Moshe Schein · Paul N. Rogers (Editors)
Schein’s Common Sense Emergency Abdominal Surgery
Moshe Schein • Paul N. Rogers (Editors)
Schein’s
Common Sense Emergency
Abdominal Surgery
Second Edition
With 97 Figures and 21 Tables
Moshe Schein, MD, FACS, FCS(SA)
Surgical Specialists of Keokuk, Keokuk, IA 52632, USA Formerly: Professor of Surgery, Weill College of Medicine Cornell University, New York, NY, USA
Paul N. Rogers, MB ChB, MBA, MD, FRCS (Glasgow)
Consultant General and Vascular Surgeon, Department of Surgery Gartnavel General Hospital, Glasgow, Scotland, UK
Editorial Adviser: Robert Lane, MD, FRCSA, FACS
Graphics: Evgeny E. (Perya) Perelygin, MD and Alexander N. Oparin, MD
Library of Congress Controll Number: 2004104706
ISBN 3-540-21536-0 Springer Berlin Heidelberg New York
ISBN 3-540-66654-0 1st ed. Springer-Verlag Berlin Heidelberg New York
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provision of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable to prosecution under the German Copyright Law.
Springer is a part of Springer Science+Business Media springeronline.com
© Springer-Verlag Berlin Heidelberg 2000, 2005 Printed in Germany
The use of designations, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
Product liability: The publisher can not guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature.
Editor: Gabriele Schröder, Heidelberg, Germany Desk editor: Stephanie Benko, Heidelberg, Germany Production editor: Ingrid Haas, Heidelberg, Germany Cover-Design: Frido Steinen-Broo, Pau, Spain
Typesetting: Fotosatz-Service Köhler GmbH, Würzburg, Germany
Printing and bookbinding: Strauss-Offsetdruck GmbH, Mörlenbach, Germany Printed on acid-free paper. 24/3150 ih - 5 4 3 2 1 0
Moshe Schein, MD, FACS, FCS(SA)
Surgical Specialists of Keokuk, Keokuk, IA 52632, USA Formerly: Professor of Surgery, Weill College of Medicine Cornell University, New York, NY, USA
Paul N. Rogers, MB ChB, MBA, MD, FRCS (Glasgow)
Consultant General and Vascular Surgeon, Department of Surgery Gartnavel General Hospital, Glasgow, Scotland, UK
Editorial Adviser: Robert Lane, MD, FRCSA, FACS
Graphics: Evgeny E. (Perya) Perelygin, MD and Alexander N. Oparin, MD
Library of Congress Controll Number: 2004104706
ISBN 3-540-21536-0 Springer Berlin Heidelberg New York
ISBN 3-540-66654-0 1st ed. Springer-Verlag Berlin Heidelberg New York
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provision of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable to prosecution under the German Copyright Law.
Springer is a part of Springer Science+Business Media springeronline.com
© Springer-Verlag Berlin Heidelberg 2000, 2005 Printed in Germany
The use of designations, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
Product liability: The publisher can not guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature.
Editor: Gabriele Schröder, Heidelberg, Germany Desk editor: Stephanie Benko, Heidelberg, Germany Production editor: Ingrid Haas, Heidelberg, Germany Cover-Design: Frido Steinen-Broo, Pau, Spain
Typesetting: Fotosatz-Service Köhler GmbH, Würzburg, Germany
Printing and bookbinding: Strauss-Offsetdruck GmbH, Mörlenbach, Germany Printed on acid-free paper. 24/3150 ih - 5 4 3 2 1 0
Dedication
MS dedicates this book to his late father Karl Schein (1911–1974), a surgeon on the Eastern Front during World War II, and later in Haifa, Israel.
Editors’ Note
This book has been assembled – in pieces – during 20 years of intensive personal involvement, clinical and academic, with emergency abdominal surgery in South Africa, Israel, USA, UK and Australia.
