XianJun Yu Duodenopancreasectomia laparoscopica

So this is a 79-year-old male with ABMI at 22.8.

患者是因为肝功能异常一个月左右的时候去看病的。

And the patient went to the hospital because of the abdominal liver function test for about one month.

患者在10月17号的时候因为一个体检的时候发现了肝功能异常,

其中ALT-102, AST-886.3,总胆红素和职业胆红素都是正常的。

And the patient underwent a physical examination at an outside hospital on October 17th,

which reviewed abnormal liver function tests with the ALT at 120, AST at 86.3,

and total bilirubin and direct bilirubin at the normal range.

患者当时没有恶心,有吐,然后没有腹痛,没有黑便,黄胆这些症状。

At that time, the patient denied the symptoms of nausea, vomiting, abdominal pain, malignant, etc.

随后呢,他们做了一个腹部增强MRCP和MR,然后显示呢,是有一个胰胆管的扩张。

After that, they conducted an abdominal contrast enhanced MRI and MRCP,

indicating significant dilation of the common bile duct,

intrahepatic bile duct, and the main pancreatic duct.

随即做了一个ERCP,

显示在12指肠乳头是有一个肿瘤样的增生改变。

And then we conducted the ERCP,

and it showed that there is a tumor-like transformation of the major duodenal papilla.

肿瘤表面糜囊,炙脆,一出血。

The papilla is with surface erosion, redness, and azate bleeding on contact.

随后做了病理活检,病理活检提示是一个十二指长的乳头的一个腺癌。

And then the biopsy pathology was conducted and it confirmed the adenocarcinoma of duodenal papilla.

为进一步诊疗来我院,门诊以12只肠乳头癌收治入院。

So the patient presented to our hospital and the patient was admitted to the hospital

because of the duodenal papilla cancer.

患者寄往是没有高血压,糖尿病,冠心病,老梗这些寄往史的,

只有40年前开过一个开服的蓝尾切除术。

The patient had no past history of hypertension, diabetes, coronary heart disease or cerebral infraction

患者一般情况渴的,然后精神状态也是好的,皮肤拱膜都是没有黄染的。

治我院就诊的时候,他的一个胆红素基本是正常的,6.7,止胆也是正常的,

三点一健胆的话是三点六,然后ALT,AST也都到正常水平了。

So when he was presented to our hospital, his bilirubin levels were all basically normal,

such as the direct bilirubin or indirect, ALT and AST all within the normal range.

肿瘤标注物查呢,199,CA199,CA125,AFP,CEA,这些都是正常范围以内的。

And also for the tumor markers, they are also within the normal range.

然后来我们看一下它的一个影像学的片子。

这个是静脉相。

And this is the imaging results.

这个是动脉相,在没有放胆图管支架之前的。

它的一个胆移管都是明显扩张的。

12指肠乳头部看到一个疑似的膨胆。

So for this one, this is at the arterial phase before placing the common bio-doctor stent.

and we can see that for the bowel and pancreatic ducts, there were significant dilation.

And for the venous phase, it also showed the same result.

Therefore, we diagnosed the patient with carcinoma of the duodenal papilloma

and the status post-appendectomy.

计划做的是一个腹腔镜遗杀脂肪切除术。

And we plan to conduct a laparoscopic pancreatinal duodenectomy.

好的,以上就是今天的这个病例简介。

So this is the overall summary of the patient today.

Thank you very much for the clear description of the case.

It's a very interesting case. Thank you.

非常感谢您的介绍,这是一个非常有趣的病例,谢谢。

Can we ask you, the main surgeon, to explain what he's doing and what he did before the connection, please?

Can you ask our doctor to explain what he's doing and what he's been doing before the meeting?

I have one.

Is it okay?

Okay, so this patient is having the carcinoma at the duodenal papilla.

So previously, we have suspended the left side of the liver,

and now we are trying also to suspend the right side of the liver,

and we have already conducted the knock maneuver.

And we have conducted the knock incision.

So we have lowered the column and we have dissected the right side of the column.

It's very nice how the manoeuvre with the exposure of the vena cava, it's very nice to see how do you manage this part of the operation.

能够看到我们整体的技术,整体的动作都非常的流畅,刚刚的解考也做得很好。

然后我们做了一个长期膜上静脉的预暴录,然后这个是胃结肠共同干。

And we have also tried to pre-expose the SMV, and as you can see, here is the gastrocolic

tract.

And now we are trying to isolate the stomach.

Actually, today we have a quite standard case.

Professor, so if you have any question and you can just ask directly, so any question

is welcomed.

Thank you very much.

Thank you.

I really appreciate it.

I'm just looking at how you are managing the lesser sac

in order to do the clear also lymphadenectomy of all this section.

Thank you.

Okay.

Thank you very much for giving us this opportunity.

I'm also looking at how you deal with this small sac.

Thank you.

You're pulling the chain really hard, Chen.

Yes.

Okay.

Chen.

Yes.

可以请他们介绍一下在意大利的一线的围窗的现状吗?

对,能不能让他们介绍一下这个意大利现在一线肿瘤外科的一些现状啊,规模啊?

对,对,对,对,对。

能不能让他们?

好的。

Hi, professors.

So, actually, our Chinese experts, they are wondering what is the status call of minimally invasive surgery for pancreatic tumor in Italy?

We are in several centers that are doing this kind of operation, but honestly the switch was much easier from open cases to robotic cases.

The Whipple were less diffused in Italy.

特别是如果是对于像移头

或者说一些移线的远端部分的切除的话

目前在意大利我们也逐渐将

肃腔镜手术是作为一种标准的治疗

Professor, what is your thoughts about the robot?

I mean, you have access to the robot

and if yes, how do you decide

which places you laparoscopically and which robotic?

机器人手术我觉得在一线保留功能的素质上还是有优势的,因为它是一个局部放大的效果。

但是我觉得在RPD和LPD的优势上,机器人并不明显。

OK, so I think there are certain advantages of the robotic surgery, especially for those of preserving pancreatic function.

But for RPD and LPD, I think robots are not that advantageous.

I think this is because actually our professor is so good at this surgery so he does not need that robot that much but actually for beginners I think robots are still advantages especially for like RPD and the procedures such as anastomosis still I think there is certain advantage.

Yes, I understand. It was something that I was thinking about because, you know, if you

are very used to laparoscopic approach, I mean, as you told, you don't need to change

it to the robotic stuff. Also the same things as other expert professors that they say that

they answer in the same way of you, professor.

Professor, just one thing before we answer the question, can you open your camera? Because

we'll have to do some screen shots yes perfect thank you and also could you

please repeat your comments your earlier comments oh yes I just put the screen

out just because the room here is not so nice as the operating room just for this

I understand the comment of the professor and other also other

professor that are very skilled in laparoscopic surgery, they don't need the sensory to move to

the robotic approach. I very much understand and agree with your statement. Indeed, if our

doctor's memory is as excellent as today's, it is possible that for this robot, its advantage

is not so great. My understanding is the same as yours. Thank you very much for your answer.

Thank you.

Now, we are at the top of the lymph node to detoxify the tissues around the liver.

