RESIDENCY TRAINING IN GENERAL SURGERY

GOALS:

· Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of diseases of the abdominal cavity and pelvis.

· 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.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

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:

a. Musculoskeletal envelope

b. Lesser sac

c. Subphrenic spaces

d. Morrison's pouch

e. Foramen of Winslow

f. Pouch of Douglas

g. True pelvis

h. Lateral gutters

i. Contents of the retroperitoneum

j. Major lymph node groups and their drainage

3. Surgical outcome is dependent on coexistent disease. Describe changes in the following organ systems that result from the aging process:

a. Heart d. Brain

b. Lung e. Hematopoietic system

c. Kidney f. 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:

a. Referred pain c. Guarding

b. Rebound tenderness d. Rigidity

7. Specify characteristics of the history, physical examination findings, and mechanism of visceral and somatic pain for the following processes:

a. Acute appendicitis d. Ureteral colic

b. Bowel obstruction e. Diffuse peritonitis

c. Perforated ulcer f. Biliary colic

8. List possible distinctions in the presentation and examination of the elderly patient with the following causes of acute abdomen:

a. Perforated viscus

b. Cholecystitis

9. Discuss the differences in the physiologic response to stress in the geriatric patient.

10. Explain the mechanism of referred pain in:

a. Ruptured spleen d. Renal colic

b. Biliary colic e. Pancreatitis

c. Basilar pneumonia f. Inguinal hernia

11. Discuss the following causes of paralytic ileus:

a. Postoperative electrolyte imbalance

b. Retroperitoneal pathology

c. Trauma

d. 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:

a. Laboratory evaluation

b. Urinalysis

c. Plain x-rays

d. Contrast gastrointestinal (GI) studies

e. Ultrasound

f. Computed axial tomography (CAT)

g. Biliary studies

h. Renal studies

13. When considering the possibility of wound complications:

a. What are the risk factors for abdominal wound infection?

b. What are the contributing factors for abdominal wound dehiscence and

evisceration?

c. What are the usual clinical presentations and timing?

d. What is the incidence of wound infection in surgeries involving the biliary

tree, upper GI tract, and colon?

e. List 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:

a. Left subphrenic space f. Pelvis

b. Right subphrenic space g. Left paracolic gutter

c. Subhepatic space h. Right paracolic gutter

d. Lesser sac i. Psoas muscle

e. Interloop

15. Differentiate between the conditions favoring percutaneous drainage versus operative drainage for each of the abscesses in #14. 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:

a. Esophageal c. Enteric (including duodenal)

b. Gastric d. Colonic

17. Explain the formation of fistulas in each of the following disease processes or factors:

a. Operative complications (bowel injury with abscess formation)

b. Inflammatory bowel disease

c. Acute pancreatitis

d. Foreign body or prosthetic material

e. 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 #16.

21. Describe the anatomy, clinical presentation, and complications of non-operative management for these hernias:

a. Direct and indirect inguinal, femoral, and obturator

b. Sliding hiatal

c. Paraesophageal

d. Ventral

e. Umbilical

f. Spigelian

g. Paraduodenal

h. Richter’s

i. Lumbar and Petit

j. Parastomal

k. Diaphragmatic

(1) Posterolateral (Bochdalek)

(2) Anterior (Morgagni)

(3) Traumatic

l. 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.

Senior Level:

1. Summarize the surgical procedures available for repair of the hernias listed in #21 above.

2. Outline the uses of prosthetic material and management of infection for incisional or recurrent hernias involving prosthetic material.

3. Construct a plan for the diagnosis and potential for surgical repair of the following congenital abdominal wall defects:

a. Gastroschisis c. Diastasis Recti

b. Omphalocele

6. Explain the operative approaches for each of the following, including laparoscopic:

a. Abdominal cavity: liver/biliary tract, spleen, small bowel, large bowel, and pelvis

b. Retroperitoneal organs: kidneys, pancreas, adrenal glands, abdominal aorta

c. Thoracoabdominal aorta

d. Pericardial sac

7. Outline the techniques for wound closure (including type of suture material) for each of the incisions named in #6 immediately above.

