TOM TAT pain in the epigastrium

Document Sample
TOM TAT pain in the epigastrium Powered By Docstoc
					                      LAPAROSCOPIC APPENDECTOMY
                       AT HOAN MY DANANG HOSPITAL

                                                                       Nguyen Tang Mien, Phan Phu Kiem
                                                                              Hoan My hospital, Da Nang

From 1-2002 to 7-2004, 401 cases of appendicitis were operated on laparoscopically at Hoan my
Danang general hospital. Of which there were 332 acute, 19 gangrenous appendicitis, 16 abscesses, 27
generalized and 7 localized peritonitis. In 28 patients, appendectomy was performed along with
enucleated and endocoagulated ovarian cysts or oophorectomy for ovarian cyst torsion (3 cases),
resection with electrodessication of pelvic endometriosis cysts (3 cases), resection of tube for abscesses
(4 cases) or ectopic prgnancy (1 case), resection of epiploic appendicitis or part of great omentum
necrosis (2 cases), and 14 adhesiolyses. There were no port infections. We performed only one (0.25%)
conversion to open exploration and experienced two (0.5%) complications in which one was peritonitis
needed reoperation and one was Douglas' pouch abscess needed endoscopic drainage but both were
safely discharged. Though the operative time is longer for laparoscopic cases, but patients had less pain,
early resuming of bowel movements, short hospital stay, sooner discharge and return to full activity in a
short time. It is preferred in obese patients who would require a large incision for an open approach and
in patients who are very concerned about cosmesis because minilaparoscopic approaches are based on
its low invasiveness and small surgical incisions.
Mortality was non-existent. Reoperation rate was 0.5%.
Laparoscopic appendectomy is now a safe and efficacious technique for all forms of appendicitis.

              ith the new trend and adventages of      METHODS
              laparoscopic surgery, a lot of
                                                       This is a prospective study of 401 cases of
              surgical diseases were operated on
                                                       laparoscopic appendectomy at Hoan my Danang
by laparoscopy, even though with very difficult
                                                       hospital from January 2002 to July 2004. Though
cases. Appendicitis, obviously cannot escape out
                                                       appendicitis is an urgent disease but for
of the orbit of this new application. But the most
                                                       laparoscopic surgery, all cases of laparoscopic
difficult thing is how to organize and to arrange
                                                       appendectomy must obey to some criteria as
for this kind of disease, full of emergency, being
able to run smoothly on way.
                                                         Laboratory     preoperative    examination:
From 1993-2001 only 21 cases were performed
                                                         Bleeding and coagulation time, BUN, ASAT,
at VietDuc hospital in Hanoi. At Choray
                                                         ALAT, ECG, chest X ray, urinalysis and other
hospital, at hospital of the University of
                                                         supplementary exams if the patient
Pharmacy and Medicine of Ho chi minh city and
                                                         experiences with codiseases.
at Hoan My I hospital, from August 1996 to
Agust 2000, 130 cases were operated on.                  Abdominal ultrasound
                                                         Evaluation of heart function with cardio-
From January 2001 to July 2004, 401
                                                         echodoppler on patient having cardiovascular
laparoscopic appendectomies were performed at
Hoan My Danang hospital. This report aims to
review the pathology, the manner of solution,            Patients with old incisional scar(s) were not
the surgical technique and the evalution of the          counterindicated         for      laparoscopic
the laparoscopic procedure of appendicitis.              appendectomy but the surgeon must pay
                                                         attention to introducing trocar.

