Eduardo Parra Davilla Robotic surgery in hernia and colorectal procedure

I'm from West Palm Beach, Florida, happy to share some of the work on hernia and colorectal

procedures.

These are my disclosures, I work with a lot of robotic companies, the disclosure will

be for all this, everything I'm going to talk in the next, you know, minutes or hours.

We'll have a brief introduction, we're going to touch hernia, I'm going to scroll

up our stoma, component separation starts, some complex cases in the reticulitis, and

an epidemic or pandemic that we have in the U.S. is about morbid obesity patients.

Here's where I'm at.

I'm 71 miles from Miami, for those who don't know Florida well, and I'm about 60 miles

was from the Bahamas that's our hospital that anybody wants to join us to have some fun and

share knowledge we'll be happy to to have you guys here this is a brief introduction this is

what I started doing robotics there was a big opposition and controversies about this is it

or not they used to show this slide about you know lap and robotics and if you look at them

they can be when they're small it can be pretty offensive but the rabbit even if you put them

on steroids will always be a rabbit um we did a lot of uh laparoscopy for many years and besides

staplers and energy when some articulated instruments we were not going moving anywhere

wear for years the middle tiger will grow up especially with everything is the software

robotics it's not the articulation but the software i think this will be a tool that we're

all going to be using in the future forearms you know you guys are good in football um can be

better than two arms and we can show this in the next videos problem is the surgeons you know we

always the perception is not always the reality we surgeons have an ego and we all think we do

things the best and sometimes we're um hard-headed to change things that we were doing before

we all think we're the best surgeons in the world we always think we're kings

so the surgeons have been asking for improving instruments and you can see the history and

surgery and laparoscopy they're always trying to get an articulated instrument and when we have

particular instrument everybody said it was too expensive we don't need it

so tourism very particular how we um have uh adoption of new technologies

this is just something showing is a very precarious

robot and just by having the landmarks you can uh you can do this and

you can have your hand there and knowing that

you can put it as fast as you can and it will still not touch your hand and this is what we

talk about safety and boundaries um it's not the same um henning with uh this is a

video but this is something that we can be safe for robotic i think we the world will be more

towards the robots so the problem could be um i think we reach a point that we need some help to

to cross the bridge, and right now we have a helping hand

to merge what we know in laparoscopy towards robotics.

You know, it's not always, perception is not always

what we look at until we try it,

but as far as those who haven't tried robotics do,

it's a different way, and I don't think they're enemies,

robotic and laparoscopy, this is just,

they're gonna be friends,

and they're gonna be helping each other.

So, let me start with the pentox that we have.

This is the noscleral hernias.

There's big hernias and giant hernias, as you can see in the picture.

This is a patient of mine that I was trying to lose weight before I did it.

He had kind of a loss of domain, and I was trying to lose weight and prepare him,

but he had an important event one night and he came incarcerated i'm going to show you that as well

so loss of domain you need to know a lot of things like hemoperatoneum component separation inlay

manages visceral reduction surgery and stages botox has a high recurrence you need to know what

to do with the hematomas and you need to go and advise the patient of possible care these are a

a little bit challenging and depending of the site of the patient and how many

surgeries they had before. You have to be aware that the loss of domain can be an

issue and it's something that you have to be knowledgeable about. This is a

patient of mine that I put pneumo for the perineum. You can see how the pneumo

creates a space for us to put the hernia inside. One of the things we need to know

is what to do with the scrotum of this giant hernias and my preference today is

to do them at the same time we call it scleroplasty that's very simple to take the skin off because

this skin can become very thick and a cardboard and it creates a seroma and we don't do it at the

same time so what does that mean so this this uh we usually do once we do this robotically

hybrid procedure from the outside we finish the rest of the sack and then we create the

scleroplasty we leave drains and do pepsis of the um testicles so they don't get torsions

This is more or less where this happens.

There's a lot of challenges in this between obtaining right angulations

and atomic structures and preservation of the gonads.

Can robotics make a difference?

Yeah.

This is a patient that is morbidly obese,

and you have to do this patient with a growing hernia.

I tried to do this laparoscopically, and I was bending the instruments

because the fatty pad tissue was about 10, 12 centimeters,

And I was angulating the instruments, trying to get the angle to get there.

So this was my third case of robotics, so we decided to put the robot, and at that time

I learned that the force of the arms can overcome the challenge of the abdominal wall, and I

was able to gain my angles and finish the surgery.

It was non-invasive.

That was quite an advantage with this huge band of adipose tissue that the patient had

in the area.

We left a drain in the scrotum that the section was rough at the end of the vertebra.

That's why we left the drain.

But hernias can become very challenging.

This is a recurring, recurring, recurring hernia.

Many times it's been done.

Years overcome patients from doctor to doctor until they decided to seek some help.

We decided to put a port.

