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T is process uses oxygen and simple sugars may be acute or chronic/progressive in nature symptoms 8 days after iui purchase generic diltiazem pills. A set of enzyme complexes medications with acetaminophen order diltiazem in india, designated problem is defcient energy production or its utili- as complexes (I-V) symptoms celiac disease purchase diltiazem with amex, carry out oxidative phosphorylation zation in liver, muscles, heart and central nervous within mitochondria. Disorders of complex molecules: Here manifestations a role in several other cellular activities. Acute Presentation Early onset (even on the very frst day of life), especially in Etiopathogenesis preterm neonates, points to a severe disease. Absence of a single enzyme include vomiting, breathlessness, tachypnea, seizures, leading to disturbance in that particular metabolic pathway foppiness and a peculiar body/urine odor depending 774 Systemic involvement in chronic/progressive Box 41. Note the eczema and lighter color of dislocation of lens in homocystinuria, cherry-red spots in Tay- hair and skin compared to family members. Diagnosis Additional features include facial dysmorphism, cataract, retinopathy, deafness, hepatomegaly, myopathy, It is by demonstrating serum phenylalanine level exceed- cardiomyopathy and multicystic dysplastic kidneys, etc. A neonatal screening program symptom free – at times over a period of a year or more. Dysmorphic coarse facies, cataract, dislocation of lens Treatment Chronic dermatosis, abnormal hair Abnormal urine color A low phenylalanine diet must begin before the baby is Seizures 2 weeks old, maintaining the serum phenylalanine at Organomegaly about 120–360 �mol/� (2–6 mg/d�), if mental retardation Systemic involvement (Box 41. Diagnosis is from a positive Benedict’s test and ferric chlo- ride test which gives purple-black color on a urine sample. Body fuids, especially sweat and urine, have a characteristic odor of maple syrup. Etiology Diagnosis Tis autosomal recessive disorder results from high concentration of homocysteine and its dietary precursor Diagnosis is confrmed by demonstrating high levels of (methionine) in blood and other body fuids because of branched chain amino acids in urine and blood. Treatment Clinical Features Treatment is diet low in branched chain amino acids Manifestations, usually begin after infancy, include mental (say, a special synthetic formula) and thiamine. In acute retardation, skeletal abnormalities such as scoliosis, pec- exacerbation, excess of the ofending amino acids needs tus excavatum, arachnodactyly (Fig. Prognosis is cataract, strabismus, keratitis, iris atrophy, spherophakia, guarded. Etiology Diagnosis In this rare autosomal recessive disorder, a defective Diagnosis is by demonstration of high levels of methionine transport of tryptophan in the gut and renal tubules leads and homocysteine in body fuids and/or assay of the to defciency of nicotinic acid. Factors such as sulfa drug therapy, infection, undernutrition and stress are known to precipi- tate the symptoms. Diagnosis Diagnosis is by demonstration of large amounts of indoles and indicans in urine. Treatment Treatment is administration of nicotinic acid, 50–300 mg/day, plus protection from exposure to sunshine. Note the unusual long fngers in a case of homocystinuria with tall stature and cataract. The closest differential Tyrosinemia type I, an autosomal recessive trait, results is Marfan syndrome. It consists of primarily sucrose and water, with small amounts of the monosaccharides glucose and fructose from the invert sugar created in the boiling process. Diagnosis is from estimation of specifc enzyme activity Pharmacotherapy includes: in liver biopsy or cultured fbroblasts. Manifestations include mental retardation, hyperkeratosis of palms and soles, corneal ulcers, etc. Tese are a group of conditions characterized by excretion of nonamino-organic acids in urine on account of enzyme Treatment defciencies in pathways of amino acid degradation. Treatment of tyrosinemia consists of a diet low in tyrosine, phenylalanine and methionine (only in type I). Transient tyrosinemia In infants, it manifests a few days after birth in the form of of the newborn, resulting from delayed maturation of a toxic encephalopathy with vomiting, feeding difculty, enzyme, p-hydroxyphenyl pyruvic acid oxidase, is usually seizures, lethargy and drowsiness progressing to coma. In a self-limiting condition occurring predominantly in older children and adolescents, presentation may be in preterm neonates on high protein formula. Manifestations the form of Reye-like syndrome, recurrent ketoacidosis, in symptomatic cases include feeding difculty, lethargy neurological disease with ataxia and seizures or psychiatric and poor motor activity. Reduction in intake of protein plus vitamin C helps to correct the aberrant state. Diagnosis is confrmed by: Manifestations, as and when these become evident as z Measuring the activity of deficient enzymes in episodes (often following a “stress”) include poor appe- lymphocytes or cultured fibroblasts tite, nausea, vomiting, lethargy and behavior problems. Methylmalonic academia: Hydroxocobalamin Diagnosis Propionate metabolism disorders: Metronidazole, In a clinically suspected child, the following investigations intermittently for 1–2 weeks.

