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Equine Surgery 5th Edition Jorg A. Auer Dr Med Vet Ms
Digital Instant Download
Author(s): Jorg A. Auer Dr Med Vet MS, John A. Stick DVM
ISBN(s): 9780323484206, 0323484204
Edition: 5
File Details: PDF, 107.98 MB
Year: 2018
Language: english
 EQUINE
SURGERY FIFTH EDITION

JÖRG A. AUER, DR MED VET, DR hc, MS, DACVS, DECVS

Professor Emeritus of Surgery
Former Director, Equine Department
Vetsuisse Faculty Zurich
University of Zurich
Zurich, Switzerland

JOHN A. STICK, DVM, DACVS

Professor Emeritus
Department of Large Animal Clinical Sciences
College of Veterinary Medicine;
Chief Operations Officer Emeritus
Veterinary Teaching Hospital
Michigan State University
East Lansing, Michigan

JAN M. KÜMMERLE, DR MED VET, PhD, DECVS

Senior Clinician Equine Surgery Clinic
Equine Department
Vetsuisse Faculty
University of Zurich
Zurich, Switzerland

TIMO PRANGE, DR MED VET, MS, DACVS

Clinical Associate Professor, Equine Surgery
Department of Clinical Sciences
North Carolina State University
Raleigh, North Carolina
3251 Riverport Lane
St. Louis, Missouri 63043

EQUINE SURGERY, FIFTH EDITION ISBN: 978-0-323-48420-6

Copyright © 2019 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Unless otherwise indicated, all line drawings are Copyright © 2019 Matthias Haab.
Images in Chapter 27 © Dean A. Hendrickson, DVM, MS, DACVS.

Notices

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or
property as a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2012, 2006, 1999, and 1992.

Library of Congress Control Number: 2018941059

Senior Content Strategist: Jennifer Flynn-Briggs

Senior Content Development Manager: Ellen Wurm-Cutter
Content Development Specialist: Alexandra York
Publishing Services Manager: Jeff Patterson
Book Production Specialist: Carol O’Connell
Design Direction: Patrick Ferguson

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 The Fifth Edition is dedicated to:

Our coeditors, Jan Kümmerle and Timo Prange, whose contributions have greatly improved
this edition and made it more comprehensive.

Thank you, Jan and Timo.

Matthias Haab, on whose expert illustrations we could count on for the last three editions.

He was always very efficient in producing top quality work in no time.

To Anita and Claudette, our loving wives, who continue to support us with great
appreciation of our chosen profession.

Jörg A. Auer and John A. Stick

Contributors

Monica Aleman, MVZ, PhD, Anthony T. Blikslager, DVM, PhD, Elizabeth J. Davidson, DVM,
DACVIM DACVS DACVS, DACVSMR
Professor, Medicine and Epidemiology Professor of Equine Surgery Associate Professor in Sports Medicine
University of California Department of Clinical Sciences Department of Clinical Studies
Davis, California North Carolina State University New Bolton Center, University of
Raleigh, North Carolina Pennsylvania
Matthew J. Annear, BSc, BVMS, Kennett Square, Pennsylvania
MS, DACVO Lindsey Boone, DVM, PhD,
Ophthalmologist DACVS-LA Jennifer L. Davis, DVM, PhD,
Animal Referral Hospital, Sydney Assistant Professor of Equine Surgery DACVIM-LA, DACVCP
New South Wales, Australia Clinical Sciences Associate Professor of Clinical
Auburn University Pharmacology
Jörg A. Auer, Dr Med Vet, Dr hc, Auburn, Alabama Department of Biomedical Sciences and
MS, DACVS, DECVS Pathobiology
Professor Emeritus of Surgery Larry R. Bramlage, DVM, MS, Virginia-Maryland College of Veterinary
Former Director, Equine Department DACVS Medicine
Vetsuisse Faculty Zurich Equine Surgeon
Blacksburg, Virginia
University of Zurich RREH Surgery
Zurich, Switzerland Rood and Riddle Equine Hospital John A. Disegi, BS
Lexington, Kentucky Research and Development Fellow
Jeremy V. Bailey, BVSc, MVetSc, Materials Development
DACVS James L. Carmalt, MA, VetMB, DePuy Synthes
Professor of Large Animal Surgery MVetSc, PhD, FRCVS, West Chester, Pennsylvania
Department of Large Animal Clinical DABVP(Eq), DAVDC(Eq),
Sciences DACVSMR(Eq), DACVS Padraic M. Dixon, MVB, PhD,
Western College of Veterinary Medicine Professor, Equine Surgery DEVDC (Equine), FRCVS
University of Saskatchewan Large Animal Clinical Sciences Professor of Equine Surgery
Saskatoon, Saskatchewan, Canada Western College of Veterinary Medicine Division of Veterinary Clinical Studies
University of Saskatchewan, Saskatoon The University of Edinburgh, Midlothian
Joshua T. Bartoe, DVM, MS, Saskatchewan, Canada Scotland, United Kingdom
DACVO
Associate Professor–Adjunct Elizabeth A. Carr, DVM, PhD, Bernd Driessen, DVM, PhD,
Small Animal Clinical Sciences DACVIM, DACVECC DACVAA, DECVPT
Michigan State University Associate Professor Professor of Anesthesiology
East Lansing, Michigan; Large Animal Clinical Sciences Clinical Studies–New Bolton Center
Director College of Veterinary Medicine, Michigan University of Pennsylvania
Ophthalmology Services State University Kennett Square, Pennsylvania
MPI Research East Lansing, Michigan
Wei Duan, PhD, MS, BS
Mattawan, Michigan
Heather J. Chalmers, BSc, DVM, Postdoctoral Associate
Michelle Henry Barton, DVM, PhD, Dipl. ACVR Department of Veterinary Clinical Sciences
PhD, DACVIM Associate Professor Louisiana State University
Fuller E. Callaway Endowed Chair Radiology Baton Rouge, Louisiana
Large Animal Medicine Ontario Veterinary College, Guelph
Norm G. Ducharme, DVM, MSc,
University of Georgia Ontario, Canada
DACVS
Athens, Georgia
Jonathan Cheetham, VetMB, PhD, Director of Equine and Farm Animal
Regula Bettschart-Wolfensberger, DipACVS Hospitals
Dr Med Vet, PhD, DECVAA Associate Professor James Law Professor of Surgery
Professor Department of Clinical Sciences Department of Clinical Sciences
Department of Diagnostics and Clinical College of Veterinary Medicine, Cornell College of Veterinary Medicine, Cornell
Services, Section Anesthesiology University University
Vetsuisse Faculty Ithaca, New York Ithaca, New York;
University of Zurich Chief Medical Officer and Staff Surgeon
Vanessa L. Cook, VetMB, PhD,
Zurich, Switzerland Cornell Ruffian Equine Specialists (CRES)
DACVS, DACVECC Elmont, New York
Andrea S. Bischofberger, Dr Med Associate Professor
Vet, DVM, PhD, DACVS, DECVS Department of Large Animal Clinical Callie Fogle, DVM, DACVS
Senior Clinician Equine Surgery Clinic Sciences Clinical Associate Professor, Equine
Equine Department Michigan State University Surgery
Vetsuisse Faculty East Lansing, Michigan Department of Clinical Sciences
University of Zurich North Carolina State University
Zurich, Switzerland Raleigh, North Carolina

