Rejection and function (cid:142)(cid:3) Graft function is monitored by daily urea and creat inine. (cid:142)(cid:3) Delayed graft function (DGF): the need for dialysis within the firs t week of transplantation. It should not be confused with primary non-function \200\224defi ned as a graft which has never worked. (cid:142)(cid:3) Causes for DGF: acute tubular necro sis (secondary to the preservation injury), acute rejection, vascular thrombosis, and drug nephrotoxicity. KIDNEY TRANSPLANTATION1 845 (cid:142)(cid:3) Investigations: renal Doppler and ultrasound scanning. Flow is confirmed in transplanted vein and artery (usually intra-renal arcuate vessels) and overall graft resistive index (RI) calculated. RI is a non-specific measurement calculated as the difference in peak systolic and end-diastolic velocities, divided by the peak systolic velo city. The RI is normally less than 0.7. An RI >0.8 suggests rejection. (cid:142)(cid:3) Management of DGF: avoid use of nephrotoxic immunosuppressant drugs. Maintain adequate fluid balance. (cid:142)(cid:3) Acute rejection usually occurs in the first 3 months and affects up to 30% of kidney transplant recipients. The vast majority resolve with treatment. (cid:142)(cid:3) Presentation: asymptomatic, allograft dysfunction. Diagnosis is confirmed on biopsy. These are graded histologically using the Banff criteria. (cid:142)(cid:3) Management: parenteral steroid (IV methylprednisolone 500mg x 3 daily doses) and further immunosuppression, usually antibody therapy, if required. (cid:142)(cid:3) Chronic allograft nephropathy (CAN) is the result of both immune and non-immune factors. CAN is the major cause of long term declining graft function and ev entual loss. 27 \200\22340% of all failed grafts between 1 \200\2233 years are due to CAN. Histological findings include tubular atrophy, interstitial fibrosis, intimal hyperplasia a nd glomerulo- sclerosis. Graft and patient survival (cid:142)(cid:3) 1, 3 and 5 year allograft survival rates are ap proximately 90%, 80%, and 70% respectively. (cid:142)(cid:3) Graft survival is influenced by numerous factors including donor type (living versus cadaver) and HLA-mismatching. The 10 year graft survival is greater for kidn eys from living donors (53 \200\22357%) compared to cadaveric organs (38%). 5 year patient survival is 90% and 80% for recipients of living donor and cadaveric kidneys respectively. CHAPTER 19 Transplantation 846 Pancreas transplantation Solid organ pancreas transplantation Indications (cid:142)(cid:3) Simultanous pancreas \200\223kidney transplantation (SPK) or pancreas after kidney transplantation (PAK) is indicated for diabetic patients in end-stage renal failure. Pancreas transplantation alone (PTA) is indicated in those patients who have hypoglycaemic unawareness, and/or aggressive non-renal complications of diabetes, e.g. neuropathy. (cid: 142)(cid:3) The majority of transplants performed are SPK, with between 10% and 15% being either PAK or PTA. (cid:142)(cid:3) Most pancreases used for transplantation are cadaveric; a few centers worldwide have living donor programs, using distal pancreatectomy. (cid:142)(cid:3) \211 14 000 transplants have been performed in the USA, with 1362 performed in 2001. Only 82 SPK transplants were performed in the UK in 2001. Organ retrieval (cid:142)(cid:3) Harvest the pancreas as either a segment (tail and body) o r whole organ with a cuff of duodenum. (cid:142)(cid:3) Carry out bench work at organ retrieval. Anastomose splenic and superior mesenteric arteries to a donor iliac artery bifurcated Y graft, which enables the arterial supply of the graft to be facilitated by a single anastomosis at transplantation. Transplantation (cid:142)(cid:3) The technique associated with least complications involves transplanta- tion into the opposite iliac fossa to the kidney (for SPK transplantation) us ing very similar extra-peritoneal techniques. (cid:142)(cid:3) The venous drainage of the pancreas is usually systemic (external iliac ve in), and the drainage of exocrine function is to the bladder. Bladder drained exocrine secr etions cause chemical cystitis or metabolic acidosis, and this requires changing the method of drainage. Portal venous drainage via a mesenteric vein is performed in less than 20% of transplants. (cid:142)(cid:3) Achieve enteric exocrine drainage via a Roux-en-Y loop of small intestine. Exocrine leakage of the enterically drained graft gives rise to peritonitis, int ra-abdominal sepsis and the need for re-laparotomy in up to 70%. Surgical complications (cid:142)(cid:3) Re-laparotomy within 3 months (cid:142)(cid:3) Intr a-abdominal sepsis (cid:142)(cid:3) Pancreatitis (cid:142)(cid:3) Exocrine leak rates (cid: 142)(cid:3) Vascular graft thrombosis Rejection and function (cid:142)(cid:3) Rejection may cause graft loss due to difficulty in detection. Immuno- logical damage to the pancreas is advanced before changes in blood sugar are recognized. 