I am delighted to write the preface for the fifth edition of Mastery of Surgery. I am indebted to the distinguished predecessors who were kind enough to include me in the third edition many years ago. I learned the craft of being the editor of these volumes at the feet of the masters.
It is interesting to look back at my surgical career beginning in July 1961, when I embarked on my training at the Massachusetts General Hospital while Dr. Churchill was still the chief. Dr. Churchill, of course, is the originator of the rectangular residency program, which is the dominant type of residency program that survives today. It is appropriate to point out that the Halsteadian residency program of graduated responsibility, for which Dr. Halstead appropriately gets credit, was a Germanic, elitist approach in which there was a sharp pyramid. Those who survived it were destined to become professors of surgery and leaders in the surgical field. However, as distinguished as the individuals who graduated from the Hopkins program were, the program did not and had no intention of populating the field of surgery for the needs of the patients of the United States. In addition, although those who failed the sharp pyramid were often placed in excellent programs in which the chiefs were graduates of the Halstead program, depression, anguish, and the stress of being cut from the excellent Hopkins program took its toll on those who did not make the grade. Dr. Churchill, who has many firsts in American surgery, thought that the most important thing he did was to organize the rectangular residency. He had the novel concept that he could choose which fourth year medical students would satisfy the rigid and rigorous criteria that the Massachusetts General Hospital program became.
It is amusing to recall the orientation that I underwent compared to the present. The orientation of our own surgical program is 5 days long; it includes ACLS training, and the residents are also exposed to the head of the laundry, social work, etc. All of this is important but pales in comparison to Dr. Churchill's orientation at noon on July 1, 1961, in which he looked at us, smiled, and said: 'Get to work.'
I am indebted to those who have been my mentors over the years, including Dr. Claude Welch, the Dean of Boston Surgeons; Dr. Robert Ritchie Linton, whose understanding of liver physiology was intuitive and based on hunches, yet almost always correct because he was such a superb clinician; Dr. William V. McDermott Jr., another mentor who inspired me prior to going to the National Institutes of Health as a research associate for two years, and whose named chair I now hold; Dr. George Nardi, who later became my partner, a delightful and innovative surgeon who made surgery interesting for himself and the residents who assisted him; Dr. Churchill who is among the wisest people I have ever met; later Dr. W. Gerald Austen, under whom I served as his first chief resident; and also my friends and mentors, Dr. Leslie Otinger and Dr. Ashby Moncure, who preceded me as the super-chief.
A critical period of my development was when I went to the National Institute of Mental Health as a research associate (1 of 20). The NIH had put together a fantastic educational program, and I had the privilege of working with Dr. Irwin Kopin, who had just finished a tour in the laboratory with Dr. Julius Axelrod, who later won the Nobel Prize for work that preceded my tenure. Also I was blessed to have a series of excellent technicians, among whom was Dr. Dale Horst, a conscientious objector who became a distinguished pharmacologist in his own right and who was extremely helpful.
Absence makes the heart grow fonder, yes, but it also enhanced my knowledge base. My wife to be, Karen, was still in Boston, so after putting in a 12-hour day at the laboratory, my idea of having a good time was to go to the library and read some of the wonderful classics of surgery; journals, that are not available on the internet, laid the groundwork for my physiologic approach to the practice of surgery.
But enough about me. What is it about this edition that is different? The concept of Mastery of Surgery, especially in the first edition was to take advantage of Dr. Nyhus' many contacts abroad and make Mastery of Surgery a truly international work. That generation is now no longer on the scene, and what I have tried to do in this edition is restore some of the international flavor from authorities in many countries. Communications being what they are, many of these individuals are well-known to those who will read this book and who see them at meetings such as the Clinical Congress of the American College of Surgeons and at the American Surgical. Thus, the reader will note that the number of international authorities who have contributed to this volume has been increased.