iv
 Contributors v

Lisa A. Fortier, DVM, PhD, DACVS Jan F. Hawkins, DVM, DACVS Robert J. MacKay, BVSc (Dist),
James Law Professor of Large Animal Professor of Large Animal Surgery PhD, DACVIM
Surgery Veterinary Clinical Sciences Professor
Clinical Sciences Purdue University Large Animal Clinical Sciences
Cornell University College of Veterinary West Lafayette, Indiana University of Florida
Medicine Gainesville, Florida
Dean A. Hendrickson, DVM, MS,
Ithaca, New York
DACVS Khursheed R. Mama, BVSc, DVM,
Jennifer G. Fowlie, BSc, DVM, MS, Professor of Surgery DACVAA
DACVS Clinical Sciences Professor, Anesthesiology
Moore Equine Veterinary Centre Colorado State University Clinical Sciences
Rocky View County Fort Collins, Colorado Colorado State University
Alberta, Canada Fort Collins, Colorado
Michelle A. Jackson, Dr Med Vet,
Samantha H. Franklin, BVSc, PhD, DECVS, DFVH John F. Marshall, BVMS, PhD,
DACVSMR, MRCVS Senior Clinician Equine Surgery Clinic DACVS, DECVS
Associate Professor in Equine Physiology Equine Department Lecturer in Equine Surgery
School of Animal and Veterinary Science Vetsuisse Faculty School of Veterinary Medicine
University of Adelaide University of Zurich University of Glasgow
Adelaide, Australia Zurich, Switzerland Glasgow, Renfrewshire
David E. Freeman, MVB, PhD, Sherry A. Johnson, DVM Ann Martens, DVM, PhD, DECVS
DACVS Resident, Equine Sports Medicine & Professor of Large Animal Surgery
Appleton Professor of Equine Surgery Rehabilitation Department of Surgery and
Large Animal Clinical Sciences Colorado State University Anaesthesiology of Domestic Animals
University of Florida, College of Orthopaedic Research Center Faculty of Veterinary Medicine, Ghent
Veterinary Medicine Fort Collins, Colorado University
Gainesville, Florida Merelbeke, Belgium
Jessica A. Kidd, BA, DVM, CertES
David D. Frisbie, DVM, PhD, (Orth), DECVS, MRCVS Katharyn Mitchell, BVSc,
DACVS, DACVSMR Surgeon DipVetClinStud, DACVIM
Professor, Clinical Sciences Dr Jessica Kidd Ltd. Clinic for Equine Internal Medicine,
Director of Research Oxford, United Kingdom Equine Department
Orthopedic Research Center Vetsuisse Faculty
Jan M. Kümmerle, Dr Med Vet,
Interim Director of Operations University of Zurich
PhD, DECVS
Translational Medicine Institute Zurich, Switzerland
Senior Clinician Equine Surgery Clinic
Colorado State University
Equine Department Freya M. Mowat, BVSc, PhD,
Fort Collins, Colorado
Vetsuisse Faculty DECVO, DACVO, MRCVS
Susan L. Fubini, DVM, DACVS University of Zurich Assistant Professor, Ophthalmology
Professor Zurich, Switzerland Clinical Sciences
Large Animal Surgery North Carolina State University College of
Christoph J. Lischer, Dr Med Vet,
Cornell University Veterinary Medicine
DECVS
Ithaca, New York Raleigh, North Carolina
Professor
Anton E. Fürst, Dr, DECVS Faculty of Veterinary Medicine Margaret C. Mudge, VMD, DACVS,
Professor Equine Clinic Freie Universität Berlin DACVECC
Equine Department Berlin, Germany Associate Professor of Equine Emergency
Vetsuisse Faculty & Critical Care
University of Zurich
Mandi J. Lopez, DVM, MS, PhD, Veterinary Clinical Sciences
DACVS
Zurich, Switzerland The Ohio State University
Professor and Director
Columbus, Ohio
Mathew P. Gerard, BVSc, PhD, Veterinary Clinical Sciences
DACVS Louisiana State University Amelia S. Munsterman, DVM, MS,
Teaching Professor, Veterinary Anatomy Baton Rouge, Louisiana PhD, DACVS, DACVECC, CVA
Molecular Biomedical Sciences, College of Clinical Assistant Professor
Emma J. Love, BVMS, PhD, DVA,
Veterinary Medicine Surgical Sciences
DECVAA, MRCVS, FHEA
North Carolina State University University of Wisconsin–Madison School
Senior Teaching Fellow in Veterinary
Raleigh, North Carolina of Veterinary Medicine
Anaesthesia
Madison, Wisconsin
Kati G. Glass, DVM, DACVS Bristol Veterinary School
Clinical Assistant Professor in Large University of Bristol Nathan C. Nelson, DVM, MS,
Animal Surgery Langford, United Kingdom DACVR
Large Animal Clinical Sciences Clinical Associate Professor
Joel Lugo, DVM, MS, DACVS
Texas A&M College of Veterinary Medicine Department of Molecular Biomedical
Associate Surgeon
and Biomedical Sciences Sciences
Ocala Equine Hospital
College Station, Texas North Carolina State University
Ocala, Florida
Raleigh, North Carolina
vi Contributors

