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The Surgery Clerkships |
There are four categories of surgical rotation at UVM - General ("blue") Surgery, Vascular ("red")
Surgery, Cancer ("white") Surgery, and the Specialty Surgery block. Everyone is required to do two weeks of red,
two weeks of the specialty of their choice, and a month block of either blue or white surgery. There are only spots for one or
two students in white surgery at a time - blue surgery is by far the more common (and broadly applicable) experience.
During the surgery rotation, you'll learn how to function in an operating room, how to manage surgical patients on the
floor, an enormous amount of pathophysiology, and of course, tons of anatomy.
Call is generally q3 on the red service, q3-q4 on blue, q3 on white, and specialty dependent during the specialty weeks.
If you want to be a surgeon, many students recommend buying Lawrence's Surgery and reading as much as you can before
and during the rotation. If you don't want to be a surgeon, Lawrence is still a great resource to use for individual blocks.
Basic expectations by house staff:
Carry scissors, tape (both cloth and paper), some gauze, a few pairs of latex gloves in your size, and a few pens in
your pockets at all times.
Have a copy of Mont Reid or some similar resource (Surgical Recall is my favorite) with you and read it if you get
downtime. Know about the surgery you're doing if you're in the OR. This means you should have read about it. At a minimum,
memorize the pimp material from Surgical Recall. Ask questions about what you don't understand.
The fundamental drive by surgical house staff seems to be efficiency. If you can make their day less troublesome,
you score points. Most residents won't complain if you've collected and skeletonized the charts before rounds start (this
means that you've gotten the charts for the patients on your team in one location, you've gone from room to room and written
down the vitals for each patient in their chart, and you've started a reasonable progress note), but most prefer to at least
dictate the main body of the note, so don't take too many liberties.
It's easy to look and feel like an idiot, so don't worry about it. There's way more to know than you can possibly learn in
two months, so they can always find a way to stump you - don't worry about it.
Vascular ("Red") Surgery
At UVM, the Chairman of the Surgery Department (Dr. Shackford) is a vascular surgeon. The basic anatomy
involved here is the arterial tree - from the aorta out. It helps to review the major vessels before this rotation starts. This is
probably the most intense two weeks of the year - q3, lots of surgeries, lots of patients, not much sleep, early days that last
a long time.
You should familiarize yourself with the sections on arterial, venous, and lymphatic diseases in one of the major textbooks
(such as Lawrence). Know about atherosclerosis, diabetes, effects of smoking, peripheral vascular disease, and aneurysmal disease.
- AAA (Abdominal Aortic Aneurysm)
- Carotid Endarterectomy (CEA)
- Arterial Bypass
Just read all of the pimp questions on these three surgeries over and over again in Surgical Recall.
Basics:
AAA:
- Know the layers of the fascia in the abdomen.
- Know the renal arteries - where they are and why they're important (think about blood pressure, urine).
- Dr. Pilcher will give you a little red card with a bunch of statistics - memorize it - if they don't give
it to you in Maine, make sure you know what the indications are for surgery, the mortality of various conditions, etc.
CEA:
- Lots of anatomy up there. Think about the carotids and where they come from (different on each side!!), and what
they supply. Is it OK to occlude one carotid entirely (usually it's ok)? Why (Cirlce of Willis acts as collaterals)?
- What nerves are you worried about? What happens (specifically!!) if you hurt these nerves?
- What symptoms do you look for in a patient after the surgery?
- What are the indications for the surgery?
Bypass:
- There are tons of different arteries you can bypass. Know the arterial tree from the aorta down - aorta, iliac,
femoral/deep femoral, popliteal, anterior/posterior tibial (and something else), and pedal arteries. Just knowing the names
isn't enough - know what landmarks they use to change their names, know which arteries are branches of what other arteries
(pimp question: "Which branch of the deep femoral are you worried about damaging?" Answer: "There are no branches of the deep
femoral."). How do you check for perfusion (pulses, hair on the toes, cap refill, skin color or stasis changes, ABI)?
- Know the major veins of the leg - there are only a few, and I've forgotten most of them, but you can learn them
in 5 minutes.
- Also, the "compartments" of the different parts of the leg are crucial. Three thigh compartments, three calf compartments,
and they're dissimilar. Obviously, know which muscles are in which compartments.
Other stuff:
- Varicose vein stripping - don't worry too much about this.
- Claudication = leg pain on exertion, a symptom of poor perfusion.
- Make sure you understand how to interpret an ABI (ankle/brachial index).
General ("Blue") Surgery
This rotation includes the surgeries you'll most likely need to know about in most specialties. The
anatomy involved is mostly confined to the GI tract and the abdomen.
Read the sections on colorectal cancer, diverticular disease, appendicitis, gallstones, ulcer disease, and hernias. Knowing
the anatomy of the biliary tree and the vascular supply of the stomach, liver, gallbladder, intestinal tract and pancreas
pays dividends.
- Appendectomy
- Cholecystectomy
- Gastric Bypass
- Nissen Fundoplication
- Hernia Repair
- Laparotomy
- Bowel Resection
Basics:
Appendectomy:
- Know the layers of the fascia in the abdomen. Know McBerney's point. Know what guarding and rebound are and what they
signify (usually peritoneal inflammation).
- Know the pathophysiology of appendiceal pain - starts as visceral (RLQ pain) and as the peritoneum gets inflamed, the pain
becomes parietal.
- Know what a "surgical abdomen" is.
Cholecystectomy:
- Know the layers of the fascia in the abdomen.
