PK +2\_rels/PK +2\ docProps/PK +2\ppt/PK +2\ ppt/_rels/PK +2\ ppt/charts/PK +2\ppt/charts/_rels/PK +2\ppt/embeddings/PK +2\ ppt/media/PK +2\ppt/slideLayouts/PK +2\ppt/slideLayouts/_rels/PK +2\ppt/slideMasters/PK +2\ppt/slideMasters/_rels/PK +2\ ppt/slides/PK +2\ppt/slides/_rels/PK +2\ ppt/theme/PK +2\ppt/notesMasters/PK +2\ppt/notesMasters/_rels/PK +2\ppt/notesSlides/PK +2\ppt/notesSlides/_rels/PK +2\` [Content_Types].xml PK +2\]] _rels/.rels PK +2\ 0 0 Microsoft Office PowerPoint On-screen Show (16:9) 0 15 15 0 0 false Fonts Used 2 Theme 1 Slide Titles 15 Arial Calibri Office Theme Slide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15 PptxGenJS false false false 16.0000 PK +2\|docProps/core.xml Stoma: A Comprehensive Surgical Guide PptxGenJS Presentation PptxGenJS PptxGenJS 1 2026-04-02T06:17:23Z 2026-04-02T06:17:23Z PK +2\ ppt/_rels/presentation.xml.rels PK +2\Oݨ ppt/theme/theme1.xmlPK +2\;G#yyppt/presentation.xml PK +2\Xppt/presProps.xml PK +2\ppt/tableStyles.xml PK +2\D >00ppt/viewProps.xml PK +2\H7t!ppt/slideLayouts/slideLayout1.xml PK +2\ђ77,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK +2\xWxxppt/slides/slide1.xml SURGICAL EDUCATIONStomaA Comprehensive Surgical GuideTypes · Indications · Technique · Complications · CareGeneral Surgery | Colorectal DivisionPK +2\3 ppt/slides/_rels/slide1.xml.rels PK +2\.ppt/notesSlides/notesSlide1.xml 1PK +2\:A*ppt/notesSlides/_rels/notesSlide1.xml.rels PK +2\ LPPppt/slides/slide2.xml LEARNING OBJECTIVES 1Define a stoma and describe its anatomical basis 2Classify stomas by type, mechanism, and temporality 3State indications for colostomy, ileostomy, and urostomy 4Describe surgical technique for stoma formation 5Identify immediate and long-term stoma complications 6Outline principles of stoma site marking and siting 7Explain stoma reversal criteria and techniques 8Discuss stoma care, appliances, and quality of lifePK +2\2- ppt/slides/_rels/slide2.xml.rels PK +2\ppt/notesSlides/notesSlide2.xml 2PK +2\xշ*ppt/notesSlides/_rels/notesSlide2.xml.rels PK +2\ؚPPppt/slides/slide3.xml DEFINITION & BASIC ANATOMY Stoma (Greek: στόμα = mouth/opening) — A surgically created opening between a hollow organ (bowel or urinary tract) and the abdominal wall skin surface, allowing the diversion of intestinal or urinary contents. Key CharacteristicsMucosal Surface: Pink/red, moist — identical to normal bowel mucosaProtrusion: Ideal stoma should project 2–3 cm above skin (spout) for appliance sealPosition: Pre-operatively sited within rectus abdominis muscle to prevent parastomal herniaVascularity: Dependent on mesenteric blood supply — must be tension-free and well-vascularisedSensation: No pain sensation — bowel mucosa has no somatic pain fibresOutput: Varies by bowel segment: liquid (ileostomy) to formed stool (sigmoid colostomy) Bowel Wall Layers (Outermost → Lumen)Serosa / PeritoneumOutermost layer; intraperitoneal bowel onlyMuscularis ExternaOuter longitudinal + inner circular muscleSubmucosaStrongest layer — key for anastomotic suturesMuscularis MucosaeThin smooth muscle separating layersMucosa (Epithelium)Inner lining — visible as stoma surfacePK +2\W/ ppt/slides/_rels/slide3.xml.rels PK +2\K |Őppt/notesSlides/notesSlide3.xml 3PK +2\9 Y*ppt/notesSlides/_rels/notesSlide3.xml.rels PK +2\UUppt/slides/slide4.xml CLASSIFICATION OF STOMAS By Content / OrganColostomy: Large bowel — formed/semi-formed stoolIleostomy: Small bowel — liquid, high-volume outputUrostomy: Urinary diversion — ileal conduit or ureterostomyJejunostomy: Proximal small bowel — rare, very high output By MechanismEnd (Terminal): Bowel end brought to skin; distal end closed/removedLoop: Loop of bowel exteriorised with bridge support; two openingsDouble-Barrel: Both ends brought out side by sideSplit (Paul-Mikulicz): Loop separated, two stomas in close proximity By PermanenceTemporary / Defunctioning: Protect distal anastomosis; planned for reversalPermanent: After APR, pelvic exenteration; no reversal plannedEmergency: Perforated bowel, obstruction; not pre-sitedElective: Pre-planned, pre-sited, patient counselled By LocationRight Iliac Fossa: Standard ileostomy positionLeft Iliac Fossa: Standard colostomy positionRight Upper Quadrant: Transverse colostomy, feeding jejunostomySuprapubic: Cystostomy (urinary) — bladder drainagePK +2\` ppt/slides/_rels/slide4.xml.rels PK +2\vsppt/notesSlides/notesSlide4.xml 4PK +2\J *ppt/notesSlides/_rels/notesSlide4.xml.rels PK +2\T!!ppt/slides/slide5.xml ILEOSTOMY — INDICATIONS & TYPESRIFStandard siting positionRight iliac fossa2–3 cmIdeal spout heightAbove skin level800–1200mL/day outputNormal ileostomy>2000mL/day = High outputRequires investigation Indications for IleostomyInflammatory Bowel Disease→ Proctocolectomy for UC (permanent)→ Loop ileostomy: protect ileal pouch-anal anastomosisColorectal Cancer→ Loop ileostomy: protect low anterior resection→ After right hemicolectomy leak/complicationsFamilial Adenomatous Polyposis→ Prophylactic proctocolectomy + pouch formationOther→ Intestinal failure / Crohn's disease→ Trauma, ischaemic bowel, faecal peritonitis End vs Loop IleostomyEnd Ileostomy• Terminal ileum brought to RIF skin• Single opening (spout)• Bowel end everted (Brooke technique)• After proctocolectomy — often permanent• Output: liquid 800–1200 mL/dayLoop Ileostomy• Loop of ileum exteriorised over rod/bridge• Two openings: proximal (active) & distal• Easier to reverse than end ileostomy• Defunctioning — temporary use• Higher rate of parastomal herniaPK +2\5 ppt/slides/_rels/slide5.xml.rels PK +2\W8ppt/notesSlides/notesSlide5.xml 5PK +2\Qe*ppt/notesSlides/_rels/notesSlide5.xml.rels PK +2\m뾧xxppt/slides/slide6.xml COLOSTOMY — INDICATIONS & TYPESLIFSigmoid colostomyStandard sitingFlushColostomy spout levelUnlike ileostomy150–300mL/day outputSigmoid / formedAPRPermanent colostomyAbdominoperineal resection Sigmoid ColostomyLocation: Left Iliac FossaUse: APR (permanent); Hartmann's procedureOutput: Formed stool — most continence controlNote: Irrigation possible; flush with skin Transverse ColostomyLocation: Right Upper Quadrant / EpigastricUse: Emergency obstruction (now less common)Output: Semi-formed; bulky, odorousNote: Often loop; loop bridge removed at 10 days CaecostomyLocation: Right Iliac FossaUse: Caecal volvulus, pseudo-obstructionOutput: Liquid to semi-formed stoolNote: Usually temporary; tube or formal opening Hartmann's ColostomyLocation: Left Iliac FossaUse: Perforated diverticulitis, sigmoid cancerOutput: Formed sigmoid stoolNote: Rectal stump closed; reversal possible laterPK +2\ج+ ppt/slides/_rels/slide6.xml.rels PK +2\zppt/notesSlides/notesSlide6.xml 6PK +2\=|*ppt/notesSlides/_rels/notesSlide6.xml.rels