Igor Khatkov Resezione della testa del pancreas

Hello. Hello. Hello. Good morning. Hello. Good morning. Yeah, good morning. Hi. On behalf of Professor Palacini, I just want to thank you for being with us today in Rome. Well, it's something strange compared to the other years because now we are on the net. We are not in presence right now.

So, Professor, can you show us what you are going to perform today?

Can you tell us something about the patient and the procedure you are going to perform?

Okay.

So, first of all, I want to say many thanks for the invitation.

It's a pleasure for us to be with you and to have the possibility to demonstrate something from our operating room.

So today we just have started. Just a moment, we'll clean the camera.

Do you hear me?

Yes, perfectly. Thank you. Just go ahead. Thank you so much.

So, today we have a 72-year-old woman who suffered, who entered our hospital with jaundice.

She had bilirubin level up to 150, something like this.

So, we put the external, she came from another city, so we put the external drainage, transcutaneous.

and during examination we discovered the tumor of the pancreatic head so it's

about two centimeters tumor in the head with Jordan's and also she had the tumor

of the left kidney so yesterday we performed radiofrequency ablation of the

the tumor of the kidney.

Today, everything was without any complications,

and now we started to perform laparoscopic pancreatodiodinectomy.

So up to this moment, it's not a difficult operation.

So she's not obese.

So to this moment, we...

So, we started with the transsection of the gastrocollic ligament, then mobilized duodenum here,

Coche maneuver, performed Coche maneuver, here you can see it, it's a little bit not very clean,

So here is the caval vein, inferior caval vein,

bochum maneuver, and here is the jejunum.

We transected the trates ligament here.

Perhaps I should change this sponge.

Something is a little bit bleeding here.

Sometimes it happens.

So to this moment, we didn't have any complications, any bleeding,

and it's simply, we have something from the...

So here you can see we performed the incision along the inferior border of the pancreas,

mobilized superior mesenteric vein, portal vein under the neck of the pancreas,

And here I put the sponge and some diffuse bleeding, I think, from the line that we transacted with the ultrasound scissors.

Great, professor. Thank you again for your explanation.

I'm so sorry we just connected because it should have been interesting to see how you perform all the other procedures you already have done.

Can you show us the trochanter placement?

You know, we have so many young surgeons connected to the net to take a look at your procedures.

Yes, it is very important.

So, should we do it like this?

So, you see the abdomen, here is the umbilicus,

and we place the first tracker, it's obstacle tracker,

for right near the umbilicus.

So, if the patient is small, like this woman,

we put it, it depends.

So, if the patient, no, she's like,

if it is correct to say, middle constitution, I don't know.

So, you should examine this distance between the xiphoid processus xiphoidus and umbilicus.

If it is long, it's better to put the trochanter up than the umbilicus.

If it is short, it's better to put it a little bit lower.

It influences very much on the comfort of the surgeon when you perform the operation.

So, and then we put five trochers, one of them 12 millimeters, 10, 10, and 5 millimeters trochers in the semicircle with the radius, it's above half length of the instrument.

You see, it's like this.

and we fix also here as I'll show you during the laparoscopy we fix the round

ligament of the liver here in order to put it up so that is the final vision

and at the end of the operation usually we remove the specimen or through the

incision that we make it a little bit bigger here is in the umbilicus or

Sometimes we perform small incisions.

Okay, thank you so much for the explanation.

You can see it's a very important thing.

You see how the liver is fixed here to the upper abdominal wall,

front abdominal wall, in order not to use any instruments

in order to hold the liver with the aim to provide the visualization of this field.

Now we are doing perhaps a little bit more difficult part of the operation, the mobilization

of the gapotidoid ligament because the woman, she has the drainage here, so we have some

adhesions here and infiltration because of this drainage, and you see that this section

is a little bit more difficult than in other places. So here you can see common

hepatic artery, hepatic artery left, right, we will go a little bit later along

the right artery, it's very important to see it properly in order not to damage the

common hepatic duct here, so we'll do it after we make the performance

with cholecystectomy.

