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Adult Umbilical Hernia Repair

Adult Umbilical Hernia Repair

AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION Adult Umbilical Repair

Benefits and Risks of Your Operation Patient Education B e n e fi t s — An operation is the only way This educational information is to repair a hernia. You can return to your to help you be better informed normal activities and in most cases will about your operation and not have further discomfort. empower you with the skills and Risks of not having an operation—Your knowledge needed to actively Location hernia may cause and increase in participate in your care. size. If your intestine becomes squeezed The Condition in the hernia pouch, you will have sudden Keeping You pain, , and require an immediate An umbilical hernia occurs when a tissue operation. Informed bulges out through an opening in the muscles on the near the Possible risks include return of the Information that will help you or belly button (umbilicus). About 10% of hernia; infection; injury to the bladder, further understand your operation abdominal are umbilical hernias.1 blood vessels, intestines, or nerves; and and your role in recovery. continued pain at the hernia site. Common Symptoms Education is provided on: ● Visible bulge on the abdomen, Overview ...... 1 especially when coughing or straining Expectations Condition, Symptoms, Tests ...... 2 ● Pain or pressure at the hernia site Before your operation—Evaluation Treatment Options…...... 3 may include blood tests, urinalysis, and Risks and ultrasound. Your surgeon and Possible Complications ...... 4 Treatment Options provider will discuss your health history, Preparation Surgical Procedure home medications, and pain control and Expectations ...... 5 options. Open hernia repair—An incision is made Your Recovery near the site. Your surgeon will repair the The day of your operation—You will and Discharge ...... 6 hernia with mesh or by suturing (sewing) not eat or drink for six hours before the Pain Control...... 7 the muscle layer closed. operation. Most often, you will take your Glossary/References ...... 8 normal medication with a sip of water. You Laparoscopic hernia repair—The hernia will need someone to drive you home. is repaired with mesh or sutures inserted through instruments placed into small Your recovery—For a simple repair, you incisions in the abdomen. may go home the same day. You will need to stay longer for complex repairs.4 Nonsurgical Procedure Call your surgeon if you have severe pain, Watchful waiting is generally not cramping, chills or a high recommended for adults with an umbilical (over 101°F or 38.3°C), odor or increased hernia. You may be able to wait to repair drainage from your incision, or no bowel umbilical hernias that are very small, movements for three days. reducible (can be pushed back in) and not uncomfortable.2 There is a risk of the intestines being squeezed in the hernia pouch and blood supply being cut off (strangulation). If this happens, you will need an immediate operation.3

This first page is an overview. For more detailed information, review the entire document.

AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation The Condition, Symptoms, Umbilical Hernia Repair and Diagnostic Tests SAMPLE

Intestines Keeping You Informed Umbilical Hernia Bulge Who Gets an Umbilical Hernia? Ten percent of all hernias in adults are umbilical.2 Umbilical hernias can Abdominal Muscle suddenly bulge out. They occur more often (Abdominal Lining) in adults over 60 years when the muscles Hernia Location start to weaken.5 Internal View Some risk factors are: The Condition Symptoms • Older age—muscles An umbilical hernia occurs when part of The most common symptoms are: become weaker the intestine or fatty tissue bulges through ● Bulge in the abdominal area that often • Overweight and the muscle near the belly button (navel, increases with coughing or straining —increased umbilicus). Most (9 of 10) umbilical hernias weight places in adults are acquired. This means that ● Pain or pressure at the hernia site pressure on increased pressure near the umbilicus ● Increasing sharp and abdominal muscle causes the umbilical hernia to bulge out. vomiting can mean that the hernia is • Chronic straining A reducible hernia can be pushed back strangulated. This is a surgical emergency • Family history into the opening or decrease in size when and immediate treatment is needed. lying flat. When intestine or abdominal • : excess fluid tissue fills the hernia sac and cannot in the space between be pushed back, it is irreducible or 4 the tissues lining Common Diagnostic Tests incarcerated. A hernia is strangulated if the abdomen and the intestine is trapped in the hernia pouch History and Physical Exam abdominal organs; and the blood supply to the intestine is Checks for the presence of bulge may be due to cut off. This is a surgical emergency.3 alcoholism Additional Tests (see Glossary) Herniorrhaphy is the surgical repair of a hernia. • , Other tests may include: particularly multiple Hernioplasty is surgical repair of a hernia with mesh inserted to reinforce the weak area. ● Ultrasound ● Computerized tomography (CT) scan Pregnancy ● Blood tests Considerations ● Urinalysis The repair of umbilical ● Electrocardiogram (ECG)–for patients hernias during over 45 or if high risk of heart problems pregnancy is considered only if the hernia becomes incarcerated or strangulated.2

