Surgical training is evolving, and with advancing surgical techniques, the traditional “time-served” model of residency may not best serve the needs of our learners or patients.  In this episode, we discuss recent efforts at the Indiana University surgical education program to implement a comprehensive laparoscopic cholecystectomy that utilizes all of the best practices of competency-based education.  We’re joined by first author Dr. Betsy Huffman, along with her mentors Drs. Jennifer Choi, Matthew Ritter, and Dimitrios Stefanidis for a practical review of their pioneering work.  Learning Objectives: ·       Review challenges to the current paradigm of surgical education ·       Define competency-based education ·       Discuss practical challenges facing surgical educators when implementing new curricula References: A competency-based laparoscopic cholecystectomy curriculum significantly improves general surgery residents’ operative performance and decreases skill variability – https://doi.org/10.1097/SLA.0000000000004853  Ad referenced in episode: A team at the Brooke Army Medical Center is working to better define proficiency-based metrics for competency in commonly performed general surgery procedures. If you are a PGY4/5 general surgery resident or practicing surgeon who performs robotic assisted cholecystectomies or inguinal hernia repairs, reach out to the PI, Robert Laverty, MD, at rblaverty@gmail.com, for more information on how you could be compensated up to $400 for recording and submitting those videos. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out additional BTK surgical education episodes here: https://behindtheknife.org/podcast-category/surgical-education/

Ductal carcinoma in situ, or DCIS, is a precursor lesion to invasive breast cancer; however, not all DCIS becomes invasive cancer. Given our inability to accurately determine which DCIS lesions will progress, current clinical management consists of surgical resection for everyone with the possible additions of radiation and endocrine therapy. Multiple clinical trials and leaders in the field of breast surgical oncology are challenging our assumptions about the uniform approach to DCIS and are attempting to design treatment based on biology— tune in to hear about the evolving approach to management of DCIS! Hosts: Alexa Glencer, MD Michael Alvarado, MD Rita Mukhtar, MD Laura Esserman, MD Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other breast surgery episodes here: https://behindtheknife.org/podcast-category/breast/

We are facing a difficult case tonight: stab wound to the base of the left neck. Hope you know your anatomy well and are ready for a ride. Let’s see how one manages a patient whose injury is life threatening, a challenge to correctly diagnose, approach and repair. Join Drs. Urréchaga, Neeman, and Rattan from Ryder Trauma Center in Miami as they go through a real case trying to save a life and dominate the day. Learning Objectives:  Reviewing thoracic outlet anatomy. Simplifying primary survey and immediate care for penetrating great vessel injuries. Discussing possible surgical approaches for various great vessel injuries, incisions, extensions, tips and tricks. References 1) Feliciano DV, DuBose JJ. Cardiac, great vessel, and pulmonary injuries. In: Rasmussen TR, Tai NRM, eds. Rich’s Vascular Trauma. 4th ed. Philadelphia: Elsevier, 2022: 171-198. 2) Karmy-Jones R, Namias N, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating chest trauma. J Trauma Acute Care Surg. 2014;77(6):994-1002. 3) Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg. 2013;75(6):936-940. 4) Wall MJ, Ghanta RK, Mattox KL. Heart and thoracic vessels. In: Feliciano DV,           Mattox K L, Moore EE, eds. Trauma. 9th ed. New York: McGraw-Hill, 2021: 599-         628. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our Big T Trauma Series here: https://behindtheknife.org/podcast-series/big-t-trauma/

Personal Statements and Letters of Recommendations- two things that can make or break any residency or fellowship application. Join our education fellow, Dr. Jessica Millar, Dr. David Hughes, and Dr. Gifty Kwakye as they discuss what makes a truly great personal statement and how to compile a strong team for your letters of recommendation.  Guests:  David Hughes, MD- Clinical Associate Professor of Endocrine Surgery, General Surgery Residency Program Director- University of Michigan  GIfty Kwakye, MD, MPH- Clinical Assistant Professor of Colon and Rectal Surgery, Surgical Clerkship Director- University of Michigan Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out our Medical Student and Intern Survival Guide here: https://behindtheknife.org/podcast-series/medical-student-and-intern-survival-guide/