15 \200\22335% in most large series 10 \200\22320% 2 \200\2233% 10% 2 \200\22314%. PANCREAS TRANSPLANTATION1 847 (cid:142)(cid:3) Monitoring graft function in transplants drained by the bladder is performed by urinary amylase. C peptide/insulin levels also used as markers of function. In SPK transplants, kidney rejection is usually accompanied by rejection in the pancreas. Graft and patient survival (cid:142)(cid:3) 1 year patient survival as 94 \200\22395% for S PK, 95 \200\223100% for PAK, and 97% for PTA. Graft survival at 1 year is 82 \200\22383% fo r SPK, 64 \200\22379% PAK, and 54 \200\22378% for PTA. (cid:142)(cid:3) 3 year graft/patient survival rates are approximately 83%/89% for SPK/PAK, and 60%/86% for PTA. Pancreatic islet cell transplantation In view of the surgical complications of solid organ transplantation the use of isolated pancreatic islets alone appears an attractive option. Technique (cid:142)(cid:3) Islets comprise only 2% of solid pancreatic mass. These insulin- secreting cells must be isolated from the tissue. Cell isolation involves enzymatic digesti on, mechanical disruption and purification using den- sity gradients. Currently only a prop ortion of available islets are able to be isolated. This can provide 500 000 islet equivale nt units, depending on the mass of the donor. (cid:142)(cid:3) Freshly isolated islets are infused via the radiologically cannulated portal vein (percutaneous transhepatic approach). This is done as a day case procedure. Complications Portal vein thrombosis ( \211 2%). Bleeding (requiring transfusion 5%). Graft and patient survival (cid:142)(cid:3) Between 1989 and 1999, 267 adult patients received i slet cell trans- plants; <10% were insulin-independent 1 year later. (cid:142)(cid:3) In 2000, the Edmonton group reported a series of islet cell transplants in 7 patients, all of whom were insulin independent at 1 year. (cid:142)(cid:3) Improvement s were due to better islet cell isolation, steroid free immunosuppression and an increase i n the total number of islets transplanted (average of 800 000 islets) by performing multipl e trans- plants as necessary. By 2002, over 40 patients have received transplants (82% insu lin independent at 1 year). A multi-center trial is examining whether the results can be su ccessfully replicated. (cid:142)(cid:3) The long term outcome of islet cell transplantation is unknown. The impact on secondary complications of diabetes is under review. CHAPTER 19 Transplantation 848 Liver transplantation Indications (cid:142)(cid:3) Patients with acute or chronic end-stage liver disease may be considered. (cid:142)(cid:3) Adults: primary biliary cirrhosis; sclerosing cholangitis; alcoholic liver disease (active alcohol abuse is an absolute contraindication); cryptogenic cirrhosis ; chronic active (autoimmune) hepatitis; chronic viral hepatitis (including hepatitis B and C); (cid:167)-1-antitrypsin deficiency and drug induced hepatic failure. Liver transplanta tion may be considered as treatment for primary hepatocellular carcinoma. (cid:142)(cid:3) Children: biliary atresia, in-born errors of metabolism (Wilson \200\231s disease; (cid:167 )-1-antitrypsin deficiency; haemochromatosis), and idiopathic fulminant hepatic failure. (cid:142)(cid:3) Listing and timing patients in the UK is determined by the availability of organs. Timing of transplantation in chronic liver disease is ideally when there is <50% 2 year survival, without multisystem disease. Often patients are referred for transplantatio n late, once life threatening complications have developed (e.g. variceal hemorrhage, encep halopathy, spontaneous bacterial peritonitis), and quality of life has deteriorated conside rably. (cid:142)(cid:3) The Child \200\223Turcotte \200\223Pugh score may be used as a prognostic tool, as shown below. 1 point 2 points 3 points Bilirubin ( mol/L) <34 34 \200\22351 >51 Albumin (g/L) >35 28 \200\22335 <28 Prothrombin time (seconds prolonged) 1 \200\2233 4 \200\2236 >6 Ascites None Slight Moderate Encephalopathy grade None I \200\223II III \200\223IV (cid:142)(cid:3) The score is classified as A (5 \200\2236), B (7 \200\2239) or C (10 \200 \22315). Patients with grade B have an 80% 5 year survival, whilst one third of patients with grade C die wit hin 1 year. (cid:142)(cid:3) For patients with fulminant hepatic failure, King \200\231s College London has developed guidelines to determine when transplantation is indicated. Patients falling into these criteria have a high mortality without transplantation. LIVER TRANSPLANTATION1 849 (cid:142)(cid:3) Non-paracetamol Prothrombin time (PT) >100 sec Or any 3 of the following: Age <10 or >40 years Etiology: drug induced or nonA/nonB hepatit is PT >50 sec Bilirubin >300 mol/L >7 days of jaundice, prior to encephalopathy Arterial p H <7.30 Or all of the following: PT >100 sec Creatinine >300 mol/L Grade III/IV encephalop athy (cid:142)(cid:3) Paracetamol (cid:142)(cid:3) 698 cadaveric liver transplants were performed in UK (2002); 92 of these recipients being under 17 years of age. Organ retrieval (cid:142)(cid:3) Cannulate both the aorta and the portal system via the sup erior mesenteric vein. Perfuse the portal system with cold University of Wisconsin solution and p erfuse the arterial vasculature with Marshall \200\231s hypertonic citrate. (cid:142)(cid:3) Divide the common bile duct superior to the pancreas. Return the coeliac a rtery and an aortic patch with the common hepatic artery; ligate and divide all other branc hes. (cid:142)(cid:3) Divide the vena cava above the diaphragm, and above the right kidney. (cid :142)(cid:3) Divide the mesenteric and splenic veins at the portal vein confluence. (cid:14 2)(cid:3) Liver preservation is in cold storage in sterile bags. The liver is transplanted within 12 hours of retrieval. Transplantation The recipient undergoes hepatectomy. (cid:142)(cid:3) Divide the common bil e duct at the level of the cystic duct, and ligate the hepatic artery beyond the gastrodudodenal artery. (cid:142)(cid:3) Prepare the portal vein to allow the placement of the patient on veno-venous bypass; cannulate the portal circulation and infra-hepatic systemic venous circ ulation (saphenofemoral vein) and blood returned to the heart by the axillary vein. Once by pass is established remove the liver and divide the caval attachments. Piggy-back transplantation involves preservation of the recipient vena cava, and division o f the retro-hepatic veins. (cid:142)(cid:3) Anastomose the supra and infra hepatic vena cav a followed by the portal vein. Following washout of air and preservation fluid the liver is reperfused by the portal system. Anastomose the hepatic artery end-to-end. Perform donor cholecystectomy and an end-to-end chole- docho-choledochostomy is performed over a T tube. CHAPTER 19 Transplantation 850 Split liver transplantation First performed in 1988; allows a single donor liver to be divi ded for use in two recipients, and thus maximize the potential of donated organs. (cid:142) (cid:3) The segmental vascular and biliary anatomy of the liver allows the liver to be spli t typically into right (segments IV \200\223VIII or V \200\223VIII based on drainage by mid dle and right hepatic veins) and left lateral grafts (II \200\223III or II \200\223IV based on left hepatic vein drainage). The right graft is suitable for an adult, whilst the small er left lateral graft is used for pediatric recipients. (cid:142)(cid:3) The liver may be split on the back table (ex-vivo) or in situ. Initial results showed increased incidence of primary non-function, biliary complications, and blee ding from cut surfaces. Increased experience and selective use of appropriate grafts have r esulted in 1 year graft and patient survival of 88% and 90% respectively (Kings College Hos pital, UK). Surgical complications Vascular: hepatic artery thrombosis is more common in pediatric than adult (1.6 \200\22310%) recipients. Presentation may vary from initial symptom. Early thro mbosis demands surgical correction. Many adults require re-transplantation, particularly if presentation is late. The pediatric group may develop collaterals and not require re-trans plantation. Venous thrombosis (1 \200\2232%) and hemorrhage may also occur. Biliary: biliar y obstruction 12 \200\22315% is generally dealed with non-operatively (ERCP and stenting, o r PTC). Failure of initial treatment may require surgical reconstruction or re-transplantat ion. Bile leaks may present with non-specific symptoms of sepsis and abdominal pain, often in association with deranged LFTs. Bile leak may be secondary to ischaemic necrosis due to hepatic artery thrombosis and this must be excluded. Manage- ment is by percutaneous draina ge (cid:140) re-laparotomy. Rejection and function (cid:142)(cid:3) Monitoring is by liver function tests, coagulation tests and bile pro- duction. Function may be poor in the first week (IPF \200\224initial po or function). Primary non-function (PNF) occurs in 2 \200\22310%, and requires immediate re -transplantation. (cid:142)(cid:3) Acute rejection occurs in up to 50% of patients and may lead to graft loss. Most episodes occur in the first month post transplantation. Presentation is no n-specific and includes fever, graft tenderness/ enlargement and abnormal liver function te sts. Biopsy is required for firm diagnosis. Treatment is by IV steroids. Chronic rejection is less common, presenting with progressive organ dysfunction often after repeated acute re jection episodes. Graft and patient survival 1, 3 and 5 year graft survival for liver transplants performed i n the UK 80%, 73% and 64% respectively (1994 \200\2239 cohort). UNOS data gives 1 and 3 yea r patient survival at 85% and 78%. This page intentionally left blank CHAPTER 19 Transplantation 852 Cardiac transplantation Indications (cid:142)(cid:3) Indications: cardiomyopathy, coronary artery disease, valvular disease, and congenital heart disease. Most patients have end-stag e cardiac failure resulting from a dilated myopathy. (cid:142)(cid:3) Preoperative work up is extensive in both physical and psychological terms . All conventional treatment options for heart failure must be exhausted. Non cardiac co-mo rbidity must also be thoroughly assessed. (cid:142)(cid:3) Most candidates are New York Heart Association grade IV \200\224equating t o <50% 2 year life expectancy. Cardiac catheterisation provides confirmation of poor left v entricular ejection fraction (usually <20%) and a suitable pulmonary vascular resistance (< 240 \200\223300 dynes/cm5) for transplantation. (cid:142)(cid:3) Cardiac transplantation is contra-indicated in patients with pulmonary hyp ertension as this may lead to post operative right heart failure. (cid:142)(cid:3) Numbers of patients waiting and the number of heart-only transplants performed have declined gradua lly since 1992 (UK). In 2002, 157 heart-only transplants were performed, with 111 patients left on the waiting list. Retrieval (cid:142)(cid:3) Donors are ideally \211 45 years of age with no previous cardia c history, requiring minimal inotropic support. Shortage of organs has meant donors of 45 \200\22365 years with acceptable echocardiography (cid:140) cardiac catheterisation are con sidered. Size matching of the graft is important for anatomical and physiological purposes. (cid:142)(cid:3) At the donor heart excision the heart is perfused with cold St. Thomas \200\231s cardioplegic solution and cardiac arrest occurs is diastole. The heart is stored in normal saline on ice and implantation performed as early as practicable. A co ld ischaemic time of <4 hours is acceptable. (cid:142)(cid:3) A \200\230domino \200\231 heart transplant occurs when a viable heart fro m a patient receiving a heart/lungs transplant is then transplanted into another patient. Transplantation (cid:142)(cid:3) The normal mode of transplantation is orthotopic. Heteroto pic trans- plantation is rarely performed. There are two types of orthotopic transplantatio n commonly described: standard and bicaval. Most centers now the bicaval technique. (cid:142)(cid:3) The recipient is anesthetized once the heart is in transit to the recipi- ent hospital. Orthotopic transplantation involves full cardio-pulmonary bypass and explanta tion of the native heart. In the bicaval technique the right and left atrium are excised to leave only cuffs around the vena cava and pulmonary veins respectively. Transect the left and right pulmonary veins of the donor heart within the pericardial sac, but the left atriu m left intact. Perform anastomosis between the cuffs of tissue around the right and left pu lmonary veins in the recipient and the CARDIAC TRANSPLANTATION1 853 donor veins. Leave the superior and inferior vena cava long on the graft and perform anasto mosis directly with recipient vena cava. Complete the transplant by pulmonary artery and ao rtic anastomoses. Surgical complications The main surgical complications are hemorrhage and air embolism. Rejection and function (cid:142)(cid:3) Early heart function may be poor, particularly in n eonates. Bradycardia is common, and may require permanent pacing. (cid:142)(cid:3) Rejection affects systolic and diastolic myocardial performance, and is a major cause of morbidity and mortality. Endomyocardial biopsy via a right internal jugular line is used to assess histological progress post operatively. Chronic allograft rejection results in progressive obliteration of the coronary vasculature. Graft and patient survival Overall graft survival is 84% at 1 year and 76% at 3 years. UK p atient survival for heart transplantation recipients are 80% at 1 year, 76% at 3 years and 63% at 5years. Stanford University (USA) reports a 10 year survival of 46%. CHAPTER 19 Transplantation 854 Lung transplantation Indications (cid:142)(cid:3) All potential recipients have end-stage d isease of the lung parenchyma or pulmonary vasculature, such that life expectancy without a trans- plant is estimated to be less than 2 \200\2233 years. (cid:142)(cid:3) Lung transplantation is contra-indicated with systemic disease (renal impa irment, malignancy etc.) or active fungal respiratory infections. (cid:142)(cid:3) A single lung transplant is performed where the remaining native lung will not compromise graft fun ction or present a hazard. Indications include obliterative bronchiolitis, pulmonary fibros is, emphysema, asthma and sarcoid. (cid:142)(cid:3) Cystic fibrosis and bronchiectasis require bilateral lung transplants. (ci d:142)(cid:3) Pulmonary hypertension may require single, bilateral or even heart- lung transplant. Retrieval Cadaveric: donor selection is critical. Pulmonary function of the donor is assist ed during mechanical ventilation; the peak airway pressure must be <30mmHg (<4Kpa) and the donor capable of achieving an arterial PaO2 of >100mmHg (>14Kpa) with a FiO2 of PaO2 0.4. B ronchoscopy is per- formed to assess secretions. Grafts are size matched between donor and recipient. There is significant surgical assessment at retrieval. The lungs are transported inflated. Living: the University of Southern California has reported using lower lobes of right or left lung from two living donors. There has been no donor mortality. Donor morbidi ty includes persistent air leaks, pericar- ditis, and one case of pulmonary artery thrombos is. The recipients in this series have mainly suffered from cystic fibrosis. Transplantation Incision For single lung transplantation a posterior-lateral thoracotomy is used. Procedure (cid:142)(cid:3) Perform the pneumonectomy by dividing the pulmonary arteries exposed outside the pericardium. (cid:142)(cid:3) Divide the pulmonary veins within the pericardial sac, to expose the left atrium. Engrafting involves end-to-end bronchial and arterial anastomosis. Apply a clamp to the left atrium, open the superior and inferior recipient pulmonary veins and fashion a le ft atrial cuff to allow anastomosis to a donor atrial cuff which is made at retrieval. (cid:142)(cid:3) Perform the bilateral transplantation operation via a clam shell incision. Complications Respiratory failure presents in over 50% of patients receiving transplants an d has a high mortality. This is often due to ischemia-reperfusion injury. LUNG TRANSPLANTATION1 855 (cid:142)(cid:3) Infection is another major cause, particularly opportunistic respiratory pathogens such as CMV or pneumocystis. Prophylaxis against pneumocystis is given indefinite ly. (cid:142)(cid:3) Airway complications occur in approximately 10 \200\22315%. Tracheal ischaemia may result in leak and mediastinitis. Rejection and function (cid:142)(cid:3) Rejection episodes present similar to infection (fe ver/hypoxia/chest X-ray changes). Distinction is made by performing by transbronchial biops y (bronchoscopic) and broncho alveolar lavage. (cid:142)(cid:3) Obliterative bronchiolitis occurs in 20 \200\22340% of lung recipients and is a major cause of morbidity. It presents with dyspnoea and a progressive obstructive air ways disease. The mechanism is unknown, but rejection episodes increase the risk of disease . Graft and patient survival The patient survival rates in UK for lung-only transplants (perf ormed between 1994 and 1999) are 67% at 1 year, 57% at 3 years, and 42% at 5 years. Heart/l ung transplant results are similar. This page intentionally left blank 857 <S <s Index below knee 463, 465 Burgess flap 463, 465 indications 460 level of 460 Lisfranc forefoot 46 2 skew flap 464, 465 Symes 462 through knee 464 transmetatarsal 460 appendicectomy 246 \200\22351 A abdominal aorta, exposure in children 618 laparoscopic 120, 250, 251, 342 \200\2234 390 open 246 \200\2238 pre-operative preparation abdominal aortic aneurysm repair 416, 428 \200\22330 endovascular 420 \200\2231 retroperito neal 418 transperitoneal 416 246 appendix 72 torsion 638 anal canal 76 anal sphincters 76 anaphylaxis 15 \200\22316 aneurysm arterial anastomosis abdominal incisions 58 \200\22374, 380 \200\2235 138, 141 Lanz 140 mass closure 138 oblique incisions 139 paramedian incision end-to-side technique 381, 382 abdominal aortic 416, parachute technique 428 \200\22330 carotid 448 femoral artery 448 internal carotid artery 384 \200\2235 patch angioplasty 384 arterial cannulation 20 artery forceps 100 \200\22315 axillary artery , exposure 138 Pfannenstiel 140 transverse 140 vertical 138 406 \200\2237 popliteal artery 450 \200\2231 aneurysmal internal carotid artery repair 406 \200\2237 388 abdominal malignancies, laparoscopic staging 324 \200\2235 axillary node clearance 152 \200\2233, 157 closure 158 complications 158 consent 156 incision 157 indications 156 p osition 156 postoperative care 158 procedure 157 anorectal atresia 580 anorectal examination abdominal and right thoracic subtotal oesophagectomy 212 \200\2233, 213 144 \200\2236 action 144 colonoscopy 115, abdominal wall 58 \200\22363 145 \200\2236 anterior 58 femoral canal 62, 63 femoral ring 62 inguinal canal 60, 61 digital examination 144 flexible sigmoidoscopy 114, 145 proctoscopy 144 sigmoidoscopy 145 anterior bowel resection axillary surgery 156 \200\2237 sentinel lymph node abdomino-perineal biopsy 156 resection of rectum 294 \200\2236 axillobifemoral graft 432, 286 \200\22390 433 above knee amputations anterior mediastinotomy 466 700 \200\2231 B Balfour set 105 basal cell carcinoma 798 Beger procedure 166 below knee amputations achalasia, open (Heller \200\231s) cardiomyotomy 196 \200\2237, 213, 219 acute anorectal se psis anterior tibial artery, exposure 394, 