BONI ADRINOLECTOMY? SX

Okay, I think we can start. First of all, welcome to everybody.

We are connected from Milan at the Policlinico Hospital and the first case that we're going to

do here is a laparoscopic left adrenalectomy. He's a 56-year-old male, not significant past

two five millimeter port and one 10 millimeter port for the clip application and for the extracting

the specimen what else we are gonna use the harmonic scalpel as a the harmonic case for

as energy device for the this procedure and let me just say a few words a few tanks first of all

to all personnel in the polyclinical hospital especially because we had to move the department

because we had problem with the connection with my in my ur so we moved to the urology department

so i need to thank professor montanari to let us have in his one or i need to say thanks to dr

jurati and dr santin that are two anesthetists today and of course everybody in the or elisa

troca position is a quite standard position for this kind of procedure so we're already in the

patient is in left lateral decubitus and this is the internal view i think i will have to mobilize

the spleen as usual and this will require probably mobilization also a little bit of the momentum

that as you can see here is stuck on the left so i think now we can actually start decreasing

the images that we can obtain even with a five millimeter port is really

unbelievable using a big screen I'm actually able to get a very nice

immersion feeling it's like if you are inside the abdominal cavity of the of

the patient sometimes there is a problem with when you use the the harmonic

because the definition is so high that you can see very nicely there also the

okay and so really this is a big benefit for me for the 4k because they the benefit of the

zoom they are the digital zoom is really really important so we're gonna start with the full

mobilization of the spleen and then the splenic flexor as well in order to access to the adrenal

know if there is anybody

actually

sharing this

session, if there is any question

no problem, you can actually ask

Can you hear me?

Yes, we are following you

Yes?

Okay, thank you very much

We are not on 4K here, unfortunately

I know

4K transmission is a little bit

complicated, but I think that

they are really working on that

I saw a couple of live surgery and I did once with 4k technology is a big effort

but it can be done but I think when the compression protocol we actually will

get better I think we will be able to really get the benefit is it a 5

millimeters camera five millimeters camera and the zoom is optical it's one point four

it's a digital digital zoom okay yes it's a zoom with autofocus so it's a it's really really

okay i didn't notice any any uh problem when you zoomed to 1.8 no it's very good yeah well

to identify the adrenal gland that I may be able to see over here in a minute?

The quality of the audio seems to be...

Now it doesn't speak anymore.

No? Do I need to speak? Can you hear me better?

Yes, now, yes. We had some problem with... yes.

Okay, that's good.

Okay, go here.

I need to mobilize the splenic flexure a little bit more.

I need to mobilize a little bit better here okay I need it for some of every

patient un pochino girato verso di me okay back back okay that's it okay let

me come back here here Elisa Lottica Lottica okay okay I need to move the

splenic flexure is a bit high so we just need to push it down a little bit more

need to mobilize a little bit more my tail of the pancreas okay going down a little bit more

a little bit more okay okay see i need definitely to mobilize not too much zoom

okay to mobilize the spleen okay i'm using this that is a is a a nose tampon is the tampon that

the a and t doctor they use for nose bleeding i like it it's called maricel or net cell depending

from the company is uh it doesn't have any more static capability but it does give you a little

bit of it's very soft it's hard at the beginning and then it gets soft and we use for several

a procedure it's very nice it's not very much use but it's an original idea of

the share idea between sir alfred kushiri and andrea pietrabisa and okay come back okay come

back come back okay here you need to dissect here come back here okay let me just move this is the

pancreas you see this punk the vein here and i'm gonna just to dissect a little bit more

here no no no no okay take away all the zoom now all all completely zoom okay come here

I need to detach the splenic, otherwise it will keep, stay up.

Okay, I just want now to, that's it, I just want now to clean the scope

because I think there is a little bit of cover and just to finish to evacuate the CO2.

This is completely open.

No, no, it's not open.

Okay, just remove some of the debris over there.

Let's see if the view is better.

no we need to clean the trocar as well questo questo questo okay try no it's

still dirty still dirty can I have a swab no no no no Melodia a me non faccio così

5 mm okay like this here we go okay I should be better okay go go go go go

here here here okay so let me have a look okay much better okay let me have a look here okay

see anything like this okay let me just open a little bit here because the adrenal gland

thank you okay okay so this is the main left adrenal vein let me just see that's the

well a bit too far away probably we can actually the adrenal gland is a bit higher doesn't make

much of a difference there's an answer from the audience from the audience yes do I disturb you

you know no no not at all okay and the the question is would you like to do you think

would be useful to detach completely the stomach from the its diaphragm attachment

yes in some cases especially yes no in case where where the the adrenal gland is very large

usually is. I will not be surprised if we have some negative surprise from the pathology report.

We'll see. But it's very hard thinking. It's not usually the adrenal or benign lesion is really

soft. And, you know, I just follow, try not to grab the adrenal gland at all because you start

bleeding okay the the harmonic that we are using is the last generation so it's

the one that actually is able to have a better coagulation if you touch the

right bottom so I think is quite useful in these cases need to pay attention

there

So, wait a moment, I stop for a moment, give me the vacuum cleaner,

suction a little bit, take off the zoom, no, no, leave the key.

And your system is recording in 4K?

Well, the system from Olympus is recording in 4K and simultaneously in 2K, sorry.

