Conventional Total Laparoscopic Hysterectomy Research Articles

New surgery technique combining robotics and laparoscopy using the Hugo™ RAS system.

Hybrid total laparoscopic hysterectomy combines conventional laparoscopic surgery and robot-assisted devices: the camera and assistant forceps are operated by a robotic device, whereas the surgeon performs laparoscopic procedures, enabling surgery with a completely fixed field of view and significantly reducing errors in forceps grasping and needle misalignment. Here, we examined whether using two arms of the Hugo™ robot-assisted surgery system, one for the camera and one for the assistant, would improve surgical accuracy compared with conventional total laparoscopic hysterectomy. The surgical system reduced surgeon errors in grasping the forceps during training and stabilized forceps operation. Compared with conventional laparoscopic surgery, the use of the surgical system did not result in different operative durations. The stable surgical procedure was considered a major advantage. This new technique involving new equipment can improve surgeon training and performance. In the future, we will develop new techniques to improve surgical performance.

Total vNOTES hysterectomy versus conventional total laparoscopic hysterectomy in virgin transgender men

Background and aim Comparison of the applicability, safety, and surgical outcomes of total vaginal NOTES hysterectomy (TVNH) using natural orifice transluminal endoscopic surgery, which is considered a natural orifice surgery for hysterectomy with bilateral salpingo-oophorectomy (HBSO) in virgin transgender men, with conventional total laparoscopic hysterectomy (TLH). Material and methods A retrospective cohort study was conducted between 2019 and 2021. The results of transgender male individuals who underwent HBSO operations using TVNH (n = 21) were compared with those who underwent operations using TLH (n = 62). Results TVNH was performed in 21 individuals, while TLH was performed in 62 individuals. Patients in the TVNH approach group had a longer operation duration than those in the TLH group (p = .001). Patients in the TVNH group experienced less pain at two hours (5 ± 1.56), six hours (4 ± 1.57), 12 h (2 ± 0.91), and 24 h (1 ± 0.62) postoperatively (p = .001). The postoperative hospitalization duration was shorter in the TVNH group (1.6 ± 1.01) than in the TLH group (2.9 ± 0.5) (p = .001). Conclusions For the HBSO operation of female-to-male transgender individuals, TVNH, which is completely endoscopically performed, can be preferred and safely conducted as an alternative surgical method to conventional laparoscopy.

Comparison of surgical outcomes between robot-assisted and conventional laparoscopic hysterectomy for large uterus.

We compared the effectiveness of conventional total laparoscopic hysterectomy (TLH) against robot-assisted total hysterectomy (RAH) in patients with a large uterus. According to the subtype of minimally invasive hysterectomy performed for benign indications, the patients (n = 843) were grouped as follows: TLH (n = 340) and RAH (n = 503). The median operative time (OT) for TLH was 98min (47-406min), and the estimated blood loss (EBL) was 50mL (5-1800mL). The median OT for RAH was 90min (43-251min), and the EBL was 5mL (5-850mL), with a significantly shorter OT and a lower EBL in RAH than in TLH. Uterine weight was categorized into four groups in increments of 250g. The number of cases in each group was 163 (< 250g), 116 (250-500g), 41 (500-750g), and 20 (≥ 750g) for TLH, and 308 (< 250g), 137 (250-500g), 33 (500-750g), and 25 (≥ 750g) for RAH. In patients with a uterus < 250g, there was no significant difference in OT between TLH and RAH, but in patients with a uterus ≥ 250g, OT tended to be shorter with RAH, which was also true for a uterus ≥ 750g. The EBL was significantly lower with RAH compared to TLH, regardless of uterine weight. In patients with a large uterus, the advantages of robotic surgery can be utilized, which may lead to a shorter OT and less EBL.

Comparison of surgical outcomes between robot-assisted laparoscopic hysterectomy and conventional total laparoscopic hysterectomy in gynecologic benign disease: a single-center cohort study.

