Srb's Manual of Surgery

The manual is written for the students in this firing line for their MBBS degree. Common conditions seen on a day-to-
day basis have dealt with a little more detail. the uncommon and rare conditions have been dealt briefly. the mode of
clinical presentation and the physical signs are mentioned vividly so as to register in the mind of the reader. There
is a brief mention of necessary investigations in each of the surgical conditions. the accepted mode of recent advances
in investigation and treatment has been included. This manual is meant for Final MBBS degree examination and not a
consolidated textbook. Certain chapters are included at the end of the book for the more enthusiastic students and for
those interested in participating in quiz programmes.

?Begins with general surgery, followed by chapters on the surgeries from face to rectum and anal canal, also discusses
urology, neurosurgery, thorax, adjuvant therapy, anesthesia.

?New editions include morbid obesity, gastrointestinal fistulas, surgical audit.

?Chapter containing a list of interesting new developments in surgery and uniquely new topics like fascinating signs,
misnomers, triads have been included.

?Discussion on instruments and operative procedures has been dealt with in necessary detail separately.

?Malignancies have been discussed in much more detail with new concept of staging and present oncological trends.

?More than 2000 coloured clinical photographs of very good quality, which are self-explanatory of the conditions.

?Clinching physical signs have been highlighted in box forms with different shades of colour for easy recollection.


1. General Surgery......................1
A. Wounds and Wound Healing...............................................1
Wounds 1; Classification of Wounds 1; Wound Healing 5; Compartment Syndrome 8; Crush Injury 9; Crush
Syndrome 10; Degloving Injuries 10; Keloid 11; Hypertrophic Scar 12; Problems with Wound Healing 13
B. Ulcer......14
Ulcer 14; Granulation Tissue 17; Investigations for an Ulcer 19; Traumatic Ulcer 20; Trophic Ulcer (Pressure Sore/
Decubitus Ulcer) 21; U lcer due to Chilblains 23; U lcer due to Frostbite 23; Martorell뭩 Ulcer 23; Arterial/Ischaemic
Ulcer 23; Bairnsdale Ulcer 23; Carcinomatous Ulcer (Epithelioma, Squamous Cell Carcinoma) 24; Marjolin's
Ulcer 24; Rodent Ulcer 24; Melanotic Ulcer 24; Diabetic Ulcer 25; Meleney뭩 Ulcer (Postoperative Synergistic
Gangrene) 26; Lupus Vulgaris (멛upus뮉Wolf ) 26; Tuberculous Ulcer 27; Bazin뭩 Disease (Erythrocyanosis Frigida/
Erythema Induratum) 27; Tropical Ulcer 27; Venous Ulcer (Gravitational Ulcer) 28; Syphilitic Ulcer 28; Soft Chancre/
Soft Sore/ Ducrey뭩 Ulcer/Chancroid/Bubo 28; Climatic Bubo/Tropical Bubo 29; Clinical Examination of an Ulcer 29
C. Sinus and Fistula................................................................30
Sinus 30; Fistula 30; Median Mental Sinus 33; Sequestrum 34; Preauricular Sinus 35
D. Infectious Diseases.............................................................36
Surgical Infection 36; Cellulitis 37; Erysipelas 38; Erysipeloid Disease 39; Lymphangitis 39; Abscess 40;
Bacteraemia 45; Septicaemia 45; Pyaemia 45; Metastatic and Pyaemic Abscess 46; Boil (Furuncle) 46; Hidradenitis
Suppurativa 46; Carbuncle 47; Pott뭩 Puffy Tumour 48; Pyogenic Granuloma (Granuloma Pyogenicum) 49;
Impetigo 49; Scrum Pox 49; Tetanus 49; Gas Gangrene 52; Tuberculosis 54; Leprosy 55; Syphilis (Great Pox)
(French Disease) 56; Actinomycosis 56; Madura Foot (Mycetoma Pedis) 57; Rabies (Hydrophobia) 58; Rabies
in Dogs 60; Anthrax 61; Nosocomial and Opportunistic Infections 61; Hiv Infection and Aids (Acquired
Immunodeficiency Syndrome) 62; Necrotising Fasciitis 65; Acute Pyomyositis 67; Surgical Site Infection (Ssi) 67
E. Swellings.............................................................................71
Lipoma 71; Cysts 74; Dermoids 75; Sebaceous Cyst (Wen, Epidermoid Cyst) 79; Glomus Tumour 82; Papilloma 83;
Warts 84; Fibroma 84; Bursae 85; Semimembranosus Bursa 86; Morrant Baker뭩 Cyst 87; Lymph Cyst (Lymphatic
Cyst) 88; Lymphangioma 88; Calcinosis Cutis 89; Neuroma 89; Neurofibroma 90; Neurilemmoma (Schwannoma)
92; Ganglion 93; Chordoma 93; Epignathus 93
f. Electrolyte and Nutrition...................................................95
Normal Physiology 95; Water Loss (Volume Loss) 95; Water Excess (Ecf Volume Excess) 95; Ecf Loss 96;
Ecf Excess 96; Hyponatraemia 96; Hypernatraemia 97; Hypokalaemia 97; Hyperkalaemia 98; Hypermagnesaemia
98; Hypomagnesaemia 98; Acid-Base Balance 98; Metabolic Alkalosis 99; Respiratory Alkalosis 99; Metabolic
Acidosis 99; Respiratory Acidosis 100; Anion Gap 100; Fluid Therapy 100; Nutrition 101; Gastrostomy 103; Jejunostomy
104; Total Parenteral Nutrition (Tpn) 104; Refeeding Syndrome 106; Obesity and Morbid Obesity 106; Different
Surgeries 107
G. Shock...111
Shock 111; Stages of Shock 112; Effects of Shock 112; Clinical Features of Shock 115; Investigations in
