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(BQ) Part 2 book Principles and practice of surgery presents the following contents: Surgical specialties (Plastic and reconstructive surgery, the breast, endocrine surgery, vascular and endovascular surgery, orthopaedic surgery, transplantation surgery,...).
SECTION Surgical specialties Plastic and reconstructive surgery 281 The breast 302 Endocrine surgery 325 Vascular and endovascular surgery 345 Cardiothoracic surgery 379 Urological surgery 399 Neurosurgery 424 Transplantation surgery 444 Ear, nose and throat surgery 459 Orthopaedic surgery 476 279 Intentionally left as blank J.D Watson 18 Plastic and reconstructive surgery CHAPTER CONTENTS Introduction 281 Burns 289 Structure and functions of skin 281 Prognosis 291 Wounds 281 Skin and soft tissue lesions 294 INTRODUCTION Plastic and reconstructive surgery is concerned with the restitution of form and function after trauma and ablative surgery The techniques by which this is achieved are applicable to virtually every surgical subspecialty and are not limited to any single anatomical region or system The ‘reconstructive ladder’ is broad, simple and widely applicable at its base, but narrow, technically demanding and complex at its top (Fig. 18.1) It is important to distinguish plastic and reconstructive surgery from cosmetic, or aesthetic, surgery In the latter, the techniques of the former are applied to improve appearance but not physical function, although there may be considerable psychological benefit STRUCTURE AND FUNCTIONS OF SKIN Skin consists of epidermis and dermis The epidermis is a layer of keratinized, stratified squamous epithelium (Fig. 18.2) that sends three appendages (hair follicles, sweat glands and sebaceous glands) into the underlying dermis Because of their deep location, the appendages escape destruction in partial-thickness burns and are a source of new cells for reconstitution of the epidermis The basal germinal layer of the epidermis generates keratin-producing cells (keratinocytes), which become increasingly keratinized and flattened as they migrate to the surface, where they are shed The basal layer also contains pigment cells (melanocytes) that produce melanin, which is passed to the keratinocytes and protects the basal layer from ultraviolet light The dermis is composed of collagen, elastic fibres and fat It supports blood vessels, lymphatics, nerves and the epidermal appendages The junction between the epidermis and the dermis is undulating where dermal papillae push up towards the epidermis The three types of epidermal appendage extend into the dermis and, in some places, into the subcutaneous tissues Hair follicles produce hair, the colour of which is determined by melanocytes within the follicle The sebaceous glands secrete sebum into the hair follicles, which lubricates the skin and hair The sweat glands are coiled tubular glands lying within the dermis and are of two types; eccrine sweat glands secrete salt and water on to the entire skin surface, while apocrine glands secrete a musty-smelling fluid in the axilla, eyelids, ears, nipple and areola, genital areas and the perianal region Hidradenitis suppurativa affects the latter The nails are flat, horny structures composed of keratin They arise from a matrix of germinal cells, which can be seen as a white crescent (lunula) at the nail base If a nail is avulsed, a new nail grows from this matrix If the matrix is destroyed, nail regeneration is impossible, and the layer of epidermal cells covering the nailbed thickens to form a keratinized protective layer WOUNDS A wound may be defined as disruption of the normal continuity of bodily structures due to trauma, which may be penetrating or non-penetrating In both cases, inspection of the body surface may give little indication of the extent of underlying damage Types of wound Wounds can be classified according to the mechanism of injury: • Incised wounds A sharp instrument causes these; if there is associated tearing of tissues, the wound is said to be lacerated • Abrasions These result from friction damage and are characterized by superficial bruising and loss of a varying thickness of skin and underlying tissue Dirt and foreign bodies are frequently embedded in the tissues and can give rise to traumatic tattooing • Crush injuries These are due to severe pressure Even though the skin may not be breached, there can be massive tissue destruction Oedema can make wound closure impossible Increasing pressure within fascial compartments can cause ischaemic necrosis of muscle and other structures (compartment syndrome) 281 SURGICAL SPECIALTIES 18 Table 18.1 Phases of wound healing Lag phase (2–3 days) • Inflammatory response Incremental or proliferative phase (approximately weeks) • Fibroblast migration • Capillary ingrowth (granulation tissue) • Collagen synthesis with rapid gain in tensile strength • Wound contraction Free flaps Distant flaps Local flaps Plateau or maturation phase (approximately months) • Organization of scar • Slow final gain in tensile strength (80% of original strength) Skin grafts Principles of wound healing 50 20 Plateau phase Proliferative phase • Degloving injuries These result from shearing forces that cause parallel tissue planes to move against each other: for example, when a hand is caught between rollers or in moving machinery Large areas of apparently intact skin may be deprived of their blood supply by rupture of feeding vessels • Gunshot wounds These may be low-velocity (e.g shotguns) or high-velocity (e.g military rifles) Bullets fired from high-velocity rifles cause massive tissue destruction after skin penetration • Burns These are caused not only by heat but also by electricity, irradiation and chemicals Original strength (%) 100 Fig. 18.1 Reconstructive ladder Lag phase Direct suture 40 60 Time (days) 80 100 Fig. 18.3 Phases of wound healing The essential features of healing are common to wounds of almost all soft tissues, and result in the formation of a scar Soft tissue healing can be subdivided into three phases (Table 18.1) according to the development of tensile strength (Fig. 18.3) injury, during which capillary permeability increases and a protein-rich exudate accumulates It is from this exudate that collagen is later synthesized Inflammatory cells migrate into the area, dead tissue is removed by macrophages, and capillaries at the wound edges begin to proliferate Lag phase Incremental phase The lag phase is the delay of 2–3 days that elapses before fibroblasts begin to manufacture collagen to support the wound It is characterized by an inflammatory response to During the incremental or proliferative phase, there is progressive collagen synthesis by fibroblasts and a corresponding increase in tensile strength Increased collagen turnover Keratin Epidermis Stratified squamous epithelium Basal layer Sebaceous gland Hair follicle Collaginous and elastic tissue Dermis Sweat gland Fat 282 Fig. 18.2 Structure of skin Plastic and reconstructive surgery in areas remote from the wound suggests that there may also be a systemic stimulus for fibroblast activity Collagen synthesis increases over a period of about 3 weeks, during which the gain in tensile strength accelerates Old collagen undergoes lysis and new collagen is laid down Plateau or maturation phase After weeks, the gain in tensile strength levels off as the rate of collagen breakdown first approaches and then temporarily surpasses its synthesis Excess collagen is removed during this final clearing-up process and the number of fibroblasts and inflammatory cells declines Orientation of collagen fibres in the direction of local mechanical forces increases tensile strength for some months However, skin and fascia usually recover only 80% of their original tensile strength At the time of suture removal, the edges of the newly healed wound should be directly apposed and flat Thereafter, for up to months, the scar may become progressively raised, red and thickened It can then remain static for a further months, before slowly improving to become narrow, flat and pale These changes vary with age, race, the direction of scar and the degree of dermal damage In children, scars take longer to resolve, whereas in the elderly they tend to mature and fade very quickly Hypertrophic scars secondary intention, it may still be possible to speed healing by excising the wound edges and bringing them into apposition, or by covering the defect with a skin graft SUMMARY BOX 18.1 Classification of wound healing • Healing by first intention is the most efficient method and results when a clean incised surgical wound is meticulously apposed and heals with minimal scarring • Healing by second intention occurs when wound edges are not apposed and the defect fills with granulation tissue In the time taken to restore epithelial cover, infection supervenes, fibrosis is excessive and the resulting scar is unsightly • The term ‘healing by third intention’ describes the situation where a wound healing by second intention (e.g a neglected traumatic wound or a burn) is treated by excising its margins and then apposing them or covering the area with a skin graft The final cosmetic result may be better than if the wound had been left to heal by second intention Factors influencing wound healing This is an exaggeration of the normal maturation process Such wounds are very raised, red and firm, but never continue to worsen after months They are particularly common in children and after deep dermal burns Unless under tension, they eventually resolve, often after several years Resolution can be hastened by elastic pressure garments, steroid injections or the application of silicone gel These scars should not be excised Many of the factors influencing healing are interrelated: for example, the site of the wound, its blood supply, and the level of tissue oxygenation Although some adverse factors, such as advanced age, cannot be influenced, others, such as surgical technique, nutritional status and the presence of intercurrent disease, can be modified or eliminated Keloids Blood supply These are similar to hypertrophic scars, except that they continue to enlarge after months and invade neighbouring uninvolved skin They are most likely to occur across the upper chest, shoulders and earlobes, and are common in black patients They are difficult to treat successfully If the measures described above fail, intralesional excision followed immediately by low-dose radiotherapy is sometimes considered Wounds in ischaemic tissue heal slowly or not at all They are prone to infection and frequently break down When this occurs, the wound may not be able to sustain the metabolic demands of healing by second intention Arterial oxygen tension (PaO2) is a key determinant of the rate of collagen synthesis Anaemia may not affect healing if the patient has a normal blood volume and arterial oxygen tension Poor surgical technique, such as crushing tissue with forceps, approximating wound edges under tension and tying sutures too tightly, can make well vascularized tissue ischaemic and lead to wound breakdown Epidermis Epithelium heals by regeneration and not by scar formation Epithelial cells at the edge of the wound lose their adhesion to each other and migrate across the wound until they meet cells from the other side As they migrate, they are replaced by new cells formed by the division of basal cells near the wound edge The cells that have migrated undergo mitosis and the new epithelium thickens, eventually forming normal epithelial cover for the scar produced by the dermis Primary and secondary intention Wounds may heal by primary intention if the edges are closely approximated: for example, by accurate suturing Epithelial cover is quickly achieved and healing produces a fine scar (Fig. 18.4) If the wound edges are not apposed, the defect fills with granulation tissue and the restoration of epidermal continuity takes much longer The advance of epithelial cells across the denuded area may be hindered by infection This is known as healing by secondary intention and usually results in delayed healing, excessive fibrosis and an ugly scar (Fig. 18.5) If a wound has begun to heal by 18 Infection The general risks of wound infection depend upon age, the presence of intercurrent infection, steroid administration, diabetes mellitus, disordered nutrition, and cardiovascular and respiratory disease Local factors are also important Bacterial contamination can be minimized by careful skin preparation and aseptic technique, but some wounds are more likely to be contaminated than others Bacteria may enter wounds from the atmosphere, from internal foci of sepsis or from the lumen of transected organs In some cases, contamination occurs in the postoperative period Provided contamination is not gross and local blood supply is good, natural defences are usually able to prevent and contain overt infection Devitalized tissues, haematomas and the presence of foreign material such as sutures and prostheses favour bacterial survival and growth Common infecting organisms are staphylococci, streptococci, coliforms and anaerobes Overcrowding of wards and excessive 283 SURGICAL SPECIALTIES 18 A Fibrosed suture track B Shrinkage of wound Wound Fig. 18.4 Wound healing. A Healing by primary intention B Healing by secondary intention, showing shrinkage of the wound use of operating theatres increase the bacterial population of the atmosphere and hence the risk of wound infection The failure of medical and nursing staff to wash their hands before and after touching and examining each patient is perhaps the greatest source of cross-contamination When wound contamination is anticipated, topical antibacterial chemicals or topical and systemic antibiotics can be used prophylactically For example, a single dose of 284 s ystemic antibiotic is normally used to reduce the risk of infection during gastrointestinal surgery and when prosthetic material (hip joint, cardiac valves, arterial bypass) is being inserted In acute traumatic wounds, tetanus prophylaxis is routine, but antibiotics are not normally necessary provided prompt and thorough surgical treatment is undertaken However, if there has been a delay in the treatment of such a wound, antibiotic prophylaxis may be necessary Fig. 18.5 Healing by secondary intention Plastic and reconstructive surgery Age Wounds in the elderly may heal poorly because of impaired blood supply, poor nutritional status or intercurrent disease However, as mentioned above, they tend to form ‘good’ scars Site of wound Surgical incisions placed in the lines of least tissue tension are subject to minimal distraction and should heal promptly, leaving a fine scar On the face, these lines run at right angles to the direction of underlying muscles and form the lines of facial expression Nutritional status Malnutrition has to be severe before healing is affected Protein availability is most important, and wound dehiscence and infection are common when the serum albumin is low Healing problems should be anticipated if recent weight loss exceeds 20% Vitamin C is essential for proline hydroxylation and collagen synthesis The number of fibroblasts is not reduced in scorbutic states Zinc is a co-factor for important enzymes involved in healing, and its deficiency retards healing Supplements of ascorbic acid and zinc are effective in patients with known deficiencies, but not improve healing in normal subjects Intercurrent disease Healing may be affected by the disease itself or by its treatment Cachectic patients with severe malnutrition (as seen in advanced cancer) have marked impairment of healing Diabetes mellitus impairs healing by reducing tissue resistance to infection and by causing peripheral vascular insufficiency and neuropathy Haemorrhagic diatheses increase the risk of haematoma formation and wound infection Obstructive airway disease lowers arterial PO2 and so affects healing Abdominal wound dehiscence is more common in patients with respiratory disease because of the strain put on the wound during coughing