Zollinger's atlas of surgical operations

579 Pages·2016·128.347 MB·English

by  E. Christopher Ellison, Jr Robert Milton Zollinger

TEN TH ED I TI O N
Z O LLI N G ER ’S
AT LAS O F SU R G I C AL
O P ER AT I O N S
E. Ch ph E , MD, FACS
I m D R b M. Z g P S g D g h P
T Oh S U C g M c W x M c C
C mb , Oh
R b M. Z g , J ., MD, FACS
P Em , D p m S g , C W R
U Sch M c U H p
C c P S g , U A z C g M c
F m , I c S g , H M c Sch h P B B gh m H p

c , A z
Il l ust r at ions For EN H Edit ion By
M B
Il l ust r at ions For Pr evious Edit ions By
M B , J Sm h, C D ,
M C g, P F ch , W m O
N w Y k Ch c g S F c c L b L M M x c C
M N w D h S J S S g p S
MCGH362-FM.indd 1 12/18/15 6:03 PM
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C O N T EN T S
P v s e c t io n v : s ma l l i n t e s t i n e , c o l o n ,
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44 R c Sm I
s e c t io n i : bas ic s
45 R c Sm I , S p
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47 E m 6
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48 App c m 6
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50 S g c A m L g I
51 L p I m
52 C m
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53 C C m 6
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5 A B S pp h Upp Ab m V c
55 C c m , R gh
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56 C c m , R gh , L p c p c
7 A m h L g I
57 C c m , L , E - -E A m 6
8 A m h Ab m A I V C 6
58 C c m , L , L p c p c
9 T c c P m A m
59 Ab m p R c
60 C c m P c c c m 6
61 A R c R c gm : E - -E A m 6
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62 A R c , S p
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63 A R c R c gm :
chapt er
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66 R bb B g Exc H m h
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19 C P —S bph c Ab c 6
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74 Ch c c m , P Ch c c m
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75 Ch c m 6
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76 Ch ch j j m
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77 L c R c H m , K k
24 H m g c m , B h I M h
78 B p L , Op 6
25 H m g c m , B h I S p
79 A m R c h L
26 G c m , S b
80 L c R c H p c m (N m c)
27 G c m , S b —Om c m
81 R gh H p c m (S gm , 6, , ± S gm )
28 G c m , P M h
82 L H p c m (S gm , 3, ± S gm ) 6
29 G c m , H m M h
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30 H m g c m , B h II S p 6
(S gm , , 6, , ± S gm ) 3
31 G c m
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34 F p c
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36 E ph g M m , L p c p c 6
85 P c c j j m (P w–G b P c ) 3
37 R x- -Y G c B p , L p c p c
86 R c h h P c 3
38 S G c m , L p c p c 3
87 R c h h P c w h Sp c
39 T A j b G c B , L p c p c 3
P , L p c p c 33
40 E ph g c m h 3
88 P c c c m (Wh pp P c ) 33
41 E ph g c m , h c c
89 P c c m 3
42 P m m 6
90 Sp c m 3 6
91 Sp c m , L p c p c 36
92 Sp c C 366
iii
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iv
Co ntents
s e c t io n V : g e n i t o u r i n a r y 122 R c N ck D c 6
123 Z k ’ D c c m 6
chapt er
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93 A G c g c P c O w 3 3
94 Ab m H c m 3
95 S p g c m —O ph c m 3
s e c t io n x i i : s k i n , s o f t t i s s u e , a n d br e as t
96 G c g c S m—R V g P c 3
chapt er
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125 S L mph N D c , M m
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126 B A m I c 6
98 U I j R p 3
127 M R c M c m
