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Preface to the Sixth Edition
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It is my pleasure to release the sixth edition, three years after the release of fifth edition of SRB’s Manual of Surgery. As my
earlier editions were well accepted by the students, I intend to bring out the sixth edition in the intention of updating the treatment
strategies of the needed surgical conditions. Extensive corrections, elaboration of a few topics, and updating of staging and grading
of malignant conditions as per new standards have been done in this edition. AJCC 2018, 8th edition staging system is added.
Style, formatting and fonts are rearranged as per students’ need. Newer concepts have added. Few subtopics like stings and bites
are removed. I have referred many books, journals and took the help of my colleagues in surgery and other departments. I have
retained all chapters with some rearrangements of a few chapters and topics. I sincerely thank our Dean, Professor M Venkatraya
Prabhu for agreeing to give Foreword to this edition. I dedicate this edition also to my beloved Professor Kodial Prakash Rao who
passed away recently.
For better understanding of the students, three sizes of fonts are used namely—10pt, 9pt, and 8.5pt. Important subjects are
kept in font size 10pt; remember, boxes, tables and other subjects are in 9pt; and notes, are in 8.5pt. This will be useful especially
for undergraduates to understand which topics have got priorities.
I sincerely express my thanks to everybody who have helped me and also to the publishers who are the backbone of this
upgraded edition. I hope this edition will be well accepted by the teachers, surgeons, undergraduates and postgraduates of surgery
department. I sincerely welcome all criticisms.
Sriram Bhat M
meera_sriram2003@yahoo.com
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Preface to the First Edition
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This book is born out of a desire to provide a complete, authoritative, current textbook on surgery. For the past fifteen years of
my teaching profession, watching students hurriedly jotting down notes during classes, an urge was born within me to put my
thoughts in print. I am fortunate to have been guided by my teachers and supported by my students towards this goal.
An attempt has been made to make this book simple and reader-friendly while not compromising on the aspect of providing
students with necessary information and a better clinical understanding of surgery. Recent advances in surgery till date have been
included to the best of my knowledge. Text has been presented in a simple and lucid language so as to help students understand and
recapitulate the subject better. Since a picture is worth than a thousand words, over 500 photographs, X-rays and illustrations have
been incorporated in this work to make surgery more interesting and understandable. Inspirational quotes have been interspersed
to motivate students to go the extra mile.
Discussion on Instruments and Operative Procedures has been dealt with in necessary detail separately. A chapter containing
a list of interesting new developments in surgery and uniquely new topics like Fascinating Signs, Misnomers, Triads and other
interesting chapters have been included.
While this book has been compiled with undergraduates in mind, I am confident that it will serve as a useful reference for
postgraduates and practitioners.
In compiling this book I have consulted many authoritative books and publications and I sincerely express my appreciation
and gratitude to all of them.
Suggestions and constructive criticisms towards improving this book in subsequent editions are always welcome.
Sriram Bhat M
meera_sriram2003@yahoo.com
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Acknowledgements
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I am happy to bring out one more edition (sixth edition) of the book SRB’s Manual of Surgery. This is due to constant help and
support of many.
I thank our Chancellor Dr Ramdas M Pai, Pro-Chancellor Dr HS Ballal, Vice-Chancellor of Manipal Academy of Higher Education
(MAHE); Dr Vinod Bhat, Pro-Vice-Chancellor, Dr Poornima Baliga, and Dr Surendra Shetty.
I immensely thank our beloved Dean, Prof Venkatraya Prabhu, for his constant support and affection and also I sincerely thank
him for writing foreword to this edition.
I thank our Additional Dean, Dr Alfred Augustine, Vice-Deans Dr Unnikrishnan and Dr Nuthan Kamath, for their affectionate help.
I always remember my senior teachers, Prof CR Ballal, Prof Suresh Kamath, Late Prof K Prakash Rao, Late Prof Subramanya
Bhat, Prof Bhaskar Shetty and Prof Ramachandra Pai, for their constant help.
