F. CORCIONE diverticolite

So again, this is our second case.

It is a female patient of 49 years old with a BMI of 24.3

with a past medical history of bronchial asthma

and a past surgical history of appendectomy.

In 2016, the patient presented with her first episode of acute diverticulitis,

which was with acute abdominal pain, fever, and bowel dysfunction.

function. And the following presented with blood in their stool, and for this reason,

she performed a colonoscopy, which showed unescavated lesions at nine centimeters from

the anal verge. Biopsies were taken on these lesions, and pathology showed a moderately

differentiated adenocarcinoma. She also performed a CT scan, which was negative for a secondary

their lesion. Patients underwent neoadjuvant chemoradiotherapy until October 2018, and her

most recent workup was an MRI performed three weeks ago, which still showed a thickening of

the right wall of the rectum and with a narrowing of the rectal lumen and some micronodules in the

pre-sacral space therefore the patient is now scheduled for a 3d laparoscopic low anterior

resection of the rectum

Hello, can you hear me?

or with the resonance.

Obviously, if it's not 10-12 cm...

Well, obviously...

Well, okay.

With such a long finger...

In my opinion, it's fundamental

because today there are different strategies

and many times the endoscopist

doesn't give the right...

Yes, he doesn't give the right...

and we are more and more for a transanal approach when the tumor is very low and therefore the exact

in anesthesia the exact distance from the anal margin and you can really evaluate it in

gynecological position in anesthesia allows you to make the initial choice whether to go all the way to the

the periscope or do a mixed route transanal and the periscope but this 10 cm we have not done it

transanal when you do it the t.a.t.m.i. t.a.t.m.i. that is the perineal time

We almost always do the Tata, but there is an indication of an ultra-low anastomosis of the colon.

Yes, which is not the TATME, because that should be done exclusively, at least in a narrow sense, through endoluminal via.

but if we read the literature it is one thing if then we feel the experiences of the surgeons

is another thing for the exactly you are perfectly right they are the fashions we have

the surgeons we live in fashion well fortunately you have overcome this phase for almost 30 years

And I have the school of priests.

You set the fashion.

Maybe, maybe.

Okay, sorry for the interruption, I'll pass to the linguists, to the purists.

I'll follow you anyway, ciao.

Hello, we're all here.

Francesco?

Yes, it's always me.

okay so we start with the last colorectal operation today I decided to give you all the

all the kind of the laparoscopic procedure and this is the last one this is the

did you hear the presentation yes it's a rectal cancer at nine centimeters I understand

Now, as you can see, we have this embryological attachment and we have to perform the adhesiolysis

in order to recognize the anatomy and realize this left colon that is attached to the right

colon.

It is an embryological attachment.

and second because sometimes it's better to put the staple very very closer to the rectal section

and to do this it's better to have a sobrepublic trough so i immobilize the trice ligament and

this is mandatory in this case because we did not see the mesenteric vein now it's clear look

Look, my goal now is to identify the anatomy that is not clear in these embryological adherences

and with these adhesiolysis and with the mobilization of the trites.

Look, look at the vein, it is completely covered by these adherences, embryological adherences

and now the bowel is coming out.

out and I am able now to identify the anatomy and to start as before with the

looking for the right plane, right layer between the gelato. There is

something here, I don't know what it is exactly, it's very strange, lymphatic

The mesenteric vein?

The mesenteric vein was lifted up, and in transparency I think we saw almost the vessels behind.

Okay, now look how is the bowel attached to the left mesocolon. Incredible, eh?

Okay, now it's enough to start our operation.

As usual I go down the way, it's very clear now the layer between, the section between

the gerota and toe, look, always the same, the right, the left, always the same concept,

And we have to join this dissection with the previous one,

looking for the artery that is between these two layers.

Look, we are happy.

There are some nodes here.

And as before, the best way to clip the artery is to go around the artery

with the dissection of the lymphatic tissue.

posteriorly the artery.

The lymphatic tissue is always behind the artery and here there are the nerves, the

parasympathetic plexus.

So I ask the clip.

One clip is enough if you use ultrasound.

As before, exactly as before, always the same.

And now the secret to performing the right nerve sparing technique is to leave in place

the nerve to go very, very close to the distal part of the artery to lift and to go to dissect

very, very close the posterior part of the artery, leaving in place all the nerves that

are here.

In this way, you are able to join the previous basenteric vein with the layer of the artery.

In any case, we have around the artery a small space where we have not the genital fascia.

I will show you.

but in this way it's easy to go to protect the retroperitoneal structure

with all the the gerota look look the artery coming from the aorta from the

space here we have no the gerota so it's important that we leave a very very

small part of this space without the

Gerota and then we're all around

Gerota's version yes and now always with

the traction and the contra-traction I go

medially laterally up down to mobilize

as I can okay now the last step is to

for the result okay now we go to the

the mesenteric vein. We can see the vein, the renal vein. Yes, you are right.

