C.R. FINLEY

to be seeing the inside view now why didn't you give it to security that's what they should do

you can't see okay let's okay hope you're on oh it's got a little high it'll hurt you

okay i just skip it then come on in please for a second no not right now we'll do it a little

bit later dominique you're on excuse me one second let me get my stuff out here

Let me have a grasper.

Let's go way up high and just check the fundus and see what it looks like.

Make sure this high little hernia is going to reduce.

It is.

Come on up here close, please, right up here.

Stay down.

Don't hit anything.

Let's take the fundus down.

No spleen.

So hold that up.

Have we had our reverse and back up?

A little bit.

That's good.

That will do it.

But so from yesterday, the only case I'm particularly worried about is the redo fundo

because she's tachycardic all night, white count of 19,000.

So we'll see.

So she's getting a swallow, yeah.

We don't routinely do that anymore on redos.

All right, let's come down, come down, down, down.

Let's find the pylorus back up.

Keep coming.

Pylorus should be there.

So this is where I want to start.

you know I agree with what Guyton says you know because we've done this a long

time first priority is just do the case and forget anybody's watching you know

from yesterday earlier in the day went bad yeah good hope just thank you y'all

again like 3,000 Romans or Italians watching you it's a huge meeting really

are about 3,000 people watching no no it's their meeting it's one of their

conferences and we've done it for for many years it's fun they're always kind

enough to invite us back didn't realize how big a meeting it was till one year I

i asked him i was shocked yeah so at that point so mccurden was here i said uh he's gonna come

here you haven't met him have you okay so look up a little bit right here there's a band here i want

to see what that is anyway he did the first lap coley in the united states he's coming he's moseying

in now anyway um so when i found out how many people were watching i said oh barry i talked

to your ex-wife the other day she is so sweet that set off a tirade i don't think he has to

pay her anymore now that he's all getting older so i may have to open up medially to close this

hiatal hernia is all once we get up high so we just take the greater momentum off the greater

curvature of the stomach i do not so you got two more weekends for turkey season ken i think i've

I've about given Sam all the opportunity.

No, you just don't go.

Right.

Dominique, let me go back here.

Let me see.

Oh, yeah, we're good.

Because the way I do this, I'm going to start right here.

So we're good.

We can just keep marching up the stomach.

You shot that little fellow's turkey right out from under him.

A little bit closer, just a touch.

God, Dominique, I'm sorry.

Just pardon me if I used the wrong name.

The default is Lucy.

All right, so let's see.

You know, we should, I would think, encounter some adhesions shortly from the splenectomy.

Hey, look up.

Just the hair up.

There you go.

Good.

You got the suction.

I'm going to close that.

For some reason, we're not getting back to 15.

Y'all go ahead and hook up another ed supply.

I don't know.

This thing's got a boogeyman in it or something.

We've just lost our space.

Okay, a little bit closer, please, Dominique.

so it looks like we're getting to where they did the splenectomy all right let's see what's

what back here watch that big vessel there please come in please a little bit and look up

so i need to look over the okay let me help you with this please there you go clean this please

here. So let's take our time on this until we know what's this. So I'm seeing either

accessory spleen or big vessel there. So I want to pull this down here. Okay, what do

we got here? Scar. I don't see the bleeder, Kira. There it is. What do we got? That should

be okay there. I thought I had a bleeder a little bit here. I've got to readjust my pedal.

chest here this part will you have the log 45 degree scope in here please same

Hey, you're sassy.

She goes, hey.

All right, so let's see where we're bound down up here.

Right down here in this hole.

Good, Dominique.

Look up a little bit, just keep that centered right there.

Be careful back here, please.

We do not know where the splenic vein is, all right?

And I said there must be some in there.

Let me take some of that stuff over there.

there I need to get hello Dr. Finlay can you hear me yes sir good morning

professor hi good morning I'm so sorry we have some problem to be connected

with you now the the image is very good and I can hear hear you very well so can

you explain Hans to us something about the patient in the case yes this is a 63

old woman with a body mass index of 37 with comorbid conditions she the only

other interesting thing with her she had had an open splenectomy about 20 years

ago for ITP and she desired sleeve gastrectomy and amazingly she's had very

little in the way of adhesions this is really the only adhesions we've seen as

where they took the short gastric previously the only additional thing we

found was she does have a hiatal hernia but so we're doing sleeve gastrectomy

dr. McKernan just got here he's here big dog is here but there it was amazing I

I mean, the incision, she didn't have any adhesions.

The only adhesions, we found her up here.

