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The Lymphatics

Embryology and Anatomy The primordial lymphatic system is first seen during the sixth week of development in the form of lymph sacs located next to the jugular veins. During the eighth week, the cisterna chyli forms just dorsal to the aorta, and, at the same time, two additional lymphatic sacs corresponding to the iliofemoral vascular pedicles begin forming. Communicating channels connecting the lymph sacs, which will…

Venous Disease

An understanding of venous physiology provides the surgeon with valuable information with which to formulate a diagnostic and treatment plan. Technologic advances have broadened the therapeutic armamentarium. This chapter provides the reader with a thorough overview of the physiology and pathophysiology of the venous system. Pathognomonic features of superficial and deep venous disorders are described with discussion of appropriate diagnostic modalities and therapeutic interventions. Videos Video…

Vascular Trauma

The prompt recognition and rapid and effective surgical management of vascular trauma remain challenging despite major advances in access to care produced by trauma systems development. The risk to life and limb remains significant, and the margin for error in both diagnosis and treatment of these injuries is very thin. Either delay in recognition of or failure to adequately manage vascular injuries remains alarmingly common in…

The Aorta

Diseases of the aorta encompasses a broad range of topics far beyond the scope of a book chapter. However, we can provide an overview of common diseases and surgical issues involving the aorta, with the caveat that both our understanding of the pathophysiology of aortic disease as well as the medical and surgical management of aortic disease is constantly evolving. With the somewhat simplified acknowledgement that…

Acquired Heart Disease: Valvular

The heart contains four one-way valves that regulate the directional flow of blood through its chambers. Effective cardiac pumping activity is dependent on the proper functioning of these valves. The atrioventricular (mitral and tricuspid) valves close during systole to allow for stepwise pressure gradients to be maintained between the atria and ventricles, while the semilunar (aortic and pulmonic) valves likewise close during diastole to maintain pressure…

Acquired Heart Disease: Coronary Insufficiency

Acknowledgments We would like to acknowledge Scott Weldon and Michael DeLaflor for graphic services, and Johnny Airheart for photographic support. Ischemic heart disease (IHD) is the predominant public health problem worldwide. Coronary heart disease (43.8%) is the leading cause of death attributable to cardiovascular disease (CVD) in the United States, followed by stroke (16.8%), high blood pressure (9.4%), heart failure (9.0%), diseases of the arteries (3.1%),…

Congenital Heart Disease

This chapter is designed to provide medical students, general surgery residents, and practicing general surgeons with a working tool to aid in their understanding of the features of anatomy and physiology in patients presenting for general surgical procedures in the setting of repaired or unrepaired congenital cardiac lesions. The large scope and breadth of the evolving field of congenital heart surgery precludes an exhaustive treatise on…

Lung, Chest Wall, Pleura and Mediastinum

The term thorax refers to the area between the neck and abdomen enclosed by the ribs, sternum, and vertebrae radially, the thoracic inlet superiorly, and the diaphragm inferiorly. The chest or thorax supports and protects the internal thoracic organs, provides for the negative inspiratory force that initiates ventilation and the positive expiratory force needed for vocalization, and creates a frame for the neck, upper extremities, thoracic…

The Spleen

Splenic Anatomy The spleen is the largest lymphoid tissue mass in the body; it measures 7 to 13 cm in length and weighs up to 250 g. The spleen develops from mesenchymal cells in the dorsal mesogastrium during week 5 of embryogenesis. It is initially adherent to dorsal pancreatic bud and ultimately separates from the pancreatic bud and settles into the left uppermost aspect of the…

Exocrine Pancreas

Anatomy The average pancreas weighs between 75 g and 125 g and measures 10 cm to 20 cm. It lies in the retroperitoneum just anterior to the first lumbar vertebra and is anatomically divided into five sections, the head, uncinate, neck, body, and tail. The head lies to the right of midline within the C loop of the duodenum, immediately anterior to the vena cava at…

Biliary System

Anatomy and Physiology As anatomic variations in biliary anatomy are common, occurring in up to 30% of patients, understanding of both normal anatomy and the variations is important for the management of patients with biliary disease. Bile ducts, either intrahepatic or extrahepatic, lie superior to the corresponding portal vein, which in turn are lateral and inferior to the arterial supply ( Fig. 55.1 ). The left…

The Liver

Historical Perspective The surface anatomy of the liver was described as early as 2000 bc by the ancient Babylonians. Even Hippocrates understood and described the seriousness of liver injury. In 1654, Francis Glisson was the first physician to describe the essential anatomy of the blood vessels of the liver accurately. The beginnings of liver surgery are described as rudimentary excisions of eviscerated liver from penetrating trauma.…

Anus

The anus comprises a relatively small anatomic region of the gastrointestinal tract, yet it plays a critical role in fecal continence and defecation. Because of its unique anatomy and physiology, the anus can present challenges to diagnosis and treatment. Although malignancy can occasionally develop, the anus is susceptible to a variety of common benign conditions that may cause considerable suffering and greatly impair a patient’s quality…

Colon and Rectum

Acknowledgments: Josè Adolfo Navarro, MD; Silvia Neri, MD; and Alberto Morabito, MD. Embryology of the Colon and Rectum A sound knowledge base of the gastrointestinal (GI) tract embryologic development is important in understanding colon and rectal anatomy and pathophysiology. The primitive gut tube is formed from the endodermal roof of the yolk sac. Early in the development process, beginning in the third week of gestation, the…

The Appendix

Appendicitis remains one of the most common diseases faced by the surgeon in practice. It is the most common urgent or emergent general surgical operation performed in the United States and is responsible for as many as 300,000 hospitalizations annually. Although appendectomy is frequently the first “major” case performed by the surgeon in training, the impact of a timely diagnosis and prompt treatment is as impressive…

Small Intestine

The small intestine is a marvel of complexity and efficiency. The primary role of the small intestine is the digestion and absorption of dietary components after they leave the stomach. This process depends on a multitude of structural, physiologic, endocrine, and chemical factors. Exocrine secretions from the liver and pancreas enable complete digestion of the ingested dietary components. The enlarged surface area of the small intestinal…

Stomach

Anatomy Gross Anatomy Divisions The stomach is derived from the tubular embryonic foregut and begins as a dilation during the fifth week of gestation in the caudal portion. The embryonic stomach is invested by two mesenteries: dorsal (which becomes the gastrosplenic, gastrocolic, and gastrophrenic ligaments) and ventral (which becomes the hepatoduodenal and gastrohepatic ligaments of the lesser omentum and the falciform ligament). By the seventh week…

Morbid Obesity

Obesity: The Magnitude of the Problem Until very recently, obesity was not recognized as a disease, which confounded the ability of physicians to be compensated for treatment they delivered and to treat the condition effectively. The American Medical Association (AMA) officially recognized obesity as a disease in 2013 and in 2014 voted to approve the resolution “that our AMA, advocate for patient access to the full…

Acute Gastrointestinal Hemorrhage

Gastrointestinal bleeding (GIB) is a term that describes the loss of blood from along the alimentary canal. GIB is classified by its anatomic location relative to the ligament of Treitz. Upper GIB (UGIB) is defined as being proximal to the ligament of Treitz. Upper intestinal hemorrhage is the most common presentation of GIB and is commonly from peptic ulcer disease (PUD) or esophageal varices. Pancreatic, liver,…

Acute Abdomen

The term acute abdomen refers to the signs and symptoms of abdominal pain and tenderness. This situation often represents an underlying surgical problem that requires prompt diagnosis and surgical treatment. While the ready availability of diagnostic studies such as computed tomography (CT) scans or magnetic resonance imaging (MRI) has added greatly to our ability to accurately diagnose most of the conditions responsible for the acute abdomen,…