Managing anemia and blood loss in elective gynecologic surgery patients.

Hysterectomy is the second-most-common surgical procedure among premenopausal women. The conditions that lead to the need for a hysterectomy often are accompanied by chronic blood loss that can lead to anemia. Moreover, hysterectomy and myomectomy may result in significant blood loss, which exacerbates the anemia. The presence of fatigue associated with anemia has a substantially negative impact on quality of life and the ability to perform activities of daily living. Options for alleviating perioperative anemia include minimizing surgical blood loss, blood transfusion, supplementation with hematinics, such as iron and folic acid, and treatment with recombinant human erythropoietin. Treating preoperative anemia is expected to help correct anemia prior to surgery and may have a positive impact on anemia-related symptoms and surgical outcomes.

Advanced laparoscopic gynecologic surgery.

What is the future for laparoscopy? Any procedure thought to be impossible to perform by laparoscopy or procedures that, based on conventional wisdom, should not be done laparoscopically are being performed or developed as the reader peruses this article. Technical advances in the endoscopic equipment and development of laparoscopic instruments have allowed for performance of sophisticated procedures with laparoscopic assistance. Appropriate laparoscopic skills allow surgeons to perform these procedures in a fashion nearly identical to an open procedure; however, modifications of historically proven techniques are controversial regarding the expenses generated, equipment necessary to perform the procedure, training necessary, and potential for complications. Has the obituary of laparotomy been written? The benefits of laparoscopically assisted or performed procedures are continuing to be analyzed. LAVH has been touted as a way to reduce the number of abdominal hysterectomies while increasing the number of vaginal hysterectomies. Therefore, indications for LAVH would ideally more resemble indications for abdominal hysterectomy than vaginal hysterectomy; however, LAVH does not seem to have increased the total number of vaginal hysterectomies. Conversely, the number of abdominal hysterectomies seems to be roughly the same, whereas the number of vaginal hysterectomies has decreased and the number of LAVHs has increased. Therefore, surgeons seem to be substituting LAVH for vaginal hysterectomy. Studies comparing laparoscopic Burch procedures and open Burch procedures are just now being reported. Many early reports described procedures that are not classic Burch colposuspensions. These changes make it impossible to assume that overall success and rate of complications are the same. The same can be said for techniques for correction of pelvic organ prolapse. Although laparoscopic performance and laparoscopic assistance are increasing in popularity, most cases are not handled in this way. Clearly, not every surgeon has embraced using the laparoscope to treat patients who would otherwise have undergone abdominal or vaginal surgery.

Vaginal hysterectomy in women with history of previous cesarean delivery.

OBJECTIVE: This study aimed to compare surgical outcomes with vaginal hysterectomy between women who have had >/=1 cesarean delivery and those who have not had a cesarean delivery. A secondary objective was to analyze the effect of previous vaginal birth on the complication rate of vaginal hysterectomy. STUDY DESIGN: A retrospective analysis was performed on 221 women undergoing vaginal hysterectomy. Women were separated into those who had a history of previous cesarean deliveries (N = 35) and those who did not (N = 186). The groups were analyzed for the indications for surgery, perioperative hemoglobin loss, operative time, length of hospitalization, and complications. Trends in the complication rate for women in the previous cesarean group were also studied from the perspectives of numbers of previous cesarean deliveries and of vaginal delivery history. The 95% confidence intervals for the difference between proportions as well as P values for probability tests were calculated. P <.05 was considered significant. RESULTS: Previous cesarean delivery experience did not affect hemoglobin change, hospital stay, or operative time among women undergoing vaginal hysterectomy. A total of 11.3% of women in the previous cesarean group had complications, versus 4.3% for the noncesarean group (P =.10, 95% confidence interval -3.8% to 18.0%). Complications did not increase with increasing number of previous cesarean deliveries (U = 1020.5, P =.28). Also, a trend toward fewer complications among patients with a history of cesarean delivery who had also had a vaginal delivery was demonstrated (U = 836, P =.05). Overall, women who were undergoing vaginal hysterectomy who had a history of >/=1 previous vaginal delivery had a complication rate of 3.2%, versus 17.6% for women who had not had a previous vaginal birth (P =.004, 95% confidence interval -27.5% to -1.3%). CONCLUSIONS: In this study women who had a history of previous cesarean delivery were not at higher risk for greater hemoglobin loss, longer hospital stay, more prolonged operative time, or significantly more perioperative complications when undergoing vaginal hysterectomy than were those women who had no history of previous cesarean delivery. Likewise, increasing the number of previous cesarean deliveries did not have an adverse impact on the complication rate. Previous vaginal delivery lowered the risk of complications from vaginal hysterectomy.

