Atlas of Operative Surgical Oncology Rajendra Badwe, Sabita Jiwnani, Anil D’cruz
Page numbers followed by f refer to figure and t refer to table.
Abdomen 80, 146
Abdominal defects, lower 203
Abdominal hysterectomy, total 105, 109
Abdominoperineal resection 160, 162
Adductor longus 76
Adhesive obstruction 155
Adrenalectomy, role of 71
Adrenaline infiltration 204
obstruction 42, 58
transfer 63, 63f
Alpha fetoprotein 80, 87
Alveolar nerve, inferior 32
lower 35f
upper 35f
American Academy of Otolaryngology Head and Neck Surgery 19
American College of Obstetricians and Gynecologists 105
American Head and Neck Society 19
American Society of Clinical Oncology 111
Amputation, levels of 123
Anal sphincter, external 174
Anastomosis 188
safe 159
Anastomotic dehiscence 159
Anastomotic leakage 155, 176
Anesthesia 4, 20, 30, 38, 99, 160, 164, 175, 184, 208, 215
examination under 49, 50, 228
Angioembolization, preoperative 70
Ankle disarticulation 123
Anomalous renal vessels 73
Antibiotic prophylaxis 20, 30, 38, 44
Aorta 154f, 166
invasion of 184
left border of 139f
Arm defects, upper 214
Arteriovenous malformation 73
Aspiration 59
Atelectasis 195
Audio Doppler 203
Autoimmune pancreatitis 138
clinically negative 9
coverage of 214
Axillary disease, clinically positive 9
Axillary fold, anterior 208
Axillary incision 11f
Axillary lymph node dissection 9, 12
Axillary sampling 9, 10, 12f
Axillary surgery for breast cancer 9
Azygos vein ligation 185f
Back defect, upper 214
Belly of
anterior 24
muscle, posterior 45, 53
posterior 24
Berry's ligament 41, 42
Beta human chorionic gonadotropin 80
Betadine scrub bath 75
Beta-human chorionic gonadotropin 87
Biopsy 30, 130, 131f, 138, 160, 174
disadvantages with open 133
in sarcoma 130
open 130, 133
types of 130
Bite resection 34, 35
specimen 35f
Bladder dysfunction, chronic 103
Blair's incision 44f, 48
Bleeding 16, 35
from enterostomy 164
reactionary 58
secondary 58
Blood supply 218
Bone 121
marrow examination 228
scan 70, 223
scintigraphy 228
Borderline resectable pancreatic cancer 137
Brachial plexus 25f
Branch of middle colic
left 153f
right 153f
Breast 1
advanced 12
inflammatory 4, 9
surgery for 3
surgery 3, 4
therapy 3
lump 3
reconstruction 214
Breastfeeding, loss of 16
Buccal mucosa cancer, surgery for 29
Buck fascia 84
Bulky lymphadenopathy 153
Bulky para-aortic disease 89
Bursectomy 167
Calot's triangle 147
Cancer vulva, surgery for 113
Canoe-shaped marginal mandibulectomy 33f
Carbohydrate antigen 199 146
Carbon monoxide 87
Carcinoembryonic antigen 138, 151, 160, 174
Carcinoma gallbladder, surgery for 146
Cardiac arrhythmias 195
Carotid artery
external 24
internal 25, 43
blockage 198
fracture 199
Catheter-related bloodstream infection 198
Cattell-Braasch maneuver 139
Celiac artery, branches of 169f
Celiac trunk, encasement of 166
Central nervous system 228
esophageal mobilization 187, 187f
hand sewn anastomosis 189
lymphadenectomy 188
root 26f
stapled anastomosis 188
Cervicofacial flap, anteriorly-based 45f
Cervix stages, carcinoma 95
wall defects
anterior 214
posterior 214
wound, closure of 212f
Chevassu's maneuver 80
Chevron incision 147
Chopart amputation 124
Chyle leak 27
Chylous ascites 97
Clavicular fracture 209
Cloquet's node 75, 78
Coeliac lymph nodes 148
Colectomy 151
preoperative evaluation 151
radical 152
Colic artery
left 154f
middle 153f
Colic pedicle, dissected middle 153f
Colon bed, right 154f
Colonoscopy 160, 174
Colostomy 163
Common bile duct 137, 139
dissection 141
Common carotid artery 21f, 25, 197f
