Huang Changming_Totally laparoscopic radical total gastrectomy

Hello. Hello. Do you hear me? I'm online. So you're ready. I'm fine. How are you? Oh, well, this is a nice day in Rome. The sun is shining. It's early in the morning. We are looking forward to watch your surgery.

My name is Domenico Dugo. I am an oncologic surgeon from this country. I have been visiting China several times and I have been the past president of the European Society of Surgical Oncology and now there is the Newborn Award Society of Surgical Oncology, which I will be the president-elect for. Good morning.

good morning the Chinese is the afternoon I know I know I know good

afternoon are you professor Wong your co-operator

who are you introduce yourself to our there is a lot of people here in Rome

from looking forward to watch your operation oh thank you

we are we are watching to the case presentation and uh it's a it's a gastric cancer you are going

form a fluorescence guide it

we are looking we are reading your the medical records of the patient the lab data

but if you are ready to to speak yourself and to and to describe the case we are ready to listen

Dr. Lin, would you like to introduce the patient?

Yes, of course.

Dear professors,

Today, Professor Chang Ming-Huang

performed a laparoscopic radical distal gastrectomy

with blood loss and anastomosis.

This patient is a female.

She is 57 years old, the BMI is 26.7, and the fifth complaint is the gastric cancer

device was healthy screened 10 days ago, and he had a physical examination, and he found

endoscopy with gadget pencil that is okay and the medical history was no

special the next one and physical examinations was the not positive for

found including the liver knows by the HR to the super they're selling very

valid the lymph nodes was not found and not the other positive for symptoms the

The next one, this scan found that the tumor was located near the entrance, and the pathologic

This low-logit diagnosis is a poorly differentiated adenocarcinoma, partly was the CNET-linked

cell carcinoma.

Pre-operation stage is clinical T2m0, and we'll show the scan picture, next one, that

we can find in a great great curvature the tumor was located near the engine

the next this is endoscopy funding and those copy we can see that they are too much the next one

okay may i may ask you something may i ask you something yeah yes because according to

what you showed you have the and this is very clear i see the the the site of the tumor very

clearly on the picture in any case of gastric cancer that is more than t1 according to the

echo endoscopy in italy and in europe the guideline is to discuss the case at the

multidisciplinary level within a board because especially with multi with a poorly differentiated

tumor sometimes we had bad surprises so we perform staging laparoscopy and in cases of tumors that

that are more than T2, we stop the case

and we go for neoadjuvant therapy

since the results for survival are much different

in patients that underwent neoadjuvant chemo

before radical surgery.

I just want to ask if it is your attitude in China

and if you discuss these cases at the multidisciplinary level

before going to operation.

Yes, we usually, every patient will have laparoscopic examination first, and for the T4A or M

positive, maybe we will talk to the patients to have neoadjuvant chemotherapy first, but

But in this patient, we can see that maybe the clinical T-stage is T2 or T3.

The serosal was not invasive.

So we performed a surgery for her.

Another question.

Since it's rather clear in this case that I'm watching,

that there is some some interest you know some involvement of the serosa are you performing a

peritoneal lavage before starting surgery are you are you washing with with saline solution

the peritoneal cavity in order to perform cytology for further purposes but for these cases there was

反正他是想问就是说这个病人我们要不要做个腹腔灌吸

导致细胞血

这个病人没有侵犯到那个加摩层

就是外面看不到这个病状

Okay, I would

Because this patient we can see that there was not

It's just the stage 2 and

And you don't do it, okay

it also was not invasive so we we we want to have the psychology before the operation

so you are injecting subserosal uh in the sun can you tell the dosage of your

endocyanin injection how many sites of injection and how much dilution has your solution

because I I look at the procedure and I see that the surgeon as precise points

were injecting can you explain yeah thank you for your questions dearly

before the operation the professor power injector the ICT purely for a distal

gastrectomy, we have six points. The first point is the lower and upper entrance,

this is due to entrance size. And the second in the last curvature point is in the entrance

and the angle of the stomach and the upper is the point is between the first two

the benches of the gastric artery and in a great curvature we also have three

points as you can see in the left gastric epipoint

inside the stomach water is the first point and the end of the ICG was the way we can see the

liver knows the better during the operation it's we can help us to have liver adenectomy

so it's very clear that your strategy is not injecting around the tumor in order to determine

the site of gastric resection your your objective is trying to enhance the coloring of any station

that in your pre surgical plan is destined to be removed by lymphadenectomy so you want to be

double sure that any single node of the planning will be identified by ICG what about sometimes we

We have also been discussed with other colleagues from China

the fact that their injection site is just around the tumor.

And this is done in order to verify by ICG

that the resection line of the stomach is at a safe distance.

I don't know if you ever tried this way of using ICG.

Yes, we have two methods to inject ICG.

The first is you can see that during operation, Professor Kwan has injected in a sub-serosome.

And the other method is, as you told, we have injected ICGs around the tumor.

Maybe usually it's four points of the tumor.

For example, for early gastric cancer, we will have an ICG injected around the tumor

tumor, and they will guide us to dissect the lymph nodes, because it's early stage, maybe

we will know D2 lymph nodes, a depilator D2 lymph nodes dissection.

