Netters Surgical Anatomy and Approaches Conor P Delaney MD MCH PHD Facs Frcsi Fascrs Frcsi Hon Full Chapter

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2 nd
EDITION
NETTERS
SURGICAL ANATOMY
AND APPROACHES
CONOR P. DELANEY
MICHAEL S. BENNINGER TONY CAPIZZANI
TOMMASO FALCONE STEPHEN R . GROBMYER
JIHAD KAOUK MATTHEW KROH SEAN P. LYDEN
-
JOHN H. RODRIGUEZ MICHAEL J. ROSEN
CHRISTOPHER T. SIEGEL * ALLAN SIPERSTEIN
SCOTT R. STEELE • R. MATTHEW WALSH
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2015v1.0
2 nd
EDITION
NETTER’S
SURGICAL ANATOMY
AND APPROACHES
Conor P. Delaney,
MD, MCh, PhD, FACS, FRCSI, FASCRS, FRCSI (Hon)
Chairman
Digestive Disease and Surgery Institute
Cleveland Clinic
Victor W. Fazio Endowed Professor of Colorectal Surgery
Cleveland Clinic Lerner College of Medicine
Cleveland, Ohio
Illustrations by
Frank H. Netter, MD
Contributing Illustrators
Carlos A. G. Machado, MD
Kristen Wienandt Marzejon, MS, MFA
James A. Perkins, MS, MFA
John A. Craig, MD
Paul Kim, MS
Sara M. Jarret, MFA
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
NETTER’S SURGICAL ANATOMY AND APPROACHES, SECOND EDITION ISBN: 978-0-323-67346-4

Copyright © 2021 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Permission to use Netter Art figures may be sought through the website NetterImages.com or by emailing
Elsevier’s Licensing Department at H.Licensing@elsevier.com.
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous edition copyrighted 2014.
Library of Congress Control Number: 2020939762
Publisher: Elyse O’Grady

Senior Content Development Specialist: Marybeth Thiel
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Daniel Fitzgerald
Designer: Patrick Ferguson
Printed in China.
Last digit is the print number: 9 8 7 6 5 4 3 2 1

For my colleagues who have contributed to this book.
And their inspiring excellence, attention to detail, and care for optimizing
The standard of patient care

About the Artists
Frank H. Netter, MD
Frank H. Netter was born in 1906 in New York City. He studied art at the Art Students’ League
and the National Academy of Design before entering medical school at New York University,
where he received his MD degree in 1931. During his student years, Dr. Netter’s notebook
sketches attracted the attention of the medical faculty and other physicians, allowing him to
augment his income by illustrating articles and textbooks. He continued illustrating as a sideline
after establishing a surgical practice in 1933, but he ultimately opted to give up his practice in
favor of a full-time commitment to art. After service in the United States Army during World
War II, Dr. Netter began his long collaboration with the CIBA Pharmaceutical Company (now
Novartis Pharmaceuticals). This 45-year partnership resulted in the production of the extraor-
dinary collection of medical art so familiar to medical professionals worldwide.
In 2005, Elsevier, Inc. purchased the Netter Collection and all publications from Icon Learn-
ing Systems. Over 50 publications featuring the art of Dr. Netter are available through Elsevier,
Inc. (in the United States: https://www.us.elsevierhealth.com/ and outside the United States:
www.elsevierhealth.com)
Dr. Netter’s works are among the finest examples of the use of illustration in the teaching of
medical concepts. The 13-book Netter Collection of Medical Illustrations, which includes the greater
part of the more than 20,000 paintings created by Dr. Netter, became and remains one of the
most famous medical works ever published. The Netter Atlas of Human Anatomy, first published
in 1989, presents the anatomical paintings from the Netter Collection. Now translated into 16
languages, it is the anatomy atlas of choice among medical and health professions students the
world over.
The Netter illustrations are appreciated not only for their aesthetic qualities, but, more
important, for their intellectual content. As Dr. Netter wrote in 1949, “… clarification of a sub-
ject is the aim and goal of illustration. No matter how beautifully painted, how delicately and
subtly rendered a subject may be, it is of little value as a medical illustration if it does not serve to
make clear some medical point.” Dr. Netter’s planning, conception, point of view, and approach
are what inform his paintings and make them so intellectually valuable.
Frank H. Netter, MD, physician and artist, died in 1991.
Learn more about the physician-artist whose work has inspired the Netter Reference collec-
tion: https://netterimages.com/artist-frank-h-netter.html.
Carlos Machado, MD
Carlos Machado was chosen by Novartis to be Dr. Netter’s successor. He continues to be the
main artist contributing to the Netter collection of medical illustrations.
Self-taught in medical illustration, cardiologist Carlos Machado has meticulously updated
some of Dr. Netter’s original plates and has created many original paintings of his own in the
style of Netter as an extension of the Netter collection. Dr. Machado’s photorealistic expertise
and keen insight into the physician–patient relationship informs his vivid and unforgettable
visual style. His dedication to researching each topic and subject he paints places him among
the premier medical illustrators at work today.
Learn more about his background and see more of his art at: https://netterimages.com/
artist-carlos-a-g-machado.html.
iv
Preface
The Atlas of Human Anatomy by Frank H. Netter, MD, has been the pinnacle of demonstrat-
ing the anatomy of the human body for generations of students. To those who would wish to
perform or understand surgical procedures, however, there has been no direct link between
the beautiful images created by Dr. Netter and the surgical procedures being performed. In
Netter’s Surgical Anatomy and Approaches, we try to address a request by many Netter users to tie
these anatomical diagrams to the procedures they perform, while advancing the book from the
description and images used in the first edition.
This book portrays the curriculum of basic and common general surgical procedures in chap-
ters that describe the relevant anatomy for each procedure. In his very first edition, Dr. Netter
stated that “anatomy of course does not change, but our understanding of anatomy and its
clinical significance does.” Consequently, in some cases we have been able to pair the anatomy
demonstrated in his illustrations with a modern intraoperative photograph or radiographic
image, particularly focusing on the new approaches required for minimally invasive surgery.
For many chapters, new Netter-style illustrations have been created to demonstrate key ana-
tomical points for an operative procedure or to show a key surgical perspective or orientation
that is not captured in the original Netter images. The result is a volume that covers the most
important and common areas in surgery, as well as exploring complex areas such as transplan-
tation and advanced cancer surgery.
A book like this would not be possible without the help of many people. Being fortunate to
work at an institution like the Cleveland Clinic, I elected to enlist the support of my colleagues
from many different surgical specialties. It is only with the guidance and assistance of the edito-
rial team of Michael S. Benninger, MD, Tony R. Capizzani, MD, FACS, Tommaso Falcone, MD,
FRCSC, FACOG, Stephen R. Grobmyer, MD, Jihad Kaouk, MD, Matthew Kroh, MD, Sean P.
Lyden, MD, John H. Rodriguez, MD, FACS, Michael J. Rosen, MD, Christopher T. Siegel, MD,
PhD, Allan Siperstein, MD, Scott R. Steele, MD, MBA, R. Matthew Walsh, MD, and the direc-
tion and guidance of the ever-patient Dan Fitzgerald and Marybeth Thiel at Elsevier that this
project has been completed.
On behalf of my co-editors and myself, we hope you enjoy this second edition of Netter’s
Surgical Anatomy and Approaches.
Conor P. Delaney, MD, MCh, PhD, FACS, FRCSI, FASCRS, FRCSI (Hon)
v
Contributors
EDITOR Stephen R. Grobmyer, MD

Chairman
Conor P. Delaney, MD, MCh, PhD, FACS,
Oncology Institute
FRCSI, FASCRS, FRCSI (Hon) Cleveland Clinic Abu Dhabi
Chairman Abu Dhabi, United Arab Emirates
Digestive Disease and Surgery Institute Breast and Oncology
Cleveland Clinic
Victor W. Fazio Endowed Professor of
Colorectal Surgery
Jihad Kaouk, MD
Director
Center for Robotics and Minimally Invasive
Cleveland, Ohio
Surgery
Glickman Urological & Kidney Institute
SECTION EDITORS Cleveland Clinic
Michael S. Benninger, MD Cleveland, Ohio
Chairman Urology and Gynecology
Head and Neck Institute
Cleveland Clinic Matthew Kroh, MD
Professor of Surgery Chairman
Lerner College of Medicine of CWRU Digestive Disease Institute
Cleveland, Ohio Cleveland Clinic Abu Dhabi
The Neck Abu Dhabi, United Arab Emirates
Upper Gastrointestinal
Tony R. Capizzani, MD, FACS
Assistant Professor Sean P. Lyden, MD
General Surgery Professor and Chairman
Digestive Disease and Surgery Institute Vascular Surgery
Cleveland Clinic Cleveland Clinic
Cleveland, Ohio Cleveland, Ohio
Vascular Access, Emergency and Trauma Procedures Vascular
Tommaso Falcone, MD, FRCSC, FACOG John H. Rodriguez, MD, FACS

Chief of Staff, Chief Academic Officer, Director of Surgical Endoscopy
Medical Director Advanced Laparoscopic and Bariatric Surgery
Cleveland Clinic London Digestive Disease and Surgery Institute
Professor of Obstetrics, Gynecology and Cleveland Clinic
Reproductive Biology Cleveland, Ohio
Cleveland Clinic Lerner College of Medicine Upper Gastrointestinal
Cleveland, Ohio
Urology and Gynecology Michael J. Rosen, MD
Professor of Surgery
Lerner College of Medicine
Cleveland Clinic
Cleveland, Ohio
Hernia vii
viii CO NT RI BUTO R S
Christopher T. Siegel, MD, PhD Abdul Q. Alarhayem, MD

Associate Professor of Surgery Clinical Fellow
Digestive Disease and Surgery Institute Vascular Surgery
Cleveland Clinic Lerner College of Medicine Cleveland Clinic
Cleveland Clinic Cleveland, Ohio
Cleveland, Ohio Radiocephalic, Brachiocephalic, and Brachiobasilic
Hepatobiliary Fistula
Organ Transplantation
Michael Antiporda, MD
Allan Siperstein, MD Fellow
Professor and Chair Advanced Gastrointestinal and Minimally
Endocrine Surgery Department Invasive Surgery
Cleveland Clinic Providence Portland Medical Center
Cleveland, Ohio Portland, Oregon
Endocrine Gastrectomy
Scott R. Steele, MD, MBA Sofya H. Asfaw, MD, FACS

Chairman Assistant Professor of Surgery
Department of Colorectal Surgery Department of General Surgery
Rupert B. Turnbull, M.D. Endowed Chair in Digestive Disease and Surgery Institute
Colorectal Surgery Cleveland Clinic
Digestive Disease and Surgery Institute Cleveland, Ohio
Cleveland Clinic Chest Tube Placement
Cleveland, Ohio
Lower Gastrointestinal Federico Aucejo, MD
Associate Professor of Surgery
R. Matthew Walsh, MD Transplantation Center
Professor and Chairman Digestive Disease and Surgery Institute
General Surgery Cleveland Clinic
Digestive Disease and Surgery Institute Cleveland, Ohio
Cleveland Clinic Hepatectomy
Cleveland, Ohio Living Donor Liver Transplantation
Hepatobiliary
Toms Augustin, MD, MPH, FACS
CONTRIBUTORS Assistant Professor
Department of General Surgery
Robert Abouassaly, MD
Associate Professor
Cleveland Clinic
Cleveland, Ohio
Cleveland Clinic
Distal Pancreatectomy
Louis Stokes Cleveland VA Medical Center
Cleveland, Ohio
Radical Prostatectomy Jocelyn M. Beach, MD
Assistant Professor of Surgery
Section of Vascular Surgery
Kareem Abu-Elmagd, MD, PhD, FACS
Dartmouth-Hitchcock Medical Center
Director
Lebanon, New Hampshire
Center for Gut Rehabilitation &
Carotid Subclavian Bypass/Transposition and
Transplantation (CGRT)
Vertebral Transposition
Cleveland Clinic
Cleveland, Ohio Cassandre Benay, MD
Intestinal and Multivisceral Transplantation General Surgery
Hopital de LaSalle
Montreal, Quebec, Canada
Usman Ahmad, MD, FACS
Thyroidectomy and Parathyroidectomy
Staff Surgeon
Thoracic Surgery Eren Berber, MD
Cleveland Clinic Staff Surgeon
Cleveland, Ohio Endocrine and General Surgery
Esophagectomy Cleveland Clinic
Cleveland, Ohio
Hepatectomy
Contributors ix
Riccardo Bertolo, MD Bradley J. Champagne, MD

Urologist Professor of Surgery
Glickman Urological & Kidney Institute Colorectal Surgery
Cleveland Clinic Digestive Disease and Surgery Institute
Cleveland, Ohio Cleveland Clinic
Laparoscopic Transperitoneal Radical Nephrectomy Chair of Surgery
Radical Prostatectomy Fairview Hospital—Cleveland Clinic
Radical Cystectomy Cleveland, Ohio
Right Colectomy
Vladimir Bolshinsky, MBBS, DipSurgAnat,
FRACS Julietta Chang, MD
Clinical Associate Bariatric Surgeon
Colorectal Surgery Department of Surgery
Digestive Disease and Surgery Institute Marian Regional Medical Center
Cleveland Clinic Santa Maria, California
Cleveland, Ohio Surgical Management of Achalasia
Low Anterior Resection With Total Mesorectal
Excision and Anastomosis James M. Church, MB, ChB, MMedSci,
FRACS
Paul C. Bryson, MD Staff Surgeon
Associate Professor of Otolaryngology—Head Colorectal Surgery
and Neck Surgery Digestive Disease and Surgery Institute
Laryngology Section Head Cleveland Clinic
Department of Otolaryngology Cleveland, Ohio
Cleveland Clinic Lerner College of Medicine Perianal Abscess and Fistula in Ano
Cleveland, Ohio
Tracheostomy Giuseppe D’Amico, MD
Staff Surgeon
Tony R. Capizzani, MD, FACS Hepato-Pancreato-Biliary/Liver and Intestinal
Assistant Professor Transplantation Surgery
General Surgery General Surgery
Digestive Disease and Surgery Institute Digestive Disease and Surgery Institute
Tracheal Intubation and Endoscopic Anatomy Liver Transplantation
Central Line Anatomy
Gerardo Davalos, MD
Francis J. Caputo, MD Research Scholar
Associate Professor and Program Director Surgery
Department of Vascular Surgery Duke University
Cleveland Clinic Durham, North Carolina
Cleveland, Ohio Truncal and Selective Vagotomy
Aortic Aneurysm Repair and Thoracoabdominal
Aneurysm Repair Robert DeBernardo, MD
Femoral Tibial Bypass Section Head Gynecologic Oncology
Laura J Fogarty Endowed Chair for Uterine
Walter S. Cha, MD Cancer Research
Staff Surgeon Director of the Peritoneal Surface Malignancy
Department of General Surgery Program
Digestive Disease and Surgery Institute Associate Professor of Surgery Lerner College
Cleveland Clinic of Medicine
Cleveland, Ohio Woman’s Health Institute
Common Bile Duct Surgery and Cleveland Clinic
Choledochoduodenostomy Cleveland, Ohio
Oophorectomy for Benign and Malignant Conditions
x CO NT RI BUTO R S
Conor P. Delaney, MD, MCh, PhD, FACS, Aldo Fafaj, MD

