Acute abdominal pain and abdominal mass are intimately connected; therefore, the diagnostic process for evaluating abdominal pain and abdominal masses is largely the same and has been preserved since ancient times. The primary goals in the management of patients with abdominal pain and/or abdominal mass are to establish a differential diagnosis by obtaining a clinical history, to refine the differential diagnosis with a physical examination and appropriate studies, and to determine the role of operative intervention in the treatment or refinement of the working diagnosis. This review describes the process of diagnosing abdominal pain, including taking a clinical history and performing a physical examination. Investigative studies, including laboratory tests, imaging, and pathology are reviewed. Management, including surgical treatment, is discussed. Tables describe intraperitoneal and extraperitoneal causes of acute abdominal pain, frequency of specific diagnoses in patients with acute abdominal pain, and common abdominal signs and findings noted on physical examination. Figures show abdominal pain in specific locations, a data sheet, the differential diagnosis of an abdominal mass by quadrant or region, characteristic patterns of abdominal pain, acute appendicitis with associated appendicolith, bilateral adrenal masses, adrenocortical carcinoma, retroperitoneal leiomyosarcoma, pancreatic mass, a sagittal ultrasonogram of the pancreas, ultrasonograms of the liver, a dark and well circumscribed abdominal mass, gastroesophageal junction adenocarcinoma, and percutaneous biopsy of a large abdominal mass. An algorithm outlines the assessment of acute abdominal pain and abdominal mass.

This review contains 16 figures, 22 tables, and 171 references

Keywords:  anatomy, swellings, inflammatory, opioid, palpatation, PET, COVID 19

The term jaundice refers to the yellowish-orange discoloration of skin, sclerae, and mucous membranes that results from excessive deposition of bilirubin in the tissues. A problem-based approach to the jaundiced patient that involves assessing the incremental information provided by successive clinical and laboratory investigations, as well as the information obtained by means of modern imaging techniques, is key. Current decision making in the approach to the jaundiced patient should include not only careful evaluation of anatomic issues but also close attention to patient morbidity and quality-of-life concerns, as well as a focus on a cost-effective diagnostic workup. For optimal treatment, an integrated approach that involves the surgeon, gastroenterologist, and radiologist is essential. This review covers terminology and epidemiology, clinical evaluation and investigative studies, workup and management of posthepatic jaundice, and postoperative jaundice. 

This review contains 5 figures, 13 tables, and 84 references. 

Keywords: Jaundice, biliary tree, biliary obstruction, cholangiocarcinoma, pancreatic cancer, endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography

Bowel obstruction (mechanical and functional) is a common cause of hospitalization for abdominal pain; patients with complaints of abdominal pain, nausea, vomiting, distention, and lack of flatus or bowel movement should be evaluated for obstruction. The surgeon must approach this diagnosis in a stepwise fashion to determine whether the patient has ischemia necessitating emergent operative intervention or whether initial nonoperative management is warranted. Mechanical obstruction in the small bowel is most commonly caused by adhesions from previous surgery, hernia, or mass, whereas mechanical obstruction in the colon is most often caused by volvulus, cancer, and diverticular stricture. Initial evaluation includes a detailed history, physical examination, and biochemical evaluation with initiation of resuscitative efforts as needed. CT with intravenous contrast is often most readily available and most helpful in diagnosing bowel obstruction type; specific CT findings can suggest the need for urgent operative intervention. Water-soluble contrast medium challenge has emerged as an important adjunct in evaluating the likelihood that a patient with nonischemic bowel obstruction will require operative intervention.  

This review contains 14 figures, 15 tables and 65 references

Keywords:Adhesive bowel obstruction, ileus, ischemic bowel obstruction, laparoscopic adhesiolysis, large bowel obstruction, postoperative bowel obstruction, small bowel obstruction, volvulus, water-soluble contrast medium

Despite continued advances in therapeutic endoscopy and potent medications to suppress acid production, upper gastrointestinal bleeding (UGIB), defined as bleeding that occurs proximal to the ligament of Treitz, continues to be a common reason for surgical consultation. UGIB results in considerable use of hospital resources, and carries a 2 to 14% mortality. This review covers presentation and initial management, clinical evaluation, risk stratification, investigative tests, and discussion and management of specific sources of UGIB. Figures show an algorithm for management of bleeding from duodenal or gastric ulcers, a technique for duodenotomy and three-point ligation of a bleeding duodenal ulcer, anatomic locations of gastric ulcers according to the modified Johnson classification, and an algorithm for management of bleeding from esophageal  or gastric varices. Table list the Glasgow Blatchford prediction score for UGIB, the AIMS65 prediction score for UGIB, the Rockall prediction score for UGIB, and the Forrest classification for stigmata of recent hemorrhage used to evaluate bleeding ulcers and prevalence data for each class.

This review contains 5 figures, 7 tables, and 97 references

Keywords: Upper gastrointestinal bleeding, gastric ulcer, duodenal ulcer, variceal bleeding, endoscopy, vagal truncotomy, duodenotomy

Obesity and obesity-related comorbid conditions have been steadily increasing in the United States over the past few decades. Despite the availability of several anti-obesity measures such as diet, exercise, pharmacotherapy and behavioral modifications, bariatric surgery is the only effective modality that can provide a sustainable long-term weight loss and improve obesity-associated comorbidities. In this chapter, we discuss perioperative assessment and work-up of morbidly obese patients, minimally invasive approaches to various bariatric surgery procedures including laparoscopic adjustable gastric band, sleeve gastrectomy, gastric bypass and biliopancreatic diversion with duodenal switch, and their short and long term outcomes. We also address revisional bariatric surgery and use of robotic platform and other new procedures and their role in metabolic and bariatric surgery.

This review contains 7 figures, 2 videos, 2 tables, and 110 references.

Keywords: Obesity, comorbidities, metabolic surgery, bariatric surgery, gastric bypass, adjustable gastric band, sleeve gastrectomy, Biliopancreatic Diversion with Duodenal Switch, revisional surgery

Gastroesophageal reflux disease (GERD) is common, affecting approximately 18 to 27% of adult Americans, and can have a considerable impact on quality of life. Hiatal hernias are present in 80% of patients with symptomatic GERD. This review covers the basic pathophysiology, evaluation, and treatment algorithms for patients with GERD and hiatal hernia. Figures show normal gastroesophageal junction anatomy, treatment algorithm for patients with symptomatic GERD, schematic and endoscopic images of long segment Barrett's esophagus, a normal barium esophagogram, esophageal intraluminal pressures assessed by esophageal manometry, test results from a 48-hour wireless pH study, laparoscopic Nissen fundoplication, laparoscopic gastroesophageal junction reinforcement, classification of paraesophageal hernia, and endoscopic view of Cameron ulcers at the level of the diaphragm in the setting of a type III paraesophageal hernia. Tables list risk factors for GERD and a standardized approach to Nissen fundoplication.

This review contains 10 figures, 3 tables, and 68 references.

Keywords: Gastroesophageal reflux disease, GERD, hiatal hernia, paraesophageal hernia, anti-reflux surgery, Nissen fundoplication, Barrett's esophagus, manometry, pH study

The diagnosis of uncomplicated peptic ulcers is difficult to make on a solely clinical basis. Whereas radiographic upper gastrointestinal (UGI) series remain useful, endoscopy is the most accurate method of establishing the diagnosis of peptic ulcer disease. Laboratory tests play an important role in the diagnosis of Helicobacter pylori infection and Zollinger-Ellison syndrome. Figures showing UGI series with double contrast and H. pylori organisms on gastric biopsy samples are provided. The improved medical management of peptic ulcer disease has decreased the need for surgical intervention, which is now largely reserved for urgent management of complications such as hemorrhage, bleeding, and perforation, or the management of obstruction from intractable disease. The appropriate extent of preoperative evaluation for a patient undergoing surgery for a benign gastroduodenal disorder is dictated primarily by the nature of the presenting problem. Endoscopy is the main diagnostic tool to identify the source of bleeding, and in many cases endoscopic therapy can control the bleeding. Angiographic transarterial embolization may be considered following failed endoscopic hemostasis, particularly in high-risk surgical patients. Operative planning is described. The steps of the operative technique, complications, and outcome evaluations are provided for the main surgical interventions for peptic ulcer disease, including vagotomy and pyloroplasty for bleeding duodenal ulcer; resection of bleeding gastric ulcer; omental patch for duodenal perforation (Graham patch); antrectomy; highly selective vagotomy; laparoscopic treatment of peptic ulcer disease; and duodenal diverticulectomy. Operative figures show a Kocher maneuver; omental patch; truncal vagotomy; highly selective vagotomy; Taylor procedure; Heineke-Mikulicz pyloroplasty; Finney pyloroplasty; Billroth I and II antrectomy; Braun enteroenterostomy; and duodenal diverticulectomy.

