SRB’s Manual of Surgery Sriram Bhat M
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1SRB's Manual of Surgery
2SRB's Manual of Surgery
SECOND EDITION
M Sriram Bhat MS (General Surgery) Associate Professor in Surgery Kasturba Medical College Mangalore Karnataka, India
e-mail: meera_sriram2003@yahoo.com
3Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
EMCA House, 23/23B Ansari Road, Daryaganj
New Delhi 110 002, India
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SRB's Manual of Surgery
© 2007, Sriram Bhat M
All rights reserved. No part of this publication should 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 author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters to be settled under Delhi jurisdiction only.
First Edition: 2004
Second Edition: 2007
9788180618475
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., Sector 60, Noida
4God could not be everywhere all the time,
so, He created Mothers
—Dr. SRB, 2000
This Book is in the memory of my mother
Late Mrs. Devaki Krishna Bhat
who continues to inspire and guide me.
5Foreword
A true surgeon is never fearless; He fears for his patients, he fears for his shortcomings, his own mistakes, but never fears for himself or his professional reputation.
—Samule J Mixter
The manual is written for the students in this firing line for their MBBS degree. Common conditions seen on a day to day basis have dealt with a little more detail. The uncommon and rare conditions have been dealt briefly. The mode of clinical presentation and the physical signs are mentioned vividly so as to register in the mind of the reader. There is a brief mention of necessary investigations in each of the surgical conditions. The accepted mode of recent advances in investigation and treatment has been included. This manual is meant for Final MBBS degree examination and not a consolidated textbook. Certain chapters are included at the end of the book for the more enthusiastic students and for those interested in participating in quiz programmes.
The clinical photographs are of very good quality, which are self-explanatory of the condition. The clinching physical signs have been highlighted in Box forms with different shades of colour. This mode of presentation emphasizes the point to be conveyed to the students which they can recollect when required either while arriving at a diagnosis in their examination or while in practice after obtaining the degree. This book gives a good foundation in surgery for those who wish to pursue surgery as a career.
What the surgeon ought to be?
The conditions necessary for the surgeon are four—first, he should be learned; second, he should be an expert; third, he must be ingenious; fourth, he should be able to adapt himself.
It is required for the first that the surgeon should know not only the principles of surgery, but also those of medicine in theory and practice; for the second, that he should have seen others operate; for the third, that he should be ingenious, of good judgement and memory to recognize conditions; and for the fourth, that he should be adaptable and able to accommodate himself to circumstances.
Let the surgeon be bold in all sure things, and fearful in dangerous things, let him avoid all faulty treatments and practices. He ought to be gracious to the sick, considerate to his associates, cautious in his prognostications. Let him be modest, dignified, gentle, pitiful, merciful; not covetous nor an extortionist of money; but rather let his reward be according to his work, to the means of the patient, to the quality of the issue, and to his own dignity.
—Ars Chirurgica
I thank Sriram Bhat M for giving me this privilege of writing a foreword to his excellent manual.
Dr Prakash Rao ms
Professor in Department of Surgery
Kasturba Medical College, Mangalore
6Acknowledgements
I am happy that I could bring out second edition in two years. This is probably by constant help and support from many people.
I thank our dear Vice Chancellor of MAHE, Professor HS Ballal, our beloved Dean, Professor CV Raghuveer, and our vice deans Professor Anand Kini and Professor Venkatraya Prabhu for their academic support.
I remember the Head of the surgery department, KMC, Mangalore, Professor Jayaram Shenoy for his constant encouragement in academic work and progress.
I remember my senior retired teachers professor CR Ballal and Professor Suresh Kamath for their constant affection towards me.
Our senior faculty in the department, Dr K Prakash Rao who is a guide and encourager to everybody will be remembered as a special person by me always.
Surgical unit heads Dr BM Nayak, Dr Thangam Verghese, Dr Jayaprakash Rao, Dr Harish Rao, Dr Ramachandra Pai, Dr Alfred and Dr Eril Diaz were always supportive for my work and they are worth to be remembered always.
I am grateful to all my teachers and colleagues in the surgery department who directly and indirectly helped me to bring out second edition.
Many CT, MRI and X-ray pictures for second edition are contributed by Dr Raghavendra Bhat and Dr Ravichandra, Radiology department, Yenepoya Medical College, Mangalore. I sincerely remember them. I thank Dr Devidas Shetty, Dr Venkatesh Sanjeeva, Dr K Akbar, Dr Yogesh, Dr Rajesh Ballal, Dr Kalpana Shridhar, Dr Ganesh, Dr Tantri, Dr Sandeep and Dr Ashok Hegde.
I sincerely thank professor Navinchandra Shetty head of the radiology department, KMC, Mangalore and also other faculty of the department for their guidance.
I sincerely appreciate Dr Suresh Pai Mch (CTS), Dr Ashok Shetty Mch (CTS), Dr Vivekanand Prabhu Mch (Paediatric surgery), Dr Muralidhar Pai Mch (Neurosurgery) and Dermatology department KMC Mangalore for their valid contributions.
