Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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ATLAS OF GENERAL SURGICAL TECHNIQUES ISBN: 978-0-7216-0398-8

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Library of Congress Cataloging-in-Publication Data

Atlas of general surgical techniques / [edited by] Courtney M. Townsend Jr., B. Mark Evers. -- 1st ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-7216-0398-8 (hardcover : alk. paper) 1. Surgery--Atlases. I. Townsend, Courtney M. II.

Evers, B. Mark, 1957-

[DNLM: 1. Surgical Procedures, Operative--methods--Atlases. WO 517 A8797 2010]

RD41.A782 2010

617.0022’3--dc22

2009049217

Acquisitions Editor: Judith Fletcher

Developmental Editor: Kristina Oberle

Publishing Services Manager: Julie Eddy

Senior Project Manager: Laura Loveall

Design Direction: Louis Forgione

Artwork: Michael A. Cooley

Mike de la Flor

Peggy Firth

Victoria Heim

Alexandra Hernandez

Lauren Shavell

Jennifer Smith

Gina Urwin

Electronic Publishing Services Inc., NYC

Printed in the United States

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Carlos A. Angel, MD, FACS

Associate Professor

Department of Surgery

University of Missouri—Columbia

Columbia, Missouri

Valerie P. Bauer, MD

Assistant Professor

Department of Surgery

The University of Texas Medical Branch

Galveston, Texas

Edward Y. H. Chan, MD

Surgical Resident

Department of Surgery

Mount Sinai School of Medicine

New York, New York

Celia Chao, MD

Assistant Professor

Department of Surgery

The University of Texas Medical Branch

Galveston, Texas

Charlie C. Cheng, MD

Assistant Professor

Department of Vascular Surgery

The University of Texas Medical Branch

Galvaston, Texas;

Assistant Professor

Department of Vascular Surgery

Mainland Medical Center

Texas City, Texas

Dai H. Chung, MD

Professor and Vice-Chair

Department of Pediatric Surgery

Vanderbilt University Medical Center

Nashville, Tennessee

Concepcion Diaz-Arrastia, MD

Associate Professor and Director

Division of Gynecologic Oncology

Department of Obstetrics and Gynecology

Baylor College of Medicine

Houston, Texas

B. Mark Evers, MD

Director, Lucille P. Markey Cancer Center;

Professor and Vice-Chair for Research

University of Kentucky Department of Surgery;

Markey Cancer Center Director Chair;

Physician-in-Chief, Oncology Service Line

University of Kentucky Healthcare

Markey Cancer Center

Lexington, Kentucky

James J. Gallagher, MD

Assistant Professor of Surgery

Department of Surgery

Weill Medical College;

Assistant Attending Surgeon

Department of Surgery

New York Presbyterian Hospital

New York, New York

Dennis C. Gore, MD

Professor

Department of General Surgery

The University of Texas Medical Branch

John Seely Hospital

Galveston, Texas

Baiba J. Grube, MD, FACS

Associate Professor

Department of Surgery

Yale University School of Medicine

New Haven, Connecticut

Kristene K. Gugliuzza, MD, FACS

Professor, Departments of Surgery and Pediatrics

Alonzo Alverly Ross Centennial Chair in General

Surgery

Program Director, General Surgery Residency

Director, Kidney and Pancreas Transplant Program

in the UTMB Texas Transplant Center

Scholar, John P. McGovern Academy of Oslerian

Medicine

The University of Texas Medical Branch

Galveston, Texas

Contributors

David N. Herndon, MD

Chief of Staff

Director of Research

Shriners Hospitals for Children—Galveston;

Professor of Surgery

Jesse H. Jones Distinguished Chair in Burn Surgery

The University of Texas Medical Branch

Galveston, Texas

Glenn C. Hunter, MD, FRCSC, FACS

Professor

Department of Surgery

University of Arizona;

Staff Surgeon

Department of Surgery

Southern Arizona VA Healthcare Service

Tucson, Arizona

Margie A. Kahn, MD

Associate Professor

Department of Obstetrics and Gynecology

Tulane University School of Medicine

New Orleans, Louisiana

Lois A. Killewich, MD, PhD

Professor and Chief, ad Interim

Section of Vascular Surgery

Department of Surgery

The University of Texas Medical Branch

Galveston, Texas

Thomas D. Kimbrough, MD

Professor

Department of Surgery

The University of Texas Medical Branch

Galveston, Texas

Tien C. Ko, MD

Jack H. Mayﬁ eld, MD Distinguished Professor in

Surgery

Vice Chairman for Harris County Hospital District

The University of Texas Health Science Center at

Houston

Chief of Surgery at Lyndon B. Johnson General

Hospital

Houston, Texas

Jacqueline A. Lappin, MD, FRCSI, FACS

Assistant Professor of Surgery and Director of

Pancreas Transplantation

Department of Surgery

University of Texas Health Science Center and

Memorial Hermann Hospital;

Assistant Professor of Surgery

Department of Surgery

St. Luke’s Episcopal Hospital and Texas Children’s

Hospital

Houston, Texas

Jong O. Lee, MD

Assistant Professor

Department of Surgery

The University of Texas Medical Branch;