This review contains 15 figures, 11 tables and 45 references

Keywords: Peptic ulcer disease, Zollinger-Ellison syndrome, Helicobacter pylori, ulcer bleeding, ulcer perforation, pyloroplasty, vagotomy, diverticulectomy

The overall incidence of gastric carcinoma has decreased in the past few decades, but it remains the second leading cause of cancer death worldwide. Malignant tumors of the small intestine are rare, and account for fewer than 5% of all gastrointestinal tract malignancies. This review details the classification, risk factors, clinical evaluation, investigative studies, staging, management, and follow-up and management of recurrent disease in gastric adenocarcinoma; in addition, it examines nonadenocarcinomatous gastric malignancies and small bowel malignancies. 

This review contains 7 figures, 16 tables, and 92 references.

Keywords:Gastric adenocarcinoma, gastrointestinal stromal tumor, gastric lymphoma, Helicobacter pylori, small bowel adenocarcinoma, surgical resection, staging, chemotherapy, radiation therapy

Gallbladder disease is one of the most common problems that the general surgeon will encounter. This comprehensive review discusses the management of uncomplicated gallstone disease, functional gallbladder disease, and gallbladder polyps. It provides indications for cholecystectomy in the asymptomatic patient. There is a thorough review of the diagnosis and management of symptomatic cholelithiasis, including special situations such as pregnancy and cirrhosis, and the latest evidence regarding routine versus selective cholangiography during cholecystectomy. This review also discusses the latest updates to the criteria for diagnosing functional gallbladder disease and sphincter of Oddi dysfunction. 

This review contains 6 figures, 6 tables, and 99 references.

Key words: asymptomatic gallstones, biliary dyskinesia, cholangiography, gallbladder polyps, laparoscopic cholecystectomy, sphincter of Oddi dysfunction, symptomatic cholelithiasis

Nearly 9% of men and 30% of women in the United States experience symptoms or complications of gallstone disease. As such, nearly every general surgeon in the country encounters patients with this pathology numerous times during his or her career. Cholelithiasis can cause complications such as acute cholecystitis, choledocholithiasis, gallstone pancreatitis, and the rare entities of Mirizzi syndrome and gallstone ileus. Patients with gallstones have a 1 to 3% risk per year of a complication, and that risk increases significantly to 30% in those with biliary colic. Surgical management of the complications of gallstones is especially intriguing because the cases are often perceived as low complexity; however, it is an operation that can challenge even the most seasoned attending and result in significant complications. Studies demonstrate complication rates up to 10% following cholecystectomy, with bile duct injury rates hovering at 4 in 1,000. This chapter aims to provide the reader with knowledge of the presentation, imaging, work-up, and framework for the management of complicate gallbladder disease. Furthermore, we hope to provide you with a foundation of how to perform a safe cholecystectomy in a variety of circumstances and impart a few tips and tricks for some challenging intraoperative situations.

This review contains 2 figures, 19 tables and 58 references

Keywords: cholecystitis, choledocholithiasis, cholescintigraphy, common bile duct exploration, critical view of safety, ERCP, gallstone pancreatitis, subtotal cholecystectomy

Appropriate surgical management of periampullary adenocarcinoma (ampullary adenocarcinoma, duodenal adenocarcinoma, distal cholangiocarcinoma, and pancreatic head adenocarcinoma) requires a familiarity with both anatomy and cancer biology. This review describes the clinical behavior of the various subtypes of periampullary adenocarcinoma, the appropriate diagnostic evaluation of the patient afflicted with these malignancies, the surgical anatom­y of the pancreas and peripancreatic region, and the nature and outcome of contemporary therapeutic interventions.

This review contains 9 figures, 7 tables, and 30 references.

Key words: American Joint Committee on Cancer staging system, ampullary adenocarcinoma, borderline resectable, distal cholangiocarcinoma, duodenal adenocarcinoma, locally advanced, pancreatic adenocarcinoma, superior mesenteric artery first dissection

Pancreatic neuroendocrine tumors (PNETs) comprise a diverse, heterogeneous group of tumours that range in presentation and biologic behavior, including small, asymptomatic, incidentally discovered, nonfunctional neoplasms, functional tumors (both localizable and unlocalizable) with associated clinical syndromes, and diffuse metastatic disease. Based on its functional status, the malignancy of a PNET can vary, from the benign (insulinoma) to that which is commonly malignant more than 50% of the time (gastrinoma, somatostatinoma). According to a recent study, PNETs appear to be increasing in incidence or at least in clinical detection; currently the disorder accounts for 1 to 2% of pancreatic tumors and with a reported clinical incidence of one to five cases per million persons annually in the United States. Nonfunctional PNETs make up the majority of cases, and comprise 2% of all pancreatic malignancies. Treatment has been primarily done through surgical management, particularly via resection. However, medical management has played a more increased role for patients where the disease is advanced, encompassing biotherapy, chemotherapy, and targeted therapies such as peptide receptor radionuclide therapy (PRRT). For nonfunctional PNETs—insulinomas, gastrinomas, glucagonomas, somatostatinomas, and VIPomas—the epidemiology, biology of disease, clinical presentation and diagnosis, localization of tumor, operative management considerations, surgical management of primary tumor, and prognosis and outcomes of each are discussed.

This review contains 6 figures, 18 tables, and 58 references

Keywords: Pancreas, neuroendocrine tumor, gastrinoma, somatostatinoma, VIPoma, insulinoma, incidentaloma, glucagonoma, enucleation

Pancreatic cysts are common, affecting up to 10% of the general population. Widespread use of abdominal cross-sectional imaging has increasingly identified asymptomatic patients with "incidental" pancreatic cysts. Our understanding of common pancreatic cysts has improved; however, the ideal management of patients with pancreatic cysts (particularly those with malignant potential) has not been standardized. This review discusses the clinical approach to patients with pancreatic cysts, with particular attention to those with "premalignant" cysts such as intraductal papillary mucinous neoplasms (IPMNs).

This review contains 17 figures, 13 tables, and 42 references.

Keywords: Pancreatic tumor, cyst, branch duct intraductal papillary neoplasm, main duct intraductal papillary neoplasm, incidental finding, mucinous neoplasm

This review discusses several different types of tumors that affect the liver, biliary tree, and gallbladder. Primary and secondary liver cancers are discussed, including hepatocellular carcinoma, intrahepatic cholangiocarcinoma, colorectal metastases, neuroendocrine metastases, and noncolorectal, nonneuroendocrine metastases. Clinical evaluation, investigative studies, tumor staging, and treatment options are presented for each. Benign or premalignant hepatic lesions are also discussed, including the appropriate workup and surgical options for hemangioma, hepatic adenoma, focal nodular hyperplasia, and nonparasitic cystic tumors. Cancers of the biliary tract (cholangiocarcinomas) are subdivided into intrahepatic and extrahepatic cholangiocarcinomas. The latter are subdivided into hilar and distal cholangiocarcinoma; their clinical evaluation, investigative studies, staging, and management are discussed. The clinical evaluation, investigative studies, testing, imaging, staging, and management are presented for gallbladder cancer, including incidentally discovered gallbladder cancer and gallbladder polyps. Figures include the anatomic divisions of the liver and Brisbane terminology for resections, CT and MR images showing characteristic features of the liver and biliary tract tumors, Bismuth-Corlette classification of hilar cholangiocarcinoma, and algorithms for the management of hepatocellular carcinoma and neuroendocrine metastases. Tables include the American Joint Committee on Cancer’s classification and staging systems for hepatocellular carcinoma, cholangiocarcinoma, and gallbladder cancer; Brisbane terminology for liver resections; and neuroendocrine tumors with their corresponding biochemical markers.

This review contains 14 figures, 7 tables, and 83 references.

Clinical evaluation and surgical decision making in patients with acute pancreatitis (AP) and chronic pancreatitis (CP) are two of the most complex conditions that a general surgeon faces. Each entity has unique laboratory and radiographic investigations, operations, and postoperative care. The clinical evaluation, history, and physical examination of AP is described. The clinical features necessary for diagnosis are listed, and contrast-enhanced computed tomography is described as the gold standard for diagnosis. This review uses definitions and terminology developed at the Atlanta symposium in 1992. The severity of an episode of AP is described in terms of established scoring systems (APACHE II [Acute Physiology and Chronic Health Evaluation II], Glasgow Coma Scale score, Ranson criteria). AP can range from mild to severe necrotizing, with each described. The clinical course is described in detail. For CP, the history, physical examination, and diagnosis via investigative and imaging studies are described. The anatomic and morphologic subtypes of chronic pancreatitis are listed and the operations directed at patients with CP are detailed, and can involve drainage or combined resection and drainage. 

