AbsiteAbsite Review SeriesReview Series Hernias II Hernias ... · Skandalakis J Surgical Anatomy of...

AbsiteAbsite Review SeriesReview SeriesAbsiteAbsite Review SeriesReview SeriesHernias II Hernias II ––

Abdominal Wall HerniaAbdominal Wall HerniaRavi Ravi DhanisettyDhanisetty, M.D., M.D.

SUNY DownstateSUNY DownstateSUN ow sSUN ow s7/11/20087/11/2008

www.downstatesurgery.org

ACGME Core CompetenciesACGME Core Competencies

M di l K l dM di l K l dMedical KnowledgeMedical KnowledgePatient CarePatient CareInterpersonal SkillsInterpersonal SkillsPractice Based LearningPractice Based LearningPractice Based LearningPractice Based LearningSystems Based LearningSystems Based LearningP f i liP f i liProfessionalismProfessionalism


QuestionsQuestionsQuestionsQuestions1. Which of the follow is the most common anterior abdominal wall hernia?1. Which of the follow is the most common anterior abdominal wall hernia?

a. epigastric herniaa. epigastric herniap gp gb. umbilical herniab. umbilical herniac. incisional herniac. incisional herniad. sphegalian herniad. sphegalian herniae. obturator herniae. obturator hernia

h h f h f ll f h b d f l b hh h f h f ll f h b d f l b h2. which of the following form the border of Superior lumbar hernia?2. which of the following form the border of Superior lumbar hernia?a. latissimus dorsia. latissimus dorsib. serratus posterior inferiorb. serratus posterior inferiorc. posterior border of internal obliquec. posterior border of internal obliqued. Iliac Crestd. Iliac Crest

3. Which of the following prosthetic mesh is ideal for intraperitoneal use?3. Which of the following prosthetic mesh is ideal for intraperitoneal use?a. polypropelene mesha. polypropelene meshb. PTFE meshb. PTFE meshc. vicryl meshc. vicryl meshd. parietex meshd. parietex meshpp

4. which of the following is an ideal characteristic of bio4. which of the following is an ideal characteristic of bio--prosthetic meshprosthetic mesha. causes foreign body reaction so the mesh can be well incorporated into surrounding tissues.a. causes foreign body reaction so the mesh can be well incorporated into surrounding tissues.b. non carcinogenicb. non carcinogenicc. chemically inertc. chemically inertd il bid il bi d d bld d bld. easily biod. easily bio--degradable.degradable.e. easily sterilizede. easily sterilized


Abdominal Wall HerniaAbdominal Wall HerniaAbdominal Wall HerniaAbdominal Wall Hernia

Anatomy ofAnatomy ofAnatomy of Anatomy of Abdominal WallAbdominal WallTypes of AbdominalTypes of AbdominalTypes of Abdominal Types of Abdominal Wall HerniaWall HerniaSurgical RepairSurgical Repairg pg p


Anatomy of Abdominal WallAnatomy of Abdominal WallAnatomy of Abdominal WallAnatomy of Abdominal Wall

Complex layered structure with a segmentallyComplex layered structure with a segmentallyComplex, layered structure with a segmentally Complex, layered structure with a segmentally derived blood supply and innervation derived blood supply and innervation Boundaries of Abdominal WallBoundaries of Abdominal WallBoundaries of Abdominal WallBoundaries of Abdominal Wall

Superiorly by the costal marginsSuperiorly by the costal marginsI f i l b h h i bi d l i bI f i l b h h i bi d l i bInferiorly by the symphysis pubis and pelvic bones Inferiorly by the symphysis pubis and pelvic bones Posteriorly by the vertebral column Posteriorly by the vertebral column


Anterior Abdominal WallAnterior Abdominal WallAnterior Abdominal WallAnterior Abdominal Wallwww.downstatesurgery.org

Anterior Abdominal WallAnterior Abdominal WallAnterior Abdominal WallAnterior Abdominal Wall

Rectus Abdominus muscle:Rectus Abdominus muscle:Rectus Abdominus muscle: Rectus Abdominus muscle: encased within an aponeurotic sheath encased within an aponeurotic sheath layers of which are fused in the midline at thelayers of which are fused in the midline at the linealinealayers of which are fused in the midline at the layers of which are fused in the midline at the linea linea albaalbaLateral border of the rectus muscles assumes aLateral border of the rectus muscles assumes aLateral border of the rectus muscles assumes a Lateral border of the rectus muscles assumes a convex shape that gives rise to the surface landmark, convex shape that gives rise to the surface landmark, the the linea semilunarislinea semilunaris


