EssentialsClinicalPearls

Chapter5:PreopCareandRiskAssessment
TheAmericanSocietyofAnesthesiologyclassesare
ClassIHealthypatient:limitedprocedure
ClassIIMildtomoderatesystemicdisturbance
ClassIIISeveresystemicdisturbance
ClassIVLifethreateningdisturbance
ClassVNotexpectedtosurvive,withorwithoutsurgery
Predictorsofcardiacriskinsurgicalpatientsincludethefollowing:
Majorpredictors
Unstablecoronarysyndromes
Recentmyocardialinfarctionwithevidenceofimportantischemicriskbyclinicalsymptoms
ornoninvasivestudy
Unstableorsevereangina
Decompensatedcongestiveheartfailure
Significantarrhythmias
Highgradeatrioventricularblock
Symptomaticventriculararrhythmiasinthepresenceofunderlyingheartdisease
Supraventriculararrhythmiaswithuncontrolledventricularrate
Severevalvulardisease

Intermediatepredictors
Mildanginapectoris(CanadianclassIorII)
PriormyocardialinfarctionbyhistoryorpathologicQwaves
Compensatedorpriorcongestiveheartfailure
Diabetesmellitus

Minorpredictors
Advancedage,abnormalECG(leftventricularhypertrophy,leftbundlebranchblock,STT
abnormalities),rhythmotherthansinus(e.g.,atrialfibrillation),lossfunctionalcapacity(e.g.,
inabilitytoclimboneflightofstairswithabagofgroceries)
Historyofstroke
Uncontrolledsystemichypertension

Preoperativeindicatorsformalnutrition:
Anorexia,dysphagia
Recentweightloss
Recurrentnausea,vomiting,ordiarrhea
Malignancy(renal,liver,lung)
Gastrointestinaldisorders(inflammatoryboweldisease,pancreatitis,fistulas)
Drugdependency(i.e.,alcoholism,illegalorprescriptiondrugs)
Dentaldifficulties
Impoverishedsocialstatus(homeless,disabledorelderlyindividualslivingalone)

Clinicalriskfactorsforperioperativedeepveinthrombosis:
Olderthan40years
Prolongedimmobility/paralysis
PriorDVT
Cancer
Majorsurgery(pelvic,abdomen)
Obesity
Varicoseveins
Congestiveheartfailure
Myocardialinfarction
Stroke
Fracturesofthepelvis,leg,hip
Indwellingfemoralveincatheters
Inflammatoryboweldisease
Nephroticsyndrome
Estrogenuse
Hypercoagulablestates

Chapter6:FluidandElectrolyteManagement
Themostcommoncauseofmetabolicalkalosisinsurgicalpatientsisnasogastriclossesorvomiting.
Theperitonealsurfacesrepresent50%ofbodysurfacearea.

Duringlaparotomy,theexpectedevaporativefluidlossfromtheexposedperitoneumis10mL/kg/hr.

Hyperphosphatemiamayresultfromrhabdomyolysisduetomuscleischemiaorcrushinjury.

Thestressresponsetosurgeryresultsinthereleaseofglucagon,aldosterone,cortisol,andantidiuretic
hormone.

Tonicityratherthanosmolaritydetermineswatermovement.
Sodiumdeterminesvolume,osmolarity,andtonicityofextracellularfluid.

Rapidcorrectionofhyponatremiamaycausecentralpontinemyelinolysis.

Hypomagnesemiamaycausehypokalemia,hypophosphatemia,andhypocalcemia.

Averylowurinarychlorideconcentrationisagoodindicatorofextracellularfluidcontractionfromvomitingor
nasogastriclosses.
Causesofmetabolicalkalosiscanbedividedintothosethatareresponsivetochlorideandthosethatare
unresponsive(Table66).Patientswithchlorideresponsivemetabolicalkalosisusuallyhaveacontracted
extracellularvolumeandchloridedeficit,andaurinarychloridethatislessthan10mEq/L.Vomitingandhigh
nasogastricoutputsarecommoncauses.Thevolumedeficitstimulatessodiumretention.Thepassively
absorbedsodiumintheproximaltubulerequiresanaccompanyinganion.Becauseadeficitofchlorideexists,the
anionavailabletomeetthisneedisbicarbonate.Inlatestagesofseverecontractionalkalosis,hydrogenis
exchangedforsodium,despiteplasmaalkalemia(paradoxicalaciduria).


Chapter7:NutritioninSurgicalPatients
Alwaysperformanutritionalassessmentforeachpatient.
generalcondition,anyfatigue,andtheabilitytoworkandcarryoutdailyactivities.Akeyelementisahistoryof
alteredorpoororalintake,lookingforbothpoormacronutrientandmicronutrientconsumption.Patientswith
gastrointestinalsymptomssuchasanorexia,nausea,vomiting,ordiarrheaformorethana2weekperiodwill
oftenhaveassociatedmalnutrition.Ahistoryofpoorwoundhealingisaconcern.Recentunexpectedweightloss
isveryimportant,andaweightlossof10%orgreaterrepresentsmalnutrition.Onexamination,thepatientmay
havetemporalandinterdigitalwasting.Thepresenceofascitesandankleedemaisseenwithmalnutrition,
particularlyprotein
boththediseaseandthesurgicalproceduredecreasethealbuminbecauseofleakingofalbuminfromthe
vascularspaceandrelativedecreasesinalbuminproduction,makingtheserumalbuminanunreliablenutritional
measure.

Clinicalassessmentisthebesttool.
Themetabolicresponsetosurgeryproducesbothcalorieandproteinmalnutrition,termedmarasmus.Injuryfrom
eithersurgery,trauma,orcomplicationssuchassepsisproducesawelldefinedmetabolicchangeinthehost.
Thecharacteristicsofthephenotypicchangeinclude(1)mobilizationofglucoseandthedevelopmentofperipheral
insulinresistance(2)proteincatabolismwithmobilizationofperipheralproteintosupporttheincreasedprotein
requirementsandtosupporthepaticgluconeogenesis(3)hypermetabolismwithanincreasedenergy
expenditureand(4)saltandwaterretentionwithanexpandingthirdspace.

Calculatethepatient'sfeedingweightandnutritionalrequirements.

Fortheaveragesurgicalpatient,proteinissetat1.5g/kg/daytotalcaloriesaresetat25cal/kg/day,
carbohydratesaresetat4mg/kg/min,andlipidsarenomorethan20%oftotalcalories.

Enteralnutritionaccessisthebestdeliverysystem.

Parenteralnutritioncanbeusedwithpatientswhocannotusethegastrointestinaltract,whoareseverely
malnourished,orhaveaseverediseaseorinjuryresultinginmalnutritionand/oradelayintheuseofthe
gastrointestinaltract.Usetransitionalfeedingfromparenteraltoenteralassoonaspossible.
Theuptakeofnutrientsfromtheintestinewillallowboththeliverandthepancreastocontrolthelevelsofglucose
andlipids,thusminimizinghyperglycemiaandhyperlipidemia.Inaddition,enteralfeedingreducesmucosal
atrophy,whichisthoughttobeassociatedwithtranslocationofbacteriaandtoxins.Enteralfeedingdecreases
enteralstasisandbacterialovergrowth,decreasesbiliarystasisandacalculouscholecystitis,anddecreases
gastricmucosalerosions.

Avoidtherefeedingandoverfeedingsyndromes.
Withtheintracellularglucoseuptake,amassiveandrapidshiftoccursoftheextracellularelectrolytesintothecell,
repletingthelowlevelsofpotassium,phosphorus,magnesium,andmanganese.Theconsequenceisserious
extracellularelectrolyteabnormalities,resultinginarrhythmiasandcardiacdysfunctionandfailure.Inaddition,the
relativelylowsodiumandaccompanyinganemiawillresultinrenalretentionoffluidandsodium,addingtothe
syndromeproducingcongestiveheartfailure
Otherproteinswillbeglycosylatedandbecomedysfunctional,suchascellsurfacereceptorsonmacrophages,
neutrophils,andlymphocytes,andtheimmunoglobulins.Hyperglycemia,usuallygreaterthan220mg/dL,results
inimmunosuppressionbothatthecellularandhumorallevel,witharesultantincreaseininfections.
ThehyperlipidemiaincreaseslipiduptakebytheRESsystemanddecreasesbacteriaandendotoxinclearanceby
theRES.Thebloodviscositywillincrease,withmicrovascularsludgingdecreasingflow.

Nutritionalsupportisdynamic.Changeitwithchangesinthepatient'sclinicalstate.


Thedegreeofobesityismeasuredbyusingthebodymassindex(BMI).

PatientswithaBMIgreaterthan35andlifethreateningcomorbiditiesandthosewithaBMIgreaterthan40
areconsideredforsurgery,onlyafteracompleteandcomplexpreoperativeworkup.

Thestandardbariatricoperationisagastricbypass.GastricbandingmaybeconsideredforlowerBMIs,and
abiliopancreaticprocedure,forgreaterBMIs.

Longtermclosefollowupisrequiredmonitoringfornutritional,psychological,andsurgicalcomplications.

Alwaysknowthepatient'snutritionalstategoingintosurgery.
Stopbothenteralandparenteralnutritionalsupportwhengoingtosurgery.Withparenteralnutrition,avoid
relativehypoglycemiawhenstoppingtheinfusionbeforesurgery.Use10%dextrosetocoverthepatient.

Decideonthepostoperativenutritionalstrategybeforesurgery.Ifyouthinkofit,dosomethingaboutit.

Considerenteralaccessandintestinalfunction.Gastrostomiesarepractical,butifconcernswithaspiration
arepresent,thenconsiderajejunostomy.Jejunostomyfeedingscanbestartedinthepostanesthesia
recoveryroom,providedthatthepatientishemodynamicallystable.Alwaysusealowratesuchas10
mL/hr.

Malnourishmentwillaffectthesurgicalapproach,includingwoundclosure.Securebothgastrostomiesand
jejunostomiestotheabdominalwall.Withascites,avoidgastrostomiesandjejunostomies,andconsider
usinganasoduodenalornasojejunalfeedingtubeiftheneedisfortheshortterm.

RestartPNwhenthepatientishemodynamicallystable,andmonitorforthesurgicalstressinduced
hyperglycemia.

Gastricbandingplacesanadjustablebandaroundthestomachjustbelowtheesophagogastricjunction,
creatingasmallgastricpouch.

Gastricbypasscreatesasmallisolatedgastricpouch,whichisanastomosedtoalimbofjejunum,eithera
shortlimbof100cmoralonglimbof150cmorgreater.Thebiliopancreaticlimbisanastomosedatthis
pointtocreatetheRouxenY.

Thebiliopancreaticoperationwithaduodenalswitchcreatesasleevegastricpouchof250mLanastomosed
afterthepylorustoalongalimentarylimb.Thebiliopancreaticlimbisanastomosedtothealimentarylimb,
leavingacommonchannelorlimbof100to150cmbeforetheileocecalvalve.

Chapter8:BloodandBleeding:Transfusions,Control,andPrevention
Fibrinogenlevels<100mg/dLprolongbleeding.
ThevitaminKdependentclottingfactorsareII,VII,IX,andX.

FFPorvitaminKreverseswarfarin(Coumadin).Protaminereversesheparin.

Bleedingpatientswhoseplateletshavebeenimpairedbyaspirinornonsteroidalantiinflammatorydrugs
mayneedplatelettransfusions,nomatterwhattheplateletcount.

Bleedingaftercardiopulmonarybypassmaybeduetoinadequateneutralizationofheparin.GivingFFPin
thissettingmayworsenthebleedingbecauseFFPprovidesantithrombinIII.

Microvascularbleedingoftenindicatesaplateletdefect.
Hypothermiaimpairsplateletfunctionandcanprolongbleeding.

Redbloodcellsthathavebeenwarmedto>40oCbeforeinfusionorareinfusedthroughlinescontaining
D5Warelikelytohemolyze.Bloodshouldneverbeinfusedwithmedicationsorwithanysolutionotherthan
saline.

Wounddrainagecontainsfibrinolyticsubstances.Redbloodcellsfromshedbloodusuallyshouldbe
washedbeforeuse.

Extensivetissueinjurymayresultinsignificantbloodlosswithoutobviousbleeding.Asingleinjurytothe
thighmayresultin2to3Lofbloodlossintothelargecrushedmusclemass.

Chapter9:WoundHealing
Cutaneoussuturesshouldberemovedwithin1weektoavoidrailroadtracks.
At1week,woundshave3%ofthestrengthofprewoundskin.

At3weeks,woundshave10%ofprewoundingstrength.

At6weeks,woundshave35%to50%ofprewoundingstrength.

Cleanwoundscanbeachievedbymeansofdressingchanges,waterirrigation,mechanicaldbridement,
anddetergents.

Hypertrophicscarsdevelopwithintheoriginalwoundmargins.Keloidsspreadbeyondtheoriginal
boundariesofthewound.

Inareaswhereskinisloose,woundcontractionmaycontribute90%ormoretothewoundhealingprocess.

Thethreephasesofwoundhealingareinflammation,proliferation,andremodeling.
PMNsarenotnecessaryforwoundhealing.

Woundsarefullyepithelializedafter24hourspatientsmaybatheafterthistime.

Woundsthataremoistepithelializemostquickly.Occlusivedressingsbestservethispurpose.

Factorsthatimpairhealingincludeaging,tissueischemia,malnutrition,edema,radiationtherapy,steroids,
collagenvasculardisease,anddiabetes

Ninetypercentofalllegulcersareduetovenousinsufficiency.


Intheabsenceofcellulitisorabscess,pressuresoresalmostnevercausebacteremiaandfever.