  No counterindication in cases of peritonitis            Patient position: The patient was in supine
  unless in severe toxi-infection.                        position, inclined slightly 15 degrees on the left.
  The patient body weight must be more                    Surgeons' positions:
  than10 kg.
                                                            The surgeon was at the left of the patient,
Operative technique                                         facing to monitor screen.
                                                            The assistant was at         the right side of the
Apparatus and instruments:
  Olympus apparatus set composed of: Color                  The scrub nurse was in the opposite side of the
  videomonitor, camera control unit, Xenon                  surgeon.
  light source, high flow insufflation unit, mono
  and bipolar electrical surgical unit, videotape         Ports: We were fonds of using 3 ports:
  recorder, suction irrigator.                              One umbilical port of 10mm, one LLQ of
  Instruments: Trocar 10mm and 5mm (two for                 10mm and one RLQ of 5mm. Or
  each), telescope 300, scissors, hook,                     One umbilical port of 10mm, each at LLQ and
  maryland, grasper, thread pusher, suction                 RLQ of 5mm.
  irrigator tip.
                                                          Surgical method: We observed and evaluated
  Apparatus for        anesthesia,      resuscitator,
                                                          the appendicular lesions after looking for the
                                                          appendix by using maryland and grasper. Then
  Gas CO2 was used for insufflation                       we liberated the appendix from all adherences.
  Intra-abdominal pression kept at 7 to 12 mm             The mesoappendix was electrocauterized. The
  Hg.                                                     root of the appendix was ligated with a number 1
                                                          Vicryl loop of Roeder.The appendix was
                                                          divided. Simple wash or slight blotting with
  We      used    general   anaesthesia    and            gauze was enough.The appendix was retrieved
  premedication with hypnovel, atropine,                  off the abdomen. Ports were closed.
  dimedron. We started with propofol, fentanyl
  and used suxamethonium for myorelaxation.               RESULTS
  Forane and fentanyl maitained endotrcheal
                                                          The total number of patients was 401, in whom
  intubation. Arduan and norcuron were used as
                                                          there were 191 males and 210 females.
  long myorelaxants.
  We followed bio-parameters of the patient on            Geographically: 335 patients stay in Danang and
  Critikon and Dash 2000 monitoring for non-              66 in two neighbouring provinces. Of 66 patients
  invasive blood pression (NBP), SpO2, ECG,               there were 19 coming from Quang ngai, more
  respiratory rhythm and body temperature.                than 120 km far from Danang.

Table 1. The age of patients

  <10        10-16   17-20     21-30    31-40     41-50     51-60      61-70     71-80       >80     Total
   10         40      42        89        96       52        23         27         19         3       401
        50                                237                                      49

    12,46%           10,47              59,10%             5,74%                 12,23                100%

Body temperature:
Table 2. Patients’ body temperature at admission

Temperater (C0)                   37              < 38           >38             ≥ 39              Total
                                45,5%            41,1%          4,5%             8,9%
 Per cent of cases                       86,6%                         13,4%                       100%

Number of white blood count:
Table 3. Number of white blood count at admission

 WBC/ml                 <7000         7000-10.000           >10.000        >15.0000             Total
 Per cent of cases       4,4%            21,1%               48,9%          25,6%             100%

Time evaluation:
Table 4. Time from the first pain to admission, time fron admission to operation, operating time, post-
operative flatus passage time, hospital stay time

 Duration                                        Shortest             Longest                Mean
 From the 1st pain to admission                        2h               150h             22h 25 mn
 From admission to operation                           1h                15h              1h 48 mn
 Postop. 1st flatus passage                      7 h30 mn                68h             35h 20 mn
 Operating time                                     25 mn             160 mn                 60 mn
 Hospital stay                                        40h               144h             35h 20 mn

Table 5. Lesions found during operation

 Lesions                                                                 Number of cases
 Acute appendicitis                                                             332 (82.8%)
 Gangrenous appendicitis                                                        19 (4.73%)
 Abscess                                                                        16 (3.99%)
 Diffuse peritonitis                                                            27 (3.99%)
 Local peritonitis                                                              7 (1.74)
 Retrocaecal appendicitis                                                       20
 Paracaecal, paracaeco-colic appendicitis                                       6
 Retro-ileal appendicitis                                                       3
 Hepatic appendicitis                                                           1
 Fluid and pseudo-membrane in abd.cavity                                        143
 Fissure/rupture of Graaf follicle (ovulation)                                  9
 Ovary cyst                                                                     1
 Fissure/rupture of ovary cyst                                                  8
 Twisting of ovary cyst                                                         2
 Abscess of Fallopian’s tube                                                    14
 Endometriosis                                                                  11
 Adnexitis                                                                      19
 Pregnancy                                                                      1
 Tube pregnancy                                                                 3
 Fitz Curtis Hugh Syndrome                                                      1
 Intra-abdominal adherence                                                      1
 Incisional adherence                                                           4
 Abd.wall cicatrices                                                            4
 Varice of appendix                                                             2
 Sliding hernia                                                                 2
 Inflammation of caecum                                                         2
 Fatty liver                                                                    1
 Gangrene of epiploic appendix                                                  4
 Gangrene of a piece of great omentum                                           1
 Patient with patent ductus arteriosus                                          1
 Stercolith (s)                                                                 4

