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Um uh, the guideline uh society website. It, you take you to HM Messenger there. I mean, copy this. Ok. But do you, um, we have one beer, Osama and Sama. Um, if you can hear and see us, can you please give a thumbs up uh, in the chat, please? Who is your back? It's hard to really, I, hi guys. If you can cheer and see us, can you please give a thumbs up? Uh, we'll start in a few. We are just waiting for people to join, uh, those who are joined. Can you uh, participate in the poll before we start our session? And can you give a thumbs up if we are visible and audible to you, please? In the chat? I can see us. We can start if we don't know, um, how many of them joined? Now, there were three, there are three people who have joined, but I'm just waiting for the response for them to agree. The cur see, um, if you can join the pool as well and let us know the answer to your questions. Hi. Are we audible or visible? Could you just just give a thumbs up. I don't think they can use us. Uh I mean, can you ask someone to see you can hear? Roo? Yeah, that great. Oh um we'll be starting in five minutes if you can just uh answer the phone. Oh, they can hear and see clearly, which is good. Thank you, James. Thank you for answering. Um If you could just um answer the four questions as well, we'll be starting in a few minutes. OK, Amina. Are you able to see the responses of the question uh answers? Uh I'll have to the screen uh once, wait a minute. OK. Um All right. Uh We can start now. Hi guys. Uh My name is FEHA. I'm one of the Sh Os working here in the UK. Uh I work in the NHS uh Inman orthopedic. This is a teaching session that I've uh organized and I do this on alternate weekends. Um Miss Gio has kindly um agreed to teach us about E A which is a very important topic these days and she will be talking about the guidelines that are currently followed. What is your R and how it is done? And she has some questions as well that she has mentioned in the post if you could answer. And after this session, we will take all your questions and we will also have a few questions to see if you have learned. Well. OK. So without further ado I would um ask Amina to take over MS Sana and, um, she'll introduce herself and let us know what she's going to talk about. Thank you. Uh, hi, everyone. I am, uh, Sins and Amina. Uh, I'm here for today's session on enhanced recovery after surgery. Proto protocol. I'll be, uh, talking about it. Uh, so before we begin, uh, it would be better to know how much do you know so far about the, uh, the IR protocol for this, uh, for this reason, we have created a poll, uh, so that, uh, we can know, uh, we can know about what do you know, uh, about the protocol. So, uh, I cannot see the whole wrist thing now. And where, uh, how can I see the pool results? I'll read it up to you. So for the first uh, question, which is the normal cell line is best as opera preoperative fluid, is it true or false? Um 60% have mentioned, uh, that it's true. Um Then your next question, postoperative patients should be offered uh, food from the day of surgery. Sorry, I forgot to mention the word food. Uh I think people guessed that it's true. 66%. Um, then, um, peri anesthetic medications should not be given to patients preoperatively. They've mentioned most of them said it's false. And, uh, your last question, bowel prep is a must in all colorectal surgery. 80% have agreed to it and 20% thinks that it's false. Ok. Thank you for uh participating in the poll questions. So uh the enhanced recovery after surgery protocol is totally different from conventional what we have we have so far. So at first, I would like to answer the questions. The true or false. Uh The first question is normal Salon is best as perioperative fluid. It, it was believed that it's a best fluid as a perioperative in the perioperative period. But the answer is false. So uh it's better to use hypotonic solutions in the perioperative period because the normal cell and has high quantity of uh sodium and electrolytes which is harmful for the patient. So, in these cases, uh the uh in the IRS protocol, the best fluid to give in during the perioperative period is the uh hypo like the plasma or the person shows along with uh uh combination with the sodium L solutions. So the first answer is the uh answer will be in the 1st, 2nd 1, postoperative patients should be offered uh food from the day of surgery. The person have answer the correct answer, which is true. Uh Please believe that as early we uh we can start the feeding. It's better for the patient. It's more uh closer to the normal physiology. So it's better for the patient according to uh enhanced recovery protocol. It's it is said that as uh to uh start feeding as early as possible. So the answer is, and now the question, the preanesthetic medication should not be given to patients preoperatively. The answer is said to be false but the and will be, uh, true because, uh, in the recovery protocol, the anesthetic s are, should be avoided. They are in the patients because it has, uh, it has seen, it has been seen that the patients, uh, who receive the medications, preanesthetic medications, they have a postoperative, delayed recovery and longer hospital stay. So, for this reason, pre an patients are, um, should not be given, uh, to the patients. The