Take Charge!

General Surgery and Urology A practical guide

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 Take Charge!
GENER AL SURGERY
AND UROLOGY
A practical guide to patient management

Edited by
Alexander Trevatt MBChB BSc MRCS
Specialist Registrar
Royal Free London NHS Foundation Trust
London, UK

Richard Boulton BMBS BMedSci MEd FRCS

Consultant General and Colorectal Surgeon
Queens Hospital, Barking, Havering and
Redbridge University Hospitals NHS Trust
Romford, UK

Daren Francis MD FRCS

Consultant General and Colorectal Surgeon
Barnet Hospital, Royal Free London NHS Foundation Trust
London, UK

Series Editor
Nishanthan Mahesan BSc(Hons)
MBBS MRCP(UK) MRCGP
Core Medical Trainee, North East
Thames Foundation School, UK
CRC Press
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Contents

Preface.......................................................................................ix

Abbreviations............................................................................xi

Contributors............................................................................xiii

PART I Abdominal Examination

1: Abdominal examination and surgical scars...................... 3
Jason Hol-Ming Wong

2: Stomas................................................................................. 9
Ian Robertson

PART II Gastrointestinal (GI) Tract

3: Lower gastrointestinal bleeding......................................17
Elizabeth Yang

4: Bowel obstruction............................................................ 27
Bibek Das

5: Acute diverticulitis............................................................ 35
Christopher F. Brewer, Alexander Trevatt and
Richard Boulton

6: Management of colorectal cancer...................................41

Oliver J. Smith

7: Perianal disease................................................................ 49
Prashant Singh

8: Upper gastrointestinal emergencies................................61

Suroosh Madanipour

9: Acute appendicitis............................................................ 73
Amelia Davidson

10: Hernias.............................................................................. 79
Jason Hol-Ming Wong
 11: Bowel perforation............................................................ 85
vi
Tom Pampiglione
Contents

12: Acute mesenteric ischaemia............................................ 95

Urpinder S. Grewal

PART III Abdominal Viscera

13: Gallstone disease............................................................ 103
Amelia Davidson

14: Acute pancreatitis............................................................113

Robert Adams and Christopher Limb

15: Hepatobiliary and pancreatic emergencies...................125

Thomas Clifford

16: Endocrine surgery............................................................133

Ross M. Warner and Richard Boulton

17: Vascular emergencies......................................................147

Stevan Jordan

PART IV Post-Operative Complications

18: Wound infections and dehiscence................................ 163
Deniz Hassan

19: Management of an anastomotic leak............................171

Ross M. Warner

PART V Trauma
20: Trauma principles............................................................179
Stevan Jordan

21: Burns................................................................................ 187

Stevan Jordan

22: Head injuries....................................................................197

Humza T. Osmani
PART VI Skin vii
23: Necrotising fasciitis and Fournier’s gangrene...............213

Contents
Alexander Martin

24: Breast lump assessment..................................................219

Jason Hol-Ming Wong

PART VII Urological Disorders

25: Testicular lumps.............................................................. 227
Davoud Khodatars and Sarah Y. W. Tang

26: Genitourinary malignancies........................................... 235

Davoud Khodatars and Sarah Y. W. Tang

27: Urinary calculus disease................................................. 243

Christopher Bastianpillai

28: Catheter management................................................... 249

Tom Bracewell, Thomas Maggs,
David Manson-Bahr, and Sarah Y. W. Tang

29: Benign prostatic hyperplasia..........................................261

Sarah Y. W. Tang

30: Haematuria..................................................................... 267

Christopher Bastianpillai

31: Urinary retention............................................................ 275

Christopher Bastianpillai

32: Testicular torsion............................................................ 281

Amelia Davidson

33: Obstructive uropathy..................................................... 287