- Know the classic presentation of cholecystitis ("gallstones").
- Know the biliary tree anatomy backwards and forwards - it comes up all the time.
Gastric Bypass:
- Know the layers of the fascia in the abdomen.
- Know stomach anatomy.
- Usually only performed by one surgeon, and you may not be assigned to her. Know the basics anyway.
Nissen Fundoplication:
- Know the layers of the fascia in the abdomen, and the anatomy of the thorax.
- Make sure you understand the principle of the surgery - by wrapping part of the stomach around the gastroesophageal sphincter,
you're helping to keep the sphincter competent, and you're helping to anchor that anatomy in the thorax (below the diaphragm),
which is why it's used for hiatal hernia as well as reflux.
Hernia Repair:
- Know the layers of the fascia in the abdomen. Know Hesselbach's Triangle. Know the difference between direct and
indirect inguinal hernias (direct = NOT through the inguinal canal - go figure).
- A "reducable" hernia is one in which you can push the herniated contents back through the hole.
- Kinds of hernias: inguinal, umbilical (the abdominal contents pooch through the bellybutton), ventral (ditto through the rectus
mucles - think linea alba), hiatal (the stomach rises above the diaphragm), others.
Laparotomy:
- Know the layers of the fascia in the abdomen. Know the layout of the organs in the abdomen. Know the major arteries of
every organ in the abdomen.
- This surgery is often not one you have time to prepare for - it's often "exploratory," meaning we don't know what's wrong but
we need to find out, often emergently.
- Don't confuse it with "laparoscopy," which means to use a laparoscope to perform a surgery. Laparotomy is usually an "open"
procedure, and it just means that you're looking in the abdomen.
- Know what a "surgical abdomen" is.
Bowel Resection:
- Know the layers of the fascia in the abdomen. Know the blood and nerve supply to the various parts of the intestinal tract.
- Know about mesenteric ischemia - the blood supply is compromised, and you get pain about an hour after you eat when the
intestines call for more blood and can't get it.
- Know what a "surgical abdomen" is.
Other Stuff:
- You may get to see a Whipple surgery - know what it is.
- You may work on hemorrhoids, fistulas, ulcers, the spleen, small bowel obstructions, intususseption, volvulus
(torsion), and a variety of other things. You probably won't get to work on ALL of these, but you're responsible for knowing
about them, anyway.
- Colot's triangle. The ligament of Treitz.
Transplant and Cancer ("White") Surgery
Out of your rotation of 4-6 students, only 1-2 will do white surgery. You'll see lots of breast and
thyroid disease. You'll be involved with, and understand, the emerging "sentinel node" procedures being studied here. You may get to spend some time on dialysis and
putting in "access" (bypasses) for dialysis.
You should familiarize yourself with the classifications of the various cancers. Know neck anatomy in detail. Know the
lymphatic system in detail. Know the nerves, arteries, and lymphatics of the thorax, breasts, and axillae. Know about basic
disorders of the thyroid.
- Lumpectomy / Mastectomy
- Thyroidectomy / Parathyroidectomy
- Adrenal Surgery
- Renal Transplant
Basics:
- You need to read about these surgeries in pretty extensive detail - there isn't a good thumbnail to give.
Other Stuff:
- You'll do lots of breast exams. If you're in Vermont, you'll get to be involved with "Sentinel Node Biopsy," an experimental
procedure where dyes are injected into the tumor site, and the nodes to which the dye travels are biopsied. If these nodes are
clear of cancer, it's likely that the cancer hasn't spread anywhere else, according to the theory.
- Know renal anatomy backwards and forwards, in addition to the fascial layers of the abdomen. You'll learn about
immunosuppressive and chemotherapeutic drugs - pay attention, they're fair game for pimping.
The Surgical Specialties
Anesthesiology:
- No call, relatively benign schedule.
- A major benefit is the practice you'll gain with IV's and particularly with intubation. You don't have to scrub or maintain
sterility.
- The drawback is the lack of "surgical" involvement (cutting, etc.).
Cardiothoracic:
- Call = q3. Lots of surgeries.
- A major benefit is the practice you'll gain with sutures - students are often allowed to close donor (veins from the leg)
sites with supervision. You get to take part in exciting and interesting surgeries.
- The drawback is the lack of sleep, and the high intensity of the rotation can be draining. High expectations from attendings
for students in CT.
Ophthalmology:
- No call, relatively benign schedule.
- A major benefit is the experience you'll gain in a specialty to which you may not otherwise be exposed.
- The drawback is the lack of "surgical" involvement (cutting, etc.).
Orthopedics:
- Call = q4. Lots of surgeries.
- A major benefit is the experience you'll gain with orthopedic problems, and the hands-on OR experience.
- Fairly intense two weeks, very high-powered.
Otolanryngology (ENT):
- Call = q3. Long surgeries.
- A major benefit is the expertise you'll gain with common diseases and with a difficult area of the anatomy.
- Difficult schedule.
Plastic Surgery:
- Call = q3. Lots of surgeries, good clinical experience.
- A major benefit is the expertise you'll gain in suturing, and you will be directly involved in assisting in surgeries with a particularly friendly group of attendings.
- Few drawbacks.
Urology:
- No call, relatively benign schedule.
- A major benefit is the practice you'll gain with prostate exams, with "male" medicine (urology is the male equivalent of
OB/Gyn - common, gender-specific problems), and obviously the expertise you'll gain in the renal and urinary systems. Also, the
attendings are generally very fun to work with - a relaxed atmosphere is the rule.
- The drawback may be the primarily male patient population.