Fellowship in Minimal Invasive and Hepatopancreaticobiliary Surgery

                 

Department of Hepatopancreaticobiliary and gastro surgery

Grande International Hospital Kathmandu.

 

Introduction

 The practice patterns of General and GI Surgery has changed significantly in the last three decades as a result of the increasing use and availability of rigid and flexible Endoscopes for both diagnostic and therapeutic techniques. These changes are occurring from time to time and continue rapidly with increasing the performance of Advanced Laparoscopic procedures. Residents and General Surgeons who have completed their training in conventional open surgeries and are entering the practice of general surgery must be familiar with and must be well trained and educated in these areas of surgery. Laparoscopy should be significant part of their practice and with time will become more important and more widely used.

 

Duration of training program – Two years

Criteria for enrollment

  • Masters or equivalent in general surgery.
  • Must have passed Nepal Medical council licensing examinations

Course Director – Dr. Rakesh Kumar Sah

Mentors:

            Dr. R P Chaudhary

            Dr. A K Kashyap

       

Course advisor: Dr. T D Yadav

 

 

AIM OF THE TRAINING:-


The aim of this programme is to adequately prepare general surgeons in the art of Minimal access and hepatopancreaticobiliary and gastro surgery which will benefit the patients.

Curriculum is designated under the following heading

Objectives:

Gaining laparoscopic skills is very important. Skill in conventional surgical Procedure does not necessarily confer skills in Laparoscopic surgery. The course is aimed at bridging this gap and is formulated with the following objectives in Mind.

 

  • To master the tactile sensation, altered hand and eye co-ordination due to the length and design of instruments and the absence of three dimensional depth perception due to two dimensional representation of the three dimensional abdominal cavity.
  • To learn about specialized Laparoscopic equipments and instrumentation.
  • To learn the principles of Laparoscopic surgery.
  • To learn the indications, contra-indications and limitations of MIS and Various procedures.
  • To perform abdominal insufflations using Verses needle.
  • To perform laparoscopic procedures on live animal models in the purposeful, wet laboratory in association with J&J Ethicon Lab. G. Learn to perform on human patients.
  • Sterilization and maintenance of instruments and video equipments.
  • Documentation, storage data and presentation.
  • Anesthesia in laparoscopic surgery.
  • Aim to practice MIS as an armamentarium.
  • Improving knowledge and trouble shooting in MIS.
  • Electro surgery and other newer energy sources.
  • Learning about prosthetic meshes and fixation devices.
  • To learn about tissue marcellators and organ retrieval systems.
  • To known about the complications and its managements in MIAS
  • Basic and advanced skills in Endo-knotting and intracorporal suturing techniques.
  • To understand all the basic principles (instruments, materials, equipment and anesthesia) and be able to perform the most frequently used basic laparoscopic techniques
  • To be able to perform basic technical tasks in laparoscopic surgeryincluding   intracorporal suturing and knot tying techniques, two hand coordination for dissection  and safe use of energy sources.
  • To be able to describe results and potential complications of laparoscopic procedures and manage them.
  • To be able to perform some advanced laparoscopic procedures like in fields of HBP, Bariatric, Upper GI, Hernia and Colorectal surgeries and have hands on experience of advance procedures.

TEACHING AND TRAINING ACTIVITIES

 

The fundamental components of the teaching program should include:

 

1. Case presentations & discussion- once a week

2. Seminar – Once a month

3. Journal club- Once a month

4. Grand round presentation (by rotation departments and subspecialties) - once a week

5. Faculty lecture teaching- once a month

6. Clinical Audit-Once a Month

7. A poster and have one oral presentation at least once during their training period in a recognized   conference.

8. Interdepartmental meeting.

  The rounds will include bedside sessions, file rounds & documentation of case history and  examination, progress notes, round discussions, investigations and management plan) interesting and difficult case unit discussions. The training program will focus on knowledge, skills and attitudes (behavior), all essential components of education. It is being divided into theoretical, clinical and practical in all aspects of the delivery of the rehabilitative care, including methodology of research and teaching.

 

Theoretical:

 

The theoretical knowledge would be imparted to the candidates through discussions, journal clubs, symposia and seminars. The students are exposed to recent advances through discussions in journal clubs. These are considered necessary in view of an inadequate exposure to the subject in the undergraduate curriculum.

 

Clinical:

 

         The trainee will be attached to a faculty member to be able to pick up methods of history taking, examination, prescription writing and management in rehabilitation practice.

 

Bedside: The trainee will work up cases; learn management of cases by discussion with faculty of the department.

 

 

Journal Clubs:

 

This will be a weekly academic exercise. A list of suggested Journals is given towards the end of this document. The candidate would summarize and discuss the scientific article critically. A faculty member will suggest the article and moderate the discussion, with participation by other faculty members and resident doctors. The contributions made by the article in furtherance of the scientific knowledge and limitations, if any, will be highlighted.

 

 

Research

 

COMPONENTS OF THE PROGRAME

 

The activities of the fellow will be a blend of clinical experience, research, and teaching responsibilities for medical students and General Surgery residents. Clinical experience is to include both operative time and clinic hours. Prior fellows have performed both basic science research, as well as clinical research. Topics have varied from surgical education to virtual reality simulation. Teaching responsibilities will range from formal Grand Rounds presentations for the Department of Surgery to informal clinical instruction in the operating room and surgical clinic. The activities will be divided as follows:

• Clinical- 60%

• Research-20%

• Teaching/Education-20%

 

PATIENT CARE

 

Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to perform the following:

 

  • Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families.
  • Gather essential and accurate information about their patients.
  • Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.
  • Develop and carry out patient management plans.
  • Counsel and educate patients and their families.
  • Use information technology to support patient care decision and patient education.
  • Perform competently all medical and invasive procedures considered essential for the area of practice.
  • Provide health care services aimed at preventing health problems or maintaining health.
  • Work with health care professionals, including those from other disciplines, to provide patient- focused care.

