oxford handook of clinical surgery 4th ed

OXFORD MEDICAL PUBLICATIONS
Oxford Handbook of
Clinical Surgery
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1
Oxford Handbook of
Clinical
Surgery
Fourth edition
Edited by
Greg McLatchie
Consultant Surgeon,
Hartlepool General Hospital,
Hartlepool, UK
Neil Borley
Consultant Colorectal Surgeon,
Cheltenham General Hospital,
Cheltenham, UK
Joanna Chikwe
Associate Professor, Department of Cardiothoracic
Surgery, Mount Sinai Medical Center,
New York, United States
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press, 2013
The moral rights of the authors have been asserted

First Edition published 1990
Second Edition published 2002
Third Edition published 2007
Fourth Edition published 2013
Impression: 1
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stored in a retrieval system, or transmitted, in any form or by any means,
without the prior permission in writing of Oxford University Press,
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You must not circulate this book in any other binding or cover and you must
impose the same condition on any acquirer
British Library Cataloguing in Publication Data
Data available
ISBN 978–0–19–969947–6 (fl exicover: alk.paper)
Printed in China by
C&C Offset Printing Co. Ltd.
Oxford University Press makes no representation, express or implied, that the drug
dosages in this book are correct. Readers must therefore always check the product
information and clinical procedures with the most up-to-date published product
information and data sheets provided by the manufacturers, and the most recent
codes of conduct and safety regulations. The authors and the publishers do not
accept responsibility or legal liability for any errors in the text, or for the misuse or
misapplication of material in this work. Except where otherwise stated, drug dosages
and recommendations are for the non-pregnant adult who is not breastfeeding.
v
Preface to the fourth
edition

Sometimes we have to look backward to look forward. Since 1990, sur-
gery has witnessed cataclysmic changes. In our Trust, the fi rst laparoscopic
cholecystectomy was performed in 1992, and has now become the pro-
cedure of choice for most gall bladder disease and many other surgical
operations in the western world. With the expansion of laparoscopic
surgery, we have encountered a whole new range of complications with
an escalation in the demise of general surgery as the result of hyperspe-
cialization. There are many surgical trainees who have scant experience
of open surgery and who have, due to European directives, limited time
exposure to surgical procedures. In fact, most technical training is now
obtained from emergency on call such that a new speciality of emergency
surgery is developing. A recent British Medical Journal (BMJ) article recom-
mended a training programme for surgeons wishing to work in remote
and rural surgery—not only in the Developing World, but in remote and
isolated communities in the United Kingdom! General surgery may largely
have gone, but it should not be forgotten. Most countries in the world do
not have access to these recent innovations and there is still a case in the
developed world for experience in open and general surgery to be incor-
porated in the formal training programmes of junior surgeons.
G. R. McLatchie
Hartlepool, September 2012
vi
Preface to the third
edition
This, the third edition of the Oxford Handbook of Clinical Surgery, refl ects
the changes which have occurred in general surgery over the 17 years
since the fi rst edition was published.
Firstly, we have recruited the services of two new editors, a stark con-
trast to the original, which was written by a single author with the assis-
tance of a surgical registrar.

Secondly, each chapter has been written by a specialist consultant or
registrar in the subject and, therefore, presents a modern, state-of-the-art
treatise on each topic.
Again, each condition is covered in the original two-page format with
blank pages for accompanying notes.
I am particularly grateful for the commitment that Jo Chikwe and Neil
Borley have made, and also wish to thank staff at Oxford University Press
for their support and patience. I am also grateful for the contribution and
support given by many colleagues.
G. R. McLatchie
Hartlepool, March 2007
vii
Preface to the fi rst
edition
The idea of this book was fi rst suggested by Mr Gordon McBain, consult-
ant surgeon at the Southern General Hospital, Glasgow. We have received
considerable support from the staff of Oxford University Press, and are
also indebted to Mr J. Rhind and Dr J. Daniel for their contributions and
our surgical teachers, especially Mr J. S. F. Hutchison, Mr M. K. Browne,
Mr J. Neilson, Mr D. Young, Mr A. Young, and the late Mr I. McLennan
whose practical advice and anecdotes pepper the pages….
G. R. McLatchie
S. Parameswaran
1990
viii
Dedications
For Ross, Cameron, Ailidh, Claire, and Calum
GRM
For Alexander, Christopher, and Jennifer
NB

Acknowledgements
We are grateful to the support of our colleagues and Oxford University
Press and to Mrs Pamela Lines for her diligent support in the fi nal editing
of the manuscript.
ix
Contents
Detailed contents xi
Contributors xxiii
Symbols and abbreviations xxv
1 Good surgical practice
1
2 Principles of surgery
23
3 Surgical pathology
141
4 Practical procedures
185
5 Head and neck surgery
221
6 Breast and endocrine surgery
239
7 Upper gastrointestinal surgery
271
8 Liver, pancreatic, and biliary surgery
311
9 Abdominal wall
335
10 Urology
353
11 Colorectal surgery

391
12 Paediatric surgery
423
13 Paediatric orthopaedic
457
14 Major trauma
477
15 Orthopaedic surgery
489
16 Plastic surgery
589
17 Cardiothoracic surgery
619
18 Peripheral vascular disease
641
19 Transplantation
675
20 Surgery in tropical diseases
701
21 Common operations
729
22 Eponymous terms and rarities
757
Anatomy and physiology key revision points index 777
Index 779
This page intentionally left blank
xi
Detailed contents
Contributors xxiii
Symbols and abbreviations xxv

1 Good surgical practice 1
Duties of a doctor 2
Communication skills 4
Evidence-based surgery 6
Critical appraisal 10
Audit 12
Consent 14
Death 16
End-of-life issues 18
Clinical governance 20
2 Principles of surgery 23
Terminology in surgery 24
History taking and making notes 26
Common surgical symptoms 28
Examination and investigation of the patient:
Evaluation of breast disease 30
Evaluation of the neck 32
Evaluation of the abdomen 34
Abdominal investigations 36
Evaluation of pelvic disease 38
Evaluation of peripheral vascular disease 40
Evaluation of the skin and subcutaneous tissue disease 42
Surgery at the extremes of age 44
Day case and minimally invasive surgery 46
Preoperative care:
Surgery in pregnancy 48
Surgery and the contraceptive pill 50
Surgery in endocrine disease 52
xii
DETAILED CONTENTS

Surgery and heart disease 54
Surgery and respiratory disease 58
Surgery in renal and hepatic disease 60
Surgery in neurological disease 62
Pre-optimization of the patient:
Fluid optimization 64
Nutrition in surgical patients 66
Enhanced recovery after surgery 68
Perioperative care:
Getting the patient to theatre 70
Prophylaxis—antibiotics and thromboprophylaxis 72
In-theatre preparation 74
Positioning the patient 76
Sterilization, disinfection, and antisepsis 78
Scrubbing up 79
Surgical instruments 80
Incisions and closures 82
Drains 83
Stomas 84
Knots and sutures 86
Post-operative:
Post-operative management 88
Drain management 90
Fluid management 92
Acid–base balance 94
Blood products and procoagulants 96
Transfusion reactions 98
Shock 100
Post-operative haemorrhage 102
Wound emergencies 104

Cardiac complications 106
Respiratory complications 108
Renal complications 110
Urinary complications 112
Gastrointestinal complications 114
Neurological complications 116
Haematological complications 118
Deep venous thrombosis and pulmonary embolism 120
Risk scoring 122
xiii
DETAILED CONTENTS
Critical care 124
Commonly used terms in ITU 126
Invasive monitoring 128
Ventilation and respiratory support 130
Circulatory support 132
Renal support 134
Enteral support 136
Sepsis, SIRS, MODS, and ALI 138
3 Surgical pathology 141
Cellular injury 142
Infl ammation 144
Wound healing 146
Ulcers 148
Cysts, sinuses, and fi stulas 150
Atherosclerosis 152
Thromboembolic disease 154
Gangrene and capillary ischaemia 158
Tumours 160
Carcinogenesis 162

Screening 164
Grading and staging 168
Tumour markers 170
Surgical microbiology 172
Surgically important organisms 174
Soft tissue infections 176
Blood-borne viruses and surgery 178
Bleeding and coagulation 180
Anaemia and polycythaemia 182
4 Practical procedures 185
Endotracheal intubation 186
Cardioversion 188
Defi brillation 190
Venepuncture 192
Intravenous cannulation 194
Arterial puncture and lines 196
Insertion of central venous catheter 198
xiv
DETAILED CONTENTS
Chest drain insertion 200
Management of chest drains 202
Pericardiocentesis 204
Cricothyroidotomy 206
Nasogastric tube insertion 208
Urethral catheterization 210
Suprapubic catheterization 212
Paracentesis abdominis 214
Rigid sigmoidoscopy 216
Local anaesthesia 218
Intercostal nerve block 220

5 Head and neck surgery 221
Thyroglossal cyst, sinus, and fi stula 222
Branchial cyst, sinus, and fi stula 224
Salivary calculi 226
Acute parotitis 228
Salivary gland tumours 230
Head and neck cancer 232
Facial trauma 234
Neck space infections 236
6 Breast and endocrine surgery 239
Breast cancer 240
Surgical treatment of breast cancer 242
Breast cancer screening 244
Benign breast disease 246
Acute breast pain 248
Goitre 250
Thyrotoxicosis 252
Thyroid tumours—types and features 254
Thyroid tumours—diagnosis and treatment 256
Post-thyroid surgery emergencies 258
Primary hyperparathyroidism 260
Multiple endocrine neoplasia 262
Cushing’s syndrome 264
Conn’s syndrome 266
Phaeochromocytoma 268
xv
DETAILED CONTENTS
7 Upper gastrointestinal surgery 271
Upper gastrointestinal endoscopy 272
Oesophageal motility disorders 274

Pharyngeal pouch 276
Hiatus hernia 278
Gastro-oesophageal refl ux disease 280
Oesophageal tumours 282
Peptic ulcer disease 284
Gastric tumours 286
Chronic intestinal ischaemia 288
Surgery for morbid obesity 290
Small bowel tumours 292
Acute haematemesis 294
Acute upper GI perforation 296
Acute appendicitis 298
Acute peritonitis 300
Acute abdominal pain 302
Gynaecological causes of lower abdominal pain 306
Intra-abdominal abscess 308
8 Liver, pancreatic, and biliary surgery 311
Jaundice—causes and diagnosis 312
Jaundice—management 314
Gall bladder stones 316
Common bile duct stones 318
Chronic pancreatitis 320
Portal hypertension 322
Cirrhosis of the liver 324
Pancreatic cancer 326
Cancer of the liver, gall bladder, and biliary tree 328
Acute variceal haemorrhage 330
Acute pancreatitis 332
9 Abdominal wall 335
Abdominal wall hernias 336

Inguinal hernia 338
Femoral hernia 340
Umbilical and epigastric hernias 342
xvi
DETAILED CONTENTS
Incisional hernias 344
Other types of hernia 346
Rectus sheath haematoma 347
Groin disruption 348
Acute groin swelling 350
10 Urology 353
Symptoms and signs in urology 354
Investigations of urinary tract disease 356
Urinary tract stones 358
Obstruction of the ureter 360
Benign prostatic hyperplasia 362
Stricture of the urethra 364
Scrotal swellings 366
Disorders of the foreskin 368
Common conditions of the penis 370
Erectile dysfunction 372
Adenocarcinoma of the kidney 374
Transitional cell tumours 376
Adenocarcinoma of the prostate 378
Carcinoma of the penis 380
Testicular tumours 382
Haematuria 384
Acute urinary retention (AUR) 386
Acute testicular pain 388
11 Colorectal surgery 391

Ulcerative colitis 392
Crohn’s disease 394
Other forms of colitis 396
Colorectal polyps 398
Colorectal cancer 400
Restorative pelvic surgery 402
Minimally invasive colorectal surgery 403
Diverticular disease of the colon 404
Rectal prolapse 406
Pilonidal sinus disease 408
Fistula-in-ano 410
Haemorrhoids 412
xvii
DETAILED CONTENTS
Acute anorectal pain 414
Acute rectal bleeding 416
Acute severe colitis 418
Post-operative anastomotic leakage 420
12 Paediatric surgery 423
Principles of managing paediatric surgical cases 424
Acute abdominal emergencies—overview 426
Oesophageal atresia 428
Pyloric stenosis 430
Malrotation and volvulus 432
Intussusception 434
Hirschsprung’s disease 436
Rare causes of intestinal obstruction 438
Abdominal wall defects 440
Necrotizing enterocolitis (NEC) 442
Inguinal hernia and scrotal swellings 444

Other childhood hernias 446
Prepuce (foreskin) and circumcision 448
Undescended testis 450
Solid tumours of childhood 452
Neck swellings 454
13 Paediatric orthopaedic 457
Developmental dysplasia of the hip (DDH) 458
Slipped upper femoral epiphysis (SUFE) 460
The limping child 462
The child with a fracture 464
Non-accidental injury (NAI) 466
Legg–Calvé–Perthes disease 468
Motor development 470
Club foot or congenital talipes equinovarus (CTEV) 471
Flat feet (pes planus) 472
The osteochondritides 474
14 Major trauma 477
Management of major trauma 478
Thoracic injuries 480
xviii
DETAILED CONTENTS
Abdominal trauma 482
Vascular injuries 484
Head injuries 486
15 Orthopaedic surgery 489
Examination of a joint 490
Examination of the limbs and trunk 492
Fracture healing 494
Reduction and fi xation of fractures 498
The skeletal radiograph 502

Injuries of the phalanges and metacarpals 504
Wrist injuries 508
Fractures of the distal radius and ulna 510
Fractures of the radius and ulnar shaft 512
Fractures and dislocations around the elbow in children 514
Fractures of the humeral shaft and elbow in adults 518
Dislocations and fracture dislocations of the elbow 522
Fractures around the shoulder 524
Dislocations of the shoulder region 526
Fractures of the ribs and sternum 530
Fractures of the pelvis 532
Femoral neck fractures 536
Femoral shaft fractures 538
Fractures of the tibial shaft 540
Fractures of the ankle 544
Fractures of the tarsus and foot 546
Injuries and the spinal radiograph 550
Spinal injuries 554
Acute haematogenous osteomyelitis 558
Chronic osteomyelitis 560
Septic arthritis 562
Peripheral nerve injuries 564
Brachial plexus injuries 566
Osteoarthrosis (osteoarthritis) 568
Carpal tunnel syndrome 570
Ganglion 572
Bone tumours 574
Low back pain 578
Paget’s disease (osteitis deformans) 582
The great toe 584

xix
DETAILED CONTENTS
Arthroplasty 586
Useful reading 588
16 Plastic surgery 589
Suturing wounds 590
Skin grafts 594
Surgical fl aps 596
Management of scars 598
Excision of simple cutaneous lesions 600
Skin cancer 602
Burns: assessment 604
Burns: management 606
Soft tissue hand injuries 610
Hand infections 612
Dupuytren’s disease 614
Breast reduction 616
Breast augmentation 617
Breast reconstruction 618
17 Cardiothoracic surgery 619
Basics 620
Principles of cardiac surgery 622
Coronary artery disease 626
Valvular heart disease 628
Cardiothoracic ICU 630
Lung cancer 632
Pleural effusion 634
Pneumothorax 636
Mediastinal disease 638
18 Peripheral vascular disease 641

Acute limb ischaemia 642
Chronic upper limb ischaemia 644
Chronic lower limb ischaemia 647
Intermittent claudication 648
Critical limb ischaemia 650
Aneurysms 652
Ruptured abdominal aortic aneurysm 654
xx
DETAILED CONTENTS
Vascular developmental abnormalities 656
Carotid disease 658
The diabetic foot 660
Amputations 662
Vasospastic disorders 664
Varicose veins 666
Deep venous thrombosis 668
Thrombolysis 670
Complications in vascular surgery 672
19 Transplantation 675
Basic transplant immunology 676
Immunosuppression and rejection 678
Transplant recipients 682
Transplant donors 684
Heart and lung transplantation 690
Kidney transplantation 692
Pancreas and islet transplantation 694
Liver transplantation 696
Small bowel transplantation 698
20 Surgery in tropical diseases 701
Medicine in the tropics 702

Typhoid 704
Amoebiasis and amoebic liver abscess 706
Anaemias in the tropics 708
Malaria 710
Schistosomiasis (bilharziasis) 712
Filariasis 714
Hydatid disease 716
Ascariasis 718
Leishmaniasis 719
Trypanosomiasis 720
Tuberculosis in the tropics 722
Leprosy (‘Hansen’s disease’) 724
Guinea worm infestation 726
Threadworms 727
Mycetoma (madura foot) 728
xxi
DETAILED CONTENTS
21 Common operations 729
Diagnostic laparoscopy 730
Principles of laparotomy 732
Cholecystectomy 734
Appendicectomy 736
Inguinal hernia repair 738
Perforated peptic ulcer repair 740
Haemorrhoid surgery 742
Pilonidal sinus excision (Bascom II) 744
Femoral embolectomy 746
Right hemicolectomy 748
Stoma formation 750
Wide local excision—breast 752

Below knee amputation 754
22 Eponymous terms and rarities 757
Anatomy and physiology key revision points index 777
Index 779
This page intentionally left blank
xxiii
Contributors
Alex Acornley
Consultant Orthopaedic
Surgeon,
Airedale Hospital NHS
Foundation Trust, West
Yorkshire, UK
Anil Agarwal
Consultant General and Colorectal
Surgeon,
North Tees and Hartlepool NHS
Trust, University Hospital of
Hartlepool, UK
Khalid A. Al-Hureibi
Specialist Registrar,
Department of General Surgery,
Lister Hospital, Stevenage, UK
John Asher
Consultant Transplant Surgeon,
Transplant Unit, Western
Infi rmary, Glasgow, UK
David Chadwick
Consultant Urological Surgeon,
The James Cook University

Hospital, Middlesbrough, UK
Lucy Cogswell
Specialist Registrar,
Department of Plastic &
Reconstructive Surgery, John
Radcliffe Hospital, Oxford, UK
J. H. Dark
Consultant Cardiothoracic
Surgeon,
Freeman Hospital, Newcastle upon
Tyne, UK
Richard P. Jeavons
Specialist Registrar,
Trauma and Orthopaedics
(Northern Deanery), Department
of Trauma and Orthopaedics,
University Hospital of North Tees,
Stockton, UK
Vijay Kurup
Consultant Breast and Endocrine
Surgeon,
University Hospital of North Tees,
Stockton on Tees, UK
Jamie Lyall
Consultant Head and Neck
Surgeon (Maxillofacial),
Surgical Division, James Cook
University Hospital Trust,
Middlesbrough, Queen Margaret
Hospital, Dunfermline, UK

Alan Middleton
Consultant Orthopaedic Surgeon,
Department of Hand and Wrist
Surgery, University Hospital of
North Tees, Stockton, UK
Rob Milligan
ST3 General Surgery, Northern
Deanery, UK
Sandrasekeram
Parameswaran
General Surgeon,
Cold Lake Healthcare Centre,
Visiting Surgeon, Canadian forces
base, 4 Wing, Cold Lake, Alberta,
Canada
xxiv
CONTRIBUTORS
Lakshmi Parameswaran
Senior House Offi cer,
Mater Misericordiae University
Hospital, Dublin, Ireland
Saumitra Rawat
Consultant Surgeon,
Macclesfi eld District General
Hospital, UK
Andreas Rehm
Consultant Paediatric Orthopaedic
and Trauma Surgeon,
Depatment of Orthopaedic and
Trauma Surgery, Addenbrooke’s

Hospital, Cambridge University
Hospitals NHS Trust, Cambridge,
UK
David Talbot
Consultant Transplant and
Hepatobiliary Surgeon,
Transplant Institute, Freeman
Hospital, Newcastle. Visiting
Professor, University of Sunderland.
Reader, University of Newcastle
upon Tyne, UK
Mark Whyman
Consultant General and Vascular
Surgeon,
Department of Surgery,
Cheltenham General Hospital,
Cheltenham, UK