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Contents PART I: GENERAL SURGERY Section 1 – Physiological Basis of Surgery 1. Shock ............................................................................. 3 Definition 3 • Clinical Features 3 • Classification of Shock 3 • Stages of Shock 3 • Pathogenesis 3 • Organ Changes in Shock 4 • Investigations and Assessment 4 • Treatment 5 2. Wound Healing .................................................................... 6 Introduction 6 • Wound Healing 6 • Inflammation 6 • Formation of Granulation Tissue (Organization) 8 • Collagen Synthesis 9 • e Healing Sequence 11 • Regulation of Wound Healing by Growth Factors 11 • Factors Influencing Wound Healing 12 • Disorders of Scarring 13 • Healing of Specialized Tissues 13 • Classification of Wounds 14 • Types of Wound 14 3. Hemorrhage and Blood Transfusion ................................................. 16 Hemorrhage 16 • Estimation of the Amount of Blood Loss 17 • Blood Transfusion 17 • Massive Transfusion 19 • Plasma and Blood Substitutes 19 • Preservation and Storage of Blood 19 • Preparation for Blood Transfusion—Blood Grouping, Antibody Screening and Cross Matching 20 • Hazards or Complications of Blood Transfusion 21 • Autologous Transfusion 22 4. Hemostasis and Coagulation ........................................................ 23 Phases of Hemostasis 23 • Inhibitors of Coagulation 24 • General Mechanism 25 • Fibrinolysis 26 • Laboratory Tests for Hemostasis 26 • Acquired Disorders of Coagulation 27 • Congenital Disorders of Coagulation 29 • Platelet Disorders 29 • Investigation of a Patient with Bleeding Disorders 30 • Hypercoagulable States and rombotic Disease or rombophilia 30 5. Fluid and Electrolyte Balance ....................................................... 32 Introduction 32 • Fluid Compartments 32 • Interpretation of Fluid Balance 33 • Which Fluids Go Where? 34 • Normal Water and Electrolyte Balance 35 • Disorders of Fluid and Electrolyte Balance 36 • Fluid erapy 40 • Fluid Replacement 41 • e Fluid Rule 42 6. Acid-base Balance ................................................................. 43 Introduction 43 • Body Fluid Buffer Systems 43 • Role of the Lungs 44 • Role of the Kidneys 44 • Definition of Acid-base Terms 46 • Metabolic Acidosis 46 • Metabolic Alkalosis 47 • Respiratory Acidosis 48 • Respiratory Alkalosis 49 7. Nutrition in Surgery ............................................................... 50 Introduction 50 • Assessment of Nutritional Status 50 • Indications of Nutritional Support 51 • Nutritional Requirements 52 • Nutrient Mixing 52 • Routes for Nutritional Support—Enteral or Parenteral Nutritional Support 52 • Enteral Nutrition 52 • Total Parenteral Nutrition 53 • Complications 54 8. Endocrine and Metabolic Response to Injury .......................................... 55 Introduction 55 • Systems Controlling the Response 55 • Metabolism aſter Injury 57 • Factors Determining the Magnitude of Metabolic Response 59 • Factors Reducing the Metabolic Response and Quick Recovery 59

Section 1 – Physiological Basis of · PDF file• Types of Skin Graft91 • Procedure of Partial ... Syndrome 204 • Typhoid Enteritis 205 ... 319 • Blood Supply 319 • Physiology

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Page 1: Section 1 – Physiological Basis of · PDF file• Types of Skin Graft91 • Procedure of Partial ... Syndrome 204 • Typhoid Enteritis 205 ... 319 • Blood Supply 319 • Physiology

Contents

PART I: GENERAL SURGERY

Section 1 – Physiological Basis of Surgery

1. Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3• Definition 3 • ClinicalFeatures 3 • ClassificationofShock 3 • StagesofShock 3 • Pathogenesis 3 • OrganChangesinShock 4 • InvestigationsandAssessment 4 • Treatment 5

2. Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6• Introduction 6 • WoundHealing 6 • Inflammation 6 • FormationofGranulationTissue(Organization) 8 • CollagenSynthesis 9 • TheHealingSequence 11 • RegulationofWound HealingbyGrowthFactors 11 • FactorsInfluencingWoundHealing 12 • DisordersofScarring 13 • HealingofSpecializedTissues 13 • ClassificationofWounds 14 • TypesofWound 14

