Ellis and Calne's Lecture Notes in General Surgery E-Book

Christopher Watson

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Lecture Notes
• Sprache: Englisch

Seitenzahl: 1267

Veröffentlichungsjahr: 2022

Beschreibung

Ellis and Calne’s Lecture Notes in General Surgery is a comprehensive guide that focuses on the fundamentals of general surgery while systematically covering all the clinical surgical problems that a student or doctor in training may encounter and about which they need to know.

The text includes principles of treatment that have been written at a level to inform the medical student and doctor in training. The text features color illustrations throughout and includes electronic access to a wide range of extra material including case studies, radiological and clinical images, and biographies.

Sample topics discussed in Ellis and Calne’s Lecture Notes in General Surgery include:

• Surgical strategy, human factors in surgery, fluid and nutrition management, preoperative assessment, postoperative complications, acute infections, tumours, and shock
• Trauma surgery, burns, the skin and its adnexae, arterial disease, the heart and thoracic aorta, and the chest and lungs
• The brain and meninges, head injury, the spine, peripheral nerve injuries, the oral cavity and the salivary glands
• The oesophagus, stomach and duodenum, the surgery of obesity, the small intestine, the appendix, the colon, and the rectum and anal canal
• The kidney, ureter, bladder, testes and prostate

Trusted by generations of medical students, including the current authors, the clinical emphasis of Ellis and Calne’s Lecture Notes in General Surgery makes this an essential reference for all those wishing to learn more about general surgery. It is also a perfect revision text for medical students and junior surgeons taking the MRCS examination.

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Leseprobe

Table of Contents

Cover

Title Page

Copyright Page

Author affiliations

Preface

Acknowledgements

Abbreviations

About the companion website

1 Surgical strategy

History and examination

2 Human factors in surgery

What are human factors?

Error in healthcare

What are the different types of error and failure?

What human factors in surgery should we be thinking about?

3 Fluid and nutrition management

Body fluid compartments

Fluid and electrolyte losses

Normal fluid losses

4 Preoperative assessment

Patient assessment

Management of pre‐existing medical conditions

Operative factors influencing preoperative management

5 Postoperative complications

Classification

Surgical site infection (SSI)

Complications of antibiotic therapy

Venous thromboembolism

Management of the unwell postoperative patient

Postoperative haemorrhage

Postoperative fever

Postoperative respiratory problems

Pulmonary collapse and infection

Postoperative ileus

Abdominal wound dehiscence

Anastomotic leak

Postoperative fistula

Localized intraperitoneal collections

Subphrenic abscess

Pelvic abscess

Delirium

Complications of minimally invasive surgery

Additional resources

6 Acute infections

Cellulitis

Erysipelas

Abscess

Boil

Carbuncle

Specific infections

Necrotizing soft tissue infections

Anthrax

Botulism

Actinomycosis

Additional resources

7 Tumours

Pathology

Clinical features and diagnosis

History

Examination

Special investigations

Tumour markers

Treatment

Anti‐neoplastic agents

Cancer screening

Inherited cancer syndromes

8 Shock

Aetiology

Normal regulation of tissue perfusion

Abnormal regulation of tissue perfusion

Special causes of shock

Sequelae of shock

Principles in the management of patients in shock

Prevention of hypothermia

9 Trauma surgery

Trauma types

The triad of death in trauma

Phase 1: Pre‐hospital trauma care and initial assessment

Phase 2: Initial assessment with ongoing resuscitation

Secondary survey

Damage control ethos

10 Burns

Causes

Severity

The initial management of the severe burn injury patient

Complications

Prognosis

Additional resources

11 The skin and its adnexae

General functions of the skin

Skin anatomy and embryology

Epidermoid cyst

Dermoid cyst

Verruca vulgaris (wart)

Plantar warts

Ganglion

Pilonidal sinus

Hidradenitis suppurativa

Conditions affecting the nails

Tumours of the skin and subcutaneous tissues

Pigmented skin lesions and malignant melanoma

Tumours of sweat glands and sebaceous glands

Adnexal‐derived skin cancers

Vascular anomalies

Lymph vessel tumours

Nerve tumours

Fatty tumours

Additional resources

12 Arterial disease

Arterial trauma

Aneurysm

Abdominal aortic aneurysm

Ruptured abdominal aortic aneurysm

Popliteal aneurysm

Assessing the patient with arterial disease

Lower limb peripheral arterial disease

Acute limb ischaemia (Box 12.3)

Embolism

Atherosclerotic occlusive arterial disease

Coronary occlusive disease

Mesenteric occlusive disease

Carotid artery disease (Figure 12.6)

Raynaud’s disease and Raynaud’s phenomenon

9

Buerger’s disease

Cold injury

Additional resources

13 The heart and thoracic aorta

Introduction

Cardiopulmonary bypass

Cardiac intensive care

Valvular disease

Aortic stenosis

Mitral regurgitation

Mitral stenosis

Ischaemic heart disease

Thoracic aortic disease

14 The chest and lungs

Injury to the chest

Sternal fracture

Fractures of the ribs

Complications

Empyema

Lung tumours

Carcinoid tumours

Lung cancer

Secondary tumours

Additional resources

15 Venous disorders of the lower limb

Normal venous function

Anatomy of the venous drainage of the lower limb

Aetiology of venous disease

Clinical presentation

Assessment of the patient with venous disease

Treatment of venous disease

Deep vein thrombosis

Additional resources

16 The brain and meninges

Space‐occupying intracranial lesions

Intracranial tumours

Intracranial abscess

Intracranial vascular lesions

Hydrocephalus

Additional resources

17 Head injury

Types of injury

Brain injuries

Cerebral perfusion

Management of the patient with a head injury

Indications for surgery in head injuries

Traumatic intracranial bleeding

Other complications

Brain death

Additional resources

18 The spine

Spina bifida (Figure 18.1)

Spinal injuries

Age‐related (degenerative) spinal disorders

Cervical spondylosis

Spinal infection

Spinal tumours

Additional resources

19 Peripheral nerve injuries

Classification

Special investigations

Brachial plexus injuries

Radial nerve injuries (Figure 19.1a)

Median nerve injuries (Figure 19.1b)

Median nerve compression at the wrist (carpal tunnel syndrome)

Ulnar nerve injuries (Figure 19.2)

Ulnar nerve compression at the elbow (cubital tunnel syndrome)

