Reflection: Surgery Rotation

The surgery rotation at Woodhull Hospital was one that I was anticipating greatly as I wasn’t sure exactly what my experience would be as I hadn’t much interest in pursuing surgery as a specialty.  I was pleasantly surprised to find that the format of the rotation provided a wide range of opportunities to develop skills such as reviewing patient charts in a timely fashion, presenting patients concisely during rounds, scrubbing into procedures, and following up with patients who are post-op and in need of dressing changes.  Additionally, there were lectures and conferences periodically throughout the week on various subjects including tumor boards, morbidity and mortality, as well as chairman rounds.  The general atmosphere was positive, with the attendings and residents involving all students consistently with tasks of the day, and making an effort to educate as well as allow opportunities to practice skills like suturing, wound care, and scrub into many different procedures.  

Monday, Wednesday, and Friday students were OR days, and each student would choose a couple cases to scrub into.  I found the most intimidating part of my first OR day to not be the potential pimping from the attending but the scrutiny of the scrub nurse.  Fortunately, scrubbing in went off without a hitch (minus standing slightly too close to the instruments on setting up) and from there on the process became much more comfortable.  It was an exciting experience to observe and lend a hand in the various procedures, as well as to see the inner anatomy exposed and get a sense of the true life appearance of various structures.  Especially exciting was the laparoscopic appendectomy on my first OR day where I learned exactly how they place the trocars and go about excising the appendix.  One week of the rotation was in orthopedic surgery and I was allowed to scrub into several total knee arthroplasties.  

While in surgeries I was allowed to practice closing with various types of suturing techniques, but when students were on the floor we were able to practice different approaches to wound care and dressing changes while following up with patients and assessing their recovery.  Each day there were many patients in need of dressing changes, whether it be simple gauze wrap, xeroform, and ace bandage, or replacing entire wound vacs and ostomy bags.  Rounding in the mornings was by far my favorite part of this rotation.  Arriving early in the morning and choosing a couple patients to follow, we would review the charts and note any significant overnight events, most recent vitals, as well as lab work and imaging done overnight.  Using a general template, a formal presentation was made to the attendings and residents that included an assessment and plan for what should happen that day.  Most often patients were recovering without complications, but occasionally they would present with symptoms that required investigation such as prolonged pain or abnormal labs.  I found it rewarding to see patients on clinic days come in with various complaints, find a decision was made to schedule a procedure, and to be able to follow them through that procedure, the post-op care, and once again in the clinic for follow-up.  

Outside of the more hands-on patient interactions and OR days, we were included in the various conferences and lectures throughout the week.  These included tumor boards where numerous cases of malignancy in the HHC system were summarized by us students and discussed in conferences by the involved departments.  ‘Morbidity and mortality’ presentations were also attended where the chief resident would present cases of ‘M&M’ to the attendings.  These sessions were a great compliment to the more clinical aspects of the rotation, making for a great diversity of experiences in my five weeks on surgery.

Journal Article With Summary

Köckerling F, Schug-Pass C. Spermatic Cord Lipoma-A Review of the Literature. Front Surg. 2020 Jul 23;7:39. doi: 10.3389/fsurg.2020.00039. PMID: 32793626; PMCID: PMC7393947.

Journal’s Abstract:

Introduction: A spermatic cord lipoma is found in 20-70% of all inguinal hernia repairs. The clinical picture of an inguinal hernia with bulging and pain but without an actual indirect hernia sac may become manifest in up to 8% of these cases. Missed spermatic cord lipoma can result in recurrence or pseudo-recurrence. This review presents the relevant literature on this topic. 

Materials and Methods: A systematic search of the available literature was performed in February 2020 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library, as well as a search of relevant journals and reference lists. Forty-two publications were identified as relevant for this topic. 