Much has changed in the 5 or 6 years since the fourth edition appeared. Minimally invasive surgery has had a profound effect on general, vascular, cardiac, and thoracic surgery. Minimally invasive technology and approaches have improved. Who is a candidate for the classic big incision open approach? Market forces certainly enter smaller is better. For example, witness the limited patient population which is now set for open renal atherectomy for arteriosclerotic disease. Despite the fact that long-term patency is considerably better in the open approach, the mortality of the open approach is not necessarily inferior to that of the endovascular approach. Randomized prospective trials have not yet been done in many areas in which laparoscopic is compared with open surgery. True, the length of stay is usually shorter, days on the respirator in the ICU may be shorter, but it is interesting that the mortality in this group, with many comorbidities, may not be different between open and minimally invasive approach, while the long-term patency seems to be considerably greater. The question of who is a candidate for open and who is a candidate for a minimally invasive approach has not yet been answered. Hopefully by the time the next edition appears, this will have been subjected to rigid randomized clinical trials to produce an evidence based decision. What we have now is bias smaller incision is better, even if long-term results are not quite as good.
Evidence based surgery and its emphasis is apparent throughout this volume. The importance in surgery is outcomes. This is made clear in 'pay for performance' accreditation efforts by the American College of Surgeons, and the widespread application of the National Surgical Quality Improvement Program, which not only showed how to improve surgical outcomes in the Veteran's Administration Hospital, but has now been rolled out to more than 200 hospitals,. The emphasis is not only on observed versus expected, which is risk adjusted, but also contains programs for improving outcomes. In internal medicine, pay for performance remains largely process oriented. For example, in internal medicine, pay for performance includes asking a patient to stop smoking. If this were a surgical pay for performance issue, it would likely deal with the outcome: Did the patient stop smoking or did the patient not stop smoking? The administration of perioperative antibiotics is an example of process. We should be concerned about surgical site infection as an outcome, which not only includes perioperative antibiotics but clipping versus shaving, hibiclens scrub for a few days before the operations, and a whole series of other perioperative issues, which will help determine the incidence of surgical site infection.
In a number of other fairly common areas the emphasis has changed based in part on randomized clinical trials in areas such as hernias. If one compares emphasis in the fourth edition between various repairs, the emphasis was on recurrence. While the emphasis on recurrence remains, there is an entirely new area which concerns surgeons: inguinodynia or post herniorhaphy pain. James Madura has written an excellent chapter concerning nerve entrapment, which while not exclusively the province of mesh repairs, nonetheless, has a much lower incidence in open repairs that do not include mesh. In the area of pilonidal sinus and abscess, a very common condition for which surgical attention is sought, there is now accumulating evidence that personal hygiene, removal of hair from the sinus, depilatories, as well as laser treatment in the peripilonidal sinus area may be as or more effective than excision and primary closure of pilonidal sinus.
Another innovation in this book which I think has yielded excellent results is the appointment of an associate editor, Dr. Kirby Bland, who has ably assisted in the identification of authors and in the commentary on surgical oncologic procedures. Assistant Editors Dr. Mark Callery in the hepatobiliary area and Dr. Dan Jones in the laparoscopic area have helped immensely not only in selecting the authors, but in writing cogent commentaries on the chapters. The explosion of the vascular field, including the proliferation of the endovascular techniques in which the technology is improving and the results are improving with it, has necessitated more in the vascular area including endovascular and open. Dr. Frank LoGerfo helped identify the authors; Drs. Patrick Clagett and James Seeger have been extraordinarily helpful.
The length of the book has necessitated that additional chapters appear on the Web site. Most of these are chapters of historical interest. Additional chapters of interest are those in the gynecological and the urological area, mostly in the area of oncology. The superb approaches utilizing general surgical techniques will be of interest to surgical residents and practicing surgeons alike.
Those of you who have participated in putting together a surgical volume with any number of chapters understand what a tremendous effort and how time consuming it is. I have many individuals to thank. First and foremost, Karen, my wife of 41 years and companion of 46 years, had to endure this time-consuming effort of the past 2 or 3 years, which was also associated with service on the Residency Review Committee, leaving little time for us. Her patience, wisdom, guidance, and love always leave me very grateful for what she has done for my life. My children, Erich and Alexandra, have been squeezed in between these efforts and although they are grown, have their own careers, and are no longer at home, we remain a very close family.
