“Any medical student or surgical trainee will benefit from reading the relevant chapter before an attachment to one of these surgical specialties.”
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!
- Useful Theatre knowledge
- Upper Gastrointestinal
- Lower Gastrointestinal
- Ear Nose and Throat
- Obstetrics and Gynaecology
- Interventional Radiology
Katrina Mason BSc (Hons) MBChB MRCS (ENT)
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.
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!
Jenny Robertson and Katrina Mason
Delivery of the foetus through an incision in the lower abdomen and uterus.
Caesarean sections can be performed for either maternal or foetal indications and may be planned elective or emergency procedures.
Category 4 section (performed at a time to suit the woman and maternity services):
Malpresentation (e.g., breech).
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).
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).
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.
Layers of the abdominal wall:
Rectus abdominus muscles – contained within the rectus sheath.
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.
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
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.
Figure 13.8 Exposure and incision of the uterus during a Caesarean Section
Injury to local structures – bladder, ureter, and gastrointestinal tract (<1%).
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%).
Catheter removed once mobile.
Home when pain is well controlled and vaginal bleeding is minimal.
Patients are commonly discharged 2 – 4 days postoperatively.
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.
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.