FIRST EXPOSURE TO GENERAL SURGERY Danny O Jacobs, MD, MPH Professor and Chairman Department of Surgery Duke University School of Medicine Durham, North Carolina McGRAW-HILL MEDICAL PUBLISHING DIVISION New York / Chicago / San Francisco / Lisbon / London / Madrid / Mexico City Milan / New Delhi / San Juan / Seoul / Singapore / Sydney / Toronto Copyright © 2007 by The McGraw-Hill Companies, Inc All rights reserved Manufactured in the United States of America Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher 0-07-149129-5 The material in this eBook also appears in the print version of this title: 0-07-144140-9 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs For more information, please contact George Hoare, Special Sales, at george_hoare@mcgraw-hill.com or (212) 904-4069 TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc (“McGraw-Hill”) and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise DOI: 10.1036/0071441409 Professional Want to learn more? 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If you’d like more information about this book, its author, or related books and websites, please click here To all students of surgery and we honor those who have taught us This page intentionally left blank For more information about this title, click here C O N T E N T S Contributors Preface Acknowledgments SECTION I Chapter Chapter Chapter Chapter Chapter Chapter Chapter SECTION II Chapter Chapter Chapter 10 vii xi xii FUNDAMENTAL PRINCIPLES Preoperative Assessment and Preparation Sandhya Lagoo-Deenadayalan, MD, PhD Traumatic Injury Kumash R Patel, MD Steven N Vaslef, MD, PhD Surgical Infection Wendy R Cornett, MD The Acute Abdomen C Denise Ching, MD Aurora D Pryor, MD The Operating Room L Scott Levin, MD, FACS The Postoperative Care of the Surgical Patient Philip Y Wai, MD Paul C Kuo, MD, MBA Rebecca A Schroeder, MD Wound Healing and Wound Management Detlev Erdmann, MD, PhD Tracey H Stokes, MD COMMON SURGICAL DISEASES Esophagus Shu S Lin, MD, PhD Stomach Carlos E Marroquin, MD Intestine & Colon Rebekah R White, MD Danny O Jacobs, MD, MPH v 23 59 69 85 91 121 137 139 169 196 vi CONTENTS Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 SECTION III Chapter 18 Index Hepatobiliary Surgery David Sindram, MD, PhD Janet E Tuttle-Newhall, MD Pancreas Bradley H Collins, MD, FACS Spleen Dev M Desai, MD, PhD Breast Reconstruction Michael R Zenn, MD, FACS Endocrine Surgery Jennifer H Aldrink, MD John A Olson, Jr., MD, PhD Hernias Keshava Rajagopal, MD, PhD Head and Neck Surgery Reconstruction Steffen Baumeister, MD L Scott Levin, MD, FACS FUNDAMENTAL PROCEDURES Fundamental Procedures Jose L Trani Jr., MD Matthew G Hartwig, MD Brian Lima, MD Mayur B Patel, MD Jacob N Schroder, MD Tamarah J Westmoreland, MD Rebecca P Petersen, MD, MSc Anthony Lemaire, MD Jin S Yoo, MD 214 234 267 282 294 319 341 369 371 411 C O N T R I B U T O R S Dev M Desai, MD, PhD Assistant Professor of Surgery Division of General Surgery Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 13 Jennifer H Aldrink, MD General Surgery Resident Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 15 Steffen Baumeister, MD Research Fellow Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 17 Detlev Erdmann, MD, PhD Assistant Professor of Surgery Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery Department of Surgery Duke University Medical Center Durham, North Carolina Chapter C Denise Ching, MD General Surgery Resident Department of Surgery Duke University Medical Center Durham, North Carolina Chapter Matthew G Hartwig, MD General Surgery Resident Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 18 Bradley H Collins, MD, FACS Assistant Professor of Surgery Division of General Surgery, Transplantation Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 12 Danny O Jacobs, MD, MPH Professor and Chairman Department of Surgery Duke University School of Medicine Durham, North Carolina Paul C Kuo, MD, MBA Professor and Chief Division of General Surgery Department of Surgery Duke University Medical Center Durham, North Carolina Chapter Wendy R Cornett, MD Assistant Professor of Surgery Department of Surgery Medical University of South Carolina Charleston, South Carolina Chapter vii Copyright © 2007 by The McGraw-Hill Companies, Inc Click here for terms of use viii Sandhya Lagoo-Deenadayalan, MD, PhD Assistant Professor of Surgery Department of Surgery Duke University Medical Center Durham, North Carolina Chapter Anthony Lemaire, MD General Surgery Resident Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 18 L Scott Levin MD, FACS Professor and Chief Division of Plastic/Reconstructive/ Oral Surgery Professor of Orthopaedic Surgery Duke University Medical Center Durham, North Carolina Chapter 5, 17 Brian Lima, MD General Surgery Resident Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 18 Shu S Lin, MD, PhD Assistant Professor of Surgery Division of Thoracic and Cardiovascular Surgery Department of Surgery Duke University Medical Center Durham, North Carolina Chapter CONTRIBUTORS Carlos E Marroquin, MD Assistant Professor of Surgery Department of Surgery Duke University Medical Center Durham, North Carolina Chapter John A Olson, Jr., MD, PhD Associate Professor of Surgery Division of General Surgery Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 15 Kumash R Patel, MD Assistant Professor of Surgery Department of Surgery Tulane University Hospital New Orleans, LA Chapter Mayur B Patel, MD