SEON HAHN KIM da Vinci (Si &Xi) Low anterior resection

Yes, this is Kim.

This is Marco Vitellaro from Milano, also Guglielmo

it's here with me. Hello, Gugli, I can see you

behind. It's a pleasure to meet you.

I cannot hear you very well.

Professor Kim, it's a pleasure

to meet you. Maybe now you can hear me

better. Yes, yes.

Very glad

to see you.

I'm happy to see you too. How are you?

I'm very fine. Thank you very much.

Okay. Again, congratulations

on your finishing all

the process.

Thank you very much, Professor.

For becoming

a real surgeon. All right.

Good. Very good. Thank you very much.

hello hello okay you you can start whatever you want oh now can i start yes please

oh all right okay so can you see my video or

uh the slide or not not yet we we can see now your slide okay good so i would like to start

We are preparing ourselves for the demonstration that will be in less than one minute.

Do you have any information?

Basically, totally robotic, single docking, meaning robot cart does not move,

and double targeting with arm repositioning, meaning I have two different phase of procedures.

procedures. Firstly colonic face, secondly pelvic face. And I'm using two left hand technique.

What is two left hand technique? The scope is here and you can see two robotic working

arms on my, on the left side. That is two left hand technique. This is my SI port layout

out here scope and right low quadrant 12 millimeter for stapler and later stoma

and I mostly extend the wound for specimen extraction on left low

quadrant here and I have one five millimeter port for my bedside assistant

what that means here who the robotic arm move here and I'm three robotic arm over here so I'm using

these three for the pelvis for that my assistant can use both hands using these two ports this is

how it looks like from the outside.

This is a view from the patient's head.

This is leg and side ducking here.

Scope is here.

Two left hands, one right hand.

My assistant using two hands,

mainly right hand for suction,

left hand for traction on the rectum.

Where is he? He would be here.

This is a case.

low rectal cancer

after long course

chemo radiotherapy

8 weeks after

the completion of radiation

here very much responded

my

UK

fellow

Dr. Park

she is doing

doing IMV high ligation first technique, the lifting, the root of the mesentery, my right

hand is arm one, monopolar scissors, my main left hand is arm three here, is bipolar, very

Ascolta,

fatti lasciare in uno

e dille che la richiamo.

Dille che sto moderando

su un congresso internazionale

e la richiamo tra mezz'ora.

Once lifting up

the transverse colon here.

Perché questo lui sta,

ora sta facendo,

iniziamo la,

questa è la vena,

mi sento di pensare di ore.

Allora lui sta andando

verso la flessura da sotto.

Giusto?

Alla tecnica,

all'altra.

Non quella che facciamo

da sopra,

The space into the lesser sac, IMV high ligated here, pancreas.

I know not many surgeons use this technique, but this IMV ligation, then very early entering into the lesser sac.

In order to dissect both the pancreas, it's a very good technique for spleen flexor mobilization.

Medial to lateral or inferior to superior.

Professor Kim, this is a very interesting technique from bottom to up.

I know.

Okay.

Give us some tricks.

Trig is exactly same as what you see in this video. So after ligating the IMV, then lifting up the

transverse colonic mesentery, then cut the peritoneum, then you can get in.

and later on in my very short video with XI you can see it again after that much

dissection medial lateral or inferior to superior then approach to the IMA here

still my fellow Hyumi from UK she's trying to dissect of the IMA here

here she many times told me she never did this kind of uh skeletonized technique in uk before

trying to preserve the nerve which is aortic sympathetic nerve plexus can you see this nerve

then operator changed I'm doing this surgery here cut the peritoneum

overlying the sacral pulmonary and going backwards to the IMA area to preserve

the nerves here some nerve fibers going into the mesentery you can I can cut it

but the nerves going here toward the hypogastric nerve I have to preserve so

you can see the nerves here the right side left side again my right hand

instrument is monopolar scissors the power is about 25 my left hand is

Maryland which is bipolar this is already dissected of the IMV here my

My assistant is lifting up, here you can see the xerotas fascia overlying the kidney.

So arm 2, which is cardiac force, is lifting up the mesentery.

After completion of the medial dissection, then I go laterally.

My assistant is using this 5mm port on the right flank.

I'm dissecting off along the white line.

descending colon now my left hand is bipolar so I'm using monopolar on my

right hand and bipolar on my left hand that is very useful so mostly almost

from the beginning to the end I'm not much using any energy device just

Just monopolar and bipolar is enough, mostly.

Turning around, momentum, assistant, giving me a traction on the colon.

Traction, counter-traction.

This is geratous fascia, kidney.

So even through the transverse colon, I'm just keeping the line along the, close to the colon, which is mostly a vascular plane.

because already the pancreas was dissected off earlier everything is free

from the splenic flexor it's a very floppy IMA and for the for the very low

ultra low type of resection it is better to divide the left colic artery from

from the inside and the upper part of the rectum is is mobilized using the

same position same troca so for high entry section this colonic phase of troca layout is

working now i'm using this second part of the troca layout is pelvic phase

here this arm two here is mainly counter traction anteriorly or laterally and my

main left hand is arm three here and my assistant left hand is giving me

attraction on the colon and rectum and my bedside assistant right

Right hand is for the suction here.

