Surgery Syllabus

Chair:

Kenneth D’Amato, DO FAOAO (kdamato@vcom.vt.edu)

Rotation Credit Hours:

Goals

Practice - The student will become familiar with the characteristics of the practice of general surgery, including knowledge base required, manner of patient communications, intermittent patient encounters, and aspects of clinical reasoning, lifestyle considerations, and continuing education issues.
Surgical / Clinical Reasoning - The student will develop knowledge and skills in learning to differentiate between elective, urgent, and emergent surgical clinical problems from the perspective of clinical reasoning skills.
Communication - The student will develop the ability to transmit information through a concise, accurate and timely oral presentation as well as documenting their History and Physical and record progress notes in the hospital chart where applicable.

Rotation Description

During the third year surgery rotation, students expand their knowledge of surgical conditions and gain the ability to apply this knowledge in the clinical setting. The curriculum is taught through VCOM TV on-line lectures, assigned readings, grand rounds, and through one-on-one student-preceptor experience in caring for patients in the clinical setting. The Core Surgery Competencies that are to be gained in the third year are found below.

Clinical Setting in Which Rotation Occurs
The practice of surgery occurs in the outpatient office setting and in the inpatient setting. Due to the variety of practice opportunities and formats in surgery, students should review their specific site instructions for a more detailed description of their specific practice setting.

Requirements for Completion

Required Textbooks:

Sabiston Textbook of Surgery, Townsend, Beauchamp, Evers, Mattox; 18th edition. (Available in electronic format on the VCOM Library)
Somatic Dysfunction in Osteopathic Family Medicine, Kenneth E. Nelson; Chapter 10 – The Surgical Patient

Recommended:

Cope’s Early Diagnosis of the Acute Abdomen, 21st edition, by William Silen.

Requirements for Successful Completion of the Surgery Rotation:

Attendance according to VCOM and preceptor requirements (see Student Handbook)
Completion of all Clinical Modules in the Required Curriculum
Clinical Procedure Log and Learning Contract
1. Surgery Procedure Log
2. Surgery Learning Contract
Preceptor Evaluation form at end-of-rotation
Successful completion of the end-of-rotation written exam.
The pediatric end-of-rotation exam questions will be derived directly from the specific objectives presented in each of the below modules.

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Clinical Modules - Required for Completion

The surgery curriculum is delivered through the 20 following modules which cover the core topics and clinical conditions most commonly practiced in surgery. The surgery end-of-rotation exam questions will be derived directly from the reading assignments and the video presentations from the below topics.

*Note: Unless otherwise noted, all reading assignments below are from the text: Sabiston Textbook of Surgery, Townsend, Beauchamp, Evers, Mattox; 18th edition.

1. Shock [+]

Reading Assignment: Pages 69-70, 95-111
VCOM TV video: Shock – Basic Approach and Management (Powers – MS3 Video)
Objectives:
1. Discuss mechanisms of shock
2. Describe the pharmacologic treatment of shock
3. Discuss the surgeon’s response to shock
4. Describe hypovolemic shock and its recognition and treatment
5. Describe recognition and treatment of septic shock
6. Describe the treatment of hypotension in septic shock
7. Describe the recognition and treatment of cardiogenic shock
8. Describe the recognition and treatment of shock caused by cardiac contusion and tamponade
9. Describe the recognition and treatment of shock from massive pulmonary embolism
10. Discuss shock associated with adrenal insufficiency

2. Wound Healing [+]

Reading assignment: pages 191-213
Objectives:
1. Describe tissue injury and response
2. Discuss wound-healing phases
3. Describe the inflammatory phase of wound healing
4. Describe the proliferative phase of wound healing
5. Describe the maturational phase of wound healing
6. Discuss abnormal healing including keloid formation and chronic nonhealing wounds
7. Discuss the effect infection, hypoxia, diabetes, ionizing radiation, aging, malnutrition and drugs play in would healing
8. Describe fetal wound healing
9. Discuss types of wound dressings including negative pressure-assisted wound closure.