3. Hemorrhage and Blood Transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16• Hemorrhage 16 • EstimationoftheAmountofBloodLoss 17 • BloodTransfusion 17 • MassiveTransfusion 19 • PlasmaandBloodSubstitutes 19 • PreservationandStorageofBlood 19 • PreparationforBloodTransfusion—BloodGrouping,AntibodyScreeningandCrossMatching 20 • HazardsorComplicationsofBloodTransfusion 21 • AutologousTransfusion 22

4. Hemostasis and Coagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23• PhasesofHemostasis 23 • InhibitorsofCoagulation 24 • GeneralMechanism 25 • Fibrinolysis 26 • LaboratoryTestsforHemostasis 26 • AcquiredDisordersofCoagulation 27 • CongenitalDisordersofCoagulation 29 • PlateletDisorders 29 • InvestigationofaPatientwithBleedingDisorders 30 • HypercoagulableStatesandThromboticDiseaseorThrombophilia 30

5. Fluid and Electrolyte Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32• Introduction 32 • FluidCompartments 32 • InterpretationofFluidBalance 33 • Which FluidsGoWhere? 34 • NormalWaterandElectrolyteBalance 35 • DisordersofFluidand ElectrolyteBalance 36 • FluidTherapy 40 • FluidReplacement 41 • TheFluidRule 42

6. Acid-base Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43• Introduction 43 • BodyFluidBufferSystems 43 • RoleoftheLungs 44 • RoleoftheKidneys 44 • DefinitionofAcid-baseTerms 46 • MetabolicAcidosis 46 • MetabolicAlkalosis 47 • RespiratoryAcidosis 48 • RespiratoryAlkalosis 49

7. Nutrition in Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50• Introduction 50 • AssessmentofNutritionalStatus 50 • IndicationsofNutritionalSupport 51 • NutritionalRequirements 52 • NutrientMixing 52 • RoutesforNutritionalSupport—Enteralor ParenteralNutritionalSupport 52 • EnteralNutrition 52 • TotalParenteralNutrition 53 • Complications 54

8. Endocrine and Metabolic Response to Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55• Introduction 55 • SystemsControllingtheResponse 55 • MetabolismafterInjury 57 • FactorsDeterminingtheMagnitudeofMetabolicResponse 59 • FactorsReducingtheMetabolicResponseandQuickRecovery 59

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Section 2 – Surgical Infection and Burn

9. Surgical Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60• Definition 60 • DeterminantsofInfection 60 • SourceofInfection 61 • Folliculitis,Furuncle,Carbuncle 61 • HydradenitisSuppurativa 62 • Abscess 62 • Cellulitis 63 • LymphangitisandLymphadenitis 63 • Erysepelas 63 • DogandCatBiteWounds 64 • DrugInjectionAbscess 64 • NecrotizingFascitis 64 • GasGangrene 64 • Tetanus 64 • InfectionsofHandandFoot 65 • FibrousFlexorSheaths 66 • FootInfections 67 • FungalInfections 69 • HospitalAcquired(Nosocomial)Infections 69 • SurgicalInfectionsofAbdomen 71 • SurgicalInfectionsofThorax 72 • PathogensinSurgicalInfection 72 • Antibiotics 72 • AntibioticPolicy 73

10. Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75• Definition 75 • ClassificationofBurns 75 • Pathophysiology 76 • SystemicEffectsofBurn 76 • Treatment 77 • OtherTypesofBurnInjury 78 • ComplicationsofBurnInjury 78 • PostburnContracture 78

Section 3 – Skin and Cysts

11. Keloid and Hypertrophic Scar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80• HypertrophicScar 80 • Keloid 80

12. Tumors of the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82• Classification 82 • Papilloma 83 • BasalCellCarcinoma 83 • SquamousCellCarcinoma 84 • Melanoma 85 • Marjolin’sUlcer 87 • Hemangioma 87 • Lipoma 88 • Neurofibroma 89 • vonRecklinghausen’sDisease 89 • PlexiformNeurofibromatosis 89 • CutaneousNeurofibromatosis 90

13. Skin Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91• TypesofSkinGraft 91 • ProcedureofPartialThicknessGraft 91

14. Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93• Cyst 93 • DermoidCyst 93 • SebaceousCyst 94 • MesentericCyst 94

