Laparoscopic Redo Fundoplication for Esophago-Gastric Stenosis

Case presentation, it's a very interesting case.

Yes, so let's present the next case, which in this instance will be a redo fundoplication.

Next.

It is indeed a 43-year-old female patient with a BMI of 26.1 and an ASA physical status classification of 2.

The patient's remote medical history includes peripheral neuropathy due to lumbar arthrodesis, which she underwent in 2016.

Among other previous surgeries, she underwent a laparoscopic hysterectomy with a Pfannenstiel incision, lumbar arthrodesis in 2016, and the patient had already undergone a laparoscopic anti-reflux surgery in 2016, an operation that, however, was performed in her country of origin, Burkina Faso, which is why we were unable to obtain information about the technique used.

In any case, the patient reports that after an initial period of well-being, she experienced the onset of a dyspeptic syndrome with dysphagia, first for solids and then for liquids, progressively worsening and having undergone a sharp deterioration recently.

For this reason, she underwent an EGD in June 2021.

As we can see from the slides, the EGD showed a clear reduction in the transit lumen in the lower portion of the esophagus and the esophagogastric junction due to surgical sequelae.

A reduction with a longitudinal extension of over 30 mm and a maximum transverse diameter of approximately 5 mm during emptying.

Delayed esophageal emptying is also observed, which nevertheless occurs completely.

Therefore, with a diagnosis of recurrent hiatal hernia, the proposed intervention will be a laparoscopic redo fundoplication.

A nice case, in Neapolitan I would say a real handful, because recurrences are always more difficult and unpleasant to treat.

The nun, because she is a religious person, is in Italy; she had this surgery in her home country but without any documentation.

What emerges is what the doctor told you, that is, this stenosis, right at the gastroesophageal junction,

probably caused by a

previous Nissen-Rossetti

over-calibrated

look, maybe if you remove this

from in front of your eyes, it's not a bad idea

if you remove it

so I'll start

there's nothing to divide here

I'll start with the anatomy

meanwhile, a comment

on the previous trocar placement.

the scope, there's an incision

right in the navel

and what I was saying this morning

is something we did 30 years ago, we have external images so we can show it because we

our scope is positioned halfway between the navel and the xiphoid process, whereas in the

old incision, if you don't show it, if you stand in front, you won't see it, it's right here

in the navel, so the surgeon who operated on her previously evidently had very

modest experience because from here, I repeat, placing the scope and seeing parallel

to the hiatus is much more difficult than seeing perpendicularly to the hiatus.

to restore the anatomy to what it was and therefore try to identify the

structures, and the first is, in my opinion, the most difficult part of the entire operation.

So I move to the inferior surface of the liver, where I see these adhesions, and I try to lyse them to access the crura and the hiatus.

Let's also get some scissors ready, first we'll remove the adhesions and then we'll go to the hiatus.

Angela, I hear your voice from afar, Angela, I don't know if you're talking to me.

Angela

Can you hear me?

Now yes

So I wanted to ask you

all these operations you've done

stomach, junction

do you think you can do them better

with robotic surgery?

Well then

junction, stomach

everything can be done with robotic surgery

I think if I had done it

with robotic surgery

by now I'd still be on the first operation

or maybe halfway through the second

and I would have spent

a few thousand euros more

compared to what I spent on laparoscopy

then

I don't think

I would have had any other advantages

but at the end of the day I could have said

I did 3, 4, 5 operations

robotically

and therefore I'm a super surgeon

So here I feel something hard

it could be a mesh

here we're going to discover

something whose extent we don't even fully know, the reason I wanted to put it

at Palazzini, at Palazzini we present standard things and strange things, so let's see

for a moment, come in here, let's go carefully, is the probe there? I'm afraid there might be a

prosthesis, I'm afraid there's a prosthesis on the hiatus, come in, let's surround the enemy and you

what do you think Angela, I believe that some operations where you see better, like the rectum, where truly

robotic surgery allows us to see better compared to laparoscopy, where even today, when costs

are high, we must select the indications. A hiatal hernia can be seen well even with laparoscopy.

so all these expenses, these wastes, I don't think they're very useful. However, for example, for the rectum, I

I believe that robotic surgery is helpful, that's what I think.

So I recently saw a person who had robotic surgery,

that's why I say the responsibility is sometimes ours too, for a diastasis,

a rectus diastasis, they performed a kind of robotic TAR,

so now, a year later, she obviously has the diastasis,

There's a mesh occupying her entire abdomen and an incisional hernia at the trocar incision.