FRCSI, FASCRS, FRCSI (Hon) General Surgery
Chairman Digestive Disease and Surgery
Digestive Disease and Surgery Institute Cleveland Clinic
Victor W. Fazio Endowed Professor of Laparoscopic Inguinal Hernia Repair
Colorectal Surgery
Cleveland Clinic Lerner College of Medicine Behzad S. Farivar, MD
Cleveland, Ohio Assistant Professor of Surgery
Low Anterior Resection With Total Mesorectal Department of Vascular Surgery
Excision and Anastomosis Cleveland Clinic
Cleveland, Ohio
Teresa Diago-Uso, MD Carotid Subclavian Bypass/Transposition and
Assistant Professor of Surgery Vertebral Transposition
Transplantation Center
Digestive Disease and Surgery Institute Jeffrey M. Farma, MD
Cleveland Clinic Professor
Cleveland, Ohio Surgical Oncology
Living Donor Liver Transplantation Fox Chase Cancer Center
Deceased Donor Organ Recovery Philadelphia, Pennsylvania
Inguinal and Pelvic Lymphadenectomy
Risal Djohan, MD
Vice Chairman Alisan Fathalizadeh, MD, MPH
Plastic Surgery Associate Staff Surgeon
Cleveland Clinic Department of General Surgery
Cleveland, Ohio Digestive Disease and Surgery Institute
Breast Reconstruction Cleveland Clinic
Cleveland, Ohio
Nathan Droz, MD Gastric Emptying Procedures
Vascular Surgery Fellow
Vascular Surgery Molly Flannagan, MD, FACS
Cleveland Clinic Assistant Professor of Surgery
Visceral Bypass Cleveland Clinic
Cleveland, Ohio
Bijan Eghtesad, MD Emergency Thoracotomy for Trauma
Staff Surgeon
Hepato-Pancreato-Biliary/Liver Masato Fujiki, MD
Transplantation Surgery Assistant Professor of Surgery, Transplantation
Digestive Disease and Surgery Institute Center
Cleveland Clinic Digestive Disease and Surgery Institute
Liver Transplantation Cleveland, Ohio
Deceased Donor Organ Recovery Living Donor Liver Transplantation
Intestinal and Multivisceral Transplantation
Kevin El-Hayek, MD, FACS
Section Head Juan Garisto, MD
Endoscopic Surgery Urologist
Division of General Surgery Glickman Urological & Kidney Institute
Section Head Cleveland Clinic
Hepato-Pancreato-Biliary Surgery Cleveland, Ohio
Division of Surgical Oncology Radical Cystectomy
Metro Health System
Assistant Professor of Surgery Keith Glover, MD
Case Western Reserve University Resident
Cleveland, Ohio Vascular Surgery
Gastric Emptying Procedures Cleveland Clinic
Pancreatoduodenectomy Cleveland, Ohio
Femoral Endarterectomy and Femoral Popliteal
Bypass
Contributors xi
David A. Goldfarb, MD Barbara J. Hocevar, MSN, RN, CWOCN

Professor of Surgery, CCLCM Assistant Director, WOC Nursing Education
Glickman Urological & Kidney Institute R. B. Turnbull, Jr. MD, School of WOC Nursing
Cleveland Clinic Education
Kidney Transplantation Cleveland Clinic
Cleveland, Ohio
Emre Gorgun, MD Abdominal Wall Marking and Stoma Site Selection
Director
Endoluminal Surgery Center Kristen Holler, DO
Department of Colorectal Surgery Critical Care Fellow
Digestive Disease and Surgery Institute Anesthesiology Institute
Ileal Pouch Anal Anastomosis Tracheal Intubation and Endoscopic Anatomy
Stephen R. Grobmyer, MD Stefan D. Holubar, MD, MS

Chairman Director of Research
Oncology Institute Colorectal Surgery
Cleveland Clinic Abu Dhabi Digestive Disease and Surgery Institute
Abu Dhabi, United Arab Emirates Cleveland Clinic
Mastectomy: Partial and Total Cleveland, Ohio
Abdominoperineal Resection
Morgan Gruner, MD
OB-GYN Resident Physician Farah A. Husain, MD
Department of Subspecialty Care for Women’s Division Chief
Health Bariatric Services
Cleveland Clinic Associate Professor
Cleveland, Ohio Department of Surgery
Oophorectomy for Benign and Malignant Conditions Oregon Health & Science University
Portland, Oregon
Alfredo D. Guerron, MD Roux-en-Y Gastric Bypass and Sleeve Gastrectomy
General Surgery Daniel J. Kagedan, MD, MSc, FRCSC
Duke University Health System Surgical Oncology Fellow
Durham, North Carolina Department of Surgical Oncology
Truncal and Selective Vagotomy Roswell Park Comprehensive Cancer Center
Buffalo, New York
Georges-Pascal Haber, MD, PhD Retroperitoneal Sarcoma
Chairman
Department of Urology Matthew F. Kalady, MD
Glickman Urological & Kidney Institute Professor of Surgery
Cleveland Clinic Colorectal Surgery
Cleveland, Ohio Vice-Chairman
Retroperitoneal Lymph Node Dissection Colorectal Surgery
Cleveland Clinic
David M. Hardy, MD, RPVI, FACS Director
Assistant Professor Sanford R. Weiss, MD Center for Hereditary
Vascular Surgery Colorectal Neoplasia
Cleveland Clinic Co-Director
Cleveland, Ohio Comprehensive Colorectal Cancer Program
Carotid Endarterectomy Cleveland, Ohio
Above-Knee and Below-Knee Amputation Left and Sigmoid Colectomy
Koji Hashimoto, MD, PhD Jihad Kaouk, MD

Director Director
Living Donor Liver Transplantation Center for Robotics and Minimally Invasive
Associate Professor of Surgery Surgery
Transplantation Center Glickman Urological & Kidney Institute
Digestive Disease and Surgery Institute Cleveland Clinic
Cleveland, Ohio Radical Prostatectomy
Living Donor Liver Transplantation Radical Cystectomy
xii CO NT RI BUTO R S
Hermann Kessler, MD, PhD Matthew Kroh, MD

Professor of Surgery Chairman
Section Head Digestive Disease Institute
Minimally Invasive Surgery Cleveland Clinic Abu Dhabi
Colorectal Surgery Abu Dhabi, United Arab Emirates
Digestive Disease and Surgery Institute Surgical Management of Achalasia
Cleveland Clinic
Cleveland, Ohio David M. Krpata, MD
Abdominoperineal Resection Assistant Professor
Leena Khaitan, MD, MPH Department of General Surgery
Professor of Surgery Digestive Disease and Surgery Institute
Department of Surgery Cleveland Clinic
Director Cleveland, Ohio
Metabolic and Bariatric Surgery Surgical Approach to Chronic Groin Pain Following
Center Digestive Health Institute Inguinal Hernia Repairs
Director
Esophageal and Swallowing Center Jamie A. Ku, MD
Digestive Health Institute Staff
University Hospitals Head and Neck Institute
Cleveland Medical Center Cleveland Clinic
Minimally Invasive Antireflux Surgery Selective (Supraomohyoid) Neck Dissection,
Levels I-III
Amit Khithani, MD, DABS
Faculty Surgeon Choon Hyuck David Kwon, MD, PhD
Surgical Oncology and Hepatopancreatobiliary Professor of Surgery
Surgery Transplantation Center
Department of Surgery Digestive Disease and Surgery Institute
Kendall Regional Medical Center Cleveland Clinic
Miami, Florida Cleveland, Ohio
Pancreatoduodenectomy Hepatectomy
Living Donor Liver Transplantation
Lee Kirksey, MD, MBA
Vice Chairman David J. Laczynski, MD
Vascular Surgery Vascular Surgery Resident
Cleveland Clinic Vascular Surgery
Radiocephalic, Brachiocephalic, and Brachiobasilic Cleveland, Ohio
Fistula Above-Knee and Below-Knee Amputation
Eric A. Klein, MD Judith Landis-Erdman, BSN, RN, CWOCN

Chairman Wound Ostomy Continence Nursing Team
Glickman Urological & Kidney Institute Digestive Disease and Surgery Institute
Retroperitoneal Lymph Node Dissection Abdominal Wall Marking and Stoma Site Selection
Venkatesh Krishnamurthi, MD Kelsey E. Larson, MD

Director Assistant Professor of Surgery
Kidney/Pancreas Transplant Program General Surgery
Glickman Urological & Kidney Institute University of Kansas
Transplant Center Kansas City, Kansas
Cleveland Clinic Sentinel Lymph Node Biopsy
Associate Professor of Surgery
Cleveland, Ohio
Pancreas and Kidney Transplantation
Contributors xiii
Pierre Lavertu, MD Christopher Mascarenhas, MD, FACS

Director of Head and Neck Surgery Assistant Professor
Department of Otolaryngology—Head and Division of Colon and Rectal Surgery
Neck Surgery Columbia University Irving Medical Center
University Hospitals Case Medical Center New York, New York
Professor Left and Sigmoid Colectomy
Case Western Reserve University School of
Medicine Evan R. McBeath, MD
Cleveland, Ohio Otolaryngologist
Selective (Supraomohyoid) Neck Dissection, Wood County Hospital
Levels I-III Bowling Green, Ohio
Selective (Supraomohyoid) Neck Dissection,
Tripp Leavitt, MD Levels I-III
Resident Physician
Plastic Surgery Chad M. Michener, MD
Cleveland Clinic Associate Professor of Surgery
Cleveland, Ohio Obstetrics, Gynecology and Women’s Health
Breast Reconstruction Institute
Sungho Lim, MD Vice Chair
Fellow Department of Obstetrics and Gynecology,
Department of Vascular Surgery Main Campus
Cleveland Clinic Obstetrics, Gynecology and Women’s Health
Cleveland, Ohio Institute
Aortic Aneurysm Repair and Thoracoabdominal Cleveland Clinic
Aneurysm Repair Cleveland, Ohio
Hysterectomy for Benign and Malignant Conditions
Jeremy M. Lipman, MD, MHPE
Program Director Charles Miller, MD
General Surgery Residency Enterprise Director of Transplantation
Colorectal Surgery Director
Digestive Disease and Surgery Institute Transplantation Center
Cleveland Clinic Professor of Surgery
Transverse Colectomy Cleveland Clinic
Cleveland, Ohio
Hepatectomy
Victoria Lyo, MD, MTM Living Donor Liver Transplantation
Foregut, Metabolic, and General Surgery
Eric T. Miller, MD
Division
Transplantation and Urological Surgery
University of California Davis
Sacramento, California
Cleveland Clinic
Roux-en-Y Gastric Bypass and Sleeve Gastrectomy
Cleveland, Ohio
Kidney Transplantation
Gary N. Mann, MD Pancreas and Kidney Transplantation
Associate Professor Laparoscopic Donor Nephrectomy
Surgical Oncology
Roswell Park Comprehensive Cancer Center Edwina C. Moore, BMedSci, MBBS, FRACS
Buffalo, New York Endocrine Surgeon
Retroperitoneal Sarcoma Cleveland Clinic
Cleveland, Ohio
Jeannine L. Marong, PA-C Laparoscopic Adrenalectomy
Advanced Practice Coordinator of Trauma
Services Amit Nair, MS, MD, FRCS
Hillcrest Hospital Clinical Scholar
Mayfield Heights, Ohio Transplantation Center
Arterial Line Anatomy Digestive Disease and Surgery Institute
Cleveland Clinic
Cleveland, Ohio
Hepatectomy
Living Donor Liver Transplantation
xiv CO NT RI BUTO R S
Robert Naples, DO Lee Ponsky, MD, FACS

General Surgery Resident Professor of Urology
Department of General Surgery Chief, Urologic Oncology
Digestive Disease and Surgery Institute Leo and Charlotte Goldberg Chair of Advanced
Cleveland Clinic Surgical Therapies
Cleveland, Ohio Master Clinician of Urologic Oncology Urology
Splenectomy Institute
University Hospitals Cleveland Medical Center
Ahmed Nassar, MD Case Western Reserve University School of
Transplant Surgery Fellow Medicine
Emory University Cleveland, Ohio
Atlanta, Georgia Laparoscopic Transperitoneal Radical Nephrectomy
Common Bile Duct Surgery and
Choledochoduodenostomy Ajita Prabhu, MD
Eileen A. O’Halloran, MD, MS Lerner College of Medicine
Complex General Surgical Oncology Fellow Center for Abdominal Core Health
Surgical Oncology Digestive Disease and Surgery Institute
Fox Chase Cancer Center Cleveland Clinic
Philadelphia, Pennsylvania Cleveland, Ohio
Inguinal and Pelvic Lymphadenectomy Open Flank and Lumbar Hernia Repair
Keita Okubo, MD, PhD Debra Pratt, MD

Clinical Research Fellow Medical Director
Transplantation Center Fairview Breast Program
Digestive Disease and Surgery Institute Cleveland Clinic Cancer Center Moll Pavilion
Cleveland, Ohio Central Duct Excision and Nipple Discharge
Hepatectomy
Living Donor Liver Transplantation Cristiano Quintini, MD
Director
F. Ezequiel Parodi, MD Liver Transplantation
Associate Professor Professor of Surgery
Division of Vascular Surgery Transplantation Center
University of North Carolina School of Digestive Disease and Surgery Institute
Medicine Cleveland Clinic Lerner College of Medicine
Durham, North Carolina Cleveland, Ohio
Visceral Bypass Hepatectomy
Liver Transplantation
Will Perry, MD, BS Living Donor Liver Transplantation
Resident
Vascular Surgery Siva Raja, MD, PhD
Cleveland Clinic Associate Professor of Surgery
Cleveland, Ohio Staff Surgeon
Carotid Endarterectomy Thoracic Surgery
Cleveland Clinic
Clayton C. Petro, MD Cleveland, Ohio
Assistant Professor of Surgery Esophagectomy
Center for Abdominal Core Health
Digestive Disease and Surgery Institute Kevin M. Reavis, MD
Cleveland Clinic Foregut and Bariatric Surgeon
Cleveland, Ohio Gastrointestinal and Minimally Invasive Surgery
Open Retromuscular Hernia Repair The Oregon Clinic
Portland, Oregon
Gastrectomy
Saranya Reghunathan, MD
Department of Otolaryngology
Cleveland Clinic
Cleveland, Ohio
Tracheostomy
Contributors xv
Beri M. Ridgeway, MD Christopher T. Siegel, MD, PhD