8. Describe the use and method of placement of retention sutures.

9. Explain the rationale for and mechanics of techniques of peritoneal dialysis in:

a. Renal failure

b. Management of peritoneal infections or pancreatitis

10. Assess the treatment of secondary peritoneal infections due to peritoneal dialysis catheters.

11. Describe the pathophysiology and treatment of ascites in:

a. Malignancy

b. Hepatic disease: cirrhosis, Budd Chiari Syndrome

c. Chylous leak

d. Pancreatic leak

e. Cardiac disease

f. Renal disease

g. Bile leak

12. Explain the indications for use and complications of peritoneo-venous shunts.

13. Describe the etiology, manifestations, and treatment of:

a. Desmoid tumors

b. Rectus sheath hematoma

c. Retroperitoneal fibrosis

14. Describe the more common retroperitoneal tumors, sarcomas, and liposarcomas. (What are their clinical presentations, treatments, and prognoses?)

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

1. Perform, record, and report complete patient evaluation and assessment.

2. Evaluate and diagnose the acute abdomen.

3. Assist with hernia repairs in the groin or umbilicus, demonstrating a basic understanding of the anatomy and surgical repair.

4. Interpret the following in coordination with attending radiologists and staff:

a. Acute abdominal series (identify free air, small bowel obstruction, ileus, colonic pseudo-obstruction, volvulus; the presence of ascites, atelectasis vs. pneumonia)

b. Upper GI series

c. Barium enema (identify neoplasms, signs of ischemia)

d. Abdominal ultrasound and CT scans

5. Evaluate and institute management of abdominal wound problems, including:

a. Infection

b. Evisceration

c. Fasciitis

d. Dehiscence

6. Coordinate pre- and post- operative care for the patient with the acute abdomen.

7. Institute drainage for abdominal wall fistula and protection of surrounding structures, especially skin.

8. Assist in closure of abdominal incisions; exhibit competency in suture technique.

Senior Level:

1. Open and close abdominal incisions of all varieties.

2. Treat wound complications such as infections and evisceration. Use retention sutures appropriately.

3. Assist with thoracoabdominal and retroperitoneal exposures for access to kidneys, pancreas, aorta, iliac arteries.

4. 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 (e.g., acute appendicitis, small bowel obstruction, perforated peptic ulcer [the 5th year resident should be able to guide the more junior resident through the case]).

5. Perform more complex laparotomies involving diffuse peritonitis in the septic patient (e.g., a gangrenous or severely inflamed gallbladder or perforated diverticulitis requiring resection).

6. 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.)

7. Provide appropriate surgical drainage for any intra-abdominal abscess.

8. Serve as an effective surgical team leader.

ALIMENTARY TRACT AND DIGESTIVE SYSTEM

GOALS:

· Demonstrate an understanding of the anatomy, physiology, and pathophysiology of the alimentary tract and digestive system.

· Demonstrate the ability to manage problems of the alimentary tract and digestive system that are amenable to surgical intervention.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

1. Define the basic scientific principles of the alimentary tract and digestive system

diseases to include:

a. Anatomy, embryology, and biochemistry of the gastrointestinal (GI) tract

(1) Embryologic development of primitive foregut and hindgut and its

appendages, including normal rotation and fixation

(2) Histology of alimentary tract, including differentiation of cell types

(3) Anatomy of alimentary tract from esophagus to anus with

emphasis on systemic blood supply, portal venous drainage,

neural-endocrine axis, and lymphatic drainage

(4) Abdominal anatomy, explaining its relationship to lower thorax,

retroperitoneum, and pelvic floor

(5) Mucosal transport, including mechanism of absorption of nutrients

and water

(6) Sites of electrolyte and acid-base regulation

b. GI physiology

(1) Physiology of deglutition and phases of digestion

(2) Neuroendocrine control of GI secretion and motility

(3) Regional controls of mucosal secretion and absorption (neural and

hormonal)

