F. CORCIONE gastrectomia

Female with a BMI of 33.2. She has a past medical history of hypertension, aortic valvulopathy, and diabetes.

Fortunately for us, she had no previous surgery. She has no past surgical history.

And her story started in April 2018 when she started complaining about importance with loss of 10 kilos.

Therefore, she consulted a specialist, and under his indication, she performed in September

upper gastroscopy, which showed a large and ulcerated lesion of the incisor of the stomach.

Biopsies were taken on these lesions, and they were positive for mildly differentiated

adenocarcinoma.

Obviously, she performed a CT scan, which didn't show increase of volume of gastric

nodes and was negative for secondary lesions.

The patient is scheduled today for a 3D laparoscopic partial gastrectomy.

I continue to speak English, of course, because I don't know if we are connected with all

the world.

Welcome again at the Monaldi Hospital in Naples, Corcione speaking, and we are ready for the

last operation of this amazing Palazzini Congress.

Congress, the first problem when we perform the gastrectomy is to give a look to the tumor

and it's incredible, three centimeters of lesion, we did not taste anything.

So in this case, we are waiting for the perioperative endoscopy to be sure to have the lesion in

the right plane in the right section and waiting for the endoscopist we take advantages for the

operation because we need about the gastrectomy of course for the okay for this as before we start

with the detachment of the people from the transverse colon in order to answer to the

the oncological issue at the same time to reach the lesser sac that allows us to give

a look to the posterior part of the stomach and then we go, we will go on the left side.

I don't know if there is someone in the room that can speak with us.

we will perform the same step than before, and in this case we will perform in the old

woman the subtotal gastrectomy if the endoscopist gives us the right answer that the tumor is

located in the this part of the stomach as the preoperative examiner show we

start with this woman is a little bit difficult because she's a obese patient

with the BMI 33 it's very important when you perform this surgical step to go a

little bit far from the colonic wall in order to avoid to injury and is

sometimes very easy when you don't like to have a look heavily on the

bowel with this kind of instrument look how is it difficult to identify the

my goal is to reach the lesser suck through this way here

Maybe someone? Guido? Are you there? Are you still there?

Gaetano. I'm quite sure I hear the voice of Gaetano, mythic Gaetano, the right hand of Palazzini.

I opened the lesser sack. It was not easy.

Dieci.

Pronto?

Chi è al telefono?

Professor Corcione, forse.

Rolfo.

Ciao, caro. Sei tu?

Mi hanno dato veramente Corcione?

Ti ringrazio.

Ringrazio la regia e Palazzini che mi hanno dato finalmente Corcione.

How are you, Francesco? Are you well? I see the image now for the first time, I see that you are making a detachment with the epiploic, if I'm not mistaken.

I have a stomach tumor in an old...

Ah, yes, and you would have already explained to the room what it is, yes, perfect.

It is a clinical case, it is a tumor that we do not palpate, for which I asked for an intraoperative endoscopy.

Yes.

The tumor is classified as 3 cm of a retreating ulcer on the large curve, but I can't appreciate it, so I want to be sure.

It's an old lady with some comorbidities, so I want to save, if possible, as much as possible.

as much as possible there are no signs of great infiltration as you can see without

problems for which the endoscopy will clarify a little in terms of the question the entity of the

cassette here now I stop on the mobilization of the large curve and I go to prepare

what I still have to prepare that is the duodenum for the duodenal section so I do not waste

tempo ok ho capito quindi è un'attesa attiva diciamo esatto esatto perfetto avremo il mio

obiettivo visto che non è un grande tumore una persona anziana e di fare una di uno prima ho

fatto una di due non so se eri presente in sala no io sono arrivato adesso per l'orario pomeriggiano

No, no, I was punctual, because I had to take service at 2, I arrived at 2.05, in short, punctual, it is punctual.

So, this morning I had a tumor with a Rinfectomia B2, I also had a...

Professor, I disturb you, just to greet you, a loving hug.

ciao carlo non mi ha riconosciuto ciao francesco un abbraccio e buon lavoro come faccio a non riconoscerlo eh si io guardo il best

eh si lo so un abbraccio francesco buon lavoro ciao bene hai salutato un tuo grande amico a

quanto pare benissimo ieri abbiamo visto shang se non sbaglio shang adesso il nome mi ricordo

who did a beautiful D2, also standard, for a gastric resection and ended with a Birrut 1 with anastomosis.

This one?

Japanese, Chang I think, if I'm not mistaken. I don't remember the name.

A Birrut 1?

He did an AB81, yes, after a fairly wide gastric resection, he did an AB81 with a section above the other gastric, clearly, and an anastomosis lateral-lateral with a linear suture on the duodenum.

I must say that it came out well, here.

Have you ever used AB1? I never, I must say.

Look, never.

Ah, me too.

horror and I am afraid of the tension but also because I do I did before when I did

mine of two I am sorry that it is not in the room because it has been very demonstrative but I do

my total gastrectomy in the sense that I left only a small cuff where

where, at full capacity, the ileum can reach almost a total, let's say,

for which the B. rotundum is absolutely impenetrable.

Absolutely impenetrable, of course, obviously.

And in this total gastrectomy, which you rightly call total, almost subtotal gastrectomy, but almost total,

have you ever had problems with vascularization of the gastric fund cuff?

It is linked to the fact that we leave only those two short vases as I did before and apparently it seems to us that that part of the stomach is well vascularized and then in the postoperative there is the fistula, there is the ischemia, you put the clip, in short, it happened to me more than once.

Because the connections between the right vascularization and the left vascularization of the stomach are not standard, I must say, they are not rigidly standard.

And so sometimes it happens.

Unfortunately, you don't have the possibility to evaluate well.

I mean, I've seen that the colon, when it's ischemic, it's ischemic, and when it's not ischemic, it's difficult to identify it.

The stomach makes a few more jokes.

And then, you know, the times are different, because when you prepare the colon,

and you certainly have a huge experience in this field,

then between the moment of devascularization,

so of the suture and the section of the vases,

and the anastomosis, time passes.

While, instead, as far as the resection or the total gastrectomy is concerned,

it does not pass any time, because once you have resectioned the first thing,

to do anastomosis in short you do not have the necessary times to understand if there was a damage

very well now we have chatted about various things but I think they are interesting

I first talked to guido gasparri and commented on the fact that many today do not believe

they no longer believe in the importance of omentectomy, many do not even follow it, many follow it only partially.

How did you behave?

I have always done it for school and tradition.

I have always done it also because now I do not have a case on which to document,

but I remember the lymph nodes of the first mental tract that were positive,

in short, in the transported mental tract that were positive and then I believe that you improve the

skeletalization of the pyloric vessels

because it makes you see them better

and then you can really get to the origin more easily then you know the surgery is made of

standardizations that however last 20 years

sometimes they last even 50 but sometimes they last even less then above all it allows you to

better separate the colon from the dure no yes of course precisely at the pyloric level you open a field

that otherwise you would not see and in any case you know in these cases it is often said it is not a difficult maneuver

It's not a maneuver that consumes time, in a few minutes, sometimes a little more, you follow it and you go more relaxed.

In fact, we go to the back wall of the stomach, here, we return to our steps.

I was saying before, on the other intervention, that it could happen a mesocolonium very high,

attached, a little stuck to the stomach wall.

