An estimated 12 million people have coronary artery disease (CAD) in the USA. While the majority of patients are treated conservatively with pharmacologic and percutaneous interventions (percutaneous transluminal coronary angioplasty (PTCA) and/or coronary stents) by cardiologists, over 1.4 million patients have undergone surgical revascularization for their CAD over the past decade. Coronary artery bypass grafting (CABG) is performed for the relief of anginal symptoms and to prolong life. Extended relief of angina can be expected in approximately 90% of those with reasonable distal vessel targets. Coronary artery bypass surgery is indicated in patients with angiographically proven CAD with unstable angina refractory to medical therapy or PTCA, positive results on exercise or thallium stress testing, significant left main coronary artery disease, or complex double or triple-vessel CAD. Coronary artery bypass, when compared with medical therapy, has been shown to provide a survival advantage in patients with left main coronary artery stenosis, triple-vessel disease, double-vessel disease with proximal left anterior descending (LAD) artery stenosis, and in patients with depressed left ventricular function. In those patients presenting with chest pain and an evolving myocardial infarction of less than 6 hours duration, either percutaneous or surgical revascularization are plausible treatment modalities. Intractable ventricular arrhythmias may be an additional indication for emergent surgical intervention, since control of arrhythmias and ultimate survival may occur despite the grave prognosis.

Hysterectomy is the most common gynecologic operation and the second most common major surgical procedure in the USA. The frequency of abdominal hysterectomy is 1 per 1000 in women younger than 25 years, but rises to 16 per 1000 in women older than 35 years. After the age of 35 years, women usually have completed their childbearing and also have a higher incidence of significant gynecologic disease. The mortality risk for hysterectomy in the USA has been studied by the Centers for Disease Control and Prevention, which reported 477 deaths among 317 389 women having abdominal hysterectomies from 1979 through 1980. The mortality rate for hysterectomy was higher for procedures associated with pregnancy and cancer than for procedures not associated with these conditions (29.2, 37.8, and 6.0 per 10 000 hysterectomies, respectively). Abdominal hysterectomy had a higher mortality rate than did vaginal hysterectomy. Excluding cases related to pregnancy or cancer, the mortality rate was 8.6 per 10 000 women for abdominal hysterectomy and 2.7 per 10 000 women for vaginal hysterectomy.

Simple total abdominal hysterectomy involves the removal of the uterine corpus and cervix through an abdominal incision and is performed for a variety of indications, including uterine leiomyomas, pelvic abscesses, endometriosis, and recurrent dysfunctional uterine bleeding. In addition, simple abdominal hysterectomy is performed for two malignant indications: adenocarcinoma of the endometrium and ovarian cancer. Invasive cancer of the cervix requires a radical abdominal hysterectomy.

Vulvectomy is performed for both preinvasive and malignant conditions of the vulva. This procedure may vary in extent from a skinning procedure performed for multicentric intraepithelial neoplasia to a radical vulvectomy combined with bilateral inguinofemoral lymph node dissections for invasive carcinoma. The radical procedure has changed during the past decade and may range from hemivulvectomy with unilateral inguinofemoral lymph node dissection to an en bloc resection including bilateral inguinofemoral lymph nodes. Lateralizing stage T1 lesions smaller than 2 cm are treated with a radical hemivulvectomy and ipsilateral lymph nodes dissection. For larger or midline lesions, attempts are made to perform a radical vulvectomy and bilateral inguinofemoral lymph node dissections through separate incisions (three incision technique). This generally results in fewer postoperative complications (e.g., wound infection) and a shorter hospital stay. Depending on the extent of resection, myocutaneous flaps may be needed to fill the operative defect. The time necessary for this operation is 2 to 5 hours and varies according to the extent of resection and reconstruction. General, regional, or combination anesthesia can be equally efficacious. Intraoperative transfusions are not routinely required during radical vulvectomy.

Usual postoperative course

Expected postoperative hospital stay

The duration of hospitalization ranges from 4 to 21 days, depending on the extent of resection, the required reconstruction, and the rate of wound healing.

Operative mortality

Under 1%.