For these cases, we inject six points, and the aim is to guide the D2, the extent of

the d2 lymph nodes we will have a better uh better view of the lymph nodes for for a d2

lymph nodes the dissection will be have uh we will have it water lymph nodes by the icg

it's very clear i appreciate this method because i i think it's very well uh very well shown and

i think you are right yes there are different ways of using icg even when it is used as a lymphatic

mapper you can map the tumor ways of involving the lymphatic channels and all differently you

can just map the nodes because you have a plan and you want to be double sure that your pre-op

plan is respected marking any station with your method of six point injection

and i think this is very important and i thank you for having showed that yes thank you

and today the professor is the chief surgeon and professor is assistant for this operation

can can you explain the position of the operating team around the table because there are different

ways to standing around the table when you perform a gastrectomy as I imagine from what I see is that

everybody is standing vertically at the bottom of the patient looking at the front is that right

Right. Nothing is done by a side. The surgeon is standing in between the legs, as far as I can see.

Yes. The position of the surgeon is, Professor Huan was sitting, he is sitting beside the left side of the patient.

that is using bipolar energy plus ultrasound I don't know your your

instrument your device so can you explain what is the energy that is

coming out from this device I mean is it just ultrasound or it is a double energy

know want to know what is your preference because you are doing a very clean operation is a perfect

section congratulations thank you thank you are you see the clarity of the imagine or the film

it is my honor to be here to join this event

and it's an opportunity for me to go back to school

and to learn again from the beginning.

Everybody in Italy knows that from Fujian,

there is one of the best radical surgery of the stomach in the world,

or in the entire world.

So we are looking forward to observe your technique.

And every year you show us something new, something perfect.

This idea of mapping C6 points is great

and we are appreciating that.

Jianxian, today's surgery is going to be the total gastrectomy or distal?

Distal. According to the organization's request,

we have performed the total gastrectomy for seven years.

So today, Professor Huang wants to perform a distal gastrectomy

me uh with the data shape anastomosis yeah yeah so this is a 2d or 3d vision uh 2d 2d

starts the 4k the 4k the icg the camera yeah maybe now now we are focusing around the discussion on

your strategy to reaching the removal of nodes in the best way and you will

show us maybe at the end of your operation we can focus and discuss the

difference in the anastomotic techniques but this is for later on now let's

concentrate about the lymph nodal stations so you are retracting the

stomach now and you're you're preparing the level in order to reach lymph node

station number six as far as I can understand yeah the six is the first

the lymph nodes were dissected and and the the green light is helping you in identifying the

correct plane of this section in order not to waste the membrane the embryologic membrane

surrounding the nose without breaking it i i appreciate your traction and counter traction

the method in order to open the plane in a vascular way and reaching the nodes

without wasting any tissue it's it's very interesting I like now like now

clinical trial conducted in your center yes increase the patient well my question is

this or something else yeah hey did you hear me yeah yeah i know there is a clinical trial

uh conducting your cancer center and it's a rct

ict injection can improve the lipid retrieval right and also can improve survival of the

patient receiving single center the RCT is a result of founder we can have more

more than even also by the ICG doctor survival three years over all survival

is will be better and this have been published in the JAMA surgery and

and the natural mutations.

Yeah, I understand very well.

And the final message coming out from your trial

is that precision surgery is enhancing the chances

for radical cure of gastric cancer.

This is the final message.

And I think you are totally right.

And your trial was very, very interesting.

Yes.

But my question is how to improve the data

that you know with the icg assistance also the surgery was conducted with digital session so

so do you mean that and the regular digital session will omit some lymph nodes still in

the digital session field yeah and i i think yes sometimes we will miss miss some lymph nodes

what I what I am implying is that it's not only the fact that you don't miss the nodes that you

pre plan to remove for your you know pre surgical planning of the operation is just the way you

remove it I mean it's very clear from this wonderful demonstration that you are showing

showing us that the removal of nodes is not only reaching a certain station,

but going around it in a navascular plane

in order to remove the entire embryological sac

containing the lymphatic system and the nodes.

And this is one of the best opportunities for increasing radicality.

Yes, I see so.

so this is the right gastroepiploic vein at its origin from the inlet trunk right

yes it's the lighter gastric point i mean i i know this kind of surgery but please explain

what you're doing to our audience if you want i can do it for you but it's uh it's uh more than

an honor it's a great pleasure to translate in our language what you're doing and out of

hope it's here or go see stardust orientando a la rigina de la vena gastroecobloca de destra

dopo aver marcato la stazione linfonodale numero secola tecnica che avete potuto apprezzare questo

garantisce una radicalità completa della rimozione dell'intero sacco linfatico senza mai andare a

toccare o di infrangere i piani embrionali che circondano le vie linfatiche di quest'area

Another question for Jianjian, if you find some lymph nodes with ICG dying,

beyond the decision of the D2, for example the 14V?

Yeah, if we found the number of 14 ways to have lymph nodes with ICG,

we will have to dissect it for the pathological exam alone.

Yes, I think that, of course, the ICG is marking any node.

And when you identify some nodes that are outside the D2 planning,

you have to carefully decide if you want to remove them as well.

In this case, you are talking about the 14V, right?

Yes.

yes 14b can i explain to them to the italian audience la stazione 14v la stazione successiva

la stazione 6 che riguarda quegli infonodi che sono appoggiati all'estremità anteriore

della vena mesenterica prima del suo ismo pancreatico non è nel piano operatorio di

una d2 ma in questo caso il chirurgo dimostrerà che fare una d2 plus può essere conveniente

at the end of the stadium of a disease that arises as you have seen from the margin of the great curvature

where the lymphatic pathways of the flow priority are those that go towards the region that we are

dissecting now sorry i've been explaining the concept of 14b removal in terms of performing

a d2 plus when you are operating a tumor that was located in the external surface of the greater

curvature, right? Yes. So the ICG, they have two functions. First, we can see the

lymph nodes around the D2 extender. Sometimes, the other is sometimes the

lymph nodes will be outside the D2 extender. So as the 40-bit and the number 10, so we

We have a clinical trial to dissect this lymph node and examine it a lot.

We can see how many lymph nodes will have metastasis.

Yeah, very clear.

I mean, what you're saying that removal of 14V that sometimes can be complicated must

be done in the context of a clinical study.

is not part of the typical d2 operation yes okay let us see okay that is the right place so we are

we are just below the inferior border of the pancreas yes yes yes this is what we do

of course this is a procedure that is mainly performed in the referral centers for this

disease that in Europe is not that frequent in Italy we have about 8,000 cases that are

operated every year and 14,000 cases that have been diagnosed with this disease usually the

the diagnosis is late, and most of our patients are pre-treated by neoadjuvant.

So one big discussion is what happens to the lymphatic stations after neoadjuvant therapy

because the flow of ICG is not that rapid and clear anymore.

What is your experience in appreciating the utility of ICG when a patient has previously

undergone new adjuvant and when the lymph nodes are very much involved by the disease I mean the

the flow of the of the of the dye is not the similar wonderful way that we are that we are

showing now in a patient that has no compromission of the lymphatic channels yeah yeah with locally

advanced stage that usually the lymph nodes, probably the lymph nodes will be

obstructed by the tumor and even the positive lymph nodes will be ICG

negative. So how do you resolve this problem? Yeah, exactly. And I think this is

is a good question. A few years ago the professor found a leader asking our team for new adjuvant

patients when we injected the ICG. The results also found that if the ICG was used during the

operation the more lymph nodes that we will have it and for the retrospective study the

long-term survival will be a bit better so sometimes it will not shoot with the icg but

the extent of the detail areas where we can see the sound lymph nodes truth

I think it just helped us to find more lymph nodes and made the D2 lymphoacnectomy more effective.

So right now it's dissecting the lymph node number eight.

So usually the dissecting of the lymph nodes supports pancreatic area.

Do you want to test that first or later?

Firstly, we will dissect the number 11P that will be better in the left proximal of the

splenic artery.

So after the liposuction of the 11P, 8, and 7, and then dissect the duodenum?

Yes.

Yes, yes, we were dissected the duodenal after the number 11, number 8, and number 7, and the number 1 and number 3.

Oh, okay.

We were dissected the number 1, number 3 lymph nodes in the posterior side of the stomach.

The section is holding by the assistant.

so now you are dissecting along the superior border of the pancreas in order to identify

the subtle distinction in between the hepatic artery and the nodes that are part of the

preoperative plan right yes so you are dissecting along and the first and the first station that you

the first main vessel that you find is the origin of the left gastric vein yeah yeah this case the

gas left gastric vent is in in the front of the common haptic artery yeah it's not this is the

very second I mean in in our European Anatomy it is very rarely located in that point okay but

every patient is different yeah yeah i still remember i read a textbook uh written by by

professor huang yeah some anatomic pictures and have some calculation of the percentage of the

uh universal variation uh for example property in china and the the left wing uh change to the

uh span actually gonna be 20 to 30 percent right yeah and most of the cases are chained into the

potterway yes well there are there are studies from mainly from japan in this case that see that

what we call normal anatomy in the upper gi system is not more than 55 percent of the people just

half of them all the rest is not normal so variations are very common for the

veins as you are showing here and also for the artery for example the here tall

branch the left hepatic artery is very often originating from a different

origin and you should be very aware of that when operating a gastric cancer

because you don't want to the vascularize the entire left liver so

So removing the nodes around the left aberrant hepatic artery

can be challenging because you want to preserve the vessel

and you need to remove the nodes.

Yes.

So I think in this position, the dissection of the lymph node 11P,

I think the ICG is pretty important.

I can find some lymph nodes really.

But these are not green.

These are not green.

Where you are working, are we in this?

It's along the Spallionic artery, so Professor Guang is dissecting.

I see the green nodes that are around the origin of the Celiac trunk, but as far as you go towards the spleen, the nodes are not green anymore.

Tianxian, I have a question.

Will you dissect all the green lymph nodes during the D2 dissection?

Because I think like this patient, I think the green lymph node is around the 11p, I'm not sure.

But some lymph nodes were not with green lines in the extent of the D2 lymph anectomy.

But we have the same extent as normal. If there was no green line, we also need to dissect it.

Because there is a concern that if we dissect too much lymph nodes outside the D2 extension,

and it may be destroy the local immune function right exactly this is a very important point

you i like this discussion because we are in the age of what we call de-escalation that means

doing too much and removing normal nodes is not only unuseful for curing the disease but can be

also a danger in the local immune system for the patient so patient needs normal

nodes and patient needs normal function of the local immune response so removing

too much is also a problem and that is not just an hypothesis is being already

demonstrated for prostate cancer there are papers demonstrating that removing

Removing too much of the local immune system is different for the patient prognosis.

So we have to make a plan and stick to the plan, avoiding to do too much just for removing an extreme number of nodes.

It's much more important to focus on the quality of the lymphadenectomy inside the station that we have been planning before the operation.

So I appreciate your comment very much.

Thank you.

Thank you.

Thank you.

Regarding the lymph node dissection, as we know, the Attrition 5, the adjuvant chemotherapy

plus the immunotherapy has a negative result.

So one concern is about the lymph node dissection to complete it, but not after the lymph node

loss, the immunotherapy.

so i i can explain in italian to our audience that you have been resecting along the superior

surface of the splenic artery and now you are completely dissecting the root of the posterior

mesogastrium in order to circumscribe the origin of the left gastric artery

including the nodes that are relying on the origin of the celiac trunk as you see now you see the

green light that is just on the aorta at the origin of the celiac trunk and posteriorly this

is the root of the posterior mesogastrium going towards the pillars of the diaphragm that will

be totally naked after this wonderful dissection so we are back to siamo di

nuovo alla vena gastrica di sinistra che in questo caso si muove anteriormente ai

vasi hepatici come si spiegava prima in termini percentuali di locazione

anatomica il 50 per cento degli individui sono quelli che chiamiamo

anatomia normale ma c'è un 30 50 per cento con variazioni di questo genere

both at the venous level and at the arterial level, the most frequent of which is the origin of an

hepatic left accessory artery that can cause problems with quality lymphectomy

if it must be preserved after the origin of the left gastric. Now we will see in this

patient who seems to have arterial anomalies, therefore complete dissection of the origin of the

left gastric from the left gastric vein, the foot of the posterior mesogastrium is completely

distaccato verso la sinistra del paziente e adesso sezionata la vena alla sua origine si procederà

al distacco anche del piede del mesogastrio posteriore anche dal lato destro raggiungendo

sui piani vascolari il pilastro diaframmatico del destino. So after ligating and clipping the left

gastric vein you are preparing the origin of the left gastric artery very clearly demonstrated from

your operation it's extremely clear so your technique is exposing the lymphatic root of

this group of nodes from the left and you preserve the right side of the lymphatic root on the

hepatic artery this is a technical variation that we are observing right now this is very

interesting for us do you always do this do you always preparing the splenic artery entirely and

and leave the right side where the hepatic artery is reaching this point for later on is is what you

do usually or this is just for today usually we like this because because this is interesting

you are preparing uh from the inside and now you are on the aortic surface you are preparing from

the inside this part of the lymphodermatomy that you are leaving for last this is very peculiar

and one third distal this is the border for me i mean when i understand that we are very close

to the splenic ilum that's the border but there is no rule there is no rule it's a continuation

of notes sometimes we have the posterior the gas check artery so some some experts told

there was the border of the 11p but you can imagine that this can be uh discussed in a

patient like that with a low bmi but the majority of western patients has a very high bmi so

understanding what is the border from 11 to the next station is not that you know anatomically

well defined yes seven seven years ago this is this is this is the point that is important

because usually we identify this area because when we find the posterior gastric artery this

is something that should be preserved for it for a distal gastrectomy so that at this level you can

see that this is the point where the posterior gastric artery enters the gastric wall the

posterior gastric artery is originating from the splenic and that is the point when you stop the

lymphadenectomy because you want to preserve the posterior gastric artery sometimes this artery

is so small that nobody sees it but this is what we usually look for we were discussing how to

define the end of the x-ray of lymph nodes 11 on the splenic artery in a distal gastrectomy

and generally the idea is to stop the lymphectomy at the point where the posterior gastric artery

originates from the splenic of course this is theoretically easy but that is an artery that

in obese patients is difficult to identify also because it is often so small that it is not even

nemmeno così visibile quindi la confine della fine della linfettomia verso

sinistra verso lino spenico nella gastritomia distale e il confine

dell'infettomia sulla parete gastrica posteriore che viene preservata per la

gastritomia distale è qualcosa che rimane molto teorico nelle mani delle

decisioni del chirurgo ma che non ha dei landmark anatomici perfetti so it's very

clear that you are totally cleaning from the lymph adipose tissue the posterior

posterior wall of the stomach because this part of the posterior wall of the stomach will be preserved

for the subtotal gastrectomy I I see that you'll leave for the last the dissection of the left

gastroepiploic vessels that in some cases here in Europe are the first one to be identified the

surgeon there was a state in the left side of the patient so for the number one and number three

lymph nodes dissection, we can see the posterior side of the stomach is convenient to dissect

this lymph nodes.

Yes.

Yes, I think you are perfectly right.

So the decision on which session should be approached first depends upon the position

of the surgeon or else.

Yes.

The surgeon's position determines what are the first to be...