Institute Chair Associate Professor of Surgery
OB/GYN and Women’s Health Institute Digestive Disease and Surgery Institute
Cleveland Clinic Cleveland Clinic Lerner College of Medicine
Reconstructive Surgery for Pelvic Floor Disorders Cleveland, Ohio
Hepatectomy
John H. Rodriguez, MD, FACS Living Donor Liver Transplantation
Director of Surgical Endoscopy
Advanced Laparoscopic and Bariatric Surgery Robert Simon, MD
Digestive Disease and Surgery Institute Associate Staff
Cleveland Clinic Division General and Hepatopancreaticobiliary
Cleveland, Ohio Surgery
Surgical Management of Achalasia Digestive Disease and Surgery Institute
Cleveland Clinic
David R. Rosen, MD Cleveland, Ohio
Colorectal Surgery Cholecystectomy
Cleveland Clinic Allan Siperstein, MD
Cleveland, Ohio Professor and Chair
Transverse Colectomy Endocrine Surgery Department
Cleveland Clinic
Steven Rosenblatt, MD Cleveland, Ohio
Associate Professor of Surgery Thyroidectomy and Parathyroidectomy
Department of General Surgery Laparoscopic Adrenalectomy
Cleveland Clinic Lerner College of Medicine Christopher J. Smolock, MD
Cleveland Clinic Staff Vascular Surgeon
Cleveland, Ohio Department of Vascular Surgery
Splenectomy Cleveland Clinic
Laparoscopic Inguinal Hernia Repair Cleveland, Ohio
Femoral Endarterectomy and Femoral Popliteal
Bypass
Kazunari Sasaki, MD
Transplantation Center Sean P. Steenberge, MD, MS
Digestive Disease and Surgery Institute Resident
Cleveland Clinic Vascular Surgery
Hepatectomy Cleveland, Ohio
Living Donor Liver Transplantation Femoral Tibial Bypass
Rachael C. Sullivan, MD, MS

Graham Schwarz, MD
Staff Physician
Program Director
Microsurgery and Breast Reconstruction
Cleveland Clinic
Fellowship
Cleveland, Ohio
Department of Plastic Surgery
Upper and Lower Extremity Fasciotomy
Cleveland Clinic
Cleveland, Ohio
Axillary Lymphadenectomy and Lymphaticovenous Andrew Tang, MD
Bypass Resident
Thoracic and Cardiovascular Surgery
Cleveland Clinic
Sherief Shawki, MD, MSc, MBBCH Cleveland, Ohio
Staff Surgeon
Esophagectomy
Colon & Rectal Surgery
Patrick Tassone, MD
Cleveland Clinic
Fellow in Head & Neck Oncologic and
Reconstructive Surgery
Colon & Rectal Surgery
Head and Neck Institute
Lerner Medical School of Medicine
Cleveland Clinic
Cleveland, Ohio
Cleveland, Ohio
Suture Rectopexy and Ventral Mesh Rectopexy
Selective (Supraomohyoid) Neck Dissection, Levels I-III
xvi CO NT RI BUTO R S
Luciano Tastaldi, MD Cynthia E. Weber, MD

Clinical Research Fellow Bariatric Surgery Fellow
Center for Abdominal Core Health Surgery
Digestive Disease and Surgery Institute University Hospitals’ of Cleveland
Cleveland, Ohio Minimally Invasive Antireflux Surgery
Open Flank and Lumbar Hernia Repair
Alvin C. Wee, MD, MBA
Lewis J. Thomas IV, MD Surgical Director
Urologic Oncology Fellow Kidney Transplantation
Glickman Urological & Kidney Institute Glickman Urological & Kidney Institute
Retroperitoneal Lymph Node Dissection Kidney Transplantation
Laparoscopic Donor Nephrectomy
Michael A. Valente, DO, FACS, FASCRS
Associate Professor James S. Wu, MD, PhD
Residency Program Director Staff Surgeon
Colorectal Surgery Department of Colon and Rectal Surgery
Digestive Disease and Surgery Institute Digestive Disease and Surgery Institute
Appendectomy Abdominal Wall Marking and Stoma Site Selection
Stephanie A. Valente, DO, FACS Chad A. Zender, MD, FACS

Breast Surgical Oncologist Assistant Professor
Director Department of Otolaryngology—Head and
Breast Surgery Fellowship Neck Surgery
General Surgery Case Western Reserve University School of
Cleveland Clinic Medicine
Associate Professor of Surgery Cleveland, Ohio
Department of General Surgery Selective (Supraomohyoid) Neck Dissection, Levels
Cleveland Clinic Lerner College of Medicine I-III
Case Western Reserve University
Cleveland, Ohio
Massarat Zutshi, MD
Axillary Lymphadenectomy and Lymphaticovenous
Staff Surgeon
Bypass
Colorectal Surgery
Valery Vilchez, MD Cleveland Clinic
Surgery Resident Cleveland, Ohio
Department of General Surgery Hemorrhoids and Hemorrhoidectomy
Digestive Disease and Surgery Institute Sphincter Repair and Sacral Neuromodulation
Cleveland Clinic
Cleveland, Ohio
Distal Pancreatectomy
Contents
SECTION 1 The Neck 1 Chapter 8 Gastrectomy 87

Michael Antiporda and
Section Editor: Michael S. Benninger
Kevin M. Reavis
Chapter 1 Selective (Supraomohyoid)
Chapter 9 Gastric Emptying
Neck Dissection, Levels I-III 3
Patrick Tassone, Chad A. Zender,
Procedures 95
Kevin El-Hayek and
Evan R. McBeath, Pierre Lavertu,
Alisan Fathalizadeh
and Jamie A. Ku
Chapter 10 Roux-en-Y Gastric Bypass and
Chapter 2 Tracheostomy 13
Paul C. Bryson and
Sleeve Gastrectomy 107
Victoria Lyo and
Saranya Reghunathan
Farah A. Husain
SECTION 2 Endocrine 19 Chapter 11 Surgical Management of
Section Editor: Allan Siperstein Achalasia 115
Matthew Kroh, John H. Rodriguez,
Chapter 3 Thyroidectomy and
and Julietta Chang
Parathyroidectomy 21
Allan Siperstein and
Cassandre Benay SECTION 4 Hepatobiliary 127
Section Editors: C
hristopher T. Siegel and
Chapter 4 Laparoscopic
R. Matthew Walsh
Adrenalectomy 35
Allan Siperstein and Chapter 12 Cholecystectomy 129
Edwina C. Moore Robert Simon
Chapter 13 Common Bile Duct Surgery and
SECTION 3 pper
U Choledochoduodenostomy 139
Gastrointestinal 47 Walter S. Cha and Ahmed Nassar
Section Editors: M
atthew Kroh and Chapter 14 Hepatectomy 151
John H. Rodriguez Federico Aucejo, Kazunari Sasaki,
Chapter 5 Esophagectomy 49 Charles Miller, Eren Berber, Keita
Andrew Tang, Usman Ahmad, and Okubo, Cristiano Quintini, Choon
Siva Raja Hyuck David Kwon, Christopher T.
Chapter 6 Minimally Invasive Antireflux Siegel, and Amit Nair
Surgery 63 Chapter 15 Distal Pancreatectomy 173
Cynthia E. Weber and Valery Vilchez and Toms Augustin
Leena Khaitan
Chapter 16 Pancreatoduodenectomy 181
Chapter 7 Truncal and Selective Kevin El-Hayek and
Vagotomy 77 Amit Khithani
Gerardo Davalos and
Alfredo D. Guerron
xvii
xviii CO NT E NT S
Chapter 17 Splenectomy 189 Chapter 29 Transverse Colectomy 301

Steven Rosenblatt and David R. Rosen and Jeremy M. Lipman
Robert Naples
Chapter 30 Low Anterior Resection With
Total Mesorectal Excision and
SECTION 5 rgan
O Anastomosis 311
Transplantation 195 Vladimir Bolshinsky and
Section Editor: Christopher T. Siegel Conor P. Delaney
Chapter 18 Liver Transplantation 197 Chapter 31 Abdominoperineal
Giuseppe D’Amico, Cristiano Resection 329
Quintini, and Bijan Eghtesad Stefan D. Holubar and
Chapter 19 Living Donor Liver Hermann Kessler
Transplantation 205 Chapter 32 Hemorrhoids and
Koji Hashimoto, Choon Hyuck Hemorrhoidectomy 339
David Kwon, Kazunari Sasaki, Massarat Zutshi
Charles Miller, Keita Okubo,
Chapter 33 Perianal Abscess and Fistula
Cristiano Quintini, Teresa Diago-
Uso, Masato Fujiki, Christopher
in Ano 349
James M. Church
T. Siegel, Amit Nair, and Federico
Aucejo Chapter 34 Suture Rectopexy and Ventral
Chapter 20 Intestinal and Multivisceral
Mesh Rectopexy 361
Sherief Shawki
Transplantation 217
Masato Fujiki and Chapter 35 Ileal Pouch Anal
Kareem Abu-Elmagd Anastomosis 369
Emre Gorgun
Chapter 21 Kidney Transplantation 225
Eric T. Miller, David A. Goldfarb, Chapter 36 Sphincter Repair and Sacral
and Alvin C. Wee Neuromodulation 379
Massarat Zutshi
Chapter 22 Pancreas and Kidney
Transplantation 233
Eric T. Miller and SECTION 7 Hernia 385
Venkatesh Krishnamurthi Section Editor: Michael J. Rosen
Chapter 23 Laparoscopic Donor Chapter 37 Laparoscopic Inguinal Hernia
Nephrectomy 243 Repair 387
Eric T. Miller and Alvin C. Wee Aldo Fafaj and Steven Rosenblatt
Chapter 24 Deceased Donor Organ Chapter 38 Surgical Approach to Chronic
Recovery 251 Groin Pain Following Inguinal
Teresa Diago-Uso and Hernia Repairs 399
Bijan Eghtesad David M. Krpata
Chapter 39 Open Flank and Lumbar Hernia
SECTION 6 Lower Repair 411
Gastrointestinal 261 Luciano Tastaldi and Ajita Prabhu
Section Editor: Scott R. Steele
Chapter 40 Open Retromuscular Hernia
Chapter 25 Appendectomy 263 Repair 417
Michael A. Valente Clayton C. Petro
Chapter 26 Abdominal Wall Marking and
Stoma Site Selection 275 SECTION 8 Vascular 429
Barbara J. Hocevar, Judith Landis- Section Editor: Sean P. Lyden
Erdman, and James S. Wu
Chapter 41 Carotid Endarterectomy 431
Chapter 27 Right Colectomy 281 David M. Hardy and Will Perry
Bradley J. Champagne
Chapter 42 Carotid Subclavian Bypass/
Chapter 28 Left and Sigmoid Transposition and Vertebral
Colectomy 289 Transposition 441
Christopher Mascarenhas and Jocelyn M. Beach and
Mathew F. Kalady Behzad S. Farivar
Contents xix
Chapter 43 Aortic Aneurysm Repair and Chapter 56 Breast Reconstruction 587

Thoracoabdominal Aneurysm Tripp Leavitt and Risal Djohan
Repair 449
Chapter 57 Central Duct Excision and Nipple
Sungho Lim and Francis J. Caputo
Discharge 603
Chapter 44 Visceral Bypass 463 Debra Pratt
Nathan Droz and F. Ezequiel Parodi
Chapter 58 Sentinel Lymph Node
Chapter 45 Radiocephalic, Brachiocephalic, Biopsy 609
and Brachiobasilic Fistula 473 Kelsey E. Larson
Abdul Q. Alarhayem and
Chapter 59 Axillary Lymphadenectomy and
Lee Kirksey
Lymphaticovenous Bypass 617
Chapter 46 Femoral Endarterectomy and Stephanie A. Valente and
Femoral Popliteal Bypass 479 Graham Schwarz
Christopher J. Smolock and
Chapter 60 Inguinal and Pelvic
Keith Glover
Lymphadenectomy 625
Chapter 47 Femoral Tibial Bypass 487 Eileen A. O’Halloran and
Sean P. Steenberge and Jeffrey M. Farma
Francis J. Caputo
Chapter 61 Retroperitoneal Sarcoma 631
Chapter 48 Above-Knee and Below-Knee Daniel J. Kagedan and
Amputation 499 Gary N. Mann
David M. Hardy and
David J. Laczynski SECTION 11 rology and
U
Gynecology 637
SECTION 9
Vascular Access, Section Editors: J
ihad Kaouk and
Emergency and Trauma Tommaso Falcone
Procedures 509 Chapter 62 Hysterectomy for Benign and
Section Editor: Tony R. Capizzani Malignant Conditions 639
Chapter 49 Tracheal Intubation and Chad M. Michener
Endoscopic Anatomy 511
Chapter 63 Oophorectomy for Benign and
Kristen Holler and
Malignant Conditions 653
Tony R. Capizzani
Morgan Gruner and
Chapter 50 Chest Tube Placement 525 Robert DeBernardo
Sofya H. Asfaw
Chapter 64 Reconstructive Surgery for
Chapter 51 Emergency Thoracotomy for Pelvic Floor Disorders 663
Trauma 533 Beri M. Ridgeway
Molly Flannagan
Chapter 65 Laparoscopic Transperitoneal
Chapter 52 Central Line Anatomy 545 Radical Nephrectomy 675
Tony R. Capizzani Riccardo Bertolo and Lee Ponsky
Chapter 53 Arterial Line Anatomy 553 Chapter 66 Radical Prostatectomy 685
Jeannine L. Marong Riccardo Bertolo, Jihad Kaouk, and
Robert Abouassaly
Chapter 54 Upperand Lower E
xtremity
Fasciotomy 561 Chapter 67 Radical Cystectomy 699
Rachael C. Sullivan Riccardo Bertolo, Juan Garisto, and
Jihad Kaouk
SECTION 10 Breast and Chapter 68 Retroperitoneal Lymph Node
Oncology 579 Dissection 711
Section Editor: Stephen R. Grobmyer Eric A. Klein, Georges-Pascal Haber,
Chapter 55 Mastectomy: Partial and and Lewis J. Thomas IV
Total 581 Index 721
Stephen R. Grobmyer
Video Contents
1.1 Neck Dissection

