Do not place retractors around the radial neck. - Introduction 00:00 [27] A number of these procedures were complicated by fascial dehiscence, with concomitant increases in costs, hospital length of stay, additional interventions, and associated complications. It is useful for biliary tract surgery. The general technique can be applied to other abdominal incisions (some of which are discussed more briefly below); however, it must be kept in mind that the actual layers composing the abdominal wall vary, depending on the location of the incision. Cholecystectomy | Johns Hopkins Medicine [29], In the past, abdominal midline surgical wound dehiscence rates as high as 10% were reported Background This article discusses the anatomy of the abdominal wall, anatomy of the rectus sheath and common abdominal surgical incision types (midline, paramedian, pararectal, Gridiron, Lanz, Pfannenstiel, transverse, Kocher). Kocher Manoeuvre A wide Kocher maneuver is next performed with leftward reflection of the duodenum and head of the pancreas which allows near complete exposure of the portal vein and associated structures. Br Med J. Ellison EC, Zollinger RM Jr. Laparotomy. Identify the incisions A. right upper paramedial incision The incision is made to run parallel to the costal margin, starting below the xiphoid and extending laterally. . Clinical Surgery in General. Find the perfect kocher incision stock photo, image, vector, illustration or 360 image. Some incisions avoid the muscles entirely, some split or separate them to avoid them, and some cut through layers of muscle. Optimal exposure in pediatric abdominal surgery can be achieved by a transverse incision due to the abdominal proportions of the infant. [QxMD MEDLINE Link]. Abdominal Wall Incision - Kocher - How to approach the abdominal cavity using a Kocher incision 2,005 views Oct 18, 2021 55 Dislike Incision 6.82K subscribers Notice You're signed out of. [33, 34, 35, 36] Damage-control surgery (trauma or emergency general surgery) is associated with fascial dehiscence rates of 13-50%. [QxMD MEDLINE Link]. - Timing 03:23 [4] Continuous absorbable suture may be used. The median length of the midline incision was slightly longer (12 vs. 10 cm, p < 0.05). You also have the option to opt-out of these cookies. A Kocher incision is made parallel to the subcostal margin to access the underlying liver and biliary tree. There continues to be debate regarding the most effective strategy for abdominal-wall closure. Abdominal incisions. Disadvantages include patients experiencing more pain than they would from a transverse incision, particularly during deep breathing postoperatively, and the incision is perpendicular to the Langers skin tension lines resulting in poorer cosmesis. The average length of the incision is approximately 24 to 30 inches. Instagram: https://instagram.com/geekymedics Only one prospective randomized controlled trial has been conducted to determine the value of this practice, and the authors found no significant differences in complications between closure and nonclosure. Right Kocher's incision: a feasible and effective incision for right Fortelny RH. Kocher's incision: It is an incision made several inches below and parallel to the lower border of the front of the rib cage. Abdominal Incisions and Anatomy of the Abdominal Wall The benefits of mass closure include decreased cost and decreased operating time. DO NOT perform any examination or procedure on patients based purely on the content of these videos. [16] and in a controlled clinical randomized trial. A comprehensive collection of medical revision notes that cover a broad range of clinical topics. (B) Looping of 0 polydioxanone (PDS) at vertex. The primary advantage of this method is that multiple suture strands exist, so that if a suture breaks, the incision is held intact by the remaining sutures. The Lanz and Gridiron incisions are two incisions that can be used to access the appendix, predominantly for appendicetomy. Pronation of the forearm will move the nerve further from the plane of dissection. The fascia and then peritoneum are divided under direct vision. Superficial to the external oblique lies Scarpas membranous fascia, Campers subcutaneous fatty layer, and the skin. On examination, the patient may have a palpable lump close to the lateral border of the rectus sheath, commonly at the level of Douglas. Zinner MJ, Ashley SW, Hines OJ, eds. The incision runs 2-5cm lateral to the midline, cutting through the skin, subcutaneous tissue, and the anterior rectus sheath. - Over 3000 Free MCQs: https://geekyquiz.com/ This may be used for oesophagectomy, gastrectomy, bilateral