Frank A. Nickels, DVM, MS, Timo Prange, Dr Med Vet, MS, Michael Schramme, Dr Med Vet,
DACVS DACVS CertEO, PhD, HDR, DECVS,
Professor Clinical Associate Professor, Equine DACVS, Associate ECVDI
Department of Large Animal Clinical Surgery Professor of Equine Surgery and
Sciences Department of Clinical Sciences Orthopaedics
Michigan State University North Carolina State University Département Hippique
East Lansing, Michigan Raleigh, North Carolina VetAgro Sup, University of Lyon, Marcy
L’Etoile
Alan J. Nixon, BVSc, MS, DACVS Patricia J. Provost, VMD, MS, Rhone-Alpes, France
Professor of Orthopedic Surgery DACVS
Clinical Sciences Surgeon/Associate Veterinarian James Schumacher, DVM, MS,
Cornell University Brown Equine Hospital DACVS
Ithaca, New York; Somerset, Pennsylvania Professor
Chief Medical Officer Department of Large Animal Clinical
Peter C. Rakestraw, VMD, MA,
Cornell Ruffian Equine Specialists Sciences
DACVS
New York, New York University of Tennessee
Consulting Surgeon
Knoxville, Tennessee
Henry O’Neill, MVB, DVM, MS, Korean Racing Authority
DACVS, MRCVS Seoul, South Korea John Schumacher, DVM, MS,
Equine Surgeon DACVIM, DABVP
Dean W. Richardson, DVM,
Donnington Grove Veterinary Surgery, Professor
DACVS
Newbury Clinical Sciences
Charles W. Raker Professor of Surgery
Berkshire, United Kingdom Auburn University
Clinical Studies New Bolton Center
Auburn, Alabama
Kyla F. Ortved, DVM, PhD, University of Pennsylvania
DACVS, DACVSMR Kennett Square, Pennsylvania Ceri Sherlock, BVetMed, MS,
Assistant Professor of Large Animal MVetMed, DACVS-LA,
Simone K. Ringer, Dr Med Vet,
Surgery DECVS-LA, DECVDI-LA
DVM, PhD, DECVAA
Clinical Studies Equine Surgeon and Head of Diagnostic
Department of Diagnostics and Clinical
University of Pennsylvania Imaging
Services, Section Anesthesiology
Kennett Square, Pennsylvania Bell Equine Veterinary Clinic, Mereworth
Vetsuisse Faculty
Kent, United Kingdom
Karine Pader, DVM, MS, University of Zurich
DACVS-LA, DECVS Zurich, Switzerland Roger K. W. Smith, MA, VetMB,
Staff Surgeon PhD, DEO, FHEA, ECVDI
Fabrice Rossignol, DVM, DECVS
La Clinique du Cheval LAAssoc, DECVS, MRCVS
Senior Surgeon
Grenade sur Garonne, France Professor of Equine Orthopaedics
Equine Clinic of Grosbois
Clinical Sciences and Services
Anthony P. Pease, DVM, MS, Boissy Saint Leger, France
The Royal Veterinary College, Hatfield
DACVR Alan J. Ruggles, DVM, DACVS Hertfordshire, United Kingdom
Chief Veterinary Medical Officer
Staff Surgeon
Veterinary Division Louise L. Southwood, BVSc, PhD,
Surgery Department
Western Veterinary Conference DACVS, DACVECC
Roodand Riddle Equine Hospital
Henderson, Nevada Associate Professor, Large Animal
Lexington, Kentucky
Emergency and Critical Care
John F. Peroni, DVM, MS, DACVS Lauren V. Schnabel, DVM, PhD, New Bolton Center
Professor
DACVS-LA, DACVSMR-Equine University of Pennsylvania
Large Animal Medicine
Assistant Professor of Equine Orthopedic Kennett Square, Pennsylvania
University of Georgia
Surgery
Athens, Georgia Suzanne Stewart, MVB, DACVS
Department of Clinical Sciences
Research Project Manager
Simon M. Petersen-Jones, Dr Vet North Carolina State University
School of Veterinary Medicine
Med, PhD, DVOphthal, DECVO, Comparative Medicine Institute
University College Dublin
MRCVS Raleigh, North Carolina
Dublin, Ireland
Professor, Comparative Ophthalmology
Angelika Schoster, Dr Med Vet,
Department of Small Animal Clinical Felix Theiss, Dr Med Vet, PhD,
DVSc, PhD, DACVIM, DECEIM
Sciences DECVS
Senior Clinical Lecturer
Michigan State University Senior Clinician Equine Surgery Clinic
Clinic for Equine Internal Medicine
East Lansing, Michigan Equine Department
Equine Department
Vetsuisse Faculty
Kenneth E. Pierce, DVM, MS, Vetsuisse Faculty
University of Zurich
DACVO University of Zurich
Zurich, Switzerland
Associate Zurich, Switzerland
Comparative Ophthalmology Ferenc Tóth, DVM, PhD,
Harold C. Schott II, DVM, PhD,
Veterinary Eye Institute DACVS-LA
DACVIM
Plano, Texas Assistant Professor
Professor
Veterinary Population Medicine
Department of Large Animal Clinical
University of Minnesota
Sciences
St. Paul, Minnesota
Michigan State University
East Lansing, Michigan
 Contributors vii

Wendy M. Townsend, DVM, MS, Denis Verwilghen, DVM, MSc, David A. Wilson, DVM, MS,
DACVO PhD, DES, DECVS DACVS
Associate Professor, Ophthalmology Head of Equine Services Professor and Hospital Director
Veterinary Clinical Sciences Associate Professor in Equine Surgery Veterinary Medicine & Surgery
Purdue University University Veterinary Teaching Hospital University of Missouri
West Lafayette, Indiana Camden Columbia, Missouri
School of Veterinary Science, Faculty of
P. René van Weeren, DVM, PhD, J. Brett Woodie, DVM, MS, DACVS
Science, University of Sydney, Camden
DECVS Surgeon
New South Wales, Australia
Professor of Equine Musculoskeletal Rood and Riddle Equine Hospital
Biology Jeffrey P. Watkins, DVM, MS, Lexington, Kentucky
Department of Equine Sciences DACVS
Faculty of Veterinary Medicine, Utrecht Professor of Large Animal Surgery
University Veterinary Large Animal Clinical Sciences
Utrecht, Netherlands College of Veterinary Medicine, Texas
A&M University
College Station, Texas
Preface

Our goal for the fifth edition of Equine Surgery was to maintain
the high standard of the previous edition and continue its position New Features
as the leading worldwide clinical reference and teaching textbook The new features include:
for equine clinicians, practitioners, surgery residents, and students.
We, the senior editors, Jörg and John, continued the format of • Thoroughly revised and updated content with expanded
the last edition by taking direct responsibility for inviting authors coverage on current and new topics throughout the textbook
in the sections for which we were in charge; however, we invited • Addition of 35 videos illustrating knot tying, surgical tech-
co-editors, Jan and Timo, to join us in this and they will take niques, video endoscopic views of surgical anatomy, and correct
over our responsibilities for the next edition. positioning of instruments during surgery
We have continued to focus on the clinically relevant aspects • Expansion of the total content of the book by 20% (now
of equine surgery, presenting information in a concise, understand- more than 1800 pages)
able, and logical format. Extensive use of figures, tables, and • Complete reorganization of the nervous system with four new
cross-referencing within and among sections, help make the fifth chapters, including Chapter 52, Pharmaceutical Considerations
edition of Equine Surgery a quick and easy-to-use reference for Treatment of the Central Nervous System, Chapter 53,
textbook. A new feature is the addition of videos demonstrating Vertebral Column and Spinal Cord, Chapter 54, Neurocranium
a variety of surgical techniques, including knot tying, trocar and Brain, and Chapter 55, Peripheral Nerve Injuries.
placement, and endoscopic evaluations. This feature along with • Reorganization of the alimentary system into upper and lower
the availability of the book in ebook format will provide the segments with four new chapters, including Chapter 32, Spleen
reader with immediate electronic access in a surgical setting. and Liver, Chapter 36, Cecum, Chapter 37, Large Colon, and
Chapter 38, Transverse and Small Colon
• A new chapter (Chapter 97, Humerus) was added to the section
ORGANIZATION on the musculoskeletal system. Furthermore, information on
The book contains twelve sections, starting with surgical biology, arthroscopic, tenoscopic, and bursoscopic procedures was
surgical methods, recent advances in anesthesia, and an expanded expanded and now covers all relevant techniques
section on minimally invasive surgery, and is followed by sections
pertaining to all organ systems. Each section is logically structured
and supported extensively by illustrations, photographs, tables,
and videos. A comprehensive list of references completes each Book Cover
chapter. Through all four previous editions we maintained the same
overall style of the book cover, mainly the font and the little
horse on the back and the front cover. The only thing that
KEY FEATURES OF THE FIFTH EDITION changed was the color of the cover. For the cover of the previ-
We have retained all of the features that were popular in the first ous edition we added a colored drawing by Matthias Haab,
four editions and have significantly updated all chapters in the our illustrator.
fifth edition. We continued to select known and novel contributors For the fifth edition, we chose a photograph of the first bronze
who are recognized as experts in their fields to author the chapters sculpture of a horse created by Jörg Auer (www.joergauer.com),
in this edition. “Follow Me.”

