Chief of Surgery

Houston County Medical Center

Crockett, Texas

Vice-Chair of Education

Department of Surgery

University of Texas Medical Branch

Galveston, Texas

Julian Wan, MD

Reed Nesbit Professor of Urology

Department of Urology

University of Michigan

Ann Arbor, Michigan

Stewart C. Wang, MD, PhD

First Endowed Professor of Burn Surgery

Director, Burn Center

Director, State of Michigan Burn Coordinating Center

Director, Morphomic Analysis Group

Director, International Center for Automotive Medicine

University of Michigan

Ann Arbor, Michigan

Mitchell R. Weaver, MD

Assistant Clinical Professor

Division of Vascular Surgery

Henry Ford Hospital

Wayne State University School of Medicine

Detroit, Michigan

Sharon Weber, MD

Tim and MaryAnn McKenzie Chair of Surgery

Director for Surgical Oncology, UW Carbone Cancer Center

Vice Chair of Academic Affairs, General Surgery

Professor of Surgery, Department of Surgery

University of Wisconsin School of Medicine and Public Health

Madison, Wisconsin

Theodore H. Welling, MD

Assistant Professor of Surgery

Co-Director, Multidisciplinary Liver Tumor Program

Section of Transplantation

University of Michigan

Ann Arbor, Michigan

Hunter Wessells, MD

Professor and Nelson Chair

Department of Urology

University of Washington

Seattle, Washington

Steven D. Wexner, MD, PHD (Hon)

Director, Digestive Disease Center

Chair, Department of Colorectal Surgery

Cleveland Clinic Florida

Affiliate Professor, Florida Atlantic University College of Medicine

Clinical Professor, Florida International University College of Medicine

Miami, Florida

29

Edward E. Whang, MD

Department of Surgery

Brigham and Women’s Hospital

Boston, Massachusetts

Elizabeth C. Wick, MD

Associate Professor of Surgery

University of California San Francisco

San Francisco, California

Edwin G. Wilkins, MD, MS

Professor of Surgery

Section of Plastic Surgery

University of Michigan

Ann Arbor, Michigan

Joshua H. Winer, MD

Assistant Professor of Surgery

Division of Surgical Oncology

Emory University/Saint Joseph’s Hospital

Winship Cancer Institute

Atlanta VA Medical Center

Atlanta, Georgia

Sandra L. Wong, MD, MS

Professor and Chair

Department of Surgery

Dartmouth-Hitchcock Medical Center

Geisel School of Medicine at Dartmouth

Hanover, New Hampshire

Charles J. Yeo, MD

Samuel D. Gross Professor and Chairman

Department of Surgery

Jefferson Medical College

Thomas Jefferson University

Philadelphia, Pennsylvania

Adam C. Yopp, MD

Assistant Professor of Surgery

Department of Surgery

Division of Surgical Oncology

University of Texas Southwestern Medical Center

Dallas, Texas

30

Preface

The editors are pleased to present the sixth edition of Greenfield’s Surgery: Scientific Principles & Practice.

The field of surgery has changed fundamentally in the years since the first edition of this text. Growth

in the knowledge base of clinical surgery continues exponentially. Surgical practice has been

transformed through advancements in physiologic and cellular investigation, integration of new

techniques derived from imaging and robotics, from the concept of patient-centered care, and from the

emerging field of biocomputation. The accelerating pace of scientific progress demands rapid adoption

of new ideas into surgical therapy and a commitment to lifelong learning. Accordingly, the new edition

of Greenfield’s Surgery seeks to integrate new scientific knowledge with evolving changes in surgical

care.

The sixth edition has been enhanced in every way, with changes to the book’s editorial board,

authorship, content, organization, and visual presentation. It reflects the founding principles and

guidance of Lazar J. Greenfield, MD, whose perceptive wisdom helped to create a truly unique book

that balances scientific advance with clinical practice. With this new edition, we welcome new editors—

Hasan Alam, MD and Timothy Pawlik, MD. Their expertise, energy, and vision have invigorated this

edition.

We have solicited contributions from well over 200 authors, all chosen because of their scientific and

clinical sophistication. Each contributor is currently an active practitioner in the field of surgery.

Moreover, many have presented seminal articles and developed the new concepts in their disciplines

that are featured in the text. Advances ranging from patient safety to fetal surgery mark the book as

truly unique.

