Schein's Common Sense Emergency Abdominal Surgery, 5th Edition

Rosin, Danny, Rogers, Paul N. , Cheetham, Mark, Schein, Moshe

• Publisher: tfm Publishing Ltd
• Year: 2020
• ISBN:
  9781910079881
• Topic: Medicine
• Subtopic: Surgery & Surgical Medicine

Since Mondor's times in the forties of the last century there was no other book in surgery to be written so easy and witty… Boris D. Savchuk, World Journal of SurgeryThis, the fifth edition of Schein's Common Sense Emergency Abdominal Surgery, builds on the reputation of the four previous editions. Already a worldwide benchmark, translated into half a dozen languages, this book guides surgeons logically through the minefields of assessment and management of acute surgical abdominal conditions. Tyro and experienced surgeons alike will benefit from the distilled wisdom contained in these pages. The direct, no-nonsense style gives clear guidance while at the same time providing amusing (or saddening) insights into our collective surgical psyche. Old chapters were revised or rewritten and new chapters have been added, including a completely new colorectal section with its new co-editor. Finally, in an attempt to 'rejuvenate' the book, Danny took over the helm while the aging Moshe was pushed down the line…Selected reviews and comments from readers of the previous edition: "What to say, perhaps the most appropriate medical book ever written.""This is written with short punchy chapters making it a very difficult book to put down.""By the end I was a total enthusiast… this is a text like no other I read… Unreservedly recommended to old and young alike." "A Must Have Book. I am about to end my chief year in general surgery residency — my copy of the first edition shows the wear of half a dozen total read throughs and probably hundreds of 'referencings'...""Simply perfect. The best choice in surgery for trainees! It makes the more difficult surgery areas very easy to understand. I recommend it to all surgeons.""One of the best books I have read in my life! Must read for all docs out there.""But the moral of the book is that if scientific rigorousness (protocols, guidelines, evidence-based) and common sense are at odds, follow common sense."

PART I

General considerations

Chapter 1

General philosophy

The Editors

Good judgment comes from experience, experience comes from bad judgment.

Rita Mae Brown

Wisdom comes alone through suffering.

Aeschylus, Agamemnon

Fools say that they learn by experience. I prefer to profit by others’ experience.

Otto von Bismarck

Surgeons are internists who operate…

At this moment — just as you pick up this book and begin to browse through its pages — there are many thousands of surgeons around the world facing a patient with an abdominal catastrophe. The platform on which such an encounter occurs differs from place to place — a modern emergency department in London, a noisy and crowded casualty room in the Bronx, or a doctor’s tent in the African bush. But the scene itself is amazingly uniform. It is always the same — you confronting a patient; he suffering, in pain, and anxious. And you too are anxious: anxious about the diagnosis, concerned about choosing the best management, troubled about your own abilities to do what is correct.

We are in the 21st century but this universal scenario is not new. It is as old as surgery itself. You are perhaps too young to know how little some things have changed — or how other things have changed, and not always for the better — over the years. Yes, your hospital may be in the forefront of modern medicine; it has a team of subspecialists on call to provide advice (it has an even larger administrative team of functionaries to monitor you…), its emergency room has standby, state-of-the-art spiral computed tomography and magnetic resonance imaging machines, but, practically, something has not changed: it is the patient and you (often with the entire ‘system’ against you) — you who are duty bound to provide a correct management plan and execute it. And it often feels lonely out there; even we, experienced old farts, can feel the loneliness.

The ‘best’ management of an abdominal emergency

It is useful to compare the emergency abdominal surgeon to an infantry officer (■ Figure 1.1). Away from the limelight and glory that surrounds cardiac or neurological surgeons, emergency abdominal surgery is closer to infantry engagements than it is to airborne action. You cannot win a war by remote control with cruise missiles or robots alone; you need infantry on the ground. Likewise, technological gimmicks have a limited place in emergency abdominal surgery, which is principally the domain of the surgeon’s brain and hands. To achieve the final ‘victory’ someone must agonize, sweat, bleed, and wet his hands — remember the bad smell from your hands after operating on a perforated colon? Some readers may struggle with this military metaphor but the truth of the matter is that emergency abdominal surgery shares a few simple rules with infantry action — developed in the trenches and during offensives — rules that are the key to survival and victory (■ Table 1.1). Such a code of battle echoes the ‘best management’ of abdominal emergencies.