true answer will be true. Uh, that is only 20% of the, uh, poll have answered it correctly. And the last question, bowel preparation is a must. In all colorectal surgery, 80% have answered. True, but the correct answer will be false because in the colorectal surgery, it has been seen. Now nowadays that bowel preparation is, uh, not must and, uh, in bowel preparation is harmful for the patient. I, I will, uh, I will talk about it, uh, in later on, I will explain it but, uh, the answer will be false because in all colon surgery, bowel preparation is not a mask. That's it. Thank you for joining in the pool. Now, we would, uh, we will go to 10 today's class. Um, I mean, Amina, uh, before we start, we have Doctor Aie asking a question. Um, if on long term PPI treatment does, uh, does checking and rectifying IIC hypomagnesemia cut risk of POSTOP I POSTOP uh Ile S uh in case of on long term uh PPIs uh treatment, uh There is no such recommendation up until now for the patient who, who get the long term PPIs for visualized plan should be used. Uh But there is no recommended form uh in this uh for specific specifically for the patients who use long term PPIs. Are we clear Sabiha? Uh Doctor Doctor Andy hope it helped. Um If you, if you could answer in the chat, yes. He said time we can start, I think. Yeah. So uh I'll go share my screen. No. Yeah. Can see the screen fabia. Can you see the screen? I can see? Yes. OK. So today we will be talking about the uh protocol, enhanced recovery after surgery. So um for introduction, it is an evidence based multi uh multi, it is an evidence based protocol which is multimodal and per using the perioperative period which focuses on uh to reduce the stress and it promotes an early normal body function. It has been proved to lower recovery time and postoperative complications are also lower in patients who who have been treated with the enhanced recovery protocol. It also becomes the cost effective for patient. So it fundamentally shifts the traditional patients care of uh conventional care system and standardized it based on uh evidences. So it started in the year 2000 and the uh but the is society was founded in the 2010 and its headquarters are in Sweden uh website. The all the guidelines I will be sharing with you today. Uh It's all from the this society website. Anyone can go and see for yourself uh for the guidelines. The aim of protocol is to focus on the uh preoperative counseling option, standardizing analgesia without opioid use, minimizing, using the electrolyte and using most minimally invasive approaches in the surgical techniques and promoting our embolism, embolism and the feeding. So it has four components. It actually has uh there are many uh guidelines and I have uh show I'm showing you the guideline for four updated guideline for the colorectal surgery, uh surgery. One, there are uh they are uh similar to each other, but there are few components which will be different for different surgeries. So in the colorectal surgery, it have the four, they have four components, preadmission, preoperative, intraoperative and postoperative components. So, in the preadmission components, there are uh the information optimization of the patient, pre optimization of nutrition and anemia screening. And there is uh as you can see in the screen, the blue ones are the strong recommendation and the uh yellow one that is pre habilitation has weak recommendation for uh following. So as we have uh seen in the uh previous data, the pre information counseling and education has uh been strongly recommended that helps the patient to shorter the hospital stay and improves recovery uh promotes early recovery of the cancer. And for uh and it's the same for the preoperative optimization component. That at first before admitting the patient, we should assess the risk and optimize the systemic diseases. He has he or she has like if he has a heart condition, lung condition or a kidney disease or the patient having hypertension diabetes, this should be optimized. And if the patient has anemia or malnutrition, it should be corrected. And if the patient, uh we should also encourage the patient to uh uh avoid smoking and taking excessive alcohol, which will be uh which will help in the uh overall recovery of the patient and rehabilitation. It shows a promising result in the recovery of the patient. But uh as we have seen earlier, it's weakly recommended. Uh the pre habilitation techniques can be uh the pa we can encourage the patient for taking the uh chest physiotherapy and aerobic exercise. Uh aerobic exercises. These will help in pre habilitation of the patient. And then the preoperative nutritional care, routine preoperative nutritional assessment is necessary and we can also correct it preoperatively. And patient uh at risk of malnutrition should receive nutritional treatment. Uh preferable, it's preferable to give in the oral route for at least seven to 10 days. And for, of course, if the patients cannot, are not able to take the oral route, it's individualized for the cases and they can uh there is no such recommended protocol and it, it is individualized for each surgeons and the patients now, for anemia, it's, uh, it's really, uh, it's harmful for the patient if, uh, if, when, uh, and it causes many dif different postoperative complications. So it should be corrected before surgery. So