Surgical consultation — summary

• The recording begins mid-sentence: "…of the liver we accordingly do not touch". Which part of the liver is meant is cut off and cannot be recovered. For context only: in the 16.10 call the left-lobe lesion was planned for the second stage; whether the cut-off sentence refers to it cannot be determined.
• The procedure is a right hemihepatectomy, which in itself is a major liver resection.
• Stomach tumour: removed during the same operation where possible, provided it does not require an extra-large gastric resection.
• If an extra-large gastric resection would be required, the stomach tumour is left for the second stage. The call gives no further detail on how this fits the two-stage plan of 16.10.
• The planned operation and the earlier diagnostic staging laparoscopy are different operations.
• Open versus laparoscopic access is not stated explicitly; it appears only from the phrase that patients "after open operations" return to normal activity.

Sutures and length of stay

• Family question: about the sutures.
• Standard sutures are used; they will not hinder her in any way.
• Dr Fedorov's impression (hedged, "it seems to me"): the patient expects the course to be like after the diagnostic staging laparoscopy.
• After the right hemihepatectomy she will stay in the clinic for no less than one to one-and-a-half weeks.
• The sutures will most likely be removed in the clinic during that stay; therefore they do not limit her condition.
• Post-operatively her condition will be limited by the operation itself, not by the skin sutures, which are "not such a big factor".

Early post-operative period

• Family question: what she will be like after the operation, and whether she will be unconscious. The question about consciousness was not answered directly.
• For a certain time she will have restricted movement and will be lying down; as a rule this lasts several days.
• She will be on ward regime. She will lie in bed not because the doctors want it, but because getting up will most likely be hard for her.
• Family question: whether this is because of pain. Answer: yes, there will be post-operative pain, which can usually be controlled with analgesics.
• Restricted physical activity after the operation is a natural process and cannot be otherwise; a person cannot get up and run after half of the liver has been removed.
• If all goes well, patients after open operations then return to normal activity, with restrictions.
• It will not be like after the staging laparoscopy, when she went for a 3 km walk the next day; she must understand that this is a major intervention with restrictions.

• Family question: nutrition in hospital. The patient had reported that the food during her laparoscopy stay did not suit her; the family's understanding was that it was not nutritious enough and that she cannot eat everything.
• Early post-operative period: a "zero diet" — minimal nutrition, usually liquid food (soups or porridges) — which the clinic will provide.
• Taking something from the canteen is allowed; the clinic has no separate menu beyond its standard food.
• The hospital food is "not that bad" — ordinary hospital food. It differs from personal eating habits, but the post-operative situation is not ordinary either; the food is "more or less" chosen so that patients tolerate it.
• The team will give dietary recommendations in the post-operative period (what she may and may not eat).
• Family question: the family raised ordering therapeutic hospital-type meals from an outside delivery service, as they had done in the past, and asked which diet "table" number applies.
• Dr Fedorov said the diet is usually table No. 4 (the family will clarify this later).
• Ordering such outside meals is fine, though they will not be needed on the first post-operative day.
• She should first try to eat what the clinic serves; possibly nothing else will be needed.
• "God willing" she will be able to get up and walk early "in order to eat further" (purpose of the phrase unclear).
• Further food questions can be resolved as they arise.

• Any liver resection, especially with this pathology, carries a certain risk; not all post-operative risks can be predicted.
• Deviation from the plan: the operation may depart from the planned order; intra-operative findings may change the course of the operation and the team's actions.
• Usually this does not happen; there are few risks in principle, but they exist potentially.
• Tumour rupture during the operation is the most unpleasant risk. The team hopes it will not happen, but it cannot be excluded 100 %.
• Reason: the tumour looks like an abscess — thin tumour walls with necrosis inside.
• Bleeding: such operations usually proceed without large blood loss, but this cannot be excluded either; it can occur intra-operatively.
• The clinic has the necessary blood components available for that case.
• Dr Fedorov corrected himself: not blood loss as such but bleeding is a fairly dangerous complication that can lead to undesirable consequences, and the family should understand this.
• Wound infection: such patients have a risk of post-operative wound infection, related not to the clinic's sanitary state but to weakened immunity in cancer patients, who are more vulnerable to infectious complications.
• Unpredictable course: how the post-operative period will go cannot be said before the operation; it usually goes normally, but there is always a risk of deviation from the normal course.
• Dr Fedorov then invited specific questions.

Risk numbering in the recording is inconsistent; see wording unclear.

