winchesteryear3 surgery 2012 2013

Winchester Surgery Attachment: 3rd year 1

Course Book

Surgery Attachment

Edition 1.0

Royal Hampshire County Hospital, Winchester

BM 3rd Year 2012 / 2013

Student name: ………………………………………………………................... Consultant (s) for major GI block: ……………………………………………….


THIRD YEAR SURGERY ATTACHMENT

WELCOME TO SURGERY

Course Coordinator: Mr D M Gore [email protected] Ext 5057 Course Administrator: Ms Fiona Holloway [email protected] Ext 5432 Clinical Skills: Ms Claire Townsend [email protected] Ext 4870 Southampton Marie Marshall Attachment Administrator: [email protected] Tel: 023 8079 6145


Introduction

Welcome to the 3rd year Surgery Attachment at Winchester. This booklet will help you get the

most out of your attachment so please read it. Your Surgery Attachment consists of one four

week block of GI Surgery, and one four week block of Combined Specialities (Urology, Breast

Surgery, Vascular Surgery and Accident and Emergency Medicine). These blocks take place

before, after or around the four week Obstetrics and Gynaecology block.

General Advice Regarding This Surgical Attachment The Royal Hampshire County Hospital may not be a teaching hospital in the traditional sense

but it is certainly a learning hospital. It is busy and you now have the opportunity to get stuck in

and enjoy this great clinical experience. This attachment has been designed to allow you as

much time with patients as possible, and correspondingly you must utilise every learning

opportunity. The word clinical comes straight from the ancient Greek κλινη meaning bed, and

it is at the bedside you learn your medicine and surgery. The more closely you follow the

surgical teams, the more you will become part of that team and the more you will learn. Do not

expect to be spoon-fed with formal teaching sessions but do expect to have your questions

answered in clinics, theatre and ward rounds.

The prospect of taking a history from a sick patient may be daunting, but remember that most

patients are fed up with being in hospital and they are usually quite happy to answer your

questions. Indeed most patients recognise the importance of medical training and are willing to

be examined by a student. It goes without saying that you should acknowledge this privilege by

expressing your gratitude.

Each patient is on a journey through their episode of ill health. The more that you see of each

patient’s journey, the more you will understand about the patient and his/her background, the

disease, the investigations and the treatments. Therefore if you are attending a theatre session,

take time to find out what patients are on the list and get to speak to them beforehand. Likewise

take the trouble to follow their progress post-operatively.

Knowledge of surgical pathology is an essential foundation for your learning, and in particular

you should ensure you are familiar with the natural history of surgical disease (the progress of

that disease untreated). Pathology teaching takes place every Tuesday at 1030 in the Post

Mortem Room, Brinton Wing. This is a valuable learning opportunity.

I.D. BADGES All Medical Students are required to wear their ‘Southampton University Medical Student’ photo ID badge at all times. To maintain a high standard of infection control the Trust has a policy of bare below elbows (allowing a plain wedding band as the only jewellery) when working in all clinical areas.


The GI Surgery Block

During this attachment you will have four continuous weeks with one GI surgical firm (Colorectal

or Upper GI Surgery). The curriculum has been redesigned to ensure that from Monday to

Thursday you are not distracted by skills sessions or other obligations, and correspondingly you

are expected to be present as part of the team during this block.

Activities on a surgical firm break down into the following:

assessment of new patients (clerking) on the ward or in the Accident and Emergency

department

taking part in ward rounds which usually focus on ongoing evaluation and treatment of

patients known to the team

outpatient clinics in which new and follow-up patients are assessed

special investigations including GI endoscopy (OGD, flexible sigmoidoscopy and

colonoscopy) and imaging (plain radiographs, ultrasound, CT and MR scanning)

anaesthesia and airway management

operating

clinical meetings including multidisciplinary team meetings (MDTMs)

During the GI surgical block you have the opportunity to participate in all of these and you must

make it your business to do so. Your primary obligation is to learn how to take a history,

perform an examination and present the symptoms and signs to a doctor in a coherent manner.

It follows that the more time you spend in the clinical assessment of patients, the better.