HD, HD, ok.

And of course, this is one of the problems, dealing with videos in 4K is a real nightmare.

Really, you need a dedicated PC.

the diaphragm probably this is one of those but that's usually quite small and okay let's go and

move this one here and we detach a little bit from the diaphragm okay the next case is gonna be a

right amycolectomy and it's gonna is is scheduled a little bit later on so we have time because

having to change the the operating room means here at the polyclinical means

changing also the department and we are logistically located completely separate

because we have a polyclinic so we have different structures so that will help

us to get some time okay so okay so the adrenal is over here this is all

gerota fascia i think that there is another small vessels over here i'm gonna probably put

a i'm gonna put a a clip on this another ammo lock at least on the part of the stays yeah

just give me a clip then if you give me the suction i'll try to remove a little bit of this

okay suction please just try to take away all this thing in order to give you a better view

I usually, if there is no interoperative problem, significant problem, I don't leave any drain.

And as far as I'm concerned, this patient can go home tomorrow, depending from the desire of the endocrinologist.

You know, with the advent of the laparoscopic surgery, they got a little bit scared to send the patient home.

oops the day after surgery they want to do you know cortisone treatment okay

give me the mirror so see the benefit of this sponge is actually you can place it

here and I will help you to clean the field and it's very soft so you can

place it wherever you want and carry on I entered a little bit the adrenal gland

This is why it's bleeding, but we can control it maybe with some bipolar later on.

As you can see, it's much more attached to the upper pole of the kidney in comparison to what we have usually.

Can you give me the bipolar?

Okay, I need to find...

Suction, please.

And then we can open the endo bag as well because we're almost done.

Okay, ultracism.

Sometimes, if you can put the outside view, you can see the benefit.

I think the great advantage is that you need to have this big monitor.

That is a problem logistically to get into our OR.

Yes, no, we have to get into it.

Because definitely the 4K, I mean, without a large monitor,

doesn't make much of a sense to my viewers.

It has been also proven scientifically that you need to have at least a 55-inch monitor

suction please i just put the adrenal over here oops never mind okay then i will suck through the

marrow cell that is spongy so it can allow you to suck without getting too much co2

then i will wash okay so we can revise a little bit if you can see the clip

bipolar anatomy and bleeding and then I will just be bipolar okay and they can

accuse a bit of a mustace is here and a little bit here we're gonna take the

specimen out first and then we are gonna have a quick check before after we

remove the plamo peritoneum because the problem peritoneal has a quite a large

It's not absorbable, so you always have to remember to take it out.

Okay, so now we're going to basically move back out.

I will just stop the CO2 for a moment, and let me suck the CO2.

I will remove it so I can check later if there is good hemostasis,

and I will remove it from probably I will need to enlarge a little bit

the incision on the 12 millimeter port that i'm using uh knife please some a bit light because

a bit too dark uh don't not so sure that you can see or let me just move okay can you resume the

the outside camera a little bit number okay

okay so i can i will enlarge probably a one centimeter i think we need to remove the yes

itself okay no no no no just okay okay now let me remove this okay then i'll enlarge a little bit

the muscle layer no no see if we can remove it

okay now we can open it's not i don't need to have as far as i know it's still a benign lesion

Okay, anyway, not make much of a difference.

Un cocker.

Tenga.

Mi dia una garza.

O una arcella, quello che vuole lei.

Okay.

Suction, please.

Non abbiamo un aspiratore sulle robe, ma sempre montati, ragazzi.

Montate delle robe.

Okay, I think now it's coming.

Okay.

Take this.

Oops.

Here we go.

Nice.

Dove va?

Sì.

Tieni.

Veloce.

Ok, we need to get back in.

because I don't see anything anymore.

A little bit of shalitica.

A little bit of shalitica.

Duval?

Do you have another one?

Okay.

Okay.

We need to get back in.

The marigel is inside.

I need to get it up.

Okay.

We had a problem with the bag

because we broke the bag

so I lost definitely the marigel

so we're going to pick it up again.

We need another endo bag.

Another bag.

I don't need this.

I need a duval to put something to close the hole here, an iron, a backhouse.

Okay, we can start the CO2 again.

I will take the mirror cell that I lost.

Come on, anything, come on, quickly.

We're going to do some scenes already.

Okay, okay.

Leave it out for a moment.

Wait, stay out for a moment, we'll see inside.

Okay.

let me pick up the okay let me get the marriage

okay okay okay okay now we can definitely check no no no no no hold on let me check if the

bleeding is okay and we can actually okay now you can come back in so we can okay let me suck a

a little bit, hold it, suction, yes, but sit down, okay, give me a moment to bipolar, just a second, bipolar, let me just put back the stomach and the spleen, okay, in position, okay, okay, no, no, I'm done,

Ok, I think we're finished. We're going to suck the CO2.

And that's it.

Congratulations, as they say, fast and smooth.

Shall we wait for the next intervention?

Yes, a right colon for a neoplasia of the blind.

Now I don't know what time it is, it's 11 o'clock, well, yes, it's half past noon, I think we'll be ready, because, ah, so and so, it's already here, ah, half past noon.

Ok, thank you also to Professor Palazzini.

Ok, thank you.

And congratulations again.

Thank you.