Original subtitles

Emergency case has just arrived at Glasgow's state -of -the -art vet

Medical clinician Gerard McLaughlin is called to reception.

Barry Crawford's one -year -old Whippet Indy is weak and struggling to breathe.

Over the past few days, he's been kind of slowly going downhill, finding it

hard to breathe. So we've brought him up from Ayrshire this morning and he's

just got himself.

Hi, Mr Crawford. Nice to meet you. I'm Jeremy. Do you want to come through with

Indy?

Indy's local vets have found fluid on his lungs.

I think we'll have him into our ICU because he's obviously not feeling great

if he's deteriorating, then we want him somewhere he's watched 24 hours a day

just in case there's any need for oxygen or he merited the drainage of the fluid

from his chest.

Indy's been with Barry and Laura since he was eight weeks old.

We don't have kids just now, so our dogs are, our children, everybody in the

family. We're all dog owners, so when something does go wrong with one of the

dogs, everyone's there, the whole family's there.

A genuine bleed isn't the best place. You could bleed just now and we'll do

everything we can.

Indy may have haemothorax, bleeding in the chest cavity.

Blood tests may help Gerard diagnose the problem.

This is Indy. It's an infected chemo thorax in the vets.

I'm slightly reluctant to put a needle into the jug of veins, so we'll just

it from a personal site.

We'll just send the bloods up as an emergency and the coagulation panel, and

we'll just get a quick chest x -ray on him just now, just to make sure that

there's not a huge amount of fluid in his chest and he's drained off quickly.

The x -ray results are startling.

Indy's fluid build -up is accelerating.

There's a lot of fluid in the chest here and you can see these air bronchograms

which can indicate that the lungs are much more solid than they should be so

that can be hemorrhaged into the tissue.

Indy's left lung is barely functioning.

Instead of being air -filled, it's either fluid -filled or soft tissue

So it's a basically solid lump rather than functioning as an air sac.

And then over this side, there's these small beckles of air trapping in the

field, and you can often see that if the lung has twisted on itself.

When we compare it to the vet's x -ray taken 48 hours ago, there's a different

progression of that consolidation.

Indy recently ran into a nail.

It's possible this may have caused internal bleeding.

Coupled with the history of trauma in that area from Indy, then I think it

become a case where surgical intervention is required because we have

reason why the dog is oozing or bleeding into the chest.

The blood build -up could force Indy's lung to collapse.

Gerard's called in surgeon Catherine Pratchka.

She'll need to operate soon.

I'll go and put up to pass and we'll get this.

Perfect. Get that organised and lined up.

Catherine's a specialist in small animal surgery.

She's wanted to be a vet since her school days.

We always had animals around when we were growing up. I suppose that's just

always been what I would consider that completely normal. I can't imagine not

having animals around.

I really like them as well.

I really enjoy working with them.

So it's kind of a bonus that I get to do that as part of the job.

Indy's taken to intensive care to be closely monitored before Catherine

on him.

In reception, another difficult case has just arrived.

Lindsay and Gary's cat, Oti, has been badly injured.

Oti's our youngest of three cats.

Oti's the only one that we've had since she was a kitten. She's two and a half

years old.

We went and got her just after she was born, so we're hopeful that we'll be

to do something today.

She was out on Friday night and came in the house and had been in some sort of

an accident where she was hurt.

Something's caused her tail to be pulled very, very hard away from her back.

I think it's just that we don't know what actually happened to her.

It's just such a shock.

Oti's broken tail is an unusual and serious injury.

It may have got trapped under a car wheel.

The specialists here are her last hope.

If coming up here wasn't an option, I think, unfortunately, the answer at the

moment would probably have been to put her to sleep.

So we're trying to see what can be done.

Mr and Mrs Templeton, hi.

I'm Alison.

Nice to meet you.

American animal neurologist Allison Haley is taking on the case.

First, she checks the x -rays from the local vets.

This is her spine right here. These are her vertebrae.

And, yeah, I mean, it's fairly obvious the abnormality here. So we have the

sacral vertebrae here, and there's a complete avulsion of her tail.

And then we have another view that is her laying on her back.

Here are her lumbar vertebrae, the bones of the spine.

This is her pelvis here.

These are her legs, so her thigh bone or her femur.

So this is her tail here.

