From: Subject: eMedicine - Hernias : Article by David Manthey, MD Date: Thu, 16 Aug 2007 16:21:03 +0800 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01C7E021.7122D800" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3138 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.emedicine.com/emerg/topic251.htm eMedicine - Hernias : Article by David Manthey, = MD
   
3D""=20
3D"" Home  |  = Specialties=20 | Resource=20 Centers |  Learning = Centers=20  |  CME=20  |  Contributor=20 Recruitment
=
  = = Articles Images CME=20 =20 = Advanced=20 Search  Consumer Health Link to this site

You are in: eMedicine=20 Specialties > Emergency=20 Medicine > Gastrointest= inal=20

Hernias

Last Updated: January = 3, 2007=20
Rate this = Article=20
Email=20 to a Colleague
Get CME/CE for = article=20
Synonyms and related = keywords:=20 hernia, abdominal wall hernia, indirect inguinal hernia, = indirect=20 hernia, direct inguinal hernia, direct hernia, femoral = hernia,=20 umbilical hernia, Richter hernia, incisional hernia, = spigelian=20 hernia, obturator hernia, reducible hernia, incarcerated = hernia,=20 strangulated hernia

  AUTHOR INFORMATION=20 Section 1 of = 11   =20
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography
Author: David=20 Manthey, MD, Director of Undergraduate Medical=20 Education, Associate Professor, Department of Emergency = Medicine, Wake Forest University = Baptist=20 Medical Center

Coauthor(s): Bret=20 A Nicks, MD, Assistant Medical Director, = Clinical=20 Instructor, Department of Emergency Medicine, Wake Forest University = Baptist Medical=20 Center

David Manthey, MD, is a member of the following medical=20 societies: American Academy = of=20 Emergency Medicine, American=20 College of Emergency Physicians, and Society for Academic Emergency = Medicine

Editor(s): Richard Lavely, MD, JD, MS, = MPH,=20 Lecturer in Health Policy and Administration, Department of = Public=20 Health, Yale University School of Medicine; = Francisco=20 Talavera, PharmD, PhD, Senior Pharmacy Editor, = eMedicine;=20 Eugene Hardin, MD, FACEP, FAAEM, Chair and=20 Associate Professor, Department of Emergency Medicine, = Charles R=20 Drew University of Medicine and Science; Chair, Department = of=20 Emergency Medicine, Martin Luther King, Jr/Drew Medical = Center;=20 John Halamka, MD, Chief Information = Officer,=20 CareGroup Healthcare System, Assistant Professor of = Medicine,=20 Department of Emergency Medicine, Beth Israel Deaconess = Medical=20 Center; Assistant Professor of Medicine, Harvard Medical = School; and=20 Steven C Dronen, MD, FAAEM, Director of = Emergency=20 Services, Director of Chest Pain Center, Department of = Emergency=20 Medicine, Ft Sanders Sevier Medical Center=20

Disclosure


  INTRODUCTION = Section 2 of = 11   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

Background: In = 1804,=20 Astley Cooper stated,=20

A hernia is defined as a protrusion of any viscus from = its=20 proper cavity. The protruded parts are generally contained in a = sac-like=20 structure, formed by the membrane with which the cavity is = naturally=20 lined.

Several different types of abdominal wall hernias exist, along = with a=20 larger number of associated eponyms. This article reviews the=20 pathophysiology, evaluation, and treatment of most of these = hernias from=20 an emergency medicine perspective. Hernias are brought to the = attention of=20 an emergency physician either during a routine physical = examination or=20 when the patient has developed a complication associated with the = hernia.

Pathophysiology:

Indirect hernia=20

An indirect inguinal hernia follows the tract through the = inguinal=20 canal. This results from a persistent process vaginalis.=20

The canal begins in the intra-abdominal cavity at the internal = inguinal=20 ring, located approximately midway between the pubic symphysis and = the=20 anterior iliac spine. The canal courses down along the inguinal = ligament=20 to the external ring, located medial to the inferior epigastric = arteries,=20 subcutaneously and slightly above the pubic tubercle. Contents of = this=20 hernia then follow the tract of the testicle down into the scrotal = sac.=20

Direct hernia=20

A direct inguinal hernia usually occurs due to a defect or = weakness in=20 the transversalis fascia area of the Hesselbach triangle. The = triangle is=20 defined inferiorly by the inguinal ligament, laterally by the = inferior=20 epigastric arteries, and medially by the conjoined tendon.=20

Femoral hernia=20

The femoral hernia follows the tract below the inguinal = ligament=20 through the femoral canal. The canal lies medial to the femoral = vein and=20 lateral to the lacunar (Gimbernat) ligament.=20

Because femoral hernias protrude through such a small defined = space,=20 they frequently become incarcerated or strangulated.=20

Umbilical hernia=20

The umbilical hernia occurs through the umbilical fibromuscular = ring,=20 which usually obliterates by 2 years of age.=20

Umbilical hernias are congenital in origin and are repaired if = they=20 persist in children older than 2-4 years.=20

Richter hernia=20

The Richter hernia occurs when only the antimesenteric border = of the=20 bowel herniates through the fascial defect.=20

A Richter hernia involves only a portion of the circumference = of the=20 bowel. As such, the bowel may not be obstructed, even if the = hernia is=20 incarcerated or strangulated, and the patient may not present with = vomiting. Richter hernia can occur with any of the various = abdominal=20 hernias and is particularly dangerous, as a portion of = strangulated bowel=20 may be reduced unknowingly into the abdominal cavity, leading to=20 perforation and peritonitis.=20

Incisional hernia=20

This iatrogenic hernia occurs in 2-10% of all abdominal = operations=20 secondary to breakdown of the fascial closure of prior surgery. = Even after=20 repair, recurrence rates approach 20-45%.=20

Spigelian hernia=20

This rare form of abdominal wall hernia occurs through a defect = in the=20 spigelian fascia, which is defined by the lateral edge of the = rectus=20 muscle at the semilunar line (costal arch to the pubic tubercle).=20

Obturator hernia=20

This hernia passes through the obturator foramen, following the = path of=20 the obturator nerves and muscles. Obturator hernias occur with a=20 female-to-male ratio of 6:1, because of a gender-specific larger = canal=20 diameter. Because of its anatomic position, this hernia presents = more=20 commonly as a bowel obstruction than as a protrusion of bowel = contents.=20

Reducible hernia=20

This term refers to the ability to return the contents of the = hernia=20 into the abdominal cavity, either spontaneously or manually.=20

Incarcerated hernia=20

An incarcerated hernia is no longer reducible. The vascular = supply of=20 the bowel is not compromised. Bowel obstruction is common.=20

Strangulated hernia=20

A strangulated hernia occurs when the vascular supply of the = bowel is=20 compromised secondary to incarceration of hernia contents.

Frequency:

  • In the US:
  • Approximately 700,000 herniorrhaphies are performed in the = United=20 States each year.=20

  • Approximately 25% of males and 2% of females have inguinal = hernias=20 in their lifetimes; this is the most common hernia in males and = females.=20

  • Approximately 75% of all hernias occur in the groin; two = thirds of=20 these hernias are indirect and one third direct.=20

  • Indirect inguinal hernias are the most common hernias in = both men=20 and women; a right-sided predominance exists.=20

  • Incisional and ventral hernias account for 10% of all = hernias.=20

  • Only 3% of hernias are femoral hernias.=20

  • Between 10% and 30% of children have an abdominal wall = hernia; most=20 hernias of this type close spontaneously by age 1 year.=20

  • The incidence of incarcerated or strangulated hernias in = pediatric=20 patients is 10-20%; 50% of these occur in infants younger than 6 = months.=20
  • Internationally:
  • Data from developing countries is limited; therefore, an = accurate=20 occurrence value is unavailable. Gender and anatomic = distribution are=20 believed to be similar.

Mortality/Morbidity: Morbidity is secondary to = missing=20 the diagnosis of the hernia or complications associated with = management of=20 the disease.=20

  • A hernia can lead to an incarcerated and often obstructed=20 bowel.
  • The hernia also can lead to strangulated bowel with a = compromised=20 blood supply. Reduced strangulated bowel leads to persistent=20 ischemia/necrosis with no clinical improvement.
  • Ensuing surgery to repair the hernia or its complications = may leave=20 the patient at risk for future hernias or intra-abdominal=20 adhesions.

Race:

  • Umbilical hernias occur 8 times more frequently in black = infants=20 than in white infants.

Sex:

  • Approximately 90% of all inguinal hernia repairs are = performed on=20 males.

  • Reduction of hernias in females may be complicated by = inclusion of=20 the ovary in the hernia.
  • Femoral hernias (although rare) occur almost exclusively in = women=20 because of the differences in the pelvic anatomy.
  • The female-to-male ratio of obturator hernias is = 6:1.

Age:

  • Indirect hernias usually present during the first year of = life, but=20 they may not appear until middle or old age.
  • Direct hernias occur in older patients as a result of = relaxation of=20 abdominal wall musculature and thinning of the fascia.
  • Umbilical hernias usually occur in infants and reach their = maximal=20 size by the first month of life. Most hernias of this type close = spontaneously by the first year of life, with only a 2-10% = incidence in=20 children older than 1 year.


  CLINICAL = Section 3 of = 11   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

History: Patients = with=20 hernias present to the emergency department (ED) secondary to a=20 complication associated with the hernia. Hernias also may be = detected in=20 the ED on routine physical examination. However, in relation to = the chief=20 complaint, the following issues must be considered:

  • Asymptomatic hernia
    • Presents as a swelling or fullness at the hernia = site
    • Aching sensation (radiates into the area of the = hernia)
    • No true pain or tenderness upon examination
    • Enlarges with increasing intra-abdominal pressure and/or=20 standing
  • Incarcerated hernia
    • Painful enlargement of a previous hernia or = defect
    • Cannot be manipulated (either spontaneously or manually) = through=20 the fascial defect
    • Nausea, vomiting, and symptoms of bowel obstruction=20 (possible)
  • Strangulated hernia
    • Symptoms of an incarcerated hernia present combined with a = toxic=20 appearance.
    • Systemic toxicity secondary to ischemic bowel is=20 possible.
    • Strangulation is probable if pain and tenderness of an=20 incarcerated hernia persist after reduction.
    • Suspect an alternative diagnosis in patients who have a=20 substantial amount of pain without evidence of incarceration = or=20 strangulation.
  • Femoral hernia: Medial thigh pain as well as groin pain are = possible=20 because of the position of this hernia.=20

  • Obturator hernia
    • Because this hernia is hidden within deeper structures, it = may not=20 present as a swelling.=20

    • The patient may complain of abdominal pain or medial thigh = pain,=20 weight loss, or recurrent episodes of bowel or partial bowel=20 obstruction.
    • Pressure on the obturator nerve causes pain in the medial = thigh=20 that is relieved by thigh flexion. This same pain may be = exacerbated=20 by extension or external rotation of the hip (Howship-Romberg=20 sign).
  • Incisional hernia
    • As these are usually asymptomatic, patients present with a = bulge=20 at the site of a previous incision.
    • Lesion may become larger upon standing or with increasing=20 intra-abdominal pressure.

