Primary Surgery®
Volume One: Non-trauma
Nelson Awori, Anne Bayley, Alan
Beasley, James Boland, Michael Crawford,
Frits Driessen, Allen Foster, Wendy
Graham, Brian Hancock, Branwen Hancock,
Gerald Hankins, Neville Harrison, Ian
Kennedy, Julius Kyambi, Samiran Nundy,
Joe Sheperd, John Stewart, Grace
Warren, Michael Wood
Edited by Maurice King, Peter C. Bewes, James Cairns, Jim Thornton
Online Edition on special wish of the editors Maurice King and Peter C. Bewes
expressed on the 8th. DTC Symposium in Jena 1999;
realisation by : Bernd Michael Schneider, Gustav Quade, Jürgen Quade, H.
Woltering, P. Sommer, and B.D. Domres
The production of this manual on Surgery was sponsored by the German Federal
Ministry for Economic Co-operation within the scope of the Technical
Co-operation Agreement with the Republic of Kenya, under project number
78.2048.3-01.100. It was compiled by Maurice King Peter Bewes, James Cairns,
and Jim Thornton in close collaboration with Kenyan and other experts. The
manual contains the collective views of an international group of experts. The
methods and techniques described correspond to the state of the art with
regard to their feasibility in rural hospitals, where sophisticated technical
equipment may not be available. These manuals cannot, however, replace
personal instruction by a qualified expert. Neither the editors, nor the
publisher may be held responsible for any damage resulting from the
application of the described methods. Any liability in this respect is excluded.
Das Copyright © und alle Rechte für 'Primary Surgery' liegen bei
der Deutsche Gesellschaft für
Technische Zusammenarbeit (GTZ) GmbH und bleiben unberührt.
"GTZ does not accept any liability or give any guarantee for the
validity, accuracy and completeness of the information provided in this title.
GTZ assumes no legal liabilities for damages, material or immaterial in kind,
caused by the use ore non-use of provided information or the use of erronenous
or incomplete information."
we thank GTZ for giving us the revocable rigth for distributing this
information for non-profit purpose according to the above mentioned wishes of
the editors M. King and P.Bewes as expressed on the general assembly of the 8th
DTC Symposium in Jena on 13th 11.1999 and thank the team of AGKM Uni
Tuebingen; for the support during the implementation and G. Quade for the
technical support provided during the realisation of this online - project.
These manuals are dedicated by the first editor to his aunt, then Miss
Davidona de Winton, who in the hills of Ceylon in 1932, once taught a very small
boy unwillingly to read and write.
- Table of Contents
- Foreword
-
- Six Prefaces
-
- Kenya's Minister for
Health
- Kenya's Director of
Medical Services
- The Ambassador in Kenya
of the Federal Republic of Germany
- The Head of the
Department for Health, Nutrition, and Population Activities,
Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH
- Hugh Dudley, lately
Professor of Surgery in St Mary's Hospital, London
- Maurice King, Reader in
Community Medicine, the University of Leeds
- Postscript: On being a ''knowledge
engineer''
- 1. The background to surgery
-
- The unmet need for surgical
care
- The surgical scene
- Twenty surgeons in one
- Your surgical work
- Your patients
- Referral is mostly a myth
- What should we describe? What
should you be able to do surgically? The limits of this system of
surgery
- Should you operate?
