The waves travel until they reach the air-filled middle ear, where they cause the tympanic membrane to vibrate. The peritoneum is incised along the line of Toldt and extended caudally over the iliac vessels and medial to the medial umbilical ligament. At the nadir of the collapse, the bubble radius is less than 1 m and the dynamics of the collapse is at nanosecond time scales. In dichorionic twins there is extension of the placental tissue in to the base of the intertwin membrane. Another very important step in the introduction of endoscopic treatment of renal calculi was the introduction of holmium laser systems. Fever following intracavitary bacillus Calmette-Guerin therapy for upper tract transitional cell carcinoma. Many patients are quite satisfied with a reduction in their mouth opening, as long as their facial pain is relieved. It is particularly important to use low energy levels and a limited number of shock waves in children. It accomplishes this by inhibiting the peripheral utilization of glucose by muscle and adipose tissue while simultaneously stimulating hepatic gluconeogenesis. The efferent autonomic signals are transmitted to the various organs of the body through two major subdivisions, the sympathetic nervous system and the parasympathetic nervous system. There was no significant change in serum hematocrit, no need for transfusion, and no significant hematuria or clot retention postoperatively. Successful laparoscopic treatment requires proper technique and appropriate patient selection. Trauma Trauma is probably the most common cause of disc derangement, and this includes acute injury such as blunt trauma to the jaws or whiplash injury, or chronic trauma such as habits bruxism, or occlusal trauma. This is the ideal path and the only one that meets the five requirements described above of a safe percutaneous renal puncture. Quanti-fication of calcium, oxalate and uric acid in timed urine collections evaluates excretion of solutes as com pared to normal inidividuals. Working elements included resecting loops, cold and hot knife blades, and fulguration electrodes. Irretractable clicking or clicking developed postarthroplasty is usually a consequence of anterior and/or anteromedial meniscus perforation. This is ideal except that bubbles that drift up from the spark gap or the cavitation bubbles that form along the path of the shock wave, have the potential to collect against the skin of the patient and interfere with the propagation of subsequent shock waves. This is usually accomplished by placing the open-ended catheter up to the level of the obstruction, and through which the guidewire is directed to gain proximal access. The 2F electrode is slightly more flexible and can fulgurate with lateral contact rather than the directly forward approach needed with laser therapy (see Video 41. The dating scan has several specific aims, which include fetal viability, dating, diagnosis and chorionicity of twins. Intracavitary immunotherapy/chemotherapy is a useful adjuvant therapy post endoscopic management 306 Section 2 Percutaneous Renal Surgery: Other Uses of Nephrostomy Access 38. This author manages this problem by trimming the margins of the perforation with a suction punch or by means of laser instrumentation. Seventy-nine percent of the patients were discharged home on the same day, and 97% of them within 24 h. When this value rises above the 95th centile of the range, this implies that the fetal placental perfusion is faulty. Nutritional status affects the iron stores, and repeated pregnancy and poor social factors may lead to anaemia, as will the increased iron requirements of multiple pregnancy. The snap-shots show the distribution of the maximum tensile stress inside the stone at each instant of time. The route is determined by the size of the uterus, the degree of uterine descent and the necessity for oopherectomy.