Late Prof Prakash Rao, is a guide and encourager to everybody, will be remembered as a special person by me always.
My special and affectionate thanks to Prof Thangam Verghese Joshua, for agreeing to write a foreword. She is my teacher,
constant guide in all my endevours.
My special thanks to Prof Dr Jayaprakash Rao for his affection and support.
Surgical unit heads in our college—Dr Jayaram Shenoy, Dr Thangam Verghese Joshua, Dr Harish Rao, Dr Shivaprasad Rai,
Dr Yogishkumar, Dr Alfred Augustine and Dr Shivananda Prabhu, are always supportive for my work and are worth to be
remembered always.
I am grateful to all my teachers and colleagues in surgery department, who directly or indirectly helped me to bring out this
sixth edition.
I appreciate District Medical Officer and Resident Medical Officer of Government Wenlock District Hospital, Mangaluru, Dakshina
Kannada, Karnataka, for their kind help.
I will never forget my close associates—Dr Ganapathy, Mangala Hospital, Kadri Mangalore and Dr Ashok Pandith, Urologist,
for their affectionate help and encouragement in all my endeavours. They always stood with me in my difficulties.
I thank very much to the faculty, Department of Surgery and Paediatric Surgery, JJM Medical College (JJMMC), Davangere,
Karnataka, for providing the needed photographs.
My special thanks to Prof Laxman Prabhu, Department of Urology; Prof Sribatsa Kumar Mohapathra, Veer Surendra Sai
Medical College (VSSMC), Burla, Sambalpur, Odisha, India; Prof Ramlingam, Kamineni Institute of Medical Sciences (KIMS),
Narketpally, Telangana; Dr Arun Kumar, Surgical Gastroenterologist, Thiruvananthapuram, Kerala, India, Prof Sureshchandra,
and Prof Narayanaswamy Srinivasan, Bengaluru for their contribution in this title.
I sincerely thank Prof Navinchandra Shetty, Radiologist, Mangaluru, for his help in providing and guiding me in X-rays, CT
scans and imaging methods.
I acknowledge Prof Kishore Chandra Prasad, Ex-Head, Department of ENT, for his help, guidance and encouragement in bringing
out this book.
I thank Dr Manohar Pai, Dr Ashfaque Mohammed, Dr Shibu Mohan, Dr Poornachandra, Dr Keshava Prasad, Dr Sunil Kumar
Shetty, Dr Rahul Bhat, Dr Ranjith Rao, Dr Kalpana Sridhar, Dr K Akbar, Dr Achaleshwar Dayal, Dr Raghav Pandey, Dr Rupen
Shah, Dr Ashwini Mallya, Dr Praveen, Dr Irshad, Dr Amar, Dr Rajesh, Dr Suyog, Dr Chandini, Dr Adithya, Dr Ashok Hegde,
Dr Rajesh Ballal, Dr Devidas Shetty, Dr Venkatesh Sanjeeva, Dr Shanbogh, Dr Harish Nayak, Dr Subraya Kamath, Dr Venkatesh
Shanbogh, Dr Tantri, Dr Sandeep Gopal, Dr Ganesh, Dr Suresh Shenoy, Dr Sampath, Dr Shabin, Dr Nigil, Dr Nidhin,
Dr Shijith, Dr Ramneik, Dr Lokesh, Dr Ayaz, and Dr Bichu, for their help in various aspects.
I sincerely appreciate Dr Raghavendra Bhat and Dr Ravichandra, Consultants, Department of Radiology, Yenepoya Medical
College, Mangaluru, for their contribution and affectionate help.
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I thank Dr Ganesh Pai (Paediatric Surgeon), Dr Suresh Pai, Dr Ashok Shetty (Cardiothoracic Surgeon), Dr Muralidhar Pai
(Neurosurgeon), Late Dr Vivekanand Prabhu (Paediatric Surgeon), Dr Sadashiva Rao (Paediatric Surgeon), Dr Narayana Bhat
(Paediatric Surgeon), Dr Prashanth Mallya (Anaesthetist), for their help and contributions.
