H. KIM total gastrectomy

professor kim yep good morning can you hear us good morning

i can hear you clearly okay very good we can see excellently good morning from rome what's the time

now in Seoul so now we are close to 3 p.m. okay here is a nice weather with

many surgeons attending the venue can you explain us what you're doing now and

And what is the case about?

OK.

Good morning, dear colleagues.

My name is Hyung-ho Kim, professor of Seoul National

University College of Medicine.

And I'm working for Seoul National University Bundang

Hospital.

I'm very proud to be invited for live surgery

for your fabulous Congress.

today in Seoul today is a national holiday excellent what's about it yeah children's day

anyway we are very happy to broadcast our life surgery today's case extent laparoscopic extended

total gastrectomy for advanced gastric cancer let me explain our case but we

prepare a brief slide for the case

they've lost number five sorry prof. Kim they've lost you for a while

Yes, we're back now.

Just explain it in words.

Hello.

Yes, please.

diagnosed of advanced gastric cancer on a screening test his lesion in the high body to

cardio on the lesser curvature and its size is four centimeters his step on the endoscopic ultrasound

is a suicide invasion and his staging was t4a

How old is the patient?

42. 42 years old male.

okay he his BMI allowed 24 in Western standard 24 is not of obese but in

Korean standard is a little bit obese patients okay you can see the light

catheter people are being here we dissect thank us heavy here it's an

You can see extremely well

Okay, good good morning. Thank you to be to be with us from Rome

What kind of was screening a human prof making the diagnosis for adenosine of the stomach

of the lesser curve but you usually Korean government to recommend the

annual endoscopy over 40 years old so we have we have national screening system

for gastric cancers every Korean over 40 years old they had endoscopy by annually

This patient is in the same case.

He had endoscopic pearl screening, and he had advanced gastric cancer and lesser curvatures.

And we did preoperative endoscopic sonography routinely because we have very high volume

of early gastric cancer.

so we did endoscopic sonography routinely and then he checked CT so

preoperatively we checked endoscopy and endoscopic sonography sometimes upper GI

series and CT. Do you search for H. pylori of course? Yes, yes, yes sure. What kind of

test do you use? Are you based on the biopsy or rather on fecal investigation or

serum? We checked urea breast test and endoscopic biopsy for H. pylori.

Now I ligate the epiphylloid artery here, wake up, and next I dissect the interpyloric

artery here.

You can see the interpyloric here.

Yes.

You can see clearly.

Yes, we have a very good imagination.

how many ports you made prof for these operations oh okay let me introduce our

Our surgical team, my right side, she is a designated endoscopist, laparoscopist.

And my scramblers, and my opposite side, she is my colleague, Dr. Lee.

Our surgical team is four persons, including me.

Of course, outside so many partners who broadcast our surgery to you.

It's a very young team, very nice.

Yes, yes.

And pretty, of course.

Can you see the gastrointestinal artery here?

Excellent.

This is the gastrointestinal artery.

Yes, it's a very accurate dissection.

And this is the common hepatic artery here, and the gastrointestinal.

So, we finished dissection of the posterior surface of the duodenum, covalent proctus.

way yeah this is a number six number 40 here you can see the pilot here and you

can see the light getting out to be here yes yes we will yes we will made a small

There's a little more window on the upper part of the urinal.

You can see the clothes.

Yes.

How many cases like this do you perform, Prof. Kim?

We already perform more than 1,500 laparoscopic gastrectomy last eight years.

Last year, we do more than 250 cases of laparoscopic gastrectomy.

One question, please.

What do you think about the retrocarfolia and anastomosis,

and why the correctness?

My assistant grasped left gaffer artery here and I dissect lymph node station number seven

here.

yeah you can see clearly yes first I try to find out left catholic pain and left

catholic artery first because laparoscopic view magnified the three or six times then

naked eye so it is very easy to find out left catholic artery and pain here

Prof, in your echoendoscopy evaluation, was it clear the depth of the regional nodes?

Can you see well?

Do you expect what you are watching now, microscopically?

Yes.

Usually the lymph node is very easy to find out here.

You can see the lymph node here is number seven.

and number eight sorry is the number eight lymph node we can easily find out lymph node and the

dissection plan is a soft tissue we clear the whole soft tissue above the main artery and the

The pancreas here, argon, I met some losing.

I use argon beam calculator for breathing control.

It is best option for losing ground,

for controlled losing ground.

Especially here, that is a very delicate moment of the op.

The video is excellent, Professor Kim.

We use flexible endoscopic, made by Olimp.

Sorry, Prof, can you repeat? We lost for a couple of seconds.

Okay.

Sorry, pardon me?

In the work-out of this kind of patient, do you always use echo-endoscopy?

Yes, yes, yes.

So I mentioned previously in Korea we had nationwide screening system so most

over 60% of patients of gastric cancer are only gastric cancer so we routinely

checked endoscopic ultrasonography for discriminating mucosa from some

the meticulousity of your action thank you thank you

It's a really big disease.

Right?

When we did the dissection,

there was a big one

on the other side

of the gastrohepatic ligament.