Differential diagnosis of flexion deformities of the fingers

Sciatic nerve injuries

Common peroneal nerve injuries

Lateral cutaneous nerve of the thigh compression: meralgia paraesthetica

Cervical sympathetic nerve injuries: Horner’s syndrome

8

Additional resources

20 The oral cavity

The oral cavity

Embryology

Congenital disease of the oral cavity and lips

Acquired disease of the oral cavity and lips

Non‐malignant disease of oral mucosa and oral cavity

Lesions of the oral mucosa including lip mucosa

Potential malignant disorders of the mouth

Intraoral pigmented lesions

Intraoral lumps

Malignant disease of the cutaneous lip

Malignant disease of oral mucosa and oral cavity

Reconstructive surgery in head and neck cancer

Additional resources

21 The salivary glands

Inflammation

Viral infections

Acute bacterial parotitis

Chronic recurrent parotid sialadenitis

Sjögren's syndrome

Calculi

Salivary tumours

Adenolymphoma

Carcinoma

Additional resources

22 The oesophagus

Dysphagia

Perforations of the oesophagus

Caustic stricture of the oesophagus

Achalasia of the cardia

Plummer–Vinson syndrome

6

Oesophageal diverticula

Pharyngeal pouch

Reflux oesophagitis

Tumours of the oesophagus

Carcinoma

Barrett’s oesophagus

10

and adenocarcinoma

Additional resources

23 The stomach and duodenum

Congenital hypertrophic pyloric stenosis

Duodenal atresia

Peptic ulcer

The acute peptic ulcer

The chronic peptic ulcer

Perforated peptic ulcer

Pyloric stenosis

Gastrointestinal haemorrhage

Bleeding peptic ulcer

Gastroparesis

Gastric volvulus

Gastric tumours

Gastric polyps

Gastrointestinal stromal tumours

Gastric lymphoma

Gastroenteropancreatic neuroendocrine tumours (GEP‐NETs)

Gastric carcinoma

Additional resources

24 The surgery of obesity

Obesity

25 The small intestine

Meckel’s diverticulum

Crohn’s disease

Tumours of the small intestine

Neuroendocrine tumours

Additional resources

26 The appendix

Embryology and anatomy

Acute appendicitis

Clinical features

Appendiceal abscess

Appendix mass (Box 26.2)

Appendiceal neoplasms

Additional resources

27 The colon

Constipation and diarrhoea

Diverticular disease

Angiodysplasia

Colitis

Tumours

Colostomy

Additional resources

28 The rectum and anal canal

Bright red rectal bleeding ( Table 28.1)

Haemorrhoids

Anal fissure

Anorectal abscesses

Anal fistula

Stricture of the anal canal

Prolapse of the rectum

Pruritus ani

Faecal incontinence

Tumours

Rectal polyps

Carcinoma of the rectum

Anal cancer

Additional resources

29 The acute abdomen

Aetiology

Clinical assessment

Special investigations

Principles of treatment

Non‐surgical treatment

Surgery

Peritonitis

Special causes of peritonitis

Mesenteric ischaemia

30 Intestinal obstruction and paralytic ileus

Mechanical obstruction

Closed loop obstruction

Adhesive obstruction

Volvulus

Neonatal intestinal obstruction

Distal intestinal obstruction syndrome

Intussusception

Paralytic ileus

Pseudo‐obstruction

Additional resources

31 Hernia

Definition

Abdominal wall hernias

Inguinal hernia

Anatomy (Figure 31.2)

Femoral hernia

Richter’s hernia

Umbilical hernia

Congenital umbilical hernia

Paraumbilical hernia

Divarication of the recti

Epigastric hernia

Incisional hernia

Differential diagnosis of midline hernia

Unusual hernias

Diaphragmatic hernias

Traumatic diaphragmatic hernias

Acquired hiatal hernias

Reflux oesophagitis

Additional resources

32 The liver

Liver enlargement

Jaundice

Congenital abnormalities

Liver trauma

Acute infections of the liver

Hydatid disease of the liver

Cirrhosis

The effects of liver failure

Hepatorenal syndrome

Liver neoplasms

Cholangiocarcinoma

Liver surgery

Additional resources

33 The gallbladder and bile ducts

Congenital anomalies

Cholelithiasis (gallstones)

Bile composition and function

Gallbladder physiology

Gallstone types

Clinical manifestations of gallstones

Gallbladder polyps

Carcinoma of the gallbladder

Cholangiocarcinoma

Additional resources

34 The pancreas

Congenital anomalies

Annular pancreas

Heterotopic pancreas

Acute pancreatitis

Severe acute pancreatitis

Chronic pancreatitis

Pancreatic cysts

Pancreatic tumours

Pancreatic neuroendocrine tumours

Insulinoma ( β‐cell tumour)

Gastrinoma (Zollinger–Ellison syndrome,

11

non‐β‐cell islet tumour)

Pancreatic carcinoma

Additional resources

35 The spleen

Splenomegaly

Splenectomy

Ruptured spleen

Additional resources

36 The lymph nodes and lymphatics

The lymphadenopathies

Lymphoedema

Additional resources

37 The breast

Developmental anomalies

Symptoms of breast disease

Traumatic fat necrosis

Acute inflammation of the breast (mastitis)

Chronic inflammatory conditions of the breast

Benign breast disease

Gynaecomastia

Phyllodes tumour

Carcinoma of the breast

Paget’s disease of the nipple

Inflammatory breast cancer

Patients unfit for surgery

Metastatic disease

Carcinoma of the male breast

Breast screening

Additional resources

38 The neck

Branchial cyst and sinus

Tuberculous cervical adenitis

Carotid body tumour (chemodectoma)

Additional resources

39 The thyroid

Congenital anomalies

Lingual thyroid

Thyroglossal cyst

Thyroid physiology

Pathology of goitre

Clinical features in thyroid disease

Hyperthyroidism

Hypothyroidism

Hashimoto’s disease

Riedel’s thyroiditis

De Quervain’s thyroiditis

Investigations in thyroid disease

Clinical classification of thyroid swellings

Outline of treatment of goitre

Hyperthyroidism

Complications of thyroidectomy

Thyroid tumours

Additional resources

40 The parathyroids

Anatomy and development

Physiology

Effects of increased PTH production

Hypoparathyroidism

Hyperparathyroidism

Additional resources

41 The thymus

Tumours

Myasthenia gravis

42 The adrenal glands

Physiology

Enzyme disorders

Cushing’s syndrome

Primary hyperaldosteronism (Conn’s syndrome)

The adrenogenital syndromes (Figure 42.1)

Non‐functioning tumours of the adrenal cortex

Adrenocortical carcinoma

Adrenomedullary tumours

Ganglioneuroma

Adrenal ‘incidentaloma’

Hypertension

Renovascular hypertension

Additional resources

43 The kidney and ureter

Congenital anomalies

Common renal anomalies (Figure 43.2)

Horseshoe kidney

Duplex system

Polycystic disease

Renal cysts

Haematuria

Injury to the kidney

Hydronephrosis

Urinary tract calculi

Urinary tract infections

Reflux nephropathy

Pyonephrosis

Renal abscess

Renal tuberculosis

Renal failure

Management

Acute tubular necrosis

Chronic renal failure

Renal tumours

Nephroblastoma (Wilms’ tumour

5

)

Renal cell carcinoma

Tumours of the renal pelvis and ureter

Additional resources

44 The bladder

Congenital anomalies

Urachal anomalies

Bladder exstrophy (ectopia vesicae)

