General surgery

Minimally Invasive Surgery

• Laparoscopic cholecystectomy: a 1-centimeter incision at the umbilicus and two or three other 5-millimeter incisions to extract the gallbladder
• Advantages: strong cosmetic advantage, less adhesions, faster recovery, and less postoperative pain

Robotic Surgery

• Similar to laparoscopy, but uses a robotic platform to remotely control instruments
• Advantages: improved vision, precision, and quality of movements
• Potential for integration with artificial intelligence and protocols for automatic identification of anatomical structures and anastomosis

Preoperative Evaluation

• Step 3: evaluate the type of surgery and determine if it is low risk
• Step 4: evaluate the patient's cardiovascular function using the MET score
• Step 5: investigate underlying cardiac risk index conditions

Cardiac Risk Index Conditions

• Pulmonary evaluation: consider smoking, COPD, preoperative sputum production, pneumonia, dyspnoea, and obstructive sleep apnoea
• Kidney evaluation: consider creatinine level >2 mg/dL and renal dysfunction
• Medications: beta-blockers, metformin, antithrombotic therapy, and acetylsalicylic acid

Global Risk Assessment

• American College of Surgeons' online calculator considers 20 clinical parameters and the type of procedure
• Predicts patient risk factors, but not perfect due to complexity of parameters

Frailty

• A state of reduced physiological capacity and increased susceptibility to disability caused by age-related loss of physical, cognitive, social, and psychological function
• A multi-factorial event considering age, chronic comorbidity, disability, and social and psychological function

Prehabilitation

• Prepares patients in the perioperative setting for better outcomes
• Includes nutritional assessment and supplementation, smoking cessation, physical exercise programs, and care for cognitive function and stress
• ERAS protocol reduces the stress response to surgery, while prehabilitation occurs before

Nutritional Support

• Improves surgical outcomes
• Supplementation can be oral, enteral, or parental
• Immunonutrition reduces postoperative infections
• 10-14 days of nutrition support recommended for severely malnourished patients

Prehabilitation

• Prepares patients in the perioperative setting to have better outcomes in surgery
• Includes:
  • Nutritional assessment and supplementation
  • Smoking cessation
  • Physical exercise programs
  • Cognitive function and stress management
• Improving nutritional status can improve surgery outcomes
• Malnutrition can be solved by giving supplementation (orally, enterally, or parenterally)

ERAS Protocol

• Reduces the stress response to surgery
• Occurs before surgery (preoperative)

Nutritional Support

• 10-14 days of nutrition support recommended for severely malnourished patients
• 7 days of immunonutrition (nutritional formulas aimed to regulate the immune system) recommended for all patients undergoing GI oncological surgery
• Immunonutrition reduces postoperative infections

Smoking Cessation

• High impact on patient outcomes
• Additional measures for COPD patients: breathing techniques, medications

Anemia Correction

• Iron supplementation or erythropoiesis stimulation (if it doesn't interfere with cancer treatment)
• Blood transfusions only in severe anemia with risk of organ ischemia

Telehabilitation

• Used to contact patients remotely to provide prehabilitation and monitor activity and psychological aspects

Principles of Surgical Oncology

• Distinction between surgeon and surgical oncologist
• Grading frailty:
  • Physical frailty (based on S&S: weight loss, exhaustion, weakness, slow walking speed, decreased physical activity)
  • Index frailty (considering cumulative comorbidities and illnesses)

Frailty Scale (FRAIL)

• Each affirmative answer to questions is worth 1:
  • Fatigue
  • Resistance
  • Ambulation
  • Illnesses
  • Loss of weight
• Patient is defined as frail when score is >3

Index Frailty

• Consider all comorbidities using a comprehensive geriatric assessment
• Takes into account functional status, diabetes, history of COPD, history of congestive heart failure and hypertension requiring medication

Sarcopenia

• Age-related loss of skeletal muscle mass, muscle strength, and muscle function
• More than 50% of patients > 80 years old are affected
• Large percentage of patients of any age with oncological diseases are also affected
• Associated with more complications, higher mortality, and longer hospital stay

TNM Staging

• Prefixes specify characteristics of staging:
  • cTNM: clinical, based on preoperative evaluation
  • pTNM: based on pathology data
  • yTNM: stage after chemo/radiotherapy
  • rTNM: stage for a recurrent tumor
  • aTNM: stage determined at autopsy
  • uTNM: stage based on ultrasound or endoscopic ultrasound
  • mTNM: in case of multiple tumors

Additional Parameters in TNM

• G (1-4): tumor grading
• S (0-3): elevation of serum tumor markers
• Pn (0-1): perineural invasion
• L (0-1): lymphatic vessel invasion
• V (0-2): venous invasion

Surgery in Diagnosis and Staging

• Role in diagnosis and staging:
  • Incisional and excisional biopsy
  • Exploratory laparoscopy to find metastases difficult to visualize with imaging

Prehabilitation

• Prepares patients in the perioperative setting for better surgical outcomes
• Includes:
  • Nutritional assessment and supplementation
  • Smoking cessation
  • Physical exercise programs
  • Cognitive function and stress management

Nutrition and Surgery Outcomes

• Improving nutritional status can enhance surgery outcomes
• Malnutrition can be solved by supplementation (orally, enterally, or parenterally)
• 10-14 days of nutrition support recommended for severely malnourished patients
• 7 days of immunonutrition recommended for all patients undergoing GI oncological surgery
• Immunonutrition reduces postoperative infections

Smoking Cessation and Respiratory Care

• Smoking cessation has a high impact on surgery outcomes
• COPD patients may require breathing techniques and medication
• Telerehabilitation can be used for remote prehabilitation and monitoring

Anemia and Blood Transfusions

• Correct anemia with iron supplementation or erythropoiesis stimulation
• Blood transfusions only considered in severe anemia with risk of organ ischemia

Surgical Oncology Principles

• Distinction between surgeon and surgical oncologist
• Evaluation of surgical risk involves assessing CV function and cardiac risk index conditions

Cardiovascular Evaluation

• MET score evaluates metabolic state and energy needed for daily tasks
• MET score < 4 indicates underlying CV condition
• Cardiac risk index conditions include unstable coronary disease, decompensated heart failure, and more

Pulmonary Evaluation

• Conditions that worsen surgery outcomes include smoking, COPD, and pneumonia
• Pulmonary rehabilitation reduces pulmonary impact during and after surgery

Kidney Evaluation

• Renal dysfunction affects approximately 5% of the adult population
• Creatinine level >2 mg/dL increases risk of postoperative cardiac complications

This quiz covers the laparoscopic cholecystectomy surgical procedure, including the removal of the gallbladder through small incisions. It also compares the traditional open surgery method with the laparoscopic approach.