Gang CHEN, Zhu QIDONG Laparoscopic Pancreaticoduodenenectomy (LPD)kiki

To all the international speakers and also participants from online,

hello, everyone.

I believe it's known in Italy.

And this is Chen Gang, and I am the vice president

of the First Affiliated Hospital for Wenzhou Medical University.

And we are really honored to be here as a part of this annual congress

to share with you our surgical experiences.

So, thank you very much to the organizer of this annual congress, the Italy Rome First

Medical University and also the Italian Surgical Technology Association. Thank

you to the organizers and also thank you for the participation of the two

professors, Marcello Schiavo and also Professor Eto'o Colangelo.

成为全球消化外科领域最具代表性的学术盛会之一。

Ever since its establishment in 1985, the Congress is renowned for its very special organization.

We use live streaming and in this form we can communicate with the international experts about the surgical techniques

techniques, and also this annual congress has a really huge influence around the world.

多年来,学会不仅推动了外科技术的进步,也搭建了各个外科医生之间的沟通与学习的桥梁。

我们知道,能够在这一平台上展示中国外科医生的手术技术与理念,既是一份荣耀,也是一份责任。

So, for many years, this platform actually promoted the development of the surgical skills

of the surgeons and also fostered communication and exchanges between surgeons from different

countries.

and we are greatly honored to be part of this congress to share with you the techniques and

also the concepts of surgical procedures from China and we are truly honored to be here.

And also the hepatopancreatic biliary department is really renowned for its capability to perform really complicated laparoscopic surgeries.

And last year at the 35th Annual Congress, the party secretary, Professor Shim, demonstrated the gastric, the radical gastric cancer treatment.

And this surgical procedure received really a lot of attention from the international experts.

So we were invited to participate in this year's Annual Congress.

and today we are going to demonstrate an LPD surgical procedure.

So now I will introduce to you the commentators and also the surgeons of this surgical procedure.

And I am the chief surgeon for this procedure.

And we also have Dr. Wu with us.

And Dr. Wu will be the main commentator for the surgical procedure.

And also Dr. Sun will also engage in the discussion and the Q&A session related to the surgical procedure.

And also we have Dr. Zhu, and Dr. Zhu is responsible for the surgical procedure implementation as well.

So through this pre-recorded surgical procedure, we would like to discuss the details of the

LPD surgery and promote the collaboration between different centers.

and we will also showcase the team collaboration work of our surgical team,

the paraoperative patient management,

and hopefully we can have in-depth discussions about the complexity of the surgery

and also the solutions and the strategies for the LPD surgery.

the real-time comments from the commentators.

And we believe that for this form of communication,

it can promote the in-depth discussion

between the surgeons from China and around the world.

And it's a better way to share with you our concepts

and our experiences.

And we believe that it will be a wonderful discussion

So we would like to say thank you again to the organizing committee for your support

and on behalf of the First Affiliated Hospital of Wenzhou Medical University,

I would like to say a big thank you to all the participants

And through discussions and exchanges like this, we can further promote the safety, the precision, and also the micro-invasive surgical techniques, and we can foster development and mutual learning between different centers, and we believe that this academic feast will be a complete success. Thank you so much.

and also hope and also hopefully you know the professors from Italy can get

and also the other international speakers and the panelists can get an

opportunity to come to winter to visit us and you are very welcome thank you

very much and on behalf of professor Palazzini here in Rome I think I thanks

professor Chen professor Zhu professor Sun Sun Wu and looking forward for this

this outstanding presentation.

Thank you.

OK.

Thank you very much, Dean Chen, for your introduction.

Thank you very much, Dr. Wu, Dr. Sun, and Dr. Zhu.

I look forward to the next academic event.

Thank you.

OK.

Dear colleagues, dear foreign colleagues,

Hello everyone to all the international experts and today I'm going to showcase an LPD surgery

and this is Dr. Wu Lijun from the Wenzhou Medical University First Affiliated Hospital.

