Single-port laparoscopic-assisted abdominal cryptorchidectomy in 14 dogs.

OBJECTIVE: To describe a modified laparoscopic-assisted cryptorchidectomy technique in dogs using a single-port endoscope and evaluate clinical outcome in abdominal cryptorchid dogs that underwent the procedure. STUDY DESIGN: Prospective case series. ANIMALS: A total of 14 client-owned dogs (19 abdominal cryptorchid testes). METHODS: Dogs scheduled for laparoscopic cryptorchidectomy between January 2019 and April 2022 were enrolled in the study. The dogs underwent single-port laparoscopic-assisted cryptorchidectomy (SP-LAC) performed by a single surgeon using a 10-mm single-port endoscope placed in the midline immediately cranial to the prepuce. The abdominal testis was endoscopically located and grasped, the cannula was retracted, the capnoperitoneum was reversed to allow exteriorization of the testis, and the spermatic cord was ligated extracorporeally. RESULTS: Median age was 13 months (range, 7-29 months) and median bodyweight was 23.0 kg (range, 2.2-55.0 kg). Nine of 14 dogs had unilateral abdominal cryptorchidism (7 right-sided and 2 left-sided) and 5/14 dogs had bilateral abdominal cryptorchidism. Median surgical time for unilateral abdominal cryptorchidectomy was 17 min (range, 14-21 min) and for bilateral abdominal cryptorchidectomy 27 min (range, 23-55 min). Ten dogs had additional surgical procedures performed concurrently with SP-LAC. One major intraoperative complication (testicular artery hemorrhage) occurred that required emergency conversion and two minor entry-related complications were observed. CONCLUSION: The SP-LAC procedure enabled removal of abdominal testes and was associated with a low morbidity. CLINICAL SIGNIFICANCE: The SP-LAC procedure can be performed by a single surgeon and represents a less invasive alternative to multi-port laparoscopic-assisted or single-port multi-access laparoscopic cryptorchidectomy techniques.

Laparoscopic adrenalectomy for resection of unilateral noninvasive adrenal masses in dogs is associated with excellent outcomes in experienced centers.

OBJECTIVE: To report the short- and long-term outcomes of laparoscopic adrenalectomy (LA) for resection of unilateral adrenal masses and to document risk factors for conversion and peri- and postoperative morbidity. ANIMALS: 255 client-owned dogs. METHODS: Dogs were included if LA was attempted for resection of a unilateral adrenal mass. Medical records were evaluated and relevant data were reported, including complications, conversion, perioperative death, and long-term outcomes. Signalment, clinicopathological data, and surgical experience were factors statistically evaluated for possible associations with capsular penetration during surgery, conversion, surgical time, duration of hospital stay, death prior to discharge, mass recurrence, and survival time. RESULTS: 155 dogs had left-sided tumors, and 100 had right-sided tumors. Conversion to an open approach was performed in 9.4% of cases. Capsular penetration (19.2%) and major hemorrhage (5.4%) were the most prevalent intraoperative complications. Of the dogs operated on, 94.9% were discharged from the hospital. Lesion side, portion of the gland affected, and surgeon experience influenced surgical time. Conversion rate increased with increasing body condition score and lesion size. Risk of death prior to discharge increased with increasing lesion size. Risk of conversion and death prior to discharge were lower when performed by more experienced surgeons. Capsular penetration during LA increased the risk of tumor recurrence. CLINICAL RELEVANCE: LA for resection of unilateral adrenal masses is associated with excellent outcomes in experienced centers. Surgeons with greater experience with LA have lower surgical times, conversion rates, and risk of death prior to discharge.

Evaluation of long-term outcome after lung lobectomy for canine non-neoplastic pulmonary consolidation via thoracoscopic or thoracoscopic-assisted surgery in 12 dogs.

