THE UNIVERISTY OF THE WEST INDIES

FACULTY OF MEDICAL SCIENCES

MONA

COURSE OUTLINE
___________________________________________________

COURSE TITLE: DOCTOR OF MEDICINE (GENERAL SURGERY)

DM General Surgery Code: RETH9004

DM General Surgery Part I
DM General Surgery Part II

Credits: To be assigned

Semester: 1 and 2

Level: Postgraduate

PREREQUISITE:
The applicant must be:
• A graduate in Medicine of a University or Medical School recognized by the University of
the West Indies.
• Fully registerable in the territory or territories in which the programme of study will be
undertaken. (Criteria for registration should be obtained from the relevant medical
council.)

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Candidates are required to submit a written application and will be required to attend an
interview to be eligible for selection to the programme.

Lecturers:
Mona Campus
Senior Lecturer: Dr Mark Newnham*
Associate Lecturers: At UHWI and SEHA

Cave Hill Campus:

Lecturer: Dr Alan Smith*

St Augustine Campus:
Lecturer: Prof Dilip Dan*

The Bahamas SCMR:

Lecturer: Dr Wesley Francis*

*DM Programme Co-Ordinator University of the West Indies, Mona

COURSE DESCRIPTION/RATIONALE:

Introduction:

The Specialty of General Surgery

General Surgery is the largest of the surgical subspecialty areas in Jamaica and the Region. The
Doctor of Medicine Program in General Surgery has been the foundation for the creation of the
various subspecialties in ENT, Orthopaedics, Cardiothoracic Surgery, Neurosurgery, Urology
and Paediatric Surgery. With advancement of medical knowledge and surgical techniques and
the acknowledgement of the newer subspecialties such as vascular surgery, colorectal surgery

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and surgical oncology, there is a lag in our jurisdiction for providing training in these areas and
these subspecialty areas all remain under the prevue of the general surgeon. The full remit of
general surgery therefore includes conditions of the gastrointestinal tract from the oesophagus to
the anus, the breast, endocrine organs, hernia, general acute care for all aspects of trauma (and
abdomen and thorax in the long-term), peripheral vascular disease, transplantation (kidney, liver)
and some skin problems.

The DM in General Surgery was developed to train specialist surgeons to meet the requirements
of the region and has for years replaced overseas training of our consultant staff in the General
Surgical Specialty. The training received by each graduate has provided the region with surgeons
capable of delivering an advanced level of health care to our people. General Surgery remains
the backbone of all the branches of surgery. This specialty is under the division of surgery and
will be governed by the common regulations established for surgery. General Surgery is a
surgical specialty that encompasses the basics of both acute care and elective procedures for all
facets of surgery. This specialty is integral in the delivery of optimal health care due to the wide
range of treatment offered by the health services.

Commonly encountered Clinical problems include:

 Infectious conditions and neoplasms of the breast, abdomen including the majority of the
gastrointestinal tract, vascular problems in the trunk and limbs, and goitres.

 Limited Thoracic problems

 Upper Gastrointestinal Surgery (oesophagus, gastric, hepato-pancreato-biliary)

 Colorectal Surgery

 Vascular Surgery

 Trauma care including emergency care of blunt and penetrating trauma, the care of burn
patients and major soft tissue injuries.

 Endocrine (thyroid, parathyroid, adrenal glands)

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  Transplant (Renal and Hepatic)

 The coordination of care of the surgical patient in a multidisciplinary team environment.

General Surgeons treat and follow up patients in both outpatient and in-patient settings. They
work in close association with other specialties such as Orthopedics, Otolaryngology,
Gastroenterology, Plastic Surgery, Pathology and Dietitians.

Goal and Objectives:

The General Surgical training program aims to equip residents with a general body of
information and skills that will allow them to suitably administer appropriate care in the
management of general surgical patients.

This programme will provide training, which will result in a combination of excellence in patient
care skills, strong medical knowledge, professionalism, and good interpersonal skills. This goal
will be achieved by formal lectures, provision of ongoing supervised clinical care that includes
ward rounds, procedural teaching, multidisciplinary team meetings and training in the surgical
skills lab. Other learning opportunities will be provided during the care of patients in the
outpatient clinics, teaching of undergraduates and residents, journal clubs, electives and
independent self-learning.

Entrance Requirements

Persons will be considered for entry to the programme after registration with the Medical
Council of Jamaica. Post registration time spent in surgical specialties, anesthesia or emergency
medicine would be highly recommended prior to commencement of the program. A post is
required at the University Hospital of the West Indies or a funded post by the Government of
Jamaica at the Kingston Public Hospital or the Cornwall Regional Hospital.

Date of Entry

The date of entry is July of each year and the candidate must obtain a post for the application to
be processed. Application to enter the programme may be made before securing such a post. The
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applicant may then receive provisional acceptance for entry to the programme from the Office of
the Graduate Studies and Research, on the recommendation of the Surgical Specialty Board
through the Faculty Committee for Graduate Studies, but commencement is based on obtaining
an accredited post.

Course of Study

The duration of the programme will be a minimum of five years. Training will be divided into
two parts, designated Part I, which will entail training in Anatomy, Pathology, Physiology and
Principles of Surgery and Part II, which will complete the training, including skills and
competency in performing surgical operations and culminate in the successful completion of the
Part II examination.

Course Supervision

The course will be under the general supervision of consultants in General Surgery. These are
consultants from UHWI and from the accredited Government Hospitals. Each resident will be
assigned to an academic advisor, who is a member of the academic department. The advisor will
provide academic guidance in the choice of their research project and all other relevant matters.
The Specialty Board in Surgery is the body that provides oversight of the Doctor of Medicine
programme.

