SCHWARTZ PRINCIPLES OF SURGERY NINTH EDITION

Schwartz 10th 2557

Resident
Board Review 2557 Schwartz 9th edition review
.
.
1

WHATS NEW IN SCHWARTZS NINTH EDITION

.. 1960 textbook of surgery ....... Rhoads ,
Moyer , Hardy chart 1-2 edition
.. 1967 4 Seymour I. Schwartz Richard C. Lillehei
, G. Thomas Shires David Hume Textbook of surgery 1sted .. 1969
Harrisons Textbook of Medicine
Seymour I. Schwartz ..... ....
Schwartzs Principles of Surgery ....
9
Schwartz 4
1. Schwartz 1 2 chief resident
. ...

2. Schwartz 3 4 3
... 4s Schwartz , Shires , Spencer Storer ... ...

.
resident . ..... .......
Sabiston Board 2 10-9
3. Rodney Maingot Maingots Abdominal Operation
Schwartz Maingot 9 10

Schwartzs Principles of Surgery 5 1989

5 King , Greenfield, Townsend , Goldberg
...

 6 7 Liverpool
Sabiston Greenfield
Seymour I. Schwartz ...
..... Charles Brunicardi .... . staff
Model change Schwartz 8 ...
4. Schwartz 8 9 .. 8

Seymour I. Schwartz Schwartzs Principles of Surgery .... ....
35 4 1 9
resident
Comment
Schwartz 9 8
... guideline , table keypoint
.... ... 1 2
highlight ...
....... 3 4 Mattox , Rutherford , Shackelford , Blumgart Cameron

Schwartz 9 8
Basic sciences Subspecialty

8 .....

...
twitter

BASIC CONSIDERATIONS
Basic sciences

ACCREDITATION COUNCIL FOR GRADUDATE MEDICAL EDUCATION CORE COMPETENCIES

resident general surgery training program

1. Patient care
2. Medical knowledge ....

OR see one , do one ,
and teach one resident surgical skills lab.
internet ...

3. Practice-based learning and improvement surgical morbidity mortality

conference
oral
4. interpersonal and communication skills
complication
5. Professionalism ( )
6. System-based practice health care
COMMENT
7 Schwartz 9th ......... training program ..... ....

.. 4
..... conference .... ....
.... .....
Board Review

SURGICAL INFECTIONS
Severe sepsis criteria SIRS new onset organ failure 1
noncoronary critical care units system PIRO
staging system P.117
Surgical site infection ( SSI ) surgical wound 4 class
infection rates
Class 1 clean wound repair hernia breast biopsy infection 1-5.4%
Class 2 clean-contaminated wound cholecystectomy elective GI surgery colon ...
infection 2.1-9.5%
Class 3 contaminated wound penetrating abdominal trauma , large tissue injury enterotomy case
bowel obstruction .... infection 3.4-13.2 %
Class 4 dirty wound perforated diverticulitis necrotizing soft tissue infection ....
infection 3.1-12.8%
class 2 elective colon surgery rectal space
class 2 infection rate 9.4-25% class 4
SSI , antibiotics
oxygen during colorectal surgery SSI
P.129 Guideline sepsis critical care 2008
Criteria primary peritonitis paracentesis
ascites
1. Low pH serum
2. Grams strain single organism culture 1 3
3. WBC 100 ml ( P.124 )
criteria 3 Schwartz neutrophil count sensitive
specific ...... WBC count

10

TRAUMA
Ernest E. Moore 60
Sabiston Greenfield
ATLS organ specific injuries Mattox
Current indications contraindications emergency department thoracotomy (EDT) P. 142-143
Schwartz 9th contraindications 2
1. Penetrating trauma CPR > 15 sign of life pupil response , respiratory
effort motor activity
2. Blunt trauma CPR 5 sign of life asystole
High energy transfer injury 40 km
20 ft ....
multiple injuries
Neck injuries zone 3 zone ( 8 zone )
.
Zone 1 thoracic outlet cricoid
Zone 2 cricoid angle of mandible
Zone 3 angle of mandible
Splenic injury P. 177-178
preserve spleen
young patient autotransplantation spleen
40403mm greater omentum OPSI
autologous splenic transplantation text
OPSI

11

Abdominal compartment syndrome grading system P.188

Table 7-12 bladder pressure mmHg cmH2O
Grade
mmHg
CmH2O
1
10-15
13-20
2
16-25
21-35
3
26-35
36-47
4
> 35
> 48

Minimally Invasive Surgery , Robotics , and Natural Orifice Transluminal Endoscopic Surgery
John G. Hunter
8thed ( 2005 )
2010 .... Hunter 2 Robotic Surgery
NOTES .... .... .... .....