Try to see as many of the core GI surgical pathologies as possible (see below). You must make

sure you acquire the following skills:

taking a history with emphasis on GI symptoms

examination of the abdomen (in the elective setting such as in outpatients)

examination of the acute abdomen (when a presents non-electively with abdominal

symptoms and signs)

PR (anorectal) examination

Examination for groin swellings including hernia

Clinical timetables can vary so you must find out from the teams when these sessions take

place and what sessions are best for your learning. The F1 doctors are closest to the ward

patients, but any member of the team should be able to advise you.


The Combined Specialities Block

You will spend four weeks addressing different surgical specialities. Two weeks on a Urology

firm, then two weeks in Breast Surgery with sessional attachment to Vascular Surgery. The

time available for each is relatively short, so you must indeed utilise every learning opportunity.

This block has been designed to allow you to learn history taking and examination skills relevant

to these important specialities; you may not see all the core surgical pathologies (see below) but

you should address the following skills:

taking a history with emphasis on urological symptoms

palpation of the prostate gland at PR examination

examination of the male external genitalia

understanding dipstick urinalysis

taking a history in the context of breast cancer

breast examination

taking a history in the context of peripheral vascular disease

examination of peripheral pulses in the lower limbs

examination of the abdomen for aortic aneurysm

Formal Evaluation of Your Learning During your GI surgical block attachment you must complete two pink assessment forms with

different consultants, one from your GI attachment and one from either one of the combined

specialities attachments. You must be prepared to arrange this well in advance so that you can

get this done before your attachment ends. Please collect your pink forms from Fiona Holloway

in the Administration office Education Centre RHCH 01962 825432. There is also an end of

attachment evaluation form which must also be completed and this is also obtained from Fiona

Holloway. Once all forms are completed they must be returned to Fiona. The originals will be

forwarded to School of Medicine and a copy will be kept on file at RHCH.

Log Book Please get them signed by a senior team member (ST3 or above). These are an integral part of

your end of placement assessment and if not completed may affect your final grade for this

attachment. On completion these books must be submitted to Fiona Holloway to have your

progress recorded. The log book will then be returned to you for your own records.

Winchester 3rd year Surgery Student Attachment 6

Surgical Pathology: Required Knowledge for Medical Undergraduates You will not see all these conditions, but you must have read about them and so be

knowledgeable about them. Do not expect the formal teaching sessions to cover all, or nearly

all, of these.

GI surgery Pathologies which can manifest as an acute abdomen are in italics

Pathophysiology of abdominal pain: • Somatic and autonomic innervation pathways • Pain of peritoneal inflammation/irritation and pain of colic Elective surgical assessment of the abdomen Evaluation of the acute abdomen Oesophageal cancer Oesophageal Varices and portal hypertension Hiatus hernia Gastric cancer Peptic Ulceration including Helicobacter Pylori and NSAIDs Perforation of peptic ulcer Gastric outlet obstruction, benign and malignant Acute upper GI bleeding Indications for and variants of bariatric surgery (for obesity)

Gallbladder and gallstone disease: Biliary colic Cholecystitis Mucocoele of the gallbladder Choledocholithiasis Surgical (extrahepatic) jaundice Cholangitis Pancreatitis

Pancreatitis, acute and chronic Pancreatic cancer


Indications for splenectomy

Small bowel obstruction Paralytic ileus Crohn’s disease and terminal / regional ileitis Meckel’s diverticulum Mesenteric infarction: embolus and thrombosis Carcinoid tumours

Appendicitis

Large bowel obstruction Colorectal cancer = “bowel cancer” = cancer of colon, cancer of rectum Colorectal adenoma Colonic diverticulosis Colonic diverticulitis (complicated and uncomplicated) Irritable bowel syndrome and functional bowel disorder Colitis: infective including C Difficile and norovirus Ulcerative Crohn’s and indeterminate colitis Acute fulminant colitis and toxic megacolon Ischaemic colitis Acute lower GI bleeding Stomas: ileostomy and colostomy Anal fissure Haemorrhoids Perianal sepsis and anal fistula Pilonidal sepsis

Peritonitis presenting as the acute abdomen: differential diagnosis

Abdominal abscess presenting as the acute abdomen: differential diagnosis


Gynaecological Pathologies Presenting in the Acute Abdomen Ectopic pregnancy Miscarriage and threatened abortion Acute pelvic inflammatory disease (salpingitis) Ovarian and adnexal torsion Rupture of endometrioma Rupture of functional (physiological) ovarian cyst Abdominal wall hernia Groin: Inguinal Femoral Obturator Ventral: Epigastric Para-umbilical Incisional