If you think you're going to release the people, instead you have to prepare to section the mesocolonium.

You have to be careful, go out of the plane, it's true.

Here we are in the back wall of the stomach.

and here you have to pay attention this is certainly a slightly different color so even the

expert eye but also what a pleasure to hear you a little time is yes a little time before we

feel much more frequently as life divides but does not separate as they say indeed

indeed it separates but does not divide endoscopist arrived if nothing endoscopist arrived

he is mounting all his ambaradan I go ahead for my street because this phase here

however I should finish here you see here as if it were really a scar yes yes they are then if

If the lady has a certain age, these semi-adherences with the panicle at rest in general are formed, they are found everywhere.

But they have the pleasure, and they make you happy, to be avascular, white and well-lucid.

One of the advantages that laparoscopic surgery has brought is that of teaching the surgeon to go as far as possible in the embryonic plans,

precisely those that are avascular that allow you to better manage the intervention.

Exactly.

Where there are no hands, there are no cocker, there are no gauze.

Especially the cocker, which were murder tools.

The hands.

le mani non per scuola probabilmente non l'abbiamo mai usate o almeno pochissime

situazioni marley coker si erano era un chiudi tutto e poi vediamo beh adesso si

vede bene e anche c'hai non faccio fatica a dirlo c'hai un si un rec divisione

molto bello e noi vediamo su uno schermo centrale inferiore molto bene

Now I'm going to find the gastro-epiphysis vessels on the right, I'm going to repeat exactly what I did before on the other tumor.

Yesterday I dedicated the day to the Over GI and today to the Upper GI, as you can see.

And, by the way, Rodolfo, you have just arrived, so it is the last intervention of me at Monaldi, in addition to being there at Monaldi.

Yes, I know about your move.

Tomorrow I will pass to you, to the competition.

Well, it has never been a competition.

You haven't had competition.

Let's call it a re-entry.

Let's say it's a re-entry after a few years of hospital training.

Bravo. And it's really a beautiful...

Here, be careful here.

We are ready, because when you are ready, tell me, because I will stop.

Oh, hello. Are you ready?

Ah, sorry, I was waiting for you.

So, let's go.

Let's clamp with an interstitium for a moment.

unfortunately the lesion does not palpate then I wanted to understand exactly where it is

that's why you should do this endoscopy. Clamp the trice or something else?

Clamp the stomach here too. Why? Because if they inflate it, they will not deflate it anymore.

the tumor is a little higher. Go, you can go, it is not pre-pyloric in short, here it is, excuse me, this does not hold.

So you clamp the other one? I clamp here, then with the endoscope and then you give me a clip, so eventually

and another Joan. We have Dr. Piantedosi who will start with this endoscopy.

We are happy. This sock is intended for the retraction of the liver and we are ready. Go!

It should be a three-centimeter ulcer. If you want to see the images, I don't know how to show them to you.

Maybe with a ... we are seeing, mamma mia, we have fantastic technicians. Palazzini treats us well.

At this moment we are seeing the endoscope. Listen, while you introduce the endoscope and we will see the stomach,

sometimes you use the tattoo?

Yes, we did the one before. Here, instead, we were sure to palpate it and we didn't do it.

but I will tell you that the one before had a tattoo that I have to explain a little stomach was not

tattooed that is to say that we have seen everything a lot more black than white the lymph nodes

and the fact is a lymphography I made a temporary one on which the lymph nodes and it was

negativo per fortuna per i pazienti. Benissimo.

E' stato interessante. Siamo sempre pronti. E' l'anestesista che introduce lo

strumento. Essendo anestesista ha difficoltà a capire in quale... Beh, uno

occupato, scusa, non può sbagliare, tutta più si incastra. Si è incastrato. Un tubo

more free to act, come on, ok thank you, thank you, you see the stomach or even the inside now,

the endoscopy, we see only intraoperatively, now we see the endoscopy,

Now let's see if he chooses under visual control.

For now he is still quite high.

Here, it seems to me that he has entered the esophagus.

Very good, Dr. Biantedosi.

Perfect.

Very good, Dr. Biantedosi.

Here is the heart line.

It fills up.

Dr. Biantedosi deserves to be a surgeon, so much so that he is good at doing these maneuvers.

No, no, if he's a good endoscopist, let him be a good endoscopist.

We need good endoscopists a lot.

The stomach has nice mucous membranes, but it's not swollen, so...

Yes, it's swollen.

The endoscopic images show the swelling.

Okay.

He has a nice mucous membrane, it's like a cerebroid.

I see something, but a cerebroid mucous membrane is not, in quotes, normal.

here yes towards the pylorus the other one is fine but above it looks like a gastrite I don't

remember what it's called. I see it, I see it, it's high and so we're right here on the

angulus I touch here the angulus so we have to do a near total forcibly, I have a clip here just to

to say, here it is out, out, instead they described it as a big curve, did you understand?

Yes, but from Joan I see a small curve, instead they described it as a big curve,

but it is not so high to see, in short, angular, supra-angular, up and down,

but hey now it swells I don't understand a little but it is not very high

and no those pop out of the sun

eh yes but you forgot that those pop out of the sun and there is no auto-control

ok go

go away, take off everything, suck everything, thank you, ok, ok, the clamp that we put at the bottom on the antero has been effective, go away,

everything can come out, and then now, with a firm mouth, you see the clip, the gauze is under the gauze,

Thank you very much, elderly people, I do a total NIA here.

Okay.

Yes, of course.

With this, our duodenal infection, we take the stomach here.

Thank you, Dr. Piantedosi, thank you to the endoscopists.

We thank everyone in the room.

Thank you very much.

I have my gallbladder, only that of the liver, right?

Okay, I take you to the duodenum and I have to complete the mobilization of the colon

Thank you, goodbye.

I prefer to put away this moment.

Thank you, yes.

I was saying this morning, and I repeat it to the benefit of those who are connected now

with my intervention, that there is a beautiful phrase by an English surgeon who says that a

true expert is the one who has had all kinds of complications, and therefore I consider

myself an expert in this surgery, because it is the only one who has had all kinds of

because I really had all kinds of complications.

By the way, one of those rarely described is that of the colon ischemia

linked to the mesocolon section, which I had misinterpreted in this dissection,

and I took it away with...

Ah, I remember it, I think you even showed it, if I'm not mistaken.

It could be, yes.

Yes, you did it in a black video, a session of black video, something like that.

You have a good memory, professor.

That's the only thing that's left for me, thank you.

Let's not exaggerate.

So I'm taking myself towards the back wall of the uterus.

Fall.

Liberating the uterus from the pancreas.

I have the honor of having Professor Di Matteo next to me, I tell you right away.

I heard him yesterday, I felt his voice, because yesterday I was connected in English with the Chinese, with the extracomunitarian countries, I don't know with how many countries, but I was connected with Palazzini.

And yet I felt his voice every now and then, and I was glad to hear it.

It's always more than...

I don't want to hear his voice directly, considering the affection and the esteem that binds us and especially the many years of this Congress,

from him, it must be said, organized and ideated many years ago and then brilliantly brought forward by his student Giorgio Palazzini.

Yes, the first were in the CNR room, which would contain practically 200 people instead of 2,000.

Always full.

