Rural Surgery

Matthias W. Wichmann • David C. Borgstrom

Nadine R. Caron • Guy Maddern
(Editors)

Rural Surgery
Challenges and Solutions
for the Rural Surgeon
Editors
Matthias W. Wichmann, FRACS Nadine R. Caron, MD, MPH, FRCSC
Department of General Surgery University of British Columbia-Northern
Mount Gambier General Hospital and Medical Program Prince George, BC
Flinders University Rural Medical School Canada
276-300 Wehl Street North nadinecaron@yahoo.com
Mount Gambier, SA 5290
Australia Guy Maddern, MD
matthias.wichmann@health.sa.gov.au Department of Surgery
The Queen Elizabeth Hospital
David C. Borgstrom, MD, FACS 28 Woodville Rd
Department of Surgery Woodville South, SA 5011
Bassett Medical Center Australia
One Atwell Road guy.maddern@adelaide.edu.au
Cooperstown, NY 13326
USA
david.borgstrom@bassett.org

The following figures are published with the kind permission of the respective owner

Figures: 4.1, 4.3, 4.4, 4.5, 7.2, 7.3, 12.1, 12.3, 14.1, 14.2, 15.1, 15.2, 15.3, 30.1, 30.2, 30.3,
37.1, 37.2, 39.1, 39.2, 39.3, 39.4, 40.1, 40.2, 40.3, 40.4, 40.5, 53.1, 53.2, 53.3, 53.5, 61.1,
61.2, 61.4, 63.1, 63.2

Jauch K-W, Mutschler W, Wichmann MW (2007), Chirurgie Basisweiterbildung,

Springer-Verlag, Berlin, Heidelberg

ISBN 978-3-540-78679-5     e-ISBN 978-3-540-78680-1

DOI 10.1007/978-3-540-78680-1
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To Juliane, Antoinette, Jakobus, and Evangelia – thank you for taking me “down
under”!

Matthias W. Wichmann

To Donna, Catherine, and Samantha. Thank you for your love, confidence, and
support.

David C. Borgstrom

To our fellow rural surgeons around the world.

Guy Maddern

To Gary F. Purdue† (1945–2010) – gifted surgeon, friend, humanitarian.

David C. Borgstrom
 Preface

We are very pleased to present our contribution to the developing field of rural
surgery.
Rural surgery requires the surgeon to always be prepared for a procedure or an
intervention that he or she might not have done or seen either frequently or recently –
this is the best definition of the challenge facing rural surgery. It does summarize well
what the challenges of daily work for rural surgeons can be. These challenges become
more complex due to the fact that expert support or advice and the technology require-
ments that often accompany them are frequently far away or not available.
With this textbook on rural surgery we want to provide up-to-date information for
senior as well as junior surgeons working in nonmetropolitan hospitals around the
world. The book is a guide to get through the challenges of starting a surgical practice
in a rural environment and can provide the scientific background for the routine work
of the experienced rural surgeon. The book also aims to assist surgeons who provide
locum services and may not always be used to working alone in a new environment.
We hope that this book will become a valuable companion for surgeons working
in the field of rural surgery around the world.
The editors started to work on this project in 2007 when David Borgstrom came to
present at the Annual Scientific Meeting of the Provincial Surgeons of Australia
(PSA) in Whyalla (sp) (South Australia). Matthias Wichmann, Guy Maddern, and David
Borgstrom agreed to edit a textbook on rural surgery based on the recent experience
of one of the Australian editors (MW) who at that time was just beginning to adjust
to the challenge and rewards of a rural surgical practice after moving to Australia
from Germany. Nadine R. Caron soon joined the editorial team and we started to col-
lect contributing authors around the world.
We are very grateful to all the contributing authors for their input into this text-
book. Their expertise and knowledge will help to make rural surgeons more comfort-
able with difficult situations and treatment decisions in our daily practice and serve
as a resource for the future rural surgeons who will pursue this rewarding career.
The editors would also like to express their gratitude to the team of the Springer-
Verlag in Germany. From the start the publisher was very supportive of the idea to
edit a book on rural surgery. We are especially thankful to Mrs. Stephanie Benko and
Mrs. Rosemarie Unger and Mrs. Dakshinamoorthy Mahalakshmi for their help and
assistance.

vii
viii Preface

We trust that you will enjoy this book and that it will be a valuable support for your
work in rural surgery.

Mount Gambier, SA, Australia Matthias W. Wichmann, FRACS

 Contents

Part I Challenges of Rural Surgery

1 Rural Surgical Education: The Australian Approach . . . . . . . . . . . . . . 3

Guy Maddern and Matthias W. Wichmann

2 Surgery for Rural America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

David C. Borgstrom

3 Surgery in Rural Canada: Challenges and Possible Solutions . . . . . . . 7

Nadine R. Caron and Stephen J. Pinney

Part II Pre- and Postoperative Care

4 Fundamentals of Surgical Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Hanno Niess, Karl-Walter Jauch, and Christiane J. Bruns

5 Palliative Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Matthias W. Wichmann

6 Fiber Optic Endoscopy: Bronchoscopy . . . . . . . . . . . . . . . . . . . . . . . . . 31

Matthias W. Wichmann and Fritz W. Spelsberg

7 Fiber Optic Endoscopy: Gastroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Matthias W. Wichmann and Fritz W. Spelsberg

8 Fiber Optic Endoscopy: Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Matthias W. Wichmann and Fritz W. Spelsberg

9 Endoscopy for Rural Surgeons: ERCP . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Ian C. Roberts-Thomson

10 Rigid Endoscopy: Cystoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Mark Lloyd and John Miller

ix
x Contents

11 Rural Surgical Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

David A.K. Watters

12 Acute Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Edmund A.M. Neugebauer, Astrid Althaus, and Christian Simanski

13 Prophylaxis of Venous Thromboembolism . . . . . . . . . . . . . . . . . . . . . . . 77

Robert A. Fitridge and Simon McRae

14 Nutrition of the Surgical Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Florian Brackmann, Wolfgang H. Hartl, and Peter Rittler

15 Surgical and Hospital-Acquired Infections . . . . . . . . . . . . . . . . . . . . . . 99

Wolfgang Böcker and Wolf Mutschler

16 Antimicrobial Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Christian P. Schneider and Beatrice Grabein

17 Preoperative Risk Assessment in Rural Surgery . . . . . . . . . . . . . . . . . . 133

Teresa Bueti, Munawar Rana, and Matthias W. Wichmann

18 Perioperative Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Peter Rittler and Wolfgang H. Hartl

19 Analgesia and Sedation in Intensive Care . . . . . . . . . . . . . . . . . . . . . . . 145

Christian Waydhas

Part III Operative Care

20 Anti-reflux Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Glyn Jamieson

21 Gastric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Matthias W. Wichmann

22 Gallbladder Surgery: Laparoscopic Cholecystectomy

and Management of Bile Duct Stones in the Rural Setting . . . . . . . . . . 169
Harsh A. Kanhere and Andrew D. Strickland

23 Liver Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Faud Alkhoury, Christine Vancott, and Randall Zuckerman

24 Pancreatic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

Markus Trochsler, Thomas Satyadas, and Harsh A. Kanhere
Contents xi

25 Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Martin Bruening

26 Surgery of the Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Matthias W. Wichmann

27 Complications After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 205

Brent White

28 Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Kerstin S. Schick and Johannes N. Hoffmann

29 Bowel Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

Saukat T. Esufali

30 Diverticulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Matthias W. Wichmann and Karl-Walter Jauch

31 Therapy of Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Johannes N. Hoffmann

32 Bowel Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Peter Hewett and Cu Tai Lu

33 Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Peter Hewett

34 Stoma Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Nick Rieger

35 Acute Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Hajir Nabi

36 Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

Friesen W. Randall

37 Mesenteric Ischaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

Heinrich Stiegler, Florian Brackmann, and Laura Holzner

38 Management and Surgery of Inflammatory Bowel Diseases . . . . . . . . 281

William Roediger

39 Proctology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Alexander Herold and Laura Holzner

40 Abdominal Wall Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

Reinhold A. Lang and Martin K. Angele
xii Contents

41 Thyroid Surgery for the Community General Surgeon . . . . . . . . . . . . 309

Anthony J. Chambers and Janice L. Pasieka

42 Parathyroid Surgery in the Non-Tertiary Center . . . . . . . . . . . . . . . . . 315

Anthony J. Chambers and Janice L. Pasieka

43 Adrenal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

Marlon A. Guerrero and Wen Shen

44 Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

David Walsh

45 Skin Cancer: Current Surgery for This Common Problem . . . . . . . . . 341

R. Gwyn Morgan

46 Pediatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351

Thao T. Marquez, Mara B. Antonoff, and Daniel A. Saltzman

47 Vascular Surgery: Acute Limb Ischaemia . . . . . . . . . . . . . . . . . . . . . . . 359

Mark Hamilton

48 Vascular Surgery: Management of the Diabetic Foot . . . . . . . . . . . . . . 369

Mark Hamilton

49 Minor Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

Eric Mooney

Part IV Relevant Orthopaedics for General Surgeons

50 Simple Orthopaedic Procedures and Common Diagnoses . . . . . . . . . . 389

David Wysocki and René Zellweger

51 Carpal Tunnel Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407

Hajir Nabi

52 Dupuytren’s Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Barney McCusker

53 Hand Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415

Andreas Frick and Christiane G. Frick

Part V Other Relevant Operative Specialities for General Surgeons

54 Rural Obstetrics and Gynaecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425

Colin Weatherill
Contents xiii

55 Urological Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

John Miller, Clair Whelan, and Kulendran Sivapragasam

56 Otolaryngologic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451

Cynthia Bonatucci Fisher

Part VI Emergency Care

57 Airway Management: A Surgical Perspective . . . . . . . . . . . . . . . . . . . . 465

Adrian Anthony

58 Management of the Severely Injured . . . . . . . . . . . . . . . . . . . . . . . . . . . 483

Adrian Anthony

59 Rural Burn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501

Gary F. Purdue† and Brett D. Arnoldo

60 A Guide to Neurotrauma for the Rural Surgeon . . . . . . . . . . . . . . . . . . 507

David Omahen and Stephen J. Hentschel

61 Abdominal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529

Wolfgang E. Thasler

62 Trauma Surgery: Neck Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535

Harsh A. Kanhere and Robert A. Fitridge

63 Open Extremity Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541

Ekkehard Euler

64 Traumatic Injuries of the Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547

Rudolf Beisse and Christoph Siepe

65 Trauma Surgery, Orthopaedic – Pelvic Fracture . . . . . . . . . . . . . . . . . . 555

Tim Pohlemann, Daniel Köhler, and Christopher Tzioupis

66 Trauma Surgery: Vascular Emergencies . . . . . . . . . . . . . . . . . . . . . . . . 563

Robert A. Fitridge and Mark Hamilton

67 Thoracic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571

Christian Müller

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
 Part
I
Challenges of Rural Surgery
 Rural Surgical Education: The Australian
Approach 1
Guy Maddern and Matthias W. Wichmann

1.1 Introduction results and the growing interest of students to partici-

pate in rural education, however, suggest a promising
and encouraging beginning.
Recruiting and maintaining a “critical mass” of the
medical workforce within rural centers is a difficult
challenge for the Australian society. Australia is one of
the most urbanized societies on Earth, and the majority 1.2 Rural Surgical Training in Australia
of the population (83%) lives in and around a small
number of major cities that are mainly localized on the
Surgical training in Australia has been restructured and
coastline.
is now run within the Surgical Education and Training
Until now, working in medicine in rural Australia
(SET) Program. Within the SET program, trainees are
appears to be attractive to only a few Australians and
selected directly into one of the nine specialty training
has been supported by a substantial number of health-
programs (cardiothoracic, general, neurosurgery, ortho-
care providers who are educated and trained outside
pedic, ENT, pediatric, plastic/reconstructive, urology,
Australia.
vascular). Length of training varies between 5 and
To address this significant and growing problem,
7 years depending on the specialty, and trainees can
all the major universities throughout Australia have
then present for fellowship examination.
established so-called Rural Medical Schools in order
The earliest point at which an application can be
to expose students to rural medicine at a young age,
made for the first year of training (SET1) is during
hoping to retain a significant fraction of these students
Postgraduate Year 2 (PGY2).
within the rural medical workforce. Various colleges
Trainees applying for general surgical training have
of medical specialties have also introduced dedicated
the option to enroll into the Rural Surgical Training
training programs that aim at recruiting and possibly
Program (RSTP), which has been introduced to enable
retaining medical specialists in rural Australia. Whether
early recruitment of trainees into the rural surgical
or not these new concepts of medical teaching account
workforce. The RSTP allows trainees to undertake a
for long-term success remains to be determined. Early
flexible program that includes regional, rural, and
remote practice.
Trainees within RSTP have access to a network of
G. Maddern rural surgeons and mentor assistance, and receive addi-
Department of Surgery, The Queen Elizabeth Hospital, tional financial assistance for conferences and training
28 Woodville Rd, Woodville South, SA 5011, Australia courses. Each trainee is allocated a mentor, who is
e-mail: guy.maddern@adelaide.edu.au responsible for helping the trainee develop a compre-
M.W. Wichmann (*) hensive training program, and who serves as a guide
Department of General Surgery, Mount Gambier General and counselor during the surgical training period.
Hospital and Flinders University Rural Medical School,
276-300 Wehl Street North, Mount Gambier,
Rural trainees must complete the standard general
SA 5290, Australia surgical training program and can present for the fel-
e-mail: matthias.wichmann@health.sa.gov.au lowship exam in General Surgery at the completion of

M.W. Wichmann et al. (eds.), Rural Surgery, 3

DOI: 10.1007/978-3-540-78680-1_1, © Springer-Verlag Berlin Heidelberg 2011
4 G. Maddern and M.W. Wichmann
their 5-year program. Rural surgical education aims to
equip the trainee for both metropolitan and rural surgi-
cal practice, but aims at trainees who have a rural
background or have prior rural medical experience.
The selection process for trainees who are interested in
rural surgery and those who are not is the same. This
selection involves a semi-structured interview, assess-
ment of curriculum vitae, and evaluation of referee and
supervisor reports.
During recent years, Australia has relied on a large
number of international medical graduates to maintain
surgical services in rural and remote areas. In 2007,
RSTP had produced 38 graduates since its commence-
ment in 1998. In view of these figures, it is no surprise
that foreign medical graduates currently represent a
large fraction of the rural surgical workforce.
Recent evidence suggests that a sustainable and
safe service requires a minimum of three general
­surgeons within a rural surgical center. One model of
addressing this workforce challenge is to bring rural
surgeons into a network relationship with city institu-
tions that allows for continuing professional develop-
ment, access to locum cover, forum for quality
assurance, and auditing as well as ongoing contact
with students and trainees.
Some centers are remote, but of insufficient size
to support more than one general surgeon. If only ser-
viced by one surgeon, they would need to be on call
365 days a year. To deal with this problem, some towns
have rotating surgeons from the city work in the town
for 7 days and then return to the city to be replaced by
another fresh surgeon for the following week. This
model has been highly successful and well received by
the patients of general practitioners.
Provision of reliable locum support has also been
successfully used to allow solo surgical practitioners
to have respite and enable attendance at professional
meetings. These efforts combined with major city hos-
pitals offer a viable way forward. This combined with
the joint efforts of universities, as well as the Australasian
College of Surgeons, may result in a higher proportion
of Australian graduates working in rural surgery in the
years to come.
Recommended Reading
Bruening, M.H., Maddern, G.J.: Surgical undergraduate educa-
tion in rural Australia. Arch. Surg. 137, 794–798 (2002)
Campbell, G.: Rural surgical training in Australia. ANZ J. Surg.
77, 922–923 (2007)
Gough, I.: President’s perspective. Surgical News 10, 3–4 (2009)
Green, A.: Maintaining surgical standards beyond the city in
Australia. ANZ J. Surg. 73, 232–233 (2003)
Maddern, G.J.: Rural general surgical placement: a necessity not
an option. ANZ J. Surg. 73, 975 (2003)
 Surgery for Rural America
David C. Borgstrom
It is estimated that 60 million Americans live in rural
areas far removed from urban and suburban health
care. Health care and surgical care for rural America is
at a crisis. Rural Americans are, in general, older,
sicker, poorer, and less educated than their urban and
suburban counterparts. Infant mortality and injury-
related mortality is greater, there is less insurance and
fewer physicians per capita, and it is estimated that
there is 20–30% less overall medical service for rural
and remote Americans. As the economics of health
care evolve, the constraints on rural America become
even greater. Many rural hospitals are closing at a time
when it is more and more clear that the general sur-
geon is the economic engine that drives the rural hos-
pital and the rural hospital is quite often the economic
engine of the rural community.
To compound this problem, the number of surgeons
per capita in rural America indicates this population is
underserved and it is estimated there will continue to
be a significant shortage of surgeons needed to prac-
tice in rural areas.
Further, with the aging of the baby boomer popula-
tion, the segment of America growing the fastest is
those aged 65 and over. In this group of patients, it is
estimated the general surgery workload is three times
greater than in those of a younger age.
As health care evolves, fewer and fewer surgeons
in general surgery training programs are electing to
remain in general surgery. Currently, only about 35–40%
of residents completing US general surgery education
D.C. Borgstrom
Department of Surgery, Bassett Medical Center,
One Atwell Road, Cooperstown, NY 13326, USA
e-mail: david.borgstrom@bassett.org
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_2, © Springer-Verlag Berlin Heidelberg 2011
2
programs elect to go into practice where general ­surgery
is part of their practice and of those, only 13% are elect-
ing to go into rural surgery locations. Student interest in
these opportunities has declined, and there are fewer
female students interested.
General surgeons in rural America are by and large
male, over 50 years of age; they are much more likely
to be international medical graduates and are seeking
earlier retirement than their urban/suburban counter-
parts. Where the estimated age of retirement used to be
near 70, it is now around 62 years of age.
Economic issues of lower reimbursement, technol-
ogy advances, increased liability costs and culture
diversity concerns of family make this a problem that
is getting worse.
The crisis is further compromised because of the
fact that most Americans who live in rural America do
not like the big city and would much prefer to get their
health care away from urban areas.
Fortunately, there is increasing recognition of this
crisis, not only in the lay press, but also in organiza-
tions such as the Association of Program Directors in
Surgery and the American College of Surgeons.
There is now a recognized need to refocus efforts to
not only train surgeons to feel qualified to care for this
broad diversity of surgical need, but also to make it
appealing both from an economic standpoint and an
academic standpoint. The American Association for
the Surgery Trauma has developed an acute care surgi-
cal fellowship in conjunction with a surgical critical
care fellowship. While the intent of this at first glance
is to develop mechanisms to care for the acute presen-
tation of surgical disease in large academic medical
centers, the diversity of experience is well designed for
surgeons who are interested in providing surgical care
for rural America.
5
6 D.C. Borgstrom
Finally, there are several institutions that have rec-
ognized the need to not only provide an experience in
rural surgery practice, but also diversity training. The
Oregon Health and Science University’s Department
of Surgery has a program to introduce residents to a
rural surgery practice as an alternative to spending
time in a research lab. The University of North Dakota
program also facilitates experiences for its residents to
spend considerable time in a rural setting. Bassett
Healthcare, in Cooperstown, New York, through the
Mithoefer Center for Rural Surgery, provides fellow-
ship opportunities for surgeons who have completed
their traditional general surgery curriculum who have
interest in additional training that will allow them
­better to care for rural America.
Surgical care for rural America is at a crossroads.
There is declining interest and increasing need.
Fortunately, there are organizations that have recog-
nized the critical nature of the concern and are attempt-
ing to develop programs that will not only make it
appealing for newly trained surgeons, but to also pro-
vide them the training necessary to feel qualified to
provide the broad array of surgical expertise necessary
to care for rural America.
 Surgery in Rural Canada: Challenges
and Possible Solutions
Nadine R. Caron and Stephen J. Pinney
3.1 Introduction
The provision of timely and quality surgical services is
a persistent challenge in rural Canada. As they work to
provide rural surgical services, health-care providers,
administrators, and policy makers confront consider-
able obstacles. With almost 10 million km2, Canada is
the second-largest country in the world. However, its
population density ranks in the lowest 5% of countries
– 95% of the land in Canada is rural. Despite this, only
about 20% of Canadians live in rural areas as defined
by a community having a population of less than
10,000.
These geographic factors alone produce inherent
challenges, which are increased by the economic,
socio-cultural, and political issues facing rural com-
munities: rationalization of health-care resources to
regional centers, relatively high poverty rates, plus
issues in health status disparities, most of which are
often associated with aboriginal populations. While
these challenges are longstanding and difficult to over-
come, the stress on the health-care system and the rural
populations it serves creates an impetus for change.
This chapter outlines the challenges in training for and
providing rural surgery in Canada and suggests possi-
bilities for creative solutions.
N.R. Caron (*)
University of British Columbia-Northern Medical
Program Prince George, BC, Canada
e-mail: nadinecaron@yahoo.com
S.J. Pinney
Department of Orthopaedics,
St. Paul’s Hospital, 1081 Burrard St. Room C323,
Vancouver, BC V6Z 1Y6, Canada
e-mail: spinney@providencehealth.bc.ca
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_3, © Springer-Verlag Berlin Heidelberg 2011
3
3.2 How Do We Define “Rural Canada”?
In the context of surgical practice, we define “rural” as
communities whose small population and/or remote geo-
graphic location usually requires surgeons to maintain
a broad practice with minimal clinical support and
­limited access to technical resources. In Canada, this
most commonly refers to communities with one to two
general surgeons and populations of less than 10–20,000
people.
3.3 Challenges
There are multiple challenges to providing high-
quality surgical services in rural Canada. These
include (1) the limited number of practicing general
surgeons; (2) the fact that skills needed for a rural
surgical practice are increasingly de-emphasized in
Canadian surgical training programs; (3) difficulties
in recruiting and retaining surgeons to rural commu-
nities; (4) limited resources for establishing or main-
taining surgical services and practices; and (5) poor
integration and coordination of existing surgical
services.
3.3.1 The Limited Number of Practicing
General Surgeons
Rural communities face a stark challenge: Few physi-
cians choose careers in rural surgery. We will explore
the causes for this shift in detail later, but let us begin
with two key facts: Surgeons in rural locations are
almost exclusively general surgeons, and the number
7
8 N.R. Caron and S. Pinney
of general surgeons in Canada is decreasing. Quite
simply, more general surgeons have retired than have
entered the Canadian work force over the past decade
[1, 2]. With fewer graduates entering general surgery
practice, it becomes difficult to find enough of them
to meet the needs of rural Canadian communities.
3.3.2 Skills Needed for a Rural Surgical
Practice Are Increasingly
De-emphasized in Canadian
Surgical Training Programs
Another, more subtle shift has occurred as well: The
culture of present-day surgical training in North
America encourages subspecialization as opposed to
the generalist training once well incorporated in stan-
dard General Surgery residencies [3]. Of those com-
pleting General Surgery training, a significant number
now choose subspecialization, bypassing the option
of rural surgery practice in favor of post-residency
fellowships based on anatomic association, clinical
etiology, technology utilized or age-related patient
populations. It is estimated that up to 70% of gradu-
ates from Canadian general surgery residencies ­pursue
postgraduate fellowships.
This has limited the number of surgeons who can
provide the wide range of surgical procedures required
in rural Canada. A generation ago, a graduating ­general
surgeon would feel comfortable performing a variety of
common procedures in a range of disciplines such as
caesarian sections, emergency craniotomy “burr holes”,
skin grafting, draining peri-tonsillar abscesses, and sta-
bilizing basic fractures. Today’s graduating general sur-
geons often have little hands-on experience performing
these type of procedures and therefore many new sur-
geons do not feel comfortable performing the breadth
of procedures that are needed in a rural community.
One reason for this is program planning, the pro-
cess whereby residency training programs structure
observation, training, and hands-on learning. In many
Canadian residency programs, general surgery residents
no longer experience rotations in urology, obstetrics/
gynecology, plastic surgery, neurosurgery, and ortho-
pedics. If they do, such rotations typically occur in the
junior residency years when the focus of training is not
on procedural competency but on understanding core
surgical principles. Indeed, the only “off-service” rota-
tion (not general surgery or one of its subspecialties)
mandated by the Royal College of Physicians and
Surgeons of Canada is Critical Care Medicine. General
surgery residents spend their senior years focusing on
subspecialty general surgery such as hepatobiliary,
colorectal, or minimally invasive surgery, among a
long list of others. They become comfortable and com-
petent performing complex surgeries as part of a team
at a tertiary center, but often have little experience per-
forming a wide variety of the more basic surgical pro-
cedures in other disciplines on their own. Like most
people, surgeons become comfortable with what they
have been trained to do, in an environment they are
familiar with and as a result, often distance themselves
from the concept of rural practice.
A further reason for this move toward subspecial-
ization is role modeling, a factor that education spe-
cialists recognize as one of the most powerful teaching
tools [3, 4]. Students model themselves on what they
see, and surgery residents at major training programs
in Canada tend to encounter subspecialists at greater
frequency and significantly longer in duration than
general surgeons due to their urban-based training.
These individuals serve as role models for those train-
ing to be general surgeons; implicitly, this fosters the
trend toward subspecialization that has made it so
­difficult to train generalists and recruit such surgeons
to rural practices.
Finally, we must consider that most training pro-
grams are situated in large urban centers. During the
five or more years that it takes residents to train, they
often become comfortable in this type of setting, devel-
oping friendships and/or partnerships, and building
lives that make it difficult for them to move to a rural
community when they finish their training.
3.3.3 Difficulties in Recruiting
and Retaining Surgeons
Rural Canadian communities face further challenges
in recruiting and retaining surgeons, including (a)
lower patient volumes to maintain subspecialty skills
[3] and (b) the perception that rural surgical practices
require demanding on-call schedules.
First, as we have seen, surgeons increasingly choose
to pursue subspecialization after their general training.
3 Surgery in Rural Canada: Challenges and Possible Solutions
Having done so, they often wish to maintain a focused
practice that does not extend significantly beyond their
field of expertise. Such a scope of practice is neither
predictable nor easily obtained in the rural environ-
ment, helping to explain why most subspecialty-trained
surgeons do not move to rural locations. For rural gen-
eral surgeons who have not pursued subspecialty train-
ing, their low case volume for subspecialty care creates
increased pressure to transfer patients requiring elec-
tive care in subspecialty fields to regional or tertiary
centers. This can limit the scope of rural elective gen-
eral surgery and often adds to the stress of emergent
surgical care [3].
Concerns regarding daunting emergency on-call
responsibilities pose a further challenge. Surgeons in
small rural communities simply do not have many
local colleagues with whom to share on-call workload
and this all too often correlates with increased fre-
quency of formal and informal on-call schedules.
While small populations may translate to less after-
hours work when on-call, rural surgeons grapple with
community expectations that they be available for
urgent matters. As well, they face the considerable
stress of caring for patients with challenging clinical
presentations in the absence of colleague support, both
medical and surgical. As a result, quality of life issues
and professional burnout pose real concerns for sur-
geons practicing in rural areas [5].
3.3.4 Limited Resources for Establishing
or Maintaining Surgical Services
and Practices
Ironically, government policies often discourage sur-
geons from pursuing rural surgery practices, as infra-
structure funding for hospitals, labs, and imaging
facilities tends to favor regionalization. From the
­government’s perspective, it makes sense to concen-
trate physical and human resources in larger centers.
However, this means that surgeons wanting or needing
to practice with access to these facilities and resources
(especially subspecialists) will naturally be drawn to
larger regional centers. For surgeons in rural commu-
nities, regionalization often means finding themselves
(and their patients) hours away from well-equipped
and well-staffed regional centers.
9
3.3.5 Poor Integration and Coordination
of Existing Surgical Services
Practical issues within the health-care delivery system
further undermine the potential for a more widespread
distribution of general surgeons. For example, many
general surgeons would prefer not to practice as sole
practitioners, preferring the freer lifestyle provided by a
shared practice, but the catchment base in most rural
communities is not large enough to keep more than one
surgeon busy. In addition, many of the resources required
to sustain a full surgical practice that meets clinical
guidelines and public expectations such as CT scanners,
MRIs, and laboratories are not available in rural centers.
3.3.6 Summary of Challenges
A variety of forces are thus combining to undermine
Canada’s ability to provide high-quality surgical care
in rural areas. Fewer general surgeons are being trained
and those who do graduate often are not prepared to
provide the breadth of surgical procedures required in
a rural community. In addition, trainees have limited
exposure to rural surgery and few role models to
encourage them to choose a rural surgery practice. The
prospect of a demanding on-call schedule and profes-
sional isolation with the lack of colleagues may also
act as additional deterrents. Combined with limited
funding for infrastructure and the lack of an integrated
system for providing surgical care, these factors have
lessened the ability of rural communities to recruit and
retain surgeons.
3.4 Possible Solutions
To provide surgery in rural communities, you need both
surgeons and the human and physical resources that
support them: nursing, anesthesia, operating rooms,
imaging equipment, and laboratory support.
Despite the many problems associated with provid-
ing high-quality surgical care to rural populations in
Canada – problems of surgical training, recruitment,
workload, isolation, regionalization – there are practical
strategies that would increase the number of surgeons
10
willing to work in such communities and significantly
improve the structures that support them there.
These strategies include (1) using educational and
program planning principles to encourage residents to
pursue rural surgery practices; (2) optimizing the use of
telemedicine as a means of providing clinical care and
clinical teaching; (3) using a systems-based approach
to improve integration between communities; (4) train-
ing some general practitioners to perform basic surgi-
cal procedures and provide initial trauma stabilization;
and (5) utilizing physician extenders (PEs) to extend
the range of surgeons in rural practices; and (6) increas-
ing financial incentives for rural surgeons.
3.4.1 Invoking Educational and Program
Planning Principles
In order to train a new generation of surgeons ready to
take up practice in rural Canada, medical programs
will need to apply educational and program planning
principles in a strategic fashion. Education principles
that will facilitate this change include (a) role model-
ing; (b) outcome-based education; (c) utilizing the
central role of evaluation; (d) target training to planned
scope of practice and avoid “extraction education”;
and (e) ensuring active learning. Program planning
principles will also be essential to ensure that resources
exist to support our current and future rural surgeons.
3.4.1.1 Role Modeling
Role modeling is a critical educational tool that could
be deployed to encourage more surgeons to consider
rural practices. Surgical trainees – indeed, all trainees –
are acutely influenced by role models [4]. In fact, what
trainees observe teaches them far more than any lec-
ture that they hear or paper that they read. If surgical
trainees are not exposed to surgeons who have flour-
ishing and enjoyable rural practices, very few gradu-
ates are likely to attempt this type of practice, especially
given current trends toward regionalization. To encour-
age young ­surgeons to pursue rural careers, residency
training ­programs must provide direct, sustained expo-
sure to surgeons providing high-quality care in rural
communities. Importantly, physicians chosen as role
models should be ones who enjoy their work.
Such role models would be most effectively used in
conjunction with a student population that itself had
N.R. Caron and S. Pinney
roots in rural Canada. Although growing up in a rural
community does not guarantee that individuals will
stay in a rural community once they are trained, it does
increase the likelihood of this happening. Medical
schools and surgical residency programs should there-
fore actively encourage candidates who have grown up
in rural communities and should try to match them
with mentors who both model and speak about the
attractions of rural surgical practice.
3.4.1.2 The Principle of Outcome-Based
Education
The principle of outcome-based education suggests
that training for any profession should be dictated by
what one actually needs to be able to do in practice [6].
This is the premise underlying the CanMEDS initia-
tive that attempts to identify the knowledge, skills, and
personal qualities that physicians graduating from
Canadian medical schools should have [7]. This in turn
demands that those in charge of the medical school
curriculum create learning experiences so that their
graduates will have the desired attributes. The same
principle can be applied to training general surgeons
for a rural surgery practice. For those destined to be
general surgeons in rural practices, this means per-
forming core surgical procedures in an appropriate
spectrum of specialties without tertiary and quaternary
resources. For medical schools interested in producing
surgeons ready to practice in rural Canada, this means
thinking carefully about what common clinical sce-
narios such physicians are likely to encounter and
­creating learning experiences that will allow them to
provide these services within quality standards.
3.4.1.3 Appreciating Evaluation’s Central Role
in Learning
Appreciating evaluation’s central role in learning is
critical during surgeons’ training and after they start
practice. People tend to base their actions on how they
are evaluated [8]. In this context, we are referring to
“evaluation” in the broadest sense of the word. If a
goal of residency training is to encourage more gradu-
ates into rural practices, then the content they are taught
and upon which they are evaluated should reflect this.
If medical school exams and assessments include con-
tent related to rural surgery, they will encourage mas-
tery of such issues, regardless of students’ ultimate
3 Surgery in Rural Canada: Challenges and Possible Solutions
practice type or location. Such content might involve
patient transfers (the decision-making process and
optimizing the transfer itself); telephone consultations;
the spectrum of clinical approaches to the pathology;
and clinical scenarios within the curriculum that will
be based on resources available and how to differenti-
ate such approaches. For trainees planning an urban-
based practice, the curriculum should generate an
understanding of the challenges of rural surgical care
and the responsibilities of referral centers to assist
when human or technical resources are needed.
3.4.1.4 Over Education or “Extraction
Education”
Over education or “extraction education” is a negative
principle that should be kept in mind by program plan-
ners as they promote the expansion of rural surgery.
Essentially, as individuals become more highly trained,
they usually gain more career opportunities. In the field
of surgery, individuals with higher degrees of training
(i.e., general surgeons with subspecialty training) com-
monly pursue non-rural positions. This suggests a
potential benefit of training rural surgeons locally and at
a level appropriate to what is needed for the rural prac-
tice. This will likely translate into less subspecialty rota-
tions in fields least likely to be required in rural surgery
such as hepatobiliary, complex pediatric surgery, or
transplantation and more broad based training in prepa-
ration for the case loads expected in rural hospitals.
This highlights the need for distributed training sites
for surgical rotations in targeted or specific communities,
where surgeons would master what they need for specific
practices. Such targeted training has achieved a degree of
success in General practitioner (GP) surgery training in
Canada and other parts of the world. GP surgeons acquire
the ability to perform a limited scope of identified surgi-
cal interventions with additional training dictated by a
specific community needs such as skin grafts, hand
­procedures, tubal ligations, or others. A basic curriculum
with additional procedures tailored to the community
tends to enhance physician retention.
3.4.1.5 Active Learning
Active learning refers to the principle that learning
happens most effectively when learners are physically
and/or intellectually engaged in the learning process
[9]. It facilitates efficient learning and optimizes
11
retention of information and skills. Activities with a
physical component, especially real or simulations of
real events, can be very helpful to facilitate active
learning. The “hands-on” approach to many aspects of
surgical training is an example of active learning. It is
a richer, more powerful mode of learning than the pas-
sive learning that, unfortunately, is the usual modality
in continuing medical education (CME). To ensure
maximum effect, education programs designed to
­foster skills essential to rural surgical practice should
deploy active learning principles at every level, from
residency to CME.
3.4.2 Telemedicine
Telemedicine represents a unique opportunity to
address some of the problems in providing surgical
services to rural Canadian communities. For the pur-
poses of this chapter, we define telemedicine as the
use of live interactive video and audio feeds via
the internet to facilitate either clinical care or
health-care education from a distance. With recent
advances in computing power, digital video, and inter-
net technology, an increasing number of Canadian
rural communities can now take advantage of this
resource.
There are three broad ways that telemedicine is
used: (a) physicians diagnosing and in some instances
treating patients from afar; (b) specialist physicians
helping nonspecialist physicians manage compli-
cated cases in their home community; and (c) provid-
ing interactive education to rural health-care
providers. Each of these could dramatically improve
surgical care in rural communities if the systems and
culture are ­created to optimize how telemedicine is
used.
3.4.2.1 Physicians Diagnosing and in Some
Instances Treating Patients from Afar
It is increasingly common in Canada for specialist sur-
geons to assess patients via telemedicine. This has
expanded access to specialist physicians to a much
broader segment of the population. Imagine a patient
in British Columbia whose GP has identified a lung
mass and begun a basic workup at the local hospital.
Previously, such a patient was then required to travel
3 h or more each way to be seen by a specialist in
12
thoracic surgery. This often required either a multiday
trip or more likely, multiple day trips with associated
expenses and thereby served to create a barrier to care.
Often, patients are forced to avoid or delay these jour-
neys for health-care access because of time, money,
weather, or employment restrictions, among others.
With telemedicine, patients can show up for an
“appointment” at their local hospital and be assessed
via telemedicine by a thoracic surgeon who is often
hours away. These visits are often facilitated by a local
nurse who collects all of the patient’s test results,
reviews the patients’ history, and may even help carry
out a basic physical exam under the direction of the
consulting surgeon. In many instances, telemedicine
either allows the patient to be managed locally or, if
surgery is indicated, it can be done in one trip with the
knowledge that the patient has been worked up prior to
the procedure. Postoperative follow-up care can also
benefit from this system. There are obvious limitations
to this type of telemedicine as physicians cannot per-
form a hands-on examination. However, this type of
telemedicine could serve to dramatically expand access
to specialist care in a number of cases.
Perhaps the biggest barrier to wide-scale implemen-
tation of this type of care is the traditional medical cul-
ture. Providing care via the internet may feel different to
many surgeons and especially unnatural to more senior
or less technologically savvy physicians. However,
given the tremendous potential to extend care to a wide
segment of the Canadian population that presently
does not have access to specialist treatment, it is an
approach that physicians and administrators should
­pursue vigorously.
3.4.2.2 Expert Physicians Helping Nonexpert
Physicians Manage Complicated Cases
in Their Home Community
Telemedicine can also enable urban physicians and/or
subspecialists to aid physicians in a rural area. Physi­
cians now commonly use video links to help rural
­colleagues manage a trauma patient, treat patients
with acute coronary syndrome, or appropriately man-
age any patient with a complex problem. This use of
telemedicine is likely to be more easily embraced as
it represents an extension of traditional rural prac-
tice. For several generations of Canadian rural physi-
cians, the telephone has served as a lifeline to expert
N.R. Caron and S. Pinney
consults. The ability to share images and live video
feeds dramatically improves the accuracy and extent
of care that can be provided via real-time physician-to-
­physician communications. This use of telemedicine
can be done as easily as sending an x-ray image via a
cell phone. However, for more involved interactions, a
video linkup and a coordinated program for accessing
expert physicians should be instituted.
3.4.2.3 Providing Interactive Education
to Health-Care Providers
Finally, telemedicine promises to make regular continu-
ing medical education (CME) practical and economical
for physicians practicing in rural communities. The
ability to obtain and maintain core knowledge and skills
and to learn about medical advances is particularly criti-
cal for rural physicians. However, attending a CME
program requires extended travel time, cost, and time
away from practices where few locums are available.
Distance learning via telemedicine provides a potential
solution to these problems. Interactive lecture presenta-
tions can now be easily presented online in the form of
webinars. Even a coordinated curriculum providing a
comprehensive review of a broad topic can now be pro-
vided online via distance learning complete with
instructors, regular feedback, and examinations. These
tools now make it much more manageable for rural
physicians to keep knowledge and skills up-to-date.
3.4.3 Systems-Based Solutions
Even if medical schools and their surgical residencies
were to train a new generation of surgeons for rural
Canada, many of the barriers to high-quality surgical
care would still exist. These barriers stem from sys-
temic or organizational issues. A trauma victim requir-
ing a general surgeon, an orthopedic surgeon, and a
CT scan may have to visit three different hospitals,
each hours apart. These are problems that compromise
care and the solutions to these issues require organi-
zational or system changes that need to be instituted
by the administrators of the overall health system.
These are changes that require vision, creativity, and
leadership and should be done without automatically
defaulting to the regionalization approach where all
resources are simply removed. However, as Canada
3 Surgery in Rural Canada: Challenges and Possible Solutions
has a coordinated single-payer health system, these
changes, while difficult, are not impossible.
3.4.4 Training General Practitioners
(GPs) As Surgeons
Training some general practitioners (GPs) to perform
certain basic surgical procedures and provide initial
trauma stabilization could prove to be a vital element
of improved surgical care in rural communities.
However, what procedures could be appropriately
­performed by GPs and how GPS should be trained and
certified continue to be debated. Currently, there is
only one formal GP surgery training site in Canada,
which was initiated 2 years ago.
Training rural GPs in Advance Trauma and Cardiac
Life Support (ATLS and ACLS) is practical and indeed
existing pathways for this training already exist.
Extending this to training GPs to provide basic anes-
thesia and perform basic surgical procedures such as
Caesarian sections, appendectomies, endoscopies, and
applying external fixation to long-bone fractures would
be a practical next step for GPs who are committed
to learning, and maintaining these skills.
As might be expected, there is some resistance from
specialist surgeons to training GP surgeons. However,
the benefits to rural communities are potentially pro-
found and examples exist in Canada. For example, the
ability for a mother to have a caesarian section (C/S)
performed locally would have a dramatic effect on
obstetrical care in a community. Indeed, obstetrical care
in British Columbia, Canada is in crisis. As less obste-
tricians (specialist surgeons) set up practice in rural
communities, there are more expectations that the local
general surgeons provide C/S capacity. However, as
stated previously, less general surgeons are going to
rural communities and even less are trained in C/S skills.
GP surgeons often fill this gap but the lack of training
programs and opportunities limits new GP surgeons in
filling these roles. Therefore, GPs who previously man-
aged obstetrical patients are now relinquishing their
privileges in this area due to lack of surgical backup that
then adds to an already stressful practice pattern. For
those GP’s that maintain obstetric care in the face of all
limitations, they now have extensive call duties that has
led to burnout and either moving to a center with surgi-
cal obstetrical backup or being forced to quit obstetrics
13
care. Ultimately, it is patient care that suffers. Many
pregnant patients would be able to stay in their home
communities and deliver their babies locally rather than
travel away from their family and friends – and at their
own expense – to await the birth of their child in a
strange community. Similarly, early intervention in
trauma and urgent cases such as appendicitis would
improve outcomes and decrease cost. If standardized
programs, real-time mentoring from specialists, and
close monitoring of performance were established, such
training could substantially expand surgical care in rural
Canadian communities.
3.4.5 Utilizing Physician Extenders (PEs)
to Extend the Range of Surgeons
in Rural Practices
The use of physician extenders (PEs) such as nurse
practitioners (NPs) and physicians’ assistants (PAs)
offers practicing surgeons the chance to increase the
number of patients that receive their care. NPs are
already used in many rural communities and physi-
cians’ assistants now practice in some Canadian
provinces. There are three general ways that PEs can
improve access and care in rural communities. All
are predicated on the PE being well-trained and work-
ing closely under guidance from physicians.
One model involves the PE working directly with a
surgeon to substantially increase the volume of patients
that the surgeon can see without decreasing the quality
of care. With appropriate training and division of labor,
it is not uncommon for a competent well-trained PE to
nearly double a surgeon’s clinic volume. This would
be extremely beneficial when one of the limitations
and stressors of clinical practice for rural surgeons is
workload and expectations to meet it. For this to occur,
the surgeon or physician overseeing the PE must spend
the time, often 2–6 months, to adequately train the PE
about his/her practice. In addition, often the practice
itself needs to be modified so as to facilitate a greater
flow of patients. Changes may include opening up a
separate clinic schedule for the PE as well as training
the individuals who schedule patients so that the
­delegation of patients between physician and PE
is organized for optimal efficiency.
Another model uses well-trained PEs to provide
patient care in emergency rooms and urgent-care
14
facilities under guidance from a physician. This type
of PE work could allow surgeons in a rural commu-
nity to avoid burnout knowing that they have some-
one to help manage on-call referrals. For communities
trying to recruit and retain a surgeon or surgeons, a
team of well-trained and proactive PEs can have a
positive impact on a surgeon’s lifestyle. GP surgeons
have also demonstrated this positive effect in a mixed-
model where they work in the same community with
a specialist colleague. This in turn makes it more
likely that surgeons will stay in the community in
question.
Finally, many communities use NPs to provide
independent patient care. This allows many rural com-
munities to provide basic medical care locally. This
model can work very well provided the PE is well
trained and is integrated into the wider medical system.
The ability for the NP to have a network of physicians
(including the most proximal rural surgeon) that they
can call to help facilitate and expedite patient care is
important. A coordinated program using PEs has the
very real potential of extending meaningful health care
to many rural Canadians who are presently not able to
adequately access the health-care system.
3.4.6 Financial Incentives
Finally, surgeons choosing a rural practice will need to
be rewarded financially. Perhaps the most practical
way to do this is to ensure that adequate operating time
is available for rural surgeons. This does require an
increased financial commitment from the government
and therefore can be a challenge. However, if programs
to increase the provision of surgical care are funded
with appropriate incentives, they can serve as a tool to
recruit and retain surgeons in rural areas and thereby
improve surgical care.
3.5 Conclusion
The challenge of providing surgical care in rural Canada
is real. Factors undermining the provision of surgical
care in rural Canada include: an overall shortage of
general surgeons; residency training programs that
have relatively few role models for promoting the
N.R. Caron and S. Pinney
virtues of a rural practice; persistent difficulties in
recruiting and retaining surgeons in rural communities;
and limited resources for establishing and maintaining
a coordinated surgical service. However, with these
­challenges come opportunities to develop creative solu-
tions and the Canadian health-care system in many
ways is well positioned to enact many of these solu-
tions. These solutions include better education and role
modeling to promote rural surgery as a career choice;
incorporation of telemedicine to expand and improve
care in rural communities; making systematic organiza-
tional changes to improve the delivery of surgical care
in rural areas; training GP surgeons to provide some
basic surgical care; and utilizing physician extenders to
expand the delivery of surgical care. Applying potential
solutions will require innovative leadership and a vision
that what is needed, is possible.
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Surg. 90(8), 13–18 (2005)
4. Kenny, N., Mann, K., MacLeod, H.: Role modeling in phy-
sicians’ professional formation: reconsidering an essential
but untapped educational strategy. Acad. Med. 78(12),
1203–1210 (2003)
5. Shanafelt, T.D., Balch, C.M., Bechamps, G.J., Russell, T.,
Dyrbye, L., Satele, D., Collicott, P., Novotny, P.J., Sloan, J.,
Freischlag, J.A.: Burnout and career satisfaction among
American surgeons. Ann. Surg. 250(3), 463–471 (2009)
6. Frank, J.R., Danoff, D.: The CanMEDS initiative: imple-
menting an outcomes-based framework of physician compe-
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7. Royal College of Physicians and Surgeons of Canada
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index.php Accessed/edited date feb 4, 2011
8. Reznick, R.K., MacRae, H.: Teaching surgical skills –
changes in the wind. N. Engl. J. Med. 355, 2664–2669
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9. Norman, G.R., Schmidt, H.G.: The psychological basis of
problem-based learning: a review of the evidence. Acad.
Med. 67, 557–565 (1992)
 Part
II
Pre- and Postoperative Care
 Fundamentals of Surgical Oncology
Hanno Niess, Karl-Walter Jauch, and Christiane J. Bruns
4.1 Introduction
The proceedings in characterization of molecular
changes in tumour cells have led to widespread accep-
tance of the hypothesis that on the cellular level cancer
is a genetic disease. Rapid progressions in the field of
molecular biology are increasingly suggesting that the
transformation of a normal cell to a malignant cell is a
multi-step process. This transformation of the cell could
be a result of multiple gene mutations, gene amplifica-
tions, changes in transcriptional and translational activ-
ity and constant over-activation on protein level.
The accumulation of gene mutations mostly takes
place in genes that are crucial for normal cellular
growth. Essentially, one distinguishes between two
classes of genes that are important for the development
of a tumour: protooncogenes/oncogenes, which posi-
tively influence tumour growth; and tumour ­suppressor
genes, which negatively influence tumour growth. In
sporadically occurring tumours, these mutations are
acquired in somatic cells (somatic mutation) whereas
in inheritable tumours, the gene mutations are passed
on over the germline (germline mutation) and thus the
mutations are existent in all cells of the body.
Therefore, the fields of molecular genetics and
tumour biology play an important role in the elucida-
tion of malignant diseases, and are of increasing rele-
vance in medical diagnostics, and in the near future,
also in tumour therapy.
H. Niess, K.-W. Jauch, and C.J. Bruns (*)
Department of Surgery, University Hospital Grosshadern,
Marchioninistr. 15, 81377 Munich, Germany
e-mail: christiane.bruns@med.uni-muenchen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_4, © Springer-Verlag Berlin Heidelberg 2011
4
4.2 Basic Molecular Genetics in the
Context of Tumour Formation
Most sporadically occurring colorectal carcinomas
emerge from polyps within 5–10 years in the frame-
work of the so-called adenoma–carcinoma sequence
(Fig. 4.1) [1]. In the course of the adenoma–carcinoma
sequence, mutations and losses of certain alleles,
e.g. FAP, Ki-ras, DCC, p53, accumulate within a nor-
mal mucosal cell. Within 5–10 years, these damaged
alleles can turn a mucosal cell into an adenoma and
finally into an invasive carcinoma.
In sporadically occurring ductal pancreatic carci-
noma, one can retrace a form of sequence that is simi-
lar to the adenoma–carcinoma sequence. Through
molecular triggers, normal ductal pancreatic tissue
develops into intraductal papillary mucinous neoplasms
(IPMNs), then into pancreatic intraepithelial neoplasms
(PanIN), and finally into an invasive ductal pancreatic
carcinoma [2]. The genetic cause for this sequence is,
on the one hand, loss of chromosomes on which poten-
tial tumour suppressor genes are located, e.g. loss of
1p, 6q, 9p, 12q, 17p, 18q and 21q. On the other hand,
genetic alterations of genes such as k-ras, p16, cyclin
D1, p53, MTS1, BRCA2 or SMAD4 sustain the
­progression of the pancreatic cancer sequence.
Familial adenomatous polyposis (FAP) is an exam-
ple of an inheritable disease with a detectable genetic
defect that predisposes for tumour development. One
can identify a defect in the so-called APC gene.
However, only 1% of the cases of colorectal carcinoma
are based on the existence of FAP. FAP has an auto-
somal dominant inheritance with nearly complete pen-
etrance. It is characterized by the early appearance of
multiple colorectal polyps, which inevitably leads to the
formation of colorectal carcinomas in the young adult.
17
18
Mutation/
Normal mucosa allele loss
FAP gene
Loss of DCC
Adenoma with
severe atypia
Mutation/
allele loss
p53 gene
Fig. 4.1 Adenoma–carcinoma sequence in colorectal carcinoma
In 80% of the cases, there is a germline mutation of
the APC gene, which leads to a functional inactivation
of the gene product. Certain mutations of the APC gene
result in an attenuated form of FAP in which patients
develop fewer tumours at a later time point [3].
Hereditary nonpolyposis colorectal cancer (HNPCC)
represents another inheritable tumour disease. It is char-
acterized by colorectal adenocarcinomas in patients
with less than ten polyps and an early manifestation
age (less than 50 years). It is also characterized by the
location of the carcinoma, usually proximal to the left
colic flexure (about 70% of the cases), and frequent
metachronal and synchronal occurrence of the colorec-
tal carcinomas. HNPCC is inherited in an autosomal
dominant manner with a penetrance of a colorectal
carcinoma of about 85–90% up to the age
of 70. Additionally, genetic carriers have an elevated
risk of developing carcinoma of the endometrium,
stomach, ovaries, breast, small bowel, hepatobiliary
tract, urothelium and brain. In about 44–86% of
HNPCC families, one can detect a germline mutation
in a DNA-mismatch-repair (MMR-) gene such as
hMLH1 or hMSH2, rarely also hMSH6, hPMS1 or
hPMS2. MMR-genes encode for proteins that correct
faults in DNA replication. Loss of function of the
H. Niess et al.
Mutation Ki-ras
Tubular adenoma
5–10 years
Adenocarcinoma
3–5 years
MMR-genes by inactivating mutations leads to the
accumulation of DNA errors, which can be detected as
microsatellite instability (MSI) in 85–95% of HNPCC-
associated tumours [4].
4.3 Goals of Surgical Oncology
Depending on their objective, the principles of surgical
oncology are distinguishable between curative and
palliative procedures [5].
Surgery with curative intentions has the objective of
healing the patient by means of tumour excision and
prevention of a relapse. Occasionally, additional non-
surgical tumour-specific measures are applied preop-
eratively (neoadjuvant) or postoperatively (adjuvant).
Surgery and non-operative measures performed
with palliative intentions have the purpose of pre-
venting or alleviating symptoms or, generally put, to
improve the quality of life in incurable situations
(see Chap. 5).
Cytoreductive surgery has the purpose of removing
the major part of tumour tissue (also called debulking)
to improve the initial situation for additional tumour-
destructive treatments.
4 Fundamentals of Surgical Oncology
To what extent even a tumour resection, which was
started with primarily curative intentions, leads to
healing or fulfills a palliative purpose, depends on the
type, localization and stage of the tumour disease
as well as the type of surgery performed and other
­factors. A crucial point within this scenario also is the
biology of the tumour, which until now could be
manipulated only to a limited degree.
4.4 Curative Surgical Oncology
Bearing in mind the patient’s quality of life, the top-
most objectives of surgical oncology in a multimodal
setting are clearance of the tumour and low procedure-
related morbidity and mortality.
The fundamentals in oncological surgery with cura-
tive intentions are:
1. Tumour excision within healthy tissue, including
potentially afflicted neighbouring structures
2. The removal of the regional lymphatic drainage
according to the anatomy
3. The avoidance of intraoperative tumour cell spread
To ensure the tumour excision within healthy tissue in
parenchymal organs, tumours of the soft tissue and
tumours of the GI tract, one needs to remove a circum-
ferential safety margin around the macroscopically
viewable tumour. The size of the safety margin differs
between the specific types of organ tumours and
depends on its growth characteristics and respective
tumour stage. In early tumour stages, maintaining the
respective safety margin is easier than at later stages,
and thus the rate of locoregional tumour recurrences
increases with increasing tumour stages. In case of
doubt, frozen sections performed during surgery may
help to confirm clear safety margins.
The existence of metastases does not necessarily
exclude from performing a curative surgical interven-
tion. However, the prerequisites for a curative proce-
dure in metastatic disease are that the primary tumour
and all metastases need to be removable, and that there
would be no residual metastases after the surgery.
Certainly all these requirements must be achieved with
a justifiable operative risk.
Resection of distant metastases is performed
­primarily for metastases of colorectal carcinoma and
sarcomas of the soft tissue located in lung and liver.
In individual cases, it appears to be justified to also
19
consider resection of distant metastases of renal cell
carcinoma and malignant melanoma.
Anatomic structures are of great importance in the
selection of the resection layer. The resection layer in
the curative excision of rectal carcinoma serves as a
classic example: the complete removal of the mesorec-
tum is achieved by preparation inside the avascular
layer between the parietal pelvic fascia and the visceral
pelvic fascia (Waldeyer’s fascia in dorsal position and
Denonvillier’s fascia in ventral position). This step is,
besides maintaining a sufficient dorsal safety margin,
crucial to obtaining a surgical clearance that is adequate
to the spatial extent of the tumour [6]. Another example
of an adequately radical tumour excision is the com-
partment resection for soft tissue tumours as the com-
plete removal of a tumour-afflicted muscle group [7].
With increasing tumour expansion, the probability
of lymph node involvement by the tumour increases as
well. Generally, there is a constant, anatomically defin-
able route of lymphatic drainage for each organ.
Elective and prophylactic lymph node dissection
within the framework of surgical oncology is performed
because of the fact that lymph node metastases are often
only detected during histopathological ­examination.
Therefore, the tumour-dependent regional lymphatic
drainage system is completely removed, and in most of
the cases, this needs to be performed en bloc with the
removal of the primary tumour itself.
The elective lymph node dissection is carried out for
diagnostic reasons to evaluate the tumour stage and to
estimate the prognosis. In certain tumours (e.g. breast
cancer, gastric cancer), the lymph node status is a deci-
sive prognostic parameter [8]. Furthermore, the lymph
node status serves as a criterion for adjuvant therapeu-
tic measures (colorectal cancer, breast cancer) [9].
Concerning the extent of the lymph node dissection in
a curative setting, removal of the first lymph node sta-
tion of the respective tumour-afflicted organ is accept-
able. Assuming that some patients might profit from an
extended surgical removal of further lymph node sta-
tions, this is justified only in cases where it does not
increase the operative risk.
The concept of sentinel lymph node biopsy has
evolved under the assumption of a constant lymphatic
drainage. This means that the findings in the first drain-
ing lymph node (the sentinel lymph node) are repre-
sentative for the whole regional lymph node section. In
certain tumour entities, the decision of removing or
leaving the regional lymph node section is based on
the findings in the sentinel lymph node. Breast cancer
20
and malignant melanoma are the tumour entities where
most experience with sentinel lymph node biopsies
exists. Few reports do also exist about initial results for
tumours of the gastrointestinal tract [10].
If lymph node infiltration is evident prior to surgery,
the lymph node removal is called selective or therapeu-
tic lymph node dissection.
In patients with infiltration of the tumour into ana-
tomically neighbouring structures, one should aim for
their removal together with the primary tumour (multi-
visceral en bloc resection). This is because loosening
possible adhesions between the tumour and its neigh-
bouring structures might lead to opening of the tumour
capsule and thus dissemination of tumour cells. The
decision on the extent of the surgical procedure should
be made individually based upon the quality of life, the
operative risk, and the overall prognosis under consid-
eration of the tumour biology.
For example, colon cancer with infiltration of the
neighbouring small intestine, bladder, adnexa or uterus
is preferably removed via en bloc resection without
loosening tumour adhesions or examining frozen sec-
tions [11]. In contrast to this stands the strategy of pre-
treatment of, e.g. rectal carcinoma in a neoadjuvant
setting with radio-chemotherapy to minimize and devi-
talize the tumour. This leads to the possibility of a sub-
sequent resection, which can be less extensive and thus
less risky with regard to impaired quality of life (colos-
tomy, neo-bladder, sexual dysfunction) [12].
In oncological standard procedures as for example
in colorectal cancer, the surgeon not only removes the
primary tumour with its respective safety margin and
regional lymphatic tissue but also tries to ligate the
draining veins as early as possible. This serves the pur-
pose of preventing haematogenous tumour cell dissemi-
nation and is called the ‘no-touch-isolation-technique’.
In laparoscopic oncological procedures, the preven-
tion of tumour cell dissemination is achieved by covering
the surgical incisions with foil when retrieving the tumour
from the abdomen. Metastases implanted into the skin
after removal of incidental gall bladder carcinoma have
been described and these patients usually require addi-
tional surgery including excision of the port sites.
4.5 Palliative Surgical Oncology
Despite curative objectives, only 50% of the patients
with tumours of the gastrointestinal tract can be healed.
In the other half of the patients with tumours of the GI
H. Niess et al.
tract, a surgical approach can only be considered as
being palliative.
The role of palliative surgical oncology is improve-
ment of quality of life in patients with incurable disease
by alleviating or abolishing tumour-related symptoms.
In a broader sense, palliative surgical oncology has a
prophylactic character by preventing the appearance of
complications in advanced tumour disease and main-
taining acceptable quality of life for the patients as long
as possible.
Palliative surgery includes the following proce-
dures: removal of the primary tumour despite existence
of distant metastases (e.g. colorectal carcinoma with
distant metastases to prevent bowel obstruction or
­haemorrhage), small bowel anastomoses to bypass a
tumour-induced bowel obstruction, colostomies, endo-
scopic procedures and procedures that prepare for
­supportive measures (e.g. port implantation).
However, for gastric outlet stenosis produced by
a locally advanced distal gastric carcinoma, the
­palliative distal gastric resection and thus removal
of the tumour is superior to a gastro-enterostomy as
bypass procedure, this of course only if the proce-
dure comes with a justifiable perioperative risk for
the patient.
Further examples of palliative tumour resection
include the lobectomy in abscessing advanced lung
cancer or mastectomy in ulcerating metastasized
breast cancer. Under certain circumstances, life-
threatening complications of a tumour disease may
justify extended tumour resections in case the emer-
gency situation can only be mastered by surgery, even
if they involve a substantially increased risk (e.g. gas-
trectomy in massive bleedings from gastric cancer
with distant metastases). Endocrinologically active
non-resectable tumours justify procedures to down-
size the tumour and thus alleviate symptoms and
improve quality of life.
However, in advanced tumours, often the only
remaining option is to perform procedures that
leave the tumour in situ. Besides surgery, other
­possible procedures are medicinal treatment, endo-
scopic or interventional radiology procedures, and
radiotherapy.
The selection of the correct procedure depends
on the degree of impairment of quality of life by
the tumour, the expected prognosis, the risk of the
procedure and the patient’s wishes. Supportive mea-
sures are especially relevant in incurable situations.
Among those are adequate pain therapy and nutri-
tious support.
4 Fundamentals of Surgical Oncology
4.6 Surgical Oncology as Part of a
Multimodal Tumour Therapy
Today surgical oncology usually is part of a multi-
modal interdisciplinary concept of tumour therapy.
A multimodal approach includes classic procedures
such as surgery, chemotherapy and radiotherapy.
However, nowadays it also includes interventional
radiology procedures such as chemoembolization,
radiofrequency ablation, as well as systemic molecular
biology approaches so-called targeted therapy.
The respective multimodal treatment and the order
of the different procedures should be discussed in an
interdisciplinary tumour board and ascertained for
each patient on an individual basis.
Locally advanced rectal carcinoma (T3-4, N1) rep-
resents a typical example of a multimodal treatment
approach. Before undergoing surgery (anterior recto-
sigmoid resection, low anterior resection, abdomino-
perineal resection), patients receive neoadjuvant
radiochemotherapy, which is continued as systemic
adjuvant chemotherapy after surgery. In doing so, the
prognosis of these patients has been substantially
improved and the risk of local recurrent tumour is sig-
nificantly decreased [13]. Furthermore, the rate of
sphincter-preserving surgery in tumours near the anal
sphincter has been increased without impairment of
the oncological radicality.
To allow for local resectability in pancreatic cancer,
similar approaches such as neoadjuvant radiochemo-
therapy are applied. Moreover, approaches from mole­
cular biology such as anti-angiogenic therapy (e.g.
Bevacizumab in metastasized colorectal cancer) or
thyrokinase inhibitors (e.g. Erlotinib in advanced
­pancreatic cancer) may be part of the multimodal
treatment.
The overall goal of multimodal oncological therapy
is to improve the prognosis of each individual patient
with the underlying tumour disease under consider-
ation of the prognostic factors.
4.6.1 Established Prognostic Factors
From many clinical trials the following prognostic fac-
tors relevant for therapy in oncology have evolved:
• R-status (residual tumour status)
• pTNM status
21
• Grading
• Lymph node ratio (number of lymph nodes diseased/
number of lymph nodes removed)
• Perioperative complications (nutritious status, total
blood loss, need for blood transfusions, infections)
• Tumour-specific experience of the treating centre
(‘high volume hospitals’)
4.6.1.1 Residual Tumour Status (R-Status)
The R0 status (no residual tumour) should relate to the
primary tumour, its respective lymphatic drainage
pathway and, if applicable, distant metastases.
• Absolute R0 resection: All three dimensions of the
primary tumour and the lymphatic drainage are free
of tumour (lymph node ratio < 0.2)
• Relative R0 resection: All three dimensions of the
primary tumour and the lymphatic drainage are free
of tumour but with an insufficient size of safety
margins (lymph node ratio > 0.2)
• R1 resection: Microscopic tumour residual
• R2 resection: Macroscopic tumour residual
4.6.1.2 TNM Classification
The TNM classification allows for an anatomic descrip-
tion of the tumour spread.
T describes the extent of the primary tumour:
• T0: No indications of a primary tumour (CUP: cancer
of unknown primary)
• Tis/Ta: The tumour has not infiltrated other tissue;
these tumours usually go along with a good
prognosis
• T1, 2, 3 or 4: Increasing size of the tumour/infiltration
of certain tissue layers in hollow organs/infiltration of
adjacent organs
• Tx: No statement about the primary tumour possible
N describes the existence or absence of regional lymph
node metastases:
• N0: No evidence for lymph node infiltration
• N1, 2 or 3: Increasing lymph node infiltration; clas-
sification into ipsilateral or contralateral affliction
and mobility, as well as in relation to the primary
tumour and number of positive lymph nodes
• Nx: No statement on lymph node affliction possible
22 H. Niess et al.

M describes the existence or absence of distant 4.6.1.5 UICC-Staging

metastases:
In the framework of staging tumour diseases, several
• M0: No evidence for distant metastases
TNM categories are summarized into one UICC stage
• M1: Distant metastases present
according to their prognosis.
• Mx: No statement on distant metastases possible
UICC stage pTNM categories
Stage 0 TisN0M0
4.6.1.3 Grading/Histomorphologic Features Stage I T1, T2, N0, M0
Stage II T3, T4, N0, M0
Further addenda to describe the tumour are histomor-
phologic features such as Stage III Any T, N1, N2, M0
Grading (G1–G4): Histomorphologic feature describ- Stage IV Any T, any N, M1
ing the state of differentiation of the tumour tissue
• G1 = well differentiated; which means that the The UICC stages indicate that the size of the pri-
tumour tissue resembles the tissue of origin mary tumour is not the decisive factor for prognosis
closely of the patients but the lymphatic and haematogenous
• G4 = undifferentiated; the tissue of origin is only dissemination (stage II vs. stage III).
detectable by ultrastructural or immunohistochemi-
cal analysis 4.6.1.6 Minimum Number of Lymph
Nodes to Be Examined in Tumours
L0/L1: Invasion into lymph vessels or tumour cell
of the GI Tract
emboli inside lymph vessels; contact to the lymph
­vessel wall is not necessary for the diagnosis
To be able to give an applicable statement on the lymph
V0/V1/V2: Invasion into veins (none/microscopic/
node status of the respective gastrointestinal tumour
macroscopic)
for the TNM classification, the examination of a mini-
Sx/S0, 1, 2 or 3: Serum tumour markers; these are
mum number of lymph nodes is required (Table 4.1).
only registered in malignant testicular cancer (Sx: not
The lymph node ratio is calculated from the proportion
available/examined; S0 = normal, S1–3 = at least one
of tumour-positive lymph nodes to the total number of
marker elevated)
lymph nodes removed.

4.6.1.4 Certainty of the Diagnostic Findings Table 4.1 Required minimum numbers of lymph nodes to be
removed
Adding the descriptor ‘C’ to the respective TNM cat- Localization of the tumour Minimum number of
egory creates the possibility to denote certainty of the lymph nodes to be
diagnostic findings. removed

• C1: General examination methods such as physical Stomach 15

examination or standard x-ray, etc.
• C2: Special examination methods such as ERCP,
CT, MRT, etc. Colon, rectum 12
• C3: Results of the surgical exploration, cytology or
biopsy
• C4: Insights from the surgical resection, the histo- Pancreas 10
pathologic examination; equivalent to the pTNM
classification Liver, gall bladder, 3
• C5: Insights from the autopsy including histopatho- extrahepatic biliary tract
logic results
4 Fundamentals of Surgical Oncology
4.6.1.7 Perioperative Management
One important factor that influences the outcome of
oncological operations is the preoperative nutritional
status of the patient [14]. Tumour cachexia is mostly
accompanied by a poor protein synthesis by the liver
and thus leads to immunosuppression. This status of
impaired healing can then lead to infection and sepsis
in the postoperative period. Immunosuppression on
the one hand, and paracrine or endocrine effects of
stress factors (IL-6, TNF-a, NFkB, etc.), growth fac-
tors (epidermal growth factor [EGF], vascular endothe-
lial growth factor [VEGF], etc.) secreted by the
remaining immune-competent cells on the other hand
support angiogenesis and cell proliferation and thus
lead to stimulation of tumour growth.
Hence, performing surgery with a low rate of com-
plications is also a factor relevant to prognosis (Fig. 4.2).
A similar prognostic factor has been established in
intraoperative blood loss and the amount of blood prod-
ucts given [15].
Apart from the early detection and correction of
co-morbidities (cardiovascular and pulmonary risk
factors, diabetes, renal failure, liver failure, preceding
operations, etc.), the preparation of the tumour patient
for surgery includes the optimization of his nutri-
tional status. This is achieved by substituting calories,
vitamins, trace elements, etc., depending on the extent
of malnourishment. If necessary, total parenteral
Fig. 4.2 Influence For example,
of postoperative complica- anastomotic insufficiency,
tions on tumour growth peritonitis, sepsis
23
nutrition with simultaneous application of oral immu-
nonutrition is given over a period of 5–7 days before
surgery.
4.7 Influence of Surgery
on Metastasization
Especially in colorectal cancer – but also in other
tumours of the gastrointestinal tract – it has been
discovered that the primary tumour possesses the
ability to produce anti-angiogenic substances
(e.g. angiostatin), which inhibit the outgrowth of
micrometastases, for example in the liver, to macro-
metastases. These substances are secreted amongst
others by the primary tumour and reach the liver by
bloodstream. Thus, they act as endocrine sub-
stances. As long as the primary tumour remains in
place micrometastases will form. However, they
will also remain in their micrometastatic state
because the decisive proangiogenic stimulus needed
for a macroscopic outgrowth is suppressed amongst
others by these substances secreted by the primary
tumour [16].
This phenomenon of invisible, asymptomatic
tumour cell spread is called ‘dormant disease’. As soon
as the primary tumour has been surgically removed,
the suppressing anti-angiogenic effect is absent and
Cell proliferation
TNFa, NFkB
IL-6
Immune cells
Tumour
VEGF, growth
EGF, etc.
Angiogenesis
Immunosuppression
24 H. Niess et al.

Fig . 4.3 ‘Tumour dormancy’ –

antiangiogenic effects of the
primary tumour on existing
micrometastases

Micrometastases Macrometastases

The primary tumour secretes antiangiogenic

Discontinuation of
substances (endostatin, angiostatin)
antiangiogenic substances
leads to growth of the
metastases

Primary tumour

Before resection of the primary tumour After resection of the primary tumour

the micrometastases are able to generate an ‘angio-
genic phenotype’. This leads to tumour cell prolifera-
tion and formation of visible, possibly symptomatic
macrometastases (Fig. 4.3).
Multimodal concepts of therapy, e.g. surgery with
subsequent chemotherapy, are necessary to prevent
such developments. Modern anti-angiogenic drugs and
strategies might also be helpful to avoid the outgrowth
of micrometastases.
4.8 Tumour Angiogenesis
One decisive step for tumour growth as well as for
the process of tumour cell spread is the creation of a
sufficient vascular network inside the tumour and its
surrounding tissue. Tumours that are smaller than
1 mm in diameter obtain their nutrients and oxygen by
the process of diffusion. The larger the tumour becomes
the more its growth is dependent on adequate forma-
tion of new vasculature.
The transition of a microscopic tumour, which is
not detectable by the established clinical examination
methods into a macroscopic, clinically detectable mass
is called the ‘angiogenic switch’ [17].
The development of new vasculature in tumours
is partially supported by the production and secre-
tion of pro-angiogenic factors by the tumours itself,
and partially by the production and secretion of
­pro-angiogenic factors in the surrounding tissue.
Ultimately, the formation of new vasculature depends
on the interaction between stimulating and inhibi-
tory angiogenic factors produced by the tumour and
its surrounding tissue. Presumably, the production of
a multitude of pro-angiogenic factors is necessary to
sustain vascular formation.
The initiation of angiogenesis (Fig. 4.4) then
leads to an exponential tumour growth. A very
important pro-angiogenic factor is the ‘vascular
endothelial growth factor’/‘vascular permeability
factor’ (VEGF/VPF). The receptors for the growth
factor VEGF are almost exclusively expressed on
endothelial cells. After binding to their receptors,
VEGF and others exert pro-angiogenic effects in
terms of endothelial cell proliferation, degradation
of extracellular matrix, endothelial cell migration,
tube formation, and finally development of a tumour
vessel system. Furthermore, in particular, VEGF acts
as a survival factor for endothelial cells under
hypoxia stress. A parameter used in many tumour
systems to measure the influence of pro-angiogenic
4 Fundamentals of Surgical Oncology
Tumour angiogenesis
Small localized tumour
< 1 mm3
VEGF, bFGF, IL-8,
HIF-1a, etc.
molecule
Blood vessel
Fig. 4.4 Tumour angiogenesis
factors is the so-called microvessel density. To some
extent, the microvessel density correlates with the
degree and progression of the tumour disease and the
general prognosis.
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Chirurgie. Kurzgefasste Interdisziplinäre Leitlinien 2002. 3.
Auflage (2005)
6. Heald, R.J., Häsband, E.M., Ryall, R.D.: The mesorectum in
rectal cancer surgery – the clue to pelvic recurrence? Br. J.
Surg. 69, 613–616 (1982)
25
Tumour can now grow and spread
7. Enneking, W.F., Spanier, S.S., Malawer, M.M.: The effect of
the anatomic setting on the results of surgical procedures for
soft parts sarcoma of the thigh. Cancer 47, 1005–1022
(1981)
8. Hölzel, D., Engel, J., Schmidt, M., Sauer, H.: Modell
zur primären und sekundären Metastasierung beim
Mammakarzinom und dessen klinische Bedeutung.
Strahlenther. Onkol. 1, 10–23 (2001)
9. Junginger, Th, Hossfeld, D.K., Sauer, R.: Aktualisierter
Konsensus der CAO, AIO und ARO zur adjuvanten Therapie
bei Kolon- und Rektumkarzinom von 1.7.1998. Dtsch.
Ärztebl. 96, 698–700 (1999)
10. Tsioulias, G.J., Wood, ThF, Morton, D.L., Bildnik, A.J.:
Lymphatic mapping and focused analysis of sentinel lymph
nodes upstage gastrointestinal neoplasms. Arch. Surg. 135,
926–932 (2000)
11. Hohenberger, W., Meyer, Th: Grundzüge der chirurgischen
Onkologie. Zbl. Chir. 125, W39 (2000)
12. Budach, W., Hoffmann, W., Bamberg, M.: Stellenwert der
Radiochemotherapie beim Rektumkarzinom. Verdauungsk­
rankh 16, 156–166 (1998)
13. Smith, D.E., Muff, N.S., Shetabi, H.: Combined preop-
erative neoadjuvant radiotherapy and chemotherapy for
anal and rectal cancer. Am. J. Surg. 151(5), 577–580
(1986)
14. Klek, S., Kulig, J., Szczepanik, A.M., Jedrys, J.,
Kolodziejczyk, P.: The clinical value of parenteral immu-
nonutrition in surgical patients. Acta Chir. Belg. 105(2),
175–179 (2005)
15. Takemura, M., Osugi, H., Higashino, M., Takada, N., Lee, S.,
Kinoshita, H.: Effect of substituting allogenic blood transfusion
with autologous blood transfusion on outcomes after radical
oesophagectomy for cancer. Ann. Thorac. Cardiovasc. Surg.
11(5), 293–300 (2005)
26 H. Niess et al.

16. Hahnfeldt, P., Panigrahy, D., Folkman, J., Hlatky, L.: Tumor 17. Udagawa, T., Fernandez, A., Achilles, E.G., Folkman, J.,
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lar dormancy. Cancer Res. 59(19), 4770–4775 (1999) of tumor dormancy. FASEB J. 16(11), 1361–1370 (2002)
 Palliative Surgery
5
Matthias W. Wichmann

5.1 Introduction not be available in the patient’s hometown, and there-

fore would require transfer away from the patient’s
family. This is an important factor for most patients,
Palliative surgery is an important part of surgical
and must be discussed prior to surgical intervention. It
­decision-making and should be carried out in agreement
is also important to consider that operative morbidity
with a treatment decision based on the individual
is common (up to 40%) after palliative surgery and that
patient’s decision for his or her end-of-life treatment.
a number of patients (10%) require additional surgery
The surgical team must try to identify the treatment
for the morbidity.
goals together with the patient and the patient’s family –
these may vary in patients with identical diagnosis and
prognosis and it is important that the surgeon does not
base the decision on what appears possible, but on what Palliative care is a team approach aiming at best
the patient has expressed as primary palliative treat- ­possible symptom control during end-of-life treat-
ment goals. It is also important to note and to explain, ment and focusing only on the patient’s/patient’s
that palliative treatment does not aim to prolong life family decision regarding the priorities of treat-
but to provide best possible symptom control (pain, ment goals.
nausea and vomiting, intestinal obstruction, ­dyspnoea).
Obviously, palliative (surgical) care also does not aim
to actively reduce the patient’s life expectancy.
In the author’s view, palliative surgical care should 5.2 Surgical Palliative Procedures
be a team decision with the patient and his/her family
in the center and a number of team members including
Malignant obstruction of the trachea or main bronchi:
(palliative care) nurses and allied health, social workers,
These lesions are usually suitable for bronchoscopic
psychologist, pain service, surgeons and palliative care
intervention including stent insertion, argon plasma
physicians.
beam coagulation, or laser ablation (see Chap. 6).
In the rural setting, not all of these important con-
Significant bleeding which cannot be controlled via
tributors to palliative care may be available, which
bronchoscopy may require palliative resection of the
makes the role of the team leader (surgeon, if admitted
affected lobe.
under his/her care) even more important. For the rural
Esophageal cancer: If a malignancy of the esopha-
surgeon, it is also important to consider that extensive
gus is not resectable due to advanced disease, most
surgery may require High Dependency Unit (HDU) or
patients will receive palliative radio-chemotherapy
even Intensive Care Unit (ICU) admission which may
under the care of medical and radiation oncology. In
this setting surgical intervention may become necessary
M.W. Wichmann in terms of endoscopic stenting or endoscopic place-
Department of General Surgery, Mount Gambier General ment of a feeding gastrostomy (PEG) (see Chap. 7).
Hospital and Flinders University Rural Medical School,
Palliative resection of an advanced esophageal cancer is
276-300 Wehl Street North, Mount Gambier, SA 5290,
Australia usually not recommended due to the significant mor-
e-mail: matthias.wichmann@health.sa.gov.au bidity and the range of endoscopic treatment options.
M.W. Wichmann et al. (eds.), Rural Surgery, 27
DOI: 10.1007/978-3-540-78680-1_5, © Springer-Verlag Berlin Heidelberg 2011
28
Gastric cancer: If the patient is fit for surgery,
p­ alliative gastrectomy, or partial gastrectomy should
always be considered first since these procedures offer
best palliation and symptom control compared to
endoscopic treatment or bypass surgery.
If a resection is not possible, a gastro-jejunostomy
(Roux-en-Y) as a palliative bypass should be con-
structed for malignant gastric outlet obstruction. Since
the patient usually is less mobile and spends a lot of
time in bed, an anastomosis at the posterior wall of
the stomach should be preferred unless the underlying
malignancy precludes sufficient mobilization of the
stomach. Passage of a nasogastric tube through the
anastomosis may improve the symptoms of post-
operative paresis of the upper gastrointestinal tract.
At the time of surgery, a feeding jejunostomy should
also be considered. If a bypass cannot be constructed,
a feeding jejunostomy plus a venting PEG are the
author’s treatment of choice for malignant gastric
­outlet obstruction.
Pancreatic cancer: Only 30% of all pancreatic
­cancers are resectable at the time of diagnosis. Surgical
palliation therefore is an important part of pancreatic
surgery. The decision for palliation very often must be
made during explorative surgery when a pancreatic
cancer which was considered resectable is shown to be
non-resectable. The life expectancy in these patients is
short (approximately 6 months) and surgical morbidity
must be low. Biliary bypass surgery can be done using
the gall bladder (cholecysto-jejunostomy) provided the
gall bladder has flow into the common bile duct (can
be probed via the cystic duct). If access to the common
duct is good, a choledocho-jejunostomy or hepatico-
jejunostomy should be preferred. After removal of the
gall bladder a cholangiogram can be done prior to con-
struction of a side-to-side anastomosis between a
Roux-en-Y jejunal limb and the common hepatic duct
or the common bile duct. Duodenal obstruction may
not be present at the time of initial surgery but fre-
quently develops prior to the patient’s death from pan-
creatic cancer. We, therefore, suggest to also construct
a side-to-side gastro-jejunostomy within the same sur-
gery to avoid a repeat intervention at a later point in
time when duodenal obstruction has developed.
If preoperative staging indicates a non-resectable
disease, palliative treatment may also be possible using
endoscopic stents (metallic stents) which are intro-
duced via ERCP (see Chap. 9).
Gall bladder/bile duct cancer: Surgical pallia-
tion of non-resectable disease can be done using a
M.W. Wichmann
Roux-en-Y jejunal limb bypass or endoscopic stent-
ing (usually metallic stents). There appears to be no
survival advantages of either of the two approaches.
In patients where endoscopic stent placement is not
possible due to previous surgery or due to tumor
growth, a percutaneous drainage is possible and
even a percutaneous stent insertion can be attempted.
We try to avoid ongoing percutaneous drainage
wherever possible due to significant pain and dis-
comfort resulting from a drain in the liver.
Small bowel cancer: Non-resectable small bowel
cancer can usually be treated using entero-enteric
bypasses with side-to-side anastomosis between non-
affected parts of the small bowel. We prefer a two-layer
running suture anastomosis with absorbable sutures.
Colon cancer: Patients suffering from non-resectable
large bowel cancer usually present with bowel obstruc-
tion. Non-resectability may result from the extent of
tumor disease or the patient’s general health. Endoscopic
stenting of the tumor stenosis has been shown to effec-
tively treat the bowel obstruction and can be used as a
bridging procedure prior to definite resection (after ade-
quate resuscitation of the patient) or as a sole treatment
if the patient is not considered/suitable for additional
resection of the cancer. Stenting, however, does require
a lumen which can be passed with the guide wire. If no
rest-lumen can be identified, endoscopic stenting is not
an option and palliative stoma (loop-colostomy) forma-
tion or bypass construction may be the only treatment
options.
Rectal cancer: Low rectal cancer may not be suit-
able for endoscopic stenting in view of the possibility
to cause fecal incontinence and severe perineal pain.
This has to be decided based on the exact position of
the tumor and the length of the required stent. Good
results can be obtained with stents within the recto-
sigmoid junction, although recent reports also suggest
the option of pain-free stenting within 5 cm from anal
verge. Obstructing lesions in the mid-rectum and lower
third of the rectum usually require formation of a loop-
colostomy for adequate palliation. Uncontrolled bleed-
ing from rectal cancers can very often be managed
endoscopically (injection, argon beam, laser, stent), or
may require palliative resection even if complete clear-
ance of the tumor cannot be achieved.
Malignant ureteric obstruction: Retrograde stent-
ing of the ureter is the treatment of choice, but may not
be possible in all patients. If the retrograde approach
fails, a percutaneous nephrostomy should be performed
which may allow for antegrade stent placement.
5 Palliative Surgery
In view of the significant number of patients
treated for non-resectable upper GI tract or large
bowel cancer, the rural surgeon should be familiar
with the technique of endoscopic stent applica-
tion and a selection of endoscopic stents should
be available in a rural center with an active endos-
copy unit.
5.3 Summary
Palliative surgery is a very demanding part of our work
and should ideally be part of a team approach to the
patient’s end-of-life treatment. The patient’s wishes
regarding this part of his or her life must guide any
decision made by the treating team. With regard to this,
it is of utmost importance to be aware of the fact that
technological advancements have provided the means
29
to sustain life and provide care regardless of whether
the treatment is appropriate and compassionate given
the condition of the patient. This makes palliative sur-
gery a very challenging and interesting field of surgical
decision-making.
Recommended Reading
Cady, B., Miner, T., Morgentaler, A.: Part 2: Surgical palliation
of advanced illness: what’s new, what’s helpful. J. Am. Coll.
Surg. 200, 281–290 (2005)
Coustasse, A., Quiroz, T., Lurie, S.G.: To the bitter end: dispari-
ties in end-of-life care. J. Hosp. Mark. Public Relations 18,
167–185 (2008)
Dunn, G.P.: Palliative surgery. In: Walsh, D. (ed.) Palliative
Medicine, pp. 535–540. Elsevier Saunders, Philadelphia
(2009)
Tilney, H.S., Lovegrove, R.E., Purkayastha, S., et al.: Comparison
of colonic stenting and open surgery for malignant large
bowel obstruction. Surg. Endosc. 21, 225–233 (2007)
 Fiber Optic Endoscopy: Bronchoscopy
6
Matthias W. Wichmann and Fritz W. Spelsberg

6.1 Introduction

Practical knowledge and experience with bronchoscopy

are of relevance not only for interventions within the tra-
chea and the lung, but also for interventions within inten-
sive care. With regard to this, bronchoscopy is not only a
diagnostic but also a therapeutic tool. The anatomy of 1
the bronchial system is illustrated in Fig. 6.1.

6.2 Instruments

Flexible bronchoscopy, preferably with a video-­

bronchoscope, is the standard procedure with an instru- 2
ment measuring approximately 5–6 mm in diameter. At 4 3
7
the tip, the instrument can be flexed in two directions 8
and it usually has one working channel (2.8–3.2 mm).
5 9
Rigid bronchoscopy has few indications only, e.g.,
massive bleeding, foreign body removal. 6

M.W. Wichmann (*)
Department of General Surgery, Mount Gambier General
Hospital and Flinders University Rural Medical School,
276-300 Wehl Street North, Mount Gambier,
SA 5290, Australia
e-mail: matthias.wichmann@health.sa.gov.au
F.W. Spelsberg
Department of Surgery,
University of Munich – Campus Grosshadern,
Marchioninistr. 15, 81377 Munich, Germany
1 - trachea
2 - carina
3 - right main bronchus
4 - right superior lobe bronchus
5 - right middle lobe bronchus
6 - right inferior lobe bronchus
7 - left main bronchus
8 - left superior lobe bronchus
9 - left inferior lobe bronchus
Fig. 6.1 Diagram of the tracheo-bronchial system for documen-
tation of bronchoscopic findings

M.W. Wichmann et al. (eds.), Rural Surgery, 31

DOI: 10.1007/978-3-540-78680-1_6, © Springer-Verlag Berlin Heidelberg 2011
32
6.3 Patient Preparation
Prior to the procedure, elective patients should be fasted
for at least 6 h and anticoagulants should be stopped as
indicated (7 days for aspirin, clopidogrel, warfarin,
24 h for low-molecular heparin). Atropine (0.5 mg sc)
can be given as pre-medication, and following local
anesthesia of the nasopharynx (spray, inhalation), i.v.
sedation (midazolam 3–5 mg, propofol 2 mg/kg bw)
should be given. Intraoperative monitoring of oxygen
saturation and liberal application of oxygen with a
mask are mandatory.
The bronchoscope can be introduced through the
nose (or mouth) under vision. In ventilated patients,
the bronchoscope is advanced through the endotra-
cheal tube or laryngeal mask. Within the trachea, addi-
tional topical local anesthesia should be applied with a
pump spray via the working channel.
6.4 Indications
Common indications for bronchoscopy are summa-
rized in Table 6.1.
6.5 Diagnosis and Treatment
of Haemoptysis
Any form of haemoptysis must be investigated with a
bronchoscope. Preoperative investigations have to dif-
ferentiate true haemoptysis from pseudo-­haemoptysis,
which is caused by bleeding in the nasopharynx or the
upper gastrointestinal tract. True haemoptysis usually
Table 6.1 Indications for bronchoscopy
Preoperative Intraoperative
Hoarseness Intubation
Persistent cough Position control of
ventilation tube
Dyspnea, stridor Control of tracheal
anastomosis
Haemoptysis
Histology needed
Esophageal cancer
Tracheal rupture
M.W. Wichmann and F.W. Spelsberg
has bright red foamy blood and the patient suffers
from significant dyspnea and coughing. Mortality of
this condition is as high as 80%, depending on the
underlying cause. Table 6.2 summarizes the most
common causes of haemoptysis.
Around 90% of pulmonary bleedings originate
from the bronchial arteries and 5% come from the
pulmonary vessels, which means that the systemic
arterial blood pressure is relevant for the severity
of the bleeding.
Patients with haemoptysis are initially managed
with oxygen administration, chest elevation or posi-
tioning on the affected body side (if known). Blood,
circulating volume, and coagulation factors should be
substituted as needed. Patients who are not compro-
mised with regard to blood pressure and oxygenation
should first have a computed tomography (or chest
X-ray if not available). Patients with compromised
blood pressure despite substitution should be intu-
bated early, and then require urgent bronchoscopy.
Cave: Patients with pulmonary bleeding are
­primarily endangered due to hypoxia and not due
to blood loss.
In patients with massive bleeding, a rigid bron-
choscopy may become necessary in order to directly
occlude the bleeding bronchus. Following intuba-
tion, the bleeding source or at least the side of bleed-
ing has to be established to allow for separate
ventilation of the non-affected lung (intubation of
Postoperative Intervention
Atelectasis Aspiration
Anastomotic leakage Foreign body
Bronchial stump leakage Stenosis
Anastomotic stenosis Tracheo-malacia
Follow-up Lavage
Fistula
Palliation
6 Fiber Optic Endoscopy: Bronchoscopy 33

Table 6.2 Causes for haemoptysis

Neoplastic Infectious Cardiovascular Traumatic Others
Cancer Tuberculosis Embolus Iatrogenic Bronchiectasis
Metastasis Pneumonia Cardiac failure Trauma Endometriosis
Carcinoid Abscess Aneurysm Sarcoidosis
Fungal Wegener’s Cystic fibrosis
granulomatosis
Behcet’s syndrome
Systemic lupus
erythematosus

the main bronchus or usage of a double lumen tube).
After securing the ventilation, a balloon can be used
to selectively occlude the bleeding bronchus if this
can be identified.
Bronchoscopy also allows for ablation of malignant
lesions and associated bleeding complications using
laser therapy, argon-plasma coagulation, diathermy and
cryosurgery. Furthermore, cold water and topical agents
for vasoconstriction (adrenalin) can be used for bleeding
control. In specialized centers, radiological emboliza-
tion of the bleeding vessel may be possible using super-
selective catheters. If these interventions are not available
or not successful, emergency surgery may be necessary.
6.6 Bronchoscopy-Assisted Intubation
is placed into the trachea to confirm correct position-
ing of the guide wire following puncture of the tra-
chea between the second and third cartilage and
subsequent dilatation of the opening to fit a tracheal
ventilation tube.
It is important to note that percutaneous puncture
tracheostomy carries significant risks of laceration
of surrounding tissues and intraoperative complica-
tions and should not be performed by a novice with-
out an assistant experienced in percutaneous puncture
tracheostomy.
6.8 Bronchoscopic Treatment
of Atelectasis

Due to pain and inadequate mobilization, hypoventila-

Conventional intubation may be impossible due to a
tion of one or several segments of the lung (atelectasis)
number of causes (i.e., immobile cervical spine due
can be observed after thoracic as well as abdominal sur-
to inflammatory processes/autoimmune disease, frac-
gery. This condition may require bronchoscopic inter-
tures of the cervical spine, enlarged thyroid, ENT-
vention if patient positioning and physiotherapy do not
cancer) and bronchoscopic assistance may be
resolve the problem. Bronchoscopy is much less trau-
necessary. Usually, the ventilation tube is passed over
matic than blind catheter aspiration of the lung, and
the bronchoscope and this is then passed through the
allows for selective aspiration of the mucous as well as
nose or the mouth into the trachea being subsequently
topical application of a mucolytic agent (acetylcysteine).
used as a “guide-wire” for the passage of the ventila-
tion tube. The correct position of the tube can then be
visualized prior to withdrawal of the bronchoscope.
6.9 Treatment of Tracheo-Bronchial
Stenosis
6.7 Percutaneous Puncture
Tracheostomy Stenosed segments of the tracheo-bronchial system are
a dangerous condition and cause significant discomfort
Patient requiring long-term ventilation may require a for the patient due to dyspnea, retention pneumonia,
tracheostomy, which can be constructed using a percu- bleeding, and coughing. Malignant, non-operable
taneous dilatation tracheostomy kit. The bronchoscope lesions require endoluminal therapy using laser or
34
argon-plasma coagulation as well as stenting or after
loading therapy since systemic chemotherapy and radi-
ation therapy usually do not have a sufficient local
effect on the stenosis within the tracheo-bronchial sys-
tem. Bronchoscopic re-canalization of the respiratory
tract can be a life-saving palliative intervention in these
situations. Stents may also be useful for the treatment
of tracheo-malacia and for the closure of fistulas
between the trachea and the esophagus (malignant or
postoperative). A number of various stents are avail-
able for these indications.
6.10 Complications
During bronchoscopy, hypoxia and hypercapnia can
develop, especially in patients with compromised lung
function. Furthermore, laryngeal or bronchial spasms
and arrhythmias can be observed due to the interven-
tion. Laceration of the trachea and/or bronchi can
cause bleeding or perforation of these structures.
6.11 Rigid Laryngoscopy
This procedure allows direct assessment of the
­oropharynx (base of tongue, vallecula, epiglottis),
pharynx proper, larynx (vocal cords), and proximal
M.W. Wichmann and F.W. Spelsberg
trachea. The endoscope is inserted into the back of the
mouth and delivers a magnified view of the laryngeal
structures using an angled lens system. The procedure
usually requires intubation and allows for detailed
vision, biopsy and manipulation of all structures in the
pharynx and larynx. Rigid laryngoscopy may be espe-
cially useful for removal of large foreign bodies, bleed-
ing control and can also help to better visualize
pathology within the upper third of the esophagus (i.e.,
endoscopic pouch repair).
Rigid laryngoscopy carries a higher risk of soft tis-
sue laceration, vocal cord edema and bleeding than
flexible laryngoscopy and should not be carried out
without proper training.
Recommended Reading
Freitag, L.: Interventional endoscopic treatment. Lung Cancer
45, S235–S238 (2004)
Rowe, L.D.: Otolaryngology – head and neck surgery. In:
Doherty, G.M. (ed.) Current Surgical Diagnosis and
Treatment, pp. 967–973. McGraw-Hill, New York (2006)
 Fiber Optic Endoscopy: Gastroscopy
Matthias W. Wichmann and Fritz W. Spelsberg
7.1 Introduction
Flexible endoscopy is a significant part of the everyday
workload of most general surgeons. The ongoing
development of this technology has contributed to
­significant reduction of access trauma in most surgical
specialties as well as in general surgery. Flexible
endoscopy is part of preoperative assessment and treat-
ment planning; it allows for intraoperative evaluation
of the surgical site (i.e., anastomosis after resection,
width of esophagus after fundoplication) and is part of
the management of post-operative complications (i.e.,
stenting of fistulas, dilatation of stenoses, washout of
anastomotic leakage). The endoscopic treatment of
early stages of gastro-­intestinal cancers has been estab-
lished, as well as the useful application of flexible
endoscopy during so-called rendezvous procedures
with minimal invasive surgery (i.e., resection of gas-
tro-intestinal stroma tumors). Moreover, interventional
endoscopy plays a major role in the palliative treat-
ment of a number of advanced tumors within the
­gastro-intestinal tract and allows for ­maintenance of
normal food passage and control of local complica-
tions such as blood loss or fistula formation.
M.W. Wichmann (*)
Department of General Surgery, Mount Gambier General
Hospital and Flinders University Rural Medical School,
276-300 Wehl Street North, Mount Gambier,
SA 5290, Australia
e-mail: matthias.wichmann@health.sa.gov.au
F.W. Spelsberg
Department of Surgery,
University of Munich – Campus Grosshadern,
Marchioninistr. 15, 81377 Munich, Germany
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_7, © Springer-Verlag Berlin Heidelberg 2011
7
7.2 Upper Gastro-Intestinal Tract
Endoscopy/Gastroscopy
7.2.1 Indications
Flexible endoscopy of the upper gastro-intestinal
tract is indicated when a known or suspected disease
of the esophagus, stomach, or duodenum requires
further investigation. Common indications for endos-
copy of the upper gastro-intestinal tract are listed in
Table 7.1.
7.2.2 Patient Preparation and
Technique of Examination
The patient needs to be informed about the risks and
indication for the endoscopy and should be fasted for
a minimum of 6 h. Anticoagulation therapy does not
need to be stopped unless a more invasive intervention
than biopsy is planned. The procedure is carried out
with the patient lying on the left side. Usually, local
anesthetics can be applied with a spray into the larynx
(Xylocaine spray). Local anesthesia should not be
applied in a not-fasted emergency patient since it
increases the risk of aspiration. If the patient is sedated
(Midazolam 3–5 mg i.v. or Disoprivan 50–70 mg
bolus + maintenance boli of 10–30 mg i.v.), pulse-
oxymetry is mandatory for monitoring. The use of
Disoprivan also requires the presence of a second
­physician during the investigation. The need of seda-
tion for upper GI endoscopy can be discussed with
the patient prior to surgery and should consider the
35
36
Table 7.1 Indications for upper gastro-intestinal endoscopy
Preoperative Intraoperative
Dysphagia Localization (tumor, bleeding site)
Reflux disease Inspection of anastomosis/suture
Bleeding Rendezvous
Suspected cancer
Histology needed
Staging
expected pathology, length of intervention, experience
of the investigator, as well as the patient with similar
previous interventions and the local infrastructure.
The patient needs to have a bite guard introduced
into the mouth to avoid damage of the gastroscope dur-
ing the investigation. The endoscope is then advanced
under vision, which allows for a detailed inspection of
the esophagus, cardia (from above and in inversion),
and stomach as well as parts I (bulbus duodeni) and II
(pars descendens duodeni) of the duodenum. Biopsy
forceps are used to collect specimens under vision
from the upper GI tract for histopathological evalua-
tion as well as Helicobacter pylori testing.
7.2.3 Bleeding Control Within the Upper
Gastro-Intestinal Tract
Endoscopic control of bleeding lesions within the upper
GI tract is successful in more than 90% of all patients.
A number of treatment options have been described,
and their availability may vary in different locations.
Most common causes of bleeding within the upper GI
tract are ulcers of the stomach or the duodenum.
Endoscopic treatment of these bleeding lesions is indi-
cated for an actively bleeding ulceration (Forrest I),
ulceration with a visible vessel (Forrest IIa) and ulcer-
ation with an adhering blood clot (Forrest IIb) (see
Table 7.2 for the Forrest classification). With ongoing
treatment of hemorrhagic shock, interventional endos-
copy is the most important diagnostic and possibly
therapeutic intervention and needs to be done as early
as possible. To protect the patient from aspiration, an
early intubation must be considered.
Actively bleeding ulcers are treated with irrigation
using ice-cold water and identification of the bleeding
lesion. Subsequently, the ulcer is injected with a mixture
of adrenaline (1 mg; 1:1,000) and normal saline (10 ml).
M.W. Wichmann and F.W. Spelsberg
Post-operative Intervention
Stenosis Palliation
Anastomotic leakage Dilatation
Postop. hemorrhage Polypectomy
Ischemia Feeding tube/PEG
Ulcer, gastritis Foreign body removal
Follow-up
If available, fibrin glue depots should be injected into the
base of the ulcer immediately adjacent to the bleed-
ing vessel. If a vessel can be clearly identified, clip-
application should be considered as well. The risk of
recurrent bleeding is highest (30%) during the first 72 h
after treatment, and can be reduced to 5–15% with the
endoscopic intervention and additional medical treat-
ment (proton pump inhibitor therapy 40 mg i.v. three
times/day or as continuous infusion). The usefulness of
a routine control endoscopy at 24 h after the initial treat-
ment is under constant debate. The authors are not in
favor of this and prefer on-demand treatment.
Approximately 10% of upper gastro-intestinal tract
bleedings come from esophageal varices. The prognosis
of this condition mainly depends on successful bleeding
control. Endoscopic banding of esophageal varices is
standard of care for this condition. Varicose veins of the
gastric fundus should be injected with a mixture of his-
toacryl and lipiodol. Eighty percent to 90% of all bleed-
ing variceses can be treated successfully with endoscopy.
Failed treatment requires positioning of a Sengstaken-
Blakemore or of a Linton-Nachlass tube into the esoph-
agus. This tube has to be decompressed every 6–12 h to
avoid pressure ulcers within the esophagus. Medical
treatment can be done with Terlipressin or Somatostatin
in cases of failed endoscopy, or in addition to endo-
scopic treatment.
Table 7.2 Forrest classification of upper GI bleeding
I: Active bleeding
• Ia: Spurting blood
• Ib: Oozing blood
II: Signs of previous bleeding
• IIa: Visible, non-bleeding vessel
• IIb: Blood clot in ulcer
• IIc: Blood-covered ulcer
III: Ulcer without signs of previous bleeding
7 Fiber Optic Endoscopy: Gastroscopy
Mallory–Weiss tears usually do not require endo-
scopic treatment and the bleeding stops without
­intervention. Dieulafoy lesions and gastric cancers are
the underlying cause for upper GI bleedings in less than
5%. Diffuse bleeding may be difficult to treat and usage
of Argon beam coagulation can be helpful (if available),
otherwise cold water instillation into the stomach can
also help to reduce the amount of blood loss. Figure 7.1
shows the endoscopic appearance of various lesions
causing upper gastrointestinal bleedings.
7.3 Percutaneous Endoscopic
Gastrostomy (PEG)
Endoscopic placement of an enteral feeding tube
through the abdominal wall has become standard of
care for a number of conditions causing dysphagia
(i.e., neurological disorders, malignant disease). Two
different techniques have been described:
• Puncture of the stomach under endoscopic view,
introduction of a thread through the needle and
pull-through of the thread with the gastroscope into
the patient’s mouth, joining of the thread with the
feeding tube and pull-through of the thread with the
feeding tube into the stomach, an anvil places the
Fig. 7.1 Endoscopic appearance of lesion causing upper gastro-
intestinal bleeding. (a) Chronic ulcer of the anterior wall of the
duodenal cap; (b) severe hemorrhagic gastritis without erosions;
(c) bleeding from the apex of a stromal tumor (leiomyoma) in
37
stomach against the abdominal wall and avoids
­dislocation of the tube
• Direct puncture of the stomach under vision, place-
ment of two holding stitches to fix the stomach to
the abdominal wall, placement of a feeding catheter
into the stomach
The most commonly used procedure is the pull-through
technique with a thread and transoral introduction of
the feeding tube.
7.4 Endoscopic Treatment of
Anastomotic Leakage or
Stenosis
Following esophageal resection up to 30% of the
patients can suffer from anastomotic leakage. Endoscopy
can be useful for diagnosis and treatment (debride-
ment, fibrin glue application, stent insertion) of this
dangerous condition.
Endoscopic evaluation done by an experienced
investigator is safe at any point in time after upper
GI surgery, without resulting in an increased risk
of perforation or anastomotic leakage
the fundus of the stomach; (d) close-up view of a bleeding
Dieulafoy lesion in the fundus of the stomach (Pictures courtesy
of Professor Ian C. Roberts-Thomson, Queen Elizabeth Hospital,
Adelaide)
38 M.W. Wichmann and F.W. Spelsberg

Fig. 7.1 (continued)

Stenosis of the passage through the upper GI tract
can be treated under vision with balloon dilatation
(Through The Scope, TTS) or using Guillard-Savary-
Bougies with a guide wire placed through the working
channel of the endoscope. A very short stenosed seg-
ment can also be treated with radial incisions (Truong
technique). Usually any form of treatment requires more
than one intervention to achieve long-lasting success.
7.4.1 Palliative Tumor Treatment
Inoperable stenosing cancers of the esophagus or cardia
and the mediastinum, as well as recurrent disease after
tumor resections within the upper GI tract, can be treated
with a variety of stents (Figs. 7.2a, b). In some cases an
anti-reflux stent can be applied to avoid reflux of gastric
contents (Fig. 7.3a–c).

a b

Fig. 7.2 Inoperable

esophageal cancer (a) prior to
stent placement; (b) after
stent placement of a partially
covered metal stent
7 Fiber Optic Endoscopy: Gastroscopy 39

a b c

Fig. 7.3 (a–c) Release of a self-expanding metal stent under image intensifier control

Recommended Reading

Hung, W.K., Li, V.K., Chung, C.K., et al.: Randomized trial

comparing pantoprazole infusion, bolus and no treatment on
gastric pH and recurrent bleeding in peptic ulcers. ANZ J.
Surg. 77, 677–681 (2007)
 Fiber Optic Endoscopy: Colonoscopy
8
Matthias W. Wichmann and Fritz W. Spelsberg

8.1 Introduction orifice of the appendix should, however, be clearly visu-

alized and documented with a picture (Figs. 8.1 and 8.2).
Withdrawal time after intubation of the caecum should
Flexible endoscopy of the large bowel has significantly
be at least 7 min, with double passage of each colonic
improved diagnosis and preoperative evaluation as well
as post-operative care and palliation for almost all dis-
eases of the large bowel and rectum. Colonoscopy,
therefore, is part of pre-operative assessment and treat-
ment planning, allows for intraoperative evaluation of
the surgical site (i.e., anastomosis after resection, local-
ization of pathology if not identified preoperatively)
and is part of the management of post-operative com-
plications (i.e., dilatation of stenoses, washout of anas-
tomotic leakage). The endoscopic treatment of advanced
polyps or early colon cancers (endoscopic mucosec-
tomy) has been established, as well as the useful appli-
cation of flexible endoscopy during so-called rendezvous
procedures with minimal invasive surgery (i.e., laparo-
scopic resection of advanced polyps). Moreover, inter-
ventional endoscopy plays a major role in the palliative
treatment of a number of advanced non-resectable Fig. 8.1 Endoscopic view of ileocaecal valve and appendiceal
orifice
tumors within the large bowel and allows for mainte-
nance of normal food passage and control of local com-
plications such as blood loss or fistula formation.
As part of complete colonoscopy, an attempt should
be made to also visualize the terminal ileum, although
recent studies do not indicate that routine intubation of
the ileum during surveillance colonoscopy offers any
clinical advantage. The ileocaecal valve, as well as the

M.W. Wichmann (*)

Department of General Surgery, Mount Gambier General
Hospital and Flinders University Rural Medical School,
276-300 Wehl Street North, Mount Gambier,
SA 5290, Australia
e-mail: matthias.wichmann@health.sa.gov.au
F.W. Spelsberg
Department of Surgery,University of Munich – Campus
Grosshadern, Marchioninistr. 15, 81377 Munich, Germany Fig. 8.2 Endoscopic view of colon polyp

M.W. Wichmann et al. (eds.), Rural Surgery, 41

DOI: 10.1007/978-3-540-78680-1_8, © Springer-Verlag Berlin Heidelberg 2011
42
Table 8.1 Indications for colonoscopy
Preoperative Intraoperative
Lower GI tract bleeding Localization of lesion
Search for and localization of Control of suture
tumor
Inflammatory bowel disease Rendezvous
Histology needed
Unclear diarrhea
Surveillance (>50 years)
flexure during withdrawal of the colonoscope. Inversion
in the ampulla of the rectum should also be documented
with a picture, and allows for an orientation with regard to
pathology of the anal canal. To complete the investigation
of the anal canal, a proctologic examination (inspection,
digital palpation, rigid proctoscopy) should be added.
Indications for colonoscopy are listed in Table 8.1.
To clearly identify the exact localization of a
pathologic finding within the rectum and distal
sigmoid colon, a rigid rectoscopy is required.
This procedure allows to exactly measure the dis-
tance from the dentate line, which is of relevance
for preoperative planning, as well as discussion of
neo-adjuvant treatment for rectal cancer (below
the peritoneal flexion).
Virtual colonoscopy (computed tomography colo­
no­scopy) is an attractive alternative for flexible
colonoscopy in case of a failed or incomplete proce-
dure. It, however, also requires a bowel preparation
and significant air insufflation into the large bowel,
and does not allow for a biopsy or polypectomy.
8.2 Patient Preparation and Technique
of Examination
A thorough bowel preparation is mandatory for ade-
quate visualization of the entire large bowel. A number
of various protocols have been established for this, and
all of them require the patient to also follow a diet for at
least 24 h prior to the investigation (an example for
M.W. Wichmann and F.W. Spelsberg
Post-operative Intervention
Leakage Polypectomy
Stenosis Dilatation
Hemorrhage Bleeding control
Decompression of Palliation
pseudo-obstruction (Ogilvie
syndrome)
Ischemia Invagination
Follow-up Decompression
Table 8.2 Regimen for bowel preparation (Mount Gambier
General Hospital)
Laxative combination
• GlycoPrep-C® (70 g) sachet: polyethylene glycol
• 2 PicoPrep® (15.5 g) sachets: Na picosulfate
Two days before examination
• Stop eating brown bread, cereals, vegetables, and fruits
• Do not eat anything with seeds in it
• Do not eat any yellow cheese
One day before examination
• Drink at least one glass of clear fluid each hour
• No solid foods and no milk products allowed, drink
approved clear liquids (see below) only
• Laxatives
– First dose: 1 pm – add the entire contents of one sachet
of PicoPrep in a glass of warm water and stir until
dissolved; drink mixture slowly but completely
– Second dose: 4 pm – make up sachet of GlykoPrep-C
(70 g) with 1 L of water; drink the fluid within
approximately 1 h
– Third dose: 7 pm – add the entire contents of one
sachet of PicoPrep in a glass of warm water and stir
until dissolved; drink mixture slowly but completely
Approved clear liquids (may not contain red or purple
colorings): water, clear bullion, apple juice, grape juice,
plain jelly, black tea/coffee, clear sports drinks, carbonated
beverages, clear fruit cordials
bowel preparation is listed in Table 8.2). The major
advantage of polyethylene-glycol-based iso-osmolar
solutions (e.g., Golytely®, Klean-Prep®) when compared
to saline solutions (Fleet®) is the option to also use them
for patients with impaired cardiac or renal function.
8 Fiber Optic Endoscopy: Colonoscopy
The procedure should be done using a fully flexible
video-colonoscope with forward vision and a maxi-
mum viewing angle of 140°. Most colonoscopes have
one to two working channels and are approximately
13 mm in diameter. The working length is 130 cm and
the image gives a 1:20 enlargement of the visualized
bowel. The use of so-called video-zoom colonoscopy
with special lens systems allows for 1:100 enlarge-
ment, and the practicability of this is still under inves-
tigation. The use of special dyes and filters to visualize
early neoplastic changes of the mucosa is also being
investigated. The large-scale use of these techniques
will most likely be limited due to the related costs and
the additional time required for these procedures.
Cave: In high-risk patients (cardiac valve replace-
ment, previous infectious endocarditis, leaking ­cardiac
valves), antibiotic prophylaxis should be given to pre-
vent bacterial endocarditis after the colonoscopy.
Sedation of the patient (midazolal 3–5 mg i.v. and/or
disoprivan 50–70 mg i.v. + maintenance boli 10–30 mg
i.v.) with mandatory monitoring using pulse-oxymetry
may be necessary. The investigation is started with the
patient in left lateral position and the knees bent. During
difficult investigations a repositioning (on the back or
even on the front) of the patient or manual fixation of the
bowel (pressure from the left lateral abdominal wall
toward the center of the abdomen) by an assistant may
be necessary. As mentioned above, the colonoscopy
should clearly visualize the caecum and in specific cases
(inflammatory bowel disease) the intubation of the ter-
minal ileum is necessary. Figure 8.1 shows the ileocae-
cal valve as well as the appendiceal orifice as indicators
of a complete colonoscopy. The learning curve for ade-
quate completion of diagnostic colonoscopy has been
established to be in the area of 150 procedures.
8.3 Polypectomy
8.3.1 Risk of Malignancy
Adenomatous polyps of the large bowel are ­neoplasias
which carry the potential to progress to a ­malignant
­disease (adenoma–carcinoma sequence). ­Approxi­mately
43
5% of large bowel polyps are thought to progress to
large bowel cancers. High-grade dysplasia within a
polyp is a risk factor for the development of colorec-
tal cancer. Patient age, number, and size of the polyps
as well as the fraction of villous adenomas are relevant
for the risk of malignancy. Approximately 90% of all
polyps in the large bowel are either tubular or tubulovil-
lous in nature, and only 10% are pure villous adenomas.
The risk of malignancy increases from 4% in tubulovil-
lous adenomas <1 cm to 7% in adenomas measuring
1–2 cm and 46% in lesions larger than 2 cm. If a polyp is
detected via rectoscopy, an additional colonoscopy must
be carried out since additional polypoid lesions can be
found in up to 40% of these patients.
8.3.2 Procedure
Endoscopic excision of a large polyp (>1 cm)
(Fig. 8.2) requires an adequate coagulation sys-
tem (INR 1.4, PTT < 2× normal value, platelet
count > 50,000/mm3), optimal bowel preparation, and
risk-adjusted indication (risk of perforation and pos-
sible need for emergency surgery vs. elective bowel
resection). Removal of the polyp is done using a dia-
thermy snare, with the option of prior injection of
adrenaline (1 mg, 1:1,000) mixed with normal saline
(10 ml) to prevent bleeding, and to float the polyp
off the mucosa (especially for flat and broad-based
lesions). After polypectomy, clips may be applied
for bleeding control and to close the mucosa to pre-
vent secondary perforation of the bowel wall. Polyps
smaller than 5 mm should be removed using a biopsy
forceps, since diathermy would alter the tissue too
much for adequate histological evaluation. Very large
polyps may require removal in several pieces (piece-
meal technique) or even with several procedures.
Histological evaluation of these piecemeal speci-
mens can be very difficult, and complete clearance
of the advanced polyp cannot always be achieved.
This must be considered when discussing the option
of bowel resection after biopsy and tattooing of the
advanced polyp. Figure 8.3 shows the polypectomy
site of a large polyp before and after clip applica-
tion for haemostasis and prevention of bowel perfo-
ration. Figure 8.4 shows a colon cancer as detected
by colonoscopy. Figure 8.5 shows the endoscopic
appearance of different colonic polyps.
44
a b
Fig. 8.3 Endoscopic view of polypectomy site before (a) and after (b) clip application
Fig. 8.4 Endoscopic view of colon cancer
Aim of the procedure must be complete excision
and complete retrieval of the polyp since up to
8% of all removed polyps contain parts of inva-
sive carcinomas which may be missed if only
­partial excision is done, or part of the polyp is lost
for histological examination.
Destruction of the tumor using diathermy, laser, or
argon-plasma coagulation should not be done because
they do not allow for pathological evaluation. These
techniques are of relevance, however, for palliation,
and can restore normal fecal passage.
M.W. Wichmann and F.W. Spelsberg
8.3.3 Follow-up
After complete removal of a polyp, follow-up should
be done at 3–6 months, then at 3–5-year intervals. The
author’s approach is slightly less aggressive with a
repeat colonoscopy following polypectomy scheduled
after 12 months (villous adenoma < 12 months).
Surveillance colonoscopies are needed to be sched-
uled for:
• Familial hereditary non-polyposis colorectal cancer:
every 1–2 years starting at age 20–30, annually after
40 years
• First-degree relative with colon cancer/adenoma-
tous polyp: start at age 40, then every 10 years
• Personal history of polyps: every 3–5 years
• Personal colon cancer history: 3–6 months after
treatment, then every 3–5 years
• Inflammatory bowel disease: every 1–2 years,
beginning at any age
• Family history of familial adenomatous polyposis
(AFP): annual
8.3.4 Complications
The complication rate of diagnostic colonoscopies is
very low (<0.2%) and the associated mortality is
<0.01%. The most common complications are cardio-
pulmonary problems (usually due to sedation) and
bleeding episodes (<0.02%). Perforations usually occur
8 Fiber Optic Endoscopy: Colonoscopy 45

Fig. 8.5 Endoscopic

appearance of various colonic
polyps. (a) Typical small
polyp; (b) polyp on a large
stalk; (c) typical flat polyp,
2 cm in diameter;
(d) large polyp, 4 cm in
diameter. Endoscopic
resection of polyps (c) and
(d) is often difficult and such
patients may be best referred
to specialized endoscopy
centers (Pictures courtesy of
Professor Ian C Roberts-
Thomson, Queen Elizabeth
Hospital, Adelaide)

within the recto-sigmoid junction or the sigmoid colon
and have an incidence of less than 0.05%. Abdominal
pain and discomfort is usually due to the insufflation of
air – ongoing discomfort, however, requires exclusion
of a perforation (abdominal X-ray, computed tomogra-
phy). Therapeutic colonoscopies carry slightly higher
complication rates with regard to bleeding (1–2%) and
perforation (0.1–0.3%). The mortality rate is 0.05%.
(pain treatment ± antibiotic treatment) after radiologi-
cal exclusion of a perforation. Should a ­perforation
occur, it usually requires surgical intervention, although
a conservative approach (nil per mouth, i.v. antibiotics)
can be considered if the bowel ­preparation was very
good, no cancerous lesion has been detected and the
patient is not on regular corticosteroids.

8.5 Treatment of Anastomotic
8.4 Postpolypectomy Syndrome Leakage or Stenosis

Following polypectomy a transient episode of pain with
local peritonism, fever, and raised white blood cell
count can be observed without evidence of full thick-
ness wall necrosis or perforation. This condition is
believed to result from a localized peritonitic reaction to
the polypectomy, and should be treated conservatively
After low anterior rectal resection, up to 30% of patients
suffer from a leakage at the level of the anastomosis.
In some cases, a wait-and-see policy with endoscopic
washout and fibrin-glue application can be followed,
whereas more severe cases may require endoscopic
vacuum-assisted closure. This procedure uses the
46
principle of vacuum-assisted wound healing with a
drainage connected to special foam which is being
introduced through the area of leakage and drains into
a suction bottle. This foam needs to be replaced endo-
scopically every 3–4 days and allows outpatient treat-
ment of this severe complication of rectal surgery.
The stenosis of an anastomosis within the colon or
rectum can be treated using similar techniques as in the
upper GI tract with balloon dilatation, Guillard-Savary,
or Hegar bougies.
8.5.1 Palliative Treatment
Patients with non-resectable large bowel cancer can ben-
efit from endoscopic stent placement through the malig-
nant stenosis. This can be done as a definitive procedure
or as a bridging procedure allowing for ­adequate resusci-
tation prior to palliative or curative bowel resection.
M.W. Wichmann and F.W. Spelsberg
Recommended Reading
Iqbal, C.W., Cullinane, D.C., Schiller, H.J., et al.: Surgical
management and outcome of 165 colonoscopic perforations
from a single institution. Arch. Surg. 143, 701–707 (2008)
Lee, S.H., Chung, I.K., Kim, S.J., et al.: An adequate level of
training for technical competence in screening and diagnos-
tic colonoscopy: a prospective multicenter evaluation of the
learning curve. Gastrointest. Endosc. 67, 683–689 (2008)
Tilney, H.S., Lovegrove, R.E., Purkayastha, S., et al.: Comparison
of colonic stenting and open surgery for malignant large
bowel obstruction. Surg. Endosc. 21, 225–233 (2007)
Weidenhagen, R., Gruetzner, K.U., Wiecken, T., et al.:
Endoscopic vacuum-assisted closure of anastomotic leakage
following anterior resection of the rectum: a new method.
Surg. Endosc. 22, 1818–1825 (2008)
Goldenberg, E.A., Khaitan, L., Huang, I.-P., Smith, C.D., Lin, E.:
Surgeon-initiated screening colonoscopy program based
on SAGES and ASCRC recommendations in a general
surgery practice. Surg. Endosc. 20(6), 964–966 (2006)
 Endoscopy for Rural Surgeons: ERCP
Ian C. Roberts-Thomson
9.1 Introduction
ERCP is an endoscopic procedure that involves cannu-
lation of the ampulla of Vater and use of radiologic con-
trast to outline biliary and pancreatic ducts. The
technique was first described from centers in the USA
and Japan between 1968 and 1970, soon after the intro-
duction of fiberoptic endoscopes. In 1974, a group
from Germany described endoscopic sphincterotomy
for bile duct stones and, in 1979, a different German
group described the use of endoscopic stents for malig-
nant bile duct obstruction. Despite these impressive
developments, widespread adoption of the technique
was relatively slow as the procedure was technically
demanding and associated with significant complica-
tions. Even today, ERCP is performed by only a minor-
ity of gastroenterologists or surgeons and, in Australia,
is largely restricted to major city hospitals.
9.2 Training
Training in endoscopy has always been an issue for
surgeons. In Australia and many other countries, sur-
gical trainees have only had limited access to endos-
copy training as the majority of training has been
conducted in medical departments. Furthermore, for
surgeons, training in endoscopy has only been a rela-
tively small part of the total training experience. In
contrast, the development of skills in endoscopy is a
I.C. Roberts-Thomson
Department of Gastroenterology and Hepatology,
The Queen Elizabeth Hospital, 28 Woodville Rd,
Woodville South, SA 5011, Australia
e-mail: ian.roberts-thomson@health.sa.gov.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_9, © Springer-Verlag Berlin Heidelberg 2011
9
major focus for advanced trainees in gastroenterology
and hepatology.
In relation to training for ERCP, particular issues
are low case loads (even in some tertiary centers) and
the possibility of lower success rates and higher fre-
quencies of complications when procedures are solely
or largely performed by trainees. In Australia, most of
the training in ERCP is performed in medical depart-
ments in tertiary hospitals. A formal “recognition of
training” certificate is provided by a national group
after appropriate references and documentation of 200
procedures performed independently. In most tertiary
centers, this will only be achieved after a minimum of
2 years of training.
9.3 Indications
There have been major changes in the indications for
ERCP over the last 30 years. For example, ERCP was
widely used for the diagnosis of biliary and pancreatic
disorders in the 1980’s but is now largely restricted to
­therapeutic procedures for bile duct stones, biliary and
pancreatic cancer, and miscellaneous biliary disorders.
The major reason for this change is the introduction
of various non-invasive procedures including upper
abdominal ultrasound (US), computed tomography
(CT), magnetic resonance cholangiopancreatography
(MRCP) and endoscopic US. Of these, only upper
abdominal US and CT will be readily available to most
rural surgeons.
Current indications for ERCP are summarized in
Table 9.1. At present, the majority of bile duct stones
are treated by endoscopic biliary sphincterotomy and
endoscopic extraction (Fig. 9.1). These stones may be
diagnosed before cholecystectomy, by an intraopera-
tive cholangiogram during cholecystectomy or because
47
48
Table 9.1 Indications for endoscopic retrograde cholangio­
pancreatography
Diagnostic Confirm bile duct stones
Confirm ampullary neoplasms
Define post-operative biliary disorders
Define pancreatic fistulae
Confirm sclerosing cholangitis
Therapeutic Biliary sphincterotomy for bile duct stones
Biliary stents for malignant obstruction
Biliary sphincterotomy for post-­
cholecystectomy pain
Management of benign biliary strictures
Management of post-operative biliary
fistulae
Pancreatic stents for pancreatic fistulae
Endoscopic drainage of pancreatic
pseudocysts
Extraction of pancreatic duct stones
Fig. 9.1 Images of bile duct stones taken at ERCP. (a) Single
small calculus; (b) multiple stones and one larger calculus; (c)
multiple irregular stones and at least one large stone; (d) a single
I.C. Roberts-Thomson
of the development of early or late manifestations after
cholecystectomy. Features of bile duct stones prior to
cholecystectomy include abdominal pain and changes
in liver enzymes, obstructive jaundice, cholangitis and
changes in liver enzymes without pain. After surgery,
bile duct stones should be suspected when there is per-
sisting pain with changes in liver enzymes, the devel-
opment of jaundice or the development of a biliary
fistula, usually through the cystic duct stump. Patients
diagnosed with bile duct stones months or years after
cholecystectomy present in a similar way to those with
bile duct stones prior to cholecystectomy.
For biliary and pancreatic cancer, endoscopic pro-
cedures largely involve the insertion of biliary stents in
patients with obstructive jaundice. However, ­diagnostic
ERCP can have a role, particularly when US or CT
images show obstruction close to the duodenal wall
without an associated mass. Some of these patients
have cancer of the ampulla of Vater while others have
periampullary or duodenal cancer. Endoscopic US is
also being increasingly used to assess the size and
extent of spread of pancreatic and biliary neoplasms
huge calculus. Sphincterotomy and stone extraction is likely to
be successful in (a) and (b) but (c) and (d) will be challenging,
even for experts
9 Endoscopy for Rural Surgeons: ERCP
and, if surgery seems unlikely, to obtain tissue for
assessment by aspiration cytology. At present, tissue
obtained by this technique has greater sensitivity and
specificity for the diagnosis of cancer than diagnostic
procedures at ERCP including brush cytology of duc-
tal strictures and duct biopsy.
Other miscellaneous indications for diagnostic and
therapeutic ERCP include the diagnosis and endo-
scopic management of post-operative biliary strictures
and sclerosing cholangitis. Diagnostic and therapeutic
procedures have also been promoted for pancreatic
pseudocysts, chronic pancreatitis, pancreatic trauma
and pancreatic ascites, but endoscopic management
should be restricted to experts. Another issue is that of
biliary-type pain after cholecystectomy (without
stones). If medical therapy fails, endoscopic sphinc-
terotomy should be restricted to experts as selective
cannulation of the bile duct is sometimes difficult and
there is a higher than expected frequency of pancreatitis
after the procedure.
9.4 Preparation and Sedation
Patients should fast for at least 3 h prior to the ­procedure.
Satisfactory sedation can usually be achieved with
meperidine (pethidine) and midazolam but some prac-
titioners routinely use propofol with help from anaes-
thetists or anaesthetic assistants. However, unconscious
sedation does limit the use of positional changes that
may facilitate the interpretation of ductal images.
Theoretically, meperidine is preferable to fentanyl as
the latter drug induces a greater degree of spasm in the
sphincter of Oddi.
9.5 Endoscopic Stents for Malignant
Biliary Obstruction
Patients with malignant biliary obstruction can be
treated with endoscopic stents, palliative bypass
­surgery or more radical surgery with the potential for
cure. Ideally, management in individual patients should
be discussed in a multi-disciplinary setting that
includes surgeons and oncologist. Endoscopic stents
49
are likely to be the preferred form of therapy in patients
with advanced disease and in those who are elderly
(>85 years) or with significant comorbidities. Stents
can be composed of either plastic or metal (nitinol or
stainless steel). Conventional 10-French plastic stents
are relatively cheap, remain patent for 3–4 months and
can usually be readily replaced by repeat ERCP. In
contrast, metal stents are more expensive and remain
patent for a longer period. However, most metal stents
are impossible to remove endoscopically and, in the
event of stent occlusion, options include a second
metal stent within the original stent or a plastic stent
within the metal stent. In practice, plastic stents are
often used in patients whose survival seems likely to
be short while metal stents are used in those whose
anticipated survival is > 4–6 months.
An additional issue is the use of plastic stents to
relieve jaundice prior to radical surgery. Advocates of
this policy point to the avoidance of urgent procedures
and a possible improvement in patient outcomes.
Others who prefer to avoid pre-operative stents are
concerned by stent-induced changes in ducts and a
possible increase in post-operative infections. This
issue has not been entirely resolved, although a recent
randomized trial showed that pre-operative stents did
not improve patient outcomes when the pre-operative
serum bilirubin was < 250 mmol/l (14.6 mg/dl).
9.6 Complications
The major complication of ERCP is the development
of pancreatitis. This has been defined in a number of
different ways but the clinical issue is pain after the
procedure that is accompanied by a rise in the serum
amylase to >300–500 U/l. The frequency of this com-
plication ranges from 1% to almost 25% in unselected
series but should be 7% or less. Several studies have
shown higher risks for pancreatitis when procedures
are performed by endoscopists with low case-loads.
Other risk factors for pancreatitis include difficulties
with cannulation, use of precut techniques, female
gender and procedures on patients with recurrent
­pancreatitis or post-cholecystectomy pain. As various
pharmacological agents have failed to reduce the risk
of pancreatitis after ERCP, minimization of risk
50
continues to depend on appropriate case selection and
a meticulous endoscopic technique.
Less common complications after ERCP include
duodenal bleeding after endoscopic sphincterotomy,
cholangitis and duodenal perforation.
9.7 ERCP in a Rural Setting
Competence at ERCP is largely determined by the
quality and duration of training and by ongoing experi-
ence. The minimal case-load for maintenance of ERCP
skills has not been defined but may be 50 cases/year.
This is the approximate case-load that would be gener-
ated from a population of 50,000 people. Although
ERCP in Australia is largely performed by gastroen-
terologists, there are some notable exceptions includ-
ing rural surgeons. However, a significant issue for
surgical trainees is access to ERCP training in large
metropolitan hospitals.
Recommended Reading
Coelho-Praghu, N., Baron, T.H.: Endoscopic retrograde cholan-
giopancreatography in the diagnosis and management of
cholangiocarcinoma. Clin. Liver Dis. 14, 333–348 (2010)
I.C. Roberts-Thomson
Davids, P.H., Groen, A.K., Rauws, E.A., Tytgat, G.N.,
Huibregtse, K.: Randomised trial of self-expanding metal
stents versus polyethylene stents for distal malignant biliary
obstruction. Lancet. 340, 1488–1492 (1992)
de Groen, P.C., Gores, G.J., LaRusso, N.F., Gunderson, L.L.,
Nagorney, D.M.: Biliary tract cancers. N. Eng. J. Med. 341,
1368–1378 (1999)
Freeman, M.L., Nelson, D.B., Sherman, S., et al.: Complications
of endoscopic biliary sphincterotomy. N. Engl. J. Med. 335,
909–918 (1996)
Moss, A.C., Morris, E., Leyden, J., MacMathuna, P.: Malignant
distal biliary obstruction: a systematic review and meta-
analysis of endoscopic and surgical bypass results. Cancer
Treat. Rev. 33, 213–221 (2007)
Roberts-Thomson, I.C.: Endoscopic sphincterotomy of the
papilla of Vater: An analysis of 300 cases. Aust. N.Z.
J. Med. 14, 611–617 (1984)
Takagi, K., Ikeda, S., Nakagawa, Y., et al.: Retrograde pancre-
atography and cholangiography by fiber duodenoscope.
Gastroenterology 59, 445–452 (1970)
van den Gaag, N., Rauws, E.A.J., van Eijck, C.H.J., et al.:
Preoperative biliary drainage for cancer of the head of the
pancreas. N. Engl. J. Med. 362, 129–137 (2010)
Varadarajulu, S., Eloubeidi, M.A.: The role of endoscopic ultra-
sonography in the evaluation of pancreatico-biliary cancer.
Surg. Clin. North Am. 90, 251–263 (2010)
 Rigid Endoscopy: Cystoscopy
10
Mark Lloyd and John Miller

10.1 Introduction 10.2 Indications
Cystoscopy is indicated for evaluation of lower urinary
Cystoscopy is the endoscopic inspection of the lower
tract symptoms, haematuria, bladder lesions, stones
urinary tract. Cystoscopy includes the endoscopic
and bladder outflow obstruction.
visualization of the urethra and bladder.
A cystoscopy is recommended for evaluation of all
Cystoscopy is a useful procedure for evaluation
cases of haematuria – particularly gross haematuria,
of urinary symptoms or signs including haema­turia,
and ongoing microscopic haematuria, particularly in
reduced urinary flow, urinary frequency and urgency.
those with significant microscopic haematuria, which
The male urethra is divided into penile, bulbar,
is variously defined as over 5–10 red cells detected
membranous and prostatic urethra while the female
under light microscopy per high power field.
urethra is quite short. The bladder includes base, dome,
All smokers with any degree of haematuria should
ureteric orifices and trigone.
undergo cystoscopy due to the high risk of transitional
Cystoscopy may be achieved by use of the rigid
cell carcinoma. Other risk factors for neoplasia of the
cystoscope or the more recent flexible cystoscope.
urothelium include exposure to petrochemical prod-
Rigid cystoscopy is usually performed under a gen-
ucts, solvents and herbicides and pesticides.
eral anaesthetic, particularly in the male, due to the
Recurrent urinary tract infection may also be inves-
discomfort associated with introducing the instru-
tigated with a cystoscopy.
ment. Rigid cystoscopy may be performed under
Surveillance cystoscopy following treatment for
local anaesthetic in the female owing to the short
transitional cell carcinoma of the bladder is mandatory
urethra.
and is initially repeated frequently to check for recur-
Flexible cystoscopy is performed under topical
rences and following this annually.
local anaesthetic gel. It provides a rapid and conve-
nient assessment of the lower urinary tract.
The advantage of rigid cystoscopy is the superior 10.3 Patient Preparation
vision and the ability to introduce a biopsy forceps in
order to biopsy any abnormal area. Any area of bleed-
Prior to initial cystoscopy it is useful to obtain an ultra-
ing may be diathermied by use of the monopolar dia-
sound of the urinary tract and bladder and it is recom-
thermy lead – which may also be used to stop bleeding
mended to obtain a urine microscopy and culture to
from any site of bladder biopsy.
exclude infection and to quantify any haematuria.
Urine cytology is particularly useful to check for any
malignant cells in the urine, which is suggestive of
transitional cell carcinoma.
An active urinary infection is a contraindication to
M. Lloyd (*) and J. Miller
cystoscopy not only as the cloudy urine impedes vision
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia but also due to the risk of sepsis particularly if the
e-mail: marklloyd@adam.com.au urothelium is breached.

M.W. Wichmann et al. (eds.), Rural Surgery, 51

DOI: 10.1007/978-3-540-78680-1_10, © Springer-Verlag Berlin Heidelberg 2011
52
Antibiotic prophylaxis is at the clinician’s discre-
tion but must be given if infection is suspected or if the
patient is at risk in the event of bacteraemia (prosthetic
heart valve especially).
10.4 Findings
Transitional cell carcinoma appears as a papillary or solid
mass in the bladder or urethra – this may be biopsied or
referred primarily to an urologist for management.
Cystitis appears as a diffuse inflammatory reaction
of the bladder wall and is usually indicative of infec-
tion; however, the differential diagnosis includes carci-
noma in situ (appearing as flat red areas in the bladder)
and other forms of cystitis (interstitial cystitis, post-
radiotherapy and haemorrhagic cystitis).
Bladder outflow obstruction is suggested by a benign
prostatic hyperplasia (which may also be a common
cause of haematuria if the cystoscopy is otherwise nega-
tive) or a tight bladder neck with muscular hypertrophy.
Benign prostatic hyperplasia is indicated by a large
prostate with lobes meeting and obstructing the prostatic
urethra. Bladder outflow obstruction may be associated
with bladder stones – which are easily seen with cystos-
copy – small stones may be washed out – larger stones
should be treated endoscopically at a tertiary centre.
The ureteric orifices should be inspected and nor-
mally lie symmetrically opposite at the corners of the
trigone – the ridge running transversely from one to
the other aids identification and is termed the interu-
reteric bar. The observation of a ureteric jet of urine is
helpful for location and aids in excluding obstruction.
Haematuria from a ureteric orifice is indicative of
­unilateral ureteric or renal pathology.
Ureteric orifices may be cannulated with an open-
ended ureteric catheter. A retrograde pyelogram may
be obtained by the instillation of 10 ml of radio-opaque
contrast to confirm the position. This may also be per-
formed prior to difficult abdominal/pelvic surgery – a
size 6 or 4 French catheter is used for this purpose.
Cystoscopy may be performed intraoperatively to
check for bladder or ureteric injury – this is suggested
by the presence of blood on introduction of the
­cystoscope. A thorough evaluation of the bladder,
­presence or absence of ureteric jets should be done.
Retrograde pyelogram or the instillation of methylene
blue may also be performed.
M. Lloyd and J. Miller
During cystoscopy a urethral stricture may be
detected – this may be impassable if dense but often is
a flimsy stricture which can be dilated with the cysto-
scope. A stricture may be dilated with urethral sounds;
however, the possibility of urethral injury and false
passage should be borne in mind.
Cystoscopy is not complete without a digital rectal
examination as early prostate cancer sometimes pres-
ents with a prostatic nodule and is usually asymptom-
atic. It is also a useful way of assessing prostatic size.
10.5 Technique
Cystoscopy is performed using a 21 or 23 French
sheath and a 30° and 70° optical Hopkins rod telescope.
The light source is usually halogen and the telescope is
connected to a single or triple chip camera. Single chip
cameras are perfectly suitable for cystoscopy.
Cystoscopy can be combined with endoscopic
­surgery on the lower urinary tract.
This requires the introduction of a resectoscope
using a 26 or 28 French sheath. Usually this is a dual
lumen sheath which features continuous flow to allow
any blood to be washed away by fluids keeping the
operative view clear with good light transmission.
Using this sheath resection of a bladder tumour may be
performed using an electrocautery resecting loop.
Transurethral resection of the prostate may also be
­performed. Both procedures can be complicated by
significant bleeding and hence the need for a continu-
ous flow of irrigation fluid.
Irrigation fluid may be saline, water or glycine;
however, glycine must be used if diathermy is to be
employed. Glycine is composed of amino-acetic acid
and is used to allow transmission of an electrical cur-
rent only through the instrument used and not through
the fluid itself. Its osmolarity is greater than water but
less than plasma. Saline does not allow diathermy to
be used and water is hypotonic and can cause problems
if absorbed in significant quantities. Glycine too can
cause problems with excessive absorption usually
occurring during TURP – this is termed TURP syn-
drome – it is characterized by dilutional hyponatraemia
and expansion of the extracellular fluid space. The syn-
drome is commonly detected by a confusional state – if
untreated it may lead to cerebral oedema, seizures and
coma.
10 Rigid Endoscopy: Cystoscopy
10.6 Complications
Complications which can be observed after cystoscopy
include:
• False passage – without careful visualization the ure-
thra may be perforated – this can occur at the level of
the bulbar urethra. The management is placement of
catheter into the true passage and into the bladder.
• Bleeding from biopsy or resection sites – this is man-
aged by diathermy and subsequent catheterization.
• TURP (Trans Urethral Retrograde Prostatectomy)
syndrome – managed by fluid restriction, diuretics
and occasionally hypertonic saline intravenously.
• Sepsis – managed by appropriate antibiotic therapy
and catheter drainage.
• Post-operative urinary retention or clot retention.
Clearly, the best management is prevention by careful
instrumentation of the sterile urinary tract together
with antibiotic prophylaxis.
Cystoscopy may be accompanied by prostatic
biopsy if required – the indications for this are an
­elevated PSA or the presence of a suspicious prostatic
nodule.
Prostatic biopsy is performed by a trucut needle
biopsy utilizing a spring-loaded biopsy device. The
needle biopsy may be finger guided using great care
53
not to injure one’s finger! Most biopsies are now
­performed using a transrectal ultrasound probe which
allows good visualization of the prostate and accurate
needle placement for biopsy. Six to 12 biopsies are
taken of the peripheral zone of the prostate where
­prostatic carcinoma is most likely to appear. This pro-
cedure may be accompanied by sepsis and therefore
antibiotic prophylaxis for all patients is required
together with an enema to empty the rectum before
ultrasound is employed. Any anticoagulation must be
ceased as for all surgery on the urinary tract.
Endoscopy of the lower urinary tract is safe in terms
of a diagnostic procedure.
Operative endoscopy may be accompanied by
­complications for which the surgeon should be ready –
bleeding, urinary retention and sepsis remain the most
common.
Recommended Reading
Hanno, P., Malkowicz, S.P., Wein, A.: Clinical Manual of
Urology. McGraw-Hill, New York (2001)
Tanagho, E.A., McAninch, J.W.: Smith’s General Urology
Lange Clinical Medicine/McGraw-Hill, New York (2007)
Wein, A.J., Kavoussi, L.R., Novick, A.C., Partin, A.W.:
Campbell-Walsh Urology Review Manual, 9th edn.
Saunders, Mosby (2007)
 Rural Surgical Audit
11
David A.K. Watters

11.1 Definitions a separate component from audit and peer review in

maintaining professional standards [3].
Surgical audits may include one’s whole practice
Surgical audit can be defined as ‘the systematic, ­critical
(all cases whether operated on or not), or focus on a
analysis of the quality of surgical care that is reviewed
specific procedure, presenting problem or outcome.
by peers against explicit criteria or recognised stan-
dards, and then used to further inform and improve
surgical practice’ [1, 2]. A briefer definition might be,
‘am I doing what I think I am doing?’ and ‘am I doing 11.2 Performing a Surgical Audit
it as well as others?’ in the Rural Context
Surgical audit addresses the structure (access, effi-
ciency), process (protocols, documentation and patient
Rural surgeons tend to have a broader clinical practice
journey) and outcomes (mortality, morbidity, disabil-
than their metropolitan colleagues. Country towns
ity, improvement) of care.
often struggle to attract and retain a surgical work-
To be effective, surgical audit involves a feedback
force, so specialists are often isolated. Despite their
loop where issues identified by audit and peer review
isolation, such specialists still need to perform a regu-
are reported, solutions are found, changes occur and
lar surgical audit and obtain a review by peers. The
the outcome of those changes are further monitored.
models adopted for peer review vary according to
Surgeons and their teams need to reflect on perfor-
­circumstance and are discussed below.
mance, and then engage the relevant stakeholders in
An audit must be complete (contain all cases for the
devising and communicating improvements in care [2].
particular condition or time frame), accurate and hon-
In recognition of the value of participating in surgi-
est. The focus and period of the audit need to be
cal audit and peer review, many surgical colleges and
defined. For example, all cases of colorectal surgery
hospitals have made such auditing a mandatory com-
for years x–y; alternatively, all cases managed for time
ponent of continuing professional development [3].
period z. Six monthly audits are commonly timed in
Mortality audits are specifically designed to learn from
training hospitals to coincide with registrar rotations.
deaths, though there is a wide variability of mortality
Yearly audits may be just as appropriate for the iso-
rates between specialties. The Royal Australasian
lated rural surgeon or for an audit focused on one
College of Surgeons (RACS) regards participation in
­problem or group of procedures.
the Australia New Zealand Audit of Surgical Mortality
(ANZASM) as an aspect of clinical governance,

11.2.1 What Data to Collect?

David A.K. Watters

Department of Surgery, University of Melbourne and Barwon
The data collected needs to identify what procedures
Health, Geelong Hospital, Geelong, VIC 3220, Australia were done on what sort of patients (risk, urgency,
e-mail: watters.david@gmail.com comorbidities) and the outcome of those procedures.

M.W. Wichmann et al. (eds.), Rural Surgery, 55

DOI: 10.1007/978-3-540-78680-1_11, © Springer-Verlag Berlin Heidelberg 2011
56 D.A.K. Watters

Table 11.1 Minimum and expanded data sets advised for whole Trainee logbooks should prepare the trainee for a
practice audit lifetime of surgical audit and not be simply a list of
Minimum data set Expanded data set procedures without outcomes, learning or pathology
Name (or initials)a
data [7]. The Supervision Levels recommended for
ID (or case record number)a Admission type trainee logbooks are:
S1: Surgeon Mentor Scrubbed
Date of birth (age calculated)
S2: Surgeon Mentor in Theatre
Sex Presenting problem S3: Surgeon Mentor Available
Final diagnosis Comorbidities A1: Assisting Surgeon Mentor
A2: Assisting Surgeon Registrar
Admission date Wound infection risk
Discharge date ASA grading
Operation/procedure Indication for operation
performed
Operation date Type of anaesthetic
11.2.2 How to Collect the Data for Audit
Operation urgency Operating magnitude
The earliest and simplest surgical audits were con-
Complications and grade Pathology information and
ducted on paper. Paper-based audit require consider-
(Table 11.2) diagnosis
able discipline to consistently record the cases, often in
Surgeon identifiera Outcome/discharge type a notebook. The more cases, the more challenging
a
Information that is private and not for release beyond the surgi- becomes the sorting and arranging of the information
cal unit responsible for care
and its analysis. For these reasons, most surgeons
Source: RACS Surgical Audit and Peer Review Guide, 3rd edn.
­prefer to record their data in an electronic format on a
computer or personal digital assistant (PDA). The sim-
The minimum and expanded datasets recommended plest software is to use a spreadsheet such as Excel
by the Royal Australasian College of Surgeons (RACS) (www.microsoft.com). Spreadsheets are limited in the
are shown in Table 11.1 [1, 2]. The expanded data set number of columns that can be seen on the screen at
enables better risk stratification, which may facilitate any one time and are best for logbooks of activity with
‘comparing with known standards’. The age of a a limited number of characters in each cell. The best
patient, urgency of procedure, stage of disease and audit programs are based on a database that facilitates
comorbidities are key aspects of stratifying the risk of searching, summarising and calculations. Many exam-
morbidity and mortality. Some specialties have estab- ples of successful surgical audit have employed pro-
lished scoring systems. Specialist data sets may also be grams such as Filemaker Pro (www.filemaker.com),
appropriate for specific procedures. Microsoft Access (www.microsoft.com) or HanDbase
The recording of comorbidities is difficult to (www.ddhsoftware.com). Google spreadsheets are
achieve retrospectively, and the American Society of another option. What is important is that a program is
Anaesthetists (ASA) status may be a reasonable alter- user friendly and, once the data is entered, the software
native. In colorectal audits conducted by rural sur- can be used to generate useful reports without too
geons, a count of two or more comorbidities was much extra work. All of the available programs require
associated with worse outcomes. Table 11.2 shows the a template for data entry to be created. Data entry is
comorbidities used by the Elixhauser [4] and Charlson facilitated by a value list of common conditions such
[5] classifications, the latter list carrying a score. The as is shown for the list of comorbidities and complica-
third column shows complications (Clavien) [6] to pro- tions (Table 11.2). A free downloadable program using
vide useful drop-down menus to record comorbidities Filemaker Pro has been created by the author and is
and grade complications. Risk stratification of the con- available from the RACS website, http://www.racs.
dition of the patient is essential to compare outcomes if edu.au/racs/fellows/cpd-recertification/cpd-resources-
like is to be compared with like. and-tools/david-watters-surgical-audit-tool. The above
Trainee surgeons may also collect data about the hyperlink will lead you to a program that has been
supervision level and the learning impact of the case. used by many rural surgeons but it is still only one
11 Rural Surgical Audit 57

Table 11.2 Useful comorbidities and complications for drop-down value lists
Elixhauser Charlson (score) Clavien complications (grade)
Cardiovascular Congestive heart failure Congestive heart failure (1) Atrial fibrillation
Arrhythmia Tachyarrhythmia requiring B
blocker (2)
Valvular heart disease Acute MI (1) Bradyarrhythmia requiring
pacemaker (3)
Hypertension Cerebrovascular disease (1) Heart failure leading to low output
syndrome (4)
Peripheral vascular disease Peripheral vascular Cardiac insufficiency after
disease (1) myocardial infarction (4d)
Metabolic Diabetes uncomplicated Diabetes (1)
Diabetes complicated Diabetes complications (2)
Obesity
Liver Hepatic disease Liver disease (1) Urinary tract infection requiring
antibiotics (2)
Severe liver disease (3) Reoperation for ureteric injury (3)
Renal Renal failure Renal disease (2) Renal insufficiency requiring
dialysis (4)
Pulmonary Pulmonary circulatory disorders Atelectasis requiring
physiotherapy (1)
Chronic pulmonary disease Pulmonary disease (1) Pneumonia requiring antibiotics
treated on ward (2)
Neurological Paralysis Paraplegia (2) TIA requiring anticoagulants (2)
Other neurological Postoperative stroke (4)
Cancer Solid tumour without metastasis Cancer (2)
Metastatic cancer Metastatic cancer (3)
Lymphoma
Other general AIDS HIV (6) Anastomotic leak requiring
surgery (3)
Weight loss Necrotising pancreatitis (4)
Drug abuse Wound infection opened at
bedside (1)
Alcohol abuse Wound infection requiring
antibiotic therapy (2)
Psychosis Wound dehiscence requiring OT
closure (3)
Depression Transient confusion (1)
Rhematoid arthritis/collagen
vascular diseases
Fluid and electrolyte abnormality
Coagulopathy
Blood loss anaemia
Deficiency anaemia
In Australia and the UK, obesity is defined as BMI >25 (= overweight) and >30 (= high risk). Patients with dementia are given ‘other
neurological disorder’ but it may be worth adding this. Acute myocardial infarction needs to be defined and I recommend this is
within the preceding 30 days
58
example to be considered. Verification should focus on
what data are missing or inaccurate.
Larger databases (clinical information systems)
may be used to generate the data required for audit in
individual hospitals (e.g. CORDis in Geelong/Victoria
(AUS)).
11.2.3 How to Prepare an Audit
Surgical audit should review both the workload and
the outcomes. The relevant outcomes vary according
to procedure and specialty. A whole practice audit such
as is often carried out by general surgeons in a rural
hospital should include in its outcomes all major com-
plications, unplanned reoperations, unplanned read-
missions and mortalities. Most surgeons are assisted
by a data and presentation checklist (Fig. 11.1).
Problem cases should be presented with enough detail
so that the peers have enough information on which to
assess the clinical decision-making. For example,
a single slide for each case that contains the age, sex,
presentation, risk, procedure and the clinical course
leading up to the adverse event. A PowerPoint tem-
plate for surgical audit (Fair Dinkum Audit) can be
downloaded from the RACS website, www.surgeons.
org/media/16117/PSAauditpostertemplate.ppt.
11.3 Peer Review
An isolated rural surgeon may not have a local peer
who practices in their specialty. Although there will be
value in presenting one’s audits to other specialists, it
is also important to present to at least two other sur-
geons in the same speciality. This can be achieved by
teleconference, or by the peers agreeing to meet face to
face every few months.
Another alternative is for the audit to be presented at a
conference where peers will be present. This method has
been used by the Provincial Surgeons of Australia, using a
standard poster template (Fig. 11.2) available from, www.
surgeons.org/media/16117/PSAauditpostertemplate.ppt.
A third model used by some centres in South
Australia is for the rural surgeon to visit the referral
D.A.K. Watters
centre and present the audit to the surgeons there. It is
ideal if those who work in the referral centre, usually a
city, have some appreciation of the context of rural
practice. There may also be specific procedures, such
as ERCP, that would be more appropriate to report
through a focused audit and present to peers in a major
centre to which the more complex cases would nor-
mally be referred [8, 9].
11.3.1 Conduct of the Meeting
A surgical audit meeting should generally not identify
names of patients and be conducted in an open, honest
but not aggressive way. The purpose of the meeting is
to report, review and reflect, not to name and blame.
The surgical peer review meeting should have a
chairperson who is independent of the team presenting
the audit. The chairperson should record the issues,
effect on patient or hospital recommendations, action to
be taken by whom and when (Fig. 11.3). It is a local
decision whether only surgeons are present or whether
anaesthetists, surgical ward/operating nurses and hospi-
tal managers are present. Certain technical issues aris-
ing may only require discussion within the craft group
but other events will only be able to be addressed at a
service or hospital-wide level. The Director of Surgery
should normally be invited and will act as a means of
communication between clinician and managers.
11.4 Reporting Surgical Outcomes
Outcome reporting requires some degree of risk strati-
fication as patients have individual risks of complica-
tions or mortality (Table 11.2). The simplest means is
to use ASA [10], or a count of comorbidities from the
list in Table 11.2. The use of POSSUM [11, 12] is com-
plex, challenging and usually beyond the enthusiasm of
general surgeons except in the research context [10].
The assessment and appropriate measurement of
actual outcome varies from procedure to procedure
though the principles are the same for all operations.
The various specialties need to determine by consen-
sus what the outcome indicators for operations within
11 Rural Surgical Audit 59

Unit X, Surgeons A, B,C, Audit time period: date Y to date Z

1 Surgical caseload
1.1.Total Admissions
1.2 Total Operations
1.2.1 Sub-classified by emergency (1.2.1a), urgent 1.2.1b or elective (1.2)
1.2.2 Number of Complex, Major, Moderate and Minor operations
Subclassified by emergency, urgent or elective where appropriate
1.3 Final diagnosis of non-operated admissions – table with numbers and a column that includes plan or outcomes
1.4 Types of Operation – table
Tables Subclassified by specialty groups
(e.g. endoscopies, breast, endocrine, colorectal, upper GI, etc.)

2 Morbidity and mortality (quality indicators)

2.1 Number of complications and classified by
2.1.1 Severity of complications into grades 1, 2, 3 according to their effect on the patient and the treatment required
(see minimum dataset)
2.1.2 Type of complication
2.1.3 Rates for different procedures (see Table 3)
Bile leak after cholecystectomy
Recurrent laryngeal nerve palsy rate for thyroidectomy
Colonoscopies should include completion rates and polypectomy rates
Clinical Indicators may include unplanned overnight stay (for day case) as a quality of care indicator
(The numerator is the number of complications or relevant performance indicator for each group. The Denominator is
the total number of procedures.)
2.2 Number of unplanned readmissions
2.3 Number of unplanned re-operations
2.4 Number of unplanned ICU readmissions
2.5 Transfers to a higher level of care
2.6 Near misses
2.7 Incident reports
2.8 Complaints
2.9 Number of mortalities (= type 4 complication in minimum dataset)
Sub-classify as avoidable, unavoidable and expected, unexpected

3 Case details
Each readmission, re-operation, ICU readmission, transfer, mortality, type 3 complication and case of interest should
be discussed with at least the following information (advise one slide per case):
Age and sex
Final diagnosis
Reason for Readmission/re-operation/ICU readmission/transfer
What was done (investigations, procedures etc)
Complications, adverse events (with analysis)
Outcome

4 What can be done differently?

4.1 Issues/events to report
4.2 Lessons learned
4.3 Recommendations for improvement

Fig. 11.1 Checklist of information, which might be included in a surgical audit presentation (Adapted from [2])
60 D.A.K. Watters

Fig. 11.2 Fair Dinkum Audit template. Designed by David Watters and accessible from www.surgeons.org
11 Rural Surgical Audit
Fig. 11.3 Suggested format For Surgical Units OPQ Surgeon(s) ABC Dates Y to Z
for a chairperson’s report of a Chairman Mr H
surgical audit meeting [1, 2].
The report will normally Issue Effect on
have a row for each issue. patient and
The table above is taken from hospital
the RACS Surgical Audit and
Peer Review Guide [3] and
Watters et al. [2]
their field are. Vascular surgeons may use limb salvage
rates after femoropopliteal bypass rates or stroke rates
after carotid endarterectomy. Cardiothoracic surgeons
employ mortality, rebleeding and deep sternal infec-
tion rates to monitor outcomes. A colorectal surgeon
will report outcomes based on mortality, anastomotic
leak and unplanned reoperation rates. Death may occur
so infrequently in some specialties (e.g. plastic sur-
gery) that mortality rates bear no relationship to per-
formance. Plastic surgeons often use take rates of a
split skin graft, or adequacy of excision margins for
skin cancers.
Appropriate outcome indicators are shown in
Table 11.3, which also lists some actual performance
results achieved by rural surgeons.
It is ideal if surgical outcomes can be classified as
either a success or a failure. When this can be done,
cumulative summation (CUSUM) analysis can be applied
to give visual feedback on performance (Fig. 11.4).
CUSUM involves a time plot of attempts against an
agreed binary target. Cumulative failure means that each
failure is recorded as an upstroke on a cumulative failure
chart where the horizontal axis is number of attempts
(procedures) and the vertical axis records failures; a suc-
cess is recorded as a horizontal line. CUSUM and cumu-
lative failure charts are visual and useful for feedback to
surgeons, units and services on performance. They mea-
sure variation in small samples and allow for early detec-
tion of small aberrations, natural variations and procedural
performance trends (Fig. 11.5) [13, 14].
11.4.1 Complications
Complications should be graded according to their
effect on the patient. Grade 1 complications are those
that have little effect on the patient and do not signifi-
cantly delay discharge from hospital. They include
61
Recommendation Action by Final outcome
whom and of report
when
wound erythema, postoperative retention that responds
to catheterisation and trial of void, minor fluid and elec-
trolyte derangements. Grade 2 complications are those
that prolong postoperative stay or cause the patient
­significant suffering. Examples include a scrotal hae-
matoma after inguinal herniorrhaphy, major wound
infection, pneumonia and deep venous thrombosis.
Grade 3 complications include those that require major
intervention such as radiological drainage (for a collec-
tion), nutritional support (for prolonged ileus or intesti-
nal fistula to be treated conservatively), and cardiac
stenting. Unplanned reoperations, or ICU admission
are other examples. Death is a Grade 4 complication.
An alternative is the Clavien Classification of surgi-
cal complications, which has five grades (Table 11.2).
Grade 1 complications are minor and include wound
infections opened at the bedside. Blood transfusion and
TPN are included under Grade 2 together with other
complications requiring pharmacological treatment.
Grade 3 requires surgical, endoscopic or radiological
intervention. Grade 4 requires ICU care for a life-
threatening complication and single organ (4a) or multi-
organ (4b) failure. Death is a Grade 5 complication.
11.4.2 Adverse Events and Incidents
An adverse event is defined as unintentional harm (to
the patient) arising from an episode of healthcare and
not due to the disease process itself. Surgical adverse
events include unplanned reoperation, unplanned read-
mission, medication errors and side effects, falls, pres-
sure ulcers, hospital acquired infection and inadvertent
injury during surgery. Adverse events occur in around
10% of general surgical cases. The rates vary between
specialties. Adverse events need to be reported through
both a hospital incident reporting system and through
surgical audit. Each adverse event can be graded using
62 D.A.K. Watters

Table 11.3 Key performance indicators for rural surgery

Specific procedures Performance indicator Expected result Actual results
(derived from (reported by Rural
consensus or craft Group Audit or
literature) SCARS)
Thyroid surgery Recurrent laryngeal nerve palsy (requires <2% permanent, Long-term results not
pre- and postoperative cord visualisation) <5% temporary available, temporary
palsy = 1.5%
Total thyroidectomy Hypoparathyroidism Permanent < 5% Long-term results not
available
Temporary < 30% Temporary = 17%
Elective laparoscopic Bile leak rate prolonging stay (>48 h) <5% 1.2%
cholecystectomy
Elective lap Bile leak requiring intervention <2% 1%
cholecystectomy
Elective lap Conversion after elective surgery <5–10% 6.7%
cholecystectomy
Elective lap Unplanned ERCP after completing <2% 0.6%
cholecystectomy cholecystectomy laparoscopically
Elect Lap Chole Bile duct injury <1% 0.4%
Colorectal resection Anastomotic leak after elective resection <3% 3/136 Anterior
1/135 Right
Colorectal resection Mortality after elective surgery <3% 1/136 Anterior
SCARS: 2.8%
Colorectal resection Mortality after emergency surgery <10% SCARS 8.3%
Breast cancer surgery DCIS and no axillary surgery >90% Not reported
Breast cancer surgery Invasive cancer with axillary staging surgery >90% Not reported
Breast cancer surgery Referral for radiotherapy after breast conserva- >85% Not reported
tion surgery for invasive cancer and DCIS
Breast cancer surgery Offering or prescribing hormonal treatment >85% Not reported
for oestrogen receptor positive tumours
Breast cancer surgery Clear margins for breast conserving surgery >95% Not reported
invasive cancers and DCIS
Inguinal hernia repair Postoperative pain >3/12 requiring referral <3% Not reported
to a pain clinic
Inguinal hernia repair Scrotal haematoma <2% 0.6%
The SCARS project was a voluntary audit of 877 colorectal operations by 67 rural and regional surgeons. The Rural Craft Group Audit
in Australia has amassed over 3,000 cases for inguinal hernia, thyroidectomy, cholecystectomy and colorectal and breast cancer sur-
gery. The presence of more than two comorbidities raised the overall mortality (elective and emergency) from 4.6% to 16.4% [16]

a Severity Assessment Code (Fig. 11.6) on the basis of
its effect on the patient or hospital service, and the
likelihood of it recurring.
Adverse events require honest and frank discussion
with patient and/or their family. Patients who have suf-
fered unintentional harm deserve to have their suffering
acknowledged with empathy, and apology should be
offered without necessarily admitting any fault. Adverse
events offer an opportunity to improve the system of
healthcare if the response to their occurrence is positive.
They require investigation in an atmosphere of ‘no-
blame’ with engagement of the major stakeholders.
11 Rural Surgical Audit 63

Fig. 11.4 (a, b) CUSUM and cumulative failure 10

chart for vocal cord palsy after thyroidectomy. On
the top the cumulative failure chart (a) shows two
8
permanent vocal cord palsies represented as steps
but performance remains acceptable. The
corresponding CUSUM chart on the below (b) 6
shows acceptable performance travelling with the

Cumulative Failure
two failures represented by the saw teeth. The
trend of the performance line is downwards from 4
the horizontal
2

0
1 21 41 61 81 101 121 141 161 181 201 221 241 261 281 301
Case number
−2

−4

0.5

0
1 21 41 61 81 101 121 141 161 181 201 221 241 261 281 301
−0.5 Case number

−1

−1.5
CUSUM

−2

−2.5

−3

−3.5

−4

Limited Adverse Occurrence Screening of health- 11.5 Rural Surgical Craft Group

care (LAOS) was introduced in a rural hospital to iden-
tify opportunities to improve the system. Alan Wolff
and Jo Bourke [15] were able to demonstrate reduced
adverse outcomes by reviewing and responding to
unplanned readmissions, prolonged length of stay,
mortalities and return to theatre. The technique could
be replicated in any rural hospital.
A sentinel event is defined as ‘a relatively infre-
quent, clear-cut event that occurs independently of
a patient’s condition; it commonly reflects hospital
systems and process deficiencies’. Sentinel events
are catastrophic and include operating on the wrong
site or side, retained swabs or instruments after
­surgery, ABO incompatibility and gas embolism. At
hospital and department of health level, they require
early reporting (within days), detailed investigation,
often with root cause analysis, and verifiable system
changes.
(Australia)
The ability to provide evidence of performance has
driven the rural and regional surgeons of Australia to
establish their own database. Commonwealth of
Australia funding was obtained to support surgical
audits in a number of regional and remote centres.
Over 3,000 operations and their outcomes were entered
during the first two phases of the project and a third
phase is ongoing. The findings have confirmed the
­earlier results of SCARS for colorectal surgery – that
rural and remote surgeons have acceptable outcomes
(Table 11.3). There will always be some cases that
should be referred to a specialist centre, for example
low rectal cancers. It is to be hoped that the perfor-
mance of rural surgeons will be measurable (and so
defendable) by being able to compare their results with
the database and so compare with ‘known standards’.
64 D.A.K. Watters

a Cumulative failure graph b Cusum graph

8 10

5
4
Cumulative failure

Cusum
0
0

–2
–5

–4

–6 –10
0 10 20 0 10 20
Attempt number Attempt number

Probably acceptable
Definitely acceptable
Probably unacceptable
Definitely unacceptable

Fig. 11.5 (a, b) CUSUM and cumulative failure plots for anas- CUSUM graph on the right shows a tendency to rise rather than
tomotic leak after the last 20 large bowel procedures. Cumulative drop below the line. This particular surgeon reflected on their
failure graph (left) showing possibly unacceptable performance performance and subsequently had much fewer anastomotic
in colorectal surgery anastomotic leak rate. The corresponding leaks, indicative of the value of feedback on performance

Event classification

Consequences/ISR

Likelihood Catastrophic (1) Major (2) Moderate (3) Minor (4)

Almost 1 1 1 3
Fig. 11.6 Classification of certain
incidents and adverse events
Likely 1 1 2 3
Reporting incidents into an
incident reporting system
such as RiskMan is assisted Occasional 1 2 3 4
by grading the injury
severity which is based on its 2 2 3 4
effect and likelihood of Unlikely
recurrence. Hospital risk
registers enable management Rare 3 3 3 4
to prioritise and formulate
strategies to address the most ISR = Injury Severity Risk
important risks
11 Rural Surgical Audit
11.6 Conclusion
The principles of surgical audit are the same wherever
a surgeon is based. The challenges of peer review can
be overcome even by isolated practitioners. Rural
Surgeons in Australia and New Zealand have demon-
strated their willingness and ability to participate in
craft group audit. The data so far accumulated suggests
that rural performance is more than satisfactory. User-
friendly tools to assist with data collection and presen-
tation have been developed.
References
1. Royal Australasian College of Surgeons.: Surgical audit and
peer review guide, 3rd edn. Melbourne, Australia. Available
from www.surgeons.org (2008)
2. Watters, D., Green, A., van Rij, A.: Guidelines for surgical
audit in Australia and New Zealand. ANZ J. Surg. 76(1–2),
78–83 (2006). Review
3. Royal Australasian College of Surgeons.: Continuing
­professional development information manual 2007–2009,
Melbourne, Australia. Available from www.surgeons.org
(2006)
4. Elixhauser, A., Steiner, C., Harris, D.R., Coffey, R.M.:
Comorbidity measures for use administrative data. Med.
Care 36, 8–27 (1998)
5. Sundarajan, V., Henderson, T., Perry, C., Muggivan, A.,
Quan, H., Ghali, W.A.: New ICD-10 version of the Charlson
65
Comorbidity Index predicted in-hospital mortality. J. Clin.
Epidemiol. 57, 1288–1294 (2004)
6. Dindo, D., Demartines, N., Clavien, P.A.: Classification of
surgical complications. Ann. Surg. 240, 205–213 (2004)
7. Watters, D., Green, A., van Rij, A.: Requirements for trainee
logbooks. ANZ J. Surg. 76(3), 181–184 (2006)
8. Watters, D.A., Knight, R.E.: Isolated specialists: how many
procedures do they need to carry out and how do we measure
whether they are competent? ANZ J. Surg. 78(9), 731–732
(2008)
9. Dundee, P.E., Chin-Lenn, L., Syme, D.B., Thomas, P.R.:
Outcomes of ERCP: prospective series from a rural centre.
ANZ J. Surg. 77, 1013–1017 (2008)
10. Bowles, T.A., Sanders, K.M., Colson, M., Watters, D.A.:
Simplified risk stratification in elective colorectal surgery.
ANZ J. Surg. 78, 24–27 (2008)
11. Copeland, G.P.F.A.U., Jones, D.F.W., Walters, M.: POSSUM:
a scoring system for surgical audit. Br. J. Surg. 78, 355–360
(1991)
12. Tekkis, P.P., et al.: Development of a dedicated risk-adjustment
scoring system for colorectal surgery (colorectal POSSUM).
Br. J. Surg. 91, 1174–1182 (2004)
13. Bowles, T., Watters, D.: Time to CUSUM: simplified report-
ing of outcomes in colorectal surgery. ANZ J. Surg. 77(7),
587–591 (2007)
14. Yap, C., Colson, M., Watters, D.: Cumulative sum tech-
niques for surgeons: a brief review. ANZ J. Surg. 77(7),
583–586 (2007)
15. Wolff, A.M., Bourke, J., Campbell, I.A., Leembrugen, D.W.:
Detecting and reducing hospital adverse events. Med. J.
Aust. 174, 621–625 (2001)
16. Birks, D.M., Gunn, I.F., Birks, R.G., Strasser, R.P.:
Colorectal surgery in rural Australia: SCARS; a surgeon-
based audit of workload and standards. ANZ J. Surg. 71,
154–158 (2001)
 Acute Pain Management
Edmund A.M. Neugebauer, Astrid Althaus,
and Christian Simanski
Pearls and Pitfalls
›› Sufficient pain management is a prerequisite
for enhanced patient recovery and for a
­reduction in postoperative morbidity and
mortality.
›› Pain assessment and documentation (‘fifth
vital sign’) are fundamental prerequisites for
adequate pain management.
›› Opioids remain the fundamental group of
analgesic drugs for the treatment of moder-
ate-to-severe pain.
›› Co-analgesics support the action of analge-
sics but are not sufficient alone for postopera-
tive pain relief.
›› Peripheral nerve blocks have the main advan-
tage of not compromising patient alertness.
›› Local analgesics are very effective in epidu-
ral analgesia.
›› Epidural local anaesthetics lead to a
decreased incidence of pulmonary infection
and complications overall compared with
opioids.
›› Treatment of acute pain should be procedure-
specific and treatment should be adapted to
the measured pain intensity reported by the
patient.
E.A.M. Neugebauer (*), A. Althaus, and C. Simanski
Department of Medicine, University of Witten/Herdecke,
Ostmerheimer Straße 200, 51109 Cologne, Germany
e-mail: edmund.neugebauer@uni-wh.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_12, © Springer-Verlag Berlin Heidelberg 2011
12
›› Pain management is an interdisciplinary task
requiring close liaison with all personnel
involved in the care of the patient.
›› Use of evidence-based clinical practice guide-
lines are recommended and should be adapted
locally.
Acute pain management is a basic human right
(Professor M. I. Cousins, President, Australian and New
Zealand College Anaesthetists)
Although major efforts have been taken to improve
acute pain management in recent years, we are still far
away in meeting this basic human right. In the USA
and Europe, the results of studies dedicated specifi-
cally to both medical and postoperative patients in aca-
demic hospitals have shown unequivocally that pain
remains undertreated.
Insufficient pain management originates from orga-
nizational problems, time constraints in daily clinical
routine, little motivation to change daily clinical rou-
tine, complexity of pain management, difficulties in
assessing pain intensity, and insufficient knowledge of
pain management.
However, pain should not be an accompanying phe-
nomenon of medical treatments. Adequate techniques
(epidural analgesia, epidural catheter, patient-controlled
analgesia, etc.) and effective analgesics exist and, in
principle, the possibilities for adequate pain manage-
ment are available to all. An adequate pain therapy is an
important prerequisite for enhanced patient recovery,
and will reduce the postoperative risk of morbidity and
mortality. Moreover, a significant reduction in long-term
morbidity can be achieved since moderate-to-severe
67
68
acute pain has been demonstrated as an independent
predictor for chronic postoperative pain. Adequate pain
therapy is cost-effective; it is associated with a decrease
in both intensive care and overall hospital stay. Studies
have shown that up to 70% of patients present to the
hospital because of acute pain. Furthermore, they asso-
ciate the success of medical treatment with the relief of
pain and it is of significant value from the patients’ per-
spective. Pain is therefore considered an ideal parameter
for the evaluation of the quality of in-hospital care.
12.1 Definitions
Pain, as defined by the International Association for the
Study of Pain, is ‘an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage’. Pain is
subjective and is an individual, multifactorial experi-
ence influenced by culture, previous pain events, mood,
beliefs, and an ability to cope. Acute pain is defined as
‘pain of recent onset and probable limited duration’. It
usually has an identifiable temporal and causal rela-
tionship to injury (trauma, operation) or disease (colic,
peritonitis, etc.). Chronic pain persists commonly
beyond the time of healing of an injury (>3–6 months)
and frequently has no clear identifiable cause. Acute
and chronic pain may represent a continuum.
12.2 Pathophysiological
and Pharmacological Basics
Pain development and transduction involves multiple
interacting peripheral and central mechanisms. The
understanding of principles is important for the choice
of medical treatments, and will therefore be summa-
rized briefly. The basis of each central nervous system
function is the excitation–response relationship.
Peripheral level: Acute pain starts by tissue injury
caused by mechanical, thermal, or chemical excitation.
The detection of noxious stimuli requires activation of
peripheral sensory organs (nociceptors) and transduc-
tion of the energy into electrical signals for conduction
to the central nervous system. Nociceptive afferents
are distributed widely throughout the body (skin, mus-
cle, joints, viscera, meninges).
E.A.M. Neugebauer et al.
Spinal cord level: Once transducted into electrical
stimuli, conduction of neuronal action potentials into
afferent input and dorsal horn outputs follows. This sig-
nal conduction is called transmission in the spinal cord.
The processing of pain on its way from excitation to per-
ception is subject to several transformations. Tissue dam-
age such as that associated with infection, inflammation,
or ischemia, produces an array of chemical mediators
(algetic substances such as prostaglandins, histamine,
etc.) which can sensitize nociceptors to increase pain
perception. This increase in sensitivity is termed periph-
eral sensitization, which can also lead to central sensiti-
zation. In addition to the excitatory processes, inhibitory
modulation occurs within the dorsal horn.
Central projecting level: A peripheral pain signal
which reaches the central nervous system after trans-
duction, transmission, and transformation needs to be
translated into pain perception. The areas of the brain
involved are the limbic system, cortex (e.g., cingulate
cortex, insula, prefrontal cortex), and thalamus. The
perception and experience of pain is multifactorial and
is further influenced by psychological and environ-
mental factors of each individual. Figure 12.1 gives a
schematic representation of the nociceptor pathway.
Pain perception
and experience
Cortex
thalamus
Transformation
Sympatic conduction
Spinal
and modulation
cord
Transformation
Actions potentials
Transmission
Receptor potentials
Transduction
Mechanical, thermal,
chemical stimuli
Fig. 12.1 Schematic representation of the nociceptor pathway
12 Acute Pain Management 69

12.3 Analgesic Drugs functions including gastric mucosal protection, renal

tubular function, intrarenal vasodilatation, bronchodi-
latation, and production of endothelial prostacyclin. Such
For adequate pain management, it is necessary to be
physiological roles are mainly regulated by COX-1
familiar with the main mechanisms of pain relief by
and are the basis for many of the adverse effects associ-
the different analgesic drugs. Analgesic drugs can be
ated with NSAID use. Tissue damage results in COX-2
subdivided into five major categories (Table 12.1).
­production, leading to synthesis of prostaglandins that
result in pain and inflammation.
12.3.1 Non-opioid Analgesics NSAIDs are nonselective COX inhibitors that inhibit
both COX-1 and COX-2 with a wide spectrum of analge-
sic, anti-inflammatory, antipyretic effects. Aspirin acety-
The basic action of most non-opioids (nonsteroidal lates inhibit COX irreversibly but NSAIDs are reversible
anti-inflammatory drugs – NSAIDs) is the inhibition of inhibitors of enzymes. The COX-2 inhibitors (e.g., pare-
the cyclooxygenase (COX) enzymes. Two subtypes of coxib) have been developed to inhibit selectively the
COX enzymes have been identified – the constitutive inducible form. Arylacid derivatives (diclofenac) and
COX-1 and the ‘inducible’ COX-2, and now a COX-3 aryl propionic derivates (ibuprofen) are nonselective
is being investigated. Many of the effects of NSAIDs COX-inhibitors. Para­cetamol (acetaminophen) and met-
can be explained by inhibition of prostaglandin synthe- amizol have additional central effects. A combination of
sis in peripheral tissues, nerves, and the central nervous paracetamol and NSAIDs has additive effects on postop-
system. Prostaglandins have many physiological erative analgesia. Figure 12.2 illustrates the nociceptive
pathway and therapeutic options of pain relief.

Table 12.1 Categories of analgesic drugs

• Non-opioids
• Opioids 12.3.2 Opioids
• Local anaesthetics
Opioids remain the central group of analgesic drugs
• Co-analgesics
for the treatment of moderate-to-severe acute pain and
• Adjuvant drugs transmit their action via different types of receptors.

Hypothalamus/thalamus Opioids/antidepressants
limbic system (colitis, crohn, surgery of carcinoma)

Opioids
Cortical translation (thorax/esophageal/pancreas operations)

Non-opioids
Spinal cord/brainstem (in combination with COX-inhibitors in major
operation, i.e., colon)

Afferent nerve conduction Local anesthetics (inguinal hernia repair)

Fig. 12.2 Nociceptive COX-Inhibitors, NSAID’s

pathway and therapeutic Nociceptor
(basic medication)
options of pain relief
70 E.A.M. Neugebauer et al.

Opioids can be differentiated into pure m-agonists Table 12.2 Co-analgesics and their main functions
(morphine, oxycodone, fentanyl, tramadol), mixed Antidepressant Increase function of inhibitory transmit-
agonists–antagonists (antagonistic at m-receptors and ter (e.g., serotonin, noradrenalin, i.e.,
aminotryptiline)
agonistic at k- and s-receptors, e.g., pentazocine, tili-
dine), partial agonists with high affinity and small Anticonvulsive Supportive in neuropathic pain syndro­
mes (e.g., carbamacepine, gabapentin)
intrinsic activity at m-receptors (buprenorphine), and
pure antagonists (at m-, k-, and s-receptors) such as Muscle relaxant Supportive in muscle pain and spasms
naloxone. The opioid receptors are located mostly at (e.g., benzodiazepine)
structures that are involved in transmission, transfor- Corticosteroid Anti-inflammatory
mation, and translation of afferent signals. A high den- (e.g., dexamethasone)
sity is found in the limbic system, the thalamus, the Bisphosphonate Supportive in bony pain syndromes after
pons region, and the substancia gelatinosa in the dorsal metastasis of tumours (e.g., clodronate,
pamidronate)
horn. Clinically meaningful side effects are dose-
related; once a threshold dose is reached, every 3–4 mg
increase of morphine-equivalent dose per day is asso-
However, they are extremely helpful in combination
ciated with one additional adverse event. The most sig-
with opioids and NSAIDs, and can reduce postopera-
nificant adverse effects are sedation, pruritus, nausea,
tive analgesic requirements. Adjuvant drugs are mainly
and vomiting. The risk can be reduced significantly by
used to decrease side effects of analgesic drugs such as
parallel application of NSAIDs and/or adjuvant drugs.
emesis, vomiting, and constipation. Co-analgesics can
In the management of acute pain, one opioid is not
be classified as follows (Table 12.2):
superior to others but some opioids appear more effec-
Antidepressants decrease the awareness of pain and
tive in some patients than others.
enhance the functioning of inhibiting neurotransmit-
ters (serotonin, noradrenalin). Beside their antidepres-
12.3.3 Local Anaesthetics sant effect, they also have analgesic properties.
Anticonvulsants: Carbamazepine, clonazepam and
gabapentin are the most common agents used in the
Local anaesthetics exert their effects as analgesics by
treatment of neuropathic pain.
impeding neuronal excitation and/or conduction. Short-
Tonicity reducing medication (i.e., benzodiazepines)
duration local anaesthetics (lignocaine, plasma half-life
is used in the treatment of painful muscle tension and
90 min) have to be differentiated from long-duration
spasm. The mode of action of most substances remains
local anaesthetics (bupivacaine, ropivacaine). The local
unknown.
anaesthetic effect primarily depends on the site of
Corticosteroids inhibit the formation of cytokine,
administration, the dose administered, and the presence
leukotriene, prostaglandin and macrophage activating
or absence of vasoconstrictors. Local application of 20
interferon-g, and suppress the formation of inflamma-
ml 0.25% bupivacaine in the area of trocar incision
tory processes.
sites in laparoscopic cholecystectomy or colectomy
Bisphosphonates have a repressive effect on bone
reduces significantly postoperative pain intensity. Local
absorption and are particularly used in the therapy of
anaesthetics are very effective in epidural analgesia.
bone pain and osteolytic bone metastasis.
The quality of pain relief from low-dose epidural infu-
Adjuvants can be divided into antiemetics and lax­
sion (bupivacaine 0.1%, ropivacaine 0.2%) is improved
atives and are used to manage anxiety and side eff­-
consistently from the addition of adjuvants such as
ects of analgesic therapy, i.e., nausea, vomiting, and
­opioids. The concept of fast-track recovery benefits
constipation.
most from the application of an epidural.

12.3.4 Co-analgesics and Adjuvant Drugs 12.3.5 General Pain Management

Co-analgesics support the action of analgesics but are The surgeon has a special responsibility in the treatment
not sufficient alone for postoperative pain management. of pain. Aside from pharmacological interventions,
12 Acute Pain Management
consideration should be given to the possibility of inter-
vention before, during, and after surgery to optimize
pain management. All procedures should be performed
under the philosophy of avoiding pain wherever possi-
ble (minimal invasive techniques, positioning, etc.).
Drains should be avoided and wound closure should
be performed preferably with absorbable sutures.
Postoperatively, a whole array of preventive measures
should be considered with respect to reducing pain and
associated complications: early rehabilitation (fast-
track), wound management, physio­therapy, cold/heat,
massage techniques, and removal of lines and drains as
soon as possible.
12.4 Preoperative Interventions
Preoperatively, the surgeon has to provide evidence-
based information to the patient regarding the type of
disease, available treatment options, and procedure-
related postoperative pain management. The informa-
tion about possible upcoming pain should neither
evoke unrealistic expectations nor fear. Adequate pro-
cedural information can reduce anxiety and has an
advantageous influence on the patient’s pain assess-
ment. The knowledge about the possibility to influence
the pain sensation in a positive way enhances the pain
tolerance and this in turn reduces the use of analgesics.
By contrast, insecurity about the operation and possi-
ble upcoming pain can increase the fear of the opera-
tion. A high level of anxiety and unrealistic beliefs can
in turn increase postoperative pain.
The placebo-effect plays an important role, and
should be used within the frame of positive and realis-
tic information.
Patient information and training regarding coping
and relaxation strategies have been shown to reduce
pain and distress. The patients should be convinced
that their pain is of utmost importance to the treating
team and that they can also contribute to the success of
pain management (patient as partner/co-therapist).
Information about the different possible pain therapies
need to be adapted to the patient’s experiences. The
patient needs to be informed about side effects and
alternative pain treatments.
Smaller interventions and wound care should be done
using local anaesthetics. If children are treated, a suffi-
cient wound adaptation can be achieved without a needle
71
but with adhesive tape. The patient’s position while
being operated can also influence the emergence of post-
operative pain; patients, who are operated in a dorsal
position, i.e., abdominal operations, have less postopera-
tive pain in the back if they have a pillow beneath their
knees during the treatment. During prolonged opera-
tions, it is mandatory to put the patient in a position that
avoids pressure on exposed body parts because this
might lead to nerve damage or a compartment syndrome
with additional pain (head of the fibula, sulcus ulnaris on
the elbow, popliteal fossa during lithotomy position).
12.5 Intraoperative Interventions
Intraoperatively, the choice of the operative procedure
and of the access is essential to reduce postoperative
pain. Minimal invasive operative procedures have been
established especially for operations of the appendix,
gallbladder, groin hernia, and colon and constitute
well-validated methods with significantly less post­
operative pain than the conventional procedures.
Transversal incisions cause less pain than vertical
­incisions in laparotomies, and skin incisions via diathermy
cause less pain than the conventional scalpel. Further ­pos­-
sibilities to reduce pain can be achieved by defining strict
indications for the usage of drains and tubes. Usually,
it can be abstained from placing subcutaneous suction
drains. Suture material can also influence postoperative
pain. Absorbable sutures avoid painful removal.
12.6 Postoperative Interventions
Surgeons can alleviate postoperative pain by using
­adequate bandages. Very tight or unneeded bandage
have to be avoided. Tuberosities need sufficient cush-
ioning when orthotics or orthopaedic casts are applied.
The early mobilization of patients with the assis-
tance of nursing staff or physiotherapists can help to
avoid postoperative complications. By means of a
stepwise augmentation of exposure and sufficient anal-
gesia, excessive demands can be avoided. Newer ‘fast
track concepts’ schedule the patient’s mobilization to a
chair already 5 h after the operation.
Physical treatment and adjuvant medications can be
used in addition to alleviate pain.
72
If catheters, drains, and tubes are not needed any-
more, they should be removed immediately. Analgesia
can decrease physiologic reactions to surgical compli-
cations (fever, muscular defence). Thus, the surgeon
has to be informed about increasing pain and use of
analgesics.
12.7 Medical Interventions
12.7.1 Peripheral Nerve Blockade
The main advantage of using peripheral nerve block
techniques as compared to systemic drug therapy (see
below) is that the use of local anaesthetics does not
compromise patient alertness and allows pain-free
mobilization. Peripheral nerve blocks may be used for
diagnostic and therapeutic purposes. Important techni-
cal issues include the technique of nerve location, the
type of catheter equipment, the amount of drug, and
the duration of drug efficacy. Following localization of
the nerve, a continuous block can be initiated. Local
anaesthetics such as lidocaine, mepivacaine, or prilo-
caine are effective for 2 h whereas bupivacaine and
ropivacaine can produce pain relief for up to 12 h.
Adjuvant techniques may prolong the duration of
action. For example, wound infiltration with a long-
acting local anaesthetic agent provides effective anal-
gesia following inguinal hernia repair but not for open
cholecystectomy or hysterectomy. Continuous femoral
nerve blockade provides postoperative analgesia and
functional recovery superior to intravenous morphine
with fewer side effects and comparable to epidural
analgesia following knee joint replacement surgery.
Both single injection and continuous application
carry the risk of neurological injury, intravascular
injection, dislodgment, haematoma, and infection. The
incidence of neurological injury following peripheral
nerve blocks is 0.02–0.4%.
12.7.2 Epidural Analgesia
Epidural analgesia (i.e., the provision of pain relief by
continuous administration of pharmacological agents
into the epidural space via an indwelling catheter) has
E.A.M. Neugebauer et al.
become a widely used technique for the management
of acute pain after surgery and trauma. Regardless of
the analgesic agent used, location of catheter, or the
type of surgery, it provides better pain relief than par-
enteral opioid administration.
Improved pain relief with epidural local anaesthet-
ics leads to a decreased incidence of pulmonary infec-
tion and other pulmonary complications overall when
compared with systemic opioids. The combination of a
low concentration of local anaesthetic and opioid is
superior to either of the drugs alone. The addition of
small amounts of adrenaline (epinephrine) to such
mixtures improves analgesia and reduces systemic opi-
oid consumption. Administration of a local anaesthetic
into the thoracic epidural space results in improved
bowel recovery, while this benefit cannot be observed
with lumbar drug administration. Adverse effects are
uncommon but include permanent neurological dam-
age, which is reported at 0.05–0.0005%, and epidural
haematoma (0.0005%). Others include respiratory
depression (1–15%) and hypotension (5–10%).
12.7.3 Systemic Analgesia
Necessary prerequisites for patient-orientated systemic
pain therapy are good knowledge and understanding of
the cause of pain (inflammatory, spasm, type of operation
or operative access, anxiety, or depression of the patient),
the anatomy and pain transduction, and, based on this
information, the necessary surgical, physical, psychologi-
cal, or medical therapy. Whereas chronic pain treatment
starts with non-pharmacological techniques (psychother-
apy, TENS, etc.) followed by mild non-opioid analgesics,
and, subsequently, strong opioids, the treatment of acute
pain follows the reverse order (Fig. 12.3).
Strong opioids combined with NSAIDs are used as
first-line therapy to control pain when intensity is high-
est. Analgesic drugs given by the intravenous route
have a more rapid onset of action compared with most
other routes of administration. Titration of opioid ther-
apy for severe acute pain is best achieved using inter-
mittent intravenous bolus doses (2–3 mg of morphine
at 5 min intervals until relief of pain).
Relative or absolute overdosing (also rapid injec-
tion) may lead to complications and side effects inde-
pendent of the opioid used. However, the risk of
overdosing with resultant respiratory depression is not
12 Acute Pain Management
“Reversed” WHO-pain ladder
for acute pain therapy
(Non-opioids always as basic medication)
Strong opioids
Moderate opioids
Non-opioids
WHO pain ladder for chronic pain therapy
Strong opioids
Moderate opioids
Non-opioids
Fig. 12.3 WHO pain ladder of acute and therapeutic pain
therapy
an issue as long as the patient continues to experience
pain. If it occurs, sufficient antagonists (naloxon 0.4 mg)
should always be available and the sedation level
should be assessed in parallel. Continuous infusion of
opioids in the general ward setting is not recommended
because of the increased risk of respiratory depression
compared with other methods of parenteral opioid
administration.
Non-opioid analgesics have an antipyretic and anti-
inflammatory effect. They should be administered
either solely (such as after minor operations) or in
combination with opioids.
Opioid and non-opioid drugs can be administered
systemically by a number of different routes. The
choice of route is determined by various factors includ-
ing the overall condition of the patient but also by the
ease of use, accessibility, speed of analgesic onset,
duration of action, and patient acceptability. In general,
the principle of individualization of dose and dosing
intervals should apply to the administration of all anal-
gesic drugs, whatever the route. Frequent assessment
of the patient’s pain and their response to treatment
rather than strict adherence to a given dosing regimen
is required if adequate analgesia is to be obtained. Oral
administration is straightforward, noninvasive, has
good efficacy in most settings, and has a high patient
acceptability. Other than in the treatment of severe
73
acute pain, it is the route of choice for most analgesic
drugs provided that there is no contraindication to its
use. After major operations or trauma, the aim should
be to change to the oral route as quickly as possible.
The analgesic efficacy varies from one pain model to
another and the administration of analgesics should be
procedure-specific. Although still used commonly,
intramuscular injection of analgesic agents is no longer
recommended because of the significant risk of abscess
formation, nerve lesions, and necrosis. Subcutaneous
injection shares the same problem as intramuscular
administration that absorption may be impaired in situ-
ations of poor perfusion. This leads to inadequate early
analgesia and late absorption of the drug depot when
perfusion is reestablished. Rectal administration of
drugs is useful when other routes are unavailable.
Transdermal routes for opioid administration (fentanyl
or buprenorphine patches) are not recommended for
acute pain management due to safety concerns (respi-
ratory depression) and the difficulties in short-term
dose adjustments that may be required for titration.
The general rule is that the patient should determine
their analgesic requirement within given limitations for
all routes of administration. Patient-controlled analge-
sia (PCA) refers to methods of pain relief that allow the
patient to self-administer small doses of an analgesic
agent as required. This is not necessarily associated
only to the use of programmable infusion pumps.
Adequate analgesia needs to be obtained prior to com-
mencement of PCA. Initial instructions for bolus doses
should take into account individual patient factors such
as history of prior opioid use and patient age. Individual
prescriptions may need to be adjusted and drug concen-
trations should be standardized within each institution
to reduce programming errors. A background infusion
is not recommended in acute pain management.
12.8 Non-medical Interventions
Regarding severe postoperative pain pharmacological
treatment is the first-line therapy. This can be comple-
mented by nonmedical interventions including special
nursing and physiotherapeutic techniques, psychologi-
cal interventions, acupuncture, and contra-irritation
techniques. All these procedures not only feature little
or no side effects, but also provide the patient with
attention and personal care.
74
12.8.1 Nursing and Physiotherapy
Within the postoperative therapy procedures such as
general mobilization (exercises in bed, helping the
patient to get up and walk around), demonstration of
rather pain-free motion sequences, pain-free breathing
and coughing techniques, tension-release techniques,
active or passive motion exercises, techniques of mas-
sage, and special positioning of the patient should
always be considered.
Postoperative cooling therapy is advisable after
orthopaedic surgical treatment. A recently conducted
meta-analysis including six randomized studies revealed
a significant analgesic effect in favour of patients who
were treated with cooling after an arthroscopic cruciate
ligament repair compared to the control group. In body
areas with poor blood supply, for example, in vascular
surgical patients, however, a cooling therapy is
contraindicated.
12.8.2 Psychological Interventions
Preoperatively, a combination of different cognitive-
behavioural strategies has been proven to reduce pain
and anxiety. Psychological interventions should also
be integrated in the postoperative pain management;
their efficacy is well-validated not only in the treat-
ment of chronic pain but also in the therapy of acute
pain. Cognitive-behavioural techniques as distraction,
cognitive revaluation, and positive visualization have
turned out to alleviate pain. Other strategies as imagi-
nation techniques, hypnosis, and relaxation exercises
can reduce the degree of postoperative pain and the
use of analgetics. Cognitive-behavioural techniques
within the preoperative setting are not time-consuming
and can be implemented promptly after the operation.
12.8.3 Contra-Irritation Techniques
The contra-irritation technique is based on the
­gate-control theory. After certain kinds of operations
the additional application of a transcutaneous elec­trical
nerve stimulation (TENS) with an intensity below the
pain threshold (15 mA) can reduce the ­postoperative
pain intensity as well as the need for analgetics. Positive
E.A.M. Neugebauer et al.
effects have been demonstrated after meniscus opera-
tions, thoracotomies, and shoulder joint operations.
12.8.4 Acupuncture
Acupuncture has been proven to be effective and
­efficient in the treatment of certain chronic pain
­syndromes, whereas in postoperative pain high level
evidence is still missing. In total hip replacement and
arthroscopic shoulder joint surgery the use of analget-
ics was reduced by applying acupuncture. Regarding
postoperative side effects (nausea, vomiting), a meta-
analysis revealed a significant effect of P6 acupunc-
ture compared to the application of fake acupuncture.
12.9 Assessment and Documentation
of Acute Pain
Pain assessment and documentation are fundamental
prerequisites for adequate pain management. Regular
assessment leads to improved pain management. Under
routine clinical conditions, measurement of pain inten-
sity is sufficient and should be performed by visual
analogue or numerical rating scales. Self-reporting of
pain should be used whenever appropriate as pain is by
definition a subjective experience. In the pre- and post-
operative setting scoring should include static (rest)
and dynamic (pain on sitting, coughing) measurements
at least two times a day and following treatment of
pain to determine efficacy. The score should be docu-
mented in the patient’s charts as the ‘fifth vital sign’.
Uncontrolled or unexpected pain requires reassess-
ment of the diagnosis and consideration of alternative
causes for pain.
12.10 Organization of Acute Pain
Management
Pain management is an interdisciplinary undertaking.
Successful management of acute pain requires close liai-
son with all personnel involved in the care of the patient
and should include surgeons, anaesthesiologists, and
nurses. Effective acute pain management will only result
from appropriate education and organizational structures
12 Acute Pain Management
for the delivery of pain relief. Clear-cut responsibilities
between disciplines are mandatory and this may differ
between countries or even hospitals. Effective organiza-
tional structures for the delivery of pain relief are often
more important than the anal­gesic techniques them-
selves. In some institutions, acute pain services (APS)
are responsible for managing more advanced methods
of pain relief such as PCA and ­epidural analgesia. There
is a wide diversity of APS structures (from low-cost
nurse-based through to multidisciplinary services) with
different responsibilities. A recent review of publica-
tions analyzing the effectiveness of APS concluded
that its implementation is associated with a significant
improvement of pain relief with a possible reduction of
postoperative nausea and vomiting.
Marked improvements in conventional methods
of pain relief can be expected by the introduction of
evidence-based clinical practice guidelines. However,
it is the implementation of guidelines and not their
development which remains the greatest obstacle to
their use. Professional bodies in a number of coun-
tries have published guidelines for the management
of acute pain. A procedure-specific approach is
highly recommended such as the online PROSPECT
group (www.postoppain.org). Resource availability,
staff with pain management expertise, and the exis-
tence of formal quality assurance programmes to
monitor pain management are positive predictors of
compliance with guidelines. Official guidelines need
to be adapted for individual hospital requirements
and the ward nurses play the most significant role in
local adaptation. With their support, and that of clini-
cal management and directors of surgical depart-
ments, we have been successful in translating national
guidelines on acute pain management into the
‘Initiative Pain Free Clinic’. The Cologne City
Hospital Merheim was the first in Germany to receive
board certification by an external organization. This
initiative served as a role model for other hospitals in
75
improving the organization of acute pain manage-
ment with resultant benefit to the patients and the
hospital.
Recommended Reading
American Society of Anesthesiologists: Practice guidelines for
acute pain management in the perioperative setting. An
updated report by the American Society of Anesthesiologists
Task Force on acute pain management. Anesthesiology 100,
1573–1581 (2004)
Australian and New Zealand College of Anaesthetists and Faculty
of Pain Medicine: Acute pain management: scientific evi-
dence, 2nd edn. National Health and Medial Research Council.
http://www.nhmrc.gov.au/publications/subjects/clinical.htm
(2005)
Ballantyne, I.S., Carr, D.B., de Ferranti, S., et al.: The compara-
tive effects of postoperative analgesic therapies on pulmo-
nary outcome: cumulative meta-analyses of randomized,
controlled trials. Anaesth. Analg. 86, 598–612 (1998)
Kehlet, H.: Multimodal approaches to control postoperative
pathophysiology and rehabilitation. Br. J. Anaesth. 78, 606–
617 (1997)
Kehlet, H., Gray, A.W., Bonnett, F., et al.: A procedurespecific
systematic review and consensus recommendations for post-
operative analgesia following laparoscopic cholecystectomy.
Surg. Endosc. 19, 1396–1415 (2005)
Neugebauer, E.: Initiative Schmerzfreie Klinik: (k)eine vision.
Schmerz 19, 557 (2005)
Laubental, H., Neugebauer, E., et al.: The German guidelines on
the treatment of acute perioperative and posttraumatic pain.
www.leitlinien.net-AWMF0041
Neugebauer, E., Hempl, K., Sauuerland, S.T., et al.: Situation der
perioperativen Schmerztherapie in Deutschland: Ergebnisse
einer reprasentativen, anonymen Umfrage von 1000 chirur-
gischen. Kliniken Chirurg 69, 461–466 (1998)
Veterans Health Administration D.o.D.: Clinical practice guide-
line for management of postoperative pain. http://www.oqp.
med.va.gov/cqg/PAIN/PAIN_base.htm (2002)
Werner, M.U., Søholm, L., Rotbøll-Nielssen, P., et al.: Does an
acute pain service improve postoperative outcome. Anaesth.
Analg. 95, 1361–1372 (2002)
Zhao, S.Z., Chung, F., Hanna, P., et al.: Dose-response relation-
ship between opioids use and adverse effects after ambula-
tory surgery. J. Pain Symptom Manage. 28, 35–46 (2004)
 Prophylaxis of Venous Thromboembolism
Robert A. Fitridge and Simon McRae
13.1 Prevention of VTE
13.1.1 Incidence of VTE in Hospitalised
Patients
Venous thromboembolism (VTE) is a significant
cause of morbidity and mortality in our community,
with an annual incidence of 1–2 per 1,000 individu-
als. ­App­roximately 50% of episodes of VTE are
related to recent hospital admission, with an almost
equal contribution from surgical and non-surgical
patients.
Without thromboprophylaxis, the incidence of DVT
in hospitalised patients is significant (Table 13.1).
As expected, variation is seen between different patient
categories, with the incidence highest in patients under-
going major orthopaedic procedures and experiencing
major trauma. The reported incidence of VTE is influ-
enced by the method utilised to screen for events.
Venography detects all events, including asymptomatic
isolated distal DVT, and studies using this method give
the highest reported rate. However, the incidence
of clinically significant symptomatic events in most
­studies has been shown to be directly proportional to
the venographic incidence of VTE (approximately
­tenfold less).
R.A. Fitridge (*) and S. McRae
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: robert.fitridge@adelaide.edu.au,
simon.mcrae@imvs.sa.gov.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_13, © Springer-Verlag Berlin Heidelberg 2011
13
13.1.2 Methods of Thromboprophylaxis
Both mechanical and pharmacological methods of
thrombo­prophylaxis have been clearly demonstrated in a
number of studies to decrease the risk of DVT and pul-
monary embolus (PE), including fatal events, as well as
being cost effective. The choice of approach is predomi-
nantly determined by the absolute risk of VTE associated
with a particular procedure. Generally, pharmacologi-
cal prophylaxis has been shown to be more effective than
mechanical methods alone, with the former reducing the
risk of VTE by at least 60–70% in most patient groups.
13.1.2.1 Currently Available Methods
of DVT Prophylaxis
General Measures
The importance of general measures such as adequate
hydration of hospital inpatients, and early mobilisation
while recovering from their illness or surgery should
not be underestimated, although these measures have
not been extensively studied.
Mechanical Methods
Mechanical methods include graduated compression
stockings (GCS), intermittent pneumatic compression
devices (IPC) and venous foot pump (VFP). The most
obvious advantage of mechanical prophylaxis over
pharmacological methods is that there is no increased
risk of bleeding associated with the former. This is par-
ticularly important in patients who are at high risk of
bleeding or procedures where post-operatively bleed-
ing is particularly catastrophic, e.g. neurosurgery.
77
78
Table 13.1 Risk of DVT without prophylaxis
Condition Incidence (%)
Major abdominal general 15–30
surgery
Major trauma 40–80
Stroke 20–50
Patients in high dependency/ 30–50
intensive care units
The use of IPC devices alone has been shown to be
effective in decreasing the risk of VTE in a number of
surgical patient groups [1], and therefore, this approach
should be utilised in moderate- or high-risk patients in
whom anticoagulant therapy is contra-indicated. IPC is
also often used as an adjunctive measure in addition to
pharmacological methods in patients at particularly high
risk of venous thromboembolism, an approach sup-
ported by the findings of a recent Cochrane review [2].
A recent systematic review suggested that use of
graduated compression stockings results in up to a
50% reduction in all episodes of DVT; however, the
data regarding the role of stockings in preventing the
more clinically significant proximal DVT was incon-
clusive. There is ongoing debate about the effective-
ness of knee-high GCS in comparison to full-length or
thigh-high stockings, with the available data being
inconclusive. However, frequent inappropriate appli-
cation and poor patient compliance with full length
stockings may limit their effectiveness in real life.
Pharmacological Methods of Prophylaxis
A number of pharmacological methods of VTE prophy-
laxis are now available. Unfractionated heparin (UFH)
has been used for VTE prophylaxis for a number of
decades, and is normally given at a dose of 5,000 units of
sodium heparin twice or three times daily. Low-
molecular-weight heparin (LMWH) is a chemically or
enzymatically modified form of UFH, which is generally
given as a once-daily dose. LMWH has been shown to be
more effective than UFH for a number of indications
including prevention of DVT post major orthopaedic
­surgery, major trauma and ischaemic stroke, and current
guidelines reflect these findings. Warfarin is still widely
utilised for prophylaxis post major orthopaedic surgery
in North America, and can also be used in other patient
groups if extended prophylaxis is indicated (Table 13.2).
R.A. Fitridge and S. McRae
Table 13.2 Forms of DVT prophylaxis
General Adequate hydration
Early mobilisation
Mechanical methods Graduated compression
stockings (GCS)
Intermittent pneumatic
compression devices
(IPC)
Pharmacological methods Unfractionated heparin
Low-molecular-weight
heparin
Selective factor Xa
inhibitor (Fondaparinux)
Warfarin
A number of new antithrombotic agents that selec-
tively inhibit specific activated clotting factors are
presently or are soon to become available for use in
patients requiring thromboprophylaxis. Fondaparinux
is an injectable selective indirect inhibitor of factor Xa
that has now been available for some years. Combined
data from a number of trials has demonstrated that
Fondaparinux is more effective in preventing VTE fol-
lowing major orthopaedic surgery than LMWH, at the
expense of a slight increase in bleeding risk which has
probably resulted in limited uptake of this agent.
Renal clearance is the method of elimination of low-
molecular-weight heparin and Fondaparinux. In a setting
of a creatinine clearance of <30 ml/min, a reduction in
the calculated dose of low-molecular-weight heparin or
Fondaparinux should be considered. Alternative agents
should be considered in patients with more marked renal
impairment. Due to the frequent age-related decrease in
creatinine clearance, particular care should be taken
when using these agents in very elderly.
Significant interest has surrounded the develop-
ment of a number of new oral agents likely to be used
for both prevention and treatment of VTE. Rivaroxaban
is an oral direct factor Xa inhibitor that has been
shown to be more effective than the LMWH enox-
aparin in preventing VTE following hip and knee
arthroplasty, with similar bleeding rates. Dabigatran
is an oral direct thrombin inhibitor that appears to be
as effective as LMWH in preventing VTE following
orthopaedic ­surgery. Both agents have been recently
approved in a number of health jurisdictions for the
above indications.
13 Prophylaxis of Venous Thromboembolism
13.1.3 Inferior Vena Caval Filters
There is ongoing debate regarding what constitutes
appropriate use of inferior vena cava (IVC) filters.
There is general agreement that IVC filter use is appro-
priate in patients with recent (within 1 month) symp-
tomatic VTE requiring more than brief interruption of
therapeutic anticoagulation. All other indications are
open to debate, largely due to the lack of evidence for
or against their use in other circumstances. Most con-
troversial is the use of filters in trauma patients at high
risk of VTE in whom anticoagulant therapy is contra-
indicated. The availability of temporary IVC filters
able to be retrieved has no doubt contributed to the
increase in filter use in recent years. However, it is not
uncommon for these planned temporary devices to be
unable to be retrieved, and clinicians should therefore
consider that temporary IVC filters may in fact remain
in-situ indefinitely, with their presence associated with
a long-term increase in risk of DVT.
13.1.4 Risk Stratification for VTE
As mentioned above, the risk of developing VTE can
be stratified on the basis of both patient-related
­co-morbidities and procedure-related risks. Table 13.3
summarises these risk factors. Whilst it is possible to
assess the risk for an individual patient, a more straight-
forward approach is to use simplified protocols, risk
Table 13.3 Risk factors for venous thromboembolism [3]
Patient related Previous DVT or PE
Cancer
Immobility, e.g. CVA
Oestrogen therapy (HRT or
OCP)
Thrombophilia
Obesity
Inflammatory conditions, e.g.
inflammatory bowel disease
Surgical procedure related Hip, knee, lower limb
orthopaedic surgery
Laparoscopic surgery
Cancer surgery
79
stratifying patients primarily on the basis of their
planned surgical procedure/or primary underlying
medical condition and modify this only if a number
of further risk factors are present. Figure 13.1 and
Table 13.4 show contemporary protocols for prophy-
laxis based on risk developed by the ANZ Working
Party on the Management and Prevention of Venous
Thromboembolism and the American College of Chest
Physicians. It is recommended that all health institu-
tions adopt similar guidelines, with or without local
modification as appropriate. Risk assessment should
be performed in all patients at admission to hospital, if
not already done so at surgical pre-assessment.
13.1.5 Current Compliance with VTE
Prophylaxis Guidelines
A number of studies have demonstrated inadequate
adherence to guidelines for provision of VTE prophy-
laxis. Individuals can be risk stratified regarding their
risk of developing DVT or PE on the basis of both
patient-related co-morbidities and procedure-related
risks. The ENDORSE trial [6] assessed over 68,000
surgical and medical inpatients in 32 countries of whom
45% were categorised as surgical. This study found
that 64% of surgical and 42% of medical patients were
considered to be at-risk of VTE. However, only 59% of
surgical and 40% of medical individuals considered at-
risk were receiving appropriate prophylaxis. A number
of strategies have been demonstrated to improve the
uptake of appropriate prophylaxis protocols, including
the use of pre-printed order forms attached to admis-
sion bundles, computer reminders, and ongoing audit
and feedback [7]. Adherence to VTE prophylaxis pro-
tocol guidelines is one appropriate measure for quality
of care audit in contemporary surgical practice.
13.2 Diagnosis of Venous
Thromboembolic Events
Despite appropriate prophylaxis, there is still a small
but definite risk of developing a VTE event during or
soon after hospitalisation. Subjective diagnosis of both
DVT and PE is often inaccurate, and therefore, an
 80

Surgical VTE Prophylaxiss Guide

For ALL patients undergoing surgery or when surgery is imminent
STEP 1 STEP 2 STEP 3
Assess Patient Risk Assess for Anticoagulant Prophylaxis Assess Mechanical Prophylaxis

Are there any NO Prescribe: enoxaparin 40mg daily

or dalteparin 5000U daily
contraindications to or for orthopaedic surgery Are there any NO Apply IPC and/or GCS
anticoagulant fondaparinux 2.5mg daily contraindication to
H • Hip or knee arthroplasty mechanical
prophylaxis? (commence 6-8 hrs post-op)
I • Major trauma Duration 5-10 days EXCEPT prophylaxis?
(see below) (see below)
28-35 days for hip arthroplasty YES Observe closely for VTE
G
H YES No anticoagulant
• Hip fracture surgery
Are there any NO Prescribe: enoxaparin 40mg daily
R • Other surgery with prior contraindications to or dalteparin 5000U daily Are there any NO Apply GCS and/or IPC
VTE and/or active cancer or LCUH 5000 TDS contraindication to
I anticoagulant or for hip fracture surgery mechanical
S prophylaxis? fondaparinux 2.5mg daily prophylaxis?
(see below) (commerce 6-8 hrs post-op) (see below) YES Observe closely for VTE
K • Major surgery* age > 40 years Duration 5-10 days EXCEPT
28-35 days for hip fracture surgery

YES No anticoagulant

Are there any Are there any NO Apply GCS and/or IPC
NO Prescribe: enoxaparin 20mg daily
contraindications to or dalteparin 2500U daily contraindication to
L anticoagulant or LCUH 5000 BD or TDS mechanical
prophylaxis? Duration 5-10 days prophylaxis?
O (see below) YES Observe closely for VTE
(see below)
W YES No anticoagulant
E
R
• All other surgery
Are there any Are there any Consider GCS
R NO Consider LMWH or LDUH if contraindication to NO
contraindications to
I anticoagulant addtional risk factors † mechanical
Duration until hospital discharge prophylaxis?
S prophylaxis? (see below)
(see below) YES Observe closely for VTE
K YES No anticoagulant

*Major surgery: intra-abdominal surgery
or any surgery > 45 minutes duration
†Additional VTE Risk Factors
immobility, thrombophilia, oestrogen therapy,
pregnancy or puerperium, active inflammation,
strong family history of VTE and/or obesity.
Contraindication to anticoagulant prophylaxis
Active bleeding / high risk of bleeding eg. haemophilia, thrombocytopenia
(platelet count <50 × 10° /L), history of GI bleeding
Severe hepatic disease (INR > 1.3) / adverse reaction to heparin
On current anticoagulation
Other eg. very high falls risk and palliative management.
Renal impairment with LMWH - see manufacturer’s product information
Contraindication to Mechanical prophylaxis
Severe peripheral arterial disease: Resent skin graft
Severe peripheral neuropathy: Severe leg deformity
LMWH - Low Molecular Weight Heparin
LDUH - Low Dose Unfractionated Heparin
GCS - Graduated Compression Stockings
IPC - Intermittent Pneumatic Compression
VTE - Venous Thromboembolism

Fig. 13.1 Surgical VTE prophylaxis guide [4]

R.A. Fitridge and S. McRae
13 Prophylaxis of Venous Thromboembolism
Table 13.4 Levels of thromboembolism risk and recommended thromboprophylaxis for patients in hospital [5]
Levels of risk Approximate DVT risk
without thromboprophylaxis
(%)a
Low risk <10
Minor surgery in mobile patients
Medical patients who are fully mobile
Moderate risk 10–40
Most general, open gynaecologic or
urologic surgery patients
Medical patients, bed rest or sick
Moderate VTE risk plus high bleeding risk
High risk 40–80
Hip or knee arthroplasty, hip fracture
surgery
Major trauma, spinal cord injury
High VTE risk plus high bleeding risk
a
Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving thromboprophylaxis
b
Mechanical thromboprophylaxis includes IPC or VFP and/or GCS; consider switch to anticoagulant thromboprophylaxis when
high bleeding risk decreases
objective approach to diagnostic testing is required.
Diagnostic algorithms combining non-invasive tests
have largely replaced the previous invasive gold stan-
dards of venography and pulmonary angiography.
Given the falling proportion of patients referred with
suspected VTE that have the diagnosis objectively
confirmed (as low as 10–15% in recent series), these
algorithms have attempted to limit the need for diag-
nostic imaging while maintaining patient safety.
The probability of individual patient’s having the
diagnosis of VTE being confirmed can be stratified
using clinical prediction rules, the most widely used of
which are the DVT and PE Wells’ scores (Tables 13.5
and 13.6). In patients with a low pre-test probability
(Wells score < 2, DVT unlikely), a negative sensitive
D-dimer test, a product of the breakdown of cross-
linked fibrin by plasmin, can be used to exclude DVT or
PE without performing diagnostic imaging. Patients
with either a high pre-test probability of VTE or a posi-
tive D-dimer test should proceed to diagnostic imaging,
and as the majority of patients having undergone recent
surgery will fall into one of these two categories, such
algorithms are less useful in this patient population.
Compression ultrasonography (CUS) is the com-
monly used diagnostic imaging test performed for sus-
pected DVT. This technique is accurate for ruling in or
81
Suggested thromboprophylaxis
options
No specific thromboprophylaxis
Early and “aggressive” ambulation
LMWH (at recommended doses), unfractionated
heparin bd or tds, fondaparinux
Mechanical thromboprophylaxisb
LMWH (at recommended doses), fondaparinux,
oral vitamin K antagonist (INR2-3)
Mechanical thromboprophylaxisb
ruling out proximal DVT (popliteal and above). There
is more debate regarding the accuracy (particularly the
specificity) of CUS in the diagnosis of isolated calf
vein or distal DVT, with diagnostic accuracy related to
both the quality of the ultrasound machine as well as
being operator dependent. While a negative complete
compression ultrasound (examining proximal and dis-
tal vessels) has been shown to safely exclude DVT in
most patients, where the clinician is highly suspicious
of acute DVT but the initial study is negative, it is rea-
sonable to repeat the imaging in 4–7 days to detect an
initial small thrombus that may have subsequently
propagated.
Current imaging techniques for PE include ventila-
tion/perfusion (V/Q) scanning, and increasingly spiral
computerised tomographic pulmonary angiography
(CTPA). A V/Q scan is reported on the presence or
absence of mismatched perfusion defects. A high prob-
ability scan (the presence of a segmental sized or larger
mismatched perfusion defect) is diagnostic of PE and
justifies initiation of treatment, while a normal perfu-
sion scan safely excludes PE. All other test results
should be considered non-diagnostic, and further
investigation is required. A non-diagnostic scan is
more likely in patients with pre-existing lung pathol-
ogy, and therefore, CTPA should be the investigation
82 R.A. Fitridge and S. McRae

Table 13.5 Diagnostic algorithm for patients with episode of suspected first deep vein thrombosis

Patient with suspected DVT

Assess Pre-test Probability using the

Well’s Prediction Rule (see below)

“DVT unlikely” “DVT likely” *Do not perform D-Dimer if

(score < 2) (score ? 2) (a) Anticoagulation for > 24 h
(b) Symptoms lasting > 14 days
(c) Patient is pregnant

D-dimer test Proceed directly to diagnostic

imaging in these patients.