Chapter10:PreventionandManagementofSurgicalInfections
Antibioticprophylaxis:
NoneedforprophylacticantibioticsforclassIwoundsunlessaprosthesisistobeimplanted.Use
afirstgenerationcephalosporin
ClassIIcases:
Usefirstgenerationcephalosporinforelectivecholecystectomy.
Usefirstorsecondgenerationcephalosporinforacutecholecystitis.
Usefirstorsecondgenerationcephalosporinforgastricsurgery.

Useamechanicalpreparationwithoralantibiotics(erythromycinbase,neomycin)thenightbeforesurgery
andasecondgenerationcephalosporinthedayofsurgeryforcolonsurgery.

ClassIIIcases:trauma,perforatedbowel:secondgenerationcephalosporinorampicillin/gentamycin/flagyl

UsevancomycinonlyinpenicillinallergicpatientsorifmethicillinresistantStaphylococcusaureus(MRSA)
isdocumented.

Allantibioticsmustbegivenwithin1houroftheincision.

Didthepatientreceiveprophylacticantibioticbeforetheincisionwasmade?
Insofttissueinfections,dbridementmustextendtonormaltissues.

Keeptheskinopenincontaminatedcases(classes3and4).

Thesevenintraperitonealspaceswhereabscessescanform:
Rightgutter
Leftgutter
Rightsubphrenicspace
Subhepaticspace
Leftsubphrenicspace
PouchofDouglas
Interloopspace

Chapter11:Trauma

Increaseindiastolicpressureisthefirstbloodpressurechangeseeninhypovolemia.When
present,itmeansclassIIhemorrhagicshock(lossof15%30%ofbloodvolume).
SystolichypotensionisasignofclassIIIhemorrhagicshock(lossof30%40%ofbloodvolume).
Agitationisanothersignofshock.
ProfoundhypotensionandapathyaresignsofclassIVhypovolemicshock(lossof>40%ofblood
volume).
Anormal70kgmanhasapproximately5Lofbloodvolume(70mL/kg).
Decorticateposturingincludesflexionoftheupperextremity(thearmmakesaCforde
Corticate).

Decerebrateposturingincludesextensionandexternalrotationoftheupperextremity(thearm
makesanS,likethesoftcindeCerebrate).
ThesignsofpericardialtamponadeincludeBeck'striad(hypotension,JVD,muffledheartsounds),
tachycardia,pulsusparadoxus,andelevatedCVP.
Optionsformanagingsplenicruptureincludeobservation,embolization,splenorrhaphy,and
splenectomy.
Hemodynamicstabilityandevidenceofongoingbleedingarethemostimportantfactorsinchoosing
atreatmentstrategyforsolidorganinjury.
Airwayalwayscomesfirst.
Inpenetratingtrauma,mortalityisafunctionofvascularinjury.Addressthebleedingfirst.
Inblunttrauma,stoptheactivebleedingbyanymeanspractical,includingviaangioembolization,
packing,orrepair,beforeaddressinginjuriesthatarenotcontributingtobloodloss.
Whensolidorganbleedingiscontrollableonlybypacking,thenpack.
Cathetersplacedduringemergenciesshouldbereplacedwhentheemergencyhaspassed.

Chapter12:CriticalCare

Suddenonsetofadultrespiratorydistresssyndrome(ARDS)mayreflectpathologybelowthe
diaphragm.
ARDS=(Suddenonset)+(FiO2/PO2<300)+(Diffuseinfiltrate)+(NoCHF)
Weaningfromtheventilatorrequires
Adequatemechanicalrespiratoryfunction
Adequateventilation
Adequateoxygenation
Toworkupdelirium,rememberthemnemonicWWHHHIMP:Withdrawal,Wernicke's
encephalopathy,Hypoglycemia,Hypoxia,Hypertension,Intracerebralprocess,Meningitis,and
Poisons(drugs).
Catabolicpatientsrequire1.02g/kgofproteinperday.
Ifthegutworks,useit.

Chapter13:Burns

Tangentialexcisionisthepreferredmethod,removingthinlayersofescharuntilviabletissue,
characterizedbypunctatecapillarybleeding,isencountered.
Methodsforcoveringlargewoundsincludewidelymeshedskingrafts,temporarycoveragewith
cadaverallografts,syntheticskinsubstitutes,orculturedepidermalcells.
Infiltrationofburnwoundsorskingraftdonorsitesorbothwithsalinesolutioncontaining
epinephrinecanfacilitateexcisionorharvestandmarkedlyreducebleeding.
Deeppartialthicknessburnsshouldbetreatedwithexcisionandskingraftingtospeedhealing,
reducethepossibilityofinfection,andimprovetheultimatefunctionalandcosmeticresultforthe
patient.
Mortalityformajorburnsisnowlow.Ayoungadultwithburnsof80%to90%TBSAhasa50%
survival.
Smokeinhalationworsenssurvivalbecauseofpneumoniaandmultipleorganfailure.Threetypesof
inhalationinjuryarecarbonmonoxidepoisoning,upperairwayburns,andlowerairwaychemical
injury.
Estimateburnextentbyusingtheruleofnines:Head,arms:9%TBSAeachanteriortorso,
posteriortorso,eachleg:18%TBSAeach.Thepalmofthepatient'shandis1%TBSA.

Parklandformulaforfluidresuscitation:4mLlactatedRinger'sbodyweight(kg)burnsize
(%TBSA).Thistellsyouwheretostartresuscitation,whichissubsequentlyadjustedtopatient
response.Urineoutputisthesinglemostimportantparameterofadequatefluidresuscitation.
Rememberthatedemaisprogressivethroughoutfluidresuscitation.Thepatientshouldbe
repeatedlyevaluatedforcompartmentsyndromesinvolvingtheextremitiesortorso.
Nutritionalrequirementsforburnpatientsmayexceedtwicenormal.Wheneverpossible,useenteral
nutrition:30to35nonproteinkcal/kg/day1.5to2.0grprotein/kg/day.Fatshouldnotexceed35%
ofdiet.
Indicationsforsurgery:anyburnthatdoesnotdemonstrateescharseparationandepidermal
buddingwithin14daysofinjury.

Chapter14:AcuteAbdomen

Theworkupofpatientswithacuteabdominalpain
Physicalexamination
Adetailedphysicalexaminationincludesassessment,inspection,auscultation,palpation,
percussion,andrectal/pelvicexamination.
Laboratoryvalues
CBC,electrolytes,LFTs,amylase,lipase,andurinalysiscanallprovideimportantinformationinthe
workupofpatientswithabdominalpain.Apregnancytest(urineorblood)ismandatoryinallwomen
ofchildbearingage.
Radiographictests
Imagingstudiessuchasplain,supine,anduprightradiographs,ultrasound,CT,angiography,
bariumstudies,andendoscopyareusefultoolsforthesurgeonindeterminingacauseofapatient's
abdominalpain.
Laparoscopyversuslaparotomy:Laparoscopyisoftenusedforuncleardiagnosesinpatientswith
signsofanacuteabdomen.Laparoscopicapproachescanbequicklyconvertedtoastandard
laparotomy,ifnecessary.
Peritonitis/perforation:Patientswithsignsofperitonitisorfoundtohaveperforationofahollow
viscusneedsurgicalintervention.
Appendicitis:Painthatlocalizestorightlowerquadrantaccompaniedbyanorexia,nausea,and
vomitingisaclassicsymptom.
Acutepancreatitis:Patientswithacutepancreatitisrarelyneedssurgicalinterventionbutrather
supportivemedicalcare.
Cholecystitis:Laparoscopicapproachhasbeenprovensafeinbothacuteandchronicsettings.
Diverticulitis:Patientswithdiverticulitiswillrequireemergencysurgerywithsignsofperforationand
significantabscessformation.
Bowelobstruction:Smallbowelobstructionscanbeinitiallytreatedwithanonoperativecourse
includingbowelrestandnasogastricsuction.
Mesentericischemia:Painoutofproportiontophysicalexaminationispathognomonicfor
mesentericischemia.
Rupturedaorticaneurysm:Earlydetectionandinterventionarethekeysforpatientsurvival.
Gynecologiccauses:Rupturedectopicpregnancyisthemostlifethreateninggynecologic
emergency.

Chapter15:Appendicitis

Theclassichistoryofdiffuseperiumbilicalpainmigratingtobecomemoreintense
rightlowerquadrant(RLQ)painispresentinonly50%ofcases.

Frequencyofsignsandsymptoms:Abdominalpain,95%to99%anorexia,90%elevatedwhite
bloodcell(WBC)count(orsimpleshift)plusfever,90%nausea,vomiting,and/ordiarrhea,85%.
Reboundtendernessisdefinedasvoluntaryguardingwithsuddenreleaseafterdeeppalpation.
Rovsing'ssignisdefinedasreferredtendernessandguardingintheRLQwithpalpationintheLLQ.
Psoassignisseenwhenpainiselicitedwithflexionofthehiporextensionagainstresistance.
Feverhigherthan38CandWBCmorethan20,000oftendenotesperforation.
Appendicitishasanextensivedifferentialdiagnosis.
Administerprophylacticantibioticsbeforeincision.
Operativeapproachesincludeoblique(McBurney)incision,transverse(RockyDavis)incision,
midlinelaparotomy,andlaparoscopy.
Locationoftheappendixmayvarybetweentherightlowerquadrant(RLQ),pelvic,orretrocecal
positions.ThetipoftheappendixmaylieintheRUQorLLQ.
Thebaseoftheappendixislocatedatthejunctionofthethreetenia.
Theappendicealarteryliesposteriortothececumorterminalileum.
Ifappendicitisisnotpresent,athoroughsearchforotherpathologyisimportant(Meckel's,pelvic
inflammatorydisease,ovariancyst,etc.)
Inadvancedappendicitisorperforation,searchforconcomitantabscess(pelvic,paracolicgutter,
intraloop).
Consideropenpackingofthewoundforadvancedandperforatedappendicitis.

Chapter16:Hernias

Anacutelyincarceratedherniaisasurgicalemergency.
Theposteriororpreperitonealapproachisbestforrecurrenthernias(openorlaparoscopic).
Therecurrenceratesforinguinalherniasaredirect,5%10%,andindirect,1%5%.
Theuseofaprosthesisforherniorrhaphiesismandatoryonlywhenasuturerepairwouldbeunder
unduetension.
Ventral,incisionalherniasfrequentlyoccurbecauseofwoundinfection,obesity,malnutrition,and
otherfactorsthatleadtopoorwoundhealing.
Theboundariesoftheinguinalcanalare(1)anterior,theexternalobliqueaponeurosis(2)posterior,
thetransversalisfasciaandtransversusabdominisaponeurosis(3)inferior,theinguinalandlacunar
ligamentsand(4)superior,theinternalobliqueandtransversusabdominismuscleand
aponeuroses.
Indirectinguinalherniascomethroughtheinternalordeepinguinalring,whereasdirectinguinal
herniascomethroughtheposteriorwalloftheinguinalcanal(transversalisfascia).
TwofrequentlyusedtypesofinguinalherniorrhaphiesaretheBassinirepair,inwhichthe
transversusabdominisaponeurosisandtheinternalobliqueaponeurosis(conjoinedtendon)
superiorlyaresuturedtotheinguinalligamentinferiorly,andtheCooper'sligament(McVay)repair,
inwhichtheconjoinedtendonsuperiorlyissuturedtoCooper'sligamentinferiorly.
Theboundariesoffemoralcanalare(1)anterior,theiliopubictractandinguinalligament(2)
posterior,Cooper'sligament(3)medial,thelacunarligamentand(4)lateral,thefemoralvein.
Hematomasandinfectionsoccurin1%2%ofinguinalherniorrhaphies.

Chapter17:BiliarySystem

Howtoperformsafedissection
Gallbladderisretractedsuperiorlywhiletheredundantinfundibulumisretractedlaterallytoexpose
thecysticductgallbladderjunction.
Dissectonlythegallbladdercysticductjunction.Avoiddissectingthecommonbileductunless

commonbileductexplorationisanticipated.
Clearlyvisualizeandconfirmallstructuresbeforeligatinganddividingalwaysbeattentivetothe
likelihoodofbiliaryandarterialanomaliesandvariations.
Learntoexpecttheunexpected:ductalandarterialanatomicvariabilityistheruleratherthanthe
exception.
Calot'striangleisdefinedbythecysticductlaterally,thecommonhepaticductmedially,andthe
liversuperiorly.
Painlessjaundiceisanotherwisehealthypatientiscarcinomaofthebiliarysystemuntilproven
otherwise.
Afterlaparoscopiccholecystectomy,patientsshouldhaveminimalpainandbeabletoeat.Nausea,
vomiting,andincreasingabdominalpainareoftenearlywarningsignsofapostoperativebileleakor
othercomplication
Ultrasoundexaminationsperformedforbiliarypathology:Needtoknow
presenceorabsenceofstones
gallbladderwallthickening
presenceorabsenceofcommonbileductdilatation
Patientsadmittedwithacutecholecystitisshouldingestnothingbymouth(NPO),givenantibiotics,
andoperatedonduringthatadmission
Fractionatethetotalbilirubinintodirectandindirectcomponentstodetermineobstructive(i.e.,
surgical)causesofjaundice.Highdirectsuggestsobstructivecauseforjaundice.Highindirect
suggestsnonobstructive(e.g.,hepatic)cause.

Chapter18:Liver

Theliverismadeupofeightsegments,withtheanatomicdivisionbetweentheleftandrightlobeas
alinebetweenthegallbladderfossainferiorlyandthevenacavasuperiorly.
Liverfunctiontestsactuallyreflectliverdysfunction,withtheexceptionoftheprothrombintime(PT).
Administrationoffreshfrozenplasmatocorrectliverinducedcoagulopathybeforebedside
proceduresiscostlyandnotproventobeeffective.
Solitarycongenitalcystinthelivermeansonlyone.Anypatientwiththetelltalesecondcysthas
polycysticliverdiseasebydefinition.
PortocavalshuntsforBuddChiarisyndromemustdraintheliverandsplanchniccirculationtobe
successful.
Ofthebenignlivertumors,onlyhepaticadenomarequiresroutineresectiontopreventbleedingor
malignanttransformation.
Metastaticcoloncancerisbiologicallyprivileged,inthatcurecanbeobtainedincarefullyselected
patientswithaggressivesurgicalremoval.