This review contains 12 figures, 15 tables, and 55 references

Keywords: Acute pancreatitis, chronic pancreatitis, gallbladder disease, alcoholism, amylase, Whipple procedure

The pathogenesis of portal hypertension is described, as is the subsequent development of collateral circulation and varices. Methods for diagnosis of portal hypertension are discussed and can be suspected clinically in a patient with stigmata of chronic liver disease. The two most commonly used methods to assess the severity of liver disease are the Child-Turcotte-Pugh (CTP) class and the Model for End-stage Liver Disease (MELD) score. Upper gastrointestinal endoscopy is the most common method used to detect varices. The modalities for treating portal hypertension–related bleeding are given and may be pharmacologic or surgical. The surgical modality can involve shunts (portosystemic shunts) or nonshunt procedures (esophageal transection or devascularization). The management of specific causes of portal hypertension is given for esophageal varices; gastric varices; ectopic varices; portal hypertensive gastropathy and gastric vascular ectasia; ascites; and hepatic encephalopathy. 

This review contains 17 figures, 12 tables, and 27 references.

Keywords: liver decompensation, cirrhosis, portal hypertension, sinusoid, Budd-Chiari syndrome, ascites, varices, variceal bleeding, endoscopic bang ligation, portosystemic shunt, transjugular intrahepatic portosystemic shunt (TIPS)

The rapid expansion of minimally invasive techniques over the last two decades has dramatically expanded the use of these approaches in hepatopancreaticobiliary surgery. While implementation of minimally invasive surgery has been slowed by the technically complex nature of liver and pancreatic surgery, the feasibility of laparoscopic and robotic major liver and pancreatic resections has been demonstrated at select centers. This review discusses the preoperative evaluation, indications and contraindications, operative techniques, and outcomes of minimally invasive major pancreatic and hepatic resections; including distal pancreatectomy, pancreaticoduodenectomy, right and left hepatectomy, segmentectomy, and ablative liver surgery. Tables list the clinical outcomes of large series of patients treated with laparoscopic and robotic approaches to each operation. Figures detail port placement and include a number of intraoperative photographs demonstrating anatomic and technical considerations. Videos of a robotic pancreaticojejunostomy and a robotic retropancreatic dissection are included to highlight some of the technical advantages of this approach. While the current literature suggests the safety and feasibility of minimally invasive pancreatic and liver surgery with encouraging early results, ongoing study is needed to more definitively demonstrate outcome benefits of these approaches while maintaining patient safety and oncologic principles and justifying costs associated with the technology. As more data emerges, it is likely that utilization of minimally invasive approaches for hepatopancreaticobiliary surgery will continue to expand.

This review contains 12 figures, 2 videos, 10 tables, and 129 references.

Laparoscopic splenectomy has become an established standard of care in the management of surgical diseases of the spleen, except in the hemodynamically unstable trauma patient requiring splenectomy. Although adoption of minimally invasive splenectomy has led to a gradual decrease in the indications for open splenectomy, both procedures are still essential components of spleen surgery. This review describes the indications and contraindications for procedure, preoperative preparation and consent, operative anatomy and technique, and long-term follow-up. Tables review the clinical indications for splenectomy, classification of splenectomy, a comparison of laparoscopic versus open postsplenectomy outcomes, indications and contraindications for partial splenectomy, and reported incidences of postoperative outcomes and complications after splenectomy. Figures depict splenomegaly, the American Society of Hematology 2011 evidence-based practice guidelines for management of primary idiopathic thrombocytopenic purpura in children and adults, a splenic mass, a splenic cyst, massive splenomegaly, laparoscopic splenectomy, the 2014 Centers for Disease Control and Prevention recommendations for adult and pediatric splenectomy vaccination, splenic artery embolization, various laparoscopic approaches to splenectomy, splenic vascularization, division of splenic artery branches, suspensory ligaments of the spleen, laparoscopic exposure and transection of splenic hilum, retrieval bags and related procedures, open splenectomy, stapling, and laparoscopic partial splenectomy. Videos demonstrate purely laparoscopic splenectomy and hand-assisted laparoscopic splenectomy.

This review contains 26 figures, 11 tables, 2 videos,  and 108 references.

Adrenal tumors are most commonly identified incidentally during imaging for nonadrenal causes. Others may be identified after a patient presents with symptoms of adrenal hormone excess. Adrenal tumors are categorized as functional or nonfunctional, as well as by their malignant potential. It is important to understand the functionality of adrenal glands and properly diagnose potentially hormonally active adrenal tumors. This review outlines the anatomy and physiology of the adrenal glands and details the management of the diseases that result from adrenal hormone excess.

This review contains 8 figures, 7 tables, and 27 references.

Key words: Addison disease, adrenal, aldosterone, catecholamine, Conn syndrome, cortisol, Cushing syndrome, function, glucocorticoid, malignant, pheochromocytoma 

The repair of noninguinal abdominal wall defects is one of the most common procedures general surgeons perform. Despite this, there is little agreement or consensus in the literature as to the ideal approach for this difficult problem. In recent years, population-based studies have provided better data on the true failure rates associated with the various herniorrhaphies. Wound morbidity has also emerged as an important outcome measure, and definitions by the Ventral Hernia Working Group (VHWG) have begun to standardize such benchmarks. Future evidence will come from the large multi-institutional collaborations currently forming. This topic review discusses the classification of ventral hernias, abdominal wall anatomy, and choices of prosthetic materials. Incisional hernia repair is discussed, as are the operative steps and techniques for both an open and a laparoscopic ventral hernia repair. Special circumstances, including loss of abdominal domain and contaminated surgical fields, periumbilical hernia repair, and atypical ventral hernias are also described. 

This review contains 10 figures, 18 tables, and 71 references.

Keywords: Hernia, incisional hernia, mesh, laparotomy, laparoscopy, incarceration, surgical site infection, hernia repair

Approximately 700,000 inguinal hernia repairs are performed in the United States annually, making it one of the most commonly performed operations in surgical practice. The anatomy of the inguinal region is quite complex, and a thorough understanding of this region is required to successfully and safely repair these defects. The science of inguinal hernia repair continues to evolve and over the past several years has expanded to include laparoscopic and robotic approaches, as well as time-honored open repairs that still play an essential role in treating this disease process. The following review describes the relevant anatomy, types of groin hernias, the role of different hernia prostheses and meshes, common and evolving repair techniques, and the common complications encountered in hernia surgery, including chronic groin pain after inguinal hernia repair. 

The review contains 19 figures, 15 tables, and 50 references

Keywords: Inguinal hernia, femoral hernia, transabdominal preperitoneal repair, total extraperitoneal repair, laparoscopy, Bassini repair, Lichtenstein repair

Solid surgical decision making and operative planning are the cornerstones of excellence in outcomes and performance. Beyond the knowledge of the pathologic process, they require an in-depth understanding of the anatomy and physiology of the area impacted by disease or dysfunction. The embryology and anatomy, as well as the physiology of the appendix, colon, rectum, and anus, are reviewed here, with a particular focus on their impact on surgical evaluation and decision making. Tables outline artery-dependent embryologic development of the gastrointestinal system, embryologic development and related malformations, principles and critical structures during colorectal mobilization/resection, clinical impact of anatomic differences between colon and rectum, mediators and drugs affecting colonic motility, pelvic floor muscles, and anophysiology testing. Figures depict malrotation, colon walls, computed tomographic colonography, coronal and lateral views of the rectum, rectal cancer, vascular anatomy, colonic wall innervation, diurnal variation of colonic motility, assessment of colonic transit by means of a Sitzmark study, pelvic organ prolapse, and electrolyte transport mechanisms within the colonocyte.

This review contains 12 figures, 7 tables, and 97 references.

Since the advent of the first flexible fiberoptic sigmoidoscope in 1967, lower gastrointestinal endoscopy equipment has technologically advanced and is used for a number of diagnostic and therapeutic procedures. This review covers the definition of and indications for lower endoscopy; diagnostic and screening colonoscopy, bowel preparation for colonoscopy, special considerations for patients on anticoagulants and antiplatelet agents; endocarditis prophylaxis; general technique; diagnostic and therapeutic techniques during colonoscopy, sigmoidoscopy, anoscopy, endoscopic ultrasonography, balloon-assisted colonoscopy, and lower endoscopy training; and innovations on the horizon. Figures show room setup and patient positioning for colonoscopy; technique for insertion of a colonoscope and endoluminal view of rectum, descending colon, transverse colon, and cecum; pinch biopsy and hot biopsy forceps; snare polypectomy and endomucosal resection of a polyp using the lift and cut and suction cap techniques; Haggitt classification of tissue invasion in a pedunculated polyp; endoscopic clips and their application; self-expanding uncovered metal stents and their method of deployment; an anoscope; and rigid endorectal probes for endoscopic ultrasonography. Tables list indications for colonoscopy, recommendations for screening for colorectal cancer (average risk) from the US Preventive Services Task Force, recommendations from the US Multi-Society Task Force for surveillance after baseline colonoscopy in average-risk individuals, recommendations from the US Multi-Society Task Force for screening and surveillance in colorectal cancer (high risk), bowel preparation scales, agents for bowel preparation prior to colonoscopy, and Haggitt classification of tumor invasiveness in an adenomatous polyp.