we, uh, it has been seen that newer preparations of the intravenous iron has lower risk of a and adverse reactions and they are more effective than oral iron at restoring the hemoglobin level. And we ha we are also, uh, uh in this new protocol, it has been seen that blood transfusion has a long term side effect should be avoided if possible. And uh it's seen that uh hemoglobin level more than eight or more should not receive any blood transfusion if uh unless otherwise indicated. Now, the preoperative components in the preoperative components, uh we should aim at preventing the nausea and vomiting and uh selective premedications. We should avoid anesthetic premedications as we have uh talked earlier in the questions and use prophylactic antibiotics, bowel preparation are not necessary uh and maintaining U vol volume. Yeah. Uh zero balance, vol, uh volume and uh no fasting and carbohydrate drinks. These are different from the conventional beliefs that we used to uh make the patient fast for overnight and we used to give preanesthetic medication bowel preparation. So these are different from the conventional care. And so for prevention of nausea and vomiting, we should assess the risk factors like patient is female nausea and vomiting or motion, sickly nonsmoker. Uh they, they are at risk of developing this uh postoperative nausea. Uh and use of volatile anesthetic gases like nitrous or oxide and opioid be avoided. These will help in prevention of nausea. So if the patient has a risk of uh like 1 to 2 reasons, they should receive two drug combination of prophylaxis uh using first line antics. But if the patient has more than two risk factors, they should receive 2 to 3 antics combination. And if the, if still there is nausea and vomiting, despite the prophylactic doses, then salvage therapy is, should be given in the multimodal way. Uh And it should be also discussed with the uh team uh before giving to the patient. Now, the preanesthetic medications, the pharmac lysis and the sedatives we used before, uh in the be avoided as uh if possible before surgery. And it's better to use opioid sparing multimodal medications, um can be given in combination to NSA and acetaminophen. It's uh, has seen to be helpful, uh uh instead of the, instead of using the sedatives to the patient. Now, the antimicrobial ais and skin preparation, it, uh it's usually we actually know this and we use this in our country too that the intravenous uh antibiotic prophylaxis is given within 60 hours, uh 60 minutes before incision as a single dose. So all patients undergoing surgery, any surgery. In this case, the surgery, uh In addition, the patients receiving oral uh preparation, uh oral antibiotics should be given. And um in patients who receive no bowel preparation, there is no, uh there is no recommendation for giving the uh oral antibiotics. Skin disease infection should be performed using chlorhexidine or alcohol based preparation. And now the bowel preparation, mechanical bowel preparation alone with the systemic antibiotic has no clinical advantage, no clinical advantage. And can, you can cause dehydration and discomfort for the patient. And so it should not be used routinely in the colonic surgery, but it may be used in case of rectal surgeries. And there is some evidence from the randomized control trial to support the use of combination of bowel preparation and also uh an oral tic over the uh mechanical bowel preparation alone. Or if we give bowel preparation, they should be combined with oral anti that weeks. Now, the preoperative electrolyte therapy patient should reach the anesthetic room in a closed that the patient should, uh uh if the patient have fluid or electrolyte imbalance, they can correct it before going to surgery. And uh if the preoperative fasting and carbohydrate loading, uh we have all known uh previously that the patient should be stay overnight and uh it's better to fast more than that. So now the enhanced recovery protocol suggests the patient undergoing elective surgery should be allowed to eat even in the colorectal ones should be allowed to eat until six hours and he, she he or she can take clear fluids, including the carbohydrate drinks up until two hours before initiation of the anesthesia. So, patient with delayed gastric emptying and emergency patients should remain fasted, uh fasted overnight for uh only the patient with delayed gastric emptying and the emergency patient can be fasted overnight in case of these surgeries. Now, the intraoperative components, intraoperative components all having strong recommendations to use a standard anesthetic protocol and uh and maintaining a fluid normal volume. Yeah, and a normal therm using the best possible ways to uh um to use the minimal invasive surgeries and to avoid drains if possible. Now, the in uh now the components describing the components, intraoperative fluid and electrolyte therapy, fluid excess, uh excess leading to preop perioperative weight gain, more than 2.5 kg should be avoided. So a perioperative near zero balance should be approached should be preferred and goal directed fluid therapy should be adopted especially in case of highrisk patients in uh patients undergoing surgery with large intravascular fluid loss. Thus, uh using a standard anesthetic protocol, the use of short-acting anesthetics and uh proper monitoring, cerebellar