Shock 115; Central Venous Pressure (Cvp) 116; Pulmonary Capillary Wedge Pressure (Pcwp) 116; Systemic
Inflammatory Response Syndrome (Sirs) 117; Multiple Organ Dysfunction Syndrome (Mods) 117; Oxygen
Therapy 118; Topical O2-Therapy 118; Cardiac Arrest 118
H. Haemorrhage and Blood Transfusion..............................121
Haemorrhage 121; Blood Transfusion 124; Blood Substitutes 126; Massive Blood Transfusion 126; Autologous
Blood Transfusion 127; Artificial Blood 127; Erythropoietin 127; Tourniquets 127; Disseminated Intravascular
Coagulation (Dic) 128; Mechanism of Blood Coagulation (Haemostasis) 129
I. Burns...130
Burns 130; Management of Burns 134; Eschar 136; Contracture in Burn Wound 137; Electrical Burns 139;
Inhalation Injury 141; Chemical Burns 141
Contents
xvi
SRB's Manual of Surgery
J. Trauma143
Triage 143; Spinal Injury 145; Neck Injuries 146; Bullet Injuries 146; Blast Injuries 147; Penetrating Injuries
148; Abdominal Trauma 148; Blunt Trauma of Abdomen 150; Duodenal Injury 152; Pancreatic Injury 153; Small
Bowel Injury 153; Colonic Injury 154; Liver Injury 154; Splenic Injury 154; Renal Injury 154; U rinary Bladder
Injury 154; Abdominal Compartment Syndrome 154; Seatbelt Injuries 155
K. Hand and Foot..................................................................156
Hand 156; Hand Infections 157; Acute Paronychia 160; Chronic Paronychia 161; Apical Subungual Infection
161; Terminal Pulp Space Infection (Felon) 161; Infection of Web Spaces 162; Deep Palmar Space
Infection 162; Space of Parona Infection 164; Acute Suppurative Tenosynovitis 164; Compound Palmar
Ganglion 165; Orf 166; Milker뭩 Nodes 166; Hand Injuries 166; Dupuytren뭩 Contracture 168; Volkmann뭩 Ischaemic
Contracture 168; Syndactyly 169; Mallet Finger (Base Ball Finger) 170; Heberden뭩 Nodes 170; Spina Ventosa 170;
Foot 170; Callosity 170; Corn 171; Plantar Fasciitis (Policeman뭩 Heel) 172; Ingrowing Toe Nail 172; Onychogryphosis
172; Onychomycosis 172; Athlete뭩 Foot 172; Hallux Valgus 173
L. Arterial Diseases...............................................................174
Surgical Anatomy of Thoracic Outlet 174; Arteries of Upper Limb 175; Arteries of Lower Limb 175; Arterial
Diseases 175; Intermittent Claudication 175; Rest Pain 176; Limb Ischaemia 176; Pregangrene
177; Gangrene
177; Different Levels of Arterial Obstruction 178; Other Features of Poor Circulation
178; Investigations for Arterial
Diseases 179; Diseases of the Arteries 182; Atherosclerosis 182; Thromboangiitis Obliterans (Tao) Syn. Buerger뭩
Disease 184; Takayasu뭩 Pulseless Arteritis 188; Raynaud뭩 Phenomenon 188; Temporal Arteritis 190; Treatment
of Arterial Diseases 190; Subclavian Steal Syndrome 196; Acute Arterial Occlusion 196; Traumatic Acute Arterial
Occlusion 197; Embolism 197; Reperfusion Injury 199; Saddle Embolus 200; Embolectomy 200; Fat Embolism
201; Air Embolism 201; Therapeutic Embolisation 201; Caisson뭩 Disease or Decompression Disease 202; Aneurysm
202; Mycotic Aneurysm 203; Abdominal Aneurysm 203; Abdominal Aortic Aneurysm 204; Peripheral
Aneurysm 208; Carotid Artery Aneurysm (Extracranial) 209; Dissecting Aneurysm 209; Erythromelalgia/
Erythralgia 210; Livedo Reticularis 210; Polyarteritis Nodosa 210; Scleroderma/Systemic Sclerosis 211; Acrocyanosis
(Crurum Puellarum Frigidum) 211; Gangrene 211; Diabetic Foot and Diabetic Gangrene 213; Trophic
Ulcer 214; Bedsores (Decubitus Ulcer) (Pressure Sores) 214; Frostbite 215; Ainhum 215; Endovascular
Surgeries 215; U pper Limb Ischaemia 216; Arterial Substitutes 220
M. Vascular Lesions and Hamartoma...................................221
Vascular Anomalies 221; Haemangioma 221; Vascular Malformations 225; Cirsoid Aneurysm 225; Arteriovenous
Fistula (Avf) 225; Campbell de Morgan Spots 229; Parry-Romberg Disease 229; Hamartomata 229
N. Venous Diseases...............................................................230
Anatomy of Veins of Lower Limb 230; Physiology of Venous Blood Flow in Lower Limb 231; Deep Vein
Thrombosis (Dvt) 231; Varicose Veins 235; Venous Ulcer (Gravitational Ulcer) 249; Compression Therapy for
Varicose Veins 251; Thrombophlebitis 251; Klippel-Trenauny Syndrome 252; Anticoagulants 252; Heparin 252;
Low Molecular Weight Heparin (Lmwh) 252; Oral Anticoagulants 253; Warfarin 253; Direct Thrombin
Inhibitors 253; Antiplatelet Drugs 253; Pulmonary Embolism 254
O. Lymphatics........................................................................255
Surgical Anatomy 255; Lymphangiography 257; Isotope Lymphoscintigraphy 257; Lymphoedema
257; Lymphomas 264; Hodgkin뭩 Lymphoma (Hl) 265; Non-Hodgkin뭩 Lymphoma (Nhl ) 269; Malt Lymphoma
(Maltoma) 270; Burkitt뭩 Lymphoma (Malignant Lymphoma of Africa) 270; Cutaneous T Cell Lymphoma 270; Chylous
Ascites 271; Chylothorax 271; Chyluria 271; Sarcoidosis 272
P. Peripheral Nerves.............................................................273
Peripheral Nerve Injuries 273; Tinel뭩 Sign 275; Brachial Plexus Injuries 275; Causalgia 275; Median Nerve
Injury 276; Carpal Tunnel Syndrome 276; U lnar Nerve Injury 278; Claw Hand 278; Radial Nerve Injury 279;
