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Malignant Mixed Tumour
Glands
Lymphoma
5. Neck 414
Anatomy of Lymphatics of Head and Neck
Branchial Fistula
Parapharyngeal Abscess
Torticollis
in Neck Lymph Nodes
6. Thyroid 443
SRB's Manual of Surgery
Development
449
Tests
451
Goitre
and Hyperthyroidism
Follicular Carcinoma of Thyroid
Madullary Carcinoma of Thyroid
Subacute Granulomatous
Theodor Kocher
7. Parathyroids and Adrenals 489
Anatomy
Syndrome)
Tumours
Syndrome or Adrenogenital Syndrome
405
; Adenocarcinoma of Salivary Glands
406
; Submandibular Salivary Gland Tumours
409
; Parotidectomy
420
; Pharyngeal Pouch
426
429
; Sternomastoid Tumour
435
443
; Surgical Anatomy
; FNAC of Thyroid
; Discrete Thyroid Nodule
458
; Radioactive Iodine
485
; Kocher’s Test
489
; Calcium
496
; Apudomas
498
; Adrenocortical Carcinoma
410
; Frey’s Syndrome
414
; Thoracic Outlet Syndrome
421
; Laryngocele
; Retropharyngeal Abscess
430
; Tuberculous Lymphadenitis
; Chemotherapy for Head and Neck Cancers
443
; Physiology
449
; Classification of Goitre
453
; Solitary Thyroid Nodule
466
470
; Differentiated Thyroid Carcinoma
476
; Malignant Lymphoma
478
; Riedel’s Thyroiditis
485
; Hypothyroidism
489
; Hyperparathyroidism
496
; Hypoparathyroidism
499
; Cushing’s Syndrome
500
; Neuroblastoma
406
406
; Minor Salivary Gland Tumours
411
; Facial Nerve Injury
422
; Cystic Hygroma
426
; Subhyoid Bursitis
445
; Congenital Anomalies
450
; Diffuse Hyperplastic Goitre
454
; Thyroid Neoplasms
478
; Hashimoto’s Thyroiditis
478
; Thyroid Incidentaloma
485
; Recurrent Laryngeal Nerve Palsy
490
; Parathyroidectomy
497
; Tetany
500
; Phaeochromocytoma
; Squamous Cell Carcinoma of Salivary
409
; Parotid
412
415
; Cervical Rib
431
; Cold Abscess
442
; Retrosternal Goitre
467
; Papillary Carcinoma of Thyroid
472
; Anaplastic Carcinoma of Thyroid
479
498
; Adrenals
500
; Conn’s Syndrome
416
; Branchial Cyst
424
; Ludwig’s Angina
427
; Carotid Body Tumour
434
; Secondaries
445
; Thyroid Function
451
; Multinodular
457
; Thyrotoxicosis
478
; De-Quervain’s
; Thyroidectomy
486
493
; MEN Syndrome (MEA
498
; Adrenal Cortical
500
502
479
; Emil
; Virilising
419
425
428
468
474
;
;
;
;
;
8. Breast 504
Anatomy
Fibroadenoma
Traumatic Fat Necrosis
Disease
Duct Papilloma
Staging of Carcinoma Breast
Prognostic Factors in Carcinoma Breast
Reconstruction
504
; Mammography
508
; Fibrocystadenosis
514
517
; Tuberculosis of the Breast
521
; Zuska-Atkins Disease
552
; Breast Implants
507
; Galactocele
532
; Management of Early Carcinoma Breast
; Aberration of Normal Development and Involution of the Breast
510
; Sclerosing Adenosis
514
; Mastitis
518
; Breast Cysts
521
; Mammary Fistula of Atkins
551
; Prophylactic Mastectomy
555
; Nipple Retraction
512
515
; Antibioma
518
556
; Phylloides Tumour
517
; Duct Ectasia
; Galactorrhoea
547
551
; Carcinoma of Male Breast
519
522
; Carcinoma Breast
; Advanced Carcinoma Breast
512
; Mastalgia
517
; Mondor’s
; Gynaecomastia
522
; TNM
551
; Breast
508
513
519
548
;
;
;
;
9. Peritoneum 557
Anatomy
Peritonitis
Abscess
Acute Mesenteric Lymphadenitis
Malignancy
557
; Physiology
564
; Biliary Peritonitis
566
; Subphrenic Spaces and Subphrenic Abscess
571
; Omental Cyst
557
; Acute Peritonitis
564
; Postoperative Peritonitis
570
; Mesenteric Malignancy
572
; Omental Torsion
558
; Spontaneous Bacterial Peritonitis
565
; Other Forms of Peritonitis
566
; Mesenteric Cysts
570
572
; Omental Tumour
; Mesenteric Trauma
