General Surgical Subspecialties Research Articles

Survey shows all surgical residents have exposure to robotic surgery yet no formalized curricula exist amongst programs: A Southwest Surgical Congress Survey

BackgroundIncreased robotic surgery exposure during general surgery training occurs at many institutions without a formal education curriculum. Our study evaluates the current state of general surgery robotic training within programs represented by the Southwestern Surgical Congress (SWSC). MethodsA web-based survey regarding robot-assisted surgery (RAS) and general surgery training was developed and sent to member institutions of the SWSC. General surgery program directors were asked to voluntarily complete the survey. Results were evaluated in aggregate. Descriptive analysis was used. ResultsIn total, 28 programs responded. All reported resident exposure to RAS during training. Case mix was diverse with exposure to multiple general surgical subspecialties. 89% of programs reported the presence of a formal RAS curriculum, however, only 53% reported recognition of training completion. Case volumes also varied amongst programs with 46% of programs reporting residents logging 21–40 cases and 35% logging more than 40 cases in total. ConclusionExposure to RAS among SWSC residency programs is ubiquitous, however, there is significant variation between programs in case volumes, case types, and elements of RAS curricula.

37. How Integrated are Plastic Surgery Residency Programs? Analyzing Discrepancy and Heterogeneity among Curriculums

Background: There are 84 integrated plastic surgery residency programs in the United States. Residents undergo six or seven years of training, with varying exposure to general surgery and other surgical subspecialties. This study evaluates the heterogeneity among integrated plastic surgery residencies to non-plastic surgery rotations. Methods: Curriculum as well as program integration data were obtained from individual programs’ websites, the Accreditation Council for Graduate Medical Education (ACGME), Doctority.co and Doximity websites. Data included number of weeks spent on general surgery and various general surgical subspecialties. Differences in average weeks spent on different services were compared via t tests. Results: Curriculum data from 76 integrated plastic surgery programs (86% of all programs) was analyzed. The average number of weeks spent in general surgery in total during the first three years of residency was 48.7 weeks across all programs. Residents in programs that were integrated for less than 10 years (n=33) spent 55.5 weeks in general surgery compared to 45.5 weeks for programs that have been integrated for 10+ years (n=43) (p=0.05). Residents in programs that were integrated for less than 10 years and longer than 10 years spent 1.8 and 0.39 weeks respectively (p=0.003) on colorectal surgery rotation with a similar trend for emergency general surgery (4.7 vs 1.8, p=0.004). Other rotations did not achieve statistical significance. Conclusion: No formal studies have been conducted to objectively and systematically demonstrate differences in curriculum breakdown for integrated plastic surgery programs. Understanding the heterogeneity in resident exposure to non-plastic surgery rotations can assist in improving current curricula and can assist new integrated plastic surgery residencies to achieve a balance in their curriculum.

Analysis of surgical mortality in rural South Australia: a review of four major rural hospital in South Australia.

BackgroundOne‐third of Australia's population reside in rural and remote areas. This audit aims to describe all‐causes of mortality in rural general surgical patients, and identify areas of improvement.MethodsThis is a retrospective multi‐centre study involving four South Australian hospitals (Mt Gambier, Whyalla, Port Augusta, and Port Lincoln). All general surgical inpatients admitted from June 2014 to September 2019 were analysed to identify all‐cause of mortality.ResultsA total of 80 mortalities were recorded out of 26 996 admissions. The overall mortality rate of 0.3% was the same as the 2020 Victorian state‐wide Audit of Surgical Mortality. No mortality was secondary to trauma. Mean age was 79 ± 11 years and ASA was 3.9 ± 1. Malignancy was associated in over a third of cases (41.2%), mostly colorectal and pancreatic. Most cases were related to general surgical subspecialties: colorectal (51.3%), upper gastrointestinal (21.3%), hepatopancreaticobiliary (13.8%); however, there were also vascular (6.3%) and urology (3.8%) cases. The most common causes of mortality were large bowel obstruction (13.4%), ischemic bowel (10.4%), and small bowel obstruction (7.5%). Majority of mortality were beyond the surgeon's control (73.8%). Of the 21 potentially preventable mortalities, 42.9% were attributed to aspiration pneumonia and decompensated heart failure. Only one (1.3%) mortality case was due to pulmonary embolism.ConclusionRural general surgical mortalities occur in older, comorbid patients. Rural surgeons should be equipped to manage basic subspeciality conditions. To further reduce mortalities, clear protocols to prevent aspiration pneumonia and resuscitation associated fluid overload are needed.

Variations in practice of thromboprophylaxis across general surgical subspecialties: a multicentre (PROTECTinG) study of elective major surgeries.

Despite guidelines recommending perioperative thromboprophylaxis for patients undergoing general surgery, we have observed significant variations in its practice. This may compromise patient safety. Here, we quantify the heterogeneity of perioperative thromboprophylaxis across all major general surgical operations, and place them in relation to their risk of bleeding and venous thromboembolism. Retrospective review of all elective major general surgeries performed between 1 January 2018 and 30 June 2019 across seven Victorian hospitals was conducted. A total of 5912 patients who underwent 6628 procedures were reviewed. Significant heterogeneity was found in the use of chemoprophylaxis, timing of its initiation, type of anticoagulant administered and application of extended chemoprophylaxis. These variations were observed within the same procedure, and between different surgeries and subspecialties. Contrastingly, there was minimal heterogeneity with the use of mechanical thromboprophylaxis. Oesophago-gastric, liver and colorectal cancer resections had the highest thromboembolic risk. Breast, oesophago-gastric, liver, pancreas and colon cancer resections had the highest bleeding risk. Perioperative chemoprophylaxis across general surgery is highly variable. This study has highlighted key areas of variance. Our findings also enable surgeons to compare their practices, and provide baseline data to inform future efforts towards optimizing thromboprophylaxis for general surgical patients.

Adoption of robotic technology in Turkey: A nationwide analysis on caseload and platform used.

Limited data exist regarding adoption of evolving robotic technology in surgery. This study evaluated trends and the current condition of robotic platforms in surgical specialties and general surgical subspecialties. Between January 2013 and December 2017, all robotic operations performed in Turkey were included. In the study period, 13760 robotic operations were performed at 32 hospitals. The median numbers of general surgical procedures were 43and eight cases per hospital and per general surgeon, respectively. The high-volume general surgeons performed 1734 (81%) of the cases. Forty-five percent and 55% of the general surgical operations were performed with the Xi and S/Si robots, respectively. Use of the Xi platform seems to increase caseload in general surgery operations possibly by facilitating robotic colorectal surgery. Targeting the high-volume centres and surgeons for further training and implantation of upcoming robotic technology can be more effective in terms of increasing case volume and improving outcomes.

Vascular and Endovascular Surgery (3rd edn)

The Companion to Specialist Surgical Practice series was first published in 1997. There was a core textbook and another seven, one for each of the general surgical subspecialties. They rapidly established themselves as the ‘must-have’ textbooks for those in higher surgical training in the UK and the unofficial revision guides for the intercollegiate examination. Second editions arrived in 1997 and the third editions in 2006. The latest vascular text is slightly shorter than before (410 pages) and some authors have been changed. The 19 chapters are mostly written by vascular surgeons and radiologists. Each chapter is intended as a summary of current thinking and evidence-based practice is highlighted and referenced. The editors state that the book is intended for trainees but also for established consultant surgeons to update themselves. This is the first medical book that I have read from cover to cover for over 15 years. I enjoyed it a lot and learned more than a little. Most chapters are well written and superbly referenced. The ‘scalpel code’ of evidence was invariably appropriate with prejudice creeping in only occasionally. It is as up-to-date as possible but even now some studies eagerly awaited in the literature have already been published. I noticed only one spelling mistake and one amusing error in the colour plates (can you spot it?). I learned most from the non-surgical chapters on epidemiology, angioplasty, the diabetic foot and vasospastic/vasculitic disorders. Of the others, the chapter on carotid disease is out-standing. As an exercise in trawling the evidence, expertly processing its relevance, then condensing it into a digestible form (so that the reader may perhaps use it to help make a judgement on an individual patient), it is flawless. It made me think about my own practice and encouraged further reading. All authors asked to contribute to this sort of text should read it. If you are a vascular surgeon who hasn't read a book for years, I can recommend it and you might as well read this one. I have vowed to read the next edition. The current edition is now the perfect source to look up references. Vascular trainees will buy this book anyway. They should trawl through it its contents thoroughly and repeatedly before taking the examination and should use it to extend their reading to the most important references. Not all aspects of vascular surgical practice are covered but I cannot think that there is a better book to act as a basis for study. Do not, however, assume that your examiner will agree with everything stated in it. Not all the opinions are evidence-based and some have stimulated lively (and I stress healthy) debate on my unit. The chapters that deal with our bread and butter – the assessment and treatment of chronic lower-limb ischaemia – stimulated most. I would also hope that general surgical trainees would read this book before they pass through a vascular unit on their rotation. The knowledge imparted would certainly enable them to get more out of their placement. This book is the vascular trainees' bible. It has the power to influence a whole generation of vascular specialists and is, therefore, very important. On the whole, it is an excellent effort that achieves what it sets out to do. It is the right size, the right price and aimed at the right level.

Vascular and Endovascular Surgery (3rd edn)

The Companion to Specialist Surgical Practice series was first published in 1997. There was a core textbook and another seven, one for each of the general surgical subspecialties. They rapidly established themselves as the ‘must-have’ textbooks for those in higher surgical training in the UK and the unofficial revision guides for the intercollegiate examination. Second editions arrived in 1997 and the third editions in 2006. The latest vascular text is slightly shorter than before (410 pages) and some authors have been changed. The 19 chapters are mostly written by vascular surgeons and radiologists. Each chapter is intended as a summary of current thinking and evidence-based practice is highlighted and referenced. The editors state that the book is intended for trainees but also for established consultant surgeons to update themselves. This is the first medical book that I have read from cover to cover for over 15 years. I enjoyed it a lot and learned more than a little. Most chapters are well written and superbly referenced. The ‘scalpel code’ of evidence was invariably appropriate with prejudice creeping in only occasionally. It is as up-to-date as possible but even now some studies eagerly awaited in the literature have already been published. I noticed only one spelling mistake and one amusing error in the colour plates (can you spot it?). I learned most from the non-surgical chapters on epidemiology, angioplasty, the diabetic foot and vasospastic/vasculitic disorders. Of the others, the chapter on carotid disease is out-standing. As an exercise in trawling the evidence, expertly processing its relevance, then condensing it into a digestible form (so that the reader may perhaps use it to help make a judgement on an individual patient), it is flawless. It made me think about my own practice and encouraged further reading. All authors asked to contribute to this sort of text should read it. If you are a vascular surgeon who hasn't read a book for years, I can recommend it and you might as well read this one. I have vowed to read the next edition. The current edition is now the perfect source to look up references. Vascular trainees will buy this book anyway. They should trawl through it its contents thoroughly and repeatedly before taking the examination and should use it to extend their reading to the most important references. Not all aspects of vascular surgical practice are covered but I cannot think that there is a better book to act as a basis for study. Do not, however, assume that your examiner will agree with everything stated in it. Not all the opinions are evidence-based and some have stimulated lively (and I stress healthy) debate on my unit. The chapters that deal with our bread and butter – the assessment and treatment of chronic lower-limb ischaemia – stimulated most. I would also hope that general surgical trainees would read this book before they pass through a vascular unit on their rotation. The knowledge imparted would certainly enable them to get more out of their placement. This book is the vascular trainees' bible. It has the power to influence a whole generation of vascular specialists and is, therefore, very important. On the whole, it is an excellent effort that achieves what it sets out to do. It is the right size, the right price and aimed at the right level.

Medical student electives in general surgical subspecialties

Background The purpose of the study was to evaluate how well the burn, trauma, and peripheral vascular third-year medical school electives meet the objectives of the six ACGME core competencies. Methods Medical school graduates from 1999 to 2002 completed a survey that consisted of 13 demographic/miscellaneous questions, and 28 core competency questions. Results In all, 168 of 500 students responded for a 34% response rate. All three general surgical electives ranked above average in meeting objectives in the areas of: basic science, performing complete histories and physicals, writing logical and legible notes, creating complete assessments and plan, making decisions with evidence based medicine, performing basic procedures, interpreting test results, and maintaining professional attitudes. The burn elective ranked significantly higher in 16 of 28 objectives ( P <0.05) and the trauma elective ranked significantly higher in two of 28 objectives ( P <0.05). Conclusions Despite a narrower professional focus, three general surgical subspecialty electives meet objectives in five of the six competencies set forth by the ACGME (and adopted by our medical school as objectives for the ideal graduate). The highly organized and structured burn elective can be used as a template for improving all surgical rotations to meet the six core competencies for third-year students.

Mismatch between trainees' subspecialist interest and advertised jobs; worrying implications for upper gastrointestinal trainees

AIMS: The aim of this study was first to assess the primary subspecialist interests of general surgical specialist registrars who were accredited and still looking for a consultant position, or who were within 3 years of their CCST (certificate of completion of surgical training). These interests were then compared with subspecialist interests declared in consultant vacancies advertised in the British Medical Journal over the preceding 16 months. METHODS: All trainees in general surgery holding a national training number in six regions (Mersey, North West, Trent, Yorkshire, Northern, West Midlands) were identified, and those accredited or within 3 years of their CCST (n = 136) were telephoned to ascertain their primary subspecialist interest, whether they had a higher degree and what their desired consultant job would be. The consultant vacancies advertised in the British Medical Journal between 3 January 1998 and 8 May 1999 were assessed according to the required subspecialist interest. RESULTS: Upper gastrointestinal surgery is the second most popular subspecialty (n = 37; 27 per cent of trainees) after colorectal surgery (n = 40; 29 per cent of trainees). However, there were fewer consultant vacancies in upper gastrointestinal surgery (31 of 226; 14 per cent of jobs) than in any of the other three main subspecialist areas of general surgery (colorectal, vascular and breast/endocrine). The ratio of percentage of jobs to percentage of trainees was lowest in upper gastrointestinal surgery (0.50), compared with colorectal (0.77), vascular (0.89) and breast/endocrine (2.23) surgery. CONCLUSIONS: Upper gastrointestinal surgery appears to be the most competitive of the general surgical subspecialties at present, having by far the lowest ratio of jobs to trainees. In addition, 87 per cent of upper gastrointestinal trainees have or are completing a higher degree, and 43 per cent expressed a desire to work in a teaching hospital.

General surgery, the general surgical subspecialties, and prerequisite training.

Currently, several specialties (cardiothoracic, pediatric, and colorectal) require a full general surgery residency before specialty training. Plastic surgery has, in essence, a de facto requirement since most residents have had at least 5 years of general surgery training before initiation of a plastic surgery residency. Forces within both general surgery and plastic surgery will dictate that such a de facto requirement will not persist in the future. The pressures that compel plastic surgery to modify the traditional role of general surgery as preparatory training for requisite or specialty residency training can be extended by analogy to the other specialties as well. This article will hypothesize that the premises and the conclusions about the relationship between plastic surgery and general surgery apply equally well to the other specialties. If the traditional and historical role of full general surgery residency as prerequisite training for a specialty residency is discarded, careful thought must be given to any substitute system to graduate surgical education. In particular, attention must be directed to the three components of clinical skills to be acquired and to an expectation of operative or technical experience.

The Next Generation of Surgical Residencies

I suggest restructuring general surgical residencies to facilitate training of surgical specialists and subspecialists. Basic surgical education for 1 or 2 years should provide a foundation of fundamental cognitive, technical, and patient management skills useful for all surgery residents, regardless of discipline. Intermediate surgical education for an additional 2 or 3 years should amplify cognitive, technical, and clinical skills and senior responsibility in general surgery for individuals entering a general surgical subspecialty or for advanced general surgery training. Residents seeking a career in advanced general surgery would take 2 additional years of training in advanced surgery. Such individuals could pursue additional subspecialty training and research experience to qualify as academic surgical scientists. Implementation of such innovations in general surgical education awaits the cooperative joint efforts of appropriate accrediting and certifying organizations, specialty societies, and surgical program directors.