You can see it here on the left side for pneumoperitoneum.

and this is what peritoneum looks like and the air dissecting through the

peritoneum once we know that we have a space to bring things inside we go ahead

this is the new the last version when it's not the last this was the XI with

and use the air seals when they have a challenging case right here so I can do

better suction without any problems and you can see how the small bound the

large bowel are going to be in here completely inside the inside of the

hernia this is the small ball coming out and then after that the right column is

going to come out through this area so this is with you can see the column

coming outside now so here's the right side here the left side as well so this

is nothing more than a tap you have to know that once you do these cases the

the sac you have to go as far as you can but you don't have to take it all because you're

going to do a scrotoplasty so you can sorry you can go in and go down as much as you can

and once you reach this point here this is that like any other tab once you reach this part

and you have trouble with the sac then just divide the side because this sac will be gone when you

do the scrotoplasty. So you cut the sac in there and you abandon it in the scrotum and then you

just finish the just finish the task identifying the structures. Sometimes when they're difficult

they'll be reduced and you can use Firefly if you're not sure because they're if they're very

obese sometimes it can be difficult to the to see which vessel is what and with the fat you can do

fire flying will tell you what the vessels are and you can continue with that. Once you do that,

then in this case it's recurring several times and we suture the mesh. These are anatomic meshes on

the side. You can use any piece flat or piece mesh that you have. And then we do like a soap

on top of it to reinforce everything over this area. We put a larger mesh and then we close the

defect what do we do once we close it we end up with this and uh we open the scrotum and we know

how much kin we're going to take we find the gonadals we do pexis on both sides and we leave

drains always being left on the patient until they get us they stand uh of the um and when they're

out of bed on the floor and then this is the patient post-op and this is at the end of the

procedure. A couple of weeks later, you can see where the pull was and the difference on this

patient. But not everybody needs scleroplasty. This is another large hernia. Same thing. We

dock higher than the umbilicus and then we just leave a drain and this sclerodon will regress

without any problem. So you just have to pick who scleroplasty needed and who doesn't. For this,

this patient will be okay at the end of the procedure. Sometimes you have a hernia,

is you can get them inside and to return you start dissecting and there's a piece of bowel

that is stuck up into the area of the ring and you can retrieve it and so you got two options here

if a piece of bowel is stuck up there you can bring it down you can do a hybrid procedure

or you can cut the ring a little bit from the inside make sure that you don't injure the bowel

it's the same thing you will do when we do open when we couldn't reduce the

hernia and then once we do that then you can get inside the area and look at what

is trapped inside you can see here and if you get an articulated instruments

like we got the vessel sealer here then you'll be able to get what is strapping

in there you can bring everything down and then at the end you close that up

and you put a mesh on top that's a trick that you can use when something is

incarcerated. This patient, as I showed you, was waiting for optimization.

Unfortunately, came at 3 o'clock in the morning with an incarcerated and ischemia.

I attempted this robotic, as you can see here. I did not do the same, so I went hybrid.

And I have to protect a piece of ischemic bowel as well as a mentum. And once this

was done, then we finished the rest robotic. As you can see, these patients, if

you do them this way they behave post-op like a robotic surgery and this incision here the scrotum

doesn't hold them up too much in the hospital we left the drain and we put the screens on this area

we put if they're clean contaminated we put screens we put them on antibiotics for a week

and then or you can use a biologic it depends what you discuss with abuse

sometimes you know these are all recurrences and this is a patch we don't like to use plugs because

of this sometimes it is standing right there in the way the patient has seen but this patient

was done open the plug out then if you think minimally invasive some other people say well

we're going to leave the mesh on the other side. The mesh was floating was causing

discomfort. I'm going to show you what we did with a mesh here and here we just

press from the outside and we brought the mesh towards the defect and then we

take the mesh that was placed on the outside you're going to see it here we

take it out completely remove them and then once we do that we can do the

repair so and you know you have to think minimally invasive and sometimes you

can sometimes you can we cannot but if you can and you can see there that everything is done

and then and recurrence and after recurrence this you can discuss this we try to if it comes

together we uh close this defect pain is an issue if you're not careful or uh if you grab some nerve

but these recurrence and recurrences we tend to uh on the direct areas we tend to close this up

because he had ventral hernias. Then we just put a large crease and make sure large and we cover this defect.

These are multiple tags and you're going to see here I cut into bleeding. I cut a piece of

the epigastric vessel. You can see how pinpoint and how I can control it. We had a suction in

that area and just what you know you know it's very precise how do you improve that in recurrences

and i'm going to show you that in a little bit and in another case that i use firefly to identify

better the vessel this is something that robotics can help you can see how um the dissection is

being you can see the pigastic vessels totally dissected this is a patient with a recurrency

see open recurrence laparoscopic and recurrence incisional hernia. You can see the dissection

and how the robotics can help you. You know, most of the patients going and doing this

will take the gastric vessel, clip, clip, and remove it and continue. I was able to

save them. I can work around them without any problem. This is a patient with 50 tacks

and groin pain and this is another category. This patient had five meshes in the right groin and we

took one piece of mesh after the other in pieces. We were able to take the different tacks. You can

see them there and the patient has 50 tacks. You can tell what's fibrotic and what's not. What needs

to come out and not. You just have to know what structures you can't injure. You have to see

vessels you can have to see uh ureters you have to see uh gonadal vessels if you can save them

so everything have to be you know but you can see how the tissue is all plastered the one that i

wanted to show you is in this case is once i start peeling pieces of mesh and plugs the this is what

i do now i i play spy fly and i want to peel as much as i can of the meshes because of pain and

And then I can see exactly whatever is black, I just take it, and I just stay away from the green.

And that's something that has helped us to improve the safety of these pieces.

That way I don't do what I did the last time when I showed you that area.

This is the patient afterwards.

So I think in robotic, either a tap or any type of procedure you've got to do,

an inguinal hernias, I think the, I believe the robotics can help you.

Barostoma hernias is the, I don't think it's a, it's a procedure that you want to

learn and you just have to dive into it. If you get comfortable with it and you

learn about it, it's like any other hernia except you have to take care of the

the bowels, you just have to learn some tips here.

So is it technically difficulty?