Competencies

The Curriculum is competency based. Trainees will achieve the competencies described in the
curriculum through a variety of learning methods,

The Part I programme:

The Part I programme entails three monthly surgical rotations in general surgery and the
surgical specialties for the first two years prior to sitting the Part I examination. The Part I
section of the program will be completed at the end of two years. An examination will be held at
the completion of the Part I programme and will consist of Anatomy, Physiology, Pathology and

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Principles of Surgery. The candidate must pass Principles of Surgery and at least two of the three
additional subjects before progressing to Part II.

The Part II programme:

The Part II programme allows the trainee to build on the knowledge and competencies gained
during the Part I programme and to gain skills in performing general surgery operations.

The first year following successful completion of the Part I examination is based on six-monthly
rotations in General Surgery at either the University Hospital of the West Indies or Kingston
Public Hospital. In the second-year rotation, there is the option of an elective period of the
candidate’s choosing. The final year will be spent as a Chief Resident in General Surgery
rotating in the previously designated hospitals.

The core competencies are:

1. Patient Care
 Provide patient care that is compassionate, appropriate and effective for the
promotion of health, prevention of illness, treatment of disease and care of the
patient at the end of life.
 Gather accurate, relevant patient information from all sources, including medical
interviews, physical examination, medical records, and diagnostic/therapeutic
procedures.
 Develop, discuss and implement patient management plans.
 Perform competently the operative procedures outlined in the curriculum.

2. Medical Knowledge
 Develop competence in the basic and clinical sciences that are related to the practice
of General Surgery.

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  Demonstrate knowledge of established and evolving basic sciences, clinical and
surgical techniques.
 Critically evaluate current scientific evidence and surgical management to modify
clinical problem solving, and clinical decision-making skills and modification of
surgical practice.

3. Practice-Based Learning and Improvement

 Residents should demonstrate an appreciation of scientific methods and evidence to
investigate, evaluate, and improve their patient care practices.
 Identify areas for improvement and implement strategies to improve their knowledge,
skills, attitudes, and processes of care.
 Analyze and evaluate their practice experiences and implement strategies to
continually improve the quality of their patient practices.
 Develop and maintain a willingness to learn from errors and use such experience to
implement best-practice treatment and improve the system or process of care.
 Use information technology or other available methodologies to access and manage
information and support patient care decisions and their own education.

4. Interpersonal Skills
 Demonstrate interpersonal and communication skills that enable them to establish and
maintain professional relationship with their patients, patients’ families and other
members of the health care team.
 Provide effective and professional consultation with other physicians and health care
professionals and sustain therapeutic and ethically sound relationships with patients,
their families and colleagues.
 Use effective listening, nonverbal questioning, and narrative skills to communicate
with patients and families.
 Interact with colleagues and staff in a respectful and appropriate manner.
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  Maintain comprehensive, current and legible medical records.
 Provide timely summary of in-patient care
 Ensure timely reply to letters of referral

5. Professionalism

 Demonstrate behaviour that reflects a commitment to continuous professional

development, ethical practice, an understanding and sensitivity to diversity and a
responsible attitude toward their patients, their profession and society.
 Demonstrate respect, compassion and integrity in their relationship with patients,
families, and colleagues.
 Demonstrate sensitivity and responsiveness to patients and colleagues, especially in
matters pertaining to gender, age, culture, religion, sexual preference, socioeconomic
status, beliefs, behavior and disabilities.
 Adhere to principles of confidentiality, scientific/academic integrity and informed
consent.
 Recognize and identify deficiencies in peer performance and provide appropriate
guidance.

6. Management and Decision-Making

Develop a logical and effective approach to the assessment and management of patients in
both clinic and in-patient settings under the supervision and guidance of a Consultant
General Surgeon.

 Develop a comprehensive problem list with appropriate and accurate prioritization for
action.
 Recognize the limits of one’s own knowledge, skill level, and tolerance of stress; know
when to ask for help, how to contact consultants, and where to find basic information.
 Seek information as needed and apply this knowledge appropriately using evidence-based
problem solving.
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 7. Research Competency

 Demonstrate an understanding of research methods and statistics

 Demonstrate competence in the development of a research question or proposal
 Demonstrate competence in the completion of a thesis, or research project.
 Display an interest in presentation of clinical cases and publication

Learning Resources

• Ward rounds
• Out Patient Clinics
• Operating room procedures
• Multidisciplinary team meetings
• Surgical Skills Lab sessions
• Research and audit projects
• Journal clubs
• Lectures and small group teaching
• Grand rounds
• Joint specialty meetings
• Attendance at training programmes organized on a departmental, faculty, regional or
international basis, which are designed to cover aspects of the training programme
outlined in this curriculum.
• Attendance at regional, national and international meetings in General Surgery.

Independent Self-Directed Learning:

 Preparation for assessment and examinations

 Reading of journals
 Reading of web-based material
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  Maintenance of a personal procedure log
 Audit and research projects.
 Achieving personal learning goals beyond the essential, core curriculum

Research:

Research is an integral part of the training programme and a clinical research project is
compulsory.

Interim Assessment:

The resident will have integrated assessments at three monthly intervals which will grade
performance using multiple criteria including knowledge, patient care, reliability, interpersonal
relations, surgical skills and attendance.

Part I: (Basic Sciences and Principles of Surgery)

The part I will be covered during the first two years. This involves the basic sciences, including:

Anatomy
Anatomy of the limbs, thorax, abdomen and pelvis plus relevant aspects of head and neck and
neuroanatomy. It will also include embryology.

