Schein's Common Sense Emergency Abdominal Surgery, Second Edition

458 Pages·2004·6.59 MB·English

by  Moshe Schein

Moshe Schein · Paul N.Rogers (Editors)
Schein’s Common Sense Emergency Abdominal Surgery
Moshe Schein • Paul N. Rogers (Editors)
Schein’s
Common Sense
Emergency
Abdominal Surgery
Second Edition
With 97 Figures and 21 Tables
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Dedication
MS dedicates this book to his late father Karl Schein (1911–1974),
a surgeon on the Eastern Front during World War II,and later
in Haifa,Israel.
Editors’Note
This book has been assembled – in pieces – during 20 years of intensive
personal involvement,clinical and academic,with emergency abdominal surgery
in South Africa,Israel,USA,UK and Australia.
A long line of good old friends from all around the world were helpful in
generating this book and its first edition.For the foundations in this noble surgical
field MS is indebted to George G.Decker of Johannesburg.Drs.Roger Saadia,
Asher Hirshberg and Adam Klipfel contributed to the first edition.Dr.Alfredo
Sepulveda ofSantiago,Chile,provided aphorisms and edited the Spanish transla-
tion.Professor Boris Savhcuk ofMoscow who edited the Russian translation passed
away recently.We will remember him with affection.
Special thanks to Frau Gabriele Schroeder and Frau Stephanie Benko of
Springer-Verlag,Heidelberg,for their immense support.Most ofthe aphorisms and
quotations used to decorate this book were retrieved from Aphorisms & Quotations
for the Surgeon,edited by MS and published by Nikki Bramhill’s tfm Publishing Ltd,
Harley,UK.
The reader will find that there are not a few duplications scattered along the
book.We did this on purpose,as repetition ofimportant points is crucial in adult
education.Any reader who has a question or a comment about anything mentio-
nedin this book is invited to e-mail us directly – [email protected] or
[email protected] will respond.
Finally,we are indebted to our loving wives,Heidiand Jackieand our children
Omri,Yariv,Dan,Lucyand Michaelfor their patience and sacrifice.
July 2004 Moshe Schein,New York
Paul N.Rogers,Glasgow
Preface to the Second Edition
“In literature,as in love,we are astonished at what is chosen by others.”
(Andre Maurois,1885–1967).
In the harsh environment of the competitive publishing market only a tiny
fraction ofmedical texts ever gets to see the light ofa second edition.Thus,we were
proud to hear from our publishers that the first editionofthis book has been sold
out.“Do you want us to simply re-printthe book”,they asked,“or do you think that
it deserves to be updated andre-written?”We opted for the latter.
Is there anything new in emergency abdominal surgery that merits the
revision ofa 4-year-old book? Yes.Our practice has been gradually changing for the
better and worse.Where we practice – in the “developed world”– the volume and
spectrum of emergency surgery are declining and becoming narrower.Where
any abdominal grumble is followed by a CT scan or any fart by a colonoscopy,
ruptured aortic aneurysm and acute malignant colonic obstruction are becoming
rarities.When most asymptomatic inguinal hernias undergo elective repair,one
does not see many strangulated or obstructed groin hernias.When the entire
population is being fed – or buys at the counter – anti-ulcer medications,operations
for bleeding or perforated ulcer are hardly ever performed.This,however,may
not be true in other parts ofthe world where you have the fortune (or misfortune)
to practice.
The way we practice emergency surgery has also been rapidly evolving.
With almost unlimited access to abdominal imaging,we can rapidly pinpoint the
diagnosis and avoid an unnecessary operation,or perform an indicated operation
instead ofengaging in a prolonged period ofuncertainty.We are gradually becom-
ing more selective and cautious – understanding that everything we do involves
wielding a double-edged sword,and that in emergency surgery usually doing less is
better but occasionally doing more may be life saving.Meanwhile fancy diagnostic
modalities are used chaotically by our non-surgical colleagues (and some of our
surgical ones) – producing red herringsor new “image diseases”,“incidentalomas”
and adding to the general confusion.
X Preface to the Second Edition
This brave new world of changes needed to be incorporated into this book.
We have to learn how to deal with the old s**t – which is perhaps becoming rarer –
even when its odor is masked by the perfume ofmodern practice.And this is what
we have attempted in this new edition – to recite the old basics but also show how
to apply them in the evolving modern world.
What is new in the Second Edition?We have a new co-editor.We added new
chapters (viz., historical perspectives, imaging, esophageal and diaphragmatic