Well, they usually redo, but if you do a lot of redos,

this is in your category.

And some of these hernias just open.

And so this is open, this is open.

So whatever is open, you just go open.

So still have the open approach.

To convert from laparoscopy to robotics, you can do,

but robotics back to laparoscopy,

it doesn't happen at least in us once we convert from the robotic we go open bottom line you can

reverse them if possible you repair with symptomatic you can watch them if the patient

is friable and has other issues but if they have in pain we usually do this is also another

classification by pauli when it goes small large and what he does and we're going to touch the

public technique that we do robotically as well. The evolution of parastomal hernias has been gone

from open to laparoscopic to robotics and from intraperitoneal meshes and from keyholes

and to sugar bakers and extraperitoneal meshes. The problem with parastomal hernias is what is

just right. It can be too much, you can be not enough and that's where the key is. A surgeon

from France a friend of mine he's named Eric we're here who used to tell me and

we are 20% size and 80% part and this we can argue that all day long but there's

a lot of non-evidence that we do that imperial can buy art but this is he

home you can see it on the number a and that letter a and the sugar bacon you

can see on the on the beam most of the surgeons they are being the sugar maker

from intraperitoneal to extraperitoneal so the

sugar maker went to this you can see this there's a citation down below this

is more or less with drastically V8 the vectors of the inside of the abdomen on

a hole that you have with a piece of body coming through this area the Achilles

tendon of this is sometimes from there and the other side on the one of the

size gets a little bit loose and then the past the another bar stoma comes to this area so there's a

herniated bowel and that needs to be reduced so we've been using wider and wider meshes

and try to go extra peritoneal so we can decrease this problem here's the uh uh picture of an image

of it if you can see down here that if you put this area too tight this area can have an issue

have issue with erosions and that's something that you have to be aware you're going to see

how we calibrate that and do not have any problems so how is a sugar baker that good

things about this hernias and robotics is they're usually lateral most of them are lateral sometimes

they have incision hernias and you can't put four ports but it's just parastoma you can put

four ports in it and you can see what the goal is down here in the bottom right side the first

part is adhesiolysis and this is an intemperatoneal sugar baker this is how we started we take adhesions

down and usually what you're going to find is you're going to find all tacks and meshes that

were placed before when you were there you can see a biological mesh on behind this area over

here with some tacks that doesn't use for what we see when we got recurrences i think you can put a

synthetic mesh in this, but a lot of the thoughts were just using biologic, but you can see

the recurrences. Once we do that and we dissect all the area, then we address where the ostomy

is. This is just taking down the adhesion from the previous surgery. Once you find the

ostomy and the defect, then you would like to do several things. One is dissect this

area. Two is lateralize the limb. Three is closing the defect and then putting the mesh.

this is just dissecting so we can mobilize well the the limb that is using

for the ostomy and once we do that then I clean it up completely I said all the

things so we can lateralize the edge and once we finish this and dissecting all

the sack that is there going inside that's a beauty of articulated

instruments and then we end up with this so we want to lateralize and what

What does that mean?

We close the defect first,

or after that, the license,

you can do it in either order.

You can close both ways.

When they're two-circle,

you want to convert the circle into an oval

to be able to close it.

You can use permanent or long-term or total sutures.

That's also controversial, what you like to use.

Once we fix the, once we close the defect,

one side and the other side then we lateralize so once we close the defect

lateralization what it means is grabbing a piece of the fatty tissue around in

the column and then you just put it against the abdominal wall that's called

lateralization of this area you can see how we do it by lateralizing you do one

One side, do the other side.

Once you do the other side, oops, sorry.

Once you do the other side,

once you do the other side,

once you do the other side, there you go.

Once you do the other side,

then you lateralize completely.

And once you have the defect closed lateralization,

then you're ready to put the sugar baker,

as I said, this is the, we were doing an intraperitoneal

and then you just put the mesh.

If you look at this here, this is the calibration.

This here with a few tacks that I have here

so I don't make it too tight.

The suture comes from the outside.

I leave the rest of the suture outside completely

so I don't have all the piece of proline.

This is 2-0 and I just go, I just pull the proline

and comes in the arm that I have the needle holder.

This is the tacks that I show you that I do that

or sometimes I suture it and I can do this all the way around until I reach the other side

completely and then what do I do with that once I reach this side here I just tie it up there

so you can do pretty much 180 degrees and once you get to that point you can

get one more and then you can you can tie it there and then you can tie the one that you just put at

the beginning and then you do the same thing on the other side you have the whole mesh sutured up

this is how it looks like at the end you can do a different calibration once you lateralize the edge

and this is the same thing lateralization then you can put one suture in the middle

write it up all the way if you don't want to use the tacks once you put it all the way up

you get another suture you leave that one there and then you bring another suture and then you

You just put it on each side of the limb

so it comes very comfy without, you know, too tight.

It just has to be right.

As I said, it can be too much or not enough.

So you can do that and you can see how it's still loose,

but it's still very adaptable

and tailored to what you have here.

And then you suture, once you do both sides,

then you can use the sutures to do the rest of the area.

So this evolved into the E. Pauli technique.

And this is the citation.

this is how it looked like when it was done open when you lateralized and you do a tar pretty much

with this you can see the the transverse muscle and it's going to be divided so it can be a tar

this is how it looks like this is the defect this is the defect here it's a transverse abdominus

and this is the flap that we have been created this is how it looks at the end how did that

does in the surgery this is a surgery I did in Seville in Salvador Morales meeting and you can

You can see the defect there with the parastoma.

