Lettura: La chirurgia epatobiliopancreatica H. Asbun (Jacksonville, US)

Horacio, we have chosen Pancras first.

Pancras first.

Yes.

Following a brief presentation of your work, you can start immediately.

Thank you, Professor Coppola.

Good afternoon.

I apologize I was late, but we have Lufthansa did some strikes, and my planes were delayed.

Then I had to be rerouted, and that's why we're late.

I want to thank Professor Coppola and the organizers of this Congress for having me here.

I apologize I don't speak enough Italian to do the lecture in Italian,

but I'm going to try to speak slowly for those that are not facile in English.

The title of my lecture that I was assigned was

Milliminvasive Surgery in Hepatobiliary and Pancreas.

Then it's a pretty wide lecture I cannot cover all in 45 minutes.

Then I was asking Professor Coppola if I should start with pancreas, with biliary, with liver.

Then you asked the audience, and they said pancreas, correct?

Good.

This is crowdsourcing, too, you know, like everybody votes and decides what to do,

like the president that better don't talk about that in the United States.

I'm going to start then.

And I'm going to also ask you a little bit of patience.

I don't have control of my computer.

And normally, I fast forward the videos.

Then I'm going to ask the gentleman in the back

to fast forward some of the videos.

We can start, please.

Do I have a control?

Is this it?

Good.

While I was in Lucerne at the Olympic Museum,

I saw a little lamp.

And I saw people fighting.

And I thought, what kind of sport is this?

And then I realized that it was called pancreation, and it reminded me of pancreas surgery.

It is a sport that has been now banned, doesn't exist anymore, but it was present for several

years in the Olympic Games, and almost anything was allowed, and it was like the contest,

as you can see there, continued uninterrupted until one of the contestants was forced to

submit.

That reminds me many times when I'm doing surgery on the pancreas.

It's like a fight.

But before I talk about laparoscopy or open, I just want to remember everybody that the majority of the cancers have improved over the years,

but pancreas cancer is on the last line there, line, and it has not really make any dent.

Then many people argue, should we do it open, should we do it laparoscopically?

We always have to keep in mind the most important thing is to do it well.

and for pancreas cancer we're gonna have to bring other other therapeutic

modalities to be able to be successful I have known disclosures for this then

what is the role in surgery in pancreatic neoplasms I'm gonna talk a

little bit it's like like in open surgery you could do staging palliation

treatment or prevention within the pancreas neoplasms that that's what I am

going to concentrate today. You could do a nucleation of the low-grade or benign

neoplasms. You could do a distal or subtotal left pancreatectomy, pancreatoduodenectomy,

total pancreatectomy, or you can also do pancreatic preserving duodenectomy. So we

have done several, about 65 now, where we preserve the pancreas and we're able to

separate the duodenum from the pancreas. I'm gonna concentrate on this talk with

with distal and subtotal pancreatectomy, as well as pancreatic or duodenectomy.

I'm going to show very briefly a couple of videos with it, too.

When we're talking about pancreatic resections, the most important thing is the location.

The difficulty of the procedure is going to be directly related, obviously, to where the tumor is located.

If it is in the tail, the body, or the head, the difficulty is going to be quite different.

and the skills necessary to do the surgery are going to be quite different.

I do believe today distal pancatectomy, and hopefully I'm going to be able to show you,

should be done laparoscopically in the large majority of the cases.

And I would say that for distal pancatectomy,

as long as you are a good advanced laparoscopic surgeon, you can do it.

That's different if the tumor is in the head.

If the tumor is in the head, you really have to have commitment,

and we'll talk more about that.

This is data from 2009-2014 on my institution, and basically 65% of the cases we do are laparoscopic.

But out of those, if you see on the left corner, 88% of the distals and subtotal pancatectomies are laparoscopically.

Then around 90% of those we do them through minimally invasive surgery.

Let's talk a little bit about distal pancatectomy.

2012 was the year of the meta-analysis for distal pancreatectomy.

There were five meta-analyses, and since then there have been several other ones, but that

was the main year where the majority of the world realized all the series that have been

published on distal pancreatectomy really show benefit of the minimally invasive approach

over the open approach.

And yes, these are retrospective studies.

There is no prospective randomized studies, but they will give us enough to tell us that

this is a good way of approaching the pancreas when the tumor is located in the distal pancreas.