General Surgery Resident Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 18 Rebecca P Petersen, MD, MSc General Surgery Resident Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 18 Aurora D Pryor, MD Assistant Professor of Surgery Division of General Surgery Department of Surgery Duke University Health System Durham, North Carolina Chapter 406 SECTION III REFERENCES Pate JW Chest wall injuries Surg Clin North Am 69:59–70, 1989 Deneuville M Morbidity of percutaneous tube thoracostomy in trauma patients Eur J Cardiothorac Surg 22:673–678, 2002 Millikan JS, Moore EE, Steiner E, et al Complications of tube thoracostomy for acute trauma Am J Surg 140:738–741, 1980 Etoch SW, Bar-Natan MF, Miller FB, et al Tube thoracostomy: factors related to complications Arch Surg 130:521–525, 1995; discussion 525–526 Adrales G, Huynh T, Broering B, et al Rapid atrial fibrillation following tube thoracostomy insertion J Trauma 52:210–214, 2002; discussion 214–216 Daly RC, Mucha P, Pairolero PC, et al The risk of percutaneous chest tube thoracostomy for blunt thoracic trauma Ann Emerg Med 14:865–870, 1985 Helling TS, Gyles NR 3rd, Eisenstein CL, et al The role of thoracoscopy in the management of retained thoracic collections after trauma J Trauma 29:1367–1370, 1989 INCISION & DRAINAGE OF CUTANEOUS ABSCESS Jin Yoo, MD Introduction An abscess is defined as a local infection surrounded by inflamed tissue The key fundamental principle of adequately treating an abscess is that a drainage procedure is essential and antibiotic therapy alone is insufficient However, abscess smaller than mm in diameter may resolve with warm soaks and compresses, which facilitates drainage of the pus material A drainage procedure is important since the inflamed tissue around the abscess prevents the penetration of antibiotics into the site of active infection Incision and drainage (I&D) procedure is a common surgical technique employed by many nonsurgical physicians to primarily manage and treat cutaneous abscesses Abscesses in other locations such as the lungs and abdomen are also managed by drainage procedures, but those topics are beyond of the scope of this chapter The procedure described in this section CHAPTER 18 / FUNDAMENTAL PROCEDURES 407 is applicable to cutaneous abscesses in almost any location on the body except for extremely large abscesses, deep abscesses in very sensitive areas, abscesses involving palmar or plantar spaces, and facial abscesses involving the triangle formed by the bridge of the nose and the corners of the mouth Materials Needed • No 11 scalpel blade • Curved hemostat • Sterile field towels • A container of packing material (1/2 in wide) • Sterile × gauze pads • A bottle of povidone-iodine • A 20–30 cc syringe • 16-gauge needle • 25-gauge needle • A bottle of percent lidocaine (with or without epinephrine) Description of Procedure First and foremost, achieving adequate local anesthesia is the most important factor which will maximize your chance of performing an adequate I&D procedure In addition, one should always consider the use of anxiolytics in an anxious patient since anxiety can certainly exacerbate the pain Prepare all the instruments and materials for use prior to beginning the procedure First, put on a sterile gown and a pair of sterile gloves Then, set up a sterile work area on a table with all the instruments and materials laid out Next, draw up 20–30 mL of percent lidocaine in a syringe using the 16-gauge needle Then, change the syringe to 25-gauge prior to use The area is prepped and draped in a sterile fashion using sterile × gauze soaked in povidone-iodine and the sterile field towels Then, a field block is performed by injecting percent lidocaine into the dome of the abscess and the syringe is held parallel to the skin and rotated to distribute the anesthetic circumferentially The local anesthesia should be injected in the subcutaneous space above the abscess cavity and not into the cavity itself After adequate anesthesia is obtained, a stab incision is made with the no 11 scalpel blade and a linear incision conforming to the natural folds of the skin Some would advocate in making the incision size the total length of the abscess; however, minimizing the incision size will decrease the time for the wound to heal secondarily and more cosmetically appealing The incision should just be large enough to place the tip of the hemostat into the abscess to break loculations and ensure proper drainage After all the pus is evacuated, pack the wound cavity with wet packing material to promote wound healing by performing wet-to-dry packing changes at least twice a day 408 SECTION III The patient should be instructed to follow-up in week for a wound check and to continue twice-a-day wet-to-dry dressing changes with normal saline solution The rationale for this is to frequently debride the necrotic granulation tissue in the open wound and facilitate healing by keeping the healthy granulation tissues exposed When the wet packing adheres to the surface of the wound, it adheres to the underlying tissue as it dries out Of note, a saline solution should be used to facilitate the drying process and the packing should be just barely wet and not soaking wet If it is too wet, the wound will be too moist for the packing to adhere to necrotic tissue overlying the healthy, granulation tissue Wound Culture Gram’s stain and cultures of the wound are generally not performed since drainage of the