Essentials of General Surgery 5th Ed 2

Essentials of
General Surgery
FIFTH EDITION

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About the Cover:
Portrait of Dr. Samuel D. Gross (The Gross Clinic)
Thomas Eakins
Oil on canvas, 1875
8 feet × 6 feet 6 inches (243.8 × 198.1 cm)
Philadelphia Museum of Art: Gift of the Alumni Association to Jefferson Medical College in 1878 and purchased
by the Pennsylvania Academy of the Fine Arts and the Philadelphia Museum of Art in 2007 with the generous
support of more than 3,600 donors, 2007

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Essentials of
General Surgery
FIFTH EDITION

Senior Editor
Peter F. Lawrence, MD

Wiley Barker Endowed Chair in Vascular Surgery
Director, Gonda (Goldschmied) Vascular Center
David Geffen School of Medicine at UCLA
Los Angeles, California

Editors
Richard M. Bell, MD
Professor of Surgery
University of South Carolina School of Medicine
Columbia, South Carolina

Merril T. Dayton, MD
Professor and Chairman
Department of Surgery
State University of New York at Buffalo
Buffalo, New York

Questions Editor
James C. Hebert, MD
Albert G. Mackay and H. Gordon Page Professor of Surgery
University of Vermont College of Medicine
Burlington, Vermont

Content Editor
Mohammed I. Ahmed, MBBS, MS (Surgery)
Department of Surgery
Affiliated Institute for Medical Education
Chicago, Illinois

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Acquisitions Editor: Susan Rhyner
Product Manager: Angela Collins
Freelance Editor: Catherine Council
Marketing Manager: Joy Fisher-Williams
Vendor Manager: Bridgett Dougherty
Design & Art Direction: Teresa Mallon, Doug Smock
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Copyright © 2013, 2006 Lippincott Williams & Wilkins, a Wolters Kluwer business.
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Printed in China
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by
any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval
system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews.
Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered
by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square,
2001 Market Street, Philadelphia, PA 19103, via email at , or via website at lww.com (products and services).
Library of Congress Cataloging-in-Publication Data
Essentials of general surgery / [edited by] Peter F. Lawrence. — 5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-7817-8495-5
I. Lawrence, Peter F.

[DNLM: 1. Surgical Procedures, Operative. WO 500]
617—dc23
2011051080
DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the
authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents
of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner;
the clinical treatments described and recommended may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in
accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes
in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to
check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is
particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited
use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device
planned for use in their clinical practice.
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Preface
“What do all medical students need to know about surgery to
be effective clinicians in their chosen fields?”
The primary responsibility of medical schools is to educate
medical students to become competent clinicians. Because

most physicians practice medicine in a nonacademic setting,
clinical training is paramount. The 3rd year of medical school,
which focuses on basic clinical training, is the foundation
for most physicians’ clinical training. These realities do not
diminish the other critical functions of medical school, including basic science education for MD and PhD candidates, basic
and clinical research, and the education of residents and practicing physicians. However, the central role of providing clinical education for medical students cannot be overemphasized.
The education of students, residents, and practicing surgeons should be a continuum, although it may seem fragmented at times to students. Because of the length of time
needed to completely train surgeons, surgical residents remain
“students” for 3 to 9 years beyond medical school. As a result
of this extensive training period, most medical schools have
large numbers of surgical residents, and resident training
makes up the bulk of their educational efforts. Student education is part of the continuum that starts in the 1st or 2nd year of
medical school, continues through residency, and never ends,
because continuing education and lifelong learning are essential for all physicians.

NOT JUST FOR SURGEONS
This textbook and its companion volume, Essentials of Surgical Specialties, were produced to start that continuum of
education for medical students, and to focus on medical students who are not planning a surgical career. We believe that
all physicians need to have a fundamental understanding of
the options provided by surgery to be competent, so the book
asks the question, “What do all medical students need to know
about surgery to be effective clinicians in their chosen field?”
Rather than using traditional textbook-writing techniques to
address this question, members of the Association for Surgical Education (ASE), an organization of surgeons dedicated to
undergraduate surgical education, have conducted extensive
research to define the content and skills needed for an optimal medical education program in surgery. Somewhat surprisingly, there has been consensus among practicing surgeons,
internists, and even psychiatrists about the knowledge and
skills in surgery needed by all physicians. The information
from this research has become the basis for this textbook. The

research process also identified technical skills, such as suturing skin, that should be mastered by all physicians and that are
best taught by surgeons.

FIFTH EDITION ENHANCEMENTS
The fifth edition of this textbook has continued the approach
that has resulted in its use by many medical students in the
United States, in Canada, and throughout the world:
1. This edition has been extensively revised to provide the
most current and up-to-date information on general surgery. Additionally, the entire interior has been refreshed
and is now full-color for an even more enjoyable reading
experience.
2. Our authors are surgeons devoted to teaching medical students and understand the appropriate depth of knowledge
for a 3rd-year student to master.
3. We do not attempt to provide an encyclopedia of surgery.
We include only information that 3rd- and 4th-year students need to know—and explain it well.
4. We intentionally limit the length of each section, so that it
can reasonably be read during the clerkship.
5. Through problem solving, clinical cases, and sample exam
questions, we provide numerous opportunities to practice
and test new knowledge and skills, as well as features to aid
in review and retention. We believe that this approach best
prepares students to score high on the National Board of
Medical Examiners surgery shelf exam and also prepares
them for residency training.

PEDAGOGICAL FEATURES
•
•
•
•

•

Learning objectives
Full-color art program
New and updated tables, algorithms, and charts
New Appendix including 40 four-color burn figures
Sample questions, answers, and rationales for every chapter

MORE TOOLS ONLINE
•
•
•
•
•

Bonus chapters
Question bank
Patient management problems and oral exam questions
Glossary
Fully searchable e-book
v

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vi

PREFACE

• Chapter outlines
• Image bank

COMPANION TEXTBOOK
A companion textbook on the surgical specialties, Essentials
of Surgical Specialties, is based on an approach similar to that
of Essentials of General Surgery and trains you in specialty
and subspecialty fields of surgery. This text is separate from
Essentials of General Surgery because some medical schools
teach the specialties in the 3rd year and others teach them in
the 4th year. Students who complete both the general surgery

Lawrence_FM.indd vi

and specialty programs and practice oral and multiple-choice
questions will acquire the essential surgical knowledge and
problem-solving skills that all physicians need.

SUCCESS!
You are entering the most exciting and dynamic phase of your
professional life. This educational package is designed to help
you achieve your goal of becoming an adept clinician and
developing lifelong learning skills. It will also help you get
into the residency of your choice. Best wishes for success in
your endeavor.

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Acknowledgments
Many members of the Association for Surgical Education
(ASE) provided advice and expertise in starting the first edition of this project nearly 25 years ago. Since that time, ASE
members have volunteered to assist in writing chapters and
editing the textbook. At its annual meetings, the ASE provides
an excellent forum to discuss and test ideas about the content
of the surgical curriculum and methods to teach and evaluate
what has been learned.

We would like to thank our student editors, Tamera Beam
and Jason Rogers, who reviewed many of the chapters and provided valuable student perspective on the material presented.
We would like to extend our thanks to Cathy Council, our editor in Salt Lake City, who coordinated all components of this
project. I also would like to thank our editors at Lippincott
Williams & Wilkins, Susan Rhyner, Jennifer Verbiar, and
Angela Collins.

vii

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Contributors
Mohammed I. Ahmed, MBBS, MS (Surgery)

Clinical Instructor in Surgery
Affiliated Institute for Medical Education
Chicago, Illinois

Richard M. Bell, MD
Professor of Surgery
University of South Carolina School of Medicine
Columbia, South Carolina

James Alexander, MD
Associate Professor of Surgery
Vice Chief for Education
Cooper Medical School of Rowan University
Camden, New Jersey

Juliane Bingener, MD
Associate Professor of Surgery
Mayo Clinic
Rochester, Minnesota

Adnan A. Alseidi, MD
Program Director Surgery Residents
Co-Director HPB Fellowship Program
Hepato-Pancreato-Biliary Surgery Division
Virginia Mason Medical Center
Seattle, Washington
Gina L. Andrales, MD
Associate Professor of Surgery
Dartmouth Medical School
Lebanon, New Hampshire

David Antonenko, MD
Professor of Surgery
University of North Dakota School of Medicine and Health
Sciences
Grand Forks, North Dakota
Lecia Apantaku, MD
Associate Professor of Surgery
Chicago Medical School
Rosalind Franklin University of Medicine and Science
North Chicago, Illinois
Tracey D. Arnell, MD
Assistant Professor of Surgery
Columbia University College of Physicians & Surgeons
Memorial Sloan-Kettering Cancer Center
New York, New York
Dimitrios Avgerinos, MD
Clinical Fellow
Department of Cardiothoracic Surgery
New York Presbyterian – Weill Cornell Medical Center
New York, New York

H. Scott Bjerke, MD
Clinical Professor of Surgery
Kansas City University of Medicine and Biosciences
Clinical Associate Professor of Surgery at UMKC
Kansas City, Missouri
Karen R. Borman, MD
Clinical Professor (Adjunct), Surgery
Temple University School of Medicine
Senior Associate Program Director, General Surgery Residency

Abington Memorial Hospital
Abington, Pennsylvania
Mary-Margaret Brandt, MD
Trauma Director and Surgical Intensivist
St. Joseph Mercy Hospital
Ann Arbor, Michigan
Karen Brasel, MD, MPH
Professor of Surgery, Bioethics and Medical Humanities
Medical College of Wisconsin
Milwaukee, Wisconsin
Melissa Brunsvold, MD
Assistant Professor of Surgery
University of Minnesota
Minneapolis, Minnesota
Kenneth W. Burchard, MD
Professor of Surgery
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
Arnold Byer, MD
Clinical Professor of Surgery
UMDNJ—New Jersey Medical School
Newark, New Jersey

Melinda Banister, MD
General Surgeon
Lubbock, Texas
ix

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x

CONTRIBUTORS

Michael Cahalane, MD
Associate Professor of Surgery
Harvard Medical School
Acting Chief, Division of Acute Care Surgery
Beth Israel Deaconess Medical Center
Boston, Massachusetts

Gail Cresci, PhD, RD
Research Staff
Digestive Disease and Lerner Research Institutes
Departments of Gastroenterology and Pathobiology
The Cleveland Clinic
Cleveland, Ohio

Jeannette Capella, MD
Medical Director, Trauma/Surgical ICU
Assistant Medical Director, Trauma
Altoona Regional Medical Center
Altoona, Pennsylvania

Brian J. Daley, MD
Professor, Department of Surgery
University of Tennessee Medical Center at Knoxville

Knoxville, Tennessee

Frederick D. Cason, MD
Associate Professor
Residency Program Director
Section of Gastrointestinal and Minimally Invasive Surgery
Department of Surgery
The University of Toledo College of Medicine
Toledo, Ohio
William C. Chapman, MD
Professor and Chief, Section of Transplantation
Chief, Division of General Surgery
Washington University in St. Louis
St. Louis, Missouri
Gregory S. Cherr, MD
Associate Professor of Surgery
Chief of Vascular Surgery, Buffalo General Hospital
Director, Medical Student Surgical Education
Associate Program Directory, General Surgery Program
State University of New York at Buffalo
Buffalo, New York
Jeffrey G. Chipman, MD
Associate Professor of Surgery
University of Minnesota Medical School
Minneapolis, Minnesota
Nicholas P.W. Coe, MD
Professor of Surgery
Tufts University School of Medicine
Department of Surgery
Baystate Medical Center

Springfield, Massachusetts
Annesley W. Copeland, MD
Assistant Professor of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland

Dale A. Dangleben, MD
Associate Surgery Residency Program Director
Lehigh Valley Health Network
Allentown, Pennsylvania
Debra A. DaRosa, PhD
Professor of Surgery
Vice Chair for Education
Northwestern University Feinberg School of Medicine
Chicago, Illinois
Merril T. Dayton, MD
Professor and Chairman
Department of Surgery
State University of New York at Buffalo
Buffalo, New York
Chris de Gara, MBBS, MS
Professor of Surgery
Director, Division of General Surgery
Department of Surgery, University of Alberta
Director, Department of Surgical Oncology
Cross Cancer Institute, Alberta Cancer Board
Edmonton, Alberta, Canada
Matthew O. Dolich, MD
Professor and Director, General Surgery Residency Program
University of California, Irvine

Orange, California
Serge Dubé, MD
Professor of Surgery
Faculty of Medicine
University of Montreal
Montreal, Quebec, Canada
Gary L. Dunnington, MD
J. Roland Folse Professor and Chair of Surgery
Southern Illinois University School of Medicine
Springfield, Illinois

Julia Corcoran, MD
Associate Professor of Surgery
Feinberg School of Medicine
Northwestern University
Chicago, Illinois

Virginia A. Eddy, MD
Director, Undergraduate Surgical Education
Maine Medical Center
Portland, Maine

Wendy R. Cornett, MD
Associate Professor of Clinical Surgery
University of South Carolina School of Medicine—Greenville
Greenville, South Carolina

Michael Edwards, MD
Associate Professor of Surgery
Georgia Health Sciences University

Augusta, Georgia

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CONTRIBUTORS

Timothy M. Farrell, MD
Professor of Surgery
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Patrick Forgione, MD
Associate Professor of Surgery
University of Vermont College of Medicine
Fletcher Allen Healthcare
Burlington, Vermont
Kevin N. Foster, MD
Vice Chair for Education and Research
Director Arizona Burn Center
Program Director, General Surgery residency
Department of Surgery
Maricopa Integrated Health Systems
Phoenix, Arizona
Glen A. Franklin, MD
Associate Professor of Surgery
University of Louisville School of Medicine
Louisville, Kentucky
Shannon Fraser, MD, MSc

Assistant Professor
McGill University
Chief General Surgery
Jewish General Hospital
Montreal, Quebec, Canada
Charles M. Friel, MD
Associate Professor of Surgery
University of Virginia
Charlottesville, Virginia
Gregory J. Gallina, MD
Associate Director of Surgical Education
Hackensack University Medical Center
Hackensack, New Jersey
R. Neal Garrison, MD
Professor of Surgery
University of Louisville School of Medicine
Louisville, Kentucky
Jonathan Gefen, MD
Clinical Assistant Professor of Surgery
Jefferson Medical College
Wynnewood, Pennsylvania
Bruce L. Gewertz, MD
Surgeon-in-Chief
Chair, Department of Surgery
Cedars-Sinai Health System
Los Angeles, California
Steven B. Goldin, MD, PhD
Associate Professor of Surgery
Vice Chairman of Surgical Education
University of South Florida

Tampa, Florida

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xi

Mitchell H. Goldman, MD
Professor and Chairman
Department of Surgery
Assistant Dean for Research
University of Tennessee Graduate School of Medicine
Knoxville, Tennessee
Oscar H. Grandas, MD
Associate Professor of Surgery
University of Tennessee at Knoxville
Surgical Director
Transplant Surgery Service and Vascular Access Center
University of Tennessee Medical Center at Knoxville
Knoxville, Tennessee
James S. Gregory, MD
Director Intensive Care Services
Department of Surgery
Conemaugh Memorial Hospital
Johnstown, Pennsylvania
Oscar D. Guillamondegui, MD, MPH
Assistant Professor of Surgery
Vanderbilt University Medical Center
Medical Director, Surgical Intensive Care
Department of Surgery
Tennessee Valley Healthcare System, Veterans Affairs

Nashville, Tennessee
Kenneth A. Harris, MD
Director of Education
Royal College of Physicians and Surgeons of Canada
Ottawa, Ontario, Canada
Alan E. Harzman, MD
Assistant Professor of Surgery
The Ohio State University
Columbus, Ohio
Imran Hassan, MD
Assistant Professor of Surgery
Southern Illinois University School of Medicine
Springfield, Illinois
James C. Hebert, MD
Albert G. Mackay and H. Gordon Page Professor of Surgery
University of Vermont College of Medicine
Burlington, Vermont
Jonathan R. Hiatt, MD
Professor and Chief
Division of General Surgery
Vice Chair for Education
Department of Surgery
David Geffen School of Medicine at UCLA
Los Angeles, California
O. Joe Hines, MD
Assistant Professor
Director, Surgery Residency Program
Department of Surgery
David Geffen School of Medicine at UCLA
Los Angeles, California

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xii

CONTRIBUTORS

Mary Ann Hopkins, MD
Associate Professor of Surgery
Director of Education for the Clinical Sciences
NYU School of Medicine
New York, New York

D. Scott Lind, MD
Professor and Chairman
Department of Surgery
Drexel University College of Medicine
Philadelphia, Pennsylvania

Hwei-Kang Hsu, MD
Assistant Professor of Surgery
State University of New York at Buffalo
Buffalo, New York

Kimberly D. Lomis, MD
Associate Professor of Surgery
Associate Dean for Undergraduate Medical Education
Vanderbilt University School of Medicine
Nashville, Tennessee

Gerald A. Isenberg, MD
Professor of Surgery
Director, Surgical Undergraduate Education
Jefferson Medical College
Program Director, Colorectal Residency, TJUH
Philadelphia, Pennsylvania
Ted A. James, MD
Associate Professor of Surgery
Division of Surgical Oncology
Director of Surgery Clerkship and Student Education
University of Vermont College of Medicine
Burlington, Vermont
Daniel B. Jones, MD
Professor, Harvard Medical School
Chief, Section of Minimally Invasive Surgery
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Susan Kaiser, MD, PhD
Division of General Surgery
Jersey City Medical Center
Jersey City, New Jersey
Lewis J. Kaplan, MD
Associate Professor of Surgery
Yale University School of Medicine
New Haven, Connecticut
Alysandra Lal, MD
Clinical Assistant Professor
Medical College of Wisconsin
Columbia St. Mary’s Hospital

Milwaukee, Wisconsin
Peter F. Lawrence, MD
Wiley Barker Endowed Chair in Vascular Surgery
Director, Gonda (Goldschmied) Vascular Center
David Geffen School of Medicine at UCLA
Los Angeles, California
Jong O. Lee, MD
Assistant Professor of Surgery
University of Texas Medical Branch
Galveston, Texas
Susan Lerner, MD
Assistant Professor of Surgery
The Mount Sinai Medical Center
New York, New York
Carlos M. Li, MD
Assistant Professor of Surgery
State University of New York at Buffalo
Buffalo, New York

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Fred A. Luchette, MD
The Ambrose and Gladys Bowyer Professor of Surgery
Medical Director, Cardiothoracic Critical Care Services
Department of Surgery
Stritch School of Medicine
Maywood, Illinois
John Maa, MD
Assistant Professor of Surgery
University of California, San Francisco

San Francisco, California
Bruce V. MacFadyen Jr, MD
Moretz-Mansberger Professor of Surgery
Department of Surgery
Georgia Health Sciences University
Augusta, Georgia
Barry D. Mann, MD
Chief Academic Officer, Main Line Health
Program Director, The Lankenau Surgical Residency Program
Professor of Surgery, Jefferson Medical College
Wynnewood, Pennsylvania
Alan B. Marr, MD
Professor of Surgery
Vice Chairman of Education
Department of Surgery
Louisiana State University Health Science Center
New Orleans, Louisiana
James A. McCoy, MD, PhD
Professor of Surgery
Morehouse School of Medicine
Atlanta, Georgia
James F. McKinsey, MD
Associate Professor and Chief
Division of Vascular Surgery
Columbia University
New York, New York
John D. Mellinger, MD
Professor and Chair of General Surgery
Department of Surgery
Southern Illinois University School of Medicine

Springfield, Illinois
David W. Mercer, MD
McLaughlin Professor and Chairman
Department of Surgery
University of Nebraska Medical Center
Omaha, Nebraska

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CONTRIBUTORS

Hollis W. Merrick III, MD
Professor, Surgery
Chief, Division of General Surgery
Director, Undergraduate Surgical Education
The University of Toledo
Toledo, Ohio
James E. Morrison, MD
Assistant Professor of Surgery
University of South Carolina School of Medicine
Columbia, South Carolina
Russell J. Nauta, MD
Professor of Surgery
Harvard Medical School
Chairman, Department of Surgery
Mt. Auburn Hospital
Cambridge, Massachusetts
Peter R. Nelson, MD
Assistant Professor of Surgery

Director, Surgery Clerkship
University of Florida College of Medicine
Gainesville, Florida
Leigh Neumayer, MD, MS
Professor of Surgery
University of Utah Health Sciences Center
Salt Lake City, Utah
John T. Paige, MD
Associate Professor of Clinical Surgery
Louisiana State University School of Medicine
New Orleans, Louisiana
Tina L. Palmieri, MD
Associate Professor and Director
University of California Davis Regional Burn Center
Assistant Chief of Burns
Shriners Hospital for Children Northern California
Sacramento, California
Alexander A. Parikh, MD
Assistant Professor
Division of Surgical Oncology
Vanderbilt University Medical Center
Nashville, Tennessee
Lisa A. Patterson, MD
Associate Professor of Surgery
Tufts University School of Medicine
Trauma Director
Department of Surgery
Baystate Health
Springfield, Massachusetts
Elizabeth Peralta, MD

Associate Professor of Surgery
Southern Illinois University School of Medicine
Springfield, Illinois
Timothy A. Pritts, MD, PhD
Associate Professor of Surgery
Division of Trauma and Critical Care
Department of Surgery
University of Cincinnati College of Medicine
Cincinnati, Ohio

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xiii

Jan Rakinic, MD
Associate Professor of Surgery
Chief, Section of Colorectal Surgery
Program Director, SIU Program in Colorectal Surgery
Vice Chair for Clinical Operations, Department of Surgery
Southern Illinois University School of Medicine
Springfield, Illinois
H. David Reines, MD
Professor of Surgery
Virginia Commonwealth University
Vice Chair Surgery
InovaFairfax Hospital
Falls Church, Virginia
Melanie L. Richards, MD
Professor of Surgery
Associate Dean of Graduate Medical Education

Mayo Clinic
Rochester, Minnesota
Jeffrey R. Saffle, MD
Professor of Surgery
Director, Burn-Trauma ICU
University of Utah Health Sciences Center
Salt Lake City, Utah
Hilary Sanfey, MD
Professor of Surgery
Vice Chair for Education
Southern Illinois University School of Medicine
Springfield, Illinois
Kennith H. Sartorelli, MD
Professor of Surgery
The University of Vermont College of Medicine
Burlington, Vermont
Kimberly D. Schenarts, PhD
Affiliate Professor of Surgery
Brody School of Medicine at East Carolina University
Greenville, North Carolina
Paul J. Schenarts, MD
Vice Chair, Department of Surgery
University of Nebraska Medical Center
Omaha, Nebraska
Mohsen Shabahang, MD, PhD
Director, General Surgery
Geisinger Medical Center
Danville, Pennsylvania
Saad Shebrain, MD
Assistant Professor of Surgery

Michigan State University/Kalamazoo Center for Medical Studies
Kalamazoo, Michigan
Timothy R. Shope, MD
General Surgery
Hershey, Pennsylvania
Ravi S. Sidhu, MD, PhD
Assistant Professor
Department of Surgery
University of British Columbia
Vancouver, British Columbia, Canada

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xiv

CONTRIBUTORS

Mary R. Smith, MD
Professor of Medicine and Pathology
Associate Dean for Graduate Medical Education
The University of Toledo College of Medicine
Toledo, Ohio

Samuel A. Tisherman, MD
Professor
Departments of Critical Care Medicine and Surgery
University of Pittsburgh
Pittsburgh, Pennsylvania

David A. Spain, MD
Professor of Surgery
Chief, Trauma/Critical Care Surgery
Stanford University School of Medicine
Stanford, California

Judith L. Trudel, MD
Clinical Professor of Surgery
Division of Colon and Rectal Surgery
Department of Surgery
University of Minnesota Medical School
St. Paul, Minnesota

Kimberley E. Steele, MD
Assistant Professor of Surgery
Director of Adolescent Bariatric Surgery
The Johns Hopkins Center for Bariatric Surgery
Baltimore, Maryland
Michael D. Stone, MD
Professor of Surgery
Boston University School of Medicine
Chief of the Section of Surgical Oncology
Boston Medical Center
Boston, Massachusetts

Richard B. Wait, MD, PhD
Professor of Surgery
Tufts University School of Medicine
Chairman, Department of Surgery
Baystate Medical Center

Springfield, Massachusetts
James Warneke, MD
Associate Professor of Surgery
University of Arizona College of Medicine
Tucson, Arizona

John P. Sutyak, MD
Associate Professor of Surgery
Director, Southern Illinois Trauma Center
Southern Illinois University School of Medicine
Springfield, Illinois

Jeremy Warren, MD
Instructor
Department of Surgery
Georgia Health Sciences University
Augusta, Georgia

Glenn E. Talboy Jr, MD
Professor of Surgery
Program Director, General Surgery Residency
University of Missouri—Kansas City School of Medicine
Kansas City, Missouri

Warren D. Widmann, MD
Associate Chair, Education and Training
Program Director, Department of Surgery
Staten Island University Hospital
Clinical Professor of Surgery
State of New York Downstate Medical Center

New York, New York

J. Scott Thomas, MD
Assistant Professor of Surgery
Program Director, General Surgery Residency
Texas A&M Health Science Center
Scott & White Memorial Hospital
Temple, Texas

Christopher Wohltmann, MD
Clinical Associate Professor of Surgery
Southern Illinois University School of Medicine
Springfield, Illinois

Areti Tillou, MD
Associate Professor
Associate Program Director
Department of Surgery
David Geffen School of Medicine at UCLA
Los Angeles, California

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Contents
Preface ...................................................................................v
Acknowledgments ............................................................... vii
Contributors ......................................................................... ix

Introduction .......................................................................xviii

CHAPTER 1

1

Perioperative Evaluation and Management
of Surgical Patients

33

130

Wounds and Wound Healing
Glenn E. Talboy, Jr., M.D.
Annesley W. Copeland, M.D.
Gregory J. Gallina, M.D.

57

Nutrition

CHAPTER 8

145

Surgical Infections

Gail Cresci, Ph.D., R.D.
Bruce V. MacFadyen, Jr., M.D.

James S. Gregory, M.D.
Alan B. Marr, M.D.
Jeremy Warren, M.D.

R. Neal Garrison, M.D.
Glen A. Franklin, M.D.
Oscar D. Guillamondegui, M.D., M.P.H.
Lewis J. Kaplan, M.D.
David A. Spain, M.D.

76

Surgical Bleeding: Bleeding Disorders, Hypercoagulable States,
and Replacement Therapy in the Surgical Patient
Hollis W. Merrick III, M.D.
Kevin N. Foster, M.D.
Timothy R. Shope, M.D.
Ravi S. Sidhu, M.D.
Mary R. Smith, M.D.
John P. Sutyak, M.D.

110

Samuel A. Tisherman, M.D.
Melissa Brunsvold, M.D.
Brian J. Daley, M.D.
James E. Morrison, M.D.
Paul J. Schenarts, M.D.
Christopher Wohltmann, M.D.

CHAPTER 7

David Antonenko, M.D.
Mary-Margaret Brandt, M.D.
H. David Reines, M.D.
Hilary Sanfey, M.D.
Areti Tillou, M.D.

CHAPTER 4

Kenneth W. Burchard, M.D.
Karen Brasel, M.D., M.P.H.
Jeannette Capella, M.D.
Timothy A. Pritts, M.D., Ph.D.

Surgical Critical Care

Fluids, Electrolytes, and Acid-Base Balance

CHAPTER 3

90

Shock: Cell Metabolic Failure in Critical Illness

CHAPTER 6

Virginia A. Eddy, M.D.
Tracey D. Arnell, M.D.
Kenneth A. Harris, M.D.

Imran Hassan, M.D.
James E. Morrison, M.D.

CHAPTER 2

CHAPTER 5

CHAPTER 9

161

Trauma
Matthew O. Dolich, M.D.
H. Scott Bjerke, M.D.
Jeffrey G. Chipman, M.D.
Fred A. Luchette, M.D.
Lisa A. Patterson, M.D.

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xvi

CONTENTS

CHAPTER 10

187

Burns

Steven B. Goldin, M.D., Ph.D.
Dimitrios Avgerinos, M.D.
Alexander A. Parikh, M.D.
Mohsen Shabahang, M.D., Ph.D.

202

Abdominal Wall, Including Hernia

218

244

Stomach and Duodenum

274

300

Colon, Rectum, and Anus

Lawrence_FM.indd xvi

CHAPTER 21

429

Spleen and Lymph Nodes

CHAPTER 22

450

Diseases of the Vascular System
James F. McKinsey, M.D.
James Alexander, M.D.
Arnold Byer, M.D.
Gregory S. Cherr, M.D.
Bruce L. Gewertz, M.D.
Peter F. Lawrence, M.D.
Peter R. Nelson, M.D.

Merril T. Dayton, M.D.
Gerald A. Isenberg, M.D.
Jan Rakinic, M.D.
J. Scott Thomas, M.D.
Judith L. Trudel, M.D.

O. Joe Hines, M.D.
Juliane Bingener, M.D.
Frederick D. Cason, M.D.
Michael Edwards, M.D.
Mary Ann Hopkins, M.D.

406

James C. Hebert, M.D.
Gina L. Andrales, M.D.
Patrick Forgione, M.D.
Kennith H. Sartorelli, M.D.
Warren D. Widmann, M.D.

John D. Mellinger, M.D.
Serge Dubé, M.D.
Charles M. Friel, M.D.
Alan E. Harzman, M.D.
David W. Mercer, M.D.

Biliary Tract

CHAPTER 20

Thyroid Gland: Nicholas P.W. Coe, M.D. and Wendy R. Cornett, M.D.
Parathyroid Glands: Karen R. Borman, M.D. and Melanie L. Richards, M.D.
Adrenal Glands: Richard B. Wait, M.D., Ph.D. and Alysandra Lal, M.D.
Multiple Endocrine Neoplasia Syndromes: Karen R. Borman, M.D.

Small Intestine and Appendix

CHAPTER 16

Breast

Surgical Endocrinology

John T. Paige, M.D.
Timothy M. Farrell, M.D.
Daniel B. Jones, M.D.
Saad Shebrain, M.D.
Kimberley E. Steele, M.D.

CHAPTER 15

390

Gary L. Dunnington, M.D.
Lecia Apantaku, M.D.
Ted A. James, M.D.
Susan Kaiser, M.D., Ph.D.
Elizabeth Peralta, M.D.

Carlos M. Li, M.D.
James A. McCoy, M.D., Ph.D.
Hwei-Kang Hsu, M.D.

CHAPTER 14

367

Liver

CHAPTER 19

Esophagus

CHAPTER 13

CHAPTER 18
William C. Chapman, M.D.
Adnan A. Alseidi, M.D.
Jonathan R. Hiatt, M.D.
Russell J. Nauta, M.D.
Michael D. Stone, M.D.

Leigh Neumayer, M.D., M.S.
Dale A. Dangleben, M.D.
Shannon Fraser, M.D., M.SC.
Jonathan Gefen, M.D.
John Maa, M.D.
Barry D. Mann, M.D.

CHAPTER 12

344

Pancreas

Jeffrey R. Saffle, M.D.
Melinda Banister, M.D.
Michael Cahalane, M.D.
Jong O. Lee, M.D.
Tina L. Palmieri, M.D.

CHAPTER 11

CHAPTER 17

327

CHAPTER 23

486

Transplantation
Hilary Sanfey, M.D., B.CH.
Mitchell H. Goldman, M.D.
Oscar H. Grandas, M.D.
Susan Lerner, M.D.

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CONTENTS

CHAPTER 24
Surgical Oncology: Malignant Diseases of the Skin
and Soft Tissue

505

xvii

Appendix ........................................................................... 534
Glossary............................................................................. 547
Index .................................................................................. 561

D. Scott Lind, M.D.
Mohammed I. Ahmed, M.B.B.S., M.S. (Surgery)
Chris de Gara, M.B.B.S., M.S.
James Warneke, M.D.

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Introduction: Transitioning to the
Role as a Junior Member of the
Surgical Health Care Team
DEBRA A. DAROSA, PH.D.

You are about to embark on an immersive clinical experience
in surgery. It does not matter if you plan to be a surgeon; your
surgery clerkship will provide you with learning opportunities
that will help you hone clinical skills important to a physician, regardless of chosen specialty. During your career as a
doctor, you will undoubtedly encounter patients and family
members who require surgical intervention, and the surgery
clerkship can equip you with the knowledge and skills necessary to identify surgical diseases, recognize the type of surgical consult needed, and position yourself to better understand
and empathize with the emotional, physiological, and logistical experiences they will have, should an operation or consult
be required. How you approach your role and responsibilities as a junior member of the surgical health care team will
determine the extent to which you enjoy and benefit from this
incredible educational experience.
You are already a well-seasoned learner or you would not
be in medical school. But the first day as a junior member on a
health care team, typically begun in your 3rd year of medical

school, is a profound transition and requires rethinking how
you approach learning and studying. It is no longer just about
memorizing facts and then repeating them on a test. You now
have real patients who need your understanding of their presenting complaints and disease entities. You also have serious
time constraints on reading, voluminous information needing
to be learned, and the challenge of determining the scope and
detail level of information needed to help your patients. These
challenges are not insurmountable. Variables that typically
affect clinical performance include
1. Preparatory coursework and experience—new knowledge
is constructed from existing knowledge. Learning is about
linking new information with what you already know. Students who worked hard to do more than just memorize and
accomplished a deep knowledge of anatomy, for example,
will more easily associate what they are hearing, feeling,
or seeing for the first time with this prior knowledge, to
further form solidly constructed understanding. Remembering follows understanding.

2. Quality of study methods—active learning requires students to take responsibility for their learning. Disciplined
students recognize how they best learn and maintain an
ongoing study plan that meets their learning style and
needs.
3. Organizational skills—successful lifelong learners know
how to arrange their time and priorities so as to avoid
stressful situations such as last-minute cramming.
4. Motivation and emotion—students’ enthusiasm and feelings about the content to be learned, the people involved,
and the learning environment can have a significant effect
on how a student experiences a clerkship and how their
patients and team experiences and perceives them.
5. Physical health—there is an undeniable link between how
a person feels physically and how well he or she learns.

Students need to pay attention to their own health needs.
6. Distractibility and concentration skills—students must be
active learners. Whether reading or listening to a lecture,
students who can’t be fully attentive and engaged will have
difficulties deeply processing information and translating it
into useful knowledge. It’s hard to learn when you are not
cognitively present or are sleeping!
Your aim should be to take full advantage of every teachable
moment in your surgery clerkship. Here is how:

MAXIMIZE YOUR INTELLECTUAL CAPABILITIES
•
•
•
•

Prepare, practice, and review
Organize your knowledge
Know expectations and thyself
Ask! Ask! Ask! Ask! Ask! Ask!

Prepare, Practice, and Review
You need to prepare for your clinical and didactic learning
experiences by activating prior knowledge. This can be done
by prereading about the topics you’ll be exposed to the next
day, for example in a lecture session, in the operating room,

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TRANSITIONING TO THE ROLE AS A JUNIOR MEMBER OF THE SURGICAL HEALTH CARE TEAM

or on rounds. Although few students read textual material
before a lecture, empirical evidence shows that prereading
increases comprehension and puts information into longerterm memory. It is somewhat akin to looking at a map before
going on a trip. You will know ahead of time where the route
changes and landmarks along the way. Just as looking at a
map before a trip is an advanced organizer for your journey,
prereading is an advanced organizer for the topic to be learned
or the operation to be seen. You’ll glean the most from seeing
a thyroid nodule or acute cholecystitis if you’ve read about it
beforehand—make the most of these learning opportunities
by preparing for them.
Practice is applied thinking and requires engaged learners.
Be an active listener, carry an electronic or paper notebook,
and jot down one or two learning issues or questions that
surface during the day and then read about them with a purpose that evening. Note taking doesn’t mean the transfer of
the attending’s lecture to your notebook without its passing
through your brain! Studies have demonstrated that students
who make their own notes have better retention than students
who do not. Jotting notes and self-generating questions about
the topic being addressed in a lecture or whatever learning
environment embeds information into memory.
Reviewing information on an ongoing basis is critical to
retention. Use the test questions and patient management problems provided in this book to assess your understanding of
the material read. It is also helpful to create your own tests by

listing open-ended questions or copying charts or tables and
then blanking out portions to see if you can “fill in the blanks.”
Review notes, flowcharts, tables and diagrams, and test questions while looking for patterns. Re-review throughout the
clerkship. Spending as little as 30 minutes per day can help
reinforce information and significantly affect recall capabilities.

Organize Your Knowledge
You can organize your knowledge by taking three steps to
studying.
1. Get the big picture first. Prior to reading a book chapter,
review the learning objectives listed at the start of the chapter. Review the headings and subheadings to get a sense of
how the author organized the information presented and
what s/he thinks is important for you to learn. Also, review
the questions before you read to get an additional sense of
what the author finds important. You can also list questions
you have about the topic and then read the chapter with this
purpose in mind.
2. Review the charts, tables, and diagrams. Authors emphasize
key information in these and are an excellent source for
study. As noted above, it is excellent practice to eliminate
parts of the table, chart, and diagram and test yourself to
see if you know the missing information.
3. Emphasize integration. As you read each chapter, examine the information to see how it relates to a patient you
may have seen, a lecture you attended, an image you may
have reviewed, etc. Create your own mind maps or concept
maps that help to organize the information in your mind
and create patterns where appropriate. Many senior faculty
use memories of former patients to fix surgical principles
in their minds.
Search for relationships between ideas and concepts, and note

anything confusing or difficult to comprehend for follow-up
through reading or discussions with peers, residents, or faculty.

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xix

Know Expectations and Thyself
Read the provided syllabus or Web site provided from the
clerkship director and carefully listen at orientation. Be crystal
clear as to your role and responsibilities. If this can’t be ascertained using the syllabus materials, then talk with students
who did well in prior clerkships, residents, or faculty. Most
surgeons value commitment, timeliness, and work ethic as
highly as intelligence. Once you know what you are expected
to do and what you expect from yourself, you are set up to
succeed. Secondly, think about what you want to glean from
this clerkship and outline your own learning goals. Don’t be a
reactive learner; instead be an active adult learner and have a
learning agenda in mind. For example, if assigned to attend
a breast surgeon’s clinic, reflect in advance and write what
you’d like to learn from that experience. Lastly, know your
learning style. For example, if you are someone who learns
better by talking through topics and issues, find a like-minded
study partner and do it. On the other hand, if you are a learner
who does best by sequestering yourself somewhere with no
distractions, find study spaces inside and outside the hospital
to accommodate yourself. The point is to be reflective about
this and plan your study approaches in advance.

Ask! Ask! Ask!

Persistence and assertiveness are necessary in all clerkships
including surgery. If you have a question, need performance
feedback, or have unresolved learning issues, ask someone.
Most faculty and residents are happy to help a medical student who shows interest and is invested in their learning. And
if they are too busy at the time and you happen to be told
“no”… just say to yourself “next” and go to someone else. It
is not personal. Everyone who works with you knows things
you don’t know. If you are wise, you’ll learn from everyone
on or near the surgery team including nurses, physician assistants, pharmacists, social workers, and technicians. They can’t
read your mind though, so even timid individuals will need to
reach out and ask for feedback, for assistance, or for answers
as needed.

MAXIMIZE YOUR EMOTIONAL INTELLIGENCE
• Focus forward with a positive attitude
• Set goals and celebrate successes
• Promote a supportive learning environment

Focus Forward with a Positive Attitude
It is not what happens to you in the clerkship that matters, it
is how you respond to it that determines the outcome. Make
decisions about how you respond to situations or challenges
with the end in mind. You can’t always control situations,
but you can control your response to them. If a resident or
faculty member is having a bad or overly intense day, seek
to have enough situational awareness to maintain a positive
perspective. Anticipate in the operating room when questions
might be welcome and when a surgeon needs to concentrate.
A student with high emotional intelligence maintains an open
mind, approaches responsibilities with positive energy and

enthusiasm, and seeks to make a constructive difference in his
or her patients’ and team members’ days. This doesn’t mean
we should maintain an artificial positive attitude when things
are going awry, because focus forward is not about denying

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TRANSITIONING TO THE ROLE AS A JUNIOR MEMBER OF THE SURGICAL HEALTH CARE TEAM

what we feel. Forward focus is about managing energy and
focusing on solutions and not just problems. We go toward
what we focus on.

Set Goals and Celebrate Successes
Mature-minded learners are specific about what they want to
achieve. They dream big dreams and are committed to achieving them. Surgery clerks should start their clerkship by defining
goals of what they desire to glean from the clerkship experience
and how achievement of these goals will move them toward
their long-range mission. I encourage all students to document
their short- and long-range goals—goals that are achievable,
believable, conceivable, desirable, measurable, growth facilitating, and life enhancing! What we write tends to manifest
itself internally rather than serving as passing thoughts. Goals
should address what one wants to accomplish as a learner, but
can also include financial goals, relationship goals, as well as
goals about the values you want to reflect and practice. Goals
set direction—if you don’t know where you are going, you are
not likely to get there! The notebook should also include a section for documenting successes—large and small. Overachievers and leaders tend to meet a goal and simply move to the next

one without taking the time to appreciate and honor what they
accomplished. Being able to reread written accomplishments
serves as a useful reminder of all you’ve done well, which can
be especially lifting and reinforcing to one’s self-confidence
and sense of accomplishments when needed.

Promote a Positive Learning Environment
You are going to make mistakes. A good thing about being the
junior member of a patient care team is that you have many
layers of expertise to help defray them. Your team members will have made mistakes themselves. The key is to take
responsibility for mistakes by owning up to them, and learning from them so they aren’t repeated.
Avoid keeping company with negative people or “negaholics.” These individuals are not unique to surgery, and are
important to be aware of, as they can create serious chaos
for the team. Negaholics are individuals who are beset with

Lawrence_FM.indd xx

negative attitudes and behaviors. They constantly are complaining about someone or something, and can suck the positive energy out of anyone or team. They are rigid in their
thinking and highly judgmental. If their negativity is fed, it
becomes contagious and results in reduced productivity, lower
morale, and frustration. Negaholism creates a pessimistic
learning environment and is damaging to the team’s esprit de
corps and functionality. It is important to not get caught up in
their negativity net—avoiding these individuals helps neutralize their effect.
An important element to creating a supportive learning
environment is to take care of those learners behind you,
beside you, and in front of you. This establishes trust among
team members, which is what makes a team productive and
effective and the learning environment supportive.
The electronic portion of this book includes a chapter entitled “Maximally Invasive Learning” that includes specific

suggestions on how to address five common questions faced
by students in the surgery clerkship including
Problem One: What exactly is my role? What are the expectations?
Problem Two: There is not enough time to read.
Problem Three: I am getting little or no feedback.
Problem Four: How can I do well on examinations?
Problem Five: What does it take to be an honors student?
Although there is overlap between this Introduction and the
electronic chapter, since they are mutually based on learning
principles, I’d encourage students who want to do well in their
surgery clerkship to read both for a more comprehensive overview on successful learner practices.
In summary, approach the surgery clerkship with a fire in
your belly! Do all you can to earn your credibility as a junior
member of the surgery health care team by taking measures
to maximize your intellectual capabilities and advance your
emotional intelligence. Lastly, keep in mind John Wooden’s
sage advice. He advised that although tempting when you are
in a competitive, busy, and complex environment, never try to
be better than anyone else, but never cease to be the best you
can be. That is all you need to be successful in the surgery
clerkship, and frankly, in life as well.

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1
Perioperative Evaluation and
Management of Surgical Patients
VIRGINIA A. EDDY, M.D. • TRACEY D. ARNELL, M.D. • KENNETH A. HARRIS, M.D. •
IMRAN HASSAN, M.D. • JAMES E. MORRISON, M.D.

Objectives
1. Describe the value of the preoperative history, physical
examination, and selected diagnostic and screening tests.
2. Describe the important aspects of communication skills.
3. Discuss the role of outside consultation in evaluating a
patient undergoing an elective surgical procedure.
4. Discuss the elements of a patient’s history that are essential
in the preoperative evaluation of surgical emergencies.
5. Discuss the appropriate preoperative screening tests.
6. Discuss the assessment of cardiac and pulmonary risk.

PREOPERATIVE EVALUATION
Surgery and anesthesia profoundly alter the normal physiologic and metabolic states. Estimating the patient’s ability
to respond to these stresses in the postoperative period is
the task of the preoperative evaluation. Perioperative complications are often the result of failure, in the preoperative
period, to identify underlying medical conditions, maximize
the patient’s preoperative health, or accurately assess perioperative risk. Sophisticated laboratory studies and specialized
testing are no substitute for a thoughtful and careful history
and physical examination. Sophisticated technology has merit
primarily in confirming clinical suspicion.
This chapter is not a review of how to perform a history
and physical examination. Instead, this discussion is a review
of the elements in the patient’s history or findings on physical examination that may suggest the need to modify care in
the perioperative period. Other chapters discuss the signs and
symptoms of specific surgical diagnoses.

PHYSICIAN–PATIENT COMMUNICATION
Interviewing Techniques
The physician–patient relationship is an essential part of

surgical care. The relationship between the surgeon and

7. Discuss the effect of renal dysfunction, hepatic dysfunction,
diabetes, adrenal insufficiency, pregnancy, and advanced age
on preoperative preparation and postoperative management.
8. Describe the documentation required in the medical record
of a surgical patient, including physician’s orders and daily
progress notes.
9. Describe the most commonly used surgical tubes and
drains.
10. Discuss common postoperative complications and their
treatment.

patient should be established, maintained, and valued. Good
interviewing techniques are fundamental in establishing a
good relationship. The basis for good interviewing comes from
a genuine concern about people, although there are interviewing skills that can be learned and that can improve the quality
of the interaction. Medical students should also acknowledge
their own special role in the patient’s care. Students should
not be ashamed of their status, or feel that they are ineffective members of the team. Patients commonly view medical
students as more accessible and will often share details with
them that they might withhold from the more senior members of the team. Also, the intensity and enthusiasm of the
intelligent novice is a definite asset that can be brought to the
patient’s great advantage. The role of the student is to discover the patient’s chief medical complaint, perform a focused
history and physical examination, and present the findings to
the resident or faculty member. Interviewing a patient well
requires communicating to the patient who you are and how
you fit into the team.
Effective interviewing can be challenging because of the
variety of settings in which interviews occur. These settings include the operating room, the intensive care unit,

a private office, a hospital bedside, the emergency room,
and an outpatient clinic. Each setting presents its own challenges to effective communication. To achieve good physician–patient relationships, surgeons adjust their styles to
1

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2

ESSENTIALS OF GENERAL SURGERY

the environment and to each patient’s personality and needs.
Some basic rules are common to all professional interviews.
The first rule is to make clear to the patient that during the
history and examination, nothing short of a life-or-death
emergency will assume greater importance than the interaction between the surgeon and the patient at that moment.
This is our first, and best, chance to connect with the patient.
The patient must come to understand that a caring, knowledgeable, and dedicated surgeon will be the patient’s partner on the journey through the treatment of surgical disease.
The surgeon should observe certain other rules, including
giving adequate attention to personal appearance to present
a professional image that inspires confidence; establishing
eye contact; communicating interest, warmth, and understanding; listening nonjudgmentally; accepting the patient
as a person; listening to the patient’s description of his or
her problem; and helping the patient feel comfortable in
communicating.
When the patient is seen in an ambulatory setting, the first
few minutes are spent greeting the patient (using the patient’s
formal name); shaking hands with the patient; introducing

himself or herself and explaining the surgeon’s role; attending
to patient privacy; adjusting his or her conversational style and
level of vocabulary to meet the patient’s needs; eliciting the
patient’s attitude about coming to the clinic; finding out the
patient’s occupation; and determining what the patient knows
about the nature of his or her problem.
The next step involves exploring the problem. To focus the
interview, one moves from open-ended to closed-ended questions. Important techniques include using transitions; asking
specific, clear questions; and restating the problem for verification. At this point, it is important to determine whether the
patient has any questions. Near the end of the interview, the
surgeon explains what the next steps will be and that he or she
will examine the patient. Last, the surgeon should verify that
the patient is comfortable.
Most of the techniques used in the ambulatory setting are
also appropriate for inpatient and Emergency Department
encounters. Often, more time is spent with the patient in the
initial and subsequent interviews than in an outpatient setting. At the initial interview, patients are likely to be in pain,
worried about financial problems, and concerned about lack
of privacy or unpleasant diets. They may also have difficulty
sleeping, be fearful about treatment, or feel helpless. It is
important to gently and confidently communicate the purpose
of the interview and how long it will take.
The patient is not only listening, but also is observing the
physician’s behavior and even attire. The setting also affects
the interview. For example, a cramped, noisy, crowded environment can affect the quality of communication. Patients
may have negative feelings because of insensitivities on the
part of the physician or others. Examples include speaking
to the patient from the doorway, giving or taking personal
information in a crowded room, speaking about a patient in
an elevator or another public space, or speaking to a patient

without drawing the curtain in a ward.

Informed Consent
The relationship between a patient and his or her surgeon is
one of the strongest in any professional endeavor. The patient
comes to the surgeon with a problem, the solution to which
may include alteration of the patient’s anatomy while he or

Lawrence_Chap01.indd 2

she is in a state of total helplessness. There is an immense duty
on the part of the surgeon to merit this level of trust. Part of
earning this trust involves honest discussions with patients and
their families about available choices (including the choice to
not operate) and their consequences.
Once the surgeon has gathered information sufficient to
identify the likely problem and its contributory factors, the
surgeon then identifies a number of reasonable courses of
action to pursue the evaluation or treatment of the patient’s
problem. These strategies are discussed in layman’s terms
with the patient (and family where appropriate). Together, the
patient and the surgeon select the course of action that seems
best. This is what is meant by informed consent. Informed
consent is a process, not an event, and not a form. It is the
process wherein the patient and surgeon together decide on
a plan. Informed consent is different from a consent form. A
consent form is intended to serve as legal documentation of
these discussions between the physician and the patient. It
is an unfortunate reality that consent forms must serve as a
shield behind which care providers may take shelter should

a tort claim be filed against them. The process of informed
consent serves the more noble cause; consent forms serve
the more mundane cause. Informed consent often takes place
not just in one session, but over time, in multiple sessions, as
the patient has time to digest the information and formulate
further questions.
Sometimes, patients cannot speak for themselves. In these
situations, the health care team will turn to those who might
reasonably be thought to be able to speak on behalf of the
patient. Usually, but not always, this is the next of kin. (The
reader is strongly encouraged to become familiar with pertinent state law on this matter.) These individuals are known
as surrogate decision makers. Another concept that arises
in this context is advance directives. Advance directives are
legal documents that inform care providers about the general
wishes of the patient regarding level of care to be delivered
should the patient not be able to speak for himself or herself.
Most people wish to receive enough medical care to alleviate their suffering and to give them a reasonable chance of
being able to enjoy the remainder of their life in a functional
manner. The definitions of “reasonable” and “functional” will
vary among individuals, but these are the causes that advance
directive documents are intended to serve.
Finally, there will be times when there is nobody present
who can speak for the patient in a time frame that permits acceptable medical care. In these circumstances, the
physician must remember that the first duty is to the patient,
and that duty is to improve the patient’s life. Improving life
is not always the same thing as prolonging life. It is the duty
of the physician to manage this aspect of the patient’s care
in a reverential and respectful manner. There will be times
when Physician’s must make difficult judgments about matters of life and death. The responsible physician does so,
expeditiously and thoughtfully, without attempting to evade

the painful dilemmas that arise.
It is important to begin to address the issues of informed
consent and end-of-life care early on in the relationship
between surgeon and patient. This is not so much a legal issue
as one of matching the care offered to the specific situation
of the patient. For example, if a patient with end-stage cardiomyopathy is felt to be too fragile for elective aortic
aneurysmorrhaphy, that patient is almost certainly a terrible

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CHAPTER 1 / PERIOPERATIVE EVALUATION AND MANAGEMENT OF SURGICAL PATIENTS

candidate for emergent repair of a ruptured aneurysm. Conversely, an otherwise healthy 18-year-old patient who comes
in for an elective herniorrhaphy will not require the same
degree of delicate issue exploration as the first patient mentioned. However, they should be informed that unexpected
complications could sometimes arise, including death. They
should also be informed that the treating team will manage
any unusual events to the best of their ability. In all cases, the
surgeon must be careful to explain that while they are competent and compassionate, they are also human.
The student is referred to any number of excellent sources
for further information on the subject of medical ethics. (See
bonus chapter on medical ethics at ).
Another example is The Hastings Center Report, a journal
devoted to ethical issues.

History
A careful history is fundamental to the preoperative evaluation
of the surgical patient, whether for an elective or emergent
operation. It is here that the doctor learns about comorbidities that will influence the patient’s ability to withstand and

recover from the operation. This understanding begins with
a careful review of systems intended to elicit problems that,
although perhaps not the focus of the patient’s surgical experience, are nonetheless important to his or her ability to recover
from the operation. The following sections will consider
the ways in which certain historical findings can influence
a patient’s perioperative risk, and what further evaluation
should be prompted by the discovery of certain aspects of the
patient’s history.
The history of the present illness (HPI) will obviously
direct the lines of inquiry. Within the context of the HPI, a history of the events that preceded the accident or onset of illness
may give important clues about the etiology of the problem
or may help to uncover occult injury or disease. For example,
the onset of severe substernal chest pain before the driver of a
vehicle struck a bridge abutment may suggest that the hypotension that the driver exhibited in the emergency department
may be related to acute cardiac decompensation from a myocardial infarction as well as from blood loss associated with a
pelvic fracture. Such a situation might require modification of
hemodynamic monitoring and volume restoration. Although
such scenarios sound extreme, they are encountered in emergency departments on a daily basis. These historical elements
add significantly to the physician’s ability to provide optimal
patient care.
Most clinical situations provide an adequate opportunity
for a careful review of systems. Occasionally, patients cannot
provide details of their illness, and then available resources,
including family, friends, previous medical records, and
emergency medical personnel, will be used to glean what
information is available. A review of systems, with emphasis
on estimating the patient’s ability to respond to the stress of
surgery, is imperative. It is sometimes tempting to attempt to
summarize a lengthy review of systems with statements such
as “review of systems is negative.” This terminology should

be avoided. It is often important to know exactly what the
patient was asked, what they affirmed, and what symptoms
they denied experiencing. Therefore, specific questions
should be asked and specific answers documented. Areas of
focus, explored more fully below, include in particular the

Lawrence_Chap01.indd 3

3

cardiorespiratory, renal, hematologic, nutritional, and endocrine systems. Within the nutritional review is sought information about appetite and weight change, which can impact
healing. Further, information about the timing of the patient’s
last meal can affect the timing of urgent (but not emergent)
operations. A full stomach predisposes the patient to aspiration of gastric contents during the induction of anesthesia. If
the patient’s disease process permits, it is generally best to
allow gastric emptying to occur as much as possible prior to
induction of anesthesia. This usually takes about 6 hours of
strict nil per os status. If anesthesia must be induced emergently, the rapid sequence induction technique is used to
optimize the chances for safe endotracheal intubation without
aspiration.
Family history likewise should record the specific questions asked and the patient’s actual responses. For example,
family histories of bleeding diatheses, or bad reactions to general anesthesia, are of obvious interest to the surgical team, as
would a history of myocardial infarction or malignancy in all
of the patient’s first-degree relatives.
Determining allergies and drug sensitivities is important
and will influence selection of such critical interventions as
perioperative antibiotics and anesthetic technique.
A medication history should also be taken. This history
includes prescription drugs, over-the-counter agents, and
herbal remedies (nutraceuticals). Many prescription drugs

have important implications in perioperative patient management and are detailed in Table 1-1. Some drugs adversely
interact with anesthetic agents or alter the normal physiologic
response to illness, injury, or the stress of surgery. For example,
patients who take β-blocking agents cannot mount the usual
chronotropic response to infection or blood loss. Anticoagulants such as warfarin compounds or antiplatelet agents can
carry specific risks, both if they are continued in the surgical
period and if they are discontinued perioperatively. Patients
and/or families should also be questioned about the use of
dietary supplements and over-the-counter medications. The
popularity of complementary and alternative medicines and
the use of nutraceuticals have dramatically increased worldwide. Patients should be asked specifically about these, as
many do not regard them as “medicines.” Many of these nutraceuticals have the potential to adversely affect the administration of anesthetic agents, hypnotics, sedatives, and a variety of
other medications. Some are thought to interfere with platelet
function and coagulation, and others to potentiate or reduce
the activity of anticoagulants and some immunosuppressants.
These products have been classified as “supplements” and are
not regulated by the Food and Drug Administration. As a consequence, robust scientific studies concerning their mechanism of action, herb–drug interactions, active drug content,
effectiveness, and potential side effects are difficult to identify. Further, reliable information regarding these products is
difficult to obtain. The sheer number of preparations available
makes it difficult, if not impossible, to compile detailed information on all of them.
Common nutraceuticals are listed in Table 1-2, along with
their indications for use and potential adverse side effects. The
American Society of Anesthesiologists (ASA) recommends
discontinuation of these supplements for 2 to 3 weeks prior to
an operative procedure, but this recommendation is not based
on sound scientific evidence. The hospital pharmacist or Doctor
of Pharmacy is an excellent resource for questions in this area.

7/21/2012 5:56:58 PM