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
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
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'
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
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
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
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
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
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
Difficulties with appendicitis
Biliary colic
Acute cholecystitis
Cholangitis caused by [f10]Ascaris
Primary or recurrent pyogenic cholangitis
Obstructive jaundice
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
Tubal ligation
Using a laprocator
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
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
Vacuum extraction
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
Ovarian cysts and tumours
Prolapse of the uterus
Le Fort's operation
Anterior and posterior colporrhaphy
The sequelae of female circumcision
Some other gynaecological problems
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
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
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
Undescended or maldescended testes
Phimosis and paraphimosis
Meatal strictures
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)
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
Tarsal cysts (chalazions or Meibomian cysts) and granulomas
Destructive methods for the eye
Other eye problems
Otitis media and externa
Acute mastoiditis
Foreign bodies in the ear
Blocked nose and the general method for sinusitis
Frontal sinusitis
Maxillary sinusitis
Nasal polypi
Foreign bodies in the nose
Bronchoscopy: inhaled foreign bodies in the larynx and tracheobronchial tree
Foreign bodies in ''the throat'
Corrosive oesophagitis, and oesophageal strictures
Other problems in the ear, nose, and throat
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
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
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)
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