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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 268-276

Lichtenstein hernioplasty with monocryl-prolene composite mesh in bilateral inguinal hernia


Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission09-Apr-2019
Date of Decision18-Apr-2019
Date of Acceptance02-Jun-2019
Date of Web Publication26-Nov-2019

Correspondence Address:
Ahmed Abd El Aal Sultan
Lecturer of General Surgery, Faculty of Medicine, Al -Azhar University, MD of general surgeryAhmed Abd El Aal Sultan, 25 elkhaleeg el masry St, Deer el malak, hdaaek el kobba, Floor 10 flat 1008, Cairo, 11331
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_68_19

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  Abstract 


Background Inguinal hernia repairs consume an important part of health care resources because of the high incidence of the problem. It is estimated that twenty million inguinal hernia repairs are performed globally every year. Lichtenstein tension-free hernia repair is considered as a gold standard technique for open inguinal hernia repair in the European guidelines on inguinal hernia.
Objective The aim of this study is to evaluate the light-weight composite mesh of monocryl-prolene in bilateral inguinal hernia repair (Lichtenstein technique) regarding outcome and complications.
Patients and methods A prospective interventional study was conducted on 25 patients with bilateral inguinal hernia. Complete physical examination (general and local), including PR examination; routine laboratory tests; ECG; chest radiography; and abdominopelvic ultrasound were done for all patients. Bilateral Lichtenstein procedure using monocryl-prolene mesh was planned for all patients. Patients were followed up for 12 months. Intraoperative findings (operative time and complications), hospital stay, and postoperative complications including pain and recurrence were thoroughly assessed.
Results There were no intraoperative or postoperative mesh-related complications (infection or foreign body sensation), and the mesh was well accepted by all patients. No patient had significant pain related to hernia repair. No significant scrotal complications were encountered. No recurrence after 1 year of follow-up was noted.
Conclusion Lichtenstein-style bilateral inguinal hernia repair using light-weight monofilament Ultrapro mesh appears quite acceptable, practical, effective, and safe for increased physical quality of life. There was no significant pain or infection in all patients, as well as no recurrence.

Keywords: bilateral inguinal hernia repair, Lichtenstein hernioplasty, monocryl-prolene composite mesh (Ultrapro)


How to cite this article:
Sultan AA, Morsi MH, El-Din Hussain MS. Lichtenstein hernioplasty with monocryl-prolene composite mesh in bilateral inguinal hernia. Al-Azhar Assiut Med J 2019;17:268-76

How to cite this URL:
Sultan AA, Morsi MH, El-Din Hussain MS. Lichtenstein hernioplasty with monocryl-prolene composite mesh in bilateral inguinal hernia. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 6];17:268-76. Available from: http://www.azmj.eg.net/text.asp?2019/17/3/268/271684




  Introduction Top


Inguinal hernia repairs consume an important part of health care resources because of the high incidence of the problem. It is estimated that 20 million inguinal hernia repairs are performed globally every year [1]. Every recurrence after a primary repair adds additional cost to health care economics. Moreover, secondary or tertiary operations after previous repairs carry higher risk of re-recurrence and specific complications like testicular atrophy. Therefore, every surgeon should know and perform a current repair method successfully in his daily practice [2].

Lichtenstein tension-free hernia repair is considered a gold standard technique for open inguinal hernia repair in the European guidelines on inguinal hernia [3]. Despite reducing the incidence of recurrence, that, 1–5% after a long-term observation [4], compared with sutured tissue repair, the incidence of postoperative chronic groin pain has increased and ranges from 10 to 54% of patients undergoing hernia repair by using a prosthetic mesh [5], and a feeling of a foreign body occurs in ∼44% of patients [6].