Organizationally, the book begins with topics of broad relevance to the practice of surgery, followed

with chapters arranged by organ system. Trauma and transplantation are presented in the form of

separate sections rather than subdivided chapters. The content within each has been presented as

individual chapters in appreciation of the significance of each topic.

The book has been designed to create a text that not only looks better but also works better. The text

is produced in a full range of colors, creating both visual impact and more opportunity to convey

information quickly and with greater meaning. We continue our commitment to superb medical art in

the form of line drawings. These illustrations have been enhanced to ensure a presentation that

maximizes teaching effectiveness and clinical utility. Each chapter begins with a series of highlighted

key teaching points, which are referenced within the text that follows. Individually numbered decisionmaking algorithms are featured throughout the book to provide diagnostic and management

information in a simplified format. Tables carry classification bars, such as diagnosis or results, useful

both when scanning the text for information and when accessing the book’s contents digitally. The most

important articles and chapters on the topic are highlighted in the reference list.

The sixth edition continues to be highly integrated with electronic elements to provide supplemental

educational material, including Morbidity and Mortality Case Discussions and an interactive question

bank.

Today, Greenfield’s Surgery: Scientific Principles & Practice has become the gold standard text in the field

of surgery. The editors continue their commitment to the education of contemporary surgeons, and to

improved care of the patients that they serve. We believe that with the many improvements

implemented in this sixth edition, it will continue be the text by which all other surgery texts are

judged.

Michael W. Mulholland, MD, PhD

31

Contents

Contributors

Preface

Part One Scientific Principles

1 Lifelong Learning

Gurjit Sandhu and Rebecca M. Minter

2 Principles of Intermediary Metabolism

Steven E. Raper

3 Surgical Nutrition and Metabolism

George Kasotakis

4 Obesity and Metabolic Disease

Robert W. O’Rourke and Michael W. Mulholland

5 Wound Healing

Rajiv Chandawarkar and Michael J. Miller

6 Hemostasis

Peter K. Henke and Thomas W. Wakefield

7 Inflammation

Matthew R. Rosengart and Timothy R. Billiar

8 Surgical Infections

Lena M. Napolitano

9 Shock

Joseph Cuschieri and Darren Bowe

10 Critical Care

Damon Clark and Heidi Frankel

11 Fluids, Electrolytes, and Acid–Base Balance

Richard B. Wait, M. George DeBusk, and Jeffry Nahmias

12 Burns

Benjamin Levi, Mark R. Hemmila, and Stewart C. Wang

13 Anesthesiology and Pain Management

Sachin Kheterpal and Michael R. Mathis

14 Oncology

Adam C. Yopp and John C. Mansour

15 Preoperative Risk Assessment

Pauline Park

16 Measuring the Quality of Surgical Care

Justin B. Dimick and John D. Birkmeyer

17 Policy Approaches to Improving Surgical Quality

John D. Birkmeyer and Justin B. Dimick

18 Patient Safety

Darrell A. Campbell, Jr.