Common hepatic
artery 138, 140, 148, 169, 169f, 170
duct 142
Complete blood count 104
Complete kocherization 148
Conjunctival exposure with mucus accumulation 230
Core needle biopsy 130, 131
Cosmetic deformity 27
C-reactive protein 138
Cricopharyngeal myotomy 63
Cuffed tracheostomy 66
Cystic lymph nodes 148
Cystic neoplasms 138
Cytology 138
Cytoreductive nephrectomy 69
Deltopectoral 208
Dense adhesions 95
prophylaxis 30
rehabilitation 35
Deskeletonization of larynx 62
Devascularization of larynx 62
Disease involving sclera 229
Distant metastases 114, 184
Duct carcinoma 14
Duct ectasia 14
Duct papilloma 14
Ductal carcinoma in situ 9
Duodenal injury 155
Duodenal stump leak 173
Duodenojejunal flexure 155
Duodenum, second part of 154f
Dynamic sentinel lymph node biopsy 74, 75
Dysfunctional larynx 60
Early dumping syndrome 173
Eastern Cooperative Oncology Group 60
Edema 58
above 123, 125f
below 123, 125f
disarticulation 123
Electrolyte imbalance 164
Endoscopic retrograde cholangiopancreatography 137, 149
Endoscopic ultrasonography 137, 182
End-to-end anastomosis 171
Enhanced recovery after surgery 139
Enterostomy 163
herniation 164
prolapse 164
Epiglottis 63
Esophageal cancer 181, 182f, 183t
lymphadenectomy for 181
surgery for 181
Esophagogastric triangulating anastomotic technique 189f
Esophagus, infracarinal part of 184f
Extrahepatic bile duct excision 148
Extraocular disease 228, 229
Eye, enucleation of 229f
Facelift incision 44, 44f
artery 23f
asymmetry 47
nerve 46f
divisions of 46f
injury 47
management of 46
monitoring 44
reconstruction 47
trunk of 45f
vein 45
Familial adenomatous polyposis 152
Fecal soiling of incision 164
artery 76, 117f
canal 117f, 118f
nerve 76
vein 76, 117f
Fibrin formation 198
Fine needle aspiration 138
cytology 20, 37, 38, 43, 83, 99, 105, 113, 166
Fistula, late 103
Flank incision, layers of 71f
Fluorodeoxyglucose 87
Foley catheter 75
Forehead flap 218, 219f
Forequarter amputation 123
Frank blood 144
Frey's syndrome 47
Gallbladder 89, 141
cancer 146
carcinoma, dissection for 148f
Gastrectomy 165
reconstruction, total 172f
total 166
types of 166
Gastric artery
dissection, right 169f
division of left 170, 170f
left 168, 169f, 170
right 167
Gastric conduit 189f
Gastric dilatation, acute 149
Gastric emptying, delayed 144, 173
Gastric mobilization 186
Gastric pedicle dissection, left 187f
Gastric surgery, radical 166
Gastric transection 140
Gastric tube, formation of 171, 188f
Gastric vessels
division of
right 167
short 170
Gastrocolic omentum, division of 153, 154
Gastrocolic trunk 153f
Gastroduodenal artery 140, 141f, 147, 148
dissection, right 168f
ligated, right 140f
vein 167
dissection, right 168f
Gastrojejunostomy 143, 171
Genetic analysis 38
Germ cell tumors 87
Gerota's fascia 71
Gingivobuccal mucosa complex tumors 49
Gland, dissection of body of 39
Glomerular filtration rate 70
Glossectomy specimen 56f
Gluteal region 203
Gonadal vein 71
right 154f
Greater auricular nerve 23, 24
Groin incision, right 116f
Groin node dissection 74, 116
anatomy for 116f
Gubernaculum, division of 81f
Gustatory sweating 47
Gyne-oncology 93
Head and neck
cancers 22
squamous cell carcinoma 19
Head of pancreas 137, 153f, 166
Hematoma 42, 85, 198
Hemicolectomy, left 154f, 155f
right 153f, 154f
Hemiglossectomy defect, left 57f
Hemimandibulectomy 34
Hemorrhage 27, 42, 65
intraoperative 72
postoperative 144
Hemothorax 195, 198
Hepatic artery
left 147, 148
proper 148
right 147, 148
Hepatic flexure mobilization 153