Rupture of the bladder

Diverticulum of the bladder

Bladder stone

Bladder tumours

Urothelial carcinoma

Additional resources

45 The prostate

Benign prostatic enlargement

Urinary retention

Bladder neck obstruction

Prostatitis

Prostate cancer

Additional resources

46 The male urethra

Anatomy

Congenital anomalies

Urethral injury and trauma in the male

Urethral stricture

47 The penis

Phimosis

Paraphimosis

Balanitis

Penile cancer

Erectile dysfunction

Additional resources

48 The testis and scrotum

Abnormalities of testicular descent

Scrotal swelling

Epididymal cysts

Hydrocoele

Acute infections of the testis and epididymis

Chronic infections of the testis

Torsion of the testis

Varicocoele

Disorders of the scrotal skin

Tumours of the testis

Male infertility

Additional resources

49 Transplantation surgery

Historical background

Classification of grafts

Organ donors

Exclusions to organ donation

Organ preservation

Organ recipients

The immunology of organ transplantation

Organ matching

Rejection

Principles of immunosuppressive therapy

Complications of transplantation

Results of clinical organ transplantation

Additional resources

Index

End User License Agreement

List of Tables

Chapter 1

Table 1.1 Examples of important facts to determine in patients with pain an...

Table 1.2 Common prefixes and suffixes used in surgery

Chapter 2

Table 2.1 Simplified Human Factors Analysis and Classification System (HFAC...

Table 2.2 Situations that might increase the chance of an error in the oper...

Table 2.3 Items to consider during a team briefing

Chapter 3

Table 3.1 Normal daily fluid losses

Table 3.2 Electrolyte content of intravenous fluids

Chapter 4

Table 4.1 Factors involved in the estimation of risk using P‐POSSUM

Table 4.2 The ASA grading system

Chapter 5

Table 5.1 Postoperative complications following abdominal surgery

Table 5.2 The Two‐Level Wells score for estimating the clinical probability...

Table 5.3 Causes of postoperative fever according to postoperative day

Chapter 7

Table 7.1 The 10 most common cancer killers in the UK in 2018

Table 7.2 Tumour markers

Chapter 9

Table 9.1 ATMIST Communication acronym

Table 9.2 The primary survey

Table 9.3 Blood tests for trauma patients

Chapter 10

Table 10.1 Burn comparison

Chapter 11

Table 11.1 Fitzpatrick skin types

Table 11.2 Ten‐year survival according to Breslow depth

Chapter 23

Table 23.1 Summary of Recommendations for gastroduodenal ulcer disease

Chapter 24

Table 24.1 Estimated increased risk for the obese of developing associated ...

Chapter 27

Table 27.1 Diverticulum terminology

Table 27.2 Crohn’s colitis and ulcerative colitis*

Chapter 28

Table 28.1 Rectal bleeding

Chapter 31

Table 31.1 Characteristic differences that help differentiate indirect and ...

Chapter 32

Table 32.1 Diagnosis of jaundice

Chapter 37

Table 37.1 Pathologic TNM staging for breast cancer, AJCC UICC 2010

11

Chapter 45

Table 45.1 Risk stratification for localized or locally advanced prostate c...

List of Illustrations

Chapter 1

Figure 1.1 Location of referred pain for the abdominal organs.

Figure 1.2 Example of how to record abdominal examination findings.

Chapter 2

Figure 2.1 The Swiss cheese model of human error. Each slice can act as a ba...

Figure 2.2 The WHO surgical safety checklist.

Chapter 3

Figure 3.1 Estimated electrolyte concentration in body fluids encountered po...

Chapter 5

Figure 5.1 (a–d) Progression of deep vein thrombosis. PE, pulmonary embolus....

Figure 5.2 The anatomy of the subphrenic spaces (sagittal views): (a) right ...

Chapter 8

Figure 8.1 Starling law.

Figure 8.2 Anatomical & physiological assessment and treatment of shock.

Chapter 9

Figure 9.1 The triad of death in trauma care.

Figure 9.2 Phases of damage control. DCS: damage control surgery; ICU: inten...

Chapter 10

Figure 10.1 A partial‐thickness burn (a) leaves part or the whole of the ger...

Figure 10.2 The Lund and Browder chart allows more accurate estimation of bu...

Figure 10.3 The ‘rule of nines’ – a useful guide to the estimation of the ar...

Chapter 11

Figure 11.1 Layers of the skin with adnexal structures.

Figure 11.2 (a) The normal skin contains melanocytes (shown as cells) and me...

Chapter 12

Figure 12.1 (a–c) Types of aneurysms.

Figure 12.2 Aortic repairs.

Figure 12.3 Classification of endoleaks.

Figure 12.4 Tracings of arteriograms. (a) An example of a good ‘run‐off’ fro...

Figure 12.5 Source of peripheral emboli. DVT, deep vein thrombosis.

Figure 12.6 Consequences and treatment of carotid artery stenosis.

Figure 12.7 Different measurement techniques for determining the degree of c...

Chapter 13

Figure 13.1 Cardiopulmonary bypass.

Figure 13.2 A saphenous vein graft from the aorta to the right coronary arte...

Figure 13.3 (a) A persistent ductus arteriosus – note its close relationship...

Figure 13.4 Stanford classification of aortic dissection.

Chapter 14

Figure 14.1 Flail chest. On inspiration, the detached segment of the chest w...

Figure 14.2 Tension pneumothorax produced by a valvular tear in the lung. Ai...

Figure 14.3 Underwater seal chest drain in the treatment of a pneumothorax. ...

Chapter 15

Figure 15.1 The venous system of the leg. Note that there are two main super...

Figure 15.2 Normal veins and incompetent varicose veins. Note that the vein ...

Chapter 16

Figure 16.1 The common sites of intracranial aneurysms.

Figure 16.2 The ventricular system.

Chapter 17

Figure 17.1 Coup and contre‐coup injuries – mechanism.

Figure 17.2 Decerebrate and decorticate postures.

Figure 17.3 (a) Extradural haematoma and (b) acute subdural haematoma. The l...

Chapter 18

Figure 18.1 Spina bifida.

Figure 18.2 The three‐column spine concept.

Figure 18.3 The relationship of the spinal cord and nerve roots to the verte...

Chapter 19

Figure 19.1 (a) Radial nerve injury: wrist drop, together with anaesthesia o...

Figure 19.2 Ulnar nerve injury:

main en griffe

with anaesthesia of the ulnar...

Figure 19.3 Horner’s syndrome.

Chapter 20

Figure 20.1 The oral cavity and oropharynx viewed from the front.

Figure 20.2 The ventral aspect of a foetal head showing the three prominence...

Chapter 22

Figure 22.1 (a–e) Barium swallow appearances of common causes of dysphagia....

Figure 22.2 A pharyngeal pouch emerging between the two components of the in...

Chapter 23

Figure 23.1 Ramstedt’s pyloromyotomy. The thickened muscle at the pylorus is...

Figure 23.2 The principal operations once commonly performed for peptic ulce...

Figure 23.3 Techniques to close a perforated ulcer.