I thank my friend Dr Jagadish, for his contributions to X-ray and opinion on dental and faciomaxillary topics.
My wife Dr Meera Karanth, helped me day and night in revising this edition and without her help this could not have been
possible. My beloved daughter Ananya helped me in drawing new diagrams artistically. I enjoy her love and affection towards me.
I remember my students Dr Ravi CR (Chitradurga), Dr Ashwini Polnaya (Mangaluru), Dr Ishwara Keerthi, Dr Sudesh,
Dr Narasimha Murthy, Dr Nithin, Dr Ashish Singh, and Dr Aromal, for their special contributions.
I thank all my students especially postgraduates, Department of Surgery, who were helping regularly in bringing out this edition.
SRB's Manual of Surgery
Words are not sufficient to remember all my patients who are the main material for the book. I pray for their good health always.
I appreciate Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr MS Mani (Group President), Dr Madhu
Choudhary (Publishing Head–Education), Ms Pooja Bhandari (Production Head) and all staff of M/s Jaypee Brothers Medical
Publishers (P) Ltd, New Delhi, India, for doing appreciable work in their respective field of printing and publishing. Also, my
appreciation to working team in Jaypee Brothers Medical Publishers (Bengaluru and Mangaluru branches), for their timely help.
My sincere thanks to editing team members—Ms Sunita Katla (Executive Assistant to Group Chairman and Publishing Manager);
Ms Seema Dogra (Cover Visualiser); Mr Rajesh Sharma (Production Coordinator); Mr Laxmidhar Padhiary, Mr Binay Kumar and
Mr Vakil Khan (Proofreaders); Mr Kapil Dev Sharma, Mr Kulwant Singh, Kuldeep, Akshay Thakur, Ajeet Rathor (DTP Operators),
and Mr Gopal Singh Kirola (Graphic Designer) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their
dedicated and affectionate work in bringing out the sixth edition of the title.
Contents
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1. General Surgery 1
A. Wounds and Wound Healing
Wounds 1; Classification of Wounds 1; Wound Healing 6; Compartment Syndrome 10; Crush Injury 11;
11
; Degloving Injuries 12; Scar 12; Keloid 12; Hypertrophic Scar 13; Problems with Wound
14
;
Crush Syndrome
Healing
1
B. Ulcer 15
Ulcer 15; Granulation Tissue 18; Investigations for an Ulcer 19; Management of an Ulcer 20; Traumatic Ulcer 22;
22
Trophic Ulcer
23
Ulcer
Meleney’s Ulcer
27
Ulcer
28
Bubo
; Ulcer due to Chilblains 23; Ulcer due to Frostbite 23; Martorell’s Ulcer 23; Arterial/Ischaemic
; Bairnsdale Ulcer 24; Carcinomatous Ulcer 24; Rodent Ulcer 24; Melanotic Ulcer 24; Diabetic Ulcer 25;
26
; Lupus Vulgaris 26; Tuberculous Ulcer 27; Bazin’s Disease 27; Tropical Ulcer 27; Venous
; Syphilitic Ulcer 28; Soft Chancre/Soft Sore/Ducrey’s Ulcer/Chancroid/Bubo 28; Climatic Bubo/Tropical
C. Sinus and Fistula 30
Sinus 30; Fistula 30; Median Mental Sinus 32; Sequestrum 32; Preauricular Sinus
33
D. Infectious Diseases 34
Surgical Infection 34; Cellulitis 34; Erysipelas 37; Lymphangitis 37; Abscess 38; Metastatic and Pyaemic
42
Abscess