emergencies,complications of endoscopy,pediatric emergencies,HIV patients,
before the flight,before landing,and postoperative bleeding) by new contributors.
All existing chapters have been revised or re-written by the old or new contributors
and/or the Editors.
We knew that a book like this – written in colloquial and “direct”style will
be either loved or hated.And indeed,a few reviewers – appalled by dogmas that clash
with their own – almost killed it .But many loved it;for example:
 From Germany:“Despite the “Wild West style”the book is far from being
anachronistic.Instead,it is throughout updated and modern.To the experi-
enced surgeons this book could provide joy with its wisdom and humor…
What makes this book really very readable for the surgeons are the “pregnant”
citations,aphorisms and “smart sayings”,which are often heard at the bed-
side and operating rooms but almost never reach the pages of a book”.
(P.Klein,Heidelberg,Chirurg,2000).
 From Scotland:“A surgeon of considerable experience may feel that they
have little to learn from such a book,but this is written with short punchy
chapters making it a very difficult book to put down…the wealth ofcommon
sense in the book still makes it a worthwhile read and stimulates one’s own
bias and views and challenges one’s own practice ofsurgery”.(R.A.B.Wood,
Journal Royal College ofSurgeons ofEdinburgh,2000)
 From Sweden:“Through its direct language,the book becomes not only an
entertaining lecture but also a valuable aid ofhandling patients with the acute
abdomen.”(Svante Nordgren,Östra Sjukhuset,2000).
 From Russia:“Since Henry Mondor’s times in the forties ofthe last century
there was no other book in clinical surgery to be written so easy and witty
about most important things in the emergency abdominal surgery”.(Boris D.
Savchuk,World Journal ofSurgery,2002).
And from the many letters we received:
 A terrifically refreshing book,full of wisdom as well as wit.(Mr.George
Youngson,Consultant Surgeon Aberdeen,Scotland)
 This is a very fantastic book and I have found a lot ofnew and useful advices
in it (Dr.Csaba Csonka,Head Surgeon,Ajka,Hungary)
Preface to the Second Edition XI
 Absolutely wonderful.I am going to make it compulsory reading for all ofmy
registrars.Otherwise – fantastic!! (Eddie Chaloner,UK)
 I can’t remember a surgical book which I was able to digest with so much
interest and without becoming tired even late at night. (Dr.med. Achim
Schröder,Germany)
 This is one of the most useful and interesting surgical books in my library.
You will read it in two hours with pleasure and interest and remember forever.
(Dr.Andrea Favara,Milan,Italy)
 A book like this is long overdue.(Mr.R.D.Quill.Dublin,Ireland)
 A gold mine for the trainee surgical doctor.(Mr.Saboor Kahn,Wales,UK)
By popular demand the First Edition of this book has been translated into
Spanish and Russian.
Motivated by the enthusiasm with which the book has been received across the
world – particularly among those practicing “real surgery”in the “real world”–
we set about enhancing it to produce a text that should be palatable to all of
you – wherever you try to save lives – be it in Bogota,Dundee,Teheran,Calcutta,
Naples,Dusseldorf,Krakov,Moscow or Boston.Ifyou are a surgeon who practices
the way he was trained 20 or 30 years ago you will hate this book;ifyou are being
trained by such a surgeon then you desperately need to read this book.
Anton Chekhov said:“Doctors are just the same as lawyers;the only difference
is that lawyers merely rob you,whereas doctors rob you and kill you,too.”Our chief
aim in writing this book was to help you not to kill your patients.We hope that this
modest book will be ofsome value to you.
New York/Glasgow,July 2004 The Editors (> see figure)
The Editors:Rogers is the one in the kilt…
Contents
I Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 General Philosophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Moshe Schein · Paul N.Rogers
2 A BriefHistory ofEmergency Abdominal Surgery . . . . . . . . . . . . . . . . . 9
Harold Ellis
II Before the Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3 The Acute Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Moshe Schein
4 Rational Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Moshe Schein
5 Abdominal Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Moshe Schein · Sai Sajja · Hans Ulrich Elben
6 Optimizing the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
James C.Rucinski
7 Pre-operative Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Moshe Schein
8 Family,Ethics,Informed Consent and Medicolegal Issues . . . . . . . . . . . 71
James C.Rucinski
9 Before the Flight:Pre-op Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Moshe Schein