How to Prepare For a casePatrick Nguyen, MDAssistant Professor

General and Laparoendoscopic Surgery

Most Important Points

• PREPARE, PREPARE, PREPARE!!!

Overview – How to Prepare for a Case

Read about the disease process & anatomy

Review the steps of operation

III.

II.

I. You have to know that you’re scrubbing in on a case

Know your patient

IV.

Put it all together later in the day

Talk it over with the resident before the case

V.

You have to know that you’re scrubbing in on a case

HOW DO I KNOW WHAT THE CASES ARE?

• Pre-op conference happens the week before

• Cases are posted by junior resident at least 2 days before

• Cases are posted by the OR daily by 3pm

DIVIDE CASES THE DAY BEFORE!

• Talk to fellow students

• Take into consideration who is post-call

• Don’t hog all the big cases

Know your patient

READ THE H&PClassic questions in OR:• So why is Mr. X having

surgery?• What were his symptoms?• What did the imaging

show?• Why are we doing …(for

example, if doing lap chole, why do a cholangiogram?)

TALK TO YOUR PATIENT• Introduce yourself to the

patient in holding

• Examine your patient

• Ask questions that were not on the H&P

Read About the Disease Process and Review the Anatomy

• For ALL clerkships– Review book

• NMS etc…

– Question book• Pre-test, Lange etc…

• For OR preparation– Surgical recall

• Good STARTING point• Good for quick review

RIGHT before surgery

– Review book

– Anatomy book

Review the Procedure

• Good online sites– MD consult – Khatri: Operative Surgical Manual

– Access surgery• Zollinger Atlas of Surgical Operations• Maingot’s Abdominal Operations

• Library is excellent resource – full surgical atlases available for checkout

Once you have done your “homework” – Talk to your junior resident or chief resident

Talk it over with the resident before the case

• Ask about anything you found confusing or could not visualize when reviewing the case

• Ask the resident to correlate your examination findings to theirs

FINALLY…THE OR…

“A good student will…”– BE IN THE ROOM OR

GOING BACK TO THE ROOM WHEN PATIENT ROLLS BACK

– HELP IN THE OPERATING ROOM

FINE LINE UNFORTUNATELY • INTRODUCE YOURSELF TO THE OPERATING ROOM

NURSE/SCRUB TECH

• HELP MANEUVER GURNEY NEXT TO THE OR TABLE

• MOVE BED OUT OF THE ROOM

• HELP PUT ON LEG SQUEEZERS

• PULL OWN GLOVES!!!

• HELP MOVE PATIENT BACK TO BED

During the case…• If you don’t know…• If you can’t see…• If you feel faint…

Put it all together later in the day

• Briefly review your notes or review book• Review the anatomy one more time

Questions/Comments?

Prepare for your first case…

Left Hemicolectomy

One year into the future…

• You’re on your general surgery rotation• Pre-op conference is 7am on Thursday.

Pre-op conferenceNguyen

Patient Procedure/Dx History Imaging/Path Work-up To Dos

N KWXXXXXXXX

Exploratory lap, resection of something, with a possible SB resection, possible R hemicolectomyHPI: 53 yo F with small bowel neuroendocrine tumor

PMH: HTN, GERDPSH: Hemorrhoidectomy, TAH/BSO, bladder suspension, ESWL- no complicationsSH: no t/e/dMeds: Nexium, benicar, tylenol, advil cold/sinus, Dayquil

ALL: Sulfa, Erythromycin (hives, swelling tongue); eggs (swelling tongue)

8/18 CT abd angio – mesenteric mass hypervascular with fibrotic changes suspicious for carcinoid, replaced left hepatic arteryPATH 8/3/06 Neruoendocrine carcinoma

[x] UPOMC

N MXXXXXXXXX

Left HemicolectomyHPI: 51 yo M c multiple scattered diverticula in the sigmoid and descending colon, 3 previous episodes of diverticulitis

PMH: COPD, HTN, h/o MI, arthritis, osteoporosis, fibromyalgia, h/o subarachnoid hemorrhage, dysautonomia, arrhythmias, septal aneurysmPSH: cardiac cath ’98, angiogram brain ’97, BTL ‘92SH: TOB 89-93, no Etoh, no drugsMeds: Lipitor 40, Kdur 20 BID, Fosamax 35 qweek, toprol XL 25 QD, albuterol, advair, relafen 500mg, Nexium 40, vicodinALL: erythromycin, flagyl, codeine, septra