Carbuncle
Tetanus
Madura Foot
Acute Pyomyositis
; Bacteraemia 43; Septicaemia 43; Pyaemia 43; Boil (Furuncle) 43; Hidradenitis Suppurativa 44;
45
; Pott’s Puffy Tumour 45; Pyogenic Granuloma 46; Impetigo 46; Erythrasma 46; Scrum Pox 46;
47
; Gas Gangrene 50; Tuberculosis 52; Leprosy 53; Syphilis (Great Pox) 54; Actinomycosis 54;
55
; Rabies 56; Anthrax 59; Nosocomial and Opportunistic Infections 59; Necrotising Fasciitis 60;
61
; Surgical Site Infection 62; HIV Infection and AIDS
65
E. Swellings 68
Lipoma 68; Cysts 71; Dermoids 72; Sebaceous Cyst 75; Neuroma 77; Fibroma 78; Neurofibroma 78;
Neurilemmoma (Schwannoma)
Semimembranosus Bursa
Calcinosis Cutis
F. Electrolyte and Nutrition 87
Normal Physiology 87; Water Loss 87; Water Excess 87; Hyponatraemia 88; Hypernatraemia 88;
Hypokalaemia
Metabolic Alkalosis
Fluid Therapy
Syndrome
89
91
100
; Obesity and Morbid Obesity
G. Shock 104
Shock
104
; Stages of Shock
and Monitoring
Response Syndrome
80
; Ganglion 80; Papilloma 81; Warts 81; Glomus Tumour 82; Bursae 82;
84
; Morrant Baker’s Cyst 85; Lymphangioma 85; Lymph Cyst (Lymphatic Cyst) 86;
86
; Chordoma 86; Epignathus
; Hyperkalaemia 89; Hypermagnesaemia 89; Hypomagnesaemia 90; Acid-Base Balance 90;
90
; Respiratory Alkalosis 90; Metabolic Acidosis 91; Respiratory Acidosis 91; Anion Gap 91;
; Nutrition 96; Gastrostomy 97; Jejunostomy 97; Total Parenteral Nutrition 98; Refeeding
105
; Effects of Shock
108
; Central Venous Pressure
111
; Multiple Organ Dysfunction Syndrome
86
100
105
; Clinical Features of Shock
109
; Pulmonary Capillary Wedge Pressure
111
; Oxygen Therapy
108
; Assessment, Investigations
110
; Systemic Inflammatory
111
; Cardiac Arrest
111
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H. Haemorrhage and Blood Transfusion 113
Haemorrhage
Disseminated Intravascular Coagulation
I. Burns 122
Burns
Inhalation Injury
J. Trauma 133
Triage
Injuries
SRB's Manual of Surgery
Small Bowel Injury
K. Hand and Foot 146
Hand
Terminal Pulp Space Infection (Felon)
Space of Parona Infection
Injuries
Callosity
Athlete’s Foot
L. Arterial Diseases 161
Surgical Anatomy of Thoracic Outlet
Diseases
Obstruction
the Arteries
Raynaud’s Phenomenon
Syndrome
Injury
Embolisation
Abdominal Aneurysm
Dissecting Aneurysm
Systemic Sclerosis
Ainhum
113
; Blood Transfusion
122
; Management of Burns
131
; Chemical Burns
133
; Concepts in Trauma Management
137
; Penetrating Injuries
143
; Colonic Injury
146
; Hand Infections
154
; Dupuytren’s Contracture
158
; Corn
160
; Hallux Valgus
162
; Intermittent Claudication
165
; Other Features of Poor Circulation
169
; Atherosclerosis
183
; Acute Arterial Occlusion
186
; Saddle Embolus
189
; Caisson’s Disease or Decompression Disease
198
201
; Endovascular Surgeries
147
; Acute Paronychia
153
; Acute Suppurative Tenosynovitis
158
; Plantar Fasciitis (Policeman’s Heel)
176
; Temporal Arteritis
186
191
; Abdominal Aortic Aneurysm
197
; Erythromelalgia
; Acrocyanosis
116
; Massive Blood Transfusion
120
; Mechanism of Blood Coagulation
126
; Eschar
132
138