Professor, when you performed the laparoscopic surgery,

the position of you was stated in the left side or the right side of the patient?

Well, it depends on the focus of the operation.

I personally use the central position,

position and sometimes when we have to focus on the lymphatic station that are around the

duodenum and the pylorus of course it's better to approach it from the left uh we are very class

but it depends sometimes also on the anatomy of the patient and you know the structure

this discussion is important but not that important now that a lot of people is moving

towards the robotic approach what is your experience with the robotic approach

And we have two different lobtic systems, SI and Xi, and usually one week we have one

day for the lobtic surgery, and the fee is expensive.

Yeah, it's much expensive, the Xi is very expensive.

yeah so for the uh robotic for the davinci x i also have the icg uh oh yes the five yes the five

fly the feeding is not not very good it's not yes this one yes um yes i don't want to speak about

companies but you are right the system that you are using here to enhance the lymphatic vision

and bifluorescence is much more high quality compared to what is present in other platforms

thank you for that

well uh the most is going to be completed into a copy right

yeah the construction the construction is going to be completing

yeah but usually before before speaking about reconstruction i i i would like to understand

when you are going to remove at the origin two main vessels that are still remaining that are

the right gastric artery the right gastric artery and um and left gastrofibroic vessel at the origin

we were decided number five yeah yeah it's um it's a very peculiar way because uh we are moving in a

clockwise direction you are doing differently because you want to preserve this station for

last and i understand that your decision is done because after the complete mobilization these

notes can be more precisely identified and removed and it is not that clear like you are showing

in a perfect way now the same session when you have all the stomach fix it in

its anatomic location so so it's very accurate and I think I understand why

you leave it for last

have have taken out of the missing in this region we need to proceed with

caution there's so many so this is another node that is not green you see

professor wang this node here is not here is not green right yes it's not green yeah

we lost green light but it is anyway inside your operative plan for a d2 right

now we see some green now we see some green on the other side yeah okay okay not not all of

infernos will be green yeah yeah now let's say this is interesting this is interesting yes this

is either in order to explain everybody that icg is a guide is an adjunct is a useful tool but it

is not everything i mean it's not the the you know the the bible okay yes i i i think i think so

It's the right gastric artery and the veins.

Yeah, this is the right gastric artery at the origin,

and we can see that it goes towards the anterior border of the pylorus area.

Now you have reached the other side, so the duodenum is cleared.

this is a very interesting way to approach the lymphadenometry on the border of the hepatic

vessels because this is more more precise and more accurate compared to what we usually do

that is approaching this station from the anterior side and i i understand that this

is a choice in order to have a clear duodenum and no nodes remaining in between the hepatic

cardi and the origin of the right gastric artery very good congratulations it's a perfect demonstration

this this case is was without the common half common half of the artery

This is a pretty excellent performance there, zero blood loss.

Even for the total gastronomy, where you retract the liver for the first time,

I didn't see the liver retraction in this case, right?

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

I think it's like, hold down.

I think it's like, you can't see.

Thank you.

Thank you for providing the quality of that.

Kuo Jianjian.

Yeah.

I didn't see the liver retraction before the surgery.

So usually we didn't have the left liver holding.

The assistant make the process to holding the left liver is okay.

case so this is accessory left uh yeah yes yeah it is located inside the pars condensa of the

lesser momentum we usually use this pars condensa in order to suspend the lever with some traction

Number one, number two.

Number one, yeah, yeah.

So you are releasing the duodenum a little bit

in order to have a suturing of the duodenum

that is not under tension, right?

Yeah.

We are still discussing on how to avoid the rare

but still frequent occurrence of a duodenal leak

because there is no apparent way of understanding before surgery

who are the patients that are going to develop a duodenal leak.

that is very unfrequent but when it happens it it is almost impossible to be you know anticipated

it is a low occurrence it is two three percent but when it occurs we don't understand why you

have any special consideration about that I mean for example these releasing of the duodenum is

Today we were performing the B1, so...

Ah, B1!

Ah, B1!

That's incredible.

If we had the B2, we would have shot it.

But did you know this, Chang?

So you are doing a B1.

I didn't know that.

Okay, okay.

Yeah, today we will have data...

Let me explain to our audience.

this extensive preparation of the duodenum is not done to improve the possibilities of a safe

without fistula sinking it is not done because the colleague prepares to do a b1 that is to do a direct

anastomosis between the duodenum and the gastric mucosa that he has previously prepared that will be preserved

since we are in an early stage of disease ok yes for the people we want anastomosis that you

will be a little longer.

Yeah, now it's very clear and we are very

interested to see your technique of performing

this peculiar anastomosis that nowadays in western countries

is not well performed.

How do you determine the method for

for the consumption because one plus two or raw why well uh 90 of the abrasion are ruined why now

90 yes b1 is extremely rare extremely rare so 90 in italy maybe 75 in the western world is

israel why there are there are data i mean i i'm i'm thinking i'm speaking freely but there are

data about that incidence and i think that one of the major differences between east and west is the

is the opportunity of performing a b1 and performing a b1 is the operation that can be done

in very different way a real why is always performed with the same kind of anastomosis

but b1 is uh is different from surgeon to surgeon so we are very interested to see how you're doing

and get so you are using a white cartridge this is interesting why yes like just be just below

the pylorus with the two centimeters of the first portion that the do you know that have been

totally freed this is interesting so just below the pylorus it is white but you have a long portion

of duodenum that is being free from any additions in order to prepare for a b1 great

After we transacted the duty notes, we were dissected the number 8,

partially of number 8 poster, number 8P, the liver notes.

I just told him.

Yes, this is what we've been discussing before.

You leave this part of the operation at the end

because you want to be precise and free to move in order to remove a 8p so you

are trying to go under and and and behind the origin at the border of the

portal day the comment I have to utterly is missing so we can see there was the

the poster when is it originating from the superior mesenteric i mean where is it coming from

the common hepatic

maybe maybe from the superior mesenteric yeah so you must be very careful when you prepare

the duodenum but because you can find a uh an aberrant uh hepatic artery major hepatic artery

on the on the right side of the duodenum on the posterior side of the duodenum

Grazie, abbiamo sentito tutto, tutto molto chiaro, e una sola piccola precisazione, ma il corso è prevalente a destra, mi pare, il corso più impegnato e il corso più immenso, giusto?

Sentite l'aroma? Sentite? Ecco, forse ci sentiamo.

No, chiedeva, chiedeva, chiedeva, chiedeva, chiedeva, chiedeva, chiedeva, chiedeva, chiedeva, chiedeva, chiedeva, chiedeva, chiedeva.

Very good.

Great.

Okay.

Thank you very much.

I am Professor Arcei.

And with me is Professor Tricato.

This is Sprinkler.

surgeries for get early cancer for some of the panoramas preserving

all the tumor located in I mean the body no by Lawrence preserving is never been

in our our goal because these cases are very rare there are cases now when we are discussing

another option that is not for today that is proximal gastrectomy because we we try to preserve

some function of the pylorus in proximal gastrectomy but this is the only way when we

preserve pylorus in gastric cancer so we should have a very initial tumor located in the upper

per third in the form of a c for three now this is very uncommon i mean having a subcardial small

tumor that can be treated by a polar resection is very and those are the only cases where we

preserve the pylorus with the additional issue that when you do a superior polar resection

you're removing the vagal nerves that are going towards the pylorus so why preserving something

something that is not functioning anymore so for the proximal gastronomy yeah how do you

um I mean preserve the uh I mean the function of the the yeah we think that the reservoir is

important so uh the in any way the pylorus function is lost because of the of the innervation is lost

and what is uh also important is that in order to preserve the reservoir you should not increase the

reflux and so we are we are trying to study these opportunities but it's very difficult to perform

a good trial because these cases in the western countries are so rare we will perform kamikawa

anastomosis for yeah kamikawa yeah yeah yeah in order to have a sort of of um of anti-reflux

wrap yeah yeah so you are you are taking for the last the origin of the left gastro

bucolic vessels you are going now towards the splenic hilum right yes we

dissected a number for SP the lymph nodes runs the left gastric point of

vessels it's the last last lymph nodes we were dissected yes yes it's in it's

an interesting approach I think you are you are doing right and this is very

unusual for us because we do it for for the beginning everybody you know you see

those additions between the gastric the product people like fat and the spleen

and in fatty patient when you have you know an operation with a fatty patient these additions

can be broken very easily because you fracture the stomach on the right and on the left and you

can have a bleeding so the first thing that we do is going to wash the screen you removing the

addition that you see very clearly now in the inferior pole of the spleen and then start to

dissect the stomach from the spleen and from the left gastrointestinal vessel in order not to have

during the operation some breaks because you are very delicate but sometimes in fatty patients

keeping the stomach on one hand on the other hand can break those addition that you are showing now

i mean you are going towards the the spleen and as you see it's very clear the fat is adherent

to the spleen. Imagine in a fatty

patient when you grab the stomach

up and down

you make a break. So we don't

want to have this bleeding and we do

what you're doing now as the first

part of the operation.

Exactly. This is the first part for us

because the spleen is free from

any traction. During this

lymph node dissection the surgeon's

position was changed.

He's standing in the

between the leg of the patient.

Yeah. And the

camera holder was moved to the right side of the patient and behind the system okay so you you you

move yeah we move so your your hands are going directly towards this in a very ergonomic way

i understand this position is pretty good for the hypnotization in the standing high line and they

Yeah, there is lymph nodes with green lines.

For OSP?

Yeah, for OSP.

So if the patient received total gastronomy, the lymphatic dissection in the number 10 is going to be the last step?

yes yeah it's a little master step yeah

i think that especially in this station where you are you know in the middle of a fatty tissue very

anytime the green is very useful in order to guide your dissection without any it's very clear you

see the green there and this is helping you to identify in this difficult position the right

place for dissecting. You can see some pancreas. Yeah, pancreas, yeah. The pancreas tail. Sometimes it will have some injury on the pancreas if you

some of the patient. Yeah, yes, because the vessel that we are looking for and you are

showing very, very nicely now are originating from the inferior branches of the splenic vessels.

So, these branches sometimes are confused together with the tissue of the pancreatic

tail.

Yes.

Yes.

Yeah.

