Fourth Edition
Sriram Bhat M MS (General Surgery)
Professor Department of Surgery Kasturba Medical College
Mangalore, Karnataka, India
Honorary Surgeon Government Wenlock Hospital
Mangalore, Karnataka, India e-mail: meera_sriram2003@yahoo.com
ForewordPrakash Rao
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SRB's Manual of Surgery
First Edition : 2004
Second Edition : 2007
Third Edition : 2009
Reprint : 2010
Fourth Edition : 2013
Reprint : 2013
9789350259443
Printed at
God 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
7Foreword
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 been 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; and the 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 recognise 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.
Prakash Rao MS
Retd. Professor of Surgery
Kasturba Medical College
Mangalore, Karnataka, India
9Preface to the Fourth Edition
It is my pleasure to release the fourth edition in four years after the release of third edition of SRB's Manual of Surgery. Earlier editions were well-accepted by undergraduates and postgraduates. I felt that I should bring out the fourth edition in the intention of making it much more updated with texts and illustrations. I have done extensive corrections in this edition. I added many new topics, text details, and additional topics in different chapters. Morbid obesity, gastrointestinal fistulas, and surgical audit are the newer topics added. Malignancies have been discussed in much more detail with new concept of staging and with present oncological trends. Mistakes are corrected and insufficient topics are upgraded. I have referred many books, journals and taken the help of my colleagues in surgery and other departments. I have retained all chapters with some rearrangements of few chapters and topics. Self-assessment questions at the end of each chapter are removed which allowed me to add much more text material in the same space.
I sincerely express my thanks to everybody who have helped me to bring out this edition, 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.
Sriram Bhat M
11Preface 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 photographs, 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 am 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.
Sriram Bhat M
13Acknowledgements
I am happy to bring out one more edition (fourth) 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 H S Ballal; Vice chancellor of Manipal Academy of Higher Education (MAHE), Professor K Ramnarayan; beloved Dean, Professor Venkatraya Prabhu; our associated Deans, Professor Anand Kini and Professor Vivian D'Souza for their academic support.
I thank Dr Alfred Augustine, Professor and Head, Department of Surgery, Kasturba Medical College (KMC), Mangalore, Karnataka, India, for his constant encouragement in academic work and progress.
I always remember my senior teachers, Professor CR Ballal and Professor Suresh Kamath, Professor K Prakash Rao, Professor Subramanya Bhat, Professor Bhaskar Shetty and Professor Ramachandra Pai for their constant help.
Professor Prakash Rao is a guide and encourager to everybody who will be remembered as a special person by me always.
My special thanks to Dr Jayaram Shenoy and Dr Jayaprakash Rao for their affection and support.
Surgical unit heads in our college Dr BM Nayak, Dr Thangam Verghese, Dr Harish Rao, Dr Shivaprasad Rai, Dr Yogishkumar, 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 fourth edition.
I appreciate District Medical Officer and Resident Medical Officer of Government Wenlock Hospital, Mangalore, Dakshina Kannada, Karnataka, India, for their kind help.
I will never forget my close associates, Dr Ganapathy, MD, Mangala hospital, Kadri, Mangalore, Karnataka, India, and Dr Ashok Pandith, Mch, urologist, for their affectionate help and encouragement in all my endeavours. They always stood with me in my difficulties.
I thank very much the faculty, department of surgery and paediatric surgery, JJM Medical College (JJMMC), Davangere, Karnataka, India for providing the needed photographs.
I sincerely thank Professor Navinchandra Shetty, Senior Radiologist, Mangalore, Karnataka, India, and also other radiologists for their help in providing and guiding me in X-rays, CT scans and imaging methods.
I acknowledge Professor Kishore Chandra Prasad, Senior ENT Surgeon, for his help, guidance and encouragement in bringing out this book.
I thank Dr Manohar Pai, Dr Ashfaque Mohammed, Dr Kalpana Sridhar, Dr Ramesh, Dr K Akbar, Dr Keshava Prasad, Dr Kishore Reddy, Dr Achaleshwar Dayal, Dr Raghav Pandey, Dr Rupen Shah, Dr Ashwini Mallya, Dr Praveen, Dr Shibu mohan, Dr Poornachandra, Dr Rahul Bhat, Dr Ranjith rao, Dr Irshad, Dr Amar, Dr Rajesh, Dr Suyog, Dr Chandini, Dr Adithya, Dr Ashok Hegde, Dr Rajesh Ballal, Dr Devidas Shetty, Dr Venkatesh Sanjeeva, Dr Sunilkumar shetty, Dr Shanbogh, Dr Harish Nayak, Dr Subraya Kamath, Dr Venkatesh Shanbogh, Dr Tantri, Dr Sandeep Gopal, Dr Ganesh and Dr Sampath, for their help in various aspects.
My sincere thanks to well-known in our state and country, senior Professor Narayanaswamy Srinivasan, MS, FRCS who earlier worked as—Head, Department of general surgery, Bangalore medical college; Director of Sanjay Gandhi Accident Hospital and Research Institute, Byrasandra, Bengaluru; Dean and Director of Bangalore Medical College and Research Institute, Bengaluru; Joint director of medical education, Government of Karnataka, India, for his affectionate encouragement.
I sincerely appreciate Dr Raghavendra Bhat and Dr Ravichandra, consultants, Department of Radiology, Yenepoya Medical College, Mangalore, Karnataka, India, for their contribution and affectionate help.14
I thank Dr Ganesh Pai, Mch (Paediatric Surgeon), Dr Suresh Pai, Mch; Dr Ashok Shetty (Cardiothoracic Surgeon); Dr Muralidhar Pai, MCh (Neurosurgeon); Dr Vivekanand Prabhu (Paediatric Surgeon); Dr Sadashiva Rao (Paediatric Surgeon); Dr Narayana Bhat (Paediatric Surgeon); and Dr Prashanth Mallya (Anaesthetist), for their help and contributions.
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, Dr Ashish Singh and Dr Aromal, 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 Sir (Group Chairman), Mr Ankit Vij (Managing Director), Mr Tarun Duneja (Director-Publishing) and all staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for doing appreciable work in their respective field of printing and publishing. Also, my appreciation to working team in the Branches of Jaypee Brothers Medical Publishers at Bengaluru and Mangalore, for their timely help.
My sincere thanks to editing team members—Ms Sunita Katla (Publishing Manager); Mr KK Raman (Production Manager); Ms Seema Dogra (Cover Designer); Ms Geeta Srivastava and Mr Laxmidhar Padhiary (Proofreaders); Mr Kapil Dev Sharma and Mr Kulwant Singh (DTP Operators), and Mr Sumit Kumar and Mr Ram Murti (Graphic Designers) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their dedicated and affectionate work in bringing out the fourth edition of the title.