Comprehensive Manuals of Surgical Specialties

rM LlIZJ

Richard H. Egdahl, editor

AnthonyJ.~is LuisA.Ayala RichardH.Egdahl

with 266 figures and 242 color plates

Springer Science+Business Media, LLC

SERIES EDITOR

Richard H. Egdahl M.D., Ph.D., Professor of Surgery, Boston University Medical Center, Boston, Massachusetts 02118

AUTHORS

Anthony J. Edis M.D., Department of Surgery, Mayo Clinic, Rochester, Minnesota 55901

Luis A. Ayala M.D., Centro Medico de Caracas, Plaza El Estanque, San Bernardino, Caracas 10 1, Venezuela

Richard H. Egdahl M.D., Ph.D., Boston University Medical Center, 720 Harrison Avenue, Boston, Massachusetts 02118

MEDICAL ILLUSTRA TORS

Jerome T. Glickman, Team Administrator, Educational Media Support Center, Boston University Medical Center, Boston, Massachusetts 02118

David J. Mascaro, Assistant Professor, School of Medical Illustration, Medical Col­lege of Georgia, Augusta, Georgia 30902

Karen Waldo, Office of Biomedical Communications, Dartmouth- Hitchcock Medical Center, Hanover, New Hampshire 03755

Judy M. Glick, Educational Media Support Center, Boston University Medical Center, Boston, Massachusetts 02118

Charles H. Boyter, Educational Media Support Center, Boston University Medical Center, Boston, Massachusetts 02118

GRAPHIC ILLUSTRA TOR

Douglas P. Russcll, Educational Media Support Center, Boston University Medical Center, Boston, Massachusetts 02118

Library of Congress Cataloging in Publication Data

Main entry under title:

Manual of endocrine surgery. (Comprehensive manuals of surgical specialties) Bibliography Includes index.

1. Glands, Ductless-Surgery. 1. Edis, Anthony. II. Ayala, Luis. III. Egdahl, Richard Harrison. [DNLM: 1. Endocrine glands-Surgery. WKIOO M294] RD599.M36 617'.44 75-20301

AII rights reserved.

No part of this book may be translated or reproduced in any form without written permission from Springer- VerIag.

© 1975 by Springer Science+Business Media New York

Originally published by Springer- Verlag New York Inc.

Softcover reprint of the hardcover 1 st edition 1975

ISBN 978-1-4757-1161-5 ISBN 978-1-4757-1159-2 (eBook)

DOI 10.1007/978-1-4757-1159-2

This book is dedicated to the memory of

DAVID M. HUME M.D.

whose enthusiasm and creativity contributed so much to endocrinology.

Editor's Note

The Manual of Endocrine Surgery represents the first of a planned series of Surgical Atlases organized into a format useful to the wide range of physicians who diagnose and treat surgically correctable disorders.

The use of full color to demonstrate operative techniques and to present the graphic material, which summarizes diagnosis and treatment, is unique. It should provide an unusual stimulus to assist the learning process.

Each manual will stand on its own merits as a self-contained, comprehensive reference source. I have selected subject areas for the initial volumes of the Comprehensive Manuals of Surgical Specialties. These include:

MANUAL OF VASCULAR SURGERY: E. J. Wylie, R. J. Stoney, and W. K. Ehrenfeld

MANUAL OF BURNS: B. A. Pruitt, A. D. Mason, and J. M. Long MANUAL OF UROLOGIC SURGERY: A. T. Cockett and K.

Koshiba

Planned volumes are:

Manual of Liver Surgery Manual of Pediatric Surgery Manual of Orthopedic Surgery Manual of Ambulatory Surgery Manual of Gastrointestinal Surgery Manual of Gynecological Surgery Manual of Plastic Surgery Manual of Heart and Great Vessel Surgery

In each manual the authors will rely heavily on illustrations to tell the story.

Richard H. Egdahl

This manual is intended as a comprehensive guide to the diagnosis and manage­ment of those endocrine diseases encountered by the general surgeon. Opera­tions on the pituitary gland are, therefore, specifically excluded. It should be most useful to general surgical residents and practicing surgeons, but we hope it will also prove useful to the wide range of physicians who deal with surgically correctable endocrine disorders.

The book has four sections - Surgery of the Parathyroids, Thyroid, Pan­creas, and Adrenals. Each section deals in a systematic manner with practical aspects of surgical anatomy, physiology, pathology, diagnosis, and treatment. Specific attention has been given to a detailed description of operative strategy, operative technique, and postoperative management. Individual operative steps are illustrated in full color, with specific figure legends on facing pages.

The artwork represents the distillation of twelve months intensive collabora­tion between the authors and a staff of medical illustrators to 'ensure anatomic fidelity and clarity. We believe that the use of full color has opened up a new dimension in surgical illustration by providing greater realism and allowing accent of important features.

The techniques described herein represent personal preferences. The authors recognize that there may be several satisfactory alternate approaches in every case. Where there is controversy, we have outlined our approach to the problem somewhat dogmatically in the belief that in certain circumstances a single point of view is better than several without selection.

The Manual o.fEndocrine Surgery was planned and written by the authors when they were on staff together in the Department of Surgery at the Boston Univer­sity Medical Center.

The authors wish to thank, most sincerely, the many individuals at this medical center who assisted them in different ways during their work on this book.

Our special gratitude is extended to the team of illustrators, listed on page iv, for their superb artistic efforts. Their compatible collaboration, both as a team on location as well as outside this medical center, has produced an art form of the highest caliber as well as an outstanding instructional device.

Mr. Jerome Glickman, the team administrator, worked closely with the authors and brought together the various skills of the illustrators in a workshop format which allowed for the completion of a combined work of this quality within a planne4 fifteen-month schedule. We thank them for their indispensable contributions.