Section 4 – Specialties Related to Surgery

15. Principles of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96• PreoperativeEvaluationandPremedication 96 • TechniquesofAnesthesia 99 • GeneralAnesthesia 99 • MonitoringduringAnesthesia 105 • RecoveryfromGeneralAnesthesia 105 • RegionalAnesthesia 105 • LocalAnestheticAgents—Pharmacology 106 • TypesofRegionalAnesthesia 106 • SpinalAnesthesia 107 • EpiduralAnesthesia 108 • ExtraduralSacralBlockor CaudalBlock 108 • SomeCommonPostoperativeComplications 108

16. Clinical Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112• Neoplasm 112 • Sarcoma 112 • Carcinoma 113 • DisordersofGrowth 113 • EtiologyofCancer 113 • GrowthandSpreadofMalignantNeoplasms 114 • TreatmentofCancer 114

17. Imaging in Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118• PlainRadiograph 118 • Mammography 118 • SpecialRadiologicalTechniquesusingContrastMedia 118 • Ultrasonography 119 • CTScanandMagneticResonanceImaging 120 • RadioisotopeScan 120

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PART II: SYSTEMIC SURGERY INCLUdING oRThoPEdICS

Section 5 – Head and Neck Swellings

18. Salivary Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123• SurgicalAnatomy 123 • ParotidSwellings 124 • ParotidFistula 126 • SubmandibularCalculi 126 • CarcinomaofSubmandibularSalivaryGland 127

19. The Gums and Jaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128• JawTumors 128 • Epulis 128 • Odontomes 128 • DentalCyst 129 • DentigerousCyst 129 • Adamantinoma 130 • TumorsoftheJawBones 130

20. Cleft Lip and Cleft Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131• Embryology 131 • CleftLip 131 • CleftPalate 132

21. The Tongue and Lip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134• SurgicalAnatomy 134 • UlcersofTongue 135 • Glossitis 136 • TumorsofTongue 136 • Lip 138

22. Neck Swellings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139• SurgicalAnatomy 139 • Classification 139 • Ranula 139 • SublingualandCervicalDermoid 140 • BranchialCyst 142 • BranchialFistula 142 • CysticHygroma 143 • ColdAbscess 143 • CervicalLymphadenopathy 144 • CarotidBodyTumor 145 • SternomastoidTumor 145 • PharyngealPouch 145

Section 6 – Endocrine Surgery

23. Thyroid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146• SurgicalAnatomy 146 • Physiology 148 • Investigations—TestsofThyroidFunction 149 • CongenitalAnomalies 150 • Goiter 151 • Non-ToxicGoiter 151 • ToxicGoiter (Thyrotoxicosis) 152 • SolitaryThyroidNodule 154 • NeoplasticGoiter 156 • Autoimmune Thyroiditis(Hashimoto’sDisease) 158 • SubacuteThyroiditis 158 • Riedel’sThyroiditis 159

24. Parathyroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160• Anatomy 160 • Physiology 160 • Hyperparathyroidism 160 • Hypoparathyroidism 162

25. The Adrenal Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163• Development 163 • Anatomy 163 • Histology 163 • TumorsofAdrenalMedulla 163 • TheAdrenalCortex 165 • AdrenalIncidentaloma 167 • AdrenalInsufficiency 168

Section 7 – Vascular Surgery

26. Arterial Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169• ArterialOcclusion 169 • IntermittentClaudication(IschemicMusclePain) 169 • Atherosclerosis 170 • CriticalLimbIschemia 170 • ArterialDilatationAneurysm 170 • AbdominalAorticAneurysm 171 • Gangrene 172 • PressureSores 174 • Raynaud’sSyndrome 174 • ThoracicOutletSyndrome 175 • Buerger’sDisease 175

27. Varicose Vein, Deep Vein Thrombosis, Pulmonary Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . 177• VaricoseVein 177 • DeepVeinThrombosis 180 • PulmonaryEmbolism 181

28. Lymphatics and Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182• DiseasesoftheLymphatics 182 • DiseasesoftheLymphNodes 183

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Section 8 – Gastrointestinal Surgery

29. Esophagus and Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187• Esophagus 187 • Dysphagia 188 • AchalasiaoftheCardia(Cardiospasm) 188 • Plummer- VinsonSyndrome(PatersonandKellySyndrome) 189 • TumorsoftheEsophagus 189 • CarcinomaofEsophagus 189 • DiaphragmaticHernia 190 • CongenitalDiaphragmaticHernia 190 • EventrationofDiaphragm 190 • AcquiredDiaphragmaticHernia 190

