This chapter is an overview of the surgical anatomy of the abdomen, the region of the body that is located between the thoracic diaphragm and the pelvic inlet. It is bounded by muscular layers of the abdominal wall and by the peritoneum, and contains the majority of the hollow organs of the gastrointestinal tract, as well as several solid organs. These organs play critical roles in…
Core Procedures Sternotomy Redo sternotomy Right ventricular outflow tract operations Left ventricular vent insertion Left ventricular aneurysm repair Left ventricular rupture repair Post-infarct ventricular septal defect repair Long saphenous vein harvest Radial artery harvest Internal thoracic (mammary) artery harvest Coronary artery bypass grafts Ventricles Right ventricle In the normal state, the right and left ventricles pump the same amount of blood in the pulmonary artery and…
Core Procedures Aortic valve replacement Transcatheter aortic valve replacement/implantation (TAVR/TAVI) Aortic root replacement Aortic root enlargement Embryology Septation of the initially single outflow tract begins in the fourth week of gestation (26–32 days post fertilization), occurring in the conotruncal region of the primitive heart tube, which extends from the primitive right ventricle to the boundaries of the pericardial cavity. Development of the arterial valve orifices occurs…
Core Procedures Mitral valve repair/replacement The fibrous skeleton of the heart The aortic, mitral and tricuspid valves form one continuous structure, with each valve in close approximation to the other and connected by the fibrous skeleton of the heart. They are arranged as a triangle at the base of the heart; the pulmonary valve is separate and placed anteriorly ( Fig. 51.1 ). The fibrous skeleton…
Core procedures Preoperative imaging Intraoperative imaging Postoperative imaging Non-invasive evaluation of the heart is an essential part of the assessment of patients undergoing cardiac surgery. Echocardiography is the commonly used non-invasive imaging modality. Preoperatively, it is an essential part of the decision-making process to identify patients suitable for surgery, guide the type of surgical intervention and predict outcomes. Intra- and postoperatively, it is used to assess…
Core procedures Pericardiectomy Pericardiocentesis Pericardial harvesting, e.g. closure of atrial septal defect Thoracoscopic pericardial window creation Relief of pericardial tamponade post-cardiotomy Pericardial biopsy Surgical surface anatomy The surface projections of an average adult heart are modified by age, sex, stature, ventilation, the position of the diaphragm and posture. The projection of the cardiac borders on to the anterior thoracic wall forms a trapezoid. The upper border…
Core Procedures Thymectomy Clinical anatomy The thymus is an encapsulated soft, bilobed organ; the two lobes are joined in the midline by connective tissue that merges with the capsule of each lobe. It is usually located in the anterior mediastinum. The thymus plays an important role in the immune system from the early part of life until puberty and, as a result, it is usually largest…
Core Procedures Tracheal resection: segmental resection Bronchoscopy: assessment Mediastinoscopy: assessment Wedge resection: non-anatomical wedge Segmentectomy: segment or multiple segments Lobectomy: lobe Sleeve lobectomy: lobe with segment of bronchus or pulmonary artery Pneumonectomy: whole lung Trachea Clinical anatomy The adult trachea averages 11.8 cm in length (range 10–13 cm). Typically, there are 18–22 cartilaginous rings. The larynx and the origin of the oesophagus are intimately related at the level…
Core procedures Pleural biopsy, pleural drainage, pleural debridement Spontaneous pneumothorax surgery, parietal pleurectomy Decortication of empyema Pleurectomy/decortication (extended) for mesothelioma Excision of solitary pleural tumour Thoracic sympathectomy, facial flushing, axillary and palmar hyperhidrosis, angina, splanchnicectomy Surgical surface anatomy of the pleura The surface marking of the lung represents the markings of the visceral pleura. The apex of the lung extends convexly upwards to a distance of…
Core Procedures Transthoracic oesophagectomy Minimally invasive oesophagectomy (MIO) Thoracic lymphadenectomy Embryology The oesophagus develops from the primitive foregut, a ventral diverticulum caudal to the fifth pharyngeal pouch in the third week of gestation. It is initially a single common gastrointestinal (oesophagus) and respiratory (trachea) tube, which later develops a respiratory bud from which the tracheobronchial tree develops. Failure of division results in congenital problems, such as…
