Wang Ziqiang Small vessels guided interfascial dissection for laparoscopic anterior resection for r

Okay, the video is started. Can you explain?

Yeah, you can play the video.

The patient is placed in a turn-based position.

The adhesion of the sigmoid colon to the left side of the laryngeal bone is detached.

if you want to tell us something about uh then the left is open watch the video right now

it's not not on the screen screen yeah he's on the screen he's in the live notice the small vessels

on visceral and the parietal you cannot check it there was no communicating vessels between two

Okay, if you can tell us something about the video.

In this video I want to show that we can use small vessels on each fascia as an important

landmark for facial identification. This is dependent on very good

both mesoconic and parietal fascia, glycerin and COMPLETE.

At this point here, it is quite easy, but in some other areas, this point is quite important.

We usually put a stitch on the peritoneum over the bladder.

The sigmoid column and the upper meso column is diffused up, cut the plutonium out of the white line.

Because of the tension, after the plutonium is cut, you can easily enter into the white

dissection plane.

climb onto the visceral rectum, visceral rectal fissure, from behind, from behind, from the

the ritual peritoneal fissure so another longitudinal vessel reveals and dissecting do you usually

use the lateral medial approach or sometimes you do also the medial lateral approach I

always perform it videoly from the video approach here we can see the medial running small vessel

on the posterior aspect of the mesorector, we divide it near its base.

After the retrorector dissection plane is established,

we decide to first advance to the origin of the inferior lesenterical vessel.

With the help of the hemoperitoneum, we'll be easily discovered.

Notice the longitudinal small vessels behind the stalk of IMA. Its course suggests it

belongs to the parietal-post-peritoneum fascia. By dissecting in front of it, we

observe another longitudinal vessel which seemed to run into the IM stalk,

suggesting that it is a companion vessel along the ascending parasympathetic

fiber. Behind to the descending colon, another longitudinal vessel courses in

the same direction as the gonadal vessel. Here we can see the small vessel is

accompanied by silvery nerve fiber and entering into the mesocolon. By

dissecting in front of this small longitudinal and slightly optical

The video dissecting plane, beat with the lateral dissecting plane quickly.

Then the IM storm is lifted so as to form a greater angle to the air water.

The IM wave is elevated too.

Make a small cut to let the air fill in the retroponic space.

small vessels belong to the retroparietal level.

Notice the longitudinal vessel on the parietal fascia. Blank dissection with

intermittent sharp dissection will allow establishing the correct plane

in front of the tortoise fascia. Because there are very few communication

or perforating small vessels to not divide the small vessels on the parietal fascia.

Notice that in close proximity of the midline, small vessels on the parietal fascia are mainly

these two fasciae in a bloodless way, you can see the yellow arrows in this video

provide an easier way to find out the level at which the parietal fasciae is attaching to the

In this field, two vessels from the IM store pass on to the post-peritoneum fascia, divide

the vessels at its base.

More small vessels can be found passing on to the peritoneal fascia on the midline.

Can you tell us about the case, because you didn't mention, didn't introduce the case, which...

This is low rectal cancer, not very specific, just a usual low rectal cancer.

Okay. And you want us to know this rule about the small vessels to help us the dissection for the told Gerotoplane? That's why?

Not only the Gerotoplane, but also later I will tell you something about how to

to recognize these small vessels below the peritoneal retraction.

Yes, that's really interesting. I remember when I was in Chengdu in your hospital,

and I saw a lot of really nice surgery.

I hope this will be helpful to you and your colleagues.

Yeah, that's for sure. We were all, everyone really happy about this experience. I was there with a colleague from Singapore. I don't know if you remember it.

Yeah.

You have done the vessel dissection, trying to save the left colic artery, right?

Yes, I preserve the left cardiac artery, only increases I suspect there will be severe arterial

stenosis, up to where the left cardiac vein branches off, so as to achieve full removal

of the 253 principal lymph nodes as described by Japanese now you are

following the heart area and trying to search for the EMV right I am V yes I

prefer to remove the fatty tissues over the to perform better

better lymph node dissection. But actually, the incidence of lymph node metastasis around this area is quite low.

Yeah, especially if it is a low rectal cancer.

From dissecting in front of the white and the glycerin-caused fascia, there is rare convocating vessels between the visceral and the parietal fascia.

