Annals of the Royal College of Surgeons of England (1990) vol. 72, 382-385
Delorme's operation for rectal prolapse A Mutaz Abulafi
FRCS FRCSGIas
Richard V Fiddian
Registrar in Surgery
Consultant Surgeon
Ian W Sherman MB SHO in Surgery
Consultant Surgeon
MChir FRCS
Rex L Rothwell-Jackson
MChir FRCS
Department of Surgery, Luton and Dunstable Hospital, Luton
Key words: Delorme operation, rectal prolapse
Between 1981 and 1988 inclusive, 22 patients with fullthickness rectal prolapse presenting to two surgeons in this hospital were treated using the Delorme operation. There was no mortality and morbidity was minimal. Twentyone patients (95.5%) were cured of prolapse and 19 patients (86.4%) had normal anal sphincter function after the operation.
Delorme's operation is one of the oldest operations described for the treatment of complete rectal prolapse. Since it was first described by Rene Delorme in 1900 (1), various modifications to the surgical technique have been introduced to improve the anatomical and functional results. Many studies evaluating the surgical treatment of rectal prolapse suffer from selection bias. In this series, all but two patients with complete rectal prolapse presenting to two surgeons in this hospital (RVF and RLRJ), irrespective of age, sex, condition and symptom have been treated by Delorme's operation. Two very young patients presenting to RLRJ were referred to
bleeding and incontinence, either alone or in any combination. Incontinence was present in eight patients (36.4%). Operative technique Under general, spinal or local anaesthesia the prolapse is fully extended using Babcock forceps and sufficient 1:400 000 adrenaline solution is injected submucosally to elevate all the exposed mucosa (Fig. 1). This facilitates dissection in that plane and greatly reduces bleeding. A circumferential mucosal incision is made 10-15 mm from the mucocutaneous junction (Fig. 2). The mucosa is then dissected from the muscularis to a point at least 2.5 cm beyond the apex of the prolapse. Between 8 and
other institutions for treatment.
Patients and methods Between 1981 and 1988, 22 patients with complete rectal prolapse, all females aged 44-93 years (median 75 years) were treated by Delorme's operation. The size of prolapse ranged from 6.5 to 11.5 cm and in one patient was 30.5 cm long. One patient had had a Ripstein operation 7 years earlier. The presenting symptoms were a mass,
Correspondence to: Mr A M Abulafi, Clinical Research Fellow, The Surgical Unit, The London Hospital, Whitechapel, London El BB
Figure 1. Adrenaline solution is infiltrated submucosally facilitate mucosal dissection.
to
Delorme's operation, rectal prolapse
12 plicating sutures of an absorbable material (our preference is for No. 1 polydioxanone) are inserted in the muscular wall of the rectum between the mucosal cut edges at the mucocutaneous junction and the apex (Figs. 3 and 4). The sutures are then tied forming a doughnutlike mass which is reduced gently. The mucosal sleeve is then divided and the cut ends of the mucosa are sutured together with 3/0 catgut (Fig. 5).
383
ST. tMC
S5K
AA S: mc
0
MC Mucosa MCJ Mucocutaneous junction MS Muscle
0
Figure 2. A circumferential mucosal incision is made 1015 mm from the mucocutaneous junction and the mucosa is dissected proximally.
SK Skin ST MC Stripped
mucosa
Figure 4. A longitudinal section through the prolapse illustrating the extent of mucosal dissection (beyond the apex) and the position of the plicating sutures.
-~
Figure 5. The prolapse, now converted to a doughnut-like mass, is reduced and the mucosal edges sutured with interrupted stitches.
Figure 3. When the mucosa has been stripped plicating sutures are inserted.
away,
8-12
Additional procedures A simultaneous Thiersch procedure was carried out on a patient with incontinence and a patulous anal sphincter. This was successful and the wire was removed 3 weeks later.
384
A M Abulafi et al.
Results Twenty-one patients (95.5%) were cured of prolapse. Nineteen patients (86.4%) (six out of eight patients with incontinence) had normal anal sphincter function as judged by continence to solids and flatus after operation. Hospital stay was between 3 and 14 days (median 7.5 days). Average follow-up was 29.3 months (range 3-70 months). The review was by clinical assessment of live patients (n = 17) and by review of the records of deceased patients (n = 5).