The advantages of simultaneous repair of bilateral inguinal hernias include (a) less psychological stress, (b) less time off from work, and (c) less expense. Postoperative pain and recovery period of the bilateral open tension-free hernioplasty are equally comparable with those of laparoscopic repair [7]. Additionally, the long-term recurrence rate of 0.1% for tension-free repair is significantly lower than the 1–4% short-term recurrence rate of the laparoscopic technique [8]. More importantly, the tension-free procedure is not associated with the reported complications of laparoscopic hernia repair, such as massive bleeding, intestinal perforation, bladder perforation, small bowel obstruction, trocar site herniation, seroma formation, nerve injuries (as high as 15%), and even death [9],[10],[11],[12]. These complications, which are continuously reported in the literature, are extremely rare, or even unheard of, with the open hernia repair [4].

Monocryl-prolene mesh represents a new member of the light-weight large porous mesh group. The mesh is constructed of a monofilament light-weight large porous PP mesh with pores of more than 3 mm. An absorbable monocryl (polyglecaprone 25) component is added to improve handling characteristics and to optimize implantation and increased tensile strength in the first week of repair [13],[14].

The monocryl-polypropylene composite mesh is currently the member of the light-weight large porous mesh family with the lowest foreign body reaction and optimized handling. The clinical studies have produced encouraging results to move forward with this mesh concept [15].

The aim of this study is to evaluate the light-weight composite mesh of monocryl-prolene (Ultrapro mesh) in bilateral inguinal hernia repair (Lichtenstein technique) regarding outcome and complications (early and late complications).


  Patients and methods Top


Patients

A prospective interventional study was conducted on 25 patients with bilateral inguinal hernia. Our study was carried out in General Surgery Department, Al-Azhar University Hospitals from January 2015 to December 2017. All patients with the complaints of inguinal lump, which appears on straining and disappears on lying down, pain, and discomfort owing to primary bilateral inguinal hernia, irrespective of sex and duration of illness, were enrolled in this study according to the following inclusion and exclusion criteria:

Inclusion criteria

Having no other serious disease/illness including hemorrhagic disorders, a bilateral primary inguinal hernia requiring operative treatment, patient’s approval to participate in the study, and age more than 18 years were the inclusion criteria.

Exclusion criteria

Unilateral hernia, irreducible hernia, recurrent hernia, strangulated hernia, a patient’s refusal to participate in the study or inability to understand the questionnaire, BMI more than 35 kg/m2, current malignant disease, abuse of alcohol, diseases impairing central or peripheral nerve function, other abdominal hernias, advanced dementia, or other mental inability to understand the study were the exclusion criteria.

Ethical considerations were covered by standard preoperative consent following proper instructions/guidelines according to the ethical committee of the Faculty of Medicine, AL-Azhar University (clinical/surgical methods, biological samples/laboratory tests, etc.).

All patients were subjected to preoperative full history taking such as personal history, including name, age, residence, occupation, marital status, and special habits of medical importance, and analysis of the main complaint, either a lump, pain, or incarceration under a scar of previous operation. A detailed present history was taken regarding the onset, duration, and course of symptoms and past history of previous operations and its postoperative events (wound infection, ileus, distention, wound dehiscence, and respiratory complications), chronic diseases (cardiac diseases, diabetes mellitus, etc.), drug allergy, and blood transfusion.

Our patients were subjected to preoperative clinical examination including general examination for vital signs and other systems to assess fitness for surgery and anesthesia. Local examination (abdominal examination) was done focusing on the site of the hernia, size of the hernia, and irreducible or not, and if there are any other signs of hernia complications (infection, obstruction, strangulation, etc.). In addition, the abdomen was examined for any organomegaly or other intraabdominal copathology to deal with it during hernia repair.

Laboratory (routine) investigations were done for all patients including complete blood count, alanine aminotransferase, aspartate aminotransferase, urea, creatinine, blood sugar, prothrombin time, and serum albumin. Moreover, radiological investigations such as abdominal and pelvic ultrasonography to exclude any intraabdominal copathology were done, and chest plain radiography was done in cases of previous history of smoking, bronchial asthma, or clinical signs of chest troubles.

Methods

Patients were admitted one day before surgery except for diabetic patients who were admitted 2 days before operation for control of blood sugar. The night before surgery, preparation of the site of the operation was done, followed by hair shaving just before operation in the morning. A single dose of broad-spectrum antibiotic was given with induction of anesthesia. Spinal anesthesia was used. All patients were placed in the supine position. Operative field was sterilized by povidone-iodine and toweled up in normal manner.

