Emergency Vascular Surgery: A Practical Guide

216 Pages·2017·6.544 MB·English

by  Eric Wahlberg, Jerry Goldstone

Eric Wahlberg
Jerry Goldstone
Emergency
Vascular Surgery
A Practical Guide
Second Edition
123
Emergency Vascular Surgery
Eric Wahlberg • Jerry Goldstone
Emergency Vascular
Surgery
A Practical Guide
Second Edition
Eric Wahlberg Jerry Goldstone
Department of Vascular Surgery Division of Vascular Surgery
Karolinska Hospital Stanford University School of Medicine
Stockholm, Sweden Stanford, CA
USA
ISBN 978-3-662-54017-6 ISBN 978-3-662-54019-0 (eBook)
DOI 10.1007/978-3-662-54019-0
Library of Congress Control Number: 2017954389
© Springer-Verlag GmbH Germany 2007, 2017
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Preface
As with the first edition, the focus of the second edition of Emergency Vascular
Surgery: A Practical Guide remains the management and initial treatment of
common emergencies involving the non-cardiac vascular system. As the title
implies, it is not meant to be a comprehensive textbook of the management of
vascular disease nor is it aimed primarily for the experienced vascular surgery
expert. Our purpose is to provide readily available and concise information
that will enable surgery trainees and non-vascular surgeons to safely manage
patients they may encounter in emergency departments and hospital wards.
This is especially important because rapid diagnosis and treatment are manda-
tory for the management of the bleeding and ischaemic manifestations of vas-
cular disease. It is also important because, as populations in most parts of the
world are ageing and vascular diseases become more common, there are an
insufficient number of adequately trained vascular specialists to ensure that
one will always be immediately available for emergency situations.
Like the first, this edition is organised into two main sections: specific
anatomic areas and general concepts. All of the chapters have been thor-
oughly updated with many new figures and appropriate emphasis on endovas-
cular techniques, contemporary diagnostic studies and new pharmacologic
agents. Suggested supplemental reading lists at the end of each chapter have
been updated.
We appreciate and have been gratified by the feedback that we have
received from trainees and practitioners who have used the first edition. This
is what inspired us to undertake its revision. Hopefully this second edition
will continue to serve their needs and contribute to the care of patients
everywhere.
We gratefully acknowledge the assistance and encouragement of Michael
Koy and the production staff at Springer-Verlag. We also acknowledge the
inspiration and contributions for the first edition of Par Olofsson, a dear friend
and respected colleague. Without Par, neither the first nor the second edition
would have been written.
Stockholm, Sweden Eric Wahlberg
San Francisco, CA, USA Jerry Goldstone
2017
v
Contents
Part A Specific Areas
1 Vascular Injuries to the Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2.1 Causes and Mechanism . . . . . . . . . . . . . . . . . . . . . . . . 4
1.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3.2 Clinical Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4.1 Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4.2 Blunt Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.5 Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.5.1 Management Before Treatment . . . . . . . . . . . . . . . . . . 9
1.5.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.5.3 Management After Treatment . . . . . . . . . . . . . . . . . . . 13
1.5.4 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2 Vascular Injuries to the Thoracic Outlet Area . . . . . . . . . . . . . . . 17
2.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.2.1 Magnitude of the Problem . . . . . . . . . . . . . . . . . . . . . . 18
2.2.2 Etiology and Pathophysiology . . . . . . . . . . . . . . . . . . . 19
2.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3.2 Clinical Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.5 Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.5.1 Management Before Treatment . . . . . . . . . . . . . . . . . . 22
2.5.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.5.3 Management After Initial Treatment . . . . . . . . . . . . . . 31
2.6 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
vii
viii Contents
3 Vascular Injuries in the Upper Extremity . . . . . . . . . . . . . . . . . . 35
3.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.2.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.2.2 Etiology and Pathophysiology . . . . . . . . . . . . . . . . . . . 36
3.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.3.2 Clinical Signs and Symptoms . . . . . . . . . . . . . . . . . . . 37
3.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.5 Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.5.1 Initial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.5.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.5.3 Management After Treatment . . . . . . . . . . . . . . . . . . . 44
3.6 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.7 Latrogenic Vascular Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.8 Miscellaneous Vascular Injuries . . . . . . . . . . . . . . . . . . . . . . . 45
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4 Acute Upper Extremity Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.2 Background and Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4.5 Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.5.1 Initial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.5.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.5.3 Management After Treatment . . . . . . . . . . . . . . . . . . . 50
4.6 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5 Abdominal Vascular Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.2.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.2.2 Magnitude of the Problem . . . . . . . . . . . . . . . . . . . . . . 54
5.2.3 Etiology and Pathophysiology . . . . . . . . . . . . . . . . . . . 54
5.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
5.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
5.3.2 Clinical Signs and Symptoms . . . . . . . . . . . . . . . . . . . 55
5.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.5 Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.5.1 Management Before Treatment . . . . . . . . . . . . . . . . . . 57
5.5.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.5.3 Management After Treatment . . . . . . . . . . . . . . . . . . . 69
5.6 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
5.7 Iatrogenic Vascular Injuries in the Abdomen . . . . . . . . . . . . . . 70
5.7.1 Laparoscopic Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . 70
5.7.2 Iliac Arteries and Veins During Surgery
for Malignancies in the Pelvis . . . . . . . . . . . . . . . . . . . 70
Contents ix
5.7.3 Iliac Artery Injuries During
Endovascular Procedures . . . . . . . . . . . . . . . . . . . . . . . 71
5.7.4 Iatrogenic Injuries During Orthopedic Procedures . . . 71
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
6 Acute Intestinal Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6.2.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6.2.2 Magnitude of the Problem
and Patient Characteristics . . . . . . . . . . . . . . . . . . . . . . 74
6.3 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.4.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.4.2 Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.5 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.5.1 Laboratory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.5.2 Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.5.3 Diagnostic Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.6 Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.6.1 Management Before Treatment . . . . . . . . . . . . . . . . . . 78