So we'll let him get dressed.

So you pulled an anise this morning.

Was there a rollover?

That's the way I look at it.

I'm not sure.

I guess Dr. Palazzini.

So back up and show Barry the incision.

I mean, it's amazing.

We could see this.

She didn't have it.

Look, not a single adhesion.

The only thing we've got here is a little bit up here where they took the short gastrics.

So we've just sort of slowed down here.

Got to figure out what's what here.

All right, call it in.

Let's see.

Let me get the harmonic.

She's got a high little hernia, too.

I'm just going to come right in here.

Go ahead and close, please.

Okay, let me see about.

What's that?

that. Make sure that's not stomach. I think that's just scar tissue. If I stay over here,

I should be okay. Well, yesterday was a long day. First case was converting a VBG to a

bypass, which was hard. Second was a redo funda, and she's the one I'm most worried

about. Okay, that's good. She's got a pulse of 125 or 128 all night. She's got a swallow.

okay let me regroup yeah we got to have that that's on the greater curve side isn't it

but the um bbg i had to get down below the silastic thing it was just a joke i got this

side over here i don't know how much of this i really need where splenic vein is and all this

crap probably nowhere here thank you for helping i got a big vessel i just saw back there but i had

You know the fellow, the Indian guy?

What's that?

He helped me yesterday.

He was actually pretty good.

He's, you know, the guy that, yeah, I think I saw a big vessel back here.

So I want to, yeah, clean up, please.

I got a big vessel I got to get back there.

He's a nice guy.

He's very nice.

And he's good, too.

Is he, to be where he's going?

He said he's going to have to do a little bit of trauma, like two nights.

and he was actually okay with two days old muck or something of course that's what they tell him

you never know once you get there all right let's slow down up here and get this vessel

okay we've got a little bleeder there you forgot it was an old maid

right there now let me see what that is there that was probably what was up in the chest

Yes, that might be stomach there.

That is, that's stomach.

We better not take that.

All right, this stuff right here.

Right here.

All right, let me see what we got.

Okay, so that reduced.

Nice, that's good.

Did that come back here?

All right, we'll get it.

Let me get that big vessel anyway.

We're here?

All right, let's go over here.

So I'm probably going to have to close this hiatus.

So I'll go ahead and open that gastropathic ligament here.

hang on I got this side over here Barry let me see yeah I'm gonna make a window

and then bipolar that well there it is right there

ah bipolar that vessel I think I have to close this cruise yeah that's one thing

that stuff there i don't think so or do we need to close it that's a question i don't know that

we do wouldn't it up in the chair yeah but let me see does it matter though i don't think it matters

i'm not going to create let me have the stomach back over here i may not even fool with it because

once i get rid of the part that's in the chest no we don't need to do anything to that okay let's

come down here. You got a, what do we use

on this? Is it green? What do we

use? Green? Yeah.

Do I have that? There's nothing in the stomach

is there Bubba? It's right over

here. I don't go as low as you do.

I start right about here.

Basically I'm ready to go.

So I think the operation

key to it is up high anyway.

Yeah it is.

Alrighty then.

You know Robert Guyton was in the dressing

room. He ran into Drew

who's doing the

The Robert Guyton ran into Drew, who's doing the, he's doing our technical support today.

He said a lot of the, most of the cardiac guys have stopped doing telesurgery.

I guess at Cleveland Clinic, they had one where things kind of went all balled up.

And I think people are paying more attention to the telesurgery than they were to actually doing the surgery.

Yeah, get that 38 French bougie green, please.

We've been doing it a lot longer now.

See, they now have the ability to do it with the robotics, so I don't know if they can

transmit the picture now, which we always have been able to do that.

Dr. Finley.

Yes, sir.

Good morning.

Do you never put any kind of probe inside the stomach?

We are doing that right now, actually.

That's what I'm going to do is occlude the stomach, and he's going to pass a 38 French

bougie now.

now. We're ready for that bougie. I always take just one bite, but I'm real careful right

here because this is where we've seen the stomach kink with sleeve gastrectomy. In my

opinion, we get the most durability from this operation is if we keep it narrow up at the

fundus.

Okay, thank you. I'm sorry, but sometimes I lose your voice, so it's difficult for me

to understand what I'm saying.

Sorry, so we are going to pass a number 38 French bougie.

That will be our guide or gauge.

Okay, now it's clear.

Oh, great.

And so one of the issues I was discussing was at the angularis,

we're very careful here because we've seen a couple that kink.

So I don't try to get too very careful with this bite here.

