Ding Kefeng Laparoscopic ileocecal sparing right hemicolectomy (LISH)

Hello everyone and nice to meet you online and here is the second affiliate hospital of Zhejiang University,

we are doctors from Department of Colorectal Surgery and Oncology.

Today is our leader, Professor Kefeng Ding and he will perform a laparoscopic

of the International Cholorectal Surgery and also the program director of the International

Training Program of UCHOPS.

So here is the basic information for this case.

And the patient is a 63-year-old female and with right colon cancer.

And the pathological results show the adenocarcinoma.

And also the IHC test showed it's PMMR.

As we can see by the red arrow, the tumor is located on the hepatic flexure and near to the transverse colon.

So today we are going to do a leash operation for this patient.

Okay, any problem or question, Federico?

No, no, no problem, no problem.

Just tell us the indication for this.

You see here?

Okay, Professor Ding is talking. Can you hear him?

We see the tumor located here is the transverse tumor near the hepatic fractures.

So this is suitable for doing the leash operations.

So make sure how to make the distance measured.

we can make the 10 centimeters or 5 centimeters measured from the tumor and

to the to the eddy circle vessels directly to the sending surgeon so here

is the you know and here is the circle vessels you see and the eddy circle

vessels and the poor here and we can also lead to here so here is the margin

and here is it is the course so so the distance is enough you're back check

So let's clear it up a little bit.

So for the lish, the indications for lish.

The indications of lish include the tumor of the hepatic

fracture or the ascending colon or transverse colon,

which is near the hepatic fracture.

So the indications are that the tumor projection of the tumor

should be at least five centimeters away more than five centimeters yeah so so

usually we will make a clip a hemlock clip here to mark the margin so we

measured five centimeters more than more than five centimeters at least five

centimeters from the tumor so we start from the hand to bottle to oscillate

to the right can right correct five centimeters from the tumor so we will start uh from a top to

bottom approach or uh cranial to caudal approach so first we will can you tell us also something

about the trocar disposition also yeah how many trocar do you use five yeah

Yeah, can you see the trocar placement?

Look at this.

So we have five trocars, one camera, and two for the surgeon, and two for assistance.

Here is the hemorrhagic trocas.

Oh, okay.

So in this case, we will start from the gastric colic ligament.

We'll open the omentum here.

I can see that with two trocars, you can make a very good exposition of the plane.

so we when we go into the greater sack of the momentum we will see we can see

the spleen of the pancreas

um thank you and the posterior near the posterior and then I also can't do that

oh no no no no no no no no no no no no no no no no no no no no no no no no

so it's very important for the um for the system to spread out everything spread out into a plane

so that we can do better dissection

yeah we can see really good to the plane yeah with a good exposition

Yeah, all the planar seems like the signed only 10 months in your hospital.

So just a little bit.

Can you please?

Can you please talk a little bit louder?

We can see only Professor Dinger.

Yeah, I should oscillate this lymph node.

We can see here the tranquil node issue here,

and we are trying to take it down.

There are some lymph nodes.

Yeah, we can see.

This is the sixth node.

So in the hepatic fractures, colon cancer, in the number six lymph node metastasis rate

is more than, I think, five to six percent cases.

cases but should we resect our lymph node cleaning or not they have no rule of the world but in this

cases because this lymph node is more big I should respect it yeah we can see we can see really well

the lymph node normal uh normal ground is in here there is usually no um there are no indications to

remove um this lymph node in most cases but for this patient maybe because the electrode is a

little bit big we decide to remove it ah we think we think usually this lymph node um strain from

From the stomach, the omentum of the stomach, or the mesentery of the stomach, but not from the colon.

Okay, so we'll remove this lymph node and then send it for biopsy.

We'll put it in one of the fingers of a glove and get out.

So usually there is a space between the omentum and the mesocolon, and we can bluntly dissect,

we can try to figure out where the space is by pushing against the tissues.

Okay, I think this one comes from the omentum, this vessel comes from the omentum, I'll take it.

I think that you need to put higher the volume because it's not so high and we can listen

only professor ding talking we cannot listen too much you can you hear me yeah now i can do better

so are you going to do a cme or a d3 lymphadenectomy we are going to do a cme and

maybe i think a d2 is enough for this kind of a patient it's not a very bulky tumor

and not a lot of lymph nodes in the like a mesocolon okay perfect yeah so last time we

we discussed the like concept of cme and the d3 so so in this case what will you perform like

you you would also do like a d2 or you would do like a more aggressive to like d3 d2 in my opinion

so how many audience is there uh like watching all the like live surgery now do you know

i don't know i can ask about it because we have we have people from live surgery and we have

people in the auditorium and uh okay so so so uh at this at this moment how many channel is it like

have a live surgery all of it or just uh some almost all of it all of it every channel yeah

they are start they already started just any room they need to to start the first surgery

Do you use also some intestinal preparation for the right hemicolectomy or not?