Robotic Surgery
da Vinci robot robot Uro Gyne
1. Uro robotic prostatectomy .... robotic ....
pelvic nerve ...... preserve nerve ..... ........
..... nerve
2. Gyne robot reanastomosis Fallopian tube.
tube .....
Natural Orifice Transluminal Endoscopic Surgery (NOTES )
scar free surgery technology flexible endoscopy stomach , vagina
urinary bladder chest , mediastinum peritoneal cavity
.... ...
NOTES
1. Cholecystectomy
2. Appendectomy
3. staging intraabdominal malignancy
4. assisted gastrojejunostomy colectomy
.... endoscope.

12

Skin and Subcutaneous Tissue

plastic board .....
skin cancer
skin note Sabiston 2008
Schwartz 2010 3 HPV , Cyst Giant congenital nevi
Human Papillomavirus ( HPV )
wart ...... skin verruca
verruca vulgavis palm sole verruca plantaris ( callus )
HPV type 5 , 8 , 10 SCC
biopsy
Condyloma acuminata venereal wart
......
..... HIV
HPV type 6 type 11 size ....
malignant transformation
podophyllum , recurrence ........
adjuvant therapy interferon , isotretinoin , autologous tumor vaccine immune response
modifiers imiquimod
Cyst ......... sebaceous cyst content
sebum keratin epidermal , dermal cyst hair follicle
trichilemmal cyst scalp excision cyst wall ....
Giant hairy nevi congenital lesion
nevi melanoma 20%
serial excision with local tissue expansion
advancement 2-3
skin skin loss ....tissue
engineering burn

BREAST
prof. 4 Edward M. Copeland Kirby I. Bland
breast hormonal
treatment St. Gallen
13

 Schwartz 2010 resident 1 , 2 3 , 4 Current Surgical Therapy

2008 Cameron
note revise 2553
Benign disorders ANDI Concept .... ......

Zuskas disease periductal mastitis......

......
antibiotic drainage . .......
wide debridement
Fibroadenoma ......
observe follow up .. fibroadenoma US
core needle biopsy
..... ...... 2 cm
3 options
1. Observe
2. Surgical excision
3. Cryoablation ......
ANDI concept
1. 1 cm
2. 1 cm 3 cm disorder
3. 3 cm giant disease size
3 cm
4. 5 multiple fibroadenoma disease
.... note
Mammography
screening mammography 50 mortality 33%
50 screen
Schwartz 9th digital mammography
1. 50
2. Screening mammography breast dense
3. Premenopausal perimenopausal woman
14

 Tissue diagnosis
palpable nonpalpable lesion .... core-needle biopsy
FNAB . FNA sensitivity 32% specificity > 98%
core biopsy sensitivity 98% specificity 100%
core biopsy invasive noninvasive cancer ER PR
FNA
Breast cancer risk
risk factor .... Gail model
LCIS , DCIS mutation BRCA 1 BRCA 2
Screening recommendations for BRCA mutation

9thed Gail model

1. CBE 6
2. Mammography 1 25 30
3. MRI guideline 2007
dense breast ..... MRI strong family
history breast ovarian cancer Hodgkins disease 20
bilateral breast cancer lecture resident
.... .....
Surgical approach

Chemotherapy
1. Trastuzumab Herceptin ..... recombinant
humanized monoclonal Ab HER 2 ....
metastasis
Schwartz early case .... over expression HER 2
St. Gallen 2007
trastuzumab cardiotoxic doxorubicin..... chemo.
taxane
2. Bevacizumab antiangiogenesis colorectal cancer ....
breast cancer ..... trial .... taxane taxane
Chemoprevention
tamoxifen Gail relative risk 1.7 unfavorable reaction
tamoxifen selective estrogen receptor modulator roloxifene
15

 Biomarker
ER PR gene expression tumor tissue .....
recurrence score .... score ....... early chemotherapy

Head and Neck

Schwartz 9th .... .....

