FORMAL TEACHING OF BASIC SURGICAL SKILLS

Attainment of the practical skills in surgery is an integral part of surgical training. Basic skills must be mastered prior to attempting more complex tasks and bad habits leamed early are difticult to correct. A survey of advanced surgical trainees at this hospital demonstrated that skills were usually acquired during sessions in the operating theatre. often in an ad hoc manner. We report our experience in establishing a workshop-based skills course. The programme included handling of instruments. knot tying, types and applications of needles and suture materials, wound care, ligation of vessels, and assisting at operation. Following completion of the course and demonstration of their competence, participants were awarded a certificate in basic skills. Participants reported increased confidence and involvement in operative surgery after the course and it increased interest in a career in surgery. We believe the intern year is the most appropriate time to teach such skills, but tuition need not be restricted to this group. Teaching basic surgical skills in the workshop setting is both feasible and advantageous.     

Acquiring surgical skills: the history of surgical teaching at the University of Sydney 1883–2014

There have been at least 10 major revisions of the medical curriculum since the inauguration of the Faculty of Medicine at the University of Sydney in 1883. This study traced the evolution of the teaching of surgery at our institution by examination of the set curriculum of each period; the expectations of student knowledge in the final examination as well as examining some of the insights provided by past students of their surgical experience through their writings. In the early years, medical graduates were qualified to perform operative surgery without any further training, whereas the modern postgraduate medical curriculum provides students with the basis for further surgical training.     

Surgical Revolutions

Many surgical revolutions distinguish the history and evolution of surgery. They come in different sizes and exert a variable effect on the development and practice of the discipline.

As science and technology rapidly evolve, so too does the creation of new paradigms, ideas and innovations or discoveries for the improvement of the surgical sciences.

Surgical revolutions are not new, and have existed for centuries even though they have been more frequently recognized since the middle of the 19th century, 20th century and down to the present.

Surgical revolutionaries are indispensable in the conception and completion of any surgical revolution. However, scientific and technological advances have supported the culmination of each revolution.     

A simple method for irrigation and drainage in neurosurgery

Summary A simple, inexpensive method for drainage of neurosurgical wounds, coupled with continuous irrigation, is described. Obstruction of the drain is effectively prevented with this method.     

Glove and instrument changing to prevent bacterial contamination in infected wound debridement and closure procedures: A prospective observational study

Many surgeons use a single table of instruments for both excisional debridement and coverage/closure of infected wounds. This study investigates the effectiveness of a two‐table set‐up of sterile instruments, in addition to glove exchange, to reduce instrument cross‐contamination during these procedures. This is a prospective, single‐site, institutional review board‐approved observational study of surgical debridements of infected wounds over a 17‐month period. Two separate sterile surgical tables were used for each case: Table A for initial wound debridement (debridement set‐up) and Table B for wound coverage/closure (clean set‐up). Swabs of each table and its respective instruments were taken after debridement but prior to coverage/closure. The primary outcome of interest was bacterial growth at 48 hours. There were 72 surgical cases included in this study. Culture results of Table A demonstrated bacterial growth in 23 of 72 (32%) cases at 48 hours compared with 5of 72 (7%) from Table B (P = .001). These data suggest that there is significant bacterial contamination of surgical instruments used for debridement of infected wounds. Use of a two‐table set‐up reduced instrument cross‐contamination by 78%, suggesting avoidable re‐contamination of the wound.     

Postgraduate surgical education and training in Canada and Australia: each may benefit from the other's experiences

Canada and Australia share similar cultural origins and current multicultural societies and demographics but there are differences in climate and sporting pursuits. Surgeons and surgeon teachers similarly share many of the same challenges, but the health care and health-care education systems differ in significant ways. The objective of this review is to detail the different postgraduate surgical training programs with a focus on general surgery and how the programs of each country may benefit from appreciating the experiences of the other. The major differences relate to entry requirements, the role of universities in governance of training, mandatory skills courses in early training, the accreditation process, remuneration for surgical teachers and the impact of private practice. Many of the differences are culturally entrenched in their respective medical systems and unlikely to change substantially. Direct entry into specialty training without an internship per se is now firmly established in Canada just as delayed entry after internship is mandated by the Australian Medical Board. Both recognize the importance of establishing goals and objectives, modular curricular and the emerging role of online educational resources and how these may impact on assessments. The Royal Australasian College of Surgeons is unlikely to cede much responsibility to the universities but alternative academic models are emerging. Private health care in the two countries differs, but there are increasing opportunities for training in the private sector in Australia. In spite of the differences, both provide excellent health care and surgical training opportunities in an environment with significant fiscal, technological and societal challenges.     

How will the introduction of surgical care practitioners affect future surgical training and practice?

Surgical care practitioners (SCPs) are defined as non-medical members of the surgical team who perform surgical intervention, pre-operative and postoperative care after completing a Royal College of Surgeons accredited course. Their role across the modern day National Health Service is becoming more significant due to rising waiting times and the European Working Time Directive placing restrictions on the number of hours worked by surgical trainees. The change in consent law after the judgement of Montgomery versus Lanarkshire Health Board means SCPs can play a vital role in enabling a more individualized and effective consent process, whilst evidence suggests their contribution can reduce waiting times and improve continuity of care. However, concern may arise in the future if surgical trainees see their operating exposure significantly cut due to SCPs being granted-consultant supervised elective lists. Clear guidelines are therefore necessary at local and national level to protect surgical trainees' learning opportunities in theatre and to ensure SCPs achieve their ultimate goal of improved patient care.     

