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7/23/2019 Surgical Case Study: Cranioplasty
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E. Enp|d`vcpedn
K sv|hf|u es dnf dg pof adsp sp|fssgvm z|dcf`v|fs k zkpefnp cdvm` vn`f|hd. Pof|f
k|f nvaf|dvs puzfs dg sv|hf|efs- fkco dnf pkemd|f` pd gep k cf|pken zv|zdsf- aku ep lf pd
`fmewf| k coem` / e.f. cfsk|fkn sfcpedn%- |fadwf k zk|p / e.f. c|knefcpdau%- pd wesvkmerf kn`
hken kccfss pd k sp|vcpv|f xepoen / e.f. c|knedpdau% d| pd |fzke| k `fgfcp / e.f. c|knedzmkspu%.
Poes es k cksf dg Akspf| Mkl|k`d|- \kmzo- ;< ufk|s dm`- xod xks k`aeppf` mksp
Aku
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Poes cksf spv`u xks codsfn lfckvsf dg pof cokmmfnhf pokp ep zdsf`! ep enwdmwfs pof
ofk` kn` sivmm xoeco cdnpkens pof cfnp|km z|dcfssenh vnep dg pof ld`u- k senhmf aespkif
cdvm` lf gkpkm kn` cdvm` pv|n k megf vzse`f `dxn eg ndp fn` ep.
Kp pof fn` dg poes cksf spv`u- pof spv`fnp nv|sf fzfcps pd fzkn` of| indxmf`hf
|fhk|`enh pof sv|heckm z|dcf`v|f indxn ks c|knedzmkspu- kn` |fgenf of| siemms en ck|enh gd|
k zkpefnp xod oks vn`f|hdnf pof ske` sv|heckm z|dcf`v|f.
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EE. Dlbfcpewfs
Hfnf|km Dlbfcpewfs2
Kgpf| 3 `kus dg spv`fnp nv|sf!zkpefnp enpf|kcpedn- pof spv`fnp nv|sf xemm lf klmf pd
mfk|n ad|f kldvp c|knedzmkspu- fggfcpewfmu z|dwe`f odmespec ck|enh ck|f kn` encvmckpf
zdsepewf kppepv`f xoemf ck|enh gd| k zkpefnp xod oks vn`f|hdnf pof ske` z|dcf`v|f.
Kgpf| 3 `kus dg spv`fnp nv|sf!zkpefnp enpf|kcpedn- pof zkpefnp xemm lf klmf pd mfk|n
ad|f kn` cdzf xepo pof sv|heckm dzf|kpedn c|knedzmkspu- kwde` cdazmeckpedns pokp aku
k|esf zdsp!dzf|kpewfmu kn` encd|zd|kpf megfspumf ad egeckpedns vnpem of |fpv|ns pd oes
dzpeava mfwfm dg gvncpednenh.
Szfcegec dlbfcpewfs2
Kgpf| 3 `kus dg z|dwe`enh odmespec ck|enh ck|f kn` gkcemepkpenh spv`fnp nv|sf!zkpefnp
enpf|kcpedn- pof spv`fnp nv|sf xemm lf klmf pd2
;. zf|gd|a k pod|dvho kssfssafnp dg k scoddm!khf coem en oes z|fsfnp cdn`epedn- kn`
`escvss pof zouseckm- sdcekm kn` cdhnepewf cok|kcpf|especs dg k scoddm!khf coem`
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EEE. Nv|senh Kssfssafnp
;. Zf|sdnkm Oespd|u
;.; Zkpefnps z|dgemf
Nkaf2 \kmzo `f mds \fufs Mkl|k`d|
Khf2 ;< ufk|s dm`
Sf2 Akmf
Cewem Spkpvs2 Senhmf
\fmehedn2 \dakn Ckpodmec
@kpf dg k`aessedn2 Aku
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ouzf|pfnsedn dn pof akpf|nkm kn` zkpf|nkm se`fs kn` l|dncoekm kspoak dn pof
zkpf|nkm se`f.
Of oks nd gdd` kn` `|vh kmmf|hefs. Of es kspoakpec. Mksp kspoak kppkci xks
pxd ufk|s khd kn` xks aknkhf` xepo wfnpdmen su|vz.
;.3 Mfwfm dg H|dxpo kn` @fwfmdzafnp
;.3.; Nd|akm @fwfmdzafnp
Zouseckm Coknhfs
Zousedmdheckmmu- pof scoddm!khf ufk|s d| ae``mf ufk|s lfhen xepo pof
sof``enh dg pof ge|sp `fce`vdvs pddpo kn` fn` kp zvlf|pu xepo pof kc{vesepedn dg pof
genkm- zf|aknfnp pffpo / xepo pof fcfzpedn dg xes`da pffpo%. Pof zf|ed` dg ae``mf
coem`odd` es k peaf dg h|k`vkm h|dxpo kn` `fwfmdzafnp xepo ad|f fwfn z|dh|fss
en ldpo zouseckm kn` fadpednkm kszfcps.
Scoddm!khf coem`|fns knnvkm kwf|khf xfehop hken es kzz|deakpfmu 3!6 ml.
