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TEXTBOOK OF SURGERY
Transcript
Page 1: textbook of surgery - eshop.maxdorf.czeshop.maxdorf.cz/data/dl/Textbook of surgery 58fedb7f.pdfThis publication is dedicated to you by General sponsor textbook of surgery Current Surgical

textbook of surgery

Page 2: textbook of surgery - eshop.maxdorf.czeshop.maxdorf.cz/data/dl/Textbook of surgery 58fedb7f.pdfThis publication is dedicated to you by General sponsor textbook of surgery Current Surgical

This publication is dedicated to you by

G e n e r a l s p o n s o r

textbook of surgeryCurrent Surgical Diagnosis and Treatment

maxdorf publishing

Jiří HochMD, PhD

Professor of SurgeryHead, Department of Surgery, 2nd Faculty of Medicine

Charles University, Prague

Jan lefflerMD, PhD

Associate Professor of SurgeryDepartment of Surgery, 2nd Faculty of Medicine

Charles University, Prague

Page 3: textbook of surgery - eshop.maxdorf.czeshop.maxdorf.cz/data/dl/Textbook of surgery 58fedb7f.pdfThis publication is dedicated to you by General sponsor textbook of surgery Current Surgical

This publication is dedicated to you by

G e n e r a l s p o n s o r

textbook of surgeryCurrent Surgical Diagnosis and Treatment

maxdorf publishing

Jiří HochMD, PhD

Professor of SurgeryHead, Department of Surgery, 2nd Faculty of Medicine

Charles University, Prague

Jan lefflerMD, PhD

Associate Professor of SurgeryDepartment of Surgery, 2nd Faculty of Medicine

Charles University, Prague

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Authors

n prof. Jiří Hoch, MD, phD Dept. of Surgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n assoc. prof. Jan leffler, MD, phD Dept. of Surgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher.

Jiří Hoch, Jan leffler et al. TexTbook of surGery, Current surgical Diagnosis and Treatment

Translated from Czech original J. Hoch, J. Leffler a kol. Speciální chirurgie, 3rd edition, Maxdorf Jessenius 2011

Copyright © Jiří Hoch, Jan Leffler 2013Copyright © Maxdorf 2013Illustrations © Maxdorf 2013Cover Layout © Jan Hugo 2013Cover Photo © iStockphoto/Khonji

Maxdorf Publishing, Na Šejdru 247/6a, CZ, 142 00 Prague 4 [email protected], www.maxdorf.cz.

Copy Editor: Mgr. Jan LanyCover Layout: Jan Hugo, Maxdorf PublishingTypesetting: Blanka Filounková, Maxdorf PublishingDrawings: Ing. Jaroslav Nachtigall, PhD, Maxdorf PublishingPrinted in the Czech Republic by Books print s.r.o.

Isbn 978-80-7345-375-6

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Co-Authors

n petr bavor, MD Dept. of Surgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n prof. karel Cvachovec, MD, phD, Mba Dept. of Anaesthesiology and Resuscitation, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n prof. petr Goetz, MD, phD Institute of Biology and Medical Genetics, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n Ivana Hochová, MD Dept. of Clinical Hematology, University Hospital Motol, Prague

n Zbyněk Jech, MD Dept. of Surgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n prof. roman kodet, MD, phD Institute of Pathology and Molecular Medicine, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n Tomáš krejčí, MD Dept. of Surgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n Jiří lisý, MD, phD Dept. of Imaging Methods, 2nd Faculty of Medicine, Charles University, Prague

n Jan neumann, MD, phD Dept. of Surgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n otakar nyč, MD, phD Instutute of Medical Microbiology, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n filip pazdírek, MD Dept. of Surgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n ronald pospíšil, MD Dept. of Surgery, Regional Hospital, Kladno

n assoc. prof. Jana prausová, MD, phD, Mba Radiotherapeutic-Oncological Dept., University Hospital Motol, Prague

n assoc. prof. Miloslav roček, MD, phD, fCIrse, ebIr Dept. of Imaging Methods, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n Jan schwarz, MD Dept. of Surgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n Jiří svoboda, MD Dept. of Surgery, Regional Hospital, Příbram

n assoc. prof. Marek Šetina, MD, phD Complex Cardiovascular Center, General University Hospital, Prague

n assoc. prof. Jaromír Šimša, MD, phD Dept. of Surgery, 1st Faculty of Medicine and Thomayer Hospital, Charles University, Prague

n Jaroslav Špatenka, MD, phD Center of Transplantation, University Hospital Motol, Prague

n assoc. prof. Michal Tichý, MD, phD Dept. of Neurosurgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

n Martin Wald, MD, phD Dept. of Surgery, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague

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6

PREFACE

The idea for this book grew from two earlier efforts (2001, 2003) published in Czech language. In these two editions we tried to develop a treatment of the art of surgery based on understanding the structure and functions of human body and its defects.