2.1 Tracheostomy
3.1 Thyroidectomy and Parathyroidectomy
6.1 Laparoscopic Nissen Fundoplication
7.1 Laparoscopic Truncal Vagotomy
8.1 Laparoscopic Total Gastrectomy With D2 Lymphadenectomy
9.1 Per-Oral Pyloromyotomy (POP) and Laparoscopic Pyloromyotomy
10.1 Linear Stapled Gastric Bypass (Antecolic, Antegastric)
10.2 EEA Stapled Gastrojejunal Anastomosis (Antecolic, Antegastric)
10.3 Sleeve Gastrectomy
12.1 Laparoscopic Cholecystectomy
13.1 Laparoscopic Transcystic Common Bile Duct Exploration
14.1 Laparoscopic Right Hepatectomy
14.2 Laparoscopic Left Hepatectomy
14.3 Robotic Left Hepatectomy
16.1 Laparoscopic Pancreaticoduodenectomy
17.1 Laparoscopic Splenectomy
19.1 Laparoscopic Living Donor Right Hepatectomy
19.2 Open Living Donor Left Hepatectomy
20.1 Intestinal Graft Procurement
20.2 Multivisceral Transplantation
21.1 Kidney Transplantation
22.1 Simultaneous Pancreas and Kidney Transplantation
23.1 Left Laparoscopic Donor Nephrectomy
25.1 Appendectomy
27.1 Right Colectomy
28.1 Left and Sigmoid Colectomy
30.1 Low Anterior Resection With Total Mesorectal Excision and Anastomosis
35.1 Single Incision Total Abdominal Colectomy (First Stage Restorative Proctectomy/Ileal

Pouch Anal Anastomosis)
xxi
xxii VIDEO CONTENTS
35.2 Completion Proctectomy/J-Pouch Construction

40.1 Open Transversus Abdominis Release (TAR)
43.1 Abdominal Aortic Aneurysm
61.1 Retroperitoneal Sarcoma
66.1 Robotic Prostatectomy
S E C T I O N 1
The Neck
section editor: Michael S. Benninger
1 Selective (Supraomohyoid) Neck

Dissection, Levels I-III
Patrick Tassone, Chad A. Zender, Evan R. McBeath,
Pierre Lavertu, and Jamie A. Ku
2 Tracheostomy
Paul C. Bryson and Saranya Reghunathan
C H A P T E R
1
Selective (Supraomohyoid) Neck
Dissection, Levels I-III
Patrick Tassone, Chad A. Zender, Evan R. McBeath,
Pierre Lavertu, and Jamie A. Ku
VIDEO
1.1 Neck Dissection
INTRODUCTION
Neck dissection has been a standard method of removing at-risk or involved cancerous lymph
nodes in the head and neck for more than 100 years. Crile first described the radical neck dis-
section in the early 1900s, but modifications by Bocca and others helped reduce the morbid-
ity associated with lymph node removal, allowing for nerve and structure preservation when
oncologically sound. This chapter discusses one of these modifications in detail, the selective
or supraomohyoid neck dissection. A selective neck dissection, including levels I through III, is
typically used for malignancies of the oral cavity in patients with N0 disease. When a larger
nodal burden is present, an extended (levels I-IV) selective neck dissection or a modified
radical neck dissection (levels I-V) is indicated. Lesions in the oral cavity that approach or
cross the midline require treatment of both sides of the neck.
3
4 SECTION 1 T HE NEC K
NECK ANATOMY FOR SURGICAL PLANNING

Understanding the regional lymphatic drainage pathways is critical when planning which type
of neck dissection will be employed (Fig. 1.1). A supraomohyoid neck dissection is performed
when treating patients who are at risk for micrometastasis in levels I, II, and III. The boundaries
of levels I (submental and submandibular), II (upper jugular nodal chain), and III (midjugular
nodal chain) are defined as follows:
Level Ia: Bounded laterally by the medial aspects of the anterior belly of the digastric muscles,
and ending medially at a line drawn from the mandible to the hyoid bone at the anatomic
midline.
Level Ib: Bounded by the lateral aspect of the anterior belly of the digastric muscle, the medial
aspect of the posterior belly of the digastric and stylohyoid muscles, and the inferior border
of the mandibular body superiorly.
Level IIa: Bounded anteriorly and superiorly by the posterior belly of the digastric and stylo-
hyoid muscles, posteriorly by the vertical plane defined by the spinal accessory nerve and
sternocleidomastoid muscle (SCM), and inferiorly by the horizontal plane defined by the
inferior border of the hyoid bone.
Level IIb: Bounded anteriorly by the jugular vein and inferiorly by the vertical plane defined
by the spinal accessory nerve, posteriorly by the posterior border of the SCM, and superiorly
by the skull base.
Level III: Bounded superiorly by the horizontal plane defined by the inferior border of the
hyoid bone, inferiorly by the horizontal plane defined by the inferior border of the cricoid
cartilage and/or the omohyoid muscle as it crosses the internal jugular vein, anteriorly by
the lateral border of the sternohyoid muscle, and posteriorly by the posterior border of
the SCM.
CHAPTER 1 Selective (Supraomohyoid) Neck Dissection, Levels I-III 5
Mandibular
nodes
Superior lateral
Submandibular superficial cervical
nodes (external jugular)
node
Accessory nerve (XI)
Submental Jugulodigastric node
nodes
Posterior lateral
The patient is positioned superficial cervical
on the table with his neck Suprahyoid node (spinal accessory)
extended, typically on a nodes
Superior deep lateral cervical
shoulder roll, and head (internal jugular) nodes
turned away from the Intercalated node
operative side. Superior thyroid nodes
Inferior deep
lateral cervical
Jugulo-omohyoid node (scalene) node
Anterior deep cervical
(pretracheal and thyroid) nodes Thoracic duct
(deep to infrahyoid muscles)
Transverse
Anterior superficial cervical cervical
nodes (anterior jugular nodes) chain of
nodes
Jugular trunk
Supraclavicular nodes*
Subclavian trunk
and node
*The supraclavicular group of nodes (also known as the lower deep cervical group),
especially on the left, are also sometimes referred to as the signal or sentinel lymph
nodes of Virchow or Troisier, especially when sufficiently enlarged and palpable.
These nodes (or a single node) are so termed because they may be the first
recognized presumptive evidence of malignant disease in the viscera.
Parotid
gland
Posterior
facial vein
Superior flap dissected up along deep surface of anterior facial Platysma Common
muscle facial vein
vein and facial (external maxillary) artery, thus elevating ramus
marginalis mandibulae of facial nerve out of operating field. Facial (external
Vessels ligated and distal end of vascular stump sutured to maxillary)
undersurface of flap. artery and
anterior
facial vein
Ramus
marginalis Great auricular
mandibularis nerve
of facial nerve
External jugular
Mandible vein
Accessory
Hyoid bone nerve
Fascia over Trapezius
strap muscles muscle
Anterior
jugular vein Platysma
muscle
Platysma
muscle
Transverse
cervical nerves
Sternocleidomastoid
muscle
Supraclavicular
nerves
Operative field exposed
FIGURE 1.1 Patient positioning and anatomy in neck dissection.

INCISION PLANNING AND PATIENT POSITIONING FOR NECK

DISSECTION
Positioning for a neck dissection includes extending the neck and turning the patient’s head
away from the surgeon. This usually entails placing a shoulder roll under the patient to facili-
tate adequate extension.
Various types of incisions may be employed. A “hockey stick” incision that extends from
the mastoid tip down the middle of the SCM and then across the neck in a crease, which is
usually over the lowest level that will be surgically treated (Fig. 1.2), is typically used. The inci-
sion can be brought across the midline to the contralateral neck in the same manner, creating
an “apron” incision, which will allow access to both sides of the neck when indicated to treat
bilateral neck disease.
Raising the Subplatysmal Flap

Skin and subcutaneous incisions are continued down through the subcutaneous fat and pla-
tysma muscle but not through the superficial layer of the deep cervical fascia. A superior sub-
platysmal flap is then elevated up to the inferior border of the mandible. Care is taken to keep
the plane of elevation immediately subplatysmal, to aid in identification and preservation of
the marginal mandibular branch of the facial nerve. Laterally, the platysma muscle is not devel-
oped, and elevation must proceed over the external jugular vein and great auricular nerve. This
allows for complete elevation of the flap (Fig. 1.3).
Inferior elevation is performed in a subplatysmal manner below where the omohyoid crosses
the jugular vein. This allows for complete exposure of level III and for incorporation of level IV
if needed. The flap elevation can be extended down to within 5 to 10 mm of the clavicle to aid
visualization.
Height of subplatysmal elevation
Platysma muscle elevated
C D
FIGURE 1.2 Incision design in selective neck dissection.
The incision is two fingerbreadths below the angle of the mandible (marked in purple, D) to protect the marginal man-
dibular nerve. The course of the external jugular vein (marked in blue, D) can also be seen through the skin.
LEVEL IA-IB NECK DISSECTION

After flap elevation, expose the anterior belly of the digastric muscle by making a midline inci-
sion from below the mentum to the hyoid bone. It is important to include all the fibrofatty
contents from the contralateral medial edge of the digastric muscle. The elevation continues to
the medial aspect of the submandibular gland to complete the level Ia dissection.
The marginal mandibular branch of the facial nerve can be located approximately 1 cm infe-
rior to angle of the mandible. The nerve then travels superiorly to cross the mandible around
the facial notch, where the nerve travels superficial to the facial artery and vein (Fig. 1.3). Inci-
sions brought across the neck are always two fingerbreadths below the angle to prevent inad-
vertent injury to this nerve. The marginal mandibular branch of the facial nerve lies between
the superficial layer of the deep cervical fascia and the adventitia investing the anterior facial
vein. The superficial layer of the deep cervical fascia is incised at the inferior border of the
submandibular gland. It must be elevated and may be tacked to the platysma muscle to aid in
elevation.
Care must be taken to preserve the marginal mandibular branch of the facial nerve and
reflect it superiorly, along with the superficial layer of the deep cervical fascia, and to remove
any submandibular retrovascular (perifacial) lymph nodes in the area. This is accomplished by
developing a plane between the vein and superficial layer of the deep cervical fascia, keeping
the fat pad that contains the facial nodes down in the specimen, along with the submandibular
gland, and elevating and protecting the nerve.
At this point the anterior belly of the digastric muscle is isolated, and the gland and fibrofatty
contents of level Ia are brought posteriorly across the mylohyoid muscle.
Next, retract the mylohyoid muscle, identify and preserve the lingual and hypoglossal
nerves, and identify, ligate, and divide the submandibular duct, submandibular ganglion, and
corresponding vasculature. Branches of the facial artery into the submandibular gland can be
numerous and must be controlled and divided to release the contents of Level 1B from its
posterior attachments. Level I is released and left pedicled by the inferior fibrofatty attachments
to levels II and III.
CHAPTER 1 Selective (Supraomohyoid) Neck Dissection, Levels I-III 9
Marginal mandibular
branch of facial nerve
Facial artery and vein
Level Ia
Parotid gland
Greater
auricular nerve
External
jugular vein
Digastric muscle
(anterior belly)
Mylohyoid muscle
B C
FIGURE 1.3 Subplatysmal flaps and level Ib dissection.
The greater auricular nerve (marked in yellow, C) and external jugular vein (marked in blue, C) can be seen cours-
ing together over the superficial surface of the sternocleidomastoid muscle. The marginal mandibular nerve
(marked in yellow, C) can be seen coursing over the facial artery (marked in red, C) at the facial notch of the man-
dible. The facial artery then travels deep and posterior into the neck, deep to the posterior belly of the digastric
muscle (marked in orange, C), where it takes off from the external carotid artery.
LEVEL II-III NECK DISSECTION

Identify the posterior belly of the digastric muscle, creating the digastric tunnel back to the
mastoid tip under the SCM.
Incise the investing fascial layer along the anterior border of the SCM, ligating and dividing
the external jugular vein in the process. An attempt should be made to preserve the greater
auricular nerve, if not involved with disease.
Unwrap the SCM from its investing fascia. This is accomplished along a broad, superior-to-
inferior plane, from the digastric muscle superiorly to the omohyoid muscle inferiorly.
Identify the spinal accessory nerve at its entrance into the SCM, and trace it under the pos-
terior belly of the digastric muscle. The spinal accessory nerve typically passes lateral to the
internal jugular vein just before diving under the posterior belly of the digastric muscle (Fig.
1.4A, B, and C). The nerve will occasionally bisect or run deep to the jugular vein.
The spinal accessory nerve is released from the surrounding soft tissue, and then level IIb is
released from the skull base, the back of the jugular vein, the SCM, and the deep cervical fascia.
Level IIb is left attached to IIa and brought under the spinal accessory nerve.
Once the investing fascial layer is elevated off the SCM down to the level of the deep cervi-
cal rootlets, the dissection is taken medially across the rootlets from the omohyoid muscle to
the spinal accessory nerve superiorly. Care must be taken to avoid injuring the spinal accessory
nerve in this area as it exits the SCM posteriorly.
Dissect levels II and III medially in a plane lateral to the cervical rootlets and the carotid
sheath, which invests the carotid artery, internal jugular vein, and vagus nerve (Fig. 1.4D and E).
Once the elevation reaches the jugular vein, the fascia from the internal jugular vein is
unwrapped. Branches of the vein may be ligated and divided as the specimen is brought medi-
ally. The ansa cervicalis will be transected during the inferior dissection as the specimen is
brought across the jugular vein to the lateral aspect of the strap muscles. Superiorly, the hypo-
glossal nerve, which runs lateral to the carotid artery and medial to the jugular vein, must be
protected under the digastric muscle (Fig. 1.5). The ansa hypoglossi will likely have to be tran-
sected as the specimen is brought medially to the hyoid bone and strap musculature.
The specimen is then dissected away from the hypoglossal nerve and posterior belly of the
digastric muscle until it can be easily removed. The anterior dissection will meet with the pos-
terior dissection as the specimen is brought across the strap muscles, carotid artery, and jugular
vein.
Spinal accessory nerve and level IIb dissection
Internal jugular vein
Sternocleidomastoid muscle
Spinal accessory nerve
Cervical rootlets
B C
Vagus nerve and levels IIa and III dissection
D E
FIGURE 1.4 A, B, and C, Spinal accessory nerve and level IIb dissection.
The spinal accessory nerve (marked in yellow, C) can be seen traveling from the jugular foramen through the sterno-
cleidomastoid muscle. The spinal accessory nerve divides levels IIa and IIb and is seen in its typical relationship superfi-
cial to the internal jugular vein (marked in blue, C). D and E, Vagus nerve and levels IIa and III dissection. The vagus nerve
(marked in yellow, E) can be seen traveling in the carotid sheath, medial to the internal jugular vein (marked in blue, E).
Level Ib
Mylohyoid muscle
(retracted)
Lingual nerve
Submandibular
ganglion
Hypoglossal nerve
A Submandibular gland
B C
FIGURE 1.5 Hypoglossal nerve and level IIa dissection.
The posterior belly of the digastric muscle (marked in orange, right) is retracted superiorly to reveal the hypoglos-
sal nerve (marked in yellow, C). The hypoglossal nerve can be identified running deep to the internal jugular vein
and its branches (marked in blue, C) but superficial to the external carotid artery (marked in red, C).
SUGGESTED READINGS
Janfaza P, editor. Cummings otolaryngology: head and neck surgery, 5th ed. Philadelphia:
Saunders; 2010.
Myers EN, editor. Operative otolaryngology: head and neck surgery, 2nd ed. Philadelphia:
Saunders; 2008.
C H A P T E R
2
Tracheostomy
Paul C. Bryson and Saranya Reghunathan
VIDEO
2.1 Tracheostomy
INTRODUCTION
Tracheotomy (tracheostomy) is one of the oldest surgical procedures known, with the first
reference in 3600 BCE. Chevalier Jackson is credited with standardizing the tracheotomy
procedure in 1932, outlining the individual steps for establishing a direct airway through
the anterior neck tissues and into the trachea. This technique was subsequently used dur-
ing the polio epidemic. Throughout the years, this technique has evolved to include three
primary techniques: percutaneous dilatational, open surgical, and other new percutaneous
techniques. This chapter focuses primarily on the open technique and briefly reviews the
classical percutaneous dilatation technique. At present, the tracheostomy is more commonly
used for prolonged mechanical ventilation rather than for upper airway obstruction.
INDICATIONS AND PRINCIPLES OF TRACHEOTOMY