Chapter19:PortalHTN

Whentreatingportalhypertension,hopeforthebest,butbepreparedfortheworst.Anyoperation
undertakenonpatientswithcirrhosisandportalhypertensioncanleadtosubstantialbloodloss.
Thedissectionoftheinferiorvenalcavaandportalveinisgreatlyfacilitatedthroughtheuseofa
blunt,smoothinstrument(e.g.,Yankauersuctiontip).Oftennumerousvaricesareseenwithinthe
retroperitoneumandportahepatisthesecanbleedquitesubstantially.Liberaluseofligaturesor
electrocauteryorbothisamust.
WhenundertakingthesmalldiameterHgraftportacavalshunt,thefirstanastomosistobe
constructedisthatbetweenthegraftandthevenacava.Itisimportanttoremoveawedgeofthe

venacavawallwhenmakingthevenotomytoassureadequateoutflowfromthegraft.Caremustbe
usedtoavoidinjurytothebileduct,gallbladder,andhepaticartery.
Checkintraoperativepressuresbeforeandaftershunting.Aftertheshuntiscompleted,seeka
decreaseinportalveinpressureofatleast10mmHgandaportalveintovenacavagradientofless
than10mmHg.Thepresenceofathrillinthevenacavacephaladtotheshuntwillconfirmshunt
patency.
Alteredmentalstatusinpatientswithcirrhosisandportalhypertension(encephalopathy)isa
warningsignofpoorhepaticreserveandwouldgenerallycontraindicateshuntinguntilresolved.
Dopplerultrasoundoftheportalveinisusefulindeterminingportalveinpatency.Computed
tomographyangiographyandvisceralangiographyalsoareused.Aportalveinwithgoodflowand
caliberisrequiredforshunting.
Patientswithportalhypertensionwithanacuteuppergastrointestinalhemorrhageshouldbe
admittedtotheintensivecareunit.Thepatient'sairwayissecured,andthepatientisappropriately
resuscitatedwithcrystalloid,packedredbloodcells,andfreshfrozenplasma.Invasivemonitoring
(e.g.,SwanGanzcatheter)maybehelpfulinguidingresuscitation.Anoctreotideinfusionshouldbe
initiatedearly.Expediteupperendoscopy,andaSengstakenBlakemore(SB)tubeshouldbe
readilyavailable.ReviewSBtubemanagementsothatitsusewillbeappropriate,safe,and
effective.
Thrombocytopeniaiscommoninpatientswithportalhypertension.Theinclinationtotransfuse
plateletsshouldberesisted,asplatelettransfusionswillhavelittleeffectbecauseofportal
hypertensionandsplenicsequestration.

Chapter20:SpleenandHematologicDisorders

Splenicligamentsincludethesplenophrenic,splenorenal(lienorenal),splenocolic,and
gastrosplenic.
Accessoryspleensarepresentin10%to40%ofpatients.
ThemostcommonindicationsforsplenectomyinUnitedStatesareimmunethrombocytopenic
purpura,trauma,andiatrogenicinjury.
Theprimaryfunctionsofthespleenarebloodfiltration,pittingoferythrocytes,andimmunity.
Warmantibodyautoimmunehemolyticanemia(AIHA):ImmunoglobulinG(IgG)coatedredblood
cellsaredestroyedinthespleen.Thespleenisremovedwhenpatientsfailtorespondtosteroids,
witha60%successrate.Splenectomyisnotindicatedforcoldagglutinin(IgMmediated)AIHA.
Immunethrombocytopenicpurpura:Thespleenproducesantiplateletantibodiesanddestroys
IgGcoatedplatelets.Steroidsformthefirstlineoftherapysplenectomyisthesecondline,witha
70%to80%responserate.Steroids,intravenousimmunoglobulin,orantiRhDmaybegiven
preoperativelytoincreasetheplateletcount.
Nonoperativemanagementofspleeninjuriesrequireshemodynamicstability,nootherinjuries
warrantinglaparotomy,intacthilarvessels,andminimaltransfusionrequirements.
Overwhelmingpostsplenectomyinfection(OPSI):fulminant,flulikesymptomsprogresstoseptic
shockin24hourshalfdie.Lifetimeincidenceisabout3%to5%,typicallyinchildrenorinadults
withhematologicdiseases,andwithin2yearsofsplenectomy.Streptococcuspneumoniae,
Haemophilusinfluenzae,andNeisseriameningitidesarethemostcommonbacteriainOPSI.
Splenomegalyisusuallyduetohematologicdiseases,liverdisorders,andinfection.Massive
(>1500g)splenomegalyismostcommonlyduetomyelofibrosis,nonHodgkin'slymphoma,chronic
lymphocyticleukemia(CLL),andhairycellleukemia.

Chapter21:ColonandAnorectum

Watershedareasofthecolon(poorbloodsupply):splenicflexure(Griffith'spoint),rectosigmoid
junction(Sudeck'spoint)
Thestrongestlayerofthebowelwall:submucosa
Requirementsofagoodbowelanastomosis:Goodbloodsupply,tensionfree,airtight(forrectal
anastomosistestedwithaproctoscope)
Twostructurestobeidentifiedandavoidedduringrighthemicolectomy:duodenum,rightureter
Distalpointofresectionofsigmoidfordiverticulardisease:coalescenceofteniaecoli
Alwaysperformathorough,bimanualexaminationoftheliverwhenoperatingforcolorectalcancer.
Agoodoncologicresectionofacoloncancerinvolvesproximalligationofthenamedvessel(s)
supplyingthelengthofbowelbeingremoved.
Agoodoncologicresectionofarectalcancerinvolvestotalmesorectalexcision(formidanddistal
rectaltumors)andaproximalligationoftheinferiormesentericvessels,justdistaltotheleftcolic.
Threemostcommonlocationsforinternalhemorrhoids:rightanterior,rightposterior,leftlateral
Successfultreatmentofafistulainanorequiresidentificationoftheinternalopening.
Propertreatmentofathrombosedexternalhemorrhoidinvolvesexcisionofthehemorrhoid,not
incision,andexpressionoftheclot.
Causesofcolonicobstruction(inorder):cancer,diverticulardisease,volvulus
Cecalvolvulus(ingeneral):youngerpatient,radiographshowscoffeebeanpointingtoleftupper
quadrant(LUQ),treatmentissurgical
Sigmoidvolvulus(ingeneral):elderlypatient,radiographshowsbentinnertubepointingtoright
upperquadrant(RUQ),treatmentisendoscopicdecompressionfollowedbyelectivesurgery(if
patientisnothighrisk)
Therecurrenceofasigmoidvolvulusisashighas60%afterendoscopicdecompression.
Chemotherapyrecommendedforcoloncancerstages:Tany,N1or2,M0orTany,Nany,M1
Chemotherapyandradiationtherapyrecommendedforrectalcancers:T3or4,N0,M0orTany,
N1or2,M0
Mostcommoncauseofrectalbleeding:hemorrhoids
Mostcommonpresentingsymptomofcolorectalcancer:bloodperrectum
From5%to10%ofpatientswithapositivefecaloccultbloodtestwillhavecoloncancer.
50%ofpatientswithcoloncancerwillhaveapositiveFOBT.
Incidenceofrectalbleedinginpatientswithdiverticulitis:lessthan5%
Adiverticularabscesscanbetreatedsuccessfullywithpercutaneousdrainageabout75%ofthe
time.
AnattackofdiverticulitisshouldbedocumentedbyCTscanorelevatedWBCandtreatedand
allowedtodefervescebeforeelectivesurgeryisconsidered.
Virtuallyallcoloncancersstartasanadenomatouspolyp.
Colorectalcancersmostcommonlymetastasizetotheliverandthelung.
Threemostcommoncausesofrectalpain:fissure,abscess,thrombosedexternalhemorrhoid
Onethirdofdrainedperirectalabscesseswillsubsequentlyformafistulainano.

Chapter22:IBD

Insharpcontrasttoulcerativecolitis(UC),inwhichthediseaseisconfinedtothecolorectal
mucosa,Crohn'sdisease(CD)ischaracterizedbyasegmentalinflammationthatcanaffectany
portionofthealimentarytract.ThelesionsassociatedwithCDtypicallyextendtransmurallybeyond
themucosaandsubmucosa,reflectingperhapsamorecomplexinflammatoryprocess.
Ulcerativecolitisusuallyisfirstseenwithbloodydiarrhea,abdominalpain,andfever.
ExtraintestinalmanifestationsofUCareobservedinanumberoforgansystems,includingarticular

disorders,lesionsoftheskinandoralcavity,inflammatorydisordersoftheeye,liverandbiliarytract
disorders,thromboembolicdisease,andvasculitis.
TheprincipalcategoriesofdrugtreatmentforUCincludesymptomaticantidiarrhealand
antispasmodicagents,sulfasalazineanditsanalogues,corticosteroids,immunosuppressive
antimetabolites,andcertainantibiotics.
StandardmedicaltherapyforactiveCDdependslargelyonthelocation,extent,andseverityofthe
disease,andconsistsmainlyofthesamedrugsusedinthetreatmentofUC,suchas
corticosteroids,antiinflammatoryagents,andimmunomodulators.
Indicationsforsurgicalinterventionforulcerativecolitis(UC)includeunrelentinghemorrhage,
fulminatingacuteUCthatisunresponsivetotherapy,obstructionfromstricture,suspicionor
demonstrationofcoloniccancer,toxicmegacolon,somaticandsexualgrowthinchildren,and
intractability.
TheprimaryindicationforinitialsurgeryinCrohn'sdisease(CD)ofthesmallintestineisobstruction
duetofibrosisandstricture.
SubtotalcolectomywithileostomyandHartmannclosureoftherectumistheoperationofchoice
whenanurgentsituationarisesinacriticallyillpatientwithCrohn'scolitis.
Subtotalcolectomywithileostomyistheprocedureofchoiceintheemergencysetting,orifthe
diagnosisofUC,asopposedtoCD,cannotbeclearlyestablished.
Colectomy,mucosalproctectomy,andendorectalilealpouchanalanastomosis(IPAA)has
becometheoperationofchoiceforpatientswithrefractoryUC.
AlthoughthemajorearlyoperativemorbidityafterIPAAisbowelobstruction,themostfrequentlate
complicationinpatientsundergoingIPAAisilealpouchdysfunctionorpouchitis,whichhasbeen
reportedtooccurinupto50%ofpatientsundergoingthisprocedureforUC.

Chapter23:MotilityDisorders

Completesmallbowelobstructionusuallyrequiresurgentlaparotomybecauseoftheriskof
closedloopobstructionandintestinalgangrene.
Partialsmallbowelobstructionscanusuallybetreatednonoperativelyinitiallywithnasogastric(NG)
suctionandhydration.
Cecaldilatationof9cmorgreaterrequiresurgentcolonoscopicdecompressionorsurgical
management,whetheritisduetoobstructionortopseudoobstruction.
Factorsthatincreasethedurationofpostoperativeileusincludepreoperativeboweldistention,
intraperitonealdissection,andsurgeryonthecolonorrectum.
Thetwoanalsphinctersaretheinternalsphincter,athickeningofthesmoothmusclelayerofthe
rectalwall,andtheexternalsphincter,striatedmusclearisingfromthelevatormuscles.Onlythe
externalsphincterisundervoluntarycontrol.
Inthenormalrecoveryfrompostoperativeileus,thesmallintestineresumesperistalsisfirst,
followedbythestomach.Thecolonrecoverslastandmaytake3to5daystoresumefunction.
Inapostoperativepatientwithprolongedileusandpossiblebowelobstruction,abdominalcomputed
tomographyscanwithluminalcontrastisthemostusefultest.
Inapatientwithprolongedpostoperativeileus,remembertocheckthemedicationlistfornarcotics
andotherdrugsthatinhibittransitalsochecktheelectrolytesandtheserumalbumin.
Thefirsttesttoruleoutintestinalobstructionisusuallyaflatanduprightradiographofthe
abdomen.Themostreliableradiographicsignofsmallbowelobstructionisdecreasedgasinthe
colon.
Truncalvagotomyorresectionoftheileumwillcausepostprandial(bilesalt)diarrheainmany
patients.Resinsthatbindbilesalts(e.g.,cholestyramine)areeffectivetreatments.