Should this second attempt fail, the doctor and the patient must review all possible outcomes associated with leaving the foreign body as is. Although no contrast is used with this study, the ureteral anatomy can usually be welldefined. The cylinder generator is based on a hollow electromagnetic cylinder composed of a cylindrical coil covered by an insulating membrane, which again is covered by an electrically conducting membrane of high strength. Fortunately, there are a number of devices (both rigid and flexible) created specifically for this purpose, including graspers, baskets, and stone cones. Mid stream urine C&S test is a poor predictor of infected urine proximal to the obstructing ureteric stone or infected stones: a prospective clinical study. That knowledge must consider Intrarenal access through a calyceal fornix When we made a puncture through a fornix of a calyx, venous injury occurred in fewer than 8% of the kidneys. Endoscopic management of upper tract calculi and other disorders has evidently come at a cost. Alpha-antagonists may also be prescribed postoperatively in an attempt to facilitate spontaneous expulsion of stone fragments. The peripheral fascicles and nerve fibers are affected primarily, whereas more centrally located fascicles and nerve fibers may be spared. Supracostal upper calyceal access can be advantageous in several clinical situations (Table 16. Based on the success of this experience, ureteroscopic treatment has been extended to patients with a normal contralateral kidney. This condition can be congenital or acquired, the congenital form being the more common. Practice trends in contemporary management of adult ureteropelvic junction obstruction. If this does not work, a double-J stent should be placed and the planned procedure delayed for 3 or 4 days. However, some authors consider that the presence of a safety guidewire adjacent to the endoscope may prevent its passage. Thermoregulation, dehydration and infection, however, are all important issues associated with the skin of premature infants. Suspicious lesions are visualized and biopsied ureteroscopically and many lesions can be treated ureteroscopically. Preliminary knowledge of the individual components of the relay system is essential for optimum utilization. Causes of Respiratory Alkalosis Mechanical ventilation Pulmonary embolism High-altitude respiration Pneumonia Asthma Drugs. This refocus of priorities has been successful in reducing joint pain and increasing joint mobility. The introduction of digital video recording devices now allows video footage to be recorded directly in to a digital format [i. In these cases it has been suggested to unroof the ureterocele with an electrocautery knife or holmium laser, along its inferior border, thus raising a flap of mucosa through which the stone is manipulated in to the bladder and further fragmented. Endoscopy-guided percutaneous nephrostolithotomy: Benefits of ureteroscopic access and therapy. Typically, it occurs after prolonged inflammation stages, most commonly seen in conjunction with osteoarthritis. Since the electromagnetic shock-wave generation principle does not rely on the dielectric breakdown of a liquid, all the associated threshold effects and arc-forming instabilities are avoided. Subcutaneous administration of recombinant human erythropoietin allows satisfactory increase in levels of hemoglobin. As mentioned, wide-bore nephrostomy tubes were placed routinely after percutaneous renal surgery both to drain the kidney, and tamponade the access tract and establish hemostasis (although there is no evidence to support this assumption). All stent material was extruded within 4 weeks with only one stent prematurely migrating in to the bladder at day 1. The first lithotripters were electrohydraulic devices in which the shock wave was generated by underwater spark discharge and shock-wave coupling was achieved by immersion of the patient in a water bath.
Bartter Syndrome Bartter syndrome is an autosomal recessive disorder characterized by hypokalemia and metabolic alkalosis, resulting from excessive chloride, potassium and sodium wasting in the thick ascending limb of the loop of Henle. Most other classes work by preventing bronchoconstriction or by inhibiting inflammation (which reduces airway diameter); these include steroids, mast cell stabilizers, anticholinergics, leukotrienereceptor antagonists, and lipoxygenase inhibitors. Examination would reveal an enlarged calf that would be red, swollen and hot to the touch. A randomized placebo controlled trial evaluating tamsulosin, terazosin, or doxazosin found equal rates of stone passage among all medications [17]. Initially, the fecal contents in the right colon are fairly liquid; they gradually become more solid as they move through the large intestine. This condition is often diagnosed when a patient has an area of obvious hydronephrosis and no contrast flows in to the expected calyces on a retrograde pyelogram [32]. The preauricular incision this tissue is incised to the level of fibrous connective tissue. With only fluoroscopic guidance possible, careful patient and stricture selection is needed to help reduce hemorrhage risk. Today there is a great variety of flexible ureterorenoscopes from different companies. The risk of ascending migration depends on the initial location of the calculus, the type of energy source, as well as the degree of dilation of the upper urinary tract. Should incision of ureteroenteric strictures or stone extraction be needed, they are best achieved from above. By using tissue sensitivity, the effective dose can be calculated and is expressed in Sieverts (Sv). However, being totally endoscopic, endopyelotomy can only address intrinsic factors of obstruction; extrinsic causes cannot be corrected. Preoperatively the side-to-side mobility and ability to displace the kidney in relation to the abdominal wall is assessed. A dissection is then carried inferiorly removing the attachment of the capsule to the disc and exposing the inferior joint space. Preoperative urine cultures are mandatory to identify specific pathogens that can guide perioperative antibiotic coverage. During propagation to the focal area, the pressure pulse undergoes nonlinear effects, leading to the generation of a shock wave. Valdivia supine position as the best option for percutaneous surgery of renal calculi in morbidly obese patients. Renal failure can result in an anion gap metabolic acidosis as well as a normal anion gap acidosis if due to renal tubular acidosis. Regarding the fetal liver: Glycogen is stored in large quantities in the third trimester. This means the technique will only yield qualitative information about bubble clouds or nonspherical bubbles, both of which are very common in lithotripsy-induced cavitation. Sagittal reconstructions are best for studying the relation between the thorax and upper renal pole (small arrow points to a pelvic calculus). Although reliability has improved following a greater understanding of the mechanisms leading to scope failure [54], the ureteroscope of the future needs to be increasingly robust to meet the rigors of frequent daily use and to prevent costs from escalating. Missed anterior crossing vessels during open retroperitoneal pyeloplasty: laparoscopic transperitoneal discovery and repair. Case-oriented injury prevention, neuromuscular relaxation, corporeal mechanics, and stress management to reduce abnormal mechanics to the myofascial system are implemented. This leads to one of the most common causes of acute renal failure, acute tubular necrosis. The suturing technique in this particular situation is modified from the one presented previously in the incorporation of the perforation in to the retrodiskal flexure. Small false passages that are limited to the mucosa can be treated in a conservative manner, without stenting. The laser beam is columnated, equally spaced apart and coherent in the same time and space. Even when the stone is in the lower ureter, it may migrate higher during manipulation with irrigation pressure and instrumentation.
