Moshe Schein

Schein's Common Sense Emergency Abdominal Surgery

Springer-Verlag Berlin Heidelberg GmbH

Moshe Schein

Schein's Common Sense Emergency Abdominal Surgery A Small Book for Residents, Thinking Surgeons and Even Students

With contributions by:

Adam Klipfel, MD, Assistant Editor (USA) Bashar H. Fahoum, MD, FACS (USA) Gary Gecelter, MD, FACS (USA) Pioter Gorecki, MD (USA) Asher Hirshberg, MD (USA) Per-Olof Nystrom, MD (Sweden) Paul Rogers, FRCS (Scotland) James C. Rucinski, MD, FACS (USA) Roger Saadia, MD, FRCS (Canada)

, Springer

Moshe Schein, MD, FACS, FCS (SA) Associate Professor of Surgery Cornell University Medical College, NY, Attending Surgeon, New York Methodist Hospital, 506 Sixth Street 11215-9008 Brooklyn, NY, USA

" 2002 Reprint. This reprint has been authorized by Springer-Verlag, Heidelberg, Germany, for sale in India, Pakistan, Bangladesh, Nepal and Sri Lanka only and not for export therefrom."

ISBN 978-3-540-78124-0

CIP data applied for Schein, Moshe: Schein's common sense emergency abdominal surgery: a small book for residents, thinking surgeons and even students I Moshe Schein. With contributions by: B. H. Fahoum .... - Berlin; Heidelberg; New York; Barcelona; Hong Kong; London; Milan; Paris; Singapore; Tokyo: Springer, 2000

ISBN 978-3-540-78124-0

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 provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer­Verlag. Violations are liable for prosecution under the German Copyright Law.

Springer-Verlag is a company in the BertelsmannSpringer publishing group. © Springer-Verlag Berlin Heidelberg 2000

Originally published by Springer-Verlag Berlin Heidelberg in 2000

The use of general descriptive names, registered names, 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 publishers cannot guarantee the accuracy of any information about the application of operative techniques and medications contained in this book. In every individual case the user must check such information by consulting the relevant literature.

Data conversion by Isolde Gundermann, Heidelberg Cover design: design & production GmbH, Heidelberg SPIN 10708197 24/3133/is 5 4 3 2 1

Moshe Schein, MD, FACS, FCS (SA) Associate Professor of Surgery Cornell University Medical College, NY, Attending Surgeon, New York Methodist Hospital, 506 Sixth Street 11215-9008 Brooklyn, NY, USA

ISBN 978-3-540-78124-0 ISBN 978-3-642-88133-6 (eBook) DOI 10.1007/978-3-642-88133-6 SPIN 10889671

" 2002 Reprint. This reprint has been authorized by Springer-Verlag, Heidelberg, Germany, for sale in India, Pakistan, Bangladesh, Nepal and Sri Lanka only and not for export therefrom."

ISBN 978-3-540-78124-0

CIP data applied for Schein, Moshe: Schein's common sense emergency abdominal surgery : a small book for residents, thinking surgeons and even students I Moshe Schein. With contributions by: B. H. Fahoum .... - Berlin ; Heidelberg ; New York ; Barcelona; Hong Kong ; London ; Milan; Paris; Singapore ; Tokyo : Springer, 2000

ISBN 978-3-540-78124-0 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, speeifically the rights of translation, reprinting, reuse of illustrations, reeitation, broadcasting, reproduction on microftlm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permit­ted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer­Verlag. Violations are liable for prosecution under the German Copyright Law.

Springer-Verlag is a company in the BertelsmannSpringer publishing group. © Springer-Verlag Berlin Heidelberg 2000 Originally published by Springer-Verlag Berlin Heidelberg in 2000 The use of general descriptive names, registered names, trademarks, etc. in this pub­lication does not imply, even in the absence of a speeific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use

Product liability: The publishers cannot guarantee the accuracy of any information about the application of operative techniques and medications contained in this book. In every individual case the user must check such information by consulting the relevant literature.