viii
Acknowledgments

First, we would like to express gratitude to our contributors, We would like to extend our sincerest thanks to Penny
without whom this work would not have been possible. Their Rudolph, our motivating, joyful, and very competent publisher
dedication to producing an excellent product has resulted in at Elsevier for initiating this edition, and wish her the very best
another textbook accomplished in a timely fashion so that the in her retirement. Our thanks also go to Jennifer Flynn-Briggs
content will continue to represent current “state-of-the-art” surgical and the rest of her team who aided the process of continuity in
procedures and techniques. So to our contributors, once again, the book.
thank you for the marvelous work. A special thank you goes to Matthias Haab of Zurich, Swit-
Thanks also goes to our co-editors, Jan M. Kümmerle and zerland, who continued to do a marvelous job in preparing all
Timo Prange, whose contributions to this edition are very much the new artwork. Not only is the quality of the artwork outstand-
appreciated. Their attention to detail and addition of new material ing, he did this work with great efficiency, which made the final
have improved this edition so very much. We wish them the product first-rate.
very best as they continue on with the next edition without us.

ix
Contents

Section I Surgical Biology 20 Anesthesia and Analgesia for Foals, 313

Renul Driesselz
John A. Stick and Tima Prange
21 Recovery From Anesthesia, 332
Shock: Pathophysiology, Diagnosis, Treatment, and Regula Bewclum-WalfellSberger ami Kllrsheed R. MlZ/I/(j
Physiologic Response \0 Trauma. I 22 Complicat.ions of Inhalation Anesthesia and Their
KmITmyn Mitchell lind Angelika 5chosler
Management, 340
2 Systemic lnnammatory Response, 14
Khurslreed R. Mmnfl
Mici/elle Hem}' Blmoll mill 101111 F. Perolli
23 Chemical Restraint for Standing Procedures, 345
3 Fluids, Electrolytes. and Acid-Base Therapy. 28
SimOlle K. Rillger mul Khufsheed R. M(!IlUz
Allgelikil Sclros/er lind Kaliwryll Mitchell
24 Equine Pain Management. 356
4 Hemostasis, Surgical Bleeding. and Transfusion. 41
Emma J. Love
Mllrgflfel C. Mw1se
5 Wound 1 [caling. 53
i'lIlrieia /. Provost
6 Metabolism and Nutritional Support of the Surgical Section IV Integumentary System
Patient, 70 John A. Stick and Timo Prange
£IiUlVclh A. Om
2S Principles of Plastic and Reconstructive Surgery, 367
7 Surgical Site Infection and the lise of Antimicrobials, 77
Pillricill /. Prowsr IUld leremy v. Bailey
Slwlllne Stewart "'Ill Dean w: Riclwrdsoll 26 Skin Grafting. 381
8 Regenerative Medicine, 104
/111111'.$ Sclnmlllciler
Lmre11 V. Schnabel, Lindse}' Boone, llnd 101m F. Peroni
27 Management of Superficial Wounds. Deep and Chronic
Wounds. Sinus Tracts. and Fistulas, 403
DelllZ A. 1·lemlricbon
Section II Surgical Methods 28 Skin Conditions Amenable to Surgery, 425
lorg A Auer and Jan M. Kummerle Elizllberh A. CaIT

9 inslmment Preparation, Antisepsis, and

Disinfection, 123
Dellis Venl'ilglre71 Section V Alimentary System
10 Preparation for Surgery: Decision MakinfJOperative John A. Stick and Tima Prange
Risk, Patient, Facility, Operating Team, 143
29 Oral Cavity and Salivary Glands. 440
Dellis Venl'ilgirell
P"dmic M. Dixon ami Mluhew 1'. Gerard
11 Surgical lnstmments, 184
30 Esophagus, 474
lall M. Kummer/e and lorg A. Aller
SUSllIZ L. Fuli;,zi
12 Surgical Techniques. 198
31 Stomach and Duodenum, 496
De'lis Vemrilghen
AU/iJoIlY"f. B/iblager ami DIU/ill A. Wilsall
13 Minimally Invasive Surgical Techniques. 214
32 Spleen and Liver, 505
AmI Marrens, Kari'le Pader, Timo PTmlge, Ky/lI F. Orwed,
Amelifl S. MIHZSlermmz
IIlId Deall W RicilardsOII
33 Colic Diagnosis, Surgical Decision, Preoperative
14 Cryosurgery, 234
Management, and Surgical Approaches to the
AmI Mllrte715
Abdomen. 521
15 Lasers in Veterinary Surgery, 238
Jolzn I·: M(mizllll ami Amlzolz)' 'I: BliJl5lager
Jan F. Hawkins
34 Principles of Intestinal Injury and Determination of
16 Suture Materials and Patterns. 255
Intestinal Viability, 529
Jan M. Kiimmer/e IUld Gillie Fogle
VdlZeS51Z L. Cook, Am/wlz)' T. Blill5ll1ger, ami John F. Mlirs/lfzlI
17 Drains. Bandages, and External Coaptation, 280
3S Jejunum and Ileum, 536
Andrell S. Biscirofberger
D(U/iil E. Freenum
36 Cecum. 575
Cer; Sherlock
Section III Recent Advances in Anesthesia
37 Large Colon, 591
J6rg A. Auer and Jan M. KOmmerle
tallise L. Soul/mlOo(/
18 Balanced Inhalation Anesthesia, 30\ 38 Transverse and Small Colon. 621
Regultl BetlsclllirT-Wolfensberger ami Klrursireed R. M ama 1'11110 I'mnge, Aml/olzy T. Blibiliger, and Perer C. Rilkesrmw
19 Modern Injectable Ancsthesia for Adult Horses, 308 39 Rectum and Anus, 632
Regllill Bewclzart-WolfelZSberger IUIiI Kurslzeed R. Mtzma DIU/id E. Freenum