We compared the surgical outcomes of robot-assisted laparoscopic hysterectomy (RAH) and total laparoscopic hysterectomy (TLH). This single-center cohort study compared 139 RAH cases from January, 2017 to September, 2021 and 291 TLH cases between January, 2015 and December, 2020. We retrospectively evaluated surgical outcomes, including total operative time (defined as the time from port wound incision to port wound closure), net operative time (defined as the time from the start of pneumoperitoneum to the end of pneumoperitoneum), estimated blood loss, weight of excised uterus (±adnexa), and overall complications, and the relationship between surgeon experience and operative time, net operative time, and blood loss in RAH and TLH. There was no significant difference in the total operative time between the two groups. Regardless of surgeon experience, the net operative time was significantly shorter in the RAH group than in the TLH group (p <0.001) and the estimated blood loss was significantly lower in RAH cases than in TLH cases (p = 0.01). The net operative time per uterine weight was shorter in the TLH group than that in the RAH group; however, there was no significant difference. RAH resulted in statistically better surgical outcomes in terms of net operative time and blood loss, regardless of surgeon experience. However, net operative time and blood loss also seem to be significantly affected by uterus weight. Large trials are imperative to determine the more effective surgical approach between RAH and TLH for different patient subsets.

Laparoscopic Hysterectomy with Prior Uterine Artery Ligation versus Conventional Laparoscopic Hysterectomy

Background: Hysterectomy is one of the most commonly widespread gynecologic surgeries. Total Laparoscopic Hysterectomy (TLH) being a minimally invasive surgical technique has become the new trend.Aim of the work: The study aims at comparing TLH with previous ligation of the uterine artery at its origin, with conventional TLH regarding operative time, bleeding, intra-operative complications and postoperative follow up.Patients and Methods: Among 60 women, who are planned for TLH, 30 women experienced TLH with previous ligation of the uterine artery (group A) and the other 30 women underwent conventional TLH (group B).Results: The operative time of TLH in group A was significantly less than that in group B. Both blood loss and post-operative hospital stay in group A were less than those in group B, and there were no statistically significant differences between both groups. No major intra-operative or post-operative complications occurred in both groups.Conclusion: Total Laparoscopic Hysterectomy with Prior Uterine Artery Ligation at its origin is safe effective procedure and reducing the duration of surgery.

Comparison of Surgical Outcomes between Natural Orifice Transluminal Endoscopic Surgery for Hysterectomy and Conventional Total Laparoscopic Hysterectomy

Objective: To compare surgical outcomes between transvaginal natural orifice transluminal endoscopic surgery for hysterectomy (vNOTESH) and total laparoscopic hysterectomy (TLH) for the benign uterine diseases. Materials and Methods: A retrospective review of electronic medical records of women that underwent vNOTESH between January 2019 and June 2020 (n=33) and TLH between June 2017 and August 2019 (n=33) in Bangkok Hospital Udon, Udonthani Province, Thailand was carried out. Measurement outcomes included operative time, estimated blood loss, intra- and post- operative complications, and post-operative pain assessment. Results: One woman of the TLH group was excluded from the study because of severe adhesion. The mean age and BMI were not significantly different between the groups. There was no intra-operative complication in both groups. A median operative time was significantly shorter in the vNOTESH at 73 minutes (30 to 260 minutes than in the TLH at 140 minutes (75 to 296minutes), p&lt;0.0001]. Post-operative pain scores were significantly less in the vNOTESH than in the TLH. In addition, the number of women who needed the added analgesics were significantly less in the vNOTESH than the TLH groups at 6.1% versus 46.9% (p=0.001), respectively. However, the amount of blood loss and post-operative complication were not significantly different between the two groups. Conclusion: The present retrospective study demonstrated that the vNOTES is a feasible and safe procedure for hysterectomy in experienced hands and well-selected cases. This new technique is superior not only in taking less operative time and in achieving less postoperative pain, but also from the cosmetic aspect. Hence, it may be an alternative method for hysterectomy of the benign uterine diseases in the future. Keywords: Hysterectomy; Natural orifice transluminal endoscopic surgery (NOTES); Surgical outcomes; Total laparoscopic hysterectomy

Impact of ergonomic-friendly total laparoscopic hysterectomy on operative outcome among women with pre-invasive cervical cancer

Objective: As the field of minimally invasive surgery grows, laparoscopists are exposed to risk of developing musculoskeletal disease due to increase in physical workload. We sought to compare surgical outcomes among ergonomic-friendly total laparoscopic hysterectomy (EF-TLH) that aims to ease the physical workload of laparoscopists, conventional total laparoscopic hysterectomy (TLH), and total abdominal hysterectomy for pre-invasive cervical cancer without underlying benign condition in order to minimize biased outcome.

