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Small Animal Surgery > Quiz 2 > Flashcards

Quiz 2 Flashcards

1
Q

What is the most common form of diaphragmatic hernias?

What percentage of all diaphragmatic hernias do they make up?

A
  • Aquired diaphragmatic hernias due to TRAUMA
  • 93%
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2
Q

List the radiographic signs of a diaphragmatic hernia.

A
  • Interupption of diaphragmatic outline
  • ST density in the Thorax
  • GAS filled viscera in the Thorax
  • Loss of cardiac sillhouette
  • Incidental finding
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3
Q

What time periods is mortality HIGHER when hernias are repaired after occurence?

Why?

A
  • When repaired <24 hrs. or >1 yr. after they occurred
  • Due to adhesion formation
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4
Q

Why should you delay diaphragmatic hernia SX till 1-2 wks after occurrence?

A
  • Success rate improves to 90%
  • Better suture holding
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5
Q

When must SX be performed if the STOMACH has herniated into the Thoracic cavity?

Why?

A
  • Immediately
  • Dilated stomach will cause complete & rapid collapse of the lungs
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6
Q

What is a possible POST-op complication w/ Diaphragmatic Hernia repair?

A

Reperfusion injury → Pulmonary edema

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7
Q

Which surgical approach for repairing a diaphragmatic hernia requires an accurate DX?

Why?

A
  • Thoracic approach
  • only allows access to one side of the body
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8
Q

Where do you start suturing to repair a RADIAL diaphragmatic tear?

A

at the most DORSAL margin

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9
Q

What suture patterns & suture material are recommened to repair a Diaphragmatic hernia?

A
  • Simple continuous or simple interrupted
  • 3-0 or 2-0 PDS
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10
Q

What must you do JUST before closing up on a traumatic diaphragmatic hernia repair?

A

Have the anesthestist SLOWLY EXPAND the lungs while the last suture is placed

to force air out from the pleural space

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11
Q

When should you place a thoracotomy tube(s) when repairing a traumatic diaphragmatic hernia?

A
  • w/ a chronic hernia
  • herniated liver
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12
Q

Why must you perform good post-op care/monitoring of patients recovering

from traumatic diaphragmatic hernia repair?

A

Due to risk of:

  • Reperfusion injury (esp. lungs)
  • Re-expansion Pulmonary Edema
  • Hemorrhage
  • Pneumothorax
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13
Q

What is the prognosis for traumatic diaphragmatic hernia repair?

A
  • Guarded until patient survives 24 hrs. post-op
  • Excellent after the 1st 24 hrs. → 60-90% survival rate
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14
Q

Cats & Dogs ALWAYS get what form of Peritoneo-Pericardial Herniation (PPH)?

A

Congenital form

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15
Q

PPH is associated w/ ______ hernia in 1 out of 3 dogs.

A

VENTRAL hernia

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16
Q

How do you surgically repair PPH?

A

Abdominal approach → relocate abdominal viscera → debride edges of defect → close from dorsal to ventral → DO NOT CLOSE THE PERICARDIAL SAC

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17
Q

What must you do if communication w/ the pleural cavity occurs during surgical repair of a PPH patient?

A

For 24-48 hrs. POST-op:

  • Assisted ventilation
  • Thoracic drainage
  • ICU
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18
Q

What classifies a TRUE hernia?

A

Must contain a peritoneal lining for it to be a true hernia!!

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19
Q

List the 3 examples given of FALSE hernias?

A
  • Diaphragmatic hernia
  • Herniation of kidneys
  • Perineal hernia
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20
Q

Define eventration.

A

Protrusion of the abdominal content through a debiltated area of abdominal wall due to a SXical or Traumatic origin w/ INTACT skin

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21
Q

Define evisceration!

A

The rupture of all structures constituent of abdominal wall w/ PROTRUSION of the visceral content through a wound or SX incision.

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22
Q

What is a common reason why evisceration occurs?

A

2° complication of an OVH

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23
Q

List the 2 types of Reducible hernias/eventrations.

What is the most common of the 2?

A
  • Coercible → most common
  • Incoercible
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24
Q

Define a (reducinle) Coercible hernia.

A

hernial content CAN be manually reduced & RETAINED inse the abdominal cavity

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25
Q

Define a (reducible) incoercible hernia/eventration.