Accidents and complications:
Table 6. Accidents and complications

 Accidents and complications                                             Cases
 Post-op.haematoma at trocar port                                           1
 Bleeding at moment of trocar insertion                                     1
 Hernia at trocar port                                                      1
 Extrusion of great omentum at trocar port                                  1
 Post-operative peritonitis                                                 1
 Abscess of Douglas'pouch                                                   1
 Conversion to open laparotomy                                              1

DISCUSSION                                         There were 39.8% of patients experienced
                                                   their first pain originated at epigastrium then
All    appendicites  were     indicated  for
                                                   localized later at the RLQ. There were 60.2%
laparoscopic appendectomy      at Hoan My
                                                   of patients initiated their first pain right at
Danang hospital except patients with cardio-
                                                   RLQ. The epigastric pain was a precious
vascular disorders or with severe toxi-
                                                   indicating sign for positive diagnosis.
infectious state. We also did not use
laparoscopic appendectomy for infants              The duration time from the first pain to in-
weighing under 10 kg for we have not had           hospital admission of 21 hours 25 minutes was
means to follow carbhemoglobin though in           a relatively long time. There was one patient
view point of technique, there were not any        admitted on the seventh day of disease.
obstacles.                                         The time running from admission to operation
From January 2002 to July 2004, we performed       was 1 hour 48 minutes. It was a relatively short
401 laparoscopic appendectomies with quasi-        time but sufficient to prepare laboratory exams
equal parts between male and female patients.      and complete all procedures and we all know
There were 10 patients under 10 years old and      that laparoscopic surgery demands          more
40 patients from 10 to16 years old. The totality   numerous laboratory examinations than open
of patients under 16 years old was 50, occupied    surgery.
12.46%. The group of 20 to 40-year-old             We found        35.7% of patients presented
patients filled up 58.6% (235 patients). Most      exudate or turbid fluid at Douglas' pouch, at
patients were in the group of the age from 30      RLQ or pseudomembrane around the
to 40 years old (table1). The youngest patient     appendix. There were 9 cases accompanied
was 5 years old and the oldest was 88 (average     with ovulation. There were 2 cases of adnexitis
35 years old).                                     and 4 cases of tube abscess. We also found 3
Acute appendicitis took up 82.8%. There were       cases of marked exudation non-corresponding
34 cases of peritonitis (8.47%) in whom one        to the inflammed appendix (catarrhale form).
was 12 and other was 88 years old (table5).        We did not drain systematically all cases
About a haft of the total of patients showed no    possessing exudating fluid or peritonitis.
fever at admission. The body temperature at        Among 143 cases with exudation and 34
370 occupied 45.5%. There were 86.6% of            peritonitis, we applied only 28 drainages.
patients had body temperature under 380C and       Abdominal washing was also limited. It
only 13.7% manifested above 380 (table 4).         seemed sufficient to simple impregnation of
                                                   fluid with gauze even in cases of peritonitis.
The number of leucocytes more than 10 x 106/l
                                                   We washed the abdominal cavity only in 19
occupied 49.0% and more than 15 x 106/l filled
                                                   cases with the amount of water varied from
up 25.6%. So there were 25% of cases in which
                                                   some hundred millimeters to some liters.
there were no increase of leucocytes (Table 3).

