Glavna Maingot’s Abdominal Operations

Maingot’s Abdominal Operations

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The definitive full-color illustrated guide to abdominal operations for general, colorectal, and gastrointestinal surgeons

With each edition, Maingot's Abdominal Operations has built a legacy of expertise, currency, and clinical rigor acclaimed by surgical trainees and practicing surgeons. Presented in full-color, the Thirteenth Edition offers a concise, yet complete, survey of the diagnosis and management of benign and malignant digestive diseases. This authoritative resource has everything clinicians need to understand congenital, acquired, and neoplastic disorders--and optimize surgical outcomes for any type of abdominal procedure.

? Increased number of algorithms to assist surgical decision making
? Contemporary focus on operative procedures, and new concepts in the diagnosis and management of abdominal disease
? Convenient organ/procedure presentation provides a seamless review of surgical protocols, as well as pre- and postoperative strategies and techniques
? "Perspective Chapters? provide insight from thought leaders on the latest developments in abdominal surgery
? Chapters on gastrointestinal bleeding, abdominal trauma, and abdominal vascular emergencies--along with minimally invasive surgery chapters woven throughout the text--present current, ready-to-use insights designed to enhance surgical care and recovery
? More than 1,250 illustrations (most in full color)
13th Edition
McGraw-Hill Education / Medical
ISBN 13:
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Medicine is an ever-changing science. As new research
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1. Gastrointestinal Surgery: A Historical Perspective
David L. Nahrwold

2. Preoperative and Postoperative Management
Zara Cooper / Edward Kelly

3. Enhanced Recovery Programs for Gastrointestinal Surgery
Anthony J. Senagore

4. Performance Measurement and Improvement in Surgery
Andrew M. Ibrahim / Justin B. Dimick

5. Endoscopy and Endoscopic Intervention
Nabil Tariq / Jeff Van Eps / Brian J. Dunkin

6. Fundamentals of Laparoscopic Surgery
Fernando Mier / John G. Hunter

7. Minimally Invasive Approaches to Cancer
Jonathan C. King / Herbert J. Zeh, III

8. Robotics in Gastrointestinal Surgery

Yanghee Woo / Yuman Fong

9. Pediatric GI Surgery
Tina Thomas / Cabrini Sutherland / Ronald B. Hirschl


10. Incisions, Closures, and Management of the Abdominal Wound
Robert E. Roses / Jon B. Morris

11. Inguinal Hernia
Natalie Liu / Jacob A. Greenberg / David C. Brooks

12. Perspective on Inguinal Hernias
Parth K. Shah / Robert J. Fitzgibbons, Jr.

13. Ventral and Abdominal Wall Hernias
Andrew Bates / Mark Talamini

14. Perspectives on Laparoscopic Incisional Hernia Repair
Camille Blackledge / Mary T. Hawn

15. Intestinal Stomas
Cindy Kin / Mark Lane Welton

16. Abdominal Abscess and Enteric Fistulae
Joao B. Rezende Neto / Jory S. Simpson / Ori D. Rotstein

17. Gastrointestinal Bleeding
Eric G. Sheu / Ali Tavakkoli

18. Lesions of the Omentum, Mesentery, and Retroperitoneum
Tara A. Russell / Fritz C. Eilber

19. Abdominal Trauma
L.D. Britt / Jessica Burgess

20. Abdominal Vascular Emergencies
John J. Ricotta / Cameron M. Akbari


21. Esophageal Diverticula and Benign Tumors
Marco E. Allaix / Marco G. Patti

22. Achalasia and Other Motility Disorders
Jeffrey A. Blatnik / Jeffrey L. Ponsky

23. Gastroesophageal Reflux Disease, Hiatal Hernia, and Barrett
Robert D. Bennett / David M. Straughan / Vic Velanovich

24. Paraesophageal Hernia Repair
Jeffrey A. Blatnik / L. Michael Brunt

25. Perspectives Regarding Benign Foregut Diseases and Their Surgeries
Lee L. Swanstrom / Silvana Perretta

26. Cancer of the Esophagus
Daniel King Hung Tong / Simon Law

27. Surgical Procedures to Resect and Replace the Esophagus
Jon O. Wee / Shelby J. Stewart / Raphael Bueno

28. Perspective on Cancer of the Esophagus and Surgical Procedures to
Resect and Replace the Esophagus
Joshua A. Boys / Tom R. DeMeester


29. Benign Gastric Disorders

Ian S. Soriano / Kristofell R. Dumon / Daniel T. Dempsey

30. Gastric Atony
Rian M. Hasson / Scott A. Shikora

31. Gastric Adenocarcinoma and Other Neoplasms
Waddah B. Al-Refaie / Young K. Hon / Jennifer F. Tseng

32. Perspective on Gastric Cancer
Hisashi Shinohara / Mitsuru Sasako

33. Gastrointestinal Stromal Tumors
Nicole J. Look Hong / Chandrajit P. Raut

34. Perspective on Gastrointestinal Stromal Tumors
Michael J. Cavnar / Ronald P. DeMatteo

35. Stomach and Duodenum: Operative Procedures
Joyce Wong / David I. Soybel / Michael J. Zinner

36. Morbid Obesity, Metabolic Syndrome, and Nonsurgical Weight
Ali Tavakkoli

37. Surgical Treatment of Morbid Obesity and Type 2 Diabetes
Bruce D. Schirmer


38. Small Bowel Obstruction
Kristina L. Go / Janeen R. Jordan / George A. Sarosi, Jr. / Kevin E. Behrns

39. Tumors of the Small Intestine
Michael M. Reader / Barbara Lee Bass

40. Carcinoid Tumors and Carcinoid Syndrome

Teresa S. Kim / Liliana G. Bordeianou / Richard A. Hodin

41. Appendix and Small Bowel Diverticula
Arin L. Madenci / William H. Peranteau / Douglas S. Smink

42. Short Bowel Syndrome and Intestinal Transplantation
Diego C. Reino / Douglas G. Farmer

43. Diverticular Disease and Colonic Volvulus
Timothy Eglinton / Frank A. Frizelle

44. Colonic Volvulus
Christina M. Papageorge / Eugene F. Foley

45. Crohn’s Disease
Heather Yeo / Alessandro Fichera / Roger D. Hurst / Fabrizio Michelassi

46. Ulcerative Colitis
Christina W. Lee / Freddy Caldera / Tiffany Zens / Gregory D. Kennedy

47. Perspective on Inflammatory Bowel Disease
Patricia L. Roberts

48. Hereditary Colorectal Cancer and Polyposis Syndromes
Jennifer L. Irani / Elizabeth Breen / Joel Goldberg

49. Tumors of the Colon
Trevor M. Yeung / Neil J. Mortensen

50. Laparoscopic Colorectal Procedures
Dorin Colibaseanu / Heidi Nelson

51. Perspective on Colorectal Neoplasms
Martin R. Weiser


52. Benign Disorders of the Anorectum (Pelvic Floor, Fissures,
Hemorrhoids, and Fistulas)
James W. Fleshman, Jr. / Anne Y. Lin

53. Constipation and Incontinence
Alexander T. Hawkins / Liliana G. Bordeianou

54. Cancer of the Rectum
Joel Goldberg / Ronald Bleday

55. Cancer of the Anus
Najjia N. Mahmoud


56. Hepatic Abscess and Cystic Disease of the Liver
Nikolaos A. Chatzizacharias / Kathleen K. Christians / Henry A. Pitt

57. Benign Liver Neoplasms
Kevin C. Soares / Timothy M. Pawlik

58. Malignant Liver Neoplasms
Sameer H. Patel / Guillaume Passot / Jean-Nicolas Vauthey

59. Treatment of Hepatic Metastasis
Sean M. Ronnekleiv-Kelly / Sharon M. Weber

60. Perspective on Liver Resection
Jordan M. Cloyd / Timothy M. Pawlik

61. Portal Hypertension
Douglas W. Hanto / Sunil K. Geevarghese / Christopher Baron


62. Cholelithiasis and Cholecystitis
Ezra N. Teitelbaum / Nathaniel J. Soper

63. Choledocholithiasis and Cholangitis
Yu Liang / David W. McFadden / Brian D. Shames

64. Choledochal Cyst and Benign Biliary Strictures
Purvi Y. Parikh / Keith D. Lillemoe

65. Cancer of the Gallbladder and Bile Ducts
Jason S. Gold / Michael J. Zinner / Edward E. Whang

66. Laparoscopic Biliary Procedures
Alexander Perez / Theodore N. Pappas

67. Perspective on Biliary Chapters
Steven M. Strasberg


68. Management of Acute Pancreatitis
Thomas E. Clancy

69. Complications of Acute Pancreatitis
John A. Windsor / Benjamin P.T. Loveday / Sanjay Pandanaboyana

70. Perspective on Management of Patients with Acute Pancreatitis
Stefan A.W. Bouwense / Hjalmar C. van Santvoort / Marc G.H. Besselink

71. Chronic Pancreatitis
Marshall S. Baker / Jeffrey B. Matthews

72. Cystic Neoplasms of the Pancreas
Michael J. Pucci / Charles J. Yeo

73. Cancers of the Periampullary Region and Pancreas

Csaba Gajdos / Martin McCarter / Barish Edil / Alessandro Paniccia /
Richard D. Schulick

74. Endocrine Tumors of the Pancreas
Mary E. Dillhoff / E. Christopher Ellison

75. Perspective on Pancreatic Neoplasms
Douglas B. Evans

76. Complications of Pancreatectomy
Mu Xu / O. Joe Hines


77. The Spleen
Liane S. Feldman / Amani Munshi / Mohammed Al-Mahroos / Gerald M.

78. Adrenal Anatomy and Physiology
David Harris / Daniel Ruan



Cameron M. Akbari, MD, MBA, FACS
Senior Attending Physician, Vascular Surgery
Director, Vascular Diagnostic Laboratory
Medstar Washington Hospital Center
Washington, DC

Marco E. Allaix, MD, PhD
Assistant Professor in General Surgery
Department of Surgical Sciences
University of Torino
Torino, Italy

Mohammed Al-Mahroos, MD
Fellow, Minimally Invasive Surgery
McGill University
Montreal, Quebec, Canada

Waddah B. Al-Refaie, MD, FACS
John S. Dillon Professor and Chief of Surgical Oncology
MedStar Georgetown University Hospital
Georgetown Lombardi Comprehensive Cancer Center
Washington, DC

Marshall S. Baker, MD, MBA
Clinical Associate Professor of Surgery
Loyola University Chicago
Stritch School of Medicine

Maywood, Illinois

Christopher Baron, MD
Assistant Professor
Department of Interventional Radiology
Vanderbilt University Hospital
Nashville, Tennessee

Barbara Lee Bass, MD
Bookout Distinguished Presidential Endowed Chair
Chair, Department of Surgery
Houston Methodist Hospital
Professor of Surgery
Weill Cornell Medical College and Houston Methodist Institute for

Academic Medicine
Full Member
Houston Methodist Research Institute
Houston, Texas

Andrew Bates, MD
Department of Surgery
Stony Brook University Hospital
Stony Brook, New York

Kevin E. Behrns, MD
Vice President Medical Affairs
Dean, School of Medicine
St. Louis University
St. Louis, Missouri

Robert D. Bennett, MD
Resident in General Surgery
Department of Surgery
University of South Florida
Tampa, Florida

Marc G. H. Besselink, MD, MSc, PhD
Professor of Pancreatic and Hepatobiliary Surgery
Department of Surgery, Cancer Center Amsterdam
Amsterdam UMC, University of Amsterdam
Amsterdam, the Netherlands