Formal pathology rotation during obstetrics and gynecology residency: is it beneficial?

BACKGROUND: Our objective was to assess the educational benefits of a formal pathology rotation during an obstetrics and gynecology residency program and to determine the utility of this information in clinical practice. METHODS: In this descriptive study, the benefits of a 2-month rotation in pathology for obstetrics and gynecology residents were analyzed. A computerized listing of surgical cases processed by each resident was sent to the obstetrics and gynecology program director. RESULTS: Our resident accessioned 5.4% of the total pathology cases processed each month. Reports from previous residents (over a 17-year period) and from program directors at the annual educational retreat indicate that such information was not relevant to our graduates in their clinical practice. CONCLUSIONS: A formal pathology rotation for obstetric residents can improve knowledge base, but the usefulness of this knowledge in clinical practice is dubious.

Formation of vesicovaginal fistula: the role of suture placement into the bladder during closure of the vaginal cuff after transabdominal hysterectomy.

OBJECTIVE: The objective of this study was to determine whether suture placement through the bladder during closure of the vaginal cuff at the time of transabdominal hysterectomy is associated with formation of postoperative vesicovaginal fistula. STUDY DESIGN: Virgin female New Zealand White rabbits were used to perform this study. The study protocol was approved by the institutional Animal Use and Care Committee. Animals were housed and maintained in the animal facilities at the University of Mississippi Medical Center according to appropriate guidelines. Thirty-two animals were randomized into two groups at a 2:1 ratio. All animals underwent transabdominal hysterectomy. Animals in group 1 (n = 21) had a figure-of-eight suture placed through the anterior vaginal cuff and intentionally into the bladder. Animals in group 2 (n = 11) were treated in an identical manner but care was taken to exclude the bladder when the suture was placed into the anterior vaginal cuff. Animals were put to death, and necropsy was performed 28 days after surgery. The bladder and vagina of each animal were harvested en bloc. Evidence of a fistula between the bladder and vagina was then determined in three distinct ways. Infant formula was infused into the bladder through a urethral catheter, and the vagina was inspected for leakage. Saline solution tinted with methylene blue was used in the same manner. Last, air was injected through the catheter into the bladder with the en bloc vagina and bladder preparation submerged in water. The vagina was observed for air leakage manifest by bubble formation. RESULTS: The two groups were comparable in regard to weight gain, intraoperative complications, and postoperative complications. One animal in each group died. Neither had a surgical complication directly related to the suture placement. During inspection of the vagina and bladder no animal was noted to have a vesicovaginal fistula. CONCLUSIONS: A suture placed through the bladder during closure of the vaginal cuff after transabdominal hysterectomy, as an isolated event, does not appear to be associated with formation of postoperative vesicovaginal fistula.

Hysterectomy after endometrial ablation.

OBJECTIVES: Our purpose was to determine the number of women undergoing hysterectomy after endometrial ablation and the indications for the subsequent surgery. STUDY DESIGN: Forty-two premenopausal women, who had severe menorrhagia associated with a clinically normal examination result, underwent rollerball endometrial ablation between November 1990 and December 1991. Thirty-seven women whom we gave ongoing care were evaluated by chart review. Four women who received care elsewhere were interviewed by telephone. One woman was lost to follow-up. Patients were followed up a minimum of 4 years. Age, parity, operating time, endometrial preparation, preablation sterilization, and preablation dysmenorrhea were assessed in regard to subsequent hysterectomy. Patient satisfaction was assessed at 24 months. Life-table analysis was performed to determine cumulative probability of hysterectomy. RESULTS: Fourteen of the 41 women (34%) underwent hysterectomy within 5 years after rollerball endometrial ablation. Continued abnormal menstrual bleeding and menstrual pain were significantly associated with subsequent hysterectomy. Eleven of the 14 cases of hysterectomy were associated with gross abnormality such as myomas, adenomyosis, endometriosis, and chronic hematosalpinx. A linear relationship between hysterectomy and time was noted. CONCLUSION: On the basis of our findings one third of women undergoing rollerball endometrial ablation for menorrhagia can expect to have a hysterectomy within 5 years. If the linear relationship noted during the first 5 years is extrapolated, theoretically, all women may need hysterectomy by 13 years. Most patients undergo hysterectomy because of significant pelvic abnormality. Further studies with longterm follow-up are needed to define the role of endometrial ablation for menorrhagia.

