S.H.KIM Cancro del retto robotico

okay welcome to the congress we can start with your presentation thank you very much indeed

hi professor palazzini welcome can you hear me yes pretty well thank you for inviting me

to this very very interesting congress

Yeah, this is Korea. Yeah, Seoul. Yeah, welcome. And how is the image? The operation? It's good?

Oh, really? Oh, the operation doesn't go out now? Wait a minute. What's our image here? That one?

Yes, I understand.

It's a

Then, I understand.

Let's tie it up.

My arm.

Yes, my arm.

Number 1.

Sir, please lower the seat a little bit.

And, please say hello in detail later.

Hello? Can you hear me?

Hello?

Hello?

I can hear you.

I can hear you.

Okay.

But we don't receive any video now.

Oh, you want to see the video?

Okay.

okay okay thank you change can you see the image yes very well okay uh so far just in brief the

the case is rectal cancer female uh female 50 54 year old female the tumor locates uh

8 cm from the anal verge and the clinical stage was T3 and lymph node positive.

So we gave chemo radiation of long course radiation therapy and I am doing robotic low

low entry section today actually we started one and half hour ago and we did

IMH ligation, high ligation and IMV division then medial to lateral

dissection can you hear me probably not yes we we can hear you okay and we did

did full splenic flexor mobilization already then we are now doing pelvic dissection because

I understand the attendance there probably are interested in pelvic dissection more than IMA

I just tried to broadcast the pelvic dissection phase for today's Congress.

Okay, thank you. We appreciate a lot.

Hold this. Hold this.

Hold the collar.

Hold the collar like this.

Now I'm trying to...

Put it down, put it down.

Trying to have a traction using cotton tape.

Hold one side and tie it with me.

Okay.

Do you want to hold it again?

My assistant is holding the cotton tape for traction.

Pull it.

Okay, good.

Now change here.

I want to show how the IMA was dissected already.

ready I can show it later

pull pull suction

one suction comes in and one is pulled in

good

I'm doing it with you, don't do it alone

okay suction here

suction should go in here

I'm putting it there

here

this plane lab

good

come in here

pull me, pull my left hand

pull my left hand

good

That's it. I'll pull it a little bit to the other side.

Put your head there. Good.

Excuse me. I have a question for you.

Yeah.

What kind of radiotherapy did you have for this patient?

Long course.

A long course. Okay.

In Korea, long course is just standard in most institutes.

Here, the adhesion is very severe between the vagina.

And excuse me, also how many weeks from the end of the radiotherapy?

You mean that after radiotherapy, how long I stay?

Yes.

It's going the other way.

Wait a minute.

Don't pull too hard.

If you pull too hard, the tumor can burst.

Just do this.

Let's see here.

Right?

Right?

This is the advantage of robot.

Don't pull too hard.

Don't pull too hard. It'll rip.

The margin here is not clear.

Suction.

What are you talking about? Pull it a little bit, pull it a little bit.

CO2 is turned off, right?

CO2, is it done?

Come in, come in, come in.

It's working, it's working.

Dr. Kim?

Yes?

Which side is the tumor?

Tumor side?

Which side, side?

Anterior wall, posterior wall?

Um, it's encircling. It is circumferential tumor.

Okay.

Okay.

Usually we can see the margin with not much difficulty between vagina and rectum, even

radiated, but this case quite difficult.

But she had an hysterectomy?

the most there is definitely one advantage of robot and this is more

beneficial in in male patient we can see very well okay thank you you're welcome

essential for safe stapling robotic stapler yet that that's why we anyway

need to change to conventional laparoscopy the robotic harmonic has

advantage and disadvantage is the the dissection the visual field is excellent

but a disadvantage, robotic harmonic does not have endo-wrist function. That means it can

not go this way. It always goes straight. So sometimes conventional harmonic sculptor is

better to divide this. So now I'm going to take off the robotics, then change it to conventional

laparoscopy. But before taking out the robot, I want to show, really, the IMA, my right arm,

right? Yes. Take your left arm out. Take your left arm out. Yes, it's out. You can take it out. Take it out. Take it out.

Yes. Then, my left arm, change it to the original. No, my right hand, my original right hand,

I'm going to show it to you before I do it.

Not that arm.

I have to put it on my left arm.

I don't need that arm.

On the left arm.

Okay.

That's right.

Okay.

I'm going to wipe the camera.

I'm going to wipe the camera.

Wipe the camera.

Yes, it's done.

Show me quickly.

It doesn't work.