Common Peroneal Nerve Injury 280; Foot Drop 280; Medial Popliteal Nerve Injury 281; Axillary Nerve Injury 281;
Long Thoracic Nerve Injury (Nerve of Bell) 281; Meralgia Paraesthetica 281
Q. Neoplasm..........................................................................282
Definition 282; Dysplasia 283; Carcinoma in Situ 284; Aetiologic Factors 284; Spread of Malignant
Tumours 284; Grading of Tumour 285; Staging of the Tumour 285; Paraneoplastic Syndromes 286; Investigations
for Neoplasm 286; Management Strategy for Cancers 291
R. Skin Tumours....................................................................293
Anatomy 293; Classification of Skin Tumours 293; Skin Adnexal Tumours 294; Dermatofibroma (Sclerosing Angioma
or Subepithelial Benign Nodular Fibrosis) 296; Dermatofibrosarcoma Protuberans 296; Keratoacanthoma (Molluscum
Sebaceum) 296; Rhinophyma (Potato Nose) (Bottle Nose) 297; Seborrhoeic Keratosis (Seborrhoeic Wart, Basal
Cell Papilloma) 298; Squamous Cell Carcinoma (Epithelioma) (Khangri Cancer) (Chimney Cancer) 299; Marjolin뭩
Ulcer 302; Basal Cell Carcinoma (Rodent Ulcer) 303; Turban Tumour 306; Naevi 306; Melanoma 308
xvii
Contents
S. Sarcomas...........................................................................318
Sarcoma 318; Liposarcoma 325; Fibrosarcoma 326; Malignant Fibrous Histiocytoma (Mfh) 326; Leiomyosarcoma
327; Rhabdomyosarcoma 327; Chondrosarcoma 327; Haemangiosarcoma 328; Lymphangiosarcoma
328; Synovial Sarcoma 328; Malignant Peripheral Nerve Sheath Tumour (Mpnst) 328; Kaposi뭩 Sarcoma 328
T. Amputations.....................................................................330
Amputation 330; Complications of Amputations 337; Prosthesis 339
U. Reconstruction.................................................................340
Graft 340; Skin Grafts 340; Flaps 344; Tendon 351; Tendon Repair 351; Tendon Transfer 352; Tendon Graft 352
V. Transplantation................................................................353
Preoperative Evaluation 353; Organ Procurement 354; Renal Transplantation 354; Immunosuppressive
Agents 355; Liver Transplantation 357; Bone Marrow Transplantation 359; Pancreatic Transplantation 359; Small
Bowel Transplantation 359; Dialysis 359; Cimino Fistula (Cimino-Brescia) 360
W. Stings and Bites................................................................362
Snake Bite 362; Spider Bite 362; Bee Bite 363; Mammalian Bite 363
X. Pain......364
Gate Control Theory 364
2. Faciomaxillary Diseases..... 367
Diseases of the Palate 367; Orthopantomogram (Opg) 367; Cleft Lip and Cleft Palate 368; Maxillofacial Injuries 372;
Primary
Care (Early Care) in Maxillofacial Injuries 374; Fracture Middle Third Area 375; Zygomatic Complex Fracture 376;
Fracture
of the Mandible 378; Dislocation of the Mandible 380; Preauricular Sinus 380; Jaw Tumours 381; Epulis (Greek뾏eans
Upon Gum) 382; Ameloblastoma (Adamantinoma, Eve뭩 Disease, Multilocular Cystic Disease of the Jaw) 383; Dentigerous
Cyst
(Follicular Odontome) 384; Dental Cyst (Radicular Cyst, Periapical Cyst) 385; Osteomyelitis of Jaw 385; Alveolar
Abscess (Dental Abscess) 386; Fibrous Dysplasia of Bone/Jaw 386; Cherubism (Cherub뾃ngelic Being) 388
3. Oral Cavity.......................... 389
Ranula 389; Sublingual Dermoids 390; Stomatitis 390; Cancrum Oris (Noma) 391; Syphilitic Lesions of Oral Cavity 392;
Leukoplakia 392; Erythroplakia 393; Oral Submucosal Fibrosis 393; Premalignant Conditions of Oral Cavity 394;
Oral and Upper Aerodigestive Cancers 394; Cheek 396; Carcinoma Cheek/Buccal Mucosa 396; Lip 408; Neoplasm of
Lip 410; Carcinoma Lip 410; Tongue 414; Tongue Ulcers 415; Benign Tumours of Tongue 416; Tongue Fissure 416;
Glossitis 416; Tongue Tie 417; Carcinoma Tongue 417; Carcinoma of Posterior One-Third/Base of the Tongue 422;
Nasopharyngeal Carcinoma 423; Maxillary Tumours 424; Malignant Tumours of Tonsil 426; Carcinoma Hard
Palate 427; Laryngeal Tumours 427; Malignant Tumours of Larynx 427; Trismus 430
4. Salivary Glands................... 431
Anatomy 431; Saliva 434; Sialography 434; Salivary Calculus and Sialadenitis 435; Sialosis 437; Sialectasis 437;
Recurrent
Childhood Parotitis 438; Parotid Abscess (Suppurative Parotitis) 438; Parotid Fistula 438; Sj?ren뭩 Syndrome 439;
Mikulicz Disease 440; Salivary Neoplasms 440; Pleomorphic Adenoma (Mixed Salivary Tumour) 441; Adenolymphoma
(Warthin뭩 Tumour, Papillary Cystadenolymphomatosum) 444; Oncocytoma (Oxyphil Adenoma) 445; Basal Cell
Adenoma 445; Mucoepidermoid Tumour 445; Adenoid Cystic Carcinoma (10% of Salivary Tumours) 446; Acinic Cell
Tumour 446; Malignant Mixed Tumour (Mmt ) 446; Adenocarcinoma of Salivary Glands 446; Squamous Cell Carcinoma
of Salivary Glands 447; Submandibular Salivary Gland Tumours 447; Management of Malignant Salivary Tumours 447;
Minor Salivary Gland Tumours 450; Parotid Lymphoma 451; Parotidectomy 451; Frey뭩 Syndrome (Auriculotemporal
Syndrome, Gustatory Sweating); (Lucie Frey뾒olish Surgeon?932) 452; Facial Nerve Injury (Lower Motor Nerve Lesion,
