Atlas of General Surgery

620 Pages·2009·231.216 MB·English

by  Volker Schumpelick, Reinhard Kasperk, Michael Stumpf

Volker Schumpelick
In collaboration with
Reinhard Kasperk
Michael Stumpf

I
Thieme

Atlas of General Surgery
Volker Schumpelick, MD
Professor and Chairman
Department of Surgery
University Hospital Aachen
Aachen, Germany
With the collaboration of
Reinhard Kasperk and Michael Stumpf
1223 illustrations
Thieme
Stuttgart · New York
library of Congress Cataloging-in-Publication Data is available from Important note: Medicine is an ever-changing science under
the publisher. going continual development. Research and clinical experience
are continually expanding our knowledge, in particular our
This book is an authorized and revised translation of the 2nd knowledge of proper treatment and drug therapy. Insofar as
German edition published and copyrighted 2006 by Georg this book mentions any dosage or application, readers may
Thieme Verlag, Stuttgart, Germany. Title of the German edition: rest assured that the authors, editors, and publishers have
Operationsatlas Chirurgie. made every effort to ensure that such references are in accor
dance with the state of knowledge at the time of production
of the book.
Nevertheless, this does not involve, imply, or express any guar
antee or responsibility on the part of the publishers in respect
to any dosage instructions and forms of applications stated in
Contributors: the book. Ewry user is requested to examine carefully the
Reinhard Kasperk, MD manufacturers' leaflets accompanying each drug and to check,
Professor if necessary in consultation with a physician or specialist,
Director of the Surgical Clinic whether the dosage schedules mentioned therein or the con
St. johannes-Hospital traindications stated by the manufacturers differ from the
Catholic Clinic Duisburg statements made in the present book. Such examination is par
Duisburg, Germany ticularly important with drugs that are either rarely used or
have been newly released on the market Every dosage sche
Michael Stumpf, MD dule or every form of application used is entirely at the user's
Adj. Professor own risk and responsibility. The authors and publishers request
Supervising Physician every user to report to the publishers any discrepancies or
Department of Surgery inaccuracies noticed. If errors in this work are found after pub
University Hospital Aachen lication, errata will be posted at www.thieme.com on the pro
Aachen, Germany duct description page.
Translator: Dr. Grahame Larkin, MD, East Sussex. UK
Illustrator: Gisela Tambour, Adrian Cornford, and
Rose Baumann
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v
Preface
Surgery can no more be learned from text books than can cycling or tion. Its content is general surgery-not that which remains after
swimming. Similarly, hardly any other discipline is both a teaching separation of the specialist disciplines, but rather that which a gen
and learning profession with such a dose teacher-pupil relationship. eral surgeon from the respective specialist disciplines must learn in
But rarely does the young surgeon of today have the opportunity to order to stand his ground as a surgeon.
gain enough continuous practice under supervision to the point of
reaching subcortical implementation. The restrictions of working We are glad that this concept has proven itself to the extent that an
time reduction, rare opportunities to practice techniques on labora English edition is now available. The aim of this surgical atlas is to
tory animals, and the early division of surgery into subspecialties serve trainee surgeons as a reference book, to allow them to learn
have completely changed the face of mandatory training guidelines new things, and to arouse their curiosity to learn more. But even
for basic surgical operations. As a result, the young surgeon rarely qualified surgeons may use the opportunity to recall a technique
gets to see many an operation, and those operations in which he has they have already learned and to compare standards. For easy mem
managed to gather a greater amount of personal experience are few orization and mental preparation of the respective operations, all the
and far between. Even surgical simulators, which are becoming in operative stages are structured and schematized so that the conti
creasingly available and provide excellent training opportunities, nuity of the operation is divided into labeled and reproducible single
especially in the field of laparoscopic surgery, cannot convey the steps. just as racing drivers mentally prepare themselves before the
entire spectrum of basic surgical operations. In some specific fields race by imagining each individual leg of the race course, the surgeon
they do allow manual skills and tactile coordination to be practiced, should, before any operation, recall before his or her mind's eye each
but cannot provide broad surgical expertise together with the under operative stage step by step so as to to proceed only along familiar
standing and mastering of standard operative techniques. Alongside lines at the operating table.