Physiology

Physiology of the major systems including but not limited to cardiovascular, respiratory,
gastrointestinal, genitourinary, endocrine, and CNS. It will include organization, function,

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mechanism of action, regulation and adaptations of structures, relevant to the clinical methods of
assessment (e.g. blood pressure regulation, respiratory support, intra-abdominal pressure).

Pathology

Basic principles of Pathology (with emphasis on inflammation, disorders of growth, molecular

mechanisms of disease and microbiology,)

Principles of Surgery

During this period, the student will be introduced to basic medical and surgical principles. The
student will acquire basic clinical and surgical skills. Attendance of all the surgical skills training
sessions conducted in the skills laboratory is compulsory and a prerequisite for qualification to
the Part 1 examinations.

During this period the student rotates at three months intervals through the surgical disciplines of
cardiothoracic surgery, urology, paeadiatric surgery, orthopaedic surgery, neurosurgery, and
spends a minimum of 6 months in general surgery. During this period, the student should also be
completing the introduction to research methods which is an online course and compulsory for
all residents in the postgraduate residency programmes.

Part 1 will be examined at the end of two years. Candidates will have to achieve an adequate
standard of performance before they can proceed to the second part of the programme.

Assessment – Part I

After completion of the base foundation surgical rotations satisfactorily, the candidate will be
eligible to sit the Part I examinations. This consists of written and oral examinations in the
following subjects:

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 1) Anatomy
2) Pathology
3) Physiology
4) Principles of Surgery

The candidate must pass Principles of Surgery and at least two of the three additional subjects
before progressing to Part II. All Part 1 subjects must be successfully passed within one year of
an initial attempt.

Part II

This course will be completed in the 3, 4 and 5th years. This part of the course includes the
principles of surgery related to trauma, emergency surgical problems including management of
the acute abdomen.
The trainee will commence work on the research project and casebook. During this period the
candidate will continue to gain clinical and surgical skills including laparoscopy, endoscopy and
elective surgeries, teaching, research and leadership.

The clinical research project must be submitted at the start of the second phase of the programme
and reviewed and accepted prior to sitting the Part II examinations.

Assessment - Part II

This will again be a written and oral examination that will be conducted by a panel of internal
and external examiners.

Award of Doctor of Medicine

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The certificate of competency will be awarded after successful completion of Part I and II
examinations.

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LEARNING OBJECTIVES: PART 1

ANATOMY

Upper and Lower Limbs

At the end of the first 2 years of the programme, the student will be able to identify and explain
the anatomy of the upper and lower limbs. The student will be able to:

Upper Limbs

 Recognize and identify the bones of the upper limb and their relationship to each other
and important surface landmarks
 Identify all fissures and grooves on the scapula, clavicle, humerus, ulna and radius and
describe their significance
 List the bones or the wrist and hands and their peculiarities
 Recognize and describe the blood vessels of the upper limb including the structures they
supply and drain
 Identify the contents of the axilla
 Describe and identify the components of the brachial plexus including all nerves passing
through the axilla to supply the upper limbs and be able to correlate level of nerve injury
with clinical manifestation
 Describe the muscles distributed in the upper limbs including origin, insertion and
characteristic functional losses associated with denervation
 Identify the intrinsic muscles of the hand, arterial & nerve supply, venous & lymphatic
drainage

Lower Limbs

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  Describe the bones of the lower limbs including the pelvic girdle, the femur, tibia and
fibula and the tarsal bones including all relevant surface anatomy, grooves, foramina and
peculiarities of functional significance
 Describe the formation and distribution of the lumbosacral plexus.
 Describe the muscles distributed in the lower limbs including origin, insertion and
relevant anatomy about characteristic pathologies such as compartment syndrome
 Describe the blood supply of the lower limbs including relevant anatomy of the
superficial, deep and connecting system of veins, the arterial distribution and relevant
lymphatic anatomy

Anatomy of the Thorax

At the end of the first 2 years the candidate will be able to:

- Describe the composition of the bony thorax and the relevant anatomy of the ribs and,
sternum and thoracic vertebrae

- Outline the division of the thorax into the various compartments and the associated
contents

- Discuss the arrangement of the intercostal muscles and the location of the neurovascular
bundles

- Outline the anatomy of the lungs including surface markings and relationships and
discuss the clinical significance of the unique blood supply and drainage as it relates to
pathologies such as pulmonary embolus and surgical procedures such as pneumonectomy
and lung transplant

- Outline the surface anatomy of the heart, its various cavities, muscles, valves, blood
supply and nerve supply

- Outline the anatomy of the thoracic diaphragm, including its origin and insertion, blood
supply and nerves.
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 - Outline the anatomy and epithelial histology of the oesophagus with special emphasis on
the anatomical peculiarities of the gastro-oesophageal junction.

- Describe the vascular supply and drainage of the oesophagus with clinical correlation to
pathologies such as oesophageal varices

- Outline the course of the major arteries, veins and lymphatic structures in the thoracic
cavity.

Anatomy of the Abdomen

At the end of the first 2 years the candidate will be able to:

- Describe the composition of the anterior abdominal wall and the peculiarities that lead to
hernias

- Outline the anatomy of the inguinal region and relevant embryology

- Outline the anatomy of the femoral triangle and femoral canal.

- Describe the compartments of the abdominal and pelvic cavities, including the supracolic
compartment, greater and lesser sacs, the true pelvic cavity and all relevant surface
anatomy

- Describe the division of the liver segments and relevant regional and surgical anatomy

- Describe the anatomical relationships of the spleen

- Describe the anatomy and outline the relations of the stomach, duodenum, pancreas,
intestines, rectum and anus including the blood supply, lymphatic drainage and nerve
supply.