Physical: In general, the physical examination = should=20 be performed with the patient in both the supine and standing = positions,=20 with and without the Valsalva maneuver. The examiner should = attempt to=20 identify the hernia sac as well as the fascial defect through = which it is=20 protruding. This allows proper direction of pressure for reduction = of=20 hernia contents. The examiner should also identify evidence of = obstruction=20 and strangulation.

  • When attempting to identify a hernia, look for a swelling or = mass in=20 the area of the fascial defect.
    • Place a fingertip into the scrotal sac and advance up into = the=20 inguinal canal. If the hernia is elsewhere on the abdomen, = attempt to=20 define the borders of the fascial defect.
    • If the hernia comes from superolateral to inferomedial and = strikes=20 the distal tip of the finger, it most likely is an indirect=20 hernia.
    • If the hernia strikes the pad of the finger from deep to=20 superficial, it is more consistent with a direct = hernia.
  • A bulge felt below the inguinal ligament is consistent with = a=20 femoral hernia.
  • Strangulated hernias are differentiated from incarcerated = hernias by=20 the following:
    • Pain out of proportion to examination = findings
    • Fever or toxic appearance
    • Pain that persists after reduction of = hernia

Causes: Any condition that increases the = pressure in=20 the intra-abdominal cavity may contribute to the formation of a = hernia,=20 including the following:

  • Marked obesity
  • Heavy lifting
  • Coughing
  • Straining with defecation or urination
  • Ascites
  • Peritoneal dialysis
  • Ventriculoperitoneal shunt
  • Chronic obstructive pulmonary disease (COPD)
  • Family history of hernias
  DIFFERENTIALS = Section 4 of = 11    3D"Click
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

Epididymitis =
Hidradenitis=20 Suppurativa
Hydrocele =
Lymphogranuloma=20 Venereum
Testicular = Torsion=20


Other Problems to be Considered:

Groin=20 = abscess
Hematoma
Lipoma
Lymphadenitis
Pseudoaneurysm
Sperm= atocele
Tumor
Undescended=20 or retracted testes
Varicocele

Quick Find
Author=20 Information
Introduction
Cli= nical
Differentials
Worku= p
Tr= eatment
M= edication
Fo= llow-up
Miscellaneous
Pic= tures
Bibliography

Click = for related images.

Related Articles
Epididymitis=20

Hidradenitis=20 Suppurativa

Hydrocele=20

Lymphogranuloma=20 Venereum

Testicular=20 Torsion


Continuing Education =
CME available for this topic. = Click here=20 to take this=20 = CME.

Patient Education
Click here=20 for patient education. =


=0A= =0A=
=0A= =0A=

  WORKUP = Section 5 of = 11   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

Lab Studies:

  • Complete blood count
    • Test is nonspecific.
    • Leukocytosis with left shift may occur with=20 strangulation.
  • Electrolytes, BUN, creatinine levels
    • Assess the hydration of the patient with nausea and=20 vomiting.
    • These tests are rarely needed except as part of a = preoperative=20 workup.
  • Urinalysis: This test assists with narrowing the = differential=20 diagnosis of genitourinary causes of groin pain.

Imaging Studies:

  • Imaging studies are not required in the normal workup of a=20 hernia.
  • Ultrasonography can be used in differentiating masses in the = groin=20 or abdominal wall or in differentiating testicular sources of=20 swelling.
  • If an incarcerated or strangulated hernia is suspected, the=20 following imaging studies can be performed:
    • Upright chest radiograph to exclude free air (extremely=20 rare)
    • Flat and upright abdominal films to diagnose a small bowel = obstruction (neither sensitive or specific) or to identify = areas of=20 bowel outside the abdominal cavity
  • CT scanning or ultrasonography may be necessary in the = following=20 cases:=20

    • To diagnose a spigelian or obturator hernia=20

    • Inability to obtain a good examination because of body = habitus=20
  TREATMENT = Section 6 of = 11   3D"Click <= IMG=20 height=3D10 alt=3D"Click here to go to the next section in = this topic"=20 src=3D"http://www.emedicine.com/images/next3.gif" width=3D31 = align=3Dmiddle border=3D0>
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

Emergency Department Care:

  • Reduction of a hernia
    • Provide adequate sedation and analgesia to prevent = straining or=20 pain. The patient should be relaxed enough to not increase=20 intra-abdominal pressure or to tighten the involved=20 musculature.
    • Place the patient supine with a pillow under his or her=20 knees.
    • Place the patient in a Trendelenburg position of = approximately=20 15-20=B0 for inguinal hernias.
    • Apply a padded cold pack to the area to reduce swelling = and blood=20 flow while establishing appropriate analgesia.
    • Place the ipsilateral leg in an externally rotated and = flexed=20 position resembling a unilateral frog leg = position.
    • Place 2 fingers at the edge of the hernial ring to prevent = the=20 hernial sac from riding over the ring during reduction=20 attempts.
    • Firm, steady pressure should be applied to the side of the = hernia=20 contents close to the hernia opening, guiding it back through = the=20 defect.=20

    • Applying pressure at the apex, or first point, that is = felt may=20 cause the herniated bowel to "mushroom" out over the hernia = opening=20 instead of advancing through it.
    • Consult with a surgeon if reduction is unsuccessful after = 1 or 2=20 attempts; do not use repeated forceful = attempts.
    • The spontaneous reduction technique requires adequate=20 sedation/analgesia, Trendelenburg positioning, and padded cold = packs=20 applied to the hernia for a duration of 20-30 minutes. This = can be=20 attempted prior to manual reduction attempts.

Consultations: Consult a surgeon for the = following=20 reasons:

  • Inability to reduce the hernia
  • Concern for a strangulated bowel and a patient with a toxic=20 appearance
  • Patients with comorbid risks for sedation should have a = surgeon=20 present for the initial reduction attempt.

  MEDICATION = Section 7 of = 11   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

For strangulated hernias, start=20 broad-spectrum antibiotics. Antibiotics are administered routinely = if=20 ischemic bowel is suspected.

Drug Category: Antibiotics -- = These agents=20 are to be used if the patient has a strangulated hernia.
Drug Name
 Cefoxitin (Mefoxin) -- = Multiple=20 regimens that cover for bowel perforation and/or ischemic = bowel can=20 be used. Cover for both aerobic and anaerobic gram-negative=20 bacteria.
Adult Dose 1-2 g IV q8h
Pediatric Dose 80 mg/kg/d IV divided = into 4 equal=20 doses q6h
Contraindications Documented = hypersensitivity
Interactions Probenecid may increase = effects;=20 aminoglycosides or furosemide may increase nephrotoxicity = (closely=20 monitor renal function)
Pregnancy B - Usually safe but = benefits must=20 outweigh the risks.=20
Precautions Bacterial or fungal = overgrowth of=20 nonsusceptible organisms may occur with prolonged use or = repeated=20 treatment; caution in previously diagnosed = colitis
  FOLLOW-UP = Section 8 of = 11   <= IMG=20 height=3D10=20 alt=3D"Click here to go to the previous section in this = topic"=20 src=3D"http://www.emedicine.com/images/back3.gif" width=3D31 = align=3Dmiddle border=3D0>
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

Further Inpatient Care:

  • All incarcerated or strangulated hernias demand admission = and=20 immediate surgical evaluation.

Further Outpatient Care:

  • Schedule a follow-up visit with the general surgeon within = the next=20 1-2 weeks for those patients with easily reducible hernias or = with=20 hernias found upon physical examination.
  • Discharge patients with umbilical hernias with close = follow-up care=20 if the defect is less than 2 cm in diameter and the hernia is = not=20 incarcerated or strangulated.
  • Educate patients to avoid those activities that increase=20 intra-abdominal pressure.
  • Educate patients to return for increased pain, inability to = reduce=20 hernia, fever, and vomiting.

Deterrence/Prevention:

  • Counsel the patient on avoidance of activities that increase = intra-abdominal pressure, such as straining at defecation or = lifting=20 heavy objects.

Complications:

  • If strangulation of the hernia is missed, bowel perforation = and=20 peritonitis can occur.
  • Hernias can reappear in the same location, even after = surgical=20 repair.

Prognosis:

  • The prognosis depends on the type and size of hernia as well = as on=20 the ability to reduce risk factors associated with the = development of=20 hernias.
  • The prognosis is good with timely diagnosis and = repair.

Patient Education:

  • Counsel the patient to avoid those activities that increase=20 intra-abdominal pressure, such as straining at defecation and = lifting=20 heavy objects.
  • Instruct the patient to apply support to the = hernia.
  • Even with asymptomatic hernias, early repair (ie, before it=20 enlarges) is preferred.
  MISCELLANEOUS = Section 9 of = 11   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

Medical/Legal Pitfalls:

  • Failure to consider the diagnosis of hernia in patients who = present=20 with nausea and/or vomiting
  • Diagnosing testicular torsion as a hernia (puts the testicle = at=20 risk)
  • Reducing a strangulated bowel without recognizing it (The = hernia=20 will be reduced, but the bowel will remain ischemic.)

Special Concerns:

  • Pain after reduction of a hernia may indicate a strangulated = hernia,=20 requiring further evaluation by a surgeon.
  PICTURES = Section 10 of=20 11   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

Caption: = Picture 1.=20 Anatomic locations for various hernias
3D"Click 3D"ClickView Full=20 Size Image
3D"ClickeMedicine=20 Zoom View (Interactive!)
Picture = Type:=20 Image
  BIBLIOGRAPHY = Section 11 of=20 11   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Pic= tures=20 Bibliography

  • Bobrow RS: The hernia. J Am Board Fam Pract 1999 Jan-Feb; = 12(1):=20 95-6[Medline].=20
  • Eubanks S: Hernias. In: Sabiston DC Jr, ed. Textbook of = Surgery: The=20 Biological Basis of Modern Surgical Practice. 1997.=20
  • Ginsburg BY, Sharma AN: Spontaneous rupture of an umbilical = hernia=20 with evisceration. J Emerg Med 2006 Feb; 30(2): 155-7[Medline].=20
  • Kapur P, Caty MG, Glick PL: Pediatric hernias and = hydroceles.=20 Pediatr Clin North Am 1998 Aug; 45(4): 773-89[Medline].=20
  • Levine BJ, Nabha S, Bouzoukis JK: Chronic inguinal hernia. J = Emerg=20 Med 1999 May-Jun; 17(3): 515-6[Medline].=20
  • Manthey, DE: Abdominal hernia reduction. In: Clinical = Procedures in=20 Emergency Medicine. 2003.=20
  • Mensching JJ, Musielewicz AJ: Abdominal wall hernias. Emerg = Med Clin=20 North Am 1996 Nov; 14(4): 739-56[Medline].=20
  • Rutkow IM, Robbins AW: Demographic, classificatory, and=20 socioeconomic aspects of hernia repair in the United States. = Surg Clin=20 North Am 1993 Jun; 73(3): 413-26[Medline].=20
  • Scherer LR 3d, Grosfeld JL: Inguinal hernia and umbilical = anomalies.=20 Pediatr Clin North Am 1993 Dec; 40(6): 1121-31[Medline].=20
  • Wants GE: Abdominal wall hernias. In: Schwartz SI, Shires = GT,=20 Spencer FC, eds. Principles of Surgery. 6th ed. 1994.