Robotic-assisted versus conventional laparoscopic hysterectomy for endometrial cancer.

ObjectiveThe safety and efficacy of robotic-assisted laparoscopic hysterectomy (RALH) compared with conventional total laparoscopic hysterectomy (TLH) for surgical staging of endometrial cancer has not been clearly established. With the commencement of a robotic program at our institution, our objective was to evaluate and compare the surgical outcomes of RALH with TLH for endometrial cancer.MethodsA retrospective cohort study was performed on 39 patients who underwent RALH and 41 patients who underwent TLH for endometrial cancer at a tertiary care academic institution.ResultsIn the setting of endometrial cancer RALH is significantly longer to perform than TLH (mean operating time 133 min vs 107 min, p = 0.0001). There is higher estimated blood loss in TLH cases than RALH cases (78 mL vs 22 mL, p = 0.015). Women who underwent RALH had a shorter length of stay (1.3 days vs 1.8 days, p = 0.006) than TLH patients, and six cases (15 %) of the RALH group were discharged on the same day of surgery. There were no differences between the RALH and TLH groups in intraoperative or postoperative complications and there were no conversions to laparotomy.ConclusionRALH is safe and feasible for the treatment of endometrial cancer, with low morbidity, less blood loss and shorter length of stay than TLH. RALH is associated with longer mean operating times than TLH and this may improve with enlisting a consistent experienced team. Prospective randomised studies which include analysis of quality of life measures and long-term outcomes are required to further establish the role of RALH in the surgical staging of endometrial cancer.

Postoperative Telephone-Based Questionnaire on Quality of Life after Robotic-Assisted Laparoscopic Hysterectomy versus Conventional Total Laparoscopic Hysterectomy.

Aim: The objective of the study was to evaluate the benefits of robotic-surgery for hysterectomy compared to conventional laparoscopy for benign indications. A specially prepared telephone-based questionnaire was used postoperatively. Method: All women (n = 155) undergoing total laparoscopic hysterectomy for benign indications either by the robotic-assisted procedure (RALH) or conventional laparoscopy (CL) between 1 January 2013 and 31 December 2017 at the Department of the Gynecology, University Hospitals, Campus Kiel, Germany, were eligible for analysis. Intra-operative and postoperative parameters affecting the patients’ quality of life were assessed by a telephone-based questionnaire. The latter addressed postoperative pain, limitations of basic hygiene, daily activity, active pursuit of hobbies, sexual intercourse, and days of sick leave. All patients received the questionnaire by post at least three weeks prior to being contacted on the phone. Results: 78% of the contacted patients responded to the questionnaire; 96% (n = 115) of the patients said they would recommend the operation to other patients. Both groups needed 42 days to resume their regular hobbies. In whole 90.8% (n = 108) were total satisfied with the cosmetic result of the abdominal incision; the numbers in the respective groups were 80% (80% n = 36) in RALH and 97.3% (n = 72) in CL. The difference was significant on the Chi-square test (p = 0.002). 5% (n = 7) were dissatisfied with the scar (13.3%; n = 6) in the RALH group, and 1.4% (n = 1) in CL. In all 1.7 % of patients were dissatisfied with the position of the incisions; the respective numbers were 4.4 % (n = 2) in the RALH group and no patient in the CL group. 33% of patients experienced no limitations in regard of sexual intercourse after the operation. The median number of days taken to resume sexual intercourse after the operation was 56 days in the CL group, and 49 days in the RALH group. Nearly 30% (n = 25) were hesitant to resume intercourse. The median operating time was 145 min in the RALH group, which was significantly longer than the 117 min taken in the CL group (p < 0.001). Conclusions: The RALH procedure was associated with some minor advantages for the patients according to the results, however it does not have major significant advantages, especially in regard of early restoration of sexual function, while the CL shows shorter operating times and similar limitation. Postoperative counseling of patients should be aligned to their fears and expectations in regard of sexual function.