3. Preoperative Care [+]

Reading assignment: pages 251-269
Objectives:
1. Describe the elements in the preoperative preparation of a patient
2. Discuss the systems approach to preoperative evaluation
3. Describe immunologic and hematologic elements in preoperative assessments
4. Discuss additional preoperative decisions including age, nutritional status, and obesity
5. Define a preoperative checklist.
6. Discuss prophylactic antibiotic use
7. Describe the elements of mechanical bowel cleansing, review of medications and preoperative fasting

4. Postoperative Complications [+]

Reading assignment: pages 328-350, 353-355, 358-360, 364-365
Objectives:
1. Describe diagnosing and treating surgical wound complications including seroma, hematoma, dehiscence and surgical site infections.
2. Describe the complications of thermal regulation including hypothermia, malignant hyperthermia and postoperative fever.
3. Describe pulmonary complications and their treatment
4. Discuss pulmonary embolism and venous thromboembolism and their treatment
5. Describe cardiac complications and their treatment
6. Discuss cardiogenic shock and its treatment
7. Describe the recognition and treatment of renal and urinary tract complications
8. Describe the recognition and treatment of gastrointestinal complications
9. Discuss Clostridium difficile Colitis and its treatment
10. Describe the recognition and treatment of neurologic complications

5. Anesthesia [+]

Reading assignment: pages 440-448, 454-456
Objectives:
1. Describe preoperative evaluation for the patient undergoing anesthesia
2. Describe airway assessment
3. Describe assessment of physical status using the ASA classification
4. Discuss the factors behind selection of anesthetic techniques
5. Describe what is involved in postanesthesia care in terms of complications and treatment

6. Trauma / Burns [+]

Reading assignment: pages 482-485, 560-571
Objectives
1. Discuss the surgeon’s role in trauma management
2. Describe the initial management of trauma
3. Discuss the pathophysiology of burns including burn classification
4. Describe the initial treatment of burns
5. Describe escharotomies
6. Discuss the recognition and treatment of inhalation injuries

7. Breast [+]

Reading assignment: pages 851-891
Objectives:
1. Review the anatomy of the breast
2. Discuss breast development and physiology, both normal and abnormal
3. Describe the diagnosis of breast disease
4. Describe breast imaging
5. Identify and manage high-risk breast patients
6. Describe benign breast tumors and related diseases with attention to diagnosis and treatment
7. Describe the pathology and classification of primary breast cancer
8. Describe staging systems used in breast cancer
9. Discuss the surgical treatment issues in breast cancer
10. Describe recognition and treatment of special conditions in the elderly, Paget’s disease and men.
11. Describe the modern concept of breast cancer classification using molecular markers.
12. Discuss adjuvant chemo- and radio- therapies

8. Abdomen [+]

Hernias

Reading assignment: pages 1155-1167
Objectives:
1. Describe inguinal hernia incidence, and the anatomy of the inguinal area
2. Describe how herniae are diagnosed
3. Discuss the classification of herniae
4. Discuss the nonoperative and operative management of herniae

Acute Abdomen

Reading assignment: pages 1180-1196
VCOM TV video: The Acute Abdomen
Objectives:
1. Define what is meant by Acute Abdomen
2. Discuss the anantomy and physiology of the region
3. Describe historical information which assists in the diagnosis of acute abdomen
4. Describe the physical examination of the acute abdomen
5. Discuss laboratory and imaging studies used to diagnose the acute abdomen
6. Describe the differential of the acute abdomen
7. Discuss the preparation for emergency surgery.
8. Describe atypical situations where acute abdomen is seen and its treatment
9. Describe the algorithm for management of the acute abdomen
10. Discuss the role of endoscopy
11. Develop a familiarity with the differential diagnosis
12. Describe the indications for surgical exploration

Peptic Ulcer Disease

Reading assignment: pages 1236-1256
Objectives:
1. Discuss the epidemiology and pathogenesis of peptic ulcer disease.
2. Describe the clinical manifestations of peptic ulcer disease.
3. Describe the diagnosis of peptic ulcer disease.
4. Describe nonoperative and operative treatment for peptic ulcer disease.
5. Discuss postgastrectomy syndromes secondary to gastric resection.