30. Stomach and Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192• Anatomy 192 • CongenitalHypertrophicPyloricStenosis 193 • Gastritis 193 • PepticUlcers 194 • DuodenalUlcer 195 • PerforatedGastricorDuodenalUlcer 196 • PepticUlcerHemorrhage 196 • PyloricStenosis 197 • GastricUlcer 198 • GastricCarcinoma 199 • Zollinger-EllisonSyndrome 200

31. Small Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201• SmallIntestine 201 • IntestinalTuberculosis 202 • UlcerativeTuberculosis 202 • HyperplasticIleocecalTuberculosis 202 • Crohn’sDisease 202 • DiverticularDisorders 203 • ShortBowelSyndrome 204 • TyphoidEnteritis 205 • Neoplasms 205 • EnterocutaneousFistula 206

32. Large Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207• Anatomy 207 • BloodSupply 207 • LymphaticDrainage 208 • NerveSupply 208 • Hirschsprung’sDisease 208 • UlcerativeColitis 209

33. The Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211• SurgicalAnatomy 211 • AnatomicalPositions 211 • BloodSupply 211 • Appendicitis 212 • LaparoscopicAppendicectomy 214 • NeoplasmsoftheAppendix 214 • CarcinoidTumor 214 • Adenocarcinoma 214 • MalignantMucocele 214

34. Intestinal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215• IntestinalObstruction 215 • ParalyticIleus 217 • NeonatalIntestinalObstruction 217 • Intussusception 218 • Volvulus 219

35. Rectum and Anal Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221• Rectum 221 • AnalCanal 222 • ProlapseofRectum 223 • ColorectalCarcinoma 224 • AnorectalAnomalies 226 • Hemorrhoids(Piles) 227 • AnorectalAbscess 228 • FistulaInAno 228 • AnalFissure(FissureInAno) 229

Section 9 – Hepatobiliary, Pancreas and Spleen

36. Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230• SurgicalAnatomy 230 • FunctionalAnatomy:HepaticSegments 230 • MicroscopicAnatomy 231 • FunctionsofLiver 232 • AmebicLiverAbscess 232 • PyogenicLiverAbscess 232 • HydatidCyst ofLiver 233 • LiverNeoplasms 234 • PortalHypertension 235 • Budd-ChiariSyndrome 238

37. Gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239• SurgicalAnatomy 239 • CongenitalDisordersofGallbladder 240 • Gallstone 240 • Cholecystitis 242 • StonesintheCommonBileDuct 243 • WhiteBile 244 • Courvoisier’sLaw 244 • SurgicalJaundice(ObstructiveJaundice) 244 • CarcinomaGallbladder 245

38. Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246• SurgicalAnatomy 246 • Physiology 247 • Pancreatitis 248 • Surgery 251 • PancreaticCysts 251 • PseudopancreaticCyst 251 • TumorsofthePancreas 252

39. Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254• SurgicalAnatomy 254 • BloodSupply 254 • Functions 254 • Splenomegaly 255 • Splenectomy 255 • SplenicInjury(RuptureSpleen) 255

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Section 10 – Umbilicus, Abdominal Wall, Peritoneum and Herniae

40. Umbilicus and Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256• Embryology 256 • AnomaliesofDevelopment 256 • DiseasesoftheUmbilicus 257 • AbdominalWall 258

41. The Peritoneum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260• SurgicalAnatomy 260 • PeritonealCavity 260 • Peritonitis 260 • SubphrenicAbscess 262 • PelvicAbscess 262 • SpecialTypesofPeritonitis 262

42. Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264• Definition 264 • InguinalHernia 264 • NyhusClassificationforGroinHernia 267 • DifferentialDiagnosisofGroinSwellings 267 • SpecialVarietiesofInguinalHernia 267 • RecurrentInguinalHernia 267 • StrangulatedInguinalHernia 268 • LaparoscopicInguinalHerniaRepair 268 • FemoralHernia 268 • FemoralSheath 269 • EpigastricHernia 270 • UmbilicalHernia 270 • AdultUmbilicalHernia 270 • IncisionalHernia 271 • SomeRareExternalHerniae 273

Section 11 – Breast Surgery

43. The Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274• SurgicalAnatomyoftheBreast 274 • BenignBreastDisease 275 • Aberrationsof Normal Development and Involution (ANDI) 276 • InfectiveDisorders 277 • MiscellaneousConditions 278 • PresentationofBreastDisease 279