During the past ten years, since the last publication of Special Surgery, we got convinced that our effort to present this textbook as an attempt to provide a com-prehensive integrated study of human surgery corresponds to the requirements of both undergraduate and postgraduate students is correct. The second edition quickly disappeared from booksellers’ shelves and found its readers not only at the 2nd Medical Faculty of Charles University, but, to the delight of its authors and publisher, also among the wide range of medical professionals.

Surgery is a large subject. We have tried to make it more digestible by organiz-ing the text into clearly demarcated sections, using statement headings to define what the reader can find in each section, and identifying important new terms by bold typeface.

This third revised and extended edition has a completely new form. Besides translating the book into English for the benefit of English speaking students, the texts have been updated, illustrations have been re-designed and new chapters have been added. A significant change is the addition of the chapters Cardio-vascular Surgery, and Neurosurgery. Newly included in this edition of surgery textbook are brief chapters on anesthesiology, oncology, hematology, microbiol-ogy, pathology, genetics, and imaging methods, i.e. the fields related to surgery, without which current surgery might not exist. The themes and extent of these chapters generally correspond to the advancement of respective specializations in the field of surgery.

A new section of the textbook is the picture appendix. We expect that, simi-larly to the drawings, it will help students to remember at least some surgical findings and will remind them of practices and devices mentioned in the book.

The texts have been prepared in cooperation with a number of professionals from the Clinic of Surgery and other clinics, departments and institutes of the 2nd Medical Faculty of Charles University in Prague-Motol. Despite the fact that the diction of individual authors and their focus on details are different, all of them tried hard to prepare readable, comprehensible and concise texts. Currently, the pace of research in the field of surgery (e.g. transplantations) is extremely

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7

prefaCe

rapid, and new information and insights are pouring out of the surgical rooms and laboratories at an almost unimaginable rate. To cope with this flood, students need two tools: a good framework of principles, established by this book, and the ability to use modern informatics.

We owe thanks to Ms. Jana Valterová for her diligent and thorough assistance during the preparation of the textbook. We are indeed grateful for the proof read-ing of the texts provided by Jan Lány.

Revolutionary times are nothing if not exciting. We have tried to convey the feel of fast-moving research, while providing a description in some depth of the techniques and data that are helping us to understand the evolution, nature and function of human body. This book will have succeeded if readers finish it shar-ing our excitement and enthusiasm for the continuing voyage of discovery. The journey is far from finished.

We hope that this textbook will be a good aid during the surgery studies, and the basis of surgical knowledge in the medical practice of the students and all other readers.

Jiří Hoch and Jan Leffler

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8

ContEnts

prefaCe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

abbrevIaTIons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1 neCk surGery (Petr Bavor). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.1 Neck Cysts, Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.2 Inflammations, Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201.3 Thyroid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211.4 Parathyroid Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311.5 Compressive Neck Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2 THoraCIC surGery (Ronald Pospíšil) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352.1 Thoracic Wall. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352.2 Pleura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392.3 Lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472.4 Mediastinum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542.5 Thoracic Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572.6 GI Surgery Using a Thoracic Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

3 MaMMary GlanD surGery (Martin Wald) . . . . . . . . . . . . . . . . . . . . . . . . . . 633.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633.2 Classification of Breast Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633.3 Diagnosis of Breast Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653.4 TNM Classification of Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703.5 Breast Cancer Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 713.6 Prognosis of Patients with Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . 743.7 Complications of Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743.8 Medical Surveillance after Breast Cancer Therapy . . . . . . . . . . . . . . . . . . . 763.9 Breast Reconstruction after Mastectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

4 sofT TIssue TuMors In aDulTs (Jan Leffler) . . . . . . . . . . . . . . . . . . . . . . . . . 784.1 General Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 784.2 Incidence and Localization of Soft Tissue Sarcomas . . . . . . . . . . . . . . . . . . 794.3 Symptoms of Soft Tissue Sarcomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794.4 Diagnostics and Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794.5 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

5 MalIGnanT MelanoMa (Tomáš Krejčí). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835.2 Classification, TNM Classification and Staging . . . . . . . . . . . . . . . . . . . . . . 835.3 Risk Factors, Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 875.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

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Contents

9

6 abdominal wall and hernias (Filip Pazdírek) . . . . . . . . . . . . . . . . . . . . . . . 896 .1 Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 896 .2 InflammationsandTumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 946 .3 DevelopmentalDefects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

7 esophagus and diaphragm surgery (Ronald Pospíšil) . . . . . . . . . . . . . . . . 967 .1 Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967 .2 DiaphragmaticHernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