Do you prepare the colon in any way, the bowel in any way?

Yeah, we usually apply a mechanical bowel preparation,

like drinking some laxatives for all our intestine-related surgeries.

I mean if the patient doesn't have any obstruction we will always make some

mechanical bowel preparation yeah I can hear you clearly yeah I can ask let me

ask you to speak a little bit louder because I don't know what's wrong with

this phone okay so now I think we're trying to find the space between the

the mesocolon and the duodenum.

And then now we're taking the hepatic ligament.

we should arrive at the Girota membrane.

On the surface of the kidney,

I think there's a little bit of a,

It's a little bit too deep, but we can see the kidney area.

So our assistant is playing a very important part in the surgery.

He's always making warnings about whether the dissection is too deep

or whether it's in the right plane.

Yeah, we can see really clearly the hellish trunk, yeah.

Hellish trunk, we have convergence of the gastric epicloid vein and the right colic

vein.

So it's where they converge.

and now are you going to move down yes i think we're going to move to the okay to the bottom yeah

yeah i can see it

Oh, so he has received an appendiceal surgery, appendicitis.

He had a history of appendicectomy causing the slices.

We're going to take down.

Okay.

We're going to move to the tail.

usually at the base of the ilium mesentery, terminal mesentery of the terminal ilium.

So we will sometimes change the position to a Tredelenburg position when we're doing this procedure.

We will try to move all the small bowel to expose the base of the membrane.

Yeah, to let the bowel move away from the field, yeah, from the parotid field.

Yes, that's normal, to move the patient.

Sweep away to the head, sweep the small bowel to the head.

Oh, this is Chen Lu.

Can you call?

Yeah.

Hi, Lu.

He won't hear you.

You need to talk into this phone.

Also, in this case,

the

exposure is really good, and also

the tension is really good.

So we can see really well the plane,

yeah? There are no chance

to go in the wrong plane.

the assistant is uh dr professor and he is also a very skilled surgeon

you know him right yeah we know him really well we all know him very well he is one of the

yeah one of the best surgeons in our department

we can sit down also the ureter yeah yeah yeah yeah yeah

liter yeah okay don't you use don't you use uh sometimes the icg for uh marking the no we usually

don't use the ic okay okay from here we can see the transverse segment of the duodenum and then

on top of that we can see the ica or icb maybe heliocolic vessels that runs uh on the top of

transfers you know it in the mesentery and then get a cheese on the go on the

go away get on sugar man yeah we don't mean yeah wait you know she went in

Charlotte and shall we get up or look and I can't you can't you know can't you

know you're sending a home to the system is providing very good tension and we

part of the tissue

So you see all these very long vessels they usually are should be in the bottom there's

a membrane with a lot of very long vessels they are part of the retroperitoneum we can

This is very close to the duodenum.

Here we can see very, very clearly the told Girota plane.

How's the BMI of the patient?

Yeah, as I told you before, the plane Gerota told is really easy to see.

yeah with a good traction okay the BMI is 17.7 so it's very thin very um 17.7 okay

very skinny yeah very skinny patient sometimes the the skinnier patient they have more you know

thin membranes more difficult to find the the plane not always the thinner the better so

Sometimes medium size, maybe a BMI of between around 25, these are the best.

So the vein that is near the tip of the harmonic is the ileocolic vein from the posterior side.

It's all a very thick membrane.

It doesn't work.

Let me see.

There's no water.

They didn't let me get water.

Oh, it's alive.

It's alive.

Okay, we can see the kidney over here.

I think it's a little bit deep.

Maybe we...

Yeah, a little bit deeper.

Also up, we could see the kidney.

So a little bit deeper also in the upper side.

A little bit deeper.

hi Professor Lee

happy to see you again

yeah yeah we're looking for it yeah

if it's possible can you can you show us a

the picture of

Professor Dinger and sometimes

to let

people know who is doing the

surgery in this moment

we have the screen with him

doing the operation

you can tell us again

which kind of

surgery you are doing

for the people who are connecting later

ok

and the novelty

of this

up also also the novelty of this approach yeah this is a professor team performing a lish a

procedure a lish stands for um ileocecal ileocecum preserving uh bearing a surgery for right

hemicolectomy so uh the traditional way of doing a right hemicolectomy includes um taking the the

the tumor and taking the tumor and the terminal ileum like including the ileo

sycam a professor thing thinks that for some for some patients with tumors ever

that are located near the hepatic fracture we can preserve the ileo sycam

so this way we will have more we will preserve the organ function of the

the ileocecal valve and potentially preserve the function of the appendix.

So we think that because the ileocecal valve is a very important valve, it must have some

kind of functions.

And we're also doing a lot of research on the outcome of these patients that receive

the preservation of the ileocecal valve.

But there is also a specific meaning on the histologic evaluation of the lymph nodes under the ileocecal vessel.