So, this is my landmark, the gastrointestinal artery.

I follow it so as not to make mistakes.

And on the edge of the gastrointestinal artery I go to repeat the origin of the epiproic gastro,

by taking away both lymph nodes, here they are, you can see them, and to be sure that I am going to bind them

on the 10th, not something else. So in laparoscopy, attention, it is really important

the need to follow the embryonic plans, but also to always have the right landmarks under the eye

to the colicist and obviously to the major surgery.

Here it is, and the whole lymph node package is here,

so it goes away together with the duodenum.

Here we have the gastrointestinal vein and here we have the artery,

which, as my friend Francesco Ruotolo often reminds us,

strangely do not travel together.

We are seeing, Professor, we are seeing everything.

Ah, there you are! Look, I mentioned you without knowing.

Look, there's a fight. You're so jittery that everyone wants you.

Have you seen that I love you so much? Have you seen how much I love you?

We've made a group of listeners, Francesco.

The group of listeners is composed of four or five people,

but I believe that in the room, who are close to me, clearly,

but I believe that in the room many are watching.

So, as the Master Ruotolo said, on the gastro-bibliography,

please, continue.

He says that, unlike all the other vascular structures, where the artery and the vein always walk a little together,

here, instead, there is always a more or less important distance between the artery and the vein.

He explains this very well. There is also a name for this. What is it called, Francesco?

The concept is this, that the uterine gastro gives the right fibroids, which goes for the big curve.

The vein, on the other hand, is a branch of the L-shape in a general sense, and at a certain point it goes down to the L-shape, but then it goes down to the L-shape, so for a while they are together, but then one takes an azicotic attitude, that is, it goes to hell, and the artery...

No, no, the azigoth is a vein that goes on its own. For women, for feminists, the word azegnomi, which is Greek, says I go alone, I am proud, so it is the vein that goes by itself, there is no need for the male.

schietto e allora tutto ciò che va da sola come sempre la vena tiroidea media viene chiamata

viene chiamata in vena in atteggiamento azigotico ho finito di fesserie e ti ripasso il professore

che c'è che ha ritrovato le chiavi anzi la sta parlando col professor di matteo quindi di continua

a seguire ha ritrovato le chiavi vincenti perché aveva rubate e io non rubate le chiavi del mio

I have never lost the keys of the car yesterday I came with the car the keys and the cork

with the keys in short I lost it and then I had to go back you know where I live if you don't know I'm

50 km from here I went and returned to the villa and therefore I spent more than

taxis if I had gone to China I don't know where it's okay anyway today they found me

Let's go back to the surgery, you have selected everything, how many centimeters up and down of duodenum would you take away?

I go to the bottom of the pylorus for sure, this is enough for me.

This is enough, sure.

I have to prepare it before, if I lift the colicistis a little.

By the way, you have to be on the colicistis, what do you do?

No, without calculations, let's say.

When there are calculations, we remove it even if they are asymptomatic, for example, because one of the causes of colicistitis is the nerve, of course, linked to the intervention, and one of the causes is post-operative colicistitis.

of post-operative I said that I do not do an extended infectomy to this lady

yes the mission of the problem in this age with mobility I will try but a

minimum here above all it makes me happy to do it to go to the research of the

pyloric in order to free up the space for the section of the rodent in

Here you can see the liver well.

First I did a classic D2, I have to say, here it is, I have to say, very good, very ...

No, no, close to the liver.

Here it is.

In reality, there are 15 of them.

Okay, let me see.

Here we are obviously on the pancreas, then let's wash our eyes for a moment because I went to the other side.

Ok, we are ready for the duodenum section.

My trochars are rarely available for surgery.

The advanced paroscopy provides for the placement of two trochars of 10 for the hands of the surgeon.

this is the pancreas instead they predict it and now I will explain why for this intervention

I have already said this morning I repeat it to the benefit of those who have not been able to listen to me or wanted to listen to me

now give me another Joan there are two drugs of 10 as this suturing prepares the stem

you see well all the nodes of the we remove the sound for pleasure here is the last

good very good this last stroke of the precision and it makes the experience come out

because when you do with the suture it says the little hole that is in here it bleeds after the

anastomosis after the section instead so if you want to bleed only the under

mucosa the pancreas is well prepared at the bottom and also the duodenum is well prepared

ok perfect so now I will pass my suturing in my left hand

left tipology or the white triceratops we remove the probe by courtesy you give me a

gian in order to have a perpendicular direction to the axis of the duodenum here is the

back part you see yes yes I want to be sure to understand everything with a single

And then there's the squeeze, so...

Exactly, here it is.

Let me see how it's settled down.

A little bit more down it can go.

Let's see in front.

Okay.

Now wait, the pylorus is here.

I'm at least one centimeter under the pylorus,

as it is written on the sacred texts.

It's closed one centimeter.

No bleeding.

And now let's go quickly to the tripod.

While you bring yourself to Tripede, I can't help but ask you, because then here we have seen many interventions, many different options,

white suture and blue suture, advantages of one and of the other, then a superimposition on the mucus or not a superimposition?

These are questions to which Master Corcione must answer.

So, white suture on the duodenum because we clearly assimilate it to the intestine where we always use the white suture.

So, I don't put the supragit because you see, once this artery is denuded here, it should mobilize further creating a devascularization.

instead all the branches that go to the duodenum and that start from the gastrointestinal tract,

the small branches of the reaction are not altered.

So to do an over-exercise I would run the risks of vascularization of the duodenum,

as well as hematomas and so on.

If one believes in the goodness of the suturators,

the over-exercise was done in traditional surgery,

when obviously these instruments were not available.

position these instruments today it becomes complicated and as I say the complicated things

in surgery are the most harmful and therefore in surgery there are simple things and superfluous things

and non-coded things become more harmful here I could do the re-infection and I will do it now

for the hepatic artery up to the tripod because I see some slightly thick knots and then I will

I will quickly bring you here on the tripod, yes, yes, the chair to soothe the liver.

Where are you?

We always take a look before moving on to this step on a small increase

and we go in search of any hepatic accessories that come from the left gastric

otherwise our option on the dissection of the artery would change

Instead, here it does not seem to be visible, we are almost at the pillar, I do not see hepatic

accessory arteries, ok, and so I go back to this, in quotation marks,

of necessity, just because I see some suspicious lymph nodes here, but my

goal is to do a D1 in these cases, D1 plus, as they say.

there are still many screens connected all there are only two with the

information of the direction all the others if 15 are open and connected to yours to your left

there is the christian usher and to your right there is francesco crafa you are at the center

No, I'm just, you know, in the middle of a good company.

Two thousand years ago, there was also one who was in the middle of two.

They all made the same end, though.

I hope they're not making a stomach like them.

No, Francesco is making a liver that I don't know well if it's bigger or smaller.

And Cristiano will probably have a stomach too, because he put peri-umbilicals, para-peri-umbilicals, horizontal, so I don't think he'll do a colon, but he's at the beginning, so I don't have a clear idea.

He overcomes it by image.

And Cristiano will also have the robot, because he works with robots, but the images are very red, we have to tell him, they are faded.

All right, we are making a living.

As always, Parazzini also serves this.

It must be filled.

Here we go towards the tripod.

Well, the lady is chubby, but in here she's not chubby, on the other hand she has an increased obesity and that's it.