The group at Lippincott headed by Brian Brown has been wonderful to work with; Julia Seto, the Senior Managing Editor, and a group of artists who have translated sometimes crude sketches into excellent artwork. They have all taken my suggestions with patience and good humor and are an extraordinarily talented group of people.
A work such as this does not take place in a vacuum. My office staff has been long suffering, including Iliana Ferguson, Deborah Cruise, Luisa Dello Iacono, and the production/transcription staff, including Anja Duprat, Karen Nehilla, Abigail Smith, and briefly, Stephanie Vrattos.
Time spent on this detracts from my ability to participate and help manage what I consider a superb department of extraordinary surgeons gathered under one roof. I am ably assisted by a series of Senior Faculty members who all pitch in in a 'kitchen cabinet' to take some of the pressure off of me, including, in no particular order: Dr. Chip Baker, who serves as Program Director; Dr. Jon Critchlow, who is Associate Program Director; Dr. Scott Johnson and Dr. Alan Hammond as Assistant Program Directors; Dr. Mike Cahalane who is in charge of the surgical clerkship; also a series of talented Senior Vice Chairs including, Dr. Malcolm DeCamp, Dr. Douglas Hanto, Dr. James Hurst, Dr. Callery who serves as chief of General Surgery, and Dr. Donald Moorman, Vice Chair for Safety and Quality. I would be remiss if I did not mention my alter ego, Pat Thurston, the director of the department, business manager, factotum, and person of all work, who takes an enormous amount of pressure off of me. The residents also allow me to do other things as they give superb surgical care.
I have gone on for some time, but a two volume book of 239 chapters does not happen with a sole effort. It is an extraordinarily time-consuming team effort, and I have been privileged to have such an excellent team surround me.
Table of Contents:
It is interesting to look back at my surgical career beginning in July 1961, when I embarked on my training at the Massachusetts General Hospital while Dr. Churchill was still the chief. Dr. Churchill, of course, is the originator of the rectangular residency program, which is the dominant type of residency program that survives today. It is appropriate to point out that the Halsteadian residency program of graduated responsibility, for which Dr. Halstead appropriately gets credit, was a Germanic, elitist approach in which there was a sharp pyramid. Those who survived it were destined to become professors of surgery and leaders in the surgical field. However, as distinguished as the individuals who graduated from the Hopkins program were, the program did not and had no intention of populating the field of surgery for the needs of the patients of the United States. In addition, although those who failed the sharp pyramid were often placed in excellent programs in which the chiefs were graduates of the Halstead program, depression, anguish, and the stress of being cut from the excellent Hopkins program took its toll on those who did not make the grade. Dr. Churchill, who has many firsts in American surgery, thought that the most important thing he did was to organize the rectangular residency. He had the novel concept that he could choose which fourth year medical students would satisfy the rigid and rigorous criteria that the Massachusetts General Hospital program became.
It is amusing to recall the orientation that I underwent compared to the present. The orientation of our own surgical program is 5 days long; it includes ACLS training, and the residents are also exposed to the head of the laundry, social work, etc. All of this is important but pales in comparison to Dr. Churchill's orientation at noon on July 1, 1961, in which he looked at us, smiled, and said: 'Get to work.'I am indebted to those who have been my mentors over the years, including Dr. Claude Welch, the Dean of Boston Surgeons; Dr. Robert Ritchie Linton, whose understanding of liver physiology was intuitive and based on hunches, yet almost always correct because he was such a superb clinician; Dr. William V. McDermott Jr., another mentor who inspired me prior to going to the National Institutes of Health as a research associate for two years, and whose named chair I now hold; Dr. George Nardi, who later became my partner, a delightful and innovative surgeon who made surgery interesting for himself and the residents who assisted him; Dr. Churchill who is among the wisest people I have ever met; later Dr. W. Gerald Austen, under whom I served as his first chief resident; and also my friends and mentors, Dr. Leslie Otinger and Dr. Ashby Moncure, who preceded me as the super-chief.
A critical period of my development was when I went to the National Institute of Mental Health as a research associate (1 of 20). The NIH had put together a fantastic educational program, and I had the privilege of working with Dr. Irwin Kopin, who had just finished a tour in the laboratory with Dr. Julius Axelrod, who later won the Nobel Prize for work that preceded my tenure. Also I was blessed to have a series of excellent technicians, among whom was Dr. Dale Horst, a conscientious objector who became a distinguished pharmacologist in his own right and who was extremely helpful.