Resident ENT
Resident cancer
approach neck node
Sabiston 2008 , ACS 2007 Note 2009 ....
Schwartz 2010
Esophagus
Schwartz 8th ........ .......

.....

Jeffrey .... John G. Hunter MIS 9thed

Sabiston 2
Anatomy , Physiology Esophageal function test ....
818-823 .... High- resolution manometry pressure record ....
... 825 24-Hr gastric pH GERD
24-Hr ambulary pH monitoring
NG tube pH electrode EGJ 5 cm EGJ 5 cm 24 ..
acid reflux 4% 24
GERD acid reflux 10% 24
Acid reflux pH < 4
Bravo pH capsule esophageal wall pH receiver
capsule enteroscopy pH 48 hr. sensitivity 22 %
Bravo pH capsule .... 5-7

16

 High resolution manometry motility study 3 dimension assessment record pressure

UES LES
pressure motor dysmotility
sensitivity
pressure
pressure
GERD
typical reflux symptom heartburn
( regurgitation )
typical PPI life style modification
failure conservative treatment atypical reflux symptom
med ENT 24 hr pH upper endoscope
Schwartz 9th.... ... pH PPI
pH treat ....
heartburn treat ... dose investigate .... double dose PPI
Barretts esophagus
antireflux .... endoscopic surveillance
low grade dysplasia repeat biopsy ... 8thed 6-12 9th
.... 3 high dose PPI
severe dysplasia esophagectomy
Paraesophageal hernia
indication ... ..... elective
mortality emergency
Schwartz 9thed Allen observe follow up paraesophageal
hernia 28 7 4
asymptomatic observe ....
.... Schwartz ....
laparoscopic repair open ...
repair laparoscope

17

 crural repair .... recurrence 10-40% ....

Schwartz ... mesh recurrence ... nonabsorbable mesh
erosion infection ..... 10thed biomaterial prosthesis ...
Xerox 5
antireflux package ..
Motility disorder
3
1. Pharyngoesophageal segment Zenkers
diverticulum Schwartz 9th .... scope .... diverticuloscope endoscopic linear stapler
diverticulum aspiration
Endoscopic cricopharyngotomy ... ... Shackelford
2. Body & lower esophageal sphincter
2.1 8th most common primary motility disorder Nutcracker ...
Schwartz 9th .... most common ... ....
most common achalasia
2.2 management achalasia Shackelford ... 34
Therapeutic decision of achalasia ( P.857-858 )
1. laparoscopic Heller myotomy partial fundoplication....
antireflux ... Dor Toupet .... Schwartz 9th Dor ..
2. antireflux 10 GERD > 50%
3. open Heller lap. Heller lap.
4. chest ,

myotomy gastric site adequate
5. .... pneumatic dilation
..... dilate myotomy
laparoscopic Heller , long term result .... dilate
botox myotomy
Schwartz 9th Shackelford ... new case achalasia
laparoscopic Heller dilate botox

18

 Esophageal cancer
1. PET scan ... Schwartz 9th ..... PET scan
staging
2. ... .... salvage esophagectomy
disseminated disease ... ...
.... stent , photodynamic therapy laser tumor

General approach to esophagus cancer ( P.863 )

1. T1 in situ , T1a very early confined
mucosa endoscopic treatment EMR
2. T1-2 , N0 tumor confined esophagus esophagectomy
adjacent lymph node dissection en bloc esophagectomy
3. T1-3 , N1 locally advanced neoadjuvant induction chemoradiation

4. any T , any N , M1 disseminated stent
chemotherapy radiation therapy
Salvage esophagectomy ( P.866 )
metastasis bone , lung , brain lymph node inoperable

chemoradiation ... metastasis ....

