Journal of Plastic, Reconstructive & Aesthetic Surgery
Volume 62, Issue 3 , Pages 294-306 , March 2009

Evaluation of surgical procedures for sex reassignment: a systematic review

  • P.A. Sutcliffe

      Affiliations

    • School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
    • Corresponding Author InformationCorresponding author. Address: School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK. Tel.: +44 114 222 0869; fax: +44 114 272 4095.
  • ,
  • S. Dixon

      Affiliations

    • School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
  • ,
  • R.L. Akehurst

      Affiliations

    • School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
  • ,
  • A. Wilkinson

      Affiliations

    • School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
  • ,
  • A. Shippam

      Affiliations

    • School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
  • ,
  • S. White

      Affiliations

    • East Midlands Specialised Commissioning Group, Grove Park, Leicester LE19 1SS, UK
  • ,
  • R. Richards

      Affiliations

    • Derbyshire County PCT, Babington Hospital, Derbyshire DE56 1WH, UK
  • ,
  • C.M. Caddy

      Affiliations

    • Northern General Hospital, Herries Road, Sheffield S5 7AU, UK

Received 16 August 2006 ,Accepted 6 December 2007.

References 

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 1994.
  2. Harry Benjamin International Gender Dysphoria Association . Standards of care for gender identity disorders. 6th ed.. Düsseldorf: Symposium Press; 2001;
  3. Best L, Stein K. Surgical gender reassignment for male to female transsexual people. Development and Evaluation Committee Report No 88. Southampton: Wessex Institute for Health Research & Development; 1998;
  4. Scottish Needs Assessment Programme. Transsexualism and Gender Dysphoria in Scotland. 2001.
  5. van Kesteren PJ, Gooren LJ, Megans JA. An epidemiological and demographic study of transsexuals in the Netherlands. Arch Sex Behav. 1996;25:589–600
  6. Tsoi WF. The prevalence of transsexualism in Singapore. Acta Psychiatr Scand. 1988;78:501–504
  7. Landen M, Walinder J, Lundstrom B. Incidence and sex ratio of transsexualism in Sweden. Acta Psychiatr Scand. 1996;93:261–263
  8. Whittaker M, Black D, Wylie K, et al. Policy on Gender Dysphoria Services. 2005. Report No.: NORCOM Priorities Process, North Derbyshire Public Health Network.
  9. NHS Centre for Reviews and Dissemination . Undertaking systematic reviews of research on effectiveness: CRD's guidance for those carrying out or commissioning reviews. York: University of York; 2001;[Report No.: 4]
  10. Pfäfflin F, Junge A. Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961–1991. 1998.
  11. Fang RH, Chen CF, Ma S. A new method for clitoroplasty in male-to-female sex reassignment surgery. Plast Reconstr Surg. 1992;89:679–682
  12. Giraldo F, Esteva I, Bergero T, et al. Corona glans clitoroplasty and urethropreputial vestibuloplasty in male-to-female transsexuals: the vulval aesthetic refinement by the Andalusia Gender Team. Plast Reconstr Surg. 2004;114:1543–1550
  13. Rehman J, Melman A. Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male-to-female gender surgery: functional and cosmetic outcome. J Urol. 1999;161:200–206
  14. Hage JJ, Karim RB, Bloem JJ, et al. Sculpturing the neoclitoris in vaginoplasty for male-to-female transsexuals. Plast Reconstr Surg. 1994;93:358–364
  15. Hage JJ, Karim RB. Sensate pedicled neoclitoroplasty for male transsexuals: Amsterdam experience in the first 60 patients. Ann Plast Surg. 1996;36:621–624