Their most important aspect is that they should not influence the ability to deflect the tip of the instrument. Symptomatic patients with infundibular stenosis most commonly present with flank pain. An endotracheal tube allows for positive pressure ventilation with higher airway pressures than manageable with a laryngeal mask device. If the orifices cannot be readily identified, methylene blue or indigo carmine can be administered intravenously to view efflux of dye. Endourological management of a large distal ureteral calculus in a patient with ureterosigmoidostomy diversion. Patients with celiac sprue may respond dramatically to elimination of gluten from the diet. It may also be that at slower rates the cavitation bubbles from the previous shock have more time to dissipate and in addition cumulative shear should produce less damage [111]. Peripheral protein Phospholipid bilayer Cholesterol Hydrophobic fatty acid tails Hydrophilic head Cytoskeleton (proteins) Nuclear envelope (inner and outer membranes) Nucleolus Nuclear pores Endoplasmic reticulum Cytoplasm Fluid mosaic model: describes ability of proteins to move freely within lipid bilayer In select cell types, the plasma membrane is folded to " surface area. Speculum examination revealed thick off-white discharge mixed with a little brownish blood in the vagina. A variety of minimally invasive options is available due to advances in endoscopic instruments and these offer faster patient recovery. Iatrogenic colon and rectal injuries associated with urological intervention: Report of 14 patients. Determining the depth of invasion of the primary tumor or other simultaneous lesions remains difficult, and most series have not reported accuracy in determining it. Surgery should be avoided until 14 weeks to reduce the risk of miscarriage and intervention with a corpus luteum, which should have regressed by 12 weeks. The incidence of ureteral perforation ranges from 0% in more recent studies involving flexible ureteroscopes [22] to as high as 17% in earlier series [29]. Other factors such as type of signal produced, scanning systems, and color systems also influence the characteristics of the image and its ability to be used with other equipment. Postoperative fever can often be the first clinical sign that patients may be becoming septic. Nevertheless, occasions do arise when anatomic considerations make access difficult or stone burden is so severe that ancillary measures may be welcome or even required. Comparison of Studer ileal neobladder and ileal conduit urinary diversion with respect to perioperative outcome and late complications. The type of percutaneous renal access determines in part the risk of surrounding tissue injury. Air pockets trapped during routine coupling in dry head lithotripsy can significantly decrease the delivery of shock wave energy. Also B-scan sonography can be used as a tool for localization of intrarenal arteries and avoidance of puncture by a Chiba needle. It is important to balance the size of the fiber with the deflection of the scope; a larger fiber will make it more difficult to deflect but will disintegrate the stone faster. Sevelamer hydrochloride, a calcium and aluminum free ion-exchange resin which binds phosphorus within the intestinal lumen preventing its absorption, is a safe and effective alternative to calcium containing phosphate binders, with no risk of hypercalcemia. Ureteroscopic lithotripsy using miniendoscope and Swiss lithoclast: experience in 147 cases. The "smart nail," extrapolated from orthopedic surgical technique, turned out to be rather sizable for our purposes, in many instances, transfixating the condyle.
Diseases
Percutaneous instillation of topical antifungal agents such as amphoteracin B permits administration of highly toxic antifungal drugs to patients with localized infection, thereby minimizing systemic side effects. Treatment of both conditions involves inhibition of the pathologically stimulated reninangiotensin-aldosterone neurohormonal cascade. Ureteroscopic management of lower-pole renal calculi: technique of calculus displacement. However, it does not promote lactation during this time as its function is antagonized by oestrogen. When determining patient "tolerance" of sedation, it must be considered whether the patient has known or suspected obstructive sleep apnea that may be exacerbated during sedation (especially among the morbidly obese). Her informed consent to the procedure is still valid, however, even if not in written form. The kidney may demonstrate marked parenchymal thinning (either segmental or complete), calyceal crescents, and the soap bubble nephrogram [8]. Impacted stone inside a tipless basket A calyceal stone that has been successfully caught may be too large to be extracted, but cannot be removed from the tipless basket. An imaging system that is in line with the shock-wave path facilitates their identification. Further data in the pig model indicate that delivering shock waves more slowly results in less tissue damage [64]. An analysis in the Cochrane Database of Systematic Reviews concluded that there is limited evidence that antimicrobials during the first 3 postoperative days, or from postoperative day 2 until catheter removal, reduces the rate of bacteriuria and other signs of infection in surgical patients [59]. Efficacy of tamsulosin in the management of lower ureteral stones: a randomized double-blind placebo-controlled study of 100 patients. For example, the issue of the open water bath was addressed by enclosing the shock head and by using a rubber membrane to couple the shock wave to the body. It appears that the reduction in time required to perform various minimally invasive surgical procedures may not be as dramatic in those individuals who have a large amount of experience with standard 2D video systems during endoscopic surgery [55]. The point in the opening cycle where the click occurs (early, middle, late) may correlate with the degree of ligament damage and disc displacement. This shows the divided retropelvic artery (arrow) and the needle (arrowheads) responsible for the lesion (curved arrow). What physicians (and patients) really wanted was lithotripsy that was painless, fast, and convenient with minimal to no anesthesia; a fully ambulatory walk-in-walk-out therapy. Threedimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System. Operating room personnel must wear adequate protective gear, including lead aprons and thyroid shields. Take a radiograph of the joint if the instrument cannot be located arthroscopically. Biodegradable ureteral stents Ureteral stents typically require a secondary procedure for removal if a suture tether is not used. If access is achieved but traumatically, a retrograde pyelogram should be performed and ureteral stent placement with deferral of the procedure should be considered if there is extravasation. If the cyst is not large enough to be percutaneously accessed directly, then indirect access can be utilized. If ureteral avulsion occurs, stent placement should be performed if possible, and the procedure should be aborted. In addition, the risks of ureteral stricture and the need for treatment of this complication should also be discussed. It is a solid-state pulsed laser that can fragment calculi, and coagulate, ablate, and remove tissue. All endoscopic procedures in our endoscopy suite and operating rooms are performed entirely off the video monitor(s). With the supine position, the incidence of the X-ray is perpendicular to the needle and calyx axis, and displacements of the calyceal papilla are better appreciated when the tip of the needle is pushing in front of them, making it unnecessary to rotate the C-arm fluoroscope (see Video, 10. Upper tract tumors after an initial diagnosis of bladder cancer: argument for long term surveillance.
The existence of an associated urinary infection may cause retroperitoneal abscesses. Etiologic factors Many etiologic factors have been proposed to explain the occurrence of disc derangement including trauma, joint laxity, bruxism, and changes in the joint lubrication system. This modified angle of view can be up to 10o in fluid and is helpful in visualizing working instruments as they emerge from the tip of the scope. Ureteral and bladder lesions after ballistic, ultra- Chapter 24 Percutaneous Lithotripsy and Stone Extraction 275 sonic, electrohydraulic, or laser lithotripsy. This risk tends to be exaggerated with increased length of tract, such as in obese patients. Significant bleeding requiring emergent nephrectomy is another possible complication that justifies the need for vascular or three-dimensional (3D) radiographic studies to identify aberrant vessels. It exists for certain substances because their reabsorption is dependent on membrane receptor proteins that have a finite transport capacity. Preoperative work-up must always include urine culture and sensitivities, and when positive, complete treatment prior to surgery to sterilize the urine. Complications that occur in twins can be divided in to those that occur in all twins and those that occur specifically in monochorionic twins. With the development of laparoscopic techniques for ureterolysis, the morbidity of the procedure has been reduced. It has no radiation and provides guidance for access in multiple, transverse, longitudinal, and oblique planes. Unfortunately, amiodarone commonly causes thyroid dysfunction, both hyperthyroidism (commonly) and hypothyroidism (rare), necessitating frequent monitoring of thyroid function. Despite the added ability to use the Lithoclast with a flexible ureteroscope, a significant decrease in tip displacement and velocity, and therefore effectiveness, is noted as the scope is deflected [40]. Once the access sheath is positioned in the calyx after balloon dilation of the percutaneous tract, the calyx is inspected with a rigid or flexible nephroscope to identify the papilla and the infundibulum. Ideally, vaginal delivery should be the aim; however, the second stage may be shortened in the event of maternal exhaustion. A hypo-oestrogenic state is associated with significant changes in the lipid profile that predisposes women to atheroma. Despite the apparent advantages of three-chip cameras, some clinical comparisons have favored one-chip systems. The advantage of a slight angulation on the direct vision lens is easier and quicker visualization of working instruments being passed out of the tip, reducing the potential for inadvertent iatrogenic injury to normal urothelium. Death was reported in these patients whether they had local recurrence or not, which suggests the aggressive nature of high-grade tumors with higher metastatic potential. Ultrasound scanning commences posteriorly and proceeds until the posterior axiliary line. A hysterosalpingogram will gain information on tubal patency and uterine cavity outline; however, this does not give any indication of pelvic disease, such as previous pelvic infection or endometriosis. It is, therefore, advisable to take photographs of the tubes once they are occluded at the time of surgery. They are all innervated by the mandibular division of the trigeminal nerve (cranial nerve V3). It needs to be emphasized that with the introduction of non- and low-invasive methods, the indications for active stone removal have changed, and accordingly many patients are today treated for stones that previously, when open surgery was the only available method, were left for conservative surveillance and follow-up. Intra-articular prolapse/herniation of the lateral pterygoid secondary to erosion/perforation of inflamed synovial lining at area no. During cystoscopy, the image viewed at the eyepiece is readily orientated relative to the bladder and viewer. Laparoscopic transperitoneal secondary dismembered pyeloplasty with posterior displacement of the crossing vessel was successfully performed in each case.
Overall, it is usually best to use a semi-rigid instrument if this can be safely passed to the level of the stone, even if the stone is located in the proximal ureter. Sometimes the diagnosis is made incidentally at ultrasound scan when patients come for a routine 12-week or 20-week scan. Effects of silodosin and naftopidil on the distal ureter and cardiovascular system in anesthetized dogs: comparison of potential medications for distal ureteral stone passage. Comparison of the renal hemodynamic response to unilateral and bilateral ureteral occlusion. The attenuated/"dampened" waveform, eventually oscillating down to resting potential, is used for the coagulating mode. After histologic examination it was demonstrated that injury was limited to abrasions of the epithelium [8]. However, it may still be difficult to find the reimplanted ureters due to the presence of mucus, occasionally large capacity of the diversion, lack of landmarks, and a constantly moving target due to peristalsis. The combination device required significantly less time for complete stone clearance (21. Hopkins replaced the thin relay lenses within the shaft of the endoscope with long, contoured glass rods acting as the transmission medium, whilst the thin pockets interspersed between the glass rods acted as lenses. Clinical note: Young men without coronary artery disease often present to the emergency department with anginal chest pain (and occasionally acute myocardial infarction) in a setting of recent cocaine use. Infectious complications in patients with chronic bacteriuria undergoing major urologic surgery. Bleeding occurs occasionally and can be controlled better at lower energies or by moving the fiber slightly away from the tissue to diffuse the laser beam and improve coagulation. History the salient features include dysmenorrhoea, the demonstration of cyclical pelvic pain, deep dyspareunia, a history of sub-fertility or infertility. Measuring from the midportion of the tragus anteriorly, the frontal branch of the facial would be found ranging 13 to 40 mm with a mean of 20 to 25 mm. In many orthotopic neobladder techniques, either one or both ureters are implanted in to an afferent limb of bowel that extends from the reservoir. This is because vitamin K-dependent clotting factors within the newborn may be reduced and lead to haemorrhagic disease. Children present with failure to thrive, polyuria, polydipsia, hypokalemic muscle weakness and rickets. External compression during systole essentially halts left ventricular coronary blood flow by decreasing vessel radius. Wilkes V patients, however, will have the second important pathognomonic sign, crepitation. When they occur they are, however, usually associated with severe pain, considerable blood loss, and variable effects on renal function. If the retrograde pyelogram shows extravasation, the ureteroscopy should be stopped and a stent deployed. There has been considerable interest and wide acceptance of these techniques for the treatment of some upper tract neoplasms. This shows that the two layers of the renal fascia fuse above the suprarenal gland and end fused with the infradiaphragmatic fascia (long arrow). With these cameras, there is no need for an automatic intensity-adjusting light source. To reduce resistance to breathing, the chest and abdomen are elevated on two foam rubber rolls that extend from the shoulder to the hip. An additional roll is used to slightly elevate the side of interest in order to align the posterior calyces in a more vertical position. This endoscope offers superior deflection and irrigation characteristics, in particular when larger 2. Guidelines Management of anticoagulation in the perioperative period requires an understanding of the underlying pathologic state requiring anticoagulation. When comparing groups using lidocaine jelly and a randomized control group treated without, there was significantly less proximal stone migration and a better stone-free rate at 2 weeks in those receiving lidocaine [14].
Children with chronic glomerulonephritis retain sodium and water, which contributes to hypertension. This approach has been described by several endourologists [20] and is currently the procedure of choice at our institution. A prospective randomized study comparing shock wave lithotripsy and semirigid ureteroscopy for the management of proximal ureteral calculi. There may be new stricture formation from a ureteral injury, and this should be investigated at the time of follow-up surgery. However, it has been shown that this direct wave can influence the cavitation generated by the focused wave [62]. Therefore, the diagnosis of phimosis should be made with caution in young children. Some authors have reported performing flexible ureteroscopy without a working or a safety guidewire. Use of proton pump inhibitors such as omeprazole will also cause a loss of gastrin feedback inhibition. Chapter 39 Ureteroscopic Management of Renal Calculi there is evidence that their use does not increase the rate of ureteral strictures [4]. While the management of large and complex stone disease remains the most common application for percutaneous renal surgery, the approach is also well-suited for the minimally invasive treatment of ureteropelvic junction obstruction, select upper tract urothelial carcinomas, and ablative therapy for small renal masses. This event may follow rapid balloon inflation or exceeding the recommended pressure, and can be avoided by insuring a gradual and carefully monitored pressure increase. Most of these complications are alleviated after removal of indwelling ureteral stents. The neutrophils are additionally activated and produce bactericidal substances, such as proteases and oxygen radicals. The endoscopic group was found to have less estimated blood loss (158 mL vs 211 mL, respectively, P =. Care must be taken to avoid Endoscopic diagnostic techniques Endoscopic evaluation of an abnormality in the upper urinary tract suspicious for a neoplasm includes inspection of the entire bladder and involved collecting system. Urine cytology should be examined in all patients to rule out malignant recurrence. To perform blind retrograde endoureterotomy, a glidewire and a 4F catheter must be passed through the stricture. Although it reduces the chances of severe preterm birth, multi-fetal reduction increases the chance of pregnancy loss before viability. The flexible endoscope fits in to the inner guide and can be fixed therein, allowing it to be controlled by movements of the guide via the master input device. There is microvascular injury, thrombosis, and loss of endothelial integrity (capillary leak), resulting in tissue ischemia. Acute synovitis with capillary proliferation and hyperemia at the medial synovial drape. Furthermore, the W presence of persistent symptoms in light of disc derangement does not imply that surgical correction is necessary or imminent. The more thoroughly patients are counseled preoperatively, the greater trust will persist postoperatively if these situations occur, and subsequent counseling of the patient will be facilitated. Nevertheless, the strong magnetic field used interferes with ferromagnetic foreign bodies or electronic medical devices that are frequently carried by patients, although improvements in electronic medical devices have minimized this problem [28]. The needle is positioned at the lumbar notch, oriented slightly cephalad, and angled approximately 30o in relation to the vertical axis.
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