There's always the problem of indications.

No, I mean, there's abuse.

There's abuse, there's a trend.

There's a trend.

Here I'm afraid we really have an adhesion, maybe it's better to go to the other side.

A bit of lateral movement towards De Luca, please.

take the stomach

and bring it over here

here, I have to give this to you

a compliment

which is not always showing

the standard, because we surgeons

can also find the standard

in videos

even on YouTube, for example

instead, the perspective of this

event is to

difficulty of the live broadcast

of the most difficult cases

That's what we wanted to do this year, I said it yesterday, I don't know if you were connected, this year we wanted to present complex cases, let's say unselected ones, it's clear that, I'm saying this now for the benefit of the young people, excuse me, you've drained my stomach,

the Palazzini

the Palazzini

where there's apprehension

and even I, when

I had to tackle the first live broadcasts

I tried to do

to operate on patients

the 'easier' ones, so to speak

even if the easy patient is the one who

you find easy on the operating table

it's difficult to predetermine

an easy patient and a complex patient

but a minimum of selection

I did for years

but

But now, always showing, for example, the usual TME, yesterday we did an advanced TME, meaning the patient was obese, irradiated, had cushions.

but you know also

the previous patient

that you operated on

that antral neoplasm

with a splenectomized patient.

we emphasized today

I spoke little because Francesco Ruotolo was clearly there

who is a great master

so we emphasized

the concept of vascularization

of indications

of intraoperative endoscopy

but you know how many messages to young people

we gave today? So many.

this makes me happy

your comment makes me happy

Angela, more than a master

a charmer

here we've entered the hiatus.

I always tell the young people

that the basis of everything

I realize when a young person

can or cannot be a surgeon

is anatomy

and I say that for all the years I've known you

you have emphasized within me

so many truly beautiful concepts

in me and in the young people

you have been a figure, a beacon for us

an indispensable figure

precious, yes precious, don't say precious. Even for just one, you have to earn it, right, at this

point. But did you leave? It seems we don't have pressure. When do we have? Ah, there, we don't have

the pneumo. Who opened me up? Listen, Franco, it's like you're working with two hands

and the optics, the other trocars

what they do, just for my own

curiosity, the trocars?

it's not there, no it's not there

you have five accesses, one for the optics

and four

two are your hands

but what are the other trocars doing right now?

the one at the bottom, shouldn't it be holding pulled

the stomach, in fact

do you want to see what it does?

if I let go

let go of yours

let go

so I have to take this

to do this and I don't have a hand to work here, I couldn't see what was pulling that

you understand, when I do this, someone has to hold it for me, or good, and so paradoxically in

in hiatal hernias, the fifth trocar is more useful than in a cholecystectomy, okay, see, now I can work with

my hand, oh my goodness, but did you close it? okay, enter, I don't see any stitches, I don't see any stitches, go over there, turn your forceps a bit over there, to the other side, over there, uh, I have a stitch, here it is, no, let me remove this small gauze that is, excuse me, let me say something, why is there this obstacle here? to the right, to the right, let me say to the right, to the right, oh my goodness, it's getting stuck, a small gauze, so here,

enter half a meter

let's try to understand where we are

and what we do

which is not easy here

of plastic in the chest

let me see from behind here if I can find a passage.

let's see if we find a passage

towards the pillars

so here there isn't the anatomy we described well

on the first hiatal hernia.

we still have

the altered anatomy

here, I opened here

here the pars flaccida, so now there's access to the pillar, okay, and here I access the hiatus from this side.

Here I think I'm even on the tripod, let me see well, that vein makes me suspicious, it comes out, it comes out, it comes out,

pancreas, the other side, let me see, leave everything, leave everything, it comes out, it comes out, it comes out, it comes out.

So, this could be the tripod, I ask for confirmation, Ruotolo, otherwise what are we keeping it for?

Francesco empty

it's too early to tell

it's not ready yet

Francesco

no, but excuse me, but this for me

you are an anatomist

you should know before me

it's easy for me after I've prepared everything

this is it or it isn't

and you, on the other hand, must prevent

he's not a fortune teller

you'll be upset if I say it first

understood?

so this is an intervention where

where unfortunately we cannot recognize landmarks, we cannot recognize an anatomy,

we don't have guidelines that tell you to go right and go left, you have to go a bit with common sense,

a bit with experience, a bit with luck, a bit with prayers.