2 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Surgical and Umbilical Hernia Repair Nonsurgical Treatment

Mesh Repair Sutured Muscle Repair

Laparoscopic Repair Open Repair

● Your surgeon may inject a local anesthetic Keeping You Surgical Treatment around the hernia repair site to help The type of operation depends on control pain. Informed hernia size and location, and if it is a ● With complex or large hernias, small Open versus repeat hernia (recurrence). Your health, drains may be placed going from inside to age, and the surgeon’s expertise are the outside of the abdomen. Laparoscopic Repair also important. An operation is the There is no signifi cant evidence only treatment for a hernia repair. Laparoscopic Hernia Repair on the best technique to repair an The surgeon will make several small umbilical hernia, and more study Your hernia can be repaired either as is needed. The type of repair may punctures or incisions in the abdomen. Ports an open or laparoscopic approach. also depend on the size of the or trocars (hollow tubes) are inserted into The repair can be done by using sutures hernia. the openings. Surgical tools and a lighted only or adding a piece of mesh. camera are placed into the ports. The • When comparing open mesh repair with laparoscopic mesh Open Hernia Repair abdomen is infl ated with carbon dioxide repair, there is no diff erence The surgeon makes an incision near the gas to make it easier for the surgeon to in the length of hospital stay hernia site, and the bulging tissue is gently see the hernia. Mesh may be sutured or or recurrence rate. There is a slightly lower wound pushed back into the abdomen. Sutures fi xed with staples to the muscle around the hernia site. The port openings are closed rate, including or mesh are used to close the muscle. seromas, hematomas, and with sutures, surgical clips, or glue. infection, with laparoscopic ● For a suture-only repair: The hernia sac is repair.6, 8 Both types of removed. Then the tissue along the muscle operations have similar edge is sewn together. The umbilicus Nonsurgical Treatment long- term results. is then fi xed back to the muscle. This procedure is often used for small defects.6 Watchful waiting is not usually recommended • Open repairs can be done except for very small umbilical hernias.7 A with local anesthesia instead of general anesthesia and are ● For an open mesh repair: The hernia surgical repair is recommended for adults sac is removed. Mesh is placed beneath frequently done as outpatient who have symptoms, incarceration, thinning procedures. the hernia site. The mesh is attached of the skin, or uncontrollable ascites. using sutures sewn into the stronger • Strangulated hernias may tissue surrounding the hernia. The mesh Because abdominal muscles weaken with have to be repaired as an extends 3 to 4 cm beyond the edges of age, the hernia can increase in size, and there open approach. the hernia. The umbilicus is fi xed back is a risk of incarceration and strangulation.2 • The use of mesh provides a to the muscle. Mesh is often used for Abdominal binders that apply pressure and stronger repair and decreases large hernia repairs and reduces the risk push back the bulge will not repair the hernia. the rate of recurrence.9 that the hernia will come back again. • Suture repair will result in ● For all open repairs, the skin site is closed a small incision around the using sutures, staples, or surgical glue. hernia site. Laparoscopic repairs usually have 3 to 4 smaller ● An open repair may be done with at the site of the entry ports. local anesthesia and sedation given through an IV. 3 Umbilical Hernia Repair Risks of this Procedure SAMPLE

Risks Based on the ACS Risk Calculator Open and Laparoscopic Umbilical Hernia from the ACS Risk Calculator – April 7, 2016

Percent for Risks Keeping You Informed Average Patient

Wound Infection: Infection at the Open 1.2% Antibiotics and drainage of the wound may be needed. can area of the incision or near the Laparoscopic 0.9% increase the risk of infection. where the surgery was performed

Complications: Including surgical Open 2.2% Complications related to general anesthesia and surgery may be higher in infections, breathing difficulties, Laparoscopic 3.4% smokers, elderly and/or obese patients, and those with high blood pressure blood clots, renal (kidney) and breathing problems. Wound healing may also be decreased in smokers complications, cardiac complications, and those with diabetes and immune system disorders. and return to the operating room

Pneumonia: Infection in the lungs Open 0.1% Movement, deep breathing, and stopping smoking can help prevent Laparoscopic 0.2% respiratory infections.

