ISGE December 2001 Volume 8 Issue 2


The tragic events of September 11 have, to put it mildly, thrown many people off balance. On a somewhat secondary scale, our Society was affected. The 5th Regional Meeting of ISGE in conjunction with the 2nd Brazilian Congress of Gynecologic Endoscopy took place on September 12-15, 2001.

Editor: Togas Tulandi, MD
Editorial Board: S. Duffy, P. Mangeshikar, C. Miller, F.Viscomi 

Inside this Issue:

  • Editor's Corner
  • President's Message
  • Report from the 5th Regional Meeting of ISGE in conjunction with the 2nd Brazilian Congress of Gynecologic Endoscopy
  • Tips to Laparoscopic Technique in Pregnancy
  • Robotically Assisted Gynecologic Surgery
  • Endoscopy and Ultrasound in the Evaluation of Abnormal Uterine Bleeding
  • News From Around The World
  • Letter to the Editor


The Editor's Corner
Togas Tulandi, MD 

A Trying Time

The tragic events of September 11 have, to put it mildly, thrown many people off balance. On a somewhat secondary scale, our Society was affected. The 5th Regional Meeting of ISGE in conjunction with the 2nd Brazilian Congress of Gynecologic Endoscopy took place on September 12-15, 2001. With governments having closed all airports in the United States and Canada, those from North America could not attend the meeting. Nevertheless, the meeting was a success, thanks to the quick organizational skills on the part of Francesco Viscomi and his organizing committee, as well as the generous help from speakers from other parts of the world. You can read his report in this issue of ISGE NEWS. 

Another meeting that took place this year was the 41st Japan Congress of Gynecologic and Obstetrics Endoscopy. It took place in Nagasaki, Japan on August 3-4, 2001. Not only was the meeting well organized and successful, but also the location was wonderful. Professor Ishimaru reports on his meeting in this newsletter. 

After assisting me for a year, our previous editor, Jim Carter has resigned as the associate editor of ISGE NEWS. This is due to his responsibilities as an expert in pelvic pain for the American College of Obstetricians and Gynecologists. On behalf of the Board of ISGE and the members at large, I wish to express our appreciation to Jim for all his hard work.

Finally, I would encourage others to share national or international news with our readers. Indeed, the success of our newsletter depends on member's participation and input. 

Notwithstanding recent fears regarding "snail mail," email is the method of choice when it comes to submitting articles for the newsletter. It facilitates communication and makes our editing job easier. Please send us your news regarding inventions, innovative techniques, unusual complications, national events in your country, or any other topic you would like to share with us. In order to familiarize ourselves with the fellow members, we will publish the photograph of those who contribute to the ISGE NEWS. 

Togas Tulandi M.D.

President's Message
Yap Lip Kee, MD

It was an honor to receive the "torch" from John Sciarra at our 10th Annual Congress held in Chicago. With it came the realization of our society's relative youth when John pointed out that he was the sixth president. 

Perhaps it was due to the vigor and enthusiasm of youth that we as a society have been able to respond to the many changes in our field since our founding in 1989. Coping with the rapid changes in the new millennium will be no easy task. The most immediate task is gaining acceptance within the specialty of gynecology.

Thanks to pioneering work carried out by colleagues over the past few decades, gynecologic endoscopy is no longer a new field where dangers lie around every corner. We are now at the stage where endoscopic procedures have been proven to be as effective and as safe as open surgeries in most cases. In many cases endoscopic techniques have become accepted as the gold standard. Good examples are the use of laparoscopy in the management of ectopic pregnancies and benign cysts, and the use of hysteroscopy in management of submucous fibroids. 

Recognition and acceptance, however, does not mean implementation. In most parts of the world only a small portion of the population has ready access to the techniques and the very real benefits associated with the endoscopic approach.

Singapore, where I live and work, is a city-state and as such a totally urban society, which is able to respond to, changes rapidly. Acceptance of gynecological endoscopic techniques here has been rapid. Singapore's largest women's hospital the K.K. Women's Hospital reported a swing from less than 5 percent of suitable surgeries done endoscopically to more than 90% over a 10-year period.








Ovarian Cyst








(As an indication of numbers a total of 365 ectopic pregnancies were managed in KK Hospital in the year 2000)

Penetration rate of endoscopic surgery in management of gynaecological problems needing surgery vary greatly from country to country but most have patterns similar to the Singapore experience.

Report from the 5th Regional Meeting of ISGE in conjunction with the 2nd Brazilian Congress of Gynecologic Endoscopy

The Congress was held on September 12 to 15 in So Paulo. It started following the tragic events at the World Trade Center in New York City. Accordingly, some North American colleagues including Franklyn Loffer, Charles Koh, John Sciarra and Togas Tulandi could not participate in our meeting. Thanks to other international speakers, as well as the Brazilian speakers, the meeting went on uneventfully. It was attended by 350 participants. South America was represented by Gerardo Bossano from Uruguay and Roberto Sainz from Argentina.  (photo caption: Convention center in Sao Paolo)   

The Congress discussed new approaches to endometrial pathology, endometriosis and myomas. At the opening ceremony, Dr. Yap Lip Kee gave a presentation entitled "Look at Gynecologic Endoscopy in the Next Decade." In the plenary session, Hans Brolman, Michelle Nissole and Joo Alfredo Martins discussed the correlation between ultrasonography and hysteroscopy. Kees Wamsteker gave a keynote lecture "Hysteroscopy Today." The effects of the Levonorgestrel system, endometrial effects of different combination of HRT and the guidelines for endometrial surveillance during HRT were discussed by our national speakers. In addition, Francesco Viscomi, Michelle Nisolle, Jacques Donnez and other Brazilian speakers discussed several aspects of endometriosis. Other features of laparoscopy including suturing was discussed by Rajendra Sankpal and Duncan Turner. 

Further highlights of the meeting included hysteroscopic sterilization, and new techniques of endometrial ablation. We are proud to inform you that this first meeting of ISGE in Latin America was a success. 

Francesco Viscomi
President of the Congress

ORIGINAL CONTRIBUTIONSTips to Laparoscopic Technique in Pregnancy.
by Mazen Bisharah MD*, Togas Tulandi MD**
*Fellow of Reproductive Surgery and Reproductive Endocrinology & Infertility
**Professor of Obstetrics and Gynecology, and the Milton Leong Chair in Reproductive Medicine, McGill University
Compared to that in the first trimester, laparoscopy in the presence of enlarged uterus of second trimester of pregnancy is technically more challenging. Reports of puncturing the gravid uterus with a Verres needle emphasize the importance of an open laparoscopic technique for surgery in second trimester of pregnancy. An enlarging uterus also displaces small intestines out of the pelvis risking bowel injury by the Verres needle or trocar. Despite these limitations, the second trimester is generally the safest time to perform surgery. This is due to several reasons:

1. the miscarriage rate is 5.6% in the second trimester compared to 12% in the first trimester
2. the rate of preterm labor in the second trimester is very low. However, instead of operating in the third trimester, in most cases an operative procedure can be delayed until the postpartum period. 
3. the uterus is still of such proportion that does not obliterate the operative field compared to the uterus in the third trimester.
4. the theoretical risk of teratogenesis in the second trimester is very low 

Laparoscopy during pregnancy should be performed with great deal of caution. The following steps should be taken.

1. Patient can be placed in the dorsal lithotomy position in the first half of pregnancy. In the second half of pregnancy impaired venous return by compression of the inferior vena cava by the gravid uterus is of a concern. This can be prevented by slight left lateral positioning of the patient.
2. No instrument should be applied to the cervix or inserted into the uterine cavity.
3. Because of the enlarged gravid uterus, caution should be taken with trocar insertion. The primary trocar should be inserted after determining the height of uterine fundus. Needless to say, the secondary trocars should be inserted under direct visualisation. We prefer to insert the primary trocar using an open technique. Alternatively, the trocar can be inserted at supraumbilical, subxiphoid midline or left upper quadrant. 
4. Depending on the height of the uterus, the secondary trocars are inserted higher than those in the non-pregnant condition. 
5. The risk of hypercarbia and acidosis are minimized by maintaining the intra-abdominal pressure to less than 12mmHg and short operative time.
6. The effect of carbon dioxide pneumoperitoneum on the fetus is unknown. However, the clinical safety and efficacy of laparoscopy using CO2 gas has been well documented. Other techniques such as gasless laparoscopy and laparoscopy with NO2 pneumoperitoneum have been advocated. Whether they are safer compared to CO2 pneumoperitoneum is unknown.

Robotically-Assisted Gynecologic Surgery
by Tommaso Falcone, MD
Chairman, Dept. Obstetrics and Gynecology, Cleveland Clinic Foundation

The first reference to the word robot appeared in a play written by the Czechoslovakian Karel Capek in 1921. Robots have been used industry for decades. These robotic devices are used to perform tasks that required precise repetitive motions. With the rapid development of robot language, speech recognition, and better mechanical dexterity, robotic technology is beginning to enter the healthcare system as well. Robots such as AESOP (Automatic Endoscopic System for Optimal Positioning) by Computer Motion, Inc. (Goleta, CA) and the DaVinci robot by Intuitive Inc. (Mountainview, CA) are commercially available. 

The first commercially available device was the AESOP robot that was designed to hold a laparoscope. Movement was initiated by a foot pedal or by voice control. However these robots were primarily developed to perform surgery that requires extensive, precise microsurgical technique that would be difficult to perform during conventional laparoscopy. As such, the robotic arms are adapted to hold laparoscopic instruments and to be commanded from a surgical console. 

Robotically-Assisted Gynecologic Surgery (Continued)
by Tommaso Falcone, MD
Chairman, Dept. Obstetrics and Gynecology, Cleveland Clinic Foundation

Discussion of robotic devices often includes the broader topic of the use automation in the operating room. Therefore systems can be integrated into an operating room so that most of the devices used during laparoscopy can be voice activated. For example the CO2 flow can be adjusted, the lights activated and operating room table moved by voice command. The following presentation will be restricted to the use of robots in surgical procedures.

Clinical Applications of Robotics
Robots are being evaluated in many surgical specialties. In orthopedic surgery, a robot has been introduced that can cut or ream bone for the application of prostheses with 10 times better accuracy and precision than humans. 

This system, RoboDoc (Integrated Surgical Systems, Sacramento, CA), has been reported to produce radiographically superior implant fit and positioning. In neurosurgery, navigational robotic devices allow localization and orientation during a microneurosurgical procedure such as a ventriculostomy. Robotic ocular microsurgery is being developed to allow implantation of devices or intraretinal manipulation. In urology, robots are being tested to perform percutaneous renal access and recently radical prostatectomy. Robotically assisted laparoscopic nephrectomy has also been performed in the porcine model. In cardiac surgery, robot-assisted minimally invasive solo mitral valve surgery is performed clinically .The principal robotic function in this surgery is to hold the laparoscope, which is moved by voice commands. More advanced laparoscopic cardiac surgery such internal mammary artery dissection and anastomosis to a coronary vessel is presently in clinical trials.

The first clinical trial in gynecology was to assess the use of a robot for performing a laparoscopic tubal anastomosis. We performed a prospective pilot study to evaluate the feasibility and safety of a robotic device. Ten patients with previous tubal ligation underwent laparoscopic tubal ligation reversal using a robotic suturing device. Tubal surgery was performed with the ZEUS robotic system. A two-layered closure was used for all tubes. Four stitches of 8-0 polyglactin sutures were used for each layer. The Zeus robotic system (Computer Motion Inc.) was used. The Zeus system has three remotely controlled robotic arms, allowing a single surgeon to manipulate the laparoscope camera and two laparoscopic surgical instruments simultaneously. The robotic arm that holds the laparoscope is directed by voice commands. The arms that hold the surgical instruments are controlled by two handles housed in a mobile console that can be positioned anywhere in the operating room or in a different location. A computer controller translates the surgeon's movements from the handles to the robotic arms. There is no measurable delay between the movement of the handles and the movement of the instruments. The operator's movements can be scaled according to the surgeon's specifications. For example, a scaling ratio of 15:1 means that for every 1 inch the surgeon moves the handles at the console, the robotic surgical instruments would move 1/15th of an inch at the surgical site. Tremors and small-unintended hand motions that are the result of holding instruments for a prolonged period can be filtered out. Thus, the instruments are held steady throughout the procedure. 

The procedure was completed successfully in all 10 patients. No patient required conversion to an open procedure. The mean time (+ SD) required to complete the anastomosis of both tubes was 159 + 33.8 minutes. Chromotubation at the end of the procedure showed patency in all tubes anastomosed. A postoperative hysterosalpingogram 6 weeks after surgery demonstrated patency in 17 of the 19 (89 %) tubes anastomosed. The pregnancy rate was 50%. No ectopic pregnancies occurred. There were no complications. We concluded that robotic technology could be used safely to create laparoscopic microsurgical anastomoses with adequate patency rates. Robotic technology has the potential to make laparoscopic microsuturing easier.

The other robotic system that has been used for tubal surgery is the da Vinci system. Degueldre and colleagues in Belgium performed a laparoscopic tubal reanastomosis on eight patients. The mean surgical time was 52 minutes per tube. Although no pregnancy rates were reported, they successfully performed the anastomosis on all patients. The da Vinci system is similar to the ZEUS in that the surgeon performs the surgery from a remote console. Movement of the two handles moves the robotic arms at the surgical site. The movements are scaled. The main difference is that this system has an intraabdominal articulation of the microinstruments 2 cm from the tip. This articulation serves the same function as a human wrist. In this system the surgeon controls the robotic arm that holds the laparoscope by moving a handle. In the ZEUS system it responds to voice commands. The main limitation of both robotic systems is the technical skill required setting up the robotic system around the patient. It requires a very sophisticated support staff to be able manage any technical problems that occur during a surgical procedure. All procedures have required a dedicated staff that is specifically trained on the device.

Such robotic devices would be potentially more useful if they could be used for more complex types of gynecologic surgery. In a recent animal study, we investigated whether the Zeus device could be used to perform adnexal surgery and hysterectomy. In this study we were able to perform two common gynecologic surgical procedures, adnexectomy and hysterectomy, using a robot interface. The device functioned well and allowed the surgeon to perform these procedures while sitting comfortably at a console away from the operating table. The robotic arms could be installed and removed easily and quickly. The technique used electrocautery and standard laparoscopic dissection techniques. Vascular pedicles were ligated with suture using standard laparoscopic knot tying techniques. The entire procedure was performed using the robotic device. In conclusion, although this surgical robot was designed for microsuturing procedures, it can be adapted for other types of surgery.

Another potential application of robotics in gynecology is telesurgery. A surgeon in another city can move the laparoscope and visualize a particular operative site. This gives surgeons the potential to obtain immediate intraoperative consultations from colleagues that are far away. However limitations in band width of internet lines results in a delay that does not permit the surgeon to control the robotic arms that perform the surgery. However a recent transatlantic laparoscopic cholecystectomy was performed using a satellite connection (ZEUS device).

In conclusion, the field of medical robotics is moving at a fast pace. Robotics will continue to evolve at an every increasing pace similar to the rate of Moore's Law (capacity doubling every 18-24 months), which is referenced as the pace of improvement in computer technology. This technology may not be applicable to general clinical practice today or in the immediate future, but it provides an incentive for gynecologists to participate in the development of medical robotics. 

(The future promises many exciting technologies. Robotic surgery is one of them. As the author writes, it is already here. TT)

Endoscopy and Ultrasound In The Evaluation Of Abnormal Uterine Bleeding
by James M. Shwayder, MD, Director, Gynecology and Gynecological Ultrasound, Denver Health Medical Center, Associate Professor, Obstetrics and Gynecology and Charles C. Coddington, M.D, Director, Obstetrics & Gynecology, Denver Health Medical Center, Vice-Chairman, Obstetrics & Gynecology, University of Colorado Health Sciences Center, Denver, Colorado

The differential diagnosis of abnormal uterine bleeding includes cancer, ectopic pregnancy, or dysfunctional uterine bleeding. Different age group might presents with different problem (Table 1). An endometrial biopsy is a good but invasive screening tool. Less invasive techniques are ultrasound or hysteroscopy. As seen in Table 2, hysteroscopy is a valuable tool to diagnose some causes of abnormal uterine bleeding.

Using transvaginal ultrasonography, one study showed that 28.1% of women with abnormal uterine bleeding had intrauterine pathology; of these 20.6% had either intramural or submucous myomata. Interestingly, 37% of patients were found to have other pelvic pathology that would have been missed by hysteroscopy alone (the current "gold" standard, Table 3). An important fact is that endometrial thickness changes throughout the cycle (Table 4). Accordingly, ultrasound is best performed in the follicular phase, shortly after menses. Many abnormalities can be diagnosed with a simple gray-scale transvaginal ultrasound in the office.