Complications Treatment Tese include: As soon as the diagnosis is reached symptoms questions buy 180 mg diltiazem mastercard, stomach wash should Respiratory: Pneumonia symptoms 9 weeks pregnancy order 180 mg diltiazem with visa, pneumatocele medications that cause constipation buy diltiazem with mastercard, pleural efu- be done with soap and water. Half of this dose needs to be repeated Treatment every 15–30 minutes until pupils begin to dilate (mydria- Asymptomatic Cases sis), mouth becomes dry and tachycardia results. Te dose is 25–50 mg/kg which should be charged safely after 6 hours of observation for aspiration injected over a 5 minute period slowly. Several studies have docu- ures including oxygen, artifcial respiration and postural mented that as much as 20 mL/kg of kerosene can be safe- drainage of secretions, may be warranted in serious cases. Despite its having been recently con- nated coverings avoids continued dermal absorption. Most symptomatic patients show improvement in 24 hours Confusion, tremors, incoordination and seizures. Control of seizures with pheno- z Stage I: It lasts from 1/2 to 24 hours after ingestion and is barbital or diazepam should be immediately achieved. In a suspected Considerable drowsiness is the most usual presenting case of paracetamol toxicity, plasma level should be measured feature. With increasing use of the anti-infammatory agent, ibu- Treatment profen, it is likely to be involved in overdoses (both acci- dental and intentional), leading to toxicity and poisoning Majority of the children with barbiturate poisoning respond in children. Presence of cyanosis is an Normal blood levels at 2 hours of ingestion are 70–100 µg/ml. Severe respiratory difculty may need A dose of over 1000 mg/kg is likely to be toxic. Almost always, signifcant toxicity occurs in children tus, deafness, headache, acidosis and remarkable eleva- above 6 years of age. Occasionally, ibuprofen may cause anaphylactoid Mercuric acid conjugate, a metabolite of paracetamol, is reactions in the form of circulatory collapse, pruritus the central factor in causing toxicity. Clinical Features Treatment Four clinical stages of paracetamol toxicity are recognized (Box 37. Te patient must be provided good supportive care for respiration, cardiovascular system and coma. It is dopamine in case of hypotension and hemodialysis are best given within 16 hours after ingestion and in no case benefcial. Clinical Features Clinical features: 729 z Change in sensorium, confusion and disorientation Te most remarkable feature of aspirin poisoning is z Outbursts of violence and aggressive behavior what has come to be designated as air-hunger. It includes measures such as induced vomiting and/or Large doses may cause two opposing syndromes. Some workers have reported excellent results disorientation, staggering, hallucination, stupor and following exchange transfusion. Clinical picture is dominated by acute onset of signs Clinical Features and symptoms pertaining to extrapyramidal system. Treatment Diagnosis Diphenhydramine hydrochloride, 2 mg/kg (maximum Tough it is by and large clinical, abdominal X-ray (Fig. Other indices favoring toxicity include: Tis agent is efective orally either, but the response is rather Blood sugar is more than 150 mg/dL slow. More Immediately on diagnosis, vomiting should be induced and recently, parenteral diazepam has yielded excellent results. Desferrioxamine, 90 mg/kg/day in 4–6 divided induce transient psychotic manifestations. Te total calculated dose may * Phenothiazines can also produce dangerous hypersensitivity reactions like agranulocytosis, hepatitis and dermatitis. Children with atropinism have been described as—red as beet, dry as bone, and mad as a hatter. Other measures include induction of vomiting and/or stomach wash, control of fever by hydrotherapy and/or antipyretics, sedation to calm down the patient and catheterization in case of prolonged retention of urine. If desferrioxamine is not available (which is usually the Clinical Features case in our country), give the patient 12. Occasionally, Transient abdominal pain, resistant anemia, loss of weight, irritability, vomiting, constipation, headache, in case of renal failure a dialysis or exchange transfusion personality changes and ataxia are its common symp- may become necessary.