Complications There were no perioperative deaths and no significant postoperative morbidity. One patient developed left ventricular failure, three urinary tract infection, one urinary retention, and two postoperative confusion. One patient presented 3 months after operation with difficulty in opening her bowels, but this resolved after an anal stretch. Apart from one other case (see below) there were no reports of evacuatory difficulties.
submucosal adrenaline solution which aids mucosal dissection and reduces bleeding, mucosal stripping beyond the apex of prolapse and perioperative metronidazole. Of eight patients, six (75%) with incontinence to solids regained normal control after the operation. As shown in these cases, the majority of patients had their incontinence cured with Delorme's operation alone, thus, simultaneous postanal repair is rarely indicated. However, in patients with persistent incontinence, postanal repair may prove useful although, in our experience, this has not been successful. In the only patient with incontinence and patulous anal sphincter, simultaneous Delorme's and Thiersch's operations have been successful. Since compiling this report, two elderly patients presenting with procidentia and complete rectal prolapse were treated with combined vaginal hysterectomy and Delorme's operation under epidural anaesthesia with satisfactory results. We conclude that Delorme's operation is a safe and effective treatment for complete rectal prolapse, although it may be unsuitable for patients with extensive prolapse. Any recurrence can be treated by a further Delorme's operation. Moreover, a failed Delorme's operation does not compromise subsequent abdominal procedures, as shown in one of our cases. We feel it should be considered in patients presenting with complete rectal prolapse, particularly the elderly.
Failures One patient developed recurrence of prolapse and incontinence 28 months after surgery. These were cured by an Ivalon® sponge rectopexy with no evidence of recurrence at 14 months. The second patient had her prolapse cured, but not the incontinence. The latter persisted even after a postanal repair and an abdominal rectopexy. The third patient with a 30.5 cm prolapse, developed rectal stenosis leading to chronic constipation. This was eventually relieved by a permanent colostomy.
We wish to express our grateful thanks to Sister D Reid RGN, for providing the illustrations and to the general practitioners of the South Bedfordshire District for their cooperation and interest in our work.
Discussion
References
The results in our series compare favourably with popular transabdominal procedures; Ivalon' sponge (2,3), Marlex® mesh (4), Ripstein (5), and extended abdominal rectopexy (6). In contrast, however, Delorme's operation is simple, fast and can be carried out under general, spinal or local anaesthetic. The hospital stay is usually short. Furthermore, innervation to the rectum is not interfered with and the complications of abdominal surgery are avoided. On the other hand, since the basic anatomical defect producing the prolapse is not rectified, long-term success is uncertain. Rectal stenosis can be a complication in patients with extensive prolapse, as shown in one of our patients. Since the re-emergence of Delorme's operation in the early 1970s its place in the treatment of rectal prolapse has been confined to elderly patients and those unsuitable for major abdominal procedures (7-9). However, with success rates (10-12) similar to ours comparable to abdominal procedures, proponents of Delorme's operation argue for its use as first choice in the treatment of full-thickness rectal prolapse (12). The high success rate in our series is due mainly to the improved surgical technique, which involves the use of
I Delorme R. Sur le traitement des prolapsus du rectum totaux par l'excision de la muquese rectale au rectal-colique. Bull Mem Soc Chir Paris 1900;26:498-9. 2 Morgan CN, Porter NA, Klugman DJ. Ivalon (polyvinyl alcohol) sponge in the repair of complete rectal prolapse. Br
Jf Surg 1972;59:841-6. 3 Penfold JCB, Hawley PR. Experiences of Ivalon sponge implant for complete rectal prolapse at St Mark's Hospital, 1960-70. BrJ Surg 1972;59:846-8. 4 Keighley MRL, Fielding JWL, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consecutive patients. Br J Surg 1983;70: 229-32. S Ripstein CB. Procidentia-definitive corrective surgery. Dis Colon Rectum 1972;17:334-6. 6 Mann CV, Hoffman C. Complete rectal prolapse: the anatomical and functional results of treatment by an extended abdominal rectopexy. Br J Surg 1988;75:34-7. 7 Moskalenko VW. Modification of Delorme's resection of rectal mucosa for prolapse of the rectum. Int Surg 1973;58: 192-4. 8 Nay HR, Blair CR. Perineal surgical repair of rectal prolapse. Am J Surg 1972;123:577-9. 9 Christiansen J, Kirkegaard P. Delorme's operation for complete rectal prolapse. BrJ Surg 1981;68:537-8.
Delorme's operation, rectal prolapse 10 Uhlig BE, Sullivan ES. The modified Delorme operation: Its place in surgical treatment for massive rectal prolapse. Dis Colon Rectum 1979;22:513-21. 11 Gundersen AL, Cogbill TH, Landercasper J. Reappraisal of Delorme's procedure for rectal prolapse. Dis Colon Rectum 1985;28:721-4.