adrenalectomy, hepatic resections, or liver transplantation, This may be used for the same indications as the Chevron incision, however classically seen in liver transplantation, A surgical incision is an aperture into the body to permit the work of the operation to proceed, The specific surgical incision will depend on the underlying pathology, site, patient factors, and the surgeons preference and experience, Incisions should try to follow Langers lines and muscles should be split and not cut, The wound can be covered in a protective dressing once closed. The superficial nature of these hernias makes them amenable to diagnosis by ultrasonography. [QxMD MEDLINE Link]. (For more information, seeTemporary Abdominal Closure Techniques.). The incisions cut through layers of skin, body fat and fascia (connective tissue) until they reach the abdominal muscles. Turner-Warwick's incision This type of incision is placed 2cm above the symphysis pubis and within the lateral borders of the rectus muscles. This incision became obsolete because of very high incisional hernia rate. Kocher extensile approach: the skin incision runs from the supracondylar ridge of the humerus (ca. Wound infection occurred in 12 group A patients and 10 group B patients, wound dehiscence in two group A patients and no group B patients. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. However, a few studies have reported surgical treatment for TAMH, and the optimal surgical procedure remains controversial. Prognostic models of abdominal wound dehiscence after laparotomy. It is an optimal way for emergencies, as opening the abdomen should not take longer than 40-60 seconds. [QxMD MEDLINE Link]. 1990 Jan. 77 (1):107. 41 (3):57-60. Introduction In the planning of an abdominal incision, the following factors must be taken into consideration : Preoperative diagnosis The speed with which the operation needs to be performed, as in trauma or major haemorrhage. - Radiation 02:45 Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Nothing to disclose. A surgical incision is an aperture into the body to permit the work of the operation to proceed. General considerations. J Trauma Acute Care Surg. Front Surg. [18, 43] : Retention sutures are placed outside of the primary suture line through all layers of the abdominal wall, including the skin; a large-bore suture material, usually nonabsorbable, is employed. The incision will then pass through the all the rectus sheath and rectus muscle, internal oblique and transversus abdominus, before passing through the transversalis fascia and then peritoneum to enter the abdominal cavity. The lateral (Kocher) approach can be used to access the radial head and the tip of the coronoid. 2015 Dec. 210 (6):1126-30; discussion 1130-1. But opting out of some of these cookies may affect your browsing experience. 8 Types Abdominal and Pelvic Surgical Incisions - Lybrate The incision will cut through the skin, subcutaneous tissue, and fascia, the linea alba and tranversalis fascia, and the peritoneum before reaching the abdominal cavity. 231 (3):436-42. Webster C, Neumayer L, Smout R, Horn S, Daley J, Henderson W, et al. Subcostal Also called upper oblique, Kocher's incision Gallbladder and biliary tract surgery Paramedian Upper R side (biliary tract, gallbladder) Upper L side (splenectomy, gastrectomy) Lower R side (small bowel resection) Lower L side (sigmoid colon resection) Midline Upper and lower abdominal incision Abdominal surgeries . This step of the incision is usually time consuming and is one of the limitations associated. The intercostal nerves emerge from below the costal margin and run between the layers of the internal oblique and transversus abdominis muscles. Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal closure by meta-analysis. Cengiz Y, Blomquist P, Israelsson LA. Occasionally, circumstances may dictate that permanent closure of the abdomen is contraindicated. [QxMD MEDLINE Link]. [5, 22] with the possibility of delayed primary closure, depending on the state of the wound bed as it progresses. [11]. For most closures, the authors prefer to use looped 0 polydioxanone (PDS) suture. BMC Surg. Kocher's studies on one of his patients, who was operated on in 1874, led to an early discovery. Two modifications and extensions of the Kocher incision are possible: Whilst open procedures that come with inherent drawbacks, all these subcoastal incisions provide the surgeon with good exposure to the abdominal viscera and tend to heal well. It is mainly used to gain access for gall bladder and/or biliary tree pathology. Share cases and questions with Physicians on Medscape