Corticosteroid therapy reduces the inflammatory response, impairs collagen synthesis and decreases resistance to infection The effect of steroids on wound healing is most marked if they are given within days of injury Immunosuppressive therapy and chemotherapy impair healing by reducing resistance to infection As radiotherapy greatly reduces the vascularity of the tissues, the healing of wounds in irradiated areas is often impaired Surgical technique Where possible, skin incisions are placed in the line of least tissue tension Aseptic technique, gentle handling and accurate apposition of wound edges favour healing by first intention Dead spaces must be avoided, as the accumulation of blood and exudate encourage infection Correct suturing of the deeper layers avoids dead space and often allows the skin edges to fall together without tension, so that superficial sutures or adhesive tape can achieve skin apposition Drains should be used in contaminated wounds and those where exudate is expected Drains may be connected to a suction apparatus or allowed to empty by gravity The drain site is a potential portal of entry for infection and drains should be removed as soon as possible, especially when prosthetic material has been implanted Choice of suture and suture materials Foreign material in the tissues predisposes to infection The finest sutures that will hold the wound edges together should be used Whereas 5/0 or 6/0 sutures are appropriate for the face, stronger ones (3/0 or 4/0) are needed for incisions near joints and still stronger ones for the abdominal wall The suture should be strong enough to support the wound until tensile strength has recovered sufficiently to prevent breakdown Absorbable materials are preferred for buried layers Wound infection Classification Surgical procedures can be classified according to the likelihood of contamination and wound infection as ‘clean’, ‘clean-contaminated’ and ‘contaminated’: • Clean procedures are those in which wound contamination is not expected and should not occur An incision for a clean elective procedure should not become infected In clean operations, the wound infection rate should be less than 1% SUMMARY BOX 18.2 Factors affecting wound healing The site of the wound and its orientation relative to tissue tension lines are major determinants of healing Wounds with a good blood supply (e.g head and neck wounds) heal well Infection is a major adverse factor and the risk of infection is influenced by: • general factors such as the patient's age, presence of intercurrent infection, nutritional status and cardiorespiratory disease • local factors including bacterial contamination, antibacterial prophylaxis, aseptic technique, degree of trauma, presence of devitalized tissue, haematoma and foreign bodies Intercurrent disease may impair healing Important factors include: • malnutrition • diabetes mellitus • haemorrhagic diatheses • hypoxia (e.g obstructive airways disease) • corticosteroid therapy • immunosuppression • radiotherapy Surgical technical factors that have a major influence on wound healing include: • gentle tissue handling • avoidance of undue trauma • accurate tissue apposition • meticulous haemostasis • appropriate choice of suture material 18 • Clean-contaminated procedures are those in which no frank focus of infection is encountered but where a significant risk of infection is nevertheless present, perhaps because of the opening of a viscus, such as the colon Infection rates in excess of 5% may suggest a breakdown in ward and operating theatre routine • Contaminated or ‘dirty’ wounds are those in which gross contamination is inevitable and the risk of wound infection is high; an example is emergency surgery for perforated diverticular disease, or drainage of a subphrenic abscess Antibiotic prophylaxis is appropriate for the latter two types of operation 285 SURGICAL SPECIALTIES 18 Clinical features Wound infection usually becomes evident 3–4 days after surgery The first signs are usually superficial cellulitis around the margins of the wound, or swelling of the wound with some serous discharge from between the sutures Fluctuation is occasionally elicited when there is an abscess or liquefying haematoma Crepitus may be present if gas-forming organisms are involved In some cases of deep infection, there are no local signs, although the patient may have pyrexia and increased wound tenderness Systemic upset is variable, usually amounting to only moderate pyrexia and leucocytosis Toxaemia, bacteraemia and septicaemia can complicate serious wound infection, especially where there is an accumulation of pus The differential diagnosis includes other causes of postoperative pyrexia, wound haematoma and wound dehiscence Wound haematoma may result from reactive bleeding during the first 24–48 hours after an operation It causes swelling and discomfort, but only minimal pyrexia and few systemic signs Prevention The risk of wound infection is reduced by careful patient preparation, the prophylactic use of antibiotics in high-risk patients, and meticulous attention to good operating theatre techniques Severely contaminated wounds are sometimes best closed by delayed primary suture; most gunshot wounds are treated in this way Skin sutures may be inserted at this time but are not tied for several days, by which time it should be clear that infection has been avoided Antibiotic therapy is essential for grossly contaminated wounds The aim is to achieve high tissue concentrations as soon as possible The choice of antibiotic is determined by the nature of the infection Topical agents such as povidone-iodine may also be used to combat infection in contaminated wounds Radical excision of the wound margins, thorough mechanical cleansing and delayed suture may also be required Management A wound swab or specimen of pus is routinely sent for bacteriological culture and sensitivity determination In urgent cases, a Gram stain may be useful The state of immunity against tetanus is assessed and appropriate action taken Trivial superficial cellulitis can be managed expectantly The area of redness is ‘mapped out’ with an indelible pen so that its extent can be monitored Spreading cellulitis is an indication for antibiotic therapy Many infected wounds heal rapidly without further surgery, particularly if the original skin incision is placed in the line of least tissue tension The problem is often to keep the wound open, rather than to achieve closure If it appears that spontaneous wound closure will take a long time, secondary suture or skin grafting can be considered to speed healing, but only once it is clear that infection has been eradicated The presence of clean healthy granulation tissue in the wound is usually a good indication that closure can be undertaken Involvement of other structures 286 All wounds must be inspected carefully in good light to assess the extent of devitalization and injury to other structures However, it is important to appreciate that a small, apparently innocent wound may conceal extensive damage to deeper structures Body cavities may have been penetrated, or tendons, nerves and blood vessels divided Damage to muscles, tendons or nerves is assessed by checking relevant motor and sensory function If the injury SUMMARY BOX 18.3 Principles of management of contaminated traumatic wounds • Contaminated wounds should be debrided under general anaesthesia • The contaminated wound and its margins must be cleansed thoroughly, and grit, soil and foreign bodies/ materials removed • Devitalized tissue is formally excised until bleeding is encountered • Primary closure is avoided if there has been gross contamination and when treatment has been delayed for more than hours Inappropriate attempts to achieve primary closure increase the risk of wound infection and expose the patient to the risks of anaerobic infection (tetanus and gas gangrene) • Wounds left open may be suitable for delayed primary suture after 2–3 days, or for later excision and secondary suture (with or without skin grafting) • Appropriate protection against tetanus must be afforded and the use of antibiotics should be considered involves a limb, the distal circulation must be checked Where appropriate, X-rays will help to establish whether peritoneal, pericardial or pleural cavities have been entered, and whether there is underlying bony injury Provided there is no deep damage, small, relatively uncontaminated wounds can be treated under local anaesthesia in the A&E department The wound margins are cleaned with a mild antiseptic such as cetrimide and the wound is irrigated with sterile saline Any devitalized tissue is removed, deep tissues are sutured with absorbable material and the skin margins are closed More extensive or severely contaminated wounds usually require inpatient treatment, with exploration and debridement under general anaesthesia The wound and its margins are cleansed and all obvious foreign material picked out Devitalized tissue is trimmed back until bleeding occurs In areas of poor vascularity such as the leg, or if there is severe contamination, crushing or a fracture, the wound margins are formally excised (Fig. 18.6) Bleeding from the wound margin is not a certain indication of its ultimate survival, as impaired venous drainage can lead to progressive necrosis, particularly after a crushing or degloving injury If there is any doubt, the wound should not be sutured and a ‘second-look’ dressing change should be undertaken under anaesthesia after 48 hours Primary closure should be avoided if there is significant delay in treating a grossly contaminated wound: that is, more than hours without antibiotic cover If primary closure is attempted, wound infection and breakdown are likely and there is a risk of anaerobic infection It is also too late for formal excision but foreign bodies and dead tissue should be removed in the usual way The wound is dressed and antibiotics are started The dressing is changed daily, and if the wound is clean, delayed primary suture may be carried out after 48 hours If closure is delayed, any granulation tissue is usually excised and secondary suture performed If this is not possible, split-skin grafts (see below) can be applied to the granulations Provided that surgical treatment is carried out early, prophylactic antibiotics are only required for deeply penetrating wounds, especially those from dog and human bites or those caused by nails, where adequate debridement Plastic and reconstructive surgery A B C D 18 Fig. 18.6 Technique of wound debridement for a compound fracture. A Excision of skin edges B Excision of fascial layer. C Excision of traumatized muscle. D Removal of small bone fragments may be impossible However, the early use of antibiotics in situations where a delay in surgical treatment is anticipated may allow primary suture of wounds after 8–12 hours, an interval that is normally considered safe Devitalized skin flaps A common emergency problem is posed by the patient, usually an elderly woman, who falls and raises a triangular flap over the surface of the tibia (pretibial laceration) In some cases, the flap is blue-black in colour and obviously non-viable, but in most cases viability is uncertain Similar injuries can occur elsewhere in the body The wound must be cleansed and non-viable tissue excised No attempt should be made to suture the flap back into place; because of the post-traumatic oedema this would only be possible under tension, and would lead to death of the flap A small defect can be treated conservatively on an outpatient basis by wound dressing and an elastic supporting bandage providing the arterial circulation is normal; Ch 21) and the patient is kept ambulant The wound will normally take several weeks to heal A larger defect may require a split-skin graft, either immediately or as a delayed primary procedure Wounds with skin loss If skin has been lost as a direct result of trauma, or following the excision of a tumour or necrotic tissue, direct suture may not be possible A small skin defect at a functionally or aesthetically unimportant site may be allowed to heal by secondary intention However, it is often better to speed healing by importing skin to close the wound by means of a skin graft, which requires a vascular bed as it has no blood supply of its own, or a flap Skin grafts These may be split-skin or full-thickness Split-skin grafts are cut with a special guarded freehand knife or an electric dermatome The donor site heals by re-epithelialization from epithelial appendages in the dermis within 2–3 weeks, depending on the thickness of the graft To cover very large areas, the graft can be expanded by ‘meshing’ The thinner the graft, the more easily it will take on a bed of imperfect vascularity but the poorer the quality of skin will be and the more it will shrink Split-skin grafts are used to cover wounds after acute trauma, granulating areas and burns, or when the defect is large A full-thickness graft leaves a donor defect (which needs to be sutured or grafted) as large as the one to be filled and requires a well-vascularized bed to survive However, such grafts are strong, not shrink, and look better than a split-skin graft They are rarely advisable after acute trauma but are commonly used in reconstructive surgery to close small defects where strength is needed (e.g on the palm of the hand) or where a good functional and/or cosmetic result is important (e.g on the lower eyelid) An area where there is skin to spare is chosen for the donor site (e.g the groin for the former and the area behind the ear or upper eyelid for the latter) 287 SURGICAL SPECIALTIES 18 Flaps Whereas grafts require a vascular bed to survive, flaps bring their own blood supply to the new site They can therefore be thicker and stronger than grafts and can be applied to avascular areas such as exposed bone, tendon or joints They are used in acute trauma only if closure is not possible by direct suture or skin grafting, and are more usually reserved for the reconstruction of surgical defects and for secondary reconstruction after trauma The simplest flaps use local skin and fat (local flaps), and are often a good alternative to grafting for small defects such as those left after the excision of facial tumours (Fig. 18.7) A flap may have to be brought from a distance (distant flap) and remain attached temporarily to its original blood supply until it has picked up a new one locally (Fig. 18.8) This usually takes 2–3 weeks, after which the pedicle can be divided Advances in our knowledge of the blood supply to the skin and underlying muscles have led to the development of many large skin, muscle and composite flaps, which have revolutionized plastic and reconstructive surgery One example is the use of the transverse rectus abdominis musculocutaneous (TRAM) flap for reconstruction of the breast The ability to join small blood vessels under the operating microscope now allows the surgeon to close defects in a single stage, even when there is no local tissue available, by free tissue A B A C B Fig. 18.8 Example of a pedicled (cross finger) skin flap used to cover a defect on the tip of the index finger. A Raised. B Inset C Divided transfer (Fig. 18.9) Other tissues, such as bone, cartilage, nerve and tendon, can also be grafted to restore function and correct deformity after tissue damage or loss Crushing/degloving injuries and gunshot wounds 288 Fig. 18.7 Local skin flap used to repair a defect after the excision of a skin lesion. A Before surgery. B After surgery Wounds of this type should never be closed primarily due to the extensive tissue destruction After thorough irrigation and the removal of any obviously dead tissue and INDEX 494 Calf pump, 367 Cancer, 80–89 adenoma-carcinoma progression, 80–81, 82f adjuvant treatment, 87–88 biology of, 80–83, 81f, 81t care of the dying, 89 chemoprevention, 83 counselling, 89 cure estimates, 82–83 diagnosis, 85–86 follow-up, 89, 89b GP consultation, 85 immunosuppression risks, 447 inherited, screening for, 83–84 invasion, 81–82, 82f investigations, 