Journal of Minimal Access Surgery最新文献

{"title":"Initial experience of SSI Mantra robot-assisted Transabdominal pre-peritoneal repair of primary ventral hernias.","authors":"Magan Mehrotra, Chukka Gautam Kumar","doi":"10.4103/jmas.jmas_344_23","DOIUrl":"https://doi.org/10.4103/jmas.jmas_344_23","url":null,"abstract":"<p><strong>Introduction: </strong>Small and medium sized primary midline ventral hernias are best treated by pre-peritoneal mesh placement. This helps in prevention of complications related to intra-peritoneal mesh placement. The challenges we face while performing laparoscopic transabdominal pre-peritoneal (TAPP) procedure can be overcome by robot-assisted TAPP (rTAPP), and we present our initial experience with the same. We describe the surgical technique used in rTAPP using the relatively new SSI Mantra platform for primary midline ventral hernia repair and evaluate its feasibility and present the outcomes.</p><p><strong>Patients and methods: </strong>we performed rTAPP for primary midline ventral hernia repair in 10 patients from July 2023 to September 2023. Demographic patient data, hernia characteristics and peri-operative outcomes were measured.</p><p><strong>Results: </strong>A total of 10 patients underwent elective rTAPP for primary midline ventral hernia, of which 7 were male and 3 were female. The average defect size was 3.2 cm. The average operative time was 113 min. All the patients were discharged within 24-36 h after the procedure. There were no deaths. No post-operative complications such as haematoma, clinically significant seroma, deep or superficial wound infection or recurrence were noted within 30 days.</p><p><strong>Conclusion: </strong>rTAPP is a technically feasible procedure for the repair of small- and medium-sized midline ventral hernias with defect sizes up to 5 cm. SSI Mantra robotic platform provides the same benefit that other conventional robotic platforms provide at a much lesser cost. Further studies looking at the cost-benefit ratio are required to substantiate the above.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":" ","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141879704","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Ovarian endometrioma recurrence after laparoscopic surgery: First assessment of ACSAP predicting score.","authors":"Cuili Niu, Xiaowei Bai, Xiuyin Gui, Yuanzhe Liang, Ling Zhang","doi":"10.4103/jmas.jmas_350_23","DOIUrl":"https://doi.org/10.4103/jmas.jmas_350_23","url":null,"abstract":"<p><strong>Purpose: </strong>We aimed to develop and validate a predictive score to estimate the post-operative recurrence risk after laparoscopic excision of ovarian endometrioma (OMA).</p><p><strong>Patients and methods: </strong>The prediction score was developed using a training set comprising 431 patients with OMA who underwent laparoscopic surgery at our institution between January 2015 and September 2017. A follow-up period of at least 5 years was required. Clinical data were entered into least absolute shrinkage and selection operator (LASSO) regression to build a scoring system that predicted OMA recurrence. A testing set containing 185 patients from October 2017 to October 2018 was used to assess its performance.</p><p><strong>Results: </strong>Based on LASSO regression, the final score (ACSAP score) included five clinical predictors (0-15 points): Age, cyst size, previous surgery for OMA, revised American Society for Reproductive Medicine stage and post-operative pregnancy. The area under the curve values of the score were 0.741 (0.765) and 0.727 (0.795) for predicting 3-year and 5-year OMA recurrence, respectively, in the training (testing) set. The score stratified patients into three risk groups in both sets, with significant differences in the 5-year recurrence rates (low-risk, 5.3% [0%]; intermediate-risk, 20.2% [16.5%] and high-risk, 48.0% [36.5%]; P < 0.001). Moreover, patients in the intermediate- and high-risk groups exhibited a significant reduction in the 5-year cumulative recurrence following a minimum of 15-month post-operative medical treatment (both P < 0.05).</p><p><strong>Conclusions: </strong>The ACSAP score may be a concise and useful tool for identifying patients with a higher risk of OMA recurrence after surgery who might receive long-term post-operative medical treatment.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":" ","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141879711","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Performing median arcuate ligament release surgery in celiac artery compression syndrome: Insights from a tertiary care hospital.","authors":"Ajil Antony, Santhosh Kumar Ravindran, N P Jayan, S Yadukrishna, Robbins Sebastian, Akshay Kumar, Shwetha Shyamkumar","doi":"10.4103/jmas.jmas_402_23","DOIUrl":"10.4103/jmas.jmas_402_23","url":null,"abstract":"<p><strong>Background: </strong>Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery (CA) compression syndrome, is a rare condition characterized by persistent post-meal or post-exercise abdominal discomfort, often more pronounced during expiration. Additional symptoms include nausea, vomiting, and weight loss.</p><p><strong>Aims and objectives: </strong>To document the clinical presentation, diagnostic process, and treatment outcomes of seven patients diagnosed with MALS and to evaluate the effectiveness of surgical release of the median arcuate ligament (MAL) over a follow-up period of at least six months.</p><p><strong>Materials and methods: </strong>The study included seven patients diagnosed with MALS from 2019 to 2021. Diagnosis was based on the presence of chronic abdominal pain and associated symptoms, absence of alternative diagnoses after various clinical assessments, and angiographic evidence of CA compression. The primary treatment involved surgical decompression of the CA by releasing the MAL through either open or laparoscopic techniques.</p><p><strong>Results: </strong>All seven patients underwent successful surgical release of the MAL. The patients were followed up for at least six months post-surgery. The study evaluated the persistence of symptoms and the need for additional interventions such as revascularization techniques.</p><p><strong>Conclusion: </strong>Surgical release of the MAL is the primary treatment for MALS, providing relief for many patients. However, long-term follow-up is essential as some patients may continue to experience symptoms post-surgery, necessitating further interventions.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":"20 3","pages":"318-325"},"PeriodicalIF":1.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11354951/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141761965","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Safety and perioperative outcomes of uniportal versus multiportal video-assisted thoracoscopic surgery.","authors":"Mohamed Alanwar, Mamdouh Elsharawy, Alaa Brik, Islam Ahmady, Dina Said Shemais","doi":"10.4103/jmas.jmas_84_23","DOIUrl":"10.4103/jmas.jmas_84_23","url":null,"abstract":"<p><strong>Introduction: </strong>Uniportal video-assisted thoracoscopic surgery (U-VATS) has recently become an alternative approach for many minimally invasive thoracic procedures, but although its surgical effectiveness has been proven, still its feasibility and safety are debated and unclear. the objective of this study was to compare the safety and perioperative outcomes of U-VATS versus multiportal VATS (M-VATS).</p><p><strong>Patients and methods: </strong>This was a comparative follow-up randomised controlled clinical trial, carried out on 36 randomly selected eligible patients, and fulfilling the inclusion and exclusion criteria for VATS, they were assigned randomly into two groups: Study Group I including 18 patients undergoing U-VATS with conventional treatment using standard chest tube drainage and Control Group II including 18 patients undergoing M-VATS) with the same conventional treatment using standard chest tube drainage and served as a comparable control group.</p><p><strong>Results: </strong>Patients in the U-VATS Group 1 had faster operation time, and with reduced blood loss, pleural drainage and post-operative hospitalisation, they also experienced lower average post-operative pain score on comparison with those in M-VATS Group II (P < 0.001), respectively. For either group, there were no hospital deaths or infections. There was no noticeable difference between the two groups in terms of the number of resected lymph nodes or the rates of intraoperative or post-operative complications (P > 0.05).</p><p><strong>Conclusion: </strong>U-VATS is feasible and safe in eligible selected patients with favourable short-term perioperative outcomes (operative time, duration of pleural drainage, post-operative pain, early ambulation, duration of hospital stay as well as the risk of perioperative complications), and it can be considered the preferred approach in minimally invasive thoracic procedures that open up for the possibility of fast-track thoracic surgeries.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":"20 3","pages":"294-300"},"PeriodicalIF":1.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11354947/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141761966","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Minimally invasive tools are necessary for the modern practice of liver surgery.","authors":"Young-Dong Yu, Karim J Halazun, Rohit Chandwani, Benjamin Samstein","doi":"10.4103/jmas.jmas_377_23","DOIUrl":"10.4103/jmas.jmas_377_23","url":null,"abstract":"<p><strong>Introduction: </strong>Minimally invasive liver resection (MILR) is performed for other gastrointestinal applications. At our centre, all liver resections are systematically performed using a minimally invasive approach. This study aimed to describe our experience in minimising open surgery and emphasised the importance of minimally invasive surgery.</p><p><strong>Patients and methods: </strong>We retrospectively reviewed 260 patients who underwent liver surgery and compared the surgical outcomes between the open and MILR groups.</p><p><strong>Results: </strong>A total of 154 patients (68%) underwent MILR. The proportion of patients who underwent prior abdominal surgery and resection was higher in the open surgery group. However, the proportion of patients with liver cirrhosis was similar between the two groups. The MILR group was superior in terms of operative time, blood loss, Pringle manoeuvre rate and mean hospital stay. In addition, major complication and bile leak rates were lower in the MILR group. No significant differences in the tumour size, number of lesions or underlying liver pathology were observed between the two groups.</p><p><strong>Conclusion: </strong>Acceptable outcomes can be achieved even when the minimally invasive approach is considered the primary option for all patients who require liver resection. Minimally invasive tools are necessary for the modern practice of liver surgery; therefore, laparoscopic or robotic surgery should be included in the armamentarium of liver surgeons.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":" ","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141494004","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The use of lidocaine infusion in laparoscopic cholecystectomy: An updated systematic review and meta-analysis.","authors":"Bakhtawar Awan, Mohamed Elsaigh, Beshoy Effat Elkomos, Azka Sohail, Ahmad Asqalan, Safa Owhida Mousa Baqar, Noha Ahmed Elgendy, Omnia S Saleh, Justyna Malgorzata Szul, Anna San Juan, Mohamed Alasmar, Mohamed Mustafa Marzouk","doi":"10.4103/jmas.jmas_265_23","DOIUrl":"10.4103/jmas.jmas_265_23","url":null,"abstract":"<p><strong>Abstract: </strong>Being one of the most common abdominal surgical procedures, numerous techniques have been adapted to decrease post-operative pain post cholecystectomy. However, the efficacy of intravenous (IV) lidocaine in managing post operative pain after LC is still controversial, according to many recent studies. This study aims to detect the effectiveness of IV lidocaine compared to other medications in managing post-operative pain. PubMed, Scopes, Web of Science and Cochrane Library were searched for eligible studies from inception to June 2023, and a systematic review and meta-analysis was done. According to eligibility criteria, 14 studies (898 patients) were included in our study. The pooled results of the included studies showed that the pain score after 6, 12 and 24 h after the surgery was significantly lower in those who received IV lidocaine as a painkiller (Visual Analogue Scale [VAS] 6H, mean difference [MD] = -1.20, 95% confidence interval [CI] = -2.20, -0.20, P = 0.02; I2 = 98%, VAS 12H, MD = -0.90, 95% CI = -1.52, -0.29, P = 0.004; I2 = 96% and VAS 24H, MD = -0.86, 95% CI = -1.48, -0.24, P = 0.007; I2 = 92%). In addition, IV lidocaine is associated with a significant decrease in the opioid requirement after the surgery (opioid requirements, MD = -29.53, 95% CI = -55.41, -3.66, P = 0.03; I2 = 98%). However, there was no statistically significant difference in the incidence of nausea and vomiting after the surgery between the two groups (nausea and vomiting, relative risk = 0.91, 95% CI = 0.57, 1.45, P = 0.69; I2 = 50%). Lidocaine infusion in LC is associated with a significant decrease in post operative pain and in opioid requirements after the surgery.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":" ","pages":"239-246"},"PeriodicalIF":1.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11354941/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139492631","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Laparoscopic transection and partial resection of hernia sac in the treatment of indirect inguinal hernia: A preliminary observation.","authors":"Jinyu Dai, Jian Li, Xiaobing Sun","doi":"10.4103/jmas.jmas_78_23","DOIUrl":"10.4103/jmas.jmas_78_23","url":null,"abstract":"<p><strong>Introduction: </strong>This study aimed to investigate the feasibility of applying laparoscopic transection and partial resection of hernia sac in the treatment of indirect inguinal hernia in children.</p><p><strong>Patients and methods: </strong>From December 2017 to November 2018, we recruited 20 children, who were aged 1-6 years old, with indirect inguinal hernia. At the time of admission, the participants had already developed an indirect inguinal hernia for 6 months to 1 year. A simple transection and partial resection of hernia sac was performed at the internal ring on each of the recruited children. The procedure was conducted under laparoscopy. Two 5-mm trocars were placed on either side of the umbilicus, one for the camera and the other for a surgical instrument. Another trocar was placed on the right abdomen. Laparoscopic camera curved forceps, and scissors were placed. Along the unclosed internal ring, the peritoneum was cut in a circular fashion to transect the hernia sac and dissociate it from the distal end. About 1-2 cm of the hernia sac was resected.</p><p><strong>Results: </strong>The operation was successfully completed in all 20 cases, who did not experience any complications, such as the absence of spermatic cord, vas deferens injury, scrotal swelling and incision infection. The children were discharged 1 day after the operation. In the post-operative follow-up for the first 3-4 years, recurrence and testicular atrophy did not occur in the study participants.</p><p><strong>Conclusion: </strong>The short-term results obtained from this study showed that the application of laparoscopic transection and partial resection of hernia sac in the treatment of indirect inguinal hernia is feasible. Long-term results and further observation are needed for validation.