Camille Blackledge, MD
Fellow, Division of Gastrointestinal Surgery
Department of Surgery
University of Alabama at Birmingham School of Medicine
Birmingham, Alabama

Jeffrey A. Blatnik, MD
Assistant Professor of Surgery
Department of Surgery, Section of Minimally Invasive Surgery
Washington University School of Medicine
St. Louis, Missouri

Ronald Bleday, MD
Section of Colon and Rectal Surgery
Associate Chair for Quality and Safety
Department of Surgery
Brigham and Women’s Hospital
Associate Professor of Surgery
Harvard Medical School
Boston, Massachusetts

Liliana G. Bordeianou, MD, MPH
Chair, Colorectal Surgery Center
Massachusetts General Hospital
Associate Professor of Surgery
Harvard Medical School
Boston, Massachusetts

Stefan A. W. Bouwense, MD, PhD

Fellow, Gastrointestinal Surgery
Radboud University Medical Center
Department of Surgery
Nijmegen, the Netherlands

Joshua A. Boys, MD
Cardiothoracic Surgery Fellow
General Thoracic Surgery Section
University of Virginia Department of Surgery
Division of Cardiothoracic and Vascular Surgery
University of Virginia School of Medicine
Charlottesville, Virginia

Elizabeth Breen, MD
Colon and Rectal Surgeon
Lahey Hospital and Medical Center
Program Director
Colon and Rectal Surgery Residency
Lahey Hospital and Medical Center
Burlington, Massachusetts

L. D. Britt, MD, MPH, DSc (Hon), FACS, FCCM, FRCSEng(Hon),
FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FSC(SA)(Hon),

Henry Ford Professor and Edward J. Brickhouse Chairman
Eastern Virginia Medical School
Norfolk, Virginia

David C. Brooks, MD, FACS
Director of Minimally Invasive Surgery
Senior Surgeon
Brigham and Women’s Hospital
Associate Professor of Surgery Harvard Medical School
Boston, Massachusetts

L. Michael Brunt, MD

Section Chief, Minimally Invasive Surgery
Department of Surgery
Washington University School of Medicine
St. Louis, Missouri

Raphael Bueno, MD
Fredric G Levin Distinguished Chair in Thoracic Surgery and Lung Cancer

Chief, Division of Thoracic Surgery
Co-Director, The Lung Center and the Lung Research Center
Brigham and Women’s Hospital
Professor of Surgery
Harvard Medical School
Boston, Massachusetts

Jessica Burgess, MD, FACS
Assistant Professor
Department of Surgery
Eastern Virginia Medical School
Norfolk, Virginia

Freddy Caldera, DO, MS
Assistant Professor
Department of Gastroenterology and Hepatology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

Michael J. Cavnar, MD
Assistant Professor
Department of Surgery
Section of Surgical Oncology
University of Kentucky
Lexington, Kentucky

Nikolaos A. Chatzizacharias, MD, PhD
Medical College of Wisconsin

Milwaukee, Wisconsin

Kathleen K. Christians, MD
Medical College of Wisconsin
Milwaukee, Wisconsin

Thomas E. Clancy, MD
Division of Surgical Oncology
Brigham and Women’s Hospital
Dana-Farber Cancer Institute
Assistant Professor of Surgery, Harvard Medical School
Boston, Massachusetts

Jordan M. Cloyd, MD
Assistant Professor of Surgery
Division of Surgical Oncology
The Ohio State University Wexner Medical Center
Columbus, Ohio

Dorin Colibaseanu, MD
Vice Chair of Education
Department of Surgery
Assistant Professor of Surgery
Mayo Clinic
Jacksonville, Florida

Zara Cooper, MD, MSc, FACS
Associate Professor
Department of Surgery
Associate Chair of Faculty Development
Department of Trauma Burn and Surgical Critical Care
Brigham and Women’s Hospital
Boston, Massachusetts

Ronald P. DeMatteo, MD, FACS
John Rhea Barton Professor and Chair

Department of Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania

Tom R. DeMeester, MD
The Jeffrey P. Smith Professor of General and Thoracic Surgery
Department of Surgery, Emeritus
Keck School of Medicine
University of Southern California
Los Angeles, California

Daniel T. Dempsey, MD, MBA
Professor of Surgery
Perelman School of Medicine
University of Pennsylvania
Assistant Director of Perioperative Services
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania

Mary E. Dillhoff, MD, MS
Assisatnt Professor of Surgery
Department of Surgery
The Ohio State University
Columbus, Ohio

Justin B. Dimick, MD, MPH
George D. Zuidema Professor of Surgery
Chief of the Division of Minimally Invasive Surgery
Director, Center for Healthcare Outcomes and Policy
Associate Chair for Strategy and Finance
Department of Surgery, University of Michigan
Ann Arbor, Michigan

Kristofell R. Dumon, MD, FACS

Associate Professor of Surgery
Department of Surgery
Hospital Penn Medicine
Philadelphia, Pennsylvania

Brian J. Dunkin, MD, FACS
Professor of Surgery
Weill Cornell Medical College
John F., Jr. and Carolyn Bookout Chair in Surgical Innovation & Technology
Medical Director
Houston Methodist Institute for Technology, Innovation, and Education

Houston Methodist Hospital
Houston, Texas

Barish Edil, MD, FACS
Associate Professor of Surgery
Chief, Section of Surgical Oncology
University of Colorado at Denver
Denver, Colorado

Timothy Eglinton, MBChB, MMedSc, FRACS, FACS, FCSSANZ
Associate Professor
Department of Surgery
University of Otago
Christchurch, New Zealand

Fritz C. Eilber, MD
Professor of Surgery
Professor of Molecular and Medical Pharmacology
Director UCLA—JCCC Sarcoma Program
UCLA Division of Surgical Oncology
Los Angeles, California

E. Christopher Ellison, MD
Academy Professor

Robert M. Zollinger Professor Emeritus
Department of Surgery
The Ohio State University College of Medicine
Columbus, Ohio

Douglas B. Evans, MD
Professor and Chair
Department of Surgery
Medical College of Wisconsin
Milwaukee, Wisconsin

Douglas G. Farmer, MD, FACS
Professor of Surgery
Surgical Director, Pediatric Liver Transplantation
Surgical Director, Intestinal Transplantation
Division of Liver and Pancreas Transplantation
David Geffen School of Medicine at UCLA
Los Angeles, California

Liane S. Feldman, MD
Steinberg-Bernstein Chair of Minimally Invasive Surgery and Innovation
McGill University Health Centre
Director, Division of General Surgery
McGill University
Montreal, Quebec, Canada

Alessandro Fichera, MD, FACS, FASCRS
Professor and Division Chief Gastrointestinal Surgery
Department of Surgery
University of North Carolina
Chapel Hill, North Carolina

Robert J. Fitzgibbons, Jr., MD, FACS
Harry E. Stuckenhoff Professor and Chairman
Department of Surgery
Creighton University School of Medicine

Co-editor in Chief, Hernia
CHI Health Creighton University-Bergan Mercy
Omaha, Nebraska

James W. Fleshman, Jr., MD
Sparkman Endowed Chair in Surgery
Chairman, Department of Surgery
Baylor University Medical Center
Professor of Surgery
Texas A&M Health Science Center
Dallas, Texas

Eugene F. Foley, MD, FACS
Susan Behren’s MD, Professor and Chair of Surgical Education
Vice Chair for Education
Chief, Division of Colon and Rectal Surgery
Department of Surgery
University of Wisconsin
Madison, Wisconsin

Yuman Fong, MD, Sc.D. (Hon)
Department of Surgery
City of Hope Medical Center
Duarte, California

Gerald M. Fried, MD
Edward W. Archibald Professor and Chair
Department of Surgery
McGill University
Surgeon-in-Chief, McGill University Health Centre
Montreal, Quebec, Canada

Frank A. Frizelle, MBChB, MMedSci, FRACS, FACS, FASCRS, FRCSI
(Hon), FNZMA

Professor Head of University Department of Surgery

Department of Surgery
Christchurch Hospital
University of Otago
Christchurch, New Zealand

Csaba Gajdos, MD, FACS
Clinical Associate Professor of Surgery
Department of Surgery
Jacobs School of Medicine and Biomedical Science
Buffalo, New York

Sunil K. Geevarghese, MD, MSCI, FACS
Medical Director, Acute Operations and Transplant Perioperative Services
Program Director, Vanderbilt ASTS Transplant and Hepatobiliary Surgery

Associate Professor of Surgery, Radiology and Radiological Sciences
Division of Hepatobiliary Surgery and Liver Transplantation
Vanderbilt University Medical Center
Nashville, Tennessee

Kristina L. Go, MD
Chief Resident
University of Florida
Department of Surgery
Gainesville, Florida

Jason S. Gold, MD
Chief of Surgical Oncology, VA Boston Healthcare System
Associate Professor of SurgeryHarvard Medical School
Brigham and Women’s Hospital
West Roxbury, Massachusetts

Joel Goldberg, MD, MPH, FACS
Assistant Professor of Surgery
Harvard Medical School
Colon and Rectal Surgery

Brigham and Women’s Hospital
Boston, Massachusetts

Jacob A. Greenberg, MD, EdM
Associate Professor of Surgery
General Surgery Residency Program Director
University of Wisconsin
Department of Surgery
Madison, Wisconsin

Douglas W. Hanto, MD, PhD
Deputy Chief of Surgery
VA St. Louis Health Care System
St. Louis, Missouri
Lewis Thomas Professor of Surgery Emeritus
Harvard Medical School
Boston, Massachusetts

David Harris, MD
Clinical Fellow in Surgery (EXT)
Brigham and Women’s Hospital
Department of Surgery
Boston, Massachusetts

Rian M. Hasson Charles, MD
Assistant Professor of Surgery
Department of Surgery, Section of Thoracic Surgery
Dartmouth-Hitchcock Medical Center
Geisel School of Medicine at Dartmouth
Lebanon, New Hampshire

Alexander T. Hawkins, MD, MPH
Assistant Professor of Surgery
Vanderbilt University Medical Center
Nashville, Tennessee

Mary T. Hawn, MD, MPH
Professor, Chief of Gastrointestinal Surgery
Department of Surgery
University of Alabama at Birmingham School of Medicine
Birmingham, Alabama

O. Joe Hines, MD, FACS
Professor and Chief
Division of General Surgery
Robert and Kelly Day Chair in General Surgery
Vice Chair for Administration
Department of Surgery
David Geffen School of Medicine
University of California at Los Angeles
Los Angeles, California

Ronald B. Hirschl, MD, MS
Professor of Pediatric Surgery
Department of Surgery
Mott Children’s Hospital
University of Michigan
Ann Arbor, Michigan

Richard A. Hodin, MD
Chief of Academic Affairs
Department of Surgery
Massachusetts General Hospital
Professor of Surgery, Harvard Medical School
Boston, Massachusetts

Nicole J. Look Hong, MD, MSc, FRCSC
Division of Surgical Oncology
Sunnybrook Health Sciences Centre
Assistant Professor of Surgery
University of Toronto

Toronto, Canada

Young K. Hong, MD
Surgical Oncology Fellow
Division of Surgical Oncology
University of Louisville
Louisville, Kentucky

John G. Hunter, MD, FACS
Executive Vice President and Chief Executive Officer, OHSU Health System
Mackenzie Professor, OHSU School of Medicine
Oregon Health & Science University
Portland, Oregon

Roger D. Hurst, MD
Professor of Surgery
University of Chicago
Pritzker School of Medicine
Chicago, Illinois

Andrew M. Ibrahim, MD, MSc
Robert Wood Johnson Clinical Scholar
Institute for Healthcare Policy & Innovation, University of Michigan House

