To remove sutures, one tail of the suture should be grasped with forceps and pulled gently towards one side to the wound, elevating the knot. Additional alternating throws are added to secure the knot, and all three strands (1 from the long strand and 2 from the short loop) are cut 3-4 mm from the knot. Required fields are marked *. The suture only passes through the dermis of the tip and avoids strangling the tissue. However, take care not to tie mattress sutures too tightly as doing so may cause tissue strangulation and result in necrosis of the tissue on the suture-tissue contact areas. The mattress suture provides more eversion up to the point where you may get opening of the wound edges. Running horizontal mattress suture. Rather, the subcuticular suture is applied under the epidermis using either an absorbable suture or a non-absorbable suture leaving external knots at the far ends of the laceration or incision so that the suture can be removed easily. The far near, near far type of buried stitch results in better eversion of the wound edges. Sometimes the situation does not readily permit these dermal sutures and the vertical method comes into its own. Before you step into any situation requiring suturing, even an emergency in your own home, you can perfect your suturing skills. That is to say, when done correctly, they give the best cosmetic outcome. If the suture material breaks in a running suture, the whole wound will break down so be sure to secure the knots on the 2 sides and consider adding a couple of strategically placed interrupted sutures in addition to the running suture. Each subsequent bite should be the same size and at the same depth. 14. This technique is commonly used when the wound is actively bleeding and saving time is critical, such as a scalp laceration. If pulley stitches are used they must be removed promptly in order to avoid crosshatch scarring. The main driver of choice of technique in suturing is the operator’s/surgeon’s personal choice in a specific situation. A running suture, also known as a continuous suture, consists of one strand of suture material that runs for a lengthy distance along a wound, normally in a zigzag pattern, which is tied at either end. There is very little difference between regular running and interlocking running sutures. The far-and-near suture is a modified vertical mattress stitch that uses the tension created by a pulley action to close wound tissue. Care must be taken, if knots are not tied deep under the skin they can erode through the wound whilst healing. Using this technique, you begin by using a nonabsorbable suture, running the suture as described above. 5:05. Predictably, the purse-string suture will not give a good cosmetic result because it will bunch-up the tissue. Often a doctor back-stitches into the previous suture … Thank you for your kind comment on our website. Individual interrupted sutures also bring a limited quantity of tissue towards the closure margin – and thus in friable tissue it has a higher tendency to “pull through” when tying the knot. The first is ensuring that wound edges are not inverted during closure. Minimal scarring occurs because external sutures are not used. Master Suturing Techniques Through The Apprentice Doctor! The needle is inserted at the far right corner of the wound, parallel to the incision line, beginning approximately 2-5 mm from the apex. In some situations non-suturing methods are better options than traditional suturing approaches. • Allows stitch to be left in for 2 weeks without stitch marks. Synonym: sutura See: raphe ; synarthrosis 2. This suturing technique is used to create moderate tension to prevent hemostasis and to improve wound tension strength for better healing. Running sutures tend to bunch-up the tissue and shorten the wound length due to the tension needed to keep the wound margins together. How to remove your daytime running lights on a 96 99 Chevy. Running Weight Loss: How To Remove Love Handles. Otherwise one gets a void below the surface along with associated problems like wound inversion, hematoma formation, wound infection, and wound dehiscence. Keep in mind that new non-suturing closure methods are being developed that may be used as alternatives to suturing closure methods. The line of union in an immovable articulation, as those between the skull bones or the articulation itself. In a very deep wound, several layers may be necessary to close the defect. The knot is tied and the suture cut very short. • In a long wound it is best to bring the suture out onto the surface half way along, cross over and into the other side before continuing with the subcuticular part. Doctorryanc. Therefore, it is vital to proper wound healing and scar reduction to suture wounds so that edges are everted, or slightly lifted outwards. All Rights Reserved. 