Absence makes the heart grow fonder, yes, but it also enhanced my knowledge base. My wife to be, Karen, was still in Boston, so after putting in a 12-hour day at the laboratory, my idea of having a good time was to go to the library and read some of the wonderful classics of surgery; journals, that are not available on the internet, laid the groundwork for my physiologic approach to the practice of surgery.
But enough about me. What is it about this edition that is different? The concept of Mastery of Surgery, especially in the first edition was to take advantage of Dr. Nyhus' many contacts abroad and make Mastery of Surgery a truly international work. That generation is now no longer on the scene, and what I have tried to do in this edition is restore some of the international flavor from authorities in many countries. Communications being what they are, many of these individuals are well-known to those who will read this book and who see them at meetings such as the Clinical Congress of the American College of Surgeons and at the American Surgical. Thus, the reader will note that the number of international authorities who have contributed to this volume has been increased.
Much has changed in the 5 or 6 years since the fourth edition appeared. Minimally invasive surgery has had a profound effect on general, vascular, cardiac, and thoracic surgery. Minimally invasive technology and approaches have improved. Who is a candidate for the classic big incision open approach? Market forces certainly enter smaller is better. For example, witness the limited patient population which is now set for open renal atherectomy for arteriosclerotic disease. Despite the fact that long-term patency is considerably better in the open approach, the mortality of the open approach is not necessarily inferior to that of the endovascular approach. Randomized prospective trials have not yet been done in many areas in which laparoscopic is compared with open surgery. True, the length of stay is usually shorter, days on the respirator in the ICU may be shorter, but it is interesting that the mortality in this group, with many comorbidities, may not be different between open and minimally invasive approach, while the long-term patency seems to be considerably greater. The question of who is a candidate for open and who is a candidate for a minimally invasive approach has not yet been answered. Hopefully by the time the next edition appears, this will have been subjected to rigid randomized clinical trials to produce an evidence based decision. What we have now is bias smaller incision is better, even if long-term results are not quite as good.
Evidence based surgery and its emphasis is apparent throughout this volume. The importance in surgery is outcomes. This is made clear in 'pay for performance' accreditation efforts by the American College of Surgeons, and the widespread application of the National Surgical Quality Improvement Program, which not only showed how to improve surgical outcomes in the Veteran's Administration Hospital, but has now been rolled out to more than 200 hospitals,. The emphasis is not only on observed versus expected, which is risk adjusted, but also contains programs for improving outcomes. In internal medicine, pay for performance remains largely process oriented. For example, in internal medicine, pay for performance includes asking a patient to stop smoking. If this were a surgical pay for performance issue, it would likely deal with the outcome: Did the patient stop smoking or did the patient not stop smoking? The administration of perioperative antibiotics is an example of process. We should be concerned about surgical site infection as an outcome, which not only includes perioperative antibiotics but clipping versus shaving, hibiclens scrub for a few days before the operations, and a whole series of other perioperative issues, which will help determine the incidence of surgical site infection.
In a number of other fairly common areas the emphasis has changed based in part on randomized clinical trials in areas such as hernias. If one compares emphasis in the fourth edition between various repairs, the emphasis was on recurrence. While the emphasis on recurrence remains, there is an entirely new area which concerns surgeons: inguinodynia or post herniorhaphy pain. James Madura has written an excellent chapter concerning nerve entrapment, which while not exclusively the province of mesh repairs, nonetheless, has a much lower incidence in open repairs that do not include mesh. In the area of pilonidal sinus and abscess, a very common condition for which surgical attention is sought, there is now accumulating evidence that personal hygiene, removal of hair from the sinus, depilatories, as well as laser treatment in the peripilonidal sinus area may be as or more effective than excision and primary closure of pilonidal sinus.