So my goal is, first, not to damage.

Behind here I see muscle fibers and so I continue to prepare, you see this space,

honestly I don't see fundus margins

plication unless it's all

intrathoracic because the stitches are here

above

this here is ugly

Franco, do you remember the other day that

you were holding that conference

do you remember, Franco?

tell me a bit louder

do you remember when you had the conference with Dugo?

no

what are you saying?

when you had the conference with Dugo

The other day, yes, of course.

he was talking about pseudotumors represented by the

fact that the air went up into the

mediastinum.

Here, I passed through here.

Remember, Franco?

See, I passed behind here, which I don't know

if it's the fundoplication.

I'll show you, Franco, some migrations

of fundoplication in the mediastinum and in

magnetic resonance imaging, they were talking about

pseudotumors represented by this

do you remember or not?

yes, yes, but I heard it

the other day, I also mentioned it before

in this case

maybe

in the preoperative phase

to resort to those types

of assessments

to already have an idea

that's all

so this is stomach

the stomach reaches here

but if I now

turn completely

here I find the esophagus

or at least maybe the part

because you see

I went behind the stomach here

and there's this part

that I still can't understand what it is

it can't be esophagus

it was Professor Silecchia

do we want to try to have a large probe inserted

so we can orient ourselves

the large probe

once I had the large probe

luminous

which was very convenient because here the stomach continues and here it's clearly visible and so here according to

me it's the fundoplication that turns, the probe will pass here in my opinion, go, give me the small gauze in the meantime

it's on top, it's on top, he doesn't even remember where the small gauze is, no, this one is still immaculate

Miles of a Giovanna. No, no, you, you, down there. Michela, why is it seen like this in squares? Oh really?

Placed? It didn't pass, guys. Because this could be the esophagus and this the fundoplication.

This is the esophagus, here it is, push it, push it, push it, here it is, I'm withdrawing by a million, no, no, it's fine like this, it's fine like this.

So this is the esophageal passage and this anterior one is here that turns and that has moved laterally in here and the fundoplication.

So we have this thing, now, simplistically one could put a stapler here and leave.

the problem is that

we don't know

what's behind this

therefore

it comes out a little bit

let's clear that part well

it's a solution

simplistic

that was suggested for the first time

Sante Azzagra

in fact, he showed a video

in which he had solved a problem

but then he himself

had the courtesy to say

that the problem is not solved like this because unfortunately, for those who have it, it's not that simple, meaning

it's not just about making it jump, there's a whole fibrosis and so here's the esophagus and so go ahead

why does it do all these things, because then we said that this here is the fundoplication.

and this here is the esophagus, so we should go, but anyway we have to complete the work

just to have better access

the esophagus, lower your little hand a bit

pull towards you, towards you, downwards

here it is, the esophagus

here, here, here, anterior

it's that I see the black stitches here behind the liver

if maybe he used

some stitch

the tapes

the stitches

the stitches

the stitches to fix the pillars

the things

the valves

I feel something hard here

then, by the way, initially I interpreted it

like a mesh

because I really felt a granularity

mesh-like

these are the stitches, see?

here I'm going to release this fundoplication.

that this is gastric wall anyway

if I dissect it, I'll be in trouble anyway

anterior, posterior, how is it?

what?

this fundoplication, how do you define it?

what type?

This one? A Nissen? Is it an S duplication according to you? Ah, how do I define it? It looks like a Nissen to me, meaning something, you see, if this is the esophagus, because it is the esophagus, we have this part of the gastric fundus that goes around here and so it's 360 degrees.

it generally goes behind

and I know

so I here behind

but a strange thing is that

this cord

I see it as a tract

here it is

here I bring it together as I lower it

and the cord remains there

Franco, the only sure thing

is to prepare the esophagus

and the surrounding area

then look at the other things

listen, Franco

Franco, that cord could be fixing the anterior wall of the stomach to the pillar,

the stitch that fixes some anterior walls to the diaphragmatic pillar.

Look, this is the stomach here.

It's, stomach to the pillar, it's those stitches that someone often places.

You say? And that the pillar came off then?