Staff, General Surgery University Hospitals Case Medical Center
Ann Arbor, Michigan

Jennifer L. Irani, MD
Assistant Professor of Surgery
Harvard Medical School
Associate Surgeon, General and Gastrointestinal Surgery
Brigham and Women’s Hospital and Dana-Farber Cancer Institute
Boston, Massachusetts

Janeen R. Jordan, MD
Critical Care (Intensivist)
General Surgery

Orange Park Surgical Associates
Orange Park, Florida

Edward Kelly, MD, FACS
Assistant Professor of Surgery
Department of Trauma Burn and Surgical Critical Care
Brigham and Women’s Hospital
Boston, Massachusetts

Gregory D. Kennedy, MD, PhD
John H. Blue Chair in General Surgery and Professor of Surgery
Director, Division of Gastrointestinal Surgery
University of Alabama at Birmingham School of Medicine
Birmingham, Alabama

Teresa S. Kim, MD
Assistant Professor
Surgical Oncology, Department of Surgery
University of Washington
Seattle, Washington

Assistant Professor of Surgery
Stanford University Department of Surgery
Stanford, California

Jonathan C. King, MD
David Geffen School of Medicine at UCLA
Department of Surgery
Los Angeles, California
Santa Monica General Surgery
Santa Monica, California

Simon Law, MBBChir (Cantab), MA, MS (HK), PhD (HK), FRCSEd,

Cheung Kung-Hai Endowed Chair

Chair Professor in Esophageal and Upper Gastrointestinal Surgery
Department of Surgery
The University of Hong Kong
Hong Kong, the People’s Republic of China

Christina W. Lee, MD
Resident Physician
University of Wisconsin School of Medicine and Public Health
Department of Surgery
Madison, Wisconsin

Yu Liang, MD
Assistant Professor
Department of General Surgery
UConn Health
Farmington, Connecticut

Keith D. Lillemoe, MD
Chief, Department of Surgery
Massachusetts General Hospital
W. Gerald Austen Professor of Surgery
Harvard Medical School
Boston, Massachusetts

Anne Y. Lin, MD, MSHS
Assistant Professor of Surgery
Department of Surgery
Section of Colon and Rectal Surgery
University of California Los Angeles
Los Angeles, California

Natalie Liu, MD
General Surgery Resident
University of Wisconsin
Department of Surgery

Madison, Wisconsin

Benjamin P.T. Loveday, MBChB, PhD, FRACS
Senior Lecturer in Surgery
University of Auckland
Consultant HBP Surgeon
Auckland City Hospital
Auckland, New Zealand

Arin L. Madenci, MD, MPH
Resident, General Surgery
Brigham and Women’s Hospital
Harvard Medical School
Boston, Massachusetts

Najjia N. Mahmoud, MD
Emilie and Roland T. DeHellebranth Professor of Surgery
Chief, Division of Colon and Rectal Surgery
University of Pennsylvania Health System
Philadelphia, Pennsylvania

Jeffrey B. Matthews, MD, FACS
Dallas B. Phemister Professor of Surgery and Chairman
Department of Surgery
The University of Chicago
Chicago, Illinois

Martin McCarter, MD, FACS
Professor of Surgery, Section of Surgical Oncology
University of Colorado at Denver
Denver, Colorado

David W. McFadden, MD, MBA
Murray-Heilig Professor and Chairman
Department of Surgery
The University of Connecticut

Farmington, Connecticut

Fabrizio Michelassi, MD
Lewis Atterbury Stimson Professor
Chairman, Department of Surgery
Weill Cornell Medicine
New York-Presbyterian Weill Cornell Medical Center
New York, New York

Fernando Mier, MD
Division of General and Gastrointestinal Surgery
Department of Surgery and the Digestive Health Center
Oregon Health and Science University
Portland, Oregon

Jon B. Morris, MD
The Ernest F. Rosato—William Maul Measey Professor in Surgical

Vice Chair for Education, Department of Surgery Hospital
University of Pennsylvania
Philadelphia, Pennsylvania

Neil J. Mortensen, MA, MBChB, MD, FRCS Eng, Hon FRCPS Glas,
Hon FRCS Edin, Hon FRCSI

Professor of Colorectal Surgery
Nuffield Department of Surgery
University of Oxford
Hon Consultant Surgeon
Department of Colorectal Surgery, Churchill Hospital
Oxford University Hospitals, Oxford
England, United Kingdom

Amani Munshi, MD, FRCSC, FACS
Clinical Assistant Professor
Department of Surgery

University Hospitals, St. John Medical Center
Westlake, Ohio

David L. Nahrwold, MD
Emeritus Professor of Surgery
Department of Surgery
Feinberg School of Medicine
Northwestern University
Chicago, Illlinois

Heidi Nelson, MD
Fred C. Andersen Professor of Surgery
Chair, Department of Surgery
Mayo Clinic
Rochester, Minnesota

Sanjay Pandanaboyana, MBBS, MPhil, FRCS
Consultant HBP Surgeon
Auckland City Hospital
Auckland, New Zealand

Alessandro Paniccia, MD
Chief Resident in General Surgery
Department of Surgery
University of Colorado Anschutz Medical Campus
Denver, Colorado

Christina M. Papageorge, MD, MS
General Surgery Resident
University of Wisconsin Hospital and Clinics
Department of Surgery
Madison, Wisconsin

Theodore N. Pappas, MD, FACS
Distinguished Professor of Surgical Innovation
Chief of Advanced Oncologic and Gastrointestinal Surgery

Duke University School of Medicine
Durham, North Carolina

Purvi Y. Parikh, MD, FACS
Hepato-Pancreato-Biliary Surgeon
Director, Center of Excellence for HPB Care
The Permanente Medical Group, Inc.
Kaiser–Sacramento Medical Center
Department of Surgery
Sacramento, California

Guillaume Passot, MD, PhD
Department of Surgical Oncology
CHU Lyon Sud, Pierre Bénite, France
Professor of Surgery
Lyon 1 University
Lyon, France

Sameer H. Patel, MD, FACS
Department of Surgical Oncology
The University of Texas MD Anderson Cancer Center
Houston, Texas

Marco G. Patti, MD, FACS
Professor of Medicine and Surgery
Co-Director, Center for Esophageal Diseases and Swallowing
University of North Carolina School of Medicine
Chapel Hill, North Carolina

Timothy M. Pawlik, MD, MPH, MTS, PhD, FACS, FRACS (Hon)
Professor and Chair, Department of Surgery
The Urban Meyer III and Shelley Meyer Chair for Cancer Research
Professor of Surgery, Oncology, and Health Services Management and Policy
Surgeon in Chief
The Ohio State University Wexner Medical Center
Columbus, Ohio

William H. Peranteau, MD
Assistant Professor of Surgery
The Division of Pediatric General, Thoracic, and Fetal Surgery
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Alexander Perez, MD, FACS
Assistant Professor of Surgery
Chief of Pancreatic Surgery
Duke University School of Medicine
Durham, North Carolina

Silvana Perretta, MD
Professor of Surgery
Department of Digestive and Endocrine Surgery
NHC University Hospital
Director of Education IRCAD-IHU
Strasbourg, France

Henry A. Pitt, MD
Temple University
Philadelphia, Pennsylvania

Jeffrey L. Ponsky, MD, MBA, FACS
Lynda and Marlin Younker Chair in Developmental Endoscopy
Professor of Surgery
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Cleveland, Ohio

Michael J. Pucci, MD, FACS
Associate Professor of Surgery
Sidney Kimmel Medical College of Thomas Jefferson University
Co-Director, Advanced Gastrointestinal Surgery Fellowship
Associate Director, Undergraduate Education
Division of General Surgery, Department of Surgery

Philadelphia, Pennsylvania

Chandrajit P. Raut, MD, MSc, FACS
Associate Surgeon
Division of Surgical Oncology, Brigham and Women’s Hospital
Surgery Director, Center for Sarcoma and Bone Oncology
Dana-Farber Cancer Institute
Associate Professor of Surgery
Harvard Medical School
Boston, Massachusetts

Michael M. Reader, MD, FACS
General Surgery
Houston Methodist Surgical Associates
Assistant Professor of Clinical Surgery
Weill Cornell Medical College
Houston, Texas

Diego C. Reino, MD
Cleveland Clinic Florida
Transplant and Hepatobiliary Surgery
Department of Solid Organ Transplantation
Weston, Florida

Joao B. Rezende Neto, MD, PhD, FRCSC, FACS
Associate Professor
Department of Surgery
University of Toronto
Trauma and Acute Care Surgery
Division of General Surgery
St. Michael’s Hospital
Surgeon Investigator—Keenan Research Center for Biomedical Sciences
Toronto, Ontario

John J. Ricotta, MD, FACS

Clinical Professor of Surgery
George Washington University
Washington, DC

Patricia L. Roberts, MD
Chair, Division of Surgery
Senior Staff Surgeon, Department of Colon and Rectal Surgery
Lahey Hospital and Medical Center
Burlington, Massachusetts
Professor of Surgery
Tufts University School of Medicine
Boston, Massachusetts

Sean M. Ronnekleiv-Kelly
University of Wisconsin Hospital and Clinics
Department of Surgery
Clinical Science Center
Madison, Wisconsin

Robert E. Roses, MD
Assistant Professor
Department of Surgery
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania

Ori D. Rotstein, MD
Professor and Associate Chair of Surgery
University of Toronto
Surgeon-in-Chief, St. Michael’s Hospital
Toronto, Ontario

Daniel Ruan, MD
General Surgeon
Department of Surgery
Tampa General Hospital

Tampa, Florida

Tara A. Russell, MD, MPH, PhD
Resident Physician
UCLA Department of General Surgery
Los Angeles, California

George A. Sarosi, Jr., MD
Professor and Program Director
Vice Chair of Education
Department of Surgery
University of Florida
Gainesville, Florida

Mitsuru Sasako, MD, PhD
Special Consultant Surgeon
Department of Surgery
Yodogawa Christian Hospital
Professor Emeritus
Hyogo College of Medicine
Nishinomiya, Japan

Bruce D. Schirmer, MD
Stephen H. Watts Professor of Surgery
University of Virginia Health System
Department of Surgery
Charlottesville, Virginia

Richard D. Schulick, MD, MBA, FACS
Aragón/Gonzalez-Gíustí Endowed Chair
Chair, Department of Surgery
Director, Cancer Center
Professor of Surgery
University of Colorado School of Medicine
Aurora, Colorado

Anthony J. Senagore, MD, MS, MBA
Professor, Vice Chair for Research
Department of Surgery
Western Michigan University - Homer Stryker MD School of Medicine
Kalamazoo, Michigan

Parth K. Shah, MBBS
Fellow in Complex General Surgical Oncology
H. Lee Moffitt Cancer Center
University of South Florida
Tampa, Florida

Brian D. Shames, MD
Associate Professor of Surgery
Division Chief General Surgery
Program Director General Surgery Residency
University of Connecticut School of Medicine
Farmington, Connecticut

Eric G. Sheu, MD, D.Phil
Associate Surgeon
Brigham and Women’s Hospital
Assistant Professor of Surgery
Harvard Medical School
Boston, Massachusetts

Scott A. Shikora, MD, FACS
Professor of Surgery
Harvard Medical School
Director, Center for Metabolic and Bariatric Surgery
Department of Surgery
Brigham and Women’s Hospital
Boston, Massachusetts

Hisashi Shinohara, MD, PhD
Chairman, Upper GI Division

Department of Surgery
Hyogo College of Medicine
Nishinomiya, Japan

Jory S. Simpson, MD, MEd, FRCSC
Assistant Professor
Department of Surgery
University of Toronto
Division of General Surgery
St. Michael’s Hospital
Toronto, Canada