569
; Mesenteric Panniculitis
572
564
; Sclerosing
565
; Pelvic
571
; Peritoneal
570
;
10. Abdominal Tuberculosis 573
Abdominal Tuberculosis
Tuberculous Mesenteric Lymphadenitis
Omentum
583
573
; Ileocaecal Tuberculosis
582
574
; Ileal Tuberculosis
578
; Peritoneal Tuberculosis
; Ano-recto-sigmoidal Tuberculosis
583
; Tuberculosis of the
579
;
11. Liver 584
Surgical Anatomy of Liver
Infections of Liver
Emergency Management in Severe Haemorrhage
584
; Liver Function Tests
589
; Liver Tumours
598
; Liver Cysts
612
585
; Alpha Fetoprotein
606
; Portal Hypertension
; Ascites
617
585
; Liver Biopsy
607
586
; Oesophageal Varices
; Ascites in Portal Hypertension
; Liver Injury
618
; Budd-Chiari’s
586
610
;
;
Syndrome
https://t.me/medicina_free
619
Portal Biliopathy
; Hepatic Failure
622
620
; Hepatic Encephalopathy
620
; Hepatorenal Syndrome
620
; Hepatic Resection
621
;
xxi
12. Gallbladder 623
Surgical Anatomy
Cholangiopancreatography
Cholangiopancreatography
T-tube Cholangiogram
630
Disease
Mirizzi Syndrome
Murphy’s Sign
Choledocholithiasis
649
Strictures
Gallbladder
655
; Cholecystectomy
Bile
Single Incision Laparoscopic Surgery in Cholecystectomy
Syndrome
623
; Oral Cholecystogram
625
626
627
; Congenital Anomalies of Gallbladder
; Biliary Atresia
638
640
; Gallstone Ileus
630
; Empyema Gallbladder
642
; Sump Syndrome
; Sclerosing Cholangitis
651
; Cholangiocarcinoma
655
658
; Biliary Dyskinesia
625
; Intravenous Cholangiogram
; Percutaneous Transhepatic Cholangiography
; Radioisotope Scan Study
; Gallstones
631
; Acute Cholecystitis
638
; Mucocele of the Gallbladder
640
; Cholecystoses
645
650
; Gallbladder Polyp
653
; Klatskin Tumour
; Open Approach Cholecystectomy
659
626
; Peroperative Cholangiogram
627
641
; Dissolution Therapy for Gallstones
; Courvoisier’s Law
650
; Benign Biliary Papilloma
653
; Biliary Fistulas
656
657
; Bile Duct Injuries
; Choledochal Cysts
635
; Acute Acalculous Cholecystitis
646
; Laparoscopic Cholecystectomy
625
; Endoscopic Retrograde
625
; Magnetic Resonance
626
; Postoperative
628
639
; Chronic Cholecystitis
; Surgical Jaundice
651
654
; Hemobilia
658
; Post-cholecystectomy
; Caroli’s
637
639
642
646
; CBD
; Carcinoma
654
; White
656
;
;
;
;
13. Spleen 660
Surgical Anatomy
Rupture of Spleen
Thalassaemia
Thrombocytopaenic Purpura
Artery Aneurysm
660
; Functions of the Spleen
664
; Splenomegaly
666
; Sickle Cell Disease
668
; Splenectomy
670
; Splenic Abscess
660
; Splenunculi
665
; Hereditary Spherocytosis
666
; Idiopathic Thrombocytopaenic Purpura
668
; Overwhelming Post-splenectomy Infection
671
; Hypersplenism
671
661
; Splenic Injury
665
; Immune Haemolytic Anaemia
; Splenic Cyst
671
661
; Atraumatic
667
; Thrombotic
670
; Splenic
666
;
Contents
14. Pancreas 672
Surgical Anatomy
Pancreatitis
Chronic Pancreatitis
Endocrine Pancreatic Tumours
Syndrome
Divisum
705
Pancreatic Trauma
672
; Serum Amylase
675
; Acute Pancreatitis
685
; Pancreatic Tumours
704
; Cystic Fibrosis
; Pancreatic Calculus
707
; Cystic Lesions of Pancreas
674
; Serum Lipase
675
; Complications of Acute Pancreatitis
702
; Insulinomas
704
; Annular Pancreas
705
; Pancreatic Ascites
674
; Magnetic Resonance Cholangiopancreatography
693
; Exocrine Pancreatic Tumours
702
; Gastrinomas
704
; Ectopic (Accessory) Pancreatic Tissue
706
707
; Pancreatic Exocrine Insufficiency
703
; Pancreatic Fistulae
681
; Pseudocyst of Pancreas
693
; Carcinoma Pancreas
; Glucagonomas
706
; Pancreatic Necrosis