385
12 Monson JRT, Jones NAG, Vowden P, Brennan TG. Delorme's operation: the first choice in complete rectal prolapse? Ann R Coll Surg Engl 1986;68:143-6. Received 27 April 1990
Notes on books Anatomischer Atlas by Jainos Vajda. 2 volumes, illustrated. Akademiai Kiado, Budapest. 1989. £44.00. ISBN 963 05 5504 2
Full-page photographs of anatomical dissections on the righthand side of the opened book; labelled line diagrams corresponding to the photograph on the left-hand side. Good quality photographs. Useful for anatomical revision by students attempting Part 1 FRCS.
Cancer of the Head and Neck edited by Eugene N Myers and James Y Suen. 2nd edition. 1132 pages, illustrated. Churchill Livingstone, New York. 1989. £95.00. ISBN 0 443 08597 8 The first edition of this large and comprehensive textbook was well received when it appeared in 1981. The editors have completely revised and updated this second edition and have included new chapters on radiological evaluation, the use of antibiotics, cranial base tumours, voice rehabilitation after laryngectomy, tumours of the parapharyngeal space, chemotherapy and speech and swallowing rehabilitation. The editors hope that this work represents a state-of-the-art depiction of head and neck surgery and will result in an improvement in the quality of life of patients with head and neck cancer.
Sir James Paget: The Rise of Clinical Surgery by Shirley Roberts. 223 pages, illustrated, paperback. Royal Society of Medicine Services Limited, London. £7.95. ISBN 0 905958 91 8
Sir James Paget is one of the few surgeons known to every medical student and aspiring surgeon by virtue of his name being attached to several different diseases. This small volume gives a most entertaining account of his life and importance in medical history.
Breast Cancer edited by B Hoogstraten, I Burn and H J G Bloom. 287 pages, illustrated, paperback. Springer-Verlag, Berlin. 1989. DM148. ISBN 3 540 50595 4 In less than 300 pages this monograph gives a useful update on a subject of great interest to many readers. Part 1 deals with pathology and diagnosis, including a valuable chapter on the psychological aspects of breast cancer. Part 2 deals with treatment by surgery, radiotherapy, chemotherapy and endocrine therapy. The presentation and format is welcome rather than inhibiting. The editors hope that the mixture of philosophical debate, science and clinical description will appeal to the reader-this wish should be amply fulfilled.
Operative Surgery: Principles and Techniques edited by Paul F Nora. 3rd edition. 1412 pages, illustrated. W B Saunders Company, Philadelphia. 1990. £103.55. ISBN 0 7216 2134 1
Those familiar with previous editions of this textbook, the last published 10 years ago, will know that it is mammoth in size and scope and was written as a guide for surgeons in training faced with which operation to choose for a particular condition. In this new edition a major emphasis has been placed on stapling techniques. There are extensive revisions of the sections on trauma, microvascular surgery, imaging techniques, transplantation, vascular access, lithotripsy and lasers. Many of the illustrations have been redrawn for greater clarity as well as being relabelled to enhance visual appeal. An important reference work.
Operating Room Guide to Cross Sectional Anatomy of the Extremities and Pelvis edited by Wallace B Lehman. 26 pages, illustrated. Raven Press, New York. 1989. $262.50. ISBN 0 88167 562 8
Vascular Surgery edited by G Heberer and R J A M van Dongen. 811 pages, illustrated. Springer-Verlag, Berlin. 1989. DM650. ISBN 3 540 18280 2 This is an impressive book written by outstanding vascular surgeons in Germany, The Netherlands, Austria and Switzerland. In a laudatory foreword, David Sabiston concludes that it will become a worldwide standard by which all similar works will be compared and that it will be regarded as an essential text by all surgeons who practise vascular surgery.
Twenty-two coloured plastic laminated plates in a ring binder and designed for the orthopaedic surgeon performing external fixation. The difficulty in memorising detailed anatomy is well known and these plates serve as a 'road map'. The plates may be removed from the binder and placed on an X-ray viewing box. A complete longitudinal reconstruction of each extremity is shown in both a left and a right view.
A casual glance through the pages will convince the reader that this assessment is likely to be fulfilled. Attractively laid out with superb illustrations, the text reads well (despite the translation from German) and the subject of peripheral vascular surgery is covered in its entirety and in detail. All libraries should obtain a copy and all vascular surgeons who want a reference volume for private use should consider this volume very seriously.