8 gastric and duodenal surgery (Jan Schwarz) . . . . . . . . . . . . . . . . . . . . 1078 .1 Introduction–AnatomicalandPhysiologicalComments . . . . . . . . . . . . . . 1078 .2 SymptomatologyofGastroduodenalDiseases . . . . . . . . . . . . . . . . . . . . . . 1088 .3 ExaminationsoftheGastroduodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1098 .4 GastricandDuodenalDiseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1098 .5 GastroduodenalSurgicalProcedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

9 surgery of the small and large intestines, rectum and anus (Jiří Hoch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

9 .1 AnatomicalandFunctionalNotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1249 .2 SymptomsofIntestinalDiseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1279 .3 DiagnosticNotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1289 .4 SmallIntestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1309 .5 LargeIntestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1409 .6 RectumandAnus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

10 liver surgery (Jan Leffler) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16310 .1 SymptomatologyofLiverDiseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16310 .2 ClinicalFindings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16410 .3 ParaclinicalAssessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16510 .4 BenignFocalLiverDiseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16610 .5 MalignantLiverDiseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

11 gallbladder and extrahepatic bile ducts (Jan Leffler) . . . . . . . . . . . . 17111 .1 SymptomatologyofGallbladderandBileDuctDiseases . . . . . . . . . . . . . . 17211 .2 ClinicalFindings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17311 .3 ParaclinicalAssessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17311 .4 TreatmentofGallbladderandBileDuctDiseases . . . . . . . . . . . . . . . . . . . 17511 .5 BasicSurgicalProceduresinGallbladderandBileDucts . . . . . . . . . . . . . 17711 .6 PrognosisofPatientswithGallbladderandBileDuctDiseases . . . . . . . . . 179

12 portal hypertension (Jan Leffler) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18112 .1 TypesofPortalHypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18112 .2 PathophysiologyofPortalHypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . 18212 .3 SymptomsofPortalHypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18212 .4 ClinicalFindingsandComplicationsofPortalHypertension . . . . . . . . . . . 18212 .5 DiagnosticsofPortalHypertensionComplications . . . . . . . . . . . . . . . . . . . 18312 .6 BleedingfromEsophagealVarices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18312 .7 Ascites–PossibleWaysofConservativeandSurgicalTreatment . . . . . . . 186

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TexTbook of surgery

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13 pancreas (Jan Leffler) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18713 .1 SymptomsofPancreaticDiseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18813 .2 ClinicalFindingsinPancreaticDiseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 18813 .3 LaboratoryAssessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18913 .4 ImagingMethods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18913 .5 AcutePancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19113 .6 ChronicPancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19513 .7 CysticProcessesofthePancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19913 .8 PancreaticTumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

14 spleen surgery (Jiří Hoch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20514 .1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20514 .2 FunctionandPhysiologyoftheSpleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20514 .3 SplenicMalformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20614 .4 SpleenSurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20614 .5 Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

15 acute abdomen in general, basic diagnostics (Martin Wald) . . . . . . . . . 21015 .1 IntroductionandDefinition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21015 .2 ClassificationofAcuteAbdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21115 .3 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21215 .4 DifferentialDiagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

16 ileus – intestinal obstruction (Zbyněk Jech) . . . . . . . . . . . . . . . . . . . . . 22016 .1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22016 .2 IleusClassificationBasedonItsCauses . . . . . . . . . . . . . . . . . . . . . . . . . . . 22016 .3 PathophysiologyoftheIleusandIleusDiseaseDevelopment . . . . . . . . . . 22216 .4 SymptomsofIleus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22316 .5 IleusDiagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22416 .6 Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22716 .7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

17 peritonitis (Jan Leffler) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23117 .1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23117 .2 PathophysiologyofPeritonitisandSepsis . . . . . . . . . . . . . . . . . . . . . . . . . . 23217 .3 PeritonitisClassification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23317 .4 ClinicalSymptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23417 .5 ParaclinicalDiagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23617 .6 IndicationsforSurgicalTreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23717 .7 PeritonitisTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23817 .8 PrognosisinPatientswithPeritonitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

18 abdominal trauma (Jiří Hoch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24218 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24218 .2 LiverInjuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24518 .3 SplenicInjuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

19 git hemorrhage (Jan Schwarz) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24919 .1 UpperGITHemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25119 .2 LowerGITHemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

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20 mini-invasive surgery (Jiří Svoboda) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25520 .1 LaparoscopicCholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25820 .2 LaparoscopicAppendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26020 .3 LaparoscopicInguinalHernioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26120 .4 GastroesophagealRefluxDiseaseandHiatalHernias . . . . . . . . . . . . . . . . . 26220 .5 LaparoscopicColorectalProcedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26220 .6 DiagnosticandTherapeuticThoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . 26320 .7 TheFutureofMinimallyInvasiveTherapy . . . . . . . . . . . . . . . . . . . . . . . . . 264