Comparison of anterior colporrhaphy and retropubic urethropexy for patients with genuine stress urinary incontinence.

OBJECTIVE: Our purpose was to compared the efficacy of anterior colporrhaphy and retropubic urethropexy performed for genuine stress urinary incontinence. STUDY DESIGN: A retrospective analysis was performed on women who underwent either anterior colporrhaphy or retropubic urethropexy for genuine stress urinary incontinence. Patients were identified by a computer-assisted search, and these women were contacted by telephone. The interview was used to assess current continence status. Variables reviewed included demographic data, medications, hormonal status, current smoking history, significant medical and surgical history, and time to recurrence of incontinence. Operative procedure, prior or concomitant hysterectomy, history of previous incontinence procedures, concomitant surgery for repair of other pelvic floor defects, experience level of the primary surgeon, and duration of postoperative catheterization were also documented. RESULTS: Seventy-six women who had undergone surgery for genuine stress incontinence during a 4-year period were identified and evaluated by telephone interview. Fifty-six had undergone anterior colporrhaphy and 20 retropubic urethropexy. Both groups of patients were comparable in age, social status, race, parity, and weight. The duration of follow-up (mean +/- SD) was 66.6 +/- 14.2 months (range 48 to 96 months). Concurrent surgery to repair other pelvic floor defects was more common in patients undergoing anterior colporrhaphy than in patients undergoing retropubic urethropexy (p < 0.05). Of the 56 patients treated with anterior colporrhaphy, 26 (46%) were continent at the time of interview versus 15 of 20 (75%) treated with retropubic urethropexy (p < 0.05). Times to recurrence for anterior colporrhaphy and retropubic urethropexy were not significantly different. History of previous incontinence procedures, concomitant hysterectomy, previous hysterectomy, duration of postoperative catheterization, obesity, chronic lung disease, and smoking were not correlated with success for either procedure. Experience of the primary surgeon did have a significant effect on success, with attending staff having a better cure rate than resident surgeons (p < 0.05). CONCLUSION: Retropubic urethropexy was significantly more effective than anterior colporrhaphy for long-term cure of genuine stress urinary incontinence. We believe these conclusions should be tempered because of the complex nature of genuine stress incontinence. Patients having anterior colporrhaphy may represent a high-risk group because nearly all of them had associated pelvic floor defects. Experience of the surgeon seems to enhance the likelihood of success and may reflect subtle modifications of technique.

Reduction of pain and nausea after laparoscopic sterilization with bupivacaine, metoclopramide, scopolamine, ketorolac, and gastric suctioning.

OBJECTIVE: To determine whether postoperative pain and nausea after laparoscopic sterilization can be reduced with a combination of bupivacaine, metoclopramide, scopolamine, ketorolac, and gastric suctioning. METHODS: Women undergoing outpatient laparoscopic sterilization were randomized to protocol management or nontreatment groups. Each patient received standard general endotracheal anesthesia. Protocol subjects received intramuscular ketorolac 60 mg and scopolamine 0.25 mg, intravenous metoclopramide 10 mg, and gastric suctioning; bupivacaine (2.5 mg/mL) with epinephrine (5 micrograms/mL) was injected at trocar sites and dripped onto the fallopian tubes. The nontreatment group served as controls. Visual analogue scales were used to evaluate pain and nausea (measured in millimeters). Demographic characteristics, postoperative requirements for analgesics and antiemetics, time to discharge, and unscheduled admission were also evaluated. RESULTS: During a 7-month period, 71 women were enrolled. Protocol subjects (N = 35) reported pain severity of 27.9 +/- 19.1 mm (mean +/- standard deviation), whereas controls (N = 36) reported 59.3 +/- 23.3 mm (P < .001). Fourteen protocol patients requested additional pain medication, compared with 29 controls (P < .001). Protocol patients indicated a nausea severity of 9.9 +/- 18.7 mm, whereas the controls reported 38.8 +/- 35.5 mm (P < .001). Only one protocol patient required nausea medication, compared with nine controls (P < .02). Severity of pain correlated with severity of nausea (r = 0.38166, P < .001). Protocol patients were discharged from the outpatient surgery unit in 148.6 +/- 45.0 minutes, compared with 176.4 +/- 58.5 minutes for controls (P < .03). CONCLUSION: This regimen reduced the severity of pain and nausea after outpatient laparoscopic sterilization. The need for additional analgesics and antiemetics was also reduced. Protocol patients were discharged earlier than controls. These benefits seem to accrue without significant risk. We believe that this regimen may also be useful in other ambulatory laparoscopic procedures.