PK +2\1|^^ppt/slides/slide7.xml UROSTOMY & OTHER STOMA TYPES 💧 Urostomy (Ileal Conduit)Definition: Urinary diversion using an isolated ileal segment to conduct urine to abdominal skinSiting: Right iliac fossa — below waist level; must not encroach belt lineIndications: Radical cystectomy (bladder cancer), pelvic exenteration, neurogenic bladder, severe radiation cystitis, traumaOutput: Continuous urine drainage; requires drainable bag with tap; 1500–2000 mL/daySpout: 2–3 cm spout essential to prevent urine tracking under applianceStents: Ureteric stents placed at surgery; removed at 7–10 days post-operativelyMucous shreds: Normal — from ileal mucosa; reassure patient; does not indicate infection Jejunostomy• Nutritional access (feeding jejunostomy)• After oesophagogastric resection• Very high output — electrolyte loss risk• Short bowel syndrome management Caecostomy / Appendicostomy• MACE procedure (Malone) — paediatrics• Antegrade colonic enemas for constipation• Percutaneous caecostomy for pseudo-obstruction• Temporary / rarely permanent Gastrostomy• Feeding access — PEG or surgical• Venting in bowel obstruction / gastroparesis• PEG-J: gastric venting + jejunal feeding• Long-term nutritional supportPK +2\F ppt/slides/_rels/slide7.xml.rels PK +2\)lppt/notesSlides/notesSlide7.xml 7PK +2\|g*ppt/notesSlides/_rels/notesSlide7.xml.rels PK +2\FũVVppt/slides/slide8.xml STOMA SITING — PRE-OPERATIVE MARKING⭐ Pre-operative siting by a stoma care nurse (SCN) is a Quality Standard — reduces complications and improves quality of life 1Within Rectus AbdominisReduces parastomal hernia risk. The muscle provides a firm back-plate for the stoma. 2Below Belt LinePatient must be able to see the stoma for self-care. Above a skin crease allows better seal. 3Away from Scars & CreasesOld scars, skin folds, and the umbilicus interfere with appliance adhesion. 4Away from Bony ProminencesIliac crest and costal margin prevent secure bag fitting. 5Patient Positioned in Multiple PosturesMark in standing, sitting, and lying — the optimal site works in ALL positions. 6Patient Lifestyle ConsideredOccupation, clothing style, prostheses, wheelchair use, dominant hand, BMI.If emergency surgery: aim for standard position (RIF/LIF in rectus); note limitations in post-operative periodPK +2\6 ppt/slides/_rels/slide8.xml.rels PK +2\iސppt/notesSlides/notesSlide8.xml 8PK +2\pO*ppt/notesSlides/_rels/notesSlide8.xml.rels PK +2\݂U++ppt/slides/slide9.xml SURGICAL TECHNIQUE — STOMA FORMATION End Ileostomy (Brooke Technique)1Skin trephine: Excise 2 cm disc of skin at pre-marked site2Cruciate fasciotomy: Cross-shaped incision through anterior rectus sheath3Muscle splitting: Split (not excise) rectus abdominis muscle4Peritoneal entry: Open posterior sheath and peritoneum5Bowel delivery: Deliver 5–6 cm of terminal ileum through trephine6Tension check: Ensure mesentery lies without tension or twist7Eversion (Spouting): Evert distal ileum 2–3 cm above skin — seromuscular sutures to dermis8Mucocutaneous sutures: Absorbable sutures uniting mucosa to skin edge circumferentially Loop Colostomy Technique1Skin incision: Larger elliptical/circular excision for colostomy (3 cm)2Trephine formation: Same sheath/muscle splitting technique3Loop exteriorisation: Loop of sigmoid/transverse colon delivered through wound4Bridge / rod placement: Plastic rod or bridge placed under loop to maintain position5Colotomy: Transverse incision across antimesenteric border of loop6Mucocutaneous anastomosis: Full-thickness bowel wall sutured to skin; colostomy is FLUSH7Rod removal: Bridge/rod removed at Day 7–10 post-operatively8Fascial closure: Secure bowel to fascia to prevent parastomal herniationPK +2\>$ ppt/slides/_rels/slide9.xml.rels PK +2\qppt/notesSlides/notesSlide9.xml 9PK +2\1*ppt/notesSlides/_rels/notesSlide9.xml.rels PK +2\nnppt/slides/slide10.xml EARLY STOMA COMPLICATIONS (<30 days) Ischaemia / Necrosis1–10%Cause: Excessive tension, tight trephine, mesenteric vessel injury, torsionSigns: Dusky purple/black stoma; malodour; loss of bleeding on contactMx: Assess depth with glass tube + torch; superficial = observe; full-thickness = urgent re-operation Mucocutaneous Separation5–24%Cause: Tension, ischaemia, infection, obesity, steroids, poor nutritionSigns: Wound dehiscence at stoma-skin junction; raw defectMx: Wound care with stoma paste/powder; allow secondary healing; resite if severe Retraction1–6%Cause: Excessive tension on mesentery, inadequate bowel mobilisation, weight gainSigns: Stoma retracts below skin level; leakage under appliance; skin excoriationMx: Convex appliance; may require surgical revision; skin barrier rings High Output (Ileostomy)~17%Cause: Inadequate adaptation, infection, medications (laxatives, MgSO4), short gutSigns: >2000 mL/day; dehydration; electrolyte imbalance; renal impairmentMx: Loperamide, codeine; oral rehydration; restrict hypotonic fluids; address cause Stomal Obstruction~2%Cause: Tight trephine, mucocutaneous stenosis, adhesions, volvulusSigns: No output; colicky pain; vomiting; abdominal distensionMx: Digital dilation; contrast enema; resiting or revision if persistent Parastomal Haematoma<5%Cause: Inadequate haemostasis; coagulopathySigns: Swelling, bruising at stoma base; may impede fittingMx: Usually resolves; drainage if large or infected; review anticoagulationPK +2\Ѳ!ppt/slides/_rels/slide10.xml.rels PK +2\O ppt/notesSlides/notesSlide10.xml 10PK +2\T+ppt/notesSlides/_rels/notesSlide10.xml.rels PK +2\m=k_k_ppt/slides/slide11.xml LATE STOMA COMPLICATIONS (>30 days) Parastomal HerniaUp to 50%Most common late complication. Bowel/omentum herniates through fascial defect alongside stoma. Presents as bulge. Mx: support belt, hernia repair (suture/mesh), stoma relocation. Prevention: placing stoma through rectus. Prolapse2–3%Bowel telescopes out of stoma; more common with loop colostomies. Reduce manually; surgical revision (resection/fixation) if recurrent or irreducible. Stenosis2–10%Narrowing of the stoma opening. Presents with ribbon stool, difficulty with output. Grade: mucocutaneous vs. fascial. Mx: digital dilation (mild), revision surgery if severe. Skin ExcoriationVery commonParticularly with ileostomy (enzymatic content). Peristomal skin breakdown from leakage. Prevention: well-fitting appliance, skin barriers. Mx: Stomahesive powder/paste, review appliance fit. Retraction (Late)~10%Stoma retracts below skin level secondary to weight gain, fibrosis, or initial tension. Causes chronic leakage. Mx: convex appliance system; surgical revision if severe. Fistula / AbscessRareUsually secondary to Crohn's, anastomotic leak, or suture sinus. Treat underlying cause first; surgical revision often required.📌 Late complications are more common with colostomy (50% parastomal hernia) than ileostomy. Obesity, steroids, and emergency formation increase all risks.PK +2\;!ppt/slides/_rels/slide11.xml.rels PK +2\s6ӑ ppt/notesSlides/notesSlide11.xml 11PK +2\O+ppt/notesSlides/_rels/notesSlide11.xml.rels PK +2\r'bbppt/slides/slide12.xml STOMA APPLIANCES & NURSING CARE Appliance TypesOne-Piece: Baseplate and bag combined. Simpler, cheaper. Entire appliance changed each time. Suitable for regular-shaped stomas.Two-Piece: Separate baseplate (flange) + bag. Baseplate changed every 3–4 days; bag changed more frequently. More flexible.Closed Bag: Used for colostomy (formed output). Disposed whole. Changed 1–2× per day.Drainable Bag: Used for ileostomy and urostomy. Has tap/clip at bottom. Emptied when 1/3 full; changed every 2–3 days.Convex Appliance: Convex baseplate used for retracted or flush stomas to push bowel out and improve seal. Accessories & Adjuncts◆ Stoma paste — fills skin creases/irregularities◆ Stoma powder — dries moist skin; aids seal◆ Barrier rings / seals — extra leak protection◆ Protective sprays — skin protection films◆ Deodorant drops/tablets — odour management◆ Irrigation kits — colostomy irrigation◆ Convex inserts — for flush/retracted stomas◆ Hernia support belts — parastomal hernia Post-Operative Stoma Care PrinciplesInitial 24hClear drainable bag; monitor colour (pink/red = good); document output volumeBag SizingMeasure stoma diameter; cut bag aperture 2–3 mm larger than stoma; resize as oedema reduces (6–8 weeks)Skin CareDry skin thoroughly before applying; avoid oil-based products; stomahesive powder for moist skinPatient EducationTeach stoma care before discharge; written instructions; SCN contact details; support groupsPK +2\c!ppt/slides/_rels/slide12.xml.rels PK +2\*)@ ppt/notesSlides/notesSlide12.xml 12PK +2\Fb+ppt/notesSlides/_rels/notesSlide12.xml.rels PK +2\m 99ppt/slides/slide13.xml PATIENT EDUCATION & QUALITY OF LIFE 🍽 Diet & Nutrition• No strict dietary restrictions after healing• High-fibre foods may increase ileostomy output• Odour-causing foods: fish, onion, eggs, cabbage• Gas-reducing: chew slowly, avoid straws• Adequate hydration — especially ileostomy patients• Reintroduce foods gradually post-operatively 💧 Fluid Management• Ileostomy: high water/electrolyte loss risk• Use oral rehydration solutions (not plain water)• Target urine output >1 L/day• Watch for dehydration in hot weather/exercise• Avoid high-sugar drinks (osmotic diarrhoea)• Restrict fluid with high-output ileostomy 🏃 Activity & Exercise• Light activity from 4–6 weeks post-op• Avoid heavy lifting for 3 months• Swimming: use smaller closed bag; waterproof covers• Sport: hernia support belt recommended• Colostomy irrigation allows more flexibility• Contact sports: discuss with surgeon individually 🧳 Travel & Lifestyle• Carry double supplies when travelling• Medical letter for airport security• Keep supplies in hand luggage (not hold)• Consider travel insurance (pre-existing condition)• Medic-alert ID recommended• Access cards available for urgent toilet access ❤ Psychosocial & Relationships• Body image concerns — counselling support• Sexual function: discuss openly; referral if needed• Intimacy: small pouches or stoma caps available• Partner involvement in stoma education if desired• Support groups (e.g. Colostomy UK, IA) invaluable• Psychological support — especially young patients 🏥 Follow-up & Red Flags• SCN review at 6–8 weeks post-discharge• Stoma clinic: 3, 6, 12 months• Red flags: no output >6h, bleeding, severe skin breakdown, black/purple stoma, severe pain• Annual review if permanent stoma• GP referral for ongoing prescriptions (UK: appliances on prescription)PK +2\x!ppt/slides/_rels/slide13.xml.rels PK +2\Ї ppt/notesSlides/notesSlide13.xml 13PK +2\yv+ppt/notesSlides/_rels/notesSlide13.xml.rels PK +2\1Xvvppt/slides/slide14.xml STOMA REVERSAL (CLOSURE)⏱ Timing: Loop ileostomy reversal — 8–12 weeks; Loop colostomy — 3–6 months; End colostomy (Hartmann's reversal) — 3–6 months minimum Criteria for Reversal✓ Patient nutritionally optimised (albumin > 3.0 g/dL)✓ Distal anastomosis/bowel confirmed intact (contrast study)✓ No active infection, fistula, or systemic disease✓ Underlying disease in remission (e.g. cancer surveillance complete)✓ Patient medically fit for general anaesthesia✓ Patient consents and understands risk of incontinence Operative TechniqueLoop Ileostomy: Mobilise loop at skin level; close enterotomy transversely (GIA stapler or hand-sewn)Loop Colostomy: Similar technique; colotomy closed in layers; fascial defect repairedHartmann's Reversal: Laparotomy; mobilise rectal stump; left iliac fossa colostomy takedown; colorectal anastomosisAnastomosis: Hand-sewn (2-layer) or stapled; test with air insufflation before closure Complications of Stoma ReversalAnastomotic leak2–7%Most feared; IR drainage vs. re-operationWound infection~10%Clean-contaminated procedure; prophylactic antibioticsBowel obstruction5–10%Adhesions post reversal; usually resolves conservativelyIncontinenceVariableEspecially after low anastomosis or sphincter damageAnastomotic stricture3–5%Late complication; dilation or re-operationPK +2\O!ppt/slides/_rels/slide14.xml.rels PK +2\0 ppt/notesSlides/notesSlide14.xml 14PK +2\?ݤ+ppt/notesSlides/_rels/notesSlide14.xml.rels PK +2\Cffppt/slides/slide15.xml KEY TAKEAWAYS50%Parastomal herniaMost common late complication1–2 cmColostomy levelFlush with skin surface2–3 cmIleostomy spoutAbove skin for appliance seal8–12 wksLoop ileo reversalMinimum post-op time1Pre-operative stoma siting by a trained SCN is essential — reduces complications and improves patient outcomes.2Choose stoma type based on pathology, bowel segment, patient factors, and whether reversal is planned.3Ileostomy output >2000 mL/day = High Output Ileostomy — investigate and manage electrolyte losses aggressively.4Ischaemia within 24–48h post-op is a surgical emergency — assess depth and re-operate if full-thickness necrosis.5Parastomal hernia: place stoma through rectus abdominis, use prophylactic mesh in high-risk patients.6Reversal requires: intact distal bowel (contrast study), nutrition optimised, patient medically fit, disease controlled.Stoma Surgery · Surgical Education Series · For Academic Use OnlyPK +2\*R!ppt/slides/_rels/slide15.xml.rels PK +2\Qz ppt/notesSlides/notesSlide15.xml 15PK +2\$Q+ppt/notesSlides/_rels/notesSlide15.xml.rels PK +2\K !ppt/slideMasters/slideMaster1.xml PK +2\N),ppt/slideMasters/_rels/slideMaster1.xml.rels PK +2\6TT!ppt/notesMasters/notesMaster1.xml 7/23/19Click to edit Master text stylesSecond levelThird levelFourth levelFifth