It is appropriate that a surgical teacher. Robert E. Hermann. M.D . . with a large experience in a specialized field should author the beautifully il lustrated Manual of StlrRery of the Gallbladder. Bile Ducts. and Exocrine Pancreas. This manual. which takes its place in the distinguished series sponsored by RiChard H. Egdahl, M.D . . is designed for the working sur geon. resident or practitioner. who wishes to refresh his memory or to bring himself abreast of current thinking and technics. The carefully planned format and the elegant color illustrations of Mr. Robert Reed per mit this with the expenditure of a minimum of time and effort. and sur geons who must operate on the organs and structures it covers will wish to have it available for reference. Stanley O. Hoerr. M.D. former Chairman. Division of Surgery Cleveland Clinic Chairman. Department of Surgery Fairview General Hospital Cleveland. Ohio Preface Operations on the gallbladder and bile ducts are among the surgical proce dures most commonly performed by general surgeons. In most hospitals, cholecystectomy is the most frequently performed operation within the ab domen; approximately 6()(), OOO are performed each year in the United States. In addition, an estimated 120,000 bile duct operations are performed yearly. Pancreatic surgery is less frequent, but because of the close relation between the biliary system and the pancreas, knowledge of pancreatic problems is equally essential to the surgeon.

For a long time, approximately since Oberlin and Guerin described the multifocal origin of pancreatic cancers and precancerous pancreatic lesions, no important study dealing with the entire subject of pancreatic cancer has been published in France and probably in the international literature. For some decades the knowl edge acquired 40years or more ago was not improved appreciably, though the fre quency ofthe disease started to increase in occidental countries. This has recently changed, and the progress ofthe medical sciences has spread to the pancreas. Although the surgical or medical prognosis of the most frequent form of pancreatic cancer, exocrine adenocarcinoma, remains very bad, recent studies have shown the multiplicityofits pathological forms, some being less severe so that curative surgery is possible. New experimental models, particularly in the hamster, and the use of carcinogenic drugs allow experimental studies on lesions similar to those in man. Oncologic immunology is still at its beginnings but shows promise for diagnosis and treatment. Though modem techniques of imaging sonography, aspirative cytology, CT scan, endoscopic catheterism, arteriography, and maybe in the future nuclear magnetic resonance - have not yet significantly in fluenced prognosis, they have made the diagnosis easierand more precocious. Yet in a diseasethat diffuses so rapidly to deep lymph nodes, it has not been proved whether early diagnosis can improve prognosis.

First multi-year cumulation covers six years: 1965-70.

As research in liver disease has greatly expanded over the past few decades the etiology, pathology, and natural history of many hepatic disorders have been clearly defined. Many new and accurate diagnostic tools are now available. In spite of all this progress the treatment of many liver diseases remains ameliorative. Nevertheless a more aggressive and successful surgical approach has taken place in regard to many diseases of the liver in part due to the pioneering work of Dr. William P. Longmire, Jr. and his colleagues. Dr. Longmire was among the early advocates of liver resection of neoplasms, successfully remov ing a large benign tumor of the liver in 1946. In the following decades his contributions covered the surgical treatment of trauma, tumors, cysts, and other congenital abnormalities. He has performed hundreds of operations on patients with these disorders. In 1948 he reported a procedure now named for him, in which intractable common duct obstruction was relieved by partial left hepatectomy and cholan giojejunostomy. He was one of the first to advocate side-to-side portacaval shunt for portal hypertension. Other essential contributions by this master surgeon were the periodic reviews that covered the advances in his field. Dr. Longmire, with his scholarly approach and broad background of knowl edge in all aspects of hepatic surgery, is exceptionally qualified to write this book. He and his colleague, Dr. Ronald K. Tompkins, are to be congratulated on this complete treatise.

The Manual of Pulmonary Surgery has been designed primarily as a guide to the techniques of surgery on the lungs of adults and older children. The information included and the technical points stressed are those in which, in more than 20 years of teaching thoracic surgery, I have found residents to most commonly need instruction. An effort has been made to depict the usual anatomy of the lung and its more frequent variations, as it is encountered by the surgeon. This was necessary because a detailed description of pulmonary anatomy is not readily available. The excellent monograph on Segmental Anat omy of the Lung by Professor Edward Boyden, one of my teachers, is no longer in print. The techniques illustrated are those preferred by the author; no attempt has been made to describe all of the possible variations. Deanne McKeown has illustrated the entire book. Her drawings of the procedures are based on sketches or photographs made in the operating room. The use of full color illustrations to emphasize important technical or anatomical detail adds to the ease of understanding the text. A section on the indications for pulmonary resection that contains the information commonly used for surgical decision-making has been included.

The first hospital-affiliated surgical unit designed specifically for ambulatory surgery in the state of California began functioning as part of Santa Barbara Cottage Hospital in 1973. As this text is readied for publication, the unit is in its tenth year of operation. More than 20,000 patients have undergone surgery there. The enthusiasm generated by ~\ir experience in Santa Barbara, along with the widespread, growing interest in ambulatory surgery, prompted us to undertake this volume. The first three chapters cover principles and administrative aspects, an esthesiology, and nursing in the ambulatory surgical center. Subsequent chap ters, the major portion of the text, provide detailed, meticulously illustrated descriptions of surgical procedures as they are done in the Santa Barbara Cottage Hospital Outpatient Surgical Center by the surgeons who work there. They reflect current practice and emphasize the techniques found most reliable by the surgeons who use them in the outpatient setting. This manual includes many of the operations most commonly performed in our facility and emphasizes the unique aspects of surgery and patient care in outpatient practice. The text is concise, practical, and based on our collective experience. The illustrations are, for the most part, drawn from the surgeon's perspective and faithfully render the actual appearance of the operative field during surgery. Supplementary cross-sectional and conceptual drawings are included to orient the reader.

