Safe Repair Research Articles

Revisiting subclavian flap repair for neonates and small infants.

Objective:We have utilized subclavian flap angioplasty (SFA) frequently in infants with coarctation particularly in patients with arch hypoplasia which is quite frequent. We have followed these patients with serial echocardiography and have analyzed our results in this study to determine recoartation rates, recurrent hypertension and left arm development.Methods:Thirty eight infants less than 3 months age (22 boys and 16 girls, mean age was 28±22.6 days) operated at Dokuz Eylul University Hospital between August 2007 - December 2013. Twelve (32%) patients with pulmonary banding due to accompanying VSD or AVSD were included to the study, those infants with complex pathologies such as transposition of great arteries or single ventricle, while the patients less than 1000 gram in weight were excluded.Results:The mean follow-up time was 21 months (1-76 months). Twelve (32%) patients had aortic arch hypoplasia proximal to the left subclavian artery. Operative mortality was found 7.7% for isolated coarctation, 16% for coarctation repair with pulmonary banding. In 5 patients, a residual gradient was detected and re intervention was required in 7.8% patients with balloon angioplasty.Conclusion:Subclavian flap angioplasty is a safe repair technique in small infants and neonates. High gradients and intervention more likely depends on the anatomy of the aortic arch rather than the subclavian flap angioplasty technique.

Total hip arthroplasty to treat fracture neck of femurs – Are nice guidelines being implemented?

sion approach was used and repaired with anchor sutures. Results: Time to surgery, mean of 13.6 days, follow up mean 13.5 weeks, range 9 26 weeks. 2 patients lost to follow up at 9 weeks. Full range of movement in 15/17 patients. Pre-injury strength regained in 12/17 patients. 2 patients had reasonable power at 12 weeks. Slow improvement in 2 patients at week 12. 2 patients had complications, 1 had injury to lateral cutaneous nerve of the forearm, and 1 had a superficial blister proximal to the wound. Conclusions: Single incision approach has a low complication rate and a high satisfaction outcome. It provides acceptable functional recovery of elbow and forearm mechanics and we believe it a safe repair for distal biceps tendon injuries.

The use of tranexamic acid results in decreased blood loss in patients undergoing primary lower limb arthroplasty

The use of tranexamic acid results in decreased blood loss in patients undergoing primary lower limb arthroplasty

Laparoscopic Repair of Intrapartum Concomitant Bladder and Uterine Rupture

A 38 y/o pregnant woman, G2P1, with unscarred uterus (no previous uterine surgery),vaginally delivered her 2nd baby in a seemed smooth course. But in the postpartum period, PPH and gross hematuria were noted. Concomitant bladder and uteirne rupture were noted. Laparoscopic intervention was performed, to repair the bladder and uteirne laceration hole, preventing the future formation of vesico-uterine fistula. Baby OG tubes were introduced to catheterized bilateral ureters, because the bladder laceration wound was so closed to trigone area. Both uterine wall and bladder wall were successsfully repaired under laparoscopic surgery. Concomitant bladder and uterine rupture in an unscarred multi-parous uterus is extremely rare. The technical tpis for safe repair of the bladder and uterine laceration wound will be demonstrated in this video.

Ultrasound biomicroscopy (UBM) and scanning acoustic microscopy (SAM) for the assessment of hernia mesh integration: a comparison to standard histology in an experimental model

Mesh integration is a key parameter for reliable and safe hernia repair. So far, its assessment is based on histology obtained from rare second-look operations or experimental research. Therefore, non-invasive high-resolution imaging techniques would be of great value. Ultrasound biomicroscopy (UBM) and scanning acoustic microscopy (SAM) have shown potential in the imaging of hard and soft tissues. This experimental study compared the detection of mesh integration, foreign body reaction and scar formation in UBM/SAM with standard histology. Ten titanized polypropylene meshes were implanted in rats in a model of onlay repair. 17 days postoperative animals were killed and samples were paraffin embedded for histology (H&E, Cresyl violet) or processed for postmortem UBM/SAM. The observation period was uneventful and meshes appeared well integrated. Relocation of neighboring cross-sectional levels could easily be achieved with the 40-MHz UBM and granulation tissue could be distinguished from adjacent muscle tissue layers. The spatial resolution of approximately 8 μm of the 200-MHz UBM system images was comparable to standard histology (2.5-5× magnification) and allowed a clear identification of mesh fibers and different tissue types, e.g., scar, fat, granulation, and muscle tissues, as well as vessels, abscedations, and foreign body giant cell clusters. This pilot study demonstrates the potential of high-frequency ultrasound to assess hernia mesh integration non-invasively. Although the methods lack cell-specific information, tissue integration could reliably be assessed. The possibility of conducting UBM in vivo advocates this method as a guidance tool for the indication of second-look operations and subsequent elaborate histological analyses.