703
; Zollinger-Ellison
705
; Pancreatic
708
675
682
695
706
;
;
;
;
15. Retroperitoneal Space 709
Anatomy of Retroperitoneum
711
Tumours
; Psoas Abscess
709
; Retroperitoneal Fibrosis
714
709
; Retroperitoneal Swellings
710
; Retroperitoneal
16. Differential Diagnosis of Mass Abdomen 716
Mass in the Right Hypochondrium
721
in the Lumbar Region
723
Iliac Fossa
; Mass in the Hypogastrium
; Mass in the Umbilical Region
718
; Mass in the Epigastrium
723
; Distal Rectal Examination of Prostate and Other Conditions
719
; Mass in the Left Hypochondrium
722
; Mass in the Right Iliac Fossa
720
723
; Mass in the Left
; Mass
724
17. Abdominal Wall and Umbilicus 728
Diseases of the Umbilicus
Umbilical Sinus
Tumours
730
734
; Desmoid Tumour
Abdominal Wall Abscess
Diverication of Recti
728
; Omphalitis
; Umbilical Adenoma
734
; Exomphalos
737
; Meleney’s Progressive Synergistic Bacterial Gangrene of Abdominal Wall
738
728
; Umbilical Granuloma
730
; Umbilical Fistula
735
; Gastroschisis
729
; Anomalies of Vitellointestinal Duct
731
; Patent Urachus
736
; Rectus Sheath Haematoma
731
; Abdominal Wall
729
737
737
;
;
;
18. Hernia 739
Aetiology
Sliding Groin/Inguinal Hernia
740
; Parts of Hernia
741
; Classification of Hernia
762
; Pantaloon Hernia
742
; Inguinal Hernia
763
; Femoral Hernia
743
; Strangulated Hernia
763
; Ventral Hernia
765
; Incisional
760
;
xxii
https://t.me/medicina_free
Hernia
Obturator Hernia
Surgery
19. Oesophagus 776
Anatomy
Oesophagoscopy
Reflux Disease
Barrett’s Ulcer
Corrosive Stricture of Oesophagus
Syndrome
SRB's Manual of Surgery
Benign Tumours of the Oesophagus
20. Stomach 804
Anatomy
Gastroscopy
Ulcer
Bleeding Peptic Ulcer
Duodenal Ileus
Menetrier’s Disease
Sarcomas
Gastrojejunostomy
766
; Umbilical Hernia
773
; Richter’s Hernia
774
; Parastomal Hernia
776
; Lower Oesophageal Sphincter
780
; Oesophageal Endosonography
781
; Hiatus Hernia
788
; Oesophageal Motility Disorders
793
; Tracheo-oesophageal Fistula
804
; Gastric Physiology
808
; Congenital Hypertrophic Pyloric Stenosis
813
; Duodenal Ulcer
832
; Dunbar’s Syndrome
848
; Gastrointestinal Stromal Tumours
850
816
; Pyloric Stenosis due to Chronic Duodenal Ulcer
824
; Haematemesis
834
; Duodenal Diverticula
; Retrograde Jejunogastric Intussusception
769
; Paraumbilical Hernia
773
; Lumbar Hernia
775
778
785
; Rolling Hernia
791
; Schatzki’s Rings
793
; Oesophageal Diverticulum
802
; Oesophageal Perforation
806
; Gastric Function Tests
827
; Complications of Gastric Surgery
832
; Acute Gastric Dilatation
835
770
; Epigastric Hernia
773
; Sciatic Hernia
; Dysphagia
781
; Third Space Endoscopy
786
; Reflux Oesophagitis
788
; Achalasia Cardia
811
778
793
; Boerhaave’s Syndrome
802
807
; Gastrin
; Gastritis
833
; Carcinoma Stomach
848
; Pyloroplasty
849
850
; Vagotomy
771
; Spigelian Hernia
774
; Complications of Hernia
; Contrast Study of Oesophagus
781
; Gastro-oesophageal
786
; Barrett’s Oesophagus
788
; Plummer-Vinson Syndrome
793
; Mallory-Weiss
794
; Carcinoma Oesophagus
807
; Barium Meal Study
812
; Acute Peptic Ulcer
818
; Perforated Peptic Ulcer
828
; Trichobezoar
; Gastric Volvulus
835
; Gastric Lymphoma
; Gastrostomy
851
833
849
813
; Gastric
831
; Chronic
; Gastric Polyp
846
; Gastric
; Gastrectomy
772
780
787
791
795
808
820
834
849
;
;
;
;
;
;
;
;
;
21. Small Intestine 852
Anatomy
Pneumatosis Cystoides Intestinalis
Bowel Tumours
Small Bowel Enema
Fistula
852
; Meckel’s Diverticulum
864