This is the 8th group of lymph nodes detoxification.

So currently we are dealing with the 8th group of the lymph nodes which are surrounded by the hepatic artery.

And they generally move from the celiac trunk to the hepatic artery or from the liver to the celiac trunk?

之后我们去做这个第九组互相干附近的一些操作。

Okay, so we are starting from the upper border of the pancreas

and which help us to locate the eighth group of lymph nodes.

And then we go to the hepatic artery.

And now we are looking for the gastric right artery.

And after that, we are going to deal with the ninth group of lymph nodes.

好的,刘晨,晨哥,我来了啊。

不好意思,迟到了。

你快点用英语跟外方打个招呼。

Hello, everyone.

I'm Dr. Alex from Shanghai Changzheng Hospital.

他就一点不怯场。

大家好,我是来自于我们长征医院的Alex教授。

Alex.

Alex教授。

Professor, so Professor Alex from Changzhong Hospital is saying hello to you.

Hi, Professor. It's a pleasure to see you and to have you in this great direct from this hour. Thank you.

Hello, Professor. It's a pleasure to see you and to have you in this great direct from this hour. Thank you.

The pleasure is mine

And the surgery is very interesting and fantastic

Professor Liu Chen is one of my best friends

No, not one of my best friends

He is my best friend

So the professor just mentioned that they are isolating the right side of the stomach

and they are trying to expose the GDA now.

Okay, thank you.

在三角这个地方往下面,往深部去做了,就能看到门禁脉。

So here actually we are trying to find the portal vein.

So first of all, we will isolate, we will try to locate a triangle,

which is consisted of the hepatic common artery and the GDA,

as well as the upper border of the pancreas.

So when we locate this triangle, it will be very easy for us to identify the portal vein.

所以我们这个断的这个位置要斟酌一些。

二伯,二伯。

Because the region of this patient's GDA is at the right gastric artery,

so we all have to be very careful about that.

We are trying to expose the GDA.

这个是上后动脉。

So this is the superior posterior artery here.

The superior posterior artery of the duodenum.

它是不是有简称上后动脉?

叫什么?

诚哥,你还知道?

诚哥,你还知道?

对,它有个英文的简称。

SPDA 是吗?

应该是。

应该是他们了。

好像有两根哦。

哎哟,这个什么?

算是有点...

现在把它捞过来再说。

好吧?

五毫米呢?

先把位又断掉,对吧?

我想先把它断掉吧。

先断掉清爽一点。

再来。

So now we're trying to transect the right gastric artery.

So as you can see here, the clip here, it has a certain angle, which is like 35 degree.

So compared with those straight ones, it's easier for you to locate and to do the operation.

应该是比较正常的位置吧。

比较正常的,只要不是太高应该都不会伤到的。

这里就是右肝动脉了。

So here we have the right hepatic artery.

这是右肝动脉,我们在断GDA之前常规会先要找到这个右肝动脉。

So before we transect the GDA, usually we will at first define the right hepatic artery.

避免误断。

避免误断。

So as to avoid any misoperation, like mistakenly transecting other parts?

It's a way to be safer and avoid if there is any kind of anomalies that of course the city is able to show us, but sometimes it's not really clear also after the city scan.

然后呢,可能直接从这个CT上也不能够看得特别的明显,还是要进来之后再看。

对对,这个人的GDA他有点奇怪,他等于是发了两三支的动脉,

一支是胃右,一支是移死二指肠上后动脉,上后动脉呢,他可能又有两三支在这个地方。

对,分差比较早可能。

So as you can see for the bifurcation of GDA of this patient, we have several branches here, several branches over.

And especially, and as you can see, this is the posterior side of the portal vein.

诚哥,你还好找了个翻译。

对,对,对,我就说呀,是那个陈和说我可以同声传译,那是绝对做不到的。

对,对,对。

Very nice step, very nice.

两个动作都非常的漂亮。

你看一看。

嗯,来,缝来,五个零,来的啊,也可以啊,啊,缝吧,缝一阵啊,来,五个零,你不要去捅啊,不要去捅啊。

这个是,这个是GDA吗?

对的,这个是GDA,然后我想把它分得高一点呢。

好。

后面应该有个小静脉。

后面好像应该是不是以后上的一个小动脉

应该是以后上的一个

它这个有点变异

分叉分的好像有点少

对

分叉的比较少

Very touching.

Very nice, this section.

能够看到整个的视野都非常的好。

而且我们能够看到止血也做得非常好。

There was a perfect coordination from the main surgeon and also the assistants that they collaborated in a very efficient way to stop bleeding.

Excuse me, Professor, I think there's quite a lot of noise over there. Can you just repeat it again?

There was a very nice noise here.

You can hear me?

The voice is very low and I cannot hear you clearly.

No, something's changed.

Yeah, there is like some noise in the background.

它应该指的是,止血是一个teamwork,就是要整个小组配合非常好。

Now you can hear me better?

Yeah, now it's better.

Okay, now, as Professor said, I was talking about the great teamwork,

so of course the main operator, the professor is very, very skilled,

but also the team reacts very efficiently to this situation.

So, this is the right gastric vein.

Can I ask the professor why he prefers to put the

the line before the MLOC in the closing the GDA?

Or for tension, or you prefer that you feel more safer

putting the line?

Mr. Chen, you just answered his question, right?

Yes, yes.

Okay, then I'll translate it directly.

So when they are transacting the GDA,

they use the tension very slowly

so that to ensure there will be no any damage to the inner momentum the inner

side of the organ because otherwise if you just go up the tension directly it

will easily hurt the organ the tissue thank you that's it so to avoid any kind

any risk of upset or the risk in the in the post-op

非常感谢您的解答,确实通过这种方式能够帮助我们降低很大的风险。

对,其实我预判了他的预判,我说的就是他想问的。

So the professor actually just explained, answered your question before you even asked the question.

That is nice, because it means that we are looking at the same thing, so that is nice.

非常好,说明我们都已经同频共振了,想的是一样的。

这个是胃组静脉

So this is the left gastric vein

我们又叫它冠状静脉

And we also call it the coronary vein

小生是在高铁站吗?

小生都不理你

他不好意思

他赶紧把他那边的声音给关掉了

他打扰了

神双锐英语都还可以

让他们来啊

他在线上一直来

他们就是很害羞啊

不会

就是肝腫动脉,这样对于后面的清扫各方面都会带来很大的很大的方便

So for the suspension technique that you see here, I personally named it the clothesline method

Which is that you can like just like the clothesline where you can put your clothes on

And so here we can put the first clothes or the second or even the tenth clothes

The first clothes that we're putting you here is the common hepatic artery

and it will be a great convenience for us

for the subsequent dissection

and also the dissection of the lymph nodes.

So we can see that Professor Chen is very careful and very skillful in this regard.

For example, for the small veins here, he will also suture all the small veins to ensure the stop of the bleeding.

But sometimes, like for us, we would just separate it or use hemolock.

But overall, we can see that Professor Liu is very skillful and stopped plating here, even for small vessels.

And now we are trying to transect the hyaline trunk.