; Abdominal Trauma
143
150
156
160
161
; Arteries of Upper Limb
162
169
; Thromboangiitis Obliterans
183
; Embolectomy
198
; Gangrene
201
; Upper Limb Ischaemia
128
; Contracture in Burn Wound
135
; Spinal Injury
; Abdominal Compartment Syndrome
149
; Infection of Web Spaces
; Volkmann’s Ischaemic Contracture
; Rest Pain
165
177
; Traumatic Acute Arterial Occlusion
187
; Fat Embolism
192
198
; Livedo Reticularis
199
118
; Artificial Blood
120
129
136
; Neck Injuries
138
; Blunt Trauma of Abdomen
; Chronic Paronychia
151
153
; Compound Palmar Ganglion
159
; Ingrowing Toe Nail (Onychocryptosis)
161
; Arteries of Lower Limb
163
; Limb Ischaemia
137
; Bullet Injuries
141
144
; Seat-belt Injuries
150
; Apical Subungual Infection
; Deep Palmar Space Infection
157
; Syndactyly
163
; Different Levels of Arterial
; Investigations for Arterial Diseases
172
; Takayasu’s Pulseless Arthritis
; Treatment of Arterial Diseases
184
; Embolism
187
; Air/Gas Embolism
189
; Aneurysm
; Peripheral Aneurysm
198
; Polyarteritis Nodosa
189
; Mycotic Aneurysm
196
; Carotid Artery Aneurysm
; Diabetic Foot and Diabetic Gangrene
202
; Arterial Substitutes
119
; Tourniquets
; Electrical Burns
137
; Duodenal Injury
145
154
; Hand
157
; Foot
161
; Arterial
166
; Diseases of
177
; Subclavian Steal
184
; Reperfusion
188
; Therapeutic
198
; Scleroderma/
200
; Frostbite
204
119
131
; Blast
143
150
151
158
159
175
191
196
201
;
;
;
;
;
;
;
;
;
;
;
M. Vascular Lesions 205
Vascular Anomalies
209
Fistula
N. Venous Diseases 214
Anatomy of Veins of Lower Limb
Thrombosis
216
Thrombophlebitis
Embolism
237
O. Lymphatics 239
Surgical Anatomy
Lymphadenitis
254
(Maltoma)
Chyluria
; Burkitt’s Lymphoma
256
; Sarcoidosis
P. Peripheral Nerves 258
Peripheral Nerve Injuries
260
Injury
; Carpal Tunnel Syndrome
205
; Haemangioma
214
; Varicose Veins
235
; Klippel-Trenaunay Syndrome
239
; Lymphangiography
241
; Lymphoedema
257
258
219
255
; Tinel’s Sign
205
; Vascular Malformations
208
; Cirsoid Aneurysm
; Physiology of Venous Blood Flow in Lower Limb
; Venous Ulcer
240
; Isotope Lymphoscintigraphy
241
; Lymphomas
; Cutaneous T Cell Lymphoma
259
; Brachial Plexus Injuries
261
; Ulnar Nerve Injury
232
; Compression Therapy for Varicose Veins
235
; Anticoagulants
248
; Mantle Cell Lymphoma
235
255
262
; Claw Hand
; Oral Anticoagulants
241
; Acute Lymphangitis and
; Chylous Ascites
260
; Causalgia
263
; Radial Nerve Injury
254
209
; Arteriovenous
215
; Deep Vein
236
; Pulmonary
; Malt Lymphoma
256
; Chylothorax
260
; Median Nerve
234
256
264
;
;
;
Common Peroneal Nerve Injury
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Long Thoracic Nerve Injury
265
264
; Foot Drop
264
; Medial Popliteal Nerve Injury
; Meralgia Paraesthetica
265
265
; Axillary Nerve Injury
265
;
xix
Q. Neoplasm 266
Definition
Grading of Tumour
Neoplasm
266
; Dysplasia
270
; Management Strategy for Cancers
267
; Carcinoma In Situ
268
; Staging of the Tumour
R. Skin Tumours 276
Anatomy
Dermatofibrosarcoma Protuberans
Squamous Cell Carcinoma
Melanoma
276
; Clasification of Skin Tumours
