Surgical anatomy and technique a pocket manual – 4th edition (2014)

Surgical Anatomy
and Technique
A Pocket Manual
Fourth Edition
Lee J. Skandalakis
John E. Skandalakis
Editors
123
Surgical Anatomy and Technique
Fourth Edition

Lee J. Skandalakis
John E. Skandalakis
Editors
Surgical Anatomy
and Technique
A Pocket Manual
Fourth Edition
With contributions by Panagiotis N. Skandalakis
ISBN 978-1-4614-8562-9 ISBN 978-1-4614-8563-6 (eBook)
DOI 10.1007/978-1-4614-8563-6
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2013949138
© Springer Science+Business Media New York 1995, 2000, 2009, 2014
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Editors
Lee J. Skandalakis, MD, FACS
Centers for Surgical Anatomy
and Technique
Emory University School
of Medicine
Piedmont Hospital
Atlanta, GA, USA
John E. Skandalakis, MD, FACS
Centers for Surgical Anatomy
and Technique
Emory University School
of Medicine
Piedmont Hospital

Atlanta, GA, USA
Dedicated to my father John Skandalakis who has
reached out from the grave to provide valuable
assistance for this edition.

vii
Preface to the
Fourth Edition
“They will soar on wings like eagles;
they will run and not grow weary,
they will walk and not be faint.”
ISAIAH 40:31
In this fourth edition of Surgical Anatomy and Technique: a Pocket Manual ,
several chapters were revised and a new chapter has been added. In the chap-
ter on the abdominal wall and hernias, operating room strategies have been
updated and techniques of historical interest only have been removed. A major
addition to the chapter is a section on the anatomy and principles of component
separation. The chapter on the pancreas was brought up-to-date by Drs. Har-
rison S. Pollinger and Marty T. Sellers with the addition of laparoscopic pan-
createctomy. Any techniques that involve the use of the Harmonic Scalpel or
the LigaSure have been updated to refl ect those instruments. Much credit goes
to Dr. Monica A. Hum, who did a major revision of the longest chapter in this
book, Colon and Anorectum. This revamp involved extensive rewriting; I am
most appreciative of her thoughtful emendation.
In the liver chapter, Dr. Marty T. Sellers clarifi ed for all of us the segmental
anatomy of this organ. Dr. Eyal Ben-Arie made some very useful additions to
the treatment of the vascular system through vascular access procedures. Dr.
John G. Seiler III completely revised the carpal tunnel chapter. We have also
added an additional chapter, Miscellaneous Procedures, which includes sub-
clavian vein catheter insertion, chest tube insertion, and sural nerve and muscle

viii
biopsies. I am delighted that we were also able to include a new chapter on
Bariatric Surgery written by doctors Kevin McGill and Charles Procter. This
material is timely considering the ranks of the morbidly obese are increasing
daily.
We have tried again to present what are considered to be basic surgical
techniques. As more surgeons train in laparoscopic surgery, what were once
considered advanced laparoscopic techniques have now become basic laparo-
scopic techniques. It is for this reason that I felt compelled to ask Dr. Pollinger
to add the section on a laparoscopic pancreatectomy. Though many might con-
sider it to be an advanced technique, the actual mechanics of removing the dis-
tal pancreas laparoscopically do not differ from performing this procedure in
an open fashion. What is different is the placement of ports and the positioning
of the patient in concert with “advanced” laparoscopic instruments and devices.
Once again, if a suture is mentioned, it is only a suggestion. As we all know,
there are many alternatives to various suture materials.
Though the senior and principal author (JES) passed away in 2009 he contin-
ues to infl uence this and future editions of this text. He is sorely missed.
Atlanta , GA, USA Lee J. Skandalakis, MD, FACS
Preface to the Fourth Edition
ix
Acknowledgments
I am truly privileged to have been allowed to revise Surgical Anatomy and
Technique: a Pocket Manual . The associates at Springer Science+Business
Media have made everything easy. I appreciate the faith and confi dence that
Richard Hruska, Senior Editor of Clinical Medicine, placed in me by green-
lighting this project. Andy Kwan, Editorial Assistant, provided crucial assis-
tance at the beginning of the revision.
Originally, I had my doubts about allowing illustrations to be executed in-
house at Springer. I just did not see how it would be possible to create a fi n-