primary esophagus
Schwartz 9th .... 12 complete initial chemoradiation...
... PET scan metastasis. esophagectomy
salvage esophagectomy long term survival
Schwartz 9th 4 salvage esophagectomy 1 5
Leiomyoma Esophageal perforation

Sabiston Note ......... Board Review 2009
Caustic injury Board


1. Endoscopic grading degree 1 , 2 , 3
2A , 2B , 3A 3B
19

2. nertralizing agent
antacid
.... .... resident

3. dilate adhesion stricture
4. early intraluminal esophageal stent ....
5. 2nd degree burn guideline Fig. 25-80 esophagus
stomach viable necrosis

Stomach
Daniel T. Dempsey Schwartz Daniel
Shackelford
Daniel Schwartz 8th
peptic ulcer
Schwartz 9th Daniel Shackelford

Anatomy group lymph nodes

Acid secretion gastric acid inhibit pathogen
long term PPI Clastridium difficile colitis long
term antibiotic
Gastric hormones gastrin, somatostatin gastrin
releasing peptide hormone appetite 2 leptin
hormone ghrelin
Diagnostic test high resolution helical CT
MRI virtual endoscopy digital ... CT colonoscopy
virtual endoscopy noninvasive study false negative screening test
upper endoscope resident Schwartz 10th
20

 Peptic ulcer H. pylori major role H. pylori guideline

American gastroenterology 2007 risk stratification UGI bleeding Blatchford score
Rockall score
bleeding peptic ulcer
definitive procedure BMI BMI 21 trancal vagotomy
gastrectomy stop bleeding DU
GU biopsy wedge Shackelford (
)
massive UGIB isolated gastric varice
Hypergastrinemia guideline P.926

Malignant neoplasms of the stomach P.926

adenocarcinoma 5
Genetic factors E-cadherin gene
hereditary diffuse gastric cancer mutation gene prophylactic total gastrectomy
Staging lymph nodes
nodes station TNM Schwartz 9th Schwartz 8 th
N0 negative node
N1 1-6 nodes
N2 7-15 nodes
N3 15 nodes
Diagnostic evaluation EUS , CT abdomen
pelvis IV oral contrast plain CT PET scan
laparoscopy routine NCCN 2006 laparoscope
proximal tumor spinal CT lymph node
Extent lymphadenectomy D1 gastrectomy
D2 gastric cancer Asia
( )
Daniel table 26 21 935
D2 gastrectomy morbidity mortality D1 survival
Schwartz 9th stage stage
21

survival D2 D1 stage 1 stage 2

USA stage 2 stage 3 USA

D1
D1 D2 Schwartz 10th 5
total gastrectomy jejunal pouch Roux-en-Y
Screening gastric cancer
USA low risk country screening gastric cancer
FAP , HNPCC Mntrier disease
screening
GIST , Lymphoma , Carcinoid
Miscellaneous Conditions
Mntriers disease Hypertrophic gastropathy
local overexpression transforming growth factor alpha

Cetuximab epidermal growth factorreceptor blocking monoclonal antibody

Postgastrectomy problems Dumping promote duodenal switch

procedure
Laparoscopic procedures
1.
2.
3.
4.

HSV
TV + GJ
Gastrostomy
Wedge resection G1ST , Lipoma , Diverticulum

Surgical Management of Obesity

2 field

metabolic consequence

American Society for Metabolic and Bariatric Surgery

22

 Classification of obesity BMI

1. normal weight
20-25
2. overweight
26-29
3. obese
30-34
4. severely obese
35-49
5. superobese
50
restrictive , malabsorptive combined restrictive
malabsorptive
jejunoileal bypass vertical banded
gastroplasty ( VBG )
sleeve gastrectomy restrictive
Indications for bariatric surgery
1. BMI 40 comorbid medical conditions

2. BMI 35-40 comorbid medical conditions

3. nonoperative treatment
4.
Laparoscope open ... Laparoscope
hand assisted laparoscopic procedure risk infection hernia port site
..... approach routine
conversion laparoscopic open surgery lap. , , adhesion
, , manipulate trocar
open
Laparoscopic Adjustable Gastric Banding ( LAGB )
technique .... .... .... OPD case ....

superobese BMI 50 5-8 BMI
40
band 4-6 ..... 2
..... band
band adjustment port

23

Gastric prolapse
most emergency complication LAGB stomach band
... internal hernia ....

reoperation lap ... band reduce
prolapsed
Laparoscopic Roux-en-Y Gastric Bypass ( LRYGB )
gastroscope H. pylori infection .....