- ''Oh, never, never let us doubt
what nobody is sure about''
- Creating and maintaining the
surgical machine
- The surgical care of the poor
- Primary care radiology
- How to use these manuals
- 2. Theatres, antiseptics,
-
- The major theatre
- The minor theatre
- Health centre theatres
- Aseptic theatre technique
- Boiling and autoclaving
- Disinfectants and antiseptics
- Antiseptic surgery
- Antibiotics in surgery
- Particular antibiotics
- Methods for using antibiotics
- When prevention fails[md]wound
infection
- Assisting natural mechanisms
- Arterial bleeding
- Tying the external carotid artery
- Tying the third part of the
subclavian artery
- Tying the internal iliac artery
- Tying the external iliac artery in
the groin
- Tying the femoral artery
- Tying the popliteal artery
- Bloodless limb operations
- Postoperative bleeding, reactionary
and secondary haemorrhage
- 3. Basic methods and instruments
-
- Appropriate surgical
technology[md]the equipment you need
- Scalpels and dissectors
- Scissors
- Forceps
- Retractors and hooks
- Suture materials
- Needles and their holders
- Suture methods
- Using tubes in surgery, especially
nasogastric tubes
- Drains and draining
- Miscellaneous equipment and
materials
- Instrument sets
- 4. The surgery of sepsis
-
- ''Where there is pus let
it out'
- Abscesses
- Boils
- Carbuncles
- Extradural abscesses
- Infections of the orbit, cavernous
sinus thrombosis
- Peritonsillar abscesses
- Retropharyngeal abscesses
- Dental abscesses
- Parotid abscesses
- Pus in the neck[md]Ludwig's angina
- Thyroid abscesses (acute bacterial
thyroiditis)
- Pancreatic abscess
- Axillary abscesses
- Perinephric abscesses
- Iliac abscesses
- Anorectal abscesses
- Periurethral abscesses
- Prostatic abscesses
- Abscesses in the seminal vesicles
(rare)
- Pus in the pleural
cavities[md]empyema
- Pus in the pericardium
- Peritonitis
- Abscesses in the peritoneal cavity
- Subphrenic abscess
- Pelvic abscesses
- Infection of the female genital
tract; pelvic inflammatory disease[md]PID
- Septic abortions
- Puerperal sepsis
- Infection following Caesarean
section
- Pyomyositis
- The pathology of osteomyelitis
- Acute osteomyelitis
- The general method for
osteomyelitis
- Exploring a bone for pus
- Chronic osteomyelitis
- Osteomyelitis of the humerus
- Osteomyelitis of the radius
- Osteomyelitis of the ulna
- Osteomyelitis of the femur
- Osteomyelitis of the tibia
- Osteomyelitis of the fibula
- Osteomyelitis of the calcaneus and
talus
- Osteitis of the cranium
- Osteomyelitis of the jaws
- Osteomyelitis of the spine and
pelvis (both uncommon)
- Septic arthritis
- Methods and positions for
particular joints [s8]apart from the hip, most of the methods for
which are in the next section
- Septic arthritis of the hip
- Girdlestone's operation for an
infected hip
- The general method for an infected
hand
- Subcutaneous hand infections
- Infections of the apical finger
space
- Paronychia
- Infection of the pulp space of the
finger
- Infections of the spaces over the
volar surfaces of the middle and proximal phalanges
- Web space infections
- Infection of the superficial
palmar space
- Infection of the middle palmar
space
- Infection of the thenar space of
the hand
- Infections on the dorsum of the
hand and fingers
- Infections of the flexor tendon
sheaths of the hand
- Infection of ulnar bursa of the
hand
- Infection of the radial bursa of
the hand
- Septic arthritis of the fingers
- Other problems with hand
infections
- Pus in the foot
- Before a major operation
- Laparotomy
- Resecting and anastomosing gut,
end-to-end anastomoses
- End-to-side and side-to-side
anastomoses
- Stomata and bypasses for large gut
obstruction
- Methods for ostomies
- A feeding jejunostomy
- Draining and closing the abdomen
- After an abdominal operation
- Non-respiratory postoperative
complications
- Respiratory postoperative