I will never forget my close associates Dr Ganapathy MD Mangala Hospital, Kadri, Mangalore and Dr Ashok Pandith MCh (Urology) for their affectionate help and encouragement for all my endeavors.
I thank my friend Dr Jagadish MDS for his contributions to X-ray and opinion on dental topics.
My wife, Dr Meera Karanth helped me day and night in revising this edition and without her support this could not have been possible.
I thank and appreciate all undergraduates, postgraduates and old students of the college especially Dr. Nithin (01 Batch Intern) for their valuable contributions. I acknowledge everyone who helped in the work.
I remember my students, Dr Ravi CR, Dr Ashivin T, Dr Ishwar Keerthi, Dr Sudesh, Dr Narasimha Murthy who are in constant touch and of great help to me always.
I appreciate Shri JP Vij, Chairman and Managing Director, Mr Tarun Duneja, General Manager (Publishing), Mr PS Ghuman, Sr Production Manager, Ms Sunita Katla, The Typesetting Wizard, Mr DC Gupta, Sr Copyeditor and Mr RK Mazumdar, Sr Graphic Designer of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for doing appreciable work in their respective field of printing and publishing.
Sriram Bhat M
7Preface to the Second Edition
I am overwhelmed to write the preface for second edition two years after the release of first edition. First edition was well-accepted by the undergraduates and postgraduates. I felt mistakes in first edition should be corrected and there was a need to add more illustrations and photos and so second edition is brought out early. Entire text of all chapters is carefully read, corrected, revised and material added as required. Many more tables are used in second edition for easy grasping of the subject. Topics like Pain, Day Care Surgery and Cardiac Surgery are added. In chapter Miscellaneous, ‘Most Commons in Surgery’ and ‘Surgeries’ topics are removed as I felt these topics are not necessary. In doing second edition I have referred many authorized books and publications and journals. I sincerely express my gratitude to them. I hope new book will be much more beneficial to all referring doctors, undergraduates and postgraduates.
I welcome all suggestions and criticism from readers.
June 2006
Sriram Bhat M
8Preface to the First Edition
This book is born out of a desire to provide a complete, authoritative, current textbook on Surgery. For the past fifteen years of my teaching profession, watching students hurriedly jotting down notes during classes, an urge was born within me to put my thoughts in print. I am fortunate to have been guided by my teachers and supported by my students towards this goal.
An attempt has been made to make this book simple and reader-friendly while not compromising on the aspect of providing students with necessary information and a better clinical understanding of surgery. Recent advances in surgery till date have been included to the best of my knowledge. Text has been presented in a simple and lucid language so as to help students understand and recapitulate the subject better. Since a picture is worth than thousand words, over 500 photos, X-rays and illustrations have been incorporated in this work to make Surgery more interesting and understandable. Inspirational quotes have been interspersed to motivate students to go the extra mile.
Discussion on Instruments and Operative procedures has been dealt with in necessary detail separately. A chapter containing a list of interesting new developments in surgery and uniquely new topics like Fascinating Signs, Misnomers, Triads and other interesting chapters have been included.
While this book has been compiled with undergraduates in mind, I'm confident that it will serve as an useful reference for postgraduates and practitioners.
In compiling this book I have consulted many authoritative books and publications and I sincerely express my appreciation and gratitude to all of them.
Suggestions and constructive criticisms towards improving this book in subsequent editions are always welcome.
November 2003
Sriram Bhat M
e-mail: meera_sriram2003@yahoo.com
9About the Author
The author, Dr. Srirama Bhat M MS (Gen Surgery) is an Associate Professor in the Department of Surgery, Kasturba Medical College, Mangalore and an Honorary Surgeon at the Government Wenlock District Hospital at Mangalore, South Canara, Karnataka, India. He, under the aegis of Manipal Academy of Higher Education (MAHE) has lived up to the principles and expectations of his profession.
It is a privilege to be associated with and taught by the eminent surgeons of this pioneer institution among whom the author excels. He is equally respected by his colleagues and revered by his students for his zeal and dedication at passing on his abundant knowledge to the undergraduates and postgraduates alike. He has been an unending source of motivation for many a students at viewing and understanding Surgery as the subject it is.
A simple person by nature and habit, hailing from a small hamlet in the picturesque surroundings of South Canara, Karanataka, it is his love and dedication towards his profession that has made him what he is at present; loved and respected by one and all. A gold medallist, two times, during his undergraduate study and a topper during his formative years as a Surgeon (Postgraduation) he has retained his hunger and passion for knowledge over a period of 13 years as an academician par excellence and this is what sets him apart.
With a teaching experience spanning over a period of one and a half decades, it will be no exaggeration if said that the art of teaching comes naturally to him. A teacher and an academician by heart, he earnestly deserves the ‘Best Teacher’ award conferred on him by MAHE in the year of 2000 AD.