This is the first bone of her tail. This is one of her bones of her tail as

well, so these two should be connected.

So they've been completely pulled apart from each other.

That's pretty remarkable.

Sorry for your cat.

Oti's injury is an extreme case.

The nerves she uses to urinate and defecate may also have been damaged.

Did she use the restroom at night at all for you? No, she's drank a lot of water

since she's been at home, but she didn't use the litter tree at all.

Alison needs to find out the full extent of Oti's injuries.

Gary and Lindsay may have to make a heartbreaking decision.

Indy's lung problems will pose a challenge during his surgery.

He could become apneic, where he stops breathing.

Anaesthetist Sean briefs his team.

We never inject anaesthetic drugs into a catheter you can't see, so always take

advantage of it.

So that we don't overdo it, you need to aim to give your calculated dose.

Over two minutes.

None of this treating it like thio and giving half the dose and then topping it

up, because that's how we're going to get an apneic dog. And if she's got poor

lung function anyway, she's not going to be able to cope with apnea.

Indy's operation is risky, but his life depends on it.

He's such a lovely little dog. You know, I can't wait to get him home. The house

isn't the same without him.

There's not a memory of the family just now, though. I wasn't worrying about

him.

Coming up, Alison's examination of Oti reveals a serious problem.

She's not responding to me pinching on her.

And when Catherine operates on Indy, she's astonished by what she finds.

It's amazing we're still doing as well as it is.

That's really pretty severe.

At Glasgow's Vet Hospital, neurologist Alison Haley is examining family cat

Oti's broken tail.

The store owner, Gary and Lindsay, brought her here when their own vet

help.

We're going to bang on her knees and stuff to check her reflexes.

So she's got a great reflex, which is good.

So we're just seeing if she has a withdrawal reflex.

And she doesn't like it, so she can both feel it as well as withdraw.

And then what we do is we ask her if she knows where her limbs are in the face.

Good girl.

I'm going to try to stay away from her back end because I don't want to hurt

her. And she does really well in her back legs as well.

Ellen, do you mind putting a hand on her front end?

I'm just going to try to do placing in her back legs if she'll let me.

Hi, good girl.

You're okay.

So again, does really well in the back legs as well.

Now, Allison needs to check whether Ozie has nerve damage which would make her

incontinent.

This is her anus right here, which is...

She doesn't have a great tone, but it's not awful.

And for perineal reflex, I just kind of go down on either side and see if she

winks. She's not winking that well.

You can kind of test anal tone there, too. Like, she's very easy to open.

Normally,

if I pinch around it, it...

squeezes tight or if i even just so much as tickle down it it'll squeeze tight

so that's the winking of the anal reflex or the perineal reflex which she just

she doesn't have any this is not good news ot could be permanently

incontinent she's not peeing on her own right now her bladder is quite big where

we go from here is somewhat up to you guys. There is a percentage of cats that

might get better. So if you wanted to kind of deal with her for a month, you

could. But I would say that it's not a great percentage of cats that get

So it's very much up to what you guys think you can handle. It's not easy to

teach you how to express a bladder, but it's doable.

So we could definitely teach you how to do that so you could manage her.

And then more importantly, do you want some time to talk and think?

I know you adore her, it's obvious, and want the best for her.

Okay.

So we want to give her a month and see what we can do. Okay.

Before they take Oti home, Gary and Lindsay will be taught how to empty her

bladder three times a day so they can manage her incontinence.

Over in the equine centre, clinician Mike Cathcart is happy to leave the

treatment of smaller animals to colleagues like Alison.

I like working with very large horses, and I don't like working with cats,

tend to scratch and bite a lot more.

And then it's even worse when you get down to the small animals like hamsters

and mice and things. I always find that they're more likely to bite me, so I'm

always more scared of a hamster than I am of a 500kg horse.

But Mike may have his work cut out with new patient Rosie, who's suddenly

started being aggressive.

Owners Anne and David hope Mike can cure her.

Hopefully we'll be able to ride her a bit more, maybe take a fall off her next

year, and she'll maybe stop her bad behaviour.

We will with her.

Anne's been worried by Rosie's change of temperament.

Mike suspects

Rosie's behaviour may be due to hormone trouble caused by problems with her

ovaries. She has previously already had hormone testing, which has shown that

the hormone levels are increased.