21 vascular surgery (Marek Šetina) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26521 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26521 .2 HistoryoftheDiscipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26521 .3 VascularReplacementandSutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26621 .4 AcuteArterialClosures(Outline) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27121 .5 ChronicArterialClosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27421 .6 LargeVesselInjuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27521 .7 IndividualLargeVesselAffections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27721 .8 VascularApproachesforHemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296

22 cardiac surgery (Marek Šetina) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29822 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29822 .2 CardiacSurgeryinHistoryandPresentDays . . . . . . . . . . . . . . . . . . . . . . . 29822 .3 PrincipleofExtracorporealCirculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30022 .4 PreoperativeExaminations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30122 .5 SurgicalApproachesinCardiacSurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 30222 .6 CoronaryArteryDisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30222 .7 ValvularDefects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30822 .8 AneurysmoftheThoracicAorta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31722 .9 AorticDissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31822 .10 CardiacTumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31922 .11 SurgicalTreatmentofArrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31922 .12 Mini-invasiveProceduresinCardiacSurgery . . . . . . . . . . . . . . . . . . . . . . 32022 .13 HeartTransplantation,MechanicalCardiacSupports . . . . . . . . . . . . . . . . . 32122 .14 HeartInjuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32122 .15 CongenitalCardiacDefects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

23 neurosurgery (Michal Tichý) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32823 .1 CraniocerebralInjuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32823 .2 SpineandSpinalCordInjuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33323 .3 PeripheralNerveInjuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33423 .4 DegenerativeSpinalDisorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33523 .5 ConstrictionSyndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33823 .6 CNSCongenitalAnomaliesandHydrocephalus . . . . . . . . . . . . . . . . . . . . . 33823 .7 InfectiousDiseasesoftheCNS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34223 .8 VascularBrainDiseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34423 .9 BrainTumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34723 .10 SurgicalTreatmentofEpilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

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24 modern techniques of cutting, dissection, coagulation, hemostasis, suture and tissue adhesion, viscerosynthesis (Jiří Hoch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358

25 organ transplantation (Jaroslav Špatenka) . . . . . . . . . . . . . . . . . . . . . . . 36125 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36125 .2 IssuesofOrganDonation–MultiOrganHarvesting . . . . . . . . . . . . . . . . . 36525 .3 KidneyTransplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37125 .4 LiverTransplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37325 .5 HeartTransplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37525 .6 LungTransplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38025 .7 PancreasTransplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38225 .8 IntestinalTransplantationandMultiOrganTransplantation . . . . . . . . . . . . 38425 .9 ImmunosuppressionandComplicationsofOrganTransplantations . . . . . . 38425 .10 FutureofOrganTransplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386

26 sentinel lymph nodes (Jaromír Šimša) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38826 .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38826 .2 PossibilitiesofDetectionofSentinelLymphNodes . . . . . . . . . . . . . . . . . 38926 .3 ImportanceoftheMethodinParticularTumors . . . . . . . . . . . . . . . . . . . . . 38926 .4 InVitroExamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390

27 bariatric surgery (Jiří Hoch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39127 .1 DefinitionofObesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39127 .2 TreatmentofObesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392

28 intensive care in surgery (Jan Neumann) . . . . . . . . . . . . . . . . . . . . . . . . 39528 .1 PostoperativeMonitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39628 .2 MonitoringtheCardiovascularSystem . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39728 .3 MonitoringtheRespiratorySystem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39728 .4 ExaminationofBloodGasesandAcid-BaseHomeostasis . . . . . . . . . . . . . 39928 .5 Consciousness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399

29 perioperative nutrition (Jan Neumann) . . . . . . . . . . . . . . . . . . . . . . . . . 40029 .1 EnteralNutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40029 .2 ParenteralNutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402

30 infection in surgery, antibiotic therapy and prophylaxis (Otakar Nyč) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405

30 .1 SurgicalSiteInfection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40530 .2 ClassificationofSSI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40630 .3 MicrobiologyofSSI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40630 .4 ClassificationofOperativeWoundsAccording

totheRiskofSSI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40630 .5 RiskFactorsfortheDevelopmentofSSI . . . . . . . . . . . . . . . . . . . . . . . . . . 40730 .6 MicrobiologicalDiagnosticsofSSI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40730 .7 AntibioticUseintheTreatmentofSSI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40830 .8 PrinciplesofAntibioticProphylaxisduringSurgicalProcedures . . . . . . . . . .411