Surgically Related) 453
5. Neck..................................... 455
Anatomy of Lymphatics of Head and Neck 455; Thoracic Outlet Syndrome (Tos) 456; Cervical Rib 457; Branchial
Cyst 459; Branchial Fistula 460; Pharyngeal Pouch 462; Laryngocele 463; Cystic Hygroma (Cavernous Lymphangioma)
464; Ludwig뭩 Angina 465; Parapharyngeal Abscess 466; Retropharyngeal Abscess 466; Subhyoid
Bursitis 467; Carotid Body Tumour (Potato Tumour, Chemodectoma, Nonchromaffin Paraganglioma) 468; Torticollis
(Wry Neck) 469; Sternomastoid Tumour 469; Tuberculous Lymphadenitis 470; Cold Abscess 474; Secondaries in Neck
Lymph Nodes 475; Chemotherapy for Head and Neck Cancers 482
6. Thyroid................................ 484
Development 484; Anatomy 484; Physiology 486; Congenital Anomalies 486; Thyroid Function Tests 489; Fnac of
Thyroid 489; Classification of Goitre 490; Diffuse Hyperplastic Goitre 491; Multinodular Goitre (Mng) 491; Discrete
Thyroid
Nodule 494; Solitary Thyroid Nodule 494; Retrosternal Goitre 497; Thyrotoxicosis and Hyperthyroidism 499; Radioactive
xviii
SRB's Manual of Surgery
Iodine 508; Thyroid Neoplasms 509; Differentiated Thyroid Carcinoma (Dtc) 509; Papillary Carcinoma of Thyroid (Pct) 510;
Follicular Carcinoma of Thyroid (Fct) 512; Anaplastic Carcinoma of Thyroid 515; Medullary Carcinoma of Thyroid
(Mct) 518; Malignant Lymphoma 519; Hashimoto뭩 Thyroiditis (Struma Lymphomatosa) 519; De-Quervain뭩 Subacute
Granulomatous Thyroiditis 519; Riedel뭩 Thyroiditis (0.5% Common) 520; Thyroid Incidentaloma 520;
Thyroidectomy 521; Emil Theodor Kocher 526; Kocher뭩 Test 526; Hypothyroidism 526; Recurrent Laryngeal Nerve
Palsy 527
7. Parathyroids and Adrenals 531
Anatomy 531; Calcium 531; Hyperparathyroidism (Hpt) 532; Parathyroidectomy 534; Men Syndrome (Mea
Syndrome) 536; Apudomas 536; Hypoparathyroidism 537; Tetany 537; Adrenals 538; Adrenal Cortical
Tumours 538; Adrenocortical Carcinoma 539; Cushing뭩 Syndrome 539; Conn뭩 Syndrome 540; Virilising Syndrome
or Adrenogenital Syndrome 540; Neuroblastoma 540; Pheochromocytoma 542
8. Breast.................................. 544
Anatomy 544; Mammography 547; Aberration of Normal Development and Involution (Andi) of the Breast 548; Fibroadenoma
548; Fibrocystadenosis (Fibrocystic Disease of the Breast/Mammary Dysplasia/Cyclical Mastalgia with
Nodularity) 551; Sclerosing Adenosis 552; Phyllodes Tumour (Cystosarcoma Phyllodes/Serocystic Disease of
Brodie) 552; Mastalgia (밣ain in the Breast? 553; Traumatic Fat Necrosis 554; Galactocele 554; Mastitis 555;
Antibioma
558; Duct Ectasia 558; Mondor뭩 Disease 558; Tuberculosis of the Breast 559; Breast Cysts 559; Galactorrhoea
560; Gynaecomastia (Greek뾚omen Breast) 560; Duct Papilloma 562; Zuska-Atkins Disease 563; Mammary
Fistula of Atkins 563; Carcinoma Breast 563; Management of Early Carcinoma Breast 586; Advanced Carcinoma
Breast 590; Prognostic Factors in Carcinoma Breast 592; Prophylactic Mastectomy 593; Carcinoma of Male
Breast 593; Breast Reconstruction 594; Breast Implants 596; Nipple Retraction 597
9. Peritoneum......................... 599
Anatomy 599; Physiology 599; Acute Peritonitis 600; Primary Peritonitis 600; Secondary Peritonitis 600; Tertiary
Peritonitis 600; Spontaneous Bacterial Peritonitis (Sbp) 605; Sclerosing Peritonitis 606; Biliary Peritonitis 606;
Postoperative
Peritonitis 606; Other Forms of Peritonitis 607; Pelvic Abscess 607; Subphrenic Spaces and Subphrenic
Abscess 608; Mesenteric Cysts 611; Mesenteric Panniculitis 612; Acute Mesenteric Lymphadenitis 612; Mesenteric
Malignancy 612; Mesenteric Trauma 613; Peritoneal Malignancy 613; Omental Cyst 614; Omental
Torsion 614; Omental Tumour 614
10. Abdominal Tuberculosis.... 615
Abdominal Tuberculosis 615; Ileocaecal Tuberculosis 616; Ileal Tuberculosis 621; Peritoneal Tuberculosis 621;
Tuberculous
Mesenteric Lymphadenitis 624; Ano-Recto-Sigmoidal Tuberculosis 626; Tuberculosis of the Omentum 626
11. Liver..................................... 627
Surgical Anatomy of Liver 627; Liver Function Tests (Lft) 628; Alfa-Feto Protein (Afp) 628; Liver Biopsy 629; Liver
Injury 629; Infections of Liver 631; Liver Tumours 642; Liver Cysts 649; Portal Hypertension 651; Oesophageal
Varices 654; Portal Hypertensive Gastropathy 661; Ascites 661; Ascites in Portal Hypertension 663; Budd-Chiari뭩
Syndrome 664; Hepatic Failure 664; Hepatic Encephalopathy 665; Hepatorenal Syndrome 665; Hepatic Resection
665; Portal Biliopathy 668
12 Gallbladder......................... 669
Surgical Anatomy 669; Oral Cholecystogram (Ocg; Graham-Cole Test) 670; Iv Cholangiogram 671; Endoscopic
Retrograde Cholangio-pancreatography (Ercp ) 671; Percutaneous Transhepatic Cholangiography (Ptc) 672;
Magnetic Resonance Cholangio-pancreatography
(Mrcp ) 673; Radioisotope Scan Study 673; Peroperative
Cholangiogram 673; Postoperative T-Tube Cholangiogram 673; Congenital Anomalies of Gallbladder 673;
Choledochal Cysts 675; Caroli뭩 Disease 677; Biliary Atresia 677; Gallstones 679; Acute Cholecystitis 684;