(4) Enterohepatic circulation

(5) Neuromuscular control of defecation

(6) Digestion of sugars, fats, proteins, vitamins, and cofactors

(7) Rates of mucosal turnover

(8) Nutritional needs of surgical patients

(9) Normal secretory rates for the stomach, small bowel, biliary tree,

and pancreas

c. Normal bacterial flora and their concentrations in the upper and lower GI tract

d. Immunologic properties of the GI tract and how this barrier is affected by: trauma, sepsis, burns, malnutrition, and chronic disease

e. Principles of intestinal healing

(1) Normal GI tissue integrity and strength and how this relates to

healing of anastomoses

(2) Effects of suturing and stapling techniques of the gut

2. Explain and give examples for the following aspects of gastrointestinal diseases:

a. Infections inside and outside the GI tract from esophagus to anus,

including the peritoneum

b. Embryologic abnormalities of the GI tract, including:

(1) Strictures (4) Atresias

(2) Stenoses (5) Duplications

(3) Webs (6) Malrotations

c. Congenital and acquired abnormalities of gut motility

d. Neoplasia of the GI tract

e. Ulceration of the proximal and distal GI tract

f. Causes of GI obstruction

g. Causes of paralytic ileus

h. Causes of GI hemorrhage

i. Causes of GI perforation

j. Causes of abdominal abscess formation or secondary peritonitis

k. Short gut and malabsorptive conditions

l. Acute and chronic mesenteric ischemia

m. Portal hypertension and venous thrombosis

n. 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:

a. Motility disorders d. Inflammatory disease

b. Esophageal injuries e. Gastroesophageal reflux

c. Diverticular disease f. Tumors (benign and malignant)

4. Outline the essential characteristics of routine and highly specialized diagnostic evaluation of the alimentary tract, including:

a. History

(1) Pain (4) Prior episodes

(2) Nausea/emesis (5) Past surgical history

(3) Bowel function

b. Physical examination:

(1) Inspection (3) Percussion

(2) Auscultation (4) Palpation

c. Radiologic examinations, including:

(1) Barium swallow

(2) Upper GI Series with small bowel follow-through

(3) Enteroclysis

(4) Ultrasound

(5) Transesophageal echo

(6) Computerized Tomography

(7) Magnetic Resonance Imaging

(8) Barium enema

(9) Angiograms

(10) Nuclear scans for bleeding or to evaluate for Meckle's diverticulum

d. Fiberoptic endoscopy

e. Rigid anoscopy and sigmoidoscopy

f. Tests of GI function including:

(1) Manometry

(2) pH measurement

(3) Gastric analysis (basal and stimulated)

(4) Radioisotope clearance studies

(a) Technetium 99m

(b) Technetium HIDA (hepatic 2,6-dimethyliminodiacetic acid) dynamic biliary imaging

(5) Gastric emptying studies

(6) Transit times

(7) Hormonal determinations

(8) Absorption

5. Summarize current medical management and its potential limitations; explain the role of surgical intervention when management fails in the following:

a. Peptic ulcer disease d. Gastroparesis

b. Esophageal varices e. Inflammatory bowel disease

c. Upper and lower GI bleeding f. Diverticulitis

Senior Level:

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:

a. Vagotomy

b. Pyloroplasty

c. Gastric resection for ulcer disease and reconstructive techniques

d. Small bowel resection with anastomosis

e. Ostomy formation

f. Resection of GI tract segments with nodes for tumors

g. Bypass of GI tract segments for resectable tumors

h. Drainage of pancreatic cysts (internal vs. external)

i. 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:

a. Short gut syndrome

b. Achalasia

c. Barrett's esophagus

d. Intestinal polyposis

e. Inflammatory bowel disease

f. Seropositive status for H. pylori

g. 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 preoperative, intraoperative, and postoperative management of complex diseases of the alimentary tract and digestive system, including:

a. Re-operative abdomen

b. Failed peptic ulcer and reflux operation

c. Management of post-gastrectomy syndromes

d. High output GI fistulas

e. Inflammatory bowel disease with strictures, pouches, ostomies, and perineal fistulas

f. Recurrent colon malignancy

g. Carcinomatosis

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

1. Evaluate emergency department or clinic patients who present with problems referable to the GI tract.

2. Serve as assistant to the primary surgeon during operations of the esophagus,

stomach, small intestine, colon, and anorectum.