85–87, 86f, 86t local effects, 84–85 management of patients with, 83–89 metastasis, 81–82, 82f, 89 natural history, 82–83 palliation of advanced, 89 patient's journey, 84, 84t prognosis, 89 referral, 85 screening, 83–84, 83b, 83f, 84b, 84f, 84t staging see Staging, cancer surveillance in ulcerative colitis, 242 survival data, 83 symptoms, 84–85 systemic effects, 85 treatment, 87–88, 88b, 88f see also specific sites; specific tumours Candida infections, 53 antibiotics for, 52t oral, 467 Capacity, 57–58 Capecitabine, 261 Capillary haemangiomas, 232 Caput medusae, 198 Carbimazole, 329 Carbohydrate metabolism, 7–8, 9b Carbolic acid, 45 Carbon dioxide (CO2), 17, 20 Carbuncle, 474 Carcinogenesis, 80 Carcinoid syndrome, 343 Carcinoid tumours, 343 appendiceal, 236, 343 gastric, 189 large intestine, 262 pulmonary, 394 small bowel, 243, 243f Carcinoma adenoma-carcinoma progression, 80–81, 82f adrenal, 339 after peptic ulcer surgery, 183 anal, 273b anaplastic, 330–331 basal cell see Basal cell carcinoma bile ducts, 214, 214f bronchogenic see Bronchogenic carcinoma follicular, 330, 330f gallbladder, 214 gastric, 185–186, 186f, 187, 187t hepatocellular, 202–203, 202b medullary, 331 oesophageal, 170, 178–180, 179f, 180f papillary, 330 penile, 420–421, 421f prostate see Prostate cancer squamous cell see Squamous cell carcinoma Carcinoma in situ, 296–297, 410 Cardiac arrest, postoperative complications, 119 Cardiac catheterization, 380t Cardiac disease acquired, 381–389 congenital, 389–390 see also specific type of heart disease Cardiac failure congestive, 70, 70t postoperative, 123 Cardiac output (CO), 19, 19t, 61, 71 Cardiac tamponade, 96, 115, 389 Cardiogenic shock, 18 management, 26 pathophysiology, 20 postoperative, 123 Cardioplegia, 379–380 Cardiopulmonary bypass (CPB), 34, 379, 381f Cardiopulmonary exercise testing, 65 Cardiothoracic surgery, 379–398 complications, 380 pathophysiological assessment, 379–381, 380t postoperative care, 380–381 risk assessment, 379 Cardiovascular disease day surgery patients, 130 perioperative implications of, 69–71 perioperative management of patients with, 71, 71t Cardiovascular system assessment in the trauma patient, 99 effect of shock on, 22, 22b postoperative complications, 123 preoperative assessment, 62, 63t, 65, 66b response to injury, 7f Carotid arteries disease see Carotid artery disease internal, 425 Carotid artery disease, 356–358, 357b assessment, 357, 357f asymptomatic, 358 management, 357–358, 357b, 358b, 358f pathophysiology, 356 Carotid body tumours, 475 Carotid bruits, 357 Carotid endarterectomy, 357–358, 357b, 358f Carotid stenting, 358, 358b Carpal tunnel disease, 485 Carpal tunnel syndrome, 442–443 Castration, prostate cancer, 413 Casts, urinary, 156 Catabolism, 7–8, 9b, 9t Catecholamines, 7–8 Catheter-directed intra-clot thrombolysis (CDT), 375–376 Catheters complications from, 121 postoperative care, 121 problems in parenteral nutrition, 43 Cauda equina syndrome, 441 Caval filters, 376 Cavernomas, 431 Cavernous haemangiomas, 301 liver, 196, 201 splenectomy, 232 CD4 cells, 46, 445 CD8 cells, 46, 445 Cell salvage, 34, 36 Cellular function in shock, 20–21 Cellulitis, 52, 286, 467f Censoring, cancer studies, 83 Central nervous system (CNS) effects of shock on, 22, 22b procedures, 116–117 vascular disorders and, 431b Central venous catheter, 71t insertion, 113–115, 114b, 114f in trauma patients, 97–98 Central venous pressure (CVP), 113, 119 Cerebral blood flow (CBF), 425–426, 425f Cerebral palsy, 484 Cerebral perfusion pressure (CPP), 426 Cerebral postoperative complications, 124 Cerebrospinal fluid (CSF), 116, 425 hydrocephalus, 438–440, 439f leak, 76–77 meningitis, 434 Cerebrovascular accidents (CVA), postoperative, 124 Cerebrovascular disease, 356–358, 428–431, 431b Cervical cancer and incontinence, 418 screening, 83, 83f, 84t Cervical cytology, 83, 83f Cervical intraepithelial neoplasia (CIN), 272 Cervical spine control in trauma, 96 degenerative disease, 442, 442f injury, 433 X-ray, 100, 101f Cetuximab, 261 Charcot's triad, 208 Chemical endothelial injury, 345 Chemoprevention, 83 Chemo-radiotherapy anal cancer, 273 oesophageal carcinoma, 179 Chemotherapy anal cancer, 273 bladder cancer, 410b breast cancer, 318–319, 319t, 320, 322 cancer, 87–88 colorectal adenocarcinoma, 261 complications, 320 effect on wound healing, 285 gastric cancer, 188, 188b hepatocellular carcinoma, 203 oesophageal carcinoma, 179 paediatric neuro-oncology, 438 palliative, 180 colorectal adenocarcinoma, 261 gastric cancer, 189, 189b prostate cancer, 413 see also Chemo-radiotherapy Chenodeoxycholic acid, 204–205 Chest drains, 109f pneumothorax, 395 procedure, 107 removal, 108 Chest infections, 52t Chest pain, 176 Chest wall deformities, 397 Chest wounds, open (sucking), 96, 96f Chest X-ray acute abdomen, 156, 156f cardiothoracic surgery, 380t oesophageal disorders, 171, 171f oesophageal perforation, 177 preoperative, 65, 66 thoracic surgery, 391t trauma patients, 100, 100f Childbirth, incontinence after, 418 Children abdominal pain in, 149t, 153 appendicitis in, 163 care of dying, 89 consent in, 58 cricothyroidotomy, 107 fractures in, 487 inguinal hernia, 141, 146 neuro-oncology, 437–438 orthopaedic surgery, 476, 483–484 rectal prolapse, 274 resuscitation of, 98 trauma as a cause of death in, 90 Chlamydial infection, 165 Chloride, 10 Cholangiocarcinoma, 203, 214, 214f, 225 Cholangiography, 209 Cholangiohepatitis, Asiatic, 213 Cholangitis acute, 213 antibiotics for, 52t primary sclerosing, 213–214 Cholecystectomy, 210b common bile duct exploration, 210–211, 210b, 210f complications, 209b, 211–212, 211f, 212f laparoscopic, 209–210, 210f open, 209, 209f timing of, 213, 213b Cholecystitis acute, 206, 207, 207b, 213 acute acalculous, 208 antibiotics for, 52t Boas's sign, 155 chronic, 207, 208 Cholecystokinin (CCK), 169, 205, 215 Choledochal cysts, 205–206, 206f Choledocholithiasis, 155, 207, 208 Choledochotomy, 210 Cholestatic jaundice, 193–194 Cholesteatoma, 463 Cholesterol stones, 206 Cholesterosis, 208 Cholic acid, 204–205 Chronic obstructive pulmonary disease (COPD), 62, 121 Chronic renal failure, 72–73, 73t Chronic subdural haematoma (CSDH), 432–433 Chronic suppurative otitis media, 462–463 Chronic venous insufficiency (CVI), 369, 371–374 assessment, 372 management, 372–374 pathophysiology, 371 Chronic venous ulceration (CVU), 371, 372f, 372t, 373, 373b, 373f Chvostek's sign, 334 Chyme, 169 Ciclosporin (CYA), 447, 447b Cingulate gyral herniation, 426, 427f Circle of Willis, 425, 425f Circulation, 487 postoperative monitoring, 119 shock, 23, 24f trauma resuscitation, 97–99 Circulatory overload, transfusion associated, 33t Circumcision, 420 Cirrhosis, 74, 198, 199b C-Kit gene, 242 Clark, melanoma staging, 300 Clean, definition, 68t Index Clean-contaminated, definition, 68t Clean-contaminated procedures, 285 Clean procedures, 285 Cleveland Clinic Incontinence Score, 275–276 Clingfilm, 294 Clipping, aneurysms, 429–430, 430b, 430f Clitoris, 419f, 420 Clopidogrel lower limb ischaemia, 351 preoperative assessment, 63 Closed-loop obstruction, 151, 151f, 246 Clostridium difficile, 51t, 53, 251 Clostridium perfringens, 54 Clostridium species, 51t Clostridium tetani, 54 Clotting factor deficiency, 25 Club foot, congenital, 484 Coagulation, 4, 4f, abnormal, perioperative implications of, 74–75, 74t inherited disorders of, 74 preoperative screen, 65, 65t Coagulation factors, 29 Coagulopathy acquired, 74–75 massive transfusion complications, 36t perioperative implications of, 74 in shock, 24–25 Coarctation of the aorta, 390, 390f Cocaine, 77 Cochlea, 459–460 Coeliac axis, 168 Coeliac disease, 235 Coffee bean sign, 250, 250f Cognitive impairment, consent in, 58–59 Coiling, aneurysms, 429–430, 430b, 430f Coliforms, 43–44 Colitis indeterminate, 240 ischaemic, 249–250, 249f microscopic, 251 pseudomembranous, 251 ulcerative see Ulcerative colitis Collagenous colitis, 251 Collateral blood supply, 346 Colles' fracture, 485, 489 Colloid particles, Colloids, 12, 13b Colon see Large intestine Colonic diverticular disease, 247–251, 247f, 248b, 248f, 248t Colonoscopy, colorectal adenocarcinoma, 257, 257f Colorectal adenocarcinoma, 248t, 255–258 aetiology, 255–256 clinical features, 256–257 distribution in the UK, 255, 255f investigations, 257, 257f, 258f management, 258–262 adjuvant therapy, 260–261 palliative therapy, 261 pathology, 259–260, 260f prognosis, 262 staging, 259–260, 260t, 261t surgery, 258–259, 258b, 259f population screening, 257 preoperative staging, 257–258 see also Colorectal cancer Colorectal adenoma, 252–253, 254b Colorectal cancer, 248t adenoma-carcinoma progression, 82f chemoprevention, 83 complete radical excision, 87, 88f hereditary non-polyposis (HNPCC), 83–84, 242, 256 inherited, screening for, 83–84 investigations, 86f metastases, 81 risk in ulcerative colitis, 242 screening, 84t Colostomy, 252 Colour flow Doppler (duplex) ultrasound (CDU) carotid artery disease, 357, 357f deep vein thrombosis, 374 Colovesical fistula, 249 Commensals, 45 Common bile duct, 204, 210–211, 210b, 210f Common moles, 297 Community, 46 Compartment syndrome, 281, 362, 362f, 488 Complement, 46 Complement-dependent cytotoxicity cross match (CDC-XM), 446 Compound fractures, 488 Compression therapy deep vein thrombosis prevention, 374 leg ulcers, 373, 373f lymphoedema, 377–378 Computed tomography angiography (CTA) abdominal aortic aneurysm, 363, 364f acute abdomen, 159 neurosurgery, 428 subarachnoid haemorrhage, 429 Computed tomography (CT), 117 abdominal aortic aneurysm, 364f acute abdomen, 158–159 appendicitis, 164, 164f cancer diagnosis, 85–86, 86f cancer staging, 86, 86f colorectal adenocarcinoma, 257–258, 257f, 258f gastric carcinoma staging, 187 intestinal obstruction, 245–246, 246f intra-abdominal abscess, 162, 162f jaundice, 195 large bowel investigation, 235 neurosurgery, 427 nose, 464–465, 465f oesophageal disorders, 172 oesophageal perforation, 177–178, 177f orthopaedic surgery, 477, 477f pancreatic cancer, 226, 226f pancreatitis, 218, 218f subarachnoid haemorrhage, 429 thoracic surgery, 391t thyroid gland, 326 trauma patients, 100–101, 102f urological disorders, 400 Computed tomography urogram, 400 Confidentiality, 59 Confusion, postoperative, 124 Congenital club foot, 484 Congenital hypertrophy of the retinal pigment epithelium (CHRPE), 254 Congenital non-haemolytic hyperbilirubinaemia, 193 Congestive cardiac failure, perioperative implications of, 70, 70t Connective tissue tumours, 301 Conn's syndrome, 340 Consent see Informed consent Constipation, 251 Contaminated, definition, 68t Contaminated wounds, 285, 286b, 292, 293–294 Contamination, degrees of, 68t Continuous positive airway pressure (CPAP) cardiogenic shock, 26 post-operative, in respiratory disease, 72 Contrast studies, 117 acute abdomen, 157, 157f, 158f, 159f colorectal adenocarcinoma, 257, 257f oesophageal disorders, 171, 172f oesophageal perforation, 177–178 Contusions, 92 Core biopsy, breast, 306, 306f Coronary angiography, 381, 383f Coronary artery bypass graft (CABG), 380 coronary artery disease, 382, 383f, 384b perioperative implications of, 69–70 Coronary artery disease (CAD), 381–383 assessment, 381, 382f, 383f coronary bypass, 382, 383f indications for surgery, 381–382 results of surgery, 383 surgery for complications of, 384 Corpus luteum, ruptured, 165 Cortical control, impaired, 418 Corticosteroids Crohn's disease, 238–239 effect on wound healing, 285 immunosuppression, 446, 446t osteoarthritis treatment, 480 replacement therapy after adrenalectomy, 342 septic shock, 25 side effects, 446t Corticosterone, 336–337 Cortisol, 8, 336–337, 337b, 337f Cushing's syndrome, 338 following injury, 5t Counselling, cancer, 89 Courvoisier's law, 208, 226, 226t Cowden's disease, 255 Cox's proportional Hazard models, 83 Cranial dermal sinuses, 440 Cranial nerves, 425 tumours, 435 Craniosynostosis, 440, 440f Craniotomy, 436 infection after, 434 subdural haematoma, 432–433 C-reactive protein acute abdomen, 155 pancreatitis, 218–219 Creatinine, 400 Creatinine clearance, 400 Creutzfeldt-Jakob disease (CJD), 49 preoperative assessment, 66 see also Variant CreutzfeldtJakob disease (vCJD) Cricopharyngeus, 167 Cricothyroidotomy, 107, 108f Cricothyrotomy, 471–472, 472f Critical limb ischaemia, 350–351 diabetic foot, 351 diabetic vascular disease, 350–351 endovascular management, 352 night and rest pain, 350 Critical stenosis, 347 Crohn's disease, 236–240, 240b clinical features, 237–238, 237t, 238f indications for surgery, 240b investigations, 238, 239f management, 238–240 pathology, 237, 237f Cronkhite-Canada syndrome, 255 Cross-matching, 446 blood transfusions, 30 preoperative, 65 Crush injuries, 281, 288–289 Cryoprecipitate, 29 Cryptoglandular infection, 270 Cryptorchidism, 421 Crystalloids, 11–12, 13b Cullen's sign, 155 Curling's ulcers, 181, 293 Cushing's disease, 335, 338 Cushing's syndrome, 337–340, 337f, 339b clinical features, 338, 338f investigations, 338–339, 339f management, 339–340 Cushing's ulcers, 181 Cuts, 92 Cyanosis, 389 postoperative, 119–120 Cyclical mastalgia, 308 Cystadenoma, appendiceal, 236 Cystectomy, 410 Cystic hygroma, 474 Cystitis, 52, 409–410, 418 Cysts branchial, 474 breast, 304–305, 305f, 308, 308f choledochal, 205–206, 206f dermoid, 165, 295, 295f, 474 epididymis, 423 liver, 196, 196f ovarian, 165 renal, 403 retention, 468 sebaceous, 295, 295f, 311, 474 splenic, 232 thyroglossal, 474 thyroid, 328 Cytokines, 3, 4f, 4t, 8, 46, 345 Cytology, 399–400 cancer diagnosis, 86t nipple, 305 Cytomegalovirus (CMV), 27 Cytopathic shock, 21 D Day surgery, 127–134 admission, 132, 132f anaesthesia and analgesia, 132 clinical effectiveness of, 127b cost effectiveness of, 128b discharge criteria, 133, 133t exclusion criteria, 128 facilities, 127 first patient contact, 128 patient pathway, 128–133, 128f pre-assessment, 128–131, 131b procedures, 133–134, 133t, 134t recovery, 132 scheduling for theatre, 132 23-hour surgery, 134 waiting-list, 131–132 Deafness, 460, 461f, 463 Death certificates, 60 495 INDEX 496 Debridement burns, 293 infected pancreatic necrosis, 220 wounds, 286, 287f Deep partial-thickness burns, 290, 290f Deep vein thrombosis (DVT), 67–68, 129, 374–376 aetiology, 374 complicated, 375 diagnosis, 374, 375f epidemiology, 374 management, 375–376 pathophysiology, 374 postoperative, 124–125 prevention, 374–375 uncomplicated, 375 and varicose veins, 369 venous gangrene, 374 Deformities, description of, 478–479 Degloving injuries, 282, 288–289 Dehiscence, wounds, 126, 126f Dehydroepiandrosterone sulphate (DHA-S), 336–337, 337b Delayed graft function, renal transplantation, 452 Delirium, postoperative, 124 Delirium tremens, postoperative, 124 De Quervain's disease, 328, 485 Dermal sinuses, cranial, 440 Dermatomes, 99–100, 100f Dermis, 281 neoplasms, 295t Dermoid cysts, 165, 295, 295f, 474 Desmoid tumour, 137 Detrusor muscle, 406, 417, 418 Detrusor-sphincter dyssynergia, 418 Deviated nasal septum, 465, 465f Devitalized skin flaps, 287 Dexamethasone after head injury, 432b in brain surgery, 436 Dextran, 36 Dextrose, 11, 12f, 12t, 13 D2 gastrectomy, 187–188, 188f Diabetes insipidus, 336 Diabetes mellitus day surgery patients, 130 effect on wound healing, 285 lower limb ischaemia, 351 pancreas transplantation, 455 perioperative implications of, 72, 73t vascular disease in, 350–351, 351f Diabetic foot, 351, 351f infections, 54, 54f Diagnostic aids, trauma patients, 100–101, 100f, 101b, 101f Diagnostic peritoneal lavage (DPL), 111–112 Dialysis dependent patients, 72–73 Diamorphine, 99 Diarrhoea after peptic ulcer surgery, 182 complications of enteral feeding, 41–42 fluid loss from, 11 inflammatory, 11t investigations, 235 Diet colorectal adenocarcinoma, 256 and gastric cancer, 185 Dieulafoy's lesion, 190 Diffuse axonal injury, 433 Dimercaptosuccinic acid (DMSA), 400–402 Dipstick testing, 156 Dirty, definition, 68t Dirty wounds, 285 Disc degeneration, 441 Discharge, day surgery, 133, 133t Disseminated intravascular coagulation (DIC), 4, 65, 74–75 Diuretics, 124 Diverticula bladder, 414, 414f colonic, 247–251, 247f, 248b, 248f, 248t complicated, 248–249 duodenal, 190 jejunal, 244, 244f urethra, 