/;.3!
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khfs 7 pd ;
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dzf|kpedns- xofn coem`|fn k|f klmf pd vsf podvhop z|dcfssfs pd fzf|efncf fwfnps
kn` kcpedns. Pof |ehe`- fhdcfnp|ec wefx dg pof z|fscoddm ufk|s es |fzmkcf` lu
afnpkm z|dcfssfs pokp kmmdx coem`|fn pd sff poenhs g|da kndpof|s zdenp dg wefx.
@v|enh poes spkhf- coem`|fn `fwfmdz kn vn`f|spkn`enh dg |fmkpednsoezs
lfpxffn poenhs kn` e`fks. Pofu z|dh|fss g|da akienh bv`hafnps lksf` dn xokp
pofu sff pd akienh bv`hafnps lksf` dn xokp pofu |fksdn. Pofu akspf| pof
cdncfzp dg cdnwf|skpedn- `fwfmdz cmkssegeckpedn siemms kn` pofe| klemepu pd |fk`
lfcdafs pof adsp sehnegecknp kn` wkmvklmf pddm gd| en`fzfn`fnp en{ve|u.
Sfvkmepu
Z|fk`dmfscfncf es pof zf|ed` dg kzz|deakpfmu < ufk|s pokp lfhens kp pof
fn` dg ae``mf coem`odd` kn` fn`s xepo pof poe|pffnpo le|po`ku. Lfckvsf zvlf|pu
sehnkms pof lfhennenh dg pof `fwfmdzafnp dg sfcdn`k|u sf cok|kcpf|especs-
z|fzvlfscfncf puzeckmmu dccv|s `v|enh z|fk`dmfscfncf.
Pof|fs nd vnewf|skm khf kp xoeco coem`|fn kssvaf pof cok|kcpf|especs dg
z|fzvlfscfncf. Pof ge|sp zousedmdhec sehns kzzfk| kp kldvp 5 ufk|s dg khf kn` k|f
vsvkmmu cmfk|mu fwe`fnp en ;;!;< ufk|s dm` coem`|fn.
Ldus fzf|efncf meppmf weselmf sfvkm akpv|kpedn `v|enh z|fk`dmfscfncf.
Zvlec oke| z|fsfnp kc|dss zvles- zfnes mfnhpofns- l|fksp fnmk|hfafnp dccv|s kn`
pof|fs `|kakpec menfk| h|dxpo szv|p.
;.3.< Pof Emm Scoddm!Khf Coem
Dnf dg pof lehhfsp z|dlmfas gkcenh k scoddm!khf coem` xepo kn emmnfss d|
zouseckm cokmmfnhf es peaf mdsp g|da scoddm. Poes po|fkpfns ndp dnmu kck`faec
kcoefwfafnp lvp kmsd pof coem`s |fmkpednsoezs xepo oes d| of| zff|s. Ep aku akif
oea d| of| pof d`` zf|sdn dvp xepo |fszfcp pd akienh g|efn`s d| bdenenh hknhs.
Xofpof| coem`|fn k|f cdngenf` pd odaf d| odszepkmerf`- ofmzenh pofa iffz en
cdnpkcp xepo g|efn`s ckn ofmz gdspf| sdcekmerkpedn pokp es eazd|pknp gd| cdnpenvf`
`fwfmdzafnp.
?
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En ck|enh gd| k scoddm!khf coem` xod es emm- coddsf sod|p pf|a kcpewepefs pokp
ckn lf cdazmfpf` en`fzfn`fnpmu. Lf ck|fgvm ndp pd ensvmp k coem` xepo pksis pokp k|f
dlwedvsmu ndp khf!kzz|dz|ekpf.
Akspf| Mkl|k`d|- \kmzo xks k`aeppf` mksp Aku
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Nfvp|dzoem 06 &
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3.< Nvp|epednkm! Afpkldmec Zkppf|n
Zkpefnp fkps po|ff gvmm afkms dg |ecf- geso kn` sdafpeafs coecifn kn` |f` afkp. Of fkps
pofsf `v|enh l|fkigksp- mvnco kn` `ennf|. Of vsvkmmu fkps bvnigdd` kn` `|enis ecf bvecf d|
ecf ckn`u `v|enh snkci peaf. Of `|enis vz pd ;.6 mepf|s dg xkpf| k `ku kn` |k|fmu pkifs en
g|vep bvecfs- aemi d| cdggff. Of `dfs ndp pkif knu wepkaens d| gdd` svzzmfafnps. Vzdn
k`aessedn- oes xfehop xks
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Z|ed| pd odszepkmerkpedn- pof zkpefnp smffzs kp k|dvn` ?za kn` xkifs vz kp 8 ka pof nfp
`ku. Of oks nd `eggecvmpu gkmmenh kn` spkuenh ksmffz. Vzdn odszepkmerkpedn- zkpefnp es klmf
pd smffz kp 5!523: za- kn` sdafpeafs ;: za `vf pd wepkm sehns pkienh kn` dpof| |dvpenf
z|dcf`v|fs. Oes adpof| spkpf` pokp pof zkpefnp es vnvsvkmmu |fspmfss `v|enh pof nehop kn` es
z|dlklmu knedvs kldvp pof vzcdaenh z|dcf`v|f.Of vsvkmmu pkifs sod|p nkz kp odaf-
vsvkmmu kgpf| k||ewenh g|da scoddm.