- Describe the histological similarities and differences seen in the epithelium of the hollow
viscera of the abdomen

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 - Describe the retroperitoneal organs, including the kidneys, ureters, urinary bladder, and
relevant functional anatomy of these organs. The student must also have some
understanding of the variations in congenital abnormalities that may be encountered.

- Describe the blood supply of the gastrointestinal tract including relevant embryology and
relationship to variations in anatomy that can present as clinical entities

Neuroanatomy

At the end of the first 2 years of the programme, the student will be able to:

 Describe the origin, course and distribution of all the cranial nerves
 Explain the physical and functional effects of lesions of the cranial nerves
 Describe the surface topography/surface features and functional localization of the
cerebral cortex including the main lobes of the cerebrum, gyri and sulci.
 Summarize the functions of the frontal, parietal, temporal and occipital lobes.
 Identify the cerebral lobes and diencephalon.
 Recognize the structures in a midline sagittal view, transverse view and coronal view of
the brain and the internal anatomy of the cerebrum including the hypothalamus, thalamus
(LGN), caudate and lentiform nuclei, basal ganglia, internal capsule, hippocampus and
fornix.
 Identify the association and commissural fibers and the lateral, third and fourth ventricles.
 Describe the anatomy of the brain stem with emphasis on the midbrain,
 Discuss the functions of the brain stem
 Identify the cerebellum and discuss its function
 Outline the arterial supply and venous drainage of the brain including the dural venous
sinuses
 Explain the production and circulation of cerebrospinal fluid
 Identify the cavernous sinuses and list the structures contained within them

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  Outline the anatomy of the autonomic nervous system including superior, middle and
inferior cervical ganglia and the parasympathetic (ciliary, pterygopalatine,
submandibular, otic) ganglia


Head and Neck

At the end of the first 2 years of the programme, the student will be able to

 Describe the scalp in terms of its layers, blood supply, innervations and applied aspects.
 Describe the sensory and motor supply of face with special emphasis on the 7th cranial
nerve and its relationship to the temporomandibular joint and parotid gland.
 Describe the boundaries, subdivisions and contents of anterior and posterior triangle of
neck.
 Identify the deeper structures in the neck.
 Describe the structure including blood supply, nerve supply and lymph drainage of the
ethmoidal, sphenoidal, frontal and maxillary sinuses.
 Describe the suprahyoid and infrahyoid group of muscles, their actions and innervations.
 Describe the cervical plexus and its distribution.
 Describe the disposition of deep cervical fascia and its clinical significance.
 Describe the course, tributaries and applied anatomy of external jugular vein.
 Describe the origin, course and branches of common carotid artery including external
carotid artery.
 Describe the origin, course, tributaries and termination of internal jugular vein.
 Describe the anatomy of atlanto-occipital and atlantoaxial joints and the movements at
these joints.
 Demonstrate the regions/fossae listed below and identify the structures in each of them
o Parotid region
o Temporal fossa
o Infratemporal fossa and
o Submandibular region
o Describe the anatomy of the submandibular and parotid glands
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  Describe the anatomy of temporomandibular joint, its movements and the muscles acting
up on the joint including their innervation.
 Describe the muscles of mastication and their nerve supply.
 Describe the arrangement of the lymphatic drainage of the head and neck, the major
groups of lymph nodes and the potential routes for the spread of infection and malignant
disease.
 Describe the surface landmarks and surface anatomy of major structures in head and
neck.
 Identify the major foramina in a skull and list the structures passing through them and
their function.
 Describe the embryological development and gross anatomical cognates of the
pharyngeal arches and pouches
 Describe the structure of the thyroid gland
 Describe the regional anatomy of the parathyroid glands and outline anatomical variants
in the position of these glands
 Describe the types and features of cervical vertebra.
 Describe the position and features of hyoid bone, trachea and esophagus.

LEARNING OBJECTIVES: PART 1

PHYSIOLOGY

Respiratory physiology:

Mechanisms & Control of Respiration

Gas exchange, V/P Defects & O2 Dissociation Curve

Pulmonary Function Tests, Recognition of & Management of Respiratory Failure

Recognitions & Management of ARDS

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Cardiac physiology:

Control of cardiac output & regulation of BP types

Shock; Types, recognition & management

Regulation of blood flow to specialized tissues – Brain, Kidney, Liver

Blood Transfusion; Indications and Complications

Trauma/shock

Define shock, categorize it based upon type, and explain the etiology and pathophysiology of
each type of shock:

 Cardiogenic
 Hypovolemic
 Distributive (septic, anaphylactic, neurogenic, and adrenal insufficiency mediated)
 Obstructive (cardiac tamponade, tension pneumothorax, pulmonary embolus)

Summarize the clinical presentation and hemodynamic parameters associated with each type of
shock using clinical terms (e.g., heart rate, respiratory rate, and blood pressure).

Propose an algorithm for diagnosing and initiating treatment for each shock type:

 Cardiogenic
 Hypovolemic
 Distributive (septic, anaphylactic, neurogenic, and adrenal insufficiency mediated)
 Obstructive (cardiac tamponade, tension pneumothorax, pulmonary embolus)

Discuss the pathophysiology, including the mechanism of arrest, for the following situations:

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  Acute myocardial infarction and dysrhythmia
 Congestive heart failure
 Hypovolemic shock (blood loss, dehydration)
 Hemorrhagic shock (non-traumatic)
 Burns and electrical injury
 Septic shock
 Anaphylactic shock (envenomation, drug-related)
 Acute adrenal insufficiency
 Hypothermia
 Penetrating or blunt trauma
o Tension pneumothorax
o Pericardial tamponade
o Hemorrhagic shock