416 Diverticulitis, 248 Diverticulosis, 247 DNA mutations, 80 Dominant hand, 476 Dormia basket, 211–212 Drains effect on wound healing, 285 postoperative care, 121 see also specific drains Drapes, 103 Dressings burns, 294 leg ulcers, 373 Dribble incontinence, postmicturition, 417 Drugs cardiovascular disease, 71 day surgery patients, 129–130 and impotence, 420 and incontinence, 418 interfering with haemostasis, 36 pancreatitis, 218 preoperative, 69 preoperative assessment, 63 trauma caused by, 92 in trauma patients, 97 Ductal carcinoma in situ (DCIS), 312, 312f Duct ectasia, 308, 308f, 309f Ductography, 305 Ductoscopy, 305 Duct papillomas, 309, 309f Dukes' staging, colorectal adenocarcinoma, 259–260, 260t Dumping, 182 Duodenal ileus, persistent, 222 Duodenal switch, 191 Duodenal ulcer, 180, 180f burns patients, 293 complications, 183, 184f, 185 management, 181, 182 perforated, 171, 171f Duodenostomy, 221–222 Duodenum disorders, 180–181, 190–191 diverticula, 190 examination, 170–171 investigations, 171–173 obstruction, 190 surgical anatomy, 167–169, 168f symptoms, 169–170 trauma, 190 Dupuytren's disease, 485–486 Dying patients, care of, 89 Dynamic hip screw (DHS), 489 Dynamic ultrasound, sportsman's hernia, 142 Dyspepsia, 170, 170b Dysphagia, 169–170, 170t Dysphasia, 436 Dysplasia-associated lesion or mass (DALM), 242 Dysplastic disease of the hip (DDH), 483, 484f E Ear, nose and throat surgery, 459–475 Early goal-directed therapy (EGDT), septic shock, 25, 25b Ears, 459–464 anatomy, 459, 459f assessment, 460–461 diseases of the pinna, 461, 462f external auditory meatus diseases, 462 inner ear diseases, 463–464 middle ear diseases, 462–463 physiology, 460 Ebb phase, E-Cadherin gene, 186 Ecchymoses, 92 Eccrine sweat glands, 281 ECG see Electrocardiography (ECG) Echinococcus, 197, 197f, 232 Echocardiography aortic aneurysms, 388–389, 388f cardiothoracic surgery, 380t preoperative, 65 valvular heart disease assessment, 385 Ectasia, aorto-annulo, 388 Ectopic pregnancy, ruptured, 165 Ectopic ureter, 418 Eczema, nipple, 316 Efferent arm of the immune response, 445 Effort thrombosis, 376 Eisenmenger's syndrome, 389 Ejaculation, 420 see also Retrograde ejaculation Elastic compression hosiery, 373, 373f Elbow, 485 Elderly people, appendicitis in, 163 Electrical burns, 291 Electrocardiography (ECG) cardiothoracic surgery, 380t exercise, 381 postoperative monitoring, 119 preoperative, 65 thoracic surgery, 391t Electrolyte-containing fluid loss, 5t Electrolytes, 10–17 abnormalities, 13–16 daily requirements, 10t distribution, 10f loss, 10t normal balance, 10 Electromyography (EMG), orthopaedic surgery, 477 Embolectomy, 360, 361f Embolism acute, 360–361, 361f vs thrombosis, 359, 359t Emergency department, resuscitation in, 95–100 Emergency medical technicians, 94 Emergency surgery, preoperative assessment, 67 Emotional state, incontinence and, 418 Emphysema, 100, 100f, 396 Empyema, 396–397, 397f subdural, 434 En bloc resection, 87, 258 Endarterectomy, 353, 353f carotid, 357–358, 357b, 358f Endo-anal ultrasound, colorectal adenocarcinoma, 257–258 Endocarditis, 385–386 Endocrine action, Endocrine function of pancreas, 215–216 Endocrine response to surgery, 4, 5b Endocrine surgery, 325–344 Endocrinopathy, intracranial tumours, 436 End-of-life issues, 59 Endogenous acid, 16 Endoluminal ultrasound, 172–173 Endolymph, 459–460 Endolymphatic hydrops, 464 Endoscopic drainage, infected pancreatic necrosis, 221 Endoscopic retrograde cholangiopancreato graphy (ERCP) jaundice, 195 pancreatic cancer, 226 pancreatitis, 220, 220b Endoscopic stents, oesophageal carcinoma, 179–180, 180f Endoscopic ultrasonography (EUS) gastric carcinoma staging, 187 oesophageal disorders, 172–173, 173f pancreatic cancer, 226 Endoscopy acute abdomen investigation, 159–160 cancer diagnosis, 86t cancer staging, 86 gastrointestinal bleeding, 184 oesophageal carcinoma diagnosis, 178 oesophageal disorders, 172 pancreatitis treatment, 220, 223–224 variceal bleeding, 199–200 Endothelium, 4, 4f, 5b injury, 345 Endotoxin, 45 Endotracheal intubation airway, 106–107, 106f burns patients, 292 Endovascular aneurysm repair (EVAR), 364–365, 365f, 366b, 366f Endovascular surgery, 345–378 Endovenous LASER ablation (EVLA), 369 Endovenous surgery leg ulcers, 373–374 varicose veins, 369 Energy loss of reserves, 38–39 metabolism, 6–7, 7f, 9t requirements, 40, 40t Enhanced recovery after surgery (ERAS), Entamoeba histolytica, 197 Enteral nutrition, 40–41, 42b complications of, 41f versus parenteral nutrition, 41b routes of, 41, 41f Enteritis, radiation, 244 Enterococci, 51t Enterocystoma, 137, 138f Enterogastric reflex, 169 Enterohepatic circulation, 204–205, 205f Enteroteratoma, 137, 138f Entonox, 99 Environmental factors, breast cancer risk, 311 Index Epidermis, 281, 283 cancer of the, 297 neoplasms, 295–300, 295t, 298b Epididymis, 419–420 cysts, 423 Epididymo-orchitis, 422 Epidural anaesthesia, 76–77, 77f, 77t Epidural analgesia, 78 Epigastric hernia, 143–144, 144f Epigastric pain, 176 Epilepsy, 441 perioperative implications of, 75t Epispadias, 420 Epistaxis, 466, 466b, 466f, 466t Epithelial hyperplasia, breast, 309 Epley's particle repositioning manoeuvre, 463–464 Epstein-Barr virus, 468 Erb's sign, 334 Erection, penile, 420 disorders of, 420 Erythema, burns, 291 Erythrocytes, 229 Erythrocyte sedimentation rate (ESR), 400 Eschar, 289 Escharotomy, 294 Escherichia coli antibiotics for, 51t peritonitis, 161 Estimated blood volume (EBV), 24t Ethics, 56–60 committees, 60 principles, 56–57 sources of further information on, 59t specific topics, 59–60 Eustachian tube, 459 Euthanasia, 59 Evaporative dressings, burns, 294 Evidence-based neurosurgery, 443 Excision arthroplasty, osteoarthritis, 482 Excision of lumps and swellings, 117 Exercise colorectal adenocarcinoma, 256 lower limb ischaemia, 351 preoperative, 62 Exercise electrocardiography, coronary artery disease assessment, 381 Exocrine function, pancreas, 215 Exophthalmos, 329, 329f Explicit consent, 58 Extended Spectrum Beta Lactamase (ESBL)producing Escherichia coli, 49 External abdominal hernia, 145 External auditory meatus, 459, 462 External beam radiotherapy (EBRT), prostate cancer, 413 External inguinal ring, 139, 139f Extra-anatomic bypass, lower limb ischaemia, 353, 354f, 355f Extracellular fluid, 10, 10f, 12f Extracorporeal shock-wave lithotripsy (ESWL), 405 Extradural haematoma, 432, 433f F Facial nerve (CN VII), 425 disorders, 464 Facial palsy, 464 Factor II, 29 Factor VII, 29 Factor VIII, 29 Factor IX, 29 Factor X, 29 Factor XIII, 29 Faecal incontinence, 275–276, 275t, 276b Faecal occult blood test (FOBT), 257 Fallot's tetralogy, 390 Falls, 93, 93f Familial adenomatous polyposis (FAP), 242, 254, 254f Fasciotomy, 362, 362f FAST (Focused Abdominal Scans for Trauma), 160 Fasting, preoperative, 69, 69b Fat metabolism, 8, 9b Female incontinence, 417–418 Feminization, adrenal, 340 Femoral aneurysms, 366 Femoral canal, 142 Femoral head, avascular necrosis of the, 486 Femoral hernia, 142–143, 143f, 146 Femoral neck fractures, 489, 489f Femoral ring, 142, 143f FEV1, 66t, 396 Fever, 3, 11 abscesses, 53 non-haemolytic transfusion reaction, 33t postoperative, 126, 126b FEV1/FVC ratio, 66t Fibre, dietary, 256 Fibrinogen in cryoprecipitate, 29 deficiency, 25 Fibrinolysis, 25 pulmonary embolism, 125 Fibrin sealant, 36 Fibroadenoma, breast, 305f, 307, 307f Fibroepithelial anal polyp, 272 Fibronectin, 29 Fibrosarcoma, 137, 301 Fibrotic lung disease, 62 Fine-bore nasogastric tubes, 110 Fine needle aspiration cytology, 306 Firearm injuries, 90 Fire services, 94 First aid, burns, 291–294, 291t Fissure-in-ano, 267–268, 268b, 268f, 269b Fistula branchial, 474 colonic diverticular disease, 249 in Crohn's disease, 237–238, 238f gastrointestinal, in pancreatitis, 222 intestinal, 252 mammary duct, 310 urinary tract, 419 Fistula-in-ano, 270–271, 270f, 271b, 271f Flail segment, 96 Flamazine, 294 Flame burns, 291 Flaps see Skin flaps Flat feet, 486 Flavine adenine dinucleotide (FADH2), 20 Fleming, Alexander, 45 Flora, normal, 46f Florey, Howard, 45 Flow cytometry cross match (FC-XM), 446 Flow phase, Fludrocortisone acetate, 342 Fluid balance, 10–17 postoperative care, 121 conserving measures, 5–6 daily requirements, 10, 10t distribution, 10f intravenous administration see Intravenous fluid administration loss assessing, 11 in burns, 289 following surgery and trauma, 5t insensible, 11, 11t normal daily, 10t sources of, 11, 11t management see also (Intravenous fluid administration) thoracic surgery, 397 2-Fluorodeoxy-D-glucose (2FDG), 118 5-Fluorouracil, 261 Foam cells, 345 Focal neurological deficit, 436 Focal nodular hyperplasia (FNH), 201, 202f Follicle-stimulating hormone (FSH), 5t, 334 Follicular carcinoma, 330, 330f Foot, 486 diabetic see Diabetic foot warts, 295–296, 295f, 296f Foot pump, 367 Foramenotomy, posterior, 442 Foraminal herniation, 426, 427f Forced expiratory volume in one second (FEV1), 66t, 396 Forced vital capacity (FVC), 66t Forearm fractures, 489–490 Foreign bodies airway obstruction, 120 oesophageal, 169, 170t Foreskin, 420 Fournier's gangrene, 54 Fractures, 486–490 in children, 487 classification, 487, 487f, 488f compartment syndrome, 488 compound, 488 conservative treatment, 488 healing, 487–488 intra-articular, 488 operative treatment, 488–489, 489f specific, 489–490 Frank-Starling curve, 24f Frantz tumour of the pancreas, 225, 225f Free fatty acids (FFAs), Free-standing day units, 127 Fresh frozen plasma (FFP), 29, 34 Frozen section, breast, 306 Full blood count acute abdomen, 155 preoperative, 64–65 Full-thickness burns, 290–291, 290f Full-thickness rectal prolapse, 274–275, 274f Full-thickness skin grafts, 287, 294 Fulminant Crohn's colitis, 237–238, 238f Functional neurosurgery, 440–441 Fundoplication, 174–175, 175f Fungal infections, 53 Funiculitis, 422 Furuncles, 474 FVC, 66t G Gadolinium, 118 Gallbladder, 204–214 agenesis, 205 cancer, 86f carcinoma, 214 congenital abnormalities, 205–206 physiology, 204–205 stones see Gallstones strawberry, 208 Gallstone ileus, 207 Gallstones, 206–213, 207b cholangitis, 213 cholecystitis, 206, 207, 207b, 208, 213 common clinical syndromes associated with, 207–208 investigations, 208–209, 208f non-surgical treatment, 213 pancreatitis, 217, 217f, 218, 220 pathogenesis, 206 pathological effects of, 206–207 retained, 211–212, 211f, 212f surgical treatment, 209–211, 209b Gamma glutamyl transferase (GGT), 155 Ganglioneuromas, 341 Gangrene in appendicitis, 163 diabetic foot, 54f gas, 52t, 54 ischaemic colitis, 250 synergistic bacterial, 54 venous, 374 Gardner's syndrome, 137, 254 Gas gangrene, 52t, 54 Gas transfer factor, 66t Gastrectomy, 182, 182f, 187–188, 188f Gastric banding, 191, 191f Gastric bypass, 191, 191f Gastric cancer, 185, 190b advanced, 186–187, 186f, 187f clinical features, 187 diagnosis, 187 early, 186 factors affecting survival, 186–187 hereditary diffuse, 186, 186b palliation, 188–189, 189f prognosis, 189, 189t staging, 187, 187t, 188f treatment, 187–188, 188f Gastric dilatation, 97 Gastric dysplasia, 186 Gastric emptying, 169, 172 Gastric erosions, burns patients, 293 Gastric inhibitory peptide, 169 Gastric juice, 11t Gastric lavage, 110 Gastric polyps, 185 Gastric secretions, 169 Gastric ulcers, 180 complications, 183, 185 management, 182, 182f Gastrin, 169 Gastrinomas, 181, 227, 228, 228t Gastritis, 186, 190 Gastroenteritis, 163 Gastroenterostomy, 186 Gastrografin, 117 Gastrointestinal bleeding, 184, 184t, 222, 222f Gastrointestinal fistulae, 222 Gastrointestinal ischaemia, 222 Gastrointestinal stromal tumours (GISTs), 172–173, 173f, 185, 185f, 242, 262 Gastrointestinal tract effects of shock on, 22, 22b fluid loss from, 11, 11t investigation of the luminal, 235 symptoms assessment, 233b Gastro-oesophageal reflux disease (GORD), 173–175, 174b, 175b, 175f tahir99 - UnitedVRG vip.persianss.ir 497 INDEX 498 Gastroplasty, vertical banded, 191 Gastrostomy, 41, 41f, 221–222, 221f Gelofusine, 12t General anaesthesia, 75, 132 General Medical Council (GMC), 57t General precautions, 103 Gene therapy, 88 Genetic factors breast cancer, 312 cancer, 80, 81t colorectal adenocarcinoma, 256 peptic ulceration, 181 Genitalia, external, 419–423, 419f Gentamicin, 50 Genu valgum, 478, 478f, 484 Genu varum, 478, 484 Giant hairy naevus, 298 Gilbert's syndrome, 193 Gingivitis, 467 Girdlestone's operation, 482 Glandular fever, 468 Glasgow Coma Scale (GCS) injury severity assessment, 94, 94t neurotrauma, 428t, 431–432 Glasgow Prognostic Score, 218–219 Gleeson score, 412 Gliomas, 434–435, 435f, 437 Glomerular filtration rate (GFR), 400 Glossopharyngeal nerve (CN IX), 425 Gloves, 103 Glucagon, 7–8, 215–216 following injury, 5t Glucagonoma, 228, 228t Glucocorticoids, 336–337 Gluconeogenesis, 7–8 Glucose, 20, 130, 192 perioperative control in diabetics, 72 urinary, 156 Glue ear, 462, 463f Glycerol, Glyceryltrinitrate (GTN), 26 Glycogenolysis, Glycolysis, 20, 21f Glycosuria, 399–400 Glycosylated haemoglobin (HbA1c), 130 Goitre, 326–328, 326f, 327b non-toxic nodular, 327, 327f thyrotoxic, 327 toxic multinodular, 329 Golfers' elbow, 485 Gonadotrophin-releasing hormone (GnRH), 334 Goodsall's rule, 270, 270f Gout, 404 Gowns, 103 Graciloplasty, stimulated, 276 Graft-versus-host disease, 33t Graves' disease, 329, 329f Grazes, 92 Greater saphenous vein (GSV), 367, 369 Grey Turner's sign, 155 Groin hernias see Inguinal hernia Group O blood, 30 Growth factors, 313 Growth hormone (GH), 8, 334 acromegaly, 335 following injury, 5t Growth hormone inhibiting factor, 334 Growth hormone releasing factor, 334 Gunshot wounds, 92, 92f, 93f, 282, 288–289 Gynaecological causes of acute abdomen, 150t, 165 Gynaecomastia, 324, 324f H Haemaccel, 12t Haemangioendothelioma, 203 Haemangiomas, 300–301 capillary see Capillary haemangiomas cavernous see Cavernous haemangiomas involuting, 301 non-involuting, 301 splenectomy, 232 Haematemesis, 184 Haematology cancer diagnosis, 86t jaundice, 194–195 preoperative, 64–65 Haematomas, 92 extradural, 432, 433f intracerebral, 433 perianal, 271 of the rectus sheath, 137 subdural, 432–433, 433f wound infection, 125 Haematuria, 156, 409–410, 409f Haemodilution isovolaemic, 34 normovolaemic, 36 Haemoglobin concentration preoperative, 64 threshold in blood transfusion, 31 Haemolytic anaemias, 231 Haemolytic jaundice, 193, 194 Haemolytic transfusion reaction acute, 33t delayed, 33t Haemophilia, 66, 74 Haemophiliacs influenzae, 51t Haemopoiesis, 229 Haemorrhage acute abdomen, 160 peptic ulcer, 184–185, 184f post-cholecystectomy, 211 postoperative complications, 119, 120 shock, 25 thyroidectomy, 331 in trauma patients, 97, 97b Haemorrhagic diatheses, 285 Haemorrhoidal cushions, 264–265 Haemorrhoidectomy, 266–267, 267b Haemorrhoids, 265–267, 267b clinical features, 265–266 examination, 266 history, 266 management, 266–267 staging, 266, 266f Haemothorax, 96, 107 Hair follicles, 281 Hallux rigidus, 486 Hallux valgus, 486 Halo naevus, 298 Hamartomas biliary, 201 pulmonary, 394 Hands decontamination, 48, 48f orthopaedic surgery, 485–486 Harris-Salter classification, 488f Hartmann's procedure, 248–249 Hartmann's solution, 12, 12f, 12t Hashimoto's disease, 328 Head injuries, 431–433, 433b analgesia, 99 assessment, 431–432 in children, 90 diagnostic aids, 101f, 102f management, 432 Health Act (2006), 55 Health care associated infections (HCAI), 55, 55b, 55f Health screen, day surgery, 129 Hearing tests, 460 Heart anatomy, 384b circulation, 382f surgical approach to, 382f transplantation, 457–458, 458b trauma, 389 see also entries beginning Cardiac Heart blocks, 65t Heartburn, 170, 176 Helicobacter pylori, 180 eradication, 181–182, 182b and gastric cancer, 185, 186b tests, 171 Helicopters, emergency, 94 Heller's myotomy, 176 Hemi-arthroplasty, 480–481, 481f Hemilivers, 192 Hemiparesis, 436 Heparin, 74 deep vein thrombosis, 125 low molecular weight see Low molecular weight heparin (LMWH) pulmonary embolism, 125 Hepatic artery, 192 Hepatic ducts, 204 Hepatitis B blood donation, 27 perioperative implications of, 74 preoperative assessment, 66, 67 Hepatitis C blood donation, 27 perioperative implications of, 74 preoperative assessment, 66 Hepatocellular