Indications for tracheotomy are multiple and include the need to bypass an airway obstruction
caused by congenital anomaly, vocal cord paralysis, inflammatory disease, benign or malignant
laryngeal pathology, laryngotracheal trauma, facial trauma, or severe sleep apnea refractory to
other interventions. Currently, the most common indication for tracheostomy is acute respiratory
failure with need for prolonged mechanical ventilation. The second most common indication
is in patients with neurologic insult requiring a safe, comfortable airway with possible need for
home mechanical ventilation. Upper airway obstruction is currently a less common indication
for tracheostomy.
13
PREOPERATIVE CONSIDERATIONS
Once a tracheotomy is planned, certain factors influence whether patients should have an open
tracheotomy or a percutaneous dilatational tracheotomy (PDT), as first described by Ciaglia in
1985.
If the consideration for PDT is present, the following ideally should also be present: (1) easily
palpable tracheal landmarks, (2) a skilled bronchoscopist who helps guide the proceduralist and
prevent extubation, and (3) knowledge of when conversion to open tracheostomy is necessary.
Regardless of the tracheotomy method chosen, a patient’s overall medical condition must
be optimized, body habitus assessed, and coagulation profile addressed, because these too help
determine which tracheotomy method is most ideal. Other important considerations include
the urgency of the procedure, which is often directly related to the current status of the airway.
In determining whether to perform the procedure open vs. percutaneously, surgeons must
consider availability of proper equipment, patient portability, surgeon’s experience (open vs.
percutaneous technique), and capability of the institution to perform bedside procedures. This
will determine which team performs the procedure and whether it will be done in the operat-
ing room or at the bedside in the intensive care unit.
PERIOPERATIVE CONSIDERATIONS
In anticipation of placement of the tracheostomy tube, it is prudent to consider the options for
tracheostomy tube size and type. In choosing the size of the tube, both gender and age play the
most important roles. Looking at the inner and outer diameter of tracheostomy tubes helps in
choosing the most appropriately sized tube. In the absence of time for consideration, a Shiley 6
tracheostomy often fits the widest range of adult male and female patients.
SURGICAL ANATOMY AND OPEN TRACHEOTOMY PROCEDURE

External Anatomy
The patient is placed in the supine position, with the head facing toward the anesthesia team. It
is to the surgeon’s benefit to place the neck in extension, often with the aid of a shoulder roll,
because it helps bring more of the trachea into the neck from the chest.
Next, it is critical to palpate and mark the following structures: the thyroid notch superiorly,
cricoid cartilage, and suprasternal notch inferiorly (Fig. 2.1). Typically, the horizontal incision
for the tracheostomy will be 2 cm above the sternal notch and be approximately 3 cm long. The
area of proposed incision is injected with 1% lidocaine with 1:100,000 epinephrine solution for
hemostasis and anesthesia. The local anesthesia is most critical in awake tracheostomy patients
but remains beneficial from a hemostasis perspective in patients under general anesthesia.
Once the patient is appropriately prepped and draped according to surgeon preference, the
horizontal incision is carried through the skin, soft tissue, platysma, until the midline strap
muscles are identified (see Fig. 2.1).
CHAPTER 2 Tracheostomy 15
Thyroid cartilage
1. Position of patient for tracheotomy;
shoulders elevated by sandbag Cricothyroid membrane
Cricothyroid muscle
Common carotid artery

Cricoid cartilage
Edge of sternocleidomastoid muscle
Thyroid gland
Skin incision
Dome of pleura
Tracheal incision
Strap muscles
in cervical fascia Trachea
Anterior Suprasternal notch
jugular vein
2. Anatomy and surface topography
relative to line of incision
3. Skin and fat retracted
4. Strap muscles retracted

to expose trachea
Isthmus of thyroid gland
Strap muscles
Pretracheal venous plexus
5. Pretracheal venous plexus

divided. Trachea stabilized
by hooks. Cruciate incision
in trachea.
6. Tracheotomy tube
tied securely in place
over gauze square 5a. Bjork flap
FIGURE 2.1 Tracheotomy procedure, steps 1 through 6.

Strap Muscles and Midline Raphe

The anterior jugular veins are deep to the platysma and typically located on the strap muscu-
lature and may require ligation if encountered in the midline (Fig. 2.2). In the lower neck, the
surgeon must be conscious of the innominate artery.
The innominate (brachiocephalic) artery is the first branch of the aorta. It typically crosses the tra-
chea at the level of the ninth cartilaginous ring and travels upward to divide behind the sternoclavic-
ular joint into the right subclavian artery and right common carotid artery. Before dissection of the
strap muscles, the surgeon should palpate for innominate pulsations in the suprasternal notch and
should be cognizant of the pathway of the surgical dissection in the setting of a high-riding vessel.
Midline dissection is essential for hemostasis and avoidance of paratracheal structures,
including the great vessels of the neck. The midline raphe between the paired sternohyoid and
sternothyroid muscles can be easily identified. Lateral retraction of the strap muscles along the
midline raphe will expose the underlying thyroid gland. In patients with suboptimal body habi-
tus or difficult anatomy, palpation of the trachea, cricoid cartilage, and thyroid notch can help
maintain a midline course of dissection (see Fig. 2.2).
Thyroid Isthmus
The strap muscles are separated in the midline through the avascular midline raphe and retracted
to either side until the thyroid isthmus is visible. The isthmus of the thyroid gland generally lies
across the first to fourth tracheal rings. It must be divided when overlying the tracheotomy site,
because this will make reinsertion safer and easier in the setting of accidental dislodgement.
Moreover, the isthmus is very vascular and is ideally managed in a controlled setting.
The isthmus can be addressed in one of several ways. First, the fascial attachments of the
thyroid to the anterior trachea may be dissected free, thus allowing the gland to be retracted
above or below the planned entry site into the trachea. If the thyroid is enlarged and cannot
be retracted out of the way, it will have to be divided by further dissecting it from the anterior
tracheal wall in the immediate pretracheal plane to establish a bloodless plane of dissection.
By identifying the bright-white layer of the tracheal cartilage, the surgeon minimizes bleeding
from trauma to the posterior aspect of the gland.
Once the thyroid isthmus is elevated from the trachea, the surgeon may use two clamps on
either side, then cutting in the midline with a cautery device. Once divided, the two ends of
isthmus are then suture-ligated using a running or figure-of-eight 2-0 silk stitch. If available,
energy devices may be used, based on surgeon preference. Use of cautery alone to divide the
thyroid may be appropriate in the case of a small isthmus.
Anatomy With Trachea Visualized

Once the bright white of the trachea is easily visualized, the cricoid hook should be used. It
provides stability to the trachea and is especially useful in cases of difficult anatomy, where the
trachea is deeper in the mediastinum. The cricoid hook can elevate the trachea out of the chest
in the patient with kyphosis or a low-lying laryngotracheal complex. Once the anterior wall
of the trachea is visualized, the space between the second and third tracheal rings is identified
by palpation using a hemostat. At this juncture, it is important to notify the anesthesia team
member that you are prepared to enter the airway. This allows them to free the endotracheal
tube (ETT) by either deflating it before entering the airway or advancing it distally to prevent
ETT cuff deflation. It is preferable to maintain the ETT inflated during the procedure. It allows
ventilation and minimizes the spray of blood and secretions into the surgical field.
Surgeon preference and age of the patient may influence the type of tracheal incision used.
In adults, a horizontal incision is made between the rings with a scalpel and can be extended
laterally in each direction using scissors.
In children, a vertical incision may be used. In adults a common technique is to create an
anterior tracheal window by removing a section of a single ring. Another common technique in
either children or adults is to create an inferiorly based “trapdoor” flap (Björk flap) composed of
an anterior portion of a single tracheal ring and interspace tissue below. After an intercartilagi-
nous incision is made, scissors are used to cut downward on either side to create an inferiorly
CHAPTER 2 Tracheostomy 17
Hyoid bone Digastric muscle (anterior belly)

Mylohyoid muscle
Thyrohyoid membrane
Hyoglossus muscle
External carotid artery Stylohyoid muscle
Internal jugular vein Digastric muscle (posterior belly)

Thyrohyoid muscle
Fibrous loop for intermediate
Thyroid cartilage digastric tendon
Omohyoid muscle
(superior belly) Sternohyoid and omohyoid
muscles (cut)
Sternohyoid muscle
Thyrohyoid muscle
Median cricothyroid
ligament Oblique line of thyroid cartilage
Cricoid cartilage Cricothyroid muscle
Scalene Sternothyroid muscle

muscles Omohyoid muscle
(superior belly) (cut)
Trapezius
muscle
Thyroid gland
Omohyoid muscle
(inferior belly) Sternohyoid muscle (cut)
Trachea
Clavicle
Styloid process
Mastoid process
Mylohyoid muscle Stylohyoid muscle
Digastric muscle (posterior belly)
Digastric muscle (anterior belly)

Thyrohyoid muscle
Geniohyoid muscle
Oblique line of thyroid cartilage
Sternohyoid muscle
Omohyoid muscle (inferior belly)

Omohyoid muscle (superior belly)
Sternothyroid muscle
Scapula
Infrahyoid and Sternum
suprahyoid muscles and
their action: schema
FIGURE 2.2 Infrahyoid and suprahyoid musculature for tracheotomy.
Anatomy With Trachea Visualized (Continued)

based flap of tracheal tissue. The superior edge of this flap is then stitched to the skin edge to
exteriorize and secure the trachea in an effort to reduce the distance from the skin to the airway
and “dead space” that can create a false passage. Although some consider this to be the safest
method because the airway is secured to the skin, this technique may lead to some scarring
or tracheocutaneous fistula after decannulation, both of which can typically be managed with
small procedures.
Anatomy With Tracheotomy Tube in Place

Once the airway is entered, the ETT is pulled out slowly by the anesthesiologist until it is just
above the newly created tracheotomy. The purpose of this maneuver is to keep the endotra-
cheal tube in the airway until adequate tube placement in the newly created airway is con-
firmed. Next, the tracheotomy tube or ETT is then placed through the opening into the trachea.
After the airway is secured, as confirmed by CO2 monitor or ventilator, the oral ETT is then
removed. The tracheostomy tube is then sutured to the skin using 2-0 silk to minimize the
risk of accidental dislodgement. In addition, a circumferential tie is placed and secured around
the neck, allowing at least one finger to slide underneath to minimize constriction. In obese
patients or those with fragile skin, a padded dressing may be indicated under the neck ties.
PERCUTANEOUS DILATATIONAL TRACHEOTOMY PROCEDURE

Traditionally, tracheostomy has been performed by surgeons or otolaryngologists in the oper-
ating room using standard surgical principles. Operational pressures and limited institutional
resources have prompted a re-examination of the setting for tracheotomy and the exploration
of transitioning patients from the ICU setting to longer-term ventilator facilities after trache-
otomy tube placement. In addition, open tracheostomy has a number of possible complications,
including the loss of the airway, injuries to nearby structures, bleeding, pneumothorax, tra-
cheoinnominate fistula, infection, and tracheal stenosis. Thus other “less invasive” techniques
that could be performed in the ICU at bedside have been introduced.
The most popular of these alternative surgical approaches is the PDT method proposed by
Ciaglia in 1985. Similar to the open tracheostomy, general anesthesia is administered and the
patient is prepped and draped. However, all steps are performed under bronchoscopic vision. In
addition, unlike the open tracheostomy, there is no sharp dissection.
First, a skin incision is made. The pretracheal tissue is cleared with blunt dissection. The
endotracheal tube is pulled back proximally. The bronchoscopist places the distal tip of the
bronchoscope such that the light shines through the trachea into the surgical wound.
The operator enters the tracheal lumen below the second tracheal ring with an introducer
needle. This is then serially dilated over guidewire. The tracheostomy tube is then placed under
direct visualization, which then also confirms its location.
SUMMARY
Tracheotomy is used to establish a surgical airway in patients requiring prolonged mechani-
cal ventilation or those who require anatomic bypass because of either obstruction or lack of
function. Surgeon mastery of anatomy and ability to use proper techniques in specific settings
maximizes successful patient outcomes and minimizes potential complications.
SUGGESTED READINGS
Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy: a new simple
bedside procedure: preliminary report. Chest 1985;87:715–9.
Jackson C. Tracheotomy. Laryngoscope 1909;19:285–90.
Lassen HC. A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen with special
reference to the treatment of acute respiratory insufficiency. Lancet 1953;1(6749):37–41.
Moore KL. The cardiovascular system. In: Moore KL, Persaud TVN, editors. The developing
human: clinically oriented embryology, 8th ed. Philadelphia: Saunders; 2008. pp. 285–337.
Pierson DJ. Tracheostomy from A to Z: historical context and current challenges. Respir Care
2005;50(4):473–75.
S E C T I O N 2
Endocrine
section editor: Allan Siperstein
3 Thyroidectomy and Parathyroidectomy