Part Two Surgical Practice

SECTION A: TRAUMA

19 Trauma and Trauma Care: General Considerations

32

Hasan B. Alam

20 Prehospital and New Advances in Resuscitation

John R. Taylor III, John B. Holcomb, and Bryan A. Cotton

21 Head Trauma

Phiroz E. Tarapore, Geoffrey T. Manley, and Randall M. Chesnut

22 Maxillofacial Injuries

Batya R. Goldwaser, Leonard B. Kaban, and Maria J. Troulis

23 Neck Injuries

Brandon R. Bruns and Thomas M. Scalea

24 Thoracic Trauma

Marc de Moya and George Velmahos

25 Abdominal Trauma

Kenji Inaba, Elizabeth R. Benjamin, and Demetrios Demetriades

26 Genitourinary Trauma

Hunter Wessells

27 Vascular Trauma

Adriana Laser, Shahab Toursavadkohi, and Todd E. Rasmussen

28 The Principles of Orthopedic Surgery for Trauma

Raymond Malcolm Smith

29 Pediatric Trauma

Elizabeth S. Soukup and Peter T. Masiakos

30 Geriatric Trauma

Carlos V.R. Brown, Zara Cooper, and Ali Salim

31 Trauma in Pregnancy

Felix Y. Lui and Kimberly A. Davis

32 Postinjury Management

Bellal Joseph and Peter Rhee

33 Environmental Injuries

J. Patrick Walker and Gregory J. Jurkovich

SECTION B: TRANSPLANTATION

34 Clinical Transplant Immunology

Amit K. Mathur and Satish N. Nadig

35 Organ Procurement and Preservation

Michael J. Englesbe

36 Renal Transplantation

Chris E. Freise and Peter G. Stock

37 Hepatic Transplantation

Theodore H. Welling

38 Cardiac Transplantation

Richard N. Pierson III

39 Pulmonary Transplantation

Jules Lin and Andrew C. Chang

40 Pancreas and Islet Transplantation

Randall S. Sung

SECTION C: HEAD AND NECK

41 Head and Neck

J. Kenneth Byrd and Robert L. Ferris

SECTION D: ESOPHAGUS

33

42 Esophageal Anatomy and Physiology and Gastroesophageal Reflux Disease

Daniel S. Oh and Steven R. DeMeester

43 Esophageal Tumors and Injury

Jonathan D’Cunha and James D. Luketich

SECTION E: STOMACH AND DUODENUM

44 Gastric Anatomy and Physiology

Michael W. Mulholland

45 Gastroduodenal Ulceration

Michael W. Mulholland

46 Management of Obesity

Robert W. O’Rourke

47 Gastric Neoplasms

Hari Nathan and Rebecca M. Minter

SECTION F: SMALL INTESTINE

48 Anatomy and Physiology of the Small Intestine

E. Ramsay Camp, Kevin F. Staveley-O’Carroll, Niraj J. Gusani, Jussuf T. Kaifi, and Eric T. Kimchi

49 Ileus and Bowel Obstruction

David I. Soybel and Ariel P. Santos

50 Crohn Disease

Scott R. Steele and Eric K. Johnson

51 Small Bowel Tumors

Steven G. Leeds and James W. Fleshman

SECTION G: PANCREAS

52 Pancreas Anatomy and Physiology

Taylor S. Riall

53 Acute Pancreatitis

Jason S. Gold and Edward E. Whang

54 Chronic Pancreatitis

Katherine A. Morgan and David B. Adams

55 Neoplasms of Exocrine Pancreas

Attila Nakeeb, Michael G. House, and Keith D. Lillemoe

56 Neoplasms of the Endocrine Pancreas

Harish Lavu, Jonathan R. Brody, and Charles J. Yeo

SECTION H: HEPATOBILIARY AND PORTAL VENOUS SYSTEM

57 Hepatobiliary Anatomy

Trevor L. Nydam and Richard D. Schulick

58 Hepatic Infection and Acute Liver Failure

Andrew M. Cameron and Christine Durand

59 Cirrhosis and Portal Hypertension

Michael R. Marvin, Robert M. Cannon, and Jean C. Emond

60 Hepatic Neoplasms

Junichi Shindoh and Jean-Nicolas Vauthey

61 Calculous Biliary Disease

David A. Kooby, Joshua H. Winer, and Kenneth Cardona

62 Biliary Injuries and Strictures and Sclerosing Cholangitis

Chad G. Ball and Keith D. Lillemoe

63 Biliary Neoplasms

Kaitlyn J. Kelly, Yuman Fong, and Sharon Weber

34

SECTION I: COLON AND RECTUM

64 Colon and Rectal Anatomy and Physiology

Sandy H. Fang and Elizabeth C. Wick

65 Acute Gastrointestinal Hemorrhage

Jason S. Mizell and Richard H. Turnage

66 Ulcerative Colitis

Dorin T. Colibaseanu and David W. Larson

67 Colonic Polyps and Polyposis Syndromes