And let's display. Is that a left colic vein that we see? There's a branch there.

But this is the... This is the IMV that you are isolating.

And there's a branch up there. In this case, there is another artery.

Okay, now I lift the mesocolon with my left hand, and I try to identify the right dissection

between mesocolon that go up and the pancreas, then slide down.

This is a lateral approach, under control, under visual control, with less risk to injure

the pancreas with the less risk to injury the mesocolon and now i try to reach the lesser

sac from down that we opened already before okay i reach the lesser sac okay and the posterior

gastric wall is there and now as usual i put my sponge under the inferior tail of the pancreas

and all in this moment I go laterally to dissect the left colon of course this

lateral dissection is easy if you were prepared at the posterior layer as in

this case look I go very fast

It's a great video, isn't it?

I've linked it all up in the description.

So, there's...

Yes, yes.

Ok, so, well, we have to go in.

There's...

What?

This is my phone.

Let's say hello to this.

Professor Corcione?

good morning good morning and who can be this as it is all right all right

wait for a moment in a shadowy area with a radiator here I am how it goes

Prof, can you hear me?

Can you hear me?

Yes, Prof, I can hear you.

How is the situation?

Everything is fine, Prof, as usual.

More and more, 24 codec.

Do you want it in English?

No, I want it in English.

Full room, full room, Prof.

There are no interlocutors?

No, no, Corsione.

There are no interlocutors?

Corsione in English.

Prof, I'll find a commentator.

Corsione in English.

Mr. Corcione, excuse me, I haven't heard you for a moment.

Here I am.

I had told you before, anyway.

I'm not aware.

Corcione in English.

No, no, they're here.

We're going from one table to the other for the organization.

Ah, stay close.

So what do I have to do?

Speak in English or speak in Italian?

Yes, no, in English, okay, bro.

Ah, English.

Yes.

Yes.

Go on, go on, go on.

Whatever.

Go on, go on.

I'm free to comment.

Yes.

Yes.

The splenic flexion, the concept is the same, we have to identify the tail of the pancreas

and in this way, always with the medial lateral approach, we go to dissect the mesocolon from the pancreas.

We perform the same step of the oncological dissection.

The difference with the oncological dissection is far.

We don't touch, we don't dissect the mesenteric artery in order to avoid the functional complication,

postoperative complication.

We open the vessel sac.

Hi Franco, I'm Fernando Prete.

I speak all foreign languages except English, as you know.

That is the most difficult foreign language to learn.

Listen, Franco, I wanted to tell you something.

An access to the retrocavity above 2 cm of the vein has been described.

2 cm above and laterally to the left of the lower mesenteric vein.

inferior point of access while you go more laterally you discover the tail body

of the pancreas and laterally you find this access in this case I left

I left a lump of renal in order to avoid having lesions of that branch that you can see here

for the left flexion

and so I was forced to change attitude compared to what I showed you before

because before we did the classic mobilization

here

This is a little different, I'll let it be said, and so I'm happy also because being a non-oncological patient I don't really want to take any risks, as unfortunately I have had in my experience, of devascularization of the descendant,

and also because if we preserve them as they are and then we link them to the left wing,

unfortunately we would risk the same thing.

You have a deficit of charge.

The use of endocyanin convinces you, but then you do it by choosing the case,

not, let's say, by principle.

I said before that unfortunately we still have difficulty in supplying ourselves with the green, it seems strange, it seems that it is not done in Italy, but abroad, every time the pharmacy does it for us, so when they give us these 10 drops, obviously we try not to waste them and to do them at the demand, where there is a minimum of doubt.

and the renal insufficiency consider it an absolute contraindication an increase

of creatinine

generally not if it were to be a really important pre-dialytic insufficiency

maybe yes you don't have to have scruples

You can see that it can also be the anesthesia that determines it, but in some cases it is really the anesthesia.

All right. Thank you and I leave you with your favorite language, which is not Neapolitan.

After this session, as you have seen, I put the sponge on the surface of the pancreas

And now I change like the first operation my wrist went, now it's coming from the lateral

side.

And I go around the spraining fracture, like before, it's easier than the first case, because

we have not a very high spraining fracture.

And now we go to the spine, under the pancreas, up the pancreas, ok.

Always, even in this case, the epithelium should be always in the same place.

And we go around the splenic flexion.

There are some attachments with the stomach.

Yes, you can see very well the preparation, sir.

Okay.

Right?

It's powerful, the instrument.

Okay. I touch the sponge with my hand.

And now, I finish this section.

I leave in place now the mesenteric vein.

it's enough because we

I think it's mandatory to have a good tension for anastomosis, even in the section from

the lung as it was not completely like before for our technique. And now we go to Rendelenburg,

in our space, to some inflammatory adenomyosis.

