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  • 1. Schwartz’s MANUAL OFSURGERY i
  • 2. Editor-in-ChiefF. Charles Brunicardi, MD, FACSDeBakey/Bard Professor and ChairmanMichael E. DeBakey Department of SurgeryBaylor College of MedicineHouston, TexasAssociate EditorsDana K. Andersen, MD, FACSProfessor and Vice-ChairDepartment of SurgeryJohns Hopkins School of MedicineSurgeon-in-ChiefJohns Hopkins Bayview Medical CenterBaltimore, MarylandTimothy R. Billiar, MD, FACSGeorge Vance Foster Professor and Chairman of SurgeryDepartment of SurgeryUniversity of Pittsburgh School of MedicinePittsburgh, PennsylvaniaDavid L. Dunn, MD, PhD, FACSVice President for Health SciencesUniversity at Buffalo/SUNYBuffalo, New YorkJohn G. Hunter, MD, FACSMackenzie Professor and Chairman of SurgeryDepartment of SurgeryOregon Health and Science UniversityPortland, OregonRaphael E. Pollock, MD, PhD, FACSHead, Division of SurgeryProfessor and ChairmanDepartment of Surgical OncologySenator A.M. Aiken, Jr., Distinguished ChairThe University of Texas M. D. Anderson Cancer CenterHouston, Texas ii
  • 3. Schwartz’s MANUAL OF SURGERY EIGHTH EDITION Editor-in-Chief F. Charles Brunicardi, MD, FACS Associate Editors Dana K. Andersen, MD, FACS Timothy R. Billiar, MD, FACS David L. Dunn, MD, PhD, FACS John G. Hunter, MD, FACS Raphael E. Pollock, MD, PhD, FACS McGRAW-HILL Medical Publishing DivisionNew York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto iii
  • 4. Copyright © 2006 by The McGraw-Hill Companies, Inc. All rights reserved.Manufactured in the United States of America. Except as permitted under the UnitedStates Copyright Act of 1976, no part of this publication may be reproduced or dis-tributed in any form or by any means, or stored in a database or retrieval system,without the prior written permission of the publisher.0-07-148720-4The material in this eBook also appears in the print version of this title:0-07-144688-5.All trademarks are trademarks of their respective owners. Rather than put atrademark symbol after every occurrence of a trademarked name, we use names inan editorial fashion only, and to the benefit of the trademark owner, with nointention of infringement of the trademark. Where such designations appear in thisbook, they have been printed with initial caps.McGraw-Hill eBooks are available at special quantity discounts to use as premiumsand sales promotions, or for use in corporate training programs. For moreinformation, please contact George Hoare, Special Sales, at or (212) 904-4069.TERMS OF USEThis is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”)and its licensors reserve all rights in and to the work. Use of this work is subject tothese terms. Except as permitted under the Copyright Act of 1976 and the right tostore and retrieve one copy of the work, you may not decompile, disassemble, reverseengineer, reproduce, modify, create derivative works based upon, transmit, distribute,disseminate, sell, publish or sublicense the work or any part of it withoutMcGraw-Hill’s prior consent. You may use the work for your own noncommercialand personal use; any other use of the work is strictly prohibited. Your right to usethe work may be terminated if you fail to comply with these terms.THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORSMAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY,ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINEDFROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BEACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, ANDEXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED,INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OFMERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in thework will meet your requirements or that its operation will be uninterrupted or errorfree. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else forany inaccuracy, error or omission, regardless of cause, in the work or for any dam-ages resulting therefrom. McGraw-Hill has no responsibility for the content of anyinformation accessed through the work. Under no circumstances shall McGraw-Hilland/or its licensors be liable for any indirect, incidental, special, punitive, conse-quential or similar damages that result from the use of or inability to use the work,even if any of them has been advised of the possibility of such damages. Thislimitation of liability shall apply to any claim or cause whatsoever whether suchclaim or cause arises in contract, tort or otherwise.DOI: 10.1036/0071446885