Douglas S. Smink, MD, MPH
Program Director
General Surgery Residency
Associate Chair of Surgery
Department of Surgery
Brigham and Women’s Hospital
Associate Professor of Surgery
Harvard Medical School
Boston, Massachusetts

Kevin C. Soares, MD
Resident in General Surgery
Department of Surgery
The Johns Hopkins School of Medicine
Baltimore, Maryland

Nathaniel J. Soper, MD, FACS
Loyal and Edith Professor and Chairman of Surgery
Surgeon-in-Chief, Northwestern Memorial Hospital
Northwestern Medicine
Chicago, Illinois

Clinical Assistant Professor of Surgery

Perelman School of Medicine
University of Pennsylvania
Pennsylvania Hospital
Philadelphia, Pennsylvania
Visiting Assistant Professor of Surgery
University of the Philippines College of Medicine
Philippine General Hospital
Manila, Philippines

David I. Soybel MD, FACS
David L. Nahrwold Professor of Surgery
Division Chief, General Surgery Specialties & Surgical Oncology
Vice-Chairman (Research)
Department of Surgery
Penn State Hershey Medical Center
Hershey, Pennsylvania

Shelby J. Stewart, MD
Assistant Professor
Department of Thoracic surgery
University of Maryland
Baltimore, Maryland

Steven M. Strasberg, MD
Pruett Professor of Surgery
Section of HPB Surgery
Washington University in Saint Louis
Siteman Cancer Center and Barnes-Jewish Hospital
Saint Louis, Missouri

David M. Straughan, MD
Resident in General Surgery
Department of Surgery
University of South Florida
Morsani College of Medicine

Tampa, Florida

Cabrini L. Sutherland, MD, MPH
Acute Care Surgery Service
Trauma Trust
Tacoma, Washington

Lee L. Swanström, MD
Professor of Surgery
The Oregon Clinic
Portland, Oregon

Mark A. Talamini, MD, MBA
Professor and Chair
Department of Surgery
School of Medicine, SUNY Stony Brook
Chief of Surgical Services
Stony Brook Medicine
Stony Brook, New York

Nabil Tariq, MD, FACS
Assistant Professor of Surgery
Department of Surgery
Houston Methodist Hospital
Houston, Texas

Ali Tavakkoli, MD
Interim Chief, Division of General and GI Surgery
Brigham and Women’s Hospital
Co-Director, Center for Weight Management and Metabolic Surgery
Associate Professor of Surgery, Harvard Medical School
Boston, Massachusetts

Ezra N. Teitelbaum, MD, MEd
Assistant Professor of Surgery and Medical Education
Northwestern University

Feinberg School of Medicine
Chicago, Illinois

Tina Thomas, MD
Clinical Lecturer, Pediatric Surgery
Research Fellow, Newman Lab
Department of Pediatric Surgery
C. S. Mott Children’s Hospital
University of Michigan
Ann Arbor, Michigan


Honorary Clinical Associate Professor
The University of Hong Kong
Hong Kong

Jennifer F. Tseng, MD, MPH
Utley Professor and Chair, Department of Surgery
Boston University
Surgeon-in-Chief, Boston Medical Center
Boston, Massachusetts

Jeff Van Epps, MD
Colon and Rectal Surgery
University of Minnesota
Minneapolis, Minnesota

Hjalmar C. van Santvoort, MD, PhD
Hepato-Pancreato-Biliary Surgeon
Associate professor
Regional Academic Cancer Center Utrecht
St. Antonius Hospital Nieuwegein and University Medical Center
Utrecht, the Netherlands

Jean-Nicolas Vauthey, MD, FACS
Professor of Surgery
Chief, Hepato-Pancreato-Biliary Section
Department of Surgical Oncology
The University of Texas MD Anderson Cancer Center
Houston, Texas

Vic Velanovich, MD
Professor of Surgery
Department of Surgery
University of South Florida
Tampa, Florida

Sharon M. Weber, MD, FACS
Tim and MaryAnn McKenzie Chair
of Surgical Oncology
Director for Surgical Oncology
UW Carbone Cancer Center
Professor of Surgery
Department of Surgery
University of Wisconsin
Madison, Wisconsin

Jon O. Wee, MD
Section Chief, Esophageal Surgery
Director of Robotics in Thoracic Surgery
Co-Director of Minimally Invasive Thoracic Surgery
Associate Program Director
Division of Thoracic Surgery
Brigham and Women’s Hospital
Assistant Professor of Surgery
Harvard Medical School
Boston, Massachusetts

Martin R. Weiser, MD

Stuart H. Quan Chair in Colorectal Surgery
Vice Chair, Faculty Affairs
Department of Surgery
Memorial Sloan Kettering Cancer Center
Professor of Surgery
Weill Cornell Medical College
New York, New York

Mark Lane Welton, MD, MHCM
Chief Medical Officer
Fairview Health Services
Professor of Surgery
Section of Colon and Rectal Surgery
University of Minnesota
Minneapolis, Minnesota

Edward E. Whang, MD
Associate Professor of Surgery
Department of Surgery
Brigham and Women’s Hospital
Harvard Medical School
Boston, Massachusetts

John A. Windsor, MD, MBChB, FRACS, FACS, FRSNZ
Professor of Surgery
University of Auckland
Consultant HBP/Upper GI Surgeon
Auckland City Hospital
Auckland, New Zealand

Joyce Wong, MD
Assistant Professor of Surgery
Zucker School of Medicine at Hofstra/Northwell
Lenox Hill Hospital
New York, New York

Yanghee Woo, MD, FACS
Associate Clinical Professor
Vice Chair, International Surgery
Director, GI Minimally Invasive Therapies
Division of Surgical Oncology
Department of Surgery
City of Hope National Medical Center
Duarte, California

Mu Xu, MD, PhD
Resident in Surgery
David Geffen School of Medicine at UCLA
Los Angeles, California

Charles J. Yeo, MD, FACS
Samuel D. Gross Professor and Chairman
Department of Surgery
Jefferson Pancreas, Biliary and Related Cancer Center
Department of Surgery
Sidney Kimmel Medical College
Thomas Jefferson University
Senior Vice President and Enterprise Chair, Surgery
Jefferson Health
Jefferson Pancreas, Biliary, and Related Cancer Center
Co-Editor in Chief, Emeritus
Journal of Gastrointestinal Surgery
Official Publication of the SSAT
Editor in Chief, Journal of Pancreatic Cancer
Philadelphia, Pennsylvania

Heather Yeo, MD, MHS
Assistant Professor of Surgery
Weill Cornell Medical College
Assistant Professor of Public Health

Weill Cornell Medical College
New York, New York

Trevor M. Yeung, MA, MBBChir, D.Phil, FRCS
Specialty Registrar
Department of Colorectal Surgery
Oxford University Hospitals
Oxford, United Kingdom

Herbert J. Zeh, III, MD
University of Pittsburgh Medical Center
Department of Surgery
Pittsburgh, Pennsylvania

Tiffany Zens, MD
University of Wisconsin School of Medicine and Public Health
Department of Surgery
Madison, Wisconsin

Michael J. Zinner, MD, FACS
CEO and Executive Medical Director
Miami Cancer Institute
Miami, Florida
Moseley Professor of Surgery, Emeritus
Harvard Medical School
Boston, Massachusetts


For the editors, the production of the newest edition of Maingot’s Abdominal
Operations represents a labor of love. Maingot’s has always filled a unique
niche. This text has consistently offered a comprehensive discussion of
surgical diseases of the abdomen with a focus on operative strategy and
technique. The book has served as a needed reference to refresh our
knowledge before a common operation or in preparation for a novel one. Our
intended audience for this edition is the same as for the original publication;
the book is meant for the surgical trainee as well as the practicing surgeon,
and for the American surgeon as well as for our international colleagues. We
continue to have a significant international audience and have made every
effort to develop a product that is equally valuable to readers in India as well
as Indiana. This is the fifth effort together for the senior editors, joined this
time by a new editor (O.J.H.) with a fresh vision; it continues to be not only a
pleasure but an honor and a privilege to have the opportunity to co-edit the
13th edition of this classic textbook.

Abdominal surgery has clearly evolved since Rodney Maingot’s first
edition of this text in 1940. Not only has our knowledge base increased
substantially, but the procedures themselves have become both more complex
and less invasive. The current subspecialization in abdominal surgery, a
consequence of these changes, continues to challenge the need for a
comprehensive text. Abdominal disease has been increasingly parceled
between foregut, hepatobiliary, pancreatic, colorectal, endocrine, acute care,
and vascular specialists. The editors continue to believe, however, that the
basic principles of surgical care in each of the anatomic regions have more
similarities than differences. Experience in any one of these organs can
inform and strengthen the approach to each of the others. In fact, in
community hospitals and rural settings both nationally and internationally,
practices spanning multiple subspecialties remain the norm. Few would

question the need for the abdominal surgeon to be well versed in dealing with
any unexpected disease that is encountered in the course of a planned
procedure. For many of us, Maingot’s Abdominal Operations has consistently
helped to fill that need.

This textbook remains primarily disease focused, in addition to
maintaining its organ/procedure format. The new edition of this textbook is a
significant revision and, in many areas, a completely new book. We have
continued to focus some chapters on technical operative procedures, whereas
others elucidate new and continuing concepts in diagnosis and management
of abdominal disease. The new edition is expanded compared with previous
versions, and we have continued to present the opinions and knowledge of
more than one expert. In areas where opinions and approaches differ, we
have added even more “Perspective” commentaries by experts in the field
who we expected might have distinct opinions about approaches and/or
operative techniques. In response to recent developments, we have added
chapters on quality metrics, enhanced recovery after surgery, and robotic
surgery. We have attempted to maintain an international flavor and have
included a cross-section of both seasoned senior contributors and new leaders
in gastrointestinal surgery. We continue to provide a contemporary textbook
on current diagnostic procedures and surgical techniques related to the
management and care of patients with all types of surgical digestive disease.

An extensive artwork program was undertaken for this edition. Many line
drawings have been recreated to reflect the contributors’ preferred method for
performing certain surgical procedures. Some of these drawings are new and
give the book a more consistent look. In addition, this edition continues full-
color text and color line art.

In the preface to the sixth edition, Rodney Maingot noted, “As all
literature is personal, the contributors have been given a free hand with their
individual sections. Certain latitude in style and expression is stimulating to
the thoughtful reader.” Similarly, we have tried to maintain consistency for
the reader, but the authors have also been given a free hand in their chapter

We would like to thank the publisher, McGraw-Hill, and in particular
Christie Naglieri and Andrew Moyer, for their unwavering support during the
lengthy time of development of this project. Their guidance was invaluable to
completing this project in a single comprehensive volume. Their suggestions
and attention to detail made it possible to overcome the innumerable

problems that occur in publishing such a large textbook.
Finally, we want to acknowledge the expertise of each chapter and

perspective contributor. Without their effort, this book would not have been
possible. We acknowledge our editorial assistant, Linda Smith, who has
survived the trials of this book; she has been invaluable, and we never would
have been able to do it without her. Patrina Tucker and Heather Couture have
also stepped up and made this project possible. We owe them a great debt of
gratitude for helping with every step of the work. To all of those who have
participated in the creation and publication of this text, we thank you very

Michael J. Zinner, MD, FACS
Stanley W. Ashley, MD, FACS
O. Joe Hines, MD, FACS


David L. Nahrwold

Surgeons continue to have brilliant ideas and use amazing technology to
bring safe and effective surgery to people all over the world, but it was not
always so. The evolution of surgery to its present state has taken at least 200
years, and surgery is still evolving. Each of the many abdominal operations
surgeons now performed has its own special history, from the idea that
spawned it to the present state of its art. Abdominal operations were brought
to fruition by innovative surgeons who carefully planned them and had the
courage to perform them and the wisdom to modify and improve them.

