/
Wendy Blount, DVM Wendy Blount, DVM

Wendy Blount, DVM - PowerPoint Presentation

alexa-scheidler
alexa-scheidler . @alexa-scheidler
Follow
410 views
Uploaded On 2017-03-29

Wendy Blount, DVM - PPT Presentation

Tricks of the Trade Reducing SpayNeuter Time Marvin Mackie DVM Quick Spay James Wright DVM MPH ACPVM Dr Sara White BOD ASV Spay ASAP Inc Dr Karla Brestle Medical Director Humane Alliance ID: 531034

ligament tips tricks dogs tips ligament dogs tricks knot clamp incision pedicle 100 bertha tattoo bull pit uterus suture

Share:

Link:

Embed:

Download Presentation from below link

Download Presentation The PPT/PDF document "Wendy Blount, DVM" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.


Presentation Transcript

Slide1

Wendy Blount, DVM

Tricks of the Trade

Reducing Spay-Neuter TimeSlide2

Marvin Mackie, DVM – Quick Spay

James Wright, DVM, MPH, ACPVM

Dr. Sara White

BOD, ASV; Spay ASAP Inc.Dr. Karla BrestleMedical Director, Humane AllianceDr. Mark Bohling, ACVSUniversity of Tennessee CVM

Dr. Bob Judd, ABVPJudd Veterinary ClinicDr. Philip Bushby, ACVSMississippi State CVMBrenda Griffin, ACVIMUniversity of Florida CVM

SUPER HUMAN PUBLIC HEALTH GURUSlide3

Speed per se is not the desired goal

Efficiency is the goal and

not the same as speed

Efficiency is elimination of all unnecessary tissue handling and any wasted motionExperienced surgeons who are very fast are not necessarily rushing, they just make very few “false moves.”Less tissue handling means less trauma and less pain for the patientI Feel the Need for Speed!Slide4

Halsted’s Principles

Halsted’s Principles of Surgical Technique

Gentle tissue handling

Strict asepsisMeticulous hemostasisElimination of dead space in the surgical woundSlide5

Terms Definitions

Suspensory ligament

- suspends the ovary from the dorsal wall of the abdominal cavity, and continues in the broad ligament to suspend uterus

Broad ligament – peritoneum and fat lateral to uterine bodyProper ligament – tethers the ovary to the uterus, containing the uterine tubePedicle – usually refers to the ovarian or testicular vessels and vas deferensStump – usually refers to the uterine stumpSlide6

Trouble Spots

Rate Limiting

Steps to Spay-Neuter

Finding the linea albaFinding the uterusBreaking down the suspensory ligamentFinding a dropped pedicle or stumpWaiting for light anesthesia to become surgical againWaiting for the next patientSlide7

Finding the linea alba

Overweight – excess subcutaneous fat

Lactation (flank approach)

Cats – herringbone meeting of left and right rectus rather than linea albaSlide8

Finding the linea alba

Cat

Video

(0:06)Slide9

Finding the uterus

Visual – requires largest incision

Spay hook – smallest incision

More likely to cause trauma than your finger in the hands of an inexperienced surgeonthe spay hook has no sensory nerve endingsFinger sweep – big enough to get your finger with uterus out.Slide10

Finding the uterus

Full bladders, full colons and increased intra-abdominal fat are my greatest obstacles

Technicians gently express the bladder prior to prepping

Tech trained to “leave it” if to much pressure is requiredIt is possible to rupture the urinary bladder with manual expressionSometimes excessive manual pressure is not perceived to be usedIf manual expression can’t be done safely, intra-operative expression or even cystocentesis can helpSlide11

Finding the uterus

Finding

the uterus quickly not only minimizes surgery time, but also minimizes tissue handling trauma

.When I have to hunt for the uterus, I usually give an extra intra-operative pain injection IM.Butorphanol, buprenorphine, morphineNSAID on recoverySlide12

Finding the uterus

Spay hook

sweep

(0:36)Slide13

Finding the uterus

Spay hook sweep

Cat

Video (0:48)Slide14

Finding the uterus

Finger

sweep

(0:11)Slide15

Finding the uterus

Finger

sweep

(0:21)Slide16

Three Clamp

Technique

(2:43)Slide17

Three Clamp Technique

Need big clamps for big dogs – I like Rochester-Carmalts.