  • 5. NOTICEMedicine is an ever-changing science. As new research and clinicalexperience broaden our knowledge, changes in treatment and drugtherapy are required. The authors and the publisher of this work havechecked with sources believed to be reliable in their efforts to pro-vide information that is complete and generally in accord with thestandards accepted at the time of publication. However, in viewof the possibility of human error or changes in medical sciences,neither the authors nor the publisher nor any other party who hasbeen involved in the preparation or publication of this work warrantsthat the information contained herein is in every respect accurate orcomplete, and they disclaim all responsibility for any errors or omis-sions or for the results obtained from use of the information containedin this work. Readers are encouraged to confirm the information con-tained herein with other sources. For example and in particular, read-ers are advised to check the product information sheet included in thepackage of each drug they plan to administer to be certain that theinformation contained in this work is accurate and that changes havenot been made in the recommended dose or in the contraindicationsfor administration. This recommendation is of particular importancein connection with new or infrequently used drugs. v
  • 6. To my wife, Melissa, my children, Isaac and Jackson, my mother, Rose, and mylate father, Edward Brunicardi, for their love and support FCBTo my wife, Cindy, and my children, Ashley, Lauren, Kathryn, Thomas, andOlivia DKATo Edith, Isabel and Alex TRBTo my wife, Kelli, for all of her support of my career and academic endeavors,and my children, Michael, Evelyn, Julia, and Edward DLDTo my wife, Laura, my children, Sarah, Sam, and Jillian, and the residents,fellows, and surgical faculty at OSHU who have created a community of health,collegiality, and open–minded intellectual rigor JGHTo my wife, Dina, and my children, Jessica, Sam, Eden, Noam, and Omer REP vi
  • 7. For more information about this title, click here Contents Contributors xi Preface xxiiiPART I BASIC CONSIDERATIONS 1 Systemic Response to Injury and Metabolic Support 3 J. Martin Perez, Edward Lim, Steven E. Calvano, and Stephen F. Lowry 2 Fluid and Electrolyte Management of the Surgical Patient 32 Rosemary A. Kozar and Frederick A. Moore 3 Hemostasis, Surgical Bleeding, and Transfusion 46 Seymour I. Schwartz 4 Shock 56 Andrew B. Peitzman, Brian G. Harbrecht, and Timothy R. Billiar 5 Surgical Infections 78 Gregory J. Beilman and David L. Dunn 6 Trauma 97 John M. Burch, Reginald J. Franciose, and Ernest E. Moore 7 Burns 138 James H. Holmes and David M. Heimbach 8 Wound Healing 165 Adrian Barbul 9 Oncology 183 Funda Meric-Bernstam and Raphael E. Pollock 10 Transplantation 216 Abhinav Humar and David L. Dunn 11 Patient Safety, Errors, and Complications in Surgery 245 Mark L. Shapiro and Peter B. Angood 12 Physiologic Monitoring of the Surgical Patient 275 Louis H. Alarcon and Mitchell P. Fink vii
  • 8. viii CONTENTS 13 Minimally Invasive Surgery 293 Blair A. Jobe and John G. Hunter 14 Cell, Genomics, and Molecular Surgery 309 Xin-Hua Feng, Jeffrey B. Matthews, Xia Lin, and F. Charles BrunicardiPART II SPECIFIC CONSIDERATIONS 15 Skin and Subcutaneous Tissue 329 Scott L. Hansen, Stephen J. Mathes, and David M. Young 16 The Breast 344 Kirby I. Bland, Samuel W. Beenken, and Edward E. Copeland, III 17 Disorders of the Head and Neck 369 Richard O. Wein, Rakesh K. Chandra, and Randal S. Weber 18 Chest Wall, Lung, Mediastinum, and Pleura 396 Michael A. Maddaus and James D. Luketich 19 Congenital Heart Disease 436 Tara B. Karamlou, Irving Shen, and Ross M. Ungerleider 20 Acquired Heart Disease 458 Charles F. Schwartz, Aubrey C. Galloway, Ram Sharony, Paul C. Saunders, Eugene A. Grossi, and Stephen B. Colvin 21 Thoracic Aortic Aneurysms and Aortic Dissection 496 Joseph S. Coselli and Scott A. LeMaire 22 Arterial Disease 515 Alan B. Lumsden, Peter H. Lin, Ruth L. Bush, and Changyi Chen 23 Venous and Lymphatic Disease 556 Gregory L. Moneta 24 Esophagus and Diaphragmatic Hernia 573 Jeffrey H. Peters and Tom R. DeMeester 25 Stomach 650 Daniel T. Dempsey 26 The Surgical Management of Obesity 685 Philip R. Schauer and Bruce David Schirmer