OBJECTIVE: To report outcomes of thoracoscopic (TL) and thoracoscopic-assisted lung lobectomy (TAL) for treatment of non-neoplastic pulmonary consolidation (PC) in dogs. STUDY DESIGN: Retrospective case series. ANIMALS: Twelve client-owned dogs. METHODS: The medical records of 12 dogs that underwent TL or TAL for PC at 3 veterinary institutions between 2011 and 2020 were reviewed. Signalment, history, physical examination, diagnostics, days in hospital, anesthetic and procedure times, intraoperative/postoperative complications, conversion rates, duration of indwelling thoracic drain, and long-term outcomes were recorded. RESULTS: Nine patients underwent a TL approach and 3 underwent TAL. In those that underwent TL, conversion to an intercostal thoracotomy was performed in 4 out of 9 dogs. Conversion was performed due to adhesions (n = 3) or poor visualization (1). Histopathologic examination was consistent with pneumonia due to an infectious process (n = 10), bronchioalveolar malformation with abnormal cilia (1), and left-sided cardiac insufficiency vs. pulmonary alveolar proteinosis (1). The mean duration of hospital stay was 4 days (range, 1-6 days). Complications occurred postoperatively in 7 dogs and included self-limiting hemorrhage (n = 3), self-resolving pneumothorax (2), incisional dehiscence (1), and severe dyspnea in a brachycephalic breed leading to euthanasia (1). For the 11 dogs that survived the perioperative period, there was no evidence of recurrence with a median follow up of 24 months (range, 5-120 months). CONCLUSION: Thoracoscopic (TL) and thoracoscopic-assisted lung lobectomy (TAL) is a reasonable surgical approach in select dogs with PC. CLINICIAL RELEVANCE: Conversion rates were higher than those historically reported for dogs undergoing thoracoscopic lung lobectomy for primary lung tumors.

Complications and survival after subcutaneous ureteral bypass device placement in 24 cats: a retrospective study (2016-2019).

OBJECTIVES: The aim of this study was to document survival, complications and risk factors for the development of complications and mortality prior to discharge after placement of a subcutaneous ureteral bypass (SUB) device in cats. METHODS: The medical records of cats with SUB placement between January 2016 and August 2019 were retrospectively analysed. The development of complications (overall, intraoperative, perioperative, short- and long-term complications) and risk factors for mortality prior to discharge were statistically assessed with univariate binary logistic regression. All variables with a P value ⩽0.10 in the univariate analysis were assessed in a multivariate model. Variables were significant if P <0.05. RESULTS: Twenty-four cats were included; 12 (50.0%) received a unilateral SUB, 11 (45.8%) a bilateral nephrostomy tube with single cystostomy catheter and the remaining cat (4.2%) two unilateral SUBs. Nearly 80% of the cats developed complications, ranging from mild to fatal, including (partial) SUB obstruction (33.3% of complications), lower urinary tract infection (20.8%), pyelonephritis (20.8%) and sterile cystitis (12.5%). Five cats (20.8%) died prior to discharge. Six cats (25.0%) underwent revision surgery. The overall median survival time (MST) was 274 days (range 1-311 days). Complications were most common in the long-term period (14/16 cats), followed by the short-term (9/18 cats), perioperative (10/23 cats) and intraoperative (4/24 cats) periods. Older cats had an increased risk for developing perioperative complications (P = 0.045) and were less likely to survive to discharge (P = 0.033). An increased haematocrit at presentation was a risk factor for the occurrence of short-term complications (P = 0.03). CONCLUSIONS AND RELEVANCE: Although complications similar to those previously described were observed, the complication rate was higher and the MST shorter than previously reported in cats undergoing SUB placement. Despite good short-term survival, the development of complications may necessitate regular and intensive control visits. Owners that consider SUB placement should be informed that follow-up can be strenuous and expensive.

Laparoscopic gonadectomy in dogs with ovotesticular disorder of sexual development.

Disorders of sexual development (DSD) in dogs involve most commonly an XX sex reversal syndrome, treated conventionally by gonadohysterectomy. The objective of the present case series is to describe the surgical treatment and long-term follow-up of dogs undergoing laparoscopic gonadectomy without hysterectomy for treatment of ovotesticular DSD. Six female dogs clinically diagnosed with DSD were retrospectively included in the study when laparoscopic gonadectomy was performed and histology confirmed the presence of abnormal gonads. The dogs were evaluated by ultrasound after 6 months, and owners were contacted by phone for the long-term reevaluation. Laparoscopic gonadectomy was performed using 2- or 3-portal midline techniques with 3- and/or 5-mm instruments. Additional procedures were performed in 5 dogs, including os clitoris removal in 4 dogs and vulvoplasty in 1 dog. Histological analysis of the gonads reported 11 ovotestes and 1 testis. No major or minor complications occurred perioperatively. Ultrasonographic reevaluation was performed in 5/6 dogs and the remaining abdominal genital system was considered normal. Median long-term follow-up was 617 days (range, 265-1597) with none of the dogs having any symptom related to DSD. Therefore, laparoscopic gonadectomy is a valid alternative for dogs with ovotesticular DSD and is less invasive than conventional open techniques. Removal of the gonads avoids future development of hormone-related diseases of the remaining genital tract.

