Primary Management in General, Vascular and Thoracic

Surgery A Practical Approach

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vi Preface

This is the reason why the authors have written very practical and up-to-date
chapters on different but frequent pathologies of the most critical surgical fields:
general, thoracic, and vascular surgery.

Milan, Italy Daniele Bissacco

Milan, Italy  Alberto M. Settembrini
Rome, Italy  Andrea Mazzari
Contents

1 Historical Overview ����������������������������������������������������������������������������������   1

E. Botteri, F. Bongiovanni, R. L. Meniconi, and E. Grespi

Part I Surgical Instruments and Materials

2 
Surgical Instruments and Materials in General Surgery����������������������   7
Andrea Mazzari, Pasquina M. C. Tomaiuolo,
and Roberto Luca Meniconi
3 
Surgical Instruments and Materials in Thoracic Surgery �������������������� 15
Valeria Musso and Francesco Damarco
4 
Surgical Instruments and Materials in Vascular Surgery���������������������� 21
Ilenia D’Alessio and Matteo Marone

Part II Neck
5 Supra-aortic Trunks Emergency Conditions������������������������������������������ 33
Enza Lucia Castronovo, Daniele Bissacco, D’Oria Mario,
Alberto M. Settembrini, and Sirignano Pasqualino
6 
Upper Airways Tract in Emergency Settings������������������������������������������ 49
Diotti Cristina and Francesco Damarco
7 
Multidisciplinary Surgical Consensus on Neck Emergencies���������������� 63
Emanuela Fuccillo and Marco Giovenzana

Part III Chest
8 Chest: Surgical Anatomy and General Consideration
in Emergency Settings ������������������������������������������������������������������������������ 73
Valeria Musso and Francesco Damarco
9 Acute Aortic Syndromes and Thoracic Aortic Aneurysms:
From Diagnosis to Treatment�������������������������������������������������������������������� 81
Andrea Xodo, Andrea Gallo, Paolo Magagna, and Mario D’Oria

vii
viii Contents

10 Pulmonary and Thoracic Emergencies���������������������������������������������������� 97

Francesco Damarco
11 Upper Gastrointestinal Tract Acute Conditions�������������������������������������� 119
Marco Giovenzana, Beatrice Giuliani, and Nicolò Maria Mariani
12 
Multidisciplinary Surgical Consensus on Chest Emergencies�������������� 129
Francesco Damarco, Marco Giovenzana, Diotti Cristina,
and Valeria Musso

Part IV Abdomen
13 Abdomen: Surgical Anatomy and General Consideration
in Emergency Settings ������������������������������������������������������������������������������ 137
Sarah Molfino, Giampaolo Bertoloni, and Gian Luca Baiocchi
14 Acute Abdominal Aorta and Visceral Vessel Disease������������������������������ 145
Davide Esposito and Elena Giacomelli
15  cute Abdomen and Acute Abdominal Conditions�������������������������������� 153
A
Emanuele Botteri, Gianmaria Casoni Pattacini, Alessio Giordano,
and Francesca Ratti
16 
Abdominal Emergencies Requiring a Multidisciplinary Approach������ 175
Andrea Mazzari, Pasquina M. C. Tomaiuolo, Alessio Giordano,
Roberto Luca Meniconi, and Alberto M. Settembrini
Part V Upper and Lower Limbs
17 Upper and Lower Limbs: Surgical Anatomy and General
Consideration in Emergency Settings������������������������������������������������������ 191
Matteo Marone and Ilenia D’Alessio
18 
Acute and Chronic Limb Ischemia���������������������������������������������������������� 199
Giuseppe Galzerano, Edoardo Pasqui, Gianluca Chierchini,
Alberto M. Settembrini, and Pasqualino Sirignano
19 
Popliteal Artery Aneurysm and Non-­atherosclerotic Limb Disease������ 207
Alberto M. Settembrini and Pasqualino Sirignano

Part VI Specific Clinical Pictures: Surgeon Perspectives

20 
The Infected and Septic Patient���������������������������������������������������������������� 221
Emanuele Botteri, Nicoletta Lazzeri, Silvia Mazzoleni,
and Frank A. Rasulo
21 Hemorrhagic Patient �������������������������������������������������������������������������������� 233
Samuele Colombo and Daniele Bissacco
22 The Polytrauma Patient���������������������������������������������������������������������������� 239
Matteo Marone and Ilenia D’Alessio
Historical Overview
1
E. Botteri, F. Bongiovanni, R. L. Meniconi, and E. Grespi

