which surgies in which year

[Neuropathia]

Just curious, because I'm an IMG in my third year of residency.
At what point of time do you usually perform or rather learn what kind of surgeries in the US. Do you have fixed times when you learn a surgery? How many surgeries of a kind do you have to do during your residency?

Here (in Germany) you start out with adenectomies, tonsillectomies, tracheotomies (especially before your first night shift). Then conchotomies and surgery of the nasal septal usually somewhen in the 2nd year.
We don't really have a fixed course. I've done some extirpations of the submandibular gland, while me collegue in 4th yr hasn't. But instead I havn't done a otopexie yet.
You usually don't get to a laryngectomy or neck dissection until after your residency.

Thanx in advance!

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[resxn]

I'm sure it is extremely variable depending on which program in the US that you go to. In my residency, we were really surgery heavy--over 3000 cases performed in my 4 years.

R2 - typically tubes and tonsils. But I also did lots of bronchs, trachs, submandibular glands, assists on bigger things like thyroids, necks, and parotids. A few sinuses, some tympanoplasties.
R3 - more of the same, but got more freedom and started to do mastoids
R4 - did everything as first surgeon from laryngectomies to cochlear implants. Assisted on microvascular free flaps and acoustics.
R5 - advanced endoscopic stuff like cranial base surgery, optic nerve decompressions, tumor resections. Got to do craniofacial resections as surgeon with neurosurgery chief/attending. Still was only an assist on acoustics and microvascular anastamoses (although I usually got to throw a few stitches per case). Mostly spent time being the teaching surgeon for jr residents.

My experience is going to vary widely from others in the US though. Each department has their own policies/traditions. Whereas some other programs might not allow their residents to do craniofacial resections as the surgeon, they may allow them to be the surgeon on an acoustic.

 

[Leforte]

My program seems to mirror the experience of Resxn - we are very H&N heavy, though, and perform necks as surgeon in our 3rd year on up. Less ears with us, a few scattered in our R2/R3 year, then pick up in the last 2 years. We do the approach for acoustics, but don't pick the tumor (NS does). Sinus cases in all years, optic decompressions for Graves as R4/R5s. Assist with free flaps from with beginning, but really only throw the occasional stitch in the anastamosis as R4/R5. I have not, nor will I probably ever, claim primary surgeon on the micro portion of flaps (I've done 30+ so far) as we don't do 50% as surgeon here, but we do the resection portion of the case. Lots of laryngology - thyroplasties usually from R3+, Facial plastics throughout, but at my program, it's a lot of holding sticks. Thyroids/parotids near the end of R3 on up - on your own in the chief year.

Resxn and my experience may be a bit unusual, though. The average ENT resident graduates with 1600 cases. Resxn had 3000 at the end of his training - I'm near 1800 in the middle of my R4 year. Regardless, any ENT program trains you well here.

 

[resxn]

let me add though that the 3000+ was peds heavy. I did 434 cases on my R2 peds rotation over 4 months. It wasn't unusual for us to get 15-18 cases (mostly tubes and tonsils) in one day running 2 rooms (The R4 got to do all the good stuff--LTR's, ear cases, sinuses, etc). So the 3000 is obviously inflated by a ridiculously busy service.

 

[Pir8DeacDoc]

let me add though that the 3000+ was peds heavy. I did 434 cases on my R2 peds rotation over 4 months. It wasn't unusual for us to get 15-18 cases (mostly tubes and tonsils) in one day running 2 rooms (The R4 got to do all the good stuff--LTR's, ear cases, sinuses, etc). So the 3000 is obviously inflated by a ridiculously busy service.

would you say that goes from educational and worthwhile to painful?

 

[Neuropathia]

Thanks guys. That sounds amazing compared to our figures here. But it looks like you have a much higher number of procedures/day too (we have 4 ORs, about 18 procedures a day and with 12 residents, 4 senior attendings and the head of department, OR time is highly competitive). Acoustics are done by the neurosurgeons here as well. Thyreoids are divided between general surgery and us.

After you finish your last year of residency, do you have to show your list of procedures/cases to any institution?

Does any of you know something detailed about the oto programms of the different hospitals in Ohio?

 

[resxn]

would you say that goes from educational and worthwhile to painful?

It sure does. My rule as chief at the Children's hospital was, round by 6 AM, home by 7PM. If I left the hospital after 7, I was angry, if I left before I was happy.

it's not fun rounding on 6 OSA kids who are still desatting after T&A, on top of all the bigger cases like LTR's and then all the consults.

It really was a pain discharging all of them the next morning only to bring in as many during the day. 2 resident service with 5 full-time attendings and 1 part-timer.

Yeah, that's painful.

 

[resxn]

Thanks guys. That sounds amazing compared to our figures here. But it looks like you have a much higher number of procedures/day too (we have 4 ORs, about 18 procedures a day and with 12 residents, 4 senior attendings and the head of department, OR time is highly competitive). Acoustics are done by the neurosurgeons here as well. Thyreoids are divided between general surgery and us.

After you finish your last year of residency, do you have to show your list of procedures/cases to any institution?

Does any of you know something detailed about the oto programms of the different hospitals in Ohio?

We had to keep an on-line log of all of our ENT cases which was updated yearly at the minimum. This ensured that we were meeting the minimum case requirements for the residency accreditation people. Just as important to them was that it showed whether residents had an equal number of cases each so that one person wasn't favored and getting all the "good" stuff.

