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DEPARTMENT OF SURGERY
The Department of Surgery comprises 11 divisions, which are described below. Its full-time faculty are responsible for the care of patients and the instruction of residents both at University Medical Center and the Northport Veterans Affairs Medical Center. Furthermore, the Department provides an academic and administrative umbrella over all the activities of the residency program.
The Burn Division manages University Medical Center's eight-bed specialized Burn Center, which is staffed, equipped, and designed to provide state-of-the-art care to both adult and pediatric patients with major burns. The Burn Center admits more than 100 seriously burned patients each year; of these 30% to 40% are pediatric cases. Having recognized the highly complex needs of burn patients and their families, the Burn Center staff is multidisciplinary in its approach to the planning and coordination of care for the patient.
The burn care team includes physicians and nurses specially trained and with many years of experience, in addition to physical therapists, dieticians, occupational therapists, respiratory therapists, and social workers, all of whom are experienced in the management of burn patients. This team approach allows for the integration of all aspects of burn care so that rehabilitation of patients with major burns can be achieved. Moreover, research in growing human skin for burn treatment is part of the Burn Center's effort to develop a unique living-skin bank, which reflects Stony Brook's commitment to support the most advanced medical care.
The Burn Center offers a unique opportunity for residents to obtain specialized training in the care of burn patients. This includes initial assessment of the injury and resuscitation, intensive care and surgical management of the patient, and restoration of the individual to an acceptable level of quality of life.
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Cardiothoracic Surgery Division
The Cardiothoracic Surgery Division manages the most active clinical service in the Department. In 1999, this service performed 910 adult open-heart procedures and 155 adult thoracic procedures. This is not simply a coronary service: the resident is introduced to the whole spectrum of cardiopulmonary surgery, including neonatal, valve reconstructive, electrophysiological, videothoracoscopic, and thoracic aortic surgery. Third- and fourth-year residents participate in these operations, and with a second-year resident, run University Medical Center's 10-bed cardiovascular intensive care unit, which is capable of providing postoperative care for the highest-risk heart patients.
The aim of the general surgery resident rotations on the cardiothoracic service is to formulate a solid foundation in cardiopulmonary physiology and medicine, to learn and perform thoracic surgical incisions, to develop a practiced understanding of vascular surgical principles, and to gain confidence when working around the heart and great vessels, particularly in trauma situations. Ample opportunity is afforded to gain experience and understanding in bronchoscopy, cardiac catheterization and angiography, the heart-lung machine, and the intra-aortic balloon pump.
One of four graduating residents in the general surgery program, during the last six years, has chosen to pursue fellowship training in cardiothoracic surgery, and they have matriculated at programs at top institutions that include New York University, University of Alabama-Birmingham, Texas Heart Institute, Case Western Reserve University, University of Rochester, and Tufts University.
Cardiac surgical conferences are held each week, in addition to a biweekly cardiac surgery seminar. The division has three ongoing databases to facilitate clinical research, and ongoing projects in homograft vein bypass's, cardiovascular accident prediction and prevention, and papillary muscle resuspension. Among current research projects are: angioscopic adjuncts to coronary artery surgery; myocardial mechanics and energetics; myocardial protection by cardioplegia; new endogenous myoprotective strategies utilizing preconditioning, and immunomodulation during cardiopulmonary bypass. Resident participation in the division's research activities on a formal or informal basis is encouraged, and several residents have presented their findings at national meetings.
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General/Gastrointestinal Surgery Division
The General/Gastrointestinal Surgery Division provides highly specialized care for patients with a broad spectrum of problems requiring surgical intervention. Among the procedures performed by the faculty in this division are advanced minimally invasive surgery, including hernia repair and antireflux surgery; laparoscopic cholecystectomy; and major hepatobiliary reconstruction.
In addition to standard gastrointestinal surgery, this service functions as a tertiary care referral center for hepatobiliary disease, pancreatic disease, and other complex cases including inflammatory bowel disease, major gastrointestinal bleeding, and cases requiring operation or re-operation upon the biliary tree. A state-of-the-art endoscopy lab has been established, offering residents hands-on training experience in the latest videoscopic surgical techniques.