Allan Siperstein and Cassandre Benay
4 Laparoscopic Adrenalectomy
Allan Siperstein and Edwina C. Moore
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C H A P T E R
3
Thyroidectomy and Parathyroidectomy
Allan Siperstein and Cassandre Benay
VIDEO
3.1 Thyroidectomy and Parathyroidectomy
THYROIDECTOMY
Thyroidectomy is the most common endocrine surgical procedure. By definition, a total thyroid-
ectomy requires the resection of both thyroid lobes and isthmus, whereas a thyroid lobectomy
requires the resection of one lobe with the isthmus up to the contralateral lobe. Indications for
thyroidectomy include benign causes such as mass effect of nodule(s) (on the aerodigestive
tract, recurrent laryngeal nerve [RLN], major vessels), thyrotoxicosis (Graves disease refractory
to medical therapy, Graves disease in the context of thyroid nodules, toxic nodular goiter), as
well as malignancy or suspected malignancy on cytology from fine-needle aspirations.
Although thyroidectomy is a safe procedure in experienced hands of a high-volume endo-
crine surgeon, it carries inherent rare but serious risks: cervical hematoma, hypocalcemia, and
RLN injury. Preoperative evaluation should include thyroid-stimulating hormone (TSH), com-
prehensive central and lateral neck ultrasonography to rule out metastatic disease, and, in
selected patients, voice examination by laryngoscopy.
21
22 SECTION 2 ENDO C R I NE
Surgical Anatomy for Thyroidectomy

The thyroid is a bilobed gland wrapped anteriorly to the trachea and joined by an isthmus. The
pyramidal lobe, which represents the embryologic remnant of the thyroglossal duct, can be
found on the left side of the isthmus in up to 60% of patients. The thyroid is attached poste-
riorly to the trachea by the suspensory ligament of Berry. Each thyroid lobe is supplied by the
superior and inferior thyroid arteries arising from the carotid artery and thyrocervical trunk,
respectively. Each hemithyroid is drained by the superior, middle, and inferior thyroid veins.
The upper and middle veins empty in the internal jugular, whereas the inferior thyroid vein
drains into the brachiocephalic vein (Fig. 3.1).
CHAPTER 3 Thyroidectomy and Parathyroidectomy 23
External carotid artery Hyoid bone

Internal carotid artery Superior laryngeal nerve
Infrahyoid artery Internal branch
External branch
Superior thyroid artery and vein
Thyroid cartilage (lamina)
Superior laryngeal artery
Thyrohyoid membrane Median cricothyroid
ligament
Ansa Superior root
cervicalis Inferior root Cricothyroid muscles
Common carotid artery Cricoid cartilage
Cricothyroid artery
Pyramidal lobe
Internal jugular vein (often absent
or small) Thyroid
Phrenic nerve
Right lobe gland
Middle thyroid vein
Left lobe
Inferior thyroid veins Isthmus
Ascending cervical artery
Pretracheal lymph nodes
Inferior thyroid artery
Phrenic nerve
Superficial cervical artery
Anterior scalene muscle
Suprascapular artery
Vagus nerve (X)
Thyrocervical trunk
External jugular vein
Subclavian
artery and vein Anterior jugular vein
Vagus nerve (X) 1st rib (cut)
Left recurrent laryngeal nerve

Right recurrent
laryngeal nerve
Brachiocephalic trunk
Brachiocephalic veins
Superior vena cava
Aortic arch
Thyroid cartilage
Cricothyroid ligament
Common carotid artery
Medial margin of
sternocleidomastoid muscle
Cricothyroid muscle
Cricoid cartilage
Thyroid gland
Cupula (dome) of pleura

Trachea
FIGURE 3.1 Thyroid gland, anterior view.
24 SECTION 2 ENDO C R I NE
Surgical Anatomy of the Superior Recurrent Laryngeal Nerve

In the upper neck, the superior laryngeal nerve (SLN) branches off the vagus nerve. Two to
three centimeters cephalad to the superior pole vessels, the SLN divides into an internal and
external branch. The internal branch provides sensation to the supraglottic area of the larynx
as well as the base of the tongue, whereas the external branch provides motor innervation to
the cricothyroid muscle.
The external branch of the SLN (EBSLN) crosses the superior pole vessels 1 cm or more
cephalad to the thyroid parenchyma, travels medially to the superior pole vessel, and provides
motor innervation to the cricothyroid muscle. On rare occasion, the EBSLN crosses the superior
pole vessels at the junction with the thyroid parenchyma junction, therefore increasing the
likelihood of injury and emphasizing the importance of ligating individual vessels as close as
possible to the thyroid capsule (see Fig. 3.2).
Surgical Anatomy of the Recurrent Laryngeal Nerve

The RLN is a branch of the vagus that wraps around the right subclavian artery and the aortic
arch on the left. For this reason, the left RLN is more medial than the right RLN, which enters
the neck more obliquely. The RLN travels cephalad and medial to the central neck through the
thoracic inlet. As it enters the central neck, it crosses the inferior thyroid artery, then travels
in the tracheoesophageal groove for approximately 1 cm before entering the larynx by diving
posteriorly to the inferior edge of the pharyngeal constrictors. As the RLN travels cephalad, it
passes posterior to the tubercle of Zuckerkandl, a posterolateral parenchyma protrusion of the
thyroid gland. Finally, before entering the larynx, the RLN often bifurcates into an anterior
motor branch and posterior sensory branch (Fig. 3.2).
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one of the last legislatures, who might have come out of one of
Lever’s novels. He was undoubtedly a bad case, but had a genuine
sense of humor, and his “bulls” made him the delight of the house.
One day I came in late, just as a bill was being voted on, and
meeting my friend, hailed him, “Hello, Pat, what’s up? what’s this
they’re voting on?” to which Pat replied, with contemptuous
indifference to the subject, but with a sly twinkle in his eye, “Oh,
some unimportant measure, sorr; some local bill or other—a
constitutional amendment!”
The old Dublin Parliament never listened to a better specimen of a
bull than was contained in the speech of a very genial and pleasant
friend of mine, a really finished orator, who, in the excitement
attendant upon receiving Governor Cleveland’s message vetoing the
five-cent-fare bill, uttered the following sentence: “Mr. Speaker, I
recognize the hand that crops out in that veto; I have heard it
before!”
One member rather astonished us one day by his use of the word
“shibboleth.” He had evidently concluded that this was merely a
more elegant synonym of the good old word shillalah, and in
reproving a colleague for opposing a bill to increase the salaries of
public laborers, he said, very impressively, “The throuble wid the
young man is, that he uses the wurrd economy as a shibboleth,
wherewith to strike the working man.” Afterwards he changed the
metaphor, and spoke of a number of us as using the word “reform”
as a shibboleth, behind which to cloak our evil intentions.
A mixture of classical and constitutional misinformation was
displayed a few sessions past in the State Assembly when I was a
member of the Legislature. It was on the occasion of that annual
nuisance, the debate upon the Catholic Protectory item of the Supply
Bill. Every year some one who is desirous of bidding for the Catholic
vote introduces this bill, which appropriates a sum of varying
dimensions for the support of the Catholic Protectory, an excellent
institution, but one which has no right whatever to come to the State
for support; each year the insertion of the item is opposed by a small
number of men, including the more liberal Catholics themselves, on
proper grounds, and by a larger number from simple bigotry—a fact
which was shown two years ago, when many of the most bitter
opponents of this measure cheerfully supported a similar and equally
objectionable one in aid of a Protestant institution. On the occasion
referred to there were two assemblymen, both Celtic gentlemen, who
were rivals for the leadership of the minority; one of them a stout,
red-faced man, who may go by the name of the “Colonel,” owing to
his having seen service in the army; while the other was a dapper,
voluble fellow, who had at one time been a civil justice and was
called the “Judge.” Somebody was opposing the insertion of the item
on the ground (perfectly just, by the way) that it was unconstitutional,
and he dwelt upon this objection at some length. The Judge, who
knew nothing of the constitution, except that it was continually being
quoted against all of his favorite projects, fidgeted about for some
time, and at last jumped up to know if he might ask the gentleman a
question. The latter said, “Yes,” and the Judge went on, “I’d like to
know if the gintleman has ever personally seen the Catholic
Protectoree?” “No, I haven’t,” said his astonished opponent. “Then,
phwat do you mane by talking about its being unconstitootional? It’s
no more unconstitootional than you are!” Then, turning to the house,
with slow and withering sarcasm, he added, “The throuble wid the
gintleman is that he okkipies what lawyers would call a kind of a
quasi-position upon this bill,” and sat down amid the applause of his
followers.
His rival, the Colonel, felt he had gained altogether too much glory
from the encounter, and after the nonplussed countryman had taken
his seat, he stalked solemnly over to the desk of the elated Judge,
looked at him majestically for a moment, and said, “You’ll excuse my
mentioning, sorr, that the gintleman who has just sat down knows
more law in a wake than you do in a month; and more than that,
Mike Shaunnessy, phwat do you mane by quotin’ Latin on the flure of
this House, when you don’t know the alpha and omayga of the
language!” and back he walked, leaving the Judge in humiliated
submission behind him.
The Judge was always falling foul of the Constitution. Once, when
defending one of his bills which made a small but wholly indefensible
appropriation of State money for a private purpose, he asserted “that
the Constitution didn’t touch little things like that”; and on another
occasion he remarked to me that he “never allowed the Constitution
to come between friends.”
The Colonel was at that time chairman of a committee, before
which there sometimes came questions affecting the interests or
supposed interests of labor. The committee was hopelessly bad in its
composition, most of the members being either very corrupt or
exceedingly inefficient. The Colonel generally kept order with a good
deal of dignity; indeed, when, as not infrequently happened, he had
looked upon the rye that was flavored with lemon-peel, his sense of
personal dignity grew till it became fairly majestic, and he ruled the
committee with a rod of iron. At one time a bill had been introduced
(one of the several score of preposterous measures that annually
make their appearance purely for purposes of buncombe), by whose
terms all laborers in the public works of great cities were to receive
three dollars a day—double the market price of labor. To this bill, by
the way, an amendment was afterwards offered in the house by
some gentleman with a sense of humor, which was to make it read
that all the inhabitants of great cities were to receive three dollars a
day, and the privilege of laboring on the public works if they chose;
the original author of the bill questioning doubtfully if the amendment
“didn’t make the measure too sweeping.” The measure was, of
course, of no consequence whatever to the genuine laboring men,
but was of interest to the professional labor agitators; and a body of
the latter requested leave to appear before the committee. This was
granted, but on the appointed day the chairman turned up in a
condition of such portentous dignity as to make it evident that he had
been on a spree of protracted duration. Down he sat at the head of
the table, and glared at the committeemen, while the latter, whose
faces would not have looked amiss in a rogues’ gallery, cowered
before him. The first speaker was a typical professional laboring
man; a sleek, oily little fellow, with a black mustache, who had never
done a stroke of work in his life. He felt confident that the Colonel
would favor him,—a confidence soon to be rudely shaken,—and
began with a deprecatory smile:
“Humble though I am——”
Rap, rap, went the chairman’s gavel, and the following dialogue
occurred:
Chairman (with dignity). “What’s that you said you were, sir?”
Professional Workingman (decidedly taken aback). “I—I said I was
humble, sir?”
Chairman (reproachfully). “Are you an American citizen, sir?”
P. W. “Yes, sir.”
Chairman (with emphasis). “Then you’re the equal of any man in
this State! Then you’re the equal of any man on this committee!
Don’t let me hear you call yourself humble again! Go on sir!”
After this warning the advocate managed to keep clear of the
rocks until, having worked himself up to quite a pitch of excitement,
he incautiously exclaimed, “But the poor man has no friends!” which
brought the Colonel down on him at once. Rap, rap, went his gavel,
and he scowled grimly at the offender while he asked with deadly
deliberation:
“What did you say that time, sir?”
P. W. (hopelessly). “I said the poor man had no friends, sir.”
Chairman (with sudden fire). “Then you lied, sir! I am the poor
man’s friend! so are my colleagues, sir!” (Here the rogues’ gallery
tried to look benevolent.) “Speak the truth, sir!” (with sudden change
from the manner admonitory to the manner mandatory). “Now, you
sit down quick, or get out of this somehow!”
This put an end to the sleek gentleman, and his place was taken
by a fellow-professional of another type—a great, burly man, who
would talk to you on private matters in a perfectly natural tone of
voice, but who, the minute he began to speak of the Wrongs (with a
capital W) of Labor (with a capital L), bellowed as if he had been a
bull of Bashan. The Colonel, by this time pretty far gone, eyed him
malevolently, swaying to and fro in his chair. However, the first effect
of the fellow’s oratory was soothing rather than otherwise, and
produced the unexpected result of sending the chairman fast asleep
sitting bolt upright. But in a minute or two, as the man warmed up to
his work, he gave a peculiarly resonant howl which waked the
Colonel up. The latter came to himself with a jerk, looked fixedly at
the audience, caught sight of the speaker, remembered having seen
him before, forgot that he had been asleep, and concluded that it
must have been on some previous day. Hammer, hammer, went the
gavel, and—
“I’ve seen you before, sir!”
“You have not,” said the man.
“Don’t tell me I lie, sir!” responded the Colonel, with sudden
ferocity. “You’ve addressed this committee on a previous day!”
“I’ve never—” began the man; but the Colonel broke in again:
“Sit down, sir! The dignity of the chair must be preserved! No man
shall speak to this committee twice. The committee stands
adjourned.” And with that he stalked majestically out of the room,
leaving the committee and the delegation to gaze sheepishly into
each other’s faces.
OUTSIDERS.
After all, outsiders furnish quite as much fun as the legislators
themselves. The number of men who persist in writing one letters of
praise, abuse, and advice on every conceivable subject is appalling;
and the writers are of every grade, from the lunatic and the criminal
up. The most difficult to deal with are the men with hobbies. There is
the Protestant fool, who thinks that our liberties are menaced by the
machinations of the Church of Rome; and his companion idiot, who
wants legislation against all secret societies, especially the Masons.
Then there are the believers in “isms,” of whom the women-
suffragists stand in the first rank. Now I have always been a believer
in woman’s rights, but I must confess I have never seen such a
hopelessly impracticable set of persons as the woman-suffragists
who came up to Albany to get legislation. They simply would not
draw up their measures in proper form; when I pointed out to one of
them that their proposed bill was drawn up in direct defiance of
certain of the sections of the Constitution of the State he blandly
replied that he did not care at all for that, because the measure had
been drawn up so as to be in accord with the Constitution of Heaven.
There was no answer to this beyond the very obvious one that
Albany was in no way akin to Heaven. The ultra-temperance people
—not the moderate and sensible ones—are quite as impervious to
common sense.
A member’s correspondence is sometimes amusing. A member
receives shoals of letters of advice, congratulation, entreaty, and
abuse, half of them anonymous. Most of these are stupid; but some
are at least out of the common.
I had some constant correspondents. One lady in the western part
of the State wrote me a weekly disquisition on woman’s rights. A
Buffalo clergyman spent two years on a one-sided correspondence
about prohibition. A gentleman of Syracuse wrote me such a stream
of essays and requests about the charter of that city that I feared he
would drive me into a lunatic asylum; but he anticipated matters by
going into one himself. A New Yorker at regular intervals sent up a
request that I would “reintroduce” the Dongan charter, which had
lapsed two centuries before. A gentleman interested in a proposed
law to protect primaries took to telegraphing daily questions as to its
progress—a habit of which I broke him by sending in response
telegrams of several hundred words each, which I was careful not to
prepay.
There are certain legislative actions which must be taken in a
purely Pickwickian sense. Notable among these are the resolutions
of sympathy for the alleged oppressed patriots and peoples of
Europe. These are generally directed against England, as there
exists in the lower strata of political life an Anglophobia quite as
objectionable as the Anglomania of the higher social circles.
As a rule, these resolutions are to be classed as simply bouffe
affairs; they are commonly introduced by some ambitious legislator
—often, I regret to say, a native American—who has a large foreign
vote in his district. During my term of service in the Legislature,
resolutions were introduced demanding the recall of Minister Lowell,
assailing the Czar for his conduct towards the Russian Jews,
sympathizing with the Land League and the Dutch Boers, etc., etc.;
the passage of each of which we strenuously and usually
successfully opposed, on the ground that while we would warmly
welcome any foreigner who came here, and in good faith assumed
the duties of American citizenship, we had a right to demand in
return that he should not bring any of his race or national antipathies
into American political life. Resolutions of this character are
sometimes undoubtedly proper; but in nine cases out of ten they are
wholly unjustifiable. An instance of this sort of thing which took place
not at Albany may be cited. Recently the Board of Aldermen of one
of our great cities received a stinging rebuke, which it is to be feared
the aldermanic intellect was too dense fully to appreciate. The
aldermen passed a resolution “condemning” the Czar of Russia for
his conduct towards his fellow-citizens of Hebrew faith, and
“demanding” that he should forthwith treat them better; this was
forwarded to the Russian Minister, with a request that it be sent to
the Czar. It came back forty-eight hours afterwards, with a note on
the back by one of the under-secretaries of the legation, to the effect
that as he was not aware that Russia had any diplomatic relations
with this particular Board of Aldermen, and as, indeed, Russia was
not officially cognizant of their existence, and, moreover, was wholly
indifferent to their opinions on any conceivable subject, he herewith
returned them their kind communication.[7]
In concluding I would say, that while there is so much evil at
Albany, and so much reason for our exerting ourselves to bring
about a better state of things, yet there is no cause for being
disheartened or for thinking that it is hopeless to expect
improvement. On the contrary, the standard of legislative morals is
certainly higher than it was fifteen years ago or twenty-five years
ago. In the future it may either improve or retrograde, by fits and
starts, for it will keep pace exactly with the awakening of the popular
mind to the necessity of having honest and intelligent
representatives in the State Legislature.[8]
I have had opportunity of knowing something about the workings
of but a few of our other State legislatures: from what I have seen
and heard, I should say that we stand about on a par with those of
Pennsylvania, Maryland, and Illinois, above that of Louisiana, and
below those of Vermont, Massachusetts, Rhode Island, and
Wyoming, as well as below the national legislature at Washington.
But the moral status of a legislative body, especially in the West,
often varies widely from year to year.
FOOTNOTES:
[6] The Century, January, 1885.
[7] A few years later a member of the Italian Legation “scored”
heavily on one of our least pleasant national peculiarities. An
Italian had just been lynched in Colorado, and an Italian paper in
New York bitterly denounced the Italian Minister for his supposed
apathy in the matter. The member of the Legation in question
answered that the accusations were most unjust, for the Minister
had worked zealously until he found that the deceased “had taken
out his naturalization papers, and was entitled to all the privileges
of American citizenship.”
[8] At present, twelve years later, I should say that there was
rather less personal corruption in the Legislature; but also less
independence and greater subservience to the machine, which is
even less responsive to honest and enlightened public opinion.
VI
MACHINE POLITICS IN NEW YORK CITY[9]
In New York city, as in most of our other great municipalities, the

