腹腔镜右半结肠切除术：头侧联合中间入路

因为这个视频的时间很长,之前会务组告诉我最好是没有剪辑的视频,所以这个视频的时间稍微有一点点长。

This video is quite long, and because the organizer told me not to cut or revise or modify the video, so the duration would be a little long.

因为这个手术的过程可能会比较长,所以我觉得为了准确地去解读这个视频,我用中文来说,然后可能会表达得更准确一些。

This is quite a long surgery, so in order to be more precise in my expression, so Professor Wang is going to use Chinese for the introduction, and I will translate.

Okay, no problem.

好的,没问题,王教授。

因为这个病人在中国的患者里面稍微偏胖了一点点,而且他之前经历过腹部的手术,所以我们他腹腔里面有一点点粘连,我们首先要解开腹腔里面的一些粘连。

As we can see, this patient is considered relatively fat or overweight in Chinese population.

We can see quite a lot of fat tissue in his abdominal cavity.

There is a little bit of adhesion inside, so we first need to release those adhesion.

When Professor Wang does surgery on the right colon,

he likes to go in from the cranial part, from the caudal part,

and he would go from the omentum.

So he goes in from the cranial part, and then he will also resect part of the lateral curvature of the stomach, but he will preserve most of it.

So also he would resect a little part of the omentum, but preserve most of it.

First, we went into the capsule.

We see the posterior wall of the stomach.

May I ask you a question?

Sure.

You said that the patient cannot tolerate a colonoscopy.

Even during sedation, heavy sedation, just to obtain...

因为他之前有肛门的疾病,然后他有先天性的肛门狭窄,所以我们即便是很细的场景,在进去的时候也面临着一些困难。

所以在这个手术以后,除了做一个右半截肠以外,我们还会给他做一个新的肛门成型的手术。

This patient is suffering from congenital atresia of the anus, so the patient cannot

tolerate even the smallest coloscope inside.

So after this surgery, after this hemicolectomy surgery, we will also do anoplasty for this

patient.

Okay, thank you.

Please go ahead with the video.

Sorry, I have to tell you that our images are freezed.

We have no video but a single image on our screens.

He said his video is stuck.

Now he is looking at the video of Ding Ge.

Yes, so am I.

Because this video is stuck now.

Yes.

It's better now.

Okay.

Let's start over now, Professor Wang.

Thank you.

Okay.

我会试图先把结肠的细膜分下来,我们可以看到结肠的细膜它应该是有一个完整的边界,然后跟胃之间是有一层疏松的细膜。

I'm sorry, it's freezed again.

屏幕又卡住了。

and then you can also try it here, okay?

Thank you.

I'll share mine.

We can see your sharing.

I'm also an Italian.

Dr. Granti, Dr. Battieri,

can you see the video?

Yes, we can see it now.

It's a bit blurry.

It's a bit blurry, exactly.

We can't watch this video.

We can watch it.

Okay.

Professor Wang, you can use this video to explain.

Okay.

I will try to first separate the mesocolon from the stomach.

Then we can see that the mesocolon has a more complete border.

And then it's a very smooth surface.

We can have a loose interstitial tissue between the stomach.

我们很容易就把结肠的细膜和胃这边分开。

So as we can see from here, he would try to separate the mesocollum first.

And we can see there's a very complete margin, clear margin of the mesocollum.

And also this is a very smooth plane.

And there's a very loose connective tissue between the mesocollum and the stomach.

And we can just separate them very completely.

The upper section, the stomach first, so after the surgery he would not need to go back

and then deal with the separation of the mesocolon and stomach.

As we can see, there is a little adhesion with the gallbladder.

And as we can see, whenever he does the hemicolectomy, he will try to separate the lateral rim, the lateral margin of the duodenum.

And also there is a very loose tissue between the colon and the duodenum lateral margin.

and he would expose the lateral margin of the duodenum as the mark or as the milestone of the completion of the cranial part of the surgery.