Anterior Abdominal WallAnterior Abdominal WallAnterior Abdominal WallAnterior Abdominal Wall

RECTUS SHEATHRECTUS SHEATHRECTUS SHEATHRECTUS SHEATH

Anterior and posteriorAnterior and posteriorAnterior and posterior Anterior and posterior aspects of the rectus aspects of the rectus sheath with respect to sheath with respect to pparcuate line (semicircular arcuate line (semicircular line of Douglas)line of Douglas)


Acquired Abnormalities of Acquired Abnormalities of Abdominal WallAbdominal Wall

Rectus abdominis diastasis (or diastasis recti):Rectus abdominis diastasis (or diastasis recti):Rectus abdominis diastasis (or diastasis recti):Rectus abdominis diastasis (or diastasis recti):Clinically evident separation of the rectus abdominus Clinically evident separation of the rectus abdominus muscle pillarsmuscle pillarsmuscle pillars muscle pillars

CongenitalCongenital lateral insertion of rectuslateral insertion of rectusCongenital Congenital –– lateral insertion of rectuslateral insertion of rectusAcquired Acquired -- advanced age, obesity, pregnancy advanced age, obesity, pregnancy


Acquired Abnormalities of Acquired Abnormalities of Abdominal WallAbdominal Wall

Diastasis RectiDiastasis RectiDiastasis RectiDiastasis Recti


Abdominal Wall HerniasAbdominal Wall HerniasAbdominal Wall Hernias Abdominal Wall Hernias

Anterior abdominal wall orAnterior abdominal wall or ventralventral herniasherniasAnterior abdominal wall, or Anterior abdominal wall, or ventralventral hernias hernias Defects in the parietal abdominal wall fascia and Defects in the parietal abdominal wall fascia and muscle through which intramuscle through which intra--abdominal orabdominal ormuscle through which intramuscle through which intra abdominal or abdominal or preperitoneal contents can protrude.preperitoneal contents can protrude.Due to Due to

Slow architectural deterioration Slow architectural deterioration Poor wound healingPoor wound healing

Mass or bulge in anterior abdominal wall with Mass or bulge in anterior abdominal wall with valsalvavalsalva


Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features

Uncomplicated herniaUncomplicated hernia ––Uncomplicated hernia Uncomplicated hernia Mass or bulge in anterior abdominal wall with Mass or bulge in anterior abdominal wall with valsalvavalsalvavalsalva.valsalva.Reduces spontaneously with recumbencyReduces spontaneously with recumbencyDoes not transDoes not trans illuminateilluminateDoes not transDoes not trans--illuminateilluminateEdges of defect can be easily palpatedEdges of defect can be easily palpated


ComplicationsComplicationsComplicationsComplications

A hernia that cannot be reduced is described asA hernia that cannot be reduced is described asA hernia that cannot be reduced is described as A hernia that cannot be reduced is described as incarceratedincarcerated..Obstruction:Obstruction:Obstruction:Obstruction:

Incarceration of intestinal segment Incarceration of intestinal segment 33rdrd most common cause of obstructionmost common cause of obstruction

StrangulatedStrangulated hernia hernia –– compromise to blood compromise to blood supply to an incarcerated bowel.supply to an incarcerated bowel.pp ypp yRichter’s HerniaRichter’s Hernia

Part of the bowel wall herniates through the defectPart of the bowel wall herniates through the defectPart of the bowel wall herniates through the defect Part of the bowel wall herniates through the defect


ComplicationsComplications -- Richter’s HerniaRichter’s HerniaComplications Complications Richter s HerniaRichter s Herniawww.downstatesurgery.org

Types of Ventral HerniaTypes of Ventral HerniaTypes of Ventral HerniaTypes of Ventral Herniawww.downstatesurgery.org

Ventral HerniaVentral HerniaVentral HerniaVentral Hernia

Primary Ventral herniaPrimary Ventral herniaPrimary Ventral herniaPrimary Ventral herniaEpigastricEpigastric hernias: located in midline between hernias: located in midline between Xiphoid and umbilicusXiphoid and umbilicusXiphoid and umbilicus.Xiphoid and umbilicus.