There were 19 old cicatrices of the abdominal      Lately, we used bipolar electrocauterization to
wall (16 upper and lower midline, 2                cauterize the meso-appendix. Then a no1 vicryl
Pfannelstiel and 1 Kocher incisions). Hasson's     lasso loop aì la Roeder was tied at the root of
technique was not applied to these cases,          the appendix. Guillem et al. advised a double
except one with midline incision associated        ligature at the appendicular stump in case of
with thick abdominal wall.                         stercolith for avoidance of post-operative
                                                   abscess. But Beldi et al.(6) said only one knot
We found 20 cases of partial or complete
                                                   was enough.
retrocaecal appendicitis. There was only one
retrocaecal case required a fourth port at RUQ.    We often clamped the appendix at 1 cm from
There were 6 paracaecal or paracolic, 3 post-      the stump knot and divided the appendix
ileal appendicites and particularly one sub-       without using a second knot and the resected
hepatic case (table5). These abnormal cases        appendix was put right in a condom. In case of
were obviously more difficult to devide the        using two 5mm ports at RLQ and LLQ, gauze
appendix, easily injured to intestinal loops and   wicks and condom were retrieved through
hardly controlled bleeding. Thus, the operating    umbilical port by pushing them into umbilical
time lasted rather long with these                 trocar while RLQ trocar and umbilical one
circumstances.                                     faced in alignment. We were fond of using 10
                                                   mm port at LLQ for it was very convenient
We kept the abdominal pressure at 7mmHg in
                                                   especially when we had to use several gauze
infants and maximal pressure 12mm Hg in
                                                   wicks. If there were fluid or pus in Douglas’
adult. The operating time varied according to
                                                   pouch or in abdominal cavity, aspiration and
the    position,   degree      of adherance,
                                                   wipe with gauze wicks were sufficient.
inflammation of the appendix. The shortest
                                                   Drainage through the 5 mm port at RLQ if
operatin time was 25 minutes and the longest
was 160 minutes (peritonitis).
                                                   In cases of ruptured appendicitis ending in
Normally, we used three ports: one 10mm at
                                                   local or diffuse peritonitis, there were no
the umbilicus for telescope, one 5mm at the
                                                   differences in operation in comparision with
RLQ and one 10mm at LLQ. The 5 mm port at
                                                   appendicitis, except careful controle of
RLQ could be replaced by a 5mm above pubic
                                                   intestinal loops lest it would persist pus
but this formed a narrow working angle with
                                                   between them and adequate washing of the
LLQ port. With 10mm port at LLQ, gauze
                                                   abdominal cavity with much water and good
wicks or endobag were easily put into or taken
                                                   drainage. With laparoscopic procedure, we
out of abdominal cavity. If 5mm port was used
                                                   could wash cleanly, even very cleanly the
at LLQ, there had been a time at which we put
                                                   abdominal cavity. Ball et al. advised using
wicks or condom blindely into abdominal
                                                   laparoscopic technique as the initial procedure
cavity in the absence of guidance of telescope.
                                                   of choice for most cases of complicated
At the end of operation, gauze wicks and
                                                   appendicitis. Yao et al.(30) reported that
condom (endobag) had been retrieved out of
                                                   laparoscopic appendectomy were feasible for
abdominal cavity through the 10mm umbilical
                                                   ruptured appendicitis or in cases of abscess
port. In reality, there was no difference in
                                                   formation. Laparoscopic appendectomy was
operation between the choice of 5 or 10mm
                                                   also a safe procedure for complicated
port at LLQ, but with 5mm port we gained
                                                   appendicitis in children.
much cosmesis and with 10mm port much
convenience. The appendix stump was then be        We       performed      safely     laparoscopic
sterilized by monopolar electrocauterization or    appendectomy for 4 four-month pregnant
by betadine application. We preferred the          women. Afflect et al. and Rollins et al. reported
former than the latter.                            that laparoscopic management of appendicitis
                                                   and       symptomatic cholelithiasis during
For domination of appendicular vessels, at the
                                                   pregnancy were able to be performed with
beginning we used a maryland passed through
                                                   minimal foetal and maternal morbidity, without
an avascular area of the meso-appendix and
                                                   birth defect or utrine injuries, occuring of
tied the meso with a no 1 vicryl out-abdominal
                                                   preterm delivery, birth weight change or 5-
established Roeder’s knot. We did not use clip.