Urinary tract infection: Infection of Open 0.1% Drinking fluids and catheter care decrease the risk of bladder infection. the bladder or kidneys Laparoscopic 0.4%

Venous thrombosis: A blood clot in Open 0.1% Longer surgery and bed rest increase the risk. Getting up, walking 5 to 6 the legs that can travel to the lungs Laparoscopic 0.3% times per day, and wearing support stockings reduce the risk.

Death Less than 1% Your surgical team is prepared for all emergency situations.

Risks from Outcomes Reported Percent for Keeping You Informed in the Last 10 years of Literature Average Patient

Immediate postoperative pain There is no difference The laparoscopic approach avoids a long incision. There may be a feeling in pain scores when of tightness in your abdomen because the muscle has been pulled comparing suture vs. mesh together. Your pain will be managed with nonsteroidal anti-inflammatory vs. laparoscopic repair by medications and by resting and avoiding straining or lifting. postoperative day 3 6

Recurrence: A hernia can recur after Suture repairs 0% to 14% The use of mesh or other type of patch repair appears to reduce the rate 11 the repair Mesh repairs 0% to 3% 10 of recurrence. Obesity, diabetes, and smoking can affect wound healing and increase recurrence rates.12 Laparoscopic repair is recommended for recurrent hernias because the surgeon avoids previous tissue and larger hernias.13-14 There is a higher rate of recurrence in older men with laparoscopic repair.

Seroma: A collection of clear/yellow Open & Laparoscopic Seromas can form around the former hernia site. Removal of fluid with a fluid Suture repairs 50 of 1,000 sterile needle may be required. Mesh repairs 60 of 1,000 9

Hematoma: a collection of blood in No difference in the Hematomas are treated with anti-inflammatory medications, elevation, and the wound site or occurrence rate between rest. Most will resolve on their own over time. suture and mesh repair The data have been averaged per 1,000 cases

The ACS Surgical Risk Calculator estimates the risk of an unfavorable outcome. Data is from a large number of patients who had a surgical procedure similar to this one. If you are healthy with no health problems, your risks may be below average. If you smoke, are obese, or have other health conditions, then your risk may be higher. This information is not intended to replace the advice of a doctor or health care provider. To check your risks, go to the ACS Risk Calculator at http://riskcalculator.facs.org.

4 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Expectations: Preparation Umbilical Hernia Repair for Your Operation