Gastric Cancer

Reading assignment: pages 1259-1269
Objectives:
1. Discuss the epidemiology, risk factors, pathology, clinical presentation, preoperative evaluation and staging of adenocarcinoma of the stomach.
2. Describe surgical options, palliative treatment, adjuvant therapy, outcomes and surveillance for gastric cancer.

Benign Gastric Lesions

Reading assignment: pages 1272-1274
Objectives
1. Define and discuss diagnosis and treatment for the following lesions: Mallory-Weiss tears, gastric varices, gastric volvulus and bezoars

Crohn’s Disease

Reading assignment: pages 1297-1307, 1384-1388
Objectives:
1. Describe the history, incidence and epidemiology, etiology, pathology of Crohn’s disease.
2. Discuss the clinical manifestations and diagnosis of Crohn’s disease.
3. Discuss management of specific problems associated with Crohn’s disease, e.g., Acute ileitis, obstruction, fistula, free perforation, gastrointestinal bleeding, urologic complications, cancer, colorectal disease, duodenal disease.
4. Describe the prognosis of Crohn’s disease.
5. Discuss Crohn’s colitis in terms of its etiology, pathology, diagnosis, treatment options and prognosis.

Appendicitis

Reading assignment: pages 1333-1345
VCOM TV video: Acute Appendicitis (D’Amato – Block 5 Video)
Objectives:
1. Describe the embryology and anatomy of the appendix
2. Discuss the historical perspective of appendicitis
3. Describe the pathophysiology of acute appendicitis
4. Discuss its diagnosis
5. Discuss its differential diagnosis
6. Describe the diagnostic algorithm for appendicitis
7. Describe its treatment
8. Discuss perforated appendix and an appendiceal abscess
9. Discuss chronic or recurring appendicitis
10. Discuss appendicitis occurring in the elderly.
11. Describe the diagnosis and treatment of appendiceal cancer.

Diverticular Disease

Reading assignment: pages 1364-1369
Online case: Diverticulitis
Objectives:
1. Define diverticular disease
2. Discuss its pathogenesis
3. Discuss the diagnosis and treatment of uncomplicated and complicated diverticulitits
4. Discuss the diagnosis and treatment of complications associated with diverticulitis

Large Bowel Obstruction

Reading assignment: pages 1371-1373
Objectives:
1. Discuss the classification, diagnosis and treatment of large bowel obstruction and pseudo-obstruction

Ulcerative Colitis

Reading assignment: pages 1373-1383
Objectives:
1. Describe the epidemiology, etiology, pathology, clinical presentation and extraintestinal manifestations of ulcerative colitis
2. Discuss the diagnosis of ulcerative colitis
3. Discuss nonoperative and operative treatment options for ulcerative colitis
4. Discuss the operations used for ulcerative colitis
5. Discuss postoperative care of ulcerative colitis

Colon Cancer

Reading assignment: pages 1392-1411
Objectives:
1. Discuss colorectal cancer genetics and specific genetic mutations
2. Describe what is meant by “mismatch repair genes”.
3. Discuss the adenoma-carcinoma sequence
4. Describe colorectal polyps, their diagnosis and treatment.
5. Discuss issues involved in hereditary cancer syndromes
6. Describe and discuss sporadic colon cancer
7. Describe treatment options for colon cancer

Metastatic Liver Disease

Reading assignment: pages 1507-1511
Objectives:
1. Discuss diagnosis and treatment of metastatic hepatic lesions

Cirrhosis

Reading assignment: pages 1526-1529
Objectives:
1. Describe the evaluation and treatment of the patient with cirrhosis