And now we are going to transect the...

Выключите, пожалуйста.

We are going to transect gastro-duodenal artery here.

Нечки запитываете?

Я вижу.

Clean the camera.

Now it's better.

So we use 3D visualization,

and we think it's much more comfortable for the surgeon

and more safety for the patient.

And I want to say that in my experience,

I perform about 90% of the operation in 3D.

So here you see the clip on the right gastric artery.

I can't see anything at all. Turn on the light, if you can't see anything, I'll tell you again.

Don't worry.

Do you usually use EmoLock Eclipse?

One more time.

Professor, can you hear me?

Can you hear me, professor?

What?

I was just wondering if you could hear me.

Yes, I hear you, but if you can speak a little bit louder.

So, you see that the tissue is here, that's more in the other areas.

Yes, the images are quite clear.

I think it's over there.

Yes, we can see it now.

So here is the gain.

Right hepatic and it starts somewhere here.

Here we'll see from the right side, when we perform the section on the other side, but here we can clip it now, I think.

I think that I can clip it here.

times we have I think it's important to have bipolar so sometimes it's more

safety and more comfortable to control different buildings with bipolar

coagulation here is the infiltration issues that we should check from the

other side so we do the incision from this right side of the gap to do the

ligament in the very beginning of the operation but you see we have big lymph

node here so it makes some difficulties to do it here is the portal vein from

the other side and some infiltration but here we need to find common hepatic duct

right to find it here

I'm sorry, we couldn't see your cocker maneuver. It looks like it's completed.

And I really think you are performing great. How many procedures like this do you perform per year?

I mean an average and how many people are referring to your hospital I mean

the population how many people are referring to your hospital so to this

moment we have about 410 procedures performed laparoscopically in our

hospital totally and each year I think it's so more than 100 procedures but

But from them, I think, about 60 laparoscopic procedures, 60-70 per year.

And the number is growing.

So we are working in Moscow.

So it's 12 million population here and about 20 million people who work here and live in Moscow.

so 12 million citizens and 12-20 people totally and we have several hospitals

who perform pancreatic surgery but routinely only our hospital perform

laparoscopic people procedures and we have patients from different parts of

the country not only from Moscow so for example this patient it's she's from

another city she came to our hospital simply by recommendation somebody i don't know in order to

perform pancreatic surgery not for laparoscopic simply to solve her pancreatic problems

but we perform i think if concerning whipple we perform i think about 80 90 percentages

sometimes procedures laparoscopically. Thanks. More than robotic we also started

robotic project but total I think we have about 30 procedures by robotic

assisted whipples and we have three surgeons who perform this procedure with

different experience and great young surgeons who will perform this

operation soon they have said they have assisted assist assistants says pilot tuning and magomed

with me they also practically ready i think to perform this operation and

they have the experience of distal resections and distal pancreatic thermies

so you see that all the time that we have drainage or stenting of hepatic ducts all the

the time it's more problems with tissues here like in this case it's very

important to control right right get a category before you transect the common

people you put a duct but here I think it's everything is okay yes so we can

intersected here давайте какой-нибудь клипсу большую потом сначала да передавил передавлю

луку тянуть инга то я вот он да не здесь вот я думаю и гад вы концы в юг я ботвы эти тепла

пластиковый давайте ну и большую железяку давайте если большая есть давайте длинную железяку

So, we close the duct because it's very important not to prevent the infection on all the stages of the operation.

And it is important also to transect the duct with cold scissors,

also to preserve the wall for future anastomosis.

So, on this stage, it is important, if you didn't have the opportunity to take it before

the operation, it is very important to take the swab for microbiology examination from

in order to understand if you have some infection in the post-operative period,

to understand the sensitivity for antibiotics.

So, usually we do it in the first stages after admission of the patient.