So for this Helen trunk, we can see that it's a little bit thick.

So at first, we will do the lignation at first.

But for some like thinner Helen trunks, maybe we'll just use those clips with degrees to do it.

So the same question to you, professor, for this kind of vessels, quite thick vessels,

what will you do?

Will you do the suture?

Yes, preferably with the suture is better.

I mean, as we told, if they are very thin, maybe you can just thrust the clip, but with

要么你就用缝合,如果用太夹,你可以看旁边的海姆洛克和它的对比,直径的对比,你是夹不到那么牢靠的,因为海姆洛克对它来说也偏大了。

In Professor Liu's perspective, so for something once, maybe it's more necessary for us to do the suturing,

Because as you can see, if we use the clip, the diameter of the clip is a little bit wider than the vessel.

So it cannot be very tightly put it here.

So maybe even for smaller ones, it's more necessary for us to do the suturing.

But for some other situations, maybe you can just use the ultrasonic scalpel or other methods.

But we think that for the thin ones, we have to be very careful about that.

Okay, so now we are going to transect the pancreas.

So now we can see that we are doing this suturing,

and it has three purposes, actually.

so the first one is to stop the bleeding and the second one is to help us to do the traction

and the third one is that it can be used as a marking so this procedure is of great significance

yes we also do in that way i mean we also put these border stitches to help us to the

consection

认为疑管可能要出现的地方还是会改成剪刀这种冷分离,

而不是超声刀或者电铃沟的这种热分离了。

So usually, as you can see here, we will use the ultrasonic scalpel for the first portion of the tissue,

but when it's suspected that here we have the pancreatic duct,

we will switch to some like scissors other than ultrasonic scalpel,

because otherwise it will burn or easily damage the tissue here.

So as you can see, now what we are doing is that

we are transferring from the ultrasonic scalpel to the scissors

to ensure that there's no damage.

So now we are trying to deal with the DPA.

And actually before the surgery, we have already identified its origin, which is SMA.

And now we are trying to expose the DPA.

And also, we dissected certain lymph nodes at the root of the celiac trunk here.

包括雕,雕住这个淋巴结,有暴露,有助于主刀的清扫,然后呢,有时候出血了,右手也可以去帮忙夹住这个出血的点,然后左手的吸引器可以把这个血吸干净,成为一个无血食益,非常,非常有用的一种处理。

Okay, so as you can see, our assistant here, for the assistant's right hand, usually they will hold the retractor or the dissector to deal with some of the lymph nodes.

And with the left hand, usually they will hold the suctioner, which is to suction the bleeding.

And then we can use the right hand to deal with the lymph nodes.

And if there's bleeding, then we can use the left hand to stop the bleeding.

So overall, it's going to be like a blood-free operative view.

And this is actually what we see,

because it's completely without any kind of blood in the operating field.

Very amazing preparation of the anatomy,

and they're very respectful for all the structure

and then it should be very meticulous dissection.

Okay, so for Professor Liu, the ultimate goal is not just to resecting the lesion, more importantly, what we are pursuing is what we call the white LPD, which means that there is no bleeding in the operative view, as you can see it here.

它这个其实和我们这个正常的

这个磁针的方向是不一样的

但是你可以看到

它也是非常的熟练

它这个可能是一个特点

Another interesting thing is that

as you can see here

for Professor Liu's suturing

he is actually using the needles

with reversed directions

it's not the normal direction

it's in the reverse the other way

and still he is very skillful

in for this technique

这个缝合的角度呢,这只是其中它的一个比较特殊的角度。

待会儿在移常吻合的时候,它可以有可不止反针和正针两种,它可以有七八种这种角度。

比如说30度啊,反针啊,60度反针,90度反针啊,等等。

待会儿可以展示得更加清晰一点,可以更加过瘾。

So this is the only one type of the reversed needles.

And later on, when we are doing the pancreatinal jejunostomy,

we will show you even more needles with normal or reversed directions

and with different degrees, like 30 degrees, 60 degrees, or 90 degrees.

Because the patient has gone through the appendectomy earlier,

so we can see that there is certain adhesion in the lower right part of the abdomen.

And now we are trying to transect the jejunum in the lower part of the colon.

也要通过床的体位的变化来暴露我们趋势人呆这边的小肠,因为马上要操作这块。

So now we can see the benefits of the so-called clothesline technique,

which is that on this line you can hang several pieces of tissues or vessels.

So now we are hanging the second piece here and it will be very easy for us to manipulate to operate in the area of small intestine here.

So actually, when we are doing mesojejunin,

and we will do it differently based on the different locations of the tumor.

For example, if it's IPMN, like a low-grade malignant tumor,

Usually, we can handle the marginal arch along the edge of the jejunum and resect a segment of the jejunum.

And if it's a pancreatic, like, head cancer, then we usually will start from the vascular arch of the first jejunum vein.

So it depends, like, where the tumor is located.

and I am wondering how will our Italian experts handle with this kind of mesojejunen?

Almost the same things that you told us.

But if there is an IPMN, there is a low grade of Malignant,

then we try to save as much as possible of the bowel.

Well, if there is the pancreatic cancer that is more growing in the antenatal process,

it's much more convenient to take it out more, more part of the vessel and also the jejunum.

So maybe in the antigenic process, maybe the first arterial branches can be not clearly involved,

but very close to the tumor, and then it's better to take more of these branches out with the specimen.

Do you have an experience to do a very wide cover maneuver in order to arrive to the other side of the crates and do this part on the right side of the patient?

It's not our idea, but I saw another professor doing like this, a very extended coker and

pull of the bowel in the right part, just to avoid to move the bowel up and down.

I don't know if it's one of the things that you do or if not, why you don't prefer.

Professor, do you mean that the Chinese experts do the wide culture maneuver on the right

side of the patient?

Is that right?

No, I mean this part of the variation that is now is open the trite ligament.

There are some professors that are doing from the other side, from the right side doing

the extended coger manoeuvre, they already arrived to open the trite's pigment. And I

was just asking if they do sometimes or why you don't prefer this approach.

Right, so you mean that you see other professors that are doing the extension of the

coger manoeuvre? Yes, I mean that in other descriptions and other videos

Some surgeons say that with an extended cocker maneuver, they arrive to the left side and bring the jejunum directly to the right side without doing this movement.

If he had some experience in this other kind of technique, it's just a question.

然后他想问您有没有类似的

他所看到的这样的一种

这种延伸的culture的操作

有没有相关的经验

雷哥是您先回答

还是我给他回答

你回答你回答

诚哥要回答吗

诚哥要不要回答

你们回答你们回答

要不要回答

好好好

我最讨厌

我就不通文

然后再慢慢翻译

我再给他讲吧

Actually, for the cohort maneuver, we have different directions to perform this approach, either from the left side or from the right side.

Actually, we could open the left lapland with greater momentum.

Actually, that depends on whether we would perform the artery first approach.

If we perform the left side approach from the left side, we could open the tris-legaments from the superior side of the colon.

And we would perform the anti-cover maneuver from a different direction, that means from the left side.