395 anterolateral thoracotomy 708 \200\2239 244 \200\2235 antibiotic prophylaxis 40, acute scrotum 478 \200\2239 adenoidectomy 682 \200\2233 adhesionolysis 634 adrenalectomy 18 2 \200\2233 adrenal glands 50 41, 43 463, 465 bile ducts 82 \200\2233 biliary fistula 322 biliopancreatic diversion antimetabolites 842 \200\2237 aortobifemoral graft 428 \200\22330, 446 aortoiliac occlusive disease surgical approach 346, 349 428 \200\22330 486 \200\2239 Bilroth reconstruction 203 biopsy aortobifemoral graft adverse drug reactions 428 \200\22330, 429 catheter based 15 \200\22316 breast 150, 168 open lung wedge 736 sentinel lymph node 156 VAT lung wedge 758 AIDS see HIV/AIDS airway assessment 2 airway stents 752 amputations 460 \200\2236 above kne e 466 endovascular treatment 428 extra-anatomic bladder 87 \200\2238, 89 bladder augmentation reconstruction 428 INDEX 858 bladder augmentation circular stapler 352 circumcision 494 \200\2235, breast reconstruction (contd) ileocystoplasty 520 \200\2231 160 \200\2235, 802 632 \200\2233 colectomy latissimus dorsi flap Mitroffanoff appendi- 161 \200\2232 covesicostomy 522 \200\2233 sigmoid 282 \200\2233 total 284 \200\2235 transverse 280 \200\2231 colonic atresia 578 colo nic interposition tissue expansion and bleeding peptic ulcer disease 186 \200\2237 insertion of implant 160 \200\2231, 802 transverse rectus Boerhaave \200\231s syndrome 190 bowel clamps 107 abdominis myocuta- neous (streetcar) flap 163 \200\2234, 165 Doyen 108 Hayes 107 Zachary-Cope 107 bowel preparation 42 bowel resection/ 218 \200\2239 colonoscopy 115, 145 \200\2236 colostomy 260 \200\2234 end 260 \200\2231, 263 loop 261 \200 \2233 bronchi 52, 53 bronchoscopy 692 \200\2233 flexible 696 \200\2237 rigid 694 \200\2235 bullectomy 756 Burgess flap 463, 465 burns 777, 806 \200\22311 anastomosis 264 \200\2239 common/external iliac artery, exposure 390, 391 large bowel 268 single layer interrupted seromuscular technique 264 small bowel 266, 269 st apling 364 two layer 266, 267 brachial artery exposure common femoral artery, exposure 392 computed tomography, trauma surgery 830 congenital heart disease 3 congestive cardiac failure 3 core biopsy of breast 150 corticosteroids 838 cricothyroidotomy 27 \200 \2238 causes 806 depth of injury 806 prevention 806 surgery 810 388 C Caldwell-Luc procedure brachial embolectomy 422 \200\2234 brachioaxillary PTFE graft needle 816 \200\2237 surgical 820 684, 687 458 cardiac transplantation 852 cardiomyotomy branchial cyst/sinus 604 \200\2235 cryptorchidism 564 cyst excision 672 \200\2234 laparoscopic 197 transabdominal 196 transthoracic 196 \200\2237 branchial fistula, excision branchial 604 \200\2235 dermoid 611, 610 thyroglossal 606 \200\2237, 644 cystectomy, urinar y tract reconstruction 524 \200\2239 674, 675 breast 46 \200\2237 carotid artery blood supply 46 core biopsy 150 embryology 46 excision biopsy 168 fine needle aspiration cy tology 148 \200\2239 aneurysm 448 aneurysm repair 406 \200\2237 exposure 386 cystic hygroma 608 cysto-enterostomy 161 \200\2232 cysto-gastrostomy 160 \200\2231 carotid body tumor, excision 404 \200\2235 carotid endarterectomy Hadfield \200\223Adair operation 400 \200\2233 172 D day case surgery 34 Debakey vascular carotid to subclavian bypass lymphatic drainage 46 mastectomy 154 \200\2235 mastopexy 803 \200\2234 microdochectomy 170 nerve supply 46 structural features 46 436, 437 central venous cannulation 21, 22 instruments 110 deep vein thrombosis, prophylaxis 38, 39 dehydration 572, 573 Delorme \200 \231s procedure 149, cervical mediastinoscopy 698 \200\2239 chest drain insertion 702 \200\2234 children see pediatric breast abscess 166 closure 166 incision 166 procedure 166 surgery cholangitis 322 cholecystectomy, 240 dermatome 777 dermoid cyst 610, 611 diabetes mellitus 3 diaphragmatic eventeration breast augmentation 803 \200\2234 breast conservation surgery 152 \200\2233 laparoscopic 336 \200\22340 complications 340 \200\2231 contraindications 336 difficulties and cautions closure 153 complications 153 consent 152 contraindications 152 indications 152 position 15 2 preoperative preparation 595 diaphragmatic hernia, congenital 594 \200\2235 digestive system 64 \200\22371 large bowel 6 9 \200\22370, 71 esophagus 64 \200\2235 small intestine 68 \200\2239 stomach 66 \200\2237 338 indications 336 position 336 postoperative care 340 preparation 336 technique 149, 337 152 chordee 536 \200\2237 procedure 152 \200\2233 INDEX 859 distal subclavian artery, exposure 388 transposition 235, 784 Z-plasty 784 \200\2237 carotid to subclavian bypass 436, 437 femorofemoral graft dorsal lumbotomy 488 \200\2239 Doyen bowel clamps 108 drapes 137 duodenal atresia 578 duode nal transection 360 duodenal ulcer 186 \200\2237 flexible sigmoidoscopy 114, 145 434, 435 fluid and electrolyte iliofemoral/unilateral aortofemoral/ iliopopliteal 436 obturator bypass 438 management 572 \200\2233 