Table 1.The cause of abnormal uterine bleeding related to the age of the patient

Age Range

Possible Etiologies


Precocious puberty, foreign body, coagulopathy


Anovulation, coagulopathy and blood disorders, infection, endocrine


Anovulation, pregnancy problems, anatomic problems (myomas, adenomyosis, polyps), endocrine, medications, carcinoma


Anovulation, irregular bleeding, hyperplasia, carcinoma, polyps, iatrogenic, endocrine


Irregular bleeding, hyperplasia, carcinoma, polyps, iatrogenic


Table 2. Hysteroscopy as a diagnostic tool of abnormal uterine bleeding

Indman N=234

Shwayder N=50

Towbin N=149


































Table 3. Hysteroscopic and Laparoscopic Findings in Women with Abnormal Uterine Bleeding (n=121)




Normal Cavity



Polyps/Submucous Fibroids









Ovarian Cyst



Ectopic Pregnancy
















Table 4. Endometrial Thickness


Range (mm)

Proliferative Phase


Secretory Phase


Post-menopause (no HRT)


Post-menopause (with HRT)


Atrophic Endometrium


Goldstein found that the presence of a "pencil line" endometrial echo of less than 5mm in AP diameter is uniformly associated with atrophic endometrium. On the other hand, Karlsson et al. reported that 4.5% of patients with an endometrium of 5mm had either endometrial hyperplasia or cancer. They advocated the use of 4mm as the cutoff point. However, caution should be exercised, as 1.1% of these patients may harbor endometrial hyperplasia. Thus, endometrial sampling remains one of the most important tests in the evaluation of women with abnormal uterine bleeding. The same authors found that 67.6% of their postmenopausal patients with an endometrium of >16 mm had endometrial hyperplasia or carcinoma.

Hysteroscopy is a valuable tool for the investigation of abnormal uterine bleeding. Indman compared TVS with hysteroscopic findings in 238 women evaluated for AUB. He found that ultrasound have a positive predictive value of 87%, negative predictive value of 94%, and specificity of 89% (Table 5).

Table 5





51 (89%) 

6 (11%)


33 (42%) 

45 (58%)


13 (13%) 

90 (87%)





Endoscopy and Ultrasound In The Evaluation Of Abnormal Uterine Bleeding (continued)
by James M. Shwayder, MD, Director, Gynecology and Gynecological Ultrasound, Denver Health Medical Center, Associate Professor, Obstetrics and Gynecology and Charles C. Coddington, M.D, Director, Obstetrics & Gynecology, Denver Health Medical Center, Vice-Chairman, Obstetrics & Gynecology, University of Colorado Health Sciences Center, Denver, Colorado

In the presence of normal ultrasound findings, only 11% of hysteroscopy is abnormal particularly in young women. In one study, only one small submucous myoma and five small polyps were missed. A more accurate diagnosis can be obtained by injecting solution into the uterine cavity in combination with transvaginal ultrasound (sonohysterography). The solution delineates the endometrial lining. The most commonly used medium is saline (saline infusion sonohysterography, SIS). Commercial solutions such as Albunex and or Hy-Co-Son have also been used. They can provide information about the uterine cavity, as well as the tubal patency. In another study comparing SIS vs. hysteroscopy in 50 patients with AUB, SIS had a sensitivity of 98%, a specificity of 96%, a positive predictive value (PPV) of 97% and a negative predictive value (NPV) of 100% (Table 6).

Table 6 Saline Infusion Sonohysterography (SIS) vs. Hysteroscopy

Polyp/Submucous Fibroid
Intramural Fibroid
Endometrial Hyperplasia
Retained POC

When presented with a patient with abnormal uterine bleeding, it is paramount to take a good history and perform a physical examination. Vital signs, CBC and b-HCG can be of help in assessing the acuteness of the situation. An endometrial biopsy should be done to provide tissue pathology. Using hysteroscopy, ultrasound and saline infusion sonography, one can locate and identify specific pathology.