Data conversion by Isolde Gundermann, Heidelberg Cover design: design & production GmbH, Heidelberg SPIN 10708197 24/3133/is 5 4 3 2 1

This book is dedicated to my father -a war surgeon - on the Russian-German front during the Second World War.

"During each later war I watched surgeons committing the same basic errors I learned to avoid during 1940.

Such a waste in young lives ... "

Karl Schein, MD (1911-1974)

Acknowledgments

Acknowledgments

This book has been assembled - in pieces - during twenty years of in­tensive personal involvement, clinical and academic, with emergency ab­dominal surgery in South Africa, Israel and the USA. For the foundations in this noble surgical field I am indebted to George G. Decker of Johannes­burg. About half of the chapters were written in collaboration with my good old friends from around the world, who are listed in the list of contributors. Many thanks to Roger Saadia, Asher Hirshberg, Per-Olof Nystrom, and Paul Rogers, who did not spare encouragement and sound advice. Eric Frykberg and the members of SURGINET helped find the title to this book and test-read selected chapters. Alfredo Sepulvede pro­vided a few aphorisms and quotations. I am grateful to Adam Klipfel for proofreading the manuscript, to our surgical residents for continuously exciting my mind, to Syed Gardezi for his friendship, and my Chairman -Leslie Wise for providing me with a safe haven to pursue my interests.

Special thanks to Agnes Heinz, Ph.D., Springer Verlag, Heidelberg, for trusting me with this allegedly unconventional book. Finally, it is my loving and minimally nagging wife Heidi, and my good sons Omri, Yariv and Dan, who let me spend all those years writing-instead of making more money and entertaining them.

The reader will find that there are not a few duplications scattered along the book. We did it on purpose, as repetition of important points is crucial in adult education. Any reader who has a question or a com­ment about anything mentioned in this book is invited to e-mail me directly - mscheim@mindspring.com - I will respond.

Moshe Schein, Brooklyn August 1999

vii

Preface

Preface

Smart surgeons learn from their own mistakes, smarter surgeons learn from mistakes of others, some never learn ...

You are a resident, overworked and constantly tired; sitting down with your mentor for a brief tutorial. What do you want to get out of these few minutes? To organize your thoughts and approaches to the particular problem; to learn how he - the weathered surgeon - "tackles it"; to grasp a few practical "recipes" or "goodies" and take home a message or two; to laugh a bit and unwind. This is also our goal in this book.

We hope that you are not repelled or offended by the non-formal character of this book. This is how emergency abdominal surgery is taught best, by trial and error and repetitions, with emphasis on basics. This is not a "complete" textbook, nor is it a cookbook type manual or discussion of case studies; neither is it a collection of detailed lecture notes or exhaustive lists. Instead, it consists of a series of informal, uncensored, chats between experienced surgeons and their trainees. No percentages, series, elaborated figures or complicated algorithms are included; only a surgeon's narrative, explaining how "he does it" - based on his experience and state of the art knowledge of the literature. No references are included as it was our aim to put down nothing which has not been experienced, confirmed and practiced in our own hands. The starting point of each individual contribution is that there are many ways to skin a cat, or different clinical pathways to arrive at a similar outcome; however, one of the options is "better". Another emphasis was on common pitfalls and mistakes.

This book comprises of short chapters, which are allocated to three sections: preoperative pbase, the operation, and postoperative phase. The chapters supplement each other and are best not read in isolation.

ix

Preface

x For the surgeon, emergency surgery has always been, and still is, what the battleground is for the soldier, an exhilarating place -a character-building source of skill, experience, excitement and glory. Emergency surgery remains the playing field where the surgical boys (girls) become men (women). Surgical trainees adhere to this myth and hence their inherent attraction to this topic. We hope that this book will increase your fascination with emergency abdominal surgery, helping you to practice it better.