Rohit Srinivasan

Index...................................................................................... 295
Preface
Starting as a Foundation Year 2 Doctor or a core surgical trainee
(formerly senior house officer) in general surgery or urology can be a
daunting task. Many doctors gain no surgical experience in their first
year and surgical exposure at medical school is minimal. Holding the
on-call bleep and taking referrals for the first time is stressful, and you
will often be asked questions by other specialties that you do not know
the answer to. In the vast majority of cases you will also be the first
doctor from general surgery or urology to see a patient, and you will
be expected by your seniors to produce and act upon a sensible initial
management plan.
We have all been there.
Surgical training is as rewarding as it is stressful. You often get
more autonomy than other disciplines, but don’t always have someone
more experienced to immediately turn to for advice. We have written
this book, based on our own experiences, to help relieve some of the
difficulties you will face on-call.
The common complaints from both general surgery and urology
have been included along with their initial management. Whenever
you are concerned about a patient you should escalate early to a senior.
This book is not a comprehensive overview of the management of each
surgical condition, but is instead designed to be a guide to the steps
you should take when you first see the patient, in conjunction with
escalating to your seniors. Our overall goal is to make you a safer doctor
and to give you confidence as you start your surgical career.
Good luck and enjoy!
Abbreviations
AAA abdominal aortic aneurysm
ABC(DE) airway, breathing, circulation, (disability, exposure)
ABG arterial blood gas
ACS acute coronary syndrome
AIN anal intraepithelial neoplasia
AKI acute kidney injury
ALS advanced life support
ARDS acute respiratory distress syndrome
AXR abdominal X-ray
BD bis die sumendum (twice daily)
BP blood pressure
CCrISP care of the critically ill surgical patient
CDT Clostridium difficile toxin
CEA carcinoembryonic antigen
CK creatinine kinase
CKD chronic kidney disease
CN cranial nerve
CO carbon monoxide
CRP C-reactive protein
CSF cerebrospinal fluid
CT CAP computerised tomography of chest, abdomen and pelvis
CT computerised tomography
CXR chest X-ray
DIC disseminated intravascular coagulopathy
DRE digital rectal examination
ECG electrocardiogram
EUA examination under anaesthesia
FAP familial adenomatous polyposis syndrome
FBC full blood count
GCS Glasgow coma scale
GI gastrointestinal
GIFTASUP British Consensus Guidelines on Intravenous Fluid
Therapy for Adult Surgical Patients
GP general practitioner
GTN glyceryl trinitrate
HIV human immunodeficiency virus
HNPCC hereditary non-polyposis colorectal carcinoma (now
replaced by Lynch syndrome)
HR heart rate
I&D incision and drainage
 IBD inflammatory bowel disease
xii
IV intravenous
LFT liver function tests
Abbreviations

LIF left iliac fossa

LMN lower motor neurone
MC&S microscopy, culture and sensitivity
MCV mean corpuscular volume
MDT multidisciplinary team
Mg magnesium
MRSA methicillin-resistant Staphylococcus aureus
NaCl sodium chloride
NAI non-accidental injury
NOAC novel oral anticoagulants
O&G obstetrics and gynaecology
O/P outpatient
OCP ova, cyst and parasite
OGD oesophagogastroscopy
PCA patient-controlled analgesia
P-POSSUM Physiological and Operative Severity Score for
score   the enUmeration of Mortality and Morbidity
PR per rectal
QDS quarter die sumendum (4 times a day)
RTC road traffic collision
TB tuberculosis
TBSA total body surface area
TDS ter die sumendum (3 times a day)
TNM tumour, nodes, metastases
TPN total parental nutrition
U&E urea and electrolytes
UC ulcerative colitis
UGI upper gastrointestinal
UMN upper motor neurone
UTI urinary tract infection
VBG venous blood gas
WCC white cell count
Contributors
Robert Adams Bibek Das
Specialist Registrar Specialist Registrar
Royal Free London NHS Imperial College London
Foundation Trust London, United Kingdom
London, United Kingdom
Amelia Davidson
Christopher Bastianpillai Specialist Registrar
Specialist Registrar Royal Berkshire Hospital
University Hospitals Reading, United Kingdom
Birmingham NHS
Foundation Trust Urpinder S. Grewal
Birmingham, United Kingdom Specialist Registrar
Medway NHS Trust
Richard Boulton Kent, United Kingdom
Specialist Registrar
Royal Free London NHS Deniz Hassan
Foundation Trust Specialist Registrar
Romford, United Kingdom Whiston Hospital
Merseyside, United Kingdom
Tom Bracewell
Specialist Registrar Stevan Jordan
Royal Free London NHS Specialist Registrar
Foundation Trust Royal Free London NHS
London, United Kingdom Foundation Trust
London, United Kingdom
Christopher F. Brewer
Specialist Registrar Davoud Khodatars
Royal Free London NHS Specialist Registrar
Foundation Trust Imperial College NHS Trust
London, United Kingdom London, United Kingdom

Thomas Clifford Christopher Limb

Specialist Registrar Specialist Registrar
Royal Free London NHS Royal Free London NHS
Foundation Trust Foundation Trust
London, United Kingdom London, United Kingdom
 Suroosh Madanipour Oliver J. Smith
xiv
Specialist Registrar NIHR Academic Clinical Fellow
Royal London Hospital Royal Free Hospital
Contributors

London, United Kingdom London, United Kingdom

Thomas Maggs Rohit Srinivasan

Specialist Registrar Specialist Registrar
Royal Free London NHS Royal Free London NHS
Foundation Trust Foundation Trust
London, United Kingdom London, United Kingdom