This is assistant right hand.

As you see, my main left hand is very lent,

but mostly I'm using it as a finger retractor rather than a grasper

The tissue is slightly edematous, but it's okay

because my assistant is using suction suck out the fluid and also smoke as well some nerve fibers

tip both in male and female i'm using this traction suture of course in female to the uterus

But even in male, just on the peritoneum, below the bladder, it's very useful.

And also this nylon tape around the rectum at the level of sacral promontory

is very good for traction on the rectum by my assistant.

assistant left hand is holding that tape and traction this is rectum you can see

the levator ni muscle here seminal vesicle the right side of the levator ni

left posterior side. I'm trying to get into the inter-sphincteric space

posteriorly here. You can see very clearly the anococcygeal ligament.

Anococcygeal ligament is smooth most fiber connecting the posterior side of

the lower rectum and actually upper anal canal to the coccyx. Once I divide it, that is intersphincteric

space. This is the levator ani rectum. So I'm trying to get into the intersphincteric space.

Here right side, counter traction is good technique when I'm using the robot. Anterior

part is the most challenging part. You can see the longitudinal muscle of the rectum.

this is below the almost below the prostate you can see that recto

urethralis muscle here if I go here is urethra if I go here is rectum so this

is most challenging part this is the left left side left anterior side yeah

so I'm this is almost the last part of the dissection here look can you see

here this is the levator this is very very very clear very very clear good images and obviously

it's a very great technique thank you so this is intersphincteric space this is actually almost

the external sphincter this is the levator puborectalis i would like to thank

Thank you Dr. Gulli for editing this video. Thank you very much.

You're welcome.

So checking the tumor location by finger. So after applying stapler somewhere here,

that was two fires mostly and green cartilage. This is the final view of the pelvis. So my

My own definition of Da Vinci SI-XI surgery is surgeon-controlled multi-arm operation.

And the key aspect of multi-arm operation is how to optimize the use of multiple arms

in order to maximize the success of a high-standard operation in minimal difficulties.

Today, you saw just an example in this presentation.

As you may realize, every each step is very much standardized, and Xi is nothing different

from Si, except trochlea out.

Again, this is Si trochlea out, but Xi is slightly different.

I'm using this technique.

Scope is here, meaning I'm using two left hand technique.

technique. Specimen extraction, stoma, same. Here, this is after putting the robotic trochus here. For colonic face, I'm using these four after target anatomy toward the middle of the descending colon here. Camera here, two left hands. This is how it looks like. Camera, two left hands, 12mm on right low caudal.

Yes. You can see it again. IMV first technique. Here. IMV. This is not very long video. This is short video.

So this is transverse colon. Okay. Now the tricks. Yeah. This is the trick.

After lifting up the transverse colonic mesentery here, you can see groove here.

here transverse colon mesentery and pancreas so about one centimeter above that groove

a flexion cut the peritoneum here yes now i get into the lesser set very simple of course if the

patient is of obese fat it takes a little more time but the concept is exactly the same here

lifting up yes so this is pancreas so sometimes there is a small vessels or

adhesions you can cut it now here this is pancreas just going through the

pancreas tail so this is this is stomach you can see the stomach and after

that this is different patient I sometimes I start IMA ligation

first as conventional usual way but anyway either way is okay but I would

say almost 80-90% of my case I start IMV first technique so same so I'm

using this troca layout so for after medial to lateral then lateral

attachment. But definitely compared to SI, this splenic fracture takedown around, you can see the

spleen is, if I'm using the SI, which is slightly easier than SI, no doubt. Because the second left

left hand is more flexible to use if I'm using XI compared to SI. So after colonic phase

of dissection, pelvic phase, I'm using these four and the target anatomy is mid pelvis.

Assistant has both hands working freely, exactly same as SI. Here assistant use two hands same

as SI perhaps this is the last video short video so arm one here is my second left hand is mostly

using traction counter traction as you see my main left hand Maryland is like my finger finger

retractor this is left posterior lateral same traction suture this is left seminal vesicle

Yes, again, I would like to thank Dr. Piozzi

for editing the SI ultra low entry section video,

which I showed you today.

Thank you for your attention.

Thank you very much, Professor Kim.

Angelus, I want to come to see you in Seoul.

Please, please.

Thank you very much. It was a great lecture and obviously with great images and with a clear technique where it's possible to learn. So, really, thank you very much. We really appreciate your presentation.

Thank you very much. So, I have to say goodbye.

Yes, we'd like to see you

if it's possible

Now we see the PowerPoint

presentation

Oh, okay

Here we are

So, did you enjoy?

Yes, yes

Thank you very much

and hope to see you

next year, okay?

Alright, okay

On behalf of Professor Palazzini

really, thanks a lot

for being part of

the conference

in Rome, okay?

Yeah, this is my great honor, thank you

Okay, ciao!

Bye-bye!