This video is really anatomical because you can see everything, not only the vessel really well, the dissection, but it's really methodic and really clear.

so you can see all the fascia, it is like a nebrological video, video that section, so

I really like this video. To also notice that the point where the small vessels and torte fascia

ending the field coincide with the folding line of torte fascia. This is a video level of torte fascia

I see that you are not using so much the energy you are sliding it like step by

step yes I have never seen a nothing nothing read in this in this during the

beginning of this video so it's really nice but using more brown dissection you

you will keep a complete fascia on both sides. We then start the dissection of the pelvic

mesorectum. The dissection is carried along the fasciae propria of rectum. Usually we know that

in China there is a very big amount of people that have a dolico colon so that they have a

very big sigmoid so usually you do not take down the fasciae. Pay attention to the small vessels

on the pelvic fascia, and avoid dividing them.

Maybe in one third or one fourth of our patients,

we will go up to around the splenic flexure.

There are two reasons. One is that

maybe the sigmoid colon is longer in the Asian

population. The second one is the incidence of sigmoid diverticula is quite low.

Are you using blunt pushing of the mesoretic fissure?

Yes, to be afraid of enraging the sigmoid colon.

Yes, yes. I remember during my experience in China, I have never seen a diverticula on the left side.

Yeah.

At present, here, we would like to dissect along the smooth surface of the mesorectal

facilitate the setup of the correct dissecting line.

Going forward to the anterior aspect, we do not try to identify the novalis

fascia from the anterior side.

Yes, but this depends on good tension of the tissue.

you must arrows I pointed out pay attention to the courses of these small vessels if we

follow that if we follow that vessel so we can do a good dissection without bleeding that's what you

That's also helpful to keep a very clean facial interface and the preventer is at the level

indicated by the base of the two small vessels.

By pushing along the cephaladrounding vessel, another small vessel is observed.

Meanwhile, the postvesicle space is altered.

Good traction in combination with sharp and blunt dissection allows more cephaladrounding

vessels to be observed.

Yes, we should dissect along the surface of these small vessels and the fascia, and then

divide it, divide these small vessels.

You can only view these vessels after it leaves the neural vascular bundle, the course of

of these small vessels, and then divided into the base of the small vessels, or within the

durovascular bundle is invisible during the dissection.

After division of the novatus fascia, more smell vessels can be identified on the mesorectal

So, some surgeons like to use the energy instrument continuously, but to our experience we like

to use the energy instrument one time and then followed by the blunt dissection, step

The viewing of small vessels on both visceral and parietal fasciae assure the searching of a correct plane, and avoid strain either medially or outwardly.

But the small vessel, the knowledge of small vessel is more actual, more easy to

It must be set at a low power to avoid violating the same isorectal fissure

Wow, and I see also that you are using these scissors closed, electrified

with a gum that covers a lot of parts of this scissor.

So you want to use just the tip and make a blunt dissection, that's why.

Yeah, that's the reason I used it in the past, actually.

This is a video from maybe three or four years ago.

So at the present, I prefer to use a hook, yeah, as you watch.

Yeah, I remember that you used the hook, yeah.

Or probably you also used, in one case, the plate, not the hook.

It's another device energy that was playing sometimes.

I've heard the division of several vessels from the vascular bundle in the supralater space can be entered from the anterior lateral aspect.

This is very helpful to define the dissecting planes between the esophageal and the pelvic planes.

Tension is not very good. I prefer to use a ultrasonic shear.

Back to the retro-rectal space. The wild-eye's facial is a little bit sick. It is divided according to the context of the missing rectum.

You are now in the lower part, in the downer part, posterior part.

Yes, this is the so-called, this is the bottom sign, yeah, Waldeyer, Waldeyer fascia, yeah, Waldeyer fascia, yeah, yes, this is the cataractistic sign of the bottom sign from the Waldeyer fascia with the mesorectal fascia, and they make something similar to a bottom.

Yes. After we reach the levator ani, we will turn around the camera to get a better view, to dissect the pelvic plexus and the ventricle artery.

artery so you always start from the bottom part from the posterior part and then you go to the

wing of the rectum and then you go upper uh yeah yes we start from the retro rectal space

and then we follow the misorectal fascia to find the the novatis

And then we will go again behind the visceral rectum into the retro-rectal fascia to perform the dissection.

Actually, you find that some small vessels are running from the middle sacral artery to the visceral rectal fascia.

Yes, we can see it really well.