Urology Renal cell cancer Bladder cancer Prostate cancer Testicular cancer Bladder outlet obstruction and urinary retention Benign Prostatic Hyperplasia Scrotal lumps and bumps Investigation of Haematuria Stones: renal, ureteric and bladder calculus Testicular torsion and urological trauma

Vascular Peripheral Vascular Disease Lower Limb Amputation Carotid Artery Disease, Stroke and TIA Abdominal Aortic (And Other) Aneurysm Varicose Veins and Venous Hypertension

Breast Breast cancer Breast cancer: triple assessment Breast cancer screening

Head and neck Goitre Thyroid and parathyroid neoplasia Salivary gland tumours


Recommended Resources There are many resources available in local libraries and elsewhere. Some aim to teach clinical

method as well as surgical pathology, and are particularly accessible and relevant. Many are

exhaustive surgical references and I have listed these at the end. Please do not be deterred

from consulting resources outwith these lists.

Podcast: Surgery 101 (available free from iTunes) This excellent series of podcasts is a great reference for the all the surgical pathology you will need. They are put together by the University of Alberta. Highly recommended!

www.wessexcolorectalclinic.com Go to the Patient Information tabs to read the patient information sheets – you should have a firm grasp of all the concepts described. The Patient Journey tab has some useful links to Enhanced Recovery resources. The Training tab links to YouTube with many laparoscopic colorectal operation movies (edited to about 10 minutes!). These will help you make sense of what you see in theatre.

Lecture Notes: General Surgery Ellis, Calne, Watson 11th Edition 2006: Blackwell Publishing This is aimed at medical students so well pitched in terms of detail. Compact, very readable and reliable: highly recommended it is probably the most suitable single text for covering the undergraduate curriculum. There are very few illustrations, just line drawings.

Clinical method with surgical pathology:

Browses’ Introduction to the Symptoms and Signs of Surgical Disease Browse NL, Black J, Burnand KG, Thomas WEG 4th Edition 2005: Hodder Arnold A clinical classic for proper clinical method. Great Chapter 15: The Abdomen.

Cope’s Early Diagnosis of the Acute Abdomen Zachary Cope: revised by William Silen 22nd Edition 2009: Oxford University Press. A masterly monograph considered unbeatable for learning the art of assessing the acute abdomen.

Hamilton Bailey’s Demonstration of Physical Signs in Clinical Surgery Edited by JSP Lumley 18th Edition 1997: Butterworth Heinemann. Comprehensive surgical reference books: A treasure trove of clinical wisdom. Full of

images and diagrams relating to surgical pathology of the abdomen and other systems.

Surgery at a Glance Grace PA, Borley NR 4th Edition, Wiley Blackwell An excellent and concise tour around clinical presentations and their differential diagnoses, then surgical pathologies and their key features. Well pitched for undergraduates.


Principles and Practice of Surgery Garden, Bradbury, Forsythe, Parks 5th Edition 2007: Churchill Livingstone Aimed at medical students and FY1. Well illustrated. Good overview of surgery with abdominal focus. Chapter 8 is useful: Principles of the Surgical Management of Cancer. Comprehensive organ and system-specific pathology chapters.

Essential Surgery Burkitt HG, Quick CRG, Reed JB 4th Edition 2007: Churchill Livingstone. Suitable for both undergraduate and postgraduate students of surgery, and as such probably best for undergraduates to dip into now and again. Wonderful images.

Clinical Surgery Cuschieri A, Grace PA, Darzi A, Borley N, Rowley D 2nd Edition 2003: Blackwell Comprehensive with useful “at a glance” sections in each chapter.

Bailey and Love’s Short Practice of Surgery Editors: Williams NS, Bulstrode CJK, O’Connell PR 25th Edition: Hodder Arnold This is the big daddy of comprehensive textbooks and covers all kinds of surgery. From an undergraduate perspective it is one to dip into, not least to benefit from the wonderful anecdote, eponymous biographies and history which mark it out from the rest. Single Best Answers for Surgery Patten DK, Layfield D, Arya S, Leff DR, Paraskevas PA, Darzi A 1st edition 2009: Hodder Arnold An excellent and challenging test of your surgical knowledge, authored by one of our local core trainees. In the library.