So whenever he exposed the lateral rim of the duodenum, it means that he has completed the cranial part of separation.

往结肠的分支的时候,我这个地方的分离就结束了。

Now we can see he has exposed the vessels, including the right gastroepiploic vein.

And at this point, we have completed the separation.

在这个时候呢,我会把我分离的这个结肠和胃之间的这个界面,

会放一个纱布在这里。

这个纱布呢,在后面我们从中央的去分离的时候,

这个砂布就是一个非常非常好的标志。

And he, at this point, would put a piece of gauze between the gastrum, the stomach, and the colon,

and the gauze stays there and also serves as a marker.

When we later come in from the center, we'll see the gauze as the separation between the stomach and the colon.

这个时候我会回到中央,

First of all, I need the assistant to completely expose the incision and then lift it up.

At this time, we use the end of the incision as a symbol to find the projection of the blood vessels in the incision.

Then, the assistant needs to lift up the blood vessels in the incision.

这样的话我们就可以看到这个像就是去找到这个我们叫魔桥这个地方作为我们刀切入的这种第一刀的位置。

And then he went back to the center and he will ask the assistant to expose the colon and also move the colon to the side so we can expose the ileocolic vessel and also we'll find the projection of that vessel and find this structure, which is called a membrane bridge. And this part will serve as the site of the first incision.

我们可以看到这个视频,等下我在处理这个小的血管的时候,我试图去止这个地方的血,但是呢,我止了两次,没有止住,但是我就没有再继续在这个地方去进行继续的操作。

这个地方小的出血,我们用纱布稍微压一下,这个地方的出血就会停止,我们不需要在这个出血的地方反复的去浪费我们的时间。

There are some small vessels in this area, and later you would see in the video that there are some mild bleeding in this part, but there's no need to waste more time here. We will just use some gauze and compress the bleeding points, and the bleeding will stop. And there's not much procedure here, so it should be okay.

试图进到结肠细膜的后间隙里面去,然后看到12只肠为我们的标志,这个时候我们就看到了12只肠。

And then they would enter into the space of the mesocollum, and until they see the duodenum, this would be serving as a marker, as a milestone of the surgery, and now as we can see, we're in the posterior space of the mesocollum, and we are able to see the duodenum.

At this point, we are trying to expose the vessels, the superior mesenteric vein.

We can enter into the space where the superior mesenteric vein is, and through this force-up, as we can see, we can enter, we can see the surface of the vein very easily.

And after we prepare the space, we will go on and act on our ileocolic artery.

然后现在再处理这个就非常简单。

We have further exposed the lateral margin of the duodenum, and this is the total space,

and we can see in this space the direction of the vessels are different.

We can see a large horizontal vessel down there, and at this point we can deal with the bleeding.

Previously we see the bleeding of the small vessel, but we didn't have the space to deal with them,

and now it's much easier to do it.

So we just left it for some time

and then when we have space,

we can deal with the bleeding spot.

Now we further dissect the posterior space

of the mesocollum

and now we have exposed to the pancreas.

In this area, there are some small vessels, so we should be very careful.

And very soon, we'll be able to see the Henle's trunk.

Now we can see the vessels in the middle part of the colon.

This is actually the right colonic vessel.

and the vessel in the middle part is actually in the upper side of the screen.

Now we are able to see the Henle's trunk.

Very soon, we will be able to see the gauze that we have left when we separated

the cranial part and that serves as a very good marker between the cranial

part and the posterior space I'm sorry about the quality of the video but one

minute ago a colleague of yours a Chinese colleague of yours gave me her

laptop with the same the same video that's going fluently in her laptop and

I can and I synchronized it with your images and so it's locally okay now

刚才他看画面有点卡,所以他那边有一位同事给他一台电脑,他正好现在也可以看到同步的画面了,现在画面没有问题。

但是在纱布以上的分子都是需要离断的,都是需要往结肠去的分子。

Great. Now we have separated the Henle's trunk, and a minute ago we saw the gauze that we have left in the cranial separation,

and the gauze is actually a very good marker to separate the branches of the Henle's trunk.