Technique 3
1. Roux limb transverse colon antecolic early postop.
internal hernia obstruction
follow up colon late internal hernia
retrocolic
10th
2. gastrojejunostomy weight loss .....
cm
3. gastrojejunostomy small diameter circular stapling 21-25 mm incidence
anastomotic stenosis linear stapling .... bias linear

Test leakage Gastrojejunostomy

early sign leakage tachycardia routine .....
contrast
Sleeve Gastrectomy ( SG )
linear stapler pylorus 3 cm angle of His gastric volume
200 cc
60% 3 .... SG stand alone
procedure.... BPD
SG high risk gastric polyp

24

 Metabolic Surgery
med .
1. Type 2 DM 80% American Diabetes
Association guideline 2009 Type 2 DM BMI 35
Bariatric surgery
2. HT , GERD , obstructive sleep apnea , COPD ,
Plastic surgery after weight loss
..... .... ...
.... ...
abdominoplasty body lift cosmetic .... .....

Experimental procedures
1. Implantable gastric electrical stimulator stomach ....
delayed gastric emptying ..... 22%
2. Endoscopic procedures ....
gastric pouch .... gastrojejunostomy
3. Intragastric balloon placement work
Small Intestine
Schwartz 9th Harvard
Small bowel obstruction ( SBO )
3
1. CT scan sensitivity specificity plain abdomen
strangulation gas
2. lysis adhesion laparoscopic approach recover proximal
small bowel obstruction adhesion band
multiple adhesions lap. conversion rate 33%
3. Prevention
adhesion skill tissue F.B.
F.B.
trial lap. open adhesion
25

 confirm adhesion hyaluronan based agent seprafilm

barrier
Measure to reduce postoperative ileus ( P.993 )

1. fluid
( avoid excessive- fluid )
2. early enteral feeding postoperative ileus
3. morphine .... Schwartz 8th NSAIDS ketorolac 9th ed
alvimopan postoperative ileus ,

Intestinal fistulas
conservative 6 ... 8-12 2-3
resection segment fistula
simple suture fistula ....
biological sealants.... success
Diverticula diseases
Meckel ...
medial duodenal diverticulum
Medial duodenal diverticulum
diverticulum penetrate pancreas complication
..... .... endoscopic treatment
open
1. bleeding duodenotomy lateral bleed
2. perforation wide drainage complex surgery
Small bowel perforation duodenum retroperitoneum ERCP
plain film .... ( free air ) CT scan
.... sensitive management

26

Colon , Rectum , and Anus

8thed resident 3 4

Capsule endoscopy colon colonoscopy work
uncomplicated diverticulitis
Colorectal cancer
1. screening guidelines staging
2. stage 4 ( any T, any N, M1 ) resident ....
2.1 Stage 4 .... resect ... ...
....
2.2 Rectal cancer stage 2 ( T3-4 , N0 , M0 ) 8thed neoadjuvant
chemoradiation
Schwartz 9th neoadjuvant 2007 Barcelona
Laparoscopic colectomy for colon cancer 8thed debate port site recurrence
Schwartz 9th big trial outcome open laparoscope ....
surgeon ... ... cancer recurrence , survival , ....
laparoscopic colectomy
Bowens disease AIN
SCC in situ precursor invasive SCC HPV HIV
gross
histology malignant cell invade basement membrane
biopsy

Bowens disease wide local excision control
frozen section free margin
topical 5FU , laser , PDT RT

Schwartz 9th ablation wide local excision flap .... HPV

vaccine topical aldara

27

Appendix
Schwartz 8thed
Function immunologic function IgA Schwartz 9th
IBD UC UC clear ..... Crohn
risk colon cancer
Diagnosis
classic presentation 24
RLQ rigidity RLQ appendectomy


1. ( pregnancy ) confirm US appendicitis
US repeat
2. CT scan appendicitis
CT confirm US
US screen CT scan .... approach
laparoscopy
Alvarado scale signs , symptoms white count
10 Alvarado scale Annual Emergency Medicine 1988
Schwartz 8 9
Alvarado scale scale
observe follow up work
Natural Orifice Transluminal Endoscopic Surgery
(NOTES ) vagina 2008

Antibiotics as Definitive Therapy
diverticulitis cholecystitis antibiotics ...
.... .... ...