Small and multiple Small and multiple found to contain omentum or a portion of the falciform found to contain omentum or a portion of the falciform ppligament ligament

Umbilical Hernia: at the umbilical ringUmbilical Hernia: at the umbilical ring10% of all newborns10% of all newbornsSpontaneously close by age 5 Spontaneously close by age 5


Epigastric HerniaEpigastric HerniaEpigastric HerniaEpigastric Herniawww.downstatesurgery.org


SpigelianSpigelian hernias:hernias:SpigelianSpigelian hernias:hernias:Occur along the lateral border of rectus muscle (Occur along the lateral border of rectus muscle (linea linea semilunarissemilunaris))semilunarissemilunaris))

Most commonly at or slightly above the arcuate line (linea Most commonly at or slightly above the arcuate line (linea semicircularis).semicircularis).

Usually are not clinically evident and present with Usually are not clinically evident and present with pain or incarceration.pain or incarceration.


SpigelianSpigelian HerniaHerniaSpigelianSpigelian HerniaHerniawww.downstatesurgery.org

Littre's HerniaLittre's HerniaLittre s HerniaLittre s Hernia

Hernia that contains a Meckel diverticulum inHernia that contains a Meckel diverticulum inHernia that contains a Meckel diverticulum in Hernia that contains a Meckel diverticulum in the hernia sacthe hernia sac

inguinal, 50%; femoral, 20%; umbilical, 20%; and inguinal, 50%; femoral, 20%; umbilical, 20%; and miscellaneous 10%miscellaneous 10%miscellaneous, 10% miscellaneous, 10% Repair of hernia and excision of the diverticulum Repair of hernia and excision of the diverticulum



Incisional Hernia:Incisional Hernia:Incisional Hernia:Incisional Hernia:Healing failure of a prior abdominal wall surgical Healing failure of a prior abdominal wall surgical closureclosureclosure.closure.80% of ventral hernias80% of ventral herniasUp to 10Up to 10 15% of laparotomy incisions15% of laparotomy incisionsUp to 10Up to 10--15% of laparotomy incisions15% of laparotomy incisions

Risk factors include:Risk factors include:postoperative wound infection, malnutrition, obesity, postoperative wound infection, malnutrition, obesity, immunosuppression, and chronically increased intraimmunosuppression, and chronically increased intra--abdominal abdominal pressure. pressure.


Obturator HerniaObturator HerniaObturator HerniaObturator Hernia

Obturator CanalObturator CanalObturator nerve and Obturator nerve and vessels.vessels.


Obturator HerniaObturator HerniaObturator HerniaObturator Hernia

Occurs through the obturator canalOccurs through the obturator canalOccurs through the obturator canal Occurs through the obturator canal accompanied by the obturator vessels and accompanied by the obturator vessels and nervesnervesnerves. nerves. Mostly in women and is associated with a laxity Mostly in women and is associated with a laxity of pelvic floorof pelvic floorof pelvic floor.of pelvic floor.Causes intermittent pain with palpable mass in Causes intermittent pain with palpable mass in

di l hi hdi l hi hupper medial thigh.upper medial thigh.Repair via transperitoneal approach with mesh.Repair via transperitoneal approach with mesh.


PosteroPostero--Lateral Abdominal WallLateral Abdominal WallPosteroPostero Lateral Abdominal WallLateral Abdominal Wall

The posterolateral abdominal wall is bounded asThe posterolateral abdominal wall is bounded asThe posterolateral abdominal wall is bounded as The posterolateral abdominal wall is bounded as follows:follows:

Above by the lower ribsAbove by the lower ribsAbove, by the lower ribsAbove, by the lower ribsBelow, by the iliac crestBelow, by the iliac crestPosteriorl b the ertebral col mn (fi e l mbarPosteriorl b the ertebral col mn (fi e l mbarPosteriorly, by the vertebral column (five lumbar Posteriorly, by the vertebral column (five lumbar vertebrae)vertebrae)Laterally by a vertical line starting from the anteriorLaterally by a vertical line starting from the anteriorLaterally, by a vertical line starting from the anterior Laterally, by a vertical line starting from the anterior superior iliac spine and traveling upwardsuperior iliac spine and traveling upward