Delorme's operation for rectal prolapse A Mutaz Abulafi
FRCS FRCSGIas
Richard V Fiddian
Registrar in Surgery
Consultant Surgeon
Ian W Sherman MB SHO in Surgery
Consultant Surgeon
MChir FRCS
Rex L Rothwell-Jackson
MChir FRCS
Department of Surgery, Luton and Dunstable Hospital, Luton
Key words: Delorme operation, rectal prolapse
Between 1981 and 1988 inclusive, 22 patients with fullthickness rectal prolapse presenting to two surgeons in this hospital were treated using the Delorme operation. There was no mortality and morbidity was minimal. Twentyone patients (95.5%) were cured of prolapse and 19 patients (86.4%) had normal anal sphincter function after the operation.
Delorme's operation is one of the oldest operations described for the treatment of complete rectal prolapse. Since it was first described by Rene Delorme in 1900 (1), various modifications to the surgical technique have been introduced to improve the anatomical and functional results. Many studies evaluating the surgical treatment of rectal prolapse suffer from selection bias. In this series, all but two patients with complete rectal prolapse presenting to two surgeons in this hospital (RVF and RLRJ), irrespective of age, sex, condition and symptom have been treated by Delorme's operation. Two very young patients presenting to RLRJ were referred to
bleeding and incontinence, either alone or in any combination. Incontinence was present in eight patients (36.4%). Operative technique Under general, spinal or local anaesthesia the prolapse is fully extended using Babcock forceps and sufficient 1:400 000 adrenaline solution is injected submucosally to elevate all the exposed mucosa (Fig. 1). This facilitates dissection in that plane and greatly reduces bleeding. A circumferential mucosal incision is made 10-15 mm from the mucocutaneous junction (Fig. 2). The mucosa is then dissected from the muscularis to a point at least 2.5 cm beyond the apex of the prolapse. Between 8 and
other institutions for treatment.
Patients and methods Between 1981 and 1988, 22 patients with complete rectal prolapse, all females aged 44-93 years (median 75 years) were treated by Delorme's operation. The size of prolapse ranged from 6.5 to 11.5 cm and in one patient was 30.5 cm long. One patient had had a Ripstein operation 7 years earlier. The presenting symptoms were a mass,
Correspondence to: Mr A M Abulafi, Clinical Research Fellow, The Surgical Unit, The London Hospital, Whitechapel, London El BB
Figure 1. Adrenaline solution is infiltrated submucosally facilitate mucosal dissection.
to
Delorme's operation, rectal prolapse
12 plicating sutures of an absorbable material (our preference is for No. 1 polydioxanone) are inserted in the muscular wall of the rectum between the mucosal cut edges at the mucocutaneous junction and the apex (Figs. 3 and 4). The sutures are then tied forming a doughnutlike mass which is reduced gently. The mucosal sleeve is then divided and the cut ends of the mucosa are sutured together with 3/0 catgut (Fig. 5).
383
ST. tMC
S5K
AA S: mc
0
MC Mucosa MCJ Mucocutaneous junction MS Muscle
0
Figure 2. A circumferential mucosal incision is made 1015 mm from the mucocutaneous junction and the mucosa is dissected proximally.
SK Skin ST MC Stripped
mucosa
Figure 4. A longitudinal section through the prolapse illustrating the extent of mucosal dissection (beyond the apex) and the position of the plicating sutures.
-~
Figure 5. The prolapse, now converted to a doughnut-like mass, is reduced and the mucosal edges sutured with interrupted stitches.
Figure 3. When the mucosa has been stripped plicating sutures are inserted.
away,
8-12
Additional procedures A simultaneous Thiersch procedure was carried out on a patient with incontinence and a patulous anal sphincter. This was successful and the wire was removed 3 weeks later.
384
A M Abulafi et al.
Results Twenty-one patients (95.5%) were cured of prolapse. Nineteen patients (86.4%) (six out of eight patients with incontinence) had normal anal sphincter function as judged by continence to solids and flatus after operation. Hospital stay was between 3 and 14 days (median 7.5 days). Average follow-up was 29.3 months (range 3-70 months). The review was by clinical assessment of live patients (n = 17) and by review of the records of deceased patients (n = 5).