  16. Krege S, Bex A, Lummen G, et al. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. 2001;88:396–402
  17. Rubin SO. Sex-reassignment surgery male-to-female. Review, own results and report of a new technique using the glans penis as a pseudoclitoris. Scand J Urol Nephrol Suppl. 1993;154:1–28
  18. Mate-Kole C, Freschi M, Robin A. A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals. Br J Psychiatry. 1990;157:261–264
  19. Hage JJ, Karim RB, van Diest PJ. Sparing a testis during vaginoplasty in male-to-female transsexuals: does it benefit our patients?. Plast Reconstr Surg. 2001;107:1772–1775
  20. Hirsch M, Lubetsky R, Goldman H, et al. Dorsal vein sclerosis as a predictor of outcome in penile venous ligation surgery. J Urol. 1993;150:1810–1813
  21. Harder Y, Erni D, Banic A. Squamous cell carcinoma of the penile skin in a neovagina 20 years after male-to-female reassignment. Br J Plast Surg. 2002;55:449–451
  22. Liguori G, Trombetta C, Buttazzi L, et al. Acute peritonitis due to introital stenosis and perforation of a bowel neovagina in a transsexual. Obstet Gynecol. 2001;97:828–829
  23. Siemssen PA, Matzen SH. Neovaginal construction in vaginal aplasia and sex-reassignment surgery. Scand J Plast Reconstr Surg Hand Surg. 1997;31:47–50
  24. Bodsworth NJ, Price R, Davies SC. Gonococcal infection of the neovagina in a male-to-female transsexual. Sex Transm Dis. 1994;21:211–212
  25. Cova M, Mosconi E, Liguori G, et al. Value of magnetic resonance imaging in the evaluation of sex-reassignment surgery in male-to-female transsexuals. Abdom Imaging. 2003;28:728–732
  26. Eldh J. Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals. Plast Reconstr Surg. 1993;91:895–900[discussion 901–3]
  27. Freundt I, Toolenaar TA, Huikeshoven FJ, et al. Long-term psychosexual and psychosocial performance of patients with a sigmoid neovagina. Am J Obstet Gynecol. 1993;169:1210–1214
  28. Freundt I, Toolenaar TA, Jeekel H, et al. Prolapse of the sigmoid neovagina: report of three cases. Obstet Gynecol. 1994;83:876–879
  29. Fugate SR, Apodaca CC, Hibbert ML. Gender reassignment surgery and the gynecological patient. Prim Care Update Ob Gyns. 2000;8:22–24
  30. Hage JJ, Karim RB. Abdominoplastic secondary full-thickness skin graft vaginoplasty for male-to-female transsexuals. Plast Reconstr Surg. 1998;101:1512–1515
  31. Hage JJ, Chami SZ, Edgerton MT. Conversion of the ‘kangaroo pouch’ neovagina to a skin inversion vaginoplasty in male-to-female transsexuals: Two unusual cases. Plast Reconstr Surg. 1998;101:445–452
  32. Hage JJ, Goedkoop AY, Karim RB, et al. Secondary corrections of the vulva in male-to-female transsexuals. Plast Reconstr Surg. 2000;106:350–359
  33. Hoebeke P, Selvaggi G, Ceulemans P, et al. Impact of sex reassignment surgery on lower urinary tract function. Eur Urol. 2005;47:398–402
  34. Jarrar K, Wolff E, Weidner W. Long-term outcome of gender reassignment in male transsexuals. Urologe A. 1996;35:331–337
  35. Karim RB, Hage JJ, Bouman FG, et al. Refinements of pre-, intra-, and postoperative care to prevent complications of vaginoplasty in male transsexuals. Ann Plast Surg. 1995;35:279–284
  36. Karim RB, Hage JJ, Cuesta MA. Rectosigmoid neocolpopoiesis for male-to-female transsexuals: Amsterdam experience. Ann Plast Surg. 1996;36:388–391
  37. Kwun KS, Hoon PJ, Cheol LK, et al. Long-term results in patients after rectosigmoid vaginoplasty. Plast Reconstr Surg. 2003;112:143–151
