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CHAPTER 2 Principles of surgery
32
Evaluation of the neck
Evaluation of carotid artery disease is described on b p. 658.
Positioning and inspection
Sit the patient upright at rest with the head looking straight ahead. •
Inspect the neck from the front, side, and, if necessary, behind.
Observe the neck at rest and during swallowing (a glass of water). If •
necessary, inspect rotation left and right.
Observe the neck while asking the patient to protrude the tongue.•
Inspection includes looking for the following.
Overall symmetry and lumps.• Are there obvious lumps? Are they single
or multiple? Is the lump lying in or close to the midline? Does the lump
move with swallowing (suggests thyroid-related lesion)?
Skin abnormalities.• Are there any ulcers of sinuses (suggests chronic
infection such as TB)?
Associated structures.• Is there evidence of venous engorgement or
collateral vessels visible?
Palpation
Be systematic; palpate the regions of the neck in order. Use both hands
with the fl ats of the fi ngers to compare each side, but move only one
hand at once to prevent ‘cross-palpation’. A typical sequence of palpation
is: anterior triangle (bottom to top); submental area; submandibular area;
posterior triangle (top to bottom); supraclavicular fossae; parotid, preauricular and post-auricular areas. Repalpate the neck with the patient
swallowing a mouthful of water—particularly the anterior triangle (see
Fig. 2.1). Lastly, feel specifi cally for the carotid arteries.
Lumps.• Is it single or multiple (multiple strongly suggests
lymphadenopathy)? Is it strictly in the midline (likely to be related to
the thyroid)? Does it move with swallowing (almost always thyroidrelated)? What are the general features (see b p. 42)?
Thyroid lumps.• Is it unilateral or bilateral? Does it move with tongue
protrusion?
Carotid arteries.• Are they normal, ecstatic, or aneurysmal?
Supraclavicular fossae.• Is there associated lymphadenopathy (suggests
malignancy)?
Auscultation Listen to the carotid arteries and any large masses for bruits,
suggesting a hypervascular local circulation or stenosis.
Investigations
Ultrasound
•
Easy to perform and painless.
Avoids radiation dose.•
Highly sensitive for the differentiation between solid tumours and •
cysts.
Aspiration cytology
•
Easy to perform and quick to report on—often done in one half day
during outpatients.
EVALUATION OF THE NECK
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Usually well tolerated in outpatients.•
Provides only cellular information and relies upon cellular atypia for a •
diagnosis of malignancy.
Does not provide histological information.•
Occasionally therapeutic for cysts.•
Good sensitivity and specifi city.•
Contraindicated where there is a suspicion the lesion may be vascular.•
CT scanning
Useful for assessment of extensive local invasion and regional and •
systemic staging of tumours.
Allows evaluation of the thorax in some thyroid tumours.•
CT PET scanning
Occasionally used to assess indeterminate lesions identifi ed on plain CT
and identify unsuspected metastatic disease.
MRI scanning
Useful for detailed assessment of local invasion of tumours.
Mandible
33
Ant
Midline
Sternocleidomastoid
Clavicle
Post
Trapezius
Fig. 2.1 Key revision points—triangle of the neck.
CHAPTER 2 Principles of surgery
34
Evaluation of the abdomen
Positioning
Lie the patient supine with the head slightly raised with adequate •
support for the head to ensure the abdominal muscles are relaxed.
Arms should be by the sides to relax the lateral abdominal muscles.•
The patient may be rolled into left or right lateral positions during •
palpation and percussion.
Ask the patient to cough during inspection; it may reveal hernias.•
Stand the patient up to examine the groin only if necessary; most •
hernias and groin pathology can be fully assessed in supine position.
Inspection
Perform during normal and deep respiration.•
General features.• Is there evidence of jaundice or signs of anaemia?
Does the patient looked underweight, malnourished, or cachectic?
Scars.• Where are they? How old do they appear? Is there evidence of
herniation on coughing?
