Lecture Notes: General Surgery Companion website The book is supported by a website containing a free bank of interactive questions and answers. These can be found at: www.testgeneralsurgery.com The website includes: • Interactive Multiple-Choice Questions for each chapter • Interactive Short Answer Questions for each chapter Lecture Notes: General Surgery Harold Ellis CBE DM MCh FRCS Emeritus Professor of Surgery, Guy’s Hospital, London Sir Roy Calne MS FRCS FRS Emeritus Professor of Surgery, Addenbrooke’s Hospital, Cambridge Christopher Watson MD BChir FRCS Reader in Surgery and Honorary Consultant, Addenbrooke’s Hospital, Cambridge Twelfth Edition A John Wiley & Sons, Ltd., Publication This edition fi rst published 2011© 1965, 1968, 1970, 1972, 1977, 1983, 1987, 1993, 1998, 2002, 2006, 2011 © 2011 Harold Ellis, Sir Roy Y. Calne, Christopher J. E. Watson Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientifi c, Technical and Medical business to form Wiley-Blackwell. Registered offi ce: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offi ces: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offi ces, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identifi ed as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published 1965 Fifth edition 1977 Ninth edition 1998 Revised edition 1966 Sixth edition 1983 Reprinted 1999, 2000 Second edition 1968 Reprinted 1984, 1985, 1986 Tenth edition 2002 Third edition 1970 Seventh edition 1987 Reprinted 2003, 2004, 2005 Fourth edition 1972 Reprinted 1989 (twice) Eleventh edition 2006 Reprinted 1974 Eighth edition 1993 Twelfth Edition 2010 Revised reprint 1976 Reprinted 1994, 1996 Greek edition 1968 Portuguese edition 1979 Indonesian edition 1990 Turkish edition 2005 Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Ellis, Harold, 1926– Lecture notes. General surgery / Harold Ellis, Sir Roy Calne, Christopher Watson. – 12th ed. p. ; cm. General surgery Includes bibliographical references and index. ISBN 978-1-4443-3440-1 (pbk. : alk. paper) 1. Surgery. I. Calne, Roy Yorke. II. Watson, Christopher J. E. (Christopher John Edward) III. Title. IV. Title: General surgery. [DNLM: 1. Surgical Procedures, Operative. WO 100] RD31.E4 2011 617–dc22 2010036446 A catalogue record for this book is available from the British Library. Set in 8.5/11pt Utopia by Toppan Best-set Premedia Limited 01 2011 Contents Introduction, vii 24 Acute appendicitis, 199 Acknowledgements, ix 25 The colon, 204 Abbreviations, xi 26 The rectum and anal canal, 218 27 Peritonitis, 230 1 Surgical strategy, 1 28 Paralytic ileus, 236 2 Fluid and electrolyte management, 5 29 Hernia, 239 3 Preoperative assessment, 10 30 The liver, 250 4 Postoperative complications, 15 31 The gallbladder and bile ducts, 266 5 Acute infections, 26 32 The pancreas, 276 6 Shock, 31 33 The spleen, 289 7 Tumours, 36 34 The lymph nodes and lymphatics, 292 8 Burns, 41 35 The breast, 295 9 The skin and its adnexae, 47 36 The neck, 308 10 The chest and lungs, 60 37 The thyroid, 311 11 The heart and thoracic aorta, 69 38 The parathyroids, 323 12 Arterial disease, 80 39 The thymus, 328 13 Venous disorders of the lower limb, 98 40 The suprarenal glands, 330 14 The brain and meninges, 105 41 The kidney and ureter, 335 15 Head injury, 114 42 The bladder, 353 16 The spine, 126 43 The prostate, 358 17 Peripheral nerve injuries, 137 44 The male urethra, 367 18 The oral cavity, 143 45 The penis, 370 19 The salivary glands, 153 46 The testis and scrotum, 374 20 The oesophagus, 158 47 Transplantation surgery, 384 21 The stomach and duodenum, 167 22 Mechanical intestinal obstruction, 183 Index, 391 23 The small intestine, 194 Companion website The book is supported by a website containing a free bank of interactive questions and answers. These can be found at: www.testgeneralsurgery.com The website includes: • Interactive Multiple-Choice Questions for each chapter • Interactive Short Answer Questions for each chapter Introduction The ideal medical