Because I don't think that you do this surgery only because Professor Ding thinks something like that.

You do it because of the histologic evaluation and molecular biologic evaluation, right?

Yeah, I think the basic concern is that we should preserve ileocecum when we can.

To do that, we must first ensure that it is feasible and it is oncologically safe and

surgically safe.

We are also examining all the lymph nodes that we take up to see if, like, a tumor in

the hepatic flexure region, whether it would metastasize to the ileocolic lymph nodes,

so which which lymph node you will harvest and which lymph node you will not harvest

we will harvest like everything like the 201 uh 201 202 203 and uh two um two one one two one two

and three and also for lymph nodes that goes along the ilio

This is the hand of pancreas.

Okay, this is the hand of pancreas.

Yeah, Professor Ding is pointing at the head of the pancreas.

So he is now dissecting through the anterior space of the pancreatic duodenal space.

Yeah, the anterior pancreatic duodenal space.

face. Now so we have now connected both sides of the dissection from the head and from the tail.

So at the current stage we are always performing a D3 dissection for all of our lich procedures.

but in the future maybe it's not it's not necessary if we examine that that some of

the d3 like the ileocolic d3 lymph nodes are do not have a lot of metastasis so you have

a different point of view between the Japanese between the Japanese idea right yeah we can

see also really well the kidney a little bit deep so maybe changing okay

this is this is the ed circle vessels and here is the smv and here is the hand or pancreas head

of the pancreas so and then we can also see the right colic vein that is in the left upper uh

Yeah, this is the left column vein.

And the ASPDV.

The anterior superior ventral ductal vein.

It's a very awkward name.

So we will stop here, and then we will turn to the medial approach.

vessels and using his right hand he will grab

so with the exposure with exposure the first assistant will do something like a triangle

okay i think we need to um

We need to make the patient reverse for Dellenberg.

Do you want to raise your head?

A little higher.

We can make the head higher.

Yeah, this way.

Yeah, I think that you need to move the patient.

Yeah, we need to move the patient.

Yeah, yeah, yeah.

Yeah, so the small bowel will stay in place,

and it won't keep falling down to the .

Yeah, skinny but with a great small bowel.

Yeah.

So, the first assistant is an active assistant, so he needs to make something like a triangulation

to let the first operator having an easy way how to make the operation, yeah, tension and

exposure also.

And for this procedure, we must keep in mind that the assistant should not grab too tightly

on the ileocecal vessels in case of you know making a thrombosis causing thrombosis

so on the vascular side uh where do you do the dissection in uh for the ileocecal vessel

you will uh you will dissect uh you will um remove only only the ileal part of the ileocolic vessel

then we will try to find the root uh the root of the icv and ica and then dissect

so you will do something like a peeling of the vessel artery and vein and then when where where

you where you will put the clip so where you will stop the circulation so as we dissect along the

ileocecal vessel um the vessel will branch into two uh segments one is to the colic branch and

one is to the ileo branch helium branch so we will only ligate the color they call it park

Is it possible for you to put something like something like a writing with the name of

the surgery with leash anywhere?

Where should I put it?

Yeah, something like to let people know about about this kind of surgery.

Yeah, something like a small PPT that you have in the in the branch of your screen.

distance between the tumor to the should be should be over five centimeters of the margin okay

is it possible to show the the surgery as first and then uh to have just a little bit uh

to have just a little window for for the patient information yeah like this

so we have the ppt slider and uh okay is this okay nothing changed we want to see the surgical

interface okay lymph node metastasis rate around the ed circle vessels is very lower

and in my clinical trial including more than 600 cases the physical examination

directly individually to exam these areas and info know the metastasis among

Among the 600 cases, only 11 cases is a positive lymph node metastasis in this area.

So, it's very low, about 2%.

That's perfect.

So, we can see.

Just a little bit smaller, if it's possible.

The slide with the name of the surgical intervention.

A little bit smaller, if it's possible.

we can read everything

don't worry, it's ok, also like this

the slide is ok

it's ok, don't worry

like this is perfect

around the eddy circle vessels that the zero to the two zero one two zero two two three

If the tumor located in the transverse colon near the hepatic fractures, this area, lymphoid

node metastasis, is very rare.

In the retrospective analysis, about 2 percent or 3 percent of the cases had lymphoma metastasis.

And in our clinical trial, now in all the cases is 500.

And among the 500 cases, we examined the physical examinations in this area.

The positive lymph node rate is the 11 cases, just the 11 cases among the 500 patients.

So it is a very low lymph node metastasis.

So, in the future, do you think that 201, 202, and 203 also?

Maybe in the early stage cases, it cannot be lymph node cleaning just like this one.

Okay.

So, but in the T3 or T4 cases, I think the diagnosis lymph node cleaning is the,

Professor Ding was saying that for a tumor in the transverse column near the hepatic

fracture, its metastasis to the D3 lymph nodes of the ileocecal vessels is very low, is about

2% based on our clinical research.