Leuprolide acetate in the management of cesarean scar endometriosis.

BACKGROUND: Progestin or estrogen-progestin combination therapy has not proven useful in the treatment of endometriosis of the abdominal scar after cesarean delivery. We report our experience in managing this condition with a gonadotropin agonist. CASE: A 22-year-old black woman with a history of two previous cesareans developed endometriosis of the abdominal scar. The extent of the lesion was estimated by computed tomographic (CT) scan, and a 6-month preoperative course of leuprolide acetate was administered. The patient exhibited prompt symptomatic response to the gonadotropin agonist, but the physical examination and CT scan findings were unchanged. Pathologic examination after surgical removal of the lesion confirmed the clinical diagnosis. CONCLUSION: Leuprolide acetate administered to a patient with cesarean scar endometriosis was associated with an improvement in symptoms, but there was no change in lesion size.

A randomized trial of abdominal incision suture technique and wound strength in rats.

OBJECTIVE: To determine whether interrupted en bloc suture or continuous running mass suture technique for closure of abdominal incisions results in stronger wounds, and to determine the time required for each technique. DESIGN: Randomized trial. SETTING: Arthur C. Guyton Animal Facilities, University of Mississippi Medical Center, Jackson. SUBJECTS: Male Sprague-Dawley rats. INTERVENTION: A midline laparotomy was performed on 103 rats that were separated into two groups using computer-generated random numbers. In group 1, incisions were repaired using a continuous mass closure suture technique. In group 2, incisions were repaired using an en bloc interrupted suture technique. OUTCOME MEASURES: Wound bursting pressure was determined on postoperative day 7. The time required to repair each incision was recorded. RESULTS: Continuous mass closure suture technique resulted in significantly greater wound strength (P < .05) and required significantly less time (P < .000001). CONCLUSION: Continuous mass closure suture technique is superior to interrupted en bloc closure with respect to wound strength and closure time.

Palpable uterine artery pulsation as a clinical indicator of early pregnancy.

The objective of this study was to determine if palpable uterine artery pulsation is a reliable clinical indicator of pregnancy at less than six weeks' gestation. A preliminary, nonblind study involved 299 women. Of 31 women who were at less than six weeks' gestation, 24 had definite uterine artery pulsations, and 7 did not. Of 268 nonpregnant women, 256 did not have pulsation, while 12 did (P < .001). Because other clinical parameters could bias the interpretation of uterine artery pulsation, a second, blind study was undertaken. During it, 155 patients underwent bimanual examination only, and no other clinical information was available to the examiner. Of 25 women at less than six weeks' gestation, 19 had definite uterine artery pulsation, while 6 did not. Of 130 nonpregnant patients, 121 did not have uterine artery pulsation, while 9 did (P < .001). Palpable uterine artery pulsation seems to be associated with early pregnancy, and physicians should add evaluation of pulsation to their clinical armamentarium.

Comparison of unscheduled hospital admission following ambulatory operative laparoscopy at a teaching hospital and a community hospital.