direction of political affairs has been for many years mainly in the
hands of a class of men who make politics their regular business and
means of livelihood. These men are able to keep their grip only by
means of the singularly perfect way in which they have succeeded in
organizing their respective parties and factions; and it is in
consequence of the clock-work regularity and efficiency with which
these several organizations play their parts, alike for good and for
evil, that they have been nicknamed by outsiders “machines,” while
the men who take part in and control, or, as they would themselves
say, “run” them, now form a well-recognized and fairly well-defined
class in the community, and are familiarly known as machine
politicians. It may be of interest to sketch in outline some of the
characteristics of these men and of their machines, the methods by
which and the objects for which they work, and the reasons for their
success in the political field.
The terms machine and machine politician are now undoubtedly
used ordinarily in a reproachful sense; but it does not at all follow
that this sense is always the right one. On the contrary, the machine
is often a very powerful instrument for good; and a machine politician
really desirous of doing honest work on behalf of the community, is
fifty times as useful an ally as is the average philanthropic outsider.
Indeed, it is of course true, that any political organization (and
absolutely no good work can be done in politics without an
organization) is a machine; and any man who perfects and uses this
organization is himself, to a certain extent, a machine politician. In
the rough, however, the feeling against machine politics and
politicians is tolerably well justified by the facts, although this
statement really reflects most severely upon the educated and
honest people who largely hold themselves aloof from public life, and
show a curious incapacity for fulfilling their public duties.
The organizations that are commonly and distinctively known as
machines are those belonging to the two great recognized parties, or
to their factional subdivisions; and the reason why the word machine
has come to be used, to a certain extent, as a term of opprobrium is
to be found in the fact that these organizations are now run by the
leaders very largely as business concerns to benefit themselves and
their followers, with little regard to the community at large. This is
natural enough. The men having control and doing all the work have
gradually come to have the same feeling about politics that other
men have about the business of a merchant or manufacturer; it was
too much to expect that if left entirely to themselves they would
continue disinterestedly to work for the benefit of others. Many a
machine politician who is to-day a most unwholesome influence in
our politics is in private life quite as respectable as anyone else; only
he has forgotten that his business affects the state at large, and,
regarding it as merely his own private concern, he has carried into it
the same selfish spirit that actuates in business matters the majority
of the average mercantile community. A merchant or manufacturer
works his business, as a rule, purely for his own benefit, without any
regard whatever for the community at large. The merchant uses all
his influence for a low tariff, and the manufacturer is even more
strenuously in favor of protection, not at all from any theory of
abstract right, but because of self-interest. Each views such a
political question as the tariff, not from the standpoint of how it will
affect the nation as a whole, but merely from that of how it will affect
him personally. If a community were in favor of protection, but
nevertheless permitted all the governmental machinery to fall into the
hands of importing merchants, it would be small cause for wonder if
the latter shaped the laws to suit themselves, and the chief blame,
after all, would rest with the supine and lethargic majority which
failed to have enough energy to take charge of their own affairs. Our
machine politicians, in actual life act in just this same way; their
actions are very often dictated by selfish motives, with but little
regard for the people at large though, like the merchants, they often
hold a very high standard of honor on certain points; they therefore
need continually to be watched and opposed by those who wish to
see good government. But, after all, it is hardly to be wondered at
that they abuse power which is allowed to fall into their hands owing
to the ignorance or timid indifference of those who by rights should
themselves keep it.
In a society properly constituted for true democratic government—
in a society such as that seen in many of our country towns, for
example—machine rule is impossible. But in New York, as well as in
most of our other great cities, the conditions favor the growth of ring
or boss rule. The chief causes thus operating against good
government are the moral and mental attitudes towards politics
assumed by different sections of the voters. A large number of these
are simply densely ignorant, and, of course, such are apt to fall
under the influence of cunning leaders, and even if they do right, it is
by hazard merely. The criminal class in a great city is always of
some size, while what may be called the potentially criminal class is
still larger. Then there is a great class of laboring men, mostly of
foreign birth or parentage, who at present both expect too much from
legislation and yet at the same time realize too little how powerfully
though indirectly they are affected by a bad or corrupt government.
In many wards the overwhelming majority of the voters do not realize
that heavy taxes fall ultimately upon them, and actually view with
perfect complacency burdens laid by their representatives upon the
tax-payers, and, if anything, approve of a hostile attitude towards the
latter—having a vague feeling of animosity towards them as
possessing more than their proper proportion of the world’s good
things, and sharing with most other human beings the capacity to
bear with philosophic equanimity ills merely affecting one’s
neighbors. When powerfully roused on some financial, but still more
on some sentimental question, this same laboring class will throw its
enormous and usually decisive weight into the scale which it
believes inclines to the right; but its members are often curiously and
cynically indifferent to charges of corruption against favorite heroes
or demagogues, so long as these charges do not imply betrayal of
their own real or fancied interests. Thus an alderman or
assemblyman representing certain wards may make as much money
as he pleases out of corporations without seriously jeopardizing his
standing with his constituents; but if he once, whether from honest or
dishonest motives, stands by a corporation when the interests of the
latter are supposed to conflict with those of “the people,” it is all up
with him. These voters are, moreover, very emotional; they value in a
public man what we are accustomed to consider virtues only to be
taken into account when estimating private character. Thus, if a man
is open-handed and warm-hearted, they consider it as a fair offset to
his being a little bit shaky when it comes to applying the eighth
commandment to affairs of state. I have more than once heard the
statement, “He is very liberal to the poor,” advanced as a perfectly
satisfactory answer to the charge that a certain public man was
corrupt. Moreover, working men, whose lives are passed in one
unceasing round of narrow and monotonous toil, are not unnaturally
inclined to pay heed to the demagogues and professional labor
advocates who promise if elected to try to pass laws to better their
condition; they are hardly prepared to understand or approve the
American doctrine of government, which is that the state cannot
ordinarily attempt to better the condition of a man or a set of men,
but can merely see that no wrong is done him or them by anyone
else, and that all alike have a fair chance in the struggle for life—a
struggle wherein, it may as well at once be freely though sadly
acknowledged, very many are bound to fail, no matter how ideally
perfect any given system of government may be.
Of course it must be remembered that all these general
statements are subject to an immense number of individual
exceptions; there are tens of thousands of men who work with their
hands for their daily bread and yet put into actual practice that
sublime virtue of disinterested adherence to the right, even when it
seems likely merely to benefit others, and those others better off
than they themselves are; for they vote for honesty and cleanliness,
in spite of great temptation to do the opposite, and in spite of their
not seeing how any immediate benefit will result to themselves.
REASONS FOR THE NEGLECT OF PUBLIC
DUTIES BY RESPECTABLE MEN IN EASY
CIRCUMSTANCES.
This class is composed of the great bulk of the men who range
from well-to-do up to very rich; and of these the former generally and
the latter almost universally neglect their political duties, for the most
part rather pluming themselves upon their good conduct if they so
much as vote on election day. This largely comes from the
tremendous wear and tension of life in our great cities. Moreover, the
men of small means with us are usually men of domestic habits; and
this very devotion to home, which is one of their chief virtues, leads
them to neglect their public duties. They work hard, as clerks,
mechanics, small tradesmen, etc., all day long, and when they get
home in the evening they dislike to go out. If they do go to a ward
meeting, they find themselves isolated, and strangers both to the
men whom they meet and to the matter on which they have to act;
for in the city a man is quite as sure to know next to nothing about
his neighbors as in the country he is to be intimately acquainted with
them. In the country the people of a neighborhood, when they
assemble in one of their local conventions, are already well
acquainted, and therefore able to act together with effect; whereas in
the city, even if the ordinary citizens do come out, they are totally
unacquainted with one another, and are as helplessly unable to
oppose the disciplined ranks of the professional politicians as is the
case with a mob of freshmen in one of our colleges when in danger
of being hazed by the sophomores. Moreover, the pressure of
competition in city life is so keen that men often have as much as
they can do to attend to their own affairs, and really hardly have the
leisure to look after those of the public. The general tendency
everywhere is toward the specialization of functions, and this holds
good as well in politics as elsewhere.
The reputable private citizens of small means thus often neglect to
attend to their public duties because to do so would perhaps
interfere with their private business. This is bad enough, but the case
is worse with the really wealthy, who still more generally neglect
these same duties, partly because not to do so would interfere with
their pleasure, and partly from a combination of other motives, all of
them natural but none of them creditable. A successful merchant,
well dressed, pompous, self-important, unused to any life outside of
the counting-room, and accustomed because of his very success to
be treated with deferential regard, as one who stands above the
common run of humanity, naturally finds it very unpleasant to go to a
caucus or primary where he has to stand on an equal footing with his
groom and day-laborers, and indeed may discover that the latter,
thanks to their faculty for combination, are rated higher in the scale
of political importance than he is himself. In all the large cities of the
North the wealthier, or, as they would prefer to style themselves, the
“upper” classes, tend distinctly towards the bourgeois type; and an
individual in the bourgeois stage of development, while honest,
industrious, and virtuous, is also not unapt to be a miracle of timid
and short-sighted selfishness. The commercial classes are only too
likely to regard everything merely from the standpoint of “Does it
pay?” and many a merchant does not take any part in politics
because he is short-sighted enough to think that it will pay him better
to attend purely to making money, and too selfish to be willing to
undergo any trouble for the sake of abstract duty; while the younger
men of this type are too much engrossed in their various social
pleasures to be willing to give their time to anything else. It is also
unfortunately true, especially throughout New England and the
Middle States, that the general tendency among people of culture
and high education has been to neglect and even to look down upon
the rougher and manlier virtues, so that an advanced state of
intellectual development is too often associated with a certain
effeminacy of character. Our more intellectual men often shrink from
the raw coarseness and the eager struggle of political life as if they
were women. Now, however refined and virtuous a man may be, he
is yet entirely out of place in the American body-politic unless he is
himself of sufficiently coarse fibre and virile character to be more
angered than hurt by an insult or injury; the timid good form a most
useless as well as a most despicable portion of the community.
Again, when a man is heard objecting to taking part in politics
because it is “low,” he may be set down as either a fool or a coward:
it would be quite as sensible for a militiaman to advance the same
statement as an excuse for refusing to assist in quelling a riot. Many
cultured men neglect their political duties simply because they are
too delicate to have the element of “strike back” in their natures, and
because they have an unmanly fear of being forced to stand up for
their own rights when threatened with abuse or insult. Such are the
conditions which give the machine men their chance; and they have
been able to make the most possible out of this chance,—first,
because of the perfection to which they have brought their
machinery, and, second, because of the social character of their
political organizations.
ORGANIZATION AND WORK OF THE MACHINES.