Describe the normal physiological response to a variety of insults, such as sepsis, trauma, or
surgery, by associating the adaptation of the following systems from pre-stress to post-stress
states:

 Respiratory
 Hemodynamic
 Renal
 Metabolic
 Endocrine

Endocrine systems:

Calcium Metabolism, Vitamin D and Parathormone

Thyroid Physiology

Adrenal gland physiology

The pituitary gland

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Fully discuss the secretion and control of the following:

 Thyroid stimulating hormone

 Parathyroid hormone
 Adrenocorticotropic hormone (ACTH)/cortisol
 Insulin/glucagon
 Catecholamines
 Gastrin/secretin/cholecystokinin
 Serotonin/histamine
 Estrogen/progesterone/testosterone
 Oxytocin/vasopressin
 Growth hormone
 Melanocyte stimulating hormone
 Prolactin
 Motilin/Gastric inhibitory peptide (GIP)/enteroglucagon/vasoactive intestinal peptide
(VIP)
 Somatostatin

Summarize key physiological alterations of the neuroendocrine system that occur with normal
aging. Include explanation of these alterations that can occur with advancing age:

 Increase in plasma noradrenaline concentrations

 Steady decrease in aldosterone secretion
 Decline in plasma renin activity
 Significant increase in plasma cortisol levels

Renal Physiology

Renal Function: Principles & Applications

Water and Electrolyte Balance

Describe body water volumes and distribution.

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Indicate the normal electrolyte distribution of cell water and extracellular fluid to include the
following:

 Sodium
 Potassium
 Chloride
 Bicarbonate
 Calcium
 Magnesium
 Phosphate

Outline the normal electrolyte content of body fluids such as blood, extracellular fluid (ECF),
urine, saliva, gastric juice, bile, and pancreatic fluid.

Identify water and electrolyte changes in response to various stress situations:

 Diseases, including trauma and burns

 Operative and non-operative therapy

Apply the physiology of water and sodium imbalance to the following:

 Extracellular fluid volume (ECFV) depletion

 ECFV expansion
 Hyponatremia (hypo-osmolarity)
 Hypernatremia (hyperosmolarity)

Explain the treatment of water and sodium imbalances, and complications of diuretic use and
fluid restrictions.

Summarize normal potassium physiology, causes, and consequences of depletion and excess, and
treatment for potassium imbalance.

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Discuss complexities of calcium, phosphorus, and magnesium excesses and deficiencies in the
following:

 Metastatic breast cancer

 Hepatic failure
 Hyperparathyroidism

Illustrate treatments for high and low calcium, phosphorus, and magnesium.

Outline the pathophysiology of fluid and electrolyte problems in cardiac and peripheral
revascularization, including reperfusion injury.

Gastrointestinal Function and Dysfunction:

Describe the physiological effects of pneumoperitoneum

Understand the physiology of the stomach and small bowel including:

 gastric function regulation

 gastric peptides
 gastric acid secretion
 gastric motility
 gastric barrier function
 small bowel motility
 small bowel endocrine function
 small bowl immune function

Recognize the physiological changes following bariatric surgery

Describe the physiology and function of the liver and biliary system including the following:

 Glucose metabolism
 Protein synthesis
 Coagulation
 Drug metabolism
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  Reticuloendothelial system
 Function of bile in fat metabolism
Explain the formation of bile, its composition, and its function in digestion.

Describe the pathophysiology of gallstone formation.

Correlate bile formation and composition with disease states affecting the biliary system, such as
gallstone formation and biliary obstruction.

Discuss the enterohepatic circulation of bile.

Discuss the physiology of the pancreas, including endocrine and exocrine function and hormonal
regulation.

Swallowing, defecation and control of gastrointestinal motility

Disorders of GI motility

Digestion, the exocrine pancreas and the metabolism of bile

Nutrition & Malnutrition (Gross and micronutrient)

Neurophysiology:

LEARNING OBJECTIVES: PART 1

PATHOLOGY

At the end of the 2 years the candidate should have a clear understanding of the following
pathological principles:

 Outline the appropriate means of preparing gross and microscopic specimens for
pathology evaluation, including:
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  Specimen collection, transport & storage
 Orientation of gross specimens
 Trans illumination and gross dissection
 Tissue processing and fixation
 Tissue stains
 Outline the approach to describing gross and microscopic specimens
 Describe the common adjunctive special procedures, and their applications, in the
diagnosis and classification of pathology specimens including:
 Immunohistochemistry
 Flow cytometry
 Molecular pathology/cytogenetics (PCR and variants, FISH, microarray)
 Diagnostic electron microscopy

 Discuss the procedure and uses of fine needle aspiration biopsy in pathology
 Discuss the procedure and uses of frozen section in pathology

The candidate should have in-depth knowledge and understanding of the following:

Inflammation

Wound healing

Cellular injury

Tissue death including necrosis and apoptosis

Disorders of growth, differentiation and morphogenesis

 Cellular response to changes in stress including hyperplasia, hypertrophy, atrophy

and metaplasia

Haemostasis and haemostatic disorders

Surgical immunology

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 Surgical haematology including the surgical significance of lymphoma, leukaemia and
myelodysplastic disorders

Surgical biochemistry

Pathology of neoplasia

Classification of neoplastic tumours

Specific theories of tumour development including the Adenoma-Carcinoma

Sequence

Tumour development and growth including metastasis

Principles of staging and grading of tumours

Principles of cancer therapy including surgery, radiotherapy, chemotherapy,

immunotherapy and hormonal therapy

Principles of cancer screening

The pathology of specific organ systems relevant to surgical care including:

Cardiovascular pathology

Respiratory pathology

Gastrointestinal pathology

Genitourinary disease

Breast

Exocrine and endocrine pathology

Central and peripheral neurological system

Skin

Lymphoreticular system

Musculoskeletal system
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LEARNING OBJECTIVES: PART 1

PRINCIPLES OF SURGERY

At the end of the first 2 years of the programme, the student will be able to:

Sterilization/Disinfection:

 Differentiate between the terms sterilization, disinfection and antisepsis

 Discuss the methods of sterilization, to include:
• Dry heat
• Wet heat
• Chemical
• Radiation
• Microfiltration/nanofiltration
 Discuss the methods of disinfection to include:
• iodophors
• alcohols
• chlorhexidine,
• glutaraldehyde
 Discuss the concept of decontamination, with special reference to
• the different methods available for instrument cleaning (manual and automated,
enzymatic and non-enzymatic)
• the choice of processes for different situations (high, medium and low risk)
 Discuss the indicators used to confirm sterilization (e.g. chemical, spore tests)
 Describe methods of, and outline indications for, antibiotic prophylaxis (preoperative,
intraoperative and post-operative)

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Instruments and sutures

 Compare the advantages and disadvantages of single use versus reusable instruments
 Describe and identify the instruments used in common general surgical procedures and
discuss their functions
 Discuss the advantages and disadvantages of titanium versus stainless steel instruments
 Be aware of commonly used materials in interventional medicine and surgery (nitinol,
PTFE, etc) and the physical and chemical properties that make them useful
 Describe and identify the suture materials and needles used in common general surgical
procedures, and discuss their uses

Pre-Operative

 Describe the process of obtaining informed consent (including risks, benefits,

alternatives, confidentiality, right to refuse or withdraw and what to expect before, during
and after surgery)
 Assess whether patients are mentally and psychologically fit to give informed consent
 Describe how to obtain consent in special circumstances
o emergencies and incompetent individuals
o minors
o special needs
o women of child bearing age
o pregnancy and breast feeding
 Recognize and assist patients with special needs who are undergoing a general surgical
procedure
 Describe anaesthetic options and associated risks for commonly performed surgical
procedures
 Describe how medical clearance for surgery is determined including the request of
appropriate tests and interpretation of results
 Communicate with all members of the multidisciplinary team involved in the patient’s
care including physicians, diabetologists, cardiologists and anaesthetists

29
  Discuss the role of the primary care practitioner in the pre-operative assessment of the
patient
 Discuss the pre-operative management required for pharmacological drugs and herbal
supplements
 Document the clinical findings and other relevant data pertaining to the patient’s surgical
procedure
 Determine peculiar circumstances associated with any individual patient’s care (e.g.
allergies, previous adverse drug reactions, anxiety, claustrophobia)
 Communicate effectively with other members of the team with respect to the patient’s
care and management immediately before and after surgery
 Clearly communicate postoperative rehabilitation principles and strategies

Operative

By the end of the first 2 years of the programme, the student should be able to describe the
principles of instrumentation, surgical equipment and sutures used in common general surgical
procedures. These includes:

 Incision and drainage

 Management of lacerations
 Excision of lumps and other skin lesions under local anaesthesia
 Tube thoracostomy
 Central line insertion
 Venous cutdown
 Proctosigmoidoscopy

 Emergency procedures
o Appendicectomy-open & laparoscopic
o Exploration of testis for torsion
o Debridement of the ‘diabetic foot’

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 o Lower limb amputations
 Ray
 Transmetarsal
 Below knee
 Above knee

 Elective procedures
o Inguinal hernia repair
o Femoral & umbilical hernia repair
o Circumcision
 List the major complications of commonly performed surgical procedures
 List the different types of incisions for emergency and elective laparotomy
 Perform safe midline exploratory laparotomy in a previously unoperated abdomen

Post Op Care:

At the end of the first 2 years of the programme, the student will be able to

 Describe the monitoring and management of the airways, breathing and cardiac status in
the immediate post-op period, specifically discussing blood pressure, heart rate and O2
saturation, and specifically commenting on monitoring with different types of anesthesia
 Describe the appropriate immediate post op management of specific diseases that require
close monitoring and augmentation (such as DM and related blood sugars).
 Describe pain management in relation to the types of procedures performed.
 Describe management of inflammation in relation to the type of procedure performed and
any pre-existing conditions and/or intraoperative events.
 Describe infection prophylaxis in relation to the type of procedure performed using
evidence-based decision making when possible.
 Discuss appropriate discharge procedure including timing, discharge medications and
instructions.

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 Discuss psycho-social issues that could impact outcomes of the surgery.
 Describe the necessary modifications in the post-op management of patients with
unusual psycho-social issues.
 Describe the instructions given to the patient for appropriate follow-up after discharge
including instructions should patients encounter difficulties or complications.
 Discuss post-op counseling on realistic expectations and worse case results that the
patient might encounter as well as the legal, moral and ethical obligations such as
disclosing complications experienced in surgery or complications in the post-op period as
well as below average results.
 Discuss the obligations of the surgeon to follow the patient post operatively and when can
the patient be discharged.
 Management of the post op patient who is lost to follow-up.

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LEARNING OBJECTIVES: PART 2- KNOWLEDGE

The aim is to train general surgeons who will be able to work unsupervised and independently
to the standard of a consultant in elective and emergency general surgery and who have
appropriate leadership skills that will allow them to lead the members of a general surgery team.

Therefore, all general surgery trainees at this stage will gain knowledge, clinical and technical
skills to the competency levels defined to function in elective and emergency general surgery.
They will all gain knowledge, clinical and technical skills to the competency levels in trauma,
gastrointestinal (upper and lower), minimal access, breast, transplant, vascular and endocrine
surgery.

