ADAMO gastrectomia ?

Good afternoon. Anybody there? We just started the second case.

Yes. Good afternoon, Professor Adamo. We're back right on the ball, as I think you are.

Can you tell us about this case?

So this case has got a virgin abdomen, thankfully.

Fortunately, yes. It's going to go much smoother.

Yeah, she's a 48-year-old lady with a BMI of 49, very similar to the previous one.

She has got diet-controlled diabetes the last seven years, and then she starts suffering

with depression, and that's it, really.

Apart from that, long history of dieting, which failed.

And then diabetes, well, xeric gastrectomy, it's normally a recognized procedure for diabetes.

She has been through the two-week pre-op diet for shrinking the liver, so the liver is quite

nice and thin.

so i just do i did a optical access for the primary port as usually do and now i'm inserting

the stapling ports see this will be more hopefully more standardized in terms of a poor position

everything else show me the port place i said before i always use bladeless ports so i don't

have to close the defects afterwards in this case you're going to put a lever structure i will

indeed yes so that's the first two ports accessory port accessory five and the main 12 for stapling

and on the other side pretty much contractual symmetrically will be another 12. after you put

the all ports can you give us an outside or view please i will indeed okay that's the other

stabling port and then this sorry ratio just all like this thank you so that would be the port for

the liberal retractor will be around here quite lateral so it's not in the way uh get the fast

clamp in place nick get the fast clamp for the retractor okay leave a retractor please so the

the five five ports are in place the three twelve and two fives uh standard and then uh

the liver retractor ready? No. Can we get to the outside view in the meantime, Rakesh,

please? So we're just preparing the liver retractor. What I'll do, I'll give you the

outside view so you can see the pore position. Just a bit of the camera is there. That's

fine, yes. Can you see the pore position?

Yes.

We have the primary pore. It's slightly off the midline on the patient's left. The two

stapling pores will be these two. And then on the side, we have the, on my left, this

is the liver retractor and this other one is the arm for the assistant and now i'm going to place

a clamp on the on the side of the bed for the liver retractor which will be clamped can you

clamp it for me okay get the road the big one so don't use a bariatric fast clamp so it can be used

even for very large patients that's why they've got a standard camera thanks for actually got

a standard camera there it's quite big and long that's the clamp is in place now we can put the

retractor in place. Okay. Thank you very much. So can we switch back to the internal view

now? I don't know how many of you use this type of retractors. That's why the one I prefer

is the standard small flat triangle. Okay. Head up please, man. The lever is small. That's

fine, thanks. Pressure. Hold it for one second. And do the bottom one. Thank you. So at the

the moment I'm using a zero degree camera all this please all this please okay it's fine so

zero degree camera at the moment I go full view of the stomach patient is prepared liver is partially

retracted I can adjust it later on I'm ready to start any questions before I start camera please

no no everything is clear we have a nice view everything can have the another bit please so

one thing because we are always a little bit superstitious we never open any consumables

until we have a good view.

So now it's free, so I can start opening

the thunder bit for

harmonic coagulation

and that will open the stapler as well.

So just one minute delay.

Can we deflate the stomach in the meantime, man?

The stomach is a bit inflated.

Yeah, it looks a bit puffy, the stomach.

Can we place mount instruments

properly so I can use them as well?

Thank you.

So it's very helpful if the stomach is deflated,

especially when you go to the top.

Is that ready?

Can you remove this one for me?

Just one second.

We're just setting up everything.

Nick, camera, please.

Nick, the guys are looking at the screen, okay?

So we're ready to start, finally.

We've got two instruments.

That's what's needed.

So I always advise to start in front of you.

So we've got the whole stomach in front of you there.

Always start in front.

So probably that section will be up to here,

but always better start there.

Come in, please.

