SURGICAL TECHNIQUES

■ BY MARCO A. PELOSI II, MD, and MARCO A. PELOSI III, MD

Pelosi minilaparotomy : Effective alternative to and laparotomy

This new modality—useful for normal, large, and fibroid-ridden uteri—combines the technical benefits of standard laparotomy with the convalescent advantages of laparoscopic surgery.

lthough laparoscopic hysterectomy Position, incision, and retraction offers a minimally invasive alternative are crucial to success Ato laparotomy when vaginal hysterec- ur minilaparotomy hysterectomy is a sys- tomy is contraindicated, it has its drawbacks. Otemized approach with elements derived Among them: the cost of expensive equip- from both open and laparoscopic surgery. ment, the long learning curve, and prolonged Three preparatory components are involved: operating time. • position We describe another alternative to open • incision surgery that is comparable to laparoscopic • retraction hysterectomy in postoperative pain, cosmetic All are critical to a successful hysterectomy, results, and time to return to normal activi- ensuring that the procedure never becomes a ties. Our procedure—a redesigned minila- haphazard struggle through an improvised, parotomy hysterectomy—relies on tradition- scaled-down, conventional Pfannenstiel or al open techniques and inexpensive novel vertical incision. Our approach also avoids instrumentation, making it significantly cumbersome traditional laparotomy exposure faster than laparoscopy and easy to perform maneuvers and positioning. and teach. Position: Modified lithotomy. After For patients who cannot undergo vaginal regional or general anesthesia is given, posi- hysterectomy, this new modality offers tion the patient in a modified lithotomy with an expeditious, minimal-access option. both arms tucked as for laparoscopic surgery. Gynecologists reluctant to relinquish the rou- Place the legs in boot-type stirrups, with no tine use of standard laparotomy may hip flexion and sufficient thigh abduction to find this approach an appealing, less-invasive expose the . alternative. Next, perform a thorough pelvic exami-

■ Dr. Pelosi II is director and Dr. Pelosi III is associate director, nation and place an indwelling, transurethral Pelosi Women’s Medical Center, Bayonne, NJ. catheter. A sturdy, hinged uterine manipula- CONTINUED

16 OBG MANAGEMENT • April 2003 Development of the Pelosi minilaparotomy hysterectomy technique

Standard minilaparotomy tried a minilaparotomy Kustner’s incision (3 cm to 5 The use of standard minilaparotomy—which is noth- cm) as the sole means of surgical access, assess- ing more than a conventional laparotomy of limited ment, and treatment for benign pelvic conditions. length (3 cm to 6 cm), performed either transversely or Benefits of this incision. When a sturdy uterine vertically—has been confined to the surgical treat- manipulator was used to facilitate exposure of the ment of benign pelvic pathology of limited extent. adnexa and uterine elevation/rotation, we found this To generate sufficient exposure to work effec- technique more effective than similar procedures tively, surgeons using the standard minilaparotomy using a scaled-down Pfannenstiel or Maylard inci- have relied on the length of the abdominal incision sion. In addition, because the incision was small and, secondarily, bowel packing and metal handheld and the extent of subcutaneous dissection required or self-retaining fixed retraction systems. When to expose the rectus fascia in a vertical fashion was exposure is difficult to achieve or maintain, howev- limited, there was no need for incision drainage. er, routine surgical maneuvers become frustrating Nor was the procedure associated with seroma for- and time-consuming—unless the clinician uses mation, as the full-sized Kustner’s incision had extensive traction force, extends the incision been.3 However, the minilaparotomy Kustner’s inci- length, or performs muscle-splitting. These alterna- sion still suffered from limited surgical exposure. tives often result in an uncomfortable, slow recov- Adding the retractor ery typical of most laparotomies, thereby negating It became clear that a soft, self-retaining abdominal the primary goal of minimally invasive surgery. retractor that is capable of creating a rapid, effective, Use of traditional minilaparotomy for hysterec- nontraumatic, and predictable circular area of abdom- tomy has been reported only rarely. Hoffman et al1 inal retraction would be helpful, particularly one that found the procedure safe and effective in non- could be placed through the minilaparotomy obese women in whom a vaginal approach was pre- Kustner’s incision.6 Once this retractor system was cluded. Benedetti Panicci et al2,3 also have used developed, using technology borrowed from hand- minilaparotomy successfully in benign gynecologic assisted laparoscopy,7-10 the minilaparotomy hys- disease and hysterectomy. terectomy became a much simpler, more useful sur- The Kustner incision gical option.