carcinoma (HCC), 202–203, 202b Hepatocellular jaundice, 193, 194 Hepatoma, 202–203, 202b Hereditary non-polyposis colorectal cancer (HNPCC), 83–84, 242, 256 Hereditary spherocytosis, 231 Hernia abdominal see Abdominal hernia hiatus see Hiatus hernia Herniography, 142 Hernioplasty, 141 Herniorrhaphy, 141 Herniotomy, 141 HER receptors, 313 Hesselbach's triangle, 141 Hetastarch, 12t Hiatus hernia, 145, 145f, 171, 171f, 174–176 clinical features, 176 management, 176 types of, 175f Hiccups, 121, 176 Hickman catheter, 42, 43f High intensity focused ultrasound (HIFU), benign prostatic hyperplasia, 416 Hinchey classification, 248, 248t Hip arthroscopy, 486 joint, 486 replacement, 481f, 482–483, 483f Hirschsprung's disease, 251 Histamine, 169 Histocompatibility testing, 446 Histology, cancer diagnosis, 85–86, 86t HLA genes, 446 HNPCC (hereditary nonpolyposis colorectal cancer), 83–84, 242, 256 Hoarseness, 471 Holmium laser enucleation of the prostate (HoLEP), 416 Holmium laser resection of the prostate (HoLRP), 416 Holmium only laser ablation of the prostate (HoLAP), 416 Homicides, 90 Hormonal treatment, breast cancer, 319, 320, 322, 322t Hormone replacement therapy (HRT) breast cancer risk, 311, 311t colorectal adenocarcinoma protection, 256 preoperative assessment, 63 Hormones breast development and function, 303 following surgery and trauma, 5t see also specific hormones Hospital integrated day units, 127 Hospital transfer, burns, 292 Host defence systems, 45–46, 47f Hot biopsy, 253 Howell-Jolly bodies, 229 Human albumin solution (HAS), 12t Human epidermal growth factor receptors (HER), 313 Human immunodeficiency virus (HIV) anal cancer risk, 272 blood donation, 27 preoperative assessment, 66 Human papillomavirus (HPV), 271, 272 Human T-cell leukaemia virus (HTLV), 27 Human Tetanus Immunoglobulin (HTIG), 54 Human Tissue Act, 59–60 Humoral immunity, 229 Hutchinson's melanotic freckle, 298, 299f Hyaluronic acid, 480 Hydatid disease, 197, 197f, 232 Hydrocephalus, 438–440, 439f Hydrocoele, 422–423, 422f Hydrocolloid dressings, 294 Hydrocortisone replacement therapy, 336 after adrenalectomy, 342 septic shock, 25 Hydrogel, 294 Hydrogen ions, 16, 17 Hydronephrosis, idiopathic, 405 Hydrotherapy, osteoarthritis, 480 1-α-Hydroxyvitamin D3, 333 Hyperaldosteronism, 340 Hyperamylasaemia, 155, 155t Hypercalcaemia, 332, 332t and breast cancer, 323 pancreatitis, 217–218 Hypercholesterolaemia, 351 Hyperglycaemia, 7–8, 72 Hyperkalaemia, 14, 15t management, 15t massive transfusion complications, 36t Hyperlipidaemia, 217–218 Hypernatraemia, 13–14 aetiology, 14b hypovolaemic, 13–14 Hyperparathyroidism and peptic ulceration, 181 primary, 332–333, 333f secondary, 333 tertiary, 333 tahir99 - UnitedVRG vip.persianss.ir Index Hyperplastic polyposis, 255 Hyperprolactinaemia, 335 Hyperpyrexia, malignant, 63–64 Hypersensitive bladder, 417 Hypersensitivity reactions, 18–19 Hypersplenism, 231 Hypertension day surgery patients, 130 lower limb ischaemia, 351 perioperative implications of, 71 Hyperthyroidism, 328–329 primary thyrotoxicosis, 329 toxic adenoma, 329 toxic multinodular goitre, 329 Hypertonic saline solutions, 12 Hypertrophic scars, 283, 332 Hypertrophy, juvenile breast, 307, 307f Hyperventilation, 11 Hyphen web veins, 368 Hypoadrenalism, 63 Hypoalbuminaemia, 62 Hypocalcaemia, 36t, 332, 332t Hypochloraemia, 16–17 Hypoglossal nerve (CN XII), 425 Hypoglycaemia, 72 Hypokalaemia, 11, 14–15, 15t massive transfusion complications, 36t and metabolic alkalosis, 16–17 parenteral nutrition convocations, 44 Hypomagnesaemia, 15 Hyponatraemia, 11, 14 aetiology, 14b burns patients, 293 Hypoparathyroidism, 332, 334 Hypopharynx, 469–470, 469f Hypophosphataemia, 16, 44 Hypophysectomy, surgical, 335, 335f Hypophysial stalk, 334 Hypospadias, 420 Hypotension in trauma patients, 97 treatment, 13 Hypothalamus, 7f Hypothermia, 36t Hypothyroidism, 332 Hypovolaemia, 4–6, 13, 13b Hypovolaemic hypernatraemia, 13–14 Hypovolaemic shock, 18–19 burns patients, 292, 292t causes of, 18, 18t management, 23–25, 24t pathophysiology, 19–20 postoperative, 123 I Idiopathic hydronephrosis, 405 Idiopathic slow-transit constipation, 251 Idiopathic thrombocytopenic purpura (ITP), 231 Ileal conduit urinary diversion, 410, 412f Ileostomy, 11t, 251–252, 252f Ileus, 154–155 Iliac aneurysms, 365–366 Imaging techniques, 117–118 see also specific imaging techniques Immune response, 447b afferent arm, 445 efferent arm, 445 Immunization post-splenectomy, 232 tetanus, 54 Immunoglobulins, 29 fresh frozen plasma, 29 indications and doses for, 29t Immunosuppressed patients, antibiotic prophylaxis, 49 Immunosuppression in Crohn's disease, 238–239 drugs, 446–447, 446f effect on wound healing, 285 future of, 447 risks of, 447 transplantation, 446 Impaired cortical control, 418 Impingement syndrome, 485 Implied consent, 58 Impotence, 420 Incidentaloma, adrenal, 342 Incised wounds, 92, 281 Incisional hernia, 144, 144f Incontinence, 417–419 management, 419 neurogenic disorders causing, 418 structural disorders causing, 417–418 Incremental phase, wound healing, 282–283 Indeterminate colitis, 240 Infarction acute abdomen, 150–151, 150t splenic, 232 Infected pancreatic necrosis, 220–221 Infection(s) antibiotics therapy, 50 bacterial see Bacterial infection biology of, 45–46, 47f bone, 482 breast, 309–311, 310b, 310f, 310t in diabetics, 72 diagnosis, 49–50 effect on wound healing, 283–284 health care associated, 55, 55b, 55f immunosuppression risks, 447 importance of, 45 intracranial, 433–434 joint, 482 management, 49–50, 52t mediastinal, 395 obstructed biliary tract, 208 parenteral nutrition complications, 43–44, 43t pleuropulmonary, 396–397 post-cholecystectomy, 211 preventing, 47–49, 49b see also (Prophylaxis) prosthetic grafts, 354 pulmonary, postoperative, 122 risk with prophylaxis, 46t septic shock, 18, 19f surgical, 51–53, 55, 68–69 transfusion-transmitted, 33t treated by surgical management, 53–54 viral see Viral infections Infectious mononucleosis, 468 Inferior mesenteric artery, 234, 235f Inferior vena cava filter, 376 Inflammation acute abdomen, 149–151, 150t, 152, 153f joints, 482 organ rejection, 444 Inflammatory bowel disease, 236–242 colorectal adenocarcinoma, 256 Inflammatory breast cancer, 321, 321f Inflammatory cell infiltrate, 345 Inflammatory cells, Inflammatory response acute, pancreatitis, 219 Informed consent, 57–59, 58b general considerations, 57–58 in specific circumstances, 58–59 Inguinal canal, 139 Inguinal hernia, 138–143, 143b direct, 141–142 emergency surgery, 143b femoral hernia, 142–143, 143f, 146 indirect, 140–141, 140f management, 141–142, 141b, 141f sliding, 138 sportsman's hernia, 142 surgical anatomy, 139–140, 139f Inguinal rings, 139, 139f Injections, osteoarthritis treatment, 480 Injury biomechanics, 91, 91f multiple, 90–102 severity assessment, 93–94, 94t see also Trauma Injury Severity Score (ISS), 93–94 Innate immunity, 46 Inner ear diseases, 463–464 Inotropes, 23 Insulin, 215–216 administration, 72 following injury, 5t perioperative control, 72 Insulinomas, 227–228, 228t Intensive care, 380 Intention, primary and secondary, 283, 284f Intercostal tube drainage, 109f insertion, 107 removal, 108 Interleukin-1 (IL-1), 3, 4t Interleukin-6 (IL-6), 3, 4t Interleukin-8 (IL-8), 3, 4t Interleukin-10 (IL-10), 3, 4t Intermittent claudication, 348–350, 348b clinical features, 348–349, 350f differential diagnosis, 349t endovascular management, 352 epidemiology, 349–350 indications for arterial reconstruction, 353 Internal abdominal hernia, 145, 145f Internal carotid arteries, 425 Internal inguinal ring, 139, 139f Internal jugular vein cannulation, 113–114, 114f International normalized ratio (INR), 65 Interposition arthroplasty, 482 Interstitial lung disease, 396 Intestinal failure, 40, 42 Intestinal fistula, 11, 40 Intestinal fluid, 11t Intestinal metaplasia, 186 Intestinal obstruction, 40, 245–247, 246f abdominal hernia, 146 causes of, 245t closed loop, 246 contrast radiology, 157, 158f, 159f fluid loss from, 11 X-ray, 156, 157f Intestines fistula, 252 polyposis, 137 principles of surgery, 236 stomas, 251–252, 252f see also Large intestine; Small intestine Intra-abdominal abscess, 161–162, 161f, 162f Intra-abdominal sepsis, antibiotics for, 52t Intra-aortic balloon pump (IABP), 26 Intra-arterial digital subtraction angiography (IA-DSA), 357 Intra-arterial drug administration, 361 Intra-articular fractures, 488 Intracellular fluid, 10, 10f, 12f Intracerebral haematoma and contusions, 433 Intracerebral haemorrhage (ICH), 430, 430b Intracranial infections, 433–434 Intracranial pressure (ICP), 426, 426f, 427b in neurotrauma, 432 raised, 436 Intracranial tumours, 434–438 Intra-ductal papillary mucinous neoplasm (IPMN), 224–225 Intraepidermal cancer, 296–297 Intravenous drug users (IVDUs), preoperative assessment, 66 Intravenous fluid administration, 11–13 burns patients, 292, 293 maintenance requirements, 13, 13t pancreatitis, 219 shock, 24 trauma patients, 98 treatment of hypovolaemia and/or hypotension, 13 types of fluid, 11–12, 12t Intravenous pyelography, 157 Intravenous urography (IVU), 400, 400f Intrinsic factor, 169 Invasion, cancer, 81–82, 82f Investigations acute abdomen, 155–160 day surgery, 130–131, 131t pancreatic cancer, 226–227 preoperative, 64–66 see also specific investigations Involuting haemangiomas, 301 Iodine deficiency, 327 Ionizing radiation, 117 Irinotecan, 261 Iron deficiency anaemia, 170 Iron overload, 33t Irreducible hernia, 146 Irreversible cognitive impairment, 58–59 Irritable bowel syndrome, 250 Ischaemia reperfusion injury (IRI), 444 Ischaemic colitis, 249–250, 249f Ischaemic heart disease, 381–384 perioperative implications of, 69, 69t see also Coronary artery disease (CAD) Ischaemic stricture of the colon, 250, 250f Islets of Langerhans, 215–216 Isotope scans, 391t Isovolaemic haemodilution, 34 Ivor Lewis two-phase oesophagectomy, 178, 179f J Jaundice, 193–196, 194f, 196b diagnosis, 194–196, 195f with pancreatitis, 222 perioperative implications of, 73–74 progressive, 222 Jejunal diverticulosis, 244, 244f Jejunostomy, 41, 221–222, 221f tahir99 - UnitedVRG vip.persianss.ir 499 INDEX Jejunum, 233–234 obstruction, 245 Joint(s) degenerative disease, 479–482 dislocation, 487 infection, 482 inflammatory disease, 482 replacement, 480–483, 481f Justice, 57, 57b Juvenile hypertrophy, breast, 307, 307f Juvenile polyposis syndrome (JPS), 254 K Kaolin, 395, 396 Kaplan-Meier equations/graphs, 83, 83f Kasai operation, 205 Keller's procedure, 482 Keloids, 283, 332 Keratinocytes, 281 Keratoacanthoma, 296, 296f Ketones, 8, 156 Kidney(s) anatomy, 402, 402f benign tumours, 403 cancer, 403, 403f, 404b effects of shock on, 22, 22b obstruction, 405, 405t pain, 399 palpation, 399, 400f physiology, 402–403 response to injury, 7f stones, 404–405 transplantation, 450–453, 450t, 451t, 452f, 453b see also entries beginning Renal Kinetic energy, 91 Klebsiella species, 51t Knee joint, 486 recurvatum deformity, 478, 478f replacement, 482–483, 482f, 483f Knife injuries, 90 Knock-knees, 478, 478f, 484 Kyphosis, 479 500 L Labia, 419f, 420 Lacerations, 92 Lactating breast infection, 310, 310f Lactic acid, 20, 21 Lactic acidosis, 16 Lag phase, wound healing, 282 Laminectomy, 442 Laparoscopy acute abdomen investigation, 160, 160f appendicitis treatment, 164 cancer diagnosis, 85–86, 86f cancer staging, 86 cancer treatment, 88b gastric carcinoma staging, 187, 188f hernia repair, 141–142 liver disease evaluation, 196 splenectomy, 230 Laparotomy, 196 Lapatanib, 319 Large intestine anatomy, 234, 235f examination, 235 function, 234 history, 234 investigation, 235 ischaemia, 249–251 malignant tumours, 255–262 non-neoplastic disorders, 247 obstruction see Intestinal obstruction polyps/polyposis syndromes, 252–255, 252t, 253f Laryngeal mask airway, 106, 106f Laryngeal nerve damage, thyroidectomy, 331 Laryngitis, 471 Laryngocoeles, 474 Laryngoscope, 106, 106f Larynx, 469, 469f, 470–472, 470f anatomy, 470, 470f assessment, 471 diseases, 471, 471b oedema, 120 physiology of voice, 470 spasm, 120 tracheostomy, 471–472, 472f Laser prostatectomy, 416 Left ventricular aneurysm, 384 Legislation, 56–60 Leg ulcers antibiotics, 372–373 compression therapy, 373, 373f dressings, 373 endovenous surgery, 373–374 Leiomyosarcoma, 262 Lentigo maligna, 298, 299f Lesser saphenous vein (LSV), 367, 369 Letrozole, 320 Leucocytes, 4, 46, 345 Leucocytosis, 155 Leukoplakia, 468, 468f Levator ani, 263 Le Veen shunt, 201, 202f Lichtenstein open tension-free repair, 141, 142f Lidocaine, 75, 75t, 77, 104 Limb ischaemia see Acute limb ischaemia; Critical limb ischaemia; Lower limb ischaemia Lipase, 215, 218 Lipid deposition, 345 Lipolysis, Lipomas, 301, 309 Lipopolysaccharide (LPS), 45 Liposarcomas, 301 Lister, Joseph, 45 Lithium, 63 Lithotripsy, 211–212 Little's area, 464 Littré's hernia, 138 Liver, 192–204 anatomy, 192, 192b, 193f biopsy, 195 congenital abnormalities, 196, 196f effects of shock on, 22–23 infections, 196–197 infestations, 196–197 portal hypertension, 197–201 resection, 204 response to injury, 7f transplantation, 203, 453–455, 453t, 454f, 455b, 455f trauma, 196 tumours, 201–204, 202f, 203f Liver cell adenoma, 201–202 Liver function tests acute abdomen, 155 preoperative, 65 LKB1 gene, 243 Lobectomy, 393 Lobular carcinoma in situ (LCIS), 312, 312f Lobular intraepithelial neoplasia (LIN), 312 Local anaesthesia, 75–79, 75t, 103–104 day surgery, 132 toxicity, 103–104 trauma patients, 99 Local infiltration, 77 Locally advanced breast cancer (LABC), 321, 321f, 321t, 322b Long saphenous vein, 113, 113f Long-term steroid therapy, preoperative assessment, 63 Lordosis, 479 Lower limb arterial disease see Lower limb arterial disease ischaemia see Lower limb ischaemia orthopaedic surgery, 486 venous drainage, 367, 367f Lower limb arterial disease, 347–354 anatomy, 347, 348f clinical features, 347–348 critical limb ischaemia, 350–351 intermittent claudication, 348–350, 348b management, 351–354 Lower limb ischaemia ankle to brachial pressure index, 348, 348f examination findings, 347 pulse status, 347–348 symptoms, 347 see also Critical limb ischaemia; Intermittent claudication Low molecular weight heparin (LMWH) deep vein thrombosis, 125 deep vein thrombosis prevention, 375 Ludwig's angina, 467 Lumbar disc prolapse, 441, 441b, 441f, 442f Lumbar hernia, 145 Lumbar puncture, 76, 76f, 116–117 Lumps excision of, 117 orthopaedic surgery, 477, 477t Lung(s) cancer, 391–394 collapse, 122 metastases, 394, 394f postoperative complications, 121–123 postoperative infection, 122 resection, 392–394 secretions, 397 transfusion-associated acute injury, 33t transplantation, 457–458, 458b see also entries beginning Pulmonary Luteinizing hormone (LH), 334 following injury, 5t Lymphadenopathy, 170–171, 474, 474b acute abdomen, 154 causes of, 475t Lymphatic drainage, anal canal, 265 Lymph nodes anal cancer, 273 axillary, 302, 303f, 304, 305f breast assessment, 304, 305f breast cancer, 314, 315f, 316–317 cervical, 472–473, 472f gastric cancer, 187b palpable, 87 removal, 87 swellings see Lymphadenopathy Lymphocoeles, 452 Lymphocytic colitis, 251 Lymphoedema, 376–378 clinical features, 376–377, 377f investigations, 377 management, 377–378 pathophysiology, 376 primary, 376 secondary, 376 types of, 376, 377f Lymphomas breast, 323 gastric, 189 large intestine, 262 small bowel, 243 splenectomy, 232 thyroid gland, 331 see also Non-Hodgkin's lymphoma Lynch syndrome see Hereditary non-polyposis colorectal cancer (HNPCC) M McBurney's point, 162, 162f McEvedy approach, 143 Macrocirculation, 19–20 Macrophages, 3, 4f, 46 Magnesium, 10 abnormalities, 15 Magnesium ammonium phosphate stones, 404 Magnetic resonance angiography (MRA), 118 carotid artery disease, 357, 357f neurosurgery, 428 subarachnoid haemorrhage, 429 Magnetic resonance cholangiopancrea tography (MRCP), 118 jaundice, 195 pancreatic cancer, 226 Magnetic resonance imaging (MRI), 118 breasts, 305 cancer diagnosis, 85–86 cancer staging, 86–87 fistula-in-ano, 270 jaundice, 195 neurosurgery, 428 orthopaedic surgery, 478, 478f temporal bone, 460–461, 461f thoracic surgery, 391t thyroid gland, 326 Magnetic resonance venogram (MRV), deep vein thrombosis, 