99 D N ph c m , L p c p c 3 6
128 S L mph N D c , B
100 K p 3
129 Ax D c , B 6
130 Sk G
s e c t io n i x : h e r n i a
chapt er
s e c t io n x i i i : vas c u l a r
101 R p V H , L p c p c 3 6
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102 R p V H , Op C mp P S p
131 C E c m
103 R p Umb c H
132 V c Acc , A F
104 R p I c I g H 6
133 V Acc , P P c m , I J g V
105 R p I c I g H (Sh c )
134 V Acc , C V C h , S bc V
106 R p D c I g H (McV ) 6
135 R c Ab m A c A m
107 R p I g H w h M h (L ch )
136 A m B p
108 R p I g H w h M h (R k w R bb )
137 T mb mb c m , S p M c A 6
109 R p F m H 6
138 F m m B p
110 R p F m H w h M h
139 F m p p R c c 3
111 L p c p c A m h I g R g 3
140 S ph V S A B p
112 R p I g H , L p c p c b m
141 T mb mb c m , F m
P p ( APP) 3
142 I V C F I 6
113 R p I g H , L p c p c
143 E L Ab h G S ph
Ex p ( EP) 3
V S b Ph b c m
114 H c R p 36
144 Sh g P c P H p
s e c t io n x : e n d o c r i n e
s e c t io n x i v : e xt r e mi t i e s
115 T c m , S b
chapt er
116 P h c m
145 F c m
117 A c m , B
146 E ch m 6
118 A c m , L L p c p c 6
147 P c p Amp
119 A c m , R gh L p c p c
148 Amp , S p c 6
149 I c D g I c h H 6
s e c t io n x i : h e a d a n d n e c k 150 S 66
chapt er
I x 6
120 ch m 6
121 ch m , P c D 6
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P R EFAC E
S m 75 g , h A LAS w c c m p p ch q
c mm b g g . M mp m ch g h cc h p
c g p ch q g m m m
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w c c c p c p c ch q h 1990 w c mm
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c p h b . T c gh p c h w h k h
p c c g g c g x mph c m , CAPD c h ,
c m , ch m , c , h p g h
ch q p c mp p p , p , b c h c c p . I -
w h c c mp x g p c m p c p c
ph g m m , g c m m b b , h ph g c m
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h p m c . F w p c p c h - ph c m
k p .
A m j g z h cc w h h 18 A c E
wh p c xp h b ch c b m– ch p . T -
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c c c p p c m c h gh p p c h b
m c w h g c mp m b 50 ch p x .
D g h p p h 10 h w c b p m B B
McG w H D S mp h D p m S g T Oh S U . I h
h , c p c g p g ch g h c ch h m c -
, c c b h w p mp m c c m k
c g . F h 10 h m c , M B , h p p w -
w k p h gh c w h c mp -g g ph c h w p c h g
p k k ch g wh ch k c ch b .
W h c H c S pp m b www.Zolling sA l s. om
p p cc m w h c p h h 70 h b
m cc g h A LAS. M w p c b w p c g
m ch g ch p g, p c p , m m m g -g p c .
O h w p m w w m b c g c . A -
, h p h h h p g m mp b h m ch c c c
h - z A LAS h c p c b g. T , h c p p ck w
q p c h p “ k h gh” p m
h b ck ch p g . T w c b 500 p g — z ch b h
m -1980 . A h p , h w m p c ch p g p -
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h , (2) w b h c g mb g c p c — x mp , h c c/
p m p .
F h m , h h h p b h h m c p p p h
b , b h ch h c c H c S pp m h A LAS wh h
p g m . M h ch p p m p c z c m-
p x b c g g b h h p c c , q c
k h h x b k . I h c c m c h g m c
p m . T p g p c p xp -
c , p h p b h “ ” p . T m b p c g
wh xp p q pm ch p p b p c p c m
b .
m m c b c p ch p b h x ,
h m j p m c j . H w , h w w cc b
m m c / g c c ph c . W h c c H c S pp m
w h p m h h c g c ch q c g p .
A D . C g c w h g c h c h m, m h
w h m . N w m . D . E. Ch ph E h b c m h w p c p h
wh w c h A LAS. D . E h h h Z-E m . H h R b
M. Z g P h D p m S g h Oh S U M c C .
H h cc p h p m p b h A LAS m g b ck C mb
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vi
Pr eface
h OSU D p m S g , wh D . Z g S h A LAS 40 .
F , h c , D . Z g ’ p p p h x w k m
w ch h M c H g C w h h OSU P H h Sc -
c L b wh h m c g b .