7/30 CT abd – multiple scattered diverticula in the sigmoid and descending colon, sigmoid mucosal thickening and edema, no abscesses, no free air

[x] UPOMC [ ] CXR 9/15 Colonoscopy – no masses, diverticula in sigmoid and desc. colonEGD small hiatal herni

The day before the surgery

You and your fellow students divide the cases – you are going to scrub in on the colectomy

patient in room

In holdingpatient called for

OR Board near front desk

Time Room Pt Age Procedure Site Faculty/Resident7:15 OR 10 KW 53 Exploratory Laparotomy abd Nguyen/Shah

10:00 OR 10 MX 51 Left Hemicolectomy abd Nguyen/Shah

Where should you start?• Learn about your patient

• Start with the HPI!• Why is MX having surgery?• What were his symptoms?• What did the diagnostic workup (labs/imaging/physical exam)

show?• What are his medical problems?• What surgeries has he had in the past?• Why are we doing this surgery?• Is there anything you see in his past medical history that

would increase his risks for surgery?

What do you do next?

• Learn about the case1. Disease process2. Steps of the procedure3. Anatomy review

• Review books, question books, and surgical recall will help you figure out what are the high yield points and point you in the right direction before you go into the textbooks

Disease process• This is the material that will be on your shelf exam

– diagnosis and management• Diverticular disease (Mont Reid, 5th ed.) – this just an example• Not a true diverticula – only contains mucosal and submucosal layers• Occurs at weak points in bowel where vasa recta penetrate circular muscle layer

on mesenteric side, most common in sigmoid• Common symptoms: pain diarrhea, constipation, but 80% are asymptomatic• 70% of lower GI bleeding is caused by diverticulosis, 70% stop bleeding

spontaneously and 75% do not recur• Diverticulitis – stool lodges in diverticulum which increases intraluminal pressure

which decreases venous return. Ischemia can lead to microperforations. 10-15% have free perforation

• Diagnosis: CT scan is study of choice, colonoscopy 6 weeks after symptoms resolve• Nonoperative management: 1st: Oral antibiotics for 7-10 days, low residue diet• Complications: Abscess, fistula, perforation

Left Hemicolectomy1. Incision of lateral peritoneal reflection and mobilization of sigmoid colon2. Identification of left iliac artery and ureter3. Mobilization along left pericolic gutter4. Takedown of gastrocolic ligament and enter lesser sac5. Mobilization of splenic flexure6. Division of proximal colon with gastrointestinal anastomosis (GIA)

stapler7. Ligation of mesenteric vessels8. Ligation of superior rectal artery9. Division of mesorectum10.Division of rectosigmoid colon with TA stapler11.Anastomosis with end-to-end anastomosis (EEA) stapler or hand-sewing12.Test anastomosis with rigid sigmoidoscope by filling with air while

occluding lumen proximally

Anatomy Review

• After looking at the steps of the procedure, you’ll see what structures you need to review

• Go back to your Netter’s/Grant’s/Gray’s

• Surgical Atlases (Zollinger’s)

Talk to resident

• Example questions – why are we doing a colectomy on this patient instead of medically managing him?

• I didn’t understand this part of the procedure

The patient is in holding

• You introduce yourself• You examine the patient• Then nurse and anesthesiologist come and

wheel the patient back to the room. You go with them.

Time Room Pt Age Procedure Site Faculty/Resident7:15 OR 10 KW 53 Exploratory Laparotomy abd Nguyen/Shah

10:00 OR 10 MX 51 Left Hemicolectomy abd Nguyen/Shah

patient in room

In holdingpatient called for

OR Board near front desk

Patient’s in the room!

• You help bring the patient to the room and maneuver the bed next to the OR table. Then move the bed out of the room

• Introduce yourself to the OR nurse and scrub tech

• You help put on leg squeezers• Pull your own gloves and give to scrub tech• You scrub in and enjoy

Assignment #1: Preparing for cases• Divide into groups of 5. Choose a group leader.• Your group will be preparing a common surgical case

1. Disease process – Basic science/etiology2. Disease Process – Diagnosis and Medical management3. Steps of the procedure4. Anatomy5. Pre and post operative care, complications

• Make a short 2 page review handout• Handouts will be turned in and then given to all the class

members• Keep these handouts! They’ll be useful for next year. You’ll

have 5-6 cases pre-prepared for your surgical clerkship.