And if we perform the wing first approach from the right side...

高松,我打断一下,我说一句话,这里我们可以看到空肠的动脉,我们在左后的视角可以看到这个空肠动脉的一个走形。

So here you can see the jejunal artery here.

好,你继续吧。

我说完了。

说完了。

这里先不动好了。

这是空肠的阴鱼害,阴鱼害太轻了。

我们在这里其实把这里的细膜都已经清扫了。

So actually, we have claimed the mesentery here.

So here we are doing the reversed cohort.

And as you can see that we actually started from the dorsal side of the jejunan and to have an opening here.

So in terms of the cortical maneuver,

no matter it's from the left to right-hand side

or from the right to the left,

there is no absolute answer for that question.

And I think it depends on in which way

is more convenient for us to conduct the surgery.

Thank you very much.

So as you can see here, this is the left posterior side of it.

And here we'll put a marker.

And you can see that this is the SNA.

And this is where the jugular artery joins.

There, we can see that Professor Liu is only using one hand to do the operation here.

单手调整技巧,你要跟他翻译这样。

To adjust the angle of the needle using only one hand.

对的,对的,这个翻译很准确。

I saw, but I didn't say nothing in order to not disturb in this moment, Professor.

我觉得这个是我之前确实非常少见的,做得特别好。

so now uh just so now we used the

the bipolar, and you can see that it's very effective.

Very nice.

I mean, it's a very difficult place where you start bleeding,

but it's not very easy to arrange that place.

Very good. I think the bleeding here is very difficult to control,

but overall, it's done very well.

That's it. That's it, okay?

Because we can't tell people that our Chinese medicine is...

整个就打包

So, you know, we just started from the dorsal side of the vessel

And now we are going to the ventral side of that, of the fascia

视野现在上方出现的那一只静脉

从长期膜上静脉发出向左侧的呢

就是像我们患者右侧的

就是近端背侧空肠静脉,PDGV

So now you can see the PDGV

which is the proximal dorsal jejunal vein,

and it originates from the SMA.

It's exposed here.

It's at the upper part of the field,

of the operative field here.

And now we can see that the left SNV is lifted up a little bit,

and then we can see clearly the IPDV here.

So we have IPTV and also the first judgment lane.

And when they join together, it becomes the PDGB, which is what we see here.

We can see that Professor Liu is situating every small vein and he's very careful, patient and skillful about this because this is the safest way for us to ensure that there's no bleeding.

OK, so we do have one question.

That is, what is the current situation of training for young doctors in robotic laparoscopy and surgery in Italy?

but I mean it's a nice question of course the things are doing a little bit better than in

the past unfortunately the the access to the robotic platform is not so wide but likely we

have some reality that really like to improve the skill of young surgeon and then they allowed to

to give us the access to the robot and at least for some part of the operation you can

do a sort of step-by-step procedure, but there are still no formal educational programs.

It just depends on the logger and the director's behavior.

还是取决于自己的这样的血细?

好的,谢谢了。

还有,如果血管受侵犯,

他们选择什么手术方式?

是继续枪击下作呢,还是怎么样?

So another question is that

if the blood vessels are invaded,

there is blood invasion, vessel evasion,

then what kind of surgical method will you choose?

Do you continue to use laparoscopy or other methods?

这根应该就是这根吧。

this depends from the experience of the center in the robot we select in the

robotic there is much more I mean it's not easy but it's much more easier

compared to the laparoscopic approach also to approach the vessel reconstruction but

otherwise it's better to at least for us it's better to convert in the open

And patients with the clear or with the high risk of vascular invasion

were not scheduled for mini-invasive surgery,

at least for my son.

So for at least in my center,

if the blood vessel is at a higher risk of infection

or a more clear patient,

we will not arrange for him

this kind of micro-invasive subcutaneous surgery.

Okay.

Thank you very much.

Thank you.

This is an extension type.

Now also the artery is very nice exposed and easy to see under the suction.

There is the artery, and it's a very nice view.

Chen, you are now unpacking the IPDA.

这个应该是空肠动脉的

这个我抄掉好了

空肠动脉

对

这个是第一只空肠

这个第一只空肠

第二只空肠

跟IPDA共干吗

我没看数钱的CT

没仔细看

共干的

它这样长的肯定是共干的

还是一只

不知道

So we can see there is common trunk between the jejunal artery and the IPDA.

这个共干的这个空肠动脉

我们把它断掉

这是空肠动脉

And we are transect the carbon trunk

So you can see we have the jejunal artery

And the IPDA here

五毫米呢

不要动

大家

剪刀呢

肚子有点紧

肚子有点紧啊

肚子啊

还是紧啊

对啊

挺笨的

明显的一个栏内

包括我们的脂肪

都加一种

下午的药

我们也习惯

做什么

So now we're lignate the common trunk of the IPDA and the jejunal artery.

We have clamped it.

So in some literature,

we call this kind of common trunk

as gastro-jejunal common trunk.

But for some patients,

maybe there's no such kind of common trunk.

It's less... the rest are little and there is less representation of this trunk in some patients, as you say.

是的,确实可能是只在一部分患者身上是有这样的一个公干情况。

是的。

Yes, indeed.

So all these anomalies or variants is the reason why every professional is doing...

Professor, I'm sorry, there is much noise here, we cannot...

Right, can we try again?

Now? Even better?

Stay a little bit away from the microphone, not too close.

Can we try that?

Better?

Yeah, better, yes.

Okay, and then I'm saying that for all these anatomical variants,

这是上后静脉,我们先说这个解剖,上后静脉。

So this is the superior posterior vein,

and you can see how the professor is using the scalpel here.

它是一般有时候我们用的话会用前面,

这个超声道整个长度的二分之一,

但是往往会烧到你意想不到的血管的后面,

So usually we will use like half of the ultrasonic knife to do the transaction.

But if you do it this way, it can easily burn or hurt some of the vessels unexpectedly.

So another way is like what Professor Liu is doing that he only uses the one-fifth or one-sixth part of the scalpel to do it.

and although it looks like it's a slow operation but actually it's both fast and safe and another

thing that we will have to pay attention to is that we should not use the metal tip the the head

of it like the metal part of it to contact to do any contaction because it will easily burn

the tissue or the vessel so usually what we will do is that we will use the another the other tip

that is the plastic tip like what you see here now so in this way it will not

damage the blood vessels it's not slowly it's just really accurate and it's the

proper way to to touch this part of the bridge big injury and big trouble then

then you need for sure as much time to try to fix the problem.

And then it's a very nice and very correct way to pursue the operation.

我觉得这是一个非常好的想法和技巧,

因为我觉得它并不会很慢,反而是它是很精准,

能够让我们以更快的速度来完成整个手术。

相反之下,如果说像我们去用二分之一来做这些事情,

可能会造成一系列的麻烦,

这样要花更多的时间去解决这些问题

所以我非常同意您的这个做法

我觉得这是一个非常正确且高效的做法

Exactly

然后呢他现在断了是一倍动脉

一倍动脉的右侧肢

So now we are transacting the right branch of the pancreatic

The dorsal pancreatic artery

不是这种一倍动脉啊

觉得没什么

And we will also deal with the lymphatic ducts here because usually after the surgery, if

you do not take it carefully during the surgery after the surgery there can be certain like

erosion or other uh like lesions so we are dealing with the lymphatic uh system here

So this is the right branch of DPA.