Yeah.

but he's the anesthesiologist is um passing the bougie dilator now i think it'll be what's the

other color it'll be that after this probably okay here comes the bougie yeah can you make it turn

right we can see very well now just a little bit right now push did it make the turn this is always

the most hardest part of this operation I think I don't think it is I've got it

occluded it can't be there you go show it to us Karen okay good perfect so this

is the bite that frightens me the most about getting a kink back up Karen I

can't see the notch here okay now let's look at the backside please and verify

that we've got we do have a bougie there we got plenty of room so the other thing

I try not to get it so tight because I could always tighten it with the

imbrication sutures but I can't make it bigger sorry do you have any kind of

experience in one part procedure one part is leaving a stack to me we still

think that's strictly a cosmesis situation and medical legally in our

our country, I don't know, I can't remember how Italy was, but over here, it's led to

a few lawsuits when they'd have complications, and nobody will defend somebody that does

a one-port, especially, for example, on somebody who's more than obesity. I mean,

A piece is a joke. People are doing it there

Frankly, oh, yeah, I agree with you now. Let's check the backside, please

That looks good because I can tighten that if I need to ever cases imprecation sutures and I still have a bougie. Yep

That's good

That's pretty thick

Michelle I wonder I might want to use a green

Quite frankly, the results are not the same, contrary to many people saying the results are not as good in our hands as the stapling.

But I can certainly understand in some of the countries where staplers are too expensive, India, South America, and this area,

The imbrication, just from a cost point of view, will probably get some more attention.

And do you use always a green card?

Green or blue.

And then we both over-sow the entire staple line.

We imbricate it.

For sure to prevent leaks, you've got to over-sow the superior funding portions.

Everybody's had leaks.

whether you need to

imbricate the whole thing or not

is really

kind of what everybody's wondering

I've been doing this for a long time

but we just to be on the safe

side have not had leaks

since we started imbricating

and prior to that we'd have a

oh I don't know 10 or 20%

leak

I don't think it was that high

so that's okay on the back side

okay green please

oh but we didn't have

I mean, I had one leak, so just to be on the safe side, we imbricated it.

Plus, it also makes it even tighter, of course, when you do that.

So you use a number 34 French bougie, is that correct?

Yeah.

And I use a 38, but imbricate it quite a bit.

See, that's too big on the back side probably, but I think it's okay.

I could imbricate that.

Yeah, let me get this thing here, please.

Yeah, uh-huh.

Probably gonna use green all the way

because of the splenectomy, it was a little bit thick.

Usually we'll go to blue here,

but she had a splenectomy, she had part in it in the chest.

We think it was thickened,

and we're gonna impregnate it anyway,

so we'll just probably in this case use green

because it appears to be thicker

than what we normally run into.

Well, let's make sure, let's take that.

Okay, I can understand.

Bougie is there. Let's look at the back side.

You're fine.

Looks good.

Okay, let's cut.

Alright.

Same reason.

I guess they thought they were filming the wrong people, probably.

So, how's that look to you, Barry?

let's look at the back side yeah we can ever take this did you never have any

kind of bleeding complication the staple line also inside the storm which no not

That we've never had.

Now, we're using the duet, which has got the,

if you can see on the stapler right there, is a pledget system.

But we never, before we even went to this, we never had any bleeding.

We went to duet for leak problems,

but we also started imbricating at the same time,

so we don't know which it was.

I'm pulling very hard.

Yeah, I got you.

that should be okay okay long stitch please i'll cut that hang on

let's see about the staple line i need to cut that i'll stop the bleeding a little bit less

let me come out a little bit more actually i get it i think if i didn't cut it we've ever

made damn sure yeah that might have gotten a little well we've got two staples but we might

make for damn sure. Let me stop this little bit of oozing here. Right here. This is bipolar current.

I think you probably can use monopolar. We just like bipolar. Yeah, I generally prefer bipolar.

So let's make for damn sure we guys. I think I took one of the rows of staples

away with that scissors. Let me give it where you see it. Back up here. I've got the sutures

Okay, never mind.

Ah, come here, boy.

Okay, let's go to the very top of the staple line.

You know what I mean.

It's right here.

I'll get you pulled back.

I don't see it, Barry.

Right there.

Okay.

Mm-hmm.

Right there.

This is where the leaks occurred.

We had a never biopsy.

Back up, please.

Put that here, Denise.

Scissors.

I got them.

Good, good.