So you grab the stomach,

and you lift the stomach vertically up.

that will straight the vessels which you can go and attack don't go there because if you go there

you end up damaging the gastroepipodic which is just there you always go very close to the

stomach closer with the camera please and the first thing again is to access the lesser suck

to give you a good view of the back of the stomach that's the lesser suck okay good view when you use

the harmonic device always use the active blade following the direction you're going so if i'm

going this way i will use it this way if i go this way i will rotate this way so i can control the

speed so stomach is lifted and retracted back a bit so i expose the angle to me i can stretch

this part it is usually very straightforward so you don't need accessory graspers you grab the

stomach pull the stomach towards to you retract slide laterally that opens this angle and then

it's always a full bite of the device you don't want to waste any time the higher we're going

there are more enough properties using the zero degree so i will swap to a 30 shortly can i move

it up please man yes please thank you very much so we are reaching now nearly the stage where the

30 is needed i think that's pretty much okay you don't want to leave any fat behind otherwise

specimen will be too big the trick is always to stay closer to the stomach yes what i tell my

fellow is when they do this dissection they have to burn the stomach all the way through so the

stomach has to be burned. That's a sign that you've been close enough to the stomach. Let's

send the dissection a bit more on this side. That's okay. So now we'll change to a 30-degree

camera, and that will allow me to have a better exposure of the aethos. You don't want to

change at the last minute when you are potentially struggling with space. You want to change

it now that you can see properly. Okay, just one second. We'll change the camera. You need

Do you suggest any particular landmark towards the entrance from the major vein?

Well, I've not really checked that yet.

At the moment, I have sort of extending the section here,

and that's to allow me to have a good view.

In terms of the...

So that's the palorosis here.

In this case, it's actually quite nicely seen.

So normally it's about five centimeters.

Five centimeters is around...

It's around roughly here.

So that would be pretty much the five centimetre mark where we're going to start the stapling.

So I can dissect a bit more now or later on.

Since you asked, I'll dissect now.

Thank you.

When you start, you tend to do measuring that with a tape.

Nowadays, I just eyeball it.

It's an estimate.

That's probably enough.

Okay, so let's go back to the top.

So the third degree allows us a better view of the aethos.

of course still do it with two hands so one pulls the stomach back open this corner here middle

screen thank you so at this stage you want to slow down a bit more because that's why you can

have problems if you are too fast every time you hold the stomach the secret is never to push the

stomach in otherwise you lose all the planes just always lift it stomach is an empty bug after all

so that's a vessel there we are slowly approaching the itus okay at this stage i will have a more

head up please thank you very much and the accessory grasper can we have the grass without

working please so the view is not brilliant so you have to make it good so it's always using

your instruments at the best come close up with the camera please so you still probably take a

shorty of this vessel without need for accessory grasper so the sometimes the spring can be very

attached to the stomach sometimes it's quite far away it's okay now thank you very much racial

so now i'll get the accessory grasp it in and then the first part is just to move the fat away

to expose that corner thank you very much close with the camera okay so this stage is advisable

to keep changing position so you always optimize the view um okay thank you you don't have to see

long part of this edge just enough to do the dissection so the vessel is there vessel is

there the view is not perfect so i'll have to do some changes now so see it's very it's very common

just if you don't know how to do it probably just to move the instruments too lower down eating the

the pancreas or the vessels there so always be aware of that okay so let's change technique

so the space becomes less and less which is normal give it to me please you want to move the fat away

really um to expose the spleen you can do in different ways this way seems okay for the moment

Okay, just pushing pushing. Yeah, fine. Okay, come in please. See this addition here is actually in the way

So I'll divide it now just a bit more allowing this to stretch the stomach a bit more

Okay, it's much better. So now the view is not brilliant. You see you want we want to go there

We can't really see much so we have to play a bit more with the instruments to get the right view

so this time I will again lift the stomach up with the

the accessory and have this sort of plain view now.

And now you can see the vessels.

So my normal comment is, if it looks easy, you're doing the

right thing.

If it looks difficult, you're not.

Now the pancreas becomes more into view as well.

OK, so push a bit harder, Rachel, please.

Thank you very much.

OK.

Steady view, please.

Thank you very much, Nick.

So at this stage, if you have a bleeding from one of these

short gastric vessels, the blood loss is about one liter

a minute. So if you have a bleeding now, it's a quick

decision to convert or not. You have about

80-90 seconds to make your mind up and stop the bleeding.