It’s that time of year- when medical students across the country are preparing their residency applications. The process can be a bit daunting, and there have been a number of changes to process over the past few years. Join our education fellow, Dr. Jessica Millar, and Dr. David Hughes as they review the “nuts and bolts” of this year’s residency application cycle.  Guests: David Hughes, MD- Clinical Associate Professor of Endocrine Surgery, General Surgery Residency Program Director- University of Michigan  Important Dates:  ·      June 8, 2022: ERAS application opens at 9 a.m. ET. ·      August 1, 2022: Supplemental ERAS application opens for applicants. ·      September 7, 2022: Residency applicants may begin submitting ERAS applications to programs at 9 a.m. ET. ·      September 16, 2022: Supplemental ERAS application closes for applicants at 5 p.m. ET. ·      September 28, 2022: Residency programs may begin reviewing ERAS applications, MSPEs, and supplemental ERAS application data at 9 a.m. ET. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our Medical Student and Intern Survival Guide here: https://behindtheknife.org/podcast-series/medical-student-and-intern-survival-guide/

Bringing back an oldie but a goodie - Join Dr. Patrick Georgoff and Dr. Vahagn Nikolian as they discuss common and critical intern dilemmas.  This episode is Part 2 of 2. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out our entire Medical Student and Intern Survival Guide series here - https://behindtheknife.org/podcast-series/medical-student-and-intern-survival-guide/

Bringing back an oldie but a goodie - Join Dr. Patrick Georgoff and Dr. Vahagn Nikolian as they discuss common and critical intern dilemmas.  This episode is Part 1 of 2. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our entire Medical Student and Intern Survival Guide series here - https://behindtheknife.org/podcast-series/medical-student-and-intern-survival-guide/

Pilonidal cysts – a simple disease or a sneaky nuanced problem? Drs. Shanaz Hossain,  Patrick Georgoff and Scott Steele sit down to discuss the difficulties encountered in the management of pilonidal cysts and the myriad of treatment options available, ranging from non-operative management to outpatient pit picking to major operations involving flaps. Dr. Steele dropped his “8 Key Principles for Pilonidal Cyst Management”: 1.    Control Sepsis 2.    Do the Least Amount of Work Possible 3.    Avoid Too Much Excision 4.    Remove All Hair, Un-Roof All Disease, and Debride Granulation Tissue 5.    Use Off-Midline Excision and Closure 6.    Tension Must Be Minimized with Primary Wound Closure 7.    Change the Anatomy – Flatten the Natal Cleft 8.    Never Underestimate the Impact of Postoperative Care Tune in for detailed insights regarding management and learn about all the options for surgical treatment!   Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episode on Necrotizing Soft-Tissue Infections - https://behindtheknife.org/podcast/clinical-challenges-in-emergency-general-surgery-necrotizing-soft-tissue-infections/  