Hepaticojejunostomy 143, 143f
Hepatoduodenal ligament 148
Hereditary nonpolyposis colorectal cancer 152
Hindquarter amputation 123
Hip disarticulation 123
Hyoid bone 62f
Hyperthermic intraperitoneal chemotherapy 106
Hyperthyroid goiter 38
Hypocalcemia 42
Hypoglossal nerve 24f, 53
Hypothyroidism 66
radical 99
specimen, radical 103f
Ileocecal 88
Ileocolic pedicle, dissected 153f
Ileoinguinal nerve lateralized 81f
Ileostomy 163
end 163
Ileus, postoperative 155, 176
Iliac artery, external 77
Iliac gland, dissection of
external 96
internal 96
Iliac spine, anterior superior 73, 76, 81, 81f
Iliac vein, external 77
Iliac vessels, external 96f
Ilio-obturator dissection, completed 97f
Implant migration 230
Inappropriate biopsies 123
Incision 5, 7, 21, 100, 116
Infratemporal fossa 43
Infundibulopelvic 95
Inguinal ligament 76, 77
Inguinal lymphadenectomy
modified 75
radical 76
Inguinal orchiectomy 80
Inguinofemoral lymphadenectomy 116
Inter-aortocaval lymph nodes 148
International Germ Cell Cancer Collaborative Group 88
International neuroblastoma staging system 223
International Study Group of Pancreatic Surgery 144
Interrupted hepaticojejunostomy 149f
Intersphincteric plane 174
Intersphincteric resection 174
Interval cytoreduction 105
Intracapsular dissection 41f, 48
disease 228
extension 43
Intraocular group E disease 228
Intraocular retinoblastoma, staging for 229t
Intraoral defects 214
Intrathoracic stapled anastomosis 189
Intravenous antibiotics 58
Ivor lewis esophagectomy 181
Jaundice, obstructive 137
Jaw stretching exercises 35
Jejunojejunal anastomotic leak 173
Jejunum, transection of 141
Jugular vein 20
anterior 23
external 21f, 22
internal 19, 26, 53, 187, 196
right internal 197f
Kidney, right 89, 90
Knee disarticulation 123
Kocher's maneuver 139, 139f
Kocher's incision 39
Lactate dehydrogenase 80, 87, 223
Laparoscopic gastric mobilization, ports for 189f
Laparoscopic nephrectomy, left 73f
Laparoscopic surgery, role of 149
Laparoscopic technique 73
Laparotomy 100
conventional 100
staging 107
Laryngeal entry 63, 63f
Laryngeal nerve 40
branch of superior 39
dissection 41
left recurrent 187
superior 40f
Laryngeal suspension 58
Laryngectomy 60
Laryngoscopy, direct 60
Latissimus dorsi 214
Ligament of treitz 139
Lingual artery 53
in neck, left 53f
Lisfranc amputation 124
function test 104, 146
mobilization 110
Loop colostomy 163f
Loop ileostomy 163
Lower limb 123
Low-molecular-weight heparin 75
Lumbar puncture 228
Lumbar vein, left 90
Lumpectomy, incision planning for 5f
diffusing capacity of 87
metastasis 106
wedge excision 194f
Lymph nodal mass, removal of 96
Lymph node 9, 87, 148, 159
biopsy 12f
dissection of 169f
regional 182f, 183t
supraclavicular 104
Lymphadenectomy 47, 148
abdominal 186
extent of 71, 142
Lymphatic fistula 97
Lymphedema 78, 103
Lymphocele 103
Lymphomas 38
Lymphoscintigraphy 10f
Mandibular nerve, marginal 23
Mandibular remnant, deviation of 59
intraoral marginal 33f
marginal 32, 36
types of marginal 32f
Mastectomy 7
McKeown transthoracic esophagectomy 181
Mediastinal route, posterior 189f
Medullary bone invasion 34
Mesenteric artery
inferior 89, 90, 141, 152, 154f, 161, 175
superior 138, 139, 142f, 225f
Mesenteric vein
inferior 154f, 155f
superior 138, 140f, 142, 153, 167
Mesentery, root of 106, 107
Mesorectal excision, total 157
Meta-iodo-benzyl guanidine 223
Metastatic disease 50, 147
Methylene blue injected intradermal 10f
Microdochectomy 14
incision for 15f
Midtarsal joint 124
Minimal access surgery 100