Fluorescence-guided surgery using indocyanine green in dogs with superficial solid tumours.

BACKGROUND: Near-infrared fluorescence (NIRF) imaging is a relatively novel technique that can aid surgeons during intraoperative tumour identification. METHODS: Nine canine oncology patients (five mammary gland tumours, three mast cell tumours and one melanoma) received intravenous indocyanine green (ICG). After 24 hours, tumours were resected and fluorescence intensities of tumours and surroundings were evaluated. Additional wound bed tissue was resected if residual fluorescence was present after tumour resection. Ex vivo, fluorescence-guided dissection was performed to separate tumour from surrounding tissue. RESULTS: Intraoperative NIRF-guided tumour delineation was feasible in four out of nine dogs. Wound bed imaging after tumour removal identified nine additional fluorescent lesions, of which four contained tumour tissue. One of these four true positive in vivo lesions was missed by standard-of-care inspection. Ex vivo fluorescence-guided tumour dissection showed a sensitivity of 72 per cent and a specificity of 80 per cent in discriminating between tumour and surrounding tissue. CONCLUSION: The value of ICG for intraoperative tumour delineation seems more limited than originally thought. Although NIRF imaging using ICG did identify remaining tumour tissue in the wound bed, a high false positive rate was also observed.

A laparoscopic approach for removal of ovarian remnant tissue in 32 dogs.

BACKGROUND: Surgical treatment of ovarian remnant syndrome (ORS) in dogs usually necessitates large celiotomies and considerable manipulation of organs because of the relatively deep position of ovarian remnant tissue, large patient size, and often encountered adhesions. In women, laparoscopic treatment of ORS is successful and has significant advantages over laparotomy. Since laparoscopic ovariectomy has significant advantages over open ovariectomy in dogs, including reduced surgical stress and postoperative pain and shorter convalescence period, the rationale for a laparoscopic approach of canine ORS is evident. Feasibility and efficacy of a laparoscopic approach for treatment of ORS in dogs was prospectively evaluated using a standardized protocol for diagnosis, treatment, and follow-up. Treatment success was evaluated by histology of removed tissues, postoperative hormone testing, and long-term clinical follow-up. RESULTS: Thirty-two client-owned predominantly medium and large breed dogs diagnosed with ORS underwent abdominal ultrasound for ovarian remnant localization prior to laparoscopic surgery for removal of ovarian remnants. Tissue dissection and excision was performed using a vessel sealing forceps. Laparoscopy subjectively enabled detailed visibility and facilitated detection and removal of suspected ovarian tissue in all cases. Histology confirmed ovarian origin of removed tissue in all dogs. Additionally, a GnRH stimulation test was performed in fourteen dogs after a median follow-up of 10.5 months, which verified absence of residual functional ovarian remnant tissue in all dogs. Median surgery duration was 97.5 min and mean total convalescence duration, subjectively scored by owners, was 1.5 ± 0.7 days. No major complications occurred. Adhesions were observed in 79% of the dogs, complicated the surgical approach, and significantly affected surgery duration (85 versus 109 min; p = 0.03). Minor hemorrhage occurred in 12% and significantly increased surgery duration (95.5 versus 128 min; p = 0.02). Trendelenburg position and lateral tilting of the patient were essential for proper access to ovarian remnants. GnRH stimulation test results and/or absence of clinical signs indicative of ORS after a median follow-up period of 22.5 months confirmed treatment efficacy in all dogs. CONCLUSION: Laparoscopic surgery for ORS in dogs is effective with minimal complications and short convalescence and can successfully replace the conventional, more invasive open surgical procedure.

Negative pressure wound therapy using polyvinyl alcohol foam to bolster full-thickness mesh skin grafts in dogs.