Figure 23.4 The upper panel (a) illustrates a total gastrectomy with a Roux‐...

Chapter 24

Figure 24.1 Relative risk of death from all causes according to body mass in...

Figure 24.2 The three common bariatric surgical procedures.

Chapter 26

Figure 26.1 The positions in which the appendix may lie, together with their...

Figure 26.2 The blood supply of the appendix.

Chapter 27

Figure 27.1 The relationship of diverticula of the colon to the taenia coli ...

Figure 27.2 Typical colonic operations. For a lesion in the right colon, a r...

Chapter 28

Figure 28.1 Distribution of different conditions around the anal canal.

Figure 28.2 The anatomy of anorectal abscesses.

Figure 28.3 The anatomy of anal fistulas.

Figure 28.4 Staging of rectal cancer by modified Dukes’ and TNM classificati...

Figure 28.5 Surgical procedures for carcinoma of rectum.

Chapter 31

Figure 31.1 The differences between (a) a reducible, (b) an irreducible and ...

Figure 31.2 The anatomy of the inguinal canal: (a) with the external oblique...

Figure 31.3 The anatomy of the femoral canal and its surrounds to show the r...

Figure 31.4 The relationships of an indirect inguinal and a femoral hernia c...

Figure 31.5 The development of the diaphragm. The drawing shows the four con...

Figure 31.6 (a) Sliding hiatus hernia: the stomach and lower oesophagus slid...

Chapter 32

Figure 32.1 The metabolism of bilirubin.

Figure 32.2 The sites of occurrence of portal–systemic communications in pat...

Figure 32.3 (a–c) Segmental anatomy of the liver showing inflow vessels (hep...

Chapter 33

Figure 33.1 Developmental anomalies of the gallbladder. (a) A long cystic du...

Figure 33.2 Biliary anatomy and anomalies. In the majority of individuals, t...

Figure 33.3 The varieties of gallstones.

Figure 33.4 Obstructive jaundice due to stone is usually associated with a s...

Chapter 34

Figure 34.1 (a–d) The development of the pancreas and biliary tree.

Figure 34.2 Whipple’s pancreaticoduodenectomy. (a) The initial appearance ch...

Chapter 37

Figure 37.1 Anatomical features of the breast.

Figure 37.2 The different origins of

in situ

and invasive ductal and lobular...

Figure 37.3 The lymphatic drainage of the breast.

Chapter 38

Figure 38.1 The derivatives of the branchial pouches and clefts.

Chapter 39

Figure 39.1 The descent of the thyroid, showing possible sites of ectopic th...

Figure 39.2 The relationship of the recurrent laryngeal nerve to the thyroid...

Chapter 42

Figure 42.1 Adrenocortical steroid synthesis

Figure 42.2 Scheme for investigation of incidental adrenal lesion on imaging...

Figure 42.3 Mechanism of renal hypertension.

Chapter 43

Figure 43.1 Development of the pro‐, meso‐ and metanephric systems (after La...

Figure 43.2 Renal abnormalities: (a) polycystic kidney; (b) Horseshoe kidney...

Figure 43.3 Some important causes of bleeding in the urinary tract.

Figure 43.4 Diagram of the effects of urinary calculi.

Chapter 44

Figure 44.1 Embryological development of the bladder and lower urinary tract...

Chapter 45

Figure 45.1 The clinical staging of prostatic carcinoma.

Chapter 48

Figure 48.1 Questions to resolve the differential diagnosis of a scrotal swe...

Figure 48.2 (a–d) The anatomical classification of hydrocoeles (the ring at ...

Guide

Cover Page

Title Page

Copyright Page

Author affiliations

Preface

Acknowledgements

Abbreviations

About the companion website

Table of Contents

Begin Reading

Index

WILEY END USER LICENSE AGREEMENT

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Ellis and Calne’s Lecture Notes in General Surgery

Edited by

Christopher Watson, MD BChir FRCS

Professor of Transplantation and Honorary Consultant Surgeon

Cambridge University Hospitals NHS Foundation Trust

Cambridge, UK

Justin Davies, MA MChir FRCS (Gen Surg)

FEBS (Coloproctology)

Consultant Colorectal Surgeon

Cambridge University Hospitals NHS Foundation Trust

Affiliated Assistant Professor

University of Cambridge

Fellow in Clinical Medicine

Downing College, Cambridge, UK

Fourteenth Edition

This fourteenth edition first published 2023© 2023 John Wiley & Sons Ltd

Edition History1965, 1968, 1970, 1972, 1977, 1983, 1987, 1993, 1998, 2002, 2006, 2011, 2016 by Harold Ellis, Sir Roy Y. Calne and Christopher J. E. Watson

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Christopher Watson, and Justin Davies to be identified as the authors of the editorial material in this work has been asserted in accordance with law.

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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make.Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging‐in‐Publication Applied forPaperback ISBN: 9781119862482

Cover Design: WileyCover Image: © Morsa Images/Getty Images

Author affiliations

Hemantha AlawattegamaConsultant AnaesthetistCambridge University Hospitals NHS Foundation Trust

Anita BalakrishnanConsultant HPB SurgeonCambridge University Hospitals NHS Foundation Trust

Peter A. BrennanConsultant Maxillofacial Surgeon and Honorary Professor of SurgeryPortsmouth Hospitals University TrustPortsmouth

Alexandra J. ColquhounConsultant UrologistCambridge University Hospitals NHS Foundation Trust

Aman Singh CoonarConsultant Thoracic SurgeonRoyal Papworth HospitalCambridge

Patrick CoughlinLeeds Vascular InstituteLeeds

Justin DaviesConsultant Colorectal SurgeonCambridge University Hospitals NHS Foundation TrustAffiliated Assistant ProfessorUniversity of CambridgeFellow in Clinical MedicineDowning College, Cambridge

Amer J. DurraniConsultant Plastic & Reconstructive SurgeonCambridge University Hospitals NHS Foundation Trust

Brian FishConsultant ENT/Head and Neck SurgeonCambridge University Hospitals NHS Foundation Trust

Manj GohelConsultant Vascular & Endovascular SurgeonCambridge University Hospitals NHS Foundation TrustHonorary Senior LecturerImperial CollegeLondon

Stavros GourgiotisConsultant SurgeonCambridge Oesophago‐Gastric CentreCambridge University Hospitals NHS Foundation Trust

Ian GrantConsultant Plastic SurgeonCambridge University Hospitals NHS Foundation Trust

Ekpemi IruneConsultant Laryngology, Head & Neck Surgeon Cambridge University Hospitals NHS Foundation Trust

David P. JenkinsConsultant Cardiothoracic SurgeonRoyal Papworth HospitalCambridge

Eleftheria KleidiConsultant Oncoplastic Breast SurgeonCambridge University Hospitals NHS Foundation Trust

Vasilis KosmoliaptsisHonorary Consultant Abdominal Transplant, HPB and Endocrine SurgeonAssociate Professor, Department of SurgeryUniversity of Cambridge