complications
- If a laparotomy wound becomes
infected
- Burst abdomen (wound dehiscence)
- Intestinal fistulae
- The general method for an acute
abdomen
- Diagnosing an acute abdomen
- Intestinal obstruction
- The diagnosis of intestinal
obstruction
- The management of intestinal
obstruction
- The surgery of ascariasis
- Obstruction by bands and adhesions
- Intussusception
- Volvulus of the small gut
- Volvulus of the sigmoid colon
- Closing Hartmann's operation
- Volvulus of the caecum (rare)
- Obstruction following abdominal
abscesses
- Ileus and obstruction follow
abdominal surgery
- Other problems with intestinal
obstruction
- 5. The surgery of the stomach
-
- Peptic ulcer
- Perforated gastric or duodenal
ulcer
- Bleeding from the upper
gastrointestinal tract
- Surgery for a bleeding peptic
ulcer
- Bleeding oesophageal varices
- Pyloric stenosis
- Elective surgery for chronic
duodenal ulcer
- Gastrostomy (Stamm)
- 6. The appendix
-
- Appendicitis
- Difficulties with appendicitis
- Introduction
- Biliary colic
- Acute cholecystitis
- Cholangitis
- Cholangitis caused by [f10]Ascaris
- Primary or recurrent pyogenic
cholangitis
- Cholecystectomy
- Obstructive jaundice
- Pancreatitis
- Pancreatic pseudocyst
- The surgery of the spleen
- 7. Hernias
-
- General principles
- Inguinal hernias
- Difficulties with inguinal hernias
[s8]see also 14.4[nd]6
- Giant inguinal hernias
- Inguinal hernias and congenital
hydroceles in infants and children
- Irreducible and strangulated
inguinal hernias
- Femoral hernias
- Strangulated femoral hernias
- Hernias of the umbilicus and
anterior abdominal wall
- Umbilical hernias in children
- Paraumbilical hernias in adults
- Epigastric hernias
- Incisional hernias
- Hernia of the umbilicus and
anterior abdominal wall
- Umbilical herniae in children
- Paraumbilical and umbilical
herniae in adults
- Epigastric herniae
- Incisional herniae
- Maternal mortality
- Obstetric aims and priorities
- Infertility
- Tubal ligation
- Using a laprocator
- Vasectomy
- 8. The surgery of pregnancy
-
- Surgical problems in
pregnancy
- Evacuating an abortion
- Fetal death, missed abortion, and
intrauterine death
- Suturing an incompetent cervix for
recurrent second- trimester abortions
- ''Acute' ectopic pregnancy
- ''Chronic' ectopic pregnancy
[s8](ectopic pregnancy without massive abdominal bleeding)
- Angular and cervical ectopic
pregnancies
- Abdominal pregnancies
- Autotransfusion
- APH[md]bleeding after the 28th
week
- Placenta praevia
- Placental abruption
- 9. The medicine of pregnancy
-
- Anaemia in pregnancy
- Diabetes in pregnancy
- Hypertension in pregnancy
- Heart failure in pregnancy
- Urinary infection and chronic
renal disease in pregnancy
- 10. The surgery of labour
-
- Obstetric anaesthesia
- Delay in labour
- Obstructed labour
- Managing an obstructed labour
- Oxytocin
- Vacuum extraction
- Symphysiotomy
- Destructive operations
- Which kind of Caesarean section?
- Lower segment Caesarean section
- Difficulties with Caesarean
section
- Classical Caesarean section
- Extraperitoneal Caesarean section
- Which is it to be? Elective
section, ''trial of scar', or section early in labour?
- Injuries of the birth canal
- Old third-degree tears
- Rupture of the uterus
- Vesicovaginal fistulae (VVFs)
- Rectovaginal fistulae (RVFs)
- 11. Other obstetric problems
-
- The surfactant test for
fetal maturity
- Inducing labour at term
- Preterm labour
- Premature rupture of the membranes
(PROM) and intrauterine infection (IUI)
- The mother who is
overdue[md]postmaturity
- The hopelessly malformed fetus
- Breech presentation
- More malpresentations
- Prolapse and presentation of the
cord
- Multiple pregnancies
- Postpartum haemorrhage[md]PPH
- Secondary postpartum haemorrhage (puerperal
haemorrhage)
- Resuscitating the neonate
- Intrauterine growth retardation (IUGR)
- Some of the simpler operations