Have you ever seen a bleeding from the top of the sleeve?

Yes, on videos. It's not pleasant.

Not at all. That's why it's always advisable to slow

down at this stage and then look more carefully. Come back please. I need to adjust

my left grasp just to grab the stomach in a way i can retract it better okay because of this no

ratio you're not doing what you're supposed to this is that's all right there's no problem try

this way so now we can see you're losing the light gas cable nick sorry we had a little okay so okay

it's fine come follow me so this vessel has to go now there's another one over there it's pretty

sizable veins now so you want to be just gentle and you have to trust your instruments la riunione

terminerà tra dieci minuti.

Again, top of the camera.

Thank you, Rachel.

Fantastic.

So again, that's what we are, again, in the same place.

That's the GOJ, that's the diaphragm, that's the stomach.

And this is where we need to dissect, really,

to make sure there is no stomach left behind.

You can do blood dissection like this.

You can see there are some little fibers here,

which you might want to divide.

And then try to get the grasper actually to grasp now

the stomach gently.

Bentley. Come in for the camera, please. So it's pretty solid there. So it's very difficult

to find a cross. We'll have to do a bit more work. Okay. So I don't like this setup. Come

back, please. So let's change view for a second. We'll now do from the top. So I will retract

the fundus away, lateral like this. So I will open the angle of this. Thank you. The lever

is retracted ish let me just improve that and do this middle one thank you very much do it again

slightly better retraction and now we can go to the top again that's the becky's fat pad which

is grabbed and i'll pull it towards to me immediately that's the type of that section

you would normally do in a gastric bypass you know in a gastric sleeve we lost the gasping

retraction which should be opening the angle like this thank you very much so we don't be

of dissection from the top this time trying to expose the georgia i can't stress enough

most of the dissection of the georgia has to be blunt uh too much data tell me too much harmonic

you can damage structures so trying to find out the plane okay it's better now quite solid

ideas i would say come here please any comment from the audience i know just uh wonder whether

this story of

finding this kind of

soft tissue of fat

more solid, is that the rule

or makes a difference

sometimes?

Well this is the thing, I mean I was very

conservative at the Aedus beforehand

now with time I'm becoming more and more

aggressive

and outcomes are following my

idea that you should be aggressive

at the Aedus, if you want to

come back please, be radical

with your dissection

You ought to be ready with the weight loss as well.

So it's fine, it's this way.

So we're pulling the stomach now towards the patient's right.

I can expose all these fibers here of the ligament,

which you can see going in this direction,

so we can cut this and then expose the GOJ more.

The good point is to give the right tension

to see well this point.

That's what the laparoscopy said.

edge is all about the lines of force and the traction and counter traction. Yes. So it's

a big gaitus here and probably there's a bit of hernia here as well. So that's the edge

of the cruz, this white line here. A bit more angle on the camera please Nick. Thank you

very much. Look down please a bit more. So in this case the technical difficulty is not

to separate the stomach from the spleen but just actually to set the top of the stomach

stomach, and then identify what's what. So it's quite sort of fibrous here, and then

you want to get all the stomach away. So, come in this side, there's some strands there.

I do lots of bland dissection, like this, because I want to see what's coming, what's

not coming, and to measure the resistance as well. That's a way of sort of having a

sort of tactile feedback, if you like. Come back, please. Okay, I think we're nearly there.

too much back okay go back to that so that stage that stage of the hiatus here and it's

not very well defined cruise and there's quite a lot of fat which is in line with the

patient having metabolic syndrome essential obesity and quite round abdomen she's called

male type obesity this lady yes i was about to comment that is more inside

Yeah, the inside looks like a man rather than a woman.

So there are some additions there which we might decide to cut, that's the edge.

So that's the space between the cruciate and the esophagus is this one.

In an instant I would probably dissect this one more thoroughly.

In a sleeve I'll try not to.