Denise, back up, please.

all that this morning thanks for helping me Barry

let's be mindful of where that thing was or we cut out some of the staple let us

come back this way very little bit yeah that's what yeah I like the way you do

that though we haven't been doing that the way you just rolled it for the

backside some reason we are like that oh yeah I know but I think we should have

had you in here for some reason. Hang on a second. I must be sure a staple. There it went. Or it has a knot in it. Oh, come on, Rick. Take on a second to these. I'm afraid there's a knot in this. Go ahead and cut that. Okay. Okay. You know the one that I told you that I did and she just couldn't swallow at all? Yeah. She ended up getting okay. I thought so. So I wonder if anybody in Italy is using the, what they're doing with the

robot general surgery yeah that's an interesting question dr. Finley just

asked I've hit you Barry is this where the yeah that's it anybody in Italy

using the robot in in more than I and Milan and Rome we have some hospitals

generally University of hospitals where they they perform too many procedure

with the robots. Also today we saw from Modena some

procedure in a sleeve and a nissen performed by robots.

What did he say, sleeve and nissen?

It's way too, to me the robot is way too slow.

Although the thing I've thought about is using it to

over-sew the staple line because this takes about 40

minutes to over-sew this entire staple line. The

The robot's definitely made for suturing.

To me, it's a joke.

Just go ahead.

I agree with you.

Yeah, okay.

It's showboating.

I can really understand which is the main reason to perform some procedure with the robots,

but thinking about how expensive it is.

Oh, yeah.

I mean, it was, you know, initially it was devised for the military,

And I can see possibly some use, but the irony to me is still one of the biggest problems is entry.

And who's going to put the troll cars in on the battlefield?

It's funny to me.

Maybe in space one day it'll be worth something.

Now, don't be a naysayer.

And for our country, what it's really good for is marketing.

Well, prostatectomy, though, no question.

The problem with urology is, and it's strange to me, they never learned to use a laparoscope.

And I thought it was strange because they had such a long time with the cystoscope.

And I actually did a year of urology when I was a resident,

and I never could understand why they were so reluctant to get involved with it.

Waste of money.

Perhaps the best thing is the second step.

Robot is the second step.

The first one is laparoscopy, normal procedure.

And after the experience, we can think what we can do with the robot.

But perhaps it's better in the USA because here in Italy we don't have too much money.

Well, the problem with America is that they argue over an antibiotic.

The cost of an antibiotic, which is nickels and dimes, and the robot to turn the thing on is $1,000.

It's a joke. It's a total waste.

We have a soapbox now.

I mean, really, that's a total waste.

I've got a real good friend of mine that his best friend had robotic prostatectomy

and it recurred of course. Yeah. Well it depends on who's doing it, but you got to have the right

person doing it. See the problem with prostate is you're going to do a nerve sparing operation,

okay which is in itself against you know everything we were taught about cancer

and 50% are outside the capsule microscopically after they get the

specimen back so they can't even stage him appropriately I thought Grant was

gonna have a stroke when you said morsel ate all these tubers because it you got

wait a minute wait a minute they think i mean homogenized marshallation would be like cutting

it in big pieces rick 10 millimeter diameter corks and it's doable right now it's not going

to change a thing whenever you're running out of long suture i think we've got a short suture

and grant was i guarantee you grant opposed lat kola i guarantee you he did because i ran to him

this morning he got off of his soapbox about it yeah i said tell me about radical mastectomy well

that was a double-blind study i said grant no that wasn't it what it was is crowd started lumpectomy

or you'd have never done a double-blind study so you're great or getting into it now oh yeah

i mean i think great is stuck in the mud i tried to tell him that you know we all have

CT training. Oh no, that's already over. It's not over. You got cardiologists doing

damn iliac arteries. It's ridiculous. General surgeon's attitudes are still

dinosaur in the academic community. It's a joke. So Karen, if you would observe how

Dr. McKernan is holding that for me so that you can help me on the next one

what's that that's what i've been saying all these years

i got a shirt like you got

so y'all you and grant were going at it this morning yeah i was in there once again talking

about and breath that you know they changed day to day rick i can't remember where was he

He was in the dressing room, in the lounge.

He was on the show about a year.

See, I remember, you're too young, but you did never know who Cryer was, did you?

I knew the name, but I didn't know.

He's the one that started the lumpectomy.

Rick, in the college meeting, people would stand up in the audience from the academic community.

He was academic, and they would, you can't imagine what they would do to him.

He was right.

See, y'all didn't come to blows, did you?

No, I just give it back to him, and he's not used to anybody giving it back to him, Brett.

No, he misinterpreted what I said.