We have only one in most spay packs, and open 2 more for big fat spays. We have 8 extra.

Need small clamps for cats and small dogsLarge clamps can tear small pedicles4 small clamps and 2 mosquitos in each packGood quality clamps prevent letting loose.Slide18

Three Clamp Technique

1

click on the first clamp, 1 cm proximal to the ovary

2 clicks on the second clamp half way between the first clamp and the ovary. always place your thumb and forefinger around the ovary when you apply clamp 2 to avoid clamping or cutting the ovary.3 clicks on the third clamp on the proper ligamentSlide19

Breaking down the suspensory ligament

to

get good exposureavoid “catchage”Slipped ligatures and painCheck for catchage by running your finger around the ligature before you release it into the abdomenplenty of “tissue tag” above and beyond your ligature to prevent a slipped ligaturePlenty of room to use the 3 clamp technique if you like itAvoid disrupting the ovary when you sharply dissect the pedicle awaySlide20

Breaking down the suspensory ligament

to

get good exposureSometimes stretching the ligament is fine for exposureIf the ovary does not retract back into the abdomen when you set it on the drape, your exposure is fineSome break it down from cranially and some from the proper ligament window toward cranialIn either case, the artery is avoidedSlide21

Breaking down the suspensory ligament

to

get good exposure (1:03)Slide22

Breaking down the suspensory ligament

to

get good exposure - techniquesstrum with the fingerscut with blade or scissorsCombination – nick then strumbreak down with hemostatsSlide23

Breaking down the suspensory

ligament

(0:37)

Slide24

Breaking down the suspensory

ligament

(0:16)

Slide25

Breaking down the suspensory ligament

Cat

Video (0:18)Pregnant Cat Video (0:17)Kitten Video (0:05)Slide26

Bertha the 100 lb Pit Bull

IN HEATSlide27

Bertha the 100 lb Pit Bull

Challenges spaying overweight dogs

Incision Placement

Finding the lineaFinding the uterusGrease control and getting ligatures tight when lots of fat is in the pedicleDealing with the broad ligamentClosing the linea (BCS 9/9)Slide28

Bertha the 100 lb Pit Bull

Incision Placement

More important in large dogs because the reproductive tract is longer

Especially important in deep chested dogs where distance between incision and dorsal attachment of suspensory ligament is longest1-2 cm caudal to the umbilicusExtend back 3-4 cmExtend caudally as needed to exteriorize an enlarged uterus or the uterine bodySlide29

Bertha the 100 lb Pit Bull

Incision Extension

Bluntly with hemostats or dull edges of the scissors if <1cm extension (cat video)

With blade and thumb forceps (next video)Cutting with Mayo scissors, while elevating the ventrumSlide30

Bertha the 100 lb Pit Bull

Finding the

linea

(0:27)Slide31

Bertha the 100 lb Pit Bull

Finding the uterus

In my hands, finger

sweep works much better than spay hook for fat dogs. Have to make incision that big to get the uterus out anywayIf all else fails, extend the incision caudally and exteriorize the bladder to expose the uterine body or stump found between the colon and bladder. occasionally a uterine horn can seem to be trapped beneath a very full colon – look there if not found in the usual place.Slide32

Bertha the 100 lb Pit Bull

Grease control

sterile huck towel in the pack to wipe grease off your gloves as needed

If it’s really bad and you can no longer grips the suture material without slipping, change your gloves for a fresh startUse Miller’s Knot for fat dog pedicles & stumpsFat cats don’t seem to carry much fat in their ovarian pediclesSlide33

Bertha the 100 lb Pit Bull

Miller’s

Knot

(0:45)Slide34

Bertha the 100 lb Pit Bull

Miller’s Knot

2 passes around the pedicle increases surface area of the ligature pressure

Reduces tendency of ligature to cut tissueParticularly useful for large or edematous uteriElevating the suture ends as you tighten helps to tighten both loops equallyCat Video (1:15)Slide35

Bertha the 100 lb Pit Bull

2 Clamp Technique for Fat/Enlarged Uterus

Do not clamp the uterus prior to ligation

To do so on an enlarged uterus risks transecting it with the clamp prior to ligationIt can retract under the pelvisBetter exposure by breaking down broad ligamentPlace clamps after ligationPreserve 1 cm tag of tissue on the uterine stumpSlide36

Bertha the 100 lb Pit Bull

2 Clamp Technique for Fat/Enlarged

Uterus

(0:45)Slide37

Bertha the 100 lb Pit Bull

Should uterine arteries be ligated separately?