Robert S. Bresalier and C. Richard Boland

68 Colorectal Cancer

Julio Garcia-Aguilar

69 Diverticular Disease

Lauren A. Kosinski, Kirk Ludwig, and Mary F. Otterson

70 Anorectal Disorders

David J. Maron and Steven D. Wexner

71 Diseases of Appendix

Edward A. Levine and Nathan Mowery

SECTION J: HERNIA AND SPLEEN

72 Abdominal Wall Hernias

Robert J. Fitzgibbons, Jr., Thomas H. Quinn, and Devi Mukkai Krishnamurty

73 The Spleen

Giorgos C. Karakousis and Douglas L. Fraker

SECTION K: SURGICAL ENDOCRINOLOGY

74 Breast Disease

Thanh U. Barbie and William E. Gillanders

75 Thyroid Gland

David T. Hughes and Paul G. Gauger

76 Parathyroid Glands

Gerard M. Doherty

77 Adrenal Gland

John A. Olson, Jr. and Douglas J. Turner

78 Pituitary Surgery

Brooke Swearingen and Nicholas A. Tritos

SECTION L: LUNG

79 Lung Neoplasms

Andrew C. Chang and Jules Lin

80 Non-Neoplastic Thoracic Disease

Rishindra M. Reddy

SECTION M: VASCULAR DISEASE

81 Congenital Heart Disease

Jennifer C. Hirsch-Romano, Richard G. Ohye, and Edward L. Bove

82 Valvular Heart Disease and Cardiac Tumors

Tomislav Mihaljevic, Craig M. Jarrett, Husain T. AlQattan, Shehab Ahmad Redha AlAnsari, Haris Riaz, Marijan Koprivanac, and

A. Marc Gillinov

83 Ischemic Heart Disease

Jonathan W. Haft

84 Mechanical Circulatory Support for Cardiac Failure

35

Gordan Samoukovic and Francis D. Pagani

85 Thoracic Aortic Aneurysms and Aortic Dissection

Ravi K. Ghanta and Gorav Ailawadi

86 Pericardium

Jules Lin

87 Vascular Diagnostics: The Noninvasive Vascular Laboratory

Gregory L. Moneta

88 Vascular Infection

Jayer Chung and J. Gregory Modrall

89 Cerebrovascular Disease

Martyn Knowles and Carlos H. Timaran

90 Upper Extremity Arterial Disease

Heron E. Rodriguez

91 Renal and Splanchnic Vascular Disease

Dawn M. Coleman, John E. Rectenwald, and Gilbert R. Upchurch, Jr.

92 Aortoiliac Disease

Loay S. Kabbani, Mitchell R. Weaver, and Alexander D. Shepard

93 Peripheral Arterial Disease

William P. Robinson III

94 Lower Extremity Amputation

Matthew J. Sideman, Kevin E. Taubman, and Bradley D. Beasley

95 Thoracoabdominal Aortic Aneurysms

Hazim J. Safi, Anthony L. Estrera, Charles C. Miller III, Kristofer M. Charlton-Ouw, Dianna Milewicz, and Ali Azizzadeh

96 Abdominal Aortic Aneurysms

Adam W. Beck, Kristina A. Giles, and Thomas S. Huber

97 Lower Extremity Aneurysms

Amy B. Reed

98 Venous Disease

Thomas W. Wakefield and Michael C. Dalsing

SECTION N: PEDIATRIC SURGERY

99 Fetal, Neonatal, and Pediatric Physiology

Samir K. Gadepalli and George B. Mychaliska

100 Fetal Intervention

George B. Mychaliska and Darrell L. Cass

101 Pediatric Head and Neck

Laura L. Neff and Reza Rahbar

102 The Pediatric Chest

Mary C. Santos and Robert E. Cilley

103 Pediatric Abdomen

Thomas T. Sato and Marjorie J. Arca

104 Pediatric Genitourinary System

John M. Park and Julian Wan

105 Childhood Tumors

Erika Adams Newman

106 The Pregnant Patient

Juan L. Martinez-Poyer and N. Scott Adzick

SECTION O: SKIN AND SOFT TISSUE

107 Cutaneous Neoplasms

Michael S. Sabel, Timothy M. Johnson, and Christopher K. Bichakjian

36

108 Sarcomas of Soft Tissue and Bone

Sandra L. Wong

109 Plastic and Reconstructive Surgery

Christian J. Vercler, David L. Brown, Steven R. Buchman, Paul S. Cederna, Kevin C. Chung, Jeffrey H. Kozlow, William M.

Kuzon, Jr., Adeyiza O. Momoh, and Edwin G. Wilkins

Index

37

Algorithm 8-1.

Algorithm 8-2.

Algorithm 8-3.

Algorithm 9-1.

Algorithm 9-2.

Algorithm 11-1.

Algorithm 11-2.

Algorithm 11-3.

Algorithm 12-1.

Algorithm 13-1.

Algorithm 13-2a-b.

Algorithm 15-1.

Algorithm 15-2.

Algorithm 15-3.

Algorithm 15-4.

Algorithm 19-1.

Algorithm 21-1.

Algorithm 21-2.

