Posts in category: Surgery

Estimated reading time: 3 minutes

Renal transplantation is a lifesaving intervention in end-stage renal disease (ESRD) patients. Here we take you through the key steps in a kidney transplant, from donor selection to ureteric anastomosis.

Step 1: Donor Selection

The initial and most important task of conducting a renal transplant is to find an appropriate donor kidney. There are two categories of donors:

• Live Donor: In India, live donor transplantation is the most common technique. A living individual willingly donates a kidney to the recipient. The donor nephrectomy (removal of the kidney) may be performed open or laparoscopically. Laparoscopic nephrectomy is favored because it is minimally invasive, resulting in faster recovery and fewer complications.
• Cadaveric Donor: A cadaveric kidney is obtained from a brain-dead donor. Cadaveric transplants entail the retrieval of more than one organ, which is not the case with live donation. This is practiced to a lesser extent in India because of the lack of an established cadaveric organ donation program.

Step 2: Bench Dissection

• After obtaining the kidney, it receives a bench dissection before transplantation. This entails:
• Stripping off fat and fibrous tissue.
• Recognizing and separating out the renal artery and vein.
• Perfusing the kidney with custom preservation solutions to remove any lingering blood and guarantee viability before transplantation.

Step 3: Implantation in the Recipient

The recipient receives an open renal transplant, usually in the iliac fossa instead of the kidneys’ initial anatomical site. This is known as heterotopic transplantation, in which the kidney is transplanted to a site other than where it originally existed within the body.

Surgical Incision and Preparation

• The surgeon performs a hockey-stick incision in the lower abdomen.
• The peritoneum is retracted, and dissection is carried out in the retroperitoneal space.
• The iliac vessels are exposed, and overlying lymphatic tissues are dissected to prepare the vascular bed.

Step 4: Vascular Anastomosis

The transplanted kidney must be anastomosed to the recipient’s blood vessels to function properly. The anastomosis (surgical connection) is carried out as follows:

Arterial Anastomosis

• The renal artery is anastomosed to either the external iliac artery or the internal iliac artery:
  • Internal Iliac Artery: End-to-end anastomosis.
  • External Iliac Artery: End-to-side anastomosis.
• The selection of the artery is based on the vascular anatomy and health of the recipient’s vessels.

Venous Anastomosis

• The renal vein is anastomosed to the external iliac vein with an end-to-side anastomosis.

These vascular anastomoses provide sufficient blood supply to the transplanted kidney.

Step 5: Ureteric Anastomosis

The transplanted kidney’s ureter has to be anastomosed to the recipient’s bladder in order to facilitate drainage of urine. The best method for this is the Modified Lich-Gregoir technique:

• A small cut is made in the bladder wall.
• The detrusor muscle is dissected carefully, and the ureter is implanted so that reflux (urine backflow) is avoided.
• The ureter is fixed in position to maintain optimal function and avoid complications such as leakage or obstruction.

Final Steps and Post-Transplant Care

Following successful implantation, the wound is closed, and the patient is carefully observed for evidence of organ rejection, infection, or vascular or ureteric anastomotic complications. Immunosuppressive therapy is commenced to avoid rejection, guaranteeing the survival of the transplanted kidney.

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It’s highly important to know surgical techniques in detail for any future surgeon. Conceptual Surgery offers excellent, systematic education to residents as well as practitioners in the form of vital surgical concepts through real-life case discussions and video demonstrations.

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Estimated reading time: 2 minutes

Selecting the thesis topic is an important task for first-year postgraduates of MS surgery and DNB surgery. Your thesis protocol must be submitted within the first month, first to the departmental research committee and subsequently to the institutional ethics committee for clearance. As a thesis is compulsory for the award of your degree, selecting the appropriate topic is important for both academic success and career prospects.

Importance of Choosing a Good Thesis Topic

• A thesis is required to clear MS surgery and DNB surgery.
• The duration of the thesis writing is usually two to two and a half years, subject to institutional policy.
• A well-researched thesis can result in publications in quality journals, enhancing your academic profile.
• A follow-up study over the long term from your thesis can increase your research credibility.
• Your thesis project can evolve into a postdoctoral study or even a PhD research project.

Important Points for Picking the Topic of Thesis

• Interest: Pick one that relates to your area of interest and eventual career plans. 
• Clinical Significance in surgery: Select one having clinical importance towards patient management. 
• Availability: Verify that the study is doable with enough patient access and supporting facilities.
• Guidance Availability: Think about your mentor’s knowledge and ability to oversee the research.
• Data Collection & Follow-Up: Choose a topic that enables efficient data collection and follow-up over the long term.
• Scope for Publications: A good thesis can result in conference presentations and peer-reviewed journal articles.

The Role of a Thesis in Career Development

• Recognition in surgery: A well-conducted thesis can make you an expert in the field.
• Enhanced Curriculum Vitae (CV): Published work enhances residency and fellowship applications.
• Potential For Future Research Opportunities: Your thesis can serve as a platform for further research in specialized areas.
• Chances of International Exposure: Publishing your results at international and national conferences can provide the opportunity for more research collaborations.

Conclusion: An Opportunity

The thesis is not just part of academics, it is way more than that. It is an opportunity to 

contribute positively to the surgery speciality. A well-designed research study can open new opportunities in your career, offer enriching learning experiences, and increase your prospects of academic and professional advancement.

Be inquisitive, be determined, and make your thesis journey a worthwhile one!

Estimated reading time: 4 minutes

Starting a residency program is truly a defining step for a surgeon’s journey. It is a shift from being a student to taking full responsibility for the surgeries, that directly impact the outcomes. While the road is rewarding, but not easy. Here’s a detailed guide to navigating the first year of surgery residency and building a strong base for a good surgery career.

