UNIT 5.1
NEONATAL
SURGERY
UNIT
OBJECTIVES:
Understand
the unique anatomic, pathophysiologic, and genetic conditions that affect the
fetus and neonate.
Learn
the principles of stabilization, appropriate preoperative diagnosis, and
preparation of the sick neonate.
Understand
the anatomic and physiologic principles which guide successful operative
repair of neonatal diseases.
Learn
principles of routine postoperative care and postoperative critical care
management.
Understand
how new techniques, such as fetal surgery, may offer alternatives for
treatment of certain neonatal diseases.
COMPETENCY-BASED
KNOWLEDGE OBJECTIVES:
Junior
Level:
Learn the embryology, anatomy and physiology of common neonatal surgical diseases:
1.
Describe the cardiac, pulmonary, blood volume, and gastrointestinal
changes of post-partum transitional physiology.
2.
Describe relevant mechanisms (conductive, convective, evaporative, and
radiant) of neonatal thermoregulation.
3.
Describe how neonatal renal function (decreased concentrating ability)
affects the pharmacokinetics of commonly used drugs and antibiotics.
4.
Describe factors influencing neonatal immunologic immaturity and how
this increases susceptibility to common neonatal pathogens.
5.
Describe appropriate fluid and electrolyte management of the full-term
neonate.
6.
Describe the nutritional requirements of the full-term neonate, and
calculate appropriate enteral and parenteral nutritional support.
7.
Describe the embryology of neonatal organ systems and their common
congenital anomalies, including:
a.
Craniocervical:
dermoid cysts, branchial cleft cysts, and fistulas
b.
Foregut:
esophageal atresia/tracheoesophageal fistula, duodenal atresia
c.
Respiratory:
cystic adenomatoid malformation, congenital diaphragmatic hernia
d.
Cardiac: common
cyanotic and acyanotic cardiac malformations
e.
Midgut:
intestinal atresia, malrotation, meconium ileus
f.
Hindgut:
Hirschsprung’s disease, imperforate anus, meconium plug syndrome, small left
colon syndrome
g.
Body wall
defects: gastroschisis, omphalocele, umbilical and inguinal hernias
h.
Renal: ureteral
obstruction, vesicoureteral reflux
i.
Lower GU tract:
urethral valves, hypospadias
8.
Explain the pathophysiology of necrotizing enterocolitis.
9.
Describe the arterial and venous anatomy of the neonate.
Diagnose common neonatal problems and describe surgical procedures for their correction:
1.
Describe the diagnosis, preoperative evaluation, and management of the
common congenital anomalies listed above.
2.
Outline the technical principles involved in the following procedures:
a. Gastrostomy
b. Colostomy
c. Inguinal and umbilical
herniorrhaphy
d. Circumcision
e. Central venous access
3.
Explain the perioperative care of neonates, including:
a. Basic ventilator
management
b. Fluid, electrolyte, and
nutritional management
c. Correction of
coagulopathies
d. Indications for
transfusion
e. Diagnosis of sepsis and
antibiotic use
COMPETENCY-BASED PERFORMANCE OBJECTIVES:
Junior Level:
1.
Perform a comprehensive evaluation of a neonate with suspected
surgically correctable conditions.
2.
Establish percutaneous venous and arterial access in neonates over 2
kg.
3.
Assist or perform under supervision:
a. Peripheral venous and
arterial cutdown access
b. Placement of umbilical
catheters
c. Placement of central
venous access
d. Tube thoracostomy
e. Incision and drainage of
cysts and abscesses
f. Hernia reduction
4.
Participate in the perioperative care of the neonate by recording
appropriate assessments and treatment plans in daily progress notes,
including:
a. Ventilator management
b. Fluid, electrolyte, and
nutritional management
c. Antibiotic use
5.
Complete oral or written examination of topics listed in junior level
knowledge objectives.
6.
Assist or perform surgical repairs of congenital diseases listed in
junior-level knowledge objectives.
COMPETENCY-BASED
KNOWLEDGE OBJECTIVES:
Senior Level:
The senior-level resident should function as an effective
consultant to the nursery, and be able to provide expertise in the evaluation
and definitive treatment of elective surgical conditions as well as be able to
perform emergent surgical procedures (including but not limited to vascular
access, orotracheal intubation, tube thoracostomy, exploratory laparotomy, and
exploratory thoracotomy) with little or no immediate supervision.
The senior-level resident should be prepared to direct the management
of the pediatric surgical service, including the education of junior residents
and medical students on surgical clerkships.