I'll try to do only what's needed, try to resist, dissect too much.

much. Again, go to that space again, Nick. Thank you very much. Okay, so these are the

additions that we were talking about earlier on. They are holding this part in place. She

has no history of reflux at all. Still, it's an interesting finding. Okay, now it's coming.

So see, with a bit of goodwill, you can start exposing the cross and following the cross

down. But in this case, it was a bit more unnatural. I mean, you have to really do it

and force yourself doing it would have been very tempting to leave the items the way it was

is that bleeding from somewhere relevant oh that's all right no big deal okay so now we go the cruise

going down and we are pretty much nearly at the base of it um it's difficult completely different

case from the previous one anatomy wise um so this is actually much more complicated than the other

one in terms of this section okay what are you doing nick just always look there don't move your

your camera. Okay, so now we go. It's quite stuck. There's quite a lot of sort of adhesions.

I don't know why. Normally, it's quite easy to separate these planes. There's no history

of pancreatitis, no history of gallstones or any other abdominal problems. Sometimes

you find these sort of situations. I think at this age, this is quite solid. I don't

want to go into that. I'll probably be satisfied with this exposed angle this way. Come up,

at the taking the phone calls at the centralino so she smokes a lot well she stops now and perhaps

she drinks a bit more than she should and now you can get a bit of pancreatitis for that okay

the additions are freed up sometimes by feeling these additions you can get a better view of

the top you keep progressing with a different perspective and then you profit yes we're back

Yes, we've lost you for over seven minutes.

Oh, blimey.

So the stomach has been fully dissected,

so that's the antrum dissected, that's the back.

I'm inserting at the moment the bougie.

So I will lift up the greater curvature

so the bougie will go into the lesser curvature.

Size, 32 again, or what?

Always 32.

That's part of our technique.

We always do a 32 French bougie.

and yeah i'm looking for it yeah here it is just easy easy easy easy easy come back a fraction with

the bougie okay back in back again okay push the thing is you're not looking what you're doing

okay you should look at the screen and not look at me and we lost we lost the only one of the

screens girls okay that's the bougie there push again more you're still there yes yes

Rom are you still there? Yes yes we are. Okay push the bougie bit more in that's fine so that's the

thick part of the bougie in so we pass already the thin part it's there's no twist there's no tension

we're ready for stapling okay staple please so again same technique as before I don't change it

every day so first firing from the left cartridge down green cartridge trying to get in the middle

of the dissection line which is pretty much where it is and then working on the interior wall first

sorry at least i've lost the view of my main screen and then so that's the interior wall

okay so it's fine that's your bougie there and then flip it and then posterior wall

so try to make it straight no folding and then that's the bougie there okay so we go back to

anterior wall. Thank you very much. Adjust the tension. Lock it in place. Can we wiggle

the bougie, please? I'm not happy with that. I disengaged the gun. I'll do it all over

again. I'm concerned the bougie may have tilted, guys. Can you wiggle it, please, so I can

see it? What's this? So you have to be sure the bougie is in the right place because you

can't have a mistake at this stage. It's not just embarrassing. It's dangerous. So it's

gun and try it again but once you do it has to be perfect or as perfect as you can possibly do it

okay that's okay so we're waiting a bit of time for the compression

talking through apps helps it's a type of surgery that you have to be very calm

as you are doing this rush of course i'm very calm i'm italian now of course i'm very calm

what um it feels excellent so now we'll have another cartridge please oh good and we got

the main analysis back from his coffee so we'll have full control of the bougie again

um so we'll check the staple line again the standard so i would say it is quite nice

quite nice it's a better gusty wall comparing to the previous case oh yeah that was horrible

that looked very unpleasant still it's fine so we reloading the gun in the

meantime putting that reinforcement on the staple line and ready to fire you

can also see that they are holding very well because of the thickness of the

wall which is less than before yes it's okay I grab the remnant I'll gently open

the corner and I feed the gun into the V, perfectly on the V without any overlapping.