So in practice, they would have, yes.

because I know this is over, you can see the stomach wanted to put stitches to hold it

firm to the pillar, you see that the pillar retracts, it doesn't retract willingly

to the stomach, here it is, give me a view from afar too, I'll do less harm

but it's not convenient for you to prepare the esophagus

and now it lowers a bit

lower this little hand

and yes, Francesco

having removed that specific

between the pillar and gastric wall

now it's easier to free

we manage to understand

even better what's there

so come here

if you move the probe

a little bit

how it proposes it to you

the probe is here, there it is

you can see it

you have to detach the stomach

from the left pillar

this is the probe, do you see it?

yes yes

no, you're obstructing me

hold it

no no

and it almost seems

you see that

the probe outlines a dilation

of the esophagus

it enters in here

there's a colleague, Antonio

who here at Carlos's point

below, why are we crooked?

let's see, understood? Carlos Pellegrini

the point of cala

no, I don't think they put it

but anyway, then I'm afraid here

to dissect, it could be the anterior vagus

here, but I see it

far from the esophagus

more than a vagus

it looks like a wagon

it looks like? it's a wagon more than a vagus

no, it can't be the vagus because it goes here

generally it presents like this

so can I dissect?

hey, rotate it

Ruotolo, Ruotolo, Francesco, do you want to answer? Francesco, you must answer, can I dissect it? So you've taken responsibility, I'm going, your fault, your fault, the vagus, we are playful, Ruotolo, we enjoy playing, being surgeons.

It's all my fault, like my wife, it's all my fault, this is the senate, that yes.

I'm re-entering the diaphragm, what is this atypical cellular tissue?

So, it's already something we've found again, a pillar, an esophagus, the esophagus is indeed dilated.

they really are

such interventions succeed

many times

it's dilated

it's not inserted

it's dilated but we have it abundantly

in the abdomen

it's dilated, yes, you saw

the entire precardial tract

it's certainly

this is very dilated

also a bit flaccid, I'd say

so I'd like to understand what was brought

over there

here's the passage

nicely dilated. What was dissociated before was what remained of the gastrophrenic. No, you see

here, here is the gastric fundus that goes around. Here there's something that goes behind the esophagus here. You can see it

of sector, he cannot criticize us

that we keep some trocars

unused

now all trocars are occupied

I'm sorry that I hadn't

understood my message

it was to demonstrate how important it was

that traction at the junction

when you do a hiatal

an achalasia.

I wanted to emphasize the validity

but how is it that I can't

capture your messages

I wouldn't be here today, afternoon value

How is it that I can't capture your messages?

Be careful, Palazzini will be upset later.

He records everything.

Palazzini records everything.

And he sees everything.

Yesterday he showed me that he saw things I hadn't seen.

Still the ultracision.

The esophagus begins to open up.

Show me this stomach back here.

Don't lower your little hand, why are you raising it?

Come.

Leave it a bit.

like this, go behind

here, enter

go behind, enter here

enough, enough, turn again

the new fundamentals have been

the large probe and what you said

Angela

and what you did

so this is the stomach that goes behind the esophagus

and there's no doubt about that

but it almost looks like a sheet

of stomach, here it is

here it is, there's a passage

there's a passage, here it is

there's a passage

Let's see if from behind, turn to the other side, leave yours, leave yours, leave this, leave this, we need to try now to find a space here, so we can turn over there, over there, over there, over there, over there, oh over there, yes, who is holding the bands?

leave it a bit like this, this is the old sac, in my opinion this is the old

the mesh is not there and the hard scar tissue, here are all the stitches

of the hiatoplasty, probably, excuse me if you remove this liver from

in front of my eyes and you don't do something wrong

enter with the little hand

put it here

you removed the second one for me

right? and then push it a bit for me

yes yes thank you

can I intervene

I'm Silvio Testa, excuse me

oh dear Silvio, how can you

for a fee, anything is possible

how are you?

well, I wanted to tell you this

why don't you start

I've been following this for a while

very interesting, very nice, but I was about to tell you, why don't you try to

go a bit more distally in this adhesion area with the inferior surface

of the liver because there's still the risk of unintentionally ending up

inside the stomach, I said at the beginning, I don't know if you followed me, that while

before I showed an N-Hiatal in the first instance and so I was able to

show all the steps and the entire analyzed technique,

here we have to go a bit by intuition,

a bit by, how to say, a bit by experience, a bit by intuition, a bit...

A case.

Oh yes, because there isn't...

So, I'm happy to have surrounded the esophagus,

because here I've surrounded it, okay?