In one-half of these patients symptoms gerd buy diltiazem, the accelerated tachycardia may be terminated by even faster pacing treatment 4 pink eye buy diltiazem paypal. Thus treatment xerophthalmia cheap 60 mg diltiazem otc, approximately 50% of patients with tachycardias having cycle lengths <300 msec will require cardioversion either due to rapid hemodynamic collapse without any attempts at termination by pacing or as a result of acceleration of the tachycardia (approximately evenly divided). The first extrastimulus delivered at 290 msec fails to influence the tachycardia but changes the path of ventricular activation and shortens local ventricular refractoriness so that a second extrastimulus delivered at 230 msec penetrates the reentrant circuit and terminates the tachycardia. The mechanisms of the different forms of acceleration probably differ, but documentation would require detailed study with multisite mapping of the reentrant circuit. When the morphology of the accelerated tachycardia is identical to that of the original tachycardia, one must assume that the exit from the tachycardia circuit is the same. First, it is possible that pacing could somehow increase conduction velocity in the circuit. In this circumstance the proposed mechanism of acceleration could not be operative. Second, the apparent original tachycardia cycle length is in fact double the true tachycardia cycle length owing to exit block from the circuit. Rapid pacing could shorten the refractory period of that muscle to a greater extent than in the circuit, thereby allowing each revolution of the circuit to exit. A third possible mechanism could be that rapid pacing introduced two wavelengths within a reentrant circuit that had a very wide excitable gap. In such a mechanism, the head of one wavelength would encroach on the tail of refractoriness of the second wavelength, so there is virtually no excitable gap remaining. A fourth explanation, which I believe is most plausible, is that an area of block that determines the size of the reentrant circuit is determined, to some extent, by refractoriness. Rapid pacing could shorten the refractoriness in a proximal region of the arc of block, which would in turn shorten the length of the reentrant pathway. If the distal component of the arc of block remained unchanged, acceleration of the tachycardia would occur with the same exit site and hence, the same morphology. Alternatively, rapid pacing could remove block in or to a potentially shorter potential 47 48 pathway, creating a smaller circuit. In addition, recent detailed intraoperative mapping 352 353 studies by Downer et al. However, S1 shortens the refractoriness of the intervening tissues so that S2 can depolarize the reentrant circuit and terminate the arrhythmia. If the accelerated tachycardia has a distinctly different morphology, this may be the result of a change in the exit site from the reentrant circuit, a reversal of the reentrant circuit, or the termination of the initial tachycardia and reinitiation of a different tachycardia elsewhere. This is also consistent with the pathophysiologic substrate 47 48 described by de Bakker et al. However, in the presence of antiarrhythmic drugs, acceleration to different morphologically distinct tachycardias is common. If one is lucky, the changed tachycardias will have a longer cycle length and be more readily terminated (Fig. However, as noted, acceleration of tachycardia is frequent, and failure to terminate the accelerated tachycardia, thereby necessitating cardioversion, occurs in nearly 50% of such instances. More often than not, however, these tachycardias can also be induced by programmed stimulation. Although these tachycardias may never have been seen before spontaneously or may not have been induced, if they are uniform, hemodynamically tolerated, and if their cycle length exceeds 250 msec, we consider them to be important. The use of drugs in these patients can change these properties and, hence, frequently brings out these other latent morphologically distinct tachycardias, which may originate from a similar region or disparate areas of the heart. In an attempt to terminate the tachycardia, we introduced double ventricular extrastimuli which induced a slow left bundle tachycardia after an initial period of polymorphic tachycardia. We again introduced double ventricular extrastimuli which changed this tachycardia to a slow tachycardia having a slightly different morphology. C: We delivered double extrastimuli during this slow tachycardia, which changed it to a slightly slower tachycardia with a different morphology.