So, you see, sometimes we use these stumps of arteries to hold them,

But, of course, if you are not sure that it's safe, of course, you can use special holders.

But in this case, I think it's possible to do it like this.

Professor, when did you put the transhepatic tube to resolve the jaundice?

I'm sorry, can you speak a little bit louder? Because we don't have good sound here.

I'm so sorry, I have the mic very near my mouth now.

I just wondered, when did you put the trans-hepatic tube to resolve the jaundice?

When?

So the patient came to our hospital from another city.

He has the history of jaundice.

I don't remember.

It's about a week or more.

So the bilirubin level was 150.

And she was not examined before.

so would the external when she had admitted to our hospital so sometimes if

we so we usually we try to operate to operate page not more than 80 but if we

have the patients on the initial stage of journal at the very beginning and we

have the possibility to perform the operation quickly after admission so we

we can operate them without drainage, without draining.

But in this case, again, I want to remind that the patient has the second tumor.

The kidney, yeah, the kidney.

Of the kidney, so we need to understand, first of all, what to do with it,

and then we decided that we can in these circumstances we can do

radiofrequency ablation of it and we decided to do it one by one so

so that is the reason for draining all the reasons

So you see I try to be careful here because there may be small branches.

Also it is very important to examine all the anatomy of the hepatodontal ligament of the

vessels here before the operation and in most cases we perform CT scanning and also endoscopic

ultrasound before the operation not that I understand all that I could shoot a new

little tooth but the rush I took me the hotels were the

wishes to go it's time to check никаких дальше вот он там так нет как-то нет

не вот так выдержать все нормально так что ли сделать

у вас возьмите поле полки просто вот видите когда эти кого-то достану

исполни все да все за лицо пересекаем что сейчас вот этот возьмите вот это

all lymph nodes without a rag only now until nothing pavel only takes pull-ups now

I don't need it now, I'm here, I'm looking here, hold the artery as much as possible, so now

yes, I take the lymph nodes, you are like this, yes, it's good, so I'm right, I'm right, this is the principle, so

Okay, then we'll remove it from the other side, so we are ready, I think, to transect the

pancreas.

so she didn't suffer from chronic pancreatitis and the gland is quite soft the duct is main

pancreatic duct i mean it's narrow so the according to the risk scores of post post

post-operative pancreatic fistula she has has high risk so you see that the pancreas is quite

it's not only sold but it is also has quite big diameter and the anastomosis will not be very easy

Usually we transect the pancreas by ultrasounds, scissors, and it is very important to try to

identify the duct, so usually I do it quite slowly.

You're right. It looks like the pancreas is really soft.

It looks like the duct, but I'm not sure that it is not a vessel, and if it is the duct it's better to transect it by the scissor, and if it is the vessel, it's better not to transect by the scissor, so here it is.

is I think that here we don't have it. Oh, it's the vessel. Definitely it's a vessel.

Maybe very narrow duct, but I'm not sure.

I think that it looks like the duct here.

So I think that here is the duct, so we can bipolar, bipolar, you see?

So we perform dunking and anastomosis, but it's very important to preserve the duct open even during the operation,

because in order not to block the drainage of the pancreas, which may be the cause of acute pancreatitis post-operative,

I think that should be normal.

So, don't think that we have the tumor here, but usually we make frozen section.

So, you're going to send it for a frozen section of the specimen, yep?

Yeah, so we can take it from this part also.

Yes, this is the main one.

Oop, soft.

Please press.

No, it's thin now.

Don't touch it, don't touch it.

So I think I'll mobilize the stump right now.

So we need the stump about not less than two, three centimeters

for future anastomosis, for future dark anastomosis.

How do you do it?

We started now practice, we spoke many times about this, but really began introducing it

in practice that if the risks of post-operative pancreatic fistula are very high, it's better

some total pancreatectomy in order to provide

safety for the patient to save life.

So we have good results after pancreatectomies in general.