student at the end of the clinical Because this book is written at student level, course will have written his or her own textbook principles of treatment only are presented, not – a digest of the lectures and tutorials assiduously details of surgical technique. attended and of the textbooks meticulously read. The need after only 4 years for a new, 12th, Unfortunately, few students are perfect, and most edition refl ects the rapid changes which are taking approach the qualifying examinations depressed place in surgical practice. We are confi dent that by the thought of the thousands of pages of excel- our constant updating will ensure that this volume lent and exhaustive textbooks wherein lies the will continue to serve the requirements of our wisdom required of them by the examiners. medical students. We advise you to read this book We believe that there is a serious need in these in conjunction with Clinical Cases Uncovered – days of widening knowledge and expanding syl- Surgery , which provides illustrated case studies, labus for a book that will set out briefl y the impor- MCQs, EMQs and SAQs, cases that correspond to tant facts in general surgery that are classifi ed, the chapters in this volume. analysed and as far as possible rationalized for the revision student. These lecture notes represent H . E . our own fi nal - year teaching; they are in no way a R.Y.C. substitute for the standard textbooks but are our C.J.E.W. attempts to draw together in some sort of logical way the fundamentals of general surgery. Acknowledgements We are grateful to our colleagues – registrars, (Chapters 21 and 30 ); and Andrew Doble (Chapters housemen and students – who have read and 41 – 46 ). criticized this text during its production, and Finally, we would like to acknowledge the con- to many readers and reviewers for their con- tinued help given by the staff at Wiley Blackwell, structive criticisms. In particular, we are indebted in particular to Jane Fallows, who has created to Simon Dwerryhouse (Chapters 20 and 21 ); some new diagrams and brought colour to others, Justin Davies (Chapters 22 , 23 and 25); Gordon Rebecca Huxley, who oversaw the production, and Wishart (Chapters 35 , 37 and 38 ); Neville Lindsey Williams, who has meticulously steered Jamieson (Chapters 30 – 33 and 40 ); Kathryn Nash this edition from text to fi nished product. Abbreviations ABPI ankle brachial pressure index HHT hereditary haemorrhagic telangiectasia ACE angiotensin - converting enzyme HHV human herpes virus ACTH adrenocorticotrophic hormone HIV human immunodefi ciency virus ADH antidiuretic hormone HLA human leucocyte antigen AFP α - fetoprotein HPOA hypertrophic pulmonary osteoarthropathy AIDS acquired immune defi ciency syndrome HPV human papilloma virus ALP alkaline phosphatase HRT hormone replacement therapy ALT alanine transaminase HTIG human tetanus immunoglobulin APACHE Acute Physiology And Chronic Health ICP intracranial pressure Evaluation ICSI intracytoplasmic sperm injection APUD amine precursor uptake and IFN - γ interferon γ decarboxylation IPMN intraductal papillary mucinous tumour ASA American Society of Anesthesiologists IVC inferior vena cava AST aspartate transaminase IVF in vitro fertilization ATN acute tubular necrosis IVU intravenous urogram BCG bacille Calmette – Gu é rin JVP jugular venous pressure CABG coronary artery bypass graft KSHV Kaposi sarcoma herpes virus CEA carcinoembryonic antigen ‘ KUB ’ kidneys, ureters and bladder CNS central nervous system LAD left anterior descending artery CRP C - reactive protein LCIS lobular carcinoma in situ CSF cerebrospinal fl uid LHRH luteinizing hormone- releasing hormone CT computed tomography MAG3 m ercapto - a cetyl tri g lycine DCIS ductal carcinoma in situ MCN mucinous cystic neoplasm DIC disseminated intravascular coagulopathy MEN multiple endocrine neoplasia DMSA dimercaptosuccinic acid MHC major histocompatibility complex DOPA dihydroxyphenyl alanine MIBG meta - iodobenzylguanidine