For example, on this one, presenting analysis of surgery, out of 1,814 patients, the hospital

stay was less, the blood loss was less, the overall morbidity was less, and the infections

of surgical incision infections was less.

There was no difference in terms of mortality or margins.

surgeons. This is our results. We compared first open versus laparoscopic in a six-year period.

And this is not perfect science because it's retrospective. And second, the distal pancreatectomy

is the six years where other surgeons before I arrived to Mayo Clinic where I work. Because by

the time I arrived to Mayo Clinic, the majority I did were laparoscopic. But on a three-year

period we did 82 laparoscopic and when we compared them to the open the important things again were

less blood loss, less hospital stay, and less transfusions. Otherwise the pancreatic fistula

rate is quite low. Our BC leak rate was the clinically significant fistula rate up to today

is only five percent and I attributed that to the way how we divide the pancreas and I'm going to

to show you that in a little bit. But this has been maintained. We just submitted another paper

of 200 patients. This is a pancatectomy that we have done because this data is from 2012.

And the one that we submitted, the 5% fistula rate persists. And now it's another surgeon that

I have trained. It's not just myself. Then the technique is reproducible and can be done well.

Well, in terms of the, when we put our 152, this was advanced, again, the same things

when you do overall morbidity and mortality.

The conversion rate was only 4.6%, ICU, 6.6%, and again, the estimated blood loss and the

operative time were quite appropriate.

This is the breakdown on the fistula rate.

You can see that we do have the A-type fistula that today that is basically called a biochemical leak.

It's not really clinically significant, and therefore we don't give that much importance

because the patient does not need any other intervention.

But the B and C, the clinically significant leak, again, we have 2.6 and 2%.

What is our technique?

We do what I call the clockwise technique.

I described this technique back in the early 2000s and it's not a brand new

technique but it's a little different to a way of approaching the pancreas. The

way how I was trained, you would approach the pancreas going on the lesser sac

between the stomach and the colon, open that and then go from the

patient's right to the left and or go and mobilize the spleen and go from left

to right. I always felt that the colon was attached up in the spleen in the area

and that we used to mobilize it at the end and I realized doing adrenals that

if I put my patients on a lateral position and I started by mobilizing the

colon then the first thing is I take the splenic flexure of the colon down then I

go under the surface of the pancreas divide the pancreas either at the neck

neck, or if it is distal, just in the body, and then cam number four on top, and then

mobilize the spleen.

This technique has been reproducible and has worked very well for us.

When we put the patient in position, I say we use our judo technique, particularly in

the United States, where we have a very large population of obese patients.

And I say the judo technique because in judo, you use the weight of your opponent in your favor.

And this is what we do by positioning the patient in a way that when we move the patient from one side to the other,

we use gravity, and gravity becomes our assistant.

I always say gravity is a very reliable assistant, never gets tired, never complains.

We just need to fix the patient well to the operative table, and that way the patient doesn't fall.

but as you see here we put the patient like in the big picture that is the

position it's not a complete left lateral pose right lateral position is

partially but if I rotate the table to the left like in the upper corner my

patient is flat if I rotate it to the right my patient is in a full lateral

position there are different types of the operation I'm going to be moving the

table and again I'm going to get all the organs out of my operative field this is

the ports. Very rarely we use more than four ports and this again is very reproducible and

the surgeon uses the ports on the five millimeter port on the right upper quadrant and the 12

millimeter port on the left mid abdomen. All the other ones are the assistant. Instrumentation,

we don't use anything that is absolutely sophisticated. I like to use what I call the

the finger dissector, and it helps a lot.

I borrowed that from bariatrics.

We're going to start, hopefully, yeah, this is the mobilization.

Then the patient is now on left lateral.

We don't have a pointer, do we?

Do we have a pointer by any chance?