28

antibiotics .... ... subsided

.... 25
.... .... ... ...
Schwartz 9th appendectomy .... gold standard acute appendicitis
Appendicitis ill defined mass .... abscess phlegmon ...
... antibiotics ... interval appendectomy 6

Appendicitis in the young .... ...
Schwartz 9th appendicitis ....
GI upset .... ...
... RLQ ...
appendicitis laparoscopic appendectomy
Incidental appendectomy
package promotion
4 ... ....
1. chemotherapy
2. Crohns disease cecum macroscopic disease
3.
4. Ladds procedure malrotation cecum LUQ
appendicitis
tumors adenocarcinoma carcinoid
right hemicolectomy carcinoid ....1.5 cm size > 1cm
2 cm ... right half ... location base , mesoappendiceal invasion metastases
Mucocele
1. appendectomy
2. mucin .... lap. open
.... midline appendectomy right half colectomy wide resection
mesoappendix node collection mucus
right half colectomy
1. involve base
2. positive margin base
29

3. positive periappendiceal lymph node

Pseudomyxoma peritonei cytoreductive

surgery

intraperitoneal hyperthermic chemotherapy

Liver
Schwartz 9th MD. Anderson RFA
ablation Pittsburg
Schwartz 9th liver
1. ablation
2. Atlas Zollinger
3. approach incidental liver mass

1. resident 1 2 3, 4 ....... portal hypertension ,
benign liver disease ....
2. HCC IGR
3. molecular signaling pathways..... ...
4. Shackelford Blumgart
Anatomy , Physiology Investigation Schwartz 9th liver biopsy angiogram

PET ... trial PET CT PET sensitivity

specificity detect hepatic extrahepatic disease CT
25 % PET / CT recurrence CRC PET CT

Molecular signaling pathway

Basic ... .... resident
1. acute phase reaction
30

2. lipopolysaccharide signaling
3. nitric oxide portal hypertension
4. heme oxygenase system
5. toll like receptor ( TLR ) common pathway immune recognize
microbial invasion tissue injury
Acute liver failure ...

paracetamol
... ... ...
sepsis MOF
medical treatment hemodialysis ...
.. OLT
Portal hypertension
Surgical risk MELD score Child-Turcotte Pugh score

Imaging Doppler US , CT-A MR-A

Schwartz
Surgical shunt ... Warren Sarfeh Schwartz 8th Sugiura

Warren
1. MELD score 15
2. OLT
3. TIPS
Schwartz 9th TIPS , Warren OLT
Liver infection Blumgart Schwartz

1. PLA .... Antibiotics 8
2. ALA

2.1 5 cm
2.2 left lobe pericardium
2.3 superinfection bacteria
2.4 response medical treatment
3. Hydatid cyst Schwartz 8th PAIR

31

 Schwartz 9th approach Schwartz 6 7 ( pericystectomy )

albendazole initial treatment
4. Ascaris piperazine citrate first line albendazole mebendazole second
line ERCP
5. Schistosomiasis praziquantel 40-75 mg . 1 kg
Work-up of an incidental liver mass ... ..
... ... LFT, hepatitis , tumor marker CEA, AFP CA 19-9... imaging
3D CT MRI
Hepatic cyst PAIR PAIR US CT guided
percutaneous aspiration followed by sclerotherapy
Adult polycystic liver disease ( ADPCLD )

1. few dominant cyst PAIR ... recurrence 50% ....

open lap. fenestration
2. only definitive treatment Schwartz 9th OLT ... polycystic kidney disease
package
Hemangioma , hepatic adenoma Focal nodular
hyperplasia Schwartz 6 7 ....

