Book Review

Gastroenterology — Surgical and Medical

The Practice of Surgery

N Engl J Med 1994; 331:553-554August 25, 1994

Article

The Practice of Surgery
By Ronald A. Malt. 558 pp., illustrated. Philadelphia, W.B. Saunders, 1993. $200. ISBN: 0-7216-1811-1

In his preface to “The Practice of Surgery,” Dr. Ronald A. Malt states that when he began the book in 1983, he “hoped to memorialize the practice of general surgery as it existed before its obvious degeneracy into satrapies of overspecialization.” He says that the book covers the operations that a general surgeon at the busiest point of his or her career might perform in a year of practice and that a resident in general surgery should perform in five or more years of training. He thus sets the tone for this book and defines the enormous and challenging task of producing a book that reflects his prodigious experience and practice. His book is a labor of love and reflects his dedication to the art and science of surgery.

The Practice of Surgery is not intended to be an all-inclusive textbook of surgery. Indications for surgery are not covered, and preparation of the patient for operation is limited to rudimentary descriptions of bowel preparation and the selection of antibiotics. Malt has chosen to cite only the most seminal, and usually historic, references, preferring to let the book stand on its own merits.

In the first 10 chapters, Malt provides a detailed description of preoperative and intraoperative routines, sterilization, types and uses of instruments and sutures, knot tying, staplers and electrocoagulation, and wound healing. There is even a chapter on the operative report, with examples of Malt's own reports. This chapter should be read by surgical trainees struggling to achieve a balance between the relevant description of technical detail and intraoperative decision making. The remaining 35 chapters discuss a comprehensive selection of general surgical procedures, including the more common peripheral vascular procedures, organized according to organ system.

The personal style of the book comfortably permits the author the latitude to debunk certain surgical myths. To his credit, there is a refreshing paucity of ceremonial or traditional surgical habits and practices. For example, he touts the use of one-layer intestinal anastomoses, properly performed. He states, “If these sutures are properly placed, what need is there for another layer?” Why excise the omentum during a gastrectomy for benign disease? “It gets in the way.”

The real strength of this book is the prose. Malt has produced clean and unambiguous descriptions of surgical maneuvers that are rarely if ever described in standard textbooks and are often performed unconsciously by master surgeons. Malt is most comfortable and expansive in describing maneuvers and procedures on the alimentary tract. These eloquent descriptions may well come to be his written legacy.

Experienced surgeons may disagree about personal preferences in operative surgery (for example, antecolic vs. retrocolic gastrojejunostomy, upper-midline vs. bilateral subcostal incisions, the best approach to a distal splenorenal shunt or to a mesocaval shunt), but I would be remiss if I did not point out a few flaws. Figure 29-28, which depicts the exposure of the splenic vein, is out of sequence with the other figures and the text. Figure 30-36 shows the method of identifying and dividing the gastroduodenal artery from below the duodenum during a Whipple procedure. It is best found and divided cephalad to the duodenum at its origin with the hepatic artery. In Figure 43-16 the left limb of an aortobifemoral graft is shown being passed under the sigmoid colon and then intraperitoneally to the left groin. The graft should be extraperitoneal throughout its course. In his description of a femoropopliteal bypass, Malt states that systemic heparinization should be used after dissection of the popliteal artery but before dissection of the femoral artery and the saphenous vein. Systemic heparinization should be delayed until after all the dissections are complete and be begun before the popliteal and femoral arteries are opened. Finally, the practice of using an interrupted suture technique for aortic and other large-artery anastomoses may work well in Malt's hands, but it is unnecessarily complex, tedious, and -- if done improperly -- leaky. This technique is best left to history.

The Practice of Surgery is filled with useful information that complements standard textbooks. It is liberally illustrated with beautifully rendered halftone drawings. Senior surgical residents and practicing surgeons have much to learn from Malt that they otherwise would have to learn through trial and error -- a costly and time-consuming method. Experienced surgeons will enjoy comparing their routines and opinions with those of the author, possibly concluding, as I did, that we all have something to learn from and contribute to one another. The difference is that Malt labored for a decade to convert practice and experience into the written word so we all might benefit.

John C. Bowen, M.D.
Ochsner Clinic, New Orleans, LA 70121