Rodney J. C. LaingConsultant NeurosurgeonCambridge University Hospitals NHS Foundation Trust

Arthur McPheeConsultant UrologistCambridge University Hospitals NHS Foundation Trust

Kanwalraj MoarConsultant Cleft and Maxillofacial SurgeonCambridge University Hospitals NHS Foundation Trust

Jonathan MortonConsultant Colorectal SurgeonCambridge University Hospitals NHS Foundation Trust

Ioanna G. PanagiotopoulouConsultant Colorectal SurgeonCambridge University Hospitals NHS Foundation Trust

Raaj Kumar PraseedomConsultant HPB & Transplant SurgeonCambridge University Hospitals NHS Foundation Trust

Stephen PriceHonorary Consultant NeurosurgeonCambridge University Hospitals NHS Foundation Trust

Christopher PringConsultant Bariatric SurgeonSt Richard’s HospitalChichesterVisiting ProfessorUniversity of Surrey

Peter SafranekConsultant SurgeonCambridge Oesophago‐Gastric CentreCambridge University Hospitals NHS Foundation Trust

Constantinos SimillisConsultant Colorectal SurgeonCambridge University Hospitals NHS Foundation Trust

Lynsey SpillmanHepatology and Liver Transplant DietitianCambridge University Hospitals NHS Foundation Trust

Vijay SujendranConsultant SurgeonCambridge Oesophago‐Gastric CentreCambridge University Hospitals NHS Foundation Trust

Elizabeth TweedleConsultant Colorectal SurgeonCambridge University Hospitals NHS Foundation Trust

Christopher WatsonProfessor of Transplantation and Honorary Consultant SurgeonCambridge University Hospitals NHS Foundation Trust

Preface

Many medical students will have effectively written their own textbook at the end of their clinical course – a digest of the lectures and tutorials assiduously attended and of the textbooks meticulously read. Unfortunately, students may approach the qualifying examinations burdened by the thought of many pages of excellent and exhaustive textbooks wherein lies the wisdom required of them by the examiners. Although the Internet is increasingly used as a source of information, we believe that there is still a serious need for a book that briefly sets out the important facts in General Surgery that are classified, analysed and, as far as possible, rationalized for the revision student. These lecture notes represent such a text; they are in no way a substitute for the standard textbooks, but they do draw together, in a logical way, the fundamentals of General Surgery and its subspecialties. As such we hope it will also be of use to the junior surgeon.

We wish to point the reader to the electronic resource accompanying the text, including case studies, radiographs and histology slides illustrating common conditions mentioned in the text, as well as a quiz to test the reader’s knowledge.

The first edition of Lecture Notes in General Surgery was written by Harold Ellis and Sir Roy Calne and published in 1965. This is the first edition without their involvement, and we acknowledge their huge contribution to surgery and its teaching. Surgery has changed enormously since the days of that first edition, and each subsequent edition has tried to keep pace with surgical practice. Never has the pace of change been so great as it is today. The biggest changes have been seen in the development of specialist services, at the expense of the generalist, and the development of multidisciplinary teams to optimize management. Recognizing this, previous editions have relied heavily on colleagues from other specialties to keep chapters updated and relevant. For this edition we have taken this further, and each chapter now has a nominated expert author – who, for some chapters, has updated previous content; and, for others, has written completely new content – to ensure relevance for today’s student.

Christopher WatsonJustin Davies

Acknowledgements

We are grateful to our colleagues – senior and junior doctors, and students – who have read and critiqued this text during its production, and to many readers and reviewers for their constructive criticisms. We are indebted to those colleagues in years gone by, too numerous to mention here, who have developed the text upon which the new chapter experts have built. We would also like to acknowledge the continued help give by the staff at Wiley for seeing this project through to publication, in particular James Watson, Catriona King, Mandy Collison, Ella Elliott, and Indirakumari Siva.