Figure 1.1. “Think as an infantry soldier...”

Table 1.1. The surgeon as an infantry soldier.

Rule	Infantry action	Emergency abdominal surgery
Rule 1	Destroy your enemy before he destroys you	Outmaneuver death (save a life)
Rule 2	Spare your own men	Reduce morbidity (handle tissues gently)
Rule 3	Save ammunition	Use resources rationally (every stitch must count) and avoid unnecessary tests
Rule 4	Know your enemy	Estimate the severity of disease (think how organs and cells are doing)
Rule 5	Know your men	Understand the risk-benefit ratio of your therapy (don’t try to do too much in one operation, if the patient will not tolerate it)
Rule 6	Attack at ‘soft’ points	Tailor your management to the disease and the patient (mild disease, definitive surgery; severe disease, damage control)
Rule 7	Do not call for air force support in a hand-to-hand battle	Do not adopt useless gimmicks — use your mind and hands (and sutures)
Rule 8	Conduct the battle from the front line — not from the rear	Do not take and accept decisions over the phone (when you are in charge, you are in charge)
Rule 9	Take advice from the generals but the decision is yours	Procure and use consultation from ‘other specialties’ selectively (if the consultant gives a wrong answer, change the consultant)
Rule 10	Avoid friendly fire	Reduce iatrogenesis (don’t overdo it)
Rule 11	Consider using the drones	Avoid suicidal missions (e.g. when interventional radiology can help you in difficult anatomic locations)
Rule 12	Maintain high morale among your troops	Be proud in providing the ‘best’ management (but give the anesthetists and nurses some credit)
Rule 13	Say “follow me!”	Lead by example!

There are many ways to skin a cat and you know from your various surgical mentors that different clinical pathways may arrive at a similar outcome. However, one of the diverse pathways is the ‘best’ — thus, the ‘correct’ one! To be considered as such, the preferred pathway has to save life and decrease morbidity in the most efficient way.

The ‘best’ management in each section of this book is based on the following elements:

■ Old-established principles (don’t reinvent the wheel).

■ Modern-scientific understanding of inflammation and infection.

■ Evidence-based surgery (see below).

■ Personal experience.

Today many options exist to do almost anything. Any search on Google or PubMed will overwhelm you with papers that can justify almost any management pathway, with people practicing surgical acrobatics for the mere sake of doing so. Data and theory are everywhere: the sources are numerous but what you really need is wisdom — to enable you to apply correctly the knowledge you already have and constantly gather. And wisdom is what we are trying to provide. So please open your mind.

Factors affecting decision making (■ Figure 1.2)

“There is nothing new in the story…,” Winston Churchill said, “want of foresight, unwillingness to act when action would be simple and effective, lack of clear thinking, confusion of counsel until the emergency comes, until self-preservation strikes its jarring gong…” How true is this Churchillian wisdom when applied to emergency surgery. How often do we forget old — written in stone — principles while reinventing the wheel?

The inflamed patient

Think about your patient as being INFLAMED by myriad inflammatory mediators, generated by the primary disease process, whether inflammatory, infectious or traumatic — so if you measure C-reactive protein (CRP) in these patients, in most it will be elevated! Local inflammation (e.g. peritonitis) and the systemic response may lead to organ dysfunction or failure, and the eventual demise of your patient. The greater the inflammation — the sicker the patient and the higher the expected morbidity and mortality. Consider also that anything you do in attempting to halt your patient’s inflammation may in fact contribute to it — ad...