HCC resection OLT
sorafenib
Technique hepatic resection Schwartz 9th Blumgart
Laparoscopic liver resection ... right lobe resection

Gallbladder and the Extrahepatic Biliary System

Schwartz 9th Margret
2009
1 Margret

Current Surgical Therapy Cameron

Blumgart Shackelford
32

Pancreas
Schwartz 8th 5%
Physiology 5th islet peptide hormone ghrelin islet cell
pancreas epilon cell hormone ... block insulin effect insulin release insulin
action
Acute pancreatitis
pathophysiology acinar cell .... ....
autoactivation trypsin cathepsis B pancreatic enzyme
cell death
severe acute pancreatitis .... severity ...
TLR4 toll-like receptor 4 inflammatory mediator cytokine severity
TLR 4 antagonist block receptor
...
infected pancreatic necrosis .... CT scan with contrast air
retroperitoneum .... FNA gram strain culture bacteria ... drain ....
percutaneous drain drain ...
Nutritional support
severe case .... NPO 2-3 .... enteral nutrition feeding
jejunostomy TPN TPN atrophy gut mucosa translocation
luminal bacteria
Petrov Journal of Pancreas 2008 ... .... feed NG tube
.... pancreatic exocrine secretion

severe acute pancreatitis enteral feeding

Chronic pancreatitis
1. Hereditary pancreatitis risk 40% 50 ... anionic
trypsinogen gene mutation .. hereditary pancreatitis
mutation gene ... proteolysis pancreas
2. Technique Beger Frey
3 procedure
2.1 Andersen and Topazian Frey local resection head
ultrasonic dissector aspirator bleeding fistula
2.2 Hamburg modification Frey local resection neck
2.3 Berne modification 2.2 head resection
33

 Neuroendocrine tumors
Exocrine tumor
incidence fistula Whipple PD
1. octreotide fistula
2. technique pancreaticojejunostomy
2.1 PD ( ) , pancreas ... mucosa to mucosa
2.2 PD , pancreas ... invagination
2.3 PD pancreatic duct glue ... ...
leak rate
periampullary carcinoma ....

Pancreatic cystic neoplasm ........

asymptomatic MCN IPMN 3 cm ...
1. asymptomatic MCN IPMN 1 cm observe repeat CT 1

1.1 1 cm CT
1.2 2cm CT 6
1.3 2 cm 2
2. asymptomatic MCN IPMN 1-3 cm investigation package
2.1 EUS FNA CEA CEA 200
2.2 MRCP ERCP IPMN

Spleen
carlos
Massive splenomegaly 1 kg 22 cm
2
750 gm
Nuclear imaging Tc 99m colloid location
1. unsuccessful splenectomy ITP
2. splenosis

34

.... Board

Hemato. Thalassemia Hodgkins disease

Thalassemia
1. thalassemia ... pulmonary hypertension
investigated ...

2. partial splenectomy ...

incidence OPSI
Hodgkins disease staging laparotomy
advanced imaging technology less extensive biopsy
laparoscopic route stage 1 2 nodular sclerosis
Inadvertent intraoperative splenectomy

Overwhelming postsplenectomy infection ( OPSI )

Schwartz 8th Schwartz 9th
antibiotic prophylaxis
... 5 5
vaccine work ... daily dose ... ...

Schwartz 9th ... antibiotic URI ... 5 ...
early signs ... ...

Abdominal Wall , Omentum , Mesentery , and Retroperitoneum

Schwartz
Surgical incision exposure midline , subcostal

Rectus sheath hematoma ... resident ... .. Schwartz 9th

1. confirm CT scan
2. Management
2.1 stable ... observe

35

2.2 bilateral ... admit FFP reverse coumadin

anticoagulant
2.3 expanding hematoma stable shock ... volume
resuscitation reverse anticoagulation ( )
2.3.1 stable ... observe
2.3.2 stable hematoma angiographic embolization
2.3.3 stable OR explore clot ...
bleeding
Mesenteric panniculitis sclerosing mesenteritis
CT scan PET ... tumor lymphoma ...
biopsy
Retroperitoneal fibrosis open ureterolysis ... laparoscopic ... work