Abbreviations

ABPI

ankle brachial pressure index

ABG

arterial blood gas

ABLS

Advanced Burns Life Support

ACE

angiotensin‐converting enzyme

ACTH

adrenocorticotrophic hormone

ADH

antidiuretic hormone

ADT

androgen deprivation therapy

AFP

α‐fetoprotein

AIs

aromatase inhibitors

AIDS

acquired immune deficiency syndrome

AIN

anal intraepithelial neoplasia

AJCC

American Joint Committee on Cancer

ALK

anaplastic lymphoma kinase

ALP

alkaline phosphatase

ALT

alanine transaminase

ANC

axillary node clearance

ANS

axillary node sampling

ANUG

acute necrotizing ulcerative gingivitis

APFC

acute peripancreatic fluid collection

APACHE

Acute Physiology and Chronic Health Evaluation

APTT

activated partial thromboplastin time

APUD

amine precursor uptake and decarboxylation

ASA

American Society of Anesthesiologists

ASD

atrial septal defect

ASIA

American Spinal Injury Association

AST

aspartate transaminase

ATN

acute tubular necrosis

ATLS

Advanced Trauma Life Support

AXR

abdominal X‐ray

β‐HCG

β‐human chorionic gonadotrophin

BCG

bacille Calmette–Guérin

BCS

breast conserving surgery

BMI

body mass index

BPH

benign prostatic hyperplasia

CABG

coronary artery bypass graft

CAPOX

capecitabine and oxaliplatin

CAR

chimeric antigen receptor

CaSR

calcium sensing receptor

CEA

carcinoembryonic antigen

CEAP

Clinical, Etiological, Anatomical and Pathophysiological

CHRPE

congenital hypertrophy of the retinal pigment epithelium

CMV

cytomegalovirus

CNS

central nervous system

COPD

chronic obstructive pulmonary disease

CPAP

continuous positive airways pressure

CPE

carbapenemase‐producing enterobacteriaceae

CPPS

chronic pelvic pain syndrome

CRE

carbopenem‐resistant enterobacteriaceae

CRP

C‐reactive protein

CSF

cerebrospinal fluid

CT

computed tomography

CTLA4

cytotoxic lymphocyte–associated antigen 4

CTPA

computed tomographic pulmonary angiography

CVP

central venous pressure

CXR

chest X‐ray

DBD

donation after brain‐stem death

DCD

donation after circulatory death

DCIS

ductal carcinoma

in situ

DCS

damage control surgery

DDAVP

deamino‐

D

‐arginine vasopressin

DHCA

deep hypothermic circulatory arrest

DIC

disseminated intravascular coagultion

DIOS

distal intestinal obstruction syndrome

DMSA

dimercaptosuccinic acid

DOPA

dihydroxyphenyl alanine

DST

dexamethasone suppression test

DTC

differentiated thyroid cancer

DTPA

diethylene triamine penta‐acetic acid

DVT

deep venous thrombosis

EBV

Epstein‐Barr virus

ECG

electrocardiogram

ECST

European Carotid Surgery Trial

EGFR

epidermal growth factor receptor

EGC

early gastric cancer

EMG

electromyography

EMR

endoscopic mucosal resection

EMSB

Emergency Management of Severe Burns

ER

oestrogen receptor

ERAS

Enhanced Recovery After Surgery

ERCP

endoscopic retrograde cholangiopancreatography

ESBL

extended spectrum β‐lactamase

ESD

endoscopic submucosal dissection

ESR

erythrocyte sedimentation rate

ESWL

extracorporeal shock‐wave lithotripsy

EUS

endoscopic or endoluminal ultrasound

EVAR

Endovascular Aneurysm Repair

5‐FU

5‐fluorouracil

FAP

familial adenomatous polyposis

FAST

focused abdominal sonography for trauma

FBC

full blood count

FDG

fluorodeoxyglucose

FEV

1

forced expiratory volume in 1 second

FFP

fresh frozen plasma

FIT

faecal immunochemical test

FNAC

fine‐needle aspiration cytology

FOLFOX

folinic acid and oxaliplatin

FSH

follicle‐stimulating hormone

GABA

γ‐aminobutyric acid

GANT

gastrointestinal autonomic nervous tumour

GCS

Glasgow Coma Score

GEP‐NETs

gastroenteropancreatic neuroendocrine tumours

GFR

glomerular filtration rate

GGT

γ‐glutamyl transferase

GI

gastrointestinal

GIM

gastrointestinal metaplasia

GIST

gastrointestinal stromal tumour

GLA

γ‐linolenic acid

GOJ

gastro‐oesophageal junction

GnRH

gonadotrophin‐releasing hormone

GORD

gastroesophageal reflux disease

GPA

granulomatosis with polyangiitis

GTN

glyceryl trinitrate

HAART

highly active antiretroviral treatment

HALO

haemorrhoidal artery ligation

HALT

hungry, anxious/angry, late, tired

HAMN

high‐grade appendiceal mucinous neoplasms

HbA1c

glycosylated haemoglobin

HCl

hydrochloric acid

HCC

hepatocellular carcinoma

HER2

human epidermal growth factor receptor 2

HGD

high‐grade dysplasia

HHT

hereditary haemorrhagic telangiectasia

HHV

human herpes virus

HIPEC

heated intraperitoneal chemotherapy

HIV

human immunodeficiency virus

HLA

human leucocyte antigen

HNPCC

hereditary non‐polyposis colon cancer

HoLEP

holmium laser prostatectomy

HPOA

hypertrophic pulmonary osteoarthropathy

HPV

human papilloma virus

HQIP

Healthcare Quality Improvement Partnership

HRT

hormone replacement therapy

HSV

herpes simplex virus

HTIG

human tetanus immunoglobulin

IBD‐U

inflammatory bowel disease unclassified

ICC

interstitial cell of Cajal

ICP

intracranial pressure

ICSI

intracytoplasmic sperm injection

ICU

intensive care unit

IFN

interferon

IMA

inferior mesenteric artery

IMV

inferior mesenteric vein

INR

International normalized ratio

IPMN

intraductal papillary mucinous neoplasm

IPSS

International prostate symptom score

ITU

intensive therapy unit

IVC

inferior vena cava

IVF

in vitro

fertilization

IVU

intravenous urogram

JVP

jugular venous pressure

KSHV

Kaposi sarcoma herpes virus

KUB

kidneys, ureters and bladder

LAD

left anterior descending artery

LAMN

low‐grade appendiceal mucinous neoplasms

LCIS

lobular carcinoma

in situ

LDH

lactate dehydrogenase

LGD

low‐grade dysplasia

LHRH

luteinizing hormone‐releasing hormone

LIF

left iliac fossa

LiDCO

transpulmonary lithium dilution cardiac output

LMWH

low‐molecular‐weight heparin

LUTS

lower urinary tract symptoms

MAG3

m

ercapto‐

a

cetyl tri

g

lycine

MAMC

midarm muscle circumference

MCN

mucinous cystic neoplasm

MDT

multidisciplinary team

MELD

model for end‐stage liver disease

MEN

multiple endocrine neoplasia

MHC

major histocompatibility complex

MIBG

meta‐iodobenzylguanidine

MIBI

methoxyisobutylisonitrile

MOI

mechanism of injury

mpMRI

multiparametric MRI

MR

magnetic resonance

MRC

Medical Research Council

MRCP

magnetic resonance cholangiopancreatography

MRI

magnetic resonance imaging

MRSA

methicillin‐resistant

Staphylococcus aureus

mTOR

mechanistic target of rapamycin

MUST

Malnutrition Universal Screening Tool (ch 3)

NAFLD

non‐alcoholic fatty liver disease

NASCET

North American Symptomatic Carotid Endarterectomy Trial

NCEPOD

National Confidential Enquiry into Perioperative Death

NELA

National Emergency Laparotomy Audit

NEWS

National Early Warning Score

NEN

neuroendocrine neoplasms

NHS

National Health Service

NICE

National Institute of Health and Care Excellence

NG

nasogastric

NOACs

novel oral anticoagulants

NPI

Nottingham Prognostic Index

NSAIDs

non‐steroidal anti‐inflammatory drugs

NSCLC

non‐small cell lung cancer

NSGCT

non‐seminomatous germ cell tumour

NST

no special type

OCP

oral contraceptive pill

OPG

orthopantomogram

OPSI

overwhelming post‐splenectomy infection

PAC

plasma aldosterone concentration

PBC

primary biliary cholangitis

PCI

percutaneous coronary intervention

pcr

pathologic complete response

PDE5

phosphodiesterase type 5

PDGFA

platelet‐derived growth factor receptor α

PDL

programmed death ligand

PE

pulmonary embolism

PEC

percutaneous endoscopic colostomy

PEG

polyethylene glycol

PEG

percutaneous endoscopic gastrostomy

PET

positron emission tomography

PI_RADS

prostate imaging reporting and data system

PICC

peripherally inserted central catheter

PN

parenteral nutrition

PNET

primitive neuroectodermal tumour

POEM

per oral endoscopic myotomy

POSSUM

Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity

PPE

personal protective equipment (ch 2)

PPGL

Phaeochromocytoma and paraganglioma

PPP

patient, procedure and people

PR

progesterone

PRA

plasma renin activity

PRC

plasma renin concentration

PSA

prostate‐specific antigen

PSC

primary sclerosing cholangitis

PT

prothrombin time

PTA

percutaneous transluminal angioplasty

PTC

percutaneous transhepatic cholangiography

PTCA

percutaneous transluminal coronary angioplasty

PTFE

polytetrafluoroethylene

PTH

parathormone

PUJ

pelviureteric junction

PV

portal vein

RIF

right iliac fossa

SAH

subarachnoid haemorrhage

SBP

spontaneous bacterial peritonitis

SCLC

small‐cell lung cancer

SDHX

succinate dehydrogenase subunit genes

SDM

shared decision‐making

SGA

Subjective Global Assessment

SGOT

serum glutamic oxaloacetic transaminase (synonymous with AST)

SGPT

serum glutamic pyruvic transaminase (synonymous with ALT)

