Colorectal Surgery and Community Surgery-Goals and Objectives Supplement for CTU # 1 Medical Expert/Clinical Decision Maker Knowledge: Basic Science and Anatomy To know the anatomy and physiology of the small bowel, colon, rectum and anus Know the anatomy and function of the abdominal wall Knowledge: General clinical To understand the process of diagnosis using History/physical examination To understand the preoperative decision making as it relates to workup including laboratory and diagnostic imaging To be able to describe and manage the standard post operative course following bowel surgery as well as recognize when complications are developing Proper intra-operative cancer evaluation of colorectal cancer and large ventral hernias Knowledge: Specific Clinical Problems 1. Colorectal Cancer To understand the patient and tumor characteristics that guide tumor therapy To understand intra-operative decision making -Be able to describe and apply staging systems including TNM, Modified Astler-Coller and Dukes original 1932 version. 2. Polyps To understand the clinic factors that influence treatment of colon and rectal polyps i.e. when is colonoscopy/polypectomy not adequate? What polyps are amenable to transanal excision? 3 Inflammatory Bowel Diseases Medical management of IBD Crohn's enteritis Ulcerative colitis Crohn's disease of colon and anus The differences between Crohn s disease and Ulcerative colitis- Microscopic and macroscopic
The indications for operation in Crohn s disease and Ulcerative colitis? Possible operations for ulcerative colitis and the relative pros and cons of each procedure. Fulminant colitis and its management Other areas that the resident should have knowledge of- Small Intestine Tuberculous enteritis Infectious enteritis Neoplasms-Benign, Malignant, Carcinoma, Sarcoma, Lymphoma, Carcinoid Small bowel fistula Meckel's and other small bowel diverticula Blind loop syndrome Pneumatosis cystoides intestinalis Short bowel syndrome Small bowel obstruction Colon, Rectum and Anus Ischemic colitis Infectious colitis Radiation enterocolitis Pseudomembranous enterocolitis Solitary rectal ulcer Diverticular disease Megacolon Colonic volvulus Angiodysplasia Colonic endometriosis Carcinoid tumours of the colon and rectum Rectal prolapse Anal neoplasms-benign, Malignant Hemorrhoids, Fissure in ano, Proctitis Anal infections Condyloma, Venereal disease Anorectal abscess Pruritis ani Anal incontinence Levator ani syndrome Appendix Appendicitis Appendiceal tumours-carcinoid, Mucocele, Adenocarcinoma Peritoneum Subphrenic, intra-abdominal, pelvic abscess
Abdominal Wall, Omentum, Mesentary, Retroperitoneum Abdominal wall hernias Rectus sheath hematoma Desmoid tumours Torsion of the omentum Omental cysts Omental tumours Mesenteric artery and vein-acute arterial occlusion, Chronic visceral ischemia, Acute venous occlusion, Nonocclusive mesenteric ischemia Retroperitoneal fibrosis and tumours Ambulatory clinic setting Constipation-Work-up, Diagnostic tests, Medical and Surgical Management Incontinence-Work-up, Diagnostic tests, Medical and surgical management Manometry and special investigations Understand the principles of manometry and normal values anorectal applications Define EMG and the role in investigation of incontinence. Understand the application of defecography Understand the role and application of endoanal ultrasound in colorectal surgery. Technical skills Describe and perform all aspects of bowel anastomosis including use of the stapler and suturing of the bowel Describe the most common pitfalls of stapling and how each potential complication is managed. Understand the technical approach to stapling for low anterior resection Be able to do a Pelvic dissection and be aware of the following Possible complications i.e. what structures can be injured What maneuvers can be used to prevent, detect and manage such injuries. Being aware of positioning that is used to facilitate exposure in the deep pelvis Being aware of instruments that are used to facilitate exposure in the deep pelvis Ability to define the full extent of rectal resection (TME) for cancer including -The level for ligation of the vascular pedicle for rectal cancer - Mesenteric and bowel margins. Ability to define the extent of resection for a right colon lesion, a left colon and a sigmoid colon cancer. Understand when an abdominoperineal resection vs. coloanal anastomosis vs. low anterior resection are performed for rectal cancer Understand when and how a mucosectomy is performed Perineal excision of the anus
To understand how to make the incision and what landmarks to use to define the extent of proctectomy To understand order of the dissection To understand the management of the perineal wound To understand the management of the pelvis after proctectomy Creation of a stoma Siting of the stoma Size of the fascial opening Which part of the bowel to use and how to mature the bowel Stomal complications: How do you avoid retraction, deformity, ischemia and parastomal hernia development Communicator Share information effectively with other Health Care Professionals by timely documentation in clinical and operative encounters. The ability to keep concise, pertinent, and up-to-date medical records. The ability to communicate with patients and family members, explaining the colorectal disease process including the benefits and risks of operative as well as non-operative options. The resident needs to be able to explain the complications and alternatives of operative management recommendations, in terms each individual can understand. Collaborator Be able to cooperatively manage colorectal disease with Gastroenterology, oncologists and other health care professionals including the Enterostomal Therapists The ability to supervise and teach undergraduate and postgraduate students in general surgery and the skills to educate patients, families and other health care professionals Manager Effectively manage patients with colorectal disorders utilizing health care resources wisely Health Advocate Role of screening in colorectal cancer and inflammatory bowel disease Understand the relative cost: benefit ratio and limitations of each of the screening techniques Aware of the activities and roles of support groups such as Canadian Cancer Society and the Ileitis & Colitis Society.
Scholar The discipline of continued self-education and application of this knowledge to the clinical setting. The ability to supervise and teach undergraduate and postgraduate students in general surgery; the skills to educate patients, families and other health care professionals The ability to participate in research studies. Professional The ability and willingness to work in a cooperative manner with other health care personnel and to be able to give and receive advice in a pleasant, professional manner. Respect for the patient s right to privacy. Sensitivity towards the ethnic and religious background of each patient and an understanding of the psychological needs of the patient. The capacity for supportive and compassionate care in the course of terminal disease. Honesty, reliability, a well-developed sense of responsibility, sound moral and ethical standards. Modified at the General Surgical Retreat, August 3, 2011