level‹#›PK +2\s **,ppt/notesMasters/_rels/notesMaster1.xml.rels PK +2\_rels/PK +2\ $docProps/PK +2\Kppt/PK +2\ mppt/_rels/PK +2\ ppt/charts/PK +2\ppt/charts/_rels/PK +2\ppt/embeddings/PK +2\ ppt/media/PK +2\Bppt/slideLayouts/PK +2\qppt/slideLayouts/_rels/PK +2\ppt/slideMasters/PK +2\ppt/slideMasters/_rels/PK +2\  ppt/slides/PK +2\3ppt/slides/_rels/PK +2\ bppt/theme/PK +2\ppt/notesMasters/PK +2\ppt/notesMasters/_rels/PK +2\ppt/notesSlides/PK +2\ppt/notesSlides/_rels/PK +2\` P[Content_Types].xmlPK +2\]] T$_rels/.relsPK +2\00nppt/viewProps.xmlPK +2\H7t!Srppt/slideLayouts/slideLayout1.xmlPK +2\ђ77,Auppt/slideLayouts/_rels/slideLayout1.xml.relsPK +2\xWxxvppt/slides/slide1.xmlPK +2\3 mppt/slides/_rels/slide1.xml.relsPK +2\.yppt/notesSlides/notesSlide1.xmlPK +2\:A*Fppt/notesSlides/_rels/notesSlide1.xml.relsPK +2\ LPPYppt/slides/slide2.xmlPK +2\2- ppt/slides/_rels/slide2.xml.relsPK +2\ppt/notesSlides/notesSlide2.xmlPK +2\xշ*ppt/notesSlides/_rels/notesSlide2.xml.relsPK +2\ؚPPppt/slides/slide3.xmlPK +2\W/ Ippt/slides/_rels/slide3.xml.relsPK +2\K |ŐKppt/notesSlides/notesSlide3.xmlPK +2\9 Y*Rppt/notesSlides/_rels/notesSlide3.xml.relsPK +2\UUTppt/slides/slide4.xmlPK +2\` ppt/slides/_rels/slide4.xml.relsPK +2\vsppt/notesSlides/notesSlide4.xmlPK +2\J *óppt/notesSlides/_rels/notesSlide4.xml.relsPK +2\T!!ֵppt/slides/slide5.xmlPK +2\5 *6ppt/slides/_rels/slide5.xml.relsPK +2\W868ppt/notesSlides/notesSlide5.xmlPK +2\Qe*?ppt/notesSlides/_rels/notesSlide5.xml.relsPK +2\m뾧xxAppt/slides/slide6.xmlPK +2\ج+ ppt/slides/_rels/slide6.xml.relsPK +2\zppt/notesSlides/notesSlide6.xmlPK +2\=|*ppt/notesSlides/_rels/notesSlide6.xml.relsPK +2\1|^^ppt/slides/slide7.xmlPK +2\F #ppt/slides/_rels/slide7.xml.relsPK +2\)l%ppt/notesSlides/notesSlide7.xmlPK +2\|g*,ppt/notesSlides/_rels/notesSlide7.xml.relsPK +2\FũVV.ppt/slides/slide8.xmlPK +2\6 ppt/slides/_rels/slide8.xml.relsPK +2\iސppt/notesSlides/notesSlide8.xmlPK +2\pO*]ppt/notesSlides/_rels/notesSlide8.xml.relsPK +2\݂U++pppt/slides/slide9.xmlPK +2\>$ 7ppt/slides/_rels/slide9.xml.relsPK +2\q9ppt/notesSlides/notesSlide9.xmlPK +2\1*@ppt/notesSlides/_rels/notesSlide9.xml.relsPK +2\nnBppt/slides/slide10.xmlPK +2\Ѳ!\ppt/slides/_rels/slide10.xml.relsPK +2\O jppt/notesSlides/notesSlide10.xmlPK +2\T+9ppt/notesSlides/_rels/notesSlide10.xml.relsPK +2\m=k_k_Nppt/slides/slide11.xmlPK +2\;!1ppt/slides/_rels/slide11.xml.relsPK +2\s6ӑ 3ppt/notesSlides/notesSlide11.xmlPK +2\O+:ppt/notesSlides/_rels/notesSlide11.xml.relsPK +2\r'bb<ppt/slides/slide12.xmlPK +2\c!)ppt/slides/_rels/slide12.xml.relsPK +2\*)@ 7ppt/notesSlides/notesSlide12.xmlPK +2\Fb+ppt/notesSlides/_rels/notesSlide12.xml.relsPK +2\m 99ppt/slides/slide13.xmlPK +2\x!Ippt/slides/_rels/slide13.xml.relsPK +2\Ї Kppt/notesSlides/notesSlide13.xmlPK +2\yv+eRppt/notesSlides/_rels/notesSlide13.xml.relsPK +2\1XvvzTppt/slides/slide14.xmlPK +2\O!mppt/slides/_rels/slide14.xml.relsPK +2\0 {ppt/notesSlides/notesSlide14.xmlPK +2\?ݤ+Jppt/notesSlides/_rels/notesSlide14.xml.relsPK +2\Cff_ppt/slides/slide15.xmlPK +2\*R!x=ppt/slides/_rels/slide15.xml.relsPK +2\Qz ?ppt/notesSlides/notesSlide15.xmlPK +2\$Q+UFppt/notesSlides/_rels/notesSlide15.xml.relsPK +2\K !jHppt/slideMasters/slideMaster1.xmlPK +2\N),@gppt/slideMasters/_rels/slideMaster1.xml.relsPK +2\6TT!Hippt/notesMasters/notesMaster1.xmlPK +2\s **,ۆppt/notesMasters/_rels/notesMaster1.xml.relsPK__DO