textbook of surgery. second edition

ANZ J. Surg.

2002;

72

: 925–927

BOOK REVIEWS

QBase Surgery: 1 MCQs for the MRCS

. By J. S. A. G

REEN

AND

S. A. W

AJED

. London: Greenwich Medical Media Ltd, 2001.Five Exams Plus Answers; +93 pages. ISBN 1900151 37 5.

Extended Matching Questions for the MRCS

. By S.A

UPLISH

AND

M. K. H

OSSAIN

-I

BRAHIM

. London: GreenwichMedical Media Ltd, 2001. Illustrated; xiv + 228 pages. Includesindex. ISBN 184110 062 5.

These two books on multiple-choice questions have been writtenby surgical trainees within the UK training programme and will beconsidered together. They have the same publisher and have beenreleased together. The target reader is the MRCS candidate in theUK. The MRCS is the examination that has replaced the old FRCS(well known to many Australasian surgeons) and must be passedbefore a trainee can start the last two years of the six-year pro-gramme which, upon completion, leads to the FRCS diploma.

The authors of


outlinethe syllabus for the MRCS, stating that it is made up from fivemodules relating to principles of surgery and five relating to thesystems of surgery. They have produced these books to meet thedemands of candidates taking the examination, which is presuma-bly based on the curriculum for these modules.

Green and Wajed state that the MRCS examination consistsof two MCQ papers. Their book

QBase Surgery: 1 MCQs for theMRCS

demonstrates the type of question found in the first paper,while the book by Auplish and Hossain-Ibrahim,

ExtendedMatching Questions for the MRCS

, is an example of the second.In accordance with the beliefs of modern educators, negativemarking has been abolished for incorrect responses. The bookscome with free CD ROMs, which proved somewhat difficult toload on to a laptop, but no doubt are useful for the cognoscenti.The subject matter in both books suggests a wide curriculum thatextends through the basic sciences to surgery in general. Bothbooks are well presented, easily read and have a professionalstyle. In this regard, they are better than many publications onMCQs that have preceded them.


is divided into fiveexaminations of 50 questions that are disappointingly pitched at alevel well below that expected for Part II FRACS. An exampleprobably documents the academic level to the Australasiangeneral surgeon or advanced trainee.

Inguinal hernia

a. Occur most commonly in young adult males Fb. Are indirect if the sac emerges lateral to the inferior epi-

gastric vessels Tc. Are most commonly repaired using an absorbable mesh Fd. Occur due to a weakness in the external oblique aponeurosis

Fe. Appear below and lateral to the pubic tubercle F

An interesting definition of terms to help candidates determinewhat the question means is included in the foreword of

QBaseSurgery: 1 MCQs for the MRCS.

The authors appear to havedecided what the examiners had in mind, as they do not referencetheir definition.

Characteristic, classical, predominantly reliably:

At least 90%of cases

Typically, frequently, commonly, usually:

At least 60% of cases

Often, tends to:

At least 30% of cases

Has been shown, associated, recognized:

Evidence in a recog-nized publication

Immediate:

Within 3 h

Urgent:

Within 24 h

The type of question found in

QBase Surgery: 1 MCQs for theMRCS

has been used by the Australasian Court in GeneralSurgery for the fellowship over many years. Despite a large bankof questions, the Court has not been satisfied with their quality orreliability. The Court has determined that after May 2002, thesetrue/false questions will be removed from the final fellowship.

Thus, although


may beof interest for Australasian candidates wishing to gain experiencewith MCQs, it is unlikely to find a place in the reading list for thefinal Fellowship FRACS.

Extended Matching Questions for the MRCS

is a more inter-esting book for our trainees, as this style of examination willbecome more prominent in the multiple-choice paper for the finalfellowship.

Our candidates completed 10 extended matching questions fromMay 2002, and this increased to 15 questions or 50% of the paperin the October examination, which was the first examination in thenew programme. However, the questions laid out in this book aremuch simpler than would be found in a final FRACS paper.

This type of question is probably less well known to ourfellows than the true/false MCQs, and it may be of interest forthem to read examples taken from the book. It also allows them toenvisage how they could be upgraded for our examination.

Theme: Anaemia

Options:a. Carcinoma of the stomachb. Crohn’s diseasec. Pernicious anaemiad. Carcinoma of the breaste. Carcinoma of the caecumf. Haemorrhoidsg. Diverticular disease

For each of the patients described below, select the single mostlikely diagnosis from the options listed above. Each option maybe used once, more than once or not at all.

1. A 52 year old woman presents with shortness of breath. Shehas no significant past medical history. Investigations revealiron deficiency anaemia, but she has no specific symptomsand a normal gastroscopy. Option e.

