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Publication Open Access Intraoperative Neuromonitoring in Thyroid Surgery: An Efficient Tool to Avoid Bilateral Vocal Cord Palsy(SAGE Publications Ltd, 2021) Kartal, Kinyas; Aygün, Nurcihan; Celayir, Fevzi; Besler, Evren; Çitgez, Bülent; Işgör, Adnan; Uludaǧ, Mehmet; Kartal, Kinyas, Department of General Surgery, Koç Üniversitesi, Istanbul, Turkey; Aygün, Nurcihan, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Celayir, Fevzi, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Besler, Evren, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Çitgez, Bülent, Department of General Surgery, University of Health Sciences, Istanbul, Turkey; Işgör, Adnan, Department of General Surgery, Bahçeşehir Üniversitesi, Istanbul, Turkey; Uludaǧ, Mehmet, Department of General Surgery, University of Health Sciences, Istanbul, TurkeyObjectives: This study aimed to analyze the effects of intraoperative neuromonitoring (IONM) on the prevalence of vocal cord palsy (VCP) in thyroid surgery. Methods: Data from 493 patients (839 nerves at risk [NAR]) who underwent thyroid surgery between July 2014 and May 2016 were retrospectively evaluated. The patients were divided into 2 groups: Group 1 (G1) consisted of patients who underwent surgery without IONM, whereas group 2 (G2) consisted of patients who underwent surgery with IONM. The surgical techniques were identical, and experienced surgeons performed the procedures in both groups. Intraoperative neuromonitoring was performed in compliance with the International Neural Monitoring Guidelines. Results: In total, 211 patients (170 female, 41 male) with 360 NAR were included in G1, and 282 patients (220 female, 62 male) with 479 NAR were included in G2. The number of VCP per NAR in G1 and G2 was 33 (9.2%) and 27 (5.6%), respectively (P =.005). The number of transient VCP per NAR in G1 and G2 was 27 (7.5%) and 23 (4.8%, P =.230), respectively. The number of permanent VCP per NAR in G1 and G2 was 6 (1.7%) and 4 (0.8%, P =.341), respectively. Bilateral VCP was detected in 4 (2.7%) patients in G1, whereas there was no patient with bilateral VCP in G2 (P =.033). Conclusions: Intraoperative neuromonitoring may decrease the incidence of total VCP and prevent the development of bilateral VCP, which has unfavorable results for both patients and health-care professionals. © 2022 Elsevier B.V., All rights reserved.Publication Open Access The effect of strap muscle transection on voice and swallowing changes after thyroidectomy in patients without laryngeal nerve injury(Royal College of Surgeons of England, 2022) Aygün, Nurcihan; Celayir, Fevzi; Işgör, Adnan; Uludaǧ, Mehmet; Aygün, Nurcihan, University of Health Sciences, Istanbul, Turkey; Celayir, Fevzi, University of Health Sciences, Istanbul, Turkey; Işgör, Adnan, Bahçeşehir Üniversitesi, Istanbul, Turkey; Uludaǧ, Mehmet, University of Health Sciences, Istanbul, TurkeyIntroduction Voice and swallowing symptoms are frequently reported after thyroidectomy even without laryngeal nerve injury. We aimed to evaluate the effect of strap muscle transection on voice and swallowing outcome after thyroidectomy. Methods Group 1 (G1) consisted of 17 patients who had their strap muscles transected during thyroidectomy and group 2 (G2) consisted of 17 patients who had their strap muscles preserved during thyroidectomy. None of the patients had laryngeal nerve injury. Voice impairment scores (VIS) and swallowing impairment scores (SIS) were obtained preoperatively and at 1 week and 1, 3 and 6 months postoperatively. Pre- and postoperative vocal cord examinations were performed for all patients. The external branch of the superior laryngeal nerve (EBSLN) was evaluated by intraoperative cricothyroid muscle electromyography. Results There was no significant difference in VIS and SIS between the two groups. At postoperative week 1, the VIS and SIS for each group were above preoperative values (G1: p = 0.005 and p = 0.035, G2: p = 0.031, p = 0.346, for VIS and SIS respectively). The VIS and SIS scores at 6 months postoperatively were significantly lower than those of the first week postoperatively (G1: p = 0.04 and p = 0.001, G2: p = 0.022 