And a scan was done last week, which indicated that the right ovary was

and was also abnormal.

I'm currently just feeling the ovaries.

You can tell if they're enlarged above the normal expectation.

In normal mares, you can often feel for...

Follicles, which are the structures which will produce the egg when they

ovulate.

Good girl.

Okay.

Mike's hand examination is inconclusive.

He'll need to scan Rosie's ovaries using ultrasound.

In the outpatient's department, Alison shows Gary how he can empty Rosie's

bladder at home.

So if you feel right here, right there, can you feel her ribs?

Yeah. Okay.

So then what I try to do is kind of make my hands soft and flat and go right

behind the ribs. And the belly is, unlike ours, is fairly pliable. So you

almost push your fingers together and touch your fingers through her belly.

So just back and forth, you kind of feel that water balloon.

So some gentle pressure on that.

I know, you're purring. You're such a good cat.

You're doing great.

Gary has mastered the art.

Even though the news hasn't been all good today, it's still a relief for Gary

and Lindsay to be taking Oti home for now.

From what our vet said, it was... Very bleak was the way that she put it. And

she doesn't really hold out much hope for Oti.

But we knew that this place was here.

And we asked her if we could have her referred because we just wanted to know

that we'd done everything that we could.

So from what Alison has said, it's made us feel much better because if we can

give her a month, we know that the nerve damage could heal. There's a

possibility. And it means that we can kind of look after her at home. We would

be really happy to do that.

Alison is impressed by Gary and Lindsay's determination to do everything

can for OT.

The cats sometimes, you know, they're so independent, just are not interested in

having their urine expressed.

If she were human, we could explain to her that we need to keep her bladder

empty and manage her bladder in a different factor. It's just a little bit

different when it's a cat. So whether or not she has a good quality of life is

very much going to be up to her owners.

surgeon Catherine Pratchka knows Indy's operation is going to be a challenge.

You can't be completely certain what you're going to find, so there's always

element of being prepared for finding something unexpected, which is part of

reason for doing the approach that gives you the best access and best view.

And hopefully we'll be able to...

They get to the bottom of the problem and do something about it because there

clear signs of progression in the last few days.

And if she were to continue to bleed or have another large bleed, then

potentially that could be quite serious for her.

Sorry, him. I keep saying her.

Indy is a boy.

He's a really nice dog. I hope we're not going to get any nasty surprises.

When the operation starts...

It doesn't take long for Catherine to find out why Indy's been struggling to

breathe.

Nearly two -thirds of Indy's blood supply has leaked into his chest.

Yeah, that explains an awful lot.

That fits with how hard I'm having to ventilate here.

It's amazing we're still doing as well as he is.

That's really pretty severe.

We've got hemorrhage into the mucous spinal cord there as well.

You've got the heart there. I'm not likely handling it.

I'm going to have to suction this blood out, Sean, so they can see what I'm

doing. The tissues around Indy's left lung are engorged with blood.

We've got these two pieces of tissue that are just grossly, grossly

abnormal lung.

It literally looks like either spleen or liver would normally look. This is your

classic description of either congested or collapsed lung lobes, and it's really

solid.

A dog's lungs are divided into seven parts called lobes.

Somehow, one of Indy's lobes has got twisted.

Look at that.

See that? See that twist?

360 degrees, literally like someone's taken the lungs and twisted them.

A couple of times we can actually see where they wrap around.

The twist means blood was able to flow into the lobe but couldn't flow out.

It's become so full of blood it's ruptured, flooding in his chest and

difficult for him to breathe.

It's literally like someone caught it and did that a few times, so it's sort

fun. He's still getting arterial blood pumping in, so that's also partly where

she's lost blood too.

Katherine tries to find the cause of Indy's twisted lung.

He recently ran into a nail which may have contributed to the internal bleed.

The affected lobe is full of necrotic tissue and toxins.

We untwist that. We dump the whole lot into the circulation right beside the

heart and it would probably be enough to kill her.

Catherine will use staples to seal the twisted lobe off from the rest of the

lung.

Then she will carefully remove it.

Coming up.

Rosie's ultrasound scan reveals a problem.

A normal ovary would have rounded follicle, but Rosie has lots and lots of

and they are irregular in shape.

And Indy develops complications and needs an urgent blood transfusion.

I'm going to give him transfusion so he's got some blood going red. Fabulous.