We have enrolled about 600 patients and only 11 of them were positive.

And then Professor Ding suggests that for early stage, like T2 or T1 or T2 cases,

you do not have to clean the, you do not have to dissect the D3 lymph nodes in the ileocecum region.

But in our department, usually D3 dissection is a standard approach, like a standard procedure.

always do it so the technique is i think it's easy for us it's standard training

so for a for a young sergeant when do you think the

resident or a or a young sergeant could be prepared to do an intervention like this

how many years they need to improve their surgery.

What do you think about it?

I think maybe about two years.

Can you tell us how many surgeries you are able to do in your center in one year?

Well, a bit over 2,400, I think.

Yeah, 2,400 last year, and the numbers are still growing every year.

Okay.

So that's just colorectal cancer.

And I know you show also a slide during the introduction of Professor Ding about the ICSAC program.

What do you mean about it?

It's the International Training Academy of China for colorectal surgery.

So it's a program where we will accept, offer fellowship training to residents, like a fellowship

program for doctors all over the world, so they can come to our hospital to get training

in colorectal surgery.

Initially we will just observership, and then after one or two months they will help us

us as assistants, eventually they will participate as first surgeon in cases under the supervision

of our senior surgeon. So this program was founded in, for two years, has been founded

for two years. We have received, accepted fellowship, fellows from different parts of

the world from italy from spain from mongolia from argentina mexico so there are like a dozen of

surgeons who came to train in our center and now you have a you have some some doctors some

foreign doctor actually doing this this project yeah we have a doctor from belgium and one from

So, here I should be very carefully to isolate the vessels, make sure the broad surprise

for the anastomosis ascending colon, so I think in the past why we should respect the

the eddy circle and makes the anastomosis from the ilio to the colon, that's the breast

price is a surgical reason for most of us.

So now, because the laparoscopy is showing very clearly, we can make the breast price

But now with a better visualization using the laparoscope, we can do better dissection and we can identify the different branches at the terminal region of the ileocecal vessel.

We can preserve the branches that can provide blood supply to the ileocecum.

And why do you think that maintaining the ileocecal valve can help?

Yeah, we're still looking into that. We're doing a lot of experiments, including animal experiments, to see what the actual physiological function of the ileocecum valve is.

So basically, it prevents the influx of reflux of colonic bowel contents back into the small

intestine.

It acts as a valve to make sure that the bowel, the stool, is going in the right direction.

So it has something to do maybe with flora, the microbiota of the intestines.

and and also we have observed through our clinical studies that if we preserve

the inflammation in the in the colon oh yes yes good like demonstrated by less

occurrences of polyps and adenomas but we think it has something to do with the

also perform a right hemicolectomy but whether he can perform a

leash depends on how far is the tumor to the ileocecum but we will find out

later for this patient now we are still trying to dissect the colic branch

Tang, please, before the dissection of the colic vessel, please, can you show us the

main branch and then the division between ileal and, yeah, thank you.

to follow to follow all the vessel yeah yeah yeah we can see it very clearly

yeah yeah amazing yeah yeah this is uh uh calling our arm and here is

the ilia ilia one yeah you can see very very clearly

Okay, there's usually a shift around the SMB,

so we should go into the shift

to expose the surface of the IMV.

And this way, it will make the dissection much easier

because there's usually a space between the sheath and the IMV.

So see, once he opens the sheath, everything will go smoothly.

And we can visualize the SMV very clearly.

So Federico, do you think it's very dangerous to do this kind of dissection?

I think that it's dangerous.

when you have when you have a problem it can be it can be a big problem over there yeah but for

you if you have an experience over 2,000 surgery every year I think that the point of view is a

little bit different for sure that's not a safe place yeah especially especially

cause especially cause I saw another trial where some Chinese surgeon wants

to explore also the artery on the on the right part of the artery of the EM yeah

yeah, of the SMA, yeah, yeah, to take more lymph node

and to understand the comparison between the adenectomy

before the artery or after the artery.

So that can be more dangerous.

Yeah, we believe that there are a lot of that are located near the sheath of the artery.

So that's why we usually don't want to damage the artery.

Yeah, that's for sure.

Not to skeletonize it.

Yeah, we see some more lymph nodes at the root of the middle colic artery.

We will remove that.

So this intervention will be a CME.

You are going very near to the root, yeah.

Yeah.

with a d3 dissection so in the past two months i have um maybe something like um

right hemicoctomies with d3 limb uh these were my first cases and i think they weren't

well if you know the anatomy well and you you're familiar with the

the the surgical route or the um procedure the approach then i think it's still safe

you know the uh smv is not as fragile as you think it's actually pretty tough you know i can just

like bluntly move it around with my instrument make some blood like dissection

yeah for sure not fragile such as the sma

there's some more lymph nodes here that we want to remove

Okay, there is a, what's this?