; Benign Tumours of Small Bowel
871
; Capsule Endoscopy
872
853
; Regional Enteritis
861
; Mesenteric Vessel Ischaemia
865
; Carcinoid Tumour
871
; Small Bowel Enteroscopy
855
; Surgical Complications of Typhoid
861
; Necrotising Enterocolitis
868
; Short Bowel Syndrome
872
; Enteric/Gastrointestinal
863
858
; Small
870
;
;
22. Large Intestine 876
Anatomy
Colitis
Colon
Care
Pouches
876
; Hirschsprung’s Disease
887
; Pseudomembranous Colitis
889
; Carcinoma Colon
903
; Stoma Appliances
906
; Barium Enema
877
; Diverticular Disease of the Colon
888
; Surgical Complications of Intestinal Amoebiasis
892
; Angiodysplasia of Colon
904
; Faecal Fistula
907
879
; Ulcerative Colitis
900
; Ogilvie’s Syndrome
905
; Preparation of Large Bowel for Surgery
900
; Colostomy
883
; Ischaemic
888
; Tumours of
901
906
; Surgical
; Stoma
23. Intestinal Obstruction 908
Intestinal Obstruction: Types
917
Malrotation
924
Ileus
; Meconium Ileus
; Adhesions and Bands
908
; Dynamic Obstruction
918
; Intussusception
924
; Internal Hernias
909
; Duodenal Atresia
919
; Volvulus
927
915
; Small Intestine Atresia
922
; Sigmoid Volvulus
922
; Paralytic
916
;
24. Appendix 928
Surgical Anatomy
Fistula after Appendicectomy
Appendicectomy
928
; Acute Appendicitis
938
939
929
; Incidental Appendicectomy
; Mucocele of Appendix
936
; Appendicular Abscess
938
; Neoplasms of the Appendix
937
939
; Laparoscopic
; Faecal
25. Rectum and Anal Canal 942
Surgical Anatomy of Rectum
Proctoscopy (Kelly’s)
Syndrome
Haemorrhoids
952
961
Condyloma Acuminata
942
; Surgical Anatomy of Anal Canal
945
; Sigmoidoscopy
; Rectal Prolapse
; Anal Fissure
976
; Anal Intraepithelial Neoplasia
945
; Colonoscopy
952
; Anorectal Malformations
967
; Anorectal Abscess
976
943
; Per-rectal Examination of the Rectum
945
; Carcinoma Rectum
957
; Pilonidal Sinus/Disease
969
; Fistula-In-Ano
971
; Anorectal Strictures
; Malignant Tumours of Anal Area
946
; Solitary Ulcer
958
; Piles/
976
; Sacrococcygeal
945
976
;
;
Teratoma
https://t.me/medicina_free
978
; Anal Incontinence
978
Hydradenitis Suppurativa of Anal Region
; Descending Perineal Syndrome
980
; Pruritus Ani
980
; Gastrointestinal Haemorrhage
979
; Proctitis
979
; Proctalgia Fugax
980
979
;
xxiii
26. Urology 984
A. Kidney
Anatomy of Kidney and Ureter
Retrograde Pyelography
Urethrogram
Cystostomy
Pelvis and Ureter
Hydronephrosis
Calculus
Tumour
984
988
; Isotope Renography
992
; Haematuria
995
; Retrocaval Ureter
1000
; Pyonephrosis
1005
; Ureteric Calculi
1012
; Renal Cell Carcinoma
984
; Plan X-ray—Kidney, Ureter and Bladder
987
; Renal Angiogram
988
993
; Horseshoe Kidney
1004
1009
; Staghorn Calculus
1013
987
; Micturating Cystourethrography
; Cystoscopy
996
; Ureterocele
989
993
; Cystic Diseases of the Kidney
996
; Carbuncle of Kidney
985
; Intravenous Urogram
; Catheters
; Injuries to Kidney
1011
; Benign Tumours of Kidney
990
; Nephrostomy
997
1004
; Perinephric Abscess
987
; Ascending
992
; Suprapubic
994
; Duplication of Renal
; Renal Tuberculosis
1005
; Renal
1012
; Wilms’
986
998
;
;
B. Urinary Bladder 1018
Anatomy
Cystitis
Bladder Tumours
Residual Urine
Diverticula
1018
; Ectopia Vesicae
1021
; Interstitial Cystitis
1023
1027
; Malakoplakia
1029
; Urinary Diversion
1019
; Urachal Anomalies
1022
; Schistosoma Haematobium
; Transitional Cell Carcinoma
1028
; Neurogenic Bladder
1030
; Urinary Fistulas
1019
; Vesical Calculus
1023
; Ureterosigmoidostomy
1028
1031
1019
; Cystitis
1022
; Thimble or Systolic Bladder