Biliary System and Gallbladder Disease

Reading assignment: pages 1556-1577
Online cases: Gallbladder 1 and 2
VCOM TV video: Gallbladder Disease
Objectives:
1. Discuss the epidemiology, pathogenesis natural history clinical presentation, diagnosis and management of a patient with acute and chronic calculus cholecystitis
2. Discuss the epidemiology, pathogenesis natural history clinical presentation, diagnosis and management of a patient with choledocholithiasis
3. Discuss surgery for biliary disease.
4. Describe the recognition and treatment of the postcholecystectomy syndrome
5. Discuss the diagnosis and treatment of gallstone ileus.
6. Discuss the diagnosis and treatment of recurrent pyogenic cholangitis
7. Discuss noncalculous biliary disease, its diagnosis and management
8. Describe the anatomical arrangement of the hepatobiliary system
9. Cite pertinent historical and physical examination facts related to gallbladder disease
10. Differentiate among the various diagnostic modalities used to diagnose hepatobiliary disease
11. Explain treatment options for gallbladder diseases including gallstones, acute and chronic cholecystitis, Emphysematous cholecystitis, gallstone ileus, bacterial cholangitis, choledocholithiasis and carcinoma of the gallbladder and bile duct
12. Discuss the complications as well as the prognosis in dealing with these disorders

Pancreas

Reading assignment: pages 1594-1610, 1612-1619
Objectives:
1. Define and classify pancreatitis
2. Discuss the pathology and etiology of pancreatitis
3. Describe the pathophysiology of acute and chronic pancreatitis
4. Describe the presentation of an acute attack.
5. Discuss the diagnosis and differential diagnosis of acute pancreatitis
6. Discuss the prognosis and treatment of an acute attack.
7. Describe the pathology, etiology, diagnosis and treatment of chronic pancreatitis.
8. Describe the management of chronic pain associated with pancreatitis.
9. Discuss malignant pancreatic tumors, their diagnosis, treatment and prognosis.

Splenic Trauma

Reading assignment: pages 1635-1643
Objectives:
1. Discuss general considerations behind splenic trauma
2. Discuss the diagnosis of splenic trauma
3. Describe the indications for exploration, the technical issues and splenorrhaphy.
4. Discuss nonoperative care for splenic trauma.

9. Arteries [+]

Reading assignment: pages 1954-1977
Online case: Abdominal Aortic Aneurysm
Objectives:
1. Discuss pathophysiology, reperfusion syndrome, etiology , presentation and evaluation of acute thromboembolic disease
2. Discuss the management of acute thromboembolic disease
3. Discuss pathophysiology, reperfusion syndrome, etiology , presentation and evaluation of chronic occlusive disease of the lower extremities
4. Discuss the cardiac risk factors and management issues in patients with chronic occlusive disease of the lower extremities
5. Discuss pathology, pathophysiology, diagnosis and treatment of renovascular occlusive disease
6. Discuss pathology, pathophysiology, diagnosis and treatment of mesenteric ischemia

10. Veins [+]

Reading assignment: pages 2005-2016
Objectives:
1. Discuss primary venous insufficiency in terms of its pathogenesis, risk factors, symptoms, physical exam findings, diagnostic evaluation and indications for treatment.
2. Discuss deep venous thrombosis in terms of its etiology, diagnosis, prophylaxis and treatment.

11. Fluid, Electrolyte and Acid-base disorders [+]

VCOM TV Video: Fluid, Electrolyte and Acid-Base Disorders
Objectives:
1. Describe normal body composition
2. Discuss principles of normal fluid maintenance
3. Recognize and treat water and electrolyte disorders
4. Recognize and treat acid-base disturbances

12. Lung nodules [+]

VCOM TV video: Lung Nodules
Objectives:
1. Describe various benign lung conditions and their management
2. Diagnose and manage patients with lung cancer
3. Make rational decisions faced with an incidental radiographic finding of a pulmonary nodule
4. Recognize various diagnostic measures used to differentiate pulmonary nodules