Acute Acalculous Cholecystitis 686; Empyema Gallbladder 687; Mucocele of the Gallbladder 688; Chronic
Cholecystitis 688; Cholecystoses 689; Dissolution Therapy for Gallstones 690; Choledocholithiasis 690; Sump
Syndrome 694; Courvoisier뭩 Law 694; Surgical Jaundice (Obstructive Jaundice) 695; Cbd Strictures (Biliary
Strictures) 697; Sclerosing Cholangitis 699; Gallbladder Polyp 699; Benign Biliary Papilloma 699; Carcinoma
Gallbladder 699; Cholangiocarcinoma (Bile Duct Carcinoma) 702; Klatskin Tumour 702; Biliary Fistulas 703;
Gallstone Ileus 703; Hemobilia 704; White Bile 705; Cholecystectomy 705; Laparoscopic Cholecystectomy 706; Single
Incision Laparoscopic Surgery (Sils) in Cholecystectomy 708; Bile Duct Injuries 708; Post-cholecystectomy
Syndrome 709; Biliary Dyskinesia 710
13. Spleen.................................. 711
Surgical Anatomy 711; Functions of the Spleen 711; Splenunculi 712; Splenic Injury (Rupture Spleen) 712; Splenomegaly
716; Hereditary Spherocytosis 716; Immune Haemolytic Anaemia 717; Thalassaemia (Mediterranean Anaemia/
Cooley뭩 Anaemia/Erythroblastic Target Cell Anaemia) 718; Sickle Cell Disease 718; Idiopathic (Immune) Thrombocytoxix
Contents
penic Purpura (Itp) 718; Thrombotic Thrombocytopenic Purpura (Ttp) 720; Splenectomy 720; Overwhelming Postsplenectomy
Infection (Opsi) 722; Splenic Artery Aneurysm 722; Splenic Abscess 723; Hypersplenism 723; Splenic
Cyst 724
14. Pancreas.............................. 725
Anatomy 725; Serum Amylase 726; Magnetic Resonance Cholangio-pancreatography (Mrcp ) 727; Pancreatitis
727; Acute Pancreatitis 727; Complications of Acute Pancreatitis 732; Pseudocyst of Pancreas 734; Chronic Pancreatitis
738; Pancreatic Tumours 746; Exocrine Pancreatic Tumours 746; Carcinoma Pancreas 747; Endocrine Pancreatic
Tumours 755; Insulinomas 756; Gastrinomas 757; Glucagonomas 758; Zollinger-Ellison Syndrome 758; Cystic
Fibrosis 758; Annular Pancreas 759; Ectopic (Accessory) Pancreatic Tissue 759; Pancreatic Divisum 759; Pancreatic
Calculus 760; Pancreatic Ascites 760; Pancreatic Fistulae 760; Pancreatic Abscess 761; Pancreatic Necrosis 761;
Pancreatic
Trauma 762; Cystic Lesions of Pancreas 763; Exocrine Pancreatic Disease 763
15. Retroperitoneal Space....... 764
Anatomy of Retroperitoneum 764; Retroperitoneal Fibrosis 764; Retroperitoneal Swellings 765; Retroperitoneal
Tumours 766; Psoas Abscess 769
16. Differential Diagnosis of Mass Abdomen....................................................... 771
Mass in the Right Hypochondrium 773; Mass in the Epigastrium 775; Mass in the Left Hypochondrium 778; Mass in
the Lumbar Region 778; Mass in the Umbilical Region 780; Mass in the Right Iliac Fossa 780; Mass in the Left Iliac
Fossa 781; Mass in the Hypogastrium 781
17. Abdominal Wall and Umbilicus....................................................................... 784
Diseases of the Umbilicus 784; Omphalitis 784; U mbilical Granuloma 786; Anomalies of Vitellointestinal Duct 786;
Umbilical
Sinus 787; U mbilical Adenoma (Raspberry Tumour) 787; U mbilical Fistula 788; Patent Urachus 788; Burst Abdomen
(Abdominal Dehiscence) (Acute Wound Failure) 788; Abdominal Wall Tumours 791; Desmoid Tumour 791; Exomphalos
(Omphalocele) 792; Gastroschisis (Belly Cleft) 793; Rectus Sheath Haematoma 794; Abdominal Wall Abscess 794;
Meleney뭩 Progressive Synergistic Bacterial Gangrene of Abdominal Wall 795; Diverication of Recti (Diastasis Recti) 796
18. Hernia.................................. 797
Hernia 797; Aetiology 797; Parts of Hernia 798; Classification of Hernia 799; Inguinal Hernia 800; Surgical Anatomy
of Inguinal Canal 800; Classification of Inguinal Hernia (Earlier) 802; Newer Classification of Hernia 803; Indirect
(Oblique) Inguinal Hernia 803; Direct Hernia 811; Malgaigne Bulging 817; Incarcerated Hernia 817; Strangulated
Hernia 817; Sliding Hernia (Hernia-En-Glissade) 820; Pantaloon Hernia (Double Hernia, Saddle Hernia, Romberg
Hernia) 821; Infantile Hernia 821; Femoral Hernia 822; Ventral Hernia 824; Incisional Hernia 825; U mbilical
Hernia 829; Paraumbilical Hernia (Supra- and Infraumbilical Hernia) 831; Epigastric Hernia (Fatty Hernia of Linea
Alba) 831; Spigelian Hernia 833; Obturator Hernia 834; Richter뭩 Hernia 834; Lumbar Hernia 835; Phantom
Hernia 835; Sciatic Hernia 836; Complications of Hernia Surgery 836; Parastomal Hernia 836; Different Types of
Hernia 837
19. Oesophagus........................ 838
Anatomy 838; Lower Oesophageal Sphincter (Los) 839; Dysphagia 840; Contrast Study of Oesophagus 841; Oesophagoscopy
842; Oesophageal Endosonography 842; Gastro-oesophageal Reflux Disease (Gord/Gerd) 842; Hiatus
Hernia 847; Rolling Hernia (Paraoesophageal Hernia) 848; Reflux Oesophagitis 848; Barrett뭩 Oesophagus (Norman
Barrett, British, 1950) 849; Barrett뭩 Ulcer 849; Oesophageal Motility Disorders 849; Achalasia Cardia (Cardiospasm)
850; Plummer-Vinson Syndrome (Paterson-Kelly Syndrome) 853; Corrosive Stricture of Oesophagus 854; Schatzki뭩
