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Marsupialization
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Marsupialization is the surgical technique of cutting a slit into an abscess or cyst and suturing the edges of the slit to form a continuous surface from the exterior surface to the interior surface of the cyst or abscess. Sutured in this fashion, the site remains open and can drain freely. This technique is used to treat a cyst or abscess when a single draining would not be effective and complete removal of the surrounding structure would not be desirable. The technique is often applied to Gartner's duct cysts, pancreatic cysts, pilonidal cysts, and Bartholin's cysts.[1]
In the case of a dentigerous cyst, marsupialization may be performed to allow the growing tooth associated with the cyst to continue eruption into the oral cavity.[2] It is also in use in dacryocystorhinostomy surgery in which the lacrimal sac mucosa is connected to the nasal mucosa above the level of the mechanical obstruction at the nasolacrimal duct.[citation needed]
References
[edit]- ^ Omole F, Simmons BJ, Hacker Y (2003). "Management of Bartholin's duct cyst and gland abscess". American Family Physician. 68 (1): 135–40. PMID 12887119.
- ^ Hupp, James R.; Ellis, Edward; Tucker, Myron R. (2008). Contemporary Oral and Maxillofacial Surgery. St. Louis, MO: Mosby Elsevier. pp. 455–57. ISBN 978-0-8151-6699-3.
External links
[edit]Marsupialization
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Overview
Definition
Marsupialization is a surgical technique employed in the management of cysts and abscesses, characterized by making an incision into the wall of the lesion and then suturing its edges to adjacent tissue, thereby forming an open pouch or continuous epithelialized surface that facilitates ongoing drainage.[5] This method ensures the creation of a permanent fistula-like opening, which prevents reclosure of the site and allows for gradual decompression while preserving surrounding structures.[5] By suturing the cyst or abscess lining directly to the surrounding mucosa or skin, the technique promotes reepithelization of the tract, maintaining patency and reducing the risk of fluid reaccumulation.[5] In contrast to simple incision and drainage, which merely evacuates contents for immediate relief but often leads to rapid closure and potential recurrence, marsupialization emphasizes the suturing step to sustain an open pathway, providing a more definitive approach to drainage in cyst and abscess treatment.[5]Purpose and Benefits
Marsupialization serves as a conservative surgical intervention primarily aimed at decompressing cysts or abscesses by creating an open pouch that facilitates continuous drainage and promotes gradual reduction in lesion size. This technique relieves intra-cystic pressure, which in turn diminishes inflammatory responses and supports the ingrowth of epithelial tissue to line the pouch, thereby preventing premature closure and reducing the likelihood of recurrence.[2] In cases of large odontogenic cysts, such as dentigerous cysts, the procedure lowers pressure within the cystic cavity, encouraging new bone formation around the lesion and allowing for the preservation of vital structures like unerupted teeth.[6] One key benefit of marsupialization is its minimally invasive nature compared to complete excision or enucleation, as it avoids the removal of surrounding healthy tissues and minimizes surgical trauma. This approach is particularly advantageous in pediatric patients or when cysts involve critical anatomical areas, such as the jaw, where radical procedures might necessitate tooth extraction or risk nerve damage. By enabling healing through secondary intention, marsupialization promotes natural tissue regeneration and functional rehabilitation without compromising adjacent structures.[7][8] Relative to simple incision and drainage, marsupialization offers superior outcomes for recurrent or expansive lesions by maintaining an open pathway that inhibits scar formation and re-accumulation of fluid, thus lowering recurrence rates. For odontogenic keratocysts, recurrence after less definitive methods can reach 25-60%.[9] It is a preferred option when total excision poses excessive risks to nearby structures like the inferior alveolar nerve in mandibular cysts.[10] Overall, this method balances effective cyst management with the preservation of anatomical integrity, enhancing patient recovery and long-term oral or pelvic health.[8]History and Etymology
Etymology