There's some heifer and saline on the front of my anaesthetic machine.

Clutch the two arms of the connector, that would be good.

Catherine's finished stitching up Indy's left lung.

To make sure there aren't any leaks and the lung is airtight, sterile saline is

poured into the chest cavity.

It's exactly the same principle as if you're checking your bicycle car for a

puncture.

You submerge the site where you've done the lobectomy, submerge it under sterile

saline, and then you watch for streams and bubbles as they're being ventilated.

So that tells you whether you've got a secure scene or not.

But the other reason that I'm using a larger volume of saline is that there's

old, sort of little bits of captive inflammatory tissue and sort of small

of blood stuck in there, which are...

because this has probably been going on for a couple of days, so I want to get

as much of that out as I can as well.

We don't need cold saline because we don't want to drop the body temperature,

but we also don't want to put saline that's too hot straight into the chest.

Catherine's removed 15 % of Indy's lungs.

A dog can live a normal life even if more than half of its lungs are taken

so Indy should be fine.

We're spontaneously breathing and we're holding our own.

Not too wet either.

Indy's stitched -up lung doesn't have any leaks, but he isn't out of the woods

yet.

Catherine's still not sure what caused the twist.

Spontaneous lung load torsion would be very unusual in this freeze, so we just

need to make absolutely sure there isn't something else as an underlying disease

that we would need to know about for treatment.

The twisting, or torsion, could be caused by cancer.

A biopsy is being taken.

Hopefully it'll just confirm the sort of changes you'd expect to see with

vascular congestion.

So we hope.

Come over here then, chaps.

Thank you.

Hello,

honey. I know, you've got a big floppy thing on your ear.

It's not a brief one, is it?

Indy is also at risk of pneumonia post -surgery, so he'll be closely monitored

in intensive care.

Mike's carrying out an ultrasound on Rosie, the Highland pony who's behaving

aggressively.

The scan has revealed benign tumours in her right ovary.

What we can see on the screen here is the ovary, a normal ovary which has

rounded follicles.

But Rosie has lots and lots of areas, and they are irregular in shape.

These tumours tend to have what we describe as a polyphistic appearance, so

there are multiple, lots of little cysts that we can see all through here.

Next, Mike scans Rosie's left ovary.

If it also has tumours, she won't be able to fall, which will be a real

disappointment to Rosie's owners, who have high hopes of breeding from her.

This follicle does seem to be regretting, which is what we would

ovary to do at this time of year.

Rosie's left ovary may be fine, but her right one is riddled with tumours and

needs removing as soon as possible.

Over in the outpatients' department, Dalmatian breeder Heather Shepherd has

brought in nine spotty puppies for a hearing test.

It's neurology nurse Gillian Calvo's favourite job.

I like to think that out there in Scotland and the north of England and

there are pups that are running around that, you know, because of the service

that we provide here in the hospital, you know, we're able to ensure that as

many of them out there are hearing.

How have they travelled? All right?

Yes, fine. Yeah, they're all OK?

Hi, monkey!

Are you ready?

What do you think?

And it is fun. You don't really get to deal with very many pups on such a cute

level and such a mass number. So I think it's probably one of my jobs in

particular that a lot of the other staff are probably a little bit envious of,

that once a week you get to hug lots of little puppies.

There we go, wee monkeys.

Well done.

About a third of Dalmatians have hearing problems.

Deaf puppies may be hard to pick out amongst their littermates because they

mimic their siblings' behaviour, fooling even experienced breeders like Heather.

Do you want to do the girls first? There's only three of them.

And they're not registered just yet, so just complete your documentation once

you're back. That's fine. I'll just get them all registered on here.

Hello, wee one! Have you got a wee name that we call you yet?

This wasn't new. No?

Oh, dear.

I'll just call you Bumpkin for the purpose of today, then.

Right, wee monkey -moo.

Right, we need to put this under your skin. I'm sorry. It's no nice.

Ooh!

Well done.

Good job.

So we're just placing, for us to be able to perform the test, we have to put

little electrodes beneath our skin.

And they're just very, very small little needle electrodes here. They're no more

broad really than an acupuncture needle and they're very short. And we have to

position these in three areas around the head.

So the first one just goes at the back of the neck.

The other one just goes just between the eyes at the top of the head.