A long line of good old friends from all around the world were helpful in generating this book and its first edition. For the foundations in this noble surgical field MS is indebted to George G. Decker of Johannesburg. Drs. Roger Saadia, Asher Hirshberg and Adam Klipfel contributed to the first edition. Dr. Alfredo Sepulveda of Santiago, Chile, provided aphorisms and edited the Spanish transla- tion. Professor Boris Savhcuk of Moscow who edited the Russian translation passed away recently. We will remember him with affection.
Special thanks to Frau Gabriele Schroeder and Frau Stephanie Benko of Springer-Verlag, Heidelberg, for their immense support. Most of the aphorisms and quotations used to decorate this book were retrieved from Aphorisms & Quotations for the Surgeon, edited by MS and published by Nikki Bramhill’s tfm Publishing Ltd, Harley, UK.
The reader will find that there are not a few duplications scattered along the book. We did this on purpose, as repetition of important points is crucial in adult education. Any reader who has a question or a comment about anything mentio- ned in this book is invited to e-mail us directly – [email protected] or [email protected]. We will respond.
Finally, we are indebted to our loving wives, Heidi and Jackie and our children Omri, Yariv, Dan, Lucy and Michael for their patience and sacrifice.
July 2004 Moshe Schein, New York
Paul N. Rogers, Glasgow
Preface to the Second Edition
“In literature, as in love, we are astonished at what is chosen by others.”
(Andre Maurois, 1885–1967).
In the harsh environment of the competitive publishing market only a tiny fraction of medical texts ever gets to see the light of a second edition. Thus, we were proud to hear from our publishers that the first edition of this book has been sold out.“Do you want us to simply re-print the book”, they asked,“or do you think that it deserves to be updated and re-written?” We opted for the latter.
Is there anything new in emergency abdominal surgery that merits the revision of a 4-year-old book? Yes.Our practice has been gradually changing for the better and worse.Where we practice – in the “developed world” – the volume and spectrum of emergency surgery are declining and becoming narrower. Where any abdominal grumble is followed by a CT scan or any fart by a colonoscopy, ruptured aortic aneurysm and acute malignant colonic obstruction are becoming rarities. When most asymptomatic inguinal hernias undergo elective repair, one does not see many strangulated or obstructed groin hernias. When the entire population is being fed – or buys at the counter – anti-ulcer medications, operations for bleeding or perforated ulcer are hardly ever performed. This, however, may not be true in other parts of the world where you have the fortune (or misfortune) to practice.
The way we practice emergency surgery has also been rapidly evolving.
With almost unlimited access to abdominal imaging, we can rapidly pinpoint the diagnosis and avoid an unnecessary operation, or perform an indicated operation instead of engaging in a prolonged period of uncertainty. We are gradually becom- ing more selective and cautious – understanding that everything we do involves wielding a double-edged sword, and that in emergency surgery usually doing less is better but occasionally doing more may be life saving. Meanwhile fancy diagnostic modalities are used chaotically by our non-surgical colleagues (and some of our surgical ones) – producing red herrings or new “image diseases”,“incidentalomas”
and adding to the general confusion.
This brave new world of changes needed to be incorporated into this book.
We have to learn how to deal with the old s**t – which is perhaps becoming rarer – even when its odor is masked by the perfume of modern practice. And this is what we have attempted in this new edition – to recite the old basics but also show how to apply them in the evolving modern world.
What is new in the Second Edition?We have a new co-editor. We added new chapters (viz., historical perspectives, imaging, esophageal and diaphragmatic emergencies, complications of endoscopy, pediatric emergencies, HIV patients, before the flight, before landing, and postoperative bleeding) by new contributors.
All existing chapters have been revised or re-written by the old or new contributors and/or the Editors.
We knew that a book like this – written in colloquial and “direct” style will be either loved or hated.And indeed,a few reviewers – appalled by dogmas that clash with their own – almost killed it . But many loved it; for example:
From Germany: “Despite the “Wild West style” the book is far from being anachronistic. Instead, it is throughout updated and modern. To the experi- enced surgeons this book could provide joy with its wisdom and humor…
What makes this book really very readable for the surgeons are the “pregnant”
citations, aphorisms and “smart sayings”, which are often heard at the bed- side and operating rooms but almost never reach the pages of a book”.
