SRB’s Manual of Surgery Sriram Bhat M
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1SRB's Manual of Surgery
2SRB's Manual of Surgery
THIRD EDITION
Sriram Bhat M MS (General Surgery) Associate Professor in Surgery Kasturba Medical College Mangalore Karnataka, India e-mail: meera_sriram2003@yahoo.com
3
Published by
Jitendar P Vij
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SRB's Manual of Surgery
© 2009, 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 are to be settled under Delhi jurisdiction only.
First Edition: 2004
Second Edition: 2007
Third Edition: 2009
9788184485516
Typeset at JPBMP typesetting unit
Printed at Replika
4God could not be everywhere all the time, so, He created Mothers
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 conditions. The clinching physical signs have been highlighted in box forms with different shades of colour. This mode of presentation emphasises 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 does 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.
Foremost, it is required that the surgeon should know not only the principles of surgery, but also those of medicine in theory and practice; second, he should have seen others operate; third, he should be ingenious, of good judgement and memory to recognize conditions; and the fourth, 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; neither 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
6Preface to the Third Edition
It is my pleasure to release the third edition within two years of release of second edition of SRB's Manual of Surgery. Earlier editions were well-accepted by undergraduates and postgraduates. I felt to bring out the third edition in the intention of making it much more illustrative with more diagrams and clinical and operative photographs. I have extensively done corrections in this edition. I added many new materials, text details, new additional topics in different chapters. Malignancies are discussed in much more detail with new staging and present oncological trends. Mistakes are corrected and insufficient topics are upgraded. I have referred many books, journals and took help of my colleagues in surgery and other departments like radiodiagnosis and ENT from my college KMC Mangalore. I have retained all chapters with some rearrangements of few chapters and topics.
I sincerely express my thanks to everybody who have helped me and also to the publishers who are the backbone of this upgraded edition.
I hope this new book will be well-accepted by the teachers, undergraduates and postgraduates of surgery department. I sincerely welcome all criticisms.
December 2008
Sriram Bhat M
7Preface 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 a 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
8Acknowledgements
I am happy to bring out one more edition (third) of the book SRB's Manual of Surgery. This is due to constant help and support of many.
I thank our Chancellor Dr Ramdas M Pai; Pro-Chancellor Dr HS Ballal; Vice-Chancellor of MAHE Prof Rajashekaran Warrier; our beloved Dean Prof CV Raghuveer; our Vice-Deans Prof Anand Kini and Prof Venkatraya Prabhu for their academic support.
I thank Prof Thangam Varghese, Head of Department of Surgery, KMC Mangalore for her constant encouragement in academic work and progress.
I always remember my senior teachers, Prof CR Ballal and Prof Suresh Kamath for their constant help.
Our senior faculty in the department, Prof K Prakash Rao who is a guide and encourager to everybody, will be remembered as a special person by me always.
Surgical unit heads in our college Dr BM Nayak, Dr Jayaram Shenoy, Dr Jayaprakash Rao, Dr Harish Rao, Dr Ramachandra Pai, Dr Alfred Augustine and Dr Shivananda Prabhu are always supportive for my work and are worth to be remembered always.
I am grateful to all my teachers and colleagues in Surgery Department who directly or indirectly helped me to bring out this third edition.
I appreciate District Medical Officer and Resident Medical Officer of Government Wenlock Hospital, Mangalore for their kind help.
I thank very much to the faculty, Department of Surgery and Paediatric Surgery, JJMMC Davangere for providing the needed photographs.
I sincerely thank Prof Navin Chandra Shetty, Head of Radiology Department, KMC Mangalore and also other faculty of the department for their help in providing and guiding me in X-rays, CT scans and imaging methods.
I acknowledge Prof Kishore Chandra Prasad, Head of Department of ENT for his help, guidance and encouragement in bringing out this book.
I thank Dr Shivaprasad Rai; Dr Ahfaque Mohammed; Dr Kalpana Sridhar; Dr Yogish Kumar; Dr Ramesh; Dr K Akbar; Dr Keshava Prasad; Dr Kishore Reddy; Dr Achaleshwar Dayal; Dr Raghav Pandey; Dr Rupen; Dr Ashwini Mallya; Dr Praveen; Dr Ashok Hegde; Dr Rajesh Ballal; Dr Devidas Shetty; Dr Venkatesh Sanjeeva; Dr Sunil; Dr Shanbogh; Dr Harish Nayak; Dr Subraya Kamath; Dr Venkatesh Shanbogh; Dr Tantri; Dr Sandeep Gopal; Dr Ganesh; Dr Sampath for their help in various aspects.
I sincerely appreciate Dr Raghavendra Bhat and Dr Ravichandra, consultants in Radiology Department, Yenepoya Medical College, Mangalore for their contribution and affectionate help.
I thank Dr Ganesh Pai MCh (Paediatric Surgery); Dr Suresh Pai MCh; Dr Ashok Shetty (Cardio Thoracic Surgery); Dr Muralidhar Pai MCh (Neurosurgery); Dr Vivekanand Prabhu (Paediatric Surgery); Dr Sadashiva Rao (Paediatric Surgeon); Dr Narayana Bhat (Paediatric Surgeon); Dr Prashanth Mallya (Anaesthetist); Dr Subramanya Bhat (Sonologist) for their help and contributions.
I will never forget my close associates Dr Ganapathy MD, Mangala Hospital, Kadri, Mangalore and Dr Ashok Pandit, MCh (Urologist) for their affectionate help and encouragement in all my endeavours. They always stood with me in my difficulties.9
I thank my friend Dr Jagadish MDS for his contributions to X-ray and opinion on dental and faciomaxillary topics.
My special thanks to Dr Harikiran Chekuri, Hyderabad for his help in correcting the mistakes.
My wife Dr Meera Karanth helped me day and night in revising this edition and without her help this could not have been possible. My beloved daughter Ananya helped me in drawing new diagrams artistically. I enjoy her love and affection towards me.
I remember my students Dr Ravi CR; Dr Ashwini Polnaya; Dr Ishwara Keerthi; Dr Sudesh; Dr Narasimha Murthy; Dr Nithin for their special contributions.
I thank all my students especially postgraduates of Surgery Department who were helping regularly in bringing out this edition.
Words are not sufficient to remember all my patients who are the main material for the book. I pray for their good health always.
I appreciate Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director-Publishing) and all staff of the Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for doing appreciable work in their respective field of printing and publishing.
Sriram Bhat M