CHURCHILL’S POCKETBOOKS Surgery Commissioning Editor: Laurence Hunter Senior Development Editor: Ailsa Laing Project Manager: Elouise Ball Designer: Kirsteen Wright Illustrations Manager: Gillian Richards CHURCHILL’S POCKETBOOKS Surgery Andrew T. Raftery BSc MD FRCS(Eng) FRCS(Ed) Formerly Consultant Surgeon, Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield; Member (formerly Chairman), Court of Examiners, Royal College of Surgeons of England; Formerly Member of Panel of Examiners, Intercollegiate Specialty Board in General Surgery; Formerly Member of Council, Royal College of Surgeons of England; Formerly Honorary Clinical Senior Lecturer in Surgery, University of Sheffield, UK Michael S. Delbridge MBChB (Hons) MD MRCS(Eng) Specialist Registrar in Surgery, Yorkshire and Humberside Deanery, UK Marcus J. D. Wagstaff BSc PhD FRCS(Plast) Specialist Registrar in Plastic and Reconstructive Surgery, East Midlands Deanery, UK FOURTH EDITION EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2011 # 2011 Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). First edition 1996 Second edition 2001 Third edition 2006 Fourth edition 2011 ISBN: 978-0-7020-3993-5 International Edition ISBN: 978-0-7020-3994-2 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. The Publisher's policy is to use paper manufactured from sustainable forests Printed in China PREFACE The authors (ATR and MSD) are grateful to the publishers, Churchill Livingstone, for the invitation to produce a fourth edition of the Pocketbook of Surgery. It was felt that a further younger co-author would be helpful in bringing the book up-to-date. I am pleased that Marcus Wagstaff, Specialist Registrar in Plastic and Reconstructive Surgery, has agreed to fill the role as co-author. Together we are reassured that in these days of self-directed, student-centred, problem-based learning, led by medical educationalists, there is still a place for a small book offering a didactic approach to the acquisition of surgical knowledge. It is now nearly 15 years since the first edition, 10 years since the second and 5 years since the third. Much has changed in that time and most of the chapters have been updated. When this book was written initially, it was aimed at medical students, but more recently it has been used by foundation year doctors and those in the early years of specialist training and also as a revision book for the MRCS. With this in mind, we have added sections on such topics as clinical governance, audit and the medico-legal aspects of surgery, together with a section on basic practical procedures. An outline of the important steps in a number of common operations has been added in the relevant chapters. The chapter in previous editions on conditions of the skin has been amalgamated in this edition with the chapter on plastic surgery, and basic ENT has been added to the chapter on Head, neck and otorhinolaryngology. A new chapter on gynaecology has also been added to outline conditions which the surgeon may encounter in the diagnosis of abdominal masses or the acute abdomen. The aim of this small volume, however, remains the same. Namely, to provide a concise and didactic account of the essential features of the more common surgical disorders at both a size and a price to suit the pocket. The book covers fundamental principles, as well as providing basic information on aetiology, diagnosis and management, including preoperative and postoperative care. The text covers the field of general surgery but aims also to cover the basic needs of the undergraduate and those in the early years of postgraduate training in surgery as far as the surgical specialities are concerned. It will give the student some idea of history-taking, what physical signs to elicit, the differential diagnosis, what investigations to order and how to treat the patient. Read in conjunction with Churchill’s Pocketbook of Differential Diagnosis, it will provide almost everything the undergraduate needs to know and will also have sufficient information for postgraduates studying for the MRCS. We must apologize to the medical educationalists that there is no mention of procedural knowledge, procedural improvisation knowledge, propositional adaptational knowledge or metacognitive knowledge anywhere in this book. However, the basis of this book is to supply didactic information and we make no apology for this. We hope it will continue to help you on the wards and in the clinics – and in examinations. Sheffield, 2011 ATR MSD MJDW ACKNOWLEDGMENTS We wish to gratefully acknowledge the help, advice and criticisms of the following people who kindly read sections of the book: Mr T J Locke, Consultant Cardiac Surgeon, Northern General Hospital, Sheffield; Mr B J Harrison, Consultant Endocrine Surgeon, Royal Hallamshire Hospital, Sheffield; Mr R Lonsdale, Consultant Vascular Surgeon, Northern General Hospital, Sheffield; Mr John Anderson, Consultant Urological Surgeon, Royal Hallamshire Hospital, Sheffield; Mr James Hahnel, Specialist Registrar in Orthopaedics, Yorkshire and Humberside Deanery; Mr R D E Battersby, Consultant Neurological Surgeon, Royal Hallamshire Hospital, Sheffield; Miss J Walker, Consultant Paediatric Surgeon, Sheffield Children’s Hospital, Sheffield; Mr A J Parker, Consultant ENT Surgeon, Royal Hallamshire Hospital, Sheffield; Dr Susan Snape, Specialist Registrar in Microbiology and Infectious Diseases, Nottingham University Hospitals NHS Trust; Mr B M Shrestha, Consultant General and Transplant Surgeon, Northern General Hospital, Sheffield. Any errors that may have crept in, however, remain our responsibility and not theirs. We would also like to thank Dr Matthew Bull, Consultant Radiologist, Northern General Hospital, Sheffield; Dr Sam Euinton, Consultant Radiologist, Chesterfield and North Derbyshire Hospital, Chesterfield; Dr Peter Brown Consultant Radiologist, Northern General Hospital, Sheffield, and Dr Alan Sprigg, Consultant Radiologist, Sheffield Children’s Hospital, Sheffield, for providing X-rays for the various editions of the book. We would also like to thank our former teachers, colleagues and students who have all contributed in some way to this book. We would particularly like to thank our wives for their patience and encouragement throughout the production of this book. Finally, we would like to thank Mrs Denise Smith for the hard work and long hours that she has put into typing and re-typing the manuscript. Sheffield, 2011 A T R MSD MJDW CONTENTS Abbreviations viii 10. Breast 166 Terms and definitions xi 11. Endocrine surgery 178 Biochemical values xiii 12. Abdominal wall and hernia 195 Haematological values xiv 13. Acute abdomen 205 Emergencies xv 14. Alimentary tract 217 1. Introduction to surgery 1 15. Peripheral vascular 2. An introduction to surgical disease 284 techniques and practical procedures 15 16. Urology 316 3. Investigative procedures 28 17. Orthopaedics 338 4. Shock and trauma 42 18. Neurosurgery 403 5. Preoperative and 19. Plastic surgery and skin 420 70 postoperative care 20. Paediatric surgery 449 98 6. Infection and surgery 21. Organ and tissue 7. Management of malignant transplantation