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Sacrohysteropexy followed by successful pregnancy and eventual reoperation for prolapse medications safe while breastfeeding cheap diltiazem master card. A randomised controlled trial comparing abdominal and vaginal prolapse surgery: Effects on urogenital function medications 1 order diltiazem overnight delivery. Five-year outcome of uterus sparing surgery for pelvic organ prolapse repair: A single-center experience symptoms 6 weeks buy genuine diltiazem on-line. Abdominal sacrohysteropexy in young women with uterovaginal prolapse: Results of 20 cases. Abdominal sacral hysteropexy: A pilot study comparing sacral hysteropexy to sacral colpopexy with hysterectomy. Laparoscopic sacral colpopexy approach for genito-urinary prolapse: Experience with 363 cases. Lumbosacral spondylodiscitis: An unusual complication of abdominal sacrocolpopexy. Sacral colpopexy followed by refractory Candida albicans osteomyelitis and discitis requiring extensive spinal surgery. It is further divided into different categories based on the anatomical location of the herniation to include anterior, apical, and posterior prolapse. Apical prolapse is further described as the descent of the uterus and cervix or vaginal vault in posthysterectomy cases toward the hymen. This chapter will focus on the treatment of apical prolapse using laparoscopic techniques with or without robotic assistance. Claims and encounters database estimated the lifetime risk for females 18 years and older to develop pelvic floor dysfunction and need for surgical management to be as high as 20% in the United States [1]. Several studies have shown that of these patients, up to 30% will require an additional surgery for recurrence of prolapse [3,4]. Caucasian and Latina females have a fourfold to fivefold increase when compared to African- American females [4]. McCall in 1957 using the culdoplasty technique that revealed the importance of this suspension at the time of a vaginal hysterectomy to prevent an enterocele and posthysterectomy vaginal vault prolapse [7]. Now nearly 60 years after McCall described his technique, the same attachment points and surgical principles are used via laparoscopic approaches. Laparoscopic Approach for High Uterosacral Ligament Suspension Laparoscopic Port Placement Traditionally, three laparoscopic ports are placed in the abdomen. The first is the camera port placed in the umbilicus or up to 2 cm caudal to the umbilicus depending on the patient’s habitus. The second and third ports are 5 mm ports placed suprapubically and at the right paramedian [10] (Figures 87. The patient is transitioned into steep Trendelenburg to assist with bowel retraction and to better visualize the pelvic sidewalls. To further assist with visualization of the uterosacral ligaments, a probe is placed in the vagina to hold the ligaments on tension. This will assist the surgeon in tracing the ligaments back to their proximal origin [10]. This is performed so that the pubocervical fascia and the rectovaginal fascia can be visualized. Next, a figure-eight suture is then placed approximately two- thirds cephalad to the proximal origin of the ligament and 1 cm caudal to the most anterior palpable margin of the sacrum [11]. We recommend using a delayed absorbable or permanent suture cut to a length of 36–48 in. Additionally, when first performing this technique, it is recommended to use the extracorporeal approach with a closed knot pusher to secure knot placement, as this is the easiest method to both learn and teach. After knots are secured in place, the ureters should be inspected on each side, and an intraoperative cystoscopy should be performed. It is important that cystoscopy is performed prior to the removal of the laparoscopic ports, so that any ureteral compromise can be addressed prior to the completion of the case. For the main operative ports, a line is marked 16 cm cephalad to the inferior margin of the symphysis pubis. A left and right port are then placed 9 cm lateral to this mark once the abdomen has been insufflated. This is to prevent the robot arms from colliding with each other during the procedure. The third arm port is then placed on the left side, 4 cm superior and 3 cm lateral to the camera port.