Lichtenstein tension-free mesh repair

Incision is placed about 1 cm above and parallel to the inguinal ligament, beginning from the pubic tubercle and extending 5–6 cm laterally up to the midinguinal point. The subcutaneous fat is then opened along the length of the incision, and careful hemostasis is achieved by ligating superficial pudendal and superficial epigastric vessels. The Scarpa fascia is similarly opened along the length of the incision, down to the external oblique aponeurosis. The external oblique aponeurosis is then opened along the line of incision. The ilioinguinal nerve, lying underneath the aponeurosis, is safeguarded during this procedure. The superior and inferior flaps of the external oblique aponeurosis are gently freed from the underlying contents of the inguinal canal and overturned and separated to expose the cremaster with the cord structures, the ilioinguinal and iliohypogastric nerves, the uppermost aponeurotic portion of the internal oblique muscle and conjoined tendon, and the free lower border of the inguinal ligament.

The spermatic cord, along with the cremaster, is then lifted up and separated from the pubic bone for ∼2 cm beyond the pubic tubercle to create space for extending the mesh well beyond the pubic tubercle. The patient is asked to cough, and the groin region is examined for the presence of an indirect hernia, a direct hernia, a femoral hernia, a combined hernia, or a spigelian hernia. A hernia sac can be managed by means of inversion, division, resection, or ligation. The indirect hernia sac lies anterolateral to the cord structures and is visualized by dividing the cremaster muscle longitudinally. The cremaster muscle should not be divided transversely or excised, because doing so may result in low-lying testes and dysejaculation.

A 7.5×15 cm piece of polypropylene mesh is commonly used for a Lichtenstein hernioplasty. To compensate for future shrinkage, the mesh should be wide enough to extend 3–4 cm beyond the boundary of the inguinal triangle. To compensate for increased intraabdominal pressure when the patient stands up, the mesh should be placed lax in the posterior wall of the inguinal canal in such a way that it acquires a domelike wrinkle. The first medial-most stitch fixes the mesh 2 cm medial to the pubic tubercle, where the anterior rectus sheath inserts into the pubic bone. Care should be taken not to pass the needle through the periosteum of the bone or through the pubic tubercle; this is one of the most common causes of chronic postoperative pain.

The same suture is then used as a continuous suture to fix the lower edge of the mesh to the free lower border of inguinal ligament up to a point just lateral to the internal ring. Next, a slit is made in the lateral end of the mesh to create a narrower lower tail (the lower one third) and a wider upper tail (the upper two thirds). The slit extends up to a point just medial to the internal inguinal ring. The upper tail is then passed underneath the cord in such a way as to position the mesh posterior to the cord in the inguinal canal, and the spermatic cord is placed between the two tails of the mesh. The upper tail is then crossed over the lower one, and the two tails are held in an artery forceps.

With the mesh kept lax, its upper edge is then fixed to the rectus sheath and the internal oblique aponeurosis with two or three interrupted nonabsorbable sutures ([Figure 1]). The two tails are then tucked together and fixed to the inguinal ligament just lateral to the internal ring, thus creating a new internal ring made of mesh.
Figure 1 Complete fixation of mesh on posterior wall of inguinal canal.

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Spermatic cord layers are closed with fine sutures, with care taken to avoid damaging the cord contents. Hemostasis is ensured in the inguinal canal, which is then closed by suturing the two flaps of the external oblique aponeurosis, with care taken not to injure the underlying ilioinguinal nerve. Suturing is started laterally and continued medially, where an adequate opening is left at the newly created superficial inguinal ring so as not to occlude the emerging spermatic cord. Subcutaneous tissue is approximated with interrupted sutures to obliterate any dead space, and the skin is approximated with subcuticular continuous stitch with 3-0 absorbable sutures.

Postoperatively, all patients were monitored for the following:
  1. Vital data (blood pressure, pulse, respiratory rate, and temperature).
  2. Recovery from anesthesia (time of recovery).
  3. Postoperative pain (degree, time).
  4. Any early postoperative complications (dyspnea and bleeding).