PosteroPostero--Lateral Abdominal WallLateral Abdominal WallPosteroPostero Lateral Abdominal WallLateral Abdominal Wall

The posterolateral abdominal wall is formed by 3The posterolateral abdominal wall is formed by 3The posterolateral abdominal wall is formed by 3 The posterolateral abdominal wall is formed by 3 layers of muscles:layers of muscles:

SuperficialSuperficialSuperficialSuperficialExternal oblique, lattissimus dorsi External oblique, lattissimus dorsi

MidMid--levellevelMidMid--levellevelSacrospinous, internal oblique, serratus posteriorSacrospinous, internal oblique, serratus posterior

DeepDeepDeepDeepPsoas major, transversus abdominus, quadratus Psoas major, transversus abdominus, quadratus lumborumlumborum


Boundaries of the Lumbar TrianglesBoundaries of the Lumbar TrianglesBoundaries of the Lumbar TrianglesBoundaries of the Lumbar Triangles

Superior Lumbar Triangle (Lesshaft Space)Superior Lumbar Triangle (Lesshaft Space)Superior Lumbar Triangle (Lesshaft Space)Superior Lumbar Triangle (Lesshaft Space)

Space between the latissimus dorsi, the serratus Space between the latissimus dorsi, the serratus posterior inferior and the posterior border ofposterior inferior and the posterior border ofposterior inferior, and the posterior border of posterior inferior, and the posterior border of the internal oblique muscle.the internal oblique muscle.


Boundaries of the Lumbar TrianglesBoundaries of the Lumbar TrianglesBoundaries of the Lumbar TrianglesBoundaries of the Lumbar Triangles

Inferior Lumbar Triangle (of Petit)Inferior Lumbar Triangle (of Petit)Inferior Lumbar Triangle (of Petit)Inferior Lumbar Triangle (of Petit)

space bounded by the latissimus dorsi space bounded by the latissimus dorsi posteriorly the iliac crest inferiorly and theposteriorly the iliac crest inferiorly and theposteriorly, the iliac crest inferiorly, and the posteriorly, the iliac crest inferiorly, and the posterior border of the external oblique posterior border of the external oblique anteriorlyanteriorlyanteriorly anteriorly


Lumbar HerniaLumbar HerniaLumbar HerniaLumbar Hernia

Secondary Lumbar Hernia:Secondary Lumbar Hernia:Secondary Lumbar Hernia:Secondary Lumbar Hernia:As a result of trauma, mostly surgical (e.g., renal As a result of trauma, mostly surgical (e.g., renal surgery) or infection (spinal tuberculosis withsurgery) or infection (spinal tuberculosis withsurgery), or infection (spinal tuberculosis with surgery), or infection (spinal tuberculosis with paraspinal abscesses)paraspinal abscesses)


Sciatic HerniaSciatic HerniaSciatic HerniaSciatic Hernia

Protrusion of a peritoneal sac through the majorProtrusion of a peritoneal sac through the majorProtrusion of a peritoneal sac through the major Protrusion of a peritoneal sac through the major or minor sciatic foramen.or minor sciatic foramen.

Very rareVery rareVery rareVery rarePresent with a swelling on the buttock Present with a swelling on the buttock Can entrap sciatic ner e or reterCan entrap sciatic ner e or reterCan entrap sciatic nerve or ureterCan entrap sciatic nerve or ureterrequires a prosthetic mesh repair via transperitoneal requires a prosthetic mesh repair via transperitoneal or transor trans gluteal approachgluteal approachor transor trans--gluteal approachgluteal approach


Sciatic HerniaSciatic HerniaSciatic HerniaSciatic Hernia

Types of SciaticTypes of SciaticTypes of Sciatic Types of Sciatic Hernia.Hernia.

SuprapiriformSuprapiriformInfrapiriform.Infrapiriform.Infrapiriform.Infrapiriform.Subspinous. Subspinous.


Supravesical HerniaSupravesical HerniaSupravesical Hernia Supravesical Hernia

Anterior to the urinary bladderAnterior to the urinary bladderAnterior to the urinary bladderAnterior to the urinary bladderSecondary to loss of integrity of the transversus Secondary to loss of integrity of the transversus abdominis muscle and the transversalis fascia failabdominis muscle and the transversalis fascia failabdominis muscle and the transversalis fascia fail.abdominis muscle and the transversalis fascia fail.