NOTE: =
Medicine is a = constantly=20 changing science and not all therapies are clearly = established. New=20 research changes drug and treatment therapies daily. The = authors,=20 editors, and publisher of this journal have used their best = efforts=20 to provide information that is up-to-date and accurate and = is=20 generally accepted within medical standards at the time of=20 publication. However, as medical science is constantly = changing and=20 human error is always possible, the authors, editors, and = publisher=20 or any other party involved with the publication of this = article do=20 not warrant the information in this article is accurate or = complete,=20 nor are they responsible for omissions or errors in the = article or=20 for the results of using this information. The reader should = confirm=20 the information in this article from other sources prior to = use. In=20 particular, all drug doses, indications, and = contraindications=20 should be confirmed in the package insert. FULL = DISCLAIMER=20

Hernias = excerpt

About=20 Us | Privacy | Terms=20 of Use | Contact Us | Advertising | Institutional=20 Subscribers
3D""=20 We subscribe to the
HONcode principles of the =
Health On the=20 Net Foundation		  
=A9=20 1996-2006 by WebMD
All Rights = Reserved=20
------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/images/emed_fromWEBMD.gif R0lGODlhswA5APcAAAAAAOWFnWZmZnIFBCkpKa2trWZmZvzu8rdlbbEHKhAQEJmZme/v70pKSszM zJ0KIebm5ps+Q4SEhLsiQufIzcB9giEhITo6Or29vcwAM9bW1tdEaZkVJX0iHlpaWqWlpemuvHt7 e4yMjJQgKvf3980QQdOcoo4ZIRkZGfDP1slOaP/3+wgICN5jgsXFxdIuVNaOm8A/WDMzM1JSUt2r srW1tasCI7IXNd7e3pIzNnNzc+iTqM1jeUJCQnsbGIIcHcmJkbU7T6saM6hTWJmZmfjg5/DT2dtS dawQLeJ1kenM0I0iKLUSNIImI+q4w3UZEqwoPcsJO/ro7YQPFeapt88eS9d2jLNVYM9bdP/w9dU4 YcM5V6QIJKUZL7pqcZkzM38nIsYAJfPI0/Ld4HwREuBsityVo64EJqxXXclrfObAxtaElKJHTN2n r/LBzc4WReW3wLswTLAZNsJXatp9krZscrcYOdF2h3ofGv/3+uaMnNxbfK4RL/XR2sdEYZ05QOvM 0I8rL4UkJYwhIeC2vKgJJ/bV3tBqf50OI9MsV/rs8MxTbb4qSuWgsO+0w+uitXgXFP///60IKYMh Ifnm6thHbIUXHK9eZMExUNBrgN6LnqxVXK0IIdQzXO6wv/XO2Pfe3uy6xu/EzrRpbp8XK8JVad61 tZ8zPa0tQtN+j8BUZsBteKdOVOKns88bStuBlOeNpMlKZaQPKAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAQUAP8ALAAAAACzADkA AAj/ACMJHEiwoMGDivYk2tApwMGHECNKnEixosWLGDNqLNhHS4YMLTaKHEmypMmTFQ9UChMSpcuX MGPCPPDiiMybOHPqPGjI4c6fQIMKHUq0qNGjSJMqXcpUZhEpTaNKtSgmSaIqVTZ4msq1q0Ape6Jk iEJWbBKvaJkq8liirdsSGWClnXu0RYa3b6OU6EO3b1BDeAOD9EtY5w69gfF+Kjzyw4ULBTbW6HFh QdIydxPDzVAlFOOJBXSI1iGBRKQFAFIDiIyxhmoAIpBiTjx2w6MDnyd6eK2ABAkCry9k7PEahWmj ATK3/eiqjJvcFQW8tkCCgYLXMo5X/P2aBYOjIBB//9QSgBJ0i9JVU4904XWDjLtVE0BaBO6bI46y nL+YPvV6DNcBYIEDGWlgQWoKYACUBhocVEYZfJGUghN+9SfgcRCIIMJ3GjEgggQ4/MSADjPMIMIK L2URChZ8LCIQAzjEiAOHkeDwgQQhfABBQRBgsEAIIhAIkQMLSOCBABLUsGNEDGhQwwcuhKjDdKZB AIFvENBIEA41SCCAByEs0OCLV5JgpUAQyIgDipEw4MKPIrgQUY8i6ABmkMct4IEEOjTwAUpFaLJF AgnYwINAIrCgwKLvQeABC8X9GQkJIRz4mgAHYUDca6mhoIN2BDEQAnCqKRDCDFSyt+iimBLkgAcB cv/aAIGwrvoeAwSsqkANkXwgA6c9hFgQpZZyClkkIRTQgAcf6GCSKDxMQOgNNxRyaCQSvEYADqRy CoCCDXibmrMEhSBucEsO5EC35/pnGrszELQApO16EEm4qgkHAQqvFXludgRB0F67AEjQ7AJ1xiaS Imb4QSgT1CJRSCGHCJStegOL28PF5yqIqLco8IsdjftyyoIFsar37mv2fkwwAPaimm8kJedLsGUv /sqbBfSqFoIAPwsA6kWiWCFtAtTywYckcRzihH7Yntvzy5cK5AKnMrjg2wcpkxuJhTBfOSKn67Hb 8tWcEhCnAx8IoEC8Mqemr8hUAxCvQFO+psOVOFj/yIIDgGukSCOxMJEAxNXy0bQTUBHEsWoCuKAB BuwiuADgectnGr6pATyQa6XuiEPKwhEU94WRmC1Qxqn1oGUkGvx5+txki+mAuak6wGkIBcWXWssY fUIHI9NSe0McmVABtUGPs4Cz1ZyiIKRAnF+IA6esEVR9bKi9JulAmaOuOgacKiDsQbPTTDcABKR7 L2+mhb/elt2dP5EiICxixxmIy+E/EmaQyONQoCUIpIx3BJHfaXjjPpel5j1+G9NALFQ2lkUifDCL SPpqlhoEDuRxvSGBzn5nEBG+hlcTMcQrMEEoPtzAfzCUQyHWIMDiuM+Ar5FAQRToOwDI4CBo61wk /zblroJQcGWqsRcRU5M99AVHfXorCAhpljKFGTGHE8GCHRLgwhfGUAhg5MIdaqgaFNwwZTpMIJWW SIAFuPGNP5qOBkYoIIMcMXUsW0HlJOjEmXEQAF4TCO4QFAndsQyOb1xiIB+igjN4EYZgjKQQZBHA iAzwjFhUo3ogQMe6SY9dFrBjqtglAAasDwB8NMgG17fIQQJAAYWsG6eABxEQSAKSkoxkF7ogBjJ2 CpOqSSP4psOATlJNAeuajihVhkfIMaBYqUllQVYZxXLxJpayVM17JhKDQuQSjLvswgPmMJFLBgyN O5wOJ4sjGgG4853wDAG3lHlFZpLymZySpume+P/HVl7TkPnSATwH6s7nRcQJSEBCLsP5ACiMoZw2 PGcmh6ky1vWAIvhUzzKLqLpO6nMg1FSNP0uFTdUYlCRr4EI4w0mKBwQhBRQx50BwGMx0avR0BHjd QbjDTILcUXVL/JYG+cnKgrgSljiYmgdNAgMhIOKpT0UFDHAT04jOFJ2a9E/UXjO9iFTvbzblqAXB tshpErWaAznqCvT4mou6xBCpKEUp0tAKRVxEpmjCKkX9swKApqZVD+EQ2JY6T3takHzF0WmNIhHS cRkVfpHoIQDkBJGh5QSvVJwo3ojJnt0NjQQumEGrPmCyBfimANAUnwUj0UkZOIBNJFBWzM4q0sf/ lso0QfSPx0K1gAtQ9ieYpWlqhLlZ9XwHsdoy2AdEIABLbVO4qmHB1AybROh5iwCUCdBs/VhUa95W IGADQANE8IEbNSBAv91JcPVaXP9wSASy3GYk4Cu1JVawug6sF2Np61jvIug4DGAdwdKrk6PeUKn1 7BSNPnBKcREXg6r5QPc6hcTU3E0gqCUYpqr3Q+iONDUs0A4DJCsuFNhPJyJAgQVWLIMbEmDFK7ai xVS84gsUcFQpeyUBBNBVgThGAdJVQA94tYCQhewCpumBkVEAWDSJQAYpU4AMFvAdASw5XsWEsQWI O18aW4AAQ8PADFLLAhRUpoE3MYRAzMSANuvU/81t/iycFVvIAti5ADX46EBwALjzVQfOL5rzQ5x0 567OmUNzljOgD8IADNy5AC5A803yUAcE7OfSMDHCEAYwipsATmsFwYELXIBoyanLAQ1kgANU/elI m4YBksZ0RkwQCEhAog4B+wAKSzKlBiBaIBhAQfvQBGUOmat0EwTAB3ajgBcLaAGilfVIKDAESHSg CbceSDEBeZLr4cwFnrOAjJs7ELTt1jqrIZ8ErISBX/Ug1tKWCAXqMAlIgOHe2RaIBgDQY5KwII3h CpEDFOA+GXgQsfKlbwHI9z189tsvY4DDRhRBiEsIwt5NyDi2cU2zBeyqQTGqAQp9tFsN2CgyOP9Y AIEjwQJMuWBRkRFAA0igJyon6AMNWAD5DkQgXBEHzwAwKHyXWhg1cOAKbaDqRA5AiApEwAc+uLbG M57vRAGABTGTLqam9Css84wALGgAAYDTxEhYYMMi6IGz1DYDCcyryMzimgRQgJr3LIAApAW6Qa9W Vr9QYASWOMEpVkGDFFCCTZHIQhEAQQggbCIHkyADHsAw9annmwQ1QKZpZsCCBrnmT1ezDApmDl/T XsCtA5GBBxzwQw80AAJnf48H2q7sNilABwpgQLhQ+wHy6Z0g5Ot7X/6+hCUMwhJTGMEfWIGG5rMh BycgAySiLvXKW57jhSS4QHrgVh2gYCAEsJf/Bf4EoO/oYD4E6cGyYiMBGejgArf/EgkusE2Po8ZN fC1AuoNuzZMShvjFV3yT8AM/YGvTF3WUZ30KuHHlZj7U0yrel3r2QgCREWw7ogM/5FNCZhqZpwAe MH47ghoodHa6syPhokOkpWu1l1cEBB1/JwgwGIOCoHH3VoM2eIM4+ATY93LC0gCt4hq8ojsFsALj FwkWeEEZmGySwgACIgIW8B29pX0hkB3ksyNitiP6JwH6tzcQUACL8nB+NwIBOIZkWIZmSIZk4AUN 2IOApQNhpwCY8kzkp33nZ1TzkzqlZAH0tzcXQBoCsCNWZlAk4H3MYgFmNnYCcGKMcQCAoASOO/iI kBiJkjiJjkgBD/UiDnAcJkcQBZAj6vIdqmYafFYQgaMuIZJylJVyKEQCDMJHJOAADJImrQhvhBEQ ADs= ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://emedicine.com/images/ui/search.gif