So the patient is a female, 48 years old,

and the medical history includes the radical BC surgery.

For this surgery, the chief complaint from the patient is that

that there is a bio-duct dilation and also the skin jaundice for half a month

and the bio-duct dilation for one month.

常规的体格检查是生命体征是平稳的,

一般情况可的,服务没有明显的一个阳性症状,

但是皮肤拱膜是有点哗然的。

So the PE shows that the patient is conscious and alert,

and the vital signs are very stable.

However, there is a jaundice of the skin and sclera.

As for the other examinations,

ultrasound on the July 15, 2024,

There's an enlarged gallbladder, dilated CBD, and the serial test on August 13th of 2024 shows the total bilirubin 91, direct bilirubin 54, ALT, and AST are both high, and they are 239 and 171, respectively.

So we did a contrast-enhanced CT scan for this patient,

and you can see the conclusion of the contrast-enhanced CT scan.

There is another mass in the common bile ducts,

And also we do not exclude the malignant tumor possibility

We should combine the judgment with enhanced MRI

And so we went ahead and did the MRI

And you can see the conclusion is quite similar, nodular mass in the common bile ducts and not excluding the malignant tumor possibility.

And there is a dilation of the intrahepatic, extrahepatic bile ducts and the pancreatic ducts.

And for the examination with ERCP is necessary.

接下来我们给他做了一个ERCP,可以看到这十二指长路头这是一个肿瘤。

So then we went ahead and did the ERCP for this patient, and you can see there's a possible duodenal lesion, and we suspect it's a tumor.

我们可以看一下它的一个,总共的一个血肠硅,血肠硅未见明显一个异常。

And this is the blood examination, it's CBC, and we don't see any abnormalities with the CBC examination.

它的一个肝功能,肝功能是总档数有105,直接档数就是4,其他的一个转按每是高的。

And you can see that the liver function, we know that the total bilirubin 105 and direct bilirubin 64 and the aminotransferase are both high for ASC and ALT.

Now, 凝血功能是没有明显的异常。

And for the coagulation function, no abnormality associated with coagulation.

然后肿瘤指标,消化到一个肿瘤指标,CA151199, CEA也没有见到一个明显的异常。

And as for the tumor markers, we don't see any abnormalities associated with CA199, CA125, and CEA.

接下来我们是一个临床诊断,是12指上乳头二线肿瘤,然后给他进行一个LPD手术,手术团队主导是陈刚教授,一组是朱千东主任,二组是吴立军医生。

Mm-hmm. So we have the preoperative diagnosis. It's a malignant tumor of the ampullae of the

vector. And we decided to move on with the LPD for this patient. And the chief surgeon is Professor

Chen Gang from the First Affiliated Hospital of Wenzhou Medical University. And we also have

the first assistant, Deputy Chief Zhu, and also the second assistant attending Physician Wu.

解说人员是孙鸿为主任。

The commentator or the reviewer is Deputy Chief Sun.

首先我们来看一下这个PPT术后的一个病理。

So this is the gross specimen.

Let's take a look.

病理是体质十二指三二型肿瘤。

And the pathology test shows that it's the duodenum malignant tumor.

那接下来有请另外老师共享一下手术的一个视频,视频里面包括术前的一个CT检查,磁共振检查和术中的一个手术视频,术后的一个CT复查。

So now I would like to ask my colleague to show us the video.

And in the video, we will be able to see the CT examination, the MRI examination, the surgical procedure, and also the post-op CT imaging.

好,有请老师分享一下视频。

Okay, so please share with us the surgical video. Thank you.

快速地过一下视频。

We'll quickly go through the surgical video.

这些内容我们前面已经讲过了,我们快速地过一下。

可以看一下CT的检查的一个影像片,可以看到。

So we already went through the contents, and so we will go through this part very quickly.