Comparison of hysterectomy cases performed via conventional laparoscopy or vaginally assisted natural orifice transluminal endoscopic surgery: a paired sample cross-sectional study

Hysterectomy is one of the most frequent gynaecological procedures performed for various uterine pathologies. There are several approaches for conducting hysterectomies, including abdominal, vaginal, laparoscopic and robotic. Recently, natural orifices transluminal endoscopic surgery (NOTES) has emerged as an alternative approach for conducting hysterectomies. In this study, we aimed to compare the results of total laparoscopic hysterectomy (TLH) and vaginally assisted-NOTES (vNOTES) hysterectomy procedures for the treatment of benign gynaecological diseases. Ninety-nine patients, who underwent conventional TLH or vNOTES hysterectomies, were included in this study. The operation time, presence of per/postoperative complications, visual analogue scale (VAS) scores at postoperative sixth and 24th hours, and the duration of hospital stays were all analysed. The duration of surgery was significantly shorter in the vNOTES hysterectomy group (79.56 ± 32.54 min) compared to the TLH group (120.67 ± 38.35 min) (p: < .001). Also, postoperative hospital stays were significantly shorter in favour of the vNOTES hysterectomy group (44 ± 16.47 h) compared to the TLH group (57.86 ± 21.31 h) (p: .002). These results indicate that vNOTES hysterectomy can be a promising approach for treating a variety of different uterine pathologies and, furthermore, that it can be an alternative to TLH. Impact statement What is already known on this subject? A hysterectomy can be done in a variety of different ways, such as abdominal, laparoscopic, vaginal, and robotic. Even though the standard practice guidelines recommend that a vaginal hysterectomy (VH) should be the first choice of treatment, it can be challenging in cases of non-descendent and large uteruses. In such cases, NOTES hysterectomy can be an alternative option. What do the results of this study add? The study has shown that vNOTES is associated with a shorter operation and briefer postoperative hospitalisation time, in comparison to TLH. What are the implications of these findings for clinical practice and/or further research? This study speculates that vNOTES is an approach which may offer better outcomes than a conventional laparoscopy. Further randomised controlled trials with larger sample sizes, however, should be conducted in order to establish the place of vNOTES in hysterectomy surgeries.

Gasless Total Laparoscopic Hysterectomy with New Abdominal-Wall Retraction System.

Background and Objectives:Gasless laparoscopy is an alternative method to reduce the number of carbon dioxide (CO2)-insufflated, pneumoperitoneum-related problems including shoulder pain, postoperative nausea/vomiting, and decreased cardiopulmonary function. In this study, we investigated the feasibility of gasless total laparoscopic hysterectomy (TLH) with a newly developed abdominal-wall retraction system.Methods:Abdominal-wall retraction for gasless laparoscopy was performed using the newly developed J-shape retractor and the Thompson surgical retractor. Surgical outcomes between gasless TLH and conventional CO2-based TLH were compared for each of 40 patients for the period from January 2017 to October 2019.Results:Between gasless TLH and conventional CO2-based TLH, no significant differences were observed for age, body mass index, parity, or surgical indications. The mean retraction setup time from skin incision was 7.4 min (range: 4–12 min) with gasless TLH. The mean total operation times were 87.9 min (range: 65–170) with gasless TLH and 90 min (range: 45–180) with conventional TLH, which showed no significant difference. Estimated blood loss and uterus weight also showed no significant intergroup difference. No major complications related to the ureter, bladder, or bowel were encountered.Conclusion:Our new abdominal-wall retraction system for gasless TLH allowed for easy setup and a proper operation field in the performance of laparoscopic hysterectomy.

Utilization of Robot Assisted Hysterectomy for Benign Disease: An Institutional Review

Objective: To examine procedural indications, pathology results, surgical risk factors, and surgical complications for patients undergoing conventional total laparoscopic hysterectomy (TLH) versus robotic-assisted laparoscopic hysterectomy (RALH) at an academic institution.

Outcomes in women undergoing robotic-assisted laparoscopic hysterectomy compared to conventional laparoscopic hysterectomy at a tertiary hospital in Western Australia.

