General Surgery Residency Program

Surgical Caseload

The WBAMC General Surgery Residency Program focuses the responsibility for all aspects of a patient's care on the resident surgeon and his ward team. The ward team system allows the residents to manage a patient, with a single attending, from initial consultation to post intervention convalescence. This management includes the planning and execution of the work-up, preoperative preparation, proposed surgery, postoperative care and the management of any complications.

Breast

Both General Surgery Ward teams perform breast cancer screening, breast cancer follow-up, breast biopsies and definitive breast surgery for malignant disease, which includes immediate reconstruction in conjunction with the Plastic Surgery Service. Malignant pathology, adjuvant therapy, and multi-modality treatment are discussed and reviewed at the weekly Multi-disciplinary Tumor Board Conference.

Skin and Soft Tissue

Both General Surgery ward teams perform surgery on skin and soft tissue lesions. Surgery for melanomas, basal cell carcinomas, sarcomas, nerve and muscle disorders, and lymphadenopathy are performed in close association with the Dermatology, Plastic Surgery, Orthopedic Surgery and Medicine services. Malignant pathology, prognosis and multi-modality treatment are discussed and reviewed at the weekly Multi-disciplinary Tumor Board Conference.

Alimentary Tract

Both General Surgery ward teams perform general alimentary tract surgery. The number of referrals for laparoscopic anti-reflux procedures and specialized colorectal surgery are increasing in response to the addition of surgeons with special expertise in these areas. The increased volume of endoscopy performed by the General Surgery Service has also recouped patients requiring alimentary tract surgery who were formerly being disengaged from care and referred to civilian facilities for their endoscopic work-up and definitive surgical treatment.

Abdomen

Both General Surgery ward teams perform the full range of abdominal surgery utilizing both open and laparoscopic techniques. There is a high volume of biliary tract disease in the local patient population and a moderate amount of surgical ulcer disease in the Veterans Affairs population, which provides our residents a sound experience in these areas.

Vascular

On the Vascular ward team, residents learn assessment of the vascular patient. They are exposed to non-operative care, patient selection for surgical intervention, appropriate patient work up, vascular surgery techniques, postoperative critical care, and ongoing post-surgical follow-up for these complex patients. Junior Residents gain technical experience creating dialysis A-V shunts, on venous operations and by participating on the major cases performed by PGY 5 residents. The absence of a Vascular Surgery Fellowship reserves all major vascular cases for the General Surgery residents, which results in an extensive experience. The presence of a Vascular attending has also broadened the scope of resident training in the diagnostic and therapeutic modalities of duplex scanning, angioplasty, intra-arterial stenting, catheter directed thrombolytic therapy, and angiography. Residents' experience on the Vascular Service also includes work with an interventional radiologist.

Head and Neck

Both General Surgery ward teams perform general head and neck surgery to include surgery of the thyroid, parathyroid, parotid, head and neck malignancies, neck dissections, penetrating trauma, and congenital cysts. In addition, close ties with the Dermatology, ENT, and Plastic Surgery services, permits the residents to participate in the work-up, surgery and management of patients with head and neck malignancies that present to these services. Malignant pathology, prognosis and multi-modality treatment are reviewed at the weekly Multi-disciplinary Tumor Board Conference. There are no ENT Residents at WBAMC, so our residents do H&N and Endocrine cases.

Endocrine

Both General Surgery ward teams perform endocrine surgery. The majority of patients are referred to General Surgery by the Endocrinology Service. A resident and attending review the case, arrange any additional studies for patient preparation, and then present the case at the weekly preoperative teaching conference for discussion and for the training benefit of all the residents. All thyroid and parathyroid cases generated by the ENT Service and all adrenal cases generated by the Urology Service involve the General Surgery residents in the preoperative planning, the surgery and the postoperative management. Malignant pathology, adjuvant therapy, multi-modality treatment and follow- up are discussed and reviewed at the weekly Multi-disciplinary Tumor Board Conference.

Trauma

Trauma management at WBAMC is a continuous part of the daily elective and emergent routines of all three Ward Teams. WBAMC manages approximately one third (1/3) of all the major civilian trauma in El Paso County and is a Level III Trauma Center. All major trauma cases requiring multi-disciplinary care and ICU management are managed by the General Surgery residents and their staff. The resident trauma experience is further augmented by rotating for several months at Chandler Regional Medical Center in Chandler, Arizona, which is a Level I Trauma Center.