Almost all experts in HQHVSN say it’s not necessary

There is a post on the ASV listserve several times yearly about problems with not ligating separatelyMassive bruising on the abdomen, usually a cat2-3 days after OHEOccasionally the hemorrhage is fatal the first nightThe uterine artery slips caudally beneath the ligature and there is retroperitoneal bleeding which seeps out the inguinal ring into the SC tissuesSlide38

Bertha the 100 lb Pit Bull

Dealing with the broad

ligament

(0:20)Slide39

Bertha the 100 lb Pit Bull

Dealing with the broad ligament

Self Tie of Cat Broad Ligament

(0:40)Watch using a scalpel blade with no handle on itEspecially if you place your blade on the drapeSlide40

Bertha the 100 lb Pit Bull

Dealing with the broad ligamentSlide41

Bertha the 100 lb Pit Bull

Dealing with the broad ligamentSlide42

Bertha the 100 lb Pit Bull

Dealing with the broad ligament

Break down the broad ligament

Better access to the uterine arteries for ligationAllows exteriorization of the uterine body (cat video)Use Rochester-Carmalts to crush and tear broad ligament rather than breaking down manually – 3 clicksEasier to tear the suspensory ligament with less tissue traumaLigate if needed – encircling or Miller’s. Pedicle tie does not work well in my hands for fat dogs.Slide43

Bertha the 100 lb Pit Bull

Closing the linea

Place one interrupted suture in the center with a surgeon’s knot to keep fat from erupting out every time Bertha breathes

This is probably more important when closing obese dogs with longer incisionsDropped stumps or pediclesMultiple adhesionsExploratory to confirm spaySlide44

Bertha the 100 lb Pit Bull

Closing the linea

Continuous or interrupted????

Apposition and seal better with continuousInterrupted provides back-up for suture or knot failureCruciate rather than simple interrupted cuts knot number by halfSuture reaction is greatest at the knotsKnot tying takes a little more timeSlide45

Bertha the 100 lb Pit Bull

Closing the linea

Bites at least 5-10mm from edge of rectus

Suture ears at least 3-4mm4-6 throws per knotAvoid crushing tissue with the first two throwsImpedes healingCauses animals to lick and chew at suture lineSlide46

Bertha the 100 lb Pit Bull

Closing the

linea

(0:54)Slide47

Tips Tricks

Ovarian Pedicle Ties

don’t

work well on animals with lots of fat in the pedicle.can often do a pedicle tie in even fat cats.Leave 4-5mm tissue tag beyond the hemostat to establish clamp securityPedicle Tie Female Cat (0:14)Pedicle Tie Pregnant Cat (0:27)Same techniques used for testicular pedicles in routine and cryptorchid castrations in cats and puppiesSlide48

Dogs of Maturity

Preventing scrotal hematoma

Meticulous hemostasis

Avoid branches of the caudal superficial epigastric a.Disposable JorVet handheld electrocauteryEpineprine:Lidocaine SplashThe socket is dry when I close, or I don’t closeLigation of SC vessels only when neededReduced scrotal swelling from 2 in 100 to 2 in 1000Slide49

Dogs of Maturity

JorVet handheld electrocautery

-runs on two AA batteries -2200o cautery and three tips - $67.00 -2200o cautery - $36.00 - 1100o cautery - $29.00 -replaceable tips -cautery lasts 4-6 monthsSlide50

Dogs of Maturity

Epi

-Lido “Splash”

Mix 1:9 epinephrine (1:1000) and 2% LidocaineGetting the dilution backward can cause scrotal necrosis if used as a true splashApply 2cc of the mixture to a sterile 4x4Place the 4x4 into the scrotal sac for 30-60 seconds, and then removeMackie uses 100% epinephrine for thisSlide51

Dogs of Maturity

Epi

-Lido “Splash”

(1:57)Slide52

Dogs of Maturity

Open or closed?