Internal supravesical hernia Internal supravesical hernia C b l t l p t i t i bl ddC b l t l p t i t i bl ddCan be lateral or posterior to urinary bladderCan be lateral or posterior to urinary bladder

Require intraperitoneal approach to repair.Require intraperitoneal approach to repair.


Supravesical HerniaSupravesical HerniaSupravesical Hernia Supravesical Hernia www.downstatesurgery.org

Principles of RepairPrinciples of RepairPrinciples of RepairPrinciples of Repair

Reduce the contents of herniaReduce the contents of herniaReduce the contents of herniaReduce the contents of herniaIdentify / delineate the defectIdentify / delineate the defectT iT i f l f h h i d ff l f h h i d fTensionTension--free closure of the hernia defect to free closure of the hernia defect to attain the lowest possible recurrence rate.attain the lowest possible recurrence rate.

Either primary or with bioEither primary or with bio--/prosthetic materials/prosthetic materials


Ideal BioIdeal Bio--prosthetic Materialprosthetic MaterialIdeal BioIdeal Bio prosthetic Materialprosthetic Material

should not be physically modified by tissue fluids;should not be physically modified by tissue fluids;p y y yp y y yshould be chemically inert;should be chemically inert;should not excite an inflammatory or foreign body should not excite an inflammatory or foreign body

titireaction;reaction;should be noncarcinogenic;should be noncarcinogenic;should not produce a state of allergy of hypersensitivity;should not produce a state of allergy of hypersensitivity;should not produce a state of allergy of hypersensitivity;should not produce a state of allergy of hypersensitivity;should be capable of resisting mechanical strains;should be capable of resisting mechanical strains;should be capable of being fabricated in the form should be capable of being fabricated in the form required; andrequired; andshould be capable of being sterilized.should be capable of being sterilized.


Types of Prosthetic MaterialsTypes of Prosthetic MaterialsTypes of Prosthetic MaterialsTypes of Prosthetic Materials

Polypropylene meshPolypropylene meshPolypropylene meshPolypropylene meshDecreased compliance and restricted mobilityDecreased compliance and restricted mobilityStrong scare plate formation with stiffness andStrong scare plate formation with stiffness andStrong scare plate formation with stiffness and Strong scare plate formation with stiffness and discomfortdiscomfortShould not be used against viscera as it can causeShould not be used against viscera as it can causeShould not be used against viscera as it can cause Should not be used against viscera as it can cause bowel ingrowth and fistula formationbowel ingrowth and fistula formationSepra MeshSepra Mesh -- PPM coated with protective layer so itPPM coated with protective layer so itSepra Mesh Sepra Mesh PPM coated with protective layer so it PPM coated with protective layer so it can be used against vicera.can be used against vicera.


Types of Prosthetic MaterialsTypes of Prosthetic MaterialsTypes of Prosthetic MaterialsTypes of Prosthetic Materials

Polyester meshPolyester meshyyVery soft and supple and conforms readily Very soft and supple and conforms readily Higher infection rateHigher infection rateParietex Composite mesh (collagen membrane on one side)Parietex Composite mesh (collagen membrane on one side)

Can be placed intraperitoneally Can be placed intraperitoneally

ee--PTFE patch (Polytetrafluoroethylene)PTFE patch (Polytetrafluoroethylene)ee PTFE patch (Polytetrafluoroethylene) PTFE patch (Polytetrafluoroethylene) Most inert, higher rate of infectionMost inert, higher rate of infectionCan be safely placed in peritoneal cavity.Can be safely placed in peritoneal cavity.Composite mesh Composite mesh

2 layers 2 layers –– PTFE and polypropelene PTFE and polypropelene PPM allows ingrowth of abdominal wall.PPM allows ingrowth of abdominal wall.gg


Biologic MeshBiologic MeshBiologic MeshBiologic Mesh

Human or animal tissueHuman or animal tissueHuman or animal tissueHuman or animal tissueRemove cellular component to avoid allergic reactionRemove cellular component to avoid allergic reactionStabilize the protein structure so it can act as a scaffold Stabilize the protein structure so it can act as a scaffold pp

