E. JOVINE planned surgery hepatic wedge resection and gastric resection

Good morning to everyone. Welcome to the operative room of Maggiore Hospital.

Sorry for this. Welcome to Maggiore Hospital operative room here in Bologna.

I'm Michele Sacco, general surgery resident at Chirurgia, headed by Professor Jovine.

I'm going to explain you the clinical case of today.

a male of 65 years old who in November 2015 underwent a wedge gastric resection in Sao

Paulo, Brazil. The lesion at histological examination revealed to be a low-grade GIST,

requiring no adjuvant chemotherapy. In June 2017 he underwent incisional ventral hernia repair

with the prosthetic mesh. The follow-up CT of on August 2017 showed two liver

nodules at the fifth and eighth segment of 2.2 and 1.7 centimeters of diameter

respectively and the new gastric lesion of 5.6 centimeters from the greater

On 21st of November he underwent to a EUS. They showed a solid lesion 9 centimeters of diameter from the muscular layer of the gastrofandus with the regular sharp edges in continuity with the pancreas tail.

The lesion is compatible with the recurring GIST.

After discussion at our MDT, the planned procedure is a gastric resection with the wedge resection

of the two hepatic nodules.

So now I am going to leave the microphone to Professor Elio Jovino, who will be the

surgeon. His first assistant will be Matteo Zanello, second assistant resident Claudia

Benini, anesthesiologist Lucia Farabegoli, scrub nurse Bruno Albacini. The operative

room nursing will be granted by Marco Menegatti, Daniela Amadori, Giuseppina Maglia and Nicoletta

the presence of the nodules, their position in the liver segments, and the exploration

of the nodules between the...

Can you hear me?

Now I'm leaving the phone to Professor Elio Iovine.

In what language are we speaking?

Did you explain the case?

Ask Lombardi if he saw you.

anyway and squeeze squeeze again squeeze again 258008 get out of there if you want to call

via call via whatsapp get out of there get out of there let me guide you if you are not able to use it let me

It should be nice if we can understand if there is somebody who can hear us, okay?

Okay.

Scalpel, please.

This is the typical incision we do.

We approach the liver, stomach, and pancreas.

We cannot hear anybody in the room, so we keep going without any answer.

Usually, we approach the GIST tumor laparoscopically,

but this patient has a recurrence of the first disease.

The liver resection we plan to do is very difficult in a laparoscopic way,

So we decide to approach the patient with the open technique.

We do not understand, actually, the real operation the patient has done before, because it was

done in another country.

No.

All this, please.

Is there anybody who is listening us?

We are freezing all the adhesion between the momentum and the...

Hello?

Bertolai, can you hear if anyone can hear us?

Michele, can you hear if Lombardi is there?

If you can help us to understand...

Okay.

Just to understand, electrical.

Just to understand if it makes sense that we talk alone.

Because it's like talking to your own wife.

I can also say it in English.

Hold this, please.

This is the stomach.

Let's freeze everything.

It looks like we have somebody in the room who is watching us,

so we start freezing the adhesion from the wall,

from the stomach.

see can we ask to the anesthesiology to push a little bit down the energy tube

We plan the resection of the mass, actually we exactly don't know if it's only of the

stomach or really close to the pancreas.

So we are going to open the, look at this, you see, this is the mass, recurrent mass.

It looks like it's coming from the pancreas, so we will see.

One more mass is here.

Give me this.

Vipo?

Marco, move me the Cavitron pedal now, because it breaks me and that's it.

Give it to me later, thank you.

Yes, but if I have to speak in English for the room, it's a misunderstanding.

Okay, okay.

This is a new small mass that we have already seen at the CT scan before.

This is close to the stomach, where the patient was supposed to be operated before, previously.

Clip, please.

It looks like just a peritoneal lesion.

Electrical.

Piegato, folded. The transversum column is folded right there.

Stacchiamolo prima qui.

Clip.

Basso breve.