44. Malignant Disease of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280• CarcinomaoftheFemaleBreast 280 • TreatmentofBreastCancer 282

Section 12 – Urology

45. Symptoms of Urinary Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283• Symptoms 283 • NonspecificSymptoms 283 • PhysicalExaminationoftheGenitourinary System 284 • InvestigationsoftheUrinaryTract 284

46. Kidney and Ureter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286• Embryology 286 • SurgicalAnatomy 286 • Relations 287 • CongenitalAnomaliesofKidneys andUreters 287 • HorseshoeKidney 288 • PolycysticKidney 288 • SolitaryRenalCyst 289 • Hydronephrosis 289 • RenalStone 290 • UretericStone 292 • RenalInfection 293 • AcutePyelonephritis 294 • Pyonephrosis 294 • PerinephricAbscess 295 • RenalCarbuncle 295 • ChronicPyelonephritis 295 • RenalNeoplasms 295 • Nephroblastoma(Wilms’Tumoror EmbryomaoftheKidney) 295 • Adenocarcinoma(Hypernephroma) 296 • TumorsofRenalPelvis andUreter 297 • SquamousCellCarcinomaofRenalPelvis 297

47. Urinary Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298• Embryology 298 • SurgicalAnatomy 298 • CommonCongenitalAnomaliesofUrinaryBladder 299 • Cystitis 300 • SchistosomiasisoftheBladder 302 • ThimbleBladder 303 • TumorsoftheBladder 303 • CarcinomaoftheBladder 303 • UrinaryIncontinence 304 • RetentionofUrine 305 • VesicalFistula 306 • UrinaryDiversion 306 • IlealLoopConduit 307 • NeurogenicBladder 307

48. Renal Failure and Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309• AcuteRenalFailure 309 • ChronicRenalFailure 310 • RenalTransplantation 311

49. Urethra and Penis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313• Urethra 313 • Phimosis 315 • Paraphimosis 315 • CarcinomaPenis 316 • Peyronie’sDisease 317

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50. Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318• SurgicalAnatomy 318 • Histology 318 • Relations 319 • BloodSupply 319 • Physiology 319 • Development 319 • BenignEnlargementofProstate(BenignProstaticHypertrophy) 319 • CarcinomaProstate 321

51. Testis and Scrotum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323• Embryology 323 • DescentofTestis 324 • Testes 324 • UndescendedTestis 325 • TesticularTorsion 326 • TesticularTumor 327 • Hydrocele 328 • Varicocele 329 • EpididymalCyst 330 • Spermatocele 330 • DegenerationCysts 330 • Epididymo-orchitis 330 • ElephantiasisofScrotum 331 • Idiopathic(Fournier’s)GangreneofScrotum 332

Section 13 – Trauma

52. Evaluation and General Management of Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333• Injury Control 333

53. Head Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336• Classification 336 • Pathology 336 • Management 337 • IntracranialHemorrhage 338 • FractureofSkullBone 338

54. Thoracic Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339• Types 339 • Management 339 • Investigations 340 • SpecificInjuries 340 • TraumaticHemothorax 341 • PulmonaryContusion 341 • TrachealandBronchialInjury 341 • CardiovascularInjury 341 • CardiacContusionandRupture 341 • DiaphragmaticInjury 342 • EsophagealInjury 342

55. Abdominal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343• Classification 343 • Management 343 • Laparotomy 344 • SpecificInjuries 344 • RetroperitonealHematoma 346 • DamageControlSurgeryinMajorTrauma 346 • AbdominalCompartmentSyndrome 347

56. Genitourinary Tract Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .348• KidneyInjury 348 • UretericInjury 349 • BladderInjury 349 • InjuriestotheUrethra 350

Section 14 – Orthopedics

57. Fractures and Dislocations—General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352• Definitions 352 • ClassificationofFractures 352 • HealingofaFracture 353 • TreatmentofFracture 354 • Reduction 354 • ComplicationsofFractures 356

58. Fractures and Dislocations of the Upper Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362• FractureClavicle 362 • DislocationofShoulder 362 • FractureThroughtheProximal Humerus 364 • FractureoftheShaftofHumerus 364 • SupracondylarFractureofHumerus 365 • DislocationoftheElbow 366 • FractureoftheRadiusandUlna 366 • FractureDislocations oftheForearm 366 • PulledElbow 367 • Colle’sFracture 368 • FractureofScaphoid 369