After dividing these vessels, the super-levator space is entered, and the mid-sacral vessels are identified.

I think that you arrived at the end. You have a tunnel where you arrived to the levator plane at the end of the tunnel.

Yeah, I have reached the levator, super-levator space, and then I will

push along the surface of the levator fascia. Divide the small vessel from the pelvic plexus

near the base, the intactness of both mesorectal fissure and the pelvic

fissure over the pelvic plexus can be well preserved. You can see the tension

is quite good because we have pushed and straightened the blunt dissection

is applied along the direction of the pelvic plexus with a forcep in front of the visor

rectum.

Did you change the instrument also, because this one is another one, this is the sounder

beat?

This is the sounder beat.

We turn to the pre-rectal space, and then we follow along the novadius fasciae.

Dissection is carried out in the arval plane in front of the novadius fasciae after gentle

push.

According to the courses of the small vessels, we put two fascia on very good tension, and then you can notice the small vessels.

We will divide these small vessels up their face.

the two layers of the novadius fascia, which also means to enter into the neurovascular bundle.

The dividing point of small vessels should be 1 to 2 mm away from its base.

So by performing in this way, we can keep a very complete fascia over the

neurovascular bundle. Gentle pushing back is very important to reveal more small

vessels and to maintain the completeness of the vitorectal fascia and the novidus fascia.

Why I use a video that comes from several years ago is because at that time, we perform this in a very slow and careful way, due to the heat of the pottery or harmonic, before we can even see them.

Yeah, but these vessels can be of value only when a sharp dividing is followed by a blunt

dissection, especially a pushing back.

These small vessels are usually in the cephalotic direction, which differs from small vessels

get a very good experience on the neurovascular bundle with the way how we use these new landmarks.

Actually if you want to learn more about this technique, I have an article published in

a mandatory to the successful implementation of this larval small vessel guided interfacial

dissection in the pelvic dissection of the sole rectum, especially the part near the

Is that also the theory about the MVB, the Narrow Band Vein?

That's the same?

MVB?

Neurovascular bounding.

After the mesorectum is detached from MVB, at a certain point, the superlative space is unheard.

I mean, this is the theory about the narrow band vessel, the one, the small vessel that can help you to identify

the non-VA fascia and also

the right plane without bleeding

the distally running vessel belongs to the levator fissure

and the medially running one

is on the mesorectal fissure

the window is hence not

with the guidance of this window

the detachment of the mesorectum

is carried out in the reversed tail to head direction.

Subhan.

Yes, yes, Shipan.

Yeah, the same.

Yeah, I'm the first person to talk about this.

Yeah, yeah, yeah, yes, yes, yes.

Yes, no, I know about this.

During the congresses, they showed a lot of this topic,

But I have already checked the article, your article about...

Excuse me. Another way for us to preserve the pelvic plexus is that we enter into the superlevator space from anterior first,

first, and then bisector, cranially, and then laterally to, yeah, as you see here, this

is the reverse approach for preservation of the pelvic plexus.

The reason why this is possible is that the neurovascular bundle or the blood vessels

coming to the mesorectum locates just behind and outside on the outer posterior edge of

the prostate and the vagina. So the branches are coming from a lateral band of the vascular bundle.

After you cut several small vessels, you will get access to the superior

elevator space from the anterior approach I hope I made it clear yes it's

really clear and also really well explained another video technical is to

be divided here is a sector from the posterior side and to identify this

small vessel is coming out of the pelvic plexus, with this technique, risk of residual or

misorectin or injury to the pelvic plexus can be minimized in a very precise

pattern, yeah. More small vessels are observed and divided from the pelvic

wall, and the white levator fascia is well-preserved. More small vessels are identified.

In some cases, I think maybe at least half of the patients, you can

notice bigger vessels running toward them. Back to the pre-rectal place to dissect the most distal

part of the anterior lateral aspect, which constitutes the most difficult part of this

procedure.

Notice this small vessel from the dural vascular bundle.

I believe we should divide that vessel.

In some literature, that vessel is also called the accessory medial rectal artery.

dividing them, followed by gentle pushing back. In this manner, a precise dissection

at this most difficult part of this procedure can be nearly always achieved, despite a longer

You can notice that by very careful dissection, we can always notice these small vessels coming

coming directly out of the neurovascular bundle, in this way, we can resect the mesorectum

completely without causing injury to the neurovascular bundle.

