The discipline of general surgery provides the fundamentals for surgical practice, education, and research. The definition of general surgery agreed on by the American Board of Surgery and the Residency Review Committee for Surgery serves as the basis of graduate education and certification as a specialist in surgery. The following principles are inherent in general surgery:

• A central core of knowledge and skills common to all surgical specialties (e.g., anatomy, physiology, metabolism, pathology, immunology, wound healing, shock and resuscitation, neoplasia, and nutrition)

• The diagnosis and preoperative, intraoperative, and postoperative care of patients with diseases of the alimentary tract; the abdomen and its contents; breast; head and neck; endocrine system; and vascular system (excluding intracranial vessels, the heart, and vessels intrinsic and immediately adjacent thereto)

• Responsibility for the comprehensive management of trauma and critically ill patients with underlying surgical conditions

In a community hospital, the practice of general surgery usually encompasses many aspects of surgical care. In larger teaching facilities, general surgery services are commonly specialized (e.g., breast, biliary tract, gastrointestinal, or colon and rectal surgery). The introduction of surgical specialties was the outgrowth of increased knowledge of the etiology of disease and specialized treatment of all parts of the body. General surgery, the basis for all specialties, has decreased in breadth as specialization has increased. The anatomic parts not specifically delegated to specialists have remained in the realm of the general surgeon. Other surgical disciplines depend on general surgeons for clinical collaboration in reconstruction involving the gastrointestinal and vascular systems.

The scope of this chapter focuses on procedures commonly categorized as general surgery. Technologic advances characterize many aspects of surgical practice. The general surgery team of today should be familiar with endoscopic techniques for diagnosis and treatment. Electrosurgery, lasers, and surgical staplers are part of the setup for standard general surgery. Patients are best cared for when the entire perioperative team understands the principles of available technologies and has clinical experience in the safe use of these technologies. The following are examples of technologic applications and the associated aspects of patient care:

1. Malignant lesions, especially those of the breast, thyroid, and gastrointestinal tract, account for a large percentage of surgical interventions. The extent of the surgical excision of a lesion may be determined only after thorough exploration during a surgical procedure, sometimes scheduled as a diagnostic laparoscopy or as a biopsy and frozen section.

a. Although the patient has been informed preoperatively of an anticipated procedure, the unknown factor is cause for apprehension. The circulating nurse should provide comfort while the patient is awake. A biopsy or endoscopic procedure may be performed with the patient under local anesthesia and with or without moderate sedation.

b. A definitive open or laparoscopic surgical procedure may be performed on the basis of results of the biopsy and frozen section or endoscopic examination while the patient is under anesthesia. The scrub person should be prepared with two draping and instrument setups, depending on the diagnosis established and the surgeon’s plan for the surgical procedure. Anticipated equipment and supplies should be available without delay.

2. The types of anesthesia administered are as varied as the types of surgical procedures. Blood pressure, pulse, respiration, electrocardiogram (ECG), and pulse oximetry should be monitored for all patients, regardless of the anesthetic used. Personnel responsible for monitoring patients should be qualified to interpret data, assess the patient, and effect corrective action in the event of an untoward reaction.

3. Patients are placed in the supine position for many general surgical procedures. Extra padding and accessory positioning aids should be available for other positions. The average OR bed can accommodate 350 lb of body weight. Obese patients require a suitable bed capable of managing body weight.²

4. Draping for abdominal incisions is usually standardized. Modifications are necessary for other sites, such as the breast or neck.

5. Instrumentation is quite varied and suited to function in a specific anatomic area. For example, gastrointestinal procedures require crushing clamps (e.g., Pean clamps to occlude the intestinal lumen before resection) and atraumatic clamps (e.g., Bainbridge clamps to protect delicate tissues). Included in all procedures are instruments for exposing, dissecting, grasping, clamping, suctioning, and suturing. For atraumatic retraction, various lengths of umbilical tape, hernia tape, or vessel loops may be placed around vessels or other structures to retract them. These materials should be included in the count.

6. Some procedures require minimal access and are adaptable to ambulatory surgery; others are extremely extensive. More complex procedures, such as colectomy and cholecystectomy, are often performed endoscopically and require less in-house hospitalization.

7. The electrosurgical unit (ESU), argon beam coagulator, laser, endoscope, laparoscope, and/or ultrasound transducer may be used during the procedure.

