Anaesthesia for Major General Surgery

LUHFT (Royal)

Contact: Dr Penny Edmondson (penelope.edmondson@liverpoolft.nhs.uk)

Module Details: With the service redistribution within LUHFT we can now offer a deep dive into major general surgery on the Royal site. We do regular major surgeries including cancer resections for pancreatic, oesophageal, colorectal, endocrine and urological pathology. These patients require invasive monitoring, advanced pain relief options (epidurals, rectus sheath catheters) and careful pre-operative decision making. Trainees are involved with each of these and it’s a great chance to get experience at thoracic epidurals and one lung ventilation. We have Consultant of the day shifts (‘C1/2’) that trainees can run. This involves liaising with the critical care team, meeting with surgeons to decide which operations requiring critical care can proceed and supervising junior trainees running the emergency list. It’s busy and stressful but great experience. Emergency work in our department is busy and the patient population has significant comorbidities. We would expect trainees completing this rotation to experience the perioperative care of their patients by attending MDT, pre-operative assessment clinic and reviewing their patient on the critical care unit located only across the corridor. We have an active research team and potential QI projects are varied; we encourage trainees to complete a project that they are interested in. Previous work includes rectus sheath catheter use, intrathecal diamorphine and pre- operative anaemia. We are active with NELA which is a constant source of QI work. The focus is on producing trainees that can work with the surgical team in deciding the best plan for a patient being considered for high risk surgeries and can then safety anaesthetise patients having major cancer resections. We expect trainees to be able to risk assess patients for urgent laparotomies and safely deliver anaesthetic care, whilst liaising with critical care colleagues and supervising more junior trainees.

Arrowe Park Hospital

Contact: Dr Martin Kelly (martin.kelly6@nhs.net)

Module Details: Wirral University Teaching Hospital is an efficient trust for Major Surgery and delivers care in line with ACSA standards in a friendly positive environment. We can offer a broad range of surgical specialities, each offering a major caseload. We have Gynaecology, Urology, Colorectal, ENT, Upper GI and we are also a tertiary referral centre for complex hernia repairs. We have two robots within the Trust and there is at least one robotic case each day. Regular robotic cases include: prostatectomies, cystectomies, partial nephrectomies, anterior resections/APRs, complex hernia repairs and hysterectomies. The Trust is one of the two largest urology cancer centres in the Northwest. Anaesthesia for Major General Surgery could be completed together with our Peri-operative Medicine SIA, with time in pre-op clinics. This will give understanding of how to assess, optimise, give information, discuss risk, and reach shared decisions with our patients. Post-operative pain rounds can be attended, and patients can be followed up in post-operative critical care. We also offer pre-habilitation for our major cancer work. A variety of pain and anaesthetic techniques are employed by WUTH consultant anaesthetists including: conventional pump and volatile based anaesthetics +/- diamorphine spinals, occasional epidurals for major open work, opioid free volatile anaesthesia, opioid free TIVA, lidocaine infusions, rectus sheath catheters and various other regional techniques. Surgery School could also be attended. We also have a busy emergency theatre with a mixed major caseload and being one of a few Trusts in the northwest doing big numbers of emergency laparotomies. We will provide the opportunity to act up as a consultant for day-time emergency theatre work. We will also support trainees with the development of their generic competencies, whilst providing audit and QI projects and management and other opportunities that will be helpful for the transition to becoming a consultant. On-calls could be limited to just general theatres if preferred.

Warrington Hospital

Contact: Dr Zoe Apple (zoe.apple@nhs.net)

Module Details: Warrington Hospital provides comprehensive experience in the management of elective major colorectal and urological procedures, including laparoscopic and open bowel resections and nephrectomies. A typical week in Warrington elective theatres includes three major colorectal operating lists, two nephrectomies and also a range of thyroid procedures, through which trainees can gain extensive experience in the management of major general surgical procedures. The major general surgery module would be supervised by a small group of Consultants, with a special interest in this area. The aim is for stage three trainees at Warrington is to develop their skills and become confident in the independent management of these cases. Involvement in the entire perioperative process from MDT discussion, preoperative risk assessment and optimisation through to postoperative review is encouraged and would be part of the role for Stage 3 trainees. The use of TIVA, and multimodal analgesic regimens including intrathecal diamorphine and regional techniques is standard practice and cardiac output monitoring (LiDCO and oesophageal doppler) is routine in more complex cases. The emergency theatre at Warrington has a busy and challenging workload, with a high complexity of medical issues amongst our patient population. Stage three training would include an opportunity to ‘act- up’ as the Consultant on call during the daytime for the emergency list with support available as required. Warrington has established prehabilitation and enhanced recovery programmes for colorectal surgery and there is extensive scope for developing these services further as part of a quality improvement programme. We actively participate in a number of national perioperative projects (including PQIP and NELA data collection) and would expect trainees to be involved with and lead these processes. As well as leadership experience in the clinical domain, non-clinical leadership and management opportunities can be accessed, for example participation in governance meetings, and interaction with the executive team through attendance at medical cabinet meetings.