and p = 0.034 respectively) and similar to preoperative values (G1: p = 0.924 and p = 0.086, G2: p = 0.822 and p = 0.187 respectively). Conclusion Although voice and swallowing complaints increased in the early postoperative period even without recurrent laryngeal nerve and EBSLN injuries, these symptoms are not related with the strap muscle transection. © 2023 Elsevier B.V., All rights reserved.Publication Open Access Endocrine Surgery during the COVID-19 Pandemic: Recommendations from the Turkish Association of Endocrine Surgery(2020) Teksöz, Serkan; Sormaz, İsmail Cem; İçöz, Recep Gökhan; Makay, Özer; Dural, Ahmet Cem; Hacıyanlı, Mehmet; Şahbaz, Nuri Alper; İşcan, Yalın; Soylu, Selen; Aygün, Nurcihan; İşgör, Adnan; Özdemir, Murat; Aydın, Oğuz Uğur ; Tunca, Fatih; Şenyürek, Yasemin; Uludağ, Mehmet Emin; Emre, Ali Uğur; İstanbul Üniversitesi - Cerrahpaşa; İstanbul Üniversitesi; Ege Üniversitesi; Ege Üniversitesi; Sağlık Bilimleri Üniversitesi; İzmir Katip Çelebi Üniversitesi; Sağlık Bilimleri Üniversitesi; İstanbul Üniversitesi; T.C. Sağlık Bakanlığı; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Ege Üniversitesi; T.C. Sağlık Bakanlığı; İstanbul Üniversitesi; İstanbul Üniversitesi; Sağlık Bilimleri Üniversitesi; T.C. Sağlık BakanlığıThe 2019 novel coronavirus disease (COVID-19) was initially seen in Wuhan, China, in December 2019. World Health Organizationclassified COVID-19 as a pandemic after its rapid spread worldwide in a few months. With the pandemic, all elective surgeries andnon-emergency procedures have been postponed in our country, as in others. Most of the endocrine operations can be postponedfor a certain period. However, it must be kept in mind that these patients also need surgical treatment, and the delay time shouldnot cause a negative effect on the surgical outcome or disease process. It has recently been suggested that elective surgical interventionscan be described as medically necessary, time-sensitive (MeNTS) procedures.Some guidelines have been published on proper and safe surgery for both the healthcare providers and the patients after theimmediate onset of the COVID-19 pandemic. We should know that these guidelines and recommendations are not meant toconstitute a position statement, the standard of care, or evidence-based/best practice. However, these are mostly the opinionsof a selected group of surgeons. Generally, only life-threatening emergency operations should be performed in the stage wherethe epidemic exceeds the capacity of the hospitals (first stage), cancer and transplantation surgery should be initiated when theoutbreak begins to be controlled (second stage), and surgery for elective cases should be performed in a controlled manner withsuppression of the outbreak (third stage).In this rapidly developing pandemic period, the plans and recommendations to be made on this subject are based on expert opinionsby considering factors, such as the course and biology of the disease, rather than being evidence-based. In the recent reportsof many endocrine surgery associations and in various reviews, it has been stated that most of the cases can be postponed to thethird stage of the epidemic.We aimed to evaluate the risk reduction strategies and recommendations that can help plan the surgery, prepare for surgery, protectboth patients and healthcare workers during the operation and care for the patients in the postoperative period in endocrine surgery.Publication Open Access Surgical Indications and Techniques for Adrenalectomy(2020) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; Bahçeşehir ÜniversitesiIndications for adrenalectomy are malignancy suspicion or malignant tumors, non-functional tumors with the risk of malignancyand functional adrenal tumors. Regardless of the size of functional tumors, they have surgical indications. The hormone-secretingadrenal tumors in which adrenalectomy is indicated are as follows: Cushing’s syndrome, arises from hypersecretion of glucocorticoidsproduced in fasciculata adrenal cortex, Conn’s syndrome, arises from an hypersecretion of aldosterone produced by glomerulosaadrenal cortex, and Pheochromocytomas that arise from adrenal medulla and produce catecholamines. Sometimes, bilateral adrenalectomy may be required in Cushing's disease due to pituitary or ectopic ACTH secretion. Adenomas arise from the reticularis layerof the adrenal cortex, which rarely releases too much adrenal androgen and estrogen, may also develop and have an indication foradrenalectomy. Adrenal surgery can be performed by laparoscopic or open technique. Today, laparoscopic adrenalectomy is the goldstandard treatment in selected patients. Laparoscopic adrenalectomy can be performed transperitoneally or retroperitoneoscopically. Both approaches have their advantages and disadvantages. In the selection of the surgery type, the experience and habits ofthe surgeon are also important, along with the patient’s characteristics. The most common type of surgery performed in the worldis laparoscopic transabdominal lateral adrenalectomy, which most surgeons are more familiar with. The laparoscopic anterior transperitoneal approach is the least preferred laparoscopic method in adrenalectomy. Retroperitoneal laparoscopic adrenalectomy canbe performed with a posterior or lateral approach. In addition to conventional laparoscopy, laparoscopic surgery is robot-assisted,which can be administered by transperitoneal or retroperitoneal approach. In addition, conventional or robot-assisted laparoscopicadrenalectomy can be performed transabdominally or retroperitoneally using the single-port method. Today, partial adrenalectomycan be performed using laparoscopic techniques in bilateral adrenal masses, hereditary diseases with the risk of developing multipleadrenal tumors, and solitary masses of the adrenal gland. Open surgery is indicated in the case of malignancy or suspected malignancy and large tumors when laparoscopic surgery is contraindicated. The risk of conversion to open surgery is low (approximately 5%).The open transperitoneal anterior approach is the most common open intervention, especially in large tumors with malignancy orsuspected malignancy. This procedure can be performed using a midline incision, bilateral or unilateral subcostal incision, Makuuchior modified Makuuchi incision. Thoracoabdominal incision may be required, especially in the removal of large malignant lesions as ablock. The open retroperitoneal approach can be applied posteriorly or laterally.Publication Open Access Factors Influencing the Relationship of the External Branch of the Superior Laryngeal Nerve with the Superior Pole Vessels of the Thyroid Gland(2020) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Demircioğlu, Mahmut Kaan; Demircioğlu, Zeynep Gül; Akgün, İsmail Ethem; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri ÜniversitesiObjectives: In a thyroidectomy, the external branch of the superior laryngeal nerve (EBSLN) is a potential risk during the superiorpole dissection due to its close anatomical relationship with the superior thyroid artery and its highly variable anatomy. In thisstudy, we aimed to evaluate the relationship of EBSLN with the superior pole considering Cernea classification and the factors affecting this relationship.Methods: The data of thyroidectomized 126 patients (95 female, 31 male) with 200 neck sides (mean age of 45.6±12.1 years) usingintraoperative neuromonitoring (IONM) for the EBSLN exploration were evaluated retrospectively. During the superior pole dissection, the EBSLN course was classified according to Cernea classification after being confirmed with IONM. It was defined as a largegoiter in the case of the thyroid lobe volume being >50 cc. The factors influencing the presence of type 2b, which has the highestrisk of injury, were evaluated using logistic regression analysis.Results: Of the 200 EBSLNs evaluated, 52 (26%) were type 1, 134 (68%) were type 2a, and 14 (7%) were type 2b. The mean volumesof the resected thyroid lobes were 22±25 cc (min-max: 2-136), 23±20 cc (3-163), and 39±24 cc (3-65) in type 1, 2a and 2b, respectively, which was significantly higher in type 2b (p=0.035). Presence of large goiter rates were 5.8% (n=3), 8.2% (n=11), 64.3% (n=9)in type 1, 2a, and 2b, respectively, and was significantly higher in type 2b (p=0.0001). There was no significant difference betweenEBSLN Cernea types concerning age, sex, nerve side, presence of cancer and hyperthyroidism. In logistic regression analysis, largegoiter was the only independent factor associated with Cernea type 2b. In case of a lobe volume greater than 50 cc, the probabilityof type 2b presence was approximately 25 times higher (p<0.001, odds ratio: 25.262).Conclusion: Type 2b course of EBSLN is more common in large goiters, and it is 25 times more likely to be seen in the presence ofa lobe volume over 50 cc. Thus, it should be considered that the probability of this high-risk course is significantly higher in largegoitersPublication Open Access Anatomical, Functional, and Dynamic Evidences Obtained byIntraoperative Neuromonitoring Improving the Standards ofThyroidectomy(2021) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri ÜniversitesiThe use of intraoperative neuromonitoring (IONM) is getting more common in thyroidectomy. The data obtained by the usage ofIONM regarding the laryngeal nerves’ anatomy and function have provided important contributions for improving the standardsof the thyroidectomy. These evidences obtained through IONM increase the rate of detection and visual identification of recurrentlaryngeal nerve (RLN) as well as the detection rate of extralaryngeal branches which are the most common anatomic variations ofRLN. IONM helps early identification and preservation of the non-recurrent laryngeal nerve. Crucial knowledge has been acquiredregarding the complex innervation pattern of the larynx. Extralaryngeal branches of the RLN may contribute to the motor innerva tion of the cricothyroid muscle (CTM). Anterior branch of the extralaryngeal branching RLN has always motor function and givesmotor branches both to the abductor and adductor muscles. In addition, up to 18% of posterior branches may have adductor and/ or abductor motor fibers. In 70–80% of cases, external branch of superior laryngeal nerve (EBSLN) provides motor innervation tothe anterior 1/3 of the thyroarytenoid muscle which is the main adductor of the vocal cord through the human communicatingnerve. Furthermore, approximately 1/3 of the cases, EBSLN may contribute to the innervation of posterior cricoarytenoid musclewhich is the main abductor of ipsilateral vocal cord. RLN and/or EBSLN together with pharyngeal plexus usually contribute to themotor innervation of cricopharyngeal muscle that is the main component of upper esophageal sphincter. Traction trauma is themost common reason of RLN injuries and constitutes of 67–93% of cases. More than 50% of EBSLN injuries are caused by nervetransection. A specific point of injury on RLN can be detected in Type 1 (segmental) injury, however, Type 2 (global) injury is the lossof signal (LOS) throughout ipsilateral vagus-RLN axis and there is no electrophysiologically detectable point of injury. Vocal cordparalysis (VCP) develops in 70–80% of cases when LOS persists or incomplete recovery of signal occurs after waiting for 20 min.In case of complete recovery of signal, VCP is not expected. VCP is temporary in patients with incomplete recovery of signal andpermanent VCP is not anticipated. Visual changes may be seen in only 15% of RLN injuries, on the other hand, IONM detects 100%of RLN injuries. IONM can prevent bilateral VCP. Continuous IONM (C-IONM) is a method in which functional integrity of vagus-RLNaxis is evaluated in real time and C-IONM is superior to intermittent IONM (I-IONM). During upper pole dissection, IONM makessignificant contributions to the visual and functional identification of EBSLN. Routine use of IONM may minimalize the risk of nerveinjury. Reduction of amplitude more than 50% on CTM is related with poor voice outcome.Publication Open Access Effects of Central Neck Dissection on Complications in Differentiated Thyroid Cancer(2021) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Gül Demircioğlu, Zeynep; Ünlü, Mehmet Taner; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; T.C. Sağlık Bakanlığı; T.C. Sağlık BakanlığıObjective: It is still controversial whether performing central neck dissection (CND) in addition to total thyroidectomy (TT) increases the risk of complications. In the present study, we aimed to evaluate the effect