(P. Klein, Heidelberg, Chirurg, 2000).
From Scotland: “A surgeon of considerable experience may feel that they have little to learn from such a book, but this is written with short punchy chapters making it a very difficult book to put down…the wealth of common sense in the book still makes it a worthwhile read and stimulates one’s own bias and views and challenges one’s own practice of surgery”. (R.A.B. Wood, Journal Royal College of Surgeons of Edinburgh, 2000)
From Sweden: “Through its direct language, the book becomes not only an entertaining lecture but also a valuable aid of handling patients with the acute abdomen.” (Svante Nordgren, Östra Sjukhuset, 2000).
From Russia: “Since Henry Mondor’s times in the forties of the last century there was no other book in clinical surgery to be written so easy and witty about most important things in the emergency abdominal surgery”. (Boris D.
Savchuk, World Journal of Surgery, 2002).
And from the many letters we received:
A terrifically refreshing book, full of wisdom as well as wit. (Mr. George Youngson, Consultant Surgeon Aberdeen, Scotland)
This is a very fantastic book and I have found a lot of new and useful advices in it (Dr. Csaba Csonka, Head Surgeon, Ajka, Hungary)
X Preface to the Second Edition
Absolutely wonderful. I am going to make it compulsory reading for all of my registrars. Otherwise – fantastic!! (Eddie Chaloner, UK)
I can’t remember a surgical book which I was able to digest with so much interest and without becoming tired even late at night. (Dr.med. Achim Schröder, Germany)
This is one of the most useful and interesting surgical books in my library.
You will read it in two hours with pleasure and interest and remember forever.
(Dr. Andrea Favara, Milan, Italy)
A book like this is long overdue. (Mr. R.D. Quill. Dublin, Ireland)
A gold mine for the trainee surgical doctor. (Mr. Saboor Kahn, Wales, UK) By popular demand the First Edition of this book has been translated into Spanish and Russian.
Motivated by the enthusiasm with which the book has been received across the world – particularly among those practicing “real surgery” in the “real world” – we set about enhancing it to produce a text that should be palatable to all of you – wherever you try to save lives – be it in Bogota, Dundee, Teheran, Calcutta, Naples, Dusseldorf, Krakov, Moscow or Boston.If you are a surgeon who practices the way he was trained 20 or 30 years ago you will hate this book; if you are being trained by such a surgeon then you desperately need to read this book.
Anton Chekhov said:“Doctors are just the same as lawyers; the only difference is that lawyers merely rob you, whereas doctors rob you and kill you, too.” Our chief aim in writing this book was to help you not to kill your patients. We hope that this modest book will be of some value to you.
New York/Glasgow, July 2004 The Editors (> see figure) XI Preface to the Second Edition
The Editors: Rogers is the one in the kilt…
Contents
I Background . . . 1 1 General Philosophy . . . 3
Moshe Schein · Paul N. Rogers
2 A Brief History of Emergency Abdominal Surgery . . . 9 Harold Ellis
II Before the Operation . . . 15 3 The Acute Abdomen . . . 17
Moshe Schein
4 Rational Diagnostic Procedures . . . 27 Moshe Schein
5 Abdominal Imaging . . . 33 Moshe Schein · Sai Sajja · Hans Ulrich Elben