SIADH

syndrome of inappropriate antidiuretic hormone

SLE

systemic lupus erythematosus

SLN

sentinel lymph node

SMA

superior mesenteric artery

SMV

superior mesenteric vein

SORT

Surgical Outcome Risk Tool

SSI

surgical site infection

SV

splenic vein

SVT

superficial vein thrombosis

TAD

targeted axillary dissection

TB

tuberculosis

T3

tri‐iodothyronine

T4

tetra‐iodothyronine, thyroxine

TACE

transarterial chemoembolization

TAE

tumour embolisation

TAP

transversus abdominus plane

TAVI

transaortic valve implantation

TCC

transitional cell carcinoma

TED

thromboembolism deterrent

TEVAR

thoracic endovascular aortic repair

TIA

transient ischaemic attack

TIPS

transjugular intrahepatic portosystemic shunt

TNF

tumour necrosis factor

TNM

tumour node metastasis

TOE

transoesophageal echocardiography

TPA

tissue plasminogen activator

TPN

total parenteral nutrition

TRAM

transverse rectus abdominis myocutaneous

TRH

thyrotrophin‐releasing hormone

TRUS

transrectal ultrasound

TSH

thyroid‐stimulating hormone

TUR

transurethral resection

UC

urothelial carcinoma

UC

ulcerative colitis

UFH

unfractionated heparin

UKELD

United Kingdom Model for end‐stage liver disease

UW

University of Wisconsin

VAB

vacuum‐assisted biopsy

VAC

vacuum‐assisted closure

VATS

video‐assisted thoracoscopic surgery

VAWCM

vacuum‐assisted wound closure device with mesh‐mediated fascial traction

VEGF

vascular endothelial growth factor

VEGFR‐3

vascular endothelial growth factor receptor 3

VET

venous thromboembolism

VIP

vasoactive intestinal polypeptide

VISA

vancomycin‐intermediate

Staphylococcus aureus

VRE

vancomycin‐resistant

Enterococcus

VRSA

Vancomycin‐resistant

Staphylococcus aureus

WHO

World Health Organisation

About the companion website

This book is accompanied by a companion website.

www.wiley.com/go/Watson/GeneralSurgery14

The website features:

Interactive multiple choice and short‐answer questions

Case Studies

Extra images and photographs

Biographies

1Surgical strategy

Justin Davies

Learning objectives

To understand the principles of taking a clear history, performing an appropriate examination, presenting the findings and formulating a management plan for diagnosis and subsequent investigations and treatment.

To understand the common nomenclature used in surgery.

The principles of assessing patients referred to a surgical team has changed little in recent times. These include:

Taking an accurate history

.

Examination of the patient

.

Accurate and contemporaneous documentation

(

written and/or electronic)

.

Constructing a differential diagnosis

. Ask the question ‘What diagnoses would best explain this clinical picture?’

Special investigations

. Which laboratory and imaging tests are required to confirm or refute the clinical diagnosis?

Management

. Decide on the management of the patient, including provision of adequate analgesia. Remember that this will include reassurance, explanation, and good communication skills.

History and examination

Development of clinical skills is of paramount importance in all aspects of medicine and surgery. In some circumstances, excessive reliance on special investigations and extensive imaging may be unnecessary. It is important to remember that the patient may be apprehensive and will often be in pain, especially when presenting as an emergency. Attending to these issues is an especially important aspect of good clinical care.

The history

The history should be an accurate reflection of what the patient has said. It is important to ask open questions such as ‘When were you last well?’ and ‘What happened next?’ rather than closed questions such as ‘Do you have chest pain?’ If you have a positive finding, it is important to explore this further with more directed questioning, for example, ‘When did it start?’ ‘What makes it better, and what makes it worse?’ ‘Where did it start and where did it go?’ ‘Did it come and go, or was it constant?’ If the symptom is characterized by bleeding, ask about what sort of blood (e.g. fresh, bright red, dark red), when it started, how much, whether there were clots, whether it was mixed in with food/faeces and whether it was associated with pain. Remember that most patients come to see a general surgeon, particularly in the emergency setting, because of abdominal pain or bleeding (Table 1.1). You will need to find out as much as you can about the presenting symptoms.

Keep in mind that the patient may have little accurate anatomical knowledge. They might say ‘my stomach hurts’, but this may be due to lower chest or periumbilical pain – it is important to ask them to point to the site of the pain. Bear in mind that they may be pointing to a site of referred pain, and a vague description such as ‘back pain’ will need further exploration and clarification as to where it is in the back – the sacrum or lumbar, thoracic or cervical spine, or possibly the loin or subscapular regions. Exploring pain outside of the abdomen is important, particularly shoulder pain. This may, for example, suggest referred pain from the diaphragm or gallbladder.

Table 1.1 Examples of important facts to determine in patients with pain and rectal bleeding

Pain

Rectal bleeding

Exact site

Estimation of amount (often inaccurate)

Radiation

Timing of bleeding

Length of history

Colour – bright red, dark red, black

Periodicity

Accompanying symptoms – pain, vomiting (haematemesis)

Nature – constant/colicky

Associated features – fainting, shock, etc.

Severity

Blood mixed in stool, lying on surface, on toilet paper, in toilet bowl

Relieving and aggravating factors

Accompanying features (e.g. jaundice, vomiting, haematuria)

It is often useful to consider the viscera in terms of their embryology. Thus, epigastric pain is generally from foregut structures such as the stomach, duodenum, liver, gallbladder, spleen and pancreas; periumbilical pain is midgut pain from the small bowel and ascending colon, including the appendix; suprapubic pain is hindgut pain, originating in the colon, rectum and other structures of the cloaca such as the bladder, uterus and Fallopian tubes (Figure 1.1). Testicular pain may also be periumbilical, reflecting the intra‐abdominal origin of these organs before their descent into the scrotum – this is exemplified by the child with testicular torsion who initially complains of pain in the centre of their abdomen.

Figure 1.1 Location of referred pain for the abdominal organs.

The examination

Remember the classic quartet in this order:

Inspection.

Palpation.

Percussion.

Auscultation.

Careful inspection is always time well spent. Inspect the patient generally, as to how they lie and breathe. Are they tachypnoeic because of a chest infection or in response to a metabolic acidosis? Look at the patient’s hands and feel the pulse. Asking the patient to walk may be revealing in someone with claudication or in assessment of general fitness.

Only after careful inspection should palpation start. If you are examining the abdomen in the emergency setting, it is important to ask the patient to cough. This is a surrogate test of rebound tenderness and indicates where the site of inflammation is within the peritoneal cavity. It is often helpful to examine the ‘normal’ or non‐symptomatic side first, be it the abdomen, hand, leg or breast. Look carefully at the patient’s face while you palpate, as this may provide subtle clues regarding discomfort or tenderness. If there is a lump, decide which anatomical plane it lies within. Is it in the skin, in the subcutaneous tissue, in the muscle layer or, in the case of the abdomen, in the underlying cavity? Is the lump pulsatile, expansile or mobile?