of CND on the development of complications in differentiated thyroid cancer (DTC) compared to TT. Material and Methods: The data of 186 patients (136 females and 50 males) with a mean age of 48.73±14.78 (range, 17–82) whom were operated for DTC were evaluated retrospectively. The patients were divided into two groups, TT (Group 1) and CND±TT/ Completion thyroidectomy±lateral neck dissection (Group 2). Results: There were 117 (91 F, 26 M) patients in Group 1 and 69 (45 F, 24 M) patients in Group 2. Parathyroid auto transplantation (PA) was significantly higher in Group 2 compared to Group 1 (42% vs. 6%) (p=0.000). Total (58% vs. 21.4%, respectively, p=0.000) and transient hypoparathyroidism (52.2% vs. 20.5%, respectively, p=0.000) were significantly higher in Group 2 than in Group 1, but permanent hypoparathyroidism rates were statistically not significant (5.8% vs. 0.9%, respectively, p=0.064). In the multinomial logistic regression analysis, CND alone was determined as an independent risk factor for increased both total and transient hypoparathyroidism. The relative risk (RR) of CND for total hypoparathyroidism was 5.2 times increased (odds ratio [OR]: 0.192) (p=0.007), while the RR for transient hypoparathyroidism was 3.5 times increased (OR: 0.285) (p=0.036). According to the number of nerves at risk, CND was performed in 119 neck side and only thyroidectomy was performed in 253 neck side. Total vocal cord paralysis (VCP) rate (9 [7.6%] vs. 6 [2.4%], respectively) (p=0.017) and transient VCP rate (7 [6%] vs. 4 [1.6%], respectively) (p=0.021) in patients who underwent CND were significantly higher compared to those who underwent only thyroidectomy. In multinomial logistic regression analysis performing only CND was an independent risk factor for total VCP, and increased the total VCP RR approximately 5.34 times (OR:0.184, p=0.007). Conclusion: Although CND can be applied without increasing the rates of permanent hypoparathyroidism and VCP compared to TT, it increases the risk of total and transient hypoparathyroidism, total, and transient VCP. Patients undergoing CND should be followed carefully in terms of transient hypoparathyroidism.Publication Open Access Recent Developments of Intraoperative Neuromonitoring in Thyroidectomy(2021) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri ÜniversitesiAt present, intraoperative neuromonitorization (IONM) with surface electrode-based endotracheal tube (ETT) is a standard method in thyroidectomy and can be performed either intermittently IONM (I-IONM) or continuously IONM (C-IONM). Despite the valuable contribution of I-IONM to the thyroidectomy, it still has limitations regarding the recording electrodes and stimulation probe. New approaches for overcoming the limitations of I-IONMand developing the method are taking attention. Most of the technical issues of IONM with surface electrode-based ETT are related with inadequate contact of electrodes to the vocal cords. Nowadays, efficiency of various recording electrodes is under investigation. Recording electrodes such as needle electrodes applied to thyroarytenoid or posterior cricoarytenoid muscle (PCA), surface electrodes applied to the PCA, and needle or adhesive electrodes applied to the tracheal cartilage or skin, can make safe recordings similar to the ETT electrodes. Despite their invasiveness, needle electrodes record higher electromyography (EMG) amplitudes than tube electrodes do. Adhesive surface electrodes make safe EMG recordings, although hamplitudes of these electrodes are usually lower than those of the tube electrodes. These different types of electrodes are less affected by tracheal manipulations and amplitude changes are lower compared to the tube electrodes. During C-IONM, an additional stimulation probe is applied to the vagus nerve after dissecting the nerve circumferentially. Recently, without applying a probe, a new continuous monitorization method called laryngeal adductor reflex CIONM (LAR-CIONM) using sensorial, central, and motor components of LAR arch which is an automatic, primitive brainstem reflex protecting the tracheoesophageal tree from foreign body aspiration, has been implemented. Afferent track of LAR communicates laryngeal mucosa to the brainstem by internal branch of the superior laryngeal nerve and efferent track reaches larynx through recurrent laryngeal nerve. Total outcome of LAR activation is the closure of laryngeal entry by bilateral vocal cord adduction. In LAR-CIONM, a stimulus is given by an electrode from one side of surface electrode-based ETT and amplitude response of the LAR at the vocal cord is followed on the operation side. Recently, it has been reported that real-time EMG respoPublication Open Access Parathyroidectomy Results in Primary Hyperparathyroidism:Analysis of the Results From a Single Center(2021) Yetkin, Gürkan; Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Akgün, İsmail Ethem; Ünlü, Mehmet Taner; Erol, Rümeysa Selvinaz; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; T.C. Sağlık Bakanlığı; Sağlık Bilimleri ÜniversitesiObjectives: The curative treatment of primary hyperparathyroidism (PHPT) is surgery. Persistent and recurrent disease may de velop after surgical treatment. In this study, we aimed to evaluate the surgical cure rate in patients who underwent surgery forPHPT in our clinic. Methods: The data of patients who underwent parathyroidectomy for PHPT by two experienced surgeons between 2000 and2015 in our clinic were retrospectively evaluated. Patients who were followed for at least 6 months after their first parathyroidec tomy were included in the study. Surgical cure and persistent and recurrent disease rates were evaluated in patients. Results: During this period, 368 interventions were performed in 357 patients (293 F and 64 M) who were operated for PHPT inour clinic, with a mean age of 54.9±13.1 years. In the first surgery, 116 patients (32.5%) had bilateral neck exploration, 251 patients(67.5%) had unilateral neck exploration (UNE) or focused parathyroid surgery (FPS). In the first operation, 343 patients (96.1%) hadcure, 14 patients (13 F and 1 M) remained persistent. Secondary surgical intervention was performed in 11 patients. UNE or FPS wasperformed to 10 patients (90.9%), partial sternotomy was performed to one patient. Ten of the patients had cure. Three of these pa tients had a solitary parathyroid adenoma that was not removed in the first surgery, and seven patients had a second adenoma. Fourpatients remained persistent (1.1%). Recurrent disease developed in four patients during follow-up (1.1%). Total cure rate was 97.8%. Conclusion: The only definitive treatment for PHPT is surgery. High surgical cure can be achieved by pre-operative evaluationand appropriate surgical planning. However, persistent PHPT may develop, especially due to double adenoma or ectopic location.Patients with persistent PHPT can be evaluated with repeat imaging methods and with appropriate surgical planning, a high curerate can be obtained in secondary surgery, which can increase the total surgical cure rate. Recurrence rate is rare.Publication Open Access Surgical Treatment of Substernal Goiter Part 1: Surgical Indications, Pre-Operative, and Peroperative Preparation(2022) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Ünlü, Mehmet Taner; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri ÜniversitesiSurgery is one of the most appropriate treatment options for many patients with substernal goiter (SG). However, SG surgery has some technical difficulties and a higher risk of complications compared to normal cervical thyroid surgery. Due to these technical difficulties and complication risks, which we also mentioned in our study, SG surgery should be performed by experienced and high-volume endocrine surgeons in centers with a large team and technical equipment. Pre-operative clinical and radiological evaluation and definitions in SG were evaluated in detail in our previous study. Detailed pre-operative evaluation, pre-operative risk assessment, surgical anatomy, anesthesia, appropriate surgical planning and estimation of surgical width are extremely impor tant in SG surgery, where surgical technical difficulties and increased complication risks compared to cervical thyroid surgery come to the fore. In this study, we aimed to evaluate these preoperative and peroperative preparations in detail.