consult. We report the video of the pylorus-preserving pancreatoduodenectomy performed in a five-month-old child with focal CHI.Operative techniqueBaby was placed in the supine position with both arms outstretched to the up. Its positioning however does make it susceptible to significant scars. Volkovich-Kocher sign - Sign of acute appendicitis: pain, initially arising in the epigastric region (sometimes immediately below the xiphoid process), after a few hours localized in the right illiac fossa Biography Born on December 9, 1858, Horodnia, Ukraine 1888 - Doctor of Medical Sciences 1908 - Head of the Kiev Surgical Society Results. It may be mirrored on the contralateral side to provide access to the spleen or performed bilaterally as a Rooftop incision to provide efficient access to organs such as the pancreas and biliary tree within the transpyloric plane (see below). S ummary of Layers to be Incised: . It was originally used to access much of the lateral viscera, such as the kidneys, the spleen, and the adrenal glands. Extensile Lateral and Posterolateral Exposures | SpringerLink Incisions, Closures, and Management of the Abdominal Wound Incise skin, adipose, scarpa's along the length, 11th rib incision goes from rib to lateral border of rectus mm. Closure of laparotomy wounds: skin staples versus sutures. [10] Some surgeons believe that closure of the peritoneum reduces adhesions between the abdominal contents and the suture line; however, at this time, there is only limited scientific evidence for this belief. McEvedy's incision McEvedy's original incision was a lateral paramedian incision which used to incise the rectus sheath along its lateral margin and gain access by pulling the rectus medially. It is also used by general and urological surgeons for some pelvic procedures such as radical open prostatectomy or cystectomy. Closure of a Kocher subcostal incision requires closure of the anterior and posterior rectus sheaths. The posterior sheath is formed by the posterior leaf of the internal and the transversus abdominis aponeuroses and bears the superior and inferior epigastric arteries and their anastomotic network. #geekymedics #fyp #fypviral #studytok #medicalstudentuk #medtok #studytips #studytipsforstudents #medstudentuk #premed #medschoolfinals, Cardiovascular History Tips - DON'T FORGET these 3 things . Ann Surg. 2001 Apr. Franz MG. The key principles of making surgical incisions are: Once the operation is over, surgical excisions can be closedby sutures, staples, steri-strips, tissue glue, or a combination of these agents. Surg Infect (Larchmt). A controlled clinical trial of three methods of closure of laparotomy wounds. The small-bite technique (in which the distance between the suture and the wound edge is reduced to 5-8 mm and the distance from stitchto stitch is reduced to 5 mm from the fascial edge) has been assessed in an experimental study They should be educated on signs and symptoms of incisional hernia and should be encouraged to contact the surgeon postoperatively in the presence of any of the following (any of which may portend postoperative complications): Short-term complications include wound infection and dehiscence. Complications: prevention and management. Typically, the midline incision remains above the umbilicus, still . In pediatrics the most common use of this approach is open reduction of radial head/neck fractures. Often, having the assistant cross the. A Kocher incision (no. Open Access Surg. - 2500+ OSCE Flashcards: https://geekymedics.com/osce-flashcards/ 2014 Oct. 12 (10):1105-14. [QxMD MEDLINE Link]. Adhesive tapes and synthetic glues can be used in addition to sutures and staples to reinforce closure. Between 2009 and 2013, an estimated 2 million patients per year underwent an open surgical intervention in the United States. Reattach the muscles and fascia with resorbable sutures (2/0 or 3/0). Abdominalincisions:Techniquesandpostoperative Complications The lateral edges of the incisions remain medial to the internal oblique muscles. Point defects in the aponeurotic intersections of the linea alba may facilitate the development of epigastric hernias, which often simply contain preperitoneal fat but are often disproportionately painful for their size owing to their high tendency to strangulate. Eur J Surg. The external oblique aponeurosis is then closed with an interrupted or continuous absorbable suture (see the image below). [17] The use of prophylactic mesh in high-risk patients, in comparison with primary suture closure of the midline incision, yielded a significant reduction in the incisional hernia rate. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. layers of the abdominal wall inside out: peritoneum transversalis fascia transversus abdominus muscle internal oblique muscle external oblique muscle scarpa's fascia subcutaneous fat skin (camper's fascia, dermis, epidermis) time out has been completed and the incision is made with visual oozing of blood noted, what would you pass [4] The purpose of subcutaneous closure is to close any potential space, reducing the area for seroma accumulation. Surgical Incisions Their Anatomical Basis: Learn how and when to remove this template message, http://medind.nic.in/jae/t01/i2/jaet01i2p170.pdf, "Comparison between modified Misgav-Ladach and Pfannenstiel-Kerr techniques for Cesarean section: review of literature", https://en.wikipedia.org/w/index.php?title=Surgical_incision&oldid=1099563504, Wilde's incision This post-aural incision is used for a variant mastoiditis drainage, and was named after Sir, Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in. Muscle herniation of the lower extremity, such as tibialis anterior muscle herniation (TAMH), is not a rare cause of leg pain in athletes. 19 (2):329-37. Immediate complications of a midline laparotomy incision may include anaesthetic difficulties, haemodynamic instability, primary haemorrhage from cut vessels and iatrogenic injury to surrounding tissues and viscera. The thickness of the skin and its layers is determined by its location. Many surgical procedures may now be performed laparoscopically with generally better results in terms of cosmesis, postoperative pain, recovery time and thus reduced length of stay and more expedient return to function when compared with traditional open techniques. Rajesh Mahey, Smruti Ghetla, Jitesh Rajpurohit, Dhaval Desai*, Sachin The paired rectus abdominis muscles originate from the anterior bony pubic bones toward the midline and run cephalad to insert onto the xiphisternum and costal cartilages of ribs 5-7. [QxMD MEDLINE Link]. The subcostal or Kocher incision is an oblique incision that follows the profile of the costal margin and is directed in a medio-proximal direction. 2001 May. [1] : Layered closure is sequential closure of each fascial layer individually. Make the changes yourself here! This video demonstrates how to use the SOCRATES acronym when taking a history of pain or other symptoms. 2019 Mar. [1, 15, 47] Long-term monitoring after the postoperative period is not considered necessary. Shoulder dislocation reduction method kocher's Ortho video 7 Check out the abdominal wall anatomy quiz here. Surgical incisions, implants, and wound closure - Basicmedical Key New York: McGraw-Hill; 2019. [QxMD MEDLINE Link]. Int J Surg. Two modifications and extensions of the Kocher incision are possible: right subcostal/kocher cholecystectomy paramedial incision; heals stronger sigmoid surgery median incision over linea alba, more likely to herniate trauma--quicker thoracoabdominal esophagoduodenostomy McBurney incision appendectomy Fill in the Blank Exercise 14.02 . After medical optimization, the patient was sched - uled for a laparoscopic incisional hernia repair with mesh. Starting at the superior or inferior aspect of the incision, the looped PDS is passed through the vertex of the fascia (see the image below). Lower abdominal cavity approaches:Lower abdominal cavity approaches like the Maylard, Pfannenstiel, Joel-Cohen, or lower midline can be used for gynecological, obstetrical, or pelvic surgery or can be used as an extraction site for specimen removal during for example colorectal surgery. Chapters: [QxMD MEDLINE Link]. Make a gently curved skin incision directly over the middle of the lateral condyle, initially 6-8 cm, extending proximally or distally if needed. What Are the Types of Abdominal Incisions? - MedicineNet 2005 Oct 19. Schwartz's Principles of Surgery. [28] The causes of dehiscence and poor wound healing include ischemia, infection, increased abdominal pressure, diabetes, malnutrition, smoking, and obesity. Abdominal Wall Closure in Elective Midline Laparotomy: The Current Recommendations. Like the paramedian approach, the pararectal incision has now largely been abandoned. Gallbladder, biliary tract and certain liver operations can be suited for a Kocher's incision. The goal is approximation of tissue edges to allow scar formation. 2. 1996 Feb. 162 (2):125-9. The specific surgical incision will depend on the underlying pathology, site, patient factors, and the surgeons preference and experience. Laparotomy incisions. Interrupted closure was associated with significantly less dehiscence than continuous closure , and no differences were found between the two methods with regard to hermia risk. With a Rockey-Davis incision, some benefit to closing the peritoneum has been shown. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. American Association for the Surgery of Trauma, American Society of Law, Medicine & Ethics, Association of Military Surgeons of the US, Society of Laparoscopic and Robotic Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons. The Maylard incision is placed higher than the Pfannenstiel incision, resulting in the possibility of extending it into a larger incision and gaining more exposure. Further advantages include the ease with which the incision may be extended either cephalad or caudally in order to improve access. A paramedian incision can damage the muscles lateral blood and nerve supply, which may result in the atrophy of the muscle medial to the incision. The muscles of the abdominal wall play a major role in supporting ventilation, forcing the diaphragm cephalad in order to increase intrathoracic pressure to aid expiration, and allowing it to contract into the abdomen to decrease pressure for inspiration. Wound dehiscence following midline laparotomy is a particularly distressing event for the patient, whereby classically a serosanguinous discharge is noted from the wound 7-10 days postoperatively, and a day or so later the whole wound may burst open and spill the patients intestines into their lap. 8.1 and 8.2 show the vascular and nervous supply to the abdominal wall muscles. 141 (4):510-13. 11th ed. generic complications of surgery vs those specific to the operation, and presenting as immediate, early or late complications. 5. . Also well-known to all thyroid surgeons is the "Kocher incision", a transverse, slightly curved incision about 2 cm above the sternoclavicular joints. [7, 18, 4, 3]. Layer's to Open:- Skin Subcutaneous fat External Oblique apponeurosis External Oblique muscle Internal oblique muscle Transverse addominis The rectus muscles are separated and the incision is made in the midline. surgical technique, site and orientation of incision, intra-operative contamination, lengthy procedure). 10th ed. Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N. Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis. - Examples 05:45 (C) Continuous suture. If you do not agree to the foregoing terms and conditions, you should not enter this site. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Bilateral Radial Head Fracture with Unilateral Terrible Triad Injury in The Kocher interval is between the extensor carpi ulnaris and the anconeus. [15] The results of this study underscore the necessity of carrying out further randomized, controlled trials to facilitate the development of a consensus on the best method of abdominal closure. This type of incision is good for exposure of the retropubic space but offers limited access to the upper pelvis and abdomen. Temporary abdominal closure with polytetrafluoroethylene prosthetic mesh in critically ill non-trauma patients. Frontiers | Case report: Pylorus-preserving pancreatoduodenectomy for All procedures were done under general anesthesia in a multicenter setting using the open technique. 212 (1):34-9. Andrew Howard, Theddy Slongo, Peter Schmittenbecher. The surgeon finds the gallbladder and takes it out through the incision. The main difference between the Maylard incision and any other transverse lower abdominal incision, such as the Pfannenstiel incision, is that in the Maylard incision the rectus muscle is transected instead of split. - Severity 05:32 Negative side-effects of retention sutures for abdominal wound closure. Kocher incision hi-res stock photography and images - Alamy Surgical Incision is a cut made through the skin to facilitate an operation or precedure. Seiler CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer C, et al. Of these, transverse incisions follow Langer lines of skin tension. 2000 Dec. 166 (12):932-7. The incidence and nature of complications will be influenced by the patients comorbidities. To repair the lateral thigh dermal tissue area, a local skin flap was obtained, and a blade thick skin graft was used. In three patients we performed wedge resection of liver metastasis and in one patient we performed a typical right hepatectomy that lasted 190 min. This field is for validation purposes and should be left unchanged. Suture is run in 1-cm intervals (maximally), with at least a 1-cm bite of fascia in each throw. ead wound, the autogenous dermal tissue from the lateral thigh was transplanted to the surface of titanium mesh, and the local skin flap was then applied after suturing and fixation to repair the wound on the surface of the dermis. - Associated symptoms 03:04 Primary Low Transverse Cesarean Section Operative Sample Report The incision will take a long time and is often technically difficult, however it does prevent any division of the rectus muscle and provides access to lateral structures. 