You know, I prefer the chick of women, I said before.

Yes.

Apart from jokes, male obesity.

Feminine, sure, you're right, sure.

Not because she's male and racist, you know that well.

No, no, ma perché sei chirurgo e sa benissimo che un uomo ciccio al tavolo operatorio è un'impresa, è un'impresa rispetto alla stessa, lo stesso BMI di una signora, di una donna.

Anche se i chirurghi hanno tutta la pancia.

Allora mi dai una mia?

La pancia del chirurgo.

Un po' di bipolare per piacere.

In necessità faccio questa infettomia arteriepatica.

Franco, on the hepatic artery, do you remember that case of the daughter of that colleague,

also among other things a somewhat important man, who seemed to have taken that lymph node of the

common hepatic artery and instead, fortunately, at the contemporary histological exam,

negative. That lymph node that is called the Cloquet lymph node, the same Cloquet that

has put the inguinal lymph node together with rosenmuller indeed indistinctly and what

it indicates and rulli and a surgeon coevo says precisely this is a landmark and a pallet that

is placed on the common hepatic artery and is not necessarily pathological you remember the

satisfaction of that gentleman in real time if because he had not taken the lymph node you

Do you remember it, professor?

Yes, of course.

It's a beautiful memory.

I remember it by force.

An appearance with the hepatic lobe.

I want to bring everything to a block.

Now I bring myself towards the tripod.

Yesterday we have...

It's very good.

So, yesterday's patients are very well, all of them.

But above all, it's very good

legamento arcuato Francesco che hai commentato ieri con me potrebbe andare a casa mi sento non so se mi senti

si ti sento

allora la vena è anteriore rispetto all'arteria

qua ci sono dei noduletti un poco più sospetti forse

beh ti stai avvicinando la sede della neoplasia

mi sto avvicinando alla gastrica

I haven't seen the vein, is it already sectioned? No, I haven't seen it, so...

We are here, we have it, Ernesto, and we are looking for the artery. The vein is already sectioned.

Napoli? Napoli, can you hear me?

Yes, who is it?

It's the director of Roma. We have a question from Saudi Arabia. I'll pass it to a doctor to do it.

Read. Ok, ok. Ok.

Okay, dipolare.

Ecco, immagine suggestiva in parte.

Allò?

Allò, professor Corzone, Umberto Grandi, dalla regia a Roma.

Mi sente?

Sì, sento. Chi è?

Sono Grandi, Umberto Grandi, Ravenna, in prestito al professor Palazzini.

Non si sente.

Non si sente?

Grandi, Umberto Grandi, Ravenna, in regia a Roma.

Mi sente, professore?

Sento a tratti.

Mi sente male?

I can hear someone from Ravenna, I can't understand.

Exactly, professor, can you hear me now?

I was told by Arabia Saudita.

Yes, exactly. I'm Umberto Grandi, in charge of Rome.

Yes.

There's a question.

I can hear you, sorry, there's a microphone.

No, I'm sorry. Now we have to make it work, one moment.

We'll see you in 10 minutes.

We'll see you in 10 minutes.

We'll fly.

We'll need it.

I can't hear anything.

You opened the Yusk app.

That's what they tell me.

They told me that you opened the Yusk app, which I never knew it was.

Since the old stuff is not thrown away completely, even for the memory of the past,

when in 300 years we will talk about the professor Di Matteo, about you, about Vincenti, etc.,

one will say how good they were what good people if instead for you we will hear but who is then

husk what he did he said if I take the stomach I pull it up to the back of the open cavity

what do you see in a peritoneal plaque that is cut upwards because it pleases because below

they pass the vein and the artery that you said this plaque of us that also says gastro-pancreatic ligament

there are a thousand names and it is present on the text on the chiaruggi on all the pieces and at a certain

point at a certain point therefore it must be remembered as a landmark because it avoids that

teachers like menotti and like you who have said that they have interpreted the hepatic

pesplenic by making a problem that you have solved brilliantly it is called the usk plica and this

peritoneal reflection that appears as soon as you open the retrocapita pull the stomach up

Thank you so much.

A more ultracision clip is enough.

Perfect. They were asking me about the vein, do you always close the ultracision?

Yes.

Perfect.

The vein here, yes. If it had to be the splenic vein, I'm going to say no.

No, okay, sure. There are other dimensions.

You know, at the beginning I also tried to select the left case without a clip and I was lucky because it went very well.

During the intervention, at the end of the intervention,

going to maneuver a little, cleaning with the gauze, etc.,

suddenly a flow of blood from the origin of the artery,

and then I said, well, the CRIP will make me sleep better, and so...

And it will make the patient sleep better too.

Yes.

With the possibility of waking up, while instead

a left gastric that opens once that is that you find no no no I thought this was a

vascular structure and what is this lymphatic I believe that it is transported together with all the

lymph nodes to station 1 that we reach now here it is the platform and in any case given the seat

this is the most important lymphatic part and also the type of lymphectomy on the small

The small curve will be complete because we will not be content to cut the stomach.

We will bring ourselves on the small curve and unblock we will export all this fat tissue.

You see how fat this woman has.

From Saudi Arabia no news?

In Saudi Arabia there was a big colleague who was in charge and he was telling you

I am a big colleague of Ravenna.

He was here, I think he was here, in the direction, maybe from the direction of Saudi Arabia, I don't know, but he presented himself as a great colleague of Ravenna.

Because we had, until a few months ago, a fellow from Riyadh, very good, from Jeddah, excuse me, I said, from Jeddah, Walid, immediately baptized Gennarino, because Urbetto like the Neapolitans, who always have something Arab in their blood, very good and very nice.

So I thought it was him who was connecting with us.

We didn't hear him.

Then...

Ah, yes? What do you know?

Ah, ok.

We don't know anything.

They tell you that he's following via internet the interventions and sent a message to me.

Ah, I see.

So this is the confirmation.

So, my dear Walid, if you are able to hear me, I hope that you are able to hear me.

How are you? We miss you and we are waiting for you anytime.

All the best from everybody and see you soon.

until we get to the one that will be the seat of the section, here we already have the clip so we almost have to stop,

we bring ourselves almost as if it were a total on the right and a subtotal on the large curve,

it is a way to also give the patient a better autochamber.

to the patient. Let's prepare the suture in the meantime. Ok, I'll stop here. Now we can

prepare ourselves well also on the other side. Leave your hand here, leave your hand,

take your stomach here. So, before talking about the trocars, it occurred to me that yesterday's

The oriental colleague of yesterday, of whom unfortunately I apologize, my name escapes me, I think Chang, I have already said,

he did total gastrectomy, I must say done really oriental, very precise, very good,

but the characteristic is that he was on the left of the patient with right hand and left hand beyond the optical,

that is, the para-umbilical optics and he worked with the two trocars on the left

compared to the patient and therefore he was not in the middle of the legs, in short,

he was not comfortable and he was calm, he saw from, let's talk about the

visual of the surgeon, he saw very well from right to left, especially the

piano posteriore che è salito fino su al cardia senso ma io non ho mai fatto però

mi ha colpito la l'ergonomia ecco l'ergonomia del della situazione lui o

bene in questa posizione c'è tutto frontale al massimo cambio la visione

due monitor a volte guardi in un modo avvolto massa il secondo se vado più

More to the right, more to the left.