This review contains 10 highly rendered figures, 7 tables, and 60 references.

The creation of a join between two bowel ends is an operative procedure that is of central importance in the practice of a general surgeon. Leakage from an intestinal anastomosis can be disastrous, resulting in prolonged hospital stays and increased risk of mortality. To minimize the risk of potential complications, it is important to create a tension-free join with good apposition of the bowel edges in the presence of an excellent blood supply. This review discusses the factors that influence intestinal anastomotic healing, the various technical operations for creating anastomoses, and operative techniques currently used in constructing anastomoses. Tables review the principles of successful intestinal anastomosis, consequences of postoperative dehiscence, factors linked with dehiscence, anastomotic techniques ranked by best blood flow to the healing site, comparison of hand and stapled techniques, leak rates from the Rectal Cancer Trial on Defunctioning Stoma and the Contant and colleagues mechanical bowel obstruction trial, leak and wound infection rates from mechanical bowel obstruction meta-analyses, diseases and systemic factors associated with poor anastomotic healing, lifestyle-associated leakage rates, salvage after anastomotic leakage, standard checks for creation of anastomoses, and steps for left-sided stapled colorectal anastomoses for cancer. Figures show the phases of wound healing, the tissue layers of the jejunum, interrupted and continuous suture techniques, stitches commonly used in fashioning intestinal anastomoses, double-layer end-to-end anastomosis, traction sutures, anatomic relations between the colon and the retroperitoneal organs, single-layer sutured side-to-side enteroenterostomy, Finney strictureplasty, double-layer sutured end-to-side enterocolostomy, double-stapled end-to-end coloanal anastomosis, use of a “glove” port in laparoscopic surgery, and perfusion assessment at the time of anastomotic creation.

This review contains 14 figures, 13 tables, and 85 references.

Fecal incontinence, defined as the involuntary loss of gas, liquid, or solid stool through the anal canal, occurs in an estimated 18 million adults in the United States. Fecal incontinence causes social isolation and confines patients to their homes; additionally, it contributes to medical morbidity, including urinary tract infections, perianal skin breakdown, and decubitus ulcers. Causes for fecal incontinence can be broken down into three broad categories: neurologic disease; functional gastrointestinal diseases or abnormalities; and structural injuries or abnormalities in the pelvic floor, rectum, or anal sphincter. This review describes the clinical evaluation of, investigative studies related to, and management of fecal incontinence. Tables review common causes of sphincter injury, the Fecal Incontinence Severity Index, and daily life factors measured by the Fecal Incontinence Quality of Life questionnaire. Figures show an obstetric sphincter injury, an algorithm outlining the workup and management of fecal incontinence, ultrasonograms of a normal anal sphincter and a sphincter defect, the steps involved in sphincteroplasty, sacral nerve stimulation, and an artificial anal sphincter.

This review contains 6 figures, 3 tables, and 54 references.

Pelvic floor dysfunction encompasses a broad spectrum of disorders and symptoms, including pelvic organ prolapse, fecal incontinence, dysfunctional bowel and/or bladder evacuation, urinary incontinence, and chronic pain. Challenges in treating these patients are due, in part, to inconsistent definitions and diagnostic criteria, an underreporting of symptoms, and complexities in understanding the underlying pathophysiology. Pelvic floor dysfunction is a multisystem process requiring a multidisciplinary team approach. This review describes the incidence, prevalence, and etiologic factors relating to pelvic floor dysfunction, as well as the clinical evaluation process, which includes history, physical examination, physiologic and neurophysiologic assessment, and anatomic assessment. Management of pelvic floor dysfunction is discussed. Tables include potential contributing factors in the development of pelvic floor dysfunction and anatomic and physiologic tests for pelvic floor dysfunction. Figures show an anal manometry apparatus; anorectal physiology report for a patient with fecal incontinence; pudendal nerve-stimulating electrode; pudendal nerve terminal motor latency tracing; surface electrode electromyography; anorectal ultrasound equipment; sonogram of the middle anal canal; ultrasound view of the puborectalis muscle; sonogram showing a defect in the external anal sphincter; defecography showing normal anatomy, rectocele and enterocele, sigmoidocele, and rectoanal intussusception; colonic transit study; rectocele; and enterocele.

This review contains 19 figures, 2 tables, and 81 references.

Despite having been described nearly 200 years ago, pilonidal disease (PD) continues to produce considerable morbidity and loss of work productivity, and the optimal treatment remains elusive. Surgeons must choose among numerous operative and nonoperative options that overlap and often confound therapeutic strategies. This review provides an overview of PD with an emphasis on operative treatments. Every attempt is made to guide selection of the best treatment for the specific variant of disease.

This review contains 7 figures, 4 tables, and 69 references.

Colonic volvulus accounts for 3 to 5% of bowel obstructions in the United States. Current data reveal sigmoid volvulus as the most common colonic volvulus, followed by volvulus of the cecum, transverse colon, and splenic fixture. Despite a low incidence in the United States, diagnosis, management, and patient outcome depend on an appropriate index of suspicion and adherence to the proposed algorithm highlighting the approach to the patient with colonic volvulus. This review outlines the definition, pathogenesis, and epidemiology of colonic volvulus, as well as its clinical evaluation and treatment. Tables review the demographics of colonic volvulus in the United States, the differential diagnosis of and risk factors for colonic volvulus, important radiographic findings in colonic volvulus, and nonoperative management of sigmoid volvulus. Figures show the types of ileosigmoid knot; plain radiographs of cecal,  sigmoid, transverse, and splenic flexure volvulus; contrast enema of cecal, transverse, splenic flexure, and sigmoid volvulus; cross-sectional abdominal imaging of cecal, sigmoid, and transverse colon volvulus and ileosigmoid knot; endoscopic evaluation in sigmoid volvulus; use of an esophageal overtube for placement of a rectal tube; necrotic cecum and transverse colon volvulus in the operating suite; and sigmoid volvulus in an elderly gentleman.

This review contains 14 figures, 13 tables, and 165 references

Keywords: Colonic volvulus, colonic obstruction, endoscopy, surgical intervention, ileosigmoid knot, splenic flexure volvulus, sigmoid volvulus, transverse colon volvulus, cecal volvulus

This review described the etiology and symptoms associated with anal fissures. The physical examination, medical and surgical treatment, and follow-up are detailed. The symptoms and treatment of abscesses and fistula are reviewed. Figures show chronic anal fissures, the relationship between the location of anal fissures and their cause, patient positioning on the operating table, injection of bupivacaine, the closed and open approaches to posterior lateral internal sphincterotomy, classification of anorectal abscesses, alternatives for treating abscess or fistula associated with Crohn disease, a patient with a cryptoglandular abscess/fistula, drainage of an ischiorectal abscess, surgical treatment of a horseshoe fistula, classification of fistula, Goodsall’s rule, ligation of the intersphincteric fistula tract, and advancement flaps. An algorithm outlines the approach to the patient with fissure, abscess or fistula.

This review contains 15 figures, 3 tables and 43 references

Crohn disease (CD) and ulcerative colitis (UC) were often considered one disease until Charles Wells first differentiated the two in 1952. This review outlines the disease features and symptoms of CD and UC. Indeterminate colitis is described, as are the epidemiology, diagnostic testing, and etiology of inflammatory bowel disease (IBD). The role of genetics in the development of IBD is discussed as well as innate immunity, the adaptive immune system, and cytokine signaling. Drugs used in the medical management of IBD and the future of surgical treatment for IBD are described. Tables detail histologic features and symptoms of CD and UC; genetic and demographic risk factors for IBD; common IBD-associated genes, including those associated with epithelial barrier dysfunction, innate immunity, antigen presentation, T cell differentiation, cytokine production, and cell signaling; the medical treatment of IBD; 5-aminosalicylate derivatives and sites of action; advantages of genetic markers in predicting disease course; surgical application of personalized medicine; and surgically relevant IBD genes. Figures show the timeline of IBD, gross CD pathologic specimens, gross UC colectomy specimens, histologic slides of CD- and UC-affected colonic tissue, genetic and environmental factors contributing to IBD, genes involved in innate and adaptive immunity of CD, three components of the gene key to bacterial recognition, typical course of CD, treatment for a hospitalized UC patient, top-down versus bottom-up treatment of IBD, and the Kono-S procedure.