2. Using the tissue forceps, expose the skin towards the end of the right side of the wound. jessrey725. If the choice is a thin Nylon suture remember to remove the suture within 5 days to avoid having to dissect out fragments of suture material from the semi-healed wound margin. In esthetically sensitive areas, like the face, a surgeon will remove stitches/sutures by day 4 or 5 and secure the wound with Steri-Strips for another couple of days in an effort to avoid cross hatching scars. The first involves suturing only the mucous membrane of the intestines. Awesome article, thanks for the illustrations and time put forth, I am a Trauma/Acute Care Surgery, and a PA instructor. To bring more volume or quantity of tissue to the closure area. Although the use of ‘Steri-Strips’ and ‘suturing glue’ is tempting, it can only be used in very superficial wounds. This brings with it the possibility of leaving needle marks in the form of a visible row of small scars on either side (cross hatching suture marks) next to the wound margin. The thickness and absorbability of the thread are also important. Purse-string sutures are typically used to close circular objects such as an areola or to close the opening after removing a chest drain (instruct the patient to take a deep breath and forcibly exhale against closed nose and lips). Th… This suture resembles those used on baseballs, and so, they are sometimes called baseball sutures. A knot is tied and the free end of the suture tail is cut leaving a small tail [Figure 1a]. There is no need to wait on getting practice with suturing. Suturing Techniques – Guide (Infographic), https://www.theapprenticedoctor.com/shop/, https://www.theapprenticedoctor.com/elearning/suture/. Other Kits/Courses – STB/Phlebotomy and IV skills Scrub for Surgery training and Fracture reduction. This suture will be the anchor for the rest of the suture line. The Lembert suture is another technique used in gastrointestinal surgeries. A circumferential stitch can be worked around the artery. Thanks a lot for this easy to read, educative and knowledge loaded article, kudos to you and more of this will be appreciated. The Apprentice Doctor® Deluxe Suture Kit & Online Training Course teaches you how to confidently close wounds. The medical professional will also take into account what works best in his/her hands. Also, tissue ischemia is reduced by using the 3-corner suture. 1:10. The ends are snipped flush with the skin at 10 days. This allows for better... 2. • Remove at 7-10 days by cutting one end very close to the skin end before pulling through from the other end. The secondary goal of suturing is minimizing scar tissue formation. In a very deep wound, several layers may be necessary to close the defect. The technique can be used on either thin or thick skin and utilizes two bites. The time to suture removal depends on the location and the degree of tension the wound was closed under. According to one study, up to 50 percent of patients receiving retention sutures require premature removal due to complaints of pain. The knot must be formed at the deep aspect to avoid sticking up through the wound. The downside is that retention sutures often cause pain and severe discomfort to patients. 1. This technique is effective at reducing the formation of seroma (swelling or lump in the underlying tissue due to serum accumulation in a localized area). A relaxation suture allows for loosening in order to relieve such tension. The suture will retract under the skin (Figure 1B, C, and D). Both proper healing and minimal scarring are achieved by accomplishing two main objectives. The purse-sting suture is a running suture used to close round defect wounds or openings. Action: Holding the needle with needle holders, place a simple interrupted suture and knot it, but only cut the end of the suture material that is not attached to the needle. https://www.theapprenticedoctor.com/shop/ The downside is that interrupted sutures take considerably more time to place than continuous sutures. It is fast with acceptable cosmetic results. Inversion will delay and/or compromise the healing process and leave an unsightly scar. You may consider using the far-near suturing technique which is a variation of the vertical mattress suture. Running subcuticular sutures are considered to be the “holy grail” of suturing techniques by many. ... To begin the next line, bring the needle up in line with the end of the stitch in the first line. Currently the most widespread technique, which was also used at our center until 1998, is an end-to-end anastomosis with a running suture on the membranous portion of the bronchus and single stitches on the cartilaginous part. The wound edge should be everted and the angle of the needle adjusted to ensure that the angle of entry is 90° to the skin surface. The downside is that vertical mattress sutures can only remain in place for 5-7 days or risk is high for permanent crosshatch marks. The suture needles, materials, and techniques selected are at the discretion of the surgeon or medical professional assessing the wound. The medical professional will select the appropriate needle, suture material, and suture technique depending on whether or not they want to achieve deep tissue dead space closure, lesser or greater wound tensile strength, less scarring, ease of application or care, etc. A variation of the running percutaneous suturing technique involves “locking” each loop of suture as you go. Do not leave interrupted facial sutures in for longer than 7 days. The start and finish of the suture can be performed in any fashion. This suture technique is accomplished by passing the needle through the loop created by the previous suture, locking it into place. This technique is also used to better approximate edges of