- Abnormal and ''dysfunctional'
uterine bleeding (''DUB')
- ''D and C'[md]dilatation and
curettage
- Bartholin's cyst and abscess
- Prolapse of the urethra
- Fibroids
- Ovarian cysts and tumours
- Prolapse of the uterus
- Ventrisuspension
- Le Fort's operation
- Anterior and posterior
colporrhaphy
- Hysterectomy
- The sequelae of female
circumcision
- Some other gynaecological problems
- Introduction
- Pus in the breast
- Lumps in the breast
- Carcinoma of the breast
- Simpler operations for tumours of
the breast
- Patey's operation for carcinoma of
the breast, modified to remove pectoralis minor
- The general method for thyroid
- Hyperthyroidism (thyrotoxicosis)
- Thyroglossal cysts
- Physiological goitre
- Colloid goitre
- Tumours of the thyroid
- Other problems with the thyroid
- 12. Proctology
-
- The general method for the
anus and rectum
- Anorectal sinuses and fistulae
- Rectal bleeding
- Piles
- Lord's anal stretch
- Tying and excising piles
- Anal fissure
- Pilonidal infections
- Rectal prolapse
- Other anorectal problems
- 13. Urology
-
- Equipment for urology
- Catheters and how to pass them
- Cystoscopy
- Haematuria
- Retention of urine
- Emergency (''blind') suprapubic
cystostomy, suprapubic puncture (''SPP')
- Open suprapubic cystostomy
- Postgonococcal urethral strictures
- Difficulties with strictures
- Extravasation of urine
complicating a stricture
- Impassable strictures
- Stones in the urinary tract
- Nephrostomy for calculous anuria
or hydronephrosis
- Ureteric stones
- Bladder stones in adults
- Bladder stones in children
- Urethral stones in children
- Prostatic obstruction
- Freyer's transvesical
prostatectomy
- Other causes of urinary
obstruction[md]dyskinesia and bladder-neck fibrosis
- Ghadvi's lateral perineal
prostatectomy
- Orchidectomy
- Undescended or maldescended testes
- Circumcision
- Phimosis and paraphimosis
- Meatal strictures
- Priapism
- Other urological problems
- The general method for the eye
- Operating on an eye
- The red painful eye
- Loss of vision in a white eye
- Uveitis; iritis and iridocyclitis
(anterior uveitis), and choroiditis (posterior uveitis)
- Glaucoma
- Onchocerciasis
- Refractive errors, difficulty
reading, and presbyopia
- Disease of the neuromuscular
system of the eye (squints, amblyopia, and diplopia)
- Diseases of the lids and
nasolachrymal apparatus
- Proptosis
- Tarsal cysts (chalazions or
Meibomian cysts) and granulomas
- Entropion
- Destructive methods for the eye
- Other eye problems
- Introduction
- Deafness
- Otitis media and externa
- Acute mastoiditis
- Foreign bodies in the ear
- Epistaxis
- Blocked nose and the general
method for sinusitis
- Frontal sinusitis
- Maxillary sinusitis
- Nasal polypi
- Foreign bodies in the nose
- Laryngoscopy
- Bronchoscopy: inhaled foreign
bodies in the larynx and tracheobronchial tree
- Foreign bodies in ''the throat'
- Oesophagoscopy
- Corrosive oesophagitis, and
oesophageal strictures
- Other problems in the ear, nose,
and throat
- Introduction
- Gum disease
- Extracting teeth
- Impacted third molars (''wisdom
teeth')
- Cancrum oris
- Jaw swellings
- Cleft lip and palate
- Other dental and oral problems
- 14. Primary orthopaedics
-
- The scope of primary
othopaedics
- The general method for
contractures
- Preventing contractures in the
acute and subacute stages of poliomyelitis
- Managing chronic polio
- Appliances for polio
- Contractures of the hip and knee
- Equinus deformity of the ankle
- Back pain, lumbar disc lesions
- Epicondylitis (tennis elbow)
- Stenosing tenosynovitis
- Ganglions
- The carpal tunnel syndrome
- Congenital dislocation of the hip
(CDH)
- The child with a painful hip or a
limp
- Perthes' disease (osteochondritis)
- Neonatal talipes equinovarus
- Ingrowing toe-nail
- Other orthopaedic problems
- 15. Paediatric surgery
-
- Surgery in children
- Intestinal obstruction in the
first few days of life