R0lGODlheAAWAPcAAP////7+//39/v39/fz8/vv7/fr6/fr6/Pn5/Pj4/Pf3+/b2+vX1+fPz+fLy +PHx+Ovr9efn8ubm8+Tk8uHh7+Dg8NnZ7NjY69fX69XV69XV6tTU6dPT6dLS6dLS6NDQ6NDQ58/P 5s7O5s3N5svL5cjI5MjI48fH48PD4cLC4MHB4MDA4MDA37y83bq63Lm53Lm527a227Oz2bKy2LGx 2K+v162t1qys1qys1aur1aio1Kio06en0qam06Oj0ZmZzJGRyZCQx42NxoqKxImJxImJxYiIxIaG w4WFwoSEwoSEwYODwYKCwYGBwYCAv3l5vHV1unR0uXNzuXJyuXJyuHFxuG5ut2trtWpqtGdns2Zm s2ZmsmRksWRksmNjsGBgsGBgr19fr15erllZrFhYrFdXq1RUqVFRp05Opk1NpkxMpUtLpUlJpElJ o0dHpEZGo0ZGokVFo0VFokNDokNDoUJCoUBAoEBAnz4+nz09njw8njw8nTw8nDk5nDg4mzc3mzY2 mzY2mjU1mjQ0mjQ0mTMzmTMzmjIymTIymDExmDAwmC8vlwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAQUAP8ALAAAAAB4ABYA AAj/AAsJHEiwoMGDCBMqXMiwocOHECNKnEixosWLGAv++RLkxg0fRrzQGZSxpMmTBPNAuXHixIod T9QoQkmz5sQ2T0w8ECAAgQMSRtbYpHhHyIgRLJwMLZTmR5qGdZiIGACgalUDHpTIWQrxjgQJPX7I aGDhjk0tALQ03CKDgdW3BlyIOcTV4VizAscAEHI2bcMmIAy8ffvBiqC6DY8W7NFjoJOjPfAy7XFU xtNCWpxIGfFDoBMWIyJjBiDlB1IpCYtkEDy46gYpgRAz/AHgh2SCY8NKaPD0TgMJP3o0aGD2x3Cx hXoAkGG8LNoGnEeQRriEQ4HWVVNwkc3wjnQAFnqg//YMYIxArzIKSeEtUIpf2uPT1BaI1glaFgMl 4D+IBcYC7AzgYAZ3DY3RgwVVlVWIDBZo4aAWYxVk4HsAOAbAZYWYh5ZaAil20BtHdBBAawrQMMYi BDpUFHSFfDeYQD8gCEADFA5Em0EbDuThQWgYgYECBQQJQQQRoICEG4elKOEI5hGkXIsjHCQEAD1o kUaON8JYYUE5dhhlQnNEwYMKKtRARBVDvABCDmUgoiRBdyy3WAPJXTiQFKiNYIGFamWp3nQCAdcl lAv1ccYVVICBhyJ0MBFCBT10ocdMbxZCWw+9TdlZGmQ9tV56Y2lIY59bBmrBU1NKMeiOCvHhqiGw vmbxRAsUxDAFHYRUaimNVTXQGX0SWMWCWWPw2oATDTTmZ4YyzrfqlxLZIcULF6TABBy65uXgQWNY ySWHC3V7m0l3ZDGDBjqEAUi27FbkRxZAJEHGHu3WK1EfbLARRx/29uvvvwBHFBAAOw== ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://emedicine.com/images/ui/topincline.gif R0lGODlhJwAaANUAAP///////v/++v39/v797//98P38+/z8+/v7/fr6/fr6/P776P775P763fj4 +/351/352f351v352Pf3+/351f341vz43fb2+/341/341f33y/X1+v33zP33zfT0+f33x/T0+vPz +f32xPLy+fHx+JKSyWpqtGVlsmRksWNjsWFhsF1drlxcrVparVhYqzMzmQAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAQUAP8ALAAAAAAnABoAAAbOwJeQ BCgWCoSkcslsOpPC18lRXHCu2Kx2y8VGXypE8aEpm8/otLr8BV/G67ic3Q7D5/hzW6jy3PN4e0Io E0USgIGCLymFABCIcop8I0UVkGuSQisDAwoWl2mZQi4hAAgUoHqii1QAZKkaq0Isra+gskIpIEUR qbh8CgAHtoi/mqUAqJDGfAlFGMvMLy0bRRnF0i8o1QDQaiLgZtlCLc4GvWsf6h/jfMjEmO0vK84A DHPyfH4ADWha+UJKKBAgQIHBgwgBCjFRBKFDBQpxBQEAOw== ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://emedicine.com/images/ui/spacer.gif R0lGODlhAQABAIAAAP///wAAACH5BAEUAAAALAAAAAABAAEAAAICRAEAOw== ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/images/ui/spacer.gif R0lGODlhAQABAIAAAP///wAAACH5BAEUAAAALAAAAAABAAEAAAICRAEAOw== ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/images/ui/arrow.gif R0lGODlhDgAPAMQAADMzmYSD0czM/0pJpqKj41tYsZuc3zw6m7i49GlqvJKS2FFSr7a58GhlvLu8 9ImM0UM/oHJzxamr6FVWsj89oMDD+o+P1QAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAQU AP8ALAAAAAAOAA8AAAU2ICCOZGmeaLpQ6fhYUAsoAhK1tCBIBZrrAsXA9ANWEqWiwBFgkQzA4NAE FRAmKQOjIZscZOAQADs= ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/images/arrowblank.gif R0lGODlhDwAPAPcAAAAAAEBAQGVlZYqKiq+vr9TU1AAAgL+/vwAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH+JVBvd2VyZWQgYnkgQ29s ZCBGdXNpb24gYW5kIENGWF9JTUFHRQoAIfkEAQAABwAsAAAAAA8ADwAACBsADwgcSLCgwYMIEypc yLChw4cQI0qcSPFhQAAAOw== ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/images/next3.gif R0lGODlhHwAKAPIAAAAAAP///ygwYDAwYDAwaAAAMzgwaDAoYCH5BAAAAAAALAAAAAAfAAoAQAhv AAMIHEiwoEGDAwYQGBAgoUCHDRMaELgwAIGJAg8wfFhxgAGGCi1urPixIQGKGxGejHiwJcSBDkMm BJkS5suXME0+rNmS4EqONE9WtCgA4oADLGfypBkRKYGFTzcqTBnyoFGmLCsOrWqzp1eXMwMCADs= ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/images/back3.gif R0lGODlhHwAKAPIAAP//////8CgwWDAwYDAwaDgwaDAoYDgwYCH5BAAAAAAALAAAAAAfAAoAQAiA AAUIGDAAgMGDCA0GSKiQ4cCCAAgUODDwIAEDAwQACECAAMSKADIyJEjSIAGDA04SBCBAZcGUKCGG hLiS4ciTCHHG3LlyQIGZCFM+NFkzJcEDNm3WPDhg4c6IED0aYFp0akidVFHiJOjxas6OOgcg1crz pUugF4HOXOk0qVuGAQEAOw== ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/images/top4.gif R0lGODlhHwAKAPIAAAAAAP///ygwYDAwYDAwaAAAMzgwaDAoYCH5BAAAAAAALAAAAAAfAAoAQAhD AAMIHEiwoMGDCBMWHDBA4UGGAyEGgChRYkKGGBs63BhR40SNFEF6RJjRIkeHJjMKLHnSYsWGLzmm xLhS5UmUIw0GBAA7 ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/jpeg Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/emerg/images/976REVDeme251_1.jpg /9j/4AAQSkZJRgABAQAAZABkAAD/2wBDAAgGBgcGBQgHBwcJCQgKDBQNDAsLDBkSEw8UHRofHh0a HBwgJC4nICIsIxwcKDcpLDAxNDQ0Hyc5PTgyPC4zNDL/2wBDAQkJCQwLDBgNDRgyIRwhMjIyMjIy MjIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMjL/wAARCACgAMgDASIA AhEBAxEB/8QAHwAAAQUBAQEBAQEAAAAAAAAAAAECAwQFBgcICQoL/8QAtRAAAgEDAwIEAwUFBAQA AAF9AQIDAAQRBRIhMUEGE1FhByJxFDKBkaEII0KxwRVS0fAkM2JyggkKFhcYGRolJicoKSo0NTY3 ODk6Q0RFRkdISUpTVFVWV1hZWmNkZWZnaGlqc3R1dnd4eXqDhIWGh4iJipKTlJWWl5iZmqKjpKWm p6ipqrKztLW2t7i5usLDxMXGx8jJytLT1NXW19jZ2uHi4+Tl5ufo6erx8vP09fb3+Pn6/8QAHwEA AwEBAQEBAQEBAQAAAAAAAAECAwQFBgcICQoL/8QAtREAAgECBAQDBAcFBAQAAQJ3AAECAxEEBSEx BhJBUQdhcRMiMoEIFEKRobHBCSMzUvAVYnLRChYkNOEl8RcYGRomJygpKjU2Nzg5OkNERUZHSElK U1RVVldYWVpjZGVmZ2hpanN0dXZ3eHl6goOEhYaHiImKkpOUlZaXmJmaoqOkpaanqKmqsrO0tba3 uLm6wsPExcbHyMnK0tPU1dbX2Nna4uPk5ebn6Onq8vP09fb3+Pn6/9oADAMBAAIRAxEAPwD3+iii gAooooAKKKKAOKvviZo+n6tPp1xBdLNC5jY7RjI/H3q3F4+0mXPyzrjPVfSvMvihapp3jdbjO1bg I5B9wVP6ip7BVnt2dfukHqPbr+NFzaME0erweJrG4j3x7yMZ6VaGr2x/vflXC6SvyAjhSM4+tbsZ G3k0rg6aOh/tK3/vH8qQ6nbAZL/pWC86onNZt1eM2FjHJouCp3Orl1uyiUFnPUDgetJ/blj/AM9P 0rhbvcsKBm6yDJNSAvt85WzjhgKLleyR3a6pascK5P4U46hAB1P5VyFtd4x71orcBwKLkunY221W 2UZJP5VSuPFOnWxw7P8AgKzJ5gRXOX4DyDPJzxRcapI6C4+JGjWylnS4wO4UVo+GPF1l4rW4eyhn RYCAxlUDk9MflXjHiSVbe3lUtiQjCnHB4/8Ar16d8KdP+yeEvPP/AC8zMy/7o+UfyNMicFFHc0UU UGYUUUUAFFFFABRRRQAUUUUAFFFFAHkfxssj5NjfAA4Rl6dwQR/M1l+GnEmnhn4G0KR6H/P8q6L4 3OqeFrPJAY3Bx9NhP9BXIeDys2mMjEncQcdxx/8AroN4PQ7WwIVEAPy+xrWdwIw3eqtlbgRkjOBg DNOuCVUjvUstakc0xPA69hUttbFm3Hkmq0EbvcZxwPWtmIbF4oQSdjkZrmOW7k80/Mjldp/hwcVh eIfEDaPEJ7S0uLiT/pgAR9GGc4/A12GteGbXVJWuIp5LW4P3mQZVvqPX8qy7TwLbJMs19dyXe0gi MrtQ/Uc5/Os1GSldq6O9VqPs92n2t/SHxX1xsSUaZdYdQxG6Lv8A8DrRh1K48v8A5BV4ffdF/wDF 1Yu4yASo/A02xYjCtnrW112ODdEM95cbcf2Vej/gUX/xdY11fSiUFtPuQQM4LRf/ABdddIoZd2RX