Rings 856; Boerhaave뭩 Syndrome 856; Mallory-Weiss Syndrome 856; Tracheo-oesophageal Fistula 857; Oesophageal
Diverticulum 857; Carcinoma Oesophagus 858; Benign Tumours of the Oesophagus 866; Oesophageal Perforation
867; Foreign Body Oesophagus 867
20. Stomach.............................. 869
Anatomy 869; Blood Supply of Stomach 870; Nerve Supply of Stomach 870; Histology 870; Lymphatic Drainage of
Stomach 871; Duodenum 871; Gastric Physiology 871; Gastric Function Tests 872; Gastrin 873; Barium Meal
Study 873; Gastroscopy 874; Helicobacter Pylori 875; Congenital Hypertrophic Pyloric Stenosis 876; Gastritis 877;
Acute Peptic Ulcer (Duodenal or Gastric Ulcer) 878; Gastric Ulcer 879; Duodenal Ulcer 882; Pyloric Stenosis Due
to Chronic Duodenal Ulcer 885; Perforated Peptic Ulcer 887; Bleeding Peptic Ulcer 891; Haematemesis 893;
Complications of Gastric Surgery 894; Trichobezoar (Rapunzel Syndrome) 898; Chronic Duodenal Ileus (Wilkie뭩
Syndrome) 898; Durban뭩 Syndrome 899; Acute Gastric Dilatation 900; Gastric Volvulus 900; Gastric Polyp 901;
Menetrier뭩
Disease 901; Duodenal Diverticula 902; Carcinoma Stomach 902; Gastric Lymphoma 915; Gastric Sarcomas 916;
Gastrointestinal
Stromal Tumours (Gist) 917; Pyloroplasty 918; Gastrostomy 918; Gastrectomy 919; Gastrojejunostomy
(Gj) 920; Retrograde Jejunogastric Intussusception 920; Vagotomy 920
xx
SRB's Manual of Surgery
21. Small Intestine.................... 922
Anatomy 922; Meckel뭩 Diverticulum 923; Regional Enteritis (Crohn뭩 Disease) 925; Surgical Complications of
Typhoid 928; Surgical Complications of Roundworm (Ascaris Lumbricoides) 929; Pneumatosis Cystoides Intestinalis
931; Mesenteric Vessel Ischaemia 931; Necrotising Enterocolitis 934; Small Bowel Tumours 935; Benign Tumours
of Small Bowel 936; Malignant Tumours of Small Bowel 937; Carcinoid Tumour 939; Short Bowel Syndrome (Short
Gut Syndrome) 941; Massive Bowel Resection 941; Small Bowel Enema (Enteroclysis) 942; Capsule Endoscopy 942;
Small Bowel Enteroscopy 943; Enteric/Gastrointestinal Fistula 943
22. Large Intestine.................... 948
Anatomy 948; Hirschsprung뭩 Disease (Congenital Megacolon) 949; Diverticular Disease of the Colon 951; U lcerative
Colitis 954; Ischaemic Colitis 959; Pseudomembranous Colitis 960; Surgical Complications of Intestinal Amoebiasis
960; Tumours of Colon 961; Benign Tumours/Polyp of the Colon 961; Juvenile Polyps 961; Metaplastic/Hyperplastic
Polyp 961; Peutz-Jegher뭩 Polyp 962; Adenoma of Colon 962; Familial Adenomatous Polyp (Fap) 963; Gardner뭩
Syndrome 964; Carcinoma Colon 964; Angiodysplasia of Colon 974; Ogilvie뭩 Syndrome 974; Colostomy 975; Stoma
Care 977; Stoma Appliances 978; Faecal Fistula 979; Preparation of Large Bowel for Surgery 980; Surgical
Pouches 980; Barium Enema 981
23. Intestinal Obstruction........ 983
Intestinal Obstruction: Types 983; Dynamic Obstruction 984; Duodenal Atresia 989; Small Intestine Atresia (Intestinal
Atresia) 990; Malrotation 991; Meconium Ileus 992; Intussusception (Iss ) 994; Volvulus 997; Sigmoid Volvulus
(Volvulus of Pelvic Colon) 997; Paralytic Ileus (Adynamic Intestinal Obstruction) 1000; Adhesions and Bands 1000;
Internal
Hernias 1003
24. Appendix........................... 1005
Surgical Anatomy 1005; Duplication of Appendix (Wallbridge Classification) 1005; Acute Appendicitis 1006; Incidental
Appendicectomy 1013; Appendicular Mass (Periappendicular Phlegmon) 1014; Appendicular Abscess 1015; Faecal
Fistula After Appendicectomy 1016; Mucocele of Appendix 1016; Neoplasms of the Appendix 1017; Laparoscopic
Appendicectomy 1017
25. Rectum and Anal Canal.... 1020
Anatomy 1020; Per-rectal Examination (Digital Examination of the Rectum) 1021; Proctoscopy (Kelly뭩) 1022;
Sigmoidoscopy
1022; Colonoscopy 1022; Carcinoma Rectum 1023; Solitary Ulcer Syndrome 1029; Rectal
Prolapse 1030; Anorectal Malformations (Arm) 1034; Pilonidal Sinus/Disease (Jeep Bottom; Driver뭩 Bottom) 1036; Piles/
Haemorrhoids 1038; Anal Fissure (Fissure-in-ano) 1046; Anorectal Abscess 1049; Fistula-in-ano 1051; Anorectal
Strictures 1056; Condyloma Acuminata 1057; Anal Intraepithelial Neoplasia (Ain) 1057; Malignant Tumours of Anal
Area 1057; Anal Margin Tumours 1058; Sacrococcygeal Teratoma 1058; Anal Incontinence 1059; Descending Perineal
Syndrome 1059; Proctitis 1060; Proctalgia Fugax 1060; Hidradenitis Suppurativa of Anal Region 1060; Pruritus
Ani 1060; Gastrointestinal Haemorrhage (Gi Bleed) 1061
26. Urology............................. 1065
A. Kidney............................................................................ 1065
Anatomy of Kidney and Ureter 1065; Kidney뾃natomy 1065; U reter뾃natomy 1066; Plain X-ray뾍idney,
Ureter and Bladder (Kub) 1066; Intravenous Urogram (Ivu) 1067; Retrograde Pyelography (Rgp) 1068; Renal
Angiogram 1069; Micturating Cystourethrography (Mcu) 1069; Ascending Urethrogram 1069; Isotope Renography
1070; Cystoscopy 1071; Catheters 1071; Foley뭩 Catheter (Fredrick Eugene Basil Foley뾃merican Urologist)
1072; Malecot뭩 Catheter 1073; Red Rubber Catheter 1073; Nephrostomy 1074; Suprapubic Cystostomy