Prognosis With aggressive treatment medicine identifier pill identification diltiazem 180 mg low cost, 75–90% hb treatment order genuine diltiazem, 2 year disease-free survival rate has been attained medicine xanax cheap diltiazem online master card. Prognosis is better when Wilms’ tumor is diagnosed before the age of 2 years and when its weight is under 250 g. Te common locations of neuroblastoma by a suprarenal mass and/or a paravertebral shadow are the abdomen and chest. Of course, there are Urine examination reveals an excess excretion of cat- recorded cases at any time from neonatal period to ado- echolamine and/or their metabolites, vanillylmandelic lescence. Fever, bone Treatment involves a combined application of surgery, pain, anemia and loss of weight are common presenting irradiation and chemotherapy with drugs like vincristine, complaints. Subcutaneous nodules, adrenal masses with cyclophosphamide, decarbazine and doxorubicin. Evans clinical staging of neuroblas- With the following two regimens, 50% of the patients under- toma is given in Box 33. Response to bone marrow transplantation, autologous marrow reinfusion after purging with cyclophosphamide derivatives, is being studied. If diagnosed after the age of 2 years, death occurs rapidly in over 80% of the cases despite adequate therapy. Around 80% or more with 2 year disease-free survival with therapy has been re- ported under one year of age. Next to leukemias, brain tumors constitute the most com- Hepatoblastoma mon malignancy of childhood. Tough quite infrequent, hepatoblastoma is still relatively Manifestations more common than the other primary tumor of the liver, A vast majority of them are infratentorial and close to mid- i. Vomiting, children under 3 years of age and involves predominantly headache, papilledema, ataxia, diplopia and personality the right lobe of the liver. Manifestations include noticeable abdominal distention with or without pain, anorexia, weight loss, anemia, fever Investigations and fatigue. Less frequent manifestations are vomiting, Skull X-ray often shows sutural diastasis and silver-beaten jaundice and, in boys, virilization. Liver biopsy may be done, but the fnal tissue diagnosis should be made at laparotomy. Treatment Treatment is radical excision of the involved lobe and iso- lated lung metastasis. Chemotherapy (cisplatin, vincristine, adriamycin) has a temporary, benefcial efect. Magnetic resonance imaging of a solid brainstem and seventh), ataxia, pyramidal signs and absent or mini- glioma which is the third most common posterior fossa tumor of childhood. Craniopharyngioma originates from cell rests of Rathke’s pouch and occurs at all ages. Clinical features Fourth Ventricle Tumor include raised intracranial tension, growth failure with Ependymoma occurs usually in the age group of 7–10 dwarfsm, bitemporal hemianopia, visual feld loss, years. Its characteristic features include local extension, diabetes insipidus, delayed puberty, calcifcation in early rise in intracranial tension, subarachnoid hemor- suprasellar or sellar region and ballooning of sella in rhage, cranial nerve palsies, pyramidal signs and calcifca- X-ray skull. Common pre- to white population), have a tendency to occur in adoles- senting features of supratentorial tumors are convulsions cents rather than young children. Clinical Features Manifestations include painful swelling with constitution- al symptoms like fever and malaise. Tis presentation may well initially give the clinician an impression of osteomy- elitis or eosinophilic granuloma. Diagnosis Diagnosis is supported by: X-ray showing mottled, lytic, onion-skin pattern must be confrmed by surgical bone biopsy showing round cell tumor. Rhabdomyosarcoma It is the most common among the multitude of soft tissue Clinical Features sarcomas in various tissues of origin (examples: primitive Manifestations include pain at the site of the tumor, local- sarcoma; fbrous-fbrosarcoma; lymphatic-lymphangio- ized swelling and warmth, limitation of movements, limp, sarcoma; blood angiosarcoma; synovium-synovial cell tenderness and erythema. Metastasis may lead to respira- sarcoma; smooth muscle-desmoid; striated-muscle rhab- tory embarrassment, pleural efusion, pneumothorax and domyosarcoma).

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Testimonials:

Osko, 31 years: The tip of the tunneling device should emerge lateral to the middle third of the urethra. A summary of nonevidence-based recommendations regarding nonurgent, com- mercial air travel after nonhemorrhagic stroke includes the following [26]: Time to travel for uncomplicated stroke: While no evidence suggests that earlier travel is dangerous, prudent thought suggests a waiting period of approximately 3–7 days (i.

Frithjof, 65 years: In the lung, ally initiated by allergen cross-linkage of the they cause immediate bronchoconstriction, bound IgE, a number of other stimuli can also mucosal edema and hypersecretion leading initiate the process, including the anaphyla- to asthma. Systemic degeneration Lumbar puncture z Cerebellar/Spinocerebellar z High pressure—intracranial infections, space- Friedreich ataxia Refsum disease occupying lesions Ataxia-telangiectasia z High proteins—meningitis Bassen-Kornzweig syndrome z High cell count with predominance of polymorphs— z Basal ganglia pyogenic meningitis Hepatolenticular degeneration z High cell count with predominance of lympho- Hutington chorea cytes—tuberculous meningitis Dystonia musculum deformans Hallervorden-Spatz disease.

Kor-Shach, 23 years: Dynamic magnetic resonance imaging before and 6 months after laparoscopic sacrocolpopexy. At faster rates (B) functional block occurs and activation proceeds around the block.