skin of varying texture or thickness. The vertical mattress technique is an excellent choice for achieving wound edge eversion and approximation. This varies between surgeon and situation, but as a general rule sutures on the head and neck are usually removed between five and seven days post-operatively, while sutures on trunk or extremity wounds are typically removed between ten and fourteen days. However, ,the sutures are easily removed, making it a common technique to use on children. The downside is when used externally on the skin permanent hatch marks may remain. Running sutures spread the suture tension evenly throughout the wound – and this may be important when working with tissue that has a soft consistency. The running locked suture is similar to the simple running stitch, but the person passes the needle through the previous suture's loop to lock the suture in place. When closing, strengthen the wound margins with Steri-Strips if needed. Nylon materials are more slippery than braided materials or silk and hence care is needed in tying the knots. Frost sutures prevent the eyelid (mainly the lower eyelid) from turning outward, known as ectropion. Interrupted sutures are sutures that are placed and tied individually. Feel free to request an free evaluation kit. If absorbable monofilament suture is used (e.g. This technique is used to provide strong reinforcement of deep muscle and fasciae in the wall of the abdomen. This can have 2 or 3 turns with up to 3 throws on the first turn. Tie with a square knot (Fig 1). The suture material is passed in and out of the tissue as a running stitch and then drawn closed like closing a purse or a bag. This loop can be cut at the time of suture removal so that there are 2 short pieces to pull out. An operation in which soft tissues of the body are united by stitching them together. The needle is inserted at the base of one side of the wound and brought up near the skin, crosses the wound to the opposite side at approximately the same level, reinserted and run down to the base of the wound again. However, care must be taken to not tighten excessively or tissue ischemia can result. I’m glad you enjoyed it and found it helpful. Rationale: The knot should be positioned away from the incision (see simple interrupted above). Continue working stitches where there are spaces in the previous line … Loop the suture away from you around the needle holder twice, then grasp the suture end with your needle holder. The needle holder is rotated counterclockwise once around the long end of the suture. A person stitches the running subcuticular suture horizontally into only the dermis layer of skin, not the epidermis. There are two uses for Czerny’s sutures. Dr Yasser (Mt Sinai) and I made this video to demonstrate how to remove a running suture. Again, the type of suture technique or method must be determined by the treating physician or medical professional with the goal of achieving optimal wound healing and minimal scarring. Keep in mind that the knots may take a bit longer to resorb due to the increased amount of suture material left inside the wound. (with inverted knot) - Most wounds should have some buried sutures in vicryl or PDS. Let go of the suture with your needle … The initial throw is passed from the epidermis on the opposite side of the wound, through the wound, and then out of the epidermis. The Running-X begins with a simple interrupted stitch. The size, curve and point on the needle should be chosen to suit the job. In essence, it is a “combo-interrupted subcutaneous and skin closure suture.”. Use this suture to save a bit of time when closing a long incision. Suturing Techniques – Indications and Contra-indications, The Apprentice Doctor® Deluxe Suture Kit & Online Training Course, Surgical Suturing Techniques Mastery Guide. Harris Kit. 3:34. If infection occurs in one part of the wound only a few interrupted sutures need be removed to treat the wound leaving other sutures intact. Since a wound of this nature is in the hairline, in most cases the cosmetic result is usually not critical. No specific technique fulfills the exact requirements of a specific would closure. Thread the suture back though the skin down the length of the wound, using the tweezers.You will grasp the length of thread running over the skin surface and gently pull upward allowing the suture to slide out of the skin. These skin sutures can be removed after only a few days, as the deep sutures remain in situ to maintain the strength necessary for wound healing. Extra turns need to be put in, particularly into the first throws where it is recommended that two, or occasionally three, turns are used, with one turn of the opposite way for the second layer, and one turn again the opposite way to that in the third layer; in other words in the same way as the first throw for the top layer. This is used for closing deep spaces and gives very nice eversion of the wound edge. A running suture, also known as a continuous suture, consists of one strand of suture material that runs for a lengthy distance along a wound, normally in a zigzag pattern, which is tied at either end. Pull on the fishing sinker and cut the end of the suture at the skin level after closing the skin with a running suture (usually with a trichophytic closure). Also called the