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31 hematological issues in surgery (Ivana Hochová) . . . . . . . . . . . . . . . . . 41331 .1 AntithromboticProphylaxisinSurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41331 .2 OperationonPatientsReceivingChronicAnticoagulant

andAntiaggregantTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41431 .3 SurgicalTreatmentinPatientswithNeutropenia

andThrombocytopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41631 .4 SignificantAcquiredBleedingDisordersinSurgicalPatients . . . . . . . . . . 41731 .5 SplenectomyanditsManagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419

32 anesthesiology and resuscitation in surgery (Karel Cvachovec) . . . . . . . . 42032 .1 TerminologyUsed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42132 .2 AnesthesiologicalTechniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42132 .3 TheMostWidelyUsedPharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . 42332 .4 ProvidingforAnesthesiologicalCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42432 .5 CollectiveCooperationwiththeAnesthesiologist . . . . . . . . . . . . . . . . . . . . 429

33 multimodal oncological treatment (Jana Prausová) . . . . . . . . . . . . . . 43133 .1 SurgicalTreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43233 .2 Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43333 .3 Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43433 .4 HormonalTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43533 .5 BiologicalTargetedTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436

34 tumor genetics (Petr Goetz) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43734 .1 HereditaryNon-PolyposisColorectalCancer

(HNPCC,LynchSyndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43934 .2 FamilialAdenomatousPolyposis(FAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . 44034 .3 HereditaryBreastandOvarianCancerSyndrome . . . . . . . . . . . . . . . . . . . . 44134 .4 MultipleEndocrineNeoplasiaType1(MEN1Syndrome) . . . . . . . . . . . . 44234 .5 MultipleEndocrineNeoplasiaType2(MEN2Syndrome) . . . . . . . . . . . . 44334 .6 MedullaryThyroidCarcinoma(MTC)andMEN2Syndromes . . . . . . . . 443

35 pathology (Roman Kodet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44535 .1 TheDisciplineofPathologyinSurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 44535 .2 Autopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44535 .3 BiopticPathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44635 .4 GeneralizationofOptimumPracticeinClinicalPathology . . . . . . . . . . . . 455

36 imaging methods in surgery (Miloslav Roček, Jiří Lisý) . . . . . . . . . . . . . . . . 45736 .1 Radiodiagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45736 .2 InterventionalRadiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469

imaging methods in surgery – gallery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

color image gallery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505

authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567

index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577

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AbbreviAtions

AA ��������������������������������������� acute abdomenABCDE rule ������������������������ Asymmetry, Border, Color, Diameter, EnlargingACB ����������������������������������� aortocoronary bypassACD ����������������������������������� right coronary arteryACS ����������������������������������� left coronary artery; acute coronary syndromeAF ������������������������������������� atrial fibrillationANC ���������������������������������� absolute neutrophil countAP ������������������������������������� acute pancreatitisAPC ����������������������������������� argon-plasma coagulationAPE ����������������������������������� appendectomyAR ������������������������������������� radial arteryARDS �������������������������������� acute respiratory distress syndromeARU ���������������������������������� Anesthesiology and Resuscitation UnitASA ����������������������������������� American Society of AnesthesiologistsAV ������������������������������������� atrioventricularAVM ���������������������������������� arteriovenous malformationBMI ����������������������������������� body mass indexBP ������������������������������������� blood pressureCAD����������������������������������� coronary artery diseaseCFA ����������������������������������� common femoral arteryCKTCH ������������������������������� Centrum kardiovaskulární a transplantační chirurgieCNS ����������������������������������� central nervous systemCOMECON ������������������������� Council for Mutual Economic AssistanceCPAP ��������������������������������� continuous positive airway pressureCRC ����������������������������������� colorectal cancer CRP ����������������������������������� C-reactive proteinCT�������������������������������������� computed tomographyCTS ������������������������������������ carpal tunnel syndromeCVA ����������������������������������� cerebrovascular accidentCVP ����������������������������������� central venous pressureČTS ������������������������������������ Česká transplantační společnostDCC ����������������������������������� deleted in colorectal carcinomaDGHAL ������������������������������ Doppler-guided hemorrhoidal artery ligationDIC ������������������������������������ disseminated intravascular coagulopathyDNET ��������������������������������� dysembryoplastic neuroepithelial tumorDSA ����������������������������������� digital subtraction angiographyEC�������������������������������������� extracorporeal circulationECG ����������������������������������� electrocardiographyEEA ����������������������������������� entero-enteroanastomosisEF �������������������������������������� ejection fractionEGFR and VEGF ����������������� growth factor receptorsECHO �������������������������������� echocardiographyEMG ���������������������������������� electromyographyEO ������������������������������������� endocrine orbitopathyEPT������������������������������������ endoscopic papillotomyERCP ��������������������������������� endoscopic retrograde cholangiopancreatographyES �������������������������������������� esophageal sphincter