- Operating for a neonatal acute
abdomen
- Hypertrophic pyloric stenosis
- Disorders of the
omphalo-mesenteric duct (Meckel's diverticulum)
- Anorectal malformations
- Hirschsprung's disease
- Congenital abnormalities of the
female genital tract
- Omphalocele (exomphalos)
- The surgery of neonatal jaundice
- Spina bifida, meningocele, and
myelomeningocele
- Congenital vascular lesions
- Other paediatric problems
- 16. The surgery of tuberculosis
-
- Chemotherapy for
tuberculosis
- Tuberculous lymphadenitis
- Tuberculous bones and joints
- Tuberculosis of the spine (and
idiopathic scoliosis)
- Tuberculous paraplegia,
costotransversectomy
- Abdominal tuberculosis
- The ascitic type of abdominal
tuberculosis
- The plastic peritonitis type of
abdominal tuberculosis
- The glandular type of abdominal
tuberculosis
- Urogenital tuberculosis
- 17. The surgery of leprosy
-
- Introduction
- Managing paralysis, especially
during lepra reactions
- The eyes in leprosy, iritis (uveitis)
- Lagophthalmos in leprosy
- Leprosy of the hands
- The care of anaesthetic feet
- When feet have ulcerated
- Operations on the feet in leprosy
- Tibialis transfer for foot drop,
from leprosy and other causes
- Other leprosy problems
- The surgery of neglected
infection
- Tropical ulcers
- Mycobacterium ulcerans infection
(Buruli ulcer)
- Mycetoma
- Gross enlargements of parts of
the body (elephantiasis)
- Podoconiosis (non-filarial
endemic elephantiasis of the lower legs)
- The surgery of filariasis
- Elephantiasis of the scrotum and
penis
- The surgical complications of
typhoid fever
- Pigbel disease, [s8]necrotizing
enteritis, necrotizing jejunitis, enteritis necroticans
- The surgery of intestinal
amoebiasis
- Invasive intestinal amoebiasis
- Extraintestinal amoebiasis
- Hydatid disease
- Other problems in tropical
surgery
- 18. Primary oncology
-
- Treating cancer in a
district hospital
- Primary cancer chemotherapy
- Endemic Burkitt's lymphoma
[s8]common in the Burkitt zone
- Hodgkin's lymphoma, [s8]uncommon
- Non-Hodgkin's lymphoma,
[s8]uncommon
- Nephroblastoma, [s8]uncommon
- Retinoblastoma, [s8]uncommon
- Soft tissue sarcomas,
[s8]uncommon or rare
- Rhabdomyosarcoma, [s8]uncommon
- Fibrosarcoma, [s8]uncommon
- Liposarcoma, [s8]uncommon
- Malignant tumours of bone,
[s8]uncommon
- Osteosarcomas, [s8]uncommon
- Chondrosarcoma, [s8]rare
- Giant cell tumours, [s8]rare
- Ewing's tumour, [s8]rare
- Myelomatosis [s8]multiple myeloma,
uncommon
- Basal cell carcinoma
- Squamous cell carcinoma
[s8](epithelioma) fairly common
- Malignant melanoma, [s8]uncommon
- Kaposi's sarcoma
- Carcinoma of the mouth and lips
[s8]common in India
- Salivary gland tumours,
[s8]uncommon
- Carcinoma of the oesophagus,
[s8]fairly common
- Carcinoma of the stomach,
[s8]fairly common
- Hepatoma, [s8]very common
- Carcinoma of the pancreas,
[s8]uncommon in most of the developing world
- Carcinoma of the colon and rectum
- Carcinoma of the nasopharynx,
[s8]common in some areas
- Carcinoma of the bronchus,
[s8]increasingly common
- Tumours of the kidney, [s8]rare
- Carcinoma of the bladder,
[s8]common in some areas
- Carcinoma of the prostate,
[s8]common
- Carcinoma of the penis,
[s8]common
- Block dissection of the inguinal
lymph nodes
- Tumours of the testis [s8]rare
- Carcinoma of the cervix
[s8](common) and endometrium (rare)
- Carcinoma of the vulva, [s8]rare
- Tumours of the ovary, [s8]not
uncommon
- Tumours of the trophoblast,
[s8]common in some areas
- Hydatidiform moles and
trophoblastic neoplasms
- Other tumours
- A task for every district
hospital
- Controlling cancer pain
- Varicose veins
- Hypertrophic scars and keloids
- Granuloma pyogenicum
- Sebaceous and dermoid cysts
- The management of snake bites
- Some X-ray methods for the
generalist
- Indicators of quality in district
hospital surgery
- Indicators of quality in district
hospital obstetrics