Learn the embryology, anatomy, and physiology of basic and
advanced neonatal surgical diseases. The resident is responsible for all
conditions listed above in junior-level objectives, plus:
1.
Describe the pathophysiology and
evaluation of:
a.
Respiratory distress
e. Bilious emesis
b. Cyanosis
f. Abdominal
distention
c. Gastroesophageal reflux
g. Bloody diarrhea
d. Jaundice
h. Body wall defects
2.
Describe the complications and appropriate treatment of necrotizing
enterocolitis.
3.
Describe appropriate fluid and electrolyte management of the premature
neonate.
4.
Describe the nutritional requirements of premature neonates, and
calculate appropriate enteral and parenteral nutritional support.
5.
Describe the embryology of basic anomalies (listed above) and more
complex congenital anomalies, including:
a. Craniocervical: choanal
atresia, cleft lip and palate
b. Foregut: laryngotracheal
cleft, duodenal web and duplication,
annular
pancreas, preduodenal portal vein, biliary atresia
c. Respiratory: congenital
lobar emphysema and sequestrations
d.
Cardiac: complex cyanotic and
acyanotic cardiac malformations
Diagnose common neonatal problems and describe surgical procedures for their correction:
1.
Describe the diagnosis, preoperative evaluation, operative management,
and postoperative care of the congenital anomalies listed above.
2.
Describe the immediate care, operative correction, and postoperative
management of life-threatening anomalies:
a. Congenital diaphragmatic
hernia
b. Midgut volvulus
c. Necrotizing enterocolitis
d. Gastroschisis
e. Prune-belly syndrome
3.
Describe respiratory support of the neonate, including high frequency
ventilation and extracorporeal membrane oxygenation.
4.
Describe neonatal nutritional assessment and supervision of long-term
nutritional support for neonates with short-gut syndrome.
5.
Describe indications for and technical aspects of endoscopic evaluation
of the neonate.
6.
Describe indications for and technical aspects of intubation, tube
thoracostomy, and percutaneous central venous access in the neonate.
COMPETENCY-BASED PERFORMANCE OBJECTIVES:
Senior Level:
1.
Describe the
capabilities and limitations of various diagnostic modalities used in neonatal
care.
2.
Formulate a care plan for
neonates with problems such as:
a.
Respiratory distress
e. Bilious emesis
b. Cyanosis
f. Abdominal distention
c. Gastroesophageal reflux
g. Bloody diarrhea
d. Jaundice
h. Body wall defects
3.
Perform or assist in all major surgical procedures performed on the
pediatric surgical service.
4.
Personally conduct comprehensive preoperative evaluation and
postoperative management for all critically ill neonates, and direct junior
residents in the management of routine surgical problems.
5.
Complete oral or written examination of topics listed in senior-level
knowledge objectives.
The Neonatal Surgery unit was revised by John C. Fitzpatrick, MD, Jeffrey
C. Pence, MD, and Joseph J. Tepas, III, MD, from the Curriculum, third
edition.
SELECTED
BIBLIOGRAPHY:
Avery GB,
Fletcher MA, MacDonald MG (eds). Neonatology: Pathophysiology and
Management of the Newborn (4th ed).
Philadelphia: JB Lippincott Company, 1994.
Avery ME,
First LR (eds). Pediatric Medicine (2nd ed). Baltimore: Williams &
Wilkins, 1994.
Carlson
BM. Human Embryology and Developmental Biology.
Baltimore: Mosby-Year Book, Inc., 1994.
Fuhrman
BP, Zimmerman JJ (eds). Pediatric
Critical Care (2nd ed). Baltimore: Mosby-Year Book, Inc., 1998.
O’Neill
JA, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG (eds).
Pediatric Surgery (5th ed). St. Louis: Mosby-Year Book, Inc.,
1998.
Stringer
MD, Oldham KT, Mouriquand PDE, Howard ER (eds).
Pediatric Surgery and Urology: Long Term Outcomes.
Philadelphia: WB Saunders Company, Ltd., 1998.
UNIT 5.2
PEDIATRIC SURGERY
UNIT OBJECTIVES:
Understand the unique anatomic, pathophysiologic, and genetic
conditions that affect children.
Learn the principles of stabilization, appropriate
preoperative diagnosis, and preparation of the sick child.
Understand
the anatomic and physiologic principles which guide successful operative
repair of pediatric diseases.
Learn
principles of routine postoperative care and postoperative critical care
management.
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Junior Level:
1.
Describe the development of children in terms of the following
criteria:
a. Weight, length, and
head size
b. Nutritional
requirements
c. Renal function
d. Hormonal influences
on development
e.