So first of all, we dissect the sac.

Once we have it dissected, we do the flap

and the flap is performed.

And you'll get the posterior rectal sheath.

You can see the rectus muscle.

There's a neurovascular bundles in this area.

And then I go where it calls bottoms up.

And this is like in the tap, we do the hernias

and we go from the bottom all the way up until I reach the ostomy again once I

reach it then I try to go around it and try not to injure the limb and then you

can see it there then I go up in the upper part the transverse muscle here is

thicker and we're gonna see that when I show that TART technique once you do

this you you leave you can be in the peritoneal space and you can do that

pre-transversalis. This is pre-transversalis because you can see all the muscle being

denuded completely on this area. So it makes the flap a little bit thicker and less holes in it

that if I can't get into this plane, I like to be in this plane. Once I finish this, I lateralize

the limb. We already have the flap. And what I do is I start closing and I push the limb

all the way laterally.

When this is laterally, then we lateralize the limb,

as I said before.

And again, this is a very,

these days it's kind of a standardized

to do all these steps.

And once we have this and we close the defect,

then after this and we're ready to put the screen.

And the screen is measured

and it basically plays completely.

And then again, I put a few sutures just to make sure I don't make them too tight.

And once I finish with this, then I'll close the flap, and that will be the end of that area.

This can be a little bit more challenging.

We have an ostomy and a colostomy and a urostomy.

This is a retromuscular, the first stroke where we look inside.

But after that, we place this completely extraparatonially.

and once we do that you can see the dissection and we connect one side with the other once we

connect this with the other side these are both rectus muscle size you're going to see this in a

minute once i connect it right here and you can see the troker on the other side then you pretty

much you have to put one troker in the middle for the camera and then you dot the robot this is the

the space that we have.

Once I create the space, I put three trochers,

put the robot, and then this is more or less

what you start looking at when I go all the way down.

And this is the same technique you were looking at

that I did before, it's just,

this is totally extraperitoneal.

And it gets repetitive, it just dissects out

and I do the other side, then I go down completely

where the patient had also had an incision or hernia.

This is just doing a small tart here

that I needed for a little bit more space.

It's the neurovascular bundles.

You want to be about a centimeter, half centimeter off.

This is the transverse muscle being transected.

So this is the same technique you guys saw before.

And at the end, we do the same.

We lateralize, we place the limb to the side.

we do this for both the urostomy and the colostomy place the mesh and then this

is pretty much the end of the procedure so parastomal hernias have evolved a

long way I think we haven't resolved all the problems but this is the best so far

that we can do on these on these cases anterior component separation people

won't believe okay why are you doing this robotically this is easier to teach

after I see that, after I show you what the tar is, this patient has actually

been published in several books of robotic surgery. At least I think we have

three or four chapters. This is a simple and easy. Robotic anterior is not

going away. Actually it can be a bailout when you have something underneath that

that is a disaster and you don't want to be having enterotomies all over or this space has been used

already and you can go on top in unused space this is how it looks like this is the alternative

this is the space that we enter and we measure and I'm going to show you how we do this technique

this is a morbid obese lady with recurrence with multiple meshes being placed and once I went in

I started dissecting this is this technique is I'll say I will call it simple compared to the

other ones that I'm going to show you in a little bit but this is just what you do open you just get

on top you take the meshes that you need these meshes that were there I took them out and the

anatomy is simple go on top of the fascia once you get on top remove the meshes that you need to

create the flaps that you have. And once you do that, then you start seeing your external

oblique. You can see the color here, the difference where the red is. You just get in front and that's

your anterior component separation technique. This is in a vascular plane. You can go very

easy into it. As I said, if the abdomen inside it is all hostile, you can get into the space,

is very simple and then you start getting and you create you know like we do the arsenic component

separation in the cases that we do open once we do that and you put the brokers in the succotaneous

area and then you measure it's 50 centimeters or whatever it is and then you put the mesh and then

you roll it and you hold it on that place because you're going to unroll it from the other side

Once you do that side you dock on the other side and then you start doing the

same thing you did but on the other side. This stroker is for an assistant to help

if you need it. It comes handy but not always have to be there but these cases

are usually you need some suction you need other things that the assistant can

help. Once you do the other side it's repetitive then you close as you do open

and once you close then you can roll the mesh and then I leave a drain and that's

the end of the procedure so it can be done it can you should do every every

step that you in every layer and hernias you need to understand we move a little

bit more and I'm going to bump this a little bit this is a case that I did I'm

using other things to try to decrease the recurrences this is a patient you

can see it there the width of the defect multiple surgeries more burpees and same technique we get

into the same space and once I get into the space I close it and then this is the video of the

surgery I'm trying to use something to decrease the recurrences I'm going to show you it's called

mass sutures so this is the same defect this is nothing different that I showed you before

but what is different is once I close the defect

and it's closed, I put a screen in

and when the screen gets placed,

then I'm using these sutures to reinforce the midline

as well as to reinforce the edges

where the mesh has been placed.

So this is reinforcement with mesh sutures.

I don't have science to tell you

that we have randomized control trials, et cetera,

But this, for me, makes sense to prevent recurrences.

So I'm using this right now to see if we can have better results.

So that's anterior component separation.

Let me show you what everybody likes to see is the robotar.

When we started doing robotics, we didn't get a lot of attention until the tar technique was done

and the component separation started to be done

robotically, because laparoscopically, historically,

and not a lot of patients were doing this

in a minimally invasive procedure.