• She will need medications; Oleksandr Mykolaiovych had already explained them to her and to the family (Dr Fedorov's vague wording). No medication is named in this call.
• Dr Fedorov's understanding (second-hand, "as I understood"): it had been agreed (by "them"; who is not said) that a clinic nurse will be with her in the post-operative period; he asked the family to confirm.
• The family confirmed: the patient said she has already met the nurse.
• The team will tell the family everything that is needed for the operation (for example the surgical sets); if additional medications are needed, the team will discuss this with the family.
• At the time of the call nothing further was needed beyond what was currently required; in Dr Fedorov's words, the family had done everything needed.
• Practical questions about the nurse are to be settled with Oleksandr Mykolaiovych, who will contact the family (or put them in touch) and explain how best to arrange it.
• The family has Oleksandr Mykolaiovych's contact details and will write to him.

• Family question: whether the clinic is fully state-owned rather than private. Answer: it is a state clinic participating in the NHSU (National Health Service of Ukraine) programme of medical guarantees.
• In Dr Fedorov's view, most commercial clinics do not perform such operations, and those that do usually have few such patients.
• Being operated on in a clinic that performs about one such operation a year is significantly riskier than here.
• Risks exist everywhere, but his clinic performs about 200 such operations a year, whereas low-volume clinics perform 1–2.
• The clinic has all supporting services needed to deal with potential problems: full ultrasound service, angiography, a cardiology department — "everything needed for this type of surgery".

• Family statement: the family had forgotten, the day before, to contact the CSD laboratory about preserving the tumour; asked what was meant, the family explained that they had wanted to preserve the tumour and that a colleague of Dr Fedorov's had asked something about it.
• Standard protocol: the surgeons remove the tumour and hand it to the clinic's own pathohistology laboratory.
• From then on the laboratory is responsible for it.
• If the family agrees something with the laboratory and the laboratory can do it, "let them do it".
• As standard, the laboratory will examine the tumour and the family will receive the same kind of report as before.
• He did not think anything separate or special would be done (sentence trails off).
• Family statement: "No, they don't have [it]" (referent unclear); the family had spoken with Vladyslav Oleksandrovych, and only meant to say that contact (with CSD) had not yet been made. Dr Fedorov: no problem.

• Dr Fedorov invited specific questions and said he would try to answer them.
• The family noted that the patient, being in hospital, will find some things out herself.
• The family will write if something was forgotten or new questions arise; Dr Fedorov: call or write [uncertain word] whenever needed.
• The call ended with thanks and good wishes on both sides (recording length 14:19).

• Sutures — answered (standard, removed in the clinic, not limiting).
• Hospital food — answered (zero diet early on, clinic food, canteen allowed, dietary recommendations).
• Diet table number — answered: usually table No. 4; the family will clarify this later.
• State or private clinic — answered (state clinic in the NHSU programme).
• Tumour preservation — answered with the standard protocol; any special handling can be discussed with the laboratory.
• Condition after the operation and whether she will be unconscious — the condition part was answered (bed rest, restricted movement); consciousness was not addressed directly.
• Whether the limitation is due to pain — answered (yes; usually controllable with analgesics).

• Whether she will be unconscious, sedated or in intensive care after the operation.
• Which part of the liver "is not touched" (cut off at the start of the recording).
• Whether the access is open or laparoscopic, other than the phrase "after open operations".
• The timing or details of a deferred gastric resection within the second stage.
• Names or doses of the post-operative medications.
• How long the zero diet lasts.
• The operation date (see the context note above).

• Start of the recording: the first words are cut off, so what in the liver is "not touched" is lost.
• "Get up and walk in order to eat further": the purpose is unclear (walking to the canteen, or resuming normal eating).
• Risk numbering: "first … that's one" refers to deviation from the plan; after the rupture risk he says "One. Second." before the bleeding risk, so "one" may be deviation or rupture; bleeding is "two".
• "How the post-operative period will go, before the operation, cannot be said": read as "cannot be said before the operation".
• "After open operations": the word "відкритих" (open) should be confirmed; it is the only indication of open access.
• "A colleague of yours asked something": which colleague and what was asked is not stated.
• "No, they don't have [it]": the referent is unclear.
• "They agreed" (nurse arrangement): who agreed is not said; Dr Fedorov knew of it second-hand.
• "Він зв'яже вас" (about the nurse arrangement, end of the call): either Oleksandr Mykolaiovych will contact the family, or he will put the family in touch, presumably with the nurse.
• "Call or write [?]": the second verb is uncertain.
• The clinic is not named in the recording.