Response to
stress and infection
2.
Classify congenital malformations of the newborn by type, origin, and
the need for surgical intervention:
a.
Head and neck:
thyroglossal duct cyst, lymphadenopathy, cystic hygroma
b. Gastrointestinal:
pyloric stenosis, appendicitis
c. Respiratory:
tracheal lesions
d. Abdominal wall
defects: omphalomesenteric and urachal malformations
e. Genitourinary:
polycystic kidneys, undescended testis, torsion of the testis
f. Inborn and
genetic errors: trisomy 13, trisomy 18, Down's syndrome
g.
Orthopedic anomalies which commonly occur with other malformations
4.
Summarize the basic approach to the diagnosis and management of more
common surgical problems of infancy and childhood, such as:
a.
Pyloric stenosis
b.
Perforated appendicitis
c.
Intussusception
5. Identify
the technical aspects of the following procedures:
a.
Excision of skin and subcutaneous lesions
b.
Incision and drainage of abscesses
c.
Lymph node biopsy
d.
Chest tube placement
e.
Oral intubation
f.
Herniorrhaphy in older children
6.
Describe the fundamental considerations in the pre- and post- operative
care of infants and children in the cases listed above.
7.
Explain the principles of diagnosis and treatment for common causes of
gastrointestinal hemorrhage in the neonate, infant, child, and adolescent.
COMPETENCY-BASED PERFORMANCE OBJECTIVES:
Junior Level:
1.
Evaluate surgical conditions in the pediatric population through a
comprehensive history, physical examination, and appropriate diagnostic
studies.
2.
Participate in the management of simple surgical problems in the
pediatric population, including:
a. Integument
(1) Excision of skin and
subcutaneous lesions
(2) Incision and drainage of
abscesses
b. Head and Neck
(1) Excision of dermoid
cysts and small skin lesions
(2) Lymph node biopsy
c. Thoracic
(1) Chest tube placement
d. Cardiovascular
(1) Central venous catheter
placement
(2) Venous cutdown
(3) Arterial line placement
e. Gastrointestinal
(1) Pyloromyotomy
(2) Appendectomy
(3) Herniorrhaphy
(umbilical; inguinal in patients 2 years and up)
f. Genitourinary
(1) Circumcision
(2) Orchiopexy
g. Gynecology
(1) Oophorectomy, simple
(2) Vaginoscopy for foreign
body or biopsy
h. Musculoskeletal
(1) Ganglion cyst excision
(2) Excision of
supernumerary digit
(3) Muscle biopsy
3.
Develop a working relationship with members of the pediatric intensive
care unit in managing postoperative pediatric patients.
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Senior Level:
The senior-level resident should function as an effective
consultant to the nursery, and be able to provide expertise in the evaluation
and definitive treatment of elective surgical conditions as well as be able to
perform emergent surgical procedures (including but not limited to vascular
access, orotracheal intubation, tube thoracostomy, exploratory laparotomy, and
exploratory thoracotomy) with little or no immediate supervision.
The senior level resident should be prepared to direct the management
of the pediatric surgical service, including the education of junior residents
and medical students on surgical clerkships.
Learn the embryology, anatomy, and physiology of basic and
advanced neonatal surgical diseases. The resident is responsible for all
conditions listed above in junior-level objectives, plus:
1.
Explain the approach to surgical management, (i.e., diagnosis,
perioperative care, surgical therapy, and postoperative follow-up) of more
complex surgical procedures for infants and children such as:
a.
Large skin grafts and musculocutaneous flaps
b.
Thoracotomy for pulmonary resection and vascular cardiac repair
c.
Flexible endoscopy
d.
Antireflux procedure
e.
Bowel resection
f.
Repair of hepatic, biliary, and pancreatic injury
g.
Splenectomy and splenorrhaphy
h.
Management of the seriously injured patient
2.
Analyze the pathophysiology, diagnosis, and management options in the
treatment of short-gut syndrome.
3.
Demonstrate an understanding of the special psychological, social, and
education issues confronting selected pediatric trauma/ postoperative
patients.
COMPETENCY-BASED PERFORMANCE OBJECTIVES:
Senior Level:
1.
Evaluate pediatric patients for problems requiring more complex
surgical intervention.
2.