The good thing about this is these are the same,

these are the same steps,

and this slide is from Flavio Marchera,

he's a friend of mine,

showing the same identical to open.

So it's the same technique,

except that you're not opening the patient.

and you have to know what is the preperitoneal areas

that you're going to be encounter.

You have to know what the rectus is

and I'm going to show you in the video

and then you've got to go pre-transversalis.

So this is how the patient gets positioned.

You have to know that if you're right-handed or left-handed,

you have to know how much you got to reach.

These are the arrows on the red.

The number three here, if you need an assistant,

in the beginning, I encourage you to put one.

We have suction now that you can use here robotically.

So the more, the better you get.

Sometimes you don't need this port over here.

You need to know what the transverse muscle does

when it's towards this area is a little bit thicker

until it goes down to this area that is less thin.

And you can see it here.

And that's why we do a lot of the times bottoms up.

This is what I was telling you

about the transverse adipatia and the peritoneum.

peritoneum this is you have to know how the transverse abdominal looks and with the diaphragm

fibers look at the the direction of the fibers here so when you start going cephalic once you

change direction that's your diaphragm you have to be aware that transverse salus abdominis

diaphragm okay you have to be aware that you're already going towards the diaphragm pre-transverse

salus that i showed you in the parastoma hernia pre-peritoneal in this area you can see the

the difference of the color and the tenuted fibers.

That's the end of that.

This is the procedure itself.

We dock with three arms on one side.

We tend to measure the defects

and this is about 12 centimeters by maybe 15 centimeters.

Going into the retrorectus.

So this is the space that you're gonna get

behind the rectus and you can make one line.

We like to be usually completely towards one side,

at the same level so we can be taking everything down. This is the

fossil form on the on the superior part and this is where

you're going to get behind it and you're also going to get

an appropriate to new space. There's going to be a space there

that is easy to cross. You're going to preserve all that because you're going

to use that to close so you don't have exposure of the mesh

when you do that. Then you go all the way down to the other side

you have the neurovascular bundles and this is going bottoms up you can see this here this is

the right side of the patient and then if you get into the space it's like the top space you can see

the arcuate ligament you start dividing it and then you go all the way up until you're going to

start seeing the fibers they're going to be thicker and as i show you in the other one and

and you just, there's a neurovascular bundle,

you preserve it, and then here's when you're going

to start dividing part of the transverse

because it's going to get thicker.

That's pretty much it.

You're going to start going from here all the way lateral

as much as you want and as much space as you need.

Just make sure you cauterize these well,

and once you see the white pearl kind of tissue,

that's where you want to stop,

and that's where you want to push everything that's red up.

and then you keep everything, all the rest, down. If you make holes in it, don't worry,

just close it with a micro and then you shouldn't have a problem. So once you finish one side,

you're able to do the other side and it's an identical

dissection. As I told you, this is transverse that you're going to see,

that's diaphragm over that area, and then you want to measure how much you want because you're

you're gonna put a screen in it

that's gonna cover everything in that area.

Because once you come to the other side,

you wanna have that screen placed

as you just have to unroll it.

Once you do that, you put the other ones

and you put the ports on the other side.

There's two ways to do the mesh.

You can put the mesh, as I told you, at the end.

So when you roll it, you're done.

Or you can just finish the other side

and close the both the posterior area as well as the anterior fascia that you're

going to see in a minute until this is finished and then you can put it at the

end and that's how you reach it I can do that those are the two ways to put the

mesh in once you do that side again you close the small holes and you start

closing the posterior flap it is very it's quite easy and once you do that

then you go anteriorly, anteriorly you're going to have a little more tension. So you can do what

we call the closing the curtain technique that we put them all together and getting the pieces of

the of the getting all the small pieces of the of the defect being closed but not completely and

then you start tightening it up slowly. The barb sutures help big time in these cases and most of

of the surgeons will use barbed sutures.

There's several in the market that you can use.

And like, as I said, you don't close everything up.

You decrease that, you decrease the pneumo once you're ready.

And then you start, you know, pulling all them up

until you close it completely.

Once this is closed, you have all spaces closed,

the anterior and the posterior,

and then you're able to place that mesh

that is usually in a cornea like this.

It would be like a 30 by 30 centimeters

placed completely in the space.

And these can go into your eight millimeter

or if you have an assistant port,

you can put it through the assistant port.

Once it's measured, you put it,

you can put a couple of sutures

or when the mesh is this wide,

you can just lay it out over completely.

I leave drains in the spaces,

or you can just suture in two parts or three parts

to be able to allow the mesh to not move at all.

I like to suture at least in a couple of places

and then just weld it off completely.

And if the section has been quite traumatic,

I'll use fiber glue, if it's not, I won't.

And that's pretty much it on this side.

So that is the tar.

Moving on, we're gonna switch to complex averticulitis.

And this is the morbid of ease, hold on, here.

We're going to switch to the vesiculitis.

We can be as good as we think, or maybe we're not as good as we think.

And when we look at results, especially when it goes to HINCI 3 and 4,

the perforations, this turns into a different area.

But we know that minimally invasive helps.

And usually the results are better than open,

but we also know that we have about 20% conversion.

And that's pretty much around most of the studies

is about 20% conversion.

So we still have 20% of people that we still need to open.

Can we improve that?

This is an Italian study from 2012

showing that less than 7% of the surgeons in 2010

and less than 8% of the surgeons in 2014

14 who are approaching HIN-T3 diverticulitis for a minimally invasive.

Most of the surgeons and less than 80%, less than 25% of the cases were done MIS.