59. Fractures and Dislocations of the Lower Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370• DislocationoftheHip 370 • FractureoftheNeckoftheFemur 371 • FractureShaftofFemur 373 • CondylarFracturesofFemur 374 • FracturePatella 374 • TraumaticDislocationofPatella 375 • SoftTissueInjuriesoftheKnee 375 • MeniscalInjury 376 • FracturesofShaftsofTibiaandFibula 377 • FracturesofSingleLegBone 378 • AnkleFractures 378 • FractureCalcaneum 379 • RupturedTendo-Achilles 379

60. Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380• Definition 380 • Types 380 • AcutePyogenicOsteomyelitis 380 • ChronicOsteomyelitis 382

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61. Bone Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384• BenignTumors 384 • MalignantTumors 385 • SecondaryCarcinomaofBone 389 • Tumor-likeConditionsofBone 389

62. Tuberculosis of Bones and Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391• TuberculosisofSpine 391 • TuberculosisofHip 394 • TuberculosisofKnee 396

63. Perthes Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397• PerthesDisease 397

64. Congenital Dislocation of Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399• Definition 399 • Etiology 399 • PathologicalAnatomy 399 • ClinicalFeatures 399 • Investigations 400 • Treatment 400

65. Congenital Talipes Equinovarus and Other Deformities of the Foot . . . . . . . . . . . . . . . . . . . . . 402• DeformitiesofFoot 402 • TalipesEquinovarus 403 • CongenitalTalipesEquinovarus 403

66. Miscellaneous Affections of the Soft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406• Bursitis 406 • Tenosynovitis 406 • Dupuytren’sContracture 406 • MalletFinger 407 • TriggerFinger 407 • De-Quervain’sDisease 407 • Ganglion 408 • CompoundPalmarGanglion 408 • CarpalTunnelSyndrome 408 • TennisElbow 409 • Golfer’sElbow 409 • PlantarFasciitis 409 • MorrantBaker’sCyst 409 • RupturedBicepsTendon 410 • FrozenShoulder 410

67. Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411• Indications 411 • Types 411 • GeneralPrinciples—ClosedType 412 • ComplicationsofAmputation 412 • RecommendedIdealLengthoftheStump 412 • AnIdealAmputationStump 413

PART III: PRACTICALS ANd VIVA IN SURGERY

Section 15A – Clinical Surgery (Long Cases)

68. Writing a Surgical Long Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417• Introduction 417 • GeneralPlanofWritingaSurgicalLongCase 417

69. Examination of a Swelling or Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420• GeneralPlanofExaminationofaSwellingorTumor 420

70. Examination of an Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422• GeneralPlanofExaminationofanUlcer 422

71. Thyroid Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424• GeneralPlanofExaminationofThyroidSwelling 424 • PrimaryThyrotoxicosis 429 • ThyroidCarcinoma 432 • NontoxicMultinodularGoiter 434 • Hypothyroidism 436 • Retrosternal Goiter 436

72. Breast Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437• GeneralPlanofExaminationofaCaseofCarcinomaBreast 437 • EarlyCarcinomaofBreast 440 • LocallyAdvancedBreastCarcinoma 445 • BreastCarcinomawithDistantMetastasis 445 • BreastReconstruction 446

73. Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448• GeneralPlanofExaminationofanAbdominalCase 448 • GastricCarcinoma 453 • Gastric OutletObstruction(PyloricStenosis)duetoComplicationofChronicDuodenalUlcer 457 • ChronicDuodenalUlcer 459 • ChronicCholecystitis 463 • MucoceleofGallbladder 465 • Obstructive

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JaundiceduetoPeriampullaryCarcinoma 466 • ObstructiveJaundiceduetoStoneinCBD 468• ObstructiveJaundiceduetoCarcinomaofGallbladder 469 • ObstructiveJaundiceduetoPostcholecystectomy;StrictureofCBD 470 • HydatidCystofLiver 471 • PseudocystofPancreas 474 • OnExaminationofAbdomen 474 • CarcinomaofColon 475

74. Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479• GeneralPlanofWritingaCaseofHernia 479 • ReducibleIndirectInguinalHernia 480 • IncisionalHernia 482

75. Renal Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484• GeneralPlanofWritingaRenalCase 484 • RenalCellCarcinoma 485 • Hydronephrosis 486