Now, based on this, I need to understand,

here there are adhesions with the liver

and especially now I want to see

here, going down to the pillar, what I find

here there's something that doesn't convince me

here, for example, this is the old sac in my opinion

if I bring the esophagus down

then I wouldn't mind making it release here

and pass from the esophagus to the stomach, you see this passage here, yes, this is the sac, you can see it like this

goes into the sock, no no, this standing thing here is not needed, lower your hand, lower your hand

plastic you want to do, it's definitely definitely a Toupet and not Rossetti. The problem is the hiatoplasty I...

here slowly and I go down to reach the right pillar, if doing a beautiful job, and no, but

excuse me, you're reconstructing all the anatomy, at the beginning nothing was clear and the goal when there is

a recurrence is this because otherwise you really won't get out, slowly, yes, yes, these are very

delicate procedures, I say that a Toupet is the right choice for this patient, you see here behind this

is stomach, no, this is stomach, you see here behind, evidently it's part of itself that goes to the other

side, he can't free it, that's what I want to understand, but why is it like I have it

it is, nothing happens, you take it because it's not closed, it's not closed, no, don't blame

And this reaches the pillar here, so it inserts here, as if it had, here it is, so this must be freed anyway.

So let's try to free it by understanding what we're doing.

An anterior wall, a wall...

Ah, I see, or a fundoplication was blocked on the pillars, some people do that.

In my opinion, that's it.

Oh yes, some people do it to ensure...

This is a fundoplication blocked at the right pillar.

some people do it

because as you see

you've already freed a part of it

it was what we told you before

there's this

and now there's that

if you work on the pillar as you are working

you don't risk opening the gastric wall

right?

I have fewer risks

I never say I have no risks

no, but let's say better than on the wall

otherwise you should use an endogia

at that point

here is the liver

Here is the liver, it's gradually detaching, I prudently keep towards the pillar side, I don't know if the liver is also here, detached, show me here, let's see what's here, this is the fundus, you see the fundus stuck there to the pillar and the liver,

we free it here

come out, ok take this now

hold

move laterally

lowering your hand

and this is our pillar

here there are still some mediastinal adhesions

but the part of the esophagus

recovered is quite

satisfactory

let's go to the other side

so, what I was saying

at the beginning

my hope is to restore the anatomy

and slowly we are getting there

because it's already something

to have identified and mobilized

the esophagus

with all the adhesion

the right and the right

is practically non-existent

The hiatus is this.

so Professor Corcione

I say it to the other colleagues who are

commenting

we really, dear Giorgio

let's pause for a moment

our comments

We are 15 colleagues here that Giorgio made us sit for two days, but you also need to comment, because I only comment in a classroom, you give your thanks.

So I truly publicly thank Giorgio Palazzini for giving me, the colleagues next to me, but also all of Italy, Europe, the world this opportunity, it's an incredible experience that helps even us less young people grow, we always have something to learn and it's great training for young people.

Giorgio, we publicly thank you

thanks again this year

despite all the difficulties

that are present in this period

and so thank you all

Franco, we are doing it

in all the rooms, in all the classrooms

I, along with my colleagues who are here

to comment, so

we thank him, I believe, also on your behalf

right?

And what you said, Angelo

is absolutely of great value

thank you all

he's here next to me

and he pretends not to get emotional

but he does get emotional

which is why he never appears

we know him

Borgata girl

thank you Giorgio

ok let's continue

a round of applause

so I am proceeding

guided by the left pillar

it's the more substantial one

non-existent in the sense that

it's all fibrotic

it's inserted into this

it's a bit macerated because that had been

mistreated because it had been used as support

for the procedure

this has now entered the good space

this could be the anterior vagus

no, it's more of a course

no, this one is too longitudinal

we have quite well identified it

the right one

absolutely not

it's all frayed

the right one, do you remember the previous procedure

it's always the most hypoplastic one

the less resistant one

the more flaccid one

we clean it

there's some dirt somewhere

wait a moment

the esophagus is all prepared

we just need to understand

on the right

how we can mobilize it a bit better

don't you have instead a

from what I understood

no no, I'm commenting on your operating room

ah

we're starting to have a bit of

a jealousy syndrome

no, I'm only for you

the others are for the others

there are 22 rooms

that's what I wanted to hear you say

22 rooms

now I'll comment on you

and there's Francesco Ruotolo.