374, 375f MAG-3 (radio-labelled mercaptuacetyltriglycine), 400–402 Major histocompatibility complex (MHC), 444 Malignant hyperpyrexia, 63–64 Malignant melanoma, 298–300, 300b, 300f, 301b Malleus, 459 Malnutrition, 38–39 effect on wound healing, 285 preoperative assessment, 62 Malpighian bodies, 229 MALT lymphomas, 189 Malunion, 489, 489f Mammary duct fistula, 310 Mammographic screening, breast cancer, 83, 84f, 84t, 313, 313b Mammography, 304, 313, 314f Manometry, oesophageal disorders, 173 Mastalgia breast cancer, 316 cyclical, 308 non-cyclical, 308 Mastectomy, 318, 318b, 318f Mastitis, 310 Matrix metalloproteinase (MMP) inhibitors, 88 tahir99 - UnitedVRG vip.persianss.ir Index Matrix metalloproteinases (MMPs), 81–82 Maturation phase, wound healing, 283 Maximal surgical blood ordering schedule (MSBOS), 30–31 Mayo repair, para-umbilical hernia, 144 Mean arterial pressure (MAP), 19, 19t, 426 Meatal stenosis, 421 Meckel's diverticulum, 137, 138, 138f, 244 Median nerve, 485 Mediastinoscopy, 393 Mediastinotomy, 393 Mediastinum, 394–395 infection, 395 mass lesions, 394–395, 395f Medical history, day surgery patients, 130 Medications see Drugs Medullary carcinoma, 331 Medulloblastomas, 437, 437f, 438 Megacolon, 251 Meissner's plexus, 169, 233–234 Melaena, 184 Melanocytes, 281 epidermal tumours from, 295t, 297–300, 298b Melanocyte-stimulating hormone, 339–340 Melanoma, malignant, 298–300 Melanotic freckle, Hutchinson's, 298, 299f Ménétrier's disease, 190 Meninges, 425 Meningiomas, 435, 435f, 436, 437 Meningitis, 434 Meniscal injuries, 486 Menstrual cycle, 307–308 Mental illness, consent in, 58 Meralgia paraesthetica, 443 Mercedes-Benz incision, 454, 454f Mesenteric angina, 244 Mesenteric angiography, 159 Mesenteric artery disease, 359 Mesenteric ischaemia, chronic, 245 Mesh repair hernias, 141, 141b, 142f infected, 146 ventral hernia, 144, 145f Mesothelioma, 394 Metabolic acidosis, 16, 16b Metabolic alkalosis, 16–17, 17b Metabolic complications of parenteral nutrition, 44 Metabolic encephalopathy, hyponatraemia, 14 Metabolic response to injury, 3–9, 4f, 7f consequences of, 4–8 factors mediating the, 3–4, 5b factors modifying the, 9, 9t features, urinary changes, 6, 6b Metaplastic polyposis, 255 Metastases, 81–82, 82f brain, 323, 435, 436f breast cancer, 81, 322–323, 322b, 322t, 323b investigations, 86 liver, 203–204, 323 pancreatic, 225 pulmonary, 394, 394f surgery for, 89 Methicillin-resistant Staphylococcus aureus (MRSA), 55, 55f antibiotics for, 51t preoperative screening, 47–49, 47b, 67 Methicillin-sensitive Staphylococcus aureus (MSSA), 51t, 55, 55f Microcirculation, 20, 20f Microdiscectomy, 442 Microdochectomy, 309 Microlithiasis, 217 Microscopic colitis, 251 Micturating cystourethrogram (MCU), 400 Micturition, 419b aetiology of abnormal, 418 cycle, 406–407 disorders, 399, 417–419 flow rate, 402, 402f neurological control of, 406 Middle ear diseases, 462–463 Midstream specimen of urine (MSU), 399–400 Milk line, 302 Mineralocorticoid replacement therapy, 336, 342 Minimally invasive oesophagectomy, 179 Minnesota tube, 110, 199, 199f Mirizzi's syndrome, 212 Mitral valves, 129 regurgitation, 384, 387 replacement, 384, 384b stenosis, 386, 387f surgical outcomes, 387 Mittelschmerz, 165 MLH1 gene, 83–84, 256 Model for end stage liver disease (MELD), 453, 454t Moles, 297–298, 298f Molluscum sebaceum, 296, 296f Monoamine oxidase inhibitors (MAOIs), 63 Mons pubis, 419f, 420 Moon face, 338, 338f Morphine, 99 Mortality, cardiothoracic surgery, 379 Morton's neuroma, 486 Motor neuropathy, diabetic foot, 351 Mouth, 467–468 Mouth ulcers, 468 Movement disorders, 440–441 MRC scale, muscle power, 99–100, 100t MRSA see Methicillin-resistant Staphylococcus aureus (MRSA) MSH2 gene, 83–84, 256 MSH6 gene, 256 Mucinous breast cancers, 312–313 Mucinous cystic neoplasm, pancreatic, 225, 225f Mucocoele, 207, 236 Mucosa as a defence system, 46 Mucosal disease, 462–463 Mucosal rectal prolapse, 274 Mucus, 169 Multiple endocrine neoplasia (MEN), 343 type I, 227, 228–229, 343 type II, 343 Multiple injury, 90–102 Multiple organ dysfunction syndrome (MODS), 219 Multiple sclerosis, perioperative implications of, 75t Murphy's sign, 155, 207 Muscle(s) power assessment in trauma patients, 99–100, 100t tumours of, 301 see also Skeletal muscle Musculoskeletal disease, perioperative implications of, 75 Musculoskeletal tumours, 484 MUTYH-associated polyposis (MAP), 255 Myasthenia gravis, perioperative implications of, 75t Mycophenolate mofetil (MMF), 447 Mycophenolic acid, 447 Mycotic aneurysms, 362 Myelofibrosis, 231 Myelomeningocoele, 438, 438f Myenteric plexus, 169, 233–234 Myocardial infarction (MI) perioperative implications of, 69–70, 69t postoperative, 119, 123 Myocardial ischaemia acute, 26 postoperative, 123 Myocardial preservation, 379–380 Myotomy, 176 N Naevi, 297–298, 298f Nails, 281 Naloxone, 99 Nasal septum, deviated, 465, 465f Nasobiliary catheter, 211–212 Nasogastric tubes feeding via, 41 fine-bore, 110 insertion, 109–110, 110f postoperative care, 121 Nasojejunal tubes, 41 Nasopharynx, 467 Natal cleft closure, 277 Natural braided sutures, 104 Nausea see Postoperative nausea and vomiting (PONV) Neck, 472–475 anatomy, 472–473, 472f, 473f assessment, 473–474 diseases, 474–475 Necrotizing fasciitis, 53–54, 54f Needle cricothyroidotomy, 107 Needle pericardiocentesis, 115, 115f Needles general precautions, 103 safety, 112 Negligence, 59 Neoplasms see Tumours Neostigmine, 119–120 Nephroblastomas, 403 Nerve conduction tests, 477 Nerves damage in thyroidectomy, 331 injuries, 487 tumours of, 301 Neural transplantation, 440–441 Neurilemmoma, 301 Neuroblastomas, 341 Neurofibroma, 301 Neurofibromatosis, 301 Neurogenic disorders causing incontinence, 418 Neurogenic shock, 19, 20 Neurohypophysis, 336, 336f Neurological examination, 432 Neurological status, 99–100, 100b Neuroma, acoustic, 435, 435f Neuropathic pain, 79, 79b Neuropathy, diabetic, 72, 351, 351f Neuropsychiatric disturbances, postoperative, 124 Neurosurgery, 424–443 anatomy and physiology, 424–425 evidence-based, 443 functional, 440–441 investigations, 426–428 Neurotrauma, 431–433 assessment, 431–432 management, 432 Neutrophils, 4f, 46 NICE (National Institute for Clinical Evidence), day surgery guidelines, 130, 131t Nicotinamide adenine dinucleotide (NADH), 20 Night pain, critical limb ischaemia, 350 Nimodipine, 429, 429b, 430 Nipples cytology, 305 discharge, 309f, 316 eczema, 316 Paget's disease of, 316 Nissen fundoplication, 174–175 Nitrates, 185 Nitric oxide (NO), 20 Nitrogen negative balance, 3, 8, 9t positive balance, Nodularity, breast, 308 Nodular melanoma, 299 Non-absorbable sutures, 104 Non-Hodgkin's lymphoma small bowel, 243 splenectomy, 232 Non-invasive ventilation (NIV), 72 Non-involuting haemangiomas, 301 Non-malefeasance, 57, 57b Non-mechanical bowel dysfunction, 246–247, 247t Non-specific abdominal pain (NSAP), 164–165 Non-steroidal anti-inflammatory drugs (NSAIDs), 78–79 colorectal adenocarcinoma protection, 256 and peptic ulceration, 180–181 Non-toxic nodular goitre, 327, 327f Noradrenaline, 340–341 Normovolaemic haemodilution, 36 Nose, 464–466 anatomy, 464, 464f assessment, 464–465, 465f diseases, 465–466 obstruction, 464 physiology, 464 polyps, 465, 465f Nosocomial Infection National Surveillance Service (NINSS), 55 Nosocomial infections see Health care associated infections (HCAI) Nottingham prognostic index (NPI), 315, 315t, 319 NSAIDs see Non-steroidal anti-inflammatory drugs (NSAIDs) Nuclear imaging, urological disorders, 400–402 Nucleus pulposus, 441, 441f Nuss procedure, 397 Nutcracker oesophagus, 176 Nutrition causes of inadequate, 40 postoperative care, 121 requirements, 40, 40t Nutritional disorders, 38 Nutritional status assessment, 38–39, 39f, 40b effect on wound healing, 285 preoperative assessment, 62 Nutritional support, 38–44 after surgery, burns patients, 293 methods of providing, 40–44 monitoring of, 44 pancreatitis, 219, 219b see also Enteral nutrition; Parenteral nutrition, total (TPN) tahir99 - UnitedVRG vip.persianss.ir 501 INDEX 502 O Obesity, 38 lower limb ischaemia, 351 preoperative assessment, 62, 63t surgery for, 190–191, 191f Obstruction definition, 151 nature of pain, 152, 153f see also specific anatomical areas Obstructive airway disease, 285 Obstructive jaundice, 194 Obturator hernia, 145 Occlusive dressings, burns, 294 Occupation, orthopaedic surgery, 476 Oculomotor nerve (CN III), 425 Odynophagia, 170 Oedema, 4, 4f, 315–316, 316f see also Lymphoedema Oesophagectomy, 168, 178–179, 179f Oesophagitis, 169, 176 Oesophago-gastric cancer, 172–173, 173f Oesophagogastroduodenoscopy (OGD), 172 Oesophagus Barrett's, 173–175, 174b disorders, 173–178 Doppler, 71t examination, 170–171 intra-luminal pressure, 173, 174f investigations, 171–173 nutcracker, 176 obstruction, 470 perforation, 171, 171f, 177–178, 177f pH studies, 173, 174f pouches, 177 spasm, 169, 176 stapling, 200, 200f stricture, 169 surgical anatomy, 167–169, 168f surgical physiology, 169 symptoms, 169–170 tamponade, 110–111 tumours, 178–180 varices, 198–200, 199b, 199f, 199t, 200b, 200f, 201f Oestrogen, 336–337, 337b breast cancer, 313 breast development/function, 303 following injury, 5t Oestrogen receptors (ERs), 313 Off-loading, 480 Oliguria, Oophorectomy, 319 Open biopsy, breast, 306 Open (sucking) chest wounds, 96, 96f Opioids, 78, 99 OpSite, 294 Optic nerves (CN II), 425 Oral cavity see Mouth Oral contraceptives, 63 Oral supplements, 41 Orbital cellulitis, 467f Orchiectomy, 413 Organ donation, 448–451, 448f after cardiac death, 449–450, 450t contra-indications, 448t deceased, 448 extended criteria donor, 450 living donation, 450–451, 450t management of donors, 448–449 multi-organ retrieval, 449, 449f non-heartbeating versus heart beating kidney donors, 450b organ preservation, 449 Organ failure, burns patients, 293 Oropharynx, 468–469 Orotracheal intubation, 96, 96f Orthopaedic surgery, 476–490 description of deformity, 478–479 examination, 477 history, 476–477 investigations, 477–478 paediatric, 483–484 Osteitis fibrosa cystica, 332 Osteoarthritis, 479–482, 479f knee, 486 medical management, 480, 480t shoulder, 485 surgical management, 480–482, 480t Osteomalacia, 183 Osteomyelitis, 482 Osteoporosis, 183 Osteotomy, 480, 480f Otalgia, 460, 460t Otitis externa, 462 Otitis media, 463b acute suppurative, 462, 462b chronic suppurative, 462–463 with effusion (OME), 462, 463f Otosclerosis, 463 Ovarian cysts, 165 Overflow incontinence, 417 Oxygen delivery, 20, 21f, 61–62 extraction, 20, 21f perioperative cardiovascular disease management, 71 therapy cardiogenic shock, 26 shock, 23 toxicity, 96 Oxytocin, 336 P Pacemakers, perioperative implications of, 70 Paget's disease of the nipple, 316 Pain assessment, 77 management see Analgesia, post-operative neuropathic, 79, 79b pathway, 78f somatic, 147–148, 149f visceral, 148–149 see also specific anatomical areas Palliation advanced cancer, 89 colorectal adenocarcinoma, 261 gastric cancer, 188–189, 189f oesophageal carcinoma, 179–180 pancreatic cancer, 226–227 Palpable breast cysts, 308 Palpation, acute abdomen, 153–154, 154t Palpitations, 176 Pancolitis, 242 Pancreas, 215–229 abscess, 222 annular, 216 congenital disorders, 216 infected necrosis, 220–221 pain, 216 pancreatitis see Pancreatitis physiology, 215–216 pseudocyst, 221–222, 221f response to injury, 7f suppression of function in pancreatitis, 219 surgical anatomy, 215, 216f transplantation, 455–456, 456f, 456t, 457b tumours, 218, 224–229 Pancreatic ductal adenocarcinoma (PDAC), 224 Pancreatic hormones, 5t Pancreatic islet transplantation, 457 Pancreatic juice, 11t Pancreatic neuroendocrine tumours (PET), 227–228 clinical features of, 228t functioning, 227 gastrinomas, 228 insulinomas, 227–228 miscellaneous, 228–229 multiple endocrine neoplasia type I, 228–229 non-functioning, 227, 228f Pancreaticoduodenectomy, 226, 227f Pancreaticojejunostomy, 224, 224f Pancreatitis, 216–224 acute, 208, 217–222 aetiology, 217–218, 217t alcohol-associated, 217, 218 clinical features, 218 complications, 220–222 diagnosis, 218 differentiation between gallstone- and alcoholassociated, 218 gallstone-associated, 217, 217f, 218, 220 hereditary, 217–218 management, 219–220 prognosis, 222 severity assessment, 218–219 blood tests, 155 chronic, 222–224 aetiology, 223 clinical features, 223 hereditary, 223 investigations and diagnosis, 223, 223f management, 223–224 pathophysiology, 223 surgical treatment, 224 Cullen's sign, 155 gallstone, 207 Grey Turner's sign, 155 Papillary carcinoma, 330 Papillomas, 295–296, 295f breast duct, 309, 309f Papillotomy, endoscopic, 211–212, 212f Paracetamol, 78–79 toxicity, 453t Paracrine action, Paralytic ileus, 11, 40, 246 Paramedics, 94 Paranasal sinuses, 466–467, 466f Paraphimosis, 420 Parastomal hernia, 144–145 Parathormone (PTH), 332, 333 Parathyroidectomy, 334 Parathyroid glands, 325, 332–334 calcium metabolism, 332, 332t hyperparathyroidism, 333b primary, 332–333, 333f secondary and tertiary, 333 hypoparathyroidism, 334 parathyroidectomy, 334 surgical anatomy, 332–334 Para-umbilical hernia, 144, 144f Parenteral nutrition, total (TPN), 40–41, 42–44, 44b administration of, 42, 43f complications of, 43–44 composition of solutions, 42, 42t versus enteral nutrition, 41b indications for, 42 pancreatitis, 219, 219b peripheral venous nutrition, 44 Parietal cells, 169 Parietal peritoneum, 147–148 Parkland formula, 292 Parotid salivary gland, 472–473, 472f, 473f, 474f, 475, 475f, 475t Pasteur, Louis, 45 Patent ductus arteriosus, 390 Paterson-Brown-Kelly syndrome, 470 Patient-controlled analgesia (PCA), 78 Peak expiratory flow rate (PEFR), 66t Peau d'orange skin, 315–316, 316f, 321 Pectus carinatum, 397 Pectus excavatum, 397 Pedunculated papillomas, 296 PEFR, 66t Pelvic floor muscles, 418 Pelvic fractures, 97, 98f Pelvic inflammatory disease, 52t Pelvic X-ray, 100 Pelviureteric junction obstruction, 405 Penicillin, 45 Penis, 419–420, 419f carcinoma, 420–421, 421f congenital abnormalities of, 420 inflammation, 421 Pepsin, 169 Pepsinogen, 169 Peptic ulcer, 180–181 clinical features, 181 complications, 183–185, 184f diagnosis, 181 management, 182b, 182f management of uncomplicated, 181–183 perforated, 157 special forms of, 181 Percussion, acute abdomen, 154, 154t Percutaneous angioplasty, 69–70 Percutaneous coronary intervention (PCI), 381–382 Percutaneous drainage, infected pancreatic necrosis, 220 Percutaneous nephrolithotomy (PCNL), 405 Percutaneous transhepatic cholangiography (PTC), 195 Perforation colonic diverticula, 248–249 intra-abdominal, 151, 151f nature of pain, 153f oesophageal, 177–178, 177f peptic ulcer, 183, 184f X-ray, 156 Perianal abscess, 268–269, 269f Perianal haematoma, 271 Peri-areolar infection, 310 Pericardial constriction, 389, 389f Pericardial effusion, 389 Pericardiocentesis, needle, 115, 115f Peridiverticulitis, 248 Periductal mastitis, 310 Perilymph, 459–460 Peripheral nerve block, 77, 77t Peripheral nerve lesions, 442–443 Peripheral venous cannulation, 112–113, 114–115 Peripheral venous nutrition, 44 Peritoneal dialysis catheter, 111, 111f Peritoneal lavage, 160 Peritoneovenous shunt, 201, 202f Peritoneum parietal, 147–148 visceral, 148 tahir99 - UnitedVRG vip.persianss.ir Index Peritonitis, 150, 150t, 160–162 in appendicitis, 163 colonic diverticular disease, 248–249 intra-abdominal abscess, 161–162, 161f, 162f postoperative, 161 primary, 161 spontaneous bacterial, 161 Personality disintegration, intracranial tumours, 436 Personal protective equipment (PPE), 48 Perthes' disease, 484 Pes cavus, 486 Pes planus, 486 Peutz-Jeghers syndrome, 243–244, 243f, 254 Peyer's patches, 234 Peyronie's disease, 420 Phaeochromocytoma, 340–341, 341b, 341f Phantom pain, 356 Pharmacomechanical thrombectomy, 376 Pharyngeal pouch, 169, 177, 470 Pharyngitis, 468 Pharynx, 469, 469f, 470 Phenol, 45 Phenothiazines, 63 Phimosis, 420 Phlegmasia caerula dolens, 374 Phosphate, 10, 16 Phreno-oesophageal ligament, 167 Phrygian cap, 205 pH studies, oesophageal disorders, 173, 174f Phyllodes tumours, 309, 324 Physiotherapy osteoarthritis, 480 in respiratory disease, 72 Phytobezoars, 190 Piggy-back procedure, 454 Pigment stones, 206 Piles