Documenting medical notes

We practice in an era where electronic patient records are becoming more commonplace, although currently the UK still has the majority of hospitals with paper‐based medical records. The number with electronic records will continue to increase over time.

Always write or type your findings completely and accurately in a contemporaneous fashion. Start by recording the date and time of the assessment and check that you have the correct patient’s notes open. Record all the negative as well as positive findings. Avoid abbreviations where possible since they may mean different things to different people; for example, PID – you may mean pelvic inflammatory disease, but the next person might interpret it as a prolapsed intervertebral disc. Use the appropriate surgical terminology (Table 1.2).

Table 1.2 Common prefixes and suffixes used in surgery

Prefix

Related organ/structure

angio‐

blood vessels

arthro‐

a joint

cardio‐

heart

cholecysto‐

gallbladder

coelio‐

peritoneal cavity

colo‐ and colon‐

colon

colpo‐

vagina

cysto‐

urinary bladder

gastro‐

stomach

hepato‐

liver

hystero‐

uterus

laparo‐

peritoneal cavity

mammo‐ and masto‐

breast

nephro‐

kidney

oophoro‐

ovary

orchid‐

testicle

rhino‐

nose

thoraco‐

chest

Suffix

Procedure

‐centesis

surgical puncture, often accompanied by drainage, e.g. thoracocentesis

‐desis

fusion, e.g. arthrodesis

‐ectomy

surgical removal, e.g. colectomy

‐oscopy

visual examination, usually through an endoscope, e.g. laparoscopy

‐ostomy

creating a new opening (mouth) on the surface, e.g. colostomy

‐otomy

surgical incision, e.g. laparotomy

‐pexy

surgical fixation, e.g. orchidopexy

‐plasty

to mould or reshape, e.g. angioplasty; also to replace with prosthesis, e.g. arthroplasty

‐rrhaphy

surgically repair or reinforce, e.g. herniorrhaphy

Figure 1.2 Example of how to record abdominal examination findings.

Illustrate your examination unambiguously with simple drawings when possible – use anatomical reference points and measure the diameter of any lumps accurately. When drawing abdominal findings, use a hexagonal representation (Figure 1.2). A continuous line implies an edge; shading can represent an area of tenderness or the site where pain is experienced. If you can feel all around a lump, draw a line to indicate this; if you can feel only the upper margin, show only this. Annotate the drawings with your findings (Figure 1.2). At the end of your notes, write a single paragraph summary and make a diagnosis or record a differential diagnosis. Outline a management plan and state what investigations should be done, indicating those which you have already arranged. Sign your notes and print your name, position and contact details, with the time and date recorded.

Case presentation

The purpose of presenting a case is to convey to your colleagues the salient clinical features, diagnosis or differential diagnosis, management, and investigations of the patient. The presentation should ideally be succinct and to the point, containing important positive and negative findings. At the end of a case presentation, the listening team should have an excellent word picture of the patient and their problems, what needs to be monitored and what plans you have for management.

2Human factors in surgery

Peter A. Brennan

Learning objectives

To understand the factors that can affect safe surgical practice.

To know what measures to take to mitigate risks in surgery.

What are human factors?

There are many definitions of this term, but a simple one to remember is how we interact with each other (in teams), the systems in which we work, our variability and the factors that affect our performance and those of team members. In healthcare, human factors application can lead to improved patient safety, better team working and staff morale. Important elements of human factors also include situational awareness, effective team working, safe and effective communication, and good leadership. Furthermore, by recognizing how both physical and mental performance deteriorate over time helps to consolidate their importance.

As humans, we regularly make mistakes, with an average of five to seven simple errors affecting each of us every day. These might be something simple such as forgetting a wallet or a mobile phone when leaving for work because of a distraction. While these errors or omissions might be annoying, error in healthcare is a cause of significant patient harm and mortality. We can never completely eliminate error, and as the above‐mentioned examples demonstrate, it is a familiar part of everyday life. The term ‘never event’ has been coined to describe occurrences that should not occur in a healthcare setting and includes wrong site surgery, retained instruments and swabs, and incorrect naso‐gastric tube placement. A ‘never event’ is somewhat of a misnomer as error can never be completely eliminated, but the chances of error occurring can be minimized.

The Roman Philosopher Cicero (106–43 BC) wrote ‘anyone is liable to err (make a mistake), but only a fool persists in error’. Learning from mistakes and sharing lessons widely with others is one of the most important elements to improving patient safety across healthcare.

Error in healthcare

The interplay of human error and human factors in clinical incidents (including factors that have their origins in hospitals where we work) is becoming more widely understood. It is often more than one issue (or layer) that leads to error, and this is readily demonstrated by the well‐known Swiss cheese model (Figure 2.1).

Often, factors are multifactorial and take place simultaneously – recognizing this fact is the first step to understanding human factors in surgery. These multifactorial issues include ones that affect us as individuals, such as tiredness, repetition, stress, the effects of distraction and multi‐tasking. Other factors can occur as part of team working, and these include poor communication or leadership, loss of situational awareness, and steep (or flat) authority gradients. The introduction of the World Health Organisation (WHO) surgical checklist (Figure 2.2) has improved attitudes towards pre‐surgery briefing and patient safety, and the benefits of recognizing and applying these human factors principles in surgery are well known.

Figure 2.1 The Swiss cheese model of human error. Each slice can act as a barrier.

One in 20 hospital admissions has some form of error, and of these one in 20 are serious (i.e. one in 4,000 admissions). The operating theatre is known to be one of the most potentially error‐prone places in the hospital as a result of high patient turnover, site‐specific treatments, many heterogeneous surgical procedures, staff limitations and unfamiliar teams.

What are the different types of error and failure?

The Human Factors Analysis and Classification System (HFACS) categorizes failure across four broad domains:

Organizational influences.

Unsafe supervision.

Preconditions to unsafe acts.

Unsafe acts.

All four domains can be applied to the Swiss cheese model (Figure 2.1). Failures at each level may be active (decisions, actions or attitudes by individuals or surgical teams) or latent (results of deficiencies with the hospital or management team). Examples of failures in the clinical setting that can have their origin in the employing organization include pressures of overbooked clinics or operating theatre sessions, meeting clinical and hospital targets and prolonged working hours without breaks. Medical error may, therefore, begin to develop well before the actual event itself (such as wrong site surgery) as a result of institutional failure.

What human factors in surgery should we be thinking about?

Table 2.1 summarizes some important human factors that can contribute to and ultimately lead to surgical error, as categorized by the HFACS. These include factors that affect us as individuals, such as tiredness and fatigue; nutritional status; emotional states, including anger and stress; multi‐tasking; and loss of situational awareness. These will now be considered further:

Tiredness and fatigue

Commercial aviation recognizes how tiredness and fatigue can influence personal performance and increase the likelihood of accidents, and as a result, rules are in place for maximum work hours. Tiredness (a state that can only be reversed by sleep) and fatigue (more complex in its aetiology and can be the result of chronic tiredness and/or physical or mental exhaustion) are both found in surgical team members. Both