What to Bring Preparing for Your Operation ●● Insurance card and identification Questions Home Medication ●●Advance directives (see glossary) to Ask Bring a list of all of the medications, vitamins, ●●List of medicines and any over-the-counter medicines that About my you are taking. Your medications may have ●●Loose-fitting, comfortable clothes Operation: to be adjusted before your operation. Some ●●Slip-on shoes that don’t require • What are the side medications can affect your recovery and that you bend over effects and risks response to anesthesia. Most often, you will take of anesthesia? your morning medication with a sip of water. ●●Leave jewelry and valuables at home • What technique Anesthesia What You Can Expect will be used to repair the hernia? Let your anesthesia provider know if you have An identification (ID) bracelet and allergy bracelet (Laparoscopic or allergies, neurologic disease (epilepsy, stroke), with your name and hospital/clinic number will open? Mesh or heart disease, stomach problems, lung disease be placed on your . These should be checked with sutures?) (asthma, emphysema), endocrine disease (diabetes, by all health team members before they perform thyroid conditions), or loose teeth; use alcohol or any procedures or give you medication. Your • What are the risks drugs; take any herbs or vitamins; or if you have a surgeon will mark and initial the operation site. of this procedure history of and vomiting with anesthesia. for me? Fluids and Anesthesia • Will you be If you smoke, you should let your surgical team An intravenous line (IV) will be started to performing the know, and you should plan to quit. Quitting before give you fluids and medication. For general entire operation your surgery can decrease your rate of respiratory anesthesia, you will be asleep and pain free yourself? and wound complications. Quitting also increases during the operation. A tube may be placed your chances of staying smoke-free for life. Resources • What level of pain down your to help you breathe during to help you quit may be found at www.facs.org/ should I expect, the operation. For spinal anesthesia, a small patienteducation or www.lungusa.org/stop-smoking. and how will it needle with medication will be placed in your be managed? back alongside your spinal column. You will be Length of Stay • How long will it awake during the operation but pain-free. If you have local anesthesia, you will usually go be before I can home the same day. You may stay overnight After Your Operation return to my normal if you have a repair of a large or incarcerated activities (work, You will be moved to a recovery room where your hernia. A laparoscopic repair may result in a driving, lifting)? heart rate, breathing rate, oxygen saturation, longer anesthesia time. Complications such as blood pressure, and urine output will be closely severe nausea and vomiting or an inability to watched. Be sure that all visitors wash their . pass urine may also result in a longer stay. Preventing Pneumonia and Blood Clots Movement and deep breathing after your The Day of Your Operation operation can help prevent postoperative ●● You should not eat or drink for at least complications such as blood clots, fluid in 6 hours before the operation. your lungs, and pneumonia. Every hour, take 5 to 10 deep breaths and hold each ●●You should bathe or shower and clean your breath for 3 to 5 seconds. abdomen, especially around the umbilical area, with a mild antibacterial soap. When you have an operation, you are at risk of getting blood clots because of not moving ●●You should brush your teeth and rinse during anesthesia. The longer and more your mouth with mouthwash. complicated your surgery, the greater the risk. ●●Do not shave the surgical site; the surgical This risk is decreased by getting up and walking team will clip the near the incision site. 5 to 6 times per day, wearing special support stockings or compression boots on your legs, and, for high-risk patients, taking a medication that thins your blood.

5 Umbilical Hernia Repair Your Recovery and Discharge SAMPLE

Keeping You Your Recovery Informed and Discharge Thinking Clearly High-Fiber Foods If general anesthesia is given or if you are Foods high in fi ber include beans, taking narcotics for pain, it may cause you Handwashing Steri-Strips® bran cereals and whole-grain to feel diff erent for 2 or 3 days. You may breads, peas, dried fruit (fi gs, have trouble remembering and feel tired. Wound Care apricots, and dates), raspberries, You should not drive, drink alcohol, or ● Always wash your hands before and blackberries, strawberries, make any big decisions for at least 2 days. sweet corn, broccoli, baked after touching near your incision site. potatoes with skin, plums, pears, Nutrition ● Do not soak in a bathtub until your apples, greens, and nuts. ● When you wake up from the anesthesia, stitches, Steri-Strips®, or staples are you will be able to drink small amounts removed. You may take a shower of liquid. If you do not feel sick, you after the second postoperative can begin eating regular foods. day unless you are told not to. ● Continue to drink about 8 to 10 ● Follow your surgeon’s instructions on glasses of water each day. when to change your bandages. ● Eat a high-fi ber diet so you don’t strain ● A small amount of drainage from the while having a bowel movement. incision is normal. If the dressing is soaked with blood, call your surgeon. Activity ● If you have Steri-Strips in place, Slowly increase your activity. Be sure ● they will fall off in 7 to 10 days. to get up and walk every hour or so to prevent blood clot formation. ● If you have a glue-like covering over the incision, allow the glue to fl ake off on its own. ● You may go home the same day for a simple repair. If you have other health ● Avoid wearing tight or rough clothing. conditions or complications, such as It may rub against your incisions and nausea, vomiting, , or infection make it harder for them to heal. after surgery, you may stay longer. ● Protect the new skin, especially Work and Return to School from the sun. The sun can burn and cause darker scarring. ● After recovery, you can usually return to work within 2 to 3 days. ● Your scar will heal in about 4 to 6 weeks and will become softer and ● You will not be able to lift anything continue to fade over the next year. over 10 pounds, climb, or do strenuous activity for 4 to 6 weeks following Pain surgical repair of an umbilical hernia. The amount of pain is diff erent for each ● Lifting limitation may last for 6 months person. The new medicine you will need for complex or recurrent repairs.2 after your operation is for pain control, and Do not lift anything your doctor will advise how much you should over 10 pounds. Bowel Movements take. You can use throat lozenges if you A gallon of milk have sore throat pain from the tube placed weighs 9 pounds. Avoid straining with bowel movements by increasing the fi ber in your diet with high- in your throat during your anesthesia. fi ber foods or over-the-counter medicines (like Metamucil® and FiberCon®). Be sure you are drinking 8 to 10 glasses of water each day.

6 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Umbilical Hernia Repair

Narcotic (Opioid) Pain Medication When to Contact Narcotics or opioids are used for severe Your Surgeon pain. Possible side effects of narcotics are Contact your surgeon if you have: sleepiness, lowered blood pressure, heart rate, and breathing rate; skin rash and ●●Pain that will not go away itching; ; nausea; and difficulty ●●Pain that gets worse urinating. Some examples of narcotics include morphine, oxycodone (Percocet®/Percodan®), ●●A fever of more than 101°F (38.3°C) and hydromorphone (Dilaudid®). Medications ●●Repeated vomiting can be given to control many of the side effects of narcotics. ●●Swelling, redness, bleeding, or foul- smelling drainage from your wound site Pain Control without Medication ●●Strong or continuous abdominal Distraction helps you focus on other activities pain or swelling of your abdomen instead of your pain. Listening to music, playing games, or other engaging activities ●●No bowel movement by 3 days can help you cope with mild pain and anxiety. after the operation Splinting your stomach by placing a pillow over your abdomen with firm pressure before coughing or Pain Control Splinting Your Stomach movement can help reduce the pain. Everyone reacts to pain in a different way. A scale from 0 to 10 is used to measure pain. Guided imagery helps you direct and At a “0,” you do not feel any pain. A “10” is control your emotions. Close your eyes the worst pain you have ever felt. Following and gently inhale and exhale. Picture a laparoscopic procedure, pain is sometimes yourself in the center of somewhere felt in the . This is due to the gas beautiful. Feel the beauty surrounding inserted into your abdomen during the you and your emotions coming back to procedure. Moving and walking help to your control. You should feel calmer. decrease the gas and the shoulder pain. Extreme pain puts extra stress on your body at a time when your body needs to focus on healing. Do not wait until your pain has OTHER INSTRUCTIONS: reached a “10” or is unbearable before telling your provider. It is much easier to control pain Distraction before it becomes severe. Non-Narcotic Pain Medication Most non-opioid analgesics are classified as non-steroidal anti-inflammatory drugs FOLLOW-UP APPOINTMENTS (NSAIDs). They are used to treat mild pain and or combined with narcotics WHO: to treat severe pain. Possible side effects of NSAIDs are stomach upset, bleeding in the digestive tract, and fluid retention. These DATE: side effects usually are not seen with short- term use. Let your doctor know if you have heart, kidney, or problems. Examples PHONE: of NSAIDs include ibuprofen, Motrin®, Aleve®, and Toradol® (given as a shot). Guided imagery