ished product without sitting down with the illustrators and explaining what
we needed, then having them give me something a few days later, etc. Con-
nie Walsh, Developmental Editor, worked with Carol Froman, Senior Editor,
Department of Surgery, Emory University School of Medicine, so that the
production of this book (including the illustrations) proceeded seamlessly.
Truthfully, if it were not for Carol there would not be a revised edition. Phyllis
Bazinet and Cynthia Painter provided editorial support at Emory for previous
editions.
I would like to thank Dr. Christian P. Larsen, who was the Chairman of the
Department of Surgery at Emory, for throwing his support behind this project
and allowing it to go forward. Emory University School of Medicine is in good
hands with Chris as the newly appointed Dean. I wish him the best.
Finally, I would like to thank Dr. Panagiotis G. Skandalakis for his great
ideas for this book and the wonderful illustrations that kick-started this entire
endeavor.

xi
Contents
Preface to the Fourth Edition vii
Acknowledgments ix
1 Skin, Scalp, and Nail 1
2 Neck 17
3 Breast 91
4 Abdominal Wall and Hernias 113
5 Diaphragm 217
6 Esophagus 253
7 Stomach 295
8 Duodenum 345
9 Pancreas 361
10 Small Intestine 405

11 Appendix 419
12 Colon and Anorectum 431
13 Liver 515
14 Extrahepatic Biliary Tract 565
xii
15 Spleen 605
16 Adrenal Glands 635
17 Vascular System 665
18 Uterus, Tubes, and Ovaries 689
19 Carpal Tunnel 703
20 Microsurgical Procedures 715
21 Miscellaneous Procedures 723
22 Bariatric Surgery 727
Index 743
Contents
xiii
Contributors
Eyal Ben-Arie, MD
Piedmont Heart Institute
Piedmont Hospital
Atlanta, GA, USA
J. Dewayne Colquitt, MD, FACS
Department of Surgery
Piedmont Hospital
Atlanta, GA, USA
Seth D. Force, MD
Department of Surgery
Emory University
School of Medicine
Atlanta , GA , USA

Monica A. Hum, MD, FACS, FASCRS
Atlanta Colorectal Surgery
Atlanta , GA , USA
Kevin McGill, MD, FACS
Buckhead Bariatrics
Piedmont Hospital
Atlanta, GA, USA
xiv
Daniel L. Miller
Department of Surgery
Emory University School of Medicine
Atlanta , GA , USA
Petros Mirilas, MD, MSurg, PhD
Centers for Surgical Anatomy & Technique
Emory University School of Medicine
Atlanta , GA , USA
Deepak G. Nair, MD
Sarasota Vascular Specialists
Sarasota, FL, USA
Harrison Scott Pollinger, DO, FACS
Piedmont Transplant Institute
Piedmont Hospital
Atlanta , GA , USA
Charles D. Procter, Jr., MD, FACS
Buckhead Bariatrics
Atlanta, GA, USA
John Gray Seiler, III, MD
Georgia Hand, Shoulder & Elbow
Atlanta, GA, USA
Lee J. Skandalakis, MD, FACS

Centers for Surgical Anatomy and Technique
Emory University School of Medicine
Piedmont Hospital
Atlanta, GA, USA
John E. Skandalakis, MD, FACS
Centers for Surgical Anatomy and Technique
Emory University School of Medicine
Piedmont Hospital
Atlanta, GA, USA
Marty T. Sellers, MD, MPH
Piedmont Transplant Institute
Piedmont Hospital
Atlanta , GA , USA
Contributors
xv
C. Daniel Smith, MD
Department of Surgery
Mayo Clinic
Jacksonville , FL , USA
Robert B. Smith, III, MD, FACS
Emory University School of Medicine
Atlanta, GA, USA
Ramon A. Suarez
Emory University School of Medicine
OB/GYN Education, Obstetrics and Gynecology
Piedmont Hospital
Atlanta , GA , USA
Contributors
1
L.J. Skandalakis and J.E. Skandalakis (eds.), Surgical Anatomy and Technique:

A Pocket Manual, DOI 10.1007/978-1-4614-8563-6_1,
© Springer Science+Business Media New York 2014
Anatomy
◼
SKIN AND SUBCUTANEOUS TISSUE (FIG. 1.1 )
The skin is composed of two layers: the epidermis (superfi cial) and the dermis
(under the epidermis). The thickness of the skin varies from 0.5 to 3.0 mm.
The epidermis is avascular and is composed of stratifi ed squamous epithe-
lium. It has a thickness of 0.04–0.4 mm. The palms of the hands and the soles
of the feet are thicker than the skin of other areas of the human body, such as
the eyelids.
The dermis has a thickness of 0.5–2.5 mm and contains smooth muscles and
sebaceous and sweat glands. Hair roots are located in the dermis or subcutaneous
tissue.
Vascular System
There are two arterial plexuses: one close to the subcutaneous fat (subdermal)
and the second in the subpapillary area. Venous return is accomplished by a sub-
papillary plexus to a deep plexus and then to the superfi cial veins. A lymphatic
plexus is situated in the dermis, which drains into the subcutaneous tissue.
Nervous System
For innervation of the skin, there is a rich sensory and sympathetic supply.
Remember:
✔ The epidermis is avascular.
✔ The dermis is tough, strong, and very vascular.
1
Skin, Scalp, and Nail
2

Figure 1.1. Structures of the skin.
✔ The superficial fascia is the subcutaneous tissue that blends with the

reticular layer of the dermis.
✔ The principal blood vessels of the skin lie in subdermal areas.
✔ The basement membrane is the lowest layer of the epidermis.
✔ The papillary dermis is the upper (superficial) layer of the dermis, just
below the basement membrane.
✔ The reticular dermis is the lower (deep) layer of the dermis, just above
the fat.
◼
SCALP
The following mnemonic device will serve as an aid in remembering the structure
of the scalp (see also Fig.
1.2 ).

1. Skin, Scalp, and Nail
3
Figure 1.2. Structures of the scalp.
Layers Description Observations
S Skin Hair, sebaceous glands
C Connective close
subcutaneous
tissue
Superfi cial layer avascular
deep layer vascular (internal
and external carotid lym-
phatic network). Nerves are
present (cervical, trigeminal)
Bleeding due to gap
and nonvascular
contraction
A Aponeurosis epi-

cranial, galea
Aponeurosis of the occipito-
frontalis muscle
Sensation present
L Loose connective
tissue
Emissary veins Dangerous zone = extra-
cranial and intracra-
nial infections
P Pericranium–
periosteum
No sensation. Heavy
fi xation at the suture
lines, so infection is
limited
Vascular System
Arterial Supply
The arteries of the scalp are branches of the internal and external carotid arter-
ies. The internal carotid in this area becomes the supratrochlear and supraor-
bital arteries (Fig. 1.3 ), both of which are terminal branches of the ophthalmic
artery. The external carotid becomes a large occipital artery and two small
arteries: the superfi cial temporal and the posterior auricular (see Fig.
1.3 ).
Abundant anastomosis takes place among all these arteries. All are superfi cial
to the epicranial aponeurosis.
Venous Drainage
Veins follow the arteries.

Scalp
4

Figure 1.3. Arterial blood supply shown on right . Nerve distribution shown on
left . Veins are not shown, but follow the arteries.
Lymphatic Drainage
The lymphatic network of the scalp is located at the deep layer of the dense
connective subcutaneous tissue just above the aponeurosis (between the
connective tissue and aponeurosis). The complex network has frequent anasto-
moses. The three principal zones are the frontal, parietal, and occipital.
Note:
✔ The blood supply of the scalp is rich. Arteries are anastomosed very
freely.
✔ The arteries and veins travel together in a longitudinal fashion.
✔ A transverse incision or laceration will produce a gap. Dangerous bleeding
will take place from both vascular ends due to nonretraction of the arter-
ies by the close, dense, connective layer.
✔ Always repair the aponeurotic galea to avoid hematoma under it.
✔ With elective cases (excision of sebaceous cysts, etc.), whenever possible,
make a longitudinal incision.
✔ Drain infections promptly. Use antibiotics to prevent intracranial infections
via the emissary veins.
✔ Shave 1–2cm around the site of the incision or laceration.
✔ After cleansing the partially avulsed scalp, replace it and débride the
wound; then suture with nonabsorbable sutures.

1. Skin, Scalp, and Nail
5
Figure 1.4. Nerves of the scalp and face.
✔ Use pressure dressing as required. Sutures may be removed in 3–5days.
✔ Be sure about the diagnosis. A very common sebaceous cyst could be an
epidermoid cyst of the skull involving the outer or inner table, or both,

with extension to the cerebral cortex. In such a case, call for a neurosur-
geon. The best diagnostic procedure is an AP and lateral film of the skull
to rule out bony involvement.
✔ Because the skin, connective tissue, and aponeurosis are so firmly inter-
connected, for practical purposes, they form one layer: the surgical zone
o f t h e s c a l p .
Nerves (Figs.
1.3 and 1.4 )
The following nerves innervate the scalp (their origins are in parentheses):
 Lesser occipital (second and third ventral nerves)
 Greater occipital (second and third dorsal nerves)
 Auriculotemporal (mandibular nerve)
 Zygomaticotemporal and zygomaticofacial (zygomatic [maxillary] nerve)

Scalp
6

Figure 1.5. Structures of the nail.
Figure 1.6. Nail bed.
 Supraorbital (ophthalmic nerve)
 Supratrochlear (ophthalmic nerve)
◼
NAIL
The anatomy of the nail may be appreciated from Figs. 1.5 and 1.6 .