More distally, the space between the NVB and the visor rectum is much narrower, so I believe this is the best way to keep the completeness of those important structures.

So, everyone must be very cautious to avoid damage to the urovasculobandum, because bleeding, on the left side, the same technique is applied.

This longitudinal vessel marks the fascia covering the urovasculobandum, and the cephalotronic ones belong to the recto-fascia.

especially professor Lijun that in this morning have done the live surgery with

professor Dinkafeng from that building and now we are watching you and the day

both told us that that your surgery is one of the best in China.

observed. Notice the close proximity of the mesorectal and vessels in the lumbar vascular bundle, which might partly explain why a very good quantity of mesorectal excision is not always associated with a better sexual function outcome, as that observed in our cohort.

At the most distal area, I believe that these small vessels also make up a part of the mesorectum itself.

itself. So if the tumor invades into the mesorectum, sometimes we really need to

resect a part of the neurovascular bundle. The distal rectum is tied up with a cable tie,

tumor maybe four or five centimeters away from the anal verge we can keep the completeness of

the mesorectin but for more distal and the T3 or T4 tumor there is no way to

The pelvic plexus and the neurovascular bundle is well preserved.

There is no reagent of the mesorectum.

The fascia covering the inferior mesenteric plexus is also well preserved.

And then you will do the anastomosis, circular stapler.

Usually we perform end-to-end anastomosis.

Actually, we have done a randomized genetic trial on the side-to-end anastomosis to end-to-end.

Even though the frequency of the SDUO is much lower after side-to-end anastomosis, but more

patients in the side-to-end group have constipation after one year of surgery, some patients,

but maybe about 5% to 10% of the patients may require routine bowel irrigation.

So that's quite a big problem for them.

So at present, I still prefer the end-to-end anastomosis.

okay and then can you explain us why why you before starting the next video can you explain

us why you over suture the anterior part of the anastomosis yeah this is something that in Italy

we we don't use so frequently well yes because maybe in Europe the patients

have a lateral lateral pelvic cavity so it's difficult more difficult to

to perform the enforcement of the anastomosis.

And another reason is that the purpose is to, we will hope this procedure can reduce

the rate of leakage.

and another reason is that maybe five or several years ago we do not usually perform preventive

for all patients. If the patient does not receive radiotherapy, we prefer not to do it.

Maybe we can start this video again.

Yes, wait a moment, I will make it start again.

This patient has an anus squamous cancer, he received a chemotherapy first, but the

tumor does not have a complete response, and the patient received a...

Okay, he's starting again, he's starting again, so you can explain it from the beginning.

The abdominal cavity is fully explored for distal metastasis and the resorbability of the primary tumor.

This is not a...

The patient is then placed in a symptom-based position.

The adhesion of the surgical colon to the left side abdominal wall is detached.

and then he had a perforation of the tumor, and the infection and the tumor invaded the internal obturator muscle.

So we must perform a complete resection of the pelvic muscular structure

but at a rare structure for a push.

This is the previous video.

Yes, this is the second one.

This is the new one.

Okay, let's start.

This is the new one.

Yes, she will start.

So this is laparoscopic total pelvic accentuation.

Okay, let's see.

Yes, this is the history of the patient.

Okay.

The tumor invaded the distal part of the internal ediac artery.

So we must remove the internal ediac artery with musculature on one side.

This video I'd like to show two things.

One is how to resect the internal iliac branch trunk safely.

The second one is how to resect the muscular sidewall.

or maybe we can speed that up to the video by one if it is possible or a little bit maybe 1.2 or 1.3

speed the first thing is uh have a good attention and then you can notice the

uh cup the air will go between the um interfacial space retroactive space

automatically and then yeah i can see that the tension is really really important

and the first assistant is doing a really good job with the with the tension and usually we can

see really clearly all the structure and also the the white the white tissue so well yeah this is

because I discussed with you previously that we have a different system yeah we

usually have a fixed team medical team for the care of our patients we have two

two to three surgeons to form one team so the assistant user he can perform the

surgery by himself under our supervision yeah so a team makes the work better

yeah that's the that's the the typical model that we have to we have to follow

because the team is the best at doing it, the surgeon is not a one-man show, but it's a team, it's a teamwork.

Because there is no suspicion of lymph node metastasis around the IMA,

we preserve that they perform low ligation in this case.

okay like the previous one also in the previous one you have done a low ligation

left colic artery and not from other branches right yeah yeah yeah

another reason is that this patient received a sigmoid

the ostomy, sigmoid ostomy before the surgery, yeah.

