Department of Hepatopancreaticobiliary and gastro surgery
Grande International Hospital Kathmandu.
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
Course Director – Dr. Rakesh Kumar Sah
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
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.
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.
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.
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.
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.
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%
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:
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:
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:
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:
Fellows must demonstrate a commitment to carrying out professional responsibilities and sensitivity to a diverse patient population. Fellows are expected to perform the following;
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:
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
Systems affected by Pneumoperitoneum
• Air way
• Respiratory system
• Cardiovascular System
Other Relevant systems
• Central nervous system
• Endocrine 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.
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:
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
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.