1.1 New Science

Understanding the origins of ‘new’ scientific knowledge, understanding what and

who took the first steps towards breaking free from superstition, supernatural,
rigid and immutable beliefs, is a considerable cultural step and one which brings
full enjoyment of what science can offer us both as individuals and as members of
the scientific community. Above all, intellectual effort calls for a critical mind, in
order not to simply accept what is transmitted to us. Thinking can and should be
remodelled by everyone, according to well-accepted methods to make it ever
more detailed and in keeping with the reality we wish to convey. It requires intel-
lectual honesty, as well as specialised training, and once conclusions have been
reached about any piece of work, the results should be conveyed to everyone
involved. While ‘our’ centuries-old science has managed to overcome supersti-
tion, an anti-scientific attitude has remained on the side-lines of human thought,
threatening its very foundations whenever an immediate explanation to a phenom-
enon cannot be provided. Science takes time and requires patience, a sound mind
and method.
Let us not forget that many of the western world’s values and perceptions are
inspired by the scientific method and the resulting technical progress. The ‘Scientific

E. Botteri (*)
General Surgery Unit, ASST Spedali Civili di Brescia, Brescia, Italy
F. Bongiovanni · E. Grespi
Department of Anesthesiology and Intensive Care Medicine II, Spedali Civili, University of
Brescia, Brescia, Italy
R. L. Meniconi
Department of General Surgery and Organ Transplantation, Azienda Ospedaliera San
Camillo-Forlanini, Rome, Italy

© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2022
D. Bissacco et al. (eds.), Primary Management in General, Vascular and
Thoracic Surgery, https://doi.org/10.1007/978-3-031-12563-8_1
2 E. Botteri et al.

Method’, its concepts and its dissemination underpinned the veritable knowledge
revolution of the seventeenth century. The Scientific Method represents ‘the rules of
the game’ and covers three elements in its scope:

1. LOGIC and its inductive methods (the effects are observed to confirm the causes,
according to a process of subsequent reasoning) and deductive methods (from
the cause, the effects are hypothesised, according to a process of prior reasoning).
2. Systematic application of OBSERVATION, not for mere description purposes,
but rather in order to inspire EXPERIMENTATION. Every hypothesis must go
hand in hand with repetition and reproducible tests in order for it to be affirmed.
3. Speaking the same language: the language of MATHEMATICS. Galileo Galilei
claimed that ‘the universe is written in the language of mathematics’. Used in
Plato’s era as the language of nature, especially in geometry, to avoid being mis-
led by pure sensory experiences.

The main advocates of this development were three scientists closely linked to
one another by the knowledge that ‘we have been too inefficient thus far’, Galileo
Galilei, Renè Descartes and Francis Bacon.
Nevertheless, New Science figured little, at least to begin with, in the world in
which it emerged. Inevitably, new institutions were needed; composed of people
involved with specific scientific fields, supported by patrons or corporations with
the aim of facilitating communication and debate in the scientific community—the
SCIENTIFIC SOCIETIES were born.
1606 saw the launch of Rome’s Lincean Academy, quickly followed by the
Accademia del Cimento (1657), Paris’ Academy of Sciences (1666) and the Royal
Society (1660). In the latter, the influence of the new cultural climate was so strong
that the fine arts, rhetoric, metaphysics and theology were excluded from the Articles
of Association (without, however, undermining their prominence). The importance
of communicating ideas was supported by their own dissemination means and jour-
nals such as the Philosophical Transaction, Acta Eruditorum and the Journal de
Savants.
At all levels, scientific research products should therefore be made accessible,
employing the correct language for the target audience.