Ok, I'll stop here.

Please give me the suturing.

There's no sound, right?

We didn't even put it on.

Who? Walid? Was it him?

Ah, ok.

So, let's leave this earpiece.

There's a knot on the side.

Let's take all this fabric away.

Ok, give me...

Ok.

Ok, now the charge

and gold with the reinforcement for those who believe in it and look we believe in it because

above all this stomach I think it has a wall very thick very thick look you will see that it is

very wide wide you see it tends to rotate as you take it up it tends to rotate for how much it is

pesante è proprio pesante si vede sono solo la sensazione insomma da fuori che sia uno stomaco

denso aspetta aspetta aspetta aspetta devo dire l'orientamento verso l'altra parte quella della

parte sinistra forse conviene girarla un po' alto due ne deve fare per forza ok vai via ne prepari

another one always with reinforcement I said before it is not necessary to reduce the hic it is necessary to reduce the hemorrhages of these

stomachs and I remember that in open surgery when a stomach was made a thousand systems were adopted

to bind all the bases of the mucous membranes linked to each other or the other

There was a memory, there was Valdoni, of which I learned the technique of gastric resection, there was a very nice time, which was a ballet between surgeon, first operator and second assistant,

in which the muscular axis was incited and then there to that lines cockerine

vase by vase under mucous under mucous ligature ligature ligature and in short it was a

time enough time consuming and then in the light of the facts it is probably useless

utili anche perché si facevano il il duplice piano il primo totale il

second is introspective extramucous then wait ok I have a little bit of the suturing before

positioning it I see the clip is close but it is bad I have put it on top of the lesson in fact

I'm almost at the esophagus on this side, a second, go, maybe I'll prepare one for you without a sim card, the anesthetist didn't put the probe back in, right? Good, no, because every time the anesthetist says, but what to do, I don't have the probe, and he puts the probe in, the problem is to remove it, everything here, third suturing, you see it's very low,

We need to have a reconstruction to have a good outcome.

How do you behave?

I am like you, I was born open surgeon, open criteria, etc.

And then gradually I started to think in terms of invasive plumes.

and this as a premise for which now gastritomy in the second third day we accelerate

the post-operative control a lot to feed them and therefore clearly we see the

tube first in the total we have understood that it is useless the drainage in the colon is useless

nothing here they still serve here this is a beautiful cuff and this is a beautiful one there is also

a vascularization posterior if there is that it does not hurt the wheel unfortunately it is commenting

cristiano the back gastric branch that comes from the splenic you can see very well in the

total but prepared to the effect my at these levels almost a question year total ok now

Now, give me a Joan, let's take the stomach, let's bring it together with the omen.

Together with the omen.

Like in the Toto's scene, where is the suitcase? Together with the shoes, or vice versa.

So, let's remove this calzina, otherwise we will forget it.

There is the calzina under the liver, my calzina is immaculate here, the calzina under the liver is there, ok, we leave it there.

my little house we put it next to this mark and let's go and do the reconstruction

Let's take the colon, here, the colon here, let's go and identify our landmark, here it is, the fixed lance of the trice, we bring it down a lot so that we have a longer arc, ok, now Vicky leaves the colon and takes the lance,

I said this morning that I have tried all the possible and imaginable systems and I have returned to the old one.

The preparation is longer and difficult, but the result is better.

I have had more complications with the new methods of reconstruction of the bariatricians,

which I don't know how they do in Nonavela.

And then here the only complication I can have, and I also had it this morning,

let's call it complication, an ischemia of the mucus of the lily that goes up, those two or three

centimeters that have to be resected before the anastomosis, and therefore it is parvamaterial

compared instead to the advantage of having an anus that goes up through the trans-mesochord directly,

the problem is related to the fact that we do not have the transillumination and therefore in such a way

we can't identify the passage well.

Let's use this smog.

Ok.

You see how it is complex to identify the vessel, to avoid...

But we have to invent a system for the transillumination.

then we have solved everything in reality there are only expensive ones are those those

illuminated fibers no that is the fiber itself brings the light if the me if one had it could

put it back and there would be the transillumination I remember I did a strange thing I sterilized a

a battery and then I remember this thing one then put it a pile of those in style with inside a

bag all stereo and so on but I must say that from the point of view of usability it was not

much but I tried it for now there are systems and fibers of the optical fibers illuminating

Yes, but the optical illumination can very well decrease a little bit, so in my opinion it can be done, in short.

I have never thought about it, I have always been happy to be here.

You know, there are also ureteral cathedrals that are illuminating and that urologists sometimes use even in laparoscopy, so they do the light, substantially.

Anyway, I agree with you in the medical preparation of the adjunct lance, but the bariatricians do other things, they do well, but it is a different technique.

of everything and more then I wanted to try honestly I wanted to try because I say

if it is simple if it is easy if it is fast everything is fine we are not idiots that we continue to do

difficult things except that we have done a few cases I had two complications related to the fact

that the intestine remains all high so we have two occlusions and in one we even had

in the fifteenth day, because everything had gone into tension and then I said no, I want my

trans-mesocolic anxiety and I want to sleep more peacefully at night. Now we have to

review our anxieties because in the meantime it may seem that we are distracted and therefore before

Before doing anything, I go to the trice and I go to get the fixed anus because, as an old surgeon said, it is better to have 10 cuts and a cut than 10 cuts and a cut.

ah but this is essential because you will surely have to be able to see someone

operated with an answer let's say counter-current then this is the price so if this

I take the other part that goes up, which is not the trice, to avoid wasting time, I identify the part that has to go up with two clips and so if I lose it, I know how to find it.

So, now I'm lifting the mesocolon, the instrument.

But a little...

Even here we have to find...

Here it's more important.

This obese person.

Even if there's more space, but in short...

Give me an adjuvant.

Here it seems absolutely vascular.

Yes, yes.

I think it's what the elephant wrote.

But this is a case of...

Give me a little bit of bipolar.

so you tend to open very very low just at the height of the trail I understood that

it is the part with the least risk of pancreas as the risk is only that here it is

all clear this is the passage at least I think it is open ok then give me the joan and now the

The passage of the lance, which is definitely the one to be mounted, you see, with the two clips, slides, leaves everything and I at this point make a symbolic gesture, very important I think,

instead of continuing the intervention, since the last day of school is the last intervention,

Symbolically, I leave the intervention with the anastomosis to Diego Cucurullo, who is here behind me.

Ah Diego, hello!

He is better than me, like me, but better than me, because from tomorrow he will have the primary functions,

waiting then for the execution of a competition.

So I will be here again, but not connected to the microphone, I will give the microphone to Diego.

I want to thank Rodolfo for the kindness that always distinguishes our relationship, for the competence, of course, of his comments.

Francesco Ruotolo in the room, especially Giorgio Palazzini, who once again managed to achieve great success.

and honor to the merit and congratulations always dear giorgio and to all of you with the hope

precisely the wish to see us in a new reality in a new dress but always with the same affection

ah listen don't go away because we are in two we have to greet you I am clear I thank you for the

words but above all for the surgical intervention we have learned something I do not know what

servirà a me però comunque ho imparato moltissimo e ti passo l'amico che ti vuol salutare e un

braccio a tutti francesco sono giuseppe modi come avevi già identificato un abbraccio effettuoso

sei stato bravissimo e tanti auguri per domani un abbraccio si è giuseppe domani è il primo giorno

di scuola allora il microfono a diego è il primo giorno di scuola non esagerare ma tu hai capito

They make me start school, what do I have to do?