Professor Corcione, Francesco Prete from Bari.

Yes.

And it's really remarkable that between the first operation and this operation,

the difference between the splenic flasher before and now is just that before it looked longer.

But with your approach, it didn't look that difficult.

Because once you place the little sponge over the pancreas, that's your landmark.

And I find it very easy to land laterally on your sponge.

So you don't have to see the spleen or mobilize the spleen or pull on the spleen.

You just follow your plan.

You land on the sponge, and that's the end of the fracture.

And it was very easy for me to understand and learn this procedure by your way

because you pull the splenic fracture down like it happens in open surgery,

and this is a very easy approach.

Thank you so much for your comment.

So I would like to show you the inflammatory disease. There is a small bleeding from the

reticular here. It's very rare to see this. We have a big mass of dendritum crease and we have to

dissect now, first laterally. Look the inflammatory disease is there. Always

is a blunt dissection is better even if you have a little bit of bleeding from the small vessels

but you are able to identify here the right dissection i think that in this patient

you decide at the right moment to perform this operation because we have some inflammatory

but it's easy to dissect the retroperitoneal structure.

And we try to not mobilize completely.

Very good picture.

Francesco?

Yes, it's a very clear picture.

Where are you?

We're sitting in the front row.

It's full of people here.

So this is a very big inflammatory mass.

We can see the diverticular necrosis there, hemorrhagic necrosis.

Now, in order to preserve the vessels, it's very important not to go very closer to the artery,

but to go very closer to the colon.

Starting from the previous dissection, the gastric artery, the mesenteric artery is there.

So you go on the left colic above the inferior mesenteric.

left colic artery. There is one branch that comes from the colic artery.

In this operation, the ultrasound device is mandatory to use, or bipolar, or...

We found our space over the section.

I take advantage from this layer to go closer...

to the colon.

Are you ready? Simone! Simone, come here for a minute.

Answer me!

Professor!

Very, very closer to the colon.

We give a look from the lateral part of the colon.

And in order to avoid any kind of functional complication,

instead we do the skeletalization of the mesenteric artery,

as we did before, and perform the skeletalization of the colon.

It's not a very, very elegant operation, I don't like this operation, please tell us.

But I remember always the message of my friend Bill Hill, who is the president of an older

Colorado course in Slesbury, and the first time that I performed this operation I said

the same i am not happy it's not elegant sorry busy close your eyes and answer don't worry

francesco it's not very pretty operation but it's the best that you can do for your patient so i

repeat the same message the food is not elegant i prefer the previous previous technique that i

show you for the left hemicolectomy for cancer but as you can see

more interesting for the functional post-operative results

so you are preserving the left colic and all of its branches yes to do this until

to preserve also the mesenteric branch when they arrive in the mesocolon space, between

the gerot and mesorectum, and look, I go into the meso, I don't see very well where are

the branch sigmoid artery, look, I can have some breathing, bipolar, and we are very happy

for the functional results but look this is the demonstration that we can have in surgery

impossible to have anything it's like the wife you are to choose something we have a lot of

notes inflammatory notes and this is the reason that in future we had in the first part of our

you have the dissemination of the some potential infection agent this is the

reason that starting from this experience we prepare this patient with

antibiotics for from for seven days before the operation and we use a lot

this kind of a complication. Look, this is the node that I dissected.

Inflammatory nodes.

I am very far from the artery. I try to be very close to it because it's very easy to go down

and at the end of the operation to go to the, to injury the mesenteric artery that is very close

If you are at the end of the operation, you decide to take down the spaceman, sometimes

it's more difficult.

Okay.

Do you agree?

Yeah, definitely.

Very, very close to the bowel, I insist that it's not the best surgery in my life.

I am happy only because finally I identify all the steps to standardize this technique.

It is more difficult than the oncological resection, of course.

It is longer.

It is better for the patient.

Now I identify the branch of the sigmoid vessels.

In the past, I made some mistakes because I started very well, but I went in this plane

and at the end, I finished the operation with the section of the two branches of the mesenteric

artery in the mesocolon, so this operation was useless and starting from this experience,

I learned that it's more difficult, sure, for sure, very close to the colon, with this

skeletalization.

Look, very, very close.

See?

Another problem that we have with this operation, so two different kind of complication in rapport

with the left hemicolectomy for cancer.

The first I described is the post-operative peritonitis.

And the second one, it's clear, we have more bleeding coming from the anastomosis.

Yes.

How do you control that bleeding?

Do you always do an endoscopy?

To avoid the post-operative bleeding, we prefer to perform per-operative endoscopy.

Yes.

And sometimes the endoscopist is able to put a clip or other kind of device to a good haemostasis.

Even in post-operative stay, we can have intraluminal bleeding.

And for this, we have always the help of endoscopists.