E. Ch ph E , MD
R b M. Z g , J ., MD
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ASSO C I AT E ED I T O R S
Do n M. Agn s , MD, FACS Sus n Mof -B u , MD, P D, FACS
Skin, Sof issue, and Breast General Abdomen and T orax
Associate Pro essor o Clinical Surgery Associate Pro essor o Surgery
T e Ohio State University Chie Quality and Patient Sa ety O cer
College o Medicine and Wexner Medical Center Associate Dean, Clinical Af airs or Quality and Patient Sa ety
C mb , OH T e Ohio State University College o Medicine and Wexner Medical Center
C mb , OH
P. M k Blooms on, MD, FACS
Gall Bladder, Bile Ducts, Liver, and Pancreas P Mus ll , II, MD, FACS
F . M , FL Pancreas
Esophagus and Stomach
J m s H. Bo ml , IV, MD
Associate Pro essor o Surgery
Extremities
Monte ore Medical Center/Albert Einstein College o Medicine
G g w , X
B x, NY
Willi m B. F , MD, FACS
B dl y J. N dl m n, MD, FACS
Skin, Sof issue, and Breast
Esophagus and Stomach
Pro essor o Surgery
Associate Pro essor o Clinical Surgery
Dr. Arthur G. & Mildred C. James-Richard J.
Medical Director, Comprehensive Weight Management and Bariatric
Solove Chair in Surgical Oncology
Surgery Center
T e James Cancer Center Chair in Surgical Oncology
Director, Center or Minimally Invasive Surgery
Director, T e Ste anie Spielman Comprehensive Breast Center
T e Ohio State University College o Medicine and the Wexner Medical Center
T e Ohio State University College o Medicine and Wexner Medical Center
C mb , OH
C mb , OH
Ron ld P. P ll i , MD, FACS
J f y M. Fowl , MD, FACS
Genitourinary
Genitourinary
ransplantation
Gynecologic Procedures
Associate Pro essor o Surgery
Vice Chair and Pro essor
Director, Kidney ransplantation
John G. Boutselis M.D. Chair in Gynecology
T e Ohio State University College o Medicine and Wexner Medical Center
T e Ohio State University College o Medicine and Wexner Medical Center
C mb , OH
H , OH
Kyl A. P y, MD, FACS
Al n E. H zm n, MD, FACS
Esophagus and Stomach
Small Intestine, Colon, and Rectal
Associate Pro essor o Surgery
Assistant Pro essor o Clinical Surgery
T e Ohio State University College o Medicine and Wexner Medical Center
Director, General Surgery Residency Program
C mb , OH
T e Ohio State University College o Medicine and Wexner Medical Center
C mb , OH Jo n E. P y, MD, FACS
Endocrine
J f y W. H z y, MD, FACS
Head and Neck
Hernia
Associate Pro essor o Clinical Surgery
Associate Pro essor o Surgery
T e Ohio State University College o Medicine and Wexner Medical Center
Director, Division o General and Gastrointestinal Surgery
C mb , OH
T e Ohio State University College o Medicine and Wexner Medical Center
C mb , OH J n E. S , MD, FACS
Vascular Procedures
Rob S. D. Higgins, MD, MSHA, FACS
Associate Pro essor o Clinical Surgery
T oracic Surgery
T e Ohio State University College o Medicine and Wexner Medical Center
ransplantation
C mb , OH
T e William Stewart Halsted Pro essor
Chair and Surgeon-in-Chie P i k S. V o, MD, FACS
Johns Hopkins University School o Medicine Department o Surgery Vascular Procedures
B m , MD Luther M. Keith Pro essor o Surgery
Division Director, Vascular Diseases & Surgery
L y M. Jon s, MD, FACS
T e Ohio State University College o Medicine and Wexner Medical Center
Skin and Sof issue
C mb , OH
Pro essor o Clinical Surgery
T e American Electric Power Foundation Chair in Burn Care
COORDINATING EDITOR
T e Ohio State University College o Medicine and Wexner Medical Center
C mb , OH D nnis E. M i s
Publications Editor
G go y J. Low , MD
Department o Surgery
Genitourinary
T e Ohio State University College o Medicine and Wexner Medical Center
Ureter Repair
C mb , OH
C mb , OH
W. S o M lvin, MD, FACS
Esophagus and Stomach
Pro essor o Surgery
Vice Chairman or Clinical Surgery
Division Chie , General Surgery
Director, Advanced GI Surgery
Monte ore Medical Center/Albert Einstein College o Medicine
B x, NY
vii
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Se c t i o n I
B s s
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Ch a p r
1 s u r g i c a l T e c h n i q u e
Asepsis, hemostasis, and gentleness to tissues are the bases o the surgeon’s surgery as the many other acets that ensure proper wound healing. A cut,
art. Nevertheless, recent decades have shown a shi in emphasis rom the burn, or olliculitis on the surgeon’s hand is as hazardous as the in ected
attainment o technical skill to the search or new procedures. T e advances scratch on the operative site.