There are two branches, one goes into the stomach, one goes into the column.

So anything that's below the gauze is going into the stomach.

We need to protect that branch.

Anything that's on top of the gauze is going into the colon,

and we would need to dissect that branch of the Henle's trunk.

Also, there's a branch of the Henle's trunk that goes into the pancreas.

We should also protect that one.

Maybe last year we had predisposed, where is Giuseppe, we had predisposed, let's do, yes, but I told him that we won't give it to him today, I told him that on Wednesday you, with me, we will give it to him, you have to take only the nominations and then we will prepare them, so we avoid, now he puts you to do the certificates.

And now we move on to deal with the middle colic vessel, and some people would choose to dissect

the middle colic vessel from the root, from the beginning, from the orifice, but for me it depends

on where it is. If it's a tumor that is close to the hepatic flexure, especially if it's a

transverse colon I would dissect from the root of the middle colic vessel, but if it's a

vessel but if it's a ascending column I would dissect only the right branch of

it and preserve the left branch.

After ligating all these vessels, we will further expose the duodenum and open up the

the posterior space of the mesocolon and then we can expose the fat capsule

and it would be easier for us to open up the posterior space of the mesocollum when we

deal with the caudal part.

这个地方和胆囊还有一些粘连,所以我再分到这个地方我会停下来,粘连的处理还是要谨慎一些。

At this point, we have encountered some adhesion with the gallbladder, so we paused a little bit to deal with the adhesion. We need to be very careful here.

当我把沙子肠外侧的间隙完全拓展以后,我会在这地方放我的另外一块纱布。

这块纱布等一下就是我们从尾侧分离进去的一个很好的标志,而且可以很好的去保护杀子肠。

After we further expose the lateral space of the duodenum, we'll put a second gauze there, and this gauze would serve as a very good marker to separate the caudal part and also to protect the duodenum.

把中央分离完了以后,我会从尾侧进去。

因为小肠和这边的细膜有一些粘连,我们首先把这个粘连打开。

After dealing with the middle part, we go from the caudal side of the colon,

and here we have also seen some adhesion with the small intestine,

and we need to deal with the adhesion first.

When we dissect the lateral rim and we can see the second gauze that we have left in

in the lateral space of the duodenum,

and at this point, we know that we are correctly

in the posterior space of the mesocolon.

Professor Wang, I'm sorry to interrupt you.

The New Year's Day has resolved the problem again.

They shared a video. Can you see it?

If you can't see it, can you turn off your sharing?

So they can watch their video.

I turned off mine.

Yes. Okay, thank you.

Thank you.

After we open up the posterior space of the mesocollum, we have actually only a very thin

layer of tissue left so we only need to separate further the tissue and then we

have completed the dissection part

And Professor Wang says the screen looks quite blurry, so we will try to figure out a technical issue.

Vincenzino, what do you say? Are you having fun? It's not a sin. We should always be having fun, like this.

For me, the two interventions make me more anxious. The calasias and the surrene. They make me more anxious.

Because the calasias, if you do damage, you do damage, Lilia.

At this point, we can see we have already completely dissected the mesocolon because

we can see the gauze that we have left there as a marker, but there's still a little bit

adhesion with the duodenum, so we need to deal with the adhesion first.

At this point, we have completed the dissection, the separation of the column and the mesocolon,

and the next part we would start with anastomosis.

Italy, can you see the video clearly?

My video is very blurry.

Professor Wang says the screen looks very blurry to him.

So, Professor Grandi, does it look okay on your side, high definition?

First, we need to decide the margins of resection, the scope of resection, and then we would

dissect the transverse colon.

这个时候我们要把切除的这个肠段放在一个保护袋里面,把它装起来,

然后以便不影响我们后面的蚊壳。

Now we're using the specimen back, and we put the part of the intestine of the colon that we have dissected,

resected, so that they are not in the way when we move on with our next step.