281
; Marjolin’s Ulcer
287
S. Sarcomas 296
Sarcoma
Rhabdomyosarcoma
Peripheral Nerve Sheath Tumour
296
; Liposarcoma
303
305
; Chondrosarcoma
T. Amputations 307
Amputation
307
; Complications of Amputations
U. Reconstruction 316
Graft
316
Transfer
; Skin Grafts
326
; Tendon Graft
316
; Flaps
326
V. Transplantation 327
Preoperative Evaluation
Transplantation
Small Bowel Transplantation
327
; Organ Procurement
330
; Liver Transplantation
334
279
; Keratocanthoma
; Fibrosarcoma
305
306
; Kaposi’s Sarcoma
319
; Abdominoplasty
331
; Dialysis
334
267
; Aetiologic Factors
269
; Paraneoplastic Syndromes
274
277
; Skin Adnexal Tumours
279
; Rhinophyma
283
; Basal Cell Carcinoma
304
; Malignant Fibrous Histiocytoma
; Haemangiosarcoma
306
314
; Prosthesis
325
; Tendon
327
; Graft Rejection
267
305
315
328
; Immunosuppressive Agents
; Bone Marrow Transplantation
; Cimino Fistula
334
; Spread of Malignant Tumours
270
; Investigations for
277
; Dermatofibroma
279
; Seborrhoeic Keratosis
284
; Turban Tumour
305
; Leiomyosarcoma
; Synovial Sarcoma
325
; Tendon Repair
333
; Pancreatic Transplantation
286
; Naevi
306
; Malignant
326
329
268
278
280
286
305
; Tendon
; Renal
333
;
Contents
;
;
;
;
;
W. Pain 335
Gate Control Theory
335
2. Faciomaxillary Diseases 338
Diseases of the Palate
Primary Care in Maxillofacial Injuries
of the Mandible
Dentigerous Cyst
354
Bone/Jaw
; Cherubism
338
; Orthopantomogram
343
; Fracture Middle Third Area
346
; Dislocation of the Mandible
352
; Dental Cyst
355
352
; Osteomyelitis of Jaw
338
; Cleft Lip and Cleft Palate
344
; Zygomatic Complex Fracture
348
; Jaw Tumours
353
; Alveolar Abscess
349
; Epulis
338
; Maxillofacial Injuries
350
; Ameloblastoma
353
; Fibrous Dysplasia of
345
; Fracture
342
351
;
;
3. Oral Cavity 356
Ranula
356
; Sublingual Dermoids
359
Leukoplakia
; Erythroplakia
Oral and Upper Aerodigestive Cancers
375
of Lip
Fissure
of the Tongue
Carcinoma Hard Palate
; Carcinoma Lip
380
; Glossitis
385
; Nasopharyngeal Carcinoma
380
388
357
; Stomatitis
360
; Oral Submucosal Fibrosis
361
; Cheek
375
; Tongue
; Tongue Tie
378
381
; Carcinoma Tongue
; Laryngeal Tumours
357
; Cancrum Oris
363
; Carcinoma Cheek/Buccal Mucosa
; Tongue Ulcers
385
; Maxillary Tumours
389
; Malignant Tumours of Larynx
358
360
; Premalignant Conditions of Oral Cavity
379
; Benign Tumours of Tongue
382
; Carcinoma of Posterior One-third/Base
; Syphilitic Lesions of Oral Cavity
363
; Lip
374
; Neoplasm
380
386
; Malignant Tumours of Tonsil
389
; Trismus
391
358
361
; Tongue
388
;
;
;
4. Salivary Glands 392
Anatomy
Parotid Fistula
Salivary Neoplasms
Adenoma
392
; Saliva
399
404
; Mucoepidermoid Tumour
395
; Sialography
; Recurrent Childhood Parotitis
400
; Pleomorphic Adenoma
395
; Salivary Calculus and Sialadenitis
399
; Sjögren’s Syndrome
401
; Adenolymphoma
404
; Adenoid Cystic Carcinoma
396
; Parotid Abscess
400
; Sialosis
403
; Oncocytoma
405
; Acinic Cell Tumour
400
; Sialectasis
404
398
400
; Basal Cell
405
;
;
;
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