Atlas of Surgical Techniques
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* Bryce R. Taylor

**ATLAS OF SURGICAL TECHNIQUES.** Steven G. Economou and Tasia S. Economou. 683 pp. Illust. W.B. Saunders Company, Philadelphia; W.B. Saunders Canada, Toronto. 1996. $253. ISBN 0-7216-1611-9

This atlas might be subtitled “a compilation of abdominal and head and neck elective procedures for the comprehensive general surgeon.” It is a relatively complete, beautifully illustrated anthology of surgical techniques that provides 678 large pages of three-dimensional drawings of the highest quality. The text is clear, simple and accompanies the diagrams themselves, a strategy that is very helpful in any anatomic text. The authors concentrate on elective operations and do not address such emergencies as perforated duodenal ulcer, bleeding ulcer, blunt and penetrating abdominal trauma, diverticulitis and arterial embolectomy. The omission of all venous surgery, including high ligation and stripping, is lamentable. These minor problems aside, this atlas is outstanding.

The artwork of Albert Teoli and colleagues focuses on three-dimensional black-and-white line drawings, which are very effective, and in some sections, such as head and neck, the technique of incorporating the surface anatomy simultaneously with the deep anatomy always retains perspective. In addition, frequent three-dimensional views in cross-section or sagittal section are extremely helpful to the young surgeon attempting to visualize in two and three dimensions at the same time. For some procedures — abdominoperineal resection, Whipple procedure, portacaval shunt, inguinal node dissection and amputations — the artwork reverts to a more anatomic, shaded technique in which the clarity and anatomic definition are lost. It is not clear why a different technique was used for these sections.

Some procedures are described with which, I believe, many surgeons would disagree: the choice of circumferential lower quadrant breast incisions for wide local excision rather than the more cosmetic radial incision; the approximation of deeper tissue in these incisions rather than leaving the breast space to fill in; the performance of a lower esophageal myotomy, which is “usually carried out if there is symptomatic reflux esophagitis” (I have no idea what the authors were thinking about here); the long Nissen fundoplication in a patient who would surely not swallow again soon; and the statement that a segments 5 and 8 resection in the right lobe of the liver is “the usual extent of resection for right hepatic lobectomy”. Despite these irritations, appropriate surgery was described, even though some operations, such as total esophagectomy with colon interposition, occupied more book space than would be justified for the average general surgeon.

Some refreshing additions to this atlas, procedures that are often poorly handled or not handled at all, are the takedown of a colostomy and a variety of perianal procedures. The latter especially are covered particularly poorly in most atlases, and the three-dimensional approach to anatomy in this atlas is most helpful.

In the sections on hernias, the three-dimensional anatomy, which is frequently difficult for residents to learn, is covered particularly well; however, I could not find one mention of transversalis fascia throughout the text. The options of direct repair, indirect repair, mesh and no mesh, and options for femoral repairs were extremely well done.

The section on liver resection might have been improved with the kind of exacting anatomic diagram accompanying other passages. Segmental anatomy of the liver is the cornerstone of any hepatic resection, and this was not covered at all. Dissecting caudate vessels and the right hepatic vein last (rather than first after complete mobilization of the right lobe of the liver) is a process that most hepatic surgeons would find reversed. In addition, the use of transhepatic tubes during high biliary–enteric anastomosis, although still indicated in very rare situations, is for the most part an outmoded technique. Likewise, the performance of a classic Puestow procedure in which a filletted gland is inserted completely into a loop of jejunum is a procedure that pancreatic surgeons rarely perform today.

Included in the extensive elective procedures for the true “general” surgeon are complex genitourinary operations such as establishment of an ileal conduit, radical hysterectomy and vaginal repairs, and elective vascular procedures. These, like the other procedures are beautifully illustrated.

Although many of the foregoing comments constitute concerns, this atlas is by far the best, clearest and most informative surgical atlas for the general surgeon I have ever seen. It is contemporary enough that many laparoscopic procedures such as Nissen fundoplication, cholecystectomy, hernia repair and appendectomy are included. I believe a section on general laparoscopic techniques common to all laparoscopic procedures might have been helpful.

This atlas is a welcome addition to surgical education and as the apparent first edition, it will set the standard for other surgical anatomic texts. The first edition is worth every penny; if some of these relatively minor concerns are addressed in the next edition, it will be worth its weight in gold!