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EUS ����������������������������������� endosonographyFAP ����������������������������������� familial adenomatous polyposisFBSS���������������������������������� back surgery syndromeFMTC ��������������������������������� familial MTCFNAB �������������������������������� fine needle aspiration biopsyFNH ����������������������������������� focal nodular hyperplasiaFOBT ��������������������������������� fecal occult bloodfT3 ������������������������������������ triiodothyroninefT4 ������������������������������������ thyroxineFW ������������������������������������ Fahraeus-Westergren (test)GCS ����������������������������������� Glasgow coma scaleGEA ����������������������������������� gastroenteroanastomosesGER ����������������������������������� gastroesophageal refluxGERD ��������������������������������� gastroesophageal reflux diseaseGIST ���������������������������������� gastrointestinal stromal tumorsGIT ������������������������������������ gastrointestinal tractGM ������������������������������������ glioblastoma multiformeGSV ����������������������������������� great saphenous veinHBD ���������������������������������� heart-beating donorsHCC ����������������������������������� hepatocellular carcinomaHNPCC ������������������������������ hereditary nonpolyposis colorectal cancerHR ������������������������������������� heart rateICU ������������������������������������ Intensive Care UnitIE ��������������������������������������� infectious endocarditisICH ������������������������������������ intracerebral hematomaIKEM ��������������������������������� Institute of Clinical and Experimental Medicine (Prague)IMA ����������������������������������� internal mammary arteryIPAA ���������������������������������� ileal-pouch anal anastomosisIPC ������������������������������������ idiopathic proctocolitisITA ������������������������������������ internal thoracic arteryKST ����������������������������������� Coordinating Transplant Centre (Koordinační středisko tansplantací)LA ������������������������������������� left atriumLMWH ������������������������������ low-molecular-weight heparinLT �������������������������������������� total lobectomyMALT �������������������������������� mucosa associated lymphoid tissueMAP ���������������������������������� MYH associated polyposisMAP ���������������������������������� mean arterial pressureMEN ���������������������������������� multiple endocrine neoplasiaMI ������������������������������������� myocardial infarctionMIBI ���������������������������������� methoxyisobutylisonitrileMIDCAB ���������������������������� minimally invasive direct coronary artery bypassMIU ����������������������������������� international unitsMODS ������������������������������� multiple organ dysfunction syndromeMOF ���������������������������������� multiple organ failureMOH ��������������������������������� multi organ (multiple organ) harvestingMRCP �������������������������������� magnetic resonance cholangiopancreatographyMRI ����������������������������������� magnetic resonance imagingMRM ��������������������������������� magnetic resonance mammographyMRSA�������������������������������� methicillin resistant Staphylococcus aureusMTC����������������������������������� medullary thyroid carcinomaNG ������������������������������������� nasogastricNHBD �������������������������������� non-heart-beating donors

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NMM �������������������������������� nodular melanomaNMR ��������������������������������� nuclear magnetic resonanceNOTES ������������������������������� natural orifice transluminal endoscopic surgeryNRL ����������������������������������� laryngeal recurrent nerveNSAID ������������������������������� non-steroid antirheumaticsOCHG �������������������������������� optochiasmatic-hypothalamic gliomasOPSI ���������������������������������� overwhelming post splenectomy infectionPCA ����������������������������������� patient controlled analgesiaPEEP ��������������������������������� positive end expiratory pressurePEG ����������������������������������� percutaneous endoscopic gastrostomy PET������������������������������������ positron emission tomographyPMPS �������������������������������� postmastectomy pain syndromePNO ���������������������������������� pneumothoraxPTA ����������������������������������� percutaneous transluminar angioplastyPTC ������������������������������������ percutaneous transhepatic cholangiography PTD ����������������������������������� percutaneous transhepatic drainageRC ������������������������������������� ramus circumflexusRES ����������������������������������� reticuloendothelial systemRET������������������������������������ rearranged during transfectionRFA ����������������������������������� radiofrequency ablationRIA ������������������������������������ ramus interventricularis anteriorRIND ��������������������������������� reversible ischemic neurological deficitSAH����������������������������������� subarachnoid hemorrhageSILS ����������������������������������� single incision laparoscopic surgerySIRS ���������������������������������� surrounding fatty tissue, inducing generalized inflammatory responseSLN ����������������������������������� sentinel lymph nodeSND ����������������������������������� sentinel lymph node dissectionSPECT ������������������������������� single photon emission computed tomographySSI ������������������������������������� surgical site infectionSSM ���������������������������������� superficial spreading melanomaSTE ������������������������������������ subtotal resection of the thyroid glandTAPP ��������������������������������� transabdominal preperitoneal plastyTBC ����������������������������������� tuberculosisTEM ���������������������������������� total mesorectal excision TEP������������������������������������ total extraperitoneal plastyTgAK ��������������������������������� antibodies against thyroglobulinTIA ������������������������������������ transitory ischemic attackTIPS ���������������������������������� transjugular intrahepatic portosystemic shuntTIPSS �������������������������������� transjugular Intrahepatic portosystemic stent shuntTNF ����������������������������������� tumor necrosis factorTOS ����������������������������������� thoracic outlet syndromeTRAK ��������������������������������� antibodies against a TSH-receptorTRAM �������������������������������� transverse rectus abdominus myocutaneousTSH ����������������������������������� thyroidea stimulating hormoneTTE ������������������������������������ total thyroidectomy US ������������������������������������� ultrasoundUSS ����������������������������������� ulnar sulcus syndromeVAC ����������������������������������� vacuum assisted closureVAS ����������������������������������� visual analog scaleVATS ���������������������������������� video-assisted thoracoscopyVTE ����������������������������������� venous thromboembolismWL ������������������������������������ waiting lists