And why? Because of obstruction?

Obstruction?

No, I mean why, why the sigmoid ostomy before?

Because of infection.

Yeah, infection, okay.

the infection there is a preparation of the tumor and the severe pelvic infection yeah but

perform total perfect exentration,

if there is lymph node metastasis around the proximal

part of the internal uterine artery,

we perform to dissect the internal iliac artery below the bifurcation of the posterior trunk

and the anterior trunk, that is below the superior gluteal artery.

surgeon, but when it comes to the reconstruction, we ask the help from the urologist, and sometimes

Sometimes from the myomuscular flap reconstruction, from the plastic surgery surgeons.

So you usually don't do it, and you call the plastic surgery?

Well, the plastic surgery is not very difficult, such as the VRAM and the gluteus, sometimes

Sometimes we perform it by ourselves, but for the gluteal flap, we will ask help from the plastic surgeon.

And for the gracilis muscle, you can do it by yourself?

Yes, for gracilis muscle flap, we can perform this by ourselves.

but in our first cases we are still under supervision of the plastic surgeon

yeah and we changed the surgery a little bit we at present we prefer to

preserve the proximal end attachment proximal attachment of the gracilis on the pubic bone

we preserve it this part that will make the surgery much safer yeah and

And when you're staying at our hospital, we usually cut the skin and turn the flap around.

At present, we make a tunnel.

I think making a tunnel is better.

carries reduced risk of infection. we are now dividing the ureter. we usually

dissect from behind the rectum. we are performing

forming laparoscopic TPE.

If you dissect the space before the bladder first,

you will get a very floppy tissue.

And then we dissect along the umbilicus artery

artery to find the obturator nerve for cases without lipid dissection in the proximal part

of the internal ediac artery, we prefer to perform in this way.

This will, by performing at this level, we will make a lesser defect.

If we dissect along the external artery, the defect will be huge,

And there is a chance of small bowel

herniating between the obturator nerve

and the external iliac artery.

To make the dissection safer, true plane is most important.

On the lateral side, we must first identify the obturator muscle.

muscle, and then we must divide some small vessels that are supplying the sinus muscle

and the obturator muscle on the lateral side, and then we must find the dissection plane

on the medial side.

In this case, we identify the piriformis muscle fascia first.

In other cases, if the dissecting must be performed in a more cranial level, we identify

identify the, how to say, sympathetic nerve trunk, sacrosympathetic nerve trunk first,

and then we will identify the internal ediac vein.

vein.

The reason is that there are many branches to the gluteal area from both the inner artery

and the inner vein.

vein so we must first identify the video posterior layer under the lateral posterior layer that is the

sacral plexus video lay it is the peripheral muscle as i have just mentioned

This is quite important because if the branches to the gluteal muscle is very likely to be

damaged if you do not first identify the surgical plane behind the vein.

Because there is severe edema, we must use suction for dissection, and then we divide

the small vessels to the obturator muscle, or the so-called, I can't spell the English

name of this artery, small arteries. The arteries to the sinus muscle and to the obturus muscle.

so and along the pubic uh rimas you will take out also the bladder oh yeah we will take the bladder

under the bladder under the muscle the obturation muscle the levator muscle

because the tissue is quite dense on the other side so we

we want to first approach the levator muscle from the healthier side, from the right side.

So only on the left side you will dissect the muscle?

If we continue with the left side, because there is a suspicion of invasion around the

the, how to say, ischial spine, do you know ischial spine, ischial spine, yes, because

there is a suspicion of invasion around the ischial spine, and if we approach the ischial

spine from the cranial approach only sometimes the bleeding is very difficult

to control the bleeding so we want to approach the inferior side of the

the east tube spine from the from the right side yeah yes we we we identify the spine

from the right side and then i will show this later that's the ureter down on the left on

on the right right on the right side yeah not maybe some muscle okay yeah

when the tumor is bulky

If it is performed openly, it is quite difficult to control the distal branches, especially

the internal pudendal artery and the inferior gluteal artery.

Yeah, I was meaning before, I was meaning before that the ureter is on the left, not

on the right.

It's on the left, the ureter, this one, right?

That one that you are...

Right.

Yeah.

Yeah.

Now we have a better access to the levator adium muscle on the right side, on the right

side.