76. Varicose Vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489• GeneralPlanofWritingaCaseofVaricoseVein 489 • VaricoseVein 491

77. Buerger’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494• General Plan of Examination of a Case of Peripheral Vascular Disease and Gangrene (Buerger’sDisease) 494 • Buerger’sDisease 496

78. Orthopedic Long Cases: Hip Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499• GeneralPlanofExaminationofHipJoint 499 • TuberculosisofHip 502 • PerthesDisease 506 • CariesSpine 507 • Osteomyelitis 510 • NonunitedFractureNeckofFemur 512

Section 15B – Clinical Surgery (Short Cases)

79. Skin and Subcutaneous Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514• Introduction 514 • SebaceousCyst 514 • DermoidCyst 515 • Hemangioma 515 • Lipoma 516 • Neurofibroma 517 • Keloid 518 • BasalCellCarcinoma 518 • SquamousCellCarcinoma 519 • MalignantMelanoma 520 • Marjolin’sUlcer 522

80. Neck Swellings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524• Ranula 524 • CysticHygroma 524 • BranchialCyst 525 • BranchialSinus 525 • ThyroglossalCyst 525 • TubercularCervicalLymphadenopathy 526

81. Salivary Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527• ParotidSwelling(MixedParotidTumor) 527 • CarcinomaofParotidGland 528 • Parotid Fistula 530 • ChronicSubmandibularSialoadenitisduetoSubmandibularDuctCalculus 530 • CarcinomaofSubmandibularSalivaryGland 531

82. Mouth and Oral Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532• CleftLip 532 • CleftPalate 532 • CarcinomaTongue 532 • CarcinomaLip 534

83. Hernia, Breast and Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535• CongenitalHernia 535 • EpigastricHernia 535 • UmbilicalHernia 536 • FemoralHernia 536 • LumbarHernia 536 • DesmoidTumor 536 • RaspberryTumor 537 • VitellointestinalFistulaorPersistentVitellointestinalDuct537 • UrachalFistula 537 • Breast 538

84. External Genitalia and Urethra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540• TesticularTumor 540 • UndescendedTestis 541 • Hydrocele 542 • EncystedHydroceleof theCord 543 • Varicocele 544 • FilariasisofScrotum 544 • Phimosis 545 • Hypospadias 546 • CarcinomaPenis 546

85. Orthopedics—Short Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549• CubitusValgus 549 • CubitusVarus 549 • WristDrop 550 • ClawHand 551 • Ganglion 552 • GenuVarum 552 • GenuValgum 553 • SemimembranosusBursitis 553 • RecurrentDislocation ofPatella 554 • CongenitalTalipesEquinovarus 555 • Exostosis 555 • Osteosarcoma 556

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Section 16 – Operative Surgery

86. The Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557• Introduction 557 • Thyroidectomy 557 • OperationsoftheThyroid 557 • StepsofOperation ofTotalThyroidectomy 558 • PostoperativeComplications 559 • ImportantPreoperativeManagement 560

87. The Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561• SimpleMastectomy 561 • RadicalMastectomy 561 • ModifiedRadicalMastectomy(Patey’sOperation) 562 • DrainageofBreastAbscess 562 • Fibroadenoma 564

88. The Abdomen—General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565• AbdominalIncisionsandClosure 565 • IndividualIncisions 565 • ClosureofAbdominal Wounds 567 • ExploratoryLaparotomy 567 • Colostomy 568 • LoopIleostomy 569

89. Stomach and Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570• SurgicalAnatomyofVagusNerves 570 • TypesofVagotomy 570 • Gastrojejunostomy 571 • OperationforPepticUlcerPerforation 572 • Gastrectomy 572 • Pyloromyotomy—Ramstedt’sOperation 573 • Heller’sEsophagocardiomyotomy 574

90. Hepatobiliary and Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575• Cholecystectomy 575 • LaparoscopicCholecystectomy 576 • Choledocholithotomy 578 • Choledochoduodenostomy 579 • Cystogastrostomy 579

91. The Spleen: Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581• Indications 581 • PreoperativeCare 581 • StepsofOperation 581

92. The Appendix: Appendicectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583• SurgicalAnatomy 583 • Indications 583 • StepsofOperation 583

93. Small Bowel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585• SmallBowelResectionandAnastomosis 585 • Meckel’sDiverticulectomy 586 • Stricturoplasty 587 • FeedingJejunostomy 587 • TheRouxLoop 588

