OHSU

Curriculum

Table of Contents


Ethics, Professionalism, and Communication

Endoscopy

Laparoscopy

Open Skills

Ultrasound

Vascular Skills

Medical Student Introduction to Surgery Clerkship

Surgical Interest Group

 

Ethics, Professionalism, and Communication

Course Directors: Karen Deveney, M.D., Karen Kwong, M.D.

Curriculum Description:            

This course is designed to teach the learner principles of ethics, effective communication, and interpersonal and professionalism skills. The curriculum utilizes the book Ethical Issues in Clinical Surgery published by the American College of Surgeons, Editor in Chief, Mary H. McGrath, MD, MPH, FACS and includes four small group sessions consisting of 10-12 residents in each group, meeting 1.5 hours per session. Articles are read by learners weekly and discussed in small group sessions. Faculty and small groups discuss selected cases from Ethical Issues in Clinical Surgery as well as addressing associated questions from the book pertaining to the week's topic. The curriculum is a facilitated case-based discussion, with a different topic each week.    

  • Week 1: Confidentiality  
  • Week 2: Truth-telling and the Surgeon-Patient Relationship       
  • Week 3: End-of-Life Issues and Delivering Bad News
  • Week 4: Surgeons' Obligations to Patients and Society

Learners: All general surgery residents

Skill Training: Ethics, interpersonal and communication skills, professionalism, resources

Simulators: Standardized Patients

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Endoscopy  

Course Director: Kim C. Lu, M.D. FACS, FACRS

Curriculum Description PGY-2 and PGY-3:            

This course is designed to orient the learner with colonoscopy indications, complications, common bowel preps, and appropriate conscious sedation. The course is also designed to instruct the learner how to operate the various buttons, dials, and foot controls of a colonoscope. Additionally, participants will learn the anatomic landmarks that distinguish the various parts of the colon, become facile with reducing a loop of the scope in the sigmoid colon, intubating the terminal ileum, and retroflexion of the colonoscopy within the rectum. Lastly, learners will be instructed on how to biopsy abnormal pathology.

Learners: PGY-2 and PGY-3 general surgical residents

Skills Training: Indications, complications, common bowel preps and conscious sedation for colonoscopy. Operation and procedural techniques of colonoscope.

Simulators: Accutouch Colonoscope

Curriculum Description PGY-4 and PGY-5:            

This course covers common bowel preps used for colonoscopy, learning the varying degrees of the quality of a patient's bowel preparation, and instruction on appropriate conscious sedation and counter sedation. Learners will also become facile with intubating the terminal ileum, retroflexion of the colonoscope within the rectum, biopsies of abnormal pathology, and endoscopic polypectomy. Additionally, learners will be instructed on how to take care of common complications of endoscopic interventions.

Learners: PGY-4 and PGY-5 general surgical residents

Skills Training: Procedural techniques for colonoscopy, complication assessment and management of endoscopic interventions.

Simulators: Accutouch Colonoscope

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Laparoscopy

Course Director: Donn Spight, M.D.

Curriculum Description Overview: Learners will spend four two-hour sessions focusing on topics in laparoscopy to include equipment set-up and trouble shooting, physiology, patient selection, and commonly performed procedures. Learners will also be instructed and mentored toward technical proficiency in the five essential tasks defined in the fundamentals of laparoscopic skills (FLS) curriculum.  

Curriculum Description PGY-1:

The course will provide the learner with an understanding of tools commonly used in laparoscopic surgery (camera, harmonic, bovie, Kroner). Additionally, the course covers the basic methods of laparoscopic abdominal access and associated techniques, understanding complications associated with laparoscopic abdominal access, and the mechanisms and management of common technical problems encountered during operating room set up and laparoscopic abdominal access. The course also covers the physics and management of pneumoperitoneum (PP), cardiovascular and pulmonary consequences of PP, and complications and management of PP. Lastly, the course instructs learners on the basic principles and techniques of laparoscopic cholecystectomy.

Learners: PGY-1 general surgical residents

Skills Training: MISTEL Overview/Introduction encompassing, peg transfer, pattern cutting, endoloop, extracorporeal knot tying, and intracorporeal knot tying. Laparoscopic simulation overview and introduction including, camera task, lift and grasp, two handed targeting, bovie, clip, and bowel measurement. Tissue handling, two handed instrument technique, and needle positioning, basic skills for laparoscopic cholecystectomy.