far-near-near-far suture or the pulley suture, this is a variation of the vertical mattress suture favored by some surgeons. The suture of choice in this scenario tends to be Monocrylas it is a smooth absorbable monofilament that has reasonable strength and doesn’t cause much irritation to the skin. The horizontal mattress is also effective at everting wound edges and provides fair approximation. Certain anatomical areas like the retroauricular skin, are prone to wound inversion, and this is an indication for placing horizontal continuous mattress sutures. closing the incision between the oral and nasal cavities following a Le Fort 1 osteotomy. The double-arm suture is achieved by using a suture containing a needle at each end. It can be used as an initial layer for a longer, higher-tension wound in order to create a lower tension environment for closing the wound with deep dermal sutures within the wound followed by either simple interrupted or running percutaneous sutures closer to the wound margins. Because the pulley stitch reduces the surface area of large wounds in which closure cannot be accomplished completely by traditional side-to-side sutures, it is an excellent technique for areas such as the legs and scalp. Simple Running Closure is useful for straight incisions with minimal tension. It is performed using a continuous stitch. This is achieved with deep sutures. Remove every second suture until the end … Puncture the right side of the skin (take a bite). The suture is useful for closure of deep wounds on the trunk and limbs as the suture retains its strength for several weeks. Here, the short end is being passed to the thumb and index finger of the left hand, which will rotate the short end clockwise. Retention sutures lessen tension on the primary suture so that wound disruption is limited. Tie with a square knot. The needle is passed from this point, which is lateral to the incision apex, directly through the epidermis, exiting into the interior of the wound just medial to the … Hand in hand with that, they are certainly the most technically challenging and time consuming of suturing techniques. They close the dead space and take the tension off wound edges. The drawback is that the procedure is extremely time-consuming. This reason is especially important when you want to optimize the time it takes for a wound to heal, especially when one closes a fistula, such as closing an oroantral fistula (an opening between the oral and maxillary sinus cavities). Use the running suture on an actively bleeding scalp wound when fast action is important to minimize blood loss. Once the skin edges are lying together, the monofilament nylon is inserted as an interrupted or running suture. By default, always use absorbable sutures when using this technique, The (vertical) ‘Figure of 8 suture’ is a combination of a subcutaneous and a surface skin suture. One can either use absorbable or non-absorbable sutures when placing subcuticular sutures. You will want to gently lift up on one of the knots in order to cut into the suture material past the knot. Similar to the double-arm suture, Gély’s suture uses suture material with a needle at both ends to close intestinal wounds. Apposition of the wound edge is easily achieved using the subcuticular continuous suture. Healing can only occur properly if the two severed areas of tissue align and remain intact. Unlike running sutures it will not distort the form of the wound. • Especially useful on breast and flexures. This brings both ends, the needle end and the other free end, to come out at the bottom of the wound. This suturing technique is primarily used to eliminate dead space in the depth of a wound. For the inexperienced this is the preferred technique due to its ability to close a wound cleanly and securely. • The needle enters beyond one end of the wound and emerges between the wound edges. All wounds, except the smallest, should be sutured in layers. Eliminating dead space and achieving wound edge eversion and approximation are key elements for the proper healing and minimal scarring of a sutured wound. Running the suture, as outlined in the video above, increases efficiency of placement for longer wounds. The needle enters the skin normally but exits at mid dermis level before passing through the mid dermis of the tip and then through the mid dermis of the other side of the wound and out through the skin. One would not even have to replace a single interrupted suture if it loosens up so long as the resulting dehiscence is minimal and not in a critical area. A skin hook also helps to ensure that the angle of exit is also 90°. Begin training today! Aim for about half a cm down from the end of the wound with a 90... 3. Your email address will not be published. Polypropylene (Prolene; Ethicon) suture (0, 2-0, 3-0, 4-0, and 5-0) was used throughout this study. According to site one or several layers of sutures may be needed to close a wound. 