Facing Initial Challenges

The transition from internship to residency is a step into a professional world. It is not just a matter of learning but performing duties in the management of patient care under pressure. Understanding this change is key to adapting and excelling in the early stages of your training.

1. Practical Tips for the First Year

Documentation

• Always write down the instructions given during rounds in the patient’s file.
• This saves you from miscommunication and ensures continuity of care.

Example: If a cardiac workup is missed, documented advice clarifies your role.

Punctuality and Preparation

• Reach the ward early to take your rounds and update notes before seniors arrive.
• Proper preparation earns respect and trust from seniors, setting you up for more opportunities.

Professionalism

• Be punctual, soft-spoken, and well-groomed.
• Following instructions diligently is highly valued and builds trust with your team.

2. Developing Surgical Skills

Reality Check

The level of hands-on experience varies by institution.

• Government hospitals: Earlier cutting opportunities, often unsupervised.
• DNB hospitals: Gradual but supervised training.

Decision-Making Over Cutting

• Focus on learning when to operate and managing patient care in your first year.
• Decision-making is as crucial as the act of surgery.

Mentorship

• Your learning depends on the teaching style of your mentors. Choose institutions that encourage active participation and growth.

3. Ward Work and Patient Management

Mastering ward work is the foundation of residency.

• Reach the ward early to see patients and know their history.
• Ensure all tasks, including investigations and clearances, are done efficiently.
• Be resourceful in overcoming challenges, especially in government setups with limited resources.

4. Building Trust and Reputation

The first few months of residency set the tone for your career:

• Seniors and consultants observe your sincerity and dedication closely.
• Thoroughness in patient workups and efficiency in assisting surgeries will earn you their trust.
• As trust builds, you’ll gain more significant responsibilities, including cutting opportunities.

5. Maximizing Learning Opportunities

Observe and Assist

• Follow the “observe five, assist five, operate five” principle for surgeries.
• Assisting helps you learn surgical steps and anatomy, laying the groundwork for future independence.

Supplement Practical Experience

• Watch surgical videos or attend live workshops to reinforce your understanding.
• Learn from every opportunity, from retractor holder to learning from cases.

6. Manage Expectations

Surgical residency is a marathon, not a sprint.

• Do not compare your progress to that of your classmates. Steady improvement is better than early success.
• Mastering surgery is an age-related exercise, that maintains consistency over three years.

7. Thesis Work and Research

Selecting the Right Topic

• Study the trends in the department for choosing a manageable topic where adequate cases exist.
• Prospective studies only if case records are maintained well; otherwise, work with retrospective studies.

8. Writing Tips

Start early, and avoid last-minute stress.

• Use resources and engage statisticians for data analysis work.
• Your thesis is a learning opportunity, not groundbreaking research.

9. Work-Life Balance and Long-Term Goals

Residency demands dedication but balance is also required on the same :

• If married, ensure that your partner does not find it difficult to accommodate your schedule of residency.
• Personal time has to be planned considering fixed leaves in tougher Government hospitals.
• If super specialization or MS/DNB is the goal, plan smartly for the future.

10. General Advice for Surgical Residents

Respect Patients

• Patients are your best teachers. Always treat them with respect and prioritize their care.

Humility and Growth

• Confidence is essential, but arrogance has no place in surgery. 
• Mistakes are inevitable learn from them without being overwhelmed.

Case Presentation Skills

• Observe seniors and practice presenting cases during rounds.
• Deep knowledge of a patient’s history ensures clarity and confidence during discussions.

Conclusion:

Surgical residency is one of the experiences that tests your limits and shapes you into a competent professional. Of course, you will encounter some biases and challenges, but all those who strive, are honest and devoted will always be valued. Use this residency to learn, grow, and prepare for a demanding yet rewarding life as a surgeon. Success is not just about technical skill but also the compassion and humility you bring to patient care.

Estimated reading time: 3 minutes

Are you looking for a platform where you can get the detailed solution of the DNB paper? If so you are at the right place!

Here, Dr. Amrit Nasta discusses the fourth paper of the DNB 2020 surgery exam with a detailed discussion and analysis. Unlike the previous paper, this one was slightly tough. Some questions were a little recently advanced types and there were some questions which were very standard and straightforward where you know with your basic knowledge you could have answered.

Don’t get intimidated by the tough questions. Get a grip of the easier questions, and write them well so that the overall effect is good. This paper also had 10 questions in 5 sections.

Here are the Highlights of the Video

Question 1: (Benign Prostatic Hyperplasia) BPH

Etilogy and Pathophysiology”

• Common in males aged 50-60 years, due to a decline in testosterone and a relative increase in estrogen.
• Enlargement occurs in the transitional zone or lateral lobes, leading to early urethral compression.
• Effects include bladder outlet obstruction, bladder hypertrophy, trabeculae, bladder diverticula, and obstructive nephropathy.

Surgical Management:

• Indications are severe symptoms, PIS score, obstructive nephropathy, or acute urinary retention.
• The most common procedure performed (TURP).
• Advanced techniques include HoLEP, transurethral needle ablation, water vapour ablation, and intraurethral stenting (for unfit patients).

Question 2: Head Trauma and Raised ICP

Mechanism of head injury:

• According to the Monro-Kellie Doctrine, within the confined volume of the skull, any mass or clot compresses blood, CSF, or brain tissue.
• Compromise to cerebral perfusion causes secondary brain injury and further ischemia.
• Signs include midline shift, ventricular compression, and brainstem herniation (rostrocaudal descent).

Raised intracranial pressure Management:

• Monitoring of raised ICP, for early recognition and timely intervention.
• Surgical decompression (craniotomy) would be necessary in severe cases of trauma, tumours, or cerebral edema.

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