see Haemorrhoids Pilonidal disease, 277, 277b, 277f Pinna, 459, 459f, 460 diseases of, 461, 462f Pituitary gland, 334–336 anatomy, 334, 334f anterior, 334–336, 334f, 335b, 335f disease, 339–340, 340b posterior, 336, 336f response to injury, 7f tumours, 334–335, 335b, 335f, 338, 435 Pituitary hormones following injury, 5t Pituitary stalk, 334 Plain radiography see X-rays Plantar warts, 295–296, 295f, 296f Plaque rupture, 346 Plasma, 11t Plasma-like fluid loss, 5t Plasma oncotic pressure, 10 Plasma products, 29 Plastic surgery, 281–301 Plateau phase, wound healing, 283 Platelet-derived growth factor receptor alpha (PDGFRA) gene, 242 Platelets activation, blood donation, 28 preoperative, 64 transfusion, 34 Pleural aspiration, 108–109, 109f Pleural effusion, 107 and breast cancer, 323 postoperative, 123, 123f postoperative complications, 121 Pleurectomy, 395 Pleurodesis, 395 Pleuropneumonectomy, 394 Pleuropulmonary infection, 396–397 Plummer-Vinson syndrome, 176–177 Pneumaturia, 249 Pneumonectomy, 393 Pneumothorax, 96, 97, 97t, 107, 395–396, 395f, 396f management, 395–396 postoperative, 121, 123 Police services, 94 Polycystic disease kidneys, 196, 403 liver, 196 Polygeline gelatin, 12t Polypectomy, 253, 258 Polypeptide, 215–216 Polyposis syndromes, 252–255 Polyps adenomatous, 185 fibroepithelial anal, 272 gastric, 185 large intestine, 252–255, 252t, 253f nasal, 465, 465f in Peutz-Jeghers syndrome, 243 Polythene bags, 294 Popliteal aneurysms, 361, 366 Porphobilinogen, urinary, 156 Porphyria, 156 Porta hepatis, 192 Portal hypertension, 197–201, 201b acute variceal bleeding, 198–200, 199b, 199f, 199t, 200b, 200f, 201f ascites, 201, 202f causes of, 197–198, 198t clinical features, 198, 199t effects of, 198 post-hepatic, 198 segmental, 231 Portal vein, 192, 215 Portal venous system, 198, 198f Portosystemic shunting, 198 variceal banding, 199b, 200, 200b variceal bleeding, 201f Port-wine stain, 301 Positive-pressure ventilation, 97 Positron emission tomography (PET), 118 cancer diagnosis, 85–86 cancer staging, 86, 86f colorectal adenocarcinoma, 257–258 gastric carcinoma staging, 187 jaundice, 195 large bowel investigation, 235 thoracic surgery, 391t Post-cholecystectomy syndrome, 212 Post-cricoid carcinoma, 470 Post-cricoid web, 176 Posted-transplant lymphoproliferative disorders (PTLDs), 447 Posthitis, 421 Post-micturition dribble incontinence, 417 Post-mortem examination, 60 Postoperative care, 119–126 cardiothoracic surgery, 380–381 immediate, 119–120 renal transplantation, 452 surgical ward care, 120–121 thoracic surgery, 397–398 Postoperative nausea and vomiting (PONV), 64, 79, 121 day surgery, 132, 133t Potassium, 10 abnormalities, 14–15 daily requirements, 10 homoeostasis, 65 intravenous fluid administration, 13 loss, 10 Potassium chloride, 13 Povidone-iodine, 294 PPomas, 228 Precautions, general, 103 Pregnancy acute abdomen in, 156 appendicitis in, 163 breast cancer in, 322 day surgery patients, 130 preoperative assessment, 63, 64t Preoperative assessment, 60–75 alcohol, 62 allergies, 63 anaesthesia, 61, 61f, 63–64, 64b cardiovascular system, 62, 63t day surgery, 128–131, 131b drug therapy, 63 nutritional status, 62 obesity, 62, 63t operative fitness, 60–62 perioperative risk, 60–62, 61f pregnancy, 63, 64t preoperative exercise, 62 previous operations, 63–64 respiratory system, 62, 63t smoking, 62, 62t ward round, 67–69 Presbycusis, 463 Priapism, 420 Prilocaine, 75t Primary pneumothorax, 395 Primary sclerosing cholangitis, 213–214 Primitive neuroectodermal tumours (PNETs), 437, 437f, 438 Principalism, 56–57, 57b Prion diseases, 49 see also Creutzfeldt-Jakob disease (CJD); Variant CreutzfeldtJakob disease (vCJD) Probiotics therapy, pancreatitis, 220 Processus vaginalis, 139, 140f Procidentia, 274 Proctoscopy, 266 Profundaplasty, 353, 353f Progesterone, 313, 336–337 Progesterone receptors (PgRs), 313 Prolactin-inhibiting factor (PIF), 334 Prolactin (PRL), 334, 335 following injury, 5t Prophylaxis, 47–49, 49b antibiotic see Antibiotic prophylaxis venous thromboembolism, 67–68, 68t Prostate anatomy, 406, 407f carcinoma see Prostate cancer physiology, 406–407 Prostate cancer, 410–414, 414b clinical features, 413, 413f epidemiology, 410 incontinence in, 417 investigations, 413 management, 413, 414b pathology, 411–412 prognosis, 414 screening, 84t staging, 411–412, 412t Prostatectomy benign prostatic hyperplasia, 415, 416 closed, 416 incontinence after, 417 open, 415 Prostate-specific antigen (PSA), 413, 415, 415t Prostheses heart valves, 129, 385, 385f infections of, 53, 354 Protease inhibitors, Protein depletion, 38–39, 39f metabolism, 8, 9b requirements, 40, 40t urinary, 156 Proteinuria, 399–400 Proteus species, 51t Prothrombin complex concentrates, 29 Proton pump inhibitors (PPIs), 181 Pruritus ani, 276–277 Pseudocholinesterase deficiency, 63–64 Pseudocysts, pancreatic, 221–222, 221f Pseudomembranous colitis, 251 Pseudomonas aeruginosa, 51t Pseudomonas infections, 52t Pseudomyxoma peritonei, 236 Pseudo-obstruction, 246–247, 247t Psoas stretch sign, 163 Psychiatric drugs, preoperative assessment, 63 PTEN gene, 255 Puborectalis sling, 263, 264f Pulmonary artery catheter, 71t Pulmonary embolism (PE), 67–68, 129 epidemiology, 374 pathophysiology, 374 postoperative, 125, 125f as a postoperative complication, 121 Pulmonary function tests, 66, 66t, 391t Pulse in lower limb ischaemia, 347–348 Pulse oximetry, 23, 96 Puncture wounds, 92 Purpura, post-blood transfusion, 33t Pyelonephritis, 52 Pyeloplasty, 405, 405f Pylorus, 167–168 Pyogenic liver abscess, 196–197 Pyrexia see Fever Pyruvate, 20, 21 Q Quinsy, 468 R Radiation breast cancer risk, 311 ionizing, 117 see also Radiotherapy Radiation enteritis, 244 Radioactive iodine, 329 Radioactive scintigraphy, cancer diagnosis, 85–86 Radiofrequency ablation (RFA), varicose veins, 369 Radiography, plain see X-rays Radioisotope scanning, 118 thyroid gland, 326 Radio-labelled mercaptuacetyltriglycine (MAG-3), 400–402 Radiology acute abdomen, 156–160 cancer diagnosis, 85–86, 86t jaundice, 195 pancreatitis, 218, 218f trauma patients, 100, 100f, 101f urological disorders, 400 see also specific modalities tahir99 - UnitedVRG vip.persianss.ir 503 INDEX 504 Radiotherapy anal cancer, 273 breast cancer, 318, 320 cancer, 87–88 colorectal adenocarcinoma, 260–261 complications, 320 external beam see External beam radiotherapy (EBRT) oesophageal carcinoma, 179 paediatric neuro-oncology, 438 palliative, 180 colorectal adenocarcinoma, 261 gastric cancer, 189 pituitary gland tumours, 336 prostate cancer, 413 see also Chemo-radiotherapy Ramsay-Hunt syndrome, 464 Rathke's pouch, 334 Raynaud's disease, 367 Raynaud's phenomenon, 367 Raynaud's syndrome, 367 Rebound tenderness, 153–154, 163 Receptive relaxation, 169 Recklinghausen's disease, 301 Recombinant activated factor VIIa (rVIIa), 25 Recombinant activated protein C (rhAPC), 26 Recombinant tissue plasminogen activator (rTPA), 375–376 Reconstructive surgery, 281–301 Recovery cardiothoracic surgery, 381 day surgery, 132 Rectal examination acute abdomen, 155 trauma patients, 99, 100t Rectum, 234, 235f bleeding from, 234 cancer, 258 prolapse, 274–275, 274f, 275b Rectus muscle disorders, 137 Rectus sheath haematoma, 137 Recurvatum of the knees, 478, 478f Red blood cells in additive solution, 27–29 blood donation, 27–29 following injury, serology, 30 Regional anaesthesia, day surgery, 132 Regurgitation, 170, 176 Reinke's oedema, 471 Renal adenocarcinoma, 403, 403f, 404b Renal artery disease, 359, 359b Renal artery stenosis, 452 Renal calculi, 404–405 Renal cysts, 403 Renal disease, 72 Renal failure burns patients, 293 perioperative implications of, 72–73, 73t, 74 postoperative, 124 transplantation versus dialysis, 444b Renin, 5–6, 6f following injury, 5t Renin-angiotensin system, 5–6, 6f Renography, 400–402 Reperfusion injury, 361 Research governance, 60 Resistant organisms, 49 Respiratory acidosis, 17, 17b Respiratory alkalosis, 17, 17b Respiratory disease, perioperative implications of, 71–72 Respiratory failure obstruction, 119 postoperative, 122 Respiratory system effects of shock on, 22, 22b infections, 53 injury, burns, 291, 292, 293 postoperative complications, 121–123 preoperative assessment, 62, 63t, 66, 66t Rest pain, critical limb ischaemia, 350 Resuscitation in the emergency department, 95–100 first 10 minutes, 95–99 gastrointestinal bleeding, 184 variceal bleeding, 199 see also ABC approach Retention cysts, 468 RET gene, 251 Reticular varices, 368 Retractile testis, 421 Retrograde ejaculation, 406, 416 Retrograde ureteropyelography, 400, 401f Retroperitoneal fibrosis, 405–406 Revised Trauma Score, 94 Rhabdomyosarcomas, 301 Rhesus antigens (Rh), 30 Rhesus (Rh) D-typed blood group, 27, 28, 30 Rheumatoid arthritis, 482 perioperative implications of, 75t Rheumatoid elbow, 485 Rhinitis, chronic, 465 Rib fractures, 100, 100f Rib notching, 390, 390f Richter's hernia, 138 Riedel's thyroiditis, 328 Ringer's lactate, 12, 12f, 12t Rinné's test, 460 Risk assessment for cardiothoracic surgery, 379 high risk patients, 66–67, 71b Road traffic accidents (RTAs), 90, 91, 91f Rodent ulcer, 297, 297f Rokitansky-Aschoff sinuses, 208 Rotational thromboelastometry (ROTEM), 25 Rotator cuff disease, 485 Rovsing's sign, 155, 163 Royal Marsden classification for testicular cancer, 422t Rubber band ligation, haemorrhoids, 266, 267f Rule of nines, 291, 291f S Saccular intracranial aneurysms, 429 Sacral nerve stimulation, 276 Saddle embolus, 360 Saliva, 46 Salivary glands, 472–473, 472f, 473f, 474f calculi, 473–475, 473f disease, 474–475 swellings, 475b, 475f Salmonella, 362 Salpingitis, acute, 165 Sarcomas, breast, 323 Sarcopenic obesity, 38 Satiety, early, 41 Scalds, 291 Scaphoid fractures, 485, 490 Scars hypertrophic, 283, 332 keloids, 283, 332 thyroidectomy complications, 332 Schwannomas, 435, 437 Scintigraphic renography, 400–402 Sclerosis, breast, 308 Sclerotherapy, 199, 200 Scoliosis, 479, 479f, 484 perioperative implications of, 75t Screening abdominal aortic aneurysm, 363, 363b basic health screen, day surgery, 129 breast cancer, 305b, 313, 313b (see also Mammographic screening) cancer, 83–84, 83b, 83f, 84b, 84f, 84t colorectal adenocarcinoma, 257 Scrotum, 419–420, 419f Seatbelts, 91 Sebaceous cysts, 295, 295f, 311, 474 Sebaceous glands, 281 Seborrhoeic keratosis, 296, 296f Secretions, control of, 397 Segmental portal hypertension, 231 Seizures epilepsy, 441 intracranial tumours, 436 Seldinger technique, 113, 114 Selective cyclo-oxygenase (COX)-2 inhibitors, 78–79 Semen analysis, 402 Seminoma, 421 Semi-occlusive dressings, burns, 294 Sengstaken-Blakemore tube, 110, 199 Sengstaken tube, 110 Senile warts, 296, 296f Sensation, burns, 291 Sensory neuropathy, 351 Sentinel lymph node, 314 biopsy, 300 breast cancer, 316–317 Sentinel pile, 267, 268 Sepsis, 19f anorectal, 270b burns patients, 293 catheter-related, 43t definitions, 19b intra-abdominal, 52t screening, 50t severe, 19b care pathway, 50t umbilical, 137 see also Septic shock Septicaemia antibiotics for, 52t burns patients, 293 Septic arthritis, 482 Septic shock, 18 antibiotics for, 52t causes of, 18 definition, 19b management, 25–26 pathophysiology, 20, 20f postoperative, 123 Serious Hazards of Transfusion (SHOT) scheme, 31, 32, 32f Serous cystic neoplasm, pancreatic, 225 Serum amylase, 155, 155t, 218 Serum calcium, 156 Serum lipase, 218 Sharps, general precautions, 103 Shock, 17–26 burns patients, 292–293, 292t definition, 17–18 effect on individual organ systems, 21–23, 22b management, 23–26, 23t pathophysiology, 19–21 postoperative, 123 types of, 18–19 see also specific types of shock Short bowel syndrome, 40 Shotgun wounds, 92, 93f Shoulder, 484–485, 485f Sialogram, 474–475 Sickle-cell anaemia, perioperative implications of, 75t Sickle cell test acute abdomen, 156 day surgery patients, 131 Siderocytes, 229 Sigmoid colon, 234 Sigmoid volvulus, 250, 250f Silver sulfadiazine cream, 294 Sinus bradycardia, postoperative, 123 Sinusitis, 466, 467f Sinus tachycardia, postoperative, 123 Sirolimus, 447 Six step hand hygiene technique, 48, 48f Skeletal muscle, response to injury, 7f wasting, 38–39, 39f Skin breast infection, 311 as a defence system, 46 functions, 281 grafts, 287, 294 incisions, 285 lesions, 294–301 preparation for surgery, 48 stapling, 105 structure, 281, 282f suturing, 104–105 swellings, 294, 294b, 474 tags, anal, 272 trauma, 487 tumours, 295, 295t Skin cancer epidermal, 297 immunosuppression risks, 447 see also Malignant melanoma Skin flaps, 288, 288f, 289f devitalized, 287 Skip lesions, 237, 237f, 238 Skull anatomy and physiology, 424 fracture, 432 malformations, 440 tumours, 434–437, 437b Skull base, 424 Sleep apnoea, 468–469 Slipped upper femoral epiphysis (SUFE), 484 Slow-transit constipation, idiopathic, 251 SMAD4 gene, 254 Small intestine anatomy, 233–234, 234f disorders, 242–245 examination, 235 function, 233–234 history, 234 investigation, 235 ischaemia, 244–245 obstruction see Intestinal obstruction tumours, 242–243 Smith's fracture, 489 Smoking colorectal adenocarcinoma, 256 Crohn's disease, 237 lower limb ischaemia, 351 peptic ulceration, 181 preoperative assessment, 62, 62t Smooth muscle cells, 346 tahir99 - UnitedVRG vip.persianss.ir Index Snoring, 468–469 Social factors, day surgery, 130 Sodium, 10 abnormalities, 13–14 daily requirements, 10 intravenous fluid administration, 13 loss, 10 Sodium chloride, 12, 12f, 12t, 13 Soft tissue lesions, 294–301 Soiled equipment, general precautions, 103 Solar keratosis, 296, 296f Solid-cystic tumour of the pancreas, 225, 225f Solid pseudopapillary tumour of the pancreas, 225, 225f Solitary rectal ulcer syndrome, 274, 275 Solitary thyroid nodules, 328, 328f Somatic pain, 147–148, 149f Somatostatin, 169, 215–216 Somatostatinoma, 228, 228t Sore throat, 468, 469b Spermatic cord, 139–140 Spherocytosis, hereditary, 231 Sphincter of Oddi, 213, 213f Sphincterotomy, 220, 220b, 268 Spider veins, 368 Spigelian hernia, 145 Spina bifida aperta, 438, 438f Spina bifida occulta, 438, 438f Spinal anaesthesia, 76–77, 76f, 121 Spinal cord, 425 compression, 323 damage, 418 injury, 433 Spinal degenerative disease, 441–442, 441f, 442f Spinal dysraphism, 438, 438f Spine anatomy and physiology, 424 deformity, 479, 479f traumatic injury, 433 Spleen, 229–232 abscess, 232 physiology, 229 splenectomy see Splenectomy surgical anatomy, 229 Splenectomy, 229–231 antibiotic prophylaxis, 49 complications, 230 immunization after, 232 indications for, 230t, 231–232 open technique, 229–230 postoperative course, 230 preoperative preparation, 229 spleen conservation, 230–231 traumatic, 230–231, 230t Splenic artery, 215 aneurysm, 232 Splenic vein, 215 Splinting of fractures, 97, 98f Split-skin grafts, 287, 294 Spondylitis, perioperative implications of, 75t Spondylosis, 441 Spontaneous bacterial peritonitis, 161 Spontaneous pneumothorax, 395 Sportsman's hernia, 142 Squamous cell carcinoma anal canal, 264 anal verge, 273f bladder, 409 ear, 461, 462f large intestine, 262 skin, 297, 297f tongue, 468, 468f Squamous disease, 463 Staging, cancer, 86–87, 87b anal cancer, 273, 273t bladder cancer, 409, 409f breast cancer, 313 colorectal adenocarcinoma, 257–258, 259–260, 260t lung cancer, 392–393, 393t malignant melanoma, 300, 300t prostate cancer, 411–412, 412t Stapes, 459 Staphylococci antibiotics for, 51t breast infection, 310 catheter related sepsis, 43–44 coagulase-negative, 51t Staphylococcus aureus abscesses, 53 methicillin-resistant see Methicillin-resistant Staphylococcus aureus (MRSA) Stapling oesophageal, 200, 200f skin, 105 Starvation, 7–8, 9t, 38 acute, chronic, Station manometry, 173 Stenting carotid, 358, 358b colorectal adenocarcinoma, 261 gastric cancer, 189 lower limb ischaemia, 352, 352f pancreatic duct, 223–224 perioperative implications of, 69–70 venous, 376 Sterilization of surgical instruments, 48 Sternal protuberance, 397 Sternal retraction, 397 Steroids see Corticosteroids Stomach carcinoma, 185–186, 186f disorders, 180–181, 190 examination, 170–171 investigations, 171–173 surgical anatomy, 167–169, 168f surgical physiology, 169 symptoms, 169–170 tumours, 185–189 see also entries beginning Gastric Stomas, 251–252, 252f Stomatitis, 467 Stones see Calculi Strangulated hernia, 146 Strawberry gallbladder, 208 Streptococci, 293 Streptococcus pneumoniae, 51t Streptococcus pyogenes, 51t Stress incontinence, 417, 418 Stress response, 11 Stress ulceration, 181 Strictures colonic diverticular disease, 249 ischaemic, of the colon, 250, 250f Stroke, 356, 357b, 379, 428 Strong opioids, 78 Struvite stones, 404 Subacute thyroiditis, 328 Subarachnoid haemorrhage (SAH), 428–430 grading, 428–429 investigations, 429, 429f management, 429–430, 429b, 430b, 430f saccular intracranial aneurysms, 429 Subclavian steal, 356, 356f Subclavian vein cannulation, 114, 114f thrombosis, 376 Subcutaneous swellings, 474 Subdural empyema (SDE), 434 Subdural haematoma, 432–433, 433f Sub-fascial endoscopic perforator surgery (SEPS), 373–374 Sublingual salivary gland, 472–473 Submandibular salivary gland, 472–473, 472f, 473f, 474–475 Submucosal plexus, 169, 233–234 Substrate cycling, 6–7 Succinylated gelatin, 12t Sucking chest wounds, 96, 96f, 395 Sulphate, 10 Superficial femoral arteries (SFAs), 348–349, 349f Superficial partial-thickness burns, 290, 290f Superficial spreading melanoma, 299, 299f Superficial thrombophlebitis, 370 Superior mediastinal syndrome, 43 Superior mesenteric artery, 234, 234f, 235f Superior mesenteric vein, 215 Superior rectal artery, 234 Superior vena cava (SVC) access, 42 thrombosis, 376 Supernumerary nipples/breasts, 302 Suprapubic catheterisation, 116, 116f Suprapubic cystostomy, 415 Surgery complications, 121–126, 126b Surgical airway, 107 Surgical cricothyroidotomy, 107, 108f Surgical instruments sterilization, 48 Surgical site infection (SSI), 51–52, 51b, 55, 68–69 Surgical thrombectomy, 376 Surgical ward care, 120–121 Sutures (skull), 424, 440, 440f Suturing, 104–105 effect on wound healing, 285 materials, 104, 285 removal times, 105t skin, 104–105 Swallowing, 169 difficulty, 169–170, 170t pain on, 170 physiology of, 470 Sweat glands, 281 Sweating, 10 Swellings excision of, 117 orthopaedic surgery, 477, 477t skin, 294, 294b Swollen limb, differential diagnosis, 378t Sympathetic nervous system activation, 4, 5b Synergistic bacterial gangrene, 54 Synthetic braided sutures, 104 Synthetic monofilament sutures, 104 Syphilis blood donation, 27 mycotic aneurysms, 362 Systemic inflammatory response syndrome (SIRS), 19b, 19f, 46 pancreatitis, 219 Systemic vascular resistance (SVR), 19, 19t T T3 (triiodothyronine), 325, 326, 328–329 T4 (thyroxine), 325, 326, 328–329 Tachycardia, postoperative, 123 Tacrolimus, 447, 447b Talipes equinovarus, 484 Tamoxifen, 88 breast cancer, 319, 320 cyclical mastalgia, 308 Tapeworms, 197, 197f Tarsal tunnel syndrome, 486 T cells, 46 activation, 445 receptor binding, 445 99m Tc-labelled methylene diphosphonate (MDP), 400 Tears as a defence system, 46 Technetium labelled diethylenetriamine pentaacetic acid (Tc-DTPA), 400–402 Telangiectasia, 368 Temozolomide, 261 Temporal bone imaging, 460–461, 461f Tennis elbow, 485 Tension pneumothorax, 96, 97t, 395, 395f Teratoma, 421, 437 Terminal ileum, 235 Testicles, 419–420, 419f torsion, 421 tumours, 421–422, 422t undescended, 421 Testosterone following injury, 5t in prostate cancer, 413, 414b Tetanospasmin, 54 Tetanus, 54 Tetralogy of Fallot, 390 Thallium isotope scan, 380t Therapeutic drug monitoring, 50 Therapeutic privilege, 58 Thermogenesis, Third-space losses, 11, 11t Thoracic outlet syndrome, 361 Thoracic procedures, 107–109 Thoracic surgery, 390–398 assessment, 390–391 common investigations, 391t postoperative care, 397–398 Thoracolaparotomy, left, 178 Thrombectomy, 376 Thromboangiitis obliterans, 366–367 Thrombocythaemia, 64 Thrombocytopenia, 64 massive transfusion complications, 36t platelets, 28 secondary, 231 Thromboelastography (TEG), 25 Thromboembolism, mechanism of injury, 347 preoperative assessment, 63 preoperative risk, 64 venous see Venous thromboembolism (VTE) Thrombolysis, 375–376 Thrombophlebitis parenteral nutrition complications, 43 superficial, 370 Thromboprophylaxis, 67–68, 68t Thrombosis mechanism of injury, 347 in situ, 359t, 361 vs embolus, 359, 359t Thymoma, 395 Thyroglossal cyst, 474 tahir99 - UnitedVRG vip.persianss.ir 505 INDEX 506 Thyroidectomy, 329, 331–332 complications, 331–332 patient information, 332 technique, 331–332 Thyroid gland, 325–332 cancer, 330–331, 330b, 330f, 331b development, 325–326 disease, assessment of, 326, 326f enlargement, 326–328, 326f, 327b, 327f function, 325 hyperthyroidism see Hyperthyroidism surgical anatomy, 325–326, 326f thyroidectomy, 331–332 Thyroid hormones following injury, 5t Thyroiditis, 328 Thyroid nodules, solitary, 328, 328f Thyroid receptor antibodies (TRAbs), 329 Thyroid-stimulating hormone (TSH), 325, 326, 334 following injury, 5t Thyrotoxic goitre, 327 Thyrotoxicosis, 328–329, 329f Thyrotrophin-releasing hormone (TRH), 325, 334 Thyroxine (T4), 325, 326, 328–329 Tibial plateau fractures, 490 Tinel's sign, 442–443 Tinnitus, 460 Tissue factor, TNM staging, 86–87 anal cancer, 273t bladder cancer, 409, 409f breast cancer, 313–314, 314t colorectal adenocarcinoma, 259–260, 260t gastric cancer, 187, 187t lung cancer, 393t oesophago-gastric cancer, 172–173, 173f prostate cancer, 411–412, 412t Tongue, 120 Tonsillar herniation, 426, 427f Tonsillectomy, 469b Tonsillitis, 468, 469b Tonsils, 468, 469b, 469f Topical anaesthesia, 77, 103–104 Topical antibacterial agents, 294 Total joint replacement, 481, 481f Total parenteral nutrition (TPN) see Parenteral nutrition, total (TPN) Toxic adenoma, 329 Toxic multinodular goitre, 329 Tracheal compression, 120 Tracheostomy, 107, 292, 471–472, 472f Tranexamic acid, 25, 98–99 Transanal endoscopic microsurgery (TEM) colorectal adenocarcinoma, 258 colorectal adenoma, 253 Transfalcine herniation, 426, 427f Transhiatal oesophagectomy, 178–179 Transient/irreversible cognitive impairment, 58–59 Transient ischaemic attack (TIA), 356, 357b, 428 Transjugular intrahepatic portosystemic stent shunting (TIPSS), 199b, 200, 200b, 201f Transplantation surgery, 444–458 versus dialysis in renal failure, 444b heart and lung, 457–458, 458b immunology, 444–447 kidney, 450–453, 450t, 451t, 452f, 453b liver, 203, 453–455, 453t, 454f, 455b, 455f organ donation see Organ donation pancreas, 455–456, 456f, 456t, 457b pancreatic islet, 457 Transportation of trauma patients, 94 Transtentorial herniation, 426, 427f Transurethral microwave thermotherapy (TUMT), 416 Transurethral radiofrequency needle ablation (TUNA), 416 Transurethral resection of the bladder tumour (TURBT), 410 Transurethral resection of the prostate (TURP), 416 Transverse colon, 234 Transverse rectus abdominis musculocutaneous (TRAM) flap, 288, 289f Trastuzumab, 319, 319b Trauma, 90–102 accident prevention, 91 acute limb ischaemia, 361 analgesia, 99 biomechanics of injury, 91, 91f cardiac, 389 caused by alcohol and drugs, 92 continuing care, 101–102 detailed examination, 99–100 duodenum, 190 ear, 461 epidemiology, 90, 91f from falls, 93, 93f imaging, 100–101, 100f, 101b, 101f infections following, 54 injury severity assessment, 93–94, 94t liver, 196 lower urinary tract, 407–409 nose, 465, 465f orthopaedic surgery, 476, 486–490 pancreatitis, 217–218 pre-hospital care, 94 resuscitation in the emergency department, 95–100 spinal injury, 433 splenectomy, 230–231, 230t transport, 94 wounds see Wounds Trauma centres, 94–95, 95b, 95f Treponema pallidum, 362 TRICC trial, 31 Trichobezoars, 190 Trichophytobezoars, 190 Tricuspid valve disease, 387 Tricyclic antidepressants, 63 Trigeminal nerve (CN V), 425 Trigger finger, 485 Triglycerides, Triiodothyronine (T3), 325, 326, 328–329 Trocath peritoneal dialysis catheter, 111, 111f Trochlear nerve (CN IV), 425 Trousseau's sign, 226, 226t, 334 Trunk varices, 368, 368f Trypanosoma cruzi, 176 Trypsin, 215 T-tube drainage of common bile duct, 210, 210f Tubes postoperative care, 121 see also specific tubes Tubo-tympanic disease, 462–463 Tubular breast cancers, 312–313 Tubulosaccular aneurysms, 387, 387f Tumour necrosis factor alpha (TNF-α), 3, 4t Tumours adrenal cortex, 339 anterior pituitary gland, 334–335, 335b, 335f appendiceal, 236, 236b benign, 80–81, 87 biliary tract, 214 bladder, 409–410, 409f, 410f, 411f breast, 309, 323–324 carotid body, 475 of connective tissues, 301 ear, 461, 462, 462f hypopharyngeal, 470 intracranial, 434–438 large intestine, 255–262 laryngeal, 471, 471b liver, 201–204, 202f, 203f malignant, 80–81, 87 of muscle, 301 musculoskeletal, 484 nasopharyngeal, 467 of nerves, 301 oesophageal, 178–180 oral, 468, 468f oropharyngeal, 469 pancreatic, 218, 224–229 pituitary gland, 338, 435 salivary gland, 475, 475t sinus, 467, 467f skin, 295, 295t small intestine, 242–243 stomach, 185–189 testicles, 422t testicular, 421–422 umbilical, 137 urothelial, 412b see also Cancer; specific tumours Tuning fork tests, 460 Turbinate bones, 464 Turcot's syndrome, 255 TURP syndrome, 416 23-hour surgery, 134 Tympanic bone, 459 Tympanic membrane, 459, 460 Tympanometry, 460 U Ulcerative colitis, 236–237, 240–242, 240b cancer surveillance, 242 clinical features, 237t, 240–241 indications for surgery, 242b investigations, 241, 241f management, 241–242 pathology, 240, 240f Ulnar nerve compression, 443 Ultrasonography (US), 117–118 abdominal aortic aneurysm, 363, 363f acute abdomen, 157–158 appendicitis, 164 breasts, 304–305, 305f cancer diagnosis, 85–86 colorectal adenocarcinoma, 257–258 dynamic see Dynamic ultrasound endoscopic see Endoscopic ultrasonography (EUS) gallstones, 208, 208f intra-abdominal abscess, 162 jaundice, 195 orthopaedic surgery, 477 thoracic surgery, 391t thyroid gland, 326 trauma patients, 101 urological disorders, 400, 401f Ultrasound guided foam sclero pathy (UGFS), 369, 370f Umbilical hernia, 144, 144f Umbilical sepsis, 137 Umbilical tumours, 137 Umbilicus, 137 Uncal herniation, 426, 427f Uncinate process, 464 Undescended testicles, 421 Unstable angina, perioperative implications of, 69 Upper limb arterial disease, 356, 356f orthopaedic surgery, 484–486 Urachus, 137 Urea and electrolytes (U&Es) acute abdomen, 155 preoperative, 65 Ureteroscopy, 405 Ureters anatomy, 402, 402f benign tumours, 403 calculi, 404–405, 404f ectopic, 418 obstruction, 405, 405t pain, 399 physiology, 402–403 Urethra anatomy, 406, 407f congenital valves, 416 diverticula, 416 obstruction, 416–417, 416f physiology, 406–407 stricture, 416, 416f trauma, 408–409, 408f Urethral catheterization, 115–116 in the female, 115–116 in the male, 115, 116f Urethrography, 400 Urge incontinence, 418 Uric acid stones, 404 Urinalysis acute abdomen, 156 appendicitis, 163 Urinary cellular markers, 399–400 Urinary changes, response to injury, 6, 6b Urinary leaks after renal transplantation, 452 Urinary procedures, 115–116 Urinary retention benign prostatic hyperplasia, 415, 419b postoperative, 123, 124f Urinary tract lower, 406–417, 407f (see also Bladder; Prostate; Urethra) obstruction, 452 postoperative complications, 123–124 stones, 402, 404–405, 404f symptoms, 399 upper, 402–406 (see also Kidney(s); Ureters) Urinary tract infection (UTI), 52 antibiotics for, 52t postoperative, 124 Routes of entry, 52f Urine flow rates, 402, 402f fluid loss from, 11t investigations, 399–400 (see also Urinalysis) Urine output postoperative, 124 trauma patients, 99 Urodynamic studies, 402 Urological surgery, 399–423 assessment, 399–402 upper urinary tract, 402–406 Urothelial tumours, 412b tahir99 - UnitedVRG vip.persianss.ir Index V Vagotomy, 182 Vagus nerve (CN X), 169, 425 Valvular heart disease, 129, 384–387 aortic valve disease, 386, 386f assessment, 385 endocarditis, 385–386 mitral valve disease, 386–387, 387f multiple and repeat valve procedures, 387 perioperative implications of, 70, 70f surgical management, 385, 385f tricuspid valve disease, 387 Vancomycin, 50 Variant Creutzfeldt-Jakob disease (vCJD) blood donation, 27 preoperative assessment, 66 Variceal band ligation, 199b, 200, 200b Variceal bleeding, 198–200, 199b, 199f, 199t, 200b, 200f, 201f Varicocele, 423, 423f Varicose veins, 368–370 aetiology, 369 classification, 368, 368f clinical features, 368–369 epidemiology, 368 examination, 369 investigation, 369 management, 369, 370f Vascular disease in diabetics, 72 Vascular neoplasms, 300–301 Vascular procedures, 112–115 Vascular surgery, 345–378 Vasoactive drugs, 23, 24t Vasoactive intestinal peptide, 169 Vasodilators, 26 Vasopressors, 23–25 Venepuncture, 112, 112f Venous cutdown, 113, 113f Venous disease, 367, 368b Venous gangrene, 374 Venous obstruction, 371 Venous reflux, 371 Venous stenting, 376 Venous thromboembolism (VTE), 67–68, 67b, 68t, 129, 374–376 aetiology, 374 diagnosis, 374, 375f epidemiology, 374 management, 375–376 pathophysiology, 374 prevention, 374–375 venous gangrene, 374 Ventilation burns patients, 292 by mask, 105–106 post-operative in respiratory disease, 72 trauma patients, 97, 97b Ventral hernia, 143–145, 144f, 145f Ventricular extrasystoles, 65t Ventricular septal defect, 390 post-myocardial infarction, 384 Ventriculo-peritoneal shunt (VP), 439–440 Verruca vulgaris, 295–296, 295f, 296f Vertebrae, 424 Vertebral column, 441–442 Vertebrobasilar disease, 358 Vertical banded gastroplasty, 191 Vertigo, 460, 463–464 Vestibular neuronitis, 464 Vestibular system, 460, 460f Vestibulo-cochlear nerve (CN VIII), 425 Videothoracoscopy, 393 VIPoma, 228, 228t Viral infections, 218 Visceral pain, 148–149 Visceral peritoneum, 148 Viscus obstruction, 151 perforation, 151, 151f Vitamin C, 285 Vitamin D, 256 Vitamin K, 74 Vitello-intestinal duct, persistent, 137, 138f Vocal cord palsy, 471 Vocal cords, 470 Voice, 470 Volume replacement, acute, 36 Volvulus, 151f, 250–251, 250f Vomiting, 170 complications of enteral feeding, 41–42 see also Postoperative nausea and vomiting (PONV) Von Hippel-Lindau syndrome, 227 Von Willebrand factor, 29 Von Willebrand's disease, 74 W Waiting list, day surgery, 131–132 Warfarin, 74 day surgery patients, 129 lower limb ischaemia, 351 preoperative assessment, 63 Warthin's tumour, 475 Warts, 295–296, 295f anal, 271–272 infective, 295–296, 295f, 296f senile, 296, 296f Water abnormalities, 13–14 depletion, 13 excess, 13 intravenous fluid administration, 13 loss following injury, 5t normal balance, 10 replacement in burns patients, 293 Wax, ear, 462 Weak opioids, 78 Weber's test, 460 Weight loss, 38–39, 39f after peptic ulcer surgery, 182–183 cancer, 85 Whipple's procedure, 226, 227f White blood cells, preoperative, 64 World Federation of Neurosurgical Societies (WFNS) grading system for subarachnoid haemorrhage, 428–429, 428t Wound healing, 284f classification, 283b factors influencing, 283–285, 285b phases, 282–283, 282f, 282t principles, 282–283 Wound infection, 285–286 antibiotics for, 52t classification, 285 clinical features, 286 management, 286 postoperative, 125, 125f prevention, 286 Wounds, 92, 281–289 classification, 92 crushing, 281, 288–289 debridement, 286, 287f degloving, 282, 288–289 dehiscence, 126, 126f devitalized skin flaps, 287 gunshot, 92, 92f, 93f, 288–289 healing see Wound healing infection see Wound infection involvement of other structures, 286–287 postoperative complications, 125–126 primary closure, 286 production, 92 sites, 285 with skin loss, 287–288 types of, 281–282 Wrist, 485–486 X Xeroderma pigmentosa, 297 X-rays, 117 acute abdomen, 156, 156b, 156f, 156t chest see Chest X-ray neurosurgery, 426–427 orthopaedic surgery, 477–478 trauma patients, 100, 100f, 101b, 101f Z Zinc, 285 Zollinger-Ellison syndrome, 181, 228 507 tahir99 - UnitedVRG vip.persianss.ir Intentionally left as blank tahir99 - UnitedVRG vip.persianss.ir ... Watson 18 Plastic and reconstructive surgery CHAPTER CONTENTS Introduction 28 1 Burns 28 9 Structure and functions of skin 28 1 Prognosis 29 1 Wounds 28 1 Skin and soft tissue lesions 29 4 INTRODUCTION... Consequences of burns The morbidity and mortality of burns depend on the site, extent and depth of the burn and on the age and general condition of the patient Early consequences • hypovolaemia (loss of. .. the bacterial population of the atmosphere and hence the risk of wound infection The failure of medical and nursing staff to wash their hands before and after touching and examining each patient