Some ileal branch of the thing.

Usually we will not dissect to this region,

but for this patient, Dr. Ding,

he has found a lot of enlarged lymph nodes here,

so he decided to remove them.

Oh, okay.

so he will reset the uh all the vessels at the end first of all he will explore

hold the trunk of the smv and uh because i didn't see him legating the

uh the colleague the colleague branch of the heliocolic vessel

okay then then at the end when he finished to legate everything please

make for us like a panorama of the vessels legated that would be really really interesting for the

people for okay now we're trying to track the hellish trunk because we can

see the right right colic vein from here but it converges into the Hellen's trunk

so it will point away for us

and guide us to the heliostroke.

Okay, Professor Ding is deciding

to ligate the

middle colic artery.

So, middle colic artery in the root?

Okay.

Be very careful that there might

be a vein in the back.

Yeah, yeah, yeah.

yeah and so he will do he will do an extended resection also in the

transversus column okay so it would be a right extended okay

So the vein to the right part of the...

Can you point at the trachea a little bit?

I can't see it now.

Okay, now that we have ligated it.

let me do a recap let me do a recap so and here in the channel one professor ling is doing a

laparoscopic heliosicle sparing right hemicolectomy and uh so he will uh he will uh

dissect only the colic branch of the heliocolic vessel and then he will do a cme extended with

the extended resection of the transversus colon because he decided until now to to resect the

middle colic artery at the root and we found some incidental lymph node

that he decided to keep it up keep it out and so he decided during the surgery to

extend the resection on the transversus colon

but yeah we can be sure about it in in some minutes when he finalized the

Yeah, both have to be dissected, so no problem.

Can you ask to Professor Ding, when he have to say something, to speak in English?

Because people cannot understand that you're Chinese.

is i can understand something but not them we think that in the middle of the transverse colon

art this area is the most important lymph node cleaning if the tumor is located in the transverse

or the hepatic fracture tumors, so we make here lymph node.

So I want to preserve these arm for the middle art,

so this can be make the colon cancer,

colon entomosis plus the price more safety.

so you will cut only the upper branch the one that he's holding the professor

yeah only the right branch okay okay okay in the middle is okay in the in the road is okay but this

This is enough for the margin for the lymph nodes.

So we can be sure that the first one that you clip,

it was the right one.

And now it's the middle one.

OK.

Yeah, there is something.

Bright colic arteries, they don't occur very frequently.

Yeah, yeah.

It's not very frequently also here.

here don't worry we are not so different so as we have already uh ligated one of the right

we should preserve the right branch of the in the middle colic artery to ensure that we have

sufficient uh blood supply for the transverse column especially on the left side penetrated the

uh direct a mesocolon because I think has decided to separately like a middle colic artery and the

middle okay so let's explain to the people that the middle colic artery the let's show the common

trunk and the right one and the left one yeah yeah yeah he's doing yeah yeah yeah common trunk yeah

yeah yeah main trunk right right one yeah and the left one is going down yeah

yes it's going down yeah the other one is going down perfect yeah so the right

yeah yeah that's really important

Before we cut the vessels, for arteries, we always use two clips, approximately one clip

to ensure better, more safe.

The signal is not very good.

What is this?

This is probably the, yeah, the middle colic vein.

We're not sure if it's a branch or is it...

Is there blood in the back?

Yeah, I was suspecting that if it's a middle colic vein, it's a little bit too much to the left.

so uh if we do not doing the uh uh e3 link for know the dark session uh here this neighborhood

cannot be uh section yeah in this case in this case for sure the the question is uh

doing it is to do it routinely a d3 that's not that's I don't think is the

best way not as a routine

yeah the Dallas trunk is is a dollar than this

yes we are now dealing with the vessel the vein yeah yeah yeah diana dallas rank is the downer one

into the right branch on the left branch it's like the same as a

The left branch converges into the SMB, and the right branch converges into the helix.

okay now this um the vessel that we're going to do is the right colleague yes

i think after this vessel we are finishing all the dissection and then we are like

Joe, let present us the team

team that is a that is a scrub with Professor Ding the cameraman the first assistant and also the the

nurse yeah you want to see the uh no no tell us the name the name tell us the name yeah yeah the

name the first assistant is uh uh Dr yeah my first assistant is Dr okay yes camera management is uh

Yeah, I remember, I remember very well.