4 Originally reported in 1896, this incision is avoided REFERENCES by most surgeons in favor of complete transverse 1. Hoffman MS, Lynch CM. Minilaparotomy hysterectomy. Am J Obstet Gynecol. 1998;179:316-320. or complete vertical incisions—largely due to diffi- 2. Benedetti Panicci P, Maneschi F, Cutillo G, et al. Surgery by minilaparotomy culties with exposure, troublesome seroma forma- in benign gynecologic disease. Obstet Gynecol. 1996;87:456-459. 3. Benedetti Panicci P, Zullo MA, Casalino B, et al. Subcutaneous drainage ver- tion, and wound complications secondary to sus no drainage after minilaparotomy in gynecologic benign conditions. Am J increased fluid accumulation in the large dead Obstet Gynecol. 2003;188:71-75. 4. Kustner O. Der suprasymphysare kruzschnitt, eine methode der coeliotomie space that results from wide dissection of the sub- bei wening umfanglichen affektionen der weiblichen beckenorgane. cutaneous flap. Monatsschr Geburtshilfe Gynakol. 1896;4:197-206. 5. Pelosi MA II, Pelosi MA III. The suprapubic cruciate incision for laparoscopic In the early 1990s, we realized the potential assisted microceliotomy. J Soc Laparoendosc Surg. 1997;1:269-272. benefits of a scaled-down Kustner’s incision (2 cm 6. Pelosi MA II, Pelosi MA III. Self-retaining abdominal retractor for minilaparo- tomy. Obstet Gynecol. 2000;96:775-778. to 5 cm) when assistance was needed via minila- 7. Pelosi MA II, Pelosi MA III. Hand-assisted laparoscopy for complex hysterec- parotomy during such laparoscopic-assisted proce- tomy. J Am Assoc Gynecol Laparosc. 1999;6:183-188. 8. Pelosi MA II, Pelosi MA III. Hand-assisted laparoscopic cholecystectomy at dures as uterine morcellation, tubal reanastomosis, cesarean section. J Am Assoc Gynecol Laparosc. 1999;6:491-495. and extensive uterine suture and reconstruction fol- 9. Pelosi MA II, Pelosi MA III. Hand-assisted laparoscopy (handoscopy) for megamyomectomy: A case study. J Reprod Med. 2000;45:519-525. lowing complex laparoscopic myomectomy.5 As a 10. Pelosi MA II, Pelosi MA III, Eim J. Hand-assisted laparoscopy for pelvic malig- substitute for laparoscopy and laparotomy, we then nancy. J Laparoendosc Adv Surg Tech. 2000;10:143-150.

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April 2003 • OBG MANAGEMENT 19 Pelosi minilaparotomy hysterectomy