Robotic-assisted laparoscopic hysterectomy (RALH) is associated with improved outcomes compared to open surgery in patients with endometrial cancer but data are conflicting when comparing RALH to conventional total laparoscopic hysterectomy (TLH). In October 2014, a RALH program was established in Perth, Western Australia. To compare outcomes in patients undergoing RALH with a matched cohort undergoing TLH. A retrospective matched cohort study compared outcomes in 45 patients who underwent RALH with 45 controls who were patients treated with TLH. Mean operating time was longer in the RALH group compared to controls (75.42min vs 53.18min, mean difference 22.24min, P <0.001, 95% Cl, 11.07-33.42). No differences were observed in mean pain scores (RALH 1.47 vs TLH 1.84 P=0.31), mean parenteral and oral opioid use (RALH 14.3mg and 42.4mg vs TLH 17.5mg and 52.57mg, P= 0.42 and 0.42, respectively), and mean length of stay (RALH 1.51 vs TLH 1.67days, P=0.49). Two patients in the RALH group and one patient in the TLH group sustained iatrogenic bladder injuries (P=0.62). The establishment of the RALH program at our institution appeared to be associated with equivalent morbidity, post-operative pain, opioid use and length of stay compared to conventional laparoscopy. A surgical learning curve for RALH was observed. Well-designed prospective studies are needed to further evaluate short- and long-term patient function, morbidity, quality of life and oncologic outcomes.

Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy

BackgroundTo evaluate surgical outcome in a consecutive series of patients with conventional and robot assisted total laparoscopic hysterectomy.MethodsA retrospective cohort study was performed among patients with benign and malignant indications for a laparoscopic hysterectomy. Main surgical outcomes were operation room time and skin to skin operating time, complications, conversions, rehospitalisation and reoperation, estimated blood loss and length of hospital stay.ResultsA total of 294 patients were evaluated: 123 in the conventional total laparoscopic hysterectomy (TLH) group and 171 in the robot TLH group. After correction for differences in basic demographics with a multivariate linear regression analysis, the skin to skin operating time was a significant 18 minutes shorter in robot assisted TLH compared to conventional TLH (robot assisted TLH 92m, conventional TLH 110m, p0.001). The presence or absence of previous abdominal surgery had a significant influence on the skin to skin operating time as did the body mass index and the weight of the uterus.Complications were not significantly different. The robot TLH group had significantly less blood loss and lower rehospitalisation and reoperation rates.ConclusionsThis study compares conventional TLH with robot assisted TLH and shows shorter operating times, less blood loss and lower rehospitalisation and reoperation rates in the robot TLH group.

Laparoendoscopic Single-Site Hysterectomy: A Novel Method with New Medical Instruments

Objective: The aim of this research was to demonstrate the feasibility and safety of laparoendoscopic single-site surgery (LESS) for total laparoscopic hysterectomy (TLH). A laparoscope was used with a work channel and modified conventional laparoscopic instruments. Design: This was a prospective study. Materials and Methods: Between April 2010 and December 2014, LESS-TLH was performed in 80 patients with benign gynecologic conditions at the department of laparoscopic and endoscopic surgery, at the National Center for Minimal Access Surgery, in Havana, Cuba. Results: The mean age of the patients was 45 years (range 30–76 years), mean uterus weight was 225 g (100–482 g), mean operative time was 82 minutes (50–200 minutes), and mean blood loss 54 mL (10–400 mL). The postoperative hospital stay was <1 day. One patient experienced an intraoperative complication (bladder injury). There were two postoperative complications: 1 patient with a vault abscess 2 weeks after surgery and 1 patient with endometriosis had a ureter injury. No patients required transfusion during or after the laparoscopic procedure and there were two conversions to conventional TLH. Conclusions: This LESS-TLH technique proposed in this article seems to be a feasible and safe approach, with similar operative time, and without the disadvantages of loss of triangulation and clashing of instruments, compared with other LESS hysterectomy techniques. (J GYNECOL SURG 32:91)