Although the histories of all abdominal operations are interesting, a
broader view of abdominal surgery puts those stories into perspective. The
broader view is best obtained by asking: What enabled abdominal surgery to
evolve to its present state? What were the barriers to the evolution of
abdominal surgery? How were the barriers overcome, and who overcame

them? Although recognizing the individuals who developed and perfected
individual operations is important, the perspective of this chapter is on how
modern abdominal surgery came about and how it was enabled.

Prior to the middle of the 19th century, few operations were done with the
expectation that the patient would live and be cured of the disease for which
it was performed. The fundamental barrier was the excruciating pain caused
by opening the abdomen and manipulating its contents, even when tempered
by the administration of alcohol or derivatives of opium such as laudanum
and morphine. Patients often died from postoperative bleeding, dehydration,
or malnutrition. But it was infection that was the bane of surgeons. Infections
followed almost all operations. Wound infection and peritonitis were the
killers of patients who had abdominal surgery. Without antibiotics or even
standardized methods of dressing infected wounds, the consequences of
infection were disastrous. Except in a few isolated instances, physicians knew
that surgery was not a realistic therapeutic option until infection, hemorrhage,
dehydration, and malnutrition could be alleviated or eliminated. Remarkable
progress was made during the second half of the 19th century, enabling
surgeons to bring hope to a large number of patients with diseases or
conditions that swiftly became amenable to surgery.

The modernization of abdominal surgery was dependent on the patient’s loss
of sensation, anesthesia, during the procedure. The development of anesthesia
eliminated the cruelty of surgery and enabled surgeons to incise, manipulate,
and suture tissue in a disciplined manner without the urgency and disorder
that surrounded operations in the conscious patient.

Dr. Crawford Long was the first to use ether for general anesthesia, in
1842, but he did not report it until 1849.1 Meanwhile, in 1846, the Boston
dentist William T.G. Morton demonstrated the use of ether as a general
anesthetic in the amphitheater of the Massachusetts General Hospital in a
patient with a tumor of the neck, which was removed by Dr. John Collins
Warren, former Dean of the Harvard Medical School (1816-1819).2

Louis Pasteur conducted experiments between 1860 and 1864 showing that
“pyogenic vibrio” caused puerperal fever and that fermentation of wine and
milk did not proceed in the absence of living organisms. Heating milk and
wine, now called pasteurization, killed the bacteria, but not the yeast, and
made them safe to drink.3

Robert Koch, the German physician and microbiologist who in 1876
identified Bacillus anthracis as the cause of anthrax, learned how to grow
bacteria on media and, in 1884, isolated Vibrio cholerae, the agent that
causes cholera. In 1882, Koch identified the slow-growing Mycobacterium
tuberculosis as the cause of tuberculosis. Between 1879 and 1889, he also
isolated the organisms that caused typhoid fever, diphtheria, pneumonia,
tetanus, meningitis, and gonorrhea. He found organisms in wound infections.
Koch proved that the germs in the germ theory of disease were organisms
that could be isolated and identified.4

The English physician Joseph Lister, professor of surgery at the University
of Glasgow, soaked surgical dressings in carbolic acid (phenol) and applied
them to the open leg wound of a boy who had suffered a compound fracture
(Fig. 1-1). No infection ensued, and to his surprise, the bones healed solidly
together. He published the results in a series of articles in The Lancet in 1867.
He returned to the University of Edinburgh in 1869 and continued to develop
methods of asepsis and antisepsis. Soon, surgeons performed operations
under a mist of dilute carbolic acid that was sprayed in the operating room,
instruments were dipped in carbolic acid before use, and the surgical wound
was covered in dressings saturated with it.5 This routine, with variations,
became known as listerism, which Joseph Lister introduced to the United
States during a visit in 1876.

FIGURE 1-1  Joseph Lister. (Used with permission from Wellcome Images.)

Surgeons learned from listerism of the need to maintain sterile conditions
at the operating table. Although the steam autoclave was invented in 1879, it
was not used routinely for sterilization of instruments and supplies until early
in the 20th century. Dr. William Halsted, who embraced listerism, introduced
the use of surgical gloves at Johns Hopkins Hospital. However, the original
use of the gloves made by the Goodyear Company was to protect the hands
of the surgical team from the carbolic acid.6

Measures to control infection have been used routinely since the first half
of the 20th century and affect hospital construction, all invasive procedures,
interactions with patients, and behaviors in hospitals and other medical

The medicinal use of sulfa drugs in the late 1930s, the discovery of

penicillin in 1928 by Fleming, and its clinical use by Florey and his
colleagues in the early 1940s began the successful search for many other
antibiotics to combat infections by almost all known bacteria. During the
second half of the 20th century and beyond, surgical infections have been
ameliorated or cured by the large array of antibiotics that became available,
although antibiotic-resistant bacteria from antibiotic overuse have recently
become a problem. In recent decades, the evidence-based prophylactic use of
antibiotics in abdominal surgery has almost eliminated surgical site

Hospitals were built to provide clinical material for the faculties and students
of the country’s original medical schools. They included the Pennsylvania
Hospital (1752), the New York Hospital (1771), and the Massachusetts
General Hospital (1811), all of which became the workplaces of innovative
physicians and surgeons who taught and conducted research (Fig. 1-2).
However, most cities had no hospitals; instead, almshouses, poorhouses, and
poor farms, living facilities for indigent people in the community were
established by charitable organizations and wealthy individuals. Over time,
many of them became hospitals for the sick and poor. Some physicians also
established hospitals, often by converting a large home into a place for their
sick patients. Many hospitals were dirty and poorly kept, and because some
of the occupants had infectious diseases for which there were no cures, the
other occupants also became infected and often died.

FIGURE 1-2  The Pennsylvania Hospital. (Reproduced with permission from The
Library of Congress.)

Because hospitals were known as dangerous places, middle- and upper-
class families kept sick relatives at home. The typical horse-and-buggy doctor
made rounds to the homes of his patients, and minor procedures, such as
drainage of a carbuncle or suture of a wound, were performed in the home.
Occasionally, a physician whose patient was in desperate straits would
attempt an abdominal operation on the kitchen table, usually with disastrous

As medical diagnosis and treatment advanced, medical care in the home
was no longer practical. Beginning in the latter half of the 19th century,
religious organizations, civic groups, and municipalities began aggressive
programs to build hospitals modeled after those in Europe, and by 1900, there
were more than 4000 hospitals in the United States. However, the
management, medical staffs, nursing, and other services of these hospitals
varied from excellent to poor.


Dr. Franklin H. Martin, a Chicago gynecologist, led the founding of the
American College of Surgeons (ACS) in 1912 (Fig. 1-3). He and other
leaders of the ACS were concerned about the marked variation in the quality
of hospitals throughout the country and began a program to standardize
hospitals in 1916 by establishing standards that hospitals were required to
meet.7 Surveyors visited the hospitals to determine their compliance and to
offer help in meeting the standards. The ACS also held annual hospital
standardization conferences to educate hospital personnel. The American
Hospital Association, which initiated institutional memberships in 1918, also
contributed to the modernization of hospital management.

FIGURE 1-3  Dr. Franklin H. Martin, Founder of the American College of
Surgeons. (Image courtesy of the Archives of the American College of Surgeons.)

Only 13% of the 692 hospitals surveyed in 1918 were approved by the
ACS, but by 1939, 76% of the 3564 hospitals surveyed were approved.8 Over
the years, the standards proliferated, and in 1951, the ACS transferred the
program to what is now The Joint Commission.

The Hospital Standardization Program and The Joint Commission were
largely responsible for the current organization and functions of the modern
hospital. The standards they set have saved many lives and made surgery

Although hospitals proliferated early in the 20th century, few of them hired
nurses to care for patients. Graduate nurses were hired by middle- and upper-
class patients as “special nurses” to care for them in their homes or in the
hospital during illnesses. To serve patients who could not afford special
nurses, hospitals established schools of nursing in which the students were
taught by a faculty of 1 or 2 graduate nurses and the medical staff of the
hospital. Student nurses were assigned to wards to care for patients, often
with very little supervision. Many of these schools closed during the Great
Depression, and later, colleges and universities established degree programs,
which now educate most of the country’s nurses. Prior to World War II, the
supply of graduate nurses became sufficient for hospitals to hire nursing
staffs to care for their patients. As the complexity of medical care escalated,
nurses assumed many roles other than hospital care, and they continue to be
indispensable to the healthcare system.

During the first half of the 20th century, when hospitals were simple
organizations, hospital administrators learned from a mentor or on the job. By
the middle of the century, hospitals had become departmentalized and
complex, requiring expertise in finance, personnel management, construction,
and many other fields of management. This led to the development of
advanced degree programs in hospital administration, the first of which was
established at the University of Chicago in 1934. Within a few decades, many
universities had established such programs.


Although the gross structure of the human body and its organs had been
delineated by the middle of the 19th century, the functions of organs
remained mysterious. Concurrent development of the basic sciences of
pathology, microbiology, physiology, and chemistry during the second half
of the 19th century led to an understanding of organ function and disease.
During this period, Rudolph Virchow, using the ever-improving optics of the
microscope, introduced histopathology to the medical sciences, and Friedrich
von Recklinghausen described embolism, infarction, tissue degeneration, and
many diseases and conditions such as uterine adenomyomata. Improved
techniques for fixing, embedding, and staining tissue facilitated more
accurate diagnoses in the early 20th century, and the process of preparing
frozen sections of tissues, reported by Dr. Louis Wilson of the Mayo Clinic in
1905, enabled pathologists to accurately diagnose diseases during

New techniques enabled investigators to understand normal and abnormal
gastrointestinal physiology. Between the 1890s and his death in 1936, the
Russian physiologist Ivan Pavlov used Heidenhain pouches and gastric and
esophageal fistulas in dogs to study salivary and gastric secretions as well as
conditioned reflexes, work for which he received the Nobel Prize.10 His
experiments inspired many surgical investigators to use similar methods to
study gastrointestinal hormonal physiology and motility during the 20th
century. Their work, and the work of others, resulted in a comprehensive
understanding of the biochemistry, physiology, and pharmacology of the
hepatobiliary and digestive systems in health and disease.

Army surgeon Dr. William Beaumont performed the first human
experiments in gastric physiology during the first half of the 19th century,11
but it was not until Dr. Lester Dragstedt studied gastric secretion in ulcer
patients that gastrointestinal physiology was applied to the development of
surgical procedures to combat excessive acid secretion. He introduced
vagotomy to reduce gastric acid secretion.12 Upon finding that vagotomy
inhibited gastric emptying, he and others added pyloroplasty or antrectomy.