And now I will start again going against the bougie. So some surgeons say for the first firing

you might not be tied to the bougie. That's a personal preference. This is a second firing

anyway. So now we are tied to the bougie on the anterior wall, the gun is flipped, posterior wall

exposed and there is always more stomach you can squeeze out of that boujee my point is if you are

tied to your caliper you're always creating a standardized procedure so you can evaluate your

outcomes come on on the top of the gun please thank you so again that's the anterior wall

okay bougie please it's moving fine brilliant so a bit of waiting time for them i think i think

or should put a little carry on on the stapler that force you to wait 15 to 20 seconds because

once you lock the gun it's very natural to to fire it yeah it's difficult to wait i think it's okay

let's move to number three gold please so far so good staple line seems okay in good shape uh

slightly better than the previous one now the staples are fully closed and that's there's

nothing in there and we keep progressing with number three so now i'll be stapling from my

right, so patients left. Are you still there, Rob? Yes, yes. I was asking Prof out of the

technical. Sorry. Yes. So it looks like a very easy procedure. And it is actually easy

in terms of go less steps than a bypass, for example. The problem is that you've got no

room for mistakes. If you make a mistake, it's very difficult to correct the mistake.

mistake. So it's, I would regard as a very technical procedure. So again that's the stapler

in at the V, I've closed the gun, now we control the anterior wall, try not to let the steam

gas leak too much, that's fine, that's fine. I flip the gun, roll the remnant and that's

why we have to get rid of all the fundus bulging there. Okay, very good Nick, thank you very

much see that's why you need really a good rear view because you have to really control

look at the bottom of the gun please more more the bottom bottom they are lower down

see there's a bit of stomach left which potentially can be improved yeah that's

the way so maximize your tension at the back because that's the wall you don't see

unless you go for it okay come back please and then until the wall is fine so now we can play

with it so i stretch it and now i can adjust the tension to a level i want okay

interest that yeah relaxing a little bit um i'm sure over in upper london there is a register

circuit registered surgical rotation when a register starts doing this case assisting and

then doing as a first surgeon on your superficial now so i have normally have a fellow which is not

a registrar he's a normally at the end of his registrar training so uh just before not becoming

a consultant and the fellowship is like the one in the in the states smbs fellowship so the fellow

normally does most of the procedure himself so today i'm doing it myself because it's now we

are in live link and I'll do it myself otherwise the fellow would be doing it. My fellow does

most of the cases so that's at least a primary part of the procedure so for the sleeve either

does the dissection or does the stapling, for the bypass either does the lower anastomosis

or the upper anastomosis. It's all about time, operating time, so once the fellow is able

to do the entire procedure safely in operating time which is what I want then he can do the

old procedure otherwise you only do part of it thanks so this is a teaching hospital obviously

so any procedure you do without teaching it's a wasted procedure okay this is we are not in the

private sector yeah we're not we're not earning money in per case we are doing the surgery and

teaching other surgeons that's the whole point close that please so normally it takes about one

one year to become fully comfortable. You need to nominate to do about 50 to 100 before

you get over your learning curve, depending on your skills, on your talent. Once you've

done 100, you become comfortable. You have to still do X number of cases per year to

maintain your skills. We took about 50 per year, which is a lot if you do other things.

So for example, I don't do any cancer work anymore. I don't do any upper GI resections,

no gastrectomies, no esophagectomies.

Otherwise, we won't be able to do enough of these procedures.

Is it a dedicated bariatric surgical unit?

Correct.

So my list is, most of the time,

sleek gastrectomy and gastric bypasses.

Thank you very much.

So that's number four.

Okay, still a green.

So it's still a gold.

Again, same story.

So remnant, then gently introduce the stapler

until you reach the V, which is fine.

So that's in place.

That's where I want.

half close it so the bougie will not slip on the other side and again get rid of the fundus which

is quite entertaining okay it's fine so i know it's not have to push at the moment you can just

keep it straight okay don't push it too much that's fine so that's pretty much okay so now

i'll go around the back so bariatric it is very technical but i think laparoscopic surgery is

probably the most technical uh laparoscopic surgery you can do that's why i went into

bariatric originally because I wanted to do something very technical. Come back please.