COLORECTAL WEEKLY TIMETABLE

Monday

Tuesday

Wednesday

Thursday

Friday

AM 08.00 Ward Round KW 10.00 Business Meeting 10.30 Grand Ward Round (Orthopaedic Seminar Room, Bartlett / St Cross (C983ZY)

08.00 Ward Round KW 09.00 Theatre 2 09.00 OSFSC+OPC 10.30 Autopsy Teaching

08.00 Ward Round KW 09.00 OPC 0900 OSFSC

08.00 Ward Round KW 09.00 Theatre 2 (alternate weeks) 09.00 Endoscopy

08.00 MDT Meeting (Xray Seminar Room) 09.00 Theatre 2 09.30: Ward Round

Lunch 13.00 PM 14.00

DSU/Endoscopy (alternate weeks)

14.00 OPC Follow-up 14.00 Theatre 2

14.00 DSU 14.00 OPC Follow-up

14.00 Endoscopy

13.30 Theatre 2

Key: • MDT – Multi-disciplinary team • OPC – Outpatient Clinic, Lower Outpatients • OSFSC – One-stop Flexible Sigmoidoscopy Clinic (Endoscopy Unit, Treatment Centre) • KW – Kemp Welch Ward • DSU: Day Surgery Unit, Treatment Centre Other: • FY1 Bleep: 292 and 061, • Core Trainee (SHO) 298 • Speciality Trainee (Registrar) 454 • To bleep: 369 – bleep number – Ext number - ## Colorectal Surgery (Mr Miles, Mr Gore, Mr Shata, Mr Moore): bowel cancer, diverticular

disease, inflammatory bowel disease, benign anal disease

• New patient clinics Tuesday and Wednesday 9am in Treatment Centre Endoscopy Unit,

and usually also concurrently in Lower Outpatients

• Operating all day Tuesday, Thursday and Friday (Nightingale Theatre 2)

• Colorectal Cancer MDT meeting Friday 8am (Radiology Seminar Room)

• FY1 bleep 061 and 292


UPPER GI WEEKLY TIMETABLE

UPPER GI TEAM TIMETABLE Monday Tuesday Wednesday Thursday Friday

AM

Ward round (08.00 KW)

Theatre list

(Nightingale)


Theatre list

(TC)



OGD list

(endoscopy)


Theatre list

(Nightingale)

Theatre list (TC)

PM

OPC

(outpatients)

Theatre list

(TC)

OGD list (endoscopy)

OPC

(outpatients)

Theatre list

(TC)

Theatre list

(TC)

Upper GI Surgery (Mr Wakefield, Mr Hou, Mr Szentpali): gallstone disease, surgical jaundice,

groin (inguinal) hernia, cutaneous lumps and bumps.

• New patient clinics Monday 2pm Lower Outpatients

• Operating all day Tuesday and Friday (Treatment Centre Theatre A)

• Upper GI Cancer MDT meeting Monday 8am (Radiology Seminar Room)

• FY1 bleep 296


UROLOGY WEEKLY TIMETABLE Monday

Week 1: Introduction Week 2: Renal & Prostate Ca.

Tuesday Week 1: Bladder Outlet Obstruction/BPH Week 2: Scrotal lumps & bumps

Wednesday Week 1: Haematuria Week 2: Bladder & testes cancer

Thursday Week 1: Stones Week 2: Trauma/Emergencies

Friday

AM 08.00 Ward Round KW 09.00 Theatre 1 (AA) 09.00 Men’s Health Clinic (DM, RR every 2/52) 09.00 flexible cystoscopy (Endoscopy) 09.00 TWOC Clinic (DAL)

08.00 Ward Round KW 09.00 Theatre 1 (RR) 09.00 OPC (AA) 09.00 Urodynamics (The Mount, Tina)

08.00 Ward Round KW 09.00 TC Theatre A (RR) 09.00 Haematuria Clinic (USN) 09:00 Theatre 1 (DM)

08.00 Ward Round KW 09.00 TC Theatre B (AA) 09.00 Theatre 1 or Radiology (RR) 09.00 Haematuria Clinic (USN) 09.00 Pre-assessment (The Mount, FY1 & USN)

08.00 Discharge Meeting (Costa Coffee) 08.30 Grand Ward Round 09.00 OPC (AA, RR, DM, EC) 09.00 TRUS & Bx (DM alt. weeks)

Lunch 12.30 MDT (RSM)

PM 14.00 OPC 12.30 TC Theatre B (DM)

