayed diagnosis and treatment.
    5. Specify the indications and technique for percutaneous cholangiography, endoscopic ultrasound, and common bile duct exploration (CBDE), including use of choledochoscopy.
    6. Discuss management of the patient with common duct stones, including:
      1. Choice of approach (open common duct exploration, versus laparoscopic CBDE, versus LC followed by/preceded by endoscopic stone extraction)
      2. Timing of surgery
      3. Safety and cost-effectiveness of each approach
  30. Additional Laparoscopic Procedures
    1. Describe current theories, including advantages and disadvantages, regarding the use of laparoscopic anti-reflux procedures and myotomies.
    2. Discuss advantages and limitations of thoracoscopic versus laparoscopic approach for esophagomyotomy.
    3. Discuss indications and contraindications for addition of partial fundoplication to esophagomyotomy.
    4. Describe management of paraesophageal hernia.
    5. Outline the potential benefits and limitations to:
      1. Laparoscopy-assisted colectomy
      2. Pre- and trans- peritoneal groin hernia repairs
      3. Laparoscopic ventral hernia repair
      4. Appendectomy
    6. Summarize other intra-abdominal laparoscopic procedures currently being performed, including:
      1. Adrenalectomy
      2. Gastrectomy
      3. Splenectomy
      4. Donor nephrectomy
  31. Detail the appropriate surgical management of any selected disorder of the liver or biliary tract.
  32. Analyze the technical details of each surgical procedure and options that may be available with pros and cons of each.
  33. Summarize the common complications associated with surgical management of liver and biliary tract disease.
  34. Summarize the principles of perioperative management of liver and biliary tract disease.
  35. Outline the appropriate surgical management of disorders of the pancreas to include:
    1. Pancreatoduodenectomy (Whipple Procedure)
    2. Distal pancreatectomy
    3. Total pancreatectomy
    4. Subtotal (distal 95%) pancreatectomy
    5. Longitudinal pancreaticojejunostomy (Puestow Procedure)
    6. Internal drainage of pseudocysts (cystogastrostomy, cystoduodenostomy, Roux-en-Y cystojejunostomy)
  36. Explain the technical details of the above procedures, including the options available and the pros and cons of each.
  37. Describe the common complications associated with surgical management of diseases of the pancreas.
  38. Summarize the principles of perioperative management of diseases of the pancreas.

Minimally Invasive Surgery

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal:

Objectives: The resident will be able to:

Section One: Overview

  1. Differentiate between conventional open and scope-assisted surgery, including:
    1. Anesthetic considerations
    2. Effects of pneumoperitoneum
    3. Cardiovascular stability
    4. Need for team participation
    5. Differences in patient outcome
  2. Discuss the physical limitations imposed on the user participating in minimal access surgery, including:
    1. Surgeon fatigue and diminished proficiency over time
    2. Two-dimensional perspective
    3. Visual limitations of scope and monitoring equipment
    4. Crucial importance of patient position and cannula position for optimum exposure
  3. Understand strategies to offset the difficulties suggested in #2 above, including:
    1. Proper alignment of eye-camera-instrument axes
    2. Efficient biomechanics
    3. Effective use of assistants
    4. Appropriate use of other advanced technologies such as endoscopic ultrasound
  4. Analyze the factors affecting the decision to select a minimal access approach (as opposed to an open surgical approach) for a particular clinical problem.
  5. Explain the concept of the learning curve, and discuss the need for quality control in the education and evaluation of surgical house staff in developing proficiency in minimal access surgery.
  6. Explain the mechanics and principles for safe and effective use of the following equipment/procedures:
    1. Cautery (monopolar and bipolar)
    2. Ultrasonic shears
    3. Laser
    4. Telescopic direction (straight and angled laparoscope)
    5. Insulation technique and hazards
    6. Maintaining visualization of operative field
    7. Dissecting and knot tying
  7. Discuss appropriate anesthetic management for minimal access (MA) techniques for surgery involving the abdomen, thorax, and joints and soft tissue spaces.
  8. Summarize areas of current investigation in MAS, including:
    1. Virtual reality
    2. Use of robots/robotics
    3. Three-dimensional imaging systems
    4. Dissection techniques for soft tissues
  9. Summarize protocols for appropriate cleaning, sterilization, maintenance, and handling of MA equipment.
  10. Discuss the potential economic impact of increased utilization of operating room time, advanced equipment, and disposable instruments on health care costs.