1. Skin, Scalp, and Nail
7
Figure 1.7. Incision for cyst removal.
Figure 1.8. Dissection to subcutaneous tissue.

Technique
◼
BENIGN SKIN LESIONS (FIGS. 1.7 , 1.8 , AND 1.9 )
Benign skin lesions fall into several groups. Cystic lesions include epidermal
inclusion cysts, sebaceous cysts, pilonidal cysts, and ganglia. Another group
includes warts, keratoses, keloids, hemangiomatas, arteriovenous malforma-
tions, glomus tumors, and capillary malformations.
A third group includes decubitus ulcers, hidradenitis suppurativa, and burns.
Junctional, compound, and intradermal nevi and malignant lentigos compose
another group.
Step 1. For a cyst, make an elliptical incision. For a noncystic lesion, be sure
to include approximately 2.0 mm of tissue beyond the lesion when
making the elliptical incision.


Benign Skin Lesions
8

Figure 1.9. Excision of cyst.
Step 2. Place the incision along Langer’s lines (Kraissl’s) and perpendicular
to the underlying muscles, but seldom parallel to the underlying
muscle fibers.
Step 3. Dissect down to the subcutaneous tissue but not to the fascia. Avoid
breaking the cyst, if possible.
Step 4. Handle the specimen with care by not crushing the skin or the lesion.
Step 5. Close in two layers. Undermine the skin as required. Remember that
the dermis is the strongest layer. For the dermis, use absorbable syn-
thetic interrupted suture 3–0 (undyed Vicryl); for the epidermis, use
5–0 Vicryl subcuticular continuous and reinforce with Steri- strips or
skin glue. It is acceptable to use 6–0 interrupted nylon sutures very

close to the edges of the skin and close to each other.
Step 6. Remove interrupted sutures in 8–10 days and again reinforce with
Steri-strips, especially if the wound is located close to a joint. For
most cases, a nylon epidermal continuous suture may be left in for
2 weeks without any problems.
◼
MALIGNANT SKIN LESIONS (FIGS. 1.10 AND 1.11 )
Malignant skin lesions include melanoma, basal cell carcinoma, squamous cell
carcinoma, sweat gland carcinoma, fi brosarcoma, hemangiopericytoma, Kapo-
si’s sarcoma, and dermatofi brosarcoma protuberans.
When removing the lesion, 1.0 cm of healthy skin around it must also be
removed, as well as the subcutaneous layer.
Remember:
✔ Send specimen to the lab for frozen section of the lesion and margins.
✔ Prior to surgery explain to the patient about scarring, recurrence, mar-
gins, etc.
✔ If the case involves a large facial lesion, obtain the advice of a plastic
s u r g e o n .

1. Skin, Scalp, and Nail
9
Figure 1.10. Incision for removal of malignant skin lesion.
Figure 1.11. Resection of malignant skin lesion.
Melanoma
Staging of Malignant Melanoma (After Clark)
Level I. Malignant cells are found above the basement membrane.
Level II. Malignant cells infiltrate into the papillary dermis.
Level III. Malignant cells fill the papillary layer and extend to the junction
of the papillary and reticular layers but do not enter the reticular
layer.

Level IV. Malignant cells extend into the reticular layer of the dermis.
Level V. Malignant cells extend into the subcutaneous tissue.
Tumor Thickness (After Breslow)
Level I. Tumor thickness less than 0.76 mm
Level II. Tumor thickness 0.76–1.5 mm
Level III. Tumor thickness 1.51–2.25 mm
Level IV. Tumor thickness 2.26–3 mm
Level V. Tumor thickness greater than 3 mm
Controversy
Surgical oncologists differ in their approach to treatment. Some advocate
regional lymphadenectomy when there is clinical adenopathy and no distal
metastasis. Others believe in prophylactic lymph node excision.


Malignant Skin Lesions