Oh, it works.

Okay.

Show me this.

Put the tied one in.

Put the tied one in.

Put the tied one in.

Here.

Show me.

This is outer IMA. Did you use reabsorbable ligation? Yes. The clip? Yes. No, this is hemlock. Hemlock, okay. Yeah, I can show the dissection by using conventional laparoscopy. Okay.

The doctor said the robot was here.

It's okay, it's okay.

You just need to remove the docking.

Dividing the rectum.

Can you show me the outside?

Can you move a little bit?

Please show me the robot.

the robot is approaching from the patient left side left obliquely through the uh this is the

patient head side this is a patient leg here and robot is approaching from this

left obliquely over the left anterior iliac spine I developed this technique

through this technique we do not need to move the robot from the beginning to the

the end of dissection. We call this technique single step fully robotic dissection for low

Low entry section.

Show me the inside.

Show me the inside.

Show me this.

Head up.

No, right up.

Dissect.

IMA.

IMA.

Here.

Again, this is IMA.

Here.

Usually the patient, the Asian patient has quite a long sigmoid colon, so full mobilization

of splenic fracture is not always necessary.

But my indication for that is if the patient has radiation, a part of sigmoid colon can

be also radiated.

so I usually remove whole sigmoid colon even very long and at that time I need

splenic flexor mobilization and the robot also has some advantage to to

access even very deep sitting splenic flexor

Hold this. Hold this. Wait a minute. Not that. Wait a minute.

Can you see that? The one you tied up.

Did you get it wrong? Hold it here. Hold it here.

Hold it here. With your left hand. With your left hand. Do what we do.

No, you have to grab it with a babcock. We used to do that.

No, with a babcock. Pull it a little this way.

This is my finger through the anus this is definitely free from the tumor so I'm going

to divide right here.

No, I didn't.

It's a robot.

Like this.

Here.

And then,

Get out of the way.

Camera, come in.

Camera, come in.

Okay.

How do you turn the camera in Jeju Island?

I'm in the middle.

There's a center.

There's a thing that can move at the end.

With a telescope.

Come in.

Come in there.

That's right.

Put it up.

That's right.

Good.

Come in left.

Left.

Take out the camera.

Take out the camera.

Take out the camera.

Go forward.

Go forward.

I need to change the direction.

I need to change the direction.

I need to change the direction.

Okay.

Change the hand that pulls here.

Change it to this side.

You can't put your left hand in.

I'm doing it.

I'm doing it.

I'm green.

Green ETX.

Put it in.

Put it in.

Put it in.

Camera.

Here.

Here.

Here, here, here, here.

Wash out.

A little later.

Take the camera out and grab it again.

Gently.

Okay.

Pose.

Pose.

Camera.

Hold on.

Hold on.

You have to pull your left hand a little bit.

Okay.

Okay.

Look at the front again.

Look at the front again.

Okay.

Again.

Here, here.

Here.

Give me some tension with my left hand.

Uh-huh.

Rectum, right colon, same.

Rectum, same.

Okay.

Come in.

Come in.

Come in.

Yes, yes.

Give me a clip.

Yes.

Give me a metal clip.

Yes.

Put the camera away.

Come in again.

Come in again.

Clip.

I need to take out the camera.

I need to take out the camera.

Yes.

Put it back in.

Yes.

Yes.

Yes, the stapler is working up to here, just in case I apply the clip.

The stapler was introduced from the right low quadrant port.

Nerves.

Okay.

I'm going to make an incision on the left low quadrant port.

One difference is...

Hold it. Hold the pin.

Hold the pin.

Take it off.

Take it off.

Next, I'll show you the breathing.

It's not there.

I have to give you a vision.

What is it? Give me a little bit of this.

You have to walk this.

After showing the specimen, I'm going to stop the transmission because the rest part is nothing new.

Dr. Kim, can you hear me?

Yes.

Just a question.

Which kind of anastomosis are you going to perform, side-to-hand or hand-to-hand?

In this case, probably hand-to-hand.

Okay, thank you.

This is not tumor.

The margin is about 3cm here.

This is IMA and this is IMV here.

Okay.

Dr. Yes.

Oh, thank you for your beautiful operation.

Very clear.

Dr. Thank you.

Rarely we have seen such a view of the pelvis with your robotic instrument.

Okay.

I think you can close your transmission.

Dr. Thank you.

Okay.

And thank you on behalf of Professor Palazzini and welcome in Rome again.

Dr. All right.

Thank you very much.

Okay.

Thank you again.