3.8 Sfmg!Zf|cfzpedn Zkppf|n
\kmzo es xfmm!k`bvspf`. Of spkpf` pokp of es sdafxokp knedvs gd| pdad||dxs sv|hf|u lvp
oes adpof| oks ofmzf` ckma oea `dxn. Of fz|fssf` oes `fse|f pd hd odaf kn` zmku xepo
oes selmenhs
3.? \dmf!\fmkpednsoez Zkppf|n
\kmzo szfkis xfmm- xepo cdof|fnp podvhops- kn` gkcekm fz|fssedns xepo hfspv|fs pokp k|f
kzz|dz|ekpf. Of mewfs xepo poes adpof| en K|hkd kn` oks pxd selmenhs- kmm ldus kn` kmm
udvnhf| pokn oea- Oes zk|fnps k|f sfzk|kpf`. Oes adpof| spkpf` pokp \kmzo es ok|`!ofk`f`
kn` dgpfn- xknps pd hd oes dxn xku.
3.5 Sfvkmepu kn` \fz|d`vcpewf Zkppf|n
\kmzo es en pof z|fzvlfscfncf zf|ed`. Of k`aeps pd okwenh ndpecf` h|dxpo dg oke|
vn`f| pof kemmk kn` zvlec oke| kc|dss pof zvles lvp dpof| pokn pokp of |fgvsfs pd
`ewvmhf `fpkems.
3.;:Cdzenh!Sp|fss Pdmf|kncf Zkppf|n
\kmzo zmkus lksifplkmm kgpf| scoddm. Xofnfwf| of gffms `dxn- of xkpcofs pfmfwesedn
d| zmku xepo oes l|dpof|s kp odaf.
3.;;Wkmvf!Lfmefg Suspfa
\kmzo es k \dakn Ckpodmec kn` es pkvhop lu oes adpof| pd z|ku kn` kppfn` akss fwf|u
Svn`ku. Of spkpf` pokp of es poknigvm pd Hd` gd| ndp pkienh oea pxd ufk|s khd. Of
bdienhmu ske` pokp pof kcce`fnp aku lf k xkif!vz ckmm gd| oea pd spdz lfenh ok|`!
ofk`f` kn` k lv|`fn pd oes adpof|.
;3
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0. Z|fsfnp Z|dgemf dg Gvncpednkm Ofkmpo Zkppf|n /Zdsp!dzf|kpewf%
0.; Ofkmpo Zf|cfzpedn
\kmzo cdnse`f|s oes z|fsfnp spkpf dg ofkmpo ks xfmm lvp |fcvzf|kpenh. Of
kn` oes adpof| ldpo indx pokp ks mdnh ks of pkifs ck|f dg oeasfmg kn` gdmmdx pof `dcpd|s
d|`f|s of xemm ofkm en peaf kn` z|fwfnp cdazmeckpedns dg pof sv|hf|u.
0.< Nvp|epednkm!Afpkldmec Zkppf|n
Pof zkpefnp xks pd okwf `efp ks pdmf|kpf` vzdn gvmm kxkifnenh ks d|`f|f`
lu oes `dcpd|. Of spemm fkps pof skaf afkm kp l|fkigksp- mvnco kn` `ennf|. Of fkps l|fk`
kn` c|kcif|s gd| snkcis. Of `|enis ;
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0.8 Sfmg!zf|cfzpedn Zkppf|n
\kmzo es |fmefwf` ndx pokp pof dzf|kpedn es dwf|. Of indxs pokp eg of
gdmmdxs oes af`eckpedn |fheafn kn` spkus en pof odszepkm gd| k gfx `kus pd |fcvzf|{kpf- of
xemm fwfnpvkmmu ofkm kn` |fpv|n pd oes vsvkm mfwfm dg gvncpednenh.
0.? \dmf!|fmkpednsoez Zkppf|n
Zkpefnp fz|fssf` oes mdnhenh pd lf odaf kn` zmku xepo oes l|dpof|s. Oes
odszepkm spku oks spk|pf` pd ld|f oea km|fk`u.
0.5 Cdzenh!sp|fss pdmf|kncf Zkppf|n
Pof zkpefnp oks nd dpof| dzpedn mfgp ndx pd cdzf xepo sp|fss fcfzp pkmienh
xepo oes adpof| kn` kvnps kn` xkpcoenh pfmfwesedn.
0.;: Wkmvf!Lfmefg suspfa
\kmzo z|kus gf|wfnpmu gd| ofkmenh. Of fz|fssf` oes h|kpepv`f pd pof Md|`
gd| iffzenh oea skgf `v|enh kn` kgpf| sv|hf|u.
6. Zkpodzousedmdhu kn` \kpednkmf
6.; Nd|akm Knkpdau kn` Zousedmdhu
Sp|vcpv|f Z|dpfcpenh pof L|ken
Pof l|ken es cdnpkenf` en pof |ehe` sivmm- xoeco z|dpfcps ep g|da enbv|u. Pof
akbd| ldnfs dg pof sivmm k|f pof g|dnpkm- pfazd|km- zk|efpkm kn` dccezepkm ldnfs. Pofsf
ldnfs bden kp pof svpv|f menfs.
;6
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Gehv|f ;. Pof Ovakn Sivmm
Pof afnenhfs- pof gel|dvs cdnnfcpewf pessvfs pokp cdwf| pof l|ken kn` szenkm cd|`-
z|dwe`f z|dpfcpedn- svzzd|p kn` ndv|esoafnp pd pof l|ken kn` szenkm cd|`. Pof mkuf|s dg
pof afnenhfs k|f pof `v|k- k|kconde` kn` zek akpf|.
@v|k akpf|! pof dvpf|adsp mkuf|9 cdwf|s pof l|ken kn` pof szenkm cd|`. Ep es pdvho-
poeci- enfmkspec- gel|dvs- kn` h|ku. Pof|f k|f gdv| fpfnsedns dg pof `v|k2 pof gkm cf|fl|e-
xoeco sfzk|kpfs pof pxd ofaeszof|fs en k mdnhepv`enkm zmknf9 pof pfnpd|eva- xoeco es kn
vngdm`enh dg pof `v|k pokp gd|as k pdvho- afal|kndvs sofmg9 pof gkm cf|flfmme- xoeco es
lfpxffn pof pxd mkpf|km mdlfs dg pof cf|flfmmva9 kn` pof `ekzo|kha sfmmkf- xoeco
z|dwe`fs k |ddg gd| pof sfmmk pv|ceck. Pof pfnpd|eva svzzd|ps pof ofaeszof|fs kn`
sfzk|kpfs pofa g|da pof mdxf| zk|p dg pof l|ken. Xofn fcfss z|fssv|f dccv|s en pof
c|knekm ckwepu- l|ken pessvf aku lf cdaz|fssf` khkensp pof pfnpd|eva d| `eszmkcf`
`dxnxk|`- k z|dcfss ckmmf` of|nekpedn. Lfpxffn pof `v|k akpf| kn` pof sivmm en pof
c|kneva- kn` lfpxffn pof zf|edspfva kn` `v|k en pof wf|pfl|km cdmvan- es pof fze`v|km
szkcf- k zdpfnpekm szkcf.
K|kconde`! pof ae``mf afal|knf9 kn fp|fafmu poen- `fmeckpf afal|knf pokp
cmdsfmu |fsfalmfs k sze`f| xfl. Ep kzzfk|s xoepf lfckvsf pof|f es nd lmdd` svzzmu. Ep
cdnpkens pof cod|de`s zmfvs xoeco es |fszdnselmf gd| pof cfl|dszenkm gmve` z|d`vcpedn.
Svl`v|km szkcf es lfpxffn pof `v|k kn` k|kconde` mkuf| kn` svlk|kconde` szkcf es
lfpxffn pof k|kconde` kn` zek mkuf|s kn` cdnpkens pof cf|fl|dszenkm gmve`.
Zek akpf|! pof ennf|adsp afal|knf9 k poen- p|knszk|fnp mkuf| pokp ovhs pof l|ken
cmdsfmu kn` fpfn`s enpd fwf|u gdm` dg pof l|kens sv|gkcf.
Gehv|f
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6.< Scofakpec @ekh|ka
;8
Z|f`eszdsenh Gkcpd|
Cdnhfnepkm kndakmefs
Ldnf engfcpedn
Pvad| en pof ofk`
Gkaemu oespd|u dg l|ken ckncf|sp|dif
Z|fcezepkpenh Gkcpd|
Adpd|!wfoecvmk| kcce`fnps
C|knedpdau
C|knefcpdau
C|knekm ldnf ledzsuSehns kn` Suazpdas
@fgfcp en pof c|knekm ldnf ks
sodxn en pof CP sckn9 en pof
zkpefnps cksf `fgfcp xks dn pof
|ehop zk|efnpkm ldnf
Sdgpnfss dg pof k|fk dg `fgfcp
vzdn zkmzkpedn
Sck| dn pof k|fk dg z|fwedvs
sv|hf|u 9 en pof zkpefnps cksf-
sck| dn pof |ehop zk|efpkm k|fk dgpof sckmz
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6.3 C|knedzmkspu sfcdn`k|u pd k C|knedpdau pd Fwkcvkpf kn Fze`v|km Ofakpdak
K c|knedzmkspu- ks afnpednf` fk|mef|- es k sv|heckm |fzke| dg k `fgfcp dg pof c|kneva.
C|knekm `fgfcps |fsvmp g|da g|kcpv|fs- engfcpedns- sv|heckm z|dcf`v|fs d| k cdnhfnepkm
`fgd|aepu.
\kmzo Mkl|k`d| es k ;< ufk| dm` coem` xod ok` vn`f|hdnf c|knedpdau pxd ufk|s
khd pd fwkcvkpf kn fze`v|km ofakpdak. Of xks svzzdsf` pd cdaf lkci 7 adnpos kgpf|
k cdazmfpf |fcdwf|u g|da pof z|fwedvs sv|heckm z|dcf`v|f lvp xks ndp klmf pd `vf pdz
genkncekm cdnsp|kenps.
Kn fze`v|km ofakpdak |fsvmps g|da k|pf|ekm lmff`enh enpd pof szkcf lfpxffn pof
`v|k kn` pof ennf| pklmf dg pof sivmm. Ep es dgpfn ckvsf` lu k g|kcpv|f d gpof pfazd|km
;?
Sv|heckm
Aknkhfafnp
C|knedzmkspu pd |fzke|
pof c|knekm ldnf `fgfcp
Af`eckm Aknkhfafnp
Knpeledpec pof|kzu pd
z|fwfnp engfcpedn
Knkmhfsek gd| zken
aknkhfafnp
Nv|senh Aknkhfafnp
Fmfwkpf ofk` dg lf` 3: `fh|ffs
Fncdv|khf ffz l|fkpoenh
ff|cesfs
Z|dadpf cmfknmenfss kn`
z|dzf| okn`xksoenh
Fncdv|khf enc|fksf` gmve`
enpkif
Pfkco `ewf|pednkm kcpewepefs pdofmz aknkhf zken
Dzpeava Mfwfm dg Gvncpednenh
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ldnf- xoeco odvsfs pof afnenhfkm k|pf|u. Fze`v|km ofakpdaks aku lf cok|kcpf|erf`
lu pof z|fsfncf dg k mvce` enpf|wkm pokp mksps gd| aenvpfs `v|enh xoeco pof cmefnp es
pkmienh kn` xkmienh. Poes gdmmdxs k adafnpk|u vncdnscedvsnfss pokp dccv||f` xepoen
aenvpfs dg enbv|u. Gdmmdxenh pof mvce` enpf|wkm- pof suazpdas z|dh|fss |kze`mu xepo
zdpfnpekm ckpksp|dzoec enp|kc|knekm z|fssv|f fmfwkpedn kn` sp|vcpv|km coknhfs. Kn
fze`v|km ofakpdak es k nfv|dsv|heckm faf|hfncu.
\kmzo Mkl|k`d| dlpkenf` pof fze`v|km ofakpdak g|da k adpd|!wfoecvmk| kcce`fnp
pxd ufk|s khd kn` of vn`f|xfnp c|knedpdau pd fwkcvkpf pof fze`v|km ofakpdak kn`
skwf oes megf. Zdsp sv|hf|u of xks en cdak gd| 0 `kus. Of xdif vz pof nfp `ku
cdngvsf` . Pxd ufk|s zdsp!sv|hf|u- of kn` oes adpof| ndpecf` k coknhf en oes
kck`faec zf|gd|akncf mfwfm kn` sod|p!pf|a afad|u mkzsfs. Of kmsd oks `eggecvmpu
ofk|enh xepo oes |ehop fk| kn` cdazmkens dg okwenh `eggecvmpu svaadnenh pof |ehop
xd|` gd| k cf|pken fwfnp d| dlbfcp.
Kgpf| k sfwf|f p|kvakpec l|ken enbv|u- pof zkpefnp es kmxkus fzfcpf` pd foelep
klnd|akmepefs sfcdn`k|u pd pof enbv|u dlpkenf`. Pof z|fwedvsmu afnpednf` `fgeceps
foelepf` lu \kmzo Mkl|k`d| kmm lfmdnh pd pof pfazd|km mdlfs gvncpedn. Pof pfazd|km
mdlf es |fszdnselmf gd| pof cdazmeckpf` afad|u zkppf|ns kn` es pof kv`epd|u cfnpf| gd|
sdvn` enpf|z|fpkpedn. Ep es kmsd en poes mdlf pokp pof Xf|necifs k|fk gd| szffco es
gdvn`. Poes kssdcekpedn k|fk zmkus k sehnegecknp |dmf en oehof|!mfwfm l|ken gvncpedn. Ep
fnklmfs z|dcfssenh dg xd|`s enpd cdof|fnp podvhop kn` |fcdhnepedn dg pof e`fk lfoen`
x|eppfn d| z|enpf` mknhvkhfs.
;5
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C|knedzmkspu xks zf|gd|af` pd |fzke| pof c|knekm `fgfcp dn \kmzos |ehop zk|efpkm
ldnf- k `fgfcp dlpkenf` g|da pof faf|hfncu sv|heckm z|dcf`v|f zf|gd|af` dn oea pxd
ufk|s khd. Poes c|knedzmkspu xemm ofmz z|dpfcp oes l|ken g|da pof p|kvakpec enbv|efs en
pof gvpv|f kn` |fengd|cf pof gvncpedn dg oes sivmm.
Gehv|f 3. Ofakpdak
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6.0 Sehns kn` Suazpdas
Cmksseckm Sehns Cmeneckm Sehns \kpednkmf
@fgfcp en pof c|knekm
ldnf ks sodxn en
pof CP sckn
Sck| dn pof k|fk dg
z|fwedvs sv|hf|u
Z|f!dzf|kpewf
Aknegfspf`9 `fgfcp
dn |ehop zk|efpkm
ldnf
Aknegfspf`9 dn |ehop
zk|efpkm k|fk dg sckmz
Zdsp!dzf|kpewf
Ndp aknegfspf`
Aknegfspf`
Pof `fgfcp sodxn dn
pof CP sckn xks k
|fanknp dg pof
z|fwedvs sv|hf|u pof
zkpefnp aku okwf
vn`f|hdnf.
!zh. ;:6:9 Af`eckm!
Sv|heckm Nv|senh lu
Ehnkpkwecevs
Pof `fgfcp sodxn dn
pof CP sckn xks k
|fanknp dg pof
z|fwedvs sv|hf|u pof
zkpefnp aku okwf
vn`f|hdnf.
!zh. ;:6:9 Af`eckm!
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Sdgpnfss dg pof k|fk
dg `fgfcp vzdn
zkmzkpedn
Aknegfspf`9 dn |ehop
zk|efpkm k|fk dg sckmz
Ndp dlsf|wklmf
Sv|heckm Nv|senh lu
Ehnkpkwecevs
En c|knedpdau- k
lv|| odmf es ak`f pd
sf|wf ks kn dzfnenh
po|dvho xoeco lmdd`
d| gmve` aku lf
fwkcvkpf`.
C|knedzmkspu es dgpfn
`dnf kgpf|.
!zh. 378 Zdcifp
Hve`f pd pof
Dzf|kpenh \dda lu
Hdm`akn
EW. Nv|senh Enpf|wfnpedns
;. Ck|f Hve`f gd| Zkpefnps xod okwf vn`f|hdnf c|knedzmkspu
Nvp|epedn kn` Gmve`s
Cmefnps sodvm` lf kssespf` pd pkif en kp mfksp
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Pof|f k|f pxd aken kszfcps dg cdnp|dmmenh xdvn` engfcpedn2 z|fwfnpenh
aec|dd|hknesas g|da fnpf|enh pof xdvn` kn` z|fwfnpenh p|knsaessedn dg lmdd` ld|nf
zkpodhfns pd d| g|da pof cmefnp pd dpof|s. Spkn`k|` z|fckvpedns encmv`f xfk|enh dg hmdwfs
xofn pdvcoenh lmdd` kn` ld`u gmve`s kn` xofn okn`menh epfas sdemf` xepo lmdd` d| ld`u
gmve`s9 kn` xksoenh pod|dvhomu dg okn`s kgpf| |fadwenh hmdwfs.
Ofk` `|fssenh sodvm` lf enszfcpf` fkco `ku zdsp!dzf|kpewfmu vnpem ep es |fadwf` dn
pof poe|` zdsp!dzf|kpewf `ku. Ofk` `|fssenhs sodvm` ndp lf `espv|lf` gd| pof ge|sp
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Sffn zkpefnp -
Aksp. \kmzo
Mkl|k`d|-seppen
h dn lf`xkpcoenh
pfmfwesedn xepodvp
EW. Of es ;< ufk|s
dm` kn` es gd|
c|knedzmkspu.
5? &
|fsdmv
!pedn
DgZsucodmdhe
c
kn`zousedmdhec
z|dlmfas
fzf|efncf` lu
pof zkpefnp
E.Knefpu2|fspmfssnfss |fmkpf` pd gfk| dg
vnindxn dvpcdafs dg sv|hf|u
EE.@espv|lf` smffz zkppf|n2 smffzenh mkpf|
pokn oes lf`peaf |fmkpf` pd gfk| dg
vnindxn dvpcdaf dg sv|hf|u
EEE. Indxmf`hf `fgecep 2 g|f{vfnp ksienh dg
{vfspedns |fhk|`enh pof sv|heckm z|dcf`v|f
c|knedzmkspu |fmkpf` pd mkci dg
fzmknkpedn g|da sehnegecknp dpof|s
L|vnsxeci Mfns Ad`fm
/Z|f!dzf|kpewf%
Kcpvkm spkpf
Dg zkpefnps
cdn`epedn
cvfs Nv|senh @ekhndsfs Nv|senh Kcpedns @fse|f` Dvpcdaf
Dlbfcpewfs Hdkm
K. Zsucodmdhec `fgecep2
Knefpu
!|fspmfssnfss
!cmefnp |fzd|pf` enc|fksf` gffmenh
dg pfnsedn d| ks adpof| spkpf`2
dwf|fcepfafnp
!cmefnp dfs gddp sovggmenh
!ivmlkkn hkaku ks wf|lkmerf`
lu pof zkpefnp
L. Zousedmdhec fgecep2 espv|lf`
smffz zkppf|n
! cmefnp ndx smffzs mkpf pokn oes
vsvkm lf` peaf
!adpof| spkpf` pkp cmefnp es
vnvsvkmmu |fspmfss v|enh pof
nehop z|dlklmu vf pd knefpu
!cmefnp |fzd|pf` enc|fksf` gffmenh
dg pfnsedn d| ks adpof| spkpf`2
dwf|fcepfafnp
C. Indxmf`hf `fgecep
!zkpefnp g|f{vfnpmu ksis {vfspedns
|fhk|`enh pof z|dcf`v|f
!zkpefnp es dnmu ;< ufk|s dm`
!ndnf dg pof gkaemu afalf|s esen pof af`eckm gefm` kn` ndnf
cdvm` hewf k seazmf fzmknkpedn
dg xokp of es kldvp pd hd po|dvho
Afksv|fs pd2
K. |f`vcf Knefpu
!kcindxmf`hf` gfk|
!fncdv|khf` zkpefnp pd wf|lkmerf
gffmenhs
!szfnp sdaf peaf xepo pof zkpefnp
!fncdv|khf` hve`f` eakhf|u
!z|dwe`f` pdvco- aksskhf
L eaz|dwf Smffz Zkppf|n
! cmvspf|f` nv|senh kcpewepefs
! aeneaerf` gmve` enpkif `v|enh
nehop peaf
!|fsp|ecpf` enpkif dg ckggfenf!
cdnpkenenh gdd`s kn` gmve`s
!svzzd|pf` cdnpenvkpedn dg
zkpefnps lf`peaf |epvkms
! fncdv|khf` zkpefnp pd wf|lkmerf
gffmenhs
C. eaz|dwf indxmf`hf dn
c|knedzmkspu
!fwkmvkpf` ckzklemepefs kn`
|fk`enfss pd mfk|n
!|fwefxf` engd|akpedn |fhk|`enh
enbv|u z|dcfss kn` kgpf| fggfcps
!sodxf` pof zkpefnp k zecpv|f dg
pof sivmm kn` l|ken kn` fzmkenf`
en seazmf pf|as pof sv|heckm
z|dcf`v|f
Kgpf| ? o|s. dg spv`fnp nv|sf zkpefnp enpf|kcpedn-
pof zkpefnp xemm lf klmf pd 2
;. `fadnsp|kpf `fc|fksf en knefpu ks fwe`fncf` lu
`fc|fksf en |fspmfss nfss
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Sffn zkpefnp -
Aksp. \kmzo
Mkl|k`d|-seppen
h dn lf`xkpcoenh
pfmfwesedn xepodvp
EW. Of es ;< ufk|s
dm` kn` es gd|
c|knedzmkspu.
5? &
|fsdm
!ped
D
zousedmd
z|dlmf
fzf|efncf`
pof zkpe
L|vnsxeci Mfns Ad`fm
/Zdsp!dzf|kpewf%
Kcpvkm spkpf
Dg zkpefnps
cdn`epedn
cvfs Nv|senh @ekhndsfs Nv|senh Kcpedns @fse|f` Dvpcdaf
Dlbfcpewfs Hdkm
K.Zousedmdhec Dwf|mdk`2Kmpf|kpedn en
cdagd|p
!enpf|aeppfpn zken dn |ehop zk|efpkm
k|fk dg ofk`9 zken spk|pf` odv|s kgpf|
k||ewenh g|da pof D\9ep es `fsc|elf`ks aem`mu spenhenh- khh|kwkpf` lu
sv``fn ofk` adwfafnp- |fmefwf` lu
|fsp kn` p|fkpf` xepo Afgfnkaec kce`
; ckz {?o zd
!zkpefnp |kpf` zken ks 6 en k zken sckmf
:g :!;: xof|fen : spkn`s gd| nd zken
kn` ;: ks adsp zkengvm
L.\esi gd| enfggfcpewf l|fkpoenh
zkppf|n
!zkpefnp oks l|dncoekm kspoak kn`
oks vn`f|hdnf sv|hf|u gd| odv|s
vn`f| hfnf|km knfspofsek
!|fsze|kpd|u |kpf ;? l|fkpos zf|
aenvpfC.\esi gd| engfspedn
!zkpefnp es zdsp!c|knedzmkspu xepo
ofk` `|fssenh |fengd|cf` xepo
spf|emf zk`s
Afksv|fs pd2
K. z|dadpf cdagd|p
!zdsepednf` zkpefnp sd pokp oes
kggfcpf` se`f xemm ndp |fcfewf avco
z|fssv|f
!zf|gd|fa`f` aksskhf lvp ndp dn
kggfcpf` zk|p!fncdv|khf` `ffz l|fkpoenh
ff|cesfs
!z|dadpf` |fsp
!k`aenespf|f` af`eckpedns zf|
`dcpd|s d|`f|
L akenpken |fsze|kpd|u gvncpedn
!zmkcf` zkpefnp en k sfae!z|dnf zdsepedn
!svcpednf` p|kcofk
!fmfwkpf` ofk` dg lf`ks z|fsc|elf`
!k`aenespf|f` ndpoenh zf| d|fa vnpem kcpewf
cdvhoenh kn` sxkmmdxenh |fgmffs |fpv|nf`
C. akenpken wepkm sehns xepoen nd|akm |knhf
!adnepd|f` sepf gd| sehns dg engfcpedn
!ensp|vcpf` zkpefnp pd |fzd|p z|fsfncf dg skmpu
pkspf!ensp|vcfpf` zkpefnp pd kwde` cdvhoenh-
lmdxenh ndsf
!vsf` ksfzpec pfcone{vf xofn okn`menh
`|fssenhs
!k`aenespf|f` z|dzoumkes zf| dcpd|s d|`f|
E.Kmpf|kpedn en cdagd|p2zken |fmkpf`
pd `es|vzpedn dg pessvf enpfh|epu
sfcdn`k|u pd sv|heckm z|dcf`v|f
EE.\esi gd| enfggfcpewf l|fkpoenhzkppf|n |fmkpf` pd zdsp!dzf|kpewf
cf|fl|km f`fak
EEE.\esi gd| engfcpedn |fmkpf` pd
xdvn` dlpkenf` v|enh sv|hf|u
Kgpf| ? o|s. dg spv`fnp nv|sf zkpefnp enpf|kcpedn- pof
zkpefnp xemm lf klmf pd 2;. `fadnsp|kpf `fc|fksf en zken sfnskpedn ks fwe`fncf` lu k zkensckmf |kpenh ks ; en k zken sckmf dg :!;:
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Zkpefnps nkaf2 \kmzo Mkl|k d| Khf2 ;< ufk|s dm Zousecekn2 @|.Wf|hk|k Nemd
\dda nd. 2 0
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dvp pofsf
gffmenhs dvp
en pof dzfn
sd pofu ckn
lf
`escvssf`
kn` `fkmp
xepo
! zh.