Laparoscopic direct suture of perforation after diagnostic colonoscopy

Increasing colonoscopy use increases the incidence of iatrogenic colon perforation. Operative management of iatrogenic colonoscopic perforation is diverse. This study retrospectively reviewed our experiences in treating diagnostic colonoscopy-associated bowel perforation by laparoscopic direct suturing. A total of 89,014 patients underwent diagnostic colonoscopy at our institution during the past 6 years. We identified 17 iatrogenic perforations (0.019 %) that were all managed by laparoscopic direct suturing. Perforation patients included 11 men and 6 women (mean age 60 ± 18 years). Sixteen patients (94 %) had severe comorbidities or previous abdominal surgery. Perforations were noticed by the endoscopist during the procedure in 13 cases (76 %) while the remaining 4 cases (24 %) were diagnosed within 24 h after colonoscopy. The estimated mean longitudinal perforation length was 4.4 ± 2.1 cm. Mean operation time was 2.3 ± 0.6 h, without significant blood loss or other severe complication. The mean time to bowel function return was 3.4 ± 1.2 days, the mean time to initial oral intake was 3.9 ± 2.0 days and the mean hospitalization duration was 6.8 ± 4.2 days. Diagnostic colonoscopic perforation occurred in less than 2/10,000 patients when colonoscopy was performed by experienced operators in our endoscopy center. Most of the perforation patients had severe comorbidities, to which the surgeon should pay close attention during colonoscopy. Laparoscopic primary suture of colon perforations caused by diagnostic colonoscopy is a safe and feasible repair method. Further efforts will definitively assess the feasibility of routinely using laparoscopic direct suture to repair colon perforations.

Cartilage-Supported Paramedian Forehead Flaps for Reconstruction of Full-Thickness Nasal Defects

The nose is an important esthetic structure of the human face, and its defects may lead to serious esthetic and functional losses. In the current study, our aim was to present the results of the repairs that we performed using cartilage-supported forehead flaps in patients with full-thickness nasal defects in various locations.Between March 2009 and March 2012, a total of 6 patients with full-thickness nasal defects underwent repairs using cartilage-supported forehead flaps. Among the patients, 4 were women, whereas 2 were male. The median age of the patients was 60.3 (38-67) years. The defects were caused by either tumor excision or burn wounds. Defect areas were at the dorsum of the nose, the medial canthal area, and the distal half of the nose. The repairs in all patients were performed using cartilage-supported median forehead flaps. In the method we applied, to provide framework support, a cartilage graft was placed into the pouch formed between the frontal muscle and the subcutaneous tissue within the flaps to be adapted to the defect area. The patients were followed up for a median period of 11 (4-27) months. In the long-term follow-up of all patients, satisfactory results in terms of the functional and cosmetic outcomes were obtained.Through the technique we applied, a simple and safe repair with adequate framework support and full color and texture harmony is achieved.

Novel intraoperative evaluation for mitral valve regurgitation: retrograde cardioprotective beating test

In mitral valvuloplasty, the saline injection test is commonly employed. However, discrepancies in regurgitation between the naked eye findings during the saline injection test and the postoperative echocardiographical findings are noted. Here, we describe a technique that allows direct transatrial evaluation of the valve in the fully loaded, beating heart without the risks of air embolism. Physiological systolic mitral valve movement is reproduced under aortic cross-clamping. This novel evaluation enables a complete and safe mitral valve repair.

Image-guided esophageal anastomosis in esophageal atresia

Infants with tracheoesophageal fistulas may present with complex cardiac disease that may obviate or disrupt a safe operative repair. Here we present a case of an infant who developed cardiac instability during esophageal atresia repair, precluding formal anastomosis after approximation of the distal and proximal esophageal segments. Postoperatively, anastomosis of the esophagus was achieved using an image-guided technique with subsequent dilation. This approach may provide an alternative approach for establishment of esophageal continuity in patients who are high-risk operative candidates.