7 Umbilical Hernia Repair More Information SAMPLE

For more information, please go to the American College of Surgeons Patient Education website at www.facs.org/patienteducation. For a complete review of hernia repair, consult Selected Readings in , “Hernia” 2015 Vol. 41 No. 7 at www.facs.org/SRGS. GLOSSARY REFERENCES Abdominal X ray: Checks for any Electrocardiogram (ECG): Measures The information provided in this report is chosen from recent loops of bowel or air-filled sacs. the rate and regularity of heartbeats, articles based on relevant clinical research or trends. The research the size of the heart chambers and below does not represent all that is available for your surgery. Ask Abdominal ultrasound: Sound any damage to the heart. your doctor if he or she recommends that you read any additional waves are used to determine the research. location of deep structures in the General anesthesia: A treatment body. A roller is placed on top with certain medicines that puts you 1. Klinge U, Prescher A, Klosterhalfen B et al. Entstehung und of clear gel and rolled across the into a deep sleep so you do not feel Pathosphysiolgie der Bauchwanddefekte. Der Chirurg. 1997;68:293. abdomen. pain during surgery. 2. Muschaweck U in Umbilical and epigastric hernia repair, Ascites: Excess fluid in the space Hematoma: A collection of blood that Surgical Clinics of North America. 2003;1207-1221. between the tissues lining the has leaked into the tissues of the skin 3. Malangoni MA, Rosen MD. Hernias. In: CM Townsend, RD abdomen and abdominal organs; or in an organ, resulting from cutting Beauchamp, et al. Textbook of Surgery. Philadelphia, PA. Saunders, may be due to alcoholism or liver in surgery or the blood’s inability to 2008. disease. form a clot. 4. Weinstein PR, Hoff JT. Hernias and Other Abdominal Lesions of the Advance directives: Documents Incarceration: The protrusion or . Current Surgical Diagnosis and Treatment. Eds. L.W. signed by a competent person constriction of an organ through Way and Gerald M. Doherty. 11th ed. New York: McGraw-Hill, 2004. giving direction to health care the wall of the cavity that normally 783-796. providers about treatment choices. contains it. 5. “Strangulated Hernia” retrieved from http://medicaldb.blogspot. Blood tests: Tests usually include a Local anesthesia: The loss of com/2011/01strangulated-hernia.html. Chem-6 profile (sodium, potassium, sensation only in the area of the body chloride, carbon dioxide, blood where an anesthetic drug is applied or 6. Lau H, Patil NG. Umbilical Hernia in Adults, Surgical . urea nitrogen and creatinine) and injected. 2003;17:2016-2220. complete blood count (red blood Seroma: A collection of serous 7. Greenfield’s surgery: Scientific principles and practice. Eds, cell and white blood cell count). (clear/yellow) fluid. Mulhollan M et al. Lippincott Williams & Wilkins, 2011. Pp. 1131. Computerized tomography (CT) 8. Solomon TA, Wignesvaran P, Chaudry MA, Tutton MG. Surgical Strangulation: Part of the intestine or scan: A diagnostic test using X ray Endoscopy. 2010;24:3109-3112. fat is squeezed in the hernia sac, and and a computer to create a detailed, blood supply to the tissue is cut off. 9. Arroyo A, García P, Pérez F, Andreu J, Candela F, Calpeña R. three-dimensional picture of your Randomized clinical trial comparing suture and mesh repair of abdomen. A CT scan normally takes Urinalysis: A visual and chemical umbilical hernia in adults. British Journal of Surgery. about 15 minutes or less. examination of the urine, most 2001;88:1321-1323. often used to screen for urinary tract infections and kidney disease. 10. Earle DB, McLellan JA. Repair of umbilical and epigastric hernias. The Surgical Clinics of North America. 2013;93(5):1057-1089.

11. Arslani N, Patrlj L, Kopljar M, Rajkovic Z, Altarac S, Papes D, Stritof D. DISCLAIMER Advantages of new materials in fascia transversalis reinforcement for repair. Hernia. 2010;14(6):617-21. The American College of Surgeons (ACS) is a scientific and educational association of surgeons that was founded in 1913 to 12. Martin DF, Williams RF, Mulrooney T, Voeller GR. Ventrelex mesh in umbilical/epigastric hernia repairs; clinical outcomes and improve the quality of care for the surgical patient by setting high complications. Hernia. 2008;379-383. standards for surgical education and practice. The ACS endeavors to provide procedure education for prospective patients and 13. Wright BE, Becerman J, Cohen M, Cumming JK, Rodriquez JL. those who educate them. It is not intended to take the place of Is laparoscopic umbilical hernia repair with mesh a reasonable a discussion with a qualified surgeon who is familiar with your alternative to conventional repair? The American Journal of Surgery. 2002;184:505-509. situation. The ACS makes every effort to provide information that is accurate and timely, but makes no guarantee in this regard. 14. Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia after laparoscopic surgery: A qualitative systematic review. Hernia. 2011;15:113-121. Reviewed April 2016 by: Nancy Strand, MPH, RN Mark Malangoni, MD, FACS Brian Heniford, MD, FACS

8 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation

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