tor is of paramount importance for the hys- Squeeze the inner ring into the peritoneal terectomy, as it facilitates exposure of the cavity through the minilaparotomy incision, adnexa as well as elevation/rotation of the allowing it to spring open against the parietal and the uterine attachments. We rec- peritoneum. Conduct a digital assessment to ommend the Pelosi Uterine Manipulator ensure that no viscera are trapped by elevating (Apple Medical Corporation, Marlboro, Mass) the outer ring. Next, roll the outer ring onto or its equivalent (FIGURE 1). the sleeve, collecting excess length, until it sits Incision: Modified Kustner’s. Open the firmly against the skin (FIGURES 3B and 3C). abdomen with a cruciate incision. Using a The result, when there is adequate tension conventional scalpel and the Bovie device, within the sleeve, is a circular area of retrac- make a 2.5-cm to 5-cm transverse incision tion offering excellent exposure of the pelvis. through the skin and subcutaneous fat until Note that during surgery you may need to you reach the anterior rectus fascia (FIGURE adjust the outer ring if the sleeve loosens. 2A). Clear the fat from the midline superiorly The soft, self-retaining abdominal retrac- and inferiorly to expose approximately 5 cm tor offers several advantages over traditional to 6 cm of fascia in the vertical axis. Then abdominal retraction: incise the anterior rectus fascia in a vertical Atraumatic retraction. This device distrib- direction through the full length of the utes retraction force evenly around the entire cleared area (FIGURE 2B). incision. Because standard retractors concen- Retract the rectus muscles from the mid- trate retraction force at only a few points, they line, exposing the transversalis fascia and the often lead to tissue trauma, nerve damage, underlying peritoneum. Enter the peri- bruising, and postoperative pain. toneum digitally or with scissors above the Incision protection. The retractor’s flexible level of the bladder dome, incising vertically material lines the incision, protecting the until the entrance extends the full length of wound’s edges from contamination and the fascial incision (FIGURE 2C). potential implantation of malignant cells. This modified Kustner’s incision is essen- Improved access. Because the continuous tially a vertical midline incision in its deeper retraction force is delivered more effectively to layers.1 The rapid surgical dissection of the fas- the incision, exposure is maximized. As a cia and rectus muscles and the intraperitoneal result, the need for intensive surgical assis- entry are relatively bloodless. This approach tance is dramatically reduced. yields a surgical exposure superior to that of a Adjustable height. The retractor’s design small Pfannenstiel or Maylard incision. lets it adapt to wounds of varying depth—a Note that, in some patients, a vertical inci- feature that makes it ideal for obese patients. sion can be selected if there is a prior vertical The device compresses the patient’s skin and incision or if the perioperative workup suggests peritoneum between the external and internal a malignancy that may require a later exten- rings, keeping the full thickness of the abdom- sion of the original minilaparotomy incision. inal incision constant throughout the surgery. Retraction: Soft, sleeve-type, self-re- Cost-effectiveness. The device, which costs taining abdominal retractor. This device under $100, is simple and fast to set up. In our consists of a flexible plastic inner ring and a experience, placement takes approximately 2 firmer outer ring connected by a soft plastic minutes; this compares favorably with table- sleeve (FIGURE 3A). Two models are available: mounted or self-retaining rigid retraction sys- the Mobius (Apple Medical Corporation) and tems, which may require significant capital the Protractor (Weck Closure Systems, Research expenditures (cost may run in the thousands), Triangle Park, NC). repair costs, and complicated set-ups. CONTINUED

20 OBG MANAGEMENT • April 2003 Pelosi minilaparotomy hysterectomy

FIGURE 1 Hinged uterine manipulator

A sturdy hinged uterine manipulator facilitates exposure of the adnexa as well as elevation/rotation of the uterus.

FIGURE 2 Cruciate incision

A. Make a transverse incision B. Clear the fat from the midline to C. Incise the peritoneum vertically suprapubically through the skin and expose the rectus fascia in the verti- until it extends the full length of the the subcutaneous fat to reach the cal axis, then incise the fascia in a fascial incision. anterior rectus fascia. vertical direction through the full length of the previously cleared area. The rectus muscles are retracted, thereby exposing the peritoneum. FIGURE 3 Soft, sleeve-type, self-retaining abdominal retractor

A. At left, the Protractor (Weck B. After inserting the inner ring into C. An atraumatic, circular, self- Closure Systems); at right, the the peritoneal cavity, twist the outer retaining area of retraction Mobius (Apple Medical ring downward until it inverts and is created. Corporation). rests snuggly against the skin.

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April 2003 • OBG MANAGEMENT 23 Pelosi minilaparotomy hysterectomy

