Specific Educational Goals and Education
Service: Minimally Invasive Surgery
Supervision: PGY 4 → 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 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.
- Recommended Reading
- Schwartz’s Principles of Surgery
- SCORE curriculum modules www.surgicalcore.org
- 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.
Objective: The resident will be able to:
- Perform initial consultation for inpatients with problems of the GI tract; develop differential diagnosis and initiate treatment plan.
- Select and interpret appropriate pre- and post-operative diagnostic studies.
- Assist junior residents in the diagnosis, surgical management, and follow-up care of patients with diseases of the alimentary tract and digestive system.
- Perform, under appropriate supervision, GI operations, including:
- Gastric Procedures
- Small bowel resection with anastomosis
- Drainage of pancreatic cysts
- Drainage of abdominal and retroperitoneal abscesses
- Lysis of adhesions
- Repair of enterotomies
- Creation of ostomies
- Develop diagnostic and therapeutic endoscopy skills such as:
- Diagnostic esophagogastroduodenoscopy
- Percutaneous endoscopic gastroscopy
- Dilation of intestinal strictures
- Diagnostic colonoscopy
- Perform appropriate reoperative laparotomy for a variety of gastrointestinal problems.
- Supervise post-operative care of GI and digestive tract surgical patients.
- Open and close abdominal incisions of all varieties.
- Treat wound complications such as infections and evisceration. Use retention sutures appropriately.
- Assist with thoracoabdominal and retroperitoneal exposures for access to kidneys, pancreas, aorta, iliac arteries.
- 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
- Perform more complex laparotomies involving diffuse peritonitis in the septic patient (e.g., a gangrenous or severely inflamed gallbladder or perforated diverticulitis requiring resection).
- Coach a junior resident through the repair of simple hernia (indirect inguinal or umbilical).
- Provide appropriate surgical drainage for any intra-abdominal abscess.
- List equipment needed for complex procedures, select instruments needed, set up room (including patient position) and equipment, troubleshoot equipment when malfunction occurs.
- Demonstrate facility in endoscopic knot-tying, stapling, and suturing, either in a box-trainer, an animal model, or the operating room.
- Participate in increasingly complex procedures under supervision, such as:
- Laparoscopic hiatal hernia repair
- Laparoscopic surgery for achalasia
- Laparoscopic splenectomy
- Laparoscopic inguinal hernia repair
- Demonstrate understanding of uses of endoscopic ultrasound and other intraoperative adjuncts.
- Perform detailed evaluation of patients with liver and biliary disease and plan appropriate management and operative approach.
- Perform, under supervision, increasingly complex hepatobiliary surgery:
- Laparoscopic cholecystectomy with cholangiography
- Common bile duct exploration with choledochoscopy
- Biliary drainage procedures, such as:
- Roux-en-Y and loop choledochojejunostomy
- Complicated cholecystectomy--acute, gangrenous
- Coordinate overall care of patients with hepatobiliary disease including:
- Initial evaluation
- Appropriate diagnostic studies
- Indicated consultations
- Operative management
- Coordinate overall care of patients with complex pancreatic disease, including initial evaluation, appropriate diagnostic studies, and operative management of:
- Pancreatic abscess and infected pancreatic necrosis
- Endocrine tumors of the pancreas
- Serve as an effective surgical team leader.
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.
Objectives: The resident will be able to:
- Specify the pathophysiology of multisystem problems of the alimentary tract and digestive system, including neurohumoral and hormonal interactions.
- Explain the physiologic rationale for the following gastrointestinal operations:
- Gastric resection for ulcer disease and reconstructive techniques
- Small bowel resection with anastomosis
- Ostomy formation
- Resection of GI tract segments with nodes for tumors
- Bypass of GI tract segments for resectable tumors
- Drainage of pancreatic cysts (internal vs. external)
- Drainage of abdominal and retroperitoneal abscesses (percutaneous vs. operative)
- Detail the standard intraoperative techniques and alternatives associated with each of the above operations.
- Explain the indications and contraindications for diagnostic and therapeutic endoscopy of the alimentary tract.
- Assess alternatives to surgical intervention in the management of complex diseases of the alimentary tract and digestive system such as:
- Barrett's esophagus
- Seropositive status for H. pylori
- Multifocal atrophic gastritis in the elderly
- Summarize the pre-operative, intraoperative, and post-operative management of complex diseases of the alimentary tract and digestive system, including:
- Re-operative abdomen
- Failed peptic ulcer and reflux operation
- Management of post-gastrectomy syndromes
- High output GI fistulas
- Summarize the surgical procedures available for repair of the hernias
- Outline the uses of prosthetic material and management of infection for incisional or recurrent hernias involving prosthetic material.
- Explain the operative approaches for each of the following, including laparoscopic:
- Abdominal cavity: liver/biliary tract, spleen, small bowel, large bowel, and pelvis
- Retroperitoneal organs: kidneys, pancreas, adrenal glands, abdominal aorta
- Thoracoabdominal aorta
- Pericardial sac
- Outline the techniques for wound closure (including type of suture material) for each of the incisions named in #10 immediately above.