3. Perform less complicated surgical procedures such as:

a. Gastrostomy

b. Meckel's diverticulectomy

c. Appendectomy

d. Hemorrhoidectomy

e. Anal fissurectomy and fistulectomy

f. Incision and drainage of perirectal abscesses

4. Accept responsibility for (under the guidance of the chief resident and attending

surgeon) the postoperative management of:

a. Nasogastric tubes

b. Intestinal tubes

c. Intra-abdominal drains

d. Intestinal fistulas

e. Abdominal incisions (simple and complicated)

5. Evaluate and manage nutritional needs (enteral and parenteral) of surgical patients until normal GI function returns.

6. Provide follow-up care to the surgical patient in the outpatient clinic or surgical office.

Senior Level:

1. Perform initial consultation for inpatients with problems of the GI tract; develop differential diagnosis and initiate treatment plan.

2. Assist the chief resident and attending staff with complex digestive system cases.

3. Perform, under appropriate supervision, GI operations, including:

a. Vagotomy

b. Pyloroplasty

c. Gastric resection and reconstructive techniques

d. Small bowel resection with anastomosis

e. Drainage of pancreatic cysts

f. Drainage of abdominal and retroperitoneal abscesses

g. Lysis of adhesions

h. Repair of enterotomies

i. Colon resection

j. Creation of ostomies

4. Develop diagnostic and therapeutic endoscopy skills such as:

a. Diagnostic esophagogastroduodenoscopy

b. Endoscopic control of GI bleeding

c. Percutaneous endoscopic gastroscopy

d. Dilation of intestinal strictures

e. Assist with endoscopic retrograde cholangiopancreatography (ERCP)

f. Diagnostic colonoscopy

g. Polypectomy

5. Select and interpret appropriate pre- and post- operative diagnostic studies.

6. Assist junior residents in the diagnosis, surgical management, and follow-up care of patients with diseases of the alimentary tract and digestive system.

7. Coordinate intervention of multiple specialties that may be involved in management of complex GI problems such as:

a. Variceal hemorrhage

b. Biliary obstruction

c. Chronic varices

d. Inflammatory bowel disease

e. Chronic abdominal pain

f. Chronic constipation

g. Localized and advanced malignancies

8. Perform appropriate reoperative laparotomy for a variety of gastrointestinal problems.

9. Supervise postoperative care of GI and digestive tract surgical patients.

LIVER, BILIARY TRACT AND PANCREAS

GOALS:

· Demonstrate knowledge of the anatomy, physiology, and pathophysiology of the liver, biliary tract, and pancreas.

· Demonstrate the ability to manage disease and injury of the liver, biliary tract, and pancreas amenable to surgical intervention.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

Liver and Biliary Tract

1. Describe the anatomy of the liver and biliary system, including commonly found variations.

2. Describe the physiology and function of liver and biliary system to include:

a. Glucose metabolism d. Drug metabolism

b. Protein synthesis e. Reticuloendothelial system

c. Coagulation f. Function of bile in fat metabolism

3. Explain the formation of bile, its composition, and its function in digestion.

Describe the pathophysiology of gallstone formation.

4. Correlate bile formation and composition with disease states affecting the biliary system such as gallstone formation and biliary obstruction.

5. Discuss the enterohepatic circulation of bile.

6. Outline the work-up and differential diagnosis of the jaundiced patient.

7. Identify the most significant determinants of mortality in elderly patients following cholecystectomy.

8. Discuss various types of liver cysts (echinococcal or hydatid, nonparasitic) and the appropriate management of each.

9. Discuss the principal characteristics of and the treatment for the following:

a. Metastatic lesions to the liver

b. Primary malignancies of liver and biliary tree

c. Benign tumors of the liver

10. Summarize the etiologies and management of pyogenic and amebic hepatic abscesses.

11. Explain types of infectious hepatitis (A, B, C) with:

a. Modes of transmission

b. Diagnosis

c. Time course for serologic conversion

d. Natural course

12. Outline the pathophysiology, evaluation, and management of the following:

a. Choledochal cysts h. Gallstone pancreatitis

b. Caroli's disease i. Benign biliary strictures

c. Sclerosing cholangitis j. Acute cholecystitis

d. Primary biliary cirrhosis k. Symptomatic gallstones

e. Secondary biliary cirrhosis l. Acalculous cholecystitis

f. Cholangitis m. Biliary dyskinesia

g. Gallstone ileus n. Congenital biliary atresia

Pancreas

1. Describe the anatomy of the pancreas, including regional vascular anatomy.

2. Summarize changes that occur in the anatomy of the pancreas with aging by considering:

a. Duodenal C loop c. Atrophy of pancreas

b. Head of the pancreas d. Pancreatic ductal anatomy

3. Discuss the physiology of the pancreas, including endocrine and exocrine function and hormonal regulation.

a. Endocrine—islet cells

(1) Alpha (Glucagon)