Standard technique: If the is to be preserved, amputate Exteriorize the uterus; the uterus supracervically following division divide uterine attachments, vessels of the uterine vessels. Then suture the cervi- Assess the anatomy. Using your index fin- cal stump in the traditional fashion. Upward ger and the uterine manipulator to rotate and elevation of the cervix using the uterine flex the uterus, carefully assess the uterus, manipulator expedites this step. adnexa, and pelvis, noting the location of the Complete the procedure. Once the sur- ureters. Determine the extent of any unex- gery is completed, remove the retractor, hook- pected pelvic pathology or adhesions, using ing the bottom ring by inserting a finger into traditional small retractors or gentle packing it and pulling it up and out of the incision to gain additional exposure. Perform any (FIGURE 4C). Closing a cruciate incision is adhesiolysis that is necessary. faster and requires less exposure than closing Exteriorize the uterus. Next, bring the a mini-Pfannenstiel incision. Eliminate the uterus and the adnexa above the abdominal possibility of postoperative wound hematoma wall in order to perform as much of the hys- or seroma formation by applying a vertical terectomy extracorporeally as possible. Pass pressure dressing over the incision (FIGURE the uterus or adnexa through the incision 4D). Remove the dressing 24 hours later. with the upward assistance of the uterine manipulator, then divide the upper uterine Variations for abnormal uteri attachments (FIGURE 4A). The large fibroid uterus: Begin with the Increase exposure. You can achieve addi- dominant myoma. A large fibroid uterus tional uterine elevation and targeted exposure can be easily removed with our minilaparoto- in several ways. For example, a strong traction my technique using 3 basic steps: suture can be placed in the uterine fundus, left 1. Reduce size by selective myomectomy. long, and secured with a clamp. To achieve 2. Deliver the debulked uterus through the uterine elevation, place long clamps lateral to abdominal incision. the corpus. Another effective approach is to 3. Perform extracorporeal hysterectomy. place a heavy tenaculum on the uterine fundus. First, you must conduct a thorough When lateral exposure is limited, divide assessment of the number, size, and location the proximal adnexal pedicles and round lig- of the myomas. Begin the myomectomy on aments to begin the operation, and remove the largest tumor of those closest to the mini- the adnexa separately following the comple- laparotomy incision. (Minimize bleeding by tion of the hysterectomy. injecting diluted vasopressin subserosally Divide the uterine vessels through the prior to the procedure.) small incision using clamping, division, and Incise the uterine serosa, myometrium, ligation. Unless you intend to preserve the and pseudocapsule of the myoma via scalpel cervix, mobilize the bladder to the level of the or Bovie electrocautery until the whorly anterior vaginal fornix. Inward pressure on appearance of the myoma is apparent. Next, the uterine manipulator provides additional grasp the myoma with claw-toothed forceps to elevation of the lower uterine vasculature and stabilize it and place it under traction. Then, the cardinal and uterosacral ligaments as using a combination of sharp and digital dis- these structures are ligated and divided. section, develop a plane of dissection between Amputate the uterine specimen from the the fibroid and the myometrium (FIGURE 5A). vaginal cuff using the uterine manipulator to After securing the dominant myoma, guide the vaginal circumcision (FIGURE 4B). deliver it through the abdominal incision. If Close the vaginal cuff using standard closure. the myoma is too large to be removed intact CONTINUED

24 OBG MANAGEMENT • April 2003 Pelosi minilaparotomy hysterectomy

FIGURE 4 Hysterectomy for the normal to moderately enlarged uterus

A. Exteriorize the uterus as much as B. Separate the uterus from the possible with both upward assistance of vagina using the manipulator to the manipulator and uterine fundal guide the vaginal circumcision. elevation (using clamps lateral to the (If the cervix is to be preserved, uterus, a heavy tenaculum, or a traction a supracervical amputation is suture). Then conduct a standard performed instead.) hysterectomy.

C. After completing the surgery, D. Apply a vertical pressure remove the retractor from the incision. dressing over the incision.

FIGURE 5 Hysterectomy for the fibroid uterus

A. Develop a plane of dissection B. Deliver the myoma through the C. After reducing the uterine size between the myoma and incision; if it is too large to remove by selective myomectomy, deliver myometrium. intact, morcellate it with a scalpel the debulked uterus through the or scissors. abdominal incision. Then proceed with an extracorporeal total or subtotal hysterectomy.

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April 2003 • OBG MANAGEMENT 27 Pelosi minilaparotomy hysterectomy