CT是可以看到十二指肠颅头区,可以看到一个肿瘤。

So, you can see the tumor of the duodenum at the papilla.

往下一页,颜色是...

So, next page, please.

This is the delayed phase.

往下走一下。

Please go to the next one.

这里有障位,十二指腸乳头区有障位。

And you can see the occupying lesion at the duodenum.

the papillary of the duodenum.

往下走。

Please go forward.

再往下走。

这个有点长。

It's kind of overlapping content or repeating content,

so please fast forward.

继续往下走。

这个开始已经讲过了,

这些肿瘤指标是正常的。

So all the tumor markers are normal,

so please continue to fast forward.

那手术团队已经介绍过了下一步。

Okay, next one?

对,接下来就分享手术视频。

And this will be the surgical overlay, surgical video part.

下一步分享一下。

Okay, please move on to the surgical video. Thank you.

Just a moment, please.

Okay, thank you.

稍等一下,谢谢。

下一步快一点。

胆囊接触已经把它跳过了。

So the bile duct resection was skipped.

The gallbladder, we see that the gallbladder resection was skipped.

手术录播视频放一下,麻烦老师。

Could you just play the surgical video? Thank you very much.

I don't see if there is a common cause of the left hepatic artery.

Could you just show us the LPD, surgical procedure video, the LPD video?

So are there any technical issues?

I think so.

because you are we have already seen this part so any technical issue so could

you show us the LPD surgical video we want to see the LPD surgical video thank

There are still some issues with the surgical video.

Actually, I can share screen from my side if you don't mind.

So is it okay that the Wenzhou Medical University share screen from their site?

国外的同道可以看得清楚我的分享视频吗?

Okay, now the Wenzhou Medical University Dr. Wu is sharing screen.

Can you see the video clearly?

Yes.

Professor, you can see it very clearly, Mr. Wu.

First, we have already removed the gallbladder.

After that, we will hang the left liver, the outer leaf, up.

We will hang it up with a pouch.

So, we have already resected the gallbladder,

and then we use the purse string to suspend the left hepatic lobe.

And we also lift up the liver, the right liver, adjacent to the gallbladder.

No, the surgery. Where is the surgery? Between the legs or the sides of the patient?

In China, the surgery is to be always on the right side of the patient.

Here in Italy, or in Europe, we stay between the left and the right side of the patient.

In this way, we can fully expose the surgery area.

so in such a way we can expose the surgical area completely

the surgery between the legs, the first assistant on the left, and then several on the right.

In the whole list, we also have the billing and download information for the surgery,

the prosthodontic surgery, to standardize.

And also here in Italy, we never do surgery on the side of the patient.

Always look at the buttocks.

Every surgeon has to stay in the personal hygiene preference.

So, we now open the gastric colon ligament.

So, Professor, do you think the video is very, the signal is okay?

or it's like a it's quite it's not fluent correct actually it's the same on my side as well

So, for the technical support from the Italy side, is it possible for you to share the

surgical video again because the signal from the China side is not so fluent?

We will share the video, no problem, but we have a different version of the video, so

we have to find the exact point of this video.

Just wait a moment, please.

The technical staff just put the video so please let us know if it's okay.

The China side, Dr. Wu mentioned that there are actually two versions of the video.

you there's the latest version or the final version and also the first edit version so

we are not sure which version you are sharing with us now

so thank you so much and there's no need to share the surgical video from the Italy side

because the editing may be problematic with your version so we will continue to share from

the Wenzhou side thank you okay I'm sorry it's 1 hour 47 so if we need to share just let us know

Okay, sure.

Their version is 1 hour and 47 minutes.

If you need to share with them later, you can tell them.

Thank you.

Okay.

We can switch to the Live 5 channel.

I think that's a little more smooth.

Live 5 channel?

Yes, the small screen on top.

Hey, Dongge, Live 5, I'll hang up.

If you want to use Live05 channel, this is great.