2. A 32 year old woman presents with signs and symptoms ofbowel obstruction. She has had previous similar attacks overthe past 8 months, with some weight loss. She gives a historyof bowel resection in her early teens. Her Hb = 9.0 g/dL witha MCV = 112. Option b.

3. A 70 year old woman complains of fatigue and lethargy. Onexamination she has a swelling in her left armpit. She refusesfurther examination. She has a leuco-erythroblastic anaemiaon her peripheral blood film. Option d.

926 BOOK REVIEWS

Both books are well presented, easily read and well indexed.The second has a foreword from Harold Ellis, which will do it noharm. Neither has reference books nor specific journal referencesagainst which the answers can be checked and therefore they losea good deal of impact as learning texts.

To conclude, it seems unlikely that either book will have muchimpact on our trainees who are about to take the final FRACS,although


may havereaders from our trainees before the Part 1.

P

ETER

M

ALYCHA

, FRACS

Department of SurgeryUniversity of AdelaideRoyal Adelaide HospitalAdelaideSouth Australia, Australia

Textbook of Surgery

second edition. Edited by Joe J. Tjandra,Gordon J. A. Clunie and Robert J. S. Thomas. Melbourne: Black-well Publishing, 2001. Illustrated; 717 pages, includes index.ISBN 0 86793 023 0.

This text provides a remarkably comprehensive coverage of surgeryincluding aspects of certain subspecialties such as orthopaedic sur-gery, neurosurgery, vascular surgery and urology that would be ofsome interest to general surgeons. There is an impressive faculty ofcontributors representing a broad sweep of Australasian surgeonswho are all prominent figures in their particular fields of interest.

The first hundred pages or so present basic aspects of surgeryincluding perioperative management, nutrition and surgical infec-tions. There is also a basic and easy to understand pair of chaptersaddressing molecular genetics and molecular biology in surgery.What follows is a series of chapters addressing the various areasof general surgery including upper and lower gastrointestinal sur-gery, HPB surgery, and breast, endocrine and head and necksurgery. Trauma is also addressed. Each of the chapters is writtenin a very concise way, addressing the key issues of each of theseareas. The textbook therefore presents a compact and contempo-rary overview and is not so much a reference book as a workingtome more suitable for familiarization with current trends in treat-ment and diagnosis in these various areas. There is also informa-tion for further reading at the end of each chapter and some of thechapters are nicely illustrated. Towards the end of the textbookthere is a series of helpful vignettes on problem solving thatprovide specific algorithms in management of a range of commonsurgical problems.

I found this textbook very informative and a pleasure to read.I believe it would be most useful for young surgeons in trainingbut I also think it has much to offer students of surgery at theundergraduate level and would be a useful acquisition by hospitallibraries. It is a text which provides updates on the contemporarymanagement of areas of surgery that one might not be regularlyinvolved in. I certainly found it very useful.

D

AVID

G

OTLEY

, MD, FRACS

Department of SurgeryPrincess Alexandra HospitalWoolloongabba, Queensland, Australia

The Art of Surgery: Exceptional Cases – Unique Solu-tions 100 Case Studies

. Edited by M. Trede. New York:Theime, 1999. Illustrated; v + 212 pages. Includes index. ISBN 313 116561 8 (GTV); ISBN 086577 845 0 (TNY).

The Art of Surgery

is a unique collection of ‘exceptional casesand unique solutions’ which include 100 illustrated case historiesencompassing a broad spectrum of surgery (upper gastrointestinal59, colorectal eight, vascular nine, thoracic 10 and cardiac seven).Obviously, gastrointestinal surgery has been the author’s mainarea of surgical practice. The unique feature of this book is thewealth of illustrations drawn by the author over a lifetime of sur-gical practice. This personal interest and talent in medical illus-tration has undoubtedly ensured the accuracy of the drawings,which were usually sketched at the end of a day’s operating orsoon after.

Each of the 100 cases is accompanied by a description of theclinical, operative and pathological features with the outcomealso included. In most cases the lessons learnt from each caseare presented. There is reflective commentary, which forms avaluable part of the text. The combination of high quality X-raysand photographs accompanying the artwork provide the readerwith a complete description of each case. Some of the cases pre-sented are obviously ‘once in a lifetime surgical challenges’.The author’s practice involved a significant volume of tertiaryreferrals and much emphasis is devoted to primary and reopera-tive surgery of the pancreas (35 case histories). In this difficultarea of surgery, a number of unusual surgical problems weresolved indicating considerable expertize, no doubt related to alarge experience in pancreatic surgery. In case 70, reference ismade to 592 pancreatico-duodenectomy operations performedat the Mannheim Clinic over a 25-year period. The author’straining in vascular surgery clearly assisted radical resection ofthe pancreas where large retroperitoneal venous structures werealso resected and reconstituted.

