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The anorectum

Introduction Anorectal complaints are extremely common; 2% to 3% of the population has anorectal symptoms at any given time. Pain, bleeding, discharge, itching and the presence of a lump are common presenting symptoms. Symptoms are often ignored, attributed to ‘haemorrhoids’ or hidden by the patient from relatives and doctors. It is important that perianal symptoms are elicited without embarrassment, and because these overlap with conditions affecting…

The small and large intestine

Introduction Any individual can reasonably expect to suffer infrequent gastrointestinal (GI) symptoms. Most disorders are self-limiting, benign conditions, but serious pathology can have enigmatic symptoms or none until a late stage in the natural history of the disease. Infective diarrhoea most commonly affects the young; inflammatory conditions affect those in early and middle adulthood; and cancer and diverticular disease affect those in middle and old age.…

The pancreas and spleen

The pancreas Surgical anatomy The pancreas is a glandular organ that lies in the retroperitoneum, behind the lesser sac and stomach. The pancreas develops from separate ventral and dorsal buds of endoderm that appear during the fourth week of foetal life ( Fig. 16.1 ). The ventral pancreas will become the future uncinate process and codevelops with the biliary tree, and its duct joins the common…

The liver and biliary tract

The liver Anatomy The liver is the largest abdominal organ, weighing approximately 1500 g. It extends from the fifth intercostal space to the right costal margin. It is triangular, and its apex reaches the left midclavicular line in the fifth intercostal space. In the recumbent position, the liver is impalpable under cover of the ribs. It is attached to the undersurface of the diaphragm by suspensory…

The oesophagus, stomach and duodenum

Surgical anatomy Oesophagus The oesophagus is a fibromuscular tube that carries food through the neck, thorax and abdomen. It extends between the cricoid cartilage of the trachea (at the level of the sixth cervical vertebra) and the gastric cardia (at the level of the 11th thoracic vertebra). In adults, it is approximately 25 cm long. With oesophagogastroduodenoscopy (OGD), it can be measured as starting at 15…

The acute abdomen

Introduction ‘The acute abdomen’ includes a spectrum of surgical, medical and gynaecologic conditions, ranging from trivial to life-threatening, which require hospital admission for urgent investigation and treatment. The primary symptom of the condition is abdominal pain. For the purposes of multicentre studies, acute abdominal pain is defined as ‘abdominal pain of less than 1 week’s duration requiring admission to hospital, which has not been previously investigated…

The abdominal wall and hernia

Umbilicus The umbilicus is a scar on the abdomen that all placental mammals have that can be flat, protruding or hollowed. Under the skin there is a dense fibrous ring that is easily palpable during examination. The skin around the umbilicus is innervated by the 10th thoracic spinal nerve. The linea alba is usually well defined above the umbilicus. Around the umbilicus there are portocaval venous…

Postoperative care and complications

Introduction The 2011 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reported that, every year in the UK, there are between 20,000 and 25,000 deaths in patients undergoing surgical procedures. Although most of these deaths were in high-risk patients, the enquiry concluded that improvements in preoperative, intraoperative and postoperative care were required. Recovery following an operation falls into three phases: immediate postoperative care in a…

Practical procedures and patient investigation

Introduction Surgery is the field of medicine that uses operative or instrumental techniques to treat or investigate pathologic conditions. Most surgical procedures are invasive in nature in that they involve physically cutting into a patient to repair or remove tissues or organs, to restore physiologic function or improve appearance. The key to surgical success is to do “the right operation to the right patient at the…

Trauma and multiple injury

Introduction The importance of trauma Injuries kill 5 million people each year, and trauma is responsible for nearly 1 in 10 deaths worldwide. It is also the leading cause of death between 15 and 29 years of age. For survivors of severe injury, resulting morbidity has a major impact on healthcare resources. Trauma is a global epidemic and places an additional burden on family members and…

Principles of the surgical management of cancer

The biology of cancer A neoplasm or new growth consists of a mass of transformed cells that does not respond in a normal way to growth regulatory systems. These cells serve no useful function and proliferate in an atypical and uncontrolled way to form a benign or malignant neoplasm. In normal tissues, cell replication and death are equally balanced and under tight regulatory control. However, when…

Preoperative considerations, anaesthesia and analgesia

Preoperative considerations Careful preoperative assessment is fundamental to achieve good surgical outcomes, both in emergency and elective settings. However, the amount of time available for full assessment and investigation may be compromised when an emergency condition requires urgent intervention. Assessment of operative fitness and perioperative risk Elective preoperative assessment takes place in several stages beginning at the point of referral for surgery ( Fig. 7.1 ).…

Infections and antibiotics

Introduction When healthy, the human body maintains a balance with commensal microorganisms that colonise skin and mucosal surfaces, including the gut ( Fig. 6.1 ). Disease occurs when the balance changes, either due to an encounter with a microorganism that has particular virulence or where a host defence is breached. Surgical practice has been transformed through prevention and control of infection and the correct and timely…

Nutritional support in surgical patients

Introduction The interrelationship between disease and nutrition has been recognised since at least the time of Hippocrates, who is credited with the phrase ‘let food be thy medicine’. Attention to and correction of nutritional status remain fundamental to holistic medical care. Nevertheless, approximately one-third of all patients admitted to an acute hospital will have evidence of protein-calorie malnutrition. In many cases, these abnormalities are not adequately…

Management of shock, fluid management and blood transfusion

Fluid and electrolyte balance Normal water and electrolyte balance Water forms about 60% of total body weight in men and 55% in women. Approximately two-thirds is intracellular and one-third is extracellular. Extracellular water is distributed between the plasma and the interstitial space ( Fig. 4.1A ). The differential distribution of ions (and water) across cell membranes is essential for normal cellular function. The principal extracellular ions…

Evidence-based surgery

Introduction Scientific evidence and data are widely regarded as the basis for modern medicine and surgery. However, the concept of conducting experiments to decide whether new treatments are effective and safe is a relatively recent one. The first published clinical trial that used systematic methods was conducted in 1747 by James Lind, a Scottish naval surgeon. In this study, sailors were divided into six treatment groups…

Patient safety and clinical human factors

Introduction Surgeons work in high demand, complex healthcare systems, often with people they have never met before, in dynamic multidisciplinary teams. The patient safety movement has rapidly changed the approach and understanding of risk to patients and healthcare systems since its inception in the late 1990s. As a key driver of enhancing surgery performance, Human Factors is the science of understanding and improving work systems, drawing…

Professional and ethical responsibilities

Introduction Ethics is a term derived from the Greek word ethos, defined by the Oxford English Dictionary as being ‘the moral principles that govern a person’s behaviour or the conducting of an activity’. Ethics does not always provide the right answer to moral problems. For many ethical issues, it is acknowledged that there is not a single right answer but instead a set of principles that…

Robotic thoracic surgery

Introduction The minimally invasive journey in thoracic surgery now includes robotics. This has largely been dominated by the da Vinci platform, although newer devices from Johnson & Johnson, Cambridge, Medronic, and others have emerged. The versatility and considerable improvements in vision and instrumentation have led to the development of robotics in thoracic surgery. This applies to both standard open as well as already established video-assisted thoracoscopy…

Robotic cardiac surgery

Introduction Cardiac surgery was one of the first surgical specialties that was envisioned to be ideal for robotic surgery. While the breadth of cardiac applications has been not as broad as originally hoped, in some areas it has become a highly successful field of our specialty. As cardiac surgery originally evolved from thoracic surgery, the initial approach to the heart was via large thoracotomies. This was…