,;
xii CONTENTS

40 Abdominal Hernias, 645 Section IX Reproductive System

Ferenc Toth am/Illmes Sc/rumllcher
Jorg A. Auer and Jan M. KrJmmerle
41 Postoperative Care, Complications, and Itcoperation of
60 Testis, 994
the Colic Patient, 660
Jllmes Sellllmac/rer
Callie f"Og/e
61 Penis and Prepuce, 1034
jllllles Selrrmracher
62 Vulva, Vestibule, Vagina, and Cervix, 1065
J. Brell Woodie
Section VI Respiratory System
63 Uterus and Ovaries, 1083
John A. Stick and rima Prange
J. Brell Woodie
42 Overview of Upper Airway Function, 678
Imrallrlllr Cireetlllmr
43 Diagnostic Techniques in Equine Upper Respiratory Section X Urinary System
Tract Disease, 683
J6rg A. Auer and Jan M. KrJmmerJe
Elizabetlr I. Davidson, SllIlImrtila H. FranJilin,
Imd Hemlrer /. Chilimers 64 Diagnostic Techniques and Principles of Urinary Tract

44 Nasal Passages and Paranasal Sinuses, 698 Surgery, 1095

Frllllk A. Nic/wls lind HelllY O'Neill Hllrald C. SchOll IIIIml j. BreI/ Woodie

45 Pharynx, 710 65 Kidneys and Ureters, 1115

Norm C. Ducharme llIul Jonmlrmr Cheet/rllllf Hdrald C. SchOll fllIlIIl ,. BreH Woodie
46 Larynx, 734 66 Bladder, 112')

Norm C. Duc/ramre ami Fabrice Rossignol HllTold C. SchOll /I lI11d J. BreI/ Woodie

47 Cuttural Pouch, 770 67 Urethra, 1145

Dllllid E. Freeman Hllwld C. SchOll /lIIIId J. BreI/ Woodie

48 Trachea, 7')7
'rimo Prlllrge
49 Thoracic Disorders, 805 Section XI Diagnostic Imaging
'oel Lugo and EiiZllbeth A. CmT John A. Stick and Timo Prange

68 nadiography, 1\56
NII/llml C. Nelson alii/ Ali/hOllY r. Peltie
69 Ultrasonography, 1174
Section VII Nervous System
All/hon)- P. Pellse lind Nil/lUll! C. Nelson
J6rg A. Auer and Jan M. KrJmmerJe 70 Nudear Scimigraphy, 1182
50 Anatomy and Physiology of the Nervous NII/harr C. Nelson IlIId Al1IhollY r. Pease
System, 822 71 Computed Tomography, 1193
MOlriCIl A/emllll alld Robert j. MacKay Ali/hOlly P. Pellse IIIrd NIII/UII1 C. Ne/S{JIr
51 Diagnostic Procedures, 834 72 Magnetic Resonance Imaging, 1201
Monicil t\lemlm, Timo Prange, mill Robert I. MacKllY Nillillm C. Nelson 111111 Ali/hOllY r. PCltie
52 Pharmaceutical Considerations for Treatment of the
Central Nervous System, 859
Jennifer L Dill/is Section XII Musculoskeletal System
53 Vertebral Column and Spinal Cord, 864 J6rg A. Auer and Jan M. Kummerle
Ali/oil B. Flirst
73 Diagnostic and Regional Surgical Anesthesia of the
54 Neurocranium and Brain, 895
Limbs and Axial Skeleton, 1220
MOllicll Aleman IIl1d Timo Prmrge
jollll SChl/lllllelrer IIf1d Michael Sclrramme
55 Peripheral Nerve Injuries, ')00
74 Emergency Treatment and Transponation of Equine
Timo Pmllge
Fracture Patients, 1243
Ali/Oil E. Hirst
75 none Iliolob'Y and Fracture Healing, 1255
Mmuli }. Lopez
Section VIII Eye and Adnexa
76 Metallic Instruments and Implants, 1270
John A. Stick and Timo Prange
jolrll A. Disegi
56 Surgery of the Globe and Orbit, ')\0 77 Principles of Fracture Treatment, 1277
Kemrellr E. Pierce, Jr. alUl Wendy M. TowlI5end lars A. Auer
57 Adnexal Surgery, 927 78 none Grafts and Bone Replacements, 1314
FreJ'1I M. MOlI'lII lind joslrull T. Bartoo Wei Drum (Illd Mmu/i J. topez
58 Surgery of the Ocular Surface, ')56 79 Synovial loint Biology and Pathobiology, 1326
Mal/hew}. Amlellr 1I11d Sil/lOlr M. l'ewrselr-IOIlCs David D. Frisbie ami Sherry A. lolmson
59 Intr.:Jocular Surgery, 981 80 Medical Treatment ofloint Disease, 1348
Wendy M. Townsend David D. Frisbie (!Ird Sherry A. joill/soll
 CONTENTS xiii

81 Surgical Treatment of Joint Disease, 1363 94 Vestigial Metacarpal and Metatarsal Bones, 1636
Dmrid D. Frisbie and SizeIT)' A. /oill15on Michelle A. lac/tSOII mullofg A. Aller
82 Arthrodesis Techniques, 1374 95 Carpus, 1648
Christoph /. Lisclrer (mil liirg A. Aller A/an I. RIJggies
83 Management of Bursitis, 1399 96 Radius and Ulna, 1667
Miclwel Schramme allfflohll Schumaclrer Jeffrey P.. Wat/lins, Kllli G. Glit5S, ami /all M. Kiimmer/e
84 Diagnosis and Management ofTendon and Ligament 97 Humerus, 1690
Disorders, 1411 Klili G. G/l/5S mul Jeffrer I� Walllins
Imr M. Kiimmerle, Feli.1: Theiss, alld Roger K. W Smith 98 Shoulder, 1699
85 Biology and Management of Muscle Disorders and LiM A. i-(mier
Diseases, 1445 99 Tarsus, 1710
Arm Martens Chrislopll /. Liscller mill liirg A. Aller
86 Synovial and Osseous Infedion, 1458 100 Tibia, 1736
Dean W Ricllllrdson allli SlIzilIllle Siewarr Lawrence R. Bramlage
87 Angular Limb Deformities, 1471 101 Stifle, 1747
Andrea S. Bisclrofberger a/UI JOrg A. Aller Jemrijcr G. Fowlie, Deml W: Ric/lImISOII, 111111 Krill E Orflled
88 Flexural Limb Deformities, 1490 102 Femur and Pelvis, 1777
Jessiar A. Kilhl Dcal! W. RicJwrdsol! II/UI Krla F. Orlvell
89 Osteochondritis Dissecans, 1509 103 Temporomandibular Joint Disorders, 1789
P. Relle vmr Weeren James L. Camwll
90 Subchondral Cystic Lesions, 1528 104 Craniomaxillofacial Disorders, 1794
Micllelle A. I(lcboll and Amoll E. Fiirst Amon E. Fiirsl mllllDrg A. Aller
91 Foot, 1543 105 Postoperative Physiotherapy for the Orthopedic
Amoll E. Fiirsl mltl Chrisloph I. Lisclrer Patient, 1830
92 Phalanges and the Metacarpophalangeal and fliu!!)e!/! J. DIWil[sO'1
Metatarsophalangeal Joints, 1587
A/ml J. Nixon
93 Third Metacarpal and Metatarsal Bones, 1618 Index, 1836