video films, surgical atlases are therefore the most important sources
of information for the young surgeon when it comes to practicing all We are grateful to the staff of Thieme Publishers for their support
the stages of certain operations. during the preparation of this English edition. But above all we
should also like to thank Mr. Grahame Larkin for his excellent work
The concept of this surgical atlas is directed toward presenting the in translating this atlas into English. We are looking forward to an
most common 16 general and 150 special operations of everyday equally favorable English-speaking readership of this Atlas of Generol
surgical practice to surgeons in training, to students as well as to Surgery.
qualified surgeons. In this respect, it is neither my intention with this
single-volume atlas to vie with the more detailed, multi-volume sur Volker Schumpelick
gical atlases nor to undermine the essential principle of specializa-
VI
List of Abbreviations
ASA Acetylsalicylic add
DC Dynamic compression
DIP Distal interphalangeal
DSA Digital subtraction angiography
EEA End-to-end anastomosis
EPT Endoscopic papillotomy
ERC Endoscopic retrograde cholangiography
ERCP Endoscopic retrograde cholangiopancreatography
FFP Fresh frozen plasma
IORT Intraoperative radiotherapy
MCP Metacarpophalangeal
OPSI Overwhelming postsplenectomy infection
ORIF Open reduction and internal fiXation
PDS Polydioxanone suture
PCA Polyglycolic acid
PIP Proximal interphalangeal
PTC Percutaneous transhepatic cholangiography
PTCD Percutaneous transhepatic cholangiodrainage
RBCC Red blood cell concentrate
VII
Table of Contents
General Aspects
1
General Aspects .................................. 2 8 Venous Access ................................. 21
9 Central Venous Port ............................. 25
1 Preliminary Remarks on the Surgical Intervention .... 2 10 Venous Cutdown ............................... 26
2 Use of Scalpel, Needle Holder, Forceps, and Scissors ... 4 11 ]oint Punctures ................................ 28
3 Ugation and Suture Ugation ...................... 6 12 Pleural Punctures ("Thoracentesis) .................. 31
4 Knots ........................................ 8 13 Urinary Bladder Puncture ........................ 33
5 Skin Suture ................................... 11 14 Ascites Puncture (Paracentesis) . .................. 34
6 Drains ........................................ 14 15 Fine-Needle Aspiration Biopsy .................... 35
7 Urinary Catheter ............................... 17 16 Arterial Puncture and Arterial Catheterization . ...... 36
39
Skin and Soft Tissues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Thoracic Wall and Cavity . . . . . . . . . . . . . . . . . . . . . . . . . 98
17 Excision of Skin Lesions . . . . . . . . . . . . . . . . . . . . . . . . . 40 38 Axillary Lymph-Node Oearance . . . . . . . . . . . . . . . . . . . 98
18 Removal of Soft Tissue 1\unors . . . . . . . . . . . . . . . . . . . . 43 39 Breast Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
19 Removal of Inguinal Lymph Node . . . . . . . . . . . . . . . . . . 45 40 Subcutaneous Mastectomy . . . . . . . . . . . . . . . . . . . . . . . 10 3
20 Wound Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 41 Mastectomy (Auchindos-Patey) . . . . . . . . . . . . . . . . . . . 105
21 Secondary Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 42 Chest Drain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 9
22 Carbuncle of the Neck........................... 51 43 Median Sternotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
23 Bursectomy (Elbow) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 44 Posterolateral Thoracotomy . . . . . . . . . . . . . . . . . . . . . . 11 6
24 V-Y Advancement Flap . . . . . . . . . . . . . . . . . . . . . . . . . . 55 45 Axillary Thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 0
25 Z-plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 46 Atypicallung Resection Open . . . . . . . . . . . . . . . . . . . . 12 3
26 Split-Skin Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 47 Atypical Thoracoscopic Lung Resection . . . . . . . . . . . . . 126
27 Ganglion (Wrist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 48 Right Superior Lobectomy . . . . . . . . . . . . . . . . . . . . . . . . 12 9
28 Panaritium (Felon) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 49 Pneumonectomy ............................... 132
29 Paronychia (Run-around) . . . . . . . . . . . . . . . . . . . . . . . . 64 50 Thoracoscopic Pleurectomy . . . . . . . . . . . . . . . . . . . . . . . 135
30 Ingrown Toenail (Unguis lncarnatus; One-third Wedge
Resection) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Abdominal Cavity: Diaphragm.................... 138
51 Rupture of the Diaphragm . . . . . . . . . . . . . . . . . . . . . . . 138
Neck ............................................. 69
31 Removal of Cervical Lymph Node... . . . . . . . . . . . . . . . 69
Abdominal Cavity: Esophagus . . . . . . . . . . . . . . . . . . . . 140
32 Tracheotomy (Open and Percutaneous Tracheostcma) . 71
33 Exposure of the Jugular Vein . . . . . . . . . . . . . . . . . . . . . 76 52 Hiatal Hernia Repair (Lortat-]acob Hiatoplasty)....... 140
34 Subtotal Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . 79 53 Fundoplication (Nissen-Rosetti and Toupet) . . . . . . . . . 144
35 Total Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 54 Laparoscopic Fundoplication . . . . . . . . . . . . . . . . . . . . . . 148
36 Parathyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 55 Cardiomyotomy for Achalasia (Gottstein-Heller) . . . . . . 154
37 Zenker Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Abdominal Cavity: Stomach . . . . . . . . . . . . . . . . . . . . . . 156 Abdominal Cavity: Large intestine. . . . . . . . . . . . . . . . 292
56 Percutaneous Endoscopic Gastrostomy (PEG) . . . . . . . . 156 92 Appendectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
57 Gastrostomy (Witzel) . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 93 Laparoscopic Appendectomy . . . . . . . . . . . . . . . . . . . . 300
58 Oosure of a Perforated Ulcer . . . . . . . . . . . . . . . . . . . . . 162 94 Loop Transverse Colostomy . . . . . . . . . . . . . . . . . . . . . . 305
59 Oversewing of a Bleeding Peptic Ulcer...... . . . . . . . . 165 95 End Sigmoidostomy (Hartmann Procedure) . . . . . . . . . 309
60 Gastrojejunostomy.............................. 168 96 Stoma Oosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
61 Pyloroplasty (Heineke-Mikulicz, Finney, jaboulay) . . . . 172 97 Colotomy and Polypectomy . . . . . . . . . . . . . . . . . . . . . 318
62 Selective Proximal Vagotomy . . . . . . . . . . . . . . . . . . . . . 175 98 Palliative Anastomosis between the Distal Ileum and
63 Truncal Vagotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Transverse Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
64 Gastroduodenostomy (Billroth I) . . . . . . . . . . . . . . . . . . 182 99 Right Hemicolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 325
65 Gastrojejunostomy (Billroth II) . . . . . . . . . . . . . . . . . . . . 190 10 0 Ileocecal Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
66 Roux-en-Y Gastrojejunostomy. . . . . . . . . . . . . . . . . . . . . 193 10 1 1\Jbular Resection of the Sigmoid Colon . . . . . . . . . . . . 334
67 Gastrectomy and Longmire Gastric Reconstruction.... 195 10 2 Radical Resection of the Sigmoid Colon . . . . . . . . . . . . 340
68 Gastrectomy and Roux-en-Y Gastric Reconstruction . . . 206 10 3 Laparoscopic Resection of the Sigmoid Colon . . . . . . . 342
104 Left Hemicolectomy............................ 347
10 5 Anterior Rectum Resection . . . . . . . . . . . . . . . . . . . . . . 355
Abdominal Cavity: Gallbladder and Bile Ducts . . . . 208
10 6 Rectum Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
69 Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
70 Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . . . . 212 Retroperitoneum................................. 375
71 Exploration of the Common Bile Duct . . . . . . . . . . . . . . 217
72 Hepaticojejunostomy............................ 221 107 Adrenalectomy................................ 375
108 Laparoscopic Adrenalectomy . . . . . . . . . . . . . . . . . . . . 379
Abdominal Cavity: Liver . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Proctology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
73 Wedge Resection of the Uver . . . . . . . . . . . . . . . . . . . . . 225
74 Hepatic Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 109 Hemorrhoidectomy (Miles-Gabriel) . . . . . . . . . . . . . . . 381
75 Left Hepatic Lobectomy.......................... 231 11 0 Perianal Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
76 Hepatic Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 111 Fistula-In-Ano (Including Sliding Flap). . . . . . . . . . . . . 388
77 Port Catheter of the Hepatic Artery . . . . . . . . . . . . . . . . 240 112 Perianal Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
113 Lateral Sphincterotomy (Parks).. . . . . . . . . . . . . . . . . . 395
114 Pilonidal Sinus (Schrudde-Olivari) . . . . . . . . . . . . . . . . 397
Abdominal Cavity: Pancreas . . . . . . . . . . . . . . . . . . . . . . 243
78 Necrosectomy of the Pancreas . . . . . . . . . . . . . . . . . . . . 243 External Genital Organs . . . . . . . . . . . . . . . . . . . . . . . . . . 401
79 Pseudocystojejunostomy . . . . . . . . . . . . . . . . . . . . . . . . . 246
80 Resection of the Tail of the Pancreas . . . . . . . . . . . . . . . 250 115 Testicular Hydrocele . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
116 Vasectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
Abdominal Cavity: Spleen . . . . . . . . . . . . . . . . . . . . . . . . 254
Hernias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
81 Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
82 Partial Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 117 Local Anesthesia for Inguinal Hernia Repair . . . . . . . . 406
83 Splenic Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 118 Dissection for Inguinal Hernia Repair . . . . . . . . . . . . . . 409
84 Laparoscopic Splenectomy . . . . . . . . . . . . . . . . . . . . . . . 261 119 Inguinal Hernia Repair (Shouldice)................ 417
120 Inguinal Hernia Repair (Bassini) . . . . . . . . . . . . . . . . . . 421
121 Inguinal Hernia Repair (lichtenstein).............. 424
Abdominal Cavity: Peritoneum . . . . . . . . . . . . . . . . . . . 264
122 Transinguinal Preperitoneal Mesh Repair (TIPP) . . . . . 427
85 Peritonitis and Laparostoma . . . . . . . . . . . . . . . . . . . . . . 264 123 Preperitoneal Inguinal Hernia Repair . . . . . . . . . . . . . . 431
86 Peritoneovenous Shunt . . . . . . . . . . . . . . . . . . . . . . . . . . 268 124 Laparoscopic Inguinal Hernia Repair . . . . . . . . . . . . . . 438
125 Femoral Hernia Repair (Crural Approach) . . . . . . . . . . 443
126 Femoral Hernia Repair (Inguinal Approach;
Abdominal Cavity: Small Intestine. . . . . . . . . . . . . . . . 272 I.otheissen, McVay) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
127 Femoral Hernia Repair (Inguinocrural Approach) . . . . 451
87 Segmental Resection of the Small Intestine . . . . . . . . . . 272
128 Epigastric Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
88 Intraluminal Stenting of the Small Intestine (Dennis
129 Umbilical Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
1\Jbe) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
130 Incisional Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
89 Meckel Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
131 Spigelian Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
90 End Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
91 Loop Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289