Surgisis (porcine gut submucosa)Surgisis (porcine gut submucosa)Good short term resultsGood short term resultsshould not be used as a bridge should not be used as a bridge Underlay or overlay of native tissue to allow for vascular Underlay or overlay of native tissue to allow for vascular i hi hingrowth.ingrowth.disappears completelydisappears completelyRely on the native host collagen for long term strengthRely on the native host collagen for long term strengthRely on the native host collagen for long term strengthRely on the native host collagen for long term strength


Biologic MeshBiologic MeshBiologic MeshBiologic Mesh

Alloderm (cadaver dermis)Alloderm (cadaver dermis)Alloderm (cadaver dermis)Alloderm (cadaver dermis)can stretch and lose its shape can stretch and lose its shape

No long term results are availableNo long term results are availableRecurrences occur after 1Recurrences occur after 1--2 years2 years


Incisional Hernia RepairIncisional Hernia RepairIncisional Hernia Repair Incisional Hernia Repair

Components Separation (Ramirez 1990)Components Separation (Ramirez 1990)Components Separation (Ramirez 1990)Components Separation (Ramirez 1990)enlargement of the abdominal wall by movement of enlargement of the abdominal wall by movement of the muscular layersthe muscular layersthe muscular layers the muscular layers

Steps:Steps:Di t th ki d f t ff f th l tDi t th ki d f t ff f th l tDissect the skin and fat off of the muscles to a Dissect the skin and fat off of the muscles to a distance of about 5 cm lateral to the lateral border of distance of about 5 cm lateral to the lateral border of the rectus.the rectus.the rectus.the rectus.Incision is then made in the rectus sheath and the Incision is then made in the rectus sheath and the muscle is mobilized off of the posterior sheath muscle is mobilized off of the posterior sheath pp


Incisional Hernia RepairIncisional Hernia RepairIncisional Hernia RepairIncisional Hernia Repair

Incise the aponeurosis of the external obliqueIncise the aponeurosis of the external obliqueIncise the aponeurosis of the external oblique Incise the aponeurosis of the external oblique muscle 1 to 2 cm lateral to the lateral border of muscle 1 to 2 cm lateral to the lateral border of the rectus muscle (along the entire length)the rectus muscle (along the entire length)( g g )( g g )Rectus fascia is then closed in the midline Rectus fascia is then closed in the midline

Allows advancement of the rectus 3 to 5 cm in Allows advancement of the rectus 3 to 5 cm in the upper abdomen, 7 to 10 cm in thethe upper abdomen, 7 to 10 cm in thethe upper abdomen, 7 to 10 cm in the the upper abdomen, 7 to 10 cm in the midabdomen, and 1 to 3 cm in the lower midabdomen, and 1 to 3 cm in the lower abdomen abdomen


ConclusionsConclusionsConclusionsConclusions

Abdominal wall hernias can be a challengingAbdominal wall hernias can be a challengingAbdominal wall hernias can be a challenging Abdominal wall hernias can be a challenging surgical problem.surgical problem.Understanding of the anatomy and variousUnderstanding of the anatomy and variousUnderstanding of the anatomy and various Understanding of the anatomy and various surgical options are integral to achieve good surgical options are integral to achieve good resultsresultsresults. results.


ReferencesReferencesReferencesReferences

Skandalakis J Surgical Anatomy of HernialSkandalakis J Surgical Anatomy of HernialSkandalakis, J. Surgical Anatomy of Hernial Skandalakis, J. Surgical Anatomy of Hernial Rings. Mastery of Surgery. Ed. Fischer, JE. Rings. Mastery of Surgery. Ed. Fischer, JE. 200720072007.2007.Bell, RL. Abdominal wall. Schwartz’s Principles Bell, RL. Abdominal wall. Schwartz’s Principles of Surgery Ed Billiar T 2006of Surgery Ed Billiar T 2006of Surgery. Ed. Billiar, T. 2006.of Surgery. Ed. Billiar, T. 2006.Javid, PJ and Brooks, DC. Hernias. Maingot’s Javid, PJ and Brooks, DC. Hernias. Maingot’s Abd i l O i Ed Zi MJ 8Abd i l O i Ed Zi MJ 8thth ddAbdominal Operations. Ed. Zinner, MJ. 8Abdominal Operations. Ed. Zinner, MJ. 8thth ed. ed.


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