monitoring to improve recovery and complete reversal of the neuro neuromuscular block is recommended and for preventing intraoperative hypothermia. Few steps can be taken uh reliable temperature monitoring. Then uh using active warming for the patient warmers and warming the intravenous IV fluids or blood uh blood transfusion. Uh it these these measures will avoid, will help us avoid the in uh inadvertent perioperative hypothermia. Now, minimally, as we have uh talked about earlier that minimally invasive techniques are better, a uh a minimally invasive approach to the colon and rectal cancer have clear advantage over, over the conventional open ones for improved and rapid recovery that it uh reduces the complications in and also the inn and uh fewer additions in the further surgeries, drainage of the peritoneal cavity and pelvis, it should, it has seen to show no effect on clinical outcome. So as we, we also believe that the uh an if we do an anastomosis and if we give a drain that it will help us, uh uh it will help us tou red. Uh it will help us to save the anastomosis or it will help us help the patient for early recovery. It's the wrong idea because there is no effect in clinical outcome. It's uh just for, it's better for we can uh for anastomosis, we can, it's better to use a drain only to see that uh we can, we can diagnose earlier in if there is an anastomotic leakage, that's the one benefit of using the drains and there is no clinical outcome other than this. Now, the postoperative components in the postoperative period, it's better not to use the uh uh nasogastric drainage. It's uh better to avoid it and to use multimodal analgesia, avoiding the opioids. We should give the thromboprophylaxis and uh fluid normal volume. Yeah, urinary catheterization should be given for 1 to 3 days. Prevention of hyperglycemia, post uh optimizing postoperative nutrition and early mobilization. So, getting into the components, nasogastric intubation, it should not be used routinely if it is inside during the surgery, the for reversal of anesthesia and it's also will uh depend on the surgeons too. Uh it's better to avoid the nasogastric, the postoperative analgesia, it's, it's better to avoid opioids and it causes the postoperative nausea. And so in the place of opioids, we can use the multimodal analgesics like uh thoracic epidural anesthesia, anesthesia, uh transversus abdomen is blocks. Uh these will be helpful in uh as analgesia instead of the opioid. Now, the thrombo prophy and undergoing major surgery should have a mechanical throop prophylaxis by well fitting compression, stocking and intermittent pneumatic compression until discharge. And they should also receive the log prophylaxis with low molecular weight heparin once for 28 days, artery and electrolyte therapy and N zero fluid and electrolyte balance should be maintain to hypotonic fluids instead of isotonic ones because of the electrolytes are not. And for also the replace replacement of 0 9% sodium chloride action should be avoided. So it should be replaced a balanced solution with 5% dextrose and combination with 0.5% sodium chloride ones. Patients re receiving the epidural analgesia arterial hypotension should be treated uh at first with uh correcting the volume and then using the vasopressors because in many cases, we we try to correct the volume and volume and we don't remember that the patient might be having hypotension because of the epidural. So, after correcting the volume, we should, uh, go for the vasopressors for, uh, uh, for because, uh, it's, uh, it's due to the epidural analgesia. Now, the routine urethral catheterization is recommended 1 to 3 days after surgery. Uh, the de should be individualized based on known risk factors like male gender, epidural analgesia pelvic surgery. They have more a chance of retention. So, patient with low risk should have a routine removal on the first day after surgery and be with moderate and high risk ization for up to three days and postoperative glycemic control. It has been seen that um the uh patients who are having, who have the insulin resistance um have a grave uh postoperative complications. So it's better for uh to improve the glycemic controls and uh also uh having no risk of hypoglycemia. So it for the patient diabetic diabetic patients, insulin should be used judiciously to maintain a blood glucose level, uh uh level as uh low as feasible, feasible with the available resources. Now, the postoperative nutritional care, most of most patients should be offered with food from the day of the surgery. Perioperative nutrition also should be uh also for the correct he's a surgery. Now, the early mobilization mobilization is uh it it great education of the patient. It's an very important component of the is protocol long immobilization has adverse side effects like thrombosis and also delays the wound healing of the Tenn and also causes uh and reduces the lung compliance. So, so as uh for understand, easier, when can we start operative in mostly in case of colors. As long as there is no risk of aspiration, patient can be allowed to take food from of the surgery and starting with, we can start soft water. And if he can um if he can tolerate the sips of water, like we, we will uh give the sips of water for uh if he can tolerate one liter of fluid in 24 hours, then we can shift to