That's the coronary vein.

Right?

Okay.

Now we are dissecting

around the light gastric artery here.

This is the light gastric artery.

Yeah.

As you know, Professor Kim, this is the 22nd edition of Professor Palazzini's Congress

and every year we have more and more surgeons attending from all over Italy.

We are linked now with 14 different kind of operating tiers worldwide and we are expecting over 2,500 surgeons attending today and tomorrow.

Professor Palazzini has done an excellent job and every year is better and better.

Congratulations for your successful congress.

Thanks.

I fully respect for your effort to improve surgical quality in this field.

Yes.

You can see the portal vein here.

Yes.

This is the portal vein.

Yes.

Next question.

What is the main cause in South Korea for gastric cancer?

We don't know exactly the cause of cancer, but we assume probably a high-salt diet may

contribute to developing cancer.

cancer. We are consuming more salty diet than the WHO recommendation. Probably 10 times more.

Yes. And people are educated about this. Can they do anything to change the diet habit?

Yeah, listen to it. The young generation, they have more knowledge about cancer and they are very afraid of cancer.

So they eat less salt than other people.

Now we finish the dissection of lymph node 12, 8 here, and 5, 12, 8, and 5, and 8, 8A,

and AP, 9, 7. This is a celiac axis. We cut the left gastric artery already. It's a common hepatic

artery. This is a gastroduodenal artery, and a proper hepatic artery here, and a supranac artery

here. Now we are moving to lymph node 11P. The skeletonization is excellent, Professor Kim.

Thank you. Thank you. You can see a posterior gastric artery here. It's a posterior gastric artery. It's a left crux here.

In your statistics, Prof, do you find any increase in the gastric cancer of the proximal part?

Prof. Kim, we have lost the very first part of the operation. Do you mobilize the left lobe of the liver?

No, we don't mobilize the left liver.

Yes, we are not mobilized, we are just one stitch on the hepatogastric ligament and we

lift up the left lobe here, the left lobe, and now we introduce our specialized first

string laparoscopic clamp here.

What kind of suture is this?

This is a commercially available surge flow made by Comedian.

Surge flow number, how many times is this?

Surge flow number four.

This laparoscopic processing clamp is developed by our team.

It's made by a Korean company.

Oh, I must be very proud of this.

Thank you.

What's the name again?

Sorry?

What's the name again of the company?

This is made by Eton Company. It's a venture company in Korea.

very nice prof although being in an almost blind moment is

You can see very well exposed the pancreas.

Okay, just cut here.

Huh?

The syrup fell off.

Did it go up?

How do you approach the spleen, usually the splenectomy or preserving?

right and the last and the left but just but just now we have two problems with the left

electron means with the intradominal herb really two patients

There is a small hole here.

Here is the hole.

He has made a hole.

Then another one.

Two.

It's high.

It's a small hole.

A small hole.

One question please.

We are in a drainage right for life.

I have seen the part of the drainage.

I have seen the part of the drainage.

more and more surgeons are appreciating your operation the meticulosity as you said of the

lymphodissection and gastrectomy and we made a mini raparotomy at

at the left side of the abdomen allows 3 cm for extraction of the specimen.

Are you still busy, Prof. Kim, comparing the results

between a video laparoscopic and an open surgery

for this kind of surgical treatment?

Please relax the patient.

Ah, yes, yes, yes, sorry.

We're wondering whether you're still busy comparing your results

between vitilaparoscopic and open surgery for this kind of op.

Also, we do open cataract.

And results?

cancer yes 2006 last year we finished our vision and more than 400 patients

last year. So we will wait more five years for long-term outcomes. However, we also collect

retrospective our cohort data, more than 3,200 patients. So this last April, we analyzed

Our retrospective cohort for long-term five-year actual free survival, digital free survival,

according to our data, stage 1A, 1B, a little bit laparoscopic group shows more better survival.

It's a selection bias, but each stage we had no survival difference statistical significance.

Thanks bro.

This is his specimen, his ADC region is here.

Yeah, we can see it, we can do a close-up maybe.

maybe almost four centimeter also infiltrative mass and proximal margin is a two centimeter

okay okay can you do a close-up of the lesion please

Hello, thank you for Professor Palastini, but we will see you again.

Okay, good work, thanks.

What size is this?

25.

Okay.

Pull it, pull it, pull it.

Pull it this way.

And the wheel of light and the roof.

Hello, can you hear me?

It's hard, it's hard, it's hard.

Yes, yes, we're here.

We're here for 40 minutes.

Why?

Because you're on the screen.

Yes, yes, but on the screen.

Push, push.

Come on.

Come on, come on.

Let's see.

How much is it?

It's good, right?

It's good.

How old are you?

How many gauze do you have?

I have three.

What's the name of the gauze?

Bospite?

Dissect?

There's a medial gauze.

Soxhine?

Is it bleeding?

It's not working.

Why? Soxhine doesn't work?

Let's go out and wipe it.

No, no, this way, this way.

The other way.

Let's see if there's blood later.