For postoperative pain, all patients needed Diclofenac sodium 50 mg in the first postoperative day to relieve the pain and three tablets/day of Ibuprofen 400 mg for the subsequent 2–4 days. Hospital stay ranged from 1 to 2 days. The early complications included nausea and vomiting, inflammatory reaction, urinary retention, surgical emphysema, wound infection, hematoma, and seroma. The late complications included chronic pain in the inguinal region, the feeling of a foreign body, hernia recurrence, pain not related to operation, orchitis, testicular atrophy, mesh infection, adhesive intestinal obstruction, and scar of wound healing. Pain scores were measured on a visual analog scale (VAS), ranging from 0 (no pain) to 100 (worst imaginable pain).

After discharge from the hospital, all patients were examined after 2 weeks and then after 1 month at the outpatient department by the same surgeon who performed the operation. Moreover, these patients were examined 3 months, 6 months, and 1 year after the operation date. They were paid attention to the pain in the inguinal region, to the feeling of a foreign body, and the presence of hernia recurrence.

Statistical analysis

The data collected were tabulated and analyzed by Statistical Package for the Social Sciences) version 22.0 on IBM compatible computer (Johnson & Johnson, Ethicon, Germany). Two types of statistics were done: descriptive statistics, for example, percentage, mean, and SD, and analytic statistics, for example:
  1. χ2: it was used to study association between qualitative variables.
  2. Fischer exact test for 2×2 tables when expected cell count of more than 25% of cases was less than 5.
  3. A P value less than 0.05 was considered significant.



  Results Top


A total of 25 consecutive patients with a symptomatic primary bilateral inguinal hernia were treated in the present study, mostly types III and IV according to the Nyhus classification, with a defect of the posterior wall and/or enlarged interior ring. All the patients were males, with a mean age of 48.3±14.7 years, ranging from 20 to 67 years.

Six (24%) patients were 60 years and older, 10 (40%) patients were 50 years and older but less than 60 years, two (8%) patients were 40 years and older but less than 50 years, two (8%) patients were 30 years and older but less than 40 years, and five (20%) patients were 20 years and older but less than 30 years.

Fifteen (60%) patients had a special habit of smoking but not complaining of any chest problem as confirmed by normal radiography result. BMI ranged from 19 to 33 kg/m2 with mean±SD of 24.4±3.9.

Nine (36%) patients were diabetics, and all of them were controlled with oral hypoglycemic drugs. Moreover, four (16%) patients had hypertension, controlled with drugs, and four (16%) were had diabetes and hypertension (controlled). There was one (4%) patient who had seasonal bronchial asthma, and used Atrovent nebulizer during attacks only. Radiography showed no significant findings.

On rectal examination, nine (36%) patients had enlarged prostate, where three (12%) of them had moderate enlargement, with size ranging from 48 to 56 cm2, and six (24%) of them had mild enlargement, with size ranging from 33 to 41 cm2. All of them were not complaining of any symptoms like difficult urination or retention. Only one patient had mild degree of varicocele, and the patient did not have any problem with it like pain or infertility.

One (2%) patient on the right side had a recognized recurrent hernia from previous repair, which has been repaired without any adverse event, and this may be owing to smoking and recurrent chest infections for 2 months following previous surgery. Moreover, he lifted heavy object as he returned to hard work very early postoperatively, which may have predisposed him to recurrence.

Pain was the major complaint in the first postoperative day (75% mild, 20% moderate, and 5% severe) ([Figure 2]). According to VAS, most patients (96%) had no pain of any kind after 3 months. Pain disappeared completely in the remaining (4%) of patients after 6 months ([Figure 3]). Postoperative complications included vomiting (4%), inflammatory reaction (4%), seroma (8%), pain related to repair (4%), need for drain (4%), hematoma (4%), urinary retention (4%), and recurrence (0%) ([Figure 4]).
Figure 2 Degree of pain during the follow-up period.

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Figure 3 Presence of pain during the follow-up period.

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Figure 4 Postoperative complication.