A

hernial content can be manually reduced but is NOT RETAINED inside the abdominal cavity

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26
Q

List the 2 types of Irreducible Hernias/eventrations.

A
  • Incarcerated
  • Strangulated
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27
Q

Define an (irreducible) Incarcerated Hernia/Eventration.

A

impossible reduction of hernial content w/ intact blood supply to the content

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28
Q

Define (irreducible) Strangulated hernia/eventration.

A

impossible reduction of hernial content w/ VASCULAR COMPROMISE leading to ischemic injury of the protruded viscera

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29
Q

List the 4 Herniorrhaphy Priniciples.

A
  1. Return all viable content to the abdominal cavity
  2. Close the hernial ring to prevent recurrences
    • avoid obliterating pudenal vessels
  3. Obliteration of redundant tissue in the hernial sac
  4. Use the patient’s own tissues whenever possible
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30
Q

What is the TX of choice for an Umbilical hernia?

Why?

A
  • Perform a Herniorrhaphy immediately
  • If wait → risk of entrapment due to growth of the animal
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31
Q

What 2 ways can you make your incision to correct an umbilical hernia?

A
  • Straight incision over the defect
  • Elliptical incision around the defect to remove redundant tissue
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32
Q

What is an INDIRECT Inguinal Hernia?

Who gets it?

A
  • hernia goes through the Vaginal process & into the scrotum → scrotal hernia
  • MALES only
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33
Q

What is a DIRECT Inguinal hernia?

Who gets it?

A
  • hernia goes thru the inguinal canal & CREATS a sac APART from the testicular canal
  • Males & females can get
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34
Q

List some DDX for an Inguinal Hernia.

A
  • Abscess
  • Mammary neoplasia
  • Neoplasia
  • Hematoma
  • Inguinal lymph node
  • Fat of the round ligament
  • Eventration
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35
Q

Which side must you leave open, when repairing an Inguinal hernia,

to prevent damage to the Pudenal vessels?

A

MEDIAL/Caudal side

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36
Q

What suture pattern should you use when closing the inguinal ring during a herniorrhaphy?

A

“Vest over pant”

(Mayo-Mattress suture pattern)

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37
Q

Post-op care for an Inguinal Hernia?

A
  • Analgesics/NSAIDs
  • Restrict exercise
  • Feed soft/low residue diet
  • ABXs ONLY needed if pyometra or enterectomy
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38
Q

Who do Perineal hernias most commonly occur in?

Where do they occur?

A
  • INTACT male dogs → 7-9 yrs. old
  • 2/3 are unilateral
    • tend to appear more on the RIGHT
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39
Q

Animals w/ Perineal Hernias often tend to have ___________ as well.

A

Benign Prostatic Hyperplasia

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40
Q

Why are the diverticulums usually not resected in perineal hernias?

A

due to increased collagenase activity 5-7 d. after anastomosis →

collagen degradation exceeds collagen synthesis

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41
Q

What is a Perineal Hernia?

A

Pseudo-Hernia/False Hernia

No Serosal Lining***

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42
Q

What ligament is very important for anchoring during perineal hernia repair?

A

Sacrotuberous ligament

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43
Q

How do you diagnose a perineal hernia?

A
  • CS
  • Physical Exam
  • Rectal - finger:
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44
Q

What makes a perineal hernia an emergency?

A

Herniation of bladder!

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45
Q

What do you need to remember about the anatomy of the pelvic diaphram in a Cat?

A

NO Sacrotuberous Ligament

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46
Q

What do you do PRE-op for perineal hernia patients?

A
  • Stabalize!!!!!
  • Bladder catheterization or centesis
  • Empty anal sacs
  • Purse string suture around anus → Don’t forget to remove!!!
  • NO ENEMAS
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47
Q

When repairing a perineal hernia what is the most common approach?

What is your landmark?

A
  • Perineal Approach
    • ventral recumbency w/ elevated pelvis
  • Sacrotuberous ligament is your landmark →place sutures THRU it not around it
    • May hit the Sciatic n. if go around it
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48
Q

When using implants to repair perineal hernias what is best?

A

Patient’s own tissues b/c or rejection issues

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49
Q

What are the Most common POST-op complications of perineal surgery?

A
  • Rectal prolapse → purse string w/ opening to allow defecation
  • Incontinence → Pudendal n. damage
  • Dehiscence → rare; avoid pulling sutures to tight
  • Sciatic nerve lesion → entrapment (rare)
    • fuctional recovery 2-4wks or may need corrective SX
  • Recurrance → 10-46%
    • Castration prevents
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50
Q

When correcting a Sciatic nerve entrapment what approach do you use

and which one do you never use?

A

Caudolateral Approach

NEVER via herniorrhaphy!

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51
Q

What is an alternative SX to fix perineal hernias?

What pt. does this work best in?

What order do you do the procedure?

(TQ)

A
  • Colopexy/cystopexy/deferentopexy
    • Pexy colon to the L
    • Pexy bladder to the R
    • Anchor deferens to the adjacent abdominal wall
  • Good for pts in critical contition
  • If doing both an Intra-abdominal & Perineal procedure:
    • Do the intra-abdomimal procedure first (cleanest procedure)
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52
Q

What animal is perinal gland adenoma most common in?

What animal does it NOT occur in at all?

A
  • Most common: intact, male dogs (rare in female)
  • Does not occur in cats!
    • No perianal or circumanal glands
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53
Q

What is the CLOSED technique for anal sac excision?

A
  • Make curved incision parallell to the anal sphincter
  • Peel entire gland out
    • careful not to damage muscle fibers
    • can inject wax to make it easier to remove
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54
Q

What is the #1 rule about surgery of the ear?

A

Always use antibiotics!

(it’s a contaminated procedure!)

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55
Q

What are your landmarks for ear surgery?

A
  • Anthelix
  • Tragus (ventral)
  • Intertragic incisure
  • Tragohelicine incisure (medial & lateral boarders)
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56
Q

What is the only way to evaluate a dogs ear canal?

A

Otoscopy

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57
Q

When do you perform a Total Ear Canal Ablation combined with Lateral Bulla Osteotomy (TECA-LBO)?

A

When you have a dog w/ stenotic canal(s), chronic ear infection(s) & fluid in the Bulla!

(When you KNOW there is something in the Bulla!!)

58
Q

What is an iatrogenic cause of Horner’s Syndrome?

What is Horner’s Syndrome?

A
  • Pulling to hard on the Facial n.
  • Horner’s Syndrome:
    • Miosis
    • 3rd eyelid protrusion
    • Ptosis (upper lid)
    • Enophthalmos
59
Q

What is the difference between dogs’ & cats’ 3rd eyelid?

A
  • Dogs→ 100% passive
  • Cats→ BOTH passive & non-passive movement
60
Q

Otitis media in Dogs vs. Cats?

A
  • Dogs → 2° to Otitis externa
  • Cats → 1° condition w/o Otitis externa
    • Nasopharyngeal polyp!
61
Q

What is important to remember when removing nasopharyngeal polyps?

A
  • Polyp stalks must be removed or they will regrow!!
  • If polyp is resected in pharynx or Ext. Ear Canal→Pull stalk into Bulla & remove stalk w/ epithelium via a Ventral Bulla Osteotomy
62
Q

What is laryngeal paralysis?

A

Failure of laryngeal cartilages to abduct on inspiration due too:

  • degeneration of Recurrent Laryngeal n. &/o
  • Paralysis of CAD muscle
63
Q

What is the etiology of laryngeal paralysis?

Who does it most commonly affect?

A
  • Wallerian Degeneration of Recurrent Laryngeal nerve (idiopathic)
  • Most often occurs in Medium & Large breed dogs
  • Associated w/ hypothyroidism in labradors
    • so if diagnosed, always run a thyroid test.
64
Q

What is the typical HX of a dog with laryngeal paralysis?

A
  • Inspiratory Dyspnea
    • Elbows abducted
    • Retracted commisure
    • Thick saliva
  • Stridor
  • Change in voice
  • Cyanosis
  • Hot weather exacerbates!
65
Q

What are the surgical treatments of laryngeal paralysis?

A
  • Choking & unable to intubate patient → Tracheotomy!
  • Partial Arytenoidectomy (ventriculo-cordectomy)
  • Aretenoid Cartilage Lateralization “tie back” (Aretenopexy)→ most common
  • Laryngoplasty
66
Q

What are the two approaches used during an Exploratory Rhinotomy?

What will you see with each?

A
  • Dorsal Approach
    • Rostral Nasal Cavity & Sinuses
  • Ventral Approach
    • Entire Nasal Passage, including area caudal to the Ethmoid turbinates
67
Q

How do you perform the folded flap palatoplasty on an elongated soft palate?

A
  • Remove a partial thicknes flap (1/2-2/3) of soft palate to create a thin soft palate
  • Take a piece of buccal side of mucosa & fold the free edge to an appropriate length then suture to denuded portion of soft palate
68
Q

What are the surgeries available for Brachycephalic Syndrome dogs?

A
  • AlaPLASTY
    • removal of redundant protion of nose most effective Sx for stenotic nares
  • AlaPEXY
    • enlarging nares by tacking them to skin lateral to nose better for not severely stenotic nares
  • Partial palatectomy/Partial soft palate resection
    • full thickness removal of a portion of the soft palate
  • Folded Flap PalatoPLASTY
    • best option to correct elogated soft pallate
  • Permanent Tracheostomy
    • treatment of choice for laryngeal collapse (not paralysis)
69
Q

When would you perform an Exploratory Rhinotomy?

A
  • Treatment of Nasal Adenocarcinoma (followed by radiation therapy)
  • Establish Drainage or remove FB
  • Obtain biopsy/culture specimens
70
Q

How do you perform an OPEN anal sac excision?

A
  1. Incise along the length of the gland
  2. Open gland up
  3. Peel it off up to the nexk of opening at the anal sphincter
  4. Remove gland

******Careful not to damage the External anal sphicter mm.*******

71
Q

What are the complications associated w/ Tie Back SX?

A
  • Aspiration pneumonia
  • Failure to correct condition
    • inadequate lateralization
    • failure to TX Hypothyroidism
    • MisDX of the cause of dyspnea
72
Q

What are the characteristics of 1° Brachycephalic Airway Syndrome?

A
  • Stenotic nares
  • Elongated soft palate
  • Hypo-plastic trachea
73
Q

What are the characteristics of 2° Brachycephalic Airway Syndrome?

A
  • Everted laryngeal saccules
  • Laryngeal collapse
74
Q

What is the most effective SX for treating Stenotic nares?

A

AlaPLASTY

(removes redundant tissue)

75
Q

When would you want to use AlaPEXY?

A

To surgically correct nares that are NOT severely stenotic

76
Q

When is it okay to extubate your patient following a Partial PalatecTOMY

(Partial Soft Palate Resection)?

A

When they are chewing on the tube!!

77
Q

What is the treatment of choise for Laryngeal Collapse?

What must the owners be warned about?

A
  • Permanent tracheoSTOMY
  • Bark may change or cease to exist
  • NO SWIMMING!!!!
78
Q

What additional salivary gland do CATS have?

A

Molar Salivary Gland

79
Q

What are the secretions like for each of the Salivary Glands?

A
  • Parotid gland → serous
  • ALL OTHERS → sero-mucous
80
Q

How can you DX a disease of the salivary gland?

A

Needle aspirate of the swelling→ get THICK saliva

(“honey cyst” if in the cervical region)

81
Q

Which glands must you remove in order to TX a Sialocele?

A
  • Sublingual salivary gland
  • Mandibular salivary gland
82
Q

What is the most common dz. of the Salivary system in the Dog & Cat?

Which duct is most often affected?

A
  • Salivary mucocele
  • Sublingual salivary duct
83
Q

Which type of mucocele can cause respiratory distress & be life-threatening?

A

a Pharyngeal mucocele

84
Q

How can you determine which side a Cervical Sialocele is on?

A
  • place in DORSAL recumbency → will move to the appropriate side
  • Can also use contrast radiography
85
Q

How can you differeniate a pharyngeal mucocele from neoplasia?

A

Aspirate it!! → honey mucocele is DXstic

86
Q

Where do you disect when performing a Sialaodenectomy?

A
  • BELOW the Digastricus mm. to the Lingual n.
    • Lingual n. is the boundary!!!!
87
Q

Which salivary gland is associated w/:

  1. Sialoliths?
  2. Sialoadenitits?
  3. Sialocele?
  4. K9 Necrotizing Sialometaplasia?
A
  1. Parotid
  2. Zygomatic
  3. Sublingual
  4. Mandibular
88
Q

What side of the body is the Pancreas located on?

A

RIGHT side

89
Q

What is the major excretory duct in CATS?

A

Ventral (Pancreatic) duct

90
Q

What is the primary excretory duct in DOGS?

A

Dorsal (Accessory) Duct

91
Q

What 3 things supply the LEFT lobe of the pancreas w/ blood?

A
  • Hepatic a.
  • Splenic a.
  • Gastoduodenal a.
92
Q

What supplies the RIGHT lobe of the pancreas w/ blood?

Why does this matter?

A
  • Pancreatic-duodenal a.
  • When resecting the RIGHT lobe → ONLY ligate the pancreatic vessels
    • NOT the duodenal ones
93
Q

How much of the pancrease can be removed
w/o causing Endo-/Exocrine Pancreatic Insufficiency?

A

up to 80%

94
Q

When is it OKAY to use absorbable monofilament suture material when performing duct ligation during pancreatic SX?

A

in the case of Sepsis

(otherwise want a non-absorbable like polypropylene or nylon)

95
Q

Etiology of an Insulinoma?

A

adenocarcinoma of the BETA cells

96
Q

Etiology of a Gastrinoma?

A

Adenocarcinoma of the NON-BETA cells

97
Q

What is the most common pancreatic neoplasia?

A

Exocrine Pancreatic Adenocarcinoma

98
Q

What is pathognomic for an Insulinoma?

A

WHIPPLE’S TRIAD

  • Neuro signs
  • Hypoglycemia
  • Neuro signs resolve following feeding or parenteral admin of glucose
    • C/S improve when pt. is fed.
99
Q

How often should you monitor BG when surigically treating an Insulinoma?

A

Every 5 min!

100
Q

What DXstic tool is most helpful in IDing SXical pancreatic dz?

A

Abdominal U/S

101
Q

Which side of the liver is more difficult to operate on?

Why?

A

Right side b/c it is less fissured

102
Q

What are the 2 afferent blood supplies to the liver?

A
  • Portal System
    • Low pressure
    • Supplies 4/5 of the blood that enters the liver
    • Provies 50% of the O2
  • Arterial System
    • High pressure
    • 2-5 branches from the Hepatic a.
      • Cystic a. supplies the gallbladder
    • Provides 50% of the O2
103
Q

What % of liver neoplasia are primary tumors?

A

1% → most mestastasis from other locations

104
Q

What is an important PRE-surgical consideration before performing Liver SX?

A
  • Do a coagulogram!!
    • want to be sure the animal can clot!
  • Avoid drugs metabolized by the liver → i.e. Thiopental
  • Give wide-spectrum ABXs
    • Flouroquinolones + Clavamox
    • Flouroquinolones + Clindamycin
    • Ampicillin + Metronidazole + Cephalosporins
105
Q

Surgical approach for Liver SX?

A
  • Clip WIDE → sternum to pelvis to sides of thorax
  • R lobe is harder to access than the L lobe (due to the vena cava)
  • Use Balfour retractors to hold abdomen open
  • Place Lap sponges btwn. diaphragm & liver
  • Use stay sutures to retract the stomach caudally
106
Q

What does the Pringle Maneuver do?

How long can it be SAFELLY performed?

A
  • Occuldes the Portal Triad to prevent hemorrhage:
    • Portal vein
    • Hepatic a.
    • (Common) bile duct
  • for up to 20 min.
107
Q

What is the main cause of extrahepatic biliary obstruction?

A

Pancreatic pathology

108
Q

List the 3 pathognomonic signs of Cholecystitis.

A
  • Jaundice
  • Abdominal pain
  • Fever
109
Q

What is the pathognomonic sign of a gallbladder mucocele?

A

“Kiwi sign” on U/S

110
Q

What is the smallest size the stoma can be?

A

No smaller than 2.5-3 cm long!

111
Q

What is the most common form of Congenital PSS?

A

Extrahepatic PSS

(EHPSS)

112
Q

What is the most useful tool to DX INTRAhepatic PSS?

A

U/S

113
Q

What is the best way to DX a PSS?

A

CT/MR Angiography

(CT shows you where the shunt originates & terminates)

114
Q

What is the TX of choice for PSS?

A

Surgical attenuation/ligation

115
Q

How should you attenuate vessels when attenuating a PSS?

A

Gradually!!

(aggressive ligation has a poorer outcome for the pt.)

116
Q

An Ameroid Ring Constrictor works better on which type of Congenital PSS?

A

EHPSS >>>> IHPSS

117
Q

Cellophane banding can be used to TX which type(s) of congential PSS?

A

BOTH TYPES

118
Q

What is the most critical time for PSS patients?

A

Immediately post-op!

119
Q

What are the fxns of the Spleen?

A
  • Blood filtration & phagocytosis
  • Immune activity against blood borne Ags.
  • Blood reservoir
  • Stores Fe
  • Hematopoiesis
120
Q

Where should you ligate splenic vessels?

A

Ligate vessels as close to the parenchyma of the spleen as possible

121
Q

What is the most common Splenic neoplasia seen in DOGS?

What else should you be looking for?

A
  • Hemangiosarcoma
  • Cardiac hemangiosarcoma → 25% of dogs w/ splenic hemangiosarc will also have cardiac type.
122
Q

When can you reposition the Spleen after Splenic torsion has occured?

A

ONLY if NO thrombosis is seen!

123
Q

What artery & it’s branches are important to know when performing a Pancreatectomy?

Why?

A
  • Celiac artery & branches
  • Primary blood supply to the pancreas
124
Q

What are the 4 endocrine hormones produced by the pancreas?

A
  • Insulin
  • Glucagon
  • Somatostatin
  • Gastrin
125
Q

If pancreatic neoplasia is suspected, what other 2 organs should you evaluate/biopsy?

A

Regional LN

Liver

126
Q

Blunt dissection & ligation is indicated for lesions located where in the pancreas?

A

Anywhere

127
Q

Suture, Fracture technique is indicated for lesions located where on the pancreas?

A

focal lesions on the margin

128
Q

If you have diffuse pancreatic dz, where should you BX?

A

caudal aspect of the RIGHT lobe.

129
Q

If you have focal dz. pancreatic dz in the parenchyma, how should you BX?

A

Tru-Cut technique

130
Q

How can you avoid causing iatrogenic pancreatitis when performing SX?

A

maintain good perfusion of the pancreas throughout SX

131
Q

What is the prognosis for Exocrine Pancreatic Adenocarcinoma?

A

Extremely poor

(widespread metastasis is common)

132
Q

What stain can be injected IV & used to help delineate insulinomas?

What is a side effect if use too much?

A
  • Methylene blue
  • Hemolytic anemia
133
Q

What is Zollinger-Ellison Syndrome?

A

Gastrinoma in the pancreas secretes high levels of gastrin, which go into the blood

134
Q

How do you perform a CholecysTOTOMY?

A
  • Place stay suture on GB
  • Make opening
  • Aspirate bile & remove what is needed (i.e. stones)
  • Close w/ an Inverting pattern
135
Q

What is the most commonly used technique for removing GB stones?

How’s it done?

A
  • CholecysTECTOMY
  1. Ligate Cystic a. (prevents bleeding)
  2. Bluntly dissect GB from liver lobe
  3. Ligate & remove GB
136
Q

How does the Ameroid Ring Constrictor work?

A
  • Gradually attenuates shunt over 4-5 wks due to Casein swelling
  • Constriction is more due to an inflammatory ST rxn causing it to close
137
Q

Describe Post-Op management for a PSS patient.

A
  • Watch for portal hypertension
  • Watch for seizure activity
  • Ascites is common → don’t have to remove constricting device
  • Repeat liver fxn tests 30-60 d. post-op
    • If improved wean off: ABXs, Lactulose, Low protein diet
  • Some may have to be on low protein diets for life
138
Q

List the 5 Liver Fxn Tests.

A
  • Cholesterol
  • BUN
  • Albumin
  • Glucose
  • Bile acids
139
Q

Indications for a Total Splenectomy?

A
  • 1° neoplasm of spleen
  • Splenic torsion w/ vascular thrombosis
  • Severe trauma
  • Disseminated Feline mastocytoma
  • Uncontrollable IMHA
140
Q

What are the consequences of a Total Splenectomy?

A
  • Increased Howell-Jolly bodies & nucleated RBCs
  • Increased PLT count
  • Increased chances of IDing sub-clinically infected animals w/ vector-borne dz.
  • OPSI (overwhelming post-splenectomy infection)
  • Decreased physical activity tolerance
141
Q

When should you NEVER perform a Partial Splenectomy?

A

In cases of Neoplasm

Small Animal Surgery (10 decks)

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