Special monitoring required

Patients undergoing radical vulvectomy do not require specific monitoring.

Ventral hernias encompass a wide variety of abdominal wall defects, including incisional, epigastric, umbilical, and spigelian types; for the purposes of this chapter, the term ventral hernia is restricted to the incisional type. A ventral hernia with a small ring predisposes patients to incarceration and possible strangulation of a segment of small or large intestine. Patients with significant ascites are at risk for rupture of a ventral hernia if there is only skin covering the defect. Those with large ventral hernias have difficulty wearing regular clothes and are often embarrassed by their appearance. For these reasons, elective repair of ventral hernias is indicated in patients who are healthy enough to undergo mechanical bowel cleaning and general anesthesia. Over 100 000 such repairs are performed in the USA each year.

At the time of ventral herniorrhaphy performed through an open approach, the thinned-out skin covering the hernia sac itself and all scar tissue back to normal-appearing rectus or other muscles of the abdominal wall are excised. Once the true size of the hernia defect is seen, a decision is made regarding primary repair versus insertion of a prosthetic patch. Primary repair is possible even with defects as wide as 5–6 cm using lateral divisions of the external oblique muscles from within the incision or the “components separation” technique. Because of the size of many ventral hernias after debridement, patches made of polypropylene (porous) or polytetrafluoroethylene (non-porous) are frequently inserted to fill the musculofascial defect.

The median sternotomy is the incision of choice for most patients undergoing coronary artery bypass grafting and heart valve surgery, as it provides unparalleled exposure of the heart and great vessels. Although sternal wound infections occur with a reported incidence of 5%, the associated morbidity and mortality is dramatically higher. In the early 1970s, treatment of these patients consisted largely of debridement, placement of catheters for antibiotic irrigation, and either primary or delayed primary closure of the rewired sternum. If the wound couldn't be closed, they were packed open and allowed to heal secondarily. Such management was associated with a mortality rate of 20%–50%, leading reconstructive and cardiothoracic surgeons to seek alternative treatment options. Fortunately, most institutions have abandoned these techniques with the advent of muscle flap surgery.

Wide debridement of all devitalized bone and soft tissues, removal of all foreign material (i.e., sternal wires) followed by immediate closure using various muscle and/or omental flaps is now widely performed and considered the standard of care for sternal wound infections. Typically, the overlying soft tissues are reapproximated following muscle flap transposition. When an omental flap is used for coverage, it is covered with a skin graft. The pectoralis major, rectus abdominus, and latissimus dorsi muscles are the structures of choice for mediastinal coverage and deadspace obliteration, with the patient's anatomy, wound status, and previous surgeries serving as the reconstructive surgeon's guide to proper flap selection.

Advances in surgical technique and technology have led to increasing indications for arthroscopy. The advantages of arthroscopic surgery include small incisions with lowered risks for operative complications such as infection and excessive blood loss. Video capture systems and the ability to take still photographs provide illustrations of specific points during the operation for the medical record. The benefits also carry over to the postoperative period in the form of lower requirements for analgesia, shortened hospital stays, and earlier initiation of rehabilitation protocols. Arthroscopic surgery is the most common type of orthopedic surgery, with the knee being the most frequent site of surgical treatment.

While the utility of arthroscopy has primarily been observed in its ability for administering therapeutic maneuvers, the arthroscope is also a powerful diagnostic tool for knee pathology. Therefore, the diagnostic portion of the case is the most important step in any arthroscopic procedure, as it allows for the identification of any pathology present and for development of a treatment plan. Surgeries that are performed most regularly include partial meniscectomy, meniscal repair, and ACL reconstruction. The arthroscope is also utilized for complex ligament reconstructions (ACL, MCL, PCL), meniscal transplantation, articular cartilage transplantation, and septic joint irrigation and debridement.

Indications for arthroscopy include the various injuries to the ligamentous and cartilaginous structures about the knee. Patients with meniscal pathology will often report a specific injury to their knee, describing a sharp pain on the medial or lateral side of the knee or occasionally in the back of the knee.

