G. DAPRI Single access laparoscopic cholecystectomy using curved reusable instruments

short apri yes buongiorno good morning buongiorno good morning good morning hello hello hello my name

is umberto grande it's a real pleasure to speak to you i'm so sorry for the delay but we were

arranging to put your images on the main screen in the audience and so i'm so sorry for you yet

you had to wait some minutes okay but now now you are on one of the main screens in the audience and

so you can start whenever you want what are you going to perform okay i i will perform a

called a cystectomy and the technique i showed today is a single incision with a special curved

instrument when i spoke with giorgio i arranged for a few minutes of introduction with some slide

So let me first thank Professor Palazzini for this kind invitation. This is the first time for me to operate from Brussels to Rome.

Professor Dapri, would you prefer to speak Italian? No problem at all.

Ah, ok. Vuole parl'italiano?

i i really mean it's it's not a big problem for me um you are anyway translated just just to as as

you are fit well i mean if you are comfortable with no problem at all you are the first time

that okay let's do it in italian so i feel at home oh fantastic very well then in the meantime

i thank professor palazzini for this invitation for me it is the first time that i do a live from

in Italy and in Rome and I would like to thank the organization, the moderator, the chairman.

I will pass a few slides of introduction as I agreed with Giorgio.

The first problem when we do single incision, single port laparoscopic

that there are in general problems of conflict due to the conflict between the hands of the surgeon

or between the tips of the instruments.

So often you have to cross the instruments or even with the articulated instruments

we have to cross the ends of the instruments.

Another problem that still persists when we do single incision laparoscopy is the cost of the procedure because most of the ports and instruments are disposable, so there is an increase in the cost.

and especially at the beginning, since there is a learning curve that is important,

there is still a longer operating time than the classical parascopy.

Next. This is an intervention that will be performed with special instruments.

The first part of the instruments that you will see, next, Jean,

are completely reusable curved instruments,

So we can keep the cost of the procedure similar to that of the standard laparoscopy.

And the first part of the project was presented in Prague in 2009, the next one is NextGen.

And last year at CEGES we presented the final project with 9 instruments, NextGen.

These are others, for example the Grasper for the upper GI, the bipolar clamp, NextGen

and above all also the portaghi, which to my knowledge are the only ones available on the market for now.

The instruments have been fundamentally developed with the principle, one of the principles which is the rule of the laparo,

and that is that the optics are the visor of the work angle inside the abdomen as well as outside the abdomen.

And so if we think of inserting the standard regular tools through a scar like the navel, we need a curve of the tools on the outside in order to work in an ergonomic position and a curve also on the inside in order to reach an angle of work.

Next, this is our experience up to a few days ago. As you can see, they are mainly basic surgery interventions, such as appendicitis, coli, ventral hernia and umbilical, but we have also done, as you can see, a sprenectomy and a hepatic resuscitation, a stomach resuscitation and an ENISEN.

Next, the intervention today is a colicistectomy, the first results have already been published, next, and the access, since this is the particularity, is that I do not use any port, but I use a 11mm reusable trocar, the one that we all have in the operating rooms.

I make a stock point at the beginning in order to introduce the trocar from 10 and then an orifice at 10 hours from the head of the patient for the colicistis, the anis, or the hepatic resection, for example.

I introduce the curved tool, which is the clamp through this hole, and the other tools for the right hand, which is the dominant one in general,

are introduced inside the pocket point and right next to the optical, and then the pocket point closes a bit.

il punto in borsa. Ok, io comincerei il live. Ok, Gian, un po' invoier le immagini, se ti va bene.

E ringrazio per la collaborazione il mio collega dottor Gian Broins, che è alla regia e che

trasmette le immagini della sala operatoria a voi quest'oggi. Allora, in questo caso,

is a woman of 30 years old with a BMI of 22, which presents a litiasis of the simple colicisti.

As you can see, there is an umbilical cord that is not very intraflex, so it is a standard umbilical cord.

standard in questo caso quello che in genere si utilizza fare è estrapolare l'ombelico poi

metto con un cocker metto un Kelly sotto dammi domani un bisturi e poi l'incisione ok questo

This is a classic approach that has been shown, to my knowledge, since 2007 by one of the greatest experts, Paul Cursillo from Philadelphia.

But the scissors, I think, I'm sorry, I think, so let's try, since there is a problem with the light,

let's try to use, do you want to show me how to do it? Thank you very much. Lionel, do you want to hold the

After having cut, I was saying that it is an intra-umbilical incision,

it is an incision that is generally performed, we have a size of about 15-16 mm,

anyway we will see it at the end and not for the paroscopy anyway this step that usually takes

time because it takes in general from 7 to 12 minutes and the problem is that tomorrow

and that the boss also that in general that I was saying that with this approach what

What happens in most cases, which is not in this case, is that once the cut is cut, you can immediately see the access to the peritoneum.