Simulators: Laparoscopic Box Stations, Immersion Medical Laparoscopy Simulator

Curriculum Description PGY-2:            

This course is designed to provide learners with a proficient understanding of laparoscopic tools, basic methods of laparoscopic abdominal access and techniques and an understanding of complications and management associated with laparoscopic abdominal access. Additionally, learners will be instructed on the performance of safe laparoscopic cholecystectomy and intraoperative cholangiogram, as well as common errors during laparoscopic cholecystectomy, techniques to clear stones from the common bile duct, performance of laparoscopic appendectomy and G/J tube using t-fasteners.

Learners: PGY-2 general surgical residents

Skills Training: MISTEL peg transfer, pattern cutting, Endoloop, extracorporeal and intracorporeal knot tying, and slip knots. Laparoscopic simulation overview including camera task, lift and grasp, two handed targeting, bovie, bowel measurement. Laparoscopic cholecystectomy module basic skills. Tissue handling, two handed instrument technique, needle positioning, operating against the camera, ultrasonic scalpel use (including dissection), intracorporeal bowel stapling, and T-fasteners.  

Simulators: Laparoscopic Box Stations, Immersion Medical Laparoscopy

Simulator Curriculum Description PGY-3            

 This course is designed to teach residents the keys to performing a safe laparoscopic cholecystectomy and intraoperative cholangiogram. In addition residents will learn techniques to clearing stones from the common bile duct. Learners will also receive instruction on TEPP and TAPP surgical anatomy, how to set-up and perform a laparoscopic inguinal hernia repair, the common complications and failures of inguinal hernia repair, and the performance of a laparoscopic ventral hernia repair.

Learners: PGY-3

Skills Training: Needle positioning, intracorporeal and extracorporeal knot tying, slip knots, and running suture line. Tissue handling, two handed instrument technique, lap choley module basic skills, working against the camera, intracorporeal handling and manipulation of mesh, intracorporeal tacking, transfascial suturing, and laparoscopic bowel anastomosis.

Simulators: Laparoscopic Box Stations, Immersion Medical Laparoscopy Simulator, Animal Lab

Curriculum Description PGY-4        

This course covers the steps to performing a laparoscopic Nissen including potential technical complications. Residents will also learn the key steps to medial and lateral approach colon resection and the technical challenges associated with this procedure. This course is also designed to teach the proper set-up and steps to performing safe lap choley and lap duct exploration.

Learners: PGY-4

Skills Training: Review of two handed instrument technique, needle positioning, intracorporeal knot tying, slip knots, running suture line, running the bowel, and suturing with pledgets, FLS testing and LAP SIM testing. Special emphasis on working at irregular camera angles, performing laparoscopic transcystic common duct exploration using choledochal scope.

Simulators: Laparoscopic Box Stations, Animal Lab

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Open Skills

 

Director: Slate Wilson, M.D.

Curriculum Description:    

       This course covers instrument identification and handling, knot-tying instruction and assessment, suturing instruction and assessment, tissue handling, dissection, and wound closure. In addition, PGY-2 and PGY-3 residents will cover instrument and knot-tying, GI anastomosis-open, stapling-anastomosis and open and close laparotomy instruction. PGY-4 residents will receive advanced tissue handling and complex wound closure instruction. The course is designed to teach the basic properties of suture, identification of general surgery instruments, two-handed knot-tying technique, tying at depth, tying under tension, and instrument tying, proper needle-loading technique, and learning how to adjust the spacing of sutures on curved or jagged incisions. Residents will also receive instruction on the uses of stapler including;

  • Uses for GIA, endoGIA, and other stapling devices 
  •  Stapling technique for different tissues (vascular, gut, ect)
  • Types of stapled anastomoses

Learners will also review hand-sewn anastomosis including;

  • Types of gut anastomoses
  • Hand-sewn vs. stapled 
  •  One-Layer vs. two-layer
  • End-to-end vs. end-to-side vs. side-to-side

Residents will also be instructed on a two-layered, hand-sewn gut anastomosis.

Learners: All general surgical residents

Skill Training: Loading of needle driver, simple interrupted stitch, vertical mattress, horizontal mattress, U-stitch, corner stitch, figure-of-eight, simple running suture, running locked stick, running subcuticular, interrupted Lembert stitch for bowel anastomosis, continuous Cushing and Connell suturing technique for bowel anastomosis, loading staplers and firing them, and creating a stapled anastomosis.

Simulators: Suture boards with appropriate instruments, staplers with foam bowel.

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Ultrasound

Course Director: Bruce Ham, M.D.