(2) Beta (Insulin)

(3) Delta (Somatostatin)

(4) Non-Beta (pancreatic polypeptide)

b. Exocrine—acinar cells

(1) Lipase

(2) Amylase

c. Hormonal regulation

(1) Secretin—bicarbonate secretion

(2) Cholecystokinin—enzyme secretion

4. Explain the pathophysiology of pancreatitis to include:

a. Common etiologies such as:

(1) Gallstones

(2) Alcohol related

(3) Trauma

(4) Medications

(5) Postoperative

(6) Post endoscopic retrograde cholangiopancreatography (ERCP)

(7) Idiopathic

b. Diagnosis, evaluation, and medical management

c. Role of peritoneal lavage

d. Complications of pancreatitis, such as:

(1) Adult respiratory distress syndrome (ARDS; Acute lung injury—ALI also used)

(2) Hypovolemia

(3) Pseudocyst

(4) Abscess

(5) Sterile pancreatic necrosis

(6) Infected pancreatic necrosis

e. Indications for operative management of pancreatitis

f. Management of gallstone pancreatitis with timing of surgery

g. Methods of prognostic assessment

5. Describe the incidence of these diseases in the elderly patient:

a. Cholelithiasis

b. Acute gallstone pancreatitis

c. Pancreatic carcinoma

6. Explain the pathophysiology of carcinoma of the pancreas to include:

a. Typical history and presentation

b. Diagnostic evaluation using:

(1) Computed axial tomography

(2) Ultrasound

(3) ERCP

(4) Percutaneous transhepatic cholangiography (PTC)

(5) Arteriography

(6) Laparoscopy/laparotomy

c. Indications for:

(1) Operative versus nonoperative biliary drainage

(2) Percutaneous versus endoscopic stenting

(3) Resection

(4) Concomitant gastrojejunostomy with operative biliary bypass

7. Discuss presentation, evaluation, and management of pancreatic pseudocysts with attention to:

a. Complications of pseudocysts (hemorrhage, infection, rupture)

b. Timing of drainage

c. Percutaneous versus surgical drainage

d. Indications for external versus internal drainage

e. Choice of internal drainage procedure

8. Explain the diagnosis and management of pancreatic ascites.

Senior Level:

Liver and Biliary Tract

1. Analyze alternatives to surgery in the management of gallstones, such as:

a. Oral dissolution with ursodeoxycholic acid

b. Extracorporeal shock wave lithotripsy

c. Endoscopic sphincterotomy

2. Compare laparoscopic versus open cholecystectomy.

3. Analyze the potential significance of finding a filling defect on ultrasonography or liver scan in an elderly patient. Discuss:

a. Frequency of metastatic cancer vs. primary tumors in liver

b. Correlation between incidence of gastrointestinal malignancy and increasing age

4. Assess management alternatives for common bile duct stones:

a. Open versus laparoscopic common bile duct exploration

b. ERCP

5. Since acute cholecystitis is becoming one of the more common indications for emergency admissions of elderly patients to a surgical service, specify factors contributing to its being a more complex disease in elderly vs. young patients by considering:

a. Incidence of comorbid disease such as diabetes

b. Atypical clinical presentation (right upper quadrant pain, fever, leukocytosis)

c. Signs of sepsis or septic shock

d. Jaundice

e. Altered mental status

6. Discuss the pathophysiology of hepatic cirrhosis and portal hypertension to include:

a. Various etiologies of cirrhosis (alcohol and hepatitis)

b. Differential diagnosis of portal hypertension (prehepatic, hepatic, posthepatic)

c. Medical management of ascites, encephalopathy, and other complications of cirrhosis

d. Child's classification of cirrhosis and its relationship to prognosis and surgical mortality

e. Perioperative management of the cirrhotic patient

f. Medical management of bleeding esophageal varices using Vasopressin,

Sengstaken-Blakemore tube, sclerotherapy, and transjugular intrahepatic portosystemic shunts (TIPS)

g. Surgical management of bleeding esophageal varices to include:

(1) Selection of operative candidates

(2) Appropriate selection of procedures such as:

(a) Selective and nonselective shunts

(b) Devascularization procedures

h. Surgical management of ascites with peritoneovenous shunts to include patient selection and complications

7. Discuss Budd-Chiari Syndrome (pathophysiology and management).

8. Outline indications and contraindications for liver transplantation in adults and children.

9. Explain factors important to the choice of treatment options for the elderly patient with hepatobiliary disease, including:

a. Cardiovascular disease d. Systemic hypoperfusion

b. Cerebrovascular disease e. Curative/palliative procedure

c. Renal insufficiency f. Quality of life issues

Pancreas

1. Describe the etiology, pathophysiology, and management of chronic pancreatitis to include:

a. Indications for operative management

b. Selection of appropriate operative procedure such as:

(1) Longitudinal pancreaticojejunostomy (Puestow-Gillesby Procedure)

(2) Caudal pancreaticojejunostomy (Duval Procedure)

(3) Subtotal pancreatectomy

(4) Pancreatoduodenectomy

c. Role of celiac ganglion ablation (chemical splanchnicectomy) in pain control

2. Summarize the common sequelae of chronic pancreatitis to include pain, fat malabsorption, and diabetes.

3. Discuss diagnosis, evaluation, and surgical management of cystic neoplasms of the pancreas (mucinous and serous cystadenomas; cystadenocarcinoma).

4. Compare the probabilities of coexisting intra-abdominal pathology in elderly vs. younger patients. Consider:

a. Acute pancreatitis c. Gangrenous cholecystitis

b. Mesenteric ischemia d. Perforated viscus

5. Describe the diagnosis, evaluation, and surgical management of the following islet cell tumors of the pancreas:

a. Gastrinoma (Zollinger-Ellison Syndrome)

b. Glucagonoma

c. Somatostatinoma

d. Insulinoma

e. VIPoma (Verner-Morrison Syndrome, WDHA Syndrome)

6. Describe the diagnosis and management of pancreas divisum.

Chief Level:

Liver and Biliary Tract

1. Detail the appropriate surgical management of any selected disorder of the liver or biliary tract.

2. Analyze the technical details of each surgical procedure and options that may be available with pros and cons of each.

3. Summarize the common complications associated with surgical management of liver and biliary tract disease.

4. Summarize the principles of perioperative management of liver and biliary tract disease.

Pancreas

1. Outline the appropriate surgical management of disorders of the pancreas to include:

a. Pancreatoduodenectomy (Whipple Procedure)

b. Distal pancreatectomy

c. Total pancreatectomy

d. Subtotal (distal 95%) pancreatectomy

e. Longitudinal pancreaticojejunostomy (Puestow Procedure)

f. Internal drainage of pseudocysts (cystogastrostomy, cystoduodenostomy, Roux-en-Y cystojejunostomy)

2. Explain the technical details of the above procedures, including the options available and the pros and cons of each.

3. Describe the common complications associated with surgical management of diseases of the pancreas.

4. Summarize the principles of perioperative management of diseases of the pancreas.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

Liver and Biliary Tract

1. Perform history and physical examination specifically focused on liver and biliary system.

2. Select and interpret appropriate laboratory and radiologic evaluations in the work-up of the jaundiced patient to include:

a. Alkaline phosphatase, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), direct and indirect bilirubin, prothrombin time (PT) and partial thromboplastin time (PTT)

b. Endoscopic retrograde cholangiopancreatography (ERCP)

c. Percutaneous transhepatic cholangiography (PTC)

d. Liver-spleen scan

e. Hepatobiliary nuclear scan (HIDA)

f. Oral cholecystogram (OCG)

g. Ultrasound

h. Computed axial tomography

i. Arteriography

3. Assist in the perioperative management of patients undergoing hepatobiliary surgery.

4. Assist in management of patients with bleeding esophageal varices including the use of:

a. Vasopressin

b. Sengstaken-Blakemore tube

c. Sclerotherapy

5. Perform uncomplicated hepatobiliary surgery under supervision, such as cholecystectomy, both laparoscopic and open, with operative cholangiography.