8. In complex open and laparoscopic abdominal and pelvic procedures, the following should be noted:

a. Indwelling Foley or ureteral catheters may be inserted preoperatively to decompress the urinary bladder and monitor urinary output. Some surgeons may request the placement of ureteral catheters to stent and outline the ureters for complex dissection of abdominal organs. This will require a sterile cystoscopy setup, stirrups, and a urologist before the general surgery procedure of the abdomen begins.

b. Nasogastric (NG) tubes may be passed before or during the surgical procedure to decompress the stomach and bowel. The anesthesia provider inserts the NG tube after the induction of anesthesia. The NG tube may be removed at the end of the surgical procedure.

c. After the abdominal cavity is entered, single free 4 × 4 sponges should be removed from the field. They are used only while folded and secured on a sponge stick. Wet or dry laparotomy sponges are used in the abdominal cavity. A small dissector (peanut, cherry, or Kitner) is always clamped in a forceps before being handed to the surgeon.

d. Before the peritoneum is incised, suction should be available and ready for immediate use, especially in biliary or intestinal procedures or when fluid or blood may be anticipated in the peritoneal cavity. If a cell saver is used for blood salvage, the suction tips should be kept separate from each other.

e. Drains may be exteriorized through a stab wound in the adjacent abdominal wall before closure. A nonabsorbable monofilament suture on a small cutting needle will be used to secure the drain to the skin. Drains are discussed in Chapter 29.

f. Contaminated items, such as those used to anastomose intestinal segments, are isolated in a basin on the back table.

g. Before closure, the wound is irrigated with warm, sterile, normal saline solution to remove blood and debris.

h. Retention sutures may be used to give additional strength to wound closure. Rubber or silicone bumpers or a wound bridge may be used to protect the skin from tension exerted by the adjunct wound closure sutures. Wound closure is discussed in Chapter 28.

9. Assorted sizes of drains, tubes, drainage bags, and wound suction systems should be available. Care is taken to ensure that the patient is not latex sensitive.

10. Irrigating solutions should be body temperature (not to exceed 110° F) when they are used. All radiopaque contrast media, anticoagulants, and solutions on the instrument table and their delivery devices are clearly labeled to avoid any error in administration. Hypodermic syringes with needles are not recapped by hand. Care is taken to monitor the volumes of fluid used for irrigation.

11. Blood loss and urinary output are recorded on the perioperative record. Anesthesia personnel document the amount of intravenous (IV) solution and medications administered during the case.

12. Specimens are carefully labeled and sent for processing as appropriate. Care of specimens is discussed in Chapter 22.

Breast procedures

The mammary glands are bilateral organs (modified sweat glands) lying in the superficial fascia of the pectoral area (Fig. 33-1). They are attached to the underlying muscles by loose areolar tissue and suspended by Cooper ligaments. The breasts extend from the border of the sternum to the anterior axillary line (tail of Spence) and from approximately the first to the seventh ribs.

FIG. 33-1 Sagittal section of normal breast in relation to chest wall and ribcage.

The breasts are highly vascular. The blood supply is derived laterally from the thoracic branches of the axillary, intercostal, and internal mammary arteries (Fig. 33-2). Venous drainage forms an anastomotic circle around the base of the nipple, with branches draining the circumference of the gland into the axillary and internal mammary veins. Lymphatic drainage follows the same path as the venous system and empties into the thoracoabdominal and lateral thoracic vessels. Innervation arises from the anterior and lateral cutaneous nerves of the thorax.

FIG. 33-2 Normal anatomy of the breast, including vessels and lymph nodes.

General surgery on the breast for males and females includes diagnostic procedures and those performed for known pathologic disease, such as cancer. Diagnostic techniques include mammography, ultrasonography, fine-needle aspiration (FNA), and the traditional tissue biopsy.⁷

The desired surgical procedure should be determined on an individual basis after careful diagnostic studies and histologic diagnosis. Size, location, and type of diseased tissue and stage of malignancy are important considerations. No single surgical procedure is suitable for all patients.

Incision and drainage

Surgical opening of an inflamed and suppurative area is most often carried out because of infections in the lactating breast. The cavity is usually irrigated, and the wound is packed and allowed to heal by granulation. The causative organism is often Staphylococcus.

Breast biopsy

The average size of lumps found by women who do and do not practice breast self-examination (BSE) is illustrated in Chapter 22 (see Fig. 22-3). All breast masses are considered malignant until proved benign. To determine the exact nature of a mass in the breast, tissue is removed for pathologic examination. The size and location (Fig. 33-3) of the lesion influence the type of biopsy:

FIG. 33-3 Breast cancer location by quadrant.