1998 Dec. 176 (6):666-70. ) is rarely performed in the UK. No significant difference was noted regarding analgesia requirements and early postoperative complications. [13, 37, 38] However, most of the published studies have not focused on patients who undergo emergency laparotomy. An oblique incision made in the right lower quadrant of the abdomen, classically used for. Transverse incisions are felt to have more intrinsic strength than their vertical counterparts because the abdominal fascia fibers are transversely oriented, causing sutures to be placed perpendicular to the fiber direction (see the image below). A prospective multicentre study evaluating the outcomes of the Using SOCRATES in History Taking | OSCE | Communication Skills, Abdominal Surgical Incisions and the Rectus Sheath. The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. Deep to transversus abdominis, the transversalis fascia encircles the preperitoneal fat and parietal peritoneum. These cookies track visitors across websites and collect information to provide customized ads. YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LjMxakdNallNcng0, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkJPVjVZMzBKczY4, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkxEM2VkQzB2NTBr, Start typing to see results or hit ESC to close, Deep Vein Thrombosis (DVT) Examination OSCE Guide, Pre-hospital Advanced Life Support (ALS) OSCE Guide, Adult Choking (Basic Life Support) OSCE Guide, Paediatric Intravenous Cannulation OSCE Guide, Intrauterine System (Mirena) Counselling OSCE guide, Geeky Medics OSCE Book | Clinical Examination, Complications of abdominal surgical incisions, Paediatric Gastro-oesophageal Reflux Disease, A Career as a GP with Special Interest with Dr Fiona Mosgrove, Subcutaneous fatty layer (Campers fascia), Patient-specific (i.e. [40] They also noted that using interrupted sutures for closure of laparotomy incisions in this setting reduced the risk of abdominal wound dehiscence to less than 33%. Vol 2: 1549-66. Hernia. Perioperative Antirheumatic Drug Guideline Contains Caveats, 8-Week TB Treatment Strategy Shows Potential, Physicians of the Year 2022: Best and Worst, Clinical Approach to Chronic Wound Management in Older Adults. This cookie is set by GDPR Cookie Consent plugin. 3. DO NOT perform any examination or procedure on patients based purely on the content of these videos. 1975 Oct. 62 (10):823-9. Abdominal Surgical Incisions | Gridiron | Pfannenstiel | Geeky Medics Surgical Incisions. Emil Theodor Kocher - NobelPrize.org Am J Surg. [36] Mortality in patients with midline abdominal surgical wound dehiscence ranges from 10% to 30%. Duttaroy DD, Jitendra J, Duttaroy B, Bansal U, Dhameja P, Patel G, et al. 1981 Apr. Am J Surg. Revisions: 25. Fasciotomy was reported to be effective for patients with TAMH. Ellis H, Heddle R. Does the peritoneum need to be closed at laparotomy?. Saturated dressings should be changed when noted. - Exacerbating & relieving factors 05:12 The elbow is an unforgiving articulation with significant bony congruity and a . This modification prevented the high incisional hernia rate. [Full Text]. The recti are interrupted by three paired tendinous intersections anchoring them to the anterior sheath, broadly found close to the xiphisternum, at the level of the umbilicus and then halfway between the two. Abdominal incisions - SlideShare . The cookie is used to store the user consent for the cookies in the category "Analytics". Kocher arc incision: oblique incision for opening the knee joint Kocher incision: subcostal incision performed on the right side exposes the gallbladder and common bile duct, and on the left side gives access to splenectomy or splenorenal venous anastomosis. A Pfannenstiel skin incision was then made with the scalpel and carried through to the underlying layer of fascia. For a lateral skin incision, place the elbow at 90 and palpate the lateral condyle, which is easier in thin patients. Kirk RM, Ribbans WJ, eds. It is easier to identify the intervals distally but keep in mind that distal dissection needs to be limited to protect the posterior interosseous nerve. This method uses 3 to 4 very small incisions. Incise the subcutaneous tissue in line with the incision and raise flaps to expose the fascia over the muscles.
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