 

MEDICAL KNOWLEDGE

 

Fellows must demonstrate knowledge about established and evolving biomedical, clinical, and cognitive (epidemiological and socio-behavioral) sciences and the application of this knowledge to patient care. Fellows are expected to perform the following:

  • Demonstrate an investigatory and analytic thinking approach to clinical situations
  • Know and apply the basic and clinically supportive sciences which are appropriate to their discipline.

 

 

 

 

 

 

 

PRACTICE-BASED LEARNING AND IMPROVEMENT

 

Fellows must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Fellows are expected to perform the following:

  • Analyze practice experience and perform practice-based improvement activities using a systematic methodology
  • Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
  • Obtain and use information about their population of patients and the larger population from their patients are drawn
  • Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and of information on diagnostic and therapeutic effectiveness
  • Use information technology to manage information, access on-line medical information, and supplement their own education
  • Facilitate the learning of students and other health professionals.

 

 

INTERPERSONAL AND COMMUNICATION SKILLS

 

Fellows must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients’ families, and professional associates. Fellows are expected to perform the following:

 

  • Create and sustain a therapeutic and ethically sound relationship with patients
  • Use effective listening skills and elicit and provide information using effective nonverbal, explanatory questioning, and writing skills
  • Work effectively with others as a member or leader of a health care team or other professional group.

 

PROFESSIONALISM

 

Fellows must demonstrate a commitment to carrying out professional responsibilities and sensitivity to a diverse patient population. Fellows are expected to perform the following;

 

  • Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and families that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and ongoing professional development
  • Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical treatment, confidentiality of patient information, informed consent, and business practices.
  • Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities.

 

SYSTEMS-BASED PRACTICE

 

Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Fellows are expected to perform the following:

 

  • Understand how their patient care and other professional practices affect other health care  professionals, the health care organization, and the larger society and how these elements of the system affect their own practice
  • Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
  • Practice cost-effective health care and resource allocation that does not compromise the quality of care
  • Advocate for quality patient care and assist patients in dealing with system complexities
  • Know how to partner with health care managers and health care providers to assess, coordinate, improve health care and know how these activities can affect system performance.

 

TRAINING PROGRAMME SYLLABUS

 

MINIMAL INVASIVE ABDOMINAL SURGERY: (Laparoscopic Surgery)

 

A. General Principles:

1. Equipment set up and trouble shooting

2. Patient preparation

3. Anesthesia and Monitoring

4. Access to abdomen

5. Creating pneumoperitoneum

6. Abdominal wall lift devices

7. Principles of laparoscopic haemostasis

8. Principles of Electosurgery

 

PREOPERATIVE EVALUATION FOR LAPAROSCOPIC SURGERY

 

1. Before surgery, evaluation by qualified anesthetist is mandatory. This should

Include:

Systems affected by Pneumoperitoneum

• Air way

• Respiratory system

• Cardiovascular System

Other Relevant systems

• Central nervous system

• Endocrine system

•Gastrointestinal system

 

Other relevant History

• Post anesthetic experience of the patient

• Post anesthetic family History of the patient

• Allergies to local anesthetics of the patient

• Medications taken in the past.

 

2. Monitoring and safety considerations which should include:

1. Breath sounds (Precardial or esophageal stethoscope)

2. Electrocardiogram (continuous)

3. Blood pressure, pulse (continuous, non invasive)

4. Continuous oxygen saturation (Pulse oximeter)

5. Expired carbon dioxide (Capnograph)
6. Temperature gauge

7. Ventilator and additional monitors (optional)

 

3. Fire prevention is a crucial safety consideration: The operating room is an oxygen rich environment. The ends of the fibro optic cables become extremely hot and can ignite drapes. Hence fire extinguisher should be placed just outside the laparoscopic theatre.

 

ADMINISTRATION

 

Setting up the laparoscopic surgery unit, quality control and assurance, creating  protocol for  management and organizing and coordinating of clinical meetings.

The course will ensure training in all three domains of learning i.e.

• Cognitive (Knowledge)

• Affective (Behavior, communications skills towards the patients)

•Psychomotor (Development of skills)

 

The syllabus consists of:

 

  1. Diagnostic Laparoscopy
  2. Laparoscopic Appendectomy
  3. Laparoscopic Cholecystectomy
  4. Laparoscopic Adhesiolysis

 

Advanced module in MIS FOR GENERAL SURGEONS:

 

1. Laparoscopic Herniaplasty

Direct – TEP REPAIR

Indirect – TAPP REPAIR

2. Laparoscopic Perforation Closure

3. Vagotomy and GJ (Stapling and Hand Suturing)

4. Nissen Fundoplication for GERD and Hiatus Hernia

5. CBD Exploration using C-Arm control

Laparoscopic Splenectomy

 

7. Assisted large and small bowel surgeries

8. Liver resections

9. Pancreatojejunostomy and Cystogastrostomy for Pseudocysts of pancreas.

10. Laparoscopic Rectopexy for prolapsed rectum.

11. Laparoscopic APR/Right and left colectomy

12. Trans – Hiatal Esophagectomy

13. Gastrectomy for Ca. Stomach

14. Meckels Diverticulectomy

15. Obesity surgery and Diabetic control surgery (optional)

       • Sleeve Gastrectomy

       • Gastric Bypass

16. Endoscopy / Colonoscopy

            Diagnostic as well as therapeutic.

 

 

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