  • 9. CONTENTS ix27 Small Intestine 702 Edward E. Whang, Stanley W. Ashley, and Michael J. Zinner28 Colon, Rectum, and Anus 732 Kelli M. Bullard and David A. Rothenberger29 The Appendix 784 David H. Berger and Bernard M. Jaffe30 Liver 800 Steven A. Curley and Timothy D. Sielaff31 Gallbladder and Extrahepatic Biliary System 821 Margr´ t Oddsd´ ttir and John G. Hunter e o32 Pancreas 845 William E. Fisher, Dana K. Anderson, Richard H. Bell, Jr., Ashok K. Saluja, and F. Charles Brunicardi33 Spleen 879 Adrian E. Park and Rodrick McKinlay34 Abdominal Wall, Omentum, Mesentery, and Retroperitoneum 897 Robert L. Bell and Neal E. Seymour35 Soft Tissue Sarcomas 906 Janice N. Cormier and Raphael E. Pollock36 Inguinal Hernias 920 Robert J. Fitzgibbons, Jr. and Hardeep S. Ahluwalia37 Thyroid, Parathyroid, and Adrenal 943 Geeta Lal and Orlo H. Clark38 Pediatric Surgery 989 David J. Hackam, Kurt Newman, and Henri R. Ford39 Urology 1036 Hyung L. Kim and Arie Belldegrun40 Gynecology 1061 Gregory P. Sutton, Robert E. Rogers, William W. Hurd, and Martina F. Mutone41 Neurosurgery 1102 Michael L. Smith and M. Sean Grady42 Orthopaedics 1130 Dempsey Springfield43 Plastic and Reconstructive Surgery 1169 Saleh M. Shenaq, John Y.S. Kim, Alan Bienstock, Forrest S. Roth, and Eser Yuksel44 Surgical Considerations in Older Adults 1188 Rosemarie E. Hardin and Michael E. Zenilman
  • 10. x CONTENTS 45 Anesthesia of the Surgical Patient 1201 Robert S. Dorian 46 ACGME Core Competencies 1223 Liz Nguyen, Mary L. Brandt, Samir S. Awad, Ruth Bush, David H. Berger, and F. Charles Brunicardi Index 1231
  • 11. ContributorsHardeep S. Ahluwalia, MD Department of SurgeryMedical Dean, Housestaff Brigham and Women’sDepartment of Surgery Hospital/Harvard Medical SchoolCreighton University Medical Boston, Massachusetts Center Chapter 27: Small IntestineOmaha, NebraskaChapter 36: Inguinal Hernias Samir S. Awad, MD Associate Professor of SurgeryLouis H. Alarcon, MD Chief, Section of Critical CareAssistant Professor Michael E. DeBakey DepartmentDepartments of Surgery and Critical of Surgery Care Medicine Baylor College of MedicineUniversity of Pittsburgh School of Medical Director SICU Medicine Michael E. DeBakey VeteransPittsburgh, Pennsylvania Affairs Medical CenterChapter 12: Physiologic Monitoring Houston, Texas of the Surgical Patient Chapter 46: ACGME Core CompetenciesDana K. Andersen, MS, FACSProfessor and Vice-Chair Adrian Barbul, MD, FACSDepartment of Surgery Surgeon-in-Chief, Sinai HospitalJohns Hopkins School of Medicine of Baltimore andSurgeon-in-Chief Professor and Vice-Chairman,Johns Hopkins Bayview Medical Department of Surgery Center Johns Hopkins Medical InstitutionsBaltimore, Maryland Baltimore, MarylandChapter 32: Pancreas Chapter 8: Wound HealingPeter B. Angood, MD, FACS, FCCM Samuel W. Beenken, MD,Professor of Surgery Anesthesia and FRCS(C), FACS Emergency Medicine Professor of SurgeryChief, Division of Trauma and The University of Alabama at Critical Care BirminghamUniversity of Massachusetts Birmingham, Alabama Medical School and Chapter 16: The BreastUniversity of Massachusetts— Memorial Health Care System Gregory J. Beilman, MD, FACSWorcester, Massachusetts Associate Professor of Surgery andChapter 11: Patient Safety, Errors, Anesthesia and Complications in Surgery University of Minnesota Medical SchoolStanley W. Ashley, MD Minneapolis, MinnesotaProfessor and Vice Chairman Chapter 5: Surgical Infections xiCopyright © 2006 by The McGraw-Hill Companies, Inc. Click here for terms of use.
