Anesthesiologist's Manual of Surgical Procedures, 4th Edition.  Edited by Richard A. Jaffe, M.D., Ph.D., and Stanley I. Samuels, M.D. Philadelphia, Lippincott Williams & Wilkins, 2009. Pages: 1,408. Price: $169.

I imagine that auto mechanics have it tough these days. Merely decades ago, all engines were alike and just a few repairs were routinely made. Knowing how to change the spark plugs or flush the carburetor in one model would translate to the next car in the service bay. Alas, times have changed. Nowadays, many cars no longer have oil dipsticks, and some don't even run on gasoline!

Just as modern-day auto mechanics need detailed service manuals to cover all of the different repairs performed, so too do modern-day anesthesiologists. The inconvenient truth is that an anesthesiologist's understanding of a surgical procedure may not be much more than “having a liver resection” or “getting a craniotomy.” In addition, many procedures are infrequent in a broad practice—when was the last time you saw a mandibular osteotomy and genioglossus advancement? Although a standard anesthetic plan will suffice in many instances, every anesthesiologist would like to have a deeper understanding of the operation at hand. For example, we would like to know that a Pringle maneuver may drastically alter preload during liver resections or to be reminded that a rectal cancer resection may also have a perineal incision, before planning only a low thoracic epidural for postoperative pain control. The reality is that surgery has become fantastically complex, and anesthetic plans need to evolve accordingly—we need expert explanation from both sides of the ether screen. Jaffe and Samuels' now-classic Anesthesiologist's Manual of Surgical Procedures  is the resource required.

Now available in its fourth edition, the text has been updated every 5 yr since its introduction in 1994. It provides the reader with thoughtful considerations from both surgeons and anesthesiologists for virtually every operation performed today. Obviously, clarity and readability in such a tome (more than 400 procedures are detailed) depend on organization and consistent thematic presentation across authors. Thankfully, the text remains as clearly organized as it was in previous editions. The 15 sections are based on surgical specialty (otolaryngology, cardiovascular surgery, out of operating room procedures, etc.); pediatric surgery gets its own section. Each section is broken into 5–10 subsections (e.g. , general surgery has peritoneal surgery, breast surgery, and trauma surgery). Finally, within each subsection are 2–5 pages for each operation. The index is superb and allows for directed reading on a single procedure. Appendices cover topics ranging from latex allergy to herbal drug interactions and perioperative acupuncture. One notable advantage to the previous edition was a (now absent) lengthy appendix defining the many acronyms used throughout the text.

The book was written by more than 180 authors. With so many contributing to the text, the editors are to be highly commended for keeping the voice consistent. The individual chapters are organized similarly. The description of each procedure has a separate section for surgical and anesthetic considerations. The surgical portion includes a brief background on the disease process and then follows with two tables, one summarizing the procedure and another listing the patient characteristics and comorbidities. The tables are invaluable, detailing operative length, positioning, predicted blood loss, closing time, preferences at emergence, and more. The chapter continues with the anesthetic considerations broken into preoperative, intraoperative, and postoperative epochs. Grouping is judiciously used to avoid repetition where anesthetic considerations overlap between procedures. Each procedure concludes with suggested additional readings.

The fourth edition represents a significant update. It is now approximately 300 pages longer and contains approximately 40 new procedures, many addressing laparoscopic and endovascular surgery. This edition is much improved by the new application of color to the tables, text, and figures. The surgical section headings and tables are in green, whereas anesthesia sections are in orange. Figures (almost all are surgical illustrations) are in full color. The book is dense, but the eye falls easily to each particular section. As in previous editions, figures are not unique to the text but are referenced from other publications.

As with any important contribution to the literature, a few quibbles still arise. The text and the tables are significantly improved from the aesthetic perspective, but some of the figures are starting to appear dated. A fair number of the surgical illustrations are taken from outdated editions of other texts and peer-reviewed publications from the 1980s and 1990s. A picture detailing the relationship of the mediastinoscope to the trachea and great vessels comes from a 1979 publication, and a schematic representation of a cardiopulmonary bypass circuit comes from a text published in 1988. Although such figures are not misleading per se , updated images would lend a consistently modern appearance to the text. This might be a focus of the next edition.

Several additional chapters would be useful, including an expanded handling of neurologic monitoring for spine and intracranial surgery. In addition, an expansion of the hemodialysis access chapter, focused on pairing commonly used peripheral nerve blocks with each of the approximately five common hemodialysis access procedures, would be useful.

Weighing in at 7.29 pounds (I used the scale at my local butcher's shop), the text is not readily portable. This is unfortunate because the book is not just another dust-gathering reference work—it really is to be used on a daily basis! The publishers have addressed this unavoidable reality by establishing electronic access that is free of charge with a code inside the front cover. The electronic version includes printable full text with images. A separate image bank allows flash-based downloads in .jpg or .pdf format. The full-format text with figures can be read from a smartphone or e-reader's browser but requires the usual slow scrolling and frequent zooming. A mobile site or dedicated “app” would be most welcome to end users, affording portability and catering to a modern learner's reading preferences. I hope this would be in place by the next edition, if not sooner.

As Jaffe writes in the preface, this is not a text of anesthesia, nor is it a text of surgery. It is, however, a great reference from which to formulate an informed, procedure-specific anesthesia plan. In a few minutes a day, reading from Anesthesiologist's Manual of Surgical Procedures  can only deepen understanding, increase collegiality and confidence in the operating room, and make us all better physicians.

University of Michigan, Ann Arbor, Michigan.