Laparoscopic Umbilical Hernia Repair: Technique Paper

Objective. Laparoscopic umbilical hernia repair has largely replaced open method. The purpose of this study was to document the laparoscopic umbilical hernia repair using two port, combined herniorrhaphy with intraabdominal mesh fixation with transabdominal absorbable suture technique and demonstrate that it is feasible, efficient, and safe. Methods. Thirty-two patients with umbilical hernia underwent laparoscopic repair by combined herniorrhaphy and intraabdominal mesh. Two-port technique was used and the umbilical defect was closed using transabdominal PDS suture, composite polypropylene, and PTFE mesh was placed intra-bdominally and fixed to abdominal wall using transabdominal PDS suture. Results. Thirty-two patients underwent laparoscopic repair. The operating time ranged from 45 min to 100 min (mean 64 min). Early postoperative complication was seen in five patients with two having ileus for 4 days and one patient each developed urinary retention, wound infection and seroma. Late postoperative complication was seen in 6 patients with five complaining of persistent abdominal pain which resolved without treatment and one case of keloids at port sites. None of the patients developed chronic pain or had recurrence over the follow-up period. Conclusion. Laparoscopic umbilical hernia repair with combined herniorrhaphy and intraabdominal mesh fixation using absorbable sutures offers an efficient, safe, and effective repair for umbilical hernia.

Components separation with onlay mesh: A safe and effective repair for complex abdominal wall hernias. experience with 50 cases and the development of a triple mesh technique

s / International Journal of Surgery 10 (2012) S1–S52 S46 ABSTRACTS 0354: COMPONENTS SEPARATION WITH ONLAY MESH: A SAFE AND EFFECTIVE REPAIR FOR COMPLEX ABDOMINAL WALL HERNIAS. EXPERIENCE WITH 50 CASES AND THE DEVELOPMENT OF A TRIPLE MESH TECHNIQUE Steve Hornby, James Boorer, Neil Patel, Andrew Kingsnorth. Derriford Hospital, Plymout, UK Introduction: Closuring complex major abdominal hernias risks abdominal compartment syndrome. Components separation (CS) allows midline closure in most cases. This poster outlines our experience including postoperative quality of life (QoL) and the evolution of a triple mesh technique. Method: Retrospective case notes review and structured telephone interview of patients undergoing CS between October 2005 and May 2010 at Derriford Hospital. Results: 50 patients underwent CS; 41 underwent telephone follow-up (82%). Median follow-up was 29 months (range 3.2 57.6). 29 Patients were men;medianagewas60andBMI33.8 (range20-48.1).Woundcomplications affected16(38%); themajority settlingwithconservativemanagement. There was 1 recurrence of original hernia and 2 subsequent parastomal hernias. One patient developed a hernia related to the lateral release. Since developing the triple onlay technique there have been no recurrences. The series has one death related to small bowel ischaemia. 36(88%) of patients reported improved QoL; (95%) were happy to recommend the procedure to a friend. Conclusion: CS is associated with low mortality (2%); minimal long term morbidity and improved QoL. Triple mesh technique results in a low recurrence rate. We recommend CS with a triple onlay mesh for repairing complex major abdominal wall defects. 0357: THE ROLE OF PLAIN ABDOMINAL X-RAY IN ACUTE SURGICAL SETTING: A RETROSPECTIVE ANALYSIS Luke Stroman, Mohamed Ismat Abdulmajed, Cassandra McDonald, Palanichamy Chandran. Wrexham Maelor Hospital, Wrexham,

Dimensional Considerations for Operative Repair of the Fractured Pediatric Orbit

Sir:FigureAn understanding of orbital anatomy is necessary for safe repair of the bony orbit, as iatrogenic injury to the optic nerve at the time of surgery can lead to blindness. Several case series from the adult literature indicate that the incidence of postoperative vision loss is between 0 and 8.3 percent, and was 0.3 percent in the largest of these series.1–4 Nevertheless, postoperative vision loss can be devastating, and every effort should be made to avoid iatrogenic injury to the optic nerve. Orbital dimensions are well established in adults. Adult orbital depth is 45 mm, and this is a reliable approximation of the distance from the inferior orbital rim to the point at which the optic nerve exits the optic canal.5 It is at this point that the risk for direct injury to the optic nerve is most substantial. Consequently, this area should be avoided at the time of fracture repair if possible. Although orbital depth has been characterized in adults, it has not been measured in pediatric patients. Consequently, the aim of this study was to measure orbital depth in pediatric patients, to facilitate safer orbital fracture repair. The present study is a retrospective analysis of maxillofacial computed tomographic scans of patients aged 1 month to 17 years at Helen DeVos Children's Hospital between 2005 and 2009. Patients were stratified into 14 age groups. Each of these groups was composed of randomly selected computed tomographic scans from 15 girls and 15 boys, for a total of 420 patients included in the study. No scans demonstrating orbital fractures were used in this study. The primary outcome variable was mean orbital depth, as measured from the center of the inferior orbital rim to the point at which the optic nerve exits the optic canal (Fig. 1).Fig. 1: Depiction of orbital depth (dashed line). For the purposes of measurement in this study, the caudal-to-cranial distance from the inferior orbital rim to the level of the optic nerve where it exits the optic canal and the anterior-to-posterior distance from the inferior orbital rim to the optic nerve where it exits the optic canal form two perpendicular sides of a triangle; orbital depth is the third side of the triangle.Table 1 shows mean orbital depth by age. In the 0- to 6-month age group (infancy), orbital depth was 28.9 mm, which is 64 percent of the adult value (45 mm). There is a subsequent gradual increase in mean orbital depth with increasing age. Two other notable points are ages 3 and 8 years, with mean orbital depths of 85 and 95 percent of the adult values, respectively.Table 1: Mean Orbital Depth by AgeAn analysis of pediatric orbital depth was the goal of this study. Orbital depth proves important because it is at this deepest part of the bony orbit that the optic nerve is most vulnerable to injury. Analysis of these data shows that orbital depth is already 64 percent of its adult value in infancy. Furthermore, orbital depth is 85 percent of its adult value at age 3 years, and has reached 95 percent of its adult value at age 8 years. Thus, orbital depth at age 8 years closely approximates orbital depth in adulthood, and fracture repair can proceed with the knowledge that the segment of the optic nerve most vulnerable to injury is in nearly the same position as in the adult patient. Information provided in this study should enable the reconstructive surgeon to accomplish safer repair of pediatric orbital fractures, limiting postoperative vision loss. Matthew D. Martin, M.D. Grand Rapids Medical Education Partners/Michigan State University General Surgery Residency Program, Grand Rapids Medical Education Partners/Michigan State University Plastic Surgery Residency Program Benjamin P. Rechner, M.D. Grand Rapids Medical Education Partners/Michigan State University Plastic Surgery Residency Program, and, Helen DeVos Children's Hospital, Grand Rapids, Mich.

Comments and New Ideas on the Article: A New Intraperitoneal Technique for Safe Repair of Incarcerated Inguinal Hernias: A Novel Technique to Consider”, by A. D. Ram and R. A. Wheeler.

Comments and New Ideas on the Article: A New Intraperitoneal Technique for Safe Repair of Incarcerated Inguinal Hernias: A Novel Technique to Consider”, by A. D. Ram and R. A. Wheeler.

Bioabsorbable Gore BIO-A plug and patch hernia repair in young adults

We read with great interest the report by Efthimiou et al. [1] on plug and patch hernia repair using a polyglycolic acid-trimethylene carbonate mesh. The purpose of this pilot study (ten patients with direct and indirect inguinal hernia with a mean age of 65.6 years) was to evaluate the efficacy of using a totally absorbable device (Gore BIO-A Tissue Reinforcement patch and Gore BIO-A plug), looking primarily at recurrence and chronic pain assessed 1 year after the operation. The authors stress, and we agree with, that an ideal mesh for inguinal hernia repair should cause the minimum foreign body reaction. Moreover, the excessive local inflammatory reaction that occurs when a polypropylene (PP) mesh, especially heavyweight PP, is implanted, may cause prosthetic shrinkage and chronic pain. For these reasons, surgeons would consider the use of PP with different characteristics (low-weight large porous PP, PP/polyglactine composite, PP with polytetrafluorethylene surface) or other materials as polyvinyliden fluoride (PVDF). Gore BIO-A mesh is made of a biocompatible synthetic polymer. Its design structure (with open highly interconnected pores) creates a scaffold that facilitates tissue generation, mimicking native collagen fibres. This material is fully absorbed in approximately 6 months. At 1 year follow-up, none of the patients from Efthimiou’s study had clinical signs of recurrence. Only one patient experienced intermittent pain without the need for any medication. On the other hand, the authors do not highlight any protective role on the vas deferens that could possibly be played by Gore BIO-A plug and patch repair, probably because all patients in their study were elderly. Many experimental studies in animals have shown that PP mesh can adversely affect spermatic cord structure and/ or function [2–5]. On the contrary, little clinical information is available regarding the long-term effects of PP mesh on the vas deferens. One possible reason is that most men undergoing hernia repair tend to be elderly, and thus not so concerned about maintaining their reproductive potential. However, a multiinstitutional experiment and some casereports [6–8] have confirmed the potential risk of injury when a PP mesh is placed in contact with the bare vas deferens, as in the case of plug and patch repair. PP herniorraphy is being offered to young adults whose fertility status will be an issue in the future. At present, we are unable to determine whether PP mesh will result in an higher incidence of inguinal vasal obstruction and infertility. In 2009, we began a prospective multicentre study on the use of BIO-A prosthesis in young adults (maximum age 45 years) to try to answer these questions, and to offer a safer repair to patients. Only primary indirect (L, lateral, according to EHS’s classification) hernias were included in the study. All patients underwent open plug and patch repair. C-reactive protein (CRP) samples were collected to estimate the inflammatory response. Pain was evaluated using VAS score, and quality of life status by the SF-36 system. Mid-term results (at 2 years) will be published soon. In the meantime, we wish to point out that, at 18-month follow-up, none of the 15 patients enrolled by our Centre had any complications and all patients were totally satisfied. We can also assume that no adverse events affected the cord structure. P. Negro (&) F. Gossetti M. R. Dassatti J. Andreuccetti L. D’Amore Department of General Surgery ‘‘P. Stefanini’’, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy e-mail: pal.negro@libero.it

Repair surgery after hip replacement

Objective To explore the effect of the cortical windowing of the femoral diathesis in hip revision surgery. Methods Collected 28 patients(28 Keens) who received hip revision surgery; all of them were repaired by the cortical windowing of the femoral diathesis; according to the articulation coaxes Harris score before and after surgery,analyzed the treatment effect of the cortical windowing of the femoral diathesis. Results All 28 patients got follow-up visit, no case needed repair again. The length of thighbone of integument ale cortical windowing was 3.4 cm, the extent was 1.2 cm. After surgery, integument ale and the around bone fibers closed up. Conclusion The cortical windowing of the femoral diathesis has easy operation, little hurt, and few complication. In hip revision surgery, it can look clear when take out the bone cement in thighbone pulp cavity. It is far-end stationary, and has no infection in restoration; it also cause no infection from the blood supply and muscle insertion in thighbone near-end sclerotic. The patients can be train early after surgery. It's a safe and reliable repair surgery, so it deserves to generalize in clinical medecine. Key words: hip arthroplasty; repair; cortical windowing of the femoral diathesis

Hexagonal Six-point Traction Technique for Optimum Surgical Exposure of the Subaortic Region

Surgery of the subaortic region is challenging because of spatial limitations. We present our technique of enhanced exposure of this region that allows for a smooth, expeditious, and safe repair of such lesions as subaortic stenosis, hypertrophic cardiomyopathy, subaortic ventricular septal defects, and related pathologies. Using a hexagonal 6-point traction technique, approximately 84% of the cross-sectional area of the aortic root is made available to the surgeon for a transaortic subaortic resection keeping the use of retractors to a minimum. The technique ensures protection of the aortic valve leaflets and the enhanced exposure may contribute to improved surgical outcomes.