yeah now he's moving to the to the colic uh to the colic branch hello yeah me too me too

and now they are going to make the margin for the uh ascending column yeah yeah yeah but he

need he need already to cut the colic branch of the heliocolic vessel right at the site you want

to cut the bow you like it as a vessel okay yeah we will cut the ball here so you cut it very

will use to for the stapler the white one or the blue one blue one okay also for the transverse

colon you will use the blue one yes also for the transverse colon we'll use the blue one and

we will do the anastomosis uh with a small incision and take the bow out of the body

okay so you will do an extra corporeal one yeah we will uh

the stippler through the second and do i like the side

so you will do an anastomosis between the second and the transverse colon

ascending colon okay

okay okay

okay okay they have already like it is a colonic branch of the ICA ICB yeah I already explained it

yeah yeah yeah yeah okay I was talking with Joe about it yeah about how to make the nasmosis

right yeah and also and also that he needed to ligate the colic vessel of the heliocolic

yeah so can you tell us the incidence of hernia when you do when you do the small incision into

the uh into the abdominal wall to take out the specimen into the anastomosis hernia you mean

like incision hernia yeah incisional hernia after this approach it's very rare i don't think this

approach has anything to do with an incision hernia i mean it will not increase the rate of

inhale where do you do the incision the incision is just the sample in the upper abdomen maybe

yeah okay yeah also some cases can be doing the overlap uh anastomosis but okay this is because

cause the preparation not very very satisfied so we'll make an extra corpse

or purple anastomosis yeah yeah yeah head-to-head head-to-head okay in some

cases it can be a side to side or overlap overlap

so we can see that when we preserve the the ileocecal branch the blood supply as we can

see from from the pictures blood supply is very good you can see very the red

bright red blood supply yeah we can see the blood supply really well now they will divide

that's a chinese a chinese stapler yeah it's not automatic it's like with uh

you need to press it right yeah it's not it doesn't run on battery okay it's a mechanical

it's a mechanical one yeah yeah but yeah but it's reliable yeah yeah yeah it's cheap and it's

reliable you know in china we're trying to cut expenses in for medical health care so

so it's very difficult for us to use like an imported instrument now.

Yeah.

Who is this?

Oh, Professor Cao is here.

Professor Cao, hi.

soon oh no now he says good morning yeah yeah in Italy's morning how's the time there uh what's

time it's about 5 p.m 5 p.m yeah it's 20 minutes to 5 p.m okay

now he's preparing for the transaction of the transfers colon so Federico let me see the the

vessels uh at yes please show us show us the program of the vessel yeah

he is the ed circle vessels and uh here is smv and uh this is the right uh colon colon the middle

colon right column I love our Obama middle colon the towards the I am V yeah

yeah we suspect that's I am B yeah but we have preserved the the left branch of

the middle colic artery the left branch like routine yeah sure yeah now we will exteriorize

the bowel and is it possible is it possible to use the camera yeah

Yeah, I'm trying to hold the camera.

Yes, someone with a stable hand who can.

Yeah, we want to show you the image of how we do it.

So Federico, so thank you for give us the presentations

presentations and make the chance to

Change the experience and the operation

Technique to the Italian surgeon. So maybe the different countries are different

choice for the

Cancer and

Our department that the e2 and the d3

in front of the resection is

routinely mass

So just like today's cases, maybe in early stage, you don't need to make the D3 lymph

node dissection.

But if you don't around the vessels, some cases have the lymph node metastasis.

You cannot be resected.

I think it will affect the result of the patients.

So, we choice what kind of patients should be doing the D3 and what kind of patients

should only need to the D2, near D2 dissections.

I think in the future, they have method, they have the predict, yes, there's a predict method

method to make us know that how many percent the lymph nodes have the metastasis rate so

we can choice the lymph node sections area, but now we, our, my thoughts is we should

have the ability to doing this method. This is a lymph node dissection.

So but they have also have problem just like the foreign doctor told me that you

see you can choice which kind of patient should be the can can do it in the D2

and the D3 but in your department every surgery is almost doing the D3

dissections, this is the problem in my department. So I think the normal lymph node is the benefit

for the patients. Don't need to make so clearly dissections in the patients. But before we

have no ability to predict the lymph node metastasis rate, we should have the ability

to make this taxation this is d2 and d3 and we also pay a lot of attention to

preserve the function and the preserves organs in the coronary surgery just like

today's operations maybe five years ago or ten years ago we're doing the

the traditional right coronary rectal resections,

including the ED circle, including the ED circle vessels,

and the mixed anastomosis, but in these five years,

we try our best, and now doing the clinical trial

to make the evidence

uh for the oncology oncological uh evidence and for the surgical safety evidence to

uh pushing in safety and the uh have the same by uh three years disease-free survival

i think the next year i i we will give we will get the result uh in in this clinical child

and in animal research we have found a lot of the metabolism including the

bacteria and a lot of things and I think the quality of life will be

be more better in the patients we perceive preserve the circle so this is my thinking i

hope that the italian surgeons can give us uh advance and if you have questions i can

thank you yeah you're welcome you're welcome i think that we are now in the

parenchyma sparing and the organ sparing era so now uh that's something normal to

uh try to make the sparing of of some organ or parenchyma and there are not only in the

colorectal field but also in the hpv also in the upper gi side we are doing for example

cancer, we always preserve the left colon art, not the... Besides the root of the IMA,

the lymph node have a metastasis in that area, we always preserve the left colon art and

make the root lymph node in that area. So you see also the same mechanism for preserve

the function and preserve the organs for the patients that's for sure and and also and also

uh we need to try to make a balance between the oncological safety and also the functional safety

so we need to be in the middle between these two and also about the cme and the d3

we can start with with a thinking and then we can change it during the intervention because if you

You see the lymph node macroscopically for sure you need

to do a CME if you are going very near to the vessel.