Because in most cases, as you can see here, you just have to open it and there is the appearance of the preperitoneal fat.

There I am in the abdomen, then I just enlarge, as you can see it is an incision of the fascia, this is a question that I am often asked, it is an incision of about one centimeter at the level of the fascia.

The thread I use is a PDS thread, so reabsorbable, I use a reabsorbable thread of the type polydiaxon.

and the size of the thread is quite large because it is a 1 and because it is a 1 because in our experience we started with the 2 zeros,

then there was a problem because with the closure during, to maintain the peritoneum during the lapar, it often broke and then we changed.

And so we have moved on to PDS1 for a matter of robustness.

Another aspect is that the stock exchange points are made, as you can see, I usually start at 2 o'clock,

always with respect to the position of the patient, and then I pass at 4 o'clock, then

still at 6 o'clock, here it is about 8 o'clock, and I pass because, as I said, since we do not use

important this step even if we lose a few minutes because it allows us then first to

earn it in the end because it is enough to close the point in the bag and give some additional points

and the procedure is finished and second however it allows me the point in the bag allows me to

open when I need to evacuate the smoke created by the dissection and to keep it closed naturally

to have a hermetic closure and the thread then the forgiveness point in the bag is then left and

e quindi aperto un poco per il cambio degli strumenti che ve lo mostrerò tra poco.

Allora, adesso, una volta fatto il punto, do un po' di troccarsi,

allora, a questo punto, mettiamo una trocca da 10, classico, 11 per 2 mm, reusable, ti sa?

E la malata, non l'ho detto però, è una malata che non ha precedenti chirurgici,

and I am between the legs of the patient and the cameraman who today is Dr. Dardamadis Dimitris

who comes from Athens and he is like in the classic position of the French position

to my right, in any case to the left of the patient, and then the

instrumentalist will be between the cameraman and the surgeon, and today this is

Lionel, whom I naturally call Lionello, and instead the anesthesiologist has the

classic position at the head of the patient, bonjour Hans, the anesthesiologist is Hans and

il dottor pasten else che è naturalmente avere un caffè come presumo nella maggior parte delle

sale fanta allora fino a qui è tutto chiaro mister chairman perfetto perfettamente ok

me lo dica se non ci sono domande oppure mente darmi del tuo mio nome è umberto grandi lavoro

Ok, then Umberto, my pleasure.

At this point, we have created the Pneumon, but it is still in standard position.

I use a 5 mm guide of a classic trocar.

This is because the device to make the hole for the grasper is not yet ready, it will be ready in the next few months.

I use a mandrel, I push, as you can see, I push, sorry, the tail, I put it under the tail and at 10 o'clock I gently introduce it, slowly, here it is.

One of the questions at this point is, yes, but it's a technique, this one, dangerous, right?

Because it doesn't have the control, but it's not really like that because, as you can see, first I'm blocked by the trocker because I'm exactly parallel

The second is under control of the vision and I do not see my tip.

We are at 10 o'clock because it is for the cysts.

If, for example, we do the appendix, we put it at 6 o'clock.

For the sprenectomy at 2 o'clock.

So it depends a little.

The important thing is to try to restore, if you want, a working angle outside the field.

So, the Grasper that we use for the Collecisti is the Grasper that is on the market as indicated as number 2 and as you can see it is a three-curved Grasper, in the sense that it has three curves.

The first one is this one, which is at the level of the umbilical cord.

The second one, which is this other one, which is for...

Professor Dato, excuse me, we have lost the vision for a few minutes.

We have seen the introduction of the trocker, of the trocker da 5, I mean, of the mandarin.

Ok, now you have the image.

Yes, perfect.

Ok, so the mandarin is here.

I was saying that the mandrel is introduced and one of the questions that can be asked is whether it is an introduction of a dangerous mandrel.

The answer is no, in my opinion, because as you can see the mandrel cannot move because it is in conflict with the trocar of 10,

so they are exactly above the trocar of 10 in parallel.

And second, I still have the optics that keeps the vision and the peritoneum.

The Grasper that I use for the Colicisti is a tricurve Grasper, so it has three curves, they are fixed curves, so there is a curve that has been designed to avoid conflict with the optical at the level of the umbilical cord, and it is this.

Then there is a second curve, which is the medial one, between the extremities and the umbilical,

which avoids the conflict with the optical, and therefore the optical will be in this direction.