A New Intraperitoneal Technique for Safe Repair of Incarcerated Inguinal Hernias: A Novel Technique to Consider

Inguinal herniotomy is one of the most common operations performed by paediatric surgeons. Most procedures are elective operations but occasionally the hernia is incarcerated. Complications after emergency repair of an incarcerated hernia repair are higher than those associated with elective surgery because of congestion of the sac. Operative techniques described so far include low, high, preperitoneal and laparoscopic approaches. We describe here an open intraperitoneal technique. 6 boys aged between 4-40 weeks were taken urgently to the operating room for incarcerated inguinal hernia repair. All boys were operated on using an open intraperitoneal technique. In this technique, the congested sac does not need to be separated from the adherent vas and vessels within the inguinal canal, the reduced bowel can be inspected with 3D visualisation and resected if necessary, and the peritoneum can be easily incised and sutured through a single skin incision, reducing the risk of complications and providing superior cosmesis. All patients had very good postoperative outcomes with no complications. The technique can be used not only for incarcerated inguinal hernia repair but also for problematic repairs of recurrent hernias. Disadvantages include postoperative hydrocele formation and failure to inspect the testicle.

HEAD AND NECK RECONSTRUCTION

Background: The pectoralis major myocutaneous pedicle flap (PMMPF) has been considered to be the "workhorse" of pedicled flaps in head and neck reconstruction. Despite the use of free flaps, this flap is still considered the mainstay of head and neck reconstruction. The flap is usually associated with a high incidence of complications compared with the free fasciocutaneous flaps yet its size, viability, and versatility make it a valuable tool for extending the limits of resectability and reconstruction. It is type V muscle flap with the dominant vascular supply from the pectoral branch of thoracoacromial artery. Objective: To share our experience of pectoralis major myocutaneous pedicle flap in selected cases of head and neck reconstruction. The indications, type of reconstruction and complications of the flap utilization were evaluated. Patients and Methods: Between March 2005 and August 2010, a 37 head and neck reconstructive procedures using the PMMPF were carried out. The indications for the flap use were defects due to resection of stage II-IV cancer in the head and neck region. The site, stage of the disease and the postoperative complications were all documented. Results: Pectoralis major myocutaneous pedicled flap reconstructions were used to reconstruct defects in the following sites: oral cavity (25 patients); oropharynx/ hypopharynx, (7 patients); and neck or face (5 patients). Of the 37 PMMPF reconstructions, 30 flaps were carried out as primary reconstructive procedures, whereas 7 flaps were "salvage" procedures. Twentyfive patients (67.59%) had complications. A higher complication rates were associated with the utilization of the flap as a salvage procedure, number of co- morbidities, and in oral cavity reconstructions. Conclusions: The pectoralis major myocutaneous pedicled flap is still an acceptable method of head and neck reconstruction. It is fast, reliable, provides safe repair and is indicated especially where bulk is needed.

Research of Trusted Network Security Technology

Based on the TNC architecture, using a trusted network of repair techniques in the trusted network access scenario does not meet the requirements of integrity verification solution for end users. Put forward a credible fix the overall network design, reliable model restoration and repair services, network workflow. The system is in need of restoration to provide safe and reliable repair end-user data transmission, providing a humane, reasonable repair services to ensure the credibility of fixed network and the isolation effect of the terminal to be repaired and strengthened the security of fixed server. Realized the classification of various types of repair resources management, restoration of resources in ensuring the transfer of fast, reliable, based on the performance with a certain extension.

The characteristics of inguinal hernia recurrence in the modern era and the long-term outcomes after re-operation

Re-operative hernia surgery has become more technically challenging due to the use of mesh. In addition, there has been a paucity of clinical studies. A common recommendation has been to avoid the previous site and to use a different approach. In this study of 218 patients, the anatomical characteristics of inguinal hernia recurrences were studied in relation to the previous technique of repair, including Mesh (n = 100), Laparoscopic (n = 61) and Shouldice (n = 57). The most common site of recurrence was direct (58.5%) in all three groups. Femoral recurrences were significantly lower in the Laparoscopic group. Indirect and multiple recurrences were significantly lower in the Shouldice group. The operative time in the Mesh group was significantly longer due to the dissection required of the previous mesh. A pro-peritoneal mesh repair was performed for the re-operation in 13.8%, while a Shouldice repair was performed in the others. The overall follow-up rate was 75.2% for a mean of 4.8 years. The re-recurrence rate was 1.8%. The distinct patterns of recurrence reflect the relative strengths and weaknesses of the different techniques of repair and present the anatomical and technical basis for future improvements. A safe and durable repair of an inguinal hernia recurrence can be achieved through an anterior trans-inguinal approach.