I do most of mine closed

Strip the fascia away to have minimal connective tissue around the ligationRun a hemostat along the cordIf open, I do the Mackie modified open techniqueLigate the spermatic cord and let it retract back in the tunicLigate the tunic and amputate most of itSlide53

Dogs of Maturity

Open or closed

?

(3:14)Slide54

Dogs of Maturity

What to do with the pendulous

scrotum?

A significant amount of contraction will occur with timeNot necessary to avoid scrotal swellingWe offer scrotal ablation in older dogs for cosmetic reasons for $20 extraSlide55

Tips Tricks

Skin Sutures or Not?

Not necessary in most cases with intradermal closure

Elected in high energy female dogs likely to chewElected for very large incisionsAlternatively, can do several segments of continuous for very large incisionsElected if significant skin pathologyComing back for suture removal can be an issue for low cost clientsI almost never put skin sutures in a dog castrationSlide56

Tips Tricks

Burying the knot

If the knot protrudes through the incision, it will likely need to be removed with suture scissors

Tie the knot with suture ends parallel to the incisionTake a deep last bite prior to tying the knotUse an Aberdeen knot to reduce knot sizeClose SC and skin with a continuous for only one knot, when incision is longer than can be closed with a cruciate or twoChoose suture size that is not too large to reduce knot size“smurf” the knot just prior to applying glue to skin edgesSlide57

Tips Tricks

Burying the knot

Aberdeen knot

(1:32)Slide58

Tips Tricks

Burying the knot

Continuous SC and skin closure – single knot

Only two throws in the first knot anchoring to rectusTack to body wall by taking bites between the cruciate knots in the lineaDiscussion about fetal euthanasiaExample of tattoo ink placed in the incisionContinuous Closure (3:50)Slide59

Tips Tricks

Burying the knot

Smurf the knot

(2:54)Don’t forget to trim the suture tag!Slide60

Tips Tricks

Incision Size – smaller really is better

“incisions heal side to side”

Other reasons to limit incision size to the minimum allowed to exteriorize the reproductive organsMinimize instruments and fingers in the abdomen to minimize tissue trauma, post-operative pain and adhesion formationAlso limit exposure of abdominal contents to traumaDecrease likelihood of foreign bodies left in the abdomenMinimally invasive surgery for quicker recovery and lower incidence of post-operative complicationLarger incisions take longer to close and allow fewer procedures each daySlide61

Tips Tricks

Transecting the pedicle before you ligate

Scary at first – the pedicle is no longer tethered if the clamp fails prior to ligation

Bushby – “When you consider the increased tissue manipulation necessary when ligating the pedicle prior to transection, the risk of tearing the pedicle at the proximal clamp is actually greater than a clamp slipping off”True IF you have good clamps1-2-3 click technique minimizes risk of tear by proximal clamp1 click on the proximal clamp2 clicks on middle clamp3 clicks on clamp on proper ligamentSlide62

Tips Tricks

Transecting the pedicle before you ligate

Preserving adequate tissue tag distal to clamp is key (1cm)

Also makes the ligature more secureIf you can’t do this, work on better ovarian exposureIncision placement cranial enoughBreak down suspensory ligament properlyRemove the proximal clamp just prior to the final tightening of the Miller’s knotIncreases distance between the clamp and ligation by reducing “spreading” of the pedicle by the closer clampIf you double ligate, try transecting after the first ligationSlide63

Tips Tricks

Tattoo and Glue

Texas state law requires us to either microchip or tattoo animals sterilized by releasing agencies

HEALTH AND SAFETY CODE. TITLE 10. HEALTH AND SAFETY OF ANIMALS. CHAPTER 828. DOG AND CAT STERILIZATIONSec. 828.001. DEFINITIONS. Releasing agency - a public or private animal pound, shelter, or humane organization. The term does not include an individual who occasionally renders humane assistance or shelter in the individual's home to a dog or cat.Slide64

Tips Tricks

Tattoo and Glue

Texas state law requires us to either microchip or tattoo animals sterilized by releasing agencies

RULES PERTAINING TO THE PRACTICE OF VETERINARY MEDICINE. TEXAS ADMINISTRATIVE CODE. TITLE 22, PART 24. CHAPTER 573. RULE §573.77 STERILIZATION OF ANIMALS FROM RELEASING AGENCIES (c) Identification markers. An animal sterilized under this section must be identified by a microchip and/or a tattoo indicating that it has been sterilized. (1) A new owner of an animal with a microchip shall be responsible for providing information to the data base registry of the microchip manufacturer indicating that the animal has been sterilized.Slide65