Course Description:

    This course teaches the physics of ultrasound, ultrasound in a trauma setting, acute general surgical disorders, and interventional ultrasound. Residents will learn the essential terminology and principles of ultrasound and instruction on artifacts as they relate to imaging in acute surgical conditions. Additionally, learners will gain an understanding of pulse-echo principle, attenuation and its relationship to acoustic impedance, and how frequency and attenuation are attenuated when imaging superficial and deep structures. In a trauma setting, residents will learn how to:

  • Select uses (hemopericardium, hemoperitoneum, hemothorax, pneumothorax, sterna fracture, rib fracture)
  • Limitations
  • Clinical Applications
  • Transducer positions
  • Conditions that inhibit poor imaging

With regards to acute general surgical disorders, residents will learn how to manage;

  • Acute Cholecystitis
  • Abdominal aortic aneurysm
  • Deep vein thrombosis
  • Inguinal hernia

Wound Dehiscence Interventional ultrasound skills include:

  • Central venous access
  • Thoracentesis
  • Paracentesis
  • Radial Artery line insertion
  • Drainage of Cysts/Abscesses

Learners: PGY-2 surgical residents before surgical ICU rotation, all surgery residents before completion of training, other non-surgical residents and Critical Care Fellows

Skill Training: Operational and procedural techniques of SonoSite handheld ultrasound with two probes: variable frequency high speed linear array probe and variable frequency low speed curved array probe. Ultrasound use, limitations, techniques, and applications in trauma setting, acute general surgical disorders, and interventional management.

Simulators: Live models with SonoSite handheld ultrasound with two probes: Variable frequency high speed linear array probe and variable frequency low speed curved array probe. 

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Vascular Skills  

Course Directors: Erica L. Mitchell, M.D., Nicole Wheeler, M.D., Aaron Partsafas, M.D., Gregory G. Landry, M.D., Timothy K. Liem, M.D., Gregory L. Moneta, M.D.  

Curriculum Description PGY-1:

    This course is designed to familiarize residents with the vascular physical examination, performance of an ankle-brachial index (ABI), and to understand other non-invasive studies available for evaluating upper and lower extremity peripheral arterial disease. Additionally, residents will learn surgical instruments and sutures utilized in vascular reconstructions. Residents will also learn the basics of using ultrasound for vascular access in a simple model in preparation for subsequent module of using ultrasound to facilitate arterial and venous catheterization using a more complex model. Finally, residents will become familiarized with the placing of arterial lines and central venous catheters.

Learners: PGY-1

Skill Training: Performance of vascular physical examination, operation of hand held Doppler probe, perform ankle/brachial index, interpret noninvasive peripheral arterial examinations, and interpret and understand digital artery examinations. Identification and characteristics of instruments, suture, and needle types used in vascular surgery. Identification of names and characteristics of specific instruments used for minor/major amputations including different electric bone saws. Toe, transmetatarsal and above knee, and below knee amputation techniques. Operation of Site Rite and Sonosite ultrasound machines to visualize arteries and veins. Ultrasound guided visualization and access of arteries and veins in a simple model. Identification of anatomic landmarks to safely place arterial and central venous catheters. Develop an algorithm to maximize safety in placement of arterial and central venous lines, and knowledge of the use of Site Rite and Sonosite ultrasound for the placement of central venous catheters and arterial lines. Working knowledge of the complications that can occur and a treatment plan.

Simulators: Sphygmometer, Doppler probe, Duplex Ultrasound machine, basic vascular instrument set, amputation set, Stryker saw, Gigli saw, suture, pig's feet, Sonosite ultrasound, Site Rite ultrasound, Microcatheter sets, artificial artery/vein, Central Venous kits, line kits, Dummy model – half torso and Dummy model – wrist and hand.     

Curriculum Description PGY-2 and PGY-3:

      The purpose of this course is to familiarize residents to the more complex vascular studies available for evaluating vascular disease. Also, it is to familiarize residents with the basic techniques and exposures used commonly in vascular surgery, expand the residents' familiarity with using Duplex ultrasound in planning vascular reconstructions, and finally, to familiarize residents to the fundamentals of fluoroscopy and radiation safety.