Participate in preoperative, operative, and postoperative care of more
complex problems in pediatric surgery such as:
a. Integument
(1) Pedicle graft
(2) Large skin grafts for
burns
(3) Subcutaneous mastectomy
(1) Branchial cleft and
thyroglossal duct cysts
(2) Cystic hygroma
c. Thoracic
(1) Laryngoscopy,
bronchoscopy, esophagoscopy
(2) Tracheostomy
(3) Thoracotomy for biopsy,
lung resection
(4) Diaphragm repair
d. Cardiovascular
(1)
Resection of small vascular cutaneous lesions such as (A-V)
malformation, hemangioma, or lymphangioma
(2) Repair of patent ductus
arteriosus
(3) Repair of aortic
anomaly/injury
(4) Support of a child with
extracorporeal membrane oxygenation (ECMO)
e. Gastrointestinal
(1) Flexible endoscopy
(2) Antireflux procedure
(3) Bowel resection for
inflammatory bowel disease, intussusception, intestinal duplications
(4) Hodgkin's staging
(5) Biopsy of tumor (open,
laparoscopic or endoscopic)
(6) Laparotomy for trauma
(7) Splenectomy
(laparoscopic or open), splenorrhaphy
(8) Repair of hepatic
injury, renal and/or bladder injury
(9) Cholecystectomy (open or
laparoscopic)
(10) Omphalomesenteric duct and
urachal anomalies
f. Oncologic
(1)
Neuroblastoma
(2)
Wilms’ tumor
(3)
Rhabdomyosarcoma
(4)
Teratomas
(5)
Germ cell tumors
(6)
Hepatoblastoma
(7)
Sarcomas
(8)
Hodgkin’s and
non-Hodgkin’s lymphomas
(9)
ALL
g. Genitourinary
(1)
Polycystic
kidney
(2)
Ambiguous
genitalia
h. Musculoskeletal
(1)
Torticollis
The Pediatric Surgery unit was written by Jeffrey C. Pence, MD, and John
C. Fitzpatrick, MD, following the Curriculum, third edition, by James A.
O'Neill, Jr., MD.
SELECTED
BIBLIOGRAPHY:
Avery
ME, First LR (eds). Pediatric Medicine (2nd ed). Baltimore: Williams
& Wilkins, 1994.
Carlson
BM. Human Embryology and Developmental Biology.
Baltimore: Mosby-Year Book, Inc., 1994.
Cox CC, Marvin RG, Lally KP, et al. Physiologic
problems in the pediatric surgical patient.
In: Miller TA (ed), Modern Surgical Care: Physiologic Foundations
and Clinical Applications (2nd ed).
St. Louis: Quality Medical Publishing, Inc., 1998;1337-1361.
Fuhrman
BP, Zimmerman JJ (eds). Pediatric
Critical Care (2nd ed). Baltimore: Mosby-Year Book, Inc., 1998.
O’Neill
JA, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG (eds).
Pediatric Surgery (5th ed). St. Louis: Mosby-Year Book, Inc.,
1998.
Stringer
MD, Oldham KT, Mouriquand PDE, Howard ER (eds).
Pediatric Surgery and Urology: Long Term Outcomes.
Philadelphia: WB Saunders Company, Ltd., 1998.
Web
reference
http://www.eapsa.org
UNIT 5.3/5.3G
OTOLARYNGOLOGY AND HEAD AND NECK SURGERY
PART A: OTOLARYNGOLOGY
UNIT
OBJECTIVES:
Demonstrate knowledge of the anatomy, physiology, and
pathophysiology of the ear, nose, and throat pertinent to the practice of
general surgery.
Demonstrate the ability to manage ear, nose, and throat
problems associated with the practice of general surgery.
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
1.
Identify the anatomy and explain the physiology of the ear, nose, oral
cavity, and throat.
2.
Summarize the essential components of a focused history and physical
examination for common otolaryngologic problems.
3.
Discuss the significance of the cornerstones of the physical
examination, including:
a. Visual inspection
c. Palpation
b. Auscultation
d. Percussion
4.
Analyze the clinical management of ear, nose, and throat (ENT) patients
in the intensive care unit (ICU), including:
a. Respiratory
infection management
b. Airway management
c. Wound care
5.
Describe and compare the pathophysiology of the following common ENT
diseases:
a. Sinusitis
c. Neck abscess
b. Sialadenitis
d. Epiglottitis
6.
Describe and explain the pathophysiology of presbycusis as it can be:
a. Conductive
b. Metabolic and toxic
c. Neural
d. Cochlear
e. Tumor-related
f. Age-dependent
7.
Explain how physical examination differs for delineation of conductive
versus neurosensory hearing loss.
8.
Explain the principal causes of simple epistaxis and describe its
management.
9.