And also, and also what do you think about the RELARC trial?

Because we have, we have a, we have a trial on the.

Dr. Robert R. Yeah, RELARC.

Dr. Robert R. Yeah.

Dr. Robert R.

Dr. Robert R. RELARC, the trial almost more

more than 20 hospitals in big hospital in China take part in include us to take

part in that clinical trial in that result in the stage to us early stage

three cases that the the d2 and d3 always the same oncology result and the

the d3 have not significant increase the complication of the surgeries I see the

d3 not having to have the increase the complications significantly so the

surgical is surgery is the safety and in the D in the in the stage three cases

especially in the lymph node in large that kind of cases is benefit and have

the benefit for the d3 dissections the but I think the problem is before that's

After the operations, we can analyze this, stage three or stage four, which kind of cases

is benefit for the D3 dissection.

But before the operation, or in the period of doing the operation, we don't know this

patient is D2 or D3 cases.

We don't know the patient is stage three or stage four, or stage two or stage three.

We don't know this lymph node is metastatic or not.

Just like today's cases, you have found, I think, three enlarged lymph nodes around the

SMV and the middle, root of the middle colon, transverse colon, out.

out. So if we leave this lymph node in there, don't resect it, we don't know this is metastasis

or not. So before, I think before the PREDICT method have improved the sensitivity, before that

that we should have the ability to do this kind of surgery this is my thinking yeah that's why I

told you probably the the thinking can change during the operation like what you have done

today so uh that that's really that's really important and uh remember to count on us when you

you will extend your trial also in the international way.

Yeah, because we are really interested about it.

OK, thank you.

Yeah, you're welcome.

If it's possible to see the anastomosis?

Yeah, we will show you the anastomosis.

Yeah, and then, please, Professor Ding,

can you show us the specimen when they take it out?

Yeah, sure, your anastomosis.

They are now ligating some vessel in the mesocolon.

Okay.

So, Professor Ding.

right yeah let me let me tell you let me tell you that the surgery was really really clear

yes yeah methodical also also with uh you show us step by step i don't know i don't know the

the correct of you the the italian surgery how how to think about this operation uh yes

where i can improve from your colleague or other like a surgeon at the same room

now now i uh there are there are more rumors to uh comment to comment the surgery yes in

this room now i am alone but i can tell you by the reference from the people outside that the

surgery was really academic really um really uh methodical and also really clear no bleeding so

So especially for the residents and for the younger sergeant,

it will be really useful to know the anatomy of the right mycolectomy.

Also, this new technique shows us better also the vessel,

the ileocolic vessel, not only on the root where we usually like to look at it,

but also the medial to lateral side to see also the branch,

the colic branch and the ileal branch.

So it was really satisfying,

and I think that a lot of people liked something about it.

And then let me tell you some numbers,

because it's important also for you to know the numbers of this Congress.

So yesterday there were 1,500 people,

And now there are more than 3,000 people looking at your surgery.

And they told me also 3 million people linked by net and by the auditorium looking at your surgery.

And there is something like more than 70% of people that comes from China.

Okay, thank you.

so you can represent me and represent our department to accept some advance or some

communicate from your countries doctors so i want to know how to how how they think about

this kind of operations and uh what problem uh what's the question there are questions or

problems to communicate it to us so you're operating represent me to accept

these ideas for for discussion in the future yeah let me let me check one

seven yes yes they already put the uh anastomosis device in the distal part this is the middle of

the trans uh trans transverse transverse colon so we may we we poured the uh the stable uh the

anchor in the middle of the transverse colon embo embo embo

let me let me tell you some comments from the from the auditorium okay there are there are

some doctors who are uh giving to you the congratulation for the excellent surgery that

you show to them okay okay a lot of congratulations by by the the chat also from the from the from

the audience from the from the net yeah and then i will i will give you uh some new advances

some new feedback when uh when people write will write from the chat okay don't worry yeah yeah

yeah we can continue to to see the surgery you told me that this patient already received the

the appendicectomy?

Yes, before.

Yeah, OK.

And usually during Elisha, you like to take out the appendix

or you will preserve the appendix too, OK?

Yeah, we will preserve.

I think it's an organ that is related with the bowel

like immunity or something like that.