The term "marsupialization" derives from "marsupial," an adjective describing pouch-bearing mammals such as kangaroos and opossums, reflecting the procedure's creation of a pouch-like opening in tissue to allow drainage while maintaining an everted, open cavity.[11][12] This nomenclature emphasizes the surgical analogy to a protective, pouch-shaped structure formed by suturing the edges of an incision, preventing premature closure and promoting continuous epithelialization.[13] Linguistically, the root traces to the Latin marsupium, meaning "purse" or "pouch," which itself originates from the Greek marsýpion (a diminutive of mársippos, denoting a bag or pocket, possibly of Oriental influence).[14][15] In medical contexts, this evokes the idea of an everted, pouch-formed cavity that facilitates healing without complete excision, distinguishing the technique from more radical resections.[16] The term entered medical literature in the late 19th century, with its earliest recorded use in 1889 within the New Sydenham Society's Lexicon of Medicine and the Allied Sciences, where it described conservative cyst treatments amid a growing preference for tissue-preserving surgeries over invasive methods.[17] This coinage aligned with contemporaneous advancements in surgical conservatism, particularly for benign cystic lesions, by highlighting the pouch's role in sustained decompression and reduced recurrence risk.[18]Historical Development
Marsupialization was first described in the late 19th century as a conservative surgical approach for managing cysts and abscesses, allowing drainage while preserving surrounding tissues. In 1882, Austrian surgeon Carl Gussenbauer performed the initial successful marsupialization of a pancreatic cyst, suturing the cyst wall to the abdominal incision to create a controlled drainage pouch and prevent peritoneal contamination.[19] This technique marked an early milestone in pancreatic surgery, where prior attempts at cyst management often resulted in high mortality due to infection or rupture. By 1892, Austrian surgeon Karl Partsch introduced marsupialization, known as Partsch I or cystostomy, for odontogenic cysts in the jaws, transforming the cystic cavity into an open pouch continuous with the oral mucosa to facilitate decompression and reduce recurrence risks.[20] The procedure gained significant traction in oral and maxillofacial surgery during the early 20th century, with Partsch's method detailed in 1920s literature as a preferred alternative to complete enucleation for large jaw cysts, promoting bone regeneration through gradual shrinkage.[21] In gynecology, marsupialization was adapted for Bartholin's gland cysts by the mid-20th century; in 1950, Paul Jacobson described its application, involving incision and suturing of the cyst edges to form a permanent epithelialized tract for drainage.[22] This integration reflected broader surgical trends toward less invasive interventions, particularly following World War II, when widespread antibiotic availability reduced postoperative infection rates and enabled safer management of infected cysts across specialties.[23] By the 1950s and 1960s, marsupialization expanded in applications like pancreatic pseudocysts, building on Gussenbauer's foundational work with refined techniques for internal drainage, such as cystogastrostomy, to improve outcomes in chronic cases.[19] The procedure evolved from primarily inpatient operations under general anesthesia to outpatient settings, exemplified by Buford Word's 1968 innovation of a balloon-tipped catheter for Bartholin's cysts, which facilitated office-based fistulization and epithelization without extensive suturing. This catheter represented a distinct yet complementary advancement, predated by traditional marsupialization but enhancing its accessibility for ambulatory care.[22]Indications
Common Conditions Treated
Marsupialization is primarily indicated for the treatment of benign cysts and abscesses that require decompression and drainage while preserving surrounding tissues, particularly when complete excision could risk damage to adjacent vital structures.[2] This conservative approach is favored for large, recurrent, or strategically located lesions in various anatomical sites.[22] One of the most common applications is in Bartholin's gland cysts and abscesses, which occur in the vulvovaginal region and often present with pain, swelling, or infection in women of reproductive age.[24] Marsupialization creates a permanent epithelialized opening to facilitate ongoing drainage and reduce recurrence, making it suitable for recurrent cases after initial incision and drainage fails.[13] Symptomatic Bartholin's cysts and abscesses account for approximately 2% of all gynecologic office visits annually.[22] In oral and maxillofacial surgery, marsupialization is frequently employed for odontogenic cysts, such as dentigerous cysts and odontogenic keratocysts (previously classified as keratocystic odontogenic tumors).[2] For dentigerous cysts, which develop around the crown of an unerupted tooth, the procedure decompresses the cyst to promote bone regeneration and facilitate orthodontic eruption of the involved tooth, avoiding unnecessary tooth extraction.[25] Odontogenic keratocysts, noted for their aggressive growth and high recurrence rates (up to 30% after enucleation alone), benefit from marsupialization as an initial step to reduce cyst size before definitive treatment, preserving jaw integrity.[26] Odontogenic cysts, including these types, represent a significant portion of jaw lesions treated conservatively in oral surgery, with marsupialization applied in cases involving vital structures like developing teeth or nerves.