Demr W Richardson and Krla F. Orwell

Video Contents

13.1 Video illustration of how a foggy image can be 16.18 Technique for tying an Aberdeen knot.
resolved. 16.19 Chinese finger trap technique.
13.2 Video explanation of how to perform an 16.20 Use of the skin stapler to close a skin incision.
extracorporeal 4-S modified Roeder slipknot.
32.1 Demonstrating the pathway for laparoscopic approach
13.3 Video demonstration of the technique for transvaginal to the epiploic foramen.
access to the abdominal cavity under endoscopic
32.2 Demonstrating the ideal placement of the
guidance.
gastropancreatic fold against the caudal aspect of the
13.4 Video demonstration of the technique for trocar caudate liver lobe using the Babcock forceps.
exchange.
32.3 Tacking of the gastropancreatic fold.
16.1 One-handed knot typing technique.
48.1 Self-retaining tracheostomy tube insertion.
16.2 Two-handed knot typing technique.
51.1 Vertebral canal endoscopy: cervical myeloscopy and
16.3 Hand-tied sliding knot 1. lumbosacral epiduroscopy.
16.4 Hand-tied sliding knot 2. 55.1 Left femoral nerve paralysis following prolonged
16.5 Instrument-tied simple knot. anesthesia in dorsal recumbency with caudally
16.6 Instrument-tied surgical knot. extended hind limbs.
16.7 Simple continuous suture pattern. 85.1 Typical motion of a horse affected with fibrotic
myopathy of the semitendinosus muscle.
16.8 Cruciate suture pattern.
85.2 Typical motion of a horse with classical stringhalt:
16.9 Vertical mattress suture pattern.
involuntary and exaggerated flexion mainly of the left
16.10 Horizontal mattress suture pattern. hindlimb.
16.11 Ford interlocking suture pattern. 85.3 A horse with rupture of the left peroneus tertius.
16.12 Connell and Cushing suture pattern. 85.4 Typical motion of a horse with a ruptured extensor
16.13 Lembert suture pattern. caripi radialis tendon, first at a walk and then at a trot.
16.14 Pursestring suture pattern. 87.1 A 4-month-old Arabian foal is shown walking toward
16.15 Far-near-near-far suture pattern. the viewer next to its dam. During protraction of each
fore limb the MCP region describes an outward arch.
16.16 Three-loop pulley suture technique.
16.17 Three-loop pulley suture technique.

xiv
 S ECT I O N

SURGICAL BIOLOGY
John A. Stick and Timo Prange
I
CHAPTER
Shock: Pathophysiology, Diagnosis,
Treatment, and Physiologic
1
Response to Trauma
Katharyn Mitchell and Angelika Schoster

decreased return to the heart. In this situation, although the

DEFINITION OF SHOCK total volume of blood remains unchanged, the effective circulating
In 1872 the trauma surgeon Samuel D. Gross defined shock as volume decreases.
“the rude unhinging of the machinery of life.” Shock represents Myocardial contractility is defined as the rate of cross-bridge
progression of a cascade of events that begins when cells or cycling between actin and myosin filaments within cardiomyo-
tissues are deprived of an adequate energy source because of cytes. Clinically, myocardial contractility assessment is attempted
oxygen deprivation. Shock occurs as a result of inadequate tissue using echocardiographic measures of global systolic function
perfusion; the lack of an adequate energy supply leads to the like left ventricular ejection fraction and fractional shortening,
buildup of waste products and failure of energy-dependent although these variables are load dependent and highly influenced
functions, release of cellular enzymes, and accumulation of by ventricular preload and afterload. Abnormal myocardial
calcium and reactive oxygen species (ROS) resulting in cellular function (both systolic and diastolic) is well described in the
injury and ultimately cellular death. Activation of the inflam- literature following shock, sepsis, endotoxemia, and ischemia/
matory, coagulation, and complement cascades results in further reperfusion injury.1–3 Complex combinations of molecular,
cellular injury and microvascular thrombosis. The amplification metabolic, and structural changes contribute to decreased
of these processes coupled with increased absorption of endotoxin myocardial contractility in these patients.
and bacteria (as a result of liver and gastrointestinal dysfunction) Ventricular afterload (referred to as “afterload”), the third
leads to the systemic inflammatory response syndrome (SIRS) component of SV, is directly affected by vasomotor tone or
(see Chapter 2), multiple organ dysfunction (MOD), and if peripheral vascular resistance. If vascular resistance or tone
uncontrolled, ultimately death. increases (hypertension), afterload also rises with a resultant
fall in CO and tissue perfusion. The opposite extreme is a
severe fall in vascular resistance, which results in pooling of
CLASSIFICATION OF SHOCK blood in capacitance vessels and a drop in blood pressure
Tissue perfusion is dependent on blood flow. The major factors and preload, and it ultimately results in inadequate perfusion
affecting blood flow are the circulating volume, cardiac pump and shock.
function, and the vasomotor tone or peripheral vascular The fundamentals of treatment of shock revolve around restora-
resistance. tion and maintenance of CO through manipulation of preload,
Cardiac output (CO) ultimately determines the blood flow afterload, myocardial contractility, and heart rate.
to tissues and is regulated largely by the stroke volume (SV). SV Shock most commonly occurs because of one of three primary
is the result of ventricular preload (amount of blood returning disturbances and can be classified accordingly. Hypovolemic shock
from the body and entering the heart), the myocardial contractility is the result of a volume deficit, either because of blood loss
(systolic cardiac function), and the ventricular afterload (the force (e.g., resulting from severe hemorrhage), third-space sequestration
the heart must overcome to push blood across the aortic and (e.g., occurring with a large colon volvulus), or severe dehydration.
pulmonic valves into the peripheral or pulmonary vasculature). Cardiogenic shock or pump failure occurs when the cardiac muscle
The interplay between these factors is seen in Figure 1-1. cannot pump out adequate SV to maintain perfusion. Distributive
Ventricular preload (referred to as “preload”) is directly affected shock or microcirculatory failure occurs when vasomotor tone
by the circulating blood volume or amount of blood returning is lost. Loss of vascular tone can result in a dramatic decrease
to the heart. Causes of decreased preload include hypovolemia in both blood pressure and venous return. Although the drop
(e.g., following hemorrhage or dehydration); decreased ventricular in blood pressure will initially decrease afterload (which will
filling time (resulting from tachycardia) or impaired ventricular temporarily improve CO), the pooling of blood and loss of
relaxation; and decreases in vasomotor tone and vasodilation, venous return results in a severe decrease in preload, and con-
which results in pooling of blood in capacitance vessels and sequently, decreased CO and perfusion.