M6lCrTHdnhs/hRddgVzz7xJLNNdwxNA6ZkGQ7J3OeMHFe2+Gru4sfDOnWy6JqDBIF+ZTDg5Gcj94 PWvB/FU23WI2DHJfOOw4zX0rpDRvoti0OPKNvGUwc8bRinddjKoZGseIrqxtrWQWb2ZmuRCTeeUR jy3fIxKB1QDlh171XfxrEkjIIo22TeUXEq7c7nTLEZ2DKE9/l5rq6gaytnt3tzCnlOxdlxjLFtxP 1zzn1q1KPVGJyR+ItkFVvs4IMSSn9790FVY5454YY25z3wOasReMnZGaW0iQLI0JJnATeGQctj5Q BIuTg85GOOeoigighSGKNEiRQqoowFA6AD2p+BjGBg9qfNDpH8Q1GQSie3jmXpIgYcg9RnqOKKko rIYUVU1SK4n0q6itGK3DRMIyG2/NjjntWBNa+Jpprqe2uZbSOVi8ULGJyp2OMHIYD5liOAcYY1UY 36gdVRXGTaf4pcXKRXEgQCQxeZKmd5lDLgr/AAbOMNz1HTFP1CDxdNH5VtLKpZnDsWh2kEgYXADK uM4OS2evY1Xs13QrnYUVmvDrW8+TeWCx/wAKyWrsw+pEgz+VN8nXv+f7Tf8AwCk/+O1Nl3GeU/GG SXVdetNJQZSCLeR7nk/oBWH4cR9Ou/ImGIT9x88EdOfzrV8VWt7/AMLHkS6uYTO8YYMsDBCuwdBv J7evXNasWhXc1ps+0WmD62zZ/wDQ6TS7nRDY3tKlPkBSSR2Jq1dKAC34VztlbarZ4jN1bgKf47dj j/x+r07aoyYN5Zke1q3/AMcpWXca3NmwhDruPWrrJs4HrWDZvqqDaLyyH1tX/wDjlXT/AGww/wCP 2w/8BH/+OUcq7id7lieeK3BMsirk8Z6n8KZDe2sp2RzKWPRTwT+dcHBf61barex69dWUmJG8sRRM rbc/Lk5xjGOx+tVtT1mIRkq+COQQelZVJqErXud1HBOpFPVXPSZolkQmswAx3GB61Z0y4lk0i1ku QRM0Ks4Ixg45qFyHl3jGM1ZyLTQvsmIK5HVZAkjSSNtUA4z9P1rpZ5sREZ69q52bTXvbsSS5KKM4 7CgSR5pqemXGos9w0eCrBolPUjPPSvdPhtftfeCbPectATCfoOR+hFcTqtlDHFKWGP3ZwB079a6P 4RK3/CLTv83lvcnbn/dXNNGdS1j0CiiimYhRRRQAUUUUAFFFFABRRRQAUUUUAeOfFa6t7PxXp9xE +bhIf3ygdBk4/PJrb8P38V7ZQyKwKuuQa4rx5nUPiLqEJYlAFUD0wij+eTVjQhNo8oVyTbPwp5+Q /wCBpM6IrQ9GmtBIMjrWa8TxnaR1q5YagsqgPgH1z1q3NEkoHFKxSdjMiVsg9K0UbbHlvSnLAuOK cYsrigTdzndc0+x1JVN1FlxwrglWA+oqrYeGdGspkuBbtNIDlWmcttP06Vs31vvdVzjkfiM1ahgX ZjHA6UuVN3saqrNR5U3b1Kskx6CmxliBgd81eazDEEdKlWBEX3pmd0UjayP8zcAio5AsERzjArQu LyKGEliBgVyWo6iX8xmUhMfKByWPsKAV2c94y1gRRJbqx8ydSAF9P/1V6d8NxbjwNYC3cN94yHGM MWJI/lXjt9pMs0jXVznexyoyflGen9f88el/CGZn8M3MbHOy4z+aj/CmZ1FoehUUUUzEKKKKACii igAooooAKKKKACiiigDwXxb/AKN8VrsNkKWRz6YKA5/SuzgsorizAwDleSPWuV+KEAvPiNDHH8pW yTzNvBJDEjP6VsaPfC3VNz/Kw5BPQf5xSOiN7F5bSSybCAlP7prStLw/KpJx0weoqwvl3EeQQQeh BqGW0wQy9aRV77mlG6uvBqTFZdtKY3w2Qa01dWHBouJqxm6kCBkdcVbtx+5X1xTLxA4AxUsK7YxQ HQmU4FUL258sEDqBU01wEBAPNZUm+5c4B2+vrQxpFSYtcOAAXb9BUtto6FvNmyzH1rRt7VY0BI5x mmX97HaxH5huI4HrQgbvscz4vMdtpsu3AYqQB3zjitP4Mhm0DUZTnabraCfZRn+dch4kR9QiwHJJ O7g9COn9K9H+FiwL8PNNEIXOZPMx3fe2c/pVIzqaI7KiiigxCiiigAooooAKKKKACiiigAooqrqc 32bSrycHBjgd8/RSaAPCJb461471PUGBZfM/dn0VcAfotdDd20hjxbgbgwOG6Eelc74ViV5pXAGf NZSOuM5/+t+dehQWQePBxk44NI6lZIy9Jv3S3JKsNv3o2PK+1dLb3Uc0QwetYF/p0kI8yIlZBw2O 4rLt9Tmt5lBJAxkD1GeaQNXO0MIfleopFyjcGqCasgtTK7cBclvQVUXW/M+byW2eobn8qTaRcKc5 LRG9JIoGSeaYbkKm0GqcUy3KK8b5WgxMW9qZFrbk6RtMfY9fpVlIFTnsKbH+6j5FUdS1MQR4U4J4 xTsS22SX16sLBQMuTgVympS3F1dmKIbmGCWblUGen1oF3c3so8tyNwO1vbPWteOwESDsq8sTyaCt jGvIU+xMCpO7j696tfB/UmjvNV0dshQfPjB7c7Tj9PyqS+jCwyMuCME/5/OsjwG62vxI8sH/AFkT ofrgn+lCFPVHtlFFFM5gooooAKKKKACiiigAooooAKyPFLbfCuqHOP8ARn/lWvWB42fy/BeqtjP7 gj8yBQNbnj3g6EhJSc/eIPv0r1iyiH2dfUAc15h4OB+z8Agu5HJ9hXqVn/q8YpG8tiG8i3IeM561 yGsaYvzFAd2Mrjsa7l1yCD3rB1C3JJBJHykf4UBFnMW7m70+4tMhZwhUA9AcA1l2PiGCK7i02fIu mDFkPVAOpP48VoanA0UouYFG4HLD1Hcfyqpa2FhrrSajdLtuWxGksfytsHTPrk5P0x6VLpqV5M66 VfkXI1o2b2h3nmahPFGcps3n2Ocfr/SumQEAEjANc5psNnpELrAhy7De7tlm+taf9oiRCoPH9KIJ pWZlWkpzbjsXbi7Cxds1xt7OdTvTEmTCrYYj6f8A1xTdY1Saec2kGC5yPof/AK2ab5UllbZiYJjB 6A9KJSUR0qMp7G9p1okUYcKNxOMelaxhLBQe/JrG8KX39p27lx+8t32vjoe4P+fSulZASOPfNOLu rozqxcJOL3RzmsR4VBjGHOcfQ1yXhRTF8TbI5OdxyT7iu41dD9ndwMbTnP4VwmjkQ/EjTDtJ3XC9 T68UyH8J77RRRTOcKKKKACiiigAooooAKKKKACue8cjPgrVAe8Q/9CFdDWR4ntTe+G72BRksgOPY EE/oKBrc8t8NWyxurBxsI4A7Y4r0WzGUrk9E02SHZhW2YxytdraQ7V5zUo6J7COvGaz76LeAcVst ECKqzwZUjFBCZ59rsR8oQqW8ydvLGDyo6sfqADj3x61maPGsNxOoztQjCjgDjpXSzWv2u+u7s8ww 7oIj64P7wj/gQC/8A96xtItG868lKEbH6Due1U9FY0TvqXlhaRGIyR7CiVXjgZsFmCk49cDoK09J DvBISmEA4+vrWajTNqU8MgJVuRxx6D+VKw1LWxy2mXm6R7mRedx3n0PI/pn8aq6rr9y+pQ2ltAbi CddoaPrG+cDPscgD39as6PbNBr11bsuQWDgkdj/+quystPinSdZIFMcpKuNv3h+H0qeVc13sb067 hGy3JvCOjyaTpW2Yg3M7+ZLjkKcYA/Af1ro9nyis7STNFKdPumLTxrvjkb/ltH/e/wB4cBvfB43C tvy8L0quXlVkc1So5ycpbsxdQiDQOp6EVwOn2og8YaQ7MGY3kZHsMgf0r065i3RthSeK5e20Zm8S 6e5Vt8cyt0wMAg/40IV9D02iiimc4UUUUAFFFFABRRRQAUUUUAFNkQSRsjdGGDTqKAK8dlBEuEjA Gc1IIUHQVJRQFxnlL6Vn6xKbTT2NuFN1KwhtwRkeY3AJHoPvH2BrTrIT/iYeInfrBpy7F9DO4yT/ AMBQgA/9NGHaqitbsLk9vo1pbWEVoikpFGEBY5J46k9yepqCHw7YwLMFUnzW3MT61r0VI7so2+k2 ttH5aJxUDeH7J7jzip3GtWigLswY/Cemx3rXQQ+Y1aUWmW0IwkYAq5RQF2ZupaUt3bqYGWK7gbzL eUjIVvQjupGQR6HscGnabcRahamQxGKZGMc8LHJikHVT+YIPcEHoa0KyNSiksLr+17VGfaoS7hQZ MsY/iA7uuSR6jI5OMUtVYRpfZ4/7opgs4RKJAgDg5zUsUsc8KTQuskUihkdTkMDyCD6U+pC4UUUU AFFFFABRRRQAUUUUAFFFFABRRRQAVXvbtLKBZXUsDLHFgeruqA/m1WKZLDHOgSVA6hlbBHdSCD+B ANNb6gYq+MNGeIyCacIFDsTbyDYCu9S3HGV5Gev1qKy1rSdMH2Hz5XfzpA8nlMd0nmAOWwMD53A/ EY4FWbjwvpVxdRTPbgLGu0xKBscbNg3cZ4XjrVhdC0pYzH9hhKtncGXO7LBjnPXLKCfcVpen5i1G 6Tr1lrTyixcyJGisXIwOWcY/8cP5itOqtnptnp+/7LAsRcAORyWxnGSevU/nVqs5WvoMKKKKQBRR RQAVhT+KbO0ur1LsGGC0cRmUkncxCkAAD/a9e1btVptPtLiKSKWBSsjiRscEsMYbI5zwOaqNuoHP 6dr+j2Uk8cF3M1pK++GP7LJhGO/Ko2OQzI+B6ggcEAXj4t0gMqtNKpM4tvmhdQJTj5OR1GRkds/W rraNprRmM2UO302/73/xx/8Avo0z+wdLwg+wxfI+8cfxfLyfU/Ip57qD1FU3BvW4tS1Z3K3tjb3S KVWaNZAD1AIz/Wp6ZFEkEKRRKEjRQqqOgA4Ap9ZsYUUUUAFFZGt362Ajd7iKNOdyyTCPIwcnOR04 6AnkUUAf/9k= ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/images/magnify.gif R0lGODlhIAAgAPMMAAAAABERESIiIlVVVWZmZgAA/5lm/4iIiJmZmbu7u8i0yMzM/////8i0yAAA AAAAACH5BAEAAA0AIf58SWNvbm9ncmFwaGVyIDogTWFjaW50b3NoIEJlT1MKVGhlIEljb25vbG9n IDogVGhlIEFydCBvZiBWaXJ0dWFsIExpdHRlciAKICAgICAgICAgICAgICAgaHR0cDovL3d3dy5v emVtYWlsLmNvbS5hdS9+YWZhY3Rvci8gCgAsAAAAACAAIADDAAAAERERIiIiVVVVZmZmAAD/mWb/ iIiImZmZu7u7yLTIzMz/////yLTIAAAAAAAABP6wyUmrvThfwEHoAEE0AGMCSIosRuu6qVGe44Sm nKnvPMOpIZFmWAEICIEPh5LrOX2AQ7CoAwxchZfB1HjNfCKhLbUomxcMRFoFDBPfFiPyA8fIk6Da BsRPmBKAHGI2VT9sh00+GycxAwMsWi0NjgYIM0E1KF8ckV6JmmGZbGZ8IIc4bnYcZ2lrHal1sRIg shkec0u1TAG4HbqzvHiverEAfgwJecRMiU4cgAlSg0w8pSA7U3FVp9w4Vdo+KgYLDQuO5+eV3mB6 lwgGV51ZWy1Xl6mfkfORm5gjN1+gWAsYzhI+RM2qGWqz7MaKM2VadcOkCmJEBA0QwiIykKKGCAA7 ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/pix/honcode.gif R0lGODlhLQAyAPf/AP///2NjY3t7e97e3v/399bOzr21ta2lpZyUlKWcnPfn59bGxpSEhL2lpXtr