During the 3rd and 4th of training all trainees will rotate at 6-month intervals through the
various general surgical firms at the accredited Part 2 sites and receiving increasing levels of
responsibilities.

Year 5 will see the resident in the chief resident role and will seek to consolidate their training,
with an emphasis on technical skills as they should be fully competent with the knowledge and
clinical skills of necessary for most general surgical decisions.

Emergency general surgery training will continue for all trainees throughout the five years.
Working on most surgery firms across the accredited sites will allow each resident to participate
in emergency and elective general surgery. This should give trainees the opportunity to learn

33
continuity of care, judgement, decision making, prioritization and to see how symptoms, signs
and associated pathology develop over time.

TRAUMA

At the end of their training, DM GENERAL SURGERY candidates should have achieved
competency in:

-Diagnosing and managing patients (including children) with multiple trauma, especially
abdominal trauma including bowel, splenic, hepatic and pancreatic injuries.

-Recognizing the indications for and in performing exploratory and damage limitation
laparotomy

-Diagnosing and managing peripheral and central (abdominal) vascular trauma, controlling
haemorrhage with pressure and referring on for definitive management

-The initial management of soft tissue extremity injury, referring on when necessary for
definitive management

-The initial management of head and neck injury, referring on when necessary for
definitive management

-Diagnosing and initiating management of the patient with possible injury to the urogenital
tract, involving other specialists appropriately.

-the initial management of thoracic injury; the graduate be able to carry out damage control
thoracotomy when this is required as an emergency; onward referral to more specialized
surgeons when appropriate

-The use of scoring systems in trauma

34
-The overall management of the conditions below;

Abdominal trauma: The supracolic and infracolic compartments

Damage control laparotomy

GU trauma: investigations and management

Vascular trauma

Thoracic trauma: cardiac tamponade and flail chest

Trans-mediastinal penetrating injuries

Penetrating neck injuries

Mass casualty situations

GASTROINTESTINAL and HEPATOPANCREATICOBILIARY

At the end of their training, DM GENERAL SURGERY candidates should have achieved
competency in:

-Diagnosing and managing patients presenting with emergency oesophago-gastric

conditions, referring on when necessary:

-Diagnosing and stabilizing patients with bleeding oesophageal varices, Boerhaves syndrome,
Iatrogenic oesophageal perforation etc and refer for definitive management

-Managing Acute gastric GI haemorrhage, Acute perforation. Gastric volvulus

-Diagnosing and manage patients presenting with emergency and non-emergency

pancreato-biliary conditions, referring on when necessary:

35
 Gallstone disease – acute and chronic cholecystitis, empyema, mucocoele, acute
biliary colic, cholangitis, obstructive jaundice, gall stone ileus, acute and chronic
pancreatitis,

Pancreatic disorders including pancreatic neoplasms

-Managing patients with colorectal and anal malignancy within a multi-disciplinary team
with other surgical, medical and clinical oncology colleagues, recognising that full
competence may not be achieved in all operative procedures. The operative procedures
include: all types of segmental colectomy, anterior resection, abdominoperineal resection,
fistula surgery and haemorrhoidectomy.

-Managing diverticular disease and volvulus

-Managing patients with large bowel obstruction

-Managing patients with inflammatory bowel disease

-Managing the common benign ano-rectal conditions including haemorrhoids, fissure,

abscess/fistula in ano and pilonidal sinus

-Manage patients with conditions such as faecal incontinence, rectal prolapse, solitary rectal
ulcer, constipation, irritable bowel syndrome and chronic rectal pain.

Index Procedures in Upper Gastrointestinal Surgery (SEE LIST OF SURGICAL

COMPETENCIES AS PER PGY BELOW)

36
VASCULAR

At the end of their training, DM GENERAL SURGERY candidates should have achieved
competency in:

-Managing patients with asymptomatic and symptomatic abdominal and peripheral aneurysms,
including rationales for open vs EVAR

-Managing patient with Acute arterial occlusion

-Managing patients with Acute mesenteric ischaemia

-Managing patients with the entire spectrum of chronic arterial occlusion including critical limb
ischaemia, indications for endovascular vs open bypass

-Managing patients with acute and chronic Venous insufficiency, including the recognition and
management of the phlegmasias

-Managing patients who need Vascular access

-Managing patients with Traumatic arterial and venous injuries (see section on Trauma)

ONCOPLASTIC

At the end of their training, DM GENERAL SURGERY candidates should have achieved
competency in:

-Managing Breast cancer patients; diagnostic procedures such as core biopsy, excisional
biopsies, hook wire localization and excision, therapeutic procedures such as wide excision, the
various types of mastectomy including skin and nipple sparing mastectomy, ALND, sentinel
node biopsy

-recognising and understanding the advances in breast cancer management with respect to genes
and drugs

37
-Basic Post mastectomy reconstruction; candidates should be familiar with the use of implants;
flaps (pedicled including DIEP and free), as well as the principles and techniques of the TRAM
flap

-Managing patients desirous of mammoplasty: augmentation and reduction-

-Managing benign breast/nipple conditions (cysts, pain, discharge etc)

-Understand the principles and be able to assess/give advice in pregnancy and lactation

-Assessing congenital/developmental breast/nipple problems recognizing that full

competence may not be achieved in all aspects of complex problems

ENDOCRINE

At the end of their training, DM GENERAL SURGERY candidates should have achieved
competency in:

-diagnosing the causes and managing patients who need Surgery for hypercalcemia, including
specifically the diagnosis, investigations, medical and surgical treatment of disorders of

-Managing patients with benign and malignant disease of the thyroid gland

-Assessing and making a diagnosis in a patient presenting with a swelling in the neck,
including thyroglossal cyst and cervical adenopathy.