And now we're in part where the column is meeting with the ilium, and now we're doing some dissection here.

Now we're going to anastomose the ilium and the transverse column.

The length of the anastomosis is 45 millimeters or 60? I couldn't get it.

也是可以的,但是我一般还是选择用和气把它变掉。

Yeah, and here we are using 60, and also we need to make sure that the size of the anastomosis is proper, is sufficient,

because as the orifice, the shared orifice or the shared opening, we would need to make three sutures first,

and then we will use the stitches to close it.

We can also suture all the way down, but he would choose to use a suturing set, suturing instrument.

这样我们就完成了吻合。

在有些情况下,我会把这个细膜的裂孔关起来。

当然在做右半截场的时候,也有很多人选择不关闭细膜裂孔。

但是我通常还是会选择把这个细膜裂孔做一个关闭。

Now I have completed the anastomosis, and then I will close the hiatus of the mesocollum.

Some people will choose not to close the hiatus of the mesocollum when they do the right hemicolectomy,

but Professor Wang always chooses to close it.

As far as I'm concerned, it's the same for me.

Yes, even for me, I agree with you.

我有时候还会选择用这个线把它包满一下,

以减轻这个地方的压力。

但是这个地方不包满也是可以的。

So at this site where there is an opening of both the transverse column and the ilium,

he will choose to use some stitches to reduce the pressure.

But it's okay not to do it, but he would prefer to do it.

At this point we have finished the dissection and anastomosis for this surgery.

So thank you so much for your presentation. I'm so sorry about the technical issues, but

in the end it was it was again okay. And just one question, normally when I perform a right

hemicolectomy and start medial to lateral. Is your way of proceeding, is it just an habit or

do you think there is a special reason for you to go from the head towards the foot and from

lateral to medial?

或者是从尾侧入炉,最后还是要回到前面去处理头侧。

所以呢,我会选择先把头侧处理,这是我个人的习惯。

It's his habit, because if we deal with the cranial part first,

we can separate mesocolon and mesopastrum completely,

and also it helps us to preserve the right gastroepiploic vessels.

The vessels. So if we use the other direction, if we go through the center, or if we go through from the caudal to the cranial part, then at the end, we need to go back to deal with the cranial part. So it's a habit of them to deal with the cranial part first.

And did you put any drain after the procedure?

术后有引流吗?

术后我们会放一个引流管,在第五天的时候会把引流管拔除。

he would put a drain after the surgery for five days

and at the fifth day, we would withdraw the drainage.

And when will you feed the patient?

When will you feed the patient?

For example, the patient had a surgery today

and tomorrow morning we will allow the patient to take in some liquid food and also to start

motility start movement very soon after the surgery okay thank you professor thank you for

your outstanding presentation it was a very interesting technique because we in Italy are

accustomed to begin on the right side to medial and it was very interesting to see how you do it

so congratulations and thank you we have been honored to have your presence here at this event

非常精湛,而且整个手术也做得很漂亮。

非常祝贺您,我们也很荣幸能够这次邀请到您参加我们的会议。

谢谢。

It's my great honor to attend this meeting.

I hope you guys can come to China, come to our center.

Next year, we also have a conference for laparoscopy.

And the topic is about gastrointestinal tumor.

most of the famous Chinese surgeons will attend our meeting next year in April.

I so welcome you guys to come to China to attend our meeting.

Well, we really would love to, but I really don't know if it will be possible anyway.

It's a great professor to have had you here.

here, also because it opens almost your mind when you see things made in a different way

you are used to, but greatly.

So on behalf of Professor Palazzini and myself and of course Marco Barghieri that's here

with me, we just want to thank you for staying with us today.

I mean, so late in the evening, it's 16.23, it's 11 p.m.

So thank you really for staying with us today.

We thank you also for this late evening.

We forced you to.

Thank you so much, Professor.

Okay, thank you.

Thank you so much.

Bye-bye.

Bye-bye.