But what makes this difficult and what makes it, is severe inflammation, obesity, previous

surgery, and bleeding.

Bleeding is a big conversion factor.

And here you can see this case is where they have three, four, five, six attacks of diverticulitis.

as it comes to a fibrotic, and you have a straight instrument.

This is an old video of mine.

You know, the angulations are not perfect.

You sometimes are working tangentially.

These are not easy cases.

Were we doing them?

Yes, but the conversion was still high.

And when you have patients with BMIs of 80,

and you're trying to, you know, dissect,

and it's a lot more comfortable,

and I think the surgeon gets more dexterous,

and even the fatigue with the amount of tissue being held

and the articulations, this technique improves our outcomes.

So what is usually the consequence of converting?

You got more wound infection, more pain, hernias, et cetera.

We know that already with what we've done with our invasive,

so can we do things better?

I think we can.

This is a paper from Placentia's group in Miami.

They were the first ones in 1990

to do a laparoscopic colectomy,

and they started doing robotic surgery

in some early series, they were looking at the conversion rate, and you can see there even is

very early in numbers. These guys can be very good locuscopically, and they even are saying

that the conversion rate is less in their hands as well. I think we can improve. We just have to

be open to new things, and I think overall the papers will show that that's the case.

But eventually, we need to know what apples and oranges are. We can't compare because that's a

a bit difficult in doing randomized trials that it's very difficult to put them all together

in one basket. But we have to be aware of which patients we select, which patients are

immunocompromised, and we just, they don't have a lot of reserve. We can't play any chances on them.

And we have to plan also if the surgeon is going to come next year, how can I make it easier and

no radiologic imaging? The focus on cancer is radicality and the reticulitis is safety. So what

What can I damage in these cases?

The ureters, the vessels,

during enterotomies,

we have Firefly.

When we were residents,

they were teaching us

that you needed to identify the ureters

in every case and dissect the ureters.

But it's not the case anymore.

We have gone a long way from that.

If you can see the ureters this way,

you don't even have to get near them.

So in diverticulitis,

you can stay away as long as you see them.

And you shouldn't damage the ureters

when you're seeing this like an airstrip

in an airplane so we put the truckers usually on the right side of the patient um in different

ways more angulation or less angulation now that we have modular robots they're going to be

different so we used to uh have one robot only in the market now we're going to have we have

several so this is not for every modular robot this is going to change and depending on which

robot you're using but this is what we were doing when there was only one the problem with this is

if you have x amount of surgeons you're going to have x amount of different opinions

and that is the case in 2024 there's papers that say that when a stable patient even if you have

fecal peritonitis you know the um the conduct can be you know that to do a um an anastomosis

and then do or not a diversion and this wasn't you know we go 20 years back it was a no-no

fecal peritonitis were the hormones and that was it things are changing these days and you can see

this with a swiss consensus 2024 when they're unstable everybody knows what to do but we're

not unstable they go all over the place from ileostomy and ileostomy diversion heartburn so

that consensus is not there yet but there's papers going lately in the last five years showing that

that primanostomosis is better than hormones and in thousands of patients and there's a

But the difference, it may be that the primary anastomosis patients tend to be more with less problems than the hormone patients down the road.

You can see this is a randomized trial with hormones versus anastomosis.

And you can see it after 24 months, which one, stoma-free, is higher in the primary anastomosis than the hormone anastomosis.

So this is something that we, this is from 2022, I think we're going to be looking at this.

more over and over. This is another paper. This is from the ES and Sages saying that

braminostomosis and proximal diversion is better than hormones. And I think this will be the case

for us specifically in a selected group of patients. The problem with this is that, you know,

if you look at these patients, it's 10,000 patients. These are from New York, 93% got

hormones. But if you look, 98% had hormones. But if you look at it, only 6% of these were

we're operated by colorectal surgeons,

but that's also a specialty that we have to look,

but you can see that these are not easy cases

and we've had any problems.

I think if we can stay away from the hormones, we should.

These are patients of ours.

You can see patients with hormones,

what kind of programmatic can be,

how much tissue we have,

and we can get these cases done in another way.

I think we should.

This is a case that we did minimally invasive

and you can see the difference.

You can see the cushionoid face

on this patient with steroids.

This is a patient that was requiring hormones

because of this.

We didn't, as I said,

you have to select very well your patients.

But not one size fits all.

This is a case that showed diverticulitis on the CAT scan.

And I started doing the dissection.

And, you know, it's easier just to say, you know,

let's open him up, it's too much in the field.

You obviously need to have the experience.

This is not your first, you know, case.

But if you are comfortable doing minimally invasive and doing these cases,

it tends to be that this case, after I dissected it,

it wasn't diverticulitis, it was appendicitis.

So I didn't do a resection.

I just, the appendix, you're going to see it in a minute,

is right there, is all messed up.

But the colon, it was good.

So I did an appendicitis, and I basically saved the patient.

you know, instead of going in and says hormones and get out,

this patient was lucky enough that didn't have to do that.

These are our patients with abscesses.

I try at least, you know, I can always convert.

I put, if I think I'm gonna need stents,

we put stents and we use Firefly.

And this is a case where if you see the pus,

they start dissecting.

So you need to have a target approximately on distal.

So if you can get a target where the tissue is okay, as you can start seeing here,

the tissue starts getting more friendly.

Then after washing out, the patient doesn't have major comorbidities, as we talked before.

This is a case that I would do a primary anastomosis.

So you can see my dissection here.

