Introduction The term acute abdomen is widely understood but is difficult to define precisely. Typically, the symptoms are of acute onset abdominal pain. The illness is of such severity that admission to hospital appears essential and operative surgery is a likely outcome. Many of the disorders causing an ‘acute abdomen’ are serious and potentially life threatening unless treated promptly. On the other hand, simple and relatively…

Introduction Diagnosis of nonacute abdominal complaints is an important part of the general surgical clinic workload and most patients with abdominal complaints can be managed as outpatients alone. Diagnoses made in a clinic are often quite different from those in emergency surgical admissions. Nevertheless, the surgeon in the clinic must remain alert to unfamiliar presentations that more usually present acutely, for example, an appendix mass. The…

Soft Tissue Injuries Soft tissue injuries are common, and timely, up-to-date management gives the best outcomes. Traumatic soft tissue injuries include cuts, lacerations, crushing injuries, missile injuries and impalements not involving bone or body cavities. Other causes of injury include infective, oncological, surgical and vascular insults. The holistic care of soft tissue injury involves attention to the wound and to comorbid illness and patient choice. Effective…

Head Injuries Introduction Head injury with traumatic brain injury (TBI) is the most common cause of death and disability in people aged 1 to 40 years in the United Kingdom. Head injuries cause about 3500 deaths each year in the United Kingdom, amounting to about 0.6% of all deaths. Even in survivors, there may be devastating problems, which have an enormous social and economic cost. Head…

Injury Epidemiology Injury is one of the major causes of death and disability in the world. The World Health Organization defines injury as physical damage that results when a human body is subjected to levels of energy that exceed tissue and physiological tolerances. Injury encompasses a wide range of causative energy sources, mechanisms and circumstances ( Fig. 15.1 ). Many factors also influence a patient’s exposure…

Introduction Organ transplantation is the optimal treatment for end-stage organ failure and has the potential to both improve the quality of life and prolong life. It can now be considered for patients with kidney, liver, heart, lung and intestinal failure, as well as for patients with diabetes and bone marrow failure. While the availability and long-term outcomes of transplantation have significantly improved in recent years, this…

Introduction Cancer patients make up a rising proportion of surgical cases and comprise about a third of surgical bed occupancy. Defining and ensuring optimal treatment for individual patients should be a true multidisciplinary effort involving surgeons, oncologists, pathologists, radiologists, specialist nurses, and palliative care teams. Other specialist teams often need to be involved including nutritional, psychological and social specialists. The incidence of some cancers is falling…

Introduction Any operation, major trauma or other surgical admission may be attended by complications, many of which are potentially preventable. Some complications are somewhat inherent to the condition being treated (e.g., deep venous thrombosis [DVT] following lower limb fractures) or arise from a comorbid (pre-existing) condition, such as myocardial ischaemia, whilst others can be attributed to human or system error. Poor communication between hospital staff is…

Introduction Anatomy Of The Skeleton Basic musculoskeletal anatomy needs to be understood when managing orthopaedic care. The normal locomotor system relies on a stable skeleton to provide attachment for muscles and a base for positioning the hands and feet in space. The axial skeleton consists of the skull, spine and rib cage ( Fig. 11.1A ). The appendicular skeleton evolved from fins in early fish to…

Introduction This chapter describes the operating environment and outlines the principles of operative surgery including those used in ‘minor’ surgical techniques. All of these should be understood by all doctors, not just surgeons, to help them appreciate the scope of surgery, to enable them to give meaningful explanations to patients before and after surgery and to help them assist intelligently at the operating table. Furthermore, most…

Principles of Blood Transfusion The ability to safely transfuse blood and blood products has revolutionised outcomes from major trauma and from complex surgery involving heavy blood loss, such as arterial reconstruction, open-heart surgery and organ transplantation. For replacing blood loss, stored blood restores the circulation, increases oxygen carrying capacity and helps prevents hypoxia. Modern blood transfusion is very safe but deaths and major morbidity still occur.…

Introduction General surgical operations are now performed on patients who are older, more frail and with significant and often multiple (medical) comorbidities, so it becomes even more important to appreciate and consider these ‘medical’ conditions. Detailed reports of emergency abdominal surgery outcome audits have been published by the UK National Emergency Laparotomy Audit (see: ). A high-risk patient is usually defined as one whose estimated…

Preoperative Assessment Introduction Patients with medical comorbidity and advanced age are increasingly being considered for surgery. Timely and considered preoperative assessment is crucial for ensuring any patient is safe and in the best possible condition before the operation and that healthcare resources are not wasted. This process needs both surgical and anaesthetic input. For elective surgery , patients are seen first by the surgeon who evaluates…

Principles of Screening Introduction Medical screening is a public health activity that involves examining or testing asymptomatic, apparently healthy people to detect disease at an early stage. Measures can then be taken to prevent the disease (if there is a precursor stage), treat it early (hoping for improved cure rates), or at least offer treatment to delay advanced disease. For example, colonic screening can detect adenomas…

Introduction This chapter gives an overview of imaging, endoscopic, interventional and biopsy procedures used to make a diagnosis and treat patients. Interventional radiology describes minimal access procedures using image guidance to treat conditions whilst causing least trauma. It is usually performed by radiologists or specialist clinicians. Examples include angioplasty, nephrostomy and endoscopic placement of biliary stents. Plain Radiology Body tissues absorb x-rays in proportion to their…

The Pathophysiology of Shock The term ‘shock’ can be defined as acute circulatory failure of sufficient magnitude to compromise tissue perfusion , which if untreated, proceeds rapidly to irreversible organ damage and death of the patient. Circulatory failure and subsequent hypotension in the shocked patient results in cellular and tissue hypoxia. This occurs when there is either reduced oxygen delivery to tissues or inadequate oxygen use.…

Immune Responses Introduction The innate immune response constitutes the first line of defence against invading microorganisms. The key mechanism is the body’s recognition of pathogen-derived molecules by Toll-like receptors (TLRs) found on the surface of dendritic cells. This triggers inflammatory responses to limit infection. The adaptive immune system, involving T and B cells, is much more organism specific. It evolves during the course of an infection…

Systemic Responses Factors Responsible for Systemic Responses ( Box 2.1 ) Surgical patients are subject to a variety of major stressors that make massive demands on the body’s ability to maintain physiological equilibrium and sustain life. Examples of such stressors include: Major operations —tissue trauma, blood and fluid loss, anaesthesia (particularly Trendelenburg head-down position + pneumoperitoneum for laparoscopic surgery), healing and repair Major trauma including fractures…

Approaches to Surgical Problems What Do Surgeons Do? Surgeons are perceived as doctors who do operations, that is, cutting tissue to treat disease, usually under anaesthesia, but this is only a small part of surgical practice. The range individual surgeons undertake varies with the culture, the resources available, the nature and breadth of their specialisation, which other specialists are available, and local needs. The principles of…