Yeah, yeah.

Because there is no tumor on this side, we will, this is the ureter, yeah,

now we are dividing the ureter.

If there is no lateral lymph node dissection, we can use maybe

a linear cutter to divide the visceral vessels of the pelvis.

After radiotherapy, there is usually a thick layer of the autonomic nerve, a layer that

is quite thick, so we can use a hook to divide all these nerves.

So you have done the left side, now the right side, and you will continue to take everything by yourself?

yes later I will show that I will first divide the levator muscle on the right

side and then I can reveal the sacral sacral spinous ligament sacral

with the second tissue plane yeah if you only use harmonic shear it's quite easy

to injure some veins or arteries yeah but it's dissecting is much better yeah

because there is less less color transmission less hot transmission yeah

little technical problem with your audio but no problem now we can listen okay now you are

now you are arrived down you can approach to the still we are still on the right right side yes

the video is not very clear but uh i believe at the printer i i'm planning to divide the

the internal levator muscle.

Yeah, I mean you was arrived to the levator muscle with everything inside.

Yeah.

Yeah, a little bit harder this part, over the muscle, yeah.

So, in such cases, we usually require a harmonic, maybe, because at this level the pelvic plexus is also very dense.

We must divide maybe the plexus and get a thinner layer of tissue.

levator in the getting into the posterior yeah well divided in the

levator eddy muscle from the posterior side yes

you will show you will show us also the reconstruction in this video or it's only the

welcome professor one please okay is uh in this video you will uh show us also the reconstruction

after the after the no no no no no construction no construction there is nothing special as for

for the reconstruction in this case and yeah and you finalize okay we performed uh uh a mental

plastic uh uh under uh gracilis flap oh yeah only uh we do not uh perform vram uh and we cannot see

this this reconstruction in the video right yeah yeah yes yes uh in this case i preserve the

part of the peritoneum over bladder uh to uh

So you will take out the bladder now?

Yeah, not take out the bladder.

Now I'm preserving some part of the peritoneum over the bladder

for the sake that we will later suture the peritoneum

to the oventum to separate the pelvic cavity from the abdominal cavity yeah

i did not show the reconstruction part

the space in front of the bladder.

Professor Wang, the audio stopped.

Okay.

Okay, now we can listen.

We're still in front of the bladder.

Actually, the bladder itself is not embedded.

There is no tumor in the bladder.

so we preserve the some part of the the peritoneum over it yeah then you will

use the peritoneum with the Dementoplasty to cover right that's what

yes yes yes okay but but we cannot you cannot switch the peritoneum directly

to the sacral planetary yeah in that case it will make quite a large cavity

within the pelvis you can only suture the peritoneum to the

down of the small bowel that can make obstruction and that can make it cannot prevent the falling

down of the intestine it only prevents the adhesion of the small bowel to the especially

especially to the stumps of those arteries and the veins and the clips especially when

the small intestine is attached to the clips it might cause the eroding of the intestine

intestine after several, maybe several months and years after the surgery.

So the purpose is to prevent the adhering, yeah, only prevent the adhering of the small

intestine to the pelvic structure when the omentum is sutured to the peritoneum.

okay uh uh recently we the we will feel the pelvic with the vrm vector rectus muscle and

And the white tissue is a pubic bone, pubic rimus.

This is the obturator nerve.

So here we are dividing the obturator muscle to reveal the bone.

Yes, yes, we can see it.

Yeah.

That part is really bleeding.

In that zone is really hard to avoid the bleeding and also if you have a bleeding is really hard also to stop it because we are really, really deep.

Yeah, maybe out here I made a mistake. Yeah, actually the bleeding of the obturator vessel is accidental. Usually we can prevent it.

about the nerves there is a question for you about the nerves how do you how do

you do with the hypogastric plexus hypogastric plexus you try to preserve

something or if the nerve is not invaded directly we will try to preserve the

nerve because if it is injured the patient will have difficulty to work up

us there and how do you perform after removing the bladder you will do something like something like

nephrostomy your eurostomy what do you do

urostomy yeah like a nephrostoma or a eurostoma or you reconstruct the bladder

oh you can do it okay you can do it okay yes yeah so the obturator muscle is divided and as

Then we will start from the pelvic plexus to, yes, we are now approaching the pelvic plexus.

Because the tissue is quite dense here, usually we identify the pelvic plexus first.