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There was no case of mesh-related complication (mesh infection or foreign body sensation), and the mesh was well accepted. No patient had pain after hernia repair or related to hernia repair, except for one (2%) patient on the left side owing to an intervertebral disc alteration with nerve entrapment and neuropathy and also associated with suffering from a laceration of muscles/tendons, which was caused during an artificial hip joint replacement several months before the inguinal hernia repair. The follow-up period for 12 months revealed no persistent groin pain, no foreign body sensation in the groin, and no recurrence of inguinal hernia.


  Discussion Top


In recent years, use of prosthetic material for inguinal hernia repair has increased dramatically. Tension-free repairs have gained popularity not only for primary or recurrent hernias but also for complicated inguinal hernia repairs as well.

Inguinal hernia mesh repair according to Lichtenstein ‘tension-free’ technique has gained great acceptance worldwide, showing efficacy to consolidate the posterior wall of the inguinal canal and to reduce recurrence risk because of tension on suture lines and postoperative pain [16].

The clinical results of tension-free anterior repair of inguinal hernia using a mesh revealed that the immediate complications were rare and always minor, and the rate of long-term recurrence is very low (0.5%) [17].

A tension-free operation with mesh has become the standard technique for inguinal hernia surgery. The purpose of our clinical study was to evaluate the outcomes of Lichtenstein hernioplasty by using light mesh [18].

The mean age of our patients was 48.3±14.7 years, which is less than that found in studies in Western countries [19], and 60% of our patients were less than 55 years old. The younger the patient, the more important the biocompatibility of the mesh used, as it will be in the patient for longevity.

A safe completion of all the surgeries in this study is a positive comment on the safety of the technique. Subsequently, no patient in this study developed a complication directly related to or affecting the mesh.

Main postoperative complications of inguinal hernia repair are nausea and vomiting, urinary retention, surgical emphysema, inflammatory reaction, pain not related to repair, wound infection, hematoma/seroma, orchitis, neuralgia (pain), recurrence, adhesive obstruction, delayed wound healing, and mortality [20].

In this study, the observed complications after 1 year of follow up were 4%, but in other study, it was 342/1603 (21.3%) of patients within 2 years. The overall complication rate has been reported to range from 8 to 21.3% after inguinal hernia repair [21].

According to the scientific literature, the frequency of hernia recurrence is considerably low after mesh repair; the effectiveness of inguinal hernia repair may be measured by the rate of recurrence and neuralgia [22].

We observed no recurrence in our study, whereas in another study there were four recurrences in 355 (1.1%) operations during a mean follow-up of 13 months (range, 1–30 months) [23]. In recent studies with larger population, the recurrence rate was given to be 4.9–15% [21].

There is no statistically significant difference between inguinal hernia repair by Ultrapro mesh and by other meshes regarding the recurrence rate within 1 year. This is consistent with the studies performed by many of investigators [24].

Different kinds of meta-analysis found no statistical difference in overall hernia recurrence between heavyweight and light-weight mesh in inguinal hernia repair [25]. It is worth mentioning the work of one study, where hernia recurrence was statistically significantly higher in light-weight hernia repair compared with heavyweight hernia repair. The authors did not correlate the increase of frequency of recurrence to the type of mesh. According to their opinion, the cause of this difference is technical errors of mesh fixation [26].

Importance of light-weight mesh fixation for prevention of hernia recurrence is emphasized also in European Hernia Society guidelines update. A Lichtenstein repair used in this study is practical for our surgeons because there is virtually no ‘learning curve.’ In the words of Amid, ‘the open tension-free repair is a typical example of see one, do one, teach one’ [27].

In our view, closing the defect (direct hernias) or narrowing it (indirect hernias) is a crucial step in preventing recurrence in comparison with laparoscopic hernia repair.

Regarding the incidence of pain, there was significant reduction in the first 24 h and after 2 week, as well as one, 3, 6, and 12 months in the patients with the light-weight mesh. Similar results were obtained by another study confirming the results we obtained in comparing patients with the heavyweight mesh [28].

Several factors may have an influence on the rate of chronic pain. Pain measurement and grading may not be adequately done by one-dimensional scale such as the VAS pain score or by recording the number and types of analgesics. The patients’ perception of pain may be different.