This review contains 12 figures, 23 tables, and 253 references.

Keywords Inflammatory bowel disease, colitis, Crohn disease, ulcerative colitis, immunosuppression, genetics, gut microbiota

Inflammatory bowel disease is a chronic inflammatory disease of the intestine that can be divided into two main categories: Crohn disease and chronic ulcerative colitis (CUC). Although the role of medical therapy in CUC is directed at symptom control or the underlying inflammatory process, fortunately, the intestinal manifestations of CUC can be effectively cured by surgery. The operation of choice is an ileal pouch-anal anastomosis (IPAA), which can be performed open or laparoscopically, with a hand-sewn or stapled anastomosis, or in a one-, two-, or three-stage fashion. Although pouch function and quality of life remain good following IPAA, common complications include pouchitis, anal stricture, pouch fistulas, and small bowel obstructions. The most dreaded complication is an anastomotic leak resulting in pelvic sepsis and, often, eventual pouch excision. Less common complications include pouch dysplasia or cancer and de novo Crohn disease of the pouch. Overall, regardless of age, patient satisfaction following IPAA remains high, and more than 90% of patients retain their pouches for more than 20 years. 

This review contains 11 figures, 4 tables and 85 references

Keywords: Inflammatory bowel disease, ulcerative colitis, laparoscopy, ileal pouch-anal anastomosis, pouchitis

The role of surgery in the management of Crohn disease has undergone a dramatic evolution over the past 50 years. Currently, surgical treatment of Crohn disease is seldom performed in the emergency setting; it is nearly always performed after failed medical therapy. The general indications for surgical treatment are described and include specific attention to complications of the disease, including obstruction, symptomatic fistulas, abscess formation, cancer or dysplasia, and failure to grow. The special considerations of surgical therapy are also described, including pregnancy, the marking of stoma sites, and the choice of incision, which may involve laparoscopy. Surgical management of Crohn disease is evaluated in terms of therapy at specific sites, including esophageal, gastric, and duodenal disease; jejunoileal disease; ileocolic disease; colonic disease; and anal disease. Chemoprophylaxis is also described, as is surveillance and behavioral modification. Tables outline the Vienna Classification System, Crohn Disease Activity Index, Harvey-Bradshaw Index, extraintestinal manifestations, and the medical treatment of Crohn disease. Figures show endoscopic images of Crohn disease, computed tomographic enterography, a capsule endoscopy showing large Crohn structures, surgery rates over time, caput medusa, an example of stenotic ileocolic Crohn disease, an enterocutaneous fistula, Heineke-Mikulicz strictureplasty, Finney strictureplasty, a fibrotic stricture, an example of a large ulcer, pyoderma gangrenosum, a sigmoid colon stricture, toxic megacolon, and vessel loops for drainage of abscesses.

This review contains 15 figures, 14 tables, and 80 references.

Key words: Crohn disease, inflammatory bowel disease, colorectal cancer, surgery, chemoprophylaxis, fistula, granuloma, diarrhea 

Appendicitis became recognized as a surgical disease during a presentation by pathologist R. H. Fitz at the 1886 meeting of the Association of American Physicians. In 1894, Charles McBurney first described the surgical technique that was to become the gold standard for appendectomy. Although the appendectomy has traditionally been performed as an open procedure, laparoscopy holds several advantages, such as a lower risk of wound infection, the ability to thoroughly explore the abdominal cavity, and improved outcomes in women of childbearing age, obese patients, and patients with unclear diagnoses. This review covers operative technique, special considerations, and complications and outcome evaluation associated with appendectomy. 

This review contains 12 figures, 7 tables and 91 references.

Keywords: Appendicitis, open appendectomy, laparoscopic appendectomy, larparoscopy, appendiceal tumor, abdominal emergency, appendiceal rupture

The majority of cases of inherited colorectal cancer (CRC) are accounted for by two syndromes: Lynch syndrome and familial adenomatous polyposis (FAP). In the management of FAP, the role of prophylactic surgery is clearly defined, although the optimal procedure for an individual patient depends on a number of factors. In the management of Lynch syndrome, the indications for prophylactic procedures are emerging. The authors address the clinical evaluation, investigation findings, medical and surgical therapy, and extracolonic diseases of FAP, attenuated form of FAP (AFAP), MYH-associated polyposis, Lynch syndrome, familial colorectal cancer type X (FCCTX), hyperplastic polyposis syndrome, Peutz-Jeghers syndrome, and juvenile polyposis syndrome. AFAP has been described that is associated with fewer adenomas and later development of CRC compared with classic FAP. The AFAP phenotype occurs in less than 10% of FAP patients. The clinical criteria for AFAP are no family members with more than 100 adenomas before the age of 30 years and (1) at least two patients with 10 to 99 adenomas at age over 30 years or (2) one patient with 10 to 99 adenomas at age over 30 years and a first-degree relative with CRC with few adenomas. Given that polyposis has a later onset and the risk of CRC is less well established in AFAP, some authors question whether prophylactic colectomy is necessary in all AFAP patients.

This review contains 26 tables and 173 references

Keywords: Colorectal cancer, Lynch syndrome, hyperplastic polyp, Peutz-Jeghers syndrome, juvenile polyposis syndrome, familial adenomatous polyposis

Despite advances in systemic chemotherapy, surgery remains the mainstay of treatment in colorectal cancer. While there are similarities in the principles of colon and rectal cancer surgery, there are specific considerations that are unique to the surgical management of rectal cancer. In this chapter, we discuss the surgical management of colon and rectal cancer and highlight pertinent differences in the surgical management of rectal cancer.

This review contains 9 figures, 2 tables, and 76 references.

Keywords: Colon, Rectal, Colorectal Cancer, Adenocarcinoma, Surgery, Management

Colorectal cancer (CRC) is the third most common and lethal cancer in men and women in the United States. At presentation, a significant proportion of patients with CRC are able to undergo resection with curative intent, but up to 50% of these patients will develop recurrent disease. Fortunately, recurrence rates for both colon and rectal cancer have improved with the introduction of multimodality therapies, which include chemotherapy, chemoradiation therapy, and radiation therapy. These therapies are adjuncts to surgery and can be administered before (i.e. neoadjuvant) or after (i.e. adjuvant) surgery. This review summarizes the current evidence for the use of adjuvant and neoadjuvant therapies in colon and rectal cancer.

This review contains 2 figures, 7 tables, and 77 references.

Keywords: Colon cancer, rectal cancer, neoadjuvant therapy, adjuvant therapy, total neoadjuvant therapy, induction chemotherapy in rectal cancer, chemoradiation, organ preservation, non-operative management

Colon cancer is the third most commonly diagnosed cancer in the United States. Partial colectomy is beneficial for the majority of these patients; more than 250,000 of these procedures are performed in the United States annually, with colon cancer being the most common indication. Although these procedures are commonly performed, there is considerable associated morbidity and mortality. This review details the indications for surgery, the preoperative planning, and technical considerations for colon cancer surgeries. Figures show the vascular anatomy of the colon, oncologic resections of carcinomas in different locations of the colon, anatomic relations between the colon and the retroperitoneal organs, port positioning for laparoscopic colectomy, right colon mobilization and mesenteric dissection in laparoscopic right hemicolectomy, configuration of an end-to-end stapled colorectal anastomosis, laparoscopic left hemicolectomy and sigmoid resection, and approaches to dissection of the splenic flexure. A video shows a laparoscopic right colectomy, and potential complications of colectomy are listed in a table.

This review contains 9 figures, 1 video, 2 tables, and 70 references.

Keywords: Colon, Anastomosis, Colectomy, Cancer, Flexure, Tumor, Sigmoid, Mesentry

Cancer of the large bowel is the third most common cancer diagnosed in both men and women in the United States with the exclusion of skin cancers. Surgery represents the mainstay of therapy in early-stage rectal cancer and is frequently warranted in advanced cases for palliation. Complete resection and retention of gastrointestinal continuity with low recurrence rates are the ultimate goal in treating localized disease. Local recurrence in rectal cancer essentially represents a failure of surgical therapy and is avoidable in most cases. Radiation has been shown to reduce local recurrences. This review covers the surgical anatomy of the rectum, factors to consider when evaluating patients with rectal cancer, choosing a therapeutic protocol, obtaining patient consent, preoperative considerations, and surgical technique. Local (transanal local excision, transanal endoscopic microsurgery) and radical procedures (anterior resection technique, abdominoperineal resection) are described. Laparoscopic and robotic approaches, key intraoperative concepts in rectal cancer, perioperative care, adjuvant therapy, and follow-up regimens are also detailed. Tables describe general medical issues for surgeons to review, vital knowledge for the colorectal surgeon, American Joint Committee on Cancer TNM Clinical Classification of Colorectal Cancer, American Joint Committee on Cancer Staging System for Colon Cancer, the multidisciplinary team for treating rectal cancer, risk factors associated with high rectal cancer recurrence rate, National Comprehensive Cancer Network 2013 Guidelines for Transanal Excision, and total mesorectal excision score as categorized by Quirke. Figures show procedures for local, anterior, and abdominoperineal resection.