Complications There were no perioperative deaths and no significant postoperative morbidity. One patient developed left ventricular failure, three urinary tract infection, one urinary retention, and two postoperative confusion. One patient presented 3 months after operation with difficulty in opening her bowels, but this resolved after an anal stretch. Apart from one other case (see below) there were no reports of evacuatory difficulties.
submucosal adrenaline solution which aids mucosal dissection and reduces bleeding, mucosal stripping beyond the apex of prolapse and perioperative metronidazole. Of eight patients, six (75%) with incontinence to solids regained normal control after the operation. As shown in these cases, the majority of patients had their incontinence cured with Delorme's operation alone, thus, simultaneous postanal repair is rarely indicated. However, in patients with persistent incontinence, postanal repair may prove useful although, in our experience, this has not been successful. In the only patient with incontinence and patulous anal sphincter, simultaneous Delorme's and Thiersch's operations have been successful. Since compiling this report, two elderly patients presenting with procidentia and complete rectal prolapse were treated with combined vaginal hysterectomy and Delorme's operation under epidural anaesthesia with satisfactory results. We conclude that Delorme's operation is a safe and effective treatment for complete rectal prolapse, although it may be unsuitable for patients with extensive prolapse. Any recurrence can be treated by a further Delorme's operation. Moreover, a failed Delorme's operation does not compromise subsequent abdominal procedures, as shown in one of our cases. We feel it should be considered in patients presenting with complete rectal prolapse, particularly the elderly.
Failures One patient developed recurrence of prolapse and incontinence 28 months after surgery. These were cured by an Ivalon® sponge rectopexy with no evidence of recurrence at 14 months. The second patient had her prolapse cured, but not the incontinence. The latter persisted even after a postanal repair and an abdominal rectopexy. The third patient with a 30.5 cm prolapse, developed rectal stenosis leading to chronic constipation. This was eventually relieved by a permanent colostomy.
We wish to express our grateful thanks to Sister D Reid RGN, for providing the illustrations and to the general practitioners of the South Bedfordshire District for their cooperation and interest in our work.
Discussion
References
The results in our series compare favourably with popular transabdominal procedures; Ivalon' sponge (2,3), Marlex® mesh (4), Ripstein (5), and extended abdominal rectopexy (6). In contrast, however, Delorme's operation is simple, fast and can be carried out under general, spinal or local anaesthetic. The hospital stay is usually short. Furthermore, innervation to the rectum is not interfered with and the complications of abdominal surgery are avoided. On the other hand, since the basic anatomical defect producing the prolapse is not rectified, long-term success is uncertain. Rectal stenosis can be a complication in patients with extensive prolapse, as shown in one of our patients. Since the re-emergence of Delorme's operation in the early 1970s its place in the treatment of rectal prolapse has been confined to elderly patients and those unsuitable for major abdominal procedures (7-9). However, with success rates (10-12) similar to ours comparable to abdominal procedures, proponents of Delorme's operation argue for its use as first choice in the treatment of full-thickness rectal prolapse (12). The high success rate in our series is due mainly to the improved surgical technique, which involves the use of
I Delorme R. Sur le traitement des prolapsus du rectum totaux par l'excision de la muquese rectale au rectal-colique. Bull Mem Soc Chir Paris 1900;26:498-9. 2 Morgan CN, Porter NA, Klugman DJ. Ivalon (polyvinyl alcohol) sponge in the repair of complete rectal prolapse. Br
Jf Surg 1972;59:841-6. 3 Penfold JCB, Hawley PR. Experiences of Ivalon sponge implant for complete rectal prolapse at St Mark's Hospital, 1960-70. BrJ Surg 1972;59:846-8. 4 Keighley MRL, Fielding JWL, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consecutive patients. Br J Surg 1983;70: 229-32. S Ripstein CB. Procidentia-definitive corrective surgery. Dis Colon Rectum 1972;17:334-6. 6 Mann CV, Hoffman C. Complete rectal prolapse: the anatomical and functional results of treatment by an extended abdominal rectopexy. Br J Surg 1988;75:34-7. 7 Moskalenko VW. Modification of Delorme's resection of rectal mucosa for prolapse of the rectum. Int Surg 1973;58: 192-4. 8 Nay HR, Blair CR. Perineal surgical repair of rectal prolapse. Am J Surg 1972;123:577-9. 9 Christiansen J, Kirkegaard P. Delorme's operation for complete rectal prolapse. BrJ Surg 1981;68:537-8.
Delorme's operation, rectal prolapse 10 Uhlig BE, Sullivan ES. The modified Delorme operation: Its place in surgical treatment for massive rectal prolapse. Dis Colon Rectum 1979;22:513-21. 11 Gundersen AL, Cogbill TH, Landercasper J. Reappraisal of Delorme's procedure for rectal prolapse. Dis Colon Rectum 1985;28:721-4.