94. Large Bowel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589• RightHemicolectomy 589 • LeftHemicolectomy 590 • SigmoidColectomy 591 • Colostomy 591• Abdominoperineal Resection (APR)ofRectum 591 • RectalProlapseOperations 593

95. Anal and Perianal Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 594• Hemorrhoidectomy 594 • AnalFissures 595 • AnalStretching 595 • OperationforFistula InAno(Fistulectomy) 595

96. Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596• OperationsforInguinalHernia 596 • InguinalHerniaRepairinInfantsandChildren—Herniotomy 596 • InguinalHerniaRepairOperationsinAdults(HerniorrhaphyandHernioplasty) 597 • StrangulatedInguinalHernia 598 • LaparoscopicHerniaRepair 598 • FemoralHerniaRepair 598 • OperationforEpigastricHernia 599 • OperationforInfantileUmbilicalHernia 599 • Operation forAdultUmbilicalHernia 599 • OperationforIncisionalHernia 599

97. Operations on Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602• Nephrectomy 602 • OpenSurgeryforRenalCalculi 603 • Anderson-HynesPyeloplasty 603 • OperationforUretericStones—Ureterolithotomy 604 • SuprapubicCystostomy 605 • Prostatectomy 605 • Circumcision 606 • MeatotomyandMeatoplasty 607 • AmputationofPenis 607 • Orchidopexy 609 • Orchidectomy 609 • OperationofHydrocele 610 • Operation ofVaricocele 611

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98. Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613• LumbarSympathectomy 613 • OperationsforVaricoseVein 614 • Trendelenburg’sOperationandStrippingofLongSaphenousVein 614 • LigationofCalfPerforators(CockettandDodd’sProcedure) 615 • SaphenopoplitealLigationandStripping 615 • MultiplePhlebectomies 616 • NewAlternativeTreatments 616

99. Some Minor Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617• EstablishinganIntravenousLine 617 • Venepuncture 617 • Venesection 617 • InsertionofNasogastricTube 618 • InsertionofIntercostalDrain 618 • LymphNodeBiopsy 619 • ExcisionofSebaceousCyst 619 • ExcisionofLipoma 620 • OperationforIngrowingToenail 620 • Catheterization 620 • UrethralDilatation 621

100. Orthopedic Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622• Patellectomy 622 • ExcisionofMedialSemilunarCartilage 622 • IntramedullaryNailing 623 • NerveRepair 624 • TendonRepair 624

Section 17 – Viva Voce in Surgery

101. Surgical Pathology (Specimens) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626• Introduction 626 • GastrointestinalSpecimens 626 • UrologySpecimens 633 • OrthopedicSpecimens 636

102. Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638• Introduction 638 • GastrointestinalSurgery 638 • Thyroid 643 • Breast 643 • Trauma 644 • Urology 646 • PreoperativePreparations 647

103. X-rays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649• Introduction 649 • PlainX-rayAbdomen 649 • RadiopaqueShadowsinPlainX-ray 651 • ChestX-ray 653 • ContrastFilms 654 • OralCholecystography 657 • EndoscopicRetrogradeCholangiopancreatography 658 • T-tubeCholangiography 658 • IntravenousUrogramorPyelogram 659 • Ultrasonography 660 • CTScanandMRI 660 • MRI Scan 660 • OrthopedicX-rays 661

104. Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 664• Introduction 664 • PartsofaTypicalSurgicalInstrument 664 • InstrumentsforPreparing andDraping 664 • InstrumentsforSkinIncision 665 • InstrumentsforHemostasis 666 • Retractors 667 • DissectingForceps 668 • TissuesHoldingForceps 669 • Scissors 670 • InstrumentsforTissueApproximationandWoundClosure 670 • PolyglactinSutures 671 • GastrointestinalClamps 673 • OcclusionClamps 673 • CrushingClamps 675 • InstrumentsusedinBiliaryTractSurgery 675 • InstrumentusedinRectalSurgery 676 • InstrumentsforGenitourinarySurgery 678 • OrdinaryCatheters 678 • Self-retainingCatheters 679 • BougieorUrethralDilator 680 • PyelolithotomyForceps(NephrolithotomyForceps) 680 • SuprapubicCystolithotomyForceps 681 • SpecialInstrumentsinGeneralSurgery 681 • OrthopedicInstruments 682 • Sterilization 685

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693