  38. Lemberger RJ, Bishop MC. Neovaginoplasty using rectosigmoid colon on a superior rectal artery pedicle. BJU Int. 2001;87:269–272
  39. Liguori G, Trombetta C, Bucci S, et al. Condylomata acuminata of the neovagina in a HIV-seropositive male-to-female transsexual. Urol Int. 2004;73:87–88
  40. Liguori G, Trombetta C, Bucci S, et al. Laparoscopic mobilization of neovagina to assist secondary ileal vaginoplasty in male-to-female transsexuals. Urology. 2005;66:293–298
  41. Loverro G, Bettocchi C, Battaglia M, et al. Repair of vaginal prolapse following penoscrotal flap vaginoplasty in a male-to-female transsexual. Gynecol Obstet Invest. 2002;53:234–236
  42. Maral T, Aygun C, Borman H. Management and prevention of ongoing peristaltic contractions of the neovagina following rectosigmoid neocolpopoiesis in male transsexuals. Plast Reconstr Surg. 2002;109:1667–1671
  43. Perovic S. Male to female surgery: a new contribution to operative technique. Plast Reconstr Surg. 1993;91:703–711
  44. Perovic SV, Stanojevic DS, Djordjevic ML. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. 2000;86:843–850
  45. Stein M, Tiefer L, Melman A. Followup observations of operated male-to-female transsexuals. J Urol. 1990;143:1188–1192
  46. Toolenaar TAM, Freundt I, Huikeshoven FJM, et al. The occurrence of diversion colitis in patients with a sigmoid neovagina. Hum Pathol. 1993;24:846–849
  47. Trombetta C, Liguori G, Bucci S, et al. Radiological evaluation of vaginal width and depth in male-to-female transsexuals by the use of magnetic resonance imaging. World J Urol. 2004;22:405–408
  48. Van Engeland AA, Hage JJ, van Diest PJ, et al. Colpectomy after vaginoplasty in transsexuals. Obstet Gynecol. 2000;95:1006–1008
  49. Van Noort DE, Nicolai J-P. Comparison of two methods of vagina construction in transsexuals. Plast Reconstr Surg. 1993;91:1308–1315
  50. Wedler V, Meuli-Simmen C, Guggenheim M, et al. Laparoscopic technique for secondary vaginoplasty in male to female transsexuals using a modified vascularized pedicled sigmoid. Gynecol Obstet Invest. 2004;57:181–185
  51. Blanchard R, Clemmensen L-H, Steiner B-W. Gender reorientation and psychosocial adjustment in male-to-female transsexuals. Arch Sex Behav. 1983;12:503–509
  52. Blanchard R, Legault S, Lindsay WRN. Vaginoplasty outcome in male-to-female transsexuals. J Sex Marital Ther. 1987;13:265–275
  53. Small MP. Penile and scrotal inversion vaginoplasty for male to female transsexuals. Urology. 1987;29:593–597
  54. Maas SM, Eijsbouts QA, Hage JJ, et al. Laparoscopic rectosigmoid colpopoiesis: does it benefit our transsexual patients?. Plast Reconstr Surg. 1999;103:518–524
  55. Karim RB, Hage JJ, Mulder JW. Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility. Ann Plast Surg. 1996;37:669–675
  56. Alberta Heritage Foundation for Medical Research. Vaginoplasty in Male-Female Transsexuals and Criteria for Sex Reassignment Surgery. 1997. Report No.: 25.
  57. Hage JJ, Karim RB, Bloemena E. Labial masses following vaginoplasty in male transsexuals: the differential diagnosis. Plast Reconstr Surg. 1996 May;97:1226–1232
  58. Saridogan E, Cutner A. The use of McCartney tube during total laparoscopic hysterectomy for gender reassignment: a report of two cases. BJOG. 2004;111:277–278
  59. Chapin DS. Laparoscopically assisted vaginal hysterectomy in female-to-male transsexuals. Plast Reconstr Surg. 1993;91:962
  60. Hage JJ, Dekker JJML, Karim RB, et al. Ovarian cancer in female-to-male transsexuals: Report of two cases. Gynaecol Oncol. 2000;76:413–415