- Explain the rationale for and mechanics of techniques of peritoneal dialysis in:
- Renal failure
- Management of peritoneal infections or pancreatitis
- Assess the treatment of secondary peritoneal infections due to peritoneal dialysis catheters.
- Describe the pathophysiology and treatment of ascites in:
- Hepatic disease: cirrhosis, Budd Chiari Syndrome
- Chylous leak
- Pancreatic leak
- Cardiac disease
- Renal disease
- Bile leak
- Explain the indications for use and complications of peritoneo-venous shunts.
- Describe the etiology, manifestations, and treatment of:
- Desmoid tumors
- Rectus sheath hematoma
- Retroperitoneal fibrosis
- Differentiate between conventional open and scope-assisted surgery, including:
- Anesthetic considerations
- Effects of pneumoperitoneum
- Cardiovascular stability
- Need for team participation
- Differences in patient outcome
- Discuss the physical limitations imposed on the user participating in minimally invasive surgery, including:
- Surgeon fatigue and diminished proficiency over time
- Two-dimensional perspective
- Visual limitations of scope and monitoring equipment
- Crucial importance of patient position and cannula position for optimum exposure
- Understand strategies to offset the difficulties suggested in #19 above, including:
- Proper alignment of eye-camera-instrument axes
- Efficient biomechanics
- Effective use of assistants
- Appropriate use of other advanced technologies such as endoscopic ultrasound
- Analyze the factors affecting the decision to select a minimally invasive approach (as opposed to an open surgical approach) for a particular clinical problem.
- 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.
- Explain the mechanics and principles for safe and effective use of the following equipment/procedures
- Cautery (monopolar and bipolar)
- Ultrasonic shears
- Telescopic direction (straight and angled laparoscope)
- Insulation technique and hazards
- Maintaining visualization of operative field
- Dissecting and knot tying
- Discuss appropriate anesthetic management for minimally invasive techniques for surgery involving the abdomen, thorax, and joints and soft tissue spaces.
- Summarize areas of current investigation in minimally invasive surgery, including:
- Virtual reality
- Use of robots/robotics
- Three-dimensional imaging systems
- Dissection techniques for soft tissues
- Discuss the potential economic impact of increased utilization of operating room time, advanced equipment, and disposable instruments on health care costs.
- Summarize protocols for appropriate cleaning, sterilization, maintenance, and handling of minimally invasive equipment.
- Basic Laparoscopic Skills
- Discuss techniques for gaining access to the abdomen, including:
- Veress needle
- 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 ultrasound.
- 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.
- Discuss techniques for gaining access to the abdomen, including:
- Laparoscopic Cholecystectomy (LC)
- Discuss the indications and contraindications for laparoscopic cholecystectomy.
- Describe the technical aspects of preparing for and operating on a patient undergoing LC.
- Identify major considerations for the decisions involved in converting from laparoscopic to open cholecystectomy, including:
- Difficulty identifying anatomy (i.e., common duct)
- Poor visibility
- Hemorrhage control
- 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
- 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:
- Laparoscopy-assisted colectomy
- Pre- and trans- peritoneal groin hernia repairs
- Laparoscopic ventral hernia repair
- Bariatric Procedures
- Summarize other intra-abdominal laparoscopic procedures currently being performed, including:
- Donor nephrectomy
- Bariatric Procedures
- Explain the technical details of Bariatric procedures, including the options available and the pros and cons of each.
- Describe the common complications associated with surgical management of Bariatric Patients.
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:
- Providing appropriate check out when handing patients to another team member
- Requesting consults from other services with appropriate information
- Dictating operative reports in a timely fashion
Goal: Maintain patient confidentiality
Objectives: The resident will demonstrate
- The ability to protect health-related patient information per HIPAA compliance
- 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:
- Medical students
- Nursing and support staff
- Supervising faculty
- Consulting residents
- Physician peers
- Patients and their families
Practice-Based Learning and Improvement
Goal: Identify personal and practice improvement strategies
Objective: The resident will demonstrate:
- Receptiveness to faculty instruction and feedback
- 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
Objective: The resident will demonstrate the ability to:
- Discuss studies regarding the general surgery procedures
Goal: Provide safe patient care
Objective: The resident will:
- Attend Crew Resource Management courses as required by the hospital
- Follow recommended protocols in the OR for patient safety
- Demonstrate compliance with Medical Center policy for surgical site identification
- Demonstrate compliance with Medical Center policy for patient identification
- Serve as Chief Resident on the general surgery service
- Appropriate, professional supervision of student teaching in light of educational goals
- Attend general surgery clinic as assigned
- Manage OR patients with supervision
- Assist with consultations to the general surgical service
- Round on post surgical service patient’s as instructed.
- Attend educational conferences
- Complete surgical case logs
- Dictate in a timely fashion
- Take night call as assigned
- Performance feedback will be given to the resident as appropriate for educational events and mid-term progress will be discussed
- 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.
- 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.