Minimally invasive esophagectomy 181
Motilin agonist 144
Motor innervation 214
Mucosal incision, intraoral
lateral 53f
medial 53f
Multifocal disease 7
Muscle, elevation of 211
Mylohyoid muscle 24f
Nasojejunal tube 143
Near-total glossectomy defect 58f
dissection 19, 20, 57, 62
incision for 22
modified 57
radical 19, 20
types of 19t, 20, 21
flap, closure of 58
left side 187f
nodes 50
inoperable 44
levels of 20f
ultrasonography 37
Neoadjuvant chemoradiotherapy 157
Neoadjuvant chemotherapy 105
Neoplasms of parotid 43
Nephrectomy 69, 72
open partial 72
radical 69
Nephron-sparing surgery 69, 72f
Nerve injury 103
Neuroblastoma, abdominal 223
Neuroendocrine tumors 137
Nipple 16
cytology 14
pathological 14
loss in 16
Nipple-areola complex 15
Node negative, clinically 74
Node-positive operable breast cancer 12
Nodulectomy 48
Nonregional lymph node 153, 167
disease 166
Obesity 203
Obstructive pulmonary disease, chronic 183
fossa 96f
gland 96
nerve 77
neurapraxia 103
Oculoplasty 229
for retinoblastoma 228
Omentectomy 109, 110f, 167
Omohyoid muscle 26f
Open biopsy, advantages of 133
Optic nerve 228
cancer, incision for 21
tongue 55
Orocutaneous fistula 35, 59
Orotracheal intubation 61
Orthopantomogram 50
Osteoradionecrosis 36
Ovarian cancer
advanced 106f, 108
bilateral large 106f
early stage 106f, 107
staging in early 108f
surgery for 104
treatment of
advanced 106
early 105
Pain control, postoperative 72
Pancreatic duct
anterior 142f
posterior 142f
Pancreatic ductal adenocarcinoma 137
Pancreatic fistula, postoperative 143, 144
Pancreatic neck dissection 140f
Pancreaticoduodenal arteries, inferior 141, 142f
Pancreaticoduodenectomy 137
Pancreaticojejunostomy 142
Pancreatitis, postoperative 173
Paramandibular disease, extensive 32, 34
Paramedian mandibulotomy 56f
Parametrial tunnel 101
Parathyroid dissection, superior 40
Paratracheal dissection 41
Parenchymal liver 106
cysts, multiple 43
fistula 35
neoplasm 45
surgeries 43
classification of 44
tumor 44f
Parotidectomy 48
Parotitis, acute 43
Pectoral branch 208
Pectoralis major 208
flap 208, 209f
muscle 6f
myocutaneous 209, 212
flap 57, 213
myofascial flap 61
Pectoralis muscle with sutures 198f
Pedicle, elevation of 211
Pedicled anterolateral thigh 78f
Pedicled latissimus dorsi flap 214
dissection, complications of 111
lymph node dissection 77, 77f, 95
bilateral 100
complication of 97
lymphadenectomy 100f
bilateral 76
completed 97f
sidewall, entry to 96f, 100f
wall, lateral 160, 174
Pelvis 146
Penectomy, total 85
Penile amputative surgery 86
Penile cancer 83
surgery for 83
Penile stump 85f
Percutaneous biopsy 70, 73
Percutaneous transhepatic biliary drainage 149
Periampullary tumors 138
Pericholedochal lymph nodes 148
Perineal part 161
Perineal region 203
Perineal wound infection 162
Peripheral vascular disease 203
Periportal lymphadenectomy, complete 147f, 148f
Peritoneal disease 167
Peroral wide excision 30
Pharyngeal augmentation 64
Pharyngocutaneous 64
fistula 65
Phrenic nerve 25f
Pirogoff amputation 124
Plaster of Paris slabs 126
Plastic and reconstructive surgery 201
Plastic reconstructive consultation 30
Pneumothorax 198
Polydioxanone 144
Porta hepatis 106, 107
Porta hepatis dissection 140
Portal vein 138, 142, 147, 148, 169
Posterolateral thoracotomy 193
Postoncologic defects 214
Pouch of Douglas 104
Prelaryngeal dissection 41
Pretracheal dissection 41
Prevertebral fascia involvement 44
esophagus 189f
femur resection 131f
gastrectomy 166
stomach transection 171f
Psoas muscle, left 90
Pubic tubercle 76, 81