If you can do bariatrics, you can probably do nearly every type of laparoscopic surgery,

nearly every type. Come back please. Some of my colleagues disagree, but I think it's pretty

technical, pretty difficult, can be pretty difficult. So at this stage, I'm not sure if

the stapler has moved. So all I'll do, I'll recheck. But there's no shame in double checking

again. Okay, that's now right where I want it. The back has already been checked. Top please.

please. So I'm nearly there. I'm pleased with that. So bougie, please. Happy? Excellent.

So as I said before, for a sleeve gastrectomy, the range of stapling cartridges is between

3.5 and 5. So this girl looks like she's going to have 4. If you exceed 5 cartridges,

either the patient has got a very long stomach, or perhaps you start getting a bit too much

fundus so the staple line becomes longer um that's what i learned learned in my in my experience with

the sleeve so if you start using seven eight nine cartridges might be something wrong okay another

one please let me have a look i'll tell you a second we'll have yes we'll have a gold with

sim guard so it's nearly done so that was number three and that's nearly the number three number

four so that's number four it was four you know four that's number five there now okay i lost

count oh right so we finished here actually give me the yeah it's fine give me the we seem that

please yes so again same story seems complete i don't trust it i just stapled this bridge

okay come back please come back so staple iron is again is relatively straight i can't really

This staple line looks perfect.

Would you put by principle anyhow for the staples or not?

Or for the clips or not?

I would.

I would because as you can see, yeah, there is a little bleeding point.

What I will ask also my niece is to increase the blood pressure to 120, 130 before finishing.

I have to say with the same guard on, it's very rare to have staple line bleedings.

Very rare.

um but um still i i don't trust the blood vessels of diabetic patients because they

have no elastic so they can't bleed later on yeah come in fantastic great view perfect

that's what we want for final shot bougie please that's fine can increase a bit of blood pressure

man just you're done already thanks that's complete so clips i love a multi-clip apply

please again and I will put a few of them so I'm not sure we can call this

one really bleeding but why not putting a clip if a patient has a bleed post-op

you will delay the hospital say transfusions are expensive well this has

been a totally bloodless field to see you yeah that's that's that's yeah it's

been good I have to say I cannot complain about the blood loss but

Normally, you wouldn't expect blood loss, normally.

That's perfect, yes.

So the pressure at the moment has been brought up to 160.

So that's fine.

So there is not really much bleeding.

Okay, show me that.

The usual bleeding point is this corner here.

Either they bleed at the staple line or bleed at the dissection line

because some of the vessels are bleeding.

But it looks fine.

So you can see there is not much antrum left.

The antrum has been split.

and then most of the antrum has been removed.

Okay, I think we can remove the...

I just want to say, let me just look at the top first,

and then we can remove the bougie.

Top, please. Top.

The good thing is, if you want to grab the sleeve,

rather than grabbing the staple line of the stomach,

you can grab this little bit of seam guard

and moving it around,

and it's quite sort of handy.

That's fine, that's fine.

Clip, please.

Ah, I think that's more than enough.

Okay, I think the bleeding has sorted.

Okay, bougie out, please.

please. The bougie out is one place. So stomach is fine. Yeah, the step line is not as straight

as the previous case, but it's still relatively straight. There's a little bend here going

down a bit, but that's absolutely fine. I would say that's still very acceptable. So

I won't beat myself up for that. It's fine. So now we do the leak test. The back is please.

So the leak test is very new. It's only 14 years old. So it's very important to standardize

the procedure otherwise you can't really look at your outcomes yes in some series the leakage rate

is around two three percent i believe in your hands looks everything goes well but at least

at the beginning what was your leakage rate if ever it was oh yes if you if you have a

legal strength resurgent telling you that he never had a leak he's probably not done enough or he's

is lying. So, my leak rate is around 1%, which is fine. I didn't have touching wood. I never

had any leak recently, but it doesn't mean anything. Leaks can happen. Yeah, you inflated?