[27] Pilonidal cysts and abscesses in the sacrococcygeal region, often associated with chronic infection or sinus formation, are another indication, where marsupialization provides effective decompression for both acute abscesses and recurrent disease, promoting healing with lower morbidity than wide excision.[28] Pancreatic pseudocysts, fluid collections arising from pancreatitis or trauma, may be managed with marsupialization in select cases, particularly when percutaneous or endoscopic drainage is not feasible, to allow internal drainage into adjacent viscera while avoiding pancreatic resection.[29] This approach is less commonly used today due to advances in minimally invasive techniques but remains relevant for large or hemorrhagic pseudocysts near critical structures.[30] Overall, marsupialization is preferred for these non-malignant conditions to achieve symptom relief and prevent complications through tissue-sparing drainage.[31]Patient Selection Criteria
Patient selection for marsupialization begins with diagnostic confirmation of the cystic lesion through clinical evaluation, including physical examination to assess size, location, and tenderness.[32] For Bartholin gland cysts, a pelvic exam is typically sufficient, while imaging such as ultrasound may be employed for deeper or ambiguous lesions; in cases of suspected malignancy, particularly in patients over 40 years or with atypical features, biopsy is required prior to proceeding.[22][24] Similarly, for odontogenic jaw cysts, radiographic imaging like panoramic views is essential to delineate cyst extent and involvement of adjacent structures.[33] Ideal candidates include patients with symptomatic, recurrent, or large cysts greater than 2-3 cm that interfere with daily activities, such as sitting or walking in the case of vulvar lesions.[24][3] This procedure is particularly suitable for individuals unsuitable for complete excision due to lesion location, comorbidities, or high surgical risk, as well as those with a history of failed conservative treatments like Word catheter placement.[13][34] Cooperative patients able to adhere to postoperative care, such as maintaining hygiene and attending follow-ups, are preferred, especially for intraoral applications like ranula or odontogenic cysts where prolonged decompression may be needed.[33] Contraindications are limited but include active untreated infection necessitating immediate incision and drainage without pouch formation, suspected malignancy requiring excision for full histopathological evaluation, and patient refusal or inability to cooperate, such as in very young children or those with cognitive impairments.[13][24] Marsupialization is avoided in cases of solid masses or chronic lesions suspicious for carcinoma, where biopsy or alternative surgery is prioritized.[35] Factors influencing selection encompass age, lesion size, and recurrence history; for instance, it is favored in older patients with large jaw cysts to preserve vital structures or in latex-allergic individuals over catheter-based methods for Bartholin cysts.[24][33] In recurrent odontogenic keratocysts, marsupialization serves as a conservative initial approach to reduce size before definitive enucleation.[2]Surgical Procedure
Preoperative Preparation
Preoperative preparation for marsupialization begins with a thorough patient evaluation to ensure suitability for the procedure. This includes a detailed medical history review to identify allergies, current infections, comorbidities, or contraindications such as uncontrolled diabetes or immunosuppression, which may influence patient selection.[36][13] Informed consent is obtained after discussing the procedure's purpose, potential risks (including recurrence rates of 5-15%), benefits, and alternatives like incision and drainage or catheter placement.[37][22] Diagnostic imaging is employed to assess cyst size, location, and complexity, with modalities selected based on the anatomical site: ultrasound for soft tissue or pelvic cysts, panoramic radiographs or cone-beam computed tomography (CBCT) for oral and maxillofacial lesions, and CT or MRI for other sites as needed.[22][2] If the cyst is infected or forms an abscess, preoperative antibiotics (e.g., a 7-day course of trimethoprim-sulfamethoxazole, doxycycline, or cephalexin) are administered to reduce infection risk prior to surgery.[37] Anesthesia planning is tailored to the cyst's location, size, and accessibility; local anesthesia with or without procedural sedation is often used for small, superficial cysts, while general anesthesia may be required for more extensive procedures involving larger or deeply located lesions, such as in the jaws or pelvis.[13][38] Site preparation involves gentle cleansing of the area with antimicrobial solution appropriate to the anatomical location and avoidance of irritants; prophylactic antibiotics are generally not required for uncomplicated cysts but may be given in high-risk cases, such as those with concurrent cellulitis or patient factors increasing infection likelihood.[13] Patients are advised to fast appropriately if general anesthesia is planned (e.g., clear fluids up to 2-3 hours prior) and arrive with necessary documentation.[39]Operative Technique