disease, extensive 183
embolism 78
function test 87, 182
metastasectomy 192
parenchyma 195f
Pylorus, internal dilatation of 188f
Pylorus-preserving pancreaticoduodenectomy 138
Radical colectomy, types of 151, 152t
Radical mastectomy, modified 3, 7, 10
Radical neck dissection, modified 20
Radical nephrectomy, open 70
Radical parotidectomy 44
Radiofrequency ablation 70
Ray amputation 124
Reconstruction of vulva 118
Rectal malignancy, low 157
Rectal sphincter dysfunction 103
Rectum 103
mobilization of 158
Rectus femoris 203205, 206
muscle 205
Rectus muscle identified 204f
Red blood cells 14
artery, left 71, 88, 90
cancer, surgery for 69
cell carcinoma 69
acute 226
chronic 69
function test 104
vein, left 139f
vessels, dissected left 71f
Respiratory distress syndrome, acute 195
Retinoblastoma 228
Retromandibular vein 45
hematoma 82
lymph node dissection 87
complications of 111
Rhytidectomy 44
Robotic technique 73
Ryle's tube color 144
fistula 47
leak 59
leakage 47
extensive 47
Salpingo-oophorectomy, bilateral 105, 109
Saphenofemoral junction 77, 117f
Saphenous vein 117f
Sartorius muscle exposed 116f
Scapular defect 214
Scarpa's fascia 76
Sciatic nerve 160, 174
Segmental mandibulectomy 34, 36, 56f
Semen analysis 80
Sensation over chin, loss of 35
Sentinel lymph node 11f
bilateral 76f
biopsy 9, 10
dissection 10
Seroma formation 42
calcitonin 138
carcinoembryonic antigen 157
tumor markers 87, 104
Sexual dysfunction 103, 159, 162, 176
Shock, circulatory 226
dysfunction 27
joint disarticulation 123
closure 8
erythema 11
incision 75, 224f
transverse 187f
island dimensions 209
necrosis 35
paddle 211
design 209
territory 218
Small bowel 89f
Society of Gynecologic Oncology 105
Soft tissue 121
margin by palpation 52f
sarcomas 127
Speech and swallowing dysfunction 35, 59
Sperm banking 80
Spermatic cord 76
Spinal accessory nerve 19, 20, 23, 24, 27f
Splenic artery 169, 169f, 170
Splenic flexure mobilization 154
Split skin graft 219f
Split-thickness skin graft 211
Sternocleidomastoid muscle 19, 20, 46, 187
Stoma 61
Stomach with gastroepiploic arcade 186f
Stomal complications 162
Stomal stenosis 66
Stylomastoid foramen 45
Subcutaneous emphysema 195
Submandibular gland 45, 46, 53
Subplatysmal flaps 39
Subtotal gastrectomy 165, 166, 171f
Suprahilar dissection 90
Suprahyoid muscle 54, 54f, 62f
Suprasternal incision 39f
Syme's amputation 124
Systemic inflammatory response syndrome 143
Tarsometatarsal amputation 124
Temporal area, defects of 214
Tenon's capsule 230f
Testis, normal 80
anterolateral 118, 203
flap, anterolateral 58f
Thoracic duct ligation 185f
Thoracoabdominal incision 224
Thoracoscopic esophageal mobilization, ports for 189f
anterior 193
anterolateral 193
Thorax 69, 80, 146
lymphadenectomy in 185
Throat pack 51
Thromboprophylaxis 75
artery, superior 24f, 62f
cancer 38
function tests 38
gland 40f, 62
mobilization of 40f
neoplasms 38
vein, inferior 40f
Thyroidectomy 39f
total 37
Thyroiditis 38
Toe with metatarsal head 124
Tongue cancer 50
surgery for 49
fistula 184
groove 40
prosthesis 65
failure of 66
puncture 63
Tracheostomy 58
Transection of parotid duct 46f
Transhiatal esophagectomy 181, 190
Transthoracic esophagectomy, incision 184
Transverse cutaneous nerve 23
Tumor 35
abutting mandible 32
early superficial 30
infiltrating root of mesentery 224
lysis syndrome 70
markers 38, 137
primary 74
requiring bite resection 35f
resectability 153, 167
Uncinate dissection, initial 139
Unresectable nodal disease 50
Unresectable primary disease 50, 184