1.2 Young People in Science

When we speak about young people in science, particularly about the contribution,
young people have made, make and will make, is not only a matter of age. Being
young implies a new mental approach and boundless physical endurance. One could
wonder who was the first ‘young surgeon’ to have both a young mind and a youthful
age. There is no doubt as to the answer: Giovanni Battista Morgagni (Forlì 1682-­
Padua 1771). He studied under Valsalva in Bologna before moving to the Republic
of Venice and finally settling down in Padua in 1711, when he was called to the
second chair of theoretical medicine.
1 Historical Overview 3

One of his many accomplishments was the sacrilegious method of ‘looking into
a body’ according to a new perspective that began to weaken the old assumption that
diseases were linked to an imbalance of humours (humourism), opening the door to
the idea of diseased organs and of symptoms being the ‘cry of the suffering organs’.
From Morgagni we can draw inspiration for the times in which we are about to
move away from clinical practice, touching upon research and experimentation:
curiosity, critical analysis, accepting findings which are in contradiction with previ-
ous hypotheses (indestructible unless proved otherwise) and dissemination capac-
ity. Morgagni’s work marked the beginning of pathology as we know it today: the
result of systematic observation and experimentation.
When Morgagni was aged only 22, he was named president of the Accademia
degli Inquieti, which managed to make reforms, drawing on the experience of the
Accademia del Cimento, by bringing to the fore investigative enquiries and consul-
tations, and relegating theoretical debates to a marginal role. The turning point came
in 1705 when he gave a reading of the first volume of his publication, Adversaria
Anatomica. The publication of all of these papers when Morgagni was only 24, gave
him instant international recognition as an anatomist.
Another positively larger-than-life young man, and probably for this reason,
highly creative and steadfast, was Thomas Fogarty (1934). We all know his name
thanks to his famous catheter for embolectomy which we use in our operating the-
atres, but probably only a few people are aware that the commercialisation and
widespread use of this instrument began when Fogarty was only 29 years old.
During the years spent at the Good Samaritan Hospital (where he worked as a medi-
cal instrument maintenance technician) he met Dr. Jack Cranley—his main men-
tor—and the man who inspired him to study medicine. The fact of being present
during a number of surgical procedures, meant that he witnessed the death and
suffering of a several patients suffering from acute artery ischemia. After resolving
various technical difficulties, he managed to develop his instrument in 1960, but no
one acknowledged the significance of the idea. Only a few years later, as he was
finishing his specialisation at Oregon University, did he successfully put forward his
idea to the cardiac surgeon, Al Star, who helped him to obtain the final patent in
1969. From this instrument came the idea in 1965 for the design of the first angio-
plasty balloon.
Of course, Gianbattista and Thomas are only two well-known examples of what
a young person driven by interest and passion can achieve. Unquestionably, the his-
tory of surgery is brimming with contributions by young, motivated men and women
to whom we should express our gratitude each day and from whom we should draw
inspiration.
 Part I
Surgical Instruments and Materials
Surgical Instruments and Materials
in General Surgery 2
Andrea Mazzari, Pasquina M. C. Tomaiuolo,
and Roberto Luca Meniconi

2.1 Cut and Dissect Instruments

Dissection of tissues can be done with scalpel, scissors, (Fig. 2.1) or through the use
of energy such as ultrasonic devices, laser, and radiofrequency. Conventionally,
scalpels have been used to make surgical incisions by manually cutting through tis-
sue using a sharp blade. Scalpel consists of a blade and handle and is usually used
for initial incision. Different blades are marked with a number.
Scissors are used for cutting tissue, suture, or for dissection. Scissors can be
straight or curved, and may be used for cutting heavy or fine structures.
Since its introduction in the early part of the twentieth century, electrosurgery
has been used as an alternative tool for creating incisions [1, 2]. Two different surgi-
cal effects can be achieved with electrosurgery, namely cutting and coagulating. In
the cutting mode, a continuous current rapidly produces extreme heat causing intra-
cellular water to boil and cells to explode into steam. As a result, the heat produced
in the cells dries up the tissue but is not intense enough to evaporate intracellular
water. The coagulating mode results in a greater degree of thermal damage and
necrosis of adjacent tissues.
Electrosurgery can be performed using either monopolar or bipolar energy in
conjunction with a specialized instrument.

A. Mazzari (*) · P. M. C. Tomaiuolo

General Surgery Unit, Ospedale Cristo Re, Rome, Italy
R. L. Meniconi
Department of General Surgery and Organ Transplantation, Azienda Ospedaliera San
Camillo-Forlanini, Rome, Italy

© The Author(s), under exclusive license to Springer Nature 7

Switzerland AG 2022
D. Bissacco et al. (eds.), Primary Management in General, Vascular and
Thoracic Surgery, https://doi.org/10.1007/978-3-031-12563-8_2
8 A. Mazzari et al.

Scalpels Scissors Forceps

Clamp instruments Intestinal clamp Needle holders

Fig. 2.1 Open surgery—surgical instruments

2.1.1 Monopolar Electrosurgery

Monopolar electrosurgery can be used for several modalities including cut, blend,
desiccation, and fulguration. Using a pencil instrument, the active electrode is
placed in the entry site and can be used to cut tissue and coagulate bleeding. The
return electrode pad is attached to the patient, so the electrical current flows from
the generator to the electrode through the target tissue, to the patient return pad and
back to the generator. Monopolar electrosurgery is the most commonly used because
of its versatility and effectiveness.

2.1.2 Bipolar Electrosurgery

Bipolar electrosurgery uses lower voltages so less energy is required. But, because
it has limited ability to cut and coagulate large bleeding areas, it is more ideally used
for those procedures where tissues can be easily grabbed on both sides by the for-
ceps electrode. Electrosurgical current in the patient is restricted to just the tissue
between the arms of the forceps electrode. With bipolar electrosurgery, the risk of
patient burns is reduced significantly. In the most common techniques, the surgeon
uses forceps that are connected to the electrosurgical generator. The current moves
2 Surgical Instruments and Materials in General Surgery 9

through the tissue that is held between the forceps. Because the path of the electrical
current is confined to the tissue between the two electrodes, it can be used in patients
with electrical implanted devices, to prevent a short-circuit or misfire.

2.1.3 Ultrasonic Energy

Ultrasonic dissection technology works by generating a high-frequency ultrasound

producing three main effects:

1. Cavitation/tissue fragmentation (and dissection) caused by cellular destruction

secondary to intracellular fluid evaporation.
2. Cooptation/coagulation: caused by conversion of ultrasonic energy into a local-
ized heat, this has been reported to reach from 60 °C to 100 °C. Denaturation of
collagen in the walls of hollow structures can result in the occlusion or sealing of
the lumen.
3. Cutting which is achieved by the “sharp” blade mode.

It has been reported that with ultrasonic energy, there is a minimal lateral spread
of vibration current in the surrounding tissues minimizing the risk of injury com-
pared with monopolar electrocautery.

2.1.4 Radiofrequency Energy

The main functionality of radiofrequency energy is to seal and coagulate. Hemostasis

is obtained by melting the collagen and elastin in the vessel walls; in clinical prac-
tice this technology can seal blood vessels up to 7 mm in diameter.

2.2 Grasp and Hold Instruments

Forceps are the grasping instruments that allow the surgeon to manipulate tissue, to
facilitate dissection or suturing by holding the edges of tissue (Fig. 2.1). They have
multiple uses other than holding skin when suturing: extracting needles, passing
ligatures to other instruments around vessels, grasping vessels to apply diathermy.
They could have various forms and designs and are probably the most commonly
used instrument. Forceps can be toothed (serrated) or non-toothed at the tip. Tissue
forceps are non-toothed and used for fine handling; DeBakey forceps are used for
atraumatic dissection of soft tissues and vessels; Adson forceps are toothed at the tip
and are used for skin closure; Bonney forceps are used for holding thick tissue, like
during fascial closure.
It is strongly recommended to use intestinal forceps when manipulating the
bowel to avoid incidental enterotomies especially in emergency setting, when the
intestinal wall could be frailty for edema due to peritonitis.
10 A. Mazzari et al.

2.3 Clamp Instruments

Clamping instruments are used to constrict tissue, structures, and vessels. They
could be curved on flat, on the side or straight. There are specifically designed
clamps for delicate tissue especially in vascular and in gastrointestinal surgery. The
jaws of these instruments are designed to prevent tissue damage: the intestinal
clamps have flexible and long jaws that allow a proper occlusion of the bowel but
prevent any damage (Fig. 2.1).
Hemostatic clamps are used to occlude vessels prior to ligating or to provide
hemostasis.

