Rotation Goals and Expectations

Goals

1. Know the steps and anatomy of the surgeries listed below
2. Stepwise progression through the surgical cases
3. Manage patients from pre op to discharge

Expectations

1. You should round in the mornings before cases. You should see the patients you have operated on and any post-ops of the MIS team and be done and ready before 7. Check in with APPs for the day. Check the OR patients in, confirm consent and IPHR.
2. Be on time for cases, confirm that IPHR and consent are done, and you should roll into the room with the patient. Southern Maine’s ORs typically start on time with the patient entering the room at 715am.

Schedule

This should be a high-volume operative rotation. Your time should be accounted for throughout the week and any absences should be pre-approved or scheduled. If there are no cases to cover at Biddeford, you can coordinate with the MIS/Bari chief and other residents at Portland or Scarborough to do uncovered cases. The operative schedule changes, but generally block times are:

1. MIS/Bariatrics (If you are on vacation or unable to cover cases, please discuss with the attending and the first assists to ensure that there is adequate coverage)
   1. Wednesdays
   2. Tuesdays
   3. 2nd  and 4th Mondays
   4. Breast (2nd Tuesday)
   5. Surgical Oncology (Fridays)
   6. General Surgery (As schedule allows)
2. Thursday morning you are not expected to round before conference and Thursday afternoon is a good time to get your ½ day of clinic in for the rotation at the Weight and Wellness Center.
3. Call and patient coverage:
   1. Attending call schedule can be found on Amion. We usually cover M-T and F-S.  The M-T attending is the attending on call for the week.
   2. Consults during working hours can be staffed with the attending of record for the patient. If they are not accessible, the attending on call covers. 
   3. The attending on call covers for vacation/away attendings. 
   4. MMC Biddeford rounding will be done by the operating attending at Biddeford, we will communicate amongst ourselves and let you know otherwise.

Robotics

1. You should be working your way through the robotics curriculum 
2. If it has been two months or more since you have been on the robot or you are feeling unfamiliar, reach out to the Intuitive rep for a refresher. 
3. Scrub in and do bedside cases, they are useful for learning how to troubleshoot from the console.
4. Work through simulator modules: if you want console time you must be familiar with and at least competent using the console: 
   1. Clutching, camera control and pedals 
   2. Your level of interest and proficiency will guide how much you get to do in cases 
   3. If you are not safe, you will be removed from the console.

Autonomy

Autonomy is dictated by experience and progression. The more present you are in the OR, the more you will get to do.  As you show competency and knowledge of the flow of the case, you will be able to do more. It is helpful to have a specific objective for each case. You should have a learning plan and discuss this with the operating surgeon BEFORE the case, and ideally at the start of the rotation.

Sleeve

1. Access/Port placement
2. Greater curve dissection
3. Intra operative endoscopy
4. Stapling
5. Specimen removal and closure

Gastric Bypass

1. Port placement
2. Identification of ligament of Treitz and running small bowel
3. Laparoscopic suturing/pexy of small bowel
4. Creation of JJ
5. Mesenteric closure
6. Omental splitting
7. Peri gastric dissection
8. Pouch creation
9. GJ anastomosis
10. Intra operative endoscopy
11. Closing

Hiatal hernia repair

1. Setting up the case: Entry/port placement/liver retractor
2. Intraop endoscopy
3. Hiatal dissection: if you can assist with the dissection with minimal direction, you will get more autonomy to do the dissection.
4. Hiatal closure: laparoscopic sewing and tying (Beware the aorta and IVC)
5. Sac dissection

Fundoplication

1. Setting up the case: Entry/port placement/liver retractor
2. Intraop endoscopy
3. Hiatal dissection
4. Greater curvature dissection
5. Hiatal closure
6. Wrap placement/creation

Lap inguinal hernias

1. Camera management
2. Flap creation
3. Anatomic dissection
4. Mesh placement
5. Flap closure

Open ventral hernias

1. Entry
2. Lysis of adhesions
3. Retrorectus dissection
4. Possible component separation
5. Closure and mesh placement

Robotic ventral/inguinal hernias

1. Lysis of adhesions
2. Flap creation
3. Dissection
4. Mesh placement
5. Flap closure