Marsupialization is a conservative surgical procedure performed under local or general anesthesia to create a permanent drainage pathway for cysts or abscesses by forming an open pouch. The technique involves accessing the lesion, evacuating its contents, and suturing the cyst wall to adjacent mucosa or skin without excising the cyst lining, allowing gradual epithelialization and resolution. This approach is typically completed in an outpatient setting or operating room and lasts 15–30 minutes, depending on the lesion size.[3][2] The operative steps begin with proper positioning of the patient to expose the site, followed by sterile preparation of the area. An incision is made into the cyst wall using a scalpel to create a window, with the size adjusted based on the lesion's dimensions to ensure adequate drainage without compromising structural integrity (typically 1–3 cm for smaller cysts). The cystic contents are then evacuated manually or with gentle suction, and the cavity is irrigated with sterile saline to remove debris and achieve hemostasis, using cautery if minor bleeding occurs.[40][2] Next, the edges of the cyst wall are everted using forceps to exteriorize the lining, forming a pouch-like structure. Absorbable interrupted sutures, such as 4-0 chromic gut or synthetic equivalents, are placed to approximate the cyst edges to the surrounding mucosa or skin, securing the opening and preventing premature closure. If needed for additional hemostasis or to maintain patency, the pouch may be lightly packed with gauze or a stent, which is removed shortly after. No excision of the cyst wall is performed, preserving the epithelial lining to promote natural shrinkage over time.[3][40]Postoperative Care
Immediate Aftercare
Postoperative care following marsupialization varies depending on the anatomical site and specific application, with the goal of promoting drainage, preventing infection, and supporting healing while maintaining the pouch opening. Common elements include pain management with over-the-counter analgesics such as ibuprofen or acetaminophen as needed for the first 1-2 days, and application of ice packs (wrapped in cloth) for 10-20 minutes several times a day to reduce swelling.[3][13] Patients are advised to rest for 24-48 hours, avoiding strenuous activity or heavy lifting, and to monitor for signs of infection such as fever above 100.4°F (38°C), increased pain, purulent discharge, or excessive bleeding.[3][32] Prompt contact with a healthcare provider is recommended if concerning symptoms arise. Site-specific instructions apply: In gynecological cases, such as Bartholin gland cysts, warm sitz baths (2-3 times daily for 10-15 minutes using plain warm water or saline) are advised starting postoperative day 1 or 2 to cleanse the area and promote drainage; the site should be patted dry and kept clean with mild, unscented soap, using a panty liner for light drainage. Avoid tampons, vaginal intercourse, and scented products for 4-6 weeks to minimize irritation.[3][13] In oral and maxillofacial applications, such as odontogenic cysts, good oral hygiene is essential, including gentle rinsing with saline or prescribed antiseptics (e.g., chlorhexidine); the pouch may be packed with iodoform gauze, changed every 1-2 weeks by the provider.[16] Absorbable sutures are often used to secure the pouch, dissolving naturally, though non-absorbable ones require removal after 7-10 days if applicable.[13] A follow-up visit is typically scheduled within 1 week to assess healing and manage any packing.[3]Recovery and Follow-up
Recovery after marsupialization involves gradual epithelialization of the pouch lining and cyst shrinkage, typically over 2-6 weeks, with full healing taking 4-6 weeks in many cases, though this varies by site and lesion size.[3] Patient compliance with site-specific maintenance is crucial, such as daily gentle irrigation for oral cavities to ensure drainage and prevent closure, or continued sitz baths for pelvic procedures.[16][3] In oral cases, an obturator may be used post-packing to maintain the opening until bone regeneration, adjusted periodically.[16] Follow-up visits are scheduled at 1 week for initial assessment (e.g., packing removal), 1 month for progress monitoring, and longer-term (up to 1-5 years) for high-recurrence risks like odontogenic keratocysts to detect re-accumulation or reformation.[41][16] Lifestyle measures include maintaining hygiene with unscented products, a balanced diet for tissue repair, and avoiding irritants or trauma to the site. Patients should seek immediate care for complications like increased pain, fever, or altered discharge. Recurrence rates vary by application and require vigilant monitoring, with details covered in specific sections.[3]Complications and Risks
Intraoperative Risks