And then we put the third one either on the front of the left ear or on the

right ear, depending on which ear we're testing. So we always start with the

left ear first.

Ah, good girl. Well done.

You're very brave.

Right, so it's really important now to try and keep her as still as we can so

that she doesn't pull all these wee electrodes out.

There we go.

Deaf puppies can't hear danger coming.

which makes them more vulnerable.

It's recommended they're not used for breeding.

Right, wee one. So you need this wee earphone to go over your... Oh, you're a

monkey.

You got it out already?

Deary me.

Doing very well.

There you go.

Right, and put your other wee one on there.

Don't share.

OK.

So now what we do is we just basically play a little stimulus.

into the ears and we're looking at the computer system to see the trace that

we've got coming up on the screen and what we basically don't want is a flat

line we want nice peaks and troughs and each one of these peaks and troughs

represent a different part of the pathway from the external ear all the

through to the brain and so far on the left ear of this pup that looks

absolutely fine so she's hearing in that ear absolutely fine.

Since it's rubbish music, we do not mind getting something about half a decent.

One ear done, 17 to go.

In the equine centre, Mike's about to sedate Rosie before she has keyhole

surgery to remove her right ovary.

She's had the first part of her sedation, which will allow us to place

catheter and then we'll have instant access to give her more sedation for the

procedure as well.

Rosie will be conscious and standing throughout.

It's safer than giving her a general anaesthetic, which can lead to

complications. The local anaesthetic will ensure she doesn't feel any pain.

She'll be given a constant infusion of the sedative agent, which she's already

had, and the surgeons also use local anaesthetic at the area where they'll be

inserting the laparoscope.

As Rosie's sedative takes effect, her surgeon, Porter Kelly, gets ready for

operation.

Podrick specialises in equine surgery.

We grew up with horses at home. We're fortunate enough to have had a few

and ponies as kids.

We did some show jumping and that sort of thing, and I suppose that started off

my interest in horses.

Podrick likes the rapid results you can get as a surgeon.

It suits my character more, I think. I don't know if I have the patience for

medicine. It takes quite a patient individual who is prepared to spend a

time observing really and studying stuff.

Poor Drake will remove Rosie's right ovary via keyhole surgery under local

anaesthetic. Mike will keep a close eye on Rosie's sedation levels throughout.

Operating on a semi -conscious standing animal is no easy matter.

three portals, one approximately here, through which we will insert our camera,

then we will identify the ovary and the ovarian ligament.

We'll create a second portal and inject some local anaesthetic into the ovarian

ligament, then create a third portal through which we can remove the ovary.

This mare is a little bit well -conditioned, shall we say, so that's

make things a little more difficult for us, just because of the amount of both

extra and intra -abdominal fat that is going to be there.

Poor Drake will be using a laparoscope, a small flexible tube which contains a

light source and a camera.

We're going to use a pointed troker to just bluntly dissect through the muscle.

There's quite a lot.

When the laparoscope is inserted, Aldrich gets a clear image of Rosie's

So that's the ovary right there below us.

It's right in the center of the picture.

Just that down there.

And that above it is the ovarian pedicle, or the attachments of the ovary

the blood supply, which we're going to put some local anesthetic into shortly

after the uterus then running.

Running backwards on her bladder, her bladder there, just to the top left of

picture with some small colon just below.

If Mike and the anaesthetist were to over -sedate Rosie, she could collapse.

At this end, we're just ensuring that Rosie stays sufficiently sedated, that

doesn't move around whilst the surgeons are operating, and also, unfortunately,

she doesn't get too sedated.

because they can tend to start to lose strength and they can sometimes buckle.

Yeah, if she felt anything, she would react to this at this stage, which

obviously we don't want to find out that way by her reacting.

Oh!

Jillian has nearly finished the Dalmatian hearing test, but it looks

one has a problem.

Yeah, the trace that we've got for this pup...

Left ear isn't how we would expect it.

Good boy, you're all right.

Oh, Missy, it's fine. It's fine, it's fine, it's fine.

Don't worry.

You're all right, wee one.

So what we're doing is we ran it at the... We initially run the test at 80

decibels.

And for all of the pups, that's what we've done with everyone, and they've

given us a positive trace.

When we did it with this pup for the first time, we're not getting such a

trace. So we're running it a second time on 100 decibels, which is obviously

much louder, and it's more obvious that you can hear the sucking now.