OBJECTIVE: To report the use of negative pressure wound therapy (NPWT) with polyvinyl alcohol (PVA) foam to bolster full-thickness mesh skin grafts in dogs. STUDY DESIGN: Retrospective case series. ANIMALS: Client-owned dogs (n = 8). MATERIAL AND METHODS: Full-thickness mesh skin graft was directly covered with PVA foam. NPWT was maintained for 5 days (in 1 or 2 cycles). Grafts were evaluated on days 2, 5, 10, 15, and 30 for graft appearance and graft take, granulation tissue formation, and complications. RESULTS: Firm attachment of the graft to the recipient bed was accomplished in 7 dogs with granulation tissue quickly filling the mesh holes, and graft take considered excellent. One dog had bandage complications after cessation of the NPWT, causing partial graft loss. The PVA foam did not adhere to the graft or damage the surrounding skin. CONCLUSION: The application of NPWT with a PVA foam after full-thickness mesh skin grafting in dogs provides an effective method for securing skin grafts, with good graft acceptance. PVA foam can be used as a primary dressing for skin grafts, obviating the need for other interposing materials to protect the graft and the surrounding skin.

Minimally Invasive Drainage of a Post-Laminectomy Subfascial Seroma with Cervical Spinal Cord Compression.

A 14 mo old female neutered Doberman pinscher was evaluated for difficulty in rising, a wide based stance, pelvic limb gait abnormalities, and cervical pain of 2 mo duration. Neurologic examination revealed pelvic limb ataxia and cervical spinal hyperesthesia. Spinal reflexes and cranial nerve examination were normal. The pathology was localized to the C1-C5 or C6-T2 spinal cord segments. Computed tomography (CT) findings indicated bony proliferation of the caudal articular processes of C6 and the cranial articular processes of C7, resulting in bilateral dorsolateral spinal cord compression that was more pronounced on the left side. A limited dorsal laminectomy was performed at C6-C7. Due to progressive neurological deterioration, follow-up CT examination was performed 4 days postoperatively. At the level of the laminectomy defect, a subfacial seroma had developed, entering the spinal canal and causing significant spinal cord compression. Under ultrasonographic guidance a closed-suction wound catheter was placed. Drainage of the seroma successfully relieved its compressive effects on the spinal cord and the patient's neurological status improved. CT was a valuable tool in assessing spinal cord compression as a result of a postoperative subfascial seroma. Minimally invasive application of a wound catheter can be successfully used to manage this condition.

Intralaryngeal thyroarytaenoid lateralisation using the Fast-Fix 360 system: a canine cadaveric study.

INTRODUCTION: Laryngeal paralysis is a condition in which failure of arytaenoid abduction results in a reduced rima glottidis cross-sectional area. The most commonly performed surgical techniques rely on unilateral abduction of the arytaenoid, requiring a lateral or ventral surgical approach to the larynx. AIMS AND OBJECTIVES: The aim of the study was to investigate a novel minimally invasive intralaryngeal thyroarytaenoid lateralisation technique, using the Fast-Fix 360 meniscal repair system. MATERIALS AND METHODS: Larynges were harvested from large breed canine cadavers. With the aid of Kirschner wires placed between the centre of the vocal process and the centre of an imaginary line between the cranial thyroid fissure and the cricothyroid articulation, the mean insertion angle was calculated. RESULTS: The Fast-Fix 360 delivery needle inserted intralaryngeally (n=10), according to a simplified insertion angle (70°), resulted in thyroid penetration (>2.5 mm from margin) in all patients. The Fast-Fix was applied unilaterally at 70° with the first toggle fired on the lateral aspect of the thyroid cartilage and inside the laryngeal cavity on retraction. The suture was tightened. Preprocedural (61.06±9.21 mm2) and postprocedural (138.37±26.12 mm2) rima glottidis cross-sectional area was significantly different (P<0.0001). The mean percentage increase in rima glottidis cross-sectional area was 125.96 per cent (±16.54 per cent). CONCLUSION: Intralaryngeal thyroarytaenoid laterlisation using the Fast-Fix 360 meniscal repair system ex vivo increased the rima glottidis cross-sectional area significantly.

Bacterial colonization of the ovarian bursa in dogs with clinically suspected pyometra and in controls.