The author has included small cameo paintings of surgeons todecorate the book and these indicate a further talent in artwork.The standard of the surgical illustrations in most cases is excel-lent, but there are some that appear to be ‘rough’ workingsketches that could have been improved by the author. The styleof illustrations also changes throughout the book and this wasdisconcerting, although each illustration does clearly reveal theoperative details and the message of the case. The colour ofvarious structures and malignant tissue was not consistentthroughout the book and in some illustrations large arrows weresomewhat overbearing. These features, although distracting, wereno doubt related to the fact that each drawing was completedsoon after the operation over a period of 40 years and were not‘touched up’ for the book. The more diagrammatic illustrations(the majority) were much superior to the few ‘true to life’ illustra-tions. The best illustrations were those where the artwork uni-formly used a coloured pencil technique.

The author states that there are no references in the work, andit certainly makes no pretence of being a textbook of surgery. It ismore a ‘coffee table’ book for surgeons, with engaging colourfuland informative illustrations. It will have more appeal to uppergastrointestinal surgeons and in particular those involved insurgery of the pancreas. From the viewpoint of sales, it wouldhave been preferable to substitute 26 more cases on gastrointesti-nal surgery, rather than the sections on vascular surgery, thoracicand cardiac surgery, as there is not enough in these sections toattract the surgeons of those specialties.

The book is an engaging work of special interest for thoseinterested in medical illustration. The author’s devotion to andpassion for the ‘art’ of surgical practice is obvious and the scopeof his surgical experience extensive. He has certainly proved thepoint that ‘one picture is worth a thousand words’. The book

BOOK REVIEWS 927

represents pages from an illustrated surgical diary carefully docu-mented over a lifetime.

M

ARK

K

ILLINGBACK

, FRACS

D

AVID

G

ILLETT

, MS

TurramurraNew South Wales, Australia

ChairmanDepartment of SurgeryConcord HospitalConcord, New South Wales, Australia

Transplantation Surgery: Current Dilemmas

. Edited byJohn L. R. Forsyth. London: Harcourt publishers, 2001. ISBN 07020 2588 7.

This book is the second in a series edited by John Forsyth, anabdominal organ transplant surgeon from Edinburgh. He has suc-cessfully attempted to address the problem areas in clinical trans-plantation using an authorship of UK-based transplant clinicians.The book is very readable and is a credit to the editorial input ofForsyth, who has evened out the writing styles of the multipleauthors.

The book is not one for the first-time student in transplantationsurgery. As the title would suggest, the fundamental and acceptedaspects of transplantation receive only a cursory mention infavour of addressing the issues that confront transplant surgeons.In this respect, the book has an overriding theme, that of theinequality between demand for transplant cadaver organs andsupply. The theme is so strong that it almost serves to squash theenthusiasm of those of us still excited by the prospect of curingorgan failure in very ill patients by transplantation. For example,the chapter on liver transplantation is principally about splitting asingle donor liver to benefit two recipients and living liver dona-

tion. The thoracic surgeons concentrate on techniques that avoidcardiac transplantation and the use of living lung donors. Further-more, 15% of the book is used for a chapter titled ‘Liver bio-engineering as an alternative’. The issue of declining cadaverdonor rates is not addressed, apart from the occasional clumsyreference to the promise of xenotransplantation. Perhaps this is areflection of the perceived need for the transplant community, forethical reasons, to remain at arms length from those involved incadaver organ donation.

One personal highlight was the excellent two-page summaryat the end of the chapter on immunosuppression in which theauthor recognizes the noxious nature of calcineurin inhibitorsand the need to minimize their long-term use. It was thereforedisappointing to read the view of the author in the chapter on‘Chronic rejection’, based on a 1989 reference, that chronicrejection was the commonest cause of kidney transplant loss. Amore current view is that the calcineurin inhibitors have been soeffective in reducing rejection that the commonest cause ofkidney graft loss is the nephrotoxic effect of the drugs them-selves.

An obvious omission from the book is a chapter on pancreastransplantation. I acknowledge a personal bias, but one of themost exciting recent developments in transplantation has been thesuccess of clinical islet transplantation. This has occurred withinthe time frame of the writing of this book.

In summary, I enjoyed reading this book and I would like tothink that I am now more appreciative of, and understand better,the day-to-day dilemmas that face my colleagues in other fieldsof transplantation endeavour.

R

ICHARD

D. M. A

LLEN

, FRACS

National Pancreas Transplant Unit,

Westmead Hospital,Sydney, New South Wales, Australia

textbook of surgery. second edition

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