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Textbook of Surgery
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Vijay Dhakre
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All content following this page was uploaded by Vijay Dhakre on 24 June 2022.
Kailash R Gindodia MS
Professor and Head
Department of Surgery
ACPM Medical College
Dhule, Maharashtra
ISBN: 978-93-5466-365-9
Copyright © Author and Publisher
First Edition: 2023
All rights are reserved. No part of this book may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system without permission, in writing, from the author and the publisher.
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Dr Ravi Wankhedkar
Treasurer, World Medical Association
Professor, Department of Surgery, SBH Government Medical College, Dhule
Past President, SAARC Medical Association
Past President, Indian Medical Association
Preface
T his book is born out of my desire to have a comprehensive textbook on general surgery. Recently, the
National Medical Commission announced the new curriculum. As per the new curriculum it is now
Competency Based Undergraduate Curriculum for the Indian Medical Graduate. The commission desires
that the competency should be further subdivided into specific learning objectives (SLOs) which when learnt
can make a person proficient in the desired competency. This is my humble effort to write this book, as per
the new pattern, so that the Indian Medical Graduate (IMG) shall be competent enough, in surgery, after
reading this book.
Some chapters, like ‘Basic surgical skills’, ‘Biohazard disposal’, ‘Principles of day care surgery’ and principles
of safe surgery’ are added to complete the competencies.
Some chapters like ‘Pain pathways and pain management’, ‘Energy sources in surgery’, ‘Neurogenic
Bladder’, ‘Urinary incontinence’ and ‘Urodynamics’ are added keeping the postgraduate students in mind.
My anaesthesia colleague has taken special efforts to write good detailed chapters on anaesthesia topics.
Towards the end of the book ‘A–Z of surgical triads’, ‘A–Z of surgical triangles’, ‘A–Z of surgical signs’ are
also added. A chapter on the most recent and exciting frontier of ‘Artificial intelligence in surgery’ is very
informative. A chapter on ‘medicolegal aspects of practice’ has also been added. Algorithms for palliative
care of the terminally ill have been taken from EBM of Tata Memorial Hospital, Parel, Mumbai. I sincerely
express my appreciation and gratitude to them.
In compiling this book I have consulted various authoritative books and publications on surgery. I have
mentioned them in “resource materials”. Some materials like photographs, tables and flowcharts, may have
been taken from these sources with permission. I sincerely express my appreciation and gratitude to all of
them. Without their contribution this Herculean task would not have been possible.
Hope this book serves the budding undergraduates but also shall be a great help to the postgraduate
students and a reference book for the practitioners.
Constructive criticism and suggestions are always welcome to improve the future editions.
Kailash R Gindodia
krgindodia@rediffmail.com
Acknowledgements
I am happy to bring out this first edition of Textbook of Surgery. This is my first book and I have been lucky
to get help and support from many. I sincerely thank all of them for all their help in bringing out this book.
My respectable teachers, Dr TE Udwadia and Dr AR Undre for teaching me surgical skills and blessing me
for my book.
Dr Bhaidas C Patil, the dynamic chairman of our ACPM Medical College for blessing me in this endeavour.
Dr Nimesh Verma MS, Additional Professor, General Surgery, Government Medical College, Surat, for
reviewing a few chapters and his able guidance.
Dr Sudhir Bhamre MS FIAGS, Professor and Head, Department of Surgery, Dr Vasantrao, Pawar Medical
College, Nashik, Maharashtra, for his best wishes.
Dr Vikrant Pagar, Assistant Professor of PSM, SBHGMC, Dhule, for his guidance in the initial stages of
planning this book.
My contributors Dr Vijay Dhakre, Dr Manasi A Panat, Dr SS Date, Dr MM Siddiqui, Dr Ketan Vagholkar,
Dr BM Rudagi, Dr Rajesh Oswal, Dr Arif Kaderi, Dr Bhushan Wani, Dr (Mrs) Anjali M Chitale, Dr RV Patil,
for their valuable contributions.
I express my acknowledgement, appreciation and gratitude to the various resources which were consulted
in the writing of this book. Some images, tables and flowcharts or algorithms are taken from these resources
and we express our gratitude for the same. The list of resources are mentioned the end of the text of the book.
I also thank my residents, Dr Jagruti, Dr Durga, Dr Nirav and Dr Mayur for their time to time help in
writing this book. A special mention of my undergraduate student Mr Mohammad Usman for his help with
his computer soft skills.
I am indeed indebted to my publishers CBS Publishers & Distributors for presenting my efforts in the form
of a good book.