6. Assist in more advanced hepatobiliary operations.

Pancreas

1. Perform history and physical examination focused on the pancreas.

2. Select and interpret appropriate laboratory and radiologic examinations in evaluation of pancreatic disease, including:

a. Serum amylase and lipase

b. Urinary amylase

c. Computed axial tomography

d. Ultrasound

e. Endoscopic retrograde cholangiopancreatography (ERCP)

f. Arteriography

3. Assist in management of patient with acute pancreatitis.

4. Assist in perioperative management of patients undergoing pancreatic surgery.

5. Perform minor pancreatic procedures under supervision such as external drainage of pseudocyst or internal drainage via cystgastrostomy.

Senior Level:

Liver and Biliary Tract

1. Perform detailed evaluation of patients with liver and biliary disease and plan appropriate management and operative approach.

2. Perform, under supervision, increasingly complex hepatobiliary surgery:

a. Laparoscopic cholecystectomy with cholangiography

b. Common bile duct exploration with choledochoscopy

c. Biliary drainage procedures, such as:

(1) Choledochoduodenostomy

(2) Roux-en-Y and loop choledochojejunostomy

(3) Cholecystojejunostomy

(4) Sphincteroplasty

d. Drainage of liver abscess

e. Peritoneovenous shunts

f. Complicated cholecystectomy--acute, gangrenous

g. Simple liver resection

Pancreas

1. Perform detailed evaluation of patients with pancreatic disease and plan appropriate medical or surgical management.

2. Perform increasingly complex pancreatic surgery such as:

a. Internal drainage of pseudocysts with Roux-en-Y cystojejunostomy

b. Longitudinal pancreaticojejunostomy (Puestow Procedure)

c. Distal pancreatectomy

d. Biliary bypass for carcinoma

Chief Level:

Liver and Biliary Tract

1. Coordinate overall care of patients with hepatobiliary disease including:

a. Initial evaluation

b. Appropriate diagnostic studies

c. Indicated consultations

d. Operative management

2. Perform complex hepatic and biliary surgery:

a. Anatomic liver resection

b. Portosystemic shunts:

(1) Portocaval, end-to-side and side-to-side

(2) Mesocaval

(3) Distal splenorenal (Warren)

(4) Central splenorenal

c. Complicated procedures on extrahepatic bile ducts for:

(1) Cholangiocarcinoma

(2) Choledochal cyst

(3) Benign biliary stricture

d. Liver transplant

e. Kasai procedure (hepatoportoenterostomy)

3. Supervise and instruct junior house staff in minor hepatobiliary procedures.

Pancreas

1. Coordinate overall care of patients with complex pancreatic disease, including initial evaluation, appropriate diagnostic studies, and operative management of:

a. Pancreatic abscess and infected pancreatic necrosis

b. Cystadenomas

c. Periampullary carcinoma

d. Endocrine tumors of the pancreas

2. Perform complex pancreatic procedures such as:

a. Whipple resection

b. Total or subtotal pancreatectomy

c. Operative debridement and drainage of pancreatic abscess or infected necrosis

d. Surgical exploration for islet cell tumors of the pancreas

e. Local resection for ampullary tumors

3. Supervise and instruct junior house staff in minor pancreatic procedures.

MINIMAL ACCESS SURGERY

GOALS:

· 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.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Overview

1. Differentiate between conventional open and scope-assisted surgery, including:

a. Anesthetic considerations

b. Effects of pneumoperitoneum

c. Cardiovascular stability

d. Need for team participation

e. Differences in patient outcome

2. Discuss the physical limitations imposed on the user participating in minimal access surgery, including:

a. Surgeon fatigue and diminished proficiency over time

b. Two-dimensional perspective

c. Visual limitations of scope and monitoring equipment

d. Crucial importance of patient position and cannula position for optimum exposure

3. Understand strategies to offset the difficulties suggested in #2 above, including:

a. Proper alignment of eye-camera-instrument axes

b. Efficient biomechanics

c. Effective use of assistants

d. 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 valuation of surgical housestaff in developing proficiency in minimal access surgery.