• Fine-needle aspiration. A 22- or 25-gauge needle attached to a syringe is inserted into the tumor mass. A few cells are aspirated and sent to the pathology laboratory for cytologic studies. This may be performed in conjunction with a mammogram (mammographic breast biopsy) or as an office procedure. FNA also may be used to evacuate fluid from benign cysts.

• Core biopsy. For this type of incisional biopsy, a large-bore trocar needle, such as a Tru-Cut or Vim-Silverman biopsy needle, is inserted into the mass. A core of suspected tissue is withdrawn for histologic examination. Any retrieved fluid is also sent to the pathology laboratory.

• Stereotactic breast biopsy. The patient is placed prone on a special x-ray table, and her breast is placed in an opening in the table. A computer-guided system is used to digitally locate and pinpoint nonpalpable breast lesions. The biopsy is obtained with a vacuum-assisted Mammotome while the patient is under local anesthesia.

• Incisional biopsy. The mass is incised, and a portion is removed for histologic examination.

• Excisional biopsy. The entire mass is removed for pathologic study.

• Sentinel node biopsy. The breast mass is injected with a radioisotope (technetium) in the radiology department several hours before the planned surgical procedure. In the OR, the tumor is injected with a dye containing isosulfan blue that is taken up by the lymph nodes of the breast. The nodes are excised before the primary mass.

A sterile Geiger counter probe is used on the field to locate the areas of radioactivity. The specimens are sent to pathology for immunohistochemical staining. Lead containers are used to house the specimens for 24 hours before the pathologist examines them.

• J-wire or needle localization in radiology department. The mass is identified on mammography, and the patient undergoes the insertion of a wire into the mass in the radiology department under fluoroscopy (Fig. 33-4). The wire remains taped in place as the patient is taken to the OR. The mass is excised with the wire intact (Fig. 33-5). The specimen is taken back to the radiology department to be x-rayed as a confirmation that the wire is still in the mass. After the confirmatory x-ray, the specimen is taken to pathology.

FIG. 33-4 J-wire placement in radiology.

• Fiberoptic ductoscopy. A flexible 0.9-mm scope with a 0.2-mm working channel is used in the ductal lumens of the breast. Studies have shown that 85% of breast cancer originates in the ductal system in the epithelial lining. The image is enlarged to 200 times by magnification. The scopes are approved for 10 uses each by the U.S Food and Drug Administration (FDA).

The ducts may need to be dilated with lacrimal probes before inserting the scope. Specimens can be obtained by this method, and ductal lavage can be performed for cell studies.

Preoperatively, the surgeon discusses with the patient possible findings and treatment options. The patient may agree to an immediate definitive surgical procedure such as mastectomy or lumpectomy if warranted by the biopsy and frozen section results. Two separate prepping, draping, and instrument sets are necessary to avoid mixing cancerous cells of the breast specimen with the freshly prepared reconstructive site. The team should change gown and gloves.

To minimize disfigurement, many women with early operable breast cancer (a mass less than 5 cm) opt for limited resection followed by radiation and chemotherapy (Fig. 33-6). The difference between tumor and deep tumor-free resection margin remains an important consideration in determining the most appropriate type of mastectomy incision (Table 33-1).¹

TABLE 33-1

Stages of Breast Cancer

Stage I	Stage II	Stage III	Stage IV
SIZE
≤1-2 cm	2-5 cm	≥5 cm	Large and fully integrated with surrounding tissue
LOCATION
Confined to breast	Breast mass with or without suspicious axillary lymph nodes	Breast mass with palpable, fixed axillary, and/or subclavicular lymph nodes	Distant metastasis; extension to skin
	May or may not extend to pectoral fascia or muscle	Mass may be adherent to surrounding tissue	Lymphedema above or below the clavicle
	No distant metastasis	No distant metastasis
SURGICAL OPTIONS
Segmental mastectomy	Total mastectomy	Modified or radical mastectomy	Radical or extended radical mastectomy
Breast conservation surgery for stages I and II lumpectomy with axillary node dissection and radiation therapy

Abdominal procedures

Biliary tract procedures

The gallbladder is located in the right upper quadrant in a fossa under and immediately adjacent to the right lobe of the liver (Fig. 33-9). The gallbladder is a thin-walled sac and has a normal capacity of 50 to 75 mL of bile. Bile secreted by the hepatic cells enters the intrahepatic bile ducts and progresses to the common bile duct. When not needed for digestion, bile is diverted through the cystic duct into the gallbladder, where it is stored. When bile is needed, the gallbladder contracts and empties bile into the cystic duct; the bile flows into and through the common duct into the duodenum.

FIG. 33-9 Normal anatomy of the biliary system and portal system.

Gallstones are concretions of elements of bile, particularly cholesterol (about 50%), and may be found in the gallbladder or in any portion of the extrahepatic biliary duct system.¹⁸ Brown stones are usually fatty acids, and black stones comprise inorganic salts. The incidence of stones, referred to as cholelithiasis, increases with age and is more prevalent in women and in people who are obese.¹⁸

Acute or chronic inflammation of the gallbladder, common duct stones (choledocholithiasis), carcinoma, and the congenital absence of bile ducts (biliary atresia) are the most common indications for a surgical procedure. Obstructive jaundice, which is potentially fatal, may be a sign of ductal cholelithiasis or the presence of a neoplasm. The cause of jaundice should be determined and the condition relieved to spare the patient irreversible progressive liver damage. Biliary stones are sent as dry specimens if removed separately.

The greatest hazards of biliary tract surgery are associated with the anatomic relationships of the ducts and the cystic artery and with pathologic changes in the gallbladder. Complications include hemorrhage and injury to the extrahepatic biliary duct system. Spilled bile can cause peritonitis postoperatively.

Ultrasonography, nuclear imaging such as hepatic intraductal assay (HIDA) scan, and computed tomography (CT) scanning are used for the diagnosis of gallbladder disease. Oral and IV cholecystography may be used for visualization of the gallbladder in the initial evaluation of patients with biliary symptoms.

Endoscopic retrograde cholangiopancreatography also may be performed, usually by a gastroenterologist, to identify stones, tumors, inflammatory lesions, or an obstruction. A flexible fiberoptic duodenoscope is introduced with the patient under IV sedation and with the use of a topical anesthetic to control the gag reflex.

Contrast media is injected to opacify the entire biliary tract and pancreatic duct under fluoroscopy. Care is taken when preparing the contrast in the syringe. Air bubbles will appear like stones on x-ray. Some definitive therapy is possible during this procedure, such as stone retrieval (endoscopic papillotomy), stent insertion, and sphincterotomy. A percutaneous transhepatic puncture is used to resect tumors for biopsy, dilate strictures, place stents in the bile duct, and establish temporary drainage through ducts. A contrast medium can be injected for a cholangiogram.

Cholecystectomy

Gallbladder disease is cured by removal of the gallbladder in a procedure referred to as a cholecystectomy—the most common surgical procedure performed on the biliary tract. A cholecystectomy is performed to relieve the gastrointestinal distress common in patients with acute or chronic cholecystitis (with or without gallstones); it also removes a source of recurrent sepsis. Persistent infection in the biliary tract may cause recurrent stones.

For an open cholecystectomy, the patient is placed in the supine position. As requested by the surgeon, the right upper quadrant may be slightly elevated on a gallbladder rest or pillow after the induction of general anesthesia. The OR bed may be tilted slightly into a reverse Trendelenburg’s position so that the abdominal viscera gravitate downward, away from the surgical area.

Open abdominal cholecystectomy.

With an open abdominal cholecystectomy, the gallbladder is usually exposed through a right subcostal incision (Kocher incision) that may be extended over to the midline at the level of the xiphoid. The incision should be adequate for good exposure of the gallbladder and bile ducts. After exploration of the abdominal cavity, laparotomy packs are used to wall off the surrounding organs for exposure.

The bilious contents of the gallbladder may be aspirated to prevent bile from spilling into the peritoneal cavity—a potential source of peritonitis, especially if the gallbladder is inflamed and tightly distended. The cystic duct, cystic artery, hepatic ducts, and common bile duct are accurately identified.

After palpation of the ducts for stones, the cystic duct and artery are ligated with hemostatic clips and divided. Using blunt dissection, the gallbladder is freed and removed from the liver and its fossa (Fig. 33-10). Some surgeons use ESU and/or neodymium:yttrium aluminum garnet (Nd:YAG) or holmium (Ho):YAG laser for sharp dissection and coagulation. Stones removed as part of the specimen should be sent to the pathology department for analysis and documentation. If bile leakage or hemorrhage has been excessive, a sump drain or closed-wound suction drain may be placed in the subhepatic space and brought out through a stab wound after copious intraabdominal irrigation.

FIG. 33-10 The gallbladder is dissected from the liver bed.

Laparoscopic cholecystectomy.

With a laparoscopic cholecystectomy the patient is supine in a slight to moderate reverse Trendelenburg’s position. A rigid fiberoptic laparoscope is inserted through a sheath into the peritoneal cavity. In conventional laparoscopy multiple trocars are inserted through triangulated puncture wounds in the right upper quadrant: one or two just right of midline, with the uppermost trocar slightly below the xiphoid and costal margin and the other midway to the umbilicus; one laterally in an anterior axillary line above the iliac crest at the costal margin; and another in a midclavicular line slightly above the level of the umbilicus and 2 cm below the rib. The location of puncture sites will vary according to patient size and surgeon preference (Fig. 33-11).

FIG. 33-11 Laparoscopic setup. A, Position of personnel for a basic laparoscopy. B, Trocar placement will be determined by the target organ position. C, Trocars used will vary in size according to position of function for dissection and hemostasis.

Newer technology employs a single incision in the umbilicus and insertion of a flexible multilumen port through which insufflation and additional instruments are placed. Single-incision laparoscopy is discussed in Chapter 32.

A camera attached to the laparoscope allows the surgeon to view the manipulation of instruments through the sheaths of these trocars. Viewing monitors are positioned on each side of the head of the OR bed (Fig. 33-12). With this procedure, the fundus of the gallbladder is grasped through one or more lateral ports and held by the assistant. After careful dissection, the surgeon ligates and divides the cystic duct and artery with suture loops or clips. A laser, an ESU, or microscissors may be used to transect these structures.

FIG. 33-12 Laparoscopic cholecystectomy. A, Placement of personnel and monitors for gallbladder removal. B, Trocar placement for gallbladder removal.

The gallbladder is freed, most often by using an ESU or by using argon, potassium titanyl phosphate (KTP), contact Nd:YAG, or Ho:YAG laser. The gallbladder is usually lowered into an Endo Catch pouch and aspirated to remove bile and collapse the sac. It may then be removed in one piece or cut into sections and withdrawn through the periumbilical incision.

The perioperative team must be ready to convert from laparoscopic to an open procedure in the event of bleeding or other difficulty during the procedure. Supplies and instrumentation should be immediately available. It is advantageous to have precounted sets in the room during these procedures.

Common bile duct exploration

Concomitant exploration of the common duct is often but not routinely performed during cholecystectomy. Curved stone forceps, small malleable scoops, dilators of various sizes, balloon catheters, stone baskets, and nylon brushes are useful in clearing the hepatic and biliary ducts of stones to prevent them from lodging in the duct and causing subsequent obstructive jaundice.⁴^,⁶

Palpable stones, jaundice with cholangitis, and dilation of the common bile duct are indications for exploration. A T-tube drain may be inserted to stent the duct and provide postoperative drainage. The surgeon may choose other intraoperative techniques to identify unsuspected stones, pathologic conditions, or anatomic variations in the hepatic duct system.⁴

Intraoperative cholangiograms.

X-rays are obtained during either open abdominal or laparoscopic procedures. The radiology department is notified in advance if a cholangiogram is anticipated. To check for patient position, scout films should be obtained when the patient is initially positioned on the OR bed, before the procedure is started. The circulating nurse should assess the patient for allergies or sensitivities to contrast media and should ensure that the OR bed has an x-ray top or can be equipped for x-ray or fluoroscopy. Most facilities use digital x-rays.

The radiology technician returns to the OR when the surgeon is ready for films. Cholangiograms may be obtained after the gallbladder is removed or before the cystic duct and artery are ligated. A radiopaque contrast medium, usually diatrizoate sodium (Hypaque or Renografin), is injected into the cystic duct or common bile duct with a 50-mL syringe.

Unless fluoroscopy is used, a series of three or four x-rays are obtained and displayed in digital format. Before each exposure, the surgeon injects contrast media through a Cholangiocath (a plastic catheter inserted into cystic or common duct), cannula, or direct needle puncture in the common duct (Fig. 33-13). Instruments are removed from the field to the extent possible to minimize the obstruction of structures on the x-rays. The field is covered with a sterile barrier before the x-ray machine or C-arm is positioned over the patient. Sterile x-ray tube and C-arm covers are commercially available. All other radiologic precautions for patient and personnel safety and shielding should be observed.