Kailash R Gindodia
Contents
List of Contributors vii
Foreword by Ravi Wankhedkar ix
Preface xi
Index of Competencies xxv
Introduction 110; Surgical team 110; Surgical period 110; How safe
22. Minimally Invasive General Surgery 172
is surgery? 110; Avoidable harm 110; Patients themselves 110;
Healthcare professional 111; System failure 111; Medical complexity Minimally invasive surgery 172; History 172; Extent of MIS 172;
111; How can surgery be made safer? 112; Surgeonism 113 Advantages of MIS 172; Limitations of MIS 172; Theatre set-up 172;
Tools required 173; General preoperative principles 173; Surgery
16. Pain Pathways and Pain Management 114 principles 174; Preparation for MIS 174; Operative problems 174;
Postoperative care 177; Contraindications 177; Common surgeries
Introduction 114; History 114; Physiology of pain 115; Pain receptors
performed by MIS 177; Laparoscopic and robotic surgery 177;
115; Pathways of pain sensation 116; The neurochemicals of pain
Principles of safe laparoscopic surgery 177; GI endoscopy 177;
116; Types of pain 116; Clinical model of pain 118; Method of pain
Risks of endoscopy 177; Robotics in surgery 178; Definition of a
assessment 122; Management of pain 123; Goals of therapy 123;
robot 178; Types of robots 178; Surgical robots 178; Robotic
Non-pharmacological management 123; Recent advances 127
disbelievers 178; Clinical limitations 179; Climbing the learning curve
17. Surgical Nutrition 128 in MIS 179; Future of surgery 179; Moral dilemma 179; Conclusions
180; Summary 180
Introduction 128; Nutrition requirements 128; Nutrition 129;
Postoperative nutrition requirements 129; Diet advancement 129; 23. Skin Graft and Skin Flaps 181
Micronutrients in wound healing 129; Key nutrients for wound healing
129; What is nutrition support? 129; Elements of nutrition 130; Caloric History 181; Anatomy of skin 181; Grafts 181; Definitions 181; Skin
requirements—energy expenditure 130; Nutrition in surgical patients grafts 182; Types of skin graft 182; Stages of graft intake 182;
130; Nutritional assessment 130; Enteral nutrition 130; Indications Technique 182; Skin flaps 183; Parts of flap 183; Indications 183;
for enteral nutrition 130; Contraindications to enteral nutrition Classification of flaps 183; Waltzing 185; Comparison between graft
support 130; Enteral access devices 130; Feeding tube selection and flap 185
131; Gastric vs small bowel access 131; Short-term vs long-term
tube feeding access 131; Choosing appropriate formulas 131; 24. Energy Sources in Surgery 186
Enteral nutrition prescription guidelines 131; Aspiration precautions
131; Complications of enteral nutrition support 131; Complications Introduction 186; Electrosurgery 186; Complications of electro-
of enteral nutrition 131; Enteral nutrition prescription 132; Parenteral surgery 187; How to minimise risks of electrosurgery 187; Argon
nutrition 132; Indications for parenteral nutrition support 132; PPN plasma coagulator 187; Ligasure, enseal 187; Harmonic scalpel
vs TPN 132; Parenteral access devices 132; Writing TPN prescriptions 187; Laser 188; Conclusion 188
132; Parenteral nutrition monitoring 132; Complications of parenteral
nutrition 133; Problem-based learning (PBL) 133; Enteral nutrition 25. Surgery in the Tropics 189
case study 133; Parenteral nutrition case study 133; Parenteral
nutrition prescription 134; Benefits of enteral nutrition over parenteral Amoebiasis 189; Diagnostic pointers for infection with Entamoeba
nutrition 134; Refeeding syndrome 134; Consequences of over- histolytica 190; Investigation 190; Treatment 190; Ascaris
feeding 134 lumbricoides (roundworm) 190; Diagnosis and management 191;
Filariasis 191; Symptomatology 192; Diagnosis: Wuchereria bancrofti
18. Fluid and Electrolyte Management in 192; Treatment 192; Prevention and control 192; Hydatid disease
Surgical Patient 135 192; Clinical features 193; Classification 194; Diagnosis 194;
Treatment 194; Pulmonary hydatid disease 195; Leprosy 195;
Textbook of Surgery
41. Faciomaxillary Injuries and Jaw Swellings 342 46. Tracheostomy and Airway Management 389
Faciomaxillary injuries 342; Causes 342; Clinical effects 342; Tracheostomy and airway management 389; Definition 389;
Examination of the patient 342; Investigations 342; Fractures of Functions of tracheostomy 389; Indications of tracheostomy 389;
facial skeleton 342; Specific learning objectives 343; Middle third Types of tracheostomy 390; Based on level 390; Technique 390;
fractures 343; Zygomatic complex 344; Lower third of the face Steps of operation 390; Paediatric tracheostomy 392; Postoperative
344; Fracture mandible 345; Jaw swellings 345; Applied anatomy care 392; Complications of tracheostomy 393; Procedure for
345; Causes of jaw swellings 345; Soft tissue injuries of the face 345; immediate airway management 394; Percutaneous dilational
