Preface

For the last decade and more, we—the authors of this volume—have been living under the rubric “Rome was not built in a day!”—and indeed, this Atlas of Minimally Invasive Surgical Operations has taken nearly as long as Rome to build. If my memory allows, I would like to take you back 15 years to where the story starts....

In 2003, before the birth of Facebook, Twitter, and many other institutions of the 21st century, I was approached by McGraw-Hill to create an atlas of minimally invasive surgery (MIS) to accompany their best-selling Atlas of Surgical Operations, also known as “Zollinger” by many generations of surgical residents. It was becoming clear that MIS was fast on its way to replacing many common (and uncommon) operations. I responded that I would be interested—if, and only if, I could pick the best medical artist in the country, Cory Sandone, to illustrate this work. As well, I asked McGraw-Hill to allow us 800 figures, or 200 plates, to richly illustrate these procedures, similar to the Zollinger atlas. They agreed, if I could find a corporate partner to help support so much artwork. Chuck Kennedy of U.S. Surgical, then Covidien, then Medtronic, agreed. (I think you are now getting a perspective of the length of time it took to create this atlas!) The next element we needed was expertise in areas where we clearly weren’t experts. The authors contributing to this work, including Wexner, Schauer, Soper, Young-Fadok, and others, are household names to most GI surgeons, widely acclaimed international experts in their respective fields. For other topics, a stellar array of interested and accomplished surgeons from Oregon Health & Science University (OHSU) jumped in to help, each of them now accumulating recognition and reputation in their own fields. With all the elements in place, we were off to the races. Cory and I met by phone weekly, often interrupted by other duties at Hopkins or in Oregon ... and the years ticked by. Finally, about 5 years in to this project, Cory realized that she needed help if we were ever to get this done, and I took another year or so to stumble to the same conclusion. We can’t begin to thank Jennifer Fairman and Donn Spight for agreeing to take on this “labor of love.” Without their efforts, there is little doubt in my mind that we would have a pile of half-finished drawings and rough drafts of procedure descriptions lying around. With them, we have a new atlas that we are all extremely proud of. We’d also like to recognize and thank Andrew Moyer, Brian Belval, Regina Brown, Marsha Gelber, Indu Jawwad, and Marc Strauss at McGraw-Hill, as well as April Hill, Timoree Leggett, and Pamela Sidis at OHSU, for their assistance on this project.

The Atlas of Minimally Invasive Surgical Operations represents the best thoughts and voluminous experience of the pioneers in laparoscopic surgery in the United States who have taken common open operations and adapted them to an MIS environment, bringing things they learned from each other and from masters in Europe, Asia, South America, and Australia into focus at the end of a rod lens telescope. These procedures have evolved over a quarter of a century—they have even evolved since we drew our first figure, forcing us to revise the atlas as we created it. Since our first “draft” table of contents, we have added such things as single-port laparoscopic surgery, natural orifice transluminal surgery (NOTES), and robotic surgery. As soon as the presses start to roll on this first edition, we know that we will need to be back to work, as new technology and new ideas drive procedure evolution.

This is the video generation, and some would suggest that line drawings are out of date, replaced by the surgical video, rendering an atlas such as this anachronistic. While we have been creating educational videos since the beginning of laparoscopic surgery, we realize that line drawings can do something that video struggles to accomplish. The creation of key figures by great illustrators unlocks the difficult steps of laparoscopic surgery, such as the takedown of the splenic flexure of the colon, the “shoeshine” maneuver during laparoscopic Nissen, or obtaining the “critical view of safety” during laparoscopic cholecystectomy. To demonstrate this, I’d like the surgeons reading this introduction to do an exercise: Close your eyes and picture laparoscopic inguinal hernia anatomy. Do you see a video in your mind, or do you see a line drawing or a color figure illustrating this perspective? I will bet that for most of you it is the artist’s figure that you visualize as you step to the operating table, running the operation start-to-finish in your mind, as a slalom racer runs the gates in his or her mind before leaving the starting gate. Hard to believe that a static illustration can be so powerful in something as dynamic as video surgery, isn’t it?

