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Breast

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…

Overview of the thorax and diaphragm and surgical anatomy of the chest wall

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…

Wrist and hand

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…

Elbow and forearm

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…

Shoulder girdle and upper arm

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…

Axilla

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…

Supraclavicular and infraclavicular regions

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…

Overview of the upper limb

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…

Anatomy of lumbar puncture and epidural analgesia

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…

Lumbar spine, sacrum and coccyx

Core Procedures Posterior Approach Microdiscectomy Foraminotomy Laminectomy Posterolateral fusion (PLF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) Vertebroplasty, kyphoplasty Lumbar osteotomies Lateral Approach Lateral lumbar interbody fusion (LLIF) Oblique lumbar interbody fusion (OLIF) Anterior Approach Anterior lumbar interbody fusion (ALIF) Lumbar disc arthroplasty Clinical anatomy Lumbar spine The lumbar spine usually consists of five vertebrae, although anatomical variations with either four or six…

Thoracic spine

Core Procedures Direct posterior exposure Costotransversectomy Transpedicular approach to the thoracic disc space Anterior open transthoracic exposure Endoscopic approach to the thoracic spine Lateral extracavitary approach Trans-sternal approach to the cervicothoracic junction Surgical surface anatomy There are limited reliable surface anatomy cues about the thoracic spine. This contributes to the increased risk of performing wrong-level surgery. The spinous process of the first thoracic vertebra can be…

Cervical spine

Core Procedures Anterior and posterior approaches to the occipitocervical region Anterior and posterior approaches to the subaxial cervical spine Main indications for cervical spine surgery include excision of herniated discs with either a subsequent fusion or disc replacement, excision of tumours, reduction and stabilization of fractures or dislocations, and laminectomy to decompress the spinal cord, which may be combined with instrumented fusion or laminoplasty. Understanding the…

Intervertebral joints, foramina and ligaments

Core Procedures Anterior and posterior cervical foraminotomy Lumbar microdiscectomy Lumbar laminotomy and foraminotomy Endoscopic foraminotomy and discectomy Transforaminal lumbar interbody fusion (TLIF) A number of surgical procedures are performed in and around the foramina of the spine, commonly in the cervical or lumbar spine and occasionally in the thoracic spine. They generally consist of decompressive procedures such as a foraminotomy. Different approaches to accomplish a foraminotomy…

Overview of the back and spine

The patterned anatomy of the spine is not without its drawbacks. While the study of any individual level can enlighten the surgeon about several adjacent, or even all, levels, a blind reliance on repetition and consistency can be disorienting, leading to wrong-level surgery, patient injury or even death. It is essential for surgical exposure of the spine to be done in a responsible manner. Beyond the…

Spinal cord

Core Procedures Myelotomy for intramedullary tumour Dorsal root entry zone lesioning for pain Selective dorsal rhizotomy for spasticity Cordotomy for pain Syringoperitoneal/syringopleural shunting The spinal cord lies within the upper two-thirds of the vertebral canal (spinal canal), which is formed by the vertebral bodies anteriorly, their pedicles and facet joints laterally and their laminae posteriorly. Although a discussion of the osseous anatomy of the spine is…

Brainstem and pineal region

Core Procedures Brainstem Midline suboccipital craniotomy to the cerebellum and fourth ventricle Retrosigmoid craniotomy to the lateral cerebellum and cerebellopontine angle Far lateral approach to the ventral brainstem Cranio-orbitozygomatic approach to the upper brainstem Pineal Gland Supracerebellar infratentorial approach Occipital interhemispheric transtentorial approach Posterior transcallosal approach Surgical approaches to the brainstem and pineal region are complex. The pineal gland is closely related to the confluence of…

Basal ganglia and thalamus

Core Procedures Stereotactic deep-brain stimulation electrode implantation (subthalamic nucleus, globus pallidus pars interna, Vim), radiofrequency lesioning (e.g. pallidotomy), biopsy or radiosurgery Management of any lesion (e.g. tumour, arteriovenous malformation, haematoma) partly or wholly involving the basal ganglia or thalamus Surface anatomy for frame-based stereotaxy Stereotaxy makes use of a three-dimensional coordinate system relative to a fixed frame of reference on the body to target deep lesions…

Cerebral vasculature

Core procedures Open approaches to the anterior circulation Open approaches to the posterior circulation Endovascular approaches to the anterior and posterior circulation Many vascular lesions (such as aneurysms) are approached via an endovascular route. Open surgery is more frequently performed for tumour resection, epilepsy and microvascular decompression of the trigeminal nerve rather than for aneurysm clipping. Embryology Embryological variants of cerebral vascular anatomy are commonly encountered…

Cerebral hemispheres and white matter tracts

Core procedures Treatment of medically refractory epilepsy. This chapter will address the key surgically relevant cortical and white matter anatomy of the brain and some of the principles underlying resection of limbic/paralimbic gliomas and removal of tumours in the eloquent cortex. Clinical anatomy Osseous anatomy and landmarks Sutures The cranial vault (calvaria) encloses the meninges and central nervous tissue. It consists of single frontal and occipital…

Ventricular system

Core Procedures Cannulation of the lateral ventricle Endoscopic third ventriculostomy Approaches to the third ventricle Approaches to the fourth ventricle An understanding of the three-dimensional anatomy of the ventricular system of the brain is critical to the safe and effective practice of neuro­surgery. An appreciation of the embryological development aids in comprehension of their neural and vascular relationships, and a sound three-dimensional grip on these relationships…