Tips Tricks

Tattoo and Glue

Texas state law requires us to either microchip or tattoo animals sterilized by releasing agencies

RULES PERTAINING TO THE PRACTICE OF VETERINARY MEDICINE. TEXAS ADMINISTRATIVE CODE. TITLE 22, PART 24. CHAPTER 573. RULE §573.77 STERILIZATION OF ANIMALS FROM RELEASING AGENCIES (2) A tattoo must: (A) be placed on the inside of the animal's thigh near the abdomen or on the caudal-ventral abdomen; (B) be imprinted with ink that is manufactured in the United States; (C) meet the standards of the federal Food and Drug Administration for tattooing; (D) be of a contrasting color to the predominant color of the skin in which it is tattooed; and (E) consist of the universal symbol for male or female overlain by a slash through the circle to indicate sterilization.Slide66

Tips Tricks

Tattoo and Glue

The required tattoo is almost never done

green tattoo line on the ventral abdomen is the standard of careNOTE – ear tip is not a legal way of identifying TNRed cats in TexasTNRed cats must be either microchipped or tattooed in addition to ear tipMost tattoo parallel to the incisionSome put tattoo ink in the incisionIt’s not uncommon for an owner or even a GP vet to think that tattoo ink in the incision is gangreneSlide67

Tips Tricks

Tattoo and Glue

(0:34)Slide68

Tips Tricks

Tattoo and Glue

Tattoo even tomcats on the ventral abdomen

Video incision is full thickness skinI just score the skin so there is no need for glueBlot the extra ink (peroxide) to prevent a temporary case of “green tongue”Ketchum tattoo paste is a favorite (tube)Don’t get the roll-on kind – it gets contaminated with first useApply with paper indicator strip of the back end of the scalpel blade handleSlide69

Tips Tricks

Tattoo and Glue

Take care to avoid getting glue in the subcutaneous tissues

It causes a terrible foreign body reactionDelays healingPotentiates infectionIf you touch the glue to the animal’s skin change out the application straw prior to the next patientDescribe the tattoo in the discharge instructionsSlide70

Tips Tricks

Tattoo and GlueSlide71

Tips Tricks

Minimizing Time Between Patients

Often the rate limiting step to the number of procedures that can be done each day

Less than 2 minutes surgeon down time between surgeriesShould be able to reglove, regown if needed, and start the next one without rushing2 minutes x 30 procedures = an hour of down time per day5 minutes x 30 procedures = 2-1/2 hours down time per day10 minutes – you might was well get the cot outSlide72

Tips Tricks

Minimizing Time Between Patients

Learn at what point in the procedure to call for the next induction

When I am ligating the first ovaryA little more time to induce catsA little more time for a “Labdomen”Alternate spays with neuters3 male cat neuters per surgery unit, unless infectious diseaseGo on the next one as soon as a neuter or group of neuters is brought into the ORSlide73

Tips Tricks

Minimizing Time Between Patients

Packs and gloves opened for the next patient during skin closure

Careful communication – respond, “Heard!”Forms or travel sheets minimize writing (http://omalleypet.org)Circles and checks as much as possibleBlanks to prompt information gatheringBetter yet, have a scribe for computer entry as you goColored tag systemGreen – pre-A exam completed, premedicated and ready for inductionBlue – needs vet exam prior to premedication and inductionYellow – infectious disease, surgery at the end of the dayRed tag – surgery complete or canceledSlide74

Zinc

Neutering

Zeuterin (formerly Neutersol)“Esterilsol” in other countriesArk Naturals says infertility is “permanent and irreversible” in 99.6% of dogsApproved only for dogs 3-10 months of ageOne uncontrolled study in Mexico on adultsNo studies assess fertility >12 months post-injectionA very small number of dogs do show uptick in fertility near the end of the 12 monthsSlide75

Zinc

Neutering

Zeuterin (formerly Neutersol)A very small number of dogs suffer scrotal rupture with exposed testicle 1 week to 4 months post-injection“Oligospermia” is considered “infertile” in the FDA approval studies<20 million sperm per mlUnlikely, but not impossible that these dogs could successful breedOther uncommon adverse reactions include scrotal draining tracts, erosions, self trauma, pain on injection, and preputial swellingSlide76