2.4 Suture Instruments

Needle holder (Fig. 2.1) and forceps are used for handsewn suture with absorbable
or not absorbable suture materials. Needles come in many shapes and cutting edges
for various applications. Sutures are available in sizes between 5 and 11/0. Higher
numbers indicate larger suture diameter (e.g., 2 is larger than 1), and more zeros
indicate smaller suture diameter (e.g., 4/0 is smaller than 3/0, or 0). There are two
main types of suture: braided and non-braided (or monofilament); the second one
can be absorbable and non-absorbable. Additionally, suture can be made with natu-
ral or synthetic materials.

2.5 Suction Instruments

Suction devices are attached to a vacuum source via suction tubing and are used to
remove blood and body fluid; they have various designs and “tips” attached to a
form of handle to allow suctioning of everything from small wounds to large
abdominal wounds.

2.6 Surgical Staplers and Clips

Surgical stapling devices have changed gastrointestinal surgery; the first one was
built in 1908 by Humer Hultl. Nowadays they are used both for open and laparo-
scopic surgery. Surgical staplers can seal tissue through metal clips that allows the
correct vascularization of the tissues. They are used to perform intestinal anastomo-
ses making theme quicker and easier, and for vascular ligations. Linear staplers with
a double or triple layer allows a safe closure of the tissue, but they do not have a
cutting system. Linear cutter creates a linear cut and immediately staples both free
2 Surgical Instruments and Materials in General Surgery 11

edges. Circular staplers are cylindrical in shape with a cone at the tip that can be
removable: they are used to perform end-to-end or side-to-end anastomosis in
colorectal and esophageal surgery.
Construction of intestinal anastomosis is a hallmark of surgical training; surgical
staplers facilitate the surgeon but there is no evidence that demonstrate any superi-
ority of the stapled over handsewn anastomosis [3].
Clips used in the ligation of vessels may be in metal, polymeric or absorbable
material.

2.7 Retractors

Retractors are the instruments designed to expose tissue and organs during the sur-
gical procedure, they could be hand-held or self-retained, and have a large variety of
sizes. An optimal view is mandatory for a safe procedure. The hand retractors could
be single or double ended and usually have a comfortable design. The self-retaining
retractors have multiple blades for different tissues and depth, in most cases can be
attached directly to the table to guarantee more stability in open large abdominal
surgery. Disposable self-retractors are useful to prevent surgical site infection, espe-
cially in emergency setting when the surgical field is often contaminated [4]
(Fig. 2.2).

Hand-held retractor Disposable self-retractor

Fig. 2.2 Retractors

12 A. Mazzari et al.

2.8 Laparoscopic Surgery

Laparoscopic surgery has emerged over the past two decades as the surgical
approach of choice in the treatment of many digestive disorders. Laparoscopy has
its role in the management of abdominal surgical emergencies since it provides the
same benefits: less postoperative pain and shorter length of hospital stay when com-
pared to laparotomy [5, 6]. In emergency surgery, the laparoscopic approach pro-
vides a better view of the abdominal cavity, giving the opportunity for a precise
diagnosis and, at the same time, a definitive treatment. However, its role in the
management of acute abdomen is strongly influenced by the laparoscopic skills of
the surgeon.
Most of the instruments are similar to those used in open surgery, adapted to fit
through ports placed through the skin. The camera, connected to light source
through a fiber-optic cable, magnifies the image and is connected to a monitor that
can be viewed by the surgical team. Camera vision can provide different angle of
vision, the most used are 0° and 30°. The instruments are inserted into the abdomen
between trocar and ports with different diameter (3 mm, 5 mm, 10–12 mm) and
length. Trocars can be bladed or not bladed; all the trocars have a seal which main-
tain pneumoperitoneum during the surgical procedure. Laparoscopic instruments
are similar to open and are 30–33 cm long (Fig. 2.3). Their main parts are handles
with or without ratchet device, rotator that allow a full rotation device and the opera-
tive inner that can be easily assembled. The working part as in open surgery is used
to dissect, aspirate, grasp, retract, cut, suture, and cauterize tissue.

Veress needle Trocars Laparoscopic

instruments

Fig. 2.3 Laparoscopic surgery—surgical instruments