Chapter24:Pancreas
(Nopearls)
Ranson'sCriteriaforSeverityofAcutePancreatitis:
OnAdmission

At48Hr

Age>55yr

Hematocritdecrease>10percentagepoints

WBC>16,000cells/mm3

Serumcalcium<8mg/dL

Serumglucose>200mg/dL

Basedeficit>4mEg/L

SerumLDH>350units/L

BUNincrease>5mg/dL

AST>250U/dL

ArterialpO2<60mmHg
Fluidsequestration>6L

Chapter25:SmallIntestine
Mostcommonetiologiesforsmallbowelobstruction:adhesions,malignancy,hernia,inflammatory
boweldisease,volvulus
Mostcommoncausesofileus:neurologicinjury/disease,hypokalemia,infection,opiatesand
anticholinergics,postoperativestate
Managementofsmallbowelobstruction:fluidresuscitation,nasogastrictube,earlysurgery
Clinicalindicatorsofobstructionwithstrangulation:steadypain,tachycardia,fever,absentbowel
sounds,bloodystool,leukocytosis,acidosis
MostcommonindicationsforsurgeryinCrohn'sdisease:obstruction,perforation,bleeding,
intractability
Factorspreventingspontaneousclosureoffistulas:malnutrition,sepsis,inflammatoryboweldisease,
cancer,radiation,obstructionoftheintestinedistaltotheoriginofthefistula,foreignbodies,highoutput,
andepithelializationofthefistulatract
Causesofacutemesentericischemia:embolus,thrombus,vasospasm,venousthrombosis
Problemswithprolongedtotalparenteralnutritionuse:cathetersepsis,venousthrombosis,
osteoporosis,cholelithiasis,kidneyfailure,liverfailure,cost,increasedmortality
Anatomy:jejunumisproximaltwofifthsofsmallintestineileumisdistalthreefifths.Thejejunum
hasalargercircumferenceandathickerwall,anditsmesenterycontainsmorefatthandoesthatofthe
ileum.Thestrongestlayeroftheintestinalwallisthesubmucosa.
Complicationsofintestinalresection:anastomoticleak,fistula,stricture,vitaminB12andbilesalt
malabsorptionforilealresection,shortbowelsyndrome
Criteriaforintestinalviability:(1)normalcolor,(2)peristalsis,and(3)marginalarterialpulsations.In
borderlinecases,useDopplerprobeorvisualizefluoresceindyeinthebowelwallunderultraviolet
illumination.
Meckel'sdiverticulum:Foundin2%ofpopulation,locatedwithin2feetofileocecalvalve,2%
symptomatic,2inchesinlength
Mostcommonbenignneoplasmsofthesmallintestine:adenomas,leiomyomas,andlipomas.The
mostcommonmalignantneoplasms:adenocarcinomas,carcinoids,lymphomas,gastrointestinalstromal
tumors

Strategiesforavoidingshortbowelsyndrome:resectnomoreintestinethannecessary,
stricturoplasty,preservecolon,preserveileocecalvalve

Chapter26:StomachandDuodenum
Twomotilitytypesoccurinthestomach:receptiverelaxationandaccommodationinthefundusof
thestomach,andtrueperistalsisintheantrumandpylorus.
ChronicinfectionwithHelicobacterpyloriisariskfactorforgastriccarcinoma.
Indicationsforsurgeryforaduodenalulcerincludeintractability,hemorrhage,perforation,and
obstruction.
Theearlydumpingsyndromereferstoacomplexofsymptomsincludingtachycardia,diaphoresis,
dizziness,lightheadedness,andweakness,whichtypicallyoccurwithin30minutesofeating.
Thekeytomanagementofstresserosionisprevention.
Noevidenceindicatesthatatotalgastrectomyconfersanyadditionalsurvivalbenefitoverpartial
gastrectomyingastriccancer.
Mostsurgeonsagreethata4to6cmmarginisnecessaryingastriccancerbecauseof
submucosalspreadofthetumor.
Vagotomyandantrectomyistheoperationforduodenalulcerswiththelowestrecurrence.
Truncalvagotomyandpyloroplastyistheidealoperationfortheseptic,unstable,orhighriskpatient
inwhomaquick,lowmorbidityproceduremustbedoneforcomplicationsofpepticulcerdisease.
Newerapproachestoduodenalulcerincludelaparoscopicproximalgastricvagotomyandtruncal
vagotomyoftheposteriorvagusnervewithananteriorseromyotomy.

Chapter27:Esophagus
GERDComplicationsofgastrointestinalrefluxdisease(GERD)includeesophagealstricture,aspiration
pneumonia,Barrett'sesophagus,andesophagealadenocarcinoma.TreatmentoptionsforGERDinclude
dietary/lifestylemodifications,medicaltherapywithproteinpumpinhibitors(PPIs),andsurgical
fundoplication,usuallyperformedlaparoscopically.AchalasiaThediagnosisofachalasiarequiresthefinding
ofaperistalsisonanesophagealmotilitystudy.Treatmentoptionsforachalasiaincludebotulinumtoxin
(Botox)injection,pneumaticesophagealdilation,andsurgicaltherapywithesophagealmyotomy,usually
performedlaparoscopically.EsophagealCancerAdenocarcinomaisnowmorecommonthansquamouscell
cancerintheUnitedStates.Evaluationshouldincludebariumswallowastheinitialstudy,followedby
upperendoscopytoconfirmthediagnosiscomputedtomographyandendoscopicultrasonographyare
usefulstudiesforstagingthecancer.
AnatomyRichsubmucosalvascularplexusallowsforlongsegmentmobilizationoftheesophaguswithlow
riskofcausingischemia.Extensivesubmucosallymphaticsallowcancerspreadtoremotelymphatic
drainagebasins.NissenFundoplicationFundoplicationsshouldbeshort(2cm)andfloppy,requiring
mobilizationoftheshortgastricvesselsandperformanceofthewraparoundadilator(>50F)toensure
maximalfloppiness.HellerMyotomyMyotomyinvolvescompletedivisionofthefibersofthelower
esophagealsphincterandshouldbe6to8cminlength,including2cmontothecardiaofthe
stomach.Partialfundoplication(DororToupet)isperformedtopreventgastroesophagealrefluxdisease
aftermyotomy.EsophagectomyAgastricconduitispreferredforesophagectomyinadults,whereasan
isoperistalticleftcolonsegmentisthebestesophagealreplacementinchildren.Thebloodsupplyforthe
gastricconduitisbasedontherightgastroepiploicartery,whichmustbecarefullypreservedduring
mobilizationofthestomach.

Chapter28:DisordersoftheTrachea,ChestWall,Pleura,Mediastinum,andLung

(Nopearls)

Chapter29:AcquiredCardiacDisorders
Thestagesofastandardoperationforcoronarybypassgraftingcanbedividedintofourquarters:(1)open
thechestandharvesttheconduit,(2)prepareforcardiopulmonarybypass,(3)formthebypassgrafts,and
(4)weanfromcardiopulmonarybypass,andclosethechest.Usualpreparationforcardiopulmonarybypass
involvesplacementofcannulaeintothearterialcirculationandsystemicvenouscirculationtoflowbloodto
thebody.Cardioplegiacannulaeareinsertedtoflowpreservativesolutiontotheheart.Finally,thepatient
mustbecompletelyanticoagulatedwithheparinbeforecardiopulmonarybypasscanbeinitiated.The
complicationsofcardiopulmonarybypassingeneralareemboli(eithersolidorair),aorticdissection,
hypoperfusion,hyperperfusion,inflammatoryresponse,thrombocytopenia,adultrespiratorydistress
syndrome,andrenalfailure.Theconductionsystemoftheheartcrossestheinterventricularseptum
adjacenttotheaorticvalve.Thislocationisnearthemembranousseptum,whichliesunderthe
commissurebetweentherightandnoncoronarycusps.Damagetotheconductionsystemherewith
valvereplacementsurgerycannecessitateplacementofapermanentpacemaker.Mitralvalve
annuloplastyusuallymovestheposteriorportionoftheannulustowardtheleftventricularoutflowtract.
Oneofthedangersofmitralvalverepairistomovetheanteriorleafletcoaptationpointtoofarintothis
outflowtract,therebycausingobstructiontotheflowofbloodfromtheventricle.Thisiscalledsystolic
anteriormotionofthemitral(SAM).
Theindicationsforcoronaryarterybypassgraft(CABG)canbesplitintocategoriesoflongevityand
qualityoflife.Leftmainstenosisgreaterthan50%,threevesseldiseasewithejectionfractionlessthan
45%,andtwovesseldiseasewith90%proximalleftanteriordescendingarterystenosisallimprove
longevityinsurgicallytreatedpatientsascomparedwithmedicallytreatedpatients.Problemssuchas
angina(whichlimitsnormalactivities),unstableangina,postinfarctangina,intoleranceofmedicaltherapy
forangina,andfailureofpercutaneousinterventionareallindicationsforCABG,whichimprovesquality
oflife.Theclassicsymptomsofaorticstenosiscanhelptopredictthenaturalhistoryofthediseaseifleft
untreated.Anginaisassociatedwitha5yearaveragesurvival.Syncopeisassociatedwitha3year
averagesurvival.Congestiveheartfailurehastheworstprognosis,witha2yearsurvival.Valvechoiceis
adifficultproblem.Mechanicalvalvesaredurableandhaveexcellenthemodynamicpropertieshowever,
theyrequirelifelonganticoagulation.Tissuevalvesdonotrequireanticoagulationhowever,theyarenot
asdurable,andthepatientmaybefacedwiththeprospectofreoperationwhenthevalvefails.Therefore
thepatient'slongtermexpectedsurvivalisbalancedwiththeriskofcoumadinversus
reoperation.Prolongedanticoagulationwithcoumadinmaycarrysignificantproblems,suchasa1%to2%
peryearriskofthromboembolicorbleedingcomplications,andthiseffectisadditiveoverapatient's
lifetime.Coumadinisnotgoodfortheveryelderly(olderthan85years),patientswhoarenoncompliantor
whowillnotmaintainmedicalfollowup,patientswithunderlyingprogressiveliverdisease,patientswith
significantintracranialpathology,patientswithaknownbleedingdisorder,orpatientswithmedicalillnesses
thatmayrequireothersurgicalprocedures.

Chapter30:CongenitalCardiacDisorders

Ingeneral,congenitalheartdefectsshouldberepairedearlytoavoidpulmonaryvascularocclusive
disease,topreventtheconsequencesofsevererightandleftventricularvolumeorpressureoverload,
andtoreducedamagetootherorgans.

Symptomaticpatientsshouldundergosurgicalrepairatthetimeofdiagnosis,andasymptomatic

patientsshoulddosoattheageof6to12months.Youngagebyitselfdoesnotaddrisktosurgery.

Ashuntisconsideredhemodynamicallysignificantwhentheflowinthepulmonarycirculationisgreater
thanorequalto1.5timestheflowinthesystemiccirculation(thatis,whenQp/Qs1.5).

Ifpossible,acompleterepairofanycongenitalanomalyshouldbeattemptedduringinitialsurgery,
becauseoperativemortalityandmorbidityratesassociatedwithcompleterepairsarelow,additional
proceduresbecomeunnecessary,andtheadverseeffectsofcontinuedabnormalphysiologic
mechanismsareprevented.

Palliativeprocedures,suchassystemictopulmonaryshuntsandpulmonaryarterybanding,shouldbe
reservedforspecialcircumstances.

Therepairofmostcongenitalcardiacanomaliesrequirestheuseofcardiopulmonarybypassand
cardioplegicarrest.

Deepsystemichypothermia(15Cto18C)andtotalcirculatoryarrestarefrequentlynecessarytoafford
optimalexposureinneonatesandsmallinfantswithcomplexanomalies.

Atrialseptaldefects(ASDs)andmostventricularseptaldefects(VSDs)areapproachedviatheright
atrium.ASDscanbeclosedwithacontinuoussutureorwithapatch.VSDsarealmostinvariably
repairedwithapatch.

CompleterepairoftetralogyofFallotincludesclosureoftheVSDandeliminationoftherightventricular
outflowtractobstruction.

Thearterialswitchoperationistheprocedureofchoiceformostpatientswithtranspositionofthe
greatarteries.

Aresectionwithendtoendanastomosisisthepreferredtechniqueformostpatientswithcoarctation
oftheaorta.

Inneonates,severeaorticstenosisisbestmanagedinitiallywithpercutaneousballoonvalvuloplasty.

Inolderchildren,balloonvalvuloplastyorsurgicalvalvotomyshouldbeattemptedtoallowgrowthofthe
aorta.

Chapter31:Thyroid

PatientswithGraves'diseaseforwhomsurgeryisindicatedincludethosewithverylargeglandswho
cannotbetreatedadequatelywithradioactiveiodineandthosewhoareallergictothionamidesor
whosehyperthyroidismcannotbecontrolledwiththesedrugs.

Thyrotoxicpatientswhoaretobetreatedsurgicallyshouldbeadequatelytreatedfirstwithantithyroid
medication(thionamides)torenderthemeuthyroid.

Patientswhorequireanemergencythyroidectomyandarethyrotoxicshouldbetreatedpreoperatively
for5dayswithdexamethasone,iopanoicacid,propanolol,andpropylthiouracil.

Ionizingradiationisassociatedwiththedevelopmentofthyroidcancer,andthemajorityof
radiationinducedtumorsareofthepapillarytype.

Fiveprognosticfactorsforpatientswiththyroidcancerincludemetastases,age,completenessof
surgery,andinvasivenessofthetumor.

Thepyramidallobeisaremnantofthethyroglossalduct.

Thearterialbloodsupplyofthethyroidarisesfromtwomajorsources:theinferiorthyroidartery,which
originatesfromthethyrocervicaltrunk,andthesuperiorthyroidartery,whichisthefirstbranchofthe
externalcarotidartery.

Adelphianlymphnodeisanenlargedprelaryngealnodethatisoccasionallyassociatedwiththyroid
cancer.

enousdrainageincludesthesuperiorandmiddlethyroidveins,whichemptyintotheinternaljugular
vein,andtheinferiorthyroidvein,whichalsoemptiesintothejugularveinortheinnominatevein

Chapter32:Parathyroid

Primaryhyperparathyroidism(PHPT)andmalignancyaccountfor90%ofhypercalcemiccases.

Classicradiographicmanifestationsofosteitisfibrosacysticaincludesubperiostealresorptionofthe
distalphalanges,asaltandpepperappearanceoftheskull,andtaperingofthedistalclavicles.

Primaryhyperparathyroidismmayoccurinassociationwithmultipleendocrineneoplasia(MEN)IandIIA
syndromes.

PHPTiscausedbyparathyroidcarcinomainfewerthan1%ofcases.

Thesuperiorparathyroidglandsarederivedfromthefourthbranchialpouchandmaybelocated
anywherefromtheupperborderofthelarynxtothelowerpoleofthethyroid.

Theinferiorparathyroidglandsarederivedfromthethirdbranchialpouchesandmaybelocated
anywherefromtheangleofthejawtothepericardium.