6 Optimizing the Patient . . . 55 James C. Rucinski
7 Pre-operative Antibiotics . . . 67 Moshe Schein
8 Family, Ethics, Informed Consent and Medicolegal Issues . . . 71 James C. Rucinski
9 Before the Flight: Pre-op Checklist . . . 77 Moshe Schein
III The Operation . . . 81 10 The Incision . . . 83
Moshe Schein
11 Abdominal Exploration: Finding What is Wrong . . . 87 Moshe Schein
12 Peritonitis: Contamination and Infection, Principles of Treatment . . . . 95 Moshe Schein · Roger Saadia
13 The Intestinal Anastomosis . . . 103 Moshe Schein
14 Esophageal Emergencies . . . 109 Tom Anthony Horan
15 Diaphragmatic Emergencies . . . 119 Ulrich Schoeffel · Moshe Schein
16 Upper Gastrointestinal Hemorrhage (and Portal Hypertension) . . . 125 Moshe Schein
17 Perforated Peptic Ulcer . . . 143 Moshe Schein
18 Acute Pancreatitis . . . 151 Moshe Schein
19 Acute Cholecystitis . . . 163 Moshe Schein
20 Acute Cholangitis . . . 173 Gary Gecelter
21 Small Bowel Obstruction . . . 179 Moshe Schein
22 Acute Abdominal Wall Hernias . . . 191 Paul N. Rogers
23 Acute Mesenteric Ischemia . . . 197 Moshe Schein · Paul N. Rogers
24 Inflammatory Bowel Disease and Other Types of Colitis . . . 205 Per-Olof Nyström
XIV Contents
25 Colonic Obstruction . . . 217 Per-Olof Nyström
26 Acute Diverticulitis . . . 229 Per-Olof Nyström
27 Massive Lower Gastrointestinal Bleeding . . . 239 Per-Olof Nyström
28 Acute Appendicitis . . . 245 Moshe Schein
29 Anorectal Emergencies . . . 255 Luis A. Carriquiry
30 Surgical Complications of Endoscopy . . . 265 Ahmad Assalia · Anat Ilivitzki
31 Gynecological Emergencies . . . 275 Bashar Fahoum · Moshe Schein
32 Abdominal Emergencies in Infancy and Childhood . . . 283 Wojtek J. Górecki
33 The AIDS Patient . . . 291 Sai Sajja
34 Penetrating Abdominal Trauma . . . 297 Avery B. Nathens
35 Blunt Abdominal Trauma . . . 305 Avery B. Nathens
36 The Abdominal Compartment Syndrome . . . 321 Moshe Schein
37 Abdominal Aortic Emergencies . . . 329 Paul N. Rogers
38 Abdominal Closure . . . 337 Moshe Schein
39 Before Landing . . . 343 Moshe Schein
XV Contents
IV After the Operation . . . 345 40 Postoperative Care . . . 347
Moshe Schein
41 Nutrition . . . 355 James C. Rucinski
42 Postoperative Antibiotics . . . 363 Moshe Schein
43 Postoperative Ileus vs Intestinal Obstruction . . . 369 Moshe Schein · Sai Sajja
44 Intra-abdominal Abscesses . . . 377 Moshe Schein
45 Anastomotic Leaks and Fistulas . . . 387 Moshe Schein
46 Re-laparotomies and Laparostomy for Infection . . . 395 Moshe Schein · Roger Saadia · Danny Rosin
47 Abdominal Wall Dehiscence . . . 411 Moshe Schein
48 LIRS, SIRS, Sepsis, MODS and Tertiary Peritonitis . . . 415 Moshe Schein · John Marshall
49 Wound Management . . . 425 Moshe Schein
50 Postoperative Bleeding . . . 431 Barry Armstrong
51 The Role of Laparoscopy . . . 439 Pioter Gorecki
52 In the Aftermath and the M & M Meeting . . . 449 Moshe Schein
Subject Index . . . 457 XVI Contents
Contributors
Dr. Barry D. Armstrong, MD, FRCSC
General Surgeon, Thunder Bay Regional Health Centre
Downtown North RPO Box 24002, Thunder Bay, Ontario, P71 8A9, Canada [email protected]
Ahmad Assalia, MD
Fellow, Division of Laparoscopy and the Minimally Invasive Surgery Center Mount Sinai Medical Center, New York, NY, USA
Lecturer in Surgery, Faculty of Medicine, Technion Israel Institute of Technology
Department of Surgery B, Rambam Medical Center Bat Galim, Haifa, Israel