With cancer surgery, it doesn't make any difference what you do.

That's not what I'm saying.

And you mark my words, before you quit surgery, you'll be Marshall A. Toomey.

Only 30% of metastases are noble anyway.

Anyway, what about the other damn 70%?

How are we looking?

We're not getting this too tight, are we?

No.

I don't think so.

I think it looks good.

Well, I think I've written there that you didn't see,

where, I mean, radical mass, if you even shot it.

I've seen them.

Well, I know, but I'm saying,

Hogs, Steady, and Principles were sort of like Moses.

Right.

I mean, people would just come to blows.

And I never did take radical mastectomy because it was, you know, it's not going to hurt anything, really.

Well, I saw some that had rib resections and all this.

Oh, that was the radical, and they finally quit doing that because the mortality was like 5%.

Oh yeah, they would take the whole damn injury, just on that side.

Yeah.

It's crazy, Rick.

You've seen the arms too, haven't you?

The what? Oh yeah.

And of course, how they justified it was, well, see, when you see lymphedema, that was

a cure.

Yeah, it was.

She'd have had the cure quote without it.

Yeah.

I mean, there's nothing to martial art and shit.

It'll happen.

Have y'all updated the family, Carolyn?

Been here a while.

Have you updated the family, Carolyn?

have you updated the family thank you you remember what i used to say i don't think

this laparoscopy thing is going to work that's great it wasn't gonna we're gonna take i used

to complain about it oh the one that he was the worst of was hurting i hated those things

you just go into orbit god i hated them and now i told you the germans who at one time

quit doing them because of mortality by the way. How do you have a mortality for

anyone who'll hurt you? A V.A. had two of them. I don't know, Ray, but they did.

You taking a break, kid? You can't take the pressure? One you should have heard

was the time when I was out with Woods and a bunch of the others. Bill Woods?

Yeah, it was a college meeting, and I said, you know, we ought to be able to take these breast lesions from behind the breast.

Oh, my God.

I thought I was going to have to do CPR on him.

Oh, yeah, we got, it's not too tight, is it?

Hmm?

Not too tight, is it?

Nah, oh, heaven's no.

Or something.

I have a leak from that re-donation.

It's been a long time since we had that happen.

Did what now?

So I hope I didn't have a leak from that redo nissen. It's been a long time since we saw that.

I told you I'd help you with the re-dos.

Well, actually I had that fellow. He was fine. I love it.

It went fine. I mean it was hard.

But you know the thing is I think she had a leak when they had the initial nissen.

She told me it was done at Noonan or Carrollton or something.

What's that?

I don't want a leak.

Where is the damn fluke?

That's right, we did see bubbles but never could find it.

I saw that redo yesterday, we saw bubbles and we leak tested it but we never could find

them.

Did you put the methylene blue?

Yeah, we never saw any methylene blue.

Yeah, that's what it did, I bet you that's what it did.

but she's got a white count at 19 today and a pulse of 125 you know so it's not very right

scissors it was the bypass yeah the bypass looks relatively good yeah we did a had to take a little

piece of stomach off the lady with a redo missing well yeah but i've done that a bunch oh i know

let's see what's bleeding okay let me buzz it what did i do with it i can't see a damn thing

that's where i can't see anything all right oh here it is it's a state it's the staple line

whose staples are these anyway have i fixed to get in trouble michelle do you hear what i said

yeah i think it's good where is it well this is up here somewhere i think it's

It's actually that stitch.

Hit the fab a little bit, see if that fixes it.

It did.

Yep.

I love everybody.

We'll give it a few minutes.

It'll stop.

That's what Barry always says, it'll stop.

He goes, it'll stop.

You forget open, God Almighty, remember?

You know, I was thinking back when I first did a case with my Garrity,

and you probably did this.

He would, instead of using the bovie, when he'd do a midline incision,

He'd put hemostats on everything.

And tie it.

No, not tie it.

And at the end of the case, take them off, and they'd stop.

Oh, I found that one.

That's a good one.

Yeah.

Let me get this.

I got it.

Give me that.

You've never done that?

Put the hemostats on the sub-Q fat on a midline incision,

and then you'd take them off at the end of the case?

No, I remember him tying every single one of them.

Literally.

I mean, God, I used to just want to cry.

every single one. I should have got a hematoma here. Looks like you're already getting one.

Just put a stitch all the way through. Okay, yep. So I guess this would be the downside to suturing.

It's gonna be right where I am. Okay, yep. Yep, straight across. That's too big. Perfect.