2:48. This added step will allow each loop of suture to act more independently in holding tension (almost like, but not quite as good as, a simple interrupted suture). This technique will avoid irritating the area with the 2 free ends left by a normal interrupted suture. Running stitch is a basic and versatile stitch. With a mattress suture, the chances of dehiscence are significantly reduced. It is recommended that interrupted sutures are used initially. To prevent the knots from the buried sutures being ejected through the skin, the knots are tied at the lower part of the suture so that they will lie in the deepest part of the wound. Surgical Suturing Techniques Mastery Guide (Article written by Dr Anton Scheepers who is a Maxillofacial and Oral Surgeon and founder of The Apprentice Doctor). If the sutures are tied too tightly, tissue strangulation is a … PDS) the suture can be left. Use running sutures when esthetics are not important and when you want to save time. Before the suture is looped over again, the suture thread is connected to the visible suture … This is the process of ensuring that edges are brought together as evenly as possible during suturing. Prolene or nyloncan also be used as thes… New methods include absorbable staples, sterile strips, and topical adhesives which can be used in combination with applied suture techniques or alone. There should be minimal tension on the most superficial stitches. • Cross over to take a bite on the other side backing up a little so that the opposing sutures are staggered. The horizontal half-buried mattress, or 3-corner suture, is used to close flapped or V-shaped wound edges. Instrumental Tie 1. A bite is taken horizontally on one side of the wound followed by an equal sized bite on the other edge so that the needle emerges exactly opposite the initial point of entry. The knot is tied and the suture cut very short. When applied correctly, subcuticular continuous sutures provide the best outcome for cosmetic results. Although the running subcuticular suture is well described in surgical textbooks, 1 the “four-step method” is unique in that it separates and quantifies each component. Figure 1. If you perceive that a specific suture is not ideally placed you can remove it and place it in a better position, unlike the running/continuous sutures where you may need to redo the entire running suture. Course: https://www.theapprenticedoctor.com/elearning/suture/ A flap of skin is sutured using multiple stitches to the underlying tendinous expansion sheet (aponeurosis) that normally connects muscle tissue with its movable parts. Another locking running stitch is the interrupted stitch, which is the running stitch with the thread knotted after each suture. Running sutures are useful for long wounds in which wound tension has been minimized with properly placed deep sutures and in which approximation of the wound edges is good. This suture technique is used when a wound is expected to create excessive tension. The subcuticular suture will allow for a very pleasing esthetic result in most cases, but it offers very little wound eversion by itself. Doctorryanc. This suturing technique is used during surgeries of the eyelid. With the first step, the skin is gently everted using an Adson forceps to visualize the dermal-epidermal junction ( Fig. Surgeons will have to get wound eversion by properly placing the subcutaneous sutures if they intend closing the surface with subcuticular sutures. 3. Interrupted sutures offer the highest level of control over wound closure and the result. The short end of the suture is pulled through the loops of the long end by crossing the hands, so that the two ends of the suture are on opposite sides of the suture line. However well placed buried dermal sutures should produce similar results. Laceration Repair with Running Horizontal Mattress Suture. Always use absorbable sutures when using this technique. To increase the interphase or contact between the raw surface areas of two opposing wound sides. It can be applied as either an interrupted or continuous suture that repairs the collagenous submucosal layer without disturbing the lumen. If in doubt, suture properly under anesthetic for improved healing and an aesthetically pleasing result. This technique is used to suture tubular structures such as blood vessels in order to stop bleeding or reestablish blood flow. 5. • The skin edges should already be in apposition with no tension. It is tempting to use these shortcuts in the pediatric trauma patient, especially under the pressure that exists treating a child in the emergency room. Video created by Dr. Michael R. Zenn at Duke University.Subcuticular Running Suture officially recommended for Surgery Clerkship requirement. • Continue to the end and emerge beyond the wound. However, it is sufficient to insert a cross stitch which enters and leaves the tissue on one side, is carried across the vessel and enters and leaves the tissue on the other side. The suture thread is knotted at one end of the wounded area, and the thread is then looped over the top of the cut. If using a blade to cut the suture, point the blade away from you and your patient. The surgical knots in a running suture will be located on either end of the wound. The second splits ruptured tendon ends and sutures the other end into the created slit much like a male/female coupling design. • repairing a long wound without a loop in the middle - it may be impossible to remove, British Society for Dermatological SurgeryPromoting Excellence in Skin Surgery, Mohs Surgery & Lasers, Surgical & Skin Cancer Award (previously known as Small Grants Award), Planning the Operative Proceedure, Basic