pus collection will lead to resolution even without antibiotics However, wound culture may be indicated in patients who are septic or are immunocompromised If a wound culture and Gram’s stain are needed, the sample should be collected by needle aspiration over a prepped skin area.1,2 This allows the wound culture to be sent for anaerobic cultures as well Antibiotics The use of antibiotics may have a role prior to skin incision, but it is not necessary afterward, except in patients with cellulitis and/or lymphangitis surrounding the abscess and in immunocompromised patients These patients require at least days of antibiotic treatment and possibly longer depending on their clinical response (Table 18-2).3,4 Special Section on Drugs ANXIOLYTIC OF CHOICE A common anxiolytic that is used is lorazepam (Ativan), a benzodiazepine with rapid onset and moderate duration; 0.5–2 mg IV is the recommended dose, but start with 0.5 mg at first and then give additional 0.5 mg doses every 5–10 until the total dose is reached Midazolam (versed), which is commonly used for procedures such as colonoscopy, is not ideal because it is too short acting and requires frequent dosing LOCAL ANESTHETIC The maximum dose of percent lidocaine that one can use is 500 mg (based on 70 kg bodyweight) and 300 mg with and without epinephrine, respectively (based on 70 kg bodyweight) The duration of anesthesia is 120–360 and 30–60 with and without epinephrine, respectively.5 Lidocaine is available in percent (5 mg/mL) or percent (10 mg/mL) concentrations Thus, you may use up to 60 mL of the percent lidocaine during the procedure, but watch out for early signs of toxicity—tinnitus, dizziness, and confusion CHAPTER 18 / FUNDAMENTAL PROCEDURES 409 Table 18-2 Antibiotic of Choice in Special Circumstances after I&D has been Performed Inpatient Rx Outpatient Rx Cellulitis/lymphangitis Nafcillin or cefazolin or vancomycin + clindamycin (for serious Streptococcus infections) Dicloxacillin, cefuroxime, erythromycin, clarithromycin, azithromycin Immunocompromised Trimethoprim/ sulfamethoxazole or piperacillin/ tazobactam ± Cipro Most Common Organisms Staphylococcus aureus Streptococcus pyogenes Above organisms + Pseudomonas aeruginosa REFERENCES Halvorson GD, Halvorson JE, Iserson KV Abscess incision and drainage in the emergency department Part I J Emerg Med 3(3):227–232, 1985 Meislin HW, McGehee MD, Rosen P Management and microbiology of cutaneous abscesses JACEP 7(5):186–191, 1978 Llera JL, Levy RC Treatment of cutaneous abscesses: a double-blind clinical study Ann Emerg Med 14(1):15–19, 1985 Cohen J, Powderly WG et al Cellulitis, pyoderma, abscesses and other skin and subcutaneous tissue infections Infect Dis 136–141, 2004 Miller RD Local anesthetics Anesthesia 575–586, 2005 This page intentionally left blank I N D E X NOTE: Page numbers followed by f or t indicate figures or tables, respectively A Aachen system, hernia classification, 325, 325t ABCDEF survey, 29–33 Abdomen acute See Acute abdomen trauma, 49–51, 50f Abdominal aortic aneurysms, 80–81 Abscess See also Surgical infection abdominal, 64 cutaneous, 406–408, 409t hepatic, 222–223 incision and drainage, 64, 406–408 pancreatic, 255 pathophysiology, 63–64 Achalasia, 144t, 145–147, 146f Acute abdomen assessment history and physical examination, 70–71 laboratory tests, 72 radiographic examinations, 72–74 resuscitation, 71–72 clinical scenarios, 69, 82–83 differential diagnosis with generalized pain, 78–81 by location, 74t, 75–78 indications for surgery, 81–82 Acute mesenteric ischemia clinical presentation, 80 diagnosis, 200–201, 201t etiology, 80, 200 treatment, 80, 201 Adenocarcinoma esophagus, 161–162 pancreas, 258–261 Adrenals carcinoma, 317 Cushing syndrome, 311–313 incidental masses, 317 insufficiency clinical manifestations, 315 postoperative, 114, 315 prevention, 315 treatment, 315 pheochromocytoma, 15, 316–317 primary aldosteronism, 313–315 Afferent loop syndrome, 178t, 183 Age, wound healing and, 127 Agitation, postoperative, 97 Airway management bag-valve-mask, 100 cricothyroidotomy for, 30, 30t, 402–403 postoperative, 100 tracheostomy for, 400–402, 401f Airway obstruction, postoperative, 98–100 Alcohol use, pancreatitis and, 249, 256–257 Aldosteronism, primary diagnosis, 313–314 etiology, 313 localization, 314 treatment, 314–315 Alkaline reflux gastritis, 178t, 182–183 Allen’s test, 395 American Society of Anesthesiologists (ASA), physical status classification, 6, 6t AMPLE history, 29t Ampulla of Vater, 236, 236f, 262 Amylase, 242, 251 Anaplastic thyroid carcinoma, 301 Anemia idiopathic autoimmune hemolytic, 275 postgastrectomy, 178t, 184 postoperative, 114–115 preoperative management, 13 sickle cell See Sickle cell anemia Angiography, in trauma assessment, 35 Ankle-brachial index, 55 Annular pancreas, 244 Anterior spinal cord syndrome, 40 Antibiotics after abscess incision and drainage, 408, 409t for surgical infection prophylaxis, 20, 62–63, 117 for surgical infection treatment, 63, 117t Anticoagulation, preoperative, 19–20 Anxiolytics, 408 Aorta aneurysms, 80–81 trauma, 45, 45t, 46–47f Appendix appendicitis, 69, 75, 77 See also Acute abdomen carcinoid tumor, 309–310 Areola reconstruction, 292 Arrhythmia, postoperative, 106–107 Arterial puncture anesthetics for, 395 complications, 395 contraindications, 394 indications, 394 procedure, 396 ASA See American Society of Anesthesiologists 411 Copyright © 2007 by The McGraw-Hill Companies, Inc Click here for terms of use 412 Aspiration, 102 Asthma, preoperative assessment, Atrial fibrillation, postoperative, 106 Auerbach’s plexus, 142 Axial pattern flaps, 348 B Bacteremia, vs sepsis, 67 Basal energy expenditure, 112 Bassini repair, 332, 335 Beck’s triad, 44 Bile duct See also Gallbladder; Liver anatomy, 218 injury during cholecystectomy, 229 pain from See Acute abdomen tumors, 225 Bilirubin, 221 Billroth I, 175, 175f Billroth II, 176, 176f Biopsy urease test, 173 Blind loop syndrome, 178t Blood loss assessment, 31, 31t in clotting disorders, 115 Bloomer’s shelf nodules, 190 Blunt trauma, 25 See also Trauma Boerhaave syndrome, 153–154 Bowel function, postoperative, 107 Bowel preparation, 20–21, 61 Breast reconstruction after radiation therapy, 290–291 with body tissue advantages, 285–286 gluteal free flap, 290 latissimus flap, 291 TRAM flap, 286–289, 290f, 291t immediate vs delayed, 292 with implants, 282–285, 284–285f, 286f, 287t nipple and areola, 292 stages, 291–292 Brown-Séquard syndrome, 40 Bullous emphysema, 102 Burns, 343–344 C Cancer adrenocortical, 317 colorectal See Colorectal cancer esophagus See Esophagus, cancer gastric See Stomach, cancer pancreatic, 258–261 parathyroid, 305 thyroid, 299–301 Carcinoid syndrome, 311 Carcinoid tumors appendix, 309–310 classification, 309 diagnosis, 309 preoperative assessment and management, 15 small intestine, 310 Cardiac disease, preoperative assessment, 7–9, 8t Cardiac tamponade, 44 INDEX Cardiac trauma, 48 Cardiogenic shock, 36 Carotid artery, blunt trauma, 42 Catheterization, urethral, 397–399 Caudal block, 95 Cells of Cajal, 193 Central cord syndrome, 40 Central venous catheters indications, 390 infection, 65–66, 388, 390 placement, 388, 389f short-term, 393 types, 390, 390f, 391f, 392, 392f Cerebral contusion, 37 Cerebral perfusion pressure (CPP), 39 Chagas disease, 145 Chemical pneumonitis, 102 Chemotherapy, wound healing and, 127 Chest radiograph, in aortic trauma, 45, 46f, 48f Chest trauma, 44–48, 45t, 46–47f, 48f Chest tube, 404–405, 405f Child-Pugh scoring system, 227, 228t Child’s classification, 11–12, 12t Cholangiocarcinomas, 225 Cholangitis, 23 Cholecystectomy, 229 Cholecystitis See Gallbladder, disease Cholecystokinin, 221 Cholelithiasis See Gallbladder, disease Chronic obstructive pulmonary disease, preoperative assessment, 10, 10t Chvostek’s sign, 305 Cirrhosis, 225–226 Clarithromycin, for H pylori, 174t Clostridium difficile, 118 Coagulation disorders postoperative management, 115 preoperative management, 13–14 Colorectal cancer diagnosis, 206–207 etiology, 206 liver metastases in, 225 staging, 207t treatment, 207–208, 208t Compartment syndrome, 55 Compression injury, 25 See also Trauma Computed tomography (CT) in abdominal trauma, 49 in acute abdomen, 73 in acute mesenteric ischemia, 201 adrenal, 314 in aortic trauma, 45, 46f in pancreatic cancer, 259 in pancreatitis, 257 in pelvic fracture, 53 in small bowel obstruction, 198, 199 in spinal cord injury, 41 of spleen, 272 in trauma assessment, 34 in traumatic brain injury, 39 Concussion, 37 Conn syndrome See Aldosteronism, primary INDEX Continuous epidural analgesia, 95 Corticosteroids in spinal cord injury, 41 in wound healing, 126 CPP (cerebral perfusion pressure), 39 Craniofacial reconstruction, 361–364, 363–364f, 365–366f Cricothyroidotomy, 30, 30t, 402–403 Crohn’s disease, 77, 210–211, 210t Csendes procedure, 179 CT See Computed tomography Cullen sign, 251 Curling ulcers, 185 Cushing syndrome clinical manifestations, 311 etiology, 311 imaging, 312–313 localization, 312 pathophysiology, 311–312 surgical treatment, 313 Cushing ulcers, 185 Cystic lesions pancreas, 261–262 spleen, 272–273 Cytochrome p450 system, 220 D DAI (diffuse axonal injury), 39 De Quervain’s thyroiditis, 298 Deep venous thrombosis diagnosis, 66, 116 etiology, 115 preoperative prophylaxis, 19 prevention, 116 risk factors, 115–116 Delirium, postoperative, 97 Dexamethasone suppression test, 312 Diabetes complications, 246–247 foot infection, 65 islet cell transplantation for, 248 pancreas transplantation for, 247–248 pathophysiology, 246 postoperative management, 113–114, 113t preoperative assessment and management, 14–15 Diaphragmatic rupture, 47, 48f Diarrhea, postvagotomy, 178t, 182 DIEP flap, 289 Diffuse axonal injury (DAI), 39 Diffuse esophageal spasm, 144t, 147–148 Diffuse toxic goiter, autoimmune See Graves’ disease Distributive shock, 35 Diverticulitis complications, 209t diagnosis, 208–209 etiology, 208, 209t gastrointestinal perforation in, 79–80 pain in, 77, 78 See also Acute abdomen treatment, 209 Diverticulosis, 208 413 Diverticulum, esophageal, 150–153, 151f Dohlman procedure, 152 Dor fundoplication, 157f, 158 Drains, surgical, 119 Dressings, 118–119, 131, 385–386 Duct of Santorini, 236, 236f Duct of Wirsung, 236, 236f Dumping syndromes, 177t, 181–182 E Echinococcal infections, 273 Efferent loop syndrome, 184 Electrolyte abnormalities, postoperative, 109–111, 110t Endoscopic retrograde cholangiopancreatography (ERCP), 245, 249, 257 Epidural block, 94–95 Epidural hematoma, 37, 38f Epigastric hernia, 336 Epiphrenic diverticulum, 152–153 Epithelial cells, in wound healing, 125 ERCP See Endoscopic retrograde cholangiopancreatography Esophagus anatomy and physiology, 139–143, 141f benign tumors, 158, 159 blunt injury, 42 cancer clinical presentation, 162 diagnostic tests, 162–163 epidemiology, 159–161 etiology and risk factors, 161 staging, 163, 164t treatment, 163, 165–167, 165f, 166f, 