I'm going to finish Diego, from A to Z, and we'll give him the microphone, as it's right to do.

They suggest that you go with the crampon and the bamboo basket with the snack.

Because there, look, the snack there they don't give it to you, I tell you right away.

I'm preparing it, don't worry.

I'll take it from here, don't worry.

portata da lì che sarà più più abbondante più buona comunque tanti cari auguri ben

grande applauso ci accomuna quando diego sai in linea ma ci fai sapere buongiorno rodolfo

yes they are in line hello diego so the wires that we see being manipulated are wires that

come from your hands right perfect then tell us how you will do we are clearly a

regime of formation so we do a lateral lateral I have already made the incision on the wall

wall of fasting that we have to go to anastomize now we go on the

back wall of the stomach we incite longitudinally just to

get the suture in perfect you checked well that the

regional monk has the clip because maybe the teacher

You exchanged it at the last moment.

Yes, yes, we checked it.

Ah, here it is, it's always right to check.

Joke, eh? Game?

No, no, but it's very right this.

It doesn't work.

No, it doesn't work.

Go ahead, how good.

Ok, let's make some space.

Shaper.

60, blue charge.

Now we introduce the shaper, which is a 60 with a gold charge.

We bring Lanza and we enter, we don't have much space on this stomach, on the back wall, there are some vases, let's see if we can get in well.

You are a little limited in the hole.

A little limited.

Not so much, but there is the mucosa that protrudes.

I thought I had it in the chest because I also saw the out-of-body of material.

Yes, yes, sure.

Let's take it a little higher.

The stomach cuff is small, it's not big.

I would like to check that we entered the wall well.

I would like to be sure that I entered the wall well.

I think so, but as you said,

you see we are a little limited in the incision so we have a little bit of

disparity above we have little little space on the vacuum cleaner

we also check the bleeding so if we can put a little bit of bipolar here

Here, for the check-up.

Come in, you.

Still a respirator.

You, what are you doing?

Are you taking a walk?

Come on, come on, please.

Take this card and put it under the liver, please.

It's only the liver.

But not here.

Here.

Here it goes down.

Come in, come in.

Diego, here we talk because being quiet is bad.

But in my opinion, that mucus aplica on top will cause terrible discomfort.

the upper mucosa gives you discomfort. I'm checking the muscles for a moment, I want to see

the muscles first, then we dedicate ourselves to the suture of the... No, no, take care of yourself, you have to work

quietly. They told me that you have become president of some company, is that true? Yes, it's the

ish of italy yes yes I know it with congratulations and congratulations for various reasons

compliments there is not only one to do thank you I want to do the shows well because they are

patients who, if they bleed in the operating room, have to undergo an endoscopy, then there are

coagulations, you have to suffocate a lot, there are sutures, you do very well. Then I have to say

that we have seen gastroscopy and in short there was hypertrophic mucosa and therefore certainly

hyper vascularized especially in the area where there was the

for the corners now I put two points on the corners so that I pull a little lower

bass la la breccia da suturare e quindi c'è una più maggior facilità a fare una sutura lineare

si si è una è una tecnica che franco ci ha fatto vedere più volte che abbiamo immediatamente

sbaglio vero so so so rimasto indietro monaldi ce l'avete robot no non ho capito scusa domando

Almonaldi, do you have the robot? How are you directed in the possible use of assisted robotics for gastric surgery?

We use the robot more or less with a frequency of once a week and here Almonaldi is divided and shared between general surgery, thoracic surgery and urology.

We did a gastrectomy last week, one like this, a subtotal, we use it sometimes for the rectum with the excision of the mesoretum, I am using it in parietal surgery.

I did this morning live an intervention of parietal repair, another point, for a hernia of spigelio and in my opinion on the surgery of the abdominal wall it can have a good indication,

but above all because we have talked about it many times at the congresses the laparoscopy of the

ventral hernia has been quite criticized especially for the fact that we are forced

to put an intraperitoneal prosthesis so we personally as a school but now I believe a

a bit all over the world,

a bit of a step back has been made precisely for this.

And then, if with robotic surgery, and this has been proven,

let's think that today

the robot in the United States

finds as an application in parietal surgery

the largest field of use.

If parietal surgery manages and has proven to be able to do it,

a evitare la protesi intraperitoneale ma consente di eseguire un intervento secondo riv per esempio

con il posizionamento di una protesi retromuscolare o anche addirittura una tar addirittura addirittura

una tar perché ti dicevo che negli stati uniti la chiusura parete il maggior campo di utilizzo

I have not done it yet but the surgeons of the United States and some Europeans are

doing the robotic TAR and then there it is really a great

advantage because the TAR is a resolution intervention in many

surgical situations where we think of the complex abs where we

we cannot rebuild a rear wall because there is a wide diastasis, a wide divarication,

we cannot rebuild it with a RIV, with the TAR we can rebuild the median line, but the TAR in

open, you have to give me another time a wet rag, the TAR in open causes a wide

chipping that in the operating room it manifests itself then with a serosity a serous selection

that gives a production of drains quite long in time and therefore if all this is avoided

and avoided with a robotic tar because there is no chipping under the tail the intervention is

really mini invasive you do not position the drains I talked to some

American surgeons who told me that they are even giving up after 12

hours the patient operated by tar we see that this is a real achievement

I imagine it is very clear thank you thank you

we always talk for the benefit of a comment from the room I heard you asked

this Vajkrill, do you ever use the self-locking? I call it that so as not to give

brand indications but in short the self-locking sutures. Yes, the self-locking

this part here we do it with the Vajkrill at detached points, the self-locking is

certainly a great point, we always use it in the colandesto and we do

Now we will ask the anesthetist to pass the probe.

We will do a first floor with detached points.

Do we have a preference between detached points and continuous points?

Yes, we have a preference between detached points.

We try to put a central point here and then later some lateral points.

then we will put some detention points on the suture in PDS in

Vicryl also and we will test the anastomosis with a test to a

pneumatic drop to the blue of methylene we pass the probe through

lancers so I wait for the anesthetist before tying this point I wait for the

anesthetist goes down with the probe, Damiano Giovanni, you can see through, so he could

aim somewhere, pull, yes, wait a bit, and now you can make it go down, ok, it's fine

like this, portachi, so we put this central point, we put this central point of

and then we do the suture to the right and to the left of the central point.

Very clear.

Let's go over there first, so we bring the central point towards us.

Vicky, leave the gauze there.

Pull this point a moment without doing too much traction towards you.

Perfect. Luigi, your task.

Do you understand?

Yes.

Look.

From above.

I'm seeing there these wires that remain straight, raised, you know, they have a resistance

even there.

They don't fall.

Who knows what material it is?

Let's see for a moment.

The future is there.

The industries will bring you robotics in the future.

They will give you love, for sure.

They send you.

You know that they put a robot that does the anastomosis by itself, in the sense that you

attack these two pieces and it does the same thing, not manipulated by the console.

And then there is a partnership between Google and Johnson & Johnson.