The quality of life of our patients if they are listening to the doctor

and so sometimes it's better but not in this case.

Even though it looks like the pancreas is really soft

So, I understand your worries.

So such breathings are not dangerous, you can stop them simply by putting the sponge here, but I decided to try to defuse it.

When did you start your operation? When normally do you start performing your first operation of the day?

Usually we start at 8, 8.30. Today we started, I think, at 8.30 in Moscow, so now we operate a little bit more than two hours.

so the operation time in the during our first operation it was seven hours and perhaps there

were several cases even more but for today the minimal time for whipple procedure laparoscopic

whipple procedure is about three and a half usually we perform it in a time from four to

five hours if there are no difficulties no some complications and everything is good but in general

in average it's about four and a half hours something like this but they were not hurry

but you see that the patient is not to this moment she's not very difficult except these adhesions in

the uh gap to do the new ligament and perhaps we'll have some difficulties with the pancreatic

because you see that the pancreas is soft and it is quite big in diameter so perhaps it's better

to spend more time on this anastomosis but to make it as safe as possible

so here is i afraid that i might i can put it but okay we'll see it later

have this clip make some problems can make some problems during the the anastomosis yeah yeah yes

when we'll perform anastomosis but we'll see what will okay at the city musk I think that it's enough

from the low part and we should check this one check it here the substitute could be the tartan

such cases it's better not to hurry because you can lose time on these small bleedings but

they are not dangerous but they may make some problems for for your going forward

Let me get rid of it.

Wait, I'll get it out.

There's no water.

Some. Waiting for the water.

Like in Sahara.

Like in the desert in England.

There's desert.

There's desert.

Not up to the stomach.

Is that enough?

Wait a minute.

That's probably enough.

Okay.

Let's see what else is here.

It's better to clip all the...

now we're going to turn sect

to do no man

if it is free

and in its very initial part you can pull it to the upper part of the abdominal cavity

and transect it like we do here, but if there are some problems it's better to go to the lower part of the abdominal cavity

to transect all the adhesions because it's very important to make the anastomosis without any tension.

Attention, sometimes the adhesions may prevent the gluteus.

Let's do the gluteus maximus.

It's not yours.

Don't rush.

Don't rush.

Put it down.

Do you hear?

No, it's up.

This one.

Just a little bit.

Now we'll see.

Wait, don't tear it.

There's something.

Let's do it.

The gallbladder.

It didn't go through the ventricle.

Where are the edges of the intestines?

That's what it is.

больше какая-то какая-то непонятная поближе сюда чуть-чуть нет тут ничего

тут есть как метки и посмотрите пожалуйста на смонта донсу дотогнуть

что вот это за бранч капсих тискать сам смол брэнч и это за это же туза

the some of the initial branches of mesenteric arteries so we better will be a little bit slower

and a cloth.

Let's put it here.

We'll turn it around right away.

Look.

No, no, no.

In the center.

It doesn't go any further.

It doesn't go that way.

We'll turn it around.

Is this the artery that lies there?

Yes.

Let's put it aside and look at it.

So, now I just remembered your question about your note, about Koghe maneuver, it's very important really to perform it at the very beginning stages of the operation, because if you don't know how to do it, you won't be able to do it.

not do it at the very first stage of the operation it's this part of the

operation becomes more difficult now it seems to me that we control the

specimens see all the vessels

Quattro, вместе с веной получается.

Че? Ножницы.

Правильно.

Оттекает они, потекло.

Вверху.

Смотри, тебе поляр сразу.

Есть?

Переключайся на моно, пожалуйста.

Есть?

Very much to use these ultrasound scissors.

Как им правильно назывался этот?

Harmonic.

but the order is you should understand that manipulations like this them you

should do carefully because you can damage

Here I can try to identify the superior mesenteric artery, I think it's somewhere here, it seems

that it is here, somewhere here, it's a little bit closer, here it is, yes, like this, right?

again tissues here became a little bit more firm i think it's because of it's not the tumor

the working parts of the ultrasound dissector become hot during its work so it's better not to

to hold them near the vessels for a long time.

