The Unofficial Guide to Surgery: Core Operations

The Unofficial Guide to

Surgery: Core Operations

Chief Editor: Katrina Mason

Associate Editors: Gareth Rogers, Madelaine Gimzewska

Series Editor: Zeshan Qureshi

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“Any medical student or surgical trainee will benefit from reading the relevant chapter before an attachment to one of these surgical specialties.”

Derek Alderson MD FRCS
President, Royal College of Surgeons of England

“This wonderful new book will be enormously useful to all undergraduates in Surgery. It has been produced in collaboration with students which has ensured that their need to demystify surgical procedures has been at the heart of the development.”

Philippa Tostevin

Miss Philippa Tostevin
Reader in Surgical Education and Head of the Centre of Clinical Education
St. George’s University of London

“Each operation report includes the definition of the procedure being performed, its indications, high-quality illustrations of relevant anatomy, a step-by-step guide to the procedure at a level appropriate for students and junior doctors, and interesting trivia on the operation or associated condition.”

Stella Harris

Stella Harris
Final Year Medical Student
University of Sydney

“Whether you’re a surgeon-to-be at the cutting edge of your cohort and hoping to wow your senior colleagues, or a budding psychiatrist unexcited about standing in theatre for hours on end, this textbook has something for you.”

Imogen Thomson
Final Year Medical Student
University of Sydney

“The book provides a great overview of common surgeries across a range of specialties. Plenty of diagrams, simple, straightforward language and a clear layout make the book very approachable, while still providing detail. It’s the perfect book to read before attending a surgery for the first time, as a quick reminder before assisting, and when managing surgical patients.”

Alexander Jackson BMedSci (Hons) MBChB
Anaesthetics Registrar
University Hospital Southampton

“The Unofficial Guide to Surgery targets the millennial medical student. It aims to find the narrow space between too much and too little information. It succeeds greatly. I would be delighted to see a student come to theatre with this books.”

Dermot Burke FRCS
Associate Professor in Surgery
Leeds Teaching Hospitals

“This text is an eye-opener to my generation. Young students and trainees have got together and produced an excellent core guide to surgery with key operations in each discipline described and illustrated. I predict a very wide audience not just amongst doctors but also nursing professionals and operative department assistants and I think soon a few copies will be found in every theatre in the land, Excellent! Buy it and keep it close is my advice.”

Professor Simon Kay OBE FRCS
Consultant Plastic Surgeon and Lead for Hand Transplantation UK

“This is the ideal book for both final year medical students and junior doctors who find themselves in the unknown (and often frightening) environment of surgical operating theatres. Understanding the underlying principles behind all the techniques and procedures which they will come across, will hopefully help their overall understanding and even encourage them to follow a career in surgery – surely one of the most rewarding of all!”

Simon Patterson-Brown
Consultant General and Upper GI Surgeon, Edinburgh Royal Infirmar
Honorary Senior Lecturer, University of Edinburgh.

The Unofficial Guide to Surgery is the 12th book in the Unofficial Guide to Medicine Series, selling over 60,000 books. It is a concise summary of 120 of the most common and important operations across all surgical specialities, detailing how the operation is performed, indications, contraindications, complications, the pre/post-op care and follow up.

10 step operation guide across all common specialities

Illustrated core anatomy

Indications and contraindications

Answers to surgeon’s favourite questions

The field of surgery has enchanted students for as long as it has existed, and today’s medical students are no exception. Despite surgery being vital to our healthcare system, very few students are exposed to surgical teaching at a level of detail approaching that of their instruction in medicine or critical care. This textbook seeks to excise the mystery around the operating theatre and to equip students with a thorough understanding of the principles of common operations.