Upper limb 123
Upper vagina, clamping 102
Ureter 103
dissection of 100
right 154f
Ureteral injury 97, 155
Ureteric stricture 103
Ureterovesical fistula 103
Urethra, isolated 84f
tract infections 103
vanillylmandelic acid 223
Urology 67
Uterine artery 101f
Uterosacral ligaments, division of 102
Uterovesical pouch 101
Uterus from rectum, mobilization of 101
Vascular anatomy 208
Vascular pedicles, division of 153, 154
Vastus lateralis 203205
Vein thromboembolism, early deep 103
Vein thrombosis, deep 78, 110, 119, 158, 162, 176
Vena cava
inferior 69, 88, 90, 139, 154f, 224
superior 196
Venous thrombi 71
Vesicovaginal fistula 103
Vessels, encasement of major 224
Vicryl suture 65
Vigorous palpation 195
Visceral injury 103
Vulva, anatomy of 114f
closure of 115
radical 115
Wedge resection of liver 147f
Whipple surgery, classical 140
Wire localization, preoperative 193
dehiscence 155
infection 65, 78, 85, 103
Chapter Notes

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Editors Sabita Jiwnani MCh MRCS Assistant Professor, Thoracic Surgery Department of Surgical Oncology Tata Memorial Centre Mumbai, Maharashtra, India Anil D'cruz MS FRCS Professor, Head and Neck Surgical Oncology Director, Tata Memorial Hospital Tata Memorial Centre Mumbai, Maharashtra, India Rajendra Badwe MS (General Surgery) Professor and Chief, Breast Surgery Department of Surgical Oncology Director, Tata Memorial Centre Mumbai, Maharashtra, India Forewords Praful B Desai Benjamin O Anderson Alberto Costa
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Atlas of Operative Surgical Oncology
First Edition: 2017
Printed at
Dedicated to
All our patients at Tata Memorial Centre Mumbai, Maharashtra, India
Contributors Foreword
I am deeply privileged to pen a few words for this important, informative and brief compilation, Atlas of Operative Surgical Oncology by the surgical faculty of the Tata Memorial Centre, Mumbai, Maharashtra, India. It is very appropriate that this is being released on the eve of the platinum jubilee of the institution. We are currently in a most exciting era of medicine. From molecular biology to genetics, our understanding of this disease is slowly and steadily progressing. Though the cure of cancer eludes us, there is no doubt that more patients are living much longer than ever before.
Of all the therapeutic approaches, there is little doubt that surgery, when indicated is the oldest and still the most curative approach in early stages of the disease. Despite rapid progress in chemoradiotherapy, surgery still remains steadfast as a major therapeutic approach for the cure and control of cancer. It is, therefore, necessary and imperative that surgeons dealing with cancer know the finer nuances of the surgical approach like indications, contraindications and techniques in given clinical settings. The surgeon also needs to be adept in foreseeing complications, its early diagnosis and appropriate management; indeed, most complications can be and should be prevented at the time of surgical procedure by precise and appropriate surgical techniques.
I sincerely hope and I am sure that this important, significant and brief surgical atlas will be extremely useful and helpful to many of our non-oncology and general surgeons who carry and manage a significant load of surgical oncology beyond the confines of large oncology centers and general hospitals. Even the postgraduate students will find this “Atlas” useful for their qualifying examinations.
I wish to congratulate the editors and their colleagues at Tata Memorial Centre, for this seminal effort and wish this compilation will receive a wide acceptance.
Praful B Desai ms
Senior Consulting Surgical Oncologist
Bombay Hospital and Research Centre
Breach Candy Hospital
Mumbai, Maharashtra, India
Having caused over 8 million deaths worldwide in 2013, cancer is now the second leading cause of human death. While cancer is often identified as a high-income country health problem, low and middle income countries (LMICs) account for 57% of cases and 65% of cancer deaths globally. The burden of cancer will continue to shift to less developed countries due to growth and aging of world populations with increasing prevalence of known cancer risk factors. Looking ahead, the 12.7 million cases that occurred in 2008 are predicted to rise an additional 75% to 22.2 million by 2030, the majority in LMICs.
Cancer demographics vary among countries but correlates with level of economic development. Cancers of the breast, lung, colorectum, and prostate account for half the overall cancer burden in regions of the highest Human Development Index (HDI), while cancers of the esophagus, stomach, and liver are relatively more common in medium HDI regions. Cervical cancer was more common than both breast and liver cancer in low HDI regions back in 1990, but those trends are shifting as cervical cancer prevention is improving while breast cancer rates continue to rise. Overall, the rapid societal and economic transition in many countries means that any reductions in infection-related cancers (cervical, liver, stomach) are offset by an increasing number of new cases that are more associated with reproductive, dietary, and hormonal factors (breast, colorectal, prostate) all of which require multidisciplinary treatment if curative outcomes are intended.
Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases needed surgery, some several times. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This deficit is multifactorial, but a significant obstacle is the lack of education about cancer surgery in limited resource settings, where cancer presentations differ from high-income countries and where healthcare system constraints require adapted approaches that are resource-appropriate.
The internationally recognized surgical oncology faculty from the Tata Memorial Hospital, Mumbai, Maharashtra, India, is well positioned to teach us about the unique cancer surgical needs of a lower-middle income environment like India. These accomplished surgeons previously proved that deficits of surgical education can lead to detrimental surgical outcomes. For example, of 424 patients who underwent therapeutic breast cancer surgery between 2000 and 2003, 191 (45%) had received incomplete surgery at outside non-specialty centers. Almost half of those patients who underwent incomplete surgery had surgically excisable residual disease. Of 148 patients who underwent completion revision surgery, 123 (83%) patients had residual lymph nodes in the axilla including 64 who had metastatic lymph nodes left behind in the axillary bed.
The Tata Memorial surgical experts have also shown that approaches commonly considered essential in high-income countries may not be needed in limited resource settings where patients most commonly present with clinically advanced disease. For example, in high-income countries where the majority of breast cancers are identified by mammographic screening prior to the development of clinical signs and symptoms, diagnostic mammography is considered an essential diagnostic study for patients undergoing breast conservation surgery to determine the actual extent of disease for proper surgical planning. By contrast, the Tata Memorial team showed us that in their setting where essentially all patients present with well-established clinically palpable disease, diagnostic mammography had limited value, making no difference in the decision making among 95% of the 735 breast conservation patients treated at their institution. Educational materials are clearly needed to be properly contextualized to the environment in which they are going to be applied.
This Atlas of Operative Surgical Oncology from Tata Memorial's surgical oncology faculty is a valuable contribution to the surgical management of cancer. The well-written text is brief but poignant. Key issues in diagnosis and operative preparation are discussed. The bullet point explanations of the surgical procedure provide a clear description of the operative steps, especially helpful for surgeons who may be experienced in surgery but may not have had the benefit of complete surgical training in cancer surgery. The operative photographs and diagrams are clear, well selected and highly informative. Indications, contraindications and cautions are nicely presented, providing crystal clarity of the key issues that thoughtful surgeons need to properly manage their cancer patients. The value of this document goes beyond its technical scope to touch on key issues in cancer control. The authors and collaborators should be congratulated for this important achievement.
Benjamin O Anderson md
Chair and Director, Breast Health Global Initiative
Joint Member, Fred Hutchinson Cancer Research Center
Professor of Surgery and Global Health-Medicine
University of Washington
Seattle, Washington, USA
Surgery is the core modality for the management of solid tumors. Cancer care as a whole, and particularly surgery has evolved to incorporate more effective treatment with decreasing morbidity. An important component of advancing surgery as the focal point of cancer care is surgical training. Countless lives can be saved by enabling more surgeons to deliver what is optimum. And, it is now possible to offer surgery for more advanced cancer in cooperation with other surgical branches such as plastic and reconstructive surgeons.
This atlas will not only be helpful for those who are at the beginning of their surgical oncology training but also for the experienced surgeons to enhance their surgical techniques, as this atlas highlights fine nuances developed by the masters in their respective specialties.
I had the privilege and the honor to perform one of the first Veronesi quadrantectomies at Tata Memorial in Mumbai in 1985 and I still remember the interest and the curiosity of the colleagues who were around in the theatre. A lot of time has passed and Tata is now a world leader of conservative breast surgery, supported by outstanding biological and molecular research.
Thank you for having given me the wonderful opportunity of sharing with you the pioneering work of Umberto Veronesi and our surgery group in Milan. Hope that this atlas becomes a guide for surgeons not only in Asia but across the globe.
Best wishes!
Alberto Costa md
CEO and Cancer World Editor
European School of Oncology
Milan, Italy
The concept for the Atlas of Operative Surgical Oncology was derived from the annual live operative surgical oncology workshop “OncoSurg” held at the Tata Memorial Centre since more than a decade. Surgery is the mainstay of treatment for most solid cancers, even though the role of multimodality management is increasing. Surgery for cancer has evolved from crude and mutilating excisions to a fine balance between sound oncological techniques and organ preservation, wherever possible. This book is aimed at providing a comprehensive and concise description of the surgical procedures employed in the treatment of common cancers.
We have avoided describing the disease process, but concentrated on the operative techniques. Every chapter in the book not only informs the surgeon on how best to select patients for each procedure but also when surgery is contraindicated. A brief description of the preoperative evaluation of the patient for the procedure, type of anesthesia commonly employed and the positioning of the patient is also included. This is accompanied by a step-by-step description of the procedure and a list of common complications. Variations in surgical steps, tips to avoid surgical mishaps and techniques to improve oncological outcomes and surgical safety have been addressed. Minimally invasive procedures have been mentioned wherever appropriate. Every chapter ends with key points, which include the do's and don'ts for surgery of that organ. Operative photographs, illustrations and tables are the highlights of this atlas, and make the understanding of the operative field, the technique and steps involved easier to grasp.
Complex and less common surgical oncology procedures which require a high degree of specialization have not been included in this atlas, as the focus remains on the common cancers. Even though this book has been written keeping the general surgical oncologists and general surgeons in mind, it provides enough information for the specialists. This atlas aims to serve as a ready reference for a practicing surgical oncologist, a guide for the trainees and fellows and will be useful for the undergraduates preparing for their examinations to understand the techniques in surgical oncology.
The contributors to the book are the esteemed faculty from the surgical oncology department at Tata Memorial Centre, an institution committed to service, research and education. We are extremely grateful to all the contributors who took the time to put this atlas together, summarizing their expert views on the surgical procedures that they have mastered.
Lastly, we must not forget our patients, whose trust in us is an everyday reminder of how sincerely we need to try to do our best for them.
Sabita Jiwnani
Anil D'cruz
Rajendra Badwe
We would like to thank all the authors for their steadfast support. We would like to acknowledge Dr Gouri Pantvaidya for her ideas and suggestions.
We also want to thank the medical artist department at Tata Memorial Hospital, especially Mr Nilesh Ganthade and Mr Kamlesh, who have helped us in editing the operative photographs and illustrations, and this effort would be incomplete without them.
Finally, this book would not have been published in time without the support of Shri Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Group President) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India. The team assigned to this atlas, especially Mr Sabarish Menon, Mr Joaquim Marques, Mr Rajesh Sharma and Mr Laxmidhar Padhiary have worked round the clock to ensure the successful publication of this title.