Would you like to introduce your opinion on how to work the indication performing number

10 because you have done a lot of work for splenic hilux lymph node dissection

though I want to know your opinion to perform the number 10 and before the

In 2018, I think, an advanced gastroenterologist located in the upper third of the stomach,

we will perform the number 10 lymph nodes.

But after that, after JCO 0110 clinical trial, the guideline was changed.

Now, we performed the number 10 lymph nodes when tumor was located in a great curvature

or with the serosal evasion and the posterior side of the stomach.

Not all the patients will have the number 10 lymph node dissection.

Yes, this is regarding the indications, but what is extremely important

is that everybody in the world knows your way of cleaning this plenic ilum in these cases these

selected cases with your wonderful techniques that is divided in three steps the three steps

of removing influence and we everybody is remembering your wonderful lectures and videos

about that and thank you for showing us in other occasions what is important to learn from Chinese

surgeons usually we will keep two or at least two short gastric arteries yeah yeah and and you are

preserving that because it is going to be a sub total so you want a good vascularization of the

gastric stamp so you preserve this long short this is a long short vessel long short yes

yes attention the tension

no as you told as I told you we don't perform you one so it's very clear that you we try to

be very accurate on on the gastric stamp that usually is very short and of course since there

is no tension in this case we can easily pull up a jejunal loop performing the usual lateral lateral

anastomosis that we have been learning from the obesity cases it's it's the most easy

kind of anastomosis during laparoscopy in my center we usually perform the two

it was two mostly patients yes yes we have the same symptoms but some some patients

that we were performing the first one with the data shape anastomosis

so we are looking at how to deal with the bleeding in the spleen especially caused by the

so this is the first time that you are using uh bipolar energy monopolar monopolar energy

the first time with the operation because there were a little breathing in the spring

It's okay.

I know Professor Huang has modified the delta and the tomocyst

by disrupting the dog ear right yes yeah after that do you make any other

modification for the anastomosis and you means the complication no no I mean the

professor one has modified the dirt anastomosis and after that do you make

another or any new modification for the anastomosis? Overlap, yes. We have overlapped for distal gastrointestinal.

And BILOS2, maybe sometimes totally laparoscopy with BILOS2. For BILOS1, most cases will receive

then the colleagues are discussing the technique that was called anastomosis

modified delta which is the one that was in some way advertised and shown

several times by professor wang now we will see it in action and it is always the same they call it

vascular margin so that there are no differences in length between the

front wall and the stomach wall otherwise the suture could come

unequal and the important thing is that there is the same amount of tissue

front same amount of tissue posterior between the branches of the

staff already the fact of seeing that with a 65 you can easily reach the

So I didn't see the tumour location clearly, so will you check the tumour location after

dissecting the tumour?

Yes, this tumour was located in a greater curvature near the antrum, so we can see before

the operation there is a we will check it during operations sometimes we will

make a small incision to take our stomach and check it yeah of course

there is a recent publication from Professor Woo Jin Jung from Seoul Korea

showing that the calculation of centimeters especially after the

resection when the stomach is retracting is a very you know non-objective measurement

so what he is doing is injecting the green close to the tumor not around the lymphatic

points like you did but just on the tumor in order to establish how the lymphatic

backflow of the tumor is determining the green coloring of the gastric wall and he is using the

the green in order to establish where is the dissection point it's very

interesting I think it's a theory and this under study on a trial cancer we

really injected by the endoscopy so one function is for lymph nodes dissection

the other is we can check on the tumor locations yeah let me translate for the

We are discussing the fact that this injection of endocyanin has been done in six cardinal points to better identify the stations that were planned for one of the two.

c'è anche un altro modo di utilizzare l'indocianina per i tumorale per vedere nella diffusione

linfatica del colore dove fare la sezione in caso di gastritomia sul totale piuttosto che

usare il criterio scarsamente oggettivo dei centimetri usare il criterio della diffusione

del verde per dire dove si può portare la linea di resezione quindi adesso al fine di asportare

il pezzo e confezionare questa delta shaped modified anastomosis per la b1

l'estrazione immagino avverrà attraverso un allargamento dell'accesso ombelicale

quindi un buon protector misura small

all make a smaller incision yeah along to the amber

yeah you are double checking the safety margin

We can see the the market yeah the market is not enough

this is this is a signet ring and and you know it's very important that the margin is

extensive yes no no frozen section at all you don't perform any frozen section

stiamo dicendo il margine in termini sentimenti essendo un tumore a

cellularello con castone la frozen section cioè l'estemporanea sul

margine potrebbe essere qualcosa che supera il concetto dei centimetri per

darci sicurezza di effettuare un'anastomosi addirittura una b1 quindi

vital for the patient on tissues absolutely not contaminated by neoplasia

recognition on the lymph node stations in such a particular case where the entire

hepatic artery comes from the bottom of the upper mesenteric there is no

the liver artery on this side and we have seen how the quality of the anatomical dissection

around the vessels is practically perfect we see the splenic that pulses the anterior margin of the

superior mesenteric vein that ends under the pancreatic isthmus with that last clip that

marks the famous lymph nodes 14 v here we have lymph nodes of the liver that are not in the

l'obiettivo di una di due e questo è il termine della stazione 11 che è il termine della

linfetomia radicale per una gastetomia subtotale. I vasi gastrici posteriori sono preservati,

la vascularizzazione del moncone è garantita, dettagli di hemostasis.