(Spc) 1074; Haematuria 1075; Horseshoe Kidney 1076; Cystic Diseases of the Kidney 1076; Polycystic Kidney
Disease (Pckd) 1077; Duplication of Renal Pelvis and Ureter 1078; Retrocaval Ureter 1079; Ureterocele 1080;
Injuries to Kidney 1080; Renal Tuberculosis 1081; Hydronephrosis (Hn) 1084; Pyonephrosis 1088; Carbuncle of
Kidney (Renal Carbuncle) 1088; Perinephric Abscess 1089; Renal Calculus 1089; U reteric Calculi 1094; Staghorn
Calculus 1097; Benign Tumours of Kidney 1098; Wilm뭩 Tumour (Nephroblastoma) 1099; Renal Cell Carcinoma
(Rcc) 1100; Approaches to Kidney (Surgical) 1104
B. Urinary Bladder............................................................. 1105
Anatomy 1105; Ectopia Vesicae (Extrophy of the Bladder) 1106; U rachal Anomalies 1106; Vesical
Calculus 1106; Cystitis 1110; Recurrent Cystitis 1110; Interstitial Cystitis (Hunner뭩 Ulcer, Elusive Ulcer) 1110;
Schistosoma
Haematobium (Endemic Haematuria, Urinary Bilharziasis) (Swimmer뭩 Itch) 1111; Thimble or Systolic
Bladder 1111; Bladder Tumours 1112; Transitional Cell Carcinoma (Tcc) 1112; Ureterosigmoidostomy 1115; Rupture
Bladder (Bladder Injury) 1115; Residual Urine 1116; Malakoplakia 1116; Neurogenic Bladder 1117; Vesicoureteric
Reflux 1117; Bladder Diverticula 1118; U rinary Diversion 1119; U rinary Fistulas 1120
xxi
Contents
C. Prostate.......................................................................... 1121
Anatomy 1121; Acid Phosphatase 1121; Prostate Specific Antigen (Psa) 1121; Benign Prostatic Hyperplasia
(Bph) 1122; Prostatitis 1125; Bladder Outlet Obstruction (Boo) 1125; Carcinoma Prostate 1126
D. Urethra........................................................................... 1129
Anatomy 1129; U rethral Injury 1129; Rupture of Membranous Urethra and/or Prostatic Urethra (Posterior
Urethra) 1129; Rupture of Bulbous Urethra (Anterior Urethra) 1130; Stricture Urethra 1131; Hypospadias
1132; Epispadias 1133; Posterior Urethral Valve 1133; U rethral Calculi 1134; Urethritis 1135; Extravasation
of Urine 1135; Retention of Urine 1136
E. Penis. 1138
Phimosis 1138; Paraphimosis 1139; Circumcision 1140; Balanoposthitis 1141; Chordee (Cordee) 1141; Priapism
1141; Peyronie뭩 Disease (Induratio-Penis Plastica) 1141; Ram뭩 Horn Penis 1142; Carcinoma Penis 1142; Buschke-
Lowenstein뭩 Tumour 1147
F. Scrotum.......................................................................... 1148
Anatomy 1148; Fournier뭩 Gangrene 1148; Hydrocele 1149; Primary Vaginal Hydrocele 1150; Secondary Hydrocele
1151; Haematocele 1154; Pyocele 1155; Cyst of Epididymis 1155; Spermatocele 1156; Varicocele 1157
G. Testis. 1160
Anatomy 1160; U ndescended Testis 1161; Ectopic Testis 1163; Retractile Testis 1164; Torsion of the
Testis 1164; Testicular Tumours 1165; Paratesticular Tumours 1170; Orchitis 1170; Epididymitis 1171
27. Neurosurgery.................... 1172
Head Injuries 1172; Extradural Haematoma 1177; Subdural Haematoma 1178; Subarachnoid Haemorrhage
(Sah) 1179; Depressed Skull Fracture 1180; Hydrocephalus 1181; Intracranial Abscess 1182; Intracranial Aneurysms
1182; Intracranial Tumours 1183; Pituitary Tumours 1186; Craniopharyngiomas 1187; Spinal Dysraphism
1187; Meningocele 1188; Spina Bifida 1188; Intervertebral Disc Prolapse (Ivdp) 1189; Tuberculosis of Spine
(Caries Spine) 1190; Spinal Tumours 1193
28. Thorax............................... 1194
Chest Injuries 1194; Fracture Ribs 1195; Flail Chest and Stove in Chest 1196; Pneumothorax 1197; Tension Pneumothorax
1197; Haemothorax 1198; Pleural Tap 1198; Bronchoscopy 1199; Empyema Thoracis 1199; Empyema
Necessitans 1200; Lung Abscess 1201; Intercostal Tube Drainage 1202; Shock Lung (Stiff Lung) 1203; Pulmonary
Embolism (Pe) 1203; Surgical Emphysema 1204; Lung Cysts 1204; Mediastinal Tumours 1205; Thymomas
1207; Pancoast Tumours (Superior Sulcus Tumour) 1208; Chest Wall Tumours 1208; Pericarditis 1209; Acute
Pericarditis 1209; Chronic Constrictive Pericarditis (Pick뭩 Disease) 1210; Pericardial Tap 1210; Cardiac
Tamponade 1210; Diaphragmatic Hernia 1211; Pulmonary Complications during Postoperative Period 1213; Surgical
Management of Pulmonary Tuberculosis 1214; Video Assisted Thoracoscopic Surgery (Vats ) 1214
Cardiac Surgery................................................................... 1215
Anatomy 1215; Preoperative Assessment and Preparation of the Cardiac Patient 1216; Cardiopulmonary
Bypass 1217; Congenital Heart Diseases 1217; Patent Ductus Arteriosus (Pda)?0% 1217; Coarctation of
Aorta?% 1218; Atrial Septal Defect (Asd)?% 1218; Ventricular Septal Defect (Vsd)?5% 1219; Pulmonary
Stenosis 1219; Transposition of Great Vessels 1219; Tetralogy of Fallot 1220; Acquired Heart Disease 1220; Mitral
Regurgitation 1221; Aortic Stenosis 1221; Aortic Regurgitation 1221; Valve Replacement Surgery 1222; Ischaemic
Heart Disease (Ihd) 1222; Cardiac Pacemakers 1223; Postoperative Care 1223
29. Adjuvant Therapy............. 1224
Radiotherapy 1224; Chemotherapy 1227; Cell Cycle 1227; Antimalignancy Drugs 1227; Hormone Therapy in