167f types, 161–162 diverticula epiphrenic, 152–153 midesophageal, 152 Zenker, 150–151, 151f hiatal hernias and gastroesophageal reflux, 154–158, 155f, 157–158f leiomyomas, 159, 160f motility disorders achalasia, 144t, 145–147, 146f classification, 143 diffuse esophageal spasm, 144t, 147–148 manometric characteristics, 144t nutcracker esophagus, 148 in systemic disease, 148 upper sphincter dysfunction, 143, 145 normal manometric characteristics, 144t tears and perforations, 153–154 vascular rings, 148–149 webs, 149 Extremities, trauma, 54–55 F FAST (focused abdominal sonography for trauma), 33, 49 Felty syndrome, 276 Femoral hernia, 336 Fetus, wound healing in, 129–130 414 Fever in acute abdomen, 72 postoperative, 66, 97–98, 116 Fine needle aspiration biopsy, thyroid, 299 Fistulae, intestinal, 202–203, 202t Flail chest, 47–48 Flaps anterolateral thigh, 357 deep circumflex iliac artery, 361, 362f DIEP, 289 fibula, 358–361, 359f, 360–361f free, 350–352 gluteal free, 290 jejunal, 358 lateral arm, 357 latissimus, 290, 363 local, 133–134f omental, 363–364f, 365–366f pedicled, 133–134, 135f, 348, 349–350f, 351–352f radial forearm, 354–355f, 356–357f scapular, 357 TRAM, 286–289, 290f, 291t Fluid management, postoperative, 108–109 Focal nodular hyperplasia, 224, 224t Focused abdominal sonography for trauma (FAST), 33, 49 Follicular thyroid carcinoma, 300 Foregut carcinoids, 310 Fractures pelvic, 51–53, 52–53f, 54f rib, 47–48 skull, 37 Fundoplications, 158, 157–158f G Gallbladder disease acute pancreatitis and, 249, 254 clinical presentation, 75 differential diagnosis, 75 pathophysiology, 223 surgery for, 229 treatment, 75 tumors, 225 function, 216 physiology, 221 Gallstone ileus, 223 Gallstone pancreatitis, 249, 254 See also Pancreas Gastric distention, postoperative, 107 Gastric ulcers See Stomach, ulcers Gastrinoma clinical manifestations, 186, 187t, 263, 307 diagnosis, 181, 307–308 etiology, 307 localization, 308 staging, 186–187 treatment, 181, 187–188, 308 Gastritis, stress, 185, 186t Gastroesophageal reflux disease (GERD), 76, 154–158, 157–158f INDEX Gastrointestinal bleeding, 205–206 Gastrointestinal perforation, 79–80, 82–83, 209 Gastrointestinal stromal tumor, 193–194 Gastrojejunocolic fistula, 178t, 185 Gastrojejunostomy, 175–176, 175f, 176f Gaucher disease, 277 GERD See Gastroesophageal reflux disease Geriatric patient, preoperative assessment, 15–16 Glasgow coma scale, 32–33, 32t Glucagon, 243 Glucagonomas, 309 Grafts, skin, 134, 347 Graves’ disease, 296–297 Grey Turner sign, 251 Growth factors, in wound healing, 127, 128t Gunshot wounds abdominal, 51 chest, 48 mechanisms of injury, 26 H Hamartoma, spleen, 273 Harris-Benedict equation, 112 Hashimoto’s thyroiditis, 298 Head and neck burns, 343–344 reconstruction complex injuries, 364 craniofacial, 361–364, 363–364f, 365–366f decision-making process, 352–353 flaps for, 347–352, 349–350f, 351–352f goals, 344–345 historical overview, 344 mandible, 358–361, 359f, 360–361f oral cavity, 353–358, 354–355f, 356–357f patient profile, 364, 366 pharynx, 358 primary closure, 346–347 principles, 345, 346f rehabilitation, 366 skin transplantation in, 347 trauma, 27f, 37–39, 38f, 343 tumors classification, 342–343 pathophysiology, 342 preoperative assessment and management, 17–18 Helicobacter pylori, 173, 174t Hemangioma liver, 224 spleen, 273 Hemophilia, preoperative management, 14 Hemorrhagic shock, 35, 36t Hemothorax, 44–45 Heparin, preoperative, 19 Hepatic adenoma, 223–224, 223t Hepatic disease See Liver, disease Hepatitis, 222 Hepatocellular carcinoma, 224–225 Hereditary spherocytosis, 274 INDEX Hernias anatomy anterior/lateral abdominal wall, 320, 321–323f normal inguinal, 322–324, 324f epigastric, 336 femoral, 336 historical overview, 319–320 incisional, 337 inguinal classification systems, 325–326, 325t, 326t clinical presentation, 328–329 diagnostic tests, 331–332 differential diagnosis, 330, 331t direct, 324–325, 326–327 indirect, 325, 327 nonoperative reduction, 330–331 physical examination, 329–330 risk factors, 328 surgical treatment complications, 335 laparoscopic, 334–335 mesh-based, 333–334 overview, 332 primary repairs, 332–333 results, 335 internal, 337–338 Littre, 336 lumbar, 337 obturator, 336 Richter, 337 Spigelian, 337 umbilical, 336 Heterotopia, pancreatic, 244 Hiatal hernia, 154–158, 155f HIDA scans, 72–73, 183 Hodgkin lymphoma, 273–274 Horizontal mattress stitch, 381, 382f Hydrocele, 327 Hypercalcemia differential diagnosis, 302–303 in hyperparathyroidism, 302–303 in Zollinger-Ellison syndrome, 188 Hyperglycemia in pancreatitis, 254 postoperative, 113–114, 113t Hyperkalemia in pancreatitis, 254 postoperative, 111 Hypernatremia, postoperative, 110–111 Hyperparathyroidism, 302–304, 303t Hypersplenism See Splenomegaly Hypertension postoperative, 105 preoperative management, 6–7 Hyperthermia See Fever Hyperthyroidism See also Thyroid disorders clinical manifestations, 294 etiology, 296–297 laboratory tests, 294–295 Hypertrophic scars, 130 415 Hypocalcemia after thyroidectomy or parathyroidectomy, 301, 305 in pancreatitis, 254 Hypoglycemia in insulinoma, 306 perioperative management, 14–15 Hypokalemia, postoperative, 111 Hypomagnesemia, postoperative, 111 Hyponatremia, postoperative, 109–110, 110t Hypotension, postoperative, 103–105, 103t Hypothyroidism See also Thyroid disorders clinical manifestations, 294 etiology, 297 laboratory tests, 294–295 Hypoventilation, postoperative, 100–101 Hypoxemia, postoperative, 101–102 