13.30 Theatre 1 (DM)

14.00 Ward Clerking 14.00 Andover Clinic

14.00 Ward Clerking

Key: • AA – Mr Adamson • RR – Mr Rees • DM – Mr Mclean • EC – Mr Chedgy • DAL – Discharge & Admissions lounge • MDT – Multi-disciplinary team • OPC – Outpatient Clinic • KW – Kemp Welch Ward • TC – Treatment Centre • TWOC – Trial without catheter • USN – Urology Specialist Nurse • RSM – Radiology Seminar Room Other: FY1 Bleep: 294: To bleep: 369 – bleep number – Ext number - ## Urology (Mr Adamson, Mr Rees, Mr McLean): for examination of the male genitalia, benign

prostatic hyperplasia, calculus, prostate and bladder cancer

• General Urology clinics including new patients Monday 2pm, Friday 0930 in Lower

Outpatients.


• Haematuria one-stop clinics run on Wednesday and Thursday 1130 AM (Endoscopy

Room 1, Treatment Centre)

• Operating Monday AM, Tuesday AM+PM, Wednesday AM+PM and Thursday AM in

Nightingale Theatres

• Operating Tuesday PM , Wednesday AM, Thursday AM in the Treatment Centre (TC)

• Urology Multi-Disciplinary Team Meeting (MDTM) for urological cancer: Radiology

Seminar room 1230 Monday

• Men’s Health Clinic: 0900 Monday, Dept of Sexual Health

• Urodynamics: Tuesday PM, Mount Ward


VASCULAR WEEKLY TIMETABLE

Monday Week 1: Introduction

Tuesday Week 1: Hx/Exam of peripheral vascular system Week 2: Arterial limb ischaemia

Wednesday Week 1: Varicose veins Week 2: Abdominal aortic aneurysms

Thursday Week 1: Gangrene and Amputations Week 2: Conditions involving the spleen

Friday Week 1: Thomboembolic disease Week 2: Carotid disease

AM 08.00 Theatre (Southampton)

08.00 Ward Round KW

09.00 Vascular clinic 2 students

08.00 Vascular radiology meeting XRay Seminar 09.00 Consultant WR 10.00-12.00 Paeds clinic (alternate weeks) All day: Interventional Radiology (Dr Page)

08.00 MDT meeting (Southampton)

Lunch PM 14.00 Theatre

(Southampton) 14.00 AWMH /

Paed Day case theatre (alternate)

Interventional Radiology (Dr Page)

14.00 Day theatre (TC) (alternate)

Team Mr N Wilson – ext ST bleep 289 CT/SHO bleep 293 To bleep: 369 – bleep number – Ext number - ## Key MDT – Multi-disciplinary team OPC – Outpatient Clinic KW – Kemp Welch Ward TC – Treatment Centre


BREAST SURGERY WEEKLY TIMETABLE

Monday Tuesday Wednesday Thursday Friday AM

07.30 Theatre (alt weeks only, RMR) 09.00 New referral clinic (NP,PA) 09.00 Breast screening (PA)

08.00 Ward Round ATL 09.00 Pre-assessment (The Mount, FY1) 09.00 Breast screening (PA)

07.30 Theatre (alt weeks, RMR) 09.00 Follow up clinic (SL) 09.00 New referral clinic (alt weeks only, NP)

08.00 MDT (Education Centre) 09.00 Follow up clinic (RMR) 09.00 New referral clinic (NP) 09.00 Breast screening (PA)

08.00 Ward Round ATL 08.00 Theatre (alt weeks, SL) 09.00 Follow up clinic (RMR/SL)

PM 14.00 Theatre (SL, once a month)

All day theatre (RMR)

14.00 Theatre (SL/NP/RMR)

All day theatre (alt weeks, SL)

Key: ATL Anthony Letchworth Ward RMR Mr Rainsbury SL Miss Laws PP Miss Paramanathan PA Dr Alleyne Topics: • Breast Cancer • Benign breast disease • Breast examination • Breast triple assessment • Breaking bad news • Multi-disciplinary team working • Endocrine (thyroid/parathyroid) Other: SHO bleep: 427 SpR bleep: 288 All clinics are run in Florence Portal House

Breast Surgery (Mr Rainsbury, Miss Laws, Miss Paramanathan): breast cancer and breast

examination. One student per doctor in clinic and examinations. Make sure you attend both

new patient clinics and one “breaking bad news” clinic. All Clinics are in Florence Portal House

(Clinics run in Andover and are available for teaching also).