The Unofficial Guide to Surgery: Core Operations is a practical guide to common surgical operations, and it would be a useful resource for any medical or nursing student undertaking a rotation in surgery. Whether you’re a surgeon-to-be at the cutting edge of your cohort and hoping to wow your senior colleagues, or a budding psychiatrist unexcited about standing in theatre for hours on end, this textbook has something for you. It is detailed enough to serve as a study resource for the Christina Yangs of tomorrow, but organised and concise so that even the least surgically inclined student can feel more prepared for their obligatory stint in theatre after reading through an operation report while changing into their scrubs.

The textbook features an introduction to the principles of surgery, followed by detailed operation reports for an extensive array of common procedures, organised in chapters based on speciality. Helpfully, each operation report includes the definition of the procedure being performed, its indications, high-quality illustrations of relevant anatomy, a step-by-step guide to the procedure at a level appropriate for students and junior doctors, and interesting trivia on the operation or associated condition. Students will be prepared for a niche question from even the most esoteric consultant!

Core Topics

Useful Theatre knowledge
Upper Gastrointestinal
Lower Gastrointestinal
Breast
Ear Nose and Throat
Endocrine

Vascular
Urology
Cardiothoracic
Neurosurgery
Orthopaedics

Paediatrics
Obstetrics and Gynaecology
Interventional Radiology
Ophthalmology
Plastics

Katrina Mason

BSc (Hons) MBChB MRCS (ENT)

Chief Editor

A student enters theatre, and it is easy to forget that they may be seeing a surgical procedure for the first time. This entails seeing living, functioning organs working within a body before your very eyes, and it can be an overwhelming and humbling experience. You will not be the only one who has passed out in theatre. You will not be the only one who suddenly freezes when asked a difficult question. … What we have tried to do in this book is give safe and clear guidance on how to perform common surgical procedures. Remember, variations are based not only on the unit you might work in, but also your own personal preferences. The most important thing is to understand the principles behind the procedures and to be comfortable to perform them safely. There is also no substitute for clinical experience, so scrub in as often as you can, and let the words of this book come to life in the operating room.

Good luck with any upcoming exams. I look forward to calling you my colleague one day, should surgery be your passion.

Sample Chapter

Caesarean Section

Jenny Robertson and Katrina Mason

Definition

Delivery of the foetus through an incision in the lower abdomen and uterus.

Step-By-Step Operation

Anaesthesia: regional or general.
Position: supine with left tilt to reduce aorto-caval compression.
Considerations: Prior to surgery, a urinary catheter is inserted to drain the bladder.

A 10–15-cm-long transverse ‘Pfannenstiel’ or ‘Joel- Cohen’ incision is made 2–3 cm above the pubic symphysis, and subcutaneous fat is dissected using sharp or blunt dissection with bipolar diathermy for haemostasis.
The rectus sheath is incised bilaterally for the full length of the incision. The sheath is then separated from the underlying rectus muscles by sharp and blunt dissection.
The rectus muscles are then separated in the midline, exposing the peritoneum.
Once intra-abdominal, the loose peritoneum over the lower segment is opened and the bladder is pushed down and protected with a Doyen’s retractor.
Using a scalpel, a small transverse incision is made along the lower uterine segment of the uterus until the uterine cavity is entered or membranes are seen.
The baby should be delivered with minimal delay by applying firm fundal pressure (only if cephalic lie). Once delivered, the cord is clamped in two places and divided. The baby can then be passed to the midwife or paediatric team.

Syntocinon is then administered to enhance uterine contractions and expulsion of the placenta (unless
contraindicated) while gentle traction is applied to the cord.
Once the placenta is delivered, the uterus should be explored and cleaned to ensure that there is no retained placental tissue. The fallopian tubes and ovaries are inspected for any undiagnosed pathology, and the bladder is carefully inspected for any damage. The para-colic gutters are cleared of clots.
Clamps are placed at the angles of the uterine incision, then the uterus is closed in two layers of running and/or interlocking dissolving sutures, ensuring haemostasis.
The rectus sheath is closed with a running suture, then the skin is closed with subcutaneous non-absorbable sutures or staples.