Theinferiorglandsaremostcommonlylocatedontheanterolateralorposterolateralsurfaceofthe
lowerthyroidgland.

Themajorityofectopicglandsarelocatedwithinthethymus.

Theparathyroidsreceivetheirbloodsupplyprimarilyfromtheinferiorthyroidarterieshowever,
sometimesanastomosesoccurbetweenthesuperiorandinferiorthyroidarteries.

Chapter33:Adrenals

Pheochromocytomasoccurinassociationwithseveralfamilialdisordersincludingmultipleendocrine
neoplasiaIIa(MENIIa),MENIIb,vonHippelLindau,andneurofibromatosis.

Ruleof10sforpheochromocytoma:10%bilateral,10%occurinchildren,10%extraadrenal,10%
malignant,10%incidental,and10%recur.

Aunilateralaldosteroneproducingadenoma(APA)isthemostcommontypeofprimaryaldosteronism

andistreatedwithsurgicalremoval.

AdrenalvenoussamplingisconsideredthegoldstandardfordifferentiatingaunilateralAPAfrom
primaryadrenalhyperplasia.

SpecificsignsofCushing'ssyndromeincludecentralobesity,proximalmuscleweakness,widepurple
striae,spontaneousecchymoses,andfacialplethora.

Patientswithadrenocorticalcarcinoma(ACC)haveapoorprognosis,witha5yearsurvivaloflessthan
50%.

CompletesurgicalresectionistheonlyeffectiveandpotentiallycurativetreatmentforACC.

Theadrenalglands,alongwiththekidney,areenclosedbyGerota'sfasciaandaresurroundedbyfat.

Thearterialbloodsupplytotheadrenalglandsisfromthreemainsources:thesuperiorsuprarenal
artery,whichisabranchfromtheinferiorphrenicarterythemiddlesuprarenalartery,whicharises
fromtheaortaandtheinferiorsuprarenalartery,whichisabranchfromtherenalartery.

Therightadrenalveinisshort,exitsthemedialaspectoftheglans,anddrainsdirectlyintotheinferior
venacava.

Theleftadrenalveinleavestheglandanteriorlyanddrainsintotheleftrenalvein.

Chapter34:Pituitary

Thecavernoussinusbordersthepituitaryglandandcontainstheinternalcarotidarteryandcranial
nervesIII,IV,V,andVI.

Thebloodsupplytothepituitaryismaintainedbythesuperiorandinferiorhypophysealarteries.

Thesurgicalcurerateforapatientwithacromegalyduetoamacroadenomais50%.

Prolactinlevelsassociatedwithaprolactinomaareusuallygreaterthan100ng/mL.

Medicaltherapywithadopamineagonist(bromocriptineorcabergoline)isthepreferredtreatmentfor
prolactinomas.

Measuringtheinsulinlikegrowthfactor(IGF1)levelisthebestscreeningtestforacromegaly.

Transsphenoidaladenomectomyisthepreferredfirstlinetherapyforpatientswithacromegaly

Chapter35:LymphaticandVenousSystems

Thelymphaticsareaunidirectional,closedloopsystem,whichreturnsfluidandproteinthathave
traveledfromthevascularcapillariesintotheinterstitialspaceandbacktothevenoussystem.The
thoracicductofthelymphaticsystementersthevascularsystematthejunctionoftheleftsubclavian
andjugularveins.Anumberoflymphaticductsenterthevenoussystemontherightside.

Primarylymphedemaischaracterizedascongenital(youngerthan1yearatonset),praecox(135years),
ortarda(olderthan35years).Secondarylymphedemaistheresultofobliterativecancertherapyin
EuropeandNorthAmericaandmostcommonlyiscausedbyfilariasisworldwide.

Duplexultrasonographycanprovidebothanatomicandphysiologicinformationrelevanttovenous

function.Itisthemostwidelyusedmodalitytoevaluatethevenoussystemandtodeterminetreatment.

Thetreatmentofchoiceforchroniclymphedemaisconservativeandnonsurgical,consistingof
elevation,massage,compression,exercise,andskincare.Surgicalproceduresarerarelyperformed.

Thevenoussystemiscomposedofthreeanatomicparts:deepveinsandsuperficialveins,asrelatedto
musclefascia,andperforatingveins,whichconnectthesetwosystems.

Mostpatientswithchronicvenousinsufficiencyandvenousulcershaveamixtureofsuperficial,deep,
andperforatingveinincompetence.

Chapter36:DVTandPE

Themajorityofcasesofdeepveinthrombosis(DVT)areasymptomatic.

DVToccursfrequentlyinpatientsundergoingorthopedic,abdominal,andpelvicsurgery.

YoungerpatientsinwhomDVTdevelopswilloftenhaveapredispositiontohypercoagulopathy.

Pulmonaryembolismshouldbehighonthedifferentialdiagnosisinanypostoperativepatient
experiencingrespiratorysymptomsorsuddencollapse.

Mostdeepveinthromboses(DVTs)inthesurgicalpatientoccurontheORtable.

ProphylaxisiscriticalinpreventionofDVT/pulmonaryembolism(PE).

Subcutaneousheparin(5000units),givenbeforesurgeryandcontinued(twicedaily)postoperatively
untilfullmobilizationisachieved,iseffective.Alternatively,lowmolecularweightheparinmaybeused
tothesameeffect.

IntermittentcalfcompressiondevicesalsoareeffectiveinpreventionofDVT.

Chapter37:PeripheralArterialOcclusiveDisease

Fivefactorsforsuccessfularterialreconstructionaregoodinflow,goodoutflow,goodbypassor
endarterectomy,goodsurgeon(operativetechnique),andanhonestcoagulationsystem.

BleedingthatdoesnotstopintheORrarelystopsintherecoveryroom.

NeversayOops,becausepatientsunderanesthesiaremembersuchthings.

Chapter38:Aneurysms

Theprimarycauseofdeathofpatientswithanabdominalaorticaneurysm(AAA)isrupture.

AAAexpansionratesincreaseasafunctionofthesizeoftheAAA.

ThemostconsistentresultsformonitoringgrowthofanAAAcomefromusingthecomputed
tomographyscan.

Themostcommonetiologiesforthoracoabdominalaneurysmformationareatheroscleroticmedial
degeneration,followedbydissection.

Factorspredictingneurologiccomplicationsaftersurgicalrepairofthoracoabdominalaneurysmsare
priorproximalaneurysmrepair,presenceofaorticdissection,durationofaorticcrossclamptime,

oversewingofintercostalarteries,andhypotension.

Femoralandpoplitealarteryaneurysmsaccountfor90%ofperipheralaneurysms.

Themerepresenceofapoplitealorfemoralaneurysmandnotthesizeisanindicationforsurgical
repairbecauseofthehighriskofthromboemboliccomplications.

Mostabdominalaorticaneurysmsarefoundbelowtherenalarteries.

Nobackbleedingorbriskbackbleedingfromtheinferiormesentericarteryoncetheabdominal
aneurysmisopenedindicatesthatgoodcollateralcirculationtotheleftcolonexists.

Endovascularrepairofanabdominalaorticaneurysmrequiresfrequentcomputedtomographyor
duplexevaluation,lookingforlatetechnicalcomplications.

Spinalfluiddrainageorspinalcoolingorbothhavebeenshowntoreducetheincidenceofpostoperative
neurologiccomplications.

Themostfrequentcomplicationafterthoracoabdominalaneurysmrepairisrespiratoryfailure.

Femoralarteryaneurysmsarerepairedbyexcision,andpoplitealarteryaneurysmsarerepairedby
ligationandbypass.

Chapter39:CerebrovascularDisease

StrokeisthethirdleadingcauseofdeathintheUnitedStatesandtheprimarycauseofadultdisability.

Thetwomajortypesofstrokearehemorrhagicandischemic.

ThecircleofWillisconnectstheanteriorandposteriorcirculationofthebrainandbalancestheinflow
fromthecarotidandvertebralarteriestotheanterior,middle,andposteriorcerebralarteries.

Themostcommonmechanismofcerebralischemiaisembolifromanextracranialsite.

Theabsoluteriskreductionofastrokeaftercarotidendarterectomyinsymptomaticpatientsis17%.

Thecommonfacialveinfrequentlymarksthebifurcationofthecarotidarteryintheneck.

Carotidarterydissectionistreatedwithanticoagulationfor3to6months.

Cranialnerveinjuryaftercarotidendarterectomyisuncommonandcanoccurin2%to8%ofpatients.
Vagus,hypoglossal,andglossopharyngealnervesarethenervesthatcanbeinjured.

Ipsilateralstrokeaftercarotidendarterectomyshouldnotoccurinmorethan2%to3%ofpatients.

Themajorcauseofdeathaftercarotidendarterectomyismyocardialinfarctionandoccursin1%to2%of
patients.

Chapter40:BreastCancer

AccordingtotheAmericanCancerSocietyguidelines,annualscreeningmammographybeginsatage40
years.

Lumpectomyisnotappropriateformulticentriccancers,persistentpositivemargins,orpatientswho
receivedpriorradiationtherapytothebreast.

Axillarynodedissectionisindicatedifthesentinelnodeispositiveorforaxillarynoderecurrenceafter
sentinelnodesurgery.

Chemotherapybeforesurgeryisindicatedforlocallyadvancedandinflammatorybreastcancerandfor
patientswithmattedaxillarynodes.

Provenprognosticfactorsaretumorsizenumberofpositiveaxillarylymphnodesestrogenand
progesteronereceptorstatusandage/menopausalstatusofthepatient.

Longthoracicnerveinjurycausesawingedscapula.

Intercostalbrachialnerveinjurycausespainorparesthesiasoftheaxillaorarmorboth.

Injectionsitesforsentinelnodesurgeryincludethesubareolararea,theskinoverlyingthetumorsite,
andthewallsofthetumorcavityortissueimmediatelysurroundingthetumor.

Properhandlingofthelumpectomyorexcisionalbiopsyspecimenincludesanatomicorientation,
specimenmammographyifthelesionisnotpalpableandwasradiographicallylocalizedpreoperatively,
andrequestforappropriatetumormarkers.

Removalofhardorenlargednodesorbothispartofsentinelnodesurgery,evenwithnotraceruptake.

Chapter41:PrinciplesofSurgOnc

Surgicaloncologyisaspecializedinterestdisciplinewithintherealmofgeneralsurgerythatfocuseson
thediagnosisandmanagementofthecancerpatient.

Majorareasofinterestincludeddiagnosisandtreatmentofsolidtumors,managementofacuteand
chronicproblemsrelatedtomalignancy,andguidanceofpatientsthroughtheobstaclecourseof
specialistsandspecialprocedurestoreachtheoptimumtreatment.

Thesurgeonfunctionsasthecaptainoftheshipandaggressivelypursuesearlydiagnosisusingallof
thecurrentlyavailabletechniquesandassiststhepatientinthedecisionmakingprocessaboutthe
optimumsurgicalandadjuvanttherapy.

Thesurgeonfrequentlyisinvolvedinthescreeningprocessforcommontumorssuchasbreastand
colorectalcancer.

Thesurgeonfacilitatesthemultimodaltreatmentprovidedtothepatientbyinsertingvascularaccess
devicesforchemotherapyandPEGtubesformanagementofnutrition(operativebypassmaybe
needed).

Thesurgeonconductsthelongtermpostopsurveillanceofcancerpatientstofacilitateearlydiagnosis
andtreatmentofrecurrenceorpalliation.

Earlydiagnosisofsolidtumorsisfacilitatedbyuseoffineneedleaspirationcytologyorcoreneedle
biopsyofpalpablemasses.

Ultrasoundcanaidthesurgeonindiagnosisofpalpablebreastthickeningorlumps.Cystsorsolid
masseshavedistinctiveultrasoundcharacteristics,andultrasounddirectedFNAorcorebiopsycan

providehistologicconfirmation.

Excisionalbiopsiesofsuspicioustumorsinthebreast,headandneck,andsofttissueshouldbefully
orientedbymarkingsuturespriortoexambythepathologist.

FormelanomaorSCCofskin,properbiopsytechniqueswillensureadequatehistology.Fullthickness
biopsyintosubcutaneoustissuebycore,punch,orincisionaltechniqueisneeded.Forsarcoma,initial
FNAfollowedbycorebiopsyorproperorientedincisionalbiopsymaybedone.Mucosaltumorsrequire
cupbiopsyviaendoscopeandbreastrequiresFNA,corestereotactic,oropenbiopsy.

Propermanagementofbiopsiedtissueisimportant:tissueforlymphomaassessmentorforelectron
microscopy,orspecialantibodyormoleculartestsshouldbeexaminedfresh.

Sentinelnodebiopsyoptimizeslymphaticstagingformelanoma,breastcancer,skincancers,and
certainGItumorsandcommonlyinvolveslymphscintigraphytopinpointthenodalsite.

Chapter42:DiseasesoftheBonesandJoints

Themostcommonbacteriaassociatedwithhematogenousosteomyelitisinchildrenarethe
grampositivecocciStaphylococcusaureusandstreptococci,whereasinadultstheyaregramnegative
bacteria,suchasEscherichiacoli,Pseudomonas,andSalmonella.

Magneticresonanceimagingisthemostsensitivemeansofdetectingosteomyelitis.

Inflammatoryarthritisisadisorderthataffectsthesynovialjointsandmayoccursecondaryto
autoimmuneormetabolicdisorders.Analysisofsynovialfluidistheprimarymeansbywhich
inflammatoryarthritisisdifferentiatedfromnoninflammatoryarthritis.

Osteoarthritisisclassifiedintotwogroups,primary(idiopathic)osteoarthritisandsecondary
osteoarthritis,andisthemostcommonnoninflammatoryarthriticconditionassociatedwithsignificant
disability,workloss,andhospitalizations.