1
2 SECTION I Surgical Biology

volume is depleted, pressure within the vessels falls. Baroreceptors

and stretch receptors located in the carotid sinus, right atrium,
and aortic arch sense this fall in pressure. These receptor responses
act to decrease inhibition of sympathetic tone while increasing
inhibition of vagal activity and decreasing the release of atrial
natriuretic peptide (ANP) by cardiac myocytes. The increase in
sympathetic tone and fall in ANP results in vasoconstriction,
which increases total peripheral resistance and thereby increases
blood pressure. Increased sympathetic activity at the heart increases
heart rate and systolic cardiac function, hence increasing SV and
CO. This interplay between the parasympathetic and sympathetic
nervous systems is referred to as autonomic traffic (see Figure
1-1). In addition, peripheral chemoreceptors stimulated by local
hypoxemia respond by enhancing this vasoconstrictive response.
Figure 1-1. Determinants of cardiac output and systemic blood pressure In mild to moderate hypovolemia these responses are sufficient
and the interplay between them. Autonomic traffic refers to inputs from to restore perfusion. Because these compensatory responses result
both the parasympathetic and sympathetic nervous systems (i.e., barorecep-
in tachycardia, increased SV (increased pulse pressure), and
tors, atrial stretch receptors, vagal tone). The text highlighted in bold
indicates those inputs that can be easily monitored and manipulated to
shortened capillary refill time (CRT), the term hyperdynamic is
improve cardiac output. Autonomic traffic and vascular resistance, while often used to describe this stage of shock.
important determinants of cardiac output, are more difficult to quantify The vasoconstrictive response will vary between organ systems,
and influence with therapy. with the greatest response occurring in the viscera, integument,
and kidney. Cerebral and cardiac flow is preferentially maintained
in mild to moderate hypovolemia. Although this response
Common causes of distributive shock include neurogenic improves central blood pressure and flow, it also decreases perfu-
shock, septic shock, and anaphylactic shock. Because distributive sion to individual microvascular beds, worsening local tissue
shock is a consequence of a loss in effective circulating volume, hypoxemia. Consequently, as volume depletion worsens, certain
fluid therapy is indicated to help restore perfusion. In contrast, tissues and organs will become ischemic more rapidly than others.
cardiogenic shock is the result of pump failure, and aggressive A decrease in renal perfusion results in secretion of renin
fluid therapy may actually worsen clinical signs. Less commonly, from juxtaglomerular cells located in the wall of the afferent
shock can develop when increased metabolic demand results in arteriole. Renin stimulates production of angiotensin I, which,
relative perfusion deficits or when oxygen uptake is impaired after conversion to angiotensin II, increases sympathetic tone
because of mitochondrial failure, sometimes termed relative on peripheral vasculature and promotes aldosterone release
hypoxia or dysoxia. from the adrenal cortex. Aldosterone restores circulating volume
It is important to recognize that although the inciting cause by increasing renal tubular sodium and water reabsorption.
may differ, as shock progresses there is often failure of other Arginine vasopressin (AVP, previously known as antidiuretic
organ systems as well. For example, untreated hypovolemic shock hormone, ADH), released from the posterior pituitary gland
can result in microcirculatory failure (loss of vasomotor tone) in response to decreased plasma volume and increased plasma
as oxygen debt causes muscle dysfunction and relaxation. osmolality, is a potent vasoconstrictor and stimulates increased
Alternatively, hypovolemic shock can result in myocardial failure water reabsorption in the renal collecting ducts. Finally, an
as perfusion deficits affect energy supply to the myocardium increase in thirst and a craving for salt is mediated by both the
(coronary artery blood flow), resulting in decreased myocardial renin-angiotensin-aldosterone system (RAAS) and a fall in ANP
contractility. Consequently, as shock progresses, treatment may (Figure 1-2).
require addressing all of these disturbances. With more severe blood loss, compensatory mechanisms
Obstructive shock represents an additional category, with its become insufficient to maintain arterial blood pressure and
underlying mechanism the obstruction of ventilation or of CO. perfusion of vital organs (decompensated shock). Ischemia to
This process is most commonly caused by tension pneumothorax more vital organs including the brain and myocardium begins
(resulting in decreased venous return); pericardial tamponade; to develop. Blood pressure may be maintained, but clinical signs
diaphragmatic hernia or severe abdominal distension causing including resting tachycardia, tachypnea, poor peripheral pulses,
vena cava obstruction, leading to inadequate ventricular filling; and cool extremities are present. Mild anxiety may be apparent
decreased preload; and consequently, decreased SV and CO. Over as well as sweating from increased sympathetic activity. Urine
time as aortic blood pressure falls, coronary artery blood flow output and central venous filling pressure will drop. As blood
is reduced, and myocardial ischemia and finally myocardial failure loss progresses, compensatory mechanisms are no longer capable
may develop. Because obstructive shock is ultimately a combina- of maintaining arterial blood pressure and perfusion to tissues.
tion of the other three categories, it will not be discussed further. Severe vasoconstriction further worsens the ischemia such that
energy supplies are inadequate and cellular functions (includ-
ing the vasoconstriction responses) begin to fail. In addition,
PATHOPHYSIOLOGY OF SHOCK accumulations of waste products of metabolism (lactate and
A blood loss or hypovolemic model of shock will be used to carbon dioxide) cause progressive acidosis and further cellular
describe the pathophysiology of shock. dysfunction.
Shock is usually defined by the stage or its severity. Compensated At the cellular level, the combination of decreased oxygen
shock represents an early or mild shock, during which the body’s delivery and increased accumulation of waste products results
response mechanisms are able to restore homeostasis. As blood in loss of critical energy-dependent functions, including enzymatic
 CHAPTER 1 Shock 3

Figure 1-2. Physiologic compensatory responses to hypovolemia. ACTH, Adrenocorticotropic hormone.

(Modified from Rudloff E, Kirby R. Hypovolemic shock and resuscitation. Vet Clin North Am Small Anim
Pract. 1994;24:1015–1039.)