1026
; Rupture Bladder
; Vesicoureteric Reflux
1021
; Recurrent
1028
1022
1026
; Bladder
;
;
C. Prostate 1032
Anatomy
Prostatitis
1032
; Acid Phosphatase
1036
; Bladder Outlet Obstruction
1032
; Prostate Specific Antigen
1036
; Carcinoma Prostate
1032
; Benign Prostatic Hyperplasia
1037
1033
;
Contents
D. Urethra 1040
Anatomy
Urethral Valve
1040
; Urethral Injury
1045
; Urethral Calculi
1040
; Stricture Urethra
1045
; Urethritis
1042
; Hypospadias
1046
; Extravasation of Urine
1044
; Epispadias
1046
1044
; Posterior
; Retention of Urine
1047
E. Penis 1048
Phimosis
Peyronie’s Disease
1048
; Paraphimosis
1049
1051
; Ram’s Horn Penis
; Circumcision
1051
1049
; Balanoposthitis
; Carcinoma Penis
1050
; Chordee
1051
; Buschke-Löwenstein Tumour
1050
; Priapism
1051
1055
;
F. Scrotum 1056
Anatomy
Epididymis
1056
; Fournier’s Gangrene
1062
; Spermatocele
1063
; Varicocele
1056
; Hydrocele
1063
1057
; Haematocele
1061
; Pyocele
1062
; Cyst of
G. Testis 1065
Anatomy
Testicular Tumours
1065
; Undescended Testis
1070
1065
; Ectopic Testis
; Paratesticular Tumours
1074
1068
; Retractile Testis
; Orchitis
1074
; Epididymitis
1068
; Torsion of the Testis
1075
1068
;
27. Neurosurgery 1076
Head Injuries
Fracture Skull
Abscess
Craniopharyngiomas
Prolapse
1076
; Extradural Haematoma
1084
; Depressed Skull Fracture
1086
; Intracranial Aneurysms
1091
; Spinal Dysraphism
1093
; Spinal Tumours
1096
1081
; Subdural Haematoma
1084
; CSF Rhinorrhoea
1087
; Intracranial Tumours
1091
; Meningocele
1082
1085
1092
; Spina Bifida
; Subarachnoid Haemorrhage
; Hydrocephalus
1087
; Pituitary Tumours
1085
; Intracranial
1092
; Intervertebral Disc
1083
1090
;
;
28. Thorax 1097
Chest Injuries
Pneumothorax
Empyema Necessitans
Embolism
Lung Cancers
1097
1107
1111
; Fracture Ribs
1101
; Haemothorax
1104
; Lung Abscess
1100
; Surgical Emphysema
; Pancoast Tumours
; Flail Chest and Stove in Chest
1102
; Pleural Tap
1104
; Intercostal Tube Drainage
1108
; Lung Cysts
1112
; Chest Wall Tumours
1102
; Bronchoscopy
1109
; Mediastinal Tumours
1112
; Pericarditis
1100
; Pneumothorax
1103
; Empyema Thoracis
1105
; Shock Lung
1113
1101
1107
; Pulmonary
1109
; Thymomas
; Pericardial Tap
; Tension
1103
1111
1113
;
;
;
xxiv
https://t.me/medicina_free
Cardiac Tamponade
Surgical Management of Pulmonary Tuberculosis
Cardiac Surgery 1118
Anatomy
Congenital Heart Diseases
Defect
Tetralogy of Fallot
Regurgitation
29. Adjuvant Therapy 1126
SRB's Manual of Surgery
Radiotherapy
Cancer
30. Anaesthesia 1132
Preoperative Assessment
Epidural Anaesthesia
31. Advanced Imaging Methods 1138
Ultrasound
Positron-Emission Tomography Scan
32. Operative Surgery 1144
1113
; Diaphragmatic Hernia
1118
; Preoperative Assessment and Preparation of the Cardiac Patient
1120
; Patent Ductus Arteriosus
1121
; Ventricular Septal Defect
1122
; Acquired Heart Disease
1124
; Valve Replacement Surgery
1126
; Chemotherapy
1129
; Immunosuppression
1137
1138
; Doppler
1132
1140
1128
1129
; General Anaesthesia
; CT Scan
1143
1114
; Pulmonary Complications During Postoperative Period
1117
; Video-assisted Thoracoscopic Surgery
1122
; Pulmonary Stenosis
1123
; Mitral Regurgitation
1124
; Ischaemic Heart Disease
; Cell Cycle
; Immunotherapy
1140
1128
1133
; Magnetic Resonance Imaging
1119
1120
; Coarctation of Aorta
1122
; Transposition of Great Vessels
1123
; Antimalignancy Drugs
1131
; Hybridoma
; Regional Anaesthesia
1117
; Cardiopulmonary Bypass
1121
; Atrial Septal