Anteroposteriorandlateralradiographsofthehipandananteriorviewofthepelvisarenecessaryfor
theproperevaluationofhipdisorders.

Inpatientswithdiabetesmellitus,damagetotheperipheralnervesistheprimaryeffectonthefoot.

Indicationsforsurgeryforosteomyelitisincludethepresenceofanabscessornecrosisofthebone
andsofttissueandtheneedfordrainage.

Inthesurgicalmanagementofrheumatoidarthritis,synovectomymaybebeneficialearlyinthecourse
ofthedisease,beforejointdestructionhasoccurred,becauseitmayprovidesymptomaticreliefand
delaydiseaseprogression.Eitherresectionarthroplastyorreplacementarthroplastyisindicatedifthe
diseaseismoreadvanced.

Surgicaloptionsforthemanagementofhipdisordersincludearthroscopy,arthrodesis,osteotomy,and
arthroplasty.

Totalkneearthroplastyisindicatedinpatientswhohaveradiographicevidenceofadvanced
intraarticulardiseaseandhavedisablingkneepainandothersymptomsthatcannotbemanaged
successfullywithnonoperativetreatment.

Chapter43:HandSurgery

Thepeakincidenceofdistalradiusfracturesisinpatientsage60to70years.Inthisagegroup,the
usualmechanismofinjuryisafallontotheoutstretchedhand.Inyoungpatients,theusualmechanism
isahighenergytrauma,andassociatedinjuriesarefrequentlyfound.

Carpaltunnelsyndromeischaracterizedbypain,paresthesia,andnumbnessinthepalmarradialaspect
ofthehand.

ZoneIextensortendoninjuries,suchasmalletfingerandswanneckdeformity,involvetheterminal
insertionoftheconjoinedlateralbandsatthelevelofthedistalinterphalangealjoint.

From30%to50%ofphalangealfracturesareopen,andmorethanhalfoftheseopenfracturesoccurin
theworkplace.

Afterphalangealfracture,earlymobilizationofthefingersisimportanttopreventfingerstiffness

Longitudinalincisionsarecommonlyusedthroughdorsalskinbecausetheyallowextensile
approachesandbecausetheresultantscariseasilytoleratedinthisloose,redundantskin.Incisions
throughvolarskin,however,shouldneverbelongitudinal,becausetheensuingscarformationwill
causeflexioncontractures.Forthisreason,zigzagincisionsofthevolarskinarepreferred.

Althoughfreeskingraftsareusuallywellacceptedonthedorsumofthehand,theyarerarelyindicated
onthepalmaraspect,becausetheycannotsupplytherequisitesensationandcannotwithstandthe
repetitiveshearforcesimpartedduringgrip.

Ifconservativemanagementofcarpaltunnelsyndromeisineffective,surgicalreleaseofthetransverse
carpalligamentisindicated.

ZoneIIinjuriesoftheflexortendonaregenerallyconsideredthemostchallengingtotreat,giventhe
difficultyofrepairingbothtendonsincloseoppositionwithinthetendonsheath.

Chapter44:SoftTissueInjury

Therotatorcuffiscomposedofthetendonsofthesupraspinatus,infraspinatus,teresminor,and
subscapularismuscles.

Symptomsofshoulderinstabilityaremorefrequentlyseeninathletesinvolvedinoverheadsports
activitiesthaninthegeneralpopulation.

Inallcasesofacutedislocationoftheshoulder,athoroughassessmentoftheneurovascularstatusof
thelimbmustbedonebeforeattemptsatreduction.Vascularinjuriesoccurmorefrequentlyinolder

patientsafteranacutedislocationandmayresultinischemiaoftheextremity.

Magneticresonanceimagingisthemostsensitiveandspecificstudyfordiagnosingfullthicknessand
partialthicknessrotatorcufftears,cuffdegeneration,andtendinopathy.

Mostmeniscaltearsofthekneeresultfromtwistingorrotationalforcesduringweightbearingor
sportingactivities.Kneeinstabilitysecondarytoananteriorcruciateligament(ACL)tearwillfrequently
leadtoameniscaltear.

TearsoftheACLmostoftenresultfromanoncontactinjuryinwhichapivoting,decelerating,orcutting
maneuvertakesplace.ACLtearsarefrequentlyaccompaniedbyotherligamentorsofttissueinjuries
abouttheknee.

Anklesprainsarethemostcommonathleticinjury.Aninversionoftheankletypicallycausesdamageto
ligamentsinthelateralligamentcomplex.

Afterthereductionofananteriororposteriordislocation,itisnecessarytoassessthestabilityofthe
shoulderandtoreassesstheneurovascularstatusoftheextremity.

Ifashoulderdislocationoccursinassociationwithavulsionoftherotatorcuff,earlysurgeryisindicated
toremoveinterposedbonefragmentsandsofttissues.

Anteriorcruciateligament(ACL)reconstructionreliablyrestoresACLfunction,and
arthroscopyassistedsurgeryiscurrentlythestandardtechniqueusedforACLreconstruction.

Chapter45:Fractures

Pathologicfracturesarefoundinanareaofbonethathasbeenweakenedbyadiseaseprocess.These
fracturescommonlyoccuraftersometrivialinjuryandmayoccurspontaneously.Traumaticfractures
resultfromasubstantialimpactonthebone.Stressfracturesresultfromrepeatedlowlevelstress
thatexceedsthestrengthofthebone.

Commonfracturepatternsincludespiral,oblique,transverse,compression,avulsion,segmental(two
separatefractures),comminuted(threeormorefragments),andgreenstick(incomplete)fractures.

Fracturesaredescribedaccordingtotheirlocationasproximal,middle,ordistalthirdfractures.They
alsoaredescribedasintraarticularorextraarticularfractures.

Fracturesaredescribedbytheiralignment,displacement,andangulardeformityintermsoftherelation
ofthedistalfragmenttotheproximalfragment.

Becausethethoracolumbarjunctionisthemostmobilesegment,themajorityofspinalinjuriesoccurat
thislevel.

Fracturesoftheclaviclemostcommonlyresultfromadirectfallontotheshoulder.Thesefractures
involvethemiddlethirdinmostofthecases.

Fracturesoftheproximalhumerusarecommoninjuries.Themostfrequentcauseisafallinanelderly
patientwithosteoporosis.Inyoungerpatients,highenergyinjuriesaccountformostfracturesofthe

proximalhumerus.

Fracturesofthepelviscanresultdirectlyfromblunttraumaorindirectlyfromforcestransmitted
throughthelowerextremity.Thefracturescanbeclassifiedonthebasisoftheiranatomiclocation,
mechanismofinjury,orstability.

Theincidenceofhipfracturesishighestinelderlywhitewomen.Riskfactorsincludesmoking,
inactivity,osteoporosis,dementia,andtheuseofpsychotropicmedications.

Tibialplateaufracturesmostoftenresultfromafall,amotorvehiclecollision,oranaccidentinwhicha
pedestrianisstruckbythebumperofacar.

Surgicalmanagementofthoracolumbarinjuriesisindicatedifthepatienthasanunstablespineorhas
progressiveorcompleteneurologicdeficit.

Indicationsforopentreatmentofclaviclefracturesincludeopenfracturesandinjuriestothesubclavian
vessels.

Thegoalofsurgicaltreatmentofhipfracturesistoprovidestabilityforappropriatehealingandearly
mobilization,becauseearlyfullweightbearingwilllimitlossoffunctionandreducepostoperative
complications.

Femoralshaftfracturesarebesttreatedwithintramedullarynails,becausetheiruseresultsinunionin
morethan95%ofcases.

Chapter46:PediatricOrtho

Inchildren,fractureshavetheremarkableabilitytoremodelbecauseofconcurrentlongitudinalgrowth.
Treatmentgenerallyinvolvesclosedreductionandcastingtomaintainalignmentwhilethebonesheal.
However,ifthefractureisdisplaced,surgicalinterventionmaybenecessarytorestorearticular
congruity.

Iffracturesarefoundinaninfantwhoisnotyetwalking,childabuseshouldbeconsidered.Themost
commonlongbonefracturesseeninabusedchildrenarefracturesofthehumerus,tibia,andfemur.

Scoliosisischaracterizedbylateraldeviationandrotationofthespinalcolumn.

Developmentaldislocationofthehipisthemostcommonhipdisorderaffectingchildren.

Slippedcapitalfemoralepiphysisisadisorderinwhichtheproximalfemoralepiphysisbecomes
displacedonthefemoralneck.

Pigeontoe,orintoeing,maybetheresultofarotationaldisorderofthelowerextremities.Physical
examinationisimportanttoruleoutadisorderordelineatethecauseofthedisorder.

Ininfantsyoungerthan1year,acommonproblemismetatarsusadductus,oradductionoftheforefoot
atthelevelofthetarsometatarsaljoints.

Clubfootconsistsofankleequinus,heelvarus(inversion),forefootadduction,andforefootequinus.

Ifaperiostealabscessispresentorifthepatienthasnotrespondedtoantibiotictreatment,surgical

treatmentshouldbeperformedtodecompressanddbridethebone.

Inchildrenwithchronicosteomyelitis,surgicalinterventionisrequiredtodbridenecroticinfected
bone,andadjuvantantibiotictherapyisnecessarytoeffectremission.

Severecasesofintoeingcausedbytibialtorsioncanbecorrectedsurgicallywithasupramalleolar
osteotomy.

Chapter47:ManagementofPts.withNeurosurgicalDiseases

Signsofincreasedintracranialpressure(ICP)onheadcomputedtomography(CT)scansaremidline
shift,compressionorenlargementofthecerebralventricles,andeffacementofbasalcisterns.

Cerebralvasospasmaftersubarachnoidhematomaoccursbetweendays3and20itpeaksonday7.
Angiographicspasmoccursin50%to70%ofpatientssymptomaticspasm,in30%.Themortalityrateis
7%.

ICPmonitoringisappropriateinsevereheadinjurypatients(GlasgowComaScale,38)withan
abnormalCTscan,oranormalCTscaniftwoormoreofthefollowingarenotedonadmission:SBP,
<90mmHgAgeolderthan40yearsUnilateralorbilateralmotorposturing

Immediateandcompletephysiologicresuscitationwithavoidanceofarterialhypotensionorhypoxiain
patientswithsevereheadinjuryisthesinglemostimportantfactorimprovingoutcomeinthispatient
group.

Treatmentofpatientswithseveretraumaticbraininjurywithsteroidsisnotindicated.Arecent
prospective,randomizedmulticentertrialshowedthatthemortalityofpatientswithtraumaticbrain
injurywhoreceivedhighdosedexamethasoneinfusionwasincreasedcomparedwiththatofacontrol
group.

Inpatientswithincompletespinalcordinjury,boneorothermaterialinthespinalcanalcompressing
thespinalcordshouldberemovedoperativelyifthepatientdoesnotimprovewithconservative
treatmentordeterioratesneurologically.

Operatingonpatientswhohavecompletespinalcordlesionshasnotbeenshowntoimprovetheir
function.Thereforeindicationsforspinestabilizationsurgeryinthispatientgrouparetoimprovetheir
capacitytoparticipateinrehabilitationandpaincontrol.

Stablethoracolumbarspinefracturesaretreatedwithanorthosis,suchasamoldedthoracolumbar
sacralorthosis(TLSO).Unstablethoracolumbarspinefractureswithneurologicdeficitfrequentlyshould
undergosurgicalstabilization.Posteriorapproachesareusuallypreferred,butsurgicaldecompression
andvertebralbodyresectionsometimesrequireaccessviaananterior,transthoracic,or
transabdominalapproach.

Antibioticcoatedventriculostomycathetershavebeenshowntoreducetherateofinfections
associatedwithintracranial(ICP)monitoring.

Aventricularcatheterconnectedtoanexternalstraingaugedeviceisthemostaccurateand
costeffectivewayofmeasuringICP.Italsoallowstherapeuticdrainageofcerebrospinalfluid(CSF).
Parenchymalmonitorsforfiberopticmonitoringofbraintissuepressurearealsoaccuratebutmore
expensive,andtheydonotallowCSFdrainage.RecentlyintroducedcombinedcathetersallowCSF
drainageaswellascontinuousuninterruptedmonitoringofICPviafiberopticorstraingauge
technology.

Chapter48:CNSandSpinalDegenerativeDiseasesandInfections

TheroleofneurosurgeryintheworkupofpatientswithHIVinfectionisverylimited.Aninvasivebiopsy
canusuallybeavoidedwithappropriatediagnosticworkupincludingimagingstudiessuchascontrast
MRI.

Artificialcervicalandlumbardiskshavebeenintroducedforthetreatmentofpatientswithcervical
radiculopathy,myelopathy,orchronicdisablinglowerbackpain.Theseprocedureshavethepotentialto
replacefusionsurgery,whichhasbeenconsideredthestandardofcareforsomeofthesedisorders.
Theadvantageofartificialdisksisthattheypreservemotionattheaffectedsegmentandmayprevent
degenerativediskdiseaseatadjacentlevels.

Chapter49:Neoplasms

Treatmentofbraintumorsdependsparticularlyonthetypeoftumor,thelocation,andthedegreeof
progressionofdisease.Treatmentoftencombinessurgery,radiotherapy,andchemotherapy.

Themostcommonpresentationofbraintumorsoverallisslowprogressiveneurologicdeficit,usually
motorweakness.Thisisfollowedbyheadachesinapproximately50%ofpatientsandseizuresin25%.
Headachesandnausea/vomitingarethemostcommonpresentingsymptomsinposteriorfossa
tumors.

Magneticresonanceimagingwithandwithoutgadoliniumistheimagingstudyofchoiceforbrain
tumors,especiallyfortumorsintheposteriorfossa.