Where did the gauze go?

How far do you go, Prof, with the genome?

Now we are going to esophageal heterostomy intracorporeally.

At how many centimetres do you choose the loop from the trites?

Professor Kim, at how many centimetres are you from the trites?

Usually, Iseopago-Jejuno Sturm is 5 centimetres from the Jejuno Sturm, and the Jejuno-Jejuno

Usually, we made 40cm apart from the jejunal stone, so we are already making the anastomotic

point here, like this.

And then we introduce...

Where do you get such expensive figures?

Turn it a little more.

Be gentle. Be gentle.

Get in. Get in the camera.

Bit tired, bro? No, no.

I'm not tired.

So we change our protocol for esophago-jejuno stomy intracorporeal like this.

So you do routinely this, eh?

Yeah, this procedure. This routine procedure.

We finished esophago-jejuno stomy.

Yes.

Should I do it from the inside?

Let's see this side.

Is it working?

Is it working?

Let's do it with TX.

TX white.

Side to side.

It's not working.

Give me a seed.

One more seed.

side-by-side anastomosis between the jaw?

Yes, side-to-side anastomosis.

Tx.

You can give echelon or anything.

I can't see anything.

Can I do it?

Give echelon.

White.

If it's too dark, echelon will appear.

Professor Kim, do you position an energy tube?

We don't use endolevin tube, we don't use fire, preoperatively and postoperatively.

If patient has gastric outlet obstruction, that time we use nasal gastric tube, but we usually don't use nasal gastric tube.

In this case, we don't use.

Okay, very good. Excellent.

It's an observable monofilament.

Let's do it again.

It's not working.

Let's try again.

See this?

Let's see.

It's not working.

Okay.

Now you can relax.

Relax.

Can you show me?

Yes.

We are waiting for a staple, one more staple.

Professor, may I have a question? May I ask you a question?

Sorry, Prof, what did you say?

May I ask you a question?

Yes, sure.

Cancer is also common in Italy?

Yes, indeed.

Especially in the proximal part, we are noticing it more and more.

Uh-huh. What is your best option for advanced gastric cancer in Italy?

Best option concerning the kind of surgical treatment.

How many?

Yes, these.

How about lymph node dissection?

Lymph node dissection?

Yeah, level one and two lymph node dissection. That's what we do.

And two weeks before, we organized an international guest congress in Seoul.

Yes.

And the next congress will be held in Italy, Verona.

All right. Are you coming, Prof?

Yes, yes, yes. I hope so.

You will be invited, for sure.

When do you start feeding orally this patient?

Oral feeding, usually for distal gastrectomy, we start with a liquid diet.

First operative is three days.

And usually they discharge five days after operation.

laparoscopic procedure for total gastrectomy we start water resumption three days after operation

and then usually they discharge six or seven days do you do any contrast study before starting

I don't want to examine the contrast study at all.

Okay.

Is it going in?

No. Cut.

Just one more here.

Give it to me.

Give it to me.

Did you cut the rest?

Is it done?

Why is it like this?

This is broken.

Cut here...

No no... Cut here...

You cut here?

This is cut...

Cut here...

This is cut here...

Cut here...

Give me one more stapler.

Mosquito bites me.

Mosquito bites me...

Mosquito bites me...

One more... Cut... Cut...

Mosquito bites me...

Suction.

Seed.

Good.

One more seed.

Good.

Good.

Let's cover it.

Irrigation on.

Suction on.

Cover.

Also, you're a very steady cameraman.

starting with this kind of operation young surgeons usually they trained three two or three years

after after legend training and then they usually they do this kind of surgery

Here, we closed the magentic defect here, and we finished the operation.

We insert drain, closed suction drain, two closed suction drain at left sopranic area here and right side here. Thank you.

Do you have to approach to the diaphragmatic class?

Sorry?

Do you have to do anything on the diaphragmatic hiatus, on the diaphragmatic class?

No, no, no close. We don't close. Sometimes we close the diaphragmatic hiatus, especially the high esophago-jejunal stomach. At that time we close the hiatus, but usually we don't close hiatus.

okay okay prof you made difficult operations very easy you doing acrobacy

it's excellent you made it very simple and clear what is the we finished our

operation congratulations prof really a mastery mastery of surgery thank you it's over estimation

no no no you made it in a difficult case it's simple that is thank you the complications rate

ploff you have yes this kind of surgery is a little bit usually historical historically

Historically, they report complication rate around 20% or 30%.

Fortunately, our complication rate is around 15%.

We have less than 1% esophageal or jejunal stomach leakage.

And regarding distal gastrectomy, our complication rate is around 10%.

So our mortality rate, especially laparoscopic surgery, we have no mortality at all.

So although we perform more than 1,500 cases, fortunately, we have no mortality case.

Excellent.

Overall mortality, including often gastrectomy, we had 0.05, 0.05% mortality.

Okay, very good.

Prof, thanks very much.

also to your team we hope to see you again especially here in roma and in verona for

the congress thanks very much thank you we really appreciate thank you thank you bye-bye

thank you very much