Results: Spermatic cord lipoma seems to originate from preperitoneal fatty tissue within the internal spermatic fascia in topographical proximity to the arteries, veins, lymphatics, nerves, and deferent duct within the spermatic cord. Reliable diagnosis cannot be made clinically, but rather with ultrasound, CT, or MRI. In the absence of a real hernia sac, a spermatic cord lipoma is classified as a lateral inguinal hernia with a defect size <1.5 cm according to the European Hernia Society (EHS LI). Missed or inadequately treated spermatic cord lipoma results in recurrence or pseudo-recurrence. Since spermatic cord lipoma obtains its vascular supply from the preperitoneal space, it can be reduced or resected. Conclusion:Spermatic cord lipoma is a common finding in inguinal hernia repairs and must be properly diagnosed and treated with care respecting the anatomy of the spermatic cord.

My Summary:

“Spermatic Cord Lipoma – A Review of the LIterature” is a systematic review published by Frontiers in Surgery.  A search of Medline, Google Scholar, PubMed, Embase, Springer Link, and the Cochrane Library was performed and 42 publications were found to be relevant.  Results determined that lipomas of the spermatic cord were not ‘true lipomas’ but rather preperitoneal fat tissue that is displaced into the inguinal canal as a result of gravity and intra abdominal pressure.  According to the European Hernia Society (EHS), a lipoma of the spermatic cord should officially be considered a ‘lateral inguinal hernia with a defect size <1.5 cm.’  It was determined that, since the blood supply of the lipoma is received from the preperitoneal space, these lipomas may be either resected or reduced.

These lipomas are usually found incidentally on repair of an inguinal hernia and are known as either “lipomas of the cord,” “lipomas of the round ligament,” “spermatic cord lipomas,” and “inguinal cord lipomas.”  Without a hernia sac present, a spermatic cord lipoma may mimic an inguinal hernia without any true herniation into the inguinal canal.  In one of the studies that was included, 36% of women patients were found to have a liipoma of the round ligament on exploration of the inguinal canal, while others estimate the occurrence to be closer to 12.5%.  These lipomas are not diagnosed cllinically, but must be visualized either on ultrasound, CT scan, or MRI.  On clinical diagnosis, there may be a discrepency between the size of an inguinal when compared with visualization intraoperatively.  In such a case it’s important to make a thorough search for lipomas deep in the inguinal canal.  

During an inguinal hernia repair in one of my OR days, there appeared to be some type of mass within the spermatic cord on examination.  After some deliberation it was determined to be one of these spermatic cord lipomas and was ultimately dissected from the spermatic cord.  In this case there was an indirect inguinal hernia sac present, which may add to the severity of the bulge when making clinical diagnosis prior to surgery.  

Site Evaluation Summary

My site evaluations with surgery PA Rachwalski allowed me to share several full history and physicals I had written during my rotation as well as cover numerous relevant medications via 10 ‘pharm cards’, as well as discuss the journal article mentioned above.  We did an extensive review of each of these history and physicals, discussing the all of the pertinent positives and negatives, as well as the medication lists and social / family histories.  The first H&P I presented involved an older man who came in with acute onset of cramping abdominal pain rated a 9/10.  The patient had a history of atrial fibrillation and hyperlipidemia, as well as a right inguinal hernia repair with bowel resection in November of the previous year.  Vitals were stable and within normal limits, although CBC revealed a white count of 15.43 and a lactate of 5.6.  CT revealed a small bowel obstruction.  From here we discussed the ABC’s of small bowel obstruction: adhesions, bulges (hernias), and cancer.

The second H&P involved a female patient in their 20’s presenting 7 days status post umbilical hernia repair with a painful “pinching” sensation at the umbilicus rated a 9/10 with some bloody discharge.  The patient was found to have a white count of 16.20 and CT showed small pockets of air and inflammation around the incision site, most likely from infection of a gas forming organism.  From here we discussed how I felt that the physical exam of the patient did not appear to be as severe as what was found on imaging and how this can always be the case.  With this patient the presence of moderate erythema surrounding the incision site at POD#7 was suspicious for postoperative infection with the number of days out from surgery being key.  We were able to discuss my journal article selection at length and I learned quite a bit about surprisingly common spermatic cord lipoma findings on repair of inguinal hernias.