During marsupialization, intraoperative risks are generally low due to the minimally invasive nature of the procedure, but they include bleeding, injury to adjacent structures, anesthesia-related issues, and potential introduction of infection. These risks vary by anatomical site, such as the vulvar region for Bartholin's cysts or the oral cavity for ranulas, and are mitigated through meticulous surgical technique and preoperative preparation.[13] Bleeding is a primary concern, particularly from vascular cysts like those in the Bartholin's gland, where rupture or incision can lead to hemorrhage. However, blood loss is typically minimal and managed intraoperatively with pressure application, electrocautery, or suction, often aided by local anesthetics containing epinephrine for vasoconstriction. In comparative studies, marsupialization has been associated with reduced intraoperative blood loss compared to more extensive excisions. For oral applications, such as ranula treatment, hemorrhage risk arises from proximity to salivary ducts but remains controllable with hemostatic measures.[13][42][43] Injury to adjacent structures poses another risk, including damage to nerves (e.g., lingual nerve in sublingual ranula marsupialization) or vital anatomy like the urethra in pelvic procedures or Wharton's duct in oral sites. Such injuries can result from imprecise incisions or suboptimal patient positioning, potentially causing temporary sensory deficits or functional impairment. Prevention relies on precise dissection under magnification if needed, careful anatomical orientation, and proper lithotomy positioning to avoid undue pressure on nerves or vessels in the groin or pelvic area.[13][43][44] Anesthesia complications, though rare, may include allergic reactions to local agents like lidocaine or vasovagal responses during procedural sedation or general anesthesia. These are assessed preoperatively by the anesthesiology team based on patient history, with risks minimized through standard monitoring and selection of appropriate anesthetic modalities.[13] Introduction of infection during surgery is uncommon, with an overall incidence below 5% when sterile techniques are employed, but it can occur via contamination from nearby flora, such as anal bacteria in vulvar procedures. Prevention involves rigorous antimicrobial skin preparation (e.g., povidone-iodine) and draping, potentially supplemented by preoperative antibiotics in high-risk cases.[13][37]Postoperative Complications
Postoperative complications following marsupialization, while generally uncommon, can include infection, recurrence of the cyst or abscess, scarring leading to pouch closure, hematoma formation, chronic pain, and rarely, fistula development in pelvic applications. These risks vary by site and patient factors, but overall complication rates are low, with most resolving through conservative management.[13][45] Infection occurs in approximately 5-10% of cases, often due to polymicrobial contamination or underlying pathogens such as Neisseria gonorrhoeae or Chlamydia trachomatis, and presents as cellulitis or abscess formation at the surgical site. Management typically involves broad-spectrum antibiotics (e.g., ceftriaxone and doxycycline for suspected sexually transmitted infections) and, if an abscess develops, incision and drainage. Routine antibiotic prophylaxis is not recommended for uninfected cysts but may be considered in high-risk scenarios.[13][46] Recurrence rates range from 5-15%, attributed to incomplete initial drainage, premature pouch closure, or persistent glandular obstruction, and is more common in patients with prior procedures. It is managed with repeat marsupialization or alternative techniques such as Word catheter placement, with long-term success improving through diligent follow-up.[45][13] Scarring or spontaneous closure of the marsupialized pouch can lead to fluid re-accumulation and cyst reformation, particularly if healing occurs without adequate epithelialization. Prevention involves regular irrigation or sitz baths to maintain patency during the initial healing phase, typically for 1-2 weeks postoperatively.[45][46] Hematoma formation affects 1-2% of patients, resulting from inadequate intraoperative hemostasis, and usually resolves spontaneously but may require evacuation if symptomatic. Chronic pain or dyspareunia occurs in a small subset, often linked to scarring or nerve involvement, and is managed symptomatically with analgesics and time. Fistula formation, such as rectovaginal fistula in pelvic procedures, is rare (less than 1%) but may necessitate surgical repair if it develops.[37][13]Specific Applications
Gynecological Uses