; Aortic Stenosis
1124
; Cardiac Pacemakers
1129
; Hormone Therapy in
1131
; Gene Therapy
1136
; Spinal Anaesthesia
1142
; Radionuclide Imaging
1124
1131
1117
1120
1122
; Aortic
1125
1136
1143
;
;
;
;
;
A. Sterilisation and Instruments 1144
Sterilisation
1144
; Instruments
1146
; Suture Materials
1153
; Diathermy
1155
B. Operative Procedure 1156
Abdominal Incisions
Appendicectomy
Staplers in Surgery
1161
Surgery
Surgeries
Surgery
; Laparoscopic Cholecystectomy
1162
1163
1156
; Vasectomy
1157
; Thyroidectomy
1160
; Nasojejunal Tube Feeding
; Diagnostic Laparoscopy
1157
; Circumcision
1157
; Tracheostomy
1160
1162
; Laparoscopic Appendicectomy
1162
; Retroperitoneoscopy
1157
; Hydrocele
1157
; Cryosurgery
; Gossypiboma
1163
; Natural Orifice Transluminal Endoscopic
1157
; Inguinal Hernia
1159
; Lasers in Surgery
1161
; Advantages of Laparoscopic
1162
; Advanced Laparoscopic
1157
1159
;
;
C. Dressings and Bandages 1164
Dressings
1164
; Bandages
1164
D. Day Care Surgery 1165
Day Care Surgery
1165
; Surgical Audit
1166
; Surgeon and Law
1167
33. Miscellaneous 1168
A. Fascinating Signs in Surgery 1168
B. Triads in Surgery 1177
C. Misnomers in Surgery 1178
D. Triangles in Surgery 1179
Further Reading 1180
Appendix 1181
Index 1185
Chapter
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1
General Surgery
One having a wound in his eyebrow. An ailment which I will treat. Treatment (of a wound in the eyebrow): Now after thou hast stitched
it (thou shouldst bind) fresh meat upon (it) the first day. If thou findest that the stitching of this wound is loose, thou shouldst draw
it together for him with two strips (of plaster), and thou shouldst treat it with grease and honey every day until he recovers.
circa 2500 BC
C hapter Outline
·
Wounds
·
Classication of Wounds
·
Wound Healing
·
Compartment Syndrome
·
Crush Injury
·
Crush Syndrome
WOUNDS
A wound is a break in the integrity of the skin or tissues often,
which may be associated with disruption of the structure and
function.
Wound is simply a disruption of any tissues—soft tissue or bone
or internal organs. Ulcer is disruption or break in the continuity
of any lining—may be skin, mucous membrane or others. Ulcer
is one of the types of wounds.
CLASSIFICATION OF WOUNDS
·
Degloving Injuries
·
Scar
·
Keloid
·
Hypertrophic Scar
·
Problems with Wound
Healing
¾
It is incised, clean, healthy wound without any tissue loss.
¾
Usually primary suturing is done. Healing is by primary
intention.
b.
¾
They are due to: Crushing, Tearing, Avulsion, Devitalised
injury, Vascular injury, Multiple irregular wounds, Burns.
¾
Fracture of the underlying bone may be present.
Wound dehiscence, infection, delayed healing are common.
¾
Liberal excision of devitalised tissue and allowing to heal by
secondary intention is the management.
¾
Secondary suturing, skin graft or flap may be needed.
a.
¾
They are wounds like surgical incisions and wounds caused
by sharp objects.
Tidy wound.
I dressed him and God healed him.
2
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underneath. It is more common on the skin over the bones;
lax areas like face, scrotum, eyes; vascular areas; children, old
aged, and fair skin people.
SRB's Manual of Surgery
Fig. 1.1B: Untidy wound.
Clean incised wound: It is a tidy, simple, clean cut wound with
linear cut edges; usually due to a sharp object like blade, glass
piece or knife. It is treated by primary suturing.
A
A
B
Clean incised wounds.