Small vessel.

Inspira.

Clip.

Per bene qui, devo vedere il colon.

Check on the computer if there is some question from outside.

mass right there actually I don't know if we can divide and free the mass

without tying some colonic vessels it's supposed to be the trice ligament

or only adhesion, we don't know.

This is pancreas.

The CT scan looks like it was just lying on the pancreas.

Here it looks infiltrated.

So this mask would be starting from the pancreas itself.

Electric.

There's an ancillary, Matteo.

Mesocolon, you see, I wanted to bring the mass to the retrocavity.

In order to bring the mesocolon here, the problem is that we can't do it because, you see, the mesocolon is on the mass.

We don't know because we haven't seen the pancreas from above.

Let's try it. What is this? A mesocolumn?

I don't know, I don't know.

Electric.

Someone check if we are straight. We are not straight, see?

It was supposed to be because there is no more any retro cavity.

Electrical.

Column, stay atento.

4-0.

Drip.

Luna.

Staying lavato ogni tanto.

colon with the superficial arcade.

Otherwise, if you are going this way and we make a lot of holes in the mesenterium, we

have a high risk to lose the colon.

It should be very interesting if somebody can hear us to try to suggest something or

what the people are thinking in the room.

Also from abroad.

We love suggestions.

Yes, I think.

I think it's going to feel like we reset the pancreas, reset the colon, reset the...

That's it.

I don't think the stomach needed to be resected.

Hold this, please.

Let's go this way.

Marco, controlla.

This is the vesicolic vessel going into the mass.

Actually, it could be a sarcoma, not exactly a benign lesion,

as it was supposed to be at the histologic.

I don't know. We will see because the pancreas, you never know.

Feel the splenic vessel. I'm just above the pancreas here.

Now it looks like it's infiltrated right there.

No, wait, wait, wait.

Clip.

Yes, three, two.

Splenic vessel, two holes.

straight, otherwise you don't understand anything, straight, so straight, look Marco, otherwise you don't understand anything,

if somebody's just arrived right now this is a case of

a patient with recurrence of a gut intestinal trauma tumor that was supposed to be in the

stomach at the first time, operated in another country, and arrived to us with the recurrence

of the disease in the right upper, the left upper quadrant, and with a suspicion of infiltration

of the pancreas and the stomach.

Plus, the patient has two liver metastases, probably two.

Actually, we have not the histology of the first operation because we don't know how

many, how was the histological characteristic at the first operation.

Yes, we know the gist, but we don't know, do you know the number of cellular alterations?

Sorry?

Low-grade disease.

It's very unusual that a low-grade disease has liver metastasis in recurrence of the

same place, so I do not believe the correct examination of the histologist.

After we found the pancreas, it's very close, actually it's infiltrated by the mass, right

right there. I think I'm going to resect the pancreas. The problem is that the mesocolon

transversus is infiltrated by the mass, so probably we need to resect the mesocolon.

Then we will see from the metastasis what's happened to the liver metastasis.

Okay, I don't think I can leave this colon like this. It's much better to clean up the house.

Let's mobilize the descending column, like this, not too much water, because the water

would not have been exhaled, so as you can see the mesenterium is in the mess, so we

cannot avoid to resect the column, we're going to leave most of the column without any vascularization,

so I'll just the marginal the marginal but I don't think it's much enough this

is a recurrence so we cannot leave any possibility to the to the disease to

the car again. Give me the staple please.

you can try to leave this one

This is the medium quality, this is the Riolano, the Rioline Arcade, right there, but there's nothing in between, because the mesh is infiltrating the mesocolon.

Now, one thing we can do is really cut the mesocolon close to the origin, and let's see if the corners became dark or not.

This is the only thing we can do. Very dangerous. Passalacci. Let's see, we can cut later.

Can you see it, Marco?

We are going to mobilize all the columns so later we will see what's going on when we count the damage.

Let me save the mesentericum, the arcata, if not...