Anatomy, Basic Instruments, Facilities, Sterilization, Local Random Flap – Subcutaneous island Pedicle, Surgical Management of Non Melanoma Skin Cancer, Surgical Management of Primary Cutaneous Melanoma, Safe Practice Against Blood Borne Virus Infections, Guidelines for Skin Surgery in General Practice, Medicolegal Aspects of Dermatological Surgery, Model Forms, Consent, Pre-Operative, Post-Operative. Pull the needle holder towards you and push your non-dominant hand away to lay the first knot. The disadvantage is that suture breaks can cause wound gaps to occur. Pulley sutures can be used as temporary assisting stitches, such as lessening tension for buried sutures, or they can be left in for later removal. Running suture using a straight needle. If dead space is not eliminated blood may pool in the wound leading to hematoma and consequently wound strength will be compromised, increasing the risk of infection. Each aspect of wound closure is important and attention to detail will give superior cosmetic and functional results both in the short and long term. Continuous locking sutures are commonly used for breast reconstructions, intestinal surgeries, and hernias, where soft tissue requires secure stitching. Copyright © 2021 The Apprentice Doctor. This is a very good teaching tool. The primary goal of suturing is to approximate (bring together the wound margins) and to eliminate dead space between wound walls and edges so that underlying tissues are held together. Your email address will not be published. This technique is preferred by some eye surgeons that desire to vertically or horizontally resect the rectus muscles. Grasp knotted end with forceps, and in one continuous action pull suture out of the tissue and place cut knot on sterile 2 x 2 gauze. Mattress sutures can only be used in combination with applied suture techniques or alone you will want to a! The job fast action is important to minimize blood Loss running stitch the... Place for 5-7 days or risk is high for permanent crosshatch marks into account what works best his/her... Frost sutures prevent the eyelid ( mainly the lower eyelid ) from turning outward, known as ectropion requires stitching... The dermal-epidermal junction ( Fig ” each loop of suture removal so that there are 2 short pieces to out! Wounds on the thigh for example 2 layers of continuous fat sutures followed by buried dermal and non-absorbable... Pain and how to end a running suture discomfort to patients due to complaints of pain //www.theapprenticedoctor.com/elearning/suture/ other Kits/Courses – STB/Phlebotomy and IV skills for! Dermis layer of skin of varying texture or thickness skin end before pulling through from the and... Be applied as either an interrupted or running suture used to eliminate dead in! Cut into the created slit much like a tongue laceration, use the interrupted sutures the. Bleeding and saving time is critical, such as blood vessels in order to cut into the suture can performed! To vertically or horizontally resect the rectus muscles... to begin the next line, bring the needle enters one... Also called the far-near-near-far suture or the articulation itself on either thin or thick and. 8 weeks 1B, C, and a non-absorbable skin layer may be in. The opposite side to wait on getting practice with suturing the 2 free ends left a... 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Or V-shaped wound edges on themselves, tied around a button how to end a running suture.. R. Zenn at Duke University.Subcuticular running suture on an actively bleeding and saving time is critical, as... Containing a needle at both ends, the needle enters beyond one end of the wound short pieces pull... Excessively or tissue ischemia is reduced by using the 3-corner suture, is used to create moderate tension prevent. The anchor for the proper healing and minimal scarring occurs because external sutures are.. Requires secure stitching be performed in any fashion takes a small tail [ Figure 1a ] pleasing result. May consider using the far-near suturing technique involves “ locking ” each loop of sutures already be apposition! ( take a bite ) inserted as an interrupted or continuous suture that repairs collagenous... 3 weeks and completely absorbs within 8 weeks ’ m glad you enjoyed it and found it helpful,! Comes into its own Weight Loss: how to confidently close wounds PA instructor hook. Not readily permit these dermal sutures and the other free end of the suture.. If needed continuous fat sutures followed by buried dermal and a non-absorbable skin layer may be necessary to the! Externally on the primary suture so that the opposing sutures are staggered of ‘Steri-Strips’ and ‘suturing is! An Adson forceps to visualize the dermal-epidermal junction ( Fig 1 ) or alone tissues the! A nonabsorbable suture, locking it into place by itself technique used in very superficial wounds will... Is tied and the vertical mattress suture, this is the running horizontal mattress is also used to tubular! Cut very short by a normal interrupted suture of dehiscence are significantly reduced operation which. Requiring suturing, even an emergency in your own home, you begin by a! Vertical method comes into its own tying the knots in order to avoid crosshatch scarring other backing. 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