I Idiopathic autoimmune hemolytic anemia, 275 Idiopathic thrombocytopenic purpura, 275–276 Ileus diagnosis, 199–200 etiology, 198t, 199 gallstone, 223 postoperative, 107 treatment, 200 Imatinib mesylate, 194 Incarceration, hernia, 329 Incision and drainage, 406–409, 409t Incisional hernia, 337 Infection See also Abscess in central venous catheter, 65–66 diabetic foot, 65 necrotizing fasciitis, 64, 118 postoperative, 66–67, 67t surgical See Surgical infection in trauma, 64–65 wound, 127 See also Surgical infection Inflammatory phase, wound healing, 122–123, 124f Inguinal hernia See Hernias Injury See Trauma Insulin pancreatic secretion, 242–243 postoperative administration, 113–114, 113t Insulinoma, 262, 306–307 Internal hernia, 337–338 Intracerebral hematoma, 37 Intracranial hematoma, 37, 38f Intravenous access central venous catheters See Central venous catheters implantable ports, 392, 392f indications, 387–388 peripheral, 388 peripherally inserted central catheters, 392, 393f Islet cell transplantation, 248 Islet cell tumors, 306–309 Islets of Langerhans, 240 Ivor-Lewis operation, 165–166, 166f 416 J Jaundice, 221 K Kelling-Madlener procedure, 179 Kelly-Patterson syndrome, 149 Keloids, 130–131, 130f Kidney disease in diabetes, 247 postoperative assessment and management, 114 preoperative assessment and management, 11, 14 L Large intestine anatomy, 203 bleeding, 205–206 cancer, 206–208, 207t, 208t Crohn’s disease, 77, 210–211, 210t diverticulitis, 77, 78, 208–209, 209t function, 203–204 obstruction, 204–205 ulcerative colitis, 77, 210–211, 210t Latex allergy, 99–100 Latissimus flap, 291 Lauren classification, 189 Leiomyomas, esophageal, 159, 160f Lichtenstein repair, 334, 335 Lipase, 242, 251 Littre hernia, 336 Liver anatomy, 214–218, 215f, 216f, 217f, 219f disease chronic, 225–226 infections, 222–223 laboratory tests, 226–228 preoperative assessment and management, 11–12, 12t, 14 scoring systems, 227–228, 228t, 231t surgical resection for, 229–231 surgical shunts for, 231–232 tumors, 223–225 physiology and function, 218–222 transplantation, 232 trauma, 51 Local anesthetics, 408 Lumbar hernia, 337 Lymphoma gastric, 192–193 thyroid, 301 M Macrophages, in wound healing, 125–126 Magnetic resonance cholangiopancreatography (MRCP), 257 Magnetic resonance imaging (MRI) in Cushing syndrome, 312–313 in spinal cord injury, 41 of spleen, 272 in trauma assessment, 34 Malgaigne fracture, 51, 52f INDEX Mallory-Weiss syndrome, 153, 188 Malnutrition, wound healing and, 127 MALT (mucosa-associated lymphoid tissue) lymphoma, 192 Mandible reconstruction, 358–361, 359f, 360–361f McVay repair, 332–333 Medullary thyroid carcinoma, 300–301 Meissner’s plexus, 142 MELD (model end-stage liver disease) score, 227, 231t Mesenteric ischemia See Acute mesenteric ischemia Metastases, liver, 225 Metronidazole, for H pylori, 174t Microvascular free tissue transfer, 134, 135f Midesophageal diverticulum, 152 Migrating myoelectric complex, 221 Model end-stage liver disease (MELD) score, 227, 231t Motility disorders, esophageal, 143–148, 144t Motor vehicle crashes, 25 See also Trauma MRCP (magnetic resonance cholangiopancreatography), 257 MRI See Magnetic resonance imaging Mucosa-associated lymphoid tissue (MALT) lymphoma, 192 Multiple endocrine neoplasia syndrome, 186 Myeloproliferative disorders, 274 Myocardial infarction, postoperative, 105–106 Myofibroblasts, in wound healing, 125 N Nasogastric tubes, 119–120 Nausea and vomiting See also Acute abdomen postoperative, 95–97 Neck injury, 41–43, 43f Necrosis, infected pancreatic, 255 Necrotizing fasciitis, 64, 118 Needles, 377–378, 378f Neurogenic shock, 40 Nichols-Condon bowel preparation, 61 Nicotine, wound healing and, 127 Nipple reconstruction, 292 Nissen fundoplication, 157f, 158 Nitrogen balance, 12 Nosocomial infection, 67–68 Nutcracker esophagus, 144t, 148 Nutrition parenteral, 112 postoperative assessment and management, 111–112 preoperative assessment and management, 18–19, 20 wound healing and, 127 Nyhus repair, 333 Nyhus system, hernia classification, 325, 326f O Obturator hernia, 336 Operating room communication among team members, 87, 88–89 INDEX communication with family, 86, 88 instrumentation and equipment, 87–88 patient preparation, 86–87 patient safety, 85–86, 89 principles, 86t record keeping, 89–90 sterile technique, 88 team members, 87 OPSI See Overwhelming postsplenectomy infection Orringer esophagectomy, 166–167, 167f Overpressure injury, 25 See also Trauma Overwhelming postsplenectomy infection (OPSI), 49, 68, 280 Oxygen, in wound healing, 126 P Pain management in chronic pancreatitis, 257 postoperative, 93–95 Pancreas acute pancreatitis clinical presentation, 250–251 complications, 254–256 diagnosis, 75–76, 251–252 etiology, 248–250 prognosis, 252–253, 253t treatment, 75–76, 253–254 anatomy gross, 237–240, 238f microscopic, 240 chronic pancreatitis, 256–258 congenital abnormalities, 243–244 cystic tumors, 261–262 diabetes mellitus, 246–247 embryology, 234–237, 235f, 236f endocrine neoplasms, 262, 306–309 exocrine neoplasms, 258–261 gastrinoma, 263, 307–308 glucagonomas, 309 injury, 244–246 insulinoma, 262, 306–307 islet cell tumors, 306–309 periampullary tumors, 262 physiology endocrine, 242–243 exocrine, 241–242, 241f somatostatinomas, 309 transplantation, 247–248 VIPomas, 308–309 Papillary thyroid carcinoma, 300 Paralytic ileus See Ileus Parathyroid anatomy, 304 autotransplantation, 304–305 carcinoma, 305 primary hyperparathyroidism, 302–304, 303t Parenteral nutrition, 112 Patient-controlled analgesia, 94 Pauchet procedure, 176 Pedestrian injuries, 25 Pelvic fractures, 51–53, 52–53f, 54f 417 Penetrating trauma See also Trauma chest, 48 mechanisms of injury, 26–28, 26f, 27f Peptic ulcer disease See also Stomach, ulcers gastrinoma and, 186, 187t, 263, 307–308 gastrointestinal perforation in, 79–80 Percutaneous tube thoracostomy, 404–405, 405f Perforation esophageal, 154 gastrointestinal, 79–80, 82–83, 209 Peripheral nerve blocks, 94 Peripheral vascular disease, 246–247 Peripherally inserted central catheter (PICC), 392, 393f Peritonitis, 81 Periumbilical adenopathy, 190 Pharyngoesophageal diverticulum, 150–152, 151f Pharynx reconstruction, 358 Pheochromocytoma, 15, 316–317 Physical examination in acute abdomen, 70–71 preoperative, 4–6 PICC (peripherally inserted central catheter), 392, 393f Platelet disorders, preoperative management, 13 Plummer-Vinson syndrome, 149 Pneumonia aspiration, 102 postoperative, 102, 116 Pneumothorax, 102 Portal hypertension etiology, 218, 220 pathophysiology, 226 treatment, 231–232 Postanesthesia care unit, 91–92, 92t Postgastrectomy syndromes, 177–178t, 180–185 Postoperative care fever, 66, 97–98 fluid management, 108–109 nausea and vomiting, 95–97 nutrition, 111–112 pain control, 93–95 wound care, drains, and tubes, 118–120 Postoperative complications adrenal insufficiency, 114 agitation, 97 airway obstruction, 98–100, 99t arrhythmia, 106–107 delirium, 97 electrolyte abnormalities, 109–111, 110t gastrointestinal, 107 hematologic, 114–116 hyperglycemia, 113–114, 113t hypertension, 105 hypotension, 103–105, 103t hypoventilation, 100–101 hypoxemia, 101–102 infection See Surgical infection myocardial infarction, 105–106 pneumonia, 102 pulmonary aspiration, 102 renal insufficiency, 114 418 Pregnant patient, preoperative assessment, 16–17 Preoperative assessment and management anemia and coagulation disorders, 13–14 antimicrobial prophylaxis, 20 bowel management, 20–21 of cancer patient, 17–18 carcinoid tumors, 15 cardiac disease, 7–9, 8t diabetes, 14–15 dietary instructions, 20 of geriatric patient, 15–16 of healthy patient, hepatic disease, 11–12, 12t hypertension, 6–7 nutritional status, 18–19 patient history, patient information, 21 pheochromocytoma, 15 physical examination, 4–6 of pregnant patient, 16–17 previous venous thromboembolism, 17 prophylaxis for thrombosis and embolism, 19 pulmonary disease, 9–10, 10t renal disease, 11 risk assessment, 5–6, 5t, 6t therapeutic anticoagulation, 19–20 vascular disease, 12–13 Proliferative phase, wound healing, 123, 124f Pseudocysts, pancreatic, 255–256 Puestow procedure, 258 Pulmonary disease, preoperative assessment, 9–10, 10t Pulmonary embolism, preoperative prophylaxis, 19 Pulsus paradoxus, 44 R Radial artery puncture, 394–396 Radial forearm flap, 354–355f, 356–357f Radiation therapy, wound healing and, 129, 129f Radiography in acute abdomen, 72–73 in aortic trauma, 45, 46f, 48f in pancreatitis, 252, 257 in spinal trauma, 41 in splenic trauma, 271 in trauma assessment, 34 Radionuclide scans for gastrinoma localization, 308 for insulinoma localization, 306 parathyroid, 303 thyroid, 295–296, 299 Random pattern flaps, 348, 349–350f Ranson’s criteria, 253, 253t Rectum cancer, 206–208, 208t carcinoid tumor, 310 Recurrent laryngeal nerve anatomy and physiology, 142 injury during thyroidectomy, 297, 301–302 INDEX Remodeling phase, wound healing, 124f, 125 Renal disease See Kidney disease Respiratory failure, postoperative, 98–100, 99t Rib fracture, 47–48 Richter hernia, 337 Riedel’s thyroiditis, 298 Risk assessment, preoperative in anemia and coagulation disorders, 13–14 in cardiac disease, 7–9, 8t in diabetes and endocrine disorders, 14–15 of geriatric patient, 15–16 in hepatic disease, 11–12, 12t in hypertension, 6–7 physical examination, 5–6, 5t, 6t in pulmonary disease, 9–10, 10t in renal disease, 11 in vascular disease, 12–13 Roux syndrome, 183 S Sarcoidosis, 277 Schatzki rings, 149 Scleroderma, 148 Secretin stimulation test, 186 Seldinger technique, 388, 389f Sepsis, vs bacteremia, 67 Shear injury, 25 See also Trauma Shock cardiogenic, 36 clinical parameters, 36t distributive, 35 hemorrhagic, 35, 36t neurogenic, 40 pathogenesis, 35–36 spinal, 40 Short gut syndrome, 197 Shouldice repair, 333, 335 Sickle cell anemia clinical manifestations, 275 preoperative management, 13 splenic abscess in, 275 Sideropenic dysphagia, 149 Sister Mary Joseph’s nodes, 190 Skin preparation, 62, 87 Skull fracture, 37 Small intestine acute mesenteric ischemia, 80, 200–201, 201t anatomy, 196 carcinoid tumor, 310 fistulae, 202–203, 202t function, 196–197 ileus, 107, 198t, 199–200, 223 obstruction, 79, 197–199, 198t, 329 short gut syndrome, 197 Smoking as surgical risk factor, 10 wound healing and, 127 Somatostatinomas, 309 Sphincter of Oddi, 238 Spigelian hernia, 337 Spinal block, 94 Spinal cord injury, 40–41 INDEX Spinal shock, 40 Spleen See also Splenectomy anatomy, 267–269, 268f, 270f benign lesions, 272–273 in Felty syndrome, 276 in Gaucher disease, 277 hematologic disorders affecting, 274–276 imaging, 271–272 malignant lesions, 273–274 physical examination, 270–271 physiology, 269–270 in sarcoidosis, 277 splenomegaly, 271f, 272, 273t trauma, 49–51, 50f, 277–278, 278t Splenectomy for benign lesions, 272–273 complications, 49, 68, 280 in Felty syndrome, 276 following splenic trauma, 277–278 in Gaucher disease, 277 in hematologic disorders, 274–276 for malignant lesions, 273–274 postoperative care, 280–281 preoperative care, 278–279 in sarcoidosis, 277 surgical procedure, 279–280 Splenomegaly, 271f, 272, 273t Staging colorectal cancer, 207, 207t esophageal cancer, 163, 164t Steatohepatitis, 225 Sterile technique, 88, 372–374 Stomach anatomy, 169, 170f cancer diagnosis, 190 epidemiology, 188–190 etiology, 189–190 gastrointestinal stromal tumor, 193–194 lymphoma, 192–193 risk factors, 189t staging, 191t symptoms, 190 treatment, 192 embryology, 169 gastrinoma See Gastrinoma Mallory-Weiss syndrome, 153, 188 physiology, 169–171 stress gastritis, 185, 186t ulcers classification, 171–172, 172f etiology, 172 location, 171f medical treatment, 173, 174t surgical treatment, 175–180, 175f, 176f Zollinger-Ellison syndrome See Gastrinoma Strangulation, hernia, 329 Stress gastritis, 185, 186t Subacute thyroiditis, 298 Subcuticular stitch, 381, 383f Subdural hematoma, 37, 38f Superior laryngeal nerve, 142 419 Supraclavicular adenopathy, 190 Surgeon preparation, 373–374 Surgical drains, 119 Surgical infection abscess See Abscess classification, 67t diagnosis, 59–60, 116 etiology, 66–67, 116–118 nosocomial, 67–68 prevention, 20, 61–63 treatment, 63–64, 117–118, 117t Sutures horizontal mattress, 381, 382f materials, 378–379 removal, 381–383 simple interrupted, 379–380, 380f subcuticular, 381, 383f technique, 377–378, 379f vertical mattress, 380–381, 381f Sweet operation, 163, 165, 165f T T lymphocytes, 126 Technetium scan, thyroid, 296, 299 Tension pneumothorax, 44 Tetanus diphtheria toxoid, 64–65 Tetanus immune globulin, 65 Thal fundoplication, 157f, 158 Thalassemia, 275 Thoracic trauma, 44–48, 45t, 46–47f, 48f Thoracostomy, tube, 404–405, 405f Thrombotic thrombocytopenic purpura, 276 Thyroid disorders clinical manifestations, 294 Graves’ disease, 296–297 hypothyroidism, 297 imaging, 295–296 laboratory tests, 294–295 multinodular goiter, 299 neoplasms, 299–301 solitary nodule, 298–299 thyroiditis, 297–298 toxic adenoma, 297 Thyroidectomy complications, 297, 301–302 for Graves’ disease, 297 for multinodular goiter, 297 for solitary nodule, 298, 299 for thyroid cancer, 300–301 for thyroiditis, 298 TIPS (transjugular intrahepatic portosystemic shunt), 231 Tissue expanders, 283, 284–285f Tongue reconstruction, 358 Total extraperitoneal repair, 334–335 Toupet fundoplication, 158, 158f Toxic megacolon, 77 Tracheostomy, 400–402, 401f TRAM flap, 286–289, 290f, 291t Transabdominal preperitoneal repair, 334 Transjugular intrahepatic portosystemic shunt (TIPS), 231 420 Transplantation islet cell, 248 liver, 232 pancreas, 247–248 skin, 347 Trauma abdominal and pelvic, 49–53, 50f, 52–53f, 54f chest, 44–48, 45t, 46–47f, 48f extremity, 54–55 head and neck, 37–39, 38f, 343 historic perspective, 23–24, 24f infection prophylaxis, 64–65 mechanisms of injury blunt trauma, 25, 26f penetrating trauma, 26–28, 26f, 27f neck, 41–43, 43f pancreatic, 244–246 resuscitation airway management, 29–30, 30t AMPLE history, 29t breathing and ventilation, 30–31 circulation, 31–32, 31t disability assessment, 32–33, 32t exposure of body, 33 focused abdominal sonography for trauma, 33 personnel for, 28–29 secondary survey, 33–35 shock in, 35–37, 36t spinal cord, 40–41 spleen, 49–51, 50f, 277–278, 278t Traumatic brain injury, 37–39, 38f Trypanosoma cruzi, 145 U Ulcer disease See Peptic ulcer disease Ulcerative colitis, 77, 210–211, 210t Ultrasonography in acute abdomen, 73 in pancreatitis, 252 of spleen, 271–272 of thyroid, 296, 299 in trauma assessment, 33 Umbilical hernia, 336 Universal precautions, 88–89, 374–375 Upper esophageal sphincter dysfunction, 143, 145 Uremia, preoperative management, 14 Urinary catheterization, 397–399 Urinary tract infections, postoperative, 116–117 INDEX V Vacuum-assisted wound closure (VAC), 131, 132f, 386 Vagus nerve, 142 Vascular disease, preoperative assessment, 12–13 Venous access See Intravenous access Venous thromboembolism, previous, 17 Vertebral artery, blunt injury, 42 Vertical mattress stitch, 380–381, 381f VIPomas, 308–309 Virchow’s node, 190 Vitamin A, 126 Vitamin C, 126 Vitamin E, 127 Vomiting postgastrectomy, 182 postoperative, 95–97 Von Willebrand disease, preoperative management, 14 W Warfarin, preoperative, 19 Warren shunt, 231 Webs, esophageal, 149 Whipple procedure, 260 Wound(s) assessment, 384t closed, 384–385 closure See Sutures complications, 386–387 culture, 408 dressings, 118–119, 131, 385–386 healing cellular roles, 125–126 factors influencing, 126–129, 128t fetal, 129–160 historical background, 122 hypertrophic scars and keloids, 130–131, 130f phases, 122–125, 124f, 124t, 383–384 infection, 127 See also Surgical infection management drains and tubes, 118–119 nonoperative, 131, 132f operative, 131–134, 133–134f, 135f open, 385 vacuum-assisted closure, 131, 132f, 386 Z Zenker diverticulum, 150–152, 151f Zinc, in wound healing, 127 Zollinger-Ellison syndrome See Gastrinoma ... of Surgery Division of General Surgery Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 13 Jennifer H Aldrink, MD General Surgery Resident Department of Surgery. .. Professor of Surgery Division of General Surgery Department of Surgery Duke University Health System Durham, North Carolina Chapter CONTRIBUTORS Keshava Rajagopal, MD, PhD General Surgery Resident... Patel, MD General Surgery Resident Department of Surgery Duke University Medical Center Durham, North Carolina Chapter 18 Rebecca P Petersen, MD, MSc General Surgery Resident Department of Surgery