Anterior aspect of the internal female organs.

Figure 13.8 Exposure and incision of the uterus during a Caesarean Section

Illustrated Core Anatomy

Gross Anatomy

Layers of the abdominal wall:

Skin.

Subcutaneous tissue.

Rectus abdominus muscles – contained within the rectus sheath.

Parietal peritoneum.

The uterus is usually located within the pelvis immediately posterior to the bladder and anterior to the rectum.

The full-term gravid uterus extends up to the xiphisternum and is the most anterior organ in the abdomen.

Layers of the uterine wall:

Peritoneum – outermost.

Myometrium –
consists of three layers of smooth muscle.

Endometrium – the inner lining of the uterus into which the placenta implants.

The cervix, which communicates with the upper vagina, is composed of dense collagenous tissue that retains the foetus in utero.

Neurovasculature

Parasympathetic fibres of the uterus are derived from the pelvic splanchnic nerves (S2, 3, 4). Sympathetic fibres arise from the uterovaginal plexus, a division of the inferior hypogastric plexus. Afferent sensory fibres ascend through the inferior hypogastric plexus and enter the spinal cord at T10, 11, 12, and L1. Epidural analgesia therefore provides sensory block to these fibres.

The main blood supply to the uterus is via the uterine arteries, which travel medially in the base of the broad ligament before ascending along the lateral aspect of the uterus and anastomosing with the ovarian arteries.

Figure 13.7 The full term gravid uterus

Indications and Contraindications

Indications

Caesarean sections can be performed for either maternal or foetal indications and may be planned elective or emergency procedures.

Elective

Category 4 section (performed at a time to suit the woman and maternity services):

Malpresentation (e.g., breech).

Multiple pregnancy.

Abnormality of placenta (placenta previa, vasa previa, placenta accreta).

Previous caesarean section.

Maternal infection (HSV, HIV).

Foetal bleeding tendency (haemophilia).

Macrosomia (large baby unlikely to be safely delivered vaginally).

Mechanical obstruction to vaginal birth (e.g., large fibroid).

Maternal choice.

Emergency

Category 3 section – needing early delivery but no maternal or foetal compromise (e.g., failure to progress during labour).

Category 2 section – maternal or foetal compromise that is not immediately life-threatening.

Category 1 section (aim for delivery within 30 minutes) — immediate threat to life of woman or foetus (e.g., umbilical cord prolapse, eclampsia, foetal bradycardia).

ContraIndications

Gestation under 39 weeks—a relative contraindication (as the foetal lungs may not be mature), but caesarean sections are commonly performed earlier than this in emergencies.

Complications

Early

Haemorrhage.

Uterine atony.

Injury to local structures – bladder, ureter, and gastrointestinal tract (<1%).

Ileus.

Venous thromboembolism (1%).

Foetal injury—cut to skin.

Intermediate and Late

Infection—endometritis, septic pelvic thrombophlebitis, and wound infection (2–20% – increased if chorioamnionitis at time of section).

Abnormal placentation in future pregnancies—placenta previa and placenta accrete.

Scar complications—ectopic pregnancy, incisional endometriosis, numbness, pain, and uterine rupture in subsequent pregnancy (<1%).

Abdominal adhesions.

Postoperative Care

Inpatient

Catheter removed once mobile.

Home when pain is well controlled and vaginal bleeding is minimal.

Patients are commonly discharged 2 – 4 days postoperatively.

Outpatient

The community midwife should assess the wound at 1 week – the non-absorbable suture can be removed at this visit.

Breastfeeding should be established and checked on by the community midwife.

Women should be reviewed at 6 weeks by their primary care physician.

Abdominal adhesions.

Surgeon’s Favourite Question

Why is the uterine incision made transversely wherever possible?

A transverse incision in the lower segment of the uterus heals better than a vertical incision, ruptures less frequently, and is less dangerous to make, as the placenta is less likely to be damaged because it is normally positioned antero-superiorly.