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Otolaryngology–Head and Neck Surgery Division
The Otolaryngology–Head and Neck Surgery Division is responsible for the treatment of both adult and pediatric patients with disorders of the ear, nose and throat. The otolaryngology team includes a neuro-otologist, with special expertise in neurologic aspects of hearing and balance; and a rhinolaryngologist, with special expertise in laser therapy for problems of voice and throat, as well as expertise in sinus endoscopy and functional nasal surgery. The head and neck team includes two specialized head and neck surgeons, in addition to a general surgeon with expertise in head and neck surgery and members of the Plastic and Reconstructive Surgery Division.
The Otolaryngology–Head and Neck Surgery Division also houses the Speech, Language and Hearing Program. This program serves as an additional point of entry to the service delivery system of University Medical Center, and its team works closely with the otolaryngological surgeons, to meet audiologic needs (hearing evaluation—including brainstem testing—and rehabilitation). In addition, speech and voice evaluation and treatment services are provided. Neurologic, physiologic and functional speech, hearing and language disabilities are also seen on referral from medical staff.
The Otolaryngology–Head and Neck Surgery Division is responsible for the treatment of patients with a wide variety of head and neck disorders at both University Medical Center and the Northport VA Medical Center. A multidisciplinary approach to the treatment of head and neck tumors is followed. All patients are discussed at a biweekly teaching conference attended by interdepartmental staff with expertise in therapeutic radiology, medical oncology, oral surgery, general surgery, and otolaryngology-head and neck surgery. This teaching conference provides an excellent opportunity for the training of residents in the diagnosis and treatment of disorders of the head and neck region with special emphasis on benign and malignant tumors. An active educational program focuses on bedside rounds, operating room teaching and didactic teaching in the form of lectures and conferences.
This division offers an independent, approved five-year residency in otolaryngology-head and neck surgery. The first year is the general surgery year. During the second and fourth years, otolaryngology-head and neck surgery residents work closely with general surgery residents on the head and neck service at the Northport VA Medical Center, and residents in both specialties are expected to learn the management of the common head and neck problems.
In the head and neck clinic, residents are instructed in the methods used in performing a comprehensive head and neck physical examination. The differential diagnosis and therapeutic plan are discussed with the attending physician who supervises at clinic sessions. In the operating room, the residents perform and assist at a variety of head and neck surgical procedures with a special emphasis on intricate oblative and reconstructive surgery for head and neck cancer. Residents have the opportunity to utilize the latest of surgical equipment, including flexible and ridged fiberoptic instrumentation, carbon dioxide surgical laser, and the operating microscope.
The mission of the Otolaryngology–Head and Neck Surgery Division is to provide a comprehensive service for patients of University Medical Center and to offer a range of clinical experience for residents and fellows at Stony Brook. Laboratory programs are currently being developed in the Health Sciences Center for a full complement of clinical and basic scientific studies including temporal bone analysis. A number of specialty clinics dealing with a wide variety of problems have been established.
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The Pediatric Surgery Division manages an active clinical service. Residents assigned to the pediatric surgery service, during their general surgery rotations, participate in the preoperative, operative, and postoperative care of general surgical, thoracic, and endoscopic problems in children ranging from premature infants through adolescents. This service also provides residents with experience in the ambulatory care unit of University Medical Center as well as the neonatal intensive care unit, pediatric intensive care unit, pediatric acute care unit, and Burn Center. Close association with the Department of Pediatrics and concurrent patient management are stressed.
General surgery residents at the second- and fourth-year levels rotate through the service. A pediatric resident may also be a member of the team. Newborn congenital anomalies, pediatric tumors, and trauma constitute the most demanding areas of surgical care. Inguinoscrotal abnormalities and diseases producing intestinal obstruction, bleeding, or inflammation provide a good educational exposure for the resident. The general surgery resident is expected to learn the management of common pediatric surgical diseases and to improve his or her technical skills and surgical background by involvement with specialized index cases.