The primary indication for total knee replacement is pain and dysfunction due to degenerative or inflammatory arthritis. The artificial knee consists of a resilient, highly polished metal alloy which is designed to cap the femur and articulate with a high-density cross-linked polyethylene tibial component. The polyethylene is often held in place on top of the tibia with a metal tray. Resurfacing the patella with a rounded piece of polyethylene is commonly performed. Most total knee devices use bone cement for fixation; however, some designs have porous metal surfaces which allow for bony ingrowth.

The procedure is commonly performed through a midline skin incision over the anterior aspect of the knee. An incision is then made along the medial border of the patella and the patella is everted laterally, providing full exposure of the ends of the tibia and femur so that they can be prepared by making several cuts using special guides. Careful attention is given to the alignment of the components and the balancing of the knee ligaments. The operation usually takes less than 2 hours, though complicated total knee replacements can take longer. General, spinal, and epidural anesthesia are routinely used. The surgery is usually performed with a tourniquet on the upper thigh to limit intraoperative blood loss. Postoperative bleeding will occasionally require a transfusion, though this complication is more common in total hip arthroplasty. Based on the likelihood of the need for transfusion, which is usually low for primary total knee arthroplasty, autologous blood donation is recommended.

Stroke affects about 750 000 people each year in the USA and is a leading cause of long-term adult disability. Over the past decade there have been considerable advances in treatment and prevention. This chapter will review many of these advances with emphasis on issues relevant to surgical patients.

There are two types of stroke: ischemic and hemorrhagic. Ischemic events account for about 80% of all strokes. Most of these are related to atherothromboembolic events.

Atherosclerosis is a systemic disease that most prominently affects the aorta, the coronary arteries, the extracranial carotid and vertebral arteries, and the arteries to the extremities. Atherosclerosis causes stroke by producing progressive stenosis, local thrombosis with occlusion, or distal embolization. Any one of these mechanisms can be the primary cause. For example, progressive atherosclerotic occlusion can cause distal hypoperfusion severe enough to result in tissue ischemia and infarction. Mild or moderate atherosclerotic stenosis that does not cause distal hypoperfusion can be the site of thrombosis and cause intra-arterial embolization leading to occlusion of an intracerebral artery downstream.

The relative significance of local thrombosis versus intra-arterial embolization varies according to the site of atherosclerosis. Most strokes resulting from stenosis of the proximal internal carotid artery are caused by distal embolic occlusion of the middle cerebral artery or its branches. Cerebral infarction in the basilar artery territory usually results from occlusion of the small perforating vessels by local thrombosis.

Ischemic strokes are divided into several categories including cardioembolic, lacunar, and atherosclerotic etiologies.

Cystectomy is most often performed for aggressive bladder cancer that has invaded into the muscular layer of the bladder. In males, the procedure usually includes removal of the prostate; in such cases, the operation is known as cystoprostatectomy. A nerve-sparing technique originally described for radical prostatectomy to preserve the neurovascular bundle for erectile function may be used in cystoprostatectomy in younger patients. In women, the traditional radical cystectomy includes hysterectomy, oophrectomy, and removal of the anterior vaginal wall, which is also referred to as anterior pelvic exenteration. More recently, there has been a trend towards preservation of the anterior vaginal wall.

When dealing with bladder cancer, pelvic lymphadenectomy is usually performed to complete the surgical staging, though more recent reports have also demonstrated a therapeutic role for lymphadenectomy in patients with node-positive disease showing improved survival when the lymph nodes are removed. Thus, a more extensive dissection to include the common iliac nodal tissue has become routine. With such extended dissections in the pelvis/retroperitoneum, there is more risk for lymph leak, bleeding, and third spacing in the early postoperative period.

Other indications for cystectomy include neurogenic bladder, pyocystis from defunctionalized bladder, salvage cystoprostatectomy for radiation therapy failure for prostate cancer, radiation cystitis, and refractory interstitial cystitis.

Once the bladder has been removed, reconstruction of the urinary tract is performed.