They have lymphoid tissue at the appendix.

so i think we we would choose to like preserve the appendix and then we will make an incision at the

uh the the wall of the wall of the uh uh and then do the anastomosis you will see soon

okay then then if you are okay wait a moment if you have the specimen if you have the specimen

Yeah, we will have the specimen soon, okay?

Okay.

From the audience, someone asked you, why don't you do the intracorporeal anastomosis?

Because this patient has a very bad bowel preparation.

We are afraid of like...

Okay.

Yeah, yeah, yeah.

And routinely you like...

Because it's like a severe infection in the...

Yeah, yeah, yeah.

We try to take it out.

okay okay I should say goodbye for you I should go to another meetings and doing

another operation so thank you so much to give us this opportunity to

communicate together

together. Thank you too. I hope to have another chance to give you and make the bridge of the

communication from the Chinese surgeon and the Italian surgeon. Thank you so much. Thank you.

It would be an honor for me. Thank you so much for your life.

Joe. Yeah, hello. Yeah, let me introduce with you. So, when you have the specimen,

is it possible to share it with us oh sure i will show you the uh specimen picture and

we will use the laparoscopic to let you see the specimen because now they are dealing with the

stool in the bowel okay yeah that's why that's why i was asking that's why i was asking about

the mechanical bowel preparation yes patient didn't drink the medication for the bowel

but you know you know we are we are we are colorectal sergeants so we are not scared about

the stool i know that's what i try to tell them yeah i think it's okay to show to show what

they're doing so about about the next the next operation can you can you tell professor lee to

to show us his method

to dissect the vessels from up to down.

Yeah, Dr. Lee, yeah, for the next surgery.

Cause we see now the one approach from up to down,

but the vessel from down to up.

I want to see for the next operation,

if it's possible the dissection of the vessels

from up to down, like the paper that we found on the net.

you can you can call professor Lee well actually I think I should call I'm not

sure if you can explain the well hey Joe explain the the dr. Lee's procedure from

up to down yeah you can explain I will show you later when he's doing the

operation but the principle is that we try to do more on the cranial part like

we will uh open the sheath of smv and we will dissect along with the henna trunk and we will

try to ligate the uh like a right colic vein or the superior right colic vein at the top part

so it's a cranial approach

with the smv and then to find out the branch of the ileo uh second uh vein and then we stop

okay so it's an it's an up-to-down approach yes it's our approach on our priority on the vessel

yeah that's also really interesting because here here in italy there are approaches majorly

focusing on the vessel dissection on the cranial on the top yeah because in italy we have different

school okay so someone start from bottom up make the bottom up someone else start from up to down

but the priority of the vessel is always from down to up so we would like to see something different

several years ago but recently we can do like from the bottom or from the the lower part okay

if you have a vision if you have also uh the picture of the paper of the paper that you

publish on the net about your approach of the uh do you want me to show you the paper now

no later later if it's possible later yeah for the next operation maybe i didn't

prepare that paper on the slides sorry don't worry it's okay

thank you they're still dealing with the stool in the bow okay okay

when we when you have the specimen please show us uh cannot hear you okay i will show you the

specimen when we take care of the stool okay after the anastomosis i will show you

an incision on the second and then we put the device through it and then do the end to end

anastomosis which is a transverse colon are you there can you hear me

he's doing the anastomosis yeah he's doing the anastomosis now okay you see it yeah yeah i can

see it okay okay this is like uh we we make an incision at the bottom of the sitcom and then

we put the device and get out through the uh margin that we take and then do the anastomosis

with end to end with the transverse colon like this and then we will use a stapler to

to close the incision of the cecum.

The volume is too high.

Okay, they're just going to suture this incision.

instead of using uh we can also use a linear stapler

okay yeah and uh can you turn the volume a little bit

down a little bit down yeah thank you like

like this like this yeah now it's better now it's

better okay

explain what you are doing okay we are we are closing the

Yeah, we can either do it like hand-sewn or we can use a linear stapler to close this.

And also this patient does not have an appendix because she already removed it.

So usually we would preserve the appendix.

I'm going to show you how to do it.

Let me ask you something.

I'm going to take off the clothes.

You can go in there.

Gui Bo, when it's done,

you can show us the process.

Okay.

You are hand-made.

I bought it myself.

What?

You can go in there, Gui Bo.

Come here.

You can go in there.

You can take a look.

Aiya, Aiya.

You can change the logo.

Okay.

I put it back.

You put it back.

Okay, so this is the specimen, as we can see it's only, there's only the colon, and like

different from traditional specimen which includes the terminal ileum, so this is only

The colon and the tumor is in the middle

The tumor is over here, a little bit of a structure

And it's a CME procedure

I think it's almost done

That's it

The serum is cut to the other side

Can you talk to the computer?

There's no one here, right?

There's no one here, it's over

After I talked to him, he said there's no one here

You can send it to the computer first

So you don't need the earpiece

I'll let the serum go

Okay, thank you