Theroleofconventional,opensurgeryforcertainbraintumorshasbeenchallengedbyadvancesmade
withradiosurgery.Today,radiosurgerywitheithergammaknifeorcyberknifetechnologyisan
acceptedfirstlinetreatmentforsolitarycerebralmetastasesoracousticneuromassmallerthan3cm.
Morefrequently,radiosurgerycanbeusedasanadjuncttoopensurgeryafterpartialresectionofa
braintumor.

Inpatientswhoaremedicallystableandwithareasonablelifeexpectancy,spinalepiduralmetastases
shouldbesurgicallyresected.Ifsignsandsymptomsofspinalinstabilityarenoted,suchas
radiographicevidenceofspinalcordcompression,progressiveneurologicdeficit,pain,ordeformity,
resectionshouldbefollowedbyinstrumentation.Intheabsenceofthesefindings,radiosensitive

tumorscanberadiatedasafirstlinetreatment,butthepatientsmustbemonitoredclosely.

Chapter50:OtologicandNeurootologicDiseases

Sensationfortheexternalearisfromthefacial,vagus,trigeminal,andthirdcervicalrootnerves.

ThemostfrequentorganismsinacuteotitismediaareStreptococcuspneumoniae,Haemophilus
influenzae,andMoraxellacatarrhalis.

Acquiredcholesteatomamostoftenbeginsintheparsflaccida.

Transversetemporalbonefracturesarelesscommonthanlongitudinalorobliquefractures,butare
associatedwithahigherriskoffacialnerveinjury.

Themostcommontumorofthecerebellopontineangleisacousticneuroma.

Tympanostomytubesareplacedintheanteroinferioraspectofthetympanicmembrane.

Thechordatympaniarisesfromthefacialnerveandtraversesthemiddleear,passingbetweenthe
malleusandtheincus.

Inthemiddleear,thefacialnerveisdehiscentinabout50%ofpeople.

Theinternalauditorycanaltransmitsthesuperiorandinferiorvestibularnerves,thecochlearnerve,and
thelabyrinthineartery.

Acousticneuromastypicallyarisefromtheintracanalicularvestibularportionoftheeighthcranialnerve
buthavenopredilectionforeitherthesuperiorortheinferiorbranch.

Chapter51:HeadandNeckOncologicSurgery

Pleomorphicadenomaisthemostcommontumoroftheparotid.

Invertingpapillomaisabenigntumoroftheparanasalsinusesthathasthepotentialtobecome
malignant.

Thestageofthecanceristhemostimportantfactorinpredictingsurvival.

Encapsulationdistinguishesschwannomafromneurofibroma.

NasopharyngealcancerhasbeenassociatedwithEpsteinBarrvirus.

RemovalofalllymphnodesandsparingofthespinalaccessorynerveonlyisreferredtoastypeI
modifiedradicalneckdissection.

AglotticcarcinomawithvocalcordfixationisconsideredaT3lesion.

Aneckmassinapatientwithoutinfectioussymptomsshouldbeevaluatedwithendoscopytoruleouta
primarymucosalmalignancyoftheupperaerodigestivetract.

Surgeryforadenoidcysticcarcinomaoftheparotidrequiressacrificeofthefacialnervebecauseofthe
tendencyofthiscancertoinvadeneurovascularstructures.

Healthyvascularizedtissueintheformofafreeflapmaybeneededtoreconstructalargedefectina

previouslyirradiatedtissuebed.

Chapter52:PedsOtolaryngology

Themostsignificantriskoftonsillectomyinchildrenispostoperativehemorrhage.Theliterature
reportsanoccurrenceofapproximately2%to4%.

Thetwomostcommonindicationsfortonsillectomyinchildrenarerecurrentinfectionandtonsillar
hypertrophy.

Thethreeorganismsmostfrequentlyculturedfrommiddleearinfectionsinchildreninclude
Streptococcuspneumoniae,Haemophilusinfluenzae,andMoraxellacatarrhalis.

Secondbranchialarchanomaliesarethemostcommonandrepresent90%ofbranchialcleftcystsand
associatedsinuses.

Themostcommonmalignanttumoroftheneckinchildrenislymphoma.

Thebloodsupplytothetonsilincludes(1)facialartery(tonsillarbranch),(2)dorsallingualartery,(3)
ascendingpalatineartery,(4)lesserpalatineartery,and(5)ascendingpharyngealartery.

Thechordatympaninerveinnervatestheanteriortwothirdsofthetongue.

Thefacialnerveinnervatesthestapediusmuscle,whichisattachedtothestapes.

Thesecondbranchialcleftsinustractrunslateraltothecarotidbifurcationitpassesbetweenthe
internalandexternalcarotidarteries.

Thetensorvelipalatini,innervatedbythetrigeminalnerve,openstheeustachiantube.

Chapter53:FacialPlasticandReconstructiveSurgery

Thebesttissuetouseinreplacinglosttissueisadjacenttissue.Foradefectofthecheekskin,for
example,rotatingadjacentcheekskinintothedefectwillusuallyprovideabetteraestheticoutcome
thanrepairingtheareawithaskingraftfromthethigh.Manylocalskinflapshavebeendevelopedto
facilitatethetransferofadjacenttissue.Theseincludethenoteflap,therhomboidflap,therotation
advancementflap,andthebilobedflap.Thegeometryoftheseflapsisfascinating,andtheirapplications
arequitevaried.

Autologoustissuesarepreferabletosyntheticorotherimplants.Whencartilageisneededforarepair,it
isbettertoborrowfromtheconchalbowloftheear,therib,ortheseptumthantouseasynthetic
materialthatwillhaveagreaterriskofinfectionandextrusion.

Straightlinesoccurrarelyinthehumanbody.Thusstraightlinescarsmayberevisedtobelongerbut
tohaveacurvedandbrokencoursetohelpcamouflagethem.

Ifapatientcomplainsofsignificantpainordiscomfortafterrhytidectomy,itisneccessarytoremove
thedressingandcheckforahematoma,asthiswillbethemostcommoncause.

Whenaskingraftisplaced,itreceivesnutrientsandoxygenthroughthreedistinctstages:(1)imbibition
(graftabsorbswoundexudate)(2)inosculation(vascularbudsinthewoundconnecttopreexistingand
newvascularchannelsintheskingraft)and(3)revascularization(newvesselgrowth).

Inrepairofmandibleandmidfacefractures,whereverpossible,makecertainthepatient'steetharein
properocclusionattheoutsetofthecase.Thisallowsproperalignmentoffracturedfragments.When
thisisnotpossible,correctreductioncansometimesbeaccomplishedbyworkingdownoffofstable
bonefromtheskull.

Chapter54:NewbornandPediatricPerioperativeCare
Thefetalcirculatorysystemusestheductusvenosus,theforamenovale,andtheductus
arteriosustoshuntoxygenatedbloodpreferentiallytothebrainandupperbodythese
shuntscloseatorshortlyafterbirth.
Theoxyhemoglobindissociationcurveforfetalhemoglobinisshiftedtotheleft,because
oflower2,3DPGbindingbyfetalhemoglobin.
Totalbodywaterandextracellularfluiddecreasebetweenfetallifeandadulthood,
whereasintracellularwaterincreases.
Thefunctionalimmaturityofthenewbornkidneypredisposestheneonateto
hypernatremia.
Metabolicalkalosisiscausedbyelectrolytelossandmayoccurwithprolongedgastric
suctioningorvomitingmetabolicacidosisisusuallytheresultofpoortissueperfusion
andlacticacidosis.
Parentsarelesstroubledaboutthelengthoftheirchild'sincisionthanbyitswidthand
contourirregularities.
Parentswillinspectthedressingyouplaceontheirchild'swoundandinevitablyjudgethe
skillandcarefulnessofthesurgerythatprecededit.

Chapter55:PediatricTraumaandBurns
Maintenancefluids
Infant010kg=100mL/kgD50.2NSwithKC110mEq/500mL
Next10kg=50mL/kgD50.45NSwithKC120mEq/1000mL
Adult=30mL/kgD50.45NSwithKC120mEq/1000mL
Resuscitationfluids
Infantsandchildren=20mL/kgLR2,thenPRBCs10mL/kgprn
Adults=1000mLLR2,thenPRBCs10mL/kgprn
Thepediatricairwayismoreanterior,shorter,andmorefragilethantheadultairway.
Cardiacoutputinchildrenisdependentprimarilyonheartrate.Corollary:Tachycardia
usuallyindicateshypovolemia.
Optimalmanagementofclosedheadinjuryincludespreventionofsecondarybraininjury.
Prolongedarterialspasmisthemostcommonpresentationofpediatricvascularinjury.
Thedurationofsubmersioninaneardrowningaccidentisthemostimportantfactor

associatedwithintactsurvivalsurvivalafterprolongedsubmersion(>5minutes)is
closelyrelatedtowatertemperature.
Achild'stracheaissoftandpliableusecarewhenhandlingorincisingit.
Insertionofcentralvenouscathetersinchildrenisthesameasthatforadults,exceptthat
thetoleranceforerrorisless.
Achild'schestwallisthin,andthechestcavityissmallusecarewheninsertingchest
tubes.
Hemodynamicstatusisthemostaccuratepredictoroftheneedfortransfusionor
operativemanagementorbothofapediatricsolidorganinjury.
Achildwithalapbeltmarkandanabdominalcomputedtomographyscanshowingfree
fluid,butnosolidorganinjury,hasahollowviscousinjuryuntilprovenotherwise.
Children
GalvestonLactatedRinger's5000mL/m2BSAburn+2000mL/m2,
duringthefirst8hrafterburn,other1/2overnext16hrperiod

Adults
ParklandLactatedRinger's4mL/kg/%burn,1/2duringthefirst8hrafter
burn,other1/2overnext16hrperiod

Chapter56:PediatricHead,Neck,andThoracicDisorders
Infantsareobligatenosebreathersobstructionofoneorbothnasalairwaysbya
nasogastric,endotracheal,orfeedingtube(oracombinationofthese)mayimpair
breathing.
Anteriorcervicallymphadenopathyisusuallyviralorbacterialposteriorcervical
lymphadenopathyislesscommonandmoreoftenassociatedwithsystemicdiseaseor
neoplasia.
Infantswithaposterolateralcongenitaldiaphragmaticherniaareatriskforpersistent
pulmonaryhypertensionofthenewborn(PPHN),asaresultofbilateralpulmonary
hypoplasia.
PPHNispotentiatedbyhypoxia,acidosis,andhypothermiaitincreasesrighttoleft
shuntingandexacerbateshypoxiaandacidosispreventionisthekey.
Aninfant'sairwayissmall,easilytraumatized,andhighlypronetoedemaformation
significantlossoflumendiameterisaccompaniedbystridorandtachypnea.
Thyroglossalductcystexcisionincludesexcisionofthecentralportionofthehyoidbone,
toassurethatallductalremnantsareremoved.
Breastmassesinprepubescentgirlsareusuallyobserved,toavoidinjurytothebreast
budthoseinpostpubescentwomenareusuallyexcisedtoobtainadiagnosisandallay
fear.
Repairofpectusexcavatumisprimarilycosmeticitgreatlyenhancesselfimageand
hasbeenshowntoimproveexercisetolerance.
Whenrepairingaposterolateralcongenitaldiaphragmatichernia,rememberthatthe
diaphragmaticdefectrepresentsincompletedevelopmentofthethirdmusclelayerofthe
chestwalldissectthemarginwithcare,andpatchthediaphragmoften.


Chapter57:PediatricGI,AbdWall,Inguinal,andScrotalDisorders
Knowthedifferencesinpresentation,diagnosis,andmanagementofpureesophageal
atresiaversusesophagealatresiawithtracheoesophagealfistula.
Biliousvomitingalwaysdeservesattentionbiliousvomitinginanewbornrequires
investigation.
Donotattributethesymptomsofabdominalpain,anorexia,nausea,andvomitingto
gastroenteritiswithoutfirstaskingyourself,Couldthisbeappendicitis?
Neonataljaundicebeyondage2weeksmustbeinvestigated,especiallyifthedirect
bilirubinlevel(conjugatedfraction)isgreaterthan1mg/dL.
Beabletolistseveraldifferenttypesofthemostcommonomphalomesentericduct
malformation.
Mostpostoperativeproblemsbeginintheoperatingroom.Corollary:Antibioticscannot
compensateforpoortechnique.
Iftheoperationisdifficult,youarenotdoingitcorrectly.RobertGross
Alwaysestablishdistalpatencywhenoperatingforbowelatresiaorstenosis.
Sharpdissectionandtheuseofcuttingasopposedtocauterycurrentcauseless
tissuetrauma,whichleadstobettercosmeticresults.
Knowhowacongenitalinguinalherniadiffersfromanadultinguinalherniaandhow
therepairdiffers.
Beabletolistfivereasonsforsurgicalcorrectionofanundescendedtesticle.

Chapter58:VascularAnomalies,Tumors,andTwins
Hemangiomasaretrueendothelialcelltumors,whereasvascularmalformations
representerrorsinvasculardevelopment.
Ingeneral,50%ofhemangiomaswillresolvebyage5yearsandupto70%byage7
years.
Wilms'tumoristhemostcommonrenaltumorofchildhood.
Rhabdomyosarcomaisasofttissuetumorthatcanarisejustaboutanywhereearly
biopsyiswarranted,becausestageatdiagnosisisthemostimportantprognosticfactor.
Thyroidnodulesinchildrenshouldundergohistologicevaluation,as20%aremalignant.
Lymphaticmalformationstendtoinfiltrateandsurroundimportantnormalstructures
properknowledgeofsurgicalanatomywillhelptopreservethesestructures.
WhenoperatingonaWilms'tumor,explorethecontralateralkidneyforevidenceof
bilateraldiseasebeforeproceedingtonephroureterectomy.
Preoperativechemotherapyforneuroblastomafacilitatestumorexcision,reduces
postoperativecomplications,andimprovespatientsurvival.
Benignandmalignantovarianteratomasareclinicallyindistinguishableandshouldbe
managedwithanopentechnique.