And a third curve, which is exactly in the opposite direction to the classic colicistectomy,

Because in classic colicistectomy, both the American position and the French position,

a grasper arrives in this direction for the exposure.

And in the ideal grasper from us there is the direction that is exactly the opposite.

And so the question is, but why?

And it's not that we're crazy, it's because this position allows, with this movement,

since we are in single, since as you will see I do not put any point to expose the colicisti etc.,

it allows me to highlight the callus and at the same time when we then arrive on the

dissection from the bed to pull the colicisti. So at this point, if there are no questions

for the grasper, I introduce the grasper, then I remove the mandrel from 5, I put the, I look for the

hole that I made, and slowly, ok, then, I don't always check, but anyway the introduction of the

the instrument is compared to the axis of the malato and at 45 degrees and following the curves ok

then 1 2 and 3 and here is the internal view jean ok you have the image is very good here you see umberto

that this here is the central curve that immediately allows you not to have

conflict with the return and return of the lens you see and then instead the curve

inside that allows me to take the colicistis where it is etc.

this is a good case selected and I thank my colleague Dr. Broins

because it is his patient who kindly gave me this morning and it is a good

case for rome they are not all so it is naturally then then the introduction of the grass for

we have seen the introduction of the external view jean silty play and the introduction of the other

tools we like the school here of professor cadier as you have seen we use the crochet

in most of the interventions and therefore also for the collecisti we use the crochet

and not the bipolar, but we can also use the bipolar that exists, and the curve is always the same,

that is, a monocurve, and this has been designed so as not to have, as you can see now,

the conflict between the dominant hand of the surgeon, which in this case is the right,

the cameraman who holds the lens, and my left hand.

Soprattutto io lavoro con una posizione ergonomica senza incrociare le mani o senza incrociare le punte degli strumenti come succede in genere con la maggior parte degli strumenti articolati.

The instruments for the right hand, however dominant, are all the same.

Then we have, as a curve, we have the scissors and this is the discerner, ok, the scissor, and also the scissors.

Then there is the vacuum cleaner, these are the scissors, this is the crochet, and then the vacuum cleaner.

As you can see, they all have the same shape that was designed according to this principle of the lapar with the eye in the center, etc.

So, for the introduction of the instruments, as I told you in the animation, we introduce them inside the point in the bag and parallel to the trocker from 11.

So, since I made a small incision of the poneurosis, what we use to do is that I slightly remove the 10mm trocker, I put myself inside and push the 10mm trocker.

In this moment I have introduced my tools, as you can see here, this is the crochet, so I already have a good freedom of work.

So, allow me to make a better image.

So now I ask Hans, who is my anesthetist today, to put the malate in anti-trend.

Yes, Hans, please.

Yes, like this, again.

Again, again, again.

While he mounts the table.

So you see that I have nothing.

I have an incision that we will then measure, which is still around 15-16 mm, which is that of the original umbilical cord.

originale, stop, c'est bon, e per ora non ho alcun device all'interno per esporre il

calò, per tirare la colecisti, o il fegato, eccetera. Allora, vedete bene all'interno

che ci sono, vedete come effettivamente gli strumenti non hanno conflitto con l'ottica

e nemmeno tra di loro. Allora, adesso un intervento semplice di colecistectomia che tutti sanno

fare quindi non è che sia molto interessante diciamo come tecnica quello che io credo che

sia interessante è la vedere come effettivamente sia possibile tra il diciamo così lavorare con

una buona ergonomia e che se qualche d'uno vede il video per esempio dall'ufficio e ha solo la via

endoscopic, we do not realize that we are in a single incision.

Here, in this case, I do not lose the pneumo, because, I repeat, we have opened the aponeurosis little by little.

Sorry, I'm trying to make the best image I can, otherwise I will not be able to clean it.

Sorry, I prefer to clean the optical lens.

Thank you very much.

We use an optical lens at 30 degrees.

Let's see if it's still there.

Let's hope it's still there.

Ok, perfect.

I hope you have a good image like I have.

Yes, the images are perfect.

Ok, thank you Umberto.

So, the first step in this case is probably due to the colic of the patient, there are adhesions, and you can already see that I work with a good ergonomics,

Jean, you can show the external view, if you want, and I work with a good ergonomics and I don't cross the images and the images, sorry, my hands and especially the instruments.

At this moment they are not exactly in position to form a straight angle, but they will be shortly in the main part of the Calot triangle.

is that I don't really like, like most laparoscopists who do single,

to put sutures on the cystic bone.

I know that, as we all know, there is a paper that has become famous,

famous, reported as the first coli in the world, in single, and of the colleague Giuseppe Navarra,

and in the description Navarra had used suture threads to still expose the colicisti.