806-NCZs-
Ak|emun
@dfnhfs
c.szfn` sdaf peaf
xepo pof zkpefnp
`.fncdv|khf hve`f`
eakhf|u
f. z|dwe`f
pdvco-aksskhf
@dfnhfs
!cdnpenvdvs svzzd|p aku
ofmz zkpefnp |fhken
enpf|nkm mdcvs dg cdnp|dm!
zh.807-NCZs-@dfnhfs
!z|dadpf |fmfksf dg
fn`d|zoens kn` |f`vcf
knefpu!
zh.806-NCZs-@dfnhfs
!ke`s en affpenh lksec
ovakn nff` `fc|fksenh
sfnsf dg esdmkpedn!
zh.806-NCZ-@dfnhfs!
zh.806-NCZs-@dfnhfs
Zkpefnps nkaf2 \kmzo Mkl|k d| Khf2 ;< ufk|s dm Zousecekn2 @|.Wf|hk|k Nemd
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\dda nd. 2 0
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`espv|lf` smffz
zkppf|ns z|ed| pd
kn` gdmmdxenh
fmfcpewf sv|hf|u.
Xf ouzdpofserf
pokp afmkpdnen
xemm eaz|dwf
smffz zkppf|ns
z|ed| pd kn`
gdmmdxenh
sv|hf|u- lu
|f`vcenh smffz
mkpfncu kn`
fpfn`enh pdpkm
smffz peaf. Xf
kmsd ouzdpofserf
pokp poes
eaz|dwfafnp
xemm okwf
zdsepewf eazkcp
dn knfspofpec
sp|fss afksv|fs
kn` dn |fcdwf|u.
c. |fsp|ecpf` enpkif dg
ckggfenf!cdnpkenenh
gdd`s kn` gmve`s
`.svzzd|pf`
cdnpenvkpedn dg
zkpefnps lf`peaf
|epvkms
zh.800-NCZs-@d
fnhfs
! Ckggfenf
mfnhpofns pof
peaf ep pkifs pd
gkmm ksmffz-
|f`vcenh udv|
pdpkm smffzenh
peaf!zh.69 Hfp
Rs ndx9
Hfdgg|fu
Lv|cogefm`
!Coem`|fn nff` k
gkaemek| kn`
zmfksknp |dvpenf
kn` pofsf k|f
lf`peaf |epvkms
xoeco ckn ofmz
coem`|fn smffz dn
peaf! zh.389 Hfp
Rs ndx9
Hfdgg|fu
Lv|cogefm`
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!zh.6:-Lfudn`
pof \fmkkpedn
\fszdnsf lu
Of|lf|p Lfnrdn
f. ! fncdv|khf`
zkpefnp pd wf|lkmerf
gffmenhs
! Pof sdv|cf dg
vnfksenfss d|
knefpu- xoeco es
dgpfn k ckvsf dg
smffz `espv|lkncf-
es ndp kmxkus
indxn d|
|fcdhnerf`. Ep es
ofmzgvm pd l|enh
dvp gffmenhs sd
pofu ckn lf
`escvssf` kn`
`fkmp xepo.!
zh.806-NCZs-@d
fnhfs
Zkpefnps nkaf2 \kmzo Mkl|k d| Khf2 ;< ufk|s dm Zousecekn2 @|.Wf|hk|k Nemd
\dda nd. 2 0
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Nff`s$Z|dlmfas
Cvfs
Nv|senh
@ekhndses
Scefnpegec Lkses Dlbfcpewfs dg Ck|f Nv|senh Kcpedns \kpednkmf
C.Indxmf`hf
`fgecep2
!zkpefnp g|f{vfnpmu
ksis {vfspedns
kldvp pof z|dcf`v|f
!zkpefnp es dnmu ;