Not very high, here.

Wait a minute.

Come on, take a look.

It's not too strong, right?

We are sorry we chose this case because it was an easy case.

This is also complex to understand from people who are in the room.

This is the column.

This is the electrical.

Clip.

This is the column we got.

Folded. Electrical.

It could be useful...

Well, it's too late.

Bico, to be useful ultrasound device, ok, give me this, this that we put on the colon

Controllate l'aspiratore

Or if you want to give me a stick or something.

That's fine too.

This is the splenic artery. You cannot see anything.

Show him something. Can't you see anything, guys?

No, that's it. Where is it?

Let me see.

Can't you see anything? Try to raise your hands, Matteo.

Are you straight? Yes.

You have to zoom in a little more because you can see too much stuff outside.

Increase the light of the chalice. Open the diaphragm.

Deciduous planic artery, verso il basso, cos'è, adesso levo la mano e vi faccio vedere.

Vedi se si vede, perché io da qui non riesco a capire.

Deciduous planic ray, I cannot see the mesenteric, inferior mesenteric bovine.

It is inferior.

I lost the inferior, where is the inferior?

A clip, a small one.

No, do it like this, it will be fine.

Here, go ahead.

Staple, please.

Bianca with...

With gauze.

With gauze.

Okay, we are going to cut the pancreas.

remove the mess with the sling so we will see after what's happened with the

column I would like to thank my colleagues right there because they

found me a very easy case to present in the European and Asiatic Congress I was

ironic obviously. So this is the Ercino stapler with the Syngard device.

Tira. Tira vuol dire la spatola. Non vedo molto. Non vedo assolutamente nulla. Facciamolo

al basso. This way. Ok. Spento anche toccateli la faccia del dottore, la mia manica. Ok.

Let's see.

This is longer.

With the personal column.

Like that.

Okay.

Scissor please.

Let's see.

You didn't cut the vein yet.

Let's see.

This is the vein.

Let's see.

Give me a pair of scissors.

I'll do it.

Four zeroes.

For the tie please.

One more for all.

All this.

One.

One.

A scissor please, dipolare.

I reckon it's in the stomach as well.

Adrenal gland or lymph nodes?

Lymph nodes.

Let's see.

Probably the posterior wall of the stomach is still infiltrated.

Pericardium? No.

The gastric vein, probably.

Everything is fixed.

Okay.

Ok, breathe.

We also have to remove a piece of stomach, guys.

Pinch the ring.

Put it on the stomach there and here.

Pinch this part here.

Yes, sir.

So, it infiltrated also the stomach.

Now we need to resect the stomach.

We have to have other endogies.

Thank you.

Yes, yes, the esophagus.

And the stomach.

Yes, yes, yes.

This is the sphenogastric ligament.

Let me pass you here, if there's space.

Ok.

This is the rest.

I'm going to resect from here.

Here's the stomach.

Give me a little.

Let's see.

So, this is the part of the stomach

that is going to be resected.

This way, hold it like this.

Give me your hands.

Ok.

Step up.

Like this.

That's it.

Lift the...

Lift the...

The...

The...

Hold it in your stomach.

Where is the stomp?

Let's see where we are.

Let's get the mass closer.

Ok.

Ok.

I'm sorry, it's not a very didactical operation,

but I have no other way to do it.

I can feel the esophagus right there and the NG tube.

It means that the patient is going well and unusually is still sleeping.

We need one more.

There's the NG tube.

We are waiting 30 seconds.

anytime we use the stapler before cutting the last one is a gold cartridge I think you can

use green sorry blue or green too usually for the stomach use the gold or the blue one okay

The stomach is done. Hold it like this please.

Let's go towards the adrenal gland.

Try to keep it there.

I can't see anything.

Wait, wait, wait.

That's lava. That's peta.

we can see if the patient not not exactly right there can we move okay

this is the pancreas okay let's see if there is any infiltration from the stomach

as it's supposed to be there is no infiltration in the mucosa usually this cause is coming from the

I'm not going to open the pancreas because I would like to let that to the histology.