巨大甲状腺肿瘤83例外科治疗分析

目的评价巨大甲状腺肿瘤外科治疗的临床合理性与安全性。方法回顾性分析1985年1月～1999年6月收治83例巨大甲状腺肿瘤外科治疗的临床资料。结果83例巨大甲状腺肿瘤经术后病理组织学证实良性肿瘤56例．恶性肿瘤27例；83例均获随访，随访时间为6个月～10年，其中良性病变56例均存活无复发，恶性病变27例5年生存率达96％（26／27），10年生存率达88％（24／27）。结论外科手术切除是治疗巨大甲状腺肿瘤可靠有效的治疗手段，手术力求术野清楚，操作细柔，防止意外出血，保证手术安全，减少术后并发症的发生。     

A systematic stapling defect – a potential cause of 'anastomotic' leak after restorative proctocolectomy

Objective When constructing ileal‐anal pouches with staples, a novel potential cause of anastomotic leak was recently identified at the apex of the pouch. This study was performed to assess this stapling defect. Method Careful inspection of the ileal pouch staple lines was made in eight consecutive pouch constructions. Pouch construction was further evaluated using pig small bowel. Results When constructing ileal‐anal pouches with staples, a novel potential cause of anastomotic leak was recently identified at the apex of the pouch. This defect was present in seven of eight consecutive ileo‐anal J‐pouches. It was repaired by direct suturing and no clinical or radiological leaks were identified in these patients. In the pig model, the same defect was found in five of five stapled constructions. It was avoiding in five of five cases by limiting the amount of bowel placed into the stapler on the initial firing. Conclusion This defect may be related to stapler design. It can be avoided by using less than the full staple line on the initial firing of the stapler or by using an alternative device. Surgeons creating ileal pouches using staplers, or indeed any use of this particular stapler, need to be aware of this potential for a defect in the staple line and should take steps to avoid the defect or repair it depending on the circumstances.     

再论二尖瓣成形手术适应证及手术技巧

本文研究二尖瓣成形术适应证和手术技巧，以改善远期疗效。作者分析研究210例二尖瓣成形术手术经验和长期随访资料，结果显示，手术死亡12例，其余恢复良好。13例手术后36-144个月接受了二次手术，其中10例因风湿现变复发；另15例于术后21-111个月因二尖瓣再狭窄及关闭不全离不开药物治疗，表明风湿性二尖瓣成形手术适应证必须严格掌握；提高手术技巧可以更好改善心脏功能和治疗效果。     

Clearance rate of intravenously administered lipid in postoperative patients

Elimination rate (K) of intravenously given triglyceride was studied in seventeen patients who underwent elective abdominal operations, and levels of adrenaline, noradrenaline, insulin and blood sugar were simultaneously measured, as stress-indices. All these indices, except for the insulin/blood sugar ratio, increased post-operatively. The postoperative K value increased significantly in comparison with the preoperative value. There was no significant correlation between K value and any of the stress-indices. These results suggest that the initial catabolism of the lipid emulsion triglyceride is enhanced by surgical stress.     

Choosing the Optimal Wound Dressing for Bathing After Total Knee Arthroplasty

BackgroundMany surgical dressings claim to be waterproof and safe for bathing postoperatively. The purpose of this study is to evaluate and compare the effectiveness of commonly used dressings' ability to prevent water penetration while bathing. Additionally, a survey was used to determine satisfaction and cost analysis performed.MethodsFour different dressings were applied to 17 subjects' knees: Aquacel, Opsite, Acticoat, and Tegaderm. A folded Medline Gauze Sponge was weighed and placed under each dressing before and after showering and bathing (submergence under water) in order to measure water penetration (change in weight of sponge in grams). A failure was defined as any dressing that allowed a sponge weight change greater than 1 standard deviation, or 3.9 g. All participants were additionally asked to complete a short survey after testing about the dressings.ResultsTegaderm was found to have significantly less water penetration than all other dressings except Aquacel and demonstrated no failures with showering, significantly less than all other dressings. Tegaderm was also found to have significantly less water penetration than all other dressings except Acticoat with bathing and had significantly less failures than all other dressings. Furthermore, Tegaderm was found to be the most comfortable and lowest cost per dressing.ConclusionTegaderm was overall the most effective at preventing water penetration, most comfortable, and most cost-effective. Aquacel was found to be equally as effective at preventing water penetration while showering but overall had more water penetration, had more failures, caused more discomfort, and was more expensive.     

The surgical care practitioner: a dual perspective

The ongoing balance of service delivery and training offset with the European Working Time Directive has resulted in a requirement to review the surgical workforce and new ways of working. The extended surgical team can be utilized to support the delivery of surgical services. Surgical care practitioners are trained to care for surgical patients across the whole patient pathway: in clinics, theatre and on the ward. They are continual members of the surgical team and can support both the service and training due to the flexible nature of the role. This article gives an overview of the role of the surgical care practitioner (SCP) and how the role impacts surgical training.