you always have something more than others

but because there's Francesco Ruotolo

or because there's Angela Pezzolla?

no, Francesco Ruotolo

is an incredible resource

I raised him myself

in silence, me too

even though I never took advantage of him

Francesco, defend me

but the

excuse me, has the large probe retracted again?

the large probe

further down towards me

and go

ok, but how does it retract?

ok, like this, like this, like this, two minutes like this

and here the right pillar is practically

unusable

but the abdominal esophagus is fully recovered

he doesn't understand that he shouldn't see this

no, he is

spreading something else

leave it, leave it, leave it, I'll show you how it's done

leave it, leave it, leave it

if you lift it, you close the passage

so here we are looking for

solutions for the problem

we are looking for solutions

why don't you put that mesh

like the one you put this morning

the mesh, in fact

you see you understand me immediately

you see it's another life

Franco, that colleague

Bosnian who had come

to you

friend of Bragale

a flap of fascia

lata besides the one that

Angela tells you

that is, to give structure

to that area

in the fascia lata

is used, it's even published

he even showed it to us

but more than the fascia lata, let's put

our prosthesis, the problem

is that I don't know where this prosthesis

to fix it here

I recovered this pillar but it's very fragile

it's very fragile

but you can fix it

but anyway you have to put a clip

mangled

to fix it you find the space

to close that hiatus

that you will never be able to close with stitches

with stitches

you will never be able to close it

no, no, but I have to put

a prosthesis that doesn't rest

on solid ground

it will end up dislocating

the mediastinum

the one from this morning with the clips

I'll find a place to fix it

this morning's one is nice and rigid

we will put

the one from this morning without discussion

then don't bring the solution

as you did for the stomach

that you already knew what you had to do

and you wanted to mislead that you were doing the total

I'm always Neapolitan

you were waiting for people to say

no, you have to do the total

so here I'm recovering some tissue

of the right pillar

unwillingly

you see the base begins to delineate itself

this is muscle

this is diaphragm

so if I go here

it still takes it away a bit

come in, come in between me

Tomorrow we could use this one, and then put a nice mesh on top, and then we'll make a toupee.

So before doing this, however, I would like the anesthetist to remove the large tube that I no longer need and put in a small probe.

Franco, there's a question for Antonio that asks if the right pillar is non-existent

No, make it clear Francesco, I can't hear you

So, I know, I have to do, so, Antonio, a colleague, says, if the right pillar is non-existent

Ah Antonio, ok

Wait Francesco, I'll read him the message, look

So, it's what we said before, Antonio, someone writes and says

if the right pillar is non-existent

do you think of using a prosthesis then

Professor Corcione has already answered

saying yes, he will use a prosthesis

this is on the vena cava

so you see the difference

for the left pillar that we managed to preserve

and the right one that is all

because right behind

that crushed pillar

there's the vena cava, obviously

I have to try to bring together

this to this

this and then put a prosthesis that unfortunately will also cover a bit of the liver, that is

create fibrosis at this level, because then the esophagus I have...

Because detaching it a lot, you can't even detach it much because that pillar is fused with the liver

right.

The esophagus is fully mobilized.

It's free, yes, yes.

So we will take the fundus and do, put the small probe in first, release everyone a bit

everyone

here it is

Franco, Antonio from before

enough, now you give me

kindly

60 cc

no, give me an intestinal clamp

something that tightens here

no, no, well, down here, down here

come on, is there an intestinal clamp?

give me 60 cc of blue

you understood what I want to do, right?

I need to check if I don't have

lesions, microperforations

he doesn't understand here

Here, oh my.

It's a lot of effort, huh.

Everyone sleep.

Yes, thank you.

Good thing they won't see you for two days.

What?

Good thing?

Nothing.

But I am kind, I am good.

Is it true?

Wait, give the microphone to the doctor in charge.

Huh, seriously?

Go, go.

Air, air now.

Retract it by one centimeter and give me air.

Air, air, air.

Yes, yes, abundant.

Show your own stomach.

Show this, okay, okay, okay, a little more, go in, go in here, go in here, air, air, air. Okay, more air. Excuse me, better to check today than to get into trouble this weekend tomorrow. Okay. Again. Then, yes. Are you insufflating, Nico? Okay. Then after... yes, but how do these tubes get dislodged?