Probably the same spot. Oh great. That's alright. I was doing that before. Yeah. It was. It

It all started with your stitch, didn't it?

We'll have to check it with an endoscopy.

I hope.

Make sure it's not too narrow here.

You know, but I'll leave it alone for right now.

Yep, I agree.

Right here.

Ah, I dropped the needle.

Okay, Ricky.

Check my dilatant levels.

Is that what you were going to say?

I didn't say it.

I was thinking.

Karen would have said it.

Did I hit another one?

No.

Are we still hooked up with those guys?

This is the boring part for sure.

So the original G.A.s only had two rows of staplines, right?

Originally, and the way he got them to convert was to go to three, because they were doing

three layers.

Yeah.

And if you ask anybody in any of the staple cutters, they do not know why, they do not

know that history.

Ravage, who's the one that was...

Right.

There were films made of surgery where he would hit the rest of the knuckles with a

Kelly.

I've seen them.

Somebody do that to you?

Oh, no, I never did that.

I just tap.

That's not hitting.

I mean, he would.

That's like Harlan Stone used to hit people.

That good blood supply.

Can't see it.

All right, can I suction that out, please, sir, sir?

Wait, just wait a minute.

Suction it for me.

I'm all balled up here.

Please, pretty please.

That's it.

Oh, Lordy.

Wait a minute. You're not going to be able to see.

I don't want to hear you whine.

Oh, I can do that.

I know. Believe me. There you go.

All you've got to do is come straight across now.

It's so close over here.

Straight across.

Yep.

You're going to have to come out because I can't roll it.

Yep. Good.

What about the one you thought you'd gotten too tight?

That's what I was telling you. She ended up doing okay.

Oh, shit. That's locked.

Where?

No it's not. No. I don't know if it just got a little sabotage going here. Karen sabotaged me. There we go.

What did you do to that? I don't know. Just people do things.

Karen did. Here we got no space. Karen did it. Karen didn't let that fall off.

I see this huge puddle of blood up here in the left upper quadrant. Let me just suck that out please.

The way up here please. It's not that much. Oh yeah.

How much more we got?

I'm telling you, it just goes.

It keeps on going.

Oh, Jesus.

See, Marcus only does the effort, wouldn't he?

I've forgotten.

I think he said two inches.

I didn't know that.

I'll get the bipolar.

Stop that.

Whose staples are these?

He's giving you a bad time.

Well, that's normal.

If he didn't love you, he wouldn't.

that's what his daughter said oh that's it that's that's the kind of answer i don't know

i don't know that's my understanding that's my alarm that's right uh-huh yeah we gotta stop

if it goes off again no matter what now we're cooking with gas yeah right this is your favorite

part episode of the staple i hate it i absolutely hate it of course i hated it in open surgery too

You should have been there with three-layer closures.

Jesus Christ.

Joe Miller.

I've done it with Joe Miller.

He still does three-layer.

Yeah.

You know, he would also use the harmonic and then still tie the stuff.

He'd do it open, you know, and then still tie it.

Jesus.

Well, then I'll go over there and do them.

You can do it.

No, I'm right on top of it.

It's like I don't be easier.

I'll do this one, then I'll do the next one.

In our room, something bad happened?

He said that anything bad happened.

Let me listen to that.

I can't do any more of these from over here.

All right, let me do this.

Let me pull this down.

There we go.

Ah, sheist.

I can't do this over here.

Just pull this out.

There you go.

There's your needle.

Here's your needle driver here.

He'll do anything to get me to do this.

Yeah.

I can't see a thing.

I can't either.

No, I have to do that because I've got his needle holder in front.

Oh, yeah.

Yeah, see, I don't have a choice.

Yeah, I mean, the aura was still on the needle holder.

Where are we?

Right here.

The little bikes.

We don't need big bikes here.

It's like you say, Boyce's doesn't even do this.

He doesn't.

what happened to my damn needle hitting the damn staple

got somebody chewed that up look how they chewed that up there oh yeah there we go you say there

we go there you know right there oh it is chewed up no we do that let's do this pair just go

straight through i wouldn't even try to imbricate it in other words just go just straight across

through the stapline. Here? Yeah. Come out close there. I don't want to get too big of a bite here.

You see it? Yeah. It may not pull through, we'll see. It'll pull through, it may not.

about that is it'll keep the stapline from unraveling. You come over here and sit here.

Okay.

I mean, well, I'm in that mess there.

If it leaks, I'm going to catch hell.

Oh, no, don't worry about that.

It's not going to leak down here.