This review contains 11 figures, 9 tables, and 64 references.

Keywords: rectoscope, resection, excision, anastomosis, radiation, stapler, abdominoperineal resection

Colon cancer is the third most commonly diagnosed cancer in the United States. Partial colectomy is beneficial for the majority of these patients; more than 250,000 of these procedures are performed in the United States annually, with colon cancer being the most common indication. Although these procedures are commonly performed, there is considerable associated morbidity and mortality. This review details the indications for surgery, the preoperative planning, and technical considerations for colon cancer surgeries. Figures show the vascular anatomy of the colon, oncologic resections of carcinomas in different locations of the colon, anatomic relations between the colon and the retroperitoneal organs, port positioning for laparoscopic colectomy, right colon mobilization and mesenteric dissection in laparoscopic right hemicolectomy, configuration of an end-to-end stapled colorectal anastomosis, laparoscopic left hemicolectomy and sigmoid resection, and approaches to dissection of the splenic flexure. A video shows a laparoscopic right colectomy, and potential complications of colectomy are listed in a table.

This review contains 9 figures, 1 video, 1 table, and 69 references.

An understanding of anal anatomy is essential for optimal management. Patients with anal lesions that appear suspicious or fail to respond to conventional therapy within a month should undergo a biopsy. Premalignant perianal lesions are managed with local excision. Epidermoid carcinoma of the anus is usually managed with chemoradiation. Presacral tumors are managed with excision.

This review contains 11 figures, 13 tables, and 57 references.

Keywords: anal cancer, anterior sacral meningocele, basal cell carcinoma, chordoma, epidermoid carcinoma, high-grade squamous intraepithelial lesions, retrorectal tumor 

Radiation is an integral part of therapy for many pelvic cancers, including rectal, prostate, cervical, and uterine cancers, and has been shown to decrease local recurrence and increase patient survival. Radiation injury is a sequela of treatment that manifests different symptoms depending on the organ affected. This review covers disease pathology, risk factors, disease prevention, clinical presentation, medical therapy, endoscopic therapy, and surgical therapy. Tables outline risk factors predisposing patients to the development of radiation injury, investigated prophylactic therapies to prevent radiation injury, reported frequencies of symptoms of chronic radiation proctitis, pharmacologic therapies that have demonstrated clinical benefit in randomized trials, and a scoring system for symptoms and endoscopic and histologic results. A management algorithm details evaluation and treatment of radiation-induced gastrointestinal injury. A microscopic section shows diffuse ulceration and granulation tissue formation. Photographs depict the rectal wall thickened by dense white tissue and severe perianal dermatitis.  Endoscopic views of radiation proctitis with ulceration, severe radiation proctitis, mild radiation proctitis, prominent telangiectasia, anal necrosis due to radiation, actively bleeding telangiectasia, and argon plasma coagulation are provided. Other figures include computed tomographic scans of an inflamed rectum and the rectal wall with thin mucosa, and magnetic resonance imaging of the pelvis.

This review contains 13 figures, 5 tables, and 89 references.

Formation of an intestinal stoma is frequently a component of surgical intervention for diseases of the small bowel and the colon. The most common intestinal stomas are the ileostomies (end and loop) and the colostomies (end and loop). Preoperative counseling, choice of procedure, and selection of stoma site are described. The general principles of the operative technique are listed, as is the creation of the stoma aperture. Types of colostomies are described and include end, loop, and double-barrel. For ileostomy, end, loop, loop-end, split, and continent are described. Details are provided on the stoma closure for loop ileostomy and loop colostomy. The chapter has sections on troubleshooting and complications, including ischemia, stenosis, prolapse, retraction, parastomal hernia, obstruction, and fistula. Figures show an end colostomy, loop colostomy, preparation of terminal ileum and placement of sutures for an end ileostomy, stoma closure for loop ileostomy, stabilization of retracted ileostomy, preperitoneal mesh repair of parastomal hernia, and laparoscopic intra-abdominal placement of polytetrafluoroethylene-coated mesh. Tables show indications for different types of intestinal stomas, incidence of common complications of the intestinal stomas, incidence of parastomal hernia formation, and additional complications arising after stoma formation.

This review contains 12 figures, 5 tables, and 106 references.

Patients who are immunosuppressed either due to an underlying disease process or medications to treat a disease require important perioperative considerations. Preoperative evaluation mandates a higher index of suspicion for pathology given that peritoneal and systemic markers of illness may be masked. Intraoperatively, consideration should be given for diversion more frequently than in a nonimmunosuppressed patient. Postoperatively, patients should be managed in a multidisciplinary fashion. This review largely focuses on the immunosuppressive mediations used for the treatment of inflammatory bowel disease, benign colorectal disease in an immunosuppressed patient, and colorectal malignancies in immunosuppressed patients to highlight important considerations for this patient population.

This review contains 4 figures, 19 tables, and 81 references.

Key words: anal squamous cell carcinoma, appendicitis versus typhlitis, biologic therapy, corticosteroids, human papillomavirus, immunosuppression, neutropenic enterocolitis 

Reoperative pelvic surgery is technically challenging and carries with it significant potential risk. Pelvic pathology that requires reoperative surgery typically involves recurrent malignancies, complications from ileal pouch-anal anastomoses (IPAA) for inflammatory bowel disease, complications from low pelvic anastomoses, and palliative situations. The goals of reoperative pelvic surgery are resection/repair of the primary indication and reconstruction whenever possible. This review describes pelvic anatomy and operative management for recurrent rectal cancer. Complications following IPAA, low anastomotic complications, and palliative reoperative pelvic surgery are also detailed. Tables outline prognostic factors negatively impacting outcomes following surgery for recurrent rectal cancer, absolute and relative contraindications for exenterative surgery, survival following exenteration for recurrent rectal cancer, intraoperative radiotherapy doses related to resection margin, indications for reoperative pouch surgery, and mobilization techniques for difficult reconstructions. Figures show anterior and posterior exenteration; the anatomy of presacral space after rectal mobilization; vascular exposure and dissection; unicortical transverse osteotomy; placement of Silastic mesh; division of the sacrospinous and sacrotuberous ligaments and piriformis muscle; posterior sacral osteotomy; transperineal delivery of pedicled myocutaneous rectus flap; vertical rectus abdominis myocutaneous flap; gracilis flap; total thigh fillet flap; sacropelvic resection classification; and increasing colon length with primary, secondary, and tertiary maneuvers.

This review contains 18 figures, 6 tables, and 89 references.

The concept of evidence-based medicine (EBM) and evidence-based surgery (EBS) involves combining the best scientific evidence available with the clinician’s judgment while also considering the patient’s needs and preferences. In the past, the practice of colorectal surgery was based on tradition and anecdotal experience from experts rather than scientific rationale. However, the rise of EBM has led to changes in how colorectal surgery is performed. This review discusses the hierarchy of evidence, fundamental principles of EBS, and practicing evidence-based colorectal surgery. Tables review the Oxford Centre for Evidence-Based Medicine revised levels of evidence, four steps of evidence-based surgery, key resources for evidence-based surgery, the “PICO” technique, and the Dindo-Clavien classification system.

This review contains 5 tables and 69 references.

Rectal cancer accounts for one-third of all colorectal cancers and has an increasing incidence in patients under 40 years of 1.8 to 2.6% annually. Significant advances in multidisciplinary therapy for rectal cancer have resulted in an improved relative 5-year survival; prognosis is strongly dependent on the extent of disease. Although the majority of patients present with disease localized to the mesorectum, locally advanced rectal cancer (LARC) occurs in up to 10% of patients. Surgical extirpation remains the mainstay of curative therapy for LARC and locally recurrent rectal cancer (LRRC). This review covers risk factors for pelvic recurrence, clinical presentation, diagnosis and staging, preparation for surgery, multimodality therapy for advanced and locally recurrent rectal cancer, pelvic reconstruction, and palliative procedures. Figures show Harrison-Anderson-Mick applicator for intraoperative brachytherapy, an algorithm for treating LARC (extension beyond mesorectal fascia or advanced modal disease), an algorithm for treating LRRC, and intraoperative photographs showing oblique sacral resection, extended right lateral pelvic resection, and vertical rectus myocutaneous flap procurement. Tables list risk factors associated with rectal cancer recurrence, and a classification schema of LRRC.