Algorithm 21-3.

Algorithm 26-1.

Algorithm 26-2.

Algorithm 26-3.

Algorithm 28-1.

Algorithm 29-1.

Algorithm 29-2a-b.

Algorithm 29-3.

Algorithm 36-1.

List of Algorithms

Empiric antimicrobial treatment of extrabiliary cIAIs, community acquired

versus healthcare associated

Biliary infections and algorithm for diagnosis and management

Step-up approach to management of necrotizing infected pancreatitis

Neurohormonal response to hypovolemia

Shock resuscitation algorithm

Hyponatremia

Acute hyperkalemia

Guidelines for the treatment of diabetic ketoacidosis

Protocol for frostbite injury

Decision aid for preoperative cardiac evaluation prior to noncardiac surgery.

This decision tree for preoperative evaluation takes into account not only the

patient’s physical status but also the severity of the surgical procedure

Algorithm for managing a patient on chronic buprenorphine therapy

Stepwise Approach to Perioperative Cardiac Assessment for CAD

Proposed algorithm for antiplatelet management in patients with PCI and

noncardiac surgery

Preoperative evaluation of patients with lung cancer for resection

Proposed algorithm for preoperative evaluation of patients with liver disease

2011 Guidelines for the Field Triage of the Injured Patients

Glasgow Coma Scale (GCS) triage guide for initial evaluation of head injury.

For the motor scale, the best response for any limb is recorded

Prehospital evaluation and treatment of a patient with severe traumatic brain

injury. “Signs of increased ICP” is the decision point for determining the

necessity of intracranial pressure (ICP)-lowering therapy. These signs include

pupillary abnormalities, motor posturing, or neurologic deterioration not

related to medications. The order of steps is determined by the risk–benefit

ratio for individual treatment maneuvers. This algorithm should be viewed as

“expert opinion” and used as a framework, which may be useful in guiding an

approach to field management of such patients

Evaluation and treatment of the patient with severe traumatic brain injury on

arrival at the trauma center. The order of steps is determined by the risk–

benefit ratio for individual treatment maneuvers. This algorithm should be

viewed as “expert opinion” and used as a framework, which may be useful in

guiding an approach to initial hospital management of such patients prior to

the initiation of ICP monitoring

Algorithm for the evaluation and management of renal injury

Algorithm for the evaluation and management of ureteral injury

Algorithm for the evaluation and management of urethral injury

The Denver Protocol for management of major pelvic fractures

PECARN rules to identify children at very low risk of clinically important TBI.

CT algorithm for children younger than 2 years (A) and for those aged 2 years

and older (B) with GCS scores of 14–15 after head trauma

Algorithm generated by the Brain Trauma Foundation Committee for the first

edition of the Guidelines for the Medical Management of Severe Traumatic Brain

Injury in Infants, Children, and Adolescents for first-tier therapies (A) and

second-tier therapies (B)

New ATOMAC guidelines for management of pediatric solid organ injury

Stepwise approach to the management of decreased low urine output

posttransplant

38

Algorithm 39-1.

Algorithm 41-1.

Algorithm 42-1.

Algorithm 43-1.

Algorithm 43-2.

Algorithm 43-3.

Algorithm 45-1.

Algorithm 46-1.

Algorithm 47-1.

Algorithm 49-1.

Algorithm 49-2.

Algorithm 50-1.

Algorithm 50-2.

Algorithm 50-3.

Algorithm 50-4.

Algorithm 50-5.

Algorithm 50-6.

Algorithm 51-1.

Algorithm 51-2.

Algorithm 51-3.

Algorithm 53-1.

Algorithm 54-1.

Algorithm 55-1.

Algorithm 55-2.

Algorithm 56-1.

Algorithm 59-1.

Algorithm 60-1.

Algorithm 60-2.

Algorithm 60-3.

Algorithm 61-1.

Algorithm 61-2.

Algorithm 62-1.

Algorithm 65-1.

Algorithm 68-1.

Algorithm 68-2.

Algorithm 68-3.

Algorithm 69-1.

