The last year is spent as Chief Resident where one is in charge of a team of junior residents and medical students and performs between 250 and 350 major cases. There are strict criteria for the number and variety of cases that one is exposed to. The residency is considered to be one of the most demanding, both mentally and physically, of all the medical specialties.
A general surgeon is well trained in the diagnosis and management of a wide variety of congenital, infectious, malignant and benign diseases. In addition, he or she has extensive knowledge of postoperative and critical care of patients.
Board Certification
A Board Certified General Surgeon is one who has completed the standard surgical residency with experience in a broad spectrum of surgical diseases and a minimum number of cases as set by the board.
He or she has passed a day-long written examination verifying an extensive knowledge base, and passed an oral examination. During the oral exam, candidates are interviewed by three teams of prominent surgeons who evaluate the candidates' ability to manage ordinary and complex surgical problems.
For more information about board certification, see the American Board of Medical Specialties and the American Board of Surgery.
FACS
The initials F.A.C.S. indicate that the physician is a Fellow of the American College of Surgeons. To achieve this status, the surgeon's education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation and have been found to be consistent with the high standards established and demanded by the college.
To apply, the surgeon must be in the same practice for more than two years and accumulated a certain number of cases. The application process takes another year. For more information, see the American College of Surgeons.
Specialties of a Board Certified Surgeon
A surgeon who has attained certification by the American Board of Surgery has specialized knowledge and skill relating to the diagnosis, preoperative, operative, and postoperative management of surgical problems in the following areas of primary responsibility:
Laparoscopic surgery is abdominal surgery performed using only ˝ inch or less incisions. Instead of having his or her hands in the belly, the surgeon operates using long hand held instruments that slide in and out of sheaths (trochars) going through the abdominal wall.
To begin, the abdomen is inflated to a constant pressure with CO2 gas. This makes room for visualization of the abdominal cavity using a rigid scope which transmits the image to monitors in the operating room. Specialized tools such as scissors, dissectors, graspers, ultrasonic shears and endoscopic staplers facilitate the surgeon's ability to perform complex intraabdominal surgery.
We among others have been able to master advanced laparoscopic techniques such as major vessel division, suturing and tying and intracorporal anastomosis (reconnecting the bowel without bringing it out of the abdomen).
Revolutionary Technique
Laparoscopic abdominal surgery can be used in place of almost all open operations with equal or better results, giving patients less pain and a shorter recovery. There are also smaller scars and less wound complications. In experienced hands, there are few disadvantages, although laparoscopic cases may take longer. However, not all general surgeons do complex laparoscopic surgery.
We were trained in advanced laparoscopic surgery and have made this type of surgery a primary focus of our practice. We were one of the first groups on the North Shore to perform difficult laparoscopic cases such as colectomy, splenectomy and ventral hernia repair. Our accumulated volume and experience rivals that of downtown medical centers, thus our patients can get state of the art care close to home, both at Highland Park Hospital and Lake Forest Hospitals.
A Wide Range
This includes common procedures such as removal of the gallbladder or appendix as well as rare cases like splenectomy, small bowel resection and mesenteric lymph node biopsy. We have done hundreds of laparoscopic ventral and inguinal hernia repairs and will suggest this when we feel it is the best for the patient.
For laparoscopic colon resection, the incisions keep getting smaller, and the hospital stay shorter. Using intracorporal anastomosis for both right and left colectomy, we are able to keep the largest incision under two inches. Laparoscopic colectomy is now the standard for both benign disease like polyps or recurrent diverticulitis, and malignant tumors.
Initial Detection
Breast cancer requires a multidisciplinary approach to its diagnosis and management, with primary care physicians, radiologists, surgeons, radiation oncologists, and medical oncologists playing a role. Baseline screening mammography should be performed in all women between the ages of 35 and 40. Mammography is recommended every two years until age 50 and then yearly.
This should be accompanied by a physical examination as about 15% of cancers will be palpable but not show up on the mammogram. More importantly, every woman should perform self breast examinations monthly. She is more likely to detect a breast lump at an early stage.
Diagnosis
The definitive diagnosis is made by biopsy, either by needle aspiration or open excision, and this is performed by the surgeon. Thus any patient with an abnormal mammogram or palpable breast lump should receive surgical consultation. We frequently perform needle biopsy in our office. However, many times there is only a mammographic abnormality which cannot be palpated. This requires radiographic localization, followed by excision.
A newer technique of steriotaxic needle biopsy may be employed in many cases as a less invasive modality to get a diagnosis. This is performed by the radiologist using X-ray guided needle biopsy. Once the diagnosis is made, metastatic disease should be ruled out by blood tests, chest X-ray, and possibly CAT scan or bone scan for symptomatic patients.
Surgical Treatment
The next step is surgical removal of the cancer and staging of the axillary (under arm) lymph nodes. The current trend is toward breast conservation therapy. This involves lumpectomy (removing the cancer with some surrounding normal breast tissue) and radiation to the breast. We also perform sampling of the axillary lymph nodes using sentinel lymph node biopsy. This state of the art technique allows us to find the one or two nodes which are in direct communication to the cancerous region of the breast.
These nodes are examined by the pathologist at the time of surgery, and if they are negative, the rest of the lymph nodes are left in place. This avoids unnecessary removal of all the lymph node tissue and helps to decrease complications, such as arm swelling. All of our surgeons are skilled at breast conservation therapy and sentinel lymph node biopsy. We make a special effort to see patients with suspected breast cancer emergently, and move rapidly to make a diagnosis and if necessary, perform definitive surgery.
Intracorporeal anastomosis produces superior results with shorter length of stay, decreased postoperative narcotic use, faster return of bowel function, and decreased morbidity. Many general and colorectal surgeons do laparoscopic colon surgery with or without hand assistance and use much larger incisions.
If the stones block the gallbladder duct (cystic duct) this can lead to an infection of the gallbladder or acute cholecystitis. The symptoms are right upper abdominal pain, fever, vomiting and tenderness. This necessitates admission to the hospital, antibiotics, and removal of the gallbladder. If the stones pass into the common bile duct, they can cause jaundice as well as pain and infection. If the stones pass, they can cause a back up of pancreatic secretions causing pancreatitis.
Diagnosing Gallstones
The diagnostic study of choice to identify gallstones and gallbladder infection is an ultrasound, which is a noninvasive radiological scan. If you experience upper abdominal pain on the right side, especially after you eat, you may want to consult your physician about ordering an ultrasound.
Once a person has a gallbladder attack, and an ultrasound documents gallstones, we recommend elective removal of the gallbladder using the laparoscopic technique. We are all very experienced and skilled in this technique, as it is one of the most common procedures that we perform. The recovery is much shorter with laparoscopy, with a return to normal activities and work expected in one week or less. A one night stay in the hospital is usual.
Other Causes
Less than 10% of the time, patients may experience typical upper abdominal pain and have a negative ultrasound. Other causes of this type of pain include ulcers and gastritis. A dysfunction of the gallbladder contracting mechanism, called Biliary Dyskinesia has been identified as another common cause of this pain syndrome. This diagnosis can be made by a nuclear scan called a CCK-HIDA scan. If the scan is positive, laparoscopic removal of the gallbladder is indicated to relieve the pain and prevent future episodes.
The most common diseases of the gastrointestinal tract that we treat are:
Furthermore, once hernias start, they never go away on their own. They only get larger over time due to intra-abdominal pressure. Therefore, it is standard surgical care to repair hernias electively when they are diagnosed. Due to overwhelming evidence that tension free mesh repairs offer significantly lower recurrence rates, prosthetic mesh is used in nearly all hernia surgery, and has been for almost 25 years.
Complete Care
We obtain a thorough history and physical exam during an office consultation and make a decision on further management. Pigmented lesions that are new, enlarging or bleeding can be worrisome. On the exam, we are more suspicious if the lesion has black color, irregular boarders, ulceration, and size greater than 6 mm.
Obviously benign lesions may be observed or excised based on patient preference. For suspicious or indeterminate lesions, we have a variety of biopsy techniques available in our office under local anesthesia, including shave biopsy, full thickness punch biopsy and full thickness excisional biopsy.
If a patient has a postitive biopsy for malignant melanoma, we stage the disease based on the thickness of invasion. If it is less than 1 mm thick, it is considered stage I which has a very low chance of metastasizing to lymph nodes. The treatment is a wide local excision with a one centimeter margin. This is an outpatient surgery at the hospital under twilight anesthesia. If the primary lesion has a depth of invasion 1 to 4 millimeters, it is considered intermediate thickness and does have a chance for lymph node metastasis. Thus, we recommend a sentinel lymph node biopsy. This technique allows analysis of one or two lymph nodes in the Axilla or groin. If negative, the patient is spared the morbidity of a complete lymph node dissection.
Lipomas or Sebaceous Cysts
Soft tissue tumors may represent lymph nodes, congenital cysts or benign or malignant neoplasms such as sarcoma or metastatic disease. We question patients regarding how long they have had the lesion, if it is growing, if it is painful or has ever been infected. We ask about personal or family history of malignancy. The examination focuses on skin changes, size of the lesion, weather it is fixed to the muscle and the consistency.
The initial options include imaging by ultrasound or MRI, needle biopsy or excisional biopsy. The decision is based on suspicion of malignancy. If a patient has a small superficial tumor that is stable, it can be watched. Deeper masses are usually imaged with MRI as a first step. It is not usual to perform a needle biopsy unless the lesion is thought to be a lymph node. Therefore, If it has reached a large size, is rapidly growing, is hard or fixed to the muscle, it should be removed for diagnosis and treatment. All specimens are sent for pathologic analysis. If a malignancy is diagnosed, it is sometimes necessary to perform another more radical surgery, with or without the addition of chemotherapy or radiation, depending on the diagnosis.
Our full thickness excision method involves two layer skin closure using absorbable suture. This plastic surgical technique leads to minimal scarring and increased patient satisfaction.
Skin Infections and Ulcers
Treatment of skin infections, ulcers and varicose veins rounds out our expertise. We provide urgent service to patients with skin and soft tissue infections. If a patient calls our office with a boil or severe infection we will work them in the same day for evaluation and incision and drainage when necessary. Many times, the wound is left open to heal from the bottom up. We see all our patients through the wound care process. If someone needs inpatient care, we are readily available to provide this.
About 20% of these nodules will be malignant or suspicious for malignancy and these will require surgical removal of the affected thyroid lobe. If cancer is found, total thyroidectomy is usually necessary.
Hyperparathyroidism
We also evaluate and treat patients with elevated calcium levels and hyperparathyroidism. We are able to take advantage of the newest trend in endocrine surgery, which involves the use of a rapid parathyroid hormone assay intraoperatively while performing a neck exploration for hyperparathyroidism.
Serum levels are taken at the start of the operation and then again 5 and 10 minutes after the removal of an enlarged gland. The level should fall by greater than 50%, signifying that the offending adenoma has been removed. If the level does not decrease, it may indicate a double adenoma or four gland hyperplasia, thus the surgeon would proceed with further exploration.
This allows the surgeon to achieve a higher success rate than with "blind" removal of parathyroid glands. We perform this surgery using the rapid assay at Evanston Hospital, currently the only institution in our system where this technology is available.