  61. Lim SM. Surgery in transsexuals. Ann Acad Med Singapore. 1986;15:122–126
  62. Meyer R, Daverio PJ, Dequesne J. One-stage phalloplasty in transsexuals. Ann Plast Surg. 1986;16:472–479
  63. Ergeneli MH, Hakan DE, Ozcan G, et al. Vaginectomy and laparoscopically assisted vaginal hysterectomy as adjunctive surgery for female-to-male transsexual reassignment: preliminary report. Eur J Obstet Gynecol Reprod Biol. 1999;87:35–37
  64. Burcombe RJ, Makris A, Pittam M, et al. Breast cancer after bilateral subcutaneous mastectomy in a female-to-male trans-sexual. Breast. 2003;12:290–293
  65. Colic MM, Colic MM. Circumareolar mastectomy in female-to-male transsexuals and large gynecomastias: a personal approach. Aesthetic Plast Surg. 2000;24:450–454
  66. Hage JJ, Bloem JJ. Chest wall contouring for female-to-male transsexuals: Amsterdam experience. Ann Plast Surg. 1995;34:59–66
  67. Hage JJ, van Kesteren PJ. Chest-wall contouring in female-to-male transsexuals: basic considerations and review of the literature. Plast Reconstr Surg. 1995;96:386–391
  68. Hage JJ. Metaidoioplasty: an alternative phalloplasty technique in transsexuals. Plast Reconstr Surg. 1996;97:161–167
  69. Perovic SV, Djordjevic ML. Metoidioplasty: a variant of phalloplasty in female transsexuals. BJU Int. 2003;92:981–985
  70. Lebovic GS, Laub D. Metoidioplasty. In:  Ehrlich RM,  Alter GJ editor. Reconstructive and Plastic Surgery of the External Genitalia: Adult and Pediatric. Philadelphia: WB Saunders Co; 1999;p. 355–360
  71. Akoz T, Kargi E. Phalloplasty in a female-to-male transsexual using a double-pedicle composite groin flap. Ann Plast Surg. 2002;48:423–427
  72. Barrett J. Psychological and social function before and after phalloplasty. Int J Transgend. 1998;2:[Not paginated]
  73. Bettocchi C, Ralph DJ, Pryor JP. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 2005;95:120–124
  74. Cavadas PC, Landin L. Treatment of urethral stricture in a female-to-male transsexual with a tubulized flap from the labia minora. J Reconstr Microsurg. 2005;21:153–156
  75. Chesson RR, Gilbert DA, Jordan GH, et al. The role of colpocleisis with urethral lengthening in transsexual phalloplasty. Am J Obstet Gynecol. 1996;175:1443–1449[discussion 1449–50]
  76. Chivers ML, Bailey JM. Sexual orientation of female-to-male transsexuals: a comparison of homosexual and nonhomosexual types. Arch Sex Behav. 2000;29:259–278
  77. Fang R-H, Kao Y-S, Ma S, et al. Glans sculpting in phalloplasty – experiences in female-to-male transsexuals. Br J Plast Surg. 1998;51:376–379
  78. Fang RH, Kao YS, Ma S, et al. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999;52:217–222
  79. Fisch M, Wammack R, Ahlers J, et al. Osseous fixation of a penile prosthesis after transsexual phalloplasty: a case report. J Urol. 1993;149:122–125
  80. Hage JJ. Dynaflex prosthesis in total phalloplasty. Plast Reconstr Surg. 1997;99:479–485
  81. Hage JJ, Bouman FG. Silicone genital prosthesis for female-to-male transsexuals. Plast Reconstr Surg. 1992;90:516–519
  82. Hage JJ, Monstrey S. Free-flap distal arteriovenous fistula: when to close it?. J Reconstr Microsurg. 1998;14:407–410
  83. Hage JJ, Winters HAH. Salvage of a ‘free flap’ phalloplasty by distal arteriovenous fistula: case report. J Reconstr Microsurg. 1996;12:279–282
  84. Hage JJ, Bouman FG, Bloem JJ. Preconstruction of the pars pendulans urethrae for phalloplasty in female-to-male transsexuals. Plast Reconstr Surg. 1993;91:1303–1307