Thyroidectomy is performed for nodules with suspicious cytology on fine-needle aspiration (follicular adenoma), biopsy-proven adenocarcinoma, large goiters with airway compromise or cosmetic concerns, or thyrotoxicosis. Given the 6% to 7% incidence of false-negative results on fine-needle aspiration for adenocarcinoma, nodules enlarging on medical therapy should also be treated with operation. Subtotal or total thyroidectomy continues to offer an immediate cure and the best chance of restoring a euthyroid state in certain subgroups of patients with thyrotoxicosis. Included among these are children and women of childbearing age with Graves' disease, those who have failed medical or radioiodine therapy for Graves' disease, those with toxic multinodular goiter (Plummer's disease), and those with toxic adenomas.

Preoperative preparation with antithyroid drugs, propranolol, and potassium iodide (SSKI) or propranolol alone is indicated in patients with thyrotoxicosis to prevent thyroid storm in the postoperative period. Vocal cord function is checked before the administration of paralytic agents by the anesthesiologist. Open thyroidectomy is usually performed under general anesthesia through a low collar incision, yielding excellent cosmetic results. Endoscopic thyroidectomy is also performed under general anesthesia with 3 mm and 5 mm instruments and an endoscope. After preliminary division of the superior thyroid vessels through a 1 cm lateral cervical incision, a 10 mm trocar is inserted through the incision and carbon dioxide is insufflated to a pressure of 10–12 mm Hg.

Ophthalmic surgeons may want to remove ocular structures when they are affected by neoplasia, when they are distressed by a severe infectious process, or when an end-stage ocular disease is causing pain. There are three types of ophthalmic intervention:

Enucleation

Removal of the entire eyeball, including sclera and cornea, leaving a stump of the optic nerve and the extraocular muscles. An intraorbital prosthesis is usually implanted.

Evisceration

Removal of all intraocular structures, leaving only sclera and sometimes cornea. An ocular prosthesis is usually implanted.

Exenteration

Removal of the eyeball and the orbital contents which may include removal of orbital bone.

Enucleation is the most frequently performed surgical approach for elimination of intraocular structures. When ocular disease has rendered an eye completely blind (incapable of perceiving the brightest light), any possibility of visual recovery is minimal. Frequently, such severity of pathology makes an eye painful and cosmetically unacceptable in spite of medical treatment. Although there are several procedural choices, the most widely accepted surgery is removal of the eye or enucleation because of its long-term outcome and safety. A frequent scenario where enucleation is recommended is after severe ocular trauma. A blind eye should be enucleated within 2 weeks after trauma to prevent sympathetic ophthalmia, a rare complication where the exposed uveal tissue leads to autoimmune attack of the contralateral healthy eye. Other indications for enucleation include infectious endophthalmitis, end-stage glaucoma, and malignant intraocular tumors.

Herniated disks usually occur in the cervical and lumbar spine. The thoracic spine is relatively non-mobile and thus rarely affected by disk herniations. Herniated disks typically occur in younger patients between ages 30 and 50 years and present primarily with appendicular pain (arm, leg) as opposed to axial pain (neck, back). Cervical and thoracic disks may present with myelopathy but more commonly with radiculopathy. Ninety percent of patients with disk herniation obtain relief with conservative treatment. Herniated disks are initial manifestations of the continuum of degenerative disk disease later manifested by development of osteophytes.

Cervical level

Patients with cervical disk herniation typically come to operation because of arm and periscapular pain, often with weakness, numbness, or paresthesias in a nerve root distribution. Since the majority of patients improve with non-surgical therapeutic options such as cervical collar, active rest, and physical therapy, patients should be considered for operation only if they have failed a reasonable trial of conservative therapy.

Central disk herniations are treated via an anterior approach. Foraminal disk herniations can be treated by either an anterior or posterior cervical approach. Anterior cervical diskectomy and fusion is the most common procedure performed for cervical disk herniations. After cervical diskectomy the disk space may be replaced with allograft or autograft. Studies have shown that using allograft leads to fusion in approximately 90% of patients. Addition of a cervical plating system increases the fusion rate to 96%.