in minimally invasive techniques have allowed the surgeon great exibility T e preoperative preparation o the skin is concerned chie y with
in the choice o operative techniques. Nearly all operations may be per- mechanical cleansing. It is important that the hair on the patient’s skin
ormed by an open or a minimally invasive laparoscopic technique. T e is removed with clippers immediately be ore operation; pre erably in the
surgeon must decide which approach is in the best interest o the individual operating suite a er anesthetization. T is eliminates discom ort to the
patient. In addition, application o robotic surgery has added a new dimen- patient, a ords relaxation o the operative site, and is a bacteriologically
sion to the surgical armamentarium. T roughout the evolution o surgery sound technique. T ere should be as short a time-lapse as possible between
it has been recognized that aulty technique rather than the procedure itsel hair removal and incision, thus preventing contamination o the site by a
was the cause o ailure. Consequently it is essential or the the young, as regrowth o organisms or the possibility o a nick or scratch presenting a
well as the experienced surgeon, to appreciate the important relationship source o in ection. T e skin is held taut to present an even, smooth sur ace,
between the art o per orming an operation and its subsequent success. T e as the hair is removed with power-driven disposable clippers. T e use o
growing recognition o this relationship should reemphasize the value o sharp razors to remove hair is discouraged.
precise technique. Obviously, it is a useless gesture to scrub the skin the night be ore opera-
T e technique described in this book emanates rom the school o surgery tion, and to send the patient to the operating room with the site o incision
inspired by William Stewart Halsted. T is school, properly characterized covered with a sterile towel. However, some surgeons pre er to carry out a
as a “school or sa ety in surgery,” arose be ore surgeons in general recog- preliminary preparation in elective operations on the joints, hands, eet,
nized the great advantage o anesthesia. Be ore Halsted’s teaching, speed and abdominal wall. Historically, this would involve scrubbing the skin
in operating was not only justi ed as necessary or the patient’s sa ety but with a cleansing agent several times a day or 2 or 3 days be ore the surgery.
also extolled as a mark o ability. Despite the act that anesthesia a orded an oday the patient may be instructed to shower using a specialized cleans-
opportunity or the development o a precise surgical technique that would ing agent, pre erably chlorhexidine gluconate, the evening be ore and the
ensure a minimum o injury to the patient, spectacular surgeons contin- day o the surgery. Intravenous antibiotics are ordered to be administered
ued to emphasize speedy procedures that disregarded the patient’s wel are. within 1 hour o the planned incision.
Halsted rst demonstrated that, with care ul hemostasis and gentleness to In the operating room, a er the patient has been properly positioned, the
tissues, an operative procedure lasting as long as 4 or 5 hours le the patient lights adjusted, and the proper plane o anesthesia reached, the nal prepa-
in better condition than a similar procedure per ormed in 30 minutes with ration o the operative site is begun. An assistant, puts on sterile gloves, and
the loss o blood and injury to tissues attendant on speed. T e protection o completes the mechanical cleansing o the operative site with sponges satu-
each tissue with the exquisite care typical o Halsted is a dif cult lesson or the rated in the desired solution. Chlorhexidine gluconate is the ideal cleansing
young surgeon to learn. T e preoperative preparation o the skin, the drap- agent. T e contemplated site o incision is treated rst; the remainder o the
ing o the patient, the selection o instruments, and even the choice o suture eld is cleansed with concentric strokes until all o the exposed area has
material are not so essential as the manner in which details are executed. been covered. As with all tinctures and alcohols used in skin preparation,
Gentleness is essential in the per ormance o any surgical procedure. caution must be observed to prevent skin blisters caused by puddling o
Young surgeons have dif culty in acquiring this point o view because solutions at the patient’s side or about skin creases. It is important to allow
they are usually taught anatomy, histology, and pathology by teachers using the prep solution to dry completely be ore draping in order to minimize a
dead, chemically xed tissues. Hence, students regard tissues as inanimate re hazard. T is usually requires 3 minutes with chlorhexidine gluconate.