Go, air, air, air, more air, air, oh, perfect, then you have to aspirate everything, Nico, aspirate everything, no bubbles or bleh are seen, aspirate everything, aspirate, aspirate again, aspirate again, thank you, aspirate, aspirate, aspirate, aspirate, go a little deeper and aspirate it better, there, go in, go in again and aspirate, aspirate, aspirate, aspirate.

so your

pull out the tube now

yes yes we don't need it anymore

give me a stitch

what mesh should we use?

no, the same as this morning

that one

the absorbable one

slow absorption

and I'm waiting to see something

if I can

give me a moment

excuse me

I only risk but gain nothing

because it's non-existent

maybe just barely present here

but it's not a support

it's not a pillar, which is what you're looking for

down there

so now a small stitch

anyway we put it to make

as a base

no, ask if it moved

Franco, fix a bit

the right point of the esophagus to that muscle

now

fix an esophagus to the muscle

on the right edge

because it fills that space that is there

and you put a protection against the vena cava

no, we create

because afterwards we have to put the prosthesis

where do I put the prosthesis

if I block here

it won't pass anymore

do you think so?

Francesco

and so I tricked you for once

but always

Francesco answer, I tricked you for once

No, no, he doesn't admit that I can trick him. Francesco, did I trick you for once? Did I give you an answer you didn't expect?

No, no, don't overestimate me at all.

I understand that the young man

I understand that the young man

doesn't get involved in doing surgeries

but to whoever should do it

this point you are placing

you have to say it's a delicate point

that there are particular structures there

that behind

this is the muscle that remained

as you saw

it's definitely an intervention for me

very very super specialized

much more

I mean to say

than a colon, because while for a colon I can go online and watch all the videos of all the best operators

and try to understand and learn, every time you perform a dangerous surgery, it's a new surgery,

in the sense that it's never the same as a previous one, and so either there's real experience or you cause a disaster.

It must be emphasized that at that point to the right of the pillar, great care must be taken because behind it there is the aorta and then especially the vena cava. At the point to the right of the pillar, there is the vena cava. Ah, of course, and to the right there is the vena cava here. And the vena cava, so this is what I wanted to emphasize. Yes, yes. But it's clear that the teaching is genetically induced.

in this approach he made

the mesh acts as a scaffold.

let's prepare this prosthesis

to see how it comes here

at this point it serves to create a base

on which to place the mesh

so what can be done

after we've done a toupée

a toupée that goes like this

fix the toupée

but no, the prosthesis cannot be fixed at all

okay, give me the prosthesis

I'll prepare the prosthesis though

Wait here, maybe we can prepare ourselves a little better

Andini like this

Give me the ultracision

So that it goes down a bit better

Did you tell Nicola?

Ok

So give me this mesh

I don't have to shape it

Cut

This is huge

And wet

It's already wet, so just the scissors

Because this one here

So that comment from Antonio about the pillar and therefore the prosthesis

Franco

Yes

was made by Antonio Silvestri

who says

Franco

could only have been done

with the mastery and experience

of Franco, congratulations

affectionate Antonio

but you see Antonio Silvestri is a surgeon

of a certain age

who has always had

however, the idea of updating himself

of being curious and at his age

I believe he is retired

he continues to do it

I challenge young people who don't do it

the other time

at my congress in Naples

a month ago

and I say it as a message to my young people

especially, I haven't given them this speech yet

I prefer to do it a bit more

at Palazzini's

on Saturday morning

no, meanwhile on Thursday during the inauguration

I see a group of young people

my residents

who leave the room

and head towards the exit

of the court theater of Naples

to my question

but excuse me, where are you going?

we're going to get something at the bar

and inside there was a whole

an audience of people

who were supposed to speak etc.

and they, instead, went to get something at the bar

so this already says a lot

about the young people's desire to learn

to be in the front row as they should

but then on Saturday morning

I saw that

in the Continental hall

there were

Claudio Bassi, Enrico Croce, there were, I'm just naming a few I remember, Gennaro Nuzzo, in short, super experienced people, super dedicated, super chief physicians, super directors who were there listening, almost learning.