  85. Hage JJ, Bouman FG, Bloem JJ. Construction of the fixed part of the neourethra in female-to-male transsexuals: experience in 53 patients. Plast Reconstr Surg. 1993;91:904–910
  86. Hage JJ, Bouman FG, de Graaf FH, et al. Construction of the neophallus in female-to-male transsexuals: the Amsterdam experience. J Urol. 1993;149:1463–1468
  87. Hage JJ, Bout CA, Bloem JJAM, et al. Phalloplasty in female-to-male transsexuals: What do our patients ask for?. Ann Plast Surg. 1993;30:323–326
  88. Hage JJ, de Graaf FH, Van den HJ, et al. Phallic construction in female-to-male transsexuals using a lateral upper arm sensate free flap and a bladder mucosa graft. Ann Plast Surg. 1993;31:275–280
  89. Hage JJ, Winters HA, Van LJ. Fibula free flap phalloplasty: modifications and recommendations. Microsurgery. 1996;17:358–365
  90. Hoebeke P, De CG, Ceulemans P, et al. Obtaining rigidity in total phalloplasty: experience with 35 patients. J Urol. 2003;169:221–223
  91. Gilbert DA, Horton CE, Terzis JK, et al. New concepts in phallic reconstruction. Ann Plast Surg. 1987;18:128–136
  92. Jarolim L. Surgical conversion of genitalia in transsexual patients. BJU Int. 2000;85:851–856
  93. Khouri RK, Young VL, Casoli VM, et al. Long-term results of total penile reconstruction with a prefabricated lateral arm free flap. J Urol. 1998;160:383–388
  94. Lief HI, Hubschman L. Orgasm in the postoperative transsexual. Arch Sex Behav. 1993;22:145–155
  95. Noordanus RP, Hage JJ. Late salvage of a ‘free flap’ phalloplasty: A case report. Microsurgery. 1993;14:599–600
  96. Papadopulos NA, Schaff J, Biemer E. Usefulness of free sensate osteofasciocutaneous forearm and fibula flaps for neophallus construction. J Reconstr Microsurg. 2001;17:407–412
  97. Papadopulos NA, Schaff J, Biemer E. Long-term fate of the bony component in neophallus construction with free osteofasciocutaneous forearm or fibula flap in 18 female-to-male transsexuals.[see comment]. Plast Reconstr Surg. 2002;109:1025–1030[discussion 1031–2]
  98. Rachlin K. Factors which influence individual's decisions when considering female-to-male genital reconstructive surgery. Int J Transgend. 1999;3:
  99. Santanelli F, Scuderi N. Neophalloplasty in female-to-male transsexuals with the island tensor fasciae latae flap. Plast Reconstr Surg. 2000;105:1990–1996
  100. Santi P, Adami M, Berrino P, et al. Neophalloplasty using a rectus abdominis muscle flap and a radial forearm free flap. Eur J Plast Surg. 1992;15:94–97
  101. Vesely J, Barinka L, Santi P, et al. Reconstruction of the penis in transsexual patients. Acta Chir Plast. 1992;34:44–54
  102. Vesely J, Kucera J, Hrbaty J, et al. Our standard method of reconstruction of the penis and urethra in female to male transsexuals. Acta Chir Plast. 1999;41:39–42
  103. Vesely J, Prochazka V, Valka J, et al. Use of two microsurgical flaps in one stage reconstructive surgery. Acta Chir Plast. 1994;36:99–103
  104. Zielinski T. Phalloplasty using a lateral groin flap in female-to-male transsexuals. Acta Chir Plast. 1999;41:15–19
  105. Zielinski T. Evaluation of surgical flaps used for creation of an artificial penis in female-male type transsexuals. Pol Merkur Lekarski. 2001 Jan.;10:27–30
  106. Alberta Heritage Foundation for Medical Research. Phalloplasty in Female-Male Transsexuals. 1996. Report No.: 9.
  107. Byun JS, Cho BC, Baik BS. Results of one-stage penile reconstruction using an innervated radial osteocutaneous flap. J Reconstr Microsurg. 1994;10:321–331