And I'm still not getting the nice trace, so at this moment in time, it

that this has been the last kind of death in its last year.

Now Gillian will test the other ear.

Over a third of Dalmatians with hearing problems are totally deaf.

We theoretically should be seeing a nice graph here.

We call it the anxiety factor.

It likes to just keep you in suspense for that wee bit of extra time.

You can see that that trace on the right ear looks fine. So he's unilaterally

deaf in his left ear, but he can hear fine in his right ear.

So that just will be recorded on his hearing test, but it shouldn't affect

in a lifestyle in any way, shape or format. He'll still be able to function

a normal puppy because he can hear perfectly well in that right ear. So

a worry or a concern.

It's a good result for this litter of nine.

They've all passed their test.

Although for this little fella, it was quite a close shave.

So that's really, really good.

Yay!

Do you want me to take all the wins off? That was good.

How do you think?

You know, we say we're going, so it wasn't that traumatising, was it?

Right, let's go back to your mum.

There you go.

Happy? Yeah, very.

Nine buoyant puppies, all with new owners to come.

Coming up, the results of the biopsy.

No, here.

Just hold that in. Can you feel it? I think so, yeah.

Are you over that? Do you need that?

It might be the hungriest thing to grow, but it's just a long way in, you know.

What we're trying to do is remove it through as small a hole as possible.

And the last thing we want to do is to lose our hold on it.

Poor Drake is viewing a two -dimensional image while trying to extract a

slippery three -dimensional organ.

Finally, Paul Drake secures the elusive ovary.

The tumours in the ovary were the probable cause of Rosie's aggressive

behaviour. It's not malignant, but it is producing abnormal hormones which are

making this mare have some stallion -like behaviour.

Her left ovary will still be functional and it will probably be more functional

now because this ovary will have been altering her general cycle because of

amount of testosterone produced in that ovary.

Because it's keyhole surgery, Rosie should recover quickly and be home in a

or two.

Indy's made an excellent recovery from his lung surgery.

The biopsy on the removed tissues showed no sign of cancer.

His owners, Barry and Laura, have come to pick him up.

We're just looking forward to getting our wee dog back. You know, we've had a

couple of worrying days where there's a couple of moments where we weren't sure

whether we would get the dog back or not.

We've also got our wee dog at home who's been really missing him.

Really depressed.

dog he went from being such a lively dog to being so quiet and office food and

things like that just because he's missing them but the whole family's been

same everybody's been missing them such a lovely wee dog you can't help but miss

him come on intern bia gutierrez returns indy to barry and laura

I don't even have words really right now to describe how I feel.

I've got my dog back after a week. That's the longest I've ever went

having him.

And to see him so healthy looking compared to what he was when we brought

in, it's absolutely brilliant.

Absolutely amazing.

Did you think you'd been abandoned today?

Did you think we'd left you, pal?

I'm just glad he's healing himself.

After three x -rays, an operation, a blood transfusion and several days in

intensive care, Indy's eventful stay is over.

Having grown up with animals herself, Indy's surgeon Catherine understands why

pets... means so much to their owners.

It's really nice to see how happy people are when, in some cases, they

come in thinking that they're never going to see them again or that we're

to not be able to do anything, there'll be no treatment, and then sort of think

how great it is for them, for the rest of the family.

Yeah, that's really nice.

It's very easy to kind of make the sweeping statements like, oh, you hear

often, oh, it's just a child substitute. It's like, well, who's to say that a

child isn't a dog substitute for someone?

It's their family.

There's no doubting how deeply people care and how much it means to them.

So it's really nice to see that as well.

And another patient is also about to go home.

Rosie's relieved owners have come to pick her up.

Equine specialist Mike talks Anne through Rosie's wound care.

We've left it open so that you can have a look at it. And if you find that it

starts to get swollen, if it gets quite hot or painful, and if you start to

notice any discharge, particularly yellow discharge, anything that looks

pus, then that would be a reason maybe just to get your vet to come have a look

and decide whether she needs some more antibiotics as well.

Looking good?

It won't be too long before Anne can ride Rosie again.

I would probably recommend, you can do a very light exercise with her, but if

you want to do anything a bit more strenuous, you'd maybe wait another

months. But that's the advantage of this type of surgery, they're small

incisions.