a0I5OUIpKQgAABAAACEAACkAAJSc/ykx//f3/+/v/+fn/9bW/87O/0pKY729/7W1/62t/6Wl/5yc /5SU/4yM/3t7/3Nz/xAQKWNj/1pa/1JS/0pK/zk5/zEx/ykp/xgY/xAQ/wAAGAAAxgAA/wgAxggA zggAjBAAzhAAtRgAxhgAtSEAxiEAziEAtSEAvSEAnCkAvTEAzjEAvWNaezkAvUpCWiEAY0oIvUoA xikAY2MYvWNSczkAY0IAaykAQkIAY3Nae2tSc0oAY1IAa1oAa2MAa2sAc+/n7+fe55SMlHtae3NS cxgQGAgACFoAWmsAa3MAa4RKc4xae2M5Uq1ajL1jlFoQOe/e50o5QikYIXtrc6VCc85jlIQpUnMI OYQIQloAKbVCc3MAMd5ajLWcpd7Gzu/W3ufO1s61vffG1taltb2MnDkIGDEAEGsAIfe9zrV7jK1z hFIAGN69xt6ltXtaY5xjc8ZrhL1je1oAGHsAIe/O1q2MlJRze/e1xr17jJRSY9ZzjHs5SpQxSrUx UloYKYQhOd4xWv8xY2sIIZQIKe8IQvcIQkIAEO8AOee9xsacpe+lteecrdaMnLVre2M5QveMped7 lO97lNZrhOdzjMZac4Q5SvdjhP9jhEIYIedSc6U5UmshMf9Kc5wpQv9Ca2MYKecxWrUhQloQIb0h QowYMaUYOXsQKc4YQlIIGP8YSpwIKb0IMcYIMUoAEGsAGJQAIZwAIb0AKecAMffO1t61vYxja96M nGtCSsZzhP+EnNZje71CWr05UvdKa3MhMdY5Ws4pSsYhQpQYMf8pUuchSrUYOf8QQqUIKdYIMSkA CFIAEHMAGHsAGK0AIcYAKdYAKe+9xv+lte+Upedje5xCUsZCWoQAGLUAId4AKdacpVIhKTEACGMA EGsAEJQAGN6lreelra1ze61rc4RCSlohKTkACEIACHMAELVrcwAAACwAAAAALQAyAEAI/wAlRPgn 4Rs/cPLmFSvGThy4eAILDpMnrtg4cuOKhQO3b8K3eAflhWO30Fi7Y+SOGUOJzJsiADBjxvRkzUrM T9RswhwkjYDMn3O+feMycN4wiBFuyFjKdOkLFy+aSp26goWMFB1GuLDRJxwxeYjojTtWrtMRDCWW jiBggamIDFFlkLjydIOHDwSsTl2Kg0+8oRIyEgPHKQdTFyQ6XNmwQYOGDiRa7J3cdAYfhCMrmhSW DCaBbNosWcN2KOY9RzFZmYNpJ9IAmHPw/VRWTJy8YfvGGWO3kdM3j8PCGSOHbBOtVtmQlRvHDty3 CPHAWawNbtg3CQTjcQJHjKSxcd/4UP/MZCemImp0Yi6IVeenzASrfMJUcA1UzHrs2BFDJA+ZMOaY pMcaNeXB5Ecu7bkH0zuwyEcAPIzIdMBH/AwDTgTfcCIPO0HIsAIGIVAmwwgYrLBXCVd4AMIJccmg w1fV7cPNJpsgQ04QFWwQlQoZbCCCByE45oEGI5BAQAcinCAiUzMQFUFB2EXAxT6xLJJHPVcOwkwv 5EAzSD2D5JHHJ48kAskgoYTyzief3LPHAwckoMcn9TiDUkrGZKPnL5p0BgABdMh3xz3yKaBATNAI ApMVBcgXCjQx2XEHAxE8+c0+BE2wHS+67LLNLsXwEosraGxhUC2V7JKLNb3cgg0mnPD/4QoltVDD SyLdqNoLl8foxg4imh3jJwBmEFKAerMcClM9u+gEQD0NyuSHgAB8chtu3yCjLTndFAhAAXwsEJMf tihbbbIxgVKNfGbo8VMClWL4TUZGfUOEEFqEAYYbasghxxhqxNGGGmSsYTAZY4zBxhtlgJGFFkqY AAMHSkCRhRgWgvUQdgbxwBQLH2TQQQgkkDBCyBukQBkKGJywQYlM7ZCIV4MN051JQ5yAgV4pPEbC B4qRoJYGLjBVAgAYJC2ZVDoEMoxf3xDXydRJtCzDCx148DEBKCyVwgVpnXDFCi4sPZllEwj0Tyfl kGOMOB6zLEKLUqmQFQpFL8lUDFx8/8THREcJFIPehE/GFUkoGcRdIgIS4Id8jRginx3eptOIZ9Qm 4EBMdKDDCka7EUNccdn4qUA1kKxZSCExOXMKoqsBQMcZrz0LKUyizFIJOPxcF8HU3mC0iyOfNDDH AQ38sUs7r5zTiB/ngBJKNOIwggAWi+ghCjrQZCKJHotcj4UDlyIkDnYFHYRIOMUYY0wiiPhWaYYU WYSnQ71/BA444VTUfjvkSEk7jIEhCyVCGQSwAgE8oYs7EOAKBLjDHgpRBwJY8IIRhAcpIKjAd4xj EAkkADpUUptw8EMeiShGN17CGlyICyYLWIW56vAO+QAgD6twFgBMYZ8FiQMR++MEO/9WQg5vDOtP MhHEJMxVj0o4Kw+TsOGfbNgATuxDKBIYnTeCQa0rCKB2ADCHJcz1CSemyxIOSlBMDiCQSkmgRm5j XEwKoA9qNaJcM5FcuqShEyus4oUwSYAE+haPfZTjGIkghi/E5ZMC6MITMUlGJtylIAXAIh99hMAD rhCTBGhnf9IhRuBqQIMZ4EAHOwCCKoGgg1amUpU7aCUOcGCDGdgyBri05Slt4ANEEOOX8ngIUb7R g7r9rANZS1LeKBMCDGjgZxWwig4SIY5f9kMg9PuB10SmArrJoAXNVNJeRtCBEoTgAyZayjRh5Bx+ IIIkQXCBBrS2lBb8jAQuWEE6rwD/gqa44AQqeEsLWKCXpdgAiLiJx83IYoQOfKCeIsubBwCQzhJg oGhQKQEBTja3qcwgEPz4S2CK2AlkJOECXZOBBzbAlBds4KFL6UA/U4CBDjSmoB7lA2B+1wkaIcMI RFrKBy4qAxdMVAVXyUCPOuCYZVIGB0T5B0Fm5A5u8cACGBjBUlhQMqSuoGQseEEIPODUJc2gUoTE Uzjk4bGrXAEyK2hB2VZQgpUK7QXeFNEMPrKdDRnFN0rxJwtUkAIVkK1we5mBLzVzxYg0AQlLYAIT pDAFKlDBC1+oQhUsS4UpRCEKUvCCZjcrhSgsAQlFKAJkmdAF+5GjHU8CCTgaAJML38ikFGh0jxXW 4QcFpSEAP1FEAFXSHIqwAximm4YfFGgPZ8gHEH9IzeUAoAh1JOgAy4gJbqWREXYE0yTkcEefFqUN jNRGNjBxBiRSEzs6NKN2nxhFTCyojN4Mpad6Kt18pJGgOzBCPql4BqIg+a0zcBIAoUBFTPwRIydJ IBu/KCk5QqEgPURRt7BQlHtQoYqfFABD8bCQN3rFkI3o9BvBGY47jNOKCJfjbeDgggTiIY9iDPBX HGnjpSw0khLHSAIzBoc4hlOc41xiE+5ApDzigSFwDFE/HHkOhvaBmSESMSAAOw== ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://statse.webtrendslive.com/dcsauhh66pifwz3kt81grbj8d_5p7p/njs.gif?dcsuri=/nojavascript&WT.js=No&dcsqry=page%3DHernias(emerg) R0lGODlhAQABAJH/AP///wAAAP///wAAACH/C0FET0JFOklSMS4wAt7tACH5BAEAAAIALAAAAAAB AAEAAAICVAEAOw== ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://emedicine.com/images/ui/gobutton.gif R0lGODlhGQAZAPcAANPT6dLS6NHR6M3N5M3N5szM5crK5MjI4sLC38HB4MDA3sDA37+/376+3ry8 3bq63Le327a227W12bW12LOzz7Ky2LKyzrGx1rCw17CwxK+v1q6u0a6uwq2t1a2t0Kys1ays1Kys zqur1aur1Kurzaqq1Kqq0qmp0aio06io0qmpvKen0qam0qenzqam0aWl0qamuKamuaSk0aOj0aGh z5+fzp2dzZyczZubx5qay5WVx5WVypSUyZSUx5KSyI2NxY6OsI2Nr4qKw4iIw4eHs4aGwoWFtoSE tYKCu4KCroKCrICAwICAvn9/v35+mHx8pnp6u3x8lXl5u3d3u3l5kXh4l3l5knV1unZ2lHV1oHR0 uXNzuXR0nnJyuHJyt3Fxt3Bwt3JyiHJyiW9vqW5ut21ttnFxg21tpGxsrGpqqmxskWpqpGhos2tr j2pqe2Zms2Vlr2RksWZmnGRkm2RkeWJijmJidl9flVxcrltbrVlZrFZWnFVVqlZWjlVVn1RUqVRU i1JSllBQm05OlU9PeVBQdU9PcktLpEtLn0pKnk1NdklJpEhIo0xMbU1NYktLfUtLa0pKe0lJjkdH okdHjElJXEVFgEVFYkVFY0NDh0REVT09nj09mTw8lkJCTz4+cz09dz09djs7lzo6kj4+Wj09cj09 WTc3mzs7bTw8UTo6bDc3kDg4hDw8SDc3gzk5RzMzmTQ0jTQ0ejIyizQ0eTY2UjU1Ry8viC8vjDMz Ti4uijAway8vfC8vajIySDExUTExQywshSsrfisrfSsreywsWi0tSi4uPioqeioqYyoqZyoqbCkp aysrRysrRCgoYykpUikpNygoPigoOiMjOwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAQUAP8ALAAAAAAZABkA AAj/AGEJHEiwoMGDBfN8uXKFzBs8fBghNKhnxwsRKGTY4DEECpxEoiYKXAIhQQIHFSp0WEFDB5I0 glZNLMKAgIEHLFhckCDhggkcR9YMmnWwSQMBAlaMUDCgqVMFLZLIkXSroJ4IBQKMkOC0q1MPT+5k 0kVwxwIDLrh6XUuCCyBXA/O8SPBgBBuBp5isdRqkjqVgAsGUcMBiEawcE5jA0ruXgppHvARuYVFB CKwJTn8gaHp3sdMqhGQJvDJDgxdYTRFMmLD5boofh5s6KQRKYJkbH7SgHnBI4KEBsLo03fR7gJVG nwTG8cECBKwUTg/9Dj68uBhMqATmKVLjQm/Ein+7oYadoykdUrsE/pHS48SALnjZHOAskHEGR7WW CZwEBwkOpnutZUYqvxAzECJoGNFCgF6poIkvxRDEiR9jELEBg03F4AkwzQhTUCd7nKFECAzC0Mox zihz0CiBzJEFEBZ4xYEbr0QjTTITxUJJH3W0gUUUVIRhRyW2TEPNMyLBggsrlkSiiCGQXGJKLsZA M0ySAwXDCy2hhKJKL8wgg+WYCAUEADs= ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://emedicine.com/images/ui/topnavbackground.gif R0lGODlhBwAeALMAAP///////f798P340/340v740v740/33y4SCv4OCvjMzmQAAAAAAAAAAAAAA AAAAACH5BAQUAP8ALAAAAAAHAB4AAAQiUMgpjr046827/2AojuRHnEM6BGwbAHAMJHSdKHiu73wf AQA7 ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.emedicine.com/emerg/ =0A= =0A= =0A= eMedicine Journal - Emergency Medicine - Internet Medical = Reference Library, Physician Textbooks and Medical Articles =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
=0A= =0A= =0A= =0A= =0A=
3D"eMedicine
=0A= =0A= =0A=
=0A=
   