The objective was to identify and compare causes of unscheduled admission following ambulatory major operative gynecologic laparoscopy in a university hospital and a community hospital setting. Each patient admitted on an unscheduled basis was compared with 2 patients who did not require admission. Twenty-seven variables were evaluated by univariate analysis. Significant factors (p < 0.5) were analyzed by multivariate stepwise logistic regression. Patients admitted at the university hospital were compared with patients at a community hospital. In a 7-year period, 43 patients at the University of Mississippi Medical Center and, in a 6-year period, 30 patients at Gilmore Memorial Hospital required unscheduled admission following ambulatory major operative gynecologic laparoscopy. Site-specific analysis was performed, and these groups also were combined for analysis. The only factor associated with admission by multivariate analysis was estimated operative blood loss. Postoperative emesis was the most common reason for unscheduled admission at both hospitals and occurred in 27 patients. An additional 17 patients were admitted because of the severity of postoperative pain. Operative blood loss seems to be associated with extensive operations. Furthermore, increased blood loss typically leads to a very conservative approach to the postoperative patient, whereas minimal blood loss allows patients to be managed in a routine fashion. Patients at the university hospital seem to be generally comparable to patients at a community hospital. Postoperative nausea and pain resulted in over one half of admissions. Successful therapy for nausea and pain may reduce unscheduled admissions.

Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia.

OBJECTIVES: We reviewed our experience with the use of iliococcygeus fascia for repair of vaginal vault prolapse. STUDY DESIGN: A retrospective chart review identified 110 patients who had repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus fascia from March 1981 to April 1991. All patients were followed for a minimum of 3 years. RESULTS: Thirty-seven (33.6%) patients had uterine prolapse with enterocele. Posthysterectomy enterocele was present in 73 (66.4%) patients. All had a complex pelvic floor defect including cystocele or rectocele. Mean age was 54.5 +/- 14.6 years and mean parity was 4.1 +/- 3.2 births. Forty-two (38%) were grand multiparous patients. Five were nulliparous. Length of the procedure was 163.2 +/- 11.4 minutes. Estimated blood loss was 358.2 +/- 253.6 ml. Postoperative urinary catheterization was required for 6.1 +/- 4.1 days. Duration of hospital stay was 5.5 +/- 2.0 days. Three patients had hemorrhage > 750 ml and two required transfusion. One bowel injury and one bladder injury occurred. Forty-one patients had postoperative complications. The patients have been followed up for a minimum of 3 years, and four have had recurrent defects. All recurrent defects involved the anterior vaginal wall. CONCLUSIONS: Suspension of the vagina to the iliococcygeus fascia for repair of vaginal vault prolapse provides excellent long-term results. Critical to the success of vaginal vault suspension are adequate dissection and repair of all fascial defects. Adequate repair of the perineal body also plays a pivotal role. The anterior vaginal wall remains susceptible to recurrence.

Laparoscopic Pomeroy tubal ligation as a teaching model for residents.

We reviewed our preliminary experience with laparoscopically directed bilateral midtubal resection for tubal ligation (endoscopic Pomeroy) as a potential teaching tool for the acquisition of endoscopic skills during residency training. Thirty-five laparoscopic Pomeroy and 206 banding procedures were reviewed. Age, parity and weight were similar in the two groups. The operative time for banding was reduced slightly after experience with > 10 procedures. In contrast, the operative time for laparoscopic Pomeroy procedures decreased dramatically after individual experience with only a few (< or = 5) procedures. The mean operative time for the Pomeroy group approached that of the more traditional banding technique at five procedures. Our data indicate that laparoscopic Pomeroy sterilization can be an effective teaching tool for operative laparoscopy, allowing residents to repeatedly perform an easy and safe procedure that incorporates basic techniques. Advanced operative endoscopic procedures could then be taught more efficiently after the acquisition of basic skills.

PIP: 25 gynecology residents performed laparoscopic banding (tubal rings) sterilization on 206 women and laparoscopic Pomeroy sterilization on 35 women, all of whom underwent tubal sterilization at the University of Mississippi Medical Center between September 1988 and October 1990. Three faculty members and a fourth year resident retrospectively analyzed the data of both groups to determine the effect of the Pomeroy method on operative laparoscopic skills acquired by the residents during training. Both groups were similar in age, parity, and weight. Each of the 23 residents performed 1-22 laparoscopic banding procedures. As residents gained experience, the time to perform both banding and Pomeroy methods decreased significantly (p = 0.026). After a resident had conducted 5 Pomeroy procedures, the surgery time had approached that of laparoscopic banding. These findings show that gynecology faculty can use laparoscopic Pomeroy tubal ligation as an effective teaching tool for laparoscopy by providing residents an opportunity to repeatedly perform an easy and safe procedure that includes basic techniques. After developing the basic skills, the residents can then learn more efficiently advanced operative endoscopic techniques.