Learners: PGY-2 and PGY-3

Skill Training: Interpretation of vein mapping studies (GSV, and LSV, Cephalic and Basilic veins), deep venous thrombosis and Chronic Venous Evaluation, the Carotid Duplex examination, and abdominal Duplex examination. Performing a transverse arteriotomy closed primarily in a PTFE model, a longitudinal arteriotomy and patch closure on a PTFE model, a circumferential arteriotomy and end-to-end anastomoses performed in a PTFE model, and a circumferential arteriotomy with a beveled end-to-end technique. Spatulation techniques, heel-first, toe-last sequence, and technique for releasing clamps after vascular anastomoses. Familiarization with Sonosite ultrasound machine, visualization of veins in the upper extremity with ultrasound, and real time ultrasound guided imaging. Familiarization with fluoroscopy units available in the operating room with regard to the control panel, position of the instrument and acquisition and saving of images.

Simulators: Duplex Ultrasound machine, Doppler probe, vascular instrument set with prolene suture, PTFE graft and Gortex graft, Sonosite ultrasound, C-arm, and radiation safety garments and monitoring devices.  

Curriculum Description PGY-4 and PGY-5:

     The purpose of this course is to familiarize residents to the essentials of radiology techniques and interpretation pertinent to vascular surgery. It is also to familiarize residents with complex techniques and exposures used frequently in vascular surgery, to expose the resident to the fundamentals of intra-operative angiography. Finally, the lab will also familiarize residents with the evaluation and treatment of ruptured abdominal aortic aneurysms.

Learners: PGY-4 and PGY-5

Skill Training: Interpretation of CTAs of the abdomen and thorax with respect to aneurysm sizing, assessment of aortic dissection and selection for endovascular grafts and secondary signs of possible visceral artery stenosis. Interpretation of angiograms with respect to aneurysm sizing, assessment of aortic dissection and selection for endovascular grafts and visceral and peripheral artery occlusive disease. Familiarization with parachuting technique, perform an end-to-side anastomoses when there is limited mobility of the vessel, and Carrel patch technique.  Perform side-to-side vascular anastomoses, technique for performing extra anatomic and anatomic tunnels associated with vascular grafting, familiarization with instruments and techniques of arterial endarterectomy, arterial embolectomy, and venous thrombectomy. Identification of radiographic anatomic landmarks to place femoral or axillary arterial catheters or sheaths, algorithm to maximize safety in placement of arterial catheters/sheaths, working knowledge of different contrast agents, drug interactions, complications and treatment plan if they occur. Identification and working knowledge of different sheaths and catheters most commonly used for intraoperative angiography and venography, and the steps in performing an intraoperative angiogram or venogram.

Simulators: Angiograms and CTA's, carotid and basic vascular instrument set, prolene suture, gortex suture, PTFE grafts, catheters and sheaths.

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Medical Student Introduction to Surgery Clerkship

Course Directors: Department of Surgery facilitates this course. Resident volunteers assist with workshops.

Curriculum Description:

This course focuses on teaching basic technical and patient management skills expected of any surgical intern using a hands-on approach and case-based scenarios. It includes deliberate practice sessions of all the listed technical skills with concurrent and summary feedback provided by residents and faculty. The emphasis is on preparing students to manage common problems encountered on ward patients. Students are asked to independently assess and form a plan of action for patient care (before conferring with the supervising resident) via mock pages as well as during their in-house call as the primary contact for all non-immediate life threatening problems.

Learners: Medical Students between Second and Third Year

Skill Training:  Basic Surgical Skills including knot tying, simple wound closure, and Bovie technique. Interpretation of common radiologic studies, familiarization of ultrasound use to place central venous lines and to diagnose the presence of free fluid in the abdomen or pericardium. Competently perform and describe techniques and difficulties in NGT placement, Foley placement, peripheral venous and arterial blood draws, and central line placements. Basic technique of radial arterial line placement. Management of common complains and emergencies encountered on postoperative ward patients as presented in mock scenarios. Understanding of the basic principles of electrolyte and fluid management and how various surgical conditions may affect management.

Simulation: Mock scenarios and suture boards with appropriate materials.

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Surgical Interest Group

Course Directors: Donn Spight, MD and Karen Kwong, MD

Curriculum Description:

Students will learn basic surgical skills, including laparoscopy, one-handed and two-handed knots, simple running stitch, subcutaneous stitch, interrupted and horizontal and vertical mattress stitch, subcutaneous stitch, interrupted and horizontal and vertical mattress stitches. Students will develop an awareness of the different types of sutures and their correct and potential uses.

Learners: Medical Students

Skill Training: Two-handed ties, one-handed ties, instrument tie, subcuticular suturing with no-tails knot tying, interrupted and mattress suturing. Use of laparoscopic camera focus, positioning, and appropriate maneuvering. Use of laparoscopic instruments and familiarity with ring transfer and pattern cut skill building.

Simulation: Laparoscopic box trainers and suture boards.

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