Now we can move the specimen here.

I think it will be impossible, I think that it's better to switch it.

we can clip it but uh our experience shows that it's better sometimes to gain spend several

additional minutes but to future such bleedings from the specimen it's the bleeding from the

specimen but it will be more safety and

Now she will go away completely, she will climb there.

Something short, hold it.

Short thread.

Go back a little.

Go back a little.

Sew, sew right on the knot.

That's it.

And prepare the thread.

Take it a little to the side.

I have a soft clamp.

Pavel says, don't, don't go there.

Turn your head.

Turn your head.

Let me change the napkin.

Give me the clip.

Turn your head.

Turn your head.

I will go there slowly.

Turn your head.

I have to see the artery.

Don't take it too much.

Open it like this.

So.

Here is artery.

When I go there, step back.

That's it, you don't need to do that.

You don't need to do that.

Good.

Like this.

And like this.

Right?

Give yourself a bipolar, or what?

Do you need a bipolar?

Flip here.

You are very bipolar.

I'll call you now.

Buzzer.

Buzzer.

Let's go there.

The artery has already gone, right?

Upper.

And like this.

Was there?

Buzzer.

you remember from the other side of the gapitoduodenal ligament, as you remember there were some

adhesions, but we should be very careful here.

Here, I think that we're practically finished.

Last bite.

Now we're finished.

and now we're practically ready for anastomosis.

Just a moment, we'll wash.

Did you receive any answer from the pathologist?

No, we didn't have any problems here,

but sometimes it is useful to mobilize the right flexion,

the hepatic flexion of the colon.

Perhaps I'll do it even now,

because here the jejunum will be more free here and sometimes it is necessary to do it

because simply difficult to mobilize the jejunum if you do not do this mobilization

so the new model of harmonic became more sharp and less effective

You see that the genome is free, so we'll check how it goes to the pancreas.

so I think that if I make the incision of the peritoneum it may be a little bit

absolutely free and we can start Moses let's check the upper part again because

it's usually it's the most limiting part of the pancreas of the date

So, we have the report from the frozen cell.

So we have the report from the power pathologist from the frozen section and the margins are clean.

There are no signs of tumor there, so we can start with the anastomosis.

Is it possible?

Yes, it is possible.

Here a little.

Vipolier, give me more, please.

especially in soft glands.

If you are not sure that the hemostasis is perfect, it's better to make some sutures,

to suture the vessels.

But in our case, I think it's okay.

You see that the duct is working.

Sew the effector.

Put it on the wet cloth.

What is this in the valley?

I'm not sure, perhaps it's a little bit of an idea, but I will do it later.

I don't need to think about it.

I think it's okay.

I think it's better this way.

I think it's better this way.

Wait, wait.

It should be five or six knots for it, you know.

The fire is burning.

Let's see. We haven't done anything yet.

Don't dry yourself.

Hold it a little bit. Just hold it a little bit.

So, the duct is here.

Wait, wait, wait. All, all, all.

You are burning the waste.

We are sewing it somewhere here, right?

I think I should have gone further away, I think.

To the right of the gut.

Let's get together.

Let's get together.

Or to the side.

Sometimes if the stump or the pancreas is thin, we use the tube.

Don't worry.

I think that it is more safety to do this.

you see that this moment that not I pull the knot and the tissue holds it so it's

good sign but we'll see what will be on the front wall may be more difficult

The front wall, the anterior, the anterior, the line.

You need to step back a little.

Just a little.

A little bit here.

Or that's it.

Take it for that.

No, it's hard.

We've already passed it, haven't we?

More or less, right?

Take it here a little bit.

You won't take it there.

Take it here.

Here's the burn.

Don't tear it.

Be careful.