Live05, okay.

It's better.

Oh, Live05.

It's better, but too fast.

A little faster.

It's actually 1.5 times fast forward.

Or an incredible surgeon.

so is it possible to slow down a little bit because it's 1.5 times faster forward

the speed could the speed is like 1.5 times faster than the normal speed maybe two maybe

Maybe two times faster.

A 2.0, okay.

That's crazy.

Is it okay to use the normal speed?

It is a recorded video, so technical stuff that it cannot change it.

Oh, okay.

Okay, the outside replied that this is a recording video, and they received it at such a speed.

He can adjust it with their playback.

Now it's going back, it's gone back.

They want to watch basically all of it, and then it takes two hours or so to get in.

Yes, that's right.

Yeah, so because this session is only two hours and the surgical video is one hour, like 47 minutes.

And if you want to like watch the entire surgical video, I think fast forward is the only way to go.

接下来我们要打开COC切口。

So we need to open the COC incision.

So now we are trying to cut the small venous branches.

Handy trunk.

Yeah, handy trunk.

What kind of video system do you use?

Is it a 3D system?

In this case, it looks like a 4K.

这是一个3D可视化视频吗?

是的,3D可视化。

Yes, we use a 3D visualization system.

我们找到腹右结长筋脉给它理断。

And now we cut the right gastric column vein.

Gastric column vein, yes.

So this vein is actually from the SMV, the origin of it is SMV.

We are separating the tissues adjacent to the SMV.

And you can see that the SV, the splenic vein, actually, it also connects with the SMV.

There's a complex venous anatomy because this one seems a vein draining into the middle colic.

所以就说这块的境外系统是非常复杂的

Yes, we agree. There is a mid-collect.

Yeah, very, very tricky section here.

所以在这块做离断是真的是要非常的谨慎

接下来我们把位作为的一些网膜继续离断

然后离断位

So, we are going to separate the gastric.

离端位小弯侧的一些组织血管。

然后我们用切割吻合器离端位。

So basically we are separating the tissues surrounding the gastric and including the vessels surrounding and it's something like a diatomy so it can also start like a it's like an anastomosis as well.

and now we are trying to open the tissue of the dorsal pancreas

This is a very nice device for quadrupeds and also for breast-capping.

The monopolar is also a very good energy.

The problem is that you cannot...

Do you know the data?

Yes, it is acceptable.

The power is a lot.

Yes.

So after the separation, we are now trying to find the pancreatic duct.

So just now when we were trying to separate the pancreas, there is a little bit of bleeding.

So we use a bipolar for the hemostasis.

We use scissors to cut the pancreatic duct.

That's what I do usually.

Just the same, just the same, just the same technique.

Yes.

We are now doing the lymph node dissection surrounding the duodenum ligament.

So we are trying to separate the pancreatic

a hat tissue the uh insulate the process uh surrounding the adjacent to the pot of

How do you do the liver?

You mean how long do you clamp?

I normally do it intermittent

Intermittent

Intermittent

50 minutes of clamping

and 5 minutes of deep clamping

And do you do the laparoscopy?

Absolutely

Normally

the liver can be clamped

also up to 60 minutes

But I

If you want to

to avoid ischemic injury of the liver, especially steatococcal liver or cirrhotic liver.

I think that the intermediate criteria are 15 minutes and 5 minutes of the cancer.

Before, I also performed the so-called preconditioning, that means 5 minutes.

You start with 5 minutes of clamping in order to improve clamping.

Then you start with 15 minutes of 5 minutes of clamping.

But now it is demonstrated that it is not so useful.

So you can start directly with 15 minutes of clamping.

So when we do the LPD surgery, we take great caution with it.

And for even the very small vessels, we will use the hemlock clip or clamp to clip it.