Septic peritonitis occurs relatively commonly in dogs. Secondary septic peritonitis is usually associated with perforation of intestines or infected viscera, such as the uterus in pyometra cases. The aim of this study was to evaluate the bacterial flora in the ovarian bursae of intact bitches as a potential source of contamination. One hundred forty dogs, clinically suspected of pyometra, were prospectively enrolled. The control group consisted of 26 dogs that underwent elective ovariohysterectomies and 18 dogs with mammary gland tumors that were neutered at the time of mastectomy. Bacteriology samples were taken aseptically at the time of surgery from the bursae and the uterus in all dogs. Twenty-two dogs that were clinically suspected of pyometra had sterile uterine content ("mucometra" cases); the remaining 118 had positive uterine cultures ("pyometra" cases) and septic peritoneal fluid was present in 10% of these cases. Of the 118 pyometra cases, 9 had unilateral and 15 had bilateral bacterial colonization of their ovarian bursae. However, the bacteria from the ovarian bursa were similar to those recovered from the uterine pus in only half of the cases. Furthermore, positive bursae were also seen in one mucometra dog (unilateral) and in four control dogs (two unilateral and two bilateral). The data illustrate that the canine ovarian bursa can harbor bacteria. The biological importance of these isolations remains unclear.

Laryngeal paralysis in dogs: an update on recent knowledge.

Laryngeal paralysis is the effect of an inability to abduct the arytenoid cartilages during inspiration, resulting in respiratory signs consistent with partial airway obstruction. The aetiology of the disease can be congenital (hereditary laryngeal paralysis or congenital polyneuropathy), or acquired (trauma, neoplasia, polyneuropathy, endocrinopathy). The most common form of acquired laryngeal paralysis (LP) is typically seen in old, large breed dogs and is a clinical manifestation of a generalised peripheral polyneuropathy recently referred to as geriatric onset laryngeal paralysis polyneuropathy. Diagnosing LP based on clinical signs, breed and history has a very high sensitivity (90%) and can be confirmed bylaryngeal inspection. Prognosis after surgical correction depends on the aetiology: traumatic cases have a good prognosis, whereas tumour-induced or polyneuropathy-induced LP has a guarded prognosis. Acquired idiopathic LP is a slow progressive disease, with dogs reaching median survival times of 3-5 years after surgical correction.

The effect of neuromuscular blockade on canine laparoscopic ovariectomy: a double-blinded, prospective clinical trial.

OBJECTIVE: To evaluate the effect of neuromuscular blockade (NMB) on surgical time and various anesthetic variables during laparoscopic ovariectomy in dogs. STUDY DESIGN: Prospective, double-blinded, randomized clinical trial. ANIMALS: Female dogs (n = 40). METHODS: Laparoscopic ovariectomy by bipolar electrocoagulation was performed by 1 surgeon using a standardized protocol, where 1 ovary was removed under NMB, and the other without NMB. Surgical and anesthetic (respiratory and circulatory) variables were recorded for predetermined procedural stages and were statistically evaluated. RESULTS: Mean total surgical time was 25.1 ± 6.3 minutes (range, 16-47 minutes). With NMB, mean duration of surgical excision of the ovary (5.7 ± 2.3 minutes) was not significantly changed compared to ovariectomy without NMB (5.9 ± 1.9 minutes). Arterial blood pressure was the only recorded anesthetic variable that significantly changed under NMB (5% decrease). Occurrence of intraoperative complications did not differ. In obese dogs, total surgical time was increased by 22%. Other variables, including occurrence of intraoperative mesovarial bleeding did not influence surgical duration. CONCLUSIONS: NMB did not significantly improve laparoscopic ovariectomy times and except for a 5% decrease in arterial blood pressure did not change any of the evaluated anesthetic and surgical variables.

Total venous inflow occlusion and pericardial auto-graft reconstruction for right atrial hemangiosarcoma resection in a dog.

A sizeable right atrial hemangiosarcoma in a 6-year-old Bordeaux dog, World Health Organization (WHO) stage 2, was excised using total venous inflow occlusion. The defect was restored with a non-vascularized pericardial auto-graft. The dog had a disease-free interval of 7 mo. The dog was euthanized 9 months later, at which time there were distant metastases but no indication of local recurrence.