Leuprolide acetate depot for the treatment of uterine leiomyomas. Changes in bone density, uterine volume and uterine vascular resistive index.

This study measured the changes in uterine volume, uterine vascular resistive index and lumbar vertebral bone density before and after a six-month course of leuprolide acetate depot in women with uterine leiomyomas. All nine patients studied were black. The high baseline bone density of black women may provide a greater scope for the use of gonadotropin agonists as compared to women in the general population. A significant reduction in uterine volume was achieved in the patients with leuprolide therapy. Uterine vascular resistive indices were not altered consistently following leuprolide therapy in women with leiomyomas.

Vesical endometriosis 12 years after a cesarean section.

Invasion of the bladder is an unusual manifestation of endometriosis. We report a case of an isolated vesical endometrioma that developed 12 years after an uncomplicated cesarean section. The intraoperative findings were consistent with the possibility that infiltration of the detrusor muscle by endometrial tissues resulted from disruption of the uterine incision.

Resident research projects: frequency of presentation and publication in a national forum.

OBJECTIVE: Our aim was to determine the fate of mandatory resident research projects with regard to subsequent presentation and publication. STUDY DESIGN: In this retrospective descriptive study required research projects were assessed for frequency of presentation at regional and national meetings or publication in medical journals, or both, over a 10-year period (1983 through 1992). Rising second-year house officers elected to initiate their own study with departmental support under the guidance of a faculty advisor or selected a research project from a list of potential investigations offered by departmental faculty. Projects were presented at the annual alumni meeting in April of the junior and senior years. The faculty advisor assisted in research design, protocol development, obtaining human investigation committee approval, data collection, statistical analysis, manuscript preparation, and coaching for the oral presentation. After local presentation these projects were evaluated for submission to regional and national meetings and prepared for peer-review publication. RESULTS: During a 10-year period 104 resident research projects resulted in 72 regional or national presentations and 52 peer-review publications. There was a significant increase in the proportion of projects presented at national meetings over time (r = 0.99; p < 0.0001). There was also an increase in the number of projects published in peer-review journals during the decade-long study period (r = 0.96, p = 0.0001). CONCLUSIONS: Required completion of two research studies during residency bolstered by early selection of prospective projects and departmental fiscal support, as well as intensive faculty advisor direction and assistance, has resulted in resident projects with increasingly frequent national recognition.

Extrafascial wound dehiscence: deep en bloc closure versus superficial skin closure.

OBJECTIVE: To determine closure time, pain experienced during closure, and healing time in patients undergoing deep en bloc closure or superficial skin closure of extrafascial would dehiscence. METHODS: Patients with extrafascial wound dehiscence on the obstetrics and gynecology service of the University of Mississippi Medical Center were randomized to deep en bloc closure or superficial skin closure. A 1:2 ratio was used to evaluate superficial skin closure, as deep en bloc closure is known to be effective. The wounds of patients in the deep en block group were closed with no. 1 polypropylene placed through the entire wound thickness as simple interrupted sutures. The wounds of patients in the superficial closure group were closed with 2-0 polypropylene placed through the skin as vertical mattress sutures. The wounds were closed on the patient care unit under local anesthesia. Closure was timed in minutes from initiation of local anesthesia to cutting of the last suture. Patients assessed pain by placing a mark on a 100-mm line (0 = none; 100 = maximum). Time for complete healing was measured from wound disruption to skin reepithelialization. RESULTS: During an 8-month period, seven patients were randomized to deep en bloc closure and 16 to superficial skin closure. The en bloc group required 27.1 +/- 5.5 minutes (mean +/- standard deviation) for closure, compared with 18.9 +/- 3.4 minutes in the superficial group (P < .001). The mean pain score in the en bloc group was 43.4 +/- 23.2 mm, compared with 16.6 +/- 11.4 mm in the superficial group (P < .001). The en bloc group required 22.7 +/- 7.7 days for complete healing, compared with 19.8 +/- 5.3 days in the superficial group, a nonsignificant difference. CONCLUSIONS: Superficial skin closure of extrafascial wound dehiscence appears to be superior to deep en bloc closure in terms of closure time and pain experienced during the procedure. These benefits are achieved with minimal risk while allowing timely wound healing.