It's all in, the blue? So, that's fine. So, it goes 6 ml of blue in this leaf. It's quite

nice and dilated. Yeah, yeah. Yeah, it's blowing nicely. Yes, it's perfect. So, there's no

not blue there so it's fine so the first series I presented of xericastrectomy that's fine in

I was a fellow then so we're not patient I've done myself that I presented in 2003 the leak rate was

14 percent that was without reinforcement and with two row staplers now I would say in the

The literature, leak rate is between 1% and 2%.

1%, 2% with reinforcement.

Without, it's a little higher.

So there is a problem with leaks.

We haven't really completely solved.

It's not like the gastric bypass.

We never see leaks.

With sleeves, occasionally you see leaks.

Hopefully not in this case.

It's fine.

So nasogastric tube out.

So a small technical point now.

Before removing the stomach, I would remove the liver retractor.

You know why?

No, why?

Because if the patient coughs when you remove the stomach

because it's not properly relaxed,

you can potentially split the liver.

Don't forget the liver is heavy and the contracture is smaller.

So it's better to remove the liver and contracture first

so there's no point of fixation.

And now you can take the stomach out.

Good point.

Of course, it's not going to happen today with my anesthetist,

but sometimes it can happen.

So it's better to prevent.

So let's stretch the incision.

Love the dilator, please.

Come on straight, please.

That's all right.

That's the battery low.

Here we are.

Corker, please.

Can you put your finger into the hole when it comes out?

Okay.

Just one second.

Just a little bit like this.

So what I would like to show you one second is the specimen.

Can you see the specimen?

Yes.

It's very important in the gastrectomy that the fundus is fully excised.

So you should see the sort of balloon here and all the back of the fundus,

which has been dissected so that was all the fat was and that's you know that the big part

refunders and then you can follow a staple line you can check if it's intact or not and if you

touch it you can feel this part is thicker than this part let me start showing this is thicker

anyway so that's the complete specimen and the staple line so so you can double check

what you've done by examining the specimen okay so operation is finished i will close

the poor side again and then thank you thank you take device please so the last thing i will do

before finishing off i will check if she has any abdominal wall hernias okay please that's closed

awfully enough i will test it one second my finger yeah it's fine this is the only really painful

point for the patient because you got a suture in the muscle so the thing i will do i will double

check for abdominal wall hernias. If there are hernias, I normally leave them on their own,

but at least I know. No, she hasn't got any parambolical hernia. It's fine. So, finished.

So, that's a silly gastrectomy. Staple line is decent. Bleeding is controlled.

Went according to plan. Thank you very much, guys.

Well, Prof, what comment should I make? It's perfect. Standardized procedure,

Procedure, calmness, I don't know whether you changed the entities, because the pushing was a little bit different, I think.

We had a day, and I said the registrar for a bit, that was okay.

All right, okay.

That showed you the difference between someone who does it all the time and someone who doesn't.

But that's fine, I can't really complain.

No, no, fine, fine, just joking.

Listen, prof, thanks very much, we really enjoyed your procedure.

I wonder whether you have something else to show us, because I can ask to keep the broadcasting, if possible.

Or I don't know whether...

No, that was my list, unfortunately.

Sorry?

No, I've got a plane now. I'll have to catch a plane later on this afternoon.

To Rome, or what?

Unfortunately, that's my list for today.

To Rome?

I'm finished.

No, I'll be further south, to Palermo.

All right, okay, good. Good weather then.

For the weekend.

All right, enjoyed. Thanks very much.

Thank you very much, Professor Prassini and everyone.

Thanks, everybody up in London.

I hope to see you soon.

And thanks again for everything.

Bye bye, have a good day.

Ciao, ciao, ciao, tutti.

It was a pleasure, arrivederci.

And we wait.

What is the, Prof, what's the feeling concerning

the World Cup between England and Italy,

if you are concerned about it?

So it's again?

Oh, well, well, well, we make them believe they're going to win, but they're going to

cry.

Good.

They're going to cry.

Prof, keep it up then.

Bye-bye.

Yes.

All the best, guys.

All the best.

You too.

Bye-bye.

Bye-bye.

Take care.