Foreword

Adult Chest Surgery is the culmination of a team effort. It would be unfair to single out any surgeon in particular, yet every team needs a vision, a driving force, an individual who is able to articulate that vision, recognize talent, acquire resources, seize opportunity, delegate responsibility, and lead. That is the hidden message of this book. Every surgeon who contributed to this volume is a leader in his or her own right. More than just a compilation of technical procedures, every author is trying to tell you something important, something they learned from the school of hard knocks, something that can make the difference between a successful and unsuccessful operation, and something that may impact your career in thoracic surgery. This impressive list of contributing authors also emphasizes the number of national and international surgeons who have dedicated their careers to the pursuit of general thoracic surgery. These individuals are the product of a focused and dedicated approach to general thoracic surgical training as practiced at multiple institutions worldwide.

As I look back upon my own experience, the unique events leading to the establishment of a separate division and training program for general thoracic surgery at Toronto General Hospital had far-reaching implications, the details of which I will relate herein.

Happenstance and good fortune placed me in the general surgery training program at Toronto General Hospital in the early 1950s when the seeds of our profession were sown. This was the same hospital where my predecessors, Dr. Norman Shenstone and Dr. Robert Janes, pioneered the Shenstone/Janes lung tourniquet in 1932. The purpose of the tourniquet was to control intraoperative hemorrhage, decrease mortality, and reduce the incidence of postoperative fistulae, and thereby ensure the safety of pneumonectomy and lobectomy for the treatment of suppurative lung diseases like tuberculosis. Previous to this, surgeons used to hold their breath during the difficult dissection of the hilum. As a result of this innovation, Toronto quickly became a leading center for general thoracic surgery in North America.

When my surgical career began, four surgeons (still operating within the division of general surgery) were responsible for the care of thoracic patients at Toronto General Hospital, including my mentor, Dr. Fredrick Kergin, as well as Drs. Norman Shenstone, Robert Janes, and Norman Delarue. Dr. Kergin played a key role in my development as well as in the evolution of general thoracic surgery. He was one of three general surgeons practicing thoracic surgery at the time and had an international reputation for his contributions to that specialty. Among his many contributions, he was largely responsible for the creation of a separate division of general thoracic surgery at Toronto General Hospital and for his foresight in bringing endoscopy (esophagoscopy and bronchoscopy) into the practice of general thoracic surgery. Previously, endoscopy had been the exclusive domain of otolaryngologists and ENT surgeons. This was the case not only in Canada but also throughout North America and most of the world.

Dr. Wilfred G. Bigelow, a young general surgeon with training in vascular disease, also played an important role. He introduced me to the more practical aspects of scientific research through a one-year fellowship in his physiology laboratory in 1951 to 1952. In 1953, Dr. Bigelow was named head of one of three hospital divisions of general surgery. Recognizing the need to develop specialized training for cardiac surgeons, he used his persuasion as surgeon-in-chief to create a dedicated division and training program for cardiovascular surgery. This decision influenced later events at Toronto General Hospital, and, eventually, across North America.

In 1958, just preceding a staff appointment to Toronto General Hospital, I benefited from a one-year traveling fellowship to Great Britain and Scandinavia. The McLaughlin Fellowship, as it was called, had been established to give young surgeons exposure to the international community prior to assuming a staff appointment. I spent six months as a senior house officer with the renowned esophageal surgeon, Ronald Belsey, in Bristol, England, and seven months in Sweden and Denmark, where I gained valuable exposure to mediastinoscopy. I was especially fortunate, after a chance meeting in the surgeons lounge while visiting the Karolinska Institute in Stockholm, Sweden, to be invited by Dr. Carlens to assist him in the operating room where I observed mediastinoscopy first hand.

In 1960, after returning to Canada, I joined the surgical staff of the Toronto General Hospital and we began to train a new generation of general thoracic surgeons. In 1966, with Dr. Kergin's blessing, Norman Delarue and I proposed that Toronto General Hospital establish the University's first dedicated thoracic surgical service. By 1968, the Royal College of Physicians and Surgeons of Canada had recognized general thoracic surgery as a distinct subspecialty, and I became chief of the first Division of Thoracic Surgery at Toronto General Hospital. Benefiting from my fellowship in Scandinavia and Great Britain, our division contributed to the development of mediastinoscopy, techniques of modern tracheal surgery, and the treatment of esophageal reflux disease through the introduction of the Collis-Belsey procedure. Subsequently, the “Toronto Program” became known internationally for its pioneering work in lung transplantation, minimally invasive procedures, and basic and clinical research. The training program in general thoracic surgery we had instituted at Toronto General Hospital became a model for training programs worldwide. The rest, as they say, is history.

Eventually, the notion of having independent, dedicated training programs in cardiac and general thoracic surgery expanded into the United States, with the creation of the first division of thoracic surgery at Brigham and Women's Hospital in 1988. Many academic centers followed suit. Indeed, today, the majority of academic thoracic surgery is performed by dedicated thoracic surgeons working in separate divisions or sections. This is a stark change from earlier days when cardiothoracic surgeons did it all.

This brings me full circle to the present. It is worth noting that although I have stressed the importance and value of dedicated thoracic training, thoracic surgeons are not the only professional groups qualified to perform these procedures. As a result of differences in postgraduate programs or constraints sometimes imposed by the custom of practice where care is delivered, thoracic cases may be handled by a cardiothoracic surgeon with training in both cardiac and thoracic procedures or even a general surgeon who is comfortable operating in the chest. This book is intended for all three professional groups. In my opinion, the authors and editors of Adult Chest Surgery have prepared a masterful presentation of the thoracic discipline that is well worth your time and attention.