I have a question about the lymph node sampling. Will you separate all the green lymph nodes

for lymph nodes cycling for pathological pathology. Is that all the green lymph nodes?

Yeah, we will separate. For example, the number six, we will separate the lymph nodes with green

The other part is the no green light lymph nodes, then we were sent to have the pathologic.

Yeah, I know because it will take a very long time if you want to detect all the green lymph nodes.

Another question, is there any difference between the non-green lymph nodes and green

lymph nodes in terms of the metastatic rate?

I'm sorry to interrupt, I would like to have explanation about this modified delta technique.

So we have seen that the surgeon has opened the part of the duodenal stem.

Can you explain in detail the anastomosis?

Because this is very unpopular in Europe.

We need a precise explanation of your technique.

And the first, when we transacted the diageno,

it's from the poster side to the front side.

It's not from the great water to...

I mean, when we transact the duodenal, we need to make it from the posterior side to

the frontal side, not from the great curvature to the last curvature.

We made a small hole in the posterior side.

the other small hot is in a greater curvature of the standard stomach so here in this point yes

when there is no suture just above the suture line and then you carry without the suture yeah

just above the suture line I see no gastric tube don't you don't use any gastric tube during this

No, no, no, no gastrointestinal tube. We were sectioned.

I mean not after the...

No, no gastrointestinal tube, no gastrointestinal tube.

Okay.

Usually, usually we were not made.

But if the patients with obstructions, maybe we will have gastrointestinal tube.

But most of the patients, we were without the gastrointestinal tube.

okay so the larger part is inside the stomach yes the larger then you then you close your hand

and you approach the entire device to the duodenum without okay in order to to test the tension

So it would be a modified delta and it's almost not the overlap.

Not overlap, that's it.

Yeah.

Sometimes in my center, to release the tension, we will perform the overlap.

Overlap, yeah.

Yeah, yesterday I have performed the overlap with the previous ones, but most of the time we will have delta-shaped anastomosis.

So this is overlapping, it is not delta-shaping?

No, no, it's not overlapping, it's delta-shaped.

This is delta, okay.

Our lab usually will make a small hole in the gluteal curvature, a little bit high.

It's in a poster-sized wall of the stomach and the duodenal.

We will check it in a common incision.

We can see there was no bleeding.

water this is a suture only to hold up the lips of the

margins that are missing to make a delta shape it is not a suture of closure it is only

di trazione this is just for guiding the minimum effort when you perform at the Delta shape suturing

It's the tension that makes you feel.

Let it go, let it go.

Don't let it go.

Where?

There's a problem.

Imagine the war.

It's a little easier.

It's a little easier.

This is the most basic.

Just look at me.

Just look at me.

Just look at me.

I'm the one who's going to be there first.

You're going to use this costume.

May I ask how much time do you wait before oral feeding in this anastomosis?

When the patient is going to drink?

after she has the pathway nearly two or three days post operation and when is the discharge

how many days in average yeah here is one week five days post operation we will have

semi fruit belt mm-hmm and do you ever perform barium enema control for the anastomosis function

or you just rely upon the clinical situation and and renegades sometimes we will have

have the X-ray to check the anastomosis is good.

Sometimes.

Sometimes.

And what about the drainage?

Are you using post-op?

Drainage.

Yes.

Drainage.

Drain cubes.

When we removed after she has the semi-fluid, usually it's six days or seven days.

post-operation I mean are you placing are you leaving in place some cubes

designs with ginger tube yes we will have one change the tube no Jen J I mean

drainage drainage in the surgical field yes okay everyone you can see it later

this is for the double the double goal of protecting

protecting super adhesion of the metallic clips on the adreviscus and also for having some more

hemostasis, right? Yes. It is not just for hemostasis because when we reoperate patient,

we see that where there is metal clips, there is special adhesions and I understand why you protect

it. After this, what dietary instruction will you give for your patients? I mean,

like how many meals they will have one day or what kind of food they will take

in after within one month after their operation one month or maybe it's not

it's normal doubt and the first we will have fluid that and after she have

the pathway and usually it's two or three days post operation and when the

five days post operation you will have the semi fruit yeah then one

week they were discharged and have the daily life maybe soft food is better

better yeah we have no let you want to it's okay all the operation is finished

have you any data according to your large experience in this kind of

operation have you any data about the possibility of bile reflux no we don't

have the data we don't have the well I think that everybody has enjoyed your

wonderful demonstration I think that from Fuji and we always watch at the

best surgery ever it's worldwide famous technique and every year we learn some

more. We have observed your new technique of mapping the nodes by ICG and demonstration of

the modified delta-shaped anastomosis, double check of the margin and perfect control of

hemostasis and without any kind of endonasal gastric tube. So it's great and we congratulate

with you as always. Thank you, Professor Drugo. Thank you, everyone, online. I think Professor

That's why I have performed a perfect live surgery.

Yes, we know him and we appreciate every time his wonderful demonstration.

Thank you from Rome to China. Bye-bye.

Thank you. Bye-bye.