Another innovation in this book which I think has yielded excellent results is the appointment of an associate editor, Dr. Kirby Bland, who has ably assisted in the identification of authors and in the commentary on surgical oncologic procedures. Assistant Editors Dr. Mark Callery in the hepatobiliary area and Dr. Dan Jones in the laparoscopic area have helped immensely not only in selecting the authors, but in writing cogent commentaries on the chapters. The explosion of the vascular field, including the proliferation of the endovascular techniques in which the technology is improving and the results are improving with it, has necessitated more in the vascular area including endovascular and open. Dr. Frank LoGerfo helped identify the authors; Drs. Patrick Clagett and James Seeger have been extraordinarily helpful.
The length of the book has necessitated that additional chapters appear on the Web site. Most of these are chapters of historical interest. Additional chapters of interest are those in the gynecological and the urological area, mostly in the area of oncology. The superb approaches utilizing general surgical techniques will be of interest to surgical residents and practicing surgeons alike.
Those of you who have participated in putting together a surgical volume with any number of chapters understand what a tremendous effort and how time consuming it is. I have many individuals to thank. First and foremost, Karen, my wife of 41 years and companion of 46 years, had to endure this time-consuming effort of the past 2 or 3 years, which was also associated with service on the Residency Review Committee, leaving little time for us. Her patience, wisdom, guidance, and love always leave me very grateful for what she has done for my life. My children, Erich and Alexandra, have been squeezed in between these efforts and although they are grown, have their own careers, and are no longer at home, we remain a very close family.
The group at Lippincott headed by Brian Brown has been wonderful to work with; Julia Seto, the Senior Managing Editor, and a group of artists who have translated sometimes crude sketches into excellent artwork. They have all taken my suggestions with patience and good humor and are an extraordinarily talented group of people.
A work such as this does not take place in a vacuum. My office staff has been long suffering, including Iliana Ferguson, Deborah Cruise, Luisa Dello Iacono, and the production/transcription staff, including Anja Duprat, Karen Nehilla, Abigail Smith, and briefly, Stephanie Vrattos.
Time spent on this detracts from my ability to participate and help manage what I consider a superb department of extraordinary surgeons gathered under one roof. I am ably assisted by a series of Senior Faculty members who all pitch in in a 'kitchen cabinet' to take some of the pressure off of me, including, in no particular order: Dr. Chip Baker, who serves as Program Director; Dr. Jon Critchlow, who is Associate Program Director; Dr. Scott Johnson and Dr. Alan Hammond as Assistant Program Directors; Dr. Mike Cahalane who is in charge of the surgical clerkship; also a series of talented Senior Vice Chairs including, Dr. Malcolm DeCamp, Dr. Douglas Hanto, Dr. James Hurst, Dr. Callery who serves as chief of General Surgery, and Dr. Donald Moorman, Vice Chair for Safety and Quality. I would be remiss if I did not mention my alter ego, Pat Thurston, the director of the department, business manager, factotum, and person of all work, who takes an enormous amount of pressure off of me. The residents also allow me to do other things as they give superb surgical care.
I have gone on for some time, but a two volume book of 239 chapters does not happen with a sole effort. It is an extraordinarily time-consuming team effort, and I have been privileged to have such an excellent team surround me.
Josef E. Fischer M.D.
Table of Contents:
- Perioperative Care of the Surgical Patient.
- Basic Surgical Skills: New and Emerging Technology.
- The Head and Neck.
- Endocrine Surgery. .
- The Breast, Chest, and Mediastinum.
- The Diaphragm.
- The Gastrointestinal Tract: The Esophagus, The Stomach and Duodenum, Morbid Obesity (Dan Jones, Section Editor), The Liver and Biliary Tract, The Pancreas, Portal Hypertension and Its Treatment, Surgery of the Small Intestine, Surgery of the Colon.
- Nongastrointestinal Transabdominal Surgery : The Spleen, Surgery of the Urinary Tract and Bladder, Gynecologic Surgery, Surgery of Hernia.
- Vascular Surgery.
- Hardcover: 2592 pages
- Publisher: Lippincott Williams & Wilkins; 5 edition (December 1, 2006)
- Language: English
- ISBN-10: 078177165X
- ISBN-13: 9780781771658
- Product Dimensions: 13 x 10.2 x 4.2 inches