Section Two: Basic Laparoscopic Skills

  1. Discuss techniques for gaining access to the abdomen, including:
    1. Veress needle
    2. Open (Hassan cannula)
    3. Direct visualization trocars
  2. Describe the sequence of steps involved in establishing a pneumoperitoneum, including:
    1. Selection of first puncture site
    2. Initial entry via Veress needle or Hassan cannula
    3. Tests to confirm entry into peritoneum
    4. Initial insufflation
    5. Initial exploration of abdomen
    6. Placement of additional trocars
  3. 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 ultrasound.
  4. Discuss recognition and management of complications, including major vascular injury, massive Carbon dioxide embolus, or visceral injury.
  5. List contraindications for laparoscopic surgery, and be able to explain why these conditions are considered relative or absolute contraindications.

Section Three: Laparoscopic Cholecystectomy (LC)

  1. Discuss the indications and contraindications for laparoscopic cholecystectomy.
  2. Describe the technical aspects of preparing for and operating on a patient undergoing L
  3. Identify major considerations for the decisions involved in converting from laparoscopic to open cholecystectomy, including:
    1. Difficulty identifying anatomy (i., common duct)
    2. Poor visibility
    3. Hemorrhage control
  4. Select management options for handling bile duct injuries, including immediate and delayed diagnosis and treatment.
  5. Specify the indications and technique for percutaneous cholangiography, endoscopic ultrasound, and common bile duct exploration (CBDE), including use of choledochoscopy.
  6. Discuss management of the patient with common duct stones, including:
    1. Choice of approach (open common duct exploration, versus laparoscopic CBDE, versus LC followed by/preceded by endoscopic stone extraction)
    2. Timing of surgery
    3. Safety and cost-effectiveness of each approach

Section Four: Additional Laparoscopic Procedures

  1. Describe current theories, including advantages and disadvantages, regarding the use of laparoscopic anti-reflux procedures and myotomies.
    1. Discuss advantages and limitations of thoracoscopic versus laparoscopic approach for esophagomyotomy.
    2. Discuss indications and contraindications for addition of partial fundoplication to esophagomyotomy.
    3. Describe management of paraesophageal hernia.
  2. Outline the potential benefits and limitations to:
    1. Laparoscopy-assisted colectomy
    2. Pre- and trans- peritoneal groin hernia repairs
    3. Laparoscopic ventral hernia repair
    4. Appendectomy
  3. Summarize other intra-abdominal laparoscopic procedures currently being performed, including:
    1. Adrenalectomy
    2. Gastrectomy
    3. Splenectomy
    4. Donor nephrectomy

Section Five: Thoracoscopic Procedures

  1. Identify the potential applications of thoracoscopic surgery, including:
    1. Pulmonary resection
    2. Lung biopsy
    3. Pleurectomy/decortication
    4. Esophageal surgery
    5. Sympathectomy
  2. Discuss anesthetic management of a patient undergoing thoracoscopy.
  3. Discuss pros and cons of thoracoscopic versus open surgery for pulmonary disease.

Interpersonal and Communication Skills:

Goal: Counsel patients and obtain informed consent for general surgery and surgical oncology 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 and surgical oncology 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

Professionalism:

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:

  1. Medical students
  2. Nursing and support staff
  3. Supervising faculty
  4. Consulting residents
  5. Physician peers
  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 and surgical oncology practices

Objective: The resident will demonstrate the ability to discuss studies regarding general surgery and surgical oncology procedures

Systems-Based Practice

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

Duties/Responsibilities:

  1. Serve as PGY-4 on the Methodist General Surgery service
  2. Appropriate, professional supervision of student teaching in light of educational goals
  3. Attend clinic as assigned
  4. Manage OR patients with supervision
  5. Assist with consultations to the general surgery service
  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

Evaluation:

  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 Methodist 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.

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