The donor management algorithm used at the University of Michigan in

coordination with the organ procurement organization, Gift of Life. Optimal

PEEP is determined by increasing PEEP 2 cm of H2O every 3 to 5 minutes

until compliance decreases. Recruitment maneuvers include CPAP at 30 cm of

H2O for 30 seconds every 20 minutes × 3

Workup of a Neck Mass in an Adult Patient

24-Hour Esophageal pH Monitoring

Evaluation and treatment of esophageal perforation

Proposed algorithm for evaluation and management of acute caustic ingestion

Evaluation and treatment of esophageal leiomyoma

Treatment of bleeding duodenal ulceration

Algorithm for management of abdominal pain months or years after Roux-enY reconstruction

Treatment of gastric adenocarcinoma

Algorithm for the management of adhesive small bowel obstruction

Approach to the management of malignant bowel obstruction

Crohn disease with anal complaints

Anal skin tags in Crohn disease

Hemorrhoids in Crohn disease

Anal abscess/fistula in Crohn disease

Anal fissure in Crohn disease

Anal stenosis/stricture and Crohn disease

Management algorithm for patients with advanced neuroendocrine tumors

(NETs) of the gastrointestinal tract

Algorithm showing the management of patients with small bowel

adenocarcinomas. The treatment strategy depends on disease stage and

involves en bloc resection for locoregional disease and systemic chemotherapy

for metastatic disease. All current recommendations are based on case series,

retrospective reviews or nonrandomized prospective trials because of an

absence of any randomized data

Treatment algorithms for patients with (A) advanced/metastatic GIST and (B)

resectable GIST. GIST indicates gastrointestinal stromal tumor

Algorithm for the management of acute pancreatitis

Algorithm for operative decision-making in chronic pancreatitis

International consensus guidelines for the management of IPMNs

Management strategy based on CT criteria for resectability of pancreatic

cancer

Diagnosis and management of pancreatic endocrine neoplasms

Suggested treatment options, in order of preference, for patients who fail

medical management for variceal bleeding

BCLC algorithm for treatment selection in patients with HCC

Treatment algorithm of patients with hepatocellular carcinoma (HCC) based

on serum bilirubin level and indocyanine green retention rate at 15 minutes

Multidisciplinary treatment approach for colorectal liver metastasis

Algorithm for the management of common bile duct stones

Management of acute cholangitis

Algorithm for diagnosis and management of bile duct injury associated with

laparoscopic cholecystectomy

Diagnostic steps in the evaluation of gastrointestinal hemorrhage

Approach to rectal cancer according to clinical staging

Approach to locally advanced rectal cancer based on a three-tier risk

stratification system (“the good, the bad, and the ugly”)

Stage IV rectal cancer treatment algorithm

Diverticulitis Treatment based on Modified Hinchey Score (0–IV)

39

Algorithm 72-1.

Algorithm 72-2.

Algorithm 72-3.

Algorithm 72-4.

Algorithm 74-1.

Algorithm 74-2.

Algorithm 74-3.

Algorithm 74-4.

Algorithm 75-1.

Algorithm 77-1.

Algorithm 77-2.

Algorithm 77-3.

Algorithm 78-1.

Algorithm 78-2.

Algorithm 79-1.

Algorithm 79-2.

Algorithm 79-3.

Algorithm 80-1.

Algorithm 80-2.

Algorithm 80-3.

Algorithm 80-4.

Algorithm 80-5.

Algorithm 84-1.

Algorithm 86-1.

Algorithm 92-1.

Algorithm 97-1.

Algorithm 98-1.

Management of initial inguinal hernia

Management of recurrent inguinal hernia

Management of groin pain after herniorraphy

Management of incisional hernia

Diagnosis and management of the patient with a clinically benign breast mass.

The use of imaging studies varies according to age because breast carcinoma is

infrequent in women younger than 35 years old

Diagnosis and management of the patient with a clinically indeterminate or

suspicious solid breast mass. In this circumstance, imaging studies are

insufficient to exclude malignancy, and tissue sampling is required

Diagnosis and management of the patient with a cystic lesion. Bloody fluid on

aspiration, failure of the mass to resolve completely, and prompt refilling of

the same cyst are indications for surgical biopsy

Management of the patient with an abnormal screening mammogram. When

pathology is benign, concordance or discordance with imaging findings

dictates whether surgical excisional biopsy is indicated

Management algorithm for thyroid mass

Diagnosis of hypercortisolism

Diagnosis and management of hyperaldosteronism

Diagnosis and management of the incidental adrenal mass

Treatment algorithm for acromegaly

Treatment algorithm for Cushing disease

Management of the incidental solitary pulmonary nodule

Evaluation of the patient who presents with a pulmonary mass

This algorithm illustrates the preoperative functional evaluation prior to lung

cancer resection

Algorithm for management of lung abscess

Hemoptysis management

LVRS candidate workup

Algorithm to treat pneumothorax.