Compression
Negative D-dimer Positive D-dimer Ultrasonography
(CUS)

NEGATIVE POSITIVE

DVT confirmed
DVT excluded
Proceed to treatment
algorithm

Table 13.6 Wells et al. [8] score for the diagnosis of DVT
Clinical characteristic
Active cancer (ongoing or Rx within 6 months)
Paralysis, paresis or recent plaster
immobilisation
Recently bedridden for >3 days or surgery
within 12 weeks (requiring general anaesthetic)
Previously documented DVT or PE
Localised tenderness along the distribution
of the deep venous system
Entire leg swelling
Calf swelling at least 3 cm larger than the
asymptomatic leg (measured 10 cm below
the tibial tuberosity)
Pitting oedema confined to the symptomatic leg
Alternative diagnosis as least as likely as
DVT
Interpretation:
Score < 2 = DVT unlikely; score ³ 2 = DVT likely
of choice in this group. A filling defect in a segmental
Score level or more proximal pulmonary artery on spiral
1 CTPA is diagnostic of PE and justifies treatment. A
number of recent studies have shown that it is safe to
1
withhold anticoagulation in patients with a normal
CTPA. CTPA has the additional advantage of having
1
the potential to detect alternative causes of chest pain
in patients with suspected PE.
1
1
13.3 Management of Venous
1
Thromboembolic Events
1
13.3.1 Calf Vein Thrombosis
1
−2 The majority of post-surgical DVTs will be isolated to
the calf veins below the level of the politeal vessel (iso-
lated distal DVT). These may often be asymptomatic,
but can on occasion result in significant discomfort
13 Prophylaxis of Venous Thromboembolism
and swelling. Left untreated, approximately 10–25%
of isolated distal DVTs will extend into the proximal
veins, increasing the risk of PE. Calf vein thrombosis
that is going to extend proximally normally does so
within 1 week.
There are no clear consensus guidelines at present
for management of calf vein DVT. Based on the above
natural history, a number of potential therapeutic
approaches are reasonable. These include:
(a) Symptomatic treatment alone with the performance
of repeat ultrasonography at 1 week to detect those
thrombi that have extended proximally and there-
fore require therapeutic anticoagulation.
(b) Therapeutic anticoagulation for a 6–12 week
period. This approach is likely to be appropriate in
patients with ongoing risk factors (e.g. malig-
nancy) or with more extensive thrombi.
(c) Although not widely studied, many clinicians may
utilise a shorter period of anticoagulation such as
2 weeks of LMWH, reassessing for progression at
the end of this period with a repeat ultrasound.
13.3.2 Proximal DVT
Traditionally, individuals have been formally antico-
agulated with intravenous heparin and Warfarin. This
approach required a period of in-hospital stay until
the INR has been stabilised. Currently, patients who
are judged to be reliable who do not have marked
obstructive symptoms, and who do not have marked
iliofemoral thrombus, can be managed as an outpatient
utilising once-daily subcutaneous LMWH until they
are therapeutically anticoagulated with Warfarin. This
approach requires adequate community nursing sup-
port so that regular INRs can be taken and also low-
molecular-weight heparin can be injected where the
patient is unable to do so. A recent Cochrane review
found that there is a lower risk of bleeding associated
with the use of LMWH than intravenous UFH, and
that the risk of recurrent thrombotic events was also
lower. Based on the protocols used in the initial clini-
cal trials establishing their efficacy, both LMWH or
UFH should be given for a minimum of 5 days, with
the requirement that the INR is ³2 on two occasions
24 h apart prior to parenteral anticoagulation being
ceased.
83
13.3.3 Duration of Anticoagulation
The duration of anticoagulation is a balance between
the risk of recurrent VTE once anticoagulation is
ceased, and the risk of major bleeding whilst on warfa-
rin (which is 2–3% per year in most series). The best
predictor of recurrence risk is the presence or absence
of a provoking risk factor at the time of the initial
event. Isolated distal DVT is also associated with a
lower risk of recurrent thrombosis. Based on these
facts, the following broad recommendations can be
made on duration of treatment:
(a) Isolated distal DVT – 6–12 weeks (annual risk of
recurrence < 3%)
(b) Proximal DVT or PE associated with a major pro-
voking risk factor (i.e. major surgery or trauma) –
3–6 months (annual recurrence risk ~ 3%)
(c) Proximal DVT or PE with minor provoking risk
factor (medical illness, oral contraceptive pill usage,
travel) – 6 months (annual recurrence risk ~ 3–5%)
(d) Unprovoked proximal DVT or PE – minimum of
6 months treatment, consideration of long-term
therapy (annual recurrence risk ~ 10%)
Repeat imaging should be performed at the cessation
of anticoagulation to obtain a new baseline that can
be used for comparison with future sc0ans. Patients
with unprovoked events or with events at a young
age, or with a strong family history should be consid-
ered for thrombophilia testing, as some conditions
(protein C and protein S deficiencies, antithrombin
deficiency and anti-phospholipid antibody syndrome)
may require long-term anticoagulation due to a sig-
nificant increase in risk of recurrent events. The role
of new predictors of recurrence such as D-dimer test-
ing and the presence of residual changes on imaging
are still being evaluated.
References
1. MacLellan, D.G., Fletcher, J.P.: Mechanical compression in
the prophylaxis of venous thromboembolism. ANZ J. Surg.
77, 418–423 (2007)
2. Kakkos, S.K., Caprini, J.A., Geroulakos, G., et al.: Combined
intermittent pneumatic leg compression and pharmacologi-
cal prophylaxis for prevention of venous thromboembolism
in high-risk patients (review). Cochrane Database Syst. Rev.
8(4), CD005258 (2008)
84
3. McRae, S.J., Ginsberg, J.S.: In the diagnosis of deep-vein
thrombosis and pulmonary embolism. Curr. Opin.
Anaesthesiol. 19(1), 44–51 (2006)
4. Australia and New Zealand Working Party on the
Management and Prevention of Venous Thromboembolism:
Prevention of venous thromboembolism: best practice guide-
lines for Australia and New Zealand, 4th edn. Health
Education and Management Innovations, Sydney (2007)
5. Geerts, W.H., Bergqvist, D., Pineo, G.F., et al.: Prevention of
venous thromboembolism: American College of Chest
Physicians evidence-based clinical practice guidelines (8th
edn.). Chest 133, 381–453 (2008)
R.A. Fitridge and S. McRae
6. Cohen, A.T., Tapson, V.F., Bergmann, J.F., et al.: Venous
thromboembolism risk and prophylaxis in the acute hospital
care setting (ENDORSE study): a multinational cross-­
sectional study. Lancet 371(9610), 387–394 (2008)
7. Tooher, R., Middleton, P., Pham, C., et al.: A systematic
review of strategies to improve prophylaxis for venous
thromboembolism in hospitals. Ann. Surg. 241(3), 397–415
(2005)
8. Wells, P.S., Anderson, D.R., Rodger, M., et al.: Evaluation
of D-dimer in the diagnosis of suspected deep-vein thrombo-
sis. N. Engl. J. Med. 349(13), 1227–1235 (2003)
 Nutrition of the Surgical Patient
Florian Brackmann, Wolfgang H. Hartl, and Peter Rittler
14.1 Changes of the Substrate
Metabolism After Surgical
Disturbance of Homeostasis
14.1.1 Basic Principles
The hormonal changes after surgical trauma represent the
essential basis for the adjustment of the substrate metabo-
lism during this period. Catabolism, i.e. breakdown of all
existing substrate depots in the body, is the main process.
Initially, this represents a reasonable physiological reac-
tion to provide the organism with elements for energy
production and composition of important functional pro-
teins. Thus, enhanced lipolysis in the adipose tissue
leads to increased release of free fatty acids, which can,
on the one hand, be used as an alternative substrate for
the non-obligatory carbohydrate-dependent tissues (skel-
etal muscles), and represent, on the other hand, energy
sources for the accelerated metabolism in the liver.
Parallel to the restricted carbohydrate utilization in
the skeletal muscles, a pronounced protein breakdown
takes place here as well. By that, released amino acids
fulfil mainly two purposes: on one side, the gluco­
neogenetic amino acids can be drawn on for the acceler-
ated production of glucose in the liver; on the other side,
the nitrogen carriers released from the skeletal muscles
F. Brackmann
Department of General Surgery, Mount Gambier General
Hospital, 276-300 Wehl Street North, Mount Gambier,
SA 5290, Australia
W.H. Hartl, and P. Rittler (*)
Department of Surgery, Campus Großhadern,
Marchioninistr. 15, 81377 Munich, Germany
e-mail: whartl@med.uni-muenchen.de;
peter.rittler@med.uni-muenchen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_14, © Springer-Verlag Berlin Heidelberg 2011
14
are essential for wound healing. In this context, the sup-
ply of the gastrointestinal tract with certain amino acids
(glutamine) is worth mentioning. Glutamine-dependent
repair mechanisms are said to limit the extent of integ-
rity disturbance within the g­ astrointestinal tract.
The main site of metabolic changes after trauma or
surgery is the liver. Here carbohydrates from gluco-
neogenesis and glycolysis are released into the blood.
The accelerated hepatic production of glucose together
with the peripheral insulin resistance lead to hyperg-
lycaemia, which helps to optimize the glucose supply
and by that the glucose intake and energy metabolism
in the obligatory glucose-dependent tissues (immuno-
competent cells, fibroblasts) (Figs. 14.1 and 14.2).
Utilization of endogenously released amino acids
for glyconeogenesis leads to irrevocable loss of nitro-
gen in the form of urea from the body. This loss of
nitrogen equates to a loss of body proteins and is the
biochemical correlate of the decrease of muscle mass.
After elective surgical procedures, and with uncom-
plicated postoperative recovery, the maximum of
­metabolic changes occurring in the course of the
­post-aggression syndrome will be seen within the first
2 weeks after surgical disturbance of homeostasis.
The insulin resistance with concomitant hyperglycae-
mia reaches its peak within the first 48 h, while the
decrease in body proteins will have its maximum after
2 weeks. Accordingly, the protein metabolism recov-
ers only very slowly.
Replenishment of body protein supply can only
be expected 3–6 months after extensive surgical
procedure without complications or trauma. The
body weight does not reach the initial level before
a similar period of time either.
85
86 F. Brackmann et al.

Lipolyse

Free fatty acids

Keytone bodies

Glucose
Glycogenesis

Lactate, Pyruvate
Alanine, Glutamine Proteolysis
Urea

Urea Balance

Fig. 14.1 Substrate flow in the post-aggression metabolism

Glycerol
30g
114g

Glycogen 76g 8g

Glucose Blood cells

3C 320g
130g
104g

Wound Lactate
Urea in
the urine

80g
Amino
acids
Alanine, Lactate
Gluamine

Fig. 14.2 Glucose ­regeneration during stress

14.2 Metabolic Particularities carbohydrate concentrations might -if untreated- have

of the Intensive Care Patient
With persistent Systemic Inflammatory Response Syn­
drome (SIRS) or severe sepsis, the severe disturbance
of the carbohydrate metabolism with hyperglycaemia
and insulin resistance remains because of the ongoing
hormonal activation. Under such conditions very high
negative consequences for the patient’s prognosis due
to immunosuppressive effects.
Furthermore, there is a striking protein catabolism.
Mainly four mechanisms seem to be initially respon-
sible for this prolonged massive loss of proteins:
• Immobilization of the patient
• Release of catabolic hormones
14 Nutrition of the Surgical Patient
• Regularly seen hypercatabolism with increased
metabolic rate
• Activation of certain cytokines
In long-term courses, another important mechanism to
trigger and maintain the prolonged protein catabolism
is the pathological change in the peripheral and central
nervous system. This so-called septic neuropathy (in
70–90% of all intensive care patients) is associated
with peripheral neuropathy and signs of axonal degen-
eration. Subsequently, functional denervation devel-
ops, which leads to drastic increase of protein
breakdown. More than 90% of the critically ill patients
show atrophy of the skeletal muscles (necrosis of muscle,
intracellular lipid deposits).
Another central finding with almost all intensive
care patients is the increasing fatty degeneration of the
liver caused by imbalance between fatty acid intake,
fatty acid oxidation and fatty acid administration
through VLDL-triglycerides. Protein catabolism leads
to defective VLDL-triglyceride synthesis or secretion
as well.
14.3 Nutritional Status
and Caloric Demand
Nutritional therapeutic measures are essential to
­minimise complications and achieve the best possible
quality of life in the preoperative, intraoperative and
postoperative period including the rehabilitation phase.
For all measures, appropriate consideration of nutri-
tional supply and status is required.
14.4 Assessment of Nutritional Status
Today, reliable assessment of the nutritional sta-
tus has to be regarded as a necessary component
and prerequisite of any efficient nutritional ther-
apy. Particularly severely malnourished patients
are affected by increased perioperative morbidity
and therefore benefit most from adequate nutri-
tional therapy.
Basic details regarding nutritional status are body
height and weight to calculate the BMI (Body-Mass
87
Index), and inquiring about weight loss. The BMI is
mainly established to classify overnutrition (moder-
ate > 25, definite > 30, massive > 40). To assess under-/
malnourishment, it is only valid for chronic severe
under-/malnourishment (BMI < 18.5), but not to detect
short-term under-/malnourishment in acute conditions
like malignancies, etc., and in cases of previously
existing overnutrition.
From a clinical point of view it has been proven as
useful to classify patients as normally nourished, mod-
erately undernourished or severely undernourished:
• Considered as moderately undernourished are those
patients that have lost 10–15% of their body weight
preoperatively and concurrently have hypoalbumin-
aemia or disturbances in other body systems.
• Severe undernourishment equals weight loss of
15% or more.
In practice, assessment of the nutritional status based
on the so-called Subjective Global Assessment (SGA)
or the Nutritional Risk Screening 2002 (NRS 2002) has
become widely accepted. This method mainly consists
of taking accurate medical history, physical examina-
tion and estimation of the current energy demand of
the individual patient. SGA allows making rough nutri-
tional classifications of individual patients by discrimi-
nating between
• Well nourished
• Moderately undernourished
• Severely undernourished
The variables for the SGA are listed in Fig. 14.3.
Special attention is paid to changes in body weight,
alterations in nutritional intake, gastrointestinal disor-
ders, physical activity and the underlying disease with
its relation to nutritional demand. Furthermore, in the
physical examination, loss of subcutaneous fat and
clinically evident muscular atrophy are recorded.
Additionally, ankle and flank oedema as well as ascites
are to be noted.
No defined numeric algorithm is used to get an
appropriate SGA classification. Rather, a categoriza-
tion on a basis of subjective evaluation is performed. In
spite of this subjectivity, a clear correlation between
SGA and prognosis of the surgical patient is found.
This only applies for preoperative assessment, though;
there is still no precise method for postoperative sur-
veillance or intensive care patients available.
88
Fig. 14.3 Variables of the
“Subjective global
Assessment” (SGA)
Besides those general diagnostics that should always be
done in specific situations as in chronic diseases (e.g.
liver cirrhosis, chronic pancreatitis, immunosuppres-
sion), or severe undernourishment (tumours, Crohn’s
disease), problem-oriented diagnostic investigations
F. Brackmann et al.
A. History
1. Weight change
Overall loss in past 6 months:
– amount = # ___________ kg;
– % loss = # ____________
Change in past 2 weeks:
– ___________________ increase,
– ___________________ no change,
– ___________________ decrease.
2. Dietary intake change (relative to normal)
___________ No change,
___________ Change ___________ duration = # ___________ weeks
type:
– ___________ suboptimal liquid diet,
– ___________ full liquid diet
– ___________ hypocaloric liquids,
– ___________ starvation.
3. Gastrointestinal symptoms (that persisted for >2 weeks)
___________ none,
___________ nausea,
___________ vomiting,
___________ diarrhea,
___________ anorexia.
4. Functional capacity
___________ No dysfunction (e.g., full capacity),
___________ Dysfunction ___________ duration = # ___________ weeks.
type:
__________________ working suboptimally,
__________________ ambulatory,
__________________ bedridden.
5. Disease and its relation to nutritional requirements
Primary diagnosis (specify) ___________________________________________
Metabolic demand (stress) :
– ____________ no stress,
– ____________ low stress,
– ____________ moderate stress,
– ____________ high stress.
B. Physical (for each trait specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe).
# ______________________________ loss of subcutaneous fat (triceps, chest)
# ______________________________ muscle wasting (quadriceps, deltoids)
# ______________________________ ankle edema
# ______________________________ sacral edema
# ______________________________ ascites
C. SGA rating (select one)
__________________ A = Well nourished
__________________ B = Moderately (or suspected of being) malnourished
__________________ C = Severely malnourished
Select appropriate category with a checkmark, or enter numerical value where indicated by “#”
(serum albumin level, short-lived functional proteins,
24 h urine-creatinine excretion, bioelectrical imped-
ance analysis [BIA]) can be carried out to detect and
distinguish protein deficiency or specific nutritional
deficiencies.
14 Nutrition of the Surgical Patient
14.5 Estimating the Perioperative
Caloric Demand
Postoperatively, fluid and electrolyte supply has to be
aligned to calorie and substrate supply. For that, it is
necessary to determine the patient’s energy demand
first. You start with the basic energy metabolic rate,
that can be calculated approximately according to
Harris and Benedikt for the healthy person based on
body weight, age, gender and height.
In clinical routine, the basic metabolic rate can be
calculated by Stein and Levine’s rule of thumb
(basic energy metabolism [kcal]/day = 24 × kg
bodyweight).
Generally, it can be assumed that caloric demand
immediately after elective procedures is equivalent to
the metabolic rate at rest. After mobilizing the patient
the rate increases about 10%.
Hence, only fluids and electrolytes are given on the
day of surgery. Administration of vitamins and trace ele-
ments during this period is not necessary. From the first
day on calories should be administered preferably orally
or enterally via a tube. If this is not possible, glucose and
amino acids can be administered parenterally for a few
days. Parenteral nutrition is only required for patients
who cannot be fed orally or enterally after 1 week.
Note: Caloric deficiency always leads in the
medium term to under-/malnourishment and
increases the risk for complications or delayed
rehabilitation. Therefore, especially after resolv-
ing the acute phase sufficient nutrition and, where
required, additional energy- and protein-rich drink-
ing supplements should be administered.
14.6 Substrates for Perioperative
Nutrition
Perioperative feeding can be done orally, enterally or
parenterally. Accordingly, there are commercial prod-
ucts for all three modalities.
89
14.6.1 Oral Nutrition
Usually, products for oral nutrition are supplied by the
hospital kitchen. Apart from mainly liquid diet (tea, soup,
biscuits, oral drinking supplements with high calorie-
and protein concentration), there are more preparations
with different consistencies and fibre ­concentrations
(filtered diet, light diet, full diet).
Oral food intake should be the rule. Drinking
­supplements can be used as additive measures in case
of inadequate oral food intake especially for severe
under-/malnourishment and during the postoperative
period. Studies established the merit of such measures
for old patients after hip fractures or after gastrectomy.
14.6.2 Enteral Nutrition
Substrates are administered enterally in case of dys-
phagia or malfunctioning of the upper gastrointestinal
tract (stomach/oesophagus). For enteral nutrition, fab-
ricated balanced diets are used that meet all the patient’s
needs regarding nutrients, trace elements, electrolytes
and vitamins. Most of them are suitable as full nutri-
tion but are more expensive than normal hospital diet.
Nutrient defined diets (NDD) have to be distinguished
from chemically defined diets (CDD) (Table 14.1).
For catabolic patients NDDs with higher caloric den-
sity and higher protein content are available to provide
protein rich nutrition (1.3–1.5 g/kg bodyweight/day). For
uncomplicated long-term feeding and in case of unre-
stricted gastrointestinal functioning, NDDs containing
fibre can be used. Here diets containing insoluble fibre
(cellulose) and diets with soluble fibre (prebiotics: pectin,
agar, mucilage, oligofructose) can be distinguished.
14.6.3 Diets Adapted to Metabolism
So-called diets adapted to metabolism are designed
for patients with specific organic diseases and in­­
sufficiencies as well as for situations with metabolic
peculiarities:
• Diabetes diet
• Diets with immunomodulatory effects
90
Table 14.1 Nutrient defined and chemically defined diets
Nutrient defined diets (NDD)
Composition Carbohydrates in form of oligo- and
polysaccharides (50–60%)
Intact protein from milk, soy, egg albumin
and meat protein (15–20%)
Lipids from vegetable oil
Essential fatty acids
Saturated fatty acids (short-chain,
medium-chain and long-chain fatty acids)
Low in fibre
Properties High molecular
Location of resorption Entire GI tract
Application For normal digestion and resorption
performance
• Liver-adapted tube diets
• Kidney-adapted diets
Diabetes diets contain reduced amounts of carbohy-
drates and an increased fraction of unsaturated fatty
acids and help to control glycaemia and reduce insulin
demand.
Immunomodulating diets contain substrates like
Glutamine, Arginine, Omega-3-fatty acids and nucle-
otides that have been shown to have certain immuno-
modulatory effects. In general, the aim is to dampen the
hyperinflammatory processes which occur within SIRS
and sepsis, and to strengthen the specific immune sys-
tem on the other side. Glutamine is supposed to have
further positive effects on gastrointestinal tract function.
Liver-adapted tube diets contain specific amino
acid patterns. The goal of this modification is to restore
normal plasma aminograms in patients with liver fail-
ure, especially patients with hepatic encephalopathy,
who have increased plasmatic levels of aromatic amino
acids and methionine, but decreased levels of branched
chain amino acids. Therefore, diets enhanced with
branched chain amino acids can help to improve this
amino acid imbalance.
Patients with marginally impaired kidney function
can benefit from kidney-adapted diets with a reduced
proportion of nitrogen and a high proportion of essen-
tial amino acids or adapted electrolyte compositions.
F. Brackmann et al.
Chemically defined diets (CDD)
Amino acids, tripeptides or oligopeptides
Low in lipids
Free of fibre
Low molecular slightly hyperosmolar because
of osmotically active protein hydrolysate
Jejunum and Ileum
For global impairments of the intraluminal
hydrolyse capacity and resorption (e.g. exclusive
jejunal feeding)
14.6.4 Parenteral Nutrition
In case of malfunction of the lower GI tract (small
bowel/large bowel) feeding has to be parenteral. It
should be hypocaloric for the first week after surgi-
cal trauma and normo (iso-) caloric in the second
week. For both, the early (day 1–3) and the late (day
4–6) postoperative phase, commercialised infusion
solutions are available which take the specific
­metabolic demands of each phase into account
(Table 14.2).
If electrolyte- or water imbalances occur in the
late postoperative period, it is necessary to combine
single solutions of amino acids and sugar according
to the above principles instead of using the amino
acid carbohydrate solutions. The concentrations of
sugar solutions range between 10% and 40% and
allow isocaloric nutrition for patients with such dys-
functions. Of course, the amounts of carbohydrates
administered in such manner have to be adjusted
to the extent of the post-aggression metabolism.
Additionally, it is necessary to combine this with
separate amino acid solutions that usually contain
10% synthetic crystalline amino acids. Those solu-
tions are generally composed of 40–50% essential
amino acids, the rest being non-essential amino
acids.
14 Nutrition of the Surgical Patient 91

Table 14.2 Infusion solution for the different phases of parenteral postoperative nutrition
Hypocaloric nutrition in the early Hypocaloric nutrition in the Complete isocaloric parenteral
postoperative phase late postoperative phase nutrition
Timing Day 1–3 after surgery Day 4–6 after surgery From day 7 after surgery
Composition and Slightly hypertonic High osmolarity High osmolarity
properties (700–800 mosm/l) (1,300 mosm/l) (>1,300 mosm/l)
Low caloric density (0.3–0.4 High caloric density High caloric density
kcal/ml) (0.6–0.7 kcal/ml) (1–1.2 kcal/ml)
5% glucose, 3.5% amino acids Carbohydrates, amino acids, Amino acid-carbohydrate-
and electrolyte proportioned to the trace elements, electrolytes, lipid-combination solutions
maintenance dose proportioned to the increased or amino acid-carbohydrate-
protein- (1–1.2 g/kg body weight/ solutions with lipids separate
day) and carbohydrate demand
(4 g/kg body weight/day)
Amount of infusion 40 ml/kg bodyweight/day 25–30 ml/kg bodyweight/day
Way of application Peripheral venous line Central venous line Central venous line

14.6.5 Parenteral Application of Lipids inflammatory mediators (prostaglandins, leucotrienes)

with immunosuppressive functions are made from. To
reduce these effects, new solutions contain considerably
For complete isocaloric parenteral nutrition hyperos-
smaller amounts of linoleic acids (higher proportions of
molaric amino acid/carbohydrate/lipid combination
MCT or olive oil). Furthermore, infusion solutions with
solutions are available. Lipids, however, can also be
higher fractions of omega-3 fatty acid might have posi-
administered as a separate part of parenteral nutrition.
tive immunologic effects due to the decreased synthesis
Because of its high caloric density (2 kcal/ml), only
of immunosuppressive prostanoids.
small amounts of lipids are sufficient to administer
adequate amounts of calories.
At present, there are five different infusion solu-
tions for the application of lipids with different compo-
sitions. As a general rule these solutions contain 20%
14.6.6 Special Preparations for Patients
of lipids in 250 ml: with Organ Dysfunctions
• Lipid emulsions based on soy bean oil (20 g
Similarly to enteral nutrition, there are also specific
fat/100 ml with 52% linoleic acid)
preparations of parenteral nutrition to compensate for
• MCT/LCT-solutions: soy bean or coconut oil
organ dysfunctions.
(so-called medium chain triglycerides); 10 g soy
The so-called kidney solutions contain only essential
bean oil/100 ml with 10 g coconut oil/100 ml in
and few semi-essential amino acids. Since increasingly
physical mixture
damaging effects of urea concentrations above 100 mg/
• Structured lipids: same composition as MCT/LCT-
dl can be expected, administration of daily proteins has
solutions, not physically but biochemically mixed
to be cut down to one-third of the calculated daily intake
• Lipid emulsions based on soy bean and olive oil
if haemofiltration/dialysis is meant to be postponed.
with 4 g soy bean oil/100 ml (equal to 18% linoleic
With this nutritional regime, production of urea is lower
acid) and 16 g olive oil/100 ml
than with carbohydrate supply only. Yet in case of lon-
• Preparations with higher fractions of omega-3 fatty
ger-lasting renal failure, resumption of isocaloric nutri-
acids (fish oil)
tion with full amino acid supply is preferable.
Linoleic acid plays an important role as it is the For patients with hepatic encephalopathy and
precursor substance of arachidonic acid, which many ammoniac concentrations of more than 100 mg/dl,
92
special liver solutions exist for parenteral administra-
tion that contain higher fractions of branched chained
amino acids (see above).
14.6.7. Supply of Glutamine, Vitamins
and Trace Elements
Nowadays, special amino acid solutions which include
glutamine in the form of dipeptides (in combinations
or single solutions) are available. So far, amino acid
solutions did not contain glutamine, because glutamine
is instable in solution. Linking glutamine to alanine
or glycine makes parenteral supply possible as well.
Especially intensive care patients (see below) show a
distinct glutamine deficiency both in their plasma and
in their muscle tissue.
Postoperative application of vitamins and trace ele-
ments is only required in cases of long-term parenteral
nutrition. Preparations that contain the most important
trace elements (chrome, copper, iron, manganese, fluo-
rine, molybdenum, selenium and zinc) exist and are
usually administered daily. Water-soluble vitamins can
be given additionally (thiamine, riboflavin, pyridoxine,
pantothenic acid, ascorbic acid, biotin, folic acid,
cyanocobalamine). The administration of lipophilic
vitamins (vitamin A, D2, K and E) can be done paren-
terally as well, if the patient receives lipids intrave-
nously in the context of nutritional therapy.
If the patient does not receive lipids intravenously,
the same vitamins can alternatively be administered in
specially processed normal saline.
14.7 Preoperative Nutritional Therapy
14.7.1 Indication
Indication for preoperative nutritional therapy is mod-
erate-to-severe malnourishment for all patients with
elective procedures. It has been shown that pre-exist-
ing, relevant undernourishment leads to a periopera-
tive shift of fluids into the “third space”, is associated
with muscle weakness, significantly interferes with
wound healing and leads to pronounced immunodefi-
ciency. All of these phenomenons significantly increase
postoperative morbidity and mortality. By enforcing
F. Brackmann et al.
aggressive preoperative nutritional therapy over a
period of at least 1 week, postoperative complications
can be reduced by 20–35%. A further indication for
preoperative nutrition is given in tumour patients prior
to big visceral operations, even if no relevant under-
nourishment is present. Drinking supplements with
immunomodulatory substances are used for this pur-
pose during a period of 5–7 days before surgery.
This kind of nutritional therapy is usually carried
out up to the evening before surgery, and decreases
the perioperative morbidity by reducing infectious
complications.
14.7.2 Calorie Supply
Tumour patients who are not undernourished preoper-
atively receive additive immunomodulatory supple-
ments with 500–1,000 cal.
The amount of administered calories for under-
nourished patients is not based on the expected cur-
rent metabolic rate but should be hypercaloric. Here
30–40 kcal/kg body weight/day non-protein calories
should be administered with one-third given in the
form of lipids. Proteins should be given in the
amount of 1–1.5 g/kg body weight/day. Ideally, this
calorie intake can be achieved with oral supplements
high in protein. Only in cases of dysphagia or high
risk of aspiration, enteral nutrition (nutrient defined
diet) is used.
Only if oral/enteral nutrition is impossible or insuf-
ficient, it becomes reasonable to use complete paren-
teral nutrition with balancing of vitamin- and trace
element deficiencies over the period of one week. The
efficiency of these measures is shown by an increase of
short-lived functional proteins (prealbumin, retinol
binding protein) in the circulation.
14.8 Postoperative Nutritional Therapy
14.8.1 Indication
Postoperative oral food intake should be started as
soon as possible and gradually increased according to
the conditions of post-aggression metabolism. In case
14 Nutrition of the Surgical Patient
of insufficient swallowing and/or gastrointestinal
functioning artificial alimentation has to be consid-
ered. Indication for artificial feeding (enteral/paren-
teral) is given
• for all patients who are undernourished preoper­
atively
• for patients who have no signs of undernourishment
but are expected not to receive oral food intake for
more than 7 days or only food intake not covering
their full demand
In these patients alimentation should be started after
surgery without delay.
Parenteral nutrition is indicated only in cases with
absolute contra-indications for enteral nutrition.
Possible indications are:
• Bowel obstruction with relevant impairment of
passage
• Persistent intestinal leakage
• Paralytic ileus
• Severe shock with circulatory instability
In all other cases it is recommended to at least try to
use enteral nutrition (gastric/jejunal). If the intestinal
passage is only partly restricted, enteral nutrition
should be combined with parenteral nutrition to cover
caloric demands.
Even for patients with gastrointestinal anastomo-
sis, generally a discontinuation of oral/enteral food
intake is not necessary. The gradual build-up of diet
should be adapted to the patient’s tolerance. After
anastomosis of the small bowel, colon and rectum,
oral/enteral food intake can be started on the first day
post op. For anastomosis of the upper gastrointestinal
tract (oesophagus resection, gastrectomy), enteral food
intake through a tube inserted distal to the anastomosis
or specific catheter jejunostomy during the first days is
recommended.
Even a small fraction of caloric intake is beneficial.
Small bowel mucosa enterocytes need glutamine from
an enteral source.
Early enteral diet build-up decreases the risk of
infection and at the same time shortens the length
of hospital stay.
93
14.8.2 Oral/Enteral Calorie Intake
Basic requirement for any kind of oral/enteral therapy
is a sufficient passage and resorption of the adminis-
tered substrates. In addition, the following has to be
considered:
• Capacity of passage in the GI tract
• Type of surgical procedure
After all thoracic and orthopaedic procedures, light
diet can be started immediately after operation pro-
vided the GI tract is intact.
After abdominal surgery, without harming the
integrity of the intestinal tract, oral build-up of diet can
be started on the first postoperative day as well. After
feeding mainly liquids for a short period, diet can be
switched over to light, low-fibre food already on the
second postoperative day. Here the supplied amount of
calories has to be adapted to the characteristics of the
post-aggression metabolism – as it is done in paren-
teral nutrition.
After surgery in the lower GI tract, diet build-up is
slightly held up and then started with liquid nutrition
in the first 2 days followed by the normal diet build-up
as described.
The actual intake of the supplied calories has to
be monitored carefully to avoid unexpected calo-
rie deficiency.
After procedures in the upper GI tract, especially
­gastric or oesophageal resections, feeding is done by
­special, intraoperatively placed tubes (catheter jejunos-
tomy). Special enteral nutritional solutions (see above)
are administered, starting with 250 ml continuously
for 24 h on the first day post op. If oral feeding cannot
be achieved sufficiently, infusions are carefully
increased over the next days by 250 ml/24 h every
1–2 days until the caloric demand of 24 kcal/kg body-
weight is reached.
If patients after thoracic, vascular or orthopaedic
surgery or extraintestinal abdominal procedures are
not capable of taking food orally, enteral feeding via
nasogastric tube is started early. Here, too, diet build-
up is done gradually, starting at 500 ml on the first
94
postoperative day. The intake is increased by 500 ml/
day until the caloric optimum is reached.
There is strong evidence that especially patients
after big visceral tumour surgeries or severe poly-
trauma, benefit from postoperative enteral feeding.
If there is a need for long-term enteral feeding
(>4 weeks), changing to a transcutanous tube (e.g.
PEG) is recommended.
A further specific feature applies for oncologic
patients. It is suggested to continue feeding of the
­preoperative immunomodulatory tube nutrition post-
operatively. In case of uncomplicated progress, a
period of 5–7 days is sufficient for that.
14.8.3 Parenteral Calorie Intake
Following the immediate postoperative period, and
after estimating the calorie- and water demand, it is
also important to assess the fraction of protein- and
non-protein calories in the total calorie intake. The
healthy adult needs approximately 0.8 g protein/kg
body weight/day. Patients after big ­surgical interven-
tions need between 1 and 1.2 g protein/kg body
weight/day depending on the extent of their disease.
The main focus of postoperative nutritional therapy
has to be on sufficient supply of proteins. Based on
a demand of 1 g/kg body weight/day an amount of
4 kcal/kg body weight/day should be administered
in form of amino acids during the entire postopera-
tive period.
The additional amount of carbohydrates and lipids
depends on the calculated energy demand and the
expected metabolic impairment. Therefore, only 50–60%
of the estimated calorie demand is administered
between the first and third postoperative day, i.e.
12 kcal/kg body weight/day (according to Stein and
Levine). Deducting the administered amount of pro-
tein calories from that (4 kcal/kg body weight/day)
results in a daily amount of carbohydrates of about
F. Brackmann et al.
8 kcal/kg body weight/day (equal to 2 g carbohydrates/
kg body weight/day).
Remission of the post-aggression syndrome and
increase in substrate metabolism can be expected
between day 4 and 6 post operation, if no complications
occur. During that period about three-fourths of the
amount of calories calculated as basic metabolic rate is
administered, i.e. about 18 kcal/kg body weight/day.
Deduction of the protein calories results in an amount
of carbohydrates of about 13 kcal/kg body weight/day.
Beginning with the seventh postoperative day, it is
possible to use complete isocaloric nutrition with amino
acids/proteins (1.5 g/kg body weight/day), carbohy-
drates (4 g/kg body weight/day) and lipids, usually
increasing the amount of lipid calories from 0.5 to 1 g (=
5 respectively 10 kal/kg/day). The dosage is approached
to the calculated calorie demand while careful attention
is given to the level of blood glucose and triglycerides.
If long-term parenteral feeding is to be expected,
the daily maintenance dose of vitamins and trace ele-
ments should be administered from the first day after
surgery.
14.8.4 Complications of Early Oral/
Enteral Nutrition
Early oral/enteral nutrition is not generally without
risks, and if complications occur morbidity is signifi-
cantly increased (Table 14.3). Nonetheless, taking all
positive and negative effects into account, there is still
an advantage for patients to be fed orally/enterally
early during the postoperative course.
However, in certain clinical situations considerable
variations of the usual gastrointestinal tract motility
occur (mainly gastric emptying). Repeat high residual
volumes of the stomach when aspirating through the
nasogastric tube are the best indicators of functional
failure of gastric emptying. The reason for this is
­multifactorial: sepsis, acute hyperglycaemia, autono-
mous neuropathy, catecholamines, beta2-mimetics and
analgosedation. In this case, motility enhancing drugs
(metroclopramid, erythromycin) should be used.
Another unintentional effect is the increase of the
gastric pH. This leads to weakening of the gastric acid
barrier (especially due to antacid therapy) and therefore
to ascension of bacteria and colonisation of the
14 Nutrition of the Surgical Patient 95

Table 14.3 Complications and concomitant symptoms of early by administration of prokinetics, oral/enteral therapy
postoperative oral/enteral feeding must be changed to a total parenteral regime.
Complications Possible causes and risk factors
Functional impairment Mostly extra-gastric, primary or
of gastric emptying concomitant disease
• Severe systemic disease 14.8.5 Practice of Enteral Nutrition
• Acute hyperglycaemia
• Autonomous neuropathy
• Drug effects
To commence enteral feeding some kind of access to the
GI tract has to be established, usually using transnasal
Hospital acquired Ascension of bacteria and fungi as
tubes. For nasogastric feeding tubes with the largest tol-
pneumonia a consequence of elevation of the
gastric pH erated lumen (12–14 charriere) should be used, this also
allows for decompression of the stomach.
Diarrhoea Intestinal primary or concomitant
disease, often multifactorial If the upper GI tract will not work for a foresee-
• Infections of the GI tract able period of time, a catheter jejunostomy should
• Motility-, resorption- or passage be performed during surgery. Alternatively, it can
impairments be considered to place nasojejunal tubes endoscopi-
Passage impairments in Intestinal or extraintestinal cally. This offers simple and secure access to the
small- or large bowel primary or concomitant disease upper small bowel and can also be used to bypass
• Decrease of blood circulation in an insufficient anastomosis after gastrectomy/oeso­
the abdomen
phagectomy.
• Infection of the GI tract
In principal, two different modalities of application
• Drug effects
are available: continuous administration, or bolus feed-
ing of 50–300 ml. In general, continuous administra-
tion is better tolerated leading to a higher energy- and
oesophagus and pharynx. Micro-aspirations can substrate supply, since the rate of treatment limiting
develop which increases the risk of hospital-acquired diarrhoea and aspirations is smaller. On the other hand,
pneumonia. Stopping the feeding during the night acute blockage can be missed which could lead to a
allows the gastric pH to fall and restores the acid life-threatening aspiration.
barrier.
The most common complication of enteral feeding
is diarrhoea. The cause of diarrhoea is multifactorial
In case of uncertain tube function, bolus feeding
and the composition of the feeding solution only rarely
is preferable since the nursing staff can check the
is the reason for this problem. Critical pathomecha-
amount of residual volume in the stomach before
nisms are infectious diseases of the intestinal tract and
every application and reduce the amount of feed-
impairment of motility, resorption or blood supply.
ing if necessary.
The antibiotic-induced pseudomembranous colitis has
to be considered as a differential diagnosis as well. The
diarrhoea can be treated by reducing the flow, chang-
ing the nutritional regime or modality or by changing
the antibiotics. In severe cases (haemorrhagic colitis) a 14.9 Particularities of Nutrition
total feeding pause might be indicated. in Critically Ill Patients
Apart from impairment of motility in the upper GI
tract, passage failures in the small and large bowel
are relevant. The combined small-/large-bowel ileus 14.9.1 Substrates
has to be differentiated from the isolated large-bowel
ileus (Ogilvie-syndrome, pseudo obstruction of Immunomodulatory tube nutrition for patients with
the colon). If this condition cannot be fixed with surgical sepsis is not indicated at present regardless
mechanical means (enema, endoscopic aspiration) or of the severity of the disease. Especially pro- and
96
anti-inflammatory reactions to nutrition play a role
here, although this impact has not been clearly
specified.
In patients with total parenteral feeding, glutamine
in form of dipeptides (20 g/day) should be added. This
prevents common glutamine deficiencies and the
­associated immunodeficiency. On a long-term basis,
a decrease in mortality has been reported.
The main focus of nutritional therapy in the inten-
sive care patient is to prevent protein catabolism.
Patients with severe SIRS or sepsis lose between 1.2
and 1.4 kg of protein in a period of about 3 weeks
(mainly skeletal muscles), which is approximately
13% of the baseline. The amount of calorie intake in
relation to the total metabolic rate hardly influences
protein catabolism. Even large amounts of protein
intake, can only reduce protein catabolism, but not
fully prevent it.
The optimal daily intake of proteins is about 1.5 g
protein/kg body weight/day. Larger amounts do not
have positive effects on protein metabolism. The dif-
ferent feeding modalities certainly play a role in
reducing protein loss. Enteral feeding, for example,
can almost halve the protein loss of intensive care
patients within 10 days compared to isocaloric paren-
teral feeding.
14.9.2 Caloric Demand
The vast majority of intensive care patients is
supplied sufficiently with a conservative calorie
administration of 21–25 kcal/kg body weight/day
(depending on the amount of physical activity
and analgosedation). Calorie administration at
this level is a trade-off between trying to compen-
sate losses as far as possible and reducing toxic
side effects on the other hand.
14.9.3 Additive Pharmacotherapy
Because of the well-known adverse effects of
­hyperglycaemia to the immune system, rigid control of
the blood glucose level is mandatory. Plasma glucose
F. Brackmann et al.
levels in intensive care patients should not exceed 150 mg/
dl. Hyperglycaemia needs to be treated with insulin
therapy, possibly with continuous insulin infusion via
a perfusor and close monitoring.
14.9.4 Metabolic Monitoring
At present, a reliable and easy-to-use method to clini-
cally estimate the protein demand of the individual
surgical patient does not exist. It is possible to mini-
mise the daily protein loss for most of the elective sur-
gical patients by administration of 1–1.2 g/kg body
weight/day protein. This can be increased to 1.5 g/kg
body weight/day in intensive care patients. Creatinine
or urea concentrations are only very limited indicators
for an increasing protein catabolism. However, mea-
suring those serum concentrations is necessary to early
detect toxic levels of these metabolites in acute renal
failure and to initiate adequate therapeutic measures if
needed. After overcoming sepsis, protein intake can be
increased up to an amount where urea levels are within
the upper normal range.
To monitor lipid utilization, it is necessary to measure
plasma triglyceride concentrations in regular intervals.
This helps to detect impairments of lipid metabolism at
an early stage.
Malfunctioning of the carbohydrate metabolism
can be diagnosed by measurements of blood glucose
levels several times per day (blood glucose profile).
The electrolyte demand of the patient is usually deter-
mined by measurements of their serum concentrations.
To detect real deficiencies of the so-called micro-
nutrients (trace elements, vitamins) indirect func-
tional tests would be required which are complicated
and cannot be performed in practice. Therefore,
patients at risk are usually administered appropriate
vitamins and trace elements prophylactically in regu-
lar intervals.
Recommended Reading
Alberda, C., Gramlich, L., Jones, N., Jeejeebhoy, K., Day, A.G.,
Dhaliwal, R., Heyland, D.K.: The relationship between
nutritional intake and clinical outcomes in critically ill
patients: results of an international multicenter observational
study. Intensive Care Med. 35(10), 1728–1737 (2009)
14 Nutrition of the Surgical Patient
Braga, M., Gianotti, L., Nespoli, L., Radaelli, G., Di Carlo, V.:
Nutritional approach in malnourished surgical patients: a pro-
spective randomized study. Arch. Surg. 137, 174–180 (2002a)
Braga, M., Gianotti, L., Vignali, A., Carlo, V.D.: Preoperative
oral arginine and n-3 fatty acid supplementation improves
the immunometabolic host response and outcome after col-
orectal resection for cancer. Surgery 132, 805–814 (2002b)
Griesdale, D.E., de Souza, R.J., van Dam, R.M., Heyland, D.K.,
Cook, D.J., Malhotra, A., Dhaliwal, R., Henderson, W.R.,
Chittock, D.R., Finfer, S., Talmor, D.: Intensive insulin ­therapy
and mortality among critically ill patients: a meta-­analysis includ-
ing NICE-SUGAR study data. CMAJ 180, 821–827 (2009)
97
Jones, N.E., Heyland, D.K.: Implementing nutrition guidelines
in the critical care setting: a worthwhile and achievable goal?
JAMA 300, 2798–2799 (2008)
Kondrup, J., Rasmussen, H.H., Hamberg, O., Stanga, Z., Ad
Hoc ESPEN Working Group: Nutritional risk screening
(NRS 2002): a new method based on an analysis of con-
trolled clinical trials. Clin. Nutr. 22, 321–336 (2003)
Sorensen, J., Kondrup, J., Prokopowicz, J., Schiesser, M.,
Krähenbühl, L., Meier, R., Liberda, M., EuroOOPS study
group: EuroOOPS: an international, multicentre study to
implement nutritional risk screening and evaluate clinical
outcome. Clin. Nutr. 27, 340–349 (2008)
 Surgical and Hospital-Acquired Infections
Wolfgang Böcker and Wolf Mutschler
15.1 Background
15.1.1 Basic Concepts
15.1.1.1 Infection, Infectious Disease,
and Inflammation
An infection is defined by the invasion and reproduc-
tion of bacteria, viruses, fungi, parasites, prions, or
viroids within the human body. Whether the invading
pathogen leads to a clinical manifestation of an infec-
tious disease depends on the number and virulence of
the pathogen as well as on the resistance of the
patient. The host responds to the infection with an
inflammation.
15.1.1.2 Surgical Infections
Surgical infections have to be either treated by an
operation or have been caused by a surgical interven-
tion. Surgical infection can be divided into five differ-
ent groups:
1. Primary abscessing infections (e.g., furuncle, carbuncle)
2. Secondary abscessing infections (e.g., liver abscess)
W. Böcker
University of Munich, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: wolfgang.boecker@med.uni-muenchen.de
W. Mutschler (*)
Hospital of University of Munich, Ludwigs-Maximilians-
University, Nussbaumstrasse 20, 80336 Munich, Germany
e-mail: wolf.mutschler@med.uni-muenchen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_15, © Springer-Verlag Berlin Heidelberg 2011
15
3. Non-abscessing infections (e.g., fasciitis, peritonitis)
4. Posttraumatic infections (e.g., osteomyelitis fol-
lowing open fracture)
5. Postoperative surgical site infections (e.g., wound
infection, abdominal wall abscess)
15.1.1.3 Diagnosis of Surgical Infections
Surgical infections primarily present with clinical symp-
toms. The clinical presentation on the body surface is
one or more cardinal symptoms of inflammation:
1. Rubor (= redness)
2. Calor (= heat)
3. Tumor (= swelling)
4. Dolor (= pain)
5. Functio laesa (= impaired function)
Infections of deep sites (e.g., abdominal abscess,
implants) can initially have a complete lack of local
symptoms and are sometimes difficult to diagnose.
Systemic symptoms such as chills and fever may be
present. Leukocytosis and elevated erythrocyte sedi-
mentation rate (ESR) may be the only signs. Deep
infections often need additional diagnostic tools such
as CT scan, MRI, or PET scan. Scintigram may be
helpful to diagnose infections of artificial joints and
osteosynthesis materials. Sometimes needle aspiration
with cells count and microbiology culture may give the
final clue.
15.1.1.4 Infection Defense
The goal of the body’s immune system is the elimina-
tion or inactivation of the invading organism. There are
99
100
several physiological protective mechanisms which
prevent the invasion of pathogens:
1. Intact body surface
2. Adequate tissue perfusion
3. Physiological bacterial colonization
The human body responds to infection with a congeni-
tal unspecific and an acquired specific immune system.
Several factors can lead to a failure or dysfunction of
the immune system. Apart from congenital immune
defects, acquired immune defects can impair the
immune response:
1. Accompanying disease (e.g., diabetes, HIV, malig-
noma, hematological disease)
2. Medication (e.g., steroids, immunosuppressants)
3. Nicotine use
4. Older age
5. Bad general condition and malnutrition
Several local factors favor an infection:
1. Opening of body surface (traumatic or operative)
2. Limited blood perfusion
3. Unfavorable wound conditions (necrosis, compro-
mised blood perfusion)
4. Inadequate wound care (late wound closure, hema-
toma, long surgery time)
5. Implantation of foreign bodies (i.v. access, perito-
neal dialysis catheter, long stay of drains, osteosyn-
thesis material, endoprostesis, valves)
Studies have also shown a coincidence of surgical site
infections with remote site infections. Therefore, prior
to elective surgery (e.g., joint replacement), these
infections should be treated first.
15.1.1.5 Principles of Therapy
The surgical therapy of infections consists of:
1. Operative treatment
2. Correction of the acquired immune defect (if
possible)
3. Systemic antimicrobial therapy
First-line treatment is early surgery with incision,
removal of necrosis, and placement of a drain. This is
particularly true for abscesses (Ubi pus ibi evacua!).
One exception is an intra-abdominal abscess, which
may be successfully treated by drainage alone. For
W. Böcker and W. Mutschler
local antimicrobial therapy, antiseptics can be used.
Local application of antibiotics should be avoided
because of the generation of resistance. Cooling by
alcohol packing may suppress the inflammation.
Systemic antimicrobial therapy is indicated (see
Chap. 16):
1. With generalized infection (fever, chills)
2. With particular dangerous infections (e.g., gas
­gangrene, mediastinitis, pneumonia, sepsis)
3. As prophylactic perioperative measure (inserting
implants and prosthesis; procedures, which are
accompanied by an increased risk of infection: e.g.,
gastrointestinal tract surgery; operations on neck,
eye, and breast)
Systemic antibiotic therapy alone for abscessing infec-
tion is not recommended, since the pathogens cannot
be reached by the drugs. Moreover, the treatment with
antimicrobial drugs alone would prolong the course of
infection.
15.1.2 Prevention of Surgical Infections
15.1.2.1 Hygiene
The goal of hygienic measures is the prevention of
­surgical and nosocomial infections. With hygiene
­measures on patients, infection rates can be reduced.
Mupirocin ointment is effective as a topical agent
for eradicating S. aureus from the nares of colonized
patients. Preoperative shaving of the surgical site
the night before an operation is associated with a
significantly higher risk of surgical site infections.
Therefore, shaving immediately before the opera-
tion is recommended. Several antiseptic agents are
available for preoperative preparation of skin at the
incision site. Alcohol-containing products, iodo-
phores (e.g., povidone-iodine), and chlorhexidine
gluconate are the most commonly used agents.
Hygiene measures with patient contact using masks,
gloves, and gowns protect the patient as well as the
surgical team. To prevent wound infections with
dressing changes, aseptic measure should be used.
Hygiene measures in the operating room which have
been shown to be effective are the use of ventilation,
routine cleaning of surfaces, the usage of drapes,
and sterilization of surgical instruments. Positive
15 Surgical and Hospital-Acquired Infections
pressure prevents airflow to enter from less clean
areas into the operating room.
15.1.2.2 Asepsis and Antisepsis
In general, septic and aseptic surgeries can be discrimi-
nated. If possible, patients with and without wound
infections should be separated on the ward and in the
operating room. In aseptic surgeries, no pathogens are
released. The postoperative risk of infection is signifi-
cantly below 5%. Rigorous adherence to the principles
of asepsis by all scrubbed personnel is the foundation of
surgical site infection prevention. During septic proce-
dures, a massive release of pathogens can be observed.
Antisepsis describes the use of antiseptic agents in
order to reduce the numbers of pathogens. Members of
the surgical team who have direct contact with the ster-
ile operating field or sterile instruments used in the
field wash their hands and forearms by performing a
traditional procedure known as scrubbing. This hap-
pens immediately before donning sterile gowns and
gloves. Alcohol or povidone-iodine is considered the
gold standard for surgical hand preparation. Surgical
hand disinfection is a two step process:
1. Thorough cleaning underneath fingernails (usually
with a brush)
2. Scrubbing at least for 3–5 min
After performing the surgical scrub, hands should be
kept up and away from the body (elbows in flexed
position) so that antiseptic agent runs from the tips of
the fingers toward the elbows. Jewelries and artificial
nails have to be removed before scrubbing.
15.1.2.3 Surgical Technique
Excellent surgical technique is widely believed to
reduce the risk of surgical site infections. Such tech-
niques include gentle tissue handling, removing devital-
ized tissues, eradicating dead space, preserving adequate
blood supply, preventing hypothermia, avoiding inad-
vertent entries into a hollow viscus, and appropriately
managing the postoperative incision. All foreign bodies
including suture material, prosthesis, and drains pro-
mote infections. Drains are effective in evacuating
­postoperative hematoma or seroma, which – if present –
increases the risk for surgical site infection.
101
15.1.2.4 Antimicrobial Prophylaxis
Surgical antimicrobial prophylaxis is used as a single i.v.
administration of an antimicrobial agent just before the
start of an (elective) procedure (within 30 min prior
to skin incision). Contaminated wounds often require
longer duration of prophylaxis. Antimicrobial agents are
used as intravenous infusions to reduce the microbial
burden of intraoperative contamination to a level that
cannot overwhelm host defenses. Serum and tissue lev-
els should be maintained during the whole procedure.
Antimicrobial prophylaxis is an evidence-based mea-
sure to reduce postoperative infections in a number of
­procedures (e.g., joint replacement, gastrointestinal sur-
gery). The choice of the antimicrobial agent depends on
the most likely pathogens (e.g., joint replacement: S.
aureus, coagulase-negative Staphylococci, gram-negative
bacilli; appendectomy: gram-negative bacilli, anaerobes).
15.1.2.5 Hospital-Acquired Infections
Nosocomial infections are acquired in medical institu-
tions and affect 4–10% of all inpatients and 25% of inten-
sive care patients. Most common infections are pneumonia,
upper respiratory tract, urinary tract, and wound infec-
tions as well as sepsis. Typical pathogens are Enterococcus
spp., Staphylococcus aureus, coagulase-negative staphy-
lococci, Escherichia coli, Pseudomonas aeroginosa, and
fungi. A major problem with hospital-acquired infection
is the prevalence of resistance against many different anti-
microbial agents (multiple drug resistance), which has to
be addressed with the choice of the antimicrobial agent.
15.1.2.6 Surveillance of Nosocomial Infections
Many countries have implemented regulations that require
hospitals to conduct surveillance of particular nosocomial
infections. These measures are not only meant to identify
outbreaks with pathogens that have multiple drug resis-
tance, but also to identify an increa­sed incidence of surgi-
cal site infection of certain surgical procedures. MRSA is
the most common pathogen with multiple drug resistance
and most frequently observed in intensive care, trauma
surgery, and vascular surgery wards. If there is an
increased incidence of nosocomial infection, certain mea-
sures (screening, education, changes in hygiene proce-
dures) have to be followed. A routine screening of all
patients and personnel has not been recommended.
102
15.1.2.7 Management of MRSA (Methicillin-
Resistant Staphylococcus aureus)
Methicillin-resistant Staphylococcus aureus is a feared
pathogen in nosocomial infections. These are asso­ciated
with higher morbidity and mortality. The prevalence has
increased significantly over the last few years. Patients
at risk for MRSA (positive history, transfer from an
institution with high prevalence, contact with MRSA
carrier, chronically ill patient) have to be isolated until
negative screening results are available. Colonized or
infected patients have to be isolated. Personnel have to
disinfect hands and wear gloves, mask, and gowns,
which all remain in the room before leaving. All instru-
ments (e.g., stethoscope, ECG, ultrasound) have to be
disinfected. Daily cleaning of surfaces in the patient’s
room is required. Patient’s blankets and pillows are
washed daily. Elective surgeries should be avoided, and
small procedures should be conducted in the patient’s
room. Major surgeries should be performed in the septic
operating room, and at the end of the daily operating
program. Treatment of MRSA is done according to the
sensitivity testing (e.g., vancomycin). The nares of colo-
nized patients are treated effectively with Mupirocin
ointment (3× daily, at least for 3 days). For eradication
of skin colonization, whole body washings with anti-
septic agents are performed. Also colonized personnel
have to be eradicated and should not have patient con-
tact before. Isolation of MRSA-colonized patients can
be lifted, when 3 days after completion of treatment
three consecutive smears are negative.
15.2 Surgical Infections
15.2.1 Bacterial Infections
15.2.1.1 Introduction
Bacterial infection can be discriminated by different
criteria:
1. Anatomically (skin: furuncle, fascia: necrotizing
fasciitis)
2. Pathogen (Staphylococcus ssp., Streptococcus ssp.,
etc.)
3. Urgency of surgical intervention (urgent: furuncle;
emergency: necrotizing fasciitis)
4. Extent of infection (local: abscess; diffuse: fasciitis)
W. Böcker and W. Mutschler
5. Degrees (uncomplicated infection; complicated
infection: larger surgical intervention necessary,
extension in deep soft tissues or severe comor­bidity)
6. Growing condition (aerobe, anaerobe)
7. Pus generation
In clinical practice, infections are separated into aero-
bic and anaerobic infections.
15.2.2 Aerobic Infections
15.2.2.1 Abscess
Definition: A collection of pus which accumulated in a
tissue cavity formed on the basis of an infectious process.
Abscesses can develop in any kind of solid tissue, but are
most frequently localized on the body surface (e.g., nee-
dle abscess). More rarely abscesses are found within
inner organs (brain, tonsils, teeth, liver). Typical patho-
gens are Staphylococcus, E.coli, and mixed infection.
Symptoms: Cardinal symptoms of inflammation.
Sometimes fluctuation can be observed near the body
surface. A pulsating pain is typical. Therapy: Surgical
drainage of the abscess is usually indicated once the
abscess has developed from a harder serous inflammation
to a softer pus stage. This is expressed in the Latin medi-
cal aphorism: Ubi pus, ibi evacua (“where there is pus,
evacuate it”). Curettage, flushing, and local antiseptic
agents clean the cavity. In addition, drains are frequently
placed. With smaller localized abscesses, antimicrobial
agents are not required. Needle aspiration of the abscess
as only treatment is the exception, e.g., with placement of
pigtail-catheter in intra-abdominal abscesses.
15.2.2.2 Empyema
Definition: Infection in a preformed cavity with a miss-
ing initial necrosis. Localization: pericardium, gall-
bladder, pleura, and joints. Pathogens: Staphylococcus
ssp., Streptococcus ssp., N. gonorrhoeae, E. coli,
Proteus, anaerobic organisms, frequently mixed flora.
Symptoms: Depend on localization. Shortness of breath
and thoracic pain are seen with pleural- and pericardial
empyema. Abdominal pain with gallbladder empyema.
Swelling and redness with joint empyema. Fever and
chills. Therapy: Incision, flushing, removal (where
possible, e.g., gallbladder), drainage, and systemic
15 Surgical and Hospital-Acquired Infections
antimicrobial therapy are the major steps of adequate
surgical intervention.
15.2.2.3 Furuncle
Definition: Skin infection starting from hair follicles
with localized accumulation of pus (Fig. 15.1).
Localization: All hairy body surfaces. Pathogen:
Staphylococcus ssp. Symptoms: Classical symptoms of
inflammation. Can be very painful. Therapy: Most
furuncles run their course within 1 week. Soaking the
furuncle with warm water can help to alleviate the pain
and hasten draining the pus. Incision is rarely necessary
and only performed with local pus accumulation.
Antimicrobial agents are only necessary in severe cases
and with generalized spread (furunculosis). Always
consider underlying immune suppression (e.g., undiag-
nosed diabetes, malnutrition with vitamin deficiency).
15.2.2.4 Carbuncle
Definition: Confluent skin infection originating from
several furuncles. Localization: Preferably neck, back,
and buttocks. Pathogen: Staphylococcus ssp. Symptoms:
Pain with pressure and redness of skin, sometimes with
Folliculitis Boil
Fig. 15.1 Folliculitis, furuncle and carbuncle are distinguished by the extent of infection. These skin infections are most frequently
caused by Staphylococcus ssp. infection
103
extensive necrosis. Therapy: Excision of necrosis. All
abscesses have to be drained. Frequently antimicrobial
therapy is necessary. Consider underlying undiagnosed
immune suppression.
15.2.2.5 Erysipelas
Definition: Acute Streptococcus infection of the skin
and subcutaneous tissue (Fig. 15.2). Localization: Most
frequently face and extremities. Pathogen: Streptococcus
pyogenes. Symptoms: Patients typically develop symp-
toms including high fevers, chills, and general illness
within 48 h of the initial infection. Characteristically,
the erythematous skin lesion enlarges rapidly and has a
sharply demarcated raised edge (Fig. 15.3). Therapy:
Antimicrobial therapy, immobilization, cold dressing.
Search for skin ulcerations (e.g., between toes) and
consider immune suppression.
15.2.2.6 Phlegmon
Definition: Diffuse and infiltrating infection. Due
to special enzymes (hyaluronidase, streptoki-
nase), pathogens spread in the interstitial soft tis-
sue (Fig. 15.2). Loca­lization: Skin, intermuscular
Carbuncle
104
Erysiplas Phlegmon
Fig. 15.2 Erysipelas are infection of the dermis. Phlegmon extents with special enzymes into the soft tissue of the subcutis.
Necrotizing infections are even more aggressive and invade the through fascia into the muscle
Fig. 15.3 Typical clinical presentation of erysipelas. This acute
Staphylococcus pyogenes infection characteristically enlarges
rapidly and has a sharply demarcated raised edge
and intramuscular, mediastinal, and retroperitoneal.
Pathogens: Strepto­coccus ssp., Staphylococcus ssp.,
Proteus, anaerobes (Bacterioides), enterobacteria,
sometimes mixed flora. Symptoms: Depend on type
of pathogen and localization. Frequently diffuse red-
ness and swelling is found. Fever and leukocytosis.
Therapy: Antimicrobial therapy is mandatory. In
severe cases, immediate surgical intervention is nec-
essary. Eradicate the source.
W. Böcker and W. Mutschler
Epidermis
Dermis
Subcutaneous
tissue
Fascia
Muscle
Necrotizing fasciitis
15.2.2.7 Gangrene
Definition: Complication of necrosis caused by infec-
tion and/or ischemia. A necrosis without inflammation
is called mummification. Localization: Most frequently
lower extremities. Less frequent other soft tissues:
Fournier’s gangrene (severe spontaneous gangrene of
scrotum with high morbidity and mortality). Pathogens:
Anaerobes, saprogenic microorganisms, frequently
mixed flora. Symptoms: Extended necrosis with black
to gray-green discoloration, fecal smell, often without
pain. The toxic products formed by bacteria are
absorbed and can cause systemic manifestation of sep-
ticemia as well as death. Therapy: Removal of all
necrotic tissue. Amputation of extremities is often nec-
essary. Improvement of vascular perfusion is essential.
15.2.2.8 Necrotizing Infection
Definition: Live-threatening and fast progressing infec-
tion with necrosis of fascias and muscle (Fig. 15.2).
Pathogens: Streptococcus (Streptococcus gangrene, necro-
tizing fasciitis, Streptococcus myositis), Staphylococcus
(necrotizing fasciitis), Clostridium (myositis, cellulitis),
sometimes mixed flora. Localization: Infections extend
along subcutis, fascia, and muscle septums. Symptoms:
15 Surgical and Hospital-Acquired Infections
Severe pain and characteristic livid red discoloration of
the skin. With progression development of necrosis.
Fast development of a septic picture with multiple organ
failure. Therapy: Immediate surgical intervention with
extended debridement is essential. With delayed surgi-
cal intervention, mortality exceeds 50%. Intensive care
treatment is usually needed. Systemic antimicrobial
therapy with broad-spectrum antibiotics. Hyperbaric
oxygen therapy (HOT) has significantly reduced fatal-
ity rates. After debridement, wounds are left open and
closure may be attempted after second look operation.
Vacuum-assisted closure can be considered after com-
plete surgical removal of all necrotic tissues.
15.2.2.9 Panaris and Paronychia
Definition: Infection of the nail fold or wall. Symptoms:
Initially redness and severe pressure pain. Later devel-
opment of an abscess. Therapy: In early stages, finger
bath and local anti-inflammatory treatment with immo-
bilization. Abscesses must be drained.
15.2.2.10 Bursitis
Definition: Acute or chronic inflammation of a bursa.
Commonly caused by repeated movement and exces-
sive pressure. Carries a high risk of infection with open
injuries. Localization: Typically in exposed positions
(elbow and knee). Pathogens: In open injuries,
Streptococcus and Staphylococcus. Symptoms: Pain,
redness, swelling, and fluctuation. Therapy: Surgical
excision of the bursa in case of purulent bursitis and in
open injuries. Immobilization.
15.2.3 Anaerobic Infections
15.2.3.1 Tetanus
Definition: Wound infection caused by bacteria which
secrete a neurotoxin (tetanospasmin). As the infection
progresses, the released neurotoxin causes characteris-
tic muscle spasms. In some countries, the disease is
notifiable. Localization: Any contaminated wound.
Pathogen: Clostridium tetani. Symptoms: After an
105
incubation time of 3–60 days (typically 1–2 weeks)
initial unspecific general symptoms. Thereafter, a
characteristic sequence of symptoms: muscle spasm in
the jaw (trismus or lockjaw), facial spasm (risus sar-
donicus), followed by difficulty to swallow and rigid-
ity of calf and pectoral muscle. Spasms shape the body
into a characteristic hyperlordosis called opisthotonus.
Symptoms may last for several weeks, if left untreated.
Therapy: Until now, only symptomatic treatment is
available. Therefore, tetanus prophylaxis is very
important. In addition to adequate wound care to avoid
anaerobe wound condition, prophylaxis by immuniza-
tion is essential. With existing pre-immunization,
refreshment is ­necessary with tetanus toxoid every
5 years. With no pre-immunization, a simultaneous
immunization with tetanus toxoid and passive immu-
nization with human anti-tetanospasmin immunoglob-
ulin or tetanus immunoglobulin is crucial.
15.2.3.2 Gas Gangrene
Definition: Bacterial tissue infection with gas-pro-
ducing pathogens. Rapidly progressing and life-
threatening infection. Typically, the environmental
bacteria enter through contaminated wounds and
expand in anaerobic environments. The organism not
only produces gas, but also secretes powerful exotox-
ins. Localization: Soft tissues. Pathogens: Clostridium
perfringens (90%) and other Clostridium species.
Symptoms: Extremely painful, rapidly progressing
wound infection. Charac­teristically crepitation on
palpation. Drainage of black-blood-stained fluid,
foamy, sweet-rotten smelling secretion. The affected
muscles appear gray-red. Sometimes, on X-ray, the
gas can be seen. The general condition of the patient
rapidly deteriorates with sepsis and multiple organ
failure. Therapy: Must start immediately with clinical
suspicion. Leaving this condition untreated always
ends with the patient’s death. Surgical interventions
with extended debridement have to counteract anaer-
obe wound conditions. If necessary, affected extremi-
ties have to be amputated. Antimicrobial therapy has
to start with suspicion. Even with surgery and antimi-
crobial therapy, mortality still is up to 40%. With
hyperbaric oxygen therapy (HOT), mortality rates
can be decreased to 20–25% and amputation rates
can be decreased by 70%.
 Antimicrobial Therapy
Christian P. Schneider and Beatrice Grabein
16.1 Introduction
Antimicrobial agents are widely used pharmaceuti-
cals in hospital and outpatient care. They are causal
therapeutic agents and their rational use can decrease
antibiotic resistance, and therefore, hospital stay and
treatment costs. However, due to increased quality
standards and cost pressure for public health services,
these requirements can only be achieved if up-to-date
infectious disease management strategies have been
implemented. Although guidelines and recommenda-
tions from several associations and institutions were
included in this chapter, it is important to note that
rational empiric antibiotic therapy underlies continu-
ous alterations. Therefore, therapeutic recommenda-
tions can only capture basic principles. Often various
therapeutic options are available, and the therapeutic
spectrum is not always comparable in different coun-
tries or institutions. Various treatment options help to
avoid allergic reactions and allow to choose antibi-
otic agents according to the individual patient’s risk
profile.
C.P. Schneider (*)
Department of Surgery, University Hospital Munich,
Ludwig-Maximilians University Munich, Campus Großhadern,
Marchioninistr. 15, 81377 Munich, Germany
e-mail: christian.schneider@med.uni-muenchen.de
B. Grabein
Max von Pettenkofer-Institute for Hygiene and Clinical
Microbiology, Ludwig-Maximilans University Munich,
Campus Großhadern, Marchioninistr. 15,
81377 Munich, Germany
e-mail: beatrice.grabein@med.uni-muenchen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_16, © Springer-Verlag Berlin Heidelberg 2011
16
16.2 Basic Principles of Antimicrobial
Therapy
Characterization of antibiotics, pharmacokinetics, effi-
cacy, antibiotic resistance, and side effects (Table 16.1).
The antibiotic agents described were selected with
specific consideration of their importance in the surgical
field.
16.3 Penicillins
The classification of penicillins is based on their chemi-
cal structure. Different chemical constitutions imply
varying effects against pathogens and their beta-­
lactamases. Penicillins are bactericidal due to blockade
of bacterial transpeptidases which are important for the
peptidoglycan synthesis in the bacterial cell wall.
Benzylpenicillins, aminopenicillins, and isoxazolylpen-
icillins are available in parenteral and enteral pharma-
ceutical forms, whereas acylaminopenicillins can only
be administered intravenously. Penicillins are approved
for treatment of systemic and local infections with vari-
ous gram-positive and gram-negative pathogens. A
wider range of pathogens can be treated via combina-
tion of penicillins with a beta-lactamase inhibitor.
16.3.1 Pharmacokinetics
Penicillins generally exhibit a medium to high plasma
concentration while their half-life is in the low to
middle range (0–10 h). They reside mostly in the
extracellular space with a low relative distribution vol-
ume of 0–0.4 L/kg. The rate of metabolization is low,
107
108 C.P. Schneider and B. Grabein

Table 16.1 Antimicrobial agents for parenteral application

Groups Subgroups Drugs Maximum dosage
Penicillins Benzylpenicillin Benzylpenicillin 10 million units q4–6 h
Aminopenicillin Ampicillin 2 g q8h
Aminopenicillin/BLI Amoxicillin/clavulanate 2.2 g q8h
Ampicillin/sulbactam 3 g q8h
Carboxypenicillin/BLI Ticarcillin/clavulanate 3.1 g q4–6 h
Acylaminopenicillins Piperacillin 4 g q8h
Mezlocillin 4–5 g q8h or 10 g q12h
Acylaminopenicillin/BLI Piperacillin/tazobactum 4.5 g q8h
Isoxazolylpenicillins Flucloxacillin 2 g q4–6 h
Oxacillin 4–8 g q4–6 h
Cephalosporins First generation Cephazolin 2 g q8h
Second generation Cefuroxime 1.5 g q8h
Cefotiam 2 g q8h
Third generation Cefotaxime 2 g q8h
Ceftriaxone 2 g q12h
Third generation with Ceftazidime 2 g q8h
anti-pseudomonal activity
Fourth generation Cefepime 2 g q8–12 h
Fifth generation Cefoxitine 2 g q8h
Carbapenems Group 1 Imipenem 1 g q8h
Group 2 Meropenem 1 g q8h
Ertapenem 1 g q24h
Ungrouped Doripenem 500 mg q8h
Monobactams Aztreonam 2 g q6–8 h
Fluroquinolones Group 2 Ofloxacin 400 mg q12h
Ciprofloxacin 400 mg q8h
Group 3 Levofloxacin 500 mg q12h
Group 4 Moxifloxacin 400 mg once daily
Macrolide Erythromycin 1 g q6h
Clarithromycin 500 mg q12h
Azithromycin 500 mg once daily
Glycopeptide Vancomycin 15–20 mg/kg BW q12h
Teicoplanin 400 mg q12h on day 1,and than
400 mg once daily
Lipopeptide Daptomycin 4 mg/kg BW once daily
Aminoglycoside Amikacin 15 mg/kg BW once daily
Gentamicin 5–7 mg/kg BW once daily
Netilmicin 5–7 mg/kg BW once daily
Tobramycin 5–7 mg/kg BW once daily
16 Antimicrobial Therapy
Table 16.1 (continued)
Groups Subgroups
Oxazolidinone
Lincosamide
Streptogramin
Tetracycline
Glycylcycline
Ansamycins
Nitroimidazole
Fosfomycine
Sulfonamide/
Benzylpyrimidine
q every, h hours, kg kilogram, g gram, mg milligram, BW body weight, BLI beta-lactamase inhibitor
and penicillins are mainly eliminated via the kidneys
through tubular secretion. Isoxazolylpenicillins have
a high plasma protein–binding capacity and low tis-
sue distribution compared to the other penicillins. The
best time-dependent efficacy kinetics can be reached if
drug concentrations at the site of infection are above
the minimum inhibitory concentration and therefore
short treatment intervals are necessary.
16.3.2 Efficacy and Indication
The efficacy of penicillins is dependent on their chemical
structure. It ranges from small spectrum (Penicillin G)
and extends to broad-spectrum efficacy if combined with
beta-lactamase inhibitors (Piperacillin-Tazobactam).
Application of Penicillin G is limited to Strep­
tococcus species (spp.), Pneumococci, Meningococci,
and some anaerobic pathogens (Clostridium spp.,
Actinomyces spp.) and should not be given as a single
agent if a serious infection is present. Nevertheless,
Penicillin G is still the first choice for erysipelas
and treatment of infections with Streptococcus
and Pneumococcus if cultures do not reveal mixed
pathogens.
Aminopenicillins have a broad-spectrum efficacy.
They are very effective against Enterococcus and some
gram-negative pathogens. Aminopenicillins are approved
for treatment of endocarditis and meningitis. In combi-
nation with beta-lactamase inhibitors, their spectrum is
extended to infections with several other gram-positive
109
Drugs Maximum dosage
Linezolid 600 mg q12h
Clindamycin 600 mg q8h
Quinupristin/dalfopristin 7.5 mg/kg BW q8h
Doxycyclin 200 mg q24h on day 1, and
than 100 mg once daily
Tigecycline 100 mg q24h on day 1, and
than 50 mg once daily
Rifampicin 10 mg/kg BW once daily,
(maximum 900 mg/day)
Metronidazole 500 mg q8h
Fosfomycin 4–8 g q8h
Co-trimoxazol 960 mg q12h
and gram-negative pathogens, including infections of
the upper respiratory tract, urinary tract, abdomen,
genitals, skin, and soft tissue.
Isoxazolylpenicillins have a narrow spectrum only
and are useful against Staphylococcus including those
strains producing penicillinase. Possible indications
are endocarditis, arthritis, infection of the skin and soft
tissue as long as the Staphylococcus strain is not resis-
tant against methicillin.
Acylaminopenicillins are broad-spectrum antibiotics
and include gram-positive and gram-negative aerobic
and anaerobic pathogens. Piperacillin also covers infec-
tions with Pseudomonas aeruginosa. In combination
with beta-lactamase inhibitors, they are also effective
against various beta-lactamase-producing pathogens.
Indications are infections of nearly all organ systems.
Piperacillin-Tazobactum can be used as rational empiric
antibiotic therapy for serious infections.
16.3.3 Antibiotic Resistance
Resistance of Streptococcus and Pneumococcus
against penicillin is still low at approximately 2% of
the isolates, but can reach up to 30% in some coun-
tries. The resistance rate of Escherichia coli against
aminopenicillins increased within the last years to
more than 50%. The efficacy of piperacillin-tazobac-
tam against Pseudomonas aeruginosa is still sufficient.
The fraction of oxacillin-resistant Staphylococcus
aureus (MRSA) is continuously increasing. It ranges
110
from approximately 15% of Staphylococcus aureus
isolates from hospital patients in some European coun-
tries to more than 60% in the United States. The anti-
biotic resistance rate for Staphylococcus epidermidis
and coagulase-negative Staphylococcus is commonly
more than 70%.
16.3.4 Side Effects (Table 16.2)
Allergic reactions can be observed in 0.7–10% of
all patients treated with penicillins and occur particu-
larly after repeated applications. These hypersensi-
tive reactions are characterized by nausea, vomitus,
bronchospasm, and hypotonia. Delayed allergic reac-
tions can appear 7–10 days after administration of
penicillins with fever, urticaria, lymph node swell-
ing, and hemolytic anemia, defined as Type III hyper-
sensitivity reactions (Arthus type). Neurotoxicity can
arise only after application of high dosage of penicil-
lins (80–100 Mio. IU/day). Additionally, pseudo-
allergic skin reactions may occur after treatment with
aminopenicillins if a concomitant viral infection is
present (mononucleosis). Antibiotic therapy with
isoxazolylpenicillins can increase liver enzymes.
Table 16.2 Side effects of penicillin treatment and alternative treatment options
Cross-reactivity between beta-lactam antibiotics
Penicillins ® First-generation cephalosporins
® Second-generation cephalosporins
® Third-generation cephalosporins
Penicillins ® Carbapenems
Penicillins, cephalosporins ® Aztreonam
Cephalosporins ® Carbapenems
Ceftazidime ® Aztreonam
Alternative antimicrobial substances
Gram-positive bacteria Staphylococcus spp.
Streptococcus spp.
Pneumococcus
Gram-negative bacteria Escherichia coli
Enterobacteriaceae
C.P. Schneider and B. Grabein
16.4 Cephalosporins
Cephalosporins are grouped into basic and broad-
spectrum cephalosporins. They are generally classified
into five groups. Cephalosporins are bactericidal, and
their pharmacokinetic characteristics are comparable
to penicillins. Agents of groups 1 and 2 are effective
against Staphylococci which decreases in groups 3–5.
In contrast, substances of groups 2–5 have increasing
efficacy against gram-negative pathogens. Additionally,
cephalosporins possess a good efficacy against patho-
gens producing beta-lactamase based on their stability
against various kinds of bacterial beta-lactamases.
16.4.1 Pharmacokinetics
Most cephalosporins are eliminated unmodified via
the kidneys, and their mean half-life is 2 h in patients
with normal renal function. Their distribution in the
different body compartments is also similar to those of
penicillins. Only ceftriaxone (group 3a) reveals an
extended half-life of 8 h, and therefore, a single daily
application is sufficient. Moreover, approximately
50% of ceftriaxone is excreted via the biliary system.
1.7–5.6%
~50%
Rarely
Lowly
Commonly
Clindamycin, doxycyclin,
glycopeptide, linezolid, macrolide,
rifampicin
Aminoglycoside, aztreonam,
fluoroquinolones, doxycycline
16 Antimicrobial Therapy
16.4.2 Efficacy and Indication
In general, all cephalosporins are ineffective against
Enterococci and methicillin-resistant Staph­ylococci.
Substances of the first generation ­(cephazolin) have
a good efficacy against methicillin-sensible Staphy­
lococci and Streptococci, but are weak against gram-
negative pathogens. Cepha­losporins of the second
generation (cefuroxime, cefotiam) have an extended
spectrum against gram-negative bacteria and con­
tinuing activity against gram-positive pathogens.
­Third-generation cephalosporines (cefotaxime, cef-
triaxone) have a broad-spectrum with excellent
activity against gram-negative bacteria but decreas-
ing effects against Staphylococci. In addition, cef-
tazidime (third generation with anti-pseudomal
activity) and cefepime (fourth generation) exhibit
anti-pseudomonal activity. Cefepime also has good
efficacy against Staphylococci, Streptococci and
beta-lactamase-producing bacteria compared to cef-
tazidime. Furthermore, cephalosporins of the fifth
generation (cefoxitine) are effective against anaero-
bic pathogens.
Cephalosporins are approved for treatment of vari-
ous kinds of infections, including infections of the
respiratory and urinary tracts, bones and joints, geni-
tals, skin and soft tissue. Cefotiam and cephalosporins
of the third to fifth generation are also approved for
infections of the biliary tract and abdomen. In addi-
tion, cephalosporins of the first, second, third, and fifth
generation are used as prophylactic antibiotics during
the perioperative phase.
16.4.3 Antibiotic Resistance
High rates of antibiotic resistance for second-generation
cephalosporins can be detected in Enterobacter spp.,
Citrobacter, and indol-positive strains of the Proteus
group. Since several years, increasing antibiotic resis-
tance rates up to 28% can be observed in Escherichia
coli isolated from ICU patients. Isolates of Klebsiella
pneumoniae and Escherichia coli producing extended-
spectrum-beta-lactamases (ESBL) cause antibiotic resis-
tance against third- and fourth-generation cephalosporins
ranging from 4–8% up to 55% (South America) in
hospitalized patients.
111
16.4.4 Side Effects
Possible side effects are comparable to those of peni-
cillins, but allergic reactions are fewer. Increased liver
enzymes and gastrointestinal discomfort occur in
5–10% of all treated patients. Augmented risk of bleed-
ing may appear if anticoagulants are given simultane-
ously with cefoxitin. Therapeutic administration of
ceftriaxone can rarely lead to shadows in the ultra-
sound of the gall bladder which is called transitory
­biliary pseudolithiasis.
16.5 Carbapenems
Carbapenems are also beta-lactam antibiotics with bac-
tericidal efficacy due to inhibition of the bacterial cell
wall synthesis. They are divided into two groups with
group 1 consisting of imipenem and group 2 of mero-
penem and ertapenem. Carbapenems, especially those
of group 1, are broad-spectrum antibiotics approved for
the treatment of serious life-threatening infections and
empiric therapy in patients receiving immunosuppres-
sive medication.
16.5.1 Pharmacokinetics
The distribution volume of carbapenems is small and
mainly extracellular. Protein-binding capacity is more
than 90% for ertapenem, while imipenem and mero-
penem have much lower capacities with 20% and 2%,
respectively. In part, carbapenems are metabolized and
predominately eliminated via the kidneys. Ertapenem
has a longer plasma half-life of 4 h compared to the
other carbapenems.
16.5.2 Efficacy and Indications
Carbapenems are broad-spectrum antibiotics, and
their efficacy includes almost all bacteria including
anaerobic pathogens, except for Enterococcus facium,
methicillin-resistant Staph­ylococci, and Stenotropho­
monas maltophilia. Doripenem is very effective against
112
Pseudomonas aeruginosa, Enterobacteriaceae, and
Acinetobacter spp. which are resistant against other
antimicrobial drugs. The efficacy of ertapenem is dif-
ferent with no effects against Pseudomonas aeruginosa,
Acinetobacter spp., and Enterococci. Carbabenems
are approved for the treatment of serious pneumonia,
intra-abdominal infections, sepsis, and infections of
the skin and soft ­tissue and for empiric therapy in neu-
tropenic patients.
16.5.3 Antibiotic Resistance
Currently, antibiotic resistances including Entero­
bacteriaceae are rare. It has been shown that some
Klebsiella species are resistant against carbapenems
due to release of carbapenem-hydrolyzing metallo-
beta-lactamases. Although the efficacy of carbapenems
is still good, infections with Pseudomonas aeruginosa,
Burkholderia cepacia, or other non-­fermenting bacte-
ria in hospitalized and/or immunosuppressed patients
demonstrate increased rates of resistance.
16.5.4 Side Effects
Mild gastrointestinal symptoms can be observed in
5–10% of all treated patients. Allergic reactions occur
rarely with less than 3%.
16.6 Monobactams
The only available monobactam is aztreonam. The mech-
anism of action is similar to beta-lactams. It is stable
against some beta-lactamases. Aztreonam is bactericidal
through inhibition of mucopeptide synthesis in the bacte-
rial cell wall, and thereby blocking peptidoglycan cross-
linking. It is only active against gram-negative bacteria.
Aztreonam displays good efficacy against Entero­bacteri­
aceae and non-lactose fermenters including Pseudomonas
aeruginosa. There is limited cross-reactivity between
aztreonam and other beta-lactam antibiotics, and it is gen-
erally considered safe to administer aztreonam to patients
with hypersensitivity to penicillins.
C.P. Schneider and B. Grabein
16.6.1 Pharmacokinetics
The distribution volume of aztreonam is low, but suf-
ficient levels can be reached in urine; bile; and pleural,
pericardial, and synovial fluids. Approximately 56% is
bound to plasma proteins and the plasma half-life is 2
h. Aztreonam is not metabolized and is mainly excreted
via glomerular filtration and tubular secretion as
unchanged drug.
16.6.2 Efficacy and Indication
Aztreonam has strong activity against susceptible
gram-negative bacteria, including Pseudomonas aerug­
inosa. It is approved for treatment of pneumonia, skin
and soft tissue infections, complicated and uncompli-
cated urinary tract infections, gynecologic infections,
and intra-abdominal infections and septicemia caused
by gram-negative bacteria in combination with anaero-
bic coverage.
16.6.3 Antibiotic Resistance
Anaerobic bacteria, Acinetobacter spp., Burkholderia
cepacia-complex, Stenotrophomonas maltophilia, and
gram-positive pathogens are generally resistant against
aztreonam.
16.6.4 Side Effects
Side effects include injection site reactions, rash,
­gastrointestinal disorder, and rarely toxic epidermal
necrolysis. There may be drug-induced eosinophilia.
16.7 Fluroquinolones
Fluoroquinolones are divided into four groups. Group
one has no clinical relevance and clinical relevant
agents are ciprofloxacin, ofloxacin and norfloxacin
(group 2), levofloxacin (group 3), and moxifloxacin
16 Antimicrobial Therapy
(group 4). They can be administrated parenterally as
well as orally due to their excellent acid stability.
Fluroquinolones are bactericidal through inhibition of
bacterial DNA-gyrases which are important for the
nucleotide acid synthesis.
16.7.1 Pharmacokinetics
The relative distribution volume of all fluoroquinolo-
nes is large with 2 up to 41 L/kg and they penetrate
excellently into various tissues. Their plasma protein–
binding capacities add up to <40%. The half-life varies
between 3 and 4 h for ciprofloxacin and norfloxacin,
7–8 h for ofloxacin and levofloxacin, and >10 h for
moxifloxacin. Therefore, their intervals of administra-
tion differ. Levofloxacin and ofloxacin are eliminated
via renal secretion while ciprofloxacin and norfloxacin
also are eliminated via the liver and intestines.
Moxifloxacin is almost completely eliminated via
­conjugation reactions.
16.7.2 Efficacy and Indications
Fluoroquinolones are approved for the treatment of
infections of the urinary tract, ENT and respiratory tract,
abdomen, genitals, bones, skin and soft tissues as well as
for serious systemic infections (i.e., sepsis). Ciprofloxacin,
ofloxacin, and norfloxacin (group 2) have a good effi-
cacy against gram-negative bacteria (Enterobacteriaciae,
Hemophilus influencae, Pseudomonas aeruginosa) and
a considerably lower effectiveness in the gram-positive
field (Staphylococci, Pneumococci, and Enterococci).
Levofloxacin (group 3) has better and moxifloxacin
(group 4) much better effects against gram-positive and
atypical pathogens. Moxifloxacin has a poor effectivity
against Pseudomonas aeruginosa but the antibiotic
spectrum of moxifloxacin also includes anaerobic
bacteria.
16.7.3 Antibiotic Resistance
In recent years, antibiotic resistance rates against flu-
roquinolones are on the rise in all relevant bacterial
113
strains. Escherichia coli has resistance rates from 7%
up to 20% of all isolates, Staphylococcus aureus from
15% up to 60% (mostly MRSA isolates) and
Pseudomonas aeruginosa from 10% up to 30% against
ciprofloxacin.
16.7.4 Side Effects
Side effects after treatment with fluoroquinilones are
present in 4–10% of all patients. Common symptoms
are gastrointestinal irritation, affection of the CNS
with sleep disturbances and obnubilation. Reactions of
the skin are rare, but UV exposure should be avoided
due to the phototoxic effects of all fluoroquinolones.
Caution is needed in patients with tendon degenera-
tion, since tendon ruptures have been described after
administration of fluoroquinolones. Additionally, pro-
longation of the QTc-interval has been observed after
therapy with fluroquinolones.
16.8 Macrolides
The most commonly used macrolides are erythromy-
cin, clarithromycin, and azithromycin which can be
applied parenterally, while roxithromycin can only be
given enterally. The mechanism of action of macrolides
is inhibition of bacterial protein biosynthesis by bind-
ing reversibly to the subunit 50S of the bacterial ribo-
some, thereby inhibiting translocation of peptidyl-tRNA.
This action is mainly bacteriostatic, but can be bacteri-
cidal in high concentrations. Macrolides tend to accu-
mulate within leukocytes, and therefore, they become
transported to the site of infection. Presently, their use
in the surgical field is limited.
16.8.1 Pharmacokinetics
The half-life of macrolides ranges from 2.5 h for eryth-
romycin, 2–5 h for clarithromycin, 12 h for roxithromy-
cin, and >14 h for azithromycin. The distribution volume
varies considerably from 0.7 L/kg BW for erythromy-
cin up to 25 L/kg BW for azithromycin. Erythromycin
is predominantly metabolized by demethylation in the
114
liver. The main elimination route of macrolides is via
the biliary tract, and a small fraction via the urine
(<4.5%).
16.8.2 Efficacy and Indications
Macrolides are approved for the treatment of infec-
tions of the upper airways, ENT field and the urinary
tract caused by Streptococci, Pneumococci, Chlamydia,
Legionella, Mycoplasma, and Ureaplasma. Entero­
bacteriaceae and Pseudomonas spp. are generally
resistant against macrolides. Macrolides represent an
alternative treatment option for infections with Strep­
tococci (scarlet fever, erysipelas) in patients with an
allergy to penicillins.
16.8.3 Antibiotic Resistance
Antibiotic resistance rates of Pneumococci against
macrolides range at approximately 20%.
16.8.4 Side Effects
Macrolides, mainly erythromycin and clarithromycin,
have a class effect of QT prolongation which can lead
to torsade de pointes. Macrolides exhibit enterohepatic
recycling which can lead to recurrence of the product
in the system, causing nausea, gastrointestinal disor-
der, and increase in liver enzymes. Local reactions
at the site of application (phlebitis) are frequent.
Furthermore, treatment with macrolides can cause
vertigo.
16.9 Glycopeptides
The glycopeptides vancomycin and teicoplanin are
only available for parenteral application because they
are not absorbed after oral intake. This class of drugs
inhibits the synthesis of cell walls in susceptible
microbes by inhibiting peptidoglycan synthesis. They
bind to the amino acids within the cell wall preventing
C.P. Schneider and B. Grabein
the addition of new units to the peptidoglycan.
Glycopeptides are only effective against gram-positive
bacteria. They are considered as reserve option for the
treatment of infections with multi-resistant gram-positive
pathogens, as their efficacy in beta-lactam-susceptible
pathogens is worse than that of the beta-lactams.
16.9.1 Pharmacokinetics
Glycopeptides have a time-dependent therapeutic effect
and are distributed only within the extracellular space.
Therefore, their distribution volume is very small. In
addition, their ability to penetrate into tissue is limited.
The half-life of vancomycin ranges from 6 to 8 h and for
teicoplanin from 70 to 100 h. Teicoplanin has a much
higher protein-binding capacity with 90% compared to
vancomycin with 55%. Glycopeptides are eliminated
via renal secretion. Therapeutic drug monitoring is
mandatory during treatment with glycopeptides because
pharmacokinetics vary largely between individuals.
16.9.2 Efficacy and Indication
Glycopeptides are very effective against various infec-
tions with gram-positive pathogens (Staphylococci,
Streptococci, and Enterococci), such as endocarditis,
pneumonia, bone infection, infection of the kidneys,
and serious systemic infections (sepsis). Importantly,
glycopeptides are the first-line antimicrobial agent for
infections with multi-resistant Staphylococci (MRSA
and MRCNS) and Enterococci.
16.9.3 Antibiotic Resistance
Antibiotic resistance of methicillin-resistant Staphy­
lococcus aureus and Enterococcus faecalis against
glycopeptides is still very rare but can be occasionally
observed for Staphylococcus epidermidis. In contrast,
antibiotic resistance of Enterococcus faecium against
glycopeptides can be seen frequently with varying pro-
files of resistance against both vancomycin and teico-
planin. The resistance rates can reach up to 30% which
usually occurs in intensive care patients.
16 Antimicrobial Therapy
16.9.4 Side Effects
Glycopeptides are usually given as an infusion and can
cause tissue necrosis and phlebitis at the injection site
if administered too rapidly. Indeed pain at the site of
injection is a common adverse event. One of the side
effects is called “Red man syndrome,” an idiosyncratic
reaction to bolus administration, caused by histamine
release. Some other side effects of vancomycin are neph-
rotoxicity including renal failure and interstitial nephritis,
blood disorders including neutropenia, deafness, and
gastrointestinal disorder (reversible after termination
of treatment).
16.10 Lipopeptides
Daptomycin represents the first antibiotic agent of this
new antibiotics class. Daptomycin has a distinct mech-
anism of action, disrupting multiple aspects of bacte-
rial cell membrane function dependant on calcium
integration into cytoplasmic cell membrane. It appears
to bind to the membrane and cause rapid depolariza-
tion, resulting in a loss of membrane potential leading
to inhibition of protein, DNA, and RNA syntheses,
which results in bacterial cell death.
16.10.1 Pharmacokinetics
Half-life of daptomycin is 7–9 h and more than 90%
binds to plasma proteins. Elimination takes place in
78% via renal secretion and 5% are egested via feces.
Adjustment of dosage in older patients and patients
with mild-to-moderate liver dysfunction (Child-Pugh
classes A and B) is not necessary but administration
intervals extend up to 48 h in patients with renal failure
(creatinine clearance <30 mL/min, hemodialysis, and
peritoneal dialysis).
16.10.2 Efficacy and Indications
Daptomycin is active against gram-positive bacteria
only. It has proven in vitro activity against Enterococci
115
(including glycopeptide-resistant Enterococci (GRE)),
Staphylococci (including methicillin-resistant Staphy­
lococcus aureus), Streptococci, and corynebacteria.
Daptomycin is approved for skin and skin structure
infections caused by gram-positive infections, Staphy­
lococcus aureus bacteremia, and right-sided S. aureus
endocarditis. In lung tissue, daptomycin becomes
­rapidly inactivated by surfactant, and ­therefore, dapto-
mycin is ineffective in pneumonia treatment.
16.10.3 Antibiotic Resistance
Antibiotic resistance against daptomycin has been
observed only in few cases.
16.10.4 Side Effects
Side effects commonly seen after administration of
daptomycin are elevation of creatinine kinase, gastro-
intestinal disorders (constipation, nausea, diarrhea,
vomiting, dyspepsia, abdominal pain, decreased appe-
tite, stomatitis, and flatulence), pain at the site of
administration, headache, and insomnia.
16.11 Aminoglycosides
The most important substances of this antibiotic class
are amikacin, gentamicin, netilmicin, and tobramycin
all of which can be administrated parenterally only.
Tobramycin may be given in a nebulized form as
well. Aminoglycosides demonstrate rapid bacteri-
cidal effects through irreversibly binding to the bacte-
rial 30S ribosomal subunit (amikacin works by binding
to the 50S subunit), inhibiting the translocation of the
peptidyl-tRNA from the A-site to the P-site, and also
causing misreading of mRNA, leaving the bacterium
unable to synthesize proteins vital to its growth.
Indications are serious infections with gram-negative
bacteria and also in combination with beta-lactam anti-
biotics therapy of endocarditis caused by gram-positive
cocci (Enterococci and Streptococci) due to synergistic
116
effects. However, the decision to use aminoglycosides
must be made carefully due to their poor tissue distri-
bution and high nephrotoxicity.
16.11.1 Pharmacokinetics
Aminoglycosides are almost exclusively distributed
within the extracellular space. Therefore, their dis-
tribution volume is low with a short half-life of
approximately 2 h in patients with normal kidney
function. Since the therapeutic ratio of aminoglyco-
sides is low, drug monitoring is mandatory particu-
larly if renal function is impaired. A daily single
application time point of the total dosage has been
established for all aminoglycosides because of com-
parable antimicrobial activity and reduced nephro-
toxicity compared to administration in three smaller
dosages.
16.11.2 Efficacy and Indications
Aminoglycosides are primarily used for treatment of
infections involving aerobic, gram-negative bacteria,
such as Pseudomonas, Acinetobacter, and Enterobacter
as well as Staphylococci. In general, they should be
given in combination with other antimicrobial sub-
stances, preferably with beta-lactam antibiotics due to
synergistic effects. The therapeutic administration of
aminoglycosides is approved for the treatment of seri-
ous infections (sepsis), fever in neutropenic patients,
Pseudomonas infections in patients with cystic fibrosis
(also for inhalation), and endocarditis. Amikacin is
also effective against gram-negative pathogens with
resistance against gentamicin and tobramycin.
16.11.3 Antibiotic Resistance
Antibiotic resistance develops fast because of decreased
accumulation of the substances in bacteria and loss of
binding affinity. Additionally, inactivation of aminogly-
cosides takes place through enzyme induction via acety-
lation, adenylation, and phosphorylation of the drugs.
C.P. Schneider and B. Grabein
16.11.4 Side Effects
Aminoglycosides have potential nephrotoxic and
­ototoxic side effects which are cumulatively and dose
dependant. They also interfere with neuromuscular
signaling, and therefore, they should not be given if
patients suffer from Myasthenia gravis. Allergic reac-
tions, blood disorders, and impaired liver function are
side effects which can occasionally be observed after
treatment with aminoglycosides.
16.12 Oxazolidinone
Linezolid is the only agent of this new antibiotic class
and can be given orally as well as i.v. Oxazolidinones
are protein synthesis inhibitors and stop growth and
reproduction of bacteria by disrupting translation of
messenger RNA (mRNA) into proteins in the ribo-
some. Linezolid is considered bacteriostatic against
most organisms, but has some bactericidal activity
against Streptococci.
16.12.1 Pharmacokinetics
Linezolid has a high bioavailability which is inde-
pendent of the application route (orally or intrave-
nously). Linezolid has low plasma protein–binding
capacity (approximately 31%, but highly variable)
and a volume of distribution at steady state of around
40–50 L. The tissue distribution is generally good
and half-life averages around 5–7 h. Linezolid is
metabolized in the liver, by oxidation of the morpho-
line ring, without involvement of the cytochrome
P450 system, and is eliminated mainly via renal
secretion (85%).
16.12.2 Efficacy and Indications
Linezolid is effective against all clinically important
gram-positive bacteria, notably Enterococcus faecium
and Enterococcus faecalis (including vancomycin-­
resistant Enterococci), Staphylococcus aureus (including
16 Antimicrobial Therapy
methicillin-resistant Staphylococcus aureus, MRSA),
Streptococcus agalacticae, Streptococcus pneumoniae,
Streptococcus pyogenes, the viridans group Streptococci,
and Listeria monocytogenes. It is also highly active
in vitro against several mycobacteriae.
16.12.3 Antibiotic Resistance
Resistance rates have remained stable and extremely
low, less than 0.5% of isolates in general, and less than
0.1% of S. aureus samples.
16.12.4 Side Effects
Common side effects of linezolid include diarrhea,
headache, nausea, vomiting, rashes, constipation,
altered taste perception, and discoloration of the
tongue. In particular, a decrease in leukocyte and
platelet counts can be observed after long-term use
of linezolid, and therefore, in these patients, repeated
blood counts are mandatory.
16.13 Lincosamides
Clindamycin can be given parenterally and orally. It
has a bacteriostatic effect and interferes with bacterial
protein synthesis (in a similar way to erythromycin,
azithromycin, and chloramphenicol), by binding pref-
erentially to the 50S subunit of the bacterial ribosome.
Clindamycin is usually used to treat infections with
gram-positive anaerobic bacteria.
16.13.1 Pharmacokinetics
Approximately 90% of an oral dose of clindamycin is
absorbed from the gastrointestinal tract and it is widely
distributed throughout the body, excluding the central
nervous system. Adequate therapeutic concentrations
can be achieved in bone. There is also active uptake
into white blood cells, most importantly neutrophils.
117
The elimination half-life is 1–5 h. Clindamycin is
­primarily eliminated by hepatic metabolism (80%) and
the metabolites are excreted via the urine.
16.13.2 Efficacy and Indications
Clindamycin has good efficacy against Staphylococci,
Streptococci, gram-positive anaerobic bacteria, Bacter­
oides spp., and Mycoplasma pneumoniae. Clindamycin
is used primarily to treat infections caused by suscep-
tible anaerobic bacteria, including infections of the
respiratory tract, skin and soft tissue infections, as well
as peritonitis. It is also used to treat bone and joint
infections, particularly those caused by Staphylococcus
aureus.
16.13.3 Antibiotic Resistance
Resistance rates for clindamycin range at 10% for blood
isolates of Staphylococcus aureus, 30% for coagulase-
negative Staphylococcus, and 10–20% for Bacteroides
spp. Additionally, resistance rates of MRSA and MRSE
continue to rise.
16.13.4 Side Effects
Common side effects associated with clindamycin
therapy, which can be observed in more than 1% of
patients include diarrhea, pseudomembranous colitis,
nausea, vomiting, abdominal pain or cramps, increased
liver enzyme, rash, and/or itch. High doses (both
­intravenous and oral) may cause a metallic taste, and
topical application can cause contact dermatitis.
16.14 Streptogramins
Streptogramins are cyclic peptides and are available as
a fixed combination of dalfopristin (70%) and quinu-
pristin (30%). Both agents have bacteriostatic effects
and have bactericidal effects in combination with a
­distinct post-antibiotic effect. The combination of
118
quinupristin/dalfopristin is only available for parenteral
application. Quinupristin binds to the 50S ribosomal
subunit and prevents elongation of the polypeptide.
Dalfopristin binds to a nearby site, changes the confor-
mation of the 50S ribosomal subunit, and enhances the
binding of quinupristin by a factor of about 100.
Quinupristin/dalfopristin is effective against all clinically
relevant gram-positive bacteria, notably multi-resistant
staphylococci (MRSA) and glycopeptide-resistant
Enterococcus faecium. The use of quinupristin/dalfo-
pristin should be limited to infections with gram-positive
bacteria where no other antibiotics are effective.
16.14.1 Pharmacokinetics
Quinupristin/dalfopristin has a medium distribution
­volume, and their half-lives range from 1 to 3 h. They are
mainly metabolized in the liver and eliminated via the
biliary tract. The protein-binding capacity varies from
55–78% for quinupristin to 11–26% for dalfopristin.
16.14.2 Efficacy and Indications
The use of Quinupristin/dalfopristin is limited to infec-
tions with gram-positive cocci, including multi-resistant
Staph­ylococci (MRSA) and glycopeptide-resistant
Enterococcus faecium (VRE). The drug combination
should not be used against Enterococcus faecalis.
Quinupristin/dalfopristin is approved for the treatment
of infections of the lung, skin, and soft tissues and all
infections caused by glycopeptide-resistant Enterococ­
cus faecium.
16.14.3 Antibiotic Resistance
Enterococcus faecalis, anaerobic and aerobic gram-
negative bacteria are resistant against streptogramins.
16.14.4 Side Effects
Allergic reaction at the application site is common
and administration via a central venous catheter is
C.P. Schneider and B. Grabein
recommended. Other frequent side effects include
arthralgia and myalgia, gastrointestinal disorder
(nausea, diarrhea, or vomiting), headache, and
increased liver enzymes. Quinupristin/dalfopristin
also interferes with the cytochrome P450 enzyme
system in the liver.
16.15 Tetracyclines
Tetracyclines are a group of broad-spectrum antibiot-
ics which have lost their general usefulness due to the
development of bacterial resistance. Despite this, they
remain the treatment of choice for some specific indi-
cations. The clinically most relevant agent of this
antibiotic group is doxycycline which can be admin-
istered parenterally and orally. Tetracyclines gener-
ally have bacteriostatic effects through inhibition of
protein synthesis by binding to the 30S ribosomal
subunit in the mRNA translation complex. The treat-
ment spectrum covers gram-positive and gram-negative
bacteria.
16.15.1 Pharmacokinetics
The distribution of doxycycline is mainly intracellu-
lar, and it penetrates well into all tissues. The half-
life ranges from 10 to 20 h. Doxycycline is partly
metabolized in the liver and eliminated via feces and
urine.
16.15.2 Efficacy and Indications
Nowadays, the use of doxycycline is limited to few
indications. It is frequently used to treat infections
caused by Chlamydia (trachoma, psittacosis, salpingi-
tis, urethritis and L. venereum infection), Mycoplasma,
Rickettsia (typhus, Rocky Mountain spotted fever),
brucellosis, and spirochetal infections (borreliosis,
syphilis, and Lyme disease). In general, approved indi-
cations for the use of doxycycline are infections of the
upper and lower respiratory tracts, the bile tract, and
pelvic inflammatory disease.
16 Antimicrobial Therapy
16.15.3 Antibiotic Resistance
The local resistance rates differ significantly, and there
is a lack of published data. Resistance rates range from
10% to 20% for gram-positive bacteria and are higher
in the gram-negative field.
16.15.4 Side Effects
Treatment with doxycycline can cause stomach or
bowel upsets. Of particular note is a possible photo-
sensitive allergic reaction which increases the risk of
sunburn. Allergic reactions and hepatotoxicity are
rarely seen.
16.16 Glycylcyclines
Tigecycline is the first clinically available drug in a
new class of antibiotics called the glycylcyclines and
has a similar structure as the tetracyclines. Tigecycline
has a bacteriostatic effect and is a protein synthesis
inhibitor by binding to the 30S ribosomal subunit of
bacteria.
16.16.1 Pharmacokinetics
Tigecycline has a long half-life of 25–42 h, and it has
a large distribution volume. It is eliminated via kidneys
(33%) and liver (60%) without modification. No dose
adjustment is needed for patients with impaired kidney
or liver function (Child-Pugh-Stadium A and B).
Tigecycline does not interact with the cytochrome
P450 enzyme system in the liver.
16.16.2 Efficacy and Indications
Tigecycline is active against many gram-positive bac­
teria, gram-negative bacteria, anaerobes, mycoplasma
and chlamydiae. It is also active against methicillin-
resistant Staphylococcus aureus (MRSA), multi-drug
119
resistant strains of Acinetobacter baumannii, and iso-
lates of Klebsiella pneumoniae and Escherichia coli
producing AmpC-beta-lactamases or extended-spectrum-
beta-lactamases (ESBL). Currently, the drug is licensed
for the treatment of skin and soft tissue infections as
well as intra-abdominal infections.
16.16.3 Antibiotic Resistance
In general, tigecycline has no activity against
Pseudomonas spp., Proteus spp., and Burkholderia
cepacia. Antibiotic resistance against usually suscepti-
ble bacteria has been observed only in few cases so far.
16.16.4 Side Effects
The most common side effects of tigecycline are
­gastrointestinal disorders (diarrhea, nausea, and vom-
iting). Increased serum bilirubin can also be rarely
observed.
16.17 Ansamycins
Rifampicin can be administered intravenously as well
as orally. It has bacteriostatic and bactericidal effects
on proliferating cells which depend on the adminis-
tered dose as well as the activity of the bacteria.
Rifampicin inhibits DNA-dependent RNA polymerase
in bacterial cells by binding to its beta-subunit, thus
preventing transcription to RNA and subsequent trans-
lation into proteins. It has a good efficacy against
tuberculosis as well as in combination with other anti-
biotics against multi-resistant gram-positive bacteria.
16.17.1 Pharmacokinetics
Rifampicin has a high distribution throughout the
body, and reaches effective concentrations in many
organs and body fluids, including the cerebrospinal
fluid. About 60–90% of the drug is bound to plasma
proteins. The half-life of rifampicin ranges from 6 to 7 h
120
and depends on the duration of therapy because self-
induction by the agent causes increased metabolization
rate. Approximately 7% of the administered drug is
excreted unchanged through the urine; urinary elimi-
nation, however, accounts for 30% while 60–65% of
the administered dosage is excreted via the feces.
16.17.2 Efficacy and Indications
Apart from the “typical use” for the treatment of myco­
bacterium infections, including tuberculosis and
­leprosy, rifampicin has a role in combination with gly-
copeptides or other antibiotics for the treatment of
infections with Staphylococci (including methicillin-
resistant strains), Streptococci, and Enterococci if
­susceptibility is confirmed.
16.17.3 Antibiotic Resistance
Rifampicin resistance develops quickly during mono-
therapy. Primary resistances against Mycobacterium
tuberculosis and meningococci are rare.
16.17.4 Side Effects
The more common unwanted effects include hepato-
toxicity, gastrointestinal disorder, and altered blood
counts. Rifampicin is an effective liver enzyme-
inducer, promoting the upregulation of hepatic cyto-
chrome P450 enzymes, and therefore, increasing the
rate of metabolism of many other drugs that are cleared
by the liver through these enzymes.
16.18 Nitroimidazoles
Metronidazole is the most important nitroimidazole
and it is used mainly in the treatment of infections
caused by susceptible organisms, particularly anaero-
bic bacteria and protozoa. Metronidazole has an excel-
lent bioavailability and can be administered parenterally
C.P. Schneider and B. Grabein
as well as orally. It has a high bactericidal activity
against anaerobic bacteria because it is taken up by dif-
fusion and then inhibits protein synthesis via binding
to DNA.
16.18.1 Pharmacokinetics
Metronidazole has a medium distribution volume, and
its half-life ranges from 6 to 8 h. The agent is partially
bound to plasma proteins (10–20%), and after metabo-
lization, it is eliminated mainly via renal excretion
(60–80%).
16.18.2 Efficacy and Indications
Metronidazole is approved for treatment of infections
caused by anaerobic bacteria (including meningitis and
brain abscess). It is used in combination for periopera-
tive prophylaxis. Metronidazole is further indicated for
the treatment of protozoal infections due to Entamoeba
histolytica, Giardia lamblia (Giardiasis), and Tricho­
monas vaginalis. Metronidazole has also been proven
to be effective for the treatment of pseudomembranous
colitis caused by Clostridium difficile.
16.18.3 Antibiotic Resistance
Primary resistance among anaerobic bacteria is rarely
seen. Some strains of Helicobacter pylori have devel-
oped resistance against metronidazole.
16.18.4 Side Effects
Common side effects include nausea, diarrhea, and a
metallic taste in the mouth. Therapy with metronida-
zole can be associated with leucopenia, neutropenia,
and increased risk of peripheral neuropathy. Consump­
tion of alcohol should be avoided while using metron-
idazole because a significant alcohol intolerance can
develop.
16 Antimicrobial Therapy
16.19 Fosfomycin
Fosfomycin can be given parenterally and orally, but
the enteral form (Fosfomycin-Trometamol) is only
approved for the treatment of urinary tract infec-
tions. Fosfomycin is an antimetabolite of phospho-
enolpyruvate in the enzymatic synthesis of bacterial
cell wall components and has bactericidal activity.
Fosfomycin is active against gram-positive and
gram-negative bacteria, including Pseudomonas
aeruginosa, but resistance develops rapidly under
monotherapy.
16.19.1 Pharmacokinetics
Fosfomycin is distributed selectively in the extra-
cellular space, and therefore, its distribution volume
is small. Fosfomycin does not bind to plasma pro-
teins and is eliminated unmodified via the urinary
tract.
16.19.2 Efficacy and Indications
Fosfomycin is effective against Staphylococci, gram-
positive and gram-negative bacteria. Its use is approved
for infections in different locations (particularly bone
and meninges) as long as susceptibility of the patho-
gen has been proven.
16.19.3 Antibiotic Resistance
Resistance rapidly develops under monotherapy due
to spontaneous mutations.
16.19.4 Side Effects
Gastrointestinal disorder and pain at the application
site are often seen during fosfomycin therapy. Attention
must be paid to the high sodium chloride content of the
solution.
121
16.20 Co-trimoxazole
Co-trimoxazole is a sulfonamide antibacterial combi-
nation of trimethoprim and sulfamethoxazole and is
used for the treatment of a variety of gram-positive
and gram-negative bacterial infections. Trimethoprim
and sulfamethoxazole inhibit successive steps in the
folate synthesis pathway. Each component alone
exhibits bacteriostatic effects, but together they have
bactericidal effects.
16.20.1 Pharmacokinetics
Co-trimoxazole is distributed in the intra- and extra-
cellular spaces, and its tissue distribution volume is
low for sulfamethoxazole and medium for trimethop-
rim. Seventy percent of sulfamethoxazole and 45%
of trimethoprim are bound to plasma proteins, and
their half-lives range from 10 to 12 h. Co-trimoxazole
is partly metabolized and then excreted via the
urine.
16.20.2 Efficacy and Indications
Co-trimoxazole is effective against gram-positive
and gram-negative bacteria and is predominantly
used for the treatment of infections with Stenotr­
ophomonas maltophilia, Pneumocystis jiroveci (for-
merly Pneumocystis carinii) and in combination with
other drugs for infections with methicillin-resistant
Staphylococcus aureus. It can be effective in a vari-
ety of upper and lower respiratory tract infections,
renal and urinary tract infections (UTI), and can
be used for long-term prophylaxis of UTI in patients
at risk.
16.20.3 Antibiotic Resistance
Escherichia coli, Salmonella, Shigella, and other
Enterobacteriacae have developed increased resis-
tance rates during recent years.
122 C.P. Schneider and B. Grabein

16.20.4 Side Effects fungal infection is often difficulty. Verification of fungi

in primarily sterile material or histological detection of
invasiveness in bioptic material may represent distinct
Administration of high dosages of co-trimoxazole can
markers of invasive fungal infections. Local and sys-
be associated with gastrointestinal disorders, crystal-
temic fungal infections are often seen in patients with
luria (formation of crystals and excretion in the urine),
diminished immunological competence, for example
and acute renal failure. Serious adverse effects includ-
after organ transplantation. Additionally, biological
ing Stevens–Johnson syndrome, myelosuppression,
selection of fungi occurs after long-term antibiotic
mydriasis, agranulocytosis, and hepatitis are rarely
therapy, and therefore, critical ill patients are at
seen.
increased risk of IFI. If fungal infections are assumed
or established, in particular with molds (e.g., Asper­
gillus spp.), antifungal therapy must be given for
­significantly longer periods of time compared to
16.21 Characterization of Antifungals antibacterial therapy. Efficacies of important antifun-
(Table 16.3), Pharmacokinetics, gal drugs in the clinical setting are summarized in
Efficacy, Resistance, and Side Table 16.4.
Effects (Table 16.4)

16.21.1 Introduction 16.22 Polyenes

Invasive fungal infections (IFI) only play a minor role
in the surgical field. Microbiological detection of fungi
(e.g., Candida spp.) is common but is usually due to
colonization of the host. Under these circumstances,
antifungal treatment is usually not indicated. Nonethe­
less, differentiation between colonization and invasive
Amphotericin B is available for parenteral application
as well as an oral preparation. It may also be given in a
nebulized form and for topical application, for example
intra-abdominal irrigation. A liposomal formulation of
amphotericin B for injection has been developed which
exhibits fewer side effects (particularly nephrotoxicity)

Table 16.3 Systemic antifungal agents for parenteral and oral applications
Group Drugs Maximum dosage Orally
Intravenously
Polyene Amphotericin B 1–1.5 mg/kg BW once daily n/a
Amphotericin B liposomal 3–5 mg/kg BW once daily n/a

Azole Fluconazole 10 mg/kg BW once daily 10 mg/kg BW once daily

Itraconazole 200 mg q12–24 h 200 mg q12–24 h
Voriconazole 6 mg/kg BW q12h on day 1, and then 400 mg q12h on day 1,
3–4 mg/kg BW q12h and then 200 mg q12h
Posaconazole
n/a 400 mg q12h

Fluorinated Flucytosine 25–37.5 mg/kg BW q6h n/a

pyrimidine
Echinocandins Caspofungin 70 mg once daily on day 1, and then n/a
50 mg once daily
Anidulafungin 200 mg once daily on day 1, and then n/a
100 mg once daily
Micafungin 150 mg once daily n/a
n/a non-applicable to reach therapeutic systemic levels, q every, h hours, BW body weight
16 Antimicrobial Therapy 123

Table 16.4 Antifungals’ efficacy

Cryptococcus neoformans
Aspergillus fumigatus
Candida tropicalis

Aspergillus flavus
Candida albicans

Pseudallescheria
Candida glabrata

Candida krusei

Dermatophyte

Zygomycetes
Group Drugs

Polyene Amphotericin B
Amphotericin B liposomal
Azole Fluconazol R
Itraconazol R R
Voriconazol
Posaconazol
Fluorinated Flucytosin
? ?
pyrimidine
Echinocandins Caspofungin
Anidulafungin
Micafungin

No efficacy Effective
R = potentially resistant
? = efficacy unclear

while having similar efficacy. Nystatin is only avail-
able as oral preparation. Amphotericin B antagonizes
the sterol synthesis, the main component of fungal cell
membranes, forming a transmembrane channel that
leads to potassium leakage and fungal cell death.
Polyene antifungal agents have a broad-spectrum effi-
cacy which covers Candida and Aspergillus spp.,
except Scedosporium (Pseudallescheria) spp.
can be reached in the liver while its concentration is
lower in the lungs and kidneys, but can increase up to
65% of plasma concentration in pleural, peritoneal, and
synovial fluids if infection is present. The distribution
into the cerebrospinal fluid is marginal. Amphotericin
B is slowly eliminated via the kidneys over several
days, and it cannot be removed via dialysis.

16.22.2 Efficacy and Indications

16.22.1 Pharmacokinetics
Amphotericin B and Nystatin are not absorbed after
oral intake. After parenteral application, amphotericin
B binds up to 90% to plasma proteins and its half-life
ranges to about 20 h. The highest tissue concentration
Amphotericin B is approved for the treatment of seri-
ous systemic fungal infections including peritonitis,
sepsis, meningitis, and endocarditis. The oral prepara-
tion can be used for intestinal decontamination and
therapy of thrush or other topical forms of candidiasis.
124
16.22.3 Resistance
Development of resistance under amphotericin B ther-
apy is uncommon, and only individual reports have
been published indicating primary resistance of some
Candida strains.
16.22.4 Side Effects
Nephrotoxicity is a frequently reported side effect, and
it is much milder when the liposomal formulated
amphotericin B is used. Frequently, a serious acute
reaction after infusion (1–3 h later) can be noted con-
sisting of high fever, shaking chills, hypotension,
anorexia, nausea, vomiting, headache, dyspnea, and
tachypnea. Other possible side effects include throm-
bophlebitis at the application site, several forms of
anemia and other hematological problems as well as
backache.
16.23 Azoles
Systemic applicable antifungal agents of this group are
fluconazole, itraconazole, voriconazole, and posacon-
azole, which are chemically different azole derivates
with imidazole or triazole structure. Inhibition of the
fungal enzyme 14a-demethylase which produces
ergosterol (an important component of the fungal
plasma membrane) is the common mode of action. All
azole derivates also inhibit cytochrome P450 enzyme
system and parts of the human steroid synthesis.
Therefore, careful patient evaluation must look for
possible interactions with other medications. Fluconazole,
itraconazole, and voriconazole can be given parenter-
ally and orally, while posaconazole is only available
for oral administration.
The effectiveness varies significantly among
the azole derivates. Fluconazole is highly effective
against several Candida species, but shows poor
activity against Candida glabrata and no effect
against Candida krusei and molds. Itraconazole has
similar efficacy across Candida spp. and is addition-
ally active against Aspergillus spp. Voriconazole also
covers Candida glabrata, Candida krusei, Fusarium
C.P. Schneider and B. Grabein
spp., and Scedosporium spp. Posaconazole, the most
recent azole derivate, also has good efficacy against
Zygomycetes.
16.23.1 Pharmacokinetics
Fluconazole is well absorbed after oral intake, and its
half-life reaches up to 25 h. Plasma protein–binding
capacity of fluconazole is low with approximately
12%. It penetrates well into various tissues and reaches
high concentrations in urine, saliva, sputum, and cere-
brospinal fluids. Most of the administered fluconazole
(60–80%) is eliminated unmodified via the kidneys.
Itraconazole is also well absorbed after oral intake,
particularly if taken together with alimentation.
However, the bioavailability varies individually, and
therefore, drug monitoring is necessary to modify the
dosage and reach therapeutic levels. Intraconazole has
a half-life of 24 h and is nearly 99% bound to plasma
proteins. It does not penetrate into the cerebrospinal
fluid and neither renal failure nor dialysis has an impact
on intraconazole serum levels. Voriconazole is almost
completely absorbed after oral intake. Its half-life
ranges from 6 up to 12 h and approximately 60% is
bound to plasma proteins. The cerebrospinal fluid level
of this drug can reach nearly 50% of plasma levels.
Most of the drug (95%) is metabolized in the liver,
80% is then excreted via the urine (2% unmodified),
and 20% via the feces. Posaconazole is slowly absorbed
after oral intake which depends on the fat content of
the nutrition. Posaconazole has a high distribution vol-
ume and a medium half-life of 35 h. Almost 98% of
the drug is bound to plasma proteins and the major
proportion is eliminated via the feces, while 15% is
removed via the urine.
16.23.2 Efficacy and Indications
Fluconazole is widely used for the treatment of fungal
infections caused by Candida albicans and tropicalis
while itraconazole is approved for therapy and prophy-
laxis of various kinds of mycosis in immunocompro-
mised patients. Voriconazole has approval for the
treatment of invasive Aspergillus infection and serious
16 Antimicrobial Therapy
candidiasis, which are resistant to fluconazole, as well
as fungal infections caused by Fusarium spp. and
Scedosporium spp. Posaconazole is approved for
­therapy of refractory Aspergillus infections, Fusarium
infection, and Zygomycosis.
16.23.3 Resistance
A fraction (5–10%) of Candida spp. develop second-
ary resistance under fluconazole therapy. Primary
resistance exists in Candida glabrata and krusei,
molds and dermatophytes. In HIV-positive patients,
secondary resistant Candida spp. are rarely observed
under itraconazole therapy. Resistances against vori-
conazole and posaconazole are rarely seen.
16.23.4 Side Effects
The most common side effects associated with azole
antifungal agents are gastrointestinal disorders, rash,
adverse effects on the central nervous system, elevated
liver enzymes and bilirubin, peripheral edema, and
respiratory disorders. Adrenal insufficiency can occur
under itraconazole therapy, and visual disturbances
(blurred vision, increased light sensitivity) are unique
to voriconazole.
16.24 Fluorinated Pyrimidine
Flucytosine, or 5-fluorocytosine, a fluorinated pyrimi-
dine analogue, is a synthetic antimycotic drug which is
available in oral and (in some countries) also in inject-
able form. Flucytosine represents an antimetabolite
and inhibits fungal DNA synthesis.
16.24.1 Pharmacokinetics
Flucytosine is well absorbed (75–90%) from the gas-
trointestinal tract. Small amounts are bound to plasma
125
proteins, and its half-life ranges from 3 to 4 h.
Flucytosine penetrates well into cerebrospinal and
peritoneal fluids. The drug is excreted mainly
unchanged via the urine (90%), and only traces are
metabolized and excreted with the feces.
16.24.2 Efficacy and Indications
The range of efficacy includes Candida spp.,
Cryptococcus spp., and some Aspergillus spp. The
combination of flucytosine and amphotericin B may
exhibit synergistic effects in vitro, particularly for the
treatment of life-threatening fungal infections (e.g.,
cryptococcal meningitis), but may also increase the
toxicity of amphotericin B and vice versa.
16.24.3 Resistance
Secondary resistance is quite commonly seen under
monotherapy, and therefore, flucytosine should be
combined with other antifungal agents. Resistance in
Candida spp. has been noted to occur in 10–50% and
in 2–20% of Cryptococcus neoformans isolates.
16.24.4 Side Effects
Bone marrow depression (anemia, leucopenia, pancy-
topenia, or even rarely agranulocytosis) may reversibly
occur in 10% of the patients. Elevations of liver
enzymes and bilirubin, gastrointestinal disorder, and
adverse central nervous system effects are rarely
observed during flucytocine therapy.
16.25 Echinocandins
Caspofungin is an antifungal drug, the first of a new
class termed the echinocandins, which was intro-
duced in 2001. Further derivatives, anidulafungin
and micafungin, were approved by the Food and
Drug Administration in 2005 and 2006, as well as in
126
Europe in 2007 and 2008. Echinocandins inhibit the
enzyme b(1,3)-d-Glucan synthase and disturb the
integrity of the fungal cell wall. These agents exhibit
fungicidal efficacy and cover almost all Aspergillus
and Candida spp.
16.25.1 Pharmacokinetics
All echinocandins are administered intravenously and
84–99% is bound to plasma proteins. Their half-lives
range from 9 to 11 h for caspofungin, 11–17 h for
micafungin, and 40–50 h for anidulafungin. All echi-
nocandins are slowly metabolized and egested via feces
and urine. Neither mild to medium hepatic nor renal
dysfunction has an impact on drug serum levels. None
of the echinocandines can be removed by dialysis.
16.25.2 Efficacy and Indications
These drugs are approved for the treatment of general
invasive candidiasis (acute disseminated candidiasis,
candida peritonitis, abscesses and esophageal candidi-
asis), invasive Aspergillus infection, and empiric ther-
apy in neutropenic patients with fever. Micafungin is
also approved for the prophylaxis of candida infec-
tions in patients undergoing hematopoietic stem cell
transplantation.
16.25.3 Resistance
Resistance in Candida albicans has been described for
caspofungin, but is currently still rare. Cryptococcus
spp. and Mucoraceae are primarily resistant against
echinocandins.
16.25.4 Side Effects
Fever, phlebitis, gastrointestinal disorder, adverse
central nervous system effects, increased liver
enzymes, altered blood count, rash, proteinuria and
erythrocyturia may occur under antifungal therapy
C.P. Schneider and B. Grabein
with echinocandins. Hypersensitivity reaction with
rash, facial edema, and pruritus can be observed
rarely.
16.26 General and Specific Aspects
of Antimicrobial Therapy
(Table 16.5)
Antimicrobial therapy is defined as the monocausal
use of drugs which selectively and directly affect spe-
cific pathogens. Therefore, location and kind of infec-
tion, particularly in surgical patients, has to be evaluated
and adequate antimicrobial substances have to be
selected before antimicrobial therapy is introduced.
The option of surgical intervention must always be
considered.
The rational use of antimicrobial agents for directed
therapy can only occur on the basis of sufficient micro-
biological diagnostics. For this purpose, a close cooper-
ation between attending physician and the microbiologist
is of importance.
Note: Fever alone is no indication for antimicro-
bial therapy!
16.26.1 General Principles
of Antimicrobial Therapy
• Microbiological diagnostics should always be done
prior to initiating antimicrobial therapy. Therefore,
correct sampling of suitable material and transpor-
tation in the correct medium (e.g., transport medium
for detection of anaerobic pathogens or specific
blood culture media) must be ensured.
• Selection of the agent for calculated antimicrobial
therapy should be directed by the location of the
assumed infection and by the associated microbio-
logical spectrum, as well as the local pathogen and
resistance situation. Additionally, patient-specific
issues have to be considered before selecting a cer-
tain substance (length of hospitalization, prior sur-
gical interventions, underlying disease, specific risk
factors, and previous antibiotic therapy).
16 Antimicrobial Therapy 127

Table 16.5 Selection of antimicrobial agents for different indications

Impurity infection

Gastroenteritis

Pyelonephritis
Osteomyelitis
Endocarditis
Diverticulitis

Pancreatitis

Pneumonia
Cholangitis
Abscesses

Erysipelas

Meningitis

Phlegmon
Gangrene

Peritonitis
Arthritis

Sepsis
Antimicrobial drugs
Benzylpenicillin
Ampicillin
Amoxicillin/clavulanate
Piperacillin
Mezlocillin A A A A A
Piperacillin/Tazobactam R
Flucloxacillin A A
Oxacillin A A
Cephazolin A A
Cefuroxime/ Cefotiam A A A A
Cefotaxime/ Ceftriaxone A A A A A A A
Ceftazidime A A A A A A
Cefepime A A A A R
Cefoxitine A
Imipenem R
Meropenem
Ertapenem
Doripenem
Aztreonam R R R R R R R A R R R
Ofloxacin/ Ciprofloxacin A A A A A A A A A
Levofloxacin A A A A A A A A A
Moxifloxacin R R R R R
Erythromycin R A
Clarithromycin R A
Azithromycin R A
Vancomycin/ Teicoplanin R R/A R/A
Daptomycin R R R R R R R R/A R R R/A
Amikacin R A A A A A
Gentamicin R A A A A A
Netilmicin R A A A A A
Tobramycin A A A A A
Linezolid R R R R R R R R/A R R R/A
Clindamycin A A A A A
Quinupristin/ Dalfopristin R R R R R R/A R/A R R
Tigecycline R R R R R/A
Rifampicin R/A R/A R/A R/A R/A
Metronidazole A A A A R
Fosfomycin A A A A A A A A A
Co-trimoxazol Antibiotic reserve for specific indications

= Indication A = Adjunction R = Therapeutic reserve

Note: Indication does not always equate approved specific treatment recommendations (off-label-use)
128 C.P. Schneider and B. Grabein

• Calculated antimicrobial therapy for treatment of 16.26.3 Antibiotic Resistance

serious infections (e.g., pneumonia, peritonitis,
­sepsis), especially during the postoperative course,
Currently plays an increasing role and is due to unfo-
should always be given parenterally to reach effec-
cused application of antimicrobial agents. Several
tive tissue levels rapidly.
mechanisms contribute to the development of anti­
• The antimicrobial agent should always be given at
biotic resistance of pathogens. These include pro­
the highest recommended dosage and the treatment
duction of enzymes which inactivate antimicrobial
period should be maintained as short as possible.
substances, altered target molecules, and impaired per-
After receiving microbiological results, the selected
meability (reduced cell penetration). The encoding
antibiotic substance should be adjusted according to
genes for antibiotic resistance can be located within
the antibiogram. Oral administration of the antimi-
the bacterial chromosome or in plasmids which allows
crobial substances should be considered if a medium
for a rapid horizontal spread. The development of anti-
severe infection is present and uncomplicated enteral
biotic resistance in bacteria relies on genetic variabil-
resorption of the drug is assumed. Mild infections
ity and selection of resistant mutants.
(e.g., soft tissue or urinary tract infections) can be
Development of antibiotic resistance can be influ-
treated with orally available antibiotics.
enced by the following measures:
• If clinical symptoms do not improve within 3 days
of antimicrobial therapy, the assumed site of infec- • Antibiotic therapy should be patient specific.
tion must be reevaluated and treatment with a dif- • The use of treatment regimes combining different
ferent antibiotic should be initiated. antibiotics should be preferred.
• The same diagnosis does not always require the
same antibiotic regimen.
• Indications for antibiotic prophylaxis and topical
16.26.2 Causes for Failure of application should always be considered critically.
Antimicrobial Treatment • Statistical evaluation of local pathogen environment
and Primary/Secondary and resistance rates should be documented continu-
Resistance ously and critically reviewed.
• Staff members must be continuously educated in
close collaboration with the clinical microbio­
Contradicting results of microbial sensitivity testing logists.
and clinical effects of specific antimicrobial therapy
can occur for a number of reasons. The following
issues must always be considered:
Note: We are only guests on the planet of the
• Tissue concentration does not reach therapeutic bacteria!
drug levels due to application of an insufficient
­dosage or impaired tissue diffusion.
• Discrepancy between in vivo and in vitro activities
of the antimicrobial substance, testing of nonrele- 16.27 Antimicrobial Prophylaxis
vant pathogens, change of the underlying pathogen, in Surgical Procedures
and/or development of secondary resistance during
therapy.
• Patient-specific causes (preexisting disease, imm­ 16.27.1 Definition
unodeficiency).
• Incorrect application of the antimicrobial drug Antimicrobial prophylaxis for surgical procedures is
(inactivation due to interaction with other drugs), a short-term (usually single shot) administration of
antagonism of antimicrobial drug combinations, antimicrobial agents, just before the start of (or latest
absence of bactericidal activity of the used agent. during) surgical procedures. The prophylaxis aims to
16 Antimicrobial Therapy 129

minimize the rate of surgical site infections which are Table 16.6 Risk factors of surgical site infections (Ref. 2)
caused by displaced or resident bacteria within the Patient-specific risk factors
operating field. Age
Diabetes mellitus
Immunological incompetence
Cave Reduced general condition
Obesity
Malnutrition
ASA > III
Antimicrobial prophylaxis in surgical procedures: MRSA carrier
Fever/shivering within 1 week before surgery
• Cannot compensate for insufficient basic
Female gender, e.g., colon surgery
hygiene and aseptic technique or suboptimal Male gender, e.g., trauma or vascular surgery
surgical technique Dialysis patient
• Cannot “sterilize” the tissue and prevent all Hepatitis
potential infections Substance addiction
Infections on other localizations
Generally accepted indications for antimicrobial Arterial mal perfusion
prophylaxis in surgical procedures (modified surgi- Neuropathy
cal site classification according to Cruse [1]) are: Preoperative
Emergency surgery
• Surgical procedures with high rates of surgical Extended hospital stay before surgery
site infections: “clean-contaminated” (e.g., Ineffective antibiotic prophylaxis
appendectomy, cholecystectomy) or “contami- Antibiotics was applied 2 h too late or too early
nated” operations (gross spillage from the Surgical wound classification “contaminated”
­gastrointestinal tract or incisions into acute Post-radiation
High-risk surgery
nonpurulent inflammation)
Recurrent surgery
• “Clean” surgical procedures with low rates of
Choledocholithiasis
surgical site infection, but serious conse- Increased C-reactive protein
quences if an infection occurs (prosthetic Impurity implantation
material, mesh) Hair removal not just before the operation
• “Clean” surgical procedures with specific risk Intraoperative
factors (Table 16.6) Quality of the surgeon
Time of surgery > 2 h
“Evidence-based” principles of antimicrobial Infected surgical field
prophylaxis in surgical procedures are: Surgical site contamination
−− Antimicrobial prophylaxis should only be Blood transfusion
given with clear indication. Prolonged anesthesia
−− Antibiotics should be selected considering the More than one surgical intervention
local microbiological environment as well as Use of diathermia
Systemic oxygen drop
local patterns of antibiotic resistance.
Hypothermia
−− The initial dosage should always be given Unforeseen complications
intravenously.
Postoperative
−− Bactericidal serum and tissue levels should be Presence of wound drains for more than 3 days
warranted at the time of incision. Respiratory tract infection
−− Therapeutic serum and tissue levels of the Hypothermia
antimicrobial agent should be maintained Invasive techniques: urine catheter, chest drain, nasogastric
throughout the operation and for several hours tube, central venous catheter
afterward. Evidence of Enterococcus spp., Enterobacteriaceae, or
Bacteroides fragilis in the surgical wound
130 C.P. Schneider and B. Grabein

16.27.2 Selection Criteria for concentration within the target tissue). Furthermore,

Antimicrobial Agents and
Antimicrobial Prophylaxis for
Surgical Procedures (Table 16.7)
Antimicrobial prophylaxis must be selected based
on the expected microbiological spectrum, the local
­resistance epidemiology of the institution, and
­pharmacokinetics of the substance (e.g., half-life,
toxicity and compatibility of the antimicrobial agent
must be taken into account. Controlled randomized
studies (where available) should be the basis for selec-
tion of a certain agent. Antibiotic prophylaxis in surgi-
cal practice should adhere to the following principles:
• Single-shot application of the maximum dosage.
• Administration less than 2 h before surgery to
ensure optimal plasma and tissue levels.

Table 16.7 Recommendation for antimicrobial prophylaxis in surgical procedures

Type of surgery Expected pathogens First choice antibiotics Alternative antibiotic drugs
(Beta-lactam allergy)
Colon and rectum Enterococcus spp., Second-generation cephalosporins Amoxicillin/clavulanate
surgery, appendectomy, Enterobacteriaceae, anaerobic (e.g., cefuroxime 1.5 g) + 2.2 g
liver resection, bacteria metronidazole 500 mg Beta-lactam allergy:
pancreas resection,
emergency surgery Risk patients: Clindamycin 600 mg +
(ileus, acute unclear Third-generation cephalosporins Gentamicin 1.5 mg/kg KG
abdomen) (e.g., ceftriaxone 2 g) + metronida-
zole 500 mg
Esophagus, stomach Enterobacteriaceae, Streptococcus Second-generation cephalosporins Amoxicillin/clavulanate
and bile duct surgery spp., anaerobic bacteria from the (e.g., cefuroxime 1.5 g) 2.2 g
upper respiratory tract
Risk patients vide supra Beta-lactam allergy vide
(Peptostreptococcus spp.)
supra
Vascular and implant Staphylococcus aureus, Second-generation cephalosporins Beta-lactam allergy:
surgery Coagulase-negative (e.g., cefuroxime 1.5 g) Vancomycina 1 g
Staphylococcus
Thoracic surgery Staphylococcus aureus, Second-generation cephalosporins Beta-lactam allergy:
Coagulase-negative (e.g., cefuroxime 1.5 g) Vancomycina 1 g
Staphylococcus, Pneumococcus,
Enterobacteriaceae
Orthopedic surgery Staphylococcus aureus, Second-generation cephalosporins Amoxicillin/clavulanate
­coagulase-negative (e.g., cefuroxime 1.5 g) 2.2 g
Staphylococci,
gram-negative bacteria (+ metronidazol 500 mg) Beta-lactam allergy:
Clindamycin 600 mg +
gentamicin 1.5 mg/kg KG
Plastic and hand Staphylococcus aureus, Second-generation cephalosporins Amoxicillin/clavulanate
surgery coagulase-negative (e.g., cefuroxime 1.5 g) 2.2 g
Staphylococci
Minimal invasive surgery According to the specific non-minimal invasive surgical procedures!
® No antimicrobial prophylaxis in surgical procedures CAVE: RISK FACTORS!
– Laparoscopic cholecystectomy/cyst surgery
– Hernia repair without mash
– Thyroid surgery
– Breast surgery
– Soft tissue tumors (without hollow organ involvement)
– Proctological surgical procedures
Recommendations have to be modified according to patient-specific risk factors, the expected local microbiological environment as
well as resistance epidemiology of the institution!
a
Should be administered at least 2 h before the surgical procedure!
16 Antimicrobial Therapy
• If the surgical procedure does not exceed 3 h, single-
dose administration is sufficient.
• Second shot administration should be considered if
the surgical procedure takes longer than 3 h or blood
loss exceeds 1 L.
• Antimicrobial prophylaxis for more than 24 h after
surgery is not reasonable.
• Intravenous application of the antibiotic agent is
beneficial.
• Patients who will need postoperative antimicrobial
therapy should receive these antibiotics also as
­prophylactic agents.
Reference
1. Cruse, P.J.: Feedback technique reduce surgical infections.
Hosp. Infect. Control 5, 113–114 (1978)
Recommended Reading
Beilman, G.J., Dunn, D.L.: Chapter 5: Surgical infections. In:
Brunicardi, F.C., Andersen, D.K., Billiar, T.R., Dunn, D.L.,
Hunter, J.G., Matthews, J.B., Pollock, R.E., Schwartz, S.I.
(eds.) Schwartz’s Principles of Surgery, 8th edn. The
McGraw-Hill Companies, New York (2005)
131
Classen, D.C., Evans, R.S., Pestotnik, S.L., Horn, S.D., Menlove,
R.L., Burke, J.P.: The timing of prophylactic administration
of antibiotics and the risk of surgical-wound infection.
N. Engl. J. Med. 326, 281–286 (1992)
Dellinger, E.P., Gross, P.A., Barrett, T.L., Krause, P.J., Martone,
W.J., McGowan Jr., J.E., Sweet, R.L., Wenzel, R.P.: Quality
standard for antimicrobial prophylaxis in surgical proce-
dures. Infectious Diseases Society of America. Clin. Infect.
Dis. 18, 422–427 (1994)
Wacha, H., Hau, T., Dittmer, R., Ohmann, C.: Risk factors asso-
ciated with intraabdominal infections: a prospective multi-
center study. Peritonitis Study Group. Langenbecks Arch.
Surg. 384, 24–32 (1999)
Online resources
http://www.fda.gov/
http://www.cdc.gov/
http://www.health.gov.au/
http://www.nhmrc.gov.au/
http://www.emea.europa.eu/
http://www.earss.com/
 Preoperative Risk Assessment
in Rural Surgery
Teresa Bueti, Munawar Rana, and Matthias W. Wichmann
17.1 Introduction
Preoperative risk assessment aims to identify patients
with a higher risk of peri- and postoperative compli-
cations early during the preparation for elective sur-
gery. In patients who are not properly prepared for
surgery, higher rates of cancellations and delays as
well as a longer postoperative length of stay must be
expected. Cancellations which occur on the day of
surgery are a significant waste of resources, are
expensive for the hospital and also produce a signifi-
cant psychological and financial burden for the
patient. Careful early assessment of the patient for
possible surgical and anaesthetic perioperative com-
plications can help to avoid these late cancellations.
17.2 Organization of the
Preadmission Clinic
To improve preoperative assessment and preparation
of the patient a nurse-led outpatient preadmission
T. Bueti
Outpatients Department, Mount Gambier General Hospital,
276-300 North Wehl Street, Mount Gambier, SA 5290,
Australia
M. Rana
Department of Anaesthesia, Mount Gambier General Hospital,
276-300 North Wehl Street, Mount Gambier, SA 5290, Australia
M.W. Wichmann (*)
Department of General Surgery, Mount Gambier General
Hospital and Flinders University Rural Medical School,
276-300 Wehl Street North, Mount Gambier,
SA 5290, Australia
e-mail: matthias.wichmann@health.sa.gov.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_17, © Springer-Verlag Berlin Heidelberg 2011
17
clinic can streamline the elective surgical process
and help to reduce length of stay and allow for a
co-ordinated approach to each patient’s elective sur-
gical admission. In this role the preadmission nurse
provides a link between the surgeon’s assessment
and hospital admission. After the surgeon’s review,
the preadmission nurse carries out the initial screen-
ing of patients referred for surgery.
The ageing patient population presents with
a diverse range of healthcare needs and co-mor-
bidities which requires a comprehensive and effi-
cient preoperative assessment for a good outcome.
The preadmission nurse also provides educational
and practical advice for the patient with regard to
the peri- and postoperative course and can help
to organize community support and can provide
information about pain management options. It is
the preadmission nurse’s obligation to ensure the
patient is at his/her best possible health at the time
of surgery to reduce the risk of postoperative com-
plications and/or exacerbation of pre-existing medi-
cal conditions.
17.3 Nursing Requirements
To fulfil the important tasks as outlined above, the
preadmission nurse must be an experienced nurse
with advanced skills, sound knowledge and under-
standing of the patient’s medical and psychosocial
factors, the planned surgical procedure as well as
associated anaesthesiological requirement. This nurse
must have the capacity to refer patients to other health
care providers for treatment options. To minimize
postoperative risks the preadmission nurse catego-
rizes patients into those
133
134 T. Bueti et al.

• Patients who will require an anaesthetic assessment
prior to the day of surgery
• Patients who will only need to see the preadmission
nurse
• Patients who will require intensive discharge
planning
• Patients who require additional information from
other hospitals or other health care providers
involved in their care
All results of routine preoperative testing are reviewed
by the preadmission nurse and relevant abnormalities
are discussed with the surgeon and anaesthetist. Minor
illnesses (respiratory tract infection, urinary tract
infection), unstable hypertension, or other conditions
requiring preoperative intervention will be referred
back to the patient’s general practitioner for treatment.
Surgery may then need to be rescheduled.
During preadmission assessment (Fig. 17.1) the
nurse plans all required investigations (blood tests,
ECG, anticoagulant therapy, etc.), evaluates the risk of
possible intraoperative problems (positioning, latex

Preadmission Nurse - patient assessment & referral

Preoperative Assessment
Medical History
· Allergies and intolerances
Decision to perform
elective procedure. Patient · Known medical problems
Surgeon obtains considered high · Surgical history
informed consent risk · Trauma
· Current medications (including non
prescription)
· Focused review of issues relevant
to the scheduled surgery

Physical Examination
· Vital signs
Referred to Refer to · Height and weight
preadmission clinic anaesthetist/other
· Cardiopulmonary exam
for assessment health practitioners
for further · Other pertinent exam
evaluation/treatment · Previous anaesthetic history
or surgery delayed
Electrocardiogram (ECG)
· Recommended for all patients over
50
· Other relevant investigations

Patient education
· Procedure specific
Out of guideline
All assessments, test · Hospital orientation
results etc. filed in
patient’s medical record. Discharge planning
Communicate results to · Expected length of stay
site where patient · Support at home/discharge
admitted prior to instructions
scheduled surgery · Rehabilitation/physiotherapy
· Equipment required & ordered
· Sick leave
· Transport
· Meals on wheels
· Respite

Immediate pre-procedure assessment at Community nurse

hospital admission

Fig. 17.1 Preoperative assessment by preadmission nurse

17 Preoperative Risk Assessment in Rural Surgery
allergy, etc.) and discusses possible issues with post-
operative care (in-hospital as well as after discharge).
17.4 Benefits of Preoperative
Assessment
Thorough preoperative assessment provides an inte-
grated, efficient and streamlined approach to each
patient’s elective surgical admission. The assessment
helps to generate an individual plan for patients with
complex needs as well as standardized care for patients
without specific findings in their assessment.
The preadmission nurse discusses the type and com-
plexity of surgery, the anaesthesiological requirements,
the patient-specific needs and fitness for surgery.
Evaluation of the need for perioperative DVT prophy-
laxis and testing of patients at risk for MRSA infection
is also part of the preadmission assessment. The nurse,
furthermore, coordinates all required investigations as
well as referrals to other health professionals.
The preadmission clinic aims to
• Optimize the patient’s health prior to surgery
• Educate patient and family
• Prepare discharge
• Optimize operating room scheduling
• Promote day of surgery admission
• Optimize resource utilization
To achieve these goals, a comprehensive patient
questionnaire is used (Fig. 17.2). In elderly patients
perioperative morbidity and mortality are increased.
Co-morbidity therefore must be carefully evaluated.
This may be difficult due to language barriers, cultural
barriers, intellectual disability, or impaired vision and
hearing. In these patients additional risk assessment
includes falls, mobility and skin integrity.
17.5 Healthcare Initiatives
The preadmission appointment provides a perfect
opportunity for introducing healthy lifestyle strategies
(available programs for patients who want to give up
smoking, diabetes education, cardiac rehabilitation,
etc.) to the individual patient and his family. The
135
preadmission nurse, therefore, needs to have extensive
knowledge about available services and programs
within the local environment as well as within the
metropolitan area.
17.6 Anaesthetic Risk Assessment
Anaesthetic risks can be minimized by understanding
the patient’s physiological limitations and the anaes-
thetic issues. These include preoperative, intraopera-
tive and postoperative issues.
17.6.1 Patient Issues
It is important to know that surgery puts stress on the
cardiopulmonary systems which may be comparable
to that of professional athletic competition. Optimi­
zation of the individual patient’s physiological reserves
therefore is pivotal.
Oral medications may need to be stopped or con-
tinued by weighing the risk and benefits. Generally,
most medicines can be taken with sips of water even
on the day of surgery while fasting. The need for
blood thinners and diabetic medications may need
assessment by a multidisciplinary team and/or physi-
cian with regard to timing and alternative treatment
options.
Fasting requirements usually are 2 h for clear fluids
and 6 h for solid foods.
Cessation of smoking needs to be encouraged as
it increases airway irritability and can result in peri-
operative airway complications. A common cold, flu
symptoms, or pneumonia during a 4–6 weeks period
prior to surgery increases the airway risks in the
perioperative period. The extent of surgery (minor,
intermediate or major) and the patient’s physiologi-
cal reserves as assessed from the patient’s ability to
do daily activities (distance the patient can walk,
ability to climb a flight of stairs) are good indicators
of the risk for perioperative complications (see
guidelines of the American Heart Association for
details).
It is important to note the association of obesity
with difficult airway management and reduced pulmo-
nary reserve. In these patients difficult IV access, spe-
cial bed requirements, more advanced perioperative
136 T. Bueti et al.

Affix patient identification label in this box

U.R. No.
PRE ADMISSION Surname
QUESTIONNAIRE
Given Names

D.O.B. Sex

Your anaesthetist requires the following to be completed YES NO COMMENTS

Is this patient a child or young person under the If yes refer to CHSA Rapid Response
guardianship of the Minister? (i.e. 18 years or less) protocol and checklist
Have you had a general anaesthetic in the past?
Have you had any problems with or during previous
anaesthetics?
Do you have a family history of problems with
anaesthetics?
Do you have any problems with your heart?
(e.g. angina, heart attacks, palpitations, rheumatic fever etc)
Have you ever been treated for high blood pressure?
Do you get severe shortness of breath or any chest pain
after exercise or climbing stairs?
Have you had treatment for or taken medicine for
breathing problems? (e.g. asthma, bronchitis, sleep apnoea or
any other lung disease)
Do you smoke? How many / day.............
Have you suffered a chest infection, head cold or sore
throat in the last month?
Have you ever been treated for epilepsy, convulsions,
fits, ‘strokes’ or blackouts?
Do you suffer from arthritis or muscular disease?
Have you ever been treated for anaemia or any other
blood disorder?
Have you ever had a blood clot?
Have you recently been treated with any of the following
drugs: Steroids, Aspirin, Warfarin, Antibiotics or Anti
Depressants?
Have you ever used recreational or street drugs?
e.g. heroin, LSD, marijuana, ecstasy, cocaine
Do you have loose teeth, caps or dentures?
Do you drink alcohol? How much.............................
Have you had jaundice, hepatitis or liver disease
Do you have any kidney disease?
Is there ANY possibility you may have any infectious
diseases?
Have you ever been an inpatient in another Hospital in
the last 3 months?
Is there ANY possibility that you may have MRSA and if
so have you been swabbed?
Is there ANY possibility that you may be pregnant
What operations have you had?

Are you allergic to anything? e.g. drugs, food,

elastoplast etc
Alert Sheet completed?
Are you a Diabetic? If YES please indicate last BSL Date / Time: BSL:
If YES to above please tick if you are: Insulin OR Tablet OR Diet Controlled
Are you currently taking any tablets, medications or
herbal preparations?
Your Weight in kilograms

Fig. 17.2 Example of Preadmission Questionnaire for preoperative identification of patients at risk of peri- or postoperative
complications
17 Preoperative Risk Assessment in Rural Surgery
monitoring and postoperative ventilation requirements
need to be kept in mind.
17.6.2 Anaesthetic Issues
It is important to be aware of a number of simple indi-
cators of a difficult airway. These include previous
difficulty of airway establishment, mouth opening
less than three fingers, overbite, inability to see uvula
and posterior tonsillar pillars, thyromental distance
less than 6 cm, decreased neck extension, neck cir-
cumference more than 42 cm. Any of these findings
or a combination of several result in increased risks of
airway difficulties. Any of these markers may require
specialist anaesthetist assessment in a high-risk anaes-
thetic clinic.
Special issues like MRSA/VRE patients, Latex
allergy, dialysis patients and IDDM patients require
more detailed planning by theatre and anaesthetic staff
for the required surgery. Anticipated prolonged sur-
gery, major intraoperative fluid shifts and elderly
patients with poor physiological reserves also require
more detailed planning for prevention of perioperative
complications.
A simple and reliable classification of physical fit-
ness and the associated perioperative risks for patients
undergoing surgery is the ASA score (Table 17.1).
This score should be routinely applied and can also be
used to identify patients suitable for day surgery (ASA
classes I and II).
Table 17.1 American Society of Anaesthesiologists (ASA)
classification of physical fitness
Class I Fit patient
Class II Mid-to-moderate systemic disease, no
functional limitation controlled hypertension,
mild diabetes, mild asthma
Class III Severe systemic disease with some functional
limitation plus diabetes with complications,
severe asthma, myocardial
infarction >6 months
Class IV Severe systemic disease that is a constant
threat to life plus unstable angina, severe
cardiac, pulmonary, renal, hepatic or endocrine
insufficiency
Class V Moribund patient not expected so survive 24 h
(with or without surgery)
137
17.7 High-Risk Anaesthetic Clinic
This clinic receives referral of patients who are consid-
ered to be at increased surgical and/or anaesthesiologi-
cal risks and should be seen prior to surgery by an
experienced anaesthetist. Referral usually occurs after
review of the preoperative health assessment but may
also be done directly by the responsible surgeon. High
risk particularly refers to the risk of cardiac or airway
complications. Due to time restriction not all patients
can be seen prior to surgery. To avoid unnecessary
referrals to this specialist clinic a number of recom-
mendations have been made. The following conditions
are considered to be relevant for preoperative assess-
ment by the anaesthetist:
• Any patient where the surgeon or the preadmission
nurse have concerns and feel assessment by an
anaesthetist is necessary
• Obese patients with body weight >120 kg (males)
or >100 kg (females)
• Cardiac co-morbidity: angina, congestive heart
failure, significant arrhythmias, valvular disease,
congenital heart disease (unless symptom free for
more then 6 months); coronary stents on blood
thinners
• Hypertension
• Dialysis and renal transplant patients
• Insulin-dependent diabetes mellitus (IDDM)
• Poorly controlled non-insulin-dependent diabetes
mellitus (NIDDM)
• Respiratory co-morbidity: asthma, chronic obstruc-
tive airway disease, sleep apnoea, poor exercise tol-
erance (patient can only walk <200 m due to
shortness of breath)
• Epilepsy
• Lack of physiological reserve (patient can only
walk <100 m or less than one flight of stairs)
During high-risk clinic assessment the anaesthetist
will determine the patient’s fitness for anaesthesia and
document the findings in the patient’s case notes.
During this assessment relevant drugs will be ordered
and the consent for anaesthesia will be signed by the
patient as well as the anaesthetist. If additional tests
appear to be needed, these will be organized by the
anaesthetist and a plan for peri- and postoperative pain
management will be developed.
138
17.8 Summary
Preadmission assessment by dedicated nursing staff
as well as medical specialists has successfully reduced
the risk of surgical intervention in rural surgical
practice. This clinic has contributed to a significant
reduction of delays on operating lists as well as late
cancellations due to unforeseen health problems of
elective surgical patients. Patients, relatives and
all caregivers are aware of possible risks and these
can be addressed ahead of time. A dedicated pread-
mission clinic is an integral part of elective surgery
and should be established in all (rural) hospitals
T. Bueti et al.
performing medium and major surgery on an elec-
tive basis.
Recommended Reading
American Society of Anesthesiology: ASA Classification of
Surgical Patients. American Society of Anesthesiology,
Chicago (1991)
Fleisher, L.A., et al.: ACC/AHA 2007 guidelines on perioperative
cardiovascular evaluation and care for noncardiac surgery:
executive summary. Circulation 116, 1971–1996 (2007)
Institute for Clinical Systems Improvement (ICSI): Preo­
perative evaluation. National guideline clearinghouse.
www.guideline.gov
 Perioperative Fluid Management
Peter Rittler and Wolfgang H. Hartl
18.1 Management of Postoperative
Fluid Imbalances and Electrolyte
Disorders
Because of the pathophysiological changes in micro-
circulation, the post-operative patient has to be consid-
ered hypovolaemic with a need for fluid substitution.
Usually, the common clinical signs for a fluid deficit,
i.e. the signs of dehydration, are limited significantly
due to redistribution processes such as capillary leak-
age. Fluid monitoring and management of the post-
operative patient require close control of arterial blood
pressure, heart rate and urinary output. The most
important signs of post-operative intravascular hypo-
volaemia are tachycardia with simultaneously decreased
blood pressure and decreasing renal output (<1 ml/kg/
body weight/h). The measurement of central venous
pressure is only a limited monitoring tool. Especially
in abdominal surgical patients, central venous pres-
sures (CVP) may be falsely high due to an increased
post-operative intra-abdominal pressure. Inaccurate
CVP values may prevent detection of an intravascular
fluid deficit, and a normal post-operative CVP value
does not exclude a possible need for extra fluids. Only
very low CVP values combined with oliguria can be
taken as a sign of a significant intravascular fluid defi-
cit. Another definite sign of an intravascular fluid defi-
cit is a temporary rise of blood pressure when the
patient is brought into a Trendelenburg (head-down)
position.
P. Rittler and W.H. Hartl (*)
Department of Surgery, Campus Grosshadern LMU Munich,
Marchioninistr. 15, D-81377 Munich, Germany
e-mail: whartl@med.uni-muenchen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_18, © Springer-Verlag Berlin Heidelberg 2011
18
The pathophysiological changes during the acute
post-operative phase (i.e. the first 3–4 post-operative
days) usually lead to an increased fluid and potassium
requirement and to a decreased requirement for
sodium. Demands vary with the magnitude of the sur-
gical trauma and with the extent of the consecutive
systemic inflammatory response syndrome (SIRS).
After uncomplicated operation, fluid requirements
will be maximal during the first 12–16 h after sur-
gery. The exact amount of post-operative fluids,
which are necessary to correct intravascular deficits
during that time, depends on several variables such as
length of the operation, type of operation, magnitude
of intraoperative fluid substitution, and – above all –
on perioperative complications (haemorrhagic shock,
ischaemia-reperfusion injury, release of inflamma-
tory mediators from an infectious site).
The administration of fluids and electrolytes in the
immediate post-operative period has to be guided by
haemodynamic parameters and laboratory findings.
The approximate baseline fluid requirement of an
adult patient during that phase is usually in the range
of 1–1.5 ml/kg/ h, but may be significantly higher in
severe sepsis or SIRS. If monitoring indicates a lack
of intravascular fluids despite baseline fluid adminis-
tration, fluid intake has to be increased until well-
defined haemodynamic goals have been reached.
Specific haemodynamic goals to be reached or main-
tained during the immediate post-operative phase are
shown in Table 18.1.
After major operations (possibly associated with
complications) increased fluid and potassium require-
ments may persist until the third post-operative day.
During this time, 1 ml/kg/ h will usually be sufficient
to account for those delayed deficits. Fluids are usually
given intravenously. However, oral or enteral adminis-
tration is also possible provided the gastrointestinal
139
140
Table 18.1 Haemodynamic goals for post-operative fluid
management
Mixed-venous oxygen saturation >65%
Central venous oxygen saturation >70%
Arterial lactate concentration <2 mmol/l
Mean arterial blood pressure >70 mmHg
Heart rate 70–110 beats/
min
Central venous pressure (values may be <15 mmHg
falsely high after abdominal surgery or in
abdominal hypertension)
Urine production >0.5 ml/kg/ h
tract is functioning normally. Potassium requirements
have been put at 1–1.2 mval/kg/ day and sodium
requirements at 2 mval/kg/ day. If a post-operative
patient shows persisting or new signs of circulatory
failure despite adequate fluid intake, it will be essential
to evaluate this patient thoroughly with respect to hae-
morrhage, infection or a cardiac complication. If an
infectious complication or bleeding can be ruled out,
circulatory failure will most likely be caused by a pri-
mary myocardial pathology (ischaemia, infarction,
pulmonary embolism).
It is important to adjust the post-operative fluid and
electrolyte intake to pre-existing diseases such as
severe renal failure or congestive heart disease. In such
conditions, an uncontrolled fluid therapy may eventu-
ally result in volume overload. In such high-risk
patients, tight haemodynamic monitoring is indispens-
able. A subtle clinical examination of the patient is
also essential to identify an impending volume over-
load. Visible and palpable oedemas of the hands, legs
and flanks are valuable signs suggesting excess fluids.
In case of a significant organ dysfunction (impaired
pulmonary gas exchange), a therapeutic intervention is
mandatory (water restriction and forced diuresis).
Simultaneously, fluid management of such patients
should include a precise recording of total body fluid
intakes and outputs (urine, drainages) allowing an
exact calculation of daily losses or gains.
A key parameter for post-operative fluid manage-
ment is urine production. In case of a post-operative
oliguria, it is essential to differentiate between differ-
ent causes. Oliguria may result from an intravascular
volume deficit (prerenal failure), from a post-operative
impairment of renal function (intrarenal failure) or
P. Rittler and W.H. Hartl
may be related to problems eventually arising from the
Foley catheter (postrenal failure). Management of
oliguria has to consider these differentials. It is usually
not sufficient to evaluate plasmatic renal function
parameters (urea- and creatinine concentration).
Corresponding concentrations may be abnormal with
all three differentials. As a first step, it is crucial to
exclude an intravascular volume deficit using the tar-
get values mentioned above (Table 18.1). If an intra-
vascular volume deficit has been excluded, and if there
are even clinical signs indicating a fluid overload, the
post-operative oliguria is most likely due to renal fail-
ure caused by SIRS or sepsis.
The therapeutic consequences have to follow the
underlying pathology. In patients with oliguria due to
an intrarenal failure, diuretics (furosemide, maximum
dosage of 10 mg/h) may be given to normalize diure-
sis. In patients with oliguria secondary to hypovolae-
mia, additional fluids should be given to correct the
deficit. Since, after a certain time, prerenal renal fail-
ure may cause secondary intrarenal failure, it is recom-
mended to administer small doses of diuretics in
combination with extra fluids to achieve a positive
fluid balance.
Post-operative SIRS, which represents a physiolog-
ical response to surgical trauma, is known to always
impair renal function to a certain degree even in other-
wise healthy individuals. However, in case of a very
strong SIRS (e.g. severe surgical trauma in association
with a prolonged haemorrhagic shock) severe intrare-
nal failure may develop rapidly. Misinterpretation of
this pathophysiologic mechanism, in combination with
an ongoing high fluid intake (to correct the erroneously
assumed persisting fluid deficit), will result in fluid
overload. The latter may remain without consequences
for circulatory function in patients who do not suffer
from additional cardio-pulmonary pathologies. However,
other unwanted detrimental side effects of fluid over-
load are known (such as intestinal wall oedema, intes-
tinal atony, severe ileus or even anastomotic leakage).
Therefore, fluid overloading during the post-operative
period should be avoided.
A strategy of restricted fluid intake is also a central
component of the fast-track concept. Until now, the
best way to control post-operative fluid intake has not
yet been defined. This uncertainty results from contra-
dicting study results and a lack of evidence regarding
the optimal constitution and amount of post-operative
fluid intake. Furthermore, it is likely that the clinical
18 Perioperative Fluid Management
effects of a certain amount of fluid differs according to
the magnitude of the operation, of the subsequent post-
operative SIRS, and, consequently, of the capillary
leak and its associated fluid sequestration into the third
space. There is evidence that even an excess fluid
intake (>10 L/day) may not increase post-operative
morbidity, if this amount of fluid is needed due to the
extent of the capillary leak, and if fluid therapy is
strictly guided by established haemodynamic goals.
18.2 Solutions Available for
Perioperative Fluid Replacement
18.2.1 Crystalloids
Crystalloid solutions are defined as solutions contain-
ing electrolytes or low molecular carbohydrates. They
differ in osmolarity (plasma-isotonic, -hypertonic,
-hypotonic) and in their electrolyte composition (full
strength, one-third- and two-thirds electrolyte solu-
tions). Crystalloid solutions can diffuse through the
capillary membranes. Therefore, only one-third of
their volume remains in the intravascular compart-
ment. Crystalloid solutions are an essential component
of the immediate post-operative fluid therapy in order
to cover basic requirements. The post-operative fluid
deficit (intravascular or interstitial) should be corrected
by using full strength crystalloid electrolyte solutions.
This concept is sufficient for most surgical procedures
with minor blood loss. It is important to consider the
distribution space of crystalloid solutions. The plas-
matic space (4% of the body weight) amounts to only
one-fourth of the interstitial space (16% of the body
weight). Therefore, compared to colloidal solutions,
four times as much crystalloids will be needed if the
same intravascular volume effect is required.
18.2.1.1 Full Strength Electrolyte Solutions
Full strength electrolyte solutions contain the most
important electrolytes, and their overall ­concentration
corresponds to the osmolarity of the plasma. Full strength
solutions are plasma isotonic, and various products are
commercially available which vary ­according to their
individual electrolyte content. Thereby, it is possible to
141
adjust fluid therapy to the particular requirements of
the post-operative period. These full strength electro-
lyte solutions can be also used to rapidly replace minor
blood or plasma losses, and are also the hallmark of
fluid therapy in situations with an extraordinary high
fluid demand (e.g. septic shock).
18.2.1.2 Isotonic Sodium Chloride Solutions
Isotonic sodium chloride solutions are isotonic with
respect to plasma osmolarity, but they do not reflect the
plasma electrolyte content. Compared to plasma, iso-
tonic sodium chloride solutions contain more sodium
(154 mval/l) and chloride (154 mval/l). Isotonic sodium
chloride solutions are used to correct extracellular
fluid deficits, which are combined with hyponatraemia,
hypochloraemia and also with hyperpotassaemia.
If large amounts of isotonic sodium chloride solutions
are given during over a short period of time, sodium
concentrations will rise rapidly, resulting in hyperna-
traemia or hyperchloraemia. It is essential that the
daily increase of plasma sodium concentration is less
than 10 mmol/l. A faster rise will cause central pontine
myelinolysis. Usually, such fast changes of sodium
concentration will not occur, if less than 1.5 ml/kg/ h of
an isotonic sodium chloride solution is administered.
To identify unwanted concentration changes, sodium
concentrations should be measured at least four times
per day.
To avoid a rapid increase of sodium concentration
in situations which require administration of large
amounts of fluids (e.g. septic shock in combination
with hyperpotassaemia), one may either use half
strength sodium chloride solutions, or one may admin-
ister isotonic sodium chloride solutions in combination
with 5% glucose solutions on a 1:1 basis.
18.2.1.3 Glucose 5% Solutions
Glucose 5% solutions contain 50 g glucose in 1 l water.
The solution is hypotonic and acidotic (pH-value 4.5)
with a glucose concentration of 253 mol/l. The amount
of glucose which is contained in 1 l corresponds to
200 kcal. After glucose has been metabolized in the
body, the solution no longer contains any osmotic
active substances and becomes free water. Because of
this quality, this solution is predominantly appropriate
142
to correct fluid deficits in combination with hyperna-
traemia. However, also a rapid decline of sodium con-
centration may also be detrimental, and should not
exceed 10 mmol/l/day. To avoid such rapid concentra-
tion changes, glucose 5% infusion rate should not sur-
mount 1.5 ml/kg/ h. If more fluid needs to be given,
glucose 5% solutions should be combined with stan-
dard full strength electrolyte solutions on a 1:1 basis.
Because of the low calorie content, glucose 5%
solution is not suited for parenteral nutrition. To pro-
vide an appropriate amount of carbohydrate calories,
unacceptably large volumes of glucose 5% would have
to be infused.
18.2.2 Colloidal Solutions
Colloidal solutions are characterized by a high molec-
ular weight. Therefore, they leave the intravascular
space very slowly through the capillary wall. Colloids
increase the intravascular colloid osmotic pressure and
subsequently reduce the efflux of other fluids from the
intravascular space into the interstitial space. During
an acute fluid loss (e.g. haemorrhagic shock) colloids
allow a faster and more efficient correction of defi-
cits than crystalloid solutions. Haemodynamic effects
and plasma half-life of colloids are determined by
their molecular weight, their dispersion, their viscos-
ity, and – last but not least – by their metabolism and
rate constants.
Several types of colloidal solutions are commer-
cially available. However, all products suffer from dis-
tinct disadvantages such as impaired coagulation,
Table 18.2 Association of different, non-crystalloid solutions with patient outcome (mortality) when compared to crystalloid
solutions (According to Perel and Roberts [1]
Outcome No. of studies No. of participants
Mortality
Albumin 23 7,754
Hydroxyethyl starch 16 637
Modified gelatin 11 506
Dextran 9 834
P. Rittler and W.H. Hartl
pruritus, accumulation in plasma or various tissues, or
variable haemodynamic effects. Synthetic colloids
which can be used to expand the plasmatic volume are
gelatine compounds, dextrans and hydroxyethyl
starches. Albumin is produced by the body and is a
natural colloid with ideal characteristics. However,
albumin can only be obtained from blood donations,
and its high costs and potential, albeit very rare, infec-
tious side effects prevent its use for routine fluid
replacement. Only severely burned patients, who dem-
onstrate extraordinarily high albumin losses through
their skin wounds, may profit from a large-scale albu-
min replacement.
Artificial colloids are characterized by their con-
centration, mean molecular weight, and degree of
cross-linking and of molecular substitution (hydroxy-
ethyl starch). In contrast to albumin, supply of these
colloids is unlimited, and they are stable and can be
stored for a long period of time. Furthermore, they do
not carry the risk of blood-borne infections and are
inexpensive. Because of their rapid intravascular
action, artificial colloids are the solutions of choice for
correction of acute post-operative fluid deficits.
However, none of the colloidal solutions, which are
available for post-operative fluid therapy, have proved
superior to crystalloid solutions with respect to patient
outcome (Table 18.2).
18.2.2.1 Gelatin Solutions
Gelatin solutions contain bovine collagen. For pro-
duction, collagen is depolymerized; subsequently,
the extracted polypeptide fragments are cross-linked
Statistical method Effect size
Risk ratio (M-H, fixed, Subtotals only
95% CI)
Risk ratio (M-H, fixed, 1.01 [0.92, 1.10]
95% CI)
Risk ratio (M-H, fixed, 1.05 [0.63, 1.75]
95% CI)
Risk ratio (M-H, fixed, 0.91 [0.49, 1.72]
95% CI)
Risk ratio (M-H, fixed, 1.24 [0.94, 1.65]
95% CI)
18 Perioperative Fluid Management
again. There are different compounds available, e.g.
oxypolygelatin, succinylated gelatin and polymer-
ized urea gelatin, which all possess different molecu-
lar weights. Before renal elimination, gelatin is
metabolized completely and does not accumulate in
the body. In normovolaemic healthy subjects, 50% of
the infused gelatin may eventually leave the intravas-
cular space by crossing the capillary wall. Because of
their low molecular weight, the intravascular half-life
of these compounds is short (0.5–1 h). In comparison
to dextrans and hydroxyethyl starch solutions, the
incidence of anaphylactic reactions is higher with use
of gelatin and amounts to about 0.8%. The advantage
of gelatin solutions is that they do not compromise
renal function or the coagulation system. Therefore,
these compounds may be used in patients with renal
diseases or coagulation disorders. However, when
compared to crystalloid solutions, benefits are only
minor because of the short intravascular half-life,
and crystalloids are today favoured over gelatin
solutions.
18.2.2.2 Dextran Solutions
Dextrans are glycosidically linked glucopolysaccha-
rids (junction between C1 and C6). Dextrans are pro-
duced at a molecular weight of 40 and 60 kD and
represent hyperoncotic solutions. Thereby, the effect
on intravascular volume is stronger than could be
expected by the actually infused volume. Per gram
Dextran, 20–25 ml of water can be bound in the intra-
vascular space and could eventually also be mobilized
from the interstitial space. Dextrans are metabolized
and eliminated via the kidneys; they may remain in the
intravascular space for 2–6 h depending on the indi-
vidual molecular weight and half-life.
The most important side effect of dextrans concerns
blood coagulation, where thrombocyte adhesion may
become impaired. Furthermore, anaphylactic and
­anaphylactoid reactions have been described with a
frequency of approximately 1%. Implementation of
Hapten-prophylaxis with Promit® has reduced the
severity of anaphylactic reactions. Because of coagula-
tory side effects, dextrans have not been used for fluid
replacement in the past. On the other hand, today there
is a certain role for Dextran 60, which is used for
thromboprophylaxis, and for Dextran 40, which has
been shown to improve rheology and microcirculatory
143
function. Dextrans are always given together with
electrolyte solutions to prevent a dehydration of the
extracellular space and an impairment of renal
function.
18.2.2.3 Hydroxyethyl Starch
Hydroxyethyl starch (HAES) is a non-ionic starch
derivative, which is made from corn or potato, and
which describes an acid-hydrolyzed and hydroxy­
ethylized high-branched chain amylopectin starch.
After infusion, HAES is enzymatically degraded and
is removed from the intravascular space either by
metabolization or via the reticulo-endothelial system.
HAES solutions are characterized by three different
criteria: (1) molecular weight (solutions vary between
70 and 200 kD), (2) grade of substitution (ratio of glu-
cose units, which are substituted with hydroxyethyl
groups, to the overall number of glucose units; e.g. 0.5
or 0.7), (3) position in the glucose molecule where the
hydroxyethyl group has been substituted (C2 or C6;
described as the C2/C6 hydroxyethylization ratio).
The higher the ratio, the more glucose molecules are
hydroxyethylized in position C2 compared to C6.
In general, length of intravascular stay and plasma
half-life will increase if molecular weight, C2/C6 ratio
and substitution grade rise. The haemodynamic effect
of HAES solutions correlates with the average molec-
ular weight and with the concentration of the solution
(3%, 6% and 10%).
HAES fragments with a molecular weight of less
than 60 kD are eliminated via glomerular filtration.
Larger molecules are split by serum amylase and are
taken up by the hepatic reticulo-endothelial system.
There, HAES split products may be stored for days
to weeks. Surprisingly, no data are available which
describe the precise duration of storage, or the
potential effects which stored HAES fragments may
have on the organism. In critically ill patients with
SIRS or sepsis, detrimental effects have been dis-
cussed (immune-dysfunction due to a partial block-
ade of the RES). In addition, disorders of the tubulus
system have been described following application of
HAES in critically ill patients. HAES derivatives
with a higher molecular weight (200 kD) have been
demonstrated to have increased rates of acute renal
failure, and need for renal replacement therapy and
to decrease long-term survival when used alone in
144
cases of severe sepsis compared with electrolyte or
gelatine solutions [2, 3]. These studies specifically
used 10% HAES with 0.45–0.55 substitution grade
and molecular weight of 200 kD. The same effects
have not been observed with HAES 130 kD/0.4.
(Voluven®) or HAES 70 kD/0.5 (Expafusin®), which
are lower substituted novel hydroxyethyl starches.
The occurrence of anaphylactic reactions caused by
HAES is less than in gelatin compounds and is cur-
rently quoted at 0.1%. A few days after HAES infusion
patients may experience protracted itching, which,
however, should be largely limited to products with a
molecular weight of 200 kD or more.
Similar to Dextrans, the major side effects of
HAES comprise a coating effect with a subsequent
impairment of thrombocyte adhesive capacity and
with an alteration of plasmatic and cellular blood
coagulation. Such side effects will be less pro-
nounced, if molecular weight, grade of substitution,
and C2/C6 ratio are lower. These side effects will be
also significantly less frequent or even absent, if low
molecular HAES is used with a low grade of substitu-
tion (e.g. HAES 130/0.4 or HAES 70/0.5). Such
lower substituted novel hydroxyethyl starches are
mainly eliminated via the kidneys, and only minimal
storage in the reticulo-endothelial system is observed.
However, compared to middle molecular or high
molecular hydroxyethyl starches, low molecular
compounds are less efficient in terms of their haemo-
dynamic effects because of their significantly shorter
intravascular half-life (2–3 h). Nonetheless, due to
their superior side-effect profile, low molecular
hydroxyethyl starches are favoured today for the
rapid correction of minor fluid deficits, and they are
first-line solutions to treat new and acute fluid defi-
cits. However, treatment should not go beyond a
maximum dose of 20 ml/kg/ day. At higher doses, the
extent of plasma dilution will affect plasmatic
coagulation.
P. Rittler and W.H. Hartl
References
1. Perel, P., Roberts, I.: Colloids versus crystalloids for fluid
resuscitation in critically ill patients. Cochrane Database
Syst. Rev. 17(4), CD000567 (2007)
2. Brunkhorst, F.M., Engel, C., Bloos, F., Meier-Hellmann, A.,
Ragaller, M., Weiler, N., Moerer, O., Gruendling, M.,
Oppert, M., Grond, S., Olthoff, D., Jaschinski, U., John, S.,
Rossaint, R., Welte, T., Schaefer, M., Kern, P., Kuhnt, E.,
Kiehntopf, M., Hartog, C., Natanson, C., Loeffler, M.,
Reinhart, K., German Competence Network Sepsis (SepNet):
Intensive insulin therapy and pentastarch resuscitation in
severe sepsis. N. Engl. J. Med. 358(2), 125–139 (2008)
3. Schortgen, F., Lacherade, J.C., Bruneel, F., Cattaneo, I.,
Hermery, F., Lemaire, F., Brochard, L.: Effects of hydroxy-
ethylstarch and gelatin on renal function in severe sepsis:
a multicentre randomised study. Lancet 357, 911–916 (2001)
Recommended Reading
Bunn, F., Trivedi, D., Ashraf, S.: Colloid solutions for fluid
resuscitation. Cochrane Database Syst. Rev. 23(1), CD001319
(2008)
Chappell, D., Jacob, M., Hofmann-Kiefer, K., Conzen, P., Rehm, M.:
A rational approach to perioperative fluid management.
Anesthesiology 109(4), 723–740 (2008)
Holte, K., Kehlet, H.: Fluid therapy and surgical outcomes
in elective surgery: a need for reassessment in fast-track
­surgery. J. Am. Coll. Surg. 202(6), 971–989 (2006)
Kleespies, A., Thiel, M., Jauch, K.W., Hartl, W.H.: Perioperative
fluid retention and clinical outcome in elective, high risk
­colorectal surgery. Int. J. Colorectal Dis. 6, 699–709 (2009)
Lenz, A., Franklin, G.A., Cheadle, W.G.: Systemic inflamma-
tion after trauma. Injury 38(12), 1336–1345 (2007)
Powel-Tuck, J., Gosling, P., Lobo, D.N., Allison, S.P., Carlson,
G.L., Gore, M., Lewington, A.J., Pearse, R.M., Mythen,
M.G.: British consensus guidelines on intravenous fluid
therapy for adult surgical patients GIFTASUP http://www.
renal.org/pages/media/Guidelines/GIFTASUP%20
FINAL_31-10-08.pdf (2009)
Treib, J., Baron, J.F., Grauer, M.T., Strauss, R.G.: An interna-
tional view of hydroxyethyl starches. Intensive Care Med.
25, 258–268 (1999)
Yeager, M.P., Spence, B.C.: Perioperative fluid management:
current consensus and controversies. Semin. Dial. 19(6),
472–479 (2006)
 Analgesia and Sedation in Intensive Care
Christian Waydhas
19.1 Introduction
To soothe suffering is one of the major tasks of a
­physician. There are few fields in medicine where more
distress for patients and their relatives can be found than
during intensive care treatment. Despite a broad appli-
cation of sedative and analgesic medication still more
than 70% of critically ill patients complain about mod-
erate or severe pain (e.g., during procedures such as
endotracheal suctioning, positioning, change of dress-
ing, bedside intervention). Up to 90% of intensive care
patients suffer from anxiety and agitation and a large
proportion of these patients experience periods of delir-
ium. This indicates that the attention of the medical
personal has to concentrate not only on cure and life-
sustaining therapy but also has to focus on palliation of
pain and other causes of suffering. In addition to the
medical knowledge about the drugs which can be used
to relieve discomfort, the ethical attitude of the medical
team and all care providers is of major importance.
19.2 Basic Concepts
Pain, anxiety, delirium, and states of withdrawal
have to be differentiated.
Although they may interact and there are many over-
laps between these entities the differentiation of the
patient’s complaints and symptoms is a prerequisite
C. Waydhas
Trauma Intensive Care Unit, Department of Trauma Surgery,
University Hospital Essen, Hufelandstrasse 55, 45147 Essen,
Germany
e-mail: christian.waydhas@uk-essen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_19, © Springer-Verlag Berlin Heidelberg 2011
19
for a rational therapy, since single substances predomi-
nantly affect only one of the entities. Therefore, fixed-
dose combinations of sedative and analgesic drugs
should not be used but titrated separately to the indi-
vidual requirements of a patient.
The registration of complaints and symptoms poses
no significant problem in the alert and communicable
patient. Many critically ill subjects, however, cannot talk
or are comatose for reasons of tracheal intubation and
mechanical ventilation, drug actions, brain dysfunction
due to the underlying disease or others. In these circum-
stances members of the medical team have to substitute.
This poses several problems since their observations
are subjective. Many symptoms (e.g., tachycardia, tac-
hypnoea, restlessness, agitation, sweating) that might
indicate pain, anxiety or discomfort are unspecific or
ambiguous. The assessment by a second person may be
subject to his or her personality or mood. Furthermore, it
has been shown that judgment varies between physi-
cians, nurses, or relatives. It has been shown that pain
and anxiety may be underestimated by medical personal
in more than 50% of cases. On the other hand, there also
is a significant rate of overestimation.
Validated scales and scores appear to be valuable
tools to assess pain, anxiety, and delirium more objec-
tively and independently from the observer (see
below). It has been shown that the routine use of such
tools improves therapy and reduces length of stay.
These scores should be applied to all critically ill
patients at least every 6–8 h, particularly if they are not
communicable.
Before analgesic or sedative medication is given,
other reasons that might have caused the symptoms
should be ruled out. Furthermore, general pain reliev-
ing and comforting measures should be taken.
Fever, dyspnea, hypoxia, hypotension, sepsis, prob-
lems with the ventilator (insufficient settings, mal-
function), or airway obstruction are among the major
145
146
reasons of agitation. Pain may be caused by pressure
during positioning or from immobilizing splints or by
a deterioration of the underlying condition. If sedation
and pain medication is increased without considering
and treating these conditions, serious complications
may be masked and may delay diagnosis and treatment.
Sleep deprivation is another problem as well as sensory
overload from interruption of the circadian rhythm,
artificial illumination, noises from alarms, telephones,
loud conversation, mechanical devices, interventions
or nursing procedures during night hours. In such situ-
ations, other measures than giving sedatives or analge-
sics may be more appropriate or necessary.
General measures to reduce sensory overload include
single-bed rooms, keeping doors closed, individualized
setting of alarm limits and sounds, and the consider-
ation of the circadian rhythm with respect to illumina-
tion and routine work with the patient. An empathetic
attitude toward the patient even when sedated and sus-
pected not to perceive the environment is important.
Patients should be addressed before nursing or medical
interventions are started. Discussions about the medical
condition, loud conversations, and conversations about
private topics (of the personnel) should be avoided. To
create a familiar atmosphere (pictures, photographs, or
music) may help to calm a patient and to save on
medication.
The analgo-sedation should aim at a patient that
is calm, has no significant pain, and tolerates well
mechanical ventilation, endotracheal suctioning,
the reduced option for communication, and other
interventions but remains awake or arousable.
The keystone study from Kress and colleagues
(2000) who demonstrated that a daily interruption of
sedation resulted in earlier extubation and a reduction
of days spent on the intensive care unit, initiated a
change of paradigm: It is no longer believed that
patients have to be sedated because they need artificial
ventilation, they rather have to be ventilated because
they are sedated. Less sedation means shorter ventila-
tion and reduced requirements of catecholamines. This
link between sedation and ventilation has resulted in the
general aim of having patients as awake as possible –
they should tolerate their treatment but at the same
time be calm and arousable to obey commands and
give answers. However, there are several conditions
C. Waydhas
in which the patients may require deep sedation to
achieve adequate ventilation and oxygenation such as
acute circulatory or cardiac failure, severe ARDS, or
severe traumatic brain injury. There are presently no
clear-cut criteria to determine when the shift from deep
sedation to arousing the patient is appropriate. Deep
sedation for a prolonged period of time increases the
risk of drug-overdose or unnecessary extended coma.
In order to achieve adequate analgo-sedation the
following principles should applied:
• Monitor pain and depth of sedation using
validated scores and tools
• Define a goal for depth of sedation
• Apply SOPs about which substances are to be
used and how their dosage should be read-
justed in case of over- or under-sedation
It has been shown that under most circumstances
written algorithms, standard operating procedures or
protocols improve the quality of analgo-sedation and the
adherence to given standards of care. They work well in
many different organizational models all around the
world and result in lesser days on ventilation, days in the
intensive care unit, undesired side effects, and costs.
The preference of substances used for pain control
and sedation leaves some space for decision since there
is no high grade evidence to indicate the superiority of
one commonly used drug over another. Therefore, no
specific recommendation which substances are to be
used can be made. The choice may depend on the (esti-
mated) duration of analgo-sedation, possible drug
interactions, comorbidities, acute organ dysfunctions,
costs, and other factors. Renal and hepatic disease
(acute or chronic) need to be addressed specifically,
since most drugs are degraded or eliminated via one of
these organs. Furthermore, there are distinct prefer-
ences in different countries. Regional differences in
the approval have to be accounted for as well.
A common problem for most drugs used for analgo-
sedation is their potential for addiction. Already after a
few days with a high dosage patients may develop
dependency and present with signs of withdrawal when
the drug is discontinued. After long-term application
(e.g., longer than 1 week) a gradual dose reduction is
preferred. One suggested possibility is a decrease by
19 Analgesia and Sedation in Intensive Care
10–25% from the initial dose per day. It is not rec-
ommended to antagonize the drugs used for analog-
sedation to accelerate the waking-up process.
19.3 Pain Management
Pain control is indicated not only for humane reasons.
There are virtually no contraindications to giving ade-
quate pain medication. Particularly, the concern of con-
cealing symptoms of a disease or the fear of depressing
ventilation efforts may preclude the use of analgesics.
The choice of a substance as well as the dose and route
of application must be adjusted to the individual patient’s
circumstances.
The dose required depends on the actual effects and
the dosage recommendations provided here should be
considered as a rough guide only. In individual patients,
lower (elderly people, subjects with renal or hepatic
dysfunction) or higher (patients with enzyme induc-
tion, i.v. drug users) doses may be appropriate.
19.3.1 Monitoring
Pain is highly subjective and may be markedly influ-
enced (in addition to objective triggers) by the patient’s
personality, anxiety, fear, and many other factors.
Therefore, only the patient is able to indicate whether he
or she has pain and how intense it is. Grading pain is usu-
ally no major problem as long as the patient can com-
municate. However, it may be difficult to describe pain
intensity in a reliable and reproducible way based on
verbal communication alone. It is recommended to use a
Visual Analog Scale (VAS) or a Numeric Rating Scale
(NRS). While both offer a spectrum between “no pain”
and “maximum possible pain,” the patient has to indicate
the severity of pain intensity on a continuous scale (VAS)
or a graded numeric grading scale between zero and 10
(NRS). The NRS appears to be better accepted by elderly
patients. A pain intensity of 3 or less is the aim for the
patient in rest. During smaller interventions and nursing
procedures, it is aimed to score 5 or less.
Evaluation of pain intensity is much more difficult in
patients who cannot communicate. Commonly used
signs of pain are tachycardia, hypertension, tachypnea,
lacrimation, sweating, facial movements, restlessness,
agitation, and defense. These are unspecific, however,
147
and some uncertainty about their cause always remains.
Application of a probatory dose of an analgesic may
help to elucidate the cause of such symptoms. Recently,
the Behavioral Pain Scale has been suggested and vali-
dated to describe pain intensity in the noncommunica-
tive patient. It remains to be shown whether its use results
in better patient satisfaction and improved outcome.
Monitoring and documenting pain intensity on a
regular basis (e.g., at least once per shift) with one
of the tools described above is recommended.
19.3.2 Pain Medication
19.3.2.1 Route of Application
Oral application is possible in all patients with reliable
enteral absorption. It is usually not sufficient to control
acute pain (e.g., during change of dressing, position-
ing, other painful interventions) since its onset and
magnitude of effect is usually not fast or strong enough.
Most critically ill patients require intravenous or
regional/local application.
Many postoperative patients have regional pain
catheters in place. They should be used and may lead
to significant sparing of systemic analgesic drugs with
a reduced rate of side effects. Regional pain catheters
may also be inserted in the intensive care unit and the
list of indications, contraindications, dosage recom-
mendations, and precautions is comparable to the elec-
tive situation. However, the prevalence of coagulation
disorders, application of anticoagulants, or the pres-
ence of sepsis often precludes their use.
Regional catheters are excellent to control pain after
lower extremity and abdominal surgery and after serial
rib fractures.
Patients who are awake and cooperative may benefit
from a patient-controlled analgesia also in the inten-
sive care setting.
The analgesic regime requires a basic medication
supplemented with extra analgesia during procedures.
Basic analgesia is guided by monitoring pain (see
above) and adjusting the dosage to reach the pre-
defined level (e.g., VAS of 3 or less). It may be given
continuously or by intermittent doses. While the latter
148
is usually preferred in the extubated patient, continu-
ous application via a pump is favored during invasive
ventilation. There are no clear-cut scientific data to
prefer one over the other and the management best
suited to the local circumstances can be chosen.
Intravenous application is not recommended on
an “as required” basis, since this may lead to
delayed and often insufficient pain medication.
19.3.2.2 Fentanyl
Fentanyl is one of the most frequently used opioids in
intensive care. Like all others opioids its action is
mediated via different opioid-receptors. The stimula-
tion of the m-receptor results in analgesia, euphoria,
bradycardia, constipation, and depression of breathing
effort; the k-receptors mediate sedation and miosis,
while the s-receptors are responsible for dysphoria,
delirium, and hallucinations. Due to its lipophilic
­property fentanyl has a faster onset of action (about
1–2 min), is easier to titrate, and has a 100-fold stron-
ger effect than morphine.
Typical doses vary between 0.05 and 2 mg/h for
­continuous infusion and from 0.05 to 0.2 mg for bolus
application. It is usually started by a bolus infusion.
Due to the short duration of action, this is followed by
continuous administration using a pump. For short-
term analgesia during interventions, bolus application
is appropriate. Patient-controlled analgesia requires
specific dosing regimes.
Several adverse effects are relevant:
Respiratory depression: The analgesic and respira-
tion-depressant action is mediated by the same recep-
tor. Therefore, the two effects are coupled to a certain
degree. Elderly patients and subjects with sleep-apnea
syndrome may react particularly sensitive. The side
effect can be amplified by simultaneous application
of benzodiazepines and careful titration is required.
On the other hand the respiratory-depressant effects
may not be predominant as long as the pain is persist-
ing and patients should not be left in pain due to the
fear of overdosing.
Decrease of gastrointestinal motility and ileus: A
decrease in gastrointestinal motility may lead to
C. Waydhas
persistent obstruction and paralytic ileus that are
refractory to usual treatment. Oral naloxone might
reverse the effects on the gastrointestinal tract with-
out attenuating the analgesic action.
Hypotension: During hypovolemia and conditions
of vasodilation, fentanyl might aggravate low blood
pressure (and bradycardia) which may require treat-
ment with fluid administration or vasopressors, par-
ticularly if fentanyl is given fast.
Withdrawal syndrome: Withdrawal syndrome might
present with yawning, rhinorhea, piloerection, sweat-
ing, lacrimation, mydriasis, restlessness, anxiety,
vomiting, tremor, abdominal cramps, and others.
Further important adverse effects include itching,
hallucinations, and overt delirium.
Like most other opioids, fentanyl is metabolized in the
liver and its metabolites are excreted via the kidney.
However, there are no general recommendations avail-
able how to reduce the drug in patients with hepatic or
renal dysfunction. Doses should be adjusted to the desired
effect and care should be given that underdosing as well
as major overdosing are avoided by close monitoring.
19.3.2.3 Sufentanil
In some countries, sufentanil is used as often as fenta-
nyl in critically ill patients. It differs in a somewhat
stronger analgesic action and a shorter half time which
makes it better controllable. The sedative effect is stron-
ger than that of many other opioids. Using sufentanil
might spare sedative medication. Accumulation during
long-term use is less pronounced than with fentanyl.
Typical dosages are 25–100 mg/h (0.15–1.0 mg/kg/h).
In the low dose range, sufentanil can be used during wean-
ing from ventilation and in the spontaneously breathing
patient. Adverse effects are similar to those of fentanyl.
19.3.2.4 Morphine
Morphine has a delayed onset (10–20 min) and a pro-
longed duration of action (approx. 4 h) compared to
fentanyl. Intermittent boluses of 2–10 mg i.v. or a con-
tinuous infusion of 1 to 5 mg/h are recommended for
most patients. Some data indicate that it may have
a stronger depressing effect on gastrointestinal motil-
ity and releases more histamine than other opioids.
Particularly, the histamine release might be unwanted
19 Analgesia and Sedation in Intensive Care
in hemodynamically compromised patients. There
are, however, no clinical studies that have clearly shown
the unequivocal clinical superiority of one opioid over
another. Care should be used in subjects with renal
insufficiency because active metabolites may accumu-
late and may lead to an overdose. The use of hydromor-
phone may be an alternative in such patients.
19.3.2.5 Other Opioids
Priritramid is widely used in some European countries
where it is the predominant opioid for discontinuous
application in the postoperative period. Typical dosages
are 3.75–7.5 mg given as bolus injection or short infusion.
A careful application is required in the elderly patient.
Pethidin is degraded into a metabolite that is highly
nephrotoxic and may induce delirium, hallucinations,
psychosis, and seizures. It is eliminated via the kidney
at a slow rate and quickly accumulates with repeated
doses or in patients with renal dysfunction.
19.3.2.6 Peridural Analgesia
Peridural analgesia appears to be superior to intrave-
nous opioids for postoperative pain control and a
reduction of postoperative pulmonary complications
such as atelectasis and pneumonia. Typical regimes for
regional catheters use bupivacain 0.125–0.25% with
an infusion rate of 6–10 ml/h. A similar concentration
of bupivacain is used for lumbar or thoracic peridural
catheters with infusion rates of 6–10 and 4–6 ml/h,
respectively. An initial bolus (e.g., 5 ml) is used to start
analgesia. Peridural (but not regional) catheters can be
supplemented by morphine, 2 mg tid, fentanyl, or
­clonidine. A urinary catheter for bladder drainage is
needed, because urinary retention develops in 15–90%
of patients with peridural analgesia.
19.3.2.7 Nonsteroidal Anti-Inflammatory Drugs
(NSAIDs)and Other Analgesic Agents
NSAIDs can be used as single agents or in combination
with other drugs for pain therapy in critically ill subjects.
Their use may help to reduce the need for opioid treat-
ment. They may be of specific value after restoration of
149
body homeostasis, when the patient is ready for transfer
to intermediate care or the normal ward. However, the
effects of these substances are not well studied in this
group of patients. Their influence on inflammation
and anti-inflammation, coagulation, and organ function
in the different phases of critical illness is not clear.
Therefore, these substances should be used with care.
Nonacidic antipyretics such as metamizol and parac-
etamol or coxibes may be used. When they are adminis-
tered one has to bear in mind that they reduce fever and
thus render this indicator of inflammation and sepsis
unreliable. Whether the lowering of fever has undesired
effects on the course of an infection is not known. Some
side effects have to be accounted for, which appear to be
specifically relevant in critically ill patients. Coxibes
are known for their renal and cardiac toxicity, distur-
bance of coagulation, and the induction of gastric ulcers.
Particularly elderly patients and subjects with hypov-
olemia, hypotension, and preexisting renal disease are
at an increased risk for acute renal ­failure. Metamizol
may lead to hypotension, particularly with intravenous
application and is not available in a number of coun-
tries. Paracetamol should not be used in patients with
liver disease or impaired liver function.
In hemodynamically compromised patients con-
tinuous infusion of fentanyl or sufentanil appears
to be the preferred analgesic regime because these
drugs are easier to control and have a lower poten-
tial for histamine release with consecutive vasodi-
lation and hypotension than morphine. Morphine
should be used with care in patients with renal
insufficiency.
Patients with less severe organ dysfunction and
those who can be transferred to a lower level of
care may receive nonsteroidal analgesics (with
specific focus on the profile of side effects). If
additional analgesia is required, bolus application
of piritramid or morphine may be used.
19.4 Anxiety and Agitation
Anxiety is a universal problem in critically ill patients.
Anxiety in combination with increased motor activity
may be called agitation. It has to be differentiated from
150 C. Waydhas

delirium. The aim of giving sedative medication is to Table 19.1 Richmond Agitation–Sedation Scale (RASS)
enable the patient to calmly tolerate the medical treat- +4 Combative Combative, violent, immediate
ment and especially the endotracheal tube without suf- danger to staff
fering. In the ideal situation the patient would be +3 Very agitated Pulls or removes tube(s) or
calmly awake or easily arousable and cooperative. catheter(s); aggressive
Unnecessary over-sedation should be avoided as well +2 Agitated Frequent nonpurposeful movement,
as agitated states with the risk of self-inflicted harm. fights ventilator
A lower level of sedation results in fewer days on the +1 Restless Anxious, apprehensive but
ventilator and reduced requirements for vasopressors movements are not aggressive or
and inotropes. Pain has to be controlled before seda- vigorous
tion is intensified. 0 Alert and calm
−1 Drowsy Not fully alert, but has sustained
awakening to voice (eye opening &
contact > 10 s)
19.4.1 Monitoring
−2 Light sedation Briefly awakens to voice (eye
opening &contact < 10 s)
Sedation therapy requires monitoring patients with −3 Moderate Movement or eye opening to voice
reliable tools. It may be difficult to differentiate sedation (but no eye contact)
between pain and anxiety, particularly in subjects who −4 Deep sedation No response to voice, but movement
cannot communicate. The subjective character of clini- or eye opening to physical
cal signs as well as different care providers who evalu- stimulation
ate and observe the patient are further impediments for −5 Unarousable No response to voice or physical
correct evaluation of the level of sedation. The use of stimulation
different validated sedation scores has led to a signifi-
cant reduction in the use of sedative medication and a
decrease in duration of ventilation and length of ICU-
stay. The Motor Activity Assessment Scale (MAAS), 19.4.2 Drugs
the Sedation Agitation Scale (SAS), the Vancouver
Interaction and Calmness Scale (VICS) and the 19.4.2.1 Midazolam and Other Benzodiazepines
Richmond Agitation Scale (RASS, see Table 19.1) are
among the validated scores that are recommended, Midazolam is one of the most frequently used sedative
while one of the best-known scores, the Ramsey drugs in critical care medicine. It is characterized by a
Sedation Scale has never been validated for critically high degree of lipophilia which results in a fast onset of
ill patients. action within 1–5 min. Midazolam (like all other ben-
The use of any of these scores is strongly recom- zodiazepines) is metabolized in the liver and excreted
mended. During goal-directed sedation, a score range via the urine. The elimination half-life is relatively
is defined to preset the desired depth of sedation. short (about 2 h) compared to other benzodiazepines.
Sedative medication is then continuously adjusted to However, the time interval between cessation of drug
achieve this goal. For most situations, a low level of administration and awakening is highly variable and
sedation (easily arousable or calmly awake) is desired. may not be much shorter than with substances like
In deeply sedated patients with and without muscle diazepam or lorazepam. Particularly elderly persons
paralysis in whom scoring systems or clinical judg- and those with heart or liver insufficiency are suscep-
ment are of limited value, the use of neurophysiologi- tible to a prolonged sedative effect. Depression of
cal measurements such as EEG, acoustic evoked respiratory drive can be a problem in elderly patients,
potentials, or bispectral index are discussed. None of in patients with chronic hypercapnia, and during simul-
these methods has gained wide acceptance in the criti- taneous application of opioids.
cal care setting, partly because they are restricted to Typical doses of bolus application vary between
special situations or have not been shown to be of out- 2.5 and 10 mg (0.025–0.1 mg/kg). The continuous
come relevance. administration (2–10 mg/h; 0.01–0.18 mg/kg/h) has
19 Analgesia and Sedation in Intensive Care
the imminent risk of over-sedation and is not recom-
mended by some experts. Despite its short elimination
half-life, midazolam may accumulate during prolonged
administration and may result in delays between stop
of medication and awakening of several days. Pro­
longed action may also be encountered in obese
patients. The concept of daily interruption of sedative
medication counteracts these undesired effects.
Apart from prolonged time of action one of the most
prominent undesired effects are drug withdrawal symp-
toms. The total dose of midazolam (more than 60 mg/kg)
is a more important risk factor than the duration of
administration itself. Drug withdrawal is more pro­minent
after an abrupt cessation of ­admi­nistration. Therefore, a
stepwise reduction is recommended.
Midazolam exhibits drug interactions that may
lead to prolonged or shortened duration of action.
Particularly erythromycin and theophylline should
not be administered during midazolam treatment.
Diazepam encompasses several shortcomings that
include a high potential for accumulation after repeated
doses, low solubility, incompatibility with many infu-
sion solutions, venous irritation and has lost wide accep-
tance as a sedative drug in the critically ill patient.
Lorazepam has a delayed onset of action (5–15 min)
and a long half-life of 10–20 h. It is used, particularly
in North America for long-term sedation of stable
patients. Due to the solvants polyethylglycole and
­propylglycole that are used for the intravenous prepa-
ration, there is a potential for lactate acidosis and acute
tubular necroses when high doses or prolonged admin-
istration are used.
19.4.2.2 Propofol
Propofol is a lipophilic fast-acting sedative drug (onset
of action within 1–2 min) with a short half-life. Most
patients wake up within 5–15 min after cessation of
drug administration and the risk of accumulation is
greatly reduced in comparison with other sedatives. The
drug is easily controllable and may even be used in non-
intubated patients. It may be used for short-term as well
as for long-term sedation (maximum approved duration
of application has to be attended to). Propofol is metab-
olized in the liver. It has no inherent analgesic effects!
151
Typical doses to induce narcosis vary between 25
and 100 mg (0.25–1 mg/kg), the maintenance doses
range from 50 to 300 mg/h. A dose of 4 mg/kg/h should
be exceeded only for short periods. For dose calcula-
tion the actual (not the ideal) body weight, especially
with obese patients, should be used.
One of the most relevant side effects is vasodilation
with consecutive hypotension, particularly in hypov-
olemic or hemodynamically unstable patients that may
require the use of vasopressors. In such situations other
sedative agents may be more appropriate. A rare but
life-threatening complication is the propofol syndrome
which presents with severe metabolic and lactic acido-
sis, rhabdomyolisis, acute renal failure, heart failure,
and bradycardic cardiac arrest. Since the frequency of
the propofol syndrome seems to be dose-dependent,
the upper dosage limits given above have to be adhered
to. Since the propofol syndrome is more predominant
in children, it must not be used for long-term sedation
in children below 16 years of age.
One major technical difficulty is the incompatibility
of propofol with virtually all other substances; propo-
fol has to be administered via a separate lumen. A cen-
tral venous line is required if propofol is administered
in the 2% preparation.
Propofol is supplied in a fatty emulsion and its
infusion results in a considerable administration of
triglycerides (1.1 kcal/ml). The amount of trigly­
cerides given with the propofol solution has to be
included in the calculation of (parenteral) nutrition
requirements.
19.4.2.3 a2-Adrenoceptoragonists
Clonidin is a central a2-adrenoceptoragonist that
quickly enters the central nervous system due to its
lipophilia and exerts a sympatholytic effect via stimula-
tion of a2-adrenoceptors. It is widely used as an adju-
vant to other sedative or analgesic substances and may
result in a sparing of opioids and benzodiazepines.
Clonidin may be used alone or in combination in agi-
tated patients with tachycardia and hypertension, for
prophylaxis or therapy of withdrawal syndromes after
long-term sedation or alcohol withdrawal syndromes.
Therapy is usually started with a bolus infusion of
0.075 mg, followed by a continuous infusion of 0.03–
0.15 mg/h. Oral application is an option. Typical side
effects include hypotension and bradycardia and restrict
152
its use in patients on vasopressors and with bradycardic
arrhythmias. Constipation and even ileus is of concern,
particularly if it is coadministered with an opioid.
Dexmedetomidin, a newer a2-adrenoceptoragonist
appears to have a better profile of desired and ­undesired
effects but may not be available in all countries.
19.4.2.4 Other Sedatives
Ketamine is used in many intensive care units as an
adjuvant substance during long-term sedation. It should
be combined with low-dose benzodiazepines because
if used alone it may lead to hallucinations and night-
mares. The increased rate of salivation may require the
application of vagolytic agents. Ketamine has a strong
broncholytic effect and may be helpful in patients with
concomitant bronchospasm. In contrast to most other
sedatives and analgesics, Ketamine does not lead to
hypotension and may be used in situations with low
blood pressure of non-cardiac origin. Ketamine is con-
traindicated during increased intracranial pressure,
cardiac shock, and acute myocardial infarction. A typi-
cal starting dose is 5 mg/kg/min.
Barbiturates are reserved for specific neurological
or neurosurgical indications to reduce brain metabo-
lism. These drugs should not be used to sedate criti-
cally ill patients.
For short-term sedation (e.g., postoperative) many
users prefer propofol. Its use during weaning also
appears favorable. For expected sedation periods
of less than 7 days propofol may be given prefer-
ence over benzodiazepines due to the shorter
awakening time. However, in several randomized
trials there was no consistent advantage of propo-
fol. Propofol must not be used for sedation in
children under 16 years (acceptable only during
surgery and short interventions).
For long-term sedation, propofol is not appro-
priate because of the increased risk of the propo-
fol syndrome and, therefore, is not approved for
use of more than 7 days. Midazolam is the benzo-
diazepine of choice in many intensive care units.
It may be switched to longer acting substances
(e.g., lorazepam) during withdrawal syndromes
after prolonged administration of midazolam.
C. Waydhas
19.5 Delirium
Delirium is an acute, reversible, organic psychosis that is
characterized by disturbances of vigilance, attention def-
icit disorder and disorientation, (optical) hallucinations,
affective disturbances (anxiety, irritability, restlessness)
and affection of the sympathetic system (tachycardia,
sweating), interruption of circadian rhythms, tremor, and
agitation. It has to be differentiated from withdrawal syn-
dromes, pain, and insufficient compliance with the venti-
lator. A search for treatable causes of delirium such as
sepsis, fever, hypoxia, and metabolic disorders should be
initiated.
The Confusion Assessment Method for Intensive
Care Units (CAM-ICU) may be a valuable tool to make
a diagnosis and to monitor severity. The CAM-ICU can
be applied by nurses.
Haloperidol is the most widely used drug to treat
delirium and hallucinations. It is a strong neuroleptic
substance with additional sedative and antiemetic
effects. The onset of action is within 20 min. It is usu-
ally started by intravenous bolus injection of 2.5–5 mg.
If the initial effect is not satisfactory, the dose may
be doubled every 20 min up to a maximum bolus of
20 mg. If still no adequate delirium control can be
achieved another neuroleptic substance should be tried
and an additional application of a benzodiazepine may
be helpful. The usual maintenance dose of haloperidol
is 5 mg every 4–6 h. In the further course, the dose
should be tapered gradually.
Depression of breathing efforts and hypotension are
rarely encountered. Extrapyramidal symptoms seem to
be rare in critically ill patients (below 5%); dysphoria,
however, may be a problem more often. A rare but life-
threatening complication (independent from dosage
and duration) is the neuroleptic-induced malignant
hyperthermia with a sharp rise in body temperature to
more than 41°C, muscle rigidity, rhabdomyolysis, and
acute renal failure. Early recognition and immediate
treatment with dantrolene are of utmost importance.
Another potential problem of haloperidol is the pro-
longed QT interval.
The concomitant administration of other QT-
prolon­ging substances (e.g., chinolones, amiodarone
sotalol, erythromycin) to haloperidol should be
avoided, if possible.
19 Analgesia and Sedation in Intensive Care
An alternative to haloperidol may be olanzapine. In
a randomized study, an enteral daily dose of 5 mg olan-
zapine showed a comparable anti-delirant effect as
2.5–5 mg haloperidol qid with less extrapyramidal
symptoms.
Levomepromazine and promethazine are weak neu-
roleptic substances with a stronger sedative effect.
During intravenous bolus injection, the development
of hypotension is a well-known complication and they
should be used with caution in elderly and hypov-
olemic patients.
19.6 Withdrawal Syndromes
Withdrawal syndromes are a common problem after
high-dose or long-term sedation. Symptoms and dif-
ferential diagnosis are outlined above in this chapter.
If motor activity and agitation prevail, long-acting
benzodiazepines (e.g., lorazepame) may be used.
Sympathetic hyperacitivity may be controlled with
clonidine or other a2-adrenoreceptoragomists or
b-blockers. During productive-psychotic states, halo-
peridol is recommended.
19.7 Muscle Relaxants
Muscle relaxation is only indicated during acute pro-
cedures and interventions that require a complete
avoidance of muscle activity such as some types of
surgery, tracheotomy, intubation, bronchoscopy, or
acute ventilation problems that are referred to muscle
rigidity. A more than single dose is only required in
rare exceptions. Adequate deep analgesia and seda-
tion are a prerequisite. A positive effect of muscle
relaxation in increased intracranial pressure has not
been shown. Some undesired effects comprise a sup-
pression of coughing with inadequate clearance of
153
bronchial secretions, pressure sores, critical illness
polyneuro- and myopathy, difficult weaning from the
respirator, over- or under-sedation, insufficient pain
control. If, despite these disadvantages, they are used
for more than a single dose, monitoring with periph-
eral muscle stimulation (TOF, train of four) and
bispectral index are strongly recommended. A clear
recommendation for a single substance cannot be
made. Pancuronium, however, has a strong histaminic
effect and succinylcholine should be avoided in poly-
traumatized patients.
Recommended Reading
Devlin, J.W., et al.: Motor activity assessment scale: a valid and
reliable sedation scale for use with mechanically ventilated
patients in adult intensive care. Crit. Care Med. 27,
1271–1275 (1999)
Ely, E.W. et al.: Monitoring sedation status over time in
ICU patients: reliability and validity of the Richmond
Agitation Sedation Scale (RASS). JAMA 289, 2983–2991
(2003)
Gommers, D., Bakker, J.: Medications for analgesia and seda-
tion in the intensive care unit: an overview. Crit. Care
12(Suppl 3), S4 (2008)
Hayden, W.R.: Life and near-death in the intensive care unit.
Crit. Care Clin. 10, 651–657 (1994)
Jacobi, J., Fraser, G.L., Coursin, D.B., et al.: Clinical practice
guidelines for the sustained use of sedatives and analgesics in
the critically ill adult. Crit. Care Med. 30, 119–141 (2002)
Kress, J.P., Pohlman, A.S., ÓConnor, M.F., Hall, J.B.: Daily
interruption of sedative infusions in critically ill patients
undergoing mechanical intervention. N. Engl. J. Med. 342,
1471–1477 (2000)
Payen, J.F., Bru, O., Bosson, J.L., Lagrasta, A., Novel, E.,
Deschaux, I., Lavagne, P., Jaquot, C.: Assessing pain in criti-
cally ill sedated patients by using a behavioural pain scale.
Crit. Care Med. 29, 2258–2263 (2001)
Sessler, C.N. et al.: The Richmond Agitation-Sedation Scale:
validity and reliability in adult intensive care unit patients.
Am. J. Respir. Crit. Care Med. 166, 1338–1344 (2002)
Vender, J.S., Szokol, J.W., Murphy, G.S., Nitsun, M.: Sedation,
analgesia, and neuromuscular blockade in sepsis: an evi-
dence-based review. Crit. Care Med. 32(Suppl), S554–S561
(2004)
 Part
III
Operative Care
 Anti-reflux Procedures
Glyn Jamieson
20.1 Fundoplication in Rural Surgery
Since anti-reflux surgery is essentially elective and
­discretionary surgery, the indication for performing it,
whilst agreed upon to a certain degree, nevertheless
depends also on a patient’s wishes. It can rarely be
necessary to undertake such surgery in a rural setting
in the absence of expertise to carry out such surgery.
20.2 Investigations Prior to Surgery
The essential principle, on which the indication for any
anti-reflux surgery is based, is to establish that a patient
has abnormal gastro-oesophageal reflux. To establish
this can be quite straightforward. For example,
a patient who complains of heartburn, which is abol-
ished either temporarily by antacids, or in a more
­prolonged way with proton pump inhibitors, and who
has ulcerative oesophagitis on endoscopy, really needs
no further investigation to establish the diagnosis.
Similarly, patients who regurgitate fluid into their
mouth when bending over, or who have aspiration
symptoms from regurgitated fluid at night, are highly
likely to have gastro-oesophageal reflux disease which
can be cured by surgery.
Therefore, a careful history and an endoscopy are all
that are usually required in a rural setting before a patient
should be considered for anti-reflux surgery. But there
G. Jamieson
Department of Surgery, The Royal Adelaide Hospital,
North Terrace, Adelaide, SA 5000, Australia
e-mail: glyn.jamieson@adelaide.edu.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_20, © Springer-Verlag Berlin Heidelberg 2011
20
are pitfalls. Symptoms which differ from heartburn and
regurgitation such as burning pain in the epigastrium,
chest pain or discomfort, acid taste in the mouth, bloat-
ing and fullness after eating and cough, all can be asso-
ciated with, and/or caused by, gastro-oesophageal reflux
but all can have causes which are not reflux related.
Therefore, in centres of excellence oesophageal
manometry and sometimes 24 h pH monitoring is
added routinely in the workup for surgery. Oesophageal
manometry excludes achalasia and other motility dis-
orders such as an adynamic oesophagus, and 24 h pH
monitoring can not only establish the fact that abnor-
mal reflux is occurring but also establish a temporal
relationship between symptoms and reflux events.
20.3 Indications for Surgery
Most patients who have the straightforward and com-
monest symptom of reflux, that is, retrosternal burning
(heartburn), would also obtain relief of their symptoms
with a proton pump inhibitor. When then is anti-reflux
surgery indicated?
1. When symptoms supervene in spite of proton pump
inhibitors.
Some patients initially will obtain excellent
relief of heartburn with a proton pump inhibitor but
after some years on the therapy they find that their
symptoms start to recur. These symptoms are often
called ‘breakthrough’ symptoms. This problem
may occur as a result of parietal cell hyperplasia
which can occur in patients on long-term proton
pump inhibitor therapy. The therapy is then
increased but some time later the scenario repeats
itself. Patients who develop breakthrough symp-
toms are candidates for anti-reflux surgery. In these
157
158
days of widespread use of proton pump inhibitor
therapy for reflux, this is probably the commonest
indication for anti-reflux surgery.
2. In spite of the fact that proton pump inhibitors are
extremely safe and well tolerated, there is a small
group of patients who are intolerant of the therapy
because of side effects. Obviously these patients are
candidates for anti-reflux surgery.
3. There is also a group of patients who do not wish to
be reliant on taking tablets for the rest of their life
who elect to have anti-reflux surgery.
4. Complicated reflux disease, such as patients with
stricture formation, may be an indication if strictur-
ing remains a problem in spite of dilatation and pro-
ton pump inhibitor therapy. Whether Barrett’s
oesophagus, as a complication of reflux disease, is
an indication for anti-reflux surgery is somewhat
controversial. In the absence of symptoms of reflux,
at the present time there is no compelling evidence
that anti-reflux surgery is indicated in these
circumstances.
5. Lastly, and very importantly, is volume reflux. This
is the argot for excessive regurgitation and when
this causes aspiration symptoms (usually awaken-
ing the patient from sleep) it is a very strong indica-
tion for anti-reflux surgery. More controversial is
when regurgitation or reflux is thought to be associ-
ated with supra-oesophageal symptoms such as
chronic cough, huskiness of voice, acid taste in the
mouth, dental problems, etc. Most often, and even
when abnormal reflux has been demonstrated, anti-
reflux surgery does not cure these problems. In the
absence of abnormal reflux these sorts of symptoms
should almost never be seen as an indication for
anti-reflux surgery.
20.4 The Principles Underlying
Anti-reflux Surgery
The principal objective in anti-reflux surgery is to
restore the anatomy of the hiatal region to normal and
to do so in such a way that this will be maintained. This
is done using three manoeuvres. First, to restore a por-
tion of about 2–3 cm of the oesophagus into the abdom-
inal cavity. Second, to narrow the hiatal opening to
accommodate the oesophagus only. Third, to construct
a one-way valve at the gastro-oesophageal junction.
G. Jamieson
20.4.1 Intra-abdominal Oesophagus
Most patients who come to anti-reflux surgery have a
hiatus hernia and so the oesophagus and proximal stom-
ach are required to be mobilised in order to reduce the
hernia and bring 2–3 cm of oesophagus back into the
positive pressure environment of the abdominal cavity.
20.4.2 Narrowing of the Hiatus
This can be carried out either in front of, or behind, the
oesophagus. Most surgeons favour using posterior
sutures as it seems more anatomical and tends to leave
a normal racquet-shaped hiatus. Because the hiatal
aperture is oblique, a posterior narrowing allows more
of the oesophagus to lie intra-abdominally than an
anterior narrowing. Also, anterior sutures have a
­tendency to turn the hiatal opening into a vertical slit
rather than its usual racquet-shaped appearance.
The narrowing is usually achieved using one or two
non-absorbable sutures. It is very important not to nar-
row the hiatus to a degree which impinges on the
oesophagus and it seems sensible to place a 52 French
bougie in the oesophagus so the surgeon can be certain
the closure is not too tight.
20.4.3 Construction of a One-Way Valve
Whilst not exactly controversial, there are many ways
of achieving the construction of a one-way valve. All
methods produce an acute angle of entry of the oesoph-
agus into the stomach.
Probably by far the most popular and simplest oper-
ation is a total fundoplication – often called a Nissen
fundoplication – even though the operation performed
differs substantially from the operation which Rudolf
Nissen described. In this procedure, the fundus of the
stomach is taken behind the oesophagus and then sewn
to the stomach in front of the oesophagus with two or
three sutures. Some surgeons, perhaps a majority of
surgeons, mobilise the fundus by dividing all its attach-
ments such as the short gastric and posterior gastric
vessels. Others use the anterior wall of the stomach for
the wrap, a technique first described by Rudolf Nissen
as an alternative to the technique which he initially
20 Anti-reflux Procedures
Fig. 20.1 (a) Anterior 180° a b
fundoplication, a partial
anterior fundal wrap;
(b) posterior 270° fundoplica-
tion, a partial posterior fundal
wrap; (c) Nissen 360°
fundoplication, a loose 2 cm
long fundal wrap constructed
over a 52Fr intraoesophageal
bougie, without division of
the short gastric vessels
described. Once again a 52 French (or larger) bougie is
placed in the oesophagus to try and prevent constric-
tion of the oesophagus by the wrap. However, it should
be noted that the presence of a bougie in the oesopha-
gus is not a guarantee of a loose fundoplication.
Some surgeons prefer a partial fundoplication. Such
procedures fall into two classes, either anterior or
­posterior. Varying degrees of wrap have been described
with 270°, 180° and 90°, all having been reported. The
degrees refer to the amount of the circumference of the
oesophagus which is covered by the wrap (Fig. 20.1).
There are many other variations described such as
attaching the stomach to the diaphragm (crown
sutures), attaching stomach to the hiatal pillars (gas-
tropexy) and attaching stomach to the oesophageal
wall. My preferred technique for the procedure is
described in the following.
20.5 Operative Technique
In giving a description of this operation it is assumed
that the surgeon has expertise in laparoscopic abdomi-
nal surgery in general but not necessarily in surgery
around the oesophageal hiatus.
The patient is positioned on the operating table in
the lithotomy position with the table tilted 30° head up
and the surgeon sits between the patient’s legs.
Insufflation of the abdomen is undertaken to a pressure
of approximately 12 mm of mercury. Five ports are
placed. I place the camera port about midway between
the xiphisternum and the umbilicus and about 2–3 cm
to the left of the midline. With the port placed in this
position it is usually comfortable to use a 0° laparo-
scope. Other surgeons who prefer to use a 30° or 45°
159
c
laparoscope place the port in the region of the ­umbilicus
in the midline. A five millimetre port is placed in the
mid-clavicular line just below the right costal margin
and it is important that this port is well lateral to assist
in passing an instrument behind the oesophagus. Two
further 5 mm ports are placed, one just below the
xiphisternum in the midline and one in the left flank
below the left costal margin in about the anterior
­axillary line. The right-hand working port is placed in
the mid-clavicular line, 3–4 cm below the left costal
margin (this is a 10 mm port).
After a laparoscopic inspection of the upper abdom-
inal contents, a non-traumatic grasper is used by the
assistant through the left-most port to grasp the stom-
ach just below the gastro-oesophageal junction and to
pull the oesophagus downwards and slightly to the left.
I believe the next step is very important in always
­orientating the surgeon. This is to go to the lesser-­
omentum in front of the caudate lobe of the liver and to
the left of the inferior vena cava and above the branches
of the vagus nerve to the hilum of the liver. This is an
area where it is safe to open the lesser omentum, using
diathermy. This opening can be enlarged by placing
blunt graspers through it and using a distracting force
to separate the graspers. This takes the surgeon directly
down onto the right pillar of the hiatus.
Some form of liver retraction is used through the
5 mm epigastric port and we find the Nathanson hook
a most useful retractor in this regard.
Next, a blunt instrument is placed to the immediate
left of the right pillar and gently pushed inwards. This
creates a groove between the oesophagus and the right
pillar which I call the oesophago-hiatal groove. Gentle
distracting movements with two forceps in a vertical
direction in the depth of this groove opens into the
mediastinum to the right of the oesophagus. Once
160
opened the area into the mediastinum is enlarged fur-
ther, again by gentle distraction using the two forceps in
opposing directions in a vertical plane. The peritoneum
and the retro-peritoneal tissues along the edge of the
right pillar and down towards the gastro-oesophageal
junction are then divided using diathermy. This division
is continued distally until a thick fatty bundle of tissue
is reached. This bundle of tissue contains the hepatic
branch of the vagus nerve and the left gastric artery.
Attention is now turned to the left pillar of the hia-
tus. The assistant pulls the gastro-oesophageal junc-
tion downwards and in the direction of the patient’s
right iliac fossa and once again using a blunt grasper,
the left oesophago-hiatal groove is created and the
peritoneum is divided over the edge of the left pillar of
the hiatus distally until the region of the fundus of the
stomach is reached.
If the operation is undertaken without a mentor
present then it helps enormously to have an endoscope
in position in the lower oesophagus with a light on to
show the surgeon exactly where the oesophagus sits.
Without such an aid, exact identification of the oesoph-
agus is not quite as simple as the surgeon might expect
from experience of the procedure in the open setting.
The manoeuvre which many surgeons find the most
difficult to learn, in the technique of laparoscopic fun-
doplication, is to mobilise posterior to the oesophagus
to create a window behind it. I find this best done using
the surgeon’s left-hand instrument passing with the
blunt tip behind the oesophagus and holding the oesoph-
agus forward. Dissection of the meso-­oesophagus can
then take place. The surgeon must remember that the
only major structure posterior to the oesophagus here is
the aorta. Once the instrument has passed behind the
oesophagus it can usually be seen protruding from
within the chest into the diaphragm, to the left of the
left pillar. It can then be ‘walked down’ the inside of
the diaphragm until it appears in front of the left pillar.
Once this point has been reached, a tape or small cath-
eter such as an infant gavage tube is inserted through
the 10 mm left port and brought behind the oesophagus
and then out through the port again. During the dissec-
tion behind the oesophagus, the vagus nerve is usually
seen and often it moves with the oesophagus. It can be
either included with the oesophagus or dissected away
from the oesophagus. If a total fundoplication is to be
performed then the window behind the oesophagus
should be of the order of 3–5 cm in diameter. The
assistant’s forcep now picks up the tape encircling
G. Jamieson
the oesophagus and can hold it in various directions to
facilitate further dissection of the window behind the
oesophagus.
At this juncture the oesophageal-hiatus is narrowed.
I have used both anterior and posterior sutures in the
hiatus for this narrowing. I prefer posterior sutures as
they tend to reconstruct the hiatus more anatomically.
Nevertheless, anterior sutures can be used and these
tend to make the oesophageal-hiatus more of a slit than
a round opening. If a total fundoplication is to be per-
formed, the surgeon’s left-hand grasper is passed
behind the oesophagus and the right-hand grasper takes
the anterior wall of the stomach lateral to the oesophago-
gastric junction and passes it up to the grasper behind
the oesophagus. The surgeon then gently eases the
anterior wall of the stomach behind the oesophagus
until it can be grasped by the right-hand grasper and
held in position. At this point I usually pick up different
points of the stomach to the right of the oesophagus to
find out which part lies behind with least tension. When
a ‘square’ of stomach of about 3 cm × 2–3 cm has been
produced, the assistant’s grasper is placed across the
base of the square of stomach to hold it in position for
the construction of the fundoplication. At this point a
large bougie is placed in the oesophagus and it should
be observed as it is passed into the stomach.
Non-absorbable sutures are used for the fundopli-
cation. Three interrupted sutures are used. I use 2.0
Prolene for the sutures as they are less likely to cut
either gastric or oesophageal tissue. These can be tied
either intracorporeally or extracorporeally. I usually
take a superficial bite through the wall of the oesopha-
gus with the first suture which is placed about 3 cm up
the oesophagus. The sutures are approximately 1 cm
apart so that these three sutures construct a fundoplica-
tion of about 2 cm in length. It must be realised that
even though a bougie is in position this does not stop
the formation of a tight wrap. Nevertheless, with a
bougie in position, if the wrap appears loose and
instruments can be passed through it, it is unlikely that
long-lasting dysphagia will occur.
20.6 Variations to This Technique
There are many variations that have been described,
most of them relating to lesser degrees of fundoplica-
tion. The other thing which still provokes discussion
20 Anti-reflux Procedures
is whether the fundus of the stomach should be fully
mobilised for the construction of the total fundopli-
cation. There are several randomised controlled stud-
ies in the literature to suggest that this is not necessary
and so the technique will not be ­discussed here.
20.7 Post-operative Management
Patients are placed on a liquid diet from the first day
and are usually discharged on day 2 or day 3. Nearly
all patients will experience dysphagia for solids for
some weeks. Patients are discharged on day 2 or day 3
when they are managing to take a soft and moist diet
and they are told to stay on this diet until they can
appreciate that their difficulty in swallowing lessens,
usually in the second or third week after surgery.
Patients are given 2 weeks off from their work but are
also told that heavy lifting should be avoided for
12 weeks. I also undertake a contrast swallow on the
first post-operative day as a routine. This is to check
that the wrap is in a good position, that there are no
leaks and no acute para-oesophageal hernias which
sometimes occur even in the absence of symptoms.
It is important to detect any problems early since a
return to the operating theatre in the first 2 or 3 days is
usually straightforward and does not delay a patient’s
discharge from hospital by more than 2 or 3 days.
However, even if left until the end of the first post-
operative week, re-operation can suddenly become
extremely difficult, with the tissues being woody in
consistency and difficult to work with. It is for that rea-
son that the routine contrast study is undertaken at an
early time post-operatively.
There are several things which might alert the
­surgeon to a problem in the post-operative period. The
first is undue pain. Patients should not have pain requir-
ing narcotics, and if this is the case, then there should
be a high index of suspicion that something is amiss.
Second, sometimes there is an obvious problem such
as a patient who is unable to swallow even their saliva.
Often they sit in the ward with a bowl in front of them
spitting out their saliva. Under these circumstances
161
I usually go straight to an endoscopy. If the endoscope
passes easily through the wrap then it is likely that the
problem will resolve. If there is any degree of diffi-
culty in passing the endoscope then the patient is
returned to the operating theatre. If the patient devel-
ops a leak either from the oesophagus or the stomach,
in my experience placing a drain to the area and under-
taking a feeding jejunostomy is the preferred way of
dealing with this.
20.8 Results
There is now ample evidence in the literature that if
patients are selected carefully and the operation is
undertaken in a standardised fashion then almost all
patients will have their reflux cured in the short term.
Unfortunately there is a recurrent reflux rate which
tends to occur most in the first 3 years and affects about
10% of patients. There is a very small group of patients
(probably less than 1%) who have troublesome dys-
phagia to the point that a further operation is required
at some later stage.
Revisional anti-reflux surgery should be undertaken
in a centre specialising in laparoscopic surgery of the
upper gastro-intestinal tract.
Recommended Reading
Catarci, M., Gentileschi, P., Papi, C., Carrara, A., Marrese, R.,
Gaspari, A.L., Grassi, G.B.: Evidence based appraisal of
anti-reflux fundoplication. Ann. Surg. 239(3), 325–337
(2004)
Salminen, P.: The laparoscopic Nissen fundoplication – a better
operation? Surgeon 7(4), 224–227 (2009)
Varin, O., Velstra, B., DeSutter, S., Ceelend, W.: Total versus
partial fundoplication and the treatment of gastro-oesopha-
geal reflux disease: a meta- analysis. Arch. Surg. 144(3),
273–278 (2009)
Watson, D.I., Jamieson, G.G.: Treatment of gastro-oesophageal
reflux disease. In: Griffin, S.M., Raimes, S.A. (eds.)
Oesophago-Gastric surgery, 3rd edn. Elsevier Saunders,
Philadelphia, 279–304 (2006)
 Gastric Surgery
21
Matthias W. Wichmann

21.1 Introduction
9
Surgery of the stomach can be a challenge in the rural
setting due to the potential lack of necessary infrastruc- 1 3 8
ture for the management and diagnosis of peri- and
4 2
postoperative complications. Nonetheless, treatment of 5
both benign and malignant conditions of the stomach 6
in the emergency and elective setting is an important 7
part of rural general surgery. Especially for elective
surgery, it is the surgeon’s responsibility to evaluate
whether the caseload as well as the available infra-
structure and experience (level of peri- and posto­
perative care, diagnostic/interventional radiology and
endoscopy, experience of nursing staff) are sufficient to Fig. 21.1 Blood supply to the stomach. 1 celiac axis, 2 splenic
provide safe gastric surgery. artery, 3 left gastric artery, 4 common hepatic artery, 5 right
gastric artery, 6 gastroduodenal artery, 7 right gastro-epiploic
artery, 8 left gastro-epiploic artery, 9 short gastric vessels

21.2 Relevant Anatomy
The stomach is divided into fundus (superior to the gas-
troesophageal junction), body and antrum and there are
two important physiologic divisions: the fundic gland
(parietal cell; acid production) and the pyloric gland
(antral cell; mucous production, gastrin and somatosta-
tin secretion) areas. The blood supply to the stomach is
maintained by six major vessels (right and left gastric
artery, right and left gastroepiploic artery, splenic artery
(vasa brevia), gastroduodenal artery) (see Fig. 21.1).
M.W. Wichmann
Department of General Surgery, Mount Gambier General
Hospital and Flinders University Rural Medical School,
276-300 Wehl Street North, Mount Gambier,
SA 5290, Australia
e-mail: matthias.wichmann@health.sa.gov.au
21.3 Indications
Most common indications for gastric surgery are
­cancer, ulcer disease, and associated hemorrhage as
well as feeding access.
21.3.1 Surgery for Gastric Cancer
As opposed to other gastrointestinal malignancies,
­the incidence of gastric cancer has been significantly
decreasing during recent years. Although improve-
ments in nutrition, occupational hazards, and socio-
economic conditions have been discussed, the reasons
for the decline in the incidence of gastric cancer remain
unclear. It appears that mass screening (as done in

M.W. Wichmann et al. (eds.), Rural Surgery, 163

DOI: 10.1007/978-3-540-78680-1_21, © Springer-Verlag Berlin Heidelberg 2011
164
Japan) and eradication therapy for Helicobacter pylori
also have contributed to this positive development.
The lymphatic drainage of the stomach is difficult
to predict and the submucosal extent of the adenocarci-
noma can be bigger than may be appreciated by macro-
scopic inspection. For these reasons, the ideal security
margin for gastric cancers has been considered to be
6 cm proximal and distal to the tumor. If preoperative
histology reveals cancer of the so-called intestinal type,
one should aim for an oral security margin of 8 cm.
For carcinoma of the mid and lower body and
antrum of the stomach, radical subtotal gastrectomy
has been accepted as standard of care. This procedure
includes:
• 75–90% distal gastrectomy with the aboral resec-
tion margin 3 cm postpyloric,
• Division of right and left gastric artery and right
gastroepiploic artery at their origin and clearance of
all associated lymphoid tissue,
• Removal of the lesser and greater omentum.
Lymph node dissection should include the infra- and
supraduodenal areas, the retropancreatic region, the
hepatic pedicle, the mesenteric root, and the common
hepatic and celiac arteries (D1 lymphadenectomy:
­cardia nodes, lesser curve nodes, greater curve nodes,
short gastric artery nodes, left and right gastroepiploic
nodes, nodes proximal and distal of the pylorus).
Lymph node dissection is usually done en bloc with
removal of the stomach.
With regard to the discussion of how extensive
the lymph node sampling should be carried out, it is
of interest that a recent study comparing D2 lymph-
adenectomy with more extensive para-aortic nodal
­dissection in more than 500 patients could not show
significant differences in 5-year survival rates (69 vs
70%) between both patient groups. In patients with
early nodal involvement, D2 lymphadenectomy is
of prognostic importance and should be performed
resulting in at least 25 lymph nodes available for path-
ological evaluation. D2 lymphadenectomy involves
lymph node sampling from the following areas: left
gastric artery nodes, common hepatic artery nodes,
celiac trunk nodes, nodes of the splenic hilus, splenic
artery nodes, nodes of the hepatoduodenal ligament.
Total gastrectomy has been accepted as the treat-
ment of choice for upper and middle gastric cancer.
M.W. Wichmann
It is the only surgical option for linitis plastica-type
lesions that involve most of the stomach. In addition
to the steps outlined above, the entire stomach is being
resected, and the gastrosplenic ligament as well as cru-
ral lymphatic tissue needs to be removed. For lesions
of the gastroesophageal junction, the upper resection
margin includes the distal esophagus.
Ongoing debate involves the role of palliative gas-
trectomy in stage IV gastric cancer, the role of sple-
nectomy for completion of D2 lymph node dissection,
and the role of lymph node dissection for long-term
survival (D1 vs D2/D3 dissection). A Cochrane review
that examined extended versus limited lymph node
dissection for adenocarcinoma of the stomach showed
comparable survival in both study groups, with a
higher postoperative mortality in the group of patients
undergoing extended note dissection.
Splenectomy should only be performed if the
spleen is directly involved with the malignant lesion or
grossly enlarged lymph nodes in the splenic hilum are
being detected.
During recent years, the role of palliative gastric sur-
gery has evolved and it has been shown that resectional
surgery – although it carries a high rate of morbidity
and mortality (up to 40% and 10%, respectively) – offers
better survival and quality of life than bypass proce-
dures or best supportive care only.
Staging laparoscopy prior to curative surgery or
neoadjuvant radio-chemotherapy has gained accep-
tance during recent years in view of significantly
improved survival rates with preoperative chemoradia-
tion if disseminated peritoneal disease was diagnosed
using minimal invasive surgery.
21.3.1.1 Reconstruction
Reconstruction of intestinal continuity is usually done
by a Roux-en-Y esophago-jejunostomy. The anasto-
mosis can be hand-sutured in two layers or a ­circular
mechanical stapler (25 mm diameter) can be used.
We cover the stapled anastomosis with interrupted
absorbable stitches. The entero-entero-anstomosis of
the Roux-en-Y limb is constructed as a side-to-side
anastomosis 40–60 cm distal to the esophago-jejunos-
tomy. This effectively prevents reflux of duodenal
juices (Fig. 21.2).
21 Gastric Surgery
40–60cm
Fig. 21.2 Reconstruction after total gastrectomy with pouch
and Roux-en-Y esophago-jejunostomy
There is no evidence available which favors main­
tenance of duodenal passage after gastrectomy. It
appears, however, that pouch construction improves
eating and weight maintenance in patients after gast-
rectomy within the first year after surgery. The pouch is
formed by constructing a side-to-side anastomosis
between the ascending and descending parts of the first
jejunal loop prior to the esophago-jejunostomy (Hunt-
Rodino-Pouch).
Depending on the nutritional status of the patient and
the surgeon’s evaluation of the risk of postoperative ileus
or leakage, the need for a feeding jejunostomy must be
discussed. We favor the liberal use of this device since it
allows for an early start of enteral nutrition. However, it
is important to note that a feeding jejunostomy also
165
c­ arries the risk of significant morbidity (leakage,
mechanical obstruction, bleeding, wound infection).
Drains should be placed to cover potential leaks at
the level of the esophago-jejunostomy (or gastro-
jejunostomy in patients with subtotal gastrectomy) as
well as of the duodenal stump.
21.3.1.2 Additional treatment options
for gastric malignancy
During recent years, a number of promising oncologi-
cal treatment options (e.g., MAGIC trial) have been
developed for gastric malignancies and the potential
benefits of either preoperative neoadjuvant, postopera-
tive adjuvant, or palliative (radio-) chemotherapy
should be discussed within the setting of a multidisci-
plinary tumor board.
21.3.1.3 Complications
After gastric resection and anastomosis, any suture
line may leak and has the potential to create a fatal
situation. Increasing postoperative pain, fever, abdom-
inal distension, and rising inflammatory markers must
prompt further investigations. Most importantly, a CT
scan should be done urgently which can also allow for
radiological placement of a drain. If this is not possi-
ble, a reoperation with irrigation and drainage of the
infected peritoneum must be done. The leaking seg-
ment must be decompressed and a feeding jejunostomy
should be placed (if not already done during the initial
surgery).
A number of postgastrectomy syndromes have been
described. These include:
• Dumping syndrome (early – treatment with saline
infusion, late – treatment with sugar);
• Diarrhea (truncal vagotomy);
• Gallstone disease (vagal denervation);
• Metabolic disorders: weight loss, anemia (iron
absorption, vitamin B12 and folate deficiency), fat
malabsorption, osteoporosis (disturbed calcium and
vitamin D metabolism).
It is important to monitor patients closely during
the immediate postoperative phase as well as in the
166
l­ong-term, to detect early complications and to reduce
­associated morbidity and mortality.
21.3.2 Surgery for Ulcer Disease
The introduction of very effective acid suppressive
drugs (proton pump inhibitors) and the detection of the
relevance of Helicobacter pylori for the pathogenesis
of gastric ulcer disease have resulted in a “sudden
death” of elective surgery for gastric and duodenal
ulcers. Nowadays, we are dealing with the acute com-
plications of peptic ulcer disease: bleeding, perforation
(and obstruction).
Initial bleeding control should always be
attempted using gastroscopy after the patient was
stabilized with adequate blood and fluid transfu-
sions. With the decision to perform an emergency
endoscopy, the patient should receive 10–20-mg
metoclopramide i.v. to promote gastric emptying and
clearance of old blood. Early intubation is recom-
mended to avoid aspiration pneumonia and for good
airway control during the (often lengthy) procedure.
We recommend usage of ice water for initial wash-
out and occasionally it can be worthwhile to use a
colonoscope with a wider suction canal for removal
of clotted blood from the upper GI tract. If a bleed-
ing lesion can be identified, it should be injected and
clipped (see Chap. 7 for more details). If endoscopy
does not achieve bleeding control or an early recur-
rent bleed develops, surgical intervention may be
necessary. The following findings favor the need for
definite surgical intervention:
• Total blood loss > 2,000 ml,
• Hypotension due to ongoing blood loss,
• Need to transfuse > 1,000 ml blood/24 h to maintain
patient’s blood pressure.
Definite surgical treatment can be done as distal gast-
rectomy (2/3) with Billroth I or II reconstruction or as
gastrostomy/duodenotomy with oversewing of the
ulcer, vagotomy, and pyloroplasty depending on the
performance status of the patient.
M.W. Wichmann
In patients with perforated ulcer disease, a laparo-
scopic or open omental patch closure of the perfora-
tion site should be done after washout and drainage of
the peritoneal contamination. We perform the Graham
patch technique, which places omentum over the
­perforation site and fixes the omentum in place with
three interrupted stitches. All patients are started on
H. pylori eradication immediately after surgery, fol-
lowed by long-term proton pump inhibitor therapy.
After initial successful treatment, all patients require
an endoscopy within 4–6 weeks after surgery to con-
trol for complete ulcer healing and to exclude malig-
nancy (for gastric ulcers).
21.3.3 Surgery for Feeding Access
Usually, feeding access to the stomach should be
gained using an endoscopic technique (see Chap. 7 for
details). In patients with known esophageal or proxi-
mal gastric malignancies (who are not suitable for
resection), a regular endoscopic surveillance must be
performed to not miss the development of complete
obstruction. Prior to complete obstruction, either a
stent or an endoscopic percutaneous feeding gastros-
tomy must be inserted.
If the passage into the stomach via the esophagus is
impossible due to proximal obstruction, a laparoscopic
or open gastrostomy can be performed. Two different
procedures have been described: the Stamm (tube)
gastrostomy as well as the Janeway gastrostomy.
For the tube gastrostomy, a stab incision into the
stomach close to the greater curve is made and secured
with a purse-string suture. A balloon catheter is intro-
duced through the abdominal wall and inserted into the
stomach. After closure of the purse-string suture, the
stomach is sutured to the abdominal wall with four
interrupted sutures. The balloon catheter can be
removed if access to the stomach is not needed
anymore.
The Janeway gastrostomy (see Fig. 21.3) does not
require a long-term tube insertion and consists of a
gastric “nipple” created with a linear stapling device
21 Gastric Surgery 167

a on the anterior gastric wall. The stapler is fired from

the lesser curve into the direction of the greater curve
across the anterior gastric wall, which is elevated using
Babcock clamps. This procedure creates a tunnel of
gastric mucosa (“nipple”) which is used to form a
stoma after suturing the stomach to the abdominal wall
with interrupted sutures. A catheter is only required in
this stoma until it has completed healed.

Recommended Reading

Brennan, M.F.: Current status of surgery for gastric cancer:

b a review. Gastric Cancer 8, 64–70 (2005)
Grabowski, M.W., Dempsey, D.T.: Stomach and duodenum.
In: Scott-Conner, C.E.H. (ed.) Chassin’s Operative Strategy
in General Surgery, pp. 223–322. Springer, New York
(2002)
McCulloch, P., Nita, M., Kazi, H., et al.: Extended versus lim-
ited lymph node dissection technique for adenocarcinoma
of the stomach. Cochrane Database Syst. Rev. (4):CD001964
(2004)
Pacelli, F., Papa, V., Rosa, F., et al.: Four hundred consecutive
total gastrectomies for gastric cancer. Arch. Surg. 143,
­769–775 (2008)
Sasako, M., Sano, T., Yamamoto, S., et al.: D2 lymphadenec-
tomy alone or with para-aortic nodal dissection for gastric
cancer. N. Engl. J. Med. 359, 453–462 (2008)
Thompson, J.C.: The stomach and duodenum. In: Sabiston, D.C.
Fig. 21.3 Janeway gastrostomy: fashioning of the gastric (ed.) Textbook of Surgery, pp. 756–813. W.B. Saunders,
‘nipple’ Philadelphia (1991)
 Gallbladder Surgery: Laparoscopic
Cholecystectomy and Management 22
of Bile Duct Stones in the Rural Setting

Harsh A. Kanhere and Andrew D. Strickland

22.1 Introduction therefore have to either shoulder the responsibility

of managing these problems or consider transferring
these patients to a tertiary referral centre.
Laparoscopic cholecystectomy (LC) is the current gold
It is dealing with limitations like these, and many
standard treatment of gallstone–associated biliary dis-
more that can make rural surgery, in general, and
ease. This is a procedure performed by most general
­laparoscopic surgery, in particular, a daunting pros-
surgeons worldwide. With improved imaging tech-
pect. Beyond mastering these limitations, there are
niques, better awareness of gallstone-associated symp-
several essential requirements for a successful LC.
toms and increased availability of laparoscopic training,
These are considered in further detail below.
LCs are set to become even more commonplace.
This is borne out by the fact that LCs are being
­performed at rural, regional and remote centres with
increasing confidence, especially in the developed 22.2 Laparoscopic Cholecystectomy:
world. While this is a welcome development as it Essential Requirements
decreases the workload of the frequently overburdened
referral centres, the onus falls entirely on the rural sur- To successfully undertake procedures like LC, certain
geon to perform the procedure safely. As such, not elements are essential. These include competent surgi-
only do the rural surgeons need to be technically adept, cal staff, the availability of necessary infrastructure
but also be well aware of the limitations of the system and appropriate ancillary services. These are explored
that they are working in, especially in the areas of in further detail below:
­personnel and logistics.
For a successful LC, the availability of appropri-
ately trained personnel, including assistants and nurses, 22.2.1 Competent Surgical Staff
is critical. Unfortunately, assistants well versed in lap-
aroscopic procedures, and operating room personnel
It is stating the obvious that a competent surgeon is
as well as ward nurses acquainted with postoperative
­crucial to any surgical procedure, and LCs are no excep-
care can be difficult to recruit and retain in the rural
tion: The surgeon performing a LC has to be well
setting.
trained and possess the essential skill set for performing
Additionally, patients with complex medical comor-
laparoscopic procedures. Structured supervised training
bidities require multidisciplinary input, which can be
is required to gain expertise in laparoscopy, and cur-
difficult to obtain in a rural setting. Rural surgeons
rently, this is provided by most surgical training pro-
grammes worldwide. However, it is important to note
that every laparoscopic procedure has an individual
H.A. Kanhere (*) and A.D. Strickland learning curve, and evidence suggests that complication
Department of Surgery, The Queen Elizabeth Hospital,
rates steadily reduce, then plateau after approximately
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: drhakanhere@hotmail.com, 200 individually performed LCs. Surgeons should
a_d_strickland@hotmail.com ensure their proficiency in performing a LC before

M.W. Wichmann et al. (eds.), Rural Surgery, 169

DOI: 10.1007/978-3-540-78680-1_22, © Springer-Verlag Berlin Heidelberg 2011
170
attempting to undertake the procedure within an iso-
lated rural hospital, and certainly those still in their
learning curve would be ill advised to carry out the sur-
gery when expert supervision is unavailable. If the sur-
geon is inexperienced with regard to LCs, it is essential
that additional training be arranged in performing LCs
to gain proficiency in performing the procedure.
However, technical competence is only one aspect
of competency. Among other things, a thorough knowl-
edge of normal anatomy and awareness of anatomical
variations is vitally important. Further, the ability to
recognise complications such as injury to the bile duct
and managing these expediently is essential. It is also
important to understand that some complications are
difficult to manage in the rural centre and close ties
with region wide tertiary referral centres are essential
to ensure appropriate management of these patients.
Close collaboration with the tertiary centres provides
means to a readily available specialist opinion if
required. Also, should the need arise, a rapid pathway
for patient transfer and management is available.
22.2.1.1 Assistants
Although some rural and regional surgeons may be
­privileged to have a surgical trainee attachment, most
would find recruiting assistants difficult in rural centres.
Assistants adept in assisting laparoscopic procedures are
invaluable but unfortunately not readily available in the
rural setting. Local General Practitioners (GPs) can help
address this problem. This can be achieved via a struc-
tured training programme organised with the help of
hospital administration for GPs interested in assisting
during surgery. Upon completion of the programme,
they can then be included in the surgical team regularly
as assistants.
22.2.1.2 Nursing Staff
As with surgical assistants, nursing staff trained in
laparoscopic surgery is at a premium in rural hospi-
tals. Age-old problems of social and professional iso-
lation make it difficult to attract experienced nursing
staff to the rural setting. Nurses assisting laparoscopic
procedures need to be well versed with the functioning
H.A. Kanhere and A.D. Strickland
of laparoscopic trolleys, adept in assembly of laparo-
scopic instruments, and experienced at assisting these
surgeries.
22.2.2 Patient Selection
One should never forget the principle “Choose well,
cut well, get well”.
Optimal preoperative assessment by the surgeon,
anaesthetist and nursing staff is vital and will have a
direct impact on patient outcome. Therefore, pread-
mission clinics should be organised for all patients
with a review by the consultant anaesthetist and ­nursing
staff after the surgical decision is made.
Complex medical comorbidities requiring multi­
disciplinary management mostly preclude surgery in
regional setting. Any patient perceived to be a postop-
erative ICU candidate due to such comorbidities should
be appropriately investigated and referred to a tertiary
centre.
When surgery is deemed technically difficult, such
as in patients with previous upper GI/hepatobiliary
surgeries, morbid obesity, and/or Mirizzi syndrome,
the surgeon should make the decision regarding eligi-
bility based on their own surgical expertise.
22.2.3 Appropriate Infrastructure
and Facilities
Appropriate infrastructure to support a surgical service
is essential to perform any procedure safely. This includes
the availability of well-equipped operating rooms, appro-
priate instruments, facilities to perform an intraoperative
radiological examination, a well-equipped and staffed
recovery ward and finally good surgical wards.
Surgeons should be well versed with the available
instruments and ensure that good quality instruments
in optimal working order are available. Every surgeon
has personal preferences regarding instruments and
operating room setup, and they should take steps
to ensure that these requirements are met with.
Figure 22.1 depicts most commonly used laparoscopic
instruments.
22 Gallbladder Surgery: Laparoscopic Cholecystectomy and Management of Bile Duct Stones in the Rural Setting
Fig. 22.1 Instrument tray
Fig. 22.2 Typical laparoscopic trolley
Appropriate laparoscopic setup includes good three
chip cameras, 0° and 30° telescopes, a good light
source and a gas insufflator. The surgeon should be
acquainted with the working of all of these instru-
ments. At least two such laparoscopic instruments trol-
leys should be available. Figure 22.2 shows a typical
laparoscopic trolley.
171
Summary
›› The surgeon undertaking the procedure should
be proficient in performing laparoscopic sur-
gery, be well aware of complications and be
able to deal with them.
›› Good communication and rapport with a ter-
tiary referral centre is important for specialist
advice so that transfer is facilitated in a timely
and smooth manner in case of complications.
›› Patient eligibility should be assessed thor-
oughly preoperatively.
›› Good lines of communication between anaes-
thetist, surgeon and nursing staff are essential.
›› Appropriate infrastructure and facilities are
mandatory.
22.3 Operative Technique
This section covers some pertinent ergonomic issues
with LC’s and is not intended as a detailed description
of the procedure (such a description can be found in an
operative surgery textbook). These simple steps help in
avoiding irritating technical difficulties during surgery.
The ‘open technique to create pneumoperitoneum’
is recommended by most surgical colleges.
Laparoscopes should be placed in a warmer prior to
use to avoid ‘fogging’ of the lens. Fogging necessitates
frequent withdrawal of the scope to clean the lens,
thereby causing repeated interruptions in the smooth
flow of the surgery.
172
Patient position: Patient is positioned supine with
the operating table manoeuvred into position with ele-
vation of the right side to obtain proper exposure.
Patient position should be carefully adjusted to obtain
clear views of the operative site by using gravity to
lower the hepatic flexure of the colon and duodenum
away from the operative field.
Port positioning and direction: Standard port posi-
tions include 10–12 mm umbilical and epigastric ports
and two 5 mm ports in the right upper quadrant
(Fig. 22.3). It is common practice to insert the ‘camera
port’ in close proximity of the umbilical scar. Obese
patients and those in whom the umbilicus and the
xiphisternum are spaced widely apart (more than ¾
the length of the telescope) may pose a problem
with this approach as the length of the telescope falls
short of the operative site with this distance being
­further widened after pneumoperitoneum and cranial
traction on the gall bladder compound the problem.
This will lead to suboptimal visualisation of the opera-
tive site increasing risk of heuristic perception errors.
A supraumbilical incision (2–3 cm cranial to the umbi-
licus) should be considered in this situation. This ensures
adequate reach of the laparoscope to the operative site
despite this distance being increased further with pneu-
moperitoneum and cranial retraction of the gallbladder.
The 10 mm epigastric port should be inserted as
close to the xiphisternum as possible initially directed
straight into the peritoneal cavity and then cranially
toward the patient’s right shoulder. This ensures opti-
mal ergonomic position of the wrist with good triangu-
lation of instruments after the gallbladder is retracted
a b
Fig. 22.3 Port positions
H.A. Kanhere and A.D. Strickland
cranially and to the patient’s right. An inferiorly
directed/placed port makes it difficult to perform finer
manoeuvres that are essential in dissection of Calot’s
triangle.
It is usual practice to place two 5 mm ports in the
right upper quadrant, one in the proximity of the mid-
clavicular line and the second close to the anterior axil-
lary line. Both ports should be directed cranially.
The medial port should be inserted after visualising
the fundus of the gallbladder. This ensures proper posi-
tioning in relation to the gallbladder fundus. Optimal
port positioning is also essential to facilitate perform-
ing a cholangiogram. This port should therefore be no
more than 4 cm inferior to the costal margin. Correct
port positioning allows the cholangiogram catheter
and the cystic duct to be parallel and not at an angle as
would be the case if this port is inserted inferiorly
(Fig. 22.4a, b).
Summary
›› Use an Open technique of pneumoperitoneum
– consider supraumbilical if umbilicus and
­xiphisternum are widely spaced.
›› Optimal port positioning and direction epigas-
tric port – close to xiphisternum, direct straight
inwards and then to right shoulder.
›› Medial 5 mm port – after visualising the gall-
bladder fundus, inserted subcostally, directed
cranially.
22 Gallbladder Surgery: Laparoscopic Cholecystectomy and Management of Bile Duct Stones in the Rural Setting 173

a b

Fig. 22.4 (a) Cholangiograsper, catheter and cystic duct in straight line by virtue of proper port placement. (b) Cholangiograsper
and catheter at 90° angle to the cystic duct due to inferiorly placed port

22.4 Calots Triangle and the Critical base of the liver bed is exposed by detaching the lowest
View of Safety part of the gallbladder from the liver. It is not necessary
to see the common bile duct (CBD). This is the critical
view of safety and once this is obtained, the cystic duct
22.4.1 How to Dissect and artery can be safely clipped (Fig. 22.5).
Strasberg and colleagues were the first proponents of
Dissection of the Calots triangle is the most critical the critical view of safety. Failure to achieve this critical
manoeuvre in a LC. This is the area bounded by the infe- view of safety is essentially a failure to delineate the
rior surface of the liver, the common hepatic duct and the anatomy satisfactorily which may be due to severe
cystic duct, and is traversed by the cystic artery. The cys-
tic artery and the duct have to be clearly defined to obtain
the ‘critical view of safety’. These structures are exposed
by careful dissection of the fibrofatty tissue within the
Calot’s triangle. Good lateral traction on the Hartman’s
pouch with gentle teasing and blunt dissection along
with judicious use of diathermy will ensure good expo-
sure. The Maryland forceps or an equivalent instrument
is useful in this manoeuvre. Diathermy should be used in
short sharp bursts if at all as it can cause inadvertent ther-
mal injury to the bile duct. Division of the peritoneal
attachment of the neck of the gallbladder to the liver will
enhance the angle and facilitate this manoeuvre.

22.4.2 Critical View of Safety

Once the fibrofatty tissue is cleared, the cystic artery
and the cystic duct are conclusively identified as the
only two structures passing into the gallbladder and the
Fig. 22.5 Critical view of safety: Visualisation of the liver behind
the cystic artery (a) and between the cystic artery and the cystic
duct (b) by dissection of Calot’s triangle and detachment of the
peritoneal attachment of the gallbladder base to the liver (c)
174
inflammation, aberrant anatomy or troublesome bleed-
ing, all of which are independent risk factors for bile duct
injury. An open conversion should be therefore consid-
ered if this critical view is not obtained. Overzealous
attempts to complete the procedure laparoscopically are
fraught with a high risk of bile duct injury, and thus, an
open conversion is a prudent decision.
Summary
›› Critical view of safety is vital.
›› Conclusive identification of cystic duct and
cystic artery is essential.
›› The CBD need not be visualised.
›› Conversion to an open surgery is advocated if
the critical view of safety is not achieved.
22.5 Dissection of the ‘Difficult
Gallbladder’
The wall of the gallbladder cannot be grasped easily in
presence of significant inflammation and this problem
is compounded if the gallbladder is distended. A sim-
ple solution is to puncture the gallbladder and drain the
contents, as emptying the gallbladder collapses its wall
and makes it much easier to grasp and manipulate.
Drainage can be achieved by inserting a large bore
needle (in particular, the outer sheath of a Veress nee-
dle) into the fundus and connecting the suction tubing
to the hub of the needle. Another alternative is to use
the trocar of the 5 mm port to puncture the fundus and
insert the suction into the gallbladder directly espe-
cially if the contents are very thick. Utmost care should
be taken during these manoeuvres to prevent counter-
puncture of the opposite wall of the gallbladder and
disastrous liver or bile duct injury. It is advisable to
divide all the adhesions between the liver and the
omentum at the outset. This makes the liver more com-
pliant, and it can be easily pushed cranially without the
fear of capsular tears and bleeding from shearing of
these adhesions.
Severe inflammation around the Calots triangle
sometimes makes antegrade dissection of the gallblad-
der very difficult. Judicious blunt dissection with
graspers alternating with irrigation and suction is at
H.A. Kanhere and A.D. Strickland
times the best way to progress. The suction cannula is
a very functional instrument in this regard and can be
used to bluntly dissect the adherent tissue, irrigate with
saline under pressure and suck out the fluids. If satis-
factory progress is not achieved, retrograde dissection
and a subtotal cholecystectomy should be considered.
The gallbladder is dissected off the liver beginning at
the fundus. This dissection is carried towards the neck
of the GB. Once the majority of the fundus has been
mobilised, the GB can be opened and the stones
extracted. A cholangiogram can be performed through
the gallbladder to delineate the anatomy of the biliary
tree. A subtotal cholecystectomy can then be per-
formed. The stump of the gallbladder can be closed
with endoloops or sutured laparoscopically provided
such expertise is available. Large bore drain should be
placed next to the gallbladder remnant, as the bile leak
rates are high.
Open conversion is always safe, and even then, a
subtotal cholecystectomy may be the only option to
deal with the problem.
22.6 Intraoperative Cholangiography
Intraoperative cholangiography (IOC) has been tradi-
tionally performed to diagnose CBD stones/pathology.
However, two recent publications have emphasised the
role of routine intraoperative cholangiography in
avoiding bile duct injury. Debate continues on the use
of routine versus selective cholangiography, but it is
essential that all the surgeons planning to undertake
a laparoscopic cholecystectomy are experienced in
performing a cholangiogram.
Various techniques are used to perform a cholang-
iogram. Every surgeon should select the technique that
they are most familiar with. The simplest technique is
to use a cholangiogram catheter passed through a cho-
langiogram grasper. The opening in the cystic duct is
made with scissors held in the left hand of the surgeon
and passed through the medial 5 mm port in the right
upper quadrant. This ensures that the flap of duct wall
does not obstruct the passage of the catheter into the
cystic duct.
Performing routine cholangiography will ensure
that the technical skills are maintained, and the proce-
dure is performed in optimal time as the necessary
22 Gallbladder Surgery: Laparoscopic Cholecystectomy and Management of Bile Duct Stones in the Rural Setting 175

setup and support staff is ready and prepared to under-

take the procedure. Several publications, however,
challenge the routine use of intraoperative cholangiog-
raphy. Additional costs and time needed for this proce-
dure as well as the risk of false positive findings must
be balanced against the potential benefits.

22.6.1 Interpretation of Results

Every experienced surgeon advises that performing

a cholangiogram is of no use if it is not interpreted
properly by the operating surgeon.

22.6.1.1 What Should Be Seen?

A complete anatomy of the biliary tree has to be

visualised.
This includes the right and left hepatic ducts and
the common hepatic and bile ducts. Opacification of
the segmental ducts should be sought as well. Attention Fig. 22.6 Intraoperative cholangiogram
should also be paid to delineating any filling defects
within any portion of the bile duct.
Flow of contrast into the duodenum should also be
visualised (Fig. 22.6).
Non opacification of the supracystic portion of the
bile duct should NEVER be accepted and persistent
attempts should be made to achieve a complete picture
of the biliary tree. Non visualisation of any portion of
the biliary tree despite manoeuvres like the Trendelenberg
position to opacify proximal ducts is a failure to define
the anatomy clearly and therefore an absolute indica-
tion to convert to open surgery (Fig. 22.7).

Summary
›› Evidence suggests that routine use of cholang-
iography reduces the risk of bile duct injury.
›› Surgeons should use techniques that they are
comfortable with and standardise them.
›› All attempts should be made to achieve a ‘com-
plete’ cholangiogram when one is performed
– an incomplete cholangiogram is a definite
indication for open conversion.
Fig. 22.7 Non-opacification of the supracystic portion of the
biliary tree – absolute indication for open conversion
176
22.7 Other Strategies to Avoid Bile
Duct Injury
A. All surgeons undertaking the procedure should be
aware of the risk factors for bile duct injury such as
acute cholecystitis, repeated attacks of pain, gall
stone pancreatitis, Mirizzi syndrome, and post
ERCP. Surgeons should ensure adequate assistance
and take extra care to perform a methodical dissec-
tion in these situations. A low threshold for open
conversion is advisable in the presence of these pre-
dictive factors and this should not be viewed as a
complication but rather as a means to avoid a seri-
ous complication.
B. Awareness of various anatomical variations of the
biliary tree and the hepatic vasculature is vital.
These aberrations are present in about 10% of
patients. Most commonly, an aberrant/accessory
right posterior sectoral duct joins the common
hepatic duct. This can easily be mistaken for the
cystic duct and divided if due care is not taken.
Incorrect heuristic perceptions are responsible for a
fair proportion of bile duct injuries and a second
opinion should be sought in case of any doubts
regarding the anatomy, although this is not always
possible in the rural setting. A cholangiogram
through direct puncture of the gallbladder can be
valuable in delineating the anatomy and should be
considered before any further dissection is per-
formed. A liberal view towards open conversion is
justified in these circumstances.
C. Diathermy injuries are not uncommon and judi-
cious use of diathermy in dissection of the Calot’s
triangle is advocated. Coagulation of small volumes
of tissues in short bursts is important. The cystic
duct should not be dissected/divided with dia-
thermy. This causes thermal necrosis deep to the cut
surface of the duct and will lead to a biliary leak.
D. Tenting of the CBD due to excessive traction on the
gallbladder can lead to bile duct injury, especially
when there is an inflamed gallbladder with a short
cystic duct. Awareness of this possibility is essen-
tial and if injury is detected, attempts should be
made to establish the critical view of safety.
Excessive force and traction in retraction of the
gallbladder should be avoided.
H.A. Kanhere and A.D. Strickland
E. Traction to the Hartman’s pouch should be applied
laterally and outwards carrying the gallbladder away
from the liver. This opens up the angle between the
cystic duct and the CBD and helps in achieving
the critical view of safety. A cranial retraction of the
Hartman’s pouch should be avoided as it closes this
angle and aligns the CBD and the cystic duct in a
straight line, thus appearing as a single structure and
potentially leading to misidentification injuries.
F. Intraoperative Cholangiogram – as discussed above,
two large population-based studies have inferred
that routine intraoperative cholangiography reduces
the risk of bile duct injury. This is by virtue of defin-
ing the anatomy before any structure is divided.
Once Calot’s triangle is dissected and a normal cholan-
giogram is obtained, the cystic artery and duct are
clipped and divided. The gallbladder is then dissected
off the liver using diathermy and ‘flagging’ it to divide
the peritoneum anteriorly and posteriorly. This plane is
generally avascular.
Drains – There is no evidence to support or refute
the routine use of drains in laparoscopic cholecystec-
tomy, and so this practice is generally driven by the
surgeon’s personal preference. While operating in a
regional centre, however, a somewhat liberal use of
drains may be justifiable. Drains do not prevent com-
plications like bile leaks or bleeding, but their presence
may alert the surgeon/nursing staff to these complica-
tions earlier in the postoperative period. This essen-
tially helps to deal with these complications much
earlier and quicker transfer to a tertiary centre will be
facilitated.
Summary
›› Awareness of the risk factors for bile duct
injury is vital. Extra care and meticulous
­dissection is required in these situations. Early
decision for open conversion can avoid a
potentially serious complication.
›› Awareness of aberrations of biliary anatomy.
›› Judicious use of diathermy and traction in the
dissection of Calot’s triangle.
›› Routine cholangiography.
22 Gallbladder Surgery: Laparoscopic Cholecystectomy and Management of Bile Duct Stones in the Rural Setting
22.8 Postoperative Care
Surgeons have to ensure proper postoperative care by
undertaking postoperative ward rounds and document-
ing detailed instructions regarding patient care as well
as being aware of the capabilities of nursing and sup-
port teams within this context. This is critically impor-
tant in the rural setting where resident surgical staff is
often not readily available.
Clear instructions should be provided to the nursing
staff regarding recording vital signs and observations.
A low threshold should be maintained in alerting the
surgeon to any possible complication(s). It is vitally
important to detect problems as early as possible and
therefore one of the strategies may be to use drains to
diagnose bile leak/bleeding as alluded to earlier. Good
clinical examination and close monitoring however are
indispensable.
22.9 Complications: Detection
and Management Protocol
Complications of LC include bleeding, biliary leak
and bile duct injuries.
22.9.1 Bleeding
Care should be taken during surgery to ensure a secure
application of the clips by closing the jaws of the appli-
cator firmly after the clip has completely occluded the
artery. Postoperative bleeding may necessitate urgent
intervention which may be in the form of a laparos-
copy or open exploration. Every attempt should be
made to resuscitate the patient with IV fluids, oxygen,
and regular monitoring. Blood transfusion should be
organised if warranted.
Haemodynamically unstable patients should be
­re-explored with the approach guided by the surgeon’s
expertise. A bleeding cystic artery stump can often be
controlled with laparoscopic exploration, washout and
re clipping or applying endoloops. An open approach
is always safe should the surgeon feel that laparoscopy
177
would be logistically difficult to organise in the emer-
gency setting as is often the case in the rural centres.
As discussed in the preceding sections, a well-defined
pathway for transfer to a tertiary care centre should be
in place in case the need arises.
22.9.2 Bile Duct Injuries
Bile duct injuries should never be dealt with surgically
or otherwise at regional centres unless hepatobiliary
expertise is available. Repair by a specialist hepatobil-
iary surgeon other than the one performing the LC is
advocated. There is a high rate of vascular injuries asso-
ciated with CBD injury and consequently a high stric-
ture rate if a hepaticojejunostomy is performed with the
distal bile duct. Multidisciplinary input is invaluable in
decision making and complex surgery (proximal
Hepaticojejunostomy/lateral hepaticojejunostomy with
the segment III duct) will often be required.
If a bile duct injury is suspected, a specialist hepa-
tobiliary surgical opinion should be immediately
sought before proceeding to perform any further
manoeuvres like T tube insertions. Use of T tubes in a
nondilated duct with an associated element of vascular
injury will predispose to stricture formation in the long
term. A primary repair (lateral hepaticojejunostomy to
a segment III duct) may be preferable in such situa-
tions. Large bore drains should be placed to prevent
biliary contamination of the peritoneum. Arrangements
for an urgent transfer to a hepatobiliary centre should
be made. Adequate information should be provided to
the patient. Early repairs of bile duct injuries can be
carried out if the patient is transferred within 24 h of
the surgery and generally have good results. As is
many times the case, bile duct injuries are not diag-
nosed intraoperatively and a high index of suspicion of
bile leak should be maintained in anyone who ‘appears
unwell’ on the first postoperative day.
22.10 Management of CBD Stones
CBD stones can pose a therapeutic dilemma in the
rural setting.
178
A diagnosis of CBD stones is made on the basis of
clinical, biochemical and radiological grounds.
A detailed history and clinical examination are indis-
pensable. A history of recent episode of jaundice, high
coloured urine and pale stools will alert the surgeon to
this possibility.
Every patient should have liver function tests car-
ried out prior to surgery. CBD stones may not always
be seen on an ultrasound examination, but a dilated
CBD in combination with elevated liver function tests
should always be regarded as suspicious. CBD stones
should therefore be presumed to be present in patients
with clinical evidence/history of jaundice, raised liver
function tests and a dilated CBD in presence of gall
stones. Further investigations (CT scan/MRCP) can be
carried out if clinically warranted and facilities are
available.
The various options available for management of
CBD stones include
A. Preoperative ERCP followed by cholecystectomy
B. Laparoscopic transcystic bile duct exploration with
removal of stones and cholecystectomy
C. Laparoscopic choledocotomy and extraction of
stones with choledocoscopy and cholecystectomy
D. Open bile duct exploration
Most institutes have protocols for management of
CBD stones depending on the resources available.
A. Preoperative ERCP is an effective option of remov-
ing stones from the CBD. ERCP has a success rate
of almost 90% in stone extraction. It does have the
potential short-term side effects of bleeding and
pancreatitis and the theoretical risk of long-term
sequelae from a sphincterotomy. False negative
results are also known. If facilities are not available
to perform an ERCP, a transfer to a tertiary centre
should be undertaken preoperatively. Postoperative
ERCP should not generally be relied upon if CBD
stones are diagnosed preoperatively.
B. Where technical skills and equipment are available,
laparoscopic transcystic bile duct exploration and
stone extraction is an excellent option. The obvious
advantage is a single stage treatment as well as
reduction in the number of unnecessary ERCPs
with the attendant risks. This is a cost-effective,
safe and efficacious procedure if performed by
experienced surgeons.
H.A. Kanhere and A.D. Strickland
The basic principle of a laparoscopic transcystic
bile duct exploration is to pass a balloon trawling
catheter/basket into the CBD through the cystic
duct. A cholangiogram is performed to confirm the
presence of bile duct stones. The cholangiogram
catheter is then withdrawn, and the balloon cathe-
ter/basket is passed down into the bile duct through
the cholangiograspers. The catheter is negotiated
beyond the stones, the balloon is inflated and the
stones are trawled out.
A transcystic exploration is certainly possible in the
rural setting and does not require many specialised
instruments. Large and impacted stones however
are difficult to extract by this technique.
C. Laparoscopic choledocotomy and formal CBD
exploration is a relatively specialised procedure. It
requires expertise in specialised laparoscopic skills
on the part of the surgeon. Not only is surgical skill
important but the assistant needs to be well trained
in using specialised equipment like a choledocho-
scope. However, if all these prerequisites are met, it
is feasible to perform this procedure in the rural and
regional centres.
An Australian study performed on 1,567 consecu-
tive patients undergoing laparoscopic cholecystec-
tomy in rural hospitals found 82 (5.2%) cases with
choledocholithiasis at intraoperative cholangiogra-
phy. A total of 86 laparoscopic CBD explorations
were undertaken in these patients with 37 (43%) via
a transcystic approach and 49 (57%) via a laparo-
scopic choledochotomy. All CBD calculi were suc-
cessfully removed in 78 cases, representing an
overall duct clearance rate of 90.7%. Complications
were noted in seven patients which represents a
morbidity rate of 8.5%. Median operative time for
the procedure over the study period was 173 min.
Median hospital stay was 6 days for all patients.
The authors conclude that laparoscopic CBD explo-
ration can be successfully undertaken in a rural set-
ting by general surgeons who have appropriate
laparoscopic experience, and should be the proce-
dure of choice for the management of choledo-
cholithiasis in these patients. It should not be
restricted to specialised surgical departments in
major referral centres.
Authors like Vecchio and others though advise cau-
tion as the technique requires proficiency in
advanced laparoscopic skills including suturing,
22 Gallbladder Surgery: Laparoscopic Cholecystectomy and Management of Bile Duct Stones in the Rural Setting
and knot tying, as well as using equipment such as
a choledochoscope, guidewire, dilators and balloon
stone extractors. Although laparoscopic CBD
exploration appears to be the most cost-effective
method to treat CBD stones, it should be empha-
sised that this procedure is very challenging and
thus should be performed by well-trained laparo-
scopic surgeons with experience in biliary surgery.
Note: Any instrumentation of the CBD should be
carried out with a longitudinal incision on the ante-
rior wall of the CBD to avoid injury to the blood
supply of the duct.
D. An open bile duct exploration with cholecystec-
tomy with or without T tube placement depending
on the size of the common duct is a safe option. The
rural surgeon has to possess skills to perform this
procedure as it is the only option available in case
logistical ration is the most reliable option if the
stones are large and/or impacted. Kochers manoeu-
vre is essential to obtain good exposure and access
to the bile duct. Stoproblems precluding any of the
other management pathways. Open bile duct
explones can be cleared with the use of a choledo-
coscope if one is available. Other options include
the use of a fogarty catheter to trawl the stones, or a
stone extraction forceps (Desjardins). Careful post-
operative care is essential. A T tube is usually used
to drain the bile duct and a subhepatic drain is
advocated.
Logistical limitations and lack of trained personnel
can preclude ERCP and laparoscopic bile duct
exploration in the rural setting. Thus, even if the
surgeon is skilled in performing these procedures,
careful consideration must be given to these aspects
of the surgery. Preoperative diagnosis of CBD
stones may therefore require transfer to a facility
where these procedures are regularly performed.
E. Postoperative ERCP should be undertaken if stones
are diagnosed at the time of intraoperative cholang-
iography and the technical expertise to perform a
bile duct exploration is not available. These techni-
cal and logistical problems are expectedly high in
the rural setting and consequently a higher rate of
postoperative ERCP is expected.
The use of a drain and endoloops to secure the
cystic duct stump in this situation is somewhat of
a surgical dogma. Although no clear evidence
179
exists to support it, this appears to be a logical
practice to prevent cystic duct stump leaks from
raised intraductal pressure (obstruction due to
stones and ERCP).
This approach does run the risk of a third procedure
being required if ERCP fails.
22.11 Summary
Laparoscopic cholecystectomy can be performed
safely and efficiently in rural and regional centres
where trained staff and expertise is available along
with all the necessary equipment. Criteria for patient
selection and protocols for management of complica-
tions should be clearly defined beforehand. Support
from a specialised hepatobiliary unit should always
be available should the need arise.
Recommended Reading
Avgerinos, C., Kelgiorgi, D., Touloumis, Z., et al.: One thousand
laparoscopic cholecystectomies in a single surgical unit
using the “critical view of safety” technique. J. Gastrointest.
Surg. 13(3), 498–503 (2009)
Fletcher, D.R., Hobbs, M.S., et al.: Complications of cholecys-
tectomy: risks of the laparoscopic approach and protective
effects of operative cholangiography: a population-based
study. Ann. Surg. 229(4), 449–457 (1999)
Flum, D.R., Dellinger, E.P., Cheadle, A., et al.: Intraoperative
cholangiography and risk of common bile duct injury during
cholecystectomy. JAMA 289(13), 1639–1644 (2003)
Hemli, J.M., Arnot, R.S., Ashworth, J.J., et al.: Feasibility of
laparoscopic bile duct exploration in a rural centre. ANZ J.
Surg. 74(11), 979–982 (2004)
Pierce, R.A., Jonnalagadda, S., Spitler, J.A., et al.: Incidence of
residual choledocholithiasis detected by intraoperative cho-
langiography at the time of laparoscopic cholecystectomy in
patients having undergone preoperative ERCP. Surg. Endosc.
22(11), 2365–2372 (2008)
Strasberg, S.M.: Avoidance of bile duct injuries during laparo-
scopic cholecystectomy. J. Hepatobiliary Pancreat. Surg.
9(5), 543–547 (2002)
Strasberg, J.M.: Error traps and vasculo-biliary injury in laparo-
scopic and open cholecystectomy. J. Hepatobiliary Pancreat.
Surg. 15(3), 284–292 (2008)
Thomson, B.N., Parks, R.W., Madhavan, K.K., et al.: Early
­specialist repair of biliary injury. Br. J. Surg. 93(2), 216–220
(2006)
Vecchio, R., MacFadyen, B.V.: Laparoscopic common bile duct
exploration. Langenbecks Arch. Surg. 387(1), 45–54 (2002)
 Liver Surgery
23
Faud Alkhoury, Christine Vancott, and Randall Zuckerman

23.1 Anatomical Considerations of the right hemiliver and the caudate lobe to the vena
cava, along with three major hepatic veins. These
major hepatic veins occupy three planes, known as
The anatomy of the liver is defined by the underlying
portal scissurae. The three scissurae divide the liver
vascular and biliary anatomy inside of the liver rather
into the four sections, each of which is supplied by a
than on surface features. At the first level, the liver is
portal pedicle; further branching of the pedicles sub-
divided into two hemilivers (right and left). At the sec-
divides the sections into their constituent segments.
ond level, it is divided into four sections (right poste-
The right hepatic vein passes between the right ante-
rior, right anterior, left medial, and left lateral). At the
rior section (segments 5 and 8) and the right posterior
third level, it is divided into eight segments, each of
section (segments 6 and 7) in the right scissura. This
which is a discrete anatomic unit that possesses its own
vein empties directly into the vena cava near the atri-
nutrient blood supply and venous and biliary drainage.
ocaval junction. The middle hepatic vein passes
The right hemiliver consists of segments 5 through 8
between the right anterior section and the left medial
and is nourished by the right hepatic artery and the
section (segment 4, sometimes subdivided into seg-
right portal vein; the left hemiliver consists of segments
ments 4a and 4b) in the central, or principal, scissura,
2 through 4 and is nourished by the left hepatic artery
which represents the division between the right
and the left portal vein. The caudate lobe, a portion of
hemiliver and the left. The left hepatic vein runs in
the liver that is separate from the two hemilivers, con-
the left scissura between segments 2 and 3 (which
sists of segment 1. The anatomic division between the
together make up the left lateral section). In most per-
right hemiliver and the left is not at the falciform liga-
sons, the left and middle hepatic veins join to form a
ment (the most readily apparent visual landmark on the
common trunk before entering the vena cava.
anterior liver), but follows a line projected through a
Occasionally, a large inferior right hepatic vein is
plane (the principal plane, or Cantlie’s line) that runs
present, which may provide adequate drainage of the
posterosuperiorly from the medial margin of the gall-
right hemiliver after resection of the left even when
bladder to the left side of the vena cava.
all three major hepatic veins are ligated [1].
The venous drainage of the liver consists of
The portal vein and the hepatic artery divide into
­multiple small veins draining directly from the back
left and right branches below the hilum of the liver.
Unlike the major hepatic veins, which run between
segments, the portal venous and hepatic arterial
F. Alkhoury and C. Vancott branches, along with the hepatic ducts, typically run
Department of Surgery, Hospital of St. Raphael,
1450 Chapel St. New Haven, CT 06511, USA centrally within segments. On the right side, the
hepatic artery and the portal vein enter the liver sub-
R. Zuckerman (*)
North Country Hospital, 189 Prouty Drive, Newport,
stance almost immediately after branching. The short
VT 05855, USA course of the right-side extrahepatic vessels and the
e-mail: rszmd@yahoo.com variable anatomy of the biliary tree make these

M.W. Wichmann et al. (eds.), Rural Surgery, 181

DOI: 10.1007/978-3-540-78680-1_23, © Springer-Verlag Berlin Heidelberg 2011
182
vessels vulnerable to damage during dissection [2]. In
­contrast, the left branch of the portal vein and the left
hepatic duct take a long extrahepatic course after
branching beneath segment 4. When these vessels
reach the base of the umbilical fissure, they are joined
by the left hepatic artery to form a triad, which then
enters the substance of the left hemiliver at this point.
It must be emphasized that proximal to the base of the
umbilical fissure, the left-side structures are not a
triad. A consequence of the long extrahepatic course
of the left-side structures is that for tumors that
involve the hilum (e.g., Klatskin tumors), when a
choice exists between an extended right hepatectomy
and an extended left hepatectomy, most surgeons
choose the former because the greater ease of dissec-
tion on the left side facilitates preservation of the left-
side structures.
23.2 Primary Cancers
23.2.1 Hepatocellular Cancer
Hepatocellular cancer (HCC), or hepatoma, is the fifth
most common cancer in the world. The most common
cause is viral hepatitis. In the United States, some 3
million people are infected with hepatitis C virus
(HCV), and more than one million people have liver
disease associated with hepatitis B virus (HBV). HCV
infection is more likely to lead to HCC than HBV
infection is.
23.2.1.1 Clinical Evaluation
The usual presentation of sporadic HCC consists of
pain, mass, and systemic symptoms of cancer, though
the disease may also be discovered incidentally.
HCC is often manifested first as a deterioration of
liver function with the onset of jaundice, ascites, or
encephalopathy.
23.2.1.2 Investigative Studies
Screening programs are employed in high-risk popu-
lations. These programs, which use a-fetoprotein
F. Alkhoury et al.
(AFP) levels and ultrasonographic examination of
the liver to detect early HCC, may detect asymptom-
atic tumors.
The diagnosis of sporadic HCC is based on eleva-
tion of AFP levels (an indicator with 50–60% sensi-
tivity) and the presence of a hepatic mass on axial
images. HCCs typically demonstrate hypervascular-
ity, pseudocapsule is often visualized, and multifo-
cality is also common in HCC, and this finding often
serves to differentiate it from other hepatic neo-
plasms. Routine biopsy is not indicated in patients
with a characteristic mass, those who have a mass
and an elevated AFP level, or those who are symp-
tomatic and require treatment for pain. Biopsy is
associated with a small risk of bleeding or tumor
seeding.
23.2.1.3 Surgical Staging
Staging of sporadic HCC requires axial imaging of
the abdomen and imaging of the chest. FDG-PET
scanning is only marginally useful: HCCs are typi-
cally well differentiated, and as a result, only 50% of
the tumors are visualized. Staging laparoscopy is
helpful: additional tumors are found in about 15% of
patients [3].
The Child-Pugh classification is used to determine
operability. With few exceptions, resection is limited
to Child class A patients with near normal bilirubin
levels (<1.5 mg/dl), a normal or marginally raised
prothrombin time (PT), and no or minimal portal
hypertension. The extent of resection must be tailored
to the severity of the liver disease. In Japan and China,
indocyanine green (ICG) clearance is used in Child
class A patients to determine the possible extent of
resection.
Partial liver resection is the procedure of choice for
sporadic HCC in patients with normal livers. In Child
class B or C patients with chronic liver disease, liver
resection can be hazardous, and orthotopic liver trans-
plantation (OLT) is the procedure of choice. OLT is
restricted to patients with a single tumor less than 5 cm
in diameter or to patients with as many as three tumors,
none of which are more than 3 cm in diameter (the
Milan criteria). These criteria have been shown to be
associated with OLT outcomes comparable to those
for benign conditions [4].
23 Liver Surgery
In Child class A patients with liver disease, hepatic
resection and OLT are options if the Milan criteria are
met. Currently, it would seem that the best strategy in
patients who meet the criteria for OLT is to perform
primary OLT for HCV-associated disease [5] and to
perform resection and salvage OLT for HBV-associated
disease [6] and other HCCs of non-HCV origin. In
patients who do not meet the OLT criteria, resection
would be performed even if the tumor is of HCV
­origin. At present, there is a trend toward liberalizing
the OLT criteria to include single tumors 6 or 7 cm
in diameter, especially if the source of the organ is a
living donor.
When OLT is to be performed, it is important that
the waiting time be short; these tumors progress over a
timescale of a few months, and when viewed on an
intention-to-treat basis, the results of OLT deteriorate
significantly if the waiting time is long [7]. In the
United States, this concern has been dealt with by
the introduction of the Model for End-stage Liver
Disease scoring system, which gives priority to recipi-
ents with HCC. It is common in the United States –
and usual in countries with longer waiting times – to
inhibit the growth of the HCC with various bridging-
to-transplantation strategies during the waiting period
for OLT. Such strategies include systemic chemother-
apy, local treatments (e.g., radiofrequency [RF] ablation
and alcohol injection), transarterial chemoemboliza-
tion, and even resection of the HCC (so-called bridge
resection).
As much as 70% of the liver may be safely excised
when normal liver function is present. The size of the
future hepatic remnant may be determined by means
of imaging. Portal Venous Embolization (PVE) of the
side of the liver to be resected may be performed pre-
operatively to increase the size of the future remnant.
It may also be used for this purpose in patients with
liver disease. In these patients, PVE functions as a test
of the liver’s ability to regenerate. Failure to respond to
PVE is itself a contraindication to surgery in patients
with chronic liver disease.
As a rule, liver resections for HCC should be ana-
tomic. Recurrence rates are higher with nonanatomic
resections because HCCs grow along portal veins and
metastasize locally within segments, sections, or
hemiliver, depending on how far they reach back along
the portal veins. When HCC reaches the main portal
vein, resection is generally contraindicated; the results
are very poor in this situation.
183
23.2.2 Intrahepatic Cholangiocarcinoma
23.2.2.1 Clinical Evaluation
Intrahepatic Cholangiocarcinomas arise from intrahe-
patic bile ducts. There are three types: a mass-forming
type (MF), a periductal infiltrating type (PI), and a type
that grows as an intraductal papillary tumor (IG). The
MF type is by far the most common. Intrahepatic CCA
tumor usually occurs in normal livers. The presenta-
tion is similar to that of sporadic HCC.
23.2.2.2 Investigative Studies
On diagnostic imaging, the appearance of intrahepatic
CCA is suggestive of a secondary tumor. Diagnosis of
intrahepatic CCA usually requires a biopsy, and special
stains may be helpful in differentiating this tumor from
a true secondary malignancy, but the differentiation is
rarely certain. An elevated CA 19–9 concentration is
strongly suggestive of this diagnosis if it is higher than
100 U/ml. To make the diagnosis of intrahepatic CCA,
primary tumors in other sites must be excluded by
means of axial imaging of the chest, the abdomen, and
the pelvis; upper and lower GI endoscopy; and mam-
mography. FDG-PET scanning is another means by
which an extrahepatic primary may be identified, but it
has not been fully evaluated in this setting.
23.2.2.3 Surgical Staging
FDG-PET scanning appears to be a promising staging
tool for identifying portal lymph node and distant
metastases when the primary is actually an intrahepatic
CCA. Portal lymph node metastases are a contraindi-
cation to resection in patients with MF tumors; the
results of resection in this situation are very poor. Left-
side tumors may metastasize to lymph nodes at the
cardia of the stomach and along the lesser curvature.
23.2.2.4 Management
The considerations related to resection for intrahepatic
CCA are similar to those for sporadic HCC (see above).
Liver transplantation generally is not performed for
this tumor, because of the typically poor results.
184
23.3 Secondary Cancers
23.3.1 Colorectal Metastases
23.3.1.1 Clinical Evaluation and Investigative
Studies
About 50% of the 150,000 patients who are diagnosed
with colorectal cancer annually in the United States
either have or will have liver metastases. About 20%
of patients with these colorectal metastases (CRMs)
are eligible for liver resection. CRMs may be diag-
nosed either at the time of treatment of the primary
colorectal cancer (synchronous tumors) or at a later
stage (metachronous tumors).
Synchronous tumors are diagnosed by means of
either, preoperative CT scanning, intraoperative pal-
pation, or intraoperative ultrasound. LFTs may show
elevations (especially of the serum alkaline phos-
phatase level), but these results are not specific. CEA
levels are not helpful as long as the primary tumor is
in place. Metachronous tumors are most often diag-
nosed in the course of a postcolectomy surveillance
program, either by imaging the liver with CT scans or
FDG-PET scans or by detecting a rise in the CEA
level. When synchronous metastases are discovered
preoperatively, a FDG-PET scan should be done to
complete the staging.
23.3.1.2 Surgical Staging
In about 25% of patients, FDG-PET scanning changes
management by detecting unsuspected extrahepatic or
intrahepatic disease. Sometimes, it demonstrates that
apparent metastases are actually benign lesions. Second
primaries are not uncommon in patients with metachro-
nous lesions; accordingly, such patients should also be
staged by means of colonoscopy, if this procedure was
not done in the preceding 6 months, as well as FDG-PET
scanning. Staging laparoscopy adds little to staging if an
FDG-PET scan has been done. Intraoperative ultrasound
of the liver may also detect unsuspected lesions, though
this is less likely if the patient has already been staged by
means of FDG-PET.
The main value of FDG-PET in this setting is its
ability to discover unsuspected extrahepatic disease. In
so doing, it helps eliminate futile hepatic resections.
F. Alkhoury et al.
If a patient with extrahepatic disease is treated with
hepatic resection, a “recurrence” is inevitable. Elimination
of pointless resections has a positive effect on survival:
The overall 5-year survival rate after FDG-PET was
about 60%, compared with 40% after conventional
imaging [8]. Furthermore, the study showed that after
FDG-PET scanning, the classic prognostic factors of the
secondary tumor (e.g., tumor number and tumor size)
were no longer significant; rather, the most important
prognostic factor was the grade of the primary tumor.
FDG-PET scanned patients with poorly differentiated
primary tumors did very poorly in terms of overall sur-
vival after hepatic resection [8]. Currently, standard PET
scanners are rapidly being replaced with CT-PET scan-
ners, which fuse the images and provide superior
­diagnosis and staging. However, the level of detail pro-
vided by high-quality, contrast-enhanced CT or MRI is
also required.
The criteria that determine eligibility for resection
are (1) that the primary tumor has been or can be com-
pletely resected, (2) that (with uncommon exceptions)
there is no extrahepatic tumor (other than the primary),
and (3) that it is possible to resect all tumors in the
liver while leaving enough of a hepatic remnant to
ensure that hepatic failure does not develop postopera-
tively. The considerations governing the extent of the
resection and the use of PVE are similar to those for
sporadic HCC.
Treatment of multiple tumors is more common with
CRMs than with HCC. However, non-anatomic resec-
tions are as effective as anatomic resections as long as
the resection margin is microscopically clear.
Synchronous resection of the primary tumor and
the liver metastases has proved to be safe [10] and is
desired by many patients. The decision to proceed
with hepatic resection should not be made until resec-
tion of the primary tumor has been completed and it
has been determined that the margins are clear and the
patient is stable.
23.3.1.3 Ablation of Colorectal Metastases
In situ destruction of tumors with cryotherapy, radio­
frequency (RF), or microwave ablation may expand
the surgeon’s ability to eradicate CRMs localized to
the liver [11]. RF ablation has largely supplanted
cryotherapy in this context as a result of its lower
incidence of complications and greater ease of use.
23 Liver Surgery
Ablation may be used either as an adjunct to opera-
tive management or as the sole treatment when there
are many metastases (but usually < 10). The efficacy
of RF ablation as an adjunct to surgery remains to be
determined. It is doubtful, however, that using this
modality alone to eradicate multiple lesions will
improve overall survival significantly, because the
tumor biology in such cases is likely to be that of an
aggressive tumor. FDG-PET scans should be per-
formed in all such patients; the likelihood of discov-
ering extrahepatic tumors increases as the number of
hepatic tumors increases [8].
RF ablation is not recommended for treatment of
resectable metastases: it is not approved for this pur-
pose, and using it in this way would mean substituting
an unproven therapy of unknown efficacy for a proven
therapy of known value.
23.3.2 Neuroendocrine Metastases
Neuroendocrine metastases are characteristically slow
growing. Some are functional, especially if they arise
from the ileum; metastatic liver disease from this
source may produce carcinoid syndrome. OctreoScan
provides staging information comparable to that pro-
vided by FDG-PET in patients with CRMs.
The aims of surgical treatment are (1) to eradicate
the cancer and (2) to reduce hormonal symptoms.
Resection should be performed if all cancer can be
removed and no extrahepatic cancer is detectable. In
highly symptomatic patients in whom conservative
therapy with octreotide has failed, debulking the tumor
by means of either chemoembolization or surgery may
provide relief. The former is more suitable for patients
with multiple small, diffuse metastases, whereas the
latter is preferred for patients with large localized
tumors.
23.3.3 Noncolorectal,
Nonneuroendocrine Metastases
Occasionally, liver metastases from other primary sites
behave like CRMs, in that they are localized to part of
the liver in the absence of extrahepatic disease. Such
185
patients can be managed according to the same approach
employed for CRMs, though the outcome is somewhat
less satisfactory. Tumors that have been treated in this
way with acceptable results include breast cancers,
renal cell cancers, gastric cancers, acinar cell cancers
of the pancreas, and ovarian cancers, and sarcoma.
Liver resection for more aggressive malignancies
(e.g., metastases from gallbladder cancer and pancre-
atic ductal adenocarcinomas) can be expected to yield
very poor results.
23.4 Incidentally Discovered
Asymptomatic Hepatic Mass
Now that transaxial imaging of the abdomen is com-
monly performed for a variety of complaints, the
­problem of the incidentally discovered asymptomatic
hepatic mass is being encountered with increased fre-
quency. Generally, cysts are easily distinguished from
solid tumors; the main diagnostic issue is differentia-
tion of the various solid lesions.
The differential diagnosis of the benign solid
hepatic mass includes hepatic adenoma, focal nodu-
lar hyperplasia (FNH), focal fatty infiltration, cav-
ernous hemangioma, and other rare neoplasms (e.g.,
mesenchymal hamartoma and teratoma) – all of
which must be distinguished not only from one
another but also from malignant tumors. In the past,
several diagnostic tests (e.g., ultrasonography, CT,
sulfur colloid scanning, and angiography) were used
to differentiate these neoplasms. Currently, many
perform MRI with gadolinium contrast enhance-
ment, which generally allows accurate differentia-
tion among benign tumors with a single test.
Cavernous hemangiomas are usually easy to distin-
guish because they have a characteristic appearance
on MRI (hypointense on T1-weighted images, very
intense on T2-weighted images, and filling in from
the periphery with gadolinium injection); if they are
asymptomatic, they need not be resected. It is impor-
tant to distinguish asymptomatic FNHs from hepatic
adenomas: whereas resection is recommended for
adenomas, because of their potential for hemorrhage
or malignant degeneration, asymptomatic FNHs can
safely be observed. An FNH is nearly isointense on
T1- and T2-weighted images; it shows slightly more
186
enhancement than normal liver parenchyma in the
early phase after contrast injection, and then becomes
isointense. A central scar is often, but not always,
seen. Conversely, a hepatic adenoma exhibits strong
early phase enhancement with contrast administra-
tion, and it tends to be hyperintense on T1-weighted
images.
Given that a symptomatic hepatic mass is usually
treated with resection, preoperative biopsy for tissue
diagnosis is rarely necessary or desirable. Modern
noninvasive radiologic tests, in conjunction with a
careful patient history, are often quite accurate in pre-
dicting histologic diagnosis. As a rule, biopsies
should be performed when definitive surgical inter-
vention is not planned and when pathologic confir-
mation is necessary for institution of nonsurgical
therapy.
23.4.1 Techniques/When to Refer
There has been advancement in the technology avail-
able for liver resection. Crush and clamp techniques
are still widely used and effective. Energy devices such
as ultrasonic shears and ligasure are very effective for
transecting the first few centimeters of liver in a blood-
less fashion. RF devices are very expensive but useful
as well [9]. Endo-GIA staplers are becoming routine
for parenchymal transection and are very good for con-
trolling large vessels and bile ducts.
For peripheral lesions and non-anatomic resections,
if experienced and comfortable, a surgeon could
approach these in a rural center. For resections involv-
ing more than two segments or in diseased liver, refer-
ral to a specialist surgeon is advisable.
F. Alkhoury et al.
References
1. Baer, H.U., Dennison, A.R., Maddern, G.J., et al.: Subtotal
hepatectomy: a new procedure based on the inferior right
hepatic vein. Br. J. Surg. 78, 1221 (1991)
2. Smadja, C., Blumgart, L.H.: The biliary tract and the anat-
omy of biliary exposure. In: Blumgart, L.H. (ed.) Surgery of
the Liver and Biliary Tract, 2nd edn. Churchill Livingstone,
London (1994)
3. Lo, C.M., Lai, E.C., Liu, C.L., et al.: Laparoscopy and lap-
aroscopic ultrasonography avoid exploratory laparotomy in
patients with hepatocellular carcinoma. Ann. Surg. 227, 527
(1998)
4. Mazzaferro, V., Regalia, E., Doci, R., et al.: Liver transplan-
tation for the treatment of small hepatocellular carcinomas
in patients with cirrhosis. N. Engl. J. Med. 334, 693 (1996)
5. Adam, R., Azoulay, D., Castaing, D., et al.: Liver resection
as a bridge to transplantation for hepatocellular carcinoma
on cirrhosis: a reasonable strategy? Ann. Surg. 238, 508
(2003)
6. Poon, R.T., Fan, S.T., Lo, C.M., et al.: Long-term survival
and pattern of recurrence after resection of small hepatocel-
lular carcinoma in patients with preserved liver function:
implications for a strategy of salvage transplantation. Ann.
Surg. 235, 373 (2002)
7. Llovet, J.M., Fuster, J., Bruix, J.: Intention-to-treat analysis
of surgical treatment for early hepatocellular carcinoma:
resection versus transplantation. Hepatology 30, 1434
(1999)
8. Fernandez, F.G., Drebin, J.A., Linehan, D.C., et al.: Fiveyear
survival after resection of hepatic metastases from colorectal
cancer in patients screened by positron emission tomogra-
phy with F-18 fluorodeoxyglucose (FDG-PET). Ann. Surg.
240, 438 (2004)
9. Topp, S.A., McClurken, M., Lipson, D., et al.: Salinelinked
surface radiofrequency ablation: factors affecting steam
popping and depth of injury in the pig liver. Ann. Surg. 239,
518 (2004)
10. de Santibanes, E., Lassalle, F.B., McCormack, L., et al.:
Simultaneous colorectal and hepatic resections for colorec-
tal cancer: postoperative and longterm outcomes. J. Am.
Coll. Surg. 195, 196 (2002)
11. Strasberg, S.M., Linehan, D.: Radiofrequency ablation of
liver tumors. Curr. Probl. Surg. 40, 459 (2003)
 Pancreatic Surgery
24
Markus Trochsler, Thomas Satyadas, and Harsh A. Kanhere

24.1 Introduction setting. These include necrosectomy in the context of

acute necrotizing pancreatitis, management of pseudo-
cysts and initial management of pancreatic trauma.
The pancreas is a unique organ with complex anatomy
This chapter focuses mainly on these procedures.
and physiology. It is difficult to access because of its
A brief outline of surgical management of pancreatic
deep retroperitoneal location. The gland itself is very
neoplasms will be provided for the interested reader.
vascular and often very soft and friable. It has a very
close relationship with major blood vessels and the
common bile duct. Performing surgery on the pancreas
can thus be very challenging. In the modern era, most 24.2 Relevant Surgical Anatomy
pancreatic pathologies are referred to tertiary-level
metropolitan hospitals due to these reasons.
The pancreas is a deep-seated retroperitoneal organ
Interestingly though, pancreatic surgery seems to
that is difficult to access. It lies across the spinal
have its roots in rural Germany. Friedrich Wilhelm
­column at the level of the 1st to 3rd lumbar vertebrae
Wandesleben (1800–1868), a small-town German
extending from the C-loop of the duodenum to the
physician, performed the first reported surgical
hilus of the spleen. The splenic artery and vein run
­procedure on the human pancreas. In November
along its cranial–dorsal border. The superior mesen-
1841, he surgically drained a traumatic pancreatic
teric artery originates dorsal to the body of the pan-
pseudocyst. Pancreatic cancer was first surgically
creas. The superior mesenteric vein runs upwards
tackled by pancreaticoduodenectomy, performed by
and to the left, to join the splenic vein behind the
Walter Kausch in 1912 and further modified by A.O.
neck of pancreas and forms the portal vein. The com-
Whipple in 1934.
mon bile duct descends posterior to the head of the
Most common surgical conditions of the pancreas
pancreas and enters the duodenum with the pancre-
include acute and chronic pancreatitis, trauma and
atic duct.
neoplasms. The inflammatory conditions often require
The pancreas shares its blood supply with the duo-
conservative treatment and the neoplasms are best
denum from the common hepatic and superior mesen-
managed in tertiary referral centres with multidisci-
teric artery. It is drained by the superior mesenteric and
plinary teams. Nevertheless, some pancreatic patholo-
the splenic vein. A plethora of peripancreatic lymph
gies can be successfully managed in a rural surgical
nodes primarily drain the organ and further drain –
from right to left – into subpyloric, portal, mesenteric,
mesocolic and aortocaval nodes.
The close anatomic relationship of the friable pan-
M. Trochsler (*), T. Satyadas, and H.A. Kanhere creas with these major intestinal blood vessels makes
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
bleeding a major concern in pancreatic surgery and
e-mail: markus@trochsler.ch, gensurg2000@yahoo.co.uk, trauma. Furthermore, the relative rigid fixation of the
drhakanhere@hotmail.com head of the pancreas in the C-loop of the duodenum

M.W. Wichmann et al. (eds.), Rural Surgery, 187

DOI: 10.1007/978-3-540-78680-1_24, © Springer-Verlag Berlin Heidelberg 2011
188
allows only minimal movement of the organ, and
therefore, makes it vulnerable to blunt trauma, espe-
cially over the spinal column.
24.3 Surgical Access to the Pancreas
The pancreas is best approached transperitoneally.
Various incisions can be used to provide good access
to the pancreas. The choice of incision depends on the
patient’s body habitus, the type of pathology and the
region of the pancreas to be accessed.
A midline laparotomy provides good access to the
pancreas and furthermore enables the surgeon to adapt
to the intra-abdominal findings, especially in case of
emergent surgery in trauma or acute pancreatitis.
Tumours and pathologies in the body and tail of the
pancreas can be best accessed by a left subcostal inci-
sion with a right-sided extension if required. A right
subcostal incision with a left-sided extension (roof top
incision) provides excellent access to the head of the
pancreas and the portal triad, making this a preferable
approach in pancreaticoduodenectomies.
The organ itself is accessible at its retroperitoneal
location using a combination of three manoeuvres.
The division of the gastrocolic ligament will pro-
vide access to the lesser sac to expose the body and tail
of the pancreas. The view may be limited if a generous
opening is not performed.
The access to the head of the pancreas is further gained
by performing a liberal Kocher’s manoeuvre. Incising the
peritoneum lateral to the duodenum and blunt dissection
in an avascular plane between the inferior vena cava and
the C-loop of the duodenum will provide access to the
dorsal surface of the pancreatic head. This may be com-
bined with the division of the ligament of Treitz to expand
the view to the dorsal aspect of the pancreas.
The opening of the gastrocolic omentum by divid-
ing it along the colonic wall to enter the lesser sac will
exhibit the ventral pancreatic surface in its entire
extent. The initial opening should be made towards the
left lateral aspect where the two layers of the omentum
are separate and easy access to the lesser sac can be
gained. This technique opens the lesser sac completely
and will allow the assessment of the whole organ. The
third approach combined with the Kocher manoeuvre
will allow the most comprehensive access to the pan-
creas without devascularisation of the pancreas.
M. Trochsler et al.
24.4 Necrotising Pancreatitis
24.4.1 Nonsurgical Management
Acute pancreatitis is managed conservatively when-
ever possible. This may require immediate transfer
of the patient to a tertiary care facility with a fully
equipped intensive care unit (ICU) and the possibility
of invasive monitoring (central venous or Swan-Ganz
monitoring catheter). The role of surgical intervention
in management of sterile pancreatic or peripancreatic
necrosis is controversial. In a controlled and stable
clinical situation, nonoperative treatment is favoured.
There is, however, a general consensus that some form
of intervention is required in patients with infected
necrosis – indicated by clinical suspicion, extraintesti-
nal gas bubbles or positive cultures on fine needle
­aspiration. These may include in selected patients anti-
biotics alone, or antibiotics with endoscopic drainage
or antibiotics with CT-guided percutaneous drainage.
One has to remember that the paste-like necrotic pan-
creas tissue is difficult to drain completely by small-
diameter drainage catheters.
24.4.2 Indication for Surgery
Rapid clinical deterioration with the onset of or manifest
multiorgan failure despite maximal supportive therapy
demands for immediate surgical intervention. This may
be indicated by worsening of known pancreatitis scores,
rising C-reactive protein in the presence of necrotic
and infected pancreatic tissue. The timing of the initial
surgical intervention seems to be closely related to the
outcome. Delaying the operative intervention, if possi-
ble, may lead to better demarcation of the necrosis, and
therefore, may help to distinguish between necrotic and
viable pancreatic tissue. The timing has to be ultimately
dictated by the patient’s clinical condition.
24.4.3 Surgical Management
The goal of the intervention is to remove as much as
possible of the infected necrotic tissue and provide
sufficient drainage for the remaining viable pancreatic
24 Pancreatic Surgery
tissue. The best approach is a midline or subcostal
laparotomy. Division of the gastrocolic ligament will
allow good access to the pancreas. Necrosis of the pan-
creatic tissue may not be distinguishable from necrotic
peripancreatic tissue. First step is to obtain a swab for
microbiological analysis. The fibrous capsule of the
pancreas is divided. Necrotic tissue is carefully excised.
Often blunt finger dissection will be the best technique
to achieve this goal. Vital pancreatic tissue with good
capillary bleeding should be spared. Necrosis may
extend not only in the retroperitoneal and retrocolic
space but also caudally along the base of the ­mesentery.
The superior mesenteric and splenic veins are identi-
fied and very carefully safeguarded to prevent trouble-
some bleeding, which is difficult to control. Diffuse
bleeding may make open packing necessary. After
debriding necrotic tissue and achieving hemostasis,
closed local irrigation with 6–8 L/day physiological
saline through an indwelling double-lumen catheter
should be commenced. This is continued until no dis-
charge of necrotic tissue is observed. This technique
will normally allow abdominal wall closure.
In certain circumstances like abdominal compart-
ment syndrome, the retroperitoneal space and the lesser
sac should be packed following necrosectomy. Open
drainage is achieved by laparostomy and the procedure
will need to be repeated every 2–3 days until abdominal
wall closure can be achieved. At the time of final debri-
dement, drains and a feeding jejunostomy are placed.
High-level care is essential for appropriate post-
operative care as sepsis and shock very commonly
accompany this scenario and measures should be
undertaken to transfer patients to institutes where such
facilities are available.
24.5 Pseudocysts
24.5.1 Nonsurgical Management
The presence of a pancreatic pseudocyst in itself is not an
absolute indication for intervention. Recent reports have
shown that many pseudocysts eventually resolve without
complications. Large pseudocysts (>6 cm in diameter),
however, are less likely to resolve spontaneously.
Indications for intervention include pseudocysts
that give rise to abdominal symptoms (e.g. pain, ­gastric
189
outlet obstruction), increase in size or are associated
with complications (i.e. bleeding, infection).
Various options are available for drainage and the
choice depends primarily on location of the pseudo-
cyst as well as the locally available expertise.
(a) Percutaneous drainage may be considered in poor
surgical risk patients and in the absence of endo-
scopic expertise. The major drawback is the risk of
catheter-induced infection and development of an
external pancreatic fistula.
(b) Internal drainage can be accomplished endoscopi-
cally. Depending on the anatomic location of the
pseudocyst, drainage may be achieved endoscopi-
cally by transpapillary drainage, cystogastrostomy
or cystoduodenostomy. This approach requires
advanced endoscopic expertise in endoscopic
ultrasound, which may not be available locally.
(c) Surgical indications include enlarging, symptom-
atic and complicated pancreatic pseudocysts.
Timing of surgery is determined by the maturity of
the cyst wall. As the tissues holding the sutures
must be firm, it is desirable to avoid surgery within
the first 6–10 weeks after the onset of an acute
­pancreatitis. Ultrasonography and CT is of great
value to monitor the ‘maturity’ of the pseudocyst.
24.5.2 Surgical Management
Surgical internal drainage of pseudocysts is usually
accomplished by Roux-en-Y cystojejunostomy, a side-
to-side cystogastrostomy, or as side-to-side cystoduo-
denostomy. The close anatomic relation of pseudocysts
to the stomach and the duodenum allows easy internal
drainage into these organs.
A cystgastrostomy is the simplest of these proce-
dures and can be accomplished in the rural setting
without great difficulty. A midline laparotomy is gen-
erally preferred but a left or right subcostal incision
will provide good access as well. After the abdomen is
explored for the presence of collections, an anterior
gastrotomy is performed. The posterior wall of the
stomach is opened on the dome of the cyst preferably
with a diathermy. The cyst wall and the posterior wall
of the stomach are fused together in a fully mature
cyst. Thus, opening the posterior wall of the stomach
provides direct access to the contents of the cyst. The
190
cyst is evacuated with suction and biopsies from the
cyst wall should be taken. The opening is extended for
about 5 cm and the cystgastrostomy is completed with
absorbable monofilament sutures. Care should be
taken to confirm hemostasis and wide-bore drains can
be placed in the region if deemed necessary.
Roux-en-Y cystojejunostomy can be considered as a
universal surgical approach for pancreatic pseudocysts.
Access is gained through a subcostal incision, ideally
located over the palpable pseudocyst. Division of the
gastrocolic ligament will allow good access to the pan-
creas dorsal of the lesser sac. Confirm the location of
the pseudocyst by palpation and by aspiration with an
18-gauge needle. Palpate the pseudocyst to make sure
that that there is no pseudo aneurysm. Should this be
the case, angiography and embolisation of the aneu-
rysm should be performed preferably preoperatively.
Resection of the pseudocyst can be a complex proce-
dure and hence good preoperative imaging is of utmost
importance. Palpation can confirm the maturity of the
pseudocyst and confidence of obtaining a firm tissue
base for the anastomosis. The pseudocyst is widely
incised (>5 cm), the cystic fluid aspirated and hemosta-
sis of the cystic wall confirmed. The pseudocystic con-
tent is inspected and eventual necrotic tissue is carefully
removed. A full thickness biopsy specimen of the wall
is obtained. A Roux-en-Y loop of jejunum is con-
structed, and the Roux limb is preferably placed
­retrocolic to the left of the middle colic artery, where
the transverse mesocolon is essentially avascular.
A wide two-layer anastomosis between the pseudocyst
and the blind end of the Roux loop is constructed using
interrupted sutures for the inner and outer layer. This
anastomosis as any pancreatic anastomosis must be
constructed with meticulous care to prevent leakage of
aggressive pancreatic juice. We recommend to drain
the procedure site using a large-diameter silicon drain.
24.6 Pancreatic Trauma
24.6.1 Nonsurgical Management
Due to its protected location, trauma to the pancreas is
rare. Nevertheless, 3–12% of patients with severe
abdominal trauma (blunt or penetrating) have pancre-
atic injury. Mechanism of trauma and progressive rising
M. Trochsler et al.
of serum amylase activity may indicate pancreatic
injury. Contrast-enhanced CT is the most useful non-
invasive diagnostic tool to detect pancreatic injury. The
management of pancreatic injuries depends on the pres-
ence of pancreatic duct injury or major peripancreatic
vascular bleeding. Minor contusions or lacerations of
the pancreas without duct injury may be treated by
observation only. If locally available and under stable
clinical conditions, peripancreatic vascular injuries may
be treated with angiography and embolisation.
24.6.2 Indications for Surgery
Major contusion without duct injury, pancreatic duct
injuries, pancreatic transsections, massive disruptions
and vascular injury necessitate immediate exploratory
laparotomy. Clinical deterioration of patients with
minor pancreatic injuries require surgical intervention.
24.6.3 Surgical Management
Midline laparotomy is the access of choice in patient
with pancreatic trauma. Division of the gastrocolic
ligament and a Kocher manoeuvre will allow optimal
assessment of the pancreas. Packing of the lesser sac
may help to control haemorrhage and facilitate evalua-
tion of the extent of damage. Major lacerations of the
pancreas without duct injury are traditionally treated
by debridement of necrotic tissue, adequate haemosta-
sis, and placement of thick diameter silicon drains.
Some authors advocate covering the disrupted capsule
of the pancreas using an omental patch. Injuries involv-
ing the body, neck and the tail of the pancreas, and
those with high suspicion or evidence of pancreatic
duct injury, are treated best with distal pancreatectomy
left of the injured duct. Spleen preserving procedures
are advocated but depending on clinical situation,
­presence of other injuries and surgical expertise, the
procedure may include a splenectomy.
Injuries to the head of the pancreas are most chal-
lenging, because they often involve the duodenum,
major intestinal blood vessels and the papilla of Vater.
In a damage control approach, the goal in these multi-
ply injured patients is to obtain hemostasis, minimize
24 Pancreatic Surgery
contamination and repair associated injuries. Along
with this, simple external drainage even in the pres-
ence of a pancreatic duct disruption as a first approach
is ­recommended. A small-diameter percutaneous
silicon tube inserted into the pancreatic duct may be
very useful to temporally prevent intra-abdominal pan-
creatic juice leakage. In the presence of concomitant
duodenal injury, pyloric exclusion with gastrojejunos-
tomy should be considered. A feeding jejunostomy
should be performed whenever feasible. A definitive
repair may be postponed until the patient’s condition
has improved, and should preferably be carried out at
a tertiary hospital.
24.7 Pancreatic Neoplasms
24.7.1 Introduction
Pancreatic resection is the only modality of treatment
that can provide reasonable survival and in a propor-
tion of cases, a potential for cure in cases of pancreatic
cancer. Pancreatic surgery is very challenging and tech-
nically demanding. Availability of expertise in multiple
specialties is essential to achieve good outcomes.
Over the last few decades, there has been a reduc-
tion in the mortality associated with this operation
from more than 40% to less than 5% and indeed in
specialized institutions, the mortality rate is close to
1%. This is a reflection of increasing specialization not
just among surgeons, but the other personnel involved
in the care of the patient, the gastroenterohepatologists,
intensive care physicians, anaesthetist, interventional
radiologists, dietetic services and the physiotherapists.
Modern medicine dictates that all patients with suspi-
cious periampullary or pancreatic malignancy are dis-
cussed in a multidisciplinary team (MDT) setting,
which involves all these specialties.
The rural surgeon will mostly be involved with the
preoperative workup in such scenarios. This involves
assessment of resectability and fitness for the proce-
dure. Old age in itself is not a contraindication to
­pancreatic resection and there is increasing body of evi-
dence suggesting good post-operative outcomes even
in octogenarians. It is mandatory that these patients
with lesions in the pancreas are discussed in the MDT
191
with up to date multislice, double-contrast CT scans.
Endoscopic ultrasound has shown promise in improv-
ing local staging and obtaining tissue for diagnosis.
A percutaneous biopsy or aspiration cytology
should NOT be performed if the disease is localized.
Assessment of fitness will invariably include an
echocardiography and pulmonary function tests.
24.7.2 Resection
Only a brief outline of the operative procedure will be
provided as this surgery should ideally not be per-
formed in the rural setting. The following description
is primarily intended to outline the importance of
­preoperative assessment of resectibility.
Laparotomy is done by a midline, upper abdominal
transverse/rooftop or a reverse L incision. We prefer a
transverse/rooftop incision. A thorough assessment is
done to exclude any peritoneal or liver metastasis.
The next step is to assess resectibility. An extended
Kocher’s manoeuvre is performed and the hepatic
­flexure of the colon is mobilized – the so called Cattell-
Braasch manoeuvre. The lesser sac is opened widely by
dividing the gastrocolic omentum to inspect and assess
the ventral surface of the pancreas. The superior mes-
enteric vein (SMV) can be identified at this stage and
this will also allow the assessment of the stage of the
disease and the potential for resection. Dissecting the
superior mesenteric artery (SMA) has the advantage of
thorough staging with the use of frozen section and also
allows one to be in total control of SMA whilst resect-
ing the uncinate process off the retroperitoneal tissue.
The next step is to define the retropancreatic tunnel
anterior to the SMV and portal vein (PV). The retro-
panreatic tunnel is carefully dissected with right-angled
forceps with a blunt tip. If the tumour is free from the
PV, this dissection is straightforward. However, it
requires a lot of patience and gentle handling of ­tissues.
The hepatoduodenal ligament is dissected and a chole-
cystectomy is performed. The common bile duct is iso-
lated and lymph nodes in this area are dissected. The
common hepatic artery is identified to the left of the
common bile duct and is traced backwards to identify
the origin of the gastroduodenal artery (GDA). The
suprapancreatic portion of the PV lies immediately
posterior to the GDA and is identified easily once this
192
vessel is isolated. The retropancreatic tunnel is now
completed from the cranial end.
It is essential to apply a vascular clamp on the GDA
prior to division and ligation to ascertain good hepatic
arterial flow.
Once resectability is established in this manner, the
bile duct can be transected along with the distal stom-
ach. The gastric division is carried out with a ­linear
stapling device.
The ligament of Treitz is dissected to the left of
the root of the mesentry and the proximal jejunum is
mobilized. The jejunum is divided with a linear sta-
pling device about 10 cm distal to the duodenojejunal
flexure. The harmonic shears are very useful in this
dissection. The transected jejunum is delivered to the
right from behind the superior mesenteric vessels.
The pancreas is then divided at the neck after placing
hemostatic sutures at the superior and inferior borders.
Bleeding from the cut surface of the pancreas should be
attended to at this stage. Finally, the uncinate process
is separated from the PV with careful identification and
division of venous tributaries entering the portal vein.
The specimen is removed and all bleeding is
attended to.
24.7.3 Reconstruction
We prefer a Roux-en-Y configuration for reconstruc-
tion. The roux limb is usually 70–80 cm in length.
A pancreaticojejunostomy is our method of choice for
pancreatic reconstruction. This is accomplished as a duct
to mucosa anastomosis in two layers. The outer layers
are sutured with monofilament non-absorbable material
usually 4–0 prolene. The ductal mucosa is anastomosed
directly with the small bowel mucosa with absorbable
material such as 5–0 maxon/PDS. The number of sutures
placed varies with the diameter of the duct.
The choledocho/hepaticojejunostomy is constructed
as a single layer anastomosis with absorbable monofila-
ment sutures usually 4–0 maxon/PDS. This anastomosis
is made easier by using the Blumgart technique.
The gastrojejunostomy is performed on the other
limb of the bowel. This is a standard double-layered
anastomosis with absorbable sutures.
Two wide-bore drains are placed – one on the right
next to the pancreatic and biliary anastomosis and one
M. Trochsler et al.
in the lesser sac posterior to the stomach and anterior
to the pancreas.
Thorough inspection is done to confirm complete
hemostasis.
24.7.4 Post Operative Management
All patients should be transferred to ICU post-operatively.
The post-operative care is specialized and needs thorough
knowledge of critical care physiology and post-operative
surgical anatomy.
Imaging and interventional radiology services
are frequently required. Gastroenterology support is
mandatory.
It is for these reasons that the procedure needs to be
performed in specialized institutions with the ability to
provide such services.
These patients are frequently transferred to the rural
hospital for rehabilitation and recuperation. In these
situations, the rural surgeon may come across delayed
complications from this procedure. These include
delayed gastric emptying or biliary anastomotic stric-
tures, pancreatic insufficiency, delayed pancreatic
anastomotic leaks, etc. Close liaison with the operat-
ing surgeon and the hospital where the surgery was
performed is of paramount importance.
Pancreatic anastomotic leak is the most dreaded
complication and all such patients should be preferably
transferred back to the care of the tertiary centre where
the surgery was performed. In some situations where
the patient is clinically stable and a pancreatic fistula is
established through the drain site, it can be managed in
the rural setting with appropriate fluid and electrolyte
replacements, and close monitoring of the patient’s
condition by an experienced surgeon.
In conclusion, the pancreas is a unique organ in all
respects and hence patients with pancreatic patholo-
gies require specialized care in tertiary referral centres
in most situations. The rural surgeon requires sound
knowledge of the anatomy, physiology and surgical
approaches to the organ as, emergency life saving
­procedures may need to be performed in the vicinity
of the pancreas in the rural setting e.g. in trauma.
The primary role of the rural surgeon in the elective
setting is to undertake appropriate investigations and
initiate appropriate pathways for expedient and expert
management of these conditions.
24 Pancreatic Surgery
Recommended Reading
Cannon, J.W., Callery, M.P., Vollmer Jr., C.M.: Diagnosis
and management of pancreatic pseudocysts: what is the
­evidence? J. Am. Coll. Surg. 209(3), 385–393 (2009)
Hidalgo, M.: Pancreatic cancer. N. Engl. J. Med. 362(17),
­1605–1617 (2010)
Isaji, S., et al.: JPN guidelines for the management of acute
­pancreatitis: surgical management. J. Hepatobiliary. Pancreat.
Surg. 13(1), 48–55 (2006)
Keith, R.G.: Definition and classification of chronic pancreatitis.
World J. Surg. 27(11), 1172–1174 (2003)
Michalski, C.W., Weitz, J., Buchler, M.W.: Surgery insight:
­surgical management of pancreatic cancer. Nat. Clin. Pract.
Oncol. 4(9), 526–535 (2007)
193
Schnelldorfer, T.: The birth of pancreatic surgery: a tribute
to Friedrich Wilhelm Wandesleben. World J. Surg. 34(1),
190–193 (2010)
Stawicki, S.P., Schwab, C.W.: Pancreatic trauma: demographics,
diagnosis, and management. Am. Surg. 74(12), 1133–1145
(2008)
Vege, S.S., Baron, T.H.: Management of pancreatic necrosis in
severe acute pancreatitis. Clin. Gastroenterol. Hepatol. 3(2),
192–196 (2005)
Whipple, A.O., Parsons, W.B., Mullins, C.R.: Treatment of car-
cinoma of the ampulla of vater. Ann. Surg. 102(4), 763–779
(1935)
 Pancreatitis
25
Martin Bruening

25.1 Definition and demonstrates signs of hypovolaemia. Abdominal

palpation may reveal rigidity, or on occasion, a soft
abdomen. Periumbilical bruising, known as Cullen’s
Pancreatitis can represent a challenging problem for
sign and flank bruising, known as Grey-Turner sign
the rural surgeon. There are many possible presenta-
indicates a severe form of pancreatitis known as haem-
tions of pancreatitis, ranging from acute and severe to
orrhagic necrotizing pancreatitis. Evidence of jaundice
chronic and recurrent. The definition of acute pancrea-
with associated pyrexia may indicate gallstone aetiol-
titis, as derived by the 1992 Atlanta conference, is an
ogy for the pancreatitis.
acute inflammatory process of the pancreas with vari-
able involvement of other regional tissues or remote
organ systems. Chronic pancreatitis is a condition
characterised by recurrent episodes of inflammation 25.3 Diagnosis
leading to fibrosis and the loss of exocrine and endo-
crine function. The inflammatory process is thought
The diagnosis of acute pancreatitis is made by history,
to represent autodigestion, with the activation of pan-
examination and investigation. Traditionally, an eleva-
creatic enzymes leading to damage with a local and
tion of the serum amylase level more than three times
systemic inflammatory response mediated by cytok-
the upper limit of normal has been the hallmark of the
ines. The causes of pancreatitis are many and varied,
pancreatitis diagnosis. In recent years, lipase levels
but essentially, in the civilised world, the two main
have become the preferred diagnostic serum investiga-
aetiological causes are gallstones and alcohol. Other
tion. The pancreas is the only source of lipase and this
less common causes are shown in Table 25.1.
enzyme has superior sensitivity and specificity than
amylase. In addition to lipase, a full blood count,
­electrolytes, liver function tests, calcium, albumin,
25.2 Symptoms and Signs C-reactive protein, coagulation profile and an arterial
blood gas are performed.
Radiological investigations include CT scans,
The most overwhelming symptom that patients present
which in the early stages of presentation may help rule
in acute pancreatitis is severe abdominal pain. This
out other differentials for an acute abdomen. Early CT,
pain is usually upper abdominal in nature and often
however, has provoked much debate as to the potential
radiates through to the back. The onset of the pain can
for causing deterioration in pancreatic necrosis and
be relatively sudden. Nausea and vomiting are com-
renal failure and current guidelines would suggest that
mon features. On examination, the patient looks unwell
CT scans have the most benefit in cases of severe pan-
creatitis towards the end of the first week of admission.
Pancreatic necrosis may take up to 72 h to become
M. Bruening
Department of Surgery, The Queen Elizabeth Hospital,
­evident on CT scanning, and therefore, an early CT
28 Woodville Road, Woodville South, SA 5011, Australia immediately on admission may underestimate the
e-mail: martin.bruening@adelaide.edu.au severity of the attack. A CT grading system for acute

M.W. Wichmann et al. (eds.), Rural Surgery, 195

DOI: 10.1007/978-3-540-78680-1_25, © Springer-Verlag Berlin Heidelberg 2011
196 M. Bruening

Table 25.1 Acute pancreatitis: aetiological factors and a repeat scan at a later date is required. The role of
Cholelithiasis magnetic resonance imaging (MRI) may be helpful in
Alcohol demonstrating bile duct stones (MRCP) or a pancreas
divisum, but at this point in time, the routine use of
Infection (mumps, cytomegalovirus)
MRI is not indicated.
Trauma Armed with the results from the blood investiga-
Iatrogenic (ERCP) tions and radiology, a diagnosis of acute pancreatitis
Hyperlipidaemia should be secure. The next step is to determine the
severity of the condition. In addition to the aforemen-
Hypercalcaemia
tioned radiological index, a number of scoring criteria
Pancreas divisum have developed over the years and include the Glasgow/
Drugs (azathioprine, 6-mercaptopurine) Imrie (Table 25.3) and Ranson (Table 25.4) criteria.
Hereditary
These clinico–biochemical scoring systems mea-
sure various parameters over a 48 h period to predict
Idiopathic the severity of an attack. If three or more indicators are
Neoplasms (ampullary, pancreatic) present at 48 h, the pancreatitis is deemed severe. In
Sphincter of Oddi dysfunction recent times the acute physiology and chronic health
enquiry (APACHE) score, which quantifies the degree
Scorpion bite
of abnormality of multiple physiological parameters,
Cardiopulmonary bypass has been used as a prognostic assessment tool, enabling
Vasculitis a prediction of severity of acute pancreatitis at admis-
sion rather than at 48 h. An APACHE score of greater

Table 25.2 Balthazar CT index

Table 25.3 Modified Glasgow/Imrie score
Balthazar CT index Score
Age > 55 years
A Normal pancreas 0
WBC count > 15 × 109/l
B Oedematous pancreatitis 1
Blood glucose > 10 mmol/l
C Peripancreatic inflammation 2
Blood urea > 16 mmol/l
D Single peripancreatic fluid 3
collection Arterial oxygen partial pressure < 8.0kPa

E Extensive fluid collections or 4 Serum albumin <32 g/l

peripancreatic gas Serum calcium <2.0 mmol/l
Necrosis None 0 Lactate dehydrogenase >600 IU/l
Necrosis <30% 2 Source: Blamey et al. [2]
Necrosis 30–50% 4
Necrosis >50% 6 Table 25.4 Ranson criteria
CT grade + necrosis score = CT severity index On admission After 48 h
Source: Balthazar et al. [1] Age >55 years Calcium < 2 mmol/l
WBC count > 16 × 10 /l
9
Urea > 1.8 mmol/l
increase
pancreatitis, known as the Balthazar CT Index Blood glucose > 11.1 mmol/l Haematocrit
(Table 25.2), has been developed and may prove useful decrease > 10%
in determining morbidity and mortality risks. Lactate dehydrogenase > 350 IU/l Base deficit > 4 mmol/l
Ultrasound is a mandatory investigation to establish
Aspartate transaminase > 250 IU/l Fluid sequestration > 6 l
whether gallstones are the aetiological factor in the
presentation, although it is often found that excessive Arterial pO2 < 60 mmHg
bowel gas obscures a clear picture of the biliary tree Source: Ranson et al. [3]
25 Pancreatitis
than 8 upon initial assessment denotes severe acute
pancreatitis. The overall mortality rate for pancreatitis
is upwards of 10%; however, should the degree of pan-
creatitis be classifies as severe, the risk of multiorgan
failure increases significantly and the mortality rate
approaches upwards of 40%.
25.4 Management
The initial management of acute pancreatitis is sup-
portive and revolves around fluid resuscitation.
Administration of intravenous fluids and oxygen are
critical in the early treatment phase and should be
instituted for all degrees of pancreatitis upon admis-
sion. If the pancreatitis has been assessed as severe,
insertion of an indwelling urinary catheter and transfer
into a high dependency unit with strict fluid balance
monitoring is mandatory. Analgesia should also be
prescribed with a patient controlled analgesia, a suit-
able option in selected cases. Nasogastric tube place-
ment may benefit those cases with severe vomiting and
prolonged paralytic ileus. Respiratory compromise
may necessitate the transfer to an intensive care unit
(ICU) and possible intubation and ventilation. If mul-
tisystem failure becomes established, inotropic sup-
port is also needed. Unfortunately, to date, there have
been no studies to conclusively prove that medications
such as octreotide, gabexate or lexipafant are effective.
The use of prophylactic antibiotics is equally as con-
troversial and the role of antibiotics such as miripenem
and ciprofloxacin is a work in progress. A policy of
prophylactic antibiotics only in cases of pancreatic
necrosis of more than 30% has been advocated.
Nutritional support in severe acute pancreatitis can
be delivered by either the parenteral or enteral routes.
The complications of parenteral feeding have been
well documented, and it would seem preferable for the
eneteral mode of nutrition if feasible. However, as
­paralytic ileus often accompanies a severe attack of
pancreatitis, enteral delivery may be ineffective,
thereby necessitating the use of total parenteral nutri-
tion (TPN).
25.5 Surgical Treatment
Where the aetiology of pancreatitis has been proven to
be related to cholelithiasis, several treatment options
are available. In a severe attack, where there is evidence
197
of choledocholithiasis, an early endoscopic retrograde
cholangiopancreatography (ERCP) performed within
the first 72 h has been shown to decrease morbidity. An
endoscopic sphincterotomy should also be carried out
to allow adequate biliary drainage. In any form of pan-
creatitis due to gallstones, a cholecystectomy should be
performed following resolution of the initial attack and
prior to discharge from hospital. If a laparotomy has
been performed for an acute abdomen and pancreatitis
is discovered, a cholecystectomy and operative cholan-
giogram should be performed.
Surgery on the pancreas itself is limited to cases of
severe pancreatic necrosis where the patient’s symp-
toms are persisting and a FNA (CT-guided) has docu-
mented a positive bacterial culture. The usual time
frame for this sequence of events to evolve is in the
order of 7–14 days. Radiological intervention in the
form of a percutaneous drain may be of benefit in cases
of pancreatic abscess formation, but necrosectomy and
debridement form the basis of treatment in severe pan-
creatitis with necrosis.
Pancreatic necrosectomy involves the removal of
the necrotic tissue via a blunt finger technique. This
can then be combined with a continuous lavage of the
retroperitoneum with a series of drains or alternately
planned staged relaparotomies with repeated lavage.
While radiological interventional techniques in the
form of simple percutaneous drainage have proven
largely unsuccessful due to blockage of the tube with
necrotic material, recent developments have seen the
combined use of CT-guided catheters, dilation of the
tract and either a nephroscope or laparoscope to remove
the necrotic material under direct vision. This percuta-
neous pancreatic necrosectomy is classified as a mini-
mally invasive procedure and may benefit those
patients who are critically unwell or elderly. Surgery
of any form, whether open or laparoscopic, in these
situations is prone to complications and post-operative
mortality rates in the range of 30–40% are often
quoted. Pancreatic fistula, haemorrhage and incisional
hernia represent the most frequent types of morbidity,
while long-term complications may include diabetes
mellitus and exocrine pancreatic insufficiency. The
management of these patients post-operatively, apart
from analgesia and fluid balance, requires close atten-
tion to glucose levels and insulin infusions may be
necessary.
The more likely scenario following acute pancreati-
tis in which surgery may be required is that of a devel-
oping pseudocyst. If a pseudocyst persists for longer
198
than 6 weeks after the onset of the acute attack or is
larger than 6 cm in size, the likelihood of spontaneous
resolution is unlikely and surgical drainage will be
required. Traditionally, this has involved fashioning
either a cystgastrostomy or a cystenterostomy, and in
recent years, this has been performed laparoscopically.
Radiological drainage has not been as successful in
preventing reaccumulation of pseudocyst fluid. More
success in long-term treatment has been achieved with
the use of endoscopic ultrasound to locate the pseudo-
cyst and insert a drainage catheter. This minimally
invasive approach has been shown to be effective with
minimal mortality and morbidity. A rare and often
lethal complication from a pseudocyst is haemor-
rhage into the cyst from a pseudoaneurysm rupture.
Pseudoaneurysms can form after both acute and
chronic pancreatitis and if detected can be treated
­successfully using endovascular techniques.
25.6 Chronic Pancreatitis
Chronic pancreatitis, while less of an immediate life
threatening condition, can represent a difficult prob-
lem to treat. Alcohol remains the most common aetio-
logical agent, although there is a hereditary group in
which a large proportion of those with the autosomal
dominant inheritance will experience pancreatitis
before the age of 20. Other causes of chronic pancrea-
titis are listed in Table 25.5, and are also often the same
aetiological factors responsible for the onset of acute
pancreatitis.
The predominant symptom of chronic pancreatitis
is pain. As the gland becomes increasingly fibrotic and
exocrine and endocrine function falter, symptoms
Table 25.5 Chronic pancreatitis: aetiological factors
Alcohol
Idiopathic
Hyperlipidaemia
Hyperparathyroidism
Tropical
Infection
Autoimmune disease
Choledochal cyst
M. Bruening
consistent with pancreatic insufficiency and diabetes
appear. In terms of investigations, the usual serum
blood tests are performed with the addition of a gly-
cated haemoglobin level. Faecal elastase can be used
to determine the degree of exocrine pancreatic dys-
function. Ultrasound may detect pancreatic stones,
calcification within the gland and pancreatic duct dila-
tation. CT scan remains the radiological investigation
of choice and MRCP is proving to be of increasing
benefit for delineation of the pancreatic and biliary
ducts. With the advent of MRCP, the role of ERCP in
chronic pancreatitis is limited to treatment rather than
investigation.
There are few indications for surgical intervention
in chronic pancreatitis and the treatment is limited
largely to symptom management including pain
­control, diet modification, enzyme replacement and
­abstinence from alcohol. Where there is documented
pancreatic duct dilatation, a drainage procedure, in the
form of a pancreaticojejunostomy, may be of some
value in those individuals with chronic intractable
pain. There may be cases where radiological investiga-
tions have demonstrated features of a pancreatic mass
and it can be difficult to distinguish whether the mass
represents a chronic inflammatory or neoplastic
­phenomenon. In these rare situations, resection of the
pancreatic head may be an option.
25.7 The Role of the Rural Surgeon
The management of pancreatitis in the rural setting
is dependent on the facilities available within the
regional hospital. Most cases of pancreatitis are not
severe and can be ably dealt with by the rural surgeon.
It is widely acknowledged, however, that for the treat-
ment of acute severe pancreatitis, tertiary hospital
facilities are required. Few regional hospitals in
Australia have the necessary intensive care facilities
and support services required. While there may be
individual rural surgeons with the necessary surgical
skill and expertise to perform the often complicated
and high-risk surgery on the small group of patients
requiring intervention, there are many other links in
the chain, which would necessitate a large teaching
hospital environment. The availability of experienced
surgical and anaesthetic colleagues, resident medical
staff, 24-h laboratory and radiology facilities, ERCP
25 Pancreatitis
availability, pharmacy for TPN and ICU facilities are
the basic requirements before considering whether
to launch into a surgical procedure of the magnitude
as described. The other factor to consider is that of
small volume versus large volume experience, and all
recommendations would suggest that in the case of a
patient with severe pancreatitis, early referral to a
specialist hepatobiliary unit within a tertiary hospital
setting occurs as soon as practicable. The importance
of good links between the rural and tertiary hospital
cannot be understated and clear communication path-
ways from rural surgeons to their city colleagues are
invaluable.
References
1. Balthazar, E.J., Freeny, P.C., van Sonnenberg, E.: Imaging
and intervention in acute pancreatitis. Radiology 193,
297–306 (1994)
2. Blamey, S., Imrie, C., O’Neill, J., et al.: Prognostic factors in
acute pancreatitis. Gut 25, 1340–1346 (1984)
199
3. Ranson, J.H., Rifkind, K.M., Roses, D.F., et al.: Prognostic
signs and the role of operative management in acute
­pancreatitis. Surg. Gynecol. Obstet. 139, 69–81 (1974)
Recommended Reading
Barreto, S.G., Rodrigues, J.: Comparison of APACHE II and
Imrie Scoring Systems in predicting the severity of acute
pancreatitis. World J. Emerg. Surg. 2, 33 (2007)
Bradley III, E.L.: A clinically based classification system for
acute pancreatitis”. Summary of the International Symposium
on Acute Pancreatitis, Atlanta, Ga, September 11 through
13, 1992. Arch. Surg. 128, 586–590 (1993)
Connor, S., et al.: Early and late complications after pancreatic
necrosectomy. Surgery 137, 499–505 (2005)
Lopes, C.V., et al.: Endoscopic-ultrasound-guided endoscopic
transmural drainage of pancreatic pseudocysts and abscesses.
Scand. J. Gastroenterol. 42, 524–529 (2007)
Slavin, J.: Acute pancreatitis. Surg. Int. 59, 227–230 (2002)
Taylor, Sl, et al.: A comparison of the Ranson, Glasgow, and
APACHE II scoring systems to a multiple organ score in
­predicting patient outcome in pancreatitis. Am. J. Surg. 189,
219–222 (2005)
UK Working Party on Acute Pancreatitis: UK guidelines for the
management of acute pancreatitis. Gut 54(Suppl 111),
iii1–iii9 (2005)
 Surgery of the Spleen
26
Matthias W. Wichmann

26.1 Introduction 26.2 Relevant Anatomy

Surgery of the spleen is generally done for ­hematological The arterial blood supply (approximately 7% of minute
disease or trauma. For elective procedures – as for other stroke volume) to the spleen comes from the celiac
less common indications in the rural setting – it is the axis via the splenic artery and the short gastric vessels.
surgeon’s responsibility to evaluate whether the casel- The splenic vein and artery run along the dorsal sur-
oad as well as the available infrastructure and experi- face of the pancreas. The spleen is fixed in the left
ence is sufficient to provide safe surgery of the spleen. upper quadrant below the costal arch by the spleno-
The spleen is especially suitable for laparoscopic sur- phrenic, ­splenorenal, and gastrosplenic (short gastric
gery, but the patient must be fit for open surgery as well vessels) ligaments.
since a very low conversion threshold should be adopted
to avoid postoperative morbidity and mortality. Open
splenectomy, however, is also associated with morbid-
ity rates of up to 25% and mortality rates of up to 6%.
26.3 Indications
Laparoscopic splenectomy offers significant advan-
tages with regard to wound-related morbidity, length of 26.3.1 Splenectomy for Hematological
hospital stay, postoperative pulmonary complications. Disease
In elective splenectomy, preoperative vaccination
with pneumococcal, meningococcal, and Haemophilus
Splenectomy (unfortunately) is considered the last
vaccine should occur approximately 2 weeks prior to
resort of treatment for patients suffering from hemo-
surgery. In patients after emergency splenectomy, this
lytic or thrombocytopenic disorders such as idiopathic
vaccination needs to be done as soon as an adequate
thrombocytopenic purpura (ITP), thrombotic throm-
immune response can be expected (usually within
bocytopenic purpura (TTP), autoimmune anemia,
1 week after surgery). This vaccination is necessary to
hereditary spherocytosis, or elliptocytosis.
prevent the so-called OPSI-syndrome (overwhelming
The indication for surgery usually results from a
post splenectomy infection mainly due to Pneumococci
failure of medical treatment or the patient’s refusal of
or Haemophilus influenzae infection) which occurs in
further medical treatment (i.e., side effects of steroid
up to 5% of adults after splenectomy and has a mortal-
treatment) and it is the author’s opinion that surgeons
ity rate of up to 50%.
are not involved early enough with decision making in
these patients. For discussion of surgical indications, it
M.W. Wichmann is important to note that (open) splenectomy is known
Department of General Surgery, Mount Gambier General to result in long-term hematologic success in 70–90%
Hospital and Flinders University Rural Medical School,
of all patients.
276-300 Wehl Street North, Mount Gambier,
SA 5290, Australia In patients undergoing elective splenectomy for
e-mail: matthias.wichmann@health.sa.gov.au disease, it is most important to localize and remove

M.W. Wichmann et al. (eds.), Rural Surgery, 201

DOI: 10.1007/978-3-540-78680-1_26, © Springer-Verlag Berlin Heidelberg 2011
202
accessory splenic tissue, which can be found in
15–30% of all patients with the accessory spleen usu-
ally localized close to the main organ. The accessory
spleen, however, can be localized anywhere on the
patient’s left side of the abdomen including the scrotum.
Preoperative localization can be done by ultrasound.
26.4 Surgery of the Spleen for Trauma
The easiest decision for a surgeon regarding splenic
surgery is a trauma patient with an injured spleen who
is unable to maintain hemodynamic stability despite
adequate fluid resuscitation – here the injured spleen
must be removed without hesitation (“Should be in the
bucket in less than 2 minutes!”).
Nowadays, however, the majority of splenic inju-
ries can be managed conservatively without surgical
intervention. This situation requires good radiological
imaging (best done using computed tomography),
ongoing close monitoring of the trauma patients (at
least using a High Dependency Unit) with blood pres-
sure, pulse and O2 saturation measuring, as well as
24-h availability of a surgeon and theater staff to per-
form emergency surgery whenever nonoperative treat-
ment fails and splenectomy must be carried out.
At least four units of blood and two units of fresh fro-
zen plasma should be available at any given point dur-
ing the observation period of approximately 1 week
after trauma.
Computed tomography allows for a grading of the
splenic injury (Table 26.1) which is a good indicator
of whether or not conservative treatment will be
successful.
Table 26.1 Computed tomography–based classification of
splenic injury [1]
% Pat. requiring
surgery
Grade 1 Capsular avulsion, superficial 0 Emergency splenectomy: After confirming the
laceration, or subcapsular
hematoma <1 cm
Grade 2 Laceration 1–3 cm deep, central/ 17
subcapsular hematoma <3 cm
Grade 3 Laceration >3 cm deep, central/ 67
subcapsular hematoma >3 cm
Grade 4 Fragmentation of ³3 sections, 55
devascularized spleen
M.W. Wichmann
If a patient requires surgery due to ongoing blood
loss without being hemodynamically unstable and a
splenic injury is found, a number of techniques have
been described that may be useful for splenic salvage.
These procedures include splenorrhaphy, partial sple-
nectomy, usage of haemostatic agents, and argon
beam coagulation. The potential immunological and
hematological benefits of not losing the spleen have
to be weighed against the risks of a repeat emergency
surgery for failure of this approach and the operating
time needed for the acrobatic surgical maneuvers of
splenic conservation. This is of special importance in
the rural setting, where constant monitoring of the
patient and 24-h availability of an emergency theater
may not be given. Here a reduced threshold to per-
form splenectomy appears to be justified in the
author’s view.
26.5 Surgical Techniques
Elective open splenectomy: A midline or Kehr sub-
costal incision can be used to provide adequate expo-
sure. The splenic artery should be identified by
opening the gastrocolic omentum and palpation along
the upper border of the pancreas. After identification,
the artery is tied off and transected. The short gastric
vessels can be ligated in the gastrosplenic ligament
during the exposure of the splenic artery as well. The
spleen is then pulled toward the center of the abdo-
men allowing for dissection of the splenophrenic,
splenorenal, and finally the splenocolic ligaments.
Now the spleen can be elevated out of the abdominal
cavity with the pancreatic tail still attached to the
hilus of the spleen. After dissection of the pancreatic
tail away from the posterior aspects of the spleen, the
splenic artery and vein can be identified, tied, and
transected.
splenic injury, the splenorenal, splenophrenic, and sple-
nocolic ligaments are dissected to allow delivery of the
spleen to the center of the abdomen. Bleeding control
can be achieved by compression of the splenic artery
during this procedure. Expose the posterior aspect of the
splenic hilus and identify, ligate, and transect the splenic
vessels and remove the spleen. Confirm sufficient bleed-
ing control and continue the trauma laparotomy.
26 Surgery of the Spleen
Laparoscopic splenectomy: This procedure is done
using the “hanging spleen technique” with the patient
in right lateral position and the spleen suspended by
its peritoneal attachments. Usually four ports are
needed (paraumbilical camera port, left hypochon-
drium, below the xiphoid and in the midline between
xiphoid and umbilicus) and the splenocolic ligament
is dissected first. Then, the short gastric vessels are
divided, and splenic artery and vein are dissected
(using vascular endoscopic staplers) in the hilum of
the spleen. The splenic attachments to the diaphragm
and the capsule of the kidney are divided, and the
spleen is removed using a retrieval bag. Prior to
removal from the abdominal cavity, the spleen must
be morcellated in the bag.
After any form of surgery of the spleen, a drain
should be placed into the left subphrenic space to avoid
hematoma and abscess formation.
26.6 Complications
Common postoperative complications include bleed-
ing, subphrenic abscess formation, pancreatitis, and
pancreatic fistula formation. Pulmonary complications
include atelectasis and pleural effusion which are more
common after open splenectomy.
203
Reference
1. Mirvis, S.E., Whitley, N.O., Gens, D.R.: Blunt splenic
trauma in adults: CT-based classification and correlation
with prognosis and treatment. Radiology 171, 33–39
(1989)
Recommended Reading
McCray, V.W., Davis, J.W., Lemaster, D., et al.: Observation for
nonoperative management of the spleen: how long is long
enough? J. Trauma 65, 1354–1358 (2008)
Melman, L., Matthews, B.D.: Current trends in laparoscopic
solid organ surgery: spleen, adrenal, pancreas, and liver.
Surg. Clin. North Am. 88, 1033–1046 (2008). vii
Nathens, A.B.: Blunt abdominal trauma. In: Schein, M., Rogers, P.N.
(eds.) Schein’s Common Sense Emer­­gen­­cy Abdominal
Surgery, pp. 305–319. Springer, Berlin/Heidelberg (2005)
Pachter, H.L., Edye, M., Guth, A.A.: Concepts in splenic
surgery. In: Scott-Conner, C.E.H. (ed.) Chassin’s Operative
Strategy in General Surgery, pp. 727–731. Springer, New
York/Berlin/Heidelberg (2002)
 Complications After Bariatric Surgery
27
Brent White

27.1 Introduction 27.2 Roux-en-Y Gastric Bypass

Throughout the USA and much of the industrialized The Roux-en-Y gastric bypass (RYGBP) procedure
world, rates of morbid obesity have risen rapidly over consists of a 75–150 cm Roux-en-Y limb anastomosed
the past several decades to nearly 5% of the US popula- either antecolic or retrocolic to a 50 cc proximal ­gastric
tion [1]. Surgical procedures have been developed that pouch (Fig. 27.1). The operation is principally restric-
can potentially cure or mitigate morbid obesity and its tive in its mechanism for weight loss but there is also a
attendant comorbid conditions. Numerous studies have component of malabsorption. This procedure is now
demonstrated the reduction in death and disability frequently performed laparoscopically in both the
associated with obesity surgery [2]. With the advent of USA as well as much of the industrialized world. This
minimally invasive surgical techniques, such surgeries
are now being performed more commonly than ever
before. Rates of bariatric procedures reached a rate of Roux-en-Y Gastric Bypass
140,000 operations in the USA alone in 2004 [3].
Though clearly offering benefits to the morbidly
obese, these surgeries also have significant rates of com- Esophagus
Bypassed portion
plications, as high as 32.8% [4]. Clearly a morbid obe- of stomach
sity operation is associated with the kind of complications Proximal pouch
of stomach
that can arise after any abdominal surgery under general
anesthesia (e.g., pneumonia, DVT, wound infection). In
fact due to associated comorbid conditions such as dia- “Short” intestinal
roux limb
betes, obstructive sleep apnea, gastroesophageal reflux
disease, and hypertension, these are more common than
Pylorus
in most other patient populations. In addition to these
general complications, however, obesity operations are
associated with unique problems that can arise as a
­consequence of the nature of the operations themselves.
This chapter will focus on the diagnosis and treatment
of these unique bariatric complications arising from
the two morbid obesity operations most commonly
Duodenum
­performed in the USA and the western world.

B. White
Bassett Healthcare, One Atwell Road, Fig. 27.1 Diagram of a Roux-en-Y gastric bypass (From http://
Cooperstown, NY 13326, USA www.genesishealth.com/services/bariatric_surgery/rouxeny_
e-mail: brent.white@bassett.org illustration.aspx)

M.W. Wichmann et al. (eds.), Rural Surgery, 205

DOI: 10.1007/978-3-540-78680-1_27, © Springer-Verlag Berlin Heidelberg 2011
206 B. White

operation is associated with an average loss of 61.6%

excess body weight [4].

27.2.1 Anastomotic Leak

The development of an anastomotic leak, which occurs

in 1–2% of cases, is both an early complication after
surgery as well as a potentially life-threatening one
[5]. Leaks generally manifest within the first 10 days
of the operation. Patients often have excessive abdom-
inal pain after surgery and also occasionally have
vague feelings of “impending doom.” While the diag-
nosis of a leak can be made with either an upper gas-
trointestinal fluoroscopic study or with a CT scan, the
sensitivity of these studies is only approximately 40%
[6]. Instead of imaging studies, physical examination
and the presence of tachycardia (especially >120) and/
or hypotension provide the surgeon with the most
­sensitive indicator of an anastomotic leak in the early
postoperative period. Should a leak be suspected,
prompt surgical intervention is warranted. The origi-
nal surgical approach and the operating surgeon’s
confidence with advanced laparoscopic techniques
should determine the operative approach to repairing Fig. 27.2 Potential sites for staple-line failure: (1) gastroje-
such a leak. junostomy, (2) gastric remnant, (3) closure of the stomach
Regardless of the approach chosen, there are three through which the anvil of the circular stapler was introduced,
and (4) jejunojejunostomy (From Rosenthal and Jones [7],
principle objectives when operating on an acute leak p. 366, Fig. 1)
after bypass. The first objective is to identify and
repair the source of staple-line failure. Leaks can occur
at any of the staple lines created at the time of the
operation (Fig. 27.2). While this can be readily identi-
fied in some cases (Fig. 27.3), finding the precise
source of leak can occasionally be challenging. An
endoscope or NGT carefully passed into the gastric
pouch can be used to insufflate air while the bowel is
submerged under saline – bubbles can then guide the
surgeon to the area of leak. Once the defect is over-
sewn, wide drainage of the area with closed-suction
drains is the second objective, anticipating possible
breakdown of the repair. Finally, wherever possible,
we place a feeding tube within the gastric remnant.
This allows enteral drainage in the early postoperative
course and enteral access later for nutrition while
allowing the gastrojejunal anastomotic repair to heal.
Fig. 27.3 View of gastrojejunostomy leak at laparoscopic reex-
Immediate postoperative care in this setting is best
ploration. The black arrow marks the site of free flow of enteric
achieved within an intensive care unit with parenteral fluid from the leak (Courtesy of Edward Lin, Emory University
nutrition provided. School of Medicine)
27 Complications After Bariatric Surgery
27.2.2 Anastomotic Stricture
Anastomotic strictures occur at the site of the gastroje-
junal anastomosis in 0.5–6.8% of cases [8]. Such a
diagnosis should be suspected when a patient presents
3–6 months after surgery complaining of difficulty
swallowing and/or frequent nausea/vomiting. A gas-
trografin or barium swallow study can confirm the
diagnosis (Fig. 27.4), demonstrating gastric pouch
dilatation with narrowing and/or impeded flow of con-
trast into the roux limb.
Once diagnosed, most gastrojejunal strictures can be
treated endoscopically. The chief goals in endoscopic
evaluation are to: (1) document the presence of any mar-
ginal ulceration, (2) sample the gastric pouch for pres-
ence of urease to determine if Helicobacter pylori is
present, and (3) perform dilatations as appropriate. If
marginal ulceration is present, treatment must include
the use of proton-pump inhibitor medication with repeat
endoscopic evaluation in 4–6 weeks to ensure healing of
these ulcerative lesions. If pouch biopsies are positive for
the presence of urease, then a therapeutic regimen should
be prescribed to eradicate these bacteria, which can pre-
dispose to marginal ulceration in the bypass patient.
Endoscopic dilatation can be accomplished with a
number of different dilatation techniques. While fluoro-
scopic dilatation techniques can be utilized (e.g., Savary-
Fig. 27.4 Upper GI series images in a woman 5 weeks after a
Roux-en-Y Gastric bypass with multiple episodes of nausea and
emesis. The asterisk and arrow demonstrate a tight anastomosis
207
Miller), through-the-scope balloon dila­tation is perhaps
the most common method of treating these strictures
(Fig. 27.5). In our practice, we generally utilize no more
than three different sizes of balloon in a given setting
(e.g., 6–8 mm, 8–12 mm, 12–15 mm). We believe this
reduces the chance of inadvertent perforation. Should
the dilatation prove effective but insufficient to alleviate
all the patient’s symptoms, further dilatations can be
performed over time. In one recently reported series, 38
patients with anastomotic stricture after bypass under-
went an average of 2.1 dilatations with a 95% success
rate and a 3% complication rate using this endoscopic
balloon dilatation technique [8].
27.2.3 Internal Hernia Formation
Internal hernias can occur at any of several different
sites after a gastric bypass in up to 5% of cases
(Fig. 27.6) [7]. Perhaps because of the paucity of scar
tissue formed, it has been observed that this complica-
tion occurs more frequently after laparoscopic gastric
bypass surgery than after its open counterpart. This
complication typically manifests around 6–24 months
after surgery. Patients can present with a wide range of
symptoms and signs – nonspecific mild abdominal
pain, nausea and vomiting with signs of intestinal
that doesn’t change or distend with swallowing of contrast
(From Merkle et al. [9], p. 680, Fig. 9)
208
Fig. 27.5 A through-the-
scope (TTS) balloon
photographed fully dilated
(left) as well as within the
distal esophagus viewed from
the endoscope at time of
deployment
Fig. 27.6 An internal hernia can potentially occur through
either two or three defects, depending on whether a retrocolic or
antecolic technique is used for the Roux limb (From Rosenthal
and Jones [7], p. 380, Fig. 1)
obstruction, or even fulminant sepsis and bowel necro-
sis if the hernia has compromised bowel blood supply.
When clinically suspecting an internal hernia, an
abdominal and pelvis CT scan is the most sensitive
imaging study. While some cases with associated
obstruction can be readily appreciated (Fig. 27.7), in
subtler cases the “swirl” sign can be the best indication
of an internal hernia. Looking almost like a satellite
image of a hurricane, the “swirl” sign appears when the
internally herniated bowel is associated with twisting
B. White
Fig. 27.7 CT scan image of internal hernia through Peterson’s
space with dilated jejunum (J) and an associated swirl sign
(arrow) (From Carucci et al. [10], pp. 247–260, Fig. 16b)
of its mesenteric blood supply (Fig. 27.8). One recent
study found that the “swirl” sign has a sensitivity of
78–100% and specificity of 80–90% for detecting the
presence of an internal hernia [11]. Because no test has
perfect sensitivity for this complication, surgical explo-
ration to rule out an internal hernia is justifiable in the
absence of an explanation for a patient’s symptoms –
even in the absence of clear radiologic evidence.
Efforts to repair an internal hernia require familiar-
ity with the potential places these hernias can occur
(Fig. 27.6). When using a laparoscopic approach,
placement of a 12 mm port in the peri-umbilical area
with 5 mm trocars on either side of the abdomen allows
the surgeon to “walk” the bowel its entire length. The
27 Complications After Bariatric Surgery 209

a b

Fig. 27.8 The positive swirl (seen within box) led to exploration swirl at the SMA – a herniation though Peterson’s space was
in this patient with the discovery of an internal hernia through found at time of operation (b) (From Rosenthal and Jones [7],
the jejunojejunostomy defect (a). The arrow demonstrates the pp. 382–383, Figs. 2 (left) and 3 (left))

Fig. 27.9 Laparoscopic

images at exploration for a
hernia through Peterson’s
space. Careful but thorough
running of the small bowel is
generally required to
understand the nature of the
hernia (Courtesy of Edward
Lin, Emory University
School of Medicine)

bowel must be examined from the gastrojejunal anas-
tomosis distally to the ligament of Treitz (Fig. 27.9).
While doing this, it is imperative to identify both the
areas behind the Roux limb known as Peterson’s space
as well as the mesenteric junction of the jejunojejunos-
tomy. If either of these potential spaces is open then it
must be sutured closed after first reducing any herni-
ated bowel contents. In a retrocolic Roux-en-Y, the
opening through the colonic mesentery must similarly
be inspected and repaired. In instances where the anat-
omy is confusing or the degree of herniation makes
proximal to distal examination of bowel difficult, we
recommend starting distally at the ligament of Treitz
and proceeding proximally – this will often assist
in establishing proper orientation and conducting a
successful operation.
210
27.3 Laparoscopic Adjustable
Gastric Band
The laparoscopic gastric band is an operation that
places a silastic ring around the proximal portion of the
stomach (Fig. 27.10). The band is held in place via
naturally occurring posterior gastrophrenic attachments
and imbricated gastric tissue sutured into place over the
anterolateral aspect of the band. Within this band there
is a soft, inner adjustable balloon that can be filled with
a variable amount of sterile saline via a subcutaneous
port connected to the band via silastic tubing. The lap
band is purely restrictive as a means of achieving
weight loss. It is associated with an average loss of
47.5% excess body weight [4]. Though not performed
as commonly as the gastric bypass, annual numbers of
these cases have increased rapidly in recent years.
27.3.1 Band Erosion
The erosion of the band through the full thickness of the
gastric wall occurs in approximately 1% of cases [12].
This complication usually occurs after 6 months or more
Fig. 27.10 Diagram of laparoscopic gastric band (From http://
www.davidgalloway.co.uk/Images/Surgery/LAGB%20diagram.jpg)
B. White
after surgery. Patients will frequently present with com-
plaints of vague new onset abdominal discomfort or
the sudden loss of dietary restriction. Additionally, any
infectious complication at the site of the subcutaneous
port occurring outside of the perioperative period should
be considered indicative of possible band erosion. This
complication is almost never associated with free
abdominal perforation or clinical findings of peritonitis.
When suspected, carefully conducted upper endos-
copy in the retroflexed orientation is the most effective
means of establishing the diagnosis. The endoscopic
appearance of a normal band with healthy overlying
mucosa (Fig. 27.11) needs to be kept in mind. Any
silastic band material visible on endoscopy, no matter
how small, represents band erosion (Fig. 27.12).
Once band erosion is diagnosed, current standard of
care requires removal of the gastric band. This can often
be accomplished laparoscopically. In case of a small
band erosion, the band can be cut where apparent on the
serosal surface of the proximal stomach. Any visible
defect can be sutured closed primarily with viable omen-
tum sutured over as a patch. Abdominal drains should be
placed at the discretion of the operating surgeon as well
as a postoperative nasogastric tube. In instances where
the majority of the band has eroded into the stomach
(Fig. 27.12), a gastrotomy can be created on the mid to
distal portion of the stomach and the band can then be cut
out from within the lumen of the stomach before closing
the gastrotomy. There is seldom any safe means of
replacing a gastric band at time of removal for erosion.
Fig. 27.11 Endoscopic retroflex view of the gastroesophageal
junction. The arrow points out the bulge indicating the presence
of the band with healthy overlying mucosa
27 Complications After Bariatric Surgery
a b
Fig. 27.12 Endoscopic retroflex views of the gastroesophageal
junction demonstrating 180° erosion of band (asterisk) into gas-
tric lumen (a) and 270° erosion of band (asterisk) into gastric
27.3.2 Band Slippage
Band slippage occurs when distal stomach tissue man-
ages to herniate through the band or there is migration
of the band along the stomach (Fig. 27.13). This
Fig. 27.13 Diagram of gastric band demonstrating how stomach
can herniate (arrow) up through the band, thus creating ­conditions
that can, in worst case scenarios, give rise to potential gastric isch-
emia and necrosis (From Tanner and Allen [6], pp. 103–112)
211
lumen (b) (Courtesy of Edward Lin, Emory University School
of Medicine)
complication can occur any time after surgery and occurs
in approximately 4–5% of cases [12]. Hiatal hernias that
are not corrected at time of band placement may be
associated with an increased risk of ­slippage. Patients
typically present with symptoms of nausea, vomiting,
dysphagia, or abdominal discomfort. Many of these
symptoms are very similar to a band that has been
adjusted too tightly. The first diagnostic step if the patient
presents with significant symptoms is to empty or par-
tially empty the band, especially if it has been recently
adjusted. This can be accomplished by sterilely access-
ing the port with a long Huber needle. Such a needle is
generally selected because it is non-coring and unlikely
to injury the ­diaphragm of the port (Fig. 27.14).
Fig. 27.14 Photograph demonstrating appearance of Huber
needle. Such a needle profile can be used to access the dia-
phragm of the band port repeatedly without compromising the
integrity of the diaphragm’s seal (From http://www.victor-g.
com/huber%20needle%20non%20coring%20for%20rfid.jpg)
212
a may be at risk for ischemia and damage. The band
b
Fig. 27.15 Appropriate positioning of the band on upper gas-
trointestinal series. (a) Demonstrates the band aligned so that an
open ring is not evident and the band sits at an approximate 45°
angle. (b) The gastric pouch (P) is small and the stoma (S) has
ready flow of contrast into the gastric fundus (F) (From Carucci
et al. [10], pp. 261–274, Fig. 3)
If symptoms are not completely resolved with this
maneuver, an upper GI contrast study is the most sensi-
tive imaging study to determine if the band has slipped.
An ideally positioned band sits below the diaphragm at
a 30–45° angle from an imaginary horizontal or axial
line. Contrast passing through a normal band should
demonstrate a small pouch centered over the band with
passage occurring into the remainder of a normally
appearing stomach (Fig. 27.15). If the band loses this
normal 30–45° angle or if the pouch is exceedingly
dilated and eccentric in appearance over the band then
this generally indicates slippage (Fig. 27.16). Any
­previous plain films or upper gastrointestinal contrast
studies should be used as a comparison.
Once the diagnosis is made of slippage, the band
must be removed expeditiously as herniated stomach
B. White
can usually be cut at its buckle and thereby released
without need for extensive adhesiolysis or dissection
along the gastric tunnel (Fig. 27.17). While a band
can conceivably be replaced at time of removal for
slippage, only experienced bariatric surgeons should
attempt this.
27.3.3 Concentric Pouch Dilatation
Concentric or symmetrical pouch dilatation is believed
to occur when increased pressure develops in the gas-
tric pouch proximal to the band, due to either quick,
high volume eating or over tightening of the band
device. The incidence of this complication is thought
to be relatively low (approximately 4%) [13]. Regard­
less of etiology, patients present with symptoms often
quite similar to band slippage, e.g., vomiting and abdo­
minal discomfort. The first diagnostic step, as in pouch
slippage, is completely emptying the band. This can be
accomplished as previously detailed in the section on
slippage.
As in cases of slippage, an upper GI contrast study
is the most sensitive imaging study for determining
whether pouch dilatation has occurred. However,
radiographically distinguishing slippage versus dilata-
tion can occasionally be difficult.
If emptying the band completely resolves symp-
toms, then further intervention or evaluation can be
made in an elective setting with the patient’s bariatric
surgeon. If severe symptoms persist and the UGI is
equivocal for pouch dilatation versus true slippage,
then emergent surgical evaluation may be indicated as
discussed in the previous section.
27.3.4 Port and Tubing Problems
The subcutaneous port used to access and adjust the
band is sutured to the anterior aspect of the abdominal
wall at time of surgical implantation. If the sutures
break or are inadequately secured to fascia, the port
can detach from the abdominal wall, allowing it to flip
or move subcutaneously. Additionally, the tubing
­connecting the port to the band can conceivably kink
27 Complications After Bariatric Surgery
Fig. 27.16 Progressive slippage of band. (a) Initial postopera-
tive film demonstrates normal band positioning. (b) A supine
fluoroscopic series demonstrates normal small pouch (P) with
flow through the band (arrow) and into the gastric fundus (F).
(c) A film performed in the same patient nearly a year later
demonstrates a change in the band positioning, with the band
located lower and more horizontal (arrowhead). (d) An UGI at
or crack. Both of these problems can make reliable
access to the port and therefore adjustment of the band
difficult or impossible. These problems can occur in up
to 6% of cases. Most problems with tubing only
become apparent to the adjusting bariatric physician or
provider. However, if the port becomes loose the
patient may complain of feeling the port move and
sometimes discomfort at the site.
The diagnosis of a flipped port can typically be
made on physical examination, though fluoroscopy
can be used to confirm the diagnosis in difficult cases
(Fig. 27.18). Such a condition is not an emergency
under most circumstances. A repair of this problem
typically requires operative repair of the port and or
distal tubing using a replacement kit provided by the
213
that same time in the upright position demonstrates the pouch
(P) is dilated and displaced over the band with a much narrowed
stoma (arrow). (e) Another UGI image from a follow-up a
month later demonstrating further eccentric dilatation of the
pouch (P) with displacement of the band inferior (arrowheads).
The arrow demonstrates the stoma (From Carucci et al. [10],
pp. 261–274, Fig. 11)
manufacturer of the specific band device. Under most
conditions, the replacement port and tubing are simply
attached to the existing tubing and the port is resecured
to the fascia. The surgery is conducted at the subcuta-
neous and fascial level and intra-abdominal explora-
tion is usually not necessary.
27.4 Bariatric Programs
Even as rates of bariatric surgery have increased explo-
sively over the last 10 years, so has the accreditation and
development of bariatric surgical centers of excellence.
These programs are accredited in the USA by either the
214 B. White

Fig. 27.17 Laparoscopic a

photograph of a dilated
pouch (asterisk) proximal
to a slipped band
(a). Laparoscopic
photograph of a slipped
band with obvious distal
stomach herniated through
the band – simply cutting
the buckle of the band
(asterisk) releases the band
and allows it to be removed
(b) (Courtesy of Edward
Lin, Emory University
School of Medicine)

American Society for Metabolic and Bariatric Surgery
or the American College of Surgeons. These accredita-
tions are rigorous and mandate round-the-clock cover-
age for bariatric emergencies by a bariatric surgeon as
well as long-term follow-up of postoperative bariatric
patients. With over 479 such programs in the USA, com-
munity surgeons not practicing bariatric surgery should
become familiar with neighboring programs. In most
cases, patients having undergone surgery at one of these
programs should be transferred back there to receive any
and all definitive surgical care for postoperative compli-
cations. These programs can and should also be con-
tacted for advice in the evaluation and management of
bariatric patients, even where transfers are unlikely or
not feasible, e.g., unstable patients and medical tourists.
Bariatric surgery rates have increased substan-
tively and, as a natural consequence, so have the
numbers of bariatric surgical emergencies and com-
plications that are occurring each year both here in
the USA and in much of the western world. Increasing
27 Complications After Bariatric Surgery
Fig. 27.18 A fluoroscopic image from an attempted band
adjustment demonstrates the port is inverted, making needle
access impossible (From Carucci et al. [10], pp. 261–274,
Fig. 13)
numbers of bariatric centers of excellence may
reduce the need for community surgeons to take care
of these bariatric complications in the future. For
now, the community surgeon must maintain a clear
understanding of the common bariatric procedures
performed as well as their associated complications.
In this way, bariatric patients can be assured they
will be provided expeditious evaluation and quality
surgical care no matter where they are when prob-
lems arise.
215
References
1. Hensrud, D.D., Klein, S.: Extreme obesity: a new medical
crisis in the United States. Mayo Clin. Proc. 81(10 Suppl),
S5–S10 (2006)
2. Buchwald, H., Avidor, Y., Braunwald, E., et al.: Bariatric
surgery: a systematic review and meta-analysis. JAMA 292,
1724–1737 (2004)
3. Nguyen, N.T., Root, J., Zainabadi, K., et al.: Accelerated
growth of bariatric surgery with the introduction of mini-
mally invasive surgery. Arch. Surg. 140, 1198–1202 (2005)
4. Encinosa, W.E., Bernard, D.M., Du, D., Steiner, C.A.:
Recent improvements in bariatric surgery outcomes. Med.
Care 47(5), 531–535 (2009)
5. Podnos, Y.D., Jimenez, J.C., Wilson, S.E., et al.:
Complications after laparoscopic gastric bypass: a review of
3,464 cases. Arch. Surg. 138, 957–961 (2003)
6. Tanner, B.D., Allen, J.W.: Complications of bariatric surgery:
implications for the covering physician. Am. Surg. 75,
103–112 (2009)
7. Rosenthal, R.J., Jones, D.B.: Weight Loss Surgery: A multi-
disciplinary Approach, pp. 379–385. Matrix Medical
Communications, Edgemont (2008)
8. Go, M.R., Muscarella, P., Needleman, B.J., et al.: Endoscopic
management of stomal stenosis after Roux-en-Y gastric
bypass. Surg. Endosc. 18(1), 56–59 (2004)
9. Merkle, et al.: Roux-en-Y Gastric Bypass for Clinically Severe
Obesity: Normal Appearance and Spectrum of Complications
at Imaging. Radiology 234(3), 674–683 (2005)
10. Carucci, et al.: Imaging Evaluation Following Roux-en-Y
Gastric Bypass Surgery for Morbid Obesity. Radiol. Clin. N.
Am. 45(2), 247–260 (2007)
11. Iannuccilli, J.D., Grand, D., Murphy, B.L., et al.: Sensitivity
and specificity of eight CT signs in the preoperative diagno-
sis of internal mesenteric hernia following Roux-en-Y
­gastric bypass surgery. Clin. Radiol. 64(4), 373–380 (2009)
12. O’Brien, P.E., Dixon, J.B.: Weight loss and early and late
complications – the international experience. Am. J. Surg.
184, 42S–45S (2002)
13. Brown, W.A., Burton, P.R., Anderson, M., et al.: Symmetrical
pouch dilatation after laparoscopic adjustable gastric
banding: incidence and management. Obes. Surg. 18(9),
1104–1108 (2008)
 Appendicitis
Kerstin S. Schick and Johannes N. Hoffmann
28.1 Epidemiology
Appendicitis is the most common cause of acute abdo­
minal pain, with a peak between the ages of 10–30 years
(110–200/100,000 patients per year). Diagnosis of
appendicitis is often delayed in children, elderly people,
and a significant number of patients (10–20%) present
with perforated appendicitis. In 25% the diagnosis
appendicitis is missed initially, and about 25% of the
patients undergoing surgery for acute appendicitis do
not suffer from appendicitis.
28.2 Etiology and Pathogenesis
Acute appendicitis is an enterogenous rather than a
hematogenous infection. It is thought to be facilitated
by congestion, narrowing of the intestinal lumen, devia-
tion, scar strands, or fecal stones. Contributing factors
are general and intestinal infections (local inflammatory
edema of the mucosa). Histologically, appendicitis is
characterized by migration of neutrophils into the sur-
rounding lymphoid follicles, and by superficial erosion
of the mucosa with fibrin coating. A distinction is made
between the reversible catarrhal stage with congestion
and swelling, and the seropurulent stage, which indi-
cates progression to infection. Through this progress, a
destruction of the intestinal wall occurs with increasing
permeability for bacteria. This periappendicitis may
progress to a perforation. Perforated appendicitis is
K.S. Schick and J.N. Hoffmann (*)
Department of Surgery, University of Munich – Großhadern,
Marchioninistr. 15, 81377 Munich, Germany
e-mail: johannes.hoffmann@med.uni-muenchen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_28, © Springer-Verlag Berlin Heidelberg 2011
28
observed in 10–20% of patients, and is more common
with increasing age, reaching an incidence of up to 45%
in elderly patients.
28.3 Symptoms and Diagnosis
28.3.1 History
Acute appendicitis is characterized by an acute onset
of abdominal pain. Initially, the pain is localized in the
upper and central abdomen (visceral pain fibers), it
gradually moves (within hours) into the right lower
quadrant and is described as a sharp pain (peritoneal
pain fibers). Usually the abdominal pain has been pres-
ent for less than 24 h – pain lasting longer than 24 h
without development of generalized peritonism is
unlikely to be caused by acute appendicitis.
28.3.2 Symptoms
Patients may present with loss of appetite, nausea,
vomiting, ileus or diarrhea, and fever. With disease
progression signs of generalized peritonitis (acute
abdomen) develop, and may progress to sepsis if left
untreated. Usually pain develops prior to the onset
of other symptoms. In elderly patients, however, the
clinical picture may not be as typical and a delay in
diagnosis is more likely.
It is important to note that an acute exacerbation
of Crohn’s disease can mimic symptoms of acute
appendicitis
217
218 K.S. Schick and J.N. Hoffmann

On physical examination, some clinical signs of
acute appendicitis may be found in typical localiza-
tions (the names of these signs appear to be more
important for some examiners rather than have clinical
relevance).
Clinical signs of acute appendicitis
• Tenderness and guarding in the right lower abdomi-
nal quadrant is due to peritoneal irritation through
local release of fibrin within the area of the inflamed
appendix resulting in spasm of the abdominal wall
muscles.
• McBurney’s point: pain half way between the umbi-
licus and the anterior superior iliac processus.
• Lanz point: pain in a point located one third of the
distance between the left and right anterior superior
iliac processus.
• Blumberg sign: contralateral rebound tenderness
due to peritoneal irritation.
• Rovsing sign: pain due to an attempt to apply retro-
grade pressure on the large bowel content resulting
in irritation of the inflamed area in the right iliac
fossa (this is painful in healthy individuals as well).
• Unspecific sign: Painful rectal examination when
pressure is applied to the Douglas Pouch.
• Psoas sign: painful flexion of the extended right leg
against resistance. A positive psoas sign has the
highest specificity for acute appendicitis and indi-
cates retrocecal position of the appendix.
The appendix is usually located anterior to the cecum in
the right lower abdomen. A retro cecal position is found
in approximately 25% of the patients and tends to make
the diagnosis of acute appendicitis more difficult.
In addition, the para cecal location, a very low loca-
tion in the pelvis or a raised appendix, as well as a situs
inversus can change the clinical picture. In children,
maneuvers to distract their attention (sticking the
tongue out, squeezing the examiner’s hand) may be
helpful, to identify “true” guarding.
Diagnostic steps for patients with suspected appen-
dicitis are:
• History of presenting condition
• Clinical examination
• Blood tests including inflammatory markers, urine
testing, pregnancy test for female patients of child-
bearing age
• Abdominal ultrasound
Additional tests/investigations should be arranged if
needed (CT scan), depending on the former results.
The implementation of a diagnostic and therapeutic
algorithm is highly recommended.
It is important to remember that a single negative
diagnostic parameter cannot exclude the diagno-
sis of acute appendicitis!
When in doubt, keeping the patient under observa-
tion for reevaluation with repeat examinations and
blood tests is recommended.
28.3.3 Diagnostic Scores
A number of different diagnostic scores for acute
appendicitis have been developed. These scores aim
to facilitate the diagnosis by combining a number of
different clinical parameters. The Ohmann score has
been introduced to routine daily use in a number of
institutions. With a point value of >12, the diagno­
sis appendicitis is most likely, with a value <6 it is
unlikely.
Symptoms and signs Point value
Rebound tenderness 4.5

The diagnosis or suspicion of appendicitis is usu- Blumberg’s rebound tenderness 2.5

ally made through history taking and clinical Missing dysuria 2.0
examination. It is mainly a clinical diagnosis! Continuous pain 2.0
Leukocytes >10 G/l 1.5
Once the diagnosis is made or appears to be very Age >50 years 1.0
likely an urgent operation must be performed.
Migration of pain from epigastrium 1.0
The use of a standardized investigation sheet for
to right iliac fossa
documentation of a complete physical examination is
recommended. Pain in the right iliac fossa 1.0
28 Appendicitis
28.3.3.1 Laboratory Data
Leukocytosis of 10,000–15,000 leukocytes and
increased CRP are very common.
28.3.3.2 Imaging Studies
Abdominal ultrasound is often recommended for the
diagnosis of acute appendicitis. However, the ­sensitivity
of ultrasound at German university clinics varies
between 30% and 80%. Ultrasound is dependent on the
examiner and the lack of its reproducibility is a well-
known problem. Ultrasound can detect the so-called
target sign (thickened/inflamed intestinal wall), free
fluid in the lower abdomen, or an abscess. Negative
ultrasound results have no diagnostic value. In USA
and Great Britain, computed tomography of the abdo-
men with i.v. contrast is used more and more often to
investigate appendicitis. One study suggested substan-
tial cost saving using this approach because it resulted
in a reduction of hospital stay. Due to the significant
radiation, computed tomography of the abdomen is cur-
rently not routinely used in most European countries for
the evaluation of right lower quadrant a­ bdominal pain.
28.3.3.3 Differential Diagnosis
It is important to consider pain duration and localiza-
tion as well as pain characteristics for the differential
diagnosis of acute appendicitis:
• Inflammatory bowel disease: Crohn’s disease,
ulcerative colitis
• Meckel diverticulitis
• Gynecological disorders: menarche, endometriosis,
persistence of ovarian follicles, salpingo-oophoritis,
ectopic pregnancy, ovarian cyst
• Urological disorders: cystitis, pyelonephritis, urolithiasis
• Infectious diseases: gastroenteritis, viral infections,
enteral yersiniosis
• Other less common causes: iliac aneurysms, myo-
cardial infarction, irritable bowel, bowel cancer,
typhus and paratyphus, porphyria, intoxication, for-
eign body, constipation
Laboratory tests can be misleading! Up to 30% of the
patients with acute appendicitis have pathological
urine findings with leukocyturia and bacteriuria result-
ing from inflammatory involvement of the ureter.
219
28.4 Management
After acute appendicitis has been diagnosed, an urgent
operation must be scheduled because surgery is the
only effective therapy. A recent randomized clinical
trial, however, reports that antibiotic treatment (cefo-
taxime 1 g bd i.v. and metronidazole 1.5 g od i.v. for a
minimum of 24 h) also is a safe first-line therapy in
unselected patients with acute appendicitis without
peritonitis [1]. Even when in doubt, an operation may
be performed to avoid serious complications, espe-
cially in elderly patients and children because in these
patients, development of fever, pathological laboratory
tests, and abdominal pain may be limited or delayed.
28.5 Informed Consent
The patient’s operation information should include the
main possible surgical complications such as intraop-
erative and postoperative bleeding, surgical site infec-
tion, superficial wound infection, and impaired wound
healing, injury of surrounding organs (bowel, ureter)
and should also mention the possible need for a bowel
resection.
Technical complications like bowel or ureter inju-
ries must be mentioned independent of their rare inci-
dence. The patient should be involved in the discussion
of what to do with an “innocent” appendix. At this
point, there is no evidence favoring routine appendec-
tomy or diagnostic laparoscopy only. The patient
should be included into the decision process (leave it or
cut it) before the operation, because it is possible to
diagnose appendicitis in 95% of the cases with laparos-
copy in a correct way and in these cases surgery could
be ended as a diagnostic laparoscopic procedure. If an
open appendectomy was planned, the appendix should
be removed regardless of whether or not it is inflamed.
Two surgical procedures are commonly used: open
or laparoscopic appendectomy.
28.5.1 Open Appendectomy
The most popular approach for open appendectomy is
an incision in the right lower quadrant. In cases sus-
pected to have an advanced inflammation, a pararectal
220
incision would be more advantageous because it can
be extended cranially and caudally. This incision also
allows for more extended procedures, like an ileocecal
resection. In unclear cases when surgery is exploratory,
a low midline laparotomy is advocated, because it
allows a wider exploration.
28.5.2 Laparoscopic Appendectomy
Three trocars are used, one close to the umbilicus, one
in the midline above the pubic bone, and the third in
the right or left lower abdomen. The mesoappendix is
cut using a laparoscopic stapler or bipolar coagulation
and the base of the appendix is then closed with an
endoscopic Roeder’s loop or a second endoscopic lin-
ear stapler. The appendix is removed by using a recov-
ery-bag to avoid subcutaneous wound infection. There
is also some experience with single part techniques
showing promising results.
A single i.v. dose of a second-generation cepha-
losporin or an aminopenicillin is recommended to
reduce the incidence of postoperative wound infec-
tions. Continuation of antibiotic therapy is only indi-
cated if peritonitis is found at the time of surgery.
28.5.3 Laparoscopic Versus
Open Appendectomy
While laparoscopic cholecystectomy has been estab-
lished as the standard technique for cholecystectomy,
laparoscopic appendectomy remains controversial.
A recently published double-blind randomized study
comparing laparoscopic and open appendectomy did
not show a clear advantage for the laparoscopic
approach with regard to postoperative recovery and
quality of life, but reported slightly higher complica-
tion rates. Furthermore, there appears to be a clear
advantage of shorter operating times and reduced
costs for open appendectomy.
Laparoscopic appendectomy causes significantly
less wound healing problems and allows for a faster
return to activities of daily living. Laparoscopy allows
for a better diagnostic view than conventional appendec-
tomy. Minimal invasive surgery, furthermore, is of
K.S. Schick and J.N. Hoffmann
advantage in obese patients and in women of childbear-
ing age. With regard to training in laparoscopy, it is
important to consider laparoscopic appendectomy in
uncomplicated cases as an important training procedure.
However, in patients with a perforated appendix, the rate
of postoperative abscess formation appears to be higher
when compared with conventional appendectomy. The
authors’ institution has experience with more than 1,000
laparoscopic appendectomies and when compared to
the open procedure, there is a reduced length of postop-
erative stay with a low complication rate [2].
28.5.4 Histology
All removed specimens should be examined by a
pathologist to confirm the diagnosis and to detect other
rare conditions such as carcinoid or mucinous
adenocarcinoma.
Histology identifies the following stages of acute
appendicitis:
Duration of Stage
symptoms (h)
6 Vascular injected appendix (congested
vessels in the serosa)
12 Phlegmonous appendicitis (fibrinous
purulent coated serosa)
24 Ulcero-phlegmonous appendicitis (flat
ulcers and defects of the mucosa)
48 Suppurate appendicitis (necrosis of
walls with defects, macroscopically the
appendix appears gray to green)
28.6 Results
Surgical mortality for non-perforated appendicitis is
about 0.06%, which equals the mortality risk of ­general
anesthesia. With perforation, the mortality increases
approximately 30 times. In older patients it can even
reach 5–10%.
Morbidity for not-perforated appendicitis is low
(3%). Perforated appendicitis carries a higher morbidity
(wound healing problems, abscess formation, leakage
from the appendiceal stump).
28 Appendicitis
Late complications include incisional hernias, adhe-
sions with resulting mechanical obstructions, and
stump appendicitis. Whether or not long-term compli-
cations occur less often after laparoscopic appendec-
tomy remains to be determined.
28.6.1 Complicated Appendicitis
When the correct diagnosis is not made early during
the disease process, complications are more likely to
occur. Perforation leads to localized peritonitis with
abscess formation or generalized peritonitis.
Therapy of free perforation with peritonitis follows
the guidelines treatment for peritonitis.
Perityphlitic abscess formation can be treated
­following two different strategies, which have been
established:
• Ultrasound or CT-guided abscess drainage or lap-
aroscopic drainage followed by eventually appen-
dectomy in the inflammation-free interval.
• Ileocecal resection at the time of diagnosis, which
avoids interval appendectomy.
If the postoperative course is uncomplicated feeding
can be started with tea and soup on the day of surgery.
Normal feeding can start on day one after surgery.
221
Patients are usually discharged on the first or second
day after laparoscopic appendectomy and may require
a slightly longer stay after open appendectomy.
Reference
1. Hansson, J., Körner, U., Khorram-Manesch, A., Solberg, A.,
Lundholm, K.: Randomized clinical trial of antibiotic ther-
apy versus appendicectomy as primary treatment of acute
appendicitis in unselected patients. Br. J. Surg. 96, 473–481
(2009)
2. Schick, K.S., Huettl, T.P., Fertmann, J.M., Hornung, H.M.,
Jauch, K.W., Hoffmann, J.N.: A critical analysis of laparo-
scopic appendectomy: how experience with 1,400 appendec-
tomies allowed innovative treatment to become standard in a
university hospital. World J. Surg. 32, 1406–1413 (2008)
Recommended Reading
Becker, K., Höfler, H.: Pathologie der Appendicitis. Chirurg 73,
777–781 (2002)
Katkhouda, N., Mason, R.J., Towfigh, S., Gevorgyan, A., Essani, R.:
Laparoscopic versus open appendectomy a prospective
­randomized double blind study. Ann. Surg. 242, 439–450
(2005)
Kraemer, M., Ohmann, C., Leppert, R., Yang, Q.: Macroscopic
assessment of the appendix at diagnostic laparoscopy is
­reliable. Surg. Endosc. 14, 625–633 (2000)
 Bowel Obstruction
Saukat T. Esufali
Patients with bowel obstruction may present challeng-
ing problems of management. Decision-making has to
take account of many factors and circumstances.
When discussing treatment of bowel obstruction
within rural settings with rural surgeons, there are differ-
ent points of view that have to be factored in, along with
other issues coming into play apart from surgical deci-
sion-making processes (Bruening and Maddern, 2009).
Most surgeons practising in rural settings have
trained in urban centres and teaching hospitals. As
such, it may be inappropriate to label ‘rural surgery’ as
a specialty which has major differences in practice.
The management of patients with defined surgical
problems would follow the same practice as urban cen-
tres, and there would be criticism if there were major
changes in approach. While the lack of services such
as ICU can limit the scope of surgery, this should not
change the type of surgery for defined problems.
Rural hospitals with surgical facilities can vary con-
siderably. Mount Gambier District Hospital (MGDH)
is in a developed country, Australia, in a rural centre.
The Limestone Coast region is home to 65,402 people.
Mount Gambier, the largest city in the region, has a
population of around 25,000 people and is the regions’s
(including far western Victoria) commercial centre.
http://www.infrastructure.sa.gov.au/_data/assets/
S.T. Esufali
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia and
School of Medicine, Melbourne University
of Notre Dame, Australia and
Department of Surgery,
Werribee Mercy Hospital, 300 Princess
Highway Werribee, Victoria 3030, Australia
e-mail: sesufali1@gmail.com
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_29, © Springer-Verlag Berlin Heidelberg 2011
29
pdf_file/0014/53114/ROLimestoneCoast.pdf Sep 2010.
There are in addition to MGDH small hospitals run by
family doctors, some of whom have minor operating
theatres. The flying doctor service may be relied on to
transfer a patient from MGDH to a major urban centre
within 4 h of being contacted.
In contrast, rural centres in poorer countries such
as Sri Lanka have no sophisticated transfer facilities,
and patients may face an arduous ambulance journey
by road that can take 8–10 h with little paramedic or
medical input. In these settings, the scope and type of
surgery carried out would be markedly different and
the ­surgeon has to have a much wider repertoire of
surgeries under his/her belt.
In attempting to put matters into greater perspective,
the management of bowel obstruction in a rural setting
would need to take into account the following factors:
• Surgeon training and experience: In most rural
­settings, surgeons would have adequate training and
experience to tackle bowel obstruction. They would
have the necessary skills and awareness of the differ-
ent surgical options at their disposal. With the avail-
ability of the internet and interactive learning tools,
surgeons in most rural settings are able to keep them-
selves abreast of the latest opinions based on studies
from academic institutes. Surgeons in rural settings
often work alone. They have the capacity to discuss
a case with a colleague by phone, but a hands-on sec-
ond opinion or team approach – taken for granted in
urban centres- is sadly lacking and this can be an
impediment to optimal management of medical
problems. There has been some debate recently
regarding the merits of major surgery and procedures
being performed by specialists in rural centres. The
minimum number of specific procedures/surgeries
223
224
per surgeon per year for maintaining standards has
yet to be decided and will no doubt be a matter for
debate (Dundee et al. 2007).
• Available facilities, technical support and manpower:
The problems that rural-based surgeons often encoun-
ter go far beyond their technical abilities to perform
the necessary surgical procedures. The available
radiological and laboratory backup, especially after
hours, may be inadequate. Invariably, the most chal-
lenging problems are encountered after hours, which
can tax even the most experienced surgeons. Theatre
nurses are on call and need to be called in; and first
assistants are usually theatre nursing staff, non-surgi-
cal trainee medical staff or non-surgical trainee junior
doctors. Despite their best efforts and mental motiva-
tion, they still might not be able to provide as much
technical support as colleagues or trainee surgeons.
Anaesthetic staffing shortage problems are often
experienced in rural settings in Australia. General
practitioner anaesthetists play a major role in cover-
ing the shortfall of specialists. This may become an
issue when a patient with bowel obstruction has met-
abolic, hypovolemic, nutritional or septic complica-
tions. ICU facilities are rarely available in rural
hospitals. Some patients may require ventilation,
nutritional support, second-look laparotomy or other
intervention. In this situation, the surgeon faces the
issue of transferring a patient before surgery or
immediately after surgery or later if problems arise.
Ideally, from the receiving staff point of view, early
transfer is optimal prior to organ failure states.
• Community expectations: There is a difficult and
imperceptible line when it comes to estimations of
the capability of performing surgery in a rural setting.
On the one hand, one can refer all complex surgical
problems to urban centres and avoid having problems
with regard to morbidity and mortality. On the other
hand, one can be overenthusiastic, strain the system
and subsequently encounter postoperative problems
with poor outcomes. This can lead to a negative
mindset amongst medical and nursing colleagues.
Both ways obviously have cost implications, and
ramifications for the future viability of the hospital.
An issue that recently created much public debate with
ongoing legal implications surrounded a surgeon and
complications at Bundaberg Hospital in rural
Queensland, Australia. The surgeon concerned was
found to have carried out surgery beyond his capability
S.T. Esufali
and also the facilities available locally, compounded
with a reluctance to transfer the patients prior to and
also after surgery. This led to media frenzy and may
have altered the practice of surgery in rural settings.
Properly promoting appropriate surgery in a rural
setting can ultimately be beneficial for the community,
as well as saving many patients and their families the
additional difficulties posed by travel, treatment in
unfamiliar environs and cost.
At present there is awareness about the complexities
of rural surgical practice. Most urban surgeons and spe-
cialists are cooperative and understanding when
approached for support. Many surgical trainees spend
part of their training in rural settings, and are generally
very positive about their experiences. Mount Gambier
Hospital surgeons have a close link with the urban aca-
demic surgical centre in Adelaide and have weekly
video-link with case conferences, as well as regular
audit and academic exchanges. This support is extremely
valuable in enhancing skills and confidence in rural-
based surgeons in a modern developed-world setting.
29.1 Clinical Decision Making
There are many algorithms for managing bowel
obstruction. Management-based decision-making is
preferable to a diagnosis-based approach (Table 29.1).
Patients with bowel obstruction usually present
acutely with abdominal pain, vomiting, distension and
constipation. These symptoms vary depending on the
level of obstruction within the GI tract. Other diagno-
ses could be acute appendicitis, acute pancreatitis, gas-
troenteritis. To confirm that the GI tract is obstructed,
clinical factors and investigations are needed. The
mainstay of specific investigations are radiological.
Plain X-rays were and continue to be the investigation
most used. The main features on X-rays are dilated
bowel loops, central location, paucity of gas in the rec-
tum/ colon and recognition of haustral patterns. Now
CT scan has proved to be a valuable adjunct in estab-
lishing a diagnosis and also helpful in assessing for
a closed loop bowel obstruction. Distal small bowel
obstruction and high proximal obstruction can be dif-
ficult to diagnose due to the paucity of vomiting in the
former and late constipation in the latter (Cappell,
Batke 2008). Later on in the presentation of mechani-
cal obstruction, an ileus sets in and classical colicky
29 Bowel Obstruction
Table 29.1 Algorithm for Possible bowel obstruction
Clinical Decision Making in X-rays, contrast studies, CT Scan
Bowel Obstruction
Definite bowel obstruction
CT Scan, Clinical assessment
Mechanical
Strangulation Simple mechanical
Early/emergency
Surgery
Endoscopic
Treatment
pain may not be a feature. Plain X-rays have been the
mainstay of radiological diagnosis, but more recently
CT scans with oral and intravenous contrast can be
more definitive helping to highlight the level and extent
of obstruction. CT scans are especially helpful in the
challenging situation of discerning between a mechan-
ical obstruction and a paralytic ­(adynamic) obstruc-
tion (Rhodes et al. 2001).
Blood tests need to be carried out for complete
blood count (CBC), urea, creatinine and electrolytes
(U and Es), liver function tests (LFT), C-reactive
­protein (CRP), blood group, lactate and acid studies.
Patients can have profound fluid and electrolyte shifts
with bowel stasis, especially distal obstruction states.
These need correction prior to surgical intervention.
Initial management of bowel obstruction rests with
fluid and electrolyte resuscitation, nasogastric aspira-
tion, analgesia and further regular assessments.
Monitoring the amount of urine production is a valuable
indicator of adequate volume resuscitation. Some
225
Paralytic ileus/adynamic
Generalised Segmental
Non-operative Non-operative Surgery for
Investigate Measures Causes
Eg. Appendicitis
Surgery Endoscopic
decompression
Settles Surgery/colostomy
elderly patients with cardiac disease may be easier to
manage with central venous monitoring as far as fluid
input is concerned.
Once the patient is stabilized, the next question to
address is whether the patient has a mechanical or
­paralytic obstruction. The two may coexist, especially
in the later stages of a mechanical obstruction. When
the ileus is localized due to an inflammatory focus
such as appendicitis, then the clinical signs of local-
ized peritonitis should prevail and warrant surgery,
depending on the degree of peritonitis.
The differentiation between ileus and mechanical
obstruction depends on the clinical presentation and
radiological findings (Table 29.2). Colicky pain usually
indicates a mechanical problem. Abdominal distension
disproportionate to the pain/discomfort would point to
an ileus rather than a mechanical component. Visible or
palpable waves of peristalsis across the abdominal
wall ­usually indicate a mechanical problem. Radiology
can be most helpful with plain films, CT scans and
226
Table 29.2 Clinical and radiological findings to distinguish
between mechanical obstruction and Ileus
Mechanical Ileus
obstruction
Clinical signs • Colicky pain • Localized
peritonitis (if
• Visible peristalsis due to an
inflammatory
focus)
• Abdominal
distension
disproportionate
to pain/
discomfort
Radiological • Collapsed loops • Air/gas seen in
investigations distal to the dilated colon/rectum
loops (CT)
contrast studies contributing to diagnosis. The presence
of air/gas in the colon and ­rectum is the most reliable
sign of an ileus. Collapsed loops distal to the dilated
loops on CT are indicative of a mechanical problem.
Patients with an ileus need medical attention and
observation until the problems settle. The causes may
be due to metabolic or local problems in the peritoneum;
such as ascites or haemoperitoneum (e.g. after hip or
lumbar trauma as well as post abdominal surgery).
Postoperative ileus also occurs due to fibrinous, flimsy
adhesions. The ileus usually settles within a few days
after surgery, but if it persists or recurs, then a postop-
erative event such as an anastomotic leak or collection
should be suspected. An ileus that persists despite time
and general measures, warrants continued attention and
possibly surgery. Medical agents such as dopamine
antagonists (metoclopramide) and sympathetic blockers
(neostigmine) may be of benefit. Nonetheless, we do
not recommend ongoing use since the prevailing ileus
may be masked, a perforation may occur or an underly-
ing cause for the ileus may be missed.
An ileus may be segmental as in colonic ileus (also
labelled as pseudo-obstruction) or Ogilvie’s syndrome.
Endoscopic deflation may be useful until the initiating/
prevailing cause settles. Endoscopic views of the colon
or contrast studies can also check for an obstructing
problem or a volvulus in the colon, which may occur in
the elderly. Rarely would a colostomy or ileostomy be
required, to prevent the prospect of perforation.
Even for the most experienced clinicians differentia-
tion between a mechanical and non-mechanical obstruc-
tion may be difficult. CT scans are helpful but not always
S.T. Esufali
accurate. Water-soluble contrast follow-through studies
via a nasogastric tube or jejunal tube can be most useful,
and on occasions, ­therapeutic. Contrast should be pres-
ent in the caecum/colon within 2–3 h. If the flow is
delayed and the small bowel loops continue to distend
with the contrast, this is strongly suggestive to a mechan-
ical obstruction. Radiologists have mixed views about
the use of water-soluble contrast studies when the plain
films show dilated bowel loops, because the mucosal
delineation is lost. It remains a subjective preference,
but can be a useful adjunct in the differentiation between
a mechanical and non-mechanical problem.
Patients with a mechanical obstruction generally
require intervention, either as an open surgical proce-
dure, or laparoscopic intervention if facilities exist.
The timing of surgery would depend on the risk of the
mechanical obstruction being compounded by stran-
gulation. This is particularly so with a closed loop
obstruction. The venous congestion and subsequent
vascular inflow occlusion due to the mesenteric pres-
sure lead to a rapidly deteriorating clinical state. The
combination of congestion and obstruction has the
effect of ischemia in association with bacterial multi-
plication and ensuing bacteraemia. Patients are often
more unwell than expected for the clinical presentation
and duration of symptoms. They appear septic and
toxic with tachycardia despite adequate filling, tachyp-
nea (due to acidosis), low-grade pyrexia and perito-
nism (albeit a late sign indicating perforation). The
blood parameters may show a leukocytosis, elevated
inflammatory markers, lactic acidosis amongst others.
If there is doubt as to the nature of the obstruction,
early surgery is advised. Delay in the management of
strangulating obstruction leads to increased morbidity
and mortality, and further adhesions.
Strangulated obstruction is classically caused
by adhesions, volvulus, intussusception or obstructing
inguinal/femoral herniae. Patients with sigmoid volvu-
lus and intussusception can be managed without laparo-
tomy if they are clinically stable and do not show signs
of strangulation. Sigmoidoscopy using a flexible instru-
ment may untwist the volvulus and decompress the
dilated redundant sigmoid loop. If successful and no
further episodes of volvulus occur, then surgery can be
avoided or delayed. In children intussusception is often
successfully managed by hydrostatic decompression
under radiological control (Rohrschneider et al. 1995).
Mechanical bowel obstruction without strangula-
tion can be initially managed with decompression and
29 Bowel Obstruction 227

Table 29.3 Common causes of bowel obstruction

Age group Intraluminal causes Intramural causes Extramural causes (extrinsic compression)
Neonates and infants Meconium ileus, Congenital atresias, stenoses Congenital inguinal/diaphragmatic hernia,
<24 months obstruction, foreign and webs; duplication cysts; congenial bands, midgut volvulus, postopera-
bodies intussusception tive adhesions
Children and young Foreign bodies, Crohn’s disease, benign Inguinal hernia, congenital and postoperative
adults worms neoplasms, primary adhesions, midgut volvulus, intussusception,
and secondary malignant complications of appendicitis
neoplasms
Elderly persons Foreign bodies, Crohn’s disease, tuberculosis, Postoperative adhesions; femoral, inguinal,
gallstones primary and secondary umbilical or incisional hernia; colonic
neoplasia, radiation strictures, and ovarian neoplasia; adhesion to an
complications of surgical ­inflammatory process (e.g. appendicitis or
anastomosis diverticulitis)

fluid/electrolyte maintenance. This would give time

for further investigations to delineate the level and
extent of obstruction. With time, and simple non-sur-
gical measures, some patients with adhesion obstruc-
tion may settle spontaneously. If they do not settle,
then radiological contrast studies and endoscopic
means are available to ascertain the level of obstruc-
tion and often the cause. Patients with colonic obstruc-
tion can be stented endoscopically, either as a bridging
procedure with surgical resection after stabilization or
as a definite palliative intervention.
Bowel obstruction accounts for almost 15% of emer-
gency admissions for general surgeons, and the major-
ity of these patients generally require surgery, with
adhesions/band obstruction being a major causative fac-
tor (Table 29.3). Adhesions can be challenging techni-
cally with iatrogenic injury, risk of leaks and fistulae
Fig. 29.1 Plain X-rays of patient presenting with abdominal
being a sequel (Menzies 1992). Thankfully, this hap- pain, distension and vomiting 3 months after laparoscopic chole-
pens rarely, but most ­surgeons unfortunately have had cystectomy. CT scan shown below Fig. 29.2 (Source: Benson’s
such a case and will remember that patient indefinitely! radiology, Adelaide/Mount Gambier, Australia)
Figures 29.1 to 29.5 show examples of bowel obstruc-
tion seen and treated in rural surgery.
At operation for mechanical bowel obstruction, still sound principles. Limiting the use of foreign mate-
there are dilated loops proximal to the obstruction rial/sutures has also has been shown to reduce adhe-
and collapsed loops distally. The aim of surgery is to sion formation. Lavage has not shown to offer any
restore continuity. With adhesions from previous advantages but is still a tradition with many surgeons.
operations, there is often a single dense fibrous band Dealing with large bowel obstruction may be
causing the closed loop obstruction and this requires more challenging for technical reasons and patient
division. Small bowel viability has to be confirmed, factors.
and if there is doubt then a resection is needed and con- Colonic primary anastomosis ideally requires a clean
tinuity should be restored with a primary anastomosis. bowel (although this has been challenged by a number of
Prevention of adhesions has been the subject of studies which do not support the notion that a clean
much debate (Menzies 1992). Gentle handling, sound bowel carries a reduced risk of anastomotic leakage
surgical technique and avoiding areas of ischaemia are when compared to unprepared bowel), tension-free colon
228 S.T. Esufali

Fig. 29.2 CT scan findings in a patient (Fig. 29.1) with large

bowel obstruction due to adhesions after previous laparoscopic
cholecystectomy for biliary pancreatitis (Insert images 1, 2;
Source: Bensons Radiology, Adelaide/Mount Gambier,
Australia). There was a dense band of adhesions causing a
mechanical obstruction at the mid transverse colon level. Right Fig. 29.4 Supine abdominal X-rays of patient as shown Fig. 29.3
hemicolectomy required (Source: Benson’s radiology Adelaide/Mt Gambier, Australia)

Fig. 29.3 Erect X-rays of patient presenting with Vomiting, col-

icky abdominal pain and constipation. There is gross dilatation
of small bowel. There is some air in the transverse colon and
splenic flexure. There was a past history of gynecologic surgery.
See Fig 29.4 and 29.5. (Source: Benson’s radiology Adelaide/
Mt Gambier, Australia)
Fig. 29.5 Plain film and CT scan findings in a patient with small
bowel obstruction due to an ischaemic segment of small bowel
(Insert images 3–5; Source: Bensons Radiology, Adelaide/Mount
Gambier, Australia). Laparotmy revealed an ischaemic segment
of small bowel due to a band adhesion from previous surgery
29 Bowel Obstruction
and good blood supply for healing. Due to the obstruc-
tion, patients are unwell and have adverse physiology
scores. At surgery for colonic bowel obstruction, the
colon may be loaded. On table lavage, is an option to
achieve a clean colon (Seow-Choen et al. 1993). However,
exteriorisation of the ends or decompression stoma is
often used in the acute setting. With regard to stomas fol-
lowing surgical resection of an obstructed segment of
colon, it is also important to consider that reversal of the
colostomy may not be easy because of adhesion forma-
tion and other patient-related health factors. A number of
patients after surgery live for a long time with a tempo-
rary stoma, not requesting reversal or being advised
against surgery due to the high risk of surgery for the
reversal. In conclusion, management of patients with
bowel obstruction in a rural setting can be a challenging
and rewarding experience. The options for management
vary depending on the clinical presentation. Often sur-
gery is required, and the procedure has to be carefully
tailored to the circumstances and facilities available for
post-operative care. Surgery may vary from a decom-
pression stoma (and transfer of patient to a tertiary care
centre) to a major bowel resection, using on-table bowel
lavage techniques prior to a primary anastomosis. In my
experience, regular collaboration and dialogue with
urban based surgeons and peers, has made working in a
rural setting most satisfying and rewarding.
Summary
›› Bowel obstruction is frequently seen in rural
surgical practice and often requires expedite
management often involving major surgery.
The outcome for patients has improved with
early resuscitation, early surgery in those
­reco­gnized to be at risk of strangulation and
a combined operative and non-operative
229
management of those with simple mechanical
obstruction.
›› In rural settings, the operative technique
adheres to accepted principles. The limiting
factors relate to the availability of postopera-
tive facilities such as an ICU. Adhesions caus-
ing bowel obstruction will continue to be a
frequent surgical problem, but with minimally
invasive techniques replacing open surgery, it
remains to be seen whether or not there is a
reduction in the incidence of adhesions causing
band obstruction.
Recommended Reading
Bruening, M.H., Maddern, G.J.: Rural Surgery: The Australian
experience. Surg. Clin. North Am. 89(6), 1325–1333 (2009)
Cappell, M.S., Batke, M.: Mechanical obstruction of the small
bowel and colon. Med. Clin. North Am. 92(3), 575–597
(2008)
Dundee, P.E., Chin-Lenn, L., Syme, D.B., Thomas, P.R.:
Outcomes of ERCP: prospective series from a rural centre.
ANZ J. Surg. 77(11), 1013 (2007)
Menzies, D.: Peritoneal adhesions: incidence, cause, and pre-
vention. Surg. Ann. 24, 27–45 (1992)
Rhodes, A.I., Shorvon, P.J.: Recent advances in small-bowel
imaging: a review. Curr. Opin. Gastroenterol. 17(2), 132–139
(2001)
Rohrschneider, W.K., Troger, J.: Hydrostatic reduction of
­intussusception under US guidance. Pediatr. Radiol. 25(7),
530–534 (1995)
Seow-Choen, F., Eu, K.W.: Intra-operative irrigation for acute
distal colonic obstruction caused by carcinoma. Br. J. Surg.
80, 516 (1993)
 Diverticulitis
Matthias W. Wichmann and Karl-Walter Jauch
30.1 Epidemiology
Diverticulosis is a very common finding in most western
societies, which affects approximately 12% of the popu-
lation and has an increasing incidence with age. While
only 5% of the population at age 40 present with diver-
ticulosis, approximately two-thirds of the population at
age 65 have this condition. An estimated 10–25% of
patients with diverticulosis develop symptomatic diver-
ticular disease. Only 5% of patients with diverticulosis
require surgical treatment for the disease.
A number of risk factors for the development of
diverticulitis have been established:
• Caucasian race
• Male gender
• Obesity
• Advanced age
• Low-fiber diet
• Lack of exercise
• Immune suppression
M.W. Wichmann (*)
Department of General Surgery, Mount Gambier General
Hospital and Flinders University Rural Medical School,
276-300 Wehl Street North, Mount Gambier,
SA 5290, Australia
e-mail: matthias.wichmann@health.sa.gov.au
K.-W. Jauch
Department of Surgery, University Hospital Grosshadern,
Marchioninistr. 15, 81377 Munich, Germany
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_30, © Springer-Verlag Berlin Heidelberg 2011
30
30.2 Localization
Diverticulosis mainly affects the sigmoid and descend-
ing colon. In patients with diverticular disease of the
entire large bowel, most inflammatory changes are still
observed in the left colon, whereas most bleeding
complications develop in the ascending colon. The
underlying causes for these differences in localiza-
tion of complications of diverticular disease are not
known.
30.3 Etiology and Pathogenesis
Diverticula of the large bowel are usually so-called
pseudo-diverticula, which only consist of mucosa and
submucosa (Fig. 30.1). These pseudo-diverticula pen-
etrate the circular muscles of the large bowel at the site
of entrance of submucosal vessels.
As possible causes for the development of divertic-
ulosis, the following patho-mechanisms have been
discussed:
• Chronically increased intraluminal pressure
• Defect of intestinal innervation with subsequent
muscular hypertrophy
• Changes of collagen synthesis and structure
• Changes of bowel motility with subsequent so-
called hypersegmentation (increased pressure zones
through large portions of the large bowel not lim-
ited to the space between two haustri)
231
232
Fig. 30.1 Colonoscopy finding: diverticulosis
30.4 Clinical Symptoms and Diagnosis
30.4.1 Clinical Examination
The leading symptoms of patients with diverticulitis are
pain in the left iliac fossa as well as a varying degree of
peritonitis (guarding, rebound tenderness). Occasionally,
a large mass can be palpated in the left iliac fossa.
Approximately 5% of all patients presenting with symp-
toms of acute abdominal pain suffer from diverticulitis.
30.4.2 Additional Diagnostic Options
Additional diagnostic measures aim to
• Confirm the clinical diagnosis
• Establish the severity of disease
• Allow for grading of the disease process
• Detect/exclude other potential causes for left iliac
fossa pain (colon cancer, gynecological/urological
causes, volvulus, inflammatory bowel disease,
incarcerated hernia)
The following laboratory tests should be ordered in
patients with suspected diverticulitis: full blood cell
count, electrolytes, coagulation studies, liver function
M.W. Wichmann and K.-W. Jauch
Fig. 30.2 Computed tomography: acute complicated diverticu-
litis with free perforation and abscess formation in the pelvis
(Source: K. Herrman, Department of Radiology, University of
Munich, Munich, Germany)
tests, urea, creatinine, lipase, C-reactive protein, and
urine dipstick.
The following imaging studies are available:
• Computed tomography of the abdomen with i.v.,
oral and rectal contrast (300 ml of water) (Fig. 30.2)
• (Editorial comment: rectal contrast is not consid-
ered a diagnostic standard in some countries (i.e., the
USA))
• Abdominal ultrasound
• Colonoscopy
• Contrast enema with water-soluble contrast
Computed tomography allows for a reliable diagno-
sis in almost all cases of diverticulitis and is the
imaging technique of first choice for these patients.
Major advantage of computed tomography (CT) is that
complications such as fistula formation, stenosis, per-
foration, and abscess can be diagnosed and treated at
the same time (drainage of perforation and abscess).
Moreover, the CT allows to determine the extent of
inflammatory changes as well as the risk of recurrent
disease.
Abdominal ultrasound can be considered a
­com­plimentary examination which may be helpful to
investigate other causes of acute abdominal pain
(cholecystitis, adnexitis, stones within the renal tract).
30 Diverticulitis
Colonoscopy is used as an elective tool after com-
plete clearance of the acute inflammation and should be
carried out 4–6 weeks after hospital discharge follow-
ing successful conservative treatment. There is, how-
ever, a trend to perform colonoscopy earlier (1–2 weeks)
after acute diverticulitis. This procedure allows to
exclude large bowel cancer and is necessary to evaluate
the severity of diverticular disease and the possible need
for elective surgical intervention. A ­contrast enema of
the large bowel can also be used at this stage as an addi-
tional imaging tool but provides only limited additional
information to the CT with rectal contrast.
Cave
The colonoscopy should not be carried out during
acute inflammation due to the extremely high risk
of large bowel perforation.
30.5 Classification of Diverticulitis
Two important classifications of diverticulitis exist –
the Hinchey classification (1978) and the Hansen and
Stock classification. While the Hinchey classification
(Table 30.1) is based on the intraoperative findings of
perforated diverticulitis, the classification of Hansen
and Stock (Table 30.2) considers the findings of
Table 30.1 Hinchey classification of perforated diverticulitis
I. Pericolic abscess formation
II. Covered abscess in lower abdomen, retroperitoneum or
pelvis
III. Free perforation with putrid peritonitis
IV. Free perforation with fecal peritonitis
Table 30.2 Hansen and stock classification of diverticular
disease
0. Asymptomatic diverticulosis
I. Uncomplicated diverticulitis
II. Complicated diverticulitis
(a) Inflammation and phlegm of the pericolic fatty tissue
(b) Abscess formation
(c) Free perforation
III. Chronic recurrent diverticulitis
233
clinical evaluation, colonoscopy, contrast enema, and
CT. This classification, therefore, includes all stages of
the disease and does not require surgical intervention
to be applied.
30.6 Therapeutic Strategy
Uncomplicated diverticulitis without signs of systemic
disease can be treated without hospital admission using
oral antibiotics (amoxicillin + b-lactamase inhibitor or
ciprofloxacin + metronidazole) and fluid/light diet for
3–5 days. Signs of peritonitis and/or systemic infec-
tion require hospital admission, intravenous antibiotics
(second generation cephalosporin or ciprofloxacin plus
metronidazole), and liquid/low residue diet only. The
diagnosis should be established urgently (emergency
CT). Clinical findings and the results of CT will allow
the surgeon to decide whether emergency surgery is
necessary (free perforation), or a conservative approach
can be chosen.
The flowchart in (Fig. 30.3) indicates the recom-
mended diagnostic and therapeutic steps for patients
with suspected diverticulitis.
30.7 Conservative Therapy
If uncomplicated diverticulitis is diagnosed with the
help of CT (Stage I of the Hansen and Stock classifica-
tion), there is no indication for surgical intervention.
Treatment usually consists of the following:
• Reduction of oral food intake reduced to liquids or
nil per mouth
• Intravenous fluid therapy and supplementation of
electrolytes, in severely sick patients parenteral
nutrition can be considered
• Intravenous antibiotics
Clinical assessment and blood tests (body temperature,
white blood cell count, C-reactive protein) should
show a significant improvement within 72 h after
initiation of treatment.
Should no improvement or worsening of symptoms
be detected, a repeat CT should be done to exclude a
secondary perforation.
234 M.W. Wichmann and K.-W. Jauch

After 1st episode of uncomplicated diverticulitis: plan colonoscopy 3–6 weeks after inflammation has settled.
After 2nd episode of uncomplicated diverticulitis: plan early-elective or elective resection.
Following emergency surgery: plan stoma reversal 3–6 months after discharge.

Admission diagnosis: Acute abdominal pain

Clinical impression: Acute diverticulitis

Laboratory diagnostics

Full blood cell count, electrolytes,

coagulation studies,
liver function tests, urea, creatinine, urea,
C-reactive protein

CT contrast with rectal filling

Uncomplicated diverticulitis Complicated diverticulitis: Complicated diverticulitis:

without free perforation with free perforation

Conservative therapy: Emergency intervention:

• Admission • CT/US-guided drainage Emergency operation:
• Clear fluid diet Emergency operation • Hartmann procedure
• IV antibiotics • Hartmann procedure • If possible primary anastomosis
• If possible primary anastomosis ± ± covering stoma
covering stoma
Early-elective surgery after
successful drainage

Fig. 30.3 Flow-chart: diagnostic and treatment of acute diverticulitis

If the conservative treatment is successful, oral food 30.8 Surgical Therapy

intake can be restarted and antibiotics should be given
for a total of 3–5 days.
Prior to discharge, the patient should be informed
about the need for high fiber diet, weight reduction,
and regular exercise to avoid recurrent diverticulitis.
4–6 weeks after clinical normalization, the large bowel
needs to be investigated with colonoscopy or virtual
colonoscopy (possibly contrast enema as well).
30.8.1 Timing of Surgery
Surgery can be done as an emergency, early elective
(3–7 days after onset of symptoms and initial resusci-
tation) or elective (> 3 weeks after conservative treat-
ment of acute diverticulitis) procedure.
30 Diverticulitis
30.8.2 Indication for Surgical Treatment
(a) Uncomplicated acute diverticulitis (stage I)
Following successful conservative treatment,
almost all patients will remain free of recurrent
problems and will not require additional treatment.
There is no indication for emergency surgery, and
elective surgery should only be discussed in immu-
nocompromised patients.
(b) Acute complicated diverticulitis
−− Phlegm of the pericolic fatty tissue (stage IIa):
successful conservative treatment does not
require additional elective surgery; failure of
conservative treatment or early recurrent symp-
toms justify early elective surgery
−− Pericolic abscess formation or covered perfora-
tion (stage IIb) usually requires surgical interven-
tion, which can be done after initial stabilization,
antibiotic treatment, and interventional abscess
drainage; if the clinical situation does not improve
within 72 h or interventional drainage is not avail-
able, emergency surgery is needed; it is important
to note that interventional drainage is only possi-
ble in approximately 10% of the patients and has
a complication rate of up to 5%; usually surgery
can be carried out safely as an early elective pro-
cedure within 4–5 days after initial stabilization,
which saves a second hospital admission
−− Free perforation (stage IIc) with diffuse perito-
nitis always requires emergency surgery
(c) Chronic recurrent diverticulitis (stage III)
Chronic pain following multiple episodes of acute
diverticulitis usually requires surgical interven-
tion, although it has been reported that a signifi-
cant number of patients will not remain free of
symptoms after surgery. Recent studies, further-
more, do not support mandatory surgery with
recurrent diverticulitis since most complications
appear to develop with the first episode, and not
with later episodes of diverticulitis.
30.8.3 Surgical Procedures
Aim of surgical treatment is the complete removal of
the inflamed/perforated segment of the large bowel
including the recto-sigmoid junction (RSJ) to avoid
235
recurrent disease. Non-inflamed diverticula do not
need to be removed; care should be taken, however,
not to include a diverticulum into the anastomosis.
The distal extent of resection is of major impor-
tance to avoid recurrent disease. The anastomosis
needs to be formed distal to the RSJ within the
mid-rectum to remove the recto-sigmoid high-
pressure zone.
Surgical consent must mention the major complica-
tions: covering ileostomy or loop-/end-colostomy, lac-
eration of the urether, anastomotic leakage, and sepsis.
(a) Primary anastomosis has only recently been
included into the guidelines for treatment of perforated
diverticulitis. Resection of the sigmoid colon and RSJ
with primary anastomosis can safely be done in most
patients even when free perforation has occurred.
Formation of a covering loop ileostomy should be
considered during surgery and may be useful to avoid
secondary sepsis from anastomotic failure.
(b) Hartmann procedure with resection of the
sigmoid colon and formation of an end colostomy
without anastomosis. This procedure can be very dif-
ficult to reverse and subsequently up to 45% of these
patients have a permanent end colostomy.
Primary anastomosis should not be attempted if the
patient suffers from significant comorbidity (need of
intensive care at the time of surgery, immune dysfunc-
tion, liver cirrhosis, renal failure) at the time of surgery.
Surgery can be carried out via conventional midline
laparotomy, Hockey-stick incision in the left lower
abdomen or as a laparoscopic procedure. Peri- and
postoperative care should include ongoing antibiotic
treatment for 3–5 days, low-molecular-weight heparin
and early start of enteral nutrition. In patients with
severe sepsis, a delay of enteral feeding may be neces-
sary and some of these patients may require parenteral
nutrition.
30.9 Complications of Diverticulitis
• Fistula formation: 10% of in-hospital treatment of
patients with diverticular disease; two-thirds colo-
vesicular fistula; indication for elective surgery
236
• Impaired colonic passage: irreversible fibrous
stenosis of the large bowel; indication for elective
surgery
• Bleeding: most common cause of lower gastroin-
testinal bleeding (40%); 15% of patients with diver-
ticulosis; high risk of recurrent bleeding (40%);
bleeding source usually in the ascending colon
(>50%); emergency surgery may be necessary;
selective abdominal angiogram should be carried
out for localization and possible embolization
30.10 Prognosis
The first episode of acute diverticulitis can usually be
managed with conservative treatment and 75% of these
patients do not suffer from recurrent disease and only
10% require surgical intervention at a later point in
life. Following surgical treatment, recurrent disease
has been observed in up to 11% of the patients and
reoperation is necessary in 3%. Recurrent disease
M.W. Wichmann and K.-W. Jauch
mainly results from a too high anastomosis above the
RSJ. If the inflamed large bowel is removed completely
during the primary intervention, the more proximal
diverticular do not influence the risk of recurrent
disease.
Recommended Reading
Chapman, J., Davies, M., Wolff, B.: Complicated diverticulitis:
is it time to rethink the rules? Ann. Surg. 242, 576–581
(2005)
Constantinides, V.A., Tekkis, P.P., Athanasiou, T.: Primary
resection with anastomosis vs. Hartmann’s procedure in
nonselective surgery for acute colonic diverticulitis: a
systemic review. Dis. Colon Rectum 49, 966–981 (2006)
Platell, C.: Critical evaluation: surgery for uncomplicated diver-
ticulitis. ANZ J. Surg. 78, 96–98 (2008)
Rafferty, J., Shellito, P., Hyman, N.H., et al.: Practice parameters for
sigmoid diverticulitis. Dis. Colon Rectum 49, 939–944 (2006)
Zorcolo, L., Covotta, L., Carlomagno, N., et al.: Toward lower-
ing morbidity, mortality and stoma formation in emergency
colorectal surgery: the role of specialisation. Dis. Colon
Rectum 46, 1461–1467 (2003)
 Therapy of Sepsis
Johannes N. Hoffmann
31.1 Definition
With the initiation of the first large sepsis trials, the
necessity of a common definition of sepsis was gener-
ally accepted. In contrast to the historical definitions,
which implicated bacteraemia (Schottmüller 1918), sep-
sis was for the first time defined as the systemic reaction
of the organism to infection (formally sepsis syndrome
as introduced by Bone) based on clinical criteria of sep-
sis. The change in sepsis definition was necessary since
only 20–40% of patients with sepsis show bacteraemia.
Sepsis does not necessarily implicate the diagno-
sis of bacteraemia. Thus, in 60–80% of patients
with sepsis microbiology is negative despite clear
clinical signs of infection.
A consensus definition of sepsis was published
in 1992 by the American College of Chest
Physicians, the Society of Critical Care Medicine
and other important societies. This definition is
currently accepted also in terms of clinical studies.
31.2 Systemic Inflammatory
Response Syndrome
Systemic inflammatory response syndrome (SIRS)
describes the inflammatory reaction of the organism as
a part of inflammation. Several clinical criteria were
J.N. Hoffmann
Department of Surgery, University of Munich – Großhadern,
Marchioninistr. 15, 81377 Munich, Germany
e-mail: johannes.hoffmann@med.uni-muenchen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_31, © Springer-Verlag Berlin Heidelberg 2011
31
defined, which allowed the diagnosis of SIRS, if two
or more of following symptoms are fulfilled:
• Body temperature > 38.0°C or < 36.0°C
• Heart rate > 90/min
• Respiratory rate > 20/min
• PaCO2 < 30 mmHG
• Leukocytes > 12 G/l or < 4 G/l or less than 10%
unripe leukocytes.
31.3 Sepsis
Sepsis is defined as an inflammatory reaction of the
organism to an infection. The diagnosis of sepsis
implicates occurrence of at least two criteria of SIRS
in combination with suspected or manifest infection.
Infection is diagnosed if microorganisms are detected
in normally sterile tissues or body cavities, or if there
is a strong clinical suspicion of infection. This impli-
cates that the infectious agents do not have to be identi-
fied when the diagnosis of sepsis is made.
31.4 Severe Sepsis
Severe sepsis is defined as sepsis associated with organ
dysfunction, hypoperfusion, or hypotension. Hypo­per­
fusion or perfusion abnormalities can occur as lactate
acidosis, oliguria, or changes in mental status.
31.5 Septic Shock
Septic shock is defined as hypotension despite ade-
quate volume administration or catecholamine therapy
with concomitant changes in microperfusion. Changes
237
238 J.N. Hoffmann

Table 31.1 Organ support in severe sepsis

Organ Treatment
Lung Controlled ventilation with reduced volumes
(4–6 ml/kg bodyweight) combined with PEEP
(independent from FiO2)
Circulatory failure Volume application (300–500 ml/30 min.)
as initial treatment for haemodynamic stabiliza-
tion, followed by higher amounts until
stabilization
Central venous saturation >70%, volume
application, erythrocyte concentrates to correct
Hb >8, dobutamin
Kidney Haemofiltration- or haemodialysis therapy
Intermittent or continuous treatment
Coagulation Therapy of disseminated intravascular
coagulation
Remarks
Recommendation according to multiple prospec-
tive randomized trials (ARDS network study)
Recommendation according to Rivers, who
described initial hemodynamic stabilization in
pts. with severe sepsis in an emergency unit
In acute renal failure, early high-volume haemofil-
tration is justified. High amounts of daily
ultrafiltration rates (>2 L/day) correlate with low
survival rates
Antithrombin is recommended in DIC based on
phase-II-studies. Expert opinions differ
substantially

in organ perfusion can manifest as lactate acidosis, have to be treated, the incidence of sepsis is currently
oliguria, or acute central nervous dysfunction. increasing all over the world.

31.6.1.1 Risks for the Development of Sepsis

31.6 Multiorgan Dysfunction Syndrome
• Immunosuppression (diabetes, alcoholism, chronic
Multiorgan dysfunction syndrome (MODS) is defined as renal failure)
an acute change in organ function in critically ill patients. • Tumor
To preserve haemostasis, intervention is necessary. • Higher age
The four stages of sepsis directly correlate with • Invasive procedures
mortality: Mortality of SIRS reaches 10%, sepsis has a • High BMI
mortality of approximately 20%, severe sepsis of about
40%, and septic shock leads to death in about 80%.

31.6.1 Epidemiology
Severe sepsis (sepsis with associated organ dysfunc-
tion) and multiorgan failure are the leading cause of
death of critically ill patients from non-cardiology
intensive care units. In Germany, about 60,000 patients
per year die from severe sepsis or septic shock.
Therefore, sepsis is the third common reason of death
in Germany. More than 50% of patients develop septic
shock, which is related to a mortality of 60–80%. Since
increasing numbers of older patients with complicated
illnesses or other concomitant risk factors for sepsis
31.6.2 Pathophysiology
In patients with sepsis, the primary protective pro-
cesses of local defense of inflammation convert to
detrimental actions against the host, and can lead to
“whole body inflammation.” Primarily, inflammation
is triggered by toxins or other components of the bac-
terial cellular wall, which are released from microor-
ganisms (e.g., endotoxin of gram-negative bacteria or
exotoxins from gram-positive bacteria). Also, fungal
and viral infective agents can invade the circulation via
disrupted mucosal layers. Pro- and anti-inflammatory
mediator systems may enhance release of these toxins.
31 Therapy of Sepsis
In addition, inflammatory mediators can activate dif-
ferent humoral cascade systems, such as the coagulation
system, the fibrinolytic system, and the kallikreine-
kinine system.
The underlying pathomechanisms have been well
characterized for gram-negative sepsis. Endotoxin of
gram-negative bacteria (Lipopolysaccaride) binds to
LPS-binding protein (LBP), an acute phase protein,
which is produced by the liver. Thereby, the complex
from LPS and LBP activates the monocyte/mac-
rophage receptor (CD14), which presents endotoxin
to the TLR-4-receptor. Via a complex signal trans-
duction cascade, an activation of transcription factors
within the nucleus is induced (e.g., nuclear factor
kappa beta, NFkB). This central transcription factor
initiates gene expression of multiple proinflamma-
tory cytokines such as Interleukin 1 (IL-1), IL-6, and
tumor necrosis factor alpha (TNF-a). The organism
mutates to an active player in the inflammation pro-
cesses, which induces the changes in regulation and
cascade systems.
Over the last decade, the important role of coagula-
tion in sepsis has been defined. Tissue factor release
and increased thrombin production were recognized
as main mechanisms of septic coagulopathy. Simulta­
neously, natural inhibitors of coagulation (antithrom-
bin, Protein C, tissue factor pathway inhibitor, protein
S, protein Z) are consumed. The degree of inhibitor
consumption correlates with a poor prognosis in sep-
sis. Thus, antithrombin activities < 40% are correlated
with 50% mortality in septic patients.
Changes in endothelial function are mediated by
the activation of monocytes and macrophages and
other inflammatory cells, which result in an additional
release of tissue factor. The normally anticoagulant
endothelial cell surface is changed to procoagulatory.
This change in surface characteristics induces an inter-
action of leukocytes with endothelial cells, and,
thereby, acute “microcirculatory failure” in the organs,
which is manifesting as secondary multiple organ dys-
function syndrome. Microcirculatory failure also has
been defined as the motor of sepsis.
A loss of endothelial integrity induces changes in
the endothelial barrier allowing bacterial toxins and
bacteria to evade. Thus, it has been shown that endo-
toxin can translocate from the bowel to the portal vein
and the liver, thereby inducing systemic inflammation.
For the development of therapeutic strategies, the
phase of inflammatory response plays a key role. It is
239
Table 31.2 Common sources of sepsis
Focus of sepsis
Lung 50%
Abdomen/pelvis 20%
Urosepsis and soft-tissue 10–15%
infection
Catheter infection <10%
Unclear focus ~10%
critical to discriminate between the hyperinflamma-
tory status and the status of immunoparalysis/immu-
nosuppression. This clinical important discrimination
is nowadays possible by using systemic Interleukin-6
(IL-6) and procalcitonin measurements as well as
HLA-DR-expression on monocytes.
Several studies show that early interventions in sep-
sis can improve prognosis. Thus, causative or support-
ive therapy is related to a lower mortality. In addition,
it is highly important to discriminate between the dif-
ferent stages of sepsis (SIRS, sepsis, severe sepsis,
MODS). In severe sepsis, it is crucial to introduce early
goal-directed volume therapy to stabilize the circula-
tion. Also, the early use of antibiotics has been related
to better survival in critically ill patients.
To allow an adequate diagnosis of sepsis, it is
important to know about typical localizations of the
septic focus. Table 31.2 shows the distribution of dif-
ferent sepsis focuses in critically ill patients.
In surgical patients with sepsis, more than 20%
have an abdominal focus. Patients suffering from sep-
sis with unclear focus have an extremely poor progno-
sis because causative therapy is not possible (mortality
reaches 100%). Every effort must, therefore, be made
to establish the cause of sepsis and to allow for ade-
quate treatment.
31.6.3 Past Medical History
History taking includes the documentation of impor-
tant risks for the development of sepsis. To allow the
correct diagnosis, history of operations (wound infec-
tion, anastomotic leakage) or interventions (puncture,
catheters, endoscopy, radiofrequency ablation) has to
be documented.
240
31.6.4 Clinical Symptoms
The clinical picture of patients with sepsis can show
great variation.
Typical symptoms of patients with sepsis are
• Unclear change of the mental status as a sign of
septic encephalopathy
• Fever or hypothermia, shivering
• Exsiccosis
• Hypotension, tachycardia
In postoperative patients with or without fever,
who show a change of their mental status, which
cannot be explained, sepsis must be considered as
a potential cause.
31.6.5 Diagnostic Procedures in Patients
with Suspected Sepsis
After collecting the patient’s history and clinical exam-
ination, the following steps should be considered:
• Removal of central venous catheters and other
catheters and microbiologic testing of the catheter
tips
• Before application of antibiotics: appropriate blood
sampling taken from different sites to allow blood
cultures
• Sampling of urine, pleural fluids, wounds, drain-
ages, and gram staining as well as appropriate
cultures
• At least two blood cultures (aerobic an anaerobic)
from venous puncture, or alternatively from central
venous catheters
• Laboratory tests (white blood count, IL-6, procalci-
tonin, partial thromboplastin time, thromboplastin
time, antithrombin, pO2, pCO2, pH lactate, bicar-
bonate, creatinine, bilirubin)
• Radiological imaging (chest x-ray, CT scan,
ultrasound)
If catheter-associated infection is suspected, the catheter
has to be removed. Changes via guide wire should not
be performed in this situation. Changes of catheters as a
part of the clinical routine, however, cannot minimize
J.N. Hoffmann
the risk of catheter infection. Blood cultures have to be
taken after adequate disinfection via peripheral venous
puncture. Probes should be filled with at least 10 ml of
blood and 2–3 cultures should be performed (aerobic
and anaerobic).
If a ventilator-associated pneumonia is diagnosed,
endotracheal aspirates or a protected specimen brush
sampling can be used. Quantitative measurements
appear to yield a more secure diagnosis of pneumonia.
If a wound infection is diagnosed, microbiological
specimens should be taken.
Parameters of infection should be measured as well
as indicators of organ dysfunction. Since disseminated
intravascular coagulation implies a two times higher
mortality in patients with severe sepsis, coagulatory
studies should be done. X-rays are to be performed
depending on the clinical picture and the severity of
sepsis.
31.6.6 Interventions in Postoperative
Patients
Standardized protocols should be used when dealing
with postoperative patients who are believed to suffer
from sepsis. Initially, central venous catheters have to
be removed. This measure often reduces the need for
further diagnostic steps and may be all the therapy
needed.
31.6.6.1 The Postoperative Patient
• History: When has the patient been operated?
Implantation of foreign material? Transfusions?
Septic wounds/operations?
• Clinical evaluation (septic focus?)
• Inspection of wounds. Removal of all bandages
and thorough clinical evaluation (fluctuation,
redness?)
• Signs of pulmonary infection?
• Abdominal pain? Paralysis? Guarding? Quality of
drainage secretion, bilirubin (leakage?), or creati-
nine determination in drainage fluid specimens
• Analysis of pleural effusions, ascites, fluids in oper-
ation wounds
31 Therapy of Sepsis 241

31.6.7 Therapy 31.7 Necrotizing Soft Tissue Infections

Sepsis therapy can be categorized in three steps: Necrotizing infections/necrotizing fasciitis are life-
threatening illnesses. Potential microbiologic agents
• Clearance of the septic focus (operation, interven-
are Streptococci, Staphylococci, Clostridia, and some-
tion, drainage, antibiotics)
times Candida.
• Support of organ dysfunction (mechanical ventila-
tion, haemofiltration, catecholamine, and volume
therapy)
• Adjunctive sepsis therapy
31.8 Damage Control

Damage control can be achieved by removal of necrotic

tissue during the initial operation, but also during
­second- or third-look operations. Especially in necro-
31.6.8 Clearance of the Septic Focus tizing soft-tissue infections, effective initial resection
is crucial. A gram preparation should be performed.
Histology confirms the diagnosis. Second-look opera-
The septic focus has to be cleared as fast as possible. tions after 24 h depending from the clinical status are
re­commended. Earlier reoperations have to be
­performed in case of deteriorating organ function.
Clearance of the septic focus represents the main High-dosed Penicillin G (4 × 10 M) combined with
basis for successful treatment of severe sepsis carbap­enems are recommended.
and septic shock.

A number of retrospective analyses clearly indicate
that failure of surgical clearance of the septic focus is
associated with a significant increase in mortality,
which reaches almost 100%.
In peritonitis, the time lost until effective clearance
of the septic focus is achieved correlates with an
increase of mortality.
31.9 Peritonitis
Exploration of all four abdominal quadrants is manda-
tory. Surgical clearance of the focus may be supported
by antimicrobial therapy. The primary antibiotic ther-
apy is empiric respecting the most probable bacterial
load. After receiving microbiology, calculated antibi-
otic therapy is performed.

31.10 Anti-infectious Treatment
31.6.8.1 Interventions to Clear the Septic Focus in Sepsis

Abscess Incision and drainage
Necrotizing fasciitis Resection, vacuseal treatment
Subphrenic abscess CT or ultrasound-guided abscess
drainage, operation
Septic gangrene Amputation
Peritonitis Revision surgery, wash-out,
drainage
Abdominal Laparotomy, open abdomen
compartment
Pancreatitis Surgical/radiological drainage,
removal of necrosis
Anti-infectious therapy is early performed with antibi-
otics and antimycotic substances. Also, antiviral drugs
can be used.
Current guidelines recommend antibiotic treatment
during the first hours after initiating the diagnosis.
Bacterial cultures should be taken before antibiotic ther-
apy starts. In sepsis of unknown origin, a therapy with
cephalosporins group 3, acyl-aminopenicillin plus beta-
lactamase inhibitors or carbapenems is recommended.
In suspected pulmonary infection third-generation
cephalosporins, acyl-aminopenicilline plus inhibitors
of betalactamase or carbapenems are indicated.
242 J.N. Hoffmann

For abdominal infections, acyl-aminopenicillins or
third-generation cephalosporins plus metronidazol or
carbapenems are recommended. The antibiotic regi-
men is to be tested in terms of efficacy every 72 h.
Therapeutic escalation should be performed if neces-
sary. If resistant bacteria are diagnosed, antibiotics
should be changed. Duration of antibiotic therapy
should not exceed 5–7 days.
In Pseudomonas infections, a Pseudomonas active
substance should be used (ureidopenicillins or third/
fourth generation cephalosporin or carbapenem). In
multiresistant staph. aureus (MRSA)-infection glyco-
peptides (e.g., Vancomycin) or oxazolidon (Zyvoxid)
should be used. Zyvoxid is also recommended in pul-
monary infections. A prophylactic antimycotic therapy
is not indicated with the exception of immunocompro-
mised patients with severe sepsis. In transplantations
and neutropenic patients, antimycotic therapy should
be introduced earlier.
31.11 Support of Organ Function
in Sepsis
All efforts must be made to improve microperfusion in
critically ill patients. Thereby, development of multi-
system organ failure may be prevented.
With regard to circulatory failure, early goal-
directed therapy includes volume administration
at 300–500 ml during the first 30 min for circula-
tory support followed by larger amounts until stabili-
zation. Central venous oxygen saturation is maintained
above 70% and blood transfusions are given to correct
the hemoglobin above 8. If needed, inotropes (dobu-
tamin) are used to maintain blood pressure.
31.12 Adjunctive Therapy
Adjunctive therapy of sepsis has to be combined with
standard therapy (clearance of septic focus). In the
last decade, multiple concepts investigating specific
sepsis therapies antibodies against endotoxin and exo-
toxins or sepsis mediators, e.g., anti-TNF, anti-IL-1,
anti-PAF, were investigated; all studies were negative.
However, promising results from phase-III-trials with
coagulatory inhibitors have been published. One
phase-III-trial with activated protein-C showed a
significant reduction in mortality. Confirmatory trials
have been started. Antithrombin has been effective in
septic patients without receiving concomitant heparin
(Table 31.3).

Table 31.3 Adjunctive therapy in sepsis (examples)

Medication Implementation/indication/doses
Low-dose/high-dose 200–300 mg/d continuously over 24 h n pts.
Corticoids with septic shock that does not response to
vasopressors
Recombinant activated 24 mg/kg KG/over 96 h during 24 h after diagnosis
protein C of sepsis in pts with APACHE II >25 or >2 organ
failures respecting contraindications
No indication in children
No indication in 1-organ-failure, especially after
surgical treatment
Antithrombin 6,000 IE/24 h over 4 d (AT did not result in reduction
of 28-d-mortality being combined with heparin. If
heparin administration is omitted, there was a clear
reduction in mortality in a subgroup of pts with DIC
Immunoglobulines i.v. IgGMA application reduced mortality in
multiple phase-II-trials. A recent meta-analysis
showed positive effects for IGMAs, not for IGG
Expert opinions differ substantially
Remarks
High-dose cortisone is not recommended
Randomized trial negative for low-dose
corticoids (CORTICUS trial. Sprung et al.)
Cardiocirculatory stabilization
Not generally accepted, one positive
randomized controlled trial. Confirmatory
trial (PROWESS Shock) actually
conducted
Mortality reduction only if heparin is
omitted (Hoffmann et al.), not recom-
mended by guidelines
Not generally recommended
31 Therapy of Sepsis
31.13 Summary
Sepsis remains a challenging problem in intensive care
medicine and is associated with significant mortality.
Despite a number of clinically relevant phase III treat-
ment trials, mortality has not substantially improved
during the last decades. Clearance of the septic focus
and initiation of relevant diagnostic interventions must
be done immediately if sepsis is suspected. Antibiotic
and specific surgical therapy is to be performed as soon
as possible after taking blood cultures. It has been
demonstrated that anti-inflammatory strategies target-
ing specific cytokines or other inflammatory mediators
cannot reduce mortality. Therefore, pleiotropic acting
agents are nowadays tested in phase III trials.
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Arkins, N., Utterback, B.G., Macias, W.L., Administration
of Drotrecogin Alfa (Activated) in Early Stage Severe Sepsis
(ADDRESS) Study Group: Drotrecogin alfa (activated) for
adults with severe sepsis and a low risk of death. N. Engl. J.
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Dellinger, R.P., Levy, M.M., Carlet, J.M., Bion, J., Parker,
M.M., Jaeschke, R., Reinhart, K., Angus, D.C., Brun-
Buisson, C., Beale, R., Calandra, T., Dhainaut, J.F.,
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Ramsay, G., Sevransky, J., Thompson, B.T., Townsend, S.,
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College of Chest Physicians, American College of
Emergency Physicians, Canadian Critical Care Society,
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Hoffmann, J.N., Wiedermann, C.J., Juers, M., Ostermann, H.,
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Sprung, C.L., Annane, D., Keh, D., Moreno, R., Singer, M.,
Freivogel, K., Weiss, Y.G., Benbenishty, J., Kalenka, A., Forst,
H., Laterre, P.F., Reinhart, K., Cuthbertson, B.H., Payen, D.,
Briegel, J., CORTICUS Study Group: Hydrocortisone therapy
for patients with septic shock. N. Engl. J. Med. 358(2),
111–124 (2008)
Storck, M., Hartl, W.H., Zimmerer, E., Inthorn, D.: Comparison
of pump-driven and spontaneous continuous haemofiltration
in postoperative acute renal failure. Lancet 337(8739),
452–455 (1991)
Warren, B.L., Eid, A., Singer, P., Pillay, S.S., Carl, P., Novak, I.,
Chalupa, P., Atherstone, A., Pénzes, I., Kübler, A., Knaub, S.,
Keinecke, H.O., Heinrichs, H., Schindel, F., Juers, M., Bone,
R.C., Opal, S.M., KyberSept Trial Study Group: Caring for
the critically ill patient. High-dose antithrombin III in severe
sepsis: a randomized controlled trial. JAMA 286(15),
1869–1878 (2001). Erratum in: JAMA 2002 Jan 9;
287(2):192
 Bowel Cancer
Peter Hewett and Cu Tai Lu
32.1 Introduction
In most developed nations, there has been a steady
increase in the incidence of colon cancer over the last
20–30 years. In South Australia, this has been driven
largely by an increase in the incidence of colon cancer
in males. However, colon cancer mortality rates have
shown a steady decline in the 1977–2006 periods. This
decline has been in the female population, whose
­mortality rate has dropped from over 20/100,000 in the
1970s to 11.2/100,000 [1].
As there is an increasing uptake of Faecal Occult
Blood Test, screening for bowel cancer is beginning to
show a pattern of increasing incidence and decreasing
mortality that is similar to that of breast cancer. The
reported improvements in bowel cancer survival are
promising.
There is evidence that more cancers are being diag-
nosed in the proximal sections of the large bowel,
which may reflect better diagnostic techniques. This
trend may continue as bowel cancer screening becomes
more widely adopted. Australians of northern and
western European extraction continue to have the high-
est rates of bowel cancer incidence and mortality in
South Australia.
P. Hewett (*) and C.T. Lu
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: peter.hewett@health.sa.gov.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_32, © Springer-Verlag Berlin Heidelberg 2011
32
32.2 Diagnosis
Adequate history taking and physical examination
including digital rectal examination remain vitally
important for proper diagnosis of colorectal cancer.
Digital rectal examination and rigid or flexible sigmoi-
doscopy after preparation with an enema helps diag-
nose rectal cancer. At least 50% of cancers in the lower
gastrointestinal tract are within reach of a flexible
­sigmoidoscope. Of all bowel cancer sites, rectum and
sigmoid colon account for 49.3% of all male bowel
cancers and 42.9% of all female cancers for the 10-year
period 1997–2006 [1]. Endoscopic examination of the
rectum and colon remains the definitive diagnostic
modality. If this is not possible due to technical diffi-
culties or patient comorbidity, barium enema should
be performed, or if available, CT virtual colonoscopy
is a viable alternative.
32.3 Familial Large Bowel Cancer
Familial colorectal cancer accounts for about 2–4%
of all colorectal cancer. Hereditary non-polyposis
­colorectal cancer (HNPCC)) and familial adenoma-
tous polyposis (FAP) are the two most common heredi-
tary forms of colorectal cancer.
HNPCC is an autosomal dominant condition distin-
guished from FAP by the absence of multiple colorec-
tal adenomas. The lifetime risk of colorectal cancer in
HNPCC is 80%. The associated cancers include that of
the endometrium, ovary, stomach, small bowel, renal
pelvis, and ureter. Mutations in the mismatch repair
genes (MMR) give rise to HNPCC. The product of
MMR genes repair incorrect base pair matching during
DNA replication in cell division. The defect in MMR
245
246
genes results in the accumulation of more mutations,
leading to instability in the length of microsatellite
sequences in the DNA, also known as microsatellite
instability (MSI) [2].
HNPCC is characterized by the early onset of col-
orectal cancer, in particularly proximal colonic cancer.
Other features include poorly differentiated muci-
nous adenocarcinoma, synchronous or metachronous
tumours, and marked infiltration of lymphocytes and
lymphoid aggregation at tumour margins. Cancer
registries and familial cancer clinics are involved in
counseling and undertaking germ line genetic testing
to identify affected families and affected members.
Revised Bethesda guideline can be used as an adjunct
to determine whether tumour tissue should be tested for
MSI as the first line of investigation for HNPCC [3].
1. Colorectal cancer diagnosed in a patient who is less
than 50 years of age
2. Presence of synchronous, metachronous colorectal
cancer, or other HNPCC-associated tumours regard-
less of age
3. Colorectal cancer with the MSI-H histology diag-
nosed in a patient who is less than 60 years of age
4. Colorectal cancer diagnosed in one or more first-
degree relatives with an HNPCC-related tumour,
with one of the cancers being diagnosed under age
50 years
5. Colorectal cancer diagnosed in two or more first- or
second-degree relatives with HNPCC-related
tumours, regardless of age
MSI testing is now readily available and should be per-
formed on tumours from patients that fulfil any of the
Bethesda criteria. Referral to a familial cancer clinic is
necessary if there is a suspicion that there is a familial
predisposition to formation of colorectal cancer. Upon
consultation and counseling the affected individuals,
germ line genetic testing may be performed.
32.3.1 Surveillance and Surgery
in HNPCC
Colorectal cancer surveillance is paramount. Regular
surveillance colonoscopy reduces the risk of colorectal
cancer in HNPCC [4]. In a case of confirmed HNPCC,
colonoscopy at 12 monthly intervals is recommended
[5]. In those at risk, colonoscopy every 2 years from
P. Hewett and C.T. Lu
age 25 years or 5 years younger than the index case is
recommended [5]. Surveillance for HNPCC-related
tumours should be considered as routine. Prophylactic
surgery in HNPCC remains controversial. Colectomy
for adenoma or cancer should be either total colectomy
and ileorectal anastomosis or formal hemicolectomy.
FAP accounts for less than 1% of total colorectal
cancer; it is less frequent than HNPCC. FAP is also
an autosomal dominant condition. A mutation of the
adenamatous polyposis coli (APC) gene, a tumour
suppressor gene, located on chromosomes 5q21, is
responsible for the early development of hundreds of
colorectal adenomas in early teen and eventually devel-
ops into colorectal cancer by the age of 50 years.
32.3.2 Prophylactic Surgery
Evidence suggests prophylactic surgery reduces the
risk of colorectal cancer, but long-term survival
depends on the recognition of extracolonic tumours [6].
Total colectomy and ileo-rectal anastomosis is recom-
mended as early as 15 years of age. Subsequent close
surveillance of the rectum with flexible sigmoidoscopy
is then required. The quality of life improves with less
bowel frequency and allows the establishment of fam-
ily prior to pelvic dissection in restorative proctocolec-
tomy. Desmoid tumours, in particular, intra-abdominal
desmoid tumours, are the second commonest cause of
death in FAP.
Duodenal cancer is the third most common cause of
death in FAP [7]. By 70 years of age, over 90% of FAP
would develop duodenal adenomas and the median age
at diagnosis is 38. Surveillance for extra-colonic
tumours such as duodenal cancer is mandatory.
32.4 Surgery for Colon Cancer
32.4.1 Preoperative Preparation
Careful preoperative preparation of the patient to reduce
the incidence of postoperative morbidity is an essen-
tial but often overlooked part of surgery for ­colorectal
cancer. This is particularly so in the elderly patient.
Careful assessment and preoperative ­maximization of
cardiac, respiratory and renal function, correction of
32 Bowel Cancer
preoperative anaemia, and nutritional assessment are
all measures that will assist the patient in the post­
operative period. It may be necessary to delay surgery
for a period of weeks to achieve these outcomes.
32.4.2 Mechanical Bowel Preparation
Traditional surgical dogma holds that mechanical
bowel preparation is essential for any colectomy. RCT
has shown mechanical bowel preparation is not neces-
sary for intra-abdominal colectomy [8]. However, an
RCT by Platell et al. 2006, of high-risk rectal anasto-
moses demonstrated more anastomotic leaks requiring
reoperation in the group treated with a phosphate enema
compared to the group treated with polyethylene glycol
bowel preparation [9]. In patients who will require an
anastomosis with a defunctioning proximal stoma,
bowel preparation should be given preoperatively.
32.5 Prophylactic Antibiotics
Prophylactic antibiotics in colorectal surgery have
become standard practice. Ample evidence exists to
suggest a single dose of antibiotics at or after induction
of anaesthesia reduces the risk of sepsis from colorec-
tal resection. Antibiotics selected for prophylaxis in
colorectal surgery should be active against both aero-
bic and anaerobic bacteria. Administration should be
timed to make sure that the tissue concentration of
antibiotics around the wound area is sufficiently high
when bacterial contamination occurs [10]. Triple anti-
biotic regime (ampicillin, metronidazole, and gentami-
cin) is as effective as third-generation cephalosporin
plus metronidazole, and results in a decreased inci-
dence of pseudomembranous colitis.
32.6 Thromboembolism Prophylaxis
The risk of deep vein thrombosis (DVT) and pulmo-
nary embolism (PE) in colorectal cancer resection is
significant. Low-molecular-weight heparin (LMWH)
or unfractionated heparin are both effective in reduc-
ing the risk of thromboembolism. DVT prophylaxis
protocols should be common in all institutions.
247
Administration of LMWH 2 h prior or at induction of
anaesthesia resulted in a slightly increased risk of
­haemorrhage and this risk can be significant in pelvic
dissection. The risk between postoperative bleeding
and the risk of thromboembolism is balanced by
administrating unfractionated heparin or LMWH
6 hours postoperatively. Other adjunct therapies in
thromboembolism prophylaxis include intermittent
sequential calf compression devices and graduated
compression stockings. Recently, continuation of pro-
phylaxis after hospital discharge has been advocated
for high-risk patients to reduce the risk of late onset
thromboem­bolic events.
32.7 Operative Surgery
The art of colectomy is well described in operative
texts. Key points of the operation are adequate tumour-
free margins, adequate and appropriate lympho­vas­
cular clearance, and well-vascularised, tension-free
anastomoses.
The site of colonic cancer influences the operative
approach. Right hemicolectomy and extended right
hemicolectomy are indicated for proximal colonic
cancers, whereas left hemicolectomy, subtotal colec-
tomy, and high anterior resection are for left-sided
colonic cancers. Complete oncological resection
includes a minimal 5 cm longitudinal resection margin
at both ends of the specimen, a clear circumferential
margin, high ligation of the appropriate arterial blood
supply to adequately remove the lymphatic drainage of
the colon.
32.8 Laparoscopic Colectomy for Cancer
Should colectomy for cancer be done using a laparo-
scopic-assisted approach? The evidence in regard to
advantages of operative technique can be taken from
four published randomized controlled trials COST,
COLOR, CLASSIC & ALCCaS. These trials have
shown that laparoscopic colectomy is not inferior to
open colectomy in regard to short-term morbidity but
does take about 30% more time in the operating theatre
and reduces in-hospital stay by 1–2 days. Operating
room costs are increased. Most importantly is the
248
question of whether laparoscopic-assisted colectomy
influences long-term disease-free survival. A meta-
analysis of four studies has shown no difference
between colectomy by laparotomy and laparoscopic-
assisted colectomy in regard to disease-free survival
and overall survival 3 years post operation [11]. Given
this situation, surgeons not trained in laparoscopic
colectomy can continue to offer open colectomy know-
ing that no difference exists in survival and that ­clinical
benefits of laparoscopic surgery are not overwhelming.
Conversely, surgeons trained in laparoscopic-assisted
surgery can continue to offer laparoscopic surgery to
their patients while awaiting the 5 year survival figures
from randomized controlled trials (RCTs).
Conversion from laparoscopic-assisted colectomy
to laparotomy has been associated with increased mor-
bidity, in-hospital length of stay, and cost. Careful pre-
operative assessment combined with a decision to
convert to laparotomy early in the operation if diffi-
culty is encountered will decrease the frequency of
conversion and its clinical impact.
Laparoscopic-assisted colectomy requires adequate
training in open colectomy technique followed by suf-
ficient mentored experience in laparoscopic-assisted
colectomy cases to become skilled in the technique. A
common figure quoted for this is 20 cases and this has
been used as entry criteria for the previously men-
tioned RCTs. In reality, the figure is between 50 and 60
cases before the learning curve effects level out.
A ­surgeon trained in open colectomy, who wishes to
embark on training in laparoscopic surgery, must have
a ­sufficient case load to develop and maintain skills, a
dedicated theatre team, a supportive operating room,
administration and colleagues who are able and will-
ing to assist and train the surgeon.
32.9 Stapled vs. Hand-Sewn
Anastomoses
Hand-sewn intestinal anastomoses form one of the
basic skills to master in general surgery and in par-
ticular, colorectal surgery. There are many varia-
tions in suturing techniques. The common technique
adopted by many colorectal surgeons is end-to-end
anastomoses by single interrupted suture technique
using absorbable monofilament suture material. The
requirements of this technique are avoiding excessive
P. Hewett and C.T. Lu
suture tension, evenly spacing each suture, and ensur-
ing serosa is included in each suture.
The alternate technique of stapled anastomoses has
been shown to have a similar anastomotic success rate.
This technique can be used to advantage when anasto-
mosing bowel of disparate diameter. Disposable linear
and circular stapling devices are available. They are
available in different lengths, diameters, and different
height of the staples. 3.5 mm staples are normally used
in ileo-colic anastomoses and 4.8 mm staples are for
colorectal anastomoses, as the contracted rectal wall is
thicker than colonic wall. Cost of the procedure is
increased by use of stapling devices.
There is no evidence to suggest either hand-sewn or
stapled anastomoses is superior to one another. There
is no statistical significant difference in anastomotic
dehiscence rate between the two techniques. Inverting
the staple line at the time of performing the anasto­
moses does not reduce the risk of bleeding; however,
under-running the staple line with a continuous over
and over suture might reduce the risk of haemorr­
hage but has no influence on the rate of anastomotic
dehiscence.
32.10 Complications
32.10.1 Anastomotic Dehiscence
The anastomotic dehiscence rate ranges from 2% to
4%. Multiple factors contribute to anastomotic failure,
including technical failure, patient factors, and postop-
erative factors. Early detection and prompt surgical
management will lead to decreased mortality and mor-
bidity. A high index of suspicion is required. Failure of
the patient to clinically progress, a low grade or swing-
ing high temperature, persistent tachycardia, respira-
tory failure, unexplained arrhythmia, and leucocytosis
are all signs consistent with anastomotic dehiscence.
The investigation of choice to detect anastomotic
dehiscence in right hemicolectomy is contrast CT scan
but having said that, the findings can be difficult to
determine and any doubt should result in laparotomy.
A gastrograffin enema with conventional X-ray or
preferably CT scan is the investigation of choice for
detection of a leak after anterior resection. The opera-
tion of choice is to take apart the anastomosis, perform
a thorough lavage, place drains to dependent areas, and
32 Bowel Cancer
form an end stoma. Early identification of anastomotic
dehiscence before significant soiling or inflammation
may allow repair or revision of the anastomosis with a
covering stoma. However, the proximal colon should
be cleared of stool.
32.11 Emergency Colonic Resection
Up to 20% of colonic cancers present on an emergency
basis. The majority presents with obstructing cancers
and less frequently perforation. An obstructing colonic
cancer positioned from the caecum around to the
splenic flexure can be managed with either right or
extended right hemicolectomy. There are two options
for managing an obstructed left-sided colonic cancer,
they are Hartmann’s procedure or on-table colonic
lavage with primary anastomosis with or without
defunctioning loop ileostomy.
Hartmann’s procedure remains the operation of
choice in many centres because it allows excision of
pathology and control of sepsis in situation where there
may be lack of equipment and senior assistants, espe-
cially after hours when many resections are performed.
Minimal mobilisation of the upper rectum would
­permit easier reversal of the Hartmann’s procedure.
The insertion of two nonabsorbable stay sutures to the
rectal stump allows identification if and when reanas-
tomosis is performed.
On-table colonic lavage was first described by
Dudley et al. 1980 [12]. Complete mobilisation of the
whole colon will facilitate the lavage more efficiently.
The irrigation continues until the effluent is clear, usu-
ally requires about 3–4 L of warm irrigation fluid.
Defunctioning loop ileostomy should be considered
if the colon is markedly dilated or the patient’s clinical
condition is compromised as the anastomotic leak rate
is increased in this situation. Primary anastomosis in
the presence of gross faecal peritonitis in perforated
colonic cancer is not recommended again due to con-
cern of a high rate of anastomotic failure.
The treatment of an obstructing left-sided tumour
by endoscopic stent can be used as a bridging measure
to formal resection. This technique can be useful in
patients who have widespread metastatic disease as a
definitive treatment. Stenting of obstructing transverse
and right colon cancer is technically challenging to per-
form. Stent migration and tumour perforation are known
249
complications. Balloon dilatation of the ­malignant
stricture with the stent in situ should not be performed
as it predisposes to tumour perforation. Generally, per-
manent colonic stenting should be reserved for those
whose survival is unlikely beyond 12 months [13].
32.12 Palliative Resection
Recent development and availability of novel chemo-
therapeutic agents has extended survival in patients
presenting with disseminated colonic malignancy.
Trials are proposed to see if immediate colonic resec-
tion in patient’s presenting with disseminated disease
is advantageous compared to no surgical intervention
and immediate chemotherapy.
32.13 Distant Metastases
Liver metastases were once considered to be terminal
event and survival following attempted resection was
poor. Recent advances in adjuvant chemotherapy and
improvements in the technical aspects of a liver resec-
tion have improved survival. 20–40% of patients pre-
senting with liver metastases will be suitable for
resection of the disease. The survival rate is 38% at
5 years for those with resectable liver metastases. In
those with recurrence of resectable liver metastases,
the second resection with clear margin has similar
­survival outcomes as those of the first resection. The
mortality rate in major hepatobiliary units in Australia
is less than 2% [14].
32.14 Rural Issues of Treatment
Planning for Patients with
Advanced Disease
Access to trials and other advanced treatment options
as well as diagnostic tools can be very difficult for
rural patients. A close link between rural surgeons and
a regional or metropolitan multidisciplinary cancer
treatment team should be established to help with plan-
ning and coordination of treatment for patients with
disseminated disease.
250
References
1. South Australian Cancer Registry, Epidemiology Branch:
Cancer in South Australia 2006 with projections to 2009. A
report on the incidence and mortality patterns of cancer
Cancer Series Number 29 October 2008
2. Jacob, S., Praz, F.: DNA mismatch repair defects: role in
colorectal carcinogenesis. Biochemie 84(1), 27–47 (2002)
3. Umar, A., Boland, C.R., Terdiman, J.P., Syngal, S., de la
Chapelle, A., Rüschoff, J., et al.: Revised Bethesda guide-
lines for hereditary nonpolyposis colorectal cancer (Lynch
syndrome) and microsatellite instability. J. Natl Cancer Inst.
96(4), 261–268 (2004)
4. Winawer, S., Fletcher, R., Rex, D., et al.: Colorectal cancer
screening and surveillance: clinical guidelines and rationale –
update based on new evidence. Gastroenterology 124(2),
544–560 (2003)
5. Church, J., Simmang, C.: Practice parameters for the treatment
of patients with dominantly inherited colorectal cancer (famil-
ial adenomatous polyposis and hereditary nonpolyposis col-
orectal cancer). Dis. Colon Rectum 46(8), 1001–1012 (2003)
6. Bulow, S.: Results of national registration of familial ade-
nomatous polyposis. Gut 52(5), 742–746 (2003)
7. Arvanitis, M.L., Jagelman, D.G., Fazio, V., et al.: Mortality
in patients with familial adenomatous polyposis. Dis. Colon
Rectum 33(8), 639–642 (1990)
P. Hewett and C.T. Lu
8. Ram, E., Sherman, Y., Weil, R., Vishne, T., Kravarusic, D.,
Dreznik, Z.: Is mechanical bowel preparation mandatory for
elective colon surgery? A prospective randomized study.
Arch. Surg. 140(3), 285–288 (2005)
9. Platell, C., Barwood, N., Makin, G.: Randomized clinical
trial of bowel preparation with a single phosphate enema or
polyethylene glycol before elective colorectal surgery. Br.
J. Surg. 93(4), 427–433 (2006)
10. Song, F., Glenny, A.M.: Antimicrobial prophylaxis in col-
orectal surgery: a systematic review of randomized con-
trolled trials. Br. J. Surg. 85(9), 1232–1241 (1998)
11. Bonjer, H.J., Hop, W.C., Nelson, H., Sargernt, D.J., Lacy,
A.M., Castells, A., et al.: Laparoscopically assisted vs open
colectomy for colon cancer: a meta analysis. Arch. Surg.
142(3), 298–303 (2007)
12. Dudley, H.A.F., Radcliffe, A.G., MeGeehan, D.: Intra-
operative irrigation of the colon to permit primary anastamo-
sis. Br. J. Surg. 67(2), 80–81 (1980)
13. Watt, A.M., Faragher, I.G., Griffin, T.T., Rieger, N.A.,
Maddern, G.J.: Self-expanding metallic stents for relieving
malignant colorectal obstruction: a systematic review. Ann.
Surg. 246(1), 24–30 (2007)
14. Scheisser, M., Chen, J.W.C., Maddern, G.J., Padbury, R.T.A.:
Perioperative morbidity affects long-term survival in patients
following liver resection for colorectal metastases.
J. Gastrointest. Surg. 12(6), 1054–1060 (2008)
 Rectal Cancer
Peter Hewett
33.1 Incidence
Cancers of the rectum increased in incidence through
to the 1990s, beyond which time, incidence has lev-
elled out. Mortality rates also reached a peak in the
1990s in both sexes, and have declined slightly since.
Rectal cancer accounts for 23% of colorectal cancer in
females and 27% in males in South Australia [1].
33.2 Symptoms and Signs
Symptoms such as rectal bleeding, passage of mucous
per rectum, alteration in bowel habit or tenesmus, need
to be investigated to exclude rectal cancer. Rectal
­cancer can be diagnosed by digital rectal examination
(DRE) and rigid or flexible sigmoidoscopy after prepa-
ration with an enema. DRE gives important informa-
tion about distance of the tumour from the anal verge
and degree of tumour fixation. Rigid sigmoidoscopy
gives an accurate distance measurement of the tumour
from the anal verge, which is important in treatment
planning. Full colonoscopy is mandatory to exclude
synchronous lesions. It is essential that a biopsy con-
firms adenocarcinoma before treatment occurs as
benign conditions such as solitary rectal ulcer syn-
drome can at times mimic rectal cancer.
P. Hewett
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: peter.hewett@health.sa.gov.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_33, © Springer-Verlag Berlin Heidelberg 2011
33
33.3 Imaging
When diagnosis has been confirmed, imaging is
required to accurately stage the patient. Chest X-ray
and ultrasound of the abdomen or CT scan of the chest
and abdomen will reveal pulmonary and hepatic metas-
tases. PET scanning can be used if available to deter-
mine the status of a lesion when it is unclear on routine
imaging.
Staging of the rectal cancer by imaging is by
endorectal ultrasound or MRI. Both modalities require
considerable expertise by their operators. Both meth-
ods are limited because peritumoral inflammation
cannot be precisely distinguished from infiltration by
the tumour. Correct lymph node staging is hampered
in advanced disease using trans-rectal ultrasound
(TRUS) [2].
33.4 Multidisciplinary Committee
Meetings
Combined meetings involving surgeons, oncologists,
radiotherapists, pathologists, stoma therapists and
nursing staff to discuss treatment options for patients
with rectal cancer have become established in many
institutions. The advantage of such panels is to help
standardise management to best practice, allow patients
entry to clinical trials and assess outcomes. With the
advent of video and internet conferencing, the ability
to participate in these conferences has become easier
and possible even in more rural or remote settings
where general surgeons treating rectal cancer are
located.
251
252
33.5 Preoperative Chemoradiotherapy
The role of preoperative chemoradiotherapy (CRT)
is described in an article by Ciccocioppo et al. [3].
If clinical examination and/or staging of the tumour
reveals fixation to adjacent structures, penetration
of the mesorectum by the tumour or involved lymph
node status (T3 or T4 status), preoperative CRT can
be considered. Preoperative neoadjuvant CRT has a
role in the management of rectal cancer. It may
improve survival and decrease local recurrence
rates. Improved survival was shown in the Swedish
rectal cancer trial after preoperative short-course
radiotherapy (RT) (25 Gy delivered in five frac-
tions) [4]. The Dutch colorectal cancer group
reported that preoperative short-course RT reduced
local recurrence rates but did not improve short-
term overall survival [5]. Conventional fractionated
preoperative RT with chemotherapy will also reduce
the risk of local recurrence and may be associated
with reduced toxicity compared with post-operative
CRT [6]. Prior to these trials, a meta-analysis was
undertaken to look at the efficacy of preoperative
RT [7]. Fourteen randomised controlled trials
(RCTs) were analysed that compared preoperative
rRT plus surgery with surgery alone. These only
included patients with resectable, histologically
proven rectal adenocarcinoma without metastatic
disease. Preoperative RT significantly reduced the
5-year overall mortality rate, cancer-related mortal-
ity rate and local recurrence rate. However, the mar-
gin of benefit was small and the authors concluded
that ‘criteria are needed to identify patients most
likely to benefit from adjuvant RT’ [7]. Complete
pathological response is seen in 15–25% of patients
treated. While there is some speculation that such
patients can be treated by observation to assess fur-
ther tumour growth, this is largely anecdotal and the
planned operative and post-operative treatments
should be carried out.
It should be noted that the effect of RT is to halve
the local recurrence rate. Diminishing returns exist for
this therapy as a practitioner’s known local recurrence
rate decreases. For example, local recurrence rates
vary between 2.6% and 32%. Clearly, a greater num-
ber of patients will benefit if the surgeons local recur-
rence rate is known to be high [8].
P. Hewett
33.6 Short-Course Radiotherapy Versus
Long-Course Chemoradiotherapy
Preoperative long-course CRT has been used to down-
stage disease and help obtain R0 status when imaging
has indicated that the mesorectal envelope has been
breached by tumour. Surgery is scheduled for around
6 weeks following completion of RT. Short-course RT
will not down-stage tumours but has been found to be
as effective in terms of survival, recurrence, periopera-
tive complications, sphincter preservation and toxicity.
Short-course RT gives the tumour field 50 Gray over
5 days. Operation normally is performed within 1 week
following completion of RT. Some Scandinavian cen-
tres are trialling delay in surgery for 5–6 weeks to
assess efficacy and post-operative morbidity. The abil-
ity for the patient to attend RT clinics away from home
may influence the treatment regime offered. RCTs are
underway to compare these modalities.
33.7 Preoperative Versus
Post-operative Radiotherapy
The CR07 trial compared short-course preoperative
RT versus initial surgery with selective post-operative
CRT. The primary outcome measure was local recur-
rence. It found a reduction of 61% in the relative risk
of local recurrence for patients receiving preoperative
RT and an absolute difference at 3 years of 6.2% (95%
CI 5.3–7.1) (4.4% preoperative RT vs 10.6% selective
post-operative CRT). The study recorded a relative
improvement in disease-free survival of 24% for
patients receiving preoperative RT. QOL in the preop-
erative short-course group was worse in respect to
male sexual function and faecal incontinence [9].
Optimal treatment of rectal cancer is a special chal-
lenge that calls for the best possible clearance of the
tumour in association with preservation of the anal
sphincter mechanism and avoidance of injury to the
pelvic autonomic nerves.
There are at least 22 studies of colorectal cancer
patients correlating outcome and volume (hospital/sur-
geon or both) since 1984, which show clear difference in
quality of life indicators such as permanent stoma rates
between low-volume and high-volume surgeons [10].
33 Rectal Cancer
Preoperative CRT does not take the place of
e­ xcellent surgical technique nor should it alter the
operative strategy initially decided. The principle of
Total Mesorectal Excision (TME) as described by
Heald involves removing the rectum with an intact
mesorectal fascial envelope [11]. It is a technique
that must be learnt from an experienced practitioner
and requires a sufficient case load to gain and main-
tain proficiency. The decision as to whether a restor-
ative resection should be performed is based on the
ability to obtain safe oncological margins (2 cm dis-
tal margin) and leave the anal canal intact. A history
of previous incontinence will also influence this
decision. In patients who are planned for restorative
procedures with an anastomosis localized within
2 cm of the anal verge 5 cm, long colonic reservoirs
are recommended to improve post-operative bowel
function. The advantage of these reservoirs is of
clinical relevance during the first 2 years after resec-
tion. Laparoscopic resection of rectal cancer is cur-
rently being studied in a number of prospective
randomised trials.
33.8 Abdominoperineal Resection
Routine abdominoperineal resection (APR) has the
patient in the lithotomy position and involved two
­surgeons operating from the abdominal and perineal
aspect to remove the anus and rectum. A recent devel-
opment “Cylindrical APR” is similar to the original
Miles procedure [12]. This procedure involves the
mobilisation of the rectum via the abdominal approach
as far as the origins of the levator muscle. Once the
abdomen has been closed and the stoma formed,
the patient is moved into the prone position and the
perineal dissection is commenced. This dissection will
include the removal of the coccyx with the specimen
to allow better exposure. The levator muscles are
divided and the proximal rectum can be delivered and
retracted inferiorly to place the anterior dissection
plane on tension. If the anterior margin is involved, a
portion of vagina or prostate can be excised under
direct vision. This may produce a large perineal defect
and a gluteus maximus rotation flap has been described
for closure.
253
Advantages of this technique are that Cylindrical
APR performed in the prone position for low rectal
cancer removes more tissue around the tumour, which
leads to a reduction in circumferential resection mar-
gin involvement and intraoperative perforations, which
should reduce local disease recurrence [13].
33.9 Local Excision
Local excision or transanal endoscopic excision of
­rectal cancer should be restricted to T1 rectal cancers
in selected patients according to the following
guidelines:
• Mobile tumour <3 cm
• T1 on endorectal ultrasound or MRI
• Not poorly differentiated on histology (biopsy)
Local recurrence rates of about 25% have been reported
after 5 years of follow up. Half of the patients with
local recurrence can be salvaged by additional resec-
tional surgery. As these results are worse than treat-
ment by resection, this modality should be restricted to
patients with considerable risk of severe post-operative
morbidity or mortality.
33.10 Complications
The major intraoperative complication of bleeding can
be avoided by close adherence to anatomical planes. If
presacral vessels are breached, control can be difficult.
Compression by a “thumbtack” device can be literally
lifesaving as it plugs the sacral foramina that the
­vessels retract into.
Urinary and sexual dysfunction in males following
surgery for rectal cancer is between 30% and 70% due
to damage to sympathetic and parasympathetic nerves
at the pelvic brim and around the prostate gland. Care
in identifying the nerves at this point is mandatory.
Anastomotic dehiscence will occur in ultralow
anterior resection with an increased incidence after
preoperative RT. Defunctioning the anastomosis with
a covering stoma should be performed in this
situation.
254
33.11 Extended Resections
In patients who present with involvement of adjacent
structures or who present with local recurrence follow-
ing resection, extended radical resection is a possibility.
These procedures are performed in dedicated centres
with a team of surgeons of differing specialties includ-
ing colorectal, urological, gynaecological, orthopaedic
and neurosurgeons. The aim is to clear tumour by resec-
tion through extrafascial planes to obtain negative
resection margins. Up to 40% cancer-specific 5 year
survival has been achieved with this technique [14].
33.12 Chemotherapy
Post-operative chemotherapy should be considered
when patients have nodal involvement or poor tumour
prognostic factors and who are well enough to undergo
chemotherapy. Referral to an oncologist and/or multi-
disciplinary tumour board to discuss the relative merits
of post-operative chemotherapy is usual.
33.13 Post-operative Surveillance
As in colon cancer, the aim of surveillance is to detect
local and distant recurrence and metachronous tumours.
Direct viewing of the anastomosis should occur every
6 months for 3 years. Recommendations with regard to
surveillance colonoscopy vary and the author performs
this routinely every 3 years. CT scan to detect liver
metastases should be included in the surveillance plan.
References
1. South Australian Cancer Registry, Epidemiology Branch.
Cancer in South Australia: a report on the incidence and
mortality patterns of cancer. Cancer Series Number 29,
October 2008
P. Hewett
2. Dinter, D.J., Hofheinz, R.D., Hartel, M., Kaehler, G.F., Neff,
W., Diehl, S.J.: Preoperative staging of rectal tumors: com-
parison of endorectal ultrasound, hydro-CT, and high-reso-
lution endorectal MRI. Onkologie 31(5), 230–235 (2008)
3. Ciccocioppo, A., Stephens, J.H., Hewett, P.J., Rieger, N.A.:
Complete pathologic response after preoperative rectal
­cancer chemoradiotherapy. ANZ J. Surg. 79(6), 481–484
(2009)
4. Swedish Rectal Cancer Trial: Improved survival with
­preoperative radiotherapy in resectable rectal cancer. N.
Engl. J. Med. 336(14), 980–987 (1997)
5. Kapiteijn, E., Marijnen, C.A., Nagtegaal, I.D., et al.:
Preoperative radiotherapy combined with total mesorectal
excision for resectable rectal cancer. N. Engl. J. Med. 345(9),
638–646 (2001)
6. Sauer, R., Becker, H., Hohenberger, W., et al.: Preoperative
versus postoperative chemoradiotherapy for rectal cancer.
N. Engl. J. Med. 351(17), 1731–1740 (2004)
7. Camma, C., Giunta, M., Fiorica, F., Pagliaro, L., Craxi, A.,
Cottone, M.: Preoperative radiotherapy for resectable rectal
cancer: a meta-analysis. JAMA 284(8), 1008–1015 (2000)
8. Heald, R.J., Husband, E.M., Ryall, R.D.: The mesorectum in
rectal cancer surgery-the clue to pelvic recurrence? Br. J.
Surg. 69(10), 613–616 (1982)
9. Sebag-Montefiore, D., Stephens, R.J., Steele, R., Monson,
J., Grieve, R., Khanna, S., Quirke, P., Couture, J., de Metz,
C., Myint, A.S., Bessell, E., Griffiths, G., Thompson, L.C.,
Parmar, M.: Preoperative radiotherapy versus selective post-
operative chemoradiotherapy in patients with rectal cancer
(MRC CR07 and NCIC-CTG C016): a multicentre, ran-
domised trial. Lancet 373(9666), 811–820 (2009)
10. RE Hodgson, D.C., Zhang, W., Zaslavsky, A.M., Fuchs,
C.S., Wright, W.E., Ayanian, J.Z.: Relation of hospital vol-
ume to colostomy rates and survival for patients with rectal
cancer. J. Natl Cancer Inst. 95, 708–716 (2003)
11. Heald, R.J., Ryall, R.D.: Recurrence and survival after total
mesorectal excision for rectal cancer. Lancet 1(8496), 1479–
1482 (1986)
12. Holm, T., Ljung, A., Haggmark, T., Jurell, G., Lagergren, J.:
Extended abdominoperineal resection with gluteus maximus
flap reconstruction of the pelvic floor for rectal cancer. Br.
J. Surg. 94(2), 232–238 (2007)
13. West, N.P., Finan, P.J., Anderin, C., Lindholm, J., Holm, T.,
Quirke, P.: Evidence of the oncologic superiority of cylindri-
cal abdominoperineal excision for low rectal cancer. J. Clin.
Oncol. 26(21), 3517–3522 (2008)
14. Heriot, A.G., Byrne, C.M., Lee, P., Dobbs, B., Tilney, H.,
Solomon, M.J., Mackay, J., Frizelle, F.: Extended radical
resection: the choice for locally recurrent rectal cancer. Dis.
Colon Rectum 51(3), 284–291 (2008)
 Stoma Surgery
34
Nick Rieger

34.1 Introduction mark the stoma site before making the abdominal inci-
sion, as the incision will distort the abdomen and impact
on the best stoma site. With laparoscopy, the site should
Intestinal stomas may be required in both elective and
be marked with the abdomen deflated for the same
emergency abdominal surgery. A stoma may be tem-
reasons.
porary or permanent. The creation of a stoma has major
When considering whether to perform stoma sur-
implications to the physical and psychological well-
gery, there are no easy algorithms or hard rules. In
being of a patient, and hence, must be created with due
­rectal resection, should an anastomosis be covered by
consideration and care. Education, counselling and
a proximal loop stoma? For emergency surgery (obstruct­
rehabilitation of a patient requiring a stoma, in collab-
ing cancer, diverticulitis), should the patient have a
oration with a stomal therapy service, are essential and
Hartmann’s resection or an anastomosis? Decisions
ideally should be commenced preoperatively.
are based on the experience of the surgeon, the pathol-
The sighting of a stoma must take into account the
ogy, the condition of the patient, the technical ease of
build, type of clothes worn (should the stoma be above
the operation and the perceived risk of the anastomosis
or below the belt line) and the potential skin creases of
compared to that of a stoma and its eventual closure. It
the patient in differing postures (sitting and standing).
is well recognised that reversible stomas such as a
When siting a stoma, it should be placed away from
Hartmann’s end colostomy may never be reversed even
the umbilicus, bony prominences and old scars so that
though technically feasible [2]. The attending surgeon,
the base of the stoma appliance plate fits easily to the
when considering the surgical options for a particular
skin. Siting a stoma usually places it below the level of
clinical presentation, must also be aware of options
the umbilicus, on the left or right lower quadrant, on
that may avoid a stoma. A colonic stent may be appli-
the upper surface of the lower abdominal fat mound
cable for obstructing lesions to the colon. These can be
and through the rectus sheath [1].
a bridge to later resection. A stent may also be used as
A stoma may be created with an open laparotomy
definitive treatment of a colonic carcinoma when there
incision or with the aid of laparoscopy. Consideration
are inoperable metastases [3].
of the primary pathology is important when placing
Another common dilemma applies to the acute pre-
skin incisions. Paramedian or transverse incisions may
sentation of a left-sided carcinoma with obstruction.
compromise potential stoma sites in conditions such as
The surgical options include proximal stoma and no
Crohn’s disease or malignancy. A midline incision
resection, resection and stoma (Hartmann’s proce-
skirting the umbilicus to the side away from a potential
dure), resection and primary anastomosis (with and
stoma site is usually satisfactory. In emergency surgery,
without on table washout and with or without a cover-
ing loop stoma) and subtotal or total colectomy and
anastomosis. All of these procedures are acceptable in
certain circumstances although may not always be in
N. Rieger
the surgeon’s armamentarium. Seeking advice or refer-
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia ral to a specialist centre may assist in the care of the
e-mail: nicholas.rieger@medicine.adelaide.edu.au patient in these complex circumstances.

M.W. Wichmann et al. (eds.), Rural Surgery, 255

DOI: 10.1007/978-3-540-78680-1_34, © Springer-Verlag Berlin Heidelberg 2011
256
34.2 The Stoma Trephine
Having chosen the ideal site for the stoma, a skin disc
is excised. The underlying subcutaneous fat is excised
as a core with the skin disc or split to the anterior rec-
tus sheath. The anterior sheath is exposed with retrac-
tors and incised vertically and transversely (cruciate).
The underlying rectus muscle is split vertically in line
with its fibres. Care must be taken to avoid the inferior
epigastric vessels. The posterior sheath and perito-
neum is divided vertically.
A soft grasping instrument such as a Babcock clamp
can be introduced into the stoma trephine to deliver the
bowel. The bowel should have been adequately mobil-
ised so that there is no tension to avoid later retraction
and the stoma trephine should be of adequate diameter
to deliver the bowel easily (usually admitting two
­fingers). With a fat mesentery, the posterior sheath
incision may need to be enlarged. After the stoma is
matured, a clear appliance bag should be used to ­permit
easy inspection of the stoma in the subsequent postop-
erative days.
34.3 End Stomas
34.3.1 End Colostomy
This is usually placed in the left iliac fossa. Ideally,
it is budded and projects 3–5 mm above the skin level
Fig. 34.1 End ileostomy
N. Rieger
to enable easy appliance placement. The sutures are
placed circumferentially picking up the bowel edge
and nearby serosa. The bowel should be sutured to the
dermis only and not the epidermis of the skin to avoid
peristomal granulomas. With distended bowel (e.g.,
obstruction) only a portion of the staple line should be
opened to create the stoma. The residual staple or
suture line can remain subcutaneous.
34.3.2 End Ileostomy
This is usually placed in the right iliac fossa. An ileos-
tomy may have an initial high output (>2 l per day). High
output may necessitate intravenous therapy and monitor-
ing of electrolytes until this reduces and the bowel
adapts. Bryan Brooke devised the evaginated ileostomy
in 1952 [4]. An ideal length is 2–3 cm. This is achieved
with sutures placed through the full thickness of the cut
bowel end, seromuscular to the bowel at the level of the
skin and to the dermis of the skin (Fig. 34.1).
34.4 Loop Stomas
A bridge is used to hold the bowel in position for
3–5 days until the stoma is adherent to the abdominal
wall. This prevents retraction. It may be left longer in
the obese, where there has been difficulty with mobil-
ising the bowel and where poor healing is anticipated.
34 Stoma Surgery
Fig. 34.2 Loop colostomy
34.4.1 Loop Colostomy
This usually utilises the sigmoid or transverse colon.
The mobilised colon is incised longitudinally (along
the taenia) and matured over a bridge (Fig. 34.2).
34.4.2 Loop Ileostomy
This is the author’s preferred method for faecal diver-
sion. It is easier to manage compared to loop colos-
tomy. It is also easier to close with less associated
morbidity [5]. The exteriorised loop of bowel is incised
eccentrically at the level of the skin on the distal
(non-functional) end. The proximal end can then be
folded over and evaginated over the skin bridge to pro-
duce a spout of 2–3 cm. Sutures through the cut end of
bowel also incorporate the seromuscular layer at the
skin level and the dermis of the skin (Fig. 34.3).
34.4.3 End Loop Stoma
This stoma may be utilised particularly in obese patients
or where there is a short mesentery that does not easily
permit the bowel to be mobilised, without tension,
257
Fig. 34.3 Loop ileostomy
through the abdominal wall. The distal end is oversewn
or stapled and left subcutaneously or intraperitoneally
and the proximal end fashioned as for an end stoma.
Another variation is where an end stoma cannot be
fashioned because of the proportions of the patient.
The actual distal end is oversewn. More proximally,
the bowel is brought out as a loop stoma.
34.5 Closure of Loop Stomas
Closure of a temporary loop stoma is associated with
its own morbidity. This includes wound infection,
anastomotic dehiscence, obstruction and late incisional
258
hernia. The stoma is mobilised via a circumstomal
incision into the peritoneal cavity. For a loop trans-
verse stoma, it is closed transversely with sutures to
avoid narrowing the bowel lumen. For closure of a loop
ileostomy, my preferred method is a side-to-side (func-
tional end-to-end) anastomosis with a linear stapler.
This gives a good-sized lumen and is easy to perform
especially when there is discrepancy with the size of
the bowel lumens. Alternatively, a loop ileostomy can
be closed end to end with interrupted sutures having
excised the bowel ends. This is the preferred method if
the bowel is difficult to mobilise because of adhesions.
34.6 Stoma Complications
Stoma ischaemia, retraction and stenosis are usually
due to inadequate mobilisation of the bowel or poor
attention to its vascularity. A revision of the stoma is
N. Rieger
usually required. Late complications such as prolapse
and peristomal hernia may also require revisional
surgery.
References
1. Corman, M.L. (ed.): Colon and Rectal Surgery, 4th edn.
Lippincott-Raven, Philadelphia (1998). Chapter 32
Enterostomal therapy
2. Nunes, G.C., Robnett, A.H., Kremer, R.M., et al.: The
Hartmann procedure for complications of diverticulitis.
Arch. Surg. 114, 425–429 (1979)
3. Watt, A.M., Faragher, I.G., Griffin, T.T., Rieger, N.A., et al.:
Self-expanding metallic stents for relieving malignant col-
orectal obstruction: a systematic review. Ann. Surg. 246(1),
24–30 (2007)
4. Brooke, B.N.: The management of an ileostomy including
its creation. Lancet 2, 102–104 (1952)
5. Kaiser, A.M., Israelit, S., Klaistenfeld, D., et al.: Morbidity
of ostomy takedown. J. Gastrointest Surg. 12, 437–441
(2008)
 Acute Abdominal Pain
Hajir Nabi
35.1 Preface
Abdominal pain is to the general surgeon as flour is to
the baker. They are the foundation of our practice.
The importance of clinical acumen in differentiat-
ing between its numerous causes cannot be overem-
phasised. The clues a surgeon gains from a well-taken
history and carefully executed examination aid in diag-
nosis and importantly determine the urgency with
which future management needs to be implemented.
Needless investigations, which can potentially act to
delay life-saving management, can often be obviated
by astute clinical judgements.
35.2 Presentation
A well-taken history is a key element in assessing
undifferentiated abdominal pain. A keen history taker
needs to be aware of their available resources. Collateral
information obtained from case notes, ambulance offi-
cers, nursing and allied health staff as well as relatives
and carers can be invaluable (especially when patients
are unable to communicate).
Some of the salient factors that can help differentiate
causes of abdominal pain are outlined in Table 35.1.
In addition to enquiring about pertinent surgical his-
tory, one should also seek to clarify relevant past medical
H. Nabi
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: hajirnabi@yahoo.com.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_35, © Springer-Verlag Berlin Heidelberg 2011
35
history, medications, allergies, social (cigarettes, illicit
drugs, alcohol) and family history.
An understanding of the abdominal anatomy is
important in differentiating causes based on the loca-
tion of pain (Table 35.2).
When assessing patients, always remember the
­priorities in assessment and management are:
1. Airway patency (while ensuring the cervical spine
is protected)
2. Breathing (oxygen saturations)
3. Circulation (blood pressure)
4. Disability (a drop in Glasgow coma scale score may
indicate an immediate need to secure airway
patency- Table 35.3).
The examination begins as soon as we enter the
patient’s space. The patient’s conscious level, general
appearance, body habitus, discoloration from jaundice/
icterus, cyanosis and pallor, restlessness, presence of
vomit bowls and odours (such as melena) all give valu-
able insights.
35.2.1 Vital Signs
Vital signs – and their trends – need to be carefully
assessed. Keep in mind that those who were previously
well will be able to maintain their blood pressure until
very late in the course of shock. If we wait for a fall in
blood pressure before instituting management, we will
have often already missed the opportunity to save life.
Tachycardia is often one of the first signs of shock –
whether hypovolemic, septic, cardiogenic or spinal.
A normal temperature does not exclude an infective
cause – especially in the elderly.
259
260 H. Nabi

Table 35.1 Factors to be extracted during history taking Left upper quadrant Gastritis
Factors Examples
Splenic infarction
Timing of onset Acute
Splenic laceration
Subacute
Pancreatitis
Chronic
Left lower lobe pneumonia
Acute on chronic
Pulmonary embolus
Nature Sharp
Myocardial infarction/ischaemia
Colicky
Right lower quadrant Appendicitis
Associated features Fever
Inguinal/femoral hernia
Changes in bowel motions incarceration
Dysuria Renal calculus
Haematuria Ovarian cyst torsion/rupture
Vaginal discharge Endometriosis
Radiation Back Salpingitis
Groin Mittelschmerz pain
Preceding events Trauma Pyelonephritis
Recent surgery Ectopic pregnancy
Relationship to meals
Meckel’s diverticulitis
Timing in menstrual cycle
Inflammatory bowel disease
Psoas abscess
Sigmoid diverticular disease
Table 35.2 Location of pain and likely differentials
Location Differentials Suprapubic Cystitis
Right upper quadrant Cholecystitis Pelvic inflammatory disease
Cholelithiasis Ectopic pregnancy
Hepatitis Endometriosis

Duodenal ulcer Left lower quadrant Sigmoid diverticular disease

(diverticulitis, perforation, abscess)
Pancreatitis
Colon malignancy
Right lower lobe pneumonia
Inguinal/femoral hernia
Pulmonary embolus incarceration
Subphrenic abscess Renal calculus
Hepatic abscess Ovarian cyst torsion/rupture
Peptic ulcer Endometriosis
Epigastric Pancreatitis Salpingitis
Gastritis Mittelschmerz pain
Reflux oesophagitis Pyelonephritis
Peptic ulcer Ectopic pregnancy
Myocardial infarction/ischaemia Inflammatory bowel disease
35 Acute Abdominal Pain 261

Table 35.2 (continued) Palpation needs to be systematic with all quadrants

Location Differentials palpated looking for tenderness, masses, evidence of
Generalised/central Colitis (ischemic, inflammatory, peritonism (guarding/rigidity, rebound and percussion
infective) tenderness) as well as presence and reducibility of her-
Abdominal aortic aneurysm nias (inguinal, femoral, umbilical, epigastric and inci-
Bowel obstruction sional). One needs to keep underlying anatomy in mind
Gastroenteritis while palpating. Organs such as liver, spleen and kidneys
Spontaneous bacterial peritonitis
need to be palpated, to document organomegaly and
organ tenderness. A pulsatile mass is suggestive of an
Perforated abdominal viscus
abdominal aortic aneurysm – and its dimensions should
be ascertained. Percussion for shifting dullness will con-
firm the presence of ascites. Presence or absence of bowel
Table 35.3 Glasgow coma scale (GCS) sounds may be valuable, as may auscultation for bruits.
A. Eye opening The only contra-indications to a digital rectal exam-
4. Spontaneous ination are the absence of the patient’s rectum, or the
absence of the examiner’s digit. Although unpleasant,
3. To voice
vaginal examination can often also aid in diagnosis.
2. To pain
1. Nil
B. Vocalising
35.3 Investigations
5. Orientated
4. Confused sentences 35.3.1 Blood Tests
3. Inappropriate words
2. Incomprehensible sounds (a) White cell count – When elevated, can be a useful
1. Nil marker of acute inflammation – predominantly
neutrophils. However, WCC response is altered in
C. Movements
certain patient groups – for example, immunosup-
6. Obeys orders pressed and elderly. It is important to remember
5. Localises to pain that inflammatory markers are not uncommonly
4. Normal flexion to pain normal in inflammatory conditions like acute
appendicitis and that management decisions should
3. Abnormal flexion to pain
be based on clinical decisions. The same applies
2. Extension to pain to other inflammatory markers like C-reactive pro-
1. Nil tein and erythrocyte sedimentation rate.
Total score of 3–15 is added across three fields (b) Haemoglobin – Values are concentrations and
not absolute levels. Consequently, haemoglobin
levels take time to drop in the setting of acute
35.2.2 Abdominal Examination haemorrhage.
(c) Troponin (T or I), Creatinine Kinase (MB), Lactate
Inspection may reveal many things. Scars will disclose dehydrogenase – cardiac enzymes which are elevated
a great deal about past surgical history. Abdominal after myocardial muscle death (remember that it may
­distension has many causes (fat, flatus, faeces, foetus, take several hours before levels are elevated in serum).
filthy big tumour and phantom pregnancy). Pulsations, (d) D Dimer – A sensitive but non-specific test for
abnormal peristaltic waves, distended veins, masses, pulmonary embolus.
evidence of trauma, bruising, insulin injection sites (e) Amylase/Lipase – Markers of acute pancreatitis
and obvious hernias should all be sought. (non-specific).
262
(f) Electrolytes, Urea and Creatinine – Important in
determining fluid management and for the admin-
istration of renally cleared medications.
(g) Liver function tests – Aid in the diagnosis of hepati-
tis, important for administration of hepatically
cleared medications and in the setting of biliary
obstruction (total bilirubin, alkaline phosphatase and
gamma glutamyl transpeptidase will be elevated –
often caused by gallstones in common bile duct).
(h) Arterial blood gas analysis – Gives an objective
measure of blood oxygenation, and blood pH.
(i) Serum Lactate – Important marker for ischaemic
bowel.
35.3.2 Urine Dipstick
Urine dipstick testing is quick, cheap and readily avail-
able. Urinary tract infection is suggested by positive
nitrites and leucocytes. One should send a formal mid-
stream urine specimen for microscopy, culture and sen-
sitivity prior to commencement of empirical antibiotics.
Renal colic is strongly associated with haematuria.
All women of childbearing age should be consid-
ered pregnant until proven otherwise by urine beta
human chorionic gonadotropin (hCG) testing.
35.3.3 Electrocardiogram (ECG)
An ECG can aid in differentiating myocardial ischae-
mia/infarction from intra-abdominal pathology.
35.3.4 Plain Film X-Ray
Chest X-rays are important in the identification of
lower lobe pneumonia. Free air under the hemidia-
phragms can be an indicator of bowel perforation.
Abdominal X-rays have a very limited role in the
assessment of the acute abdominal pain.
Plain X-rays are indicated when considering:
• Bowel perforation (free air)
• Bowel obstruction (loops of dilated bowel with
multiple associated air-fluid levels)
H. Nabi
Please note CT (without i.v. contrast) is the investiga-
tion of choice in investigating possible renal calculi
given the possibility of radiolucent stones or projec-
tion over bony structures [1].
35.3.5 Abdominal Ultrasound (US)
Abdominal ultrasound is particularly good at assessing
the biliary tract (visualisation of gallstones, gallblad-
der wall thickness and diameter of common bile duct).
They are also useful at assessing abdominal aortic
aneurysms, the spleen, pancreas, hernias, urinary tract,
ovaries, fallopian tubes and the uterus. Ultrasound has
limited capabilities when assessing gas-filled struc-
tures, such as the bowel. This imaging modality has
several advantages over CT – it is cheaper, involves no
exposure to radiation and can be done at the patient’s
bedside.
35.3.6 Computer Tomography (CT)
Where available, CT often proves a superior imaging
modality with reference to detection of organ damage
post-trauma (such as splenic lacerations), abdominal
aortic aneurysms, acute pancreatitis, diverticular dis-
ease, intra-abdominal abscess, bowel obstruction,
appendicitis, liver pathology, splenic infarction, pyelo-
nephritis, renal colic and viscus perforation [2].
CT has the disadvantages of expense, radiation and
contrast exposure; patient needs to be transported to
radiology department when potentially unstable and it
may delay life-saving management.
35.3.7 Diagnostic Peritoneal Lavage (DPL)
The presence of blood, intestinal contents or pus on DPL
indicates the need for laparotomy. However, no cause or
site can be ascertained form this investigation [3].
The author does not advocate the widespread use of
DPL given its invasive nature and the lack of specific-
ity in its findings. Its use has been largely replaced by
CT and ultrasounds where available.
35 Acute Abdominal Pain 263

35.3.8 Endoscopy Table 35.4 Causes of presentation to hospital with acute

abdominal pain in the Western world [5]
Cause Overall percentage
Upper GI endoscopy and colonoscopy can be useful of cases
investigatory tools in the acute setting. They may be Non-specific abdominal pain 34
able to localise and control bleeding in gastrointestinal
Acute appendicitis 28
haemorrhage. In the acute setting of diverticulitis or
peptic ulcer perforation, they can exacerbate problems Acute cholecystitis 10
by blowing air through perforation sites into the peri- Small-bowel obstruction 4
toneal cavity. Gynaecological disease 4
Acute pancreatitis 3
Renal colic 3
35.3.9 Diagnostic Laparoscopy
Perforated peptic ulcer 2
Cancer 2
Laparoscopy is a diagnostic tool that can also act as a
therapeutic tool. Through laparoscopy, various condi- Diverticular disease 1
tions can be effectively managed: appendicectomy, Miscellaneous 9
cholecystectomy, drainage of intra-abdominal abscess,
adhesion division and even oversewing of perorated
peptic ulcer [4]. 35.4.1 Acute Appendicitis

Classically presents with a history of vague genera-

35.3.10 Exploratory Laparotomy
Signs of diffuse peritonism often warrant immediate lap-
arotomy – which will be diagnostic and therapeutic. An
example of an exception to this is peritonism from acute
pancreatitis – which can be made worse by laparotomy.
However, in unstable patients for whom the cause of
acute abdominal pain is uncertain, an exploratory laparo-
tomy may be life-saving. This is especially true in the
setting of trauma. This should not be delayed while await-
ing investigations, which will not alter management.
35.4 Differentials and Management
The various causes of abdominal pain appear to be
­seasonal and are population dependant. However, some
studies looking at mainly Western populations provide
some insight on what to expect as common causes for
acute abdominal pain (Table 35.4) [5].
It is beyond the scope of this chapter to give a thor-
ough description of all possible causes of acute abdom-
inal pain; we will highlight some important disease
processes to aid with clinical assessment of common
causes of acute abdominal pain.
lised abdominal pain (visceral pain fibres) which then
becomes sharp and localised to right iliac fossa (pari-
etal pain fibres) (see Chap. 28). Can be associated with
fever, nausea, vomiting, diarrhoea and occasionally
microscopic haematuria from inflammation of adja-
cent ureter if appendix retrocaecal. Location of pain
over McBurney’s point (third of way from anterior
superior iliac spine to umbilicus) is variable because of
the unpredictable position of the appendix.
This is a diagnosis that should be made clinically –
serum inflammatory markers are often normal early,
ultrasound scans are notoriously poor at visualising the
appendix and clinical decisions should be made with-
out waiting for CT scans.
Complications stemming from perforation include
the formation of a peri-appendiceal abscess or diffuse
peritonism. This can be life-threatening as patients can
develop septic shock.
Definitive management is with laparoscopic or
open appendicectomy. The appendiceal abscess is
sometimes best managed with drainage of the collec-
tion and staged appendicectomy. Likewise, some argue
that the appendiceal mass (inflamed appendix sur-
rounded by omentum) can sometimes be managed
conservatively with intravenous antibiotics and staged
appendicectomy [6].
264
35.4.2 Acute Cholecystitis/Cholelithiasis
Pain from cholelithiasis is commonly described as sharp
constant pain in the right upper quadrant, which follows
large or particularly fatty meals, and tends to resolve in
several hours without intervention (see Chap. 22). These
patients often do not need hospital admission and can
be managed with staged elective cholecystectomy.
Cholecystitis, on the other hand, implies a prevail-
ing inflammatory process (often chemical inflamma-
tion). There is often an associated elevation in serum
inflammatory markers. Patients are clinically more
likely to be febrile and on examination be Murphy’s
test positive (inspiration is held as inflamed gallblad-
der hits examining hand held along right costal mar-
gin). Elderly patients may however be afebrile with
normal inflammatory markers. Ultrasound scans per-
formed on these patients will often reveal gallbladder
wall thickening and pericholecystic fluid. Most centres
now advocate cholecystectomy during current admis-
sion to manage acute cholecystitis.
A subcategory of patients who present with symp-
toms suggestive of common bile duct obstruction
(jaundice/icterus, pale stools, dark urine), biochemical
derangements (elevated bilirubin, GGT, ALP), dilation
of common bile duct on ultrasound or pancreatitis may
need an endoscopic retrograde cholangiopancreatogra-
phy (ERCP) to retrieve any common bile duct stones
prior to cholecystectomy.
35.4.3 Small Bowel Obstruction
Common causes of small bowel obstruction include
internal herniation (related to adhesions, often from
previous operations), external hernias (inguinal, femo-
ral, umbilical, epigastric or incisional), intussusception
(common in children and associated with malignant
lesions in adults) and volvulus (see Chap. 29).
Patients commonly present with central colicky
pain, often associated with abdominal distension,
­nausea, vomiting and constipation. On examination,
hernias need to be sought. Bowel sounds are often
described as tinkling.
Abdominal X-rays reveal loops of dilated bowel
with multiple air-fluid levels. Contrast imaging such as
gastrograffin follow-through and more commonly CT
will allow for identification of cause.
H. Nabi
Not all patients with bowel obstruction need (imme-
diate) surgery. Bowel obstructions caused by adhe-
sions often resolve with conservative measures – bowel
rest, intravenous therapy, nasogastric tube proximal
drainage. Urgent operations may be necessary if an
obstructed hernia (bowel lumen occluded within the
hernia) or strangulated hernia (impairment of the blood
supply to the bowel, giving rise to signs of peritonism)
is detected.
35.4.4 Acute Gynaecological Problems
Several gynaecological conditions can produce acute
abdominal pain (see Chap. 54). Even normal ovarian
follicle rupture at the time of ovulation can be associ-
ated with pain (Mittelschmerz). Ovarian cysts can
present with pain in either iliac fossa if they are torted
or rupture. Salpingitis – frequently related to intrauter-
ine contraceptive devices – can produce lower abdomi-
nal pain, fevers and vaginal discharge. Pregnancy
– whether intrauterine or ectopic – should be consid-
ered in all females of childbearing age.
Where appropriate, a vaginal examination can pro-
vide valuable information. Likewise, urine pregnancy
testing, pelvic ultrasounds and even diagnostic lap-
aroscopy can be particularly helpful diagnostic tools in
females presenting with lower abdominal pain.
35.4.5 Acute Pancreatitis
Patients suffering from acute pancreatitis frequently
present with epigastric pain, which may be associated
with nausea, vomiting and fevers (see Chap. 25).
There is often evidence of peritonism on abdominal
examination.
In the developed world, acute pancreatitis is most
commonly caused by gallstones and alcohol. Less
common causes can be remembered by using the GET
SMASHED pneumonic (Gallstones, Ethanol, Trauma,
Steroids, Mumps, Autoimmune, Hyperlipidaemia/
Hypercalcaemia, ERCP, Drugs – such as thiazide
diuretics and azathioprine).
Scoring criterion, such as the modified Glasgow
criteria, can be used to grade severity of episodes on
35 Acute Abdominal Pain
Table 35.5 Modified Glasgow criteria for grading severity of
acute pancreatitis on admission
Criteria can be remembered with the pneumonic
PANCREAS
P – PO2 <60 mmHg
A – age >55 years
N – neutrophils (WCC >15 × 109/L)
C – serum calcium (Ca2+ <2 mmol/L)
R – serum urea >16 mmol/L
E – enzymes (AST >200 iu/L, LDH >600 iu/L)
A – serum albumin <32 g/L
S – sugar (blood glucose >10 mmol/L)
Mild 0 criteria
Moderate 1 criterion
Severe 2 or more criterion
admission (Table 35.5). Severe episodes require early
imaging (i.e. CT scan) and are more likely to require
transfer to intensive care facilities [7]. One needs to be
aware of the numerous complications of acute pancre-
atitis and manage them actively. These complications
include pancreatic abscess formation, hypocalcaemia,
disseminated intravascular coagulation, septic shock,
pancreatic pseudocyst formation, development of
chronic pancreatitis (steat­orrhoea, malabsorbtion and
diabetes mellitus), acute res­piratory distress syndrome
and multiorgan failure.
Initial management involves supportive measures.
Intensive care referral should be made early, as patients
can deteriorate rapidly. Intubation may be required.
Intravenous therapy is required to compensate for third
space fluid losses. Alcohol withdrawal needs to be
managed. Early ERCP may be required early (if there
is evidence of cholangitis) [8]. Percutaneous drainage
of collections and even pancreatic necrosectomy may
be required later.
35.4.6 Renal Colic
Renal Colic commonly presents with colicky flank
pain which radiates to the groin (see Chap. 55). This
may be associated with haematuria. Patients will often
be very restless as they struggle to find a position that
alleviates the pain.
265
CT scans are the investigation of choice, as a small
portion of stones is radiolucent, and others may be
positioned over bony structures. Stones 5-mm diame-
ter or less often pass spontaneously. Larger stones and
those leading to hydronephrosis may require interven-
tion by urologists.
35.4.7 Perforated Peptic Ulcer
Patients with perforated peptic ulcers commonly
­present with epigastric or diffuse abdominal pain (see
Chap. 21). On examination, diffuse peritonism is com-
mon. Signs may be localised if the perforation has
sealed itself off.
Free gas is seen under the hemidiaphragms on plain
CXR. In selective cases, sealed-off perforations can
be managed conservatively. Laparoscopic repair of
perforations is possible. Most surgeons would prefer
omental patch repair.
35.4.8 Acute Diverticular Disease
Diverticular disease is most often limited to the sig-
moid colon (see Chap. 30). Complications of divertic-
ular disease include diverticulitis, perforation, abscess
or stenosing stricture formation, haemorrhage and fis-
tula formation (enterocutaneous, enterovesical, etc.).
Diverticulitis commonly presents with constant left
iliac fossa pain, often associated with fevers. If a
redundant loop of ­sigmoid colon exists on the right
side, right iliac fossa pain may be the presenting
symptom.
Diagnostic tool of choice is the CT scan with i.v.
and oral contrast. Most cases of diverticulitis can be
managed conservatively with antibiotics – oral antibi-
otics in the community if mild, or inpatient intravenous
antibiotics if severe. Perforations can be managed with
radiologically guided percutaneous drains if sealed off.
Others may require laparotomy and sigmoid colectomy
(often Hartman’s procedure necessary). Colonoscopy
in the acute setting is ill-advised. To document the
extent of diverticular disease, patients can be brought
back and colonoscopy can be performed in the outpa-
tient setting once the inflammation has subsided.
266
35.4.9 Urinary Tract Infections
Urinary tract infections range from mild cystitis to severe
pyelonephritis (see Chap. 55). Dysuria and fevers accom-
panying lower abdominal pain is suggestive of cystits.
When associated with flank pain, imaging to exclude
pyelonephritis should be performed. Urinary dipstick
testing provides a quick indicator of urinary infection –
­positive nitrites and leucocytes are suggestive. One
should ensure midstream specimens are taken for M,C&S
prior to the initiation of empirical treatment.
35.5 Summary
Acute abdominal pain is a common reason for referral
to the rural general surgeon. Its causes range from the
relatively trivial to the life-threatening. In view of their
proportionately limited resources, rural surgeons have
to place great emphasis on their clinical judgement in
managing these patients. By adopting a systematic
approach to one’s assessment and management, the
intimidating task of differentiating between potential
causes is made much easier.
H. Nabi
References
1. Forster, T.H., Bonkat, G., Wyler, S., Ruszat, R., Ebinger, N.,
Gasser, T.C., Bachmann, A.: Diagnosis and therapy of
acute ureteral colic. Wien. Klin. Wochenschr. 120(11–12),
325–334 (2008)
2. Urban, B.A., Fishman, E.K.: Targeted helical CT of the acute
abdomen: appendicitis, diverticulitis, and small bowel
obstruction. Semin. Ultrasound CT MR 21(1), 20–39 (2000)
3. Whitehouse, J.S., Weigelt, J.A.: Diagnostic peritoneal
lavage: a review of indications, technique, and interpreta-
tion. Scand. J. Trauma Resusc. Emerg. Med. 17, 13 (2009)
4. Perri, S.G., Altilia, F., Pietrangeli, F., Dalla Torre, A.,
Gabbrielli, F., Amendolara, M., Nicita, A., Nardi Jr., M.,
Lotti, R., Citone, G.: Laparoscopy in abdominal emergencies.
Indications and limitations. Chir. Ital. 54(2), 165–178 (2002)
5. de Dombal, F.T.: Diagnosis of Acute Abdominal Pain
[A Compilation of Scientific Studies of Abdominal Pain
Completed over 20 years.], 2nd edn. Churchill Livingstone,
Edinburgh (1991)
6. Meshikhes, A.W.: Management of appendiceal mass:
­controversial issues revisited. J. Gastrointest. Surg. 12(4),
767–775 (2008)
7. Nathens, A.B., Curtis, J.R., Beale, R.J., Cook, D.J.,
Moreno, R.P., Romand, J.A., Skerrett, S.J., Stapleton, R.D.,
Ware, L.B., Waldmann, C.S.: Management of the critically
ill patient with severe acute pancreatitis. Crit. Care Med.
32(12), 2524–2536 (2004)
8. Gupta, R., Toh, S.K., Johnson, C.D.: Early ERCP is an
essential part of the management of all cases of acute
­pancreatitis. Ann. R. Coll. Surg. Engl. 81(1), 46–50 (1999)
 Gastrointestinal Bleeding
36
Friesen W. Randall

Gastrointestinal bleeding, or hemorrhage, is a common (i.e., the duodenojejunal ligament) marks the point at
presentation to physicians everywhere. While its sever- which the origin of a bleed is designated as one or the
ity may vary, it often provokes concern and anxiety in other.
both patient and doctor. The rural surgeon requires skills For practical purposes, bleeding episodes are usu-
in rapid assessment and intervention, and in addition, ally classified based on clinical presentation. Upper
must often address questions of triage and transport. bleeds manifest as hematemesis (vomiting of frank
This chapter will discuss the following: blood, clots, and/or “coffee-ground emesis,” and ­melena
stools). Lower bleeds may present with frank hemato-
1. Definitions chezia, varying in severity from traces of blood on ­toilet
2. Diagnosis paper, to passage of large amounts of frank blood and/
3. Management or clots.
a. Supportive
b. Specific
i. Pharmacological
ii. Hematological 36.1.2 Acute Versus Chronic
iii. Procedural
c. Patients on anticoagulants
Blood loss may be catastrophic, leading to shock and
4. Rural issues
even death (e.g., aorto-enteric fistula). It may also be
a. Triage
very chronic, occurring so slowly that its occurrence
b. Transport
may not be noticed until symptoms of anemia set in, or
a fecal occult blood test becomes positive (e.g., colon
cancer). This variability in acuity necessarily leads to a
36.1 Definitions variable algorithm, and thus early and accurate evalua-
tion of acuity takes priority in assessment.

36.1.1 Upper Versus Lower

Gastrointestinal Hemorrhage
36.2 Diagnosis
Gastrointestinal hemorrhage, generally referred to as
“GI Bleed,” is commonly divided geographically into 36.2.1 Upper Versus Lower
“upper” and “lower” cases. The ligament of Treitz
Distinguishing between an upper and a lower origin
of bleeding may be simple, as when frank hematem-
F.W. Randall
esis occurs. Retrograde flow of blood from below the
Department of Surgery, Victoria Hospital,
1200 - 24th Street West, Prince Albert, SK S6V 5T4, Canada ligament of Treitz almost never occurs, so such bleeds
e-mail: rfriesen@paphr.sk.ca are always considered “upper.” Change in stool color

M.W. Wichmann et al. (eds.), Rural Surgery, 267

DOI: 10.1007/978-3-540-78680-1_36, © Springer-Verlag Berlin Heidelberg 2011
268
(in the face of bleeding) is affected by factors such as
gut transit time, rapidity of blood loss, dietary and
drug intake. One can be misled by the presence of
melena, diagnosing an upper GI bleed when the actual
source is the right colon.
36.2.1.1 History
However, frank hematemesis or hematochezia can
originate from a wide variety of pathological condi-
tions. Common causes of upper bleeds include esopha-
geal varices, gastritis, and/or gastric ulceration (often
associated with anti-inflammatory drug use), and
­duodenal ulceration. Lower causes include colonic
diverticulosis or angiodysplasia.
Thus, obtaining an accurate history is paramount.
Information from the patient, the family physician,
family members, friends, co-workers, ambulance staff,
nurses, pharmacists, and other caregivers can usually
establish a working diagnosis without resorting to
emergency diagnostic procedures. Data from previous
investigations must be rigorously sought after, whether
from local clinical charts, from other physicians, or
even from remote institutions. A history of retching or
vomiting prior to onset of hematemesis should raise
the suspicion of a traumatic mucosal tear (so-called
Mallory-Weiss tear).
Detection of underlying diseases is also very help-
ful. For example, if signs of chronic liver disease are
detected, portal hypertension becomes a more likely
etiologic factor for bleeding. Likewise, consumption
of anti-inflammatory drugs (even small doses such as
ASA 81 mg) must be vigorously pursued in taking a
history. Many patients do not consider these over-the-
counter medications to be significant, and omit them
unless specifically questioned.
Similarly, consumption of ethanol and other chemi-
cal irritants must be documented, both short and long
term. Acute gastritis after a weekend binge may mani-
fest much like an acute variceal bleed, but their treat-
ments are quite different. Note that household members
are often more objective in their quantification of
­ethanol intake than the patient.
Determining the actual amount of blood lost in
an acute setting can be very difficult, and is typi-
cally overestimated by patients and observers.
Referring to objective measures when asking ques-
tions helps avoid vague descriptions such as “there
was blood everywhere,” or “the toilet bowl was full
of blood.”
F.W. Randall
The most vital history seeks for symptoms of hypo-
volemia. Aside from patients with known esophageal
varices or coagulopathy, most patients without symp-
toms can be initially assessed outside of a hospital.
All aspects of history take on significance. The
­family history may reveal bleeding tendencies, liver
disease, or peptic ulcers. The psychosocial history
might reveal the use of street drugs or ethanol abuse.
36.2.1.2 Physical Examination
The vital signs comprise the most “vital” part of physi-
cal evaluation. These must be interpreted in light of the
patient’s age and their usual parameters. Vital signs are
the primary method for triaging cases, both in an office
setting, and in a hospital emergency department.
In the absence of equipment to assess blood pres-
sure, palpation of peripheral pulses gives the most
basic assessment of vascular perfusion. Severe pallor,
dyspnea, diaphoresis, peripheral vasoconstriction, and
orthostatic dizziness/syncope are also valuable clues.
These signs must take into account the effect of drugs;
e.g., beta-blockers prevent tachycardia and peripheral
vasoconstriction, thus concealing evidence of shock.
While the presence of pallor must always remain
subjective, experienced clinicians still assess for it
generally, and in anatomic locations where skin pig-
mentation is absent (e.g., oral mucosa, conjunctiva).
Stigmata of chronic hepatic dysfunction include club-
bing, asterixis, spider nevi, ascites, dependant edema,
and gynecomastia. Unless previously done by an expe-
rienced and trusted practitioner, rectal examination
should be done by the surgeon.
If the source of bleeding is uncertain, gastric lavage
may help to confirm a proximal source. This should
however only be considered if an urgent or semi-urgent
(depending on the amount of blood loss) upper gastro-
intestinal tract endoscopy cannot be done. “Blind”
insertion of a nasogastric tube can lead to disruption of
a clot or may cause bleeding from varices. Furthermore,
bleeding from below the pylorus cannot be excluded
with a nasogastric tube alone since it is usually posi-
tioned proximal to the pylorus and may not detect
blood distal to a competent pylorus.
36.2.1.3 Laboratory Tests
While hematological parameters are not necessary for
primary triage and the diagnosis of shock or severe
36 Gastrointestinal Bleeding
blood loss, they are very helpful in guiding treatment.
Either the hemoglobin or the hematocrit will provide
an approximate idea of the extent of blood loss, but in
very rapid loss, will underestimate the actual loss,
because both of these values reflect ratio of red blood
cells, or hemoglobin, to blood volume – as opposed to
the total circulating volume of RBC’s or hemoglobin.
Assessment of platelet numbers must also be per-
formed, even though adequate numbers do not guaran-
tee adequate function (see below).
The lab values must always be interpreted in light
of the clinical presentation; isolated values alone can-
not provide certainty about degree of urgency or exact
nature of any treatment plan. For example, a young fit
person may withstand a hemoglobin level as low as
40 g/L (4 g/dL) with only mild cardiovascular stress,
while an elderly person with cardiac dysfunction might
be at risk of serious complication with a hemoglobin
level of 90 g/L (9 g/dL).
Whether bleeding is acute or chronic, coagulation
should always be assessed. Prothrombin time (PT) and the
associated international normalized ratio (INR) need to be
measured, usually in conjunction with activated partial
thromboplastin time (APTT). Antiplatelet drugs will affect
clot formation, but tests of platelet function are not as
functionally useful, and are not always readily available.
In all cases of significant blood loss, as evidenced
by cardiovascular compromise or by very low hemo-
globin levels, determination of blood group (ABO)
and type (Rh status) must be done. Screening tests for
circulating antibodies are often done at the same time
(i.e., “group and screen” test), so that if cross-matching
is requested, it can be done expeditiously.
Fecal occult blood testing (FOBT) has only an
occasional role to play; the low specificity and sensi-
tivity render these tests of little utility in most cases. If
utilized, a fecal immunochemical test (FIT) should be
preferred over other older types (i.e., guaiac-based)
since it is specific for human blood.
36.2.1.4 Imaging
The advent of flexible GI endoscopy has brought
opportunity for rapid and precise diagnosis of the ana-
tomic location and pathological cause of most bleeds.
The equipment and skills for esophagogastroduo-
denoscopy (EGD), in particular, can and should be
readily available in most hospitals where bleeds com-
monly present (Figure 36.1). Barium studies are best
avoided, as they interfere with other imaging studies.
269
The timing of EGD depends on the acuity of the
presentation. Ideally, all patients with suspected upper
GI hemorrhage should undergo endoscopy within
24–48 h. If bleeding is suspected to come from esoph-
ageal varices, a higher degree of urgency for both diag-
nostic and therapeutic endoscopy is indicated. Those
patients with significant ongoing bleeding need more
rapid testing, so that treatment can be directed at the
anatomic site and underlying pathology (see below). If
a patient remains unstable despite adequate blood and
fluid administration, an emergency endoscopy must be
performed. During this procedure, ice-water irrigation
of the stomach/bleeding lesion can help to identify the
blood source and may contribute to a reduction of
blood loss. Care should be taken not to make a bleed
worse with these interventions.
For lower GI bleeding, assessment is hampered by
the presence of stool. Bowel cleansing for an acute
bleed should be done cautiously, to avoid aggravating
bleeding or inducing hypovolemia. A brisk bleed will
itself act as a cathartic, and enemas can cleanse the
lower colon and rectum efficiently and safely. Unlike
EGD, lower endoscopy offers little in the way of thera-
peutics, as most cases of bleeding settle without treat-
ment, and many causes are not amenable to endoscopic
intervention, anyway (e.g., diverticulosis).
Other endoscopic techniques such as enteroscopy and
capsule endoscopy are typically available only in large
referral centers, and are rarely helpful in the acute setting.
Where radionuclide imaging is available, a “tagged”
RBC scan will help. One must select cases in which the
bleeding is brisk enough to show up, but not so brisk as
to place the patient at risk because of the time required to
perform such testing. There is no therapeutic benefit
with this modality, but it can be repeated (within 24-48
hours, without another radionuclide injection)... in the
event of intermittent symptomatology. In brisk bleeding,
angiography becomes useful for localization; immediate
treatment by embolization may cure the patient, or at
least slow down bleeding temporarily. Occasionally,
imaging modalities such as CT scanning, MR imaging,
and similar modalities may help in diagnosis; CT angiog-
raphy may hold promise for localization of bleeding.
Rarely, operative intervention may be required.
Laparoscopy may show either a general site (as evi-
denced by proximal extent of blood in the gut), or a
specific anatomic pathology (e.g., leiomyoma of small
bowel). Laparotomy may be required for severe bleed-
ing as a lifesaving measure; one might only be able to
estimate the general area of bleeding, and then resect a
segment of gut “blindly.”
270 F.W. Randall

Fig. 36.1 Endoscopic

appearance of lesions causing
upper gastrointestinal
bleeding. (a) Chronic ulcer
on the anterior wall of the
duodenal cap. (b) Severe
hemorrhagic gastritis without
erosions. (c) Bleeding from
the apex of a stromal tumor
(leiomyoma) in the fundus of
the stomach. (d) Close-up
view of a bleeding Dieulafoy
lesion in the fundus of the
stomach. (Source: Prof. Ian
Roberts-Thomson, Adelaide)

36.3 Management for RBC use. There is much evidence to indicate that

36.3.1 Supportive
For acute hemorrhage, oxygen and intravenous iso-
tonic fluids through a large-bore catheter constitute
essential interventions. Central venous access may be
useful, but large-bore peripheral venous catheters are
the first choice because of availability, efficiency, and
efficacy.
Transfusion of red blood cells should be consid-
ered whenever bleeding is catastrophic or response to
isotonic fluids fails to meet expectations. Non-cross
matched RBC’s should be given only if bleeding is
immediately life-threatening. The older algorithms
tended to rely on laboratory parameters as indicators
the safer, although more complex, route is to use
physiological parameters such as organ perfusion
and global function (e.g., urine output, vital signs,
ability to do normal activities without difficulty) to
determine when and how much to transfuse.
Basic homeostasis must be sought after; thus, core
temperature must be normalized, using warm fluids
whenever possible. Urine output should be carefully
monitored via a urinary catheter in any unstable patient.
Monitoring of central venous pressure may be useful,
especially if significant underlying cardiac dysfunc-
tion exists.
Iced saline lavage has been used, but without con-
vincing evidence of effectiveness. Nasogastric suc-
tion tubes have not been shown to be helpful, and
certainly do carry some morbidity and discomfort.
36 Gastrointestinal Bleeding
Placement of intraluminal balloons (e.g., Sengstaken-
Blakemore tube) to tamponade variceal bleeding
might provide temporary control, but in the long
term does not make a significant difference in
outcomes.
36.3.2 Specific
36.3.2.1 Pharmacologic
Most upper GI bleeding will stop within 24 h on pro-
ton pump inhibitor (PPI) therapy alone. Typical proto-
cols require an intravenous bolus, followed by an
ongoing infusion. For less acute bleeds, oral therapy
may replace the infusion; the initial treatment for an
acute bleed should always be intravenous. Histamine
(H2) blockers do not have a detectable effect on bleed-
ing, nor do oral antacids.
There is no recognized role for vasopressors.
Measures to control portal venous pressure (e.g., soma-
tostatin analogues, beta-blockers) do help control
bleeding and to decrease transfusion requirements in
variceal bleeding. In the acute setting, beta-blockers
should be avoided to allow for a physiological response
to blood loss. Vitamin K (orally or parenterally) will
help patients with demonstrated or suspected coagul-
opathy (e.g., patients on warfarin, those with impaired
fat absorption, etc.).
Do not forget to withhold offending agents (e.g.,
anti-inflammatory drugs, antiplatelet drugs, etc.).
Re-introduction of such drugs should be done only
after weighing the pros and cons (e.g., giving clopi-
dogrel to a patient who has had TIA’s or recent place-
ment of coronary artery stents).
36.3.2.2 Hematologic
If no coagulopathy exists, and bleeding is not massive
(a universal definition of “massive” is lacking), routine
use of blood products is not recommended. These
products are generally, but not universally safe. They
have limited availability and are expensive.
Traditionally, infusing coagulation factors was done
only when coagulopathy was proven. More recently,
271
use of such products has been advocated in all cases
where bleeding is brisk, and where transfusion require-
ments exceed two units of RBC’s. Some experts rec-
ommend “routine” use of fresh frozen plasma (FFP);
they suggest a ratio of RBC to FFP units of between
two and four. Whether this should apply to all cases of
bleeding, or a specific population of patients, is not
clear. Consider FFP use when the traditional standard
for massive bleeding (i.e., need for six units of RBC’s
in 24 h) is met.
If laboratory findings on coagulation are abnormal,
correction of these parameters is almost always
required. FFP is often readily available and is easily
administered. Cryoprecipitate may be useful if dis-
seminated intravascular coagulation (DIC)/consump-
tion coagulopathy is present. For specific cases,
administration of Factor VIII concentrate should also
be considered, especially if a family history of bleed-
ing is manifest.
If brisk bleeding occurs in a patient taking antiplate-
let medication (e.g., clopidogrel), platelet transfusion
should be considered earlier rather than later. Aspirin,
on the other hand, rarely calls for such measures.
Thrombocytopenia requires attention; if consumption
or platelet destruction (e.g., hypersplenism) is ongo-
ing, repeated transfusion may be needed. Do not wait
for laboratory results (e.g., bleeding time) before order-
ing platelets (see above for rationale).
36.3.2.3 Procedural
Procedures to control bleeding can be done through
endoscopic, vascular, or surgical means. Clinical judg-
ment must be exercised in all cases, based on one’s
knowledge of each technique, one’s skill in applying
the technique, and the availability of other options. An
inexperienced endoscopist can get into trouble with
precipitating worse bleeding, perforation, and pulmo-
nary aspiration of blood.
Fiber-optic GI endoscopy has revolutionized the
management of upper GI hemorrhage. Forces can be
brought to bear on the exact location of the bleeding
source. This force may be mechanical (e.g., applica-
tion of a clip to a spurting or visible vessel, or of an
elastic band to an esophageal varix). It may be thermal
(e.g., YAG laser, heater probe, bipolar cautery, etc.).
272
It may be a combined effect, as in injection treatment
(e.g., saline, adrenalin, glues, etc.). These techniques
are best done with video equipment, an experienced
endoscopist, and a skilled endoscopy assistant. Two
working channels allow for simultaneous suctioning
and application of therapeutic devices.
Lower GI bleeds are more problematic, as visual-
ization is typically poor. Although unproven, the belief
that bowel cleansing exacerbates such bleeding seems
intuitive. Thus, both diagnosis and intervention can be
safely delayed in the stable patient. Fortunately, the
vast majority of cases (most commonly diverticular
disease and angiodysplasia) do not require specific
intervention, as their natural history is one of sponta-
neous cessation.
Controlling blood loss through vascular means
requires angiography facilities (Figure 36.2). The cre-
ation of a transvenous intrahepatic porto-systemic
shunt (“TIPS”) will decrease portal venous pressure
and associated bleeding. Embolization of arteries is
mentioned above.
Operative techniques are seldom required when the
above measures are skillfully applied. However, lap-
aroscopic and open procedures may be both diagnostic
and curative. The most common traditional indication
for surgery was duodenal ulcer; endoscopic measures
now almost always suffice. Emergency open porto-
systemic shunts are rarely justifiable.
Given the rarity of surgery for bleeding, such opera-
tions should be undertaken only when clearly neces-
sary, and with skilled assistance. Blood and blood
products must be readily available. Localization of
bleeding may be achieved laparoscopically, especially
if the source is in the small bowel (e.g., leiomyoma,
neuro-endocrine tumor, Meckel’s diverticulum, etc.).
Triage Factors to be Accounted for
Patient factors Hemodynamic stability Etiology of bleeding
Transport mode Helicopter Fixed-wing aircraft
Transport security Weather Terrain
Hospital support Blood bank Endoscopy
Transport personnel Availability Number
F.W. Randall
Intraoperative endoscopy may help, (e.g., after intra-
operative “on table” colonic lavage).
Massive gastric hemorrhage from diffuse gastritis
may require extensive gastric resection; morbidity
will be high. When the location is the bowels, careful
segmentation of the lumen with non-crushing clamps
(or fingers!) may reveal the area of bleeding, thus
allowing isolation to tamponade and/or resect of that
segment.
36.3.3 Patients on Anticoagulants
Patients on anticoagulant drugs require special atten-
tion. They are more likely to bleed from pathology that
would not ordinarily result in bleeding. They are more
likely to be elderly, frail, and compromised in terms of
cardiovascular function. They may require extensive
and expensive drugs and/or blood products to normal-
ize coagulation, and their definitive investigations and
interventions are thus often delayed.
For patients on warfarin, if Vitamin K and FFP do
not restore normal clotting parameters quickly enough
to allow for such tests and treatments, prothrombin
complex concentrate (PCC) (where available) should
be considered. It is safe and rapidly effective.
Protamine sulfate can be used to reverse the effects
of heparin. Its utility in patients on low molecular
weight (LMW) heparins varies, depending on exactly
which type of heparin is in use; consult manufacturer’s
documentation and online sources for up-to-date data.
Always bear in mind that the effects of protamine are
almost always of a shorter duration than that of LMW
heparin, thus necessitating repeated doses of the for-
mer until the latter has “worn off.”
Comorbidities Patient preferences
Ambulance Other
Distance Military issues
Nursing personnel Staff to go with patient
Training Experience
36 Gastrointestinal Bleeding 273

Fig. 36.2 Bleeding large bowel lesion on angiography with ­successful bleeding control using embolization. (Pictures courtesy of
Department of Radiology, Flinders Medical Centre, Adelaide)
274
36.4 Rural Issues
36.4.1 Triage
When resources are limited, as is inevitably the case in
rural settings, the question of transfer to another loca-
tion becomes crucial. Is it safe to send a very ill patient?
If not, should attempts be made to make it safe, or
should resources be directed at arranging definitive care
at the local facility? What is the expected duration of the
trip? Will weather conditions permit travel, and if so,
will they influence the timing or the duration of the trip?
Is the receiving facility ready and willing to accept the
case? What are the patient’s (or the family’s) wishes? Is
qualified staff available to care for the patient en route?
If blood transfusion is required during transport,
proper infusion devices and clerical processes must be
place to ensure safety. Skills and medications must
also be in place to deal with transfusion reactions.
Sometimes the best treatment modality is not avail-
able at a rural facility. However, the risk of the patient
coming to harm because of delays related to transport,
must be weighed against the risk of the patient coming
to harm because of suboptimal treatment. This kind of
risk assessment requires experience and judgment;
often, a discussion with a physician at the receiving
facility prior to transport helps.
36.4.2 Transport
Once a decision has been reached to send a patient else-
where for care, the physician must try to anticipate
events during the trip, and to thus plan for them. Vital
resuscitation equipment, oxygen, intravenous fluids,
vital signs monitoring devices, suction tubing, and good
temperature regulation are all essential. Having said
this, experience shows that such preparation consumes
time, and delays often lead to worsened outcomes.
F.W. Randall
Ambulance personnel vary widely in their qualifi-
cations; ancillary hospital staff (e.g., respiratory tech-
nician, nurse) may need to accompany the patient. If
the patient is grossly unstable, a physician may be
required. In facilities with very limited personnel,
sending staff out may render that facility unable to pro-
vide essential services; thus, such decisions must be
made carefully.
In summary, triage decisions are complex and must
take into account a wide range of non-medical data, as
well as knowledge of local resource issues, to allow for
best outcomes for rural patients.
Recommended Reading
Adler, D.G., Leighton, J.A., Davila, R.E., Hirota, W.K.,
Jacobson, B.C., Qureshi, W.A., Rajan, E., Zuckerman, M.J.,
Fanelli, R.D., Hambrick, R.D., Baron, T., Faigel, D.O.,
ASGE: ASGE guideline: the role of endoscopy in acute non-
variceal upper-GI hemorrhage. Gastrointest. Endosc. 60(4),
497–504 (2004)
Barkun, A., Bardou, M., Marshall, J.K., Nonvariceal Upper GI
Bleeding Consensus Conference Group: Consensus recom-
mendations for managing patients with nonvariceal upper
gastrointestinal bleeding. Ann. Intern. Med. 139(10),
843–857 (2003)
Davila, R.E., Rajan, E., Adler, D.G., Egan, J., Hirota, W.K.,
Leighton, J.A., Qureshi, W., Zuckerman, M.J., Fanelli, R.,
Wheeler-Harbaugh, J., Baron, T.H., Faigel, D.O., Standards
of Practice Committee: ASGE guideline: the role of endos-
copy in the patient with lower-GI bleeding. Gastrointest.
Endosc. 62(5), 656–660 (2005)
Murray, M., Bullard, M., Grafstein, E.: for the CTAS and CEDIS
National Working Groups: revisions to the Canadian emer-
gency department triage and acuity scale implementation
guidelines. CJEM 6(6), 421 Oops. Nov, 2004
NSW Health (Sydney, Aust.). Triage and management of
patients in NSW rural and remote EDs where there are no
On-site doctors. SHPN: 040128; ISBN: 0734736878 (http://
www.health.nsw.gov.au/pubs/2004/pdf/triage_rural_remote.
pdf) (01 Aug 2004) accessed 20 Feb, 2011
Thompson, J.M., Irvine, H., Von Hollen, B., Peters, M.: Triage
system for rural hospital emergency services. Can. Fam.
Phys. 37, 1252–1266 (1991)
 Mesenteric Ischaemia
37
Heinrich Stiegler, Florian Brackmann, and Laura Holzner

37.1 Epidemiology 37.3 Aetiology and Pathogenesis

The incidence of acute mesenteric ischaemia (AMI) is
Sixty percent of AMI cases are caused by impairment
about 1/100,000 per year. In 0.4–1.0% of all patients
of arterial perfusion, 25% are of non-occlusive origin
with unclear abdominal pain, it is the underlying cause.
(NOMI), 15% of mesenteric ischaemias are due to
The risk increases with age and reaches 3.8% in the
venous occlusion. Irrespective of the cause but based
population over 80 years. Venous occlusion is less
on a common final pathway, it always leads to necrosis
­frequent; it differs in pathogenesis and therapy from
of the mucosa (possibly only in the form of damage to
ischaemia due to arterial occlusion and will therefore
the internal layer) and subsequent disintegration of
be discussed separately.
intestinal barrier function, finally advancing to necro-
sis of musculature and possibly resulting in perforation
37.2 Localisation and peritonitis (Table 37.1).

Mesenteric ischaemia usually involves the area sup-

plied by the superior mesenteric artery, i.e. ischae-
mia usually occurs about 5–7 cm distal of the 37.4 Clinical Symptoms and Diagnostics
ligament of Treitz (blood supply by the celiac trunk
to this point) down to the left colonic flexure, where The following triad is characteristic:
the blood supply via the inferior mesenteric artery
• Acute onset of abdominal pain
starts. Depending on the extent of arterial obstruc-
• History of cardiac problems
tion, smaller and simultaneously sequential ischae-
• Lactate acidosis.
mic areas are possible.
Prior to the introduction of Angio-CT, these signs were
indication for emergency laparoscopy or laparotomy.
H. Stiegler (*) As differential diagnosis for acute abdominal pain,
Department of General-, Visceral- and Vascular Surgery,
Klinikum Kaufbeuren-Ostallgäu, the following causes have to be kept in mind:
Dr. Gutermannstr. 2, 87600 Kaufbeuren, Germany
• Myocardial infarction
e-mail: heinrich.stiegler@kliniken-oal-kf.de
• Basal pneumonia
F. Brackmann • Pleurisy
Department of General Surgery, Mount Gambier
General Hospital, 276-300 Wehl Street North, • Biliary colic
Mount Gambier, SA 5290, Australia • Pancreatitis
L. Holzner • Perforation of an ulcer
Department of General Surgery, Mount Gambier General • Ruptured/sealed rupture of aortic aneurysm
Hospital and Flinders University Rural Medical School,
276-300 Wehl Street North, Mount Gambier, SA 5290, The clinical course can be divided into three typical
Australia phases (Table 37.2).

M.W. Wichmann et al. (eds.), Rural Surgery, 275

DOI: 10.1007/978-3-540-78680-1_37, © Springer-Verlag Berlin Heidelberg 2011
276 H. Stiegler et al.

Table 37.1 Causes of mesenteric ischaemia 37.5 Further Investigations

Arterial occlusion
− Embolism of the superior mesenteric artery (cardiac origin In previous times, angiography, duplex sonography or
in case of hypokinetic disorder, atrial fibrillation, valve occasionally explorative laparotomy was most preva-
defects)
lent; presently, angio-CT is the diagnostic method of
− Thrombosis of the superior mesenteric artery due to choice. This tool allows the superior mesenteric artery
arteriosclerosis
to be visualized with all its branches, e.g. the ileocolic
− Aortic dissection artery. In addition, the angio-CT provides important
− Vasculitis/arteritis information regarding differential diagnosis. Traces of
free air can be detected with the CT rather than with an
− Direct trauma (e.g. mesenteric tear, ligation of the inferior
mesenteric artery) x-ray, signs of peritonitis, thickening of the intestinal
wall or gas trapping in the intestinal wall (Pneumatosis
NOMI
intestinalis) can be seen as well. For differential diag-
− Hypotension nostic considerations, the following investigations are
− Cardiac insufficiency needed:
− Septic shock −− Chest x-ray in two planes
− Hypoperfusion due to medication (catecholamines, calcium −− ECG and cardiac enzymes
antagonists, nitrates, diuretics, beta blocker, ACE inhibitors) −− Lipase
Venous occlusion Sensitivity for the AMI in the angio-CT is 80%. NOMI
Primary is more difficult to detect which means that in case of
− Hereditary thrombophilia (deficiency of protein C, S, doubt, angiography or laparoscopy has to be done.
AT III, APC-resistance, antiphospholipid syndrome, Especially for peripheral thrombosis or embolisms in
homocysteinaemia) the mesenteric artery, angiography has some diagnos-
Secondary tic advantages and local lysis therapy as well as other
− Pancreatitis
drugs (e.g. Papaverin) can be administered through the
catheter in place.
− Inflammatory bowel disease Figure 37.1 shows the diagnostic and therapeutic
− Appendicitis algorithms if AMI is suspected.
− Portal hypertension
− Paraneoplastic syndrome

Table 37.2 Time flow of acute mesenteric ischaemia (h)
0:00 Acute abdominal pain, cardiac history, lactate
acidosis (depending on the extent of ischaemia)
3:00 Changing of pain symptoms, hyperperistalsis,
‘silent interval’
6:00 Increased guarding, translocation peritonitis
Severe abdominal pain with sudden onset in the
beginning, followed by varying abdominal pain which
is less severe than during the acute period at the start of
ischaemia and can conceal the true extent of the condi-
tion. This contrast to the overall impression of a
severely ill patient indicates the need for an aggressive
workup. Anamnestic evidence of prior embolisms
(arm, leg, apoplexy) can add to the suspicion.
37.6 Therapeutic Strategy
The main problems of this disease are its low inci-
dence, its initially diffuse character, and the short
period of time in which therapy has to be started to
reduce the high mortality rate (50–85%). Within 3 h,
severe wall damage occurs, which may be reversible if
vascular reconstruction is done. Six hours after com-
plete occlusion of the superior mesenteric artery, the
bowel usually cannot be rescued in spite of successful
embolectomy.
The urgency of immediate measures makes alert-
ness for this condition eminently important; it has
to be ‘on your mind’ to promptly initiate ­angio-CT
and if confirmed conduct laparotomy.
37 Mesenteric Ischaemia
Fig. 37.1 Algorithm for the clinical
approach if acute mesenteric ischaemia
is suspected
AMI
Doubtful prognosis
Laparoscopy
Explorative laparotomy
Palliative/best supportive care
During laparotomy, the superior mesenteric artery
is exposed at the lower pancreatic margin, a prepara-
tion which can be very difficult in obese patients
because of the jejunal veins. After looping the artery
and systemic administration of heparin, the embolec-
tomy is performed; the mesenteric insertion is com-
pressed digitally to mobilize potential small thrombi
retrogradely. The transverse arteriotomy is closed with
a monofilament non-resorbable suture (6–0, 7–0).
If the reconstruction of the vessel is complicated
due to calcification, a venous patch can be formed
using the Saphenous vein. Therefore, this area has to
be kept in mind when draping the patient.
The bowel is packed in warm towels and reperfu-
sion is awaited. The parts of the bowel which do not
show recovery have to be resected, although slightly
damaged inner wall can be left if the embolectomy
went well. Bowel parts in doubt will be left for a
‘­second look operation’ 24 h later, possibly even a
‘third look operation’ as well.
277
Clinical suspicion for AMI
Angio-CT
Unclear findings
Angiography
Possibly local lysis
Intra-arterial therapy
Embolectomy
Resection
Second look where applicable
Life-long anticoagulation
Further therapeutic measures are:
• Injection of papaverin where appropriate
• Systemic administration of heparin, PTT-controlled
• Diet build-up according to peristaltic movement
• Antibiotic coverage
• PPI administration
In cases of central ischaemia of the superior mesenteric
artery and irreversible damage to the bowel, extensive
resection with high jejunocecostomy can be performed
in the young patient even after embolectomy. Depending
on the age of the patient, small bowel transplantation
or enteral ‘home nutrition’ has to be considered later.
If the patient is very old and has numerous comor-
bidities, an individual decision with respect to the
patient’s will has to be made; possibly the laparotomy
or laparoscopy has to be stopped and considered explo­
rative, and best supportive care started. It is reasonable
to leave the patient analgosedated under ventilation at
ambient air; death can be expected within 1–2 days.
278
In cases of peripheral embolism of the superior mes-
enteric artery, angiography with an interventionalist on
standby can be sensible. Lysis is done with rtPA (e.g.
10 mg in 100-ml NaCl, inoculation of the clot with
5-ml bolus each, usually less than 10-mg rtPA are suf-
ficient). The selectively placed catheter can be left; it
allows further administration of Papaverine and sec-
ondary angiography.
After successful revascularisation (and resection if
needed), heparin treatment has to be changed to
Warfarin after a sufficient amount of time to allow for
mucosal healing.
Changeover to Warfarin should not happen too
early to prevent complicated Warfarin-related
bleeding if inner wall damage exists.
37.7 Complications
• Secondary bleeding under Warfarin: As a preven-
tive measure, doubling of the PTT should only be
approached after 24 h.
• Anastomotic leakage: This requires immediate
re-laparatomy.
• Short-bowel-syndrome: Due to the damage of the
mucosa, exudative exacerbation can occur and may
require parenteral feeding.
37.8 Prognosis
Despite medical and surgical progress, the prognosis
of acute mesenteric ischaemia is still poor with mortal-
ity ranging from 50% to 93%. If intervention starts
within 12 h, mortality ranges from 17% to 40%. The
worst outcome has to be expected in mesenteric ischae-
mia resulting from disseminated arteriosclerosis in the
context of NOMI.
37.9 Acute Thrombosis of the Portal
Vein/Superior Mesenteric Artery
Mesenteric ischaemia resulting from venous obstruction
is not as common, and pain is less severe than in AMI.
H. Stiegler et al.
In these patients, recanalisation due to endogenous lysis
often starts parallel to the development of the thro­
mbosis. Therefore, a quick diagnosis with efficient
­anti­coagulation is required to optimize the effect of
endogenous lysis.
37.10 Aetiology
The causes of venous occlusion are listed in the
scheme above (Table 37.1). If hereditary thrombo-
philia is homozygous, occlusions can already occur
in adolescents. In this case, a broad thrombophilia-
screening is needed. Secondary causes of venous
occlusion occur within paraneoplastic syndromes,
sometimes favoured by local infiltration of the vein,
e.g. in pancreatic cancer.
Regarding inflammatory diseases, not only Crohn’s
disease and ulcerate colitis have to be considered, but
also protracted appendicitis can cause a venous occlu-
sion of the superior mesenteric vein in terms of an
ascending thrombophlebitis.
37.11 Therapy
Figure 37.2 shows a therapeutical algorithm. In cases
of acute abdominal pain, laparatomy/laparoscopy is
inevitable. The extent of bowel resection depends on
the extent of the venous gangrene. A venous thrombec-
tomy is reserved for very rare indications (due to the
low-flow-system, the danger of rethrombosis is extraor-
dinarily high). If symptoms are less severe, an explor-
ative laparoscopy can precede a laparotomy; otherwise,
clinical control under sufficient heparinisation with
subsequent parallel changeover to Warfarin is usually
adequate.
37.12 Prognosis
The prognosis of the disease is usually determined
by its cause. The slower and more gradual the thro­
mbosis develops, the more likely is recovery under
anticoagulation.
37 Mesenteric Ischaemia 279

Fig. 37.2 Algorithm for the Clinical suspicion

approach to acute thrombosis Subtle symptoms
of the portal vein or superior
mesenteric vein

Angio-CT

Acute abdomen Questionable acute abdomen Subclinical findings

Laparotomy Laparoscopy Clinical control

Venous bowel gangrene Questionable finding

Resection Second look operation where applicable

Life-long anticoagulation
 Management and Surgery
of Inflammatory Bowel Diseases
William Roediger
38.1 Introduction
Inflammatory bowel diseases comprise ulcerative coli-
tis, Crohn’s disease, and more recently, indeterminate
colitis and pouchitis [1, 2], which remain distinct from
colitis related to Clostridium difficile, Mycobacteria,
Cytomegalovirus, Salmonella, Shigella and entero-
toxic E.coli.
38.2 Diagnosis of Inflammatory Bowel
Disease
A combination of specific clinical criteria often
described as a “phenotype,” in conjunction with ­precise
histological features, are essential to separate ulcer-
ative colitis from Crohn’s colitis and indeterminate
colitis [3].
38.3 Ulcerative Colitis
38.3.1 Clinical Symptoms and Diagnosis
The cardinal symptom of ulcerative colitis is rectal
bleeding with loosening of bowel motions, usually in
younger patients (aged 16–38) while manifestation in
W. Roediger
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Road, Woodville South, SA 5011, Australia
e-mail: bill.roediger@adelaide.edu.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_38, © Springer-Verlag Berlin Heidelberg 2011
38
older patients is the same with the added concern of
colonic neoplasia. Typically, ulcerative colitis manifests
in attacks, which descriptively are graded into mild,
moderate or severe (Table 38.1). Confirmation of dis-
ease is made on complete colonoscopy to the caecum
with disease manifestation seen in those areas of the
colon where prolonged microbial contact occurs; that
is, the distal colon and rectum or appendiceal lumen.
Mucosal appearances on colonoscopy comprise (1)
loss of mucosal light reflex, (2) redness with loss of
definition of blood vessels, (3) friability of the mucosa,
(4) diffuse granularity and micro-ulceration or (5)
gross ulcers and pseudo polyp formation. The extent
and exact length of the disease along the rectum or
colon must be recorded and whether “sparing of the
rectum” has occurred. A colitis involving the whole
colon is now rarely found unless symptoms have been
neglected for a long time.
Histological changes on biopsy are increased num-
bers and variety of inflammatory cells in the lamina
propria and epithelial cell changes of increased crypt
branching, increased apoptosis, diminished mucus
­production and diminished surface microvilli. Crypt
abscess formation hallmark ulcerative colitis before
obvious ulcers, epithelial cell atrophy and inflamma-
tory pseudo polyps manifest. As ulcerative colitis is a
“pre-neoplastic” disease a statement on the degree of
dysplasia should be included in all histological reports.
To clinch a diagnosis of ulcerative colitis, exclusion
of other disease conditions needs to be made by, for
example, stool culture, stool toxin analysis and anti-
body detection of Yersinia and amoebiasis. In elderly
patients, two conditions may mimic ulcerative colitis:
(1) ischaemic colitis when there is vascular compro-
mise of the superior and inferior mesenteric arteries;
and (2) the presence of diverticular colitis secondary to
active diverticulitis.
281
282 W. Roediger

Table 38.1 Clinical grading of “attacks” of ulcerative colitis Patients should be made aware of the treatment goals,
Mild Moderate Severe the necessity of their cooperation and the fact that ben-
Frequency of 3–4 4–6 6–10 efits of treatment may only accrue after 6–8 weeks of
bowel actions therapy.
Stool Solid to Semi Mushy
consistency semi solid solid
Mucus +/− – – 38.3.4 Medical Management
production
Blood in stool Occult + to +++ ++++
Systemic − +/− ++ (a) Microbes: Dietary change to diminish an excess of
involvement sulphur amino acids reaching the colon, thereby
changing provision of substrates for bacterial fer-
mentation with decrease in sulphide formation.
Probiotics, living bacteria such as Bifidobacteria,
38.3.2 Aetiological Considerations in the E.coli Nissle, prebiotics such psyllium husks or
Medical and Surgical Management plantago and synbiotics, which are a combination
of Ulcerative Colitis of prebiotics and probiotics have proven value
in both acute and maintenance therapy of ulcer-
ative coltis [5]. Non-absorbable oral antibiotics
A broad generalization of the aetiology of ulcerative (Tobramycin) may be useful. Salazopyrin or the
colitis is [1, 2] “the presence of an overactive immune active ingredient 5-aminosalicylic acid diminishes
system responding in a specific genetic setting to colonic sulphide formation.
unknown environmental factors, mainly an altered (b) Epithelium: Providing probiotics, which promote
microbial population in the colon.” Frequent reference n-butyrate formation, the chief metabolic substrate
of a “dysbiosis” leading to ulcerative colitis has been for colonic epithelial cells, may be of value.
made and one newer proposal of a dysbiosis is exag- Addition of folic acid (5 mg/day) may boost epi-
gerated bacterial denitrification in the colon, which thelial cell function and ability to detoxify nitric
leads to harmful levels of nitric oxide being produced oxide.
[4]. An excess production of sulphide in the colon has (c) Immune or cytokine suppression: Prednisolone
also been proposed to cause colitis. Many other hypoth- (maximum of 60 mg/day), azathioprine (up to
eses for the production of ulcerative colitis have been 150 mg/day), methotrexate and monoclonal anti-
put forward [1, 2]. bodies against TNF-a provide options to diminish
immune cell activity [6] that damages the colonic
epithelium. The use of azathioprine, methotrexate,
38.3.3 Medical and Surgical Treatment cyclosporin and biologicals are preferably dealt
of Ulcerative Colitis with by a gastroenterological physician interested
in inflammatory bowel disease.
Ideally, this constitutes input from three sources: self-
directed treatment by the patient, overview of treat-
ment by a gastroenterological physician and the
standby of a gastroenterological surgeon. Treatment 38.3.5 Surgical Management
emphasis is on controlling an acute attack of colitis
followed by maintenance therapy to prevent remission The need for surgical treatment of ulcerative colitis
of disease. Surgery is employed to eliminate colitic can be divided into absolute, strong or relative, high-
mucosa but entails the loss of the colon. In principal, lighting that medical therapy may not control all con-
therapy is directed at (1) colonic microbial popu­lations, tingencies of ulcerative colitis. Failure of medical
(2) restoration of epithelial integrity and (3) suppres- therapy may occur in the acute or chronic phases of the
sion of immune cell activity and cytokine production. disease.
38 Management and Surgery of Inflammatory Bowel Diseases
38.3.6 Indications for Surgical Treatment
Severe acute colitis
Absolute − Perforation
− Life-threatening haemorrhage
Strong − Dilatation of the colon with an irregular
mucosal line on the plain x-ray of the
abdomen. This appearance usually
indicates that there is deep mucosal
ulceration, which has penetrated to
involve the external muscle coats of the
colon. The situation is potentially
reversible in its early stages by medical
treatment but persistent or increasing
dilatation is a danger sign
Relative − Failure to respond to potent medical
treatment usually Prednisolone 60 mg
daily by intravenous infusion over
several days
Chronic colitis
Absolute − Carcinoma
Strong − Growth failure/sexual retardation
Macroscopic lesion(s) (elevated, villous
or polypoid area) associated with
dysplastic epithelium, or high-grade
dysplasia confirmed by sequential
biopsy in flat mucosa
Relative − Physical disability social disability –
especially urgency and frequency of
defaecation. Statistical carcinoma risk –
extensive colitis, history greater than
10 years (associated disorders, e.g. liver
disease)
Quiescent colitis
Absolute − Carcinoma
Strong − Macroscopic or high-grade dysplasia
(as above)
Relative − Recurrent severe acute attacks.
Statistical carcinoma risk (as above)
38.3.7 Emergency Surgery
Cases with perforation, “toxic” megacolon (an indica-
tor of deep penetrating ulcers) or fulminant colitis resis-
tant to all medical therapy requires a prompt operation.
The prime operation is a colectomy with ileostomy
and either preservation of the rectum that is closed off
or bringing out the rectosigmoid as mucous fistula. Of
283
these two options, a rectal stump and Brooke type
everting ileostomy after colectomy is preferable. The
rectal stump may be prone to continuing inflammation
as “diversion colitis” though this is treatable with fibre
suppositories and rectal steroid administration.
A mucous fistula often presents more problems (wound
infection, slow healing), then any potential advantages
of such a procedure and is now rarely performed.
Whatever distal colon or rectum is left, it should have
sufficient length to enable an elective ileorectal or
ileoanal pouch anastomosis.
38.3.8 Elective Surgery
The choice for an elective operation, based on the
criteria given above, is a proctocolectomy, either with
(1) Brooke type everting end ileostomy, (2) ileorectal
anastomosis or (3) a restorative pouch with ileoanal
anastomosis. The last option can be done with a muco-
sectomy and hand-sewn anastomosis or by a circular
stapling technique, which leaves a cuff of 1–2 cm of
anal mucosa. Of all these options, a restorative ileal
J pouch of 15–20 cm length with a stapled ileoanal
anastomosis is currently the most favoured procedure.
The nature of ileal pouch, either a J, S or W pouch,
rests on which pouch leads to least frequency of bowel
actions and the best continence at night.
The debate as to who should or should not be given
a pouch continues: elderly patients and cases of
Crohn’s colitis should be steered away from a pouch
towards an end ileostomy. The risks of pouchitis in
ulcerative colitis cases resistant to all forms of medical
therapy before surgery may be an unconvincing reason
for not offering pouch surgery.
Laparoscopic appendicectomy has recently been
advocated to diminish the severity of ulcerative colitis
in the colon. Controlled trials so far have produced
conflicting results and the utility of appendicectomy in
the treatment of ulcerative colitis remains an open
question. The technical aspects of surgery are excel-
lently described by Keighley and Williams [7].
38.4 Crohn’s Disease
Crohn’s disease of the ileum and colon was first clini-
cally described by Dalziel almost 100 years ago (1913).
The disease was named after Burril Crohn whose own
284
observations, listed as “regional ileitis,” were described
in 1932. The disease comprises, in its early phases,
apthous ulceration from oral cavity to anal canal and
genitalia. In decreasing frequency, it involves the
ileum, colon, perianal region, rectum, jejunum, oral
cavity, stomach, duodenum and oesophagus. Over the
last five decades, the disease has been more frequently
reported in the developed countries, compared to the
developing world [8, 9], and the disease expression of
severe stenosis and transmural fissuring has given way
to manifestations of early inflammation. Clinical
awareness of Crohn’s disease and development of
endoscopes may have led to such a change.
38.4.1 Clinical Symptoms
and Investigations
Symptoms of the initial presentation can be grouped
according to the point in the gastrointestinal tract at
which disease prevails. Symptoms of chronic, estab-
lished Crohn’s disease may however differ from the
initial presentation.
(a) Abdominal pain may either be in the mid or lower
abdomen and be intermittent or colicky, yet severe
enough for the patient to seek medical advice. A
time/duration record of the pain is useful and espe-
cially the frequency of pain per day or week.
Occasionally, overt bowel obstruction may occur
but this is more usual in chronic disease.
(b) Perianal abscess or inflammation of a fissure or
haemorrhoid, particularly in young patients
(<35 years), may be an initial presentation. Perianal
or even genital ulceration may more rarely be the
initial presentation.
(c) Diarrhoea, loose bowel actions and rectal bleed-
ing, usually intermittent can present in Crohn’s
disease and mimic ulcerative colitis.
(d) Malaise, weight loss, low-grade fever and tiredness
may accompany the above symptoms. The diagno-
sis of active Crohn’s disease is sometimes only made
6–12 months after the initial onset of symptoms.
Abdominal findings on examination are variable ranging
from mild tenderness to frank peritonitis. A palpable
mass may reflect chronic abscess formation. Perianal
plum discolouration or ulcers, fissures and fistulation
may be visible.
W. Roediger
Diagnostic confirmation of inflammation by C
Reactive Protein (CRP) and less convincingly erythro-
cyte sedimentation rate (ESR) or by technetium-
labelled white cell scan or PET scan may pinpoint the
level and extent of inflammation. These investigations
are helpful in monitoring disease or the detection of
recurrent active disease.
Colonoscopy, preferably to the caecum and includ-
ing the ileum may show the hallmark features of Crohn’s
disease: discrete apthous ulcers, which are superficial,
course patchy linear ulceration, inflammatory polyps,
with reddened mucosa or those features observed in
ulcerative colitis may be a part of Crohn’s colitis.
Biopsies are helpful in leading to a diagnosis but at
best only 60% of cases show chronic granulomata, the
hallmark of Crohn’s disease. Other features of epithe-
lial cell destruction, increased inflammatory cells,
fibrosis and fissuring of tissue are also diagnostic of
Crohn’s disease.
Barium meal with a follow-through study, CT and
MRI scanning are a good means to assess the small
bowel. Thickening of the bowel wall, mucosal ulcer-
ation, narrowing and stricturing are typically features
of Crohn’s disease. MRI scanning is needed to assess
perianal disease, particularly fistula in the perineum.
38.4.2 Grading of Crohn’s Disease
There are a number of clinical diseases activity indices
(Crohn’s disease activity index [CDAI] Harvey-
Bradshaw and Van Hees indices), based on numerical
scores assigned to symptoms, signs and blood investi-
gations. These indices are good for clinical trials and
assessment of drug treatment but are not used in rou-
tine clinical practice. Regular CRP estimation is the
best means to assess progress, whether improvement
or deterioration, of active Crohn’s disease.
38.4.3 Aetiological Clues in the
Management of Crohn’s Disease
The antigens leading to the inflammation in Crohn’s
disease are unknown and make treatment of the dis-
ease empirical. Crohn’s disease is most likely an infec-
tive process, a conclusion derived from two primary
38 Management and Surgery of Inflammatory Bowel Diseases
observations. Firstly, luminal diversion of small bowel
improves existing Crohn’s disease or prevents recur-
rent disease after primary resection [10]. Secondly,
antibiotics often have a remarkable curative effect in
many cases of acute Crohn’s disease.
Three microbial agents have attained “candidate sta-
tus” as being potentially causative of Crohn’s disease.
1. Atypical mycobacteria (MAP) cause enteritis in
cattle, sheep, goats, deer and alpacas, though in
these animals no mucosal ulceration or luminal
stenosis is apparent. Acid fast bacilli so far have not
been found in Crohn’s disease in humans, though
found with cases of MAP in animals. A large body
of work both for and against MAP in human Crohn’s
disease exists. The final verdict of MAP being caus-
ative of Crohn’s disease remains undecided and the
debate continues.
2. Adherent invasive E.coli (AIEC) has been promul-
gated as causative of Crohn’s disease. These spe-
cific E.coli have yet to reach diagnostic value in the
disease process as well as in management or
therapies.
3. Entero-epithelial mycoplasma, particularly Myco­
plasma fermentans, have been detected by poly-
merase chain reaction (PCR) in acute Crohn’s
disease. A large number of clinical correlates bet­
ween mycoplasma infection and the spectrum of
Crohn’s disease [11] have given mycoplasma a
strong consideration in the disease process of ongo-
ing Crohn’s manifestation. Certainly, antibiotics
aimed at mycoplasma (clarithromycin) have been
found effective in the treatment of a number of
cases of acute Crohn’s disease.
If Crohn’s disease is an infective disease, then early
treatment with antibiotics appears mandatory but
­convincing support for this view has yet to be
developed.
38.4.4 Medical Management
• Cessation of smoking is essential as response to
medical therapy is thereby improved and also
­disease progress is diminished.
• Steroid therapy may improve mural oedema and
suppress inflammatory cell activity. Intravenous
hydrocortisone progressing to oral Prednisolone up
285
to 60 mg daily for 12 weeks is permissible.
Prolonged use of steroids causes osteoporosis, bone
fragility or fractures.
• Elemental diets, preferably low in fat, have been
shown to improve acute Crohn’s disease.
• The use of Salazopyrin or 5-aminosalicylic acid do
not have a statistically proven benefit in manage-
ment, nevertheless are widely used for active
Crohn’s disease.
• The use of macrolide antibiotics in acute Crohn’s
disease may produce dramatic improvement
(Clarithromycin 500 mg tds for 6 weeks). The aim
is to suppress MAP or mycoplasma.
• Metronidazole (200 mg tds × 14 days) as a suppres-
sant of anaerobic bacteria has been found of modest
benefit in acute Crohn’s disease.
• Administration of more powerful immunosuppres-
sion with cyclosporin, methotrexate, azathioprine
or monoclonal antibodies against TNF-a is prefer-
ably supervised by a gastroenterological physician.
38.4.5 Surgical Management
The principles of surgical management are given in
Table 38.2. The extent of surgical excision has over the
last 50 years moved from radical excision to a limited
local excision [12] with strong emphasis on post-­
operative medical management to prevent recurrences
[13] (see below). The former operation of “bypass sur-
gery” for active disease is no longer practised and is
generally ineffective. Defunctioning of chronic disease
by ileostomy is also no longer practised unless to
­protect an anastomosis of the colon.
38.5 Regional Surgical Management
38.5.1 Perineal Disease
Perineal abscesses need prompt drainage. Established
fistulae are preferably treated by Seton to avoid abscess
collection. Fistulectomy in one procedure or staged
procedure should be done in a quiescent phase and
­following optimal immunosuppression.
286 W. Roediger

Table 38.2 Principles of surgical management

Obstruction Inflammatory Steroids and diet
Fibrosis Resection
Strictureplasty Heineke-Mikulicz
Finney
Fistula − Can be left for long time
− Bowel to bowel – excision in “burn out phase” if possible
− Bowel to elsewhere – excision +/− colostomy
Abscesses – Drain
Bleeding – Control by resection
Carcinoma – Resection

38.5.2 The Crohn’s Appendix
The histological finding of Crohn’s disease after appen-
dicectomy is an occasional finding. Evaluation of the
small bowel (Barium meal with follow through or cap-
sule endoscopy) and large bowel by ileocolonoscopy is
warranted. If apthous ulceration is found, such cases
would benefit from a course of macrolide antibiotics.
38.5.3 Ileitis Found at Appendicectomy
Acute ileitis due to Yersinia or campylobacter may be
responsible for the finding of an inflamed ileum.
Diagnostic workup and antibiotic management may be
warranted. Removal of the appendix makes histologi-
cal assessment possible.
38.5.4 Abdominal Mass and Fistulisation
Chronic palpable masses with fistulisation from small
bowel to small bowel or small bowel to colon may not
necessarily require operation. Depending on systemic
responses, drainage of abscesses and limited resection
of the involved bowel may be worthwhile.
38.5.5 Bowel to Other Organ Fistulisation
Fistulisation to bladder or vagina are a problem of
long-term management. Surgical correction during a
quiescent phase of the disease may only achieve a
50% success rate.
38.5.6 Bowel Stricturing
Strictures and chronic Crohn’s disease may occur in the
distal small bowel or colon. Two surgical possibilities
exist: (1) local excision with careful anastomosis under
antibiotic cover is one option, or (2) if multiple stric-
tures are found, the procedure of strictureplasty (analo-
gous to the principles of pyloroplasty) can be undertaken
provided no acute Crohn’s inflammation is detectable.
Either a Finney type or Heineke-Mickulicz type stric-
tureplasty have been used and both of these procedures
preserve bowel length as no resection is involved.
38.5.7 Bleeding and Carcinoma
These should be treated along standard surgical prin-
ciples. The incidence of carcinoma in longstanding
chronic Crohn’s colitis is higher than in the general
population.
38.6 Post-operative Treatment
of Crohn’s Disease
All cases of Crohn’s disease operated on need post-
operative surveillance and further treatment for
3–5 years or up to a point where a burn-out state has
38 Management and Surgery of Inflammatory Bowel Diseases
been achieved. From 5% to 50% of ileocolonic resec-
tions will develop a recurrence just proximal to the
anastomosis. Prophylactic treatment with metronida-
zole [13] or clarithromycin, has been shown of value.
Continuing immunosuppression may also be of use.
A number of clinical trials are currently being con-
ducted in this area.
References
1. Sartor, R.B., Sandborn, W.J.: Kirsner’s Inflammatory Bowel
Diseases, 6th edn. Saunders, Edinburgh (2004)
2. Jewell, D.P., Mortensen, N.J., Steinhart, A.H., Pemberton,
J.H., Warren, B.F. (eds.): Challenges in Inflammatory Bowel
Disease, 2nd edn. Blackwell Publishers, Oxford (2006)
3. Geboes, K., Van Eyken, P.: Inflammatory bowel disease
unclassified and indeterminate colitis: the role of the pathol-
ogist. J. Clin. Pathol. 62, 201–205 (2009)
4. Roediger, W.E.W.: Nitric oxide from dysbiotic bacterial
­respiration of nitrate in the pathogenesis and as target for
therapy of ulcerative colitis. Aliment. Pharmacol. Ther. 27,
531–541 (2008)
287
5. Fujimori, S., Gudis, K., Mitsui, K., et al.: A randomized
controlled trial on the efficacy of synbiotic versus probiotic
or prebiotic treatment to improve the quality of life in
patients with ulcerative colitis. Nutrition 25, 520–525
(2009)
6. Rutgeerts, P., Vermeire, S., Van Assche, G.: Biological
­therapies for inflammatory bowel diseases. Gastroenterology
136, 1182–1197 (2009)
7. Keighley, M.R.B., Williams, N. (eds.): Surgery of the Anus,
Rectum and Colon, 2nd edn. Saunders, London (1999)
8. Russel, M.: Changes in the incidence of inflammatory bowel
disease: what does it mean? Eur. J. Intern. Med. 11, 191–196
(2000)
9. Das, K., Ghoskal, U.C., Dhali, K., et al.: Crohn’s disease in
India: a multicenter study from a country where tuberculosis
is endemic. Dig. Dis. Sci. 54, 1099–1107 (2009)
10. Rutgeerts, P., Geboes, K., Peeters, M., et al.: Effect of faecal
stream diversion on recurrence of Crohn’s disease in the
neoterminal ileum. Lancet 338, 771–774 (1991)
11. Roediger, W.E.W.: Intestinal mycoplasma in Crohn’s dis-
ease. Novartis Found. Symp. 263, 85–98 (2004)
12. Andersson, P., Olaison, G., Hallbook, O., Sjodahl, R.:
Segmental resection or subtotal colectomy in Crohn’s colitis?
Dis. Colon Rectum 45, 47–55 (2002)
13. Ng, S.C., Kamm, M.A.: Management of postoperative
Crohn’s disease. Am. J. Gastroenterol. 103, 1029–1035
(2008)
 Proctology
Alexander Herold and Laura Holzner
39.1 Haemorrhoids
Above the dentate line below the rectal mucosa, there is
a circular arteriovenous conglomerate, the corpus caver-
nosum recti. A hyperplasia of these vascular structures
is called haemorrhoids; if the hyperplasia additionally
causes pain, it is considered as haemorrhoidal disease.
These arteriovenous cavernous bodies, which predomi-
nantly occur in three, seven and 11 o’clock with the
patient in the lithotomy position are of great importance
for the anal fine continence. Arterial blood supply to the
haemorrhoids comes from the superior rectal artery.
39.1.1 Symptoms
The complaints resulting from haemorrhoids are non-
specific and occur in many other proctological diseases
as well. They do not correlate with the size of the hae-
morrhoids. Bleeding is the most common symptom. It
usually occurs during or after defecation and varies in
intensity. Typically are alternating phases: bleeding
that appears daily with each defecation and stops after
weeks or months without special treatment. Very often,
the faecal continence is impaired. This might lead to
weeping, smearing, and quite frequently, stool-stained
A. Herold ()
End- und Dickdarmzentrum Mannheim, Bismarckplatz 1,
68165 Mannheim, Germany
e-mail: a.herold@heroldhomeline.de
L. Holzner
Department of Surgery, Mount Gambier & Districts Health
Service, Wehl Street North, Mount Gambier SA 5290,
Australia
e-mail: laura.holzner@gmx.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_39, © Springer-Verlag Berlin Heidelberg 2011
39
underwear. Anal eczemas with pruritus are a direct
consequence of enlarged haemorrhoids.
Haemorrhoids usually do not cause pain. Some
patients, however, might complain about occasional
anal pressure unrelated to defecation or a foreign body
sensation in the anus. Pain often results from a coexis-
tent small fissure (with grade II haemorrhoids in up to
70%). However, severe pain does occur with a throm-
bosed and incarcerated prolapse of the haemorrhoids.
39.1.2 Diagnostics
Non-prolapsing haemorrhoids (grade I haemorrhoids)
are only visible with a proctoscope. Prolapsing hae-
morrhoids clearly show after defecation or while
pressing during the medical examination. Grade II
haemorrhoids reduce spontaneously, grade III haemor-
rhoids have to be reduced digitally. Haemorrhoids that
are not reducible at all (grade IV haemorrhoids) can be
easily assessed on inspection. There is no need for fur-
ther examination for haemorrhoids. However, to
exclude other colorectal pathology further examina-
tions (e.g. rectoscopy, colonoscopy, function tests
amongst others) are required.
39.1.3 Differential Diagnosis
Very often, perianal skin tags are mistaken as haemor-
rhoids. Haemorrhoids frequently appear in combina-
tion with mariscas or anodermal prolapse. Even the
perianal thrombosis (though confusingly commonly
termed ‘external haemorrhoid’) is not an actual haem-
orrhoid but a small blood clot in the perianal subcuta-
neous veins. It is only its nodular appearance that
makes it resemble haemorrhoids.
289
290
39.1.4 Therapy
Every causal treatment aims to reconstruct the
anal canal, restore the physiology and ease the
complaints but not to radically eradicate the hae-
morrhoidal plexus.
Bowel regulation should be the basic therapy before
starting any further treatment. Local treatment with
creams, suppositories or anal tamponades will not cure
the complaints that solely ascribe to the haemorrhoids
(e.g. bleeding), but can help to relief attendant inflam-
matory or oedematous changes.
39.1.5 Sclerotherapy
Sclerosing of the haemorrhoids can be done as
described by Blond or Blanchard. Both methods are
the treatment of choice in grade I haemorrhoids.
Blond method. The sclerosant (e.g. Polidocanol,
Thesit, Chinin, Calcium zinc chloride) is circularly
injected in the submucosa above the dentate line
through a proctoscope with lateral fenestration (Bond
proctoscope). For this treatment, 0.5–1 mL sclerosant
should be sufficient.
Blanchard method. One milliliter to 3 mL phenol in
almond or peanut oil is injected into the supplying hae-
morrhoidal arteries at 3, 7 and 11 o’clock with the
patient in the lithotomy position. Often, three to four
sessions at 2-weekly intervals are required to ease the
complaints occurring in grade I haemorrhoids. The
therapeutical effect results from a fixation and scarring
contraction of the haemorrhoidal convolutes above the
dentate line.
Complications. Complications occur in less than 5%
of the cases. The most common complication is bleed-
ing, which in rare cases, mostly 8–14 days after treat-
ment, can reach drastic intensity. Sometimes, unpleasant
pressure or foreign body sensation can occur after treat-
ment. Sclerosants containing Chinin cause allergic
reactions in about 3–4% of the cases. In isolated cases,
rectal necrosis and septic complications resulting in
death were reported. Bleeding can be ­successfully
treated in over 80%. There is a high long-term ­recurrence
rate of 70% after 3 years.
A. Herold and L. Holzner
39.1.6 Rubber Band Ligation
Procedure. Nodular haemorrhoids can be treated and
removed quite elegantly with small elastic bands
(Barron-Ligature). With a special applicator and a
proctoscope with a distal opening, the nodular haem-
orrhoids are ligated proximal of the dentate line. The
bands cause ischemic necrosis of the haemorrhoids,
which slough off in a few days. By this, the haemor-
rhoid convolute can be prevented from prolapsing
without being completely destroyed. Continence
problems as a consequence of this treatment are not
to be expected, even though some patients show a
weaker anal sphincter after the procedure. Due to
possible complications, multiple ligatures should
preferably not be done at one session. Usually, three
to four single bands are placed at intervals of
3–4 weeks.
Complications. Besides pain (in 14% of the cases),
significant bleeding can occur. Furthermore, in isolated
cases, urinary retention, fever, abscesses, thrombosis
and fistulas may develop. Very rare cases of clostridial
infections after rubber band ligation resulting in death
have been reported.
Results. The therapeutic success of rubber band
ligation of grade II haemorrhoids is around 70–80%
after 3–5 years. The recurrence rate of 25% is signifi-
cantly lower than in sclerotherapy.
39.1.7 Doppler-Guided Haemorrhoidal
Artery Ligation
The therapeutic option to reduce grade II and III hae-
morrhoids with Doppler-guided haemorrhoidal artery
ligation (HAL) was originally described by Morinaga
and modified by Meintjes. This method allows one to
find the supplying haemorrhoidal arteries using a spe-
cial proctoscope with attached Doppler transducer.
This method allows one to ligate very precisely, which
quickly leads to a contraction of the haemorrhoidal
convolutes. Not only should this remove the haemor-
rhoidal prolapse but also the associated pain.
There is no prospective and randomised study eval-
uation on this method of treatment at this point. A final
evaluation of both indication and efficiency is not pos-
sible yet.
39 Proctology
39.1.8 Operative Therapy
Grade III haemorrhoids that prolapse during defeca-
tion and do not reduce spontaneously but have to be
reduced manually are only in rare cases successfully
treated with conservative measures. Usually these hae-
morrhoids require surgery. Haemorrhoidectomy can
be performed in the following techniques:
Fig. 39.1 (a–d) Milligan–Morgan haemorrhoidectomy. Each of
the affected segments is excised ovally and between the exci-
sions a 1.5 cm broad anodermal bridge is left. The supplying
291
• Open Milligan–Morgan haemorrhoidectomy
• Closed Ferguson haemorrhoidectomy
• Subanodermal Parks haemorrhoidectomy
• Reconstructive Fansler–Arnold haemorrhoidectomy
• Supraanodermal Whitehead haemorrhoidectomy
• Stapled supraanodermal mucosectomy
The Milligan–Morgan and Ferguson method
(Fig. 39.1) are especially recommended in segmental
arteries are ligated proximally. All excisions remain open to heal
by secondary intention (From Herold 2005)
292
haemorrhoidal prolapse. The enlarged haemorrhoidal
nodules are resected in segments leaving an adequate
anodermal bridge to prevent stenosis or incontinence.
In the Milligan–Morgan operation, the anodermal
wounds are left open to heal by secondary intention
while the Ferguson technique leaves slightly more of
the anoderm to allow for suture of the wound. The
complication rate is usually below 10%. The reoccur-
rence rate is quoted between 3% and 26%, depending
on the definition of ‘reoccurrence’ and the period of
follow-up.
Another possibility for subanodermal/submucosal
resection of the haemorrhoids is the operation tech-
nique according to Parks. It includes a reposition of
the displaced anoderm and is therefore preferred in
higher grade findings.
Only in recent years, the stapled-haemorrhoidopexy
has been established in the treatment of circular grade
III haemorrhoids (Fig. 39.2). Using a staple gun (that
has been used in visceral surgery for more than 20 years)
and a special introducer, the prolapsed haemorrhoids
are reduced and the proximal mucosal tissue is circu-
larly resected. Thus the prolapsing anoderm and haem-
orrhoidal tissue is fixed in its physiological intraanal
position and in the further course reduced to normal
size due to secondary alteration. Since there is no wound
in the sensitive anoderm, this technique has become an
effective alternative with higher comfort for the patient.
The main advantage is less postoperative pain. The
complication rate is lower than in conventional haemor-
rhoidectomy; length of stay in hospital and invalidity
are shorter.
Non-reducible haemorrhoidal prolapse is consid-
ered as grade IV haemorrhoids.
For chronic, fibrosed and fixed findings, mostly with
concomitant circular anoderm prolapse, the plastic-
reconstructive Fansler–Arnold procedure can be useful.
This method, which is much more complex regarding
technique and time (operation time 30–60 min),
achieves resection of the haemorrhoidal tissue and cir-
cular or semi-circular complete reconstruction of the
anal canal with a sliding flap. This technique has a high
postoperative complication rate of up to 20%. In cases
of acute thrombosis or incarceration, conservative treat-
ment with antiphlogistics, analgesics and local treat-
ment is preferable. Experienced surgeons might also
operate immediately. In this case, particularly, the dan-
ger of postoperative stenosis due to excessive resection
in the oedematous state has to be considered.
A. Herold and L. Holzner
Results. With all techniques, over 90% of the
patients are free of symptoms after 2 years. The num-
ber of relapses increases over the years, but most of
them can be treated conservatively. The reoperation
rate lies below 5%. Incontinence as the patient’s most
feared complication occurs in up to 30% immedi-
ately after the operation, long-term dysfunction is
seen in up to 5% while a permanent incontinence
even for solid faeces only appears in very few iso-
lated cases.
39.2 Anal Fissure
39.2.1 Pathogenesis
The anal fissure is an elongated ulcer-like defect in the
highly sensitive anoderm.
A chronic course of the disease over years is com-
mon. The development of anal fissures is multifacto-
rial. Faecal consistence seems to be of great importance
since both hard and loose stool can promote the devel-
opment of anal fissures. Haemorrhoids seem to play an
important part too. It appears that even the physiologi-
cal pressure during defecation can lead to tears in the
anoderm, which tend to heal poorly. The progression
of the disease is promoted by severe pain, causing
reactive muscular spasm with ischemia of the tissue
and consecutive healing deficiency. This vicious circle
is also influenced by an elevated internal anal sphincter
tonus, which offers an option for treatment of this
condition.
39.2.2 Symptoms
The characteristic symptom is sharp burning pain that
starts during defecation and can last for hours. This
often leads to reflexive spasm of the internal sphincter.
The anodermal defect is constantly eroded by the
stools, which often show streaks of blood. As chronic-
ity advances, the constant secretion leads to weeping
and development of a secondary anal eczema.
Anal fissures occur in 80% of the cases in the mid-
line posteriorly, in 10–15% in the midline anteriorly
and in few cases in the lateral sectors. Acute anal
39 Proctology
Fig. 39.2 (a–d) Stapled-haemorrhoidopexy. In contrast to con-
ventional techniques, the haemorrhoids are reduced and moved
into the stapler by means of a circular purse-string suture. This
fissures are elongated defects of the anoderm. In the
beginning, the bottom of the wound is blood stained
and coated with smudge. The edges are well defined
and mostly reddened by local inflammation. Chronic
anal fissures show typical secondary changes: solid
ulcer, exposed internal sphincter, inflamed indurated
margins, anal fibroma on the proximal edge and a sen-
tinel pile (an inflamed, oedematous marisca) on the
293
device resects and closes the resulting lesion with titanium clips
in a single step (From Herold 2005)
distal edge. As the inflammation progresses and
reaches deeper regions, fistulas in the subanoderm and
in between the sphincters may follow. These fistulas
usually start proximally and are often incomplete, so
they run pouch-like below the anoderm. In English
­literature, the chronicity is usually determined by time:
If the symptoms last for more than 6 weeks, it is
­considered a chronic fissure.
294
39.2.3 Diagnostics
As the fissures usually lie in the distal anoderm, they are
easy to see during inspection by gently parting the mar-
gins of the anus. Because of the intense pain caused by it,
this examination should be done under local anaesthet-
ics. Fissure-like defects in Crohn’s disease and anal car-
cinoma have to be considered as differential diagnosis.
39.2.4 Conservative Treatment
Stool regulation for smooth stool, which ensures
physiological, constant extension of the anal
canal, is both causal and preventive treatment.
Conservative measures like injection of local anaes-
thetics beneath the ground of the fissure will usually
relief the pain. This enables many patients to do a daily
dilatation of the anal sphincter by passing an anal-­
dilator supplied with an anaesthetic lubricant. In less
painful anal fissures, this initial treatment can be done
without local anaesthetics. Up until recent years, this
was the only conservative option for treatment.
Nowadays, newly developed ointments are used as
primary treatment: Glyceryl trinitrate ointment (GTN)
relaxes the internal sphincter when locally applied in a
concentration of 0.1–0.4%. This improves the subano-
dermal perfusion and allows the fissure to heal. For
chronic fissures, prospective randomised studies show
significant short-term pain relief in 50–70% and heal-
ing of the fissure after 8–12 weeks. Alternatively and
with analogue effect, 2% ointments mixed with calcium
antagonists can be used. The treatment with Botulinum
toxin aims in a similar direction. Applied intramuscu-
larly, it causes a 3-month paralysis of the muscles and a
reduction of the muscle tone by blocking the distribu-
tion of acetylcholine. A transient impairment of conti-
nence has to be expected in 2–3% of the cases. The
therapeutical outcome is comparable to GTN.
39.2.5 Anal Fissure
Occasionally, conservative management for anal fis-
sure fails. Once stool softeners, fiber bulk agents, and
correction of dysfunctional bowel habits have been
A. Herold and L. Holzner
tried and are unsuccessful, there are two other modali-
ties that have been tried with a great deal of success by
the author.
The first option is a medical therapy for the hyper-
trophic spasm of the internal anal sphincter. Nifedipine
paste has been used with a great deal of success. The
patient is instructed to take a pea-sized dollop of the
ointment and place it up into the anal canal as far and
comfortably as they can twice daily. Clearly, those
who have significant pain early on may not be able to
make considerable strides very quickly, but eventually,
patients are able to get this paste to the anal canal. The
smooth muscle blocking effects of the Nifedipine paste
help to get the patient over the most difficult time of
spasm of the anal sphincter, breaking this vicious cycle
of spasm, loss of relaxation and further trauma. It is the
author’s experience that this is almost always success-
ful and since the use of this has begun, the author has
had to resort to surgical intervention only very rarely.
• Nifedipine powder, surgilube and propylene glycol
are used. 0.2 g of powder is wet with propylene
­glycol to make a paste. Surgilube is levigated with
the paste to bring total weight of 100 g. This amount
lasts about 1 month. The entire amount should be
used, even when symptoms improve.
On those rare occasions when the above medical thera-
pies are unsuccessful, then surgical intervention is
warranted. The preferred approach is a lateral internal
sphincterotomy (LIS). The key issues to performing
this are: first, to assure that there is minimal risk of
incontinence related to cutting too much of the sphinc-
ter mechanism, and second to determine if the patient
can have this done as an outpatient under local anaes-
thesia or will require regional or general anaesthetic.
In the office, if the patient can tolerate a digital
­rectal examination in the setting of an anal fissure, then
LIS can be performed in the clinic with the patient in
the dorsal lithotomy position. The area may be topi-
cally controlled with some Lidocaine gel, but ulti-
mately, either 3 or 9:00 position of the ano–rectal verge
is infiltrated with 0.25% Lidocaine solution with
Epinephrine. Gentle digital examination is then per-
formed. With the patient comfortable, the surgeon then
delivers an #11 blade scalpel through the skin just dis-
tal to the dentate line parallel to the skin fold. With a
finger in the anal canal, the hypertrophic anal sphincter
can easily be identified. The knife is slid up along side
39 Proctology
of the finger in a subcutaneous plane. Then the blade,
of course, is turned out away from the finger within the
anal canal. With a gentle push of the anal canal finger
against the backside of the blade; the surgeon can feel
the fibers of the internal sphincter being cut slightly.
The scalpel is then gently removed.
Typically, it takes very little surgical intervention to
get the patient to the point where they can break the
cycle of spasm and loss of relaxation with bowel func-
tion. This also minimizes the risk of incontinence. It is
better to have to repeat the procedure once than to
leave the patient with incontinence.
Finally, as an alternative, if the patient is too tender
from the fissure to allow digital rectal examination in
the clinic, the procedure can be performed in the oper-
ating room with either regional or general anaesthesia.
This is a very safe, effective method to allow final
recovery of those occasional refractory patients with
an anal fissure.
39.2.6 Surgical Therapy
An operation is indicated if conservative treat-
ment did not show any success or if healing can-
not be expected due to secondary changes as a
hypertrophic anal papilla with deep crypts or
undermined sentinel piles but also fistulas in the
subanoderm and in between the sphincters at the
base of the fissure.
There are two methods for operative treatment of
anal fissures: the lateral sphincterotomy and the tan-
gential fissurectomy.
Lateral sphincterotomy. The aim is to reduce the
sphincter tone through an incision of the distal margin
of the internal sphincter and by that promotion of the
healing process. However, if the spincterotomy is done
too extensively, continence dysfunction must be
expected in up to 30% of the cases. In Anglo–American
countries, this technique is the standard operation for
fissures.
Tangential fissurectomy. During fissurectomy, the
fissure is excised including its scarred margins, the
sentinel pile and hypertrophic anal fibromas.
Results. These techniques accomplish a long-term
cure of the fissure in 90–98% of the patients.
295
39.3 Abscess and Fistula
39.3.1 Pathogenesis
Abscess is the acute, fistula the chronic form, of the
same inflammatory process. Periproctal abscesses are
mostly based on an infection of the rudimentary proc-
todeal glands. These cryptoglandulary structures occur
in the majority of the cases in the area of the midline
posteriorly. If the inflammation cuts its way along
­predefined gaps in the submucosa, subanoderm, in
between or across the sphincters, this leads to
abscesses. Without treatment, they can perforate into
the rectum, the anal canal or outwards, depending on
the location of the abscess. In most of the cases, the
permanent contamination and insufficient drainage
lead to a persisting fistula; only 20–40% recover com-
pletely. A dysfunction of the continence organ is an
inevitable consequence.
39.3.2 Classification
Classification is made according to the relation to the
sphincter, which also defines the subsequent therapy
(Fig. 39.3).
39.3.3 Symptoms
The main symptoms of the abscess are pain and swell-
ing; the fistula mostly causes secretion and pruritus.
The complaints caused by the abscess range from
inconvenient pressure or foreign body sensation to
severe pain with fever or chills. In contrast to abscesses,
the clinical symptoms of perianal fistulas are less dra-
matic. Purulent serous secretion can lead to irritation
of the perianal skin or distinct anal eczema. Superficial
epithelisation of the external opening of the fistula
might temporary restrain the secretion without actu-
ally healing it. The collection of secretion will in most
cases perforate the thin epithelial skin layer again
within a few days. If the secretion remains in the ­fistula,
an acute abscess might develop again.
296
Fig. 39.3 Schematic classifica-
tion of abscesses and fistulas
(From Herold 2005)
Pelvic rectal
abscess
M.levator
ani
M.sphincter
ani internus
Ischioectal
abscess
Intersphincter
abscess
Subcutaenous,
subanodermal
abscess
39.3.4 Diagnostics
An abscess can be diagnosed solely by inspection and
palpation based on the typical anamnesis. Superficial
abscesses show the typical painful reddening and
swelling. The rare deep pararectal abscesses are invis-
ible from the outside, but in most cases, may be
detected by palpation. The diagnosis needs to be con-
firmed by further examination.
Fistulas show an outwards aperture with more or less
pronounced induration of the surrounding skin or towards
the inner aperture. With some experience, the path of the
fistula can be easily followed using a button probe. If the
fistula cannot be displayed with this simple clinical mea-
sure, an examination under general anaesthesia is the
next step. The fistula can not only be illustrated here but
treated at the same time. Only in special, often compli-
cated, cases diagnostic imaging is necessary: Retained
secretion, scarred lesions and fistula pathways can be
displayed using endosonography, computed tomography
A. Herold and L. Holzner
Extrasphincteric
fistula
supra-
sphincteric
fistula
Transsphincteric
fistula
Intersphincteric
fistula
Subanodermal
fistula
or MRI. Using an x-ray (fistulography) is unnecessary
for it does not give any further information.
39.3.5 Differential Diagnosis
In case of inflammations in the anal region, Crohn’s
disease always needs to be considered. Ten per cent to
30% of the Crohn’s patients show their first symptoms
in the anal area. As in the typical fistula, these inflam-
matory processes can be based on an infection of the
proctodeal glands. The typical Crohn’s fistula, how-
ever, does not stick to predefined structures but pene-
trates destructively into any surrounding tissue.
Anal fistulas have to be distinguished from inflam-
matory lesions caused by inverse acne. Those multiple
confluent abscesses with numerous apertures typically
show blue-livide surroundings. The fistulas are not
connected to the anal canal or the rectum. In very few
39 Proctology
cases, perianal fistulas associated with tuberculosis
have been reported.
39.3.6 Therapy of the Abscess
An anorectal abscess is generally opened imme-
diately after diagnosis.
There must not be any delay in starting the therapy for
there is always danger of progressive infection up to
generalised sepsis. Therapy consists in a broad, funnel-
shaped opening of the skin with subsequent secondary
healing. When opening an abscess, the latitude of the
excision should always be bigger than the profundity
of the wound to make sure healing starts from the
ground and not only the skin is closing, which would
bear the risk of a relapse.
Note: Working close to the anus (1–2 cm), it is
important to particularly mind the sphincter!
To avoid huge wounds in very big ischio- or pelvi-
rectal abscess cavities (e.g. a horseshoe-fistula), a
small incision with counter-incision might allow suf-
ficient drainage. Special drainage catheters are nor-
mally restricted to few special cases (e.g. peritoneal
expansion).
An exclusive or additional treatment with antibiot-
ics is only useful in very few cases, e.g. with immuno-
suppression, accompanying soft tissue phlegmone or
severe concurrent sepsis.
During every operation of an anorectal abscess, the
experienced surgeon should try to find the cause at the
same time. If the connection between fistula and anal
canal can be found, the fistula may be primarily
repaired or it can be drained with a thread for some
weeks and later taken care of surgically. If the fistula
cannot be found during the revision, the surgeon should
abstain from further manipulation to avoid the danger
of causing a via falsa. Further assessment should fol-
low after remission of the acute inflammation.
297
39.3.7 Therapy of the Fistula
The aim of every operative repair of a fistula is reha-
bilitation without loss of continence and without
relapse. Which operative technique is chosen depends
on the fistula pathway and its relation to the sphincter.
Fistulas in the subanoderm, submucosa, in between
or distal (deep) across the sphincters. Those fistulas
only embrace a small part of the sphincter muscles and
can be split completely without having an impact on
anal continence. The recurrence rate is below 10%, the
continence dysfunction depends on the extent to which
the sphincter is involved. While in previous years, up
to two thirds of the sphincter was cut, nowadays a more
careful approach is chosen. There are no general speci-
fications on how much of the sphincter can be cut
without causing continence problems, because conti-
nence depends on many other factors (e.g. age, sex or
stool consistency) and is influenced by the patient’s
individual conditions (e.g. previous operations, recur-
rent fistulas or localisation of the fistula) that have to
be considered when opening the abscess. The reported
range of postoperative incontinence, therefore, varies
from 5% to 40%.
Fistulas proximal (high) across, above or outside
the sphincters. Fistula pathways that embrace sub-
stantial parts of the muscles are primarily drained with
a thread and at the next session in the non-inflamed
stage extirpated and plastically occluded. After com-
pletely extirpating the fistula pathway, especially in
the cryptoglandulary region, the sphincter muscles are
directly joint and the closure is secured with a trans-
posed flap consisting of mucosa or mucosa/submu-
cosa/internal sphincter to close the inner aperture of
the fistula (Fig. 39.4). An immediate suture insuffi-
ciency appears in 10–25%, the recurrence rate is
between 5% and 30%.
Apart from the methods above, other techniques
can be used in certain cases:
• Direct complete splitting and reconstruction of the
musculature in one or two steps
• Interposition of muscles, e.g. gracilis muscle or rec-
tus abdominis muscle, long-term drainage with a
thread and joining with fibrin
• Drainage with a thread according to Hippokrates
aiming at a slow dissection of the sphincter muscles
298 A. Herold and L. Holzner

is contraindicated because of the high incontinence

rate and the severe pain it causes.
Recto- and anovaginal fistulas. Diagnosis and treat-
ment of this special form of fistulas are analogues to
the principles above. However, due to their location,
plastic surgery is necessary in most of the cases. Due
to the lack of connective tissue and muscle tissue of the
rectovaginal septum in that area, the success rate is
lower than in other anal fistulas.
Anorectal Crohn’s fistulas. Anal Crohn’s fistulas
are as other fistulas in 75% of cryptoglandulary origin
and follow the pathways mentioned above. However,
25% do not follow anatomical structures and penetrate
the surrounding tissue destructively. Treatment is done
according to the strategies described above. It is espe-
cially important to mind the sphincter as the high
recurrence rate of the primary disease often requires
repeated surgery. Prior to any fistula reconstruction,
the systemic disease must be under control and no
local inflammation should be present. In complex fis-
tulas with recurrent exacerbation, the long-term drain-
age with a thread for months or years is a good method
that 39.4
Fig. is usually
(a–d) tolerated veryofwell
Plastic closure to avoid
a fistula or at least
(flap-technique). closed with few sutures. After mobilising a muscularis-mucosa-
delay
A the application
funnel-shaped of aofstoma.
extirpation the peripheral part of the fistula flap with a proximal pedicle, it is pulled over the muscle suture
(outside the musculature) is done, the part penetrating the mus- with a second suture row and fixed distally (From Herold 2005)
cles is excided or curetted. After that, the muscular defect is
 Abdominal Wall Hernias
40
Reinhold A. Lang and Martin K. Angele

40.1 Definition and Classification alba, the semilunar line of Spieghel, the diaphragm.
Muscle atrophy or surgery may result in additional
predisposing areas within the abdominal wall for the
Hernias are defined as a protrusion of the peritoneum
development of hernias.
through acquired or congenital gaps (hernial orifice).
Predisposing factors for hernia development are:
A hernia consists of the hernia orifice and the hernia
• Chronic increase in abdominal pressure due to:
sac. The hernia orifice represents the defect within the
–– Obesity
abdominal wall, the hernia sac is an outpouch of the
–– Recurrent
peritoneum and may contain abdominal organs (bowel,
–– Respiratory disease
large omentum, etc.) (Fig. 40.1). A hernia is consid-
–– Chronic constipation
ered external if the sac protrudes through the abdomi-
–– Recurrent vomiting
nal wall, internal if the sac is within the visceral
–– Ascites
cavity.
–– Prostate hypertrophy
If the hernia content can be returned into the abdom-
–– Pregnancy
inal cavity, the hernia is reducible, otherwise it is not
–– Tumors
reducible.
• Diminished collagen synthesis and traumatic dam-
age of the abdominal wall.

40.2 Epidemiology and Etiology

40.3 Symptoms
The estimated incidence of hernias is 2–4% with a pre-
ponderance of the male gender. With increasing patient
Many hernias are asymptomatic and only a lump may
age, the incidence of hernias as well as the need for
be palpable. Hernia symptoms usually are unspecific
hospitalization go up. Ninety-five percent of hernias
and due to the content of the sac and the pressure by
are external, 75% of these are inguinal hernias. Hernias
the sac on adjacent tissue. The discomfort is increased
develop where aponeurosis or fascia are not supported
during the day and symptoms are relived at night when
by striated muscle. Physiologically, many such sites
the patient reclines.
are present, e.g., in the groin, the umbilicus, the linea
In particular, with small hernias, incarceration of
small bowel and greater omentum may occur. An
incarceration is defined as an irreducible mass within
R.A. Lang and M.K. Angele (*) the hernia sac. In rapid succession, incarceration can
Department of Surgery, University of Munich,
Campus Großhadern, Marchioninistr. 15,
be followed by mechanical ileus and bacterial transmi-
D-81366 München, Germany gration. Regional pain, swelling, and cellulitis are con-
e-mail: martin.angele@med.uni-muenchen.de tinuously increasing.

M.W. Wichmann et al. (eds.), Rural Surgery, 299

DOI: 10.1007/978-3-540-78680-1_40, © Springer-Verlag Berlin Heidelberg 2011
300
Fig. 40.1 Therapeutic
algorithm for the treatment of
hernias (Adapted from
Chirurgie Basisweiterbildung,
Springer, Hrsg. Jauch,
Mutschler, Wichmann) No
Incarceration
Outpatient care
Elective
40.4 Diagnosis
External hernias can be diagnosed by physical exam-
ination. Physical examination consists of inspection
and palpation of the tissue and the hernia orifice.
Typically, a hernia sac with its contents enlarges and
transmits a palpable impulse when the patients
strains or coughs. In particular, adipose patients may
require ultrasound or CT scan for an adequate
diagnosis.
40.5 Complications
The most serious complication of hernias is strangu-
lation resulting in compromised vascularity of the
protruded viscus. In these cases, venous congestion
leads to edema, which ultimately causes arterial per-
fusion deficits. Necrosis of the affected tissue may
result. In addition, strangulation may cause perfora-
tion with subsequent bacterial peritonitis and sepsis.
Some patients present with signs of a mechanical
ileus due to incarcerated bowel. Reduction of
R.A. Lang and M.K. Angele
Hernia
Recent Incarceration, Incarceration, reduction
currently reduced not possible
Admission
observation
Early Elective Emergency
Surgery
a strangulated hernia is contraindicated if there is
sepsis or if the contents of the sac are thought to be
gangrenous. Lactate measurements or radiological
imaging may help with diagnosis of complications
due to incarceration.
40.6 Different Forms of Incarceration
Fecal incarceration: Gas distension induces increased
bowel volume within the prolapsed loop.
Elastic incarceration: Despite decreased intraab-
dominal pressure, the hernia sac does not reduce.
Retrograde incarceration (Maydl hernia): Herniation
of mesentery or small bowel leads to necrosis of
intraabdominal bowel loops.
Richter–Littré-hernia: As opposed to regular her-
nias, only part of the circumference of the bowel wall
is involved. Delayed diagnosis after perforation and
peritonitis may result.
Omental incarceration: Portions of incarcerated
greater omentum usually only cause localized inguinal
pressure pain.
40 Abdominal Wall Hernias
40.7 Therapeutic Strategies
The following principles apply to all types of hernias:
• Only surgical management allows for persistent
therapeutic success.
• Incarceration requires emergency surgery.
• Forceful reposition maneuvers should be omitted.
To avoid complications during reposition, adequate
analgesia must be provided.
For the reposition maneuver, the hernia sac is pushed
into the abdominal cavity with two hands. During the
maneuver, there is a risk of reposition of gangrenous
bowel, perforation of the bowel, or reposition en bloc
(despite “successful” reposition, the bowel remains
within the neck of the hernia).
Due to these potential complications following
reposition, the following approach is recommended:
• Early surgical repair is required following success-
ful reposition. The patient should stay in the hospi-
tal until definite treatment is provided.
• When the reposition maneuver fails, emergency
surgery is indicated.
40.8 Umbilical Hernia
The umbilicus represents one of the weak areas within
the abdominal wall. In particular, incomplete fusion of
the periumbilical fascia at the base of the umbilical
cord may contribute to the development of an hernia.
The infantile umbilical hernia closes without sur-
gery. If they appear in adult patients, umbilical hernias
are generally treated surgically. In cases of major
comorbidity (e.g., ascites caused by liver cirrhosis),
surgical treatment should only be considered in
selected patients.
Female adults are affected more often than males.
Obesity, pregnancy, and ascites predispose for umbili-
cal hernias. Umbilical swelling and pain are typical
symptoms in these patients.
After the resection of the sac, nonabsorbable sutures
are used for primary repair of the fascia defect. In
patients with large defects, prosthetic mesh reinforce-
ment may be needed (mesh plug, inlay mesh).
301
Morbidly obese patients may need a laparoscopic
umbilical hernia repair using a composite mesh.
40.9 Epigastric (Ventral) Hernia
An epigastric hernia is located within the linea alba
between the xiphoid process and the umbilicus. This
potentially multilocular hernia occurs without previ-
ous surgery. In most cases, preperitoneal fat is herni-
ated into the sac.
Nonspecific epigastric discomfort is variable due to
posture and abdominal tension. Affections of organs in
the upper abdomen (e.g., stomach, duodenum, pan-
creas, bile duct) have to be considered as differential
diagnosis.
Indication for surgery is based on clinical symptoms.
40.10 Diastasis of the Rectus Muscle
Diastasis recti is defined as a separation of the rectus
abdominis muscle into right and left fractions, which
normally are joined at the linea alba at the midline.
Diastasis of this muscle occurs in newborns and preg-
nant women. The protrusion down the midline to the
umbilicus becomes prominent with muscular strain
and usually resolves with muscular relaxation.
Most patients do not require any treatment but may
benefit from physiotherapy. Selected cases of diastasis
recti may require a surgical approach using direct
suture of the rectus sheath. Surgical repair has a high
recurrence rate and the application of alloplastic mesh
grafts is more and more common.
40.11 Incisional Hernia
Incisional hernia formation is a very common postop-
erative complication after abdominal surgery. An inci-
dence of up to 29% within 5 years after laparotomy has
been reported.
Secondary hemorrhage, wound infection, type
of incision formation, and obesity contribute to the
302 R.A. Lang and M.K. Angele

development of incisional hernias as well as cough- a

ing, ­constipation, straining, hypoproteinemia, factor
XIII deficiency, anemia, nerve injury, and medications
(e.g., steroids).

40.11.1 Therapy

The objective of incisional hernioplasty is anatomic

reconstruction of the abdominal wall. Because of a
reduction of intraabdominal adhesions and completion
of the wound healing process, hernia repair should be
avoided within the first 6 months after primary
surgery. b
Primary repair by approximating the edges of the
aponeurosis with sutures is associated with recurrence
rates as high as 50%.
Due to this unacceptable high recurrence rate, ten-
sion-free repair approaches using mesh material have
been introduced and should be considered the standard
procedure. Alloplastic mesh grafts (e.g., Polypropylene,
Gore-Tex, etc.) can be placed ventral to the anterior
fascia (onlay technique) (Fig. 40.5a), posterior to it
(inlay technique) or posterior to the posterior fascia
(sublay technique) (Fig. 40.5b). Taking into account
that the fascia defect represents the beginning of a
complex incisional hernia, complete coverage of the
whole primary incision line is required. The mesh has c
to overlap the fascia edge by at least 5 cm. The onlay
or sublay technique is combined with an adaptation of
the fascia edges.
In an attempt to realize a tension-free hernia repair,
a laparoscopic approach has been introduced. With this
technique, the fascia defect is covered by a mesh with-
out adapting the fascia edges. Thus, a visible swelling
and palpable fascia defect persist despite adequate
repair. Furthermore, excessive preparation within the
abdominal wall muscle layers can be avoided, as allo-
plastic material special grafts (composite mesh) with
an anti-adhesive surface facing toward the intestines to
avoid adhesions and fistula formation are needed.
Although several studies have been conducted,
there is no evidence favoring conventional vs. laparo-
scopic surgery, onlay vs. sublay mesh position, loca- Fig. 40.2 Preparation of the inguinal area during anterior hernia
tion and fixation of mesh grafts as well as the best repair. (a) Identification of the spermatic cord. (b) Elevation of
material for mesh grafts. the spermatic cord. (c) Plication of transversalis fascia. (Adapted
from Chirurgie Basisweiterbildung, Springer, Hrsg. Jauch,
To avoid hernia recurrence, patients are advised not Mutschler, Wichmann)
to lift weights of more than 5 kg for 8 weeks after
surgery.
40 Abdominal Wall Hernias
40.12 Less Common Abdominal Hernias
40.12.1 Spigelian (Lateral Ventral)
Hernia
A defect at the spigelian fascia occurs between the inter-
nal oblique muscle, semilunar line, and the lateral rectus
sheath. The peritoneal sac can contain preperitoneal fat,
omentum, or intestine. Patients’ complaints may be
nonspecific abdominal pain, palpable resistance in the
anterior abdominal wall, and intestinal obstruction. If
the hernia extends intramurally under the external
oblique muscle, palpation will be difficult, especially in
obese patients. Additional investigation, i.e., ultrasound
or CT-scan may be indicated to obtain a reliable diagno-
sis. Incarceration may be the first symptom of these her-
nias and has been reported to occur in 20% of cases. For
hernia repair, a transverse or oblique skin incision is
useful, the hernia sac can be excised or inverted. In most
cases, the hernia is treated by primary repair. Very large
defects with diminished fascia may be closed with allo-
plastic mesh graft. For better identification of the defect,
a laparoscopy can be necessary, which can also be used
for hernia repair using a composite mesh.
40.12.2 Obturator Hernia
These hernias occur within the obturator foramen ante-
rior or medial to the neuromuscular bundle following
the obturator vessels and the obturator nerve. It occurs
below the pectineal muscle and is only in one-fourth of
patients palpable inside the thigh. Obturator hernias
appear in elderly females suffering from increasing
atrophy of the pelvic floor. After previous attacks of
nausea, abdominal pain, and constipation, a mechani-
cal ileus may result. Irritation of the obturator nerve
causes pain in half of the patients, which intensifies
during flexion of the thigh with adduction of the leg.
Surgical treatment is done by primary suture repair
ventrally underneath the pubic bone.
40.12.3 Sciatic Hernia
Sciatic hernia leave the sciatic foramen either above
or below the piriform muscle (Supra-/Infrapiriform
303
h­ ernia) or in front of the sacrotuberal ligament
(Spinotuberal hernia). The hernia sac usually contains
omentum or intestine, sometimes ovary or parts of the
ureter. The hernia may even cause urinary obstruction.
40.12.4 Perineal Hernia
Perineal hernias occur before or behind the deep trans-
verse perineal muscle, they penetrate the pelvic floor
or the levator ani muscle (ischiorectal hernia). Perineal
hernias represent a rare form and are mostly iatrogenic.
Abscesses, cysts, or tumors like lipoma have to be
­considered as differential diagnosis.
40.12.5 Internal Hernia
Congenital internal hernias are very rare. The follow-
ing intraperitoneal openings are physiological weak
spots through which peritoneal contents may protrude:
omental bursa, duodenal flexure, Treitz hernia, meso-
colon, caecum, sigmoid. The hernia sac is formed by
or via duplications of the peritoneum. Nausea, vomit-
ing, abdominal obstruction culminating in ileus, and
small bowel gangrene can be observed. In most cases,
internal hernias are confirmed surgically.
Most internal hernias, however, are acquired fol-
lowing previous surgeries caused by insufficient or
defaulted closure of the mesenteric gap.
40.13 Inguinal Hernia
The clinically most relevant hernia is the inguinal her-
nia (approximately 75%). Inguinal hernias arise above
the abdominocrural crease as opposed to femoral her-
nias that occur below. Indirect inguinal hernias (mostly
congenital, not completely obliterated processus vagi-
nalis, origin lateral to the epigastric vessels, passes the
inguinal canal, 60–70% of all inguinal hernias) and
direct hernias (always acquired, origin medial to epi-
gastric vessels, passes medial to the spermatic cord)
have to be distinguished. Both sexes develop inguinal
hernias although men are 25 times more often affected.
Indirect inguinal hernias are twice as often on the right
304 R.A. Lang and M.K. Angele

as on the left side. This is due to a delay in the atrophy

of the processus vaginalis that follows the normally
slower descent of the right testicle.
It is important to examine both groins since bilat-
eral hernias are present in 15% of the patients.

40.13.1 Indication

Symptomatic inguinal hernias clearly require surgical

repair. The need for surgery in completely asymptom-
atic hernias is still under debate and requires an indi-
vidualized decision. Elective surgery is recommended
for inguinal hernias with a narrow neck and for non­
reducible hernias, and if the patient has pain during
activities of daily life. If a strangulation is detected, the
patient should undergo emergency surgery without
delay. Higher age and/or comorbidity usually do not
justify conservative therapy because inguinal hernias
can be treated using local anesthesia only.
Inguinal hernias carry a high risk of strangulation
independent of age and comorbidity and strangulation
is most likely within the first 3 months after hernia
development. Small hernia orifices bear a higher risk
of incarceration but big orifices are affected as well.

The goal of groin hernioplasty is to augment the

dorsal wall of the inguinal canal. This strengthen-
ing can be done using synthetic mesh implants or
by placation of tissue. Two competing surgical
procedures are available, open and a minimal
invasive surgery.
40.13.2 Therapy
40.13.2.1 Open Approach: Suture Techniques
Without (e.g., Shouldice) and With (e.g.,
Lichtenstein) Alloplastic Mesh Graft
A ventral, extraperitoneal access is used for open
suture techniques. Most procedures can be done under
local anesthesia.
The most commonly used technique for hernia
repair without alloplastic material is the Shouldice
Fig. 40.3 Mesh placement during hernia repair in Lichtenstein
technique (Adapted from Chirurgie Basisweiterbildung,
Springer, Hrsg. Jauch, Mutschler, Wichmann)
technique (Fig. 40.2 a–c). In brief, the hernia sac is
excised and divided of the cremaster muscle through
an opening of the transversalis aponeurosis. For recon-
struction of the posterior wall, the transverse fascia
must be duplicated by a separate suture line. In a sec-
ond layer, the internal oblique muscle and the transver-
salis muscle are fixed to the inguinal ligament.
The Lichtenstein technique includes reconstruction
of the posterior wall using a mesh graft. A 15 × 10 cm
polypropylene mesh is covering the pubic tubercle
along the inguinal ligament (Fig. 40.3). A slit in the
lateral part of the mesh graft contains the spermatic
cord. Main advantages of the Lichtenstein technique
are the technical convenience as well as a low recur-
rence rate of approximately 5%.
40 Abdominal Wall Hernias
Fig. 40.4 Laparoscopic hernia repair. Main surgical landmarks for the TAPP technique (Adapted from Chirurgie Basisweiterbildung,
Springer, Hrsg. Jauch, Mutschler, Wichmann)
A number of additional techniques for open ingui-
nal hernia repair have been described (e.g., Bassini,
McVay, Lotheissen, etc.).
40.13.2.2 Endoscopic Techniques (TAPP:TEP)
For the endoscopic technique, a transabdominal prep-
eritoneal (TAPP) as well as a total extraperitoneal
(TEP) are available. Using the TAPP technique, the
left and right site can be explored for the existence of
hernias.
TAPP: First the peritoneum is opened (Fig. 40.4a),
the hernia exposed and the inguinal hernia sac reposi-
tioned into the abdominal cavity. The epigastric
305
vessels, dividing indirect (lateral) and direct (medial)
hernias and the spermatic cord can be identified
(Fig. 40.4b). For hernia closure, a polypropylene mesh
is inserted (Fig. 40.4c). Finally, the peritoneum is
readapted to cover the mesh (Fig. 40.4d).
There is a risk of intraabdominal complications,
which have to be considered. TAPP and TEP require
the placement of a 11 × 15 cm polypropylene mesh
graft covering all possible hernia orifices with an ade-
quate overlap. For these procedures, general or spinal
anesthesia is necessary.
Inguinal hernias in children are treated with the
Halsted–Ferguson procedure. The hernial sac is excised
without suturing of the posterior wall of the inguinal
canal.
306
Fig. 40.5 Illustration of mesh placement for hernia repair with
onlay (a) and sublay (b) technique (Adapted from Chirurgie
Basisweiterbildung, Springer, Hrsg. Jauch, Mutschler, Wichmann)
40.13.2.3 Complications
The most common early complications are temporary
urinary retention and scrotal hematoma. Wound infec-
tions have been observed in less than 2% and are usu-
ally treated locally. Mesh infection requiring removal
of the alloplastic material occurs in only few cases.
Late complications like testicular atrophy due to
ischemic orchitis, infertility, and dysejaculation syn-
drome are reported in a small number of patients. In
particular, nerval irritations are bothering for patients
and difficult to treat. Postoperative pain is a significant
long-term complication after inguinal hernia repair
and has been observed in up to 10% of patients inde-
pendent of the selected surgical repair technique.
40.13.2.4 Recurrences
Within the first 6 months, a recurrence must be consid-
ered to be technical failure. Recurrence rates do not
vary significantly between the different tension-free
procedures and have been reported in up to 10% of all
patients.
• Injury of vas deferens
• Injury of testicular vessels and testicular atrophy
• Scrotal hematoma
R.A. Lang and M.K. Angele
• Nerve injuries (ilioinguinal and iliohypogastric
nerves)
• Injury of femoral vessels
• Wound infection
• Chronic inguinal pain
• Recurrence
40.14 Femoral Hernia
Whereas inguinal hernias are located above the ingui-
nal ligament, femoral hernia occur below it and pass
through the lacuna musculorum or through lacuna
vasorum of the femoral canal. In this canal, the femo-
ral vein can expand for increased venous return.
Femoral hernias are more common in females (f:m/3:1)
and usually occur in patients over 50 years.
The incidence of strangulation in femoral hernias
is high and small bowel obstruction may be caused by
a femoral hernia.
The diagnosis is often difficult and femoral hernias
can be rarely palpated. Until incarceration occurs, they
are inconspicuous. In some cases, dys- and haematuria
are caused by involvement of the bladder.
40.14.1 Therapy
Due to the high risk of incarceration, femoral her-
nias should be treated promptly. The surgical
approach can be performed inguinal (Lockwood’s
infra-inguinal approach, Lotheissen’s trans-inguinal
approach, Mc Evedy’s high approach), as well as
femoral. Infra-inguinal approach is preferred for
elective repair. After resection of the hernia sac, the
inguinal ligament is sutured to the pectineal liga-
ment. In any approach, injury to the urinary blad-
der, which is often a part of the medial part of the
hernial sac, and constriction of the femoral vein
should be avoided.
Complications are similar to inguinal hernia repair.
Recommended Reading
Kehlet, H., Kingsnorth, A.: Meta-analysis of randomized clini-
cal trials comparing open and laparoscopic inguinal hernia
repair. Br. J. Surg. 90, 1479–1492 (2003)
40 Abdominal Wall Hernias
Müller-Riemenschneider, F., Roll, S., Friedrich, M., Zieren, J.,
Reinhold, T., von der Schulenburg, J.M., Greiner, W.,
Willich, S.N.: Medical effectiveness and safety of conven-
tional compared to laparoscopic incisional hernia repair: a
systematic review. Surg. Endosc. 21(12), 2127–2136 (2007)
Pham, C.T., Perera, C.L., Watkin, D.S., Maddern, G.J.:
Laparoscopic ventral hernia repair: a systematic review.
Surg. Endosc. 23, 4–15 (2009)
307
Schumpelick, V., Klinge, U., Junge, K., Stumpf, M.: Incisional
abdominal hernia: the open mesh repair. Langenbecks Arch.
Surg. 389(1), 1–5 (2004)
Stickel, M., Rentsch, M., Clevert, D.A., Hernandez-Richter, T.,
Jauch, K.W., Löhe, F., Angele, M.K.: Laparoscopic mesh
repair of incisional hernia: an alternative to the conventional
open repair? Hernia 11(3), 217–222 (2007)
 Thyroid Surgery for the Community
General Surgeon 41
Anthony J. Chambers and Janice L. Pasieka

41.1 Introduction patient. Symptoms of compression of the airway or

Disorders of the thyroid gland occur commonly in the
general population, and as a result are a common form of
presentation to surgeons in community practice. As many
as 4–8% of the population may develop nodular lesions of
the , which become clinically palpable, and high-resolu-
tion ultrasound can detect nodules in 50% of those 50 years
of age or older. The overwhelming majority of such lesions
are benign each, yet must be differentiated from those due
to malignancy. Surgeons in community practice play an
important role in the evaluation and management of
benign and malignant thyroid disorders, and in many
cases, may act as the first point of referral for patients with
these conditions. The following chapter aims to provide a
framework for the evaluation of benign and malignant
lesions of the thyroid, and their surgical management.
41.2 Clinical Evaluation of Thyroid
Disorders Presenting to the
Community Surgeon
Discovery of a nodule or a mass arising from the thyroid
gland is a common presentation to surgeons in commu-
nity practice. The evaluation of such patients involves
careful history, physical examination, and appropriate
use of investigations. The thyroid mass may be noted by
the patient, or more commonly discovered on routine
physical examination in an ­otherwise asymptomatic
A.J. Chambers and J.L. Pasieka (*)
Department of Surgery, The University of Calgary,
1403-29th Street NW, Calgary, Alberta, T2N 2T9, Canada
e-mail: janice.pasieka@albertahealthservices.ca
esophagus should be sought. Patients should also be
evaluated for symptoms ­suggestive of hyperthyroidism.
Symptoms of voice change and hoarseness can occur as
a result of involvement of the recurrent laryngeal nerve
(RLN) with malignancy, and should be further investi-
gated by direct laryngoscopy to examine vocal cord
movement. The patient should be questioned carefully
regarding prior exposure to ionizing radiation, particu-
larly radiation treatment during childhood for benign or
malignant conditions, and occupational radiation expo-
sure. Patients living in the Ukraine and surrounding
regions at the time of the Chernobyl nuclear accident in
1986 are also at risk of thyroid cancer secondary to
environmental radiation exposure. Previous ionizing
radiation exposure is a life-long risk factor for thyroid
cancer, increasing the risk of this by 50 times, and as
many as 50% of thyroid nodules developing in this con-
text are malignant [1]. A family history of thyroid
malignancy may be present in patients with familial
medullary thyroid cancer (MTC) or multiple endocrine
neoplasia (MEN) syndromes types 2A or 2B. In addi-
tion to MTC, a family history or prior history of
­pheochromocytoma, extra-adrenal paraganglioma, or
hyperparathyroidism may be present in patients with
MEN 2A or 2B. Familiar papillary thyroid cancer (PTC)
is becoming more prevalent. Although the genetic cause
is yet unknown, a history of first degree relatives with
PTC increases the risk of the nodule being cancer.
On physical examination, the number, size, and loca-
tion of palpable nodules within the thyroid gland should
be determined. Mass lesions that are hard to palpation
or with fixation to surrounding neck structures are fea-
tures suggestive of malignancy. Enlarge­ment of cervi-
cal lymph nodes may indicate regional spread of thyroid
malignancy. Cervical ultrasound is now commonly
used to assess the thyroid and regional lymph nodes.

M.W. Wichmann et al. (eds.), Rural Surgery, 309

DOI: 10.1007/978-3-540-78680-1_41, © Springer-Verlag Berlin Heidelberg 2011
310 A.J. Chambers and J.L. Pasieka

41.3 Investigation o­ ne-third of cases will stabilize; and in the remaining

An algorithm outlining the diagnostic work-up and
management of the patient with a thyroid nodule is
shown in Fig. 41.1. Thyroid function should be assessed
by measurement of serum thyroid stimulating hormone
(TSH). Suppression of TSH indicates overproduction
of thyroid hormone due to autonomous secretion by
toxic follicular adenoma or nodule(s) within a mul-
tinodular goiter (Plummer’s disease). Further assess-
ment of patients with suppressed TSH using Iodine-123
(I123) scanning should be performed to identify the
hyperfunctioning lesions, seen as “hot”nodules. In
contrast, hyperthyroidism due to Grave’s disease shows
diffusely increased uptake of I123 within the thyroid.
Hot autonomous nodules within the thyroid are usually
benign follicular adenomas, and therefore fine needle
aspiration biopsy (FNAB) is not indicated. The natural
history of hot autonomous nodules within the thyroid
is that in one-third of cases, it will increase in size;
one-third, will reduce in size during follow-up. Surgical
resection is indicated for hot nodules greater than 3 cm
in size, and where hyperthyroidism fails to respond to
radioactive iodine ablation with Iodine-131.
Radioactive thyroid scans for patients with thyroid
nodular disease where the TSH level is normal is rarely
useful and is not recommended. In patients with a family
history of MTC or where MEN 2A or 2B are suspected,
raised serum levels of calcitonin, or carcinoembry-
onic antigen (CEA) may indicate the presence of MTC.
High-resolution ultrasonography is the imaging
modality of choice for the evaluation of thyroid
lesions. The size and number of nodules within the
gland can be accurately determined, particularly the
presence of bilateral or multinodular disease.
Ultrasonographic features of nodules, which have
been associated with an increased likelihood of
malignancy, include hypoechoic or heterogeneous
internal echotexture, lesions with irregular borders,

-No Family history Family history of Compressive Radiation

-No compression MTC symptoms exposure
-No radiation

-urine metanephrines -Direct laryngoscopy

TSH -serum Calcium & PTH -CT neck & thorax
-CEA & Calcitonin levels -pulmonary function tests

suppressed normal

- Medical control:
antithyroid drugs Radioactive Ultrasound
-surgery or I-131 lodine scan
ablation

-Aspirate x3 Simple Solid nodule Solid nodule

-surgery if recurrent cyst Benign features Malignant features

FNA

Inadequate Benign Follicular/ Malignant

Hürthle cell
neoplasm

-Repeat FNA U/S guided x1 Clinical Diagnostic Total

-then diagnostic lobectomy observation lobectomy & thyroidectomy
isthmusectomy

Completion thyroidectomy if
malignant

Fig. 41.1 Algorithm summarizing the diagnostic work-up and management of patients presenting with a thyroid nodule or mass.
TSH serum thyroid stimulating hormone, U/S ultrasonography
41 Thyroid Surgery for the Community General Surgeon
hypervascularity, and internal microcalcifications [2].
Ultrasound can also differentiate simple cysts from
other thyroid lesions, which can be safely aspirated.
Where a solid component is present, or a complex
cystic mass seen, a cystic malignancy of the thyroid
should be suspected. Cervical lymph nodes in the cen-
tral and lateral compartments can also be evaluated by
ultrasound. Enlargement in size, loss of the fatty
hilum, and distortion of normal lymph node architec-
ture on ultrasound are indicators of nodal involvement
with malignancy. Where local invasion of surround-
ing structures by thyroid malignancy is suspected on
clinical grounds, cross-sectional imaging with com-
puted tomography (CT) or magnetic resonance (MR)
should be performed to evaluate the presence and
extent of locally advanced disease. CT of the neck and
thorax is also indicated where retrosternal or intratho-
racic extension of thyroid enlargement is suspected,
to evaluate the extent of this extension and the rela-
tionship to mediastinal structures.
FNAB of thyroid lesions is perhaps the most impor-
tant investigation in the evaluation of the thyroid lesion,
and the correct interpretation of FNA results is critical
in the further management of these lesions. FNA can be
performed as an office procedure at the time of initial
evaluation of palpable lesions, or can be performed
under ultrasound guidance. Where multiple lesions are
present in the thyroid, FNA of the largest lesions or
those with features suspicious of malignancy on ultra-
sound or clinical evaluation should be undertaken [12].
The cytological results can be grouped into one of
the following four categories:
1. Insufficient sample
2. Consistent with benign lesion
3. Consistent with follicular or Hürthle cell lesion
either neoplastic or non-neoplastic
4. Consistent with malignant lesion [3]
The cytological features associated with these four
­categories and the differential diagnoses for each are
shown in Table 41.1.
Simple thyroid cysts where a solid component is not
seen on ultrasound and FNA does not show any malig-
nant cells can be safely managed by aspiration alone.
Recurrence of simple cystic lesions after three or more
aspirations may indicate an underlying malignancy, and
is an indication for surgical resection. Solid components
of complex cystic lesions should always be biopsied
directly under ultrasound guidance. Thyroid lesions other
311
than simple cysts where the results of FNA are inade-
quate should have the FNA repeated, preferably under
ultrasound guidance to reduce any sampling error.
Where FNA is consistent with a benign lesion, it is
important that this be placed into the context of the
patient’s clinical evaluation. If there are clinical fea-
tures suggestive of malignancy on history or physical
examination, a history of previous radiation exposure
or ultrasonographic features of malignancy, then surgi-
cal resection is still indicated regardless of the results
of FNA in order to rule out malignancy. Where none of
these features are present and the lesion is clinically
consistent with a benign diagnosis, the patient can be
reassured. Follow up with regular physical examina-
tion can be undertaken, and ultrasound and FNA
repeated if features suspicious for malignancy are
found. Repeat ultrasound at 6 months for nodules with
benign cytology on FNA has been recommended
­previously, looking for an increase in size of the index
lesion that may be associated with malignancy.
However, as many as 23% of benign nodules may
increase in size on long-term follow-up, and malignant
lesions can be indolent and slow-growing, and for this
reason, changes in lesion size are a poor indicator of
the risk of underlying malignancy [4].
For lesions with FNA cytology consistent with a
­follicular or Hürthle cell lesion can be either neoplastic
or non-neoplastic. The non-neoplastic lesions in the
appropriate clinical text can be followed similar to the
benign lesions. It is not possible to differentiate benign
neoplasms (follicular or Hürthle cell adenoma) from
malignant lesions (follicular or Hürthle cell carcinoma)
based on the FNA cytology findings [5]. Due to the
benign appearance of the malignant cells that comprise
well-differentiated follicular or Hürthle cell carcino-
mas, the diagnosis of malignancy for such lesions relies
on demonstrating capsular or vascular invasion on final
histopathology. Underlying malignancy is encountered
in 24% of lesions with FNA cytology consistent with a
follicular or Hürthle cell neoplasm on final histopathol-
ogy [6]. Due to this risk of malignancy, surgical resec-
tion is recommended for definitive diagnosis and is best
achieved by diagnostic lobectomy and isthmusectomy.
Intraoperative frozen section examination of the nodule
at the time of diagnostic lobectomy is not reliable in the
diagnosis of malignancy as capsular and vascular inva-
sion cannot be accurately determined using this tech-
nique, and this is therefore not recommended [7].
Where permanent section histopathology shows vascu-
lar or capsular invasion, which are the defining features
312 A.J. Chambers and J.L. Pasieka

Table 41.1 Fine-needle aspiration biopsy results for lesions of the thyroid and their differential diagnosis
Cytology Cytological appearance Differential diagnosis
category
Inadequate Acellular or hypocellular Sampling error
<6 cells clusters per slide Thyroid cyst
Necrotic or cystic malignancy
Benign Scattered clumps of normal appearing follicular cells Hyperplastic nodule
features
Abundant colloid Colloid nodule
Macrofollicles Adenomatous nodule
Occasional Hürthle cells Nodular Hashimoto’s
Occasional macrophages, lymphocytes
Follicular or Sheets of normal appearing follicular or Hürthle cells Hyperplastic nodule/Colloid nodule Non-neoplastic
Hürthle cell
lesions Large clusters of cells Follicular adenoma Neoplastic
Scant or absent colloid Hürthle cell adenoma Neoplastic
Hypercellular Follicular carcinoma Neoplastic
Microfollicles Hürthle cell carcinoma Neoplastic
Follicular variant of PTC Neoplastic
Malignant Nuclear changes of PTC (enlarged, atypical, optically PTC
clear nuclei nuclear crowding, overlapping or folding,
pseudoinclusions, prominent nucleoli)
Neuroendocrine cells Medullary thyroid cancer
Amyloid deposition
Stains positively for calcitonin
Anaplastic, pleomorphic, or spindle cells Anaplastic thyroid cancer
Monoclonal lymphocyte proliferation Lymphoma
PTC papillary thyroid cancer

of a follicular or Hürthle cell carcinoma, completion
thyroidectomy to remove the remaining thyroid lobe
will then be required. Frozen section can however
be helpful in confirming a malignant diagnosis in the
setting of suspicious lymph nodes.
Where FNA cytology is consistent with a malignant
lesion, this is highly specific and more than 98% of
such lesions will be confirmed as malignant on final
histopathology [3]. Further management is dependent
on the type of malignancy identified. Papillary thyroid
cancer (PTC) accounts for more than 80% of malig-
nant lesions, and FNA cytology shows nuclear changes
including grooving, crowding, and overlapping of
nuclei with prominent nucleoli and pseudo-inclusions.
Total thyroidectomy is recommended for patients with
PTC due to the increased risk of multifocal disease
involving both thyroid lobes (demonstrated in 40% of
cases), to enable the administration of radioactive
iodine (RIA) as an adjuvant therapy, and to allow bio-
chemical surveillance for recurrent disease using
serum thyroglobulin measurements during follow-up
[8]. As many as 60–80% of patients with PTC harbor
metastatic disease within regional cervical lymph
nodes, with the central nodal compartment (level VI
nodes) most commonly affected. The central compart-
ment is defined as that region of the central neck
bounded laterally by the common carotid arteries,
inferiorly by the suprasternal notch and superiorly by
the hyoid bone. This compartment contains pretracheal
(“Delphian”), paratracheal, and peri-thyroidal lymph
nodes, as well as the parathyroid glands and the RLN
bilaterally. Nodal recurrence in the central compart-
ment accounts for 60% of disease recurrence in patients
with PTC during long-term follow-up, even following
adjuvant treatment with RAI. Recurrence of PTC is
being increasingly diagnosed with the use of regular
41 Thyroid Surgery for the Community General Surgeon
serum thyroglobulin assays and high-resolution ultra-
sound scanning. Reoperative surgery for recurrence in
this anatomic region is technically challenging and
places the parathyroid glands and RLN at risk, and for
this reason, routine ipsilateral dissection of the central
compartment at the time of total thyroidectomy for
patients with PTC is being increasingly recommended
[9]. Systematic removal of all lymph node-bearing tis-
sue in the central compartment with identification and
preservation of the parathyroid glands and their blood
supply and RLN is critical in performing central nodal
dissection, and this should only be performed by
­surgeons trained in this technique.
Medullary thyroid cancer (MTC) is a malignancy
of parafollicular C-cells and accounts for 7% of thy-
roid cancers. MTC is diagnosed on FNA cytology by
the characteristic appearance of oval or spindle-shaped
neuroendocrine cells staining positively for calcitonin
on immunohistochemistry. Patients with MTC regard-
less of whether a family history is present should be
investigated for the coexistence of other tumors related
to the MEN 2A and 2B syndromes, namely hyper­
parathyroidism and pheochromocytoma. Pheochro­
mocytoma should be ruled out by measurement of
urinary or serum metanephrines, particularly prior
to operation as this can precipitate life-threatening
hypertensive crisis in such patients. All patients with
MTC should also be referred to a clinical genetics ser-
vice for testing to identify the presence of RET proto-
oncogene mutations associated with familial MTC,
MEN 2A and MEN 2B. Identification of RET gene
mutations in index cases has important implications
for the assessment of other family members, and
should be carried out in conjunction with appropriate
genetic counseling. For patients with confirmed MTC,
the surgical management of this disease is critical as
no effective adjuvant therapy exists, unlike the use of
RAI for carcinoma of follicular cell origin. Lymph
node metastases occur commonly in MTC, with
central and ipsilateral cervical chain metastases seen
in 50–60% of cases, and contralateral cervical
chain involvement in 20–30%. For these reasons, the
initial surgical management of MTC involves total
thyroidectomy in conjunction with formal central
compartment lymph node dissection and plus or minus
modified selective neck dissection of lateral nodal
compart­ments [10, 11]. Due to the complexity of the
initial operative management and subsequent follow-
up of patients with MTC, referral to an appropriately
specialized institution is recommended.
313
Anaplastic and poorly differentiated thyroid can-
cers are malignancies of follicular cell origin that lack
the well-differentiated character usually associated
with thyroid cancer, and are associated with rapid
growth, local invasion into surrounding structures, a
high incidence of disseminated metastatic disease and
a poor prognosis. Extrathyroidal invasion into the
RLN, trachea or larynx, esophagus or vascular struc-
tures is seen in 60% of cases at presentation and is best
assessed by cross-sectional imaging with CT or MRIz
[11]. FNA cytology shows loosely arranged, poorly
differentiated giant or spindle-shaped cells, with pleo-
morphism and irregular nuclear forms. The manage-
ment of patients with anaplastic or poorly differentiated
thyroid cancer involves multimodality therapy. Patients
with locally invasive disease that is not surgically
resectable are best managed initially with combination
radiotherapy and chemotherapy, with surgical resec-
tion reserved for patients responding to this treatment
where the disease becomes resectable [12]. All patients
with anaplastic and poorly differentiated thyroid can-
cer should be referred to specialized institutions where
a multidisciplinary approach to management can be
instituted.
41.4 Operative Technique: Diagnostic
Lobectomy and Isthmusectomy
Diagnostic lobectomy involves removal of the ipsilat-
eral thyroid lobe with the entire thyroid isthmus and
pyramidal lobe. A curvilinear incision is made in the
skin of the lower neck, and deepened to incise the plat-
ysma muscle. Superior and inferior skin flaps are raised
deep to platysma to the level of the hyoid bone and
suprasternal notch. The strap muscles are then divided
in the midline, and on the side to be removed are dis-
sected separately. Prior to dissecting in the plane
between the strap muscles and the thyroid lobe, palpa-
tion through the sternothyroid muscle of the underly-
ing thyroid nodule is performed to identify invasive
disease. If invasion of the thyroid lesion into the strap
muscles is suspected, the muscle should be resected
en-bloc with the thyroid lesion and not dissected free.
If invasive disease is not present, then the strap mus-
cles are dissected off the thyroid lobe and reflected lat-
erally. The strap muscles of the contralateral side are
not disturbed to facilitate completion thyroidectomy if
this is ultimately required. As an early maneuver, the
314
pyramidal lobe (if identified arising from the thyroid
isthmus) is removed with its suspensory ligament and
thyroglossal duct remnant to the level of its insertion
into the body of the hyoid bone. Removal of the pyra-
midal lobe during diagnostic lobectomy is important in
the event that malignancy is diagnosed and completion
thyroidectomy is required, as this is more difficult to
achieve in the reoperative surgical field. Dissection of
the thyroid lobe is then carried out, identifying the
external branch of the superior laryngeal nerve
(EBSLN) in proximity to the superior lobe vessels, the
RLN in the tracheo–esophageal groove, and both the
superior and inferior parathyroid glands. The preserva-
tion of all of these structures and their vascular supply
is of paramount importance, particularly in the event
that reoperation is required, and their status at the end
of the procedure should be carefully documented in
the operative report. Parathyroid glands that are devas-
cularized during dissection of the thyroid lobe are set
aside, finely minced and transplanted into the ipsilat-
eral sternocleidomastoid muscle at the end of the pro-
cedure. A frozen section of the suspected parathyroid
gland should be performed to confirm correct histol-
ogy and avoid implant of a lymph node into the sterno-
cleidomastoid muscle. Once the thyroid lobe has been
fully mobilized, this is removed with the entire thyroid
isthmus up to its junction with the contralateral lobe,
and this is again important in facili­tating completion
thyroidectomy. As stated above, where diagnostic
lobectomy is performed for follicular or Hürthle cell
neoplasms, frozen section examination of the resected
lesion is not reliable in the diagnosis of malignancy
and is not recommended. Where malignancy is clini-
cally apparent at the time of initial surgery, as indi-
cated by the presence of local invasion into strap
muscles or surrounding structures, or where abnormal
or enlarged lymph nodes are found and confirmed to
be malignant on frozen section examination, then total
thyroidectomy should be performed.
41.5 Summary
Nodules and mass lesions within the thyroid gland are
a common presentation to surgeons in community
practice, the majority of which will be benign in etiol-
ogy. Clinical evaluation of the patient, ultrasound
A.J. Chambers and J.L. Pasieka
imaging and the results of FNA cytology provide the
basis for diagnosis and guide further management [13].
Surgical resection in the form of diagnostic lobectomy
and isthmusectomy plays an important role in both the
diagnosis and definitive treatment of thyroid nodules
where FNA is consistent with a follicular neoplasm.
Where FNA is consistent with thyroid malignancy,
further surgical management of the primary tumor and
regional lymph node compartments is dependent upon
the type of malignancy encountered, and referral to
specialized centers for definitive management of such
cases is recommended.
References
1. Tucker, M.A., Morris-Jones, P.H., Boice, J.D., et al.:
Therapeutic radiation at a young age is linked to secondary
thyroid cancer. Cancer Res. 51, 2885 (1991)
2. Frates, M.C., Benson, C.B., Charboneau, J.W., et al.:
Management of thyroid nodules detected at US: Society of
Radiologists in Ultrasound consensus conference statement.
Radiology 237, 794 (2005)
3. Yang, J., Schnadig, V., Logrono, R., et al.: Fine-needle
­aspiration of thyroid nodules: a study of 4703 patients with
histologic and clinical correlations. Cancer 111, 306 (2007)
4. Kuma, K., Matsuzuka, F., Yokozawa, T., et al.: Fate of
untreated benign thyroid nodules: results of long-term
­follow-up. World J. Surg. 18, 495 (1994)
5. Baloch, Z.W., LiVolsi, V.A.: Our approach to follicular-­
patterned lesions of the thyroid. J. Clin. Pathol. 60, 244
(2007)
6. McHenry, C.R., Huh, E.S., Machekano, R.N.: Is nodule size
an independent predictor of thyroid malignancy? Surgery
144, 1062 (2008)
7. Udelsman, R., Westra, W.H., Donovan, P.I., et al.:
Randomized prospective evaluation of frozen-section analy-
sis for follicular neoplasms of the thyroid. Ann. Surg. 233,
716 (2001)
8. Dackiw, A.P., Zeiger, M.: Extent of surgery for differenti-
ated thyroid cancer. Surg. Clin. North Am. 84, 817 (2004)
9. White, M.L., Gauger, P.G., Doherty, G.M.: Central lymph
node dissection in differentiated thyroid cancer. World J.
Surg. 31, 895 (2007)
10. Scollo, C., Baudin, E., Travagli, J.P., et al.: Rationale for
central and bilateral lymph node dissection in sporadic and
hereditary medullary thyroid cancer. J. Clin. Endocrinol.
Metab. 88, 2070 (2003)
11. Kross, R.T., et al.: Medullary Thyroid cancer management
guidelines of the ATA. Thyroid 19, 565 (2009)
12. Pasieka, J.L.: Anaplastic thyroid cancer. Curr. Opin. Oncol.
15, 78 (2003)
13. Cooper, D.S.: Revised ATA management guidelines for
patients with thyroid nodules and differentiated thyroid
­cancer. Thyroid 19, 1167 (2009)
 Parathyroid Surgery in the Non-Tertiary
Center
Anthony J. Chambers and Janice L. Pasieka
42.1 Introduction
Hyperparathyroidism is a group of disorders associ-
ated with excessive production of parathyroid hormone
(PTH). PTH is produced by the parathyroid glands in
response to low serum levels of calcium, and acts to
increase calcium resorption from bone by osteoclasts,
and increases renal calcium resorption, thereby reduc-
ing calcium excretion. Hyperparathyroidism is catego-
rized into primary, secondary, and tertiary forms.
Primary hyperparathyroidism (PHPT) is due to auton-
omous secretion of PTH by abnormal gland or glands
in the absence of a secondary stimulus. PHPT is the
commonest cause of hyperparathyroidism, occurring
with an incidence of 0.1–0.4% of the population.
Secondary hyperparathyroidism occurs where para-
thyroid hyperfunction is driven by a secondary stimu-
lus, and is most commonly seen in association with
chronic renal failure due to reduced renal production
of 1,25 dihydroxy vitamin D, reduced phosphate
­excretion/phosphate retention, and resistance of bone
to higher PTH levels. Tertiary hyperparathyroidism is
seen in patients with chronic renal failure after suc-
cessful renal transplantation, where autonomous para-
thyroid hyperfunction occurs despite normalization of
renal function, and autonomous parathyroid secretion
in patients on long-term dialysis with prolonged sec-
ondary hyperparathyroidism.
As PHPT is being increasingly detected in other-
wise asymptomatic patients, and parathyroidectomy
A.J. Chambers and J.L. Pasieka (*)
Department of Surgery, The University of Calgary,
1403-29th Street NW, Calgary, Alberta, T2N 2T9, Canada
e-mail: janice.pasieka@albertahealthservices.ca
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_42, © Springer-Verlag Berlin Heidelberg 2011
42
offers the only effective treatment for this condition,
surgeons will be increasingly involved in the manage-
ment of this condition. It is important that surgeons
involved in the management of patients with PHPT
should have an understanding of the biochemical
work-up required to confirm the diagnosis of this con-
dition, the indications for surgical intervention, the
role of localizing imaging studies to identify hyper-
functioning glands and the options for operative
management.
42.2 Primary Hyperparathyroidism
PHPT can present with symptoms related to hypercal-
cemia, loss of bone mineralization, and renal calculus
disease, and is also being increasingly diagnosed as an
incidental finding on routine biochemical investiga-
tions in patients who are either asymptomatic or with
minimal symptoms. PHPT is due to a single parathy-
roid adenoma in approximately 80% of cases, due to
two or more parathyroid adenomas in 5%, and due to
hyperplasia of all four glands in 10% of cases [1].
Parathyroid carcinoma is a rare cause of PHPT,
accounting for less than 1% of cases. PHPT occurs in
both sporadic and familiar forms. Sporadic PHPT
occurs most commonly in older age groups (mean age
60 years), and effects females four-times more com-
monly than males. Familial PHPT occurs in associa-
tion with multiple endocrine neoplasia (MEN)
syndrome type 1 due to mutation of the MENIN gene
(in association with pituitary adenomas, pancreatic
and duodenal neuroendocrine tumors, bronchial and
thymic “carcinoid” neuroendocrine tumors, adrenal
adenomas, lipomas, and cutaneous and mucosal
angiomas), as part of the MEN 2A syndrome due to
315
316
mutation on the RET proto-oncogene (in association
with pheochromocytoma and medullary thyroid carci-
noma), and as part of the hyperparathyroidism-jaw
tumor syndrome due to mutation of the HRPT2 gene
(associated with parathyroid carcinoma, fibro-osseous
tumors of the mandible and maxilla, renal stromal
tumors, and renal cysts). The age of onset of familial
forms of PHPT is earlier than for sporadic forms of the
disease, and is more likely to be due to multiple ade-
nomas or four-gland hyperplasia. Where a family his-
tory of PHPT or its clinical manifestations (particularly
renal calculi), or of tumors associated with the MEN 1,
MEN 2A, or hyperparathyroidism-jaw tumor syn-
drome are present, patients should be referred to a
clinical genetics service for genetic testing and coun-
seling. The management of familial causes of PHPT is
highly specialized, and where this is suspected, refer-
ral to a specialist institution or endocrine surgical
­service is recommended.
The elevation of serum calcium levels in PHPT
leads to an increase in renal calcium excretion, pre-
disposing to the formation of renal calculi, which is
seen in 15–20% of patients. In the longer term, pro-
longed renal exposure to high calcium loads can also
lead to a deterioration of renal function. Activation of
osteoclast function in PHPT causes bone demineral-
ization, which over time leads to osteopenia and an
increased risk of fractures. In severe cases, now
uncommonly seen in clinical practice due to the ear-
lier diagnosis of the condition, the classic features of
osteitis fibrosa cystica occur with bone cysts (seen on
skull radiographs as a “pepper-pot” appearance),
reabsorption of subperiosteal bone (best seen at the
radial aspects of the middle and distal phalanges of
the hand), fibrous tissue replacement of bone and
“brown tumor” formation, osteopenia, and pathologi-
cal fracture. Patients with severe hypercalcemia from
PHPT can present with complications of hypercalce-
mic crisis, with dehydration, polyuria and polydipsia,
confusion and reduced levels of consciousness, acute
pancreatitis, and acute renal failure. Such patients
require urgent resuscitation and lowering of serum
calcium levels. It is being increasingly recognized
that patients with PHPT also manifest a range of less
acute symptoms that are frequently overlooked or
attributed to other conditions, including fatigue,
­muscle weakness, joint and bone pain, depressed
mood, irritability, memory disturbance, and poor
work-­performance [2].
A.J. Chambers and J.L. Pasieka
42.3 Diagnosis and Clinical Evaluation
The diagnosis of PHPT is made on biochemical cri-
teria, demonstrating hypercalcemia in the presence of
elevated PTH levels, after ruling out causes of second-
ary hyperparathyroidism. Serum calcium, phosphate,
and PTH levels are measured. An elevated serum
­calcium in conjunction with an elevated PTH level
confirms the diagnosis of hyperparathyroidism and
differentiates this from other causes of hypercalcemia,
including metastatic malignancy, multiple myeloma,
Paget’s disease, tuberculosis, and sarcoidosis. In these
conditions, PTH levels will be secondarily suppressed
or within the normal range. Serum phosphate lev-
els are typically low or within the low-normal range
in PHPT. Serum creatinine is measured to rule out
chronic renal insufficiency as a cause of secondary
hyperparathyroidism. Twenty-four hour urinary col-
lection of calcium and creatinine should be performed
in all patients to rule out benign familial hypocalciu-
ric hypercalcemia (BFHH). In this familial syndrome,
heterozygous mutation of the gene encoding the PTH-
receptor causes hypercalcemia, inappropriate eleva-
tion of PTH, and reduced urinary excretion of calcium.
This condition is differentiated from PHPT based on
urinary calcium excretion, which is reduced in BFHH
and elevated in PHPT. This is most accurately per-
formed by calculation of the calcium excretion frac-
tion, derived from serum and urinary calcium and
creatinine levels as shown in (Fig. 42.1). A calcium
excretion fraction of less than 1% is consistent with
the diagnosis of BFHH. Patients with BFHH are not
candidates for parathyroidectomy, and for this reason,
it is critical to exclude this condition in all patients
with suspected PHPT. Serum levels of 25-hydroxy
­vitamin D, the storage form of this vitamin that best
reflects total body stores, should also be performed to
rule out vitamin D deficiency as a cause of secondary
elevation of PTH levels. Where vitamin D deficiency
is found, oral supplementation should be commenced
and biochemical testing for PHPT repeated after
6 weeks of replacement.
Urinary calcium
x
Serum creatinine
Serum calcium Urinary creatinine
Fig. 42.1 Formula for the calculation of the calcium excretion
fraction for the diagnosis of benign familial hypocalciuric
hypercalcemia
42 Parathyroid Surgery in the Non-Tertiary Center
Where PHPT is confirmed on biochemical criteria,
the only effective treatment for the condition is para-
thyroidectomy. In patients with complications of PHPT
such as renal calculi and osteopenia, the rationale of
surgical intervention is to reduce the formation of new
renal calculi and to reduce the rate of further bone
demineralization driven by high PTH levels. Where
complications of PHPT are present, namely renal cal-
culi, renal impairment, bone disease or pathological
fracture, or hypercalcemic crisis, there is a clear indica-
tion for surgery for this condition. As a large proportion
of patients with PHPT are diagnosed on routine bio-
chemical testing and are otherwise asymptomatic or
complain of vague nonspecific symptoms only, guide-
lines have been formulated to assist in the selection of
patients for parathyroidectomy. It is being increasingly
recognized that patients with nonspecific symptoms
related to PHPT, even where the above criteria for para-
thyroidectomy are not met, may still obtain measurable
improvement in symptoms and quality of life measures
after surgery [3, 4]. A consensus development confer-
ence held at the National Institutes of Health in 1990
formulated guidelines for the management of asymp-
tomatic patients with PHPT, and these were revised in
2002 (Table 42.1) [5]. A recent revision of these guide-
lines published in 2009 recommends that all patients
with biochemically proven PHPT should be referred to
an experienced parathyroid surgeon for assessment
regarding the risks and benefits of surgery for this con-
dition, regardless of the presence or absence of symp-
toms [6]. When surgery is not undertaken, it is
recommended that patients undergo annual biochemi-
cal surveillance of serum calcium and creatinine levels,
and annual bone mineral densitometry, for the early
identification of progressive disease.
Table 42.1 National Institutes of Health consensus development
conference guidelines for parathyroidectomy in asymptomatic
primary hyperparathyroidism (2002)
1. Serum calcium > 0.25 mMol (1 mg/dL) above normal range
2. Total 24-h urine calcium excretion > 10 mMol (400 mg)
3. Creatinine clearance reduced > 30% (compared to
age-matched controls)
4. Bone mineral density of spine, hip, or distal radius
reduced more than 2.5 standard deviations below peak
bone mass, i.e., T-score <−2.5 at any of these sites
5. Age younger than 50 years
6. Patients not suitable for regular medical surveillance
317
42.4 Localizing Imaging Studies
Prior to parathyroidectomy for PHPT, imaging studies
can assist in the localization of hyperfunctional para-
thyroid glands and thereby assist the surgeon in identi-
fying these at the time of surgery. Localizing imaging
studies have no role in the diagnosis of PHPT, and are
only employed after biochemically confirming this
condition. High-resolution ultrasound and nuclear
scanning with radiolabeled sestamibi are the two most
commonly employed imaging modalities for the local-
ization of hyperfunctioning glands [7].
High-resolution ultrasound of the neck aims to
identify enlargement of parathyroid glands. Advantages
of this technique include its noninvasive nature and
relatively low cost. However, this technique is operator
dependent, and is limited by a relative lack of specific-
ity, where thyroid nodules and cervical lymph nodes
may be misinterpreted as parathyroid enlargement.
Enlarged parathyroid glands in a retro-esophageal or
retro-tracheal location, glands located inferiorly in the
root of the neck or in a retrosternal location may also
be poorly imaged due to their anatomical position. The
sensitivity of high-resolution ultrasound for the detec-
tion of enlarged parathyroids varies between 72% and
89%, and false positive results are reported in as many
as 15–20% of studies [7].
Nuclear medicine scanning using technetium-99
radiolabeled sestamibi can be used to detect enlar­
ged or hypersecreting parathyroid glands (Fig. 42.2).
Fig. 42.2 Techniecium-99 radiolabeled sestamibi scan showing
increased uptake in a left superior parathyroid adenoma in a
patient with primary hyperparathyroidism (arrow)
318
Sestamibi is taken up by mitochondria, and the high
mitochondrial content of abnormal parathyroid tissue
forms the basis for its identification using this tech-
nique. Scanning of the thyroid gland with radiolabeled
pertechnetate is typically performed initially to enable
comparison with the later sestamibi scan images.
Parathyroid enlargement is seen as areas of increased
sestamibi uptake, and may be more prominent on
delayed images. Cross-sectional imaging using single
photon emission computed tomography (SPECT) can
assist in the three-dimensional localization of enlarged
parathyroid glands, particularly in locating superior
parathyroid glands in a posterior or retro-esophageal
location. The wide field of scanning is useful in the
detection of abnormal parathyroid glands located out-
side the neck, particularly inferior parathyroid glands
in a mediastinal or high-cervical location. False-
positive results can occur due to uptake of sestamibi
within thyroid nodules and neoplasms, particularly
mitochondria-rich Hürthle cell adenoma and carcino-
mas. The sensitivity of sestamibi scanning for the
detection of abnormal parathyroid glands varies from
68% to 88% [7]. Sestamibi scanning is limited in its
ability to identify multiply enlarged parathyroid glands,
as occurring in four-gland parathyroid hyperplasia
or multiple parathyroid adenomas. In only 30–40% of
such patients will two or more abnormal glands be
identified; in the remaining patients only a single
abnormal gland will be demonstrated (30%) or no
abnormal glands are seen (30%) [7].
42.5 Surgery for Primary
Hyperparathyroidism
The aim of surgery for PHPT is the identification of all
hyperfunctioning parathyroid glands and their surgical
excision. Historically, bilateral neck exploration with
inspection of all four parathyroid glands has been the
operative approach of choice for PHPT. Successful cure
of PHPT is reported in more than 95% of cases after four-
gland exploration in most large series. With the introduc-
tion of localizing imaging studies in recent years, less
invasive operative strategies have evolved. Where a single
abnormal parathyroid gland is identified on preoperative
imaging, a unilateral neck exploration to identify the two
parathyroid glands on the side of detected abnormality
A.J. Chambers and J.L. Pasieka
can be performed, or image-directed parathyroidectomy
of the enlarged gland via small incision or video-endos-
copy assisted techniques [8]. Rapid measurement of PTH
levels intraoperatively has been developed with the aim
of improving the success rates associated with these less-
invasive approaches [9]. Documenting a fall in intraop-
erative PTH levels after removal of the enlarged gland
or glands enables the surgeon to confirm removal of all
hyperfunctioning parathyroid glands without inspection
of all four glands.
In patients with PHPT where preoperative sesta-
mibi scanning and/or ultrasonography fail to localize
an abnormal parathyroid gland, four-gland exploration
is required. It can be argued that for surgeons who do
not perform a high volume of parathyroid procedures,
or where intraoperative PTH measurement is not avail-
able, that four-gland parathyroid exploration remains
the procedure of choice regardless of imaging
­localization, and is associated with the highest rate of
successful cure of the disease [10]. A leading cause of
persistent hyperparathyroidism after parathyroidec-
tomy is failure to identify multi-gland disease (second-
ary to four-gland hyperplasia or dual adenomas) at
the time of initial surgery, which occurs in 15–20%
of cases, and routine four-gland exploration aims to
­minimize the risk of this occurrence [11].
42.6 Operative Technique of Four-
Gland Parathyroid Exploration
Four-gland parathyroid exploration requires general
anaesthesia, and a curvilinear incision centered over
the midline of the lower neck is made. The underlying
platysma muscle is divided, and superior and inferior
skin flaps raised deep to this layer. The strap muscles
are incised in the midline and reflected laterally, dis-
secting them free from the underlying thyroid lobes.
The inferior thyroid artery is identified as a landmark.
The superior parathyroid gland is typically encoun-
tered on the posterolateral surface of the thyroid lobe
just above the level of the inferior thyroid artery, and
this region should be inspected to look for fat-pads
that may be associated with parathyroid tissue, or an
enlarged gland itself [12]. The posterior location of the
superior gland means that it may be located in a retro-
esophageal position, and may enlarge in an inferior
42 Parathyroid Surgery in the Non-Tertiary Center
direction here toward the posterior mediastinum. Blunt
dissection to the prevertebral fascia and behind the
pharynx and esophagus is performed to allow pal-
pation with the index finger in this space. Palpation
behind the esophagus, sweeping the index finger in
a cranio-caudal direction to feel the posterior aspect
of the thyroid lobe, may identify an enlarged supe-
rior gland here. Sweeping this finger laterally, below
the inferior thyroid artery, and performing bimanual
palpation with the index finger of the other hand in
this region may also identify an enlarged gland in this
location, which can be “balloted” between the fingers.
Finally, the thyroid lobe is retracted medially to allow
palpation at the edge of the thyroid above the entry of
the inferior thyroid artery.
The inferior parathyroid gland is typically located
at the inferior aspect of the thyroid lobe in the region of
the thyrothymic tongue. The appearance of fat-pads in
this region associated with the parathyroids may assist
in their identification. A tongue of thymic tissue
extending superiorly toward the inferior pole of the
thyroid is often seen “pointing” to the inferior parathy-
roid gland.
Abnormal parathyroid glands are identified based
on their increase in size (greater than 7 mm in largest
dimension). All four glands should be identified and
inspected prior to removal of any abnormal glands.
Experience is required to recognize the appearance of
abnormal and normal parathyroid glands, and to accu-
rately differentiate these. Where the surgeon is uncer-
tain regarding whether a structure is parathyroid tissue,
a small biopsy of the distal part of the gland may be
taken using fine “iris” scissors and submitted for frozen
section histology for confirmation. Routine biopsy of
all normal appearing parathyroid tissue is not recom-
mended due to the risk of devascularizing the remnant
glands. All resected glands should be submitted for fro-
zen section histology to confirm parathyroid tissue, as
lymph nodes and fatty tissue may closely resemble
parathyroid glands macroscopically. Where a single
enlarged parathyroid gland is encountered, and the
remaining glands are confirmed to be normal in size,
the abnormal gland can be safely resected. Where two
enlarged parathyroid glands are seen, extra care should
be taken to inspect the remaining two glands and con-
firm that they are indeed normal, and that four-gland
hyperplasia is not present. If double adenomas are con-
firmed, the two abnormal glands are removed and sub-
mitted to frozen section confirmation. Where four-gland
319
hyperplasia is encountered, subtotal parathyroidectomy
is performed [11]. This involves identification of the
smallest or least abnormal appearing parathyroid gland,
which is partially dissected, taking care to preserve its
blood supply to the hilum of the gland. A metal clip is
placed across the gland, leaving a 50 mg remnant of
gland proximally, and the distal part of the gland is
removed and sent for frozen section to confirm para-
thyroid etiology. If the gland remnant remains vascu-
larized and viable, removal of the remaining three
parathyroids glands is then performed. If the single
gland remnant is not considered viable, this is instead
removed and the next smallest parathyroid gland
selected as the remnant gland, using the previously
described technique. Ideally, an inferior parathyroid
gland is preferred as the remnant gland, pulled away
from the recurrent laryngeal nerve in case reoperation
for recurrent hyperparathyroidism is required.
Where an abnormal parathyroid gland cannot be
located at the time of time of neck exploration, it is
important that the surgeon reconfirms the status of all
the parathyroid glands identified up to that point. As
the majority of parathyroids will be in symmetrical
positions bilaterally, this should be used to guide the
surgeon if the corresponding contralateral gland is
identified. In the event that an abnormal parathyroid
gland cannot be found despite detailed search of likely
locations, the strategy for further exploration is depen-
dent on whether the unidentified gland is likely supe-
rior or inferior in origin.
Superior parathyroid not identified. Where an
abnormal parathyroid gland has not been identified
and is thought to be superior in origin, thorough
­inspection of the posterior aspect of the thyroid lobe
and into the retro-esophageal space should be per-
formed. Dissection in this space inferiorly toward the
posterior mediastinum may reveal a gland in this loca-
tion. Thorough inspection of the surface of the thyroid
lobe should also be performed, looking for any sugges-
tion of an intrathyroidal parathyroid, which may be
visible beneath the capsule of the gland (1% of para-
thyroids occur in an intrathyroidal location).
Inferior parathyroid not identified. Due to its embryo­
logical descent as part of the third branchial pouch, the
inferior parathyroid gland has a more variable location
than its superior counterpart. Detailed inspection of the
inferior aspect of the thyroid lobe and tissues within the
thyrothymic ligament should be ­performed. The ipsilat-
eral thymus should be gently dissected upward from the
320
anterior mediastinum and removed, taking care to pre-
serve the recurrent laryngeal nerve. Failure to identify
the missing gland within the thymus should lead to the
exploration of locations along the embryological decent
of the gland. The carotid sheath should be opened and
inspected as this is rarely the site of an inferior gland.
Superior sites adjacent to the superior thyroid pole and
along the superior pole vessels should also be inspected
to look for an inferior gland that failed to descend.
Inspection of the thyroid lobe for evidence of intrathy-
roidal parathyroid tissue should also be performed.
Where an abnormal parathyroid gland cannot be
found despite thorough and systematic exploration
of possible locations, the intraoperative opinion and
assistance of a second or more experienced surgeon
should always be sought if available. Thyroid lobec-
tomy of the side of the missing parathyroid should be
considered in case of an intrathyroidal parathyroid.
A possible explanation for the failure to identify an
abnormal gland ­during bilateral neck exploration is
the presence of a parathyroid adenoma in an ectopic or
mediastinal location, and this explains the 5% failure
rate of neck exploration reported even by specialized
centers. When an abnormal parathyroid gland cannot
be found despite a thorough bilateral exploration, the
location of all identified normal parathyroids should be
carefully documented and the procedure terminated.
Parathyroid glands with a normal size and appear-
ance should not be removed. The patient should be
referred to an appropriately specialized institution for
further management. Reconfirmation of the diagnosis
of PHPT and further localization studies with radio-
labeled sestamibi scanning, cross-sectional imaging
of the neck, and mediastinum with computed tomog-
raphy or magnetic resonance and/or selective venous
sampling will be required.
42.7 Unilateral Versus Image-Directed
Parathyroidectomy
When preoperative sestamibi scanning and/or ultra-
sound localizes a single abnormal parathyroid gland, a
unilateral exploration of the parathyroid glands on the
side of the imaging abnormality can be undertaken [8].
The unilateral approach minimizes the extent of opera-
tive dissection, and the risk of injury to contralateral
parathyroid glands and the recurrent laryngeal nerve. In
A.J. Chambers and J.L. Pasieka
this approach, exploration is commenced on the side of
the imaging abnormality, and both parathyroid glands
on this side are identified and inspected. Identification
of an abnormal gland corresponding to the imaging
abnormality in association with a parathyroid gland of
normal appearance on this side rules out the presence of
four-gland hyperplasia, and exploration of the contralat-
eral parathyroid glands is not required. In the event that
an abnormal gland cannot be identified on the index
side, the contralateral side must be explored to identify
the hyperfunctioning gland. In the event that normal
parathyroid gland is not identified in association with
the abnormal gland, the contralateral neck must be
explored to rule out parathyroid hyperplasia/multi-gland
disease. The unilateral approach will not detect the rare
occurrence of a double adenoma occurring in the con-
tralateral side. Persistent elevation of calcium and PTH
is seen after a unilateral exploration and parathyroidec-
tomy, that multi-gland disease was present, and explora-
tion of the contralateral side is indicated. Patients such
as this with persistent or recurrent PHPT after parathy-
roidectomy should be referred to specialized centers for
further investigation and management.
Image-directed parathyroidectomies can be done;
however, the need for intra-operative PTH to confirm
all parathyroid tissue has been removed makes this
technique rare in the community hospital setting.
Focused image-directed parathyroidectomy requires a
great deal of experience as exposure is ­limited and the
risk to the RLN can be increased. Therefore, it is our
opinion that the unilateral approach to is a much safer
operation for the community surgeon to undertake.
42.8 Conclusion
PHPT is being increasingly diagnosed in asymptom-
atic or minimally symptomatic patients in the com­
munity setting. The diagnosis of PHPT is made on
bio­chemical criteria after ruling out causes of second-
ary elevation of PTH. The only effective treatment for
this condition is parathyroidectomy, with four-gland
parathyroid exploration considered the “gold-­standard”
operative approach for this condition, associated with
the lowest risk of persistent or recurrent hyperparathy-
roidism. This approach is recommended for surgeons
not performing a high volume of parathyroid proce-
dures, and for those working in the community setting.
42 Parathyroid Surgery in the Non-Tertiary Center
Unilateral exploration is an acceptable alternative to
four-gland exploration in patients where sestamibi
scanning or ultrasonography can localize an abnormal
parathyroid preoperatively. Focused image-directed
parathyroidectomies should be limited to centers where
intra-operative PTH is available.
References
1. DeLellis, R.A., Mazzaglia, P., Mangray, S.: Primary hyper-
parathyroidism: a current perspective. Arch. Pathol. Lab.
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2. Pasieka, J.L., Parsons, L.L., Demeure, M.J., et al.: Patient-
based surgical outcome tool demonstrating alleviation of symp-
toms following parathyroidectomy in patients with ­primary
hyperparathyroidism. World J. Surg. 26(8), 942–949 (2002)
3. Caillard, C., Sebag, F., Mathonnet, M., et al.: Prospective
evaluation of quality of life (SF-36v2) and nonspecific symp-
toms before and after cure of primary hyperpa­rathyroidism
(1-year follow-up). Surg. 141, 153–159 (2007)
4. Mack, L.A., Pasieka, J.L.: Asymptomatic primary hyper-
parathyroidism: a surgical perspective. Surg. Clin. North
Am. 84(3), 803–816 (2004)
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5. Bilezikian, J.P., Potts Jr., J.T., Fuleihan Gel, H., et al.:
Summary statement from a workshop on asymptomatic
­primary hyperparathyroidism: a perspective for the 21st cen-
tury. J. Bone Miner. Res. 17(Suppl 2), N2–11 (2002)
6. Udelsman, R., Pasieka, J.L., Sturgeon, C., et al.: Surgery for
asymptomatic primary hyperparathyroidism: proceedings of
the third international workshop. J. Clin. Endocrinol. Metab.
94(2), 366–372 (2009)
7. Johnson, N.A., Tublin, M.E., Ogilvie, J.B.: Parathyroid
imaging: technique and role in the preoperative evaluation of
primary hyperparathyroidism. AJR Am. J. Roentgenol.
188(6), 1706–1715 (2007)
8. Russell, C.: Unilateral neck exploration for primary hyper-
parathyroidism. Surg. Clin. North Am. 84, 705–716 (2004)
9. Chen, H., Pruhs, Z., Starling, J.R., et al.: Intraoperative para-
thyroid hormone testing improves cure rates in patients
undergoing minimally invasive parathyroidectomy. Surg.
138, 583–587 (2005)
10. Beyer, T.D., Solorzano, C.C., Starr, F., et al.: Parathy­
roidectomy outcomes according to operative approach. Am.
J. Surg. 193, 368–372 (2007)
11. Rose, D.M., Wood, T.F., Van Herle, A.J., et al.: Long-term
management and outcome of parathyroidectomy for ­sporadic
primary multiple-gland disease. Arch. Surg. 136, 621–626
(2001)
12. Doherty, G.M., Moley, J.F.: Conventional exploration for
hyperparathyroidism. Operative Techniques in General
Surgery 1, 4 (1999)
 Adrenal Surgery
43
Marlon A. Guerrero and Wen Shen

43.1 Introduction manifestation of a clinical syndrome. Though there

are no specific symptoms diagnostic of an adrenal
tumor, the astute clinician must be aware of the
Tumors of the adrenal gland are rare. Their retroperito-
symptoms associated with these syndromes
neal location and inconsistent biochemical activity
(Table 43.1).
results in a variable clinical presentation and can pose
Advances in modern imaging technology have
a diagnostic dilemma. Surgical resection is the pre-
improved the diagnostic capability of clinicians for a
ferred treatment modality for tumors that are hormon-
myriad of diseases. These improvements, however,
ally functional, malignant, or have features suspicious
have led to an overuse of imaging in the diagnostic
of malignancy.
process. As such, the prevalence of finding an inci-
The proper work-up of adrenal tumors entails a
dental adrenal tumor has increased from 0.5–2% to
comprehensive biochemical and radiographic evalua-
4% [8]. Although the majority of adrenal incidenta-
tion. Both open and laparoscopic techniques are utilized
lomas are non-functioning, it is important to perform
for surgical resection. Though laparoscopic adrenalec-
a comprehensive hormonal evaluation of these
tomy has become the gold standard for benign tumors,
tumors.
the appropriate approach is dependent on tumor size,
malignant potential, and patient anatomy. Regardless
on the approach utilized, meticulous dissection and Note: It cannot be overstressed that fine needle
careful vascular control is imperative. aspiration biopsy of an adrenal mass has no role in
the work-up of an adrenal mass. The only excep-
tion is in patients with an adrenal tumor and a
43.2 Clinical Presentation known history of malignancy and only after a pheo-
chromocytoma has been biochemically excluded.

The presentation of a patient with an adrenal tumor is

usually nonspecific and ranges from an incidentally
discovered mass to hormonal hyperactivity produc-
ing a clinical syndrome. The most important process 43.3 Biochemical Evaluation
in the evaluation of a patient with an adrenal tumor is
to determine its biochemical activity. Hypersecretion
of one or more adrenal hormones may result in the 43.3.1 Pheochromocytoma

The incidence of pheochromocytomas is two to eight

M.A. Guerrero (*) and W. Shen
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: marlon.guerrero@ucsfmedctr.org,
wen.shen@ucsfmedctr.org
per million [1], but pheochromocytomas comprise
5–11% of adrenal incidentalomas [8]. Screening entails
obtaining a 24-h urine collection of metanephrines and
fractionated catecholamines or plasma-free metaneph-
rines has a high sensitivity of 99% and specificity of

M.W. Wichmann et al. (eds.), Rural Surgery, 323

DOI: 10.1007/978-3-540-78680-1_43, © Springer-Verlag Berlin Heidelberg 2011
324 M.A. Guerrero and W. Shen

Table 43.1 Hormonal syndromes associated with adrenal cortisol level <5 mg/dL excludes Cushing’s syndrome.
tumors An elevated cortisol necessitates confirmation with
Tumor Symptoms
either a 24-h urinary free cortisol, midnight salivary
Pheochromocytoma Headache, chest palpitation, cortisol test, or a high dose (8 mg) dexamethasone sup-
hypertension, vision changes,
pression test. Plasma adrenocorticotropic hormone
anxiety, sweating
level should also be obtained [3, 4].
Cushing’s syndrome Weight gain, central obesity,
peripheral muscle wasting, posterior
neck fat pad, hypertension, acne,
hirsutism, diabetes 43.3.3 Aldosteronoma
Conn’s syndrome Hypokalemia, hypertension

Primary aldosteronomas account for 1.5–3.3% of adre-

89% and is therefore recommended as the diagnostic
test of choice by the NIH [2]. This test is especially
useful in testing patients genetically predisposed to
develop a pheochromocytoma (Table 43.2). However,
it has a high false-positive rate of 10%, so caution must
be used if using it for a screening test [1]. Though
80–90% of pheochromocytomas are sporadic [1], their
frequent association with other diseases should prompt
a complete genetic evaluation.
nal incidentalomas [8]. Primary hyperaldosteronism is
suggested in patients with concurrent hypertension and
hypokalemia. A normotensive patient with normal serum
potassium excludes aldosteronism. However, in hyper-
tensive patients, a plasma aldosterone to renin activity
ratio should be calculated. A ratio >20 and a plasma
aldosterone level >15 ng/dL confirms the presence of
an aldosteronoma [2].

43.3.2 Cushing’s Syndrome
Screening for Cushing’s syndrome involves an over-
night dexamethasone (1 mg) suppression test. A
43.3.4 Virilizing/Feminizing Tumors
Most patients with adrenal incidentaloma do not
require testing for virilizing or feminizing tumors;
testing for these tumors is generally reserved for

Table 43.2 Inherited syndromes with pheochromocytoma

Syndrome Associated diseases Genetic defect
MEN 2A Pheochromocytoma, medullary thyroid cancer, primary RET gene on chromosome
hyperparathyroidism 10q11.2
MEN 2B Pheochromocytoma, medullary thyroid cancer, RET gene on chromosome
mucocutaenous neuromas, muscular hypotonia, 10q11.2
marfanoid habitus
Von Hippel-Lindau Pheochromocytoma, retinal hemangiomatosis, cerebellar Chromosome 3p26-p25
hemangioblastoma, renal tumors, pancreatic tumors
Neurofibromatosis type I Pheochromocytoma, neurofibroma, schwannomas, café Chromosome 17
(Von Recklinghausen’s disease) au lait spots, glial tumors, skeletal manifestations
Sturge-Weber Port-wine stain, seizures, mental retardation, glaucoma,
leptomeningeal angioma
Tuberous sclerosis Hamartomas, seizures, developmental delay, renal TSC1 on chromosome 9 q34 and
angiomyolipomas, renal cell carcinoma, lung cysts, TSC2 on chromosome 16 p13.3
cardiac rhabdomyomas, retinal lesions
Carney’s Paraganglioma, gastric leiomyosarcoma, pulmonary
chondroma
MEN multiple endocrine neoplasia, VHL von Hippel-Lindau
43 Adrenal Surgery
patients with clinical evidence of androgen or estrogen
excess. Evaluation of virilizing or feminizing tumors
involves checking for all the sexual steroids and their
precursors. Serum levels of testosterone, dehydroepi-
androsterone sulfate (DHEA-S), androstenedione,
17-hydroxy-progesterone, and 17-b-estradiol should
be tested. It is important to note that an elevated level
of DHEA-S is highly suggestive of an adrenocortical
carcinoma (ACC). Even ACC that are not hormonally
active are found to have high levels of androstenedione
or 17-hydroxy-progesterone [4].
43.4 Imaging
Patients found to have an adrenal mass should
undergo dedicated imaging to evaluate for size, extent
of tumor involvement, and distant metastasis. Feat­
ures suggestive of malignancy include irregular bor-
ders, heterogeneity, stippled calcifications, necrosis,
local tissue invasion, lymphadenopathy, or distant
metastasis.
43.4.1 CT
The preferred imaging modality is a high-resolution
computed tomography (CT) scan of the abdomen.
The lipid content on the adrenal mass measured by
Hounsfield units (HU) and the timing of contrast
washout help distinguish the adrenal mass. Adrenal
adenomas have a density of £10 HU on unenhanced
CT and <30 HU on contrast-enhanced CT with
rapid washout of contrast ³50% at 10 min.
Adrenocortical carcinomas are typically vascular,
with slow washout (<50%) and >10 HU on unen-
hanced CT [5].
43.4.2 MRI
Magnetic resonance imaging (MRI) of the abdomen,
though more expensive than a CT scan, is also utilized
to evaluate adrenal tumors. Features on MRI that sug-
gest malignancy include heterogeneous signal
325
intensity on T1 and T2-weighted imaging, peripheral
nodular enhancement, and central hypoperfusion on
contrast MRI [6].
43.5 Open Adrenalectomy
In the era of minimally invasive surgery, laparoscopic
adrenalectomy has now become the standard approach
for most adrenal tumors. Clear indications for open
surgery remain and the surgeon must be well versed
with this technique. The absolute and relative indica-
tions for an open adrenalectomy include:
Absolute
1. Known or suspected adrenocortical carcinoma
2. Complications (bleeding, bowel injury) during a
laparoscopic adrenalectomy
Relative
1. Reoperation for recurrent adrenal tumors
2. Large tumor size (>10 cm)
3. Local or vascular invasion
4. Extensive lymphadenopathy
5. Virilizing tumors in women or feminizing tumors in
men because up to 80% of these tumors are adreno-
cortical carcinomas
43.5.1 Anterior Approach
The anterior approach is the most common open
procedure performed. The advantages of utilizing
this approach are the surgeon’s familiarity with the
anatomy, feasibility of performing a complete abdom-
inal exploration, and accessibility to the contralateral
gland without needing to reposition the patient. These
benefits must be outweighed by the increased mor-
bidity associated with the open approach; for exam-
ple, wound complications in obese Cushing’s
patients.
The incision should be tailored to the surgeon’s
familiarity and includes a midline, bilateral subcostal,
or unilateral subcostal incision. Upon entering the
peritoneal cavity, a thorough abdominal exploration is
performed.
326
43.5.1.1 Right-Sided Tumor
Right-side dissection is begun by obtaining adequate
exposure. The triangular ligament of the liver is dissected
and the liver is retracted superomedially. If the tumor is
large or has a retrohepatic extension, the coronary liga-
ment may be divided to completely mobilize the right
lobe of the liver. The hepatic flexure of the colon is taken
down and the colon is retracted caudad. A Kocher
maneuver may be performed to mobilize the duodenum
medially. These maneuvers provide wide exposure to the
adrenal gland and inferior vena cava (IVC). Meticulous
dissection should proceed along the medial border of the
gland, from superior to inferior, to identify the right
adrenal vein. The right adrenal vein courses a short dis-
tance to enter the IVC posteriorly. The vein is carefully
doubly ligated and divided. Several small arteries supply
the adrenal gland and should be divided. Accessory
adrenal veins may also be present; these should be
divided after assuring that they do not correspond to the
renal vascular pedicle. Dissection ensues along the infe-
rior border of the adrenal gland laterally. The Harmonic
scalpel or Ligasure can be used to expeditiously divide
the inferior and lateral attachments of the adrenal gland.
43.5.1.2 Left-Sided Tumor
The key to resecting left-sided adrenal tumors is also expo-
sure. First, the splenic flexure is mobilized by dissecting
the lateral aspect of the gastrocolic ligament and the supe-
rior lateral attachments of the descending colon. Further
exposure is obtained by dividing the lateral attachment of
the spleen and pancreas to reflect both organs anteromedi-
ally. As with right-sided tumors, dissection proceeds along
the medial border of the adrenal gland. The inferior phrenic
vein has a superolateral to inferior course and is usually
encountered first. This vein should be ligated and divided.
The left adrenal vein is longer than the right and drains into
the left renal vein rather than the IVC. It should be doubly
ligated and divided along its course in the inferior-medial
aspect of the adrenal gland. The rest of the dissection pro-
ceeds in a similar fashion as right-sided tumors.
43.5.2 Posterior Approach
The posterior approach was initially described by
Young in 1936 [7]. The advantage of this approach is
M.A. Guerrero and W. Shen
that it is extraperitoneal and avoids a large abdominal
wound and its associated complications. It also offers
a more direct route to the adrenal glands compared to
the other open approaches. The disadvantage is that
only one gland can be resected per incision. It is also
limited by the exposure for large tumors, so the limit of
resection is up to 5 cm [9]. Also, vascular exposure and
control is more challenging with this approach.
As with any other surgical procedure, positioning
and exposure is the key to a successful operation. The
patient is placed in prone jack-knife position with the
bend of the table at the level of the 12th rib. A trans-
verse incision that follows the course of the 12th rib or
a hockey stick incision is performed through the subcu-
taneous tissues. The latissimus dorsi muscle and sacros­
pinalis muscle are transected. The costal attachment of
the sacrospinalis muscle is transected. The lumbodor-
sal fascia is then incised and the posterior subcostal
ligament is divided to release the pleura. The 12th rib is
divided after the periosteum is elevated. The 11th rib
and pleura are then retracted upward. After this expo-
sure, dissection begins through perinephric fat to
expose Gerota’s fascia. The kidney is retracted caudally
and the adrenal gland is dissected from superior to
inferior direction. Vessels entering the adrenal gland
are carefully divided. The adrenal vein is then doubly
liga­ted and divided. Dissection continues circumferen-
tially to freely mobilize the adrenal gland [9].
43.6 Laparoscopic Adrenalectomy
The first transabdominal laparoscopic adrenalectomy
was performed by Gagner et al. in 1992 [10]. Since
then, it has become the gold standard approach for
benign adrenal tumors. The advantages of the laparo-
scopic approach is the shorter hospital stay, improved
recovery time, decreased pain, and reduced blood loss
compared to the open approach [11].
In 1995, Mercan et al. described the posterior
laparoscopic adrenalectomy [12]. Though many sur-
geons prefer the transabdominal approach because of
familiarity with the anatomy, the use of the posterior
approach has become more prevalent [13, 14]. This
approach allows direct access to the adrenal gland and
vasculature without needing to mobilize any abdominal
organs. This is especially advantageous in patients with
prior abdominal surgery. Both laparoscopic approaches
are described below.
43 Adrenal Surgery
43.6.1 Transabdominal Lateral Approach
43.6.1.1 Right-Sided Tumor
The patient is positioned in the left lateral decubitus
position (right-side up). A 1 cm transverse incision is
made in the midclavicular line. A Veress needle is
inserted to establish pneumoperitoneum to 15 mmHg
with CO2. A 10 mm trocar is inserted for a 30-degree
camera. Under direct visualization, a 10 mm port is
placed laterally at the anterior axillary line. Two more
10 mm ports are placed, splitting the difference
between the previously inserted ports. All ports should
be placed 1–2 cm below the costal margin. A liver
retractor is inserted through the most medial port for
anteromedial retraction. The angled camera is used
through the adjacent port. The remaining two lateral
ports are the surgeons working ports. The surgeon
stands on the left side of the table with the assistant
standing adjacent and cephlad to the surgeon.
The key to a successful and bloodless operation is
adequate exposure by first mobilizing the liver. The
lateral hepatic attachment is divided utilizing hook
electrocautery and the dissection is continued to the tri-
angular ligament. The liver fan-retractor is used to
retract the liver anteromedial. The dissection is then
continued in a cephlad to caudad direction creating a
“V” in the plane between the IVC and medial border of
the periadrenal tissue. We prefer hook electrocautery
for this part of the procedure because it allows for opti-
mal visualization. Cautious dissection should continue
inferiorly as the adrenal vein is approached. The adrenal
vein has a short course as it exits the medial border of
the adrenal gland. A blunt grasper is then used to care-
fully dissect the adrenal vein free. The vein is divided
after placing two clips medially and one laterally.
Dissection is continued along the inferomedial aspect
of the adrenal gland with the adrenal gland retracted
superolaterally. This allows for clear visualization of the
kidney and avoids potential injury to the hilar vessels.
Once the superior pole of the kidney is visualized, the
Harmonic scalpel is used to finish the dissection later-
ally. The adrenal tumor is removed in a specimen bag
through the lateral port. Tumor morselization allows for
effortless removal without needing to extend the port
incision. The ports are then removed under direct visu-
alization after confirming adequate hemostasis. The
incisions are closed in standard fashion.
327
43.6.1.2 Left-Sided Tumor
The patient is placed in the right-lateral decubitus posi-
tion with the left side up. The surgeon and assistant
stand on the right side of the table in the positions out-
lined above. The abdominal cavity is accessed as
described for right-sided tumors except that three
10 mm ports are used. The first port is situated 2 cm
below the costal margin at the midclavicular line. The
lateral port is placed under direct visualization at ante-
rior axillary line. The remaining port is placed between
these two ports. The two lateral ports are the working
ports. A fourth port may be inserted for additional
retraction if visualization is inadequate.
The splenic flexure is first mobilized to expose the
splenorenal ligament. The splenorenal ligament is
divided in a cephlad direction until the stomach and
short gastric vessels are visualized. This allows for
medial mobilization of the spleen and tail of the pan-
creas. As described for right-sided tumors, the hook
electrocautery is used to dissect in a cephlad to caudad
direction creating a “V” between the aorta medially
and periadrenal tissue laterally. The inferior phrenic
artery is often encountered along its superolateral
course from the aorta and may be divided with impu-
nity. Caution should be used along the inferior border
of the adrenal gland as the adrenal vein exits along the
inferomedial margin of the gland. Once the vein is
bluntly dissected free, it is transected between clips.
The adrenal gland is retracted in a superolateral direc-
tion and the Harmonic scalpel is used to continue the
dissection laterally. It is important to visualize the
superior pole of the kidney before proceeding with
the lateral dissection to assure that the renal vessels are
free from the tumor. The specimen is removed in a
specimen bag. Hemostasis is confirmed prior to remov-
ing the ports and the incisions are closed in the stan-
dard manner.
43.6.2 Posterior Approach
General endotracheal anesthesia is performed in the
supine position. The patient is then placed in the prone
position. The pressure points are protected with pad-
ding and the thorax is secured laterally with bolters.
Once the patient is secured, the table is placed in the
jackknife position. A transcuteneous ultrasound can be
328
used to map the kidney and adrenal tumor on the skin
[13]. The technique used is modified by that described
by Walz et al. [14, 15]. A 1.5 cm transverse incision is
made 2 cm inferior and parallel to the 12th rib. The
retroperitoneum is accessed using an open technique.
An index finger is then used to create a space within
the retroperitoneum. A 10 mm port is placed medially
using the index finger to guide its entry. The same tech-
nique is used to place a lateral 10 mm port. A 10 cm
spherical dissecting balloon may also be used to create
a space within Gerota’s fascia under direct visualiza-
tion [13]. After all three ports are placed, pneumoretro-
peritoneum is achieved to 20–24 mmHg with CO2.
A 30° videoscope is placed into the middle port.
Blunt dissection is used to create a space within the
retroperitoneum. Gerota’s fascia is entered and the
superior pole of the kidney is identified. The adrenal
gland is dissected along its inferior margin by bluntly
retracting the periadrenal tissue cephlad and kidney
caudad. Dissection proceeds medially until the adrenal
vein is identified. The vein is then clipped and tran­
sected. Using a Harmonic scalpel, the adrenal gland is
dissected laterally and superiorly. Leaving the superior
attachments of the adrenal gland optimizes visualiza-
tion of the adrenal vein.
Another technique is to approach the adrenal gland
along the superior margin to separate it from the dia-
phragm. The harmonic scalpel is used and dissection
continues laterally. The inferior border is then dissected
off the superior pole of the kidney. The medial border is
dissected last and the adrenal vein is carefully transected
after clips are applied. The adrenal gland is removed
using an endobag and the incisions are closed in the
usual manner after assuring that hemostasis is achieved.
43.7 Complications
The risks of adrenalectomy should be discussed with
the patient in detail prior to proceeding with surgery. It
is also important to set accurate patient expectation.
Open procedures are associated with increased
morbidity compared to the laparoscopic approach. The
open approach may result in more pneumonia, unplan­
ned intubation, unsuccessful ventilator wean, systemic
sepsis, cardiac arrest, renal insufficiency, and wound
infections [6]. The patient should also be aware that
the laparoscopic approach is associated with a 0–4.5%
M.A. Guerrero and W. Shen
conversion rate [3]. Studies comparing open versus
laparoscopic adrenalectomy have shown that the open
approach results in increased operative times (3.9 ± 1.8
h versus 2.9 ± 1.3 h, p < 0.0001), transfusion require-
ments (0.7 ± 1.8 U versus 0.1 ± 0.5 U, p < 0.0001),
length of stay (9.4 ± 11.0 days versus 4.1 ± 4.7 days,
p < 0.0001) and 30-day morbidity rates (17.4% versus
3.6%, p < 0.0001) [16].
43.8 Summary
Although rare, the medical and surgical implications
of adrenal lesions are clinically significant. Identi­
fication of symptoms and syndromes may be the more
common presentation in rural populations with less
access to advanced radiologic imaging. Regardless of
presentation, the discussed biochemical work-up and
radiologic evaluation is vital. Laparoscopic approach
has well-documented benefits when indications are
appropriate. Consideration for referral is based on sur-
gical and anesthesiology expertise and should be
strongly considered in rural environments with limited
medical and critical care support.
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 Breast Surgery
44
David Walsh

44.1 Introduction • Mastectomy
• Sentinel lymph node biopsy
−− Axillary
Surgical procedures on the breast divide logically into
−− Internal mammary
those performed for benign disorders (including diag-
• Axillary clearance
nostic procedures) and surgical interventions for malig­
nant disease. For benign conditions, cosmesis is a key
consideration, whilst for malignant disease the focus is 44.2 Benign Disorders
clearly oncological control. This chapter will address
the following operative procedures for both benign and 44.2.1 Breast Abscess
malignant diseases.
Benign disorders Breast abscesses have traditionally been considered
• Breast abscess to be a lactation-related phenomenon. Recently, early
• Mammary fistula post-natal care employing breast emptying techniques,
• Incisional breast biopsy antibiotics and lactation suppression, have reduced the
• Excisional breast biopsy need for surgical drainage of breast abscesses in this
−− Palpation situation. In current surgical practice, most abscesses
−− Guided requiring operative drainage are seen in peri-­menopausal
• Microdochectomy women, usually secondary to infections arising in areas
• Central duct excision of duct ectasia. In general, infected localised collec-
tions in the breast can often be successfully managed
Malignant disease by antibiotic cover for gram-positive and anaerobic
organisms, and repeated needle aspiration, either by
• Wide local excision
palpation or more commonly targeted by ultrasound.
−− Palpation
However, if a patient is systemically unwell, has an
−− Guided
abscess >5 cm, fails to respond to repeated aspiration or
there are features where the possibility of malignancy is
present, then open surgical intervention is indicated.

44.2.1.1 Technique

• General anaesthesia is preferred.

D. Walsh
Department of Surgery, The Queen Elizabeth Hospital,
• The incision should be placed over a central area of
28 Woodville Rd, Woodville South, SA 5011, Australia the abscess. If possible, a circumareolar incision
e-mail: leawalsh@ozemail.com.au will be most cosmetic in the long term.

M.W. Wichmann et al. (eds.), Rural Surgery, 331

DOI: 10.1007/978-3-540-78680-1_44, © Springer-Verlag Berlin Heidelberg 2011
332
• The incision is deepened towards the liquefied
­centre of the abscess, which may only be a small
component of the entire inflammatory mass. If the
pus within the mass is difficult to identify, it can be
helpful to probe the area with an artery forceps.
• Once the abscess cavity is identified, a swab for cul-
ture is taken and any loculations are broken down to
create a single space, the incision is enlarged to give
adequate access for post-operative dressings.
• A full thickness biopsy of the abscess wall should
be sent for histological assessment in all cases.
• After lavaging the cavity with saline and establish-
ing haemostasis, the cavity is packed lightly with
a dressing, with an alginate dressing being most
­comfortable for the patient post-operatively.
44.2.1.2 Rural Issues
• Antibiotics are generally not needed after 48 h.
• Nursing care will consist of daily dressings for a
week and then two to three dressings weekly for
around 6 weeks (often easier to organise in the rural
setting than the city).
• Breastfeeding patients will almost always need phar-
­maceutical suppression of lactation, DOSTINEX
(Cabergoline) 1 mg stat orally works within 24 h.
44.2.2 Mammary Fistula
Most women with mammary fistulae have underlying
duct ectasia. In cases of recurrent disease, the proce-
dure of central duct excision may be more appropriate
than just laying open the fistula surgically.
44.2.2.1 Technique
• General anaesthesia is generally preferred, and a
single dose of prophylactic antibiotics given.
• The fistula opening on the areolar margin in care-
fully entered with a medium lacrimal probe and the
fistula into the nipple is defined.
• The fistula is laid open onto the probe.
• The epithelialised lining and any granulation tissue
is curetted away. Tissue should be sent for biopsy
and culture.
D. Walsh
• After establishing haemostasis, the cavity is packed
lightly with a dressing, with an alginate dressing
being most comfortable for the patient post-
operatively.
44.2.2.2 Rural Issues
• Nursing care will consist of daily dressings for a
week and then two to three dressings weekly for
around 6 weeks (often easier to organise in the rural
setting than the city).
• A key risk factor for mammary fistulae is nicotine
usage and if possible this should be addressed
before surgical intervention.
44.2.3 Incisional Breast Biopsy
Incisional biopsies are performed where there is a large
breast lesion that cannot be excised for technical rea-
sons (e.g. malignancy fixed to chest wall) or cosmetic
reasons where the area is likely to be a benign process.
Increasingly, locally advanced stage III breast cancers
are being offered neo-adjuvant therapy prior to resec-
tional surgery; in these cases, a core or incisional biopsy
is generally undertaken before treatment begins.
44.2.3.1 Technique
• General or local anaesthesia are suitable.
• The key issues are the placement of the incision and
securing haemostasis.
• Incisions must be placed within the skin envelope
that would subsequently be excised in a resectional
procedure, such as a mastectomy.
• The tissues removed should include viable tumour
(necrotic material alone is unhelpful) and skin if
dermal involvement is present.
• If the pathological process could be benign, judge-
ment is needed in removing enough tissue for a
diagnosis, without needlessly distorting the breast.
• Bleeding, wound breakdowns and infections delay
treatments and distress patients.
• Tissue should be formalin fixed, oestrogen, proges-
terone and Her2 receptor assays are routinely
requested.
44 Breast Surgery
44.2.3.2 Rural Issues
• Incisional biopsies are virtually always performed
on palpable lesions, so localization issues are rare.
• This procedure is an important early step in breast
cancer management and is readily achieved in the
rural setting.
• Usually multi-disciplinary consultation is under-
taken prior to an incisional biopsy for breast
cancer.
• Frozen section assessments have almost nothing to
add in this procedure.
44.2.4 Excisional Biopsy
Removal of an entire breast lesion is performed for
therapy in benign masses and for diagnostic purposes
in indeterminate cases. Unlike excisions in cases of
proven malignancy, cosmetic considerations are fore-
front, and the lesion is removed intact but with a
­minimal margin.
44.2.4.1 Technique
• A palpable mass must be marked with the patient
awake and involved, if there is any doubt around
identification (often an initial biopsy haematoma
resolves)….stop, re-think, localise.
• General or local anaesthesia are suitable.
• The key issues are the placement of the incision and
securing haemostasis.
• Incisions must be placed within the skin envelope
that will subsequently be excised in a resection
­procedure, such as a mastectomy. Skin is usually
not removed for an excision biopsy.
• A surgical margin of a few millimetres is adequate.
• Avoid the temptation to diagnose a malignant pro-
cess with your fingers and change to an unplanned
more radical procedure. Await formal histology.
• Closure is an important issue. The author prefers
to avoid closing the deep breast cavity. This allows
a controlled seroma to form, which gradually
resorbs leaving minimal cosmetic distortion in the
long term.
• Drains are generally not required.
333
44.2.4.2 Rural Issues
• This is an ideal procedure for the rural settings.
• The technique can be used for palpable and image-
detected lesions. For image-detected lesions, local-
ization using a hook wire or carbon technique can
be used. (see Wide Local Excision).
• Ultrasound is used for mass imaging lesions and
a hook wire employed for areas of more subtle
­mammographic distortion or calcification.
• Localised biopsies can be undertaken in rural cen-
tres, but will depend on the timely availability of
radiological services.
• Frozen section assessments have almost nothing to
add in this procedure.
• Pathology in the removed specimen must be corre-
lated with the pre-op expectations, biopsies and
imaging. Often, follow-up with imaging 3 months
after the biopsy is prudent, to ensure that a missed
lesion is not still present.
44.2.5 Microdochectomy
Microdochectomy is the removal of a specific breast
duct in isolation, as compared to central duct excision,
which removes the entire retro-areolar duct complex.
This procedure allows the diagnosis and treatment of
pathological nipple discharges, whilst preserving the
ability to subsequently breastfeed. It is the procedure
of choice for nipple discharge in the setting of younger
women (who wish to breastfeed), a single duct dis-
charge and bloody nipple discharge (where a localised,
intraduct papilloma is likely).
44.2.5.1 Technique
• General anaesthesia is usually preferred. If local
anaesthesia is employed, adrenaline and vasospastic
agents must be used with caution around the
nipple.
• The pathological duct is identified by expressing
fluid (avoid attempting to express any discharge
fluid for several days prior to the procedure) and
then cannulated with a lacrimal probe.
• A radial incision is performed over the line of the
probe from the duct orifice towards the areolar
334
­ argin. It is not necessary to go beyond this mar-
m • A circumareolar incision is used along the inferior
gin, and incisions within the nipple aeolar complex
will heal virtually imperceptibly.
• With the lacrimal probe in place, fine scissors are
used to develop the plane adjacent to the pathologi-
cal duct. Surrounding ducts are left intact.
• Dissection of the duct extends radially outwards
until retromammary fat or non-pathological breast
parenchyma is identified.
• The specimen is orientated and sent for histology.
• Haemostasis is secured and the cavity is closed in
layers with absorbable sutures.
• No drain is required.
44.2.5.2 Rural Issues
• Pre-op imaging with mammography and ultrasound
is essential.
• If the pathology being dealt with is likely to be
mammary duct ectasia, then microdochectomy has
a significant rate of discharge recurrence. Central
duct excision may be more appropriate.
• If the pathological duct cannot be identified, it may
be prudent to abandon the procedure and await
events.
44.2.6 Central Duct Excision
This procedure involves the complete removal of the
retroareolar breast ducts. It is the procedure of choice
for women with multiple discharging ducts in the set-
ting of mammary duct ectasia or recurrent mammary
fistulae. This procedure precludes subsequent breast-
feeding and so must be used selectively in younger
women. It is both therapeutic and diagnostic and can be
used for recurrent discharges after microdochectomy.
44.2.6.1 Technique
• A single dose of prophylactic antibiotics with gram
positive and anaerobic cover should be considered.
• General anaesthesia is usually preferred. If local
anaesthesia is employed, adrenaline and vasospas-
tic agents must be used with caution around the
nipple.
D. Walsh
line of the nipple complex. This avoids compromis-
ing the blood supply to the nipple, which enters via
subcutaneous vessels at 2 and 10 o’clock.
• A plane under the areola is developed, avoiding
­buttonholing or compromising the viability of the
nipple or areola, until the breast ducts under the
nipple are identified.
• Blunt dissection with an artery forceps is used to
encircle the duct system and then to clip the bunched
ducts.
• The ducts are amputated just below the nipple and
the clip on the duct stumps is used for retraction
whilst the duct system is sharply dissected as a disc
of tissue down to the retro mammary fat.
• The specimen is orientated and sent for histology.
• Haemostasis is secured and the cavity is closed in
layers with absorbable sutures. The cylindrical
space is best closed with a series to deep purse
string sutures.
• A suction drain is used very selectively.
44.2.6.2 Rural Issues
• Pre-op imaging with mammography and ultrasound
is essential.
• If a woman is still premenopausal, then a microdo-
chectomy, which preserves the potential for breast-
feeding, may be more appropriate.
44.3 Malignant Disease
44.3.1 Wide Local Excision (WLE)
This procedure is used to locally resect proven breast
malignancies. Unlike an excisional biopsy, there is a
deliberate attempt to remove the known breast lesion
with a macroscopic margin of normal surrounding
breast parenchyma. A correctly performed WLE with
pathologically proven clear margins and post-­operative
radiotherapy is equivalent to performing a mas­
tectomy for the management of breast cancer. The
decision to perform a WLE excision involves an
important balance between adequate tumour control
and final cosmesis of the breast. The introduction of
44 Breast Surgery
mammographic screening of asymptomatic women,
with detection of smaller invasive breast cancers and
higher rates of in situ malignancy, means that WLE is
now the commonest procedure for breast cancer.
Nearly all patients with breast cancer should have an
overall management plan formulated before proceed-
ing to a definitive procedure such as WLE. For inva-
sive cancers, concurrent axillary lymph node staging
is generally performed.
44.3.1.1 Technique
• General anaesthesia is used in all but exceptional
circumstances.
• If there have been recent breast procedures (e.g.
hook wire placement, SLNB studies), antibiotic
cover is given.
• Incisions must be placed within the skin envelope
that would subsequently be excised in a resectional
procedure, such as a mastectomy.
• A key difference in the procedure occurs depending
on whether the tumour is palpable or not.
(a) Palpable masses
−− Carefully mark the tumour and establish the
likely boundaries of the excision before making
the incision. Prior biopsy sites are included if at
all possible.
−− Aim to excise an ellipse of skin over the tumour
and sharply divide the breast parenchyma 2 cm
for the tumour edge. This is most easily done on
the side away form the nipple where the breast
disc is less dense and the tumour margin more
readily palpated. A 2-cm surgical margin will
generally translate into an acceptable pathologi-
cal margin of around 1 cm.
−− Realise that final cosmesis relates closely to the
extent of skin removed and less directly to the
volume of tissue removed.
−− The tissue removed is always excised from skin
to chest wall, meaning that when subsequent
pathology reports are considered, only the lateral
margins of excision are relevant, re-excision or
mastectomy will not improve superficial or deep
margins if this approach is employed.
−− Once the chest wall is identified, the tumour is
mobilised and is more easily palpable, which
assists in obtaining a clear margin on the central
breast disc side.
335
−− The specimen is orientated and sent for histol-
ogy. Typical orientation uses different length
sutures (short = superficial, medium = medial,
long = lateral).
−− After excision, the tumour cavity is carefully
palpated to check for additional masses and the
specimen is checked to ensure that there are ade-
quate margins as far as can be discerned macro-
scopically. Many surgeons routinely re-excise or
biopsy the narrowest margin.
−− Tissue should be formalin fixed, oestrogen, pro-
gesterone and Her2 receptor assays are routinely
requested.
−− Careful haemostasis is secured. Bleeding, wound
breakdowns and infections delay treatments and
distress patients.
−− Metallic clips are placed in the edges to facilitate
subsequent radiotherapy planning and follow-up
breast imaging.
−− Closure is an important issue. The author prefers
to avoid closing the deep breast cavity. This
allows a controlled seroma to form, which grad-
ually resorbs leaving minimal cosmetic distor-
tion in the long term.
−− Drains are generally not required.
−− Tissue should be formalin fixed, oestrogen, pro-
gesterone and Her2 receptor assays are routinely
requested.
(b) Non-palpable masses
−− The tumour should be localised. Blind excisions
are not acceptable. Ultrasound or stereotactic
mammography can be used. Ultrasound is used
for mass lesions and a stereotaxis employed for
areas of more subtle mammographic distortion
or calcification.
−− Either a hook wire or a carbon track can be used
for localization, but the surgeon must be aware
of the details of the localization (site and direc-
tion). All relevant imaging must be available at
the time of the procedure.
−− All of the principles of WLE for palpable
tumours apply to localised procedures.
−− Whilst hook wires can be intercepted via a skin
incision away from the insertion site in excep-
tional circumstances, for carbon tracks and most
hook wires insertion sites are generally excised
in the skin ellipse excised with the tumour.
−− The principle is to follow the wire or track to the
breast lesion. The hook wire is excised with a
336
pre-determined margin around the tip based on
the tumour size. Masses are often palpable as
they are approached.
−− Using carbon, then the area to be removed is excised
without interrupting (seeing) the carbon track.
−− Remember, hook wires can be pulled out and
diathermy lesions can look like carbon.
−− The excised tissue is then sent for specimen
mammography.
−− Metallic clips on the specimen (1 = superior, 2 =
medial, 3 = lateral) can allow orientation and
interpretation of the specimen X-ray.
44.3.1.2 Rural Issues
• WLE for palpable tumours is easily undertaken in
the rural setting.
• Issues of concurrent axillary surgery (SLNB),
radiotherapy and systemic treatments for breast
cancer are more complex.
• Localised WLE can be undertaken in rural centres,
but will depend on the timely availability of radio-
logical services.
• Hook wires can be placed 24 h ahead of the proce-
dure, and carbon tracks can be undertaken well
ahead of schedule.
• The key rural issue is often the issue of specimen
imaging during the intra-operative phase.
• Specimen imaging and expert interpretation is a key
requirement for localised WLE.
• For mass lesions, surgeon-performed intra-op ultra-
sound can be a solution in the rural setting.
44.3.2 Mastectomy
Whilst the majority of breast malignancies are now
treated with breast conservation, there remains an
important role for mastectomy that is unlikely to
change.
Current indications include:
Extensive disease (large tumour, small breast, 4 cm
is a watershed)
Multi-centric/multi-quadrant disease (not necessar-
ily just multi-focal)
D. Walsh
Failed attempted breast conservation
Desire for a single procedure in a marginally fit
patient
Extensive in situ malignancy
Contraindication/desire to avoid radiotherapy
Local recurrence after prior breast conservation and
radiotherapy
Prophylactic surgery
Patient Preference
Male breast cancer
If mastectomy is contemplated, then a multi-­
disciplinary team opinion is recommended prior to
surgery. Women facing a mastectomy need careful
counselling and the involvement of an experienced
breast care nurse. Locally advanced tumours (T3, 4)
are best offered pre-op systemic neo-­a djuvant
­therapy, rather than attempting a heroic salvage
mastectomy.
44.3.2.1 Technique
• General anaesthesia is required.
• Simple, total mastectomy is employed. No pectoral
muscle resection is required unless there is unan-
ticipated chest wall involvement.
• Marking of skin flaps is important. Prior incisions
and biopsy sites are excised whilst retaining suffi-
cient skin for a tension-free closure. Care with ten-
sion and flap viability is especially important in the
elderly and diabetics.
• If immediate breast reconstruction is planned, then
skin preserving flaps can be planned.
• Skin flaps are dissected at the level of subcutaneous
fat using scissor or cutting diathermy.
• Breast tissue is excised from clavicle, to infra-
mammary fold, leaving bare pectoral muscle.
• Concurrent axillary surgery can be undertaken, or if
mastectomy only is being undertaken, the dissec-
tion of the axillary tail ceases as soon as the clavi-
pectoral fascia is reached.
• The mastectomy specimen is orientated with a
suture placed at 12 o’clock. Tissue should be for-
malin fixed, oestrogen, progesterone and Her2
receptor assays are routinely requested.
• Haemostasis is secured and suction drains placed
under the skin flaps and axilla if dissected.
44 Breast Surgery
• Drains under the mastectomy flaps can be removed
at 48 h, and a temporary breast prosthesis can be
used from this point.
• Chest wall seromas can be drained by simple aspira-
tion, but only if they are symptomatic. Patience is often
needed if seromas are persistent, they will settle.
44.3.2.2 Rural Issues
• Mastectomy, especially with axillary clearance, is
well suited to a rural setting, but a rural setting
alone does not justify treating a breast cancer with
mastectomy.
• Local rural supports are a great asset for women
facing mastectomy, a breast care nurse is worth
their weight in gold.
44.3.3 Sentinel Lymph Node Biopsy
(SLNB)
Essentially, SLNB has two advantages for women with
invasive breast cancer. First, it offers reduced axillary/
arm morbidity compared to formal axillary clearance.
Second, the combination of focused pathology and
immunohistochemical studies performed on SLN
offers better tumour staging. SLNB is most accurate
when performed using a combination of radio lympho-
scintigraphy and patent blue dye. This poses issues for
performing the procedure in the rural practice.
Successful SLNB requires co-ordination of expert
radiology, nuclear medicine specialists and theatre
staff. Surgeons performing SLNB need specific train-
ing in the procedure. Current evidence suggests that
SLNB is indicated for all invasive breast cancers. It
should not be for used for DCIS unless a mastectomy
is being performed. Obviously involved LNs are con-
traindication to SLNB and these cases should proceed
to formal axillary dissection.
44.3.3.1 Technique
• General anaesthesia is usual, but the technique is
easily adapted to local anaesthesia.
• A limited incision of 2–3 cm is employed, usually
transversely just below the hairbearing region of the
337
axilla. If the SLNB has been marked at the time of
lymphoscintography, this can be used to modify the
incision placement.
• The incision is deepened to divide the clavipectoral
fascia at the edge of pectoralis minor, and the axilla
is entered.
• Here blue dye may be seen in lymphatic channels
and these can be traced up to the SLN.
• If no blue dye can be seen, then palpation and the
gamma probe are used to identify the SLN.
• All blue, all hot and all palpable lymph nodes are
considered SLN. They should be carefully
removed, preserving all axillary neurovascular
structures.
• If radio lymphoscintography is used, the initial
gamma probe axillary counts should be reduced by
at least 90% after hot SLN removal. Care needs to
be taken to reduce shine through artefact counts
from the primary tumour injection site.
• Generally, four SLNs is the limit removed, but
removing multiple SLNs does increase the accuracy
of the procedure.
• All SLNs are sent for histological examination,
which should include serial slicing and routine
­epithelial IHC studies.
• After obtaining haemostasis, the wound is closed in
layers. No drain is used.
• If a surgeon cannot identify an SLN confidently,
they and the patient should be prepared to perform
a level II axillary clearance to ensure accurate axil-
lary staging (an axillary LN replaced with tumour
may not take isotope or blue dye).
• Patients with SLNs involved by tumour (including
micrometastases) should be offered a completion
Level II axillary clearance.
• Intra-operative pathological assessment of SLNs is
practised in some centres. It is however, not ­routine
and generally not practical for rural surgeons.
(a) Radio Lymphoscintography
• This procedure requires close co-ordination with an
experienced nuclear medicine service.
• The isotope injection can occur up to 24 h prior to
the SLNB, the dose being adjusted to fit the timing
of surgery.
• Isotope injection technique varies. In Australia, it is
common to inject each quadrant peritumourally,
and if no SLN is seen after 90 min. to perform
a periareolar injection. In the USA, periareolar
­injection is done initially.
338
• SLNs seen on lymphoscintography have their loca-
tions carefully marked on the skin pre-op. A posi-
tive SLN on lymphoscintography correlates closely
with successful identification at surgery.
• Non-palpable tumours may need image-guided
injections.
• A hand-held gamma probe must available in theatre.
• Radiation exposures are minimal to all involved
with standard techniques.
(b) Blue dye
• Patent Blue V (Isosulafan Blue in the USA) is used.
In the author’s experience, Methylene blue does not
work, but different opinions about this exist with
good results when used via periareolar injection.
• Two millilitre of dye is diluted in 2 ml saline and
injected as above, after the induction of anaesthesia,
and the breast is massaged for 5 min.
• Split dye can permanently tattoo the skin.
• Impalpable tumours are usually dealt with by a
quadrant localised injection.
• The dye can interfere with pulse oximetry readings
and cause blue urine.
• Allergic reactions are uncommon (<1%), but poten-
tially catastrophic.
(c) Extra-axillary SLNs
• These occur in approximately 1–5% of cases.
• They will only be identified if radio lymphoscintog-
raphy is used.
• They are controversial; the author’s practice is to
resect such LNs only when no axillary SLN can be
identified.
• LNs in regions such as the supraclavicular fossa can
be resected as per axillary SLNs.
• Internal mammary SLNs are a particular challenge,
as they are usually small, behind the costal carti-
lages and adjacent to the internal mammary vessels,
lung and heart.
• Additional scarring, haemorrhage, pericardial injury
and pneumothorax are potential compli­cations.
• The prognostic significance of extra-axillary SLNs
is not clear.
44.3.3.2 Rural Issues
• The ability to perform SLNB is one of the major chal-
lenges to breast cancer surgery in the rural setting.
D. Walsh
• Timely access to local nuclear medicine facilities
and intra-op gamma probes make radio-guided SLN
localization difficult for many rural surgeons.
• Blue dye alone techniques are possible, but require
formal training and usually a learning period using
radioisotope techniques.
• Case volume will often determine how practical it
is to offer SLNB in a rural setting.
44.3.4 Axillary Clearance
Prior to SLNB, axillary clearance was the benchmark
for axillary staging in breast cancer. Indeed most
studies in breast cancer have based patient prognosis
on information obtained from this procedure. Its
primary role has now been replaced by SLNB and
this has been a challenge for rural breast surgery.
Much of the feared surgical morbidity of breast can-
cer surgery (e.g. lymphoedema) relate to this proce-
dure. Currently LN involvements rates are only
20–30% in breast cancer at diagnosis, and so for most
women this procedure can be avoided. Bulky, fixed
axillary LNs are best treated with pre-op systemic
neo-adjuvant therapy, rather than attempting heroic
procedures.
44.3.4.1 Technique
• General anaesthesia is required.
• A curved skin incision is made just below the bor-
der of the axillary hairbearing area.
• The incision is deepened into the subcutaneous fat
and superior and inferior skin flaps are raised over
3–4 cm to improve access to the axilla. The incision
is considerably more cosmetic if it remains behind
the anterior axillary skin fold.
• The pectoralis muscle lateral border is defined and
the clavipectoral fascia is opened.
• Once the inferior border of the axillary vein is
encountered, this forms the upper margin of dis-
section. Inferior tributaries of the axillary vein
are then divided to begin mobilising the pyramid
of fat and lymph nodes to be removed in the
clearance.
44 Breast Surgery 339

• It is generally accepted that an acceptable axillary • Axillary seromas can be drained by simple aspiration,
clearance involves removal of level I and II nodes. but only if they are symptomatic. Patience is often
This means nodes behind pectoralis minor, but not needed if seromas are persistent, they will settle.
above, are removed. A typical yield would be • Early and full shoulder movements are encouraged
12–15 nodes. immediately.
• Dissection above pectoralis minor medially and the
axillary vein laterally, increases the risk of subse-
quent lymphoedema without oncological benefit.
44.3.4.2 Rural Issues
• In general, the axillary contents are removed in a
complete fascial envelope, down to the axillary tail.
• Axillary clearance is a procedure well suited to
• Removal of the lymph nodes involves a some-
rural practice.
what mystical combination of sharp and blunt
• Management of issues such as care for drains and
dissection, diathermy, sutures, surgical clips and
dealing with post-op seromas is often easier using
judgement.
local rural supports, than it can be achieved in urban
• The thoracodorsal nerve, long thoracic nerve and
surgical practice.
medial pectoral nerve should be identified and pro-
tected. The issue of preserving the sensory intercos-
tobrachial nerves is more controversial, especially Recommended Reading
after a prior SLNB.
• The removed specimen is orientated with an apical
NHMRC Clinical practice guidelines management of early
suture. Many surgeons submit the apical one or two breast cancer. www.nbocc.org.au/bestpractice/resources/
nodes as a separate specimen. CPG124_clinicalpracticeguid.pdf. Published 2001, accessed
• A suction drain is placed and the wound closed in Jan 2010
NHMRC Recommendations for use of sentinel node biopsy in
layers with absorbable sutures.
early (operable) breast cancer. www.nbocc.org.au/bestprac-
• The drain is removed if it becomes non-functional, tice/resources/SNBG_recommendationsforus.pdf. Published
drains <40 ml in 24 h, or after 1 week. 2008, accessed Jan 2010
 Skin Cancer: Current Surgery
for This Common Problem 45
R. Gwyn Morgan

45.1 Skin Malignancies nodule, which with time often shows a central area of
necrosis and crusting formation.
The superficial spreading BCCs present as ery-
Australia has the highest skin malignancy rate in the
thematous plaques or macular lesions whilst the mor-
world. This is almost certainly due to the preponder-
phoeic tumours have more the appearance of an old
ance of fair-skinned individuals in our population and
scar and may have what appears to be skip lesions.
the high ambient solar ultraviolet radiation.
Australians living in rural communities have the
highest incidence of skin malignancies because of
their occupations which subject them to high levels of 45.1.2 Squamous Cell Carcinoma
radiation.
Squamous cell carcinomas (SCCs) of the skin have only
about one-third the incidence of BCCs. But like BCCs
45.1.1 Basal Cell Carcinoma the incidence increases with decreasing latitude. The
highest incidence again is on the face with the dorsum of
the hands and forearms being the next most affected
Basal cell carcinomas (BCCs) are the most common
areas. Bowen’s disease is a variant of squamous cell
skin malignancies seen in Australia, the incidence
­carcinoma in that it is a squamous cell carcinoma in situ.
being inversely related to latitude. Overall, males show
Bowen’s disease is more commonly found on the limbs.
a greater frequency than females. The highest inci-
Bowen’s disease tends to be reasonably well defined
dence is in the areas exposed to the sun with the face
round or oval hyper keratotic plaques and they are usu-
being the commonest site. The paler skins of people of
ally quite erythematous. These lesions are usually long
Northern European origins have the highest incidence.
standing and grow only slowly (Fig. 45.2).
Basal cell carcinomas are clinically of three types, the
SCCs initially have the appearance of an erythema-
nodular lesion, superficial spreading and the mor-
tous nodule and may be surrounded by areas of hyper
phoeic type of tumour (Fig. 45.1a–c).
keratosis. With the passage of time they become
The nodular BCCs and the morphoeic ones tend to
increasingly more tender. Ulceration and bleeding are
occur more frequently on the head and neck whilst the
common in these lesions (Fig. 45.3).
superficial spreading BCCs occur more commonly on
Another lesion that may be confused with the
the trunk and limbs. The differing clinical types of
squamous cell carcinoma is the keratoacanthoma. It
BCCs are quite distinctive, the nodular lesions typi-
is thought by some to be a well-differentiated form
cally presenting as a translucent or pearly papule
of squamous cell tumour; however, these spontane-
ously regress after growing very rapidly initially.
Their distribution is similar to that of squamous cell
R.G. Morgan
Department of Plastic Surgery, The Flinders Medical Centre,
carcinomas.
Bedford Park, SA 5042, Australia The distinguishing feature of a keratoacanthoma
e-mail: drgwynmorgan@gwynmorgan.com.au is the rapid growth with a dome shape that rapidly

M.W. Wichmann et al. (eds.), Rural Surgery, 341

DOI: 10.1007/978-3-540-78680-1_45, © Springer-Verlag Berlin Heidelberg 2011
342 R.G. Morgan

a c

Fig. 45.1 (a) Nodular basal cell carcinoma. (b) Superficial spreading basal cell carcinoma. (c) Morphoeic basal cell carcinoma

Fig. 45.2 Bowen’s disease Fig. 45.3 Squamous cell carcinoma

develops a central keratin plug. These can grow to the appearance of these tumours can be mimicked by a
quite a large size and are very often extremely tender. rapidly growing SCC. If one is suspicious of these,
If one follows these, the keratin plug falls out and the then total excisions of the lesion and histological
lesion resolves, usually leaving a pale scar. However analy­sis are mandatory (Fig. 45.4).
45 Skin Cancer: Current Surgery for This Common Problem 343

SCC metastasis occurs more frequently with

tumours on the hand and face. The factors influencing
metastasis include tumour size (greater than 2 cm),
depth of invasion (greater than 4 mm), the presence of
perineural invasion and the degree of differentiation.
Poorer differentiated lesions are more likely to metas-
tasise. Patients who are immune suppressed are also
more likely to show metastasis.

45.1.4 Merkel Cell Tumours

Merkel cell tumours are an extremely rare and aggres-

sive form of skin cancer that are believed to arise in the
Fig. 45.4 Keratoacanthoma
neuroendocrine cells called Merkel cells. Like the pig-
ment cells, they migrate from the neural crest to the
skin. Their incidence is about 60 times less than that of
melanomas. These tumours are rare in people under
45.1.3 Prognosis of Basal Cell the age of 50 and like all of the other skin cancers are
and Squamous Cell Carcinomas more common in the pale-skinned Northern European
patients.
The prognosis of BCCs depends very much on the site The aetiology is unknown but it does appear to be
and the size and the depth of invasion of the lesion. linked to sun exposure and again the smaller the lati-
The recurrence of basal cell carcinomas has been tude the greater the incidence.
observed to be greater around the facial areas particu- These tumours present as pink or reddish nodule
larly lesions on the nose, eyes and ears. This may well tumours that grow very rapidly over a few weeks or
reflect more conservative excisions in these particular months, rather like keratoacanthomas. More than 50%
regions. of these tumours occur on the head and neck, espe-
Once cartilage or bone is invaded, control of the cially around the eye and the eyelid. The next common
disease may be more difficult because of one’s inabil- areas of occurrence are on the sun-exposed parts of the
ity to accurately define the margins of the tumour. arms and legs. These tumours are not usually painful
Perineural spread particularly from the nose and eyelid and biopsy is usually required to differentiate them
area also carries a graver prognosis as the tumour can from the other skin malignancies (Fig. 45.5).
track along the nerves to the brain.
With SCC the prediction of the prognostic outcome
will be aided by using the TNM classification where T is
the size of the lesion, N is the presence or absence of
involved regional nodes and M is the presence of distant
metastases. This latter factor if present indicates a grave
prognosis. The T classification extends from T1 to T4,
T1 the tumour size less than 2 cm, T2 greater than
2–5 cm, T3 greater than 5 cm and T4 involving deep
extra dermal structures such as cartilage, skeletal muscle
or bone. The presence of nodal metastases significantly
reduces the overall 5-year survival. Perineural spread is
relatively rare in squamous cell tumours, the majority
involving the facial cranial nerves and will necessitate a
much wider excision of the primary lesion. Fig. 45.5 Merkel cell tumour
344 R.G. Morgan

45.2 Melanoma A useful guide for establishing the diagnosis of a

melanoma is the ABCDE guide (Table 45.3).
The differential diagnosis of the amelanotic mela-
Melanoma, if one excludes non-melanoma skin can-
noma is listed in (Table 45.4 and Fig. 45.7).
cer, is the third most common cancer in Australia.
Because in many cases diagnosis is delayed mortality
is higher than it need be. A high index of suspicion
Table 45.2 Differential diagnosis of pigmented melanoma
should be maintained with all pigmented lesions if
Dysplastic naevus
there has been any change in its appearance (Table 45.1
and Fig. 45.6). Spitz naevus
People with dysplastic naevi syndrome or first- Pigmented basal cell carcinoma
degree relatives with melanoma have a significantly Blue naevus
higher risk of developing melanoma. Melanoma dan-
Haemangioma
ger signs are listed in Table 45.1.
Diagnosis can often be difficult and pigmented Pigmented seborrhoeic keratosis
lesions need to be differentiated from pigmented mela-
noma (Table 45.2).
Table 45.3 ABCDE guide for melanoma diagnosis
Table 45.1 Melanoma danger signs
A = Asymmetry
1. Change in size
B = Border
2. Change in colour
C = Colour
3. Change in surface characteristics
D = Diameter
4. Change in consistency
E = Elevation
5. Change in shape or outline
6. Change in surrounding skin
7. Change in sensation
Table 45.4 Differential diagnosis of amelanotic melanoma
8. Sudden appearance of a new pigmented spot in an area Dermatofibroma
that used to be normal
Desmoplastic melanoma
Pigmented basal cell carcinoma
Spindle cell tumour

Fig. 45.6 Malignant melanoma Fig. 45.7 Amelanotic malignant melanoma

45 Skin Cancer: Current Surgery for This Common Problem 345

Table 45.5 Prognostic factors for malignant melanoma For a small pigmented lesion, i.e. 5 mm in diameter
Tumour thickness or less, excision biopsy is the preferred option
Clark level (Fig. 45.8).
The tumour should be marked out with the aid of
Mitosis rate
magnification and then the proposed excision marked
Anatomical local of the tumour out above this.
Ulceration On the face, the orientation of excision should be
Satellitosis along the lines of expression (Fig. 45.9).
Lymphatic invasion

Table 45.6 Ten-year survival of malignant melanoma related

to tumour thickness
Ptis – melanoma in situ 100%
PT1 – melanoma < 0.75-mm thick 99%
PT2 – melanoma < 0.75–1.5-cm thick 90%
PT3 – melanoma < 1.5–3-cm thick 75%
PT4 – melanoma < 3.0-cm thick 55%

45.2.1 Prognosis of Malignant Melanoma

Fig. 45.8 Excision biopsy

In stages I and II of melanoma, where the disease is

localised to the primary lesion site, the tumour thick-
ness is a more objective indicator of prognosis than the
Clark level. Microscopic satellitosis or lymphatic inva-
sions are indicators of a high possibility of occult
regional node metastasis.
The higher the mitosis rate the worse the progno-
sis as is with the presence of ulceration. Tumour
sites where a delay in diagnosis occurs frequently,
such as subungual, sole of the foot and palm of the
hand, scalp and ear, also have a worse diagnosis
(Table 45.5).
The 10-year survival rate for primary melanoma is
closely related to the tumour thickness (Table 45.6).

45.3 General Principles for Excision

of Skin Malignancy

If unsure of the diagnosis a biopsy should be

obtained.
For larger tumours, a punch biopsy of at least 3 mm
is usually adequate. Fig. 45.9 Lines of expression
346 R.G. Morgan

Table 45.7 Recommended excision margins for malignant older patients. Often the margins are quite indistinct
melanoma and careful marking out of the lesion with magnifica-
Ptis melanoma in situ 5 mm tion is recommended (Fig. 45.10).
PT1 or PT2 melanoma 10 mm Many basal cell and squamous cell carcinomas can
0–1.5 cm be excised and the defect closed primarily. On special
PT3 melanoma 1.5–4 cm 10–20 mm areas such as the nose, eyelids and ears skin grafts or
PT4 melanoma >4 cm 20–30 mm
skin flaps may be necessary for closure.
(Excision depth should equal the minimal excision margin)
Full thickness skin grafts are to be preferred in these
areas as they do not contract and will give a better aes-
thetic result. It is possible to place dermis grafts
The margins of clearance depend on the nature of beneath these grafts later to fill in contour defects
the tumour. With BCCs a 3 mm clearance is perfectly (Fig. 45.11a, b).
adequate. With SCCs the recommended margin is Melanoma excision may be followed by direct clo-
4 mm. This also applies to keratoacanthomas, as the sure, graft or flap repair depending on the site and
diagnosis may not be possible until the lesion has been adequacy of excision (Fig. 45.12a, b).
excised. Prophylactic node dissection is not recommended
Merkel cell tumours, being so highly aggressive in the absence of confirmed lymph node involve-
malignant tumours that metastasise early, should ment. Confirmation should be obtained by needle
be given a clearance of at least 3 and 5 cm if biopsy in the first instance or if the surgeon is trained
possible. in the technique then sentinel node biopsy is an
Melanoma in situ requires a 5-mm margin, it should alternative.
be pointed out, however, that the margins of in situ
melanomas are often very indistinct and it is better to
err on a slightly larger clearance.
Melanoma, 0–1.5-mm thick, a 10-mm clearance is
regarded as adequate.
Melanomas thicker than 1.5 mm should have a mar-
gin of at least 2 cm.
For lesions greater than 4 mm, the recommended
margin is 3 cm around the lesion.
The depth of the excision should equal the minimal
excision margin where possible (Table 45.7).
It is imperative that a marker suture for orientation
for reporting by the pathologist is placed in every
specimen. This enables the pathologist, if an incom-
plete excision has been carried out, to supply a dia-
gram to show where the tumour extends to the
margin.

45.3.1 Lentigo Maligna

Lentigo maligna (Hutchinson’s Freckle) is an in situ

melanoma. These lesions are often seen on the face of Fig. 45.10 Lentigo maligna
45 Skin Cancer: Current Surgery for This Common Problem 347

a b

Fig. 45.11 (a) Skin lesion prior to excision. (b) Skin lesion after full thickness skin graft

Subungual melanomas on fingers or toes should be
treated by ray amputation (Fig. 45.13a–c).
In the case of the thumb, disarticulation at the
inter-phalangeal joint along with skin to just prox-
imal to the metacarpo-phalangeal joint will give
adequate clearance. This can then be reconstructed
with a flap such as a groin flap along with a
­n eurovascular island flap from the ring finger to
­p rovide sensation to the new pulp and tip
(Fig. 45.14a–c).
348 R.G. Morgan

a a

b
b

Fig. 45.12 (a) Rotation skin flap for melanoma excision prior Fig. 45.13 (a) Malignant melanoma on fourth toe. (b) Outline of
to surgery. (b) Complete healing after melanoma excision and fourth ray amputation. (c) Surgical result after ray amputation
closure with skin flap
45 Skin Cancer: Current Surgery for This Common Problem 349

Fig. 45.14 (a) Malignant melanoma of the thumb. (b)

Intraoperative finding after resection of the tumour. (c) Result
after r­ econstruction or the thumb
 Pediatric Surgery
Thao T. Marquez, Mara B. Antonoff, and Daniel A. Saltzman
46.1 Introduction
Children can be a unique challenge to the general sur-
geon. They may present with a special set of surgical
problems related to congenital anomalies or specific
to pediatric pathophysiology. Surgical diagnoses that
are common to adults and children require additional
consideration of the age-specific physiology of the
child.
46.2 Pediatric Physiology
and Resuscitation
46.2.1 Age-Specific Physiology
When evaluating a pediatric patient, especially in the
newborn period, important physiologic differences
must be noted. Their smaller size, volume capacities,
and immature organ systems make them physiologi-
cally distinct from adults. When evaluating vital signs
in a child, one must consider age-specific normal
T.T. Marquez and M.B. Antonoff
Senior Resident in Surgery, Department of Surgery,
University of Minnesota, 195 MMC 420 Delaware Street SE,
Minneapolis, Minnesota 55455, USA
D.A. Saltzman (*)
Associate Professor of Surgery and Pediatrics Chief,
Division of Pediatric Surgery, University of Minnesota Medical
School, Surgeon-in-Chief, University of Minnesota Amplatz
Children’s Hospital, 195 MMC 420 Delaware Street SE,
Minneapolis, Minnesota 55455, USA
e-mail: saltz002@umn.edu
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_46, © Springer-Verlag Berlin Heidelberg 2011
46
ranges (Table 46.1). A child’s cardiopulmonary reserve
is large; therefore, hypotension will be a late manifes-
tation of an uncompensated shock state. Infants and
young children are at high risk for hypothermia and
significant hypovolemia from insensible losses; there-
fore, close attention should be paid to maintaining
normothermia, with radiant heaters, and replacing flu-
ids aggressively with warmed solutions.
46.2.2 Fluid Resuscitation
When assessing a child’s fluid replacement needs,
one must assess the child’s preexisting fluid deficits,
ongoing metabolic demands, and ongoing fluid losses.
Volume depletion should be categorized as mild (5%),
moderate (10%), or severe (>15%). Signs and symp-
toms of volume depletion in a child include weight
loss, mental status changes (hyperirritable to lethargy),
elevated heart rate, delayed capillary refill time (>2 s),
dry mucous membranes, dry or sunken eyes, absence
of tears, and a sunken fontanel. For mild volume defi-
cit, and if able, one should consider oral replacement
fluids. Moderate or severe volume depletion should
promptly be replaced intravenously. An initial 20 ml/
kg fluid bolus of isotonic fluid (normal saline or
Lactated Ringers) should be administered. Repeat the
crystalloid bolus once as needed. Additional hypov-
olemia due to blood loss should be replaced with
packed red blood cells at 10 ml/kg, repeated as needed
once. Goals of fluid resuscitation include correction of
water deficits, electrolyte abnormalities, and metabolic
acidosis. Following initial fluid resuscitation, the child
should be placed on age and weight appropriate IV
maintenance fluids.
351
352 T.T. Marquez et al.

Table 46.1 Normal pediatric vital signs 46.3 Abdominal Pathology

Age Heart Blood Respiratory
rate pressure rate
Premature 120–170 55–75/35–45 40–70 46.3.1 Evaluation of the Pediatric
0–3 months 100–150 65–85/45–55 35–55
Acute Abdomen
3–6 months 90–120 70–90/50–65 30–45
History taking is complex in the ill child and often the
6–12 months 80–120 80–100/55–65 25–40
parent must relay symptoms for their child, a difficult
1–3 years 70–110 90–105/55–70 20–30 task. One should obtain as best as possible the time
3–6 years 65–110 95–110/60–75 20–25 frame and duration of abdominal symptoms. Oral
intake, to include their most recent meal, as well as
6–12 years 60–95 100–120/60–75 14–22
symptoms of nausea and vomiting should be assessed.
12+ years 55–85 110–135/65–85 12–18 The character (e.g., bilious, projectile), frequency, and
amount of emesis should be noted. Evidence of bowel
inflammation should be documented (blood/mucous in
46.2.3 Vascular Access stools) as well as any diarrhea, constipation, and
change in stooling pattern should be noted. Subjective
Vascular access in the child and infant can be chal- increase in abdominal girth, fevers, and sick contacts
lenging. Vascular access procedures are one of the should also be queried.
most commonly performed procedures by pediatric An important initial component of the physical
surgeons. Peripheral access sites are initially attempted. exam is observation. Does the child appear sick? Is it
These include the superficial dorsal veins of the hands lethargic? Abnormal vital signs should be noted and
and feet. In infants, scalp vein including the superfi- reassessed frequently. Anxiety, fear, and crying can
cial temporal, supratrochlear, and posterior auricular make the abdominal exam challenging. Increased cry-
veins are options. If peripheral IV access cannot be ing/fussing with abdominal exams could indicate ten-
accomplished, and dependent on the urgency of the derness. Evaluate for focal tenderness, with diffuse
clinical scenario, other vascular options exist such peritonitis often resulting in involuntary guarding or
as interosseous access, peripheral vein cut-down, or rebound tenderness. The abdomen should be inspected
central venous access. for distension and percussed. The inguinal areas as
Interosseous access can provide rapid access to the well as a rectal exam should always be performed in a
venous system in the acute emergency setting. This child with abdominal pain.
allows for fluid resuscitation, blood sampling for
laboratory data, and the administration of drugs. The
proximal tibia is the ideal site for interosseous access. 46.3.2 Adjunct Studies in the Pediatric
A 15–18 gauge, half long bone marrow aspirate needle
Patient
is inserted approximately 2 cm below the tibial tuber-
osity at a 45–60° angle inferiorly, away from the
growth plate. Other less common sites for interosseous Laboratory tests often supplement the clinical history
access are the distal tibia and fibula, sternum, and iliac and physical exam. A complete blood count, chemistry
crest. Contraindications include fracture or infection panel, and inflammatory markers Erythrocyte Sedi­
near the proposed insertion site, osteoporosis, and mentation Rate and C-Reactive Protein are often
osteogenesis imperfecta. Peripheral vein cut-downs obtained. Urinalysis should also be performed. Abdo­
(via greater saphenous, median basilic, or cephalic minal radiographs are commonly helpful to evaluate
veins) can be attempted given each surgeon’s comfort obstruction, constipation, and the evaluation for free
level/discretion. Central venous access in children is air in the setting of an acute abdomen. Evaluation with
often referred to a pediatric surgeon. CT imaging can be utilized, with care to minimize
46 Pediatric Surgery
unnecessary ionizing radiation for children. Adjunct
studies such as contrast enemas and abdominal ultra-
sounds often aid in the diagnosis.
46.3.2.1 Specific Disease Processes
Appendicitis
Pediatric appendicitis occurs at a mean age of
10–12 years and is rare in those <5 years old. Perforation
occurs commonly between 12 and 24 h after onset of
symptoms with a perforation rate approaching 35–45%
in the pediatric population, with perforation rates as
high as 65% in those under 5 years of age. History and
clinical exam by a surgeon can accurately diagnose
appendicitis in up to 80% of cases. Presenting symp-
toms commonly include abdominal pain, nausea +/−
vomiting, anorexia, and fevers. Local tenderness often
can be elicited over McBurney’s point or there may be
evidence of diffuse peritonitis following appendiceal
perforation. Evaluation with ultrasound or CT imaging
can further confirm the diagnosis of appendicitis, how-
ever, should be reserved only for cases where the diag-
nosis of appendicitis is unclear. A palpable abdominal
mass should be further evaluated with imaging.
Treatment of appendicitis includes IV resuscitation,
IV antibiotics and appendectomy for early acute
appendicitis without complications such as a phleg-
mon or abscess. Open versus laparoscopic appendec-
tomy approach should be based upon surgeon
experience and skill.
Hernias
The incidence of inguinal hernias in children ranges
from 0.8% to 4%, with a higher incidence in premature
infants (16–25%). Hernias most commonly occur on
the right with a 3–10:1 male to female ratio. A patent
processus vaginalis results in a congenital inguinal
hernia. It is recommended that all hernias in children
be repaired due to the risk of incarceration. Evidence
of incarceration or ovarian contents at any age should
be repaired emergently. High ligation of the hernia sac
at the level of the internal inguinal ring should be
353
performed. Each surgeon should weigh the risks and
benefits of contralateral exploration based on their per-
sonal experience and expertise.
Abdominal Wall Defects
Umbilical hernias are common reasons for children to
present to a surgeon (incidence 10–25%). A majority
of umbilical hernias close spontaneously by age 4.
Evidence of incarceration or strangulation (rare)
prompts emergent repair. Operative repair is recom-
mended after age 4 or if the defect is larger than
1.5–2 cm. The fascial defect should be repaired pri-
marily with running suture. Other abdominal wall
defects include gastroschesis and omphalocele. For
these conditions, referral for definitive care of these
children to a pediatric surgeon and dedicated children’s
hospital is recommended. As neonates with either gas-
troschesis or omphalocele can have a significant risk
of evaporative fluid losses due to exposed abdominal
contents/hernia sac, it is paramount to keep these new-
borns warm. Place the child in a sterile bowel bag to
the axillae. An NG tube should also be placed for
decompression of the gastrointestinal tract, early IV
access must be established, and the child requires fluid
resuscitation prior to transfer.
46.3.2.2 Obstructive Processes
Pyloric Stenosis
Hypertrophic pyloric stenosis (HPS) is a common sur-
gical condition of infancy, presenting in 3/1,000 live
births. The precise etiology remains unknown despite
many theories (e.g., abnormal endocrine signals, work
hypertrophy, neurologic immaturity, or degeneration,
etc.). HPS commonly presents as non-bilious, projec-
tile vomiting in a child 3–6 weeks of age. An epigas-
tric mass or “olive” can typically be palpated. These
children are often hypovolemic with a metabolic alka-
losis. The study of choice to confirm the diagnosis is
an abdominal ultrasound. HPS will often have US
findings of a pyloric channel length greater than
15 mm and pyloric muscle thickness >4 mm. If the
354
ultrasound is inconclusive or there is concern for gas-
troesophageal reflux or malrotation, an upper GI
endoscopy should be performed. Following adequate
resuscitation to correct any electrolyte abnormalities,
the child should be taken to the operating room for an
extramucosal pyloromyotomy. Surgeon preference
and expertise should dictate operative approach (open-
subcostal or periumbilical incision vs. laparoscopic).
Postoperative recovery is typically rapid with ability
to feed 6 h postoperatively if there was no concern for
mucosal disruption.
Intussusception
Intussusception refers to the prolapse of one segment
of bowel (the intussusceptum) into the lumen of an
adjoining segment (the intussuscipiens). In the ­pediatric
population, intussusception most frequently involves
the distal ileum invaginating into the coecum. The nat-
ural course of intussusception includes bowel obstruc-
tion and progressive bowel ischemia.
Infants and toddlers represent the most commonly
affected age group. An identifiable anatomic lead-
point for intussuception is uncommonly found in
children. Most cases are idiopathic, and thought to be
the result of hypertrophic Peyer’s patches in the face
of viral gastrointestinal illness. Presentation fre-
quently includes severe, intermittent abdominal pain,
accompanied by vomiting and the passage of bloody
mucous (red currant jelly) per rectum. A “sausage-
shaped” mass has been described in the right
abdomen.
For infants with suspected instussusception, barium
(or air-contrast) enema is recognized as the gold stan-
dard for diagnosis, and additionally may provide ther-
apeutic reduction, as well. This should be performed
with a surgeon present, with the column of barium no
greater than 3 ft high (app. 1 m), and with no greater
than three attempts made.
Indications for surgery include failure of enema
reduction as well as initial presentation with peritoni-
tis, sepsis, or suspicion of bowel necrosis. Access
is gained through a right-lower quadrant incision.
Appli­cation of retrograde pressure by squeezing the
intussusceptum proximally within the intussuscipiens
should be attempted. Resection should be performed if
the intussusception cannot be reduced, if the reduced
T.T. Marquez et al.
bowel appears nonviable, or if an anatomic lead-point
is identified.
Bowel Atresia
Duodenal atresia is felt to be due to a failure of reca-
nalization of the lumen in utero. Its presentation resem-
bles that of other sources of proximal obstruction, with
bilious vomiting on the first day of life and a “double
bubble” sign seen on abdominal plain film. Annular
pancreas and duodenal web will present similarly.
Surgical treatment is nearly always indicated, and the
operation of choice is a duodenoduodenostomy. This is
usually performed with a proximal transverse duode-
notomy and a longitudinal distal duodenotomy, fol-
lowed by anastamosis.
In contrast to more proximal atresias, jejunal and
ileal atretic segments result from in utero vascular
accidents. The affected bowel subsequently becomes
fibrotic or is entirely absorbed. Infants may present
bilious vomiting in the first week of life, abdominal
distention, and failure to pass meconium. Abdominal
films will reveal dilated loops of bowel with air/fluid
levels, and barium enema will show a small unused
colon. Following appropriate resuscitation, the infant
should be explored surgically. After identifying the
area of atresia, the distal bowel should be opened and
examined to rule out distal atresias. Prior to perform-
ing primary anastomosis, the dilated proximal segment
should be tapered. The bowel should be run to exclude
any synchronous lesions.
Malrotation
Normal midgut anatomy results from in utero events
including 270° of counterclockwise rotation and fixa-
tion of the cecum in the right iliac fossa and the duode-
nojejunal junction at the ligament of Treitz. Insufficient
rotation (180°) or nonrotation may occur, followed by
inappropriate fixation via adhesions known as Ladd’s
bands. This can result in a narrow-based mesentery,
leaving the bowel vulnerable to volvulus, ischemia,
and loss of bowel supplied by the superior mesenteric
artery.
Patients with malrotation and midgut vovulus may
present with abdominal pain, bilious emesis, and
46 Pediatric Surgery
radiologic suggestion of small bowel on the right side
of the abdomen, with the colon and coecum residing
on the left. With suspicion of volvulus, urgent laparo-
tomy is indicated in order to prevent loss of viable
bowel. Operative repair includes resection of any com-
promised bowel, followed by a Ladd’s procedure: (1)
detorsion of the midgut, (2) division of abnormal peri-
toneal attachments (Ladd’s bands), (3) broadening of
the mesenteric vascular pedicle, and (4) incidental
appendectomy to prevent future confusion due to
unusual anatomy. If time permits referral for definitive
care of these children to a pediatric surgeon and dedi-
cated children’s hospital may be necessary.
46.3.2.3 Complex Abdominal Pathology
Stabilization
Children may present with a variety of complex abdom-
inal pathologies, including, among other diagnoses,
Hirschsprung’s Disease, necrotizing enterocolitis,
imperforate anus, small left colon syndrome, and intes-
tinal duplication. Regardless of the diagnosis, it is the
role of the general rural surgeon to achieve stabilization
followed by timely transfer to definitive care.
Resuscitation
Children with obstructive processes, perforation, or
abdominal sources of sepsis should have adequate
vascular access, resuscitation to euvolemia (as assessed
by age-appropriate urine output), initiation of nutri-
tional supplementation, nasogastric decompression if
obstructed, and appropriate antimicrobial therapy for
bowel perforation or infectious etiologies.
Diversion/Decompression
Patients with atresias and other anatomic causes of
obstruction may need to be temporarily diverted prior
to definitive management. Depending on the circum-
stances of transfer to definitive care, including dis-
tance, availability of transportation, and availability of
receiving pediatric surgeon, diversion of enteric stream
may be appropriate prior to transfer. Depending on the
355
child’s specific anatomy, this may be accomplished by
diverting loop ileostomy.
When to Transfer
All patients with complex abdominal pathology should
be transferred to centers with pediatric surgeons and
the availability of a pediatric critical care unit. Patients
should be stabilized prior to transfer; however, transfer
should not be delayed for diagnostic studies.
46.4 Genitourinary Pathology
46.4.1 Circumcision
Circumcision is a common procedure performed by a
variety of practitioners (surgeons, pediatricians, obste-
tricians, family practitioners). A general anesthetic is
advised for boys greater than 6 weeks of age with local
anesthesia in the form of a penile block for adoles-
cents. Operative approaches include the dorsal slit
circumcision, adjunctive devices such as the Gomco
clamp or Plastibell®, or free hand sleeve circumcision.
The circumcision suture line is covered with antibiotic
ointment, which should be continued twice daily for
7–10 days.
46.4.2 Torsion
Testicular torsion presents as acute, unrelenting scrotal
pain with swelling. It may have associated nausea and
vomiting. Physical exam should attempt to rule out
other etiologies of scrotal pain such as inguinal hernia,
epididymitis (non-tender testes with posterior tender-
ness at the site of the epididymis), or torsion of the
appendix testis (upper pole testicular tenderness with
blue nodular discoloration – “blue dot sign”). Diagnosis
is confirmed with a doppler flow ultrasound. Attempt
at manual detorsion should be made to preserve tes-
ticular viability. Emergent exploration should always
be performed for suspected torsion, even with success-
ful manual detorsion. Exploration is through a midline
356
raphe incision. If the involved testicle is viable, bilat-
eral orchidopexy should be performed by suture fixa-
tion of the tunica to the dependent scrotum. If obvious
necrosis is present, the testicle should be removed.
46.4.3 Hydrocele
A hydrocele in a child is the result of a patent or
delayed closure of the processus vaginalis. It is a cystic
mass, which transilluminates, and is non-tender.
Simple hydroceles should be observed as most resolve
by age 1. Aspiration of a hydrocele is contraindicated.
Persistent hydroceles beyond age 1, or communicating
hydroceles should be repaired via an inguinal
approach.
46.5 Thoracic Pathology
46.5.1 Evaluation and Differential
Diagnosis
There are a number of congenital thoracic abnormalities
that may occur in a neonate, including diaphragmatic her-
nia, lobar emphysema, cystic adenomatoid malformation,
pulmonary sequestration, bronchogenic cysts, esophageal
atresia, and tracheoesophageal fistula.
Esophageal atresia is strongly suggested when
there is difficulty in passing a nasogastric tube, and
the tube is seen to coil in the proximal esophageal
pouch on X-ray. Congenital diaphragmatic hernia
may be suspected in a neonate with respiratory dis-
tress, and may be confirmed with X-ray findings of
air/fluid filled loops of bowel in the chest and medi-
astinal shift. In general, clinical clues to thoracic
pathology include difficulty with breathing and oral
intake. Helpful information may be found on plain
radiograph alone, but diagnosis may require further
studies such as a water soluble upper GI contrast
series and chest tomography.
46.5.2 Stabilization
Patients unable to ventilate independently should have
definitive airways established and receive ventilatory
T.T. Marquez et al.
support. Nutrition should be provided enterally or par-
enterally, as appropriate.
46.5.3 Transfer to Definitive Care
Regardless of the etiology, patients with thoracic sur-
gical pathology should be transferred to facilities with
pediatric surgeons and the ability to provide multidis-
ciplinary and critical care. This transfer should occur
as soon as the patient has been stabilized, even if a
definitive diagnosis has not been reached.
46.6 Pediatric Trauma
46.6.1 Initial Assessment
Children with traumatic injuries should be evaluated
under the same principles of Advanced Trauma Life
Support which are used for adults, beginning with a
primary survey and adjunctive studies, followed by a
secondary survey.
46.6.2 Primary Survey
During the primary survey, the patient is examined sys-
tematically, with efforts directed toward identifying life
threatening injuries and addressing them immediately
as they are found. It is always conducted in the same
sequence, easily remembered by alphabetical order: (1)
Airway, (2) Breathing, (3) Circulation, (4) Disability,
and (5) Exposure, where stabilization of the cervical
spine takes place as part of the airway evaluation.
46.6.3 Airway
The first priority in managing an injured child (or any
patient) is establishment and maintenance of an ade-
quate airway. This may be as simple as performing
a jaw thrust maneuver or placement of a nasal/oral
airway. Children with cyanosis, tachypnea, GCS < 8,
or otherwise unable to protect their own airway require
intubation. A good rule is to use ETT size of child’s
fifth finger. With severe maxillofacial trauma or
46 Pediatric Surgery
inability to place endotracheal tube, a surgical airway
may be needed. All patients should have supplemen-
tary oxygen and cardiopulmonary monitoring. A chest
X-ray confirms endotracheal tube placement and can
be used to rule out hemo/pneumothoraces.
46.6.4 Breathing
Children should have breathing assessed by inspection
for asymmetrical chest wall excursion, increased work
of breathing, nasal flaring, retractions, anxiety, and tac-
hypnoea. Subsequent auscultation confirms appropriate
breathing mechanics. Chest X-rays may reveal hemo-
or pneumothoraces. Tension pneumothoraces should be
immediately managed by needle thoracostomy in the
second intercostal space, mid-clavicular line, followed
by tube thoracostomy, the definitive management for
hemothorax and pneumothorax. This should be placed
in the fifth intercostals space at the midaxillary line.
Because of pliability of a child’s ribs, significant pul-
monary injury can occur without rib fracture.
46.6.5 Circulation
Children may demonstrate normal blood pressures
despite losses of up to 40% of their blood volume;
therefore, clinical indicators can be helpful in deter-
mining the volume status in a pediatric patient. These
include level of consciousness, temperature/mottling
of extremities, capillary refill, pulse pressure, heart
rate, and respiratory rate. During assessment, venous
access should be obtained with two large-bore IV’s.
Difficulty with obtaining peripheral venous access
should not delay resuscitation. In difficult cases,
saphenous vein cut-down, femoral venous cannula-
tion, and interosseous catheters can provide vascular
access. Fluid resuscitation should be initiated with
20 ml/kg of crystalloid, which may be repeated once.
Subsequent fluid resuscitation, if needed, should
include 10 ml/kg of type-specific red blood cells.
46.6.6 Disability
In the primary survey, the disability evaluation involves
assignment of a Glasgow Coma Score, using a modi-
fied version of the scoring system for young children
357
as appropriate. Children should also be assessed at this
time for gross sensorimotor deficits and have a pupil-
lary examination.
46.6.7 Exposure
All items of clothing are removed, the child is ­carefully
examined for outward signs of injury, and care is taken
to warm the child and maintain normothermia.
46.6.8 Secondary Survey
The secondary survey consists of a systematic head-to-
toe physical examination to recognize all injuries,
including minor or occult injuries that may not have
been apparent on the primary survey.
46.6.9 Stabilization
If, at any point during evaluation, the child decompen-
sates or deteriorates in any way, the primary survey
should be repeated, going back systematically to air-
way first. Prior to transferring a child to definitive care,
the airway should be secured, the child should be
adequately breathing or receiving ventilatory support,
fluid resuscitation should be initiated through appro-
priate vascular access, and the child should be exposed
and warmed. Obtaining a chest X-ray as part of the
airway and breathing evaluation, placing a nasogastric
tube with intubation, and placement of a Foley catheter
during evaluation of circulation are all additional
appropriate steps. Transfer to definitive care should not
be delayed for any detailed imaging or further
workup.
46.6.10 When to Transfer
Children with significant injury should be transferred
to trauma centers as soon as they are stabilized.
Transfer should be preceded by physician-to-physician
communication.
358
Recommended Reading
American College of Surgeons Committee on Trauma: Extremes
of age: pediatric trauma. In: Advanced Trauma Life Support
for Doctors Student Course Manual, 7th edn. American
College of Surgeons, Chicago (2004)
Dalla Vecchia, L.K., Grosfeld, J.L., West, K.W., et al.: Intestinal
atresia and stenosis: a 25-year experience with 277 cases.
Arch. Surg. 133, 490–497 (1998)
Kavoussi, L.R., Novick, A.C., Partin, A.W., et al.: Wein:
Campbell-Walsh Urology, 9th edn. Saunders Elsevier,
Philadelphia (2007)
Kleigman, R.M., Behrman, R.E., Jenson, H.B., et al.: Nelson
Textbook of Pediatrics, 18th edn. Saunders Elsevier,
Philadelphia (2007)
Ladd, W.E.: Congenital obstruction of the duodenum in chil-
dren. N. Engl. J. Med. 206, 277–283 (1932)
T.T. Marquez et al.
McCollough, M., Sharieff, G.Q.: Abdominal pain in children.
Pediatr. Clin. N. Am. 53, 107–137 (2006)
Mittenburg, D.M., Nuchtern, J.G., Jaksic, T., et al.: Laparoscopic
evaluation of the pediatric inguinal hernia-a meta-analysis.
J. Pediatr. Surg. 33(6), 874–879 (1998)
Ravitch, M.M.: Intussusception in infancy and childhood: an
analysis of seventy-seven cases treated by barium enema.
N. Engl. J. Med. 259, 1058 (1958)
Stone, K., Humphries, R.: Current Essentials of Emergency
Medicine. McGraw-Hill, New York (2005)
Tepas, J.J., Ramenofsky, M.L., et al.: The pediatric trauma score
as a predictor of injury severity: an objective assessment.
J. Trauma 28, 425–429 (1988)
Young, D.G.: Intussusception. In: O’Neill Jr., J.A., et al. (eds.)
Pediatric Surgery, 5th edn, pp. 1185–1198. Mosby, St Louis
(1998)
Ziegler, M.M., Azizkhan, R.G., Weber, T.R.: Operative Pediatric
Surgery. McGraw-Hill, New York (2003)
 Vascular Surgery: Acute Limb Ischaemia
Mark Hamilton
47.1 Introduction
The management of the acutely ischaemic limb remains
a challenge for even experienced vascular surgeons.
This chapter aims to give rural or remote surgeons a
straightforward algorithm for the management of the
acutely critical ischaemic limb, and some guidance in
the operative techniques utilised in the management of
these patients. Clearly many of these issues are best
dealt with in a more appropriate centre; however, we
recognise that this is not always feasible and this chap-
ter aims to assist in the local management of these
problems.
47.2 Acute Upper Limb Ischaemia
Acute upper limb ischaemia is a less common presenta-
tion than lower limb acute ischaemia and remains a rela-
tively prevalent presentation in the elderly population
with underlying cardiac co-morbidity in particular. The
natural history of upper limb acute ischaemia is more
benign than lower limb acute ischaemic insult due to the
presence of extensive collaterals around the shoulder
and elbow; however, it still requires operative interven-
tion in a significant proportion of presentations.
The indications to intervene in the acute setting are
similar to those in the lower limb, particularly, advanced
signs of ischaemia including ischaemic rest pain,
numbness and paraesthesia and evidence of evolving
muscle damage (muscle tenderness).
M. Hamilton
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: mark.hamilton@health.sa.gov.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_47, © Springer-Verlag Berlin Heidelberg 2011
47
The vast majority of upper limb ischaemic events
are related to embolisation; however, trauma is also a
common presentation.
47.3 Acute Lower Limb Ischaemia
47.3.1 Definition/Classification
See Rutherford scale (Table 47.1).
47.3.2 Aetiopathogenesis
The common aetiologies of acute limb ischaemia
include embolism, trauma, thrombosis, arterial
dissection and the rarer and more esoteric causes
such as the non-atherosclerotic popliteal artery
pathologies.
The commonest cause of acute limb ischaemia is
embolism, the predominant pathology being atrial
fibrillation (AF), and is prevalent in the elderly popu-
lation. Approximately 80% of acute limb ischaemia
from embolic sources is related to AF. Other patholo-
gies causing embolic ischaemia include patients post
acute myocardial infarction (MI). This usually occurs
within the first few days to weeks post MI and is asso-
ciated with the increased thrombogenicity of infarcted
myocardium, as well as areas of dyskinesia or akinesis
within the ventricle.
Embolic events secondary to rheumatic fever, strep-
tococcal valvular disease and septic emboli from
subacute bacterial endocarditis (SBE) have become
uncommon.
359
360
Table 47.1 Rutherford scale for classification of acute limb ischaemia
Category Description Capillary
return
I – Viable Not immediately Intact
threatened
IIa – Threatened Salvageable if treated Intact/slow
promptly
IIb – Threatened Salvageable if Slow/absent
treated immediately
III – Irreversible Unsalvageable Absent/dermal
fixed staining
Atheroembolic disease from aortic plaque or throm-
bus is more commonly a cause of lower limb than
upper limb symptoms, the presentation is more classi-
cally that of the ‘blue toe syndrome’ or small areas of
infarcted or ischaemic digital skin. Imaging often
reveals a significantly diffusely diseased aorta from
arch through the thoracic and abdominal segments.
Atheroembolic disease of the arch and ascending aorta
may present as TIA or upper limb acute ischaemic
symptoms.
Aneurysm disease and post stenotic dilatation of
arteries is most commonly seen in patients with popliteal
or aortic aneurysmal disease where chronic embolisa-
tion from a thrombus-lined aneurysm is the primary
pathology. This also occurs in the upper limb in patients
with thoracic outlet syndromes and subclavian/axillary
artery compression and stenosis. Development of a post
stenotic aneurysm is more common in the upper limb
than true aneurysms, which are rare.
Acute on chronic occlusive disease occurs as a cause
of acute ischaemia in patients with established periph-
eral arterial disease where they develop acute deteriora-
tion in their limb perfusion secondary to occlusion of a
pre-existing stenosis or extension of a segmental occlu-
sion. This will occasionally occur in association with
an inciting stimulus such as intercurrent surgery or ill-
ness, or prothrombotic state. Often this situation does
not lead to immediately limb-threatening ischaemia
and the situation can be managed conservatively with
anticoagulation and re-assessment. It does make diag-
nosis of the primary aetiologic mechanism difficult.
Thrombotic causes are mainly related to acute
occlusion of either vascular grafts or limb aneurysms.
Graft thrombosis/occlusion occurs in the setting of a
patient with a pre-existing bypass graft where there
M. Hamilton
Muscle Sensory loss Doppler signals
paralysis Arterial Venous
None None Audible Audible
None Partial Inaudible Audible
Partial Partial/complete Inaudible Audible
Complete/tense Complete Inaudible Inaudible
compartment
are a number of possible causes of acute graft thombo-
sis. These include failure of the runoff or inflow of the
graft, or in-graft stenosis. Patients with severe periph-
eral arterial disease (PAD) often develop deterioration
of their distal circulation over time and in the absence
of graft surveillance, the graft may fail. Similarly with
vein grafts, in-graft stenosis may go unnoticed in the
absence of surveillance until such a time as flow rates
within the graft fall below the thrombotic threshold
velocity with subsequent graft occlusion. Development
of further occlusive disease proximal to the graft can
similarly lead to graft occlusion. Unfortunately, in
grafts that have been performed for critical limb
ischaemia, the limb is often profoundly ischaemic
when the graft occludes, compared with grafts per-
formed for claudication. Thrombosis of peripheral
arterial aneurysms, in particular popliteal aneurysms,
occurs because aneurysm of the popliteal artery often
goes unnoticed until such time as it thromboses and
the limb becomes acutely ischaemic. Unfortunately,
by the time this occurs, it is usually the sequela of
chronic embolisation to the tibial arteries and if this is
the case, there are frequently no or very limited recon-
structive options.
Note: Early detection of popliteal aneurysms, and
elective treatment of aneurysms >2–2.5 cm in
diameter or with significant thrombus load remains
the ideal treatment.
Occasionally, in the setting of a preserved runoff cir-
culation, a non-threatened limb (Rutherford Grade 1)
and the availability of interventional radiology facilities,
47 Vascular Surgery: Acute Limb Ischaemia
intra-arterial thrombolysis may be a useful adjunct to
limb salvage surgery in acute thrombosis of the popliteal
artery.
Thrombophilias and Paraneoplastic syndromes are
another non-mechanical cause of thrombosis of the
arterial tree. The treatment of these pathologies is
based on managing the underlying disorder when the
acute limb has been managed. The outcomes from
patients presenting with these pathologies are gener-
ally worse than those from trauma or embolism due to
the other systemic aspects of their underlying condi-
tion. Thrombophilias in particular pose problems in
regards to revascularisation and maintenance of pat-
ency of grafts in the perioperative period. The paraneo-
plastic thrombophilias usually improve once the
underlying malignancy is dealt with.
Dissection of the thoracic aorta can lead to either vis-
ceral or lower limb ischaemic symptoms that can be
either fixed or dynamic in nature. The most common
scenario causing acute lower limb ischaemic is the exten-
sion of the dissection into the iliac artery and compres-
sion of the true lumen by a pressurised false lumen. Less
commonly, the dissection may extend to the femoral
vessels. Embolisation may also occur from dissection
flaps or rupture of the false lumen. Traumatic dissection
of the abdominal aorta as an isolated pathology is seen in
relation to seatbelt injuries in motor vehicle accidents
and should always be considered in patients with signifi-
cant seat belt bruising, lumbar spine fractures or other
visceral injuries consistent with a compressive mecha-
nism. Acute lower limb ischaemia in this setting is some-
times mistaken for traumatic paraplegia/paralysis.
The non-atherosclerotic/aneurysmal popliteal artery
pathology includes popliteal artery entrapment and
adventitial cystic disease. These are relatively rare and
the management of an acutely ischaemic limb in these
situations should follow standard management principles
with heparinisation and revascularisation as required.
Compartment syndrome is a further cause of acute
limb ischaemia. Acute compartment syndrome is defined
as an elevation in intra-compartmental pressures to above
the normal physiological pressure within that tissue
compartment, leading to a detrimental effect on tissue
perfusion in that compartment. Compartment syndrome
in the setting of orthopaedic or vascular trauma, or reper-
fusion injury can have catastrophic consequences if not
recognised. A low threshold for performing fasciotomy
is necessary in the acutely ischaemic limb.
361
Note: Reperfusion after >6 h of ischaemia almost
mandates fasciotomy at the time, and certainly
regular clinical assessment of the patient in the first
24–48 h post-revascularisation is required to mini-
mise the risk of missed compartment syndrome.
47.3.3 Diagnosis
The diagnosis of acute limb ischaemia remains largely
a clinical diagnosis, with investigations augmenting
the history where it is unclear what is going on.
The history is usually quite classical and is that of
an acute onset painful limb with altered sensorium and
motor impairment. There is usually a temperature dis-
crepancy described by the patient. This may be worse
than the pre-existing symptoms in patients that have
claudication or a past history of Peripheral Arterial
Disease (PAD). Pain is often resistant to opioid analge-
sia. The clinical findings are those of a pulseless cool
limb with some difference to the contralateral limb.
There will be sensorimotor abnormalities that progress
over time, and are worse with more proximal large
vessel occlusion. With advanced ischaemia, skin
changes occur with initial reversible mottling advanc-
ing to fixed staining (this sometimes appears similar
to a ‘port wine stain’).
A number of investigations are useful and include
bedside tests, and imaging procedures. Bedside tests
include the use of a hand held static/pencil Doppler to
determine the presence or absence of distal pulse wave
forms. In an ischaemic limb, this is helpful in differen-
tiating the degree of severity using the Rutherford crite-
ria. It is also a useful tool to determine whether there is
likely to be a target vessel to revascularise in the situa-
tion of an acutely ischaemic limb. Occasionally placing
the limb in a dependant position and checking the
Doppler signals over the dorsalis pedis, peroneal or pos-
terior tibial arteries can demonstrate a signal in a patent
vessel where none was audible with the patient supine.
Non-invasive imaging modalities include ultra-
sound, CT and MR Angiography. Duplex ultrasound
has the limitation of being operator dependant, but it
does give useful information about level of occlusion,
and presence of other disease. It is useful in the diag-
nosis of peripheral aneurysmal disease, and offers the
362
ability to scan for a conduit for repair of a vessel if
required. It has limited utility in the diabetic patient,
those with extensive calcification, and of obese body
habitus (particularly in imaging proximal or abdomi-
nal vessels). It can be time consuming to perform and
should only be utilised in patients with a minimally
ischaemic limb. CT Angiography has become the
imaging modality of choice in many institutions, and
has the advantage of being able to image from the aor-
tic arch to the foot in one to two acquisitions, taking
minimal time. It is able to be reformatted into coronal,
sagittal and 3D formats on readily accessible worksta-
tions and allows planning of intervention with a high
degree of accuracy. Most institutions now have a
multi-detector spiral CT scanner that will allow 1-mm
slices, and thus, the spatial resolution of CT is almost
as good as catheter angiography. It is sometimes lim-
ited by the presence of heavy calcification, and does
require a contrast bolus, so it may be relatively con-
traindicated in patients with renal impairment. In
these patients, however, the utility of the modality
sometimes outweighs the risk of worsening renal
function, employing adjunctive measures such as pre-
hydration, N-acetyl cysteine, etc. The patient with
mild-to-moderate impairment of renal function can
still be safely imaged using CTA. MR Angiography
shares a number of similarities to CT Angiography
and has the ability to acquire volumetric data which
can be formatted in a number of planes. It gives simi-
lar anatomical detail, and is less limited by moderate
calcification. There are limitations in the patients who
can have MRI scans (pacemaker, claustrophobia,
metal foreign body, etc.), and Gadolinium contrast is
not as benign as previously thought – especially in
patients with established dialysis-dependant renal
failure in whom nephrogenic systemic fibrosis (NSF)
has been reported.
Invasive imaging with catheter angiography remains
the gold standard investigation for both chronic and
acute limb ischaemia and can be performed either prior
to an intervention or after revascularisation to confirm
adequate clearance of clot from distal vessels. Catheter
studies can be performed in a dedicated angio suite, or
on-table at the time of surgery with a portable C-arm
image intensifier. Catheter angiography also allows for
the administration of intra-arterial thrombolytic agents
and the placement of balloons and stents; thus, it has
the advantage of being a therapeutic as well as diag-
nostic modality.
M. Hamilton
47.3.4 Initial Management
Simple medical therapy should not be neglected in
these patients; they usually have multisystem disease
processes and the overall optimisation of the patient’s
medical status is imperative. Analgesic therapy in crit-
ical limb ischaemia will usually require intravenous
opioid analgesia to alleviate symptoms. In proximal
acute vessel occlusion, this will still often be inade-
quate and the rapid restoration of arterial supply is the
best therapy. Antiplatelet therapy should be instituted
as part of an overall best medical therapy approach to
managing patients with peripheral arterial disease, and
likely underlying cardiac co-morbidity. Aspirin, dipyri-
damole in combination with aspirin, or clopidogrel are
all appropriate depending on the situation. Anticoa­
gulation utilising Heparin in the acutely ischaemic
limb is used to prevent extension of thrombus into pre-
viously unaffected vessels. It is not a thrombolytic
agent and does not ‘dissolve’ clots. It is not a substi-
tute for prompt revascularisation in the ischaemic
limb. Heparin can be utilised in upper limb ischaemia
in patients with a viable limb if the patient requires
preoperative medical optimisation as a temporising
measure, and some patients will improve with heparin
therapy alone. In this setting, intravenous unfraction-
ated heparin is used in preference to Fractionated/
LMW Heparin.
Thrombolytic agents such as urokinase or rTPA can
be utilised as a therapy for acute limb ischaemia as either
a primary treatment modality in the Rutherford Grade 1
ischaemic limb, or as an adjunct in the setting of surgical
thrombectomy to clear thrombus from small distal ves-
sels. As a primary therapy, they are most useful in clear-
ing prosthetic or vein grafts with occlusion for <24 h.
These agents have the risk of haemorrhage from the
infusion site, and most catastrophically intracerebral
haemorrhage. This is a less common complication in the
era of intra-arterial catheter-directed thrombolysis. The
requirement for interventional radiology facilities and
staff reduces the utility of percutaneous thrombolysis.
On-table thrombolysis intra-operatively can assist in
maximising clot clearance from tibial vessels and may
demonstrate runoff that was not previously seen.
Optimal medical management of these patients
includes the appropriate use of ACE inhibitors, beta
blockers and statins in the perioperative period and on
an ongoing basis. It should be remembered that patients
47 Vascular Surgery: Acute Limb Ischaemia
who develop critical limb ischaemia will also com-
monly have underlying cardiac co-morbidity and will
therefore require management of cardiovascular risk
factors for primary and secondary prevention of car-
diovascular and cerebrovascular complications.
Preoperative workup and resuscitation includes
adequate expedient assessment of the patient’s fitness
for surgical intervention, and need for appropriate
resuscitation. These remain integral parts of the treat-
ment algorithm and should not be neglected; however,
definitive surgical intervention is the mainstay of treat-
ment and should not be unnecessarily delayed.
47.3.5 Decision Making
Assessing the severity of ischaemia and the likely via-
bility of limb requires some experience; however, there
are several objective assessments that can assist here.
The history of the patient’s symptoms, including dura-
tion of symptoms, and severity of symptoms, including
altered sensation, pain and loss of function, all influence
the likelihood of limb salvage. The patient who has a
Rutherford Grade I limb can be managed in a less urgent
fashion, and allows the opportunity for timely imaging
to be performed, and on occasion a catheter-directed
interventional procedure to be utilised. Rutherford II
limbs require expedient intervention, with a IIb limb
requiring immediate revascularisation to prevent pro-
gression to irreversible limb damage and amputation.
Rutherford III limbs are unsalvageable and will usually
have established fixed skin staining, paralysis and
numbness. These limbs should have primary amputa-
tion or the patient should be palliated.
Note: The optimal time period for revascularisa-
tion of an acutely ischaemic limb is within 6 h of
onset of symptoms.
This minimises the risk of reperfusion-related com-
partment syndrome and improves likelihood of limb
salvage and patient survival. Clearly, the more ischae-
mic is a limb, the greater the urgency. Although the
preoperative optimisation of the patient’s medical con-
dition is important, intervention should not be unnec-
essarily delayed for this to occur.
363
Which intervention should be utilised is not clearly
defined in all cases. Often the underlying anatomy of
the lesion and primary pathology will be the factor
which defines mode of intervention. In the setting of a
patient with no previous history of PAD, and an obvi-
ous embolic source (e.g. AF or thrombus load in a
documented aortic aneurysm), and normal contralat-
eral pulses, embolisation is the most likely cause and
urgent operation is the intervention of choice. This
can involve on-table angiography subsequent to
thromboembolectomy, but should not be delayed for
preoperative imaging. The patient who has a more
lengthy history of chronic symptoms and who devel-
ops new acute symptoms requires expedient imaging
to determine whether the patient has a reconstructible
lesion that can be treated surgically. The ability to
base operative intervention on appropriate imaging is
useful, and may allow a planned bypass if appropriate.
Occasionally, preoperative imaging will allow a
planned percutaneous intervention with the possibility
of surgical intervention as a fallback position. These
decisions are more complex and must take into account
the experience of the surgeon or interventionalist, and
the availability of appropriate infrastructure for percu-
taneous intervention.
In some cases, palliation is the most appropriate
treatment. Amputation can be an appropriate damage
control or palliative strategy in patients with multiple
comorbidities in whom revascularisation would carry
prohibitive risk. This is particularly the case in patients
with a delayed presentation in whom a bail out or dam-
age control procedure is preferable to a lengthy attempt
at revascularisation with the concomitant risk of reper-
fusion injury and compartment syndrome, along with
myocardial depression from metabolites from the
ischaemic limb.
47.3.6 Operative Management
In general terms, the main objective of treating acute
limb ischaemia is to restore pulsatile flow of oxygenated
blood to the target tissue in an expedient fashion. There
is minimal time for delay, and attempts to postpone sur-
gery on patients with a critical acutely ischaemic limb
to allow for ‘medical optimisation’ should be resisted
within reason. This may mean surgery being performed
under local anaesthetic or regional anaesthesia; however,
364
this is preferable to delaying revascularisation of a bor-
derline limb until the limb is unsalvageable and requires
amputation.
Similar principles to all vascular surgery apply:
obtaining adequate safe proximal inflow control
(including slinging the vessels with a silastic loop or
similar), identifying target vessels for revascularisa-
tion and appropriate conduit or material for patching
or grafting. In broad terms, this will often not be neces-
sary as the vast majority of patients only require simple
embolectomy; however, it is wise to be prepared for
the possibility of needing to bypass an occlusion to
salvage a limb. This involves prepping the entire ipsi-
lateral limb, and in the situation of trauma, the contral-
ateral limb as a vein donor site. The foot/hand should
always be visible to assess adequacy of reperfusion at
the end of the case, prior to undraping the patient. The
utilisation of on-table completion angiography is
almost mandatory in lower limb embolectomy, partic-
ularly where there is a pattern of contralateral PAD
(suggesting the presence of symmetrical pattern ipsi-
lateral disease) and assessment of the adequacy of
revascularisation is complicated by the presence of
chronic disease.
47.3.7 Anatomic Approaches
The most common sites accessed for revascularisation
are laid out below. It would be unusual for access to the
following vessels to not allow restoration of some
inflow to a target tissue.
47.3.7.1 Brachial Artery
The brachial artery is most commonly approached via
a transverse incision across the cubital fossa just
below the elbow crease. This allows mobilisation and
identification of both the inflow artery, and also the
origins of the radial and ulnar arteries with a view to
being able to pass a Fogarty catheter down both ves-
sels in a directed fashion. The artery lies deep to the
bicipital aponeurosis which should be incised care-
fully. There will be a number of brachial venae comi-
tantes around and crossing the artery which should be
carefully divided ­during mobilisation to allow ade-
quate mobilisation with minimal risk of troublesome
M. Hamilton
venous bleeding. The brachial bifurcation will some-
times also have a recurrent radial or posterior interos­
seous artery off the back of the main brachial artery
and this will occasionally require separate control.
Care should be taken if the brachial artery in the
cubital fossa appears very small, as this is sometimes
an anatomical variant with a high brachial bifurcation
(in the upper arm). In the presence of reliable imag-
ing, this is unlikely to be an issue; however, it may be
discovered at the time of surgery if there has been no
prior imaging.
47.3.7.2 Femoral Artery
The artery is best approached via longitudinal inci-
sion directly over the artery, or when the artery is not
palpable due to proximal thrombosis, at the mid-
inguinal point. The incision should come from just
above the inguinal ligament to the apex of the femoral
triangle to allow adequate exposure of all major vas-
cular structures in the region. The artery lies deep to
the deep fascia of the leg within the femoral sheath,
and is bounded medially by the femoral vein in close
proximity to the artery. Proximal control should be
gained at the level of the inguinal ligament and care
should be taken to control the four or five branches
that come off the common femoral artery. Passing a
silicone loop around the Common Femoral Artery
(CFA) allows the artery to be controlled using digital
pressure while performing embolectomy. The objec-
tive of dissection should be to mobilise the artery
closely on its surface, within the areolar tissue around
the vessel, and dissect the patient’s tissues away from
the vessel.
The superficial femoral artery passes distally in
the thigh exiting at the apex of the femoral triangle
and is the direct continuation of the CFA. The pro-
funda femoris artery on the other hand is quite vari-
able in its position and number of branches. There
are often two main profunda branches and care should
be taken to clearly identify all deep posterior branches
off the CFA at the level of the bifurcation. While
mobilising profunda, care should be taken to avoid
inadvertent injury to the lateral circumflex femoral
vein and profunda vein as it passes in the crutch of
the SFA and PFA. Minimal mobilisation of the PFA
is probably desirable in less experienced hands.
47 Vascular Surgery: Acute Limb Ischaemia
Again, the use of the silicone loop around all vessels
allows control using traction and digital compression
if required.
47.3.7.3 Popliteal Artery
In the event that embolectomy from the CFA is not
able to reperfuse a foot, an approach to the popliteal
artery and the tibial trifurcation is sometimes required.
This is performed via a medial approach in the upper
calf from the level of the insertion of the pes anseri-
nus. The skin and subcutaneous tissues are incised,
taking care not to injure the great saphenous vein in
the process as it may be required as a conduit, and the
fascia of the leg is incised. The Gastrocnemius should
be reflected posteriorly and the popliteal fossa should
be entered. The popliteal vein is commonly adherent
to the medial side of the artery and should be mobil-
ised off the artery which can then be traced distally to
the level of the anterior tibial artery takeoff. The ante-
rior tibial artery commonly passes anterolaterally off
the popliteal artery at an almost perpendicular angle
away from the operator. The anterior tibial vein also
crosses the tibioperoneal trunk at around this level,
and occasionally needs to be divided to allow loop
control and identification of the artery. Similarly, the
soleus muscle will occasionally need to be taken down
from the tibia to allow adequate exposure of this area.
This should be done with electrocautery as close to the
tibia as possible to minimise soleal venous bleeding.
To allow better exposure of the proximal below knee
popliteal artery, the pes anserinus can be taken down
off the tibia – there is not usually any need to formally
reconstruct this at the completion of the case.
47.3.7.4 Thromboembolectomy
In broad terms, the use of a Fogarty type balloon cath-
eter to remove thrombus from the vessel is relatively
straightforward. The decision as to whether to perform
transverse or longitudinal arteriotomy is often difficult
and is largely defined by the likely aetiology of the
acute ischaemic insult. In the instance of a clearly
embolic cause where imaging reveals an isolated
embolic lesion, transverse arteriotomy will usually
suffice. This provides the opportunity to close the arte-
riotomy primarily using a 5/0 or 6/0 polypropylene
365
suture – either interrupted or continuous. On the other
hand, where there is extensive underlying atheroscle-
rotic arterial disease and the possibility of a patch
angioplasty and/or bypass graft being required to
restore adequate flow, a longitudinal arteriotomy
should be performed. This will require repair with a
patch to minimise arterial narrowing around the site.
The arteriotomy should be positioned to allow access
to the origins of all vessels distal to the occlusion, to
facilitate the passage of a Fogarty catheter down these
vessels for removal of clot. The catheter is introduced
with the balloon deflated, passed down the vessel and
then the balloon is gently hand inflated to a set volume
while withdrawing the catheter. Several passes may be
required for adequate clot removal. Appropriate sizes
include 3Fr for tibial and forearm vessels, and proxi-
mal brachial in women, 4Fr for superficial and pro-
funda femoris and proximal brachial in men, 5Fr for
iliacs. The vessels should then be flushed with hepa-
rinised saline. On-table angiography should be consid-
ered when available at the end of the case prior to
closing the groin. This allows the possibility of defin-
ing ­remnant occlusions, and may facilitate a further
embolectomy.
47.3.7.5 Interposition Grafting
In the setting of acute ischaemic injury related to
trauma, interposition grafting may be required to bypass
an occluded vessel. The preferred conduit for all infrain-
guinal grafts is autogenous saphenous vein. In the set-
ting of trauma, it is preferred that this be taken from the
contralateral limb. In non-traumatic acute limb ischae-
mia, the ipsilateral Great Saphenous Vein (GSV) may
be utilised. The technique for interposition grafting
using an end-to-end anastomosis and reverse vein is
well described in a number of operative texts (refer to
recommended reading list at end of chapter). Other
techniques, including end-to-side anastomosis, are also
utilised on occasion, in particular for bypass grafting to
the popliteal artery in a femoro-popliteal bypass graft.
47.3.7.6 Intraoperative Imaging
When available, the use of completion angiography is
a useful adjunct to revascularisation of the limb, par-
ticularly in patients who have pre-existing PAD and
366
where the surgeon may not be able to feel peripheral
pulses due to pre-existing occlusive disease. The sim-
plest method of performing on-table angiography util-
ises a 20 G IV cannula placed directly in the artery
after closing the arteriotomy, and injecting 50:50 solu-
tion of IV contrast and Heparinised saline, and using a
C-arm capable of digital subtraction angiography.
47.3.7.7 Damage Control Options
In the setting of a patient with significant and pro-
longed limb ischaemia, revascularisation may not be
the most appropriate procedure. The revascularisation
of an infarcted limb may lead to significant washout of
toxic metabolites including potassium and lactate, and
may cause cardiac arrest. In this situation, the most
appropriate damage control manoeuvre is often pri-
mary amputation at a level that is well vascularised.
This may be above the knee in a significant proportion
of patients with acute lower limb ischaemia. Individuals
with injuries to the lower limb resulting in a dener-
vated and devascularised limb that has had lengthy
ischaemic time, an amputation and re-look at 24 h with
the aim of delayed primary closure at this or a later
time may be an appropriate technique.
47.3.8 Complications
of Revascularisation
The inflammatory and metabolic mediators which are
released from revascularising an acutely ischaemic
limb are beyond the scope of this chapter to discuss
and are well described in other works; however, acute
compartment syndrome is a common consequence of
restoration of blood supply to an ischaemic limb.
Compartment syndrome is defined as a clinical syn-
drome associated with an acutely elevated tissue pres-
sure in a non-expansile space. It applies predominantly
to muscle compartments; however, it also occurs in the
abdomen. Compartment syndrome results from intra-
compartmental pressure increasing above venous clos-
ing pressure (4–7 mmHg). Consequent to this, an
increase in capillary pressure leads to increased tran-
sudation and further swelling. The recognition of com-
partment syndrome is based on clinical assessment
and a high index of suspicion. It is characterised by
poorly localised, non-specific and severe pain in the
M. Hamilton
region concerned, which is worse on passive stretch-
ing of the muscles in that compartment. There is often
pain on palpation of the compartment. Sensory neuro-
logical dysfunction is an early sign with motor signs
coming later. Compartment pressure measure­ment
may be useful, and compartment pressures over
30 mmHg or pressures within 25 mmHg of diastolic
pressure/30 mmHg of MAP mandate intervention
by fasciotomy. Early four compartment fasciotomy
through large incisions is the treatment of choice, and
in many situations of revascularisation of the acutely
ischaemic limb, fasciotomy at the time of initial sur-
gery is preferable to delayed presentation and the
development of established muscle death/dysfunction.
This is particularly true in patients with a lengthy delay
prior to revascularisation. It is important to remember
that distal pulses may still be present in compartment
syndrome. Other tests such as ultrasound/MRI/CTA
do not add to diagnosis and should be avoided.
47.3.9 Peri and Post Operative Care
and Management
Adequate management of pain and other organ sys-
tems is vital in the perioperative period. Ongoing
washout of metabolites such as lactate, myoglobin and
potassium can lead to significant derangement in car-
diac and renal functions and an awareness of the strate-
gies for optimising the function of these systems is
necessary to optimise these patients care.
Cardiovascular optimisation includes appropriate
heart rate control and anticoagulation in the setting of
patients with AF, and the management of underlying
ischaemic events which have led to AMI. The presence
of cardiac valvular lesions and mural thrombus needs
to be elucidated with echocardiography to plan long-
term goals in relation to anticoagulation and treatment
of valvular disease.
The acute renal sequelae from the acute insult of
myoglobinuria from reperfusion rhabdomyolysis can
be minimised by ensuring adequate hydration, active
diuresis and alteration of the pH of the urine to mini-
mise precipitation of myoglobin in the tubule. There
are some instances in which the immediate deteriora-
tion in renal function may require acute dialysis. It
should also be remembered that reperfused muscle can
absorb large volumes of fluid and that standard main-
tenance IV fluid therapy is usually inadequate for these
47 Vascular Surgery: Acute Limb Ischaemia
patients and IV therapy should be aimed at producing
an adequate urine output.
Recommended Reading
Fitridge, R.A., Thompson, M.M.: Mechanisms of Vascular
Disease: A Textbook for Vascular Surgeons. Cambridge
University Press, Cambridge (2007)
367
Norgren, L., Hiatt, W.R., Dormandy, J.A., Nehler, M.R., Harris, K.A.,
Fowkes, F.G., et al.: Inter-society consensus for the manage-
ment of peripheral arterial disease (TASC II). Eur. J. Vasc.
Endovasc. Surg. 33(Suppl 1), S1-75 (2007). PMID
17140820
Rutherford, R.B.: Vascular Surgery, 6th edn. Elsevier Saunders,
Philadelphia (2005)
Valentine, R.J., Wynd, G.G.: Anatomical Exposures in Vascular
Surgery, 2nd edn. Lippincott Williams & Wilkins,
Philadelphia (2003)
 Vascular Surgery: Management
of the Diabetic Foot 48
Mark Hamilton

48.1 Introduction Doppler signal (triphasic/monophasic) is also helpful

in assessing presence of proximal or distal disease. The
use of toe pressures is preferable to ankle-brachial
The diabetic foot can be defined as a constellation of
indexes (ABI); however, it requires the use of appropri-
clinical findings that are usually (but not exclusively)
ate cuffs and photoplethysmography (PPG) probes to
seen in diabetic patients that include particular mor-
assess perfusion. Toe pressures are more consistently
phologic, vascular, neurological, and biomechanical
reliable in diabetics than ABI and are a better indicator
changes.
of likelihood of healing.
Critical limb ischemia (CLI) is defined as persis-
tent, recurring ischemic rest pain requiring opiate anal-
gesia for at least 2 weeks, ulceration, or gangrene of
48.2 General Principles of Assessment the foot or toes, and ankle systolic pressure less than
50 mmHg or toe systolic pressure less than 30 mmHg;
48.2.1 Vascular therefore, the utility of doppler pressures is clear in
defining those patients requiring revascularisation. The
absence of pedal pulses in diabetic patients is also
The assessment of adequacy of perfusion of the dia-
considered a marker for CLI.
betic foot is a vital component of all parts of manage-
ment in the acute and chronic phases of the diabetic
foot. A combination of varying degrees of severity of
large vessel atherosclerotic disease, small vessel dis- 48.2.2 Neurological
ease, and microangiopathic changes may be present in
the diabetic foot. These may range from what is clini-
The diabetic foot is partly a consequence of the devel-
cally a normally perfused foot that suffers the conse-
opment of diabetic peripheral neuropathy. This is a
quences of autonomic neuropathy and subsequent
combination of autonomic, sensory, and motor neu-
cutaneous shunting, to the foot with demonstrable criti-
ropathy. The presence of autonomic neuropathy can
cal ischaemia. Clinical examination is reliable to assess
be assessed by the loss of eccrine and sebaceous
large vessel circulation; however, it is limited in patients
gland activities with dry cracked and flaky skin, and
with extensive vascular calcification, which is often
increase in callus formation. Skin wrinkling on
present in long-standing diabetes. This vascular calcifi-
immersion in warm water is also predictably absent
cation is worse in combination with renal impairment
in patients with auto-sympathectomy. The presence
and chronic renal failure. The characteristic of the
of significant cutaneous shunting (a warm pink look-
ing foot even in the absence of a pedal pulse) is also
characteristic.
M. Hamilton
Department of Surgery, The Queen Elizabeth Hospital,
The situation is worsened considerably by the
28 Woodville Rd, Woodville South, SA 5011, Australia presence of stocking/glove sensory neuropathy. It is
e-mail: mark.hamilton@health.sa.gov.au common for diabetic foot patients to report they are

M.W. Wichmann et al. (eds.), Rural Surgery, 369

DOI: 10.1007/978-3-540-78680-1_48, © Springer-Verlag Berlin Heidelberg 2011
370
completely unaware of the presence of a noxious
stimulus or wound on the foot. This loss of protective
sensation and blunting of nociception leads to repeti-
tive trauma and the development of skin damage
secondary to pressure or trauma. Sensory neuropathy
causes blunting of the normal neurohormonal res­
ponse to noxious stimulus. The normal response to
trauma includes release of substance P, neuropeptide
Y and calcitonin gene–related peptide. These media-
tors cause mast cell degranulation; release of hista-
mine, TNF-alpha; and promote white cell migration
to the area of trauma. Neuropeptide Y also causes
ischaemia-stimulated angiogenesis. The loss of these
mediators causes an alteration in the neurohormonal
response to injury. These changes are able to be dem-
onstrated prior to the presence of sensory neuropathy
and many of the other components of the diabetic
foot. The use of a Semmes Weinstein 10 g monofila-
ment for assessment of sensory neuropathy is neces-
sary to quantify neuropathy objectively. Motor neuropathy
causes abnormality of innervation to the intrinsic
muscles of the foot, predominantly lumbricals, and
causes the characteristic claw-like appearance of the
advanced diabetic foot. Subluxation of the metatarsal
(MT) heads leads to alteration in the biomechanics of
the foot, repetitive trauma over the MT heads and the
development of callus and potential ulceration of the
overlying skin in the region. A neuropathic foot also
requires more perfusion than a normally innervated
foot to resist ulceration, presumably secondary to the
neurohormonal abnormalities described above.
48.2.3 Biomechanical
Assessment of the gait pattern and pressure loading of
the sole of the foot is an important part of develop-
ment of a biomechanical offloading strategy. The
typical biomechanical features of the diabetic foot are
clawing of the forefoot with plantar subluxation of
the metatarsal heads, and dorsal clawing of the toes.
This is accompanied by shortening of the Achilles
tendon and increased loading of the forefoot. The
alterations in skin flexibility, eccrine and sebaceous
activities lead to increased callus formation with the
effect of a foreign body under these increased pres-
sure loading areas.
M. Hamilton
48.2.4 Endocrine
Optimisation of glycaemic control and related endo-
crine abnormalities including vitamin D, Parathyroid
hormone and vitamin C are vital for the ongoing pre-
vention of complex foot problems. There is a link
between poor glycaemic control and the development
of alterations in collagen crosslinking. This glycation
of collagen is implicated in the development of the
cheiroarthropathy of the diabetic foot syndrome and
also the development of shortening of the tendo achilles.
Optimal management of glucose levels is also impli-
cated in reducing infection risk, and the development
of advanced foot sepsis. Measurement of HbA1C lev-
els is a useful indicator of long-term glycaemic control,
and provides a target for control. Patients with poor
glycaemic control also present with other endocrine
abnormalities, and vitamin D and C deficiencies are a
common finding. This has an impact on bone minerali-
sation and also collagen strength. They may also have
other coexistent endocrinopathy such as hypothyroid-
ism which would otherwise go undiagnosed. These
factors should be addressed by an endocrinologist.
48.2.5 Microbiological
Infection of diabetic foot ulcers is a common conse-
quence of the disease process. This can be limited to
polymicrobial colonisation of the wound bed, or can
involve invasive infection and systemic sepsis.
Diabetic foot infections can be life or limb endanger-
ing if not managed aggressively. The polymicrobial
nature of diabetic foot infection and the blunted neu-
rohormonal response to injury along with coexistent
ischaemia mean that infection in a foot may worsen
rapidly to the point where the foot becomes unsal-
vageable. The key components to assessing infection
in the foot include adequate clinical examination,
probing the ulcer or cavity to demonstrate likely
underlying osteomyelitis (probing to bone carries a
>90% positive predictive value for osteomyelitis in a
chronic foot ulcer) and determining the presence of
collections or tenosynovitis. Microbiological sam-
pling with superficial wound swabs may be of some
use; however, these swabs commonly grow a broad
array of bacteria, and do not always point to the
48 Vascular Surgery: Management of the Diabetic Foot
primary causative organism. Deep swabs or tissue
specimens are required to direct appropriate antibiotic
therapy. These can be obtained at the time of surgical
debridement of an infected wound or abscess. Early
involvement of the infectious diseases team is manda-
tory in patients with advanced diabetic foot sepsis.
Radiological imaging of the soft tissues is useful in
the patient with foot cellulitis. MRI of the foot may
demonstrate underlying osteomyelitis or collections
that are not appreciable clinically. MRI can guide
degree of debridement required in some patients.
48.2.6 Classification
Diabetic foot lesions are often classified using the
University of Texas Wound Classification System
(UTWCS) (Table 48.1), or the Wagner scale (Table 48.2).
The UTWCS has the advantage to include information
about the degree of infection.
48.3 Acute Management
The acute management of the diabetic foot is based on
the principle of providing adequate tissue perfusion, and
managing septic complications of the underlying pathol-
ogy, along with immediate offloading and pressure man-
agement. These rely on adequate assessment of the
patients need for revascularisation, the presence of sep-
sis and the biomechanics of the foot. The quantification
of the relative contributions of ischaemia, infection, bio-
mechanics and endocrine allows prioritisation of man-
agement of each of these issues. The most common
surgically acute presentation in the ­diabetic foot is that
of limb-threatening foot sepsis. In general, the principle
Table 48.1 University of Texas wound classification system
0 I
A No open lesion Superficial ulcer
B + Infection + Infection
C + Ischaemia + Ischaemia
D + Infection and + Infection
ischaemia and ischaemia
371
here is that of immediate broad-spectrum antibiotic ther-
apy, and aggressive drainage and debridement of the
foot sepsis and necrotic tissue. The key points are that all
devitalised or necrotic tissue should be removed, to a
level where healthy bleeding tissue is present, and that
all sinus tracts should be laid open to drain. This may
involve long plantar or lateral drainage incisions, and
may also involve amputation of digits. The temptation to
salvage a significantly marginal digit should be avoided.
The debridement of infected and necrotic tissue should
not be delayed to allow revascularisation, but rather the
decision be made to perform an acute sepsis control deb-
ridement then a subsequent revascularisation procedure
when the patient has stabilised enough to allow safe per-
formance of a larger procedure. The debridement site
should be re-examined at 12–24 h to reassess the viabil-
ity of remaining tissue and the presence of further sep-
sis. Deterioration may require further debridement. It is
also quite common for the wounds to deteriorate some-
what prior to improving when the limb is reperfused.
Note: In general, drainage of foot lesions should be
through plantar or lateral surfaces, and dorsal inci-
sions are largely avoided except where drainage of
extensor tendon sheaths is required and as a compo-
nent of digital amputation. If possible some effort
should be made to minimise plantar skin loss.
Digital amputation may be required to allow adequate
drainage of web spaces and the forefoot. Wounds should
be left open to drain, and are generally left to granulate
with a regular review to ensure progress. If toes are
amputated, the cartilage from the metatarsal head should
be removed entirely to avoid a sequestrum of cartilage
that will prevent granulation. This can be achieved while
preserving a component of the metatarsal head to
II III
Ulcer deep to tendon, joint Ulcer penetrating
or fascia joint or bone
+ Infection + Infection
+ Ischaemia + Ischaemia
+ Infection and ischaemia + Infection and
ischaemia
372
Table 48.2 Wagner scale
Depth Definition Treatment
classifi-
cation
0 At risk foot, no Education, footwear,
ulceration clinical assessment
1 Superficial ulceration, Total contact cast
not infected (TCC), offloading
2 Deep ulceration Debridement, wound
exposing tendons and care, offloading,
joints Antibiotics
3 Extensive ulceration Debridement, partial
or abscess amputation, offloading
4 Forefoot gangrene Amputation
5 Hindfoot gangrene Major amputation
maintain foot morphology and spacing. In the diabetic
foot where the amputation is for acute or chronic sepsis,
there is probably little benefit in preserving part of a
phalanx, as these proximal phalangeal components add
little to foot function, and are often involved in the septic
process.
On occasion, a formal ray amputation may be
required through the metatarsal body, and in advanced
forefoot sepsis involving several toes, a guillotine
transmetatarsal amputation is the procedure of choice,
leaving the wound open. It is preferable to attempt to
leave some plantar flap component if possible as this
aids in closure at a later date, and assists in mobilisa-
tion long term. Extensive wounds can be managed with
a negative pressure (VAC) dressing and subsequently
skin grafted if required. In patients with extensive foot
sepsis involving the midfoot, who have evidence of
midfoot and or hindfoot necrosis or sepsis and who are
systemically unwell, the procedure of choice is proba-
bly major amputation. The level of major amputation
will be largely defined by the extent of sepsis, the
patient’s comorbidities and the consequent likelihood
of the patient being able to mobilise with a prosthesis
at a later date, and the presence of adequate perfusion
to heal the amputation. In general terms, the presence
of a popliteal pulse means a below knee amputation is
likely to heal, its absence decreases this likelihood sig-
nificantly. Frail and obtunded patients who are unlikely
to mobilise on a prosthesis in the future should be con-
sidered for above knee amputation as this has the high-
est healing potential in these patients and maximises
the likelihood of them leaving hospital.
M. Hamilton
48.3.1 Investigations
During the initial phase of management, objective
assessment of perfusion with toe pressures and ABIs
is necessary when pulses are not clearly palpable. In
the presence of ischaemia, some form of angiography
should be performed, either MRA CTA, or occasion-
ally DSA with a view to intervention at the time.
Duplex has somewhat limited utility in diabetics due
to the presence of significant vascular calcification in
the tibial vessels which limits the ability to insonate
these vessels. Duplex is however useful for assess-
ment of the more proximal and larger vessels with a
view to delineating the presence of a potentially treat-
able large vessel lesion. Anatomical imaging allows
the surgeon to plan an appropriately staged revascu-
larisation procedure with the aim of healing the tissue
loss. The optimal distal target vessel is that which is
most likely to allow pulsatile perfusion to the area
concerned. On occasion this may be a dorsalis pedis
or posterior tibial artery.
Microbiological assessment at the time of acute
management should involve sending deep tissue speci-
mens of the infected area, including bone, and if man-
aging an episode of digital sepsis, an amount of ‘clean’
deep tissue to define the post drainage or debridement
microbiological flora. This allows the optimisation of
antibiotic therapy and the minimisation of use of overly
broad-spectrum antibiotics for long periods of time. In
the initial 24–48 h, the use of broad-spectrum agents is
appropriate; the choice of agent will depend on institu-
tional preferences and the local microbiologic milieu,
and the likelihood of the presence of multiresistant
organisms. Some appropriate agents include triple
antibiotic therapy with Amoxicillin or Flucloxacillin
1 g q6H, Gentamicin 5–7 mg/kg ideal body weight q24h
and Metronidazole 500 mg q12h; Timentin is also
­utilised as a first-line agent on occasion, and in the
situation where the organism is known to be a methi-
cillin-resistant staphylococcus, Vancomycin is added
to the regime. Clindamicin has utility in MRSA also,
and has excellent tissue penetration. Ciprofloxacin or
some of the newer fluoroquinolone agents such as
moxifloxacin are useful for these commonly polymi-
crobial infections; however, their gram-positive cover
is relatively poor, and they also promote emergence of
resistance in Pseudomonas when used as a single agent
to treat this organism. Largely their use should be
48 Vascular Surgery: Management of the Diabetic Foot
restricted to combination antipseudomonal therapy in
this setting. The early involvement of a microbiologist
or infectious diseases specialist is vital in guiding
appropriate therapy for these complex patients.
Imaging of the diabetic foot for delineation of sep-
tic complications and delineation of the presence of
Charcots neuroarthropathy versus acute foot sepsis
has advanced significantly in the era or magnetic reso-
nance imaging. MRI has the ability to differentiate
between changes of osteomyelitis or acute infection,
and Charcots degenerative change, and also to deter-
mine the presence of underlying septic arthritis or the
presence of soft tissue infections only. In the presence
of a red swollen foot, but a medically stable patient,
the time taken to perform MRI is justified in that it
may prevent unnecessary operation. Nuclear medicine
and in particular labelled white cell scans for osteo-
myelitis still remain useful in patients who have con-
traindication to MR imaging; however, these are not
always useful in differentiating Charcot changes from
osteomyelitis. Plain radiography of the foot is useful
when other modalities are unavailable, and when
serial examinations are performed for follow-up of
chronic changes in patients being managed conserva-
tively or with antibiotic therapy only. There is unfor-
tunately a significant lag time between clinical
osteomyelitis and the appearance of classical plain
radiograph findings. There is some utility in plain
x-ray to exclude the presence of radio-opaque foreign
body in the acutely septic foot with a history of trauma
in particular. It should be a standard component of the
initial assessment of the diabetic foot and will also
demonstrate other bony changes of the chronic dia-
betic foot including midfoot collapse, MTP joint sub-
luxation and clawing of the toes. Ultrasound is a useful
modality to image for echogenic but non-radio-opaque
373
foreign material which may be present in a case of
diabetic foot sepsis. The proviso on all imaging of the
foot is that it should not delay the timely drainage of
foot sepsis.
48.4 Chronic Management
Once identified as being high risk, diabetic patients
benefit from being enrolled in a high-risk foot surveil-
lance programme with multidisciplinary input from
podiatry, orthotics, infectious diseases, endocrinology,
vascular and orthopaedic surgery. The aim of these
programmes is to optimise the component manage-
ment of the patients’ foot, with the benefit of regular
reassessment of the foot by multiple teams in one sit-
ting. The aim is that patients have a plan in place that
allows optimisation of all risk factors and that once the
foot is healed it can be kept healed.
Recommended Reading
Beard, J.D., Gaines, P.A.: A Companion to Specialist Surgical
Practice: Vascular and Endovascular Surgery, 3rd edn.
Elsevier Saunders, Philadelphia (2006)
Fitridge, R., Thompson, M.: Mechanisms of Vascular Disease.
Cambridge Press, Cambridge (2007)
Norgren, L., Hiatt, W.R., Dormandy, J.A., Nehler, M.R., Harris,
K.A., Fowkes, F.G., et al.: Inter-society consensus for the
management of peripheral arterial disease (TASC II). Eur. J.
Vasc. Endovasc. Surg. 33(Suppl 1), S1–75 (2007). PMID
17140820
Rutherford, R.B.: Vascular Surgery, 6th edn. Elsevier Saunders,
Philadelphia (2005)
Wagner FW. The dysvascular foot: a system for diagnosis and
treatment. Foot and Ankle. 2(2):64–1 22 (1981)
 Minor Procedures
Eric Mooney
49.1 Skin Grafts and Flaps
Skin grafting and flaps are means to an end: replacing
lost or deficient tissue. This is true when dealing with
either wound closure or reconstructive cases. When
dealing with open wounds, it is best to consider the
repair in terms of reconstructive options so that the
best choice can be made. A useful conceptual tool is
the “reconstructive ladder” (Fig. 49.1). The reconstruc-
tive ladder represents a hierarchy of closure techniques
proceeding from the least complex to the most com-
plex procedures as one progresses up each “rung” of
the ladder.
Thus, one proceeds from healing by secondary
intention as the ground floor to direct closure as the
DISTANCE FLAP/FREE FLAP
COMPLEX
REGIONAL FLAP
LOCAL FLAP
SKIN GRAFT
SIMPLE DIRECT CLOSURE
SECONDARY
INTENTION
Fig. 49.1 The Reconstructive Ladder: each ascending “rung”
on the ladder is becomes more complex. Normally, the simplest
procedure that will accomplish the job is chosen unless the more
complex procedure offers compelling advantages
E. Mooney
Department of Surgery, Bassett Healthcare,
One Atwell Rd, Cooperstown, NY 13326, USA
e-mail: eric.mooney@bassett.org
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_49, © Springer-Verlag Berlin Heidelberg 2011
49
first rung and subsequently to the higher “rungs” of
skin grafting, local flaps, regional flaps and, ­ultimately
free tissue transfer. One usually considers each rung
of the ladder and used the lowest rung applicable to
the wound under consideration unless a higher rung,
or more complex technique offers specific advan-
tages. A common example would be an open avulsion
of the dorsal hand with exposed ­tendons. Healing by
secondary intention will lead to contracture. Grafting
will not work over the relatively avascular tendons.
The next step up the ladder, local flaps, are rarely
large enough or dependable enough for coverage.
One then proceeds to regional flaps and finds that a
radial forearm flap based on the radial artery will
often suffice for coverage. In addition, this flap will
provide normal skin and subcutaneous fat for tendon
gliding. However, because this type of flap is often
bulky, one may want to consider the highest “rung” as
well: free flap coverage. Perhaps a free ­fasciocutaneous
flap will allow for better, thin, and vascularized clo-
sure. The important point about the reconstructive
ladder is not to become a lexicon of flaps but to be
able to ­consider wound closure options in a system-
atic way. In this way, optimum closure for the avail-
able skills can be chosen. For most surgeons in a rural
setting, the choices will usually be between primary/
nondary intention, grafting, local flaps, or perhaps
simple regional flaps.
Lastly, wound bed preparation is of paramount
importance. No matter what technique is chosen, all
dead tissue and eschar must be removed before ­closure.
This includes nonviable longitudinal structures such
as nerves and tendons as well. All infection should
be controlled through debridement and antibiotics
­(systemic or topical). When operating for tumor, all
­margins should be cleared before coverage. Tempo­
rary coverage with appropriate dressings or biologic
375
376
devices can temporize the wound until ­pathologic con-
firmation of margins is obtained. In summary:
• Before closure, control infection and remove all
nonviable tissue.
• Consider each wound in terms of the reconstructive
ladder, choosing the lowest “rung” unless a higher
one has specific advantages.
49.2 Skin Grafting
Skin grafting is the most basic and broadly useful of
wound closure techniques and should be part of every
rural surgeon’s tool kit. It is also the “escape hatch” or
“plan B” used when more complicated procedures fail.
While it is often obvious that large wounds that will not
heal secondarily will need grafting, in smaller wounds
that would otherwise heal, some judgement is required
to decide which would benefit from early grafting. Some
judgement is required for smaller wounds that would
otherwise heal by themselves. The decision to graft is
based on wound size and time to closure as well as antic-
ipated morbidity of contracture entailed in healing by
secondary intention. When dealing with open wounds, a
rule of thumb has been that any wound that does not heal
by 4 weeks is at risk for healing with significant scar and
contracture if at all. These wounds should be considered
for early grafting. Because of the risk for contracture
with subsequent distortion and loss of mobility, wounds
in certain anatomic regions such as the periorbital area,
hands, and joints should be considered for early graft-
ing. Full thickness grafts contract less than split thick-
ness grafts and should be considered for these areas.
Skin grafts require a noninfected, well-vascularized
wound bed. One should always aim for 100% graft
take and not use a graft to “clean up” a wound. Wounds
should be thoroughly debrided of all necrotic and non-
viable tissue. Infection should be controlled with local
and systemic antibiotics as appropriate. Appropriate
dressings should be used until the wound shows signs
of granulation with the exception of areas where early
grafting prevents delayed functional problems (such as
the hand or eyelids).
Skin grafts will not “take” or grow on poorly vascu-
larized tissue such as cartilage or bone. These will require
flap coverage. A vacuum assisted closure device may be
used to assist granulation and control drainage before
E. Mooney
grafting. When possible, edema should be controlled
with pressure garments before grafting chronic wounds.
When deciding between graft thickness, several
factors are entertained. Split thickness grafts are those
that contain part of the dermis while full thickness
grafts incorporate the entire dermis. The skin itself
ranges from 17 thousandths to 150 thousandths of an
inch (0.43–3.81 mm) in thickness so that the usual split
thickness graft is taken at 12–18 thousandths of an
inch thickness. Split thickness grafts contract more
than full thickness grafts. In general, though, larger
donor sites are more available (thigh, buttocks, etc.)
for split thickness grafts. Full thickness grafts incorpo-
rate more dermis proportionately and are therefore
more mobile and pliable than split thickness grafts. As
alluded to above, they are more appropriate for the
eyelids, periorbita, joints, hands, and areas of cosmetic
concern where contracture is to be avoided and mobil-
ity is at a premium. A disadvantage of full thickness
grafts is that they are less likely to take on suboptimal
wound beds. For example, one might consider a rela-
tively thin, meshed split thickness graft on an exuda-
tive trunk wound. An example of full thickness grafting
would be a defatted full thickness graft harvested from
the beltline of the abdomen (a crescent excision across
the abdomen just above the inguinal creases) for graft-
ing neck contractures or dorsal hand burns. Large
donor site areas for full thickness grafts are limited
(groin, lower abdomen, neck, retroauricular sulcus).
Lastly, the rule of “like replaces like” should be con-
sidered. A full thickness graft taken from the contralat-
eral upper eyelid is most appropriate for an excisional
eyelid defect due to the need for thin, mobile, uncon-
tracted skin at the eyelids and periorbita.
49.2.1 Mechanics of the Operation
Before the operation, the wound is inspected and
assessed specifically for cellulitis (infection), vascular-
ity and granulation (adequate wound bed), and eschar
or areas of devitalized tissue requiring further debride-
ment. Next, potential donor sites are inspected with
regard to patient positioning. Postoperative wound
care instructions are given at this time while the patient
is alert and perhaps accompanied by a caregiver.
The operation proceeds by first addressing the
wound, finishing any required debridement down to
49 Minor Procedures
healthy bleeding tissue. Hemostasis must be achieved to
prevent hematoma beneath the graft. Post-debridement
cultures and pulsed lavage may be considered.
The most common donor site for a split thickness
graft is the anterior and lateral thigh. The illiotibial
tract provides a convenient flat surface for harvesting.
Both the dermatome and the donor site are lubricated
(mineral oil or K-Y jelly). When using the dermatome,
it is important to put the donor site under tension and
to let the machine do the work by applying only mod-
erate pressure. The graft is most often harvested at a
thickness of 12–18 one-thousandths of an inch (0.36–
0.45 mm) (skin itself ranges from 17 thousandths to
150 thousandths of an inch in thickness). A gauze or
Telfa soaked in a dilute epinephrine solution is applied
to the donor site while the graft is meshed and inset.
The donor site is best dressed with an occlusive dress-
ing (such as Tegaderm®). Petrolatum impregnated
gauze may also be used. The buttock area is often con-
sidered a donor site for young females but is harder to
harvest than the thigh. If a dermatome is not available,
a split thickness graft can be harvested by hand with a
Humby knife.
Reasons for meshing the graft are (1) to expand the
graft, (2) to allow the graft to conform to the complex
surface of the wound, and (3) to facilitate serous drain-
age. Meshing the graft will not prevent hematoma.
Most frequently, a 1:1½ ratio is chosen. A ratio of 1:3
is very difficult to handle. Make sure the dermis side of
the graft is applied to the wound bed. With experience,
this can be judged by the surface markings, color, and
sheen of the epidermis when viewed obliquely to the
light source. Staples or sutures are used generously to
ensure that the graft conforms to the wound bed. Slow
setting fibrin glue may be used as an adjunct for graft
adherence particularly in edematous wounds or areas
of high mobility where dressings are difficult. The
fibrin glue has not been shown to affect adversely
imbibition or graft take. In order to hold the graft
against the wound bed, a bolster is often fashioned by
sandwiching moist cotton or a surgical sponge between
two layers of petrolatum impregnated gauze. Silk
sutures are placed around the circumference and tied
over the bolster. A vacuum assisted closure device can
also be used on a low setting (100 mmHg) to hold a
graft in place.
The donor site is dressed with an occlusive dressing
such as tegaderm. This is simply left in place until the
donor site heals. Any blood collections can be needle
377
aspirated and patched with a smaller tegaderm.
Alternately, petrolatum gauze can be used to dress the
wound. This should be exposed on the first postop day
and gently dried with a hairdryer on a low setting if
necessary. While this process is painful, once the dress-
ing is dry, it forms a comfortable “man-made scab” that
can be trimmed as the underlying epithelialization loos-
ens it. The donor site should be monitored for infection,
in particlular, pseudomonal colonization or infection.
Full thickness grafts are usually harvested from the
upper eyelid, the preauricular cheek, a neck fold in the
elderly, or the lower abdomen and inguinal crease.
A “pinch test” is performed to gauge how much skin
can be removed and still obtain primary closure. The
graft is harvested through the subcutaneous fat plane
and then defatted with scissors. Full thickness grafts
are inset and bolstered in the same fashion as split
thickness grafts.
Dressings applied to the grafted wounds must
­conform so as not to create shear. Immobilization with
splints and bed rest should be considered.
49.2.2 Postoperative Care
The most common reasons for graft failure are: (1)
inadequate wound bed, (2) shear forces, (3) infection,
and (4) hematoma. Postoperative care can be facili-
tated by keeping these in mind and avoiding them. For
instance, as noted above, immobilization and bed rest
help to prevent shear. Antibiotics should be considered
for 3–5 days as the wound revascularizes.
Bolsters are usually removed on postoperative day
5. At this time, a non-adherent daily dressing is then
used. One may consider removing a bolster somewhat
earlier on postoperative day 3 or 4 if the wound bed is
exudative or overgrown with pseudomonas. If a VAC®
(vacuum) device was placed, it should be removed on
day 3 or 4 as prolonged use may adversely affect the
graft and even lead to granulation of the graft
interstices.
For legs, a graduated progressive scheme of gravi-
tational dependency may be started around postopera-
tive day 5 but attention should be paid to edema. Grafts
are typically adherent enough to withstand showering
around postoperative day 10. Around this time, if the
interstices of the mesh pattern are epithelialized, dress-
ings can be discontinued and a simple hydrating lotion
378
or petrolatum may be used on the grafted site. If hyper-
trophic areas of granulation occur, these can be treated
with topical silver nitrate. Occupational therapy can be
started around day 10 but in areas such as the hand
where more aggressive motion is needed, starting on
postoperative day 5 with monitoring of the stress
placed on the graft may be considered. While healing,
grafts should be protected from strong sunlight to
­prevent hyperpigmentation.
The donor site is often healed around day 10 or 12.
At this time, the occlusive dressing may be removed
and hydrating lotion applied to the epithelium.
49.3 Flaps
Flaps are used for coverage in situations where poorly
vascularized tissues are exposed in the wound bed.
Grafts will not take on cartilage, tendons, or bone.
Flaps are also used in areas where the contraction of a
graft cannot be tolerated, such as the hands, periorbita,
etc. A further application of flap closure is in areas of
cosmetic concern.
Flaps are classified into various ways. As mentioned
above, the reconstructive ladder conceptualizes flap
options in terms of local, regional, and distant flap
options. Flaps may be classified by blood supply: ran-
dom or axial. The majority of local flaps are based on
a random blood supply. In this situation, the base of the
flap must not be unduly narrowed. The old rule of
thumb that the flap length should not exceed three
times the base is unreliable. An axial flap is a flap
based on a known cutaneous artery. These arteries are
limited in distribution. An example would be a radial
forearm flap based on the radial artery or a groin flap
based on the superficial inferior epigastric artery. These
flaps are, in general, highly reliable.
Flaps may also be classified by advancement or
movement technique: advancement (e.g., V-Y), rotation
RANDOM
E. Mooney
(bilobe), transposition (Z-plasty, rhomboid), etc. Lastly,
flaps may be classified by their components: cutaneous,
fasciocutaneous, musculocutaneous, etc.
When planning a wound for flap coverage, it is best
to apply the principles of the reconstructive ladder as
discussed above. Use the simplest, most dependable
flap that will fulfill the requirements of reconstruc-
tion. Note that the term reconstruction, rather than
“wound closure” is used. Another reconstructive con-
cept to keep in mind when planning a flap is that “like
replaces like.” For instance, a pedicle flap from the
upper eyelid can be used to reconstruct a lower eyelid
defect.
Wound bed requirements are similar to those of
grafting. Infections must be controlled and all nonvia-
ble tissue must be debrided. Since flaps bring their own
blood supply to the wound bed, prior vascularization
of the wound bed (granulation) is not necessary. When
closing oncologic defects, all tumor should be removed
and margins cleared, particularly in recurrent or locally
aggressive tumors (e.g., morpheaform basal cell carci-
noma). In areas where mobility is a premium, all scar
should be removed when possible.
49.3.1 Particular Local Flaps
49.3.1.1 V-Y
A V-Y advancement flap is performed by cutting a flap
in the shape of a V and then advancing the flap, closing
the wound behind the advancing apex. The result is a
Y-shape.
A classic example, if not a large one, is closing a
sacral decubital ulcer as two V-Y flaps based on the
glutei. Another application is closure of a fingertip
wound by either advancing the volar tuft as a so-called
Kleinert flap, or by using two axial V-Y flaps.
AXIAL
49 Minor Procedures
2
1
2
ADVANCEMENT ROTATION
A disadvantage of the flap is that the blood supply
to the flap comes from a central pedicle directly beneath
the flap. Therefore, the mobility of the underlying sub-
cutaneous tissues limits the amount of advancement
achieved. The flap is best performed in areas of high
skin mobility, typically where subcutaneous fat is
rather ample. Advancement is often disappointing in
the fingertips.
49.3.1.2 Z-plasty
A Z-plasty is a form of transposition. It is used to
“break up” linear contractures, to lengthen and reori-
ent scars. Z-plasties work by transposing the longer
379
B
A
B
TRANSPOSITION
base of two triangles into the axis of the contracture or
scar.
Ideally, normal supple skin is transposed into the
axis at the same time, allowing for distensibility and
motion. This should be kept in mind when planning
Z-plasties, particularly near joint or flexion creases:
plan the Z-plasty in a way that incorporates normal
skin when possible. Theoretically, a 90° angle at each
limb provides the most lengthening. However, 90°
limbs are hard to rotate and difficult to work with. 60°
or so is more clinically useful and have been shown
mathematically to provide the maximum practical
scar lengthening. A 30° angle will provide 25% length-
ening; a 45° provides 50%; and a 60° angle will
achieve 75% lengthening. Z-plasties are particularly
380 E. Mooney

50%
A
45°
A B
A

B D C
A
A E B D E
C
49 Minor Procedures
important in burn reconstruction. A classic example of
a Z-plasty is release of axillary webbing after postburn
contraction. Flaps should be kept relatively thick and
broad-based when dealing with such scars or in
smokers.
Multiple Z-plasties can be planned along a single
long scar to release it over its entire length. Multiple
small Z-plasties or a W-plasty can be used to reorient
and camouflage scars such as those that have “pin-
cushioned.”
A “jumping man flap” is a special variant of
Z-plasty and useful for curved or web-like scars. An
example of its use is in breaking up a first web space
contracture of the hand or in correcting a medial can-
thal web.
49.3.1.3 Rhomboid
A rhomboid flap is useful in areas where adjacent dis-
tensible skin is available for transposition into a defect.
A classic application of the rhomboid flap is the temple.
The lesion (such as a carcinoma) is excised in a rhom-
boid in shape and the adjacent flap is transposed into
the defect by first cutting the flap as a parallelogram at
one of the vertices of the defect. Each rhomboid shaped
defect has eight associated possible flap orientations
(two at each vertex). The key to planning is to make
sure there is enough skin to close the flap donor site by
pinching along the axis of the diagonal base of the flap.
This will also be the line of maximum tension.
Several possible rhomboid flaps are possible
around the margin of the defect. In choosing the loca-
tion of the particular flap to be used, the residual lax
skin is gauged by a pinch test as noted above. An
advantage of the rhomboid flap is that it transposes
adjacent skin of similar thickness and pigmentation
B B
A A A1
C B1
C1
A1
381
into the wound, obeying the principle “like replaces
like.” A classic example is closure of a temporal fore-
head defect.
49.3.1.4 Bilobe Flap
A bilobe flap is used for roughly circular shaped
defects. The bilobe flap is composed of a primary lobe
and a secondary lobe attached at a broad base. The pri-
mary lobe is slightly smaller than the defect and
planned adjacent to it. The secondary lobe is about half
the width of the primary lobe. As the primary lobe is
rotated into the defect, the secondary lobe is rotated
into the primary lobe defect. The secondary defect is
then closed primarily. The bilobe flap is really a means
of rotating lateral skin into the primary defect in
“stages.” For the flap to be successful, the secondary
flap must come from an area of loose skin. A classic
example is closure of a dorsolateral nasal defect.
Cosmetic results are usually excellent especially in the
older patient.
49.3.1.5 Regional Flaps
Regional flaps are those brought from an area near, but
not adjacent to the defect itself, contrary to local flaps
that are adjacent to the defect (for example, rhomboid
or V-Y) and distant flaps (free tissues transfer, groin
flap, cross-leg flaps, etc.). Regional flaps are based on
a sound knowledge of the blood supply to the flap and
are designed specifically to incorporate that blood sup-
ply. Regional flaps may be axial, or based on a known
cutaneous artery such as a forehead flap based on the
supratrochlear artery branches or a radial forearm flap
based on the radial artery.
1 2
B1
8 3
7 4
C C1
6 5
382 E. Mooney

The flap is delayed for several weeks before cutting

and insetting the base.

49.3.1.7 Radial Forearm Flap

The radial forearm flap is a fasciocutaneous flap based

distally on the radial artery. The flap is used exten-
1 sively as a free flap but can be used to provide thin
coverage of hand defects. A skin island slightly larger
than the defect is marked on the volar forearm distal to
the antecubital fossa centered on the radial artery. The
radial artery is mapped by doppler and by palpation.
An Allen’s test is performed to ensure adequate perfu-
sion of the hand through the superficial palmar arch
and the ulnar artery. The length of the pedicle is mea-
sured to ensure adequate rotation to the defect without
kinking. A tourniquet may be used to facilitate dissec-
tion. Some surgeons prefer to not use the tourniquet so
as to be able to palpate the radial pulse. The radial
artery is located beneath the brachioradialis muscle in
2 the proximal forearm. The brachioradialis is swept
1 radially to expose the vascular bundle. The radial artery
and venae comitantes are transected and dissected
from proximal to distal, protecting the superficial
49.3.1.6 Forehead Flap branch of the radial nerve distally. Care is taken to pre-
serve the septum running between the artery and skin
A classic reconstruction of large dorsal nasal or nasal lying between the brachioradialis and flexor carpi radi-
tip defects is the forehead flap (midline or parame- alis muscles. The superficial fascia is dissected off
dian). The flap is designed with the supratrochlear ves- these muscles in continuity with the intermuscular sep-
sels at its base. Usually, the contralateral vessels are tum in order to preserve the septum. Several muscular
used to facilitate flap rotation. branches are ligated during dissection. The entire vas-
The flap is very hardy and quickly elevated. If the cular bundle should be taken; the artery should not be
flap is kept 2–3 cm in width, the donor site can be pri- skeletonized so as to preserve venous drainage through
marily closed by broadly undermining the forehead. the venae comitantes.
49 Minor Procedures
49.3.1.8 Groin Flap
The groin flap is a fasciocutaneous flap based on the
superficial circumflex iliac artery (SCIA) and vein.
The flap is a hearty flap that has been used to provide
urgent hand coverage. The flap is typically very bulky
and often requires thinning and revision in a delayed
fashion. A line is drawn from the anterior superior iliac
spine (ASIS) to the pubic tubercle. The axis of the
pedicle lies 3 cm inferior to this line and parallel to it.
Standard flap elevation is lateral to medial, from the
ASIS to the medial border of the sartorius muscle. The
plane of dissection is just superficial to the fascia lata
until sartorius muscle is encountered. Here, dissection
is just under the superficial muscle fascia. Dissection
stops at the medial edge of the muscle where the pedi-
cle lies. The flap is left inset for about 3 weeks and
before dividing the pedicle, the vascularity is tested by
constricting the base with a penrose drain for 5 min.
The classic application of this flap is an avulsion injury
of the dorsum of the hand.
49.3.1.9 Muscle Flaps
Muscle flaps are used where a copious blood supply is
needed, such as open fractures, osteomyelitis, irradi-
ated tissue, exposed prosthetics (including vascular
prosthetics), and seroma (particularly the groin). Flap
viability relies on preservation of the blood supply.
A classic and relatively straightforward muscle flap is
the rectus flap. The flap may be based superiorly (on
the superior epigastric vessels) or inferiorly (based on
the deep inferior epigastric vessels). Other readily
usable muscle flaps are Pectoralis major, Latissimus
dorsi, and Gastrocnemius.
383
49.3.1.10 Distant Flaps
The last category of flap coverage is that of distant
flaps. Current usage of this term usually refers to free
tissue transfer (free flaps) in which the flap and its
blood supply are completely disconnected from the
donor site and then reattached using microsurgical
techniques at the recipient site. Free tissue transfer is
beyond the scope of this chapter but it is worthwhile
noting what kind of defects should be referred for free
tissue transfer consideration. These defects are usually
composite defects of bone and soft tissue; defects
which have poorly vascularized wound beds and insuf-
ficient regional flap options; wounds requiring special-
ized contours, gliding surfaces (for tendons excursion),
or cosmesis which cannot be met by locoregional flaps.
When considering free tissue transfer, form and func-
tion of the deficit are analyzed and an attempt is made
to reconstitute them. It is worth noting that many
wounds which would have required free tissue transfer
in the past, particularly those with poorly vascularized
wound beds, are now vascularized using a vacuum
assisted closure device followed by grafting (such as
wounds of the distal third of the lower extremity).
Historically, other distant flaps were designed and
transferred based on the delay principle. In the delay
procedure, a flap is incised and then inset into the
recipient site without cutting the blood supply from the
donor site. A time period is then allowed to pass in
order to allow a blood supply to grow in from the
recipient site wound bed. After this has occurred, the
original blood supply or pedicle from the recipient site
is cut, leaving the flap to live off its new blood supply.
Examples of this procedure would be a cross-finger
flap, a groin flap (for hand coverage), nasolabial flaps,
forehead flaps, and cross-leg transfers. A key to this
384
procedure is to leave the flap in the defect for at least
2–3 weeks before transecting the original blood sup-
ply. Do not be in a hurry! Smokers, and scarred wound
beds require longer periods of delay. The blood supply
can be tested by occluding the original blood supply
with an elastic vascular loop or noncrushing clamp for
a few minutes before transection. Be sure the flap
remains pink without venous (dusky) insufficiency.
The flaps are usually less technically demanding than
free tissue transfer and can often replace it in under-
served areas. The disadvantage of these flaps is that
they are often bulky with poor contour, requiring
revision.
49.4 Circumcision
The American Academy of Pediatrics Task Force on
Circumcision published a policy statement in 1999
stating: “Existing scientific evidence demonstrates
potential medical benefits of newborn male circumci-
sion; however, these data are not sufficient to recom-
mend routine neonatal circumcision. In circumstances
in which there are potential benefits and risks, yet the
procedure is not essential to the child’s current well-
being, parents should determine what is in the best
interest of the child.” The potential medical benefits
are those of decreased incidence of UTI and penile car-
cinoma in circumcised males. It is not clear what the
role of circumcision plays in sexually transmitted dis-
ease (STD) transmission. Indications beyond the new-
born period may include phimosis, paraphimosis,
balanoposthitis (infected loculations of smegma), and
condylomata. It is inadvisable to perform urgent cir-
cumcision at the time of paraphimosis because of the
attendant edema.
Neonatal circumcision should not be performed in
infants with hypospadias, epispadias, chordee, or meg-
alourethra. Local regional anesthetic should be used
and is considered more effective than EMLA (eutectic
mixture of lidocaine/prilocaine) used as a topical anes-
thetic. Using a 27-gauge needle, 0.4 cc of 1% lidocaine
is injected dorsolaterally at the 10 o’clock and
2 o’clock positions at the base of the penis. The needle
is angled posteriomedially until Buck’s fascia is
entered. Alternately, a subcutaneous ring block of
0.8 ml 1% lidocaine can be injected at midshaft.
Typically, a device such as a Gomco or Plastibell is
E. Mooney
used. In 90% of neonates, the glans is fused to the pre-
puce and is not retractable. The first step is to release
the preputial adhesions to the glans. A dorsal slit is
often necessary to place the bell over the glans. With a
Gomco, a plate is placed over the bell and glans. The
prepuce is then fed through the hole to the level of the
previously marked coronal ring. The screw is used to
tighten the plate over the bell and is left in place sev-
eral minutes. The prepuce is then excised sharply (do
not use electrocautery with a metal bell in place). The
plate and bell are then removed. The most common
complication is bleeding which is usually controlled
with gentle pressure. Cautery, suture, or topical hemo-
static agents may be used. Other complications include
infection, penile adhesions, removal of too much or
too little skin, phimosis, and injury to the glans, ure-
thra, or shaft. If too much shaft skin is removed, ­healing
by secondary intention usually provides a satisfactory
result rather than attempts at grafting or primary
closure.
In adult circumcision, the level of the coronal ridge
is marked circumferentially around the shaft. The pre-
puce is retracted, bluntly lysing adhesions between the
glans and prepuce. A dorsal slit may be necessary if
phimosis is present. This may be accomplished by
inserting one limb of a straight clamp beneath the pre-
puce to the level of the coronal ring and, making sure
the clamp is not in the urethra, closing and crushing
the prepuce for a few minutes before dividing the pre-
puce with a scissors. The proposed line of incision in
the inner preputial sac is then marked 3 mm below the
coronal sulcus. Both circumferential lines (the shaft
and the subcoronal lines) are incised and the skin is
removed between them. Hemostasis is obtained and
the skin is closed with absorbable sutures.
49.5 Vasectomy
Vasectomy is the only form of male birth control cur-
rently available. It is advisable to involve the spouse or
significant other in the decision making process and in
witnessing the consent. The genitalia should be exam-
ined for the presence of large varicocele or hydrocele
as this may indicate the need for doing the procedure in
the operating room rather than a procedure room. After
shaving and prepping the scrotum, the right vas is
manipulated to the midline raphe, using the thumb and
49 Minor Procedures
the index finger to drape and tense it over the long fin-
ger held behind it. The overlying scrotum is injected
with 2% lidocaine. The needle is then directed parallel
to the vas in the direction of the external inguinal ring
and the external spermatic sheath is injected as the nee-
dle is withdrawn. The left vas is then manipulated to
the midline wheal and similarly injected. The right vas
is again brought to the midline and a 1 cm incision is
made transversely over it, continuing down to the vasal
sheath. The sheath is then incised vertically and the vas
is gently grasped. It should be easily pulled from the
sheath and if it is not, the sheath may need deeper inci-
sion. A small mosquito clamp is then used to gently
dissect the vessels from the posterior aspect of the vas.
The testicular end is then ligated and the vas is transected
at least 1 cm above the ligature. A handheld cautery is
then used to cauterize 1 cm of the lumen of the abdomi-
nal end of the vas. This is to cause fibrosis of the lumen.
The abdominal end is allowed to retract and the vasal
sheath is closed over the stump with a gut suture. A
1 cm segment of the testicular end of the vas is then
transected and sent for pathological inspection. The
scrotum may be closed with dissolvable sutures but
meticulous hemostasis should be first obtained. The
patient should lie supine for 12–24 h and intermittent
ice packs (packages of frozen peas do well) are helpful.
Scrotal contraction may decrease hematoma rates.
Patients should abstain from sexual intercourse for at
least 1 week to allow for lumenal fibrosis.
The time to azoospermia is most dependant on
the number of ejaculations. Ninety-eight percent of
patients are azoospermic after 24 ejaculations. Sixty-
seven to ninety-eight percent of patients are azoosper-
mic at 3 months. Therefore, patients are scheduled for
the first semen analysis at 3 months and 24 ejacula-
tions. They return at 4 months for the second semen
analysis. Patients should use contraception until two
azoospermic semen analyses are achieved.
Recanalization rates or failure are less than 1%.
Scrotal hematoma rates may be 3%. Complications such
as sperm granuloma and chronic scrotal pain are rare.
49.6 Lymph Node Biopsy
Perhaps the most important consideration in undertak-
ing lymph node biopsy is to carefully consider the dif-
ferential diagnosis and to seek out regional causes of
385
the lymphadenopathy. For instance, one should never
embark upon removing a solitary jugular chain node
before a complete examination of the head and upper
aerodigestive are performed. The face, parotid, and
scalp should be examined for primary lesions. The role
of radiologic evaluations such as CT, MRI, and PET
scan should be entertained as well. If the lymph node
is low in the cervical chain, evaluation of the chest
should be included. In a large review of neck masses,
Skandalakis found 3% to be inflammatory, 85% to be
malignant, and 12% to be congenital, emphasizing the
importance of regional workup particularly in the adult
patient. Fine needle aspiration should be performed
before open lymph node biopsy. Open biopsy should
only be performed when the nature of the mass remains
unconfirmed despite exhaustive clinical, laboratory,
and radiologic evaluation.
Patterns of metastasis to the neck nodes are predict-
able and can be used to focus clinical exam. The floor
of the mouth, anterior tongue, and buccal cavity all
drain to the submaxillary, submental, and upper jugu-
lar lymph node group. The nasopharynx tends to drain
to the upper posterior triangle. The larynx, hypophar-
ynx, and thyroid drain to the midjugular group. The
upper esophagus, hypopharynx, and thyroid gland
drain to the lower group. The lung, ovary, breast, stom-
ach, and prostate may drain to the supraclavicular
­triangle (Virchow’s node). Once an open biopsy is per-
formed, the surgeon should be prepared to perform a
neck dissection if frozen section reveals squamous cell
cancer. Neck dissection is contraindicated if special
stains reveal lymphoma. If frozen section results are
equivocal or reveal an undifferentiated cancer, therapy
must await the final pathologic reading.
In performing lymph node biopsy of the neck, the
initial incision is either made in Langer’s lines (relaxed
skin tension lines) or planned so as to be extended into
a neck dissection if necessary. The subcutaneous fat
and platysma are then incised. Superficial veins are
ligated and divided as necessary. These veins are teth-
ered to the cervical fascia and tend to remain open and
bleed when cut. As the node is dissected free, all lym-
phatics to it are ligated. The superficial sensory nerves
to the neck, scalp, and ear pierce the cervical fascia at
the posterior border of the sternocleidomastoid muscle
halfway between the mastoid and the clavicle (Erb’s
point). They should be preserved when possible. In
particular, the greater auricular nerve travels craniad
on the superficial aspect of the sternocleidomastoid
386
from Erb’s point to the ear and its lobule. Should the
biospy occur near the venous angle of the internal jug-
ular and the subclavian veins, particularly on the left,
the presence of the terminal thoracic duct complex
should be remembered. The complex can be plexiform
in 7–26% of the cases so an effort should be made to
tie off all transected lymphatics so as to avoid wound
complications and lymphatic leak. Lastly, in the infe-
rior neck and the posterior triangle, the brachial plexus
should be avoided by bluntly performing dissection of
the posterior aspect of the node to be removed.
49.7 Ingrown Toenail (Onychocryptosis)
Ingrown toenail may occur as a result of trauma, tightly
fitting shoes, or improper trimming. Most ingrown
nails respond to conservative treatment starting with
identifying and correcting the underlying problem.
The nail is then separated from the nail fold so that it
has an unobstructed path for growth. Warm soaks may
help. If this treatment does not work partial nail
removal with or without germinal matrix ablation may
be necessary. A digital block of 1% or 2% lidocaine is
administered. A penrose tourniquet may be used at the
base of the toe. Fine scissors are inserted under the
portion of nail to be removed so as to separate it right
down to the base of the nail fold. A #15 blade can be
used as well, keeping the belly of the blade against,
and visible through the nail. Once the nail is separated,
a partial removal is completed by scissors. Alternately,
a mosquito clamp may be used to grasp the nail all the
way to the base. The entire nail is then removed by
rolling the nail out of the fold from side to side in the
same fashion that one opens a can of sardines with a
key. Partial or total nail bed ablation is performed by
applying phenol to the germinal matrix for at least two
cycles, 1 min each. Bleeding is controlled with pres-
sure or silver nitrate.
Recommended Reading
Grafts
Aston, S.J., Beasley, R.W., Thorne, C. (eds.): Grabb and Smith’s
Plastic Surgery, 5th edn. Lippincott-Raven, Philadelphia
(1997)
E. Mooney
Mathes, Stephen (ed.): Plastic Surgery, vol. 1, 2nd edn. W. B.
Saunders, Philadelphia (2006)
Circumcision
Elder, J.S.: Abnormalities of the genitalia in boys and their surgi-
cal management. In: Walsh, P.C. (ed.) Campbell’s Urology,
8th edn, pp. 2334–2337. W.B. Saunders, Philadelphia (2002)
Lannon, C.M., Bailey, A.G.D., Fleischman, A.R., et al.: Circumcision
policy statement. Pediatrics 103(3), 686–693 (1999)
McAleer, I.M., Kaplan, G.W.: Circumcision. In: Graham, S.D.
(ed.) Glenn’s Urologic Surgery, 6th edn, pp. 8522–8526.
Lippincott, Williams, & Wilkins, Philadelphia (2004)
Skoog, S.J., Scherz, H.C.: Office pediatric urology. In: Gillenwater,
J.Y. (ed.) Adult and Pediatric Urology, 4th edn, pp. 2675–
2676. Lippincott, Williams, & Wilkins, Philadelphia (2002)
Vasectomy
Pryor, J.L.: Vasectomy. In: Graham, S.D. (ed.) Glenn’s Urologic
Surgery, 6th edn, pp. 450–454. Lippincott, Williams, &
Wilkins, Philadelphia (2004)
Lymph Node Biopsy
Cohen, M., Dolezal, R.F.: Diagnostic approach to neck masses.
In: Nyhus, L.M., Baker, R.J. (eds.) Mastery of Surgery, 2nd
edn, pp. 147–162. Little, Brown, and Co, Boston (1992)
Monsen, H.: Anatomy of the anterior and lateral triangles of the
neck. In: Nyhus, L.M., Baker, R.J. (eds.) Mastery of Surgery,
2nd edn, pp. 145–146. Little, Brown, and Co, Boston
(1992)
Skandalakis, J.E., Gray, S.W., et al.: Tumors of the neck. Surgery
48, 375 (1960)
Skandalakis, J.E., Skandalakis, L.J., Skandalakis, P.N.: Anatomy
of the lymphatics. Surg. Oncol. Clin N. Am. 16(1), 1–16
(2007)
Stiernberg, C.M., Mostert, J.F.: Unknown primary lesion. In:
Shockley, W.W., Pillsbury, H.C. (eds.) The Neck. Diagnosis
and Surgery, pp. 431–437. Mosby, St. Louis (1994)
IGTN
Chavez, M.C., Maker, V.J.: Office surgery. In: Rakel, R.E. (ed.)
Textbook of Family Practice, pp. 662–663. W.B. Saunders,
Philadelphia (2002)
 Part
IV
Relevant Orthopaedics for General
Surgeons
 Simple Orthopaedic Procedures
and Common Diagnoses
David Wysocki and René Zellweger
50.1 General Assessment of Injuries
to the Extremities
A history must be taken from the patient or a witness to
the injury. The limb should be inspected prior to a sys-
tematic palpation and assessment for stability and range
of motion. Open wounds should be washed thoroughly
and dressed with gauze soaked in an antiseptic solution.
The primary goal of the emergency treatment of
limb injuries is reduction and splinting of fractures and
dislocations. By reducing the displaced bone, further
insult to the soft tissues can be avoided. Reduction will
improve local and peripheral vascularisation. Exact
reposition is secondary at this time. Put the extremity
into axial alignment, restore the local and peripheral
vascularisation and treat the pain with analgesia. Open
fractures can be treated like closed fractures after the
application of a sterile dressing.
50.2 Principles of Closed Reduction
and Non-operative Fracture
Treatment
50.2.1 Closed Reduction
Whether a fracture is treated operatively or not,
a fracture with unacceptable displacement of frag-
ments must be reduced to decrease the pressure
D. Wysocki and R. Zellweger (*)
Department of Orthopaedic Surgery, Royal Perth Hospital,
Wellington Street Perth, WA, Australia
e-mail: rene.zellweger@health.wa.gov.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_50, © Springer-Verlag Berlin Heidelberg 2011
50
on the soft tissue, vessels and nerves as soon as
possible.
To effectively reduce a fracture, the mechanism of
injury should be understood. For example, an external
rotation injury to the ankle may produce a spiral distal
fibula fracture and dislocation of the talus laterally. It is
tempting to simply force the talus back underneath the
tibia with lateral force. While this may achieve reduc-
tion to some extent, by placing traction and internally
rotating the foot a more anatomical reduction can be
achieved. All manoeuvres should be done slowly, not
with sudden force. Care should be used if latex gloves
are worn, especially in the elderly, as skin tears can be
created.
Prerequisites for a closed reduction include suffi-
cient analgesia and enough staff to apply traction,
countertraction and create the plaster. Reduction radio-
graphs in two planes must follow to ensure adequate
position.
50.2.2 Plaster Casting
With the advent of modern methods of internal fixa-
tion, the application of a good plaster is a skill, which
has become somewhat overlooked. However, the appli-
cation of an appropriate plaster, which prevents loss of
reduction, can often negate the need for a patient to
have surgery.
A full plaster should never be placed on a patient in
the acute setting. As the limb swells, a complete cast
could create a compartment syndrome. A cylinder
plaster, which is split, is the only safe method of immo-
bilisation. As the swelling subsides, the plaster can
become loose allowing the fracture to lose posi­
tion. The patient should be advised to re-tighten the
389
390
overlying bandage every 48 hours. A good plaster will
only immobilise the required joints. A common mis-
take is extending a plaster designed for a distal radius
fracture past the metocarpophalangeal joints. Patients
should be encouraged to move the non-splinted joints
to prevent stiffness. If a patient complains of pain in a
plaster, it should always be removed and examined for
pressure sores.
50.2.3 Traction
Traction is a simple way of initially managing most
lower limb and humeral fractures. The principal disad-
vantage of traction treatment is a longer confinement
of the patient to bed. With today’s modern methods of
internal fixation, traction is rarely used to treat a frac-
ture until complete union. It remains a useful method
to provide analgesia to patients who require transfer or
bed rest while awaiting surgery.
There are two major types of traction: skin and
skeletal tractions. Skin traction employs tapes, boots
or straps. Skeletal traction requires a surgical proce-
dure to insert a metal pin through the bone enabling
larger forces to be applied to the injured limb. The
pins must always be clean to avoid infection, and
traction equipment should be checked regularly to
ensure proper position and exertion of force. The
amount of traction required will vary with the method
of traction, the size of the patient and the type of
fracture.
50.3 Operative Treatment: External
Fixator and Osteosynthesis
50.3.1 External Fixation
The concept of external fixation is rather simple.
Metal frames are placed outside the skin, which stabi-
lise the bone fragments through wires or pins
­connected to one or more longitudinal bars. The
advantages are less damage to the blood supply of the
bone and minimal interference with the soft tissue
cover. The rigidity of the fixation is adjustable with-
out surgery and the technique requires less experience
D. Wysocki and R. Zellweger
and surgical skills than does internal fixation. These
advantages are offset by the complications related to
the pins in the bone.
Indications:
• Open fractures
• Damage control orthopaedic surgery in severe
­multiple-trauma patients
• Bone infections or increased risk of infections
50.3.2 Principles of Osteosynthesis
Osteosynthesis refers to operative stabilisation of a
fracture, which can be achieved with two different bio-
mechanical principles: anatomical reduction and abso-
lute stability, which creates union through direct
healing of the two bone ends, or relative stability and
bone healing through callus formation. The two prin-
ciples are determined by either compression between
the two fragments for stability or no interfragmentary
compression. The selected way of fracture treatment
can be achieved using various techniques of osteosyn-
thesis. The decision of which technique to choose from
a biomechanical point of view depends on the possible
accompanying soft tissue injury, the nature of the frac-
ture, the direction of the fracture line and the number
of bone fragments.
The principles stated by the AO Group (working
group for osteosynthesis) formed in Switzerland in
1958 have remained consistent and clear over the last
60 years. Their principles relating to anatomy, stabil-
ity, biology and mobilisation still stand as fundamen-
tals today.
AO principles:
1. Preservation of the blood supply to soft tissue
and bone
2. Anatomic reduction of the fracture fragments
3. Stable internal fixation or splintage
4. Early active mobilisation
Indications for internal fixation are fractures that can-
not be reduced and held with conservative measures,
fractures that have failed conservative treatment by
progressing to a nonunion or by losing acceptable
reduction, open fractures, pathological fractures or
fractures that if treated conservatively, will result in an
unacceptable period of recumbence.
50 Simple Orthopaedic Procedures and Common Diagnoses
50.4 Distal Radial Fractures
50.4.1 Introduction
Distal radial fractures account for approximately 15%
of all fractures seen and treated in emergency depart-
ments. The incidence of distal radius fractures peaks in
two age groups: between 6 and 10 years of age and
between 60 and 80 years of age. It is associated with
moderate to severe trauma in young adults.
50.4.2 Mechanism of Injury
The classical trauma resulting in a distal radius frac-
ture is a fall on the outstretched hand. Depending on
the position of the hand, there are different bending
and compression forces, which cause different fracture
types.
50.4.3 Classification System
There are many classifications used for distal radial
fractures but none have been accepted as the standard
method. However, there are eponyms that are
a b
Fig. 50.1 Common distal radial fractures. (a) Colles fracture
(b) Volar Barton’s fracture (c) Smith’s fracture (d) Chauffeurs
fracture The existing figure will be replaced by a new one which
391
ubiquitous in clinical practice. Four commonly used
include (See Fig. 50.1):
Colles fracture (see Fig. 50.1a): This injury is clas-
sically seen in patients suffering with osteoporosis
and presents with a dinner fork deformity. The frac-
ture occurs within approximately 2.5 cm of the wrist
joint. The most obvious features are dorsal displace-
ment and dorsal angulation of the distal segment. This
is usually accompanied with elements of radial dis-
placement, radial angulation of the distal fragment
and also impaction and comminution of the dorsal
cortex. The fracture can also extend into the joint
surface.
Volar Barton’s fracture (see Fig. 50.1b): This frac-
ture extends from the volar cortex into the wrist joint.
The fracture is usually unstable demonstrated by volar
displacement. Often subluxation of the carpus follows.
Smith’s fracture (see Fig. 50.1c): This is an extra-
articular fracture of the distal radius with volar dis-
placement of the ­distal segment.
Chauffeur’s fracture (see Fig. 50.1d): This is a frac-
ture of the radial styloid. The injury occurs due to a fall
onto the outstretched hand but has classically been
described as being caused by the kickback of starting
an engine with a handle. The fracture is often associ-
ated with injury to the scapho-lunate ligaments, as
seen on radiographs by widening of the joint space
between the ­scaphoid and the lunate. This injury usu-
ally requires surgical repair.
c d
my wife will draw and then send to Springer to have it modified
by their grafic’s department
392
50.4.4 Examination and Diagnosis
Swelling, deformity and painful restriction of move-
ment are common features of all fractures of the distal
radius. Examination should rule out wounds, which
may represent an open fracture. Careful examination
of the neurovascular status of the hand is important.
The median nerve runs across the volar aspect of the
wrist and is at risk from sharp fracture edges and also
stretching injures from displaced fractures. Persisting
or progressing median nerve symptoms after reduction
is an indication for emergency carpal tunnel release.
Radiographs should be taken in anterior–posterior
and lateral planes. Examination should also exclude
associated injuries such as scaphoid fractures, disloca-
tion of the distal radio-ulnar joint and proximal upper
limb fractures.
50.4.5 Treatment
The emergency treatment includes the reduction of
dislocations and displaced fractures and application of
an appropriate split plaster.
Indications for operative treatment must be indi-
vidualised based on the nature of the injury, general
health and functional requirements of the patient.
The restoration and maintenance of anatomy will
enhance the potential for a full functional outcome.
The normal radiographic features of the wrist include
approximately 10° of volar tilt, 20–25° of radial incli-
nation and a radial styloid length of approximately
10 mm. Indications for open reduction and internal
fixation in an otherwise healthy patient include a step
or gap in the articular surface of greater than 1 mm,
loss of radial length greater than 2 mm, obvious loss of
volar tilt or radial inclination.
50.4.5.1 Non-operative Treatment
The undisplaced or reduced fracture is initially held in
a well-moulded split plaster to allow for swelling.
Radiographs taken through the plaster at 1 and 2 weeks
will detect loss of reduction of the fracture. If a new
plaster is applied, radiographs in that plaster should
be taken. The fracture should be immobilised for
D. Wysocki and R. Zellweger
4–6 weeks then a radiograph out of plaster should be
taken to assess for callus. If clinical examination to
assess for union is reassuring, then the patient can
begin gentle motion of the wrist.
50.4.5.2 Operative Treatment
There are three commonly used methods of surgical fixa-
tion: Kirschner wires, external fixation and fixation with
plates. They can be used separately or in combination.
Kirschner wires are a minimally invasive, cheap
method of fixation and, if used in isolation, usually
require an additional 6-week plaster fixation. The wires
should be inserted to penetrate the proximal cortex.
They are normally removed after a period of 6 weeks.
It can be difficult to hold osteoporotic bone in position
with Kirschner wires alone.
An external fixator is used as primary stabilisation
if there is an accompanying severe soft tissue injury or
in highly comminuted fractures. Two pins are inserted
into the distal third of the radial shaft and two into the
lateral aspect of the metacarpal shaft of the index fin-
ger. With pull and positioning of the hand, the reduc-
tion is mainly achieved with ligamentotaxis. The main
disadvantage of this treatment is that it is a joint-bridging
fixation and therefore functional rehabilitation is not
possible until the fixator can be removed, which can
result in significant stiffness of the joint. Therefore after
healing of the soft tissue, a definitive fixation with a plate
is advisable.
Plate osteosynthesis is usually done with volarly
or dorsally positioned plates. With the advent of lock-
ing plate technology, volar plates can be used very
successfully in osteoporotic fractures. They also
allow early mobilisation of fractures in patients with
good bone quality. Dorsal plating is associated with
significant risk of tethering the extensor tendons, is
only indicated in highly comminuted fractures and
must be done by experienced orthopaedic trauma
surgeons.
50.4.6 Complications
Median nerve injury and compartment syndrome need
to be considered when patients present with the injury.
Stiff wrist joints are common following immobilisation,
50 Simple Orthopaedic Procedures and Common Diagnoses
and it is important that plasters leave the metacarpal
joints free to prevent unnecessary stiffness in the hand.
Reflex sympathetic dystrophy is a serious complication
of both operative and non-operative treatment, which
needs to be treated with attentive hand therapy and spe-
cialised pain management. Rupture to the extensor ten-
dons can occur early or later due to abrasion on screws
passing through the dorsal cortex. Later complications
include post-traumatic osteoarthritis from damage to
the joint surface or malunion. Nonunion is rare.
50.5 Clavicle Fracture
50.5.1 Introduction
Clavicle fractures account for approximately 5% of all
fractures seen in the emergency department. The clav-
icle serves as the primary connection between the tho-
rax and the upper limb, connecting the sternoclavicular
joint medially to the acromioclavicular joint laterally.
Associated damage to the underlying neurovascular
structures, scapula, ribs or lungs is uncommon.
50.5.2 Mechanism of Injury
Most clavicular fractures result from a fall on to the
shoulder or a direct blow to the clavicle or shoulder.
Less commonly, the impact can be transmitted up the
arm from a fall on the outstretched hand.
50.5.3 Classification
Clavicle fractures are classified by their location:
medial, middle and lateral thirds.
50.5.3.1 Fracture of the Middle Third
Middle third fractures are the most common, account-
ing for approximately 80% of clavicle fractures.
Generally, the lateral portion is pulled down by the
weight of the arm and the proximal portion is pulled
upward by the sternocleidomastoid muscle.
393
50.5.3.2 Fracture of the Lateral Third
Lateral third injuries account for 10–15% of clavicle
fractures. The proximal portion may be displaced
upwards if the coracoclavicular ligaments are ruptured.
50.5.3.3 Fracture of the Medial Third
Medial third fracture is a rare injury associated with
high energy and often other concomitant injuries.
50.5.4 Examination and Diagnosis
The patient will typically present holding the injured
limb with the unaffected side. Localised tenderness over
the fracture is typical. There may be a deformity of the
clavicle and occasionally the skin will be tented by the
fracture. An open clavicle fracture is rare, as is associ-
ated neurovascular damage. However, if the fracture is
severely displaced, damage can occur to the medial cord
of the brachial plexus so that a neurological assessment
has to be performed to exclude this. The fracture is best
visualised with an anterior–­posterior radiograph.
50.5.5 Treatment
The majority of clavicle fractures can be treated non-
operatively (see Fig. 50.2). Strong indications for
operative treatment include open fractures, neurovas-
cular compromise and symptomatic nonunion.
Displaced lateral clavicle fractures with associated
coracoclavicular ligament rupture should be treated
operatively as should clavicle fractures associated with
a glenoid neck fracture. Relative indications for sur-
gery include 2 cm of shortening, 1 cm of displacement
or significant clinical deformity. These have even more
relevance to overhead athletes and manual labourers.
50.5.5.1 Non-operative Treatment
Non-operative treatment involves early immobilisation
in a broad arm-sling, usually for 2–3 weeks. Once the
patient’s pain begins to settle, they can proceed with a
394
1
2 4
5
3 the supra-clavicular nerves are cut. Patients often feel
Fig. 50.2 Non-operative treatment: 1 - medical clavicle fracture,
2 - lateral clavicle fracture, 3 - glenoid, 4 coracoid, 5 - acromion
gentle range of motion. Despite deformity, healing usu-
ally proceeds rapidly. Union occurs with prominent cal-
lus seen on radiographs. Distal clavicle fractures may
have a higher incidence of nonunion, but most of these
are asymptomatic. A small number will require surgery.
50.5.5.2 Operative Treatment
Operative treatment can be done with either a plate or
elastic nailing. With plate fixation, a large strong plate
is required to overcome the bending and torsional forces
on the clavicle. Therefore, plates can be prominent and
often have to be removed after 12–18 months.
Elastic nailing is an option, which is less invasive
and avoids most of the problems of the plate. However,
migration of the nail can require further unplanned
surgery. The nail can be inserted at the sternal or lateral
end of the clavicle. Removal of the nail is necessary
after 3 months.
The patient should be advised to wear a broad arm-
sling for some days after the surgery, mainly for com-
fort and better wound healing. After that time period,
D. Wysocki and R. Zellweger
the patient should be encouraged to begin moving the
shoulder and the arm. Usually callus can be seen on
x-ray after 4–6 weeks.
50.5.6 Complications
Fractures, which are widely displaced, are at risk of
soft tissue interposition and can have higher rates of
nonunion. Significantly shortened clavicles will result
in asymmetry of the shoulders and are at risk of reduced
overhead function.
The surgical approach can create a numb area over
the anterior wall of the chest, as low as the nipple if
discomfort of the palpable plate under the skin. It is
important to advise them that fixation of the fracture
will likely require removal of the metalwork in the
future.
50.6 Shoulder Dislocation
50.6.1 Introduction
The shoulder joint is the most commonly dislocated
joint, making up 50% of all dislocations presenting
to the emergency department. The shoulder has both
static restraints (labrum and capsular ligaments) and
dynamic restraints (rotator cuff and long head of
biceps) that contribute to its stability. The shoulder
has little in the way of osseous restraints, making it
both the most mobile and inherently the most unsta-
ble joint in the body. In more than 90% of cases, the
first dislocation of the shoulder is traumatic. The
majority of all shoulder dislocations happen before
the age of 30.
50.6.2 Classification
The relation of the humeral head to the glenoid classi-
fies shoulder dislocations: anterior, posterior and infe-
rior dislocation of the shoulder. Anterior shoulder
dislocations account for approximately 85% of all
shoulder dislocations.
50 Simple Orthopaedic Procedures and Common Diagnoses 395

50.6.3 Mechanism of Injury

Anterior dislocations occur due to falls or being struck

on the externally rotated and abducted shoulder. The
supero-lateral aspect of the humeral head may strike the
antero-inferior glenoid causing fracture of the greater
tuberosity, impaction of the cortical bone over the tuber-
osity (Hills Sachs lesion), rupture of the anterior capsule N
1
and labrum (Bankart lesion) or fracture of the glenoid
(bony Bankart lesion). Muscle spasm will pull the
humeral head medial to the glenoid. This injury is com-
mon in the age group of 18–25 years of age due to high-
energy motorcycle and athletic injuries, and also in the
elderly where the stability of the shoulder may be
impaired by muscle degeneration. The older population
will either fracture the greater tuberosity or rupture the
rotator cuff. In rare cases, there can be damage to the
neurovascular structures, particularly the axillary nerve.
Posterior dislocations occur due to falls on the 3
2
­internally rotated shoulder or from direct blows on the
anterior shoulder. Inferior dislocations (luxatio erecta)
occur due to falls onto the abducted shoulder or hyper
abduction, with the humeral shaft levering on the
Fig. 50.3 Dislocation of the shoulder: N normal, 1 anterior
­acromion, dislocating the shoulder inferiorly. d­ islocation, 2 posterior dislocation, 3 luxation erecta

Fracture of the greater tuberosity does not ­influence

50.6.4 Examination and Diagnosis
With anterior and posterior dislocations, patients will
typically present supporting the injured arm at the
elbow with the other hand. The lateral contour of the
shoulder is lost, with a palpable gap beneath the acro-
mion. The humeral head should be palpable either
anterior or posterior to its normal position. In a doubt-
ful case, palpation of the humeral head in the axilla
will confirm anterior dislocation.
Inferior dislocations will present with the patient
unable to lower the arm from an abducted position.
Before attempting reduction, it is important to take
radiographs to confirm the diagnosis and to exclude fur-
ther osseous injures. The majority of anterior disloca-
tions show quite clearly on the standard anterior–posterior
radiograph, unless the humeral head has minimal medial
displacement. Posterior dislocations are evidenced by
rotation of the humeral head on anterior–posterior
radiographs; however this can be easily missed (See
Fig. 50.3). Both anterior and posterior ­dislocations can
be confirmed on an axillary view radiograph.
the initial treatment, but will require subsequent atten-
tion following reduction. Often an anatomical reduc-
tion of the greater tuberosity fracture will be achieved
with reduction of the dislocated shoulder.
50.6.5 Treatment
50.6.5.1 Anterior Dislocation
In total there are more than 20 different reposition tech-
niques. By far the most common are (1) the Kocher
method and (2) the Hippocratic method. Excessive
force should not be applied with any method, as further
injury to the limb, such as damage to neurovascular
structures or fracture to the neck of the humerus, is pos-
sible. It is important to relocate the shoulder as soon as
possible to prevent articular cartilage necrosis and palsy
of the surrounding nerves.
All reduction methods will require analgesia and
perhaps sedation. In muscular patients it may be neces-
sary to give neuromuscular blockade.
396
1. Kocher’s method: Apply traction and begin to rotate
the arm externally. Take plenty of time for external
rotation. In the conscious patient, if muscle resis-
tance is felt, stop for a moment while distracting the
patient’s attention. It should be possible to reach 90°
of external rotation. The shoulder frequently reduces
with a clear ‘clunking’ sensation during the external
rotation procedure. If this does not happen, adduct
the shoulder so that the elbow starts to come across
the chest. Then internally rotate the shoulder bring-
ing the patient’s hand towards the opposite shoulder.
If reduction has not occurred, repeat all stages,
attempting to get more external rotation in the initial
stage. If severe pain and muscle spasm prevent rota-
tion, or reduction has not been achieved in the sedated
patient, a general anaesthesia will be required.
Complete failure is rare under general anaesthesia.
2. Hippocratic method: Place the patient in a supine posi-
tion. Apply traction on the forearm while either the
clinician’s foot or a looped sheet is placed in the axilla
for counter traction. The dislocated shoulder is held in
abduction and external rotation and moved into adduc-
tion and internal rotation during the procedure.
50.6.5.2 Posterior Dislocation
Reduction is accomplished by applying traction longi-
tudinally and laterally. Gentle internal rotation may be
required to disimpact the head while external rotation
and/or posterior force will reduce the head.
50.6.5.3 Inferior Dislocation
Reduction is accomplished by applying traction in
abduction (the position in which the limb is lying) and
gently moving the arm into adduction.
50.6.6 Aftercare
Post reduction, radiographs should be taken to confirm
relocation, before anaesthesia is discontinued if possible.
The arm should be supported in a broad arm-sling after
reduction to lessen the risks of immediate redislocation
and to help relieve pain. In younger patients, the
D. Wysocki and R. Zellweger
shoulder should be kept immobile for 3–4 weeks to
allow torn tissue to heal. In older age groups, where risk
of redislocation is minimal, gentle range of motion
should begin as soon as pain allows to prevent stiffness.
The risk of redislocation following a traumatic first
dislocation decreases as the age of the patient increases.
An 18 year old will have a high risk of redislocation
which falls to less than 10% by age 40.
Young patients with symptomatically instability
may require a shoulder stabilization procedure. Older
patients with ongoing painful shoulder or reduced
range of motion should be investigated for rotator cuff
tears, which may need surgical repair.
Dislocations of the shoulder with associated frac-
ture of the glenoid (bony Bankart) have a high risk of
recurrent dislocation and should be referred to an upper
limb specialist.
A fracture of the greater tuberosity, which does not
reduce after reposition of the shoulder, will require
surgical fixation. Reduced fractures should be followed
up with regular radiographs to ensure that there is no
late displacement due to the pull of the rotator cuff
superiorly and posteriorly. These patients should be
immobilised in a sling for 6 weeks until signs of union,
allowing only passive pendulum exercises after
10–14 days to prevent stiffness.
50.6.7 Operative Treatment
Open reduction may have to be considered, if closed
reduction fails. This is usually due to interposition of
capsule or torn rotator cuff tendon. Shoulders, which
have been dislocated for some time, may also require
open reduction.
50.7 Humeral Shaft Fractures
50.7.1 Introduction
Humeral shaft fractures account for around 3% of all
fractures. The majority of the humeral shaft fractures
can be treated non-operatively. However, there are
­certain fracture patterns that are preferably treated
surgically.
50 Simple Orthopaedic Procedures and Common Diagnoses
50.7.2 Mechanism of Injury
Humeral shaft fractures commonly occur with falls on
to the outstretched arm, motor vehicle accidents or
direct blunt force. The mechanism of injury will be
reflected in the pattern of fracture. Torsional injuries
will create long spiral fractures, whereas blunt force
produces transverse fractures.
50.7.3 Classification System
No classification scheme for humeral shaft fractures
has gained universal acceptance. Traditionally, humeral
shaft fractures have been described according to the
anatomical features. The location is described as prox-
imal, middle and distal shaft, the pattern as transverse,
oblique, spiral, segmental or comminuted.
50.7.4 Examination and Diagnosis
Patients with a humeral shaft fracture present with arm
pain, deformity and swelling. The arm is shortened,
with movement at the fracture site and crepitus on
manipulation. The incidence of associated radial nerve
palsy with humeral shaft fractures is almost one in five,
so a careful neurological examination of the upper
limb must be done.
50.7.5 Treatment
Non-operative treatment is the standard treatment for
humeral shaft fractures, with high union rates of greater
than 90%. In comparison with other shaft fractures,
the shaft of the humerus heals relatively quickly and
with a good functional result. Acceptable alignment
of humeral shaft fractures is considered to be 30° of
varus/valgus angulation, 20° anterior–posterior angu-
lation or 3.0 cm of shortening.
Indications for operative treatment include inability
to maintain an acceptable reduction of the fracture. This
can be due to the pattern of fracture, such as ­transverse
fractures, open or pathological fractures. Fractures,
397
which progress to nonunion, and fractures, which can-
not be reduced due to soft tissue interposition, will all
require surgical intervention. Obesity and non-compli-
ance of the patient can indicate the need for surgery.
Associated radial nerve palsy does not necessarily
require surgical exploration, as the majority will recover
within months. Acute and delayed repairs of the radial
nerve have the same outcomes. A radial nerve palsy
which develops after fracture reduction is an absolute
indication for surgical exploration. Fractures, which
extend into the joint surface, creating a step in the artic-
ular margin, will require open reduction. Associated
injures, such as ipsilateral forearm, contralateral
humerus fractures or spinal cord injuries, are relative
indications for internal fixation to aid in rehabilitation.
50.7.5.1 Non-operative Treatment
Humeral shaft fractures are often initially very painful
and require good immobilisation. The ability to make
an effective hanging arm cast is an important skill for
the emergency physician or rural surgeon. The patient
should be advised to sleep propped up on pillows and
avoid leaning on the elbow, or placing ­pillows under the
elbow as effective reduction relies on the weight of the
elbow and forearm supplying traction to the fracture.
The hanging arm cast can be replaced with a functional
arm brace, such as the Sarmiento brace, at 1–3 weeks.
This will allow some movement of the elbow and
shoulder. The brace is usually required for a further
6–10 weeks. Regular check radiographs in the cast and
brace are required to ensure adequate reduction is
maintained. A mild malunion is common, but this will
not create a functional deficit or clinical deformity.
50.7.5.2 Operative Treatment
The operative treatment options are fixation with a
plate, intramedullary nailing or external fixation. Plate
fixation will require a strong, usually a broad or nar-
row 4.5-mm plate. Three or four dual cortical screws
are needed on either side of the fracture. The most sat-
isfying results with this method are obtained in patients
with a humeral shaft fracture with no comminution
and with an oblique component to allow lag screw
fixation. In contrast, comminuted fractures are best
398
treated with the bridging plate principle. They may
also require bone grafting. In proximal third humeral
shaft fractures, the plate is most commonly placed on
the antero-lateral surface of the humerus. In the case of
a segmental fracture, an additional interfragmentary
lag screw might be needed. Generally, fractures of the
mid and distal shaft should be plated posteriorly. The
posterior approach exploits the interval between the
lateral and long heads of the triceps. The medial head
is then incised down the midline to expose the poste-
rior aspect of the humeral shaft. Some surgeons, how-
ever, favour the anterior or antero-lateral approach in
order to avoid injury to the radial nerve.
Intramedullary nails can be used in multiple-trauma
patients, pathological or osteopenic fractures. They
have a good healing rate and often allow early weight
bearing. Intramedullary nails have certain advantages
and disadvantages when compared to fixation with
plates and screws. The nails are closer to the normal
mechanical axis and are subject to lower bending
forces, making implant failure by fatigue less likely to
occur. Intramedullary nails can be placed without
direct fracture exposure and with much less soft tissue
damage. They can be inserted either anterograde or
retrograde. The anterograde approach demands split-
ting the rotator cuff which can compromise shoulder
function. Retrograde insertion requires a distal triceps
splitting approach. The neurovascular bundle is at risk
while locking the distal nail. Also the intramedullary
canal narrows distally, which can cause difficulty. This
technique should not be used if radial nerve palsy is
present.
An external fixator can be used with a severe soft
tissue injury, gunshot fractures as well as with a mul-
tiple injured patient and with open fractures. If used as
a primary fixation, it can be changed to a plate or nail
after the soft tissue has recovered, usually after
5–14 days.
50.7.6 Complications
Nonunion is a rare complication in humeral shaft frac-
tures. It is seen slightly more often in fractures treated
surgically. In cases with radial nerve palsy, where no
improvement is seen after approximately 6 weeks,
electrophysiological studies may be required to predict
outcome.
D. Wysocki and R. Zellweger
A note should be made of the position of the radial
nerve in relation to the plate at the time of surgery so
that reference can be made in cases, which require
removal of the metal. In all cases, the patient should be
encouraged to begin a gentle range of motion of the
shoulder and elbow as soon as sufficient fracture
­stability has been reached to avoid joint stiffness.
50.8 Soft Tissue Knee Injuries
50.8.1 Introduction
Soft tissue injuries to the knee account for 15–30% of
all sporting injuries. To correctly diagnose knee inju-
ries, it is important to have an understanding of the
functional anatomy of the knee. There are four bones
that come together at the knee. Movement and weight
bearing occur where the femoral condyles match up
with the tibial plateaus. The patella sits in the trochlea
of the femur, which forms the patellofemoral joint.
The patella is stabilised in the trochlea on either side
by the retinaculum. The quadriceps tendon contains
the patella, which is renamed the patella tendon below
the patella.
Four major ligaments maintain the stability of the
knee joint. The medial collateral ligament (MCL) is the
primary stabiliser of the knee joint against valgus stress.
The lateral collateral ligament (LCL) prevents the joint
from lateral dislocation. The anterior cruciate ligament
(ACL) and the posterior cruciate ligament (PCL) form
an ‘X’ on the inside of the knee and prevent the knee
from anterior and posterior dislocation. They also limit
the internal rotation of the knee joint and act as second-
ary stabilizers to varus and valgus forces.
Inside the knee, there are the lateral and the medial
shock-absorbing menisci that sit on the top surface of
the tibia. The menisci conform to the femoral condyle
to distribute weight across the tibial articular surface to
reduce friction.
50.8.2 Mechanism of Injury
The knee is vulnerable to twisting or stretching inju-
ries, taking the joint through a greater range of motion
50 Simple Orthopaedic Procedures and Common Diagnoses
than it can tolerate. If the knee is stressed from one
specific direction, the ligament trying to hold it in place
against that force can tear.
Twisting injuries to the knee also put stress on the
cartilage and the menisci. This can create tears in the
menisci and damage to the articular cartilage.
Fractures of the distal femur and tibial plateau are
associated with high-energy injuries such as motorbike
accidents and falls from heights.
50.8.3 Examination and Diagnosis
Diagnosis can usually be made from a good history
and confirmed on examination. Key questions to be
asked include the exact mechanism of injury. Valgus
force will suggest a MCL injury. Twisting knee inju-
ries are associated with ACL rupture. Patients will
describe their knee ‘popping out’ with patella disloca-
tion. The onset of swelling will give a hint to the under-
lying injury. Instantaneous swelling indicates a
haemarthrosis and will point to injury to the ACL,
which is contained within the capsule of the joint.
Once the patient can begin weight bearing again, they
may complain of the sensation of giving way, which
may indicate ACL injury or locking that indicates
meniscal tear.
The knee is then examined, beginning with general
inspection. Examine for grazes or bruising. A knee
held slightly flexed can be a clue that there is fluid in
the joint space.
Palpation is the next step in the examination. An
effusion is demonstrated with the swipe test or a patella
tap. Tenderness over the joint line, most easily felt with
the knee flexed to 45°, may indicate meniscal pathol-
ogy. Tenderness directly over the patella may indicate
patella fracture. Tenderness over the medial aspect of
the patella may be due to rupture of the medial reti-
naculum associated with lateral dislocation of the
patella.
The specific ligaments of the knee should be exam-
ined. Comparison to the uninjured side will give the
clinician further information for what is normal for
that patient. The MCL and LCL are examined under
valgus and varus stress respectively, both in full exten-
sion and in 30° flexion. By bending the knee, the clini-
cian isolates the ligament, which is assisted by the
capsule when the knee is straight. The ACL is assessed
399
with Lachman test or anterior drawer test. The PCL is
assessed with the posterior drawer test. The menisci
are examined with McMurray’s test; however, the most
reliable sign is joint line tenderness.
Close assessment of the distal neurovascular status
must be made if a dislocated knee is suspected.
Radiographs will exclude fracture or demonstrate
avulsion injuries associated with ligamentous instability.
50.8.4 Treatment
Immediate treatment is rest, ice, compression and ele-
vation (RICE). The knee should be splinted if ligamen-
tous injury is suspected and the patient kept non-weight
bearing. Serial examination of the patient 1 or 2 weeks
after injury can be useful in demonstrating clinical
signs once the patient has become more comfortable.
Treatment will then vary depending on the injury.
50.8.4.1 MCL Injuries
The knee should be splinted for 6 weeks. After this
period, the knee should be re-examined for ongoing
instability and also other associated injuries, which
may have initially been missed, especially ACL rup-
ture. A hinged brace will prevent the patient from
developing a stiff knee. Protected weight bearing can
usually begin after 2 weeks.
50.8.4.2 ACL Injuries
Initially the knee is splinted. The patient can begin
weight bearing and bending the knee as pain allows.
The patient should be referred for physical therapy to
build hamstring and quadriceps strength to help stabi-
lise the knee before considering reconstruction. If
diagnosis is uncertain, MRI is the investigation of
choice to confirm ACL injury.
50.8.4.3 Mensical Tears
It may be possible to repair a large tear in the meniscus of
a younger patient if the tear occurs in the outer area of the
meniscus where there is good blood supply. In patients who
400
are troubled by ongoing intermittent swelling, locking or
sharp pain with bending or turning, arthroscopic debride-
ment can be offered. Degenerative meniscal tears are
common in patients with osteoarthritis.
50.8.4.4 Patella Dislocation
The patella invariably dislocates laterally. Often it will
reduce spontaneously, but occasionally needs to be
reduced with analgesia in the emergency department.
Again the knee is splinted, mainly for analgesic pur-
poses, and once the pain settles the patient can start
with weight bearing and bending the knee. Physical
therapy to build the strength of the medial portion of
the quadriceps can help prevent recurrence and also
improve the tracking of the patella on the trochlea that
often can cause anterior knee pain. Recurrent disloca-
tions may need surgical correction.
50.9 Tibia Shaft Fractures
50.9.1 Introduction
High-speed lifestyles with motor vehicles and motor-
cycles, as well as the increasing popularity of extreme
sports, have contributed to the growing occurrence of
tibial shaft fractures. Those who sustain them face a
slow recovery, with possible permanent deformity and
disability. Tibial fractures vary so widely in severity
that general prescriptions for treatment are not appli-
cable to each patient. The spectrum of injury extends
from trivial enough to be ignored to so severe that
amputation is the best treatment.
50.9.2 Mechanism of Injury
The tibia is vulnerable to torsional stress (e.g. in sporting
injuries like skiing), to force transmitted through the feet
(e.g. in falls from a height) and from direct blows (e.g.
falling rock). Isolated fractures of either the tibia or fib-
ula may occur from direct force, although this is com-
paratively uncommon. The type of force placed on the
tibia will produce typical fracture patterns, with torsional
D. Wysocki and R. Zellweger
force creating spiral fractures, direct blows transverse or
short oblique fractures and higher energy injuries pro-
ducing more comminuted fractures.
50.9.3 Classification System
No classification of tibial fractures has been univer-
sally accepted.
50.9.4 Examination and Diagnosis
The patient usually reports severe pain. An inability to
bear weight on the affected leg and a visible deformity
of the leg are often present. In the clinical examination,
it is important to assess the neurovascular status of the
patient’s injured leg. The overlying skin should also be
examined. Due to the subcutaneous nature of the ante-
rior tibia, open fractures or displaced fractures threat-
ening the skin are common. Always obtain radiographs
of the whole length of the tibia and the two adjacent
joints. If the skin is threatened by displaced bone or the
foot is poorly perfused, reduction should not be delayed
by getting radiographs.
50.9.5 Treatment
The emergency management of tibia fractures is to
reduce any deformities and immobilise the fracture in a
split plaster. Most displaced fractures of the tibia are so
unstable that anatomical reduction with a plaster is
impossible. Any open fractures should be thoroughly
washed and dressed with antiseptic soaked gauze. In
these cases, prophylactic antibiotics and tetanus boost-
ers should also be given. Compartment syndrome should
be excluded. Other injuries should be sought due to the
high-energy trauma associated with tibia fractures.
Undisplaced or minimally displaced tibial shaft frac-
tures can be treated non-operatively. Unlike angulations
in femoral shaft fractures, which can be compensated to
some extent at the hip, varus, valgus and rotational
deformities are poorly tolerated in the tibia.
Absolute indications for operative fixation include
damage to neurovascular structures, open fractures,
50 Simple Orthopaedic Procedures and Common Diagnoses
compartment syndrome or failure of non-operative
management to hold position or unite the fracture.
50.9.5.1 Non-operative Treatment
A long leg plaster is applied. The cast should extend
from the mid thigh to the metatarsal heads. The ankle
should be placed in 90° of flexion and the knee in 10 to
15 degrees of flexion. Check radiographs should be
taken in plaster to confirm an adequate position and the
limb elevated for the first 3–7 days until the swelling
has reduced. Check radiographs should be taken for
the first 2 weeks to ensure reduction is maintained.
Weight bearing can usually begin from 6–8 weeks.
Adequate callus formation generally takes 6–8 weeks
and on average up to 16 weeks to fully unite. Apparent
­radiological union assessed out of plaster should be
confirmed by clinical examination.
50.9.5.2 Operative Treatment
Possible surgical treatments are external fixation, Ilizarov
frame, intramedullary nailing or fixation with plates.
Plating tibial shaft fractures has been the treatment of
choice; however, this requires surgical approaches,
which may interfere with the vascular supply to the frac-
ture. Therefore, intramedullary nailing is now the fixa-
tion of choice when possible in tibial shaft fractures.
Nailing cannot be used to correct displaced intra-articu-
lar fractures and extreme care must be taken when used
with fractures with an undisplaced intra-articular exten-
sion. Due consideration must be given before using a
nail in an open fracture as an infected implant is difficult
to treat. Advantages to tibial nails include a less invasive
approach, and therefore less disruption to the blood sup-
ply to the bone around the fracture, mechanical stability,
allowing early weight bearing, and also the ability to
dynamise within the canal of the tibia, compressing the
fracture and thus promoting healing.
Plates should be considered when fixation is required
for fractures of the proximal or distal metaphysis that
are not suitable for intramedullary nailing. Good surgi-
cal experience and skill, as well as careful judgment,
are required for this surgical treatment. This section
does not describe further details of this technique, as it
might be best to treat the patient temporarily with an
401
external fixator, and then send the patient to the special-
ist if there is mechanical benefit of plating in the long-
term management of the tibial fracture.
The external fixator is a widely used and a successful
method of treatment for open fractures, severely com-
minuted fractures, or fractures with extensive soft tissue
injury. It might also be the method of choice for tibiae
with a narrow canal. The surgeon must be familiar with
the anatomy of the lower leg to avoid injuries to vessels,
nerves, muscles and tendons. The pins should be placed
so they will not interfere with the surgical approach for
open reduction and internal fixation if planned in the
future. The fixator is applied after reduction or can be
used as a reduction tool. For the latter technique, a pair
of pins is inserted into each main fragment and joined
by a short rod. The two rods are then connected by a
short third rod and two rod-to-rod clamps. This con-
struct allows to manipulate and reduce the fracture and
to hold it after reduction (Fig. 50.4a, b).
50.9.6 Complications
Nonunion, malunion, stiffness of the adjacent joints,
compartment syndrome and deep vein thrombosis can
all follow a tibial shaft fracture.
50.10 Ankle Joint
50.10.1 Introduction
The ankle is a complex hinge joint and is the most com-
monly injured joint in sport. The talus inhabits the bony
mortise created by the medial malleolus, tibial plafond
and lateral malleolus. The ligaments supporting the ankle
are the deltoid ligament medially, the lateral ligament
complex and the syndesmotic ligaments. These structures
create a ring, which if broken in two or more places can
allow the talus to lose its position in the ankle mortise.
50.10.2 Mechanism of Injury
The different mechanisms creating ankle injuries have
been well studied, allowing prediction of involvement
402 D. Wysocki and R. Zellweger

a b 50.10.3.2 Danis–Weber Classification

The Danis–Weber classification is based on the loca-

tion and appearance of the fibular fracture with regard
to the syndesmosis. This classification divides frac-
tures into Types A, B or C (See Fig. 50.5).
Type A: Fracture below the syndesmosis. Usually a
transverse fracture created by internal rotation on the
adducted foot. Fractures are stable unless associated
with a medial malleolar fracture.
Type B: Fracture at the level of the syndesmosis.
Usually a short oblique fracture created by external
rotation. It is the most common ankle fracture.
Type C: Fracture above the level of the syndesmo-
sis, implies disruption of the syndesmotic ligaments.

Note: Beware the isolated medial malleolus frac-

ture, as this can be associated with complete rupture
of the syndesmotic ligaments and interosseous mem-
brane up to a high fibular fracture (Maison­neuve’s
type ­fracture). This injury does poorly with non-
operative management, so careful physical examina-
tion or full-length leg radiographs should be taken.

A B

Fig 50.4 Application of external fixator: (a) Insertion of two

pins in each fragment according to the soft tissue conditions
(b) After reduction the two bars are united by a third tube and
two tube-to-tube clamps

of ligamentous and bony structures with known mech-

anisms. However, this is rarely of use in everyday
practice. The most common mechanism of ankle injury
is supination and external rotation, accounting for over
three quarters of ankle fractures (see below Weber B). C

50.10.3 Classification

50.10.3.1 Anatomical Classification

An easy descriptive and commonly used classification

is simply to divide ankle fractures along anatomical
lines as single malleolus fractures, bimalleolar frac-
tures or trimalleolar fractures (i.e. an additional pos-
tero-lateral or Volkmann triangle fragment). Fig. 50.5 Danis-Weber Classification: Type A, B, and C
50 Simple Orthopaedic Procedures and Common Diagnoses
50.10.4 Examination and Diagnosis
Careful note should be taken of the location of
swelling, ecchymosis and bruising. All structures
should be palpated, including the medial malleolus,
the deltoid ligament, the whole length of the fibula
and lateral ligament complex and the anterior
aspect of the syndesmosis. Swelling or tenderness
on both sides of the ankle may indicate an unstable
injury. In the deformed ankle, suggesting sublux-
ation or dislocation of the talus, note should
be made of the presence of pulses and sensation of
the foot.
Radiographs of the ankle should include lateral and
mortise views. The mortise view (created by internally
rotating the leg 15°) allows the clinician to detect any
shift of the talus within the mortise by comparing the
medial to the superior joint space
50.10.5 Treatment
Studies have shown that small displacements of the
talus within the mortise can create large changes in the
contact area of the tibia and the talus. The aim of treat-
ment is to restore and maintain the normal alignment
of the talus within the ankle mortise to prevent post-
traumatic arthritis.
Attempts should be made as soon as possible to
reduce any dislocated or subluxated ankles. Dorsiflexion
will help reduce any posterior dislocations, whilst
inversion and internal rotation may be needed to reduce
laterally subluxated ankles.
50.10.5.1 Non-operative Treatment
Ankle Sprains
Injuries to the ligaments around the ankle can be
treated initially with rest, elevation and ice after
radiographs have excluded an ankle fracture.
Immobilisation in plaster may be appropriate in
injuries involving ligaments on both sides of the
ankle. Weight bearing can begin as tolerated.
Physiotherapy, to prevent recurrent ankle injury
via muscle strengthening and proprioception, is
recommended.
403
Ankle Fractures
Small avulsion type injuries to the distal fibula can be
treated in a similar manner to ankle sprains.
Weber Type A and non-displaced Weber Type B
fractures of the lateral malleolus can be treated non-
operatively provided the medial ankle side is not
injured. All other fractures usually require surgery.
The fracture is treated in a split plaster until swell-
ing has subsided. This can then be changed to a full
cast. The total time of immobilisation is between 6
and 8 weeks. Check radiographs in the plaster should
be taken at 1 and 2 weeks to ensure the fracture is
held in a good position. Radiographs should be taken
out of plaster at the end of immobilisation, to look
for signs of bony union, and the fractures assessed
for ongoing tenderness before beginning weight
bearing.
50.10.5.2 Operative Treatment
All displaced ankle fractures should be treated opera-
tively, as minor changes involving the joint mortise can
cause chronic pain due to early post-traumatic arthri-
tis. Often the ankle will be too swollen for early fixa-
tion and a period of elevation in a split plaster is
required. This can be for as long as 2 weeks. Check
radiographs may be required during this time as loss of
reduction of the ankle fracture may prevent the soft
tissue from recovering. In cases with large blisters, or
open injuries, external fixation will maintain reduction
while allowing the clinician to monitor progress of the
soft tissue.
The surgical treatment aims to reconstruct the bone
anatomically. Injuries, which damage the syndesmo-
sis, will require one or two screws passing from the
fibula to the tibia to prevent diastasis of these two
bones. The deltoid ligament does not need to be
repaired or approached unless it has become interposed
in the ankle joint preventing reduction of a lateral
­malleolus fracture.
50.10.6 Complications
Fracture healing in a non-anatomical position will
likely result in post-traumatic arthritis. Nonunion and
ongoing ligamentous instability is very uncommon.
404
Persistent swelling for weeks or even months after an
ankle injury is so common as to be expected. However,
in cases of swelling into the calf, venous thrombosis
needs to be considered.
50.11 Achilles Tendon Rupture
50.11.1 Introduction
The Achilles tendon is the largest and strongest tendon
in the human body. The tendon of the gastrocnemius
and the soleus muscles forms it. The principal function
of the Achilles tendon is plantar flexion of the ankle
joint.
50.11.2 Mechanism of Injury
An Achilles tendon rupture typically happens in the
30–50 age group with a peak around 40 years of age.
The ratio between men and women is approximately
5:1. The vast majority of injuries occur during sudden
muscle contraction while playing sports. Some medi-
cations such as corticosteroids may also increase the
risk of rupture.
50.11.3 Examination and Diagnosis
Patients typically describe hearing a loud snap with the
sensation of being struck by something in the back of
the calf. Pain and difficulty walking follow. On clinical
examination, there is a palpable gap or depression
along the Achilles tendon with weakness of plantar
flexion against resistance. Standing on the toes of the
affected side is impossible. A positive Thompson test
for Achilles tendon rupture is obtained by placing the
patient in a prone position and squeezing the affected
calf. In a patient with a ruptured tendon, there will be
no plantar flexion of the ankle with this manoeuvre. In
the majority of cases, diagnosis can be confirmed on
examination and only in unclear situations is ultra-
sound required.
D. Wysocki and R. Zellweger
50.11.4 Treatment
Initial treatment is to place the patient in split plaster in
a plantar flexed position to approximate the ruptured
ends of the tendon.
There is little evidence to suggest that patients under-
going surgical repair have better function or faster
return to normal activities than those treated non-oper-
atively. However, some studies have shown that the risk
of re-rupture is slightly reduced for those treated with
surgery. In general, it is thought that patients who wish
to return to sporting activities and with low risk for sur-
gical complications can be offered surgical repair.
Delayed diagnosis or patients with ­re-rupture should
also be considered for surgical repair. Care should be
taken when selecting patients for surgical intervention,
as wound complications can be very difficult to treat.
50.11.4.1 Non-operative Treatment
The patient should be placed in a below knee full plan-
tar flexed cast. At 2-week intervals, the plaster should
be replaced to gradually bring the ankle to 90° over
6–8 weeks. Walking on the cast is allowed at this time.
Cast immobilisation should be for approximately
6–10 weeks. Following cast removal, a heel-lift in the
shoe should be worn for an additional 2–4 months.
During this time, a rehabilitation programme with the
physiotherapist should be initiated to improve the gait
pattern and the calf strength.
50.11.4.2 Operative Treatment
Open reconstruction is undertaken using a medial lon-
gitudinal approach. This approach is made easy in a
prone position. The ends are approximated and sutured
with a strong suture using a modified Kessler, Krackow
or Bunnell suture technique. Care should be taken not
to over tighten the tendon. Following surgery, the ankle
is placed in a plantar flexed plaster for 2 weeks. Serial
plastering can then be done in a similar manner to con-
servative treatment, or specific orthosis can be used.
This allows a staged return to range of motion of the
ankle. Following immobilisation, a heel raise is again
recommended for 2–4 months.
50 Simple Orthopaedic Procedures and Common Diagnoses 405

50.11.5 Complications
Surgical complications include damage to the sural
nerve, wound dehiscence and adhesions. Both opera-
tive and non-operative treatment groups are at risk of
venous thrombosis.
McRae, R., Esser, M.: Practical Fracture Treatment, 4th edn.
Elsevier Churchill Livingstone, Philadelphia (2002)
Sarmiento, A., et al.: Functional bracing of fractures of the shaft
of the humerus. J. Bone Joint Surg. Am. 59, 596–601
(1977)
Solomon, L., Warwick, D., Nayagam, S.: Apley’s System of
Orthopaedics and Fractures, 9th edn. Hodder Arnold,
London (2010)

Recommended Reading

Browner, D.: Skeletal Trauma, 4th edn. Saunders, Philadelphia

(2008)
Hoppenfeld, S., Deboer, P., Buckley, R.: Surgical Exposures in
Orthopaedics: The Anatomic Approach, 4th edn. Lippincott
Williams & Wilkins, Philadelphia (2009) http://www.ao-
asif.ch/wps/portal/aofoundation.org
 Carpal Tunnel Release
Limited Distal Incision Open Carpal Tunnel Release
Hajir Nabi
51.1 Preface
As with other procedures in general surgery there are
numerous techniques available for the release of the
flexor retinaculum to decompress the median nerve at
the level of the carpal tunnel [1].
Many surgeons in larger volume centres now advo-
cate the use of endoscopic release of the flexor reti-
naculum. However, risks of neurovascular damage are
increased in inexperienced hands [2]. The procedure
described here is a safe and easily reproducible method
of releasing the flexor retinaculum using surgical
equipment readily available. Through a limited distal
skin incision – preserving the skin bridge over the
wrist joint – the incidence of complications can be
decreased. Advantages include fewer wound healing
problems over the wrist, reduced likelihood of damag-
ing the muscular (recurrent) branch and accelerated
return to full function [3].
51.2 Anatomy
A concave trough is formed on the flexor surface of
the carpal bones. This trough is roofed by the flexor
retinaculum forming a fibro-osseous channel known as
‘the carpal tunnel’ [4].
The flexor retinaculum is a strong fibrous band of
tissue with four bony attachments (Fig. 51.1):
H. Nabi
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: hajirnabi@yahoo.com.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_51, © Springer-Verlag Berlin Heidelberg 2011
51
1. Radial side
(a) Tubercle of scaphoid
(b) Ridge of trapezium
2. Ulna side
(a) Pisiform
(b) Hook of hamate
The carpal tunnel contains the following structures:
1. Tendons of flexor digitorum profundus
All four tendons lie in the same plane, but only the
tendon of the index finger has separated at this level.
2. Tendons of flexor digitorum superficialis
All four tendons are separate at this level and are in
two rows (middle and ring fingers superficial, and
index and little fingers deep).
3. Tendon flexor pollicis longus
4. Median nerve
Passes beneath flexor retinaculum between tendons
of flexor digitorum superficialis of middle finger
and flexor carpi radialis (which runs in Vertical
groove).
The Median nerve divides into three terminal
branches after passing through the carpal tunnel:
1. Medial branch
Supplies sensation to palmar skin as well as clefts
and adjacent sides of ring to middle and middle to
index fingers. Latter branch to second lumbrical
muscle.
2. Lateral branch
Supplies sensation to palmar skin and radial side of
index finger and thumb. Index branch supplies first
lumbrical muscle.
3. Muscular (recurrent) branch-
Passing superficial to flexor pollicis longus it sup-
plies the thenar muscles.
407
408
Fig. 51.1 Bony attachment of
flexor retinaculum to (a) distal
a
and (b) proximal rows of carpal
bones forming the carpal tunnel Hook of hamate
Capitate
b Flexor retinaculum
Pisiform
Triquetrium
Lunate
A palmar branch is given off proximal to the carpal
tunnel and runs superficial to the flexor retinaculum
supplying the thenar eminence. Hence, sensation over
the thenar eminence is preserved during compression
at the level of the carpal tunnel.
In addition to preservation of the palmar cutaneous
branch, compression of the median nerve at the level
of the carpal tunnel can be distinguished from com-
pression that is more proximal by the preservation of
the relevant forearm flexors (notably flexor policis
­longus – flexion terminal phalanx thumb preserved).
51.3 Presentation
The term ‘carpal tunnel syndrome’ refers to any condi-
tion leading to compression of the median nerve as it is
transmitted in the carpal tunnel. Conditions that pre-
dispose to diminution in the size of the carpal tunnel
include arthritis, hypothyroidism, tenosynovitis, old
carpal fractures, and inflammation. However, the
majority of cases are idiopathic [5].
Patients describe paraesthesia and anaesthesia over
the radial three and a half digits. Due to interpersonal
H. Nabi
Flexor retinaculum
Vertical groove
Carpal
Tunnel
Tubercle of trapezium
Trapezoid
Carpal Tunnel
Tubercle of scaphoid
differences, the pulp of the index finger is the most
reliable area of sensory disturbance.
Motor losses include weakness in abduction and
opposition of the thumb (thumb flexion preserved,
flexor pollicis longus intact). Wasting of the thenar
eminence is a late sign.
Symptoms may be reproduced using Tinel’s test
(tapping over carpal tunnel) and Phalen’s test (holding
wrist joint in flexion).
The author advocates the use of nerve conduction
studies to confirm clinical suspicions (particularly in
uncertain cases) where available. Given the increas-
ingly litigious nature of our practice, this can prove an
important medico-legal document.
51.4 Procedure
The procedure can be safely and effectively performed
under local anaesthetic. Due to the need for a tourni-
quet, concurrent intravenous sedation is useful.
The author prefers to use a mixture of short and
long-acting local anaesthetics (5 ml 1% lignocaine +
5 ml 0.5% bupivacaine).
51 Carpal Tunnel Release
A median nerve block can be performed by adminis-
tering 5 ml of the local anaesthetic mixture 1–2 cm
proximal to the proximal wrist crease between palmaris
longus (where present) and flexor carpi radialis tendons.
One needs to be aware of the risk of infiltrating beneath
the perineurium of the median nerve and consequent
nerve damage. Consequently, one needs to ensure there
is no resistance when infiltrating. The remaining 5 ml of
local anaesthetic should then be administered subcuta-
neously over the planned incision site (Fig. 51.2).
Prophylactic antibiotics are not necessary.
Once the hand has been prepped circumferentially
with antiseptic solution (betadine or chlorhexidine) to
the level of the proximal forearm, a hand table should
be positioned under the arm. The arm is elevated, an
Esmark bandage applied and the tourniquet switched
on (at 250 mmHg).
The skin incision can then be made over the distal
half of the flexor retinaculum in the line of the middle
to ring finger web-space. Incisions made in palmar
skin creases lead to preferable scarring and wound
healing (Fig. 51.2).
Fig. 51.2 Incision site and Tendon of palmaris longus
landmarks for median nerve
block
409
Once through the epidermis and dermis a variable
depth of subcutaneous tissue is seen and divided lead-
ing to the palmar aponeurosis (termination of palmaris
longus) – a thin white fibrous layer. The flexor reti-
naculum is deeper to this, and is composed of thicker
fibrous tissue. Retractors (such as Cat’s paws or small
Langenbeck’s) held by an assistant (or alternatively a
self-retainer) will aid in visualisation. Small bands of
muscle may be encountered at this stage, which can be
divided. These are the fibres of abductor pollicis brevis
and their division leaves no functional deficit.
The scalpel blade is then used to pierce a small inci-
sion through the retinaculum. Once through the reti-
naculum a flat bladed retractor (such as McDonald’s or
Watson Chain) is inserted through the remaining distal
retinaculum and elevated to protect the underlying
median nerve. The scalpel can then be reversed so the
blade faces up. The scalpel is then run along the retrac-
tor to divide the retinaculum fibres. Once divided dis-
tally, the retractor is inserted proximally, and the steps
repeated to free the proximal retinaculum with a skin
retractor inserted under the proximal edge of the skin
Skin Incision
Extent of flexor retinaculum
not included in skin incision
X
X Site of infiltration for
median nerve block
Tendon of flexor carpi radialis
410
incision to aid with visualisation of the proximal
­retinaculum fibres.
Bipolar diathermy to cauterise potential bleeding
vessels is recommended to prevent potential post-
operative haematomas that could compress the median
nerve.
Skin closure with interrupted vertical mattress
sutures (5-0 nylon sutures) aids in everting skin edges.
Hypafix dressing to skin with overlying compressive
dressings such as softban and crepe are then applied
before the tourniquet is released.
51.5 Post-operative Care
Compressive softban and crepe dressings can be remo­
ved 48 h post-op. Hypafix dressing should be left intact
until sutures are removed (10 days postoperatively).
Patients should be encouraged to continue to use their
hand immediately post-op to avoid joint stiffness. It is
important to ensure dressings do not restrict movements
of the metacarpal joints. After sutures have been removed
patients should be encouraged to return to full function.
51.6 Complications
Patients should be made aware of the following possible
complications prior to consenting for the procedure:
1. Bleeding: Should a haematoma develop, the risk of
secondary wound infections increases, and the pos-
sibility of median nerve compression from the
expanding haematoma needs to be considered.
2. Infection: Superficial cellulitis around the incision
site is not uncommon, and usually resolves with the
administration of oral antibiotics. Although rare,
deeper infections may require re-exploration for
adequate drainage of pus, and a course of intrave-
nous antibiotics may become necessary.
3. Damage to median nerve: Although exception-
ally rare, one should always mention the possibil-
ity of median nerve damage to patients, and the
consequent motor and sensory deficits this entails.
More realistically median nerve damage is likely
to be limited to the recurrent (muscular) branch
and consequently can lead to deficits in thumb
movement.
H. Nabi
4. Recurrence of symptoms: With the formation of
scar tissue, symptoms may recur after several years.
The procedure may need to be repeated to divide
tight bands of scar tissue causing further median
nerve impingement.
5. Non-resolution of symptoms: Long-term median
nerve compression may lead to non-reversible loss
of median nerve function. Patients should be aware
that their symptoms may not completely resolve
post-operatively. This is more likely in patients that
have been symptomatic for many years prior to
intervention, those with thenar wasting, and those
with nerve conduction studies suggesting severe
compression of the median nerve.
6. Incisional pain: Although rare, some patients may
experience persisting pain along the incision.
Patients can be advised that this usually resolves
spontaneously within 6 months.
51.7 Summary
Given that the facilities for endoscopic release are not
always available in the rural setting, the limited distal
incision open carpal tunnel release is a safe, easily
reproducible means of decompressing the median
nerve at the level of the carpal tunnel. The proposed
benefits of this approach are reduced wound complica-
tions at the level of the wrist, reduced risk of recurrent
branch damage and quicker return to function given
the smaller length of incision.
References
1. Scholten, R.J., Mink van der Molen, A., Uitdehaag, B.M.,
Bouter, L.M., de Vet, H.C.: Surgical treatment options for
carpal tunnel syndrome. Cochrane Database Syst. Rev. (4),
CD003905 (2007)
2. Kretschmer, T., Antoniadis, G., Richter, H.P., König, R.W.:
Avoiding iatrogenic nerve injury in endoscopic carpal tunnel
release. Neurosurg. Clin. N. Am. 20(1), 65–71 (2009)
3. Lee, W.P., Strickland, J.W.: Safe carpal tunnel release via
a limited palmar incision. Plast. Reconstr. Surg. 101(2),
418–424 (1998)
4. McMinn, R.M.H. (ed.): Last’s Anatomy, 9th edn. Churchill
Livingstone, Edinburgh (1994)
5. Aroori, S., Spence, R.A.: Carpal tunnel syndrome. Ulster
Med. J. 77(1), 6–17 (2008)
 Dupuytren’s Contracture
52
Barney McCusker

52.1 History the MP joint, this would put this hand into the difficult
category. If there is skin contraction involvement such
that it is likely that there will be a deficiency of skin
Baron Guillaume Dupuytren was born in 1777 and
once resection of the Dupuytren’s Contracture tissue is
died in 1835, and spanned that part of French history
achieved at operation and skin grafting seems likely,
highlighted by the Napoleonic Wars.
this then would put this case into the difficult category.
He had an exciting childhood, which included being
Finally, any Dupuytren’s where there has been
kidnapped as a child, raised by a rich family, and even-
recurrence with significant contracture would make
tually educated by a cavalry officer from Napoleon’s
this a difficult case. I would recommend that all such
army.
cases, which fall into this difficult category, be referred
He had the typical medical student’s life of poverty
to a practitioner who has a special interest in hand
and studying late into the nights in poor conditions and
­surgery or a major teaching hospital that has a specific
was fascinated with anatomy.
Hand Unit.
He devoted his life to medicine in both teaching and
The simple cases are all those cases where there is
operating, and had the largest private practice in Paris,
only one or two ray involvement and where there is
and as a result, became very rich.
minimal contracture of the PIP joint and MP joint and
He described a number of conditions in medicine
where no skin deficiency or skin grafting is thought
but is best known for his description of Dupuytren’s
unlikely after surgical correction.
Contracture of the hand.
The important feature of making sure that your
region has a minimal number of difficult cases and a
maximum number of simple cases is colleague educa-
52.2 Country Perspective tion and to encourage your referring doctors to send
along cases of Dupuytren’s earlier rather than later,
even when they do not think that surgical management
From a country practice point of view, Dupuytren’s
is warranted at that stage. I believe it is better for you to
Contracture can be split into two broad categories, the
see these cases earlier before surgery is warranted, so
difficult ones and the simple ones.
that you can undertake a regular review of these cases,
Difficult contractures involve widespread involve-
so that surgery can be instituted when it is appropriate.
ment of the palm of the skin and involving more than
two rays. If there is more than 20° of fixed flexion
deformity at the PIP joint or more than 45° of flexion at
52.3 Surgical Technique

B. McCusker I believe this surgery should be done in a fully equipped

Department of Orthopaedic Surgery, Mount Gambier General
Hospital, 276-300 Wehl Street North, Mount Gambier,
SA 5290, Australia
e-mail: barney.mccusker@bigpond.com
operating theatre on an elective basis with general
anaesthesia or good regional anaesthesia, so that a
tourniquet can be used.

M.W. Wichmann et al. (eds.), Rural Surgery, 411

DOI: 10.1007/978-3-540-78680-1_52, © Springer-Verlag Berlin Heidelberg 2011
412
I think it is important to have a proper hand table
and lead hand available and with loop magnification, if
required.
I use a marker pen to map out my incisions and
favour a Brunner incision.
The first phase of the dissection is the reflection of
the skin flaps back and sutured back out of the way.
This is a dissection between the skin and the underly-
ing aponeurosis, and at this stage, one has to be careful
not to buttonhole the skin when there is some close
tethering from the aponeurosis to the skin.
Once the skin flaps have been fully dissected and
are retracted with skin sutures, this should expose the
contracted Dupuytren’s tissue.
The next phase of dissection is to resect the
Dupuytren’s tissue, starting proximally and working
from proximal to distal and freeing the Dupuytren’s
tissue from the underlying structures via careful blunt
dissection of the Dupuytren’s connections, which are
tending to anchor the cord down to the underlying
structures. In particular, one has to be very mindful of
the digital nerves, particularly as one heads towards
the area of the MP joint and the A1 pulley. It is often
said that Dupuytren’s surgery is the dissection of digi-
tal nerves, but indeed these structures do not have to be
dissected out if you are operating on the early cases,
which do not have severe contracture.
Provided the case has been well selected, without
severe contractures, closure of the Brunner’s incisions
should not be a problem requiring partial closure and
late skin grafting.
At this stage, the operator can either make the deci-
sion to close the skin flaps before releasing the tourni-
quet or releasing the tourniquet and controlling any
bleeding with bipolar diathermy, being careful not to
go near the digital vessels and compromise the vascu-
lar supply of the digits.
My preferred method of closure is to do sequential
interrupted mattress suturing of the skin using either
4/0 or 5/0 prolene with tourniquet still inflated and
then releasing the tourniquet and keeping a firm pres-
sure with a surgical pack on the hand for 3–5 min. If
there is any significant swelling under the skin or
bleeding from the skin, then this can be explored by
re-inflating the tourniquet and reopening the wound
and then dealing with any specific bleeding points. In
general this is unnecessary.
B. McCusker
Post-operatively I dress these wounds with a
Betadine-soaked dressing and quite often immobilise
them in a plaster volar backslab for comfort, which
also controls bleeding, as it stops soft tissue shearing
in the first few days post-operatively.
52.4 Pre-operative Assessment
It is important in the pre-operative assessment to
­specifically look at the patient’s history and, in particu-
lar, their medication history, for any features that may
predispose to post-operative bleeding.
This would include the obvious problems such as
bleeding diatheses.
In general, I would want to see a complete blood
picture to make sure that there were adequate platelets
and that there is no undiagnosed haematological
­condition leading to post-operative bleeding.
It is also important to check whether the patient is
on any anticoagulants, such as Aspirin, Warfarin or
Plavix (Clopidogrel). Non-steroidal anti-inflammato-
ries can also lead to post-operative bleeding but not of
such an extent as the previous medications. If the
patient were on blood thinners, I would involve a phy-
sician for advice, as each of these requires a different
pre-operative planning regime.
52.5 Post-operative Regime
I normally rest the patient in hospital overnight, since
they are quite often living at some distance from the
operative centre, and I like to check for any signifi-
cant bleeding in the first 24 h before allowing them to
go home.
First review on an outpatient basis is after a 7–9 day
period and either alternate sutures are removed at that
time, or at about the 11–12 day period together with
the splint.
If possible, the patient should be seen by a hand
physiotherapist, as recovery of motion is better under
the care of dedicated physiotherapy.
Patient review should be scheduled at the 1-week
and 2-week stages and again at the 6-week stage.
52 Dupuytren’s Contracture 413

52.6 Histopathology Larson, D., Jerosch-Herold, C.: Clinical effectiveness of post-

operative splinting after surgical release of Duputren’s
­contracture: a systemic review. BMC Musculoskelet. Disord.
I always send the resected material for histological 9, 104 (2008)
examination.

Recommended Reading

Amadio, P.C.: What’s new in hand surgery. J. Bone Joint Surg.

Am. 91, 496–502 (2009)
 Hand Injuries
53
Andreas Frick and Christiane G. Frick

Hand injuries can be differentiated in open and closed

lesions. They range from small finger lesions to amputa-
tion injuries with the complete loss of one or more
fingers, the middle- or the entire hand. The principal aim
of hand-surgical care is the best restoration of function.

Any injury should be addressed within a 6 h

limit. Larger injuries or amputations must be
operated on as soon as possible, so that surgical Fig. 53.1 Intrinsic plus position to immobilize the fingers
treatment can be started immediately. An
adequate primary care already decides on the
outcome of the best functional recovery, the
primary aim of hand-­surgical treatment.
The finger should be immobilized in the so-
called intrinsic-plus position, namely, the
metacarpophalangeal joints in 80–90° flexion
During the clinical examination, functional testing of and the proximal and distal phalangeal joints in
the fingers and wound inspection are of major impor- maximum extension (Fig. 53.1), except in cases
tance to estimate the exact extent of the injury. Associated with a tendon injury.
lesions especially of tendons and nerves should be
repaired during the same procedure if possible.
In smaller injuries, complete recovery is possible.
Due to possible post-traumatic and postoperative
However, in extended trauma, functional deficits can
swelling of the tissue, fresh injuries initially have to be
remain, despite adequate surgical care within the time
immobilized on splints and not in circular casts. The
frame of 6 h.
splints are placed on the side of the hand/arm opposing
to the injury and operation.
53.1 Immobilization In this way, the collateral ligaments of the finger
joints are extended in their maximal length during the
3–5 weeks of immobilization. Therefore, they cannot
Fractures, tendon, nerve, and extensive soft tissue inju- shrink and cause a flexed and contracted finger.
ries require postoperative immobilization.

53.2 Fractures of the Hand and Fingers

A. Frick () and C.G. Frick
Department of Surgery, University Clinics of Munich,
Marchioninistr.15, D-81366 Munich, Germany A fall on the outstretched hand can not only result in a
e-mail: andreas.frick@med.uni-muenchen.de fracture of the radius. In particular, scaphoid fractures,

M.W. Wichmann et al. (eds.), Rural Surgery, 415

DOI: 10.1007/978-3-540-78680-1_53, © Springer-Verlag Berlin Heidelberg 2011
416
the most frequent carpal fractures (80%), must not be
missed. Carpal fractures carry a high risk to form a
pseudoarthrosis due to limited vascularization.
In inconspicuous wrists, X-rays in two projections
are required: a dorsopalmar view and a view in
ulnar abduction (Fig. 53.2). In addition, a com-
puted tomography of the scaphoid bone might be
useful.
Scaphoid fractures are immobilized using a forearm
cast in association with an immobilization of the proxi-
mal phalanx of the thumb. An upper-arm plaster is not
required. An overview of the required periods of
immo­bilization is given in Table 53.1.
Fractures of the proximal third of the bone are indi-
cations for a surgical repair, because conservative ther-
apy needs up to 12 weeks of immobilization (Table 53.1).
Non-dislocated transverse fractures in the middle third
may also require an operation depending on the patient’s
profession or level of activity; this reduces the period of
immobilization to 2–3 weeks.
The osteosynthesis is subchondrally anchored in
the bone using the so-called Herbert screw which
carries two threads. Compression can be achieved by a
target device in older screws. The newer generation
has two different threads and produces pressure by
screwing in. Even after successful osteosynthesis, a
fragment necrosis can occur.
Fig. 53.2 X-ray in ulnar abduction with cortical fractures ulnar
and radial
A. Frick and C.G. Frick
Table 53.1 Conservative treatment of scapoid fractures
Localization Immobilization time
Not dislocated tubercle 3 weeks
Distal third 4–6 weeks
Medium third 6–10 weeks
Proximal third Of up to 12 weeks
A fall on the dorsal flected hand can result in flake
fractures of the triquetrum. This capsular and ligamen-
tary rupture is immobilized for 1–2 weeks until pain
settles.
Corpus fractures of the carpal bones are immobi-
lized for 3–4 weeks. The middle-hand bones can frac-
ture proximally to the caput, at the shaft and at the
base. The intrinsic interosseus muscles cause a palmar
tilt. Dislocations over 20° are repositioned and usually
require fixation with Kirschner wires.
Rotational dislocations of the fragments can only
be assumed on X-ray imaging and must be
clinically examined. They are diagnosed by fist
closure and are an indication for surgery.
Shaft-fractures can be stabilized with tractor screws.
Transverse fractures should be treated with osteosyn-
thesis using dorsal plates. Base fractures with dorsal
dislocation require surgical stabilization.
Fractures of the phalanges may dorsally dislocate
due to the pull of the extensor tendons and can be fixed
on an aluminum bar in a so-called Boehler’s plaster or
by osteosynthesis.
53.3 Fractures of the Thumb
On the base of the first middle-hand bone the abductor
pollicis and the adductor pollicis tendons insert. They
pull the radial fragments proximally and towards the
radius. There are
• Intra-capsular luxation fractures (Bennett’s fracture)
• Intra-capsular, y-like comminuted fractures (Rolando’s
fracture)
• Extra-articular slope fractures (Winterstein’s fracture)
53 Hand Injuries
In the majority of cases, it is possible to neutralize the
tension of the tendons with a closed reposition and
per-cutaneous fixation. Kirschner wires fix the first
and second metacarpal bone to the trapezium tempo-
rarily. With large fragments after open reduction a
tractor screw osteosynthesis should be performed.
53.4 Rupture of the Fibrocartilago
Volaris
At the metacarpophalangeal and the middle interpha-
langeal joints of the fingers, there are fibrocartilaginous
capsules. A closed, bony rupture of the fibrocartilago
volaris is a joint injury. After short-term immobiliza-
tion, it is functionally treated with a tape. An operative
re-fixation is indicated in larger joint fractures with
subluxation.
53.5 Carpal Injuries
Physiologically, the carpal bones are not in their anatom-
ical resting position, but spread by the dorsal and palmar
ligaments. An injury in particular of the scapholunar
Fig. 53.3 Scapholunate
dissociation with an increased
scapholunate gap. A.p.-view
(a), lateral view (b)
417
ligamentary connection results in a dilated scapholunar
gap of 2–3 mm and a rotational palmar subluxation of
the distal pole of the scaphoid and a dorsal subluxation of
the lunate bones. This increases the scapholunar angle
between the two longitudinal axes of these bones to more
than 60°. In a dorsopalmar X-ray projection, the scaphol-
unar gap is widened, the distal scaphoid pole orthogradly
taken and presents as a so-called seal ring sign (Fig. 53.3).
A subluxation in radial abduction is called a dynamic
rotational instability, and in neutral position of the wrist
it is called a static rotational instability. In ulnar abduc-
tion of the wrist, the scaphoid is in its physiological
erected position. In fresh injuries, the scaphoid is reposi-
tioned into its physiological position and immobilized in
a splint or circular cast for 8 weeks. If it cannot be
retained in an erected position, the scaphoid is temporar-
ily fixed with Kirschner wires. The easiest way is to fix
the repositioned distal scaphoid pole to the capitate bone.
A second Kirschner wire can fix scaphoid and lunate.
The Kirschner wire’s fixation must be immobilized in a
splint or plastic cast. Reposition obstacles need to be
restored in an open procedure. In a lunate luxation, the
lunate jumps completely out of its palmar association
and is rotated by 90°. It is repositioned, the ligamentary
structures repaired and temporarily fixed with Kirschner
wires. In a perilunar luxation de Quervain, the palmar
and dorsal capsule and ligaments are ruptured and the
418
carpus is completely luxated dorsally out of the articula-
tion between lunate and capitate bones. In addition, in
the transscaphoidal, perilunar luxation fracture, the sca-
phoid is broken. This injury requires an open reposition
possibly with the osteosynthesis of the scaphoid with a
Herbert screw, reconstruction of the dorsal and palmar
ligaments and a temporary Kirschner wire fixation.
53.6 Skier’s Thumb
A fall while skiing with ski-poles can lead to overex-
pansion and bony or ligamentary rupture of the ulnar
collateral ligament of the proximal thumb joint. In the
dorsopalmar view, X-rays of the thumb in two projec-
tions show a dislocated distal fragment, which is bro-
ken out of the base of the ulnar phalanx. In dislocated
joint fracture, an operative restoration and a trans-ossal
re-fixation is indicated with a delayed absorbable suture
(e.g. PDS™ [Fig. 53.4]) or a steel pull-out suture. The
metacarpophalangeal (MP) joint can be temporarily
Fig. 53.4 Skier’s thumb: ulnar collateral ligament reinserted
using a pull-in and pull-out suture
A. Frick and C.G. Frick
fixed trans-articularly with a Kirschner wire (Ø1 mm).
To avoid an implant rupture, a plaster or plastic cast is
applied in medium opposition of the thumb as after
osteosyntheses using Kirschner wires. For pure liga-
ment injuries, the stumps are readapted by delayed
absorbable suture material (PDS™) in figure-of-8 tech-
nique similar to extensor tendon sutures (Fig. 53.4).
The thumb joint is also temporarily fixed with a
Kirschner wire. Other authors recommend to only treat
the purely ligamentary Stener’s lesion surgically, where
the longer proximal ligamentary stump is turned by
180° to the proximal. Non-significant injuries are
immobilized for about 3 weeks in a skier’s thumb cast
with inclusion of the proximal phalanx of the thumb.
53.7 Injuries of the Extensor Tendons
A typical injury mechanism is to put sheets on a mat-
tress. A subcutaneous rupture of the extensor tendon
distal to the proximal interphalangeal joint of a long fin-
ger may result. After an osseous rupture from the base
of the end-phalanx has been excluded by X-rays, this is
the only tendon injury in the event of extension deficit
up to about 40° for a primary conservative immobiliza-
tion in a Stack’s splint for 8 weeks continuously and
following this for another 4 weeks in an overnight splint.
Subluxation injuries of the end-phalanx with involve-
ment of more than one-third of the joint area require an
operative reinsertion either closed in an extension block
of Ishiguro or through an open osteosynthesis with tem-
porary Kirschner wire fixation of the distal joint.
Open extensor tendon injuries, closed ruptures
over the end-joint of the thumb and all other proximal
joints require operative treatment. Tendons are bra-
dytrophic tissues and consist of multiple fibres. In
order to unite the stumps, special suture techniques
have been developed. In extensor tendons of the pha-
langes whipped sutures in figure-of-8 technique are
applied or shoelace sutures according to Bunnel are
used (Fig. 53.5).
Slowly absorbable (PDS™) or not absorbable suture
materials (Ethibond™) are used; in the middle hand
and forearm, steel wires may be inserted. Postoperatively,
patients are discharged with a plastic splint for
4–5 weeks. The wrist is immobilized in 30–40° exten-
sion, the basic joints in approximately 20° flexion, the
middle and distal phalanges in full stretch.
53 Hand Injuries 419

a b A fine adaptation of tendon stumps can be sup-

Fig. 53.5 Extensor tendon sutures. (a) Whipped sutures in
­figure-of-8 technique; (b) Bunnel’s shoelace suture
53.8 Injuries of Flexor Tendons
Flexor tendons have a circular geometry. Often tendon
sutures according to Kichmayr–Kessler (Fig. 53.6a) or
Zechner (Fig. 53.6b) are performed.
ported by circular fine sutures. In the area of middle
and basic phalanges and in the palm of the hand, the
former “no man’s land” and the current “not-every-
one-country” a functional Kleinert’s after-treatment
is necessary, to avoid bonding and scarring of the
tendons. Rubber bands are attached to the nails to
allow active stretching and passive flexion back into
flexion position. In this way, the re-anastomosed ten-
dons can glide tension-free in their slide bearing.
Dorsally, a forearm cast or plastic splint is fixed to
the wrist with approximately 30° flexion, the basic
joints 70° flexed and middle and distal joints fully
stretched.
Fingers and hand require immobilization for 5 weeks,
lower arm injuries for 4 weeks. Then we recommend
patients to start an active exercise treatment. After
8 weeks, the flexor tendons are suitable for normal
activities. Re-ruptures, however, do occur in 4–8%.
If there is no immediate and definitive surgical
treatment option available, a temporary wound closure
should be done and the patient requires transfer to a
surgeon experienced in hand-surgery for definite surgi-
cal care. Post primary tendon sutures are performed
within a period of 2 weeks. Even more delayed proce-
dures are called early-secondary (2–5 weeks) and late-
secondary (over 5 weeks) flexor tendon sutures.

a b

Fig. 53.6 Tendon suture

according to Kirchmayr–
Kessler (a) and Zechner (b)
420 A. Frick and C.G. Frick

53.9 Nerve Injuries ipsilateral neurovascular flaps. They should, however,

be done by appropriately experienced surgeons.
Nerve regeneration starts from the nerve cell in the
central axon. At the peripheral nerve stump, Waller’s
degeneration occurs. Without a guiding structure for 53.12 Amputation Injuries
regeneration, a neuroma can develop. An epi- and peri-
neural microsurgical nerve suture under a microscope
Amputation injuries are differentiated into total and
allows for a bundled outgrow. In dehiscent nerve end-
subtotal ones. In total amputations, all anatomical
ings, grafts from the cutaneous antebrachii ulnaris or
structures of a limb are cut, the bones, the flexor and
suralis nerves can be inserted.
extensor tendons, all arterial and venous vessels
Absorbable suture material such as Polygalactin 910
and nerves. Subtotal amputations consist of transected
(Vicryl™), 0.3 or 0.4 metric is used. After surgery, the
blood vessels with intact bones as well as tendon and
nervous sutures are immobilized for about 3 weeks. After
skin bridges.
combined flexor tendon and digital nervous sutures, a
functional postoperative Kleinert’s treatment is possible.
If no operating microscope and/or no surgeon expe-
rienced in microsurgery is available for initial care, a 53.12.1 Conservation of Amputates
temporary wound closure similar as for tendon injury
with adaptive skin sutures and a transfer for definitive
The amputate must be placed into a dry or moist com-
care are necessary. The best time frame for nerve
press and is then kept in a watertight plastic bag.
sutures is within approximately 3 weeks.
A second bag is filled with water and ice. The ice water
should have a temperature of 4°C. Ambulances should
carry appropriate dual-chamber bags on board.
53.10 Vessel Injuries

Transection of both digital arteries results in a mini- Cave

mal perfusion of the finger. The reconstruction of a
single digital artery can alleviate trophic disturbances.
Digital and interdigital arteries are microsurgically
­re-anastomosed under an operating microscope in
single stitch technique. Not absorbable suture material
(Ethilon™), 0.3 or 0.2 metric, can be used. The radial
and ulnar arteries at the wrist can be sutured in a single
stitch technique even without optical aids. In dehis-
cent vessel stumps small venous grafts, harvested
from the forearm can be used.
53.11 Soft Tissue Injuries
Epithelial defect and small skin defects (<5 mm) can
be observed and left for secondary healing. Larger
defects without bony injuries are covered with split or
full thickness skin grafts. Defects distal to the root of
the nail can be treated with one or two VY-plastics
with their tips in the distal flexion fold. Larger, espe-
cially palmar defects must be covered with special
Amputates floating in solution usually are not
suitable for a replantation. Pure ice, frozen
gel-packages and cooling aggregates can result in
frostbite of the amputate.
53.13 Replantations
The indications for replantation of amputated limbs
are differentiated into absolute and relative ones.
Absolute indications exist for smooth or relatively
smooth (saw injuries) thumb amputations in the inter-
phalangeal joint or proximal, in the middle-hand, up to
the distal forearm and amputations of multiple fingers.
Individual finger amputations and even amputations
distal to the distal phalanges in children are also abso-
lute indications.
Relative indications exist for smooth (axe, cutting
machine) interphalangeal amputations proximal up to
the middle of the endphalanx, proximal to the nail root,
53 Hand Injuries
lacerated amputation zones in the thumb, middle hand,
forearm and fingers as well as single long fingers
(depending on profession, hobby, aesthetic reasons). If
a replantation is not medically indicated and an urgent
desire of the patients exists, they have to be informed
about the possibility of developing significant trophic
disorders as well as pain.
It is advisable to begin the replantation by stabiliz-
ing the bone. Middle fingers and hand are often fixed
with Kirschner wires. Then the flexor and extensor
tendons are stabilized using the above mentioned tech-
niques. Finally, the microsurgical anastomses of the
blood vessels and nerves are performed under an
operating microscope.
Postoperative treatment: The limb is immobilized on
a plastic splint. Hydroxyaethylstark can be given intrave-
nously to improve the microvascular perfusion during the
421
peri- and postoperative period for about 5 days. Platelet
inhibitors can be helpful, but in the absence of recapil-
larization or venous stasis a microsurgical revision under
the microscope is indicated. Systemic application of hep-
arin should be used restrictively, for example, after
venous graft transfers, because it can lead to haematoma
formation which may impair the venous outflow.
Recommended Reading
Green, D.P.: Green’s Operative Hand Surgery. Churchill
Livingstone, New York (2005)
Pechlaner, S., Kerschbaumer, F., Hussl, H.: Atlas of Hand
Surgery. Thieme, Stuttgart/New York (1999)
Schmitt, R., Lanz, U.: Diagnostic Imaging of the Hand. Thieme,
Stuttgart (2007)
 Part
V
Other Relevant Operative
Specialities for General Surgeons
 Rural Obstetrics and Gynaecology
Colin Weatherill
54.1 Introduction
Whilst any surgeon might find themselves face to face
with pathology that is typically the domain of a
gynaecologist or obstetrician, this likelihood is consid-
erably increased for those who find themselves work-
ing in a rural area. Many such locations find it difficult
to retain a local specialist workforce and thus either by
design or providence one might be required to perform
surgery of a type that is less than familiar. This chapter
will outline the features of some of the more typical
emergency obstetric and gynaecological emergency
procedures, thus serving as a reference when forced to
operate outside of your comfort zone. It thus assumes
that the surgeon is already very comfortable with open
and laparoscopic procedures.
54.2 Obstetrics
54.2.1 Caesarean Section
There are numerous indications for emergency caesar-
ean section and this chapter presupposes that typically
the surgeon would not be called upon to make this
decision in isolation (if at all). Nevertheless possible
reasons include abnormal presentation (breech, trans-
verse or oblique), concern regarding foetal well-being,
failure to progress and haemorrhage (due to placental
abruption or placenta praevia).
C. Weatherill
Obstetrics & Gynaecology, Mount Gambier Hospital,
Wehl Street North, Mt Gambier, SA 5290, Australia
e-mail: c.weatherill@flinders.edu.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_54, © Springer-Verlag Berlin Heidelberg 2011
54
Table 54.1 shows the four most common indications
for emergency caesarean section performed in South
Australia in 2007 [1].
54.2.1.1 Anaesthesia
Indications for general anaesthesia in obstetrics are
decreasing and to some extent now confined to
­situ­ations of considerable urgency, expressed patient
preference, failed regional technique or where sig-
nificant difficulties are anticipated (as in placenta
accreta/percreta); thus, most women will have either
a spinal or epidural anaesthesia for caesarean sec-
tion. For those who already have the latter in place
for the purpose of labour analgesia, this will usually
be ‘topped up’ to achieve a surgical level of anaes-
thesia. For those without an epidural, spinal anaes-
thetic is usually employed.
54.2.1.2 Preparation
In most circumstances a group and hold should be per-
formed pre-operatively, though for caesareans per-
formed with an increased risk of haemorrhage blood
will need to be matched. A urinary catheter should be
in situ. Under ideal circumstances the pubic hair can
be clipped down to the level of the pubic symphysis to
allow for subsequent dressings. Skin preparation and
draping are performed to accommodate a pfannenstiel
incision. Prophylactic antibiotics should be given and
indeed recent evidence suggests greater benefit if
given prior to commencement rather than the tradi-
tional approach of administration once the baby is
delivered [2]. Consideration should also be given to
thromboprophylaxis.
425
426
Table 54.1 Breakdown of emergency caesareans in South
Australia 2007
Indication for emergency (%)
caesarean section
CPD/failure to progress 41.6
Foetal ‘distress’ 25.5
Previous caesarean 8.2
Malpresentation 7.8
54.2.1.3 Surgical Technique
The right-handed surgeon stands on the patient’s right
with the opposite applying for those who are left-
handed. Skin and fat are then incised horizontally
approximately 2 cm above the pubic symphysis. The
incision needs to be wide enough to accommodate the
foetal head comfortably – particularly for the occasional
surgeon to this procedure. The sheath is also opened
transversely exposing the rectus muscles. The sheath is
then dissected superiorly and inferiorly from the under-
lying muscles and linea alba in order to allow free lat-
eral movement of the recti themselves. Once the recti
are separated in the midline and the peritoneum opened
and stretched, a Doyen’s retractor is inserted over the
inferior edge of the incision, reflecting skin, fat, sheath
and peritoneum/bladder. The next step is to reflect the
uterovesical peritoneal fold to ensure inferior displace-
ment of the bladder to keep it safely clear of the lower
uterine segment. This loose fold of peritoneum is picked
up with forceps, opened in the centre then extended lat-
erally in each direction. Blunt finger dissection is usu-
ally used to reflect down behind the bladder; the Doyens
retractor is then repositioned to hold the bladder down
off the resultantly exposed lower uterine segment.
Before incising the uterus it is wise to check at this point
that your exposure will be sufficient to allow delivery –
this comes with experience and thus it is wise to be gen-
erous if unsure. The uterus is next incised horizontally
in the midline of the lower segment progressively deep-
ening the incision but being cautious not to cut the baby.
In situations where the membranes have already rup-
tured (and particularly if the baby is presenting by the
breech whereby you are cutting over foetal soft tissues)
it can be difficult to appreciate just how close the baby’s
skin is. For this reason many, including myself, prefer to
complete the final stage of uterine entry with blunt dis-
section to avoid accidental laceration.
C. Weatherill
54.2.1.4 Delivery: Cephalic Presentation
In most situations the presentation will be cephalic. In
this situation the surgeon inserts their hand through the
uterine incision and under the foetal head thus elevat-
ing it through the uterine and subsequently skin inci-
sions. Simultaneous axial fundal uterine pressure is
applied by an assistant to aid in the process. If access
is tight making it difficult to place a hand under the
foetal head then this same task can be accomplished by
using a single or both obstetric forceps blades (the sur-
geon need not be too concerned with which one is used
as this has greatest importance when negotiating sacral
curves during vaginal application).
Having delivered the head, gentle downward trac-
tion is applied to bring the anterior shoulder into view.
To minimise the risk of brachial plexus injury occa-
sioned by excessive neck traction the surgeon then
places a finger under the axilla lifting the posterior
shoulder into view. A finger is then placed under the
posterior axilla and the baby lifted clear of the mater-
nal abdomen. Foetal oral suction should not generally
be performed by the surgeon as this can cause a diving
response and delay respiration. Most importantly, flat
meconium-stained neonates should undergo laryngos-
copy by the paediatric doctor before unnecessary
­stimuli with the potential to promote spontaneous
­respiration which could cause meconium aspiration.
Following complete delivery Oxytocin (Syntocinon®)
is administered intravenously by the anaesthetist in
line with local policy or guidelines.
54.2.1.5 Delivery: Non-cephalic Presentation
In the case of non-cephalic presentations, upon pas-
sage of the surgeon’s hand onto the uterus a quick sur-
veillance of foetal orientation takes place and unless
readily correctable to a cephalic presentation the
breech is brought to the incision. This can be done by
applying traction with a finger placed in the approxi-
mate position of hip flexion at the foetal anterior supe-
rior iliac spines. If the feet are more readily accessible
then these are brought in turn (or together) through the
uterine incision before delivering the breech. In either
case, subsequent gentle traction delivers the trunk. As
for cephalic presentations, simultaneous axial fundal
pressure is applied by an assistant – in this case so as
to minimise traction-induced deflexion of the foetal
54 Rural Obstetrics and Gynaecology
head. If the knees are extended (and feet still inside the
uterus) then when sufficient delivery of the trunk has
been occasioned the knees are flexed (with slight lateral
rotation of the hips) so as to bring the feet across the
baby’s abdomen and thus out of the wound. Arms need
to be delivered before the foetal head and thus when the
scapulae appear the arms are brought down and across
the foetal chest by gentle digital manipulation – this
can be facilitated by rotation of the trunk in such a
manner that the trailing arm is brought anteriorly (rela-
tive to the foetus). With all but the head delivered the
baby is positioned such that the trunk and legs are infe-
rior to the maternal incision, the trunk and head are
rotated such that the baby is essentially prone. This
process is facilitated by placing the index or middle
finger of the surgeon’s dominant hand into the foetal
mouth. An assistant then progressively elevates the
foetal trunk by lifting the baby’s feet whilst the sur-
geon through a combination of gentle jaw traction and
simultaneous non-dominant hand pressure above the
wound flexes the baby’s head out of the wound (in
more difficult cases obstetric forceps may be required
to complete this).
Once the baby is delivered the cord is double
clamped then divided. At this point the anaesthetist
needs to administer intravenous oxytocin as per local
guidelines (5–10 Units). If antibiotics were not given
earlier then they should now. It is usually then prudent
to drain a small sample of uncontaminated cord blood
into a receiver for later analysis as required by the pae-
diatric team. The placenta should next be delivered.
With oxytocin having been administered this may be
expelling spontaneously, if not then gentle cord trac-
tion should be applied. If the placenta is still delayed
then it is removed manually by forming a plane of
cleavage digitally (further explained under ‘Manual
Removal of Placenta’). Following removal, gentle
internal inspection is performed to ensure no placental
cotyledons or large membranous fragments remain.
54.2.1.6 Closure
Typically one or more Green-Armitage clamps are
placed on the edges of the uterine incision – particularly
at the sites of any significant bleeding. The uterus is
then closed with 1 vicryl or similar utilising a continu-
ous locking or non-interlocking technique. Long
threads to which artery clips are secured are left at
427
each end to identify the angles. A second continuous
non-interlocking suture is then applied to the uterine
incision to invert the primary closure. It is good prac-
tice at this point to visually check the adnexae for
unforeseen pathology. The peritoneum may be closed
or left open. After having established adequate haemo-
stasis of the uterine closure, the rectus sheath is repaired
with continuous 1 vicryl before closing the fat if neces-
sary. A continuous subcuticular skin suture is normally
employed which can be removed 5 days later and a
sterile dressing is applied.
54.2.2 Manual Removal of Placenta
1.5% of women giving birth have a retained placenta
[3] (2% of those having vaginal births). This can result
in significant blood loss and haemodynamic compro-
mise. Thus it is typically considered prudent to take
steps to remove this manually after 1 h of unsuccessful
non-operative attempts (or sooner of course if accom-
panied by haemorrhage). Initial management is aimed
at stabilisation with adequate assistance, intravenous
access and a group and save (or match), IV fluids,
­oxygen and uterotonics (i.e. oxytocin, ergometrine,
misoprostol and/or prostaglandin F2a). Choice of
anaes­thesia is usually at the discretion of the anaesthe-
tist. Antibiotic prophylaxis is recommended utilising
broad spectrum coverage or (if available) in accor-
dance with local guidelines or policies.
The patient is placed in the lithotomy position. The
surgeon prepares by wearing a waterproof gown or
alternatively a standard gown with long gloves. After
vaginal/genital antiseptic preparation the surgeon uses
liberal obstetric lubrication then inserts his/her hand
gently identifying the cervix then passing fingers
beyond. The surgeon’s non-dominant hand is simulta-
neously placed above the uterine fundus and down-
ward pressure applied to facilitate the progress of the
inserted hand. Typically a few fingers can be passed
through the cervix which has often by this stage con-
stricted somewhat. The surgeon must nevertheless
attempt to identify the plane between the placenta and
uterine wall and develop this to separate the two.
Sometimes this is partially completed until sufficient
placenta can be held to facilitate removal. Before con-
sidering the procedure complete it is important to
ensure that no significant fragments remain. Curettage
428
of the uterus with a large blunt curette after manual
removal of the placenta can be considered; small
curettes, however, must be avoided to reduce the risk
of perforation of the uterus. Whilst uterine contraction
is usually far more efficient once the placenta has been
removed it is prudent to maintain an oxytocin infusion
post-operatively which can be cautiously weaned over
the next few hours or as the clinical condition allows.
A typical regimen would be 40 units of oxytocin in 1 L
of crystalloid commencing at 200 mL/h and weaning
by half every couple of hours. An indwelling catheter
can be considered but is not considered mandatory by
this author – being individualised depending on the
clinical condition of the patient.
Abnormal placentation is becoming increasingly
common with an ever-increasing proportion of parturi-
ents having had prior caesarean section. This increases
the likelihood of placenta accreta, increta or percreta.
Thus if initial attempt at manual removal of the pla-
centa does not seem to work – i.e., there is no obvious
plane of cleavage then immediate specialist obstetric
advice should be sought as there are entire textbooks
solely on the subject of the management of postpartum
haemorrhage.
54.2.3 Repair of Genital Trauma
Genital trauma is a common complication of vaginal
delivery. Repair is effected so as to restore anatomy
and function; thus, considerable care must be taken.
Most commonly there is a posterior midline laceration
of the vagina and/or perineum though lateral and labial
injuries are not uncommon. Trauma can involve the
anal sphincter or even the anal mucosa. For these more
extensive third and fourth degree tears, respectively, an
operating theatre environment needs to be considered
but for lesser injuries repair can usually be completed
in the labour ward with local or regional anaesthesia.
A common approach for the more common second
degree tear is to commence a continuous locking suture
of 2/0 vicryl at the internal apex of the wound. From
here closure is progressed outwards towards the hyme-
nal ring aiming for accurate apposition and thus
­haemostasis but without excessive tensioning. Once
reached, this too is reconstituted but without knot-
ting. The long loose end is left for later attachment of
the ascending suture. With the perineum laid open
C. Weatherill
interrupted sutures of 2/0 vicryl or similar are used to
reconstitute the perineal body and posterior vaginal
musculature. This done, a subcutaneous knot is placed
at the most posterior extent of the wound. Using a sub-
cuticular technique the perineal skin is closed. Once
again, close attention to alignment is important and
observance of skin colour variations can facilitate this
process. Once the fourchette is closed and the hymen
approached from below the advancing loose end can
be secured to that left from closing the vaginal mucosa
as noted above (thus minimising knots at the fourchette
or posterior vestibule which can lead to later discom-
fort and dyspareunia). It is prudent to perform a digital
rectal examination at completion to exclude suture
breach which could lead to later fistula development.
(This is also an ideal opportunity to insert rectal anal-
gesia such as NSAIDs and/or paracetamol).
54.3 Gynaecology
54.3.1 Ectopic Pregnancy
Ectopic pregnancy needs to be considered and/or
excluded in any pregnant woman presenting with pel-
vic pain and where an intrauterine gestation cannot be
confirmed.
Note: Indeed whilst heterotopic pregnancy is
rare, consideration of explorative surgery may
still be necessary if there is evidence of intraab-
dominal bleeding even if there is a confirmed
intrauterine pregnancy.
The differential will include all the usual suspects
but from a gynaecological perspective the most com-
mon differentials are corpus luteal cyst accidents and
miscarriage.
First steps always involve haemodynamic appraisal
and resuscitation as needed. Having decided that surgi-
cal evaluation is necessary then in all but the most
unstable situations a laparoscopic approach is employed
having first taken appropriate resuscitative steps. Most
ectopic pregnancies are tubal though other sites include
ovary, uterine cornu, peritoneum and previous surgical
54 Rural Obstetrics and Gynaecology
scars. Should one of these rare sites be suspected then
telephone advice should be sought for specific guid-
ance. The following is appropriate guidance for the far
more common tubal pregnancy (Figs. 54.1 and 54.2).
The patient is placed in the lithotomy position and
the bladder drained. Pneumoperitoneum is typically
established via the lower margin of the umbilicus using
a standard technique. The laparoscope is then inserted.
Having first concluded that there is not a viable intra-
uterine pregnancy, pelvic access, particularly to the
pouch of Douglas, can be greatly facilitated by the use
of a uterine manipulator – the simplest form of which
is a dilator carefully inserted through the cervix paying
careful attention to uterine orientation so as to avoid
perforation. Two or possibly three 5 mm ports will also
be required in the lower abdomen avoiding the inferior
epigastric arteries. A suction irrigator is commonly
Fig. 54.1 Ectopic pregnancy prior to removal
Fig. 54.2 Ectopic pregnancy after removal
429
one of the first instruments required to clear blood and
clot. Whilst tubal-sparing surgery can sometimes
be performed, for the occasional operator a salping­
ectomy is usually going to be the most appropriate
approach.
The damaged tube is identified and can be removed
by sequential diathermy and dissection along its mes-
entery proceeding from fimbrial end toward the uterus.
Care must be taken to avoid compromising ovarian
blood supply by unnecessarily dividing the infundibu-
lopelvic vessels running superolaterally to the pelvic
side wall. Once dissected free the tube is removed
using a bag or sponge holders through a widened
suprapubic port site. A final pelvic washout is com-
pleted with documentation as to the state of the remain-
ing adnexum to assist future pregnancy counselling.
54.3.2 Evacuation of Retained Products
A common cause of significant vaginal blood loss is
the incomplete expulsion of products of conception.
This can occur in the first trimester as an “incomplete
miscarriage” or following childbirth with fragments or
the entire placenta being retained.
In the case of bleeding due to failed first trimester
pregnancy, surgical management is typically suction
curettage often supplemented by an initial removal of
larger tissue pieces using uterine polyp forceps. Prior to
any internal instrumentation however bimanual assess-
ment is employed to determine uterine size and orienta-
tion so as to minimise the risk of uterine perforation.
Often the cervix is already dilated sufficiently but if not,
serial dilatation up to about 8 mm is usually required.
Generally if the cervix is already open a 10–12 mm
curette is used on the supposition that broader instru-
ments will be less likely to perforate. If dilatation is
required then 8 mm instruments will usually suffice as
more aggressive dilatation may be damaging to the cer-
vix. Once the suction curette is introduced it is moved
up and down and rotated along its axis until products
seem to have ceased. It may require removal once or
twice to clear blockages. Following suction a metal
curette is then gently run along all internal surfaces to
verify completeness of evacuation.
Antibiotics are typically not required unless there is
evidence of infection – in such cases special care is
required not to perforate. Most practitioners do not use
430
oxytocics for first trimester evacuations though ergome-
trine may be considered if bleeding does not adequately
slow once the uterus is emptied. Anti-D should be
administered if the patient is rhesus negative without
prior alloimmunisation.
54.3.3 Hysterectomy
Emergency hysterectomies are a rare event, perhaps
most commonly performed in the obstetric arena for
indications such as the aforementioned placenta accreta
or percreta. As such, when considering an emergency
hysterectomy it is worth discussing the circumstances
of the case with a gynaecologist over the phone.
Gynaecologists are increasingly using vaginal and/
or laparoscopic approaches for hysterectomy. This
said, the general surgeon who finds that they need to
perform a hysterectomy will no doubt feel most com-
fortable utilising an abdominal approach. Prophylactic
antibiotics should be given and a group and save
obtained. A urinary catheter should be inserted. Consid­
eration is also given to thromboprophylaxis.
If an incision has not already been made then unless
the uterus is approaching the umbilicus in size or there
is other surgery to perform then a pfannenstiel incision
will usually suffice. Having thus exposed the uterus,
sturdy graspers (typically Kocher’s) are placed on each
side adjacent to the fundus across the tube, round and
ovarian ligaments. The uterus is thus now able to be
manipulated as required.
In turn, each round ligament is secured with a Black’s
and divided medial to this clamp. With it the anterior
leaf of the broad ligament is thus opened. This opening
is continued inferiorly above the bladder. The surgeon’s
finger is passed behind the tube and ovarian ligament
(just lateral to the Kocher’s clamp securing the uterus)
and poked through the posterior leaf of the broad liga-
ment. The upper pedicle is thus now defined and can be
clamped, divided and tied. A Zeppelin clamp or similar
is placed lateral to the ovary if simultaneously perform-
ing an oophorectomy or medial to the ovary if conserv-
ing it. The lateral round ligament stump is typically tied
off with vicryl or similar leaving a long trailing end
identified with an artery clip for later identification and
access to the retroperitoneal space if required.
The next step in a classical 3 pedicle hysterectomy
is to secure the uterine arteries. One must remember
C. Weatherill
at this point that the ureter passes under this vessel in
relatively close proximity. The first step is to push
the bladder down off the lower segment and cervix
(the uterovesical peritoneum having previously been
divided). Again a Zeppelin type clamp, aligned par-
allel to the side of the uterus, is now rolled off it so
as to be immediately adjacent to the myometrium –
in this way avoiding injuring the ureter (which may
be identified via the retroperitoneal space if required).
Division with scissors or scalpel medial to the clamp
establish the pedicle which is then secured using
vicryl.
The remaining pedicle is the cervix (taking cardinal
and uterosacral ligaments together). This is performed
in a similar fashion to that used for the uterine artery
pedicle – rolling the clamp off laterally whilst holding
the bladder out of the way so it does not get caught.
Division of this pedicle will enter the vaginal vault at
each angle and thus by incising the anterior and poste-
rior vaginal walls – thus joining the angles – the uterus
is now detached and can be removed. The vaginal
angles are secured with vicryl and the vault closed
with interrupted or continuous sutures. Haemostasis is
checked and the abdomen closed in a fashion similar to
caesarean section. (Note that in practice it may take
two pedicles each side to progress down a long cervix
and thus enter the vaginal vault.)
Post-operatively there is no need to fast with light
diet being allowed as desired unless there are other
considerations such as simultaneous bowel surgery.
54.3.4 Ovarian Cystectomy
Ovarian cysts are a common source of female pelvic
pain but it is important to remember that they are also a
normal part of the monthly hormonal cycle during the
reproductive years. From midcycle through the luteal
phase a finding of a 20–30 mm ovarian cyst is usually
going to be an incidental rather than a pathological
­finding. Nevertheless cysts are a cause of pain either
due to leakage, bleeding, torsion, progressive neoplas-
tic expansion or as part of a tubo-ovarian abscess.
Cystectomy is usually a laparoscopic procedure.
The overlying ovarian capsule is either linearly coagu-
lated over 2–3 cm or infiltrated with a vasoconstrictor
prior to incising the capsule with scissors. The latter
can be achieved using a spinal needle with a local
54 Rural Obstetrics and Gynaecology
pain is fairly severe and may be accompanied by
­nausea and vomiting. Doppler interrogation during
Fig. 54.3 Opening the capsule exposing an ovarian cyst
anaesthetic/adrenaline mixture passed directly through
the abdominal wall whilst the ovary is held up by a
bowel grasper on the ovarian ligament. Two or three
graspers are then used to progressively enucleate the
cyst, hopefully intact, which is then removed usually
in an endobag. Haemostasis of the ovary then needs to
be confirmed using bipolar diathermy as needed. The
ovary itself is not usually closed though if it was in any
way turned inside out this needs correcting. If there is
any concern as to malignancy then special care should
be made to avoid spillage with dissection over or actu-
References
ally in a bag. Alternatively, consideration could be
given to performing an oophorectomy (Fig. 54.3).
54.3.5 Ovarian Torsion
Ovarian torsion can be difficult to diagnose with cer-
tainty prior to surgery. Classically lateralising pelvic
431
ultrasound examination may also be helpful. In most
cases there will be an adnexal mass or cyst of at least
4–5 cm as normal ovaries and tubes rarely tort.
A laparoscopic approach is again the usual tech-
nique. If the adnexum is clearly necrotic then it will
need removal (usually this can only be determined
after untwisting and watching for several minutes). To
remove the torted tube and ovary the infundibulopelvic
ligament/vessels are coagulated and divided. In like
manner the ovarian ligament and proximal tubal attach-
ment to the uterus are also divided. With peritoneal
division the mass can then be removed. As an alterna-
tive, an endoloop (or two for safety) may be able to
secure the whole twisted pedicle. Again an endobag or
enlarged port site can be used for removal though some
gynaecologists prefer to utilise a posterior culdotomy
(an incision in the posterior vaginal fornix) to mini-
mise breaches to the anterior abdominal wall.
If the adnexum is not necrotic and the ovary can be
salvaged then the offending lesion – typically an ovar-
ian cyst – is removed as above.
1. http://www.dh.sa.gov.au/pehs/PDF-files/090210-
pregnancy-outcome-report-2007.pdf
2. Costantine, M.M., Rahman, M., Ghulmiyah, L., et al.:
Timing of perioperative antibiotics for cesarean delivery: a
metaanalysis. Am. J. Obstet. Gynecol. 199, 301.1–301.6
(2008)
3. Chan, A., Scott, J., Nguyen, A.-M., Sage, L.: Pregnancy
Outcome in South Australia 2007, p. 24. Pregnancy Outcome
Unit, Epidemiology Branch, SA Health, Adelaide (2008)
 Urological Conditions
John Miller, Clair Whelan, and Kulendran Sivapragasam
55.1 Urinary Retention
55.1.1 Introduction
In all communities, metropolitan, rural or regional,
urinary retention can be defined as acute or chronic
and occurs in both sexes. Ultimately, evaluation and
treatment by an urologist or uro-gynaecologists in
some female cases is required. In most cases, the initial
management after history and examination confirms
urinary retention is placement of an ind­welling urinary
catheter. This chapter will discuss acute and chronic
urinary retention in males, if seeking information
regarding female urinary retention an excellent sum-
mary can be found in female urology (S. Razz). In all
cases, male and female consultation and referral to an
urologist should result in further evaluation and treat-
ment within a short time frame.
55.1.2 Acute Urinary Retention in Males
Estimates of acute urinary retention (AUR) range
from 4 to 130 per 1,000 patient years, leading to
10 year cumulative incidence rates ranging from 4% to
73%. In patients presenting in acute urinary ­retention
the commonest cause is benign prostatic hypertrophy
J. Miller (*), C. Whelan, and K. Sivapragasam
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: urology@internode.on.net
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_55, © Springer-Verlag Berlin Heidelberg 2011
55
(BPH); other causes such as urethral stricture, stones
or intra-luminal foreign bodies and neurogenic causes
need to be considered and excluded. Risk factors
identified from epidemiological studies show an
increased incidence with advancing age and baseline
symptom severity. Incidence rates increased from
2.6 to 9.3 per 1,000 years for men aged in their fifth
and eighth decades, respectively with mild symp-
toms, and 3–34.7 with more than mild symptoms.
A relative risk increase greater than threefold is seen
in association with each parameter in men with: (1)
moderate to severe symptoms, (2) maximum urinary
flow rate under 12 mL/s and (3) prostate volume over
30 cc as measured by trans-rectal ultrasound. Control
studies give additional information regarding AUR
within the community and in men with diagnosed
Benign Prostatic Hyperplasia (BPH). The VA coop-
erative study showed an incidence of 9.6/1,000 person
years. In another study of 500 men with BPH diag-
nosed with sufficient voiding symptoms to warrant
prostatectomy by urologists who declined surgery,
AUR occurred at a constant rate of 25/1,000 person
years. Well-constructed placebo-controlled prospec-
tive medication trials have shown AUR rates of
14/1,000 patient years. In the Medical Therapy of
Prostatic Symptoms study (McConnell et al. 2003),
the incidence rate was 0.6/100 patient years.
Trans-urethral Resection of the Prostate (TURP) is
performed in 2–3% of men aged over 60 years per
year and within this group, 25–30% of cases are per-
formed for urinary retention. The aetiology of AUR is
not well understood with prostatic infection; bladder
over distention, excessive fluid intake, sexual activity,
general debility and poor mobility, constipation and
pharmacological side effects are all implicated in some
cases of AUR. Clinically, it is important to differen­
tiate spontaneous from precipitated AUR. The latter
433
434
comprises retention which has a triggering event such
as post-surgery, anaesthetic and other medications or
post-catheterisation; it has a better prognosis than
spontaneous urinary retention with lower incidence of
subsequent acute urinary retention and lower need for
TURP.
Over the last 20 years, many risk factors for AUR
have been identified. Incidence increases with
advancing age and symptom severity. The reported
AUR incidence in men with mild symptoms is 0.4 per
1,000 patient years for men aged 45–49 years, and
increases to 7.9/1,000 patient years in men aged
70–83 years. In men with moderate symptoms, the
corresponding rates were 3.3 and 11.3 per 1,000
patient years, respectively. Jacobson et al. (1997)
found age, symptom severity, prostate volume and
maximum urinary flow rate were all factors affecting
the risk of urinary retention. The relative risk
increased for men with prostate volume over 30 cc as
measured by Trans-Rectal Ultrasound (TRUS) (three-
fold), older men with moderate to severe symptoms
(3.2-fold) and those with a flow rate under 12 mL/s
(3.9-fold). In this study, the highest hazard ratio was
seen in men aged 60–69 years with more than mild
symptoms and a flow rate under 12 mL/s, giving a
10.3-fold greater risk of AUR. In other more recent
studies of men with known BPH prostate volume,
serum PSA and severity of symptoms were all pre-
dictors of AUR. Roehrborn et al. (2001) in an analy-
sis of over 100 variables found a combination of
serum PSA, urinating less than 2 hourly, maximum
flow rate, hesitancy and symptom score was only
slightly superior to PSA alone in predicting episodes
of urinary retention.
55.1.3 Definition
Acute urinary retention is defined as an acute inability
to void and is generally associated with severe urge to
pass urine and supra-pubic and abdominal discom-
fort. Chronic urinary retention is generally not associ-
ated with an acute urge to void or supra-pubic pain,
but the patient is unable to empty the bladder com-
pletely with post-micturition residual urine in excess
of 300 mL.
J. Miller et al.
55.1.4 Diagnosis
Acute urinary retention is generally diagnosed on the
clinical history of an inability to pass urine and con-
firmed on clinical examination and if needed, the
investigative findings. Examination findings include a
man in obvious pain, a palpable tender, supra-pubic
globular mass arising from the pelvis, and on rectal
examination, normal anal tone with an enlarged pros-
tate gland.
55.1.5 Investigation
Standard investigations should include an assessment
of renal, hepatic, haematological and biochemical
function. A pelvic and renal ultrasound may be per-
formed in cases where the diagnosis is in dispute or
where another indication such as associated renal
impairment, urinary tract infection or haematuria
exists. Prostate Specific Antigen (PSA) estimation is
not generally recommended unless cancer is suspected
clinically, as in cases of acute urinary retention the
level can be artificially raised. A urinalysis and urinary
microscopy, culture and sensitivity should be per-
formed once urine is collected.
55.1.6 Treatment of Acute Urinary
Retention
55.1.6.1 Non-surgical Treatment
Trial of Voiding
In one Danish study of patients with acute urinary
retention who underwent a trial of voiding 73% re-
presented with retention to the emergency department
within 1 week. Another study in 1989 found 72% of
men presenting with AUR failed a trial of voiding. The
long-term outcome in those who pass an initial trial of
voiding is not clear but it is not uncommon for subse-
quent retention to occur.
In cases of acute urinary retention where a precipitat-
ing cause is identified, the success in a subsequent trial
55 Urological Conditions 435

of voiding is high, with 91% avoiding repeat episodes length of time until definitive surgical treatment, or
and only 26% requiring subsequent prostatic surgery. trial of voiding and other medical conditions that man-
With spontaneous episodes of acute urinary retention, date antibiotic cover.
up to 85% will successfully pass a trial of voiding but
over 75% will eventually require surgery for symptoms
or further episodes of acute urinary retention.
55.2 Surgical Treatment of Acute
Urinary Retention
55.1.6.2 Medication for Acute Urinary Retention
55.2.1 Prostatectomy
In both groups, the chance of a successful trial of void is
increased by use of an alpha-blocker. A trial of void 24 h
post-treatment initiation demonstrated superior success 55.2.1.1 Transurethral Resection
in the treatment group over the placebo group (55% of the Prostate
­versus 29%), with results better in younger men. Although
not specifically recommended for men with acute uri- Transurethral resection of the prostate (TURP) is the
nary retention, the use of Finasteride (5-alpha reductase treatment of choice for urinary tract obstruction in men
inhibitor) has been shown alone or in combination with with BPH. Although most cases are performed for
an alpha-blocker to reduce the incidence of acute urinary symptom relief, acute urinary retention, recurrent
retention in men with proven BPH over time. infection due to incomplete bladder emptying, obstruc-
tive nephropathy and recurrent haematuria of prostatic
origin are considered absolute indications for surgery.
Anaesthesia is tailored to the patient but generally
55.1.6.3 Catheter Usage to Treat Acute regional (spinal or epidural) approaches are preferred
Urinary Retention with some evidence supporting less blood loss, less
post-operative pain and lower mortality in those ­having
Clean, intermittent self-catheterisation (CIS) is an option spinal anaesthesia.
for all forms of urinary retention. It is commonly used in Urinary tract infections are found in 8–24% of
cases of chronic retention due to neurogenic causes or patients scheduled for TURP and should be treated
cases where the detrusor muscle is hypotonic and out- before surgery. Urinary catheterisation is a major risk
flow surgery has been unsuccessful at assisting bladder factor for UTI with duration of catheterisation associ-
emptying. A cooperative, well-motivated patient with ated with increased colonisation. After 7–10 days of
good hand–eye coordination is an essential requirement catheterisation, UTI is almost universal. Abundant
for successful utilisation of this technique. studies now support the use of prophylactic antibiot-
Continuous indwelling urethral catheterisation is the ics before surgery, with most recommending gentam-
standard initial treatment for acute urinary retention. As icin and either a first-generation cephalosporin or
a short-term measure, it relieves symptoms and allows ampicillin.
planning of definitive elective surgical relief of the With the patient placed in lithotomy position an
obstruction. Supra-pubic catheterisation is an equally appropriate antiseptic skin preparation and sterile
adequate means of relieving urinary retention and allows drape is placed, and a preliminary cystourethroscopy
for a trial of void with accurate assessment of post-­ performed. After excluding any urethral and bladder
micturition residual urine. A supra-pubic catheter is the pathology, urethral calibration, and if needed dilata-
initial treatment of choice where a urethral catheter can- tion or urethrotomy, is performed prior to placement of
not be inserted or where pelvic trauma is present. a resectoscope sheath and working element. Various
Antibiotic cover is recommended at the time of techniques for transurethral resection using an electro-
catheter insertion due to the high incidence of bacte­ cautery element are described, with all employing a set
ruria seen with catheterisation. Subsequent antibiotic regime using video-endoscopy techniques. The resec-
treatment depends on the presence of urinary infection, tion aims to remove all the prostatic adenoma, overall
436
approximately 50–60% of prostatic tissue volume is
removed. The adenoma is resected to a level where the
pseudo-capsule is reached with resection of the floor
of the prostate and bladder neck area described first
in most surgical textbooks. The adenoma is resected
in quadrants with resected fragments flushed into the
bladder before being washed out at the end of the pro-
cedure. The aim is to resect down to the level of the
external sphincter and generally the internal anatomy
corresponds with the sphincter commencing around
the level of the verumontanum and, therefore, although
prostatic adenoma may extend beyond this level it is
generally best left unresected. Resection at the apex of
the prostate should be careful and involve smaller
resection specimens to avoid the risk of subsequent
incontinence.
Key points with the surgery are to avoid resecting
beyond 1 h where possible, careful resection around
the external sphincter mechanism to preserve func-
tion and careful resection around the bladder neck
and bladder base. The procedure is a difficult one to
learn and should be taught by experienced transure-
thral resection surgeons within a training hospital
environment.
55.2.2 Results
Specific results for men with acute urinary retention
are not always reported separate from TURP results
performed on all men. In clinical practice, however,
more than 90% of men with acute urinary retention
pass their trials of void following transurethral pros-
tatic resection post AUR. Those that fail are ultimately
due to detrusor failure or poor surgical technique (inex-
perienced resectionist).
Mortality within 30 days following TURP is low
with most modern series recording rates of under 0.5%,
Mebust and co-workers (1989) reported a mortality of
0.23% in over 3,240 procedures. Roos and associates
(1989) suggested the mortality was more related to
patient co-morbidity than the procedure itself. Meyhoff
and Nordling (1986) reported 90% of patients had
­satisfactory results at 5 years; in 1993, Ala-Opas et al.
found 92% of TURP patients were satisfied with the
result of surgery 6.5 years following their surgery.
Another review study by Montorsi and colleagues
J. Miller et al.
found 95% of patients were objectively unobstructed
and subjectively satisfied with their urinary status
5 years after surgery.
55.2.3 Complications
55.2.3.1 Intra-operative
Intra-operative complications are generally related to
patient, anaesthetic and surgical factors. Patient factors
include co-morbidity such as nutritional status, mobil-
ity and cerebral capacity, cardiovascular and respira-
tory status and the presence or absence of untreated
urinary tract infections or recent major surgery.
A review of 166 patients aged over 80 years undergo-
ing TURP, found 88.5% were assessed as American
Society of Anesthesiologists (ASA) score of III or IV
indicating significant medical illnesses were present
and such patients were poor anaesthetic risks. This age
and patient group is commonly seen on most urology
unit operative surgery lists.
Surgical intra-operative complications relate in
many cases to the operative surgeon’s experience with
the TURP technique. The accepted learning curve for
TURP is a long one and even after many 100 proce-
dures an occasional operative case can pose challenges;
as such this is not a procedure for the occasional opera-
tor. Familiarity with the surgical technique and equip-
ment is paramount in achieving satisfactory outcomes
for the patient. Damage to the lower urinary tract can
occur even in experienced hands with urethral trauma
leading to false passages, strictures and lifelong mis-
ery for the patient. In contemporary series, the inci-
dence of urethral damage at the time of surgery is low
with meatal dilatation and/or urethrotomy also reduc-
ing the longer-term risk of urethral and meatal stric-
tures. During resection of the bladder neck and median
lobe tissue, the risk of undermining the bladder neck
exists and, if noted early in the operation, is best treated
by early placement of a large bore urethral catheter
using a Seldinger technique over a wire or using a ure-
thral catheter introducer in experienced hands. The
procedure can then be rescheduled after 10–14 days
and safely completed. Prostatic capsular penetration
can occur relatively easily and the resection should be
completed expeditiously to minimise irrigation fluid
extravasation and absorption. Excessive absorption of
55 Urological Conditions
irrigation fluid can lead to water over-intoxication and
glycine toxicity, leading to hyponatraemia with atten-
dant cardiovascular complications including hyperten-
sion, pulmonary oedema with eventual cardiac arrest
and cerebral complications including visual distur-
bances, blindness, confusion, loss of consciousness,
seizures and in severe cases death from so-called
TURP syndrome. Blood loss from the procedure can
result in the need for intra-operative or peri-operative
transfusion; generally, larger glands with more pro-
longed resections are at increased risk of bleeding
complications, particularly in patients on aspirin or
newer anti-platelet agents which cannot be stopped
for medical reasons. All of these operative surgical
­morbidities are reduced in experienced resectionist’s
hands. Rarer intra-operative complications such as
prostato-rectal fistula formation and external sphincter
damage are likewise reduced in the hands of experi-
enced endoscopic prostate resection surgeons.
55.2.3.2 Post-operative
Mebust and co-workers in 1989 reported an immediate
complication rate of 18% post TURP. McConnell et al.
(1994) found a mean post-operative complication rate
of 14.95% with other more recent retrospective studies
noting an immediate complication rate of 3.1–7.8%.
Wasson and colleagues (1995), in a prospective ran-
domised study found 91% of patients had no compli-
cations within 30 days of surgery.
55.2.3.3 Acute Post-operative Period
Post-operative pain is generally not an issue and sim-
ple oral analgesia usually suffices. The major cause of
pain post-operatively is clot retention leading to blad-
der distention. Usually this can be cleared with bladder
washouts and subsequent continuous bladder irriga-
tion, but in more resistant or recurrent cases return to
operating theatre and wash out through the cystoscopy
sheath is required.
Haemorrhage post-operatively can result in clot
retention, and ongoing bleeding, which increases the
duration of catheterisation and/or irrigation, and may
lead to anaemia requiring blood transfusion (1–2.3%
in contemporary studies). Secondary haemorrhage
generally occurs in association with UTI and or
437
physical activity 10–21 days post surgery. The resul-
tant clot retention requiring re-catheterisation is a
rare but significant event with incidence under 2%
and more common in those men on anti-platelet or
anti-coagulant therapy. Hospital readmission data
indicates the rate for TURP is low in experienced
units but increases in low volume operative centres.
Failure to pass a trial of void in the early post-­
operative period occurs in 0.5–12% of cases. Reynard
et al. examined 379 TURP patients and found a 12%
failure to void rate, 10% of those with acute retention,
38% in those with chronic retention, and 44% in pati­
ents with a chronic preoperative large post-micturition
residual, failed to void post TURP. Only 1% of those
treated for acute retention required longer-term cathe-
terisation. Wasson et al. also noted the most frequent
complication was recurrent retention, which required
re-catheterisation in 4% of cases post TURP.
55.2.3.4 Intermediate and Longer-Term
Complications
Considering the number of procedures performed, the
published data that exist on the intermediate and long-
term results and complications of TURP seem some-
what inadequate.
55.2.4 Urethral Stricture, Bladder Neck
Stenosis and Re-operation for
Recurrent or Residual Adenoma
Urethral stricture was noted in 3.1% of 2003 patients
in the BPH guidelines report. Zwergel and colleagues
and Uchida et al. reported identical stricture rates of
1.9%. Wasson and co-workers studied 280 men who
underwent surgery. At 3-years follow-up, nine men
had developed a bladder neck stenosis, nine had
required treatment for a urethral stricture and eight had
undergone a repeat TURP, four of whom had carci-
noma of the prostate. Bruskewitz et al. (1986) noted a
10% bladder neck stenosis rate and 2% re-operation
rate at 3 years post TURP. Meyhoff and Nording (1986)
noted an 8% re-operation rate at 5 years. Lu-Yao et al.
studied 285,000 Medicare claimed patients in the USA
and found that the rate of retreatment by TURP within
438
7 years for recurrent adenoma was 5.7% for men aged
75 years or older and 5.4% for men under 75 years of
age. The reoperation rate in the study of Sidney and
co-workers of 8,000 men undergoing TURP was 1.3%
at 1 year, 4.2% at 5 years and 7.6% at 7 years. Both of
these more recent studies have a lower re-operation
rate than the study by Roos et al., which reported rates
of 12–15.5% at 7 years.
55.2.5 Erectile and Ejaculatory Problems
Erectile dysfunction post TURP is not well researched,
with a reported incidence of 3–40%. The exact mecha-
nism of impotence creation is unknown but may relate
to thermal (electrical current) damage or extravasation
of fluid leading to scarring around the neurovascular
bundles, which are located postero-lateral to the blad-
der neck and prostatic capsule. Increasing age is asso-
ciated with a higher incidence of post-operative
impotence. In a TURP population, the risk of de novo
post-operative impotence was reported as 4.2%.
Although not a universal result of TURP, disruption
of bladder neck function by surgery results in a degree
of retrograde ejaculation in up to 75% of men undergo-
ing prostatic surgery. This outcome is stressed to all
men in the consent process.
55.2.6 Incontinence
Total incontinence of urine following TURP is rare
and occurs in less than 1%. Stress urinary incontinence
is reported in 1–2% of cases and is due to damage to
the external sphincter mechanism during resection; in
most cases this is minor but more severe cases can be
treated by injectable bulking agents, urethral slings or
an artificial urinary sphincter. Urgency and urge incon-
tinence has a wide range of reported presence in the
post-prostatectomy patient group (5–25%). In many
cases, these symptoms may have been present preop-
eratively and detrusor instability and poor compliance
is found in up to 67% of these men, suggesting bladder
muscle dysfunction is responsible, rather than pros-
tatic or other outflow obstructive causes. This may
help explain why nocturia, urgency and frequency are
the most common persisting symptoms post TURP.
J. Miller et al.
55.2.7 Alternatives to Transurethral
Prostatectomy
Over the last two decades numerous alternative mini-
mally invasive techniques have evolved and are chal-
lenging TURP as a treatment for urinary retention;
many have claimed to have comparable outcomes. The
use of laser energy for ablation or resection does have
comparable published results to TURP with short
­hospitalisation, less haemorrhagic, fluid and electro-
lyte complications and intermediate and long-term
outcome results in experienced surgical hands. Large
prostates can safely be treated with this technique as
can associated problems such as bladder calculi.
However, the costs of initial setup and ongoing usage
make adoption of this technology slow, and as such,
the gold standard of transurethral prostatectomy will
remain for some years to come particularly in country
and regional centres.
55.2.8 Open Prostatectomy
Open prostatectomy was first performed in 1894 and
promoted by Freyer in London in the early years of
the twentieth century using the trans-vesical tech-
nique. In 1945, Millin demonstrated improved results
for open retro-pubic prostatectomy. The operative
technique is well described in many surgical textbooks
and has changed little since the initial descriptions.
The results of open and transurethral prostatectomy
for outflow obstructive symptoms and acute urinary
retention are comparable. The advantages of the open
operation include a lower incidence of recurrent ade-
noma and reoperation rate over time, elimination of
the risk of TURP syndrome and ability to deal with
bladder pathology such as calculi and diverticuli at the
same operative setting. Disadvantages include the
need for an abdominal incision and attendant pain,
risks of wound and pelvic infection, increased risk of
intra-operative and post-operative haemorrhage, and
consequent transfusion needs and increased thrombo-
embolic risk (Deep Vein Thrombosis and Pulmonary
Embolism). Length of hospitalisation and duration
of convalescence and time off work is greater with
the open surgical approach. The open retro-pubic
55 Urological Conditions
approach is recommended in cases where large pros-
tates (>75 g) are identified and particularly when the
endoscopic technique would require over 60–90 min
to perform, therefore, increasing the risk of dilu-
tional hyponatremia (TURP syndrome). Other indi-
cations include patients who cannot be placed in
lithotomy position due to hip or pelvic pathologies
and those with significant sized bladder calculi not
amenable to transurethral fragmentation. In experi-
enced laser prostatectomy centres, large adenomas
and bladder calculi can be treated by the transure-
thral approach without the increased risk normally
associated with the standard electro-cautery tran-
surethral techniques.
55.3 Surgically Sustained Injuries
to the Urinary Tract
55.3.1 Introduction
While damage to the urinary system is commonly con-
sidered in the context of trauma, surgical injury
(whether expected or inadvertent) accounts for the
greatest proportion of ureteral and bladder injuries
with pelvic surgery being primarily to blame. As
expected, surgery to irradiated tissue or pelvic surgery
requiring extensive resection carry increased risk. High
rates of delayed detection are associated and the pos-
sibility of occult urinary tract injury should be consid-
ered in those patients with delayed or stormy
post-operative recovery. The morbidity of such inju-
ries is significant and includes loss of kidney function
and stricture or fistulae formation.
55.3.2 Ureteric Injury
Surgical procedures most at risk of ureteric injury
include hysterectomy, colorectal surgery, multiple
lower segment caesarean section (LSCS), pelvic sur-
gery and abdominal vascular surgery. Laparoscopic
procedures are associated with lower intra-operative
detection rates although overall around a third are
­recognised during the procedure.
439
55.3.3 Types of Injury
• Transection of the ureter
• Involvement of the ureter in the operative site (as in
pelvic malignancy)
• Ischaemic injury from extensive “skeletonisation”
or mobilisation, crushing with a clamp or transmit-
ted through operative energy sources (diathermy,
ultrasonic scalpel devices, LASER)
• Ligation of the ureter with sutures or clips
55.3.4 Prevention
Relevant anatomy of the ureter is beyond the scope of
this summary. The proximity of the uterine vessels in
its distal course has been well described. Note also the
blood supply of the ureter runs in its adventitial layer.
Careful assessment of preoperative imaging for any
sign of ureteric involvement in the operative site is
mandatory. Cystoscopic insertion of ureteric catheters
or stents prior to or at the time of surgery will aid with
identification if concern about the path or involvement
of the ureter is raised. Early involvement of an urolo-
gist can make the expected ureteric injury a far more
manageable problem. At either laparoscopic or open
surgery, the usual prevention principles apply; follow
the path of the ureter where visible before searching in
the unknown. Lowering the intensity of light or chang-
ing camera ports often aid in the visibility of a coloured
stent through the ureteric wall.
55.3.5 Diagnosis
Intra-operative: Large transections may be obvious but if
the diagnosis of ureteric injury is suspected intra-­
operatively, 1–2 mL methylene blue injected into renal
pelvis with a fine gauge needle will demonstrate a leak.
Intravenous administration of methylene blue (20 mL)
and frusemide is an alternate; as is performance of an
­on-table retrograde pyelogram or intravenous pyelogram.
Post-operatively: Late presentations are suspected on
the basis of fever, loin or renal angle tenderness, unex-
plained leukocytosis, haematuria, ileus or abdominal
distension (particularly where associated with irritative
440
peritonitis), watery vaginal leak (suggesting a fistula) or
high drain output. In addition, biochemical abnormali-
ties result from urine absorption across peritoneum
(pseudo renal failure with hypernatraemia, hyperkael-
emia increased creatinine) and high drain fluid creati-
nine (i.e. in keeping with urine rather than serum) point
to the diagnosis. Ultimately, the diagnosis will be con-
firmed on imaging with computed tomography with
delayed views to delineate the entire ureter (CT IVP) or
retrograde pyelography. Renal ultrasound is often per-
formed as an initial investigation to look for hydroneph-
rosis but has the disadvantages of failing to delineate the
ureter and delaying more appropriate investigation.
A normal ultrasound does not rule out ureteric injury.
“Tampon tests” in the assessment of urinary fistulae have
been replaced by imaging as above, with the advantage
of assessing for multiple fistulae and defining location.
55.3.6 Management
Adherence to certain general principles increases the
success rate of primary repair:
1. Mobilise the injured ureter carefully, sparing the
adventitia widely to prevent devascularisation.
2. Débride the ureter liberally until the edges bleed.
3. Repair ureters with spatulated, tension-free, stented,
watertight anastomosis, placing retroperitoneal
non-suction drains afterward.
4. Consider omental interposition to isolate the repair
when possible.
In the case of surgical ligation, minor contusions or
clamping, remove the offending device and observe
for return to normal appearance and ureteral peristal-
sis. These injuries are well served by stenting regard-
less of need for further intervention as risk of ischaemic
injury (with subsequent risk of ischaemic stricture or
fistulae) is present. Stents can be removed at around
4–6 weeks post-operatively with a retrograde pyelo-
gram performed at the time of removal.
Injury by electrocautery can often extend beyond
the visible region. While the risk of transmitted heat
artefact is reduced with use of bipolar diathermy or
ultrasonic coagulation devices, this does still occur and
should not be considered a safe option. Debridement
of the ureter to ensure a bleeding edge prior to repair
gives the best chance of healing.
J. Miller et al.
Foley catheter drainage of the bladder in combina-
tion with stenting optimises drainage during the recov-
ery phase. The catheter should be removed only once
drain output has minimised, and the drain left in situ
for a subsequent 24 h to check for patency of repair.
Any sign of increased drain output during this period is
initially managed with re-catheterisation.
Ideally, surgical transection recognised intra-opera-
tively should be repaired using the above principles
where the surgeon is comfortable and the anastomosis
can be achieved without tension. More complex
manoeuvers are sometimes required to achieve ade-
quate ureteric length, particularly if a segment of ­ureter
over approximately 2 cm has been sacrificed in the
resection. Arrangements should then be made for uro­
logist involvement, which may include transfer to an
appropriate centre for repair. Ultimate techniques for
overcoming damaged ureters beyond simple ureter-
oureterostomy range through transureteroureteros-
tomy, ureteroneocystostomy (with or without Boari
flap), ileal interposition to autotransplantation.
If transfer is necessary for further treatment of an
injury identified intraoperatively, leave adequate drain-
age of the injured area. Staged repair may be required
in haemodynamically unstable patients, such as severe
sepsis. In those cases tying off the ureter and placing a
nephrostomy tube will aid in second stage and protect
renal function during stabilisation or transfer.
Timing of repair is controversial in cases of delayed
recognition of ureteral injury. The placement of a ure-
teric stent, if able, or percutaneous nephrostomy inser-
tion is the first priority for protecting renal function.
Transfer to appropriate centre for repair can then be
arranged. Institution of appropriate antibiotic and renal
replacement therapy as indicated should be consid-
ered. The benefit to the patient of an early repair must
be weighed against the patient’s concurrent medical
status and intra-operative difficulties often encoun-
tered at immediate second operation.
55.3.7 Bladder Injury
Intra-operative bladder injury is seen in all pelvic sur-
geries but is particularly related to hysterectomy, cae-
sarean section (especially repeated section), endoscopic
urological procedures and orthopaedic trauma such as
internal fixation of the pelvis.
55 Urological Conditions
55.3.8 Prevention
Again, planning for anticipated difficult resections in
the pelvis offers the best chance of preventing (or at
least early recognition and repair) of bladder injury.
Bladder catheterisation with at least a 16 Fr Foley
­optimises bladder drainage and, therefore, collapse.
Smaller catheters often fail to keep the bladder fully
empty.
55.3.9 Diagnosis
Most are recognised intra-operatively, but if not cysto-
gram or CT cystogram will confirm diagnosis if
­performed adequately, with sensitivities approaching
100%; 300– 400 mL of dilute contrast (50% contrast
with 50% saline or water) is ideal. The bladder should
be retrogradely filled with contrast rather than relying
on adequate filling from progress views after CT IVP.
The possibility of concurrent ureteral injury may need
to be considered.
• Bladder perforation can be defined as intraperito-
neal or extraperitoneal – an important management
distinction and able to be differentiated on
cystogram.
• Suspicion of intraperitoneal urine leak is raised
with signs of peritonitis, oliguria, haematuria, unex-
plained fever, leukocytosis, “pseudo” renal failure
or high drain output. Drain creatinine is elevated.
• Extraperitoneal leaks present with haematuria.
Signs may be minimal whilst catheter is in place
and only on removal are supra-pubic discomfort,
poor voided volumes and low residual volumes on
bladder scanning a feature.
55.3.10 Management
• Repair of immediately recognised injuries can be
achieved with two–layer closure of the bladder wall
with an absorbable suture. The surgeon should be
confident that the injury is away from the ureters
and bladder trigone if this to be achieved safely.
A large bore Foley catheter (minimum 18 Fr) is left
441
for 7–14 days and the repair checked with a cysto-
gram prior to removal. Prophylactic oral antibiotics
provide for infection-free healing.
• Intraperitoneal bladder leak can be managed the
same way with washout of the irritant urine at the
time. A lower midline incision provides sufficient
access to the bladder dome. A non-suction perito-
neal drain will give good additional drainage to the
region.
• Extraperitoneal injuries largely resolve with pro-
longed catheterisation – again with large bore
­catheter and ensuring infection-free environment.
A cystogram performed at day 7–10 will confirm
resolution. Around 15% fail to settle by day 10;
most of these will have resolved by 3 weeks.
• Urinary fistulae: rarely, unrecognised damage to the
bladder or ureter results in the development of a
­urinary fistula. The repair of an identified urinary
fistula should only be undertaken in consultation
with an urologist experienced in fistula repair.
55.4 Open Nephrectomy
55.4.1 Introduction
The first planned nephrectomy was carried out by
Gustav Simon in 1869, using the dorsal lumbotomy
incision. Since then various ways in carrying out a
nephrectomy have emerged. One of the early great
controversies in the early half of the last century was
regarding the merits of extra-peritoneal versus trans-
peritoneal exposure of the kidney. In present times
with development of improved and safer techniques
both approaches are equal in terms of safety. The intro-
duction of laproscopic nephrectomy by Ralph Clayman
in 1990 has further advanced the field. With rise in
detection of small tumours with the increased avail-
ability of Computed Tomography (CT), there has been
increase in the volume of nephron-sparing surgery or
partial nephrectomies being carried out.
In the rural setting, a simple nephrectomy can be
carried out provided the surgeon is familiar with the
surgical anatomy of the kidney as well as experienced
in the procedure. In emergency cases such as emphy-
sematous pyelonephritis, where the patient is too ill for
transfer, there may be a need to do an emergency
442
nephrectomy. This can be a challenging operation as a
simple nephrectomy is very rarely simple. The surgical
planes around the kidney are often ill-defined due to
repeated infections. Surgery for renal cancers should
preferably be done in a hospital which has urological
services and access to oncology units. Large tumours
and those complicated with renal vein thrombus are
challenging cases that should be carried out by uro-
logical surgeons. Certainly, laparoscopic nephrectomy
and nephron sparing surgery require specialised train-
ing in centres that perform such surgery on a regular
basis.
55.4.2 Preoperative Evaluation
A careful preoperative evaluation and optimisation is
essential prior to a nephrectomy being carried out.
Cardiopulmonary system has to be assessed and opti-
mised if necessary. In the flank position, compression
on the IVC and the dependent position of the legs lead
to decreased venous return. Pressures on the dependent
lung when the patient is positioned laterally, causes a
decrease in the vital capacity. Both these conditions
can cause significant stress on the cardiopulmonary
system. Post-operative respiratory function can further
be seriously impaired due to pain from the upper
abdominal incision as well inadvertent injury to the
pleura or diaphragm. Underlying renal insufficiency
may further worsen after a nephrectomy especially in
patients with existing renal impairment. Proper imag-
ing of the renal system in the form of a CT is essential
as it helps in the staging of the tumour, in the planning
of the type of incision and approach, as well confirm-
ing the presence of the contra-lateral kidney. Overall
renal function particularly the function of the contra-
lateral kidney is best assessed by a radio-nucleide
renogram and is highly recommended in patients with
impaired renal function.
In all cases regardless of approach and pathology
recent biochemical and haematological evaluation
should be performed and blood grouped and
matched in case of massive intra-operative blood
loss. Recent and appropriate radiological imaging
must be present in the operating theatre to confirm
the correct operative side and patient. Preoperatively,
anti-embolic compressive stockings and intermit-
tent compression devices should be fitted with
J. Miller et al.
anticoagulants (heparin or low molecular weight
components) given intra-operatively at induction or
when the anaesthetic team are happy for it’s usage.
Chest physiotherapy for post-operative care and a
high dependency unit bed should be available for
the patient post-operatively.
55.4.3 Surgical Approach to the Kidney
Familiarity with the surgical anatomy of the kidney is
essential before embarking on simple or a radical
nephrectomy. This can be sought in the relevant texts
or atlases on urological surgical anatomy.
The surgical approach one chooses depends on
­factors such as the underlying renal pathology, the kind
of operation to be performed, the need to do bilateral
operations, obesity and skeletal deformities. The
approaches can be broadly classified into extra-­
peritoneal flank incision, anterior abdominal incision,
abdomino-thoracic incision or posterior dorsal lum-
botomy. In this summary, a simple nephrectomy using
the extra-peritoneal flank approach and a radical neph-
rectomy using an anterior sub-costal trans-peritoneal
approach shall be described.
55.4.4 Simple Nephrectomy
55.4.4.1 Indications
1. Irreversibly damaged kidney due to reno-vascular
hypertension from renal artery disease
2. Severe unilateral parenchymal damage caused by:
• Chronic infection
• Obstruction
• Calculus disease
• Severe traumatic injury
• Nephrosclerosis
• Chronic pyelonephritis
• Xanthogranulomatous pyelonephritis
• Reflux nephropathy
• Congenital dysplasia of the kidney
• Emphysematous pyelonephritis
55 Urological Conditions
55.4.4.2 Position and Incision
The simple nephrectomy as mentioned earlier can be
performed through a variety of incisions. The flank
approach with the patient positioned laterally is popu-
lar with most urological surgeons.
Position
With the patient under general anaesthesia and appro-
priate monitoring devices placed by the anaesthetic
team, a urinary catheter is inserted and the patient is
turned to the lateral decubitus position with his or her
back toward the edge of the table and the tip of the
12th rib right over the kidney rest. The patient is placed
on the operating table so that the kidney rest is just
cephalad to the anterior superior iliac spine.
The lower limb is flexed to 90° at the hip and knee
with appropriate padding at the knee and ankle. The
upper limb is appropriately padded with pillows and
kept gently flexed, which helps to keep the flank mus-
cles stretched and also provides stability. The patient
should then be secured to the table with 2-in. adhesive
tape over the patient’s hip and lower chest.
Appropriate sponge or silicon padding to protect
and avoid brachial plexus injury is mandatory, with the
upper extremities secured to an arm board and sling
support or Mayo stand. The table is then flexed until
the flank muscles are tense, and the kidney rest ele-
vated; this should be done slowly and at completion
the flank should be horizontal. In some cases a suction/
vacuum bean bag is useful in maintaining the patient’s
position. It is important to remember that the patient
should be positioned with the table flexed before the
bean bag is activated.
Incision
The position of the kidney determines the level at
which to make the incision. This can be determined by
drawing a horizontal line on the urogram from the
hilum of the kidney to the most lateral rib that it
intersects.
The standard flank incision is made directly over
the appropriate rib at the lateral border of the sacrospi-
nalis muscle. The latissimus dorsi and external oblique
are divided with cautery.
443
The periosteum over the rib is divided and reflected
off using the periosteal elevator. The rib is transected
as far back as possible using the guillotine rib resector.
This allows the retracted muscle mass too fall back
over the sharp cut edge. An incision through the
periosteal bed is made and the fascial attachments of
the pleura are sharply incised to allow superior reflec-
tion of the pleura. The peritoneum is bluntly dissected
from the deep surface of the transversalis fascia by
sweeping it medially with the fingers. The medial
extent of the incision is completed with division of the
external and internal oblique and the transverses mus-
cles. A self-retaining retractor is then utilised to main-
tain exposure.
55.4.4.3 Nephrectomy
The dense peri-nephric fascia (Gerota’s) is identified
beneath the retroperitoneal fat and is incised laterally
to avoid injury to the peritoneum. The kidney is then
dissected free from the surrounding peri-nephric fat
using blunt and sharp dissection. The adrenal is nor-
mally in a separate compartment within Gerota’s ­fascia
allowing it to be readily separated and retained.
The vascular pedicle can be approached anteriorly
or posteriorly with the renal artery identified including
possible aberrant vessels, particularly lower-pole
branches. Ligation of the artery before the vein pre-
vents renal congestion and is thus preferred. The ves-
sels are ligated in continuity using two large ties
proximally and a single tie distally or if preferred with
suture ligation or multiple vascular clips or staples.
The ureter is quickly identified by blunt dissection in
the fat inferior to the kidney. It is divided between liga-
tures or clips. The adrenal gland can be dissected off
with sharp dissection, taking care to clip all vessels.
55.4.4.4 Sub-capsular Technique
In patients undergoing simple nephrectomy for stone
disease or for infection, severe perirenal inflammation
can make dissection between the kidney and surround-
ing tissues extremely difficult. In these cases, it is
advantageous to come down to the renal capsule, incise
it, and continue the dissection under the capsule to the
hilum. At this point the renal vessels may have already
divided into several branches which are ligated and
444
transected as far laterally as possible to allow satisfac-
tory proximal control. The upper ureter is then ligated
and divided to complete the nephrectomy.
55.4.4.5 Closure
Drains can be placed through a separate stab incision.
The table break is reduced to facilitate tissue closure
by careful approximation of the corresponding muscle
and fascial layers in two layers using strong suture
material. Skin closure is completed via the surgeons
preferred technique.
55.4.4.6 Complications and Outcomes
Mortality (1%)
Haemorrhage (6%)
Pneumothorax (4–5%)
Flank bulge
55.4.5 Radical Nephrectomy
55.4.5.1 Indication
• Treatment of choice for localised renal cell carci-
noma with a normal contralateral kidney.
• Concomitantly with resection of a solitary meta-
static lesion.
• Palliative nephrectomy.
55.4.5.2 Principle
The basic principles as described by Robson are early
ligation of the renal artery and vein, removal of the kid-
ney together with the peri-nephric fat intact within the
Gerota’s fascia, removal of the ipsilateral adrenal gland
and complete regional lymphadenectomy. However, in
recent years it has been shown that there is no benefit
in removing the ipsilateral adrenal gland unless the
tumour is in the upper pole of the kidney or there is
extensive involvement of the kidney. There has also
been much debate regarding the therapeutic benefits of
doing a lymphadenectomy. Many urologists do not do
a lymphadenectomy as part of a radical nephrectomy.
J. Miller et al.
55.4.5.3 Surgical Approach
The surgical approach depends on the size of the
tumour, its location in the kidney and the build of the
patient. One common approach used is the anterior
trans-peritoneal approach. It provides early access and
good exposure of the renal pedicle. A sub-costal inci-
sion can be carried out and this incision can be extended
medially into a chevron incision or laterally into a tho-
raco-abdominal incision if better exposure is needed.
Using this approach an incision is made from near the
tip of the 11th or 12th rib 2 cm below the costal margin
and extended medially to the xyphoid process. If nec-
essary the incision is then gently curved across the
midline. The anterior rectus fascia is then divided and
in the lateral aspect of the incision, the latissmus dorsi
muscle is divided. The external and internal oblique
fascia and muscles are then divided, and the fibres of
the transversus abdominis split. The rectus muscle and
posterior rectus sheath are divided with the superior
epigastric artery ligated and divided if needed. The
peritoneum is entered in the midline and the ligamen-
tum teres divided. A thorough exploration of the intra-
abdominal contents is then performed.
55.4.5.4 Radical Nephrectomy:
On the Right Side
The posterior peritoneum lateral to the colon is incised
along the length of the ascending colon and reflected
medially with the hepatic flexure then mobilised. The
plane between the mesentery of the colon and Gerota’s
fascia is then developed using a combination of sharp
and blunt dissection. By Kocherizing, the duodenum,
the vena cava is exposed and dissection is continued on
the vena cava to expose the renal vessels at the renal
hilum. The right renal vein is identified exiting from
the vena cava, isolated, and encircled with a right-angle
clamp and a vessel loop applied. The renal artery is
identified; the exposure may be enhanced by the use of
a vein retractor on the renal vein. The vessels are ligated
in continuity (artery first) using two large ties proxi-
mally and a single tie distally or if preferred with suture
ligation or multiple vascular clips or staples. The ureter
is identified and encircled with a vessel loop. The
gonadal vein is ligated and divided. The entire renal
mass with overlying peri-nephric fat is then dissected
off the posterior abdominal wall and fully mobilised
55 Urological Conditions 445

external to Gerota’s fascia laterally and superiorly. Lymphocele/lymph or ascites 1–5%

Medially, the adrenal vessels are ligated and the ­adrenal fistulab
removed in continuity with the kidney. Paralytic ileusb 20–50%
Respiratory

55.4.5.5 Radical Nephrectomy: On the Left Side • Basal atelectasis 20–50%

• Sub-phrenic collection, seroma, 20–50%
The posterior peritoneum lateral to the colon is incised haematoma
along the length of the descending colon and reflected • Pneumonia 1–5%
medially. The lienorenal ligament is incised to mobil-
Renal impairment 5–20%
ise the spleen cephalad. The plane between the mesen-
tery of the colon and Gerota’s fascia is then developed Pancreatic injury/pancreatitis/ 0.1–1%
pancreatic cyst/pancreatic fistula
using a combination of sharp and blunt dissection.
The duodeno-jejunal flexure is reflected medially to Bowel injury (stomach, duodenum, 0.1–1%
expose the renal vessels. The dissection is then carried small bowel, colon)b
cephalad along the aorta. The renal vein is isolated as Urine leakage /collection (urinoma)a 1–5%
it courses over the aorta. The left adrenal, gonadal and Small bowel obstruction (early or 1–5%
lumbar veins are identified emanating from the left late)a
renal vein. These are ligated and divided. A vessel loop Diaphragmatic injurya 1–5%
is passed around to tag the vein. The left renal artery
Splenectomy c
2–5%
and vein are then ligated as described previously.
The ureter and gonadal veins are identified and Venous thromboembolism 5–20%
­subsequently ligated and divided. The entire renal mass Pain/discomfort/tenderness
with overlying peri-nephric fat is then dissected off the
• Short term (<4 weeks) 50–80%
posterior abdominal wall and fully mobilised external
to Gerota’s fascia laterally and superiorly. Medially, • Long term (>12 weeks) 0.1–1%
the adrenal vessels are ligated and the adrenal removed Nerve injury/sensory changes 1–5%
in continuity with the kidney. Hemoclips along the Lumbar plexus or branches, 1–5%
superior and medial border are useful to control any sympathetic chaina
potential bleeding during this portion of the procedure. Urinary retention/catheterisation 0.1–1%
The kidney is then removed. Meticulous haemostasis
is performed. Drains are placed using separate stab Wound scarring/deformity/poor 1–5%
cosmesis
incisions. The incision is closed in two layers approxi-
mating the corresponding muscle and fascial layers. Incisional hernia (avoid lifting/ 1–5%
straining for 8 weeks)
Skin is closed as per individual preference.
Drain tube(s)a 1–5%
a
Dependent on underlying pathology, surgical technique prefer-
Complications, risks and Estimated ences, incision used and location on the body
consequences frequency b
Incidence may be higher for large or extensive masses
Most significant/serious c
Splenic preservation may sometimes be possible for splenic
complications traumatic injury
Infectiona
• Subcutaneous/wound 1–5%
• Urinary/systemic 1–5%
55.4.6 Perspective
• Intra-abdominal 1–5%
• Chest infection 1–5%
For tumours confined within Gerota’s fascia, the pro-
Bleeding, haematoma/seroma 1–5% cedure is relatively well defined and overall, carries a
formation
smaller risk. For more advanced tumours, extensive
446
surgery is associated with a higher risk of complica-
tions. Severe bleeding and injury to adjacent structures
can occur, but are uncommon. Injury to the pancreas
may invoke pancreatitis or pancreatic leakage, leading
to a pancreatic collection, which may become infected
and sometimes form an external fistula. These can be
chronic and debilitating. Seromas or lymphatic collec-
tions are not uncommon, but may not be symptomatic,
unless large, compressing other structures, or when
infected. Small bowel obstruction due to adhesions
from the extensive dissection can be recurrent and may
require later surgery.
55.4.7 Major Complications/
Consequences
Bleeding is one of the major potential complications
of nephrectomy. Transfusion is rarely required for
nephrectomy (1–5%). Slow ooze and either seroma or
haematoma formation can occur, and may develop
secondary infection and abscess formation. Wound
infection and rarely wound dehiscence, can result in
later incisional hernia formation. Infection may occa-
sionally lead to systemic sepsis and even multi-system
organ failure, which is a significant cause of early
mortality. Later mortality is due to tumour recurrence
or persistence. Splenic injury and splenectomy are rare
complications with left nephrectomy, largely depen-
dant on tumour extension. Significant lymphatic leak-
age may very rarely occur from thoracic duct injury,
which will lead to lymphatic ascites or collection.
Small bowel obstruction may be a recurrent major
issue, often treated well conservatively, but surgery
may be required.
55.5 Laparoscopic Nephrectomy or
Partial Nephrectomy
55.5.1 Description
General anaesthesia is used. Nephro-ureterectomy is
performed for transitional cell carcinomas of the
upper tracts and requires in most cases removal of a
­surrounding bladder cuff around the vesico-ureteric
J. Miller et al.
junction. The usual indication for a nephrectomy or
partial nephrectomy is a renal cell carcinoma and
rarely end-stage kidney disease in association with
hypertension. Other indications for nephrectomy are a
non-functioning atrophic kidney, an obstructed kidney
with recurrent infection and living related donor neph-
rectomy. The aim of the procedure is to remove the
kidney (totally or partially).
Surgery is determined by the extent of disease with
the laparoscopic approach confined to smaller tumours
generally under 7 cm diameter but larger tumours can
be removed depending on the surgeons experience and
skill. Resection of the kidney, adrenal and proximal
ureter is usual, with surrounding lymph nodes, and
involved organs, if appropriate. The extent of resection
and consequent complications are largely determined
by the extent of disease. The approach used depends
on the pathology, lesion site, size, and extent, required
access and surgeon preference. Laparoscopic partial
nephrectomy has been used with excellent outcomes
for benign and selected malignant renal tumours. Port
placement using an anterior trans-peritoneal or lateral
flank extra-peritoneal approach is usual, depending
on pathology, lesion size, extent, required access and
surgeon preference.
The patient is prepared as per an open nephrectomy
with the additional consent taken for a laparoscopic
procedure. General endotracheal tube muscle relaxant
anaesthesia is utilised with urinary catheter and
i.v. cannulas placed prior to positioning. The patient is
placed in a modified lateral position as per the stan-
dard loin incision approach with appropriate padding
and allowing gravity assisting in dissection. After
establishing the pneumo-peritoneum and initial three
ports, an incision is made along the peritoneal reflec-
tion of the colon from the level of the iliac vessels to
the diaphragm with the colon dissected and mobilised
medially including division of the lieno-renal liga-
ment on the left side. On the right side, the duodenum
is mobilised and lifted off the vena cava, with hilar
dissection commencing with dissection and division
of the gonadal vein with subsequent dissection and
mobilisation of the lateral margin of the IVC and renal
vein. The adrenal vein is dissected and clipped before
dividing prior to superior mobilisation of the renal
vein and its junction with the IVC. The renal artery
is identified and dissected free prior to ligation and
division with haemostatic locking clips or vascular
stapling devices. After the artery has been divided, the
renal vein can be dealt with in a similar manner.
55 Urological Conditions 447

On the left side, after medial mobilisation of the colon Injury to the bowel or blood vessels 0.1–1%
and duodeno-jejunal flexure the vascular dissection is (trochar or diathermy)
carried out in a similar fashion with initial dissection • Duodenum/stomach/small bowel/colon/
and division of the gonadal vein followed by dissec- iliac or mesenteric arteries
tion of the renal artery and vein with division of the
Conversion to open operation 1–5%
adrenal and posterior lumbar veins prior to ligation
and division of both the artery and vein. The ureter is Gas embolus 0.1–1%
then dissected and divided prior to full mobilisation of Pneumothorax 0.1–1%
the kidney medially, posteriorly, laterally and superi- Deep venous thrombosis 0.1–1%
orly using sharp and blunt dissection. The dissection
Splenectomy c
0.1–1%
is performed outside Gerotas fascia in a radical neph-
rectomy or within the peri-nephric fat for a simple Less serious complications
nephrectomy. The specimen is then removed after Pain/discomfort/tenderness
insertion into a specimen bag and removed via a skin • Short term (<4 weeks) 5–20%
crease incision incorporating the lower abdominal
port site if removed intact or via the umbilical port if • Long term (>12 weeks) 0.1–1%
specimen morcellation or fragmentation is allowed Urinary retention/catheterisation 0.1–1%
(benign pathology). Nerve injury/sensory changes 0.1–1%
lumbar plexus or branches, sympathetic 0.1–1%
chaina
Complications, risks and consequences Estimated
frequency Wound scarring (deformity/poor cosmesis) 1–5%
Most significant/ serious complications Port-site hernia (avoid lifting/straining 0.1–1%
for 8 weeks)
Infectiona

Drain tube(s)a 1–5%

• Subcutaneous/wound 1–5% a
Dependent on underlying pathology, surgical technique prefer-
• Urinary/systemic 1–5% ences and location on the body
• Intra-abdominal 1–5%
b
Incidence may be higher for large or extensive masses
c
Splenic preservation may sometimes be possible for splenic
• Chest infection 1–5% traumatic injury
Bleeding, haematoma/seroma formation 1–5%
Lymphocele/lymph or ascites fistula b
1–5%
Paralytic ileus
b
5–20%
55.5.2 Perspective
Respiratory
• Basal atelectasis 5–20% For tumours confined within Gerota’s fascia, the
• Sub-phrenic collection, seroma, 20–50% ­procedure is relatively well defined and overall, carries
haematoma less risk. For more advanced tumours, extensive sur-
• Pneumonia 1–5% gery is associated with a higher risk of complications,
Renal impairment 5–20% including major complications. An open procedure
may be preferable and the patient should be pre-
Urine leakage/Urine collection (urinoma) b
1–5%
warned of risk of conversion to an open procedure.
Small bowel obstruction (early or late) a
1–5% Severe bleeding and injury to adjacent structures are
Pancreatic injury/pancreatitis/pancreatic 0.1–1% the most immediate issues that can lead to further
cyst/pancreatic fistula major complications, such as infection, peritonitis and
Bowel injury (stomach, duodenum, 0.1–1% abscess formation. Injury to the pancreas, especially
small bowel, colon)b with left renal surgery, may invoke pancreatitis or pan-
Bladder injurya 0.1–1% creatic leakage, leading to a pancreatic collection,
which may become infected and sometimes form an
Diaphragmatic injury a
0.1–1%
external fistula. These can be chronic and debilitating.
448
Seromas or lymphatic collections are not uncommon,
but may not be symptomatic, unless large, compress-
ing other structures, or when infected. Small bowel
obstruction due to adhesions from the extensive dis-
section can be recurrent and may require later surgery.
Partial nephrectomy can preserve renal function and
has been used successfully for malignancy in selected
cases.
55.5.3 Major Complications/
Consequences
Bleeding is one of the major potential complications
of nephrectomy. Transfusion is rarely required. Slow
ooze and either seroma or haematoma formation can
occur, and secondary infection may develop some-
times leading to abscess formation. Peritonitis can
also be a significant complication. Wound infection
and rarely wound dehiscence, can result in later inci-
sional hernia formation. Infection may occasionally
lead to systemic sepsis and even multi-system organ
failure, which is a significant cause of early mortality.
Later mortality is due to tumour recurrence or persis-
tence. Pancreatic leak, collection and fistula are very
rare, but can be debilitating. Gas embolism, major
vascular injury or bowel injury are relatively rare.
Bowel injury (or involvement) may very rarely require
stoma formation. Splenic injury and splenectomy are
rare complications with laparoscopic left nephrec-
tomy, largely dependant on tumour extension. Signi­
ficant lymphatic leakage may occur from thoracic duct
injury, leading to lymphatic ascites or collection.
Small bowel obstruction may be a recurrent major
issue, often treated well conservatively, but surgery
may be required.
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Emberton, M., Neal, D.E., Black, N., et al.: The national pros-
tatectomy audit: the clinical management of patients during
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Emberton, M., Neal, D.E., Black, N., et al.: The effect of
­prostatectomy on symptom severity and quality of life.
Br. J. Urol. 77, 233–247 (1996)
Estey, E.P., Mador, D.R., McPhee, M.S., et al.: A review of 1486
transurethral resections of the prostate in a teaching hospital.
Can. J. Surg. 36, 37–40 (1993)
Fuglsig, S., Aagaard, J., Jonler, M., et al.: Survival after tran-
surethral resection of the prostate: a 10-year follow-up.
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Gibbons, R.P., Stark, R.A., Correa Jr., R.J., et al.: The prophy-
lactic use—or misuse—of antibiotics in transurethral pros-
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Hindley, R.G., Mostafid, A.H., Brierly, R.D., et al.: The 2-year
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resection of the prostate. BJU Int. 88, 217–220 (2001)
Jacobsen, S.J., et al.: Natural history of prostatism: risk factors
for acute urinary retention. J. Urol. 158, 481–487 (1997)
Kadow, C., Feneley, R.C., Abrams, P.H.: Prostatectomy or con-
servative management in the treatment of benign prostatic
hypertrophy? Br. J. Urol. 61, 432–434 (1988)
McConnell, J.D., et al.: The effect of finasteride on the risk of
acute urinary retention and the need for surgical treatment
among men with benign prostatic hyperplasia. Finasteride
long term efficacy and safety study group. N. Engl. J. Med.
338, 557–563 (1998)
McConnell, J.D., et al.: The long-term effects of doxazosin,
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benign prostatic hyperplasia. N. Engl. J. Med. 349, 2385–
2396 (2003)
Mebust, W.K., Holtgrewe, H.L., Cockett, A.T.K., et al.:
Transurethral prostatectomy: immediate and postoperative
complications. A cooperative study of thirteen participating
institutions evaluating 3,885 patients. J. Urol. 141, 243–247
(1989)
Meigs, J.B., Barry, M.J., Giovannucci, E., et al.: Incidence rates
and risk factors for acute urinary retention: the health profes-
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Meigs, J.B., Mohr, B., Barry, M.J., et al.: Risk factors for clinical
benign prostatic hyperplasia in a community-based popula-
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Melchior, J., Valk, W.L., Foret, J.D., et al.: Transurethral pros-
tatectomy: computerised analysis of 2, 223 consecutive
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Meyhoff, H.H., Nordling, J.: Long term results of transurethral
and transvesical prostatectomy: a randomised study. Scand.
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Roehrborn, C.G., Boyle, P., Bergner, D., et al.: Serum prostate-
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prostate specific antigen concentration is a powerful predic-
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with clinical benign prostatic hyperplasia. Urology 53,
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55 Urological Conditions
Roehrborn, C.G., Bruskewitz, R., Nickel, G.C., et al.: Urinary
retention in patients with BPH treated with finasteride
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ultimate outcomes. The PLESS Study Group. Eur. Urol. 37,
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Roehrborn, C., Malice, M., Cook, T.J., Girman, C.J.: Clinical
predictors of spontaneous acute urinary retention in men
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the pooled placebo groups of several large clinical trials.
Urology 58, 210–216 (2001)
Roos, N.P., Wennberg, J.E., Malenka, D.J., et al.: Mortality and
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320, 1120–1123 (1989)
Surgically Sustained Injuries to the
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Preston, J.M.: Iatrogenic ureteric injuries: common medico-
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Blaivas, J.G., Weiss, J.P. (eds.): Benign prostatic hyperplasia
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Ras, S.: Female Urology, 2nd edn. W.B. Saunders, Philadelphia
(1996)
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C.A.: Campbell – Walsh Urology, 9th edn. Saunders Elsevier,
Philadelphia (2007)
 Otolaryngologic Emergencies
Cynthia Bonatucci Fisher
56.1 Otolaryngologic Emergencies
in Rural Surgery
This chapter aims to optimize surgical consultation for
head and neck emergencies and facilitate coordination
of otolaryngologic care rendered by rural surgeons.
Most otolaryngology residencies in the USA require
1 year of general surgery training (PGY 1) followed by
at least 4 years of otolaryngology residency. There are
over 100 surgical procedures in the otolaryngology
residency curriculum. Which procedures individuals
lacking otolaryngology certification should perform
varies with regional and national practice patterns,
urgency of the clinical situation, and availability of
otolaryngology consultation. Contemporary malprac-
tice concerns have a bearing on this. In a survey of
Otolaryngology Residency Program Directors, Carr
[1] reviewed a list of procedures monitored by the
American Board of Otolaryngology. Some of the cases
routinely delegated to lower level otolaryngology
­residents (tonsillectomy, myringotomy and tubes, tra-
cheotomy, peritonsillar abscess drainage, control of
nosebleeds, submandibular gland excision) have been
performed by general surgeons previously and have
evolved into otolaryngology procedures. Just how much
experience is needed to perform these procedures?
Once trained, how often must one perform a procedure
or operate in a specific area to maintain clinical compe-
tency? Approximately 75% of responding Residency
C.B. Fisher
Department of Surgery, Division of Otolaryngology,
Bassett Healthcare Network,
One Atwell Rd., Cooperstown, NY 13326, USA
e-mail: cynthia.fisher@bassett.org
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_56, © Springer-Verlag Berlin Heidelberg 2011
56
Otolaryngology Directors felt incision and drainage
(I&D) of a peritonsillar abscess and tonsillectomy
could be mastered by PGY 2 level residents. They felt
that with appropriate supervision performing an I&D
of a peritonsillar abscess 4.9 times as the principal sur-
geon and performing a tonsillectomy 9.4 times would
enable a resident to perform it competently (Table 56.1).
In 2002, otolaryngologists taking their boards had
­performed a mean number of 18.0 incision and drain-
age procedures for peritonsillar abscesses and 127 ton-
sillectomy cases. Carr’s data suggests that a general
­surgeon who has performed several incision and drain-
age procedures under supervision of a well-trained
surgeon should be able to perform incision and ­drainage
of peritonsillar abscesses competently. Tonsillectomy
with and without adenoidectomy is more challeng-
ing. Maintaining clinical competency is more diffi-
cult for the general surgeon who may not routinely
operate in the oropharynx. A thorough understanding
of the anatomy of the parapharyngeal space and
oropharynx is a prerequisite. If one performs periton-
sillar abscess drainage under general anesthesia,
awareness of risk factors and management of airway
fires is indispensable.
Space constraints prevent a comprehensive discus-
sion of surgical indications and techniques for elective
procedures, e.g., tonsillectomy, branchial cleft cyst
excision, lymph node biopsy, and submandibular gland
removal. A modicum of additional training outside of or
within a general surgery residency can expand a trainee’s
scope of practice to handle the majority of these issues.
We will also point out issues that unquestionably require
otolaryngologic consultation. These emergencies fall
into three categories: airway, infection, and bleeding. In
a true emergency, action is frequently easier to explain
than inaction to patients, families, lawyers, and our
­personal and collective conscience.
451
452
Table 56.1 Acquisition of surgical competency
Procedure PGY level % Agreeing
directors
Tonsillectomy 2 84
Peritonsillar drainage 2 87
Myringotomy and tubes 2 87
Posterior nasal pack 2 79
Tracheotomy 2 61
Thyroglossal duct cyst 3 57
Submandibular gland exc 3 54
Source: Carr [1]
56.2 Airway Emergencies
Securing an airway is the most critical and gratifying
procedure a surgeon can accomplish. The goal of air-
way management is optimal outcomes [2, 3]. In rural
communities, experienced otolaryngologic colleagues
and anesthesiology personnel are frequently unavail-
able. After the pre-hospital emergency transportation
phase, the responsibility of assessing the quality and
security of the airway falls to the emergency physician,
who frequently enlists the rural surgeon’s help.
56.2.1 Diagnosis
The indication for securing an airway is primarily a
suspicion of current or evolving airway compromise.
The symptoms of airway distress are voice change,
dyspnea, dysphagia, odynophagia, pain, and cough.
Signs of airway compromise are cyanosis, hoarseness,
stridor (noisy breathing), anxiety, restlessness, and
drooling or suprasternal retractions [4]. Phonation
occurs when chest compression of air overcomes the
elastic and muscular folds of vocal cord closure: Subtle
changes are audible. Significant injury can be associ-
ated with bleeding, subcutaneous emphysema from
disruption of the aerodigestive tract or palpable frac-
ture of the face, palate, larynx, or trachea. Noisy
breathing on inspiration occurs when obstruction or
swelling is at or above the level of the cords. Both the
degree of obstruction and the rapidity of breathing
determine stridor. Long deep breaths may minimize
stridor despite significant obstruction, especially in
adults.
C.B. Fisher
Number to Mean number
competence report ABO
9.4 127
4.9 18
10.1 175
4.5
9.4 73.7
5 5.4
5.5 10.1
If a patient is moderately stable and the examiner is
capable, mirror exam of the hypopharynx and larynx,
or flexible fiber-optic examination is pertinent. Neither
of these should be performed by the inexperienced in a
doubtful airway. Visualization of the airway improves
diagnosis and treatment with the important exception
of the pediatric airway. Children are at great risk of
laryngospasm with airway irritation. Experience with
an indirect laryngeal mirror as well as a fiber-optic
­laryngoscope or bronchoscope should be obtained in
stable patients and extended to emergency situations.
The flexible adult laryngoscope and intubating bron-
choscope are smaller and better tolerated (4 mm or less
ID (inside diameter) than the typical flexible broncho-
scope (5.7–6.0 mm ID)). Pulse oximetry and arterial
blood gases do not dictate the need for securing the
airway, but they can measure undiagnosed hypoxia.
Trauma to the head, facial skeleton, and neck can
abruptly compromise the airway. The ATLS protocol
is the contemporary and systematic evaluation and
treatment technique employed for injured patients [5].
Patients with head injury have a greater risk of cervical
spine injuries (4.9% vs. 1.1% without) [4]. The inci-
dence of cervical spine injury increases as the Glasgow
coma scale decreases. Delay in diagnosis of cervical
fractures occurs in 10–14% of patients, usually because
a physician misread the films. All trauma patients in
high-risk categories (motor vehicle accidents, high-
velocity impacts) should be treated as cervical spine
injuries with cervical immobilization. Neck extension
should be avoided. If intubation or securing the airway
is needed before the cervical spine status can be deter-
mined, presume the cervical spine is unstable [6].
If the patient is not in respiratory distress, radio-
graphs can be helpful. In addition to the cervical spine
56 Otolaryngologic Emergencies
films and chest X-rays that surgeons routinely obtain
evaluating neck trauma, a lateral neck film with soft
tissue technique can reveal epiglottic or retropharyn-
geal swelling, as well as, subcutaneous emphysema.
Computerized axial tomographic (CAT) scans can be
helpful in stable patients to localize or rule out an
abscess and assist surgical planning. [7].
56.2.2 Therapeutic Options
Acute airway management follows three basic princi-
ples: Select the simplest form of securing the airway,
bypass the lowest level of the obstruction, and consider
the precipitating event. In addition, it is helpful to have
an alternate plan [3, 4]. The first decision to make is
whether, when, and where to secure the airway. If the
patient has lost his or her airway or is losing it, act
immediately and decisively. If the patient is stable and
tolerating airway compromise, consider transfer to the
operating room to secure the airway. Thirty to forty
minutes with supplemental oxygen and a surgeon in
attendance can prove a great investment if an on-call
team is available. It is easier to visualize an airway or
perform a cricothyroidotomy in an operating room bed
with surgical lighting and more hands on deck than in
the emergency room or intensive care unit. With mild-
to-moderate obstruction that is expected to improve
and the ability to monitor closely, observation is an
option. The clinical situation that would most often fall
into this category is a peritonsillar abscess or severe
tonsillitis. Management would include oxygen, antibi-
otics, and intravenous steroids [8]. In a thermal injury,
mortality increases three fold with inhalation injury.
Upper airway obstruction, carbon monoxide poison-
ing, and subsequent pneumonia frequently complicate
the injury and culminate in mortality [3]. If a burn
patient’s level of consciousness is decreased, they
should be intubated and ventilated. It is common for
the aggressive hydration associated with burn resusci-
tation to increase airway edema. With inhalation injury,
early intubation is the rule.
To strategize, weigh advantages and disadvantages
of the nonsurgical versus surgical airway options.
Difficult mask ventilation and difficult intubation may
occur in parallel.
Transoral endotracheal intubation is the standard of
comparison for airway management, and its speed and
453
safety is unparalleled. Contraindications include cervi-
cal spine fracture, laryngeal or severe oral injury.
Blind nasotracheal intubation can worsen lacerations.
The addition of fiber-optic endoscopy to nasotracheal
­intubation permits direct visualization of the process of
nasal intubation. A disadvantage is that one needs
bronchoscopic experience to do a fiber-optic intubation
in an emergency. In lieu of that expertise, the ­surgeon
should defer to the anesthesia or emergency physician
and stand by with the cricothyroidotomy tray while
they attempt to visualize and intubate the airway fiber-
optically. If there is no fiber-optic view of an airway or
if the surgeon is the only operator on site, the surgeon
proceeds with cricothyroidotomy. Videolaryngoscopy
(Glidescope, Verathon) should not tempt the operator
to sedate or paralyze a patient before securing the air-
way. The major advance that videolaryngoscopes pro-
vide is the ability for the surgical and anesthesia team
to visualize the airway simultaneously.
When a food bolus obstructs the airway, a Heimlich
maneuver should be performed. If that fails, a cricothy-
roidotomy is indicated. Rigid bronchoscopy and for-
eign body removal should not be attempted until an
airway is established and then thoracic or otolaryngologic
surgeons perform foreign body removal. Novices
should not attempt endoscopic pulmonary foreign body
removal in a patient who can ventilate, due to the risk
of dropping the foreign body down the unobstructed
mainstem bronchus that is ventilating after disimpac-
tion of the foreign body. Reinflation of the previously
obstructed bronchus is not always immediate.
Transtracheal needle intubation can be lifesaving in
airway emergencies. It is more temporizing than defin-
itive. The surgeon punctures the cricothyroid mem-
brane with a 16-gauge or 14-gauge plastic-sheathed
needle. The needle is removed and the plastic cannula
is attached to oxygen under pressure (50 lb per square
inch) and jet ventilation techniques are used [3]. Even
without availability of jet ventilation, this provides a
narrow tract for oxygenation until a formal cricothy-
roidotomy is performed.
Cricothyroidotomy is the treatment of choice for
total upper airway obstruction. If facial or laryngeal
mask ventilation is possible, it should be continued
while the trachea is intubated. A cricothyroidotomy
usually takes less than 4 minutes. If the cervical spine
is intact, the neck is hyperextended and the shoulders
are supported on a shoulder roll. Once the thyroid notch
and cricoid cartilage is palpated, local anesthesia
454
(if available) is injected and a horizontal skin incision
is made in the midline. The larynx is stabilized with
one hand, and the cricothyroid muscle is divided with
the knife. Using a hemostat, the cricothyroid membrane
is punctured. A hook is used to elevate the cricoid car-
tilage, reflecting it inferiorly. After the opening is
dilated, secretions are suctioned; a tracheal dilator can
be used to widen the opening to admit a tracheostomy
tube. Usually an 8.0-mm OD (outside diameter) for
men (which is a #6 Jackson or Shiley tube) or a smaller
tube for women is inserted. If tracheotomy tubes are
not readily available, an endotracheal tube can be sub-
stituted. Percutaneous cricothyroidotomies have their
advocates. Whether doing a cricothyroidotomy percu-
taneously or open, double check all landmarks, proceed
calmly, and choose whichever approach you are more
comfortable performing. A level head is the most use-
ful instrument.
Cricothyroidotomy may sound simple but it is usu-
ally performed under suboptimal albeit hair-raising
conditions. Because of the proximity of the cricothy-
roid membrane to the vocal cords and the cricoid carti-
lage (the only complete tracheal ring), the potential for
laryngeal injury is high. Cricothyroidotomy has a low
incidence of subglottic stenosis. A patient requiring an
artificial airway longer than 1 week is a candidate for
elective conversion to tracheostomy. When the airway
has been secured with an endotracheal tube and there
is an expectation that prolonged intubation will be
required due to persistent upper airway obstruction, a
tracheotomy is indicated. Consider the ability for per-
sonnel to reintubate the patient if the endotracheal tube
becomes dislodged. If that is in doubt, opt for cricothy-
roidotomy or tracheotomy instead of endotracheal
intubation before leaving the hospital.
Tracheotomy is condemned in total airway obstruc-
tion and a poor choice for acute airway control [2–4].
Tracheotomy is difficult in the obese patient with a
short neck. Occasionally in laryngeal fractures or huge
tumors the cricothyroid membrane is nonpalpable and
a tracheotomy is indicated [4]. When palpable carti-
laginous landmarks are absent, a vertical incision is
preferred to allow the operator to move up and down to
the correct level (between tracheal rings 2 and 3 or 3
and 4) for tracheal entry. Emergency tracheotomies are
difficult and should rest in the hands of the most expe-
rienced surgeon. If a surgeon makes a horizontal inci-
sion too low and cannot find the cricoid, there are two
choices: If the thyroid is visible, divide the thyroid
isthmus with clamps and get to the trachea after
C.B. Fisher
controlling it or make a second incision. If the patient
has a thin neck and one can get above or below the
isthmus, the surgeon can slip a clamp under the isth-
mus and control it. In most instances, reincision higher
up and cricothyroidotomy should be done, rather than
converting to a tracheotomy. In the lower neck, the tra-
chea is deeper and surrounded by veins, and dealing
with the thyroid isthmus quickly can be daunting. The
most common mistake when performing a cricothy-
roidotomy is incorrect tube placement (13%) through
the thyrohyoid membrane [3]. In a child, slash trache-
otomies are hazardous because the innominate artery
may cross the trachea in the neck.
56.3 Infections
56.3.1 Peritonsillar Abscess
Quinsy (peritonsillar abscess) is the most common
deep infection of the head and neck in adults despite its
decline since the introduction of antibiotics. The spread
of infection is from the superior pole of the tonsil.
Pus forms between the tonsillar bed and the tonsillar
capsule. Pus can tract through the superior constrictor
muscle into the parapharyngeal space. There is a high
incidence of anaerobic bacteria found in peritonsillar
abscesses (usually bacteroides) as well as aerobes
(beta-hemolytic streptococci, Haemophilus influenzae,
and Staphylococcus aureus). Fibrosis in the tonsil and
peritonsillar area from previous tonsillar or dental infec-
tions favors the growth of anaerobic organisms and
impedes antibiotic penetration. Most peritonsillar infec-
tions are unilateral. The patient’s history usually spans
several days and peritonsillar abscesses may occur
despite treatment [9]. Severe pain is the most common
presenting symptom. Pain frequently in­creases rapidly
in the face of a more indolent sore throat. Referred otal-
gia to the ipsilateral ear is due to glossopharyngeal
nerve involvement, odynophagia, dysphagia, and even
drooling occur. Family members usually notice a
change in the patient’s voice and describe the patient
speaking with a “hot potato voice.” Trismus (pain or
difficulty opening the mouth) is ­common as a result of
pterygoid muscle irritation.
Physical examination is the primary diagnostic
technique for peritonsillar abscess. Asking the upright
patient to open the mouth and breathe or phonate best
56 Otolaryngologic Emergencies
facilitates physical examination of the oropharynx.
The examiner can gently depress the tongue with a
tongue depressor or the finger. Tongue protrusion will
limit visualization due to tongue base elevation. The
soft palate on the affected side will appear swollen,
erythematous, or edematous, and the abscess or phleg-
mon will displace the tonsil downward and medially.
The anterior faucial pillar will usually be displaced
anterior on the abscess side and appear to be coming to
the examiner. The faucial pillar and/or soft palate on
the abscess side will appear adynamic compared to the
other side which should elevate when the patient
breathes or phonates. The uvula may appear shifted
contralaterally. Fever and leukocytosis usually accom-
pany an abscess.
The location of swelling in the oropharynx, the
presence or absence of pus on aspiration, the response
to treatment of peritonsillar abscess, and previous or
concurrent infections aid in reaching a differential
diagnosis. Treatment of sizable abscesses requires
­surgical drainage in addition to antibiotics. The use of
needle aspiration versus incision and drainage versus
quinsy tonsillectomy is controversial [10–12]. In most
patients, three point aspiration (superiorly, laterally,
and inferiority) of the anterior faucial pillar just lat-
eral to the tonsil under local anesthesia is diagnostic
and therapeutic. Topical anesthesia precedes submu-
cosal injection with a 25-gauge needle in the periton-
sillar area. Aspiration with a larger 18- or 20-gauge
needle pointed posteriorly, not laterally, is easy to
learn. It is inexpensive, safe, and provides immediate
relief of trismus. If needle aspiration is productive and
the patient can swallow liquids, oral antibiotics and
follow-up within 24–48 h on an outpatient basis for
observation and possible repeat aspiration is indicated
[13]. In symptomatic patients who do not improve,
admission is advisable.
In a prospective study of permucosal needle aspira-
tion in 104 patients, 75 patients (72%) were positive
for pus. Thirty-nine (52%) of these needed only one
aspiration; the remainder needed one or two serial
aspirations. In this study, needle aspiration plus oral
antibiotics resolved 85% of the peritonsillar abscesses.
All of the patients with negative aspirates had to be
hospitalized for hydration and pain control. Eleven
(15%) patients had a recurrent peritonsillar abscess in
less than a year (16–18). In a retrospective study com-
paring needle aspiration versus incision and drainage
[14], Wolf found that recurrence of peritonsillar
abscess was not related to a history of recurrent
455
tonsillitis. They followed patients for 2.1 years and
found that 2 of 74 (2.7%) patients treated with incision
and drainage versus 9 of 86 (10.4%) treated with nee-
dle aspiration had recurrent peritonsillar abscesses;
this was a significant difference. Other data quote a
recurrence rate of peritonsillar abscess in the United
States of 10%, which differs significantly from the
recurrence rate of 15% worldwide [12, 15, 16].
Incision and drainage (I&D) is performed under
topical and local anesthesia with the patient sitting or
partially reclining with the head supported. If general
anesthesia is necessary, the Trendelenburg position
should be employed. Bulging of the tonsillar pillar and
palpation help localize the abscess. Using just the tip
of a No. 11 scalpel blade on a long-handled scalpel,
the mucosa is superficially incised over the abscess
and a blunt tip hemostat is used to spread the tissue
and break up loculations. When using a curved clamp
or angulated closed forceps point the curved tip toward
the tonsil and away from the internal carotid artery,
which travels just lateral to the peritonsillar space [9].
If a patient has had a history of frequent tonsillitis,
elective tonsillectomy 6–12 weeks after acute drain-
age is the norm. Approximately 30% of patients with
peritonsillar abscess have relative indications for ton-
sillectomy [10]. If the patient must go to the operating
room for drainage, quinsy tonsillectomy should be
considered. This means draining the abscess and doing
a tonsillectomy in the same operative setting, which
can avoid a second anesthetic, but is more technically
difficult because both tonsils are acutely infected. The
side opposite the abscess is usually the most trouble-
some. A large abscess may have done some of the dis-
section on the abscessed side, but the inflammation
throughout the oropharynx causes obliteration of the
planes and increased bleeding. Quinsy bilateral ton­
sillectomy is not an option for the occasional tonsil
surgeon. Christiansen and Schonsted-Madsen [17]
­followed patients for 3–4 years after unilateral tonsil-
lectomy, and suggested unilateral quinsy tonsillectomy
as routine treatment for peritonsillar abscess in patients
with no history of frequent tonsillitis. After operative
incision and drainage, the tonsil may seem to be mini-
mally attached. Completing a unilateral quinsy tonsil-
lectomy is a concept that merits serious consideration
in patients with no history of tonsillitis. Unilateral
immediate tonsillectomy is far simpler after I&D than
bilateral quinsy tonsillectomy, and appears to be asso-
ciated with a very low rate of subsequent chronic
pharyngitis.
456
Peritonsillar abscess occurs in all age groups but
is more common in young adults 20–40 years old.
Patient age is a factor in management. In a national
survey [15] of treatment patterns in the UK, 94% of
respondents admitted every peritonsillar abscess
patient. Management strategy differed depending on
volume of cases. Abscesses can occur in patients
whose chronic tonsillitis has been insufficiently
treated or when an acute tonsillitis progresses to
peritonsillar cellulitis then ultimately peritonsillar
abscess. When it occurs in young children, consider
immune deficiency, malnutrition, diabetes, leuke-
mia, or lymphoma. Young children are less coop­
erative with needle aspiration or I&D under local
anesthesia frequently requiring operative drainage or
quinsy tonsillectomy. Peritonsillar cellulitis can be
mistaken for a peritonsillar abscess. If a patient has
severe unilateral pain, and needle aspiration is nega-
tive, admission, intravenous hydration, and antibiot-
ics are indicated. This will resolve and improve
peritonsillar cellulitis and severe tonsillitis. If there
is no improvement, CAT scan of the neck with con-
trast can rule out an abscess and confirm diffuse
swelling and cellulitis, avoiding an unnecessary
transfer to a tertiary center [18]. Some studies sug-
gest intraoral ultrasound is diagnostic in cooperative
patients [19, 30]; airway evaluation and observation
is warranted, and the airway is maintained. Medical
management of peritonsillar abscesses includes
hydration, antibiotics, and steroids. Penicillin was
historically the drug of choice for peritonsillar
abscess; however, with the increase in beta-lactamase-
producing organisms, clindamycin either 500 mg
twice daily or 300 mg orally 3 times daily is pre-
ferred [31]. A third-generation cephalosporin would
be the second choice or a trial of penicillin with the
addition of metronidazole if there is no improvement
after 24 h. A single high-dose steroid in patients who
underwent needle aspiration and hospitalization for
intravenous antibiotics improved clinical outcome
with respect to hours hospitalized, throat pain, fever,
and trismus [8].
Needle aspiration is the simplest surgical option in
peritonsillar abscess management and should be part
of every rural surgeon’s armamentarium [20]. Incision
and drainage is routinely performed and not difficult to
learn. Although it is more definitive, bilateral tonsil-
lectomy in an acute setting depends on the experience
of the surgeon and is rarely necessary.
C.B. Fisher
56.3.2 Odontogenic Infections
Dental infections are ubiquitous in the rural emergency
setting, and access to dental care may parallel limited
specialty care in remote areas. These infections arise
because of endogenous flora. Predominant organisms
are Gram-positive cocci (Streptococcus species), Gram-
negative cocci (Neisseria species), Gram-positive bacilli
(Corynebacterium species), Gram-negative bacilli
(Bacteroides species, H. influenzae), etc. This laundry
list is quite reminiscent of the offending organisms in
peritonsillar abscesses. This multi-organism etiology
has implications for antibiotic selection. Until culture of
the offending organisms can direct therapy, full spec-
trum coverage including clindamycin and ceftriaxone is
recommended.
Odontogenic infections stem from necrosis of the
pulp of a tooth and invasion of the infection into deeper
tissues. This can strangulate the blood supply of the
tooth and lead to further necrosis. Once the infection
permeates the local mandibular bone, it spreads in all
directions. Further spread is dictated by the thickness
of the bone and the relationship to muscle attachments
to the maxilla or mandible [7]. Thin labial bone is the
most vulnerable, and this leads to a vestibular abscess
on the lateral aspect of the mandible. This looks like a
pouch of pus in the soft tissue over the affected tooth.
If they do not spontaneously rupture, a simple tran-
soral incision and drainage procedure under local
anesthesia with antibiotics and later dental follow-up
to definitively address the offending tooth are war-
ranted. A similar process occurs in these instances
regardless of whether the tooth is mandibular or
maxillary.
More worrisome is when mandibular infection
involves the deep fascial spaces and planes of the neck.
The primary spaces (involved with direct extension of
infection from teeth) are submental (rare), subman-
dibular, and sublingual. The sublingual space lies
between the oral mucosa and the mylohyoid muscle; it
is open posteriorly and communicates with the sub-
mandibular space. The mylohyoid line is an area of
attachment of the mylohyoid muscle to the mandible
that delineates spaces. Once infection travels below
the mylohyoid, it has entered the neck. Secondary
spaces become infected by spread from the more ante-
rior spaces. The secondary spaces are the pterygoman-
dibular, masseteric, and temporal. The three secondary
spaces communicate and together form the masticator
56 Otolaryngologic Emergencies
space. Pterygomandibular space involvement is insidi-
ous because it lies between the medial aspect of the
mandible and the medial pterygoid muscle. There is
little to no oral or external swelling; however, the
patient usually has trismus. The masticator space is
bounded by the masseter, medial pterygoid, and
temporalis muscles [7]. When all three of the pri-
mary spaces are involved (sublingual, submental,
and submandibular), the infection is known as Ludwig’s
Angina. This is bilateral, rapidly spreading, and gan-
grenous. There is usually minimal or no fluctuance,
severe trismus, drooling, tachypnea, and dyspnea.
Woody induration on neck soft tissues has been
described. Recovery can be slow and is not assured
because of the aggressive gangrenous, descending
nature of Ludwig’s angina. After securing the airway,
the decision as to whether to handle this definitively in
a rural setting is dependent on intensive care unit sup-
port and transfer options. These infections are prefer-
ably treated in hospitals with otolaryngologists and
thoracic surgeons if necessary. In Ludwig’s angina, the
primary cause of death is airway loss. Establishing an
airway by fiber-optic nasal intubation or blind nasal
technique in the awake, unparalyzed patient should
be attempted, and a cricothyroidotomy performed if
necessary. In these circumstances, a ventilating patient
should not be paralyzed with muscle relaxants until an
airway is established. In an uncomplicated dental
infection with unilateral involvement, airway embar-
rassment is rare and these patients can be closely
observed.
In clinical infections, determine whether the airway
is intact. If not, establish one. If so, consider the extent
of trismus, which frequently determines the ability to
intubate orally, visualize the airway, and proceed with
a neck CAT with contrast. Neck CAT scans are useful
adjuncts in an outreach setting. As with peritonsillar
infections, the CAT scan with contrast will help deter-
mine if you have a deep cervical infection or a local-
ized abscess. If erythema extends below the omohyoid
muscle, proceed with a neck and chest CAT with
­contrast to rule out mediastinitis.
Thirty percent of cervical or deep neck abscesses
arise from odontogenic infections [7]. The lateral pha-
ryngeal space is cone-shaped with the base at the apex
of the skull and the apex at the hyoid bone. The styloid
process divides it into an anterior and posterior com-
partment. The anterior portion is closely related to
the tonsillar fossa [2]. The post-styloid compartment
457
contains the carotid sheath and the 9th–12th cranial
nerves. Signs and symptoms differ depending on which
compartment is involved. Anterior compartment infec-
tions result in marked trismus because of internal ptery-
goid muscle irritation but the tonsil may be normally
sized. Retrostyloid compartment infection lacks the
classic triad of tonsil prolapse, trismus, and parotid
region swelling. Posterior compartment findings are
swelling of the posterior tonsillar pillar and posterior
lateral pharyngeal wall. Fever, odynophagia, and neck
rigidity are common to anterior and posterior compart-
ment lateral parapharyngeal space abscesses. More
commonly, lateral pharyngeal space and retropharyn-
geal space infections arise from variety of sources.
Findings are odynophagia, trismus, and lateral pharyn-
geal wall bulging in the oropharynx or hypopharynx
visible on flexible laryngoscopy. Lateral neck swelling
is common but not necessarily pronounced. CAT scan
will reveal an enhancing abscess. Direct pressure from
the abscess can result in internal jugular vein thrombo-
sis. The retropharyngeal space lies medial to the
parapharyngeal space [32]. Lateral space involvement
can lead to retropharyngeal abscess. The retropharyn-
geal space extends inferiorly to C7-T1 and enters the
posterior mediastinum. This portends a grave progno-
sis. Retropharyngeal space involvement can lead to the
prevertebral space. This space lies between the layers of
the prevertebral fascia and extends to the diaphragm.
56.3.3 Other Serious Infections
According to Andreassen and Guldfred [21, 22],
­epiglottitis in children is rare (incidence of 0.02
cases/100,000/year in 2008) due to the H. influenzae
type B (HiB) vaccine. However, vaccination rates are
not 100% and there is some evidence that acute epi-
glottitis in children may be rising in the UK. The inci-
dence of adult epiglottis has been constant [21]. The
main symptoms are odynophagia, drooling, and his-
tory of fever, respiratory difficulty, muffled voice and
occasionally stridor. These patients usually have epi-
glottic swelling and erythema, but approximately 30%
have severe swelling and edema of the epiglottis.
Leukocytosis is common. Airway management rec-
ommendations in adult supraglottitis encompass a
broad spectrum. Some studies suggest establishing an
artificial airway in all patients; some authors suggest
458
conservative management. In otolaryngologic prac-
tices, adults may be initially managed in intensive
care settings with frequent fiber-optic laryngoscopy,
intravenous antibiotics, and steroids. Cefotaxime or
Ceftriaxone is the usual choice. Adults with epiglotti-
tis can decompensate quickly and endotracheal intu-
bation initially is wise if there is any question of
impending obstruction. These intubations can be dif-
ficult, and if the airway cannot be visualized, cricothy-
roidotomy is indicated. Do not manage an adult with
epiglottitis without an artificial airway, unless you are
familiar with this entity and can frequently fiber-­
optically assess the larynx.
Infected branchial cleft cysts can present as neck
abscesses. These rarely cause airway compromise and
should be treated with intravenous antibiotics and
­elective removal when the acute infection abates.
Intracranial complications of ear and sinus disease
frequently prompt otolaryngology referral. Acute and
chronic otitis media causes otologic complications
such as coalescent mastoiditis, facial nerve paralysis,
petrositis, and labyrinthitis. The intracranial compli-
cations of ear disease include meningitis, extradural
abscess, lateral sinus thrombophlebitis, subdural
abscess, brain abscess, and otitic hydrocephalus. These
entities require antibiotics and surgical otolaryngo-
logic care. Organisms are frequently Gram-positive
cocci but Pseudomonas aeruginosa can cause severe
otologic infections. Broad coverage dictated but local
sensitivities are the norm. These infections are outside
the purview of a rural general surgeon.
Sinusitis can cause orbital cellulitis (diplopia and
visual loss), periorbital abscess, meningitis, and cav-
ernous sinus thrombosis. Visual or central nervous
system complications of sinusitis are likewise not the
realm of general surgeons. Understanding the full
spectrum of ear disease is a necessary complement
to myringotomy and tube insertion and follow-up
care. Emergency physicians, pediatricians, and fam-
ily practitioners have at times been trained to per-
form myringotomy or diagnostic tympanocentesis.
Emergency myringotomies are performed for acute
mastoiditis which is an otologic complication that
should be managed in conjunction with an otolaryn-
gologist. Elective ear surgery specifically myringo-
tomy and tube insertion entails the management of
hearing loss and cholesteatoma; it falls outside the
scope of general surgery and should be delegated to
otolaryngologists.
C.B. Fisher
56.4 Bleeding
The basic tenets of surgical hemostasis and manage-
ment of bleeding apply to otolaryngologic bleeding
emergencies: post-tonsillectomy hemorrhage, epistaxis,
and carotid artery blowout; all of these involve tract
bleeding. Airway bleeding can complicate these ­entities
and lead to obstruction and aspiration.
56.4.1 Oropharyngeal Hemorrhage
The most common complication of tonsillectomy is
bleeding, which occurs in 4–8% of cases regardless of
the surgical techniques used. Cautery is the most com-
mon method used to perform tonsillectomy in the USA.
Other dissection techniques include cold-dissection
techniques, harmonic scalpel, Coblation, and laser.
Bleeding can occur either early (within the first 24 h)
or late (usually 5–14 days postoperatively). Early
bleeding is usually due to inadequate hemostasis. The
second peak in incidence occurs when the tonsillar
eschar sloughs. Rural surgeons who do not routinely
perform tonsillectomy may be called to help stabilize a
patient with a serious bleed who underwent tonsillec-
tomy out of town at any time during this 2-week post-
operative period. Delayed bleeding occurs from small
surface vessels, and a clot forms that prevents the
vessel vasoconstriction. Repeated bleeding is associ-
ated with life-threatening hemorrhage, so patients with
“sentinel” repeated bleeds should be admitted and
observed although small isolated bleeds can be evalu-
ated and treated as outpatients. When performing ton-
sillectomy, bleeding can be excessive if the dissection
is too deep amidst fibrosis or if an aberrant vessel is
present. Severe nonfatal bleeding requiring external
carotid ligation still occurs [23]. Management of
delayed bleeding requires clot evacuation [24].
Bleeding can be controlled by putting a tonsil ball or
sponge on a clamp and applying direct pressure to the
tonsillar fossa. Chemical cautery with silver nitrate
sticks is sometimes helpful. Topical astringents on the
tonsil ball such as boric acid powder may suffice. Local
anesthesia and electrocautery is successful in coopera-
tive patients. Some patients require operative control
either employing a suction cautery, electrocautery, or
sutures (Fig. 56.1). This requires a tonsil mouth gag,
headlight, Yankauer suction, Hurd elevator, suction
56 Otolaryngologic Emergencies
Fig. 56.1 Suction bovie cautery control of tonsillectomy bleeding
cautery, and tonsil balls. An insulated bipolar cautery
and sutures are helpful. Airway fire is a real risk when
cauterizing the oropharynx, tonsil balls and strings
should be wet, and inspired oxygen concentrations
should be maintained under 30%. Sutures should be
superficial remembering the proximity of the carotid
artery to the tonsillar fossa.
If direct control of bleeding fails, external carotid
ligation under local or general endotracheal anesthesia
is the last resort. One makes the initial incision along
the anterior border of the sternocleidomastoid muscle
and extends it to the earlobe. After the incision is car-
ried through the platysma, the plane of the anterior
sternocleiomastoid muscle is developed, and the mus-
cle is retracted posteriorly. The internal jugular vein
fascia is incised and the common facial vein is identi-
fied, this lies just proximal to the carotid bifurcation.
The common facial vein is divided between suture
ligatures, allowing retraction of the internal jugular
vein posteriorly. The carotid sheath is opened longitu-
dinally and the common carotid artery mobilized in the
lower portion of the incision. The vagus nerve is iden-
tified and protected; once the common carotid is iden-
tified, its bifurcation should be identified. The external
carotid has branches; its first branch is the superior
thyroid artery. Both arteries should be dissected.
Superiorly, you should identify the hypoglossal nerve
coursing diagonally across the internal and external
carotid arteries. A right angle forceps is passed beneath
the external carotid artery and the vessel doubly ligated
with 0 silk ties. The wound should be irrigated and
closed in layers with absorbable sutures and stainless
steel clips.
459
How do you determine which patients are unsuit-
able for tonsillectomy in a rural setting?
Patients with coagulopathies, severe sleep apnea
patients, or children under the age of three should
have tonsillectomy performed in a hospital with pedi-
atric subspecialists available. Atlantoaxial sublux-
ation (Grisel’s syndrome) is more common in patients
with Down syndrome and preoperative cervical spine
radiographs in flexion and extension, CT and possibly
MRI may demonstrate decalcification of the anterior
arch of the atlas. Great attention should be paid to cer-
vical spine manipulation during surgery in patients
with Down syndrome.
56.4.2 Epistaxis
Epistaxis is the most common bleeding disorder of the
head and neck [25]. The blood supply to the nose is
vigorous. The external carotid artery is the major con-
tributor via the internal maxillary artery and the facial
artery. The arteries supply most of the nasal septum and
turbinates. The internal carotid artery supplies the ante-
rior ethmoid artery which supplies the anterior septum
[33]. Ninety to ninety-five percent of nosebleeds occur
within the anterior nasal region.
Exsanguinating epistaxis is uncommon but can be
found in the setting of midfacial trauma associated
with maxillary artery laceration [34]. Airway control
precedes control of bleeding and fluid resuscitation.
Anterior and posterior packs are placed, and nasopha-
ryngeal and oropharyngeal packs of 3- or 4-inch gauze
460
may be required. Additionally, external carotid artery
ligation may be necessary. Mortality from epistaxis can
be cardiovascular due to hypertension, hypotension, or
hypoxia. The majority of patients with epistaxis are
hemodynamically stable. Anterior epistaxis in
Kiesselbach’s area (Little’s area) on the anterior sep-
tum is primarily venous. Posterior epistaxis arises from
the posterior septum or the posterior lateral nasal wall
and is arterial [26]. Treatment of epistaxis is simplified
if the bleeding site can be identified. This permits more
localized and usually more comfortable treatment. To
identify the bleeding site, the patient should be in a sit-
ting position. Illumination from a headlight or head
mirror and exposure from a nasal speculum facilitates
examination. Both Frazier straight suction and Yan­
kauer oral suctions are used to evacuate nasal and oral
clots respectively. Vasoconstriction of mucosa with
oxymetazoline hydrochloride (0.05%) or neosyneph-
rine (0.5%) applied by spray, drops, or soft pledget will
open the nasal airway. Topical anesthesia with a 50/50
mixture or 2% lidocaine/oxymetazoline mixture will
decongest and anesthetize mucosa. If a specific bleed-
ing source is identified, chemical cautery (silver nitrate
sticks) or electrocautery after local anesthetic injection
is often sufficient. Overcauterization can result in sep-
tal perforation because the blood supply of cartilage
comes from the overlying mucosa. After cautery, saline
nasal mist and daily antibiotic ointment for 7–10 days
will help healing [29]. Avoidance of aspirin and non-
Fig. 56.2 Nosebleed
equipment and packs. Left to
right, top to bottom: frasier
suction, balloon posterior
pack, nasal speculum,
bayonet forceps, silver
nitrate, merogel, foldable
pack, 8 centimeter merocel
sponge before and after
hydration
C.B. Fisher
steroidal anti-inflammatories as well as discontinuation
of warfarin (after discussion with cardiology or pri-
mary care to determine feasibility) is recommended for
2 weeks. If cauterization is impossible or unsuccessful,
a nasal pack should be inserted.
Nasal packing materials are absorbable and non-
absorbable (Fig. 56.2). In patients with coagulopathy,
an absorbable pack of microfibrillar collage (Avitene®,
Med Chem Products, Woburn, Mass) or oxidized
­cellulose (Surgicel®, Johnson and Johnson, Arlington
Texas), Gelfoam® (Pharmacia and Upjohn, New York,
NY) or Merogel® (Medtronic Xomed, Mystic, CT) can
be inserted. This avoids subsequent pack removal and
abrupt reexposure of traumatized mucosa. Med Chem
manufactures a 5-mm syringe applicator to help insert
the Avitene pack posteriorly, but these packs may
require a large volume of absorbable material if a
bleeding site is not visualized. There are many types of
non-absorbable packs. Classical posterior packs have
been largely replaced by balloon packs. Vaseline gauze
packing (Sherwood Medical, St. Louis, MO) is readily
available but difficult for novices to insert properly.
Unless vaseline gauze is stacked firmly, it becomes
dislodged precipitating panic. Non-absorbable com-
pressed sponges (Merocel®, Americal Corporation,
Mystic, CT) are available in a variety of convenient
sizes and can be custom trimmed prior to insertion.
Please note Merogel sponges are absorbable, Merocel
sponges are not. Most male noses can accommodate
56 Otolaryngologic Emergencies
the Merocel 10-cm “Pope posterior” size. Compressed
sponges are relatively comfortable packs for the
patients. After nasal decongestion and clot evacuation,
lubricate the sponge with a little antibiotic ointment
and slide it directly along the floor of the nose straight
back – not up. Warn the patient that they will feel a
quick, sharp pain (this takes less than 3 s when done
properly) and that you are injecting the pack – not the
patient. If a patient has a very large nose due to a con-
cavity on the side of bleeding, two sponges may be
inserted on that side. In this situation, insert the second
sponge immediately after the first, before hydrating
the first sponge, or letting blood distend it. Once the
first sponge is expanded, the second cannot be inserted.
Sponge packing remains in place 3–5 days. Stevens–
Johnson Syndrome has been reported. Oral antibiotics
to prevent sinusitis and analgesics are recommended.
If sponge nasal packing fails, inflatable balloon
packs may be required. These have one or two balloons
depending on their design. Unfortunately, they are pain-
ful and overinflation can cause mucosal ulcers. Some
types are inflated with air, and these frequently leak
requiring reinflation. The fluid-filled balloons maintain
their pressure longer. Posterior balloons can interfere
with swallowing, and if they are visible, the balloon is
too low. Patients with posterior packs or ­balloons are
admitted to the hospital. Admission and oxygen satura-
tion monitoring should be considered with bilateral
anterior packs in elderly patients or patients with severe
chronic obstructive disease and/or sleep apnea. Pain
control, antibiotics, hydration, and baseline and serial
blood counts are facilitated. Nasal packing can induce
hypoxia or exacerbate pre-existing obstructive sleep
apnea. If packing fails to control bleeding, referrals to
an otolaryngologist for arterial ligation or endoscopic
cautery or an interventional radiologist for selective
arterial embolization are options.
56.4.3 Carotid Artery Blowout
Acute carotid and lingual artery blowouts occur in
head and neck cancer patients, which are typically
­preceded by carotid artery exposure complicating an
oropharyngeal fistula or recurrent disease in a radiated
field. Threatened carotid blowout syndrome denotes
an imminent hemorrhage; impending carotid artery
blowouts are heralded by a sentinel hemorrhage [27].
461
With threatened or impending carotid blowouts,
workup includes angiography and a trial of balloon
occlusion. If occlusion is successful and without
­neurological sequelae, particle or coil embolization is
­performed. If balloon occlusion is not tolerated, endo-
vascular stenting should be attempted. When carotid
artery exposure has been identified, the patient and
family should be counseled about the possibility of
impending blowout and stroke [28]. Acute carotid
artery blowout is associated with 40% mortality and
60% morbidity from stroke. Resuscitation status
should be discussed if carotid exposure is detected or
blowout occurs. Many of these patients have a trache-
otomy, facilitating airway protection. Emergency treat-
ment is direct pressure and oropharyngeal packing,
analgesia and anti-anxiety medication, and fluid and
blood resuscitation [28]. Transfer to a head and neck
surgeon is optimal. Carotid artery blowouts are terrify-
ing for patients, families, and staff. A multidisciplinary
team including clergy, counselors, a surgeon, and pri-
mary care provider offers needed support during these
horrifying tragedies.
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 Part
VI
Emergency Care
 Airway Management: A Surgical
Perspective 57
Adrian Anthony

57.1 Introduction the initial part of resuscitation. In this regard, treatment

algorithms provide a useful framework for a system-
atic, orderly and thorough approach to resuscitation.
A compromised airway is a life-threatening condition.
Not all airway interventions are in response to an air-
The risk of mortality or permanent disability is high
way emergency. There are many times, such as during
without timely and effective intervention. Failure of
anaesthesia, where airway control occurs as a planned
airway control remains a significant cause of prevent-
event. Although the context requiring airway interven-
able death following injury. Similarly, in the non-injured
tion is different, the principles and skills involved
critically ill patient, the airway is often inadequately
remain the same and, in some instances, the challenges
assessed or poorly managed, contributing to prevent-
present are no less than when confronted with an acute
able morbidity and mortality. Although a patent airway
airway problem.
is a necessary requisite for cellular oxygenation, it is
by itself not sufficient. Aerobic metabolism also requires
adequate ventilation and perfusion, the latter depend-
ing on circulating blood volume and cardiac function. 57.2 Airway Management Skills
Because a patient will die from an airway obstruction
before succumbing to a breathing or circulatory prob-
The resuscitation of a patient requires a range of cogni-
lem, airway security commands the highest priority in
tive and psychomotor skills and is best undertaken as a
resuscitation. Indeed, the immediacy of threat to life
team. Controlling the airway requires a distinct set of
from airway, breathing and circulatory deficits is
skills, ranging from simple and easily executed
reflected in the priority given to them in trauma and
manoeuvres to more complex and invasive procedures,
critical care algorithms (i.e., the A, B, C’s of resuscita-
as dictated by the difficulty of an airway problem. The
tion). Furthermore, the critically ill patient with an air-
lay public and first aiders can be taught the simplest of
way problem will, not uncommonly, have concurrent
these skills. Most doctors, and those involved with
problems associated with breathing and circulation.
acute patient care, would be expected to have basic air-
Bypassing the airway to attend to a respiratory or cir-
way management skills. This does not include the abil-
culatory problem may prove fatal. Treating a compro-
ity to establish a definitive airway. A number of
mised airway without progressing to ensure adequate
professional groups could lay claim to having advanced
ventilation and circulation also risks a poor outcome. It
airway management skills. They are trained and expe-
is therefore important to understand that, in the injured
rienced in assessing and managing difficult airways.
or acutely unwell patient, airway management is but
Vocationally trained emergency physicians, critical
and intensive care physicians and anaesthetists are
undisputed experts in airway management. In some
settings, general practitioners also possess a range of
A. Anthony
Department of Surgery, The Queen Elizabeth Hospital,
competencies in advance airway management. Increa­
28 Woodville Rd, Woodville South, SA 5011, Australia singly, ambulance or paramedical (i.e., pre-­hospital)
e-mail: adrian.anthony@adelaide.edu.au personnel are being trained in the insertion of the

M.W. Wichmann et al. (eds.), Rural Surgery, 465

DOI: 10.1007/978-3-540-78680-1_57, © Springer-Verlag Berlin Heidelberg 2011
466
laryngeal mask airway and some seek training in endo-
tracheal intubation. Anaesthetic technicians and physi-
cian assistants in various parts of the world are also
trained in airway management to varying levels of
competency. Both these groups are non-existent or are
only just emerging in the Australian health scene.
Among the professional groups with advanced airway
skills, it should not be assumed that all individuals
possess the entire set of skills at the same level of
expertise. Emergency physicians, intensivists and
anaesthetists can all be assumed to be proficient at
endo-tracheal intubation. Their ability to perform
fibre-optic intubation, percutaneous cricothyroidotomy
or tracheostomy will be more variable. Surgeons, of
course, are not generally recognised as having airway
management skills, nor are they seemingly expected to.
Yet, they would appropriately be expected to have
basic airway control skills and be able to perform a
surgical airway, either in the elective setting or as an
emergency. In this regard, surgeons play a vital role in
the spectrum of airway interventions.
57.3 Airway Management in the
Rural Setting
Given the range of professional groups with advanced
airway skills, the patient with an airway problem in a
metropolitan environment would appear to be well
served. Pre-hospital and hospital personnel have ample
opportunities to train for, develop and maintain the
skills. The emergency response and transportation time
to a hospital for definitive care is short. Hospital-based
critical care services are sufficiently sophisticated and
well resourced to respond to any emergency. In this
environment, increasingly invasive airway interven-
tions can be successfully attempted, and in relative
safety. In the most complex of airway problems, the
required team of experts can be rapidly assembled to
secure a definitive airway and deal with concomitant
morbidities.
By contrast, the situation may be entirely different
when a difficult or complex airway problem presents
in the rural setting. Although the principles and prac-
tices of airway management are the same irrespective
of one’s environment, the capacity to respond to any
airway emergency in the rural setting is limited by a
number of factors. The emergency response and
A. Anthony
subsequent transportation time to hospital is likely to
be longer. A hospital’s critical care service and facili-
ties may be rudimentary and unsophisticated. The
number of skilled personnel available to assist with
resuscitation is likely to be small. Furthermore, pre-
hospital and hospital personnel in rural and remote set-
tings often find it difficult to access training in
managing difficult airway problems. Even when per-
sonnel are suitably qualified, there is limited opportu-
nity to maintain the skills and to gain the depth of
experience possible in more populated centres. To
compound the lack of local expertise, timely access to
specialist help in airway management is often restricted
by geography and distance. The need for a secondary
transfer for definitive care poses further, significant
challenges. There is the extended transportation time.
Organising a mode of transportation that is safe, rapid
and one that provides a stable, controlled environment
in which to care for the patient may not be easy. Most
importantly, it may be difficult to provide a consis-
tently high standard of in-transit patient care, aimed at
maintaining airway security, adequate ventilation and
satisfactory circulation. Clearly, patient transfers and
retrievals are inherently dangerous and require thought-
ful planning and execution.
When one considers that a compromised airway is
an imminent threat to life, there is no question that, in
the rural setting, rural practitioners, including sur-
geons, who anticipate finding themselves in a situa-
tion with limited assistance and resources, should
seek to be self-sufficient and acquire basic and
advanced resuscitation skills. Skills may be main-
tained by periodic simulation training, attending
courses to refresh skills and arranging clinical attach-
ments to a metropolitan hospital. The skills being
sought should complement those of other personnel in
the same practice environment. Therefore, a range of
hospital staff including nurses should be familiar with
basic airway management and be able to support an
airway until further help arrives. Although advanced
airway management skills may be provided by a spe-
cialist anaesthetist, in many rural settings, these skills
are provided by someone other than a specialist and
who has received the appropriate training. The sur-
geon may, under exceptional circumstances, need to
fulfil this role. The greatest asset a surgeon has in
managing an airway emergency is the operative skill
to provide a surgical airway. Therefore, it is more
likely that the surgeon will become involved when all
57 Airway Management: A Surgical Perspective
other manoeuvres to secure an airway have not
succeeded.
Airway interventions require equipment and instru-
ments. The rural practitioner should be familiar with
the equipment and instruments necessary for basic and
advanced airway management (Table 57.1). The equip-
ment should be stored in a dedicated trolley. Airway
trolleys should be easily identifiable, readily accessible
and appropriately distributed in the hospital. They
should be checked routinely to ensure items are ade-
quately stocked and that equipment is in working order.
Staff who are expected to be involved in airway man-
agement should be familiar with and trained in the use
of the equipment.
A system for responding to urgent airway problems
should be implemented that includes the involvement
of nursing and medical staff. In reality, the system
would be developed for responding to any emergency
in any part of the hospital (e.g. a medical emergency,
code blue or arrest team). Personnel with advanced
Table 57.1 Airway equipment
Basic Suction equipment
Pharyngeal airways (range of sizes)
Bag-valve-mask
Advanced Endo-tracheal tubes (cuffed, range
of sizes)
Laryngoscopes (various sized blades)
Laryngeal mask airway
Drugs – induction, sedative, paralysing
agents
Surgical Large bore needle-cannula
Surgical airway set (scalpel, retractors,
dilators, airway tube)
Tracheostomy set (percutaneous
or surgical, range of sizes)
Mini-tracheostomy set
Jet insufflation set
Miscellaneous Syringes and needles
Connector tubes
CO2 detector
Ribbon ties
Tracheal introducer (stylet)
Magill forceps
467
airway management skills should be included in the
response team. In the rural setting, such persons should
be readily contactable even when not in the hospital.
The surgeon should be prepared to play a role, either as
a regular member of the response team or when sum-
monsed to provide a surgical airway (or for that matter,
to assist with any other part of the resuscitation requir-
ing surgical input).
57.4 Indications for Airway
Management
57.4.1 Recognising an Airway Problem
The presence of an obstructed airway may be complete
or partial, overt or subtle, acute or insidious in onset
and may sometimes be intermittent and progressive.
Early identification of a threatened airway is a critical
step in managing the airway. The overt signs of a
­partial or complete airway obstruction should prompt
immediate intervention (Table 57.2). Hoarseness or
Table 57.2 Signs associated with an obstructed or potentially
compromised airway
Absence of airway sounds, breathing, unable to speak
Noisy breathing
• Wheezing (lower airway)
• Inspiratory stridor (laryngeal)
• Dysphonia – hoarseness (laryngeal)
• Snoring or gurgling (pharyngeal)
Paradoxical respirations
Agitation (i.e., hypoxia)
Reduced consciousness, obtundation (i.e., hypercarbia)
Head or neck subcutaneous emphysema (crepitus)
Facial or cervical deformity following trauma
• Oedema
• Bruising
• Palpable laryngeal fracture
• Burns or carbonaceous deposits around head and neck
• Oro-/naso-pharyngeal blood or secretions
Evidence of trauma above the clavicles
468
stridor, gurgling or noisy breathing or the absence of
respiratory sounds are all highly indicative of an
obstructed airway. On the other hand, subtle, insidious
and progressive airway obstruction may go unrecogn-
ised until airway compromise is well advanced.
Subcutaneous emphysema (i.e., crepitus) in the head
and neck regions, neck oedema, bruising or tender-
ness, carbonaceous deposits around facial orifices and
any injury above the clavicles are all indicators of
actual or potential upper airway injury. It therefore
pays to be vigilant for a possible airway problem and
to hold a high degree of suspicion, even anticipation,
in the critically ill or injured patient.
57.4.2 The Injured Patient
Hypoxia and hypoventilation remain leading causes
of trauma-related preventable deaths. Accordingly,
airway control is the single most important life-saving
intervention in the pre-hospital setting. Where it is
not possible to determine the security of an unsup-
ported airway or to establish a definitive airway in the
pre-hospital environment, the airway must be sup-
ported and frequently assessed. Upon arrival in hospi-
tal, the airway is reassessed and steps taken to secure
the airway. If the patient arrives with an endo-tracheal
tube in situ, it must also be checked to ensure correct
positioning and that it has not dislodged during
transport.
There are a number of injuries that will always war-
rant airway intervention (Table 57.3). Many of these
will require a definitive airway for an obstructed or
unprotected airway (e.g. laryngeal trauma, the uncon-
scious patient). A definitive airway may also be neces-
sary as a pre-emptive step because of an impending
obstruction or potential for obstruction (e.g. inhalation
burns, unstable maxillo-facial injuries, blunt and pen-
etrating neck injuries, risk of aspiration). A patient
who has sustained burns to the head and neck area
must be assumed to have airway trauma from inhala-
tion burns. Carbonaceous deposits around the mouth
and nostrils are pathognomonic of inhalation burns.
This may not cause immediate airway obstruction, but
as the inflammatory response and tissue oedema pro-
gresses, airway obstruction will result. This may be
precipitous and without warning. Similarly, patients
with facial or neck injuries must be suspected as
A. Anthony
Table 57.3 Indications for definitive airway intervention in the
injured patient
Apnoea
Airway obstruction or impending obstruction
• Unconsciousness
• Unstable maxillo-facial injury
• Airway tract injury
Glasgow coma score £ 8
Inability to maintain patent airway
Inability to protect airway from aspiration
Need for assisted ventilation
• Respiratory failure
• Respiratory arrest or hypoventilation
• Cardiac arrest
• Severe haemorrhagic shock
• Significant thoracic trauma (e.g. flail chest)
• Severe head injury
having potential airway problems and must carefully
be assessed. With facial and neck injuries, the airway
may be compromised by haematoma, oedema, ana-
tomical disruption, bony displacement, foreign body,
loose teeth, blood, secretions or by any number of the
aforementioned. Another common indication for a
definitive airway following trauma is to provide
mechanical ventilatory support, even though the air-
way may be intact (e.g. respiratory arrest or failure,
flail thoracic segment). In the severely injured patient,
there are often multiple reasons for a definitive airway.
The unconscious patient with a severe head injury
requires both airway security, due to the patient’s
inability to maintain and protect their own airway, and
mechanical ventilation to regulate oxygen and carbon
dioxide in order to prevent secondary brain injury.
57.4.3 The Non-injured Patient
Any patient with reduced consciousness is at risk of
obstructing the airway from a prolapsed tongue. There
is also little or no ability to cough or gag as a protec-
tive mechanism against aspiration. Patients who are
sedated, recovering from general anaesthesia, shocked
57 Airway Management: A Surgical Perspective
or who have any number of pathologies that result in
an altered conscious state fall in this risk category.
Other causes of supra-glottic airway compromise
include a retropharyngeal abscess, head and neck or
aerodigestive malignancy and airway oedema from
anaphylaxis, radiotherapy or infection. The airway
may be directly compromised during surgery for which
an elective tracheostomy is usually required as part of
the operative strategy (e.g. laryngectomy).
Following head and neck surgery, airway obstruc-
tion may result from post-operative haemorrhage. This
is a particularly dangerous situation. The presence of a
wound drain does not guard against extrinsic airway
compression from haemorrhage. The wound should be
opened immediately but expect that the relief from
obstruction will be variable. Not only is the airway
compromised from the mass effect of an expanding
haematoma, the associated interstitial oedema and
blood is significant, occurs rapidly and may be the pre-
dominant contributor to airway obstruction. The patient
should undergo urgent endo-tracheal intubation and
return to theatre. In some cases, a surgical airway is
required because the degree of pharyngeal and laryngeal
oedema precludes endo-tracheal intubation. Arresting
the bleeding and evacuating a haematoma is not suffi-
cient to restore airway patency. Accordingly, the surgi-
cal airway will need to remain in situ until the oedema
resolves over several days. Patients should therefore
have frequent assessment of the wound and the airway
during the first 12 h following neck surgery.
57.5 Airway Interventions
Manoeuvres to control the airway follow a hierarchy
of interventions (Fig. 57.1). Adequate airway control
aims to establish airway patency, ensure reliability of
patency, protect the airway from further threats (e.g.
aspiration) and allow oxygen delivery and ventila-
tion. All airways should be assessed starting with
simple manoeuvres. Most airway problems can be
managed effectively without having to proceed to
advanced manoeuvres. More complex airway prob-
lems will require a definitive airway whilst few would
ever need an emergency surgical airway. Importantly,
basic airway interventions do not protect the lower
airway from aspiration and may not be sufficiently
secure to safely transport a critically ill patient. Those
469
managing the airway should be familiar with the hier-
archy of airway care, be decisive and know when to
seek assistance. When faced with an acute airway
problem, it is important to maintain a calm and delib-
erate approach in what can be a daunting and intimi-
dating situation.
57.5.1 Protecting the Cervical Spine
For injured patients and those with known or sus-
pected cervical spine pathology (e.g. rheumatoid
arthritis), care must be taken to protect the cervical
spine during airway manipulation. The aim is to avoid
converting a cervical vertebral fracture into a spinal
injury or exacerbating an existing spinal injury.
Stabilisation of the cervical spine does not take prece-
dence over airway control, nor is it given a lower pri-
ority for the sake of airway security. Rather, controlling
the airway and protecting the spine are performed
concurrently. The head and neck should be stabilised
in the neutral position. In the injured patient, a cor-
rectly fitted stiff or semi-rigid protective cervical
­collar is applied during pre-hospital resuscitation.
Cervical collars may, however, impede access for sub-
sequent airway assessment and intervention. When
this occurs, an assistant should provide manual in-line
immobilisation of the patient’s head and neck before
the collar is carefully opened. The hands of the assis-
tant are firmly placed on either side of the head and
held steady. The technique minimises any rotational,
lateral or flexion-extension movements of the cervical
spine and the head. In-line immobilisation is main-
tained until the airway has been secured and the cervi-
cal collar reapplied. This approach ensures a reasonable
level of stability of the atlanto-occipital and interver-
tebral joints. Spinal immobilisation is maintained until
such time that a significant cervical injury has been
excluded.
57.5.2 Clearing the Airway
The majority of airway problems may be managed by
simple and rudimentary steps. A prolapsed tongue in
the unconscious patient is the most common cause of
an obstructed upper airway. Either the ‘chin lift’ or
470 A. Anthony

Fig. 57.1 Airway manage- Airway control required

ment algorithm

Basic airway manoeuvres

(protect cervical spine where indicated)
· Open and clear airway
· Chin lift/jaw thrust
· Pharyngeal airway if required

Patient able to oxygenate, ventilate

and protect airway

Yes No
· Requires definitive airway
· Call for assistance

Oro-tracheal intubation
· Rapid sequence intubation preferred

Yes No
· Failed maximum three attempts, or
· SpO2 < 90%

Emergency interim interventions

(does NOT provide for a definitive airway)
· Laryngeal mask airway
· Needle cricothyroidotomy and jet insufflation

Surgical airway
· Percutaneous or surgical cricothyroidotomy
· Tracheostomy if time permits

‘jaw thrust’ will elevate the tongue from the oro-phar-
ynx. Airway clearance is not complete unless there is
careful inspection of the oro-pharyngeal cavity,
removal of any foreign body (e.g. by using the index
finger to sweep out an object, or an instrument such as
Magill forceps) and gentle suctioning of secretions,
blood or vomitus from the pharynx and hypo-pharynx.
The suction device should be rigid but care should be
taken not to traumatise the pharynx and to avoid
breaching through a basilar skull fracture. There should
be adequate lighting to ensure visualisation of the
mouth and pharynx.
57 Airway Management: A Surgical Perspective 471

57.5.3 Pharyngeal Airways flange abuts the lips. Care should be taken not to dam-
age teeth or traumatise the palate. Alternatively, the
OPA can be inserted right way up, under direct vision
If airway patency cannot be achieved without employ-
by using a laryngoscope, displacing the tongue with
ing a ‘chin lift’ or ‘jaw thrust’ (e.g. in an unconscious
the laryngoscope blade and advancing the OPA over
patient), either an oro-pharyngeal or naso-pharyngeal
the tongue and into the hypo-pharynx. An OPA that is
airway is inserted to keep the tongue from occluding
too small may not prevent the tongue from occluding
the oro-pharynx. There are benefits and limitations in
the oro-pharynx. An oversized OPA may obstruct the
the use of such devices (Table 57.4). Oro-pharyngeal
airway by depressing the glottis over the hypo-
airways (OPAs) are rigid, curved plastic or rubber
pharynx.
devices with a flange at one end. They are colour-coded
Where the patient is sufficiently awake not to toler-
for size complying with an international standard. An
ate an OPA, or where it is not possible to gain access
appropriately sized OPA is selected by matching the
via the patient’s mouth (e.g. through clenched teeth),
distance between the corner of the mouth and the ear
an alternative is to insert a naso-pharyngeal airway
lobe, with the length of the OPA. This will ensure the
(NPA). NPAs are soft rubberized gently curved tubes,
OPA reaches over the base of the tongue and into the
flared at the nostril end. The lumen is smaller than that
hypo-pharynx. In the adult, the OPA is inserted upside
of a corresponding OPA. The curvature is congruent to
down, with its concave side towards the roof of the
the curvature of the naso-pharyngeal route. The NPA
mouth. When the tip of the OPA reaches the soft
must be appropriately sized to match both the diameter
palate, the OPA is rotated 180° and advanced until the
of the nostril and the distance from the tip of the nose
to the ear lobe. The correct length ensures the tip of the
Table 57.4 Pharyngeal airways
NPA reaches over the base of the tongue into the hypo-
Advantages Disadvantages
pharynx. The NPA is lubricated and gently inserted
OPA Easy, simple to insert Causes gag reflex, unsuitable until the flared opening sits against the nostril. If there
for conscious patient
is resistance to passage, insertion through the contra-
Allows suctioning Cannot insert through lateral nostril should be attempted. An NPA should not
clenched teeth
be inserted where there is a mid-face or basilar skull
Maintains airway Does not secure hypo- fracture.
for spontaneous ­pharynx or trachea
breathing
Prevents closure May dislodge
of mouth and teeth 57.5.4 Bag-Valve-Mask Ventilation
May obstruct airway
if incorrectly inserted Once the upper airway is controlled, supplemental
May obstruct glottis if too oxygen can be given and ventilation assisted via a
large ­bag-valve-mask. Bag-valve-mask ventilation is indi-
Require range of sizes cated for patients who are apnoeic or hypoventilating.
May cause soft tissue In most situations, basic airway control and assisted
or dental injury ventilation can deliver oxygen for prolonged periods
NPA Easy, simple to insert Narrow lumen
until expert help arrives or until resources are gathered
for a definitive airway if required. Whilst preparing
Allows suctioning May cause nasal trauma for a definitive airway, and if the situation permits,
and bleeding
time should be spent oxygenating the patient via the
Can be tolerated by Contra-indicated for basilar bag-valve-mask.
awake patient skull fractures
The bag-valve-mask device must be correctly
Alternative to OPA Require set of sizes assembled and connected to high-flow oxygen. The
if clenched teeth
airway must be patent and an adequate seal achieved
Does not secure hypo- between the mask and the airway. With a two-person
­pharynx or trachea technique, one person maintains seal and the second
472
person provides manual compression of the bag. A
single person technique is also effective but requires
practice to achieve a consistent seal. Modern bag-
valve-mask devices come pre-assembled whereas
older devices can be disassembled for cleaning and
may not have been correctly reassembled. It is prudent
to quickly inspect a dismantable bag-valve-mask prior
to its use to ensure that it has been correctly
assembled.
57.5.5 Laryngeal Mask Airway
The supra-glottic airway can be controlled with a
laryngeal mask airway (LMA). The LMA consists of a
rigid tube attached to an inflatable, silicon-based,
cuffed mask. When correctly inserted and inflated, the
LMA seals the pharynx and provides an airway for
oxygenation and ventilation. The advantage of the
LMA is that it is relatively easy to insert and does not
require direct laryngoscopy, can be inserted with the
patient sitting upright (e.g. before extrication from an
accident scene), requires minimal manipulation of the
head and neck to place and enables rapid rescue of an
obstructed airway when endo-tracheal intubation is
unsuccessful. Notably, the LMA does not traverse the
glottis and, therefore, does not protect against aspira-
tion. Nor does it allow suctioning of the infra-glottic
airway. Its use is therefore contra-indicated when air-
way obstruction is distal to the oro-pharynx or where
there is a risk of aspiration. Modifications to the LMA
allow gastric decompression and intubation of the
­larynx via additional lumens. These devices require
greater skill to correctly deploy.
The technique for LMA insertion is relatively
simple.
1. The upper airway is cleared and the patient
­pre-oxygenated
2. The LMA cuff is deflated and lubricated
3. The mouth is opened and the LMA is inserted,
­leading with the apex of the mask with its opening
facing the upper surface of the tongue
4. The apex of the mask is blindly and gently advanced
towards the uvula, following the curvature of the
oro-pharynx
5. Once the mask comes to rest snugly in the distal
pharynx, the cuff is inflated to create a pharyngeal
seal
A. Anthony
6. Auscultation, observing chest wall movement and
measuring end-tidal carbon dioxide are used to
­confirm airway patency and adequate ventilation
57.5.6 Definitive Airway
A definitive airway is one that is secure, reliable, pro-
tected from obstruction (aspiration or sputum reten-
tion) and allows oxygen delivery and ventilation. The
indications for a definitive airway include failure to
secure or maintain an airway by other means, the need
to protect the lower airway from aspiration and the
need for mechanical ventilatory support (Table 57.3).
Definitive airway tubes are characteristically semi-
rigid or rigid, made from polyvinyl chloride and
are cuffed by an inflatable balloon. The inflated cuff
seals the airway and protects the lower airway from
aspiration and allows positive pressure ventilation. The
­sizing system of airway tubes refers to the internal
diameter (ID) of the tube in millimetres. An outside
diameter (OD) is also annotated on some tubes.
Appropriate tube sizes for the typical adult range
between 7.5 mm ID (females) and 8.5 mm ID (males).
A 7.5-mm ID tube would suit most adults of either
gender.
The method of establishing a definitive airway is
dictated by the complexity of the airway problem, the
expertise of the person managing the airway and the
availability of equipment and instruments. An airway
management algorithm may be useful and assist in
decision-making (Fig. 57.1).
57.5.7 Oro-tracheal Intubation
Oro-tracheal intubation via direct laryngoscopy is the
most common method for securing a definitive airway.
Establishing a definitive airway requires training in
advanced skills. In a setting where expertise is limited
but the situation demands an urgent definitive airway,
endo-tracheal intubation can be attempted if the intu-
bator has had some training. If endo-tracheal intuba-
tion is unsuccessful, a prompt decision should be made
to move along the airway management hierarchy and
consider a surgical airway. The use of neuromuscular
paralysis is not required when the patient is obtunded
57 Airway Management: A Surgical Perspective
and flaccid. Where the patient is awake, rapid sequence
intubation (RSI) is the method of choice for trauma or
in critical situations. The advantage of RSI is the high
rate of successful intubation and lower risk of aspira-
tion. However, RSI requires the administration of
pharmacological agents to achieve sedation and neuro-
muscular paralysis. Therefore, unless the intubator is
trained and sufficiently familiar with the use of these
drugs, RSI should only be undertaken by those suit-
ably qualified. Awake intubation performed without
sedation and paralysis requires a cooperative patient
and adequate local anaesthesia of the supra-glottic and
infra-glottic spaces. It may be less expedient than intu-
bation in an obtunded patient or with RSI and requires
a skilful intubator.
There are a series of key steps in oro-tracheal
intubation.
1. Prepare the equipment and personnel
2. Pre-oxygenate the patient if time permits
3. Protect the cervical spine where necessary
4. Position the head and neck preferably in the ‘sniff-
ing position’ but dependent upon cervical spine
­stability (i.e., head slightly extended and lower neck
slightly flexed to align the oral, pharyngeal and
laryngeal tracts)
5. Apply cricoid cartilage pressure (i.e., Sellick’s
manoeuvre) to prevent gastric aspiration
6. Correctly place the endo-tracheal tube via direct
laryngoscopy
7. Secure and confirm the tube placement
The laryngoscope is always held in the left hand. Its
blade is passed under vision, displacing the tongue to
the patient’s left to expose the epiglottis. The blade tip
is passed under the epiglottis or into the vallecula.
With careful anterior retraction, the glottic opening is
exposed. The technique of retraction is important to
avoid trauma to teeth and to minimise cervical spine
movement. The laryngoscope is elevated upwards in a
plane parallel to its handle. ‘Rocking’, rotating or
levering the laryngoscope posteriorly must be avoided.
An assistant should apply firm pressure on the cricoid
cartilage to prevent pharyngeal reflux of gastric con-
tents via the oesophagus. To help bring the glottic
opening into view, cricoid pressure can be applied
backward, upward and slightly to the right. Whilst the
left hand operates the laryngoscope, the right hand is
free to suction the airway and insert the oro-tracheal
tube. The tube is passed under vision between the
473
vocal cords. When intubation is difficult because of
limited line of sight or airway space, a stylet-introducer
is first passed under vision into the trachea. This allows
the endo-tracheal tube to be inserted over the intro-
ducer into the trachea before removing the introducer.
An assistant must hold the introducer steady as the
tube is advanced through the larynx. Once the tube is
passed, it is held in position whilst the cuff is inflated
and the laryngoscope carefully removed. The tube is
securely tied around the patient’s neck. Correct tube
placement is indicated by visualising its passage
through the vocal cords, auscultation of breath sounds
over both lung fields, absence of breath sounds over
the stomach, rise and fall of the chest wall with ventila-
tion and condensation in the tube during expiration.
The gold standard of adequacy of ventilation is the
measurement of end-tidal carbon dioxide via a capno-
graph where available.
57.5.8 Naso-tracheal Intubation
The nasal route for endo-tracheal intubation provides
for an alternative definitive airway where the patient
is breathing spontaneously. The route is not recom-
mended for patients who are apnoeic, have severe
maxillo-facial trauma or who may have a basilar skull
fracture. A combative patient, inability to pre-oxygenate
the patient, coagulopathy and raised intracranial pres-
sure are relative contraindications to the procedure.
Naso-tracheal intubation is less expedient, is under-
taken blindly, is technically more challenging and has
a higher risk of failure. It has largely been replaced
by RSI.
57.5.9 Fibre-optic Intubation
The use of a fibre-optic endoscope may assist endo-
tracheal intubation for patients with short necks or
with maxillo-facial or cervical spinal injuries. The
patient’s condition should permit the time required to
perform the intubation. The technique requires appro-
priate equipment and a skilled operator. It is less
­expedient and, in the emergency situation, the decision
to resort to a fibre-optic approach must be carefully
considered.
474 A. Anthony

57.5.10 Complications intubate, cannot ventilate’, the situation is time critical

A complication that arises as a result of attempting to
secure a definitive airway is potentially fatal. In an
injured patient, even when obtunded, significant rises
in intracranial pressures can occur during intubation
that may adversely impact on a severe brain injury.
Aspiration and airway trauma during intubation may
dramatically escalate the degree of airway obstruction.
Cricoid pressure affords some protection against aspi-
ration and a meticulous approach reduces the risk of
trauma to the airway, teeth and cervical spine. Unrecog­
nised oesophageal intubation and failure to access the
trachea are leading causes of preventable deaths. The
inexperienced intubator is more likely to intubate the
oesophagus or fail to gain airway access. When check-
ing the position of the tube, there should be no doubt as
to its correct placement. When faced with ‘cannot
and urgent airway rescue is required. Failure to intu-
bate is an unarguable indication to promptly abandon
repeated attempts at endo-tracheal intubation and
progress to a surgical airway.
57.5.11 Sub-glottic Airway Access
Most airway problems involve the upper airway at,
or proximal to the glottic opening. When a definitive
airway cannot be established by the supra-glottic route,
access to the trachea is gained via a sub-glottic
approach through the anterior neck. Both a cricothy-
roidotomy and tracheostomy are well accepted sub-
glottic interventions with defined indications, merits
and limitations (Table 57.5).

Table 57.5 Sub-glottic airway access

Needle cricothyroidotomy
Surgical cricothyroidotomy
Tracheostomy
Advantages
Simple and effective technique
Minimal equipment, easily accessed
Rapid access into airway
Permits time to prepare for definitive airway
Minimal manipulation of neck (trauma)
Simple and effective technique
Rapid airway access
Minimal equipment
Provides definitive airway
Able to suction airway
Adequate oxygenation and ventilation
Minimal manipulation of neck (trauma)
Rapid airway access
Provides definitive airway
Minimal manipulation of neck (trauma)
Long-term ventilation support
• Facilitate weaning off ventilation
• Allow tracheo-bronchial toilet
• May permit vocalisation
• Improved patient comfort
Disadvantages
Limited rates of oxygen delivery
Limited ability to ventilate
Risk of hypercarbia
Unable to suction airway
Risk of bleeding, aspiration, haematoma
May create false passage
Subcutaneous bleeding, haematoma
ET tube may occlude bronchus
Transient hoarseness
Sub-glottic stenosis if secondary to
­prolonged ­endo-tracheal intubation
Technically challenging
• Difficult anatomy
• wwDifficult pathology
May create false passage
Bleeding from multiple sites
Sub-glottic stenosis if too proximal
Requires surgical skills and assistant
57 Airway Management: A Surgical Perspective
57.5.12 Cricothyroidotomy
A cricothyroidotomy is an effective intervention that
permits rapid access to the airway distal to the glottis.
It is the intervention of choice when all other manoeu-
vres for endo-tracheal access have been unsuccessful.
The cricothyroid segment is the most superficial part
of the airway, located in the mid-anterior neck where
the subcutaneous fat is minimal. The thyroid cartilage
is easily palpable. The cricoid cartilage lies just inferi-
orly and is also readily palpable. The space between
the two is occupied by the cricothyroid membrane (or
ligament) in the midline. The airway is accessed
through this membranous space either by percutane-
ous insertion of a needle or by a simple surgical
technique.
A needle cricothyroidotomy involves inserting a 12
or 14 gauge plastic cannula over a needle, angled 45°
caudally, through the cricothyroid membrane. Airway
access is confirmed by aspirating air via the needle.
The needle is withdrawn, the cannula left in situ and
immediately connected to high-flow oxygen. If a
Y-piece connector is not available, a side hole is cut
into the oxygen tubing, which is connected via a Luer
lock directly to the cannula. Needle cricothyroido-
tomy allows for jet insufflation of oxygen and inter-
mittent ventilation by occluding either the end of the
Y-piece or the side hole with the thumb. Occlusion is
for 1 s in every 5 s. Suctioning is not possible.
Oxygenation and ventilation is sufficient but only
effective for approximately 30 min. The limited abil-
ity for exhalation results in carbon dioxide retention.
It may be possible to connect a bag-valve-mask to a
cut syringe barrel attached to the cannula. This may
improve oxygen delivery but does not avoid hypercar-
bia. Therefore, after 30 min, an alternative airway is
required. This timeframe should be sufficient to call
for assistance and prepare for either a surgical crico-
thyroidotomy or tracheostomy.
A surgical cricothyroidotomy also gains rapid air-
way access. Furthermore, a surgical cricothyroidotomy
allows for a definitive airway not possible via a percu-
taneous needle. With the cricothyroid structure stabi-
lised between the index and thumb of one hand, a
2–3-cm transverse incision is made immediately below
the thyroid cartilage, through the skin and through the
cricothyroid membrane. This should be performed
expeditiously and with minimal strokes of the scalpel.
The airway opening is dilated with a pair of curved
475
artery forceps and a 5–7-mm ID cuffed tracheostomy
tube inserted. The cuff is inflated. The tube is tied in
place and connected for immediate oxygenation and
ventilation. It is preferable to use a tracheostomy tube
although a small calibre endo-tracheal tube will suf-
fice. Care is taken with an endo-tracheal tube to ensure
it is positioned in the trachea and not in a bronchus. A
4-mm ID mini-tracheostomy tube can also be used. It
is, however, an uncuffed airway and does not afford
any protection from aspiration.
In children under 12 years old, the cricoid cartilage
provides the only circumferential upper tracheal sup-
port. Surgical cricothyroidotomy is therefore not rec-
ommended for those under 12 years old.
Traditionally, a tube cricothyroidostomy was a
short-term definitive airway due to the perceived risk
of glottic and sub-glottic stenosis. The evidence, how-
ever, indicates that a surgical cricothyroidotomy is not
associated with an increase risk of stenosis unless it is
a secondary procedure to endo-tracheal intubation of
greater than 7 days or if there is concomitant laryn-
geal trauma or pre-existing laryngeal infection.
Therefore, as a primary intervention for a definitive
airway, tube cricothyroidotomy is a safe procedure of
low morbidity.
57.5.13 Tracheostomy
The trachea is a midline structure in the anterior neck.
It is angled slightly posteriorly as it passes caudally
towards the sternal notch. Tracheal access is improved
by positioning the head and neck in the ‘sniffing’
­posture as described earlier. Alternatively, a padded
object between the shoulder blades will improve the
anterior presentation of the trachea. These manoeu-
vres are performed if cervical spinal stability is
ensured. Subcutaneous adiposity, a short neck, mid-
line shift or soft tissue deformity from trauma may
make it difficult to palpate the trachea. Nevertheless,
it is a relatively accessible part of the infra-glottic
­airway for securing a definitive airway.
Tracheostomy tubes come in varying configura-
tions. The essential feature is a curved, rigid tube with
a neck-plate or flange. All tubes permit oxygenation,
ventilation and tracheo-bronchial toileting of sputum.
Cuffed tubes provide a seal for positive pressure venti-
lation and to protect against aspiration. A fenestrated
476
tube allows phonation. An inner cannula makes tube
cleaning simpler and, when coupled with a fenestrated
tube, facilitates progression to phonation.
A tracheostomy is performed either as a percutane-
ous Seldinger technique or as a surgical procedure.
The method of choice will depend on the clinical indi-
cation, the environment and the capabilities of the
operator. The clinical indications are either urgent or
non-urgent, with non-urgent indications being more
common (Table 57.6). Although a tracheostomy can
provide an airway in an emergency, in the dire situa-
tion of ‘can’t intubate, can’t ventilate’, there are rea-
sons why a cricothyroidotomy remains the procedure
of choice. It may be difficult to locate the trachea for
the reasons listed above. When gaining tracheal access,
bleeding is more likely to occur from subcutaneous
vessels, from the strap muscles or from a divided thy-
roid isthmus. Some degree of tissue retraction and
lighting is required to visualise the trachea. The inter-
space between tracheal rings does not permit the easy
placement of a tube without creating an incisional or
excisional tracheal stoma, or by taking the time to suf-
ficiently dilate an opening. Failure to achieve adequate
haemostasis risks blood entering the stoma, further
compromising the airway. The procedure may there-
fore not be a simple nor rapid intervention at a time
when a definitive airway is most urgently needed.
Tracheostomies are most commonly performed for
patients who are already ventilated via an endo-­tracheal
tube. The decision to convert to a tracheostomy is
based on the need for prolonged ventilation. A tra-
cheostomy avoids the risk of glottic stenosis that is
associated with long-term endo-tracheal intubation.
There are other advantages in converting the airway to
a tracheostomy. A tracheostomy helps wean the patient
off prolonged assisted ventilation. Nursing the airway
and tracheo-bronchial toileting is easier. A cuffed
Table 57.6 Indications for tracheostomy
Urgent Glottic or supra-glottic obstruction –
oedema, trauma, compression
Severe maxillo-facial trauma
Failure of endo-tracheal intubation
Non-urgent Long-term assisted ventilation
Long-term or permanent airway
Planned part of laryngectomy or other
head–neck surgery
Tracheomalacia (rare)
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tracheostomy protects the airway from aspiration. A
tracheostomy is well tolerated by the awake patient
and, depending on the type of tracheostomy tube, the
patient may vocalise with the tube in situ and may be
fed orally.
57.5.14 Percutaneous Tracheostomy
In the intensive care setting, conversion to a tracheos-
tomy is commonly performed as a percutaneous
Seldinger technique using a commercially assembled
kit. The technique is generally not suitable for gaining
emergency access to the airway. The procedure requires
one person to insert the tracheostomy and another to
manage the anaesthesia and remove the endo-tracheal
tube in a coordinated exchange. The coordination is
important to maintain airway access at all times. The
procedure can be performed by the patient’s bedside,
and is generally a safe and effective intervention. It
relies on favourable anatomy for ease of tracheal
access. A percutaneous approach is preferred over a
surgical tracheostomy in the setting of coagulopathy.
The technique involves the following key steps.
1. Position the head and neck and protect the cervical
spine as necessary
2. Ensure asepsis
3. Identify the cricoid cartilage and sternal notch and
mark the skin over the second and third tracheal
rings by palpation from the cricoid cartilage
4. Infiltrate the skin and subcutaneous tissue with
local anaesthesia and adrenalin; create a 1-cm
transverse skin incision over second and third
inter-space in the midline
5. Insert the introducer needle on a syringe through
the inter-space at 45° angled caudally; confirm
entrance into trachea by aspirating air
6. Introduce the guide wire through the needle, then
remove the needle; lubricate and pass the dilating
sheath over the wire into trachea; swap the dilator
for a larger introducer over the wire; remove the
wire leaving the introducer in situ
7. Sequentially pass dilators over the introducer,
each one larger than the previous dilator; employ a
gentle rotating motion with mild force; extend the
skin incision if needed to permit adequate dilata-
tion; dilators are matched with various tracheos-
tomy tube sizes and the final dilator used should
57 Airway Management: A Surgical Perspective
match the tracheostomy tube to be used; remove
the dilator leaving the introducer in situ
8. Test the tracheostomy balloon cuff for leaks;
deflate and lubricate the tracheostomy tube and
pass over a dilator one size smaller than that of the
tube; pass the dilator and tracheostomy tube over
the introducer and stop just short of the trachea
9. Before advancing the dilator and tracheostomy
any further, deflate the endo-tracheal cuff and
withdraw the endo-tracheal tube to the larynx;
now advance the tracheostomy tube; remove the
dilator and introducer, leaving the tracheostomy in
situ
10. Completely remove the endo-tracheal tube only
when the tracheostomy tube is fully inserted
11. Suction the tracheostomy tube and inflate the
­balloon cuff; connect the tracheostomy to the
ventilator
12. Secure the tube and check for correct positioning
(chest auscultation, movement and end-tidal car-
bon dioxide)
The potential pitfalls of the percutaneous technique
include insertion in the incorrect inter-space, creation
of a false passage, premature removal of the introducer
before tracheostomy placement and the uncoordinated
removal of the endo-tracheal tube leading to potential
loss of airway control. A tracheostomy tube that is sited
adjacent to the cricoid cartilage may result in sub-­glottic
stenosis as the tracheal stoma heals by cicatrisation. If
sited too low, the tip of the tracheostomy tube may
erode through the anterior tracheal wall into the innom-
inate artery, resulting in catastrophic bleeding into the
trachea. Unless urgent haemostasis can be achieved, the
arterio-tracheal fistula is likely to be fatal.
57.5.15 Surgical Tracheostomy
This is commonly performed as a planned conversion
from an endo-tracheal tube for the same reasons as out-
lined above. An operative approach is preferred when
there are anticipated difficulties in accessing the tra-
chea. In particular, a short or fat neck reduces the chance
of a successful percutaneous tracheostomy. An elective
tracheostomy is also undertaken as part of major neck
surgery for malignancy. Rarely is it required for
­trac­heomalacia following a thyroidectomy. A surgical
477
tracheostomy is a sterile procedure performed in an
operating theatre with an assistant. The key steps for
the procedure are as follows.
1. Check equipment and instruments including tra-
cheostomy tube (tube size to match endo-tracheal
tube), surgical sucker, suction tubing for airway,
bipolar diathermy
2. Position the head and neck and protect the cervical
spine as necessary
3. Ensure a sterile field
4. Identify the cricoid cartilage and sternal notch and
mark skin over the third tracheal ring by palpation
from the cricoid cartilage
5. Infiltrate skin and subcutaneous tissue with local
anaesthesia and adrenalin; stabilise the trachea
between fingers and create a 2–3-cm transverse
skin incision over the third tracheal ring in the
midline and between the medial borders of the
sternomastoid muscles
6. Dissect through platysma to the pretracheal fascia;
ligate vessels before dividing
7. Vertically incise fascia between strap muscles
to expose tracheal rings and thyroid isthmus;
divide isthmus between clamps and oversew for
haemostasis
8. Using a #15 blade then a pair of scissors, create a
stoma by excising a portion of the anterior tracheal
wall centred on the third or fourth ring; match the
stoma to the size of the tracheostomy tube; avoid
the use of diarthermy once the trachea is opened – the
anaesthetic gases and oxygen are highly inflammable;
haemostasis is achieved by suturing bleeding points
9. Check tracheostomy balloon cuff for leaks; deflate
cuff, lubricate and place at entrance to stoma
10. Instruct anaesthetist to deflate the endo-tracheal
balloon and slowly withdraw no further than the
larynx; suction any secretions that may start to
exit through the stoma
11. Once endo-tracheal tube passes proximal to stoma,
insert tracheostomy tube, remove obturator, inflate
cuff, suction tube and connect to ventilator
12. Check correct placement of tracheostomy (chest
auscultation, movement and end-tidal carbon
dioxide) then secure with tapes
13. Only remove the endo-tracheal tube when tra-
cheostomy tube is confirmed in correct position
14. Approximate wounds with interrupted sutures
and dress wound
478
A cricothyroidotomy remains the preferred surgical
intervention in an airway emergency. Nevertheless,
emergency surgical tracheostomy has been described. If
performed, a midline vertical incision is made through
the skin, platysma, pretracheal fascia and onto the ante-
rior tracheal wall with minimal attention to haemosta-
sis. Bleeding will follow division of the thyroid isthmus
unless time permits its division between clamps. The
third and fourth rings are identified by palpation, and
incised vertically. The tracheotomy edges are held
opened using a pair of curved clamps and a tracheos-
tomy tube inserted, sometimes blindly but guided by
palpation. Haemostasis is achieved after securing the
airway tube. The trachea should be suctioned to remove
any blood that may have entered during the procedure.
The midline incision minimises bleeding but the proce-
dure may nevertheless be bloody.
57.5.16 Mini-tracheostomy
When the main indication for a tracheostomy is to
improve tracheo-bronchial toileting for sputum, a
smaller calibre (e.g. 4-mm ID) uncuffed tracheostomy
is used. It provides sufficient access to the trachea and
its small size reduces the amount of scarring that will
occur with closure of the stoma following its removal.
A percutaneous Seldinger method is used to insert the
mini-tracheostomy. A mini-tracheostomy tube can be
used for an emergency crico-thyoridotomy. It is not an
ideal airway for oxygenation and ventilation but will
suffice in an emergency. It is uncuffed and lends no
protection against aspiration.
57.5.17 Complications Associated
with Tracheostomy
Complications may occur intra-operatively or post-
operatively (Table 57.7). Serious complications are
uncommon, but they are potentially life threatening.
They include the loss of airway control from the pre-
mature removal of the endo-tracheal tube during an
exchange, tracheal airway burn injury from gaseous
ignition, an occluded tracheostomy tube, a tracheo-
arterial fistula, a tracheo-oesophageal fistula, tube dis-
lodgement and stomal tract bleeding with tracheal
A. Anthony
Table 57.7 Tracheostomy related complications
Intra-operative Bleeding
Tracheal burn injury (diarthermy)
Uncoordinated exchange with ETT – loss
airway access
Difficult anatomy – failure to correctly
Puncture of posterior tracheal wall
(percutaneous insertion)
Pneumothorax
Post-operative Dislodgement
Subcutaneous emphysema
Bleeding from stomal tract
Occlusion from inspissated mucus plug
Occlusion from herniated/overinflated cuff
Tracheo-arterial fistula (innominate artery)
Tracheo-oesophageal fistula
Sub-glottic stenosis
Wound infection
Tracheitis from desiccation
aspiration. Premature removal of the endo-tracheal
tube and airway ignition injuries are entirely prevent-
able if care is taken with the operative technique.
Humidification and regular tracheo-bronchial toileting
will minimise the risk of mucus plug occlusion.
Humidification is also important to avoid tracheitis
from drying of the mucosa. If an occlusion cannot be
overcome, prompt deflation of the cuff with oxygen-
ation and ventilation via the oro-pharyngeal route alle-
viates the urgency and allows time to prepare for a tube
exchange. Tube exchange should be performed in the
operating room. In the rare case when an overinflated
cuff has herniated over and obstructed the tip of the
tracheostomy, cuff deflation should immediately
resolve the problem. Some tracheostomy tubes have an
‘inner’ cannula that can be removed and cleaned or
exchanged whilst the tracheostomy tube remains in
situ. Removing the inner cannula that is plugged by
inspissated mucous relieves the obstruction. Erosion
of the tip of the tracheostomy tube anteriorly into the
innominate artery is a catastrophic event of high lethal-
ity. A tracheo-oesophageal fistula forms from cuff ero-
sion through the posterior tracheal wall. This is also
potentially fatal from pulmonary sepsis. Steps taken to
minimise the risk of tracheal wall erosion include
selecting the correct tube size and length, correctly
57 Airway Management: A Surgical Perspective
siting the tube, monitoring cuff volumes, avoiding
over-inflation of the cuff and avoiding excessive torque
applied to the tracheostomy by its connection to the
ventilator. Tube dislodgement is serious if the patient
does not have an intact proximal airway for oxygen-
ation and ventilation. However, in the majority of
patients, the oro-tracheal airway is intact and can be
used in an emergency for oxygenation and ventilation.
This provides time to organise for resiting a tracheo-
stmy tube, preferably in the operating room. Attempts
at blindly recannulating the tract may result in creating
a false passage or cause bleeding. Stomal tract bleed-
ing, often from granulating tissue, is usually minor but
carries a risk of tracheal aspiration. It is best managed
with direct pressure, maintaining cuff inflation to pro-
tect against aspiration and suctioning the tracheostomy.
Subcutaneous emphysema is usually of little conse-
quence but signifies an air leak around the tracheos-
tomy. Selecting the correct tube size and ensuring
adequate cuff inflation should prevent this problem.
57.5.18 Decannulation
Removing a tracheostomy tube is safe when undertaken
as a planned manoeuvre. A number of criteria must be
met for safe decannulation. The upper airway must be
intact and secure and the underlying reason for requiring
the artificial airway must have resolved. The patient
must be alert, have a strong cough reflex and have mini-
mal tracheo-bronchial aspirates. The patient’s oxygen
requirements should be as close to normal as possible
and the fraction of inspired oxygen should be less than
40%. A trial period of breathing via the normal upper
airway may be possible by capping off the tracheostomy.
This is only feasible with an uncuffed tracheostomy.
For decannulation, the patient is sat upright, moni-
tored with a pulse oximeter and given supplemental
oxygen via a face mask. The tracheostomy is suctioned
and the securing ties undone. With the suction catheter
inserted just beyond the tracheostomy tip, the cuff is
fully deflated and the tube slowly removed whilst suc-
tioning any mucous that may dislodge from the outer
surface of the tube. Failure to fully deflate the tube dur-
ing removal may result in airway obstruction. With the
tube removed, cover the fistula with an airtight dressing.
Ensure the patient remains adequately oxygenated. The
skin over the stoma should close within a day or two.
479
57.5.19 Long-Term Tracheostomy
Where there is an ongoing dependence on ventilatory
support, where the normal upper airway anatomy has
been compromised or where the patient is unable to
maintain or protect their own airway for a protracted
time, a tracheostomy provides a reliable, long-term
­airway. It allows for progressive weaning from ven­
tilation, is comfortable, enables phonation and oral
nutritional intake, facilitates tracheo-bronchial toilet-
ing and provides a safe airway during mobilisation and
transportation. Long-term or permanent tracheostomy
tubes differ from the cuffed tube that may have been
inserted early in the patient’s care. If positive pressure
ventilatory support is not required, and there is little
risk of aspiration, the cuffed tube is exchanged for a
shorter, uncuffed tube made of non-perishable mate-
rial. A fenestrated tube facilitates phonation but may
not be necessary if sufficient air can pass around the
uncuffed tube.
57.6 Challenges in Airway Control
57.6.1 Rural Setting
The rural setting can undoubtedly be a testing environ-
ment in which to manage complex airway problems.
The lack of advanced airway expertise, limited
resources, difficulties in maintaining skills and the
infrequent opportunities to develop experience are fac-
tors that compound the challenges faced by the rural
practitioner. Furthermore, the patient who requires a
secondary transfer for definitive care, whether by road
or air, is at some risk of losing a definitive airway
whilst in transit. The mode of transport does not offer
a controlled environment and a lost airway may be
disastrous. Airway security is therefore of high prior-
ity and must be assured before the patient commences
travel.
57.6.2 Cervical Spine Trauma
The possibility of a cervical spinal injury from trauma
necessitates strict immobilisation of the head and neck
480 A. Anthony

during airway management. Although the amount of short mandible, narrow mouth or large tongue is an
head extension to access the airway is restricted, rapid impediment to airway access. Manipulation for oro-
sequence endo-tracheal intubation via direct laryngos- tracheal intubation may be restricted by joint dis-
copy remains the recommended practice. It is a safe eases affecting the neck and mandible. Manipulation
manoeuvre as long as head and neck stability is is similarly limited in the morbidly obese patient
assured. with a fat neck or pendulous submental adiposity
and in the patient with a short or no neck (i.e., bull-
neck). When endo-tracheal intubation is not possible
under these circumstances, a surgical airway is the
57.6.3 Airway Trauma preferred option. Even then, the thyroid and cricoid
cartilages may not be easily palpable to perform a
Patients with gross disruption of the pharyngeal or cricothyroidotomy. The trachea may be located by
supra-glottic airway, from injury or other pathology, blindly passing a long needled cannula in the mid-
will invariably require a surgical airway. When related line of the neck until air is aspirated. Under the cir-
to trauma, soft tissue and bony deformity and bleeding cumstances, whether the needle passes through the
cause both extrinsic compression and intrinsic obstruc- cricothyroid membrane is not critical as long as it is
tion of the airway. Inhalation airway burns may go deemed to be in the trachea. Once the cannula is
unrecognised until airway obstruction becomes overt, sited in the airway, jet insufflation is commenced
making even a surgical airway difficult. Chest wall and preparations made for a surgical cut down onto
full thickness burns may require escharotomy to allow the trachea, being careful not to dislodge the can-
for adequate ventilation. Obstruction of the infra-­ nula. The alternative is to use the in situ cannula to
glottic (i.e., laryngotracheal) airway can really only be insert a percutaneous tracheal airway, dilating the
managed if an airway tube is placed across the disrup- tract to permit a larger bore tube to be inserted. The
tion, effectively stenting the trachea. This may require risk is losing tracheal access and creating a false pas-
performing a surgical airway through disrupted sage during the procedure. It is also time consuming.
anatomy. If all else fails, an urgent surgical tracheostomy is
required. This is the lesser option as it too is time
consuming and requires a skilled operator and ade-
quate instrumentation. The procedure should ideally
57.6.4 Severe Brain Injury be undertaken in an operating theatre. The degree of
urgency will of course dictate to what extent the con-
Traumatic brain injury is the commonest indication ditions can be optimised to perform a tracheostomy.
for a definitive airway in the injured patient. The Note that the trachea in the short or no necked patient
aims of a definitive airway are to oxygenate and ven- may commence close to the thoracic inlet near the
tilate, whilst avoiding further insults that contribute sternal notch. In this situation, the trachea is not only
to secondary brain injury. Specifically, hyperventila- lower but more posterior in the neck than usual.
tion, hypoxia, hypercarbia and intracranial hyperten- Once again, a cricothyroidotomy is the preferred
sion are to a lesser or greater extent regulated by route for a definitive airway if endo-tracheal intuba-
oxygenation and ventilation. How effectively the air- tion fails.
way and subsequently ventilation are controlled are
important determinants of the risk of secondary brain
injury.
57.7 Failures in Airway Management

57.6.5 Anatomy Unsuccessful airway management results from cogni-

tive and procedural factors. Cognitive factors include
The patient’s anatomy and body habitus can some- failed or delayed recognition of a compromised airway,
times preclude easy access to the airway. A thick and indecision or misjudgement regarding choice of airway
57 Airway Management: A Surgical Perspective
intervention, not adhering to an airway management
protocol or algorithm and failure to recognise or man-
age complications arising from airway interventions.
Procedural failures result from inadequate skill and
experience, a misplaced airway tube (e.g. oesophageal
intubation), inability to intubate, inability to ventilate,
failure to maintain a secure airway and failure to pro-
tect the airway from aspiration. Procedural failures
may primarily be a reflection of the underlying airway
pathology (e.g. short neck, disrupted laryngotracheal
airway) and not from lack of operator competence. For
the experienced and inexperienced, familiarity of the
risks and pitfalls in airway management is an impor-
tant step in avoiding those situations that can result in a
preventable death.
481
Recommended Reading
American College of Surgeons Committee on Trauma: Advanced
Trauma Life Support for Doctors: Student Course Manual,
8th edn. American College of Surgeons, Chicago (2008)
Dorges, V.: Airway management in emergency situations. Best
Pract. Res. Clin. Anaesthesiol. 19(4), 699–715 (2005)
Fowler, R.A., Pearl, R.G.: The airway – emergent management for
non-anesthesiologists. West. J. Med. 176(1), 45–50 (2002)
Kummer, C., Netto, F.S., Rizoli, S., Yee, D.: A review of traumatic
airway injuries: potential implications for airway assessment
and management injury. Int. J. Care Injured 38, 27–33 (2007)
Lecky, F., Bryden, D., Little, R., Tong, N., Moulton, C.:
Emergency intubation for acutely ill and injured patients
(Review). Cochrane Database Syst. Rev. (3), (2009)
Toschlog, E.A., Sagraves, S.G., Rotondo, M.F.: Airway control.
In: Feliciano, D.V., Mattox, K.L., Moore, E.E. (eds.) Trauma,
Chap. 12, 6th edn. McGraw-Hill, New York (2008)
 Management of the Severely Injured
58
Adrian Anthony

58.1 Introduction victim, while also establishing a health-care system that

facilitates the coordination of trauma care. The complex
disruption to anatomy and physiology caused by injury
Injury is one of the most common diseases to afflict
necessitates a multidisciplinary approach to trauma
humans throughout time. Arguably, no other patient
management. The front line role of the surgeon in this
demands immediate attention, challenges surgical
regard is self-evident, even understanding that 60% of
decision making and consumes significant resources
injured patients do not require operative intervention.
as much as one who is severely injured. Survival
Furthermore, it is not unreasonable that the surgeon
depends very much upon intervention being timely,
assumes the lead role in trauma management particu-
systematic and coordinated. As a multi-system disease
larly in the regional, rural or remote setting. There is
arising largely from circumstance and behaviour,
no expectation that the surgeon should bear sole
injury should be predictable and preventable, and
responsibility or work in isolation in trauma manage-
indeed advances have been made in trauma prevention
ment, but the ubiquitous nature of trauma dictates that
and management with improved outcomes. In spite of
the individual surgeon be knowledgeable and skilled
this, injury remains a chronic public health epidemic
in early trauma management, whether working in a
affecting a staggering 18% of the Australian popula-
tertiary metropolitan trauma centre or as a remote solo
tion each year. The social and economic burden of
practitioner. Indeed, the surgeon working with limited
injury is enormous and trauma continues to feature
support and resources, or who infrequently encounters
prominently as a leading cause of mortality, morbidity
the injured patient, is likely to benefit most from pos-
and long-term disability, most notably among the
sessing essential and broad-based skills in early trauma
young and fit.
management. Far fewer surgeons are required to be
Deaths from trauma occur in a well-recognised tri-
trauma specialists who work in designated trauma cen-
modal distribution (Fig. 58.1). Only strategies aimed at
tres. Indeed, it is estimated that less than 15% of injured
preventing injuries can realistically reduce deaths that
occur immediately after or within minutes of trauma.
These deaths result from injuries considered incompat- Mortality
ible with life. Deaths that occur in the hours or days and
in the weeks subsequent to trauma, however, may be
prevented through judicious resuscitation and early
management strategies. Such strategies have evolved to
focus on the individual skills of those treating the trauma

A. Anthony minutes hours weeks - months

Department of Surgery, The Queen Elizabeth Hospital, Time
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: adrian.anthony@adelaide.edu.au Fig. 58.1 Tri-modal distribution of injury-related mortality

M.W. Wichmann et al. (eds.), Rural Surgery, 483

DOI: 10.1007/978-3-540-78680-1_58, © Springer-Verlag Berlin Heidelberg 2011
484
patients require care at a dedicated trauma centre. What
is critical in the rural context is the establishment of
functional links between non-trauma facilities and rec-
ognised trauma centres.
58.2 Challenges in Rural Trauma Care
Australia is a highly urbanised society with 88% of its
population living in major metropolitan centres. The
remaining 12% represent a significant minority who
are sparsely and widely distributed in non-metropolitan
locations. This is reflected in population densities of
less than 1 person per square kilometre for much
of Australia, while the average population density of
2.7 persons per square kilometre is one of the lowest in
the world. Because large distances frequently separate
non-metropolitan communities from each other and
from major cities, social and essential services includ-
ing medical care are widely dispersed and can be
­difficult to access. The terms ‘regional’, ‘rural’ and
‘remote’ are often used interchangeably but each may
also describe varying degrees of rurality based on pop-
ulation density and accessibility to services. There are
various definitions to categorise non-urban communi-
ties and, in broad terms, a ‘regional’ centre is one with
a population over 25,000 with good access to many but
not necessarily all community services, a ‘rural’ centre
has a population under 25,000 with reduced access to
services and a ‘remote’ centre has a population fewer
than 5,000 and with significantly restricted access to
services. This differentiation is important when con-
sidering why, in rural Australia, the rate of injury is
half that of metropolitan centres, while the associated
mortality rate is twice as high. Precisely what aspects
of accessibility and sophistication of trauma care
diminish with increasing rurality? Several factors not
unique to, but relevant to the rural setting, need to be
better understood (Table 58.1). Two key factors directly
impact on the rate of preventable deaths. They are: the
time to definitive care and the quality and sophistica-
tion of trauma care.
58.2.1 Time to Definitive Care
Any delay in definitive care carries the risk of worsening
both the severity of injury and an adverse outcome. In a
remote setting, delays can be expected for several
A. Anthony
Table 58.1 Factors affecting trauma outcomes in the rural
setting
Delay in patient discovery
Poor vehicular access
Hostile geography and terrain
Low population density
Sparsely distributed medical resources
Limited specialist medical personnel
Prolonged on-scene time
Prolonged time to definitive care
Long transportation distances
Limited trauma care resources and capabilities
Inadequate resuscitation
Delay in diagnoses
Inadequate patient escort during inter-hospital transfers
Limited training and experience of pre-hospital and hospital
personnel
Fragmented trauma management system
Unreliable communication systems
reasons. An injured patient may remain undiscovered for
some time. Communication systems to summon assis-
tance may be unreliable or ineffective. There may not be
pre-existing lines of communication to coordinate pre-
hospital and inter-hospital care. The physical environ-
ment and terrain may hinder easy access to the injured
patient, and distances travelled to definitive care are
indeed large. The most appropriate mode of transporta-
tion may not be immediately available. This is important
because rapid patient transport over large distances can
be achieved with various forms of air transport. In this
regard, distance per se is not the sole determinant of the
time lapse between injury and definitive care. This is not
to ignore the fact that geographical distance in the rural
setting may play a significant role in the ability of injured
patients to access definitive trauma care in a timely man-
ner. So much so, that the imperative of commencing
definitive care within the ‘golden hour’ becomes an
unrealistic and unattainable goal in many rural settings.
58.2.2 Quality of Trauma Care
The quality and sophistication of care provided during
various phases of injury management also influences
58 Management of the Severely Injured
the number of preventable deaths. The ability to pro-
vide effective trauma care is determined, to a large
extent, by appropriate training, exposure and experi-
ence, opportunity to develop and maintain skills and
availability of appropriate resources. In practical terms,
this translates to specialists trained and experienced in
trauma care, 24-h access to laboratory for blood test-
ing, radiology services including ultrasound and com-
puter tomography, a blood transfusion service, surgical
and anaesthetic services and the ability to maintain
ventilated patients. The number of specialist consul-
tants per head of population is lower in the rural sector
than in metropolitan centres. In the rural setting, per-
sonnel involved in both pre-hospital and hospital
trauma care are more likely to have had limited and
less advanced training and experience, have sporadic
exposure to injured patients, minimal opportunities for
skill maintenance and have access to a limited or rudi-
mentary range of resources. The incidence of inade-
quate and prolonged on-scene resuscitation, failure to
recognise injuries and provide early intervention and
difficulties in accurately triaging patients are corre-
spondingly higher. The problem is compounded when
injured patients are first transferred long distances to a
primary treatment facility before a secondary, pro-
tracted transfer to reach definitive care. On occasions,
the severity of a patient’s injury would normally require
a doctor to accompany the patient during secondary
transfer. A suitably skilled and experienced escort is
less likely to occur in the rural setting. Rural hospitals
also vary considerably in their capability to provide
trauma care. The more remote the health service, the
lesser its resource allocation, the lower its ability to
provide a coordinated, sophisticated and specialist
approach to trauma care and the more restricted its
access to definitive trauma care.
Many of these challenges can be addressed if a
coordinated, integrated and collaborative approach is
taken in determining how best trauma care can be
delivered in the rural environment.
58.3 Models of Trauma Care
The contemporary approach to trauma care in many
countries was born largely from the American experi-
ence during the Korean and Vietnam wars. These
experiences demonstrated improved survival rates with
485
rapid transport of casualties from the battlefield to
a forward definitive surgical facility. Adopting this
­concept of trauma care has similarly improved injury
survival in the civilian context. Trauma care in many
developed countries has since evolved into a sophisti-
cated and organised system, requiring multi-organisational
and government involvement. Trauma care should,
ideally, be integrated as part of the public health sys-
tem. The ultimate goal of developing a functional
model of trauma care is to enhance the community’s
health.
Effective trauma care systems have consistently
been shown to improve injury survival by lowering the
preventable death rate. There is no evidence that one
trauma care system is superior to another. What is
important is that models of trauma care are developed
and adapted to the unique circumstances of the geogra-
phy and population. That is, there must be a high level
of integration between metropolitan and rural trauma
services, sufficient to accommodate for the sparseness
of the population, dispersed resources and the vast
areas that must be serviced. Furthermore, the approach
to trauma care services provided in metropolitan
regions, both pre-hospital and hospital, can be expected
to be vastly different to what may be achievable in the
rural sector.
In general terms, an effective trauma care system
addresses injury prevention, pre-hospital care, hospital
care and rehabilitation (Table 58.2). Successful inte-
gration of these major components within a system
relies on the critical pillars of education and training,
efficient communication systems, reliable triage and
transfer systems, the ability to audit and research per-
formances and outcomes and a governance structure
that oversees rational distribution of resources and
effective coordination of the entire system. A useful
measure of a system’s efficacy over time is the achieve-
ment of a low preventable death rate nearing 1–2%.
58.3.1 Injury Prevention
Only the prevention of injury is able to avoid deaths
that occur immediately or shortly after trauma. Such
injuries are considered universally fatal and account
for 50% of injury-related mortality. As such, signifi-
cant improvements in injury rates and associated mor-
bidity and mortality can be achieved through injury
486 A. Anthony

Table 58.2 Trauma care model

Phases of injury management Components of trauma care Essential support processes
Prevention Injury prevention programmes Registry and audit
Pre-hospital care Pre-hospital care Research
Trauma retrieval service Education and training
Triage system Communication
Transport protocol Resource and system coordination
Hospital care Hospital trauma response Public health policy
• Pre-hospital preparation Legislation
• Resuscitation and stabilisation Political and clinical governance
• Definitive management
• Management of complications
• Transfer protocol
Rehabilitation Rehabilitation programmes

prevention. Effective injury prevention seeks to modify Table 58.3 Examples of injury prevention interventions
behaviour and the physical environment. Social, cul- Legislation or public Influence environment/
tural and political dimensions influence the shape of health policy behaviour
injury prevention programmes for any given society. Transportation Environment and behaviour
Successful programmes are usually founded in legisla- • Seat belt
tion and linked to long-term public interventions
• Bicycle and m
­ otorcycle
(Table 58.3). The persistent challenge is the ability to helmet
enforce such legislation, particularly when the inter-
• Speed limit
vention relies on influencing standards of behaviour
(e.g. wearing seat belts, driving within the speed limit, • Drink driving
work place practices). Enforcing such interventions • Vehicle safety
becomes more problematic in sparsely populated • Road surface safety
places.
• Driver education
• Driver restrictions
Compulsory pool fencing Environment
58.3.2 Pre-hospital Care Gun licensing Environment and behaviour
Domestic smoke alarms Environment
The pre-hospital phase of injury management is per-
Work place safety Environment and behaviour
formed by the ambulance service. The objective of
pre-hospital care is to transport the injured patient as Competitive and Environment and behaviour
safely and as quickly as possible to the nearest and ­professional sports rules,
policies and regulations
most appropriate hospital. The initial resuscitation and
immobilisation must be prompt and be practical to Mental health policy Environment and behaviour
­perform in the field. Although life-preserving mea-
sures are taken against immediate threats to life, treat- of avoiding unnecessary delays in patient transfer. The
ment must also be aimed at preventing secondary sooner the patient is delivered within the ‘golden hour’
problems or injuries that may occur at a later time. All to a hospital for definitive care, the better the chances
the while, the pre-hospital personnel must be cognisant of survival.
58 Management of the Severely Injured
Within the pre-hospital phase of care, the time to
on-scene intervention, the quality of the intervention,
the decision as to which is the closest and most appro-
priate hospital to offer definitive care, the time to taken
to reach definitive care, the quality of care during
transportation and the ability to seamlessly continue
care at the receiving hospital are all critical determi-
nants of patient survival. Within an urbanised popula-
tion, the time between injury and on-scene medical
intervention is generally within 10 min, and delivery of
the patient to a hospital within 30 min of injury. In situ-
ations where the patient can be delivered to definitive
care within a relatively short time, it is appropriate to
adopt a ‘scoop and run’ approach. The pre-hospital
personnel provide basic life support measures consist-
ing of non-invasive airway management and security,
protection of the cervical spine, manual ventilatory
support if necessary, control of external haemorrhage
and full immobilisation of the patient including that of
fractures. Rapid pre-hospital response becomes less
achievable in more sparsely populated areas. In some
instances, the location of an accident prohibits easy
vehicular access and may require a rescue team to walk
in or be airlifted to the scene. Transportation may be
by any combination of road, off-road, air or by foot.
Under these circumstances, resuscitating and stabilis-
ing the patient for extrication to hospital can be
extremely challenging. An effective pre-hospital res­
ponse requires a high level of coordination, reliance on
effective communication systems, and availability of
various transportation modes and highly trained per-
sonnel with a wide range of skills. Basic life support
measures may be inadequate to sustain the patient dur-
ing a protracted journey to hospital. Instead, the patient
may require advanced life support consisting of air-
way intubation and mechanical ventilation, intrave-
nous fluid resuscitation and even chest drain ­insertion.
In the urban setting, ambulance personnel possess, at
the very least, basic life support skills. An increasing
number will also have been trained in advanced life
support skills and be able to intubate an airway, gain
intravenous access, administer a limited range of drugs
and undertake some invasive life-saving procedures.
By contrast, there are fewer rural paramedics and
ambulance personnel trained to an advanced level of
pre-hospital trauma care, although there is arguably a
greater need for advanced life support measures in the
rural setting. In many instances, volunteers with lim-
ited training and experience make up for the shortage
487
of professional ambulance personnel. Coupled with
infrequent exposure to injured patients and ­limited equip-
ment and resources, trauma management practices in
many rural locations are less well rehearsed. Under
these circumstances, it is difficult to deliver a consis-
tently high standard of pre-hospital care.
Pre-hospital personnel are also required to triage
patients and determine the most appropriate and clos-
est hospital to transport the patient. Triage refers not
only to prioritising the treatment of single or multiple
casualties, but to which hospital any given patient
should be transported. Importantly, the receiving hos-
pital should be one that is capable of managing the
injuries sustained by the patient. There is good evi-
dence that bypassing the nearest hospital for the most
appropriate facility improves patient survival. In the
rural context, however, this principle is not always
practical to adhere to when the most appropriate hospi-
tal is a substantial distance away and arranging retrieval
to a designated trauma hospital requires time. It may
therefore be more appropriate to stage the transfer by
initiating early assessment, resuscitation and stabilisa-
tion at the nearest hospital before a secondary transfer
to a designated trauma care hospital. The quality of
care during secondary transfer from rural sites varies
considerably and is an additional and important deter-
minant of survival. In some jurisdictions, trauma care
systems have been developed to allow medical teams
from a designated trauma care facility to retrieve the
severely injured patient, either directly from an acci-
dent scene or from a hospital. Although the process
inherently consumes time, and is expensive, it does
expedite the delivery of pre-hospital and definitive
care using well-trained personnel. In much of rural
Australia, the Royal Flying Doctor service has become
an integral part of pre-hospital care and trauma retrieval
service. In some regions, private aero-medical retrieval
organisations also fulfil this role.
The transition between the pre-hospital and hospital
phases of care necessitates clear and precise commu­
nication. The pre-hospital personnel are responsible
for providing a standard set of information to the
receiving hospital. This includes the nature of the trau-
matic incident, the number of casualties, the patient’s
approximate age and gender, a summary of the patient’s
vital functions, a list of known injuries, treatment given
and the estimated time of arrival at the hospital. The
hospital is able to provide advice to pre-hospital per-
sonnel if necessary, to prepare for the patient’s arrival
488 A. Anthony

and to help triage and anticipate the care of one or to adequately prepare for the arrival of an injured
more injured patients. The pre-hospital information patient. It is recognised that triage assessments are not
may pre-empt arrangements for a secondary transfer at without limitations. Information may be difficult to
the earliest possible moment. Upon delivery of the obtain or verify and some criteria require subjective
patient to hospital, the pre-hospital personnel should assessments under stressful conditions and in a limited
provide documented information of the patient’s timeframe. Injury presents a dynamic situation with
­condition and treatment. The documentation should changing anatomical and physiological dysfunctions.
be standardised to allow easy review and interpretation All these factors affect the inter-observer and intra-
by hospital personnel. This information may prove to observer reliability of triage systems. Under-triage
be vital at any time during the patient’s hospital stay. occurs when there is an underestimation of injury
severity, or when there is overestimation of the resources
and capabilities of the hospital to which the patient is
transported. Under-triage has the potential to result in
58.3.3 Pre-hospital Triage increased morbidity and preventable mortality. Over-
triage occurs when injury severity is overestimated or
Triage is the process of prioritising the care of patients there is underestimation of a hospital’s capability to
based on an initial assessment. Pre-hospital triage manage the patient. Although over-triage is less likely
requires an assessment of the patient’s injuries before to increase morbidity and mortality, it may unduly bur-
deciding which is the most appropriate hospital that den a hospital with patients who could have been man-
will provide definitive care. Because resources are aged elsewhere and is therefore an inefficient use of
finite, a key principle of triage is to selectively match resources. Over-triage may also prolong the transpor-
individual patients to trauma care facilities best able to tation time, adding to the risk of preventable morbidity
meet the needs of any given patient, thereby enabling and mortality. The need to accurately determine which
all patients in a trauma care system to receive the hospital is able to provide definitive care for a given
appropriate level of care. There are numerous pre-­ severity of injury is most relevant in an urbanised
hospital triage systems in use and the decision making trauma management system. In a rural setting where
derived from triage assessments varies according to only one hospital facility may exist, deciding which
regional differences in resources and operational hospital a patient is to be transported is pre-determined.
­processes. Triage systems are intended to be simple to However, accurate triage assessment remains impor-
implement and applicable to all types of injuries, but tant in the early identification of those patients who
require personnel to be appropriately trained and expe- may require secondary transfer to a distant hospital for
rienced to achieve consistently accurate assessments. definitive care.
There is no consensus to support the use of one triage Whether a pre-hospital triage system is effective can
system over another. It is, however, important that one be measured by correlating triage assessment grades or
triage system be agreed to within a trauma care service scores with in-hospital injury severity scores and out-
and both pre-hospital and hospital personnel are famil- comes. Notwithstanding differences in the various
iar with the specific triage criteria for the system in ­in-hospital injury severity scoring systems, triage scores
use. Assessment of triage criteria should be practised that predict for mild injury should correlate with low
and triage assessment should be part of the informa- morbidity and mortality whilst triage scores that predict
tion communicated to hospitals. Triage assessments for more severe injuries are associated with increased
arrive at a quantifiable grade of injury severity, most morbidity and mortality. Furthermore, retrospective
commonly based on scoring the anatomical extent of review of pre-hospital triage scores can be undertaken
injury, the physiological disruption from injury and the to determine the rates of under-triage and over-triage.
mechanism of injury. Some triage criteria include The acceptable rate of underestimating the severity of
information about a patient’s co-morbidities, age and injury is less than 1% and that of overestimating the
time to definitive care (Table 58.4). Triage assessment capabilities of the hospital is less than 10%.
not only assists pre-hospital personnel to prioritise There are different emphases of triage assessment
care, it helps predict and anticipate the likelihood of when dealing with a single patient, with multiple patients
morbidity and mortality and allows hospital personnel or with mass casualties. For a single patient, triage
58 Management of the Severely Injured 489

Table 58.4 Pre-hospital triage criteria

Physiological parameters
• Quantifiable measurement of vital physiological functions
• Degree of deviation from normal correlates with injury severity
• Alterations in physiology may take time to evolve or may not be immediately evident
Anatomical disruption
• Visual assessment of external injuries
• Internal injuries less likely to be quantified
• May anticipate anatomical disruption from mechanism of injury
Mechanism of injury
• Mechanism and force of injury predicts likelihood and severity of injury
Age and co-morbidities
• Age and chronic disease states increases risk of injury-related morbidity and mortality
• Co-morbidities may be difficult to ascertain
Time to definitive care
• Prolonged pre-hospital and transportation times (>30 min) correlate with poorer survival outcomes
Pre-hospital triage systems Physiological Anatomical Mechanism Age Co-morbidities Time to treatment
parameters assessment of injury
Trauma index (TI)   
Glasgow coma score (GCS) 
Triage index (TI) 
Trauma score (TS) 
Revised trauma score (RTS) 
Trauma triage rule (TTR)   
Circulation respiratory  
abdominal/thoracic, motor
and speech (CRAMS Scale)
Pre-hospital index (PHI)    
Pre-transport index (PTI)     
Simple triage and rapid  
transport (START) – decision
algorithm
American College Surgeons     
Field triage system (FTS) –
decision algorithm

helps categorise the severity of injuries, guide the
urgency of intervention and identify the hospital most
capable of managing the patient. For multiple patients,
triage relies on assessing each patient, prioritising the
order in which patients will receive definitive care,
deciding which hospital is best able to manage each
patient, determining how many patients a hospital is
able to cope with and ensuring there are ­sufficient
resources to transport patients in a timely ­manner. The
most appropriate hospital is determined by the hospi-
tal’s capability and capacity and the transportation
time to reach the hospital. Severely injured patients
will be taken immediately to a designated trauma centre
whilst the patient with less severe injuries may be
490
transported with less urgency to a hospital with lower
but adequate trauma management resources. The dis-
tribution of multiple patients based on the principle of
capability and capacity is appropriate and desirable to
minimise preventable deaths and avoid overloading any
given hospital. In contrast, trauma management resources
are overwhelmed in an incident resulting in mass casual-
ties. The time and resources expended in managing those
with severe injuries would preclude effective manage-
ment of patients with less severe injuries. The associated
rate of preventable morbidity and mortality in this latter
group of patients would be significant. Accordingly, tri-
age of mass casualties focuses on identifying and prior-
itising care for those patients who have the highest
probability of survival. The most severely injured
patients with the least chances of survival are given a
lower priority of care for the sake of saving the greatest
possible number of patients. This is a difficult and emo-
tionally challenging task best undertaken by experi-
enced, appropriately trained personnel, working in a
medical triage team that is well rehearsed in implement-
ing pre-defined triage algorithms.
In the rural context, the principles of mass casualty
triage may need to be applied whenever the number
of injured patients far exceeds the available local
resources. This may occur with even relatively low
numbers of injured patients. The lack of resources
may be offset by mobilising assistance from outside
the region and by rapid mass transfer of patients to
centres able to provide definitive care. The rural hospi-
tal may need to act as a triage point whilst stabilising
patients as best as possible prior to transfer. As in any
other setting, to what extent a rural hospital is capable
of providing definitive care and for how many is deter-
mined by its resources and personnel. Patients with
needs that exceed a hospital’s capability and, or capac-
ity should be transferred to an appropriately resourced
hospital. Clear communication, efficient coordination,
a high level of cooperation and clear triage and trans-
fer protocols are required to effectively manage such
situations.
58.3.4 Hospital Triage
A hospital triage assessment helps to confirm or
­re-prioritise the needs of the patient upon admission.
It complements the pre-hospital triage assessment,
A. Anthony
predicts the likely resources required to manage the
patient and helps plan for definitive care. Without a
hospital triage system, resources and personnel risk
being either under- or overutilised with an adverse
affect on patient outcome. Hospital triage systems
mirror systems used for pre-hospital triage.
In rural hospitals, the ability to predict the likely
resources required to manage a set of injuries is par-
ticularly important. Assuming that the demands of a
severely injured patient would exceed the capabilities
of the hospital in providing definitive care, hospital
­triage criteria should be useful in predicting which
patients may be categorised as severely injured to
prompt early referral and transfer of the patient to a
major trauma care facility. There are various injury
severity scoring systems that have been developed to
compare injury severity with outcomes. These scoring
systems use similar criteria to that of triage scores and
incorporate a range of additional data. There are, how-
ever, a number of problems in quantifying injury sever-
ity using such scoring systems. First, there is no single
standard set of criteria to define major or severe inju-
ries. Even when using the same scoring system, vari-
ous facilities apply different scores to define severe
injury. Second, there are numerous scoring systems
that use various criteria, which may or may not be
comparable to the pre-hospital triage criteria being
used. This raises problems in comparing categories of
injuries to pre-hospital triage scores when auditing
outcomes. Third, scoring systems to define injury
severity are frequently reliant on retrospective analysis
of clinical and other information. This precludes the
use of injury severity scores in identifying which
patients would benefit from prompt transfer to a major
trauma hospital. Given these limitations, it would be
appropriate to agree upon what triage score should
reflect a major or severe injury and to rely on triage
assessments to predict injury severity. Familiarity and
experience in undertaking hospital triage assessment
greatly enhance the reliability of triage criteria.
58.3.5 Patient Transport and Transfers
The primary transfer of a patient from the accident
scene to a hospital is a critical step in trauma manage-
ment. The aim of the primary transfer is to safely trans-
port the patient to the nearest and most appropriate
58 Management of the Severely Injured
Table 58.5 Factors determining safe and effective patient transfer
Identification of all injuries
Accurate assessment of injury severity
Adequate and ongoing resuscitation and stabilisation
Early decision for transfer
Skilled and experienced personnel
Appropriate equipment for safe transfer
Appropriate mode of transportation
Communication with receiving hospital
Use of pre-defined transfer criteria and protocol
hospital in the shortest possible time. A successful
­primary transfer is predicated by accurate triage assess-
ment, distance and time to the receiving hospital, mode
of transportation, quality of patient care during transit
and the preparedness of hospital personnel in receiving
the patient (Table 58.5). If a secondary transfer to
another hospital is required for the patient to receive
definitive care, similar principles that determine a suc-
cessful primary transfer apply.
The rural environment poses a number of chal-
lenges for both primary and secondary transfers.
Firstly, the proportion of patients needing secondary
transfers can be expected to be higher in the rural sec-
tor compared to a similar cohort of patients in urbanised
centres. Secondly, resources for all forms of emer-
gency patient transport are costly, concentrated in few
locations, service a large geographical area and are in
high demand. Road transport remains the most com-
mon mode of transferring patients and is suitable when
patients are within 30 min from definitive care.
However, poor roads, inaccessible terrain, the large
distance and prolonged time to definitive care are
impediments to safe and timely patient transport. Fixed
wing or rotary aircraft, whether combined with road
transport, may be the preferred or only mode of patient
transfer in many instances. Deploying air transport is
conditional upon suitable climatic conditions, an
accessible and safe landing and takeoff site and avail-
ability of aircraft. The distance to be travelled, and the
time taken, must be carefully considered. In general,
rotary air transport is confined to distances under
400-km return trip and is suitable when there is no
landing strip for fixed wing aircraft. Fixed wing aircraft
travel longer distances and may carry multiple patients
but requires a suitable landing strip in proximity to the
491
patient. Whether by road or air, the need for transfer
protocols, effective communication and a high level of
logistical coordination are prerequisites for safe trans-
fer processes in the rural context.
In non-urbanised locations, several primary and
secondary transfer scenarios may apply (Fig. 58.2). In
many situations, an injured patient can be transported
to the nearest hospital for definitive care and without
need for a secondary transfer. When a secondary trans-
fer is necessary, prompt arrangements should be made
for a designated trauma care centre to receive the
patient. Under other circumstances, the patient is trans-
ferred directly from the accident scene to a designated
trauma care centre. This may occur if there is no local
hospital, if the local hospital is unable to provide any
level of trauma care, if the accident scene is so remote
from a local hospital that it is more efficient for the
patient to be transported directly to a designated trauma
centre, or if the injuries are of a magnitude that it is
imperative the patient bypasses the local hospital en
route to a trauma centre.
Whether the primary or secondary transfer to a des-
ignated trauma centre is provided by the local hospital
or the receiving facility is dependent upon the resources
and capabilities of the local hospital, the injuries of the
patient, the distance and time to the receiving hospital
and the availability of the preferred mode of transpor-
tation. For example, for the patient requiring expert
trauma care in transit and, or who is to travel by air, the
receiving hospital may dispatch a trauma retrieval team
to permit the safe transfer of the patient.
Much has been made of the quality of patient care
during transportation, particularly during secondary
transfers. It must be recognised that caring for a criti-
cally ill patient in a cramped, noisy, poorly illuminated,
uncomfortable and physically disruptive environment
requires a high level of skill and experience. Suboptimal
outcomes result primarily from failure to recognise the
severity of injuries, inadequate diagnosis, investigation
and management of critical injuries, inadequate resus-
citation and stabilisation of the patient during transpor-
tation and poor communication of relevant information.
These factors are largely dependent on the skill and
experience of personnel providing the pre-transfer and
in-transit care. Poor outcomes are compounded by the
lack of appropriate equipment to help provide in-­transit
care and delays in completing the transfer. Delays in
transport can be minimised if there is early recognition
of the need for secondary transfer, prompt initiation of
492 A. Anthony

Fig. 58.2 Patient transfer a P

b P
scenarios: remote from Legend
trauma centre. (a) Patient
retrieved by local hospital LH LH P Patient
may require transfer to
trauma centre due to injury
severity. (b) Patient retrieved
by local hospital, transported LH Local hospital

directly to trauma centre due

to injury severity and/or
distance back to local
hospital. (c) Patient retrieved
by trauma centre due to
remoteness and/or absence of
local hospital. (d) Trauma
centre retrieves patient from
local hospital due to injury
severity and lack of
c d
appropriate transfer resources
at local hospital
TC TC
TC Trauma centre
Patient retrieved by local Patient retrieved by local
hospital, may require hospital, transported
transfer to trauma centre directly to trauma centre
Primary transportation
due to injury severity due to injury severity and/or
distance back to local
hospital.
Secondary transfer
P P

LH

TC TC

Patient retrieved by Trauma centre retrieves

trauma centre due to patient from local hospital
remoteness and/or absence due to injury severity and
of local hospital. lack of appropriate transfer
resources at local hospital.

the transfer, ready access to the preferred mode of
transportation and a system that permits a coordinated
and orderly execution of a transfer. Many of the factors
that impact on the quality of patient transfer remain
unquantified due to the lack of an effective audit
process.
58.3.6 Transfer Protocols
Whenever a transfer occurs, there should be a clear
reason for the need of a transfer and the benefits of a
transfer should outweigh the associated risks. Transfer
protocols are aimed at optimising patient outcomes by
specifying under what conditions a transfer should
occur, by what means and with what resources. Such
protocols greatly facilitate secondary transfers and
should be tailored to the environment they are intended
for. Transfer protocols may rely on three sets of cri­
teria upon which to base a decision for a transfer.
Patient-related criteria define the type and severity of
injury and the number of patients involved. Hospital-
related criteria outline at what level a hospital is able to
provide care necessary for the type and severity of
injury. In particular, hospital-related criteria are impor-
tant in establishing how well resourced a hospital is in
order to resuscitate and stabilise a patient, to undertake
radiological and other investigations, to provide for a
range of clinical services, to provide for trained and
experienced personnel and to manage the secondary
transfer of patients. Transport-related criteria define
the preferred mode of transportation, the appropriate
number of personnel to accompany the patient, what
expertise personnel should have, what equipment is
necessary for safe patient transport and to which
trauma care facility patients are transferred. Transport-
related criteria should take into account geographical
factors that impact on patient transport, including the
distance and time to complete a secondary transfer
and whether a specialist trauma retrieval team should
be dispatched from the designated trauma centre to
58 Management of the Severely Injured
manage the secondary transfer. Transfer protocols should
also adopt a number of guiding principles. These
include identification of the need for transfer at the ear-
liest possible time, selection of the most appropriate
mode of transportation, adequate resuscitation and sta-
bilisation of the patient prior to, and during transfers,
availability of appropriate equipment and personnel to
maintain the care of the patient during transit, mini-
mising delays in the transfer process by a coordinated
approach and preparedness of the designated trauma
centre to receive the patient. Importantly, protocols
should facilitate communication between the hospital
seeking to transfer a patient and the accepting or des-
ignated trauma centre such that discussions, advice,
mutual understanding and mutually agreed decisions
occur without hindrance. The evidence clearly suggests
that, in the rural setting, departing from practices out-
lined in transfer protocols results in an increased rate
of preventable deaths.
58.3.7 Trauma Care Facilities
The majority of traumatic injuries are not severe.
Severe injuries are less frequent but account for a high
percentage of morbidity and mortality. It is therefore
appropriate, and indeed necessary to concentrate the
management of severe injuries to trauma centres capable
of managing complex trauma pathology. This improves
outcomes in a sustainable, efficient and cost-effective
way. Within most circumstances, relatively few spe-
cialist, or major, trauma centres are required and these
centres sit comfortably in urban populations. To maxi-
mise efficiency in the system, it is also necessary that
less severely injured patients be managed in hospitals
other than those designated as major trauma centres.
An acceptable approach has been to establish a tiered
structure of trauma care facilities, differentiating hos-
pitals based on the ability to manage increasingly
severe and complex injuries (Table 58.6). The com-
monly used four-level classification system readily
identifies a hospital’s capabilities and allows an
informed decision on patient disposition based on the
pre-hospital triage. A level 1 trauma care centre is
resourced with a full range of specialty and support
services, provides around-the-clock definitive care for
all types and severities of injuries and incorporates
trauma education, training and research programmes.
493
Table 58.6 Designated levels of trauma care hospitals
Trauma care Capabilities
level
1 Full range of diagnostic and
interventional capabilities
Full range of medical, surgical and critical
care services
Specialised trauma unit
Dedicated trauma research, education and
training
Liaises with and assists lower level
trauma care hospitals
2 Similar capabilities to level 1 trauma care
facility
May not have full range of definitive care
services (e.g. spinal injury unit, burns
unit)
May not have dedicated trauma research
and education
3 Initial resuscitation and stabilisation of
major trauma
Capable of definitive surgical intervention
for some injuries
Limited specialist expertise
Established transfer agreements and
protocols with level 1 and 2 hospitals
4 Initial resuscitation and stabilisation of
major trauma
Limited or no definitive surgical
capability
Established transfer agreements and
protocols with level 1 and 2 hospitals
A level 2 facility has similar capabilities but without
the entire breadth of clinical services. It may or may
not engage in systematic trauma education and
research. A level 3 hospital can provide definitive sur-
gical care for some injuries but will need to stabilise
and transfer patients with injuries whose management
exceeds the capability of the hospital. A level 4 hospi-
tal would not normally have resident specialty and sur-
gical services. It may or may not be able to provide
definitive surgical care, and only for a limited range of
injuries. For any significant injuries, the focus for a
level 4 facility is on early management, stabilisation
and prompt transfer. Importantly, level 3 and 4 centres
rely on being supported by level 1 and 2 centres in
494
accepting secondary transfers. It is therefore impera-
tive that level 3 and 4 trauma care hospitals have well-
developed triage and transfer protocols. Furthermore,
pre-hospital personnel must become proficient in pre-
hospital triage and be familiar with the designated
trauma classification of various hospitals to ensure
appropriate decisions are made in where any given
injured patient should be transported to. Therefore,
where possible, patients with major injuries should
bypass level 3 and 4 hospitals for level 1 or 2 centres,
whilst those patients who can be managed in level 3 or
4 centres should be taken to these hospitals if time and
distance to travel permit. The evidence consistently
supports such an inter-dependent and integrated sys-
tem of trauma care centres. In particular, this system
works well in major cities where only a few hospitals
receive all the severely injured patients, whilst less
severely injured patients can receive definitive care in
the many more level 3 and 4 hospitals.
For rural communities, the capabilities of local
­hospitals vary depending on the size of the population
being serviced. Although some regional hospitals may
only have capabilities of a level 3 trauma centre, the
hospital of a large regional centre may be designated
as a level 2 facility to manage all but the most severe of
injuries. A regional level 2 hospital may be required to
transfer patients to a level 1 centre for specific types of
injuries (e.g. spinal cord, burns, cardiac, paediatric
injuries). These transfers would also occur in metro-
politan settings. Hospitals serving rural and remote
centres are likely to be level 3 or 4 with sufficient capa-
bilities to commence early management and stabilise
the severely injured patient in preparation for a sec-
ondary transfer. In the latter case, the demands of
resuscitating, stabilising and organising a secondary
transfer may still exceed the capabilities of a small
rural hospital, and this should be appreciated by the
hospital accepting the secondary transfer.
58.3.8 Rural Trauma Care Services
Given the disparity in trauma care facilities between
rural and urbanised populations, it is simply not pos-
sible to provide a self-sufficient and totally compre-
hensive trauma care service in the rural sector, akin
to large metropolitan cities. The only practical option
is to integrate rural and metropolitan trauma care
A. Anthony
services. A three-tier system would see level 3 and 4
country hospitals, level 2 hospitals in large regional
areas and level 1 and 2 trauma hospitals in metropoli-
tan centres be vertically integrated. The level 3 and 4
country hospitals would be dependent upon a level 2
regional hospital or a level 1 or 2 metropolitan hospital
for providing definitive trauma care for patients.
Whether a patient is transferred from a country hospi-
tal to a level 2 regional hospital or a level 1 or 2 metro-
politan facility would depend on the injuries sustained,
distances to travel and established transfer protocols.
When necessary, a level 2 regional hospital would refer
injured patients to a level 1 metropolitan trauma cen-
tre. Under such a tiered system, the metropolitan major
trauma care facility takes on the responsibility for
trauma service provision in both the metropolitan and
rural sectors.
It is self-evident that rural communities must rely
on functional relationships with major trauma care
centres in order to access essential trauma care ­services.
Both rural hospitals and major trauma care facilities
take joint responsibility in ensuring this occurs, whilst
the metropolitan level 1 trauma centre is responsible
for supporting all aspects of the trauma care system
including that for the rural sector. How rural trauma
services integrate with metropolitan-based major
trauma centres is a critical issue that many jurisdic-
tions are attempting to understand. A whole of govern-
ment approach is required if designated trauma centres
are to support and, in some situations, assume respon-
sibility for rural trauma care services. An effective sys-
tem to coordinate and deliver trauma care services is
likely to rely on robust communication systems, well-
developed triage, transport and transfer protocols,
appropriately trained and resourced pre-hospital per-
sonnel, trauma retrieval teams, safe and reliable modes
and routes of transport, common educational and train-
ing programmes and a system for collecting and
analysing data on outcomes. All involved should work
cooperatively in overcoming the innumerable barriers
that exist in order to achieve a fully integrated trauma
care service.
As an example, and essential to developing affilia-
tions between rural and metropolitan hospitals, a major
trauma care centre should have an understanding of the
resources, infrastructure and expertise of personnel for
any given rural hospital. Similarly, rural hospitals
should be mutually familiar with the range of services
of one or more designated trauma care centres. Both
58 Management of the Severely Injured
groups should agree upon adopting common triage and
transfer protocols. There should be a dedicated line of
communication such that any rural hospital is able to
directly contact a major trauma care unit to discuss
management, seek opinions and advice, arrange a
transfer or organise a retrieval and enquire about the
outcome of a patient. Communication may be via con-
ventional landline, tele-video conferencing, satellite
links, the internet or a combination of different media.
Education and training of pre-hospital and hospital
personnel, whether working in the rural or metropoli-
tan environment, should be referenced to a common
curriculum. The principles, practices and objectives of
trauma care, and the language used should be common
across various trauma education and training pro-
grammes. Exchange or placement programmes for
pre-hospital and hospital personnel between rural and
metropolitan trauma care services facilitate skill devel-
opment and maintenance and, importantly, a mutual
appreciation of each other’s environment and of each
other. Rural hospitals should be invited to participate
in periodic peer review audit of patient outcomes with
major trauma care centres they have a relationship
with. An inclusive approach to reviewing patient out-
comes identifies what works well in the system and
what needs improvement, fosters collaboration in how
issues are managed, reinforces joint ownership of the
trauma care service, strengthens the affiliation between
a rural hospital and the major trauma unit and works
towards a more seamless integrated service.
58.4 Hospital Trauma Response
In most systems, the first that a hospital is aware of an
impending arrival of an injured patient is when it is
notified by pre-hospital personnel. The notification
should be timely, meaning that it should provide
­sufficient time for the hospital to prepare itself for
receiving the patient. In some systems, the hospital is
alerted at the time an ambulance is dispatched to the
accident scene. The available information is usually
limited at this point but enables the hospital to be on
‘standby’. The hospital subsequently receives further
communication with pre-hospital triage details that
should allow it to escalate its preparedness. Whatever
may be the process of communication, all trauma noti-
fications should come through a designated channel to
495
a designated place and/or person in the hospital. Upon
receipt of notification, the hospital’s trauma response
system should be activated. The aim of a trauma
response system is to enable a coordinated and system-
atic approach to trauma care in order to minimise
errors and omissions, avoid delays in treatment and
avoid confusion in a stressful situation. Activation of
the trauma response system should include alerting
various hospital staff and facilities to be on standby
(e.g. radiology, transfusion service, blood pathology
service, orderlies, clerical staff, operating theatre,
intensive care, pharmacy, social workers and chaplain
services).
58.4.1 The Trauma Team
Central to a trauma response system is the formation
of a trauma team (Table 58.7). This is as relevant in a
small rural hospital as it is in a major trauma care
facility. It is likely that the size, experience and scope
of practice of the trauma team will be different in
a rural hospital compared to a major trauma care cen-
tre. Nevertheless, rural hospitals should consider the
­merits of creating a trauma team as part of its trauma
response. The composition, assigned roles and roster-
ing of the team should be pre-determined, circulated
and updated as required. Each member of the team
should be familiar with their respective roles and the
roles of others. Team members should be trained to
perform their respective tasks. The team should be
familiar with the work environment and the availabil-
ity and location of equipment. New members of the
group should be introduced to the team beforehand
and orientated to the individual roles and that of the
team as a whole. A reliable communication system is
necessary to ensure all team members respond to a
trauma notification in a timely manner. The response
should be rehearsed periodically and includes assem-
bling team members in a designated resuscitation
area. Priority should be given for team members to be
freed of immediate duties when called to attend a
trauma response. When the team assembles, the initial
time is spent preparing for the patient’s arrival. This
includes identifying the presence of all team mem-
bers, clarifying roles, donning protective clothing,
checking equipment and reviewing the pre-hospital
triage information.
496 A. Anthony

Members of the trauma team would normally com-
prise of doctors, nurses and other allied health staff.
Team members should be assigned to be responsible
for the airway, circulation, radiography and documen-
tation (Table 58.7). Additional personnel should be
used as assistants. Someone must take on the impor-
tant role of team leader. The team leader may or may
not have direct hands on involvement in assessing and
managing the patient. Irrespective of this, the leader is
required to maintain an overview of the situation in
order to make critical decisions and direct the flow of
management. The leader must be willing and capable
of performing the tasks expected of the role. The
resources and personnel available within the hospital
will dictate the composition of any trauma team. In
many instances, particularly in the rural setting, lim-
ited resources and personnel will require team mem-
bers to merge roles (Table 58.8). For example, the
airway doctor may also assume the role as team leader.
The circulation doctor may also obtain radiographs if

Table 58.7 Trauma team composition and roles

Personnel Designation Roles and responsibilities
Doctor Team leader • Ensures team members assembled and prepared
• Reviews pre-hospital information and briefs team
• Coordinates trauma team function and directs care of patient
• Liaises with paramedics
• Remains with patient until transferred for definitive care
Doctor Airway doctor • Establishes and secures airway
• Protects cervical spine
• Establishes ventilation
• Communicates with patient
Nurse Airway nurse • Assists airway doctor
Doctor × 2 Circulation doctors • Controls external haemorrhage
• Gains venous access
• Obtains blood specimens
• Commences intravenous fluid resuscitation
• Provides CPR if required
• Assesses for disability and other injuries
Nurses × 2 Circulation nurses • Assists circulation doctors
Orderlies × 2 Assistants • Assists with positioning/immobilising patient
• Couriers equipment and specimens
• Relays messages
Radiographer Radiographer • Obtains radiology imaging
Nurse Scriber • Documents trauma management, times of intervention, patient progress
• Keeps time
Nurse or doctor Family liaison • Notifies and liaises with family and friends
Others Assistants • Various designated roles as required
58 Management of the Severely Injured
Table 58.8 Trauma team – merged roles
Personnel Designation and roles
Doctor × 1 Team leader
Airway doctor
Nurse × 1 Airway nurse
Doctor × 1 Circulation doctor
Radiographer
Scriber
Nurse × 1 Circulation nurse
Scriber
Orderly or radiographer × 1 Assistant
Radiographer
trained to do so. The airway or circulation nurse may
also be the scriber. A radiographer may be required to
assist in numerous tasks other than to obtain x-rays.
Under such circumstances, any number of other staff
(e.g. nurses, orderlies, medical students, clerks) may
be recruited to assist the team. The greatest challenge
occurs when the only members of the team consist of
one doctor and one or more nurses. The principles and
practices of early trauma management will guide the
priorities of resuscitation. The doctor will need to be
judicious in delegating tasks as the team leader and
nurses will need to be skilled in order to undertake a
range of tasks. It would be prudent to enlist pre-­hospital
personnel to assist with the efforts of resuscitation and
with other tasks as necessary.
Irrespective of who is assuming which role, it is
important that role assignments are clearly decided
well beforehand, that personnel are trained and capa-
ble of performing the assigned role and that the prin-
ciples and practices of trauma assessment and
management remain unchanged. That is, with respect
to early trauma management, what is achieved with a
team of 10 can also be ultimately achieved with a team
of a lesser number.
58.4.2 Early Management
The most significant advancement in the early manage-
ment of the injured patient has been the change in the
philosophy and practice of trauma care championed by
497
the Advanced Trauma Life Support (ATLS) course for
doctors. The course was developed under the auspices
of the American College of Surgeons with interna-
tional input, and has long since been adopted globally
as an effective approach to managing trauma patients
during the initial hours following injury. The principal
objectives of the ATLS course are identification and
correction of life-threatening injuries, resuscitation
and stabilisation of the patient, identification of the
nature and extent of other injuries, prioritisation of the
management of injuries and planning for definitive
care. The Early Management of Severe Trauma
(EMST) course is the Australasian version of ATLS.
Almost all surgeons and many emergency physicians,
anaesthetists, intensivists and rural practitioners have
completed the EMST programme in Australia. The
ATLS/EMST approach acknowledges the need for
simultaneous assessment and intervention, and pro-
vides a framework for the systematic identification of
injuries and their management in order of threat to life.
It helps direct management towards a definitive con-
clusion whilst minimising the chance of errors and
omissions that have in past times resulted in higher
rates of preventable deaths. The strength of the ATLS
approach is its simplicity, efficacy and applicability in
any environment. Its effectiveness is not so much reli-
ant on the available resources as much as equipping
individuals and teams, whether they encounter injured
patients frequently or infrequently, to deliver care
with whatever resources are available. In the rural
­setting, as with any other trauma care setting, it is
imperative that pre-hospital and hospital personnel are
familiar with the ATLS approach to early trauma
management.
Not surprisingly, other trauma and critical care
skills courses aimed at paramedics, doctors, nurses
and others have stemmed from the ATLS course. The
common philosophies, principles and practices propa-
gated across these courses offer a significant benefit.
It ensures that the objectives and priorities in the early
phase of trauma management are the same, irrespec-
tive of whether care is given by pre-hospital, emer-
gency department, surgical or other personnel. It also
ensures that communication between personnel within
a team, across disciplines and from one phase of care
to another, is based on a common language. As an
example, the Pre-Hospital Trauma Care (PHTC) course
for paramedics and ambulance officers, the Advanced
498
Trauma Life Support (ATLS) course for doctors and
the Definitive Surgical Trauma Care (DSTC) course
for surgeons all ascribe to similar philosophies and
principles and teach to common objectives. This pro-
motes a shared purpose as well as mutual understand-
ing, trust and respect for one another’s roles and
capabilities when the various personnel work together
in treating the injured patient. Such values are essential
in a team approach to trauma care.
58.5 Role of the Rural Surgeon
Surgeons in Australia and throughout the world have
been leaders in advancing the cause of trauma man­
agement. This has been done in partnership, not only
across clinical disciplines but also with communities,
industry and government. Trauma pathology clearly
requires a multidisciplinary approach to management
and the surgeon is expected to play a significant part in
the delivery of care. The role of the surgeon in trauma
care is no better defined than by the unique challenges
posed by injured patients in the rural setting. Within
rural hospitals, the surgeon is usually one of few, or
may be the only specialist with any trauma care train-
ing and experience. Almost all rural surgeons in
Australia hold EMST certificates and a growing num-
ber have completed the DSTC course. Surgeons are
very familiar with the skills required for interventional
resuscitation such as establishing a surgical airway,
chest drain insertion, gaining venous access, immobil-
ising fractures and controlling bleeding. Although
many injured patients do not require operative inter-
vention, the surgeon remains well positioned to antici-
pate and recognise injuries requiring surgery, to
determine the optimum timing of any surgery and
whether surgery should be undertaken in rural ­facilities.
In critical circumstances, the surgeon may be required
to perform damage control surgery, in order to stabilise
the patient prior to a secondary transfer. Even when
surgery is not required, the in-patient care of the injured
is usually under the responsibility of the surgeon. The
role of the surgeon is not to allow patient care to
become fragmented. Fragmented care occurs when
there is focus on one aspect of management or injury
to the exclusion of recognising and prioritising the
management of all injuries. For these reasons, the rural
surgeon is often called upon to either lead the trauma
A. Anthony
care team or be a contributor to key decisions in the
assessment and management of the patient. This
requires the rural surgeon to assume leadership respon-
sibilities, including the ability to liaise with personnel,
foster collaboration and consensus amongst personnel,
delegate tasks, formulate a definitive management plan
and utilise resources effectively and efficiently. Where
surgeons assume such frontline roles in rural trauma
care, they may need to undertake additional training to
develop and enhance leadership skills.
Surgical leadership encompasses the duty of care of
a surgeon to members of the trauma care team. Treating
personnel should take measures to minimise harm
from the physical environment. The surgeon should
also be cognisant of the psychological impact on indi-
vidual personnel as a result of managing injured
patients. Such encounters are deemed critical incidents
that have the real potential to elicit adverse psycho-
logical responses amongst hospital staff. Some hospi-
tal trauma response systems incorporate a compulsory
debrief session with personnel in order to minimise the
risk of post-traumatic stress disorder (Table 58.9).
Although the surgeon is not expected to be an expert in
counselling personnel who are psychologically dis-
tressed from experiences encountered at work, as a
leader in trauma management, the surgeon may be
expected to conduct a debrief session and organise
expert input where necessary.
Table 58.9 Critical stress incident debriefing process
1. Conduct debrief immediately (within 48–72 h)
2. Allow dedicated and sufficient time
3. Ensure confidentiality throughout the process
4. Rely on experienced counsellor, familiar to trauma
personnel
5. Encourage sharing of experiences within a cohesive group
(a) Involve each member
(b) Full discussion of events
(c) Acknowledge expressions of thoughts, impressions,
feelings, emotions
(d) Challenge inappropriate feelings
6. Offer practical support
(a) Coping strategies
(b) Where to go for help
7. Ensure adequate follow-up with personnel
58 Management of the Severely Injured
Apart from direct clinical involvement with trauma
management, it is incumbent on the rural surgeon to
ensure that the pre-hospital triage and transport crite-
ria, the hospital trauma response and trauma team, and
the hospital triage and transfer protocols are appropri-
ate for the environment and are duly implemented as
required. As part of the triage and transfer protocol, the
rural surgeon must be familiar with the lines of com-
munication with a major trauma care centre. It is the
surgeon who is likely to be liaising with a tertiary hos-
pital for advice, to arrange a transfer or to seek retrieval
of the patient. The surgeon may also need to ensure
that pre-hospital and hospital personnel are appropri-
ately trained and that ambulance and hospital facilities
are adequate to maximise the capabilities of the rural
trauma service.
As resource allocations and evidence-based improve-
ments in trauma care rely heavily on accurate data,
rural surgeons must consider their involvement in data
analysis and review. This may be achieved via a regional
or local network peer-reviewed surgical audit process.
An alternative is for the rural surgeon to collaborate
with a major trauma care centre with which a rural hos-
pital is affiliated. Major trauma care facilities are usu-
ally well resourced to collate and analyse data, and
usually have established and appropriately constituted
audit processes. The rural surgeon should be welcomed
as an active participant in the periodic review of such
data with the responsibility of highlighting that part of
the data that has relevance to rural trauma care. In par-
ticular, issues relating to pre-hospital and hospital man-
agement, triage and transfers and patient outcome
parameters should be reviewed. Audit reviews are
likely to identify various issues that may be best
addressed through changes in management protocols
and policies, resource allocation or education and
499
training. A systematic process of data review may also
identify the need for research in order to effect improve-
ments in trauma care. By contributing to the audit
review process, rural surgeons are more effective in
maintaining trauma management skills, ensuring mul-
tidisciplinary involvement in the care of their patients,
sharing the burden of responsibilities for various
issues and advocating for improvements in trauma
management.
Recommended Reading
American College of Surgeons Committee on Trauma: Advanced
Life Trauma Support for Doctors: Student Course Manual,
8th edn. American College of Surgeons, Chicago (2008)
Atkin, C., Freedman, I., Rosenfeld, J.V., Fitzgerald, M., Kossmann,
T.: The evolution of an integrated state trauma system in
Victoria, Australia. Injury 36(11), 1277–1287 (2005)
Australian Government Department of Health and Aging.
Review of the Rural, Remote and Metropolitan Areas
(RRMA) Classification. Discussion paper. Canberra: DoHA.
www.ncwg.org.au/rrma.review.pdf
Croser, J.L.: Trauma care systems in Australia. Injury 34(9),
649–651 (2003)
Danne, P.D.: Trauma Management in Australia and the tyranny
of distance. World J. Surg. 27(4), 385–389 (2003)
Fatovich, D.M., Jacobs, I.G.: The relationship between remote-
ness and trauma deaths in Western Australia. J. Trauma
67(5), 910–914 (2009)
Moore, E.E., Feliciano, D.V., Mattox, K.L.: Chapter 4: Trauma
systems; triage and transport. In: Trauma, 6th edn. McGraw-
Hill Companies, New York (2008)
Nathens, A.B., Brunet, F.P., Maier, R.V.: Development of trauma
systems and effect on outcomes after injury. Lancet
363(9423), 1794–1801 (2004)
National Trauma Registry Consortium (Australia and New
Zealand, 2004). The National Trauma Registry (Australia
and New Zealand) Report:2002. Herston: National Trauma
Registry Consortium (Australia and New Zealand)
 Rural Burn Care
59
Gary F. Purdue† and Brett D. Arnoldo

59.1 Introduction First degree – damages only the epidermis. The

classic injury is sunburn. Burns appear erythematous
and edematous, with burned skin being intact to
Burn injury is ubiquitous, affecting individuals of all
the underlying tissue on gentle rubbing (negative
ages and socioeconomic strata. With occasional excep-
­Niko­lsky’s sign). Treatment is application of cool
tions, nearly all burns are preventable, caused by some-
water compresses initially and pain relief with oral
one having done something that either common sense
opiates or non-steroidal anti-inflammatories, followed
or their mother should have told them not to do.
by several times daily application of any bland emol-
Children comprise about 1/3 of admitted burn patients,
lient lotion (cocoa butter, Vaseline Intensive Care
with nearly one-half of those injuries occurring in the
Lotion®, Lubriderm®, aloe vera, Eucerin cream®, Vita­
kitchen and 5–7% being the result of child abuse.
min D or E, Udder Butter®, Bag Balm®, etc.) with no
Scalds from hot liquids are the most frequent cause of
evidence that any one agent is better than another.
childhood burns, with many related to cooking. Adults
Topical antimicrobials and oral/intravenous antibiotics
most frequently have flame burns, with inappropriate
are unnecessary.
use of a highly flammable liquid (BBQ, trash/brush
Second degree (partial thickness) – characterized
ignition, and carburetor priming) being frequently
by blisters which are filled with clear fluid. The
responsible. Males predominate at about 3:1[1].
underlying tissue is wet, pink, edematous, and
Populations at special risk include the neurologically
extremely painful. Initially, the burn may not have
impaired (substance abuse, seizure disorders, neuropa-
developed blisters with the burned skin shifting on
thies, paraplegics). Diabetics with neuropathies and
gentle rubbing (positive Nikolsky’s sign). Causes
peripheral vascular disease are both at risk for injury,
include flash injuries and spill scalds with water-like
subsequent infection, and morbidity.
liquids. Healing is from below upward, originating
from surviving epithelial cells, primarily those in the
hair follicles and pores. Treatment is wound protec-
59.2 Initial Evaluation tion with avoidance of infection and desiccation
until reepithelialization occurs. This is generally
The two most important determinants of burn severity achieved by application of a dressing or antimicrobial
are burn size and burn depth. While the cutaneous (and ointment.
hence visible) nature of the burn should make evalua- Third degree (full thickness) – may or may not have
tion very simple, misdiagnosis is frequent. Burn depth blisters, the blister fluid is often hemorrhagic, and the
is usually described as first, second, or third degree as underlying tissue white to deep red. These injuries
described below. often involve flame, grease, or prolonged contact with
hot liquids. Contact with very hot solids such as oven
racks or engine manifolds also causes full-thickness
G.F. Purdue† and B.D. Arnoldo (*)
burns. Care is with a topical antimicrobial such as sil-
Department of Surgery, UT Southwestern Medical Center,
5323 Harry Hines Blvd. Dallas Texas, USA ver sulfadiazine, excision, and skin grafting. By defini-
e-mail: brett.arnoldo@utsouthwestern.edu tion, this is a burn which heals only from the outside

M.W. Wichmann et al. (eds.), Rural Surgery, 501

DOI: 10.1007/978-3-540-78680-1_59, © Springer-Verlag Berlin Heidelberg 2011
502
edges in where, for practical purposes, burns much
larger than 3 cm in smallest size require a skin graft
for wound closure.
Some burns are of “indeterminate” (the observer
cannot determine whether the burn is second or third)
depth on initial evaluation. Watchful waiting for several
days usually separates these burns from one another.
The most important single determinant of severity
is burn size, where the size of the patient’s handprint
is roughly 1% of their total body surface area (TBSA).
This works well for calculating the size of small
burns (less than 5% TBSA). For larger burns, the
Rule of Nine’s is a quick and practical method for
determining burn size (Fig. 59.1). Keys to usage
include using only the proportion burned (for exam-
ple, if only 2/3 s of an upper extremity is burned, then
burn size is only 6% TBSA). The Rule of Nine’s can-
not be used for children younger than 10 years of age
who have relatively large head sizes and small lower
limb proportions. The Berkow chart (Fig. 59.2) is
-9-
-9-
18 18
1
9 9 9 9
Rule of
Nine’s
Fig. 59.1 Rule of nine’s
G.F. Purdue† and B.D. Arnoldo
appropriate for children and permits more accurate
diagnosis by the dividing body proportions into
smaller units. First-degree burns are never, ever
counted in burn size.
59.3 Minor and Major Burns
The American Burn Association criteria for referral to
a Burn Center are shown in Table 59.1. These criteria
have been developed to provide optimal care of burn
patients from wound, rehabilitation, and psycho/social
standpoints. The initial decision to treat a burn not
requiring referral to a burn center is whether the injury
can be treated as an outpatient or inpatient. Patients
(and their caregivers when appropriate) who have
their pain under control, resources available for care,
and can demonstrate ability to care for their burn
wound may be treated as outpatients. Some patients
can treat all wounds themselves with weekly follow-
up, while others may need to have more frequent
(even daily) office, clinic dressing changes or visits by
home health care.
59.4 Immediate Care
Emergent burn care is immediate, short application of
tap water as a simple cooling modality with exposure
for only 30–60 s. Application of ice or ice water has no
place in burn care, risking both cold injury of the
burned area and general hypothermia. Wrap the burned
areas in sterile or clean sheets with minimal debride-
ment. For larger burns, maintain normo-thermia with a
warm external environment, fluid warmers, minimal
exposure, warm blankets, and an external warmer (Bair
Hugger®). Avoid burn wound desiccation and do not
allow the warmer to blow directly on the wound. Place
a sheet between the patient and the warmer and a blan-
ket over it to secure the warmer in place. Prophylactic
antibiotics are not indicated.
Airway management continues to be a troublesome
area. Patients with deep burns of the lower face and
neck and those with large burns require airway protec-
tion with an endotracheal tube while those with more
superficial burns need only elevation of the head of the
bed to minimize face/neck swelling.
59 Rural Burn Care 503

DALLAS COUNTY HOSPITAL DISTRICT

Dallas, Texas

BURN RECORD

To be completed upon admission:

Date:

Height: Weight:

2° +3° = %

Partial
thickness

Percent surface area burned

Full (Berkow formula)
thickness

1–4 5–9 10–14 15

Area 1 YR. ADULT 2° 3°
YRS. YRS. YRS. YRS.
Head 19 17 13 11 9 7
Neck 2 2 2 2 2 2
Ant. Trunk 13 13 13 13 13 13
Post. Trunk 13 13 13 13 13 13
R. Buttock 2½ 2½ 2½ 2½ 2½ 2½
L. Buttock 2½ 2½ 2½ 2½ 2½ 2½
Genitalia 1 1 1 1 1 1
R.U. Arm 4 4 4 4 4 4
L.U. Arm 4 4 4 4 4 4
R.L. Arm 3 3 3 3 3 3
L.L. Arm 3 3 3 3 3 3
R. Hand 2½ 2½ 2½ 2½ 2½ 2½
L. Hand 2½ 2½ 2½ 2½ 2½ 2½
R. Thigh 5½ 6½ 8 8½ 9 9½
L. Thigh 5½ 6½ 8 8½ 9 9½
R. Leg 5 5 5½ 6 6½ 7
L. Leg 5 5 5½ 6 6½ 7
R. Foot 3½ 3½ 3½ 3½ 3½ 3½
L. Foot 3½ 3½ 3½ 3½ 3½ 3½

Total 034
ps 352 7/91

Fig. 59.2 Berkow chart

504
Table 59.1 American Burn Association criteria for referral
to a burn center
• Partial-thickness burns >10% TBSA
• Third-degree burns in any age group
• Burns that involve the face, hands, feet, genitalia perineum,
or major joints
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Burn injury in patients with pre-existing diseases which
could affect therapy or outcome
• Patients with burns and concomitant trauma in which the
burn poses the greatest risk of morbidity or mortality
• Burns in patients who will require special social,
­emotional, or rehabilitative intervention
59.5 Minor Burn Care
Partial-thickness (second-degree) burns are best cared
for by debridement of loose blisters and application of
either a biologic dressing (porcine heterograft or
Biobrane®) or silver-impregnated sheet (Aquacel Ag®
or Acticoat®), covered by a simple gauze dressing.
These may be left in place for either 3 days (Acticoat®)
or until the wound heals. Intact blisters on the palm of
the hand in any patient and soles of the feet in children
may be left intact. All of these burn coverings should
be evaluated for adherence/infection at 24–48 h post
application. If not adherent, the dressing is removed
and either reapplied or replaced with the silver sulfa­
diazine protocol presented below.
Indeterminate or full-thickness burns are debrided
and treated with silver sulfadiazine cream applied in a
1–2-mm thick layer and covered with fine mesh gauze
and roller gauze wrap to hold the dressing in place.
Dressings are changed daily with removal of the dress-
ing and gentle washing with soap (any mild soap or the
soap that the patient normally uses) and tap water to
remove all dead tissue and old topical agent. Washing
can be with either gauze pads or wash cloths, which
have been run through a Clorox wash and can be reused
after washing again. The cream is then reapplied and
the wound dressed. Burn washing can take place in a
basin, shower, or bathtub. “Mother-in law” clean is a
term most patients understand and can adhere to. While
G.F. Purdue† and B.D. Arnoldo
a non-adherent dressing (such as Telfa®) may be used,
its lack of debridement on removal mandates extra
effort at removing all debris by washing. Encourage
the use of light dressings that will allow joint motion.
Simple, inexpensive dressings can be fabricated from
white cotton underwear or athletic socks washed in a
Clorox wash. Socks can be especially effective for
children, when taped at the wrist or ankle to prevent
removal. Emphasis is on simple and light with both
active and passive range of motion encouraged. Be cer-
tain to supply the patient with enough pain medication.
Oral narcotics alternating with a non-steroidal anti-
inflammatory will usually achieve adequate pain control.
Burns are tetanus prone wounds requiring appropriate
immunizations. Burn wound cellulitis is treated with a
first-generation cephalosporin given either orally or
intravenously depending on the severity of infection. If
this fails or the patient is a diabetic with a lower extrem-
ity burn, an orally administered quinolone antibiotic is
utilized.
59.6 Major Burn Care
Burns larger than 10% TBSA should have two periph-
eral intravenous catheters placed and resuscitation
begun with Ringer’s lactate with an hourly rate of burn
size times weight in kilograms divided by four. This is
the first 8 h rate as calculated by the Parkland formula.
IV catheters may be placed thru the burn wound and
should be sutured securely in place with multiple
sutures. Avoid the use of adhesive backed dressings
that are typically non-adherent to a burn wound.
Cutdowns, either thru burned or unburned tissue, may
be necessary with central venous access reserved for
patients with no other route of access. Intraosseous
access may be required in children.
59.7 Special Injuries
59.7.1 Tar Burns
Tar is both slick and sticky, with working temperatures
significantly higher than water and no potential for
reabsorption of the heat of vaporization. Immediate
59 Rural Burn Care 505

dousing with ice water is usually performed at the abdomen. Immediate irrigation with large volumes of
work site. On office/hospital arrival, the most expedi- tap water at a comfortable temperature is the first ther-
tious treatment is application of a thick (2 mm) layer of apy along with removal of all patient clothes and bed-
petrolatum-based neomycin or bacitracin ointment ding. Caregivers must wear full personal protective
which is allowed to stay on the wound 12 h, then equipment. Following initial irrigation, more pro-
washed off and wound care as usual performed. Citrus longed irrigation is performed in a shower with patient
oil and hydrocarbon solvents may remove tar more selected water temperature, soap, and a wash cloth to
efficiently, but present pro­blems with ready availabi­ remove all possible residual chemical. There is no
lity or toxicity/flammability. place for attempting to neutralize an acid with a weak
alkali and vice versa. Significant injuries should be
referred to the local burn center, as should questions
59.7.2 Electrical Burns regarding injury with special chemicals such as hydro-
fluoric acid, phenol, and phosphorus.
Injuries caused by electricity are divided into low volt-
age (<1,000 V) where what you see is what you get and
high voltage (³1,000 V) which has the potential for
­hidden deep myonecrosis. Cardiac monitoring in the 59.8 Summary
emergency room is indicated for those patients with
arrhythmias which are treated appropriately as for any
Burns occur frequently, having affected virtually
medical patient. If the ECG is normal and no arrhyth-
every adult in the United States. Treatment of small
mias are detected, further cardiac monitoring is unneces-
burns has emphasis on clean and simple, with larger
sary [2]. Evaluation of cardiac enzymes is not indicated.
and more complex injuries being referred to a burn
Patients with no visible contact points can be discharged
center.
with no follow-up, while those with small (2–4 mm)
contact points should have daily dressing changes with
mafenide acetate (Sulfamylon®) cream. Refer patients to
a burn center if these do not heal or are larger. Grossly
visi­ble pigment in the urine (darker than pink lemonade) References
is treated immediately with mannitol 25 g given IV push
and two ampules of sodium bicarbonate also given IV 1. National Burn Repository: 2006 Report. American Burn
push, followed by Ringer’s Lactate at a rate to establish Association (2007)
a brisk diuresis. Dip evaluation of urine reacts positively 2. Purdue, G.F., Hunt, J.L.: Electrocardiographic monitoring
after electrical injury: necessity or luxury. J. Trauma 26,
to both myo- and hemoglobin pigments and is too sensi- 166–167 (1986)
tive to be useful, as are CK levels. There is approxi-
mately a 15% incidence of traumatic injury, mainly
associated with falls. Contact with the burn center is rec-
ommended for any questions regarding depth or size.
Recommended Reading

59.7.3 Chemical Burns ABLS Now: American Burn Association. www.ameriburn.org

Herndon, D.N.: Total Burn Care, 3rd edn. Saunders Elsevier,
Philadelphia (2007)
Chemical burns are true medical emergencies, treated Resources for Optimal Care of the Injured Patient: Committee
initially with the same urgency as a stab wound of the on Trauma American College of Surgeons, 79 (2006)
 A Guide to Neurotrauma
for the Rural Surgeon 60
David Omahen and Stephen J. Hentschel

60.1 Introduction 60.2 Prehospital Care

Managing trauma in a rural setting without ready 60.2.1 Initial Management

access to specialist consultation and the latest technol-
ogy can be difficult. Head and spinal injuries in par-
Management of neurotrauma begins prior to arrival in
ticular can be anxiety provoking for the generalist;
hospital. Maintaining perfusion to the brain and spinal
however, the initial diagnosis and management of these
cord is of paramount importance; so as with all trauma
injuries is relatively straightforward.
patients, careful attention must be paid to the ABCs:
The central nervous system does not always recover
airway, breathing, and circulation [1]. In addition, the
well after serious insults. Injury to the central nervous
nervous system must be protected from additional
system occurs in two distinct phases: the initial dam-
insults. It is better to err on the side of caution, and so
age done at the time of the accident, and secondary
in consequence, the trauma patient must be treated as
injury, which occurs in a delayed manner. In manag-
though a spinal cord injury is present until proven
ing neurotrauma, the goal is to minimize the second-
otherwise.
ary injury [1, 2]. Basic precautions and management
The airway should be secured, preferably with
techniques can protect the nervous system from fur-
endotracheal intubation in patients with a GCS of less
ther insults, thereby affording the patient the greatest
than nine, those unable to maintain an airway, or those
chance for recovery.
with persistent hypoxia despite provision of supple-
In this chapter, we will present a basic approach to
mental oxygen [3]. Intravenous lidocaine (1.5 mg/kg)
neurotrauma, which will help the rural traumatologist
is often given to blunt increases in ICP during intuba-
diagnosis and manage CNS trauma using clinical
tion [3]. In-line stabilization of the cervical spine is
skills and basic equipment. Although tools such as CT
required.
scanners provide valuable information, good-quality
The most rapid way to lower intracranial pressure is
clinical management is even more essential in ensur-
hyperventilation [4]. If signs of herniation (as dis-
ing the best possible outcomes. Even with the most
cussed later in the chapter – see Table 60.9) such as
advanced and up-to-date technology, poor basic clini-
asymmetric dilated or unreactive pupils, extensor pos-
cal management can have devastating consequences.
turing, or a decline in the GCS (see Table 60.1) of more
than two points (from an initial GCS < 9), current rec-
ommendations call for hyperventilation (20 bpm in an
D. Omahen adult or 30 bpm in a child) [3, 4]. In the setting of
Victoria General Hospital, Victoria, BC, Canada intact cerebral blood flow autoregulation, hyperventi-
e-mail: domahen@ualberta.ca
lation lowers pCO2, leading to vasoconstriction,
S.J. Hentschel (*) thereby lowering the volume of blood in the cranial
Division of Neurosurgery, Victoria General Hospital,
compartment, leading to a decrease in intracranial
University of British Columbia, 1 Hospital Way,
Victoria, BC, Canada pressure. Caution must be exercised however, as too
e-mail: stephen.hentschel@viha.ca aggressive hyperventilation (pCO2 < 30) can lower

M.W. Wichmann et al. (eds.), Rural Surgery, 507

DOI: 10.1007/978-3-540-78680-1_60, © Springer-Verlag Berlin Heidelberg 2011
508 D. Omahen and S.J. Hentschel

Table 60.1 Glasgow coma scale the accident. In the setting of a motor vehicle accident,
Points Motor Verbal Eye key points include the speeds of involved vehicles,
response response opening
seatbelt use, airbag deployment, amount of intrusion
6 Obeys into the vehicle, ejection from the vehicle or starring of
commands
the windshield, alcohol/drug use, and the nature of the
5 Localizes to Oriented crash. Extrication time should be noted. Initial level of
pain consciousness, presence of seizure-like activity, blood
4 Withdraws Confused Spontaneous loss, obvious injuries, and evidence of submersion or
from pain speech hypothermia should also be noted.
3 Abnormal Inappropriate To voice The Glasgow Coma Scale [5] (GCS) is a widely
flexion words used and reliable indicator of head injury severity
(decorticate) (Table 60.1). Points are assigned for eye opening, ver-
2 Abnormal Incomprehensible To pain bal response, and motor response; scores range from 3
extension sounds (dense coma) to 15 (normal level of consciousness).
(decerebrate)
When assessing an intubated patient, the verbal por-
1 None None None tion is not included and the GCS is scored out of 10.
Source: Teasdale and Jennett [5] Note that response to central pain is used to calculate
the motor score. Even patients who are brain dead may
withdraw limbs to peripheral pain, as this is a reflex
blood flow to the point of ischemia. Thus, prophylactic mediated at the level of the spinal cord. Such patients
hyperventilation should be avoided [3, 6]. should not be scored as withdrawing to pain. It is
Hypotension (systolic blood pressure < 90 mmHg) important to note the best GCS attained following the
and hypoxemia (<90% oxygen saturation) in the pre- accident, as this may provide clues to the nature of
hospital setting have both been linked to poor out- injury suffered. For example, a head-injured patient
comes after CNS trauma [3]. A single episode of who is initially alert and talking on scene and then
hypotension increase mortality by 150% [1]! Thus, deteriorates is more likely to have an expanding mass
simple maneuvers such as establishing and maintain- lesion, while a patient with an initial GCS of three who
ing an airway, supplying supplemental oxygen, and remains deeply comatose may have another condition,
supporting blood pressure are critical. The initial fluid such as a diffuse axonal injury. A post-resuscitation
therapy of choice is normal saline [7], and the goal is GCS of 3–5 has a positive predictive value of 70% for
to avoid hypotension. Hypotonic solutions should be a poor outcome [3]. Predicted mortality for a GCS in
avoided as they are less effective and more likely to this range is 50% for helicopter-transferred and 61%
exacerbate cerebral edema [8]. The use of hypertonic for ground-transferred patients. Level II evidence sup-
resuscitation solutions may have scientific merit, but ports direct transport to a trauma center when feasible
their use cannot be endorsed until further study has of patients with a GCS of less than nine [3].
been completed [4]. The concept of “running patients
on the dry side” in the setting of head injury for fear of
worsening cerebral edema is outdated, and euvolemia
should be maintained. Since hypoglycemia can mimic 60.3 In-Hospital Management
many signs and symptoms of neurological injury, this
should be ruled out [9].
60.3.1 Clinical Evaluation

60.2.2 History
Keep points on history include the nature of the trauma,
the patient’s best GCS on scene, whether the patient
was mobilizing, and the condition of others involved in
60.3.1.1 Primary Survey
Upon hospital arrival, the ABCs should be reassessed.
The airway should be secured in all patients unable to
maintain oxygenation on supplementary oxygen, those
with a GCS of less than nine, or those unable to protect
60 A Guide to Neurotrauma for the Rural Surgeon
their airway. Care must be taken to ensure that the cer-
vical spine is maintained in a neutral position, and full
spinal precautions should be observed until a spinal
injury can be ruled out. Intravenous lidocaine is admin-
istered prior to intubation, as outlined above [3]. It is
critical to avoid hypoxia. Hyperventilation should be
reserved for patients with objective evidence of cere-
bral herniation. Until a basal skull fracture can be ruled
out by CT scanning, nasogastric tube insertion is
avoided. Orogastric tubes are used in this setting.
A Foley catheter is inserted as per ATLS protocols.
Isotonic crystalloid is the initial IV solution of
choice [3]. Normal saline is preferred over Ringer’s
lactate due to its higher tonicity. Hypotension must be
avoided to ensure adequate perfusion of the brain and
spinal cord [4].
60.3.1.2 AMPLE History
Next, a more detailed assessment is undertaken. An
AMPLE history [1] is acquired from EMS workers, wit-
nesses, family members, or the patient if possible. The
components of an AMPLE history are: allergies, medi-
cations, past medical/surgical history, last meal, and
events leading up to the accident. For example, two pos-
sibilities exist for patients with subarachnoid hemor-
rhage following an MVA: the most common explanation
is a traumatic subarachnoid hemorrhage, but the possi-
bility of an aneurysmal SAH causing the accident must
not be discounted. Other information collected by ambu-
lance personal (as outlined above) should also be noted.
60.3.1.3 Secondary Survey
Next, a head-to-toe secondary survey as outlined in
standard ATLS protocols is undertaken [1]. More than
half of patients with severe brain injury also have other
major injuries ![10] Up to 8% of patients with head
injury also sustain a cervical spine injury [1]. In this
chapter, we will highlight portions most germane to
the assessment of neurotrauma.
60.3.1.4 Neurological Examination
In the awake and cooperative patient, a standard screen-
ing neurological examination is performed, including
509
Table 60.2 Key muscle groups in motor examination
Key muscle groups
C5 Elbow flexors
C6 Wrist extensors
C7 Elbow extensors
C8 Finger flexors (distal phalanx
middle finger)
T1 Finger abductors (little finger)
L2 Hip flexors
L3 Knee extensors
L4 Ankle dorsiflexors
L5 Long toe extensors (great toe)
S1 Ankle plantarflexors
Source: Adapted from ASIA scoring system [11]
assessment of vital signs, GCS, cranial nerves, motor
and sensory function, reflexes, coordination, speech,
and higher mental functions. In the patient with a
potential spinal cord injury, it is important to record
motor strength in all muscle groups. The initial exami-
nation will serve as a baseline, and any deterioration in
function will be measured against it. A reasonable
screening motor examination can be made based on the
ASIA motor grading system [7, 11] (Table 60.2,
Fig. 60.1). The MRC motor grading scale is universally
accepted (Table 60.3). Likewise, if sensory deficits are
identified, both dorsal column and spinothalamic func-
tion should be assessed (light touch, pinprick sensation,
and joint position sense). Note is made of the presence
of a Horner’s syndrome (ptosis, miosis, and anhidro-
sis), which implies interruption of the sympathetic
pathway to the pupils, as can be seen in brainstem
injury, cervical spinal injury, or carotid artery injury.
In the comatose patient, the examination [1] focuses
on cranial nerve function, motor responses to pain,
tone, and reflexes. The size and reactivity of pupils
should be noted, as should any deviation of the eyes or
disconjugate gaze. Asymmetry is defined as a differ-
ence of 1 mm or more [3]. It should be noted that
approximately 20% of the normal population have
some anisocoria. Direct and consensual responses to
light should be noted. The pupil is nonreactive if no
change in size >1 mm is noted [3]. Note must also
be made of any evidence of orbital trauma. If for any
reason the pupils are dilated pharmacologically, this
should be clearly documented on the chart. In the early
510 D. Omahen and S.J. Hentschel

Fig. 60.1 American Spinal Association (ASIA) assessment of spinal cord injury [11]

Table 60.3 Medical Research Council grading of motor power
MRC grading of muscle strength
0 Total paralysis
1 Visible flicker/palpable
contraction
2 Full range of motion with
gravity eliminated
3 Antigravity power
4−4 Movement against gravity plus
4+ some resistance, but not full
power
5 Full power
Source: Greenberg [7]
hours after the onset of raised intracranial pressure,
papilledema is not usually observed [1], and its absence
does not rule out the possibility of raised ICP. Corneal
reflexes are checked by lightly brushing the cornea
(not the sclera!) with a wisp of cotton. Contact lenses
should be removed prior to this maneuver, and it bears
noting that corneal reflexes may be depressed in habit-
ual contact lens wearers. The condition of the tympanic
membranes should be assessed by otoscopic examina-
tion. The presence of blood or CSF should be noted.
Since the cervical spine cannot be cleared in the coma-
tose trauma victim, the doll’s eye maneuver is NOT
performed. Caloric testing is generally only performed
as part of assessment of brain death. The presence of a
cough or gag reflex can be assessed by gentle manipu-
lation of the endotracheal tube, and by noting the
response to suctioning. In the spontaneously breathing
patient, note is made of the rate, depth, and rhythm of
any respiratory efforts.
The motor component of the GCS is defined as the
best response elicited to central pain. In the absence
60 A Guide to Neurotrauma for the Rural Surgeon
of major chest trauma, this is traditionally assessed
using a sternal rub. Other methods such as pressure
on the supraorbital nerve may be more appropriate
in the setting of a high cervical spinal injury, as the
sternal area may be rendered insensate by high spinal
injury. Tone in all limbs and responses to peripheral
pain (nailbed pressure) are also assessed. Withdrawal
of a limb to peripheral pain should not be counted as
a withdrawal response for the purposes of the GCS,
as this usually represents a reflex mediated at the
level of the spinal cord. Deep tendon reflexes are
recorded at the following sites: biceps, brachioradia-
lis, triceps, knee, and ankle. The plantar reflexes are
also recorded.
Note is made of obvious injuries about the head,
neck, and back. The skull and orbits should be
­palpated to assess for fractures. Stability of the mid-
face should be assessed. Scalp lacerations should be
palpated for evidence of fracture and inspected for
egress of CSF or brain matter, which implies a
breech in the dura mater. After debridement and irri-
gation, definitive closure of isolated scalp injuries
should be performed in two layers using absorbable
suture for galeal closure, followed by skin closure.
Auscultation over the carotid arteries and skull may
reveal the presence of bruits. While maintaining
alignment (logrolling), the entire spine should be
palpated to assess for tenderness or deformity.
Presence of CSF otorrhea/rhinorrhea, raccoon eyes,
or Battle’s sign (postauricular ecchymosis) may
indicate a basal skull fracture. Finally, a rectal
examination and assessment of the bulbocavernosus
reflex should be performed. Note is made of any
priapism.
60.3.1.5 Bloodwork
Standard trauma bloodwork is sent. In the setting
of intracranial hemorrhage, any coagulopathy must
immediately be corrected. Platelets should be
maintained above 50,000 (>1,00,000 is preferred
prior to neurosurgical procedures), and INR/PTT
values should be normalized. Hemoglobin should
be maintained above 80, and electrolytes should be
closely monitored for signs of diabetes insipidus
(DI) or more commonly the syndrome of inappro-
priate ADH (SIADH); normoglycemica should be
maintained.
511
60.4 Head Injury
60.4.1 Classification of Head Injuries
Head injuries can be classified into minor, mild, mod-
erate, and severe, based on the level of consciousness
[12] (see Table 60.4). They can also be described by
mechanism (blunt vs. penetrating trauma), or by the
resulting pattern of injury identified clinically, radio-
graphically, or pathologically.
60.4.2 Radiological Imaging
of Head Injury
If available, X-ray and CT scan imaging can be a
­valuable adjunct to physical examination.
60.4.2.1 Skull X-rays
Skull X-rays have largely been supplanted by CT scans
where available, but can provide clues to aid the sur-
geon without access to a CT scanner. Presence of a
skull fracture increases the probability of a surgical
cranial injury 400-fold in the conscious patient, and
20-fold in the comatose patient [7, 13]. The false-­
negative rate is very high, so a normal skull X-ray
should not provide reassurance that significant intrac-
ranial injury has not been sustained; three quarters of
patients with minor head injury and a lesion on CT
scan had normal skull X-rays [14].
Table 60.4 Grading of head injury severity
Minimal GCS = 15
No loss of consciousness (LOC)
No amnesia
Mild GCS = 14 OR
GCS = 15 with brief LOC (<5 min)
or impaired alertness/memory
Moderate GCS 9–13 OR
LOC > 5 min OR
Focal neurological deficit
Severe GCS 5–8
Critical GCS 3–4
Source: Reilly and Bullock [12]
512 D. Omahen and S.J. Hentschel

Skull X-rays can be used to identify fractures,

a­ ir-fluid levels in cranial sinuses, intracranial foreign
bodies, and pneumocephalus. Fractures need to be
­distinguished from normal vascular markings of the
skull. In contrast to vascular markings, fractures appear
as well-demarcated, non-corticated, non-branching
hypodense lines that do not cross suture lines [15]. On
occasion, shift of calcified midline structures such as
the pineal gland can provide clues to accompanying
mass lesions [7]. At least two views at right angles to
each other are recommended [15].

60.4.2.2 CT Scanning

A noncontrast CT scan of the head is the best initial

imaging modality to assess for cranial trauma. The ini-
tial purpose is to rule out any surgical lesion and assess
for the presence of intracranial hemorrhage, edema,
hydrocephalus, fracture, or associated pneumocepha-
lus. Shift of midline structures and effacement of basal
cisterns are radiographical correlates of potential
intracranial hypertension [16].
A CT scan is indicated for any patient with GCS < 14,
those with evidence of skull fracture, inebriated
patients, patients with amnesia, seizures, coagulopa-
thy, or focal deficit, or those who require general anes-
thetic which will preclude serial neurological
examination [15, 17]. A history of loss of conscious-
ness increases the probability of finding an intracere-
bral hematoma fivefold [18], while anticoagulation
increases the risk tenfold [19]. There is an 80% chance
of finding a mass lesion in an initially lucid patient
who subsequently becomes comatose [20]. Repeat CT
scanning is indicated in patients with a decline in
GCS > 2 points, new or progressive deficit, persistent
vomiting, worsening headache, seizures, and in the
unexaminable patient initially scanned less than 6 h
post injury [7].
When assessing a CT scan, examine the basal cis-
terns for patency (see Fig. 60.2), and the ventricular
system for evidence of hydrocephalus or mass effect.
Bone windows aid in assessing for skull fractures (see
below, Fig. 60.4). Fluid in sinuses should be noted;
opacification of the mastoid air cells may be indicative
of a basal skull fracture. The brain parenchyma should
be inspected for acute blood (bright) or ischemia/
edema (dark). The degree of gray–white matter differ-
entiation and visibility of the sulcal pattern should be
Fig. 60.2 CT scan showing complete effacement of the basal
cisterns. The hypodensity in the right anterior temporal region
was from a prior surgery. Note the hyperdense blood layered
along the tentorium cerebelli. The brain stem and medial left
temporal/occipital regions are hypodense, consistent with a pos-
terior cerebral artery infarct secondary to vessel occlusion due to
extremely elevated intracranial pressure
compared bilaterally. Acute blood can be differen­
tiated from calcification by lower Hounsfield unit
measurements (75–80 vs. 100–300 for calcium) [7].
Extraaxial hematomas in the supratentorial and
infratentorial spaces should also be noted. Hematoma
volume can be approximated using the modified ellip-
soid formula:
Volume = (length ´ width ´ height) / 2
Large or irregularly shaped hematoma volume may be
underestimated using this formula [21].
60.4.2.3 Magnetic Resonance Imaging (MRI)
While MRI is more likely to demonstrate intracranial
lesions [22], and does provide some prognostic infor-
mation, the pickup rate of significant new surgical
lesions is not high enough to justify routine use early
in head injury.
60 A Guide to Neurotrauma for the Rural Surgeon 513

60.4.2.4 Vascular Imaging Table 60.5 Indications for CT scan in minor head injury
Canadian CT head rule for minor head injury
Consideration should be given to imaging of intracra- High risk (for neurological intervention)
nial vascular structures (by CT or MR angiogram, or • GCS score <15 at 2 h after injury
formal digital subtraction angiography) when suspi-
• Suspected open or depressed skull fracture
cion of vascular injury exists. Possible indications
• A
 ny sign of basal skull fracture (hemotympanum, “raccoon”
include unexplained stroke, penetrating injury, suspi- eyes, cerebrospinal fluid otorrhoea/rhinorrhea, Battle’s sign)
cion of aneurysmal SAH, cervical fracture through the
• Vomiting ³ two episodes
foramina transversarium, facet joint dislocation, or
• Age ³ 65 years
symptoms of arterial dissection (neck pain, brainstem
findings, partial Horner’s syndrome, hypodensity in a Medium risk (for brain injury on CT)
known vascular distribution [23]). Cervical carotid • Amnesia before impact >30 min
or vertebral dissection occurs in approximately 1% • D
 angerous mechanism (pedestrian struck by motor vehicle,
of blunt trauma victims and delays in diagnosis are occupant ejected from motor vehicle, fall from height >3 ft
or five stairs)
common, with severe consequences including a 67%
Source: Stiell et al. [26]
delayed stroke rate and 25% mortality [23]. a
Minor head injury is defined as witnessed loss of conscious-
ness, definite amnesia, or witnessed disorientation in patients
with a GCS score of 13–15
60.4.3 Common Patterns of Injury
in a location remote to the site of impact – a so-called
60.4.3.1 Concussion contre-coup injury [24, 27] (see Fig. 60.3). The more
superficial location of contusions contrasts with deeper
A concussion is defined as “an alteration of conscious- location of brain lacerations [24]. Contusions have a
ness as a result of nonpenetrating traumatic injury to
the brain” [7]. CT scans are normal, or may show mild
edema from resultant hyperemia. However, it is becom-
ing increasingly recognized that mild axonal damage
may occur [24]. MRI imaging can show abnormalities
in up to 25% of concussions [25].
Although rules and algorithms should not be seen as
a substitute for clinical judgment, clinical tools such as
the Canadian CT head rule (Table 60.5) can help iden-
tify patients who require further evaluation with a CT
scan [26]. Developed for use in patients with an initial
GCS of 13–15, this rule has a sensitivity of 98.4% and
specificity of 48.6% for identifying clinically important
brain injury [26]. Between 8% and 46% of patients with
a minor head injury have CT abnormalities, most fre-
quently contusions [7]. Any patient with an unexplained
depressed level of consciousness, focal neurological
findings, penetrating injury, or skull fracture should be
admitted to hospital and undergo CT scanning [7].

Fig. 60.3 CT scan showing cerebral contusions. Scattered

60.4.3.2 Contusion/Intracerebral Hematoma
Contusions usually involve the crests of cortical gyri
adjacent to internal bony prominences [24], sometimes
hyperdense contusions, mainly in the left frontal region. Low-
density edema surrounds the contusions. Small contusions
are also located in the anterior temporal regions bilaterally.
Note that the contusions are located along the cortical surface,
abutting the inner surface of the skull
514 D. Omahen and S.J. Hentschel

propensity to evolve or “blossom” over time as areas a

of punctate hemorrhage coalesce and surrounding
edema increases over the first 3–5 days [15]. Eventually,
an intracerebral hematoma, defined as a lesion com-
prised of more than two thirds blood, may form [2, 15].
An increase in size of the involved area is often docu-
mented on serial imaging. Low temporal contusions
(adjacent to the brainstem), large bifrontal contusions,
and posterior fossa hemorrhages are particularly
worrisome.

60.4.3.3 Epidural Hematoma

Epidural hematomas occupy the potential space between

the inner surface of the skull and the dura. They are
more common in younger patients in whom the dura is
less tightly applied to the skull than in older persons.
A so-called classic lucid interval preceding deteriora- b
tion is documented in less than 25% [17]. The most
common location of an epidural hematoma is in the
temporal region, and they are usually associated with a
skull fracture that causes a laceration of a middle men-
ingeal artery branch [7]. Since the source is usually
arterial blood under high pressure, a rapid decline in
the patient’s clinical condition can occur, and rapid
evacuation is essential. Posterior fossa EDH (<5% of
EDH) from occipital fractures may be formed second-
ary to venous sinus bleeding and may be associated
with rapid deterioration from brainstem compression
[17]. Good outcomes are more likely than in the setting
of subdural hematomas since the underlying brain is
compressed but not usually directly injured.
Unfortunately, these bleeds still have a considerable
mortality [1].
On CT scans, an epidural hematoma tends to have a
biconvex shape, and will not cross suture lines; an over-
lying skull fracture is discernable in up to 80% [17]
(Fig. 60.4). Enlargement of an EDH is most likely
within the first 8 h, and is very unlikely after 36 h [28].
Fig. 60.4 CT scan of right epidural hematoma. (a) Right tem-
poral skull fracture (arrow), which overlies the course of the
middle meningeal artery. (b) The underlying epidural hema-
60.4.3.4 Subdural Hematoma toma. It is biconvex in shape and does not cross suture lines

Subdural hematomas (SDH) are situated between the

dura and the brain in the subdural space. Acute subdural
hematomas are more likely to be associated with injury On imaging, subdural hematomas are crescentic in
to the underlying brain parenchyma [1] and generally shape and can cross suture lines (Fig. 60.5). Acute
have a worse prognosis than epidural hematomas. SDHs are hyperdense, in contrast to hypodense chronic
60 A Guide to Neurotrauma for the Rural Surgeon
Fig. 60.5 CT scan: acute left-sided subdural hematoma. Note
the inhomogenous hyperdensity underlying the cranium on the
patient’s left side. Some blood also tracts along the anterior por-
tion of the falx cerebri. The brain is shifted to the right and the
occipital horn of the left lateral ventricle is effaced (compare
with the size of the right occipital horn). A subdural hematoma
SDHs (>3 weeks old), and often result from low-­
pressure venous bleeding, frequently from tiny bridging
veins draining from the cortical surface into the supe-
rior sagittal sinus. Subacute blood (7–10 days old) may
be isodense to brain and difficult to discern [15].
60.4.3.5 Subarachnoid Hemorrhage/
Intraventricular Hemorrhage
Subarachnoid hemorrhage (SAH) is seen in one quar-
ter to one third of severely head-injured patients [15].
Ten percent of severe injuries have evidence of intra-
ventricular hemorrhage [15].
60.4.3.6 Diffuse Axonal Injury (DAI)
When the brain is subject to acceleration/deceleration
forces with an angular or rotatory component, neuronal
axonal projections are subjected to shear forces [27].
In contrast to the lucid interval often seen with extraax-
ial hematomas, victims of DAI are usually rendered
deeply comatose from the moment of injury [2].
515
typically has a crescentic shape and crosses suture line boundar-
ies. A vertical line has been drawn from the anterior and poste-
rior midline attachments of the falx, which remain relatively
fixed. The perpendicular distance from this line to the displaced
positions of normal brain midline structures represents the
degree of midline shift, 1.46 cm in this case
Although CT scans may seem less impressive than
in other injury patterns, DAI is a devastating injury.
Markers of DAI on CT imaging include brainstem
hemorrhage, diffuse edema, and so-called gliding
­contusions in the corpus callosum.
60.4.4 Pathophysiology of Intracranial
Hypertension
Since the skull is essentially a nonelastic box, the
intracranial pressure is determined by the volume of its
contents: a concept known as the Monro–Kellie doc-
trine [29]. Normally, the skull contains cerebral tissue
(1,200–1,600 cc), cerebrospinal fluid (100–150 cc),
and blood (100–150 cc, mainly venous) [29]. The
volume of brain matter is essentially fixed. As the
volume of a mass lesion (e.g., an intracerebral hema-
toma) increases, some venous blood can be displaced
extracranially. Likewise, CSF can be shifted into the
thecal sac of the spinal cord. Eventually, these com-
pensatory mechanisms reach their limits and ICP
will rise precipitously with further small increases
516 D. Omahen and S.J. Hentschel

Monro-kellie Doctrine Table 60.6 Components of Cushing’s triad

Cushing’s triad
1. Hypertension
2. Bradycardia
3. Respiratory irregularity
ICP

Table 60.7 Approach to treatment of intracranial hypertension

Management of elevated intracranial pressure
Nonsurgical:
Intracranial volume
• Elevate head of bed 30° (or reverse Trendelenburg if spinal
Fig. 60.6 In Monro–Kellie pressure–volume curve. The skull is fracture suspected)
rigid and nonelastic. Normal cranial contents include brain mat- • Avoid hyperthermia/shivering
ter, cerebrospinal fluid (CSF), and blood (mainly venous). As an
additional mass lesion increases in size, some compensation • Prompt treatment of seizures
occurs via shift of venous blood and CSF outside the cranial • P
 revent venous constriction: no tight cervical collars/endo-
compartment, blunting the rise in intracranial pressure (ICP). tracheal tube ties
When these compensatory mechanisms are exhausted, the ICP • Ensure adequate sedation
rises precipitously with the addition of any additional volume
• Hyperventilation (never lower pCO2 below 30!)
• Mannitol (20% solution: 0.25–1 mg/kg)
in the size of the mass lesion (Fig. 60.6). Conversely, at • Alternative to mannitol: hypertonic saline
this point on the pressure–volume curve, small reduc- • Pharmacological paralysis
tions in the volume of blood, CSF, or interstitial fluid • Barbiturate coma
can cause dramatic declines in ICP. Understanding of Surgical:
this concept is essential to successful management of
• CSF drainage
intracranial hypertension.
• Evacuation of mass lesion
A key variable in the treatment of raised ICP is the • Decompressive craniectomy
cerebral perfusion pressure (CPP). It is calculated by
subtracting the intracranial pressure from the mean Contraindicated:
arterial pressure (MAP): • Hyperventilation below pCO2 30
• Steroids
CPP = MAP - ICP • Active cooling
Cerebral blood flow is relatively constant within a CPP
range of approximately 60–160 mmHg, a phenomenon
known as cerebral autoregulation [29]. Although the
subject of some controversy, there appears to be a increased ICP are also available. Ideally, ICP manage-
threshold of CPP below which cerebral ischemia ment is guided by intracranial pressure monitoring,
results from insufficient delivery of oxygen to brain but treatments can also be initiated if intracranial
tissue. Thus, it is recommended that the CPP be main- hypertension is deemed likely based on clinical and
tained above 60 mmHg [6]. In the setting of intracra- imaging findings. Elevated intracranial pressure is
nial hypertension, Cushing’s triad [7] (hypertension, documented in up to 80% of patients with a severe
bradycardia, and respiratory irregularity) may be seen head injury [29]. Even with a lack of mass effect evi-
(Table 60.6). dent on initial CT scan, victims of severe brain injury
There are several general strategies that are rou- have a 10–15% risk of developing raised ICP [30, 31].
tinely utilized in the setting of potentially elevated Table 60.7 outlines a general approach to ICP
ICP. In addition, specific treatments for obvious ­management [7, 12].
60 A Guide to Neurotrauma for the Rural Surgeon
60.4.5 Nonsurgical Treatment Measures
for Intracranial Hypertension
60.4.5.1 Promote Venous Return
According to the Monro–Kellie doctrine (see above),
intracranial pressure is related to the total volume of
the contents of the cranial cavity. One way to help
lower ICP is to promote egress of venous blood from
the brain. Elevation of the head of the bed (approxi-
mately 30°) uses gravity to promote movement of
blood out of the head and back to the heart [29]. Ensure
that cervical collars are not so tight as to impede venous
return by compression of vessels in the neck [32].
60.4.5.2 Treat Fever/Shivering/Coughing
As mentioned above, hypothermia has been tried as a
measure to lower ICP by lowering the cerebral meta-
bolic rate. Rises in temperature can increase cerebral
metabolic rate by 10–13%/°C [33], promoting an
increase in blood flow and a resulting rise in ICP. In
addition, shivering can also elevate ICP.
Coughing or straining on an endotracheal tube can
result in valsalva maneuvers which impede venous
return to the heart and result in ICP spikes; these should
be prevented by adequate sedation. In addition, lido-
caine 50–100 mg can be given either intravenously or
down the endotracheal tube prior to suctioning or bron-
choscopy to blunt the cough response and associated
ICP effects [7].
60.4.5.3 Treat/Prevent Seizures
Seizures occur in about 15% of patients with a head
injury [34]. Seizure activity elevates ICP both through
an extreme elevation in cerebral metabolic rate and
through the effects of muscle contraction on venous
return [28]. Seizures should be treated immediately in
the patient with suspected intracranial hypertension.
Signs of seizure may include tonic–clonic movement,
pupillary dilatation, and eye deviation. Status epilepticus
is defined as greater than 30 min of continuous seizure
activity, or multiple seizures without full recovery in
between [7]. Nonconvulsive status epilepticus is thought
517
Table 60.8 Management of status epilepticus
• ABCs
• Lorazepam 4 mg IV, repeat after 4 min if ineffective
• Load with phenytoin 20 mg/kg (<50 mg/min)
• If ineffective: phenobarbital up to 1,400 mg (<100 mg/min)
• I f still seizing after 30 min: intubate and give pentobarbital
15 mg/kg
Source: Adapted from Greenberg [7]
to occur in up to 35% of moderate to severely head-
injured patients [28]. An approach to the medical treat-
ment of status epilepticus is given in Table 60.8 [7].
It is estimated that 20–25% of patients sustaining a
severe TBI will suffer at least one seizure, but the litera-
ture on prophylactic anticonvulsants can be confusing
[35]. Treatment of early seizures does not appear to
influence the later development of post-traumatic epi-
lepsy, but it must be born in mind that seizures can cause
potentially harmful elevations of intracranial pressure.
Based on prospective studies, it appears reasonable to
initiate 1 week of prophylactic dilantin in patients suf-
fering a severe TBI [36]. Patients with a documented
seizure should be started on anticonvulsants. It is impor-
tant to note that pharmacological paralysis prevents the
motor manifestations of seizures, but this is NOT neces-
sarily an indication that seizures have ceased.
60.4.5.4 Sedation
Sedation with CNS-depressants lowers the cerebral
metabolic rate. Under normal conditions, cerebral
blood flow is matched with the metabolic requirements
of the brain [1]. If autoregulation is intact in the injured
brain, a concomitant decline in cerebral blood flow
(and thus in volume of intracranial contents) will result
from this lowering of metabolism.
Short-acting opioids such as fentanyl are commonly
used in head injury. Care must be exercised in the
spontaneously breathing patient since respiratory
depression may lead to hypercarbia and an increase in
ICP. Continuous infusion has theoretical advantages
over bolus administration which may have deleterious
effects on ICP [8]. Benzodiazepines combine sedative
and anticonvulsant properties [8]. Short-acting agents
such as Midazolam are preferred. Propofol leads to
518
reductions in cerebral blood flow (CBF) and cerebral
metabolic rate [8] and has the added advantage of
being short acting, allowing intermittent neurological
assessment of the brain-injured patient.
60.4.5.5 Mannitol
Intravenous administration of mannitol (20% solution)
in doses of 0.25–1 mg/kg every 4–8 h is a long-standing
treatment for intracranial hypertension [8, 37]. It has
several mechanisms of action including osmotic diure-
sis, a reduction in blood viscosity (improving brain
perfusion), and possible scavenging of free radicals
[8, 29]. Onset of action is seen in 15–30 min, and the
effects last 1.5–6 h [3]. Administration guided by
direct ICP measurement appears to yield better results
than administration guided by clinical signs alone [37].
Definitive evidence for prehospital use is lacking [37],
but use is widespread when clinical suspicion of intrac-
ranial hypertension is strong. Although definitive evi-
dence is lacking, many would advocate a full dose of
1 mg/kg in the setting of cerebral herniation. Care must
be exercised in the setting of heart failure, as an initial
increase in intravascular volume results. Serum sodium
and osmolarity must be monitored regularly and treat-
ment withheld for Na > 155 or osmolarity > 320 [1].
60.4.5.6 Hypertonic Saline
Recently, hypertonic saline has been touted as an alter-
native to mannitol for the treatment of elevated intrac-
ranial pressure [38]. Efficacy appears to be similar to
mannitol, but definitive studies are lacking at present
[39]. It should not be used in the treatment of hypov-
olemic shock, however [38].
60.4.5.7 Pharmacological Paralysis
Pharmacological paralysis is often employed in the
treatment of refractory intracranial hypertension [7].
Short-acting agents such as rocuronium are preferred,
especially in the acute phase of head injury, since
their short half-lives allow for intermittent clinical
assessment. It should be noted that rates of pneumo-
nia might be increased in the setting of prolonged
paralysis [40].
D. Omahen and S.J. Hentschel
60.4.5.8 Hyperventilation
Through the phenomenon of cerebral autoregulation,
lowering pCO2 leads to a decrease in cerebral blood
flow, lowering ICP by reducing the volume of blood
within the cranium. While this brings about a rapid
drop in ICP, hyperventilation becomes less effective
over the course of several hours; when utilized, it should
be weaned slowly to prevent rebound intracranial
hypertension [41]. Prophylactic hyperventilation should
be avoided as it leads to worse outcomes [42]. pCO2
should not be lowered below 30 mmHg, since there are
concerns that this may result in cerebral ischemia.
60.4.5.9 Barbiturate Coma
Barbiturates reduce cerebral metabolism (CMRO2),
lower ICP, and exhibit neuroprotective properties [8],
but clinical trials have not proven improved outcome
with their use [43]. The use of barbiturate coma (titrating
to isoelectric EEG) is a second-tier treatment usually
reserved for refractory intracranial hypertension when
all other options have been exhausted [4].
60.4.6 Surgical Methods of Treatment
for Raised ICP
60.4.6.1 External Ventricular Drainage (EVD)/
Intracranial Pressure Monitoring
Placement of a catheter by a neurosurgeon into the
­lateral ventricle allows simultaneous measurement of
ICP and drainage of CSF. CSF drainage causes a shift
toward the left on the pressure-volume curve and can
be an effective method of reducing ICP. Measurement
of ICP is invaluable in guiding treatment of intracra-
nial hypertension. The goal of ICP management is to
maintain the ICP £ 20 mmHg, which has been linked to
better outcomes [4, 31].
Indications for insertion of an EVD [4] include
GCS < 10 with an abnormal CT or a normal CT scan with
a GCS < 8 or two of age > 40, BP < 90 mmHg, or motor
posturing, or prolonged inability to monitor neurological
status (e.g., when undergoing surgical procedures) [29].
Monitoring of intracranial pressure is associated with
improved outcome following severe brain injury [4, 44].
60 A Guide to Neurotrauma for the Rural Surgeon 519

60.4.6.2 Evacuation of Mass Lesions Table 60.9 Cerebral herniation syndromes

Site of Structures involved Clinical
The Brain Trauma Foundation [4] has formulated a list herniation
of indications for the surgical evacuation of traumatic Subfalcine Cingulate gyrus Lower extremity
intracranial lesions. Although unproven, many neuro- Pericallosal arteries weakness
surgeons support prophylactic antibiotics and anticon- Uncal Oculomotor nerve Ptosis, ipsilateral
vulsants, and limited debridement for missile wounds Cerebral peduncle mydriasis
Posterior cerebral Contralateral
of the brain in potentially salvageable patients [7, 45]. artery hemiparesis
Except in extreme situations, operations for intracranial Decreased LOC
mass lesions should be performed by a neurosurgeon.
Tectal Superior colliculi Upgaze palsy
An extremely rare possible exception, exploratory burr
Bilateral ptosis
holes and limited craniectomy, is discussed below.
Central Basilar artery Decreased LOC
perforating branches Respiratory
Brainstem/reticular irregularity
60.4.6.3 Decompressive Craniectomy formation Cushing’s triad
Impaired eye
Although conclusive evidence is still lacking, much movements
interest has been focused on the role of decompres- Tonsillar Medulla Apnea
sive craniectomy in the management of elevated ICP Source: Adapted from Yanagihara et al. [33]
[46–48]. Both bifrontal and frontoparietal craniectomies
have been used with success [49]. These operations may
be combined with duraplasty (opening the dura and In such cases, it is preferable to immediately discuss
using a pericranial or synthetic patch to augment intra- the situation with a neurosurgeon, if possible. It has
dural volume), and/or resection of noneloquent or dam- been documented that survival rates are improved when
aged brain (e.g., temporal lobectomy). These surgical a trained neurosurgeon rather than a general surgeon
procedures should only be undertaken by a qualified performs a craniotomy for acute subdural hematoma
neurosurgeon. [52, 53]. Even for acute epidural hematomas, the
weight of evidence favors transfer to a neurosurgical
center without delay [54].
In patients with moderate-to-severe head injuries,
60.4.6.4 Exploratory Burr Holes/Emergency 0.5–12% will have an epidural hematoma, while
Craniotomy 12–18% will have a subdural hematoma [50]. These
numbers increase in the setting of a skull fracture.
In total, approximately one quarter of comatose trauma Table 60.10 provides a differential diagnosis for
victims will have a surgical lesion [7]. These are best dealt delayed deterioration in the brain-injured patient [7].
with by experienced neurosurgeons whenever possible. In one series of 100 patients with evidence of
Although primarily a diagnostic procedure, in ­herniation and/or brainstem compression, 56% had
exceptional circumstances (e.g., development of signs positive exploratory burr holes [55]. Positive explora-
of transtentorial herniation unresponsive to mannitol tion was more likely with lower speed impacts and in
and hyperventilation) when excessive delay in transfer patients greater than 30 years old. Unilateral SDH was
to neurosurgical care is anticipated exploratory burr found in 70%, bilateral in 11%. The correct side was
holes may be a life-saving maneuver [50, 51] initially chosen in 86%. Significant clot was missed in
(Table 60.9 lists symptoms of intracranial herniation only 6% of patients. Mortality was still 70%, but no
syndromes [33]). Note that compression of the contral- morbidity was attributed to the exploratory burr holes.
ateral cerebral peduncle can result in ipsilateral weak- This procedure is preferably done in the operating
ness. This example of a “false-localizing sign” is known room, but may be performed in the emergency depart-
as Kernohan’s notch phenomenon. It must be stressed ment if delay is anticipated. The side ipsilateral to the
that burr holes or craniotomy should only be attempted blown pupil is chosen first, as this has better localizing
by a general surgeon in exceptional circumstances. value than the side of hemiparesis (due to the existence
520
Table 60.10 Causes of delayed deterioration in head trauma
Differential diagnosis of delayed deterioration in the
brain-injured patient
• Expanding intracranial hematoma
• Diffuse cerebral edema
• Hydrocephalus
• Tension pneumocephalus
• Seizures
• M
 etabolic (hypoxia, hypoglycemia, adrenal insufficiency,
and electrolyte abnormality)
• Drug withdrawal
• Oversedation
• V
 ascular event (dissection, aneurysm rupture, stroke/
embolism)
• Meningitis/sepsis
• Hypotension/shock
Source: Adapted from Greenberg [7]
of Kernohan’s notch phenomenon) [1]. If both pupils are
dilated and the order of dilation is unknown, begin on the
side with obvious external trauma, or the dominant (left)
hemisphere if no other lateralizing clues are present [7].
Exploratory burr holes are placed to facilitate sub-
sequent development of a “trauma flap” and definitive
craniotomy [7, 49] (see Fig. 60.7). Unlike their chronic
counterparts, acute extraaxial hematomas are gener-
ally too thick to be evacuated via burr holes and require
a formal craniotomy for definitive management. The
side to be explored is turned uppermost, aided by a roll
under the shoulder. The head is supported by a horse-
shoe head holder, beanbag, or skull pins. The scalp is
widely shaved on both sides with clippers. A preoper-
ative dose of antibiotics covering skin flora is adminis-
tered (e.g., cefazolin or clindamycin). Mark out a
“reverse question-mark,” as illustrated in Fig. 60.4.
Begin 1 cm anterior to the tragus, at the level of the
zygoma. The trauma flap proceeds superiorly, then
curves posteriorly above the pinna. Approximately
5 cm behind the pinna, it curves upward before finally
curving forward on the ipsilateral side of the head
2 cm from the midline (to avoid the superior sagittal
sinus), terminating frontally just behind the hairline.
The area is then sterilely prepped and draped.
Short portions of this marked trauma flap line will
be opened to allow exploratory burr hole placement, as
shown in the illustration. Begin with a temporal burr
hole, just superior to the zygomatic arch (#1). This is
D. Omahen and S.J. Hentschel
Exploratory Burr Hole Placement
2
3
1
4
Fig. 60.7 Location of exploratory burr holes. Exploratory burr
holes are placed along the path of a reverse question mark-
shaped “trauma flap” to facilitate future craniotomy. Start on the
side of the suspected hematoma. Begin with the temporal burr
hole (#1). If negative, perform a temporal burr hole on the oppo-
site side, then proceed with the frontal (#2), parietal (#3), and
posterior fossa (#4) burr holes (see text for detailed description)
the most common location for an epidural hematoma,
and provides access to most convexity subdural hema-
tomas. The skull is incised sharply and the temporalis
muscle divided to expose the skull. Bipolar cautery is
useful in controlling bleeding from the skin edges or
superficial temporal artery. A self-retaining retractor is
then inserted. A drill or Hudson brace is used to care-
fully create a quarter-sized hole in the skull. The skull
will be relatively thin in the region of the squamous
temporal bone. First, the drill bit will encounter the
relatively hard outer table of the skull, followed by can-
cellous bone, then the harder inner table (these layers
may be less pronounced in this thinner area of temporal
bone). When using a bit and brace, the bit may “catch”
just as each table of the skull is penetrated. Stop and
check your depth frequently and avoid the use of exces-
sive downward pressure as the inner table is penetrated
to prevent “plunging” of the drill. Once the inner table
is penetrated, bone curettes can be used to remove the
remaining bone from the full diameter of the burr hole.
If an epidural clot is encountered, bone rongeurs
can be used to expand the burr hole and fashion a small
temporal craniectomy, allowing some of the clot to be
removed using a combination of suction and irrigation
with body temperature saline. An epidural drain is left
60 A Guide to Neurotrauma for the Rural Surgeon
in place and the skin is closed loosely, pending defini-
tive neurosurgical management. If the dura is encoun-
tered, it can be opened sharply in a cruciate manner if
suspicion of a subdural hematoma is high, or if it is
tense and has a bluish discoloration, indicative of
underlying clot. Care must be taken with this opening
since brain will lie directly under the dura if no sub-
dural clot is present. The dural edges can be cauterized
back to enlarge the opening if clot is encountered.
Suction and/or irrigation can be used to evacuate part
of any hematoma encountered, and rongeurs can be
used to enlarge the bony opening. Again, care must be
taken not to apply suction directly to the brain surface.
Upon closure, a Jackson–Pratt drain may be left, but a
large amount of suction should be avoided by only
­partially priming or “thumb-printing” the drain.
If this first burr hole is negative, a temporal burr hole
is next performed on the contralateral side in the same
manner [7]. If also negative, ipsilateral frontal (#2) and
parietal (#3) burr holes are attempted. Posterior fossa
burr holes (#4) are potentially risky and have a low
yield. They should only be employed if the potential
benefits outweigh the risks (e.g., with a documented
posterior fossa epidural hematoma in the setting of pro-
gressive brainstem compression). Ensure that posterior
fossa burr holes lie below the level of the transverse
sinus, the path of which is approximated by a line run-
ning posteriorly from the zygoma to the inion, or mid-
line bony prominence of the occipital region. Profuse
epidural bleeding may originate from the dural venous
sinuses in the posterior fossa. Packing with gelfoam and/
or application of hemostatic clips yields better results
than extensive use of cautery, which should be avoided.
If the exploration is negative, a piece of gelfoam is
placed in the skull defect and the overlying skin closed
in two layers: using absorbable suture for the galea,
followed by skull suture or staples. A sterile head
dressing is applied.
60.4.7 Unproven and Ineffective
Treatments
60.4.7.1 Steroids
Steroids are effective in reducing peritumoral cerebral
edema by reducing levels of inflammatory mediators
such as VEGF. Several studies have failed to demon-
strate improved outcomes in head injury, and they may
521
increase infectious complications [56]. There is no role
for steroids in the treatment of traumatic brain injury
[4, 43].
60.4.7.2 Induced Hypothermia
Induction of hypothermia (generally to 30–33°C) has
been shown to lower cerebral metabolism and ICP, but
unfortunately clinical outcomes do not improve [57].
Complications such as increased infection and coagul-
opathy appear to negate any beneficial effect of the
decrease in ICP.
A recent Cochrane review emphasizes the lack of
evidence for efficacy of this treatment and suggests it
should only be used in the context of a clinical trial
[58]. Recent evidence suggests that cooling to 35°C is
effective and has a lower risk of complications [59]. If
a patient does arrive to the hospital hypothermic, most
physicians will not actively rewarm once temperatures
are above 33°C. Hyperthermia appears to be deleteri-
ous and should be avoided [60].
60.5 Management of Spinal Injury
Similar to brain injury, management of spinal injury
focuses on the prevention of secondary injury. Trauma
patients should be treated as though they have a spinal
injury until proven otherwise [61]. A key concept in
the management of spinal injury is the concept of sta-
bility. Stability can be defined as the ability of the spine
under physiological loads to limit displacement so as
to prevent injury, incapacitating deformity, or pain due
to structural change [7].
60.5.1 Management of Spinal Injury
60.5.1.1 Clinical Assessment
As outlined above, management of spinal injury begins
with the ABCs and institution of spinal injury precau-
tions. The patient is logrolled onto a spine board, and
the cervical spine is immobilized using a combination
of sandbags or tape and a rigid cervical collar [62].
Padding beneath the occiput helps ensure a neutral
position and helps prevent occipital pressure sore
522
formation [63]. Once transferred to hospital and all
initial investigations have been completed, the patient
should be promptly logrolled off the hard spinal board
to prevent skin ulcer formation [64]. To protect the
skin, paralyzed patients should be logrolled side to
side at least every 2 h [65].
The airway and breathing must be continually mon-
itored [61], as the function of accessory muscles of
respiration and that of the diaphragm itself (innervated
by the phrenic nerve C3–C5) may be compromised in
the setting of spinal cord injury.
It is imperative to avoid hypoxia and hypotension.
To ensure adequate perfusion of the injured spinal
cord, a MAP of 85–90 mmHg is recommended for the
first week after injury. Dopamine is the vasopressor of
choice [7] and is preferred over aggressive infusion of
fluids. Phenylephrine should be avoided due to possi-
ble exacerbation of bradycardia [7]. Bradycardia may
be treated with atropine if needed. A thorough neuro-
logical documentation must be performed and recorded,
as the initial examination will serve as a baseline with
which to compare future exams. The level of the lesion
should be determined from the information gleaned at
physical examination. Injury to the brain, brain stem,
nerve root, brachial or lumbosacral plexus, or periph-
eral nerves should be differentiated from injury to the
spinal cord.
It is imperative that bladder distension be prevented.
Foley catheterization is recommended in all patients
with spinal cord injury who have impairment of blad-
der function. DVT prophylaxis in the form of graduated
compression stocking and low-molecular-weight hepa-
rin are instituted unless contraindications exist (e.g.,
impending surgery and intracranial bleeding) [4].
60.5.1.2 Neurogenic Shock and Spinal Shock
60.5.2 Radiological Evaluation
A source of much confusion is the difference between
neurogenic shock and spinal shock [66]. Neurogenic
shock refers to hypotension related to loss of sympa-
thetic tone after spinal cord injury. Unopposed para-
sympathetic action often leads to bradycardia. Since
vasodilatation occurs distal to the level of the lesion, the
term “warm shock” is sometimes applied to ­neurogenic
shock. Venous pooling of blood in the extremities due to
loss of muscular tone causes a relative hypovolemia.
Spinal shock refers to the transient loss of all neuro-
logical function, including reflexes, below the level of
spinal cord injury. Initial flaccidity below the level of
D. Omahen and S.J. Hentschel
Table 60.11 NEXUS cervical spine evaluation criteria
NEXUS low risk criteria for cervical spine injury
• No posterior midline cervical tenderness
• No evidence of intoxication
• Normal level of alertness/consciousness
• No focal neurological deficit
• Absence of major distracting injuries
Source: Vinson [68]
the lesion is replaced by spasticity as spinal shock
resolves over several weeks. The bulbocavernosus
reflex is often one of the first to return [66].
60.5.1.3 Clearing the C-Spine
In oriented and alert patients free of intoxication, neu-
rological deficit or major distracting injuries, the cervi-
cal spine may be cleared clinically without X-rays if
they lack midline cervical tenderness and demonstrate
full, pain-free range of active motion [7, 67]. The
NEXUS group has devised a set of criteria to aid in
deciding which patients require C-spine X-rays [68]
(Table 60.11). Application of the guidelines resulted in
a sensitivity of 93% in the detection of significant cer-
vical spinal injury [69].
If patients do not meet these criteria, they should
undergo further radiological evaluation. Any patient
with a dangerous mechanism, neurological deficit, or
pain/deformity upon palpation of the thoracolumbar
spine should undergo further radiological evaluation of
these regions.
of Spinal Injury
60.5.2.1 Plain X-rays
In addition to basic trauma X-rays (e.g., chest X-ray),
plain films of the cervical, thoracic, and lumbar spine are
useful in identifying spinal fractures and dislocations.
Presence of soft tissue swelling without fracture is
an indication that further imaging is required [70].
Twenty percent of patients suffering a major spinal
column injury will have injury at a second, possibly
noncontiguous level [7].
60 A Guide to Neurotrauma for the Rural Surgeon
Cervical Spine
A normal lateral cervical spine x-ray is provided in
Fig. 60.8 for reference. A simple approach to reading a
lateral cervical spine X-ray is to follow the “ABCs”
(see Table 60.12).
“A”: stands for adequacy and alignment. Visualiza­
tion from the skull base to the C7–T1 junction is man-
datory. Swimmer’s views may be utilized to visualize
the C7–T1 junction. The vertebrae should be aligned
forming four smooth lines: along the anterior and pos-
terior aspects of the vertebral bodies, the spinolaminar
lines, and the tips of the spinous processes.
“B”: stands for bone. Each portion of every verte-
bral body should be inspected for evidence of fracture.
“C”: stands for “cartilage”. Disc spaces should be
inspected for evidence of widening.
“s”: stands for soft tissue. As a rule of thumb, the
space should be <7 mm at C3 and <21 mm at C7
(pneumonic: 3 × 7 = 21)
Next, the same procedure is followed for the lateral
and open mouth odontoid views. If unable to visualize
the odontoid well, a CT scan through the upper cervi-
cal spine may be required [71].
Fig. 60.8 Normal cervical spine X-ray. This film clearly shows
the entire cervical spine from skull base to T1. The prevertebral
soft tissues are normal in contour and thickness. There is good
alignment along the front and back of the vertebral bodies, as
well as along the spinolaminar line and tips of the spinous pro-
cesses. Disc spaces are normal as is the interval between the
anterior aspect of the dens and C1
523
Table 60.12 Method for evaluation of cervical spine X-rays
Evaluation of cervical spine X-rays
Pneumonic: “ABCs”
A: Adequacy
• Must see occiput to top of T1
• Swimmer’s view may aid in visualizing C7/T1 junction
• Open mouth odontoid view
Alignment: (evaluate 4 lines)
• Anterior/posterior vertebral bodies
• Spinolaminar line
• Tips of spinous processes (less even curvature)
• Edge of vertebral bodies and spinous processes for AP view
• Rule of Spence: on odontoid view, sum of overhang of C1
edge over C2 edge >7 mm implies rupture of transverse
ligament
B: Bony structures
• Inspect all portions of each vertebra individually
C: “Cartilage”
• Look for widening of disc spaces
• Atlantodental interval should be <5 mm in adults
s: Soft tissue swelling
• Guideline: 7 mm at C3, 21 mm at C7
• Difficult if endotracheal tube in place
X-rays provide detailed information about bony
structures, but integrity of the ligamentous complex is
inferred from cervical alignment. In the neurologically
intact patient without subluxation >3.5 mm, supervised
flexion-extension X-rays to rule out ligamentous injury
are obtained if midline cervical tenderness is present
[71]. If the patient is unable to flex and extend through
a full range of motion due to pain or muscle spasm,
they may be mobilized in a rigid cervical collar and
dynamic imaging is repeated after 1–2 weeks when the
pain has subsided [7].
Thoracolumbar Spine
AP and lateral thoracolumbar X-rays are viewed using
the same type of systematic approach outlined above
for cervical spine X-rays. It is often difficult to view
the upper thoracic region, and CT scanning is some-
times required if suspicion of a fracture exists.
60.5.2.2 CT Imaging
Bony anatomy is best delineated with CT scanning.
A CT scan should be obtained in any patient with an
524
abnormal plain X-ray, inadequate plain films, or a
documented fracture. Increasingly, CT scans are
now routinely being employed as part of the initial
radiological workup of the trauma victim [61]. Scans
of the thorax and abdomen can show evidence of
thoracolumbar fracture, but dedicated fine cut spine
CT imaging through areas of suspected fracture is
preferred.
60.5.2.3 MR Imaging
The spinal cord, nerve roots, and plexi are best visu-
alized with MRI imaging. Details such as gross spi-
nal alignment, hemorrhage, edema, intervertebral
disc herniation, and cord/nerve root compression
can be gleaned from an MRI [61]. Any patient with
a new neurological deficit should undergo MRI
imaging.
60.5.3 Treatment of Spinal Injury
Definitive management of spinal injury lies outside the
scope of this chapter. Emphasis should be placed on
proper evaluation and documentation. Measures to
prevent secondary injury (ABCs, immobilization, etc.)
should be instituted. Mean arterial pressure should be
maintained above 85–90 mmHg [72]. Proper skin and
bladder care prevent much morbidity [73]. If neuro-
logical compromise or evidence of spinal injury exists,
appropriate levels of spinal injury precautions should
be employed and consultation with a spinal surgeon
obtained. It is always better to err on the side of cau-
tion when dealing with potential spinal injury.
60.5.3.1 Cervical Traction
The purpose of cervical traction is to maintain or
restore cervical alignment, or to decompress nerve
roots or spinal cord deformed by cervical fracture, dis-
location, or facet subluxation. Early reduction of cervi-
cal spine injuries is often advocated [72]. Since
intervertebral disc disruption or herniation is docu-
mented in one third to one half of patients with cervi-
cal dislocations, prereduction MRI has historically
been recommended, but is now not included in
D. Omahen and S.J. Hentschel
Table 60.13 Contraindications to cervical traction
• Atlantoaxial dislocation
• Proximal spinal column injury
• Underlying fracture or infection at the pin sites
• Hangman’s fractures (types IIA or III)
Source: From Greenberg [7]
guidelines for the management of the fully awake and
cooperative patient [66, 74]. Traction should not be
instituted prior to discussion with a spinal surgeon.
Cervical traction is contraindicated (Table 60.13)
in the setting of atlantoaxial dislocation, proximal spi-
nal column injury, underlying fracture or infection at
the pin sites, and in certain types of C2 hangman’s
fractures (types IIA or III – those with angulation or
subluxation) [7, 66].
Although several types of traction devices are avail-
able, Gardner–Wells skull tongs are the easiest to apply
and have the most widespread availability [7, 61]. Skin
is shaved and prepped with betadine solution prior to
application. Pins are placed 3–4 cm above the pinna,
directly in line with the external acoustic meatus for
neutral longitudinal traction. Applying the pins 2–3 cm
posterior to this point will provide some flexion, which
can be useful for the reduction of facet dislocations;
conversely, applying the pins more anteriorly will
­produce a component of extension. A central spring-
loaded force indicator is located on one of the pins.
The pins are tightened until the force indicator pro-
trudes 1 mm.
Traction is applied incrementally, and the patient
must be reexamined after every change in traction.
Repeat lateral cervical X-rays demonstrate whether
reduction has occurred. Traction is usually started at
3 lb per level proximal to the site of injury, and
should not exceed 10 lb per level. The patient may be
placed in a reverse Trendelenburg position while in
traction, and cervical collars can be removed while
in traction.
60.5.3.2 Role of Steroids in Spinal Cord Injury
The use of steroids in spinal cord injury has been the
effort of intense study and controversy over the years
[75–77]. The traditional dosing regimen is intravenous
methylprednisolone: 30 mg/kg bolus, followed by a
5.4 mg/kg/h infusion over the next 23 h [76]. The use
60 A Guide to Neurotrauma for the Rural Surgeon
of steroids is still listed as an option in contemporary
spinal cord injury guidelines when started within the
first 8 h [78], but most neurosurgeons now feel they
lack efficacy [79]. Their continued use may be driven
more by fear of litigation than by scientific evidence
[79]. The authors do not endorse their ­routine use.
60.6 Transfer of Neurotrauma Victims
Early communication with a neurosurgeon should be ini-
tiated in cases of severe neurological trauma. Many health
regions have linked online radiological image archives. If
not available, images obtained with a digital camera or
cell phone can be sent via e-mail and provide valuable
information to the neurosurgical c­ onsultant [80].
During transfer, all pertinent information should
accompany the patient. Ensure that ambulance reports,
information gleaned from bystanders and family mem-
bers, all bloodwork, radiology reports, and actual copies
of any radiological imaging are sent with the patient.
It has been recommended that neurosurgical pro-
cedures for symptomatic mass lesions be performed
within 4 h of injury. A study from Cambridge, England
concluded that direct air transfer was faster than
transfer by land ambulance when the distance cov-
ered was greater than 23 miles [7]; this will vary
greatly depending upon the availability of transport
mechanisms.
If concerns exist about the patient’s airway, it should
be secured prior to transport. Neuromuscular blockade
and heavy sedation are often employed, but it must be
recognized that they obscure clinical neurological evalu-
ation, and may increase rates of pneumonia and sepsis
[40]. Consequently, if sedating and paralyzing agents are
used, frequent use of short half-life agents is preferred, as
the receiving neurosurgeon will need to perform an accu-
rate neurological assessment upon patient arrival.
60.7 Conclusion
Definitive management of trauma to the central nervous
system can be a delicate and difficult endeavor, and neu-
rosurgical advice and/or involvement is advisable when
potentially serious injury occurs. Nonetheless, careful
assessment, vigilance, and erring on the side of caution
525
can help optimize patient outcome. Following the meth-
ods outlined in this chapter will greatly assist the rural
surgeon in identifying injuries, preventing further dete-
rioration, and aiding receiving physicians in the care of
transferred patients.
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 Abdominal Trauma
Wolfgang E. Thasler
Abdominal trauma is usually separated into blunt and
penetrating trauma. It is important to consider the
injury severity and the bleeding risk of solid organs
early after trauma due to delays of initial treatment or
due to missed injuries during initial assessment.
For the treating surgeon, four key questions must be
answered urgently:
1. Is the patient hemodynamically unstable?
2. Does ultrasound show free fluid in the abdomen
(FAST scan)?
3. Which organ systems are involved with the trauma?
4. Does the patient need a laparotomy?
61.1 Epidemiology
Approximately 20–30% of the patients with multiple
trauma require treatment of intra-abdominal injuries.
The injuries affect with decreasing frequency the liver,
spleen, large bowel, genitals, peritoneum, pancreas,
and diaphragm. Following blunt abdominal trauma,
injury of the spleen is the most common indication for
laparotomy. In 50% of cases, the intestine is injured
during penetrating abdominal trauma.
61.2 Prognostic Significance
Polytraumatized patients with abdominal injuries,
especially to the spleen and liver, have a significantly
higher mortality rate within the first 24 h. This is
W.E. Thasler
Department of Surgery, Grosshadern Hospital,
Ludwig-Maximilians-University München,
Marchioninistr 15, D-81377, München, Germany
e-mail: wolfgang.thasler@med.uni-muenchen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_61, © Springer-Verlag Berlin Heidelberg 2011
61
mainly due to the hypovolemic shock, which in terms
of bleeding control emphasizes the importance of rapid
and effective treatment. When treatment is delayed,
there is a significant increase of mortality.
When compared to complex limb or brain injuries,
few patients suffer from long-term handicaps once the
initial trauma has been survived.
In patients with splenic laceration, a conservative
approach should be attempted if the patient is not in
shock due to the lifelong risk of septic complications
after the splenectomy (OPSI syndrome, see Chap. 26).
Currently, 70–90% of all infant injuries and 40–50%
of all adult injuries of the spleen can be treated without
surgery.
Due to the complex healing process and the severity
of accompanying injuries, pancreatic injuries have a
high mortality rate of up to 25%.
61.3 Clinical Findings, Initial Treatment,
Emergency Admission
61.3.1 Blunt and Penetrating
Abdominal Trauma
Clinical findings of blunt abdominal trauma usually
are acute abdominal pain, caused by peritoneal irrita-
tion due to free intra-abdominal blood or a tear of the
peritoneum. Pain projected into the back or genitals
is usually caused by an injury of the retroperitoneal
organs (pancreas, kidney). The pain intensity often
does not correlate with the injury severity; however,
the extent of hypovolemic shock dictates the urgency
of therapeutic interventions. Bruises and pain localiza-
tion give a first indication of potentially injured organs.
529
530
A splenic injury is correlated with left lower rib frac-
tures in ¼ of all patients.
Potential blood loss must be monitored with repeated
measurements of hemoglobin and hematocrit.
During the initial assessment in the emergency
room, free intra-abdominal fluid in the Morrison pouch,
around the spleen and in the Douglas pouch must be
excluded or diagnosed by ultrasound; it is mandatory
to repeat the ultrasound after 30 min to diagnose sec-
ondary delayed hemorrhage.
In cases of large amounts of free fluid and signs of
hypovolemia (drop in systolic blood pressure <90 mmHg,
tachycardia >120/min despite volume resuscitation as
well as a decrease of hemoglobin), a clear indication
for immediate laparotomy and definite bleeding con-
trol is given (Fig. 61.1).
During the primary assessment in the emergency
room, a bladder catheter is inserted to detect or exclude
a hematuria which can be caused by renal or urinary
tract injuries. The catheter, furthermore, allows kidney
function monitoring as an indicator of adequate or
inadequate fluid administration.
The option of intra-abdominal pressure measure-
ments using the bladder catheter can be useful to diag-
nose abdominal compartment syndrome early and allow
for surgical decompression, especially for patients with
multiple injuries during intensive care treatment.
Clinical evaluation + ±
± +
Hemodynamically
stable
Further diagnostics
- CT
- angiography
- endoscopy
−
Intensive care
Fig. 61.1 Diagnostic
algorithm for abdominal
Conservative therapy
trauma
W.E. Thasler
If pelvic and perineal injuries must be suspected,
inspection of the anus and perineum as well as rectal
examination is mandatory (see ATLS guidelines).
If you are dealing with a penetrating abdominal
trauma, it is important to leave the penetrating
foreign body in place, and it should be fixed in
position until the patient is in theater, intubated and
has sufficient intravenous access as well as moni-
toring devices inserted. Early removal of the for-
eign body can cause severe hemorrhage and death.
61.4 Diagnostic Imaging
61.4.1 Ultrasound
During recent years, the use of peritoneal lavage for
the diagnosis of intra-abdominal bleeding or hollow
organ perforation has been replaced by ultrasound
examination (FAST scan). Ultrasound is a means of
easy and cheap monitoring of trauma patients and
should be considered the diagnostic tool of first
choice.
Abdominal trauma
Ultrasound
Hemodynamically
instable
Emergency laparotomy
+ stop bleeding
Surgery
Intensive care
definite repair
61 Abdominal Trauma 531

61.4.2 Conventional Abdominal X-Ray 61.4.4 Angiography

Especially for gunshot wounds and other penetrating A key advantage of direct angiography is the option to
injuries, plain X-rays of the abdomen (supine and selectively embolize bleeding vessels (Fig. 61.4), espe-
erect) may be useful to detect perforating injuries and cially in patients with hepatic or retroperitoneal blood
to localize the foreign body in the abdomen. loss.

61.4.3 Computed Tomography 61.5 Therapeutic Approach

In comparison to ultrasound scanning, a non-contrast 61.5.1 Exploration and Definite

computed tomography can provide more information
regarding combined injuries as well as their severity;
in particular, intra-abdominal and retroperitoneal
fluid collections can be clearly identified (Figs. 61.2
and 61.3). The diagnostic value of the CT scan is fur-
ther increased if intravenous contrast is used. Since
i.v. contrast can mask small amounts of intracranial
blood loss, the enhanced CT scan should follow native
CT scanning of the skull, if indicated. The introduc-
tion of spiral CT scanners did shorten the time needed
for this examination down to a few minutes only. In
addition to the precise evaluation of all solid organs,
the aorta with its abdominal branches can also be
assessed.
Surgical Treatment
In patients with confirmed free intra-abdominal fluid
and a drop in hemoglobin, emergency laparotomy is
needed within 1 h after admission especially if the
patient has signs of compromised circulation. If mul-
tiple trauma is present, cardiac and thoracic causes of
shock must be excluded. If circulation is not compro-
mised, urgent surgery may be necessary for the treat-
ment of organ lacerations as detected by CT scanning,
unclear abdominal findings, signs of hollow organ
perforation, or solid organ rupture (pancreatic gland,
liver).

Laparotomy

Evaluation of all 4 quadrants in a clockwise direction

Stabilise the patient’s condition by management of critical bleeding

Bleeding stopped Provisional tamponade Persistant bleeding

Debridement, definitive Bleeding stopped Packing

maintainance of blood vessels
and bile ducts

Persistant bleeding
Repacking, until causes of
Total vascular isolation
coagulopathy have been
a) subdiaphragmatic
corrected, i.e. “damage
Exploration and aortic clamping
control”
treatment of laceration b) intracaval shunt

Angiography Reexploration Treatment of Hepatectomy

Fig. 61.2 Surgical approach embolisation transfer patient bleeding site
for abdominal trauma
532 W.E. Thasler

Classification of the severity of organ injury

Grade Liver injury description Spleen injury description Pancreatic injury description

I Subcapsular, no swelling, <10% Subcapsular, no increase in size, Small contusion without ductal injury,
of the surface area, laceration of
<10% of the surface area, laceration superficial laceration without ductal
the capsule with no bleeding, of the capsule without bleeding, injury
>1cm deep <1cm in parenchymal depth
Subcapsular, no swelling, 10% – Subcapsular, no increase in size, 10– Major contusion without ductal injury;
II
50% of the surface area, 50% of the surface area, no Major laceration without ductal injury
intraparenchymal, laceration of intraparenchymal size increase,
the capsule with bleeding, diameter <5cm, capsular laceration,
1–3cm deep, <10cm long active bleeding, parenchymal depth 1–
3cm without trabecular vessel
involvement
III Subcapsular, >50%ofthe Subcapsular >50% of the surface area Distal transection or parenchymal injury
surface area or expanding, or expanding, ruptured subcapsular with ductal injury
ruptured subcapsular hematoma, hematoma with active bleeding,
active bleeding, intrahepatic intraparenchymal hematoma >5cm or
hematoma >2 cm or expanding, expanding, parenchymal depth >3cm
>3 cm deep or with trabecular vessel involvement
Intrahepatic rupture, active Ruptured intraparenchymal hematoma Proximal transection or parenchymal
IV
bleeding, parenchymal disruption with active bleeding, laceration injury with ampulla involvement
(25–50% of a liver lobe) involving segmental or hilar vessels
producing major devascularisation
(>25% of the spleen)
V Parenchymal disruption (>50% of Completely shattered spleen Massive disruption of the pancreatic
hepatic lobe), juxtavenous Hilar vascular injury with head, often combined with injuries to the
hepatic injury to the retrohepatic devascularised spleen neighbouring organs
vena cava or major hepatic veins

VI Hepatic avulsion – –

Fig. 61.3 Grading of Severity of Organ Injury

A long midline laparotomy is considered to be the
standard access in adult patients (horizontal in chil-
dren), since it allows for exploration of all abdominal
quadrants and subsequent treatment of injuries of the
abdomen (liver, hollow organs, mesenterium) as well
as the retroperitoneum. Primary goal of surgery is
bleeding control and prevention of prolonged hypov-
olemic shock. Especially in patients with severe liver
lacerations, ruptures and pronounced hemorrhagic
shock, surgery must be reduced to liver packing only
and definite treatment is done during second (or third)
look operation or with radiological intervention (embo-
lization) after adequate stabilization of the patient.
With splenic injuries, the spleen must be mobilized
from its dorsal adhesions to allow for accurate assess-
ment of injury severity and subsequent definitive treat-
ment (preservation vs splenectomy). With regard to
organ conservation, it is important to note that at least
1/3 of the organ mass must be preserved to guarantee
adequate function after surgery.
Segmental resection and bowel anastomosis must
be done for hollow organ injuries; direct sutures can be
used for small perforations after excision of the wound
margins.
61.5.2 Damage Control Surgery
Damage control aims at cleaning the peritoneal cavity.
This peritoneal toilet must include removal of all con-
taminants and infectious fluids; whether or not peritoneal
lavage in this situation reduces mortality is not known.
Damage control surgery aims at fast clearance of all
contaminants and control of any source of contamina-
tion. Usually, anastomosis or definite repair of defects
61 Abdominal Trauma
a diaphragmatic injury and helps to examine the perito-
b
Fig. 61.4 (a) Interventional embolization of ruptured right liver
vein. (b) Completed healing after intervention and revision surgery
is not part of this surgical strategy. The major goal of
damage control surgery is to allow for fast return of the
patient to intensive care for stabilization and assure
survival of the trauma. Therefore, the main tools of
damage control surgery are linear staplers, drains,
packs, and sutures with large needles.
61.5.3 Diagnostic Laparoscopy
Laparoscopy should only be done in patients with uncom-
promised circulation. Due to often missing information
regarding depth and direction of possible penetrating
trauma, this may be investigated using minimal invasive
surgery. Laparoscopy enables detection and treatment of
533
neum and intestine after penetrating injuries. With unclear
findings, a low threshold to conversion is important
because the rate of missed injuries can be as high as 20%.
Minimal invasive surgery allows for bleeding control
from minor solid organ injuries as well as closure of pen-
etrating injuries of the stomach, intestine, or diaphragm.
Gunshot wounds usually require laparotomy due to the
multitude of possible injuries caused by the projectile.
This approach can vary with different levels of experi-
ence with gunshot injuries.
61.5.4 Conservative Therapy
Criteria for conservative treatment are:
1. Uncompromised circulation
2. Minimal solid organ injuries with small amounts of
free fluid detected by imaging techniques
3. Absence of severe accompanying injuries
Intensive care or high dependency unit care and moni-
toring are mandatory. In case of splenic trauma, an
increased risk of life-threatening blood loss exists up
to 1 week after injury. This is due to possible second-
ary bleeding from a ruptured subcapsular hematoma
after an interval of a few days after the trauma. For this
reason, we suggest in-hospital stay and close observa-
tion for 10 days in these patients. Failure of conserva-
tive treatment, delayed laparotomy, and missed
perforations of hollow organs or ruptures of solid
organs can be recognized if delayed deterioration of
the patient’s condition after initial stabilization and
improvement of clinical findings is detected.
Recommended Reading
Bashir, M.M., Abu-Zidan, F.M.: Damage control surgery for
abdominal trauma (review). Eur. J. Surg. Suppl. July(588),
8–13 (2003)
Chelly, M.R., Major, K., Spivak, J., Hui, T., Hiatt, J.R., Margulies,
D.R.: The value of laparoscopy in management of abdomi-
nal trauma. Am. Surg. 69(11), 957–960 (2003)
Franklin, G.A., Casós, S.R.: Current advances in the surgical
approach to abdominal trauma (review). Injury 37(12),
1143–1156 (2006). Epub 7 Nov 2006
534
Nelson, R., Singer, M.: Primary repair for penetrating colon
injuries (review). Cochrane Database Syst Rev. 2003(3),
CD002247 (2003)
Schein, M., Rogers, P.N. (eds.): Schein’s Common Sense Emer­
gency Abdominal Surgery, 2nd edn. Springer, Berlin (2005)
W.E. Thasler
Stengel, D., Bauwens, K., Sehouli, J., Rademacher, G., Mutze,
S., Ekkernkamp, A., Porzsolt, F.: Emergency ultrasound-
based algorithms for diagnosing blunt abdominal trauma
(review). Cochrane Database Syst Rev. 18(2), CD004446
(Apr 2005)
 Trauma Surgery: Neck Trauma
Harsh A. Kanhere and Robert A. Fitridge
62.1 Neck Trauma
62.1.1 Introduction
Trauma to the neck is most often due to penetrating
injuries. These can be present in isolation – e.g. stab
wounds or as part of multi-trauma with projectiles
causing penetrating injuries as in motor vehicular acci-
dents or explosions. Blunt trauma to the neck is rare,
and this chapter will therefore focus on the manage-
ment of penetrating neck injuries.
Non-surgical management of neck wounds led to a
high incidence of mortality in the past and therefore
focus shifted to exploration of all neck wounds where
the platysma was breached. The current trend is for a
more selective approach to neck exploration.
62.1.2 Treatment Principles
Initial assessment and management: The initial assess-
ment and management of the trauma patient should be
carried out according to the ATLS/EMST principles.
Airway and breathing: An important aspect of injuries
to the neck is the potential for rapid airway obstruction.
Due to distortion of anatomy, intubation and main-
tenance of a patent airway is often difficult. An anaes-
thetist skilled in airway management is therefore
H.A. Kanhere (*) and R.A. Fitridge
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: drhakanhere@hotmail.com
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_62, © Springer-Verlag Berlin Heidelberg 2011
62
invaluable and should always be a part of the trauma
team. The rural surgeon has to possess critical skills in
rapid intubation and securing a patent airway should
the anaesthetist not be readily available. Cervical spine
protection is critically important in these patients.
Careful choice of route of intubation should be made,
and at times, a cricothyroidotomy below the site of
injury may be a safer option. Use of paralysing agents
should be with utmost caution, for the airway may be
held open only with the use of patient’s muscles.
Circulation: Attention should concurrently be given
to the victim’s haemodynamic status. Blood pressure
and pulse rate along with capillary refill should be
assessed to gauge the severity of blood loss. Immediate
resuscitative measures as outlined in the ATLS/EMST
guidelines should be instituted.
Direct pressure should be applied to control bleed-
ing from an obvious source. Direct finger pressure to
major bleeding vessels in the neck will achieve good
temporary control. Probing a neck wound is not advis-
able especially if it is not bleeding.
Disability assessment and proper exposure of the
patient are mandatory and should be performed con-
currently with the initial resuscitative measures.
The possibility of cervical spine and laryngeal inju-
ries should be kept in mind at all times and all protec-
tive measures should be implemented.
62.1.3 Definitive Management
Note: A neck wound that does not penetrate
beyond the platysma in a haemodynamically sta-
ble patient generally does not require surgical
exploration.
535
536 H.A. Kanhere and R.A. Fitridge

Mandatory exploration of all neck wounds penetrat- Zone I – cricoid cartilage to clavicle/thoracic outlet
ing the platysma was in vogue after World War II; how- Contents – trachea, oesophagus, great vessels, thoracic
ever, in recent years, an increasing number of trauma duct and lung apices
centres are adopting a selective exploration policy.
Zone II – cricoid to the angle of mandible
In the rural setting however, decision-making has to
Contents – carotid arteries, jugular veins, and the upper
be swift and safe, based on the resources available.
aerodigestive tract
Careful close observation along with facilities to per-
form investigations such as angiography, endoscopy, Zone III – between angle of mandible and base of skull
bronchoscopy, etc. at any time is required where a selec- Contents – distal carotid arteries, and vertebral arter-
tive exploration policy is adopted and this may not ies, jugular veins
always be possible at a rural centre. A more liberal atti-
tude towards neck exploration is therefore advisable.
A brief, focussed history should be taken and a rapid
clinical assessment to rule out other life-threatening
62.1.4 Surgical Principles of Management
injuries should be performed prior to exploration.
The emphasis on management of a patient with Mandatory versus selective neck exploration
neck trauma is on CONTROLLING HAEMORRHAGE
• In a stable patient where the platysma is not pene-
and TEMPORISING AIRWAY injuries.
trated, a neck exploration is not warranted.
Most visceral (oesophageal) injuries of the neck do
• Haemodynamically unstable patients with isolated
not require immediate repair as they do not have
penetrating neck injury and signs of vascular and
­immediate life-threatening implications. These should
airway injury require urgent surgical exploration.
be preferably transferred and managed in a spe­cialist
• Pharyngeal/oesophageal injuries are generally not
trauma referral centre after ensuring there are either no
immediately life threatening and exploration can be
vascular and airway injuries or that these have been
performed after transfer to a specialist centre after
adequately dealt with.
excluding vascular and airway injuries.
• In a stable patient with injury penetrating deep to
platysma, a grey area exists. Various authorities
62.1.3.1 Zones of the Neck
have advocated observation with non-operative
evaluation using investigative techniques such as
Location of the injury within the neck dictates the
arteriography/CT angiography, bronchoscopy and
management and the surgical approach. The neck is
thin barium studies, etc. These techniques are gen-
divided into three zones for better categorization of
erally not readily available to the rural surgeon on
these injuries shown in Fig. 62.1.
an emergency basis and hence a liberal policy of
exploration of these wounds may be the most appro-
priate course of action.

62.1.5 Surgical Exploration

62.1.5.1 Priorities

A. Maintain airway
B. Stop bleeding – digital pressure, fogarty/foley catheter
C. Further management based on patient stability
Surgical management of penetrating neck injuries
depends on the location and nature of injuries. The
carotid artery and internal jugular vein are commonly
Fig. 62.1 Zones of neck injured in penetrating trauma. The larynx, pharynx,
62 Trauma Surgery: Neck Trauma 537

trachea and oesophagus are equally at risk of injury.

Gunshot wounds are likely to cause more damage
than stab wounds. The treatment should be based on
the anatomic zones of the neck. Multiple organs are
often injured, and a thorough exploration is therefore
required.

62.1.6 Vascular Injuries

62.1.6.1 Access to the Neck

Position – patient placed supine with arms at the side.

Entire chest and shoulder should also be prepared.
Head should be extended and rotated to the opposite
side if feasible, bearing in mind the potential of aggra-
vating spinal injuries. The same issue holds true for
placement of a sandbag between the shoulders. Ideally
Fig. 62.2 Midline sternotomy with anterior sternomastoid incision
one should prepare and drape one leg in case a saphen-
ous vein is required for vascular repair.

Zone I

These injuries provide the maximum challenge to the

surgeon and are especially difficult to treat in the rural
setting. The surgeon undertaking the exploration needs
to possess sound anatomical knowledge of the neck
and the thorax.
Patients with uncontrollable haemorrhage from
injury in this zone will require a thoracotomy to gain
proximal access to the vessels. The rural surgeon
should therefore be well versed in performing thoraco-
tomies and sternotomies and should consider under-
taking extra training if required to achieve this skill.
The operation requires good backup from the assis-
tants and nurses. This is perhaps the most challenging
situation to deal with in a rural hospital with a limited
Fig. 62.3 Trap door incision
resource of trained personnel, and mortality rates in
these situations are expectedly high.
Sternotomy with a supraclavicular extension to the be contemplated if one is skilled in performing vascu-
right in right-sided injuries will provide best access for lar surgery but will be beyond the scope of most
proximal and distal control as shown in (Fig. 62.2). general surgeons working in a rural hospital.
A left anterior thoracotomy and a supraclavicular
incision provide optimal access on the left. A trapdoor
thoracotomy (Fig. 62.3) is advocated by some but is Zone II
an extremely difficult and morbid procedure and
should not be performed in the rural hospitals unless The most universally used approach to any neck injury
no other choice exists. A definite vascular repair can is an anterior sternomastoid incision (Fig. 62.4). The
538
Fig. 62.4 Anterior sternomastoid incision
incision is placed along the anterior border of the ster-
nomastoid muscle, and the platysma and the investing
layer of fascia are divided. The sternomastoid muscle
is then exposed and retracted laterally/posteriorly to
expose the carotid sheath. Lateral traction on the
internal jugular vein and the carotid vessels will
expose the pharynx, larynx, oesophagus and trachea
(Fig. 62.5).
This incision has the advantage of being able to be
extended proximally or distally or continued as an
anterior sternotomy.
Zone III
Injuries in this region are very difficult to deal with.
Great care is required in management. An anterior
Internal carotid
artery
External carotid Internal jugular
artery vein
Fig. 62.5 Exposure of carotid artery and jugular vein via
anterior sternomastoid approach
H.A. Kanhere and R.A. Fitridge
sternomastoid incision is used, but the access to the
distal stump of the internal carotid artery is difficult.
A Fogarty catheter can be extremely useful to control
bleeding from the distal segment. Techniques such as
mandibular dislocation can be useful, but urgent con-
trol of haemorrhage is often possible only with a bal-
loon catheter. In some centres, endovascular approaches
such as placement of covered stents are utilised for
dealing with inaccessible carotid lesions.
In penetrating neck injuries, exposure of the bleed-
ing vessel should be the first priority once the airway is
secured. In zone II, The carotid vessels can be very
nicely exposed by ligating and dividing the common
facial vein and retracting the internal jugular vein lat-
erally and once the bleeding vessel is isolated with
proximal and distal control, sterile tubing can be used
as a stent to stop the bleeding and maintain cerebral
blood flow if a vascular shunt (e.g. JavidTM) is not
available. The stent is secured by ligating the vessel
wall over the stent. Definitive management can then be
carried out in a specialist trauma centre.
A balloon catheter (Fogarty/Foley) is a useful
means to control haemorrhage. The catheter is inserted
within the lumen of the vessel and the balloon inflated
to stop the bleeding. The catheter is then secured with
sutures and once the patient is stabilised, definitive
repair/transfer to a trauma centre can be considered. If
a selective approach to neck exploration is adopted,
arteriography should be easily and readily available.
Neurological status at the time of exploration does
influence the method of repair. If the patient has nor-
mal neurological status, an attempt to maintain cere-
bral blood flow should always be made. Tying off the
carotid vessels should be the last option.
Other Visceral Injuries
Injuries to major viscera within the neck can be
accessed with the anterior sternomastoid incision.
A collar extension of the incision gives excellent bilat-
eral exposure.
If major vascular and laryngotracheal injuries caus-
ing airway obstruction are excluded, these organ inju-
ries are best managed by specialist trauma units in
tertiary referral centres.
62 Trauma Surgery: Neck Trauma
Direct closures of injuries to the oesophagus and
pharynx are often possible, but do require multidisci-
plinary input and should therefore be treated in a
tertiary centre.
Good drainage should always be provided for these
repairs. In severe oesophageal injuries, a cervical
oesophagostomy is sometimes required and can be life
saving along with a draining gastrostomy and feeding
jejunostomy.
In conclusion, neck injuries are difficult to manage in
rural surgical setting. Clear protocols for management
are essential with prioritisation of treatment options.
Immediate exploration is necessary in major vascu-
lar injuries and the goal of the rural surgeon should be
to control haemorrhage, and try to maintain cerebral
blood flow whenever possible. Further management
should be carried out by specialist teams in tertiary
centres.
539
Recommended Reading
Advanced Trauma Life Support (ATLS): Manual of trauma.
www.facs.org/trauma/atls
Casey, M.M., Wholey, D., Moscovice, I.S.: Rural emergency
department staffing and participation in emergency certifica-
tion and training programs. J. Rural Health 24(3), 253–262
(2008)
Duchesne, J.C., Kyle, A., Simmons, J., et al.: Impact of tele-
medicine upon rural trauma care. J. Trauma 64(1), 92–97
(2008). Discussion 97–98
Hansen, K.S., Uggen, P.E., Brattebø, G., et al.: Team-oriented
training for damage control surgery in rural trauma: a new
paradigm. J. Trauma 64(4), 949–953 (2008). Discussion
853–854
Liverpool Trauma: www.swsahs.nsw.gov.au/livtrauma
Royal Australasian College of Surgeons – Trauma education:
www.surgeons.org/education
Trauma.Org – Care of the Injured: www.trauma.org
 Open Extremity Fractures
Ekkehard Euler
Open fractures have a high incidence of bone healing
problems and infections, especially the tibia. An open
bone fracture is therefore to be considered a surgical
emergency. The extent of the wound and the degree of
soft-tissue injury and contamination influence the
result of the treatment substantially.
63.1 Scoring
In German-speaking regions, the classifications
according to Tscherne and Oestern are used to
­evaluate the severity of soft-tissue injury, whereas in
­Anglo-American language regions, the classifica-
tions according to Gustilo and Anderson (Table 63.1);
(Fig. 63.1) are most commonly referred to. The sever-
ity of soft-tissue injury, which can be described in
detail using the Hannover Fracture Scale (HFS), influ-
ences the result of the treatment. Deep infections after
primary UTN-stabilisation of open tibia fractures
average 5–11% of type III injuries according to Gustilo
and are significantly more frequent than in type I and
II injuries.
For high-grade extremity injuries, the MESS
(Mangled Extremity Severity Score) and the NISSSA-
Score according to McNamara (higher specificity and
sensitivity compared to the MESS; Table 63.2) respec-
tively, are important references for the decision of limb
salvage versus amputation. The ‘cut off point’ is seven
E. Euler
Chirurgische Klinik und Poliklinik,
Ludwig-Maximilians-Universität – Innenstadt,
Nußbaumstraße 20, 80336 München, Germany
e-mail: ekkehard.euler@med.uni-muenchen.de
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_63, © Springer-Verlag Berlin Heidelberg 2011
63
points on the MESS and 11 points on the NISSSA-
Score, i.e., a higher number of points has a positive
predictive value of 100% in favour of amputation.
63.2 Compartment Syndrome
An open fracture does not exclude the development of
a compartment syndrome, e.g., in open fractures of
type I. Fracture haematoma and/or oedema leads to
increased pressure in the afflicted compartment, and
subsequently the circulation especially of the muscles
and neural structures can be permanently disrupted to
the point of necrosis. The indication for a fasciotomy
to reduce the pressure in a manifest compartment syn-
drome is given on the basis of clinical parameters such
as severe pain, massively swollen and hardened soft
tissue as well as deficits of sensitivity and motion
(despite palpable peripheral pulses!). The clinical
diagnosis can be further confirmed by measuring the
pressure within the compartment where the fracture is
located. The decisive factor is the numeric difference
between the diastolic pressure and the compartment
pressure (DP). An indication for fasciotomy is given at
DP > 20–30 mmHg.
63.3 Diagnostic Steps
For the inspection of the wound, it has to be kept in
mind that the sterile dressing applied at the place of
accident must not be taken off outside the operation
room! Checking circulation, sensitivity and movement
ability as well as imaging are part of the standard
­preoperative work up.
541
542
Table 63.1 Classification of soft-tissue injury in open fractures according to Tscherne and Oestern as well as open fractures
according to Gustilo and Anderson
Tscherne/Oestern
Type I Minimal soft-tissue damage, indirect violence, simple
fracture pattern
Type II Superficial abrasion of contusion caused
by pressure from within, simple fracture pattern
Type III Deep contaminated abrasions associated with
localised skin or muscle contusion, impending
compartment syndrome, severe pattern
Type IV Extensive skin contusion or crush, underlying severe
muscle, decompensated compartment syndrome,
associated major vascular injury, severe pattern
Fig. 63.1 Classification of
soft-tissue injury according to
Gustilo
Cave
The premature – and possibly according to hier-
archical order multiple – opening of the dressing
in ambulance rooms multiplies the risk of infec-
tion and must be refrained from.
63.4 Antibiotic Prophylaxis
For all open fractures, a prophylactic 1-day treatment
with antibiotics is advised. According to current
­recommendations, it should be a Cephalosporin of the
second generation and additionally an Aminoglycoside
E. Euler
Gustilo/Andersen
Superficial clean wound smaller than 1 cm in diameter,
appears clean, simple fracture pattern
A laceration larger than 1 cm but without significant
soft-tissue crushing, including no flaps, degloving, or
contusion. Fracture pattern may be more complex
An open segmental fracture or a single fracture with
extensive soft-tissue injury. Also included are injuries older
than 8 h. Type III injuries are subdivided into three types
Type IIIA: adequate soft-tissue coverage of a fractured bone
despite extensive soft-tissue laceration or flaps or high-
energy trauma irrespective of the size of the wound
Type IIIB: extensive soft-tissue injury with periosteal
stripping and bony exposure. This is usually associated with
massive contamination
Type IIIC: open fracture associated with arterial injury
requiring repair
for type III injuries. If extensive soft-tissue injuries
are at hand and require a planned second look
­operation, the antibiotic treatment will continue for up
to 72 h.
63.5 Soft-Tissue Management
63.5.1 Primary Closure
Uncomplicated, small wounds can be treated according
to Friedrich: canny but complete ‘en-bloc’ ­excision of
contusioned, dirty and contaminated tissue and tension-
free primary closure under sterile precautions.
63 Open Extremity Fractures 543

Table 63.2 NISSSA-Score according to McNamara. Scores above ³11 have a predicative value towards an amputation of 100%
Type of injury Degree of injury Points Description
Nerve injury Sensate 0 No major nerve injury
N Dorsal 1 Deep or superficial peroneal nerve, femoral nerve injurya
Plantar partial 2 Tibial nerve injurya
Plantar complete 3 Sciatic nerve injurya
Ischaemia None 0 Good to fair pulses, no ischaemia
I Mild 1 b
Reduced pulses, perfusion normal
Moderate 2 b
No pulse(s), prolonged capillary refill, Doppler pulses present
Severe 3 b
Pulseless, cool, ischaemic, no Doppler pulses
Soft tissue/ Low 0 Minimal to no ST contusion, no contamination (Gustilo type I (5,6))
contamination
S Medium 1 Moderate ST contusion, low-velocity GSW, moderate contamination,
minimal crush (Gustilo type II (5,6))
High 2 Moderate crush, deglove, high velocity GSW, moderate ST injury may
require soft-tissue flap, considerable contamination (Gustilo type IIIA (5,6))
Severe 3 Massive crush, farm injury, severe deglove, severe contamination, requires
soft-tissue flap (Gustilo type IIIB (5,6))
Skeletal Low energy 0 Spiral fracture, oblique fracture, no or minimal displacement
S Medium energy 1 Transverse fracture, minimal comminution, small calibre GSW
High energy 2 Moderate displacement, moderate comminution, high velocity GSW,
butterfly fragment(s)
Severe energy 3 Segmental, severe comminution, bony loss
Shock Normotensive 0 Blood pressure normal, always >90 mmHg systolic
S Transient hypotension 1 Transient hypotension in field or emergency centre
Persistent hypotension 2 Persistent hypotension despite fluids
Age Young 0 <30 years
A Middle 1 30–50 years
Old 2 >50 years
Nerve injury as assessed primarily in emergency room
a

Score doubles with ischaemia >6 h

b

63.5.2 Debridement debris that cannot be mechanically removed otherwise.

However, caution is advised with regard to contamina-
tion of deep soft-­tissue layers caused by Jet-Lavage.
The surrounding area of dirty and contaminated wounds
is cleansed with an antiseptic soap solution (‘brushed’)
and shaved. The wounds are, after application of a ster-
ile cover, mechanically debrided and rinsed. Debridement
means: Eradicative excision of contusioned and con- 63.6 Osseous Stabilisation
taminated skin-, hypodermic-, fascia-, and muscle-tis-
sue as well as of denuded small bone fragments. After osseous stabilisation – preferably with external
Exempted from this are nerval and vital vascular struc- fixation if extensive soft-tissue injury is present – vascular
tures as well as bone fragments that are important for reconstructions are carried out, using venous inter-
the stability. Jet-Lavage is recommended for extensive ponates if necessary.
544
Separated nerves are anastomosed using micro-
surgical techniques (magnifying glasses, surgical
microscope).
63.7 Wound Closure
The therapeutic goal for open fractures and soft-tissue
injuries, apart from the prevention of infections, is the
early coverage of bones, sinews, joints and neurovas-
cular structures within no more than 1 week. Type I
and most Type II injuries according to Gustilo can be
primarily closed. For small, superficial and uncontu-
sioned wounds, synthetic skin replacement patches
(Epigard) are used to temporarily cover the wound.
The closure of the wound takes place after granula-
tion, in accordance to the degree of swelling of the
soft-tissue, either with a secondary suture (delayed
primary suture) or with a so-called dynamic suture,
given that no significant skin defects are at hand. With
the ‘dynamic suture’ (restraint), it is possible to grad-
ually approximate the edges of the wound. This is
primarily used after the splitting of compartments
(Fig. 63.2). If a skin deficit is at hand, the wound can
be closed with a skin transplant, e.g., split-skin graft.
Extensive soft-tissue damage requires additional
measures. In past years, vacuum-assisted closing
methods, using PVA-sponges (Polyvinylacetate),
which are inserted into the damage, have increasingly
been used. The sponge, sealed with foil, is kept under
continuous sub-atmospheric pressure via a tube-pump-
system, which leads to a reduction of the soft-tissue
oedema and activates granulation even across an
exposed bone. On the second or third post-traumatic
Fig. 63.2 Scheme of a ‘dynamic
suture’ (restraint); strong monofil
thread is used and either pinned
directly intracutaneous or kept in
place with the aid of skin suture
clamps; repeated retightening in
regular intervals leads to an
approximation of the edges of the
wound
E. Euler
day, a planed ‘second look’ including debridement and
necrotomy is necessary. The vacuum-assisted-closure-
treatment needs to be continued until necrotisation is
suspended and enough granulation tissue well suited
as a matrix for skin transplants, e.g., split-skin grafts
has been built.
Granulation tissue, however, often does not build
up adequately across deperiosted, exposed bones,
­sinews and joints. If this is the case, the closure of the
wound can be accomplished by using skin flaps. In
recent years, random pattern flaps have been further
developed, e.g., the sural-flap to cover injuries espe-
cially at the distal lower leg, the soleus-flap to cover
injuries in the medial and distal third of the leg and the
gastrocnemius-flap for injuries in the upper third of the
tibia and across the patella. Microsurgical skin flaps
are an alternative, though technically demanding.
63.8 Stabilisation of Fractures
63.8.1 Shaft Fractures
The options of treatment to surgically stabilise an open
fracture of the shaft are basically the same as for closed
fractures. For fractures of the shaft, intramedullary
nailing with an unreamed intramedullary nail is
advised and possible for soft-tissue injuries up to type
III A according to Gustilo. For type III C injuries,
external fixation is recommended. No generally valid
recommendation can be given for type III B injuries, as
the facts are not clear. When in doubt, external fixation
should be used. The decision whether the fracture
63 Open Extremity Fractures
should heal with external fixation or if a change of
methods towards internal fixation should be sought
has to be made on an individual basis, depending on
the soft-tissue situation. A change of methods is only
recom­mended once the soft-tissue is properly healed.
If the change of methods from external fixation to an
intramedullar nail takes place within 2 weeks post
trauma and the place of entry of the Schanz screw does
not show any signs of infection, the change can be
made in one single session.
63.8.2 Reaming
In femoral fractures, reaming of the marrow-cavity
causes embolisation of bone and bone marrow parts
into the lungs and has therefore been associated with
the development of a so-called adult respiratory dis-
tress syndrome (ARDS), especially in patients with
a thorax trauma. Regarding problems of choosing
the right method for polytraumatised patients please
see below.
63.8.3 Joint Fractures
Open joint fractures are subject to the same principles
of treatment as open shaft fractures. Immediate surgi-
cal reconstruction and osteosynthesis are desirable for
monotraumata with soft-tissue injuries types I and II
and are occasionally possible (e.g., ankle-, elbow- and
wrist fractures). Often however, the accompanying
injury of soft-tissue has already caused distinctive
swelling so that an additional soft-tissue injury caused
by extensive surgery is not desirable (e.g., pilon frac-
ture, tibia head fracture). In these cases, the main frag-
ments are stabilised with screws or Kirschner wires
using external fixation across the joint after debride-
ment and osteosynthesis. In a similar fashion, a joint
reconstruction is performed after debridement for type
III soft-tissue injuries with these techniques and we
aim for a reposition as anatomically correct as possi-
ble. The extremity is stabilised with external fixation
across the joint, and the soft-tissue injury is closed
using vacuum sealing. The definite reconstruction and
stabilisation of the joint surface is done after the soft-
tissue oedema has decreased.
545
63.9 Specific Considerations for
Polytraumatised Patients
In managing polytraumata, the treatment of open frac-
tures is – after the immediate live-saving measures
(emergency thoracotomy or laparotomy respectively for
‘massive haemorrhage’) without which survival and
continuing treatment would not be possible – considered
highly important for control of infectious complications
and avoidance of organ failure. The choice of the stabi-
lisation method for open extremity fractures depends on
the condition of the patient. As the usage of unreamed
intramedullary nails reduces the risk of a pulmonary
embolus but does not eliminate it, the recommendation
for polytraumatised, so-called borderline patients with a
thorax trauma is to primarily stabilise the extremity frac-
tures according to the damage control principle with
external fixation and to change the method subsequently
after stabilisation of the patient’s condition. In patients
with circulatory failure or other life-threatening organ
dysfunction, even closed shaft and joint fractures are sta-
bilised with external fixation to ensure sufficient further
treatment can be given in the intensive care unit.
Criteria for a borderline situation in a polytrauma
case (according to Pape and Krettek)
• ISS > 20 + thorax trauma
• Abdomen/pelvis trauma + RR < 90 mmHg
• ISS ³ 40 without thorax injury
• Bilateral lung contusion
• mPpu.art. > 24 mmHg
• mPpu.art.-rising > 6 mmHg at intramedullary nailing
• Coagulopathy
• Surgery >6 h
Uncomplicated soft-tissue injuries should be closed
within 72–96 h post trauma. From day 8 after trauma
onwards, reconstructive measures for complex injuries
can usually be done provided that no long-lasting organ
dysfunction has developed and no local infections are
present. A change of the osteosynthetic procedure, bone-
and soft-tissue transplantations and extensive joint recon-
structions can be done safely after this time interval.
546
63.10 Loss of Bone
If bones are lost after an extremity fracture, different
methods are available depending on the situation. These
include cancellous bone graft in the dia- and metaphy-
seal area, corticospongious bone graft transplantation
(random and axial) as well as the transfer of segments
using external or completely implanted systems.
Recommended Reading
Gustilo, R.B., Mendoza, R.M., Williams, D.N.: Problems in the
management of type III (severe) open fractures: a new classifica-
tion of type III open fractures. J. Trauma 24, 742–746 (1984)
Johansen, K.J., Daines, M., Howey, T., Helfet, D., Hansen, S.T., Jr.:
Objective criteria accurately predict amputation following
lower extremity trauma. J. Trauma 30, 568–572 (1990)
Krettek, C., Simon, R.G., Tscherne, H.: Management priorities
in patients with polytrauma. Lang. Arch. Surg. 383, 220–227
(1998)
E. Euler
McNamara, M.G., Heckman, J.D., Corley, F.G.: Severe open
fractures of the lower extremity: a retrospective evaluation
of the mangled extremity severity score (MESS). J. Orthop.
Trauma 8, 81–87 (1994)
Mittlmeier, T., Khodadadyan-Klostermann, C., Haas, N.R.:
Grundsätze der Akutversorgung. In: Mutschler, W., Haas,
N.P. (Hrsg.) Praxis der Unfallchirurgie, 2 Aufl., pp. S55–S98.
Thieme, Stuttgart/New York (2004)
Müller, C.A., Dietrich, M., Morakis, P., et al.: Klinische
Ergebnisse der primären Marknagelosteosynthese mit dem
unaufgebohrten AO/ASIF Tibiamarknagel von offenen
Tibiaschaftfrakturen. Unfallchirurg. 101, 830–837 (1998)
Pape, H.C., Krettek, C.: Frakturversorgung des Schwerverletzten
– Einfluss des Prinzips der “verletzungsadaptierten
Behandlungs-strategie” (“damage control orthopaedic sur-
gery”). Unfallchirurg. 106, 87–96 (2003)
Tscherne, H., Oestern, H.J.: Die Klassifizierung des Weich­
teilschadens bei offenen und geschlossenen Frakturen.
Unfallheilkunde. 85, 111–115 (1982)
Wenda, K., Ritter, G., Ahlers, J., et al.: Nachweis und Effekte von
Knochenmarkeinschwemmungen bei Operationen im Bereich
der Femurmarkhöhle. Unfallchirurg. 93, 56–61 (1990)
 Traumatic Injuries of the Spine
Rudolf Beisse and Christoph Siepe
64.1 Epidemiology
Traumatic spine injuries represent only a small frac-
tion 0.5–1% of all skeletal fractures. This low number
is, however, in strong contrast to the immense impact
of these types of injuries and their consequences for
the individual patient as well as society. Approximately
one fifth of these injuries are associated with neuro-
logical deficits including para- and tetraplegia.
64.2 Localisation
Specific anatomic and biomechanical considerations
explain the varying distribution of spinal column in­­
­juries. Particularly transitional areas between highly
mobile to less-mobile sections of the spine such as
the cervicothoracic or thoracolumbar segments show
the highest incidence of spinal injuries with as many
as 50% of all spinal traumas affecting these regions.
The underlying pathomechanisms are predominantly
compression or flexion type injuries. Spinal trauma
is frequently associated with cranial injuries, ster-
num or calcaneal fractures. These associating inju-
ries as well as the underlying pathomechanisms are
R. Beisse (*)
Chief Surgeon, Department of Spine Surgery,
Orthopedics and Trauma Hospital Rummelsberg,
Rummelsberg 71, 90592 Schwarzenbruck,
Germany
e-mail: rbeisse@googlemail.com
C. Siepe
Department of Spine Surgery, Orthopedic Hospital Munich,
Schoen Klinik München Harlaching,
Harlachinger Str. 51, D-81547
München, Germany
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_64, © Springer-Verlag Berlin Heidelberg 2011
64
strong indicators for a possibly associated spinal
trauma:
• Cut/wound to forehead/haematoma ® dens fracture
• Sternum fracture ® injury of thoracic spine
• Oblique safety belt injury ® injury of the thora-
columbar junction
• Calcaneal fracture ® fracture of the lumbar spine
• Transverse process fracture L5 ® unstable Type C
pelvic fracture
64.3 Aetiology and Pathogenesis
Typical mechanisms leading to spinal injury include high
velocity trauma, falls from heights of >2.5 m as well as
injuries resulting from diving into shallow waters.
Motorbike accidents, horse riding injuries, accidents sus-
tained during swimming/diving or air-borne sports may
also hint at possible spinal trauma. Among the different
types of winter sports, skiing and snowboarding injuries
prevail, followed by bob sleigh injuries.
64.4 Symptoms and Clinical Diagnosis
As a general rule, every traumatic injury should be
treated as implicating a possible spinal injury until
proven otherwise by diagnostic imaging.
The circumstances surrounding the accident and the
testimonies of the patient or witnesses may ­provide
useful information pertaining to a possible underlying
spinal injury. If the patient is conscious, additional infor-
mation such as paralysis, respiratory insufficiencies and
sensory disturbances – ‘I don’t feel my legs any more’ –
may point to a possible spinal trauma. Similarly,
547
548
difficulties to hold or stabilise the head or a fixed head-
neck malalignment are also signs of a potential underly-
ing cervical spine injury.
A standardised head-to-toe screening examination is
conducted, which includes the palpation of the head and
facial skull as well as the neck and cricoid. A neck brace
should be applied at this stage and should be removed
only once a cervical injury is excluded by diagnostic
imaging. The torso should be carefully inspected for
externally visible signs of injuries such as bruises, espe-
cially girdle contusions. A presternal haematoma may
point to a possible fracture of the sternum, which is fre-
quently associated with thoracic spinal injuries. Oblique
superficial safety belt bruises in the upper abdominal
region may be signs of a pelvic girdle injury, which can
lead to severe injuries of organs in the upper abdomen,
i.e., pancreas or duodenal ruptures, or to translational
injuries of the spinal column. Haematomas, abrasions or
décollments in the back or flank region can be signs of a
roll-over trauma or a rotational injury.
A discontinued alignment of the spinous processes
can occasionally be detected upon visual inspection.
Malalignment can, at times, be observed upon pal­pation
during the subsequent physical screening examination.
The injured region or level may furthermore be
localised by a ‘pain upon percussion’ examination.
Clinical tests implying axial pain provocation are not
recommended and should be avoided.
Note: During physical examination, any active
or passive rotations of the head and/or the torso
or flexion manipulations such as raising of
the head or the upper body should be strictly
avoided. Functional examinations are obsolete
unless any discoligamentary instabilities have
been excluded.
64.5 Neurological Symptoms
Any signs of neurological deterioration should be
urgently followed up by means of diagnostic imag-
ing, which may result in immediate surgical interven-
tion. Lesions above the level of C4 result in complete
­respiratory insufficiency due to paresis of the phrenic
nerve, which necessitates immediate resuscitation.
R. Beisse and C. Siepe
For injuries below the level of C4, a degree of respi-
ratory activity will remain due to the residual inner-
vation of the diaphragm. Due to the loss of function
of the intercostal muscles, however, this remaining
respiratory activity will be insufficient. Motor func-
tion deficits include the typical signs of tetraplegia.
The sensitive innervation of the dermatoma which are
innervated by the cervical spinal cord have a distribu-
tion into the upper thorax aperture. For example, the
dermatoma of C4 ends approximately at the level of
the clavicule, bordering immediately next to the area
of the Th2 dermatoma. For a clinical differentiation of
injuries that occurred at the cervicothoracic junction
between the levels C6 and Th1, the clinical examina-
tion therefore has to include and evaluate the derma-
tomas and the segment indicating muscle of the hands
and forearms. The dermatoma C6 includes the thumb
as well as the radial forearm; fingers 2–3 represent the
C7 dermatoma, whilst fingers 4–5 and the ulnar side
of the hand and wrist are C8 dermatoma, respectively.
The area around the elbow is the Th1 dermatoma.
This triangular representation of the dermatoma
C6-Th1 is commonly referred to as the ‘neurological
control triangle’, which may be a useful tool for doc-
tors that are not involved in the treatment of spinal
pathologies on a daily basis.
Another simple to use diagnostic tool is the clinical
evaluation of the hand’s motor functions. The levels
C7/C8 are responsible for flexion and extension move-
ments of the fingers, whilst the M. lumbricales and
interossei, which are responsible for the spreading and
adduction of the fingers, receive their innervation from
the cervicothoracic junction (levels C8/Th1). Further
clinically important landmarks include the mamilla
(Th4), the level of the umbilicus (Th10), the groin (L1),
the medial (L4) and lateral malleolli (S1).
More caudal traumas of the spinal cord such as inju-
ries of the conus medullaris or the cauda equina show
signs of paraplegia, areflexia, sensitivity loss of the
torso and the lower extremities as well as impaired
bladder and bowel functions. Unspecific signs of ­spinal
injuries indicating signs of spinal shock with involve-
ment of the vegetative nervous system include priapism,
bradycardia as well as cardiac arrest and low blood
pressure without signs of any relevant blood loss.
The examination of the sacral segments at the levels
S2 and below includes the clinical examination of the
flexion capability of the toes (S2) as well as evaluation of
the sensory and motor functions of the perianal region.
64 Traumatic Injuries of the Spine 549

64.5.1 Radiological Imaging awake and conscious patients under lateral fluoro-

scopic control.
In the acute posttraumatic period, the use of MRI is
X-rays of the spine should generally include the ante-
restricted to a limited number of indications, which
rior-posterior and lateral views. Radiological imaging
include
of the entire spine should be performed under the
­following circumstances: • Further differentiation of neurological deficits such
as intraspinal haematoma or contusions in the presence
• Signs of spinal injury at one particular segment
of regular, unharmed bony structures
(cervical/thoracic/lumbar)
• Further diagnostic evaluation of discoligamentary
• Polytrauma
injuries
• Mechanisms of injury
• Exclusion and evaluation of pathological fractures
–– Fall from heights >2 m
in different sections of the spinal column
–– High velocity trauma
• Further deterioration of neurological deficits
–– Pedestrian/cyclist involved in motor vehicle
accident A number of measurements can be made to evaluate
–– Fall from stairs associated with unconsciousness the bony structures of the vertebral column. These
include:
Special imaging techniques include:
• Angle between the cranial and caudal endplates of a
• Atlas and odontoid-views through the open mouth.
vertebral body. A kyphotic deformity is defined with
The X-ray focus is aimed at the C1/2 joint.
a negative angle, while a lordotic deformation is rep-
• Oblique views of the cervical spine are performed
resented with a positive angle. The angle only defines
at a 15° angle for better imaging of the articular
the bony deformation of a single vertebral body.
processes or at a 45° angle for optimal viewing of
• Angle between the cranial and caudal endplates of
the neuroforamina. A rotation to the left will enable
two vertebral bodies. The caudal endplate of the
the depiction of and viewing into the right neurofo-
caudal vertebral body and the cranial endplate of
ramina and vice versa.
the cranial vertebral bodies are used as reference
Further diagnostic evaluation including CT-evaluation lines. The angle assesses deformation of the verte-
is indicated under the following circumstances: bral body as well as the disc.
• Sagittal index: the ratio of the height of the anterior
• Evaluation of transitional spinal regions (occipito-
vertebral body to the posterior vertebral body
cervical, cervicothoracic, thoracolumbar)
• Scoliosis angle according to the Cobb measurement
• Morphological evaluation of an already diagnosed
technique
conventional fracture for further classification of
• Sagittal or lateral displacement, measured in mm or
injury-type
percentage of displacement
• Imaging of the facet joints in patients with disloca-
tion injuries An injury is defined as ‘stable’ if activities of daily
• Evaluation of the cause and the extent of an occlu- ­living will not result in a deformation, displacement or
sion of the spinal canal dislocation of the traumatised spinal region, and if
increased loads will not result in increased pain or
In patients with severe head and skull injuries, a CT scan is
development of any neurological deficits.
normally conducted whereby the transitional spinal regions
and the cervical spine are also routinely examined.

64.6 Classification and Therapy

64.5.2 Additional Imaging of Cervical Spine Injuries

Functional flexion/extension X-ray images may reveal The cervical spine consists of seven vertebral bodies,
or exclude discogenic or discoligamentary instabilities which can be divided into the upper and lower cervi-
of the cervical spine. The images are performed on cal spines. The upper cervical spine consists of the
550
occipital condyles, the first vertebral body (atlas), the
second cervical vertebra (axis) as well as their con-
necting joints and tissues. The lower cervical spine
consists of the cervical vertebra C3–C7.
64.6.1 Upper Cervical Spine
The most common injuries of the upper cervical spine
include fractures of the atlas, dens axis as well as
­traumatic spondylolysis of the axis, which can be sub-
divided into stable and instable types.
Fractures of the atlas are considered stable and can
be treated conservatively if the fragments are not dislo-
cated and if the transverse ligament, which passes the
dens posteriorly, is still intact. Unstable fractures are
referred to as Jefferson fractures (Jeanneret 1994) and
are commonly treated surgically.
Dens axis fractures are divided into three groups
according to the Anderson and d’Alonso classification
system. A fracture of the dens apex is classified as a type
1 fracture; a proximal fracture of the dens at the base is
classified as a type 2 fracture, whilst fractures that reach
into the vertebral body are referred to as type 3 fractures.
Type 1 and type 3 fractures are treated conservatively by
immobilisation with a neck brace for 8–12 weeks. Due
to posttraumatic instabilities and a high risk of pseudar-
throsis formation, type 2 fractures are treated surgically
with a screw fixation via an anterior approach.
A traumatic spondylolysis is also commonly referred
to as a ‘hangman’s fracture’, with the fractures extend-
ing into the posterior vertebral arch. The most decisive
criterion for this type of injury is an involvement of the
disc between the second and third cervical vertebrae.
An unharmed disc is a sign of a stable situation, which
can be treated conservatively. Conversely, the injury of
the disc will result in a dislocation of the second verte-
bra. This instable type of injury requires surgical
stabilisation, commonly performed as a fusion via an
anterior approach or via a direct screw fixation of the
posterior arches of C2 as described by Judet et al.
64.6.2 Lower Cervical Spine
In contrast to the upper cervical spine, the vertebrae of
the lower cervical spine are homogenously shaped and
show similar injury patterns to those of the lumbar
R. Beisse and C. Siepe
spine. The classification of injuries of the lower cervical
spine is therefore based on the AO (Arbeitsgemeinschaft
für Osteosynthese, working group for osteosynthesis)
criteria of fracture classification (see below). The clas-
sification system distinguishes between axial compres-
sion (type A) and flexion-distraction (type B) injuries
and those in which a significant torsion has occurred
between the vertebrae involved (type C).
Stable type 1 injuries (impaction fractures), which
are characterised by an impaction of the cranial end-
plate are treated by immobilisation in a neck brace.
This also applies to mere fractures of the spinous pro-
cesses. For these fractures, however, an unstable situa-
tion first needs to be excluded by means of guided
functional images under fluoroscopic control. The so-
called teardrop phenomenon at the anterior circumfer-
ence of a vertebral body can indicate a bony avulsion
of the anterior longitudinal ligament as a result of a
hyperextension of the cervical spine and consecutive
injury of the ligamentous structures as well as the
intervertebral disc.
Instable injuries of the lower cervical spine are com-
monly treated via an anterior approach in between the
nerve-vessel bundles laterally and the medial structures
such as the trachea, thyroid gland as well as the oesoph-
agus. The damaged disc and the fractured portion of the
vertebral body are removed and the gap is filled with a
solid bone graft or a vertebral body replacement implant.
The defect is additionally stabilised with anterior plat-
ing and screw fixation to the adjacent vertebral bodies.
Highly instable (type C) fractures with an accompa-
nying destruction of the posterior column require an
additional posterior stabilisation. This is usually per-
formed with screws which are inserted into the massa
lateralis of the posterior vertebral arches and are then
fixed with connecting rods. Alternatively, the stabilisa-
tion can also be performed with screw fixation into the
pedicles. Following surgical stabilisation, instable
injuries are immobilised in a soft cervical collar for
6 weeks and accompanying stabilising physiotherapy
can be administered.
64.7 Classification and Therapy of
Thoracic and Lumbar Spine Injuries
The most widely used classification system for tho-
racic and lumbar spine injuries was introduced by
Magerl et al. in 1994. The classification system is
64 Traumatic Injuries of the Spine
based on the analysis of 1,445 traumatic injuries of the
lumbar spine and incorporates the mechanism of the
injury as well as typically associated injuries of the
vertebral bodies, discs and ligaments. Three different
injury mechanisms have been described and are used
to ­classify thoracic and lumbar spine injuries.
• Compression: Type-A Injury
• Distraction: Type-B Injury
• Rotation: Type-C Injury
64.7.1 Type-A Injuries
Injuries classified as type A are caused by axial com-
pression. Depending on the severity of the external
force as well as the integrity of the bony structures, the
trauma will result in
• A1: impaction fractures
• A2: split fractures
• A3: burst fractures
Impaction fractures (A1) are considered as stable and
can be treated conservatively. In the case of split frac-
tures (A2), the fracture line can either be in the frontal
plane or the coronal plane. If a vertebral body is
exposed to significant compressive forces from adja-
cent vertebral bodies, this will result in a frontal frac-
ture line as well as a central damage zone. This instable
type of fracture is also referred to as a ‘pincer fracture’
(type A2.3), which is associated with a high risk of
pseudarthrosis due to disseminated and interposed disc
fragments. Type-A3 burst fractures are the most com-
mon of all instable fractures of the lumbar spine. The
severity of the destruction of the vertebral body as well
as the degree of the instability increases progressively
from A3.1 to A3.3.
64.7.2 Type-B Injuries
Type-B injuries are the result of forceful hyperexten-
sion or hyperflexion movements, which will lead to a
disruption of the ligaments (B1) or the bony structures
of the spine (B2), including the anterior or posterior por-
tion of the disc or the vertebral body (B3). In cases of a
posterior disruption, the lateral X-ray images generally
show an increased angulation of the spine at the level of
the fracture, which is furthermore associated with a dis-
sociation of the spinous processes and the facet joints.
551
64.7.3 Type-C Injuries
This category represents a heterogeneous group of
injuries which all have a rotational component as
the most predominant underlying pathomechanism in
common. Typical radiological criteria of rotational
injuries are
• Fractures of the lateral transverse processes as well
as rib fractures which are located in close proximity
to the spine;
• Rotational malalignment of one or more vertebrae,
which can be detected through irregular distances
between the posterior arches and the spinous
processes.
Type-C injuries can be divided into three main catego-
ries: C1 is defined as a type-A compression fracture
with an additional rotational component. The same
applies to C2-injuries, which incorporates type-B flexion-
distraction injuries with a rotational component. C3
injuries are defined as all rotational-translational frac-
tures which are highly instable and which are associ-
ated with the highest rates of neurological deficits.
64.8 Therapy
Treatment goals include
• Restoration of the morphology of the vertebral body
as well as the affected section of the spine;
• Clearance of any narrowing/occlusion of the spinal
canal;
• Restoration of the mobility and strength of the
­vertebral column.
For stable fractures, these goals can be achieved with
conservative treatment. Conversely, instable fractures
are stabilised surgically, which can then also be mobi-
lised at an early stage.
64.8.1 Conservative Therapy
Typical injuries that are still treated conservatively to
date include type-A1 compaction fractures. Prior to
initiation of conservative treatment, additional injuries
of the posterior column (type B) must be excluded.
552
The therapy includes:
• Immobilisation for 2–3 days;
• Early mobilisation with a three-point brace;
• Teaching of ‘spine-adequate’ movements while
–– Mobilising out of bed
–– Eating
–– Lifting
• Period of muscular stabilisation within the first
6 weeks;
• Initiation of the training therapy from week 7 after
injury with instructions for coordination and muscle
build-up.
64.8.2 Surgical Therapy
In accordance with the anatomic circumstances, ­certain
accesses and procedures have been established over
the course of time for the reconstruction and stabilisa-
tion of the lumbar spine.
64.8.2.1 Principles of Posterior Stabilisation
Stabilisation with internal fixation is the most impor-
tant procedure of all posterior stabilisation techniques.
Following detachment of the erector spinae muscles,
the screws/rods are inserted through the pedicle via
the posterior approach into the adjacent and unharmed
cranial and caudal vertebral bodies. The screws on
either side are connected with a rod. The joint con-
nection between the rods and screws can then be used
to apply distraction or to reconstruct lordosis or
kyphosis. The advantages of this type of procedure
include the considerably short operating time as
well as the possibility of an anatomic reconstruction
including the option to indirectly decompress the spi-
nal canal. In cases of a severe occlusion of the spinal
canal, the spinal canal can furthermore be decom-
pressed with a hemilaminectomy during the same
procedure. The disadvantages include the risk of
false pedicle screw placement as well as scar forma-
tion within the paraspinal muscles, which can be
R. Beisse and C. Siepe
associated with functional deficits or the potential to
cause postoperative discomforts.
64.8.2.2 Principle of Anterior Stabilisation
Depending on the type of access, the anterior
approaches can be separated into
• Open procedures with a common large incision:
1- or 2-cavity approach (Anetzberger u. Friedl 1997);
• So-called less-invasive procedures with a reduction
of the size of a conventional approach using addi-
tional optical aids (operation microscope/endoscope;
Mayer 2005);
• Endoscopic approaches using minimal incisions
and image transmission onto a monitor system
(Regan and Liebermann 2005, Beisse 2006).
Independent of the type of approach that is used to the
anterior spine, the remaining surgical procedure and
operative strategy around the discs and vertebral bod-
ies is largely standardised. The fractured portions of
the vertebral body (hemicorporectomy) as well as the
injured disc are removed and replaced with either a
solid bone graft or a vertebral body replacement type
of implant which are available in titanium, carbon or
synthetic material. The remaining defect is filled up
with bone, which is grafted from the fracture zone. The
necessity of an additional anterior augmentation with
plates and screws is controversially debated.
Over the past few years, kyphoplasty (Boszczyk et al.
2003) has been established as a minimally invasive treat-
ment option for the treatment of instable osteoporotic
compression fractures in elderly patients. The underly-
ing principle is based on the reconstruction of the verte-
bral body height through a balloon or stent which is
inserted through the pedicles into the vertebral body and
which is then dilated. Following removal of the balloon,
viscous bone-cement is filled into the vertebral body
cavity via externally introduced tubes in order to aug-
ment the trabecular bone structure. With proper patient
selection and adequate implementation of the procedure,
an almost immediate pain relief and restoration of the
load-bearing capacity of the spine have been reported.
64 Traumatic Injuries of the Spine
Recommended Reading
Anetzberger, I.L., Friedl, H.P.: Wirbelsäule. Thieme, Stuttgart-
New York (1997)
Apfelbaum, R.I., Lonser, R.R., Veres, R., Casey, A.: Direct ante-
rior screw fixation for recent and remote odontoid fractures.
J. Neurosurg. 93, 227–236 (2000)
Beisse, R.: Endoscopic anterior repair in spinal trauma. In:
Regan, J.J., Liebermann, I.H. (eds.) Atlas of Minimal Access
Spine Surgery, pp. 285–320. Quality Medical Publishing,
St. Louis (2004)
Beisse, R.: Endoscopic surgery on the thoracolumbar junction
of the spine. Eur. Spine J. 19(Suppl 1):S52–S65 (2010). doi:
10.1007/s00586-009-1124-4
Boszczyk, B.M., Bierschneider, M., Hauck, S., Vastmans, J.,
Potulski, M., Beisse, R., Robert, B., Jaksche, H.: [Conventional
553
and semi-open kyphoplasty]. Orthopade. 33, 13–21 (2004).
doi: 10.1007/s00132-003-0575-2
Hofmeister, M., Buhren, V.: Therapeutic concept for injuries of
the lower cervical spine. Orthopade. 28, 401–413 (1999)
Jeanneret, B.: Obere Halswirbelsäule. Thieme, Stuttgart/New
York (1994)
Magerl, F., Aebi, S., Gertzbein, S.D., Harms, J., Nazarian, S.:
A comprehensive classification of thoracic and lumbar inju-
ries. Eur. Spine J. 3, 184–201 (1994)
Mayer, H.M.: Minimally Invasive spine Surgery. Springer,
Berlin/Heidelberg/New York (2005)
Reinhold, M., Knop, C., Beisse, R., Audige, L., Kandziora, F.,
Pizanis, A., Pranzl, R., Gercek, E., Schultheiss, M.,
Weckbach, A., Buhren, V., Blauth, M.: Operative treatment
of traumatic fractures of the thorax and lumbar spine. Part II:
surgical treatment and radiological findings. Unfallchirurg.
112, 149–167 (2009). doi: 10.1007/s00113-008-1538-1
 Trauma Surgery, Orthopaedic – Pelvic
Fracture
Tim Pohlemann, Daniel Köhler, and Christopher Tzioupis
65.1 Epidemiology
Pelvic injuries include approximately 3% of all ­skeletal
injuries and can occur in 4–18% of those sustaining
high energy injuries (ISS > 12). Despite implementa-
tion of all modern treatment strategies, morbidity
­following pelvic injuries is high – often the result of
the high energy trauma and a number of associated
injuries. Mortality rates following pelvic trauma range
from 9% to 27%. The risk of sustaining a pelvic ring
injury increases with the severity of the injury (ISS),
and in about 25% of all polytraumatised patients,
­concomitant pelvic injuries must be expected. In the
younger population, most injuries result from motor
vehicle collisions (occupant, pedestrian or motorcy-
cle). Falls from a height and other causes are also
­considered as risk factors.More than 80% of patients
with pelvic injuries have a concomitant injury of
another body region.
In elderly patients, even low energy trauma, i.e.,
domestic fall, may lead to undisplaced fractures of
pubic and ischial bones. Particularly, women around
the seventh life decade constitute a second group of
patients amenable to pelvic injuries, being held respon-
sible for a second incidence peak.
Special attention has to be paid to children with
­pelvic fractures as the impact of the injury is often
D. Köhler (*) and T. Pohlemann
Department of Traumatology, Hand- and Reconstructive
Surgery, Kirrbergerstr. 1, D-66421 Homburg, Germany
e-mail: tim.pohlemann@uks.eu; daniel.koehler@uks.eu
C. Tzioupis
Academic Department of Orthopedics, Leeds School of
Medicine, Leeds General Infirmary, Great George Street LS1
3DL Leeds, UK
e-mail: ctzioupis@gmail.com
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_65, © Springer-Verlag Berlin Heidelberg 2011
65
underestimated due to the higher bone elasticity. The
rate of complex pelvic injuries in children with concom-
itant soft tissue and organ injuries which are potentially
life-threatening is 20% and twice as high as in adults.
65.2 Anatomy and Pathophysiology
The pelvic ring comprises the sacrum and three bones
on each side that coalesce during adolescence to form
the innominate bone of the adult pelvis. The sacrum
connects to the ilium via an irregular joint, the ili-
osacral joint, which is technically an apophyseal joint.
The ilium becomes the pubis anteriorly and the ischium
inferiorly. Anteriorly, the two pubic bones connect to
one another via the symphysis and thus close the ring.
The strongest structures are located dorsally and trans-
mit the essential part of impact from the lower extrem-
ities to the trunk. While isolated fractures of the
anterior ring have no consequence for pelvic stability,
a complete rupture of the dorsal ring always results in
instability of the pelvic ring. Direction of impact and
the magnitude of transmitted energy determine the
anatomic localisation and the character of pelvic ring
injury and therefore its degree of instability.
65.3 Classification
Modern classification systems for pelvic ring injuries
represent a key instrument for orthopaedic trauma sur-
geons for evaluating the extent of pelvic trauma and
judging the risk for potentially life-threatening inju-
ries. The alphanumeric classification of the AO/OTA
(Arbe­itsgemeinschaft für Osteosynthese, working
group for osteosynthesis) for pelvic ring injuries is
555
556 T. Pohlemann et al.

commonly used. Based on the mechanism of the injury,

the residual pelvic ring stability is estimated, thus dic-
tating the subsequent treatment strategy. In principle,
three different fracture types are distinguished and
complemented by subgroups and modificators to allow
a complete compilation of all possible combinations of
injuries. The knowledge and imaging interpretation of
the three basic fracture types is sufficient for the physi-
cian in order to decide upon the further treatment of
these injuries [6].
 ype A includes pelvic fractures, which do not com-
T
promise the stability of the ring (boundary fractures
of the ilium, avulsion fractures, undisplaced frac-
tures of pubic and ischial bone, transverse fractures
of the sacrum) (Fig. 65.1). Fig. 65.2 Type B fracture (“open book fracture”) in a 54 old
man after motorcycle injury
Type B includes injuries with partially remaining
stability of the posterior ring. These injuries are
caused by anterior-posterior compression with
external rotation of one or both hemipelvises (open-
book-injury) or by lateral compression with con-
secutive internal rotation of the hemipelvis. In many
cases, these fractures of the pubic or ischial bone
are impacted and undisplaced and thus assure rela-
tive stability (Fig. 65.2).
Type C implicates translational, vertically unstable
fractures of the posterior ring involving a com-
plete rupture of all stabilising structures: One or
both hemipelvises are separated from the trunk
(Fig. 65.3).

Fig. 65.3 Type C fracture (right transpubic and transiliacal frac-

ture) in a 43 year old woman after domestic fight with her
husband

The above described classification in combination with

Fig. 65.1 Type A fracture in a 32 year old woman after horse
kick on the right anterior superior iliac spine
a descriptive system emerges as an excellent tool for
clinical use, further abstaining from the numeric terms
of subgroups and modificators. Further treatment strat-
egies adapt to the remaining stability of the pelvic ring,
for which the nomination of the fracture types A, B or
C is sufficient. In addition, the single lesions of the
pelvic ring are systematically listed after their ana-
tomic location (transsymphyseal, transpubic, transac-
etabular, transilical and transsacral). Using this system
even for non-specialists, a precise and memorable
description of the injury is possible.
65 Trauma Surgery, Orthopaedic – Pelvic Fracture
65.4 Definitions
Apart from the AO classification of pelvic ring inju-
ries, a number of definitions are useful for the identifi-
cation of concomitant soft tissue injuries in order to
focus on acute life-threatening injuries and potential
complications [12].
65.4.1 Simple or Uncomplicated Fractures This complex trauma injury comprises an opening of
This type of fractures comprises all injuries without
concomitant soft tissue damage while all kinds of insta-
bility may occur. The absence of significant peripelvic
soft tissue damage allows a more time-consuming
analysis of injuries without risking hazardous treat-
ment delays. About 90% of all pelvic fractures belong
to this category. Mortality is defined by concomitant
injuries (‘polytrauma’) and is rising up to 6%.
65.4.2 Complex Pelvic Fractures
These pelvic injuries are complicated through significant
concomitant pelvic soft tissue damage (vessels, nerves,
urogenital injuries, bowel injuries, skin- and soft tissue
injuries). In general, this emergency situation mandates
an immediate surgical intervention. About 10% of pelvic
ring injuries account for complex fractures. Mortality
rises significantly and reaches up to 20%.
65.4.3 Complex Fractures with
Haemodynamic Instability
If the complex fracture leads to blood loss of more
than 2,000 ml [3], an acutely life-threatening condition
exists. Despite substantial improvements of primary
patient stabilisation, mortality is still over 30% [5].
65.4.4 Hemipelvectomy
The hemipelvectomy is an avulsion of one or both
hemipelvises with concomitant transection of large
vessels and nerves. Normally, these seriously injured
557
patients die at the scene of the accident. Due to
improvement of the pre-hospital treatment, many
patients survive the initial trauma and reach the hos-
pital which results in slightly improved survival
rates.
65.4.5 Open Pelvic Fracture
dermal coat or of hollow organs (rectum, vagina, blad-
der). The possibility for subsequent complications
is particularly high. The incidence of secondary
­infections or even sepsis is high, especially if the ini-
tial injury was not properly identified or treated ina­
dequately.
65.5 Clinical Diagnosis
History taking is often impossible in severely injured
patients. Information given from the paramedics is
crucial to estimate the magnitude of injury. The
objective of the primary evaluation is to identify
potential life-threatening situations for immediate
treatment.
Therefore, standardised management protocols,
i.e., the ATLS-concept, are used, which always contain
modules for the evaluation of pelvic ring injuries [4].
Clinical examination provides pivotal information
about pelvic ring instability especially when it is
accompanied by shock or initial haemoglobin values
less than 8 g/%. This combination is always indicative
of a life-threatening situation.
Systematic examination of the undressed patient
also includes the inspection for existing lacerations
and haematomas. Blood from the orificium urethrae
or the perineum must be identified. Stability of the
pelvic ring is assessed by both anterior-posterior and
lateral compression. For exclusion of anal and rectal
wounds, rectal examination is imperative; in male
patients, the position of the prostate is identified.
Sphincter tone should be tested when the patient is
awake. Ultrasound of the abdomen is performed in
every patient during initial assessment for identifica-
tion of free peritoneal fluid especially in the lower
abdomen.
558
65.5.1 Imaging
Radiographic examination includes a pelvic X-ray,
which is sufficient for emergency measures [7, 13].
If fracture lines are detected, then inlet and outlet
projections are performed. If the patient is in a stable
physiologic condition, CT-scans should be done as a
number of injuries of the posterior ring are not rec-
ognised on plain X-ray films (50% of sacrum frac-
tures are primarily not identified) [10]. With the use
of faster CTs in emergency rooms, the diagnostic
investigation sequence can be modified. MRI cur-
rently has no place in the acute setting of primary
diagnostics.
65.5.2 Emergency Treatment of
Complex Pelvic Fractures
Life-threatening situations require different and pre-
cise algorithms to rescue the patient’s life and avoid
residual sequelae. Absolute indications for immediate
life-saving measures are traumatic hemipelvectomy
and complex pelvic fractures with external or internal
mass bleedings.
Patient stabilisation by means of blood loss replace-
ment, haemostasis and pelvic ring fracture stabilisa-
tion can be usually achieved by mechanical means.
Therefore, early immobilisation and compression of
both hemipelvises in the best anatomic position feasi-
ble should be seeked in order to minimise the blood
loss and the consumption of haemostatic factors.
During the pre-hospital treatment, the use of a vacuum
mattress or a pelvic binder is useful. Compression can
also be achieved by use of a circumferentially applied
sheet sling combined with internal rotation of the
lower limbs. Upon arrival in the emergency room, pel-
vic clamps or external fixateurs should be applied.
Both measures allow for a better stabilisation of the
pelvic ring. If haemodynamic stabilisation is achieved
after substitution of haemostatic factors (responder),
time for further diagnostics and therapy options is
attained.
If no haemodynamic stabilisation can be achieved
after 15–20 min (non-responder), further measures
should be undertaken. In 80–90% of all cases, massive
bleeding derives from the paravesical and presacral
T. Pohlemann et al.
venous plexus or from cancellous bone of the fracture
planes. Pelvic tamponade as a way of mechanical hae-
mostasis has been proved to be effective [8]. Following
the pelvic stabilisation by external fixation, a longitu-
dinal laparotomy is performed, through which the
lesser pelvis can be reached and the retroperitoneal,
paravesical and presacral spaces can be packed with
abdominal packs. This method is simple and applica-
ble anywhere and provides effective haemostasis in
cases of both venous lacerations and branches of the
internal iliac artery [11]. Only in exceptional cases,
arterial embolisation is required in addition [1, 2]. The
prompt implementation of these measures is crucial
for the restoration of the patient’s physiology
(Fig. 65.4).
65.6 Treatment
Ultimate treatment goal is the complete recovery of the
patient and the return to the level of pre-injury activi-
ties. Despite the different indications initially set for
either conservative or operative treatment, early mobil-
isation should always be instituted.
Correct restoration of the anatomy is the cornerstone
of any operative treatment, ensuing a stable pelvic gir-
dle, thus reducing the possibilities for postoperative
pain and difficulties encountered during mobilisation.
The indications for operative treatment are set mainly
based on the degree of total injury severity and the
classification of pelvic injury.
65.7 Definitive Stabilisation
(A) Concepts in Type A fractures of the pelvic ring
Indications for operative treatment are limited to
very specific cases, i.e., open fractures or mark-
edly displaced fractures with impending skin per-
foration. Otherwise an early mobilisation therapy
under adequate analgesia without weight-bearing
is indicated. Usage of crotches for pain relieve
may help during the first days.
(B) Concepts in Type B fractures of the pelvic ring
Due to the partially preserved stability of the pos-
terior ring, stabilisation of the anterior ring is
­sufficient. The operative treatment depends on
65 Trauma Surgery, Orthopaedic – Pelvic Fracture 559

Fig. 65.4 Module for emergency treat- “Complex Pelvic Fracture”

ment of complex pelvic fracture
Pelvic Mass Bleeding or
1st Decision Rollover/Crush Injury?
3 – 5 min
− + Operation Room

Massive Fluid Resuscitation

X-ray: Chest, Pelvis/ “FAST” sonography

Stable Vital Parameters? + Polytrauma Algorithm

2nd Decision
10 – 15 min −

External stabilization (pelvic C-clamp,

supraacet, Fixateur externe, Pelvic binder, Sling

3rd Decision Stable vital Parameters? + Polytrauma Algorithm

15 – 30 min
−

Pelvic Tamponade

the location of the injury with standardised

procedures.
1. Symphysis Pubis
Pfannenstiel or midline incision if laparotomy
was initially performed. Longitudinal splitting
of linea alba and careful dissection of the rectus
muscle (which is most often bunked out on the
side of the injury). Stabilisation with a 4-hole-
DCP with craniocaudal screw direction.
2. Transpubic instabilities
Application of an external fixateur with supraac-
etabular Schanz screws. In case of a coexistent
symphyseal rupture, symphyseal plating is fol-
lowed by transpubic tension screw insertion or
additional external fixation (Fig. 65.5).
Fig. 65.5 Stabilisation of a type B fracture with combined high
(C) Concepts in Type C fractures of the pelvic ring transpubic instability right and pubic diastasis
Only a combined posterior and anterior stabilisa-
tion can allow early mobilisation. As patients are
generally seriously injured, stabilisation is per- tension screws and DC- or reconstruction
formed in a supine position if possible. According plates along the linea terminalis (Fig. 65.6).
to the location of the injuries, standardised proce- 2. Sacroiliac displacement
dures have been established. Standard procedure is ventral plating with two
1. Transiliac instabilities 3-hole-4.5 mm DC-plates placed in an angle of
Approach via longitudinal incision over the 60°–70° to each other. After antero-lateral
iliac crest and subperiostal detachment of the incision over the iliac crest (first window of the
iliac muscle. Depending on the structure of the ilioinguinal approach) and detachment of the
fracture, stabilisation can be achieved with iliac muscle towards the midline, the saroiliac
560
Fig. 65.6 Stabilisation of the iliac wing in a type C fracture
Fig. 65.7 71-year old man with unstable pelvic ring fracture
(sacroiliac displacement plus pubic diastasis) after fall from an
apple tree. Initial stabilisation of hemodynamic stable patient
with supraacetabular fixateur. Definitive surgery on day 8 after
admission
joint is visible. The advantage of a supine posi-
tion lies in the exposure of both symphysis and
sacroiliac joints to facilitate the reduction.
Nowadays, there is a tendency towards percu-
taneous insertion of SI screws for posterior
lesions of the pelvic ring (Fig. 65.7).
3. Sacral fractures
Therapy of sacral fractures has evolved. The
indications for operative stabilisation are given
for non-satisfying results after conservative
treatment such as unstable fractures of the
sacrum with and without radicular compres-
T. Pohlemann et al.
Fig. 65.8 33 year old man with complex pelvic ring fracture.
After consolidation of soft tissues open reduction was performed
on day 11 after admission
Fig. 65.9 sacroiliac screw fixation in a “suicidal jumper’s
fracture”
sion. Stabilisation is performed in prone posi-
tion. Thereby, plate-osteosynthesis should be
pertained to the sacrum itself (local osteosyn-
thesis). Alternatively, transiliosacral screw
insertion can be performed either in supine or
prone position (Figs. 65.8 and 65.9).
65.8 Fractures of the Acetabulum
Fractures of the acetabulum are a great challenge for
the trauma surgeon mainly due to involvement of the
joint surfaces. Their prognosis depends mainly on
65 Trauma Surgery, Orthopaedic – Pelvic Fracture
the initial traumatic joint damage and the achieved
reduction of the articular surface. In case of a hip
dislocation, the immediate reduction of the femoral
head and temporary supracondylar traction of the
unstable hip are mandated. Early neurological exam-
ination should be performed to exclude the most fre-
quent injuries of the peroneal and ischiadic nerve.
All displaced fractures of the acetabulum are abso-
lute indications for an operative treatment. Given the
complexity of these techniques, the treatment of such
devastating injuries should be performed by experts in
specialised trauma centres.
65.8.1 Imaging
Initial radiological assessment includes X-rays of the pel-
vis and oblique views by 40° lifting of the right and left
hemipelvis (iliac/obturator view). Additional CT-scans
with multiplanar reconstruction and 3D views should be
performed to identify depressions of femoral head and
acetabulum and intraarticular fragments [9].
65.8.2 Classification
The classification is based on the examinations of
Letournel and Judet from the 1960s to 1970s. They
divided fractures of the acetabulum in ten different
fracture types by defining the anterior and posterior
column with their bony structures for systematic
description.
65.8.3 Indications for Conservative
or Surgical Treatment
Conservative treatment is implemented in patients
with a stable and congruent joint. Intraarticular gaps
of 1–2 mm are tolerable. If the results of closed
reduction are not satisfactory, traction treatment only
increases the possibilities for high complication rates
without any benefit for the patient. In all cases with
displacement measuring more than 2 mm, an open
reduction and internal fixation should be performed
561
with the intention of anatomic reconstruction of the
hip joint as only this treatment results in 70–90% of
all cases (depending on fracture type) in long-term
survival of the joint without arthrosis. The decision
for these complex interventions should be made
under careful consideration of the individual patient’s
situation.
A successful service for pelvic and acetabular
trauma requires an extensive and specialised infra-
structure (blood supply, cell saver, special instrumen-
tation, intensive care unit) and special knowledge.
Therefore, an early transfer to a special trauma centre
must be considered and is certainly justified. A 2-week
delay can substantially decrease the possibilities of a
successful reconstruction due to callus formation
which affects the outcome unfavourably.
In complex trauma situations accompanied by life-
threatening haemorrhage, obtaining a patient’s consent
is usually not possible. In alert patients, the increased
risk of thrombosis caused by non-operative treatment
should be explained (the conservative therapy of a
C-type fracture implements extension for a minimum
of 12 weeks). On the other hand, the operative treat-
ment allows early weight-bearing but also entails
severe operation-related risks. Extensive bleedings
(A./V. femoralis, A./V. gluteae, paravesical and pre-
sacral venus plexus) as well as iatrogenic nerve injuries
(N. femoralis, N. ischiadicus, Truncus lumbosacralis
‘root L5’) may occur. Further complications are reduc-
tion with residual displacement, misplacement of
screws and loss of reduction in case of inappropriate
techniques of osteosynthesis. Additional risks to be
mentioned are thrombosis, emboli, haematomas and
infections, which are significantly higher in complex
trauma.
65.8.4 Complications
Thromboembolic complications following pelvic frac-
tures are frequent. Therefore, sufficient prophylaxis,
early definitive stabilisation and early mobilisation are
imperative. Open pelvic fractures and complex trauma
have a higher incidence of soft tissue complications.
Primary treatment includes extensile debridement and
further revisions in case of doubt to avoid infections,
haematomas or seromas.
562
Neurological and urological injuries are most often
fatefully related with the injury. Early identification
permits immediate initiation of specialty assistance
(i.e., functional urological diagnostics).
65.9 Follow-up Care
1. Pelvic ring
Bed-to-chair and sit-up mobilisation can be initiated
up after 12 weeks, whereas remaining disabilities
mostly result from concomitant injuries (neurologic,
urologic, visceral). Before discharge, a neurologic
consultation should be carried out as in a multitude
of cases neurological deficits are not recognised pri-
marily (60% of all patients with C-type fractures
have persistent neurological deficits after 2 years;
30% in B-type fractures).
2. Acetabular fractures
Surgical goal is the anatomical reconstruction of
the joint’s articular surface with stable fixation of
all fragments for early functional mobilisation con-
sisting of passive movements with special devices
and non-weight-bearing of the affected limb. Due
to prolonged recovery periods, non-weight-bearing
must be strictly maintained for 8 and up to 16 weeks
depending on fracture type and individual condi-
tions. Radiological assessment should be per-
formed after 12 and 24 months as early arthrosis
can be recognised in nearly all cases within the first
2 years. Patients should be made aware of this
potential complication during their hospital stay.
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of the pelvic ring disruption. Clin Orthop 240, 63–78
(1989)
8. Ertel, W., Keel, M., Eid, K., Platz, A., Trentz, O.: Control of
severe hemorrhage using C-Clamp and pelvic packing in
multiply injured patients with pelvic ring disruption. J
Orthop. Trauma 15, 468–474 (2001)
9. Falchi, M., Rollandi, G.A.: CT of pelvic fractures. Eur J
Radiol 50, 96–105 (2004)
10. Harley, J.D., Mack, L.A., Winquist, R.A.: CT of Acetabular
fractures: Comparison with conventional radiography. Am J
Roentgenol 138, 413–417 (1982)
11. Pohlemann, T., Gänsslen, A., Bosch, U., Tscherne, H.: The
technique of packing for control of hemorrahge in complex
pelvic fractures. Techniques in Orthopedics. 9, 267–270
(1995)
12. Tscherne, H., Pohlemann, T(Ed.). Becken und Acetabulum.
Springer, Berlin Heidelberg New York (1998)
13. Young, J.W., Burgess, A.R., Brumback, R.J., Poka, A.:
Pelvic fractures: value of plain radiography in early assess-
ment and management. Radiology 160, 445–451 (1986)
Recommended Reading
Tscherne H, Pohlemann T: Unfallchirurgie - Becken und
Acetabulum, Springer, Berlin 1998
 Trauma Surgery: Vascular Emergencies
Robert A. Fitridge and Mark Hamilton
66.1 General Considerations
Vascular trauma is associated with a significant inci-
dence of morbidity and mortality. Morbidity of vascu-
lar trauma is often related to associated neurological
and soft tissue injuries. Venous injuries are frequently
more difficult than arterial injuries to deal with and
may be associated with a higher incidence of major
blood loss and potential death.
Aetiology of vascular trauma includes penetrating
and blunt injuries and iatrogenic injuries. The relative
incidence of each of these forms of injury vary widely
in different environments and largely depend on the
incidence of violence in communities in which sur-
geons work. In most environments, extremity injuries
account for 80% of vascular trauma. This includes mili-
tary environments where the use of body protection
results in most non-fatal injuries occurring to the rela-
tively exposed extremities. Similarly, in countries where
land mines are common, lower limb injuries account
for an overwhelming proportion of vascular trauma.
66.2 Clinical Presentation
The clinical presentation of vascular injuries will
broadly present in one of several ways.
R.A. Fitridge (*) and M. Hamilton
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia
e-mail: robert.fitridge@adelaide.edu.au,
mark.hamilton@health.sa.gov.au
M.W. Wichmann et al. (eds.), Rural Surgery,
DOI: 10.1007/978-3-540-78680-1_66, © Springer-Verlag Berlin Heidelberg 2011
66
• Bleeding – external or internal
• Ischaemia distal to the site of injury (either limb
or end-organ)
• Pulsatile haematoma/false aneurysm
• Unexplained blood loss
Observed pulsatile bleeding, absent distal pulse, obvi-
ous expanding haematoma and arterial bruit or thrill
over the area of injury are termed the ‘hard signs’ of
extremity arterial injury. The ‘soft signs’ of arterial
injuries include a penetrating injury passing close to a
vessel, reduced pulses distal to the site of trauma, unex-
plained hypotension or shock and neurological deficit
(when the affected nerve is located adjacent to the site
of injury). A number of arterial injuries are associated
with specific clinical and radiological findings, which
are shown in Table 66.1.
66.3 Types of Vascular Injury
The common types of arterial injury are shown in
Table 66.2.
66.4 Investigations for Vascular Trauma
A range of investigations are able to be performed
when vascular trauma is suspected and are shown in
Table 66.3. In situations where it is quite clear that an
arterial/venous injury has occurred and the location is
clear, no formal investigation is required or indeed
appropriate. Prompt clinical assessment and manage-
ment should be undertaken.
563
564 R.A. Fitridge and M. Hamilton

Table 66.1 Common arterial injuries with associated clinical 66.4.1 Ultrasound/Duplex Scanning
and radiological findings
Arterial injury Clinical and radiological
findings Ultrasound/duplex scanning is widely used in all
Thoracic aortic transection Widened mediastinum forms of arterial and venous assessment and cer-
tainly has a significant role in the assessment of vas-
Fractured first/second rib
cular trauma. The advantages of ultrasound are that
Pleural capping the procedure can be performed in the emergency/
Carotid dissection Horners syndrome resuscitation room and may rapidly give the informa-
CVA tion required by the attending surgeon. However,
ultrasound is ‘operator dependent’. Ultrasound pro-
Brachial artery (children) Supracondylar fracture
vides minimal information for chest injuries (unless
Tibioperoneal artery Tibial plateau fracture a trans-oesophageal echocardiogram is performed)
and has a limited window of exposure to both sub-
Table 66.2 Types of arterial injury and technique of repair
clavian arteries. In these situations, it is not particu-
Type of injury Repair larly useful. Similarly in patients with significant
soft tissue injuries, ultrasound is impractical and
Partial laceration/avulsion Direct suture (‘lateral suture’)
of branch should not be used.
Ligate or oversew branch
Transection End-to-end repair
Interposition graft 66.4.2 Spiral CT/CT Angiography
Contusion Conservative ?Heparinise
Interposition graft Spiral CT/CT angiography has become the investiga-
Repair ± patch tion of choice for trauma in general and also for the
assessment of vascular trauma. Many emergency
False aneurysm Variable (see text)
departments have a spiral CT scanner located in the
Compression Decompress soft tissue department or patients are able to be transported in a
On table angiogram short space of time to the CT scanner. In patients with
Arterio-venous fistula Ligate/oversew fistula multiple trauma, frequently CT head and/or abdomen
is required and combining this with a CT angiogram
Covered stent placement

Table 66.3 Investigation of vascular trauma

Investigation Advantage Disadvantage
None • Saves time in emergency situation • May miss vascular or soft tissue lesion
Ultrasound • Can be performed in emergency room • Operator dependent
• May not be technically possible
• Some areas (chest, subclavian artery) not easily accessible
CT angiography • Rapid • May require transfer to radiology
• Highly accurate • Substantial contrast load
• Performed at time of CT for other injuries
(e.g., head, abdomen)
Angiography • Accurate • May delay management of multiple trauma patient
if transferred to angiography suite
• Often endovascular therapy (e.g., covered • May miss some lesions seen on CT angiography
stent) can be performed at the time
of angiography
66 Trauma Surgery: Vascular Emergencies
allows vascular structures in the appropriate regions to
be imaged. With new 64 slice scanners, it is possible to
image the entire arterial tree in one or possibly two
runs.
66.4.3 Angiography
Angiography (Digital Subtraction Angiography) has
the advantage of allowing endovascular therapy to
occur at the time of imaging. Procedures such as cov-
ered stent placement for partial lacerations or embo-
lisation of pelvic arterial and/or venous bleeding
can be performed at the time of diagnostic angiogra-
phy. High-quality angiography can be performed in
many operating theatre suites, and thus, imaging +/−
intervention can be performed in association with
other surgical procedures. The main limitation in the
use of catheter angiography is the requirement for
­appropriately skilled and experienced interventional-
ists, and the availability of required equipment and
stents.
66.5 Forms of Surgical Repair
The technique of vascular repair will depend on the
type of arterial injury. The availability of a number
of appropriate vascular clamps in every operating
suite cannot be overemphasised. The technique of
repair will largely depend on the type of injury. In
general terms, polypropylene sutures are used in
vascular surgery. For large vessels, continuous
repair is frequently used; however, in smaller ves-
sels, interrupted sutures reduce the risk of ‘purse-
stringing’ and thus narrowing the vessel. Arterial
repairs in children should usually be performed
using interrupted sutures as this allows for vessel
growth.
The most common technique for repair of partial
lacerations of vessels is the lateral suture closure. In
instances where there is a significant amount of vessel
injured, a bypass or interposition graft using autoge-
nous conduit is preferred. Table 66.2 outlines the most
frequently used techniques to repair specific types of
vascular injuries.
565
66.6 Regions of the Body
66.6.1 Vascular Injuries of the Neck
See Chap. 62 Trauma Surgery–Neck Trauma.
66.6.2 Vascular Injuries to the Thorax
The majority of patients with injuries to the thoracic
aorta die at the time of injury or soon after and do not
present to hospital. Nonetheless, a proportion of
patients (particularly deceleration injuries in motor
vehicle or motor cycle accidents) present with con-
tained rupture of the descending thoracic aorta. The
injury commonly occurs at the site ligamentum arte-
riosum which is generally about 1.5 cm below the left
subclavian artery origin. The common chest X-ray
findings are noted in Table 66.1. A thoracic ­aortic
injury may also be suspected when an intercostal
drain is inserted for haemothorax and major blood
loss is noted. In this setting, clamping the drain to
allow tamponade may be a life-saving manoeuvre in
the initial resuscitation, and allow time for definitive
management.
Spiral CT angiography of the thoracic aorta is the
investigation of choice. Management of this injury lies
in prompt open surgical or endovascular repair. As
most of these affected patients have significant associ-
ated injuries, the majority of these cases are managed
by endovascular technique. This involves placement
of a covered stent graft which is inserted through the
femoral artery. An 8-mm diameter access vessel is
generally required so that occasionally, particularly in
women, an iliofemoral conduit may require construc-
tion to allow the graft to be passed up into the thoracic
aorta. When the injury is closer than 1.5 cm to the
­subclavian origin, it may be necessary to consider
­covering the left subclavian artery.
Covering the left subclavian artery appears to be
relatively benign in the majority of patients. Surgeons
may also need to embolise/ligate the proximal subcla-
vian artery to allow a seal to occur. Situations in which
a bypass needs to be performed to revascularise the
subclavian artery include the development of severe
ischaemia of the left upper extremity, when the left
internal mammary artery has been used for coronary
566
bypass surgery, or when the left subclavian artery is
the dominant vessel to the posterior cerebral circula-
tion (e.g., absent or hypoplastic right vertebral artery).
There are a number of concerns expressed in the
literature regarding the use of the endovascular devices
in relatively young trauma patients, but at this time the
overall consensus appears to be that as a life-saving
manoeuvre, the use of these techniques offers signifi-
cantly reduced mortality and morbidity in comparison
to open repair of major truncal vascular injuries.
In the situation where open repair of a transected
descending thoracic aorta is required, the preferred
access route is via anterolateral fourth interspace tho-
racotomy. In the instance where bilateral thoracic vas-
cular injuries are suspected/discovered, this approach
can be converted to a bilateral ‘Clamshell’ thoraco-
tomy and allows exposure of the upper anterior medi-
astinal vascular structures. Open repair of these injuries
is associated with significant mortality even in major
centres.
66.6.3 Vascular Injuries to the Abdomen
Abdominal trauma presenting with associated vascular
injury presents a major challenge to the surgeon.
Whilst a proportion of individuals presenting with
such injuries will be imaged pre-intervention with CT/
CT angiography (mainly blunt injuries), many will
require resuscitation and urgent intervention due to
haemodynamic instability. These individuals may
undergo abdominal ultrasound (‘FAST SCAN’) in the
emergency room which will usually confirm the pres-
ence of free blood but is unlikely to clarify the site of
bleeding in the majority of cases. The majority should
be promptly transferred to the operating room without
delays for imaging. Lines should be inserted in the
upper limbs/internal jugular vein and controlled resus-
citation commenced. A degree of controlled hypoten-
sion is probably beneficial rather than no or very
aggressive fluid replacement.
The history of trauma will be of great importance in
making a provisional diagnosis of the likelihood of
vascular injury and vessel affected. This is usually
easier in penetrating and iatrogenic injuries. Blunt
injuries (e.g., motor car, motor cycle accidents, falls)
generate a great force which is distributed over a large
area/volume and thus frequently results in severe
R.A. Fitridge and M. Hamilton
damage to a number of organs as well as injury to
­adjacent arteries and veins.
66.6.3.1 General Issues
The risks of the development of hypothermia and
coagulopathy are significant. It is thus worthwhile
warming the operating theatre to 40–42°C and warm-
ing infused fluids. Pre-emptive ordering of clotting
factors and platelets in addition to blood should also be
considered. The use of point of care coagulation stud-
ies (Thromboelastography or TEG studies) provides a
useful real time direction to the use of coagulation fac-
tors and provides physiological information about
clotting rapidly and in a reproducible fashion with no
delay.
A plain abdominal X-ray performed in the resusci-
tation room is valuable particularly when the injury is
caused by a gunshot wound. Both thighs should be
exposed so that saphenous vein can be harvested if a
graft is required.
66.6.3.2 Retroperitoneal Haematoma
A large retroperitoneal haematoma presents a major
challenge to the surgeon. Proximally (and ideally distal)
control of arterial and venous structures should be
obtained prior to opening the retroperitoneum. Even
with proximal and distal control, significant bleeding
is often encountered due to large collateral vessels
close to the site(s) of injury.
Pelvic injuries are often associated with significant
blood loss. Ideally, all pelvic fractures, especially ‘open-
book’ fractures, should be stabilised or reduced using a
pelvic binder/external fixateur or definitive repair to
help control bleeding. It is essential to avoid hypo-
thermia and coagulopathy in these cases. Significant
on-going bleeding frequently requires coil embolisation
via radiological approaches.
66.6.3.3 Iatrogenic Injuries
Iatrogenic vascular injuries are not infrequently encoun-
tered in open and laparoscopic intraperitoneal surgery.
The incidence of vascular injury associated with lap-
aroscopy has dramatically reduced since the technique
66 Trauma Surgery: Vascular Emergencies
of trochar insertion has changed from ‘sharp’ to formal
cutdown and blunt insertion of the port. Prompt recog-
nition of the vascular injury is important. Treatment
involves general resuscitation measures, request for
extra assistance if appropriate and prompt conversion to
midline laparotomy (not Pfannenstihl!). As the injury is
often adjacent to the aortic bifurcation, control of the
aorta and both iliac arteries needs to be obtained if the
injury is arterial. Dissection down both sides of the ves-
sels is adequate as slinging the vessels is often associ-
ated with bleeding from behind the vessel. When
necessary, venous control is obtained in the same fash-
ion. Occasionally, venous bleeding can be controlled
with the use of ‘swabs on sticks’ for applying pressure
above and below the site of injury. This may minimise
the risk of further venous injury that occurs with the
blind use of clamps etc. Bleeding from collaterals may
make exposure and repair difficult and may require fur-
ther dissection. Packing of a venous injury in particular
may be appropriate if assistance is not immediately
available.
Intra-abdominal vascular injuries associated with
gut contamination, particularly large bowel or in the
setting of delayed exploration with sepsis present, are
associated with significant risk of vascular complica-
tions. Direct suture repair of the vascular injury and
ideally coverage of the repair with an omental flap is
unlikely to result in problems. However, inserting a
prosthetic vascular graft (e.g., in the iliac artery) is
associated with significant risk of graft sepsis.
Consideration should be given to vessel ligation and
performing some form of extra-anatomical bypass
(e.g., femoro-femoral crossover graft). No immediate
reconstruction may be appropriate if the lower limb is
clearly viable after iliac artery ligation.
66.6.4 Abdominal Compartment
Syndrome
Intra-abdominal pressure (IAP) is defined as the
steady-state pressure within the abdominal cavity
and abdominal perfusion pressure (APP) is the dif-
ference between mean arterial pressure (MAP) and
the IAP [1, 2].
Abdominal compartment syndrome (ACS) is
defined as sustained intra-abdominal pressure (IAP)
>20 mmHg, with or without an abdominal perfusion
567
pressure (APP) <60 mmHg, that is associated with
new organ dysfunction/failure.
Intra-abdominal hypertension (IAH ³ 12 mmHg)
and abdominal compartment syndrome have become
increasingly recognised as contributors to poor out-
comes in severely ill patients. A number of surgical
and medical conditions are associated with the devel-
opment of IAH/ACS. The most important of these
from the perspective of the rural surgeon are listed in
Table 66.4. For more details, please refer to Malbrain
et al. [1].
It will be apparent to the surgeon that conditions
resulting in ACS can be caused by both increased intra-
abdominal contents or fluid shifts into the abdomen
associated with resuscitation or management of
sepsis.
Primary ACS is used to describe conditions associ-
ated with injury or disease in the abdomen or pelvis
that frequently require early surgical or interventional
radiological treatment. Secondary ACS refers to con-
ditions not originating in the abdomen or pelvis.
Clinicians should have a strong index of suspicion
of intra-abdominal hypertension in all new intensive
care admissions and/or evidence of clinical deteriora-
tion of a sick patient in those individuals at risk of
IAH, as shown in Table 66.4.
IAP measurements are taken with the patient
supine via an indwelling urinary catheter (bladder
Table 66.4 Conditions associated with Intra-abdominal hyper­
tension/abdominal compartment syndrome
Acidosis (pH < 7.2)
Multiple transfusions
Coagulopathy
Sepsis
Systemic
Intra-abdominal
Liver failure, cirrhosis/ascites
Massive fluid resuscitation (>5 L)
Major trauma
Intra-abdominal bleeding (e.g. post ruptured AAA)
Burns
Large incisional hernia repair
Peritoneal dialysis
568
instilled with £25 mL of saline) at end-inspiration.
Individuals in whom primary ACS is diagnosed
should undergo abdominal decompression with tem-
porary abdominal closure. Individuals with secondary
ACS should commence medical therapy to reduce
IAP and an underlying diagnosis should be confirmed,
decompression is required if medical options have
failed.
Our approach to decompression is to (re)open the
abdomen widely, deal with any intra-abdominal pathol-
ogy relevant to the development of ACS and then
suture in situ a large ellipse of Dacron mesh covered
on both sides with ‘Opsite’. Many other techniques are
used routinely.
The laparostomy can be closed completely at
24–48 h or on occasion, the laparostomy can be pro-
gressively closed over a number of days.
Patients considered at very high risk of developing
ACS may be closed at their initial procedure with a
laparostomy (e.g., selected ruptured AAA, trauma and
intra-abdominal sepsis patients).
66.6.5 Extremity Vascular Injuries
The ‘hard’ and ‘soft’ signs of vascular injury have been
previously discussed.
In dealing with extremity vascular injuries, it is
vital to free drape an unaffected leg for harvest of
saphenous vein, as this is the conduit of choice for all
peripheral reconstructions. If technically feasible, a
tourniquet should be placed proximal to the injury and
inflated if required.
Intra-arterial drug injection (accidental iatrogenic
or illicit) invokes an intense vasospastic response.
Local infection or false aneurysm may be present. In
the setting of severe pain and distal ischaemia, Treiman
et al. [3] recommend:
(a) Full heparinisation
(b) Dexamethasone 4 mg intravenously every 6 h
(c) Dextran 40 intravenously at 20 mL/h
(d) Adequate pain relief
(e) Limb elevation
(f) Aggressive physiotherapy to prevent contracture
formation.
This protocol is continued until the symptoms are
­stable or resolved and this generally takes 3–7 days.
R.A. Fitridge and M. Hamilton
66.6.6 Upper Extremity Injuries
Injuries to the upper limb arteries are rarely associated
with limb-threatening ischaemia due to excellent col-
lateral blood supply. This may result in arterial injuries
being missed at presentation but also allows the sur-
geon to ligate affected arteries and consider deferring
reconstruction in unstable patients or those with heav-
ily contaminated wounds if the hand is viable after
arterial ligation. The use of upper limb tourniquet for
control of bleeding is problematic in that it also
occludes collateral circulation, and thus causes pro-
found upper limb ischaemia. For this reason, the use of
prolonged tourniquet for transport of patients to a
­tertiary centre is contraindicated, and ligation of the
injured vessel is the preferred management.
66.6.6.1 Subclavian and Axillary Artery Injuries
Penetrating or blunt injuries to these vessels are fre-
quently associated with major musculo-skeletal and
nerve (often brachial plexus) injuries. The associated
neurological injuries are the primary determinant of
long-term outcomes of these injuries. The presence of
particular skeletal injuries, in particular first rib frac-
tures, has a strong correlation with underlying vascular
injury.
Iatrogenic injuries to these vessels are often associ-
ated with misplaced venous catheter insertion, often in
patients with significant co-morbidities. These injuries
are best treated by radiological placement of a covered
stent either via the brachial or femoral approach, or the
use of a percutaneous arterial closure device if in the
subclavian artery. If the inadvertent catheter placement
is recognised at the time of insertion, it should be left
in situ until the covered stent has been positioned
across the puncture site immediately prior to
deployment.
The open surgical approach to the right subclavian
artery requires a median sternotomy but the left sub-
clavian artery is difficult to access and may require a
left anterolateral thoracotomy or ‘trapdoor’ incision.
Both axillary arteries can be approached via infra-
clavicular incisions; however, initial supraclavicular
incisions may be required for proximal control.
Endovascular repair may be undertaken in selected
cases, especially stable false aneurysms, traumatic
66 Trauma Surgery: Vascular Emergencies
arteriovenous fistulae and iatrogenic injuries. Endo­
vascular treatment generally requires 1–1.5 cm cover-
age of adjacent unaffected artery, so that injuries in
close proximity to the common carotid or vertebral
artery origin may not be suitable for repair by endovas-
cular techniques.
Brachial artery injuries are frequently iatrogenic.
Blunt injuries associated with supracondylar fracture
may only require reposition of the fracture; however,
on occasion, exploration and decompression of adja-
cent fibrous bands may be needed. Occasionally inti-
mal injuries may present with later thrombosis of the
artery and these can initially be managed with antico-
agulation (unless contraindicated for other reasons)
and subsequent exploration/repair. Radial and ulnar
injuries (in particular distal arm injuries) can generally
be managed with ligation or repair unless there is an
incomplete palmar arch or both vessels are involved in
which situation repair is mandatory.
66.6.7 Lower Extremity Injuries
Lower limb vascular injuries are caused by penetrat-
ing, blunt and iatrogenic trauma.
CT angiography is particularly useful when the
patient is haemodynamically stable, when limb ischae-
mia is present and when there are multiple potential
sites of injury.
66.6.8 Femoral Vessels
Groin vascular injuries are often associated with per-
cutaneous catherisation, inadvertent injection of thera-
peutic or illicit drugs and work accidents. Common
presentations are active bleeding, limb ischaemia (due
to occlusion, proximal dissection or distal embolisa-
tion) or false aneurysm (occasionally infected if iatro-
genic, more frequently infected if secondary to illicit
drug injection). False aneurysms due to illicit drug
injection and those associated with redness over the
aneurysm, a leukocytosis, fever or elevated inflamma-
tory markers should be considered likely to be
infected.
Most angiography-related false aneurysms can
be treated with ultrasound-guided compression or
569
percutaneous thrombin injection under ultrasound
guidance. In the absence of limb ischaemia or com-
pression of adjacent structures causing neurovascular
impairment, the initial management of angiography-
related false aneurysms, less than 2 cm in diameter can
be conservative with observation and repeat duplex
scanning at a later date. Many smaller femoral false
aneurysms related to catheter angiography will sponta-
neously thrombose. False aneurysms causing skin
necrosis or neurovascular compromise, or with rapid
expansion should be treated surgically.
Whilst a direct surgical approach over the femoral
vessels commencing a little above the level of the
inguinal ligament allows easy exposure and repair of
vessels, active bleeding from the groin or false aneu-
rysms with no or minimal ‘neck’ below the inguinal
ligament are best dealt with by preliminary control of
the external iliac artery via a small retroperitoneal inci-
sion. Distal control should then be obtained, although
this can be difficult (or impossible) in the case of the
profunda femoris artery when the false aneurysm or
injury is directly anterior to this vessel. Manual com-
pression with a finger may provide enough control to
allow the placement of a suture to repair the injury.
A blind attempt to clamp placement may actually cause
further injury and should be avoided. Injuries to the
distal braches of the profunda femoris artery are diffi-
cult to access and ideally managed by percutaneous
embolisation if diagnosed prior to intervention.
In uninfected wounds, a 5/0 prolene suture to the
defect or possibly interposition with saphenous vein
may be required. Injuries with low-grade or possible
infections may be managed with repair (never pros-
thetic) and coverage with a sartorius flap. Frankly
infected wounds (generally false aneurysms) should be
managed with vessel ligation, wound debridement and
sartorius muscle flap coverage. If the limb appears
viable, no immediate reconstruction is needed. If the
limb appears ischaemic, an external iliac to superficial
femoral artery bypass is usually constructed, ideally
via a trans-obturator route (or at least passed well away
from the infected field).
66.6.8.1 Superficial Femoral Artery
Injuries to the superficial femoral artery may be asso-
ciated with distal femoral fractures, stab or bullet
wounds. Endovascular (covered stent) or open repair
570
may be performed. Any graft or surgical repair to a
lower limb artery requires adequate tissue coverage at
the time of surgery, and this may be difficult in the
­setting of significant tissue loss. Occasionally, extra-
anatomical routing of the graft may be required in this
situation. Shotgun injuries in particular mandate angio-
graphic imaging (usually with CT angiography), as
there may be multiple sites of vessel injury, even in the
absence of hard signs of vascular injury.
66.6.8.2 Popliteal Artery
Popliteal artery injuries are often caused by knee dislo-
cation, stab or gunshot wounds. Frequently popliteal
vein and tibial nerve injuries are associated with the
arterial injury and significantly affect outcome. Ideally
the popliteal vein should be repaired as ligation is
associated with a high risk of limb loss.
Injuries above and below the knee should be
repaired through a medial approach. Isolated wounds
at the level of the knee (dislocation or stab wound) in a
haemodynamically stable patient are probably best
approached via a posterior incision with the patient
prone. Most injuries are repaired by end-to-end anas-
tomosis or vein interposition graft. Gentle thrombec-
tomy of the distal vessel with a ‘3’ Fogarty catheter
(and infusion of 20 mL of heparinised saline) may be
required. Completion on-table angiography should
always be considered following repair of all arterial
injuries from the superficial femoral artery distally.
Factors associated with limb loss include severe soft
tissue (including nerve) injury and/or infection and
lengthy duration of preoperative ischaemia. In some
instances where the limb is severely mangled and there
is clear devastating neurovascular injury, primary
amputation may be the most appropriate management.
In the instance where there is a combined skeletal
injury, the timely placement of a temporary shunt may
allow the limb to be restored to length and stabilised
using external fixations, and then a definitive vascular
reconstruction performed.
66.6.8.3 Tibial Artery
Tibial artery injuries to single vessels rarely cause
ischaemia and can be ligated or coiled using endovenous
techniques. Injuries to two or three tibial vessels
require repair.
R.A. Fitridge and M. Hamilton
66.6.9 Limb Compartment Syndromes
Limb compartment syndromes are defined as elevated
pressures within the fascial compartment(s). Causes
include tissue swelling and fluid exudation due to
ischaemia-reperfusion injury (usually when there has
been a lengthy duration of severe ischaemia prior to
revascularisation), muscle crush injuries, intracom-
partment bleeding and circumferential burns. The
application of plasters can cause compartment
syndromes.
Clinical features include severe pain over the
compartment, altered sensation and a tight compart-
ment on examination. Distal pulses may be present
or absent. Whilst compartment pressures can be
measured, decompression fasciotomies should be
undertaken whenever the index of suspicion is high.
Most vascular and trauma surgeons consider per-
forming lower limb fasciotomies at the time of revas-
cularisation if the duration of ischaemia is greater
than 6 h and/or there has been a significant soft ­tissue
injury.
References
1. Malbrain, M.L., Cheatham, M.L., Sugrue, M., et al.: Results
from the international conference on intra-abdominal hyper-
tension and abdominal compartment syndrome: I. Definitions.
Intensive Care Med. 32, 1722–1732 (2006)
2. Cheatham, M.L., Malbrain, M.L.N.G., Kilpatrick, A., et al.:
Results from the international conference on intra-abdominal
hypertension and abdominal compartment syndrome: II.
Recommendations. Intensive Care Med. 33, 951–962
(2007)
3. Treiman, G.S., Yellin, A.E., Weaver, F.A., et al.: An effective
treatment protocol for intra-arterial drug injection. J. Vasc.
Surg. 12(4), 456–465 (1990)
Recommended Reading
Fitridge, R., Raptis, S., Miller, J.H., et al.: Upper extremity inju-
ries: experience at the Royal Adelaide Hospital, 1969 to
1991. J. Vasc. Surg. 20(6), 941–946 (1994)
Jamieson, G.G.: The Anatomy of General Surgical Operations,
2nd edn. Elsevier Churchill Livingstone, London (2006)
Rutherford, R.B.: Vascular Surgery, 6th edn. Elsevier Saunders,
Philadelphia (2005)
Valentine, R.J., Wynd, G.G.: Anatomical Exposures in Vascular
Surgery, 2nd edn. Lippincott Williams and Wilkins,
Philadelphia (2003)
 Thoracic Emergencies
67
Christian Müller

67.1 Introduction Thoracic trauma is an important contributing factor

to trauma-related death (25%) which is due to the asso-
ciated blood loss as well as development of respiratory
Chest involvement can be observed in up to 20% of all
failure after chest trauma.
trauma patients. This may be as trauma to the chest
only (25–35%) or as thoracic trauma in addition to
other injuries (65–75%). Leading causes for thoracic
trauma are motor vehicle accidents (65%), domestic 67.2 Symptoms
(15%), and work-related injuries (8%).
The most common injury is blunt thoracic trauma
More than ¾ of the patients do not have external signs
(90–95%), which may easily be underestimated with
of trauma to the chest. For this reason, the trauma
regard to its significance. Despite missing external
mechanism has to be thoroughly investigated. This
signs of trauma, significant injuries can be found
allows one to draw conclusions with regard to the
within the thoracic cavity. This may lead to danger-
potential extent of the chest injury. In young patients
ous delays in clinical detection resulting in a signifi-
with a more flexible chest wall, rib fractures may be
cant higher mortality of blunt compared to open
missing and the kinetic energy is transferred further
chest trauma. The incidence of penetrating chest
into the thorax, which may result in a high incidence of
injury varies significantly between different coun-
lung injuries or injuries of mediastinal structures in
tries and is related to the availability of knives and
these patients. Elderly patients usually suffer from rib
guns as well as presence of occupational health and
fractures which absorb the major part of the impact
safety regulations. Penetrating chest injuries may
energy within the chest wall.
only have small superficial wounds, which are by no
The consequences of the initial injury are not always
means an indicator of the damage within the thoracic
clear from the start. Respiratory failure due to lung
cavity.
contusion is maximal after several hours which makes
Potential injuries include simple contusions of the
it necessary to observe an asymptomatic patient after
chest wall and rib as well as sternum fractures (70%),
significant chest trauma for a minimum of 6 h.
lung contusion or laceration (60%), hemato-­pneumothorax
Clinical signs which can indicate injuries of the
(30%), laceration of the heart or major vessels (10%),
central airway or the lungs are dyspnea and emphy-
laceration of the diaphragm (5%), or esophagus (1%) as
sema of the mediastinum or the thoracic soft tissue.
well as injuries to the thoracic vertebral column.
Fractures of the chest wall are characterized by pain,
crepitation, and abnormal movements. Pulse deficit or
pulse differences between the left and right arm may
be indicators of cardiac or aortic injuries. The age of
trauma patients is of relevance because comorbidities
C. Müller
(e.g., COAD/COPD, cardiac failure) may influence the
Department of Surgery, The Queen Elizabeth Hospital,
28 Woodville Rd, Woodville South, SA 5011, Australia interpretation of diagnostic findings during the trauma
e-mail: mueller.1chir@marienkrankenhaus.org workup.

M.W. Wichmann et al. (eds.), Rural Surgery, 571

DOI: 10.1007/978-3-540-78680-1_67, © Springer-Verlag Berlin Heidelberg 2011
572
67.3 Diagnostic Steps
The patient must be evaluated at the scene of the acci-
dent as well as during the primary survey within the
receiving Emergency unit (pulse oxymetry reading as
early as possible).
In patients with chest trauma, computed tomography
(CT) can be considered diagnostic standard and should
be done as soon as possible where available. Conventional
X-rays must be done if CT is not available. CT allows to
evaluate injuries to the chest wall, the lungs, mediastinal
organs as well as major blood vessels and the vertebral
column. Ultrasound may be considered for the differen-
tiation of hemato- and pneumothorax during a fast scan
but cannot replace computed tomography.
If an injury of the esophagus or the trachea cannot
be excluded, gastroscopy as well as bronchoscopy
should be done early. Endoscopic evaluation allows
fast diagnosis and classification of injuries of these
structures and should be considered a standard proce-
dure in patients following significant chest trauma.
Cardiac injuries are more common following direct
ventral impact and it is important to consider ­commotio
cordis, contusio cordis, or compressio cordis, trauma-
induced myocardial infarction as well as cardiac
ruptures.
Commotio cordis is defined as blunt cardiac trauma
with transient functional deficit without pathomorpho-
logical findings. Cardiac arrhythmia is frequent, most
often not requiring specific therapy. Sudden death is
instantaneous, and victims are most often found in
ventricular fibrillation.
Contusio cordis is more severe and presents with
intramyocardial hemorrhage, often leading to arrhyth-
mia and possibly leading to cardiac tamponade. This
condition requires immediate surgical intervention to
prevent death.
Compressio cordis is defined as structural demoli-
tion of the heart with rupture of papillary muscles and
valvular lesions, leading to a variety of clinical symp-
toms. Cardiac surgery is usually required, provided the
patient survives the initial trauma.
Specific symptoms may be missing or may be simi-
lar to acute myocardial infarction. Diagnosis should
be based on myocardial enzyme testing (Troponin),
12 channel EKG, and ECHO (Echocardiography) in
order to be able to estimate the extent of cardiac injury.
In few cases, a coronary angiogram may be needed to
evaluate injuries to these vessels.
All of the patients suspected to have experienced
cardiac trauma require hospital admission and
C. Müller
observation, especially patients with an asymptomatic
primary course, since commotio cordis may second-
arily lead to contusio cordis.
Each deceleration trauma carries the risk of aortic
rupture, usually at the level of the aortic isthmus.
This injury usually is fatal at the site of the accident;
survivors suffer from dyspnea, pain radiating into
the back, reduced breathing sounds on the left side
(hematothorax), blood pressure difference between
the right and left arms, undetectable inguinal pulses
as well as hemorrhagic shock. Again CT should be
carried out early for the diagnosis of this condition
and may be completed with ECHO and aortography.
Ruptures of the diaphragm are rare even in
severely injured patients (2–7%), and up to 30% of
ruptures are missed during the initial examination
and may be detected after stabilization of the patient.
After blunt chest trauma, the majority of ruptures are
observed on the left side, whereas penetrating chest
trauma does not follow this rule. The diagnosis can
be based on the conventional X-rays and can be con-
firmed by CT or conventional X-rays with additional
oral contrast. The correct diagnosis is made in
30–60% of the patients during the initial surgery
since additional trauma requires early surgical inter-
vention (Fig. 67.1).
Injuries due to guns, knives, or other weapons only
cause 5% of chest traumas in European countries. In
other countries, these patients may represent a much
larger group. Again it is important to note that the exter-
nal injury does not necessarily correspond to the damage
within the thoracic cavity. Therefore, it is important to
Fig. 67.1 Rupture of the left diaphragm
67 Thoracic Emergencies 573

a Hemato-/pneumothoraces result from blunt thoracic

trauma with penetration of fractured ribs into the lung
or a rupture of the lung parenchyma due to the impact.
Insertion of a chest tube is the treatment of choice to
evacuate air and blood from the chest cavity and to
b prevent a tension pneumothorax from developing.
Penetrating chest injuries are also initially treated with
a chest drain and may require additional surgical inter-
vention (removal of foreign body). In hemodynami-
c cally unstable patients after penetrating chest injuries,
an emergency thoracotomy is mandatory as a life-­
saving procedure.
Contusion of the lung can only be confirmed using
serial images. Interstitial bleeding results in dyspnea,
and supplementary oxygen and chest physiotherapy
are needed for these patients. Patients require close
monitoring in order to not miss the indication for
­artificial ventilation which may be needed to avoid
posttraumatic pneumonia and SIRS.
Laceration and tearing of the lung parenchyma can
occur after blunt as well as penetrating chest trauma.
Fig. 67.2 Weapons causing stab injuries (a, b) and sites of pen- Radiological imaging indicates a ball-shaped hema-
etration (c): Knife (a) Chest: Lung and spleen, Knife (b) toma within the lung tissue. If this collection ruptures,
Abdomen: Muscle injury only a hematothorax develops. Ongoing bleeding or infec-
tion requires surgical intervention and resection of the
know about the kind of weapon (length of knife, caliber affected lung. In some cases, lung lesions can be sewn
of gun) and the direction of the attack to estimate the but only, if intrapulmonary hemorrhage is limited,
depth and severity of internal organ injury (Fig. 67.2). since extended intraparenchymal hemorrhage may
lead to severe infection (Fig. 67.3a–c).
Less common causes of a pneumothorax are inju-
67.4 Common Injuries and Therapeutic
ries of the trachea or the bronchi and are diagnosed
Interventions by bronchoscopy. These injuries may only affect the
Pars membranacea or can present as more complex
Initial treatment of thoracic injuries is based on the ruptures of the upper airways. Due to their close rela-
principles of trauma care (secure airway, breathing, and tionship, a significant laceration of the trachea also
circulation) and aims to correct life-threatening injuries requires an investigation of the esophagus via endos-
immediately (respiratory failure, tension pneumotho- copy. Depending on the localization as well as sever-
rax, hematothorax). In approximately 90%, conserva- ity of the injury, it may be treated by insertion of an
tive treatment with analgesia, oxygen, chest drainage, endotracheal tube, temporary insertion of a stent in
and administration of drugs for breakdown of mucous case of incomplete tracheal or bronchus rupture or
within the airways (mucolytics: acetylcysteine, bromhex­ surgical reconstruction with or without resection of
ine, dornase alpha) is sufficient. the depending lung parenchyma. The radiologic
Single or multiple rib fractures are the most fre- ­finding of a complete rupture of a main bronchus is
quent thoracic injuries. Conservative treatment includes the hanging lung sign. This type of injury is rarely
analgesia and physiotherapy and is usually sufficient. survived (Fig. 67.4).
Multiple rib fractures may cause a flail chest requiring Esophageal injuries are usually localized within the
ventilation; only very few patients will require surgical distal third and require immediate surgical interven-
stabilization of the chest wall. Fractures of the sternum tion which can include stenting, suture closure and
are treated in a similar fashion, they are usually due to fundoplication or drainage only.
a direct trauma and it is important to consider the pos- If there is an indicator of thoracic vertebral column
sible underlying cardiac trauma in these patients. injuries, the patient must be immobilized. This is
574
c Emergency thoracotomy should be done in patients
Fig. 67.3 (a, b) CT-scan soft tissue phase and parenchymal
phase of lung rupture. (c) Lobectomy preparation
especially true for unconscious patients, who must
be treated as spinal trauma patients until proven
otherwise.
67.5 Indications for Surgical Intervention
A primary surgical intervention is needed in approxi-
mately 10% of the patients after blunt thoracic trauma,
whereas penetrating chest trauma requires a thoraco-
tomy in up to 30%.
C. Müller
Fig. 67.4 Complete rupture of the right main bronchus with
hanging lung sign
Table 67.1 Indications for thoracotomy
Bleeding Initial evacuation >1,500 mL
or >250 mL/h
Parenchymal fistula >20% of tidal volume
Others Intrathoracic organ lesion
with massive initial or continuous blood loss
(Table 67.1), parenchymal fistula with loss of ventila-
tion volume of more than 20% (Fig. 67.5), rupture of
the trachea or the bronchi, and in cases with diaphrag-
matic ruptures (Fig. 67.1).
The surgical approach is standard thoracotomy.
Clamshell incision (bilateral transsternal thoraco-
tomy) or sternotomy should be done with respect
to the expected intrathoracic lesions. Immediate
­surgery should, however, only be done if there are
still recordable signs of life, i.e., pupil reaction to
light, breathing effort, spontaneous movements of the
patient.
Note: If a thoracotomy does not result in normal
heart actions and maintenance of systolic blood
pressure at 70 mmHg for a minimum of 30 min
with full medical support (volume substitution,
inotropes), the patient has no chance of survival.
After emergency thoracotomy for blunt thoracic
trauma, mortality is as high as 95%; penetrating
67 Thoracic Emergencies
a
b Recommended Reading
Fig. 67.5 (a, b) Parenchymal fistula with >20% loss of
ventilation volume, intraoperative findings
chest injuries, however, have a better survival rate of
up to 20%.
Semi-urgent procedures are performed 6–24 h after
admission and include treatment for esophageal
trauma, traumatic aneurysms of the thoracic aorta,
ruptures of the diaphragm, fistula formation of the
lung parenchyma (>20% of the breathing volume), and
other ­penetrating injuries which did not undergo emer-
gency thoracotomy. Persisting bleeding >1,500 mL/24 h
requi­res surgical intervention if a coagulation dis­
orders has been excluded (or treated) as underlying
cause.
Residual disease after previous chest trauma
(blood clots, empyema) can be treated early-elective
via thoracoscopy or conventional thoracotomy. If a
575
diaphragmatic herniation is diagnosed with delay, a
surgical reconstruction should be attempted to avoid
complications (bowel obstruction, bowel ischemia,
dysphagia) by laparotomy.
Lung injuries which require a surgical intervention
in terms of direct suturing, wedge, or anatomical resec-
tion have a low incidence of not more than 5% of all
thoracic injuries.
Key Message
The majority of thoracic injuries can be sufficiently
treated with symptom control using analgesia and
oxygen supplementation (30–35%) as well as
insertion of a chest drain (60–65%). Surgical inter-
vention is only needed in 2–16% and ranges from
up to 6% of patients after blunt trauma to 30% in
patients after penetrating chest trauma. Injuries of
the lung parenchyma are usually treated by direct
suture repair or wedge resection (60–75%); up to
40% of the patients may, however, require anatomi-
cal resections or even pneumonectomy. It is impor-
tant to note that mortality increases with the extent
of resection needed.
Demetriades, D., et al.: Trauma deaths in a mature urban trauma
system: is “trimodal” distribution a valid concept? J. Am.
Coll. Surg. 201(3), 343–348 (2005)
Flowers, J.L., et al.: Flexible endoscopy for the diagnosis
of esophageal trauma. J. Trauma 40(2), 261–265 (1996).
Discussion 265–266
Gomez-Caro Andres, A., et al.: Medical and surgical manage-
ment of noniatrogenic traumatic tracheobronchial injuries.
Arch. Bronconeumol. 41(5), 249–254 (2005)
Helling, T.S., et al.: Complications following blunt and penetrat-
ing injuries in 216 victims of chest trauma requiring tube
thoracostomy. J. Trauma 29(10), 1367–1370 (1989)
Karmy-Jones, R., et al.: Timing of urgent thoracotomy for hem-
orrhage after trauma: a multicenter study. Arch. Surg. 136(5),
513–518 (2001a)
Karmy-Jones, R., et al.: Management of traumatic lung injury:
a Western Trauma Association Multicenter review. J. Trauma
51(6), 1049–1053 (2001b)
Lang-Lazdunski, L., et al.: Videothoracospy in thoracic trauma
and penetrating injuries. Ann. Chir. 128(2), 75–80 (2003)
Mackenzie, R.: Spinal injuries. J. R. Army Med. Corps 148(2),
163–171 (2002)
576
Mandal, A.K., et al.: Posttraumatic empyema thoracis: a 24-year
experience at a major trauma center. J. Trauma 43(5),
­764–771 (1997)
Patel, V.I., et al.: Thoracoabdominal injuries in the elderly:
25 years of experience. J. Natl Med. Assoc. 96(12), ­1553–1557
(2004)
Rhee, P.M., Acosta, J., Bridgeman, A.: Survival after emergency
department thoracotomy: review of published data from the
past 25 years. J. Am. Coll. Surg. 190, 288–298 (2000)
C. Müller
Rosenthal, M.A., Ellis, J.I.: Cardiac and mediastinal trauma.
Emerg. Med. Clin. North Am. 13(4), 887–902 (1995)
Simpson, J., et al.: Traumatic diaphragmatic rupture: associated
injuries and outcome. Ann. R. Coll. Surg. Engl. 82(2),
97–100 (2000)
Stark, P., Jacobson, F.: Radiology of thoracic trauma. Curr. Opin.
Radiol. 4(5), 87–93 (1992)
Stewart, K.C., et al.: Pulmonary resection for lung trauma. Ann.
Thorac. Surg. 63(6), 1587–1588 (1997)
 Index

A organ injury, severity of, 532

Abdomen, vascular emergencies ultrasound, 530
iatrogenic injuries, 566–567 epidemiology, 529
issues, 566 prognostic significance, 529
retroperitoneal haematoma, 566 therapeutic approach
Abdominal compartment syndrome (ACS), 567–568 conservative therapy, 533
Abdominal pain, acute damage control surgery, 532–533
anatomy, 260–261 exploration and definite surgical treatment, 531–532
differentials and management laparoscopy, 533
appendicitis, 263 Abdominal wall hernias
cholecystitis/cholelithiasis, 264 complications, 300
diverticular disease, 265 definition and classification, 299
gynaecological problems, 264 diagnosis, 300
pancreatitis, 264–265 diastasis recti, 301
perforated peptic ulcer, 265 epidemiology and etiology, 299
renal colic, 265 epigastric (ventral) hernia, 301
small bowel obstruction, 264 femoral hernia, 306
urinary tract infections, 266 incarceration, forms of, 300
examination, 261 incisional hernia, 301–302
Glasgow coma scale (GCS), 261 inguinal hernia
investigations indications, 304
blood tests, 261–262 indirect and direct, 303–304
computer tomography, 262 therapy, 304–306
diagnostic laparoscopy, 263 internal hernia, 303
diagnostic peritoneal lavage (DPL), 262 obturator hernia, 303
ECG, 262 pediatric, 353
endoscopy, 263 perineal hernia, 303
exploratory laparotomy, 263 sciatic hernia, 303
plain film X-ray, 262 spigelian (lateral ventral) hernia, 303
ultrasound, 262 symptoms, 299
urine dipstick, 262 therapeutic algorithm, 300
priorities in assessment and management, 259 therapeutic strategies, 301
salient factors, 260 umbilical hernia, 301
vital signs, 259 Abdominoperineal resection (APR), rectal cancer, 253
Abdominal pathology, pediatric surgery Abscess
acute abdomen, 352 aerobic infections, 102
adjunct studies and fistula
complex abdominal pathology, 355 classification, 295, 296
disease processes, 353 diagnostics, 296
obstructive processes, 353–355 differential diagnosis, 296–297
Abdominal trauma pathogenesis, 295
blunt and penetrating, 529–530 symptoms, 295
diagnostic imaging therapy, 297–298
angiography, 531, 532 Acetabular fractures, 562
computed tomography, 531 classification, 561
conventional abdominal X-ray, 531 complications, 561–562

M.W. Wichmann et al. (eds.), Rural Surgery, 577

DOI: 10.1007/978-3-540-78680-1, © Springer-Verlag Berlin Heidelberg 2011
578 Index

conservative/surgical treatment, indications for, 561 emergencies

imaging, 561 diagnosis, 452–453
Achilles tendon rupture, 404–405 therapeutic options, 453–454
Acupuncture, acute pain management, 74 equipment, 467
Acute mesenteric ischaemia (AMI) failures in, 480–481
aetiology and pathogenesis, 275, 276, 278 indications for
clinical symptoms and diagnostics, 275–276 airway problem recognition, 467–468
complications, 278 injured patient, 468
diagnostic and therapeutic algorithms, 277 non-injured patient, 468–469
epidemiology, 275 obstructed or potentially compromised airway, 467
investigations, 276 interventions
localisation, 275 algorithm, 469, 470
portal vein/superior mesenteric artery, acute thrombosis of, bag-valve-mask ventilation, 471–472
278 cervical spine protection, 469
prognosis, 278 clearing, 469–470
therapeutical algorithm, 278, 279 complications, 474
therapeutic strategy, 276–278 cricothyroidotomy, 475
time flow of, 276 decannulation, 479
Adherent invasive Escherichia coli (AIEC), 285 definitive airway, 468, 472
Adjunctive therapy, sepsis, 242 fibre-optic intubation, 473
Adjuvants, 70 laryngeal mask airway, 472
Adrenal tumor long-term tracheostomy, 479
biochemical evaluation mini-tracheostomy, 478
aldosteronoma, 324 naso-tracheal intubation, 473
Cushing’s syndrome, 324 oro-tracheal intubation, 472–473
pheochromocytoma, 323–324 percutaneous tracheostomy, 476–477
virilizing/feminizing tumors, 324–325 pharyngeal airways, 471
clinical presentation, 323 sub-glottic airway access, 474
complications, 327–328 surgical tracheostomy, 477–478
CT imaging, 325 tracheostomy, 475–476, 478–479
hormonal syndromes, 324 in rural setting, 466–467
laparoscopic adrenalectomy skills, 465–466
advantages, 326 trauma, 480
posterior approach, 327–328 Aldosteronoma, 324
transabdominal lateral approach, 327 American Burn Association criteria, 502, 504
MRI, 325 American Society of Anaesthesiologists (ASA) classification,
open adrenalectomy of physical fitness, 137
absolute and relative indications, 325 American Spinal Association (ASIA) assessment, of spinal
anterior approach, 325–326 cord injury, 510
posterior approach, 326 America, rural surgery for, 5–6
a2-Adrenoceptoragonists, 151–152 AMI. See Acute mesenteric ischaemia (AMI)
Advanced Trauma Life Support (ATLS), 497 Aminoglycosides
Aerobic infections antibiotic resistance, 116
abscess, 102 efficacy and indication, 116
bursitis, 105 pharmacokinetics, 116
carbuncle, 103 side effects, 116
empyema, 102–103 Aminopenicillins, 109
erysipelas, 103, 104 Amphotericin B, 122–124
furuncle, 103 Amputation injuries, 420
gangrene, 104 Anaerobic infections
necrotizing infection, 104–105 gas gangrene, 105
panaris and paronychia, 105 tetanus, 105
phlegmon, 103–104 Anaesthetic risks, preoperative assessment, 135, 137
Airway Anal fissure
control conservative treatment, 294
anatomy, 480 diagnostics, 294
cervical spine trauma, 479–480 editorial comment on, 294–295
in rural setting, 479 pathogenesis, 292
severe brain injury, 480 surgical therapy, 295
trauma, 480 symptoms, 292–293
Index 579

Analgesia fosfomycin, 121

acute pain management glycopeptides, 114–115
co-analgesics and adjuvant drugs, 70 glycylcyclines, 119
general management, 70–71 indications, selection of, 127
local anaesthetics, 70 issues, 128
non-opioid analgesics, 69 lincosamides, 117
opioids, 69–70 lipopeptides, 115
and sedation, in intensive care macrolides, 113–114
analgo-sedation, 146 monobactams, 112
anxiety and agitation, 149–152 nitroimidazoles, 120
concepts in, 145–147 oxazolidinone, 116–117
delirium, 152–153 parenteral application, 108–109
muscle relaxants, 153 penicillins, 107, 109, 110
pain management, 147–149 polyenes, 122–124
withdrawal syndromes, 153 principles of, 107, 126, 128
therapy, 362 prophylaxis, in surgical procedures
Anastomotic leakage/stenosis definition, 128–129
colonoscopy, 45–46 evidence-based principles of, 129
gastroscopy, 37 indications for, 129
Angiogenesis, tumour, 24–25 recommendation for, 130
Angiography selection criteria for, 130–131
abdominal trauma, 531, 533 surgical infections, prevention of, 101
vascular emergencies, 565 surgical site infections, risk factors of, 129
Ankle streptogramins, 117–118
anatomical classification, 402 tetracyclines, 118–119
complications, 403–404 Antiplatelet therapy, 362
Danis-Weber classification, 402 Anti-reflux procedures
examination and diagnosis, 403 fundoplication in, 157
fractures, 403 indications for
mechanism of injury, 401–402 proton pump inhibitor, 157, 158
sprains, 403 reflux disease, 158
treatment, 403 volume reflux, 158
Ansamycins investigations, 157
antibiotic resistance, 120 operative technique, 159–160
efficacy and indication, 120 post-operative management, 161
pharmacokinetics, 119–120 principles
side effects, 120 hiatus, narrowing of, 158
Antibiotic prophylaxis intra-abdominal oesophagus, 158
bowel cancer, 247 one-way valve, construction of, 158–159
open extremity fractures, 542 results, 161
Anticoagulants, gastrointestinal bleeding, 272 Antisepsis, 101
Anticoagulation, in VTE prophylaxis, 83 Anxiety and agitation
Anticonvulsants, 70 barbiturates, 152
Antidepressants, 70 ketamine, 152
Antifungals midazolam and benzodiazepines, 150–151
efficacy, 123 monitoring, 150
systemic agents, for parenteral and propofol, 151
oral applications, 122 Appendicitis
Antimicrobial therapy acute, 218, 263
aminoglycosides, 115–116 complicated appendicitis, 221
ansamycins, 119–120 diagnostic scores
antibiotic resistance, 128 differential diagnosis, 219
antifungals, 122, 123 imaging studies, 219
azoles, 124–125 laboratory data, 219
carbapenems, 111–112 epidemiology, 217
cephalosporins, 110–111 etiology and pathogenesis, 217
co-trimoxazole, 121–122 history, 217
echinocandins, 125–126 informed consent
fluorinated pyrimidine, 125 comparison of, 220
fluroquinolones, 112–113 histology, 220
580 Index

laparoscopic appendectomy, 220 laparoscopic cholecystectomy, 177

open appendectomy, 219–220 otolaryngologic, 459–461
management, 219 carotid artery blowout, 461
results, 220–221 oropharyngeal hemorrhage, 458–459
symptoms, 217–218 Blood circulation, 357
Asepsis, 101 Blunt abdominal trauma, 529–530
Atelectasis, bronchoscopic treatment, 33 Bowel atresia, pediatric, 354
Atheroembolic disease, 360 Bowel cancer
Atrial fibrillation, 359 colon cancer, surgery for
Atypical mycobacteria (MAP), 285 mechanical bowel preparation, 247
Australia, rural surgical education in preoperative preparation, 246–247
Rural Surgical Training Program (RSTP), 3 complications, 248–249
Surgical Education and Training (SET) Program, 3 diagnosis, 245
trainees, 3–4 distant metastases, 249
Autonomic neuropathy, 369 emergency colonic resection, 249
Azoles familial large, 245–246
efficacy and indication, 124–125 incidence of, 245
pharmacokinetics, 124 laparoscopic colectomy, 247–248
resistance, 125 operative surgery, 247
side effects, 125 palliative resection, 249
Aztreonam, 112 prophylactic antibiotics, 247
stapled vs. hand-sewn anastomoses, 248
B thromboembolism prophylaxis, 247
Bacterial infections, 102 treatment planning, rural issues, 249
Bag-valve-mask ventilation, 471–472 Bowel obstruction
Barbiturates, 152 clinical decision making
coma, 518 algorithm for, 225
Bariatric surgery, complications causes of, 226
laparoscopic gastric band colonic obstruction, 227, 229
band erosion, 210–211 CT scan findings, 228
band slippage, 211–212 diagnosis-based approach, 224
concentric pouch dilatation, 212 erect X-rays of, 228
port and tubing problems, 212–213, 215 management of, 225
morbid obesity operations, 205 mechanical and ileus, clinical and radiological
programs, 213–215 findings, 225, 226
Roux-en-Y gastric bypass (RYGBP) plain film and CT scan findings, 228
anastomotic leak, 206 plain X-rays of, 227
anastomotic strictures, 207, 208 stomas, 229
diagram of, 205 strangulated obstruction, 226
internal hernia formation, 207–209 supine abdominal X-rays of, 228
Basal cell carcinoma (BCC), 341–343 community expectations, 224
Benign familial hypocalciuric hypercalcemia (BFHH), 316 facilities, technical support and manpower, 224
Bile duct surgeon training and experience, 223–224
cancer, palliative surgery, 28 Bowel stricturing, 286
CBD stones, 178, 179 Bowen’s disease, 342
injuries, in LC, 176, 177 Brachial artery, 364
stones, ERCP, 47, 48 Branchial cleft cysts, 458
Biliary bypass surgery, 28 Breast and endocrine surgery
Bilobe flaps, 381 benign disorders
Bisphosphonates, 70 breast abscess, 331–332
Bladder injury, 440–441 central duct excision, 334
Bladder outflow obstruction, cystoscopy, 52 excisional biopsy, 333
Bleeding incisional breast biopsy, 332–333
and carcinoma, 286 mammary fistula, 332
control, in gastroscopy microdochectomy, 333–334
esophageal varices, 36 malignant disease
Forrest classification of, 36 axillary clearance, 338–339
lesion, endoscopic appearance of, 37–38 mastectomy, 336–337
ulcers, 36 SLNB, 337–338
control, in upper gastro-intestinal tract, 36–37 wide local excision (WLE), 334–336
diverticulitis, 236 Breathing, 357
gastrointestinal (see Gastrointestinal bleeding) Bronchoscopy
Index 581

atelectasis, 33 Central duct excision, breast cancer, 334

complications, 34 Cephalosporins
haemoptysis, diagnosis and treatment of, 32–33 antibiotic resistance, 111
indications for, 32 efficacy and indication, 111
instruments, 31 pharmacokinetics, 110
intubation, 33 side effects, 111
patient preparation, 32 Cerebral herniation syndromes, 519
percutaneous puncture tracheostomy, 33 Cervical spine, 523
rigid laryngoscopy, 34 lower injuries
tracheo-bronchial system instable injuries of, 550
anatomy of, 31 stable type 1 injuries, 550
stenosis, treatment of, 33–34 trauma, 479–480
Burn injury upper injuries
American Burn Association criteria, 502, 504 dens axis fractures, 550
chemical burns, 505 traumatic spondylolysis, 550
electrical burns, 505 X-ray, 523
immediate care, 502 Cervical traction, spinal injury, 524
initial evaluation Chemical burns, 505
Berkow chart, 503 Chemically defined diets (CDD), 89, 90
burn size, 502 Chemoradiotherapy, for rectal cancer, 252
first degree, 501 Cholecystectomy, laparoscopic, 169–179. See also
partial-thickness (second-degree) burns, 501 ­Laparoscopic cholecystectomy (LC)
Rule of nine’s, 502 Cholecystectomy, open, 72
third degree, 501–502 Circumcision, 355, 384
major burn care, 504 Clavicle fracture
minor burn care, 504 classification, 393
tar burns, 504–505 complications, 394
Bursitis, 105 examination and diagnosis, 393
mechanism of injury, 393
C treatment, 393–394
Caesarean section Clindamycin, 117
anaesthesia, 425 Clonidin, 151
cephalic presentation, 426 Co-analgesics and adjuvant drugs, 70
closure, 427 Colectomy, 247–248
indication for emergency, 425, 426 Colecystitis/cholelithiasis, acute, 264
non-cephalic presentation, 426–427 Colloidal solutions, perioperative fluid management
preparation, 425 dextran solutions, 143
surgical technique, 426 gelatin solutions, 142–143
Calf vein thrombosis, 82–83 hydroxyethyl starch (HAES), 143–144
Caloric demand, of surgical patient, 87 patient outcome (mortality), 142
Calots triangle, in laparoscopic cholecystectomy Colon cancer
dissection of, 173 mechanical bowel preparation, 247
and safety, 173–174 palliative surgery, 28
Canada See Rural Canada, surgery in preoperative preparation, 246–247
Carbapenems Colonoscopy
antibiotic resistance, 112 anastomotic leakage/stenosis, treatment of, 45–46
efficacy and indication, 111–112 colon polyp, 41, 45
pharmacokinetics, 111 diverticulitis, 232, 233
side effects, 112 flexible and interventional endoscopy, 41
Carbuncle, 103 ileocaecal valve and appendiceal orifice, 41
Carotid artery blowout, 461 indications for, 42
Carpal injuries, 417–418 patient preparation and technique of examination
Carpal tunnel release bowel preparation, 42
anatomy video-colonoscope, 43
flexor retinaculum, 407, 408 polypectomy
median nerves, 407 complications, 44–45
palmar branch, 408 follow-up, 44
structures, 407 procedure, 43–44
complications, 410 risk of malignancy, 43
post-operative care, 410 surveillance colonoscopies, 44
presentation, 408 postpolypectomy syndrome, 45
procedure, 408–410 virtual colonoscopy, 42
582 Index

Colorectal carcinoma, 17, 18 See also Bowel cancer Curative surgical oncology, 19–20
Colorectal metastases (CRMs) Cushing’s syndrome, 324
ablation of, 184–185 Cyclooxygenase (COX), 69
clinical evaluation and investigation studies, 184 Cystitis, 52
surgical staging, 184 Cystoscopy
Colostomy advantage of, 51
end, 256 bladder outflow obstruction, 52
loop, 257 complications, 53
Common bile duct (CBD) stones, management cystitis, 52
laparoscopic choledocotomy and formal exploration, 178–179 indications, 51
laparoscopic transcystic bile duct exploration and irrigation fluid, 52
extraction, 178 patient preparation, 51–52
open bile duct exploration, 179 prostatic biopsy, 53
postoperative ERCP, 179 retrograde pyelogram, 52
preoperative ERCP, 178 technique, 52
Commotio cordis, 572 ureteric orifices, 52
Compartment syndrome, 361, 366, 541 urethral stricture, 52
Compressio cordis, 572
Computed tomography (CT) scan D
abdominal pain, acute, 262 Dalfopristin, 118
abdominal trauma, 531 Daptomycin, 115
adrenal tumor, 325 Decannulation, 479
bowel obstruction, 228 Deep vein thrombosis (DVT)
cerebral contusions, 513 diagnosis, 82
diverticulitis, 232 prophylaxis
epidural hematoma, 514 forms of, 78
head injuries, 512 measures, 77
splenic injury, 202 mechanical methods, 77–78
subdural hematoma, 515 pharmacological methods, 78
Computerised tomographic pulmonary angiography (CTPA), proximal, 83
81, 82 Delirium, 152–153
Concussion, head injuries, 513 Dextran solutions, 143
Contusio cordis, 572 Diabetic foot
Contusion/intracerebral hematoma, 513–514 acute management
Corpus fractures, 416 digital amputation, 371–372
Corticosteroids, 70 limb-threatening foot sepsis, 371
Co-trimoxazole microbiological assessment, 372–373
antibiotic resistance, 121 MR imaging, 373
efficacy and indication, 121 perfusion assessment, 372
pharmacokinetics, 121 assessment, general principles of
side effects, 122 biomechanical, 370
Cricothyroidotomy, 453–454, 475 endocrine, 370
Critical limb ischemia (CLI), 369 microbiological, 370–371
Critically ill patients, nutrition neurological, 369–370
additive pharmacotherapy, 96 vascular, 369
caloric demand, 96 Wagner scale, 372
metabolic monitoring, 96 wound classification system, 371, 372
substrates, 95–96 chronic management, 373
Crohn’s disease Diagnostic peritoneal lavage (DPL), 262
aetiological clues, 284–285 Diarrhoea, in enteral nutrition, 95
clinical symptoms and investigations, 284 Diastasis recti, 301
Crohn’s appendix, 286 Diazepam, 151
description, 283–284 Diffuse axonal injury (DAI), 515
grading of, 284 Distal radial fractures
medical management, 285 classification system, 391
post-operative treatment, 286–287 complications, 392–393
surgical management, 285, 286 examination and diagnosis, 392
Crystalloids, perioperative fluid management mechanism of injury, 391
full strength electrolyte solutions, 141 treatment, 392
glucose 5% solutions, 141–142 Distant flaps, 383–384
isotonic sodium chloride solutions, 141 Diverticular disease, acute, 265
Index 583

Diverticulitis indications, 47–49

acute, 234 malignant biliary obstruction, endoscopic stents for, 49
classification of preparation and sedation, 49
Hansen and stock, 233 in rural setting, 50
Hinchey, 233 training in, 47
clinical examination, 232 Endoscopy
complications of acute abdominal pain, 263
bleeding, 236 gastrointestinal bleeding, 269, 272
fistula formation, 235 inguinal hernia, 305–306
impaired colonic passage, 236 stents, 28, 29, 49
conservative therapy, 233–234 Enteral nutrition, 94–95
diagnostic options Entero-epithelial mycoplasma, 285
colonoscopy, 233 Epidural analgesia, 72
computed tomography (CT), 232 Epidural hematomas, 514
goals in, 232 Epigastric (ventral) hernia, 301
laboratory tests, 232 Epiglottitis, 457–458
ultrasound, 232 Epistaxis, 459–461
epidemiology, 231 exsanguinating, 459–460
etiology and pathogenesis nasal packing materials, 460–461
colonoscopy finding, 232 ERCP. See Endoscopic retrograde cholangiopancreatography
pseudo-diverticula, 231 (ERCP)
localization, 231 Erysipelas, 103
prognosis, 236 clinical presentation of, 104
risk factors, 231 dermis, 104
surgical therapy Esophageal cancer, palliative surgery, 27
Hartmann procedure, 235 Excisional breast biopsy, 333
indication for, 235 Exploratory laparotomy, acute abdominal pain, 263
primary anastomosis, 235 Extensor tendon injuries, 418–419
timing of, 234 External ventricular drainage (EVD)/intracranial pressure
therapeutic strategy, 233 monitoring, 518
Doppler-guided haemorrhoidal artery ligation, 290 Extremity vascular injuries, 568
Doxycycline, 118, 119
Duodenal obstruction, palliative surgery, 28 F
Dupuytren’s contracture Fair Dinkum Audit template, 60
categories, 411 Familial adenomatous polyposis (FAP), 17, 18, 245, 246
classification, 412 Fecal occult blood testing (FOBT), 269
history, 411 Feeding access, gastric surgery
post-operative regime, 412–413 Janeway gastrostomy, 166–167
pre-operative assessment, 412 tube gastrostomy, 166
surgical technique, 411–412 Femoral artery, 364–365
Femoral hernia, 306
E Femoral vessels
The Early Management of Severe Trauma (EMST), 497 false aneurysms, 569
Echinocandins popliteal artery, 570
efficacy and indication, 126 superficial femoral artery, 569–570
pharmacokinetics, 126 tibial artery, 570
resistance, 126 Fentanyl
side effects, 126 gastrointestinal motility and ileus, decrease of, 148
Ectopic pregnancy, 428–429 hypotension, 148
Elective open splenectomy, 202 respiratory depression, 148
Electrical burns, 505 withdrawal syndrome, 148
Electrocardiogram (ECG), acute abdominal pain, 262 Fiber optic endoscopy
Electrolyte disorders and postoperative fluid imbalances, bronchoscopy, 31–34
139–141 colonoscopy, 41–46
Emergency splenectomy, 202 gastroscopy, 35–39
Emergency thoracotomy, 574, 575 Fibre-optic intubation, 473
Empyema, 102–103 Fibrocartilago volaris rupture, 417
Endoscopic retrograde cholangiopancreatography (ERCP), Fine-needle aspiration biopsy (FNAB),
178, 179 thyroid surgery
bile duct stones, 47, 48 benign lesion, 311
complications, 49–50 cytological features, 311
584 Index

cytological results, 311 examination and diagnosis, 397

follicular/Hürthle cell lesion, 311–312 mechanism of injury, 397
malignant lesion, 312–313 treatment, 397–398
Fistula, 295–298 non-operative treatment
Flaps plaster casting, 389–390
classification, 378 traction, 390
local flaps osteosynthesis, 390
bilobe, 381 thumb, 416–417
distant flaps, 383–384 tibia shaft
forehead flap, 382 complications, 401
groin flap, 383 examination and diagnosis, 400
muscle flaps, 383 mechanism of injury, 400
radial forearm flap, 382 treatment, 400–402
regional flaps, 381 Fundoplication, in anti-reflux procedures, 157
rhomboid, 381 Furuncle, 103
V-Y advancement flap, 378–379
Z-plasty, 379–381 G
reconstructive ladder, 375 Gallbladder
uses, 378 and bile duct cancer, palliative surgery, 28
wound bed requirements, 378 dissection, 174
Flexor tendon injuries, 419 surgery
Fluconazole, 124 bile duct injury avoidance, strategies to, 176
Flucytosine, 125 CBD stones, management of, 177, 179
Fluid management. See Perioperative fluid management dissection of, 174
Fluorinated pyrimidine intraoperative cholangiography (IOC), 174–175
efficacy and indication, 125 laparoscopic cholecystectomy (see Laparoscopic
pharmacokinetics, 125 cholecystectomy (LC))
resistance, 125 postoperative care, 177
side effects, 125 Gangrene, 104
F-18 Fluorodeoxyglucose-positron emission tomography Gas gangrene, 105
(FDG-PET), colorectal metastases, 184 Gastric band, 210–215
Fluroquinolones Gastric surgery
antibiotic resistance, 113 anatomy, 163
efficacy and indication, 113 blood supply, to stomach, 163
pharmacokinetics, 113 cancer
side effects, 113 complications, 165–166
Focal nodular hyperplasia (FNH), 185 lymph node dissection, 164
Fondaparinux, 78 palliative gastrectomy, 164
Forehead flaps, 382 palliative surgery, 28
Fosfomycin radical subtotal gastrectomy, 164
antibiotic resistance, 121 reconstruction, 164–165
efficacy and indication, 121 splenectomy, 164
pharmacokinetics, 121 staging laparoscopy, 164
side effects, 121 total gastrectomy, 164
Fractures treatment options, 165
clavicle feeding access, 166–167
classification, 393 ulcer disease, 166
complications, 394 Gastrointestinal anastomosis, 93
examination and diagnosis, 393 Gastrointestinal bleeding
mechanism of injury, 393 acute vs. chronic, 267
treatment, 393–394 angiography, 273
distal radial definition, 267
classification system, 391 diagnosis, upper vs. lower
complications, 392–393 history, 268
examination and diagnosis, 392 imaging, 269
mechanism of injury, 391 laboratory tests, 268–269
treatment, 392 physical examination, 268
external fixation for, 390 endoscopy, 272
hand and fingers, 415–416 management
humeral shaft anticoagulants, 272
classification system, 397 hematologic, 271
complications, 398 pharmacologic, 271
Index 585

procedural, 271–272 fractures, hand and fingers, 415–416

supportive, 270–271 immobilization, 415
rural issues nerve injuries, 420
transport, 274 open and closed lesions, 415
triage, 274 replantation, 420–421
upper vs. lower, 267 skier’s thumb, 418
Gastrointestinal (GI) tract tumours, lymph nodes in, 22 soft tissue injuries, 420
Gastroscopy thumb fracture, 416–417
anastomotic leakage/stenosis vessel injuries, 420
inoperable esophageal cancer, 38 Head injuries
palliative tumor treatment, 38 classification of, 511
self-expanding metal stent, release of, 39 CT scanning, 512
flexible endoscopy, 35 induced hypothermia, 521
percutaneous endoscopic gastrostomy (PEG), 37 intracranial hypertension
upper gastro-intestinal tract nonsurgical treatment measures, 517–518
bleeding control, 36–38 pathophysiology of, 515–516
indications, 35, 36 MRI, 512
patient preparation and technique of examination, 35–36 patterns of
Gelatin solutions, 142–143 concussion, 513
General practitioners (GPs), rural Canada, 13 contusion/intracerebral hematoma, 513–514
Genital trauma repair, 428 diffuse axonal injury (DAI), 515
Genitourinary pathology, pediatric surgery, 355–356 epidural hematomas, 514
Glasgow coma scale (GCS), 261, 508 subarachnoid hemorrhage/intraventricular
Glucose regeneration, during stress, 86 hemorrhage, 515
Glutamine supply, in perioperative nutrition, 92 subdural hematomas (SDH), 514–515
Glycopeptides raised ICP, 518–521
antibiotic resistance, 114 skull X-rays, 511–512
efficacy and indication, 114 steroids, 521
pharmacokinetics, 114 vascular imaging, 513
side effects, 115 Hematological disease, splenectomy, 201–202
Glycylcyclines Hematoma volume, 512
antibiotic resistance, 119 Hemipelvectomy, 557
efficacy and indication, 119 Hepatocellular cancer
pharmacokinetics, 119 clinical evaluation, 182
side effects, 119 investigation studies, 182
Groin flaps, 383 surgical staging, 182–183
Gynaecology Hereditary non-polyposis colorectal cancer (HNPCC),
ectopic pregnancy, 428–429 18, 245–246
hysterectomy, 430 Hernias, 299–306. See also Abdominal wall hernias
ovarian cystectomy, 430–431 Hippocratic method, shoulder dislocation, 396
ovarian torsion, 431 Hospital-acquired infections, 101
retained product evacuation, 429–430 Hospital trauma response
communication, 495
H early management, 497–498
Haemoptysis, diagnosis and treatment, 32–33 trauma team, 495–497
Haemorrhoids Huber needle, 211
diagnostics, 289 Humeral shaft fractures
differential diagnosis, 289 classification system, 397
Doppler-guided haemorrhoidal complications, 398
artery ligation, 290 examination and diagnosis, 397
operative therapy, 291–293 mechanism of injury, 397
rubber band ligation, 290 treatment
sclerotherapy, 290 non-operative, 397
symptoms, 289 operative, 397–398
therapy, 290 Hydrocele, 356
Haloperidol, 152 Hydroxyethyl starch (HAES), 143–144
Hand injuries Hypafix dressing, 410
amputation injuries, 420 Hypertonic saline, in intracranial hypertension, 518
carpal injuries, 417–418 Hypertrophic pyloric stenosis (HPS), pediatric, 353–354
extensor tendon injuries, 418–419 Hyperventilation, in intracranial hypertension, 518
fibrocartilago volaris rupture, 417 Hypothermia, induction of, 521
flexor tendon injuries, 419 Hysterectomy, 430
586 Index

I rural trauma care

Iatrogenic vascular injuries, 566–567 definitive care, 484
Ileitis, acute, 286 factors affecting, 484
Ileostomy quality of, 484–485
end, 256 trauma care models
loop, 257 effective trauma care systems, 485, 486
Incisional breast biopsy, 332–333 facilities, 493–494
Incisional hernia, 301–302 hospital triage, 490
Incontinence, 438 injury prevention, 485–486
Infection patient transport and transfers, 490–492
defense, 99–100 pre-hospital care, 486–488
first-line treatment, 100 pre-hospital triage, 488–490
infectious disease and inflammation, 99 rural trauma care services, 494–495
surgical (see Surgical infections) transfer protocols, 492–493
surgical therapy of, 100 Intensive care patient, nutrition, 86–87
systemic antibiotic therapy, 100 Intermittent pneumatic compression devices (IPC), 78
Inferior vena cava (IVC) filters, 79 Internal hernia, 303
Inflammatory bowel diseases formation, RYGBP, 207–209
abdominal mass and fistulisation, 286 Intra-abdominal hypertension (IAH), 567
acute ileitis, 286 Intracranial hypertension
Crohn’s disease nonsurgical treatment measures
aetiological clues, 284–285 barbiturate coma, 518
appendix, 286 fever/shivering/coughing, 517
clinical symptoms and investigations, 284 hypertonic saline, 518
description, 283–284 hyperventilation, 518
grading of, 284 mannitol, 518
medical management, 285 pharmacological paralysis, 518
post-operative treatment, 286–287 sedation, 517–518
surgical management, 285, 286 seizures, 517
diagnosis of, 281 venous return, 517
regional surgical management, 285–286 pathophysiology of
ulcerative colitis approach to treatment of, 516
aetiological considerations, 282 cerebral perfusion pressure (CPP), 516
clinical symptoms and diagnosis, 281–282 Cushing’s triad, components of, 516
elective surgery, 283 Monro-Kellie pressure-volume curve, 515, 516
emergency surgery, 283 Intracranial pressure (ICP)
indications for, 283 decompressive craniectomy, 519
medical and surgical treatment, 282 exploratory burr holes/emergency craniotomy
Informed consent, appendicitis, 219 cerebral herniation syndromes, 519
Ingrown toenail, 386 delayed deterioration, causes of, 520
Inguinal hernia Kernohan’s notch phenomenon, 519
indications, 304 location of, 520
indirect and direct, 303–304 posterior fossa, 521
pediatric, 353 external ventricular drainage (EVD)/intracranial pressure
therapy monitoring, 518
complications, 306 mass lesions, evacuation of, 519
endoscopic techniques, 305–306 Intrahepatic cholangiocarcinoma
recurrences, 306 clinical evaluation and investigation studies, 183
suture techniques, with and without alloplastic management, 183
mesh graft, 304–305 surgical staging, 183
Injury management, severe Intraoperative cholangiography (IOC), 174–175
hospital trauma response Intussusception, pediatric, 354
communication, 495 Isotonic sodium chloride solutions, perioperative fluid
early management, 497–498 management, 141
trauma team, 495–497 Isoxazolylpenicillins, 109
injury-related mortality, 483 Isthmusectomy, 313–314
rural surgeon, role of Itraconazole, 124
critical stress incident debriefing process, 498
fragmented care, 498 J
resource allocation, 499 Janeway gastrostomy, 166–167
triage and transfer protocol, 499 Joint fractures, 545
Index 587

K peri and post operative care and management,

Ketamine, 152 366–367
Kocher’s method, shoulder dislocation, 396 revascularisation complications, 366
Rutherford scale, 360
L upper limb, 359
Laparoscopic cholecystectomy (LC) Lincosamides
Calots triangle antibiotic resistance, 117
dissection of, 173 efficacy and indication, 117
and safety, 173–174 pharmacokinetics, 117
complications, detection and management protocol side effects, 117
bile duct injuries, 177 Linezolid, 116, 117
bleeding, 177 Lipids, parenteral application, 91
limitations, 169 Lipopeptides
operative technique antibiotic resistance, 115
patient position, 172 efficacy and indication, 115
port positioning and direction, 172, 173 pharmacokinetics, 115
requirements side effects, 115
competent surgical staff, 169–170 Liver surgery
infrastructure and facilities, 170–171 anatomical considerations
patient selection, 170 portal vein and hepatic artery, 181–182
Laparoscopic gastric band, bariatric surgery venous drainage of, 181
band erosion, 210–211 asymptomatic hepatic mass, 185–186
band slippage primary cancers
dilated pouch, 214 hepatocellular cancer, 182–183
Huber needle, 211 intrahepatic cholangiocarcinoma, 183
progressive slippage of, 213 secondary cancers
upper gastrointestinal series, colorectal metastases, 184–185
positioning of, 212 neuroendocrine metastases, 185
concentric pouch dilatation, 212 noncolorectal, nonneuroendocrine metastases, 185
diagram of, 210 Lobectomy, 313–314
endoscopic retroflex view, of gastroesophageal junction, Local anaesthetics, 70
210, 211 Long-term tracheostomy, 479
port and tubing problems, 212–213 Lorazepam, 151
Laparoscopy Lower extremity injuries, 569
abdominal trauma, 533 Lower limb ischaemia, acute
acute abdominal pain, 263 aetiopathogenesis
adrenalectomy aneurysm disease and post stenotic dilatation, 360
advantages, 326 atheroembolic disease, 360
posterior approach, 327–328 atrial fibrillation, 359
transabdominal lateral approach, 327 chronic occlusive disease, 360
appendectomy, 220 compartment syndrome, 361
choledocotomy and formal CBD exploration, non-atherosclerotic/aneurysmal popliteal artery
178–179 pathology, 361
colectomy, 247–248 thoracic aorta dissection, 361
nephrectomy thrombophilias and paraneoplastic syndromes, 361
complications, 447, 448 thrombotic causes, 360–361
description, 446–447 anatomic approach
tumour perspective, 447–448 brachial artery, 364
splenectomy, 203 damage control options, 366
Laparotomy, abdominal trauma, 531, 532 femoral artery, 364–365
Laryngeal mask airway (LMA), 472 interposition grafting, 365
Lentigo maligna, 346–349 intraoperative imaging, 365–366
Limb compartment syndromes, 570 popliteal artery, 365
Limb ischaemia, acute thromboembolectomy, 365
lower limb (see also Lower limb ischaemia, acute) decision making, 363
aetiopathogenesis, 359–361 diagnosis
anatomic approach, 364–366 catheter angiography, 362
decision making, 363 hand held static/pencil Doppler, 361
diagnosis, 361–362 non-invasive imaging, 361–362
initial management, 362–363 initial management, 362–363
operative management, 363–364 operative management, 363–364
588 Index

peri and post operative care and management, 366–367 N

revascularisation complications, 366 Naso-tracheal intubation, 473
Rutherford scale, 360 Neck trauma
Ludwig’s angina, 457 definitive management, 535–536
Lumbar spine injuries, 550–551 management, surgical principles of, 536
Lymph node surgical exploration, 536–537
biopsy, 385–386 treatment principles
dissection, gastric cancer, 164 airway and breathing, 535
in GI tract tumours, 22 circulation, 535
initial assessment and management, 535
M vascular injuries
Macrolides anterior sternomastoid incision, 537, 538
antibiotic resistance, 114 carotid artery and jugular vein, exposure of, 538
efficacy and indication, 114 trap door incision, 537
pharmacokinetics, 113–114 visceral injuries, 538–539
side effects, 114 zones of, 536
Magnetic resonance imaging (MRI) Necrotising pancreatitis
of adrenal tumor, 325 indication for, 188
head injuries, 512 nonsurgical management, 188
spinal injury, 524 surgical management, 188–189
Malignant biliary obstruction, endoscopic stents, 49 Necrotizing infections, 104–105
Malrotation, pediatric, 354–355 soft tissue, 241
Mammary fistula, 332 Nephrectomy
Mannitol, in intracranial hypertension, 518 laparoscopic/partial
Mastectomy, 336–337 complications, 447, 448
Medical Research Council grading, of motor power, 510 description, 446–447
Medullary thyroid cancer (MTC), 313 tumour perspective, 447–448
Melanoma open
danger signs, 344 complications, 446
differential diagnosis preoperative evaluation, 442
amelanotic, 344 radical nephrectomy, 444–445
pigmented melanoma, 344 simple nephrectomy, 442–444
malignant, 344, 345 surgical approach, 442
Mensical tears, 399–400 tumour perspectives, 445–446
Merkel cell tumours, 343 radical (see Radical nephrectomy)
Metastasization, in surgical oncology, 23–24 Neuroendocrine metastases, 185
Methicillin-resistant Staphylococcus aureus (MRSA) Neurogenic shock, 522
management, 102 Neurotrauma
Metronidazole, 120 head injuries
Microdochectomy, 333–334 classification of, 511
Midazolam, 150–151 concussion, 513
Monobactams contusion/intracerebral hematoma, 513–514
antibiotic resistance, 112 CT scanning, 512
efficacy and indication, 112 diffuse axonal injury (DAI), 515
pharmacokinetics, 112 epidural hematomas, 514
side effects, 112 induced hypothermia, 521
Morphine, 148–149 intracranial hypertension, 515–518
Motor neuropathy, 370 MRI, 512
Multiorgan dysfunction syndrome raised ICP, 518–521
clinical symptoms, 240 skull X-rays, 511–512
diagnostic procedures, 240 steroids, 521
epidemiology, 238 subarachnoid hemorrhage/intraventricular hemorrhage,
past medical history, 239 515
pathophysiology, 238–239 subdural hematomas (SDH), 514–515
postoperative patient intervention, 240 vascular imaging, 513
septic focus, clearance of, 241 in-hospital management
therapy, 241 AMPLE history, 509
Multiple endocrine neoplasia (MEN) syndrome, bloodwork, 511
315–316 comatose patient, 509
Muscle flaps, 383 MRC motor grading scale, 510
Muscle relaxants, 153 muscle groups, in motor examination, 509
Index 589

neurological examination, 509–511 preoperative nutritional therapy

primary survey, 508–509 calorie supply, 92
secondary survey, 509 indication for, 92
prehospital care substrate metabolism, changes of
history, 508 post-aggression metabolism, 85, 86
initial management, 507–508 stress, glucose regeneration, 86
spinal injury
clinical assessment, 521–522 O
C-spine, 522 Obstetrics
CT imaging, 523–524 caesarean section
MRI imaging, 524 anaesthesia, 425
neurogenic shock and spinal shock, 522 cephalic presentation, 426
NEXUS cervical spine evaluation criteria, 522 closure, 427
plain X-rays, 522–523 indication for emergency, 425, 426
stability, 521 non-cephalic presentation, 426–427
treatment of, 524–525 preparation, 425
victims, transfer of, 525 surgical technique, 426
Nissen fundoplication, 158 genital trauma repair, 428
Nitroimidazoles placenta, removal of, 427–428
antibiotic resistance, 120 Obturator hernia, 303
efficacy and indication, 120 Occlusive disease, 360
pharmacokinetics, 120 Odontogenic infections, 456–457
side effects, 120 Oncology. See Surgical oncology
Nociceptor pathway, 68, 69 Onychocryptosis, 386
Non-opioid analgesics, 69 Open adrenalectomy
Nonsteroidal anti-inflammatory drugs absolute and relative indications, 325
(NSAIDs), 149 anterior approach, 325–326
Nosocomial infections, surveillance of, 101 posterior approach, 326
Nuclear medicine scanning, PHPT, 317–318 Open appendectomy, 219–220
Nurse practitioners (NPs), in rural Canada, 13–14 Open extremity fractures
Nutrient defined diets (NDD), 89, 90 antibiotic prophylaxis, 542
Nutrition, of surgical patient classification, of soft-tissue injury
assessment of, 87–88 Gustilo, 542
caloric demand, 87 Tscherne and Oestern, 542
critically ill patients compartment syndrome, 541
additive pharmacotherapy, 96 diagnostic steps, 541
caloric demand, 96 loss of bone, 546
metabolic monitoring, 96 NISSSA-score, 541, 543
substrates, 95–96 osseous stabilisation, 543–544
intensive care patient, 86–87 polytraumatised patients, 545
perioperative caloric demand, estimation of, 89 scoring, 541
perioperative nutrition, substrates for soft-tissue management
diabetes diets, 90 debridement, 543
enteral nutrition, 89, 90 primary closure, 542
glutamine, vitamins and trace elements, stabilisation of
supply of, 92 joint fractures, 545
immunomodulating diets, 90 reaming, 545
kidney solutions, 91 shaft fractures, 544–545
lipids, parenteral application of, 91 wound closure
liver-adapted tube diets, 90 dynamic suture, 544
liver solutions, 92 skin flaps, 544
oral nutrition, 89 vacuum-assisted closing methods, 544
organ dysfunctions, 91–92 Open nephrectomy
parenteral nutrition, 90, 91 complications, 446
post-operative nutritional therapy preoperative evaluation, 442
bolus feeding, 95 radical nephrectomy, 444–445
catheter jejunostomy, 95 simple nephrectomy
early oral/enteral nutrition, complications of, 94–95 closure, 444
indication, 92–93 complications and outcomes, 444
oral/enteral calorie intake, 93–94 indications, 442–443
parenteral calorie intake, 94 position and incision, 443
590
sub-capsular technique, 443–444
surgical technique, 443
surgical approach, 442
tumour perspectives, 445–446
Open prostatectomy, 438–439
Opioids, 69–70
Oral nutrition, of surgical patient, 89
Oropharyngeal hemorrhage, 458–459
Oro-tracheal intubation, 472–473
Orthopaedic procedures
achilles tendon rupture
complications, 405
examination and diagnosis, 404
function, 404
mechanism of injury, 404
treatment, 404
ankle joint
classification, 402
complications, 403–404
examination and diagnosis, 403
mechanism of injury, 401–402
treatment, 403
clavicle fracture
classification, 393
complications, 394
examination and diagnosis, 393
mechanism of injury, 393
treatment, 393–394
closed reduction, 389
distal radial fractures
classification system, 391
complications, 392–393
examination and diagnosis, 392
mechanism of injury, 391
treatment, 392
external fixation, 390
humeral shaft fractures, 396–398
limb injuries, assessment of, 389
non-operative fracture treatment
plaster casting, 389–390
traction, 390
osteosynthesis, 390
shoulder dislocation
aftercare, 396
classification, 394
examination and diagnosis, 395
mechanism of injury, 395
operative treatment, 396
treatment, 395–396
soft tissue knee injuries
examination and diagnosis, 399
knee anatomy, 398
ligaments, 398
mechanism of injury, 398–399
treatment, 399–400
tibia shaft fractures
complications, 401
examination and diagnosis, 400
mechanism of injury, 400
treatment, 400–402
Orthotopic liver transplantation (OLT), 182, 183
Index
Osseous stabilisation, 543–544
Osteosynthesis, 390
Otolaryngology
airway emergencies
diagnosis, 452–453
therapeutic options, 453–454
bleeding
carotid artery blowout, 461
epistaxis, 459–461
oropharyngeal hemorrhage, 458–459
emergencies, rural surgery, 451
infections
branchial cleft cysts, 458
epiglottitis, 457
odontogenic, 456–457
peritonsillar abscess, 454–456
sinusitis, 458
surgical competency, 452
Ovarian cystectomy, 430–431
Ovarian torsion, 431
Oxazolidinone
antibiotic resistance, 117
efficacy and indication, 116–117
pharmacokinetics, 116
side effects, 117
P
Pain management
analgesic drugs
co-analgesics and adjuvant drugs, 70
general management, 70–71
local anaesthetics, 70
non-opioid analgesics, 69
opioids, 69–70
assessment and documentation, 74
definitions, 68
intraoperative interventions, 71
medical interventions
epidural analgesia, 72
peripheral nerve blockade, 72
systemic analgesia, 72–73
medication, in intensive care
fentanyl, 148
morphine, 148–149
NSAIDs, 149
peridural analgesia, 149
pethidin, 149
priritramid, 149
route of application, 147–148
sufentanil, 148
monitoring, in intensive care, 147
non-medical interventions
acupuncture, 74
contra-irritation technique, 74
nursing and physiotherapy, 74
psychological interventions, 74
organization of, 74–75
pathophysiological and pharmacological basics
central projecting level, 68
peripheral level, 68
spinal cord level, 68
Index 591

postoperative interventions, 71–72 superior parathyroid gland, 318–319

preoperative interventions, 71 thyroid lobectomy, 320
Palliative surgery hyperparathyroidism, 315
colon cancer, 28 primary hyperparathyroidism
endoscopic stents, 28, 29 causes, 315
esophageal cancer, 27 diagnosis and clinical evaluation, 316–317
gall bladder/bile duct cancer, 28 familial, 315–316
gastrectomy, 164 localizing imaging studies, 317–318
gastric cancer, 28 parathyroidectomy guidelines, 317
malignant ureteric obstruction, 28 serum calcium levels, 316
oncology, 20 surgery, 318
pancreatic cancer, 28 symptoms, 315
rectal cancer, 28 unilateral vs. image-directed parathyroidectomy, 320
small bowel cancer, 28 Parenteral nutrition, 90, 91
team approach, 27 Partial nephrectomy, 446–448
trachea/bronchi, malignant Patella dislocation, 400
obstruction of, 27 Pediatric surgery
Palliative treatment abdominal pathology
colonoscopy, 46 adjunct studies, 352–355
gastroscopy, 38, 39 pediatric acute abdomen, 352
Panaris and paronychia, 105 appendicitis, 353
Pancreatic cancer, palliative surgery, 28 genitourinary pathology
Pancreatic surgery circumcision, 355
anatomy, 187–188 hydrocele, 356
necrotising pancreatitis torsion, 355–356
indication for, 188 pediatric trauma, 356–357
nonsurgical management, 188 physiology and resuscitation
surgical management, 188–189 age-specific physiology, 351, 352
neoplasms fluid resuscitation, 351
post operative management, 192 vascular access, 352
reconstruction, 192 thoracic pathology, 356
resection, 191–192 Pediatric trauma, 356–357
pancreatic trauma Pelvic injuries
indications for, 190 acetabulum, fractures of
nonsurgical management, 190 classification, 561
surgical management, 190–191 complications, 561–562
pseudocysts conservative/surgical treatment, indications for, 561
nonsurgical management, 189 imaging, 561
surgical management, 189–190 anatomy and pathophysiology, 555
surgical access to, 188 classification, 555–556
Pancreatitis clinical diagnosis, 557
acute, 264–265 emergency treatment of, 558, 559
aetiological factors imaging, 558
acute, 196 definitions, 557
chronic, 198 definitive stabilisation, 558–560
definition, 195 epidemiology, 555
diagnosis of follow-up care
Balthazar CT index, 196 acetabular fractures, 562
modified Glasgow/Imrie score, 196 pelvic ring, 562
Ranson criteria, 196 treatment, 558
scoring systems, 196–197 Penetrating abdominal trauma, 529–530
management of, 197 Penicillins
rural surgeon, role of, 198–199 antibiotic resistance, 109–110
surgical treatment, 197–198 efficacy and indication, 109
symptoms and signs, 195 pharmacokinetics, 107, 109
Papillary thyroid cancer (PTC), 312 side effects, 110
Paraneoplastic syndrome, 361 Peptic ulcer, perforated, 265
Parathyroid surgery Percutaneous endoscopic gastrostomy (PEG), 37
four-gland parathyroid exploration Percutaneous puncture tracheostomy, 33
inferior parathyroid gland, 319–320 Percutaneous tracheostomy, 476–477
subtotal parathyroidectomy, 319 Perforated peptic ulcer, 265
592 Index

Peridural analgesia, 149 Primary hyperparathyroidism (PHPT)

Perineal disease, 285 causes, 315
Perineal hernia, 303 diagnosis and clinical evaluation, 316–317
Perioperative caloric demand, estimation of, 89 familial, 315–316
Perioperative fluid management localizing imaging studies, 317–318
colloidal solutions parathyroidectomy guidelines, 317
albumin, 142 serum calcium levels, 316
artificial colloids, 142 surgery, 318
dextran solutions, 143 symptoms, 315
gelatin solutions, 142–143 Priritramid, 149
hydroxyethyl starch (HAES), 143–144 Proctology
patient outcome (mortality), 142 abscess and fistula
crystalloids classification, 295, 296
full strength electrolyte solutions, 141 diagnostics, 296
glucose 5% solutions, 141–142 differential diagnosis, 296–297
isotonic sodium chloride solutions, 141 pathogenesis, 295
postoperative fluid imbalances and electrolyte disorders symptoms, 295
central venous pressures (CVP), 139 therapy, 297–298
haemodynamic goals for, 140 anal fissure
oliguria, 140 conservative treatment, 294
Perioperative nutrition, 89–92 diagnostics, 294
Peripheral nerve blockade, 72 editorial comment on, 294–295
Peritonitis, 241 pathogenesis, 292
Peritonsillar abscess, 454–456 surgical therapy, 295
Pethidin, 149 symptoms, 292–293
Pharyngeal airways, 471 haemorrhoids
Pheochromocytoma, 323–324 diagnostics, 289
Phlegmon, 103–104 differential diagnosis, 289
PHPT. See Primary hyperparathyroidism (PHPT) Doppler-guided haemorrhoidal artery ligation, 290
Physician extenders (PEs), in rural Canada, 13–14 operative therapy, 291–293
Placenta, removal of, 427–428 rubber band ligation, 290
Plaster casting, 389–390 sclerotherapy, 290
Polyenes symptoms, 289
efficacy and indications, 123 therapy, 290
pharmacokinetics, 123 Propofol, 151
resistance, 124 Prostatectomy, 435–436
side effects, 124
Polygalactin 910, 420 Q
Polypectomy, 43–45 Quinupristin/dalfopristin, 118
Polytraumatised patients, 545
Popliteal artery, 365, 570 R
Posaconazole, 124, 125 Radial forearm flaps, 382
Positron emission tomography (PET), 184, 251, 284 Radical nephrectomy
Postgastrectomy syndromes, 165 indications, 444
Postoperative fluid imbalances and electrolyte on left side, 445
disorders, 139–141 principle, 444
Post-operative nutritional therapy, 92–95 on right side, 444–445
Postpolypectomy syndrome, 45 surgical approach, 444
Preoperative nutritional therapy, 92 Radical subtotal gastrectomy, 164
Preoperative risk assessment Radiofrequency (RF) ablation, in colorectal metastases, 184, 185
anaesthetic Radiotherapy
ASA classification, of physical fitness, 137 long-course chemoradiotherapy vs. short course, 252
patient issues, 135, 137 preoperative vs. post-operative, 252–253
benefits of, 135 Rectal cancer
healthcare initiatives, 135 abdominoperineal resection, 253
high-risk anaesthetic clinic, 137 chemotherapy, 254
nursing requirements complications, 253
assessment, 134 extended resections, 254
patients, categorization, 133–134 imaging, 251
preadmission clinic, organization of, 133 incidence, 251
preadmission questionnaire for, 136 local excision, 253
Index 593

multidisciplinary committee meetings, 251 Sciatic hernia, 303

palliative surgery, 28 Sclerotherapy, haemorrhoids, 290
post-operative surveillance, 254 Secondary hyperparathyroidism, 315
preoperative chemoradiotherapy, 252 Sedation, in intracranial hypertension, 517–518
preoperative vs. post-operative radiotherapy, 252–253 Seizures, 517
short-course radiotherapy vs. long-course Sentinel lymph node biopsy (SLNB)
chemoradiotherapy, 252 advantages, 337
symptoms and signs, 251 rural issues, 338
Regional flaps, 381 technique, 337–338
Renal colic, 265 Sepsis
Residual tumour status (R-status), 21 adjunctive therapy, 242
Retroperitoneal haematoma, 566 anti-infectious treatment, 241–242
Rhomboid flaps, 381 damage control, 241
Richmond Agitation-Sedation Scale (RASS), 150 definition, 237
Rifampicin, 119, 120 multiorgan dysfunction syndrome
Rigid endoscopy, cystoscopy, 51–53 clinical symptoms, 240
Rigid laryngoscopy, 34 diagnostic procedures, 240
Roux-en-Y cystojejunostomy, 189, 190 epidemiology, 238
Roux-en-Y gastric bypass (RYGBP), bariatric surgery past medical history, 239
anastomotic leak, 206 pathophysiology, 238–239
anastomotic strictures, 207, 208 postoperative patient intervention, 240
diagram of, 205 septic focus, clearance of, 241
endoscopic dilatation, 207 therapy, 241
endoscopic evaluation, 207 necrotizing soft tissue infections, 241
gastrojejunostomy leak, laparoscopic reexploration, 206 organ function, support of, 242
internal hernia formation, 207–209 peritonitis, 241
staple-line failure, sites for, 206 septic shock, 237–238
through-the-scope (TTS) balloon, 207, 208 severe
Rubber band ligation, 290 definition, 237
Rural Canada, surgery in organ support, 238
challenges shock, 237–238
general surgeons, number of, 7–8 systemic inflammatory response syndrome, 237
recruiting and retaining surgeons, 8–9 Shaft fractures, 544–545
resources for, 9 Shoulder dislocation
surgical services, poor integration and aftercare, 396
coordination of, 9 classification, 394
training programs, 8 examination and diagnosis, 395
definition, 7 mechanism of injury, 395
financial incentives, 14 operative treatment, 396
invoking educational and program planning principles treatment
active learning, 11 anterior dislocation, 395–396
appreciating evaluation’s central role, in inferior dislocation, 396
learning, 10–11 posterior dislocation, 396
outcome-based education, 10 Sigmoidoscopy, 226, 251
over education/extraction education, 11 Sinusitis, 458
role modeling, 10 Skier’s thumb, 418
physician extenders (PEs), 13–14 Skin cancer
solutions, strategies, 10 basal cell carcinoma, 341, 342
systems-based solutions, 12–13 excision principles
telemedicine excision biopsy, 345
definition, 11 lentigo maligna, 346–349
interactive education, 12 lines of expression, 345
patients, from afar, 11–12 recommended excision margins, 346
physician communications, 12 melanoma
training general practitioners (GPs), 13 amelanotic, differential diagnosis, 344
Rural Surgical Training Program (RSTP), 3 danger signs, 344
malignant, 344, 345
S pigmented, differential diagnosis, 344
Sacral fractures, 560 Merkel cell tumours, 343
Sacroiliac displacement, 559, 560 prognosis, BCC and SCC, 343
Scaphoid fractures, 416 squamous cell carcinoma, 341–343
594 Index

Skin grafting hematological disease, 201–202

conceptual tool, 375 laparoscopic splenectomy, 203
decision making, 376 trauma
graft thickness, 376 computed tomography, 202
operation mechanics, 376–377 splenic salvage, 202
postoperative care, 377–378 vaccination, 201
reconstructive ladder, 375 Splenectomy, 164
wound bed preparation, 375–376 Squamous cell carcinoma (SCC), 341–343
SLNB. See Sentinel lymph node biopsy (SLNB) Stapled vs. hand-sewn anastomoses, 248
Small bowel cancer, palliative surgery, 28 Status epilepticus, 517
Small bowel obstruction, 264 Stenosed segments, of tracheo-bronchial
Soft tissue system, 33–34
hand injuries, 420 Steroids
knee injuries head injuries, 521
examination and diagnosis, 399 in spinal cord injury, 524
knee anatomy, 398 Stocking/glove sensory neuropathy, 369–370
ligaments, 398 Stoma surgery
mechanism of injury, 398–399 colonic stent, 255
treatment, 399–400 complications, 258
management, 542–543 end stomas, 256
Spigelian (lateral ventral) hernia, 303 loop stomas
Spinal injuries closure of, 257–258
clinical assessment, 521–522 colostomy, 257
C-spine, 522 end, 257
CT imaging, 523–524 ileostomy, 257
MRI imaging, 524 sighting, 255
neurogenic shock and spinal shock, 522 stoma trephine, 256
NEXUS cervical spine evaluation criteria, 522 Streptogramins
plain X-rays antibiotic resistance, 118
cervical spine, 523 efficacy and indication, 118
thoracolumbar spine, 523 pharmacokinetics, 118
stability, 521 side effects, 118
trauma Subarachnoid hemorrhage, 515
aetiology and pathogenesis, 547 Subclavian and axillary artery injuries, 568–569
anterior stabilisation, 552 Subdural hematomas (SDH), 514–515
cervical, 549–550 Sub-glottic airway access, 474
conservative therapy, 551–552 Subjective global assessment (SGA), 87–88
epidemiology, 547 Sufentanil, 148
hand’s motor functions, 548 Superior mesenteric artery, acute thrombosis
level of C4, 548 of, 278
localisation, 547 Surgical audit
neurological control triangle, 548 audit meeting, conduct of, 58, 61
neurological symptoms, 548–549 checklist of information, 59
posterior stabilisation, 552 data collection method, 56–58
radiological imaging, 549 data sets, 55–56
surgical therapy, 552 definitions, 55
symptoms and clinical diagnosis, 547–548 drop-down value lists, comorbidities and complications
thoracic and lumbar, 550–551 for, 57
treatment goals, 551 Fair Dinkum Audit template, 60
vertebral column, bony structures of, 549 outcome reporting
treatment of adverse events and incidents, 61–64
cervical traction, 524 complications, 61
steroids, 524–525 CUSUM and cumulative failure charts,
Spinal shock, 522 61, 63, 64
Spiral CT/CT angiography, vascular emergencies, rural surgery, indicators for, 62
564–565 sentinel event, 63
Spleen, surgery of peer review, 58
anatomy, 201 preparation, 58
complications, 203 rural surgical craft group (Australia), 63
elective open splenectomy, 202 trainee logbooks, 56
emergency splenectomy, 202 Surgical Education and Training (SET) Program, 3
Index 595

Surgical infections diaphragm, ruptures of, 572

aerobic infections, 102–105 weapon injuries, 572–573
anaerobic infections, 105 injuries and therapeutic interventions
bacterial infections, 102 lung parenchyma, 573, 575
diagnosis of, 99 parenchymal fistula, 574, 575
prevention of surgical intervention, indications for
antimicrobial prophylaxis, 101 semi-urgent procedures, 575
asepsis and antisepsis, 101 thoracotomy, 574, 575
hospital-acquired infections, 101 symptoms, 571
hygiene, 100–101 Thoracolumbar spine, 523
MRSA, management of, 102 Thorax
nosocomial infections, surveillance of, 101 and lumbar spine injuries, 550–551
surgical technique, 101 pediatric pathology, 356
types, 99 vascular emergencies, 565–566
Surgical oncology Thromboembolectomy, 365
curative, 19–20 Thromboembolism prophylaxis, 247
gene mutations, 17 Thrombolytic agents, 362
goals of, 18–19 Thrombophilias, 361
metastasization, 23–24 Thromboprophylaxis, 77–78
molecular genetics, in tumour formation Thumb fracture, 416–417
adenoma-carcinoma sequence, in colorectal Thyroid stimulating hormone (TSH), 310
carcinoma, 17, 18 Thyroid surgery, community general surgeon
ductal pancreatic carcinoma, 17 clinical evaluation, 309
familial adenomatous polyposis (FAP), 17, 18 diagnostic lobectomy and isthmusectomy, 313–314
HNPCC, 18 investigation
multimodal treatment, 21 anaplastic and poorly differentiated thyroid
palliative, 20 cancers, 313
prognostic factors, therapy in cytological results, 311
diagnostic findings, 22 diagnostic algorithm, 310
GI tract, lymph nodes in, 22 FNAB, 310–312
grading/histomorphologic features, 22 medullary thyroid cancer, 313
perioperative management, 23 papillary thyroid cancer, 312
residual tumour status (R-status), 21 TSH, 310
TNM classification, 21–22 ultrasonography, 310–311
UICC-staging, 22 Tibia
tumour angiogenesis, 24–25 artery, 570
Surgical tracheostomy, 477–478 shaft fractures
Systemic analgesia complications, 401
administration routes, 73 examination and diagnosis, 400
opioids, 72, 73 mechanism of injury, 400
patient-controlled analgesia (PCA), 73 treatment, 400–402
WHO pain ladder, 73 Tigecycline, 119
Systemic inflammatory response syndrome, 237 TNM classification, surgical oncology
distant metastases, 22
T extent of primary tumour, 21
Techniecium-99, PHPT, 317 regional lymph node metastases, 21
Telemedicine, in rural Canada, 11–12 Tonicity reducing medication, 70
Tertiary hyperparathyroidism, 315 Trachea/bronchi, malignant obstruction of, 27
Testicular torsion, 355–356 Tracheostomy
Tetanus, 105 complications, 478–479
Tetracyclines indications for, 476
antibiotic resistance, 119 long-term, 479
efficacy and indication, 118 mini, 478
pharmacokinetics, 118 percutaneous, 476–477
side effects, 119 surgical, 477–478
Thoracic emergencies tube configurations, 475–476
blunt and penetrating trauma, 571 Tracheotomy, 454
diagnostic steps Traction, 390
commotio cordis, 572 Transoral endotracheal intubation, 453
compressio cordis, 572 Transtracheal needle intubation, 453
contusio cordis, 572 Transurethral resection of the prostate (TURP), 435–436
596 Index

Trauma surgery in males, acute, 433–434

care medication, 435
definitive care, 484 non-surgical treatment, 434–435
effective trauma care systems, 485, 486 Urinary tract infections, 266
facilities, 493–494 Urine dipstick, 262
factors affecting, 484 Urological conditions
hospital triage, 490 acute urinary retention, surgical treatment
injury prevention, 485–486 alternative minimally invasive techniques, 438
patient transport and transfers, 490–492 complications, 436–437
pre-hospital care, 486–488 erectile and ejaculatory problems, 438
pre-hospital triage, 488–490 incontinence, 438
quality of, 484–485 mortality, 436
rural trauma care services, 494–495 open prostatectomy, 438–439
transfer protocols, 492–493 prostatectomy, 435–436
neck (see Neck trauma) urethral stricture and bladder neck
pelvic injuries, 555–562 stenosis, 437–438
rural surgeon, role of bladder injury, 440–441
critical stress incident debriefing process, 498 laparoscopic or partial nephrectomy
fragmented care, 498 complications, 447, 448
resource allocation, 499 description, 446–447
triage and transfer protocol, 499 tumour perspective, 447–448
spine injuries, 547–552 open nephrectomy
vascular emergencies, 563–570 complications, 446
Tube gastrostomy, 166 preoperative evaluation, 442
Tumour radical nephrectomy, 444–445
angiogenesis, 24–25 simple nephrectomy, 442–444
dormancy, 24 surgical approach, 442
growth, postoperative complications, 23 tumour perspectives, 445–446
ureteric injury
U diagnosis, 439–440
Ulcerative colitis management, 440
aetiological considerations, 282 prevention, 439
clinical symptoms and diagnosis, 281–282 types, 439
elective surgery, 283 urinary retention
emergency surgery, 283 catheterisation, 435
indications for, 283 definition, 433, 434
medical and surgical treatment, 282 diagnosis, 434
Ulcer disease, gastric surgery investigation, 434
bleeding control, 166 in males, acute, 433–434
perforated, 166 medication, 435
surgical intervention, 166 non-surgical treatment, 434–435
Ultrasound
abdominal trauma, 530 V
acute abdominal pain, 262 Vancomycin, 114, 115
vascular emergencies, 564 Varicose veins, 36
Umbilical hernia, 301 Vascular access, pediatric, 352
Upper limb ischaemia, acute, 359 Vascular emergencies
Ureteric injury abdomen, 566–567
diagnosis, 439–440 abdominal compartment syndrome, 567–568
management, 440 clinical presentation, 563, 564
prevention, 439 considerations, 563
types, 439 extremity vascular injuries, 568
Ureteric obstruction, 28 femoral vessels, 569–570
Ureteric orifices, cystoscopy, 52 investigations for
Urethral stricture, cystoscopy, 52 angiography, 565
Urinary retention spiral CT/CT angiography, 564–565
acute, surgical treatment, 435–439 ultrasound/duplex scanning, 564
catheterisation, 435 limb compartment syndromes, 570
definition, 433, 434 lower extremity injuries, 569
diagnosis, 434 surgical repair, forms of, 565
investigation, 434 thorax, 565–566
Index 597

types of, 563, 564 risk of, without prophylaxis, 78

upper extremity injuries, 568–569 risk stratification for, 79
Vascular imaging, 513 surgical guide, 80
Vascular injuries, neck trauma thromboprophylaxis, methods of, 77–78
anterior sternomastoid incision, 537, 538 Vessel injuries, digital and interdigital arteries, 420
carotid artery and jugular vein, exposure of, 538 Virilizing/feminizing tumors, 324–325
trap door incision, 537 Visceral injuries, 538–539
visceral injuries, 538–539 Vitamins supply, in perioperative nutrition, 92
Vascular surgery Voriconazole, 124, 125
acute limb ischaemia
lower limb (see Lower limb ischaemia, acute) W
upper limb, 359 Wagner scale, diabetic foot, 372
diabetic foot Wide local excision (WLE), breast cancer
acute management, 371–373 rural issues, 336
assessment, general principles, 369–371 technique
chronic management, 373 non-palpable masses, 335–336
Vasectomy, 384–385 palpable masses, 335
Venous thromboembolism (VTE), prophylaxis Withdrawal syndromes, 148, 153
diagnosis of Wound closure, 544
compression ultrasonography (CUS), 81
CTPA, 81, 82 X
DVT, 82 X-rays
ventilation/perfusion (V/Q) scanning, 81 of bowel obstruction
management of erect, 228
anticoagulation, duration of, 83 plain, 227
calf vein thrombosis, 82–83 plain
proximal DVT, 83 cervical spine, 523
prevention of thoracolumbar spine, 523
guidelines, compliance with, 79 skull, 511–512
incidence, in hospitalised patients, 77 traumatic spine injuries, 549
inferior vena cava (IVC) filters, 79
levels of risk and recommended thromboprophylaxis Z
for, 81 Z-plasty flaps, 379–381