I dissected it out, took out the other side, and started getting the splenic flexure down

so I can bring a good piece of bowel down.

and this is just nothing from now on it's nothing different than what we've

done before except for here I need to get a target down so the vessel sealer

helps to get hemostasis and once I get an area that I can and a superior rectum

I transected it that's now going down from the promontory this is a lady you

can see the uterus being dubbed and again after we do the

the stapling, then this doesn't do anything different.

We accommodate the superior rectum

and then we do the anastomosis

and then we suture things up.

I usually do this robotically.

At that time, the probo got contaminated,

so I just suture it up with a scalpel.

There's another case with also fecal

and this was in the bladder.

you can you know call urologists if you're comfortable with it or you've been in the

hospital for quite some time you work with the urologist together they tell you just you know

get it done if you have any problems just call us so this one we intersected this area

and then we suture suturing robotic is easier than open and you can see this here we close the

I can see the ureters close up and then finish the case.

And then you can do the anastomosis.

Not everything is easy.

This is a patient where you're gonna see

that I start getting into this area.

If I'm having trouble in this part and I can't see much,

I try to go proximally.

And if I go proximally, I'll divide here.

And once I divide,

then I work my way down from here down as I said if these patients have a colonoscopy before

recently or not the risk of cancer is two percent only so most of these cases will be benign and

then we stay close to this area and we got we start going very close to the colon so we don't

have to worry about damaging any structures and once I did that and I went down all the way

then I started getting this tissue and then the anatomy started getting very

obscure everything looked like a disaster with bites everywhere and I

didn't feel comfortable going more down and damaging maybe another structure so

what I did in this case I just stayed up to the perforations and all the

disaster that the patient had here and I try to place a stapler the stapler

didn't take due to the thickness and the fibrotic of the tissue. So I just did, I just cut it

completely with the scissors. Once we cut this with the scissors and we know there's nothing

else behind with the colonoscopy, you can see if there's anything in the colon still intact behind

it. Once that's done, then this patient was going to get a harness and we close it with bar sutures.

Once we close it, as I said, we need to remember who's going to come next.

In this case, it's going to be me.

So I leave some proline sutures when I come back to reverse this patient.

And another friendly day, I can finish the dissection and put this patient back together.

That's pretty much it.

So these cases are challenging.

I think these are something that we can be done minimally invasive if you can.

And to finish, I'm going to talk a little bit of what we do with morbid obesity.

These cases are challenging.

Unfortunately, we have a pandemic in the U.S.

This is where I live.

This is Palm Beach County, where two-thirds of the patients are overweight.

And there's a lot of misleading reports that minimum invasive overcomes everything

thing for minimally invasive? Well, it's not as easy. It depends on what you call minimally

invasive. A lot of the minimally invasive papers call morbid obesity 28 BMI. For us, morbid obesity

is 35, 40 and above. And there's some papers showing that the anastomosis are a risk in this

type of patients, even if they're considered less morbid obese. Okay. So this is to show you how

how many, if robotics can help in this high risk patients.

And I believe without randomized trials

that we have less conversions, less blood,

shorter time and less hospital stay.

But again, papers need to be produced,

but our experience that we think is that

robotics can overcome a lot of the issues.

This patient I showed you already,

these are patients that we do.

And what happens with this patient is that patients

that trap in this massive amount of obesity,

This is a patient I just showed you, and this is a patient that is not produced.

This patient was almost 1,000 pounds.

You can see the size of the table.

He already lost a lot amount of weight, but this BMI is different than others.

And if you can bear for me for a little bit, I'm going to talk to you about what visceral fatty tissue is and what subcutaneous fatty tissue is.

So this patient is a BMI of 27, this patient and this patient, the right side and the left side.

I'll take the right side this one anytime with the robot this fatty part here it can be overcome

easily this part here is a lot more complex to do surgery because all the fatty tissue is inside

so saying that not every this is just a gallbladder in a patient that my fellow was doing and they

couldn't expose and they were having trouble exposing the gallbladder this is a simple

gallbladder but the patient had BMI of 70. So how many gallbladders do you have to take out

the falciform okay and divide it on the way towards your camera and then we still have

traumas exposing and then they were getting a little bleeder from retracting and they were

and then take out the falciform completely so finally and this is just a simple gallbladder

imagine a low anterior section so even the colonoscopies these patients are rough this

This is a patient with BMI of 80.

You can see that the anatomy doesn't,

we don't look at the umbilicals anymore.

We put a troker and then we decide

where the other trokers go.

There's some longer trokers that are in place

that we can use.

This is the largest version.

We can use when we have thick abdominal walls

that we can do them.

This is a patient with a large BMI.

This is a biuretic bed.

This is a patient that they started

a low anterior resection laparoscopically.

They aborted in five, 10 minutes

and they sent it to us for doing this

robotically. Patient was not

a candidate for radiation

and this is the patient on the table

and this is what we do. These are our

severe morbid disease patients

this already show you what we do

and this is for real. This fatty tissue

in the secutaneous is real

and you can have problems with the ostomies

I have to put this ostomy from this

side all the way in the right upper quadrant

shaving all this fatty tissue because I was getting

necrosis and went off to the other one

This is a patient with an necrotizing fasciitis from a drainage of an abscess in a doctor's office,

and they entered into the cecum.

And once they didn't notice it, and then he became septic and a necrotizing fasciitis.

And this is a patient that you can see the size.

This used to be my partner.

The kid came from Orlando, and this case he lost almost 200 pounds in the hospital by the time we closed him.

So the data is confusing.