minute Apgar scores alteration of new born.            surgery because of difficulty in affirmation of
                                                       the appendix due to its huge cystifying
We had not suitable instruments for infants but
                                                       formation. In order to reduce conversion rate
with normal instruments for adults, operation
                                                       and infection complications, surgeon must
was still feasible for them. Of 46 cases of
                                                       increase their laparoscopic skills. Their studies
petients under 16 years old, only one was
                                                       showed that the rate of attempted laparoscopic
complicated with Douglas' abscess by lack of
                                                       appendectomy rose from 67% to 100% for
cleaning the Douglas' pouch in a gangrenous
                                                       perforation and low conversion rate from
appendicitis. Vernon et al. showed the
                                                       100% to 22%. Over half of their patients could
operative times and post-operative lengths of
                                                       be managed as out-patients without jeopardy to
hospital stay were similar in laparoscopic and
                                                       outcome. Carus et al. reported the rate of
open appendectomy. Suttie et al. assessed that
                                                       reoperation was 1.4% (of 280 patients) and
extracorporeal technique to be significantly
                                                       wound infection was 3.5% compared to 8.2%
quicker with a slightly increased complication
                                                       with open appendectomy.
rate than intracorpreal one. Intra- and extra-
corporeal laparoscopic appendectomy can be             The rate of appendix perforation, mal-
applied safely for acute appendicitis.                 diagnosis, post-operative complications and
                                                       mortality rate were reliable to the time flowing
At the old age, the evolution and outcome of
                                                       from the appearance of the first pain to the
appendicitis are different (14, 27), it might be due
                                                       admission and the moment of operation. Rub et
to retardation in reaction of the elderly.
                                                       al. reported that perforated appendicitis
The mean operating time was 60 minutes,                occupied 45% with a mortality rate 3.2% in
longer than open surgery but not so long for           elderly.
discussion.. The time of flatus passage after
                                                       The interesting thing is with laparoscopic
operation was 35 hours 25minutes, more
                                                       appendectomy we can easily discover some
shorter than open surgery. Nouaille J.M.
                                                       accompanied lesions or verify the false
reported 98% of patients presented flatus on
                                                       diagnosis of appendicitis such as epiploic
the first day. The patient was able to drink and
                                                       appendicitis that we met two cases. The
eat at ealier time. This permitted a short mean
                                                       epiploic appendicitis is an uncommon lesion
hospital stay of 66 hours 36 minutes. This rapid
                                                       and the diagnosis is usually made at surgery as
post-operative recovery showed a real benefit
                                                       the disease is generally mistaken for an
of laparoscopic appendectomy. On the
                                                       appendicitis. CT scan allowed a non-invasive
average, our patients were discharged on the
                                                       diagnosis with manifestation of a fatty mass
third day. Nouaille J.M. gave an account of
                                                       located to the antero-lateral wall of the colon,
70% of patient were discharged on the first
                                                       deliniated by an hyperattenuating rim and
day and 27% on the second day while Alvarez
                                                       infiltration of the peri-colic fat, and avoiding
et al. reported even with ruptured appendicitis,
                                                       an unnecessary surgery because it can be
patients could be discharged 24 hours after
                                                       managed conservatively. We also performed
operation without any cases of readmission or
                                                       along with laparoscopic appendectomy other
having complications (38 patients).
                                                       lesions found at operation like resection of
In a total of 401 cases of laparoscopic                twisted or not twisted ovary cysts (3 cases),
appendectomy, we did not find any case of              electro-dessication of endometriosis (3 cases),
complication during operation. There were              tube abscesses (4 cases), ectopic pregnancies
only one post-operative peritonitis and an             (1 case), infarctus of part of great omentum (2)
abscess of Douglas’ pouch due to lack of               and adhesiolysis (14).
controle of the intraluminal content of the
                                                       There were no lesions occurred when making
appendix and negligence of cleansing of the
                                                       incisions for ports or screwing trocars through
Douglas’ pouch. Agresta et al. reported per-
                                                       ports, even though in cases of having old
operative complications were 0.39% in
                                                       midline cicatrices. Exception        was one
laparoscopic appendectomy and 0% in open
                                                       hematoma at trocar site that self resorbed 10
                                                       days later and one bleeding at port obliged to
We had one case of conversion into open                widen for hemostasis and later appearing