Then the patient is in a left lateral decubitus position,

and the first thing that we do is we mobilize the splenic flexure,

and there is a plane that is very reproducible.

there's a plane there's a plane that is very reproducible between the girotas fascia and the

colon it is always there even in obese patients and it is a plane that if you are on the correct

plane you can mobilize it bluntly you really don't need to do much and you just you just need

to make sure that you are in the correct plane you mobilize that and then mobilize the descending

colon a significant amount. In that way, the colon is going to be able to drop by gravity

and be able to give you access to where you want. Now, I go up above the pancreas and I get it

into the lesser sac at the most lateral portion of the lesser sac, meaning at the gastrocolic

omentum and the most lateral portion. Once you are there, you're going to put your instrument

into that small window and start mobilizing from cauda to cephalad going towards the fundus of the

stomach. I am not even looking for the pancreas. I'm having the pancreas find me. I'm just taking

everything away of the area. In that way, I have access to the pancreas. And you see by mobilizing

the stomach, the pancreas appears. And I don't need to even worry about where it is. Next.

then we we go I'm gonna skip this but we go along the inferior edge of the

pancreas we can can you click on the movie you're so kind can you click thank

you some some start automatically some I'm gonna ask you to click and some

don't play then we do the division of the pancreas and this this is where I

use the finger dissector and I create a window behind the pancreas around the

vessels. A lot of people says you need to go and get the vessels first. If the

division is in the tail of the pancreas, I don't worry about the vessels. If it is

close to the celiac trunk at the neck or close in the body proximally, then yes,

you need to go and isolate the vessels. But if it is well in the tail of the

pancreas, you just need to make sure you have a wide window behind the pancreas

to apply the stapler. Now I show this video because you can see the pancreas is quite

thick and it's not a very thin small pancreas where we're going to divide it. We create a window

and then after we create a window, we're going to pass the stapler. You can advance a little bit.

And now when we pass the stapler, this is to me the most important part of the procedure

in terms to avoid the leaks. We use a stapler that it compresses and we squeeze

a little bit and wait for 15-20 seconds until there you can see the resistance

goes away and squeeze a little bit more and wait another 15-20 seconds. We call

it the progressive stepwise compression technique. We don't close it right away,

way. We don't go gradually. We just squeeze until we have resistance and then squeeze a little bit

more. Every 15, 20 seconds, you feel the resistance is less. And then you have here the division.

And I do believe, even though I don't have a cause and effect, that I can prove it to you

that this is the reason why we have such a small fistula rate. One more time, we put the stapler,

we compress, wait. As soon as I feel resistance by the pancreatic parenchyma, I wait for our

15-20 seconds. I compress a little bit more and during this time there's no

moving rotation or anything of the stapler because the pancreatic

parenchyma is under tension. If you rotate it you're gonna crack it and then

just divide the pancreatic parenchyma. If we're gonna go out the level of the

celiac trunk then that is different. After you divide the pancreas you have

not included the vessels because now we're at the level of the neck. You can

can see there the splenic portal vein junction. And on this case, you need to go and do the

dissection independent of each of the vessels. We come over here and do the dissection. We go

under the splenic vein. This dissection under the splenic vein is actually pretty straightforward.

It's not difficult as long as you have the right plane. We put a vascular stapler. We come over

here, put a vascular stapler, and then divide the vein, and once we divide the vein, then we go and

look for the artery. Sometimes you're going to have a coronary branch that you need to divide

first, but you can see that is a coronary branch, or sometimes that is the inferior mesenteric vein.

In this case, it's the inferior mesenteric vein that entered the splenic vein quite in the center.

then you have to isolate it and divide it. You see this is very different than

the division of the parenchyma at the level of the spleen, I mean when it's

closer to the spleen. At that point you just put the stapler and divide

everything together. Here we're dividing that inferior mesenteric vein and once we

have that then we can mobilize the pancreas a little bit medial and we're

going to expose the celiac trunk and this is now the celiac trunk that is

the splenic artery we can create a window put clips on the splenic artery

and then divide it again this is reproducible and when you're close to

the celiac trunk or in the proximal body you do need to do this individually not

in block and then you just proceed proceed with the dissection above number

number four, and number five. And again, the exposure here has been mainly because of the

patient's position. What about pancreatoduodenectomy? Thank you. I appreciate it. Good. We have a

pointer. Pancreatoduodenectomy is a totally different story. It is not like distal pancatectomy.

And I've been doing now pancreatoduodenectomies over 10 years, and more than that, actually 13

years. I've done over 250 fully laparoscopically, but I started very slow. I mean, 250 in 10 years

is not, in 12 years is not much, but that's because I was initially very selective. Interestingly,

now I'm still very selective, but I do the most difficult ones laparoscopic. In the past, I used

to do the easiest ones. Now the most difficult ones I do laparoscopic. The ones that is close

close to the vein, the ones that have been post neoadjuvant therapy, the obese patient,

all of those I prefer to do laparoscopically.