Go on, go on.

You see?

The Unis, Johnson & Johnson, put the abdominal aspect, the gluteus, etc.

And Google, facial recognition.

You know, there are sites...

So they intend to do a facial recognition inside the abdomen,

so the recognition of normal things, compared to normal things...

The two engines, the tacks, the pettines, everything is there, there is no need for anything else.

I don't know what to say, it's very, very...

I don't know what to say, until 1990 my first job was in the 90s, let's say in the 90s.

Then slowly, slowly, in 1991, 1992, it was my first job.

obviously that of steel and at the beginning the part is a little more difficult we hope that then

going a little further in the suture this part of the right is easier because there is better

exposition you have seen that I have given the traction of the central point to the help

now if you take this margin here of the suture just just of the sin guard ok I try to

Maybe with this point I can put another one.

Are you ready for it?

Are you ready?

Come on, these points are needed, you can't wait, we have to close the whole supply chain.

No, what can I say, we have to continue with the supply chain, I know.

In fact, let's see if this is long enough to be able to do one.

Even if we talk about remuneration.

Come on, Portachi.

Come on, Portachi.

Diego, excuse me, I sat down for a moment, I apologize to you.

No, no, no, figure, we went ahead.

Yes, I was doing anastomosis, so this is still the foreground.

This is still the foreground?

Of the detached points, right.

The detached points, the left part, Rodolfo.

Yes, the left part. The right part, have you already done it?

No, I have cut from there, which was the part a little more sketchy, let's say, because it is the most distal.

Sure.

This is a short string, but let's try not to lose it.

Is it a 3-0? Just out of curiosity.

It's a short string because the tuner found himself out of tune, so we're trying to use it.

He did it on purpose to show how good it sounded.

Very good.

Give me the harmonica to cut.

And then, we still have points, we have to close the left side too.

Do you take the liver now?

Ricky, can you lift the liver a little better?

Look, you can lift it like this, look.

Then?

I don't know if you can hear me.

you see that we have put the first point in the corner here pulling a little on that initial point

yes very useful this is short so give me another whole one let's see a moment you who can do

She certainly has one more scar.

Where is your scar?

There should be two scars inside.

Let me see it for a moment.

Here it is.

So we give it here, so it doesn't stick to the liver.

And you have to try to keep it like this.

Come here, so maybe you're more comfortable.

Here, Vicky, for prosthetics.

Okay?

Keep it like this, don't move.

Did you remove the other card?

No, there are two, I think.

Ah, there are two, sure.

Yes, it's here, the other one.

Perfect.

They have a great method to keep track.

They always have five cards

and they sign with tools

how many cards there are inside

and they are very good at not letting anything escape.

It's a nice security, but let's say that in Tuscany they say it's better to be afraid than to look for it.

It's logical, even because then one is focused on doing other things.

Of course.

It can also happen that they are the ones to tell us at the end and we were just completely forgotten about that car.

zina poi dopo allora ti racconto ti racconto fatti reali racconto a chi ci ascolta pure

allora in un sistema di controllo di qualità nel quale in qualche modo sono stato coinvolto

a livello nazionale abbiamo messo in piedi in due in varie asle regionali un sistema di qualità

to the operating room security control etc. and many have been the operating units that have put it

into practice among the many from the many indicators there was the count of the cars and therefore the fear of the

foreign post-operative body well in the period of surveillance with the performance of the

controlli ci sono stati due casi di corpi estranei ritenuti a durante il periodo esatto due casi

lunga con tutti i controlli che erano standardizzati le schede qualcuno c'è rilevatore

posto fa perioperatorio niente sono stati due corpi estranei una garza in ferro aspetta ma

but in my memories I think I have taken away in my life a quantity let's say not secondary

of foreign bodies and someone also from our team unfortunately the most beautiful was a

24 cm clamber that was 12 years old that the lady had in her abdomen and made an absolutely normal life

until, since there was back pain, they told him to make a strip of the spine and it was seen that there was a 23 cm clemmer in the abdomen.

It had given no sign, no problem?

It was incised in the ovent, but it was a Klemmer, the father of a famous surgeon with whom I spoke later.

He remembered that in the technique he used for the preparation of the duodenum, he put the Klemmer as the haemostasis of the six peri-duodenal vessels from the pancreatic part.

and so much is true that when I went to take off the clemmer and out of the hole

and out of the bile for which he was attached to the bile but he had not given signs of himself for 12 years

everything went well the lady entered with the legal doctor in my study the legal doctor was

been convinced for the good of all not to do anything in particular

everything is fine, you know that I beat a lot on the problem of

communication especially in recent years foundation

surgeon and citizen etc. a good communication sometimes is a certain

riconoscimento degli eventuali disturbi perché molti vengono vengono maltrattate comunque un

racconto storico questo succedeva quando poi e succedeva nelle mie prime esperienze a benevento

parlo degli anni 80 quindi si parla di una chirurgia degli anni 60 65 e ha comportato

la la dimenticanza di un ferro ecco quindi parliamo 80 anni fa ecco il primo intervento

che fece la signora lo fece circa 80 anni fa 1960 altro mondo altri tempi altra situazione

chiaramente no eh sì altra chirurgia altre cose allora adesso noi cambiamo questa calzina quindi

now we have only one inside there is also a thread there is a thread with a needle but I would like to

do before putting some other point on it I would like to do the hydropneumatic test so I would

ask the anesthetist to equip himself with this here give a clean case this I would remove

you do it with the dye or with the dye with the blue of methylene diluted diluted yes we put a

pot around so as to see then we put a little physiological solution there on the right

we put an enterost at the valley of the sondino here it is and a little physiological solution

with the vacuum cleaner, let me open the water, let's see, we see both bubbles and blue, we hope

not to see any of the two, however, yes, he put the blue first, now it swells with the air,

okay, let's see that it swells slowly, okay, okay, okay, you can suck it, the test is negative,

this is the blue of the fettuccia that is near the gauze that is cut and so now

we put some discharge points on the anastomosis we do not make a real second layer for a

period we did a second layer in pds a continuous one but we have seen that the anastomosis that

can be tested, it can also be satisfied with the single layer, they are points that I will put

in the trans-mesocolic passage. Yes, of course, to avoid autosuccessions, hernias and so on.

L'hai fatto cortissimo.

L'hai fatto corto, eh?

now give me another one to celebrate

this is the fixation of the lance as we said before yes you can see the internals and then we have to do

the dance foot so bring the two afferent and the afferent close and also make a lateral

laterally then at this point if we can remove a little bit of anti-trending position

instead of giving a little bit of trend in burgundy it could be useful let's take the lake we have another

card inside or no there is no longer anyone okay just like that we do the check of the cards with

with the tuner

all out, now we take the mesocolon

so you go there

we lift the transverse upwards

still a little, lift a little here

yes, this is the passage that

launches the feed, we go to find the

traitz, wait, give me a fork

Maybe we can lower the table even more.

Let's count the 50 cm here, there are 10, 20, 30, 40 and 50 cm, the height is this, let's see

how we find ourselves better, maybe we find ourselves better anisoperistaltic and therefore we will make a suture

like this, so at this point a suture point to keep the two anuses close that we will then give to Vicky,

this point we need to pull a little up because this is an anastomosis discomfort,

It is an uncomfortable anastomosis because ergonomically we have been led to do an over-mesocolic intervention and therefore we are comfortable up to this point.