• New patient clinics

o Monday 0900: Miss Paramanathan


o Tuesday 0900: Dr Anderson, Miss Paramanathan

o Wednesday 1400: Miss Paramananathan (alternate weeks)

o Thursday 0900: Miss Paramanathan

o Friday 0900: Mr Rainsbury / Miss Laws

• Follow-up clinic (breaking bad news)

o Wednesday 0900: Miss Laws

o Thursday 0900: Mr Rainsbury

• Breast screening

o Monday 0900: Dr Alleyne

o Tuesday 0900: Dr Alleyne

o Thursday 0900: Dr Alleyne

o Monday 2pm in Florence Portal House

• Pre-admission Clinic Tuesday 9am Pre-Admission Clinic, Mount Ward

• Operating Wednesdays all day, Thursday 2pm in Florence Portal House

• Breast Cancer MDT meeting Education Centre Room 4 Thursday 0800

• Breast SHO grade 427

In addition to the inpatient surgical services above, you should be familiar with the range of

anaesthetic interventions commonly used on surgical patients. Most of our patients have an

anaesthetic experience, and anaesthetists are usually very happy to teach. Do not miss out on

this valuable resource.

Furthermore there are several clinical and diagnostic services which will accommodate medical

students on a sessional basis:

• Radiology: ensure you are familiar with the common modalities used in evaluation of

abdominal pathology, namely ultrasound and CT scanning. Moreover make sure you are aware

of the imaging modalities used for breast cancer evaluation.

• Endoscopy: you should be familiar with OGD (oesophagogastrodudenoscopy), flexible

sigmoidoscopy, colonoscopy and flexible cystoscopy and the demands these studies place on

patients, in particular with regard to oral mechanical bowel preparation in the case of

colonoscopy.

If you have any particular questions, please get in touch via Claire Townsend 01962 824870,

Medical Education Co-ordinator at the Education Centre.

D M GORE AUGUST 2012


Cancer epidemiology

In 2009 more than 320 000 people were diagnosed with cancer in the UK. In 2010 more than

157 000 people died of cancer. Please make yourself familiar with the following data from

Cancer Research UK, and do use the Cancer Research UK web pages.

Most cancers are carcinomas (cancers of epithelial origin), the exceptions being leukaemia and

lymphomas. While common, non-melanoma skin cancer is not considered in these statistics.

This category consists almost wholly of basal cell carcinoma which does not spread other than

by direct invasion, has a very low mortality rate, is often managed in a community setting and is

incompletely reported.


10 Most Commonly Diagnosed Cancers: 2009

Numbers of New Cases, Males, UK

Cancer Sites Cases

Percentage of all cancer cases excl NMSC

Deaths 2010 % Mortality

Prostate 40841 25.2% 10271 25

Lung 23041 14.2% 19410 84

Bowel* 22711 14.0% 8705 38

Bladder 7632 4.7% 3294 43

Non-Hodgkin Lymphoma 6614 4.1% 2402 36

Kidney 5706 3.5% 2451 43

Malignant Melanoma 5668 3.5%

Oesophagus 5418 3.3% 5105 94

Stomach 4880 3.0% 3102 64

Leukaemia 4844 3.0% 2526 52

Other Sites** 34942 21.5%


10 Most Commonly Diagnosed Cancers: 2009

Numbers of New Cases, Females, UK

Cancer Sites Cases Percentage of all cancer cases excl NMSC Deaths %

Mortality

Breast 48417 30.6% 11556 24

Bowel* 18431 11.7% 7308 40

Lung 18387 11.6% 15449 84

Uterus 7835 5.0% 1937 25

Ovary 6955 4.4% 4295 62

Malignant Melanoma 6209 3.9% Non-Hodgkin Lymphoma 5680 3.6%

Pancreas 4232 2.7% 4029 95

Kidney 3580 2.3%

Leukaemia 3458 2.2%

Other Sites** 34986 22.1% *Bowel including anus (C18-C21) **4% of all female cases are registered without specification of the primary site

*Bowel including anus (C18-C21)

winchesteryear3 surgery 2012 2013

Documents

winchester surgery attachment

surgical attachment

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week block of gi surgery

learning hospital

teaching hospital