Because if I have the elderly lady that's very thin and has a very clear tumor with

a hard pancreas, those ones we can do open in three hours obviously, therefore it's not

worth to be doing a six hour surgery laparoscopically and those we just go in and do them open.

but the difficult ones are laparoscopic. I just want to ask though, does it make

sense? And why do we ask ourselves if it makes sense? Because it has been adopted

at a much slower pace, still today is confined to selected centers. Having said

that, many centers now are doing them. There's a need for high level of

laparoscopic skills and there's no clear, it's not clear yet if the advantages

And I'm not going to stand here and say, oh, this is fantastic because it takes a lot to train somebody on this, and we have not seen a significant major advantage yet.

Then if you tell me my personal preference, yes, and I'll tell you why in a little bit.

But what we do need to do, and this is very important for those people that oppose to

the laparoscopic Whipple, is we need to overcome the idea that the reason why we do laparoscopic

pancreatal duodenectomies is to obtain a smaller incision or to shave a couple of days from

the hospital stay.

I don't do laparoscopic Whipples for my patients to go one or two days earlier because the

The complexity of the procedure is such that it doesn't matter if the patient stays one

or two more days.

I don't do it to do a small incision.

In fact, all of these things today, because of our laparoscopic approach, we have changed

on our open approach.

And today our open approach is done through a midline incision, not bilateral subcostal,

that is usually between 13 and 15 centimeters.

and also patients go home between five and seven days open because we started

enhanced recovery, then I cannot justify doing laparoscopic surgery for that. Then

why am I doing it? To ask, can we improve the quality of life of these patients?

Can we get these patients to chemotherapy earlier than when we do it

open? Can we actually do a better operation? That is going to be a

a difficult one to prove, but I truly believe that I personally today do a better laparoscopic

operation than when I do it open. In the right situation, is this a better oncologic operation?

And I know many of you that do open whipples must be thinking, how is it going to be? How is it

going to be oncologic better? Hopefully, I'm going to be able to show you. This is a variety

of series. This is from a publication that we did in 2013. This is a chapter that we wrote last year

for a bloom guard and shows basically again meta-analysis now we see that

there are several patients that there are several series that now have you

know decent number of cases 300 laparoscopic versus open now I'll show

you two pictures because in one it was too much of this and you can see that

the majority of the series is tell you that there is a significant difference

on blood loss, all series, significant worsened operative time, and sometimes it's two more

hours. Length of stay is less. Some of them have a better margin. Some of them have more

lymph nodes. Again, the same thing here. These are other series. You see this series compares

5,000 minimally invasive versus 1,000, I mean 5,000 open versus 1,000 minimally invasive.

This is a meta-analysis from China, but of course this includes the whole world.

And again, less blood loss, more operative time, less length of stay, and some of them margins.

But we cannot say this is real science.

Who knows which individual is doing selecting the patients?

Because there must be a bias in who selects the patients.

Very few of us have been doing it long enough that are doing the most difficult laparoscopically.

The majority, rightly so, start with the easiest laparoscopically.

Then, yet, this data tells me that on the right situation, on the right hands, it's worthwhile trying to do it.

This is our results.

Our initial results have shown complications, no difference.

We compared 250 open versus 53.

Again, this is 2012.

And I'm going to walk you through our thought process since I arrived to Mayo Clinic in 2008.

Our first series of comparisons were 2012, but I'll tell you how the results have been changing.

The early results, our leak rate was, again, quite decent, BNC 9.5 and 9%.

For laparoscopic, 9.5 is very good.

Our hospital stay, blood loss were much better laparoscopic.

Again, blood loss transfusions.

Operative time was much more in open, much more laparoscopic, and that is because we trained.

Now, if we update this up to last year, and again, I'm updating now this year,

165 versus 168, now done by the same surgeons, myself and my junior partner who I have trained.

Morbidity maintained the same, no differences.

differences the transfusion rate now because we apply the principles that we did laparoscopic to

our open there was no significant difference on on transfusions before there was on the prior

surgery therefore we improve our open technique to match the laparoscopic vascular resection we

became doing more complex procedures laparoscopically you see that in laparoscopic we had 16 percent of

of cases that we did vascular resection.

We're no longer doing the small little cases.