Every good scientific manuscript ever written contains a paragraph on limitations, so let me suggest the limitations of this atlas. Fundamentally, we illustrate one way of accomplishing each operation. Where there are two equally compelling techniques, we have tried to illustrate the alternative method, but we fully recognize that for each procedure we show you, there are 10 (at least) other ways to accomplish the goal with equal, maybe greater, efficiency and expertise. Some of these methods, as we learn them, will appear in the next edition of the atlas. Some may stay rooted in a single surgeon or single institution. As well, we do not yet have companion videos for each of these procedures. Many companion videos can be found online, on Access Surgery or YouTube. With the next edition, we hope to create to links from the atlas to a video demonstrating each step of the technique, but we didn’t want to delay another fortnight in getting this atlas into your hands. I hope, on behalf of Cory, Jeni, Donn, and myself, that you enjoy this work.

The opportunity to work on a major surgical atlas is the dream of many medical illustrators. When John Hunter proposed the idea to create a companion to Zollinger’s Atlas of Surgical Operations describing minimally invasive procedures, we were very familiar with the 5th edition of Zollinger’s in our department library. We often referred to it for operative information and artistic inspiration.

This was a great opportunity: to learn and understand procedures at the forefront of surgical advancement, to collaborate with a surgeon who valued illustrations enough to support an ambitious art budget for this Atlas of Minimally Invasive Surgical Operations, and to communicate surgical content in black-and-white illustrations when the emerging mode for depicting minimally invasive surgery was full-color videos that captured what the camera could—and no more. A medical illustrator can communicate far more in well-designed images, often “zooming out” to provide more anatomic context; using transparency to indicate the position of underlying structures; and incorporating cross sections, diagrams, and cutaway views to illustrate concepts not easily observed through the limited view of the scope. We accepted the challenge of this bicoastal collaboration to depict a comprehensive series of minimally invasive surgical operations.

It didn’t take long to realize this project would go much faster and be more fun if we brought on an additional illustrator and author. Jennifer Fairman and Donn Spight joined the team. Donn’s tireless, careful review was essential to the accuracy of the figures; his unwavering enthusiasm for the process made this project a joy. The Atlas was greatly enhanced by the outstanding illustration and design talents of Jennifer Fairman. Both artists trained at Johns Hopkins and currently teach in the graduate program in the Department of Art as Applied to Medicine. To maintain a consistent illustration style, we shared techniques in graphite and Adobe Photoshop to develop an efficient, smooth workflow.

Most appealing about this project was Dr. Hunter’s positive response to the dynamic, robust quality of our sketches. Often, the authors would provide text and a video or photo and say, “What you can’t see here is that....” We’d work up a quick sketch to be sure we understood the concept. In earlier stages, Dr. Hunter would often respond more positively to the sketch than to the final illustration. These sketches had the energy and immediacy that can sometimes get “polished off” in refining them. He’d suggest we use the first sketch—it captured the concept! We made sure the images were clear and accurate while retaining a vigorous drawing style.

We had Friday phone calls for over a decade to create this massive body of work-nearly a thousand illustrations. We would review iterations of the figures, ask questions, and clarify content. The authors would teach us surgery, one hour a week, calling in at 11:00 a.m. Baltimore time and 8:00 a.m. Portland time. As procedures changed, we’d revise earlier illustrations and add or replace figures. As we worked together illustrating chapters, we continued to hone our skills as effective communicators of surgical technique. Our individual approaches blended into one unique style that is signature to this Atlas.

Minimally invasive surgery continued to evolve throughout the development of this comprehensive work. Technical innovation in these procedures will persist, making it challenging to bring a project of this scope to completion. With the support of McGraw-Hill and the entire team, it is our pleasure to bring this Atlas of Minimally Invasive Surgical Operations to print.