Lacerated wound: It has ragged edges with some part of
the tissues getting devitalized; viability of the tissues may be
impaired; depth of the injury and tissue damage should be carefully assessed. Proper adequate wound excision, thorough warm
saline wash and suturing of the wound layer-by-layer is required.
Bruise or contusion: It is due to blow or blunt force to the skin
and tissues underneath wherein blood vessels or capillaries
are damaged underneath. There is skin discolouration without
breaking of the skin; broken vessels cause seepage of blood
underneath; minor soft tissue injury crushes small vessels
without breaking the skin, accumulating the trapped blood
B
Lacerated wounds.
Haematoma: It is a localized collection of blood after blunt
trauma or after surgery. Collected fluid blood gets clotted in
few minutes to hours; later eventually it liquefies to form a
discolored fluid. It may be located in subcutaneous/intramuscular/subfascial/intra-articular regions. Large haematoma may
get infected to form an abscess; so large haematoma needs
drainage under general or regional anaesthesia. Small haematoma usually gets absorbed (like scalp haematoma). Often
haematoma contains reddish plasmatic fluid which should be
aspirated using wide bore needle. Complications are—pressure
effects and abscess formation; both needs incision and drainage
under anaesthesia. Haematoma causing cosmetic problems may
require needle aspiration. Haematoma can occur spontaneously
in coagulation disorders (haemophilia) or in individuals who are
on anticoagulant drug therapy.
A B
(A) Haematoma of eyelid; (B) Subungual
haematoma. Often nail may need to be removed to evacuate the
blood clot.
Haematoma in the groin being aspirated. Haematoma
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may get infected or can compress adjacent structures.
Hematoma leg—after aspiration clot is evacuated.
Abrasion: It is superficial injury (scratch/graze/pressure/contact)
and is due to shearing of the skin where the surface is rubbed off.
This tangential force causes loss of epidermis exposing dermal
vessels and nerves leading to profuse painful oozing. Abrasion
heals by epithelialisation. Any dirt or foreign body on the abrasion
should be removed to avoid formation of poor tattoo like scar.
Deeper vital structures or organs may be injured, so should be
assessed; foreign body or object may be present in the depth of
the wound. Wound should be explored under general or regional
anaesthesia to assess the depth and severity of the injury and
sutured layer by layer after a through saline wash.
Penetrating wound of the abdomen.
Penetrating wounds: They are similar to puncture wounds;
occur to stab. Abdomen and chest are common sites. Liver,
bowel, spleen, major vessels and other visceral organs may be
involved. Ultrasound and CT scan should be done to evaluate
deeper organ injuries. Under general anaesthesia wound should
be explored properly.
Traction and avulsion injuries:
where the tissues are displaced from their normal anatomical
position and alignment. It can occur in single plane like in subcutaneous tissue or in multiple planes like in machinery injuries,
major injuries or degloving injuries. Ischaemia, bleeding, sepsis,
loss of wide tissue area are common problems. Open traction
injury occurs on the surface. Closed traction injury can occur in
deeper plane like brachial plexus injury or traction bowel injury.
After initial resuscitation, definitive treatment like skin graft or
nerve repair should be done.
Crush injury: It is due to major wounds, war wounds, natural
disaster like earth quake injuries, tourniquet injury. It leads
into—compartment syndrome; muscle ischaemia; loss of
tissues; gangrene; sepsis. Muscle will lose its viability which is
identified by its colour (dark coloured with loss of shining); lose
its contractility; becomes turgid, and will not bleed on cutting.
These are complex injuries
3
CHAPTER 1A General Surgery: Wounds and Wound Healing
Typical look of abrasion in face.
Puncture wounds and bites: It is usually a stab wound with a
pointed object; here depth of the wound is more than the width.
A great part, I believe, of the art of medicine is the ability to observe.—
Severe crush injury leg.
4
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Gunshot injuries: These injuries may be superficial or deep.
Usually entry wound and exit wound will be present. It causes
explosive and destructive injuries along with burn injuries in the
deeper planes and organs. It can be high velocity injuries with
massive bleeding and major organ injuries.
Injuries to bones and joints: It is common in all major injuries;
should be identified clinically and confirmed radiologically. It
needs specialized management like reduction, plating, etc.
Injuries to nerves, arteries, veins (major vessels), deeper
organs: It needs initial resuscitation, later staged management
as per individual patient basis depending on the severity and
extent of injury and loss of function.