Ave Maria because I don't know if it's a good way to perform to put some

stitches along the anastomosis or to do another anastomosis when we go down we

We are very, very close to the bowel, and we touch the mesorectum from the upper.

In this way, we don't touch all the nerves of the mesorectum.

I finish my dissection here.

I can see that you have a very good vision, and is retraction very important at this stage?

Yes.

Yes.

We are hearing only.

No, we are not seeing.

We are not seeing.

The skeletalization of the colon.

And I have a question.

What if you find that you have diverticula on the proximal stump?

It's impossible.

What kind of anastomosis?

Yes.

When we take out the specimen,

we decide where is exactly the point of the section with the anastomosis.

And if you have some big diverticula, we perform the lateral side, the side terminal anastomosis.

There are lots of people here around me saying yes while you say this.

All agree?

Thank you to everybody.

Look, I don't touch the mesorectum, and now I finish.

Okay.

Very clear.

Now I take my stapler.

As before, it's 45, look at it.

Ok, 45.

I try to put it perpendicularly.

But now I come back to the 45, even for the colon and for the rectum.

That's nice.

Francesco.

Yes, Prof.

And I prepare for the colorectal surgery right in the colon after rectal cancer.

all kind of laparoscopic procedures.

You're a full rainbow of colonic procedures today.

This day with the Dunbar syndrome.

Oh, wow.

If we have the time.

Try the quants.

Okay, okay, any time.

Okay, now we take the reclass.

You see very well the ischemia of the colon.

Yes, it's well demarcated now.

With this technique it's more easy to identify the vascular ischemia,

so it's useless to perform the look, the difference, the color.

Yes, it's a clear demarcation, so you know where to cut now.

Try to, yes, I finish my distinction this way.

And it's very important when we take out the specimen to be very, very gentle, very kind,

and safe traction, because we did not perform.

And we have a very small vessel around the pancreas.

The artery that you preserved.

Okay.

Giovanni?

We are ready.

It's fantastic to see this.

It's very clear.

Okay, go.

The soufflate, history.

Okay.

The editor in Delembourg.

Duce di Sala.

It's very beautiful.

It's very beautiful.

Do you have the exterior view?

Yes.

The exterior view.

Right.

Stefano.

Yes.

To check if there are some questions coming from...

our friends that can ask for our computer, no?

We see it very clearly.

but it's enough yes

In this operation, in my experience, it was the most difficult to stand up, to lean, and to teach.

We can see that the sequence is very clear.

I will prepare the plane, then the flexure, then the vessels.

What is the size of circular stapler that you are going to choose for this one?

29.

even if you do

side to end lateral anastomosis

yes that's a

but if you

perform a lateral anastomosis

do you always choose the 29

same size

Yes, always 29.

Okay.

There is a little bit bleeding from the bipolar.

Sometimes it's difficult to put this 99 because of the size of the colon.

And in that case, we have to be patient before.

Yeah.

Sometimes on the side of the anastomosis we find other diverticula and we decide to put

inside of the anastomosis.

You see here that we have a lot of vessels.

It's very nice.

Close to it.

You can see it on the screen now.

head in the way

thank you

we need a very strong

so you can keep your strategy for the same anastomosis

Because it's better if you don't have any kind of diverticulum around the line of the

shape.

Okay.

Right?

Even if you have some small diverticulum around the column, of course.

Yes.

yes he's in the room and they're saying yes to to the second maneuver so people agree that they

They would save the anastomosis by including the second averticula.

It looks very clean.

It's very clean.

Clean the scope, please.

Okay.

Clean the scope.

Okay.

Join me.

got the image outside now not yet there is no laparoscopic image now still in darkness

This complication is to see the stopper coming, yes, go, and to identify the line of, okay,

the line of the, stop, stop, yeah, oh, right, of a section.

We can see it clearly now.

But in the first part of my experience, one of the first 50 cases, I had one of these

I was happy when I leaned by Gilead and heard the saints.

Everything happened to the sergeant.

Perfect.

Starting from this experience, it's mandatory for a woman to see exactly the step coming from the line.

Right in the middle now.

Now I can see.

I would like to see the right position of the tenor.

Okay.

Right.

Check.

Check, check, check, check, check.

Up and down.

Yes, it's well in place, it's right there, it's well clear, and we can see pulsating

actually.

You're an endoscopist.

Surgeon, proctologist, endoscopist, businessman.

Multi-talent.

With a rigid endoscopy, of course.

Of course.

Nothing.

Okay.

Thank you so much.

We finish our operation.

Thank you.

This is a beautiful demonstration.

Thank you.

Thank you, Francesco.

So now they are preparing the third case, right hemicolectomy for cancer, or the second.

And I think I need five minutes to have a coffee, a break.

Okay, I'm going to talk as before.

Thank you. In five minutes we...

Thank you, Professor. We'll be waiting for that.