Beginning with the administration of intravenous fluids to surgical
patients by Dr. Rudolph Matas in 1924, many advances in biochemistry and
physiology led to a greater understanding of body composition, nutrition, and
fluid, electrolyte, and acid-base balance. The studies of Dr. Francis Moore
and others culminated in his magisterial text, Metabolic Care of the Surgical

Patient, which taught surgeons how to deliver the highest level of pre- and
postoperative care.13 Drs. Jonathan Rhoads and Stanley Dudrick emphasized
the importance of nutrition in surgical patients and demonstrated that
intravenous alimentation could support normal growth and development of
puppies and babies.14

The basic science of immunology matured during the 20th century,
enabling the first kidney transplantation by Dr. Joseph Murray and his
associates in 1954 and the first liver transplantation by Dr. Thomas Starzl in

After Karl Landsteiner identified the major blood groups A, B, and O in
1901, transfusion of blood and blood products became safer. Dr. George W.
Crile, professor of surgery at Case-Western Reserve University, and Dr.
William Halsted of The Johns Hopkins Hospital employed blood transfusions
during surgical procedures. Reactions to transfusions were frequent until
1940, when the Rh system was discovered and taken into account in
matching donor blood to patients. Dr. Bernard Fantus established the first
hospital blood bank in the United States at Cook County Hospital in Chicago
in 1937.15

Liquid and reconstituted dried plasma was used extensively for
resuscitation from wounds during World War II. Lessons learned from the
Korean conflict, the Vietnam War, and subsequent conflicts have been
applied to the management of civilian trauma and burns, especially the
techniques of resuscitation from shock, which were studied extensively by
Dr. G Thomas Shires and his colleagues.16 The wartime concepts of rapid
evacuation for resuscitation and early transport to a major healthcare facility
are embodied in the existing trauma system in the United States. The military
experience has also informed the management of abdominal gunshot and
knife wounds and blunt abdominal injuries in the civilian population.

More than 200 years have elapsed since Ephraim McDowell performed the
first abdominal operation in the United States to remove a huge ovarian

tumor from a woman in Danville, Kentucky.17 Subsequently, and especially
during the latter half of the 19th century, operations were developed in
Europe and the United States to deal with almost every abdominal disease or
condition. The need to design and manufacture surgical instruments spawned
an entirely new field, biomedical engineering, which became institutionalized
in the late 1960s when universities began degree programs in biomedical
engineering. The manufacture of surgical instruments and supplies is now
vested in a huge industry that produces products ranging from silk sutures to

Manufacture of most surgical instruments was routine by the beginning of
the 20th century, including retractors, hemostats, scissors, forceps, and a
variety of tools designed to grasp, hold, or manipulate abdominal organs and
tissues. Improvements such as the disposable scalpel blade in the 1920s and
disposable instruments in the 1970s have reduced labor costs of hospitals.
The introduction of staplers for gastrointestinal side-to-side and end-to-end
anastomoses by Russian investigators, brought to the United States and
developed by Ravitch and Steichen18 in the 1960s, was a major advance.

Hemostasis was facilitated by the development of a diathermy machine for
electrosurgical cutting and cautery by William T. Bovie and introduced into
clinical use by Harvey Cushing at the Peter Bent Brigham Hospital in 1920,
eliminating the need to clamp and ligate small vessels. Since then, topical
preparations, clips, electrical energy, and ultrasonic energy have been
incorporated into various devices that have enabled minimally invasive

Development of minimally invasive surgery was dependent on the
visualization of organs in the abdominal cavity through a scope. In 1806,
Phillipp Bozzini made a major contribution by constructing a “lichtleiter,” a
scope that incorporated mirrors to reflect light back to the eye. It was used
primarily for gynecologic examinations (Fig. 1-4). The development of small
bulbs illuminated by electric current enabled laparoscopy for diagnosis
beginning in the first half of the 20th century, and flexible fiberoptic scopes
for examining the interior of the gastrointestinal tract followed in the 1950s.

FIGURE 1-4  Bozzini’s lichtleiter. (Image courtesy of the Archives of the American
College of Surgeons.)

Numerous advances in technology, many driven by the computer and the
computer chip television camera, enabled laparoscopic surgery, which
revolutionized abdominal surgery.

Laparoscopic surgery had its origin in obstetrics and gynecology, with the
first laparoscopic organ removal, salpingectomy, performed by Tarasconi in
1975.19 This was followed by laparoscopic cholecystectomy, first performed
by Muhe in Germany in 1985, by Mouret in France in 1987, and Reddick in
the United States in 1988.20 Since then, every abdominal organ has been
subjected to laparoscopic procedures.

The most recent technological development is the use of robots in surgery.
After years of research and development by many organizations, the da Vinci
surgery system was approved by the US Food and Drug Administration in
2000 for general laparoscopic surgery. The surgeon sits at a console where
the interior of the abdomen is projected on a screen and uses a computer to
control a robotic arm to which are attached various instruments. Newer
versions, including a console for an assistant, have been used in general

surgery and the surgical specialties. The advantages and disadvantages of
robotic surgery are still under evaluation as experience accumulates and the
technology continues to improve.

Early abdominal surgery was enabled by the discovery of general anesthesia,
means to control or eliminate infection, and the evolution of the hospital,
where patients could be housed and surgeons could work in a supportive
environment that included nurses and hospital administrators. Later,
development of the basic sciences enabled the development of new
operations and methods to deal with altered physiology and body chemistry
caused by illness, trauma, and complex surgical procedures. Most recently,
striking advances in technology have enabled the development of minimally
invasive and robotic surgery.

1. Long CW. An account of the first use of sulphuric ether by inhalation as an anesthetic in surgical

operations. South Med Surg J. 1849;5:705-713.
2. Keys TE. William Thomas Green Morton (1819-1868). Anesth Analg. 1973;52(2):166.
3. Schwartz M. The life and works of Louis Pasteur. J Appl Microbiol. 2001;91(4):597-601.
4. Blevins SM, Bronze MS. Robert Koch and the “golden age” of bacteriology. Int J Infect Dis.

5. Lister Centenerary Celebration. American College of Surgeons. Detroit, MI, October, 1927;

Descriptive Catalogue. Lister Collection. 1927; Wellcome Historical Medical Museum.
6. Cameron JC. William Stewart Halsted: our surgical heritage. Ann Surg. 1997;225(5):445-458.
7. Nahrwold DL, Kernahan PJ. A Century of Surgeons and Surgery. The American College of

Surgeons 1913-2012. Chicago, IL: American College of Surgeons; 2012.
8. Twenty-second annual hospital standardization report. Bull Am Col Surg. 1939;24(5):316.
9. Wilson LB. A method for the rapid preparation of fresh tissues for the microscope. JAMA.

10. Babkin BP. Pavlov, a Biography. Chicago, IL: The University of Chicago Press; 1939.
11. Myer JS. Life and Letters of Dr. William Beaumont. St. Louis, MO: CV Mosby Company;

12. Dragstedt LR, Owens FM Jr. Supra-diaphragmatic section of the vagus nerves in treatment of

duodenal ulcer. Proc Soc Exp Biol Med. 1943;53:152-154.
13. Moore FD. Metabolic Care of the Surgical Patient. Philadelphia, PA: WB Saunders; 1959.
14. Dudrick SJ, Rhoads JE. New horizons for intravenous feeding. JAMA. 1971;215(6):939-949.
15. Fantus B. The therapy of the Cook County Hospital: blood preservation. JAMA. 1938;111(4):317.
16. Shires GT. Shock and Related Problems. London, United Kingdom: Churchill Livingstone; 1984.

17. Rutkow IM. The History of Surgery in the United States, 1775-1900. Vol 2. Novato, CA: Norman
Publishing; 1988.

18. Steichen FH, Ravitch MM. Stapling in Surgery. Chicago, IL: Year Book Medical; 1971.
19. Tarasconi JC. Endoscopic salpingectomy. J Reprod Med. 1981;26(10): 541-545.
20. Blum CA, Adams DB. Who did the first laparoscopic cholecystectomy? J Minim Access Surg.


Zara Cooper • Edward Kelly

Surgeons of every specialty face increasingly complex surgical challenges. In
addition, modern surgical treatment can be offered to more fragile patients,
with successful outcomes. Mastery of the scientific fundamentals of
perioperative management is required to achieve satisfactory results. The
organ system–based approach presented here allows the surgeon to address
the patient’s pre- and postoperative needs with a comprehensive surgical
plan. This chapter will serve as a summary guide to best practices integral to
conducting surgical procedures in the modern era.

The most common neuropsychiatric complications following abdominal
surgery are pain and delirium. Moreover, uncontrolled pain and delirium
prevent the patient from contributing to vital aspects of his or her care, such
as ambulation and respiratory toilet, and promote an unsafe environment that
may lead to the unwanted dislodgment of drains and other supportive

devices, with potentially life-threatening consequences. Pain and delirium
usually coexist in the postoperative setting, and each can contribute to the
development of the other. Despite high reported rates of overall patient
satisfaction, pain control is frequently inadequate in the perioperative
setting,1 with high rates of complications such as drowsiness from
overtreatment and unacceptable levels of pain from undertreatment.
Therefore, it is mandatory that the surgical plan for every patient include
close monitoring of postoperative pain and delirium and regular assessment
of the efficacy of pain control.

Pain management, like all surgical planning, begins in the preoperative
assessment. In the modern era, a large proportion of surgical patients will
require special attention with respect to pain control. Patients with preexisting
pain syndromes, such as sciatica or interspinal disc disease, or patients with a
history of opioid use may have a high tolerance for opioid analgesics. Every
patient’s history should include a thorough investigation for chronic pain
syndrome, addiction (active or in recovery), and adverse reactions to opioid,
nonsteroidal, or epidural analgesia. The pain control strategy may include
consultation with a pain control anesthesiology specialist, but it is the
responsibility of the operating surgeon to identify complicated patients and
construct an effective pain control plan.

Opioid Analgesia
Postoperative pain control using opioid medication has been in use for
thousands of years. Hippocrates advocated the use of opium for pain control.
The benefits of postoperative pain control are salutary and include improved
mobility and respiratory function and earlier return to normal activities. The
most effective strategy for pain control using opioid analgesia is patient-
controlled analgesia (PCA), wherein the patient is instructed in the use of a
preprogrammed intravenous pump that delivers measured doses of opioid
(usually morphine or meperidine). In randomized trials, PCA has been shown
to provide superior pain control and patient satisfaction compared to interval
dosing,2 but PCA has not been shown to improve rates of pulmonary and
cardiac complications3 or length of hospital stay,4 and there is evidence that
PCA may contribute to postoperative ileus.5 In addition, PCA may be
unsuitable for patients with a history of substance abuse, high opioid

tolerance, or those with atypical reactions to opioids.

Regional Analgesia
Due to the limitations of PCA, pain control clinicians have turned to regional
analgesia as an effective strategy for the management of postoperative pain.
Postoperative epidural analgesia involves the insertion of a catheter into the
epidural space of the lumbar or thoracic spine, enabling the delivery of local
anesthetics or opioids directly to the nerve roots. The insertion procedure is
generally safe, with complication rates of motor block and numbness between
0.5% and 7%,6 and an epidural abscess rate of 0.5 per thousand.7 Potential
advantages of epidural analgesia include elimination of systemic opioids, and
thus less respiratory depression, and improvement in pulmonary
complications and perioperative ileus. There have been several large trials,8-
10 a meta-analysis,6 and a systematic review11 comparing PCA with epidural
analgesia in the setting of abdominal surgery. These studies indicate that
epidural analgesia provides more complete analgesia than PCA throughout
the postoperative course. Furthermore, in randomized prospective series of
abdominal procedures, epidural analgesia has been associated with decreased
rates of pulmonary complications12,13 and postoperative ileus.14,15 Epidural
analgesia requires a skilled anesthesia clinician to insert and monitor the
catheter and adjust the dosage of neuraxial medication. Some clinicians may
prefer correction of coagulopathy before inserting or removing the catheter,
although the American Society of Anesthesiologists (ASA) has not issued
official guidelines on this issue.