Occlusion totale du remplissage veineux et reconstruction par autogreffe péricardique pour une résection d'un hémangiosarcome atrial droit chez un chien. Un hémangiosarcome atrial droit considérable chez un chien Dogue de Bordeaux âgé de 6 ans, stade 2 de l'Organisation mondiale de la santé (OMS), a été excisé en utilisant l'occlusion totale du remplissage veineux. Le défaut a été rétabli par une autogreffe péricardique non vascularisée. Le chien a connu une période de sept mois sans maladie. Le chien a été euthanasié 9 mois plus tard, lorsque des métastases distantes ont été décelées, mais sans indication d'une récurrence locale.(Traduit par Isabelle Vallières).

Pneumomediastinum and subcutaneous emphysema in a cat associated with necrotizing bronchopneumonia caused by feline herpesvirus-1.

This report describes a 1-year-old cat with acute dyspnea. Thoracic radiography revealed a pneumomediastinum and severe subcutaneous emphysema. Lower airway surgical exploration was unable to determine the cause. At postmortem examination, acute necrotizing bronchopneumonia and fibrinonecrotic tracheitis due to feline herpesvirus-1 were diagnosed.

Surgical resection of a mature teratoma on the head of a young cat.

A 4-month-old kitten was presented with a large mass over the temporal area involving the base of the left ear. Cytological evaluation of a fine-needle aspirate was not diagnostic. Computed tomography was used to determine tumor extent. Surgical resection was performed, which included parts of the orbital rim, masticatory muscles, the complete ear canal, and the pinna. Reconstruction of the ocular muscles was performed, and the skin defect was reconstructed using a single pedicle advancement flap. Despite unilateral facial paralysis, postoperative clinical function was excellent and aesthetics were good. Histological examination revealed the tumor to be a teratoma. After a follow-up period of 3 years, no signs of recurrence were evident. Extragonadal teratomas should be considered in the differential diagnosis when young animals are presented with a growing mass located outside the abdominal cavity. Surgical excision of a mature teratoma can be considered curative.

Making a rational choice between ovariectomy and ovariohysterectomy in the dog: a discussion of the benefits of either technique.

OBJECTIVE: To determine if ovariectomy (OVE) is a safe alternative to ovariohysterectomy (OVH) for canine gonadectomy. STUDY DESIGN: Literature review. METHODS: An on-line bibliographic search in MEDLINE and PubMed was performed in December 2004, covering the period 1969-2004. Relevant studies were compared and evaluated with regard to study design, surgical technique, and both short-term and long-term follow-up. CONCLUSIONS: OVH is technically more complicated, time consuming, and is probably associated with greater morbidity (larger incision, more intraoperative trauma, increased discomfort) compared with OVE. No significant differences between techniques were observed for incidence of long-term urogenital problems, including endometritis/pyometra and urinary incontinence, making OVE the preferred method of gonadectomy in the healthy bitch. CLINICAL RELEVANCE: Canine OVE can replace OVH as the procedure of choice for routine neutering of healthy female dogs.

Monopolar versus bipolar electrocoagulation in canine laparoscopic ovariectomy: a nonrandomized, prospective, clinical trial.

OBJECTIVE: To compare the effect of using monopolar (MEC) or bipolar electrocoagulation (BEC) on surgical time for laparoscopic ovariectomy in dogs and to evaluate the influence of age, weight and obesity, and estrus or pseudopregnancy on surgical time. STUDY DESIGN: Prospective, nonrandomized, clinical trial. ANIMALS: One hundred three female dogs. METHODS: Laparoscopic ovariectomy was performed with MEC or BEC by 1 surgeon using a standard protocol. Surgical time was recorded for the different procedural stages and was statistically evaluated for differences between MEC and BEC (chi(2), Student t test, and ANOVA). The influence of significant variables was analyzed using multiple linear regression analysis. RESULTS: Mean surgical time was 47 minutes (range, 27 to 110 minutes). With BEC, surgical time was significantly shorter (41 minutes; P <.001) than with MEC (53 minutes). Obesity (56 vs. 42 minutes; P <.001) and intraoperative mesovarial bleeding (56 vs. 46 minutes; P =.03) increased surgical time. Dog age, estrus, and pseudopregnancy did not significantly influence surgical time. CONCLUSIONS: BEC decreased laparoscopic ovariectomy time, decreased intraoperative hemorrhage, and, with the technique used, facilitated exteriorization of the ovaries. CLINICAL RELEVANCE: Laparoscopic ovariectomy can be performed more rapidly when using BEC instead of MEC and with less risk of mesovarial hemorrhage.