6.6.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.6.3 Management After Treatment . . . . . . . . . . . . . . . . . . . 82
6.7 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
7 Abdominal Aortic Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
7.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
7.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
7.2.1 Magnitude of the Problem . . . . . . . . . . . . . . . . . . . . . . 85
7.2.2 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
7.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
7.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
7.3.2 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
7.3.3 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . 87
7.3.4 Clinical Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
7.5 Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
7.5.1 Management Before Surgery . . . . . . . . . . . . . . . . . . . . 88
7.5.2 Open Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
7.5.3 Management After Treatment . . . . . . . . . . . . . . . . . . . 97
7.6 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
7.7 Unusual Types of Aortic Aneurysms . . . . . . . . . . . . . . . . . . . . 98
7.7.1 Inflammatory Aneurysm . . . . . . . . . . . . . . . . . . . . . . . 98
7.7.2 Aortocaval Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
7.7.3 Thoracoabdominal Aneurysm . . . . . . . . . . . . . . . . . . . 99
7.7.4 Mycotic Aneurysm. . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
7.8 Ethical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
x Contents
8 Acute Aortic Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
8.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
8.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
8.2.1 Magnitude of the Problem . . . . . . . . . . . . . . . . . . . . . . 104
8.2.2 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
8.2.3 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
8.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
8.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
8.3.2 Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . 109
8.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
8.5 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
8.5.1 Initial Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
8.5.2 Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
8.5.3 Type B Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
8.5.4 Endovascular Treatment . . . . . . . . . . . . . . . . . . . . . . . . 113
8.6 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
9 Vascular Injuries in the Legs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
9.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
9.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
9.2.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
9.2.2 Magnitude of the Problem . . . . . . . . . . . . . . . . . . . . . . 116
9.2.3 Etiology and Pathophysiology . . . . . . . . . . . . . . . . . . . 116
9.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
9.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
9.3.2 Clinical Signs and Symptoms . . . . . . . . . . . . . . . . . . . 117
9.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
9.4.1 Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
9.4.2 CT Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
9.4.3 Duplex Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
9.5 Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
9.5.1 Management Before Treatment . . . . . . . . . . . . . . . . . . 119
9.5.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
9.5.3 Endovascular Treatment . . . . . . . . . . . . . . . . . . . . . . . . 128
9.5.4 Management After Treatment . . . . . . . . . . . . . . . . . . . 128
9.6 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
9.7 Fasciotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
9.8 Iatrogenic Vascular Injuries to the Legs . . . . . . . . . . . . . . . . . . 131
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
10 Acute Leg Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
10.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
10.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
10.2.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
10.2.2 Magnitude of the Problem . . . . . . . . . . . . . . . . . . . . . 134
10.2.3 Pathogenesis and Etiology . . . . . . . . . . . . . . . . . . . . . 134
Contents xi
10.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
10.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
10.3.2 Clinical Signs and Symptoms . . . . . . . . . . . . . . . . . . 135
10.3.3 Evaluation of Severity of Ischemia . . . . . . . . . . . . . . 136
10.4 Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 137
10.4.1 Management Before Treatment . . . . . . . . . . . . . . . . . 137
10.4.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
10.4.3 Thrombolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
10.4.4 Management After Treatment . . . . . . . . . . . . . . . . . . 143
10.5 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
10.6 Conditions Associated with Acute Leg Ischemia . . . . . . . . . 144
10.6.1 Chronic Ischemia of the Lower Extremity . . . . . . . . . 144
10.6.2 Acute Ischemia After Previous
Vascular Reconstruction. . . . . . . . . . . . . . . . . . . . . . . 145
10.6.3 Blue Toe Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 145
10.6.4 Popliteal Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . 146
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Part B General Concepts
11 Acute Complications Following Vascular Interventions . . . . . . 151
11.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
11.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
11.2.1 Magnitude of the Problem . . . . . . . . . . . . . . . . . . . . . 152
11.3 Ischemic Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
11.3.1 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
11.3.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 153
11.3.3 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
11.3.4 Management and Treatment . . . . . . . . . . . . . . . . . . . . 156
11.3.5 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . 157
11.4 Bleeding Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
11.4.1 Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
11.4.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 158
11.4.3 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
11.4.4 Management and Treatment . . . . . . . . . . . . . . . . . . . . 159
11.5 Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
11.5.1 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
11.5.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . 163
11.5.3 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
11.5.4 Management and Treatment . . . . . . . . . . . . . . . . . . . . 165
11.5.5 Results and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . 166
11.6 Local Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
11.6.1 Lymphocele and Seroma . . . . . . . . . . . . . . . . . . . . . . 167
11.6.2 Postoperative Leg Swelling . . . . . . . . . . . . . . . . . . . . 167
11.6.3 Wound Edge Necrosis . . . . . . . . . . . . . . . . . . . . . . . . 168
11.6.4 Local Nerve Injuries . . . . . . . . . . . . . . . . . . . . . . . . . 168
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169