SOAP Notes:

Typhon Report:

Site Visit Summary:

Site visits challenged my knowledge of surgery and led to thorough conversations on differentials, treatment, and patient planning post-surgery. These site visits were a learning experience that allowed me to expand my knowledge of surgery via discussions with other students in my cohort. My understanding of the differences in surgical and medical management grew with the use of these site visits. For example, in surgery, the patient’s diet, IV fluids, pain control, and catheter placement/removal were essential in the patient’s management. I also learned from my classmates about different diagnoses, drugs, and special cases they participated in. The site evaluator also challenged and strengthened my knowledge of procedures, differentials, and treatment plans.

Case And Journal Summary:

Case: Pt is a 74 y/o F with PMHx of stage IV Hiatal Hernia who had a robotic hiatal hernia with ovitex mesh partial toupet fundoplication wrap currently is POD 1 complaining of chest pain and abdominal pain that does not improve with pain medication. 

Journal Article: Bhatt, H., & Wei, B. (2023). Comparison of laparoscopic vs. robotic paraesophageal hernia repair: a systematic review. Journal of thoracic disease, 15(3), 1494–1502. https://doi.org/10.21037/jtd-22-819

Summary: 

Comparison of laparoscopic vs. robotic paraesophageal hernia repair is a systematic review published in the 2023 Journal of thoracic disease. Bhatt and Wei performed a systematic review using Medline, Embase, Cochrane and Scopus to compare the benefits of standard laparoscopic and robotic surgery for large paraesophageal hernia (PEH) repairs. Benefits of procedures were measured via decreased conversion rate, patient satisfaction and shorter hospital stays. They predicted that robotic repair is not inferior to laparoscopic PEH. The researchers studied a total of 7 publications between the years of 2012- 2022 with 171,093 patients with 160,005 in the laparoscopic group and 11,075 in the robotic repair group. 

Bhatt and Wei found that robotic PEH repair had a comparable if not more favorable perioperative outcome compared to laparoscopic PEH repair. Robotic PEH repair had decreased length of stay, an improved complication rate,lower recurrence rate ,and a decreased rate of esophageal-lengthening procedures compared to laparoscopic. Compared to robotic PEH repair, Laparoscopic repair was found to have an 11% risk of conversion rates. However, the cost for a robotic repair is higher than that of a laparoscopic and  has a potentially higher rate of perioperative complications. 

All in all, robotic PEH repair provides at least comparable if not better results than laparoscopic. However, there are limitations of the study such as selection bias and the complexities of hernias in patients who underwent robotic vs. laparoscopic. For example, surgeons early in their robotic experience could prefer to do “difficult” cases laparoscopically or  surgeons can choose to do patients with larger hernias via a robotic approach due to the increased camera maneuverability and control of retraction. Further research with larger cohorts that are more up to date needs to be done. 

Rotation Reflection:

My eighth surgical rotation was at St. Francis which is located in Roslyn, NY. St.Francis is a Catholic Health hospital that specializes in heart health. St. Francis serves a predominantly caucasian community with a minority group of Asians, Hispanics, and African Americans. My eighth rotation had a selective array of patients and diagnoses. I worked closely with the general surgery team and was able to first and second assist in multiple surgeries of different specialties. I had the privilege of first assisting in orthopedic, and plastics, and second assisting in GI cases. I was also able to perform physical examinations and post-op examinations.

During my rotation, I sharpened my skills in anatomy (open and laparoscopic), reading and understanding laboratory values, and imaging such as CT and MRI scans. I also gained experience in different suturing skills, procedures such as NG tube and CBI placement, and post-surgical management. I got the opportunity to scrub into complex and rare cases such as a cholecystectomy in an in situ total patient or an open nephrectomy for tumor resection obstructing the inferior vena cava (IVC). I was able to practice obtaining a patient’s history, write patient-specific soap notes, and perform physical exams which improved my skills. Writing notes for a surgical patient differs from a regular medical note by including topics such as diet, pain management, and DVT prophylaxis. With time and practice, I was able to do soap notes and review them with the clinicians present. I also learned multiple different suturing techniques and the ability to explain procedures to patients.

I had difficulty learning laparoscopic anatomy. The laparoscopic view of anatomy is different from regular open anatomy. Laparoscopic anatomy is based on where the camera is facing and the angle making it more difficult to understand the anatomy. However, with the help of the surgeons, scrubbing into more cases, and studying I was able to formularize myself with laparoscopic anatomy. I learned from the experienced surgeons and general surgery PAs at St. Francis the importance of anatomy and its role in successful surgery. I also learned that surgery requires precision, proper communication, and is hands-on. All the clinicians and staff at the facility were nice and had the determination to teach. I enjoyed my time at St. Francis and look forward to my next rotation: Psychiatry at QHC.