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":" ","pages":"266-270"},"PeriodicalIF":1.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11354952/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139576601","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Novel laparo-endoscopic hybrid technique of management of a rare case of duodeno-duodenal intussusception.","authors":"K Ganesh Shenoy, Srikanth Gadiyaram, B S Ramesh","doi":"10.4103/jmas.jmas_112_23","DOIUrl":"10.4103/jmas.jmas_112_23","url":null,"abstract":"<p><strong>Abstract: </strong>We herein report a rare case of duodeno-duodenal intussusception (IS) presenting with obstruction caused by tubulovillous adenoma in an adult with malrotation that was managed by a novel laparoendoscopic hybrid technique. This was done by passing transjejunal nasogastric tube (NG) through one of the ports and manoeuvring it towards the IS. Two hundred and fifty millilitre of saline was flushed by aseptosyringe with pressure connected to the NG. This hydrostatic reduction technique resulted in distension of the jejunal and duodenal loop achieving reduction of IS. Intraoperative endoscopy was performed to exactly localise the mass lesion. The duodenum was kocherised and was delivered through a 4-cm transverse incision. Anterior duodenotomy was performed; the mass was excised; and duodenotomy was closed transversely. An extensive literature search did not show any case report of duodenoduodenal IS being managed by this technique. The combination of novel retrograde decompression and intraoperative endoscopy helped us to manage this rare case by this novel technique.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":" ","pages":"345-348"},"PeriodicalIF":1.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11354944/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41240104","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Laparoscopic repair of iatrogenic celiac artery injury during median arcuate ligament release: A retrospection and tips at troubleshooting.","authors":"Ganesh Shenoy, Marina Thomas, B S Ramesh","doi":"10.4103/jmas.jmas_253_23","DOIUrl":"10.4103/jmas.jmas_253_23","url":null,"abstract":"<p><strong>Abstract: </strong>Median arcuate ligament (MAL) syndrome or celiac artery (CA) compression syndrome previously treated mainly by vascular surgeons using the open approach is now being increasingly performed by general surgeons with training in advanced laparoscopy. Although this approach has all the advantages of minimal access surgery, the procedure is fraught with serious complications like injury to major vascular structures during dissection. Vascular injury by far is the major cause of conversion to open procedure. Herein, we report a laparoscopic repair of iatrogenic CA injury by intra-corporeal suturing during MAL release. We also elaborate the causes, the preventive measures that can be applied to avoid such catastrophic occurrences in future. To the best of our knowledge, this is the first report of a laparoscopic repair of CA bleed during MAL release.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":" ","pages":"359-362"},"PeriodicalIF":1.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11354949/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139425748","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A new method of pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy: A retrospective analysis of 93 cases.","authors":"Junhan Li, Jianqiang Xiang, Jie Zhu, Mengnan Wang, Meng Lin, Haibiao Wang, Hong Li","doi":"10.4103/jmas.jmas_59_24","DOIUrl":"10.4103/jmas.jmas_59_24","url":null,"abstract":"<p><strong>Introduction: </strong>Pancreaticojejunostomy have been studied and modified for more than a hundred years. We investigated a new method of pancreaticojejunostomy to explore its value in laparoscopic pancreaticoduodenectomy.</p><p><strong>Patients and methods: </strong>A retrospective analysis was conducted on the clinical data of 93 patients who underwent laparoscopic pancreaticoduodenectomy with 'Shunt-block combined' pancreaticojejunostomy at Ningbo Medical Center Lihuili Hospital from April 2017 to February 2023.</p><p><strong>Results: </strong>All patients successfully completed the surgery, with two cases requiring conversion to open surgery. The average operation time was 328.5 (180-532) min, the average intraoperative blood loss was 182.9 (50-1000) mL and the average laparoscopic pancreaticojejunostomy time was 29.6 (20-39) min. There were no cases of grade C pancreatic fistula postoperatively, 10 cases of grade B pancreatic fistula, 43 cases of biochemical fistula and 40 cases without detected pancreatic fistula.</p><p><strong>Conclusion: </strong>'Shunt-block combined' pancreaticojejunostomy was a safe and effective method for pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy.</p>","PeriodicalId":48905,"journal":{"name":"Journal of Minimal Access Surgery","volume":" ","pages":""},"PeriodicalIF":1.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141494003","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}