liquid. And if he can tolerate the, the liquid ones, then we can shift to the normal diet. And when to mobilize the patient, the patient should, should be out of bed for two hours a day, increasing up to six hours per day till discharge. So we can, it's a um it's the duty of the surgeons and the doctors to encourage the patient to sit and cough uh at the day of the surgery or uh the day after surgery. Uh and to get out of the bed, take a few steps. It uh it's a, it's the duty of the doctors to uh help mobilizing the patient because it's a very important component of the is protocol. So when can we give discharge in if we follow the is protocol uh completely, then the patient can be discharged once the patient has taken solid food diet and he can tolerate it. He uh his bowel has moved, his uh pain is controlled with oral medication and it's uh he is mobilizing sufficiently self uh self with selfcare and he uh there is no need to be dependent on anyone and there is no complications requiring hospital care. So, um uh as we have uh talked about, about all the components. Now we talk about how does it work? Usually the body physiology respond to stress in a cata bolic manner. So the central nervous system, it mediates this and produce different kinds of hormones, stress hormones and inflammatory mediators, which importantly causes the insulin resistance. So unlike the traditional care, it does protocol aim at with the development of insulin resistance because it uh tries to keep the body in no uh close to normal physiology so that it reduces the stress and reduces the insulins. It's a key element for prolonged uh insulin resistance is a component for producing prolonged recovery and increased morbidity. So, beginning with preoperative counseling, clear information to the reduces the anxiety and uh facilitate postoperative recovery and pain control also increases the care and uh and allowing for early recovery of the patient and earlier discharge. So all this will help us in uh it will reduce the all the it will um it it it will reduce all postoperative complications and hence promote recovery that it will be shorter hospital stay and also will be causative to the patient. But there are some difficulties in ation of this protocol because challenge, uh, challenge to the traditional belief and practice of this, that we believe that the patient should be fasted overnight. Bowel preparation is necessary. And, uh, all the, all the beliefs, it's a challenge to this. So it's difficult to implement this protocol. Uh, I did a paper on the, uh, enhanced recovery protocol in case of emergency colorectal surgery. And it was uh I also did uh so has the uh compliance to the protocol in that uh there, the compliance team was really poor because no one was uh uh no one was believing that it will work. So it's a challenge. And there is also a la uh uh in this protocol, there should be a collaboration between, between the surgeons at is and the nurses and all the health professionals uh for and proper communication within the team. And uh it's a, it's a huge challenge for uh collaboration. If it is lacking, then uh the, then the protocol can't be implemented. And also uh the patients are, should be, should believe this protocol because if they don't uh believe in it, uh there will uh we won't be able to implement this. And also there uh there is another challenge uh for implementation is that lack of the gene stuffs. So these are the difficulties in implementation of this protocol. So I you have understand up until now Thank you. Uh I hope you, you have learning from this session. Thank you so much. Thank you. That was a great session. So, um should I give the four of the, the questions that you wanted to ask? Yeah. Uh Any questions? Uh Yes, of course. If you have any questions, please, you can ask uh in the chat box and I'll read that out to you. And in the meantime, I'll just ask a few questions which was provided by Amina herself. Yeah, any questions guys, we're open to every question regarding this topic, please. Um Also I want to add uh we will have um teaching sessions as well as portfolio building sessions um in the upcoming days. If you would like to join, just keep an eye on the this particular channel and I'll keep up dating if you follow this. Um You will get updates as well. So uh you uh you have shared the post test questions. Uh I'm sharing now. Yes, there's one. Also we have a estrogen maybe or no. Uh If you see the pools, um you can answer through the pulse. Uh Are there four questions? Aina Yeah. Ok. And uh would you like to discuss, what is your next uh topic that you want to talk about in the next sessions? We can uh I think there is a question from uh from someone is irre suitable to apply Gian of surgery. Yes, it's applicable to all surgeries and um I I it, there are guidelines in the society website. I will uh send you link so that I have the is society where said have guidelines for all the surgeries. I will share the link so you can go to the uh er society website and see for yourself. It's actually a new guidelines. So it is uh they're, they're have they, the papers are uh very recent, they are a 2010 did it's form and after this, the uh guidelines have been coming out. So in the next session, we can uh talk about Crisp or if uh whatever we can do both one by one um to the people who have