13. Neck masses [+]

Reading assignment: pages 930-934
Online case: Adult Neck Mass
VCOM TV video: Neck Masses
Objectives:
1. Identify key anatomic relationships in the neck
2. Describe an organized approach to the examination of the neck
3. Diagnose common neck lesions in childhood and in adults based on historical features, physical findings and investigative studies
4. Discuss basic concepts of head and neck tumors
5. Describe the work-up and diagnosis of a solitary thyroid nodule
6. Discuss the evaluation and differential diagnosis of a patient with a thyroid nodule
7. Discuss treatment options for thyroid nodules
8. Select appropriate treatment options for common abnormalities including malignancies of the thyroid gland

14.Perianal problems [+]

Reading assignment: pages 1440 - 1450
VCOM TV video: Perianal Problems
Objectives:
1. Describe the important anatomical landmarks of the anorectal area
2. Define the causes and treatment of pelvic floor disorders including incontinence, obstruction, and rectal prolapse
3. Diagnose and treat benign common anal disorders such as hemorrhoids, anal fissures, anorectal abscess and fistula as well as pilonidal disease
4. Describe the treatment options for anal canal neoplasms
5. Describe the clinical presentation, diagnostic evaluation, non-operative and surgical treatment for hemorrhoids.
6. Describe the clinical presentation, diagnostic evaluation, non-operative and surgical treatment for anal fissure.
7. Describe the clinical presentation, diagnostic evaluation, non-operative and surgical treatment for anorectal suppuration.
8. Describe the clinical presentation, diagnostic evaluation, non-operative and surgical treatment for pilonidal disease.

15. GI Hemorrhage [+]

Reading assignment: pages 1199-1220
VCOM TV video: GI Hemorrhage
Objectives:
1. Define the different types of GI bleeding
2. Describe the different causes of Upper and Lower gastrointestinal bleeding
3. Discuss certain historical and physical characteristics of a GI history and physical examination
4. Describe diagnostic modalities used to diagnose GI bleeding disorders
5. Develop familiarity with the treatment and prognosis of gastrointestinal bleeding
6. Describe the approach to the patient with acute gastrointestinal hemorrhage
7. Describe acute upper gastrointestinal hemorrhage in terms of specific causes, diagnosis and management
8. Describe acute lower gastrointestinal hemorrhage in terms of specific causes, diagnosis and management
9. Describe and discuss diagnosis and treatment of acute gastrointestinal hemorrhage from obscure sources
10. Discuss specific causes of small bowel bleeding, diagnosis and treatment.

16. Abdominal Wall and Groin Masses [+]

Reading assignment: pages 1155-1167
VCOM TV video: Abdominal Hernia
Objectives:
1. Discuss current treatment for hernia
2. Describe operative treatment of Inguinal hernia
3. Describe non-surgical approaches for treatment
4. Discuss prognosis

17. OMM for the surgical patient [+]

Reading assignment: Chapter 10 – “The Surgical Patient” in Somatic Dysfunction in Osteopathic Family Medicine, by Kenneth E. Nelson
Objectives:
1. Discuss the role OMM plays in the preoperative through late postoperative phases of surgical care
2. Describe the indications and techniques of inhibitory pressure, compression of the fourth ventricle, cervical, thoracic and lumbar maneuvers, rib raising and balancing, pedal pump, pectoral traction to enhance diaphragmatic motion and indirect wound scar release.

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Clinical Performance Objectives

While the end-of-rotation exam is derived from the didactic curriculum and objectives described above in the “Clinical Modules – Required Curriculum” section, the end-of-rotation evaluation completed by your surgery preceptor is based on clinical core competencies. Your end-of-rotation evaluation from your preceptor will be based directly on your performance in the following core competencies listed as follows:

Medical Knowledge – the student will be able to demonstrate medical knowledge related to the clinical modules and specific conditions discussed by the surgery preceptor.
Communication Competencies
1. The student will be able to demonstrate a complete pre-surgical history including the significant components of:
  1. Chief complaint
  2. History of chief complaint (or present illness)
  3. Previous medical history
  4. Previous surgical history and complications
  5. Medications and previous side effects
  6. Allergies
  7. Coagulopathies or blood disorders
  8. Pregnancy state
  9. Family history
  10. Social history
2. Anesthesiology – the student will be able to perform a pre-surgical risk assessment, including:
  1. Goldman’s criteria
  2. Coagulopathies
  3. ASA classification
  4. Cardiopulmonary risk factors
  5. Neurological risk factors
3. The student will demonstrate effective communication so as to:
  1. Gain the confidence of the patient
  2. Develop an appreciation of the effect of age, racial and cultural background, and economic status on the health of the patient.
  3. Document the patient’s history in a well-organized written and oral report.
  4. The student will accurately and legibly write preoperative, and postoperative chart notes and orders at the discretion of the preceptor and institution.
Clinical Skills
1. The student will be able to:
  1. Perform a focused examination as it relates to the presenting surgical condition
  2. Perform a complete physical examination as it relates to pre-surgical clearance
  3. Perform an exam on an acute trauma patient, using ABCD protocols of trauma
  4. Interact with the patient to assure comfort and privacy
2. The student will be able to:
  1. Generate a differential for the most common surgical conditions
  2. Develop a management plan which includes:
    1. Appropriate laboratory and diagnostic studies
    2. Determination of surgical treatment needed
    3. Determination of urgency of surgical treatment needed
    4. Provide for patient education
    5. Plan for continuing care
  3. The student will demonstrate:
    1. Principles of sterile procedure
    2. Prevention of nosocomial infection
    3. Implementation of Universal precautions
    4. Prevention of HIV infection
    5. Assessment of metabolic implications of surgery
      1. Metabolic and nutritional assessment
      2. Calculation of patient needs
      3. Principles of delivery per catheter, feeding tube, etc.
    6. Identify the indications for various imaging techniques for surgical cases
    7. Implement the appropriate rehabilitation during the post-operative period
    8. Perform the following surgical skills at the request and guidance of the surgical staff:
      1. Surgical scrub and gown
      2. Venous and arterial line placements
      3. Arterial blood gas and interpretation
      4. Bladder catheterization
      5. Nasogastric tube placement
      6. Stapling and suturing of skin (wound and incision repair)
      7. Suture or staple removal
      8. Calculate parental feedings
    9. Assist the surgeon in the surgical suite on common surgical procedures
Professional and Ethical Behaviors and Skills
1. The student will know and explain to their preceptor the following as to patient’s legal rights:
  1. Informed consent
  2. Right to refuse care
  3. Transfusion consent
  4. Surrogate decision makers
  5. Options and alternatives
  6. Risk management
  7. Contractual nature of medical care
  8. Advanced directives and how they relate to surgery
2. The student will follow all HIPPA and Confidentiality rules
3. The student will treat all patients and members of the health care team with respect
4. The student will arrive on time and stay until all patient care is completed
5. The student will accurately document and honestly identify errors, assume responsibility and correct any errors in an appropriate manner.
6. The student will arrive prepared for all patient duties and cases.
Osteopathic Principles
1. The student will consider the whole patient attending to surgical, mental, spiritual, and cultural needs.
2. The student will counsel the patient on risk factors and prevention when appropriate.
3. The student will perform soft tissue, indirect, and muscle energy techniques, when appropriate, under the preceptor’s observation.

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For Students Surgery Clerkship Requirements (3rd Year)
•	Surgery Syllabus
•	Required Booklist
•	Evaluation Forms; Clinical encounter log, procedure logs

Surgery Rotation Sites & Faculty
•	Meet the Surgery Faculty
•	Surgery Site-Specific Instructions

Surgery Fellowship and Career Information
•	Surgery Fellowships and Careers
•	Surgery Web Links and Resources

For Faculty
•	Faculty Development and CME Program
•	Useful Faculty Development Links (go to Quick Links)
•	Clinical Faculty Application
•	Preceptor Evaluation of Students

SURGERY

For Students

For Faculty

Surgery Syllabus

Chair:

Rotation Credit Hours:

Goals

Rotation Description

Requirements for Completion

Clinical Modules - Required for Completion

Clinical Performance Objectives