Join our Emergency General Surgery team as they discuss Necrotizing Soft-Tissue Infections. Hosted by Drs. Jordan Nantais, Ashlie Nadler, Stephanie Mason and Graham Skelhorne-Gross. Necrotizing Soft-Tissue Infections: - Also known as “flesh eating disease”, gas gangrene, necrotizing fasciitis/myositis, Fournier’s gangrene. - Early findings are non-specific - Rapidly fatal - diagnostic delay can lead to tremendous additional morbidity and mortality Classification: - Type 1 - polymicrobial category (most common) found in immunosuppressed or elderly - Type 2 - monomicrobial infection [Group A Streptococcus > Methicillin-resistant Staphylococcus aureus (MRSA)] - Type 3 - monomicrobial infection (Vibrio or Clostridium) - Type 4 - fungal (rare) in immunocompromised or after penetration or trauma from candida or Zygomycetes. Initial Workup - History: (comorbidities, immunosuppression, recent infections or trauma) - Exam: swelling, open lesions, drainage, erythema, crepitus, and pain out of proportion      - Most common: swelling, pain, erythema      - Bullae, skin necrosis, crepitus are less common - Labs: Hb, wbc, Na, Creat, glucose, and CRP - Imaging: CT, MRI *sensitive and specific but may not change management - Cut-down: bedside vs in OR - Gm stain  Management - Initially: two large bore IVs, foley catheter, aggressive fluid resuscitation, broad spectrum antibiotics, vasopressors PRN - Abx choices: carbopenem or piperacllin-tazobactam or cefotaxime plus metronidazole. Clindamycin (antitoxin effect) and vancomycin (MRSA) should be considered. - OR: must debride all dead/infected tissue, involve other surgical specialties as needed      - Mark edge of cellulitis and use as initial debridement      - Healthy dermis – pearly and white      - Healthy fat – pale, yellow, glistening      - Healthy fascia – should bleed, doesn’t easily separate from muscle      - Healthy muscle – contract with cautery      - Dressing: betadine-soaked gauze on the wound      - Most patients will need at least 3 ORs (second OR generally 8-12 hours after the first)      - No VAC or stoma at first OR References:  1.    Pelletier J, Gottlieb M, Long B, Perkins JC Jr. Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician. J Emerg Med. 2022 Apr;62(4):480-491. doi: 10.1016/j.jemermed.2021.12.012. Epub 2022 Jan 31.  2.    Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88.  3.    Edlich RF, Cross CL, Dahlstrom JJ, Long WB 3rd. Modern concepts of the diagnosis and treatment of necrotizing fasciitis. J Emerg Med. 2010 Aug;39(2):261-5 4.    Hoesl V, Kempa S, Prantl L, Ochsenbauer K, Hoesl J, Kehrer A, Bosselmann T. The LRINEC Score-An Indicator for the Course and Prognosis of Necrotizing Fasciitis? J Clin Med. 2022 Jun 22;11(13):3583 5.    Bulger EM, May A, Bernard A, Cohn S, Evans DC, Henry S, Quick J, Kobayashi L, Foster K, Duane TM, Sawyer RG, Kellum JA, Maung A, Maislin G, Smith DD, Segalovich I, Dankner W, Shirvan A. Impact and Progression of Organ Dysfunction in Patients with Necrotizing Soft Tissue Infections: A Multicenter Study. Surg Infect (Larchmt). 2015 Dec;16(6):694-701. 6.    LRINEC Score from: https://www.mdcalc.com/calc/1734/lrinec-score-necrotizing-soft-tissue-infection#:~:text=Patients%20were%20classified%20into%20three,%25%20and%20NPV%20of%2096%25. Retrieved July 2022. If you liked this episode, check out our recent episode titled, "Journal Review in Colorectal Surgery: Timing of Biologics and Surgery in the Setting of Crohn’s Disease" - https://behindtheknife.org/podcast/journal-review-in-colorectal-surgery-timing-of-biologics-and-surgery-in-the-setting-of-crohns-disease/ Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

You get consulted on a 34-year-old with ileocolic Crohn’s disease on Humira. You determine he needs surgery for recurrent partial obstructions. When do you do the surgery? How long should he be off his biologic medication? When to restart it post op? Join Drs. Abelson, Marcello and Aulet as they take us through two articles to help us figure it out! Learning Objectives: 1.     Describe the complications of biologic medications in the peri-operative period 2.     List the different classifications of medications for Crohn’s disease 3.     Discuss the approach to managing timing of surgery for patients with crohn’s disease Articles: Cohen BL, Fleshner P, Kane SV et al. Prospective Cohort Study to Investigate the Safety of Preoperative Tumor Necrosis Factor Inhibitor Exposure in Patients With Inflammatory Bowel Disease Undergoing Intra-abdominal Surgery. Gastroenterology. 2022 Apr 10;S0016-5085(22)00359-6. doi: 10.1053/j.gastro.2022.03.057. Online ahead of print. Brouquet A, Maggiori L, Zerbib P, Lefevre JH, Denost Q, Germain A, Cotte E, Beyer-Berjot L, Munoz-Bongrand N, Desfourneaux V, Rahili A, Duffas JP, Pautrat K, Denet C, Bridoux V, Meurette G, Faucheron JL, Loriau J, Guillon F, Vicaut E, Benoist S, Panis Y; GETAID chirurgie group. Anti-TNF Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort. Ann Surg. 2018 Feb;267(2):221-228. doi: 10.1097/SLA.0000000000002017. PMID: 29300710.  Steele S, et al. The ASCRS Textbook of Colon and Rectal Surgery, fourth ed. 2022.  https://link.springer.com/book/10.1007/978-3-030-66049-9 Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.