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Both the above pathways are ‘OK’, right? Yes, but pathway 2
clearlyisthe‘best’one:safer,fasterandcheaper.
Today many options exist to do almost anything. Any search on
GoogleorPubMedwilloverwhelmyouwithpapersthatcanjustifyalmost
anymanagementpathway,withpeoplepracticingsurgical acrobaticsfor
themeresakeofdoingso.Dataandtheoryareeverywhere:thesources
are numerous but whatyou really need iswisdom — to enable you to
apply correctly the knowledge you already have andconstantly gather.
Andwisdomiswhatwearetryingtoprovide.Sopleaseopenyourmind.
Generalphilosophy( Figure1.2)
Figure1.2.“Eachofushasadifferent‘generalphilosophy’…”
“Thereisnothingnewinthestory…,”WinstonChurchillsaid,“wantof
foresight,unwillingnesstoactwhenactionwouldbesimpleandeffective,
lackof clear thinking,confusionofcounseluntiltheemergencycomes,
until self-preservation strikes its jarring gong…”. How true is this
Churchillianwisdomwhenapplied to emergency surgery.How often do
we forget old — written in stone — principles while reinventing the
wheel?
The‘best’managementineachsectionof thisbookisbased on
thefollowingelements.
Old-establishedprinciples(don’treinventthewheel).
Modern-scientificunderstandingofinflammationandinfection.
Evidence-basedsurgery(seebelow).
Personalexperience.
Theinflamedpatient
ThinkaboutyourpatientasbeingINFLAMEDbymyriadinflammatory
mediators, generated by the primary disease process, whether
inflammatory, infectious or traumatic — so if you measure C-reactive
protein (CRP) in these patients, in most it will be elevated! Local
inflammation (e.g. peritonitis) and systemic inflammatory response
syndromes (SIRS) may lead to organ dysfunction or failure, and the
eventualdemiseof your patient. The greater the inflammation — the
sicker the patient and the higher the expected morbidity and
mortality.Consider also thatanythingyoudoinattemptingtohalt
your patient’s inflammation may in fact contribute to it — adding
fuel to the inflammatory fire. Excessive surgery, inappropriately
performed, and too late, just adds nails to your patient’s coffin.
RememberalsothatSIRSisantagonizedbytheso-calledcompensatory
anti-inflammatory response syndrome (CARS), mediated by antiinflammatorycytokines,whichinturnpromotesimmunesuppressionand
facilitates infections that are so common after major operations and
severetrauma( Figure1.3).
Figure 1.3. The inflamed surgical patient. SIRS = systemic inflammatory response
syndrome; CARS = compensatory anti-inflammatory response syndrome. (Read the
classicbythelateRogerBone:BoneRC.SirIsaacNewton,sepsis,SIRS,andCARS.Crit
CareMed1996;24:1125-8.)
Thephilosophyoftreatmentthatweproposemaintainsthatinorderto
cure or minimize the inflammatoryprocesses andthe anti-inflammatory
response, management should be accurately tailored to the
individual patient’s disease; as the punishment fits the crime, so
shouldtheremedyfitthedisease.Awell-trainedfootsoldierdoesnot
fire indiscriminately in all directions. These days he can summon the
dronesforasurgicalstrike!
Evidence
Economic considerations sometimes motivate the
physicianstoacceptthatpartofthescientificevidencethat
bestsupportsthemethodthatgiveshimthemostmoney.
GeorgeCrile
Afewwordsaboutwhatwemeanwhenwetalkabout‘evidence’.Many
formalclassificationsofscientificevidenceareincirculation.Hereisone
versionalongwithwhatsomepeoplethinkaboutit( Table1.3).
To the above ‘official’ classificationwe wish to add a few more
categoriesfrequentlyusedbysurgeonsaroundtheworld.
V — “In my personal series of X patients (never published) there were no
complications.”
VI—“Irememberthatcase…fortyyearsago…”
VII—“ThisisthewayIdoitanditisthebest.”
VIII—“Mygrandmotherthinksthisisagoodidea.”
Note that level III retrospective case series form the main bulk of
surgicalliteraturedealingwithabdominalemergencies,whereaslevelsVVIIIarethemainformsofevidenceusedbysurgeonsingeneral—think
about your own departmental meetings! And level VIII evidence may
remind you of your chairman! To paraphrase a quote from Memoirs of
HadrianbyMargueriteYourcenar:“Inanycombatbetweenfanaticism
(dogmatism) and common sense the latter has rarely the upper
hand.”