[email protected] Luis A. Carriquiry, MD
Professor and Head, Second Surgical Clinic
Maciel Hospital School of Medicine University of the Republic
Rafael Postoriza 1451, Apt. 502, Montevideo 11600, Montevideo, Uruguay [email protected]
Hans Ulrich Elben, MD
Leitender Arzt der Radiologischen Abteilung Kreisklinikum Schwarzwald-Baar GmbH
Sonhaldenstrasse 2, 78166 Donaueschingen, Germany [email protected]
Harold Ellis, CBE, MCh, FRCS
Professor, Applied Biomedical Research Group 5thFloor, Hodgkin Building, Guy’s Campus London SE1 1UL, Great Britain
Bashar Fahoum, MD, FACS
Attending Surgeon, Director of SICU
Department of Surgery, New York Methodist Hospital 516 Sixth Street, Brooklyn, 11215 NY, USA
Gary Gecelter, MD, FACS
Associate Professor of Clinical Surgery, Albert Einstein College of Medicine Department of Surgery, Long Island Jewish Medical Center
New Hyde Park, NY, USA [email protected] Pioter Gorecki, MD, FACS
Director of Laparoscopic Surgery, New York Methodist Hospital 516 Sixth Street, Brooklyn, 11215 NY, USA
[email protected] Wojtek J. Górecki, MD, PhD
Assistant Professor, Department of Pediatric Surgery Jagiellonian University, University Children’s Hospital
265 Wielicka Street, 30-663 Kraków, Poland [email protected]
Anat Ilivitzki, MD
Department of Surgery B, Rambam Medical Center Bat Galim, Haifa, Israel
Thomas Anthony Horan, MD, FACS, FRCSC
Thoracic Surgeon, Sarah Network of Hospitals Brasilia-DF, Brazil
[email protected] Alexander N. Oparin, MD
Attending Surgeon, Department of Surgery
Mediko-Sanitarnaya Chast No. 4, 178 Novo-Sadovaya, 443011 Samara, Russia
[email protected] Robert Lane, MD, FRCSC, FACS
General Surgeon, Morristown, TN 37813, USA roblane@charter. net
John Marshall, MD, FRCSC, FACS
Professor of Surgery, Eaton North 9-234
Toronto General Hospital, University Health Network 200 Elizabeth Street, Toronto, Ontario, Canada [email protected]
XVIII Contributors
Avery B. Nathens, MD, FACS
Associate Professor of Surgery, University of Washington
Division of General Surgery and Trauma, Harborview Medical Center Box 359796, Seattle, WAS 98104, USA
[email protected] Per-Olof Nyström, MD, PhD
Associate Professor of Surgery, Consultant Colorectal Surgeon Department of Surgery, Linkoping University Hospital SE-581 85 Linkoping, Sweden
[email protected] Evgeny E. Perelygin, MD
Attending Surgeon, Department of Surgery Krasnovishersk Regional Hospital
3 Pobedy, 618550 Krasnovishersk, Permskaya Oblast, Russia [email protected]
Danny Rosin, MD
Department of General Surgery & Transplantation Sackler School of Medicine, Tel Aviv University Sheba Medical Center, Tel Hashomer, Israel [email protected]
James C. Rucinski, MD, FACS
Director of Surgical Education, New York Methodist Hospital 516 Sixth Street, Brooklyn, 11215 NY, USA
[email protected] Roger Saadia, MD, FRCS (Ed)
Professor of Surgery, University of Manitoba and Health Sciences Centre 820 Sherbrook Street, Winnipeg, R3A 1R9, Canada
[email protected] Sai Sajja, MD
Chief Resident, Department of Surgery, Bronx Lebanon Hospital 1650 Selwyn Avenue, Bronx, NY 10457, USA
[email protected] Ulrich Schoffel, MD
Professor für Chirurgie, Universität Freiburg Leitender Arzt der Allgemein- und Viszeralchirurgie Rotes Kreuz-Krankenhaus Lindenberg
Jägerstrasse 41, 88161 Lindenberg, Germany [email protected]
XIX Contributors