Algorithm for management of tracheal masses

Current algorithm for assessing patients with advanced heart failure for heart

transplantation and mechanical circulatory support. Transplant status is

initially assessed to determine appropriate indication for MCS use; BTT vs. DT

This algorithm outlines the initial approach to a patient with a large

pericardial effusion

Patient with symptomatic aortoiliac occlusive disease

Management of femoral pseudoaneurysm

Treatment of chronic venous insufficiency

40

Part One Scientific Principles

41

Chapter 1

Lifelong Learning

Gurjit Sandhu and Rebecca M. Minter

Key Points

1 Self-regulated learning is a skill that can be taught to trainees.

2 The Dreyfus model of skill development is helpful for understanding the growth and depth of selfregulated learning from novice to expert level.

3 As self-regulated learning solidifies and becomes habitual for the trainee, it enhances transitions into

effective lifelong learning.

4 Lifelong learning is an essential component of safe patient care with up-to-date knowledge and skills.

5 Surgeons who are lifelong learners are better prepared to deal with the complexities of future

practice.

LIFELONG LEARNING FOR PERSONAL, PROFESSIONAL, AND

SOCIAL RESPONSIBILITY

The Accreditation Council for Graduate Medical Education (ACGME) Task Force on Quality Care and

Professionalism has drawn a clear and explicit connection among professionalism, safe patient care, and

lifelong learning.1 This is a direct reference to ensuring that graduate medical education programs are

graduating fully trained physicians who are prepared to practice independently.1,2 In order to achieve

this goal, exposure to the curriculum is insufficient. Surgeons in training must demonstrate that they are

able to perform the activities of a specialist in that field. This becomes a complex feat of curriculum

development and learner assessment when one considers that even as learners are graduating from their

training programs, their specialties are evolving. With a patient population that is older, has higher

acuity, greater number of chronic diseases and comorbidities, accompanied with unprecedented growth

in medical knowledge, it is naive to assume that trainees will graduate with mastery of every facet of

their discipline.3,4 Hence, graduating physicians who are primed for lifelong learning becomes a salient

professional and social responsibility of graduate medical education programs.

Ultimately, lifelong learning is about bringing together individual responsibility with safe patient

care. The commitment to ongoing reflective learning lends itself to a practice where research,

education, and experience come together to best serve the needs of the patient. ACGME emphasis on

lifelong learning is evidenced in two concrete ways: (1) by the continuum with which milestones are

developed – beginning with the pretrained novice and extending throughout the physician’s career –

reinforcing learning and growth beyond graduation; and (2) an explicit ACGME Common Program

Requirement stating “residents must demonstrate the ability to investigate and evaluate their care of

patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based

on constant self-evaluation and lifelong learning.”5,6 Several surgical specialties have gone on to include

lifelong learning as a milestone within the practice-based learning and improvement competency.7–10

If lifelong learning is an outcome that is sought among high performing, safe, up-to-date surgeons, it

is imperative that surgeons in training develop appropriate knowledge, skills, and attitudes during

training that will foster this habitual behavior for when they are in professional practice. Just as

management of complex problems or knowledge about postoperative complications of most essential

operations are milestones that are met in a progressive manner, the same is true about lifelong learning

as a milestone that is met in a progressive manner. As a trainee works toward honing and

demonstrating expertise for lifelong learning, progressive development toward this goal while still in a

residency program would be called self-regulated learning. In other words, the goal over time is for a

resident/fellow to fully and intuitively adopt self-regulated learning and graduate from training

entrusted to embrace lifelong learning. Before considering the development of self-regulated learning in

42

a graduated manner across the continuum of graduate medical education, it is important to define and

establish the relationship between self-regulated and lifelong learning.

SELF-REGULATED LEARNING

1 Self-regulated learning has been used to describe students who are “metacognitively, motivationally,

and behaviorally active participants in their own learning process.”11 This includes the ability to plan

and organize self-instruction, monitor and assess self, and seek out optimal learning opportunities.

White et al.12 argue that these are not merely innate attributes, but skills that can be taught during

medical training. Self-regulated learning is framed as a cycle of four phases

12: