Abstract Background Umbilical hernia is a common finding in patients undergoing abdominoplasty, especially those who are postpartum with rectus divarication. Concurrent surgical treatment of the umbilical hernia at abdominoplasty presents a “vascular challenge” due to the disruption of dermal blood supply to the umbilicus, leaving the stalk as the sole axis of perfusion. To date, there have been no surgical techniques described to adequately address large umbilical herniae during abdominoplasty. Objectives To present an effective and safe technique that can address large umbilical herniae during abdominoplasty. Methods A prospective series of 10 consecutive patients, undergoing concurrent abdominoplasty and laparoscopic umbilical hernia repair between 2014 and 2017 were included in the study. All procedures were performed by the same general surgeon and plastic surgeon at the Macquarie University Hospital in North Ryde, NSW, Australia. Data were collected with approval of our ethics committee. Results At 12-month follow up there were no instances of umbilical necrosis, wound complications, seroma, or recurrent hernia. The mean body mass index was 23.8 kg/m2 (range, 16.1-30.1 kg/m2). Rectus divarication ranged from 35 to 80 mm (mean, 53.5 mm). Umbilical hernia repair took a mean of 25.9 minutes to complete (range, 18-35 minutes). Conclusions We present a technique that avoids incision of the rectus fascia minimizes dissection of the umbilical stalk and is able to provide a gold standard hernia repair with mesh. This procedure is particularly suited to postpartum patients with large herniae (>3-4 cm diameter) and wide rectus divarication, where mesh repair with adequate overlap is the recommended treatment. Level of Evidence: 4 Rectus divarication and laxity of the anterior abdominal wall is a common condition, particularly after pregnancy and/or significant weight loss.1 It is often associated with a concomitant umbilical hernia and consequently, abdominoplasty and umbilical herniorrhaphy may be required to maximize the quality of the surgical outcome. Standard abdominoplasty techniques necessitate circumferential incision around the umbilicus and dissection of the umbilical stalk down to the rectus fascia, preserving an axis of blood supply (via the stalk) to the umbilical skin. In contrast, open umbilical herniorrhaphy traditionally involves supra or infraumbilical incisions with extensive dissection or transection through the umbilical stalk in order to isolate the hernia sac and reduce the hernia. This leaves the dermal plexus as the principle blood supply to the umbilicus. In these patients, surgeons are presented with the opportunity to concurrently address both the abdominoplasty and the umbilical hernia. Unfortunately, combination of the standard abdominoplasty and open umbilical herniorrhaphy would lead to division of both axes of umbilical blood supply and subsequent necrosis. Modified techniques of concomitant open umbilical herniorrhaphy and abdominoplasty have been described to address this problem,2-4 however have, we believe, potential vascular, technical, and recurrence risks. We present a surgical procedure that combines laparoscopic herniorrhaphy and abdominoplasty, thereby eliminating the need for incisions near the umbilicus and which allows for good visualization of herniae to accurately perform herniorrhaphy with a decreased potential for vascular compromise of the umbilical stalk and likely a lower rate of hernia recurrences. METHODS This research study was approved by the Macquarie University Human Research Ethics Committee and conforms to the World Medical Association Declaration of Helsinki (June 1964) and its subsequent amendments. A series of 10 consecutive patients undergoing simultaneous laparoscopic umbilical hernia repair and abdominoplasty, between June 2014 and February 2017, were included in the study. Patients that met the inclusion criteria were those between ages 18 and 60 years requiring abdominoplasty with clinically evident large umbilical hernia on physical examination. Exclusion criteria were ongoing smokers, diabetics, and those who have had previous upper abdominal surgery. Small, clinically insignificant umbilical hernia were not included in the patient group. All patients underwent informed consent that included the option of an open suture repair of the umbilical hernia. All procedures occurred at the Macquarie University Hospital in North Ryde, NSW, Australia, and were performed by a single senior plastic surgeon (S.M.) and a single senior general surgeon (A.G.). Surgical Technique Immediately preoperatively, the patient was marked for abdominoplasty in the usual manner. The surgeries were performed under general anesthetic, with standard deep vein thrombosis prophylaxis and antibiotic administration. The abdomen was prepared with povidone-iodine and draped in the usual manner, with the lateral drapes positioned low, at the level of the surgical table. The laparoscopic umbilical herniorrhaphy was performed first, followed by the abdominoplasty. The Laparoscopic Hernia Technique A 5 mm Kii Fios First Entry (Applied Medical, Rancho Santa Margarita, CA) visual port was used to establish pneumoperitoneum in the left upper quadrant just below the costal margin in the midclavicular line. With insufflation, one or two other 5 mm port sites were determined within the area of the lower left abdominal skin planned for removal at the abdominoplasty (Figure 1). One or two ports were placed, depending on subsequent ability to manipulate the mesh one handed. The contents of the umbilical hernia were reduced (if not already spontaneously done so with peritoneal cavity insufflation); critically, the sac was not dissected or excised, so as not to disturb the collateral blood supply of the umbilical cicatrix (Figure 2). To ensure a 4 cm overlap of the hernia defect, either a 90 or 120 mm Parietex Composite mesh (Medtronic, Minneapolis, MN), with sutures, was pulled through the left upper quadrant port. An Endo Clos (Medtronic) device was used to deliver the mesh transfixion sutures in a transverse, rather than cranio-caudal, direction relative to the umbilicus (Figure 3). This orientation of suture transfixion prevented the edge of the Parietex (Medtronic) mesh, closest to the ports, from moving with the subsequent placement of AbsorbaTack (Medtronic) fixation. The whole mesh was fixed to the anterior abdominal wall with AbsorbaTack (Medtronic) fixation tacks (Figure 4). The transfixion sutures were not tied, so as not to interfere with the subsequent abdominoplasty. Figure 1. View largeDownload slide The configuration of the laparoscopic hernia repair in relation to the planned abdominoplasty in a 41-year-old woman. Evidence of the hernia is visible at the umbilicus (A). The 5mm Kii Fios First Entry (Applied Medical) visual port in the left upper quadrant (B) and the two 5 mm working ports within the planned abdominoplasty markings (C) are also demonstrated. Figure 1. View largeDownload slide The configuration of the laparoscopic hernia repair in relation to the planned abdominoplasty in a 41-year-old woman. Evidence of the hernia is visible at the umbilicus (A). The 5mm Kii Fios First Entry (Applied Medical) visual port in the left upper quadrant (B) and the two 5 mm working ports within the planned abdominoplasty markings (C) are also demonstrated. Figure 2. View largeDownload slide A view of the anterior abdominal wall in a 41-year-old woman showing the hernia defect (A), the parietal peritoneum (B), and the free edge of the peritoneum after division of adhesions and reduction of the hernia (C). Figure 2. View largeDownload slide A view of the anterior abdominal wall in a 41-year-old woman showing the hernia defect (A), the parietal peritoneum (B), and the free edge of the peritoneum after division of adhesions and reduction of the hernia (C). Figure 3. View largeDownload slide A view of the mesh overlying the hernia defect, in a 41-year-old woman, and being held in position with the transfixion sutures (A). Figure 3. View largeDownload slide A view of the mesh overlying the hernia defect, in a 41-year-old woman, and being held in position with the transfixion sutures (A). Figure 4. View largeDownload slide Final position of the mesh, in a 41-year-old woman, with all AbsorbaTack (Medtronic) sutures in place. The mesh is overlying and demonstrating adequate overlap of the hernia defect. Figure 4. View largeDownload slide Final position of the mesh, in a 41-year-old woman, with all AbsorbaTack (Medtronic) sutures in place. The mesh is overlying and demonstrating adequate overlap of the hernia defect. The Abdominoplasty Technique After deflation of the abdomen, the abdominoplasty was performed in standard fashion, including excision of the umbilical stalk from the skin and dissection to the rectus sheath (Figure 5). A suprascarpa’s fascial dissection of the lower abdominal flap was performed, followed by dissection of a supramuscular epigastric tunnel, to allow full length exposure of the rectus divarication (Figure 6). Next an ON-Q Painbuster (Halyard Health, Alpharetta, GA) was laid along the midline from pubis to xiphisternum, followed by full length, wide rectus divarication repair by 2-layer plication using 1 V-Loc (Medtronic) polybutester barbed suture (Figures 7-8). The use of the ON-Q Painbuster (Halyard Health) is standard procedure for all our abdominoplasties and not related to any increased pain related to this procedure specifically. The abdominal flap was advanced and excess excised. Progressive tension sutures were placed, and final flap closure performed in two layers, superficial fascial system and dermal, again utilising V-Loc (Halyard Health) barbed sutures. Finally, the umbilicus was delivered through a carefully determined circular midline skin excision at the appropriate vertical position, and secured with both fascial and dermal sutures. A “neo-umbilicus” was not required in any of our cases, and would not be our preferred first option as, in our opinion, results in an inferior aesthetic umbilical appearance, and would only be considered in umbilical vascular compromise. Figure 5. View largeDownload slide A view of the abdomen of a 33-year-old woman, where a healthy umbilicus is visible after herniorrhaphy. Some AbsorbaTack (Medtronic) sutures, that have traversed the abdominal wall, can be seen surrounding the umbilicus (arrows). Figure 5. View largeDownload slide A view of the abdomen of a 33-year-old woman, where a healthy umbilicus is visible after herniorrhaphy. Some AbsorbaTack (Medtronic) sutures, that have traversed the abdominal wall, can be seen surrounding the umbilicus (arrows). Figure 6. View largeDownload slide View of the abdomen of a 41-year-old woman, demonstrating the umbilicus following herniorrhaphy (A), the rectus diastasis (B), and the preserved Scarpa’s fascia (C). Figure 6. View largeDownload slide View of the abdomen of a 41-year-old woman, demonstrating the umbilicus following herniorrhaphy (A), the rectus diastasis (B), and the preserved Scarpa’s fascia (C). Figure 7. View largeDownload slide A view of a 33-year-old woman, demonstrating the umbilicus after herniorrhaphy (A), the position of the ON-Q Painbuster (Halyard Health) (dashed line) and the start of the running V-Loc (Medtronic) rectus plication (B). Figure 7. View largeDownload slide A view of a 33-year-old woman, demonstrating the umbilicus after herniorrhaphy (A), the position of the ON-Q Painbuster (Halyard Health) (dashed line) and the start of the running V-Loc (Medtronic) rectus plication (B). Figure 8. View largeDownload slide Final view of the abdomen of a 41-year-old woman, demonstrating the umbilicus (A) following herniorrhaphy and completed rectus plication (B). Figure 8. View largeDownload slide Final view of the abdomen of a 41-year-old woman, demonstrating the umbilicus (A) following herniorrhaphy and completed rectus plication (B). RESULTS All patients were female, nonsmokers, and as can be seen in Table 1, were aged between 33 and 45 years (mean, 37.2 years) with a body mass index of 16.1 to 30.1 kg/m2 (mean, 23.8 kg/m2). Apart from one nulliparous and one primiparous woman, all were multiparous (2-4) and had moderate to large umbilical herniae with rectus divarication from 35 to 80 mm (mean, 53.5 mm). The laparoscopic herniorrhaphy took between 18 and 35 minutes (mean, 25.9 minutes) to complete. At 12-month follow up, there were no instances of umbilical necrosis, wound complications, seroma, or hernia recurrence (Figure 9). Table 1. Individual Patient Measurements and Results Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Age (years) 33 33 40 33 41 34 37 34 45 42 Parity 4 3 4 2 1 2 2 1 3 2 BMI (kg/m2) 25 19.7 26.7 25.7 26 30.1 22.5 23.2 23 16.1 Rectus divarication (mm) 70 55 40 40 60 75 40 35 80 40 Laporoscopic time (min) 30 25 27 25 32 28 28 18 26 20 Length of follow-up (months) 12 12 12 12 12 12 12 12 12 12 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Age (years) 33 33 40 33 41 34 37 34 45 42 Parity 4 3 4 2 1 2 2 1 3 2 BMI (kg/m2) 25 19.7 26.7 25.7 26 30.1 22.5 23.2 23 16.1 Rectus divarication (mm) 70 55 40 40 60 75 40 35 80 40 Laporoscopic time (min) 30 25 27 25 32 28 28 18 26 20 Length of follow-up (months) 12 12 12 12 12 12 12 12 12 12 View Large Table 1. Individual Patient Measurements and Results Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Age (years) 33 33 40 33 41 34 37 34 45 42 Parity 4 3 4 2 1 2 2 1 3 2 BMI (kg/m2) 25 19.7 26.7 25.7 26 30.1 22.5 23.2 23 16.1 Rectus divarication (mm) 70 55 40 40 60 75 40 35 80 40 Laporoscopic time (min) 30 25 27 25 32 28 28 18 26 20 Length of follow-up (months) 12 12 12 12 12 12 12 12 12 12 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Age (years) 33 33 40 33 41 34 37 34 45 42 Parity 4 3 4 2 1 2 2 1 3 2 BMI (kg/m2) 25 19.7 26.7 25.7 26 30.1 22.5 23.2 23 16.1 Rectus divarication (mm) 70 55 40 40 60 75 40 35 80 40 Laporoscopic time (min) 30 25 27 25 32 28 28 18 26 20 Length of follow-up (months) 12 12 12 12 12 12 12 12 12 12 View Large Figure 9. View largeDownload slide (A, C) Preoperative and (B, D) 12-month postoperative photographs of a 45-year-old woman. The umbilical hernia and sequelae of wide rectus divarication are evident preoperatively. The postoperative neo-umbilicus shows no sign of vascular compromise. Figure 9. View largeDownload slide (A, C) Preoperative and (B, D) 12-month postoperative photographs of a 45-year-old woman. The umbilical hernia and sequelae of wide rectus divarication are evident preoperatively. The postoperative neo-umbilicus shows no sign of vascular compromise. DISCUSSION Umbilical hernia accounts for up to 14% of all hernia repairs5,6 and its incidence is associated with multiparity, obesity, heavy lifting, ascites, coughing, and straining.1 Patients presenting for abdominoplasty often have concurrent umbilical herniae that, although frequently asymptomatic, contribute to the anterior abdominal musculo-fascial deficit and aesthetic concern. Many patients request concurrent repair of these herniae. With large or complicated umbilical herniae, this may present a surgical challenge and there is a risk of umbilical stalk necrosis or recurrence of the hernia.7 The umbilicus is formed as the remnant cicatrix of various tubed structures required during foetal circulation. These include the round ligament (umbilical vein), median umbilical ligament (urachus), and medial umbilical ligaments (foetal umbilical arteries).8,9 In the adult, it relies on two principle routes for its blood supply; firstly, via the umbilical stalk and secondly via the dermal plexus. Traditional abdominoplasty and open umbilical herniorrhaphy therefore present a “vascular challenge” since, if performed concurrently, they will completely devascularize the umbilical stalk. There is a paucity of data on the incidence of umbilical necrosis in abdominoplasty, with or without concurrent hernia repair. In a retrospective review of 1008 abdominoplasty patients, Neaman et al found a 0.2% incidence of umbilical necrosis and a 0.9% umbilical revision rate.7 Garcia-Garcia et al found a 4.2% umbilical necrosis rate in 72 postbariatric surgery patients undergoing abdominoplasty,10 while Koolen et al found that wound complications were more common in patients undergoing concurrent abdominoplasty and ventral/umbilical hernia repair (11.7%) compared to abdominoplasty alone (6.3%).11 Nevertheless, several authors have presented techniques that aim to address this challenge and mitigate the associated risks. Neinstein et al describe a lateral approach to the hernia, leaving the contralateral blood supply to the umbilicus uninterrupted. A Ventralex (Medline, Northfield, Ill) patch is used to repair the defect.4 McKnight et al also describe a lateral approach, but dissects in a preperitoneal and retro-rectus plane.3 After reduction of the hernia, a lightweight polypropylene mesh is laid on the defect and sutured in place. Bruner et al approach the hernia through a midline laparotomy incision that starts 2 cm inferior to the umbilicus. After reduction of the hernia, the defect is repaired with interrupted nonabsorbable monofilament sutures.2 Approaching the umbilical stalk laterally necessarily reduces the blood supply along the umbilical stalk and incisions in the linea alba may predispose to future incisional herniae, while dissecting in the retro-rectus space risks damage to umbilical perforators. Placing mesh through an open approach risks wound related complications due to the overlying umbilical suture line.12 A laparoscopic approach circumvents these concerns by avoiding dissection of the umbilical stalk, linea alba, or deep inferior epigastric artery perforators. It provides excellent visualization of both the abdominal wall defect and the hernia sac and allows for placement of a sizeable, intraperitoneal mesh with an adequate 3 to 4 cm overlap,13 while providing the added benefit of separating the mesh from any surgical wounds.12 Umbilical herniae can be treated by either a primary suture repair or a repair with mesh. A randomized clinical trial, performed by Arroyo et al, to compare primary open suture repair with open mesh repair, found a significantly lower recurrence rate (1% vs 11%) in the mesh repair group at a mean follow up of 64 months.14 Similarly, Sanjay et al conducted a retrospective series that found lower recurrence rates in mesh repair when compared to suture repair (0% vs 11.5%, P > 0.007).15 A meta-analysis by Aslani and Brown16 as well as the latest guidelines from the International Endohernia Society suggests that all abdominal wall herniae should have a mesh repair, regardless of the size of the defect.17 From the available evidence it is clear that the use of a mesh is associated with decreased hernia recurrence. When applying this evidence to abdominoplasty patients, it is important to remember that the suture repairs are usually accompanied by additional reinforcement in the form of a rectus plication. The effect of this plication on hernia recurrence has not yet been quantified, but in a systematic literature review, Hickey et al found varying rates (0% to 40%) of rectus diastasis recurrence following plication18 while Al-Qattan found a 100% recurrence rate in 20 grand multiparous patiens.19 This large range may be due to differences in technique between surgeons. Cheesborough20 and Lincenberg21 posit that recurrence is likely related to suture pull though and advocate for reinforcement with a large retro-rectus mesh. Further research comparing techniques of rectus plication and their specific effect on hernia recurrence are needed. Maintaining vascular supply to the umbilicus is critical during abdominoplasty procedures. It is therefore advantageous to minimize dissection that may compromise this supply. Current recommendations advocate for the use of a synthetic mesh to reinforce ventral hernia repairs of defects greater than 3 cm diameter.13,22 Primary repair of ventral herniae >4 cm has a recurrence rate of 52% when compared to 25% in hernia <4 cm diameter.23,24 Using an open approach to place a mesh that has an adequate 3 to 4 cm overlap in order to take advantage of Pascal’s principle and Laplace’s law, while maintaining adequate umbilical vasculature, may become challenging in patients with large or complex herniae. By combining a laparoscopic hernia repair with a conventional abdominoplasty, the patient benefits from an uncompromising herniorrhaphy, whilst the plastic surgeon is able to perform their usual abdominoplasty with added peace of mind that the umbilical blood supply has not been unduly compromised. During the rectus plication, the previously secured retroperitoneal mesh may be brought together in a way that could cause it bunch in certain areas. This phenomenon would be similar in open repair with mesh, but because the laparoscopic mesh is secured deep to the parietal peritoneum it would still act to separate the abdominal contents from the hernia defect. The Parietex (Medtronic) mesh is very thin and has not been palpable nor caused any discomfort or contour irregularity in any of our patients. There is a lack of large randomized control trials that compare recurrence rates between laparoscopic and open umbilical hernia repairs. In a review of 253 ventral hernia repairs over 3 years, Ramshaw et al found that, at an average of 21 months follow up, there was a 20.7% recurrence rate in open repair with mesh compared to a 2.5% recurrence rate in the laparoscopic group.25 Similarly, Gonzalez et al reviewed 76 patients and found a lower recurrence rate in laparoscopic hernia repairs (0%) when compared to open repair with mesh (20%).22 Interestingly, Gonzalez et al concludes that patients with larger herniae (>3 cm) benefited from a laparoscopic approach, a view that is echoed by Earle and McLennan.26 Lau et al, in a review of 102 patients, did not find a significant difference in the recurrence rates between open mesh and laparoscopic hernia repairs, but both techniques were superior to primary suture repair.13 A recent literature review by Kulaçoğlu also found no significant difference between laparoscopic and open hernia repair with mesh.27 A laparoscopic approach is recommended in incisional herniae, incarcerated herniae, where multiple defects are suspected, in cases where the defect is >4 cm in diameter and in obese patients.26,28,29 There may be concerns regarding peritoneal inflation during herniorrhaphy and its effect upon subsequent skin excision during the abdominoplasty. In our experience, insufflation in these patients demonstrates an enhanced view, as the rectus divarication allows additional expansion. It should be expected that a small amount of residual gas will remain in the peritoneal cavity, but insufflation time is short, between 15 and 30 minutes in all cases, and the skin rapidly returns to normal with deflation, without resulting in any apparent technical or clinical compromise for the abdominoplasty. Patients who have a large amount of visceral fat may present with umbilical hernias that are more difficult to repair when compared with those who are quite deflated and have redundant abdominal wall laxity to aid with the repair. In our cohort of patients, with a mean BMI of 23.8, we did not encounter this problem, but we believe that a laparoscopic repair with mesh would provide a more robust repair than an open repair, due to the improved accuracy of mesh placement as well as the ability to place a wider mesh in order to distribute tension more broadly. Increasing operative time is associated with increased morbidity.30,31 In our study the average time for laparoscopic herniorrhaphy was 25 min. Although not statistically significant, Gonzalez et al found, that open repair with mesh, took on average 20 minutes longer than a laparoscopic repair, but that primary suture repair was 25 minutes faster than laparoscopic repair.22 From our results and the work of Gonzalez et al, it is evident that in experienced hands, a laparoscopic repair does not add significantly to the overall operative time. The slight increase in morbidity related to a prolonged operative time needs to be weighed against the risk of two independent procedures. There is some scientific debate regarding the safety and efficacy of combined surgeries. Combination abdominoplasty and gynecological surgery has been extensively studied with some smaller early studies suggesting an increase in operative time and postoperative complications.32-34 This is in contrast to the most recent study, by Sinno et al, who compared 25 consecutive patients undergoing combined abdominoplasty and gynecological surgery (hysterectomy ± salpingo-oopherectomy) between 2000 and 2009 with two control groups who underwent these procedures separately.35 They found statistically significant reductions in overall operative time, estimated blood loss and, total days of hospitalization when compared to the sum of the two control groups. These results suggest an overall benefit from combined surgery in appropriately selected patients and echoes similar findings by Gemperli et al, who performed the largest consecutive series to date.36 The results may also reflect improvements in surgical technique and preoperative care since the early studies that were published in the mid-1980s. There may also be financial implications related to combining an aesthetic procedure like abdominoplasty which would not attract insurance coverage with a hernia repair that would normally be covered by health insurance. It is important to perform a proper financial consent with all patients prior to any elective surgery and encourage them to check their out of pocket estimate with their insurance company prior to committing to an operation. This study is limited by its small cohort size and lack of a control group, but it serves to present a safe technique that addresses large umbilical herniae during abdominoplasty in accordance with current guidelines. As case numbers increase it may be illuminating to compare the short and long-term outcomes of these patients with those treated with an open hernia repair. CONCLUSION Umbilical herniae present a vascular challenge when performing abdominoplasty. Open surgical techniques have been described to address this challenge, but they rely on a compromise in the blood supply via the umbilical stalk or in the integrity of the anterior abdominal wall. According to current recommendations, small herniae (<3 cm) may be adequately treated by primary suture repair, but larger, more complex herniae are more appropriately treated by repair with mesh. A laparoscopic hernia repair minimizes vascular compromise of the umbilical stalk, while allowing a gold-standard hernia repair with minimal scarring of the abdominal wall and importantly, allows for a routine abdominoplasty to follow. Although adding to the overall operating time, this needs to be weighed against the time and morbidity of two separate procedures and anesthetics. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Halm JA, Heisterkamp J, Veen HF, Weidema WF. Long-term follow-up after umbilical hernia repair: are there risk factors for recurrence after simple and mesh repair. Hernia . 2005; 9( 4): 334- 337. Google Scholar CrossRef Search ADS PubMed 2. Bruner TW, Salazar-Reyes H, Friedman JD. 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Aesthetic Surgery Journal – Oxford University Press
Published: Apr 20, 2018
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