Oh, this picture can be cut off.

5 mm.

As long as it's not translated.

As long as it's not translated.

That's right.

Here, be careful not to go too close.

It's better to point back.

Don't go too close to the point.

Blur. Blur.

And then I didn't do it here.

5 mm.

Let's do it here.

Yes, it's here.

It's a little bit separated here.

It's not that big.

It's enough for you.

It's about right.

It's not suitable for me.

What?

It's not suitable for me.

But it's because we don't know how to use it.

People use it well, but they still use it too much.

Where's my brother?

He's being sucked in.

He's crying.

He's crying.

Where's my brother?

He's taking care of it.

I'll take a 6-0. I know they definitely didn't take it.

So I'll take a 5-0.

Very nice, this section. Compliment.

没能看到整个分离离断都做得特别的好。

可以休息一下,我拿标本啊。

可以稍微休息一下。

So we will take a short break and we'll get the commencement.

How many pancreatic resections were performed in the professor center each year?

任教授,外方专家想请问在您中心,就是在贵院的话,

So for our department, in terms of the pancreatic nodule tenectomy,

including open surgery, minimally invasive surgery, and robotic surgeries,

it's about 1,200 cases every year in our department.

And also for radical surgery for pancreatic cancer,

it's more than 2,000 cases in our department every year.

How many surgeons are performing pancreatic surgery in their center?

So we have like four primary groups, but for the chief surgeons, we have eight to ten.

And it means around 100 procedure each surgeon for a year, roughly.

说我好了,说我自己,五百多台应该有的呀,对吧?

我个人的组大概是五百多台吧,每年。

您是说整个组是吗?

对,我们整个一个组。

Oh, okay.

So actually it's more than 100, like for example in my group,

it's about more than 500 cases per year.

Okay, thank you.

But I was talking about the single surgeon volume, not the department, not the unit and the department.

There are impressive numbers and I say congratulations to the professor.

Yeah, let me just check with him again.

Professor, he wants to know the number of surgeries per year for a single surgeon.

Okay, so for one chief surgeon, it's about 300 to 400 cases.

Yes, surgeries every year.

Can you ask the specimen from which side was taken out?

If it's the fan steel or if it's the large one of the port?

So the professor is showing you where he takes the specimen?

Thank you very much.

Okay. So, Professor, we have two questions here. So, the first one is that for cases of LPD and RPD, what is the cost for the patient to do this kind of surgery? And the second question is, how long does it take for you to finish this kind of surgery?

And regarding the cost, you mean the cost for the patients in terms of money?

like the total cost and also because like for in China we do have health

insurance so some of the some of the cost will be covered by the government

so maybe in Italy do you have also that like the same system in Italy we have

that all the costs are covered by the government then for the patients is

completely free and it doesn't matter if the procedure was performed more open

and laparoscopically or robotic.

OK.

In Italy, all the surgery costs are paid by the government.

So for the patient, it's completely free.

Whether it's open surgery,

or robotic surgery, it's all free.

Or if you want, you can do it in a private hospital

and do it privately,

but it's up to you.

It's your choice.

But of course, if it's very urgent,

and you don't want to queue up,

you can do it privately.

If you do it privately, you have to pay for it.

Right.

And in China, there is different if the patient was operated minimally invasive or open in terms of money for the patients.

And he also wants to ask about the cost in China.

For example, will the patient's financial burden be different due to the different ways of surgery, open surgery or micro surgery?

Dan, you can answer.

So for like the head of the pancreas,

the surgery usually costs like 100,000 yuan.

Yeah, this is the general price.

But is it dependent if you use a mini invasive approach or open?

It's the same?

Yes, generally this price.

So actually they also have the second question,

which is how long does it take for you to finish this kind of surgery?

再请教一下,就是在意大利这个BMI指数偏高的病人比例多吗?

So another question is that, what is the percentage of patients with relatively high BMI in Italy?

IPMN呢?

你是指对于这个IPMN的患者吗?

I mean, for patients who need to conduct pancreatic surgeries.

Okay, I mean, the numbers are a little bit lower than your numbers, because I think that the general of the number that the professor told us before is quite almost the whole Italy pancreatic resection performance.

each year because we have several centers with a very high volume but not the volume that you told

us before. So you mean it's a little bit smaller than the BMI of this patient that we have today,

right? You talk about with BMI? Yes, BMI. The BMI normally is higher. It's around the medium is

It's between 26 to 30.

This is a very skinny patient for us.

And in China, this is the median BMI of this patient.

He said that their BMI is between 26 and 30.

So, between 26 and 30, this BMI is already a very thin patient for them.

And he also wanted to ask, in China, what is the average BMI for our patients?

OK, so generally speaking,

our patients' BMI are within the normal range, but it also depends. Like, for example, for people

coming from the southern part of China, usually their BMI is lower, but for those who are coming

from the northern part of China, usually it's higher. It's like what you just mentioned,

the 26 to 30, but that's usually for the northern part of China. Also, here there is a variation

between the north and the south of Italy but there is I mean it's not so markedly but generally

the BMI is a little bit higher.

I think BMI is a risk factor for pancreatic surgery.

I mean for patients with high BMI, it's going to be more risky for them.

Yes, it's risky in general, but also for the anastomosis issue for the pancreas

And also for the recovery, sometimes these patients can have respiratory problems,

lung failure, and then it's for sure the obesity,

the higher BMI or obesity is a very issue in this kind of patients.

Yes, I also think BMI, if it's high BMI, it's also a risk,

especially if it may cause us some difficulties in our balance.

Thank you very much for your answer.

So I think we share the same concern in terms of BMI.

I do have another question that is,

what is the incidence of leak for this kind of PD surgeries in Italy?

And also, what is the mortality rate of PD surgery?

the mortality rate and the complication rate is really depends about the in Italy about today

kind of procedure I mean you as you know there are PD and PD I mean if you are doing vascular

resection of course the mortality and the complication rate increase a little bit but

we can say that there the range in the high volume center could be from regarding the

mortality between 1 and 3.5 without vascular reconstruction if you if you add vascular

reconstruction maybe this mortality can rise a little bit and the the complication it's

general complication it's around 40 percent the very the clavian dindo more than three or

or with severe complications, it's around 20% of patients.

So I know that there is a very famous pancreatic surgery expert in the University of Pisa.

I don't know whether you know this professor.

Professor Bojie, of course.

Yes, and we really want to know what he is doing right now and what like clinically or in the research respects.

Both are fine. We want to know more about him.

He is still in Pisa, he is working in Pisa, now he is the president of the Italian chapter of the HPBA and he is the leading of his group and as the colleague knows he is the chief of the highest volume center in Italy especially for borderline locally advanced pancreatic cancer.

You're welcome.