No, it shouldn't.

I'm sure not the one who cheated up.

Okay.

What do you want to do now?

Keep a seat, sir.

Okay, sit, sir, mother.

Yeah, it's short.

Yeah.

Okay, now let's see this damn spot.

I think here, don't you?

and get below it yeah that's fair is that too much yeah i don't think so

i keep sitting down thing full suture in all that thing too much too yeah scissors up here

this is your favorite part over suing the staple line i talked to your ex-wife the other day she

is so sweet she told me she wanted to meet you big time yeah all right now you're going to

Implicate me for me. I'm gonna need some help. I think it pulled out

They did I guess I can okay. I can help now. No Judy likes to do it

Yeah, I told them all I'll quit soon. Oh hell

There's no way that woman will ever remarry.

No.

No, it's not that. Nobody can afford her.

Seriously, the reason I divorced her was the spending addiction.

When she still buys high-heeled shoes, they're $400 a pair.

It's crazy.

So here we don't want to get too tight, for sure,

because we're right at this angle.

If you want to just go straight across it, I'm not opposed to that.

Tell me what you want.

Yeah, well, I'm not planning.

You want to go straight across or not?

You can, yeah, this one right here at this angle I would.

I'd go right under, you know, under the stapline, just straight across.

Yeah, that's what I want to do here.

We need to pull suture in.

That's really torquing on that thing.

We're getting there.

It just takes a while.

If I'd have had my trocars a little lower, I could suture.

Sure.

Well, I might be.

Actually, I could probably suture if you pull it up.

I think I can do it because it's a better.

That's a bad angle over there.

What's that?

Pull it up that way.

Grab the sutures up there.

That's why it's so close to me down here.

Yeah, oh, yeah, thank you.

Oh, yes.

Keep it up there, Barry, please.

All right, I got it.

Scope.

Clean up, please.

I can't see a damn thing.

I guess Morris Franklin is operating for him.

Wonder what he's doing, a colon or something?

I don't know.

Probably.

Why don't you get me another five trocar?

I'm going to move down, step down in here,

and then I can get this thing done,

otherwise we'll be here all day.

We've already been here all day.

I knew that was coming.

You have another five to these?

OK.

Second.

Let's pull it up away from me up here.

Yeah.

Yeah.

Hold anything.

Hey, Hope.

How's she doing?

Is the upper GI done?

Did they do the upper GI?

Did they do the upper GI?

What did it show?

Can you find out?

That's sort of what I'm really interested in.

Please.

Yeah, but let's just find out what the upper GI showed.

It may not be back yet.

You may have to go to radiology, Grasper.

See if we were using the robot, Barry, it would already be done.

Yeah, we'd be done right now.

Yeah, that's sort of what everything sort of hinges on at this point.

Is it up there?

What does it say?

Oh, good.

Okay, good.

Perfect.

So that helps.

So now we've got to figure out why she's tachycardic and having pain.

Okay.

Okay.

Yeah, yeah.

Okay.

All right.

well we'll check into that a little bit later yeah thank you for checking on

that I really appreciate it happening where were you I saw that what

were you doing we disconnected this guy's sacrum and took it out did they

cure the guy you think well it's mainly for pain but who knows there's a huge

tumor.

Pour it on me.

Here you go, Denise.

Okay, now you pull it back to you with your left hand.

Yeah.

I can keep it up there then.

Give me another needle holder, Denise.

This one won't hold.

Please.

This one won't hold a needle.

So I guess in Italy they're a lot more cost conscious on stuff as far as staplers.

Same, same.

I wonder if they have the legal problems we have here.

They do.

They do?

Oh, man.

Not the same way.

Um, strange.

They don't have lawyers with them.

Stitch, you need to get a chest X-ray of that lady.

Well, the thing that I thought was kind of funny is part of the reason they, the Emory

boys quit doing x-rays on various ones is the false positive quote. Yeah, but I never saw a false positive. That's what I was going to say. I haven't either. But you know the other thing, one of our folks down at, that moved from Mass General to Atlanta, you know who I'm talking about? Moved over to LaGrange or whatever. So one of the suits was, quote, you made the pouch too big.

And the thing that saved him was he did have an uppercut on post-op day one.

I said, here it is.

It was the right size.

So it was a good thing he had one.

When he was at Mass General?

Yeah.

Because the lady, you know, after a bypass, didn't lose much weight.

The claim was the pouch was too big, but the x-ray saved him.

Well, she overate the pouch.

That's exactly what that meant.

So if you don't have that to fall back on,

there's no way you can prove that you made a small pouch.