It's not necessary to let go, you don't have to hold it too much.

I've already injected it, but only at the moment of injection it was necessary.

Wait, wait.

We talked about eucalyptus, right?

In terms of the disease, what to do?

It turned out fine, right?

Fire.

Right here, in the long run, like this.

Good.

Yes.

Next, how?

there is no tension also seems to be good from this point of view it looks like this one is a

solid layer really I was somehow worried about the softness of the gland I'm so sorry I'm sorry

can you speak louder because i i really have the mic very near my mouth but i'm so sorry i don't

know what the problem should be i was telling you that no no problem probably it's a technical

problem i think it's not your fault and i told you that i was somehow worried about the softness of

of the gland, but it looks like this is a solid layer.

No, the gland is soft, really.

And according to the scales for the risk of post-operative fistula,

it's a high-risk patient, but you see that the tissue is not fragile.

So I pull the knot and the gland holds it.

so it's good I hope we'll look at the anterior well now you see that another

difficulty and the danger that it is very long the pancreas is diameter is

quite big so it's also more risky for post-operative deliquent and then

question it's long incision you see and this incision of the dejunum should not

build not the most possible tight tight tightness it please you can

Here it is.

The lymph node has gone there somewhere.

This is the iron, right?

Like this and there somewhere.

Oh, it's okay.

Isn't it boring?

Now it will stretch like this.

Maybe a little bit like this.

Let's see now.

How much time?

Three and a half hours, right?

I came.

Pavel, take it here.

trap, now, wait, don't show it, here, hold it, just in case, sometimes it's, hold it, hold it, it's okay,

What is your personal experience about stenting the main pancreatic duct during the anastomosis?

for Lannister Moses but you see that in this case it's the fifth I think it's the

first time in my practice because it's very long soft pancreas so I try to put

sutures very close to each other that is the reason for overusing of sutures I

hope that we'll leave enough taekwond for our future operations

Let's push it down a little.

Here, both parts.

Push a little.

This thing needs to be pushed down.

Why are you not interrupting?

That's it, leave.

And this is from the mucous membrane, or what?

That's where it's bent, isn't it?

What should I load?

We've come too close to the edge.

Or a little.

Something is bad.

That's why I try to take it somehow.

For the whole world.

The tip of the bladder.

What? No, what to start with?

Give me this monocryl.

Not monocryl, what is it called?

Fiber, huh?

Fiber, give it to me.

Here it is, straight hair.

Some kind of fat.

So-so, of course.

Take it.

Something very small.

How many zeros?

A little bit.

A little up, a little bit.

Back.

Is there?

Is it broken?

With a needle or not?

What is it?

Back.

problem is that there is no clear border of the pair of the banker of the

pancreatic tissue and the fat very pancreatic facts so I think that I

simply put the previous future you know suturing on only the fat so damage the

vessel and it is very important to close it now I'm in the vessel oh what we're

spending more time here but i hope that will success is successful successful

Now I want simply to put the suture on the jejunum, so I think that to close it and perhaps

Perhaps it will be an additional thing that will compress the line from the internal space.

Hello? Hello? Can you hear me?

Hello, can you hear me?

Hello, can you hear me? Here is Rome. Give me an answer, please.

These headphones, we changed the headphones too, you can hear them, now I put them here, obviously.

But this happened all of a sudden, because it worked perfectly.

I think it's okay now.

Can you hear me?

No problem.

We'll take care of it.

There, that's it.

Wait, that's it.

You're holy, you're holy.

We're the ones who don't know.

We don't know.

Now we can't hear it.

I made the watch from that one.

Now we can hear it.

I don't know how to write it.

Let's sew it on this one.

so i'm sorry we had some noise here and we don't understand now are we could you hear us or

from the inside, why don't they prick me from the outside, this one spins worse, you say, it's good, it holds better, it

just spins, it spins harder, the main thing is that we are in the auditorium there or not, can anyone say

That's it, that's enough, hold it there, now pick up the thread.