foreskin retraction 634 Fournier \200\231s necrotising fasciitis, debridement 476 extra-anatomic reconstruction 428 extracorporeal shockwave E embolectomy 422 anesthesia 422 brachial 422 \200\2234, 425 femoral 424 indications 422 in frainguinal 427 popliteal 426 embolism 12 \200\22315 empyema Frey procedure 166 Frey \200\231s syndrome 662 lithotripsy 552 G gall bladder 82, 83 gastric banding 201, 222 gastric bypass 201, 221 gastric cancer, radi cal F facial skeleton, access incisions , 686 \200\223689 complications 689 coronal flap 688 equipment required 688 incision 688 indications 686 posi tion 688 transoral flap 689 surgery 202 \200\2235, 222 gastric cancer subsites decortication 750 rib resection 748 endarterectomy 398 \200\2239 203 gastric resection 202 gastroenterostomy 203 loop gastro-jejunostomy carotid 400 \200\2233 endocrine surgery family history 5 fasciotomy 454 femoral anastomotic aneurysm 452 204 adrenal glands 50, 182 \200\2233, 486 \200\2239 breast see breast pancreas 84 \200\2235, 18 4 parathyroid glands 50, lymphadenectomy 202 Roux-en-Y reconstruction 204 femoral artery aneurysm gastric interposition 448, 449 216 \200\22317 femoral canal 62, 63 femoral embolectomy 180 \200\2231 gastroenterostomy 203 thyroid gland 48, 49 endocrine system 48 \200\22350 stapling 362 424 gastro-oesophageal reflux disease 192, 195 femoral hernia 372 \200\2233 high approach 372 low approach 372 \200\2233 McEvedy approach 372 adrenal glands 50 parathyroid glands 50 thyroid gland 48, 49 gastroplasty horizontal 201 vertical 200 ENDOLOOP ligature 121 endoscopic equipment 112 femoral ring 62 femorofemoral graft gastroschisis 582 \200\2233 gastroscopy set 112 gloves, punctured 137 Golliger set 106 Grea t Ormond Street solution 689 gridiron incision 139 colonoscope 115 flexible sigmoidoscopy 434, 435 femoropopliteal bypass grafting 440 \200\2231 fine needle aspiration 114 gastroscopy set 112 proctoscopy/ cytology breast 148 \200\2239 thyroid gland 174 fissure-in-ano 226 \200\2237 fistula sigmoidoscopy set 113 endoscopic retrograde H Hadfield \200\223Adair operation cholangiopancreatogra- phy 308 biliary 322 pancreatic 322 thyroglossal 606 \200\2237 vesicovaginal 530 \200\2231 endoscopic ultrasound 172 308 hemorrhoids 228 \200\22333 endoscopy, upper gastroin- haemorrhoidectomy 230 injection sclerotherapy testinal 142 \200\2233 fistula-in-ano 234 \200\2237 flank incision 87 \200\2238 flaps 782, 783 epigastric hernia 376, 622 excision biopsy of breast 228, 229 perianal haematoma 232 rubber band ligation lump 168 exomphalos 584 external carotid artery ligation 670 \200\2231 extra-anatomic bypas s advancement 784, 785 blood content 782 fasciocutaneous 782 free 788 \200\2239 Limberg 784, 787 muscle 782 rotation 784, 785 228 \200\22330 stapling 366 thrombosed/strangulated 232 432 \200\2238 hand-held retractors axillobifemoral graft 432, 101 \200\2232 433 INDEX 860 Hartmann \200\231s procedure hydrocele 496, 628 \200\2239 hypertension 3 intercostal drain insertion 300 \200\2231 824 Hayes bowel clamps postoperative 19 hypertrophic scars 768 hypospadias 536 \200\2237 hypotension 18 hypoxaemia 12 \200\22315 hypoxia 18 intercostal space 55, 57 intestinal atresia 578 \200\22381 intraoperative 107 head and neck surgery 639 \200\22389 complications 8 \200\22316 anesthetic factors 8 \200\2239 cardiovascular problems access incisions to facial skeleton 686 \200\2239 adenoidectomy 682 \200\2233 branchial cys t excision 8 \200\22311 patient factors 8 surgical factors 8 I ileocystoplasty 520 \200\2231 ileostomy 254 \200\22360, 292 \200\2233 714 intubation branchial fistula excision complications 27 indications for 27 see also individual techniques 674, 675 Caldwell-Luc procedure 684, 687 end 254 \200\2236 laparoscopic loop external carotid artery ligation 670 \200\2231 intussusception 614 \200\22315 islet cell transplantation 256 \200\22390 neck dissection 666, 667 neck lump dissection loop 256, 258 \200\223259, 338 and proctocolectomy 847 islet cell tumor, 664 \200\2235 292 \200\2233 enucleation 315 parathyroidectomy immunophilin binders 652 \200\2235 838 parotidectomy 659, 661 pharyngeal pouch excision J jejunolileal atresia 578 \200\22381 Jolles retractor 104 immunosuppression 838 \200\22340 676 \200\2237 incisional hernia 378 infection, risk factors 41 inferior vena cava 78 infragenicular prost hetic sublingual gland excision 658 \200\22363 submandibular gland excision 653, 655, 656 \200\2237 K keloids 768 kidney, surgical approach grafts 442 infrainguinal bypass thyroglossal cyst excision 440 \200\2235 644 femoropopliteal bypass grafting 440 \200\2231 486 \200\223527 thyroidectomy 646 \200\2239 tonsillectomy 678 \200\22380 tracheostomy 640 \200\2234 kidney transplantation incisions 440 indications 440 infragenicular prosthetic 842 \200\2235 cadaveric organ retrieval hemicolectomy left 274 \200\2239 right 269, 270 \200\2233 hepatobiliary surgery 