A. Introduction

Contributing Authors 
Introduction
The Aetiological Sieve
The Anatomical Sieve

Contributing Authors 

Professor Eugenio Panieri 
Consultant Endocrine, Breast, Sarcoma and General Surgeon
Groote Schuur Hospital
University of Cape Town 

Professor Lydia Cairncross 
Consultant Endocrine, Breast and Sarcoma Surgeon
Groote Schuur Hospital
University of Cape Town 

Dr Adam Boutall 
Consultant Colorectal Surgeon
Groote Schuur Hospital
University of Cape Town 

Dr Marc Bernon 
Consultant Hepato-Billiary and Pancreatic Surgeon
Groote Schuur Hospital
University of Cape Town 

Dr Francois Malherbe 
Consultant Breast and Endocrine Surgeon
Groote Schuur Hospital
University of Cape Town 

Introduction

Most junior doctors in South Africa and in many developing countries are expected to manage surgical patients in stressful, compromised circumstances, with little senior supervision and guidance. This is the reality. It is confronting and disheartening. Surgery is a hard, unpredictable job, and the feeling of helpless isolation, when surrounded by acutely ill patients is one that many of us are familiar with or remember vividly. 

The purpose of this book is to provide a guide to the evaluation of common surgical problems - particularly those that present at odd hours, and test diagnostic and troubleshooting skills when there is no-one else to help or to ask for advice, and special investigations and fancy tests are not available. 

So, first of all, you must always apply your mind to what the clinical diagnosis may be. To do this, you must be inquisitive, interested, persistent and driven to make a diagnosis and to resolve your patient's problem - a half-baked clinical assessment followed by a battery of tests and scans is a poor way to practice, may be frankly dangerous, and is for the intellectually destitute. 

To be a competent surgeon you have to be a good, thorough diagnostician: this can only be done by taking a comprehensive, insightful history, followed by a proper clinical examination of the patient - nothing can replace the fundamental value of this. 

A proper clinical evaluation is always driven by thinking about what the likely differential diagnosis is for any given complaint - thus your working algorithm is: 

• What is the core complaint/ symptom and what could be causing this? 
  • What other symptoms are associated with this? 
  • What are the precipitating factors/ predisposing conditions? 
  • Are there other symptoms on systemic enquiry 
  • How fit is this patient, if we need to operate? 
• Do a proper clinical examination 
• Formulate a working differential diagnosis 
  • what are the most common diagnoses? 
  • what is a rare diagnosis that you don’t want to miss? 
• Request tests (or not!) to confirm or disprove your diagnosis, and some tests to evaluate the patient’s fitness for surgery, if this is necessary 
• Treat the illness that you have diagnosed 

We have chosen common clinical problems that almost all junior doctors will face when working in surgery. Most of them are surgical emergencies, but some will present to you in an outpatient clinic, and others in the ward. 

Some topics lend themselves to some therapeutic discussion, whilst others are too broad to enter into details; there are many excellent, comprehensive surgical textbooks and online resources that will help you in these situations. Use this book in conjunction with these resources, specifically with regards to understanding the pathophysiological processes, and the many varied therapeutic processes that follow. 

Each chapter is deliberately short and consists of our opinion about key differential diagnoses, evaluation algorithms, with some selected images, and hints and suggestions. 

We emphasize what are the most likely diagnoses, and which rare ones are dangerous to miss, rather than give you an exhaustive list of weird possibilities. 

In cases of uncertainty, it is helpful to use a systematic approach to the possibilities, using one of the two classical “Surgical Sieves”- these will give you a comprehensive list, but it is your local knowledge and experience that will guide you which of these are the most likely causes of the complaints facing you. 

The Aetiological Sieve

• Congenital
• Acquired
  • Traumatic
  • Inflammatory (physical, chemical, infective)
  • Neoplastic (benign or malignant, primary or secondary)
  • Circulatory / Vascular
  • Autoimmune
  • Nutritional / Metabolic
  • Endocrine
  • Drugs / Iatrogenic
  • Degenerative
  • Psychosomatic

The Anatomical Sieve

This is helpful to consider pathologies given the anatomical site of the symptoms / and or clinical signs; i.e. an abdominal “lump” may arise from:

• Skin
• Subcutaneous tissues
• Muscular
• Adjacent joints
• Underlying visceral organs
• Lymphatic structures
• Vascular structures
• Bones

Our aim is not to produce a comprehensive textbook of surgery. We have noticed there is a paucity of clinically driven books and guidelines of surgical diagnoses - and we want to fill this gap, and specifically give it South African, and developing world relevance. If you are a medical student, these topics will guide you to put surgical conditions in context - but this is just the tip of iceberg knowledge.