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The Surgeon’s Role in Mass Casualty Incidents

“Those who are dangerously wounded should receive the first attention, without regard to rank or distinction. They who are injured in a less degree may wait until their brethren in arms, who are badly mutilated, have been operated on and dressed, otherwise the latter would not survive many hours; rarely, until the succeeding day.” Dr. Baron Larrey, Memoirs of Military Surgery, 1812 Mass casualty (MASCAL) incidents…

Bedside Surgical Procedures

Bedside surgical procedures have become a standard in many intensive care units (ICUs), replacing the operating room (OR) as the preferred location for select procedures in critically ill patients. Performing appropriately selected procedures within the ICU limits the risk of transporting critically ill patients, facilitates flexibility in timing and scheduling, and reduces cost. The ability to perform some operations at the bedside may be lifesaving in…

Surgical Critical Care

Intensive care units (ICUs) represent a triumph of medicine: the ability to support and replace a large number of bodily functions. And yet, these actions are not cost free. Nearly every intervention has side effects and risks, all of which must be mitigated. While rapid decision-making is often possible and desired in the management of emergency center or ward patients, this approach can be prone to…

Bites and Stings

Snakebites Epidemiology Snakebites are a public health problem primarily in warm areas across the globe. The burden of injury is greatest in the tropical and subtropical regions of the world, primarily affecting Southeast Asia, India, Australia, South America, and parts of Africa. The World Health Organization reports approximately 5.4 million snakebites worldwide, with 2.7 million snakebite envenomations each year resulting in 81,000 to 138,000 deaths with…

Burns

General Considerations In 2017, approximately 400,000 people were burned in the United States, of whom 3400 died. The epidemiological trends from 2001 to 2017 demonstrate that the U.S. population has increased from 285,000,000 to 326,000,000 people, a nominal 14% increase. Correspondingly, the incidence of burns decreased from 520,000 to 403,000, a 23% decrease. Fatal burns also decreased from 3800 deaths in 2001 to 3400 deaths in…

Emergency Care of Musculoskeletal Injuries

Epidemiology of Orthopedic Injuries Fractures occur when the applied load to the bone exceeds its load-bearing capacity. Fracture patterns relate to bone strength and the forces that cause the injury. The patient’s age and the mechanism of injury are both strong determinants of the fracture pattern and the soft tissue injury that occurs concurrent with the fracture, both of which will drive the treatment strategy. In…

The Difficult Abdominal Wall

Although the midline laparotomy is a common incision used in abdominal surgery, there is little evidence to guide surgeons regarding the optimal closure of the abdominal wall. The goal of this chapter is to illustrate techniques of both temporary and permanent closure of the abdominal wall. We pay particular attention to difficult and high-risk abdominal closures. Suture Material Abdominal wall closure has changed over time in…

Management of Acute Trauma

Overview and History Injury management has been an important assignment of the practicing surgeon. Throughout the history of medical care, the treatment of trauma necessitates a mastery of diverse skills spanning all areas of anatomy and physiology. Because of the great disease burden due to injury sustained in conflict, care for the trauma patient has been advanced most profoundly during wartime. Box 17.1 lists some major…

Robotic Surgery

Preface Robotic surgery is arguably the most disruptive and perhaps the most enabling twenty-first century surgical innovation. Born of military technology, developed by industry, and championed by surgeon pioneers, robotic surgery is increasingly adopted as an alternative to laparoscopy to perform a wide breadth of surgical procedures for both benign and malignant diseases ( Box 16.1 ). Since the U.S. Food and Drug Administration (FDA) approval…

Emerging Technology in Surgery: Informatics, Electronics

There has been a dramatic change in surgical care over the past 30 years with the introduction of digitization, miniaturization, improved optics, advanced diagnostic and therapeutic tools, and computerized information systems in the operating room (OR). Whereas surgery has traditionally required large incisions sufficient to allow the surgeon to introduce his/her hands into the body and to allow sufficient light to see the structures being operated…

Anesthesiology Principles, Pain Management, and Conscious Sedation

The history of anesthesiology began only a little more than 150 years ago with the administration of the first ether anesthetic. Throughout much of the subsequent history, the risk of anesthesia-related mortality and morbidity was unacceptably high as a consequence of primitive equipment, complication-prone drugs, and lack of adequate monitors. However, during the past four decades, rapid technological and pharmacologic progress has resulted in the ability…

Surgery in the Geriatric Patient

Life expectancy has increased dramatically in the last several decades. An average 65-year-old woman today can expect to live an additional 20.6 years, nearly twice as long as her counterpart in 1900. An average 80-year-old female can expect to live nearly 9.8 years ( Table 13.1 ). With this increase in life expectancy comes an increase in the number of people living into old age with…

Surgical Complications

The current health care environment has increased our focus on the cost and quality of surgical care. As a result, many hospitals and physicians are devoting significant efforts to understand and benchmark the risk of complications in surgical patients. One approach uses risk-adjusted administrative data sets (e.g., Vizient) to generate reports comparing observed to expected complications among different hospitals and departments. Another, the American College of…

Surgical Infections and Antibiotic Use

Surgical infections encompass a wide-ranging group of diseases, which account for a large burden of mortality and morbidity worldwide. Surgical infections include de novo infectious diseases that require surgery or procedural interventions for cure; common examples include abscesses, intraabdominal infections such as cholangitis and appendicitis, and necrotizing soft tissue infections (NSTIs), all of which are dealt with in detail in this chapter. Another major type of…

Principles of Preoperative and Operative Surgery

Principles of Surgical Evaluation Patient–Surgeon Relationship Clear, precise, and unambiguous communication to establish an understanding of mutual expectations and trust is at the pinnacle of the patient–surgeon relationship. A surgeon’s initial encounter with a patient most commonly is in the context of a new diagnosis and is initiated by either a professional or self-referral. A history and physical examination, whether in an urgent/emergent or elective setting,…

Safety in the Surgical Environment

The intent of surgery is to improve health, so it was galvanizing when a series of eye-opening reports published in the 1990s provided clear evidence of high rates of serious adverse events that resulted in serious harm to hospitalized patients. In its landmark report To Err is Human, published in 1999, the Institute of Medicine estimated that 1 million people per year were injured and 98,000…

Critical Assessment of Surgical Outcomes and Health Services Research

The practice of surgery has undergone a dramatic evolution over the last century with the availability of new scientific evidence supporting the use of different surgical techniques and management. Central to this mission is the process of critically appraising the surgical evidence base at every opportunity and deciding what can and should be applied to routine clinical practice. Critical appraisal is defined as the process of…

Regenerative Medicine

Regenerative medicine is a continually developing field that combines the diverse disciplines of cellular and molecular biology, tissue engineering, and biomaterial science in order to design therapies to restore or maintain cells, tissue, and organs. While many other complex organisms retain the capacity to regrow limbs and repair organs throughout adult life, humans have traded in this regenerative potential for speed and strength of repair, which…

Wound Healing

Although the treatment and healing of wounds are some of the oldest subjects discussed in the medical literature, and although there have been numerous advances in understanding the steps involved in wound healing, the exact mechanisms underlying wound healing remain unclear. Tissue Injury and Response Attempts to restore mechanical integrity, to repair barriers to fluid loss and infection, and to reestablish normal blood and lymphatic flow…

Metabolism in Surgical Patients

Metabolic Science Metabolism encompasses all of the biochemical and biophysical reactions that maintain the organism-level energy homeostasis necessary for continued cellular life in response to ever-shifting environmental conditions. , Fully understanding the metabolic processes at work in living systems requires exploring the overlap between chemistry, physics, and biology. Conceptually, these processes are organized into pathways in which enzymes and substrates interact in a stepwise manner to…