The Manual of Upper Gastrointestinal Surgery was compiled as an aid to surgeons, residents, and students who want to acquire a broader knowl edge of the surgical techniques used in the upper gastrointestinal area. Of necessity, a considerable amount of the work of a general surgeon will be confined to this region. The techniques described herein are those preferred by the authors and most, but not all, of their colleagues at the Mayo Clinic. No attempt has been made to include all of the available possibilities and technical varia tions. Likewise, no attempt has been made to include many of the stapling techniques. Although they are good and quite useful, their inclusion would require a complete and separate volume. The omission of an accepted procedure is not meant as a criticism; our aim was to emphasize only the techniques that are most commonly used in day-to-day practice. Gains in knowledge about the anatomy and physiology of the esopha gus, stomach, and duodenum have been highly instrumental in the devel opment of surgical procedures in these areas, particularly the techniques for benign diseases (for example, ulcer, gastritis, and esophagitis).

The surgeon who desires an atlas of techniques covering operations on the colon and rectum almost surely prefers a concise volume rather than an encyclopedic compilation of the innumerable procedures that have been described in the literature. This book includes the operations that have proved to be useful and have survived the test of time. They now are in general use in the Massachusetts General Hospital. Space limitations have necessitated exclusion of detailed illustrations of a number of infrequently performed procedures, such as pelvic exenter ation for cancer of the rectum. In such instances bibliographic references have been provided for ready reference. The bibliography emphasizes recent contributions because they are easily available to the reader. Critical comments by the authors concerning certain technical pro cedures may be due to personal bias and certainly do not imply that the alternative methods are undesirable. Furthermore, the brevity of discus sion of anatomy, physiology, and pathology and the neglect of details of medical therapy of numerous colorectal diseases must be attributed to the fact that this volume is directed primarily toward the practicing surgeon. Thanks are due to the artists Mrs. Edith Tagrin and Mr. Robert Galla, and to Miss Evelyn Hall for help in the preparation of the manuscript. Claude E. Welch, M.D. Leslie W. Ottinger, M.D. John P. Welch, M.D. .

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.

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

The Mallila/ qf Gyn('c%Ric SurRery is a comprehensive guide for opera tive decision-making and technique in female pelvic surgery. For a wide array of problems requiring surgical intervention, this volume examines the anatomy, preoperative evaluation, surgical strategy, details of tech nique, postoperative management, and anticipated results. The manage ment of operative complications and injuries to bowel, urinary system, and pelvic vessels is discussed. This volume is divided into three sections: ambulatory, vaginal, and abdominal surgery. The ambulatory section will be particularly useful to the family physician. The abdominal section explains complication man agement for the gynecologist whose surgical background may not include gastrointestinal or urinary tract surgery.. The section on ovarian surgery contains additional data for the general surgeon who may encounter unexpected ovarian lesions. Although the book should be most useful to gynecologic residents-in-training and practicing gynecologists, it will also be of use to general surgeons who perform gynecologic operations and to all physicians who perform ambulatory gynecologic procedures. The operative techniques depicted are currently used procedures based on the newer concepts of wound healing and suturing, utilizing mod ern surgical instrumentation. When several techniques are available, the author's personal preference is described. This book, which was produced by the project manager system, rep resents the efforts of 21 persons in three cities. Christine G. Williamson managed the project with drive, understanding, and skill. She was responsi ble also for coordinating information retrieval, organizing the chapters, and editing the text.

The color photographs and illustrations appearing in select monographs over the past decade represent a significant advance in surgical commu nication. Previously, black and white renderings were standard because color printing had not been perfected and its cost was prohibitive. We be lieve the gradual change from black and white etchings and reproductions to detailed color illustrations represents a tremendous twentieth century achievement. In our own urologic practices it became evident that the use of black and white sketches for teaching operative urology, while helpful, left too much to the surgeon's imagination. Even the dimension of depth, produced by varying the intensity of shading, often was inadequate in demonstrat ing subtle surgical details in a fossa or bed. Since color photography recently has been used to demonstrate oper ative techniques, we climbed on the bandwagon and photographed in color many of the major operative procedures. However, the reflection of light caused by normal tissue fluid significantly reduces the clarity of photo graphs. Not infrequently, the crucial operative step is obscured by light reflected on a trickle of blood. Even when meticulous care is taken to ir rigate and clean the surgical field, the tissue sheen obscures portions of the field. Color paintings by a gifted artist are not only unique, but can be extraordinary; the vividness with which subtleties can thus be portrayed cannot be matched by photography, black and white or color.

This manual is intended as a comprehensive guide to the diagno sis and management of the burn patient. The author:s feel that this volume can serve as a practical reference for the wide range of physi cian and allied health personnel involved in the care of these critically ill patients. The Manual of Burns was planned and written by the authors when they were on staff together at the United States Army Institute of Surgical Research, Brooke Army Medical Center, Fort Sam Houston, Texas. The authors support the concept that appropriate therapy of the burn patient requires a multidisciplinary approach. The talents of physi cians from many medical specialties, supported by nurses, therapists, and other allied health science personnel, must be coordinated if such a patient is to receive optimum care. Although the main thrust of this manual is directed at current techniques of diagnosis and treatment and therefore of primary inter est to the physician, the authors also hope that the photographic and illustrative material will make this book useful to any member perform ing service in a burn treatment unit.

Of all the developing fields of surgery, few have had the impact of vascular surgery in affecting so large a segment of the population with its potential for relief of disability or the prolongation of life. As would be anticipated, the interest of surgeons in this evolving specialty has been largely focused upon the selection of the most appropriate operations and the development of modifications or new procedures to overcome the limitations of previous ones. The literature contains numerous conflicting claims on the relative merits of various procedures. Those approaching this field for the first time may understandably be confused. Yet, if one were to approach any single vascular surgeon at any given time, he would, upon request, receive a firm and precise listing of preferred procedures. The procedures described in this two-volume publication are those which we currently favor. Their selection is the result of continuing anal ysis of our own experience of the last 25 years. All patients have been available for prolonged follow-up evaluation. Late failures often identified techniques that lessened the durability of initially satisfactory operations and stimulated the development of modifications or trials with alternate op erations. Particular attention is directed here to the manner in which knowledge of the natural history of disease influences the choice of opera tion.

Of all the developing fields of surgery, few have had the impact of vascular surgery in affecting so large a section of the population by offering the potential relief of disability and the prolongation of life. As would be anticipated, the interest of surgeons in this evolving specialty has largely been focused upon the selection of the most appropriate operations and the development of modifi cations or new procedures that overcome the limitations of previous ones. The literature contains numerous conflicting claims about the relative merits of various procedures, and those aPlJoaching this field for the first time may understandably be confused. Yet, if one were to approach any single vascular surgeon at any given time, he would upon request be given a firm and precise listing of preferred procedures. The procedures described in this two-volume publication are those that we currently favor. Their selection is the result of continuing analyses of our own experience during the past 30 years. All patients have been available for prolonged follow-up evaluation. Late failures often helped us to identify techniques that lessened the durability of an initially satisfactory operation, and they became a stimulus for the development of modifications or trials with alternative operations. Particular attention is directed to the manner in which knowledge of the natural history of disease influences the choice of operations.