Joe. Can you go straight across if I do that? I don't know. Show it to him, Karen. No, it's above me. Well, yeah, you had it. I'm sorry, I looked at the wrong place. You're just trying to speed this train up. No, I was just trying to come up with a way to speed it up. I don't think you can. It's just like painful. Okie dokie, thank you. Yeah, I've got to go through the same hole up. This is getting frustrating.

don't turn it because it just wraps the suture around here so as long as we

don't have it too tight that bit more so we should be okay

now you can do it go holder yep all right just get get this needle holder to

do what i wanted to do today i don't know meaningful

that's not let's let me try to pick up on this like this

say again i believe so why why

Well, we're going to get done here pretty soon.

Within a week or so.

Stitch.

What's that?

I don't know.

No, don't sit it out.

We'll get a grasper.

Oh, if it's just covered, soon we'll make him late.

That's all right.

He had two more cases after we finished last week.

He did not do one of them.

Oh, okay.

So that's why he's back here at 11 o'clock today.

Yeah, I'm trying, but it's just the angle's not...

It is for this side here, but then when I try to go across, I get sort of clustered

up.

Bingo!

I feel better.

do that you were almost that anyway you've been very patient a killing me

Probably, you're about to have a stroke by this point.

incision surgery isn't it so they're they're not in favor of that either stupid particularly for

like a bariatric i can understand a gyn with a 90 pound woman for hysterectomy or something but i

don't see any of this like that one they wanted me to try to defend 68 year old lady yeah give me a

a damn break.

Are they out of their minds?

Hang on.

I'm just trying to help you.

No, you're...

My trocars are a little too high

for this particular operation.

Get the hell...

Oh, no!

...got enough tissue.

Wait a minute.

There we are.

Okay.

That's the last one.

Let me go scoper.

Wait a minute.

Wait a minute.

Scissors.

You want me to scoper?

No, I'll do it.

I want to see what it looks like.

I always feel like to see what I did that way because I can be paranoid, you know.

You know how I get.

I'd let you look.

You'd let me look?

Okay.

Yes, dear.

I'll take it out myself.

Yep.

I will need some help putting the go-fit.

Okay, well, let's see if we suit you to bougie yet.

Okay, all righty then.

Hey, bougie's coming out.

It pulls her up there pretty good.

white balance it you up to a woman look at that hair oh you made it did you white power for some

reason I'm not white balancing to the Philly yes sir do you put any kind of drainage yes I do some

of the folks don't i don't don't work go ahead is it if you never so we're doing our endoscopy

to assess the caliber of the sleeve which i'd like to see about the same caliber as the esophagus

and we'll check for leaks he's up to that there you go i'll take it from here

y'all ready guys coming down barry do you think we need some more sutures in that staple line i

I know that you enjoyed that.

Oh, I hate that.

That's okay.

I'm going to be gone soon.

Leak test this with air as well as methylene blue

because we've seen methylene blue escape a tiny leak.

The air does not.

Okay, it should be now just coming into this time.

This morning I've seen his leaf gastrectomy performed in Spain,

and they always perform also a test with the blue.

They do too, huh?

What did he say?

that's what it is they test with the blue too oh okay good and they scope them too do they do

endoscopy am i down below uh sure yeah oh yeah he ripped down at me at the um there's floors

look up a little bit right i saw it okay so let's assess this that looks it's not uh too tight

that's for sure it looks about right are they able to see the endoscopic view

over here yeah yeah sure it's looking very good so it looks about to be about

maybe a little smaller than the caliber of the esophagus so this is esophagus

and then sleeve is slightly smaller than esophagus so I'm happy with that we have

no bleeding and this is the angle right here that I always carefully check

because we had one obstruct here.

But no, this looks good.

Okay, I'll put methylene blue in and we should be done.

Okay, I'll come back in and do that.

I don't think Barry's up for any more suturing.

I'm over it.

He's over it.

One trick we noticed with endoscopy,

if you can't, by putting air in,

if you can't open up the lumen with the air,

in other words, if you have to push the scope

through a narrowing part it may obstruct so you want to be sure you could open it up with the egg

yeah sure so thank you very much yes sir thank you for inviting me for your procedure

and uh and i think the today the the title is a man against the robot it's not a new book

written by Stephen

Kings, but the name

of a group, I will

create tomorrow on Facebook.

I will give you the link.

Okay, great.

See you. Bye.

Thank you. Bye-bye.

Bye, guys.

Enjoyed it.

Thank you very much, sir.