This course provides PGY-3 residents with a solid foundation in the anatomical basis of all aspects of general surgery. Through 10 sequential laboratories, each focusing on a different aspect of anatomy, residents will acquire the in-depth anatomical knowledge, techniques of exposure, and skills required of a general surgeon.
LABORATORY 1: SKIN, INCISIONS, WOUND CLOSURE, AND SKIN FLAPS
Correct use of surgical instruments; relaxed skin tension lines and incision placement; superficial body layers (skin, subdermal plexus, subcutaneous fat); wound closure, sutures, and staples; undermining and skin flaps (rotation flap, advancement flap, Z-plasty); maybe vascular and bowel anastomoses.
LABORATORY 2: LIMBS FOR GENERAL SURGEONS
Superficial layers (venous access sites, local anesthesia); limb organization, compartments and deep neurovascular structures; limb arterial access, common vascular occlusion sites, and limb vascular bypass grafts (maybe femoral-popliteal bypass); limb fasciocutaneous, myocutaneous and osteomyocutaneous flaps and pedicles (maybe radial forearm and fibular flaps).
LABORATORY 3: BREAST, CHEST WALL, ABDOMINAL WALL, AND HERNIAS
Breast anatomy; anatomy of breast surgeries (lumpectomy and various mastectomies); breast lymphatic drainage; axillary anatomy, and dissection of level 1,2,3 axillary nodes; anatomic basis of breast cancer staging; thoracic wall layers and neurovascular supply pattern; abdominal wall layers and neurovascular supply pattern; abdominal wall hernia sites; anatomical consequences of abdominal incision, trochar, and port placement; internal surface of abdominal wall (including triangle of doom, triangle of pain); inguinal canal, spermatic cord, and inguinal hernia repairs (TEP, TTAP, and open repairs), and femoral triangle, and femoral hernia repair. If time permits, TRAM or DIEP flap breast reconstruction.
LABORATORY 4: LATERAL APPROACH TO THE THORACIC CAVITY
Review embryology of respiratory and thoracoabdominal diaphragm development; anatomical considerations in thoracentesis and chest tube placement, right lateral thoracotomy incision and very large non-surgical extension for access to thoracic cavity; exploration of pleural space, lysis of adhesions, identification of pleural regions and pulmonary ligament; identification of lung lobes, fissures, and lung root structures; lung resections (segmentectomy, lobectomy, pneumonectomy); diaphragm, phrenic nerve, and diaphragmatic hernia sites; mediastinal structures accessible through right lateral thoracotomy. Repeat thoracotomy and procedures on left side.
LABORATORY 5: ANTERIOR APPROACH TO THE THORACIC CAVITY
Pericardiocentesis; pericardiotomy through left lateral thoracotomy; disarticulation of acromioclavicular joints, detachment of sternopericardial ligaments and elevation of anterior chest wall; exploration of pericardium and pericardial sinuses; venous plane of mediastinum and subclavian central line placement; arterial plane of mediastinum and cardiopulmonary nerve plexuses; removal of heart and exploration of superior and posterior mediastinum (trachea, bronchi, mediastinal node stations, anatomic basis of lung cancer staging; esophagus, thoracic duct, sympathetic trunk, azygos vein, vagus nerves and recurrent laryngeal branches, thoracic aorta). Heart dissection, if useful, and review of congenital cardiac anomalies.
LABORATORY 6: INTRAPERITONEAL ABDOMINOPELVIC VISCERA IN SITU AND MOBILIZATION OF INTRAPERITONEAL VISCERA
Review embryology of digestive system, mesenteries, and blood supply; lysis of adhesions, identification of peritoneal regions, spaces, and gutters; identification of abdominopelvic organs in situ; ventral mobilization of right colon, ventral mobilization of left colon, Kocher maneuver; identification of abdominal aorta, coeliac axis, superior mesenteric artery, inferior mesenteric artery and associated autonomic nerve plexuses; identification of all arterial branches and all anastomoses to GI tract; identification of portal vein and all tributaries; identification of portal-caval anastomosis sites; position of common variations in arterial supply and venous drainage; mesenteric and preaortic lymph nodes.
LABORATORY 7: RESECTIONS, ANASTOMOSES, AND TRANSPLANATION OF ABDOMINAL ORGANS
Identification of hepatogastric and hepatoduodenal ligaments and contents; gall bladder, bile ducts, triangle of Callot, 3 o’clock and 9 o’clock arteries on common bile duct, cholecystectomy; liver, surgical lobes, Couinaud segments, portal vein within liver, hepatic veins, liver resections, liver transplantation; stomach, blood supply and gastric resections?; pancreas, pancreatic blood supply, uncinate process and superior mesenteric vessels, pancreatectomies; spleen, splenic vessels, and splenectomy; small bowel resections, anastomoses and rearrangements, (Roux-en-Y and gastric bypass; Whipple procedure); anatomic bases of liver, gallbladder, and GI cancer staging and hepatic and splenic injury grading.
LABORATORY 8: EXTRAPERITONEAL ABDOMINAL AND PELVIC VISCERA
Kidney (Gerota’s fascia, kidney basic anatomy, neurovascular supply, bisected kidney with calyces and pelvis, renal injury grades); ureter (abdominopelvic course, blood supply), adrenal glands and blood supply; aorta, branches to paired abdominopelvic organs, AAA repair and anatomic indications; inferior vena cava and tributaries from paired abdominopelvic organs and trunk wall, caval-caval anastomoses; para-aortic lymph nodes and anatomic basis of renal and adrenal cancer staging; posterior abdominal wall muscles.
LABORATORY 9: COLON, RECTUM, PELVIS, AND PERINEUM
Colonic resections (right hemicolectomy, extended right hemicolectomy, segmental resection transverse colon, left hemicolectomy, extended left hemicolectomy, sigmoid resection, total colectomy); rectum, mesorectum, presacral space, and lymphatic drainage; rectal resections (LAR, APR and colostomy); prepubic space and extraperitoneal approach to pelvic viscera (bladder, pelvic urethra; prostate, vas deferens and seminal vesicles OR ovaries, uterine tubes, uterus and vagina; pelvic floor; male and female perineum.
LABORATORY 10: HEAD AND NECK FOR GENERAL SURGEONS
Head and neck vascular anatomy (carotid sheath, carotid arteries, carotid endarterectomy, internal jugular vein, IJ central line placement); larynx (laryngeal neurovascular supply, cricothyroidotomy); thyroid and parathyroid glands (vascular supply, thyroidectomy, parathyroidectomy); tracheostomy; pharynx and retropharyngeal space; anatomy basic to nasogastric intubation and orotracheal intubation (oral, pharyngeal, and laryngeal axes and ‘sniffing position’).
Department of Surgery
Beth Israel Deaconess Medical Center
Lowry Medical Office Building
110 Francis Street, Suite 9B
Boston, MA 02215