Cancer 1227; Immunosuppression 1229; Immunotherapy 1229; Hybridoma 1229; Gene Therapy 1230
30. Anaesthesia...................... 1231
Preoperative Assessment 1231; General Anaesthesia 1232; Anaesthetic Agents 1232; Oxygen 1232;
Muscle Relaxants 1232; Reversal Agents 1232; Instruments in Anaesthesia 1232; Complications of General Anaesthesia
1234; Postoperative Care 1234; Monitoring the Postoperative Patient 1234; Regional Anaesthesia 1235; Topical
Anaesthesia 1235; Infiltration Block 1235; Field Block 1235; Nerve Block 1235; Intravenous Regional Anaesthesia (Bier뭩
Block) 1235; Spinal Anaesthesia 1235; Saddle Block 1236; Epidural Anaesthesia 1236; Caudal Anaesthesia 1237
31. Advanced Imaging Methods......................................................................... 1238
Ultrasound 1238; Doppler 1240; Ct Scan 1240; Magnetic Resonance Imaging (Mri) 1242; Radionuclide Imaging 1243;
Positron-Emission Tomography (Pet Scan) 1243
xxii
SRB's Manual of Surgery
32. Operative Surgery............ 1244
A. Asepsis and Sterilisation.............................................. 1244
Sterilisation 1244; Disinfection 1244; Antisepsis 1244; Asepsis 1244; Different Methods of Disinfection/
Sterilisation 1244
B. Instruments................................................................... 1247
Cheatle뭩 Forceps 1247; Sponge Holding Forceps (Rampley뭩) 1247; Mayo뭩 Towel Clip 1247; Artery Forceps
(Haemostat) 1247; Right Angle Forceps 1248; Kocher뭩 Forceps 1248; Allis?Tissue Holding Forceps 1248; Babcock뭩
Forceps 1248; Lane뭩 Tissue Holding Forceps 1249; Morant-Baker뭩 Appendix Holding Forceps 1249; Volkmann뭩
Retractor 1249; Langenbeck뭩 Retractor 1249; Czerny뭩 Retractor (Hernia Retractor) 1249; Morris?Retractor 1249;
Deaver뭩 Retractor 1249; Doyen뭩 Retractor 1250; Self-retaining Retractor 1250; Single Hook Retractor 1250; Plain
Non-toothed Dissecting Forceps 1250; Toothed Dissecting Forceps 1250; Surgical Needles 1250; Needle
Holder 1251; Joll뭩 Thyroid Retractor 1251; Moynihan뭩 Occlusion Clamp 1251; Payr뭩 Crushing Clamp
(Gastric) 1251; Desjardin뭩 Choledocholithotomy Forceps 1251; Bake뭩 Dilator 1251; Sinus Forceps (Lister뭩) 1252;
Scissors 1252; Volkmann뭩 Scoop 1252; Tracheostomy Tube 1252; Drains 1252; Foley뭩 Catheter 1254; Malecot뭩
Catheter 1254; Simple Red Rubber Catheter 1254; Lister뭩 Urethral Dilator 1254; Ryle뭩 Tube 1254; Infant Feeding
Tube 1255; Kehr뭩 멦?Tube 1255; Proctoscope 1255; Flatus Tube 1255
C. Suture Materials............................................................ 1256
Classification I 1256; Classification Ii 1257; Classification Iii 1257; Classification Iv 1257; Classification V 1257
D. Diathermy (Electrocautery)......................................... 1258
Types 1258
E. Operative Procedure..................................................... 1259
Abdominal Incisions 1259; Vasectomy 1260; Circumcision 1260; Hydrocele 1261; Inguinal Hernia 1261;
Appendicectomy 1262; Thyroidectomy 1262; Tracheostomy 1263; Cryosurgery 1264; Lasers in Surgery
(Light Amplification Stimulated Emission of Radiation) 1265; Staplers in Surgery 1265; Nasojejunal Tube
Feeding 1266; Gossypiboma (Gossypium뾅otton Based in Latin) 1266
F. Laparoscopic Surgery................................................... 1267
Advantages of Laparoscopic Surgery 1267; Laparoscopic Cholecystectomy 1268; Laparoscopic Appendicectomy
1269; Advanced Laparoscopic Surgeries 1269; Diagnostic Laparoscopy 1270; Retroperitoneoscopy
1270; Natural Orifice Transluminal Endoscopic Surgery (Notes ) 1270
G. Dressings and Bandages.............................................. 1272
Dressings 1272; Bandages 1272
H. Day Care Surgery........................................................... 1274
Day Care Surgery 1274; Surgical Audit 1275; Surgeon and Law 1276
33. Miscellaneous................... 1277
A. Fascinating Signs in Surgery......................................... 1277
B. Triads in Surgery........................................................... 1287
C. Misnomers in Surgery................................................... 1288
D. Triangles in Surgery...................................................... 1289
E. Drugs at a Glance.......................................................... 1291
Antibacterials 1291; Sulfonamides 1291; Quinolones 1291; Penicillin 1292; Ampicillin/Amoxycillin/Talampicillin/
Pivampicillin 1292; Methicillin 1292; Cloxacillin/Dicloxacillin/Flucloxacillin 1292; Carbenicillin/
Ticarcillin 1292; Piperacillin/Azocillin/Mezlocillin 1292; Clavulanic Acid 1292; Sulbactum 1292; Tazobactum
1292; Carbapenem/Imipenem/Meropenem 1292; Lincomycin/Clindamycin 1292; Vancomycin/Teicoplanin
1293; Cephalosporins 1293; Macrolides 1293; Aminoglycosides 1293; Tetracyclines 1294; Chloramphenicol
/ Thiamphenicol 1294; Drugs For Tuberculosis 1294; Antiamoebic Drugs 1295; Important
Antihelminthics 1295; Anticoagulants 1296; Other Drugs 1296
Appendix.................... 1299
Further Reading....... 1303
Index........................... 1305