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1 neck surgery

1.1 Neck Cysts, Lymph Nodes1.2 Inflammations, Tumors1.3 Thyroid Gland1.4 Parathyroid Glands1.5 Compressive Neck Syndromes

1.1 Neck Cysts, Lymph NodesIntermsofneckorgandiseases,surgicaltreatmentinthisregionpertainstoneckcysts,thyroiddiseases,inflammationsandlymphadenopathies .

Medial neck cystsareformedfromthethyroglossalduct,theembryonicrouteofthedescendingthyroidgland,whosebasedevelopsintheareaoftheforamencecumofthetongue .Thethyroglossalductiscommonlyobliteratedtoformafi-brousband,oritpersistslesscommonlyasacranialprojectionfromthethyroidglandisthmusasthepyramidallobe .Whenthecranialpartfailstoclose,aninnerfistuladevelops,i .e .anopeningatthetongueroot .Retentionofitscontentleadstotheformationofacysticstructureundertheskinonthehyoidbonelevel .Thecystmayperforateandappearoutsideduetosecondaryinfectionortrauma,thusleadingtoformationofacompletemedialfistula .Asfordifferentialdiagnostics,medialcystsmayberepresentedbyadermoidcystor,morerarely,anectopicthyroidgland,whichmaybethesingletissueofthethyroidgland .Unlessthetumorexhibitsclearcysticcharacteristics,scintigraphyfocusedonthethyroidglandshouldbeperformedbeforesurgicaltreatment .Medialcystsareexcisedtogetherwiththemediumpartofthehyoidbone,whileligatingtheinnermouth .Arelapsemayoccuruponincompleteremoval .

Lateral neck cysts areformedfromthepersistingthymopharyngealduct .Theyhavetwomouths:Theinnermouthisfoundonthearchofthesoftpalate,andcystsrunalongtheinnercarotidartery,whiletheoutermouthisfoundinthester-noclavicularfossa,atthemedialedgeofthesternocleidomastoidmuscle .Morecommonly,lateralfistulasareincomplete .Radicalexcisionshouldbeperformedinlateralneckfistulasduringthefirstyearoflife,beforethecystbecomesinfected .

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Chap

ter 1 Cystic hygroma colli arepolycysticstructuresfilledwiththinliquid,formed

fromtherudimentoftheembryoniclymphsac .Theyareusuallylocatedonthelateralsideoftheneckbelowthemandible .Cranially,theymayreachfromthefloorofthemouthuptothetongue,andcaudallyuptotheaxilla .Hygromasymptomsdependonthesizeandlocalization .Ahygromabecomeshazardousincaseswhereitspreadsonthetongueandinthemediastinum,whichismanifestedbydyspnoea .Thetreatmentisbasedonextirpationassoonaspossibleafterbirth .

Lymphadenopathy –anecklymphnodedisorder–isaffectedbyprimaryandsecondary(metastases)tumorsormanifestationofasystemdisease .Itmaybebenignormalignant .

Lymphadenities,asaresponsetoacuteinflammationsinthesurroundingar-eas,arethemainbenigncauseofnecklymphnodeenlargement .Themainma-lignantcauseofnecklymphadenopathyconsistsincancermetastasesthatstemfromtumorsofthepharynx,larynx,trachea,esophagus,bronchi,digestivetract(Virchow’snode–inthesupraclavicularregionontheleft)andthethyroidgland .Malignantinvolvementofnecklymphnodesusuallyoccurswithalymphoma–Hodgkin’slymphogranulomatosis .

Surgicalremovalofthenodeforhistologicalassessmentisessentialindif-ferentialdiagnosticsofnecklymphadenopathies .