Introduction Anthony J. Edis, Richard H. Egdahl, Tracy K. Mcintosh, Contents Lester F. Williams xi 1 Surgery of the Parathyroids General Introduction 1 SURGICAL ANATOMY Primary Hyperparathyroidism 7 PATHOLOGY 7 DIAGNOSIS 11 PREOPERATIVE LOCALIZATION STUDIES 22 TREATMENT 27 Secondary Hyperparathyroidism 35 SIGNS, SYMPTOMS, COMPLICATIONS 35 CLINICAL MANAGEMENT 36 Tertiary Hyperparathyroidism 37 Operative Technique 38 CERVICAL EXPLORATION WITH REMOVAL OF A PARATHYROID ADENOMA 46 SUBTOTAL PARATHYROIDECTOMY FOR HYPERPLASIA 59 PARATHYROIDECTOMY FOR CARCINOMA 60 MEDIASTINAL EXPLORATION FOR PARATHYROID TUMOR 61 References 66 2 Surgery of the Thyroid 71 General Introduction 71 SURGICAL ANATOMY 72 Nodular Goiter and Thyroid Carcinoma 79 PATHOLOGY 79 DIAGNOSIS 82 TREATMENT OF THYROID NODULES 94 TREATMENT OF THYROID CANCER RELATED TO PATHOLOGIC TYPE 97 Hyperthyroidism 110 Graves' Disease 111 PATHOLOGY 111 DIAGNOSIS 112 TREATMENT 115 Plummer's Disease 120 PATHOLOGY 120 DIAGNOSIS 120 TREATMENT 122 Complications of Thyroid Surgery 123 PREVENTION AND MANAGEMENT 123 viii CONTENTS 127 Operative Techniques TOTAL THYROID LOBECTOMY 127 REMOVAL OF A SUBSTERNAL GOITER 134 SUBTOTAL THYROID LOBECTOMY 136 MODIFIED NECK DISSECTION FOR PAPILLARY THYROID CARCINOMA 141 References 144 3 Surgery of the Adrenals 151 151 General Introduction SURGICAL ANATOMY 152 Pheochromocytoma 155 PATHOLOGY 155 156 DIAGNOSIS PREOPERATIVE 162 TREATMENT 166 172 Primary Aldosteronism PATHOLOGY 172 DIAGNOSIS 174 178 PREOPERATIVE LOCALIZATION STUDIES TREATMENT 180 Cushing's Syndrome 181 CLASSIFICATION 182 DIAGNOSIS 187 PREOPERATIVE LOCALIZATION STUDIES 192 TREATMENT 194 Adrenal Gland and Metastatic Breast Carcinoma 198 Adrenocortical Carcinoma 200 DIAGNOSIS 201 PREOPERATIVE LOCALIZATION STUDIES AND STAGING 201 TREATMENT 202 PROGNOSIS 203 Nonfunctioning Adrenal Tumors 203

Initially we asked Springer-Verlag why they thought the world needed another book about aesthetic surgery. They pointed to the popularity of the Compre hensive Manual of Surgical Specialties Series, suggesting that completeness required our contribution. We recalled the current masters of aesthetic surgery: Rees, Sheen, among others. Each had produced his own monograph-all of them established classics. What could we add? Furthermore none of us was recognized exclusively for aesthetic surgery achievements. Nevertheless, each of us was committed to the challenge of teaching residents aesthetic surgery during their residency, not afterward as was done in the past. Furthermore, Dick Egdahl, Senior Editor and designer of CMSS, made clear to us the specific orientation of the manuals to residents-in-training. as did Springer-Verlag, well known for their commitment He won our support, to high-quality color illustrations. We appreciate being asked by Dr. Egdahl to contribute to CMSS. We were not even offended by his original plan to embrace all of plastic surgery in one volume. He should have known better! The Manual of Reconstructive Surgery will follow this volume in 2 years. Defining its scope remains an unmet challenge. Limiting the scope of Manual of Aesthetic Surgery has been an easier task. It is a sourcebook for beginning residents, not an encyclopedic reference.

for a significant portion of the new information in this book. His ability to select the important developments from the literature of the last five years was essential to the completion of this second edition. Further, Dr. Stone's original research on wounds and sutures is included in this volume. Dr. Felix Rutledge and Dr. Laman Gray, Sr., in addition to all the named authors, made valuable comments. Their years of experience were especially helpful in updating the chapters on ovarian surgery and vaginal hysterectomy. My personal Administrative Assistant, Elizabeth Davies, successfully coor dinated my various clinical schedules, speaking engagements and department obligations, providing me the time necessary for writing this book. The advice and support of Jerry Stone, Senior Medical Editor, Springer Verlag, also were invaluable in the production of this edition. Lastly, one of our team became ill while we were preparing this book and subsequently died of a rare malignancy. Her outstanding work while with us and her continued interest and encouragement, even though quite of us. Mrs. Sue Koenig was a bright, competent ill, was an inspiration to all and effective co-worker whom is missed by all of us in the Department of Obstetrics and Gynecology at the University of Louisville.