I'm afraid that

Xiaosheng

Xiaosheng is very introverted

Of course

You can ask me again

I think today's translator

She

Very professional

Including English

Express very well

How to add WeChat

This

This

没想到我更内向

画面静止了

Here we have a problem in connection

Because there is a freezing of the imaging

I don't know if it's also for you

Yeah, it's the same for all of us

Okay

Maybe we'll just wait for a few sec

Yes, of course

我还以为翻译老师专门去掉微信了

高生

哎

对对

可能这个空场在那个地方会有一些堆叠

我自己这样认为哈

但是一般来说

但是这种情况下呢

这个胆肠混合可能会就会简单一些

他因为他这个比较长

但是如果说当然如果确实像松哥你说的这个这种哎

他当然如果说确实连这个我们可能走L孔都难以完成的话

那么可能就需要

可能就需要开服啊

或者是一些其他的办法

可能会更安全一些

Okay, we are back to the imaging for the procedure.

Yes, that's right.

Unfortunately, we were disconnected in this moment.

Yes, and now we can see it.

Yes, but already the professor...

He already, the professor already did the posterior layer, and we can ask the professor

in which technique the posterior layer is in a running suture or single stitches, what

is his preference and which kind of line he's using.

It seems to be Pauline, but I would like to ask to him.

Thank you.

Okay.

Professor Hao, because he just cut the line, and he doesn't know what you just did.

这是胰肠吻合,胰肠吻合呢,我们一般是用改良的BloomGut方法,就是在胰腺的,胰管的上下缘贯穿各缝一针,固定这个肠盘,然后内圈呢,就是主要就是这个导管对粘膜的这个方式。

Okay, so now we are going through...

你说,你说,你说。

Now we are doing the anastomosis and we are going to do pancreatinal jejunal anastomosis.

And usually we will suture like to go through the upper and lower edges of the pancreatic duct

and then to fix the intestinal loop.

And then you can see that now we are trying to align the duct with the mucosa.

So we use the default all praline line and all the sutures are interrupted sutures.

So he fixed the catheter with the praline and that it means that the catheter should

remain there in place and to good.

I mean it's not a suture that is reabsorbable or long-term restored and he would like to

have the catheter in place.

And did you have any issues sometimes with this catheter in place, such as pancreatitis or other things?

都会掉,都会脱落的,即使你固定了它这个里面的这个腐蚀性还是很强的,它还是会掉的,还是会脱落的。

So for the vast majority of the patients, this catheter will fall off naturally after six months to about like less than one year.

Even if you fix it still, because of the coerciveness inside, it will still just fall off.

非常感谢。

OK, so our question is that in your center,

when you are doing pancreatic jejunal anastomosis,

will you do single layer suturing or double layer suturing?

The technique is quite similar to the technique that is used by the professor.

For example, the catheter was not fixed, it remained free without the stitch,

but the technique is similar with the posterior layer, then the ducto-tubulcosa,

all around 360 degrees, and then another layer on the top.

Do you have any experience with pancreatic gastrostomy?

In terms of GI reconstruction,

usually what we will perform is the pancreatinal jejunal anastomosis.

And we will not do like the anastomosis, like the gastro part.

We will just do the pancreatic anastomosis for GI reconstruction.

And the loop of the bowel is a single loop or you do any kind of isolated loop just for the pancreatic anastomosis, for example?

are yeah could you clarify your question is that whether they will do like single

layer or double layer I mean that the the rest of Moses you can use the today

not the digital loop the ones that is doing the anastomosis he will perform

the particle to genos to me in the same part of the genome or you just cut and

and use another part.

It's called the isolated loop.

The anastomosis is in the isolated loop

or is a single loop anastomosis.

Okay.

他应该说的是就是关于这个空肠瓣。

他应该说的就是我们在做消化道重建的时候,

然后呢是在原来的地方去做,

还是说我们在额外的独立这个之外再做一个?

陈哥,他是问用哪个孔上提空肠?

就用的是R孔

就是结肠的这个

结肠那个动脉

右动脉的那个右侧的那个孔

就是R孔

昂贵是对于L孔

对

So this actually depends

Like the anatomy of each patient is different

And for like for this patient

Usually what we will go through

Is to use the L choker

But for this case here today

Because we can see that there are many

Blood vessels around the L

And there are so many arteries

And we do not want to sacrifice the blood vessels here

So we used the R troca, the R port

Which is like the right side of the artery

Yes

小姐姐,它这个还不是choker的意思,是说在锡膜上打的锡膜的那个孔,锡膜裂孔,它不是那个choker。

不是choker,不是choker,是锡膜上的裂孔。

对。

Sorry, it's not choker, it's like a hole that they put on the mesentery fissure.

我觉得他可能问的不是这个问题。

Thank you.

Actually, Professor Coppola, continue with your issue.

I know that we're only concerned that we don't use the primary loop because it's the hernia.

It's the hernia of the jejunum after the anastomosis.

Actually, I have encountered nearly five cases for the hernia of the jejunum after the pectodermal jejunal stomy.

So we don't use the primary loop that you referred.

We just open a hole on the right side of the mesentery artery, make a right loop, make a hole on the right loop, and perform an osmosis.

But for some people who perform RPD, robotic pancreas deutectomy, they would use the loop you referred, the primary loop.

Thank you.

Thank you.

And in the same part of the bowel, you put all the anastomosis.

I mean, the pathogenostomy will be 30 centimeters above this anastomosis, right?

Or in another loop?

Or you take another loop?

So actually we will create another one

and to ensure that this is the most appropriate

create an anastomosis position and for us to create the loop.

Yes, I was just trying to teach him.

Can you ask the Italian experts,

do they do some electric shock in the back of the anastomosis?

Or do they use other kind of bandages to do some packaging?

So we do have one question.

As you are doing the pancreatinal diagenal anastomosis,

will you put a place like padding behind the anastomosis site or use like some

other like interfering ligaments for like wrapping wrapping it will you do

that well thank you for the question I mean

honestly I've not only one answer because it depends from the place where

I work because I work in different place and then we have my different chiefs

said they have different habits you know sometimes there is also a sort of us

charismatic things to do on the pancreatic anastomosis sometimes the

round ligament was was around and in another case we do a flap with the

momentum but it's not something that is routinely performing it depends also for

example if there is a more and more advanced dissection of the vessel

vessel structure if the pancreatic duct is very thin I mean it's but it's not

something that we do routinely something that we can do if we feel more

comfortable in some occasion

我一点都听不清你说话,他们这里的这个,你不行让那个姑娘复述一遍吧,我一点都听不清。

好的,老师,您能听到我说话是吗?

你说话非常清楚,对。

好的,好的,好的。

I think that this stitch in the corner is one of the most important one that is helpful to close the elastomosis,

is the one on the top and the other in the bottom that are very important to the corner of the

anastomosis i think the stitch you are making here is very important because it determines

how we make this seam and you can see that this step is very stable and this is a very

thing in this kind of procedure you also have to to have all the team that is very skilled in this

kind of procedure because if you see in the video there are no that time i mean the the stitch one

One came out, one came in, very fast, and there is no time to wait for the stitch.

And if you see also the assistants are doing a very nice job, helping him in a very proper and good way.

And I would like to say compliment to all the team in the OR.

Thank you very much.

Actually, we can see that our two professors, they are working as a team.

And one used the left hand to do the first part of the procedure of the suturing.

And the other one will hand it over to finish it.

So we can see the angle here is very perfect, and they're working effectively.

Yes.

确实如此。

Did the professor ever try to do a running suture on the superior layer,

or in the posterior and then the superior layer of this anastomosis, and not single stitches?

所以他想请问的是除了这种单针的这种缝合,

您之前有没有会在这个吻合上面去做连续的这种缝合?

连续,如果说这个移管很宽很宽的话,你可以考虑做连续吻合,

但是,颐床吻合因为是我们这个PD手术当中一个非常重要的步骤,

所以我还是希望采用间断吻合的方式来保证它的安全。

Right. So in terms of like the continuous suturing, if the pancreatic duct is very wide, I think it's appropriate for us to do this kind of like running anastomosis.

But for this one, I think for the sake of safety, it's best for us to use the interrupted approach.

It's not standard, it's something that you adapt to the patients,

especially to the pancreatic tissue.

That is quite good.

I mean, it's completely correct.

Yes, I understand and support your opinion.

We still need to look at the patient's situation and look for safety,

especially for our gastrointestinal surgery.

因此呢,反而是度过血液曲线

用这样的阶段层合可能更适合

所以除了考虑病人的因素

医生的因素也是一个考虑因素

So Professor Gao just want to add another comment

Except for the patient's condition

It's also very important for us to consider

The chief surgeon's expertise

For example, like Professor Liu

He is very good at both these two types of suturing

So that when he conducts

No matter it's continuous or interrupted

surgery he will not do damage to any of the tissue so it's very good for him to

do that before it like some young young surgeons or who are not very experienced

in this regard maybe they it's better for for them to do like the continuous

这个倒磁线做得都很好。

他说你倒磁线做得好啊。

你听到了没有啊?

这是常规操作,不用说的。

他说谢谢。

我们把这个长度录下来,作为我们手指护士的宣教的一个长度。

And here in the part of the genus.

啊,我说话。

Sorry, sorry, go ahead.

Professor, you can go ahead.

后臂连续前臂做间断

Okay, so if it's like a very small bile duct,

we will use the 5-O PDS.

For the posterior side, we will do the continuous,

and for the anterior part, we will do the interrupted.

Thank you.

That's exactly what I would like to ask.

The technique about the hepatic degeneracy is always the same,

and how do you manage it?

Thank you.

特别感谢您的解释,因为我刚刚其实就是要问这个问题,您已经预先知道了我要问的问题,谢谢。

And can I ask you, the professor, how the technique is different in, if the technique is different in when you perform open cases in spite of these laparoscopic cases?

还有一个问题想要请教您的就是,如果是做开放手术和我们的腹腔镜手术的话,您所采取的这样的一些技巧会有什么不同吗?

开放手术应该是差不多,但是我很久没有做开放手术了,应该是差不多的,差不多。

I think it should be basically the same, because I haven't done open surgery for quite a long time. So yeah, but basically it's the same, I think.

因为刘晨教授应该是国内枪警比例最高的几位教授之一了,接近百分之百的。

Because for Professor Liu, he's like one of the top professors in China who have conducted so many laparoscopic surgeries.

It's almost like 100% for him to do laparoscopic rather than open, yeah.

technical issue that I think that is very important that is that despite the

fact that the professor is more than skilled of course is one of the the best

that we can say is he put in the stitch you always do two step he avoid to put

the the needle in the jujitsu and then come up to the to the bile duct of our

to the bile duct because in that way as we can see we can change the angle of

the needle and before and put a very precise stitches with a very precise distance between

each stitches and the correct distance in the bowel and also in the bile duct and then it's

very nice because as you can see here you cannot easily go to the gallbladder to the bile duct but

But that way, the angle will be not very perfect as he is doing in every single stitch.

Compliment.

Thank you very much for your comment. So, usually I will use this kind of like reversed

needles because I think it can be controlled more easily and more precisely. Of course,

you can use like the other way around, the normal needles, but I think maybe it's not that precise

in that way. Exactly, in that way you are more precise and it could, you know, sometimes in

meaning basically you try to do less movement in order to don't lose the

direction the view and also the don't waste time sometimes but in that case is

you you clearly show how it is important to do always the same step and then it's

not a wasting of time but it's a very is a correct way to put these stitches every

stitches in a very proper way and moving the the cord the the angle of the needle you can do this

without any any problem and it's very nice to see confident.

而且能够十分的精准,所以我想的话,而且能够看到您每一针的这个调整的角度都是非常准确的,所以我再一次的想要表达对于这样的,您的这样的一个技术的欣赏,谢谢。

好,谢谢,谢谢。

Thank you, thank you very much.

再补一针就不要了。

Thank you to the professor for this nice demonstration of technique.

也要感谢教授您今天能够向我们展示您的精湛的技术,谢谢。

Professor Liu, he conducts surgeries requiring for blood vessel reconstruction very frequently.

But today, this case is not necessary to do that. But still, he shows you how he managed to use this

kind of reversed needles. And we say that this is like needle dancing. You can ensure the precise

precise use of the needles it's just like it's dancing so it's a very

brilliant and fantastic technique yes thank you that he also we saw when he

put the the stitches of the vessel on the bowel he used only one hand and then

I can imagine also in other occasion again is very this should be very nice

to see a vascular reconstruction performed by him laparoscopically

我刚刚其实也见识到了,我看到您在做一些这个缝针的时候,您甚至只用了一只手,所以我也大概可以预想在其他的复杂的,比如说需要血液重建的手术当中,您的大概的这样一个操作的画面,我觉得整体上是非常流畅精准,值得我们学习的。

希望下次如果能有机会再一起演示的话,我可以选一个稍微复杂一点的病例。

So maybe next time, if we have the opportunity, I can choose a more complex case for you to do the demonstration.

Thank you very much.

Or I can take a plane and come to see the professor in person.

非常感谢,或者我就直接搭飞机直接来找您了。

谢谢,那我就下来了,我让我的助手陈和教授做这个胃肠吻合。

我一般是做完胰肠我就下来了

但是今天做完了胆肠

OK, so I have finished my part

And I will hand it over to Professor Chen He

So usually I will only perform the gastrointestinal anastomosis

But today I also finished the second part

And now I will hand it over to Professor Chen

Thank you

非常感谢

So this is really an excellent team.

Of course, we have Professor Liu who is very skillful and at the same time we have a superb team such as Professor Ma and also we have a fixed team like Professor Zhou.

They have been working together for a long time and they are a fixed team so they know each other's pace and they can work in a very effective way.

Thank you. Thank you because it's exactly what we saw from this operation. It is a perfect dance of all the instruments and you know that everybody knows exactly the next step and then how to help each other.

Okay, so now we are using the 6-0 to do the suture to perform the gastroenterostomy.

And you can see here there's going to be a common opening between the stomach and the intestine.