  108. Dabernig J. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 2005;96:1422–1423
  109. Hage JJ. Phalloplasty for female transsexuals. Microsurgery. 1994;15:895
  110. Hage JJ, Bloem JJ. Review of the literature on construction of a neourethra in female-to-male transsexuals. Ann Plast Surg. 1993;30:278–286
  111. Hage JJ, de Graaf FH. Addressing the ideal requirements by free flap phalloplasty: some reflections on refinements of technique. Microsurgery. 1993;14:592–598
  112. Hage JJ, Bloem JJ, Bouman FG. Obtaining rigidity in the neophallus of female-to-male transsexuals: a review of the literature. Ann Plast Surg. 1993;30:327–333
  113. Hage JJ, Bloem JJ, Suliman HM. Review of the literature on techniques for phalloplasty with emphasis on the applicability in female-to-male transsexuals. J Urol. 1993;150:1093–1098
  114. Mulcahy JJ. Use of penile implants in the constructed neophallus. Int J Impot Res. 2003;15:S129–S131
  115. Rohrmann D, Jakse G. Urethroplasty in Female-to-Male Transsexuals. Eur Urol. 2003;44:611–614
  116. Futterweit W, Deligdisch L. Histopathological effects of exogenously administered testosterone in 19 female to male transsexuals. J Clin Endocrinol Metab. 1986;62:16–21
  117. Sengezer M, Sadove RC. Scrotal construction by expansion of labia majora in biological female transsexuals. Ann Plast Surg. 1993;31:372–376
  118. Hage JJ, Taets van Amerongen AH, van Diest PJ. Rupture of silicone gel filled testicular prosthesis: causes, diagnostic modalities and treatment of a rare event. J Urol. 1999;161:467–471
  119. Hage JJ, Bouman FG, Bloem JJ. Constructing a scrotum in female-to-male transsexuals. Plast Reconstr Surg. 1993;91:914–921
  120. Ozgur F, Ozcan G. Re: Scrotal construction by expansion of labia majora in biological female transsexuals. Ann Plast Surg. 1995 Apr.;34:451
  121. Aggressive Research Intelligence Facility. Gender Reassignment Surgery. 2004.
  122. Brown GR. A review of clinical approaches to gender dysphoria. J Clin Psychiatry. 1990;51:57–64
  123. Day P. Trans-gender reassignment surgery. NZHTA Tech Brief Report 2002 Vol. 1 No 1. Christchurch: New Zealand Health Technology Assessment (NZHTA); 2002;
  124. Lundstrom B, Pauly I, Walinder J. Outcome of sex reassignment surgery. Acta Psychiatr Scand. 1984;70:289–294
  125. Paul A, Thompson S. Policy on Gender Identity Disorder Service. 2005.
  126. Bockting W, Robinson B, Benner A, et al. Patient satisfaction with transgender health services. J Sex Marital Ther. 2004;30:277–294
  127. Landen M, Walinder J, Hambert G, et al. Factors predictive of regret in sex reassignment. Acta Psychiatr Scand. 1998;97:284–289
  128. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32:299–315
  129. Smith YLS, Van Goozen SHM, Kuiper AJ, et al. Sex reassignment: Outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med. 2005;35:89–99
  130. Rakic Z, Starcevic V, Maric J, et al. The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes. Arch Sex Behav. 1996;25:515–525
  131. Bouman FG. Sex reassignment surgery in male to female transsexuals. Ann Plast Surg. 1988 Dec.;21:526–531
  132. Frederick RW, Leach GE. Abdominal sacral colpopexy for repair of neovaginal prolapse in male-to-female transsexuals. Urology. 2004;64:580–581
  133. Cairns TS, de VW. Vaginoplasty. S Afr Med J. 1980;57:50–55

PII: S1748-6815(07)00663-8

doi: 10.1016/j.bjps.2007.12.009

Journal of Plastic, Reconstructive & Aesthetic Surgery
Volume 62, Issue 3 , Pages 294-306 , March 2009