Inguinal Hernias
... ..
... hernia chapter abdominal wall ...
Sabiston work
Epidemiology
1. USA 89% inguinal hernia repair OPD case
lap. 14% , open 86 %
2. lap. processus
vaginalis 12 % 5 ... hernia 4
3. lap. occult hernia 22 %
Classification
Nyhus Gilbert Schwartz 9th Schumpelick ...
classification ....
system ....

work classification

36

 Imaging
, recurrence

MRI most sensitive US CT US false

positive
Postherniorrhaphy pain syndrome
complication .... ...........
> 3
1. Somatic pain .... exercise
.... movement ... resident
NSAIDs , rest reassurance
2. Visceral pain refer pain visceral function ejaculation injury
sympathetic nerve plexus ... ....
conservative refer case
3. Neuropathic pain burning , sharp pain nerve nerve
entrapment
NSAIDS steroid
... groin neurectomy
Mesh complication azoospermia mesh vas deferens ...

Technique repair .... ... lap. bilateral hernia

incision recurrence hernia prostatectomy
Conservative management , defect
high risk .... incarceration 0.3%
Thyroid , Parathyroid , and Adrenal
... Orlo H.Clark
explore parathyroid 4 glands primary
hyperparathyroidism (PHPT) Schwart 9 th ... ...

37

 Thyroglossal duct cyst (TDC)

1 % TDC PTC 85 % .... PTC total thyroidectomy
PTC TDC total thyroidectomy Sistrunk

total thyroidectomy TDC
1. large tumor
2. thyroid nodule
3. cyst wall invasion
4. lymph node metastases
Thyroid imaging
metastasis screening... US CT ...
PET
preoperative staging PET scan
Thyroiditis
Hashimoto lymphoma Schwartz 9th lymphoma

Modular genetics of thyroid tumorigenesis

oncogene
1. BRAF mutation PTC 44 %, ATC 22 % FTC.... aggressive,

2. PPAR gamma-1 FTC
Papillary thyroid cancer (PTC)
2
1. minimal occult microcarcinoma PTC 1 cm , local invasion
angioinvasion prognosis lobectomy isthmus ...
occult PTC aggressive ... ...
total
2. routine bilateral lymph nodes dissection central group ....in trend...
... PTC microscopic metastases routine central
nodes dissection 2 survival recurrence
Schwartz... Clark bilateral central nodes dissection nodes
... routine .... ... hypoparathyroidism ....
....
38

 Follicular thyroid cancer ( FTC )

FNA-B thyroid nodule benign malignant
lobectomy permanent report FTC total thyroidectomy
Schwartz 9th FTC gene 3-6 ....
patho .....
molecular marker gene genetic defect total thyroidectomy
admit
Follow up serum Tg .... F.U. neck node FNAB
node Tg node Tg node positive ( ) .... metastatic nodes
Tg RAI US negative PET scan recurrence cancer
Medullary thyroid cancer ( MTC )
1. thyroid total thyroidectomy Schwartz 9th
tumor 1 cm MRND ... ... 1 cm
lymph node metastasis 60%
ipsilateral MRND node MRND ( contralateral )

2. MTC response adjuvant therapy RAI , RT chemotherapy

Glivec GIST MTC ....
Anti-CEA monoclonal antibody lobetuzumab ...
3. Follow up MTC .... PET scan
Minimally Invasive Approaches trocar axilla anterior chest wall
.... open technique

1. < 3.5 cm volume < 30 ml

2. Virgin neck
3. substernal extension
Primary hyperparathyroidism
1. NIH consensus 1990
NIH 2002
2. preoperative localization Schwartz 8th ... .... ... ....
parathyroid

39

 endocrine surgeon 80 % Clark

sestamibi scan sensitive 80% CT MRI .... MIBI neck US

intraoperative PTH
preoperative localization Clark ....
... MIBI ....... routine
....
Clark preoperative localization
1. reoperation
2. focus approach mini-explore MIS
Medication for hypercalcemia
parathyroid cancer serum calcium
calcimimetic cinacalcet HCl. calcium sensing receptor cell (
CASR )
Adrenal gland laparoscopic adrenalectomy

... note ... ...

... .... .... ... ... ....

... ...
Board ... ...

40