385
12 Monson JRT, Jones NAG, Vowden P, Brennan TG. Delorme's operation: the first choice in complete rectal prolapse? Ann R Coll Surg Engl 1986;68:143-6. Received 27 April 1990
Notes on books Anatomischer Atlas by Jainos Vajda. 2 volumes, illustrated. Akademiai Kiado, Budapest. 1989. £44.00. ISBN 963 05 5504 2
Full-page photographs of anatomical dissections on the righthand side of the opened book; labelled line diagrams corresponding to the photograph on the left-hand side. Good quality photographs. Useful for anatomical revision by students attempting Part 1 FRCS.
Cancer of the Head and Neck edited by Eugene N Myers and James Y Suen. 2nd edition. 1132 pages, illustrated. Churchill Livingstone, New York. 1989. £95.00. ISBN 0 443 08597 8 The first edition of this large and comprehensive textbook was well received when it appeared in 1981. The editors have completely revised and updated this second edition and have included new chapters on radiological evaluation, the use of antibiotics, cranial base tumours, voice rehabilitation after laryngectomy, tumours of the parapharyngeal space, chemotherapy and speech and swallowing rehabilitation. The editors hope that this work represents a state-of-the-art depiction of head and neck surgery and will result in an improvement in the quality of life of patients with head and neck cancer.
Sir James Paget: The Rise of Clinical Surgery by Shirley Roberts. 223 pages, illustrated, paperback. Royal Society of Medicine Services Limited, London. £7.95. ISBN 0 905958 91 8
Sir James Paget is one of the few surgeons known to every medical student and aspiring surgeon by virtue of his name being attached to several different diseases. This small volume gives a most entertaining account of his life and importance in medical history.
Breast Cancer edited by B Hoogstraten, I Burn and H J G Bloom. 287 pages, illustrated, paperback. Springer-Verlag, Berlin. 1989. DM148. ISBN 3 540 50595 4 In less than 300 pages this monograph gives a useful update on a subject of great interest to many readers. Part 1 deals with pathology and diagnosis, including a valuable chapter on the psychological aspects of breast cancer. Part 2 deals with treatment by surgery, radiotherapy, chemotherapy and endocrine therapy. The presentation and format is welcome rather than inhibiting. The editors hope that the mixture of philosophical debate, science and clinical description will appeal to the reader-this wish should be amply fulfilled.
Operative Surgery: Principles and Techniques edited by Paul F Nora. 3rd edition. 1412 pages, illustrated. W B Saunders Company, Philadelphia. 1990. £103.55. ISBN 0 7216 2134 1
Those familiar with previous editions of this textbook, the last published 10 years ago, will know that it is mammoth in size and scope and was written as a guide for surgeons in training faced with which operation to choose for a particular condition. In this new edition a major emphasis has been placed on stapling techniques. There are extensive revisions of the sections on trauma, microvascular surgery, imaging techniques, transplantation, vascular access, lithotripsy and lasers. Many of the illustrations have been redrawn for greater clarity as well as being relabelled to enhance visual appeal. An important reference work.
Operating Room Guide to Cross Sectional Anatomy of the Extremities and Pelvis edited by Wallace B Lehman. 26 pages, illustrated. Raven Press, New York. 1989. $262.50. ISBN 0 88167 562 8
Vascular Surgery edited by G Heberer and R J A M van Dongen. 811 pages, illustrated. Springer-Verlag, Berlin. 1989. DM650. ISBN 3 540 18280 2 This is an impressive book written by outstanding vascular surgeons in Germany, The Netherlands, Austria and Switzerland. In a laudatory foreword, David Sabiston concludes that it will become a worldwide standard by which all similar works will be compared and that it will be regarded as an essential text by all surgeons who practise vascular surgery.
Twenty-two coloured plastic laminated plates in a ring binder and designed for the orthopaedic surgeon performing external fixation. The difficulty in memorising detailed anatomy is well known and these plates serve as a 'road map'. The plates may be removed from the binder and placed on an X-ray viewing box. A complete longitudinal reconstruction of each extremity is shown in both a left and a right view.
A casual glance through the pages will convince the reader that this assessment is likely to be fulfilled. Attractively laid out with superb illustrations, the text reads well (despite the translation from German) and the subject of peripheral vascular surgery is covered in its entirety and in detail. All libraries should obtain a copy and all vascular surgeons who want a reference volume for private use should consider this volume very seriously.