Adhesions from previous abdominal operations are the most common cause of mechanical small bowel obstruction in adults. In the past, attempts to limit the number and magnitude of postoperative adhesions through instillation of agents such as heparin and hydroxyethyl starch into the peritoneal cavity proved unsuccessful. In recent years, a number of newer compounds such as oxidized, regenerated cellulose or the combination of sodium hyaluronate/carboxymethyl cellulose were approved by the FDA and are now in widespread use.

Patients with adhesive small bowel obstruction present with either partial or complete obstruction. In patients who are still passing flatus and have only moderate cramping, minimal abdominal distention, and display no signs of peritonitis, a trial period of nasogastric tube suction, hydration, and observation is worthwhile. Laparotomy has been avoided in 40% of such patients with nasogastric tube decompression and in 70% to 90% with endoscopic placement of long intestinal tubes. Patients with a history of complete bowel obstruction or with closed loop obstruction (steady pain), elevated temperature, signs of peritonitis on examination, progressive leukocytosis, or a “stepladder” appearance of dilated intestinal loops on flat plate radiographs of the abdomen should undergo urgent operation. Ischemia and even gangrene of the obstructed bowel can occur in the absence of the classical symptoms and signs.

Dehydration and electrolyte abnormalities (hyponatremic hypokalemic metabolic alkalosis) are common in patients with repeated episodes of vomiting related to proximal obstruction of the small bowel.

Common bile duct exploration is indicated for radiologically confirmed (laparoscopic or open cholecystectomy) or palpable (open cholecystectomy) gallstones in the duct (choledocholithiasis) that are asymptomatic or causing obstructive jaundice, gallstone pancreatitis, or toxic cholangitis; to diagnose and treat obstructive jaundice from a benign or malignant stricture; to diagnose and treat stenosis of the sphincter of Oddi; or to repair an injury caused by operation or trauma. The need for open or laparoscopic common bile duct exploration has decreased significantly in recent years. In general, a preoperative ERCP with sphincterotomy to allow release of, or access to, common bile duct stones is cost effective if the risk of such stones is 80% or higher. Therefore, patients with resolved cholangitis, persistent jaundice, unresolving pancreatitis, or common bile duct stones documented by other tests are ideal candidates for preoperative ERCP.

General anesthesia is used for both open and laparoscopic common bile duct exploration. The procedure adds 60 minutes to a routine open cholecystectomy because of the need to expose and open the duct (choledochotomy), extract the stones and perform choledochoscopy, insert a T-tube, close the duct around the T-tube, and perform a completion T-tube cholangiogram. Laparoscopic common bile duct exploration also adds 30 to 60 minutes to a routine cholecystectomy. The ideal approach involves balloon dilation of the cystic duct, passage of a flexible fiberoptic endoscope (outer diameter = 3 mm) through the cystic duct, and basket extraction of common duct stones under direct vision.

Aortobifemoral bypass is performed in patients with atherosclerotic disease primarily involving the infrarenal aorta and iliac arteries. This typically causes claudication of the hip and buttock and may produce vasculogenic impotence in men in severe cases (called LeRiche syndrome). On examination, patients have diminished or absent femoral pulses and are frequently younger – 10 years younger on average – than the typical patient with symptomatic femoropopliteal disease.

Preoperative assessment usually includes contrast angiography, which may be performed via a brachial arterial approach if there are no palpable femoral pulses. Since aortobifemoral bypass is a physically stressful operation, an assessment of the patient's overall medical condition is imperative; some evaluation of cardiac function is frequently a part of this preoperative evaluation. If the patient's condition is not suitable for aortobifemoral bypass, other less invasive options that are not quite as durable may exist, including axillary-bifemoral bypass or endoluminal angioplasty.

The procedure requires a general anesthetic, a laparotomy incision, and bilateral groin incisions. After clamping the infrarenal aorta, a prosthetic graft is sewn onto the aorta proximally. The limbs of the graft are then tunneled in a retroperitoneal plane and sewn onto the femoral arteries. The procedure typically takes 2–4 hours and often requires packed red blood cell transfusion or the use of a cell saver autotransfusion system.

Usual postoperative course

Expected postoperative hospital stay

7 to 10 days.