Is there a stoma?• What type? Does it look healthy or abnormal? What
is the content in the stoma appliance?
Overall appearance.• Is the abdomen symmetrical? Is there evidence
of global distension (e.g. ascites, distended bowel)? Is there evidence
of local distortion (e.g. a local mass or organomegaly)? Does the
abdomen move well and symmetrically with deep respiration (reduced
in peritoneal irritation)? Is there any discoloration (periumbilical
bruising (Cullen’s sign) or fl ank bruising (Grey Turner’s sign), where
either suggests retroperitoneal haemorrhage or major infl ammation)?
Umbilicus.• Is it herniated? Is there discharge or ulceration suggestive of
infection or a malignant deposit?
Pulsation.• Is there visible pulsation? (Further assessment requires
palpation.)
• Is there visible peristalsis? (Identifi cation may take several
Persistalsis.
minutes of observation.) It is rarely possible to suggest a cause or level
of obstruction related to the pattern of visible peristalsis.
Palpation
Be methodical. Use the fl at of one hand (usually the right). It is usual to
examine and describe the abdomen in areas. It can be divided it into nine
regions or fi ve ‘quadrants’ (see Fig. 2.2). Examine the areas lightly at fi rst
in a set order. Identify any masses or areas of tenderness. Repeat the
examination with deeper palpation. Go back to any identifi ed masses and
try to ascertain their key features.
Signs of peritoneal irritation.• Are there signs of local visceral peritoneal
irritation (tenderness and pain on palpation)? Are there signs of mild
parietal peritoneal irritation (guarding) or signs of marked parietal
peritoneal irritation (rigidity)? Rigidity may be localized or generalized.
Rebound tenderness is an unnecessary test; it merely confi rms the
presence of guarding and is often excessively painful for the patient.
Masses.• Assess their surface, edge, consistency, movement with
respiration, and overall mobility.
EVALUATION OF THE ABDOMEN
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Organs.•
Liver• . Palpate from right lower quadrant into right upper quadrant,
feeling for the liver edge during inspiration every few cm upwards
until it is found. Assess the edge. Is it smooth/nodular/craggy?
Assess any palpable surface. Is it smooth/nodular/craggy?
Spleen• . Palpate from right lower quadrant into left upper quadrant,
feeling for the spleen edge during inspiration as for the liver. Assess
the edge and any palpable surface.
Kidneys• . Palpate bimanually in each loin. ‘Ballotting’ (bouncing the
kidneys between each hand) is of little additional value.
Percussion
Percussion identifi es the presence of excessive amounts of gas or fl uid. It
is also useful, when done carefully, in the confi rmation of the presence of
mild to moderate parietal peritoneal irritation (‘percussion tenderness’).
Gas• (hyperresonance). Is it generalized or localized? Is there
evidence of loss of dullness over the liver (suggestive of copious free
intraperitoneal gas)?
Fluid• (ascites). Usually identifi ed as ‘shifting dullness’; dullness in
the fl anks in the supine position moves to the lower portion of the
abdomen on turning to the lateral position.
Auscultation
To fully assess bowel sounds, it is necessary to listen for at least 1min, but
they are a notoriously unreliable sign of either intra-abdominal pathology
or bowel function. If commented on, bowel sounds should broadly be
divided into: absent, normal, active, or obstructive (characterized by highpitched, frequent sounds often with crescendos of activity, e.g. ‘tinkling’,
‘bouncing marbles’).
Abdominal assessment should always include a rectal examination in
adults; this is very rarely useful and should usually be avoided in children.
35
RUQ
Central
Fig. 2.2 The fi ve quadrants: RUQ, right upper quadrant; LUQ, left upper
quadrant; LLQ, left lower quadrant; RLQ, right lower quadrant.
LUQ
LLQRLQ
CHAPTER 2 Principles of surgery
36
Abdominal investigations
Faecal occult blood testing
May be chemical or immunological.•
Commonest use is as the primary community test for colorectal •
carcinoma (see b p. 400) as part of the National Bowel Cancer
Screening Programme.