This review contains 6 highly rendered figures, 2 tables, and 119 references

Of patients who present with major gastrointestinal (GI) bleeding, 20 to 30% will ultimately be diagnosed with bleeding originating from a lower GI source. Lower GI bleeding has traditionally been defined as bleeding originating from a source distal to the ligament of Treitz; however, with the advent of capsule endoscopy and deep enteroscopy allowing for visualization of the entire small bowel, the definition has been updated to GI bleeding originating from a source distal to the ileocecal valve. Lower GI bleeding can range from occult blood loss to massive bleeding with hemodynamic instability and predominantly affects older individuals, with a mean age at presentation of 63 to 77 years. Comorbid illness, which is a risk factor for mortality from GI bleeding, is also more common with increasing age. Most deaths related to GI bleeding are not due to uncontrolled hemorrhage but exacerbation of underlying comorbidities or nosocomial complications. This review covers the following areas: evaluation of lower GI bleeding (including physical examination and diagnostic tests), initial management, and differential diagnosis. Disorders addressed in the differential diagnosis include diverticulosis, arteriovenous malformations (AVMs), ischemic colitis, anorectal disorders, radiation proctitis, postpolypectomy bleeding, and colorectal neoplasms. Figures show an algorithm for management of patients with suspected lower GI bleeding, tagged red blood cell scans, diverticular bleeding, colonic AVM, ischemic colitis, bleeding hemorrhoid, chronic radiation proctitis, and ileocolonic valve polyp. Tables list descriptive terms for rectal bleeding and suggested location of bleeding, imaging modalities and differential diagnosis for lower GI bleeding, endoscopic techniques for hemostasis, and an internal hemorrhoids grading system.

This review contains 8 figures, 9 tables, and 108 references

Keywords: Gastrointestinal bleeding, hemoglobin, diverticulosis, colorectal neoplasm, endoscopy, polyposis

Recurrent fistulas, fistulas with multiple external openings, those involving more than one third of the anal sphincter complex, and fistulas involving adjacent organs are considered complex. Fistulas occurring in the setting of perianal Crohn disease or following pelvic radiation are also considered complex. Evaluation of a fistula includes a detailed history and physical examination. Imaging with ultrasonography helps delineate the course of a fistula relative to adjacent structures as well as identify occult branching of the fistula tract. The initial step in treating fistulas is resolving associated inflammation. When treating fistulas with multiple branching tracts, the portion of the tracts outside the anal sphincter complex should be unroofed, with the goal of transforming the complex fistula into a simpler fistula with a single internal opening. The selection of the most appropriate treatment for a complex fistula depends on the etiology, anatomy, patient comorbidities, and condition of surrounding tissue.

Key Words: anal fistula, anovaginal fistula, Crohn disease, fistulotomy, rectourethral fistula

The peritoneum and retroperitoneum, once considered just spaces, are now recognized as primary locations for trauma, inflammation, infection, benign neoplasms, and malignancies. To understand the spread of disease in these locations, one must first understand their anatomy, physiology, and relationship. As both the peritoneum and retroperitoneum contain multiple organs, the relationships of the abdominal organs within these spaces are critical. This review defines both the peritoneum and retroperitoneum and then describes the most common disease states and spread of disease within these spaces. Spread of disease, in particular, spread of malignancy, within the peritoneum is complex but predictable and can be treated in certain instances with heated intra-abdominal chemotherapy intraoperatively.

This review contains 5 figures, 5 tables, and 37 references.

Key words: ascites, carcinomatosis, desmoid, hyperthermic intra-abdominal chemotherapy, peritoneum, peritonitis, retroperitoneal sarcoma, retroperitoneum

The peritoneum and retroperitoneum, once considered just spaces, are now recognized as primary locations for malignancies. Spread of disease, in particular, spread of malignancy, within the peritoneum is complex but predictable. This review covers the pathophysiology, diagnosis, and treatment of malignant peritoneal tumors such as peritoneal metastases and peritoneal carcinomatosis, pseudomyxoma peritonei, and mesothelioma, including a section on cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. In addition, primary malignant disease of the retroperitoneum is discussed, with particular emphasis on retroperitoneal sarcomas.

This review contains 9 figures, 3 tables, and 33 references.

Key words: hyperthermic intraperitoneal chemotherapy, peritoneal carcinomatosis, peritoneal malignancy, peritoneal mesothelioma, peritoneal metastasis, peritoneal tumors, pseudomyxoma peritonei, retroperitoneal malignancy, retroperitoneal sarcoma

Diet advancement after bariatric surgery has not been standardized across various bariatric programs. It is generally agreed that patients should advance through a textured progression while the gastrointestinal tract heals; however, the content of each diet stage is open for interpretation. The postoperative diet is intended to promote healing and weight loss while minimizing diet-related complications. This review presents the literature regarding the progression of patients through a postoperative bariatric surgery diet, macro- and micronutrient needs in the early postoperative period, and management of common diet-related complications, including nausea, dumping syndrome, gastroesophageal reflux disease, and defecatory dysfunction.

This review contains 5 tables and 45 references

Key words: Bariatric surgery, bariatric surgery diet, postoperative diet, macro-nutrient needs, micro-nutrient needs, diet-related complications

Although constipation is no longer treated primarily with surgery, surgeons continue to regularly see patients with constipation in ward and ambulatory settings. It is therefore critical that surgeons have a practical approach to the patient with constipation in respect of diagnosis, investigation, and management. This review covers background knowledge in terms of the definition, classification, epidemiology, and etiology of constipation. It then addresses the clinical evaluation and investigation of the patient with chronic constipation. A subsequent review follows on to cover medical and surgical management.

This review contains 6 figures, 8 tables and 59 references

Key Words: chronic constipation, constipation, defecation disorder, defecography, dyssynergia, intussusception, manometry, proctography, rectocele, slow-transit

This review follows the general review entitled “Constipation,” which introduced the definition, classification, epidemiology, etiology, clinical evaluation, and investigation of constipation. This review addresses the medical and surgical management of constipation with a focus on surgical management. The latter is a subject of much controversy, and this review aims to provide a balanced view between those who favor radical surgery for the colon (colectomy) and rectum/pelvic floor (forms of rectopexy, rectal excision, and reinforcement) and those who have concerns that the unpredictable outcomes of such procedures push the risk–benefit analysis against surgical intervention for most patients.

This review contains 5 figures, 2 tables and 80 references

Key Words: chronic constipation, colectomy, constipation, ileorectal, intussusception, pelvic floor, rectocele, rectocele repair, rectopexy, slow-transit, stapled transanal rectal resection

Minimally invasive approaches for liver surgery are being increasingly used at highly specialized centers. Both laparoscopic and robotic techniques appear to be associated with improved short-term outcomes such as decreased morbidity and shorter hospital stay. However, there are still concerns with regard to cost-effectiveness and technical training that have prevented widespread dissemination of these techniques. Within the realm of liver surgery, laparoscopic approaches have gained acceptance; however, robotic surgery still remains a relatively new technique. This chapter discusses the preoperative considerations and operative techniques of minimally invasive liver surgery, while also reviewing the current literature detailing short-term and long-term outcomes.

This review contains 6 figures, 5 tables and 33 references

Key Words: clinical trials, laparoscopic, liver cancer, minimally invasive, morbidity, mortality, oncologic outcomes, open, robot-assisted,

Minimally invasive approaches for pancreatic resections are being increasingly utilized at highly specialized centers. Both laparoscopic and robotic techniques appear to be associated with improved short-term outcomes such as decreased morbidity and shorter hospital stay. However, there are still concerns with regards to cost-effectiveness and technical training, which have prevented widespread dissemination of these techniques. For pancreatic surgery, both laparoscopic and robotic techniques have gained acceptance for all pancreatic resections, most notably in distal pancreatectomy where minimally invasive approaches have become the standard of care at high-volume centers. This chapter discusses the preoperative considerations and operative techniques of minimally invasive pancreatic surgery while also reviewing the current literature detailing short-term and long-term outcomes.

This review contains 46 references, 6 figures, 5 tables, and 2 videos.