Chapter59:SurgicalTechniquesandWoundManagement
Itisimportanttodeterminewhetherwoundclosurerequiresonlyanemergencyroom
physicianorwhethertheexpertiseofaplastic,general,ororthopedicsurgeonis

required.Itisequallyimportanttodeterminewhetherthewoundclosurecanbecarried
outintheemergencyroomorthepatientneedstogototheoperatingroom.
Openwoundsareusuallyreferredtoaschroniciftheyhavebeenpresentformorethan
1month.
Awoundisusuallyheldtogetherwithsutures,staples,tape,orglue.
Ahealingwoundwillcontractinthreedimensions,resultinginashorteningofthescar.
Incisionsshouldbeplacedinconspicuouslysothatneitherthepatientnoranyoneelse
canseethem.Whenthisisnotpossible,theyshouldbeplacedintherelaxed
skintensionlines,whicharegenerallythesameaswrinklelines.
Whendesigningskinexcisions,itisimportanttoplacethescarinorparalleltothe
relaxedskintensionlines.Italsoisimportanttodesigntheexcisionsothateversionof
theskinedgesiscreated.
Wounddbridementisusuallycarriedoutwithascalpelunderlocalorgeneral
anesthesia.Allnecrotictissueisremoved,and,inaddition,tissuethathasquestionable
viabilityandissignificantlycontaminatedshouldberemoved.
Ingeneral,allanatomiclayersofwounds,suchasmuscle,fascia,dermis,and
epidermis,shouldbeclosed.Subcutaneousfathasminimalholdingstrength,and
suturesareusuallynotplacedinthislayer.
Inskinwounds,thedermalclosurecontributesmostofthestrength.

Chapter60:ReconstructiveandAestheticBreastSurgery
Macromastiaresultsfromanincreasedsensitivitytohormonalstimulationofbreast
tissuethatmaybehereditary,becausewomenwithlargebreastsoftenhaveafamily
history.
Macromastiamayappearduringmenarche,oritmaybetheresultofpregnancy,with
failureofthebreaststoreduceinsizesubstantiallyafterdeliveryandnursing.
Macromastiaisoftencausedbyobesity,inwhichcase,themajorityofthebreastis
madeupofadiposeratherthanglandulartissue.
Thegoalwithbreastreductionproceduresistoreducethesizeofthebreastsandatthe
sametimetomaintaincirculationandsensationtothenippleandpossiblyalsosome
lactatingfunction.
Moststudiesofbreastreductionproceduresshowpatientsatisfactionratesbetween
95%and98%.Dissatisfactionisusuallyassociatedwithscarring.
Forsmalltomediumsizebreastreductions,manyplasticsurgeonsprefertousea
verticaltechnique,whichlimitsthemedialandlateralscars.
Forreductionofextremelylargebreastswithapreoperativesuprasternalnotchtonipple
distanceofatleast40cm,anipplegraftingtechniqueiscommonlyused,whichreduces
theriskoftissuenecrosisorinfection.
Thebreastimplantsthatarecurrentlyusedhaveashellofasiliconeelastomerand
containnormalsaline.Inmostpatients,asubmuscularimplantispreferred.A
submammary,peripheraltransareolaroraxillaryincisioncanbeused.With
salinecontainingimplants,itmustbeonlyapproximately2.5cmlong.

Chapter61:AnatomyandOncology
Theleftrenalveinhasthreebranches(gonadal,lumbar,adrenal)therighthasnone.
Aradicalorchiectomyisperformedthroughaninguinalincisiontoavoidviolatingthe

lymphaticdrainageofthescrotum.
Unilateralhydronephrosisinthefaceofbladdercancerimpliesmuscleinvasive

disease.
Santorini'splexusisanetworkofveinsonthedorsumoftheprostate.
Theneurovascularbundlessitnexttotheprostateatthe5and7o'clockpositions.

Theyprovideimportantinputintheinitiationandmaintenanceofanerection.
Normalprostatespecificantigenisdefinedaslessthan4ng/mL,butthedefinitionof

normalcanvaryaccordingtoage.
Theperipheralzoneoftheprostateisresponsibleformostprostatecancer.
Themostcommoncauseofbladdercancerissmoking.
Bladdercancermostoftenisfirstseenasgross,painlesshematuria.
Only10%ofpatientsinitiallyhavetheclassictriadofrenalcellcancer(flankpain,

abdominalmass,hematuria).
Urgeincontinencecausedbybladderobstructionmaynotresolveaftersurgeryto

relievetheblockageinupto25%ofpatients.

Chapter62:UrinaryTractDysfunction
PosttransurethralresectionsyndromemanifestsasMSchanges/seizures,
bradycardia,andhypotension.Itiscausedbyhyponatremiaduetotheabsorptionofirrigation
fluids.
Thedistallimitofresectionduringatransurethralprostatectomyisthe

verumontanum,whichestimatesthepositionofthevoluntaryurethralsphincter.
Briskhemorrhageduringaslingoperationisusuallycausedbyinjurytothe

perivesicalvenousplexus.
ThepotentialspacebetweenthebladderandthepubisiscalledthespaceofRetzius.
Slingoperationshavethehighestratedlongtermsuccessforthetreatmentofstressurinary

incontinence.
Thesizeofaman'sprostateisnotagoodpredictoroftheamountofurinarysymptomsthat

hemayhave.
Benignprostaticenlargementandstressurinaryincontinencearediseasesofpatient

preference(i.e.,theseverityofbotherusuallydeterminesthelevelofmanagement).
Strongindicationsforatransurethralprostatectomyincludegrosshematuria,recurrent

urinarytractinfections,urinaryretention,renalinsufficiencyduetobladderdysfunction,and
bladderstones(GRRRS).
Urgeincontinencecausedbybladderobstructionmaynotresolveaftersurgerytorelievethe

blockageinupto25%ofpatients.
Chapter63:UrinaryTractLithiasisandInfections
Themostcommontypeofurinarystoneiscomposedofcalciumoxalate.
Urinarycalculiaremostlikelytocauseobstructionattheureteropelvicjunction,the

pelvicbrim,ortheureterovesicaljunction.
Extracorporealshockwavelithotripsyiscontraindicatedinthefaceofactiveinfection,

coagulopathy,andpregnancy.
Theholmiumlaserhasadepthofpenetrationof0.5to1.0mm.
Percutaneouskidneystonesurgeryisusuallyreservedforstoneslargerthan2cm.
Onlyuricacidcalculicanbedissolvedwithoralmedication(creatingurinaryalkalinization).
Ofurinarystones,90%areradiopaque.
Theriskofkidneystonerecurrencecanbereducedbystrivingtoproduce2Lofurineper

dayandmaintainingalowsaltandlowanimalproteindiet.
Acutebacterialinfectionmakesupasmallcomponentofallmendiagnosedwithprostatitis.
Roughly50%ofpatientswillhavearepeatedstoneepisodewithinthenext10years.

Chapter64:Anesthesia
Specialproblemsinpatientswithmorbidobesity
Obstructivesleepapnea
Difficultintravenousaccess

Rapiddesaturationduringintubation
Riskofaspiration
Difficultoxygenation/ventilation
Difficultintubation
Riskofpositioning/nerveinjury
Multiplecomorbidities
Specializedpostoperativemonitoring
Injurytostaff

Chapter65:DermatologicSurgery
SkincanceristhemostcommoncancerinAmerica.Annualized,morethanone
personanhourdiesofskincancerintheUnitedStateseachyear.

MoreskincancersarediagnosedintheUnitedStateseachyearthanallother

cancersofallanatomicsitescombined
Ofpatientsdiagnosedwithaskincancer,in40%,asecond,unrelatedskincancerwill

developwithinthenext5years.
Mohssurgeryisthetreatmentofchoicefornonmelanomaskincancersin

cosmeticallysensitiveareas,forwhichothertherapies(e.g.,standardexcision)havefailed,that
haveaggressivehistologies(e.g.,morpheaform),orthathaveahighriskofmetastasis.
TheABCDsofmelanomastandforasymmetry,borderirregularity,changingcoloror

twoormorecolors,andlargeorchangingdiameter.
EsteranestheticsshouldnotbeusedinpatientswithallergiestoPAST:

paraaminobenzoicacid,sulfurdrugs,andthiazidediuretics.
Amideanesthetics(bupivacaine,mepivacaine)haveanibeforecaine.
Concaveareas(suchasalargroove,medialcanthus)healwellbysecondary

intention.Thescalp,whichisconvex,alsohealswellbysecondaryintentionandistheexception
tothisrule.
Beforeinfiltratingthesurgicalareawithanesthesia,markouttheskintensionlinesand

cosmeticunitsoftheface.
Wheninjectinglocalanesthesia,directtheneedleintoareasthatarealreadyanesthetized,

andthenadvancetheneedleinthesubcutistotheareathatmustbeanesthetized.
Whensuturingonascalpwithdarkbrown/blackhair,usepolypropylene(Prolene)suture,

whichisblue,ratherthannylonsutures,andleavelongtails.Thiswillmakeiteasiertofindand
removethestitchesonthedayofsutureremoval.
Whensuturingaflapinplace,donotputmanydeepstitchesatthetipoftheflap.Thiscan

strangulatethiscriticalareaoftheflapandleadtotipnecrosis.
Whensewingagraft/flapinadifficulttoreachlocation(e.g.,conchalbowl),considerusing

dissolvablesuturestosparethepatientandstafffromtryingtoremovethesutureslateron.
Anellipticalexcisionshouldhavea3:1ratioofthelongaxistotheshortaxisandapexangles

of30degrees.
Tensiononthewoundedgesisthenumberonekillerofflaps(flapnecrosis).


Chapter66:MinimalAccessSurgery
Incomparisonwithopensurgery,laparoscopicsurgeryisusuallyassociatedwith
smallerincisions,shorterhospitalizations,lesspostoperativepain,fasterrecuperation,and
decreasedcosts.
Diagnosticlaparoscopyisespeciallyusefulfortheevaluationofabdominalpainin

womenofchildbearingageorinpatientswhosediagnosisisunclear.
Laparoscopictechniqueshavereducedthethresholdforsurgicalreferralforseveral

commondiseases,includingsymptomaticcholelithiasisandgastroesophagealrefluxdisease.
Laparoscopiccholecystectomyisnowthegoldstandardforremovingadiseased

gallbladder.
Laparoscopicinguinalherniorrhaphymaybeperformedtransabdominallyor

completelyextraperitoneally.
Contraindicationstolaparoscopicabdominalproceduresincludeadvanced

generalizedperitonitis,hypovolemicshock,massiveabdominaldistentionwithclinicalevidence
ofbowelobstruction,uncorrectedcoagulopathy,andinabilityofthepatienttotolerateaformal
laparotomy.
TheCO2pneumoperitoneummaycausehypercapnia,acidosis,andcardiac

arrhythmias,especiallyinpatientswithcardiopulmonarydiseases.
AlternativestotheCO2pneumoperitoneumshouldbeconsideredinhighrisk

patients.
Impropertrocarplacementduringlaparoscopicsurgerycanresultinmajorvascular

injury,intestinalinjury,orairembolism.
Beforelaparoscopyisbegun,allelectronicequipmentshouldbechecked.
BeforeaVeressneedleisinserted,itshouldbeexaminedtoensurethatthespring

mechanismisintactandthatthelumenflusheseasily.
Theriskofbloodvessel,bowel,andbladderinjuriesislowerwithopentrocarinsertionthan

withclosedtrocarinsertion.
Thelocationsfortrocarplacementdependontheprocedurebeingperformed.The

appropriatelocationforasecondaryportcanbeverifiedbysoundingitoutwithaVeressneedle.
Allsecondarytrocarsshouldbeplacedunderdirectlaparoscopicvision.
Extracorporealknottyingtechniquesareusefulontissuethatwilltolerateextrasuture

materialbeingdrawnthroughit.
Toavoidtissuetearingduringextracorporealknottying,theknotpushershouldbetreatedas

anextensionofthesurgeon'sfinger.
Intracorporealknottyingtechniquesareappropriatefordelicatetissues.
Duringintracorporealsuturing,thesuturetailshouldbekeptshortandnexttotheknotto

facilitateknottying.
Chapter67:Transplant
Themostcommontechnicalcomplicationassociatedwithkidneytransplantationis
lymphocele.(Acollectionoflymphaticfluidsurroundingthegraftmaycauserenalcompression,
hydronephrosis,andelevatedcreatininelevels.)
Cytomegalovirusinfectionafteratransplantusuallycausesfeverandmalaiseand

commonlyoccursapproximately6weeksaftertransplant.Italsomaybeassociatedwith
tissueinvasivedisease,suchasgastroenteritisorhepatitis.
Spontaneousbacterialperitonitisoccursinpatientswithchronicliverdisease,isthe

resultofsevereproteinsynthesisdysfunction,andindicatesaninabilitytoopsonizebacteria.Of
thesepatients,50%diewithin6monthsofthisdiagnosisifnotgivenatransplant.
Areplacedhepaticarteryreferstoabranchthatusuallyarisesfromtheproximal2cmofthe

superiormesentericartery.Ittravelsposterolateraltotheportalvein,supplyingtherightlobe.Itis
presentin15%ofpeople.
Theureteroftherenalallograftisusuallycutshortbeforeanastomosistothebladder

becausethebloodsupplytotheuppertwothirdsoftheureterarisesfromtherenalartery,and
thelowerthirdissuppliedbyarterialbranchesfromthebladder.Thusonlytheproximalureter
hasreliablearterializationaftertransplant.
Thepancreashasadualbloodsupply.Theheadofthepancreasreceivesbloodvia

gastroduodenalandinferiorpancreaticoduodenalarteries,whereasthebodyandtaildependon
branchesofthesplenicartery.