Sorry, no Ohio experience here.

 

[Pir8DeacDoc]

It sure does. My rule as chief at the Children's hospital was, round by 6 AM, home by 7PM. If I left the hospital after 7, I was angry, if I left before I was happy.

it's not fun rounding on 6 OSA kids who are still desatting after T&A, on top of all the bigger cases like LTR's and then all the consults.

It really was a pain discharging all of them the next morning only to bring in as many during the day. 2 resident service with 5 full-time attendings and 1 part-timer.

Yeah, that's painful.

Thanks for the thoughts. I could imagine that is painful. Luckily for me we only have one pedi attending. Plus, without a surgery center and slow turnover time here, we're limited in the number of T&A's that can be done in one day.

 

[drivesmecraazee]

I'm sure it is extremely variable depending on which program in the US that you go to. In my residency, we were really surgery heavy--over 3000 cases performed in my 4 years.

R2 - typically tubes and tonsils. But I also did lots of bronchs, trachs, submandibular glands, assists on bigger things like thyroids, necks, and parotids. A few sinuses, some tympanoplasties.
R3 - more of the same, but got more freedom and started to do mastoids
R4 - did everything as first surgeon from laryngectomies to cochlear implants. Assisted on microvascular free flaps and acoustics.
R5 - advanced endoscopic stuff like cranial base surgery, optic nerve decompressions, tumor resections. Got to do craniofacial resections as surgeon with neurosurgery chief/attending. Still was only an assist on acoustics and microvascular anastamoses (although I usually got to throw a few stitches per case). Mostly spent time being the teaching surgeon for jr residents.

My experience is going to vary widely from others in the US though. Each department has their own policies/traditions. Whereas some other programs might not allow their residents to do craniofacial resections as the surgeon, they may allow them to be the surgeon on an acoustic.

Which procedure was the most difficult for you?

 

[resxn]

It's hard to say which procedure was the most difficult because it tends to be based on how you define "difficult."

If arduous, it would be a dual free-flap case that was both fibula and latissimus with composite resection. In our program, we did both the extirpation and the reconstruction. As the chief on that case, I started at 0730 in the morning one day and finished at 0420 the next morning. I've been involved in longer cases (the longest was 28 hours) but this one required more technical skill--doing a microvascular anastamosis in your 16th hour straight is not easy.

If scary, by far and away a 15 month old who aspirated a chunk of rubber ball. If it was mainstemmed, we could maintain sats, but as soon as we tried to bring it up, it would get stuck in the subglottis and sats would drop dramatically so we'd have to shove it back in a mainstem and try again when sats were up. Kid was so small we didn't want to trach him to get it out, so we used endoscopic scissors cut it in two and then took it out. I've done 2 slash trachs and neither scared me like this kid did.

If high sphincter tone, I was always more uncomfortable drilling into the cochlea on a cochlear implant than I was doing a parotid or using a scalpel on the internal jugular. Everyone in this aspect is very different though.

If in terms of emotional stuff, I always had a tough time doing repeat procedures on infants with syndromes. Don't know why. Just seemed tough seeing infants with bad stuff needing to be operated on so many times.

That's my thoughts, anyway.

 

[drivesmecraazee]

I'm sure it is extremely variable depending on which program in the US that you go to. In my residency, we were really surgery heavy--over 3000 cases performed in my 4 years.

R2 - typically tubes and tonsils. But I also did lots of bronchs, trachs, submandibular glands, assists on bigger things like thyroids, necks, and parotids. A few sinuses, some tympanoplasties.
R3 - more of the same, but got more freedom and started to do mastoids
R4 - did everything as first surgeon from laryngectomies to cochlear implants. Assisted on microvascular free flaps and acoustics.
R5 - advanced endoscopic stuff like cranial base surgery, optic nerve decompressions, tumor resections. Got to do craniofacial resections as surgeon with neurosurgery chief/attending. Still was only an assist on acoustics and microvascular anastamoses (although I usually got to throw a few stitches per case). Mostly spent time being the teaching surgeon for jr residents.

My experience is going to vary widely from others in the US though. Each department has their own policies/traditions. Whereas some other programs might not allow their residents to do craniofacial resections as the surgeon, they may allow them to be the surgeon on an acoustic.

Could anyone here explain me this procedure, I understand what the others mean but I don't find any similarity with spanish in the words "free flap", and would like to know what is it.
Thanks

 

[drfunktacular]

Could anyone here explain me this procedure, I understand what the others mean but I don't find any similarity with spanish in the words "free flap", and would like to know what is it.
Thanks

"Free" flaps are called this to distinguish them from, e.g., pedicle flaps. A pedicle flap is one in which a flap of skin/sub-q or skin/sub-q/muscle is lifted up from the underlying tissues, but the blood vessel feeding the flap is left intact. The flap can then be rotated (using the intact vascular bundle as the "pivot" point) to cover a defect. Thus the vascular supply to the flap tissue remains intact, so the risk of tissue necrosis is low while the flap develops new vascular supply in its new location.

A free flap, by comparison, is when ALL the blood supply to a flap of tissue is disrupted eek, and then the major feeding vessels must be attached to the native vasculature at the recipient site by microscopic sutures. Then you cross your fingers, tighten your sphincters, and pray that the flap (now all hooked up in its new location) turns pink again when you release the tourniquet on the vessels it was just sewed onto. Oh, and generally this is 12-16 hours after you started the case.