SRB's Manual of Surgery
Closed blunt injury: It may be due to fall or blunt injury wherein
no obvious external injury is seen but deeper injury can occur; it
Acute deep wound adjacent to elbow joint.
may be often severe enough to cause major injury like in blunt
abdominal injury causing bowel/liver/spleen/renal injuries.
matory phase. Diabetes, venous/arterial diseases, nutritional
deficiencies are the causes. Hypoxia initially is a potent stimulus
Note:
Wound may be closed (bruise, haematoma, blunt injury); open (abrasion,
incised, lacerated, penetrating) or complex (traction/avulsion, crush or
gunshot injuries).
Superficial wound involving only epidermis and dermal
papillae.
Partial thickness wound with skin loss up to deep dermis
with only deepest part of the dermis, hair follicle shafts and
sweat glands are left behind.
Full thickness wound with loss of entire skin and subcuta-
neous tissue causing spacing out of the skin edges.
Deep wounds are the one extending deeper, across deep
fascia into muscles or deeper structures.
Complicated wounds are one associated with injury to
for fibroblast activity and angiogenesis; but persistent hypoxia
impedes fibroblast and collagen activity and also allows bacterial invasion to make wounds chronic. Chronic wounds are
chronically infected with biofilms which interfere mainly with the
inflammatory phase of healing, contributing to the non-healing.
A biofilm is a complex structure of microorganisms contained
in an extracellular matrix of proteins and polysaccharides that
adhere to a surface, creating a protected environment for the
organisms. Chronic ulcers are unresponsive to dressing treat-
ment; it requires biopsy, culture study, definitive treatment like
wound debridement, VAC (vacuum-assisted closure) therapy,
skin grafting or flap. Specific conditions like tuberculosis if
present should be treated. Malignancy if confirmed is treated
by wide local excision and skin graft.
vessels or nerves.
Penetrating wound is one which penetrates into either natural
cavities or organs.
Simple wounds are one involving only one organ or tissue.
Combined/complex wounds are one involving mixed tissues.
Acute wounds are generally defined as those that progress
through the normal phases of healing and typically show signs of
healing in less than 4 weeks; examples are—surgical or traumatic
or burn wounds; progress through the healing phases in a timely
Chronic wound over the scalp.
and orderly fashion—haemostasis, inflammation, proliferation,
and remodeling or maturation.
A wound is considered chronic if healing does not occur within
the expected period according to its aetiology and localization.
Chronic wounds can be classified as typical and atypical. Typical
wounds include ischaemic, neurotrophic and hypostatic ulcers
and diabetic foot and decubitus ulcers. Atypical chronic wounds
can be caused by autoimmune disorders, infectious diseases,
vascular diseases and vasculopathies, metabolic and genetic
diseases, neoplasm, external factors, psychiatric disorders,
drug-related reactions, etc. They do not follow the normal
healing process and show no signs of healing. It fails to progress
through the normal phases of healing but with prolonged inflam-
VI -
1. Clean wound: Elective, primarily closed; no entrance of
normally or frequently colonized body cavities; no break in
sterile technique. Examples are—hernioplasty, excisions,
thyroidectomy, surgeries of brain, joints, heart and transplant.
Infective rate is less than 2%.
2. Clean contaminated wound: Controlled opening of a normally
colonized body cavities; minimal spillage or break in sterile
technique. Infective rate here is up to 30%. Examples are—
Appendicectomy, gastrojejunostomy, pancreatic and biliary
surgeries.
3. Contaminated wound: Acute inflammation; break in sterile
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technique; spillage from hollow organs; penetrating trauma
less than 4 hours from injury; chronic open wounds. Examples are—acute abdominal conditions. Infective rate is up to
60%.
4. Dirty wound: Purulent abscess; perforation with colonized
bacteria; penetrating trauma more than 4 hours from injury.
Examples are—abscess, perforated viscous with peritonitis,
faecal contamination. Infective rate is more than 60%.
Clean wound of thyroidectomy surgery.
5
CHAPTER 1A General Surgery: Wounds and Wound Healing
Contaminated wound—burst appendicitis.
Appendicectomy wound, which is a clean
contaminated wound.
T
• Simple wounds: Only skin is
involved
• Complex wounds: Vessels,
nerves, tendons or bones are
involved
• Closed wounds: • Clean wound
– Contusion
– Abrasion
– Haematoma
• Open wounds:
– Incised wounds
– Lacerated wounds
– Crush injuries
– Penetrating wounds
• Tidy wounds
• Untidy wounds
• Clean contaminated
wound
• Contaminated wound
• Dirty wound
A
B
Acute peritonitis with frank pus in peritoneal
cavity due to bowel perforation is a dirty wound.
Wound causing extensive skin loss and necrosis.
Start by doing what’s necessary, then do what’s possible and suddenly you are doing the impossible.
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