Rigid proctoscopy and sigmoidoscopy (see b p. 216).
Flexible sigmoidoscopy
Very low risk (perforation 1 in 5000) outpatient procedure, usually •
performed without sedation.
Should visualize up to the descending colon.•
Allows minor therapeutic procedures (polypectomy, biopsy, injection).•
Colonoscopy
Low risk (perforation 1 in 1000) outpatient procedure, usually •
performed with sedation; requires bowel preparation.
Should visualize the entire colon (>95% of the time).•
Allows minor therapeutic procedures (polypectomy, including •
‘advanced’ endoscopic mucosal resection (EMR) and endoscopic
submucosal dissection (ESD), injection, marking by tattoo, and biopsy).
Typically used for: assessment of (suspected) colitis, diagnosis and •
assessment of colonic neoplasia, investigation of rectal bleeding.
Transabdominal ultrasound
Easy, safe, non-invasive, and avoids radiation dose.•
Typical uses include:•
Identifi cation of ovarian disease, e.g. in suspected acute appendicitis.•
Primary investigation of the biliary tree for gallstones, bile duct size, •
and liver parenchymal texture.
Investigation of suspected subphrenic or pelvic collections.•
Assessment of the liver/splenic parenchyma.•
Identifying free fl uid in abdominal trauma.•
CT scanning
Easy, non-invasive; requires signifi cant radiation exposure and •
intravenous (IV)/oral (PO) contrast.
Typical uses include:•
Primary assessment of all intra-abdominal masses.•
Staging of intra-abdominal and pelvic malignancy.•
Investigation of acute abdominal pain of unknown origin.•
Investigation of suspected intestinal obstruction.•
May be specifi cally tailored for pancreatic, biliary, visceral vessel •
assessment.
Investigation of suspected post-operative complications.•
MRI scanning
Conventional body scanner with external coils.•
Avoids radiation dose.•
ABDOMINAL INVESTIGATIONS
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May be performed with specialized ‘contrast’ agents (e.g. ferumoxides).•
Typically used for:•
Investigation of suspected bile duct disease.•
Assessment of liver disease/possible metastases.•
Assessment of pancreas.•
Assessment of pelvic and retroperitoneal soft tissue disease, e.g. •
pelvic cancers.
Plain abdominal radiograph
Limited use.•
May identify intestinal obstruction, urinary tract stones, free intra-•
abdominal air, intra-abdominal fl uid.
Barium enema (double contrast, single contrast)
May be single contrast (contrast material fi lling the colon) or double •
contrast (dilute contrast and air to coat the mucosal surface of the
colon).
Requires bowel preparation and relatively mobile patient.•
Single contrast used to identify strictures and obstructions (used to •
assess colorectal anastomoses in dilute or water-soluble form).
Double contrast typically used to identify colonic neoplasia, assess •
colonic anatomy.
Intestinal transit studies
Serial abdominal X-rays to identify the progress of ingested radio-•
opaque markers.
Used to assess intestinal motility and transit time.•
PET scanning
Injection of radioactive metabolic substrate to identify metabolically •
active tissue.
Combined with high resolution CT scanning to co-locate ‘hot spots’.•
Typically used to:•
Identify unsuspected metastatic tumour deposits.•
Differentiate fi brosis from tumour post-surgery.•
Physiological testing
Manometry testing of the oesophagus, including lower oesophageal •
sphincter and the anal canal.
Pressure sensitivities of the oesophagus and anal canal.•
pH testing of the contents of the oesophagus (isolated or continuously •
for 24h).
Used to assess anorectal function, oesophageal motility and function, •
and gastro-oesophageal refl ux.
37
CHAPTER 2 Principles of surgery
38
Evaluation of pelvic disease
Positioning and inspection
Examination is performed in up to three positions: supine (for transabdominal palpation of the ‘false’ pelvis); supine with hips fl exed and abducted
(for vaginal and bimanual palpation which may be performed to help assess
rectal disease); and left lateral position with hips fl exed (for rectal palpation and rigid endoscopy). Any intimate examination should always have a
chaperone present and particularly so for pelvic examinations.