David Manson-Bahr Sarah Y. W. Tang

Specialist Registrar Specialist Registrar
Royal Free London NHS Royal Free London NHS
Foundation Trust Foundation Trust
London, United Kingdom London, United Kingdom

Alexander Martin Alexander Trevatt

Specialist Registrar Specialist Registrar
Royal Free London NHS Royal Free London NHS
Foundation Trust Foundation Trust
London, United Kingdom London, United Kingdom

Humza T. Osmani Ross M. Warner

Specialist Registrar Specialist Registrar
Royal Free London NHS Northampton General Hospital
Foundation Trust Northampton, United Kingdom
London, United Kingdom
Jason Hol-Ming Wong
Tom Pampiglione Specialist Registrar
Specialist Registrar Royal Free London NHS
Royal Free London NHS Foundation Trust
Foundation Trust London, United Kingdom
London, United Kingdom
Elizabeth Yang
Ian Robertson Specialist Registrar
Specialist Registrar Royal Free Hospital
Frimley Park Hospital London, United Kingdom
London, United Kingdom

Prashant Singh
Specialist Registrar
Royal Free London NHS
Foundation Trust
London, United Kingdom
 Part I
Abdominal Examination
 Chapter 1
Abdominal examination
and surgical scars

Jason Hol-Ming Wong

A comprehensive abdominal examination is an essential part of

diagnosing and managing surgical patients. This chapter will guide you
through a complete ‘exam style’ abdominal examination.

The key points to consider when examining the surgical abdomen are:

• To correlate the clinical findings with the history to make a diagnosis

• To assess whether the patient has an ‘acute abdomen’
• To assess the need for surgery and how urgently this is required

Examination
Always: Introduce yourself, explain the procedure, check for pain and
ask for permission to examine the patient. Wash your hands and don a
pair of gloves if appropriate.

Tip: Keep a stethoscope as your registrar is unlikely to be wearing

one and keep a supply of lubricant in your pocket; your time is too
valuable to search A&E (accident and emergency) when it is needed.

• Exposure
⚬⚬ Ask the patient to lie supine
⚬⚬ Expose the patient adequately in order to examine them
appropriately, whilst maintaining dignity
Offer a chaperone where appropriate.

Tip: Document the name of the chaperone present or if one has

been declined. For male colleagues it may be appropriate to insist on
a chaperone for your own medical legal protection.
 • General inspection
4
⚬⚬ Look around the bed for clues (i.e. infusions, catheters, drains, etc.)
⚬⚬ Assess the patient’s general condition
Abdominal examination and surgical scars

◼◼ Glasgow coma scale (GCS) including breakdown if reduced (eyes,

voice, motor) – see Chapter 22

◼◼ Breathlessness or obvious discomfort

◼◼ Jaundice or pallor

⚬⚬ Abdominal distension
⚬⚬ Any scars/masses/stoma/skin changes
⚬⚬ Visible hernias: Ask the patient to cough/lift head off the bed

• Inspection
⚬⚬ Hands
◼◼ Nails: Koilonychia (iron deficiency)/leuconychia (hypoalbuminaemia)

◼◼ Capillary refill time (normal <2 seconds)

◼◼ Palmar erythema (decompensated liver disease)

◼◼ Finger clubbing (e.g. malignancy, inflammatory bowel disease,

suppurative lung disease)

◼◼ Dupuytren’s contracture (decompensated liver disease, mechanical)

◼◼ Asterixis (decompensated liver disease, uraemia)

⚬⚬ Eyes and mouth

◼◼ Jaundice (decompensated liver disease)

◼◼ Pallor (anaemia)

◼◼ Angular stomatitis (iron deficiency)

◼◼ Glossitis (B12 deficiency)

◼◼ Ulceration (e.g. Crohn disease)

⚬⚬ Neck
◼◼ Virchow’s node (left supraclavicular node – GI [gastrointestinal]

malignancy)
◼◼ Lymphadenopathy

• Trunk
⚬⚬ Spider naevi (IVC [inferior vena cava] distribution, >6 –
decompensated liver disease)
⚬⚬ Gynaecomastia (decompensated liver disease, puberty, drug-induced
[e.g. spironolactone, digoxin, finasteride, marijuana])
• Palpation
⚬⚬ Systematically palpate each of the nine segments in a logical
sequence, first superficially then deep. Start at the furthest point
away from any pain
⚬⚬ Deep palpation
◼◼ Hepatomegaly

◼◼ Splenomegaly

◼◼ Appendix

◼◼ Bladder distension