Okay.

Okay.

I'm back.

Let's see.

Okay.

This is not bleeding.

Let's check if everything is fine.

This is the stomach.

Hold this, please.

Let's see.

This is the pancreas.

Can you see it or not?

This is the vein.

splenic vein, splenic artery, this is the pancreas, right there, let's leave a sponge

place, I don't know if, ok, give me a stitch,

Give me a 4.0 point.

I don't see the hands.

I have the hands in front.

Here, here.

The hands are here, in front.

Another one here.

Clip for me.

The mechanical one.

Not because it's bleeding,

but because I don't like it.

Probably this is the place where the

resection was done before.

Let's see the colon, what color it is, looks pretty dark, so I think as we plan we need

to do a colonic resection, unfortunately, I think you can see the posterior part right

we left the marginal axis because i can feel the pulse right there but the columns

this is the margin

Green.

Green?

Yes.

If you want.

Outside.

A little bit of the wall outside.

One more.

If you don't want it, pass it to us.

This is it?

Yes.

Pass it to us.

Two zeros.

A little bit.

Up.

Here.

Good.

Let's see.

A little bit more.

Are you ready?

Come up here.

No?

No.

It won't come up.

Let's do the mechanics.

It's already white.

It's already white.

We are performing the colonic anastomosis between the two pieces of the transverse column.

Actually it is a very dangerous anastomosis because it is the place with less arterial

support.

but we already checked it three times and so we are confident that the anastomosis

will be arterial supplied. Scissors?

4-0

okay check the mesenterium I love to do the anastomosis with the white cartridge

because it's less hemorrhagic we could have done this anastomosis also by

but you know you look faster

with the one layer today's is a two day two two layer days

Let's see if the mesoclone is closed or not, it's not, let's see, let's close the mesoclone,

weight

move it

the helium went in the wrong place

there

flush the flannel

you have to reconstruct it

spatula

weight, side pancreas

ok

stich

stich, stitch

give me another little bit here, sorry

little bit

be careful, this one is for me

the pancreas has to be there

Matteo

yes, give me a little bit

mosquito

pull hard

It's burning.

Ok guys, up.

Slowly.

Let's see if we can get it.

It seems like it.

This is the middle.

Let's check the liver now.

Possiamo mettere l'attacca sul schermo?

Is the fish in reverse in Dellenburg?

Do you have the CT scan?

Now I want to show you the MRI, the last one MRI, to show you where the lesion was supposed

to be.

One I can feel it on the segment 4B8, probably 4B.

I think I have to cut another piece, let's see if it comes a little, do we have it?

Like this? Ok, do you want to see, let's show the introspective ultrasound, freeze, ok, a bit of

darkness in the room, even the chalice, thank you, even the chalice, I don't see anything, no, turn it off,

don't move it, otherwise when we want to put it back on, we're done, press reverse, because it's the

Do you see the CT scan?

Reduce the depth a bit.

What do you see?

This is the CT scan. This is the caudal slope.

This is the vena cava.

This is the portal bifurcation, right and left.

And these are the right hepatic veins

and probably the middle of one vein for segment seven and as you can see the

lesion is right there in the segment four because he's on the left side of

the sorry he's on the right side of the middle hepatic vein the allergism the

reason was supposed to be on the segment here segment seven the big one is two

two centimeter and a half and almost esophitic or partially esophitic. So we

look for other lesions. The left lobe is very small and very superficial. I'm

checking from below the left lobe. Now I am above. This is the stomach. This is the

gallbladder and this is the lesion of segment 4. So I would like to remove

these two lesions because the patient needs to be cleaned up and let's start from the difficult

this one i mean the more difficult between the two then we will approach this one

okay so let's mobilize the liver light please

thank you to the anesthesiologist keeping the pressure the central pressure very low

This is the MRI you can see on the on the on the screen

Sorry, this is segment 7 lesion

Okay, this is the MRI you can see the MRI with the lesion for segment

Segment 7 and segment 4 you can see them the the the liver mass

We already removed on the right side of the screen

really attached to the pancreas.

Okay, we can switch to the

operatory field now.

This is the right triangular ligament.

Unfortunately there were a lot of adhesions

also in the right side. I can't understand why.

I don't know what happened in the first operation.

Push it down. This is the right hepatic vein.

Okay.

There's something down here that's still attached.

Let's see.

Matteo, help here.

Come on.

Let's see here.

Breathe, because it's encapsulated, because the lesion is here.

Let's see.

Let's put the clear vein.

The flannel.

Ok.

We can encircle the pedicle, the right, the portal pedicle.

You never know.

Give me a piece of paper.

A piece of paper.

Ok, give me your needle, put it behind, this finger goes down here.

Ok.

We always check with the, with the...

...hyggeography, the lesion and the margin.

So, this...

I don't...

Ehm...

It doesn't matter, no.

Ok.

Give me the electric.

We just mapped the...

...on the...

...lever surface...

...the margin...

...and the level of this wall.

The same, the same.

The same, the same.

This is the left margin.

Okay.

We need a closer.

Do you have a closer?

Yes.

Okay.

You have a plate in front of you.

Bruno, can you give me another gas below?

Give me another gas below.

In front of you.

This is the right vein.

This is the middle hepatic vein.

This is the right.

Okay.

Ok, very strong guys, too much.

and then we go deeper in the parenchyma with the fuser.

Can you reduce the power a bit?

A bit of power?

Less? Less power?

Done?

These fasciae are very superficial, so you can bowie with the bipolar

or clipping with the clip.

I put it on the spray at 100%.

There's something that doesn't work because...

What program is it?

What program is it on?

Standard, what is it?

I don't know, I don't know.

The feeling is that you break it,

it breaks everything and makes few marks.

The suction is good, yes?

That there is too much suction, I don't know.

No, it doesn't work, it doesn't work well, it increases the power, I don't know, it doesn't break everything, but it doesn't, it doesn't break everything, so it's too little, it doesn't work.

With the power.

Power, yes, cut here, yes, it breaks everything a little, but it's better.

How much will it have of central pressure, more or less, or how much will it have of...

It has a little bit of selectivity, so it's in the middle of the selectivity.

It's at 3 of the power, 4 of the volume.

Look, it seems to be really much more traumatic, look.

Traumatic, look, look how I'm going.

So, look, it's all gone.

Try the throat.

Yes, I see a lot of blood, which usually shouldn't be like this, I don't know.

I'm going to clamp it to make it look like this.

It's bleeding too much. I don't like it.

Let's clamp the islands.

Give me a...

Let the time start.

Clamp it. No, wait, wait, I'll turn it.

Pull it up. I have to turn it.

If you don't... Pull it up.

Start from the column.

We should check with the ultrasound.

The freeze. Come on, freeze.

So you can see, if you are in the right way, in the right plane, it looks like...

The light is not high, is it?

The light is...

No, it's down.

It's down, isn't it?

It centers on the injury.

Clip, clip.

No, we'll leave that.

We'll leave it like this, otherwise we'll have to put another clip.

Another clip?

Time of clamping.

Clip.

Clip.

We are checking with the ultrasonic we put a white small sponge on the inferior part

of the lateral part this one I don't I don't know if you can see it but it shows that we

are in the right place.

Ok, turn the switch on, the same thing.

You don't have to superficialize it.

There.

Slowly, slowly, slowly.

Here, here.

Click.

Pull down here.

Minutes.

Six.

Seven.

Ok.

It breaks too much.

It breaks too much.

You have to be careful.

Go.

Go, go, go.

There.

It doesn't work anymore.

Try to stop the suction.

How long do you need to cook it?

Wait a minute.

It doesn't seem to have 5% of pressure.

Not even 7%.

How many minutes? 10?

Unclamp.

Give me two minutes.

Minutes of clumping.

I don't know if you understand what I'm saying.

Click here.

These are the hepatic vessels, these are the hepatic vessels, show that the central pressure

The pressure is still high.

Let's go fast from the beginning.

Flip.

Hold it there.

And that's it.

Be patient with this water.

4.0

Flip.

We still have another vessel.

I'm creating force.

Come on, up.

Here. Slowly, slowly.

Up.

I'm sorry.

I'm sorry.

Ok, one moment please.

Now, down, there, there.

Pull it here.

There.

Clip.

Clip.

Do you want to put it here?

Yes, yes.

No, higher.

No, it seems higher, I mean.

Pull it there.

Clip.

Yes.

Don't pull hard, it's our part.

There was no clip, bro.

No, it's not here.

It's open, there.

Cut.

Clip, small.

I'll go, I'll go.

Clip.

Clip.

Ok.

There.

Oops.

Do you want to see it?

No.

Put the spray again.

It's 54.

4B, yes.

Do you have it?

Yes.

Let's declamp.

How many are the clamping minutes?

10 minutes and 40 seconds.

10 minutes plus 7.

Bico, you have to suck it.

We use the spray like the argon.

Suck it, Claudio, for a moment.

We can also wait and leave a pot.

Let's see.

Give me some water.

Okay.

Let's leave it a little in peace here.

Let's go see the other lesion.

Okay.

Let's take care of the other lesion right there.

Bipolar.

Let's see the vena cava, please.

I don't see it.

Flip.

Marco, lift your head up a little bit.

Please, like this.

With the cava ligament, or Makushi ligament.

It's supposed to be a vascular, but it's always bleeding.

That's it.

Wait, I haven't come out yet.

Give me a bipolar.

Wait.

Be careful, I can't see.

Are you there, Matteo?

Yes, I'm there.

Give me a small pair of scissors.

Then click, click.

Let's see where the lesion is,

if we can avoid tying everything up.

Close the shape.

Okay.

Now another guard.

This is the guns.

These are for the seventh segment.

Right there.

So it's Segment 7 lesion.

Bipolar?

Yeah.

Uncomfortable.

Yes.

Take it like this.

There?

Yes.

If you want.

Okay.

I'll put it.

Enough, enough.

Lower the light a little.

I'm a little hungry.

Remove the spray.

Remove the spray.

First, I'll go to China.

Excuse me.

This is segment 7 vein coming from the small vein, coming from the 6 or 7 portal.

Bipolar? Bipolar?

This is the plane.

Teresa, I have the feeling that you are pulling a little.

Maybe I'm wrong, but there is no room to move.

Clamp it again.

Clamp it.

It's yellow. Clamp it, guys.

Clamp it.

Cut it.

Cut it.

Here?

Here?

Here?

No.

It must be here.

Ok here?

The fatigue is open.

Fatigue brain open?

A little elastic.

Here?

Yes.

Move the

If we don't burn it.

Do it.

Here?

Do it here.

Come on.

Come on.

Electric.

Pull on the peg.

If you don't see it, you can cut it, you have to cut it here, here, here, cut it, it's fine.

Another little one, no, you see it on the side?

Clip.

Sorry?

Clip.

Clip.

Clip.

This is the pedicle, you see, of Segment 7, it's coming from the scissor, and I need a point.

done if somebody has some questions from the audience

Let's see, let's take a look around.

Give me the light.

Spray.

The lettuce is sprayed there.

Give me the gas from the back.

It's a little slippery, but I think it's okay.

You can also put it on the fans.

Okay, done.

Now we put two drains, one in the splenic

on the left hypochondrium and one on the right. The hemoglobin right now is 8.8

so the patient doesn't need any transfusion and okay we've seen the

PO period what's going on. Thank you everybody see you next