• Is the anus deformed? Is there evidence of mucosal or rectal
Anus.
prolapse? Does the vaginal introitus look normal? Is there vaginal
prolapse or evidence of a cystocele? Are there scars from previous
surgery, sinuses, or evidence of sepsis?
Look for additional or abnormal tissue.• Are there skin tags, external
haemorrhoids, warts, or abnormal areas of skin (such as anal
intraepithelial neoplasia (AIN))? Is there an external punctum (as may
be seen in a fi stula) or the outer limit of a fi ssure visible?
Palpation
Palpate the lower abdominal quadrants.•
Rectal examination.• Is anal tone normal and the sphincter symmetrical?
Is the prostate normal size with a normal central sulcus? Does the
rectal mucosa feel normal? Is there any mass or tenderness anterior
to the upper rectum (pouch of Douglas)? The latter may be due to
sigmoid disease, small bowel in the pelvis, a pelvic appendix, or ovarian
disease.
Vaginal examination• (often omitted unless there is a clear indication
that valuable information may be gained from it). Is the cervix
present and normal? Is the vagina of normal calibre and feel? Is there
tenderness in either vaginal fornix?
Investigations
Rigid proctoscopy (‘anoscopy’)
•
Performed in outpatients without sedation.
Only visualizes the very lowermost rectum and anal canal (referred to •
as anoscopy in USA). Views may not be good if done without enema
preparation.
May be combined with therapy (banding, injection, or cryotherapy) for •
anorectal disorders.
Rigid sigmoidoscopy
•
Performed in outpatients without sedation.
Aims to visualize the rectum to the recto-sigmoid junction. The •
sigmoid colon is NOT adequately seen with this (referred to as
proctoscopy in USA). Views may not be good if done without enema
preparation.
Flexible sigmoidoscopy
Low risk, outpatient procedure, usually performed without sedation.
•
Should visualize up to the descending colon.•
Allows minor therapeutic procedures (polypectomy, tattoo, injection).•
EVALUATION OF PELVIC DISEASE
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Transabdominal/transvaginal ultrasound
Easy, safe, and avoids radiation dose.•
Good for identifi cation of ovarian disease (e.g. in right iliac fossa pain).•
Endoanal/transrectal ultrasound
A 360• ° scanning endoanal/endorectal probe without sedation.
•
Endoanal scans. For assessment of anal sphincter integrity.
Transrectal scans. For assessment of some rectal tumours, prostatic •
disease (including biopsy), pre-sacral lesions.
CT scanning
•
Easy, safe, but signifi cant radiation exposure and IV contrast.
Investigation of choice for undiagnosed pelvic symptoms and post-•
operative complications.
MRI scanning
Usually via conventional body scanner with external coils (occasionally •
performed with endorectal coil).
Investigation of choice for the assessment of advanced rectal, •
gynaecological, and urological cancer, or complex pelvic sepsis.
Investigation of choice for complex pelvic and anal sepsis.•
Key revision points—pelvic anatomy
The true pelvis lies between the pelvic inlet (sacral promontory, •
illiopectineal lines, symphisis pubis) and outlet (coccyx, ischial
tuberosities, pubic arch).
Pelvic fl oor muscles (such as levator ani) support and are integral •
to the function of the anorectum, vagina, and bladder. They are
innervated by anterior primary rami of S2, 3, 4.
Anterior relations of the rectum (palpable during PR exam) are
•
(from below up):
Women—vagina, cervix, pouch of Douglas.•
Men—prostate, seminal vesicals, recto-vesical pouch.•
39
CHAPTER 2 Principles of surgery
40
Evaluation of peripheral vascular
disease
Positioning and inspection
Ideally, the patient should be examined in a warm environment at rest.
Remember fi rst to take the pulse and blood pressure, and examine the
abdomen (aneurysm, scars). Inspect the limb in the supine position, then
elevated (passively), and fi nally dependent. Expose the entire limb, including the foot or hand to allow thorough inspection. If necessary, take any
dressings down (or ask for them to be removed if you are not happy to).
For venous disease, the patient should also be examined standing.
During supine inspection, look for the following.
• Are there any areas of established skin necrosis (dry
Appearance.
gangrene, e.g. apex of digits, between digits, heel of the foot)? Are
there changes of chronic venous stasis (fl are veins, venous eczema,
lipodermatosclerosis, leg ulceration)?
Colour.• Waxy white suggests severe acute ischaemia; blue and mottled
suggests potentially irreversible acute ischaemia; dark red/purple
suggests chronic ischaemia.
Colour changes during position.• Note the angle at which the skin of
the limb blanches when passively elevated (Buerger’s test). Normal
limbs may not blanch at all. An angle of 15° or less suggests severe
ischaemia. Note the presence and delay in change in colour when the
limb is dependent. Ischaemic limbs slowly turn deep purple.
Ulcers.• What is the location (digital or foot suggests arterial disease)?
Be sure to inspect between the toes/fi ngers and on the plantar surface
of the foot (especially for diabetic disease).
Venous inspection.• Stand the patient up. Inspect for varicose veins. Are
they in the long saphenous or short saphenous distribution?
Palpation
Temperature.• Does the skin feel cold or warm? Is there a transition
level?
Skin capillary compression and refi ll.• Normal is 2s or less. A delay of
greater than 5s suggests signifi cant ischaemia.
Peripheral pulses.• Start with the most proximal (major) vessels and
work distally. Record if the pulse is normal, reduced, or absent. Record
if there are any thrills palpable.
In venous disease, tests of • venous competence may be performed (see
b p. 666).
Surgical grafts.• Palpate the course of any surgical grafts and record the
presence or absence of pulses.
Auscultation
Listen for bruits. Are there bruits in the proximal vessels (suggestive of
stenosis)?
EVALUATION OF PERIPHERAL VASCULAR DISEASE
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Investigations
Doppler ultrasound
Straightforward and portable.•
May be used to confi rm or refute the presence of fl ow in a vessel or •
graft.
May be used to evaluate the relative fl ow in vessels by measuring the •
pressure at which detectable fl ow ceases using a compression cuff.
The commonest example is ankle–brachial pressure index (ABPI).
May be used to evaluate the presence of refl ux in veins.•
Colour fl ow duplex
Combined two-dimensional (2D) ultrasound image with Doppler-•
derived fl ow represented using colour, superimposed in real time.
May be used for assessment of stenosis/occlusion in vessels or grafts.•
May be used for assessment of refl ux or occlusion in deep and •
superfi cial veins.
Direct angiography
Most commonly, digital subtraction angiography (DSA; used to reduce •
background image ‘noise’ and convert the arterial images to black for
easier viewing).
Invasive, requiring direct arterial puncture with the associated risks.•
Requires IV contrast with the small risk of allergy (relatively •
contraindicated in renal dysfunction or where renal blood fl ow is
poor).
Gives direct views of arterial tree, but lumen only so not good for •
aneurysm sizing.
Magnetic resonance angiography
•
Provides images of an arterial tree based on the presence of arterial
fl ow during scanning.
Safe and non-invasive; requires no ‘contrast’, but commonly gadolinium •
used to highlight fl owing blood.
Tends to overestimate degree of stenosis due to very low fl ow being •
underrepresented.
CT angiography
•
Requires multislice rapid acquisition (‘helical’/’spiral’) scanner.
Images acquired in arterial phase after IV injection of contrast.•
Three-dimensional (3D) reconstruction allows ‘virtual angiogram’ •
images to be produced.
Fast and relatively safe, especially where direct angiogram is diffi cult, •
e.g. visceral vessels.
Requires dose of IV contrast, so caution with allergy and renal •
dysfunction.
41
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