Koraz, 36 years: In this case, the Poisson distribution can be used to 1 For simplicity, the Poisson distribution is discussed in terms of intervals, but other units, such as a volume of matter, are implied. Satellite, or linked, potentials occur after the main potential and usually represent early reinnervation of muscle fibers.

Enzo, 43 years: The abductor pollicis brevis muscle inserts on the radial condyle of the first metacarpal and the adductor pollicis muscle inserts on the ulnar condyle. Similarly, when suprapubic catheterizable continent stomas have been constructed, indwelling catheterization through the stoma during the third trimester may be required to avoid recurrent urinary tract infections from status [60].

Jaffar, 41 years: The overall variance (difference between longest and shortest intervals) in 4-second snapshots was 31. Acute-onset unilateral weakness or speech defcit is concerning for stroke, and similar symptoms associated with altered mental status are concerning for intracranial hemorrhage, both needing diversion for time-sensitive treatment.

Oelk, 24 years: A large unilocular cyst tender and swollen with red and edematous adjacent may respond to intralesional sclerotherapy in the form of skin. As with A-V nodal reentry, drugs that produce retrograde block in the bypass tract are most effective in suppressing spontaneous recurrences.

Roy, 52 years: Obviously, there are some risks associated with this create a shallow hollow which can help deepen the angle. One of the strange phenomena about the an- tibody molecule, the immunologists faced, is Template Theories its specificity to foreign material or antigen.

Yussuf, 35 years: Phenol as a peeling agent may be used cedure, the skin is covered with a waterproof dressing and alone or in combination with other substances, such as water, left for about 48 h. The retrograde atrial activation can now conduct antegradely down the normal conducting system to produce an echo complex.

Porgan, 53 years: We know that even if our sample were drawn from a normal distribution of values, sampling variability alone would make it highly unlikely that the observed and expected frequencies would agree perfectly. Te lesions appear as grayish-white exudates Recurrences may occur in a proportion of the cases.

Malir, 47 years: Renal and pelvic ultrasound may demonstrate a dilated or abnormal upper pole renal moiety, and a cystic structure may be seen in the pelvis or vaginal area. Firstly, absolute eosinophil count which should be greater than 2,000/mm3 though in most cases it is much more than the cut off limit in tropical eosinophilia.

Ballock, 49 years: In our practice, we routinely advise a mild suppository on the second postoperative day to ensure normal bowel function prior to discharge. In posthysterectomy cases, the addition of a Breisky vaginal retractor is placed into the vagina to further delineate the anterior and posterior vaginal wall at the level of the vaginal cuff and apex.

Kulak, 40 years: Lung abscesses require lung isolation to prevent contamination of the healthy lung. That said, it is easier to try to secure all vascular elements with clips, as it is diffcult to apply sutures laparo- scopically in the liver as the tissue is very friable.

Navaras, 32 years: The potential disadvantages of bowel preparation include dehydration, electrolyte disturbance, patient discomfort, and intraoperation diarrhea. However, if a fistula is suspected based on the presence of patient risk factors, it must be ruled out.

Larson, 22 years: A decisive turn came in 1959 after the publication of Orentreich’s studies, which determined the beginning of Finally, Nataf [10, 11], resuming Passot’s ideas, described modern hair transplantation [8]. One study failed to confirm construct validity, with continent and incontinent women showing no difference in pad weight gain [75].

Ketil, 60 years: This process must continue in order for incontinence to be removed from the list of conditions associated with stigma so that people can and will seek help. Instead, application of controlled, low-level radio frequency energy results in acute, focal collagen denaturation (Figure 77.

Hjalte, 29 years: Posterior vaginal wall prolapse does not correlate with fecal symptoms or objective measures of anorectal function. Melike E, Erdem T, Ayhan N, Aydin S (2009) The effects of the size Fat grafting is plastic surgery’s “disruptive technology”.

Fadi, 56 years: When evaluating operative outcomes, careful consideration should be given to who performs the surgery as well as carefully deliberating which patients are appropriate for surgery. This is a blunt intramuscular procedure with some direct With the use of the cautery, the muscle incision is opened visualization; the goal is to maintain a 2–3 cm muscle thick- medially and laterally to its full fascial incision length.

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