FIG. 33-13 Cholangiograms are taken with x-ray. The cystic duct is ligated.

Ultrasonography.

Ultrasonography, a noninvasive technique, takes less time and does not have the radiation hazards of intraoperative cholangiograms. A sterile ultrasound probe is manipulated along the common bile duct from the liver to the duodenum. The probe transmits high-frequency sound waves back to the ultrasound unit in the form of echoes, which are displayed on a screen as black-and-white real-time images. To enhance the transmission of ultrasound waves, the abdominal cavity is irrigated with warm normal saline solution. Density in tissue causes sound waves to echo in altered patterns and directions. Gallstones appear as bright echoes, often with an acoustic shadow. Photographs or a videotape can be obtained to document the findings of ultrasonography.

Choledochoscopy.

Intraoperative biliary endoscopy provides image transmission and illumination, thus allowing the surgeon visual guidance in exploring the biliary system. Intrahepatic and extrahepatic bile ducts can be visualized with a flexible fiberoptic choledochoscope introduced into the common duct. To provide distention of the biliary tract, normal saline solution must continuously flow through the irrigation channel.

Stones are easily seen and are usually free-floating under the pressure of the irrigating solution. A flexible stone forceps or a basket or a balloon-tipped biliary catheter may be inserted through the instrument channel of either a rigid or flexible scope to allow manipulation of a stone under direct vision. A biopsy forceps may be inserted to obtain a tissue sample. An Nd:YAG laser fiber may be used through the choledochoscope to crush bilirubin stones in the distal common hepatic duct; this allows easy removal of the stones.

Cholelithotripsy.

Cholelithotripsy is a noninvasive procedure in which high-energy shock waves are used to fragment cholesterol gallstones. The procedure is performed under IV sedation or general anesthesia. The patient is usually placed in the prone position but may also be in the supine or lateral position, on a lithotripter table, or submerged in a water bath. Spark-gap shock waves generated from an electrode pass through a fluid medium into the body until they reach the stone, which is focused with an ultrasound probe and computer.

The shock waves are synchronized with the R waves of the patient’s cardiac rhythm, which is monitored by ECG to avoid dysrhythmias. Each shock pulverizes the stones into small fragments, which then pass through the bile duct. This passage may be aided by oral administration of deoxycholic acid (ursodiol) taken daily after lithotripsy to dissolve the fragments.

Choledochostomy and choledochotomy.

With choledochostomy, a T-tube is used to drain the common bile duct through the abdominal wall. A choledochotomy is the incision of the common bile duct for the exploration and removal of stones. Intraoperative cholangiography may be performed before and after exploration and/or stone removal.⁴ The duct is irrigated after calculi are removed. Patency of the duct and of the ampulla of Vater is investigated, often through a choledochoscope. If a neoplasm is found during exploration, resectability is determined; many tumors of the liver or pancreas are inoperable.

Cholecystoduodenostomy and cholecystojejunostomy

Either a cholecystoduodenostomy or cholecystojejunostomy is performed to relieve an obstruction in the distal end of the common duct. Through anastomosis, these procedures establish continuity between the gallbladder and either the duodenum or jejunum. Careful evaluation precedes the surgical procedure.

Cholecystoduodenostomy and cholecystojejunostomy are bypass procedures to avoid further obstructive jaundice, but they do not solve the problem. Common causes of the obstruction are calculi, stricture of the duct, or neoplasms of the duct, ampulla of Vater, or pancreas.

Choledochoduodenostomy and choledochojejunostomy are side-to-side anastomoses between the duodenum or jejunum and the common duct. These procedures are carried out for difficult or recurrent biliary or pancreatic obstruction as a result of benign or malignant disease.

Liver procedures

The liver, the largest gland in the body, is divided into left and right segments (or lobes) and is located in the upper right abdominal cavity beneath the diaphragm (Fig. 33-14). Part of the stomach and duodenum and the hepatic flexure of the colon lie directly beneath the liver. A tough fibrous sheath, Glisson capsule, completely covers the organ; the tissue within this capsule is very friable and vascular. The hepatic artery, a branch of the celiac axis, maintains the arterial supply. Blood from the stomach, intestine, spleen, and pancreas is carried to the liver by the portal vein and its branches.