from the abdominal cavity, morcellate it using using external abdominal pressure and the a scalpel or scissors (FIGURE 5B). Then con- uterine manipulator. tinue systematic removal of the remaining Once both round ligaments and adnexal myomas using the same approach. It is not pedicles are divided, dissect the bladder flap necessary to remove all myomas—the goal of to expose the uterine arteries (inward pressure this process is merely to permit delivery of the on the uterine manipulator provides helpful uterine body for subsequent hysterectomy. countertraction). Then clamp, divide, and Once the uterus is debulked, deliver it ligate the uterine arteries (FIGURE 6B). through the abdominal incision. Hysterectomy The uterus is now ready for supracervical then is easily completed (FIGURE 5C). amputation. Upward traction on the isthmus The ‘solid’ uterus: In situ supracervical by means of a rubber tourniquet facilitates hysterectomy and uterine morcellation. uterine division (FIGURE 6C). After the uterus Very large uteri are sometimes homogeneous is amputated, push it toward the upper and solid in nature, possessing few or no indi- abdomen to increase exposure for suturing of vidual myomas. This so-called cannonball the cervical stump (if the cervix is preserved) fibroid uterus is the most challenging type of or for cervical excision and vaginal cuff clo- uterus to remove. The selective-myomectomy sure (when total hysterectomy is chosen). approach cannot be used because of the poten- Next, remove the uterine specimen by tial for massive bleeding and the technical morcellation through the minilaparotomy anatomical difficulties that arise when operat- incision. Using the Doyen ladder-shaped ing through such a small abdominal incision. uterine morcellation technique (originally Instead, manage this type of uterus by described in the early 1920s) grasp an area of performing a deliberate in situ supracervical the uterus and, alternating right and left, hysterectomy through the minilaparotomy make deep but incomplete incisions on the incision. At the end of this procedure, morcel- uterus, creating a ladder shape.2 Because of its late the amputated fibroid uterus. elasticity, the retractor can stretch quite signif- Begin the surgery by dividing the upper icantly without tearing the edges of the uterine attachments. Regardless of uterine abdominal incision (FIGURE 6D). This allows size, the origins of the round and adnexal lig- the easy exteriorization of uteri with diame- aments will always be lateral to and within ters considerably larger than that of the retrac- easy reach of a transverse minilaparotomy tor, mimicking the stretching of the perineum incision. (Access to these areas is the only fac- during the crowning of the fetal head. tor that determines the feasibility of this pro- When the surgery is complete, remove cedure; uterine size is completely irrelevant.) the retractor, close the minilaparotomy inci- We have found that these elongated ligaments sion, and apply a vertical pressure dressing are quite lax. Thus, in most cases it is rela- over the incision. Neither vaginal packing nor tively simple to navigate your index finger lat- bladder catheterization is required. erally and, using digital traction, elevate these structures into the minilaparotomy incision A short learning curve (FIGURE 6A). You can then clamp, cut, and ince it uses conventional open techniques suture the ligaments in the standard fashion Sand traditional instrumentation, this in whatever sequence is most efficient. method can be learned and mastered quickly. Thanks to the retractor, minimal assis- We tend to think of this procedure as a tance is necessary during the surgery. You can transabdominal “vaginal” hysterectomy, since create additional exposure by deflecting the the average diameter of the minilaparotomy uterus toward the opposite side of the pelvis opening is approximately the same as the vagi- CONTINUED

28 OBG MANAGEMENT • April 2003 Pelosi minilaparotomy hysterectomy

FIGURE 6 Hysterectomy for the large, solid, fibroid uterus

A. Draw the upper uterine attachments to the B. Divide the round ligaments and proximal surgical field with finger traction. adnexal pedicles, then carry out division of the uterine vessels bilaterally.

C. After dividing both round ligaments, adnexal D. After trachelectomy, the large uterine pedicles, and uterine vessels, place the uterine specimen is removed by morcellation. isthmus in traction with a rubber tourniquet and Notice that the retractor is able to stretch perform an in situ supracervical amputation. significantly, allowing the exteriorization of uteri with diameters considerably larger than that of the retractor.