The machinery of any one of our political bodies is always rather
complicated; and its politicians invariably endeavor to keep it so,
because, their time being wholly given to it, they are able to become
perfectly familiar with all its workings, while the average outsider
becomes more and more helpless in proportion as the organization
is less and less simple. Besides some others of minor importance,
there are at present in New York three great political organizations,
viz., those of the regular Republicans, of the County Democracy,[10]
and of Tammany Hall, that of the last being perhaps the most
perfect, viewed from a machine standpoint. Although with wide
differences in detail, all these bodies are organized upon much the
same general plan; and one description may be taken in the rough,
as applying to all. There is a large central committee, composed of
numerous delegates from the different assembly districts, which
decides upon the various questions affecting the party as a whole in
the county and city; and then there are the various organizations in
the assembly districts themselves, which are the real sources of
strength, and with which alone it is necessary to deal. There are
different rules for the admission to the various district primaries and
caucuses of the voters belonging to the respective parties; but in
almost every case the real work is done and the real power held by a
small knot of men, who in turn pay a greater or less degree of fealty
to a single boss.
The mere work to be done on election day and in preparing for it
forms no slight task. There is an association in each assembly or
election district, with its president, secretary, treasurer, executive
committee, etc.; these call the primaries and caucuses, arrange the
lists of the delegates to the various nominating conventions, raise
funds for campaign purposes, and hold themselves in
communication with their central party organizations. At the primaries
in each assembly district a full set of delegates is chosen to
nominate assemblymen and aldermen, while others are chosen to
go to the State, county, and congressional conventions. Before
election day many thousands of complete sets of the party ticket are
printed, folded, and put together, or, as it is called, “bunched.” A
single bundle of these ballots is then sent to every voter in the
district, while thousands are reserved for distribution at the polls. In
every election precinct—there are probably twenty or thirty in each
assembly district—a captain and from two to a dozen subordinates
are appointed.[11] These have charge of the actual giving out of the
ballots at the polls. On election day they are at their places long
before the hour set for voting; each party has a wooden booth,
looking a good deal like a sentry-box, covered over with flaming
posters containing the names of their nominees, and the “workers”
cluster around these as centres. Every voter as he approaches is
certain to be offered a set of tickets; usually these sets are “straight,”
that is, contain all the nominees of one party, but frequently crooked
work will be done, and some one candidate will get his own ballots
bunched with the rest of those of the opposite party. Each captain of
a district is generally paid a certain sum of money, greater or less
according to his ability as a politician or according to his power of
serving the boss or machine. Nominally this money goes in paying
the subordinates and in what are vaguely termed “campaign
expenses,” but as a matter of fact it is in many instances simply
pocketed by the recipient; indeed, very little of the large sums of
money annually spent by candidates to bribe voters actually reaches
the voters supposed to be bribed. The money thus furnished is
procured either by subscriptions from rich outsiders, or by
assessments upon the candidates themselves; formerly much was
also obtained from office-holders, but this is now prohibited by law. A
great deal of money is also spent in advertising, placarding posters,
paying for public meetings, and organizing and uniforming members
to take part in some huge torchlight procession—this last particular
form of spectacular enjoyment being one peculiarly dear to the
average American political mind. Candidates for very lucrative
positions are often assessed really huge sums, in order to pay for
the extravagant methods by which our canvasses are conducted.
Before a legislative committee of which I was a member, the
Register of New York County blandly testified under oath that he had
forgotten whether his expenses during his canvass had been over or
under fifty thousand dollars. It must be remembered that even now—
and until recently the evil was very much greater—the rewards paid
to certain public officials are out of all proportion to the services
rendered; and in such cases the active managing politicians feel that
they have a right to exact the heaviest possible toll from the
candidate, to help pay the army of hungry heelers who do their
bidding. Thus, before the same committee the County Clerk testified
that his income was very nearly eighty thousand a year, but with
refreshing frankness admitted that his own position was practically
merely that of a figure-head, and that all the work was done by his
deputy, on a small fixed salary. As the County Clerk’s term is three
years, he should nominally have received nearly a quarter of a
million dollars; but as a matter of fact two thirds of the money
probably went to the political organizations with which he was
connected. The enormous emoluments of such officers are, of
course, most effective in debauching politics. They bear no relation
whatever to the trifling quantity of work done, and the chosen
candidate readily recognizes what is the exact truth,—namely, that
the benefit of his service is expected to enure to his party allies, and
not to the citizens at large. Thus, one of the county officers who
came before the above-mentioned committee, testified with a naïve
openness which was appalling, in answer to what was believed to be
a purely formal question as to whether he performed his public
duties faithfully, that he did so perform them whenever they did not
conflict with his political duties!—meaning thereby, as he explained,
attending to his local organizations, seeing politicians, fixing
primaries, bailing out those of his friends (apparently by no means
few in number) who got hauled up before a justice of the peace, etc.,
etc. This man’s statements were valuable because, being a truthful
person and of such dense ignorance that he was at first wholly
unaware his testimony was in any way remarkable, he really tried to
tell things as they were; and it had evidently never occurred to him
that he was not expected by everyone to do just as he had been
doing,—that is, to draw a large salary for himself, to turn over a still
larger fund to his party allies, and conscientiously to endeavor, as far
as he could, by the free use of his time and influence, to satisfy the
innumerable demands made upon him by the various small-fry
politicians.[12]
“HEELERS.”
The “heelers,” or “workers,” who stand at the polls, and are paid in
the way above described, form a large part of the rank and file
composing each organization. There are, of course, scores of them
in each assembly district association, and, together with the almost
equally numerous class of federal, State, or local paid office-holders
(except in so far as these last have been cut out by the operations of
the civil-service reform laws), they form the bulk of the men by whom
the machine is run, the bosses of great and small degree chiefly
merely oversee the work and supervise the deeds of their
henchmen. The organization of a party in our city is really much like
that of an army. There is one great central boss, assisted by some
trusted and able lieutenants; these communicate with the different
district bosses, whom they alternately bully and assist. The district
boss in turn has a number of half-subordinates, half-allies, under
him; these latter choose the captains of the election districts, etc.,
and come into contact with the common heelers. The more stupid
and ignorant the common heelers are, and the more implicitly they
obey orders, the greater becomes the effectiveness of the machine.
An ideal machine has for its officers men of marked force, cunning
and unscrupulous, and for its common soldiers men who may be
either corrupt or moderately honest, but who must be of low
intelligence. This is the reason why such a large proportion of the
members of every political machine are recruited from the lower
grades of the foreign population. These henchmen obey
unhesitatingly the orders of their chiefs, both at the primary or
caucus and on election day, receiving regular rewards for so doing,
either in employment procured for them or else in money outright. Of
course it is by no means true that these men are all actuated merely
by mercenary motives. The great majority entertain also a real
feeling of allegiance towards the party to which they belong, or
towards the political chief whose fortunes they follow; and many
work entirely without pay and purely for what they believe to be right.
Indeed, an experienced politician always greatly prefers to have
under him men whose hearts are in their work and upon whose
unbribed devotion he can rely; but unfortunately he finds in most
cases that their exertions have to be seconded by others which are
prompted by motives far more mixed.
All of these men, whether paid or not, make a business of political
life and are thoroughly at home among the obscure intrigues that go
to make up so much of it; and consequently they have quite as much
the advantage when pitted against amateurs as regular soldiers
have when matched against militiamen. But their numbers, though
absolutely large, are, relatively to the entire community, so small that
some other cause must be taken into consideration in order to
account for the commanding position occupied by the machine and
the machine politicians in public life. This other determining cause is
to be found in the fact that all these machine associations have a
social as well as a political side, and that a large part of the political
life of every leader or boss is also identical with his social life.
THE SOCIAL SIDE OF MACHINE POLITICS.

The political associations of the various districts are not organized
merely at the approach of election day; on the contrary, they exist
throughout the year, and for the greater part of the time are to a
great extent merely social clubs. To a large number of the men who
belong to them they are the chief social rallying-point. These men
congregate in the association building in the evening to smoke, drink
beer, and play cards, precisely as the wealthier men gather in the
clubs whose purpose is avowedly social and not political—such as
the Union, University, and Knickerbocker. Politics thus becomes a
pleasure and relaxation as well as a serious pursuit. The different
members of the same club or association become closely allied with
one another, and able to act together on occasions with unison and
esprit de corps; and they will stand by one of their own number for
reasons precisely homologous to those which make a member of
one of the upper clubs support a fellow-member if the latter happens
to run for office. “He is a gentleman, and shall have my vote,” says
the swell club man. “He’s one of the boys, and I’m for him,” replies
the heeler from the district party association. In each case the feeling
is social rather than political, but where the club man influences one
vote the heeler controls ten. A rich merchant and a small tradesman
alike find it merely a bore to attend the meetings of the local political
club; it is to them an irksome duty which is shirked whenever
possible. But to the small politicians and to the various workers and
hangers-on, these meetings have a distinct social attraction, and the
attendance is a matter of preference. They are in congenial society
and in the place where by choice they spend their evenings, and
where they bring their friends and associates; and naturally all the
men so brought together gradually blend their social and political
ties, and work with an effectiveness impossible to the outside
citizens whose social instincts interfere, instead of coinciding with
their political duties. If an ordinary citizen wishes to have a game of
cards or a talk with some of his companions, he must keep away
from the local headquarters of his party; whereas, under similar
circumstances, the professional politician must go there. The man
who is fond of his home naturally prefers to stay there in the
evenings, rather than go out among the noisy club frequenters,
whose pleasure it is to see each other at least weekly, and who
spend their evenings discussing neither sport, business, nor scandal,
as do other sections of the community, but the equally monotonous
subject of ward politics.

Netters Surgical Anatomy and Approaches Conor P Delaney MD MCH PHD Facs Frcsi Fascrs Frcsi Hon Full Chapter

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NETTER’S SURGICAL ANATOMY AND APPROACHES, SECOND EDITION ISBN: 978-­0-­323-­67346-­4

Previous edition copyrighted 2014.

Library of Congress Control Number: 2020939762

Publisher: Elyse O’Grady

Last digit is the print number: 9 8 7 6 5 4 3 2 1

The standard of patient care

EDITOR Stephen R. Grobmyer, MD

Tommaso Falcone, MD, FRCSC, FACOG John H. Rodriguez, MD, FACS

Christopher T. Siegel, MD, PhD Abdul Q. Alarhayem, MD

Scott R. Steele, MD, MBA Sofya H. Asfaw, MD, FACS

Riccardo Bertolo, MD Bradley J. Champagne, MD

Conor P. Delaney, MD, MCh, PhD, FACS, Aldo Fafaj, MD

David A. Goldfarb, MD Barbara J. Hocevar, MSN, RN, CWOCN

Stephen R. Grobmyer, MD Stefan D. Holubar, MD, MS

Koji Hashimoto, MD, PhD Jihad Kaouk, MD

Hermann Kessler, MD, PhD Matthew Kroh, MD

Eric A. Klein, MD Judith Landis-­Erdman, BSN, RN, CWOCN

Venkatesh Krishnamurthi, MD Kelsey E. Larson, MD

Pierre Lavertu, MD Christopher Mascarenhas, MD, FACS

Robert Naples, DO Lee Ponsky, MD, FACS

Keita Okubo, MD, PhD Debra Pratt, MD

Beri M. Ridgeway, MD Christopher T. Siegel, MD, PhD

Rachael C. Sullivan, MD, MS

Luciano Tastaldi, MD Cynthia E. Weber, MD

Stephanie A. Valente, DO, FACS Chad A. Zender, MD, FACS

SECTION 1 The Neck 1 Chapter 8 Gastrectomy 87

Chapter 17 Splenectomy 189 Chapter 29 Transverse Colectomy 301

Chapter 43 Aortic Aneurysm Repair and Chapter 56 Breast Reconstruction 587

1.1 Neck Dissection

35.2 Completion Proctectomy/J-­Pouch Construction

section editor: Michael S. Benninger

1 Selective ­(Supraomohyoid) Neck

NECK ANATOMY FOR SURGICAL PLANNING

FIGURE 1.1 Patient positioning and anatomy in neck dissection.

INCISION PLANNING AND PATIENT POSITIONING FOR NECK

Raising the Subplatysmal Flap

Platysma muscle elevated

LEVEL IA-­IB NECK DISSECTION

Facial artery and vein

LEVEL II-­III NECK DISSECTION

Internal jugular vein

Spinal accessory nerve

Vagus nerve and levels IIa and III dissection

INDICATIONS AND PRINCIPLES OF TRACHEOTOMY

SURGICAL ANATOMY AND OPEN TRACHEOTOMY PROCEDURE

Common carotid artery

4. Strap muscles retracted

Isthmus of thyroid gland

Pretracheal venous plexus

5. Pretracheal venous plexus

FIGURE 2.1 Tracheotomy procedure, steps 1 through 6.

Strap Muscles and Midline Raphe

Anatomy With Trachea Visualized

Hyoid bone Digastric muscle (anterior belly)

Internal jugular vein Digastric muscle (posterior belly)

Scalene Sternothyroid muscle

Mylohyoid muscle Stylohyoid muscle

Digastric muscle (posterior belly)

Digastric muscle (anterior belly)

NETTER’S SURGICAL ANATOMY AND APPROACHES, SECOND EDITION ISBN: 978-0-323-67346-4

Eric A. Klein, MD Judith Landis-Erdman, BSN, RN, CWOCN

SECTION 1 The Neck 1 Chapter 8 Gastrectomy 87

Chapter 17 Splenectomy 189 Chapter 29 Transverse Colectomy 301

Chapter 43 Aortic Aneurysm Repair and Chapter 56 Breast Reconstruction 587

1.1 Neck Dissection

35.2 Completion Proctectomy/J-Pouch Construction

1 Selective (Supraomohyoid) Neck

LEVEL IA-IB NECK DISSECTION

LEVEL II-III NECK DISSECTION

3 Thyroidectomy and Parathyroidectomy