I don't like this technique very much, it's just a problem that I don't want to avoid the leakage of the bile,

and therefore the reason for which, thanks to this collaboration with Storz, I have developed these instruments and therefore, thanks to the curves, I cannot avoid any device for the exposure of the colicisti.

Naturalmente, c'è da dire che ci vuole una selezione dei malati.

Questo è più che riconosciuto anche in letteratura quest'oggi.

Perché? Perché specialmente in primi casi è importante la selezione

in quanto possiamo tenere il tempo operatorio comunque in un certo range

and second the conversion rate remains low then one of the questions you can

tell me is ok but this is a simple case but in the case in which for example the

calo triangle is not well highlighted what or in any case you can't

I simply opt for the option of putting a verres, a 2 mm millimetrical wire in the right hypochondriac,

right, thank you very much, and so at least I expose, because the verus

arrives here, and so I expose the liver, I expose the calo triangle, lifting it

in this way, and so I have a better access. But I repeat, it may be that it will be

necessary in this case, I don't think so, we'll see, because it depends a lot on the

anatomia del fegato del malato. Non tutti i casi sono come questi.

Non ho un'immagine corretta, un vanitoyer du H-silvople.

Come vedete, per ora non c'è perdita di pneumo importante, c'è un pneumo mantenuto

sufficiente grazie a una minima chiusura del punto in borsa.

If I had to lose a bit of pneumo, what I do is that I ask Dr. Dardamadis to pull the suture thread a bit, and that's it.

I can still show you if you have a little external view.

And as you can see, I continue to work in an ergonomic position.

So I was saying that for the devices, because when you have to expose the calo or the colecystis, if you don't have, for example, these instruments, what can you use?

suture threads, or another possibility is to use anchors, for example in Israel

since about, I think, in 2008, however the project started in 2007, there is this device

called Endograb, which allows with a part that is applied on the peritoneal leaf

parietale e l'altra a livello del letto della colicisti per esempio di esporre e di aumentare

l'esposizione del triangolo di calò. Allora come vedete io utilizzo nella maggior parte

degli interventi e comunque per tutto l'intervento il crochet, gentilmente.

Professor, there is a question from Professor Vitellaro, just a moment, I'll pass it to you.

Yes, thank you.

Hello, Marco Vitellaro. Listen, a question. Have you ever tried to use an optical lens

operating at 10? You know, the one in which you actually have a real 5-inch lens and an

operating channel in which you can put a tool.

Yes.

In reality it would give you one more hand, you could in some way with the instrument go to take the colicisti and with the free hand lower the pancreatic dendritic block, for example.

Can I give you yours?

You absolutely must.

you are perfectly right

and it is the principle for which

it has been developed

probably

you have already tried it

the spider of the Transenterix

yes, it is an excellent

option, but

I repeat, I

had the opportunity to develop

these instruments, I tried to do

things with

optics and

trockers that most

but most of the surgeons who perform the surgery are in the operating room.

However, it is an option that is quite valid and therefore it is very good.

But in fact the consideration was born of the fact that I think that an operative perspective,

probably for an idea of adherence, we all have it in our corredo,

the suggestion because surely what we are seeing is extremely

interesting and therefore maybe it is a great suggestion anyway I thank you and as you said

we can see the inside really thanks this here is the crochet and it is a crochet that the tip of the

crochet as you can see is a particular one because it allows the back part to dry out

as I try to show you here ok because it is less smooth you see the back part the

inside part instead that is cutting is crochet that is devised by professor cadier always with

stores as a tip and I say this is our classic lymph node now I go what you could

tell me at this moment is that the column is not well exposed and for now but slowly

this should be the cystic which is rather short this here is the lymphatic

like this before moving on to the calo and therefore dedicating myself to the calo book slightly

back so then I don't have to change the position of the colicisti every time

I'm a little bit stressed by the image because I would like you to have a perfect image, now it's fine.

It's an HD, of course, the optical, high definition.

This problem here is a bit because I use the trocker from 10.

and therefore what happens is that every now and then there is the problem of the insufflation that goes

in the direction of this moment I have to do more traction so I change again you see that every

Every time I try to maneuver my Grasper with both hands and this is because due to the curves,

unlike classic tools, you can't do much more and therefore there is a bit of difficulty at the beginning.

Now here, for the preparation, every now and then I also go to the back, so as you can see here,

I slowly, here we see the cyst that goes in the biliary vein, I go to prepare myself slightly behind.

I repeat, I am now doing, I am looking, because it seems to me a case that is quite suitable to do without any

insertion of any device available to better expose the heat. In the

case it was not so, it is better to introduce it naturally. Now let's see if I can

prepare it slowly, otherwise we introduce, I repeat, I introduce the Verres.

One other thing that you see in this moment is that my tool for the right hand,

however the crochet in this moment, however also the others, thanks to this technique is

that it is free and therefore I have absolute freedom of movement and this is once again

one of the differences between this direct access and the use of the ports,

because with the port there are movements

which are, however, movements, let's say, almost mandatory.

Sorry, the image is no longer excellent.

At this point I go to the back.

What we could discuss again, if you want, is the selection of the sick.

because it is important for example at the beginning I was always looking for I was stressed by the fact

of the bmi of the patient and then you see here that for example I could put a beres to expose

better I could put it now if I can in general there are tricks that I have learned

slowly for which it is still possible to expose without we are here this is our cystic

I have not yet released as I should try to open behind later but let's see the

Thank you very much.

This is the discerner that I showed you before, it is simply a classic discerner, it is at a right angle but with the jowls that are not very long, because we are in single so to avoid the problem of introduction.

However, it is once again introduced inside the stock point and next to the 11mm trocker.

And as you have seen, no internal view.

Lionella has immediately closed the stock point to avoid the loss of tires.

come see if you please and then we are here in the dissection ah yes internal view jean jean jean

ah perfect merci jean then so we are here at the part of the dissection slowly I am

close to the cystic bone naturally now I go from the other side there is a little bleeding

piano piano c'è un piccolo sanguinamento chiedo scusa adesso lo controllerò e vediamo bene

questo cistico qua dietro c'è la via biliare qui ok allora ho preparato un po' posteriore

there's still a little bit of the back leaf. Now I'm inhaling a little bit because there's a little bit of blood.

It's quite interesting here because, as you can see, the vacuum cleaner is still the same,

so with a single curve. And I said it's quite interesting because,

the cyst is not very long but this is not important the fact is that it is very there is as you can see

here the collegium here behind and the infundibolo is glued well above there and therefore the cyst is

quite short and then my colleague dr. bronze as often in the live when he sees that he takes

un po' di tempo, siccome dice che non dobbiamo prendere più di tanto tempo, mi invita a mettere

un verres. Jean, je fais encore un essai, sinon je mets un verres. Allora, provo ancora un pochettino,

sennò poi metto un verres, giusto, sarebbe molto più facile, non lo metto in dubbio.

I prepare a little more because it seemed to me to have passed, but I have not yet opened the back as it should be.

Let's see, this is the opening.

It seems to me that you can see the artery now.

Yes, but it is very glued here.

So, since it seems to me to have passed earlier, I am close to the colicist in order to release.

Come back, please.

Dimitris, time, Umberto, un minuto, se è così, mettiamo un Verres, perfetto.

No, nessun problema, assolutamente, take your time, se preferisci procedere senza Verres, senza un ulteriore accesso.

No, no, ma è perché non è una questione di dimostrazione, ripeto, è una colecisti, quindi non è una dimostrazione, vedi che ero passato, vedi qui la finestra?

Sì, si vede perfettamente.

Because I had the feeling, but behind I had not opened well, and so, well, interesting.

Now here I try to electrify it a little more.

So, one of the things, Umberto, is that when, perfect, when I said for the strategies of the intervention,

Here we are doing a classic call with retrograde access, but what I learned in single, I repeat, this is my personal experience, so it is debatable,

What I have learned is that, especially when the BMI is higher than about 32-35,

to do an anterograde or in cases of acute cholecystitis,

acute, because I have also tried those cases there, even if now I do not do them anymore, because I prefer to cool it down.

I think we are still at a good point.

And

I was saying to do an

anterograde and not the classic way. At this moment you have seen that I clamped with my

clamp to rest my liver gently. I go back, so

it seems to me that here we are at a good point.

So, I clean it lightly and put the clips.

So, as for the technique of the cystic section and the artery, in this case I have not yet seen the artery.

If it was too small in diameter, it may be that I did it during the preparation.

And here there is still a good preparation of the opening, you see, which is perfect.

As far as we use the clips, the clips that we use today, the external views, which in general are the ones we use during a concert,

these are the E-Mallocs, it is not to sponsor anyone, but what we have created with the instruments is this device

that allows the insertion of the clip without the closure in such a way that it replaces if you want

the change then the problem however is that the clips are not yet curved and therefore straight

then you will see that at this moment I will ask lionel to keep the point in the bag because

because when I have to clip, I'm in conflict with Dimitris Dardamadis' hand,

and so every time I enlarge the hole at the level of the navel, and then I lose the pneumo, ok?

And now you can hear it, and Lionel has heard, you have heard the name,

you have heard the name, so he got ready immediately,

As you can see, it closes the bag.

Retir to amp with the optic.

Here you can see the clip.

We can have the vision of the periscope, because we still have the external one, please.

Ah, sorry, sorry.

Here, very good, very good.

So, I was here, so the clip comes like this.

Inside, if you want, you don't have much, let's say, a problem of, let's say, a problem of, voilà.

So, you see, this is interesting, I was saying that inside you don't have, come back please, you don't have a conflict problem, but outside yes, so I have to close the pocket point.

Here the clip didn't close well, you see Umberto, this is because we are live, because if it wasn't live it would have closed.

So, at this point I try to solve this, I leave it there, I remove it at the end.

We still have a clip.

You have to hold your finger, Lionel.

Hold your fingers.

You have to hold your finger, Lionel, so you don't lose the pneumo.

Otherwise, since it's a device to insert and it doesn't have a valve, I lose the pneumo.

Show me well, please.

There is a problem with the clip because, as you can see, it does not close.

Now we have two clips inside. It is very good because the live broadcast is beautiful for this,

in the sense that in general not everything is always as it should be, so it is interesting to see

come si ovvia i vari problemi con quando c'è un sanguinamento che bisogna controllarlo

sono cose in un filmato non avresti visto no sono cose che in genere filmato tolgo

immediatamente come la maggior parte credo abbiamo cambiato pinza sperando che questa

Do you see what happens? Umberto, I closed the clip too much, so I closed the clip.

I was saying that I use the clips, but if I do an anterograde, what I use to do,

which of course is not the case today, but especially if the artery is small, I coagulate it.

In general, I coagulate the artery, I made another mistake of closing it too much, and so I said that what I do in the anterograde is to put an endoloop.

I learned this when I started here in Belgium in 2004, with the normal collecists, and so I adapted the same technique.

I have a problem with the clips.

I don't know what happened today.

Umberto, I'm sorry.

No problem.

problem then of course if you have a multi clip that shoots tattata that is already finished

so I am making a collection of clips inside it has with bianca 3 4 if it does not work

I take the disposable ones then in this case if we want to use larger tweezers the problem

change the optics because we have only one change sheet and I have a thing

prepare the clip disposable if you want well if I need I have a problem with

the clip today I have a problem to put the clip so give me more

There are still some green clips.

Green clips, please.

They are down there, look.

Wait a moment.

Green clips first.

Yes, one more time.

But still, if I can,

if I can't, I put those in titanium.

Disposable.

Always.

This is really interesting.

I can't put a clip.

Leave it a bit.

Leave it.

So, once again, if it doesn't work, let's put...

These here, the clips, you see, they have a hook behind them.

And it's the reason why I like them a lot, because in general they work.

They are the ones I normally use on the lower mesenteric in colic resections.

Ah, good.

Well, in general they work. I don't know why I have this problem today.

Anyway, let's open it.

ok good then now scissors

these are the scissors once again as you can see the shape is classic

now the scissors as you can see have the direction of the tip of the extremities towards the

outside is also this has been chosen because I repeat we have tried to look at the minimum

particular then umberto one of the things that at this point comes to me because in general a

I have a question for Colangio. Do you use Colangio in all cases?

Quite routinely, unless there is no kind of symptom, no alkaline phosphatase in a high gamma-gt.

Here we are, since the sick are generally the gastroenterologists who send it to us, if there is a doubt, etc., they do a colangio IRM and then an RCP.

This is just to tell you that if we don't do colangio in general, we don't do it routinely, but if you want to do it in single, you can do it, the problem is that it is a conflict.

In order to avoid the conflict, I try to resume the collecistic and above all...

Can you show us inside?

Ah, sorry.

It was again Marco Vitellaro who intervened.

Yes, you're right. Jean, can you please leave the internal view, please?

then here this here this here is probably the artery in general I repeat the

artery if it is small in size in diameter I generally coagulate it but now let's see here sorry

another question obviously in the sense of simplifying those that are then the use of

of the instruments. Have you ever tried to use a whistle-blower to make these

passages where you can certainly manage the whole part better?

Yes, do you mean also for the binding of the cyst? No, in the sense that I have always done the

colicisti con il croceo le forbici bipolari e quindi non ho esperienza naturalmente come

tutti dell'ultracision o del ligature ma non per gli interventi di base come questo no,

una questione anche credo di costi e comunque si puoi farlo per carità di Dio.

Voilà, ok, finalmente sono riuscito a esporla come volevo.

Fammi vedere, per favore.

Eh, perdono, ci fermiamo un tre, merci.

In questo caso io l'arteria l'ho coagulata durante la mia preparazione,

perché era piccola, credo che era qua, prima di questo cambio qui.

Di nuovo Umberto.

Avevo avuto la sensazione che l'arteria di piccole dimensioni fosse parallela al cistico,

In the side view, from the right, I don't want it to be inside the clip, but that doesn't bother us.

Yes, I also had that impression, here behind, but when I cut it, in general you see it here, the little mouth,

but it seems to me to identify a single mouth, I don't know, but it seemed to me

instead rather that it was small and that I did it now before changing in this position it seemed to me

however, as regards this here is another if I had to move on to the clips for example in September

We were in Germany, there was a live, there was also Paul Cursillo, and he had a problem, not a problem, sorry, he had a very large cystic, and therefore he had to put the clips at 10, and he too has started to use the 5-way lens.

in the sense that in this technique, as in the others, where you use practically a 10-inch lens,

of course you do not have access and therefore you have to switch to a 5-inch lens.

Once again, I prefer to do it with a 10-inch lens, as you have seen,

because the 5-inch image is good, but it is not the image you have with the 10-inch, everything there.

but I repeat it is possible the only thing I like to do the intervention similar if you want to the

classic lapar and therefore without how to say change too many tools and so on in the sense

the optics can be done without any problem another thing is that most of the single

The surgeons who do single axis have the use of the 5 mm because they do not maintain this rule that I showed you before of the optical as a bisectrix of the angle.

So there is the introduction of the other instruments in the other directions.

Here we have almost finished.

Then you prepare a normal pince, please.

You prepare a normal pince.

The control of the haemostasis, I do it in general right away.

I take the foie.

Show a little.

I take as before, in the previous passage.

We leave it like that, we don't put any fulguration.

If necessary, I put the fulguration.

Fulgurazione, Fulgurazione, perdone.

Ok, allora, prima di togliere la colecisti, incomincio a togliere le varie clip.

Scusa, ma la colecisti la togli con un sacchetto?

Assolutamente sì.

E allora non ti conviene una volta che metti dentro il sacchetto mettere le clip nel sacchetto?

Va bene, facciamo così, ok.

Sì, sì, va bene, non c'è nessun problema.

Ma no, siamo qua, stiamo partecipando anche noi al tuo intervento, quindi ci viene spontaneo essere in sala operatoria con te e dirti le cose.

All right. Umberto, absolutely yes.

So, look at the bag now.

This was Marco Vitellaro.

And we were discussing this.

Sorry, Marco.

We agreed that if you use a bag, it is worth putting it inside.

Absolutely yes.

It's because I don't have the habit, in general, I don't have this problem.

So one goes for it.

In general, you don't have the clips under the liver, in fact.

It usually works.

But this is the direct one.

This was direct.

Yes, I was distinguished by you.

So, now for the bag, it's Marco and Umberto.

I would like to say that probably you don't have anyone who breaks your boxes next to you.

No, no, no, it's jovial.

Then, I repeat, let me hear at home.

So, the bag, this is a bag that costs about 8-10 euros,

because it comes from the box where there are the round thyroids and therefore why this first

because it is a then what I do is that I give an opening, I have the opening on the outside here

and that I did it with the scissors then the bag I introduce it naturally through the

trocar da dieci e praticamente non è un sacchetto come il classico endobag, quindi risparmio.

E dall'altro lato una delle domande potrebbe essere, Marco ti aspetto che mi dici come

Come fai a chiudere dentro?

Come fai a chiudere dentro?

Vi en do, Jean, s'il te plait?

Vi en do, merci.

Merci, Jean-Bruns.

Allora,

guarda, all'interno

vedi, io cerco di litigare con

i miei strumenti, voilà,

e la domanda che adesso Marco

mi fa è, oh, questo è un sacchetto che non

costa niente, ma però

non so come cavolo fai a chiuderlo.

Allora, prima...

Do you close it with an endo-loop?

This is a very nice answer, wait a minute.

We just want to see how you do it, but we are sure that you close it with an endo-loop.

Yes, yes, now I'm coming, wait a minute.

In the meantime, let me put the clips in the bag.

It's the first time I put the clips in the bag.

when it happens to me that I have the loss of one or two it has never happened to me so much

but it is not a problem is that I remove them every time you have to pull out the instrument

to introduce the instrument while so it is easier you are right I do not know why you did not

suggest it to me you are right no but you are right really marco where do you come from but I work in milan

I'm from Caravaggio in the province of Bergamo.

I have worked for years in the province of Bergamo.

I learned gynecology and laparoscopy with Lorenzo Novellino.

Ah, ok.

So...

Do you have all the clips?

Yes, yes, all of them.

All of them?

Yes, yes.

Ok, you see? Thank goodness you are watching.

So, come and see, please.

I keep the bag here.

I put the collocists inside, hoping not to lose these well-known clips.

So, Marco, look.

We are here. Don't tell me you're making a knot because I don't believe it.

No, I'm not making a knot, I'm just helping.

Look at the anaesthetist, who is Elspastain, she understands Italian because she is married to an Italian and so now she is laughing because she says what questions they ask you.

All right, hold on, I've almost completely closed it, generally what I do is like this, you see, and I also help a little with the wall.

Wait, I'll show you a little better, if I can.

All right, okay?

So, at this moment, external view, Poulain.

Jean, can you...

So, at this moment, let's remove it with the cysts.

nel sacchetto, io uso sempre il sacchetto

anche perché Marco se tu lavori il tumore

mi dirai è obbligatorio

giusto? esatto

molto bene, grazie

grazie Dimitris

allora io lo uso ma non solo per un problema

di carcinosi perché

ho avuto nonostante il sacchetto

l'unico caso

che ho dovuto

aprire a 4 cm

perché avevo un calcolo

more than two and in addition he also made me the infection, prepare the aspirate, I stress

Lionel, Lionel you aspirate, please, aspirate well, because otherwise you are going to have an infection now

and the bile is not usually, as in this case, it is not an NPM so this is not a classic

I think the calculations are less than a centimeter and a half but now let's see if

this is the moment fatidic where everything happens even more than usual

Ecco, vedi, questo abbiamo già visto come, grazie alla fuoriuscita della bile, il sacchetto sia indispensabile non solo per una questione oncologica, di rischio.

Allora, i calcoli qua, microlitir, la doma in pensa, ebbè doma anche lì, o là, no, ci pronsa?

but even more banal only for the fact that if you had to break you had to break

the cysts in the phase of extraction you risk then to find you have to go and recover the

calculations all over the place absolutely and then here is the bag I show you preserved

my clips inside now what I do anyway is that I return to see me in

generally do not wash if there has not been spillage of bile or if there has not been important bleeding

here it seems to me that in the end it seems to me that in the end it was there was some cc as

usual not very important and therefore now let's see anyway I repeat if there was

In fact, clearly, if I drill, there is still a bulge of the pus, etc. I wash, otherwise I don't wash and I don't drain, of course, but it's not even the classic, the glue is normal.

I don't know if you, unless there have been really serious problems, for the love of God.

We are just going to vacuum and we finish. Do we have the centimeters ready?

Did you clean the vacuum cleaner? Attention, Dimitris, if you're ready, show a little bit over there, please.

I know Marco well. Ok, so we leave it like that, there you go, there you go, then at the end, the grease,

I always take it off, you can show it on the outside. Ah, very good. I take it off following the

curves ok then now desuflation I take everything off and what you can

show well a little closer no no no endo is finished on the outside

ah yes we are going to clean maybe the image is better this way you can send it

already I believe

maybe if you use the laparoscopic we see it from above the umbilical

Now, what I do is, I put my good finger, I close and check if it is closed.

Here it is closed well. Dyer, you see it too, I think.

and anyway if it is not closed well what I do is that I remove the point in the bag and I give some points

using the valkyrie the one with the five-octave needle and in any case I give these points to the same now I

simply close the point in the bag so pds 1 reabsorbable and then I still give

some additional points to close the aponeurosis more and also the window that is here.

So now I separate the cut and close there with just a simple point.

So I'll show you the final incision so then if you have other lives ...

And then, wait, hold on, then you see that in this case, I try to show you well, however, it is exactly from 13 to 14 millimeters.

Are you there?

Yes, yes, perfectly.

You see, because it's closed.

Ok?

Voilà.

I think I'll close now with tranquility and give you the points of cut.

I thank you for your kindness in moderation.

I thank Giorgio Palazzini for the invitation and all my Italian friends.

We thank you for the demonstration that, as a final closing, I must say that it was absolutely interesting.

You, for the guinea pigs of the live broadcast, read the homologues that have been lost under the liver

and we also had the opportunity to see your great ability to do this intervention,

which was absolutely interesting and I must say also nice as a connection between...

I tried to contain it, but here is Marco Di Tellaro, who is uncontainable, so...

Say hello to me, Marco, I'll say hello to you and maybe one day we'll meet again.

Of course, gladly.

Thank you, bye bye.

Bye, see you soon.

Thank you, thank you.

Bye, bye.