Then now we are down here and we have the discomfort of having to perform this anastomosis.

No, it's yours.

but putting a point here that gives us a little traction upwards can certainly help us

it is also a bit uncomfortable for the introduction of the sutures of the sutures

sure because the drugs are positioned for other surgery let me remove the

You can also do it like this, look. You can do it like this so that I try to ...

So, now you give me the harmonic, let's adjust ourselves more or less for the length of 6 cm,

even if there will be a part of the anza di giurale that we will never get to the end,

but in any case we try to stay for six centimeters right let me see a little better

closer good don't move you always keep the same attention if while I am

stretching you slow down your position too little this here I don't do the section

where I wanted it where I wanted to do it no the suture and the berestal if it is not her pull me more

more behind than the trocar because otherwise we can not open it, very well, pull me out a little

the trocar please, pull me out a little the trocar please, otherwise it does not open, ok,

Yes, to eliminate more than bleeding, to eliminate the interstitial water, the interstitial liquids.

A check inside and it seems to me that there is no bleeding here.

And we proceed to the suture.

And always keep the same tension.

this is a point that we need more than alignment we need for the traction of the

the back part at the end, a bit like we do when we do the colon d'esso, because by lifting here

we then see perfectly at the end the margin of the V to suture, so this is something that

we can use later. Here too you behave like in the gastro ligula? Yes, here we use the

we use the point, give me another one on top, let's do, Rodolfo, what you said at the beginning of the suture, we did it at the top,

yes, I understand, a self-blocking, this is always Vajra, but let's put only the two points above and below,

the risk of this intracorporeal anastomosis is that of stenotizing it too much, and this is something that is paid for later,

because when this is stenoidized a little the patient also makes a transit and it is good and

good and you can see both the anastomosis, you can see the passage because the gastrogaphy is very

thin, it begins to feed, the anastomosis goes under tension, this foot dance because it is

stenoidized and going under tension we have an adhesion of the gastroenterous anastomosis or

or even worse than the esophagus of Juno, and here it is something to pay the most attention to

not to take too much tissue also because the caliber of these anuses is never a

very satisfactory caliber, the lumen is small and therefore you have to pay attention

pay attention to not stenotize, especially with the second suture, with the first and also with the second suture

because here we will put a PDS above, since it is an anastomosis that we cannot test, we put a PDS as a second layer

This is 23 cm Luigi, maybe here you can give me even 15 cm because the suture is not the best.

So now you take this.

I have...

I have...

Go, bring the person over there.

Perfect, without turning.

Hold the...

There is Giorgio.

Yes, this is Sandrato.

You understood, eh?

A little bit out of focus.

Greetings to Giorgio.

What channel is it?

What channel is it?

The black one.

The black one?

I have another great friend because I love him very much.

Babbo, right?

Congratulations.

See you very soon.

Don't move.

Now let's sit down.

Like this?

If we regulate ourselves in this way, the non-testable anastomosis with trial, we reinforce it with a double-stratum.

I have always been an author of the double stratum, but a monostratum during fasting,

in short, extra-mucous as you are doing I think it is compatible with a good success in short

when in fact to tell you one you have made a passage between the monostratum and the duplicated

stratum or from the very beginning it was duplicated stratum from the very beginning duplicated stratum

but also me sometimes I did the single with this block you know who they are you know very well

there are many colleagues who go ahead single stress single layer in short in general and with

with which we have discussed several times, yes, maybe better, yes, etc.

I have always done double, so I am on the double side,

but many do monostrade.

Here is a personal choice, but I think it is not only a personal choice,

but at least connected to an experience that could not be evidence-based,

but at least a personal experience.

that's why we put a few points then you do what you have to do this is what we had

sutured at the beginning this very useful is one of the cardinal points cardinal to be sure to do

an asthomosis to close the foramen and not leave an angle torn I want to hear you I

I leave it like this, come on. No, no, I don't want responsibility. In my opinion it is a perfect

stoma, then I saw that you took it rigidly extra-mucous, so in short, the distance

between one point and the other is minimal, it will be less than half a centimeter, it is fine.

It seems that he agrees with you, we are in three here. Okay, then I leave it like this.

the point on the passage we have put it

so I wanted to know the stomach is already in bag?

no

then give me a little bit of aspiration first then give me the bag

let's make a mini funnestil to extract the piece

well with such a big piece mini just a funnestil

but it collapses yes yes since we have to use it only to remove the

reperto which are two one is the increase and the other the stomach is detached

increase and as far as I remember yes okay no I arrived later

yes I have seen from the beginning it seems to me that we put in the back

first the omentum and then he prepared the stomach and put the stomach to repair everything

well a big stomach that even if the laparoscopy is gigantic but in short a big stomach the

bag from 15 surely 15 15 is a trocar from 15 and the one from 15 but that enters the

trocar da 10 ah capito dovrebbe essere eccola se ricordavo bene lo facciamo scendere un po

bene ok chiudiamo è tutto dentro sacca questo qui ok dammi da tagliare un po il filo che è

lungo mettiamo i drenaggi e poi insomma drenaggi dimmi subito dove 22 drenaggi ne mettiamo uno

One for the duodenal that also goes on the anastomosis and the other in the dagrass, two.

I understand.

Sondino is there, how many days, two?

We do a check-up on the fourth day, third, fourth day, a transit and then we take everything.

Food?

Food just after the transit, so always on the third, fourth.

I understand.

And the hospital remains here?

If everything goes well, a week.

week perfect so today friday we can do it on tuesday but well we are there on tuesday

from the point of view of the let's say of the various controls there was how you are

systematized in the post of mission you have a system of mission protected you have a

un centro di riferimento oppure così farà solo dei controlli in genere delle problematiche da

dover approfondire con dei esami post operatori facciamo una dimissione protetta una giovanna

facciamo una dimissione protetta nel senso che già richiediamo l'esame da fare un controllo mi

I am referring for example to a TAC control or something else with a

protected admission otherwise we put the patient away and we make her return to

ambulatory control. I understand. We put it back here, but there is the liver that

holds it, then we will put one in the douglas from this other

from this other hole, so we exploit the two accesses, the two trochars, and we

find the bag inside the stomach at the moment, with that small trochar

that is there in the epigastric, the one that kept the liver up, so that then we

push it down and do the funnestill and we find the extraction

Perfect, perfect. Last question. How long do you maintain the drainage regularly?

Regularly until the transit. If we see that the transit is good, we remove the drainage and the patient begins to feed.

perfect that in the douglas the same in contemporary I want to say it is not that one of both is fine

listen I have to leave you so much I think that the extraction is practically finished I thank

those who followed us and thank you for the precise punctuality and the comments from the expert surgeon

quale sei e per l'amicizia rodolfo ti ringrazio di tutto guarda non siamo in quattro a guardarti

perché ci saranno se almeno 700 persone qua dentro in sala ancora adesso a quest'ora stanno

qui da ieri mattina devo dire che giorgio ha fatto ha avuto un'invenzione insieme al professor di

matteo incredibile ti saluto tanto grazie grazie auguri per il futuro grazie saluti

da mori che acqua vicino a saluti anche a lui io devo andare via