1.2 Inflammations, TumorsCarbuncle(carbunculusnuchae)isatypicalinflammatory manifestationintheneckarea .Mostoften,itdevelopsindiabeticsthroughthefusionofseveralfuruncles,reachingdeepdowntothesolidfascia .Ittendstobehighlypainful;thesolidfibroussubcutisandfasciapreventtheinflammationandedemafromspreadinginthearea .Itistreatedbywideexcisionoftheinflammatorytissueuptothefascia .Thedefectislefttohealper secundam .Alessradicalmethodconsistsinawidecrossincision,alwaysinconnectionwithantibiotictreatment .

Deepphlegmonesoccurrarely,andtheymayoriginatefromoralcavitydis-eases,apenetratinginjuryofthepharynx,esophagus,tracheaoranadvancedpurulentinflammationofnecklymphnodes .Theseinflammationsputthepatientatriskofasepticconditionorinvolvementofimportantneckstructures(bloodvessels,trachea,etc .),particularlyuponlatediagnosis .Theconditionistreatedsurgicallybyopeningthelesion,drainingitandadministratingantibiotics .

Asforbenigntumors,fibromasandlipomas,feltaspalpableresistances,pre-dominate;oftentheyareasymptomatic .Surgicalextirpationisusedtomanagethecondition .Histologicalassessmentisalwaysneeded .

Primary malignant tumorsaffectingtheareaoftheneckincludeparticu-larlythyroid and larynx cancersandtheyarediscussedinrespectivechapters .Secondary tumorsaffecttheentirelymphaticsystem .

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Chap

ter 1

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1.3 Thyroid GlandThethyroidglandisbutterfly-shapedandconsistsoftwolobesconnectedwithanisthmusofvariedwidth .Thethyroidglandislocatedventrallyandlaterallyfromthetracheaandthelarynx .Theisthmusisfoundonthelevelofthe2ndand3rdannularcartilages .Thenon-constantpyramidalloberunscraniallyfromtheisthmusandisanembryonicresidueofthethyroglossalduct .Nutritionforthethyroidglandisensuredbysuperiorthyroidarteries(thefirstbranchoftheex-ternalcarotidartery)andinferiorthyroidarteries(originatinginthethyrocervicaltrunk) .Venousoutflowisdirectedtotheinternaljugularvein .Lymphdrainagereachesthepre-andparatrachealnodesfirst(thecentralgroup),thennodesalongtheinternaljugularvein(lateralgroup)andtheuppermediastinum .Parathyroidglandsarefoundintheimmediatevicinityofthethyroidgland,ventromedi-ally,andrecurrentnervesrundorsolaterallyinthetracheoesophagealsulcus .AnatomicalconditionsandrelationshipsareillustratedinFigs .1 .1,1 .2,and1 .3 .

1.3.1 SymptomsThesymptomsofthyroiddisordersarelocal–conditionedbyanatomicalchang-esofthegland,associatedwithpressureexertedonthesurroundingstructures(neck“enlargement”,afeelingofpressure,difficultswallowing,respirationdis-orders,pain,andvoicedisorders)–andgeneral,causedbyafunctionaldisorderofthegland .Functionaldisordersofthethyroidglandaremanifestedashypo-

Fig. 1.1 Cross­section of the neck at the height of the thyroid gland

Obr. 1-1

Superfi cial fascia colli

Carotid sheath

Thyroid gland

esophagus

Vagus nerve

Sympathetic trunk

Sternohyoid muscle

parathyroid gland

Sternocleidomastoid muscle

Trachea

int. jugular vein

Common carotid artery

omohyoid muscle

laryngeal recurrent nerveCarotid sheath parathyroid gland laryngeal recurrent nerve

int. jugular veinint. jugular vein omohyoid muscle

Sympathetic trunkSympathetic trunk

parathyroid gland

esophagusesophagus

parathyroid glandparathyroid glandparathyroid gland

Vagus nerveCommon carotid artery

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Chap

ter 1

Fig. 1.2 Anatomical situation of the thyroid gland – vascular supply

Obr. 1-2

Superior thyroid artery

external carotid artery

inferior thyroid artery

internal jugular vein

Axillary veinSuperior vena cava

Aorta

Trachea

Aorta

Superior vena cava

Trachea

Fig. 1.3 Anatomical situation of the thyroid gland – course of recurrent nerve

Obr. 1-3

pyramidal lobelobe, right and left Thyroid glands

right laryngeal recurrent nerve

left laryngealrecurrent nerve

right vagus nerve left vagus nerve

pyramidal lobepyramidal lobe

right laryngeal recurrent nerveright laryngeal recurrent nerve

Trachea

left laryngeal

Trachea

left laryngealrecurrent nerveleft laryngeal

right vagus nerve left vagus nerve


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