K. CAMPBELL resezione laparoscopica per diverticolite

Good morning. Welcome in Rome.

Good morning. Good morning from Dundee.

I'm Marco Freschi. I have to give you the President Palatini greetings.

Okay. Thank you. We're Ken Campbell in Dundee, Scotland, here.

This is Ninewells Hospital.

We are starting a laparoscopic resection for diverticular disease.

And you're just joining us as we've done nothing, really.

This is the pancreas here.

duodenal flexure here.

Swing up, Sasha.

The transverse colon is being elevated up here

through a port in the left side of the abdomen.

And all we've done is close in here now,

is lifted up the inferior mesenteric vein

to begin our mobilization of the splenic flexure.

So I think we're just going to open up that plane underneath.

You can see the line of dissection there.

there. So we're just going to open up that avascular plane there and just move very slowly

over gyrotis fascia. We'll move at a speed which hopefully will prevent us getting any

bleeding. We don't want to go too far underneath the pancreas. Just keep the horizon flat for

me now. That's good, yeah. And we'll divide the inferior mesenteric vein at a convenient

This lady is unusually young for us. She's 37 years old, but she's been hospitalized

with a significant attack of diverticulitis, elevation of her white cell count, C-reactive

protein requiring intravenous antibiotics over a week, and subsequent to her discharge

charged from hospital, she's had endoscopic assessment showing diverticular disease and

she's also had a barium enema which we don't use very frequently but in this situation

I use a barium enema for people I'm considering operating on for diverticular disease because

it gives me the nicest overview of the extent of their disease and what their resection

will entail. So we're moving over a gyrotus fascia laterally and descending colon appearing

as we move laterally. You can see our plane nicely here. We try and keep it bloodless

and keep the horizon flat.

Do you perform this kind of bland dissection always with a monopolar scissor?

I do, yes. Because colorectal surgery is within avascular tissue planes, I don't personally use the harmonic scalpel much at all.

I like to know that I'm definitely within the right plane.

If I'm not encountering bleeding with simple diathermy, then I know that I'm within the right plane.

plane. Sometimes the harmonic can create a bloodless

plane falsely. That's a personal view and of course many

people use the harmonic and many of my colleagues here in Dundee use the harmonic scalpel.

It's just a personal approach but I've just got used to dissecting this way.

I'm using this pledget holder to hold the duodenal-jejunal flexure back.

I think we can now bring that in to help open up there.

Hang on to that there for Melinda.

And if I'm avoiding using the harmonic scalpel for dissection,

that leaves me free to use an energy source

for vascular control.

So I'm going to use an energized vessel sealing device.

Previously, I was using ligature fairly extensively.

we've started using the NCO device recently

so I think we'll probably use that today

I tend to use one or the other of these two

and we'll use that to divide the IMV

in due course

I don't tend to divide the IMV until I have to

back out of view a little bit

just gently there

and this dissection is done head up

up, which is useful.

This patient's fairly obese, not the worst for UK terms,

but she's got a BMI of 31.

I think we established, Christina, wasn't it, 31?

Her weight is 80 kilograms.

Her height is just 150 centimeters.

OK, just watch her.

We're clashing a little bit.

bit so and oops we've just inadvertently caused some bleeding so come back out find our pledge it

back out find the pledge it yeah as soon as we encounter some bleeding we'll come back in and

we'll we'll solve that okay good come in again now sasha and i might swap to the hook i can do that

myself and we have reason we sorry we have another question from the audience uh do you perform some

mechanical preparation of the bowel in colonic surgery or not?

Yes. I don't use any

oral bowel preparation, but I use, I think it's very important

to say we don't not use bowel preparation. What we use is

phosphate enema. We don't use any oral bowel preparation.

It's an important distinction to make. Hang on to that there.

Because we need to put a staple gun up through the anal canal, we

We intend to use a stapled anastomosis, intracorporeal anastomosis.

So that has to be clear and empty.

And we deliver phosphate enema the night before surgery

and another phosphate enema on the morning of surgery, early in the morning.

And we find that empties the whole left colon.

And on occasions we've had to do endoscopy during the case

and sometimes find a polyp where the marking

hasn't worked. And we've always been successful in doing that.

Okay. So now let's back out the view now.

So we've taken that mobilization

reasonably far. We'll pull this back out.

Pop it up over the top for now.

Keep the horizon flat for me now. I'm working over here.

Yeah, come in.

Come in, bring in the camera.

That's good.

We need the 30-degree camera is invaluable in this situation

for giving us a view.

We don't want to go too far underneath the pancreas

because the plane that we're looking for

is the base of the transverse mesocolon, which is up here.

Give me a view up here.

That's it opening up just here.

So we'll continue that dissection up here.

Yeah.

And that opens us into the lesser sac over the top of pancreas.

We can continue that dissection.

Right over here.

Yep.

Okay.

And again, because I'm not using any energized dissection,

I know I'm in exactly the right plane

because we're not experiencing bleeding.

Good.

I'm back out now.

So I think it would be useful to take the IMV now.

Can we set up the NCO device now?

Okay.

So while we're setting up NCO, let's clean the camera.

We've got a slight smear on the lens.

So while we clean the camera,

are you able to give an external view of the barium, Alan?

on. We can show you a picture of the Berium Enema films. Yeah, you can hang on to that.

Ports come out. Shoot. No, don't push. That's it. Okay. Watch the optic. Okay. Okay. So

I've cleaned the camera. We set up the NCO device. The NCO, like all the energized devices,

is expensive, so we don't open it until we're certain that it's going to be of value in

the case. Okay. Do you have enough

slack to use that?

Well, okay. That's good. Alright.

So come in. Give me that

view there. That's fine.

Enseal all set? No.

No, it's fine. Alright.

Linda, are you okay to

hang on to that? Okay. Alright.

Fine. Let's take

this out. Okay.

Good. Alright.

So, we're going to divide

IMV now. So this

is enseal device. It'll take

vessels up to seven millimeters in diameter at 700 millimeters of mercury. So we'll take the

tension off the vane. We'll start activating the energy and then we'll move very slowly. Close in

Sasha. Just use the optic to give a view of the top of the device. Yeah. Yeah. That's it. Yeah.

And you can see the bubbling representing the seal zone. We'll go very slowly here. That's it.

and just watch the imv down there give me a view of that so if i let go that's nicely sealed

okay that's fine now we can continue to work along the top of the pancreas here good

yeah let's move this okay now you need to work with your when you're able to hold that just

give sasha two hands to to work with the okay that's fine don't worry don't worry too much

about. We'll tuck that in down here. We don't want to be as low as that. And just keep that

horizon right for me. Okay. Fine. Okay. We'll seal that. Just keep that horizon there. Sweep

that a little bit up for me there. Yeah. Okay. Good. And I'll just go back to working with

with my hook. Yeah. Okay. Good. Fine. Okay. All right. Now, back out the view a little

bit. Let me just touch that there with the diathermate. This little spot weld on that

bleeding. Okay. Back out view again now for me. Yeah. Okay. All right. So we'll continue

to knock that plane over top of pancreas. Yeah. It's just this flimsy tissue tethering

the transverse mesocolon down onto the upper surface of pancreas, and a fold of peritoneum

that goes down to the IMV, and that's the space of the lesser sac there.

Okay, it's a little bit stuck in there, that could well be, she's got sort of quite scattered

diverticular disease, so there may be some reaction in her lesser sac, it's not too bad

at this moment okay just use this to elevate a little bit higher yeah just push that right down

there that's good that's it okay let's open up this window all the way along in our lesser sack

yeah you can see some of these adhesions in our lesser sack which is stopping it opening up as

nicely as we would like and they're on to stomach i think because it's a little thickened we'll go

go back to the end seal usually conventional diathermy is all right here that we can just

that's it so we can steer clear of the pancreas just sweep it downwards we should have a slightly

nicer view of the less yes you can see the inflammatory process that's occurred in there

this should just open up nicely now let's move our pledget into that space yeah okay good yeah

Yeah, that's our problem.

Lesser sac, that's some inflammatory process,

whether it's the diverticular disease, don't know.

Let's sweep that down that way for just now.

Yep, okay, clashing a little bit.

So we just want to open up a decent piece of lesser sac

so we've got a target for dissection.

So that's fine.

So we've opened up lesser sac.

We'll take our pledget, put it into that space,

and we'll continue the dissection over the tail of the pancreas

a little bit here, yep, and we'll just

take these adhesions off

here, it's easier to get to these from this side

than laterally, and there's

spleen there, gone through to the other side there

so we can complete this

camera angle, camera, yep, so we have the

anatomy that we want to see, we've got the pancreas

in full view, we've got the

the spleen in full view now.

So we've completely detached the transverse mesocolon there.

So I think we can leave that dissection and come back.

And we'll deal with the omentum next.

OK, so I'll put that up there.

Relax on that one now.

Take this one back out.

Give the pledget back now, Linda.

Now, you can see some adhesions of the omentum

over on the far side.

So we probably should deal with these next.

I think I'll use the scissors.

Linda, can you pop the diathermy onto the scissors?

Ah, now you can see a technical problem we have with our grasper,

which has fallen apart.

Another grasper.

I think that's going to be a constant problem.

We should open another one.

Yeah, when it starts doing that, it does it all through the case.

So I think we'll...

Okay, this is more evidence of our diverticular disease.

Alan, are we still attached? Are we still on audio contact?

Okay, obviously we don't want any traction on the spleen.

Cautiously see what's on the spleen there.

Okay, so that's fine. Let's come back

and we'll try and go underneath the omentum, I think.

So, look to open up that plane there.

So, Sasha, I can probably give you this

just to potentially hold the transverse colon down

to give me counter-traction.

Okay, yeah.

Go back to the hook just for the moment.

Okay, so as long as we've got a spare grasper that works.

Okay, okay.

Okay, and again I use the hook to open up these tissue planes.

It's exactly what you don't want.

Okay, let's have another net so please.

So just to prove that harmonic would probably be better.

When it comes to the omentum, there aren't the same bloodless planes to work in.

So we'll probably go back.

You see, that's colonic fat there, I think.

I usually find the plane without bleeding

and then switch to the energized device.

I've failed to do that this time.

Okay, you get that spare grasper now, Linda?

You come across this net cell before, Sasha?

You come across this net cell device before?

No, this one.

This, no? Okay.

It's much more efficient than a swab.

we can recycle it

it was written up

in surgical endoscopy

by Luigi Boni

who spent some time here

with Sir Alfred

Kishere

a few years ago

but we routinely use it

almost everyone that's worked in Dundee

ends up using that

ok

so yeah

what we'll do is we'll try and get this

dry

we'll let it go clean in a second

let me just get

organized here

we'll just try and stop these bleeders

I got a question

we all know that

sometimes colonic resection

for the vertical disease

can be very tricky

so thinking about

a procedure that can be so

difficult, in my opinion

opinion, the most important point is the right indication. I find some articles and review

that tells about the indication. Historically, we put an indication after the second diverticular

a particular attack but in some review they don't agree with this point of view.

So which are in your opinion the right indication not in cases with stenosis or

bowel obstruction?

Well I think it's a very good question. I think in the UK in general we are very

conservative about indications for diverticular disease.

I think the right indications, or the indications that you can't argue with, would be stenosis and fistula.

I think the two attacks of diverticulitis is discredited now.

There's a large population-based study from the United States of 60,000 patients followed over years in Washington State.

state and the actual incidence of patients post two attacks of diverticulitis requiring

an emergency resection in the future is extremely low.

So I think I don't do any preventative operations. I don't think there's good data now to support

the two attacks of diverticulitis even in young patients and I'm sure the American

American Society of Colon and Rectal Surgeons will probably vary that advice next time.

I know Abe Fingerhart is interested in reviewing the European Association of Endoscopic Surgeons

consensus on diverticulitis because there have been a lot of developments, our ability

ability to see the disease and CT scan to perform percutaneous aspiration and the

washout, laparoscopic washout for attacks of acute diverticulitis, just come in a

little bit Sasha, has changed things enormously. So this patient is not having

the reception because of their attack of diverticulitis, it's because of ongoing

ongoing pain and I think she's a degree of stricturing in place.

Okay, let's try and get this looking a bit better.

You know, I think because this lady is 37, she's facing a long time.

She's been on antibiotics several times. I have a very careful discussion with her.

I think some of the symptoms she experiences may well be from spasm and irritable bowel

syndrome and I've had a very frank discussion with her about the fact that these symptoms

may not improve. But what I've told her will improve are the attacks where she requires

antibiotics and she responds well to antibiotics. I think that's fairly good evidence.

Her barium x-ray is not particularly impressive but bear in mind she's 37 years old so we

might have to wait a few years for her x-ray to be more impressive. But with ongoing symptoms

You know, she's trying to, she has a job, she has a busy life and stopping to have antibiotics

almost monthly at the moment I think is what's driven me to do, this is the youngest diverticular

patient I've operated on and it's the patient with the least impressive x-ray.

We're normally dealing with a less fit elderly population where the level of the surgery

surgery, it makes you think twice about it. But we certainly aren't using a single second

or third attack of diverticulitis as an indication per se. If they have one attack every six

months, come into hospital for a couple of days and have antibiotics, we would accept

that and not pursue surgery unless they've got daily symptoms more or less. It does mean

mean that the patients we're operating on are less friendly patients. They're more difficult.

Their disease is more advanced. But there's no evidence that doing preventative surgery

is worthwhile. Now let's see if we can see what progress we're making here. It's important

to pull the flexure over towards us, bearing in mind the spleen. Okay, that's good. So

just to get this bowel pulled over towards us.

We're progressing a little bit slowly through things here.

Let's see if we can speed up.

Now, we've opted to go between the omentum and the colon,

which is sometimes a nice play.

And it might be that if it's going

to be very stuck like this, that we should just

go underneath the gastroepiploix

and take the omentum with us.

that devascularizes the omentum sometimes.

You end up then having to still resect the omentum

because it's devascularized.

So what we're hoping to do is

get back into the lesser sac from this direction

and then meet up with our swab.

Now we're just hitting that same problem we had

with the lesser sac before.

Let's see if we can...

The lateral thermal spread on this device

device is actually very little, okay.

Now that's our...

Yes, I think it's less than one millimeters.

Yeah, because the blade that you see coming across there compresses things

very strongly so they can deliver the energy in a much more controlled fashion.

It means there's more user input into the device and you can control the speed with

with which you progress, which is a difference from ligature.

So I've just started using it in the last three or four weeks.

But I'm quite enjoying using it compared to ligature.

OK, so we're getting a little bit lost in the momentum here

as usual, but let's just detach it from here

and see if we can find our dissection from the other side.

Yeah, if you could give me some traction, just even that.

keep the horizon

keep things flat

try and find the point with the least

just keep the horizon

very frustrating working with the momentum

it's very floppy and then if you don't concentrate

you'll get it bleeding

bleeding. Now, look for is our dissection over the pancreas. See if we can, struggling

with this one here. Okay, yeah, lift that up for a minute now. See if we can, yeah,

the two limbs seem to be fused really here. We could go in up here and that might be what

might be what we need to do. Just push it. Push it that way. That's good. So if we go

up here, we will devascularize the omentum. There, that's better. Okay, that's better.

in there now. Yeah, Linda, you just push it

that way. That's good. And we'll carry on here.

It's all pretty thick. And so we can see now all we have to do is go through this stuff.

It's pretty nasty. But if we just work our way through

we'll come out on the other side.

We tried to find a nice plane, but we failed. So we're just going to have

the attachment to the spleen which i didn't really like very much so okay so that's good so now we

can finalize the the mobilization of the splenic flexure now all right so i'm going to swap the

net so the nco to there okay now if you can swing that down either either linda or sasha and come

in over the top push it yeah come in over the top there we might change ports which is because

Because she's quite small, we might not need to.

Okay, so there we are.

I'll just mobilize the last few strands here.

Just use your optic to give me a view around the corner here.

So, laenocolic ligament being mobilized there.

Yes, yeah, we'll just take all of this stuff just now.

Now, for an unfit patient, it means you can do a lot of the procedure head up, which the

anesthetists prefer.

So let's come back out wider view now.

Okay, now, what we don't know at this stage is how much mobility we really need.

But certainly, I'm happy that we have the pancreas, gyrotus fascia, the spleen all exposed

with the transverse colon coming down from there.

We can remove this now, put it down the lateral part of the colon,

and I think we can probably move to the next phase of the procedure

and go to a head-down procedure and look at the zygmoid colon.

So, Christina, we're going to go head-down now.

Okay, so we can relax on that.

We had two net cells, didn't we?

Just let's have a look for the other net cell first.

Just stop the change of position.

Sasha, just follow me down here now.

That's that one.

So let's just take these two out for just now.

And just let me get that net saw there.

Okay, that's fine.

So, yeah, clean the lens, and we're going to go head down position now.

That's good.

And you'll swap positions now.

Okay, a couple of graspers.

So let's just come back up to the omentum,

and we'll put the momentum up into the, yeah, going slowly.

We're just going to push the colon back up

into the supracolic compartment.

Okay, swing left a little bit with the view, yeah.

We don't have a pneumoperitoneum at the moment

waiting for our gas to be changed,

so we're just going to do some non-critical.

That's it, pneumoperitoneum should be filling up,

so our view will be restored.

Let's go down to the pelvis now.

now. Okay, let's have a look. She's got a very large cecum in her way, which hopefully

gravity will let pull up. Her appendix is trailing. We'll take as much head down as

you can actually give us, Christine. Give me a view just underneath the appendix there,

Sasha. Sometimes there are adhesions here that we need to divide to get this to... Yeah,

Yeah, let's have a look.

Okay, and we'll flip the small bowel over.

Yeah, take your net cell, one of the net cells back again then.

Yeah, now it's not so easy to put them in actually.

Well, give me the threads, yeah.

Sometimes we can use that net cell just to keep the small bowel out of our way.

Okay, and we'll have a look at our sigmoid colon.

Now you can see how things are stuck up here.

Yeah, another adhesion down there.

Now, we want to be able to push the zygmoid colon up

out to the pelvis.

So we're actually going to start with dividing

some of these adhesions.

We're going to do a medial to lateral approach.

But we just need to do some preliminary dissection

down there.

And I think for this, what we'll do is let's put a 5 millimeter

port in there.

We'll watch the horizon.

That's the uterus, so that should be right at the top.

Okay, all right, just give me a view up here, Sasha.

Okay, so we're just going to put a suprapubic port in.

This will be unobtrusive below the hairline.

It's very stretchy here at times.

It's best to give some counter-traction.

Okay, I'll take the scissors now.

Just attach the diathermy to my scissors, please.

So I'm not doing a lateral to medial dissection here.

I'm just taking down some of these inflammatory adhesions, really, more or less.

And this is just to allow us to push the zygmoid colon up and out of the pelvis.

So I think it's clear that she's had genuine diverticular problems.

So that's what we expect to see, really.

Yeah, yeah, okay, that's good.

Yeah, I think I'll divide some of that stuff there.

I try to maintain the peritoneum, so I just divide the lesions between the sigmoid mesocolon

and the peritoneum, but not divide the peritoneum.

Yeah, you see that that's the anatomical attachments down here.

These are non-anatomical attachments.

So the patient is in Trondheimberg position.

How many degrees?

Oh, I don't know.

Christina, how many degrees are Trondheimberg away?

More or less, because in my hospital it's always a fight against the anaesthesiologist.

Five degrees.

One degree more, no, it's not possible.

It's a process of negotiation.

But the problem is that my anaesthesiologist is a man.

Oh, yeah. Yeah. Well, you have to wait till they leave the room and then adjust the table

yourself.

So the nurse will beat me.

But we're fortunate this is a fit patient. She has no other medical problems. We have

other patients. Now, the rest of the operation that we were doing from above was in the head

head-up position, reverse Trendelenburg. If the patient is very unfit or very obese,

I would do a lot more of the dissection from above in that position and leave the Trendelenburg

position until we're at the very last moment. So I think the sigmoid is now free. I think

at the top of the rectum.

Keep the view there, shush, shush, yeah.

Our anastomosis will be somewhere here

where the tinea are fusing.

So we don't need to do much more dissection down there.

Give me a grasper with a ratchet.

OK, that's fine.

It's over here, Linda, I've got it.

OK, all right, now.

OK, so let's push the sigmoid up out of the rectum.

Okay, Linda, are you able to hang on to that?

Okay, now just watch the horizon again.

Give me a view right down here.

No, that was good.

Okay, all right.

Give me a view down here, Sasha.

Right down here?

Okay, so the small bell has come back up to annoy us,

but it's not too bad.

Okay, all right.

Watch the horizon now.

That is the opposite twist.

That's it.

So what we want is a view.

Yeah, Linda, just hang on to that.

That's good.

Yeah, OK.

So there's the base of the transverse

of the sigmoid mesocolon, sorry.

There's a smear on the lens.

Let's clean the lens so you've got a good view.

Yeah, pop it in here.

Yeah, yeah.

Good.

OK.

Artery clip, please.

And what to do?

Hang on, Sasha.

Just focus on the port so you know that your view is good.

OK.

So that's fine.

And you know that there's no blood on the port.

OK.

So you can go in now.

Go slow.

That's good.

OK.

So that's a nice picture again now.

OK.

So move that back.

OK.

So now we're going to keep that.

That's the horizon there.

I think that's the artery probably there.

there, so I want nice views, nice views of that, okay, close in now, so we're going to

open up the peritoneum here, and the gas should flow into the tissues, and just with enough

traction, keep that horizon, keep the horizon, yeah, that's it, good, that's good, okay,

so long peritoneal incision, following superior rectal artery, and then we always move up,

and we want to drop all the structures down and I want to drop the hypogastric

plexus down. Now I look for the fascia, fascia on the back of the vessel. Okay

probably possibly a ureter there. There's a ureter there. Yeah so we want to stay

up very high. I want all that tissue to drop down because that's all I think

hypogastric plexus

there. So keep our horizon.

The ureter should be flat, so

that's the horizon.

Yeah, okay. Good.

And our plane as dissection

will be well up there.

Now, that's

our superior

rectal artery there.

So we want to be right underneath the superior

rectal artery, with everything else

dropping down.

That's the ureter down there.

Okay, so we just

Let's get the net cell again.

Just swing around. Give me a view of the net cell.

That's that device there.

We'll just pop that in.

If we've got a bit of bleeding, we want to mop that up.

Just leave that there for now.

We'll open up a little bit more here.

Okay, and that would be our mesorectal plane.

If we're going to do much in the way of rectodissection,

we'll open up a little bit here.

The only reason for doing rectodissection

would really be to facilitate our stapler coming up.

We have a long rectal stump.

We may struggle to get the stapler to come up.

Okay, so that's the plane.

That's our artery there.

Everything else should drop down from the artery.

There's probably the plane of dissection up there.

That's a nerve.

That's nerve.

So we want everything to come down from here, really.

Okay, come back now.

Let's find, okay, we can take a little bit more here.

Okay, now, bring me the nitzel in.

Possibly due to inflammatory changes,

we don't have a nice plane opening up here.

We're safe with the ureter,

but we haven't normally the plane right on the back of the,

that's hypogastric plexus probably down there.

Normally the plane right on the back of the vessel

is the one which takes you into the correct plane.

So we're just going to have to see if things tease the tissues apart

and see where it's willing to open up.

Yeah, it's a little stuck, isn't it?

Okay, there's the artery.

Everything else should drop down, really.

It's whether that is the plane in there.

That may be the plane there.

but I think it may well be a little stuck.

Okay, back out view again.

Well, we may be getting too close to the vessel.

Let's just stop.

We need to see if it will open up somewhere here.

I'm not convinced that we've found the correct plane.

If we rush this and don't find the correct plane,

we'll end up taking more time at the end.

Let's keep that view for me.

Let's just see.

That's possibly this gonadal vessel.

If you can just always keep a horizon,

always keep the horizon, because I get confused.

OK, let me just mop up here.

change. Okay, so this plane should open up much more nicely than that, but...

As in diverticular disease? Yes, I think so, yeah.

Perhaps this is the most challenging time of the operation.

But I think it's nicer to find the ureter medially

than be forced to go lateral.

But if we take time to find the plane,

it will be quicker in the end.

If we become impatient and go into the wrong plane,

then we'll prolong the operation.

OK, so I think that's the plane at last, which has opened up.

And there's the line that we were searching.

Normally this is very easy, there it is, that's the line we should come up and join our gyrotis fascia.

Yeah, yeah, I agree with you, this is the right route.

Okay, so normally this is bloodless, so I think what we have to decide is on our vascular ligation.

and find the net cell for me now.

Should I just put that in there?

Because we don't have to take anything for oncological reasons.

It depends on how much bowel we have to resect, really.

Part of that decision is going to be made when we exteriorize,

because I think a part of it will be the...

Because the colon's covered in fat here,

we might have to feel,

And I'll, by feel, try and find a nice, soft part

of the descending colon free of diverticular disease.

But it leaves me with a decision about where

I divide the vessels.

I also may preserve the superior rectal artery

so that the distal rectal stump has a good blood supply.

All right.

Right, so I think we'll leave the IMA in place for just now.

Linda, I'm going to swap you around to do this.

And go to the lateral side.

Yeah, and then we'll do a little dissection here.

You're in good view.

Let's just have a look down to the rectum now.

Just adjust the horizon for me now.

This should be flat.

It's actually at horizon, well away from the nerve's pelvic side wall.

Okay, so I don't think we need to do any more dissection there.

Okay.

All right, back out of view.

Yeah, and let's clean the lens.

Lens is smeared.

I can take this.

Okay, no.

So what you have to do is clean the lens, then check there.

That's all fine.

Just need to dry that a little bit.

bit. Okay, and then go in slowly. Okay, that's pretty good. Okay, so we now have a reasonably

mobilized colon. Let's complete things laterally now. Linda, just hang on to that there. Okay,

so use your 30 degree lens to give me a view around the corner there, Sasha. Yeah, that's

change ports probably now i'm wrapped around there a little bit okay this port's still not

going to be good okay let's just get a view on what more we have to do yeah yeah just there okay

Okay, come in again over the top.

Okay, and we should join up dissections.

Just work with the camera so we don't clash.

Yeah, okay.

Oops, Sasha, you might be able to assist a little bit.

If we can just hold on to that there.

You might have to squeeze the jaws a little bit.

Okay, so that's the view of our plane from the other side.

that's why it's why it's bloody that's fine okay let's cool back relax on that

now a very mobile colon now based on its blood supply really entirely a little bit of

adherence there now we're entirely held on that um iliacolic area we've come through there

we have to decide what we're going to do with with IMA so I've been tempted just to take it

take it up here um let's see just watch that horizon yeah that's it a bit bloody let's mop

up there so what I think we might do is preserve the superior rectal artery find a plane between

between the bowel and the superior rectal artery and then open up along there so we

conserve the vasculature.

Okay, so I think Linda, if you're able to hang on to that.

Let's swap to a hook, seeker, let's give that a wee clean, okay.

Okay, so I think if we scrutinize that colon,

that all looks fairly soft and healthy.

So I would anticipate coming across here, I think.

So I think what we'll do is open up the peritoneum here,

preserve our artery there, and try and find a window.

We could divide the colon prior to dividing the mesorectum.

Some months ago I managed it in this way, this step.

I divided the colon.

Divide the colon first?

Yeah, first.

I'm not sure it's really, really the right thing,

but the colon and the mesorectum was very, very hard.

The inflammatory tissue was very hard and it was impossible for me to understand anything.

I think, I mean, some people routinely do that, divide the colon first of all.

What we want to do here is preserve the superior rectal artery.

And so I want to leave the artery there, find a space in here,

and then come up the way and take the vessels non-anatomically.

Now, this is the plane which will lead us around the colon,

and it's going to bleed a little bit, so we'll go back to NCO.

And I think if I can open up this space here.

For this step, this is a very, very good device.

Yes.

I'm waiting for the new generator.

because I've got only ultrason but the new generator can wash all the devices.

Well, we've been promised the new generator any day now. It's coming today?

Or it's posted today? Alright, okay. So I hear ours is in the process of arriving.

With a new handle I think which will be ergonomically better perhaps.

And about devices, I found also that the new stapler, the Echelon is better, for column

is better, because the branches can open 22mm I think.

I use the gold cartridge for the rectum

I think that 1.8mm size is good for the rectum

so that's the plane at the back of the rectum there

between mesorectum and the bowel wall

so we could place a stapler across there

we've opened that plane between the two there

so that's something we could do what I think I will do now though is come up preserving that

superior rectal artery and come along the side of the mesorectum I agree with you perhaps if

we want to preserve them superior rectal artery it's not good to divide a column because if you

If you divide the rectum, you can lift up it, but you can lose the right plane.

Yes, potentially, yeah.

So I think you could place a stapler across there now and then lift up,

but I think we can do it this way and then place the stapler perhaps more accurately.

Yeah, I agree with you now.

are. So now Sasha back here. Sasha, yeah. And in the vertical disease, do you try to preserve also

the left colic artery or do you extend always the dissection and the resection to the descending

colon? I usually, I find always that you would probably have to take it back to descending

colon because the whole zygmoid is generally involved and it's thick and you want to get back

back to nice, healthy bowel for the anastomosis.

Now, we may be able to preserve the left colic artery.

And I'm going to divide all the sigmoid branches, first of all,

and leave the left colic artery till last.

And we might even exteriorize the specimen

and see what healthy bowel we have.

And if we need to divide some more vasculature later on,

we can do that.

So now, this is very floppy.

So we'll use another element of assistance here.

Sasha, can you hold that up?

Yeah, you might need to squeeze the jaws.

Okay, so I'm just going to follow the mesentery along here.

She has quite thin mesentery.

Sometimes you have to go in two layers.

Sometimes you have to create a layer

and then come back and get right onto the vessels themselves.

themselves. We can join up with a window that we had made there, not deliberately.

Okay, just rearrange things again. Just press on that. Sasha, if you can come up to somewhere

like, yeah, what we want to do is tint that up. Yeah, you got that there? No, that's good.

Okay, and we'll come up, let's see, go in layers again,

close in the view a little bit.

It sort of depends how much we have to resect now.

Okay, just let this, let that support that enceal.

Okay, so it's a case of deciding where we're going to resect.

I think we may exteriorize the colon now

so we can assess the extent of our resection

because I'm going to rely on touch and feel

to tell me what's healthy

I think we still have a little attachment up the top there

okay, so Sasha, I'll get you to follow me up here

that's the transverse colon which is coming down now

out there. Just hold that there.

Let me take the end seal out just now.

Interested in just around the corner here.

Are we free there? Oh yes, we are.

Just follow me up there.

So that whole colon is entirely free there.

And what's holding us is the blood supply

down here.

So it depends.

So I think we will finalize the vascular division

with the specimen out so we can see what's what's healthy and what's not so

I think what we're going to do next is divide the divide the rectum so we'll

again yeah I think we might have a little bit more to do down here that's

That's where we'd anticipated coming.

And that's healthy.

I think we can leave a long stump because it's well vascularized.

So I don't think there's a problem with that.

Okay, let's go back to the enceal.

in the mesorectum there a little bit.

Okay, that's fine.

So if we've got the echelon now, yeah.

And there's a very, you know, there's a good blood supply going in there,

so you're confident.

And it's reasonably mobile, so I think we'll get a steeple gun up there.

Let's just suck it while we're waiting.

Okay, watch the horizon.

Okay, yeah.

Okay, now back out of view.

Wider view, wider view, wider view.

Okay, now come in underneath and just see what we think.

Okay, that kind of view.

Okay, we could go a little distally maybe.

I think that's reasonable.

Back out now.

Okay, we'll leave that 15 seconds now.

Okay, so now we know that's a well-vascularized rectal stump

stump because we've got our superior rectal artery running down there towards it.

So I don't think we have any problem with the blood supply there.

I think we will now extract the colon and take a look and see what we have.

So we're going to stop. We'll make a little suprapubic extraction

port over here. So we need a diathermy pencil please and we

We need some overhead lights on.

Diathermy handset.

Do you have some irrigation attached now?

Let's come down to the pelvis now.

And you can see we could very easily do some more dissection there if we needed to.

Okay.

So let me know when you have the diathermy pelvis now, Sasha.

A bit of bleeding from the staple line, so that's good.

Okay.

Yeah.

Okay.

All right.

Right, so it's here.

Okay, diatherm on 3434, please.

Yeah.

Okay, and overhead lights, please.

So, I had a big wound just to go through the fat.

Dry swell, please.

Yeah, we've got that on the end, don't we?

Yeah, no, that's fine.

We can pull out now.

Alan, you could give them a view of the barium enema, perhaps,

but uh okay hang on to that yeah okay so i just do a muscle splitting uh decision here gas off yes

okay so down a layer yeah no that's okay yeah it's a long way yeah we need longer longer bags

yeah hopefully we don't need to have them in for for too long okay yeah get into that layer there

yeah okay okay all right retractors right now and I just do muscle muscle

splitting incision appendix it seems to heal quite well okay Alexis now okay you

could go back to an external view now on we could do us was there you got a view

So you have this, Alan, yeah.

Babcox, please, now.

Same name, yeah.

I think they're all the same name.

So it's quite hard to see where there's diverticular disease in there.

This is the thickened part here.

That's, I mean, I have to say it's the least impressive diverticular resection.

I've ever performed. That's the section on her barium there. She still has diverticular

disease there. It's whether we do a more extensive resection because we can divide more blood

supply. This is the blood supply which is holding us here. So we can take that extracorporeally

with the NCO. Excuse me, can you zoom a little bit

on the operation field because your hands are

overexposed. Yes, yeah. Thank you, sorry.

See what you can do. We don't have an overhead camera unfortunately

at the moment. Oh, this is good. Now it's good.

Okay, I'll show you the, I'll show this is

the specimen that we have so far. It's more by

By feel, I don't know how it's zoomed in.

There's diverticular disease here.

This is very thickened, lots of circular muscle hypertrophy.

And I knew that a lot of it would be by feel.

There are diverticulae scattered up here,

and one or two just up here at the upper extent of the resection.

If we divide the IMA closer to its origin,

this whole left colon, left transverse will come down.

It's difficult to know.

This, I think, has been the source of the trouble here,

this part, which was stuck into the pelvis.

She's got scattered diverticulae elsewhere.

But because that's so mild, I'm not really

used to resecting for that type of mild disease.

So I'm left wondering.

It's not thick-walled here, although there

are diverticulae.

there's no circular muscle hypertrophy

that I can feel

and if we look at the barium

I think we've taken the part in the barium

that looked abnormal

so a little serosal tear

that's what happens when you don't have the mobility

looking at her barium enema

she has scattered diverticulae throughout the colon

in a way

So I think that is the problem there.

This is the thick area here.

So I think we'll be relatively conservative

and just divide the colon.

We'll divide the colon here

and just perform a stapled anastomosis

and that will be it, really.

So, okay, we can use the end seal again.

Can we have another firing of the ligature?

yeah of the echelon and we'll have um can we have the the extended uh 29 millimeter cdh you know the

just lift that up diathermy handset is somewhere up here oh is that diverticulum there

It is, isn't it?

So I think if we divide just...

Is that another one?

Okay, we'll go just above that one.

Okay.

We have a betadine-soaked swab, please.

Okay, lift that up there.

We'll just come back a tiny bit.

That should be fine there.

Okay, now, can we get the head of the gun,

the head of the circular stapler?

Yeah, betadine.

And I need more betadine on this.

I need a proper soaked betadine swab yeah yeah then we can do a site to end

that's where we're coming across there isn't it right in there so we can so we

can open up here and it's quite clean so that's good okay so head of the circular

or stapler whenever you have it might need to make sure it's totally unwound what's that yeah

well it doesn't need a bit of ky yeah this is the ethicon so it's it doesn't need you familiar with

the covidian yes yeah okay yeah okay that's fine that's all we need yeah she's quite small that

Just go slowly so we don't hear anything.

This is actually very small.

Babcock please now.

Now, have you got the Echelon staple gun now?

Okay, it won't close unless it's in there.

That should be well vascularized I think, shouldn't it?

Might bleed a little bit.

We'll leave it 15 seconds.

So we've taken out a reasonable specimen egg.

Okay, so that's that specimen away.

Okay, some bleeding is good.

No, it doesn't need to go fresh, it can be fixed, no.

Do you have a surgical forceps to improve?

Yes.

And a 3-0.

Okay, now what I need is...

You've got the journeys there.

but i think that's going to be fine a bit more betadine now please

yeah site to end yeah yeah yeah okay gas on again please now lights on that's okay now

Yeah, we're slacking that.

Yeah, and we can, that should, that should seal.

Okay, all right, back around here then, Sasha.

Yeah, that's finished with, yeah.

Okay, gas on, please.

Yeah, okay, so it's cleaned the camera.

75 is okay, actually.

So just check the view on the port before you go in,

just to make sure it's crystal clear.

That's clear.

Just look, you can see on the port there was a bit of blood there,

so you can just as a shortcut you can quickly drop the swab you can just quickly rub the end

of the camera into it okay okay and pop it in that should be okay i think it's fairly clean

okay that's fine we'll take that net so out actually just now how many nets was so this

is the only one that's in just now okay let's take that out overhead light off now please

Okay, let's take a look in the pelvis.

Okay, I want to just reorganize our small pelvis.

Okay, that's not an issue really.

Yeah, it's a little, we put washout in there, so it's probably just, maybe the staple line.

Okay, so I don't mind bleeding at the staple line.

That's going to, that will settle down, I'm sure.

But when we see bleeding from the staple line, it's a good...

Yes, absolutely, yes, I don't mind that at all.

There's the clot on the staple line, so that's good.

I'd rather bleed from the staple line

than have ischemia.

Okay, so I think that's fine.

We might just have a look.

Before we anastomose, I'll just make sure

that there's no problems elsewhere.

Just have a look up into this.

Come right over the top, Sasha, right over the top.

Some blood will have run up from the head down position up here.

Yeah, come in.

That all seems to be fine.

here. Just hold the camera for a second there, Linda. Okay, start putting your staple gun

in cautiously, Sasha. Do a rectal exam and see if you think it's tight. Slightly impaired

view. Okay, so just hold that view there. Linda, that's fine.

Do you always perform a trans-signal anastomosis?

For the left side, yes. Almost always, really. Because I think you have to divide at the

the rectum. So I rarely find I'm doing a sigmoid anastomosis.

And also with the stapler because my chief sometimes has to me to perform a manual anastomosis

but I don't like it really. Perhaps because I'm not a good surgeon.

Well, it's time-consuming, isn't it?

And I think you need a bigger wound

if you're going to do a hand-sewn anastomosis sometimes.

I mean, this lady's quite fat.

She's fairly obese.

So in order to get the bowel ends up, you would need...

That's good, that's good, that's good, Sasha.

Yeah, okay.

Let me just try and straighten that out a little bit.

Yeah, okay.

That's good.

so happy with that. But for me it's not

only time consuming but the stapler is a standard

Yeah, yes it's reproducible

The manual is not a standard, you can perform the anastomosis

in too many different ways. Oh, stop, hang on

I'd like to bring it out above the staple line if I can. Okay, push the gun

in a little bit, that's good, okay, push the gun in a little bit more, okay, alright

right, wind out now. Hold on. Yeah, that's good. Okay. All right. Good. That's fine.

Okay, Linda, that's fine. Let's give a slightly wider view here. That's great. Just there.

Okay. Pull that back. Okay. Now, that's fine. Now we'll just swing to the left a little

bit and we'll find our end, hopefully. Okay, just keep the view. We're losing our pneumoperitoneum

him from somewhere? Okay.

Alright.

Okay. Now.

Okay. So

keep still at your

end, Sasha,

for now. Okay.

Now, if you can point over that

way a little bit, that's good.

Now, Linda, just give me a wider view.

I can just...

That's good. So we've clicked into position.

The biggest danger

is that we have a twist now,

but I think you can start closing the staple gun

a little bit. Open up, yeah, okay, that's good.

Yes, okay, close tight now. Okay, so we're bleeding at both ends

so that's a good sign. So it's in the green zone. Okay, now

just leave it there while we just check that there's no twist, that orientation

is good. Okay, Linda

take the camera again now. Okay, so there's the mesentery there, so I don't think

there's any question of a twist. And follow my forceps

there. That's good. Just center view there. Okay.

Alright. And just back out a little bit again.

Okay. So the orientation is correct.

So I think you could tighten up a little tiny bit more because it's quite thin tissue.

So yeah. Stop there. Okay. Alright.

No. Okay. So wait 15 seconds now.

Focus a little bit. Okay. That's good.

Good. So, another seven seconds.

There's a superior rectal artery pulsating there,

so that's taking good blood supply into that stump.

There's the bleeding end of the side-to-end anastomosis.

Okay, you can fire now, Sasha.

Hold the camera again, Ellen.

Okay, that's good.

All right, so that's fine.

I'll just support the rectal end here.

Now, it's a three-quarter turn.

Okay, that's good.

And then rotate the whole gun 90 degrees.

No, don't fish it out like that.

Rotate the whole gun.

Rotate, rotate, rotate.

Keep rotating, keep rotating, keep rotating.

Ah, okay.

Alright, okay.

Good.

You can check the donuts, please.

I'll give you an artery clip from here.

Okay.

That's good.

You can pull the white disc out.

Okay, Linda, just swing right a little bit.

That's good.

Okay. A bit more irrigation.

No, no, we don't need to send the donuts.

No. No donuts. No.

No, they can just be discarded.

Okay. Center view, just view downwards a little bit.

That's good. Yeah. I think it's fine.

So just come back now.

I don't think there's any tension here.

It sweeps backwards and forwards.

Okay. So I think we're complete, really.

We could do an underwater test.

Yeah, we could do that.

Sasha, we'll blow some air in to do our test.

Yes.

Okay.

Hang on to that camera there just for a second.

All I'll do is see if I can find some colon upstream that we could occlude.

Not at all, Yusuf.

So a bladder syringe and a rectal catheter.

Yeah.

Okay.

Okay, so just keep an eye on that.

No, if you stay there just now,

because I need to look for the bubbling.

So, where's Sasha now?

Sasha, if you just do this non-sterile,

if you can blow some air into the anastomosis.

Yeah, okay.

Okay, and just put a catheter in and rectal, yeah, yeah, take that, take that rectal tube,

I can, that's sterile, yeah, okay, take that, and a bladder tip syringe, and bladder tip

syringe there too, oh yeah, okay, all right, that's fine, and just blow air, blow air in.

I always perform this kind of test.

But the question is, what do we have to do if we see some bubbles?

Well, I think if you could see the source, in theory, I don't always do this

because sometimes the anastomosis is so inaccessible that if I see bubbles,

I know that I can do nothing about it, to be honest.

Here, the doughnuts are intact, the ends are well vascularized, and there's no tension.

So I'm confident.

Even if I saw bubbles, I would be reluctant to do an awful lot about it, but some people

feel quite strongly about it.

And I think the problem mostly is poor blood supply, so that the anastomosis may be fine

at the time when you blow in the air, the trouble is poor blood supply and the problem

occurs several days later. Okay. Blow in some air now, Sasha. Okay.

Yes, I agree. The leakage is generally some days later, the operation. But we have

We have too many young surgeons here. In Brum, we are here, and the only is about 2,400 surgeons

coming from all over Italy. And I think it's...

I agree. This is the correct thing to do. But as you say, the debate is what to do if

you get some bubbles. So we've got air filling the colon now with no bubbles, so I'm quite

quite happy. So Sasha, okay, so if you can try and suck

the air back out again now. So with that, essentially, we're finished

really. We're going to just take the ports out and close up.

Okay. Thank you. Thank you very much. It was really a pleasure for me to speak

with you, to see your excellent procedure and to hear some lovely voices from your team.

Okay, well, I'm sure the team are delighted to hear your compliments, but thank you very

much. It's been a pleasure to transmit to you.

Thank you again, and sorry, but I'm Italian. I have to bring my flag.

Okay, I hope to see you again here in Brooklyn.

I hope so, yes, maybe in Turin.

Goodbye.

Goodbye.

Thank you very much.