  • 12. xii CONTRIBUTORSRichard H. Bell, Jr., MD, FACS Timothy R. Billiar, MDLoyal and Edith Davis Professor and George Vance Foster Chair Professor and ChairmanDepartment of Surgery Department of SurgeryFeinberg School of Medicine University of Pittsburgh School ofNorthwestern University MedicineChicago, Illinois Pittsburgh, PennsylvaniaChapter 32: Pancreas Chapter 4: ShockRobert L. Bell, MD, MA Kirby I. Bland, MD, FACSAssistant Professor Fay Fletcher Kerner Professor andDepartment of Surgery ChairmanYale University School of Medicine Deputy Director, UABNew Haven, Connecticut Comprehensive Cancer CenterChapter 34: Abdominal Wall, Department of Surgery Omentum, Mesentery, and University of Alabama at Retroperitoneum Birmingham Birmingham, AlabamaArie Belldegrun, MD, FACS Chapter 16: The BreastRoy and Carol Doumani Chair in Urologic Oncology Mary L. Brandt, MDProfessor of Urology Chief, Colorectal Clinic and Chief,Chief, Division of Urologic Oncology Pediatric Surgery ClinicDavid Geffen School of Medicine at Texas Children’s Hospital, Houston, University of California, Los Texas Angeles Professor of Surgery, Michael E.Los Angeles, California DeBakey Department ofChapter 39: Urology Surgery Professor of Pediatrics, BaylorDavid H. Berger, MD, FACS College of MedicineAssociate Professor and Vice Chair Houston, TexasMichael E. DeBakey Department of Chapter 46: ACGME Core Surgery CompetenciesBaylor College of MedicineOperative Care Line Executive F. Charles Brunicardi, MD, FACSChief, Surgical Services DeBakey/Bard Professor andMichael E. DeBakey Veterans Chairman Affairs Medical Center Michael E. DeBakey Department ofHouston, Texas SurgeryChapter 29: The Appendix Baylor College of MedicineChapter 46: ACGME Core Houston, Texas Competencies Chapter 14: Cell, Genomics, and Molecular SurgeryAlan Bienstock, MD, BS Chapter 32: PancreasResident Chapter 46: ACGME CoreDivision of Plastic Surgery CompetenciesMichael E. DeBakey Department of Surgery Kelli M. Bullard, MD, FACSBaylor College of Medicine Assistant Professor of Surgery andHouston, Texas Laboratory Medicine andChapter 43: Plastic and Pathology Reconstructive Surgery University of Minnesota
  • 13. CONTRIBUTORS xiiiMinneapolis, Minnesota Division of Vascular Surgery andChapter 28: Colon, Rectum, Endovascular Therapy and Anus Michael E. DeBakey Department of SurgeryJohn M. Burch, MD Baylor College of MedicineProfessor of Surgery Houston, TexasUniversity of Colorado Health Chapter 22: Arterial Disease Sciences CenterChief of General and Vascular Orlo H. Clark, MD Surgery Professor of SurgeryDenver Health Medical Center University of California, SanDenver, Colorado Francisco/Mt. Zion MedicalChapter 6: Trauma Center Department of SurgeryRuth L. Bush, MD San Francisco, CaliforniaAssistant Professor of Surgery Chapter 37: Thyroid, Parathyroid,Division of Vascular Surgery and and Adrenal Endovascular TherapyMichael E. DeBakey Department of Stephen B. Colvin, MD Surgery Chief, Cardiothoracic SurgeryBaylor College of Medicine New York University School ofHouston, Texas MedicineChapter 22: Arterial Disease New York, New YorkChapter 46: ACGME Core Chapter 20: Acquired Heart Competencies DiseaseSteven E. Calvano, PhD Edward E. Copeland, III, MDAssociate Professor Distinguished Professor ofDivision of Surgical Sciences SurgeryDepartment of Surgery University of Florida College ofUniversity of Medicine and Medicine Dentistry of New Jersey—Robert Gainesville, Florida Wood Johnson Medical School Chapter 16: The BreastNew Brunswick, New JerseyChapter 1: Systemic Response to Janice N. Cormier, MD, MPH Injury and Metabolic Support Assistant Professor of Surgery Department of Surgical OncologyRakesh K. Chandra, MD The University of Texas M. D.Assistant Professor Anderson Cancer CenterDirector, Division of Nasal and Houston, Texas Sinus Disorders Chapter 35: Soft Tissue SarcomasResidency Program DirectorDepartment of Otolaryngology— Joseph C. Coselli, MD Head and Neck Surgery Professor and ChiefUniversity of Tennessee Health Division of Cardiothoracic Science Center SurgeryMemphis, Tennessee Michael E. DeBakey Department ofChapter 17: Disorders of the Head Surgery and Neck Baylor College of Medicine Houston, TexasChangyi Chen, MD, PhD Chapter 21: Thoracic AorticProfessor of Surgery Aneurysms and Aortic Dissection
  • 14. xiv CONTRIBUTORSSteven A. Curley, MD, FACS Mitchell P. Fink, MDProfessor, Department of Surgical Professor and Chairman Oncology Department of Critical CareChief, Gastrointestinal Tumor Medicine Surgery Watson Chair in SurgeryThe University of Texas M.D. University of Pittsburgh Anderson Cancer Center Pittsburgh, PennsylvaniaHouston, Texas Chapter 12: Physiologic MonitoringChapter 30: Liver of the Surgical PatientTom R. DeMeester, MD William E. Fisher, MD, FACSThe Jeffrey P. Smith Professor of Associate Professor of Surgery General and Thoracic Surgery Michael E. DeBakey Department ofChairman, Department of Surgery SurgeryKeck School of Medicine, Baylor College of Medicine University of Southern California Houston, TexasLos An