Staff Surgeon

Shriners Hospitals for Children—Galveston

Galveston, Texas

David B. Loran, MD

Thoracic, Vascular, and General Surgery

Meadville Medical Center

Meadville, Pennsylvania

William J. Mileski, MD, FACS

Professor

Chela and Jimmy Storm Distinguished Professor

Chief of Trauma Services

Department of Surgery

The University of Texas Medical Branch

Galveston, Texas

William H. Nealon, MD

Professor and Vice Chairman

Department of Surgery

Vanderbilt University;

Associate Surgeon-in-Chief

Department of Surgery

Vanderbilt University Hospital

Nashville, Tennessee

CONTRIBUTORS

vii

Colin D. Pero, MD

Clinical Assistant Professor

Department of Otolaryngology—Head and Neck

Surgery

University of Texas Southwestern Medical School

Dallas, Texas;

Department of Otolaryngology—Head and Neck

Surgery, Facial Plastic and Reconstructive Surgery

Baylor Regional Medical Center

Plano, Texas

Anna M. Pou, MD, FACS

Professor and Program Director

Otolaryngology—Head and Neck Surgery

Louisana State University Health Sciences Center,

New Orleans

New Orleans, Louisana

Lori Cindrick Pounds, MD, FACS RVT

Peripheral Vascular Associates

San Antonio, Texas

Taylor S. Riall, MD, PhD

Associate Professor

Department of Surgery

The University of Texas Medical Branch

Galveston, Texas

Arthur P. Sanford, MD, FACS

Associate Professor

Department of Surgery

Loyola University Medical Center

Maywood, Illinois

Michael B. Silva, Jr., MD

The Fred J. and Dorothy E. Wolma Professor of

Vascular Surgery

Professor of Radiology

Director

Texas Vascular Center;

Department of Vascular Surgery

The University of Texas Medical Branch

Galveston, Texas;

Department of Vascular Surgery

Mainland Medical Center

Texas City, Texas

Courtney M. Townsend, Jr., MD

Professor

John Woods Harris Distinguished Chairman

Department of Surgery

Robertson-Poth Distinguished Chair in General

Surgery

The Unversity of Texas Medical Branch

Galveston, Texas

Michael D. Trahan, MD

Surgeon

Martha Jefferson Surgical Associates

Charlottesville, Virginia

Kenneth J. Woodside, MD

Assistant Professor of Surgery

Division of Transplant and Hepatobiliary Surgery

Department of Surgery

University Hospitals Case Medical Center

Cleveland, Ohio

Joseph B. Zwischenberger, MD

Johnson-Wright Professor and Chairman

Department of Surgery

University of Kentucky College of Medicine

Lexington, Kentucky

CONTRIBUTORS vii

“An education in medicine involves both learning and learning how; the student cannot

effectively know, unless he knows how.”

—E

XCERPT FROM ABRAHAM FLEXNER,

“Medical Education in the United States and Canada,” 1910.

The fundamental core knowledge of general surgery remains the cornerstone of all surgical

disciplines. Over the last decades, we have witnessed a proliferation of surgical specialties. The

majority of graduating residents elect to pursue additional training in highly specialized ﬁ elds

of surgery. However, a sound foundation in general surgical techniques and principles is criti-

cal for success in these areas. Therefore, an atlas describing common general surgical proce-

dures in a clear and concise fashion is an essential complement to current surgical textbooks

to ensure that the student not only “learns how” but, most importantly, “knows how.” With

that said, putting together a surgical atlas is a daunting challenge. Coordinating schedules of

busy surgeons and medical illustrators is, at times, akin to herding cats. So, why expend the

time and effort to put this together?

For one, we have been privileged to edit the Sabiston Textbook of Surgery for the last three

editions. This text provides a comprehensive compendium on the physiology, diagnosis, and

treatment of surgical diseases, yet we are limited in the ability to describe the operative proce-

dures in any detail. A good textbook must provide the basic knowledge to ensure that the

student “learns” the material. However, it is vastly different from an atlas which teaches the

student “how.” Textbooks that have tried to be a comprehensive text as well as an atlas have

usually failed on both accounts. Therefore, this surgical atlas series provides an important and

necessary complement to the Sabiston Textbook of Surgery (Saunders).

The illustrations have been meticulously drawn by medical illustrators who share the same

philosophy of art design. Illustrations are drawn in detail from the perspective of the operat-

ing surgeon, yet the drawings are simple enough that the reader is not distracted with extrane-

ous colors or overly complicated design. The essential steps of the procedure are illustrated

with an emphasis on surgical anatomy. Each concludes with three to ﬁ ve “pearls” or pitfalls

from master surgeons with years of experience. Recognizing that many general surgical proce-

dures are now performed laparoscopically, we have illustrated steps of both the open and the

minimally invasive techniques where applicable. Except for the approach and the instruments,

the basic tenets of the dissection and attention to detail are common to both techniques.