Many studies [29] had reported that preoperative pain increases the risk for development of chronic pain. As in our study, most patients had pain preoperatively, and we decided to evaluate whether severe preoperative pain (VAS score > 50) was a risk factor for development of chronic pain, so excluded from our study.

In a clinical study [30], significantly lower rates of chronic pain were recorded where a mesh with larger pores was used, which is similar to this study, where we used Ultrapro mesh with large pores and light-weight. Similarly, in another study [31], the usage of mesh with larger pores resulted in less pain on examination and when rising from lying to sitting at 3-year follow-up. However, contrary to our study, in the aforementioned studies, the meshes used differed not only in pore size but also in weight.

Although chronic pain and feeling of a foreign body in inguinal area are the main problems of mesh repair surgery, these complications significantly affect the quality of life of patients.

Only one (4%) patient in our study was demonstrated to have chronic pain (on left side) not related to hernia repair but to other causes (an intervertebral disc alteration with nerve entrapment with neuropathy and also associated with suffering from a laceration of muscles/tendons which was caused during an artificial hip joint replacement several months before the inguinal hernia repair).

This has been discovered by clinical exclusion of groin pathology and a thorough neurological examination of the patient. Some scientific results show the chronic pain is significantly decreased in light-weight mesh [25].

In attempts of reducing chronic pain, more interest has been recently focused on the mesh material. The introduction of the light-weight meshes was found to be associated with less chronic pain, less patient’s discomfort, and better quality of life after mesh repair of inguinal hernia with no difference in recurrence rate, as was shown in our study and also other studies, when compared with the classic heavyweight prolene mesh [32].

Several investigators confirmed that the main reasons of these complications are the reaction of organism on a foreign body (polypropylene). Thus, a light-weight mesh with a reduced weight of nonabsorbable components has been developed to minimize foreign body reactions after surgery [33].Light-weight composite meshes are reported to have better biocompatibility than traditional ‘heavyweight’ polypropylene meshes, being less dense, with bigger pores and having greater flexibility.

The monocryl-prolene composite mesh we used in this study is a new light-weight partially absorbable monofilament mesh, and this study showed that it is a practical choice for our patients who may have to carry it for many years. Besides, the absorbable part of the mesh starts to be absorbed after 3 weeks and becomes completely absorbed after 3 months. This also allows the patients to have early return to work than the other meshes, which agreed with the study carried out by other study [28].

Based on our results the feeling of a foreign body in groin is similar in other scientific series after 3 and 6 months but significant decrease of the symptom has been found in light-weight mesh at 3, 6 months, or 1 year after surgery. Several investigations confirm our results underlining the prevalence of light-weight mesh concerning feeling of a foreign body, but the work of other series [34] showed no difference in this indicator between using of monocryl-prolene mesh and using of other meshes.

The inflammatory intensity of foreign body reaction depends on the porosity of meshes. According to one study [35] an increased pore size had a major effect on the biological response. Moreover, some studies [36] have even classified the meshes used for hernia repair, based mainly on porosity.

In the case of small pores, a dense scar plate will develop around the entire mesh and the extent of foreign body reaction does not permit the ingrowths of the local tissue. Larger pores are filled with the local fat tissue forming a thin scar network, which results in the proper elasticity of the implant. Large pores will also preserve elasticity and hamper the bridging of inflammation across the pores. For polypropylene meshes, 1000 μm is the least distance that prevents the bridging of the scar tissue, which then fills out the entire pore.


  Conclusion Top


Lichtenstein-style inguinal hernia repair using light-weight monofilament Ultrapro mesh appears quite acceptable, practical, effective, and safe for increased physical quality of life. There was no significant pain or infection in all patients and also no recurrence.

The clinical evidence weighs in favor of adopting routine use of light-weight monofilament mesh for inguinal hernia repair in our environment. However, the cost of meshes needs to be considered. The use of light-weight Ultrapro meshes is associated with less incidence of postoperative and chronic pain that allows for early return to work with no significant incidence of recurrence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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