Marsupialization serves as a primary surgical intervention in gynecology for managing Bartholin's gland cysts and abscesses, which arise from obstruction of the gland ducts located at the 4 and 8 o'clock positions on the posterior labia majora.[22] This procedure is particularly indicated for recurrent cases or cysts larger than 3 cm, where simpler drainage methods may fail to prevent reaccumulation.[37] It is often performed as an office-based procedure under local anesthesia, offering a minimally invasive alternative to gland excision.[45] The technique involves making a 1.5- to 2-cm vertical incision over the cyst or abscess in the vulvar vestibule, just distal to the hymenal ring, to access the glandular wall.[13] The incision edges are then everted using forceps and sutured to the surrounding vestibular mucosa with absorbable chromic sutures, forming a permanent epithelialized pouch that maintains drainage and reduces the risk of premature closure.[22] This adaptation ensures continuous mucus secretion into the vestibule, mimicking the natural gland function. Clinical outcomes demonstrate high efficacy, with success rates approaching 90% in resolving symptoms without the need for further intervention.[47] Recurrence rates for marsupialization are reported at 8.3%, significantly lower than the 18.8% observed with Word catheter placement in comparative studies.[46] It is especially favored when Word catheters have previously failed due to premature expulsion or inadequate drainage, providing a more reliable option for persistent or complex presentations.[24]Oral and Maxillofacial Uses
In oral and maxillofacial surgery, marsupialization serves as a conservative treatment for odontogenic cysts, particularly dentigerous cysts and odontogenic keratocysts (OKCs), by creating a communication window between the cyst cavity and the oral mucosa to enable decompression and drainage. This approach decompresses the expanding lesion, promotes bone apposition, and preserves adjacent teeth and neurovascular structures that might otherwise require aggressive resection.[48][49] The technique involves a 1-cm incision through the overlying mucosa to expose the cystic cavity, followed by excision of a small bony window if necessary and suturing of the cyst lining to the adjacent oral mucosa using absorbable sutures to form an open pouch. This variation allows continuous drainage while the cyst shrinks, often serving as the initial phase before definitive enucleation once the lesion has reduced in size. Pouch maintenance for ongoing drainage is achieved through simple irrigation protocols.[48][49] Clinical outcomes demonstrate substantial cyst size reduction, with reports of 50-70% volume decrease within 3-12 months, facilitating easier secondary surgery and bone healing. Adjacent or involved teeth are preserved in the majority of cases, enabling spontaneous or orthodontically assisted eruption, as observed in small series where all pertinent teeth uprighted post-procedure. Recurrence rates remain low at approximately 10-20%, especially when marsupialization precedes enucleation.[50][51][48] Key advantages include its minimally invasive profile for large cysts exceeding 5 cm, which reduces risks such as mandibular fracture or inferior alveolar nerve injury compared to immediate enucleation, while supporting orthodontic management for unerupted teeth.[49][51]Other Uses
Marsupialization has been applied to pancreatic pseudocysts, particularly in cases arising from trauma or necrotizing pancreatitis, where an open or laparoscopic approach creates a pouch for internal drainage into the stomach (cystogastrostomy) or jejunum (cystojejunostomy).[29] This technique facilitates decompression and resolution of the pseudocyst by allowing continuous drainage while minimizing extensive resection, though it is now less common due to advances in endoscopic methods.[52] Clinical resolution rates for such surgical interventions range from 70% to 85%, with recurrence influenced by underlying pancreatic pathology.[29] In the management of pilonidal cysts and chronic sinus tracts in the sacrococcygeal region, marsupialization involves incision of the cyst wall followed by suturing the edges to adjacent skin, promoting epithelialization and drainage to prevent reaccumulation.[53] This method is particularly suited for recurrent or infected cases, offering a balance between tissue preservation and effective sinus tract obliteration. Recurrence rates are typically under 10%, with studies reporting figures as low as 6% in large cohorts.[54] For Gartner's duct cysts, remnants of the Wolffian duct along the vaginal wall, marsupialization employs a transvaginal approach to incise and evert the cyst edges, creating a permanent opening for drainage while avoiding deep dissection near adjacent structures.[55] This conservative technique is indicated for symptomatic cysts causing dyspareunia or urinary issues, with successful outcomes in the majority of cases and minimal morbidity.[56] A variant of marsupialization is used in endoscopic dacryocystorhinostomy for nasolacrimal duct obstruction, where the lacrimal sac is exposed intranasally, incised, and marsupialized to the nasal mucosa to restore tear drainage.[57] This approach avoids external scarring and achieves anatomical patency and symptomatic relief in over 90% of patients, comparable to traditional external techniques.[58]References
- https://en.wiktionary.org/wiki/marsupium