I saw the field today in the morning, but he doesn't come in anymore.

And he always likes this seam, when it turns out.

What, where is she?

They let me in for nothing, okay, wait a second, let me pull the line, they didn't follow the stranger, try for a second, it will break.

Hold it, okay, hold it.

Turn your stomach a little so that I can see. No, no, no, on the contrary, on me, so that I can see this loop.

Go back, go back, go back!

So, I've got it here. Well, take it here.

It's further here.

No, you have to take it, you don't have to, it's on its side.

You take it here, turn it a little and that's it.

Petya, hold it.

So, which of them is further?

Yes, yes, yes.

Come on, hold it, please.

Come on, so that it doesn't twist anywhere.

Now, okay, that's it, go.

For now, you can let go.

Wait, don't, why did you come?

You drive badly.

Don't touch anything yet.

Now you have to.

I've heard this word, but it's still negative.

It's from here.

It has this shade.

When this Dvojnikov, remember?

He was sent to live there.

so professor i'm so sorry can you hear me now hello yes oh so so you can hear me now

we had some problems yeah we had some problem with the audio and i had to change my settings

So, I'm right back to you.

I realized that you couldn't hear me before because there was a question about the pancreatic anastomosis,

but now I see you are on the biliary tract.

But you can answer any questions.

So, you see there are some difficulties.

We see that the main difficulty was because the pancreatic tissue was soft.

Good thing that it was.

I don't know if you could hear us, we tried to explain all the difficulties,

but again, so the pancreatic tissue was soft, but not fragile, so it was not bad.

But the diameter of the pancreas, that pancreatic stamp, was large,

so we used five or six even needles for suturing it,

and we had some difficulties with bleeding

from the parapankinetic fat tissue

and we tried to stop it

with suturing and tried to be safe

and we hope that we

it seemed to us

for us that we managed to do it

have a look that Instamosis looks quite

there is no tension

so we'll put drains and I think

hope that everything will be

so here we didn't

take off this

clump because

we had quite long stump here

and in order not to

let the

possible bile infection

to get into the abdominal

cavity so we

made an estamosis

without taking off the

clump, it seems to be

not bad and

the situation that we have

we have the drainage the external drainage of bile ducts it's also helps

yes we are able to provide additional safety for it we were able to use it the

tube I mean in the beginning of the operation are right through through the

liver we were able to see it yes here it is here it is yes perfect cool so

So usually we put the sponge here to control possible bio-leakage, but usually when we

have the tube there we have no leakages, but still we put it here simply to have a look

at it later.

Dissector, long, big, good.

Put your head and legs evenly.

What is it?

No, long clamp, no, not a dissector.

Clamp, my usual.

Stop, stop.

Now I've got to take off the middle.

Well, don't do it, because the curtain, give it here.

No.

Is there?

Wait, wait.

Come in there.

Spikes between the paddles, or what?

Well, look, what do we need?

Look, it doesn't interfere.

Where is it?

Not this one, not the lower one.

No, wait, here it goes.

Here, the gut is gone.

Here is the loop.

See?

So we need to be sure that it is the proper loop.

You don't need to move it, just hold it.

Let it go.

40, that's enough.

Is that how it works?

So I think it's better to transect the momentum here because of this adhesion to the lateral wall, to the anterior wall of the abdominal cavity, so I think it may be in less tension.

sewed acrylic and where is the driver here, this is the driver, Pavel, the driver is not up to the right,

so here are the soft ones, the soft ones, you should give yourself a higher check, where is the tic-tic, do not ride

here, the driver, the driver, tell me there should be a higher one for us, so I will check the site

Yes, it is.

Ok, let's go.

When we have to lie down, we have to lie down with the leading leg up.

Let me see.

That's how it works.

And the holder?

Which one is it?

The leading leg.

It's not like me.

Pull your leg up a little.