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Plastic and Reconstructive Surgery Division
The Plastic and Reconstructive Surgery Division provides reconstructive and aesthetic surgery for the care of both children and adults. Problems commonly managed are congenital anomalies of the head and neck, particularly cleft lip and palate, cancer of the head and neck requiring excision and reconstruction, injuries of the hand, deformities following burns, trunk and lower extremity deformities, and body-image problems necessitating aesthetic surgery. Conventional surgical approaches, as well as microsurgical techniques, are used.
Members of this division direct an active clinical program in reconstructive microsurgery at University Medical Center, and specialize in microsurgical reconstructive operations involving free-tissue transfers used for some of the most clinically vexing problems that, until recently, were virtually unsolvable. Residents have the opportunity to learn current approaches and techniques in plastic and reconstructive surgery. The Plastic Surgery Indications Conference, held once a month, further enhances our residents' educational experience in this subspecialty.
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The Surgical Oncology Division is responsible for the care of patients with breast cancer, gastrointestinal malignancies, soft tissue sarcomas, and melanomas. Residents assigned to rotations on the general surgery service participate in the preoperative evaluation and diagnosis of patients with various types of tumors. Residents are involved in the staging, planning and implementation of multimodality therapy, as well as the performance of definitive cancer operations including extensive exenterative resections. Postoperative management, rehabilitation, selection of patients for adjuvant therapy, and follow up are other aspects of cancer management in which residents actively participate.
In the overall care of patients with cancer, the surgical oncology team works closely with the attending staff of several other departments and divisions, including medical oncology, radiation oncology, pathology, radiology, gastrointestinal medicine, and gynecologic oncology. There are numerous teaching conferences concerned with oncology, among which are the surgical oncology rounds, multimodality tumor board, and mammographic-pathologic correlation conference. As patients treated by the surgical oncology team have the opportunity to participate in national cooperative clinical trials, residents are able to gain an especially broad experience in the management of patients with cancer.
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The Surgical Research Division is dedicated to basic science research related to surgery. With the help of an excellent technical staff and dedicated surgical residents, it has revitalized the research efforts within the Department. Much progress has been made towards the Department's goal of becoming a nationally and internationally recognized center for the study of the metabolic and nutritional alterations produced by surgery and other stress conditions.
A number of "core" laboratories have been established within the Department. The services provided by these labs are available to all investigators within the Department—all faculty, fellows, and residents—in an effort to facilitate ongoing research efforts, and to aid those investigators wishing to gather preliminary data for future research and/or grant applications. Residents may elect to spend a year or two within this division to gain basic science research skills.
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The Transplantation Division was one of the first specialized tertiary care divisions established in the Department. Its research activities in histocompatibility received international recognition by the award of the Nobel Prize in Medicine to Professor Jean Dausset of Paris in 1980, in part as a result of the joint collaborative work he performed with this division's founder, Dr. Felix T. Rapaport. The Transplantation Division's Histocompatibility Testing Center has continued to maintain close collaborative ties with Dr. Dausset, and his laboratories, now at the National Center for the Study of the Human Genome, University of Paris, continue to serve as the reference facility for the Transplantation Division. The Transplantation Division has an ongoing research program in organ preservation and transplantation, and has continued investigative efforts designed to induce transplant tolerance in various species.
Currently, 36 to 40 clinical kidney transplants are performed annually by the transplant team with a high success rate. A number of ongoing clinical investigative programs have developed from this new patient population, which includes postoperative recipients as well as approximately 100 patients throughout the Long Island region now awaiting renal transplantation at Stony Brook.
Residents rotate through the clinical transplantation service during their training period. Special emphasis is given to the importance of bringing problems from the bedside to the laboratory, and to the development of skills designed to permit investigators to return laboratory advances to the bedside. Full-time research and clinical fellowships are available to qualified personnel.