Yes, it can be, but I think once you get to use the robot,

you can see a lot of things.

This is how the ports are placed.

I'm not going to entertain this for now, but you have to be flexible.

These patients definitely can benefit from this technology,

as I showed you in the diverticulitis cases.

The anterior approach, one arm up here for retraction,

another arm down, pulling down, and then you can get in the middle.

So traction-contra-traction with articulated instruments

and with the force the robot has can be very efficient.

This is also another interior part

that you can see very well.

This is actually seen better than open

when we used to do the open cases

for the exposure that we have with these instruments.

And once we go into the male pelvis,

the robotic actually excels more than the laparoscopy.

This is rectal traction as we learned from the Koreans

that you put your assistant, you don't want them to rip anything, you can put a umbilical cord and

then you can traction on it and that's part of the function of the assistant is traction and also

suction. Terram retraction when the area is very, very heavy, you can pass the arm underneath it

and you can swing this around and it's something that I want is once you have four arms then you

You swing it, and then you get the exposure.

Once you do that, you can start working

underneath this area very comfortably,

and then your sister can help you with the suction as well.

In this case, you can see the obesity.

A lot of the novus surgeons will go down here

and dissect here, and actually the plane is on this area.

This is just a cushion of fatty tissue

in the morbid obese patient,

and just the traction, contact traction,

gives you the way that you want to be entering.

ring. These are BMIs of 40, traction and contra-traction. Due to time, I'm not going to

detain on this. You saw a lot of this in the diverticulitis. Using a gauze here for pressing

on it helps you with the angulations as well, but these cases, as you can tell, can be very

challenging due to the amount of tissue that you have to be dissecting. You can use endoscopy at

the same time, so you can see if the patient has a very narrow pelvis, so you can get clear margins.

This is called Firefly.

You can also use natural orifices

that you can use here,

transecting, and you can use the vagina for extraction

using a wound protector,

and then bringing the specimen down

and you can do the anastomosis,

avoiding having an incision on these patients.

This is also another one.

It's the-

It's a transection of the-

Once you do that-

The important needle is in-

Once you do that,

then you can actually, if you have staplers

or you can have a vessel sealer,

you can do a natural extraction.

Once you cut this with a vessel sealer,

you can open up the tissue with this.

You can actually take it off the,

out of the rectum and one that's performed.

You can cut the mesentery to make it thinner.

This, I learned this from Morris Franklin,

where you can just cut all the mesentery off

and make it one long piece.

And this will come out with the natural extraction.

When this gets done,

you need to learn intercorporeal suturing.

This is, as I said, if you try this,

this is better than open and you have everything there.

No tremor, the visualization is excellent.

You can do an end-to-end anastomosis

in a very, you know, economic contained way

without any staplers in this case.

I'm gonna finish this up.

This is preparing the rectum.

Let me get this to this area.

You can check the ureters with ICG or ICG mode,

or you can have the lightest stents

if they were used in the past,

but this is something that we have available these days.

Trinic flexure, you can use this

going with the vessel sealer.

This angulation helps you with this dissection.

I can encourage you, you can use a lateral way, once we use the hockey stick, and this

will facilitate your splenic flexures.

Let me just get this because I'm getting that.

Some of the obese patients, this is my last video, will be lateral medial because you

can't actually bring the mesentery up because sometimes they have short mesenteries.

This is a lateral approach and you can see how much fatty tissue you have here.

so we tend to do these lateral and then go medial so we can lift up the piece

and go down to the vessels in case we get any trouble narrow pelvis this is a

narrow as it can get you can see it here this is a challenge for laparoscopy

robots can help you on this case so let me just finish this to finalize this

trans anal is something that can help us as well with modular in obese patients

This is another technique that we can use as well.

So I know I'm running out of time.

So basically my message is this is something that you can have in your momentary.

Encourage the younger surgeons to embrace this technology.

Once we have better software and we have what we call reality, safe zones, etc., it has become a safer technology.

I want to thank the opportunity to address you all and if you have any questions.

yes okay congratulations for your presentation a very high quality of pictures and videos

very interesting cases we think that the robotic surgery is a real upgrade over laparoscopic

surgery especially to the abdominal hernia repair but actually in italy the causes is very very very

So, just two questions to you.

The first question is what do you think about the cost of the robotic surgery to the abdominal

wall repair?

And the second question is how many robotic abdominal line repairs do you perform per

year in your center, your hospital?

Thank you.

Okay.

Thank you for the questions.

The first one, I think the cost will be a matter of the next maybe two, three years.

I think in less than five years, I think we'll have systems that can be as economic as laparoscopic surgery.

There's about 40 platforms.

At least a lot of them are from Asia, India, that will be coming to the market.

and I think prices will be level a lot more that we're seeing today and we'll

have more competition with all the systems are coming out so I don't think

the discussion will be cost in the next five years I think the discussion is

which rover is better than other in which cases yeah robotically regarding

another question how many surges we do I do about 1,200 is that here my practice

is divided between hernia, colorectal,

DNA surgery, and bariatrics.

We do approximately about 300 cases

to 400 cases in hernias.

Most of them are robotic.

But you can be very cost-effective in hernia.

If you do a retromuscular

and you use flat meshes

without using intraperitoneal underlay meshes,

underlay meshes sorry then your cost will be pretty much average if you take that tax and

the cost of the measure so if you want to start now the way it is you can actually tell your

administration that you can be cost effective using different measures thank you thank you

so much and congratulations thank you thank you very much thank you for the opportunity