Pavel, why the transition? Just up.

We took it close. Now it will interfere.

Just pull it up and that's it.

Take it higher, it's not too late.

What's going on?

I don't know.

How long do I have to go in there?

Maybe it doesn't go through, it's not where I'm going.

Hold it there, behind the upper wall.

It flew out.

Why did you let it go?

Take it there, pull it out so it doesn't go through.

Right there, to the stomach, along the stomach.

Pull it.

Here.

So, we try to put the anastomosis on the anterior wall of the stomach in order to isolate as

maximum as possible it from the pancreas.

And we'll put the omentum under the gastroenterine anastomosis in order to think that it helps

to avoid delayed gastric emptying after a ration.

to check the suture line

for possible bleeding.

for your anastomosis, I see.

Hold the line of the seam, otherwise it seems to be stretched.

Is your stomach so healthy? Have you already finished the liver or not?

Lie down here. Just close to the stomach.

Hold the tension.

Jumped, drove.

Let go now.

There it is.

The guts are smaller.

Don't let go. Why did you let go? It was good.

That's it, that's it, that's it, that's it.

Now we will have to sew the stomach.

Music is all small difficulties.

The stomach, right? Or is it the stomach?

This is the stomach.

Now, now, now.

So what?

Yes, almost right in the stomach.

Hold it now.

Wait a second.

Let it go there.

Maybe we'll blow it up?

Do you have a stomach now?

Why?

Why are you pulling it out?

I don't understand.

So I'm not sure in this corner, so I simply would like to put some several additional

sutures here.

Leave the napkin.

The sponge is clean.

No bile.

Yes, no any bile here.

So we've finished the operation.

Now we'll put the drains.

I think that usually we put two drains,

but when we think that there is high risk,

make it a high risks with I mean post-operative pancreatic fistula helps

it's better to put three one of them it's quite thin drain under the

anastomosis just under it so we'll start with the problem national

right now you don't it's natural pollution new bullshit rockers motion

broken pipes, there are holes, let's not break the pipes, something is stuck there, soft,

what is this, through this, through this, now we will put it, and we will not put it here, let's put another one,

We see the same. Only one? Only enough?

The hole is ours.

The hole is enough?

I'll try to crawl on that side.

Not yet.

I'll take it there.

Until I crawl there.

Now. Yes, look.

Everything is fine. Now, quietly.

Is there a thinner one?

Class.

Although there is a thinner one.

Is there a thinner one?

No?

Come on, let's go through the holes ourselves.

Do you see it here?

Just so that it doesn't bend over.

Closer, isn't there such a thing?

Here they are a little thinner and a little tighter.

Not bad.

Here or through another hole?

Go back.

Now I want to understand.

Will he come here with one movement?

So, we finished the operation.

Are there any questions we can answer?

Can you hear me, professor?

So, now the assistants will make a small incision and will remove...

so it's 12 millimeters 12 millimeter troco wheel put the sutures here

okay so if there are no questions then professor can you thank you very much thank you for very

much for the attention and can you hear me professor no you can yes oh okay great so i

just want to thank you on behalf of professor palestini for staying with us and showing such

such a great skill in performing this pancreatic surgery and I really hope to see you very soon

on the same screens and the sensation is strange I mean normally we have a crowd of people here in

Rome but now because of the COVID of course we are only online we are only the moderator and

And the presidents are here in Rome to stay with you, all the surgeons from all over the world.

And we really hope we will be in a better situation in the near future.

Thank you very much.

And thank you for this great organization, because we see a lot of screens, everything is working.

everybody is working and I think it's a very good chance for many people to see

different situations of online so we also hope to see everybody offline to be

pleasure for us thank you so much I'm so sorry about the audio problems we really

hope when the next time they will and so we will be able to to stay with you

along. Thank you so much, professor. Hope to see you soon. Ciao. Thank you.

Thank you. Thank you. Thank you. Have a good day.