But in this case, because it's too thick, we have some difficulty of performing this.

Usually we first identify, divide all the internal iliac vessels, and then we will start

from the, how to say, in front of the pelvic plexus to divide the obtusinal muscle.

Okay, I have another question also about the bladder.

And do you, do the ilion cord do it in the same time or you do a stoma

and then after it you will do it in a second time?

in the same operation in the same operation

yeah yeah i i noticed some surgeon performed two stage surgeries

usually we perform one stage yeah yeah i understand now we have noticed that they have a

plexus and maybe this is the final branch of the internal edeka yeah i i think so i think so i

cannot see any other branches then we identify down you have the bone yeah yeah yeah and then

Well, divide the obturator muscle and reveal the ischial bone.

Ischial bone, yeah.

So you took the obturator muscle from the left side,

but on the right side it was safe, so you didn't...

Yeah, there is no tumor on the right side, only on the left side.

Okay. I don't know what happened. I think that is finished.

First, the abdominal cavity is fully explored for distal metastasis.

There is a problem with it.

Yes, it was finished. Wait a moment.

Yes, let me ask to put it back, wait a moment.

of the sigmoid colon to the left side abdominal wall is detached, then the left

paraconic gutter is opened at the white line. Notice the small vessels on

More than halfway, two-thirds.

First, the abdominal cavity is fully explored for distal metastasis and the resectability of the primary tumor.

The patient...

No.

Yes, this one, this one.

This one, but go still forward, forward a little bit.

Over, forward.

the white tissue is a tendon of the obturator muscle oh too much you have forwarded too much

you have passed here behind the clips this is a maybe backward a little bit

yes let me back one second let me call the technician to make it back maybe

okay okay okay okay perfect perfect okay professor one but now this is the time this is the

we are now we are now again at the the previous phase so yeah okay oh i watch a second maybe

maybe maybe four minutes backwards yeah yes everything down this is the posterior side

posterior lateral posterior lateral posterior side has finished oh yeah yes

you're making the conjunction yeah before this part I divided the levator from the

right side to the left side and then we revealed as a sacral tuberous

ligament and the sacrospinous ligament from behind and divide it yeah yeah we saw that part when you

was uh not online when you when your connection fall down we saw that part the sacrospinosis

ligament yeah yeah yeah okay okay uh we divided that that part and then by doing this we go behind

under the ischial spine, and that

make the division of the internal pubic artery safer.

And in front, we dissect along the pubic bone.

Actually, we are to the cortex, or below the cortex

of the pubic bone because we can see that you are very near to the bone previously very near

to the ischium and now very near to the to the you must be very near to the bone or there is a

very high risk of bleeding yeah also from the nephroscopic approach or from the per perennial

approach yeah and now we are going the bottom yeah performing the perineal approach part because we

have a divided was a levator a muscle we can easily insert two fingers into the pelvis so

So the perineal protein is much easier.

Yeah, we can see it really properly, yeah.

So you will take out everything, and now we are in the upper part.

Yeah.

And you will take out also the vagina, everything, upper, upper, all of it, all of it, until the pubic bone.

Yeah.

Yeah, yeah.

The dissection is carried out along the pubic rimus, or the inferior pubic rimus.

But we think because the perforation of the tumor out of this area is not very rare, this

video I want to tell you that if the bone itself is not embedded, we can still resect

all the muscular structure and get a clear dissection plane by a laparoscopic approach.

After the surgery, this is a ischiospinous ligament.

You can see all the structures within the pelvic cavity is removed.

And finally, we performed two gracivus flaps for the covering of the perineal defect.

After surgery, you can notice the small bowel still fall into the pelvic cavity, but it's

over the omentum.

So this patient had an uneventful recovery after surgery.

This surgery, in this video, I introduced the way we perform total internal iliac vessel resection

and also tell about how to perform total muscular layer structure resection

yeah by the first literally along the ischial bone and posteriorly we dissect

dissect the levator ad muscle along the distal part of the sacral bone,

and then laterally to divide the ischial spinous ligament and the ischial tuberous ligament.

so in this way we can safely deal with the distal part of the internal iliac artery safely.

Actually this is quite important because if you do not perform in this way, you leave the

the dissection around the

ischial spine to the perineal side, you

must turn the patient

into a

what to say, into a prone position

into a prone position or if you

do it from a tremendous

In supine position, it's very difficult for the control of bleeding.