And then we will do the continuous anastomosis for this common opening.

and we will do even an reinforced suture to ensure the suturing, yes.

We trust in stable, but we prefer to put also some stitches, just to be sure.

Yes, although we will use a sewing machine,

we still need to add some sewing lines to make the sewing more safe.

这些病人胃肠蚊和口有出血的这样的一些情况,所以我们觉得还是做一个加固会来得更加安全一点。

Yes, indeed. If we only use the stapler, maybe it's not that strong like the suturing.

So usually we will also use like the lines to do another like another layer of the suturing,

because otherwise for some patients they will encounter bleeding at the gastroenterostomy site.

so we think it is necessary to do reinforcement to do like this kind of line surgery and to ensure

the safety of our patient and can i ask you that this is a you you already use another line that is

a auto stoppable line that is different from vlog this other one and why you use this kind of line

in the stomach and for example for the bile duct you use another one you have preference

For instance, just because we just ran out of the other kind of the line,

so we have to switch to another kind, yeah.

Okay, I mean, it's not a difference between these two types of anastomosis.

Yes.

You trust in both.

Okay, he just commented on it.

He was just curious why it would change, but now he knows.

order to be sure to don't catch the posterior anterior layer suturing the reinforcement of

when you think yeah okay I'm asking if he now they are closing the the all of

the osmosis if they leave this part as last part because when we do the

reinforcement of the stable you can have the risk to take the posterior the

anterior wall together and that way you can they can check inside an osmosis

after the two sutures that they already done.

为了去确保我们这个缝合的内部一切都是通畅的,然后没有这个风险。

这个孔是我们一个共同开口,是我们打吻合器的一个共同开口,我们必须要把它缝起来,是这样的。

So we have to sew this hole up, because this is the common opening that we create during the surgery, so now we are just closing it.

因为我们前面有一个动作,就是我们通过这个共同开口进去看过一眼,就是看到这个前后壁都是完整的,它没有被缝合在一起,然后再关闭这个共同开口。

Yes, indeed. So before we close this common opening, we will ensure that the anterior and posterior walls were not mistakenly sutured together.

And earlier we have already performed this examination through this common opening, and now we have confirmed that, so we proceed to close this common opening.

Can I ask to the professor how many drains he will use and how many drains he will place at the end of the procedure?

Professor, he wants to ask how many flow tubes will be placed after the surgery.

He said will he place gastric tubes, right?

Do you mean for the gastric drainage?

No, I mean at the end of the operation in the abdomen, how many drains you will left put in the abdomen.

就是在胆肠吻合口的后方,另外一根是在胰肠吻合口的下方放一根,然后最后一根是放在后腹膜,门经脉的后方,一共是放三根。

So, usually we will place three drinks, and one is at the Omentum for Raman, located behind the biliary enteric anastomosis, and the other one is placed below the hepatogenostomy, and another one is placed in the retroperitoneum behind the portal vein. So, this is like a total of three drinks.

Thank you.

Thank you.

And the management of these three drains, when he will remove these drains.

那在您把这些引流管拆除的时候,您会怎么样去来管理这三个引流管呢?或者您会在什么时候移除这些引流管?

那如果说最后就是五到七天没有腹腔的积液,CT做出来的积液都没有,然后引流液、定粉酶也是好的话,我们就会慢慢的一根一根把这个引流管移除了。

Okay. So generally, we will perform an abdominal CT for the patient on the fifth day after the surgery and to check the amylase levels in the drainage.

And we will also check the amylase levels in the drain on the first, third, fifth, and seventh days after the surgery.

And if after five to seven days, there is no abdominal effusion in the CT test result and the amylase levels in the drainage is normal, then we will gradually remove the drainage one by one.

So all the patients will perform a CT scan in post-operative day five or only if they have high amylase in the drain?

还是说只有那些它的这个淀粉酶水平比较高的才去做呢?

对,我们所有的患者都会在五天左右做复顾的CT。

It's for all the patients, they will do it on the fifth day after the surgery.

And when they start to feed the patients,

in which day they start to eat this patient, drink and then eat this patient?

When they start to feed the patients and...

Yes, it's when they start to drink and then to eat.

um so uh usually in on the second

so on the second post-operative day if the gastric tube is performing like normally without

any blood stained fluid then we will remove the gastric tube and then gradually uh start to allow

the patients to drink water on the second or third post-operative day um and then we will try

followed by semi-liquid, and then gradually drinking water and then liquid.

Usually, it starts on the third day.

Thank you very much.

非常感谢。

And do you use in your postoperative treatment Octodid, or avoid to use Octodid?

您在术后的治疗当中是会使用Octodid?

如果患者这个淀粉酶是正常的,

然后可能就会准备把管和停用这个奥奇钛或者肾脏益素。

不知道松哥你们那边是怎么样的?

我们这边是不常规用奥奇钛的。

So usually like in our center,

we will use octreotide or somatostatin for about like five days post-operatively.

If the patient's on the fifth day,

the patient's amylase level is normal,

then we might prepare to remove the tube

and discontinue the use of octreotide.

So, yes, so this is in our center.

非常感谢。

应该是可以看得到。

好了,沈哥,可以了,有声音,有画面了。

我们刚才就是用这个肝源韧带

把这个脊椎肝动脉这里包了一下。

沈哥,你抬起来给他们看一看。

别急啊,人家刚才断了呀,不要拿这个二波,就是保护这个GDA的这个残端。

Okay, so we wanted to protect the remnant of the GDA, so around the round ligament, we encircled it to ensure another layer of protection.

满满的都是细节啊。

你又出现了。

我上去花了十分钟就做好了呀。

So now we are putting the drainage tube and this is the first one.

We will place it on the upper edge of the small omentum pores of the pancreas.

So we can see that this is a very effective and fast procedure

because it only takes us like three hours.

So we are adding another suture here.

and this is at the reinforced root of the inner right vein.

刚才我卡了一下,但我猜你说的制裁前。

对。

你现在是先放这一根。

这一根是我们放到后腹膜区的一根引流管。

So for this drainage tube, we put it at the retroparitoneum.

这是在门静脉的侧后方,在下腔的前方这里放一根。

It's at the lateral and posterior side of the portal vein

and also the anterior to the IVC in the abdomen.

So this is the last one.

We go through it from the left side opening

and to put it behind the pericardial jejunal anastomosis site.

Many thanks to all the distinguished guests

who are presented here today

and especially I'd like to extend

my sincere gratitude to our professors

coming from the Italian side and I think we have almost finished our procedure today it's such a

pleasure and honor to have this kind of online exchange with you and thank you all of our

organizers and our colleagues for your great attention today thank you so much thank you

very much professor it was a very pleasure to be here and to see your wonderful operation I

Very impressive technique and I think that was something that we really appreciate and we learned a lot by your procedure.

Thank you again and thank you to all the other commenters and discussants of this operation.

It was very nice to hear your point, your idea and thank you again.

Thank you, Brother Chen.

Thank you, Brother Chen, for this invitation.

You have learned a lot today.

Thank you, Brother Chen.

Thank you.

Bye-bye.