In some instances, the authors relied on photographic material which was granted as a courtesy. Appreciation is acknowledged and credit is cited on page 269.

The interest, assistance, and support of the publisher is most gratefully acknowledged.

Anthony J. Edis Louis A. Ayala Richard H, Egdahl

Preface

Acknowledg­ments

The surgical treatment of endocrine disease constitutes only one facet of the work ofthe average general surgeon. But it is an area of increasing importance - partly because the domain of general surgery has been pared by increasing subspecialization, but partly too because of an apparent increase in the incidence of endocrine disease.

The widespread use of multichannel biochemical screening as part of the general medical examination has made the diagnosis of primary hyper­parathyroidism relatively commonplace. In fact, cervical exploration for parathyroid disease is now performed more frequently than thyroidectomy in some large surgical clinics. We have learned too only comparatively recently of the existence of a number of hereditary syndromes in which multiple endocrine abnormalities may be present simultaneously in the same individual. New syndromes involving various gastrointestinal hormones have also come to light only recently, and there is a distinct possibility that other, although perhaps less spectacular, syndromes are yet to be discovered. Paralleling these new clinical discoveries there have been some remarkable advancements in the areas of laboratory diagnosis and research. In particular, radioimmunoassay techniques have been developed for most ofthe known hormones, permitting a specificity and precision in the diagnosis of endocrine disease which was not possible a few years ago.

It is appropriate at this time, therefore, that an endocrinology text should appear which is specifically oriented to the practicing general surgeon. This manual is designed to serve as a comprehensive, fully referenced guide for the surgeon. It deals in a systematic manner with the surgical anatomy, physiology, pathology, diagnosis, and operative treatment of endocrine disease involving the parathyroids, thyroid, adrenals, and pancreas. The pathology is fully discussed with the aid of accompanying photographs. The principles of diagnosis are emphasized with the aid of colorful schematics. Operative stratagems employed in dealing with the specific endocrine disorders are presented and operative techniques are described in detail.

We are particularly proud of the operative illustrations; each was individu­ally designed and carried to completion under the careful supervision of the authors themselves. Wherever possible, the orientation of the operative field has been depicted as the surgeon himself sees it - not as the illustrator or camera might see it over the surgeon's shoulder or from an observation point overhead. We think that the use of full color conveys the technical and anatomic features of each operative step far more vividly and clearly than black and white line drawings or even color photography.

Intro­duction

1 Surgery of the Parathyroids

2

General Introduction SURGICAL ANATOMY

Primary Hyperparathyroidism 6

PATHOLOGY 6 DIAGNOSIS 8 TREATMENT 21

Secondary Hyperparathyroidism 24

Tertiary Hyperparathyroidism 25

Operative Techniques 26

CERVICAL EXPLORATION WITH REMOVAL OF A PARATHYROID ADENOMA 26 SUBTOTAL PARATHYROIDECTOMY FOR HYPERPLASIA 48 PARATHYROIDECTOMY FOR CARCINOMA 49 MEDIASTINAL EXPLORATION FOR PARATHYROID TUMOR 50

References 56

Surgery of the Thyroid 59

General Introduction 59

SURGICAL ANATOMY 60

Nodular Goiter and Thyroid Carcinoma 66 PATHOLOGY 66 DIAGNOSIS 66 TREATMENT OF THYRO ID NODULES 76 TREATMENT OF THYROID CANCER RELATED TO PATHOLOGIC TYPE 79

Hyperthyroidi sm 88

PATHOLOGY: GRAVE'S DISEASE 88 PATHOLOGY: PLUMMER'S DISEASE 89 DIAGNOSIS 89 TREATMENT 93

Operative Techniques 100 TOTAL THYROID LOBECTOMY 100 REMOVAL OF SUBSTERNAL GOITER 108 SUBTOTAL THYROID LOBECTOMY 110 MODIFIED NECK DISSECTION FOR THYROID CARCINOMA 114

References 118

Contents

3 Surgery of the Adrenals

General Introduction SURG ICAL ANATOMY

Pheochromocytoma PATHOLOGY DIAGNOSIS TREATMENT

Primary Aldosteronism PATHOLOGY DIAGNOSIS TREATMENT

Cushing's Syndrome PATHOLOGY DIAGNOSIS TREATMENT

Adrenogenital Syndrome TREATMENT

Adrenalectomy for Metastatic Breast Cancer PREDICTION OF RESPONSES TO ADRENALECTOMY COMPARISON OF ADRENALECTOMY WITH OTHER FORMS OF TREATMENT

Adrenalectomy for Metastatic Prostatic Carcinoma

Operative Techniques POSTERIOR APPROACH TO ADRENALECTOMY ANTERIOR APPROACH TO ADRENALECTOMY FOR PHEOCHROMOCYTOMA THORACOABDOMINAL APPROACH-RESECTION OF RIGHT ADRENAL

CARCINOMA

References

4 Surgery of the Endocrine Pancreas

General Introduction SURG ICAL ANATOMY

Insulinoma PATHOLOGY

123

123

124

127

127 128 137

142

143 144 150

152

152 154 161

163 164

166

166 170

173

174

174 188

197

204

209

209

211

213

215

DIAGNOSIS TREATMENT

Operative Technique SURGICAL APPROACH FOR INSULINOMA

Zollinger-Ellison Syndrome PATHOLOGY DIAGNOSIS TREATMENT

Operative Technique TOTAL GASTRECTOMY FOR ZOLLINGER-ELLISON SYNDROME

Watery-Diarrhea Syndrome PATHOLOGY DIAGNOSIS TREATMENT

References

Index

216 224

228 228

244

244 246 252

255

255

261 261 261 262

263

271