E-Book, Englisch, 620 Seiten, ePub
Schumpelick Atlas of General Surgery
1. Auflage 2009
ISBN: 978-3-13-257970-5
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
E-Book, Englisch, 620 Seiten, ePub
ISBN: 978-3-13-257970-5
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
The is a highly practical, how-to reference for the most frequently performed operations. For precise and quick orientation, each surgical chapter presents a brief introduction to surgical preparation, anesthesia, positioning, relevant anatomy, risks, complications, and postoperative care, and then illustrates the operative technique through excellent drawings and detailed legends.
Key features:
- Covers all common surgeries any general surgeon needs to know
- Step-by-step guide to each operative procedure
- More than 1,200 high-quality drawings demonstrate surgical anatomy and technique, with each illustration showing one operative step
- Didactic page layout allows for easy comprehension of the material
- Practical tips, tricks, and pitfalls highlight crucial information
Ideal for all surgeons in training the is a handy, one-volume text that provides an overview of this broad field. It also serves as a valuable reference for the bookshelf of practicing surgeons who would like to consult a rapid review before surgery.
Zielgruppe
Ärzte
Autoren/Hrsg.
Weitere Infos & Material
General Aspects
1 Preliminary Remarks on the Surgical Intervention
2 Use of Scalpel, Needle Holder, Forceps, and Scissors
3 Ligation and Suture Ligation
4 Knots
5 Skin Suture
6 Drains
7 Urinary Catheter
8 Venous Access
9 Central Venous Port
10 Venous Cutdown
11 Joint Punctures
12 Pleural Punctures (Thoracentesis)
13 Urinary Bladder Puncture
14 Ascites Puncture (Paracentesis)
15 Fine-Needle Aspiration Biopsy
16 Arterial Puncture and Arterial Catheterization
Operations
17 Excision of Skin Lesions
18 Removal of Soft Tissue Tumors
19 Removal of Inguinal Lymph Node
20 Wound Management
21 Secondary Suture
22 Carbuncle of the Neck
23 Bursectomy (Elbow)
24 V-Y Advancement Flap
25 Z-plasty
26 Split-Skin Coverage
27 Ganglion (Wrist)
28 Panaritium (Felon)
29 Paronychia (Run-around)
30 Ingrown Toenail (Unguis Incarnatus; One-third Wedge Resection)
31 Removal of Cervical Lymph Node
32 Tracheotomy (Open and Percutaneous Tracheostoma)
33 Exposure of the Jugular Vein
34 Subtotal Thyroidectomy
35 Total Thyroidectomy
36 Parathyroidectomy
37 Zenker Diverticulum
38 Axillary Lymph-Node Clearance
39 Breast Biopsy
40 Subcutaneous Mastectomy
41 Mastectomy (Auchinclos-Patey)
42 Chest Drain
43 Median Sternotomy
44 Posterolateral Thoracotomy
45 Axillary Thoracotomy
46 Atypical Lung Resection Open
47 Atypical Thoracoscopic Lung Resection
48 Right Superior Lobectomy
49 Pneumonectomy
50 Thoracoscopic Pleurectomy
51 Rupture of the Diaphragm
52 Hiatal Hernia Repair (Lortat-Jacob Hiatoplasty)
53 Fundoplication (Nissen-Rosetti and Toupet)
54 Laparoscopic Fundoplication
55 Cardiomyotomy for Achalasia (Gottstein-Heller)
56 Percutaneous Endoscopic Gastrostomy (PEG)
57 Gastrostomy (Witzel)
58 Closure of a Perforated Ulcer
59 Oversewing of a Bleeding Peptic Ulcer
60 Gastrojejunostomy
61 Pyloroplasty (Heineke-Mikulicz, Finney, Jaboulay)
62 Selective Proximal Vagotomy
63 Truncal Vagotomy
64 Gastroduodenostomy (Billroth I)
65 Gastrojejunostomy (Billroth II)
66 Roux-en-Y Gastrojejunostomy
67 Gastrectomy and Longmire Gastric Reconstruction
68 Gastrectomy and Roux-en-Y Gastric Reconstruction
69 Cholecystectomy
70 Laparoscopic Cholecystectomy
71 Exploration of the Common Bile Duct
72 Hepaticojejunostomy
73 Wedge Resection of the Liver
74 Hepatic Cyst
75 Left Hepatic Lobectomy
76 Hepatic Rupture