Yeah, and when you were telling us about Professor Solomon to resect the pelvic muscle,

have you ever done something like that?

At present, I haven't.

And there is an advantage of that tactic.

After the division of the pubic rimus, both the superior rimus and the inferior rimus,

you can get a better view

of this side wall

and the risk of

bleeding may be lesser

I think, I believe

but the restructuring part

is much difficult

because you have

resected the

the fixed point of the vectors of the vertical rectus muscle.

Yeah.

So all the structure can fall down,

and probably you have no upper.

All the structure will fall down.

So we are very afraid of the reconstruction part.

So we introduced this technique to tackle with most cases, I believe.

Let's send a message also for all the residents that are following us and for all the young sergeants.

It's really our best, as you have seen in this video, it's really hard, the resection part.

but we can say that it's also interesting and also very hard, the reconstruction.

So it's not only the resection, but also the reconstruction is really important to know how to do it.

And Professor Wang can tell us which kind of approach is better for beginning the reconstruction phase.

Which is the most simpler one? What do you think about it?

I think the most simple one is the vertical rectus myocutaneous flap.

Yeah, because the inferior epigastric artery, the course of this artery is quite fixed.

There is very little variation.

So you can remove all parts of the rectus muscle and the fatty tissue over it to fill the pelvis.

In the past, we used the skin of this flap to reconstruct the perineal defect.

defect, the perineal defect. In that case, the volume used to fill the pelvic cavity

is very very small. so at present I suggest that we remove all the

skin of the VRM, vertical rectus muscle flap. we use all the flap to fill

the pelvic cavity and use the omental flap or omentum the great omentum to cover this muscle

that that that will from the internal part yeah that will fill the pelvic cavity better

for the perineal for the perineal reconstruction the skin if there is a

skin of and the subcutaneous defect of skin and the subcutaneous tissue we use

one side or two side of gracilis muscle flap I think that's a best way to feel

the pelvic cavity in case that the sacral bone is resected up to the S3 level or sacral 3 level

level, we usually use the upper superior gluteal artery, the upper gluteal myocarditis flap,

that is called.

okay yes yes we i in my during my experience in gen joe i have seen a lot of gluteal muscle

so with the same indication that you already proposed let me ask you another two questions

that comes from the chat so the first one is uh can you tell us your indication for a pelvic

eccentric ratio and the second one is do you do everything by mdt do you use the mdt to

and the people yeah every patient who will go undergo no pelvic exit duration

will be discussed her out of the MDT discussion yeah and usually we do not

have a special MDT team for the pelvic exentration. We do not have a

routine discussion of including the urologist and the plastic surgeon

but we will send the patient to them for suggestion and if there is a

difficulty in performing reconstruction we will ask the urologist and the plastic surgeon to help us

to perform difficult reconstructions. Okay yeah that's right. As for the indication

of the surgery R0 resection must be ensured yeah and usually we do not

perform pelvic exentration for for non curative intent yeah if there is a

distant metastasis or diverse metastasis or long metastasis we are very cautious about

surgery in such indication only when there is a particle lesions and it is resectable and after

After a long period of observation, there is no new lesion in the distant organs.

I think I totally agree, because you want to avoid an overtreatment for the patient,

and I think it's something not useful.

Okay, so I would like to invite you, I will talk with Professor Palazzini about it, to

invite you next year for a lot for um for a live surgery in uh i want i want you to show us

how do you do the lateral pelvic lymph node i know that you are famous in china

for the for the lateral lateral pelvic lymph so i would like to let you show your your surgical

quality in in here during the live surgery i think that you are really talented uh the professor and

And when I moved to my first step in China,

people told me you need to go in Chengdu

for the pelvic surgery.

And the master one is Professor Wang Zichang.

So that's an honor to have you here in this Congress.

Thank you so much for your videos

and for your time and for your attention.

Yeah, all the video was really didactic.

I think that all the people that look at it, that watch at it, was really impressed about this kind of subject.

So, thank you so much.

Thank you for having me.

Yeah.

Okay.

I'd like to give a live demonstration next year.

Sure.

Yes.

Yeah, it will be something important and interesting.

Thank you again.

Bye-bye.

have a good night i know i know that in china china is uh 11 11 p.m probably oh oh yeah nearly

12. nearly 12. okay so have a good night bye-bye thank you bye-bye bye-bye thank you thank you