hernia.                                             REFERENCES
There were no wound infections.
                                                    1.   Alvarez C., Voitk AJ.: The road to ambulatory
The mortality rate was 0%. Agresta et al.                laparoscopic    management        of     perforated
reported that the post-operative mortality rate          appendicitis. Am. J. Surg. 2000 Jan.; 179(1):63-6.
was 0.4% and reoperation rate was 1.1%. Our         2.   Ball C.G., Kortbeek J.B., Kirkpatrick A.W.,
reoperation rate was 0.5%.                               Mitchell P.: Laparoscopic appendectomy for
                                                         complicated appendicitis : an evaluation of
Laparoscopic appendectomy gave an accurate
                                                         postoperative factors. Surg. Endosc. 2004 Jun.;
diagnosis, a complete estimation of lesions,             18(6):969-973.
less post-operative complications and short         3.   Beldi G., Muggli K., Hebling C., Schlumpt R.:
hospital stay      than open appendectomy.               Laparoscopic Appendectomy Using Endoloops: A
Particularly in cases of gangrenous or ruptured          prospective Randomized Trial. Surg. Endosc.
appendicitis, the hospital stay length and the           2004 May; 18(5):749-750.
operating time showed much shorter.                 4.   Boudiaf M., ZidiSH., Soyer P., Hamidou Z., Panis
                                                         Y., Felage JP., Rymer R.: Les appendicites
Laparoscopic      appendectomy      has    been          epiploiques         primitives:       diagnostic
popularized all over the world since more than           tomodensitometrique     pour    un   traitement
a decade and has been considered as a safe               conservateur. Presse Med. 2000 Fev.; 29(5):231-
and effective surgery (Browne D.S., Aust. NZ             6.
Obstetr. Gynecol. 30:231, 1990; Bryant TI, J.       5.   Guillem P., Mulliez E., Proye C., Pattou F.:
Laparoendosc Surg 2:343, 1992; Cox MR vaì                Retained appendicolith after laparoscopic
                                                         appendectomy: the nee4d for systemic double
Cs, Aust NZ J Surg 63:840, 1993; Pier A. vaì
                                                         ligature of the appendiceal base. Surg. Endosc.
Cs, World J Surg 17:29, 1993). It was olso               2004 Apr.; 18(4):717-718.
confirmed by EAES conference in 1995 (Surg,
                                                    6.   RA.:a Appendectomy in the pre- and post-
Endosc. 9:556, 1995). We think that it does not          laparoscopic eras. J.Gastrointest. Surg. 1999 Jan.;
matter of position, state and stage of lesion of         3(1):67-73.
the appendix, all can be operated on by             7.   Nguyeãn hoaøng Ñònh vaø Cs: Möùc ñoä an toaøn vaø
laparoscopic surgery with good result in adults          hieäu quaû cuûa caét ruoät thöøa noäi soi. Hoäi nghò khoa
and in infants. These consideration were                 hoïc chaøo möøng thieân nieân kyû thöù 3. Hoäi ngoaïi
similar with those of a great deal of authors. It        khoa Vieät nam 8-9.12.2000, 41. Ngoaïi Khoa, soá
                                                         4-2001, 6-10.
is important do not forget cleanse up the
Douglas’ pouch for avoidance of a complicated       8.   Nguyeãn Taêng Mieân, Phan Phuù Kieåm, Traàn vaên
                                                         Long, Nguyeãn Thò Leä Hoa: Phaãu thuaät noäi soi caét
residual abscess.
                                                         ruoät thöøa. Noäi san Y khoa Beänh vieän Hoaøn Myõ
                                                         2003, Soá 3: 11-18.
CONCLUSION                                          9.   24- Paya K., Rauhofer U., Rebhandl W., Deluggi
Laparoscopic appendectomy provokes little                S., Horcher E.: Perforating appendicitis, an
                                                         indicating for laparoscopy? Surg. Endosc. 2000
pain, rapid re-establissement of bowel
                                                         Feb.; 14(2):182-4.
mouvements after operation, so the patient can
                                                    10. Rollins M.D., Chan K.J., Price P.R.: Laparoscopy
drink and eat earlier in the post-operative time.       for appendicitis and cholelithiasis during
All these reduce the length of hospital stay.           pregnancy: a new standard of care. Surg. Endosc.
The patient rapidely return to normal activities.       2004 Feb.; 18(2):237-241.
On the other hand, with laparoscopic surgery,       11. Suttie SA.: Outcome after intra and extra-
the incisions for trocar ports are very small,          corporeal laparoscopic appendectomy technique.
they show very cosmetic, suitable to female,            Surg. Endosc. 2004 Jul.; 18(7):1123-1125.
obese or diabetic patients. Laparoscopic            12. Vernon A.H., Georgeson F.K., Harmon C.M.:
appendectomy is an approach of choice for               Pediatric laporoscopic appendectomy for acute
                                                        appendicitis. Surg. Endosc. 2004 Jan.; 18(1): 75-
whom the early return to work is necessary, for
athletes, and for all who concern about
cosmesis of the abdomen.


Shared By: