Introduction
KevinE. Behrns
ecent advances in surgical and medical care have
R extended the survival of patients with multiple dis-
eases, and vascular and enteral access procedures have
played a quiet and unassuming role in this lengthened
survival. Patients with alimentary tract or renal failure
have suffered devastating organ loss, yet survive to enjoy
personal relationships largely because of vascular or en-
teral access procedures. These operations receive little
attention in the medical literature and are expected "to go
well." Meticulous attention to detail may allow the access
device to be little more than an appendage to a patient,
but a poorly placed or bothersome device will prove a
major burden for the already troubled patient. The goals
of this issue of Operative Techniques in General Surgery are
to present the breadth of operative vascular and enteral
access procedures, to provide step-by-step approaches to
the techniques, and to highlight the benefits and risks of
each procedure.
With access procedures, the surgeon too often passes
quick judgment about performing the procedure and
which procedure should be done. As always, preoperative
assessment is critical in these patients, who may need a
lifetime of access. The initial questions that the surgeon
should ask are, "What is the disease process and how can
it be remedied by an access procedure?," then, "Which
access procedure will provide low-risk insertion and can
be easily managed by the patient?," and finally, "How can
I provide the necessary medical education such that the
patient and significant others understand the purpose of
this 'tube' and can care for it well?" Once these questions
are addressed, performance of these procedures with me-
ticulous technique will make the operation straightfor-
ward. These procedures often can be performed in the
outpatient setting or by a minimally invasive approach;
therefore, time available for instruction may be limited,
Copyright9 2001 by W.B.SaundersCompany
doi:10.1053/otgn.2001.27698
202 Operative Techniques in General Surgery, Vol 3, No 4 (December), 2001: p 202
Guest Editor
and a separate appointment with allied personnel to dis-
cuss the use and care of the device is often beneficial.
This issue of Operative Techniques in General Surgery
presents a number of different approaches to the vascular
system and the alimentary tract by experts in various
disciplines. General surgeons are well trained to gain ac-
cess to many of the necessary locations, but increasingly,
vascular and cardiovascular surgeons are required in pa-
tients with difficult access, and interventional radiologists
routinely perform vascular and intestinal access proce-
dures. I am delighted that this issue will provide the
perspective of general, laparoscopic, vascular, and cardio-
vascular surgeons and interventional radiologists. Access,
to the vascular system through the internal jugular, sub-
clavian, and lumbar veins is described, as is right atrial
access. Intestinal access via the pharynx, stomach, and
jejunum is addressed through descriptions of open and
minimally invasive approaches. The beauty of this issue is
in the simplicity of the presentations. The authors have
masterfully limited the text but provided well-conceived
diagrams, expertly illustrated, that stress the technique of
the operation.
This collection of illustrated procedures is informative
for the novice and expert surgeon alike. Newer minimally
invasive and percutaneous approaches, as well as "time-
tested" procedures, are presented. The wide range of pro-
cedures discussed highlights the multidisciplinary ap-
proach to these patients and also demonstrates the expert
care rendered. The contributors to this edition have de-
voted precious time to their well-presented topics. I thank
them for their devotion and attention to detail. The illus-
trations are elegant and immediately draw one's focus to
the important aspects. Finally, the editors should be con-
gratulated for choosing a topic that receives little atten-
tion, but impacts so many patients. This issue provides
clear, easy-to-follow operative techniques; please enjoy.
Kevin E. Behrns, MD
Guest Editor