Finally, we were inspired to produce this atlas series based on our interactions over the

years with numerous talented and hard-working surgical residents who need a concise refer-

ence to study and review prior to entering the operative suite. This atlas is meant to provide

these trainees with the essential steps in performing common general surgical procedures. We

recognize that the atlas is not all-inclusive. In the interest of space, we have omitted some

procedures which are less commonly performed by the general surgeon in practice. However,

we believe that this atlas provides a great start.

COURTNEY M. TOWNSEND, JR., MD

B. MARK EVERS, MD

Preface

Acknowledgments

We would like to recognize the invaluable contributions of publication coordinators

Karen Martin, Steve Schuenke, Eileen Figueroa, and administrator, Barbara Petit. Their

dedicated professionalism, tenacious efforts, and cheerful cooperation are without parallel.

They accomplished whatever was necessary, often on short or instantaneous deadlines, and

were vital for the successful completion of the endeavor.

Our authors, all respected authorities in their ﬁ elds and busy physicians and surgeons, did

an outstanding job in sharing their wealth of knowledge.

We would also like to acknowledge the professionalism of our colleagues at Elsevier:

Developmental Editor, Kristina Oberle; Publication Service Manager, Julie Eddy; Project

Manager, Laura Loveall; Designer, Louis Forgione; and Publishing Director, Judith Fletcher.

CHAPTER

STEP 1: SURGICAL ANATOMY

◆ A comprehensive understanding of the anatomy of the neck is critical before undertaking

surgical procedures on the thyroid.

◆ Figure 1-1 demonstrates key anatomic structures that must be considered with

thyroidectomy.

◆ Figure 1-2 demonstrates the relationship of the thyroid gland with the underlying trachea

and esophagus and also demonstrates the usual anatomic location for the recurrent

laryngeal nerve in the tracheoesophageal groove.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The indications for thyroid resection include the following:

◆ A solitary thyroid nodule usually with ﬁ ne needle aspiration (FNA) indicative of a

suspicious lesion or cancer;

◆ A multinodular goiter with continued enlargement and symptoms ranging from

dysphagia, choking, pain, or cosmetic concerns;

◆ Occasionally hyperthyroidism particularly if radioiodine ablation or antithyroid

medications are contraindicated.

◆ Thyroid resections range from lobectomy and isthmusectomy, subtotal thyroid resection,

or total thyroidectomy.

◆ Decisions regarding the extent of resection are operator dependent and can be contro-

versial.

Thyroidectomy (Lobectomy,

Subtotal Resection, Total

Thyroidectomy)

B. Mark Evers

Superior thyroid artery and vein

External juglar vein

Hyoid bone

Trachea

Left recurrent laryngeal nerve

Inferior thyroid vein

Thyrohyoid muscle

Thyroid cartilage

Cricothyroid muscle

Sternothyroid muscle

Sternohyoid muscle

Middle thyroid vein

Left recurrent laryngeal nerve

Thyroid membrane

Vagus nerve (X)

Internal jugular vein

Enlarged thyroid gland

Vagus nerve (X)

Inferior thyroid artery

Common carotid artery

FIGURE 1 –1

Sternohyoid muscle

Fascia of infrahyoid muscle

Recurrent laryngeal nerve

Esophagus

Platysma muscle

Sternothyroid muscle

Enlarged thyroid

Normal thyroid

Internal jugular vein

Carotid sheath

Internal carotid artery

Superficial (investing) fascia

Pretracheal fascia

Parathyroid gland

Sternocleidomastoid muscle

Vagus nerve (X)

Internal jugular vein

Omohyoid muscle

Trachea

FIGURE 1 –2

CHAPTER 1 • Thyroidectomy (Lobectomy, Subtotal Resection, Total Thyroidectomy) 3

4 Section I • Head and Neck and Endocrine Procedures

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Proper positioning of the patient is critical for adequate exposure of the thyroid gland. This

is normally accomplished by hyperextension of the neck using a rolled sheet between the

shoulder blades. The head is then supported with a foam rubber doughnut-shaped ring. In

addition, the patient is placed in the semierect (semi-Fowler) position (Figure 1-3).

◆ The incision must be carefully planned to allow optimal access to the thyroid gland, as well

as to provide a cosmetically acceptable scar. The incision line is normally approximately

two ﬁ ngerbreadths above the sternal notch, placed to conform to Langer’s lines. The

incision should be symmetrical and extend equidistant from the midline and have a gentle

upward curve. Some surgeons use a heavy silk suture to outline the incision site by

compressing the suture on the neck (Figure 1-4).

◆ The incision extends through the subcutaneous tissue; the platysma muscle is divided using

the electrocautery (Figure 1-5).

◆ Flaps are then mobilized superiorly and inferiorly using the cautery, as well as blunt

dissection, just deep to the platysma muscle. The superior ﬂ ap is extended to the level of

the thyroid cartilage and the inferior ﬂ ap extends to the clavicular heads and suprasternal

notch (Figure 1-6).

2. DISSECTION

◆ A Mahorner retractor is used to retract the skin ﬂ aps. The dissection then proceeds in the

midline raphe, which provides a bloodless plane for the separation of the strap muscles

(Figure 1-7).

◆ Continuing in the midline, the loose pretracheal fascia is incised using sharp dissection or

the electrocautery (Figure 1-8).