joined. Um You can also give us um options that you want us to discuss as Amina has mentioned about Crisp and etls. These are topics that uh because Amina has, I think uh completed hers and she will be able to answer questions regarding how to do the uh course itself because um if, if you are willing to enter surgical, really good courses that you can do and it adds up to your portfolio if you have completed these courses. So let us know if you want us to discuss about these topics and I can surely arrange something. Uh So I've added two questions and I'm adding the rest if you could answer these. And at the end of the session, I'll give you a feedback form to fill up if you fill that up, there will be a certificate that is generated and it will be sent by email. Any other questions that you might have uh for the po questions you have added two and uh I think we have two more questions. Yeah, I'm just giving the options now. Ok. Writing down the option. Yeah. Yeah. Ok. There was the third one. The last one is about to go up uh Amina if you would like to discuss the questions that have already been answered. Uh I think it's after all fours, given all four kids. Ok. Ok. And do anyone have any questions about the um about today's session? Nobody. And um again, uh guys, I'll ask you a question regarding what do you want us to discuss? Um in terms of surgical topics, it would be really helpful to know if you want to um add any topic. So I'll, I'll just arrange that uh apart from portfolio building ones. So the uh three questions are, that's the last one. Uh that's the last one I've added all the questions if you could answer. And I mean, if you could give us the proper answers, I have also provided um the feedback form to all of you guys. Um You'll be able to get your certificate after answering the questions from your feedback. Yes, Amina. Three. Ok. Uh Let's just take two more minutes so that we can answer and then we'll start explaining. Yeah. I think uh should start now. So the first question was epidural anesthesia, uh reduces the hormonal and metabolic response to surgery, but it also causes hypotension. 85% of uh the pole answered it correctly. That is true because uh epidural anesthesia, it reduces the hormonal and metabolic response. It's a benefit. So it's using the uh enhanced recovery protocol. But there is also a very uh grave, there is also a very grave side effect that it causes hypotension. So we should be careful uh in patients using the epidural anesthesia. Now, the second one is just a second. Yeah, the second one will be yes. Regarding mobilization, the patient should be out of bed for two hours on the day of surgery and increasing up to hours on the day of 100% of the population 100%. Uh people give them. That is the, that is true. And for the third one, by using the enhanced recovery protocol, it improves patient compliance uh and reduces complications by 25 to 30%. And and the third one is all of above. So the correct answer is all of above. It improves patient's compliance uh by 50 to 70%. It has been seen in the statistics and also uh in studies and also it reduces the complications by 25 to 30%. So the correct answer is 71% if the correct answer all of above. And now the third question is and hence uh the co uh all the comp the components of I protocol are evidence based perioperative care, multidisciplinary and multiprocessing, interactive audit and reporting. And uh fourth one is all, everyone gave the correct answer. That is all. And for another uh yeah, these are the four questions. I think everyone has understood it clearly because most of them gave the correct answer. So that's a relief. I hope you have under understand, understood today's session. And if you have any questions up until now, uh feel free to share in the messages, it would be helpful for you and also for us any questions. Um I can't see any questions to be honest. Um It either means you have done a really good job. Yeah. Um Well, you did a good job. So I would say that you are a good teacher. But um if you have any questions, we'll take them in the next couple of minutes. But Amina, thank you so much because you are doing this from a different time zone and I really appreciate you coming up and being a good sport about it. Um You're very busy as well. Oh, I know you've been doing surgeries the whole day. So thank you. Thank you for coming over and we'll have more sessions with you, I believe. And those who are watching, we will have more sessions, as I've mentioned twice earlier, uh regarding teaching sessions, uh regarding uh topics and surgery and I'll try to expand um the field to different medical specialties as well. Uh I'm just trying to reach out more um people that is and our next session will be regarding portfolio um uh and uh as well as teaching uh in acute abdominal uh cases, surgical cases. Uh I'll put up the poster. Very, very. Um and thank you for joining. Should we end, end the session then? Because we don't have any questions? Yeah, thank you so much. Ok, if you could um fill up the feedback form, uh you'll get the um, certificates via email. And if you have any questions later on that, you want to come back to this teaching session again, it will be saved here in the website so that you can come back and see it again. All right. Thank you so much. Thank you. Ok, thank you. Bye bye bye.