Operative mortality

The operative mortality for aortobifemoral bypass is 1% to 3%.

Chest pain and shortness of breath are frequently encountered medical problems in the postoperative period. The time at which they appear after surgery is important in determining their cause. This chapter reviews the possible causes for these presenting symptoms.

Myocardial infarction

Chest pain in the postoperative period is always worrisome because of the possibility of myocardial infarction (MI). This concern is well founded. Mortality rates are 30% to 50% for a first postoperative MI and even higher for subsequent MIs in the perioperative period. Although no data are available concerning specific treatment in this situation, standard therapy for MI is likely to be helpful.

The incidence of postoperative MI approaches zero in patients who have no history of, or possess risk factors for, ischemic heart disease compared to 6% in those with a history of ischemic heart disease. The incidence of postoperative MI has been reported to peak between 3 and 5 days after surgical procedures. More recently, this at risk period has been found to occur as early as 24 to 48 hours after surgery.

Two groups of patients appear to be at greatest risk for postoperative MIs and probably sustain the largest number of postoperative MIs as well: those with clinically diagnosed coronary artery disease and those with significant peripheral vascular disease. Diagnosing postoperative MI can be difficult. Incisional pain, gastrointestinal or respiratory complications, and sedative and pain medications may obscure symptoms.

Introduction

The acute confusional state known as delirium is the most common cause of altered mental status in surgical patients. Despite its common occurrence, delirium can often go unrecognized, leading to delays in treatment. This can have significant implications as patients with delirium suffer from higher mortality, postoperative complication rates, longer lengths of stay and delayed functional recovery.

Delirium is usually acute in onset but may develop gradually. It can persist for hours to days and can fluctuate throughout the course of a day. The cardinal feature of delirium is an alteration in the level of consciousness that fluctuates over time. Patients may also display hyperalert, irritable, or agitated behavior. The sleep–wake cycle is often markedly disrupted. Sleep is usually fragmented, with restlessness and agitation. Psychomotor abnormalities may range from hyperactivity to lethargy, stupor, obtundation, and catatonia. Most cases of delirium improve or resolve within 1 to 4 weeks if sufficient attention is given to correcting the underlying disorder causing the cerebral dysfunction. Nonetheless, the development of delirium serves as a marker for those patients at risk of progressive functional decline.

Multiple signs and symptoms may accompany delirium. Patients may be grossly psychotic with severe perceptual distortions that can include hallucinations (tactile, auditory, visual, olfactory), paranoia, delusions, thought disorganization and language incoherence resembling schizophrenia. Signs of cognitive dysfunction such as disturbances in memory, attention, concentration, and orientation are usually the first to be recognized. Behavioral abnormalities such as agitation, disinhibition, and combativeness may also occur.

Owing to the rich blood supply to the intestines, symptoms of chronic mesenteric ischemia are rare. The major vessels supplying the intestines are the celiac artery for the foregut, the superior mesenteric artery for the midgut, and the inferior mesenteric artery for the hindgut. Additionally, the inferior mesenteric artery receives a rich collateral flow from branches of both internal iliac arteries. In the event of chronic occlusion of one or more of the main arteries supplying the bowel, an extensive network of interconnecting branches ensures adequate collateral flow to the intestines. Hence, for symptoms of chronic mesenteric ischemia, stenosis or occlusion in two or more of the three major vessels is often necessary.

The diagnosis of chronic mesenteric ischemia can usually be suspected on clinical grounds alone. Postprandial pain is the most prevalent complaint, which may be accompanied by symptoms of bloating, weight loss, “food fear,” nausea, vomiting, diarrhea, and/or constipation. The pain is typically dull and crampy, poorly localized to the midepigastric region or midabdomen, and usually occurs within the first hour after eating. The symptoms are often severe enough to cause the patient to restrict food intake (“food fear”). The weight loss may be so acute as to result in cachexia and prompt a work-up for an underlying neoplasm. In the only available natural history study of chronic mesenteric ischemia, 86% of the patients developed symptoms significant enough to attempt revascularization or they died due to bowel ischemia.