Critical Care

Surgical Critical Care is integrated as a continuous part of the daily elective and emergent routines of all three ward teams. As a result, residents become very confident and capable of managing ICU patients along with their other duties. General Surgery residents will be consulted to oversee and assist in the critical care management of all patients admitted to the Surgical ICU from the other surgical services. A Board Certified Surgical Intensivist on the faculty supervises the overall care in the ICU and assists with complex cases. Formal ICU rounds are conducted with the residents and staff to monitor the progress, problems, and treatment plans for each patient. This provides the opportunity for residents to learn from every ICU patient and to have the broadest possible critical care experience over their five years of training.

The Intermediate Resident or Junior Resident is responsible to place a daily comprehensive note on each general surgery ICU patient. In addition, any significant procedures, clinical changes, and study results will be documented on the clinical record as needed. The SICU team resident is responsible for all chart documentation on off-service patients in the SICU. The Chief Residents must forecast SICU bed requirements for postoperative patients, track the bed census of the ICU's and cooperate in managing ICU beds to permit the ER to remain open for civilian trauma and the surgical services to perform elective surgery. Questions concerning bed management, the ER status of Trauma, and ICU requirements for elective surgery should be referred to the medical director of the SICU.

In addition to daily exposure to the ICU, Junior Residents and Interns rotate on the SICU Service. In addition to their duties as ICU resident, the Junior Resident also acts as the SOD (Surgeon on Duty) during the day. This allows residents on the other teams to concentrate either on the clinic duty or the operating room.

Sub-Specialty Rotations

The absence of surgical subspecialty fellowships permits General Surgery residents to be involved with all major Thoracic, Plastic, Otolaryngology, Urology, Neurosurgery, and Pediatric surgery cases. The subspecialty exposure is orchestrated to maximize resident involvement in patient care from initial consultation to postoperative management in each of the respective disciplines.

Thoracic Surgery

The Thoracic Surgery training goals are to familiarize residents with surgical pulmonary disease, to teach them thoracic anatomy and to provide them an operative experience, to include open thoracotomy. Both General Surgery ward teams perform non-cardiac thoracic surgery. Residents achieve the training goals by managing thoracic surgery patients and by performing progressively more complex procedures throughout the residency. Junior Residents begin with the placement and management of tube thoracostomies. Intermediate Residents perform thoracoscopic procedures and limited thoracotomies. Chief Residents progress to open thoracotomies with major pulmonary resections.

Pediatric Surgery

Residents rotate with a busy pediatric surgeon at a local hospital and do more than 50 cases per month. This occurs during the PGY 4 year with Pediatric Surgical Associates of El Paso. Residents gain experience by performing elective and emergency surgery on children to include herniorrhaphy, pyloromyotomy, vascular access, exploratory laparotomy, appendectomy, and selected congenital diseases, under the supervision of the pediatric surgeons.

Neurosurgery

The training goal of this rotation is to teach residents the assessment of the neurologic patient, the operative and non-operative management of head and spine trauma, the criteria for operative intervention, and techniques of invasive intracranial monitoring. Residents learn how to drill burr holes, turn a flap, perform a craniotomy and repair the dura. Finally, they gain experience in the critical care management of elective and emergent neurosurgery patients.

Orthopedics

The goals of this rotation are to provide residents experience in the assessment of acute orthopedic trauma, the assessment of hand injuries, the operative and non-operative management of orthopedic injuries, the criteria for operative intervention, and the use of splints, casts, and traction techniques to stabilize injuries. Residents at the PGY 1 level rotate for one (1) month on the Orthopedic Surgery Service to master these skills.

Transplant

The goals of this rotation is to familiarize the residents with the essentials of transplant surgery to include patient selection, organ harvest, preoperative patient preparation, management of immune suppression, technical aspects of transplant surgery and postoperative care. The residents also learn to identify and manage the complications of immune suppression and graft rejection. Residents at the PGY 4 level perform a one (1) month rotation on the Transplant Service.