=0A=
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
3D""=0A= =0A= =0A= =0A= =0A= =0A=
3D""=0A= Home=0A=  | =0A= Specialties=0A= |=0A= Resource=0A= Centers | =0A= Learning = Centers | =0A= CME =  |  Contributor=0A= Recruitment
=0A= =0A= =0A= =0A= =0A=
=0A= =0A= =0A= =0A= =0A= =0A=
=0A= =0A= =0A= =0A= =0A= =0A=
 =0A= =0A= =0A= =0A= =0A= Articles =0A= =0A= Images =0A= =0A= CME =0A= =0A= =0A= =0A= =0A= =0A= =0A= Advanced=0A= Search =0A= =0A= =0A= =0A= =0A=  Consumer=0A= Health Link=0A= to this site
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
=0A=
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
EMERGENCY MEDICINE=0A= - Medical Reference
 
=0A= =0A= =0A= =0A= =0A= =0A=
Table of = Contents
Alphabetical Index of = Topics

Allergy = And Immunology
Cardiovascular
Dermatology
Ear, Nose, And Throat
Emergency Medical = Systems
Endocrine = And Metabolic
Environmental
Epidemiology
Gastrointestinal
Genitourinary
Hematology And = Oncology
Implantable = Devices
Infectious = Diseases
International = Emergency Medicine



Legal Aspects Of = Emergency Medicine
Managing The = Emergency Department
Neurology
Obstetrics And = Gynecology
Ophthalmology
Pediatric
Psychosocial
Pulmonary
Rheumatology
Special = Aspects Of Emergency Medicine
Toxicology
Trauma And = Orthopedics
Warfare - Chemical, Biological, Radiological, Nuclear And = Explosives
=0A=
=0A=
=0A= =0A= =0A= =0A= =0A= =0A= =0A=
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
Chief=0A= Editors
  Jonathan = Adler, MD
Richard G Bachur, MD
Barry Brenner, MD, PhD, = FACEP
Robert G Darling, MD, FACEP
Steven C Dronen, MD, = FAAEM
Pamela Dyne, MD
Craig Feied, MD, FACEP, FAAEM, FACPh
Rick = Kulkarni, MD
William K Mallon, MD
Robert E O'Connor, MD, = MPH
Scott H Plantz, MD, FAAEM
Charles V Pollack, Jr, MD, MA, = FACEP
Raymond J Roberge, MD, MPH, FAAEM, FACMT
Asim Tarabar, = MD
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
Copy=0A= Editors
  Julie = Bohlen
Marianne Rieser
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
CME=0A= Editors
  John = Halamka, MD
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
Pharmacy=0A= Editors
  Robert = Konop, PharmD
Francisco Talavera, PharmD, PhD
John T VanDeVoort, = PharmD
Mary L Windle, PharmD
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
Medical=0A= Editors
 Roy Alson, = MD, PhD, FACEP, FAAEM
Jerry Balentine, DO
Kirsten Bechtel, = MD
Michael S Beeson, MD, MBA, FACEP
Edward Bessman, MD
Jeffrey = Glenn Bowman, MD, MS
David FM Brown, MD
William K Chiang, = MD
Steven A Conrad, MD, PhD
Francis Counselman, MD
Dan Danzl, = MD
Peter MC DeBlieux, MD
Daniel J Dire, MD, FACEP, FAAP, = FAAEM
Michelle Ervin, MD
Miguel C Fernandez, MD, FACEP, FAAEM, = FACMT
Theodore Gaeta, DO, MPH
Michael Glick, DMD
William = Gossman, MD
Robin R Hemphill, MD, MPH
Fred Henretig, MD
Edmond = Hooker, MD
B Zane Horowitz, MD
David S Howes, MD
Eric Kardon, = MD, FACEP
James E Keany, MD, FACEP
Samuel M Keim, MD
Mark Keim, = MD
Richard S Krause, MD
Lance W Kreplick, MD, MMM
Richard = Lavely, MD, JD, MS, MPH
David C Lee, MD
James Li, MD
William = Lober, MD
Mark Louden, MD, FACEP
Robert M McNamara, MD, = FAAEM
Edward A Michelson, MD
Jerry L Mothershead, MD
Jerome FX = Naradzay, MD, FACEP
Robert Norris, MD
David A=0A= Peak, MD
Joseph J Sachter, MD, FACEP
Joseph A Salomone III, = MD
Assaad J Sayah, MD
Erik D Schraga, MD
Mark S Slabinski, = MD
Debra Slapper, MD
Dana A Stearns, MD
Suzanne White, = MD
Garry Wilkes, MD
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
Managing=0A= Editors
  Jeffrey L = Arnold, MD, FACEP
John G Benitez, MD, MPH, FACMT, FACPM, = FAAEM
Howard A Bessen, MD
Paul Blackburn, DO
Michael J Burns, = MD
Robert G Darling, MD, FACEP
David Eitel, MD, MBA
Gino A = Farina, MD
Mark W Fourre, MD
Jonathan A Handler, MD
Fred = Harchelroad, MD, FACMT
Eugene Hardin, MD, FACEP, FAAEM
Robert C = Harwood, MD, MPH
Jon Mark Hirshon, MD, MPH
Michael Hodgman, = MD
J Stephen Huff, MD
A Antoine Kazzi, MD
Rick Kulkarni, = MD
Eddy Lang, MDCM, CCFP (EM), CSPQ
Douglas Lavenburg, MD
Eric = Legome, MD
David Levy, DO
Mark L Plaster, MD, JD
Matthew M = Rice, MD, JD
Tom Scaletta, MD
Gary Setnik, MD
Barry J Sheridan, = DO
Richard Sinert, DO
Jeter (Jay) Pritchard Taylor III, = MD
James S Walker, DO
Eric L Weiss, MD, DTM&H
Wayne Wolfram, = MD, MPH
Grace M Young, MD
Mark Zwanger, MD, MBA