Young people represented 10% of the people present in the hall. I had a photo taken that I jealously kept because at the first opportunity for a master lecture on the idea of training, the teaching of young people, I'll take it out and say that the training of young people comes through the will to undertake a path of sacrifices, things that today's young people, and there are many here, have not understood.

ok I liked this Palazzini-style lesson well I had kept it just for you

always sliding who's there Umberto so here can you give me a couple of non-absorbable threads

as you freed it, you could do

even a Nissen

yes yes but you understood

she has a manometry

with slowed esophageal motility.

for how you freed it

not as an indication

don't misunderstand the message

Silvio, is Silvio there?

what do you have to do after achalasia?

it's after the last surgery, achalasia.

and today, yesterday we did

the upper GI and surgery

on the side, too bad you didn't see

We saw the adrenal gland, it was a pheochromocytoma and we finished at 8 last night. The patients are doing very well.

That para-aortic lymph node, what was it?

It was there, we don't know why we didn't do it, but it's strange, it was very, it was big, fibrotic, granular, in my opinion it could be pathological.

No, don't push, bring my microphone closer, closer.

I then saw, Franco, regarding the ligation of the right gonadal vein, important surgeons ligate it, others leave it, but they say that when you hit the ureter and the whole mass, sometimes it's left, and since it's a bit of a tricky vein, they prefer to section it.

the one from yesterday, so on the right

who ligates it and who doesn't

also because the treatment of varicocele

is ligating it

no, I didn't ligate it

yes, but precisely, I mean

there are those who ligate it and those who don't

but there's another important thing, Franco

what that colleague said

who is Nicola

that in fact urologists

unless it's of a particular level

by doing some

partial nephrectomies

by doing posterior nephrectomies

by doing a series of procedures

always the high renal reflex

and puts an inexperienced surgeon in crisis

and which is good from a medico-legal point of view

because he doesn't know these modern techniques

this, yes, I agree

we have a small gauze

we need to do the second row of stitches on this side

but since Bracale was looking at me like that

almost with his eyes he was asking me to do something

and we'll let him do it

because tonight

they want to make us eat

go Umberto go

Umberto, do you also make bows/knots?

or are the bows/knots only the director's?

Angela

Umberto, to lighten the mood a bit

I was saying

but will you also make bows/knots like your director?

or are the bows/knots only yours?

absolutely yes

so then

so then he can't say that he put those in and I put those in. I recommend, make bows/knots, this is what I wanted to advise you, I've had many years in university life, so make bows/knots.

No, it's fine, make a bow/knot, come on, I've done a continuous one, okay, give it to me. Umberto, please continue. I didn't hear, Angela. I said please continue, keep doing it.

what a mess they had made for him

for this purpose

in my opinion

they had done

a somewhat atypical plasty

which rarely

is done

they tied both the posterior wall

and anterior to the right pillar

because when he

Franco sectioned

that collar

if it's the stomach valve

they fixed everything to the right pillar

in fact you saw

the anterior wall

he had put stitches

with the right pillar

so much so that he tore the pillar

and it had pulled behind

and he freed it

the posterior wall

came back from behind

to fix it always to the right pillar

so an anterior and posterior plasty

fixed to the right pillar

do you agree, Francesco?

I don't know why

when you cut the bridge

of the valve

at a certain point

there should be

two leaks

through the stomach

I stop

a bit of gastric wall

to the pillar and that's it

creating that situation

otherwise we had

open in the stomach

but

Umberto, you stop, right?

Yes, yes, enough, enough

four stitches

and the rest instead

the prosthesis, how do you fix it?

I didn't understand

I hear you very badly, Francesco

it's the microphone

this microphone or I am voiceless

but the microphone

I'm holding it really badly

I can't wait to close it

but the prosthesis that was placed

this bio-mesh of the kind

in the highest part

how do you fix it?

No, I believe he doesn't fix it

because he put some small clips underneath

where he knew he could fix them

he put glue behind

so at that point the prosthesis can no longer

dislocate

We can't fix it because there's the liver

it's not worth it because

there's also a diaphragm

a diaphragmatic one

No, he fixed

only at the points with clips

Francesco, where it was safe

and he wasn't risking anything

he put good glue behind

that prosthesis isn't going anywhere anymore

ok, we're done

thank you

thank you all

to Francesco

because it was very difficult

and one takes away great messages

only the live broadcast

only the difficult moments faced together with you

Franco

they gave us so much today, truly

I truly thank you from the bottom of my heart

Francesco, Professor Ruotolo, thank you

will you also be at the achalasia?

Francesco, will you also be there

at the achalasia, Professor Ruotolo?

Ah, ok

on the microphone and I say yes

definitely present

thank you, thank you

you outside, right?