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30 OBG MANAGEMENT • April 2003 Pelosi minilaparotomy hysterectomy nal canal. Further, as in vaginal hysterectomy, the abdomen, as well as those performed in only 1 portion of the uterus, adnexa, or liga- conjunction with minilaparotomy, have con- ments must be exteriorized at a given time. sistently failed to identify a link between these Thus, this approach requires less general combinations and morbidity or lengthy recov- exposure but offers effective targeted exposure. ery. A “large” minilaparotomy incision is still The technique also removes the need for superior to a standard abdominal hysterecto- frequent use of traumatic metal retractors, my in terms of convalescence, and it is signif- extensive bowel packing, and extended inci- icantly faster and more cost-effective than a sion exposure. The benefits: diminished post- prolonged laparoscopic or laparoscopic- operative discomfort and bowel dysfunction. assisted vaginal hysterectomy.3-10 High success rates. We have performed Do any conditions contraindicate mini- more than 100 minilaparotomy procedures laparotomy? In patients with documented or using this technique in patients in whom strongly suspected severe pelvic conditions (for vaginal hysterectomy was contraindicated. example, advanced endometriosis, pelvic Uterine weight ranged from 80 g to 2,500 g. inflammatory disease, bowel disease, or malig- Mean operating time was 50 minutes. All nancy), preliminary laparoscopic evaluation to patients were discharged within 36 hours. determine the pathologic condition’s severity Mean return to work time was 12 days, and and extent is strongly recommended. there have been no intraoperative or postop- If during this assessment you detect erative complications. All surgeries were suc- pathology that is not appropriate for laparo- cessfully completed without laparoscopy or scopic surgery or minilaparotomy, perform a conversion to traditional laparotomy. traditional laparotomy. If, however, this eval- uation demonstrates that pelvic pathology is Devices that simplify the procedure amenable to laparoscopic surgery, a laparo- ccasionally, hysterectomy using traditional scopic hysterectomy or laparoscopic-assisted Oclamp, division, and suture ligation can be minilaparotomy hysterectomy is indicated. ■ tedious, frustrating, and time-consuming, especially when exposure is limited or difficult. REFERENCES 1. Kustner O. Der suprasymphysare kruzschnitt, eine methode der coeliotomie bei Several devices developed for laparoscopic sur- wening umfanglichen affektionen der weiblichen beckenorgane. Monatsschr gery can ease suture ligation and the division Geburtshilfe Gynakol. 1896;4:197-206. 2. Doyen E. Surgical Therapeutics and Operative Technique. Vol. III. Spencer-Browne of blood vessels, ligaments, and tissue bundles H, translator. London, England: Bailliere, Tindal and Cox; 1920. during minilaparotomy hysterectomy. They 3. Benedetti Panicci P, Maneschi F, Cutillo G, et al. Surgery by minilaparotomy in benign gynecologic disease. Obstet Gynecol. 1996;87:456-459. include the Hem-o-lok ligating clip (Weck 4. Benedetti Panicci P, Zullo MA, Casalino B, et al. Subcutaneous drainage versus no Closure Systems); the LigaSure Atlas, a vessel drainage after minilaparotomy in gynecologic benign conditions. Am J Obstet Gynecol. 2003;188:71-75. sealer-divider (Valleylab, Tyco Healthcare, 5. Pelosi MA II, Pelosi MA III. The suprapubic cruciate incision for laparoscopic Boulder, Colo); the ETS 45-Flex endoscopic assisted microceliotomy. J Soc Laparoendosc Surg. 1997;1:269-272. 6. Pelosi MA II, Pelosi MA III. Self-retaining abdominal retractor for minilaparoto- linear cutter (Ethicon Endo-Surgery, my. Obstet Gynecol. 2000;96:775-778. Cincinnati, Ohio); and the PK bipolar cutting 7. Pelosi MA II, Pelosi MA III. Hand-assisted laparoscopy for complex hysterectomy. J Am Assoc Gynecol Laparosc. 1999;6:183-188. forceps (Gyrus Medical, Maple Grove, Minn). 8. Pelosi MA II, Pelosi MA III. Hand-assisted laparoscopic cholecystectomy at cesare- an section. J Am Assoc Gynecol Laparosc. 1999;6:491-495. 9. Pelosi MA II, Pelosi MA III. Hand-assisted laparoscopy (handoscopy) for Additional concerns megamyomectomy: A case study. J Reprod Med. 2000;45:519-525. Is the incision too large? Fears that inci- 10. Pelosi MA II, Pelosi MA III, Eim J. Hand-assisted laparoscopy for pelvic malig- sions over 5 cm might nullify minimally inva- nancy. J Laparoendosc Adv Surg Tech. 2000;10:143-150. sive surgery’s benefits have proven unfounded. Dr. Pelosi II reports that he is a consultant for Apple Medical Corporation. Dr. Pelosi III reports no affiliations or financial Laparoscopic procedures that use a 7-cm arrangements with any of the manufacturers of products mentioned to 8-cm incision to introduce the hand into in this article or their competitors.

April 2003 • OBG MANAGEMENT 33