General Surgery (Oncology/Endocrine) (R3) - VUMC

Practice-based Learning & Improvement, Medical Knowledge, & Patient Care:
By the completion of the third year, the general surgery resident should be able to:
-Demonstrate normal thyroid anatomy in the operating room, including the thyroid gland, its vascular supply and venous drainage, the parathyroid glands, recurrent laryngeal nerves, strap muscles and platysma.
-Describe normal variants in recurrent laryngeal nerve anatomy including frequency.
-Describe normal thyroid and parathyroid embryogenesis.
-Outline the normal thyroid hormone synthetic pathway including iodine metabolism and feedback mechanisms.
-Outline the normal calcium and parathyroid hormone pathway.
-Outline appropriate lab testing for the following clinical scenarios, including interpretation of predicted test results:
a) Thyroid nodule
b) Goiter
c) Hyperthyroidism
d) Hypothyroidism
e) Hypercalcemia
-Develop an algorithm that includes pertinent history, examination findings and diagnostic evaluation of:
a) A palpable thyroid nodule
b) A nonpalpable nodule discovered on ultrasound performed for non-thyroid pathology
c) Hypercalcemia
-Recognition and treatment of common postoperative complications:
a) Hematoma
b) Hypocalcemia
c) Thyroid storm
d) Voice changes
-Outline algorithms for the evaluation and treatment of:
a) Well-differentiated thyroid cancer
b) Medullary thyroid cancer
c) Thyroid lymphoma
d) Anaplastic thyroid cancer
-Describe risk factors for well-differentiated thyroid cancer, medullary thyroid cancer and anaplastic thyroid cancer
-Outline the staging and prognosis in thyroid cancer
-Outline the complete evaluation and management of nontoxic multinodular goiter and substernal goiter
-Describe the management of intraoperative recurrent nerve injury
-Describe the approach for reoperative thyroid and parathyroid surgery

Patient Care Skills:
-Obtain a focused history, perform an examination and institute the diagnostic evaluation of a patient with the following conditions:
a) Thyroid nodule
b) Goiter
c) Hyperthyroidism
d) Hypercalcemia
-Palpate and describe a thyroid nodule
-Palpate and describe a goiter
-Identify exophthalmos
-Perform a fine needle aspiration biopsy of a palpable thyroid nodule
-Perform the initial steps in thyroid surgery, including
a) Patient positioning and marking
b) Skin incision and raising subplatysmal flaps
c) Opening strap muscles
d) Identification of recurrent laryngeal nerve
e) Ligation of the superior and inferior pole vessels
f) Mobilization of thyroid lobe
g) Close strap muscles, platysma and skin
-Interpret thyroid ultrasound and parathyroid scan
-Interpret intra-op intact PTH values

Medical Knowledge & Patient Care Milestones:
-Understands thyroid & parathyroid anatomy
-Understands neck fascial planes
-Able to raise subplatysmal flaps
-Understands surgical options for thyroid CA
-Understands hyperparathyroidism
-Able to w/u thyroid nodule
-Understands concept of neck dissection
-Understands the basics of thyroid and parathyroid ultrasound
Appendix to R3E
  • General principles of Thyroid and Parathyroid and Adrenal problems
  • Anatomy: Including muscular layers, vascular supply, nerves and various anomalies
  • Embryogenesis: Particularly role in anatomy
  • Metabolism: Thyroid hormone, calcium homeostasis, PTH, Vitamin D, adrenal hormones
  • Diagnostic work up of clinical scenarios: Including choice of test(s) and interpretation of data Thyroid nodule: Palpable and/or incidental finding on imaging study
  • Goiter including special circumstance of substernal goiter
  • Thyrotoxic goiter including toxic nodule, toxic MNG (Plummers), and Graves Disease
Cancer: Risk factors and staging
  • Well differentiated (Papillary and Follicular and their variants)
  • Medullary Cancer Familial MTC, MEN2a and MEN2b, RET
  • Anaplastic Cancer
  • Thyroid Lymphoma
  • Metastases to the thyroid (RCCA, other)
  • Imaging: Ordering and interpreting
  • Tumor Markers (thyroglobulin, CEA, calcitonin)
  • Surgical treatment (including extent of lymph node dissection)
  • Medical treatment (Levothyroxine and RAI ablation why/when?)
  • Differential diagnosis of hypercalcemia
  • 1,2,3ry Hyperparathyroidism patho-physiology
  • Imaging (ultrasound, sestamibi, CT scan, other)
  • Indications for surgery
  • MEN-1, MEN2a, Lithium-induced hyperparathyroidism
  • Surgical procedures for primary, secondary/tertiary hyperparathyroidism and
  • cancer of the parathyroid
  • Location of ectopic parathyroids.
  • Workup of an adrenal INCIDENTALOMA
  • Hormonal analysis: Cortisol/ACTH axis, Aldosterone/Renin, Catecholamine, Venous
  • Imaging (CT, MRI, PET scan)
  • Genetic syndromes associated with adrenal tumors (MEN, familial paraganglioma
syndrome, NF-1, VHL etc)
  • Cancer: staging, risk factors, surgical and medical treatments available
Technical skills & operative issues:
-- Be able to perform an ultrasound of the thyroid and soft tissues of the neck (identify adverse nodule features and normal and abnormal lymph nodes)
-- FNA (expect to be familiar with Thyroid-FNA how its done but not necessarily perform one)
Surgical procedures Thyroid and Parathyroid:
  • Positioning: Very important and UNDERVALUED
  • Skin Incision
  • Raising flaps
  • Vascular landmarks
  • Superior pole how to avoid injury to the superior laryngeal nerve
  • Recognition/preservation of recurrent laryngeal nerve
  • Mobilization of the gland and handling of the gland (retraction)
  • Identify parathyroids
  • Closure
Intra-operative complications:
  • Recognized recurrent laryngeal nerve injury
  • Tracheal injury
  • Devascularized parathyroids (what to do?)
Special circumstance of re-do surgery in the neck
Common complications, recognition and treatment:
  • Hematoma
  • Hypocalcemia
  • Voice changes (what do we do?)
  • Thyroid storm
  • Specifics to parathyroid operations:
  • What do you do if you cant find the missing parathyroid?
  • Intraoperative localization methods, intra-operative testing and interpretation
  • Autotransplantation of parathyroids (SCM, Brachioradialis)
  • Thymic parathyroid/deep in the mediastinum
  • Be familiar with positioning, operative techniques, and complications of laparoscopic, retroperitoneoscopy and open adrenalectomy.
  • These procedures are not very common (one or two a month) so the resident is not expected to master the surgical approaches to the adrenal but he or she should be familiarwith them.
8.12.13: Last update submitted 2012-13