Zinc

Neutering

Zeuterin (formerly Neutersol)All dogs have scrotal swelling which peaks at 48 hours post-injection0.5-2% are fertile after injection2-5% have adverse reactions requiring castration5% euthanized for excessive testosterone driven behaviorInfertility occurs within 30 daysSlide77

Zinc

Neutering

Zeuterin (formerly Neutersol)Example - 2,500 castrations per year10-50 will remain fertile50-125 will need to be castratedACC&D - Potential for mild adverse injection site reactions to progress to serious reactions in dogs that are not properly supervised should be considered carefully. ACC&D recommends Esterilsol use be limited to dogs with owners/caregivers that can provide appropriate care.Alliance for Contraception in Dogs and CatsReasonable option when anesthesia potentially dangerousSlide78

Tips Tricks

Suture Size and Material

Monosorb seems to break a little bit easier than PDS –

may need one size larger for stumps and pediclesIf you break the suture, grab one size up to try again Polysorb in my hands has poor knot security, as compared to Vicryl and other similar generics.Suture size for closing the linea albaNo larger than 0 PDS for even the largest spays3-0 PDS fewer suture reactions than 2-0 for cats2-0 PDS for medium dogs3-0 to close SC and skinSlide79

Tips Tricks

Suture Size and Material

Swaged on more

expensive than reelLess tissue trauma with swaged onNeedle sharperNo double thickness as suture loops through needle eyeDon’t need thumb forceps for intradermal suturingReels allow you to pick and choose different suture types and sizes for the same surgery without wasteThreading needles with reel suture takes more timeDon’t cold pack suture pack leftovers – feline retroviruses are transmitted with waySlide80

Tips Tricks

Patient Positioning

Front legs pulled down to the side rather than over the head can help for deep chested dogs

Decreases traction on the ovarian pedicles via the suspensory ligamentTables that “V” keep patients from tipping right and leftCrossing the front legs before tying can also help with this in deep chested dogsSlide81

Tips Tricks

Patient Positioning

(0:30)Slide82

Tips Tricks

Avoiding Dehiscence of the Abdominal Wall

Avoid crushing tissue as you close the first two throws of each knot

Make sure you are closing the rectus sheath, not subcutaneous tissuesTake bites at least 5-10mm from the edge of the incisionKnots are not properly tightened, or don’t have enough throwsThe sheath, not the muscle tissue is the holding layerSlide83

Tips Tricks

Dealing with a Dropped Pedicle

Extend the incision cranially to the manubrium

Use the biological retractors to move organs out of the way to caudal to each kidneyLeft pedicle dropped – reflect descending colon to the rightRight pedicle dropped – reflect duodenum to the leftGrasp the pedicle with 2 fingers to exteriorize, then clampThe ureter is just beneath the ovarian arteryUsing a clamp to grasp the pedicle can result in trauma to or ligating the ureterPooling hemorrhage can obstruct the normal view of the ureterSlide84

Treasure

Hunt

Tips for Cryptorchid SurgeryDetermine which side is cryptorchid by retropulsing the normal testicle into its inguinal canalIf testicle can be palpated, make an incision over the testicleIf not, make incision same as spay in the catParamedian incision along the cranial half of the prepuce in the dogFind the vas deferens there and follow it to the testicleSlide85

Treasure

Hunt

Tips for Cryptorchid SurgeryMIA cat testicles are more often in the inguinal canalCan be very difficult to dislodgeHave an assistant put pressure upward on the inguinal canal with a gloved hand from inside the abdomenThis allows palpation of and incision over the hidden testicleThey can be very small in the catSlide86

Tips Tricks

Why are these Techniques Different from those taught in Vet School?

These skills are for the experienced surgeon

Those taught in vet school are for the inexperienced surgeonLarger incisions to compensate for infamiliarity with surgical anatomyDouble ligation to compensate for poor knot securityLigation prior to transection to prevent a dropped pedicle due to overmanipulation of the instruments or other poor techniqueMASTER BASIC TECHNIQUES BEFORE WORKING ON INCREASING EFFICIENCY