Contents

Contents Xl

1. General Philosophy ... 1

Section A: Before the Operation . .. 7

2. The Acute Abdomen ... 9

3. Rational Diagnostic Procedures ... 17

4. Who Should Look After the "Acute Abdomen" and Where? ... 27

5. Optimizing the Patient ... 29

6. Pre-operative Antibiotics ... 41

7. Family, Ethics, Informed Consent and Medicolegal Considerations ... 45

Section B: The Operation . .. 51

8. The Incision ... 53

9. Abdominal Exploration: Finding What Is Wrong ... 57

10. Peritonitis: Contamination and Infection: Principles of Treatment ... 67

11. The Intestinal Anastomosis ... 75

12. Upper Gastrointestinal Hemorrhage ... 81

13. Perforated Peptic Ulcer ... 97

14. Acute Pancreatitis ... 107

15. Acute Cholecystitis ... 121

16. Acute Cholangitis ... 131

17. Small Bowel Obstruction ... 137

18. ''Acute'' Abdominal Wall Hernias ... 151

19. Acute Mesenteric Ischemia ... 159

20. Inflammatory Bowel Disease ... 169

Contents

xii 21. Colonic Obstruction ... 179

22. Acute Appendicitis ... 193

23· Acute Diverticulitis ... 203

24· Massive Rectal Bleeding ... 215

25· Gynecological Emergencies ... 223

26. Penetrating Abdominal Trauma ... 233

27· Blunt Abdominal Trauma ... 239

28. The Abdominal Compartment Syndrome ... 253

29· Abdominal Closure ... 261

30. Ruptured Abdominal Aneurysm ... 267

Section C: After the Operation . .. 275

31. Nutrition ... 277

32. Postoperative Antibiotics ... 287

33. Postoperative Care ... 291

34. Postoperative Ileus Versus Intestinal Obstruction ... -97

35. Intra-abdominal Abscesses ... 303

36. Abdominal Wall Dehiscence ... 315

37. Re-laparotomies and Laparostomy for Infection ... 321

38. LIRS, SIRS, Sepsis, MODS and Tertiary Peritonitis ... 333

39. Anastomotic Leaks and Fistulas ... 341

40. Wound Management ... 349

41. The Role of Laparoscopy ... 355

42. In the Aftermath and the M & M Meeting ... 361

Subject Index . .. 369

Contributors

Contributors

Bashar H. Fahoum, MD, FACS Attending Surgeon, Director S.I.C.u. Department of Surgery New York Methodist Hospital 506 Sixth St. - 6th Fl. Brooklyn, New York 11215, USA (Chapter 25)

Gary Gecelter, MD, FACS Chief, Division of General Surgery Long Island Jewish Medical Center 270-05 76th Avenue, Research Building - Room B-235 New Hyde Park, New York 11040, USA (Chapter 16)

Pioter Gorecki, MD Attending Surgeon Department of Surgery Nassau County Hospital 2201 Hempstead Tpk. East Meadow, New York 11554, USA (Chapter 41)

Asher Hirshberg, MD Associate Professor of Surgery Department of Surgery Baylor College of Medicine & Ben Taub General Hospital Houston, Texas, USA

• (Chapter 2,3,8,9,25,26,27)

Adam Klipfel, MD Surgical Resident Department of Surgery New York Methodist Hospital 506 Sixth St. - 6th Fl. Brooklyn, New York 11215, USA (Assistant Editor)

xiii

Contributors

xiv Per-Olof Nystrom, MD Associate Professor The University of Linkoping Chief of Colorectal Surgery Linkoping University Hospital 58185 Linkoping, Sweden (Chapter 20,21,23,24)

Paul Rogers, FRCS Consultant, General and Vascular Surgery Department of Surgery Gartnavel Western Hospital Ardersier 59 Langlands Drive Newlands, Glasgow G43 2QX, Scotland (Chapter 3,18)

James c. Rucinski, MD, FRCS Instructor in Surgery Director of Surgical Education New York Methodist Hospital 506 Sixth St. - 6th Fl. Brooklyn, New York 11215, USA (Chapter 5,,7, 19,31)

Roger Sa;ldia, MD, FRCS Professor of Surgery Department of Surgery University of Manitoba Health Sciences Center and St Boniface General Hospital Winnipeg, Canada (Chapter 10,1,7, 26, 2,7, 32, 33, 37)