Article = Excerpts
=0A= =0A= 		=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
3D"My
3D"Register
3D"Get
3D"Authors
=0A=
=0A=
=0A= =0A= =0A= =0A=
=0A=

=0A=
=0A=

 

=0A=

 

 

=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
About=0A= Us | =0A= Privacy | Terms of Use=0A= | =0A= Contact Us | =0A= Advertising =0A= | =0A= Institutional Subscribers
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
3D""We=0A= subscribe to the=0A=
=0A= HONcode principles of the=0A=
=0A= Health On the Net Foundation		 =0A=
=A9 1996-2006 by=0A= WebMD
=0A= All Rights = Reserved =0A=
=0A=
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.emedicine.com/images/ui/extsearch.gif R0lGODlhAgAjALMAAP/////98/775fn5+f33y+vr69bW1rq6ul9fqDMzmQAAAAAAAAAAAAAAAAAA AAAAACH5BAQUAP8ALAAAAAACACMAAAQWMMlJq70YIwRACEQohoJwHIZRFMPQRQA7 ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://emedicine.com/images/ui/rightbackground.gif R0lGODlhLAEJANUAAP/99f341P764P/6zEc5bf340vLrxf/+9/33z0g5bf330P/71v///P765fLt 6vTux0k5b0o6b/Twz/3521JBdfLu8v/++v3401NAdf/87/Prxf751f/7zvbz9P751P33zP/99v// /v////33ywAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAAAAAAALAAAAAAsAQkAAAblQExF RCwaj8ikcslsOp/QqHRKrVqv2CwW4jiAvuCweEwum8/otHrNbrvfIIAc/s3Q7/h8WQ4AHSwJDxwf hIWGh4iJiouMjY6PkJGSk5QfI5eVhCOZnJ2eipeXGwIEBgOhqKmqq6ytrq+wsbKztLW2t7i5uru6 AaSmvMHCw8TFxsfIya6+pafKz9DR0tPUz74JGs7V29zd3t/IvhESCx7m5+jp6uvs7e7v8PHy8/T1 9hcKCgUB9uYf/QADCnwXoAACBAUmNKDQIYTDhxAjSpxIsaLFixgzatzIsaPHjxMZgBxJsqTGIAA7 ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: text/css; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.emedicine.com/asp/emed.css BODY { SCROLLBAR-FACE-COLOR: #135184; FONT-SIZE: small; = SCROLLBAR-HIGHLIGHT-COLOR: #d6d6d6; SCROLLBAR-SHADOW-COLOR: #d6d6d6; = COLOR: #000000; SCROLLBAR-3DLIGHT-COLOR: #135184; SCROLLBAR-ARROW-COLOR: = white; SCROLLBAR-TRACK-COLOR: white; FONT-FAMILY: arial, helvetica, = sans-serif; SCROLLBAR-DARKSHADOW-COLOR: #135184 } P { COLOR: black; FONT-FAMILY: arial, helvetica, sans-serif } UL { COLOR: black; FONT-FAMILY: arial, helvetica, sans-serif } BR { COLOR: black; FONT-FAMILY: arial, helvetica, sans-serif } LI { COLOR: black; FONT-FAMILY: arial, helvetica, sans-serif } A:hover { COLOR: red; FONT-FAMILY: Arial, Helvetica, sans-serif; TEXT-DECORATION: = none } .articlemenu { BORDER-RIGHT: #333399 thin ridge; BORDER-TOP: #333399 thin ridge; = WORD-SPACING: 4px; BORDER-LEFT: #333399 thin ridge; COLOR: #000000; = BORDER-BOTTOM: #333399 thin ridge; FONT-FAMILY: Arial, Helvetica, = sans-serif; LETTER-SPACING: normal } .menu { BORDER-RIGHT: thin groove; BORDER-TOP: thin groove; WORD-SPACING: 5px; = BORDER-LEFT: thin groove; BORDER-BOTTOM: thin groove; LETTER-SPACING: = normal } .smalltext { FONT-SIZE: 14px; FONT-FAMILY: Arial, Helvetica, sans-serif } .news { FONT-SIZE: small; COLOR: #000000; FONT-FAMILY: Arial, Helvetica, = sans-serif } .bigtext { FONT-SIZE: x-large; FONT-FAMILY: Arial, Helvetica, sans-serif } .Whitelink { FONT-WEIGHT: bold; FONT-SIZE: 12px; COLOR: #ffffff; FONT-STYLE: normal; = FONT-FAMILY: Arial, Helvetica, sans-serif } .noboarder { BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium = none; BORDER-BOTTOM: medium none } .tinytext { FONT-SIZE: xx-small; FONT-FAMILY: Arial, Helvetica, sans-serif } A:link { COLOR: #333399 } A:visited { COLOR: #333399 } A:active { COLOR: #333399 } .articlelink { FONT-SIZE: 14px; FONT-FAMILY: Arial } .11pxarial { FONT-SIZE: 11px; FONT-FAMILY: Arial, Helvetica, sans-serif } .12pxarial { FONT-SIZE: 12px; FONT-FAMILY: Arial, Helvetica, sans-serif } .13pxarial { FONT-SIZE: 13px; FONT-FAMILY: Arial, Helvetica, sans-serif } .14pxarial { FONT-SIZE: 14px; FONT-FAMILY: Arial, Helvetica, sans-serif } .16pxarial { FONT-SIZE: 16px; FONT-FAMILY: Arial, Helvetica, sans-serif } .imageCaption { COLOR: #666699 } ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.emedicine.com/medlook.js // MedLook 2.0 var msgWindow; function LTrim(str) { var whitespace =3D new String(" \t\n\r"); var s =3D new String(str); if (whitespace.indexOf(s.charAt(0)) !=3D -1) { var j=3D0, i =3D s.length; while (j < i && whitespace.indexOf(s.charAt(j)) !=3D -1) j++; s =3D s.substring(j, i); } return s; } function RTrim(str) { var whitespace =3D new String(" \t\n\r"); var s =3D new String(str); if (whitespace.indexOf(s.charAt(s.length-1)) !=3D -1) { var i =3D s.length - 1;=20 while (i >=3D 0 && whitespace.indexOf(s.charAt(i)) !=3D -1) i--; s =3D s.substring(0, i+1); } return s; } function Trim(str) { return RTrim(LTrim(str.toLowerCase())); } function popup(loc) { self.name =3D "body"; msgWindow =3D = window.open("http://knowledge.emedicine.com/cgi-bin/knijavascript.htm?" = + loc, "displayWindow", = "scrollbars=3Dyes,resizable=3Dyes,height=3D532,width=3D580,screenX=3D0,le= ft=3D0,screenY=3D0,top=3D0"); msgWindow.onerror=3Dnull; if (msgWindow.opener =3D=3D null) { msgWindow.opener =3D content; } } function display(e) { if (document.getSelection) { var str =3D document.getSelection(); } else if (document.selection && document.selection.createRange) { var range =3D document.selection.createRange(); var str =3D range.text; } else if (window.getSelection) { var str =3D window.getSelection(); } else { var str =3D ""; alert("The browser you are using is incompatible with the Medical = Dictionary Lookup feature. Please try using another browser."); return; } str=3D"va=3D"+escape(Trim(str)); if (str.length > 40 ) status=3D"You have selected a large amount of text. This text is = copyrighted by eMedicine.com, Inc."; else if (str.length > 5) { if (window.event) { var elm =3D window.event.srcElement if ( typeof(elm.name) !=3D "undefined" ) return; } popup(str); } } =20 ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.emedicine.com/asp/gotosearch.js function gotosearch() { if (document.search_page.radiobutton[0].checked) {var nexturl =3D = "http://www.emedicine.com/cgi-bin/foxweb.exe/searchengine@/em/searchengin= e?boolean=3Dand&book=3Dall&maxhits=3D40&HiddenURL=3D&query=3D"}=20 else if (document.search_page.radiobutton[1].checked) {var nexturl =3D = "http://www.emedicine.com/asp/image_search.asp?query=3D"} else if (document.search_page.radiobutton[2].checked) {var nexturl =3D = "http://www.emedicine.com/cgi-bin/foxweb.exe/searchengine@/em/searchengin= e?boolean=3Dand&book=3Dall&maxhits=3D100&hiddenurl=3D&cme=3DT&query=3D"} else if (document.search_page.radiobutton[3].checked) {var nexturl =3D = "http://www.emedicine.com/cgi-bin/foxweb.exe/searchengine@/em/searchengin= e?boolean=3D&book=3Daaem&book=3Dgeneral&book=3Dwild&maxhits=3D40&sortorde= r=3Dhits&query=3D"} window.location.href =3D nexturl + document.search_page.query.value =20 } ------=_NextPart_000_0000_01C7E021.7122D800 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.emedicine.com/asp/images.js function MM_swapImgRestore() { //v3.0 var i,x,a=3Ddocument.MM_sr; = for(i=3D0;a&&i0&&parent.frames.length) { d=3Dparent.frames[n.substring(p+1)].document; n=3Dn.substring(0,p);} if(!(x=3Dd[n])&&d.all) x=3Dd.all[n]; for = (i=3D0;!x&&i'); ------=_NextPart_000_0000_01C7E021.7122D800--