77 Port Catheter of the Hepatic Artery
78 Necrosectomy of the Pancreas
79 Pseudocystojejunostomy
80 Resection of the Tail of the Pancreas
81 Splenectomy
82 Partial Splenectomy
83 Splenic Rupture
84 Laparoscopic Splenectomy
85 Peritonitis and Laparostoma
86 Peritoneovenous Shunt
87 Segmental Resection of the Small Intestine
88 Intraluminal Stenting of the Small Intestine (Dennis Tube)
89 Meckel Diverticulum
90 End Ileostomy
91 Loop Ileostomy
92 Appendectomy
93 Laparoscopic Appendectomy
94 Loop Transverse Colostomy
95 End Sigmoidostomy (Hartmann Procedure)
96 Stoma Closure
97 Colotomy and Polypectomy
98 Palliative Anastomosis between the Distal Ileum and Transverse Colon
99 Right Hemicolectomy
100 Ileocecal Resection
101 Tubular Resection of the Sigmoid Colon
102 Radical Resection of the Sigmoid Colon
103 Laparoscopic Resection of the Sigmoid Colon
104 Left Hemicolectomy
105 Anterior Rectum Resection
106 Rectum Resection
107 Adrenalectomy
108 Laparoscopic Adrenalectomy
109 Hemorrhoidectomy (Miles-Gabriel)
110 Perianal Abscess
111 Fistula-In-Ano (Including Sliding Flap)
112 Perianal Thrombosis
113 Lateral Sphincterotomy (Parks)
114 Pilonidal Sinus (Schrudde-Olivari)
115 Testicular Hydrocele
116 Vasectomy
117 Local Anesthesia for Inguinal Hernia Repair
118 Dissection for Inguinal Hernia Repair
119 Inguinal Hernia Repair (Shouldice)
120 Inguinal Hernia Repair (Bassini)
121 Inguinal Hernia Repair (Lichtenstein)
122 Transinguinal Preperitoneal Mesh Repair (TIPP)
123 Preperitoneal Inguinal Hernia Repair
124 Laparoscopic Inguinal Hernia Repair
125 Femoral Hernia Repair (Crural Approach)
126 Femoral Hernia Repair (Inguinal Approach; Lotheissen, McVay)
127 Femoral Hernia Repair (Inguinocrural Approach)
128 Epigastric Hernia
129 Umbilical Hernia
130 Incisional Hernia
131 Spigelian Hernia
132 Inguinal Hernia in Children
133 Orchidopexy for Inguinal Testes (Shoemaker)
134 Circumcision
135 Pyloromyotomy (Weber-Ramstedt)
136 Femoral Embolectomy
137 Femoral Thrombectomy
138 Crossectomy, Long Saphenous Vein Stripping, and Perforator Ligation
139 Dialysis Shunt (Cimino Arteriovenous Fistula)
140 Finger and Toe Amputation
141 Below-Knee Amputation
142 Above-Knee Amputation
143 Traction Management of Fractures
144 Harvesting Cancellous Iliac Bone for Grafting
145 Septic Arthritis of the Knee
146 Fasciotomy of the Lower Leg
147 Per- and Supracondylar Fracture of the Humerus (Child)
148 Olecranon Fracture–Tension Band Wiring
149 Fracture of the Radius Shaft–ORIF Plate Fixation
150 Distal Radius Fracture–ORIF Plate Fixation
151 Distal Radius Fracture–Kirschner Wire Fixation
152 Dupuytren Fasciectomy
153 Flexor Tendon Repair
154 Extensor Tendon Repair
155 Carpal Tunnel Release
156 Pelvic External Fixation
157 Dynamic Hip Screw (DHS)
158 Proximal Femoral Nailing
159 Femoral Head Replacement (Hemiarthroplasty)
160 Femoral Shaft–ORIF Plate Fixation
161 Patella Fracture–Tension Band Wiring
162 Intramedullary Nailing of the Tibia
163 Lower Leg–External Fixation
164 Medial Malleolus–ORIF
165 Lateral Malleolus–ORIF
166 Fibular Ligament Suture and Ligament Reconstruction with a Periosteal Flap
167 Achilles Tendon Repair
34 Subtotal Thyroidectomy
1 Indications
Elective: Nodular goiter with circumscribed and diffuse changes to the thyroid gland, especially where there is suspected malignancy or hyperfunction that is not controllable by medication
Contraindications: Confirmed (e.g., by frozen section) malignancy
Alternative Procedures: Enucleation, (hemi-)thyroidectomy, radioiodine therapy
2 Preoperative Preparation
Preoperative Investigations: Thyroid function parameters and antibodies, scintigraphy, ultrasound (consider puncture cytology), rarely computed tomography; exclusion of a multiple endocrine neoplasia
Patient Preparation: Euthyroid state is required: administration of thyrostatic agents, ß-blockers, iodine for overactive thyroids
3 Specific Risks, Patient Information, and Consent
Recurrent goiter (5%, especially in the presence of hyperthyroidism)
Vascular injury
Nerve injury, especially the recurrent laryngeal nerve (0.5% at the primary operation) with subsequent hoarseness, tracheostoma after bilateral injury (0.1%)
Calcium insufficiency secondary to hypoparathyroidism (< 2%)
Extension of the operation/aftercare for malignancy
Possible need for sternotomy
4 Anesthesia
General anesthesia (intubation)
5 Positioning
Supine, reclined head, pillow between the shoulder blades, upper body slightly elevated
6 Approach
Kocher collar incision, just reaching the sternocleidomastoid laterally, possible need for (partial) sternotomy for intrathoracic goiter
7 Operative Steps
Positioning
Draping
Skin incision and division of the platysma
Division of the superficial neck veins
Mobilization of wound margins
Division of the strap muscles
Identification of the superior pole vessels
Division of the superior pole vessels
Ligation of the superior pole vessels
Ligation of the inferior thyroid artery
Division of the inferior pole vessels
Division of the thyroid isthmus
Separation from the anterior tracheal aspect
Incision of the thyroid capsule
Capsule suture
Wound closure
8 Relevant Anatomy, Serious Risks, Tricks
The superior thyroid artery emerges from the external carotid and leads to the superior pole; the inferior thyroid artery from the thyrocervical trunk courses more from lateral than caudal to the thyroid, showing close proximity to the recurrent laryngeal nerve and the inferior thyroid.
The recurrent laryngeal nerve runs in the groove between the trachea and the esophagus. Delicate and careful identification of the nerve is the best protection against injury.
In cases of potential malignancy, begin initially as a hemithyroidectomy on the affected side to avoid any necessary revision.
9 Measures for Specific Complications
Sternotomy is only rarely necessary, even for retrosternal and so-called intrathoracic goiters.
If an unexpected anaplastic carcinoma is encountered intraoperatively, which has diffusely invaded the surrounding structures, a formal resection should not be forced. Only a possible resection of the isthmus to decompress the trachea and, of course, histological confirmation is important.
10 Postoperative Care
Medical Aftercare: Remove suction drain on day 2. Begin hormone substitution therapy only after confirmation of benign histology and depending on the underlying disease.
Dietary Progression: Immediately
Mobilization: Immediately
Physiotherapy: Speech therapy for paralysis of the recurrent nerve
Time Off Work: 1 to 2 weeks
Operative Technique
Positioning
Draping
Skin incision and division of the platysma
Division of the superficial neck veins
Mobilization of the wound margins
Division of the strap muscles
Identification of the superior pole vessels
Division of the superior pole vessels
Ligation of the superior pole vessels
Ligation of the inferior thyroid artery
Division of the inferior pole vessels
Division of the thyroid isthmus
Separation from the anterior tracheal aspect
Incision of the thyroid capsule
Capsule suture
Wound closure
Positioning
Positioning is with the head maximally reclined in a headrest. A pillow is placed beneath the shoulder blades. The head is completely draped and the breathing tube has an extension attached. The eyes can be protected with gauze swabs against accidental pressure damage.
Draping
The operating field is draped to expose the lower jaw cranially, the suprasternal notch caudally, and the sternocleidomastoids laterally on either side. For marking, it is recommended to take a size 2–0 thread and press it symmetrically against the neck 2 to 3 cm above the suprasternal notch. The resulting imprint can then be taken as the incision line. A symmetrical scar is imperative for cosmetic reasons. Natural skin crease lines serve as a guide.
Skin incision and division of the platysma
The skin incision is the Kocher collar incision between the muscle bellies of the sternocleidomastoid on either side. After division of the skin, the platysma is divided with the diathermy. Small vessels are coagulated individually.
Division of the superficial neck veins
Both skin and platysma flaps are mobilized cranially and caudally. The superficial veins of the neck are divided between clamps and suture ligated (3–0 PGA) because simple ligatures often slip off during the operation.
Mobilization of the wound margins
Mobilization of the cranial and caudal skin and platysma flaps is performed dorsal to the divided veins, holding the flaps continuously under traction ventrally with sharp hooks until the larynx is just exposed cranially and the suprasternal notch caudally. Laterally, the medial border of the sternocleidomastoid should be displayed on either side. This preparation is done in a layer that is practically free of vessels.
Division of the strap muscles
After mobilization of the wound margins, the strap muscles are divided longitudinally in the midline. After dissection down to the thyroid capsule, the longitudinal muscles are retracted laterally with curved Kocher clamps to display the lobes of the thyroid.
Identification of the superior pole vessels
Dissection of the right thyroid lobe begins with division of the lateral capsule veins. These are grasped between Overholt clamps, divided, and ligated (3–0 PGA). The right thyroid lobe is grasped with a damp gauze swab or a Kocher clamp and retracted caudally to place the superior pole vessels under traction. Adequate pull on the hooks allows the superior pole vessels to be well displayed.
Division of the superior pole vessels
Clamps are passed behind the vessels, which are divided under vision. The superior laryngeal nerve must be protected during this maneuver because it lies cranially alongside the larynx near the thyroid.
Ligation of the superior pole vessels
The superior pole vessels are divided and secured with suture ligatures (2–0 PGA). Simple ligation is at risk of slipping off. Depending on the anatomical conditions, it may also be advisable to divide the superior pole vessels in several stages.
Ligation of the inferior thyroid artery
The next step is to display the inferior thyroid artery. It usually crosses over the recurrent laryngeal nerve, which should always be dissected free. Similarly, the lower parathyroid gland should be exposed and safeguarded. The inferior artery is merely ligated; for safety reasons ligation should preferably be done at the de Quervain point (i.e., near the carotid artery, lateral to the thyroid gland). Ligation is done using 3–0 PGA.
Division of the inferior pole vessels
After sufficient lateral mobilization with unequivocal identification of the recurrent nerve, the inferior pole vessels may be divided between Over-holt clamps and secured with suture ligatures.
Division of the thyroid isthmus
The last step of the dissection is to divide the isthmus. For this purpose, the isthmus is mobilized by blunt dissection off the trachea, and Overholt clamps are passed beneath it. Under no circumstances should the trachea be injured during this maneuver. The divided parts of the isthmus are secured with suture ligatures.
Separation from the anterior tracheal aspect
Adhesions to the trachea are separated and pinpoint bleeds coagulated so that the thyroid lobes are subtotally mobilized. This part of the dissection is completed further for total thyroidectomy until the parathyroid glands lie entirely free and the thyroid gland is completely separated.
Incision of the thyroid capsule
After the thyroid lobe has been mobilized on all sides, the resection line is marked out with Kocher clamps, the thyroid capsule is incised with the scalpel, and the gland is resected under partial “excavation” of the remaining dorsal residual lobe.
Capsule suture
The remaining residual capsule is closed with a double row of continuous sutures (3–0 PGA), which are drawn tight after every stitch to leave a bloodless field.
Wound closure
Two suction drains are placed to drain the wound area. They each exit from the contralateral corner to achieve a good cosmetic result. The strap muscles are approximated with interrupted sutures. Subcutaneous sutures and skin staples...