So we now expose the GDA and we have the anterior branch and the posterior branch.

if the transsection is bleeding, especially in open surgery, I trap very rarely. In laparoscopic

surgery, I trap more frequently because it's a very few days. It's not very easy to get

rid of the transsection. I think it's a real problem.

I think that if you have more than 16 years...

So there's a question for you, professor. Can you hear me fine?

Yes, I hear you.

So when you separate the GDA, do you normally tie it up?

like make a lock and then after that you use a hemlock clip to clip it so is that

also the same technique with you I do exactly the same either in laparoscopic

and open surgery because I think this is one of the drawback of the pancreatic

duodenectomy since you have a if you have a fistula is here where where the

the GTA can be eroded by the fistula and eventually cause an important postoperative hemorrhage.

So I do exactly the same.

Now, we are cutting the bile ducts and we need to expose the tissues surrounding the

bile ducts.

I do the same in an ampullary tumor since the biliary margin is not a concern, I mean the length of the margin on the bile duct.

So the axis of the trochlea is right side combined with the middle trochlea, the middle axis.

You already prepared a mesocollic window for the bowel loop, correct?

Yes, correct. Your understanding is correct.

I saw a nice demarcation line when you cut it.

然后我们继续游离沟通的部分。

So now we are continuing to cut the arsenate process.

这是我们以12层下进来。

This is the inferior, the IPDA, the inferior pancreas, the colodendron artery, the IPDA.

So now we cut the IPDA.

So we were still fast forwarding and actually one of the part we use a hemlock clip to clip it, but it's not locked very well.

and then we use a proline suture to suture it up.

外方教授,我们现在在理断那个胆中管啊。

So we are cutting the common bile duct.

就是外方教授,我有一个疑问,

就是你们平时操作的时候,

胆中管要切远,要送冰冻吗?

做一时二十三切除的时候。

So when you do the PD surgery for the common bile duct,

Doctor, do you normally do frozen section for the pathological tests?

Yes, always, always.

Yes, we always do frozen section and then send the patients.

We often encounter some situations where the body is positive when the tree is frozen,

but the post-treatment body is positive when the tree is frozen.

Have you often encountered this situation?

uh so we often encounter this scenario so intraoperative frozen section uh it uh

indicates that should be benign and however uh post-op the margin shows uh positive so do you

often encounter a situation like that as well yes sometimes especially when when their biliary

drainage is is positioning preparatively which causes inflammation and sometimes the histological

picture is uh not not not so clear it happens it happens to me absolutely

We will stitch up the dorsal pancreas artery and after that we will do the anastomosis of pancreatic genome.

What kind of, can you describe the kind of anastomosis you use, please?

The blonde duct, mucosal, duct to mucosal.

For the duct to mucosal, eight stitches.

That's the pancreatic adrenal anastomosis.

You mean now?

You mean the suture?

Yeah, the suture I'm seeing now, right now.

Okay.

So two stitches, one from the superior margin of the pancreas and the other one is inferior.

So two stitches.

我们缝针是横挂,那个横挂一线的,全程的。

It's the transverse running stitch, like it crosses the whole pancreas.

是Pro-link,Pro的防线对吗?

是的。

Correct, yes.

然后我们用的这个一线导管是用的是那个头皮针,是树叶式的树叶器的一个针头,那个软组织,软针头。

So we use a soft needle and the kind of needle used for the scalp, scalp acupuncture, scalp puncture.

So, it's a soft needle. The needle is used for scalp needle puncture.

Have you seen how they listen?

Professor, do you have a lot of food cuts this year?

So, Professor, a question for you.

Do you have a very large volume of the PD surgery?

I used to, not a large volume.

It depends on, you know, in Italy, my large volumes are small volumes for Chinese.

But apart from this, I used to because when I work at the National Cancer Institute in Milan,

now we have the situation has changed in in our region so I I cannot perform so many PDs nowadays

because of a change in in regional laws you know so there's a few centers performing pancreatic

surgery authorized centers and my center is not among them.