Evaluate patients with facial trauma and develop a treatment plan for
the management of:
a. Fractures
c. Hemotympanum
b. Lacerations
d. Epistaxis
10.
Describe the indications for tracheostomy in adults and children.
11.
Discuss the indications for biopsy of lesions of the skin of the face,
neck, and oral cavity.
12.
Compare the use of the following procedures in evaluating ENT problems:
a. Radiography
b. Contrast studies
c. Ultrasound
13.
Describe the indications for simple endoscopy and its diagnostic
contributions such as:
a. Nasopharyngoscopy c.
Esophagoscopy
b. Direct laryngoscopy
14.
Summarize the characteristics of the common neoplasms of the ear, nose,
and throat, and describe appropriate surgical intervention.
15.
Outline the diagnostic approaches to otolaryngologic neoplasia,
including:
a. Direct
visualization
c. Use of radiography
b. Indirect
visualization d.
Fine-needle biopsy
16.
Describe diagnostic and therapeutic procedures utilized in treating the
following:
a. Abscess
c. Oral ulcer
b. Neck mass
d. Salivary gland mass
17.
Describe and demonstrate methods for removing foreign bodies from the
trachea, bronchus, and esophagus.
18.
Compare surgical approaches using surgical flaps for repair of ENT
defects and trauma of the lip, alar rim, and helix.
19.
Outline the diagnosis and repair of facial fractures of the mandible,
nose, and frontal sinus.
20.
Summarize diagnostic and therapeutic considerations in the management
of caustic injury to the mouth, nasopharynx, trachea, and esophagus.
21.
Discuss the management of airway in patients with terminal carcinoma of
the thyroid and trachea.
22. Describe the signs
and symptoms and discuss the health care significance to elderly patients from
the pathophysiology of:
a.
Tinnitus
c. Cerumen impaction
b.
Vertigo
d. Basilar artery
stenosis
COMPETENCY-BASED PERFORMANCE OBJECTIVES:
1.
Perform and record a focused ENT history and physical examination.
2.
Manage the emergent/elective airway; using visual inspection,
radiographic evaluation, indirect invasive and non-invasive visualization
techniques (direct speculum and indirect mirror evaluations, direct fiberoptic
and rigid evaluations); with consideration for:
a. Nose, nasal passages
d. Larynx
b. Nasopharynx
e. Trachea
c. Oropharynx
3.
Be prepared to manage airway obstruction as the result of:
a. Edema
d. Anaphylaxis
b. Secretion
e. Foreign body
c. Benign and malignant
tumors (including, vascular malformations and infectious processes)
4.
Evaluate patients with facial trauma, including fractures, lacerations,
hemotympanum, and epistaxis.
5.
Perform tracheostomy on adults under direct supervision.
6.
Perform biopsies of lesions of skin of face, neck, and oral cavity.
7.
Perform evaluation of a neck mass, and provide appropriate treatment.
8.
Correctly differentiate between the indications for and management of
cricothyroidotomy and tracheostomy, demonstrating varying techniques and
choice of instrumentation for emergent airway management and ventilation in
each.
9.
Interpret radiologic examinations of sinuses.
10.
Perform simple endoscopy including:
a. Nasopharyngoscopy
c. Esophagoscopy
b. Direct laryngoscopy
11.
Evaluate head and neck tumor patients, and be prepared to perform a
tumor biopsy.
12.
Perform tracheostomy on children with supervision.
13.
Evaluate radiologic studies of the head and neck, including computed
axial tomography (CAT) scanning.
14.
Evaluate and treat head and neck abscesses and other masses.
15.
Remove esophageal foreign bodies endoscopically.
16.
Perform diagnostic bronchoscopy.
17.
Reconstruct facial and neck defects with transposition and myocutaneous
flaps.
18.
Manage facial fractures with appropriate consultation.
19.
Evaluate and treat caustic injury.
20. Manage airway in
patients with terminal thyroid or tracheal carcinoma.
PART
B: HEAD AND NECK SURGERY
UNIT
OBJECTIVES:
Demonstrate
understanding of the anatomy, physiology, and pathophysiology of the head and
neck amenable to surgical intervention.
Demonstrate
the ability to manage surgical problems of the head and neck in a variety of
settings.
COMPETENCY-BASED
KNOWLEDGE OBJECTIVES:
1.
Define and discuss the three-dimensional anatomy of the head and neck
region with regard to:
a.
Interrelationships
of anatomy
b.
Fascial planes
c.
Path and course
of cranial nerves
d.
Major arterioles
and venous structures
e.
Musculature of
face and neck
f.
Anatomy of
larynx and cervical trachea