843 grafts 442 position 440 preoperative preparation graft and patient survival 845 indications 842 living donor 842 organ retrieval 842, 843 rejection and function 305 \200\22322 440 chronic pancreatitis 166 investigational procedures in situ vein graft 441, 443 308 \200\2239 infrainguinal embolectomy 844 \200\2235 pancreatic mobilization 427 surgical complications 310 inguinal canal 60, 61 inguinal hernia 328 \200\22330, 844 pancreatic necrosis knot tying 124 \200\22334 Kocher \200\231s incision 139 316 \200\22317 pseudocyst 318 368 \200\22371 Bassini repair 369, 371 direct 368 indirect 368 laparoscopic repair hernia 367 \200\22378 L laboratory investigations 5 Lancy vascular instruments congenital diaphragmatic 594 \200\2235 epigastric 376, 622 hiatus 194 \200\2235, 209, 211 incisional 378 inguinal 328 \200\22330, 368 \200\22371 umbilical 374, 624 328 \200\22330 Lichenstein mesh repair 109 368, 369 Shouldice repair 369, 371 inguinal herniotomy Lanz incision 140 laparoscopic abdominal rectopexy 240 \200\2232 laparoscopic equipment hiatus hernia, para-oesophageal repair 194 \200\2235, 209, 211 626 \200\2237 116 inguinal orchidopexy 5mm instruments 118 10mm claw grasper 119 appendicectomy 120 camera 116 Hirschsprung \200\231s disease 588, 492 \200\2233 589 inguinal orchiectomy HIV/AIDS, precautions 44 horizontal gastroplasty 201 510 in situ vein graft 441, 443 INDEX 861 cholecystectomy 121 ENDOLOOP ligature 21 endopath 117 heater probe 119 insulator 117 laparo scope 116 laser instruments 118 monitor 116 scissors 118 trochar 117 surgical complications N nasopharyngeal airway 850 lobectomy 712 \200\22322 left lower 722 right lower 718 right middle 716 right upper 714 \200\22315 loop gastro-jejunostomy insertion 24 nausea and vomiting 18 neck dissection 666, 667 equipment required 666 204 incisions 667 indications 666 postoperative lower limb trauma 794, laparoscopic surgery 324 \200\223 797 lung 52 \200\2234 49 complications 668 appendicectomy 120, 250, transplantation 854 wedge biopsy 758 lymphangioma 608 procedure 667, 669 neck lump dissection 251, 342 \200\2234 cholecystectomy 336 \200\22340 cryptorchidism 564 hepatobiliary disease 664 \200\2235 necrotising enterocolitis 590 \200\2231 M magnetic resonance cholan- gio-pancreatography 308 \200\2239 309 needle cricothyroidotomy inguinal hernia repair 816 \200\22317 328 \200\22330 needle holders 94 \200\2235 needle thoracocentesis Nissen fundoplication 332 \200\2234 822 Mainz pouch 526, 527 malignant hyperthermia pyeloplasty 560 radical nephrectomy 558 retropubic radical neonatal surgery 568 \200\2239 nephrectomy 490 15 \200\22316 partial 502 radical 500 \200\2231, 558 nephroureterectomy malrotation 620 \200\2231 Mammotome 150 mastectomy 154 \200\2235 prostatectomy 562 splenectomy 199, 326 \200\2237 staging for abdominal 500 \200\2231, closure 155 complications 155 incision 154 incisions 155 indications 154 position 154 posto perative care 155 preoperative preparation malignancies 324 \200\2235 Nissen fundoplication urological 556 \200\2237 weight reduction 346 \200\2239 332 \200\2234 complications 334 difficulties 333 indications 332 position 332 postoperative care laparoscopic ultrasonography 325 laparotomy, trauma surgery 830 large bowel 69 \200\22370, 71 obstruction 302 \200\2233 333 154 preparation 332 technique 332 procedure 154 skin sparing 155 laryngeal mask airway 25, 26 Meckel \200\231s diverticulum laryngospasm 12 \200\22315 left hemicolectomy 274 \200\2239 anastomosis 277, 279 O obesity surgery see weight reduction surgery obturator bypass 438 oesophageal anastomosis 252 \200\2233, 616 meconium ileus 586 medial sternotomy left intrapericardial 710 \200\2231 pneumonectomy 732 left lower lobectomy 722 left thoracic subtotal oesophagectomy 208 \200 \2239 mediastinal mass, excision 740 \200\2231 mediastinotomy anterior 700 \200\2231 cervical 698 \200\2239 220 \200\2231 stapled 220, 221, 222 sutured 220 left upper lobectomy melanoma 799 metal clips 353 microdochectomy 170 microsurgery 788 \200\2239 Miller cuff 442 , 444 minimally invasive thoraco- oesophageal replacement colonic interposition 720 \200\2231 linear cutter 353 linear stapler 353 Lisfranc forefoot 218 \200\22319 gastric interposition 216 \200\22317 amputation 462 oesophageal rupture liver 78 \200\22381 liver transplantation 848, scopic splanchnicectomy 166 190 oesophageal varices, stapling 358 oesophagectomy 848 Mitroffanoff appendicovesi- graft and patient survival costomy 522 \200\2233 monoclonal antibodies 850 abdominal and right thoracic subtotal 212 \200\22313 organ retrieval 849 rejection and function 852 myocardial infarction 3 myocardial ischaemia 12 850 complications 224 split liver 850 INDEX 862 oesophagectomy oesphageal atresia consent 662 equipment required 663 extracapsular dissection (contd) left thoracic subtotal 208 \200\2239 576 \200\2237 orchidopexy 630 \200\2231 preauricular skin tag and