Key Words: clinical trials, laparoscopic, minimally invasive, morbidity, mortality, oncologic outcomes, open, pancreatic cancer, robot-assisted

The management of symptomatic hemorrhoidal disease is based on the severity of symptoms and preexisting medical conditions that may preclude one treatment option over another. The majority of patients can be managed in the office setting with nonexcisional methods including injection sclerotherapy, rubber band ligation, and infrared coagulation. The small percentage of patients that fail this management warrant evaluation for surgical excisional hemorrhoidectomy. In recent years, newer techniques such as advanced energy devices for excision, circular stapled hemorrhoidopexy, and Doppler-guided hemorrhoidal artery ligation have been introduced. The purported advantage of these device-driven surgical options is similar efficacy with less pain. Unfortunately, although there are proponents for each approach, the device costs remain problematic, and the outcome improvement has been limited, especially in terms of long-term efficacy. Surgeons are urged to learn the standard techniques so that they can assess the newer options for themselves.

This review contains 9 figures, 4 tables, and 71 references.

Key Words: bipolar diathermy, direct current electrocautery, Doppler-guided hemorrhoidal artery ligation, excisional hemorrhoidectomy, harmonic, infrared coagulation, LigaSure, rubber band ligation, stapled hemorrhoidopexy

Tumors in the liver arise from either the underlying hepatic parenchyma, resulting in benign or malignant lesions, or as metastatic deposit from extrahepatic malignancies. Treatment of these tumors is complex and requires a careful clinical evaluation. Recent improvement in diagnostic imaging techniques and reporting facilitates for appropriate characterization of hepatic tumors. In addition, utilization of genetics allows for careful classification of malignant potential in certain hepatic tumors. This chapter discusses several different types of hepatic tumors and examines the underlying etiologies, clinical presentation, diagnostic studies, staging, treatment, and prognosis. The staging of the malignant lesions is updated to reflect the American Joint Committee on Cancer’s eighth edition system.

This review contains 7 figures, 4 tables and 82 references.

Key Words: Barcelona Clinic Liver Cancer system, CAPOX, future liver remnant volume, FOLFOX, LI-RADS, stereotactic body radiation therapy, transarterial chemoembolization, transarterial radioembolization, β-catenin

Since the beginning of the 1970s, flexible endoscopy of the gastrointestinal tract has been the dominant modality for the diagnosis of gastrointestinal disease. Over the same period, developments in technology and methodology have made possible the use of endos-copy to treat a host of conditions that once were considered to be manageable only by means of surgical intervention. The concept of performing endoscopic surgery has become a reality with the advancement of endoscopic therapies to control hemorrhage and perform mucosal ablations, resections, and tissue approximation. In addition, investigation into intra-abdominal interventions has begun with the progression of natural orifice transluminal endoscopic surgery (NOTES). The tools created for both intraluminal and transluminal procedures will allow the endoscopist to continue to supplant surgical therapies for numerous gastrointestinal diseases. The integration of flexible endoscopic techniques into the armamentarium of the gastrointestinal surgeon permits a more multidi-mensional approach to the treatment of digestive system disorders. The modern surgeon must continue to stay abreast of these en-doscopic advances to provide appropriate patient care.

This review contains 12 figures, 2 tables, and 21 references.

Key words: optical biopsy, chromoendoscopy, over the scope clips, endoscopic suturing techniques

Advanced endoscopy techniques use the same principles as basic upper endoscopy but involve more complex maneuvers and additional imaging modalities. Most endoscopists after mastering basic upper endoscopy will pursue additional training to become adept with advanced endoscopy techniques. This chapter reviews these techniques.

This review contains 9 images, 8 tables, 1 video and 26 references.

Key words: endoscopic submucosal dissection, organ sparing endoscopic surgery, submucosal tunneling endoscopic resection, endoluminal bariatric procedures, over the scope clips, endoscopic suturing techniques, endoluminal lumen apposing metal stents

Diverticulitis is the cause of 300,000 inpatient admissions in the United States each year. Surgical evaluation and treatment are commonly required for the treatment of diverticulitis. This chapter discusses the diagnosis, triage, and treatment of acute diverticulitis. Medical treatment, as well as the indications for surgical treatment for diverticulitis, is discussed. Current controversies, including the need for antibiotics for a patient with acute uncomplicated diverticulitis, necessity of colonoscopy after resolution of an acute episode, and indications for urgent surgery, are reviewed.

 This review contains 10 figures, 3 tables, and 67 references.

keywords: acute diverticulitis, colonic fistula, complicated diverticulitis, diverticular abscess, diverticular disease, diverticulitis, diverticulosis, perforated diverticulitis, uncomplicated diverticulitis

Diverticulitis in certain subpopulations of patients may require different treatments, especially in the elective setting. Diverticular bleeding, another complication of diverticulosis, is another source of burden on United States healthcare from diverticular disease. This chapter discusses the special circumstances of right-sided diverticulitis, diverticulitis in young patients or immunocompromised patients, recurrent diverticulitis after resection, giant colonic diverticulum, and rare presentations of diverticulitis. Atypical types of diverticulitis such as segmental colitis associated with diverticulosis (SCAD), symptomatic uncomplicated diverticular disease (SUDD), and smoldering diverticulitis are also reviewed, and indications for surgical intervention are summarized. Current controversies are reviewed, including the decision to operate in young or immunocompromised patients; management of SCAD, SUDD, or smoldering diverticulitis; and best localization method to diagnose diverticular bleeding.

This review contains 6 figures, 2 tables, and 55 references.

Key Words: atypical diverticulitis, diverticular bleeding, diverticular disease, diverticulosis, gastrointestinal bleeding, right-sided diverticulitis, segmental colitis associated with diverticulosis, smoldering diverticulitis, symptomatic uncomplicated diverticular disease, total abdominal colectomy

Surgical evaluation and treatment is commonly required for the treatment of diverticulitis in both the acute and elective situations. This chapter discusses the surgical treatment of the clinically important manifestations of diverticular disease. Different options for surgical treatment are described for patients in both the urgent and elective settings, including technical aspects of these options. Current controversies are reviewed, including resection versus laparoscopic lavage for the treatment of purulent peritonitis, the use of gastrointestinal diversion in the surgical treatment of acute diverticulitis, and timing of operation for recurrent diverticulitis.

 This review contains 8 figures, 4 tables, and 67 references.

Key Words: acute diverticulitis, complicated diverticulitis, diverticular disease, diverticulitis, diverticulosis, Hartmann procedure, laparoscopic lavage, sigmoid resection with primary anastomosis, uncomplicated diverticulitis

Biliary tract tumors are derived from the underlying intrahepatic or extrahepatic biliary epithelium. Molecular analysis of the biliary neoplasms suggests a stepwise tumor progression from benign to malignant lesions. Treatment of these tumors remains complex and requires a careful clinical evaluation. Revisions of staging systems allow for appropriate evaluation of the extent of the malignancy. Refined surgical techniques and advances in adjuvant therapies provide improved treatment options. Despite these efforts, the prognosis remains poor. This chapter discusses several different types of biliary tumors, including the gallbladder carcinoma, and examines the underlying etiologies, clinical presentation, diagnostic studies, staging, treatment, and prognosis. The staging of the malignant lesions is updated to reflect the American Joint Committee on Cancer’s eighth edition system.

This review contains 7 figures, 5 tables, and 77 references.

Key Words: α-fetoprotein, American Joint Committee on Cancer, biliary intraepithelial neoplasia, Bismuth-Corlette, CA19-9, cystadenoma, endoscopic retrograde cholangiopancreatography, intraductal papillary neoplasm of the bile duct, Magnetic resonance cholangiopancreatography, primary sclerosing cholangitis, percutaneous transhepatic cholangiography

Rectal prolapse is the full thickness intussusception of the rectal wall with protrusion out of the anus.  It is a benign condition associated with multiple anatomic abnormalities such as a redundant sigmoid colon, attenuation of sacral attachments, diastasis of the levators, a patulous anus, and a deep cul-de-sac.  It often presents with concomitant symptoms of fecal incontinence and constipation, or both.  In this review, we will discuss widely accepted abdominal procedures for the repair of rectal prolapse as well as advances in the arena.  Pre-operative evaluation, management and planning as well as perineal procedures are discussed in a separate review.

This review contains 9 figures, 1 table, and 44 references. 

Key Words:  Rectal prolapse, abdominal procedures, resection, rectopexy, mesh, laparoscopic, robotic

Rectal prolapse is a condition wherein a full thickness intussusception of the rectal wall protrudes out of the anus. The diagnosis is rare, ~ 0.5% of the population, and occurs most often in elderly females. The diagnosis is associated with constipation, fecal incontinence, or both. The repair of rectal prolapse can be divided into perineal and abdominal procedures. In this review, we will discuss preoperative evaluation, management and planning as well as describe key widely accepted perineal procedures, the Delorme and Altemeier, and report recent advances. Abdominal procedure and advances in that arena will be discussed in a separate review.

This review contains 9 figures, 7 tables, and 32 references. 

Key words: Rectal prolapse, perineal procedure, resection, Altemeier, Delorme, Thiersch wire, perineal stapled resection, levatoroplasty