6. Explain the mechanics and principles for safe and effective use of the following equipment/procedures:

a. Cautery (monopolar and bipolar)

b. Ultrasonic shears

c. Laser

d. Telescopic direction (straight and angled laparoscope)

e. Insulation technique and hazards

f. Maintaining visualization of operative field

g. 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:

a. Virtual reality

b. Use of robots/robotics

c. Three-dimensional imaging systems

d. 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.

Basic Laparoscopic Skills

1. Discuss techniques for gaining access to the abdomen, including:

a. Veress needle

b. Open (Hassan cannula)

c. Direct visualization trocars

2. Describe the sequence of steps involved in establishing a pneumoperitoneum, including:

a. Selection of first puncture site

b. Initial entry via Veress needle or Hassan cannula

c. Tests to confirm entry into peritoneum

d. Initial insufflation

e. Initial exploration of abdomen

f. 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.

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 LC.

3. Identify major considerations for the decisions involved in converting from laparoscopic to open cholecystectomy, including:

a. Difficulty identifying anatomy (i.e., common duct)

b. Poor visibility

c. 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:

a. Choice of approach (open common duct exploration, versus laparoscopic CBDE, versus LC followed by/preceded by endoscopic stone extraction)

b. Timing of surgery

c. Safety and cost-effectiveness of each approach

Additional Laparoscopic Procedures

1. Describe current theories, including advantages and disadvantages, regarding the use of laparoscopic anti-reflux procedures and myotomies.

a. Discuss advantages and limitations of thoracoscopic versus laparoscopic approach for esophagomyotomy.

b. Discuss indications and contraindications for addition of partial fundoplication to esophagomyotomy.

c. Describe management of paraesophageal hernia.

2. Outline the potential benefits and limitations to:

a. Laparoscopy-assisted colectomy

b. Pre- and trans-peritoneal groin hernia repairs

c. Laparoscopic ventral hernia repair

d. Appendectomy

3. Summarize other intra-abdominal laparoscopic procedures currently being performed, including:

a. Adrenalectomy

b. Gastrectomy

c. Splenectomy

d. Donor nephrectomy

Thoracoscopic Procedures

1. Identify the potential applications of thoracoscopic surgery, including:

a. Pulmonary resection

b. Lung biopsy

c. Pleurectomy/decortication

d. Esophageal surgery

e. Sympathectomy

2. Discuss anesthetic management of a patient undergoing thoracoscopy.

3. Discuss pros and cons of thoracoscopic versus open surgery for pulmonary disease.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

1. Provide assistance in laparoscopic surgery (e.g., manage camera, first assist).

2. Demonstrate familiarity with laparoscopic equipment, including setup and trouble-shooting:

a. Insufflator

b. Camera

c. Video equipment

3. Demonstrate understanding of basic principles of patient positioning and room setup for diagnostic laparoscopy and LC.

4. Perform entry of body cavities using open (Hassan cannula) and closed (Veress needle) access techniques.

5. Recognize when satisfactory pneumoperitoneum has been achieved. Demonstrate familiarity with danger signs (e.g., hypotension, hypercarbia) and appropriate action when patient does not tolerate pneumoperitoneum.

6. Perform MAS procedures of increasing complexity under supervision, including:

a. Diagnostic laparoscopy

b. LC

c. Laparoscopic appendectomy

d. Other procedures not requiring suturing or other advanced techniques

7. Demonstrate facility with laparoscopic suturing and knot-tying using a box trainer or other simulator.

8. Demonstrate the ability to convert from an MA to an open approach in a variety of surgical settings.

9. Perform appropriate preoperative work-up, and supervise postoperative care of patients undergoing laparoscopic procedures.

Senior Level:

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:

a. Laparoscopic hiatal hernia repair

b. Laparoscopic surgery for achalasia

c. Laparoscopic splenectomy

d. Laparoscopic inguinal hernia repair

4. Demonstrate understanding of uses of endoscopic ultrasound and other intraoperative adjuncts.

5. 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.

Residency Training in General Surgery