Peripheral nerve blocks are also effective in perioperative pain control and
do not carry the same potential morbidities as the epidural approach. Using
ultrasound guidance, a skilled practitioner can deliver a long-acting local
anesthetic into the transversus abdominis plane (TAP) or in the rectus sheath
to establish analgesia both intraoperatively and postoperatively. Randomized
clinical data have confirmed the efficacy of regional blocks in controlling
pain and reducing use of opioid analgesia.16,17

Analgesia with Nonsteroidal Anti-Inflammatory

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) have long been used for
postoperative analgesia in the outpatient setting and, with the development of
parenteral preparations, have come into use in the inpatient population. This
class of medication has no respiratory side effects and is not associated with
addiction potential, altered mental status, or ileus. In addition, these
medications provide effective pain relief in the surgical population. However,
use of NSAIDs has not been universally adopted in abdominal surgery due to
concerns regarding the platelet dysfunction and erosive gastritis associated
with heavy NSAID use. In prospective trials, NSAIDs were found to provide
effective pain control without bleeding or gastritis symptoms following
laparoscopic cholecystectomy,18 abdominal hysterectomy,19 and inguinal
hernia repair.20,21 NSAIDs have also been shown to improve pain control and
decrease morphine dosage when used in combination following

The sensation of pain is very subjective and personal. Accordingly, the
surgeon must individualize the pain control plan to fit the needs of each
patient. The pain control modalities discussed above can be used in any
combination, and the surgeon should not hesitate to use all resources at his or
her command to provide adequate relief of postoperative pain.

Postoperative Delirium
Delirium, defined as acute cognitive dysfunction marked by fluctuating
disorientation, sensory disturbance, and decreased attention, is an all too
common complication of surgical procedures, with reported rates of 11% to
25%, with the highest rates reported in the elderly population.23,24 The
postoperative phase of abdominal surgery exposes patients, some of whom
may be quite vulnerable to delirium, to a large number of factors that may
precipitate or exacerbate delirium (Table 2-1). These factors can augment one
another: postoperative pain can lead to decreased mobility, causing
respiratory compromise, atelectasis, and hypoxemia. Escalating doses of
narcotics to treat pain can cause respiratory depression and respiratory
acidosis. Hypoxemia and delirium can cause agitation, prompting treatment
with benzodiazepines, further worsening respiratory function and delirium.
This vicious cycle can result in serious complications or death. Preoperative
recognition of high-risk patients and meticulous monitoring of every patient’s

mental status are the most effective ways to prevent postoperative delirium;
treatment can be remarkably difficult once the cycle has begun.


Narcotic analgesics
Sleep deprivation
Withdrawal (alcohol, narcotics, benzodiazepines)
Electrolyte imbalance (sodium, potassium, magnesium, calcium, phosphate)
Infection (pneumonia, incision site infection, urinary tract infection)
Medication (antiemetics, antihistamines, sedatives, anesthetics)
Postoperative myocardial infarction

Patient factors that are associated with high risk of perioperative delirium
include age greater than 70 years, preexisting cognitive impairment or prior
episode of delirium, history of alcohol or narcotic abuse, and
malnutrition.22,25 Procedural factors associated with high delirium risk
include operative time greater than 2 hours, prolonged use of restraints,
presence of a urinary catheter, addition of more than 3 new medications, and

Once the patient’s risk for postoperative delirium is identified,
perioperative care should be planned carefully to decrease other controllable
factors. Epidural analgesia has been associated with less delirium than PCA
after abdominal surgery.26 Sedation or “sleepers” should be used judiciously,
if at all, with high-risk patients. If the patient requires sedation, neuroleptics
such as haloperidol and the atypical neuroleptics such as olanzapine are

tolerated much better than benzodiazepines.27 The patient’s mental status,
including orientation and attention, should be assessed with every visit and
care should be taken to avoid anemia, electrolyte imbalances, dehydration,
and other contributing factors.

Once the diagnosis of postoperative delirium is established, it is important
to recognize that some of the causes of delirium are potentially life-
threatening, and immediate action is necessary. Evaluation begins with a
thorough history and physical examination at the bedside by the surgeon. The
history should focus on precipitating events such as falls (possible traumatic
brain injury), recent procedures, use of opioids and sedatives, changes in
existing medications (eg, withholding of thyroid replacement or
antidepressants), and consideration of alcohol withdrawal. The vital signs and
fluid balance may suggest sepsis, hypovolemia, anemia, or dehydration. The
exam should include brief but complete sensory and motor neurologic
examinations to differentiate delirium from stroke. Pay attention to common
sites of infection such as the surgical wound, the lungs, and intravenous
catheters. Urinary retention may be present as a result of medication or
infection. Deep venous thrombosis may be clinically evident as limb
swelling. Postoperative myocardial infarction (MI) may often present as acute
cardiogenic shock.

The history and physical examination should then direct the use of lab
tests. Most useful are the electrolytes, blood glucose, and complete blood cell
count. Pulse oximetry and arterial blood gases may disclose hypercapnia or
hypoxemia. Chest x-ray may disclose atelectasis, pneumonia, acute
pulmonary edema, or pneumothorax. Cultures may be indicated in the setting
of fever or leukocytosis, but will not help immediately. Electrocardiogram
(ECG) and cardiac troponin may be used to diagnose postoperative MI.

Resuscitative measures may be required if life-threatening causes of
delirium are suspected. Airway control, supplemental oxygen, and fluid
volume expansion should be considered in patients with unstable vital signs.
The patient should not be sent out of the monitored environment for further
tests, such as head computed tomography (CT), until the vital signs are stable
and the agitation is controlled. Treatment of postoperative delirium depends
on treatment of the underlying causes. Once the underlying cause has been
treated, delirium may persist, especially in elderly or critically ill patients,
who regain orientation and sleep cycles slowly. In these patients, it is
important to provide orienting communication and mental stimulation during

the day and to promote sleep during the night. The simplest ways are the
most effective: contact with family members and friends, use of hearing aids,
engagement in activities of daily living, and regular mealtimes. Sleep can be
promoted by keeping the room dark and quiet throughout the evening and
preventing unnecessary interruptions. If nighttime sedation is required,
atypical neuroleptics or low-dose serotonin reuptake inhibitors such as
trazodone are better tolerated than benzodiazepines. If agitation persists,
escalating doses of neuroleptics (or benzodiazepines in the setting of alcohol
withdrawal) can be used to control behavior, but underlying organic causes of
delirium must be investigated.


Risk Assessment
It has been estimated that 1 million patients have a perioperative MI each
year, and the contribution to medical costs is $20 billion annually.28
Thoracic, upper abdominal, neurologic, and major orthopedic procedures are
associated with increased cardiac risk. Diabetes, prior MI, unstable angina,
and decompensated congestive heart failure (CHF) are most predictive of
perioperative cardiac morbidity and mortality, and patients with these
conditions undergoing major surgery warrant further evaluation29 (Table 2-
2). Patient factors conferring intermediate risk include mild angina and
chronic renal insufficiency with baseline creatinine ≥2 mg/dL.30 It is worth
noting that women were underrepresented in the studies on which the
American College of Cardiology and the American Heart Association
(ACC/AHA) guidelines are based.31 A retrospective study in gynecologic
patients found that hypertension and previous MI were major predictors of
postoperative cardiac events, as opposed to the ACC/AHA guidelines, which
indicate that they are minor and intermediate criteria, respectively.32 Vascular
surgical patients are at highest risk because of the prevalence of underlying
coronary disease in this population.29,33 Other high-risk procedural factors
include emergency surgery, long operative time, and high fluid replacement
volume. Intraperitoneal procedures, carotid endarterectomy, thoracic surgery,
head and neck procedures, and orthopedic procedures carry an intermediate

risk and are associated with a 1% to 5% risk of a perioperative cardiac



Recent myocardial infarction (within 30 days)
Unstable or severe angina
Decompensated congestive heart failure
Significant arrhythmias (high-grade atrioventricular block, symptomatic

ventricular arrhythmias with underlying heart disease, supraventricular
arrhythmias with uncontrolled rate)

Severe valvular disease

Mild angina
Any prior myocardial infarction by history or electrocardiogram
Compensated or prior congestive heart failure
Diabetes mellitus
Renal insufficiency

Advanced age
Abnormal electrocardiogram
Rhythm other than sinus (eg, atrial fibrillation)
Poor functional capacity
History of stroke
Uncontrolled hypertension (eg, diastolic blood pressure >10 mm Hg)

Perioperative evaluation to identify patients at risk for cardiac
complications is essential in minimizing morbidity and mortality. Workup
should start with history, physical exam, and ECG to determine the existence
of cardiac pathology. Screening with chest radiographs and ECG is required
for men over 40 and women over 55. According to the ACC/AHA guidelines,
initial preoperative cardiac risk can be assessed using a clinical calculator, the

Revised Cardiac Risk Index (RCRI).34 This index includes history of
ischemic heart disease, CHF, cerebrovascular disease, diabetes, chronic
kidney disease, and planned high-risk procedure. Advanced or invasive
testing is reserved for patients with 2 or more of these risk factors. Overall
functional ability is the best clinical measure of cardiac fitness. Patients who
can exercise without limitations can generally tolerate the stress of major
surgery.35 Limited exercise capacity may indicate poor cardiopulmonary
reserve and the inability to withstand the stress of surgery. Poor functional
status is the inability to perform activities such as driving, cooking, or
walking less than 5 km/h.

Intraoperative risk factors include operative site, inappropriate use of
vasopressors, and unintended hypotension. Intra-abdominal pressure
exceeding 20 mm Hg during laparoscopy can decrease venous return from
the lower extremities and thus contribute to decreased cardiac output,36 and
Trendelenburg positioning can result in increased pressure on the diaphragm
from the abdominal viscera, subsequently reducing vital capacity.
Intraoperative hypertension has not been isolated as a risk factor for cardiac
morbidity, but it is often associated with wide fluctuations in pressure and has
been more closely associated with cardiac morbidity than intraoperative
hypotension. Preoperative anxiety can contribute to hypertension even in
normotensive patients. Patients with a history of hypertension, even
medically controlled hypertension, are more likely to be hypertensive
preoperatively. Those with poorly controlled hypertension are at greater risk
of developing intraoperative ischemia, arrhythmias, and blood pressure
derangements, particularly at induction and intubation. Twenty-five percent
of patients will exhibit hypertension during laryngoscopy. Patients with
chronic hypertension may not necessarily benefit from lower blood pressure
during the preoperative period because they may depend on higher pressures
for cerebral perfusion. Those receiving antihypertensive medications should
continue them up until the time of surgery. Patients taking β-blockers are at
risk of withdrawal and rebound ischemia. Key findings on physical
examination include retinal vascular changes and an S4 gallop consistent with
left ventricular hypertrophy. Chest radiography may show an enlarged heart,
also suggesting left ventricular hypertrophy.

ECG should be obtained in patients with chest pain, diabetes, prior
revascularization, prior hospitalization for cardiac causes, all men age 45 or

older, and all women age 55 or older with 2 or more risk factors. High- or
intermediate-risk patients should also have a screening ECG. A lower-than-
normal ejection fraction demonstrated on echocardiography is associated with
the greatest perioperative cardiac risk and should be obtained in all patients
with symptoms suggesting heart failure or valvular disease. Tricuspid
regurgitation indicates pulmonary hypertension and is often associated with
sleep apnea. The chest x-ray is used to screen for cardiomegaly and
pulmonary congestion, which may signify ventricular impairment.

Exercise testing demonstrates a propensity for ischemia and arrhythmias
under conditions that increase myocardial oxygen consumption. Numerous
studies have shown that performance during exercise testing is predictive of
perioperative mortality in noncardiac surgery. ST-segment changes during
exercise including horizontal depression greater than 2 mm, changes with low
workload, and persistent changes after 5 minutes of exercise are seen in
severe multivessel disease. Other findings include dysrhythmias at a low
heart rate, an inability to raise the heart rate to 70% of predicted, and
sustained decrease in systolic pressure during exercise.