Osseous tumours 345; Epulis (greek means upon gum) 345; tracheostomy 395
Classification 346; Clinical features 346; Treatment 346; Common
features of jaw swellings 346; Odontomes 346; Pathology 346;
Investigation 346; Dental or radicular cyst 346; Treatment 346;
SECTION VI: ENDOCRINOLOGY AND
Dentigerous (follicular) cyst 346; Odontogenic tumours 346; Tumour
of odontogenic epithelium—ameloblastoma 347 BREAST DISEASES
42.Salivary Gland Disorders 348
47. Adrenal Gland 398
Anatomy of salivary glands 348; Parotid gland 348; Specific learning
Anatomy 398; Embryology 398; Histology 398; Applied physiology
objectives 349; Submandibular gland 349; Sublingual glands 350;
Textbook of Surgery
management 779; Postoperative management 779; Intestinal disease 841; Urological investigations 842; Urine routine and
obstruction 779; Definition 779; Aetiology of dynamic intestinal microscopic examination 842; HB and CBC 843; Blood sugar level
obstruction 780; Etiology of adynamic (paralytic ileus) obstruction (BSL) 843; Blood urea level (BUL) and serum creatinine 843;
781; Classification of intestinal obstruction 781; Clinical features in Biochemical assessment of renal function 843; Plain x-ray abdomen
different types of obstruction 781; Pathology 781; Clinical features (ABD) AP KUB 843; Ultrasonography of kub (USG) 843; Intravenous
782; Clinical examination in intestinal obstruction 782; urography (IVU) 844; Retrograde pyelography (RGP) 845; Asu/rgu
Investigations 783; Management of acute intestinal obstruction (ascending or retrograde urethrogram) and mcug (micturating
783; Different situations 784; Gallstone ileus 785; Obstruction due cystourethrogram) 845; CT scan 845; Isotope renography 846; Renal xxi
to food bolus, bezoars or roundworms 785; Intussusception 785; angiography and digital subtraction angiography (DSA) 847;
What is intussusception? 785; Pathology of intussusception 786; Cystoscopy 847
Causes of intussusception 786; Symptoms of intussusception 786;
Clinical signs of intussusception 786; Diagnosis 786; Treatment 786;
77. Acute Renal Failure: Anuria 849
Volvulus 786; Sigmoid volvulus 787; Caecal volvulus 788; Transverse Acute vs chronic renal failure 849; History 849; Acute renal failure
colon volvulus 788; Paralytic ileus (adynamic obstruction) 788; 849; Etiology of acute renal failure 849; Anuria: Post-renal causes
Causes 789; Postoperative ileus 789 850; Anuria: Clinical aspects 850; Causes of death in ATN 850;
Diagnostic approach to ARF 851; Differential diagnosis 851; anomalies 905; Bladder injury 905; General considerations 905;
Treatment of ARF 851; Mortality-associated with setting of ATN 852 Aetiology 905; Clinical features 906; Investigations: Imaging 906;
Aast organ injury severity scale 906; Practical classification 906;
78. Congenital Anomalies of Management 906; Complications 907; Retention of urine 907;
the Kidneys and Ureters 853 Clinical features 907; Causes of retention of urine 907; History 907;
Treatment of retention of urine 907; Urinary incontinence 908;
Embryology 853; Common congenital anomalies of urinary tract Diagnosis of urinary incontinence 908; Causes of incontinence 908;
853; Congenital abnormalities of the kidney and ureter 853; Types of incontinence (especially in females) 908; Bladder stones
Absence of one kidney 854; Supernumerary kidney 854; Simple 908; Clinical features 909; Treatment 909; Bladder diverticulum 909;
renal ectopia 855; Crossed renal ectopia with and without fusion Urinary fistulae 910; Lower uti in adults 910; Urothelial bladder
855; Horseshoe kidney 856; Anomalies of rotation 856; Anomalies carcinoma 910; Occupations with increased risk of ca bladder 910;
of vasculature 856; Polycystic kidney disease (PKD) 857; Simple Molecular “players” in bladder ca 911; Bladder cancer staging 911;
renal cysts 857; Congenital abnormalities of the renal pelvis and Invasive bladder cancer 911; Urinary diversion 913; History 913;
ureter 857; Duplication of the kidneys and ureters 857; Ectopic ureter Temporary diversion 914; Permanent diversions 914; Options in
858; Other anomalies 858; Congenital PUJ obstruction 858; continent urinary diversion 914; Complications of urinary diversion
Ureterocele 859; Vesicoureteric reflux (VUR) 859 914
Contents
xxiii
Index of Competencies
Competency Based Undergraduate Curriculum for the Indian Medical Graduate
Index of Competencies
of management
Vascular Diseases
SU27.1 Describe the etiopathogenesis, clinical features, investigations and principles of 34 270
treatment of occlusive arterial disease
SU27.2 Demonstrate the correct examination of the vascular system and enumerate and describe 34 270
the investigation of vascular disease
SU27.3 Describe clinical features, investigations and principles of management of 34 270
vasospastic disorders
SU27.4 Describe the types of gangrene and principles of amputation 35 283
SU27.5 Describe the applied anatomy of venous system of lower limb 36 293
