ABDOMINAL SURGERY

Abdominal access
techniques (including
laparoscopic access)

elicited when the musculature of the abdominal wall is relaxed,

influencing the surgical approach. Common abdominal incisions
are shown in Figure 1.
Positioning
The patient is positioned to allow optimal access to the area of
interest. This is most often supine, however for surgery involving
the pelvis or perineum, the Lloyd-Davies or lithotomy (legs up)
positions provide better access. In the latter, so named from the
Greek to cut for the stone, the patient is supine with the
buttocks placed at the lower break in the table and the legs flexed
at the hips and knees, with sufficient abduction to allow access to
the perineum. The lower legs are placed in attachable pneumatic
supports or hanging stirrups. In the Lloyd-Davies position, often
used in colorectal surgery, the legs are abducted with slight
flexion of the knees and hips. Supports are now usually a cushioned boot design to reduce pressure, especially on the popliteal

Cara Baker
Ralph Smith
Sukhpal Singh

Abstract
This article discusses the safe exposure of intra-abdominal organs using
laparoscopy and laparotomy. Newer methods of minimal access surgery
including single incision laparoscopic surgery (SILS), and natural orifice
transluminal endoscopic surgery (NOTES) are also discussed. Common
abdominal incisions are illustrated.

Common abdominal incisions

Keywords

Laparoscopy; laparotomy; natural orifice

endoscopic surgery; single incision laparoscopic surgery

transluminal

D
B

Introduction

The word laparotomy has Greek roots, lapara referring to the

soft parts of the body between the costal margin and hips and
tome meaning cutting. The first successful elective laparotomy
is attributed to Ephraim McDowell, in 1809 in Kentucky, USA.
Through a nine-inch left lower abdominal incision he removed
a large ovarian cyst in a 46-year-old lady on his kitchen table e
without anaesthetic! The lady recovered and lived to the ripe age
of 78 years. The first laparoscopy in a human was credited to
Hans Christian Jacobaeus of Sweden in 1910. In 1981, a German
gynaecologist Kurt Semm published on the first laparoscopic
appendicectomy and Phillipe Mouret is credited as performing
the first laparoscopic cholecystectomy in France in 1987. Minimally invasive laparoscopic methods are now routinely used in
many branches of surgery.

G
H
I

J
K

Considerations of surgical method

Preparation in the operating theatre
The abdomen of the anaesthetized patient should be examined as
further information regarding intra-abdominal pathology may be

Cara Baker MRCS PhD is a Surgical Registrar in the Southwest Thames

Deanery, UK. Conflicts of interest: none declared.
Ralph Smith MRCS is a Research Registrar at the Royal Surrey County
Hospital, Guildford, UK. Conflicts of interest: none declared.
Sukhpal Singh MS FRCS (Gen) is a Consultant Oesophagogastric Surgeon
at Frimley Park Hospital and the Regional Oesophagogastric Unit, Royal
Surrey County Hospital, Guildford, UK. Conflicts of interest: none
declared.

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A
C

Name of Incision

Commonly used for

A Palmers point

Insertion of Veress needle

B Kochers

Open cholecystectomy

C Rooftop

Liver surgery

D Mercedes Benz

Liver transplantation

E Midline

Can be upper, lower

many abdominal operations

F Paramedian

Now less commonly used for laparotomy

G Transverse

Closure of stomas

H Gridiron

Open appendicectomy
(now old fashioned)

I Lanz

Open appendicectomy

J Rutherford Morrison

Renal transplant
(either on left or right side of abdomen)

K Pfannenstiel

Gynaecological, laparoscopic colectomy

Figure 1

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ABDOMINAL SURGERY

fossa and common peroneal nerve. Prolonged placement in this

position increases the risk of deep venous thrombosis or
compartment syndrome and intermittent pneumatic compression
can be applied to reduce the former.
The position may be further adjusted to facilitate different
steps of the operation, for example:

Trendelenberg (head-down, to facilitate access to the pelvis)

reverse Trendelenberg (for better access to the upper
abdomen)

left or right tilt.

most commonly infra- or supra-umbilical, longitudinal or transverse, depending on surgeon preference; the intended procedure
and risk of conversion; surface anatomy; previous scars.
Important adjuncts to optimizing access at laparoscopy are
catheterizing the bladder to allow better views of the pelvis, and
decompressing the stomach with a naso/orogastric tube.
Closed method
The closed method uses a spring-loaded Veress needle to insufflate the peritoneal cavity with carbon dioxide followed by blind
introduction of the first port. The anterior abdominal wall is often
elevated to provide countertraction, traditionally manually, more
usually with skin clips, or following dissection down to the
umbilical cicatrix-linea alba junction and elevation with clips or
sutures (Figure 2). The needle angulation should vary from 90
in overweight or obese to 45 in thin patients. As the needle
traverses the abdominal wall two clicks/points of resistance
should be noted, the first passing through the linea alba and the
second entering the peritoneal cavity. Confirmation of the correct
position can be by several methods as well as the double click,
these include:

Preoperative removal of hair

Hair should be removed preoperatively if necessary, ideally with
electric clippers. Premature (before theatre), inappropriate or
unskilled hair removal may traumatize the skin and allow colonization with potentially pathogenic microorganisms at the
surgical site.
Cleaning
Surgical-site infection has been estimated to occur in up to 5e
15% of clean and 30% of contaminated surgery. Skin is cleaned
with an antiseptic agent, usually povidone-iodine or chlorhexidine in either aqueous or alcoholic solution, progressing from
the incision site to the periphery. A randomized control trial has
shown a significantly lower rate of surgical-site infection (41%
reduced risk) with chlorhexidine (2% in alcohol) compared to
aqueous povidone-iodine (10%).1
Areas of high microbiological counts (groin, axilla, pubis,
open wounds) should be prepared last and stoma sites isolated
from the prepared area. The antiseptic agent must remain on the
skin for sufficient time to achieve maximum effectiveness. This is
the time taken to air-dry for alcoholic agents; at least 30 seconds
is needed for non-alcoholic agents. Alcoholic agents should not
be used on mucous membranes or open wounds. Care must be
taken to prevent alcoholic antiseptic agents from pooling beneath
the patient or around diathermy pads to reduce the risk of burns.

Manometer test: the insufflator is connected with low flow. If

the needle is in the correct place, the gas flows freely, initial
intra-abdominal pressure is low and increases gradually with the
volume of gas insufflated. If not correctly sited, the pressure is
high and the flow should be halted and the needle replaced or
another entry method performed.
Hanging drop test: a drop of saline is placed on the open end of
the Veress needle and is sucked into the peritoneal cavity by
negative intra-abdominal pressure when the anterior abdominal
wall is manually elevated.
Aspiration test: a syringe with saline is attached to the Veress
and instilled and aspirated: aspiration should not possible if the
needle is intraperitoneal, but saline may be aspirated if the
needle is placed extraperitoneally. Bowel content or blood may
be aspirated if the needle is within an intra-abdominal viscus or
vessel. If blood or bowel contents are present, the needle should
be left in place and preparation made for a rapid laparotomy to
control and repair the injury.
The first port is then introduced blindly (Figure 3). Most
complications of laparoscopy (Box 1) are related to blind insertion of the Veress needle or first port. A recent review of 17
randomized controlled trials containing 3040 patients concluded
there is no increase in major complications compared with the
open methods described below. Extraperitoneal or failed insufflation was reportedly higher when using the Veress needle.
Safety shields, retracting or optical trocars do not prevent injury,
however the potential complications associated with blind
insertion of the Veress needle and primary port make the open
technique the first-choice method for many surgeons.
It is important to be aware of the proximity of the abdominal
wall and the retroperitoneum, and in thin people this can be as
little as 1e2cm. The distal aorta and the origin of the right
common iliac artery can lie directly below the umbilicus and are
particularly vulnerable. Fatalities can occur related to massive
gas embolism or bleeding.

Drapes
The prepared area of the skin and drape fenestration should be
sufficiently large to accommodate extension of the incision, the
need for additional incisions, and all potential drain or stoma sites.
The passage of bacteria through surgical drapes is a potential
cause of wound infection so the drape type should be appropriate
for that procedure. Drapes may be permeable linen or impermeable (disposable or non-disposable). Impermeable drapes result in
significantly fewer bacteria in the operative field and wound
compared with permeable linen drapes (through which bacteria
can easily penetrate). Adhesive plastic drapes, with or without
iodine impregnation, through which the surgeon makes the incision are sometimes used, however a systematic review has shown
no evidence of reduced surgical-site infection and some evidence
of increased infection rates (relative risk 1.23, p 0.03).2
Laparoscopy
Laparoscopy provides a less traumatic access to all parts of the
abdominal cavity, superb views of anatomy, excellent cosmetic
result and an attenuated stress response to surgery.
The pneumoperitoneum may be achieved via open (Hasson) or
closed (Veress needle, see below) methods. The initial incision is

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Figure 3 Insertion of the first trocar following induction of pneumoperitoneum with Veress needle (Figure 2). The index finger prevents the trocar
from being fully inserted.

incision made along its length. The abdominal cavity is probed

using a clip (Figure 5). A gas leak is less likely with this method.
The procedure may not be appropriate if a patient has had
multiple previous operations because the abdomen is not entered
under direct vision. Under such circumstances, the pneumoperitoneum may be created by placing the Veress needle in the
right or left upper quadrant (Palmers point, Figure 1) and the
first port introduced under direct vision using an optical trocar
(e.g. Visiport, Optiview) (see below).
When inserting secondary trocars, this should be performed
under direct vision to avoid visceral injury. In the pelvis, care
should be taken to avoid the bladder (reduced risk if catheterized). The most common minor vascular injury is to the
inferior epigastric vessels, especially in hernia repairs, and these
should be visualized if possible and avoided.

Ports and trocars

A wide range of port and trocar designs have been developed
(Figure 6). Each has their own specialist indications, advantages,

Figure 2 Veress needle insertion. (a) Following incision just below the
umbilicus, the umbilicus is elevated with a towel clip and the stalk is
dissected and the junction with the linea alba defined. (b) Insertion of the
Veress needle. The needle is held halfway down the shaft with the tap
open. The ring and little finger stabilize the needle as it is advanced
through the abdominal wall at the base of the umbilicus with abdominal
wall elevation as countertraction.

Complications of laparoscopy
Specific
Immediate: extraperitoneal insufflation, injury to viscera or blood
vessels, intra-abdominal, of the abdominal wall or retroperitoneum
Early: pain in shoulder tip
Late: incisional (port site) hernia, metastases at port site

Open methods
The first method is essentially a mini-laparotomy, whereby the
linea alba is identified, incised, the peritoneum identified,
elevated with two clips, and incised (Figure 4). The main
problem with this method is that there is often a gas leak, which
may be minimized by using a threaded Hasson cannula or
balloon-tip port.
The second semi-open method involves incising the umbilical
ligament: the central part of the umbilicus is elevated with
a towel clip and a 1 cm transverse or longitudinal skin incision
made. The umbilical ligament is identified, grasped, and an

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General
Immediate: bradycardia, inadequate oxygenation secondary to
diaphragmatic splinting by excessive peritoneal insufflation or
extreme head-down position in an obese patient, reduced
venous return, pneumothorax, pneumomediastinum, gas
embolism
Early: deep vein thrombosis/pulmonary embolism, hypothermia,
nausea and vomiting
Box 1

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ABDOMINAL SURGERY

surgery. Hand-assistance has the advantage of allowing tactile

feedback, safe retraction, facilitates dissection, tumour assessment and anastomosis.
Minimal access to the retroperitoneum or extraperitoneal
space
Retroperitoneoscopy, with dissection of the retroperitoneal space
via a balloon catheter, balloon trocar or finger dissection with
a hand-port, allows excellent access to the kidneys (e.g. in donor
nephrectomy for renal transplantation), adrenal glands, blood
vessels, lymph nodes and the lumbar spine.
Access to the extraperitoneal space for mesh repair of bilateral
or recurrent inguinal hernia is achieved via a subumbilical
transverse incision, starting in the midline and extended 2 cm
laterally. The anterior rectus sheath is dissected out, incised in
the line of the incision, and the rectus muscle retracted laterally
to reveal the posterior rectus sheath. The extraperitoneal space is
then developed manually with the laparoscope or with a balloon
dissector.

Figure 4 Semi-open technique I. The fat of the umbilical ligament bulges

through the vertical incision.

disadvantages and surgeon preference. Trocars are usually

disposable, but reusable are available.
Classification of trocars
Cutting: trocars with cutting blades e either a flat blade or
pyramidal-tipped to cut the tissue in either a single plane or three
planes, and generally are fitted with retractable shields.

Hand-assisted laparoscopic surgery

Hand-assisted laparoscopic surgery (HALS) is so-called because
the surgeon inserts a hand into the abdomen through a hand-port
device to assist with surgery while the pneumoperitoneum is
maintained. This has been applied to many surgical procedures,
from colorectal resections to nephrectomy and aneurysm

Single incision laparoscopic surgery (SILS)

The introduction of multi-instrument access ports has enabled
laparoscopic surgery through a single incision, that is, SILS, also
known by a myriad of other acronyms including SPA (single port
access), SAES (single access endoscopic surgery), OPUS (one
port umbilical surgery) and LESS (laparo-endoscopic single-site
surgery) (Figure 7). Many procedures have now been performed by SILS and include appendicectomy, cholecystectomy,
inguinal hernia repair, gastric banding and sleeve gastrectomy,
colectomy and hysterectomy. Potential benefits include reduced
postoperative pain, improved cosmesis and postoperative
recovery. Difficulties associated with this technique include
loss of triangulation and clashing of instrumentation and
considerable experience with standard laparoscopic surgery is
required. Curvilinear and angulated laparoscopic instruments are
now available that allow more intracorporeal triangulation and
improve surgical ergonomics.
In development is magnetic anchoring and guidance system
(MAGS) technology, whereby deployable intra-abdominal
instruments can be manoeuvred, for example to facilitate
retraction or provide imaging, by an external handheld magnet.

Figure 5 Semi-open technique II. The peritoneal cavity is entered with an

artery clip.

Natural orifice transluminal endoscopic surgery (NOTES)

NOTES is a term coined in 2005 to describe scarless surgery.
Access to the peritoneal cavity is gained by a viscerotomy
through either stomach, oesophagus, vagina, rectum or bladder.
An operating endoscope is inserted for peritoneoscopy and flexible instruments used to perform the surgical procedure. Difficulties relate to achieving adequate triangulation, retraction and
the quality of suitable endosurgical instrumentation. There is
also still a major concern about the consequences of causing
a perforation in an otherwise normal organ for access and
subsequently achieving a secure closure.
A recent review of published NOTES in humans has described
432 operations, 90% of which were performed in a hybrid
fashion with laparoscopic assistance.3 Cholecystectomy was the
most common procedure with transvaginal access and closure
the most feasible technique for entry into the peritoneal cavity
(inevitably precluding half the population). Other procedures

Non-cutting: basic designs include pointed conical trocars that

penetrate by separating tissue fibres along the paths of least
resistance and blunt conical trocars that dilate an expandable
sheath inserted over a Veress needle.
Optical trocars, either with or without a blade, are composed of
a transparent distal shaft into which the 0 laparoscope is
inserted to visualize the tissue planes as the trocar goes through
the abdominal wall. They are especially useful in obese patients
with a deep abdominal wall.

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Figure 6 Ports and trocars. (a) Radially expanding, (b) retractable bladed, (c) balloon and (d) optical (reproduced with permission from Covidien
Autosuture).

described include appendicectomy, percutaneous endoscopic

gastrostomy (PEG) rescue, cystgastrostomy and transoesophageal myotomies in achalasia. At present NOTES is
considered an interesting and developing new technology that
has some way to go before being used in routine clinical practice.

Incisions placed more transversely in Langers lines offer

comparable access to focused intra-abdominal structures as
vertical incisions and can have fewer complications (pain,
respiratory complications, dehiscence) as well as an excellent
cosmetic result, but are more difficult to extend.

Laparotomy
There must be sufficient exposure to allow the procedure to be
done efficiently and safely. The required exposure depends on:

the diagnosis (if known) and the planned surgery

whether surgery is elective or emergency

the speed at which exposure must be achieved

whether exposure can be increased if required by extending the incision

previous surgical history, scars and body habitus

potential placement of stomas.

The incision: diathermy or knife?

Traditionally, a knife has been used for the skin incision, but
recent data suggest that the diathermy blade allows the incision
to be done more quickly, with less blood loss, less postoperative
pain and no adverse effects on wound healing or cosmetic effect.
The incision: pointers and pitfalls
Much has been written on whether to incise around or
through the umbilicus when carrying out a midline laparotomy. Either method is acceptable if appropriate care is
taken, although incising around the umbilicus provides less
risk of inadvertent damage to the hernia contents if an
umbilical hernia is present.
The easiest place to enter the peritoneum with a midline
laparotomy wound (having incised skin, subcutaneous fat, and
the linea alba) is the umbilicus. The peritoneum is grasped
between two clips, elevated and incised, and the peritoneal
contents fall away as air enters the abdominal cavity. The inner
aspect of the incision line is palpated to ensure that there are no
adherent structures, and the incision completed.
The falciform ligament will be encountered in midline incisions
that extend above the umbilicus. Rather than incising the falciform
(which increases the risk of bleeding) it is more elegant to dissect
to one side or other in the extraperitoneal plane and enter the
peritoneal cavity lateral to the falciform ligament. The peritoneal
cavity should be entered on the left of the falciform for surgery in
the left upper quadrant, and conversely for surgery in the right
upper quadrant. Injury to the bladder must be avoided for midline

Classification of laparotomy incisions

Laparotomy wounds can be classified as:

vertical (midline or paramedian)

transverse, for example Pfannenstiel (commonly gynaecological or pelvic surgery)

oblique, for example Kochers subcostal incision (open
cholecystectomy)

complex, for example Chevron (rooftop), Mercedes Benz
(an inverted Y, e.g. liver transplant).
Midline vertical incisions allow rapid access, with minimal blood
loss, and are easily extended. Non-midline incisions can be
muscle splitting or cutting. Paramedian incisions provide access
to more lateral structures and, in theory, are more secure as the
rectus can support the re-approximated anterior and posterior
sheath incisions. However, they take longer, are associated with
more blood loss, and risk denervating or devascularizing the
muscle medial to the incision.

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hand-held retractors (Deavers, Morris, St Marks)

self-retaining retractors (Golighers, Balfour)

ring retractors (Turner-Warwick)

fixed retractors (Thompson, Omnitract).
Strategies to control unwanted viscera from entering the operative field include systematic packing with swabs, or using
a bowel bag, which also limits loss of heat and fluid from
externalized bowel. Ceiling-mounted overhead lighting, which is
moved and focused on the operative field, is an essential adjunct
for optimizing access. This may not be sufficient in certain
circumstances and headlights, or a light mounted on a retractor
(e.g. St Marks), may improve visualization deep into the
abdomen or pelvis.
Postoperative pain and wound healing
The complications of laparotomy are shown in Box 2. Obtaining
adequate exposure must be balanced with minimizing postoperative pain. The size and location of the incision is paramount, but the strategy for relief of postoperative pain must be
considered preoperatively and should be multimodal.
Pharmacological methods include:

local anaesthetic blockade at time of surgery or by infusion
catheter postoperatively

spinal injection or epidural catheter

patient-controlled analgesia devices to deliver intravenous
boluses of opiod

regular or as-required use of analgesics (World Health
Organization analgesic ladder) including paracetamol, nonsteroidal anti-inflammatory drugs, opioids.
Non-pharmacological methods are also important including
explanation, reassurance, education, emphasized in the context
of enhanced recovery or fast-track surgical pathways.
Careful closure of wounds avoids the complications of wound
dehiscence (see below), infection or incisional herniae. Systematic review and metaanalysis have concluded that a continuous
closure technique is superior to interrupted and a non-absorbable
(nylon) or slowly absorbable suture material such as number 1
(PDS) monofilament suture should be used. Traditionally, mass
closure involves 1-cm bites of tissue, 1 cm apart, at least 1 cm
from the wound edge (through all layers of the incision apart
from the skin). Studies have shown that the most important
factor is using a suture length to wound length ratio of 4:1
(Jenkins rule).

Figure 7 Single incision laparoscopic surgery (SILS) ports and TriPort in

use (reproduced with permission from Covidien Autosuture and Olympus
KeyMed).

incisions that extend towards the symphysis pubis. The potential

requirement and site for a stoma should also be considered.
One must avoid inadvertent enterotomy when entering the
distended abdomen, or where there have been multiple previous
laparotomies. For this latter group, it is preferable to extend the
incision onto the unscarred abdominal wall and enter the peritoneal cavity there because there is less risk of damaging
adherent bowel. The incidence of inadvertent enterotomy during
reopening of the abdomen can be as high as 20%. Patients with
inadvertent enterotomy during adhesiolysis are more at risk of
postoperative complications, relaparotomies, intensive care unit
admissions, use of parenteral nutrition and hospital stay.

Complications of laparotomy
Specific
Immediate: injury to adherent intra-abdominal structures
Early: wound infection, wound dehiscence
Late: incisional hernia, poor cosmetic result, adhesions
General
Early: cardiovascular (myocardial infarction/arrhythmias) respiratory (basal atelectasis, pneumonia, deep vein thrombosis/
pulmonary embolism), renal failure

Optimizing access at laparotomy

Access is optimized and maintained by skilled assistance and
retraction. Retractors vary from the assistants hand to:

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Box 2

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wound infection

conditions associated with impaired healing of wounds
(e.g. diabetes mellitus, corticosteroid therapy, malnutrition,
morbid obesity, smoking, pulmonary disease, malignancy,
age).
Good access is fundamental to successful surgery, but optimizing access requires careful planning. This is relatively
straightforward for elective surgery but, for emergencies, careful preoperative examination, patient positioning and an
appropriately sited incision allows the operation to proceed
smoothly and successfully. Increasingly, enhanced recovery
programmes are being used with laparoscopic and open surgery
to reduce surgical stress and optimize patient recovery after
surgery.
A

The skin is closed with clips, interrupted non-absorbable

sutures, or a subcuticular absorbable suture (the first two
options are more appropriate if infection is present). Care must
be taken to achieve a good cosmetic appearance.
Wound dehiscence, which classically occurs at 8e10 days
postoperatively, signifies technical failure. It can be initially
recognized by a serosanguinous ooze arising from the wound
and, on further inspection, intra-abdominal contents (usually
small bowel) can be evident. If not recognized, intestinal evisceration or a burst abdomen can occur. In the latter, the
mortality rate is dramatically increased. The management of
wound dehiscence involves:

intravenous access, resuscitation and analgesia/reassurance

covering the wound and exposed bowel with sterile
dressings

urgent return to theatre and resuturing of the wound under
general anaesthesia.
Occasionally, abdominal wound closure is not possible, for
example after dehiscence or loss of abdominal wall volume by
necrotizing infection, as part of damage-control surgery or
management of abdominal compartment syndrome. Strategies
for management include temporary abdominal closure methods
with a sterile plastic sheet, that is, Bogota bag or incorporation
of absorbable or non-absorbable mesh.
Alternatively, vacuum-assisted closure devices (VAC) have
been used to accelerate wound healing following superficial
abdominal wound dehiscence and laparostomy.4 An occlusive
low negative pressure continuous suction dressing is applied to
the abdominal wound to generate improved blood flow and
formation of granulation tissue. Benefits include reduced
frequency and pain of dressing changes and accelerated wound
healing. However there is the risk of promoting or delaying
healing of established entero-cutaneous fistulae.
Abdominal wall disruption can be complete or incomplete,
early as above or late, in the form of incisional hernia. Predisposing factors to incisional herniae include:

poor surgical technique

rapidly absorbable sutures

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REFERENCES
1 Darouiche RO, Wall MJ, Itani KMF, et al. Chorhexidine-alcohol versus
povidone-iodine for surgical-site antisepsis. New Engl J Med 2010; 362:
18e26.
2 Webster J, Alghamdi AA. Use of plastic adhesive drapes during surgery
for preventing surgical site infection. Cochrane Database Syst Rev
2007 Oct. Issue 4. Art. No.: CD006353.
3 Auyang ED, Samtos BF, Enter DH, Hungness ES, Soper NJ. Natural
orifice translumenal endoscopic surgery (NOTES): a technical review.
Surg Endosc 2011; 25: 3135e48.
4 Stevens P. Vacuum-assisted closure of laparostomy wounds: a critical
review of the literature. Int Wound J 2009 Aug; 6: 259e66.
FURTHER READING
Ahmad NZ, Ahmed A. Metaanalysis of the effectiveness of surgical scalpel
or diathermy in making abdominal skin incisions. Ann Surg 2011; 253:
8e13.
Ellis H. Cambridge illustrated history of surgery, Greenwich Medical Media;
2000. Cambridge University Press
Santos BF, Hungness ES. Natural orifice translumenal endoscopic surgery:
progress in humans since white paper. World J Gastroenterol 2011; 17:
1655e65.

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