教授,你们那边现在你们科室的现在一个疾病谱是主要是以什么疾病为主呢?

So then what about the disease spectrum?

The numbers?

No, no, no.

The disease spectrum in your center, like what kind of surgeries or what kind of diseases do you mostly cover?

Mostly local advanced pancreatic cancers.

基本上是局部晚期的一线癌。

局部晚期哦。

对,局部晚期。

那教授,你们会做那个肝癌手术吗?

或肝门部肝管癌手术吗,这些?

So, do you do like a hepatic surgery?

Yes, I do.

Yes, I come from an HPV and transplant center, so I do pancreatic surgery and hepatic surgery too.

Yes, I come from a liver transplant center, so I do liver cancer and liver cancer surgery, these two are done.

problems with my you know travel to my town because there's a strike here in italy today so

but i want i want to thank all all the professors involved in this operation in this presentation

Outstanding presentation, very nice surgery.

My congratulations to all the team.

I'm sorry, I might have to leave for a moment.

If the surgery is not over yet,

because we have a traffic situation here.

There is a strike here in Italy, right?

Professor, right?

Yes, strike.

Okay, this part has a bug.

Some problems with trains, you know.

Oh, yeah, I know, I know.

Their train system has a bug, so they have to leave later, or they can't go back.

Okay, okay.

Thank you for your sharing, Professor.

另外他也说在这里非常的感谢

就是这个手术的团队主刀

还有手术的团队

真的是非常的精彩的一个手术

也非常荣幸能够去观摩这么精彩的手术

手术也做得非常的漂亮

So professor, you need to leave in

Like in 5 minutes or 10 minutes?

15 minutes

Which means 9.30 by our time, right?

Yeah.

Okay.

2.30 p.m. in Italy.

Oh, sure, sure.

他这边最多可以待到半点,就是因为那个火车系统这个工人罢工的情况,他最多只能待到半点,然后必须要走。

OK,那我们一场网络看完了之后,我们就请那个点评嘉宾孙主任过来点评一下吧。

Okay. So maybe after the anastomosis, we ask the reviewer or the commentator, the chief surgeon, Sun, to come over and...

Okay, sure, sure.

Let's go back.

Maybe we ask the commentator or the reviewer to come over and make some questions.

so we ask the reviewer to come over and make some comments

okay yes okay

So, thank you very much, and I will be very brief.

This is Sun Hongwei from the First Affiliated Hospital of Wenzhou Medical University,

and thank you very much for inviting us to do this demonstration of the pre-recorded surgery.

Dr. Wu showed us a very comprehensive case from the preoperative imaging and the lab

test results and also the feasibility of the surgical procedures and also Dr. Wu showed us

the surgical planning and also the anastomosis and how the lymph node dissection was done and

how the anastomosis was done and it's really mature LPD surgical technique.

And during the surgery, the lymph node dissection and also the selection of the surgery,

免得耽误教授的时间

Professor, have a good day

And also apologies for not being able to turn on the camera

Because it's broken

And that's all from me

And we understand that you need to catch the train

So please go ahead and wish you a good day

Thank you very much

Thank you very much

And thanks to all of you

And what can I say?

See you next time

See you next time

Bye-bye. Thank you very much.

Bye.

非常的感谢

非常的感谢我们温州医科大学第一附属医院的

手术团队的所有的专家

那么希望我们下次再会

手术做得非常的精彩

期待下次再会

谢谢

Bye-bye

Bye-bye

Bye-bye

Bye-bye

那么我们这边是继续观看视频

主持人,现在还有哪些老师吗?

主持人

我来帮着问一下,您稍等

So the hospital side, the first affiliated hospital of Wenzhou Medical University

The surgical team is asking should we continue on with the surgical video

Or can they also leave the Zoom meeting

欢迎老师

然后现在线上已经没有任何的外防专家了

那谢谢各位老师,再见

好的,谢谢,再见