SU27.6 Describe pathophysiology, clinical features, Investigations and principles of 36 293
management of DVT and varicose veins xxvii
SU27.7 Describe pathophysiology, clinical features, investigations and principles of 37 304
management of lymph edema, lymphangitis and lymphomas
SU27.8 Demonstrate the correct examination of the lymphatic system Clinics, DOAP
Code Competency Chapter Page no
Abdomen
SU28.1 Describe pathophysiology, clinical features, Investigations and principles of 55 488
management of hernias 56 507
SU28.2 Demonstrate the correct technique to examine the patient with hernia and identify 55 488
different types of hernias
SU28.3 Describe causes, clinical features, complications and principles of mangament of peritonitis 58 516
SU28.4 Describe pathophysiology, clinical features, investigations and principles of management of 59 521
intra-abdominal abscess, mesenteric cyst, and retroperitoneal tumors
SU28.5 Describe the applied anatomy and physiology of esophagus 61 542
SU28.6 Describe the clinical features, investigations and principles of management of benign and 61 542
malignant disorders of esophagus
SU28.7 Describe the applied anatomy and physiology of stomach 62 570
SU28.8 Describe and discuss the aetiology, the clinical features, investigations and principles of 62 570
management of congenital hypertrophic pyloric stenosis, peptic ulcer disease, 63 589
carcinoma stomach
SU28.9 Demonstrate the correct technique of examination of a patient with disorders of the stomach 62 570
SU28.10 Describe the applied anatomy of liver. Describe the clinical features, Investigations and 65 604
principles of management of liver abscess, hydatid disease, injuries and tumors of the liver
SU28.11 Describe the applied anatomy of spleen. Describe the clinical features, investigations and 68 723
principles of management of splenic injuries. Describe the post-splenectomy
sepsis—prophylaxis
SU28.12 Describe the applied anatomy of biliary system. Describe the clinical features, 66 659
investigations and principles of management of diseases of biliary system
SU28.13 Describe the applied anatomy of small and large intestine 69 730
SU28.14 Describe the clinical features, investigations and principles of management of disorders 69 730
of small and large intestine including neonatal obstruction and short gut syndrome
SU28.15 Describe the clinical features, investigations and principles of management of 72 794
diseases of appendix including appendicitis and its complications 76 840
SU28.16 Describe applied anatomy including congenital anomalies of the rectum and anal canal 73 800
SU28.17 Describe the clinical features, investigations and principles of management of 73 800
common anorectal diseases
SU28.18 Describe and demonstrate clinical examination of abdomen. Order relevant 56 507
investigations. Describe and discuss appropriate treatment plan Clinics, DOAP
SU29.1 Describe the causes, investigations and principles of management of Hematuria 76 840
SU29.2 Describe the clinical features, investigations and principles of management of congenital 78 853
anomalies of genitourinary system
SU29.3 Describe the Clinical features, Investigations and principles of management of 80 867
urinary tract infections
SU29.4 Describe the clinical features, investigations and principles of management of 81 874
hydronephrosis
SU29.5 Describe the clinical features,investigations and principles of management of renal calculi 82 884
SU29.6 Describe the clinical features, investigations and principles of management of renal tumours 83 892
84 899
SU29.7 Describe the principles of management of acute and chronic retention of urine 85 904
SU29.8 Describe the clinical features, investigations and principles of management of 85 904
bladder cancer
SU29.9 Describe the clinical features, investigations and principles of management of disorders 89 936
Textbook of Surgery
of prostate
SU29.10 Demonstrate a digital rectal examination of the prostate in amannequin or equivalent Skill lab, DOAP
SU29.11 Describe clinical features, investigations and management of urethral strictures 90 947
SU30.1 Describe the clinical features, investigations and principles of management of phimosis, 90 947
paraphimosis and carcinoma penis
SU30.2 Describe the applied anatomy clinical features, investigations and principles of 91 958
management of undescended testis
SU30.3 Describe the applied anatomy clinical features, investigations and principles of 91 958
management of epidydimo-orchitis
SU30.4 Describe the applied anatomy clinical features, investigations and principles of 91 958
xxviii management of varicocele
SU30.5 Describe the applied anatomy, clinical features, investigations and principles of 91 958
management of hydrocele
SU30.6 Describe classification, clinical features, investigations and principles of management of 92 967
tumours of testis