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Trauma/Surgical Critical Care Division
The sections of trauma and surgical critical care have recently been combined into a single division. This division is responsible for the initial management of all injured adult patients at University Medical Center. General surgery residents provide 24-hour in-house coverage of the trauma service. They perform the initial assessment of the traumatized patient, coordinate the diagnostic work-up, perform surgery as indicated, and co-manage all trauma patients in the 20-bed surgical intensive care unit (SICU). To gain the fundamentals of trauma care, all residents on entering the residency program receive special training that leads to certification in advanced trauma life support (ATLS).
As a Level I trauma center, University Medical Center provides both primary and tertiary care of trauma patients for a large catchment area. The hospital is serviced by Medivac helicopter, a mobile ICU, and is the center for advanced life support (ALS) prehospital care control. All critically ill patients managed in the SICU are co-managed by the trauma team and the attending staff of this specialized unit.
This division provides pre- and post-operative care for all classes of surgical patients, with the exception of open-heart patients and burn patients who are treated in other specialized units managed by the Department of Surgery. All aspects of patient care, including invasive hemodynamic monitoring, pulmonary support, nutritional support, preoperative evaluation and preparation of the patient for the operating room, and all aspects of postoperative care are performed in the SICU. Residents rotating through the unit learn how to manage a broad array of clinical problems in a heterogeneous patient population.
Rounds take place at least twice daily and serve both as teaching rounds as well as work rounds. Additionally, residents usually participate in rounds conducted by the primary team responsible for each patient. All procedures done in the SICU are performed by the residents assigned to the unit. An interdisciplinary trauma conference reviewing the care and course of all patients admitted to the trauma service is held weekly.
The division actively pursues both clinical and basic science investigations. The Trauma Research Laboratory is a mature unit pursuing investigations relating to metabolic alterations attending both hemorrhagic and septic shock states. Ongoing clinical research focuses on the use of studies of nutrition and body composition, hemostatic fibrin agents, laparoscopic trauma intervention, and body-water alterations attending shock and resuscitation.
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The Vascular Surgery Division is responsible for the treatment of patients with a wide variety of vascular disorders, at both University Medical Center and the Northport VA Medical Center. Between the two institutions more than 400 major reconstructive procedures are performed each year, including aortic, renal mesenteric, extracranial cerebral vascular, and peripheral arterial reconstruction. The Vascular Surgery Division is also responsible for the care of patients with portal hypertension as well as the maintenance of angio access for two large dialysis centers. Numerous other procedures such as amputation, muscle flaps, venous reconstruction, and skin grafting procedures necessary for the total care and rehabilitation of patients suffering from vascular-related diseases are also performed by the Vascular Surgery Division.
General surgery residents rotate on the vascular services as junior residents and return again during their fourth or fifth years. In senior years, the resident is expected to obtain a good deal of operative experience. While the Vascular Surgery Division offers an approved residency (fellowship) in general vascular surgery, the senior chief resident does not rotate on the same service with the fellow; thus, the vascular fellow in no way diminishes the surgical responsibility of the general surgery resident on the vascular services. The goals of teaching residents, at all levels, the care of patients with vascular disease are met through teaching in the form of lectures and conferences, as well as at the bedside and in the operating room.
The Noninvasive Vascular Laboratory houses a wide variety of up-to-date equipment, including Duplex scanners and transcranial Doppler units, used not only as aids in the diagnosis of circulatory disorders, but also in the follow-up of a large number of outpatients. The Noninvasive Vascular Laboratory is complemented by an excellent special procedures division of the Department of Radiology, which likewise has the latest in angiography equipment and CT scanners, at both University Hospital and the Northport VA Medical Center. The special procedures division provides service in all the techniques of interventional radiology, including balloon dilatation, invasive pressure monitoring and therapeutic embolization.
General surgery residents also gain experience in vascular surgery during their rotation on the vascular surgery service at Winthrop-University Hospital. This service, under the direction of Dr. George L. Hines, does a high volume (about 500 cases per year) of vascular surgery, including both categories I and II cases.
The Vascular Surgery Division will continue to grow and expand its scope of diagnosis and treatment of circulatory disorders. The general surgery resident is expected to obtain a good understanding of the physiology and pathophysiology of the vascular system and to become familiar with the techniques of vascular reconstructive surgery.
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