News From Around The World41st Japan Congress of Gynecologic and Obstetrics Endoscopy
A Success of Science and Reflection of Culture
Professor Tadayuki Ishimaru
Professor and Chairman, Nagasaki University

The 41st Japan Congress of Gynecologic and Obstetrics Endoscopy was held in the Brick Hall of Nagasaki City, Japan on August 3-4, 2001. This congress was attended by 570 registrants from all over Japan and abroad. This participation outnumbered all the previous endocopy congresses in Japan. Besides lecture by invited speaker, educational lecture, special lecture, symposium and workshop, 51 scientific papers were selected for oral presentation. The number of oral presenters in this congress was also higher than the previous congresses. The highlights of the meeting include:

1) Special lecture on the present and perspective in endoscopic surgery by Dr. Shirakusa.
2) Educational lecture on natural history of endometriosis by Dr. Suginami and laparoscopic surgery in ectopic pregnancy by Dr. Akira Fujishita. 
3) Invited lecture on laparoscopic treatment of endometriosis and endometrioma by Professor Togas Tulandi of McGill University, Canada. This lecture stimulated interests among the local gynecologists. Besides his main lecture, Dr. Tulandi also demonstrated hands on training on laparoscopic microsuturing in a pre-meeting session. 
4) Workshop: The subject of laparoscopic uterosacral nerve ablation (LUNA) for endometriosis-related pelvic pain was presented and discussed. 
5) Symposium on development and progression of instruments and technology for endoscopic surgery. 

The combination of the latest scientific information, cultural image of Nagasaki city, well organized activity of all staffs of Nagasaki University under the careful direction of Professor Ishimaru and gracious support of different pharmaceutical companies made this congress a successful meeting.

Nagasaki City is located in the Kyushu island, the most western part of Japan. Nagasaki city is called the 'Gateway of Japan' for the first entrance of foreign culture, trade, religion and political relations in Japan. Nagasaki is a very popular sight-seeing place for its natural beauty, historical background as well as traditional mixed culture. President of this endoscopy meeting, Dr. Tadayuki Ishimaru, who is also the Professor and Chairman of Nagasaki University, tried his best to make this congress well arranged, disciplined and scientifically success. Unlike the previous congresses in Japan, Professor Ishimaru did not hesitate to give a cultural taste of Nagasaki City to all the participants. The popular dragon dance of Nagasaki performed during the welcome party amused all the audiences. The latest development of gynecologic endoscopy as well as the cultural image of Nagasaki were the outstanding presentation for the success of this meeting. 

Letter to the Editor

Deleterious effects of CO2 gas can be prevented by gasless laparoscopy 
by Daniel Kruschinski & Bernd Bojahr 
Institute for Endoscopic Gynaecology, University of Witten/Herdecke, &
Dept. for Gynaecology and Obstetrics, University of Greifswald, Germany

We would like to comment on Ott's article in the last ISGE Newsletter (June 2001 / Volume 7 Issue 2) on how to maintain delicate integrity of the peritoneum. There are indeed many animal studies suggesting the possible deleterious effects of CO2 pneumoperitoneum on peritoneal integrity, on adhesion formation, and on tumor cell spreading. (Laparoscopy: Maintaining Delicate Integrity)

These changes are partly related to the newer insufflation systems. For example, high flow insufflator prevents gas leakage, but very high insufflation of cold CO2 can affect the peritoneum negatively. Heated-CO2 on the other hand desiccates peritoneal surfaces; adding humidity can prevent this. Clinically, CO22 insufflation can cause hypercarbia, metabolic acidosis, and high intraabdominal pressure leading to decreased organ perfusion. 

In order to reduce the potential disadvantages of CO2 pneumoperitoneum, we propose laparoscopy without carbondioxide insufflation (gasless laparoscopy) using AbdoLift (Storz). Abdolift is a reusable abdominal wall lifting apparatus (Figure 1). Contrary to that of conventional CO2 laparoscopy, we can use flexible and valveless trocars (Figure 2), conventional instruments and standard surgical techniques. We believe this system is cost effective to the patients, the surgeons, the hospital and the health care system. Using this system, we can also palpate the intraabdominal organs and tissue. Possible intrabdominal injury due to the insertion of Veress needle or trocar is eliminated.

Gasless laparoscopy allows us to perform laparoscopy in patients with cardiac insufficiency, in those with chronic obstructive lung disease or in pregnant women. It can also be done under regional anaesthesia. The theoretical risks of spreading tumor cells due to pneumoperitoneum may be avoided with gasless laparoscopy. 


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