General Surgery Rotation Day 5 17-June-2011 and Community Service 18-June-2011

The last and final day of general surgery rotation, time flies by too fast. I started the day along with Bor-Han with the book reading meeting in the meeting room on the 7th floor. Today the topic presented was splenectomy. The most interesting thing about the presentation was the discussion about laparoscopic splenectomy being the gold standard for splenectomy for elective spleen removal without splenomegaly. Apparently most of the splenectomy procedures done in the hospital have not been elective cases as after a brief recount by the recount by the physicians at the meeting they could only recall about one video of a laparoscopic splenectomy being done in the hospitals in the records. It seems that in most cases at least in this hospital splenectomy is an emergency procedure and laparoscopic removal would be too slow.

After the meeting at 10:30 I met with Dr. Fan and we continued to discuss about breast cancer management. Dr. Fan gave a brief introduction of the ranking of risk factors for breast cancer in Taiwan and commented about some problems including insurance payouts depending on breast cancer classification. Interestingly Dr. Fan is interested in seeing more studies and research done for breast cancer in the Han Chinese population as he feels eventually specific protocols should be developed as more target therapies are being made available. He also gave a introduction about the different types of surgical procedures for breast cancer starting from the historical perspective of the radical mastectomy, where entire breast, the axillary lymph nodes, and the pectoralis major and minor muscles behind the breast are removed and the serratus anterior and latissimus dorsi are resection to prevent skin necrosis to the move to breast conservation surgery (BCS). Of special interest apparently preserving the shape of the breast after BCS is an ever improving field for plastic surgeons given that they never really know what they are going to get as selective portions of the breast tissue is removed based on what is cancerous. Overall given the short time in the surgery department I am glad that I was given the opportunity to see so much from my preceptor Dr. Fan on the rest of the surgical department.

On Saturday we all got up bright on early to get on the bus at 6:30am to go help out for the integrated community health screening that the Taipei Hospital sponsoring. Bor-Han and I ended up in the oral exam unit where we observed Dr. Li, a dentist examine the local community for various oral problems. For the epidemiologists everyone Dr. Li saw had gingivitis. I am not sure how helpful we were, but I am glad that we had a chance to interact with the community.

Genral Surgery Rotation Day 5 (June 17, 2011)

June 17, 2011

My last day in surgery rotation started with a presentation about splenectomy. The surgery department had the first part of the presentation last week already, so today’s topic focused mainly on follow-up care of asplenic patients. Asplenic patients are known to be more vulnerable to infections especially to encapsulated bacteria like Streptococcus pneumonia, Haemophilus influenzae type b and Neisseria meningitides. Therefore vaccination is important for those who received splenectomy. Early recognition of infection is also important for these patients since they can quickly develop septic shock, DIC, and organ failure.

After the presentation, Dr. Kuo told me that he will be pretty busy until later afternoon, so I went to follow Mickey’s preceptor, Dr. Fan. He gave us a lecture about breast cancer, which is increasing rapidly in Taiwan. He pointed out several risk factors of breast cancer. For example, previous finding of atypical ductal hyperplasia can increase the risk to 8-10 folds and family history of breast cancer can increase the risk to 4 folds. Birth age > 30, menarche age < 10, and menopause age > 55 all can increase the risk too. Like Dr. Chen from my previous oncology rotation, Dr. Fan also said that the information we learned can be out of date or incorrect in the future. So he suggested us to focus on learning how to make the decision for treatment instead of memorizing all the possible treatments.

In the afternoon, Mickey and I met Dr. Kuo in the conference room again. Since we will have a case presentation next Monday and I am in charge of the surgery part, I discussed with him about how much material I should put into my presentation and made sure anything I have is correct. He suggested me to keep my presentation short and simple and not provide too detailed information since a lot of our audiences may not know much about surgery. His corrections and suggestions are really useful and prepare me well for the upcoming case presentation.

During this week of general surgery rotation, I not only learned a lot about common surgeries such as appendectomy and laparoscopic surgeries but also gained experiences in basic surgical skills such as suture and using laparoscopic instruments. I deeply appreciate Dr. Kuo for giving me the lectures about those basic and common surgeries and providing me the access to practice basic surgical skills. I also want to thank Dr. Ou and Dr. Fan for providing us the opportunity to watch real laparoscopic cholecystectomy surgery and guide us through the operation. The experiences I had in this week of general surgery rotation not only prepare me well for my future surgical rotation but also are helpful even I go to other non-surgical specialty in the future.

Genral Surgery Rotation Day 4 (June 16, 2011)

June 16, 2011

Today we attended the journal reading meeting of surgery department. Dr. Xiao, a resident physician in the department, gave us a presentation of an article about the use of extracorporeal membrane oxygenation (ECMO) vs. interventional lung assist membrane ventilator (iLA) on ARDS patients. She made a comparison between these two techniques. For example, unlike ECMO that can remove CO2 and add O2, iLA can only remove CO2 from the blood passing through it. Even though iLA has less distance of circuit, they both have anticoagulation complications as result of using heparin. Dr. Chen, the cardiovascular surgeon in the hospital, gave his comment after the article presentation. He mentioned that more and more hospitals in Taiwan will perform ECMO because it’s covered by the National Health Insurance. He also pointed out that even though no scientific evidence supports ECMO as treatment for ARDS, it’s logical to use this technique to buy patients more time so that other treatments can work out. This idea will be important for me when I deal with the patients with lung or/and heart failure.

Since Mickey’s preceptor would be pretty busy whole day, Mickey came to Dr. Kuo’s lecture with me. His first topic for today is hemorrhoid, a pathological change of anal cushions that can lead to bleeding, swelling, or/and pain. It’s associated with not only constipation but also diarrhea and pregnancy. It’s classified to external or internal depending on if it’s outside of dentate line. He also introduced different treatments (e.g. rubber band ligation, hemorrhoidectomy, and procedure for prolapse hemorrhoid) for different stages. Then he switched the topic to talk about inguinal hernia. We learned the different etiologies between children and elders and two types of operations, tissue repair and tension-free repair, used to treat it. Dr. Kuo ended his lecture by talking about soft tissue infections such as cellulitis and necrotizing fasciitis. The symptoms include redness, swelling, tenderness, and local heat. But he also pointed out that the symptoms can vary depending how deep the infection is. For example, the infection of deep soft tissue like fascia and muscles usually show no redness and swelling until advanced stage. The treatment for soft tissue infections usually starts with antibiotic therapy, and drainage and debridement operations are used when the symptoms persist. After the lecture, Dr. Kuo checked the gauzes I used to practice suture yesterday and said that we can get more suture lines from the operating room to practice. We later got more suture lines from the OR and practiced to improve our suture skill.

General Surgery Rotation Day 4 Suture Practice Time 16-June-2011

Start off the day at the Surgery meeting at the 7^th floor meeting room. Today was a presentation about using extracorporeal devices in the management of ARDS with extrapulmonary involvement, in particular the use of ECMO (extracorporeal membrane oxygenation) and iLA (Interventional lung assist) in patients that have compromised lung function. I got a good review about the criteria of ARDS compared to acute lung injury. Both the advantages and limitations of using ECMO and iLA were presented. In regards to ECMO there is little to no support supporting its use as an effective treatment and the cost often limits its use. However as Taiwan national insurance pays for ECMO (very surprising as it is deemed expensive) it is often utilized as more a supportive care rather than treatment for patients that come in with ARDS and/or lung function compromise. At the meeting they explained that often the ECMO will be set up in the venous to venous (veno-venous ECMO) to bypass the heart as while ECMO can replace the heart when set up in Veno-arterial orientation, ECMO has not been shown to support the heart as it does support other organs in any format.

After the meeting Bor-Han and I received a mini-lecture from Dr. Kou about some common surgical procedures including hernia repair, and hemorrhoid management. Then we remained in the meeting room to practice suturing using gauze. Again pictures below:

The set up:

Bor-Han suturing

Me suturing:

General Surgery Rotation Day 3 OR Observation 15-June-2011

This was the first day that I was able to see a complete surgery done at the OR. At the start of the day I met with Dr. Fan at 9:10 where he performed a removal of a suspected cancerous lesion (firm and immobile) in a patient’s lower extremity. Even though Dr. Fan said it was a very simple procedure I was excited to see him in action and interesting to hear him explain about the whole process. Later on in the afternoon Bor-Han and I got to see a laparoscopic cholecystectomy (gallbladder removal) which uses four ports. The procedure was done by one of the residents with the chief resident as a teacher and under the supervision of Dr. Ou, Liang-Hung (Dr. 歐亮宏), Dr. Fan was also present most of the time and offered us many explanations on what was happening during the procedure. Dr. Ou also took some time to explain to us about the different types of laparoscopic procedures currently in use including ones done with natural orifices such as with an endoscope and offered to let us see a single port laparoscopic procedure such as an appendectomy if one becomes available. Overall it was very interesting to see a complete procedure from the start, anesthesia to finish, removal of the gallbladder and suture. I will be looking forward to the rest of the days in the surgical department. Now for some pictures with our scrubs on, guess mine turned out blurry:

Me in scrubs:

Bor-Han in scrubs:

Genral Surgery Rotation Day 3 (June 15, 2011)

June 15, 2011

In the morning, Dr. Kuo gave me an introduction of basic skills and tools they used in surgery. He first showed me how to hold the tweezers and scalpel blades like holding pens. He said that’s why you can distinguish surgeons from internists when they are eating steak. He also demonstrated surgeon’s way to hold the forceps, scissors, and needle hold. He grasped by the finger loops by thumb and ring fingers and used the index to help guide the instrument. He then introduced the absorbable and non-absorbable suture lines. He also talked the four suture methods that can be used in different situations and demonstrated how to do two of them, simple and vertical mattress. With his help, I finished my first simple and vertical mattress sutures on gauzes, and I practiced more sutures later by myself.

Before Dr. Kuo left, he told me that he will be busy later today for the outpatient clinic but he can arrange me to watch a laparoscopic cholecystectomy leaded by Dr. Ou in the afternoon. Since Mickey’s preceptor also provided Mickey the opportunity to watch this surgery, we went together to the operating room. The patient is a 69 years old male who had pacemaker installed for more than ten years. Since the patient is obese (95 kg weight), it took longer time to make penetration to abdominal cavity so that CO2 can be pumped in to distend the abdomen, which will allow more space for the surgery. Four small incisions were made to allow access of laparoscope and other instruments. Surgeons started with cutting through the connective tissue to find the cystic duct and cystic artery. Once they were identified, titanium clips were put on and then they were cut. After complete detachment, the gull bladder was put into a bag in the abdominal cavity. The surgeon then broke the gull bladder and bile was sucked out. This way the size of gull bladder got small enough to be taken out through the small incision. Dr. Ou told us that the gull bladder will be sent to pathology to check if there is any malignancy. This experience to watch laparoscopic cholecystectomy not only gave me an idea what a real surgery is like but also helped prepare me better for later surgical rotation.

Genral Surgery Rotation Day 2 (June 14, 2011)

June 14, 2011

My second day of general surgery rotation started with a presentation about a new ultrasound machine. The surgery department recently purchased this new ultrasound machine with probe specially designed for the use during laparoscopic surgery. So someone from the company gave the surgeons a presentation about how to use and take care of the machine and probes. Even though I don’t have much experience with ultrasound, I still learned something from the presentation. For example, I learned that high frequency gives better spatial resolution of image but low frequency has better depth of image.

After the meeting, Dr. Kuo told me to meet him at 10:30 am in OR. And he would have a small surgery to get skin biopsy from a 91 yo male patient whom Dr. Kuo suspects to have melanoma. Since Mickey’s preceptor was very busy this morning, he got the permission from Dr. Kuo to observe the surgery as well. Before we headed to the OR, we talked to Dr. Ou, the director of surgery department. He is the surgeon who operated on the colon carcinoma patient who will be in our case presentation. He drew a picture to show us where he had skin incisions on her abdomen. And he said that we can get the video of the laparoscopic surgery from OR.

When we went to the OR with the scrubs on, Dr. Kuo first showed us how to brush the hands and arms to make sure they are clean. Then he showed us how to wear the gloves in certain way so that can keep sterile. After he finished cutting off the skin biopsy, Dr. Kuo explained to us why he cut it from peripheral region instead of central region of the dark mole on one of the patient’s toes. Peripheral region has the most active cancer cells compared to central region where most cells are after necrosis. Therefore if we want to make diagnosis from skin biopsy, it’s important that we collect the active cancer cells instead of dead cells.

After the lunch, Dr. Kuo gave me a presentation about laparoscopic cholecystectomy and surgery for appendicitis. We talked about the indications that help to decide if the patient needs to have the surgery. For example, an asymptomatic patient will still be suggested to have laparoscopic cholecystectomy if he/she has gall stone > 2cm, polyp > 1cm, or calcified gallbladder (Porcelin gallbladder). I also learned several signs that can be used to find out if the patient has appendicitis. They include: tenderness on McBurney point (1/3 from ASIS to umbilicus), Rovsing sign (RLQ pain induced by palpation of LLQ), Psoas sign (pain when extending right thigh with patient lying on left side), and Obturator sign (pain when internally rotate the flexed hip). He also mentioned that even though appendicitis is the very first disease most surgeons learn to operate, many experienced surgeons still can miss the sign and delay the treatment. If the patient doesn’t receive any treatment for more than one week, the appendix can rupture and develop to tumor formation appendicitis. And the treatment at that stage will not be surgery but the use of antibiotics.

Mickey and I later attended the case presentation held by physicians from surgery, radiology, pathology, and oncology departments. Both cases are diffuse B-cell lymphoma. The tumor was found in ileum in one case and ascending colon in another case. Dr. Huang and Dr. Ou from surgery department presented the physical findings, patient history, and what they found during the surgeries. A radiologist showed us X-ray and CT scan for the cases and told us what she interpreted from the images. Dr. Hsieh from pathology department described the biopsy sample she received and her diagnosis from the histologic slides. My previous preceptor, Dr. Chen from oncology department, ended the presentation by pointing out the epidemiology and characteristics of GI lymphoma. According to him, it’s very rare to see primary GI lymphoma case, and we were really “lucky” to see two these cases. From this case presentation, I not only learned more about GI lymphoma but also got the idea how multiple departments can work together on same cases through discussions and information exchange. This experience will also be useful for preparing our upcoming case presentation.

General Surgery Rotation Day 2 14-June-2011

In the morning I attended the general surgery meeting with Bor-Han, Amanda and Sandy, where a medical equipment company introduced the new ultrasound machine that was just purchased. Bor-Han and I ended up using the practice laparoscopy machine for a bit after the meeting as there was some free time. Pictures below:

Bor-Han on the practice machine:

Me on the practice machine:

A success:

After words I ended up following Bor-Han’s preceptor Dr. Kou, Chin-Chang (Dr. 郭錦璋) as my preceptor Dr. Fan requested. Bor-Han and I ended up going to the OR where Dr. Kou showed us how to properly prepare ourselves before surgery including how to watch our hands and put on gloves. Putting on the gloves in the way we were taught proved to be a challenge and we both decided to repackage our gloves so we could practice on our own time. We then caught the end of the biopsy procedure that Dr. Kou did where he explained that it is important to take the periphery of the suspected lesion to get the most accurate results as usually is the periphery is usually the portion that is still proliferating and most active.

In the afternoon I meet up with Dr. Fan where we discussed about breast cancer which is one of his specialties. Apparently for general surgery in Taiwan there has been a shift from doing cases like ulcer removals, liver abcess to more cancer management and trauma in recent years. Starting form the beginning Dr. Fran talked about the screening and diagnostic procedures used (Physical Examination, Mammography, Sonography and MRI). Reporting is done using the BI-RADS (Breast Imaging-Reporting and Data System) which utilize 6 categories to describe findings. BI-RADS assessment categories

0: Incomplete

1: Negative

2: Benign finding(s)

3: Probably benign

4: Suspicious abnormality

5: Highly suggestive of malignancy

6: Known biopsy – proven malignancy

Dr. Fan also brought up special issues including the controversy of using self-breast examinations citing the paper sponsored by the Fred Hutchinson Cancer Research Center which concluded that intensive instruction in BSE did not reduce mortality from breast cancer, hence why self-breast examinations are deemed optional in some countries however in Taiwan it is still used part of the screen. Other differences include that it is recommended that women 45 and older receive a mammogram every 2 years and that sonography is routinely used in Taiwan because the cost is relatively low. Another interesting thing he brought up regarding diagnostic imaging is that CT is not very useful for primary screening and diagnosis of breast cancer due to the fact that having things cut in planes means lesions could be missed. However Dr. Fan did say that it was great to use CT to check for the spread of the cancerous lesion as CT is good for accessing depth.

Later at 4:00pm Bor-Han and I attended the surgery pathology meeting which was jointly held by the surgery, pathology and oncology department. Several cases were presented including a rare case of primary diffuse B-cell lymphoma in the GI tract. Overall it was an interesting day and I am looking forward to tomorrow where I will be able to see Dr. Fan perform some operations in the OR.