Wewanttoshowyouthatthisisnotalwaysthecase!Youshould
educateyourselfto think in terms of levels ofevidence and resist
local dogmas. Webelieve that support for muchof what we write
here is available in thepublished literature, but we choosenot to
citeitbecauseitisnotthatkindofbook.Whenhigh-levelevidence
isnotavailable,wehavetouseanindividualapproachandcommon
sense,andthatismuchofwhatthisbookisabout.
Evidenceisthebaseofmedicinebutcommonsenseisthe
saltofit.
SlavaRyndine
Theabsenceofevidenceisn’ttheevidenceofabsence.
HenryBlack
As far as the surgical literature goes, use the ‘Texas
mockingbird approach’: eat everything in sight and vomit
whatyoucan’tuse.
LewFlint
Remember: You can get away with a lot… but not always. Most patients treated
accordingtotheabove-mentionedpathway1willdojustfine,butafewwillnot.Thefollowing
pageswillhelpyoutodevelopyourownjudgment—pointingtothecorrect/preferredpathway
inanysituation. This is obviously notabiblebut it is based onathoroughknowledge of the
literature and vastpersonal experience. So wherever you are — in India, Pakistan, Norway,
Chile, Botswana, Canada or Palestine, and whatever your resources are — the general
approachtoemergencyabdominalsurgeryshouldbethesame.Socomeandjoinus:todoit
well,decreasemorbidity,savelives,havefun—andattainglory!
“Thegloryofsurgeonsislikethatofactors,whichlasts
only for their own lifetime and can no longer be
appreciated once they have passed away. Actors and
surgeons…areallheroesofthemoment.”
HonorédeBalzac
“The operation is a silent confession to the surgeon’s
inadequacy.”
JohnHunter
Chapter2
Abriefhistoryofemergencyabdominalsurgery
HaroldEllis
[We are proud to offer this chapter by Professor Ellis of London: a
renowned surgeon, educator, writer, editor, anatomist, and surgical
historian. Among his many books, we would particularly recommend
Operations That Made History and A Brief History of Surgery. The
Editors.]
In the study of some apparently new problems we often
makeprogressbyreadingtheworkofthegreatmenofthe
past.
CharlesH.Mayo
From the earliest days until comparatively modern times, surgeons
wereignorant aboutthecauses ofthe vastmajorityof acuteabdominal
emergencies and equally ineffectual in their treatment. They were, of
course,wellfamiliarwithabdominaltraumaandthedireconsequencesof
perforatinginjuriesofthebelly,thegreatmajorityofwhichwouldbefatal.
Thus,intheBiblewereadintheBookofJudges:
ButEhudmadehimadagger,whichhadtwoedgesofacubitlength,andhedidgirditunder
theraimentofhisrightthigh.AndhebroughtthepresentuntoEglon,KingofMoab.AndEglon
wasaveryfatman...AndEhudputforthhislefthsandandtookthedaggerfromhisrightthigh,
andthrustitintohisbelly.Andthehaftwentinafterthebladeandthefatclosedovertheblade,
sothathe couldnotdrawthebladeout ofhisbelly;andthedirt cameout...Andbeholdtheir
Lordwasfallendowndeadontheearth.
Occasionally,afecalfistulawouldform,andthepatientsurvived.That
great16th century Frenchmilitarysurgeon, Ambroise Paré,recordedin
hisCaseReportsandAutopsyRecords:
IntimeIhavetreatedseveralwhorecoveredafterhavinghadwoundsbyswordorpistolpass
throughtheirbodies.Oneofthese,inthetownofMelun,wasthestewardoftheAmbassador
of the King of Portugal. He was thrust through with a sword, by which his intestines were
wounded,sowhenhewasdressedagreatdealoffecal matter drained from the wound, yet
thestewardwascured.
Occasionally,aprolapsedloopofbowel,projectingthroughalacerated
abdominal wound, might be successfully reduced. Still less often, an
enterprising surgeon might suturea laceration in sucha loop and thus
savethepatient’slife.
In1676 TimothyClarkrecorded thecase ofa butcherwho attempted
suicidewithhisbutcher’sknifeinthevillageofWayfordinthecountryof
Somerset,locatedinthesouthwestcornerofEngland.Threedayslater,
a surgeon who Clark does not name replaced the prolapsed gut,
removed extruded omentum and prolapsed spleen and the patient
recovered.Clark,himself,in1633hadremovedthespleenofadogwith
survival, thus showing that the organ was not essential to life and
confirminganobservationmadebyVesaliusacenturybeforehand.
Strangulated hernias were also well known to ancients. Treatment
usuallyconsistedofforciblemanipulativereduction,whichwasaidedby
hot baths, poultices, and the use of the head-down, feet-up position.
Sometimestheireffortssucceeded, buttherewas,ofcourse,adirerisk
ofruptureofthegut,especiallyinadvancedcases.WilliamCheseldenin
1723reportedthecaseofawomaninher73rdyearwithastrangulated
umbilical hernia. At operation, he resected 26 inches of gangrenous
intestine. She recovered with, of course, a persistent fecal fistula. The
extremedangerofstrangulatedherniaiswelldemonstratedbythefact
thatQueenCaroline,wifeofGeorgeIIofEngland,diedofastrangulated
umbilicalherniaattheageof55in1736.
Acuteabdominalemergencieshavenodoubtaffectedhumankindfrom
itsearliest existence,yet ithas onlybeenincomparativelyrecenttimes
—the pastcouple ofhundred years—thatthepathology andthen the
treatment of these conditions were elucidated. This is because over
many centuries post-mortem examinations were either forbidden or
frowned upon in most societies. Operations on the abdomen were
performedrarely,ifatall,untilthebeginningofthe19thcentury.So,what
BerkeleyMoynihan called “the pathologyoftheliving”, the pathology of
the abdominal cavity as revealed inthe operatingtheater,awaited toa
largeextentthe development of anesthesia in the 1840s and antiseptic
surgeryinthe1870s.
Knowledgeofthe causesoftheacuteabdomenadvancedlittlein the
2000yearsfollowingthedaysofHippocratesinthe5thcenturyBC.The
GreekandRomandoctorswerekeenclinicalobservers.Theyrecognized
that, from time to time, a deep abdominal abscess might discharge
spontaneouslyorbe amenabletosurgical drainagewithrecoveryofthe
patient.Every other serious abdominal emergencywasgiventhe name
of‘ileus’or‘iliacpassion’andwasconsideredtobeduetoobstructionof
thebowels.Ofcourse,thefatalabdominalemergenciestheywereseeing
wereindeeddueeithertomechanicalobstructionortotheparalyticileus
ofgeneralperitonitis.ThusinHippocratesweread:
Inileusthebellybecomeshard,therearenomotions,thewholeabdomenispainful,thereare
feverandthirstandsometimesthepatientissotormentedthathevomitsbile...Medicinesare
notretainedandenemasdonotpenetrate.Itisanacuteanddangerousdisease.
Overthecenturiestherewaslittletoofferthepatientbeyondpoultices
tothe abdomen, cupping, bleeding,purgationand enemas, all of which
probably did more harm than good. It was not until 1776 that William
Cullen,ofEdinburgh,coined theterm‘peritonitis’forinflammationofthe
lining membrane of the abdominal cavity and its extensions to the
viscera. However, he did not think the exact diagnosis of great
importance since “when known, they do not require any remedies
besidesthoseofinflammationingeneral”.
Appendicitis
LorenzHeister,ofHelmstadtinBrunswig,mustbegivencreditforthe
first description of the appendix as the site of acute inflammation,
reportingthisat an autopsy in 1755. For more thanacenturyafter this
there were occasional autopsy reports, but most cases were
unrecognizedorlabelled‘typhlitis’,‘perityphlitis’or‘iliacpassion’.
In1848,HenryHancock,ofCharingCrossHospital,London,reported
the drainage of an appendix abscess in a young woman who was 8
monthspregnant.Sherecovered,butinspiteofHancock’splea,sofixed
was the idea that it was useless to operate once peritonitis was
establishedthathisadvicewasignoredforsome40years.Indeed,itwas
a physician, not a surgeon, who advised appendicectomy and early
diagnosis. This was Reginald Fitz, Professor of Medicine at Harvard,
who,in 1886,publisheda reviewof 257 cases,which clearlydescribed
the pathology and clinical features and advised removal of the acutely
inflamed organ or, in the presence of an abscess, surgical drainage.
Fitz’sadvicewas takenuprapidlyintheUnitedStates.ThomasMorton
ofPhiladelphiawasthefirsttoreport,in1887,thecorrectdiagnosisand
successful removal of a perforated appendix (although Robert Lawson
Taitasearlyas1880hadasimilarcase,hedidnotreportthisuntil1890).
The surge in early diagnosis and operative treatment was particularly
pioneered by Charles McBurney of the Roosevelt Hospital, New York,
whodescribed ‘McBurney’spoint’anddevised the musclesplitincision,
and J.B. Murphy of Chicago, who emphasized the shift in pain in
‘Murphy’ssequence’. In1902, Fredrick Treves, of the London Hospital,
drained the appendix abscess of King Edward VII, 2 days before the
coronation,anddidmuchtoraisethe generalpublic’sawarenessofthe
disease.
Therupturedspleen
Thespleen is the most commonlyinjuredviscus in closed abdominal
trauma,yettherewassurprisingdiffidenceamongthepioneerabdominal
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