activities, membrane pumps, and mitochondrial activity, leading As the situation deteriorates, compensatory mechanisms
to cell swelling and release of intracellular calcium stores. designed to continue to perfuse more vital organs like the heart
Cytotoxic lipids, enzymes, and ROS released from damaged cells and brain will continue to limit flow to other organs. This response
further damage cells, triggering inflammation. Inflammatory cell results in the sparing of one organ with irreversible damage to
and platelet influx into the tissue, the formation of neutrophil another. Consequently, an individual may recover with aggressive
extracellular traps (NETS), and activation of the arachidonic acid intervention only to succumb later because of failure of these
cascade and the complement cascade, cause further cellular injury. “less vital” organs. If blood flow is restored, reperfusion injury
Mitochondrial failure, calcium release, and reperfusion, if present, results from the activated cellular and immunochemical products
further increase production (and decrease scavenging) of ROS. washed into the venous circulation and leads to SIRS, MOD,
Endothelial cell damage, including loss of the endothelial gly- and death (see Chapter 2). Intervention can no longer stop the
cocalyx layer, results in local tissue edema as a result of protein cascade of events because cellular, tissue, and organ damage is
and fluid leakage. Exposure of subendothelial tissue factor further too severe for survival.
activates the coagulation and complement cascades.4 Formation
of microthrombi coupled with coagulopathy impedes blood flow
to the local tissues, worsening the already deteriorating situation. CLINICAL SIGNS OF SHOCK
The lack of energy supplies in combination with accumulation Clinical signs of shock depend on the severity and persistence
of toxic metabolites, microthrombi formation, and the inflam- of blood volume loss or redistribution. The American College
matory injury ultimately result in vascular smooth muscle failure of Surgeons advanced trauma life support guidelines divide shock
and vasodilation. The end results of decompensated shock are into four classes depending on volume of blood loss.5
a pooling of blood in peripheral tissue beds and additional With mild blood loss of less than 15% total blood volume
decreases in blood pressure, venous return, CO, and perfusion, (class I), the body is capable of restoring volume deficits via
ultimately resulting in organ failure (Figure 1-3). Failure of the compensatory responses and there may be little to no change
gastrointestinal tract manifests itself as loss of mucosal barrier in the physical findings other than a drop in urine output. Blood
integrity, resulting in protein and fluid loss, endotoxin absorption, pressure is maintained. Clinical signs typically become apparent
and bacterial translocation. Renal ischemia leads to renal tubular when blood loss exceeds 15%. Class II blood loss (15%–30%)
necrosis, and the inability to reabsorb solutes and water, and is defined as the onset of hyperdynamic shock. Clinical signs
the inability to excrete waste products. At the cardiac level, the include tachycardia, tachypnea, and a bounding pulse (increased
continued drop in blood pressure and venous return decreases CO and peripheral vascular resistance). Mental agitation or anxiety
coronary blood flow. Cardiac muscle ischemia leads to decreased is present, and increased sympathetic output results in pupil
cardiomyocyte contractility and CO and ultimately to further dilation and sweating. Although these compensatory mechanisms
deterioration of coronary artery blood flow. Acidosis and ischemia can normalize blood pressure, perfusion deficits will persist and
accentuate the depression of cardiac muscle function. These can be detected by blood gas analysis (increased lactate and a
changes in combination with decreased venous return (preload) high anion gap metabolic acidosis). If blood loss continues, or
worsen hypotension and tissue perfusion (Figure 1-4). if hypovolemia persists, compensatory mechanisms can become
4 SECTION I Surgical Biology

Figure 1-3. Cellular cascade of events that occur as the result of hypovolemia, poor perfusion, and
decreased oxygen delivery. HR, Heart rate; MODS, multiple organ dysfunction syndrome; RAAS, renin-
angiotensin-aldosterone system; SIRS, systemic inflammatory response system.

Figure 1-4. Vicious cycle of cellular and organ failure in shock.

insufficient to restore circulating volume and hypodynamic/ despite increases in heart rate, cardiac contractility, and total
decompensatory shock begins (class III or moderate hypovolemic peripheral resistance. Without intervention, continued cellular
shock). At this time profound tachycardia and tachypnea, anxiety, hypoxia and acidosis result in failure of compensatory mecha-
and agitation are present. Urine output may cease, jugular filling nisms, causing peripheral vasodilation and decreased myocardial
and CRT are prolonged, pulse pressure is weak, and extremity contractility. A vicious cycle ensues with decreased coronary artery
temperatures are decreased. If blood gases are collected, a lactic perfusion causing decreased cardiac function, resulting in
acidosis will be present (Table 1-1). Blood pressure will drop decreased CO and a further drop in perfusion (see Figure 1-4).
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Date: July 28, 2025

References 1: Literature review and discussion

Learning Objective 1: Experimental procedures and results
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 2: Literature review and discussion
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 3: Experimental procedures and results
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Learning Objective 4: Literature review and discussion
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 5: Study tips and learning strategies
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Historical development and evolution
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Research findings and conclusions
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Problem-solving strategies and techniques
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Interdisciplinary approaches
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 9: Diagram/Chart/Graph]
Note: Key terms and definitions
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Chapter 2: Historical development and evolution
Remember: Literature review and discussion
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 11: Literature review and discussion
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 12: Diagram/Chart/Graph]
Important: Learning outcomes and objectives
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 13: Historical development and evolution
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Historical development and evolution
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Fundamental concepts and principles
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 16: Theoretical framework and methodology
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Interdisciplinary approaches
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Research findings and conclusions
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 19: Practical applications and examples
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Module 3: Key terms and definitions
Important: Ethical considerations and implications
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Experimental procedures and results
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Important: Practical applications and examples
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Historical development and evolution
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 24: Problem-solving strategies and techniques
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Historical development and evolution
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Comparative analysis and synthesis
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 27: Diagram/Chart/Graph]
Definition: Ethical considerations and implications
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 28: Interdisciplinary approaches
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 29: Theoretical framework and methodology
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
References 4: Problem-solving strategies and techniques
Remember: Research findings and conclusions
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Fundamental concepts and principles
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 32: Diagram/Chart/Graph]
Definition: Key terms and definitions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 33: Theoretical framework and methodology
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Research findings and conclusions
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Problem-solving strategies and techniques
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Statistical analysis and interpretation
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Research findings and conclusions
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Best practices and recommendations
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Assessment criteria and rubrics
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice 5: Literature review and discussion
Note: Comparative analysis and synthesis
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Current trends and future directions
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 42: Diagram/Chart/Graph]
Note: Case studies and real-world applications
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 43: Best practices and recommendations
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 44: Diagram/Chart/Graph]
Key Concept: Research findings and conclusions
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Comparative analysis and synthesis
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Statistical analysis and interpretation
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 47: Diagram/Chart/Graph]
Note: Comparative analysis and synthesis
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Theoretical framework and methodology
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Fundamental concepts and principles
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Quiz 6: Theoretical framework and methodology
Remember: Theoretical framework and methodology
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Historical development and evolution
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 52: Comparative analysis and synthesis
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 53: Diagram/Chart/Graph]
Example 53: Practical applications and examples
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Important: Comparative analysis and synthesis
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 55: Diagram/Chart/Graph]
Example 55: Literature review and discussion
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Problem-solving strategies and techniques
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Case studies and real-world applications
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Best practices and recommendations
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 59: Current trends and future directions
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 60: Diagram/Chart/Graph]
Topic 7: Ethical considerations and implications
Remember: Case studies and real-world applications
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Fundamental concepts and principles
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Theoretical framework and methodology
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Case studies and real-world applications
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 64: Diagram/Chart/Graph]
Important: Critical analysis and evaluation
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 65: Literature review and discussion
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Case studies and real-world applications
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Best practices and recommendations
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 68: Practical applications and examples
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 69: Critical analysis and evaluation
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Conclusion 8: Assessment criteria and rubrics
Important: Current trends and future directions
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Definition: Statistical analysis and interpretation
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Learning outcomes and objectives
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Ethical considerations and implications
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Example 74: Theoretical framework and methodology
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Practical applications and examples
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Fundamental concepts and principles
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Practical applications and examples
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 78: Theoretical framework and methodology
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Historical development and evolution
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 80: Diagram/Chart/Graph]
Results 9: Current trends and future directions
Example 80: Literature review and discussion
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Key terms and definitions
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Historical development and evolution
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Learning outcomes and objectives
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 84: Research findings and conclusions
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 85: Learning outcomes and objectives
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Interdisciplinary approaches
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 87: Diagram/Chart/Graph]
Key Concept: Literature review and discussion
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Study tips and learning strategies
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
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