Unfortunately, many patients are unable to achieve adequate workload in
standard exercise testing because of osteoarthritis, low back pain, and
pulmonary disease. In this case, pharmacologic testing is indicated with a
dobutamine echocardiogram. Dobutamine is a β-agonist that increases
myocardial oxygen demand and reveals impaired oxygen delivery in those
with coronary disease. Echocardiography concurrently visualizes wall motion
abnormalities due to ischemia. Transesophageal echocardiography may be
preferable to transthoracic echocardiography in obese patients because of
their body habitus and has been shown to have high negative predictive value
in this group.37 Nuclear perfusion imaging with vasodilators such as
adenosine or dipyridamole can identify coronary artery disease and demand
ischemia. Heterogeneous perfusion after vasodilator administration
demonstrates an inadequate response to stress. Wall motion abnormalities
indicate ischemia, and an ejection fraction lower than 50% increases the risk
of perioperative mortality. Angiography should only be performed if the
patient may be a candidate for revascularization.

Coronary Disease
Most perioperative MIs are caused by plaque rupture in lesions that do not

produce ischemia during preoperative testing.38 This presents an obvious
challenge for detecting patients at risk. Stress testing has a low positive
predictive value in patients with no cardiac risk factors and has been
associated with an unacceptably high rate of false-positive results.39

Preoperative optimization may include medical management,
percutaneous coronary interventions (PCIs), or coronary artery bypass
grafting (CABG).40 The ACC/AHA guidelines29 recommend
revascularization for patients whose preoperative testing reveals severe
disease that warrants intervention according to practice guidelines for
coronary artery disease, independent of their perioperative status.

Patients warranting emergent CABG will be at greatest risk for that
procedure. A recent study from the Veterans Administration hospitals
recommends against revascularization in patients with stable cardiac
symptoms.41 Preoperative PCI does not decrease the risk of future MI or
mortality in patients with stable coronary disease, and only targets stenotic
lesions, rather than those most likely to rupture. One retrospective study
found no reduction in morbidity or perioperative MI after percutaneous
transluminal coronary angioplasty, and the authors proposed that surgery
within 90 days of balloon angioplasty increased the risk of thrombosis.42
However, PCI done more than 90 days before surgery did provide benefit
when compared to those who had no intervention at all. Another retrospective
study found that patients who have surgery within 2 weeks of stenting had a
high incidence of perioperative MI, major bleeding, or death.43 Although a
retrospective review from the Coronary Artery Surgery Study registry
showed a lower mortality rate in patients with coronary artery disease who
were post-CABG than those without CABG (0.09% vs 2.4%), this benefit did
not include the morbidity associated with CABG itself. Unfortunately, the
benefit was overwhelmed by the 2.3% morbidity rate seen with CABG in this
cohort.44 Survival benefit of CABG over medical management is realized at 2
years or more after surgery,45 so preoperative mortality may decrease overall
short-term survival. Revascularization and bypass grafting should be
restricted to patients who would benefit from the procedure independent of
their need for noncardiac surgery. One of the disadvantages of PCI in the
preoperative setting is the need for anticoagulation to prevent early stent
occlusion. The use of platelet inhibitors to prevent stent occlusion must be
included in the overall risk assessment, especially for surgery of the central

nervous system.
Catecholamine surges can cause tachycardia, which may alter the tensile

strength of coronary plaques and incite plaque rupture.46,47 Catecholamine
surges can also increase blood pressure and contractility, contributing to
platelet aggregation and thrombosis after plaque rupture and increasing the
possibility of complete occlusion of the arterial lumen.48 Perioperative β-
blockade mitigates these effects and has been shown to reduce MI and
mortality from MI by over 30% in vascular surgical patients with reversible
ischemia.46 Patients at highest risk still have a cardiac event rate of 10%,
even with adequate perioperative β-blockade.29

In 1998, a landmark study49 demonstrated a 55% reduction in mortality in
noncardiac surgical patients with known coronary disease who were given
atenolol perioperatively. This was followed by the DECREASE trial,50 which
showed a 10-fold reduction in perioperative MI and death compared to
placebo. Thereafter, perioperative β-blockade was widely adopted as a
quality measure. However, additional later investigations have shown that
although perioperative β-blockers benefit patients with known ischemia, low-
risk patients may in fact be harmed.51 Tight rate control has been associated
with increased risk of hypotension and bradycardia requiring intervention and
stroke without any significant decrease in mortality.52-55 Furthermore, critical
analysis of the literature shows that studies have been inconsistent in the type
of medication administered, the duration and timing of administration, and
the target for heart rate control.56 Consequently, results are difficult to
interpret. Thus, prophylactic perioperative β-blockade should be restricted to
patients with cardiac ischemia and has a limited role in patients with low or
moderate risk of postoperative cardiac events.29

Congestive Heart Failure and Arrhythmia
CHF is associated with coronary disease, valvular disease, ventricular
dysfunction, and all types of cardiomyopathy. These are all independent risk
factors that should be identified prior to surgery. Even compensated heart
failure may be aggravated by fluid shifts associated with anesthesia and
abdominal surgery and deserves serious consideration. Perioperative
mortality increases with higher New York Heart Association class and
preoperative pulmonary congestion. CHF should be treated to lower filling

pressures and improve cardiac output before elective surgery. β-Blockers,
angiotensin-converting enzyme inhibitors, and diuretics can be employed to
this end. The patient should be stable for 1 week before surgery.57

Arrhythmias and conduction abnormalities elicited in the history, on
exam, or on ECG should prompt investigation into metabolic derangements,
drug toxicities, or coronary disease. In the presence of symptoms or
hemodynamic changes, the underlying condition should be reversed and then
medication given to treat the arrhythmia. Indications for antiarrhythmic
medication and cardiac pacemakers are the same as in the nonoperative
setting. Nonsustained ventricular tachycardia and premature ventricular
contractions have not been associated with increased perioperative risk and
do not require further intervention.58,59

Valvular Disease
Valvular disease should be considered in patients with symptoms of CHF,
syncope, and a history of rheumatic heart disease. Aortic stenosis (AS) is a
fixed obstruction to the left ventricular outflow tract, limiting cardiac reserve
and an appropriate response to stress. History should elicit symptoms of
dyspnea, angina, and syncope; examination may reveal a soft S2, a late-
peaking murmur, or a right-sided crescendo–decrescendo murmur radiating
to the carotids. AS is usually caused by progressive calcification or
congenital bicuspid valve. Critical stenosis exists when the valve area is less
than 0.7 cm2 or transvalvular gradients are greater than 50 mm Hg and is
associated with an inability to increase cardiac output with demand. If
uncorrected, AS is associated with a 13% risk of perioperative death. Valve
replacement is indicated prior to elective surgery in patients with
symptomatic stenosis.29 Myocardial ischemia may occur in the absence of
significant coronary artery occlusion in the presence of aortic valve disease.
Perioperative management should include optimizing the heart rate to
between 60 and 90 beats per minute and avoiding atrial fibrillation if
possible. Because of the outflow obstruction, stroke volume may be fixed and
bradycardia will lower cardiac output. Similarly, hypotension is also poorly

Aortic regurgitation (AR) is associated with backward flow into the left
ventricle during diastole and reduced forward stroke volume. Bradycardia

facilitates regurgitation by increased diastolic time. Chronic AR causes
massive left ventricular dilatation (cor bovinum) and hypertrophy, which is
associated with decreased left ventricular function at later stages. AR is most
often caused by rheumatic disease or congenital bicuspid valve. Medical
treatment includes rate control and afterload reduction. Without valve
replacement, survival is approximately 5 years once patients become
symptomatic. This is an obvious consideration when planning any other
surgical procedures.

Tricuspid regurgitation is usually caused by pulmonary hypertension
secondary to severe left-sided failure. Other causes include endocarditis,
carcinoid syndrome, and primary pulmonary hypertension. Hypovolemia,
hypoxia, and acidosis can increase right ventricular afterload and should be
avoided in the perioperative period.

Mitral stenosis is an inflow obstruction that prevents adequate left
ventricular filling. The transvalvular pressure gradient depends on atrial kick,
heart rate, and diastolic filling time. Tachycardia decreases filling time and
contributes to pulmonary congestion. Mitral regurgitation is also associated
with pulmonary hypertension with congestion, as the pathologic valve
prevents forward flow, causing left atrial dilatation and subsequent atrial
arrhythmias. History and physical exam should focus on signs of CHF such
as orthopnea, pedal edema, dyspnea, reduced exercise tolerance, and
auscultatory findings such as murmurs and an S3 gallop. Neurologic deficits
may signify embolic sequelae of valve disease. Perioperative rate control is
essential for maintaining adequate cardiac output. ECG findings will reflect
related arrhythmias and medications but will not be specific for valve disease.
Laboratory studies should identify secondary hepatic dysfunction or
pulmonary compromise. Left ventricular hypertrophy is an adaptive response,
which may cause subsequent pulmonary hypertension and diastolic

Prosthetics in the mitral position pose the greatest risk for
thromboembolism, and the risk increases with valve area and low flow.
Mechanical valves pose a higher risk than tissue valves in patients with a
history of valve replacement. Diuretics and afterload-reducing agents will
enhance forward flow and minimize cardiopulmonary congestion. Patients
with mitral valve prolapse (MVP) should receive antibiotics.

Mitral regurgitation may also impair left ventricular function and lead to
pulmonary hypertension. Stroke volume is reduced by backward flow into the

atrium during systole. The left ventricle dilates to handle increasing end-
systolic volume, eventually causing concentric hypertrophy and decreased
contractility. The end result may be decreased ejection fraction and CHF. A
decrease in systemic vascular resistance and increase in atrial contribution to
the ejection fraction can both improve forward flow and reduce the amount of
regurgitation. Echocardiography can clarify the degree of valvular
impairment. Medical treatment centers on afterload reduction with
vasodilators and diuretics. MVP is present in up to 15% of women and is
usually associated with a midsystolic click and late systolic murmur on
physical exam. Murmur is indicative of prolapse. Although MVP is
associated with connective tissue disorders, it usually occurs in otherwise
healthy, asymptomatic patients. Echocardiography is used to confirm the
diagnosis and evaluate the degree of prolapse. Chronically, MVP may be
associated with mitral regurgitation, emboli, and increased risk of
endocarditis. Prolapse may be aggravated by decreased preload, which should
be minimized in the perioperative period. Patients with MVP are at risk of
ventricular arrhythmias with sympathetic stimulation and endocarditis, which
can be addressed with pain control and antibiotic prophylaxis, respectively.

Individuals with underlying structural cardiac defects are at increased risk
for developing endocarditis after invasive procedures. Surgical procedures
involving mucosal surfaces or infected tissues may cause transient bacteremia
that is usually short-lived. Certain procedures are associated with a greater
risk of endocarditis and warrant prophylaxis (Table 2-3). Abnormal valves,
endocardium, or endothelium can harbor the bloodborne bacteria for a longer
period of time, and infection and inflammation can ensue. Although there are
no randomized trials regarding endocarditis prophylaxis, the AHA
recommends prophylaxis for those60 at high and moderate risk for developing
the condition. The highest-risk patients have prosthetic heart valves, cyanotic
congenital heart disease, or a history of endocarditis (even without structural
abnormality).61 Conditions associated with moderate risk include congenital
septal defects, patent ductus arteriosus, coarctation of the aorta, and bicuspid
aortic valve. Hypertrophic cardiomyopathy and acquired valvular disease also
fall into this category. MVP is a prevalent and often situational condition.
Normal valves may prol