Core Procedures Surgical Repair of Aortic Arch Proximal aortic arch (so-called hemiarch) Distal aortic arch (so-called reverse hemiarch) Total aortic arch (involves at least one epi-aortic vessel) Total aortic arch and elephant trunk: conventional elephant trunk; reverse elephant trunk; frozen elephant trunk Surgical Repair of Descending Thoracic Aorta (DTA) Type A DTA (proximal third) Type B DTA (distal third) Type C DTA (entire thoracic portion) Core…
Core procedures Mastectomy: simple; skin-sparing; nipple-sparing, skin-sparing Wide local excision of breast lesion Wire-localized wide local excision Sentinel lymph node biopsy Microdochectomy Development Developmentally, the breast is a modified and highly specialized apocrine gland, composed of glandular tissue and ducts making up the breast parenchyma, supported by a connective tissue framework, adipose tissue and vasculature, which make up the breast stroma. Breast development begins in utero…
Core Procedures Chest drain (tube) insertion Sternotomy Three-port thoracoscopic approach Posterolateral thoracotomy Anterolateral thoracotomy Left anterior thoracotomy Left thoraco-abdominal incision Right anterior mini-thoracotomy and minimally invasive approach to the mitral valve Hemi-sternotomy and minimally invasive approach to the aortic valve The chest wall is commonly affected in patients with both blunt and penetrating thoracic injury. The surgical approach to rib fractures, sternal fractures, flail chest and…
Core Procedures Dorsal and palmar approaches to the wrist, e.g. for access to joints, fractures; for tendon, ligament and nerve repair (see Table 41.1 ) TABLE 41.1 Core procedures: wrist Region Approach Indication Dorsal Arthroscopic Triangulo-fibro-cartilaginous complex (TFCC) injuries, synovectomy, ganglia Dorsal midline Open reduction internal fixation (ORIF) fractures, wrist fusion, wrist replacement proximal row carpectomy, etc. Mid-ulnar/dorso-ulnar Access to distal radio-ulnar joint, TFCC Anatomical snuffbox…
The primary function of the elbow is to help position the hand in space. This is achieved by means of three joints: the radiocapitellar, humero-ulnar and proximal radio-ulnar joints. The functional range of movement has been described by Morrey et al as being 30–130° of flexion, 50° of pronation and 50° of supination, but for modern living more flexion is required. Core Procedures Lateral, medial, anterior and…
Core Procedures Surgical Exposures Around the Shoulder Girdle and Upper Arm Approaches to the shoulder girdle Approaches to the shoulder joint Medial extensile exposures Distal (brachial) extensile exposures While arthroscopy has allowed access to the glenohumeral, sternoclavicular and acromioclavicular joints and to the subacromial–subscapular space, enabling surgeons to undertake a variety of reconstructive procedures, it is not always possible to use a minimally invasive approach for…
Core Procedures Axillary dissection Sentinel node biopsy Axillary reverse mapping (ARM) procedure Removal of tail of Spence during total mastectomy The lymph of the upper limb, most of the breast, and the skin of the trunk above the umbilicus (that is, above Sappey's line ) drains ultimately into the axillary nodes, making a knowledge of the anatomy of the axillary region essential for general and oncological…
Core Procedures Excision of a lump from the neck Exploration of the supraclavicular brachial plexus Excision of the first rib Exploration of the infraclavicular brachial plexus Anaesthetic nerve blocks Surgical surface anatomy The margins of the posterior triangle, the superior border of the clavicle, the lateral border of sternocleidomastoid and the anterior border of trapezius are all palpable. The upper trunk of the brachial plexus can…
The upper limb functions as a series of articulated segments, which act in a coordinated manner to allow the hand to manipulate and sense its surrounding environment. The degree of coordination of these movements is such that the hand can be positioned with remarkable precision. The freedom of movement allowed by the highly mobile thoracoscapular and glenohumeral joints means that, when combined with the actions of…
Core Procedures Epidural injections: commonplace in obstetrical anaesthesia, as well as in the treatment of radiculitis throughout the spine Epidural catheterization: permits continuous administration of an anaesthetic agent Lumbar puncture: single injection of local anaesthetic into the subarachnoid space via lumbar puncture offers excellent surgical anaesthesia for abdominal, pelvic and lower-extremity procedures The epidural space is the potential space that lies outside the dura and is…