But there wasn't any difference.

This is what was interesting.

Remember I told you that in the beginning,

our first series is we have three days of hospital stay,

less for the laparoscopic.

Well, we instituted in 2014

the enhanced recovery pathways.

I assume you are familiarized with what enhanced recovery is.

is just trying to facilitate and improve the patient experience

and trying to change to mobilize the patients earlier and so on.

And you can see that the length of hospital stay,

when you put laparoscopic and open before the enhanced recovery,

altogether was seven, after the enhanced recovery was five.

Then it's not the laparoscopy that's making us send the patients earlier.

It's the enhanced recovery.

recovery.

Hence, again, I cannot tell you that I need to sell you a laparoscopic Whipple, contrary

to the laparoscopic distal.

As I said before, laparoscopic distal should be the standard of care.

Nevertheless, we still see that this is good.

Now, are those good results that I have shown you in Whipple procedures the same across

the board?

Well, there is the NISQIP data that is in United States is a database of everybody,

not just the people that publishes.

And it showed that the complications on the mini-invasive, now this is not

the people that normally publishes, are much worse for

the Whipple mini-invasive versus open.

Reoperation is much worse.

Morbidity and mortality much worse for this.

Then, this show me that we created a problem.

because we stand up and show these beautiful videos of how we do it and we

don't tell you how difficult it is for this to get to do it. Then I felt

responsible for a while and that's why now I pause and I include this on my

lectures because yes you can do a great procedure but you need to go through the

steps and the reason is because the majority of the people that reported

we're doing two to five Whipple's a year.

No wonder they have these complications.

And somebody that says, okay, let's just do it laparoscopically without going

through the process.

Then today, there is no reason to start a laparoscopic Whipple program

without going to a center where it's well established and people are doing it.

And that is a very important message that I didn't use to give because I was so

excited showing all the nice things we can do.

But then when you see these results, you feel responsible.

I want to talk a little bit about how do we do it tomorrow, and we're going to do a live

Whipple that I have to make a disclaimer, it is a risk.

Doing live surgery is always a risk, much more so doing a laparoscopic Whipple.

Having said that, it's not the first time, and I think it is extremely beneficial in

in terms of education, because it shows,

and it is beneficial also for the patients in many ways.

As one of my patients says,

and this is not something I'll be able to talk tomorrow,

but I was going to do surgery

that was going to be transmitted to India,

and where there were 2,200 people serving,

and my anesthesiologist was not very keen,

it was from my center, and says,

do you think this is ethical?

And I said, ask the patient, and he asked the patient,

and the patient said, well, if the doctor is going to have 2,300 surgeons seen,

he's going to make sure he's going to do a much better job than when no one is seeing him.

Then there are different ways of seeing things,

but I am conscious that any time there could be a complication,

and live surgery should never be taken lightly.

I know you here in Italy do tons of live surgery.

Professor Coppola just showed me the auditorium where there are 14 procedures being transmitted.

It's amazing.

But there's a lot of ethics, and we need to make sure that we take this seriously,

and this is not just a demonstration of, look how good I do it.

We take this very seriously.

Having said that, what we do is, I'm going to show you the details tomorrow,

but I'm going to, some of the snaps here, I don't know if you can go and click on the video, please.

In the back, can you click on the video, please?

Then the hepatododinal ligament, normally, particularly in obese patients,

you don't know where the artery is, and laparoscopically, you go from cauda to

cephala, and you need to make sure that you don't injure the hepatic artery. Then you look

for 8A lymph node, the hepatic artery lymph node. If you resect the hepatic artery lymph node first,

then you're going to immediately going to have the artery find you. Once you have the artery exposed,

then you start walking immediately towards the hepatododinal ligament. We took the gallbladder

out. This is the cystic duct. Then you find the gastroduodenal artery. On this area, this is the

gastroduodenal artery. We use a stapler. You can use clips if you want, but since I live in the

United States, I can use a lot of money. That's supposed to be a joke. Then you divide that.

After you divide the gastroduodenal artery, over here is going to be the portal vein,

and then you can just go bluntly. This is the hepatic artery. You see the portal vein there,

and you can just go blindly everything to the left to the right it's going to

be the duct as well as lymph nodes and you can see we put a bulldog clamp here

to be able to open the duct and as I said laparoscopically we have learned a

lot of things that now we do open to for example we open the bile duct anteriorly

and this is something that I think why I didn't think about this before when I

I used to do only open surgery.

On these small ducts, I go down a little bit

and I divide the posterior layer

around three to four millimeters lower.

And then you have, when you're doing the anastomosis later,

you have this lower edge that is gonna be so much better

to be able to put the stitches.

We take some lymph nodes there, just an expose it.

But you see, this is gonna allow us to do that.

And this is the portal vein over here.

then this is what I was saying you divide the bile duct anteriorly here

posteriorly there and you end with a longer posterior wall that's going to

facilitate the reconstruction this is the reconstruction and you start and you

see you have the longer the longer edge down below we use running sutures this

is what we do now in open to and you can go ahead and create even in a small

old duct as the one that I have shown you, you can put several stitches, and you can see every

stitch I place, you have the opening clearly here. You're not doing surgery from anterior to

posterior. You're doing surgery from cauda to cephalad, and then you continue and finish the

anastomosis. You do the anterior layer and complete there. I don't want to bore you showing you all

the suturing. You'll show more. In terms of identifying the pancreatic duct, again, this is

is something we learn laparoscopically that now we do it also in an open technique. Please go ahead

and press the video. We identify the pancreatic duct within the parenchyma. Again, that seems to

be crazy, but it is not. And over 80% of the time we can do that, even on small pancreatic

parenchymas. We divide with the harmonic scalpel the lower arcade, no need to put stitches. And

then once you have divided and ligated the lower arcade, you start doing this like if it will be

the acusa, and we learned that, I learned that as I get closer, since I go there, I'm going to see a

little bleeding. The pancreatic duct has some parallel vessel. It's quite interesting, and then

you come over here, and you start seeing the bleeding, and you know you're going to be close

to the duct, and now you start seeing this structure, and we do the same thing as I did

before for the bile duct. I cut away from the division of the parenchyma. In that way, I have

two to three centimeters, I mean two to three millimeters of pancreatic duct

protruding outside the parenchyma. That will allow me to be able to do a better

anastomosis. Once I have divided that, then I come in and divide the rest of

the pancreas, but I have my pancreatic duct, and I purposefully show this is a

very small pancreatic duct. This is a five millimeter suction device, therefore

this pancreatic duct is around two to three millimeters, or less than that

actually then we divide this is the superior mesenteric portal vein and you

can see that stump of pancreatic duct is going to help me to do a division the

ansenite process dissection I'm just gonna skip it how are we doing in time

yes the ansenite process dissection go ahead and click 10 minutes 10 minutes

I'm sorry minutes yeah fine perfect then we'll leave the ansenite process

dissection for tomorrow. Hopefully it's not going to bleed. The pancreatic

jejunostomy, we do it in two layers. The posterior layer is an averting

anastomosis and what we do is we, because we have the laparoscope, we can see the

posterior aspect here and then we put the stitches in a way that's going to be

averted and you see I show you this to show you this is a very thin pancreas.

Difficult to do the posterior layer, but if you avert it, eventually this duct is

is gonna come and do the anastomosis there.

To do the anastomosis, even in small ducts,

you can do traction.

I'm gonna show you that in a second.

And we can start this video.

These are videos that we submitted

also for the Bloomer technique.

Again, this is a little thicker pancreas.

We start by mobilizing around two to three centimeters

of the pancreas.

And we're gonna do the posterior layer.

This is the splenic vein.

This is superior mesenteric vein. We do a running 4-0 proline for the posterior

layer. This is a monofilament non-absorbable suture and again our open

technique has changed and we do this now in our open technique and our results

have improved. We put a drain early on laparoscopically. We realized before we

do the pancreatic jejunostomy we put our drain in because afterwards it's

more difficult to manipulate and we're going to put our stitches you see with

the laparoscope I can clearly see the posterior wall of the pancreas and I

just put the stitches to the seromuscular and we're going to run it

and one more time the reason to put at this posterior is in that way this part

of the duct is going to be averted to be able to put it above then we finish the

posterior layer, now you can see the duct is averted outside and I have two to

three millimeters of the duct exposed and that's because I individually

isolated it. Not always you can do that but around 80% of the time you find them.

We do a small opening on the jejunum. Now this anastomosis is very reproducible. We

put the stitches, I put a pediatric feeding tube, this is a 3.5 French

meaning 1.3 millimeters you can see that that's the size of the duct 1.3

millimeters or maybe even a little less I use the stent to be able to help me

put the stitch we put a six o'clock stitch first the six o'clock stitch is

passed for retraction you can see laparoscopically I see the submucosa and

the mucosa that's why now today I feel more comfortable doing this

laparoscopically I see much more this stitch is very reproducible I put the

needle like this and rotate it backwards, it's always the same way, it's not intuitive,

but you can rotate it and then you bring it back.

We usually put between six to eight stitches, between I would say four to eight stitches

depending on the size of the duct.

We don't tie the center six o'clock suture, the assistant is pulling this one, and this

upper one is tied, that's the eight o'clock stitch.

I'm using a three millimeter needle driver.

I'll show you again.

Now we put the stent again

because it helps input the stitches.

This is the six o'clock stitch.

Now we put this one here.

It's gonna be around four o'clock.

And again, look at how close the eyes are

that allows us to see well.

This is a three millimeter needle driver

that we put a five millimeter shaft on top.

It's made especially because I think

the three millimeter needle driver allows me

to manipulate the the needle very well again remember this seems to be very complicated very

complex but this is a complex anastomosis even if we do it open because this duct is very small

it's only around one to two millimeters in size and then we just continue once the posterior

layer is completed then we put those three stitches then we tie and again the assistant

make sure that this suture doesn't get mixed with the other ones and we tie

that we're gonna tie this other one and we can and that's the six o'clock we tie

that other one and again this is extremely important not to mix the

sutures we take this this drain out and I'm gonna use a small pancreatic stent

because this pediatric feeding tubes we have had one that has been lost distally

but you can see the anastomosis there and now I'm going to put a pancreatic stent that the

gastroenterologist used that is curled on this area in that way it doesn't do we cut the stitch

at six o'clock we put the stent in and now we're going to put the anterior stitches you see the

stent in the center and we have one retraction stitch there and this one's you can come in and

clearly see the passage of the needle through the duct you try to lift and

then you can see how the needle comes out inside the duct very precise and

again all of this is thanks to the magnification you move the needle up and

the needle comes down inside there then you put it on the jejunum and then

finish the anastomosis you can fast forward can you fast forward a little

In the back, please.

Hello.

Un pochino più veloci, più avanti.

Avanti, avanti.

Pronto, pronto.

More, more, more, more.

That's it.

Thank you.

And then after we finish, we go and do the rest of the anastomosis.

Avanti, avanti, avanti, avanti, avanti.

Okay.

And this is the anastomosis that's completed.

Then I'm going to skip this because of time,

but our results for the oncologic results are the same and with this I'm

just going to conclude the lecture since we are now on time thank you very much

ovviamente la lettura non prevede un domande quindi però non so se professor

Gulotta è d'accordo se ci fosse qualche curiosità particolare ecco prego

professor Testini the question is what is my opinion regarding the robotic

the robotic application for this type of operation I think it is a great

application I personally don't use it I feel this is my bias I feel that if you

use the robot you probably are gonna stop pushing yourself to learn certain

skills because the robot facilitates things and for many years I did not like

the robot because you cannot change the patient position and as I have shown you

to me it's very important to be able to manipulate the table. Today's robot

though, the last version, you can move the table. Therefore I think that it is an

advantage. What I am totally against is what has happened in the United States

and those data of the complications are part of people that were pancreatic

surgeons, had never done a laparoscopic approach. All of a sudden, the hospital buys a robot,

and now they think they can become minimally invasive pancreatic surgeons because they have

a robot. Then if you're going to use the robot, go through the training the same way if you should

go through the laparoscopy. But I think it's a good application. Thank you very much.

Just a question. I've seen that on the posterior wall of the duct, you use the monofilament.

in the anterior wall it's the same suture or it's different on the posterior wall of the

pancreas is monofilament non-absorbable yeah on the duct to mucosa is absorbable yes suture

and it is absorbable it's black because the it actually it is a ophthalmologic suture yeah that

it is white comes white because of the needle that i use is called a tf needle it's a very nice angle

and comes from eye surgery

but the nurses like me

and they color it with a pen

in that way I can see it better

because of course on the anterior wall

it's easier to make stitches

it's black because they have colored

but that's a good point

it is a good point

thank you

thank you very much