- Performing the appropriate operative procedure for the above conditions including lymph
node dissection.

-Managing the patient after thyroid surgery.

Managing the patient with Adrenal disorders such as pheochromocytoma & other neoplasms

-Diagnosing and investigating disorders of the adrenal gland that present as an adrenal mass

-Performing an adrenalectomy and managing the patient postoperatively

38
MISCELLANEOUS

Medicolegal aspects of surgery; from informed consent to court

Anaesthesia for the surgeon: Respiratory management of the ventilated patient

Ethics and the ICU: The dying patient

Scores as related to predicting outcome in Trauma management, Sepsis and Cancer care

Management skills for the surgeon: Management of the medical practice

Management skills for the surgeon: The surgeon as SMO

39
RECOMMENDED TEXTS

Principles of Surgery

Principles and Practice of Surgery by O. James Garden MB ChB MD FRCS(Glasgow)

FRCS(Edinburgh) FRCP (Edinburgh) FRACS(Hon) FRCSC(Hon) Professor, Andrew W.
Bradbury BSc MBChB MD MBA FRCSEd Professor, John L. R. Forsythe MD FRCS(Ed)
FRCS, and Rowan W Parks
Bailey and Love's Short Practice of Surgery 25th Edition by Norman S. Williams (Editor),
Christopher J.K. Bulstrode (Editor), P. Ronan O'Connell (Editor)
Anatomy
Last's Anatomy: Regional and Applied (MRCS Study Guides) by R.J.
Last and Chummy Sinnatamby

Pathology
Robbins Basic Pathology by Vinay Kumar MBBS MD FRCPath, Abul K. Abbas MBBS,
Nelson Fausto MD, and Richard Mitchell MD PhD
Physiology
Ganong's Review of Medical Physiology, 23rd Edition (Lange Basic Science)

40
UNIVERSITY OF THE WEST INDIES
SURGICAL RESIDENT COMPETENCIES
At the end of the year specified, the resident should have achieved competency in the follow

PGY 1 AND PGY2

Abscess (including breast) drainage

Breast biopsy (core)
breast biopsy (needle)
Breast biopsy (OPEN)
Chest tube insertion
Haemorrhoids; Injection
Haemorrhoids: banding
Hydrocele: aspiration
Hydrocelectomy
Laparotomy closure
Laparotomy incision
Lump and bump removal
Lymph node biopsy
Open & close any surgical operative site
Open appendicectomy
Open hernia repair umbilical
Open hernia repair, Femoral
Open hernia repair: inguinal
Orchidectomy
Orchidopexy
Ray amputation
Sigmoidoscopy
Skin graft
Wedge resection

41
PGY3

PGY1/2 refined experience in addition to;

Amputation above knee
Amputation below knee
Amputation transmet
Anal fistulectomy

Arterial embolectomy

Circumcision
Closure of colostomy

Gastroenteric bypass
Gastrostomy
Grahams patch for perf DU
Haemorrhoidectomy
Laparoscopic cholecystectomy
Laparoscopic appendicectomy
Laparotomy: trauma
Laparotomy: non trauma
Lateral sphincterotomy

Lysis of adhesions
Mastectomy: partial
Mastectomy: simple
Mastectomy:modified radical
Right hemicolectomy
Small bowel resection; trauma
Small bowel resection: non trauma
Splenectomy

Vagotomy and drainage

Saphenous vein stripping

42
PGY4

PGY 3 refined experience in addition to;

Aneurysm repair: pseudoaneurysm
Aneurysm repair non aortic
Breast oncoplastic surgery
Damage control laparotomy
Fem-pop bypass
Colonoscopy & UGI endoscopy
Hernia repair: incisional
Laparoscopic right hemicolectomy colectomy
CBD exploration
Left hemicolectomy
Low anterior resection
Mastectomy: skin sparing with recon
Melanoma excision
Neck exploration hemithyroidectomy
Neck exploration parathyroidectomy

Pancreatectomy: distal
Perforator ablation/ligation
Popliteal artery: aneurysm
Repair of major vascular injury
Saphenous vein ablation

SLNB
Thyroidectomy
Total colectomy
Tracheostomy

43
PGY5

PGY 4 refined experience in addition to

Abdominoperineal resection
Adrenalectomy open and laparoscopic
Aneurysm repair; aortic
Carotid artery endarterectomy
Liver resection
Pancreatectomy: whipple’s
Total proctocolectomy
with ileo-anal pouch
Total gastrectomy

EXAMPLE OF RESIDENT INTRAOPERATIVE ASSESSMENT OF COMPETENCIES

FORM

Residents name and

year
Consultant

Bi-annual assessments

Knowledge of specific procedure Excellent

needed instructions at most steps
knew some important steps steps
knew all the important steps
Flow of the Operation
stopped frequently, unsure of next move
demonstrated some forward
planning
effortless flow from one move to the next
Instrument handling
Awkward
mostly competent use of
instruments
44
 fluid with no awkwardness
Knowledge of Instruments
Use of wrong/inappropriate instrument
knew names of most instrument
obviously familiar with names
Use of assistants
poor use
appropriate most of
time
uses assistants strategically
Tissue handling
unnecessary force causing damage
carefull with occasional inadvertent damage
consistent tissue handling with minimal damage
Relationships in OT
ineffective communication with other team members
appropriate most of
time
Appropriate all of the time including wrt 'time-
out'

OVERALL GRADE ASSIGNED

A Able to supervise and teach the operation
B Able to perform the operation unsupervised
C Able to perform the operation under limited supervision
D Able to perform the operation under strict supervision
Able to assist
E
adequately

45