Total Laparoscopic Hysterectomy With and Without Robotic Assistance

Hysterectomies are very common, and most of them are still performed abdominally. The minimally invasive alternatives are perceived as difficult by gynecologists. Robotic assistance is thought to facilitate laparoscopic surgery. The aim of this study was to compare the surgical outcomes of robotic-assisted and conventional total laparoscopic hysterectomy. Patients, candidate to hysterectomy for benign indications, were allocated to either robotic or conventional laparoscopy in a quasi-randomized fashion. Patients were operated following a standardized surgical protocol. Main outcome measures were total surgical time, conversions to laparotomy, blood loss, hospital stay, and complications. Fifty-one patients underwent robotic hysterectomy (mean age = 46.59 years) and 54 conventional laparoscopy (mean age = 50.02 years). The groups were homogeneous in body mass index and uterine weight. Robotic-assisted hysterectomies were significantly shorter (154.63 ± 36.57 vs 185.65 ± 42.98 minutes in the control group; P = .0001). Patients in the robotic group also had a significantly smaller reduction in hemoglobin (9.69% ± 8.88% vs 15.29% ± 8.39% in controls; P = .0012) and hematocrit (10.56% ± 8.3% vs 14.89% ± 8.11%; P = .008). No intraoperative conversions to laparotomy were required. Complication rate was low and similar in both groups. All patients were fully recovered at 1-month follow-up outpatient visit. Significantly lower operative times and blood loss indicate that robotic assistance can facilitate surgery already during the learning curve period. Nevertheless, proficiency can be reached in conventional laparoscopy through training, and the cost-effectiveness of robotic hysterectomy for benign conditions is yet to be confirmed.

Transumbilical single-port access versus conventional total laparoscopic hysterectomy: surgical outcomes

The objective of the study was to compare surgical outcomes and postoperative pain between transumbilical single-port access total laparoscopic hysterectomy (SPA-TLH) and conventional 4-port total laparoscopic hysterectomy (TLH). We retrospectively reviewed 157 patients who underwent SPA-TLH (n = 52) or conventional TLH (n = 105). A single-port access system consisted of a wound retractor, surgical glove, 2 5 mm trocars, and 1 10/11 mm trocar. The SPA-TLH group had less intraoperative blood loss (P < .001), shorter hospital stay (P = .001), and earlier diet intake (P < .001) compared with the conventional TLH group. There was no difference in perioperative complications. Immediate postoperative pain score was lower in the SPA-TLH group (P < .001). Postoperative pain after 6 and 24 hours was lower in SPA-TLH with marginal statistical significance. SPA-TLH is a feasible method for hysterectomy with lower immediate postoperative pain and better surgical outcomes with respect to recovery time compared with conventional TLH.

Needlescopic hysterectomy: incorporation of 3-mm instruments in total laparoscopic hysterectomy

Progression to needlescopic techniques for advanced gynecologic procedures currently performed with conventional laparoscopy still is in its infancy, and published series are currently lacking in the gynecologic literature. This study aimed to report initial experience with incorporating needlescopic instruments in the performance of total laparoscopic hysterectomy (TLH). The study group consisted of 32 consecutive women undergoing needlescopic hysterectomy. The control group included 54 women who underwent conventional TLH over the preceding 12-month period and met the same inclusion criteria as the study group. Conventional TLH was performed using 5-mm working ports and a 10-mm laparoscope. The needlescopic hysterectomy differed from the conventional laparoscopic procedure in that 3-mm working ports were used as well as a 3- or 5-mm laparoscope at the umbilicus. Otherwise, the trocar layout and surgical technique were identical. Parameters of technical feasibility (operating time, estimated blood loss, perioperative complications) were considered major statistical end points. In the study group, all but one procedure were performed successfully using the needlescopic approach. One patient in the needlescopic group required conversion to standard TLH because of uncontrollable bleeding from the uterine artery. The operative time and estimated blood loss of needlescopic hysterectomy were comparable with those of standard TLH. No significant complication occurred in either group. For properly selected patients, the needlescopic technique can be applied to TLH safely and effectively.

Supracervical laparoscopic hysterectomy (SCLH)

In 50 women without cervical pathology, a SCLH was performed with extraction of the uterus by means of a posterior colpotomy under endoscopic visual guidance. All cases were performed after a diagnosis of dysfunctional uterine bleeding or uterine leiomyomata and treatment with GnRH analogs for 3 months. Uterine fundal measurements ranged from 6-10 cm in greatest diameter. Results, including operating time, blood loss, subjective feelings of nausea, emesis, oral tolerance, and resumption of ambulation were all evaluated in the immediate postoperative period. All patients resumed their normal daily activities at 6 to 10 days postoperatively. A preliminary report addressing sexual function and satisfaction at 3 months postoperatively as compared with the preoperative period was developed. No difference in experience was noted. An economic evaluation was performed at the Clinica Ginemedex that revealed a 30% savings in terms of postoperative care and medication when performing a SCLH as opposed to the more conventional total laparoscopic hysterectomy (LH). SCLH appears to offer several advantages over total LH.