material that may be handled without concern. T ey must learn that living Similarly, electrocardiographic (ECG) and cautery pads should not be wet-
cells may be injured by unnecessary handling or dehydration. A review o ted. Some surgeons pre er to paint the skin with an iodine-containing solu-
anatomy, pathology, and associated basic sciences is essential in the daily tion or a similar preparation.
preparation o young surgeons be ore they assume the responsibility o per- A transparent sterile plastic drape may be substituted or the skin towels
orming a major surgical procedure on a living person. T e young surgeon in covering the skin, avoiding the necessity or towel clips at the corners o
is o en impressed by the speed o the operator who is interested more in the eld. T is draping is especially use ul to cover and wall o an ostomy.
accomplishing a day’s work than in teaching the art o surgery. Under such T e plastic is made directly adherent to the skin by a bacteriostatic adhe-
conditions, there is little time or review o technique, discussion o wound sive. A er application o the drape, the incision is made directly through
healing, consideration o related basic scienti c aspects o the surgical pro- the material, and the plastic remains in place until the procedure is com-
cedure, or the criticism o results. Wound complications become a distinct pleted. When, or cosmetic reasons, the incision must accurately ollow the
problem associated with the operative procedure. I the wound heals, that lines o skin cleavage, the surgeon gently outlines the incision with a sterile
is enough. A little redness and swelling in and about wounds are taken as inked pen be ore the adhesive plastic drape is applied. T e addition o the
a natural course and not as a criticism o what took place in the operating plastic to the drape ensures a wide eld, that is, surgically, completely ster-
room 3 to 5 days previously. Should a wound disrupt, it is a calamity; but ile, instead o surgically clean as the prepared skin is considered. At the
how o en is the suture material blamed, or the patient’s condition, and how same time, the plastic layer prevents contamination should the large drape
seldom does the surgeon inquire into just where the operative technique sheet become soaked or torn.
went wrong? Super cial malignancies, as in the case o cancer o the skin, lip, or
T e ollowing detailed consideration o a common surgical procedure, neck, present a problem in that a routine vigorous mechanical scrub is too
appendectomy, will serve to illustrate the care necessary to ensure success ul traumatic causing irritation or bleeding. Gentle preparation with painting
results. Prior to the procedure, the veri ed site o the incision is marked is pre erred. Following hair removal with clippers, a germicidal solution
with the surgeon’s initials by the operating surgeon. T en the patient is should be applied care ully. Similarly, the burned patient must have special
trans erred to the operating room and is anesthetized. T e operating table skin preparation. In addition to the extreme tissue sensitivity, many times
must be placed where there is maximum illumination and adjusted to pres- gross soil, grease, and other contaminants are present. Copious ushing o
ent the abdomen and right groin. T e light must be ocused with due regard the burned areas with isotonic solutions is important as mechanical cleans-
or the position o the surgeon and assistants as well as or the type and ing is carried out with a nonirritating detergent.
depth o the wound. T ese details must be planned and directed be ore the Injuries such as the crushed hand or the open racture require extreme
skin is disin ected. A prophylactic antibiotic is administered within 1 hour care, and meticulous attention to skin preparation must be observed. T e
o the skin incision and, in uncomplicated cases, is discontinued within hasty, inadequate preparation o such emergency surgery can have disas-
24 hours o the procedure. trous consequences. A nylon bristle brush and a detergent are used to
T e ever-present threat o sepsis requires constant vigilance on the part scrub the area thoroughly or several minutes. Hair is removed by an
o the surgeon. Young surgeons must acquire an aseptic conscience and dis- electric clipper or a wide area around the wound edges. Copious irriga-
cipline themselves to carry out a meticulous hand-scrubbing technique. A tion is essential a er the skin is prepared, ollowed by a single applica-
knowledge o bacterial ora o the skin and o the proper method o prepar- tion o a germicide. An antibacterial sudsing cleanser may be use ul or
ing one’s hands be ore entering the operating room, along with a sustained cleansing the contaminated greasy skin o the hands or about traumatic
adherence to a methodical scrub routine, are as much a part o the art o wounds.
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